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NEW   YORK  MEDICAL  JOURNAL 

INCORPORATING  THE 

PHILADELPHIA  MEDICAL  JOURNAL 

AND  THE 

MEDICAL  NEWS 


A  WEEKLY  REVIEW  OF  MEDICINE 


VOLUME  CXIL 

JULY  TO  DECEMBER,  1920,  INCLUSIVE. 


NEW  YORK 
A.  R.  ELLIOTT  PUBLISHING  CO 
.1920 


LIST  OF  ILLUSTRATIONS  TO  VOLUME  CXII 


Page 

Abdominal  exercises  before  and  after  delivery. 

Four  Illustrations  722-723 

Amputation  of  the  cervix  uteri.    Two  Illus- 
trations  711 

Asthma,  diagnostic  tests  in.  Six  Illustrations.  112 
Benzyl  benzoate  in  circulatory  conditions.  One 

Illustration   270 

Bodies,    foreign,   in   bronchi   and  esophagus. 

Fifty-two  Illustrations  654—665 

Carcinoma  of  middle  ear.    Two  Illustrations.  .  675 
Cervical  laceration,  cystocele,  prolapsus  uteri, 
and  multiple  fibromata.     Three  Illustra- 
tions 714—715 

Congenital    megacolon    (Hirschsprung's  dis- 
ease).   Two  Illustrations  1030-1031 

Cutaneous  anthrax.    Two  Illustrations  931 

Dental  infection.    Four  Illustrations. 354,  355,  356 
Diseases  of  the  cervix  uteri.    Seven  Illustra- 
tions 707-709 

Empyema  in  children.    One  Chart   987 

Eye,  choked  disc  of,  unilateral.  Two  charts.  .  .  157 

Female  pelvic  ureters.    One  Illustration   721 

Fissure  fracture  of  the  tibia.  Two  Illustrations.  365 
Gallbladder  afTections,  diagnosis  and  treatment 

of.    Three  Illustrations   2 

Gastric  superacidity.     One  Illustration   5 

Gastrointestinal  conditions,  diagnostic  charts  in. 

Four  Illustrations   125 

Hay  fever,  diagnostic  tests  in.     Six  Illustra- 
tions  112 


Rontgen 


Hirschsprung's  disease.  Two  Illustrations. 103Q((l' 
Historical  notes  on  the  practice  of  medicine  i  l 
Xew  York  City.    Two  Illustrations  an 

Three  Portraits  350,  35 

Infant  mortality  in  United  States  birth  regi^ 

tration  area.    One  Illustration  1 

Infections  of  hand  and  their  surgical  treatmen 

Seven  Illustrations  66^ 

Instrument  for  simplifying  tonsillectomy.  Onj 

Illustration  \ff 

Posture,  good,  underlying  factors  in.  Thrf 

Illustrations  81-^ 

Protein  fever.    Five  Charts  32- 

dose   estimation.     Fifteen  Illustn 

tions  93- 

Salvarsan  administered  by  rectum  in  the  fori 

of  enteroclysis.    One  Illustration  T 

Stereoscopic  campimeter  slate.    Four  Illustr; 

tions  949f" 

Surgical  mensuration,  standardization  of.  Xii 

Illustrations  

Typhoid  fever  epidemic.    One  Chart  

Ulcer,  peptic.    Nine  Illustrations  

Underdevelopment,  congenital.    Two  Illustr 

tions  6/^ 

Weak  foot  in  child.    Ten  Illustrations  9ir-'i. 

Xeroderma     pigmentosum.       Two  Illustr 

tions  9JMS6 

X  ray  an  essential  guide  for  producing  artifici 
pneumothorax  in  pulmonary  tuberculos 
Seven  Illustrations  S'J^li] 


I  f 


COPYRIGHT.  1920,  A.  R.  ELLIOTT  PUBLISHING  CO. 


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LIST  OF  CONTRIBUTORS  TO  VOLUME  CXII. 

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


|age 
304331 

uic 


A.BBOTT,  George  Knapp,  A.  B.,  M.  D., 

Sanitarium,  Cal. 
A.PPEL,  H.,  M.  D.,  Brooklyn,  N.  Y. 
*Arrowsmith,  Hubert,  M.  D.,  F.  A. 
C.  S.,  Brooklyn,  N.  Y. 

I 

Ball,  Charles  R.,  M.  D.,  St.  Paul, 
Minn. 

3AXDLER,  Samuel  W.,  M.  D. 
Barnes,  George  Edward,  M.  D.,  Her- 
kimer, N.  Y. 
Bark,  Martin  W.,  M.  D.,  Elwyn,  Pa. 
Baxgert,    George    Schuyler,    Ph.  G., 

M.  D.,  East  Orange,  N.  J. 
Barach,  Joseph  H.,  M.  D.,  Pittsburgh, 
Pa. 

Basch,  Seymour,  M.  D. 
i5l[352    Bassler,  Anthony,  M.  D. 

iATES,  W.  H.,  M.  D. 
..jOlO    Je.ates,  Henry,  Jr.,  M.   D.,   Sc.  D., 
m  Philadelphia. 

^5^669    5EHREND,  MosES,  M.  D.,  Philadelphia. 
)n|         Jland,  P.  Brooke,  M.  D.,  F.  A.  C.  S., 

•681  Philadelphia. 

f"         !lau,  Arthur  I.,  M.  D. 

^1.816  '.launer,  Samuel  A.,  M.  D. 

.j2}32/    iLODGETT,  Stephen  H.,  M.  D.,  Boston. 

SBoLDUAN,  Ch.\rles  F.,  M.  D.,  Wash- 
943     ington,  D.  C. 
int         .rewer,  Isaac  W.,  M.  D.,  Watertown, 

275    N.  Y. 
iral     _  Brink,  Louise,  A.  B. 
^-947    rown,  Alexander  A.,  M.  D.,  San  An- 
tonio, Tex. 

110 
14Q 

adwallader,  Joseph  M.,  A.  M.,  M.  D., 
San  Antonio,  Tex: 


-678 


ARTER,  C.  Edgerton,  M.  D.,  Los  An- 


fi-673 


901  i^''"' 

..hurch,  James  Robb,  M.  D.,  Colonel, 
Medical  Corps,  United  States  Army, 
-9^6  Washington,  D.  C. 

LEMONS,  E.  Jay,  M.  D.,  Los  Angeles, 
Cal. 

-"louting,  Charles  A.,  M.  D.,  London. 
)OPER,  Xavroji  a.,  M.  D.,  Bombay, 
India. 

RNWALL,  Leon  H.,  M.  D. 
tt,  George  F.,  M.  D.,  Buffalo. 
tter;  Lawrence  H.,  M.  D. 
UGHLiN,  William  T.,  M.  D.,  F.  A. 
Z.  S.,  St.  Louis,  Mo. 
AMPTON,   C.   Ward,    M.   D.,  Battle 
Ireek,  Mich. 

kwford,  James  P.,  M.  D.,  San  Fran- 
isco. 

ucHET,  Rene,  M.  D.,  Bordeaux, 
•■ranee. 

jmming.  Hugh  S.,  M.  D.,  Surgeon 
General,  United  States  Public  Health 
Service,  Washington. 


Cummings,  W.  Clovis,  M.  D.,  Okla- 
homa City,  Okla. 

*CuMSTON,  Charles  Greene,  M.  D., 
Geneva,  Switzerland. 

Darnall,  William  Edgar,  A.  M.,  M.  D., 
F.  A.  C.  S.,  Atlantic  City,  N.  J. 

Davis,  Edward  P.,  M.  D.,  F.  A.  C.  S., 
Philadelphia. 

Diamond,  Joseph  S.,  M.  D. 

♦Diamond,  Moses,  D.  D.  S. 

♦Donnelly,  William  Henry,  M.  D., 
Brooklyn,  N.  Y. 

Duncan,  Louis  C,  M.  D.,  Washington. 

Dunnington,  John  H.,  M.  D. 

Edgar,  Thomas  W.,  M.  D. 
Einhorn,  Max,  M.  D. 
*Elliott,  George,  M.  D.,  Toronto. 
Epstein,  J.,  M.  D. 

Forbes,  Henry  Hall,  M.  D. 

Fordyce,  John  A.,  M.  D. 

♦Foster,  Matthias  ' Lanckton,  M.  D., 

New  Rochelle,  N.  Y. 
Foster,  Nellis  B.,  M.  D. 
Fowler,  W.  Frank,  M.  D.,  Rochester, 

N.  Y. 
Fox,  Howard,  M.  D. 
Friedman,  Joseph,    M.   D.,  Brooklyn, 

N.  Y. 

FussELL,  M.  H.,  M.  D.,  Philadelphia. 

Gershenfeld,  Louis,  Ph.  M.,  B.  Sc., 
Philadelphia. 

Geyser.  Albert  C.  M.  D. 

GiFFiN,  H.  Z.,  M.  D.,  Rochester,  Minn. 

Glenn,  Elizabeth,  .A.  B.,  M.  D.,  Phila- 
delphia. 

Goldberger,  I.  H..  M.  D. 

Goldblatt,  David,  M.  D. 

Goldfader,  Philip,  M.  D..  Brooklyn. 

Goldstein,  Hym.\n,  M.  D. 

Goldstein,  Hyman  I.,  M.  D.,  Camden, 
N.  J. 

Goodman,  Herm.^n,  B.  S.,  M.  D. 
♦Goodman,  Max,  M.  D. 
Gordon,  Alfred,  M.  D.,  Philadelphia. 
Graham,  John  Randolph,  M.  D. 
Granet,  Adolph,  M.  D. 
Graves,  William  P.,  M.  D.,  Boston. 
Greenberg,  David,  M.  D. 
Greenfield,  Samuel  D.,  M.  D.,  Brook- 
lyn, N.  Y. 

Greenough,  Robert  B.,  M.  D.,  Boston. 
Grossman,  Jacob,  M.  D. 
Guttman,  John,  M.  D. 

Hammer,  A.  Wiese,  M.  D.,  Philadelphia 
Hammond,  L.  J.,  M.  D.,  Philadelphia. 
Hart,  T.  Stuart,  M.  D. 
Hayes,  W'illiam  Van  V.,  M.  D. 
Hays,  Melville  A.,  M.  D. 
Heineberg,  Alfred,  P.  D.,  M.  D.,  Phila- 
delphia. 


Heller,  Edwin  A.,  M.  D.,  Philadelphia. 
Hirst,  Barton  Cooke,  M.  D.,  Philadel- 
phia. 

Hood,  C.  T.,  M.  D.,  Chicago. 
Horovitz,  a.  S.,  M.  D.,  Cincinnati,  Ohio. 
Hubbard,  S.  Dana,  M.  D. 
Hyman,  Albert  S.,  M.  D.,  Boston. 

Ittelson,  M.  S.,  M.  D.,  Brooklyn. 

Jacoby,  a.,  M.  D.,  F.  a.  C.  S.,  New  Or- 
leans, La. 

♦Jelliffe,  Smith  Ely,  A.  M.,  M.  D., 
Ph.  D. 

Jones,  E.  L.,  M.  D.,  Cumberland,  Md. 
Jones,   Frank   A.,   M.   D.,  Memphis, 
Tenn. 

Jones,  John  F.  X.,  B.  Sc.,  M.  D.,  A.  M., 

F.  A.  C.  S.,  Philadelphia. 
Joyce,  Thomas  F.,  M.  D. 

Kaiser,  Albert  D.,  M.  D.,  Rochester, 
N.  Y. 

Ke.iiRney,  J.  A.,  M.  D. 
Kellgren-Cyriax,  Mrs.,  L.  R.  C.  P., 

Edin.  London. 
♦Kellogg,  Elenore. 
Kerley,  Charles  Gilmore,  M.  D. 
Kidder,  Walter  H.,  ]\I.  D.,  Oswego, 

N.  Y. 

♦Knopf,  S.  Adolphus,  M.  D. 

ICOHN,  L.  WiNFIELD,  M.  D. 

Koster,  H.,  M.  D.,  Brooklyn. 
Kramer,  David  W.,  M.  D.,  Philadelphia. 
Krauss,  Frederick,  M.  D.,  Philadelphia. 
Krupp,  David  Dudley,  M.  D.,  Brooklyn. 
Kunstler,  M.  B.,  M.  D. 

Lane,  Harold  C,  M.  D.,  Denver,  Colo. 
Langrock,  Edwin  G.,  M.  D. 
Langstroth,  Francis  Ward,  Jr.,  M.  D. 
Lankford,  J.  S.,  M.  D.,  San  Antonio, 
Tex. 

Lapent.\,  Vincent  Anthony,  A.  M., 
M.  D.,  Indianapolis,  Ind. 

Lazarus,  David,  M.  D. 

Leiner,  Joshua  H.,  M.  D. 

Lerch,  Otto,  A.  M.,  Ph.  D.,  M.  D.,  New 
Orleans,  La. 

Levin,  Oscar  L.,  M.  D. 

♦Lieb,  Charles,  M.  D. 

Lloyd,  Ralph  I.,  M.  D.,  F.  A.  C.  S., 
Brooklyn,  N.  Y. 

Lobsenz,  Moses,  M.  D. 

Love,  Louis  F.,  M.  D.,  Philadelphia. 

Lowenburg,  Harry,  A.  M.,  M.  D.,  Phila- 
delphia. 

Lynah,  Henry  Lowndes,  M.  D. 
Lyon,  B.  B.  Vincent,  M.  D. 

McEvoy,  L.  Donald,  M.  D. 
McMurray,  T.  E.,  M.  D.,  Wilkinsburg, 
Pa. 

McNaik,  Robert  H.,  M.  D.,  Springfield, 
Mass. 


McNuLTY,  John  J.,  M.  D. 
Macht,  David  I.,  M.  D.,  Baltimore. 
Marsh,  Chester  A.,  M.  D.,  New  Cas- 
tle, Ind.' 

Martin,  Sergeant  Price,  M.  D.,  Buffalo, 
N.  Y. 

Mason,  Frederick  Raoul,  M.  D. 

Massey,  G.  Betton,  M.  D.,  Philadelphia. 

Meltzer,  Maurice,  M.  D. 

Meyer,  William  H.,  M.  D. 

Miller,  Edwin  B.,  M.  D.,  Philadelphia. 

Miller,  George  I.,  M.  D.,  Brooklyn. 

monteith,  s.  r.,  m.  d. 

Montgomery,  E.  E.,  M.  D.,  LL.  D., 
F.  A.  'C.  S.,  Philadelphia. 

Morse,  John  Lovett,  A.  M.,  M.  D.,  Bos- 
ton, Mass. 

Muller,  George  P.,  M.  D.,  Philadelphia. 

Musser,  John  H.,  M.  D.,  Philadelphia. 

NicoLL,  Alexander,  M.  D.,  F.  A.  C.  S. 

Norman,  N.  Philip,  M.  D. 

NoRRis,  George  William,  A.  B.,  M.  D., 

Philadelphia. 
Oliver,  James,  M.  D.,  F.  R.  S.  (Edin.) 

London,  England. 

Palefski,  I.  O.,  M.  D. 

Parke,  William  E.,  M.  D.,  F.  A.  C.  S., 
Philadelphia. 

Paschall,  Benjamin-  S.,  M.  D.,  Seat- 
tle, Wash. 

Pearl,  Raymond,  Ph.  D.,  Baltimore, 
Md. 

Pedersen,  Victor  Cox,  A.  M.,  M.  D., 

F.  A.  C.  S. 
PoLAK,  John  Osborn,  M.  Sc.,  M.  D.* 

F.  A.  C.  S.,  Brooklyn. 
Popper.  Joseph,  M.  D. 
Pottenger,  F.  M.,  a.  M.,  M.  D.,  LL.  D., 

F.  A.  C.  P.,  Monrovia,  Cal. 

Qu.\CKENBOs,  Maxwell,  M.  D.,  M.  R. 
C.  S.  (Eng.). 

Rachford,  B.  K.,  M.  D.,  Cincinnati. 
Ramirez,  Maximilian  A.,  M.  D. 
Rammol,  Harry  M.,  M.  D. 
Ravdin,  L  S.,  M.  D.,  Philadelphia. 
Redfield,  Casper  L.,  Chicago. 
Remer,  John,  M.  D. 
Retan,  George  M.,  M.  D.,  Syracuse, 
N.  Y. 

Rhodes,  William  L.,  M.  D.,  Wichita 
Falls,  Tex. 


Richardson,  Frank  Howard,   M.  D., 

Brooklyn,  N.  Y. 
RiDDELL,  Honorable  William  Renwick, 

LL.  D.,  F.  R.  H.  S.,  Toronto,  Canada. 
Rivers,   W.   H.   R.,   M.   D.,   LL.  D., 

F.  R.  S.,  Cambridge,  England. 
Riviere,  Joseph,  M.  D.,  Paris,  France. 
♦Rogers,  James  F.,  M.  D.,  New  Haven, 

Conn. 

Rohdenburg,  G.  L.,  M.  D. 

Root,  Manly  B.,  M.  D.,  Syracuse,  N.  Y. 

♦Root,  M.  T.,  M.  D.,  Ithaca,  N.  Y. 

Rose,  Robert  Hugh,  M.  D. 

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

Rout,  Ettie  A.,  London. 

♦Rucker,  W.  C,  M.  D.,  United  States 
Public  Health  Service. 

Ruderman,  Louis  M.,  M.  D.,  Brooklyn, 
N.  Y. 

Russell,  Thomas  Hubbard,  M.  D.,  New 

Haven,  Conn. 
RuTZ,  Anthony  A.,  M.  D.,  Brooklyn. 

*Sajous,  Charles  E.  de  M.,  LL.  D., 

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

Philadelphia. 
Satterthwaite,  Thomas  E.,  M.  D. 
♦Scarlett,  Rufus  B.,  M.  D.,  Trenton, 

N.  J. 

Scheimberg,  H.,  Brooklyn,  N.  Y. 

Scheppegrell,  William,  A.  M.,  M.  D., 
New  Orleans. 

Schroeder,  Theodore,  Cos  Cob,  Conn. 

Schwartz,  Samuel,  M.  D. 

Shanahan,  William  T.,  M.  D.,  Son- 
yea,  N.  Y. 

Shapiro.  Isidor  F.,  M.  D. 

Smith,  Ethan  H.,  M.  D.,  San  Fran- 
cisco. 

Sobel,  Jacob,  M.  D. 

SoLis-CoHEN,  Myer,  A.  B.,  M.  D., 
Philadelphia. 

Solomon,  Meyer,  M.  D.,  Chicago. 

♦Steinbugler,  William  F.  C,  M.  D. 

Steinfeld,  Edward,  M.  D.,  Philadelphia. 

Stevens,  J.  Thompson,  M.  D.,  Mont- 
clair,  N.  J. 

Stewart-Cogill,  Lida,  M.  D.,  F.  A.  C.  S., 
Philadelphia. 

♦Stragxell,  Gregory,  M.  D. 

Strickler,  Albert  A.,  M.  D.,  Philadel- 
phia. 


Taylor,  J.  Madison,  A.  B.,  M.  '. 

delphia. 
Taylor,  R.  Tunstall,  ^1.  D., 

Baltimore. 
Thom,  Burton  Peter,  M.  D. 
TovEY,  David  W.,  M.  D. 
Tridon,  Andre. 
TousEY,  Sinclair,  A.  M.,  M. 
Tucker,  Henry,  M.  D.,  Philad 

Underhill,  B.  M.,  V.  M.  D., 
phia. 

Uniker,  T.  E.,  Stamford,  Cor 
Upham,  Roy,  M.  D.,  F.  A.  C. 
lyn. 

Vandegrift,  George  W.,  M. 
Van  Paing,  John  F.,  M.  D., 
Vander  Veer,  Albert,  Jr.,  M. 
♦Vedin,  Augusta,  M.  D. 


PlCS 


ibia. 


bihddi 


ME 


Walsh,   Joseph   W.,   M.   S.  Jl  D 

Brooklyn. 
♦Warburton,  Gladys  Bagot.  ! 
♦Waterson,  Davina. 
Watkins,  Harvey  M.,  M.  D  P 

Mass. 

Wechsler,  I.  S.,  M.  D. 
Wehner,  William  H.  E.,  M. 

delphia. 
Weiss,  Samuel,  M.  D. 
West,  James  N.,  M.  D. 
♦Whitford,  William,  Chicag 
Wile,  Ira  S.,  M.  D. 

Wilensky,  Abraham  O.,  M. 
C.  S. 

Williams,  Tom  A.,  M.  D.,  Wiii^o 
♦Williamson,  Jefferson. 
Witherbee,  W.  D.,  M.  D. 

♦WOLBARST,  AbR.  L.,  M.  D 

Woloshin,  Benjamin,  M.  E 
Woodbury,    Frank  Thoma 

M.  D.,  Edgewood  Arsenal, 
WooLSEY,  George,  M.  D.,  F. 
Wright,  Jonathan,  M.  D., 

ville,  N.  Y. 
Wright,  V.  William  M.,  M.j),Piii^ 

delphia. 

Wyatt,  B.  S.,  M.  D.,  Plano.rei 


Young,  John  J.,  M.  D. 


CPhy* 

F.  .  C.  S 


INDEX  TO  VOLUME  CXII. 


,  liladel 
S  Brook 


iM. 


!  ,  Phil: 


F 


Page. 

A  BBOTT,    George    Knapp.  Periodical 

headaches  of  ovarian  origin   724 

Abdomen,  acute,  treatment  of   233 

disorders  of,  acidosis  in   42 

tender  points  in,  percussion  of   42 

Abdominal  cyst,  unusual   743 

exercises   854  • 

before  and  after  delivery,  value  of . .  .  722 

incisions   235 

noninfected,  syphilis  as  cause  of  de- 
layed healing  in   539 

relaxation,  rhythmic  electric  currents  in 

treatment  of   441 

section,  suppurating  wounds  following.  606 
symptoms  in  influenza  simulating  surgi- 
cal lesion   216 

m  \r    r   viscera,  disorders  of   752 

"  M.  lAbduction  treatment  of  fracture  of  neck 

)  '"hicaei       °^  femur   651 

■'  ■        °  Abnormalities,  with  congenital  absence  of 

i  I.                vagina    742 

\bortion,  missed   829 

treatment  of,  complicated  by  sepsis.  . . .  829 

■\bscess  of  liver   872 

peritonsillar,    chronic                           .  .  .  193 

'->   pulmonary,  x  ray  in   841 

\bsence  of  vagina,  congenital,  with  other 

abnormalities   742 

\bscesses,  multiple,  of  brain   60S 

unopened     mammary,     aspiration  and 

pressure  treatment  of..._   735 

D  Pa1mp^^^'"^'"'°"  °^  membranous  bones   1051 

"     Hcacia,  gum,  action  of,  on  circulation....  692 
\cid,  chromic,  in  suppurative  dacryocys- 
titis   827 

phenylacetic,  toxicity  of   383 

picric,  use  of,  in  preparing  skin  for  oper- 
ation   829 

salicylic,    hypodermic   injections    of.  in 

gout  and  rheumatism   691 

\cidity.  gastric,  excess  of   5 

Acidosis  256,  287 

history  of   246 

in  acute  abdominal  disorders   42 

Vccidental  hemorrhage   742 

Occidents  from  ladders   597 

Vcne.  X  ray  treatment  of   839 

Vction  of  digitalis,  effect  of  high  temper- 
ature upon   782 

Vcute  encephalitis  in  children   739 

Vdenitis,   venereal,   injections  of  milk  in 

Ui^rrt^      treatment  of   496 

hUlgtC  X  ray  in   842 

Adenoiditis,  acute,  in  children   638 

Adenomata,  thyroid  toxic,  mild  types  of.  .  695 

Vdenomyomata,  submucous   742» 

Adenopathy,    tracheobronchial,  diagnostic 

signs  in    1047 

Adolescence,  autoerotic  phenomena  in....  334 
Adrenalin  injections,  effect  of,  upon  blood 

pressure  in  dementia  prascox   691 

,  modification  of  action  of,  by  chloroform  1047 

Aftertreatment  in  surgical  cases   1048 

I          Age,  old,  mental  disorders  of   604 

alcoholism  and  tuberculosis   876 

gllkali  tolerance  test,  Sellard's   256 

ilkalosis.   unusual   case  of,  with  impair- 

'leasar               of  excretory  power  of  kidneys.  966 
jnerican  Revolution,  medical  men  in.... 

345.  410,  455,  501 

jnniotic  hernia   737 

.,  Philmputation  of  cervix  uteri   710 

of  leg   233 

tissue  sparing,  of  foot   428 

.nalgesia,  postoperative   903 

ex.       spinal   300 

in  labor   562 

naphylactic  manifestations,  new  method 

of  preventing   693. 

shock,  simple  means  of  obviating   1048 

natomical  anomalies,  clinical  importance 

of,  in  biliary  surgery   473 

theories  of  Plato   141 

natomy,    comparative,    of  genitourinary 

organs  of  lower  animals   525 

nemia;   pernicious  307,  359 

secondary  types  of   360 

splenic    360 

and  Banti's  disease   305 

nemias,  relationship  of,  to  life  insurance  358 

nesthesia    315 

ether  oil  colonic,  in  treatment  of  toxic 

thyroid    744 

ethyl  chloride,  brief  or  prolonged   339 

general   472,  693 

in  labor   562 

local,  combined  with  morphine  and  sco- 
polamine narcosis,  in  Caesarean  sec- 
tion   339 

in  rectal  surgery   339 

with  ethyl  chloride  in  fractional  amounts  233 

nesthetic,  local,  action  of  saligenin  as.  .  693 

benzyl  carbinol  as   339 

aesthetics  in   shock   338 

neurysms,  formation  of  in  acute  endaor- 

titis    547 


B. 


P.\GE. 

Animals,   lower,   comparative  anatomy  of 

genitourinary  organs  of   525 

Anomalies,  anatomical,  clinical  importance 

of,  in  biliary  surgery   473 

Anteflexion,  acute,  of  uterus   703 

Anthrax,  cutaneous   931 

himian,  treatment  of,  by  normal  bovine 

serum    692 

meningitis,  primarj'   604 

transmission  of,  from  shaving  brush....  604 

Antiseptic,  chlorine   472 

Antitoxin  administration  in  diphtheria  783,  871 

Aorta,  rupture  of   547 

Aortic  regurgitation,  venesection  in   901 

Aortitis,   specific   559 

Apoplexy,  thyroid,  tetany  in  adult  due  to.  739 
Appel.  H.  Lumbar  puncture  in  diseases  of 

children    1021 

Appendectomy,  late  results  of   40 

volvulus  complicating .  .  .  ,   22 

Appendicitis,  chronic,  operations  for   42 

Appendix,  diseases  of   94 

Arbuthnot.   Dr.  John — physician  author.  .  551 

Aristotle,  theory  of  pneiuna  in   833 

Army,  United  States,  influenza  in   342 

-Arrhythmia    288 

Arsenic,  colloidal,  in  influenza   648 

poisoning  following  salvarsan  administra- 
tion   559 

Arsenical    products,    ocular   accidents  at- 
tributed to   506 

Arsphenamine,  intensive  administration  of  494 
reactions  following  intravenous  adminis- 
tration of    498 

toxicity  of   516 

trypanocidal  activity  -of   515 

Arterial  fibrosis,  hypertension  in  relation  to  152 

hypertension,  treatment  of   570 

Arteriosclerosis,    etiology   and  symptoma- 
tology, of   60S 

gastrointestinal  infections  in  relation  to.  13 
Arteriovenous  fistula,  effect  of,  upon  heart 

and  bloodvessels   960 

Arthritic  cellulitis,  treatment  of   375 

Arthritis,  chronic,  distant  foci  of  infection 

in    108 

following    ingestion    of  hexamethylena- 

mine    560 

multiple,  complicating  lobar  pneumonia  161 

treatment  of  prostate  in   652 

of  seminal  vessicles  in   652 

Arthrodesis  for  nontuberculous  hip  joint.  828 

Arthroplasty  of  knee  joint   828 

Artillery  fire,  lethal  aspects  of   784 

Asexualization,  report  of  eighteen  cases  of  500 

hypertension,  treatment  of   570 

Aspiration  and  pressure  treatment  of  un- 
opened mammary  abscesses   735 

Association,  free,  and  its  right  to  use....  862 

Asthma,  bronchial,  in  childhood   399 

protein  sensitization  in   108 

diagnostic  tests  in   112 

problem    392 

treatment  of,  with  benzyl  benzoate  by 

injection    403 

Astigmatism,  cause  of   816 

distaurbances  of  heart  and  liver  caused 

by  low  grades  of   447 

Asylums,  lunatic,  inmates  of   420 

Ataxia,  cerebrocerebellar,  acute   1007 

Atropine,  use  of,  in  treatment  of  hyper- 
tonic infant   971 

Aurae,  a  consideration  of  the  nature  of. . .  342 
Aural  suppurations  coupled  with  syphilis, 

intracranial  complications  in   341 

Auricle,    invoK-ment    of.    and  conduction 

pathways  of  heart  following  influenza  873 

Autohemotherapy  in  protracted  infections  692 
Azotemia,    with   chronic   nephritis,  intra- 
venous injection  of  hypertonic  glucose 

solution  in    471 

BACILLARY    dysentery,  complications 

of    1046 

in  children   1046 

Bacillus,  colon   522 

in  kidney  infections  652,  694 

tubercle,  presence  of,  in  blood  stream .  .  1005 
Backache  from  viewpoint  of  general  sur- 
geon   409 

Bacteriology  of  colitis   1005 

Ball,  Charles  R.  Doctor  and  neuropath..  575 
Bandler,  Samuel  W.  Placental  gland  and 

placental  extract   745 

Bangert,   George   Schuyler.     Seven  gen- 
erations of  physicians   277 

Banti's  disease  and  splenic  anemia   305 

Barach,  Joseph  H.     Cholesterol  thorax.  .  .  811 
Barium  chloride  and  cardiac  inhibition...  781 
Barnes,  George  Edward.    Cause  of  astig- 
matism   816 

Barr,   Martin   W.     Observations  on  the 
stigmata  of  degeneration  as  found  in 

the   feebleminded   80 


Page. 

Basch,  Seymour.    Primary  sarcoma  of  the 

stomach    9 

Bassler,  Anthony.    Chronic  intestinal  tox- 
emia   45 

Bates,    W.    H.      Shifting    as    an   aid  to 

vision    158 

Baths,  carbonated  brine   83 

Beates,  Henry,  Jr.    Horatio  C.  Wood....  308 
Behrend,    Jloses.      Backache   from  view- 
point of  general  surgeon   409 

Benign  mammary  timiors  and  interstitial 

toxemia    787 

Benzyl  benzoate  by  injection  in  asthma.  .  403 

in  treatment  of  whooping  cough   122 

nonleucotoxic  properties  of   160 

use  of,  in  circulatory  conditions   269 

carbinol  as  a  local  anesthetic   339 

Bile  ducts,  anomalies  of   561 

Biliary    surgery,     clinical    importance  of 

anatomical  anomalies  in   473 

tract,  interesting  surgical  conditions  of  741 

Bilious  hemoglobinuric  fever   100 

Binocular  single  vision   320 

Birth  registration  area  in  United  States, 

variation  of  rate  of  infant  mortality  in  1009 
Bismuth  subnitrate,  kaolin  as  substitute 

for    41 

Bladder,  inflammation  of   544 

leucoplasia  of   738 

rupture  of,  during  labor   742 

tuberculosis   of   546 

tumors  of   546 

value  of  radium  in  treatment  of   474 

urinary,  disorders  of  function  of   544 

Bland,  P.  Brooke.    Treatment  of  displace- 
ment of  uterus   702 

Blau,  Arthur  M.    Schick  test,  its  control, 
and     active     immunization  against 

diphtheria    279 

Blauner,   Samuel   A.     Physical  signs  of 

pneumonia  in  children   1032 

Blind,   needlessly   465 

Blodgett,    Stephen   H.     Urea  output  as 

practical  kidney  function  test   483 

Blood,  analysis  of,  of  insane  patients   311 

changes    following    Rontgen   ray  treat- 
ment of  leucemia   828 

determination  of  magnesium  in   605 

effect  of,  on  picrate  solutions   1006 

fetal    735 

letting,  indications  for   898 

maternal    735 

occult,  in  gastric  contents   619 

tests    to    determine    presence    of,  in 

gastric  contents   619 

of  insane  patients,  analysis  of   311 

pressure    258 

and  gallop  rhythm   784 

control  of    406 

in  dementia  praecox,  effect  of  adrena- 
lin upon   69 1 

stream,  presence  of  tubercle  bacillus  in.  1005 
study    after   splenectomy,    with  special 

reference  to  leucocytes   873 

sugar,  studies  in   1006 

tolerance    as    an    index    in  hyper- 
thyroidism   827 

transfusion  in  obstetrical  practice   951 

Bloodvessels    and    heart,    effect    of  arte- 
riovenous fistula  upon.   960 

Bodies,  foreign,  in  bronchi  604,  653 

in  esophagus   653 

X  ray  treatment  of   841 

vertebral,  delayed  symptoms  in  fracture 

of    873 

Bodily    mechanics    in    relation    to  cyclic 
vomiting  and  other  obscure  iiftestinal 

conditions    1008 

Bone  flap  in  cranial  surgery   871 

formation,     heteroplastic,     in  fallopian 

tube    828 

grafts    302 

Bones,  long,  fractures  of   301 

role  of  cancellous  tissue  in  healing  bone  916 

membranous,  absorption  of   1051 

BOOK  REVIEWS: 

Allen,  R.  W.    Practical  Vaccine  Treat- 
ment   910 

Anderson,  Sherwood.    Poor  White   958 

Andreyev,  Leonid.    Satan's  Diary   1044 

Arbeiten  aus  der  deutschen  Forschungs- 

anstalt  fiir  Psychiatrie  in  Munchen  644 
Bain,    F.    W.     The    Substance    of  a 

Dream    513 

Bakewell,    Charles    M.      Story    of  the 

American  Red  Cross  in  Italy   869 

Barnett.  E.  de  Barry.    The  preparation 

of  Organic  Compounds   72 

Baroja,  Pio.    Youth  and  Egolatry   469 

Baruch.  Simon.   An  Epitome  of  Hydro- 
therapy   957 

Benoit,  Pierre.    Atlantida  (L'Atlantide)  295 

Bergson,  Henri.    Mind  Energy   689 


1054 


INDEX  TO  VOLUME  CXI  I. 


BOOK  REVIEWS:  Pace. 

Bidou,  Gabriel.    De  I'Orthopedie  instru- 

mentale    138 

Binder,  Rudolph  M.    Health  and  Social 

Progress    690 

Birk,  Walter.  Leitfaden  der  Kinder- 
heilkunde  fiir  Studierende  und 
Arzte    1000 

Bleuler.  E.  Das  autistitsch  undiszipli- 
nierte  Denken  in  der  Medizin  und 
seine  Ueberwindung    72 

Bojer,   Johan.     Life   911 

Box,  Charles  R.    Postmortem   Manual.  36 

Bram,  Israel.    Exophthalmic  Goitre  and 

its  Nonsurgical  Treatment   556 

Braun,  Heinrich.  Die  Oertliche  Be- 
taubung,  ihre  wissenschaftlichen, 
Grundlagen  und  praktische  An- 
•Aendung    230 

Brebner,  Percy  James.    The  Ivory  Disc  558 

Brooks,    Van    Wyck.    The    Ordeal  of 

Mark   Twain    264 

Brophy,  Truman  W.  Oral  Surgery.  A 
Treatise  on  the  Diseases,  Injuries, 
and  Malformations  of  the  Mouth 
and  Associated  Parts   265 

Burnet,  James.    Manual  of  Diseases  of 

Children    1000 

Burton-Opitz,     Russell.     Textbook  of 

Physiology    36 

Bushnell,  George  E.  Study  of  Epidemi- 
ology of  Tuberculosis   600 

Cabell,  James  Branch.     Beyond  Life..  136 

Cream  of  the  Jest   136 

Domnei    1003 

Cajori,  Florian.  A  History  of  tlie  Con- 
ceptions of  Limits  and  Fluxions  in 
Great  Britain  from  Newton  to 
Woodhouse    1002 

Cannan,  Gilbert.    Anatomy  of  Society.  646 

Chekov,  Anton.    The  Chorus  Girl  and 

Other  Stories    424 

Letters    of    Anton    Chekhov.  With 

Biographical  Sketch   424 

Chesterton,  G.  K.    The  Superstition  of 

Divorce    380 

Child,  Richard  Washburn.  The  Vanish- 
ing Men   200 

Conklin,  Edwin  Grant.  Heredity  and 
Environment  in  the  Development 
of  Man   104 

Conkling,    Hilda.    Poems   by    a  Littl^ 

Girl    199 

Conrad,  Joseph.    The  Rescue   645 

Cufi,  Herbert  E.    A  Course  of  Lectures 

on  Medicine  to  Nurses   1043 

Cunningham's     Manual     of  Practical 

Anatomy    37 

Davison,  Henry  P.    The  American  Red 

Cross  in  the  Great  War   336 

Danysz,  J.  Origine,  evolution  et  traite- 
ment  dcs  maladies  chroniques  non- 
contagieuses    37 

Dock,  Lavinia  L.    A  Short  History  of 

Nursing    513 

Dostoevsky,  Fyodor.    An  Honest  Thief 

and  Other  Stories   424 

Einhorn,  Max.  The  Duodenal  Tube  and 

Its    Possibilities   911 

Feldman,  W.  M.  Principles  of  Ante- 
natal and  Postnatal  Child  Physi- 
ology   334 

Fletcher,  J.  S.    The  Paradise  Mystery.  266 

Folks,   Homer.    Human    Costs  of  the 

War    198 

Fox,  L.  Webster.    Practical  Treatise  on 

Ophthalmology    198 

France,  Anatole.    The  Bride  of  Corinth 

and  Other  Poems  and  Plays   1045 

The  Seven  Wives  of   Bluebeard  and 

Other  Marvelous  Tales   1045 

Frank,  Waldo.    The  Dark  Mother   1002 

Frankau,   Gilbert.    Peter  Jameson   231 

Frazer,  James  George.     Folklore  in  the 

Old  Testament   168 

Freud,  Sigmund.  A  General  Introduc- 
tion to  Psychoanalysis   294 

Friel,  A.  R.    Electric  Ionization   956 

Gage,  Harold  C.  X  Ray  Observations 
for  Foreign  Bodies  and  Their 
Localization    866 

Gardiner,  Frederick.   Handbook  of  Skin 

Diseases    426 

Garrison,  Fielding  H.    An  Introduction 

to  the  History  of  Medicine   825 

Gerster,  Arpad   G.    Recollections  of  a 

New  York  Surgeon   733 

Gibbs,  Philip.    Now  It  Can  Be  Told..  37 

Gilbert,  Professor.    L'Art  de  prescrire.  36 

Giles,  Arthur  E.    Sterility  in  Women.  778 

Gillies,  H.  D.    Plastic  Surgery  of  the 

Face    688 

Goldring,  Douglas.    Reputations   690 

Gregory,  Lady.    Visions  and  Beliefs  in 

the  West  of  Ireland   169 

Gruner,  O.  C.    The  Exact  Diagnosis  of 

Latent  Cancer   601 

Harris,  Wilfred.    Electrical  Treatment.  956 

Hartley,  C.  Gasquoine.    Women's  Wild 

Oats    38 


BOOK  REVIEWS:  Page. 

Henry,  Augustine.    Forests.  Woods  and 

Trees  in  Relation  to  Hygiene   512 

Henry,     O.     Memorial     Award  Prize 

Stories    232 

Hess,  Julius  H.  Principles  and  Prac- 
tice of  Infant  Feeding   1000 

Hewlett,  Maurice.    The  Light  Heart..  867 

Hitschmann,  Von  Dr.  Eduard.  Gott- 
fried Keller.  Psychoanalyze  des 
Dichters  Seiner  Gestalten  und 
Motive    468 

Hofmannsthal,  Hugo  von.    The  Death 

of   Titian   73 

Holmes,  George  W.  Rontgen  Inter- 
pretation   866 

Hudson,  W.  H.    The  Purple  Land   106 

Hunter,  William.  Typhus  and  Relapsing 

Fevers  in  Serbia   1002 

Ibanez,  V.  B.    Woman  Triumphant...  105 

Ivey,'  Burnett    Steele.    The    World  at 

Seven    295 

Jack,  William  R.    Wheeler's  Hanabook 

of  Medicine    73 

Jensen,  Albrecht.  Massage  and  Exer- 
cises Combined   1042 

Jones,  Ernest.  Treatment  of  the  Neu- 
roses   468 

Jones,      Livingston      French.  Indian 

Vengeance    295 

Kelly,   Howard   A.    American  Aledical 

Biographies    779 

Kenealy,  Arabella.    Feminism  and  Sex 

Extinction    469 

Ker,      Claude      Buchanan.  Infectious 

Diseases    5 13 

Key,     Wilhelmine     E.     Heredity  and 

Social  Fitness   230 

Knox,  Robert.  Radiography  in  Exami- 
nation of  Liver,  Gallbladder,  and 
Bile  Ducts   866 

La  Motte,  Ellen  N.    Civilization,  Tales 

of  the  Orient   266 

Lawrence,  David  H.    Touch  and  Go...  557 

Lay,     Wilfred.       Man's  Unconscious 

Passion    733 

Lindsay,  Vachel.    The  Golden  Whales 

of  California   199 

Locke,    William    J.     The    House  of 

Baltazar    74 

Longstreth,  T.  Morris.     Mac  of  Placid.  780 

Low,  Barbara.  An  Outline  of  Psycho- 
analysis   378 

Lowie,  Robert  H.    Primitive  Society..  137 

Lust,  F.    Diagnostik  und  Therapie  der 

Kinderkrankheiten    1000 

McVail,  John   C.     Half  a  Century  of 

Smallpox  and  Vaccination   72 

Macleod,  J.  J.  R.  Physiology  and  Bio- 
chemistry in  Modern  Medicine....  866 

Marks,  Henry  K.     Peter  Middleton .  . . .  104 

Marx,   Magdeleine.     Woman   379 

Maublanc,  Dr.,  and  Ratie,  Dr.  Guide 
pratique  pour  I'examen  medical  des 
aviateurs,  des  candidats  a  I'aviation, 
et  det  pilotes    37 

Merrick,    Leonard.    When    Love  Flies 

Out  o'  the  Window   230 

The  Wordlings   2 JO 

Merwin,  Samuel.    Hills  of  Han   265 

Menzies,  K.  Autoerotic  Phenomena  in 
Adolescence.  An  Analytical  Study 
of  the  Physiology  and  Psychopath- 
ology  of  Onanism   334 

Miles.  Eustace.    Self  Health  as  a  Habit  602 

Monkhouse.  Allan.    True  Love   1003 

Morelli.  Professor  Eugenio.  Treatment 

of  Wounds  of  Lung  Aid  Pleura.  .  .  .  732 

Morse,  John  Lovett.  Diseases  of  Chil- 
dren   1000 

Diseases    of    Nutrition    and  Infant 

Feeding    1000 

Murray,  Gilbert.    Our  Great  War  and 

the  War  of  the  Ancient  Greeks...  826 

Muscio.  Bernard.  Lectures  on  Indus- 
trial   Psychology   335 

Nietzsche,  F.  W.    The  Antichrist   231 

O'Brien,  Frederick.    White  Shadows  in 

the  South  Seas   170 

Oldfield.    Carlton.     Herman's  Difficult 

Labor    733 

Orrin,  H.  C.    X  Ray  Atlas  of  Systemic 

Arteries  of  Body   601 

Oxford   Medicine   824 

Paddock,  Charles  E.     Maternitas   779 

Park,  William  Hallock,  and  Williams, 
Anna  Wessels.  Pathogenic  Micro- 
organisms   36 

Paterson,  Marcus.  Shibboleths  of  Tu- 
berculosis   600 

Pearl,  Bertha.  Sarah  and  Her  Daugh- 
ter   335 

Proceedings  of  British  Medical  Asso- 
ciation   138 

Problems  of  population  and  parenthood.  644 

Punnett.  Reginald  Grundall.    Mendelism  72 

Ratie,  Dr.,  and  Maublanc,  Dr.  Guide 
pratique  pour  I'examen  medical  des 
aviateurs,  des  candidates  a  I'avia- 
tion, et  des  pilotes   37 


INDEX  TO  VOLUME  CXI  I. 


1055 


Page 


Cancer,    control  ot. 


Page. 
.  565 


73- 
53; 

3! 

10; 
104. 

95i 
19: 

37' 


cure.  Toronto  ,   553 

diagnosis    of   601 

esophageal,  radium  in   568 

of  cervix,  operation  or  radium  for   650 

of  esophagus,  clinical  signs  of   328 

of  middle  ear   69 

radium  puncture,  in  treatment  of   647 

research,  present  position  of  432,  476 

tissue  resistance  to     830 

uterine,   inoperable,  copper  sulphate  in 

local  treatment  of   736 

Cancerous  liver,  sulphur  metabolism  in...  785 
91!    tumors,   empirical   results  of  treatment 

of,  with  radium     737 

Carbohydrate,    availability   of,    in  certain 

68       vegetables                                         .  300 

diets  in  diabetes,  experimental  studies 

104           on  effects  of   1048 

Carbon  monoxide   intoxication,  treatment 

60        of    916 

77  Carbonated  brine  baths   83 

Carcinoma,  borderline,  of  cervix   786 

of  duodenum   76 

42.    of  middle  ear   675 

64    x  ray  treatment  of     840 

Cardiac  acceleration,  orthostatic,  of  abdo- 

37        minal   origin   300 

dyspnea,  venesection  in   -900 

7',    inhibition  and  barium  chloride....-   781 

manifestations  in  influenza   857 

J  7    murmurs,  clinical  significance  of   362 

64Cardiotherapy,  intracardiac  pressure  as  a 

g2        standard    in   781 

ggCardiovascular  reaction  to  epinephrin .  .  .  .  959 

Carotid,  ligation  of  common  _   337 

•(Carter,  C.   Edgerton.     Mental  health  of 

7g       child    1018 

gjCase  reports   742 

Cataract  extraction,  capsule  in   604 

-Cautery,  knife,  in  surgery  of  thorax   673 

Cecum,  volvulus  of   32 

jQ^Cellular  therapeutics   809 

gfjCellulitis,    arthritic,    diagnosis    and  clin- 
ical  forms   of   375 

treatment  of   375 

^Cerebellar  localizations,  a  contribution  to 

the  study  of   342 

Cerebral  cortex,  deep  localization  in   605 

toxemia,  severe,  after  intravenous  nov- 

■            arsenobillon    472 

T^erebrocerebellar  ataxia,  acute   1007 

g,Cerebrospinal  fevc*,  injections  of  cerebro 


104 
.91 


91 


spinal  fluid  in   896 

fluid,  colloidal  gold  reaction  with   560 

injections  of,  in  cerebrospinal  fever.  .  896 

xanthochromia  of,  significance  of   1007 

■  608 
606 
712 


i (Cervical  cancer,  radium  treatment  of 


of 


382 
107 


of 


th 


endometritis,  neglected  form  of 

laceration   

^Cervix,    borderline    carcinoma    of,  treat- 

'       ment   of   786 

cancer  of,  radium  or  operation  for   650 

uteri,  amputation  of   710 

^        diseases  of   706 

" thalazion-internal  stye   238 

Chancroid,    cure   of,    with    the   high  fre- 

quency  current   428 

treatment  of,  with -salts  of  rare  earth 

5'          metals    518 

^Chekov,     Anton     Pavlovitch  —  physician 

author    951 

3  Chemical     disinfection     of  tuberculosis 

5'       sputum    740 

^Chemotherapy  of  chronic  tuberculosis....  647 

°Chest.  condition  of,  in  influenza   215 

6    gunshot  injuries  of   614 

3  measurements   

£    surgery  of  

"Chickenpox    and    some    cases    of  herpes 

^       zoster,  common  origin  of   739 

63hild.  circumcised,  ulcerated  meatus  in...  1049 

health  work  in  the  Solvay  schools   248 

9   malnourished,  in  public  school   1031 

6  mental  health  of   1018 

modern  American,  cauee  and  prevention 

4  of  overstimulation  of   914 

6  physiology,  antenatal  and  postnatal   334 

postmature,  treatment  of   140 

Nvea.k  foot  in  988,  1026 

4'hildhood  delinquency,  medical  and  social 

7  problems  of   964 

5  malignant  tumors  in   1046 

7  period  for  mental  hygiene   1046 

'^Children,  acute  encephalitis  in   739 

and  infants,  congenital  syphilis  in   1049 

pneumonia  in,  during  recent  epidemics  1050 

■'  bacillary  dysentery,  in   1046 

5  cicatricial  laryngeal  stenosis  in   781 

^  defective  development  of,  unappreciated 

.         agencies  in   1016 

"  diflferential  diagnosis  of  diseases  of  hip 

joint    in   1046 

^  disease  of  middle  ear  in   1024 

'  diseases  of,  lumjiar  puncture  in   1021 

'    idema  in,  due  to  fat  starvation   977 

'  empyema  in   987 

,   ocal  infections  in   1052 

•   lyperchlorhydria   in   76 


Page. 

Children,  latent  sinusitis  in    1036 

malnutrition  in,  class  method  of  treating  973 

physical  signs  of  pneumonia  in   1032 

pleural  disease  in   124 

urine  of,  suffering  from  nutritional  dis- 
orders, nature  of  reduc.ng  sub- 
stance in   1008 

Chloral,  action  of,  on  pupil   740 

Chloride,  barium,  and  cardiac  inhibition..  781 

Chlorine    antiseptic  '.  472 

Chloroform,  late  deaths  from,  in  liver  dis- 
ease, especially  cirrhosis  of  the  liver.  339 
modification  of  action  of  adrenalin  by..  1047 

Chlorosis,  action  of  iron  in   1005 

Cholecystectomy,  indications  for   236 

Cholecystitis,  diagnosis  of  23,  56,  236 

treatment  of  23,  56 

Choledochitis,    diagnosis    and  treatment 

of   23,  56 

Cholelithiasis,     diagnosis     and  treatment 

of   23,  56 

Cholesterin  content  of  feces   33 

Cholesterinemia  in  liver  diseases   34 

Cholesterol   thorax   811 

Chorea,  chronic  nondegenerative  heredi- 
tary   917 

Christian  science  and  sex       851 

Chromic  acid  in  suppurative  dacryocystitis  827 

Chronic  fatigue,  treatment  of   428 

nephritis,    nonprotein    nitrogen    of  the 

blood  in   692 

phenolsulphonephthalein  test  in   692 

Cicatricial  laryngeal  stenosis  in  children..  781 

Circulation,  action  of  gum  acacia  on.....  692 

Circumcised  child,  ulcerated  meatus  in...  1049 
Cirrhosis  of   the   liver,   late  deaths  from 

chloroform   in   339 

Clemenceau,    Georges    B.    E.,  physician 

author    463 

demons.  E.  Jay.    Hemorroidectomy   613 

Clinic,  too  popular  treatment.   953 

Clinical  form  of  arthritic  cellulitis   375 

notes   from   First   Surgical   Division  of 

Fordham    802 

significance  of  cardiac  murmurs   362 

Clinics,    pay   318 

public  school,  in  connection  with  State 

School  for  Feebleminded   1035 

Coccygeal   neuralgia   925 

Coccygodynia    171 

Coles,  Dr.  Abraham,  physician  author...  819 

Colitis,  bacteriology  of   1005 

Colloidal  arsenic  and  silver  in  influenza.  .  .  648 

gold  reaction  with  cerebrospinal  fluid...  560 

Colloids  in  general  practice   133 

use  of,  in  health  and  disease   379 

Colon    bacillus   522 

in  kidney  infections   652 

role  of,  in  infections  of  kidney   694 

diseases  of   94 

nonrotation  of   44 

Compensatory  movements  in  reference  to 

peripheral  nerve  injuries   383 

Complications  of  bacillary  dysentery   1046 

Concentration,     nonprotein     nitrogen,  of 

blood,  in  chronic  nephritis   692 

Congenital  absence  of  uterus  and  vagina.  383 

of  vagina  with  other  abnormalities...  742 

megacolon    1030 

syphilis  in   infants  and  children,  treat- 

yient   of   1059 

Conjunctivitis    242 

catarrhal    238 

phlyctenular    245 

Constipation  and  effect  of  purgatives  on 

heart  and  vessels   48 

dietary  treatment  of   53 

Control,    neural   628 

Convulsions    284 

Convulsive  disturbances  cured  by  surgical 

operations    691 

states  and  parathyroid   877 

Cooper,   Navroji  A.     Case  of  erysipelas 

with  complete  loss  of  vision   817 

Injections     of     cerebrospinal     fluid  in 

■        cerebrospinal  fever   896 

Copper  sulphate  in  local  treatment  of  in- 
operable uterine   cancer    736 

solution,  ammoniacal,  intravenous  in- 
jection of,  in  puerperal  sepsis.  ...  915 

Cord,  spermatic,  torsion  of   596 

Corn   gluten   meal,   commercial,  nutritive 

value  of   124 

Cornea,  foreign  bodies  on   239 

Cornwall,  Leon  H..  and  Crawford.  James 
P.  An  epidemic  of  typhoid  fever  of 
water  borne  origin  and  carrier  trans- 
mission  145,  189 

CORRESPONDENCE : 

London  letter  67.  98,  131,  163,  225, 

328,   372,  416,  460,   593,  635 

Paris   letter   30 

Cott,  George  F.    Protein  fever   325 

Cotter,  Lawrence  H.  and  Young,  John  J. 
Tricuspid  stenosis  and  tricuspid  insuf- 
ficiency   798 


Page. 

Coughlin,  William  T.    Acute  infections  of 

hand  and  their  surgical  treatment....  665 
Crampton,  C.  Ward.     Underlying  factors 

in  good  posture  812,  852 

Cranial  surgery,  bone  flap  in   871 

Crawford,  James  P.,  and  Cornwall,  Leon 
H.  An  epidemic  of  typhoid  fever 
of    water    borne    origin    and  carrier 

transmission   145,  189 

Cruchet,  Rene.    Bordelaise  conception  of 

encephalitis    lethargica   173 

Cimiming,    Hugh    S.      National  health 

problems    609 

Cummings,  W.  Clovis.  Repair  of  inju- 
ries to  pelvis  floor   718 

Cumston,  Charles  Greene.  Cardiac  mani- 
festations in  influenza   857 

Encephalitis   lethargica   in    France  and 

Switzerland    185 

Intestinal  symptoms  in  malaria   632 

Intravenous  medication    369 

Treatment  of  puerperal  infection   760 

Wassermann  reaction   547 

Cupping,  therapeutic  value  of   584 

Curara,  action  of,  on  output  of  epine- 
phrine from  adrenals   172 

Cutaneous    anthrax   931 

Cyclic  vomiting,  bodily  mechanics  in  rela- 
tion to   1008 

Cyst,  abdominal,  unusual   743 

large,  of  epididymis   605 

Cystitis    545 

Cystocele    712 

Cystoma,  epidermoid  papillary   604 

Cysts,  dermoid,  of  ovary,  etiology,  diag- 
nosis and  treatment  of   742 

lutein,  accompanying  hydatiform  mole.  .  651 

retrovesical  hydatid,  diagnosis  of   331 

ACRYOCYSTITIS,  suppurative,  chro- 
mic acid  in   827 

Dakin's   solution    in   chronic  suppurating 

otitis    234 

Darnall,  William  Edgar.  Syphilis  as  cause 
of  delayed  healing  in  noninfected  ab- 
dominal inoison   539 

Darwin,  Dr.  Erasmus — physician  author..  773 
Davis,  Edward  P.     Complete  forceps  op- 
eration   756 

Death,  fetal,  significance  of  syphilis  in...  516 
Deaths,  late,  from  chloroform  in  liver  dis- 
ease, especially  cirrhosis  of  the  liver.  .  339 
Deformities,     industrial     and  traumatic. 

treatment  of   960 

spinal,  with  pituitary  syndrome   649 

Degeneraton,  stigmata  of,  among  feeble- 
minded  .  80 

Delinquency,  childhood,  medical  and  social 

problems  of   964 

Delivery,  value  of  abdominal  exercises  be- 
fore and  after   722 

Dementia  praecox,  effect  upon  blood  press- 
ure of  adrenalin  injections  in   691 

Dental  infection     .  353 

Dentists,  need  for  more,  in  Great  Britain.  417 
Dentures,  artificial,  intermittent  hydrops  of 

parotid  due  to   960 

Dermoid  cysts  of  ovary,  etiology,  diagnosis 

and  treatment  of   742 

Development,  defective,  of  children   1016 

Diabetes,  carbohydrate  diets  in,  experi- 
mental studies  on  effects  in   1048 

due  to  syphilitic  disease  of  pancreas.  .  .  .  561 
experimental,  pancreas  emulsions  in....  234 

in  wartime   1005 

mellitus,  diets  for  ambulant  treatment  of  427 
modern  individualized  dietary  treatment 

in    427 

Diabetic  patients,  preoperative  treatment 

of   871 

Diagnosis,  clinical,  of  diphtheria   872 

of  typhus  fever   872 

differential,  between  pelvic  disorders  of 

women  and  abdominal  viscera   752 

of  diseases  of  hip  joint  in  children...  1046 

early,  in  tuberculosis   361 

of  hyperthyroidism,  blood  sugar  toler- 
ance as  an  index  in   827 

of  pregnancy   766 

etiology  and  treatment  of  dermoid  cysts 

of  ovary   .•  -.  • 

group,    evolution    of    modern  medicine 

leading   to   312 

gynecological,  errors  in   606 

of  arthritic  cellulitis   375 

of  chronic   conditions   by   spinal  reflex 

system   621 

of  hemorrhagic  diseases   693 

of  hydrocephalus   915 

of  inflammations  of  male  urethra   521 

of  luetic  involvement  of  the  optic  path- 
ways   517 

of  nervous  disorders  of  stomach  and  in- 
testines   429 

of  peripheral  nerve  injuries   383 

of  pregnancy    767 

of  pulmonary  tuberculosis   869 

importance  of  accuracy,  in   874 


1056  INDEX  TO  VOLUME  CXI  I. 


Page. 

Diagnosis,  or  retrovesical  hydatid  cysts..  331 

of  unusual  cases   77 

physical,  versus  x  ray  in  disease  of  lungs  841 
practical  clinical  laboratory,  in  gastroin- 
testinal disease    695 

urological,  in  practice  of  general  surgeon  651 
Diagnostic  charts  in  gastrointestinal  con- 
ditions   123 

signs  in  tracheobronchial  adenopathy...  1047 
Diamond,  Joseph  S.  Peptic  ulcer.. 60,  88,  116 
Diarrhea,  hemorrhagic,  epidemic  of,  due  to 

streptococcus  mucosus   1008 

Diet  for  ambulant  treatment  of  diabetes 

mellitus    427 

in  constipation   51,  55 

in  diseases  of  pelvic  bowel   76 

vi'eight,  and  efficiency   27 

Dietary  treatment,  modern  individualized, 

in  diabetes    427 

Dietetic  deficiency  and  endocrine  activity  431 
Diets,   carbohydrate,    in   diabetes,  experi- 
mental studies  on  eflEects  of   1048 

Digestive    disturbances,    chronic,    in  gas 

poisoning    43 

Digitalis,   administration    of   150 

effect  of  high  temperature  upon  the  ac- 
tion and  toxicity  of   782 

Dilatation  of  lateral  ventricles  as  a  com- 
mon brain  lesion  in  epilepsy   913 

Diphtheria,    active   immunization  against, 

by  Schick  test   279 

antitoxin  administration  in   871 

clinical  diagnosis  of   872 

mode  of  administration  of  antitoxin  in.  783 

prophylaxis   139 

toxins    994 

treatment  of    960 

Dirt,  industrial    819 

Disc,  unilateral  choked,  of  eye   157 

Disease,   chronic,  diagnosis  of,  by  spinal 

reflex  system    621 

definition  of   572 

gastrointestinal,  clinical  laboratory  diag- 
nosis in   695 

Hirschsprung's    1030 

incipient  mental,  periodical  examinations 

in    775 

liver,  late  deaths  from  chloroform  in.  .  .  339 

nervous,  early  symptoms  of   227 

of  lungs,  physical  diagnosis  versus  x  ray 

in    841 

of  middle  ear  in  children  ,  1024 

purgatives  in   52 

venereal,  problem    500 

society  for  prevention  of   417 

Diseases,  endocrine,  symposium  on   694 

gastric,  diagnosis  of   18 

hemorrhagic,  diagnosis  and  treatment  of  693 

infectious    513 

prophylaxis    against,    in  Macedonian 

campaign    603 

of  lymphatic,  x  ray  treatment   840 

of  cervi.x  uteri   706 

of  children,  lumbar  puncture  in   1021 

of  gallbladder,  malignancy  in   381 

of  hip  joint  in  children,  differential  diag- 
nosis of   1046 

respiratory,  prevention  of,  in  early  child- 
hood   382 

right  upper  quadrant   93 

skin,  standardized  Rontgen  ray  in  treat- 
ment of   837 

Disinfection,     chemical,     of  tuberculosis 

sputum    740 

Dislocation,  congenital,  of  hip   647 

Dispensary,  needs  for  an  efficient   319 

records  of  public  health  committee.  New 

York  Academy  of  Medicine   586 

Displacement  of  uterus,  treatment  of   702 

Disturbances  of  heart  and  liver  caused  by 

low  grades  of  astigmatism   447 

Diverticulitis    43 

Doctor,  seaport    134 

Donnelly,  William  Henry.    Class  method 

of  treating  malnutrition  in  children.  .  .  973 

History  of  acidosis   246 

Doyle,  Dr.  Conan — physician  author   226 

Dressings,    dry,    wet    and    ointment,  for 

wounds    1048 

Drug  addiction,  biochemistry  of   585 

treatment  of    220 

habitues,  new  method  for  detecting....  222 
Drugs,  mechanism  of  fever  reduction  by..  740 
Drummond,     William    Henry  —  physician 

author    684 

Duncan,   Louis   C.     Medical  men   in  the 

American  Revolution ...  345,  410,  455,  501 
Dunnington,    John    H.     Some  practical 

considerations  of  squint   452 

Duodenum,   carcinoma   of   76 

congenital  anomaly  of   44 

diseases  of    93 

ulcer  of,  operative  results  in   84 

perforated,  symptomatology  of   235 

Dysentery,  bacillary,  complications  of.  .  .  .  1046 

in  children    1046 

severe,  surgery  in   40 

surgical  aspect  of   771 

Dyspepsia,  insomnia  due  to   165 

Dysphagia  in  tuberculous  laryngitides.  .  . .  101 


Page. 

Dyspituitarism,  socalled    1051 

Dystonia  musculorum,  familial,  of  Oppen- 

heim    920 

Dystrophies     resulting     from  hereditary 

syphilis    516 

rAR,  middle,  cancer  of   69 

'—'    carcinoma  of    675 

disease  in  children   1024 

plastic  surgery  of   828 

Eclampsia,  Caesarean  section  for   718 

Ecphylaxis    406 

Ectopic  gestation,  icterus  in   738 

Eczema,  treatment  of,  by  x  ray   838 

Edema    286 

in  children  due  to  fat  starvation   977 

EDITORIALS: 

Adenoiditis,  acute,  in  children   638 

Arbuthnot,  Dr.  John,  physician  author.  551 
Arsenical  products,  ocular  acidents  at- 
tributed to    506 

Association,  free,  and  its  right  to  use.  .  862 

Asylums,  lunatic,  inmates  of   420 

Bilious  hemoglobinuric  fever   100 

Blind,  needlessly    465 

Blood  transfusion  in  obstetrical  practice  951 

British  National  Insurance  Act   508 

Burial,  premature    685 

Calculators,  prodigious  mental   291 

Canada's  work  for  disabled  soldiers.  ...  166 

Cancer  cure,  Toronto   553 

of  middle  ear   69 

Causation  of  rickets  

Cellulitis,  arthritic,  diagnosis  and  clinical 

forms  of    375 

Chekov,    Anton    Pavlovitch,  physician 

author    951 

Children,  latent  sinusitis  in   1036 

Cholesterin  content  of  feces   33 

Cholesterinemia  in  liver  diseases   34 

Clemenceau,   Georges   B.   E.,  physician 

author    463 

Clinic,  too  popular  treatment   953 

Coles,  Dr.  Abraham,  physician  author.  .  819 

Colloids  in  general  practice   133 

Cord,  spermatic,  torsion  of   596 

Correction    953 

Cow,  nervous   .•  •  ■  • 

Cysts,  retrovesical  hydatid,  diagnosis  of  331 

Darwin,  Dr.  Erasmus,  physician  author  773 

Diagnosis  of  arthritic  cellulitis   375 

of  retrovesical  hydatid  cysts   331 

Diphtheria  toxins    994 

Dirt,  industrial   819 

Disease,  incipient  mental,  periodical  ex- 
aminations in    775 

Doctor,  seaport                                       .  134 

Drummond,  William  Henry,  physician 

author   

Editorial  announcement    196 

Electrotherapeutics  in  treatment  of  para- 
lysis   683 

Emotions,  estimating    860 

Epidermophytia,  inguinal    228 

Era,  new,  in  gynecology   726 

Erysipelas  in  elderly  subjects   464 

Eyebrow    863 

Eyes  of  workers   685 

Family  trees    102 

Fatigue,   industrial    421 

Fertility,  middle  class   906 

Fever,  scarlet,  mystery  of   550 

Fibromyomata,  intraligamentous  uterine  772 

Food,  dried  milk  as   1036 

Free  association  and  its  right  to  use...  862 

Future  of  hospitals   418 

Gas  gangrene,  French  research  on   638 

Generosity,  refined    509 

Goldsmith,  Dr.  Oliver,  physician  author  727 

Gorgas,  General  W.  C   68 

Gynecology,  new  era  in   726 

Hall  of  Fame,  physician  in   775 

Health  and  wealth   421 

hours  of  work  in  relation  to   195 

Heart,  disorderly  action  of   994 

Holland,  Josiah  Gilbert,  physician-author  595 

Hospitals,  future  of  418,  772 

Hygiene,  new    818 

Hypnotism   and  psychotherapy   in  six- 
teenth century   904 

India,   expectant    421 

Industrial  dirt    819 

medicine,  progress  of   860 

Insomnia  due  to  dyspeptic  states   165 

Insurance  Act,  British  National   508 

Intestinal  vertigo    331 

Intraligamentous    uterine    fibromyomata  772 

Journal,  new   332,  774 

Labor,  luxury,  and  the  surgeon   134 

Ladders,  accidents  from   597 

Latent  sinusitis  in  children   1036 

Leprosy,  some  conclusions  as  to   292 

Light,  steady,  for  workers   863 

Living  beyond  our  means   952 

Locke,  John,  physician  author   507 

Lunatic  asylums,  care  of  inmates  of.  .  .  420 

McCrae,  Dr.  John,  physician  author...  419 

McGill  University    820 


EDITORIALS; 

Mandeville,  Dr.  B.  de,  physician  ai^odj^^ 

Medical  lunch   

attention,  proper   

Medicine,  industrial,  progress  of. 

Memory,  free  use  of  

Menace  of  typhus  in  Europe  

Men  of  science  in  Russia  

Mental    calculators,  prodigious..., 
disease,      incipient,  periodical 

aminations  in   

starvation   

Middle  class  fertility  

Milk,  dangers  of  infection  from.  . 

dried,  as  food  

Mitchell,    Dr.    Silas    Weir,  phy; 

author   

Music  with  work  

Neighbors,  cleanliness  of  our  

Nervous  disease,  early  symptoms 

Nutrition,   vitamines  in  < 

Obstetrical  journal,  new  

practice,  blood  transfusion  in.. 
Ocular  accidents  attributed  to  ars^jcal 

products   

Oculists  and  peoples  

Ontario  medical  association  

temperance  law   

Orangeade   

Osier  memorial  number  

Paradox   

Paralysis,   electrotherapeutics  in 

ment  of   

facial,  and  tabes  

Penal  regulation,  true  basis  for. 

Philosopher  and  poet  

Physician  authors :   

Arbuthnot,  John   

Chekov,  Anton  Pavlovitch  


Clemenceau,  Georges  Benjamin  E  eK  46 


S9? 
860 
IB 
;  JSC 

391 

■  I/S 
,  »21 
,  fit 

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mi 

I 

,  Sil 
,  H! 

.  13; 
.  22; 

.  J7i 
.  J?l 
.  !5: 

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(8. 
101 
68 
55 
iO 
99 

68 

26 
26 
99 
19 

.  55 
95 


.  72 
.  )9 
,  33 
.  iO 
.  41 
.103 
.  86 
.  19 
.  26 
.  99 
.  29 
.  90 
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63 
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.  81 
64 


Coles,  Abraham 

Darwin,  Erasmus   

Doyle,  Conan   

Drummond,   William  Henry  

Goldsmith,  Oliver   

Holland,  Josiah  Gilbert  

Holmes,    Oliver  Wendell  

Locke,  John   

McCrae,  Dr.  John  

Mandeville,   Dr.   Bernard  de... 

Mitchell,  Dr.  Silas  Weir  

Rabelais,  Francois   

Ramsay,  Dr.  David....?  

Schiller.  Johann  C.  F.  von.... 

Schnitzler,  Dr.  Arthur  

Vaughan,  Henry   

Wight,  Orlando  Williams  

Young,  Francis  Brett  

Physician  in  Hall  of  Fame  

Physiopathology  of  tendon  reflex 
Pigmentation,  custaneous,  etiolog:|)f. 
Placentas,    large,    and   syphilis.  . 
Pneumonic  residues  in  children.. 

Poet  and  philosopher  

Problem  of  lunatic  asylums  

Progress  of  industrial  medicine.. 
Prohition  in  Ontario  a  huge  joke 

Proper  medical  attention  

Psychiatry,  progress  in  

Psychology  and  commerce  

and  internationalism   

therapeutic  importance  of  

Psychotherapy    and    hypnotism  i 

teenth  century   

Publisher's  announcement   

Rabelais,  Francois,  physician  aut  r, 
Ramsay,  David,  physician  author 
Reflexes,   tendon,  physiopatholog 
Retrovesical  hydatid  cysts,  diagn 
Rickets,  causation  of.  .  .  . 
Russia,  men  of  science  in 
Sanitation,  good  work  in  relatior|) 
Scarlet  fever  mystery 
Schiller,   Johann  C.   F.   von,  ph 
author 

Schnitzler,  Arthur,  t)hysician  autji 
Science  and  spirits  

imagination   in  relation  to 

men  of,  in  Russia  

Selfcertified   

Simulation  and  the  camera.  . 
Sinusitis,   latent,   in  children 

Skin,  pigmentation  of  

Sleeping  sickness  

Sorrows  of  travel  

Spirits  and  science  

discarnate   

Spirochetosis,  icterogenic  . . . 

Starvation,  ment^il   

Sterility  in  female  from  gonorrl)  j,.  "j 

fcction   

Stimulant,  overwork  a  

Subnormal  citizens   

Suprarenin,  general  effects  of. 

Surgeon,  mind  of  a  

Syphilis  and  large  placentas... 

hereditary   transmission  of.. 
Tabes  and  facial  paralysis.... 
Tendon  reflexes,  physiopatholog)^, 
Tetanus,  treatment  of 


19 
26 
of.  8] 
si  33 
99 
103 
7 
SS 

99 
29 
4( 
1( 

10; 
7; 
7; 
!), 

i( 

S! 
H 


INDEX  TO  VOLUME  CXI  I. 


1057 


Page. 


EDITORIALS: 

[Q39    Torsion  of  spermatic  cord   596 

gg:    Toxins,  diphtheria    994 

99;    Transfusion,  blood,  in  obstetrical  prac- 

86(    951 

72C    Travel,  sorrows  of   953 

95(    Tuberculous  laryngitides,  dysphagia  in.  101 

103!    Typhus  in  Europe,  menace  of   950 

29]    Uterine  fibromyomata,  intraligamentous  772 

Vacations,  need  for   164 

77     Vaughan,  Henry,  physician  author....  906 

g2     Venereal   prophylaxis   682,  995 

90i    Vertigo,  intestinal    331 

72;    Vitamines   in   the  nutrition   375 

103'    Voh-ulus  of  secum   32 

Vomiting  in  nurslings,  treatment  of.  .  .  165 

g5     Wealth  and  health   421 

64     Wight,  Dr.  O.  Williams,  physician-author  374 

j3     Women  workers  in  Nova  Scotia   821 

22'    Work,  music  with   641 

37  Young,  Francis  Brett,  physician  author  639 
77  Edgar,  Thomas  W.  Sterility,  sex  stimula- 

95        tion  and  the  en3ocrines   848 

Educational,  medical,  of  women   316 

5Q  Efficiency,  military,  and  mental  and  nerv- 

gg        ous  states    382 

lOiEinhorn,  Max.    The  diagnosis  and  treat- 

6g        ment  of  gallbladder  affections   1 

55 Electric  currents,  rhythmic,   in  treatment 

50        of  abdominal  and  pelvic  relaxation.  .  441 

99 Electricity   in   medicine   956 

Electrotherapeutics  in  treatment  of  para- 

68        'ysis    683 

26  Embolism   following  gynecological  opera- 

26        tions    781 

99  Embolus  of  central  artery  of  retina   172 

jgEmetine  bismuthos  iodide,  new  vehicle  for  41 

55EmotionaI  crisis    964 

95Emotions,  estimating    860 

4gEmpirical  results  of  treatment  of  cancer- 

gl        ous  tumors  with  radium   737 

77Empyema,  acute,  surgical  treatment  of,  by 

22       valve  drainage    471 

gg    in  children    987 

72    treatment  of    337 

59    with  fluid    1034 

33EncephaIitis,  acute,  in  children   739 

50       myoclonic    914 

4  J    epidemic    201 

J03       catatonic  symptoms  in  relation  to...  204 

gg       cerebrospinal,   sugar  content   in   203 

J9       prognosis    and    treatment   of   204 

26       spinal  type  of   961 

99       unusual  case  of   963 

29    lethargica  182,  201,  202,  203,  299 

90       antitetanic  servrni  in   202 

37       Bordelaise  conception  of   173 

63       case  of,  with  postmortem  examination  973 

77       clinical  aspects  of   178 

gl       disturbances  of  the  reflexes  in   341 

g4       epidemic    1006 

90       polymorphism  of   926 

^    59       injection   of  turpentine  oil  in  treat- 

[    99          ment  of    428 

[    42       late  sequelae  of   204 

I    g5       meningeal  reaction  in   203 

I    g5       ocular  manifestations  in   340 

■     95       oculocardiac  reflex  in   204 

[    55       serpiginous  character  of   202 

'     ](       special  number  devoted  to   173 

;      symptoms  of    175 

',    4f       syphilis  in  relation  to   204 

■'.             transmissibility  of    340 

9(       treatment  of    298 

trismus  in    341 

{<      virus  of   201,  203 

\    2p°'^3°''f'*'s.  acute,  with  formation  of  two 

]     g^     aneurysms  and  rupture  of  aorta   547 

3Sndocrine  activity    43I 

91  diseases,  symposium  on   694 

[  IQ    disturbances,  treatment  of,  as  viewed  by 

\      ;          internist    428 

'     5;  influence,  mental  and  physical,  in  women  742 

n         organ,  thymus  as  an   872 

9iindocrines    g4g 

\     2'  !"  gynecology    697 

4(  in  relation  to  constipation   51 

■     ii^in  relation  to  hypertension   156 

10  endocrinology,  plea  for  systemic  research 

7     work  in    3g2 

7  endometritis,  cervical,  neglected  form  of  606 

. .  10i;°^''Sy.  vital,  experiments  in   824 

ginteroclysis,    administration   of  salvarsan 

5',          ""ectum  in  form  of   275 

]'     ginterocolitis,  treatment  of   648 

•  4interostomy    for    postoperative  intestinal 

5^     obstruction    41 

■ entomology,    conference   of    the  imperial 

g  ^  bureau  of   ■   417 

n'.     2  jtropion,   treatment   of   369 

aresis    744 

'. .     -  d'demic    hemeralopia    due    to    lack  of 

vitamines    1005 

_j     f  ,nfluenza,  in  China   234 

?  ,>f  hemorrhagic  diarrhea  due  to  strep- 

1  ,      tococcus  mucosus    1008 

5  ,ayoclonus  multiplex    917 

...  •;   typhoid   145,  lg9 

..         idemics  of  grippe,  acquired  immunity  in  381 


Page. 


Epidermophytia,   inguinal   228 

Epididymis,   cyst   of   60S 

following  torsion  of  testicle   605 

Epididymitis,  tuberculous,  treatment  of.  .  322 
Epilepsy,  comparative  study  of  phenomena 

of    885 

control  of  seizures  in   1005 

dilatation  of  lateral  ventricles  as  com- 
mon brain  lesion  in   913 

essential,  aftercare  in  arrested  cases  of.  914 

therapeutics  of    913 

mentality  in    889 

potassium  borotartrate  in   913 

treated  with  luminal   891 

Epileptic  seizures,  of  doubtful  etiology...  963 
Epileptics,  more  adequate  provision  for.  .  879 
practical   experience    in    training  treat- 
ment of   892 

Epinephrine,  action  of  curara  on  output  of  172 

cardiovascular  reaction  to   959 

Epithelioma  from  x  ray,  radium  treatment 

of    871 

X  ray  treatment  of,  with  thin  filter....  935 

Epstein  J.    Therapeutic  value  of  cupping  584 

Equipment,  proper,  for  a  rural  physician.  371 

Era,  new,  in  gynecology   726 

Erysipelas  with  complete  loss  of  vision...  817 

in  elderly  subjects   464 

Esophagus,  cancer  of,  clinical  signs  of...  328 

radium    in    568 

series  of  foreign  bodies  in   653 

ulcer  of   29 

Ether  oil  colonic  anesthesia,  in  treatment 

of  toxic  thyroid   744 

Ethyl  chloride  anesthesia  233,  339 

Evolution  of  modern  medicine  leading  to 

group  diagnosis    312 

Excretory  power  of  kidneys,  impairment 

of    966 

Exercises,  abdominal,  value  of,  before  and 

after  delivery    722 

Exophthalmus    1051 

Extension,    advantages    of,    in  diseased 

joints    871 

Extract,  luteum    742 

placental   745 

Eye  cases  handled  by  general  practitioner  237 

report  of  five  operative   241 

word    to    general    practitioner  about 

handling  of    237 

choked  disc  of,  unilateral   157 

conditions    of    interest    to    the  general 

practitioner    242 

disturbances,    gastrointestinal  disorders 

in    91 

electrical  osmosis  of   474 

examination  of,  essential  in  physical  ex- 
amination   403 

gas  mantles  in  relation  to   171 

human,  toxicity  of  mustard  gas  to   739 

infections,  milk  injections  in   234 

radium  in  treatment  of,  and  adnexa....  959 
Eyeball,  treatment  of  penetrating  injuries 

of    871 

Eyebrow   g63 

pACCLTV'  and  student    921 

•'-      Fallopian    tube,    heteroplastic  bone 

formation    in    828 

Familial  dystonia  musculorum  of  Oppen- 

heim    920 

Family   trees    102 

Fat  starvation,  cause  of  edema  in  children  977 

Fatigue,  chronic,   treatment  of   428 

industrial    421 

Favus,  X  ray  treatment  of   839 

Feces,  cholesterin  content  of   33 

Feebleminded,  public  school  clinics  for...  1035 

stigmata   of  degeneration  among   80 

Feeding  of  infant  simplified   977 

Female  organism,  role  of  ovary  in   719 

pelvic  ureters   720,  744 

sterility  in    606 

Femur,  fracture  of,  treatment  of   916 

Fertility,  middle  class   906 

Fetal  blood    735 

death,  significance  of  syphilis  in   516 

Fever,  bilious  hemoglobinuric   100 

cerebrospinal,  injections  of  cerebrospinal 

fluid  in    896 

gonococcemic  pseudomalarial    916 

hay,  diagnostic  tests  in   112 

protein   sensitization   in   108 

protein    32S 

reduction,  mechanism  of,  by  drugs   740 

scarlet,  mystery    550 

typhoid,    epidemic    of  145,  189 

intussusception    in   108 

typhus,  clinical  diagnosis  of   872 

yellow    7gS 

leptospira  icteroides  in   785 

Fibroma  of  mesentery   66 

of  ovary    788 

Fibromata,  multiple    712 

with  especial  reference  to  radium  treat- 
ment   782 

Fibromyomata,  intraligamentous  uterine..  772 

of  uterus,  x  ray  in   735 


Page. 


Fibrous  tumors  of  palm   739 

Filing  conveniences  for  physicians   620 

Fire,  artillery,  lethal  aspects  of   784 

Fissure  fracture  of  the  tibia   364 

Fistula,  arteriovenous,  efifect  of,  upon  heart 

and  bloodvessels    960 

jejimocolic,  after  gastrojejunostomy   960 

therapeutic  tracheal,  in  laryngeal  tuber- 
culosis   869 

Fistulae,  bronchial,  treatment  of   783 

Fixation,  complement,  in  influenza   382 

Flat  foot,  flexible  988,  1026 

Focal  infections  in  children   1052 

Folliculitis,  X  ray  treatment  of   839 

Followup  system  for  obstetrical  patients.  .  608 

Food,  dried  milk  as    1036 

heavy  metals  in   34 

Foods  and  races    845 

Foot,  flat,  flexible  988,  1026 

tissue  sparing  amputations  of   428 

weak,  in  child  988,  1026 

Forbes,  Henry   Hall.    Use  of  radium  in 

esophageal  cancer    568 

Forceps    operation,  complete   756 

prophylactic    564 

Fordham   university,   clinical    notes  from 

first  surgical  divison  of   802 

Fordyce,  John  A.     Faculty  and  student..  921 
Foster,  Nellis.     Reports  of  unusual  cases  77 
Fowler,    W.    Frank.    Cervical  laceration, 
cystocele,    prolapsus   uteri,   and  mul- 
tiple fibromata   •.  712 

Fox,  Howard.    Standardized  Rontgen  ray 

in  treatment  of  skin  diseases   837 

Fracture,  fissure,  of  the  tibia   364 

of  femur,  treatment  of   916 

of  neck  of  femur,  abduction  treatment  of  651 
of  ulna,  treatment  of,  with  dislocation 

of  head  of  radius   473 

of  vertebral  bodies,  delayed  symptoms  in  873 
Fractures    of    civil    life,    application  of 

methods  developed  during  the  war  *o  344 

of  long  bones   301 

Free  association  and  its  right  to  use   862 

Friedman.  Joseph,  and  Greenfield,  Samuel 

D.  Middle  ear  disease  in  children...  1024 
Friedlander    pleuropneumonia    with  fetid 

rhinitis   and  jaundice   785 

Function,  bronchial,  Rontgen  ray  studies 

of    765 

Functional  insufficiency  of  pulmonary  ori- 
fice in  association  with  mitral  stenosis  740 

menstrual  disturbances    738 

Fusion,  spinal,  operation  for   827' 

Fussell.  M.  H.    Diagnosis  and  treatment 

of  hyperthyroidism    205 

n  ALLBLADDER   aflfections,  diagnosis 

and  treatment  of   1 

diseases   of    93 

early  lesions  in   76 

fish  scale    561 

malignancy  in  diseases  of   381 

special  points  in  the  surgery  of   343 

Gallop  rhythm  and  blood  pressure   784 

Gangrene,  gas,  French  research  on   638 

of  small  intestine   744 

of  testicle    605 

Gas  gangrene,  French  research  on   638 

mustard,  toxicity  of,  to  human  eye.  .  .  .  739 
poisoning,  chronic  digestive  disturbances 

in    43 

Gastric    contents,    examining    filtrate  for 

occult  blood  in   619 

tests  to  determine  presence  of  occult 

blood  in    619 

diseases,  diagnosis  of   18 

secretions  in  neurocirculatory  asthenia.  42 

superacidity    5 

ulcer,  operative  results  in   84 

surgical  treatment  of   385 

Gastroenterological  numbers  of  New  York 

Medical  Journal    145 

Gastrointestinal      conditions,  diagnostic 

charts  in    123 

disease,     practical     clinical  laboratory 

diagnosis  in   ;   695 

diseases,  symposium  on   695 

disturbances  in  ocular  affections   91 

infections  in  relation  to  arteriosclerosis.  13 

service  in  army  hospital   43 

tract,  upper,  practical  clinical  examina- 
tion  of   696 

Gastrojejunostomy,  jejunocolic  fistula  after  960 

Gehrung  pessary    744 

Generations,  seven,  of  physicians   277 

Generative  organs  treated  by  x  ray   736 

Generosity,  refined   509 

Genital  organs,  sporotrichosis  of   559 

Genitourinary    numbers    of    New  York 

Medical  Journal                            .477,  521 

organs,  comparative  anatomy  of.  of  lower 

animals    525 

Giffin,  H.  Z.    Relationship  of  the  anemias 

to  life  insurance   358 

Gershenfield,  Louis.    Importance  of  micro- 
scopical examination  of  human  milk..  984 
Gestation,  ectopic,  icterus  in   738 


1.058 


INDEX  TO  VOLUME  CXI  I. 


Page. 


Geyser,   Albert   C.    Diagnosis   of  chronic 

conditions  by  spinal  reflex  system...  621 

Gland,  placental    745 

sex.    implantation    of   300 

Glands,  hypertrophied  mammary,  milk  in- 
jections in  the  treatment  of   297 

sex,  disturbance  of  internal  secretions  of  694 

tuberculous,  of  neck,  treatment  of   472 

Glaucoma    245 

acute    239 

Glenn,  Elizabeth.    Empyema  in  children.  987 

Glove,  rubber,  behind  the  times   741 

Glucose,   hypertonic   solution,  intravenous 
injection  of,  in  chronic  nephritis  with 

azotemia    471 

in  treatment  of  pneumonia.    869 

Glycosuria,  influence  of  calcium  upon   827 

Goitre,    exophthalmic,    nonsurgical  treat- 
ment of    556 

measurements  of,  on  the  living   303 

Goldberger,  I.  H.    New  site  for  smallpox 

vaccination   1035 

Goldblatt,  David.     Intravenous  and  intra- 
spinous   treatment    of  meningococcus 

meningitis    187 

Goldsmith,  Dr.  Oliver,  physician  author. .  727 
Goldstein,  Hyman.    Evolution  of  modern 

medicine  leading  to  group  diagnosis.  312 

Goldstein,  Hyman  I.     Nephritis  254,  283 

Goldfader,  Philip.    Results  in  treatment  of 

neurosyphilis    536 

Gonococcal  type  of  urethritis   523 

Gonococcemic  pseudomalarial  fever   916 

Gonorrhea,  clinical  status  of   491 

in  female,  sterility  due  to   132 

injections  of  milk  in  treatment  of   496 

sodium  taurocholate  in  prophylaxis  of..  517 

when  is  it  cured   492 

Goodman,  Herman.    Intensive  administra- 
tion of  arsphenamine   494 

Gordon.  Alfred.  Persistent  voluntary  mut- 
ism   433 

Polymorphism  of  epidemic  encephalitis 

lethargica    926 

Gorgas.  William  C,  death  of  68 

Gout,    hypodermic    injections    of  salicylic 

acid  in    691 

Graham,  John  Randolph.     Cutaneous  an- 
thrax   931 

Granet,  Adolph.    Eugen  Steinach's  work 

on  rejuvenation    612 

Graves,  William  P.    Endocrines  in  g>ne- 

cology    697 

■Greenberg,     David.      Lobar  pneumonia 

complicated  by  multiple  arthritis....  161 
Greenfield,    Samuel    D.,    and  Friedman, 

Joseph.  Middle  ear  disease  in  children  1024 
Greenough,  Robert  B.  Relation  of  medical 
profession  to  campaign  for  control  of 

cancer    565 

Grippe  epidemics,  recent,  acquired  immun- 
ity in    381 

Grossman.  Jacob.    Fissure  fracture  of  the 

tibia    364 

Guttman,  John.    Carcinoma  of  middle  ear  675 

Gynecology,  endocrines   in   697 

new  era  in   726 

problems  of    607 

use  of  radium  in   474 

Gynecological  diagnosis,  errors  in   606 

numbers  of  New  York  Medical  Journal 

697,  745 

operations,  embolism  following   781 

pulmonary  infarction  following   781 

venous  thrombosis  following   781 

problems  in   industrial  medicine   606 

LIALL  of  Fame,  tablet  to  physician  in.  775 
^  Hammer,  A.  Wiese.    Vomiting  from 

a  surgical  viewpoint   64 

Hammond.  L.  J.    Condition  of  the  chest 

in  influenza    215 

Hand,  acute  infections  of,  and  their  surgi- 
cal treatment    665 

Hart.  T.  Stuart.    Administration  of  digi- 
talis   150 

Hay  fever,  diagnostic  tests  in   112 

Hayes,    William   Van   V.    Gastric  super- 
acidity    5 

Hays,  Melville  A.    Proper  equipment  for 

a  rural  physician   371 

Headaches,  periodic,  of  ovarian  origin...  724 

Health,  altitude  in  relation  to   557 

and  religion    867 

and  wealth    421 

forestry  in  relation  to   512 

hours  of  work  in  relation  to   195 

mental,  of  child   1018 

of   recruits,   effects   of   occupation  and 

race  on    873 

of  school  children,  protection  of   407 

problems,  national    609 

work  in  the  Solvay  schools   248 

Heart,   acute   dilatation   of,    opium   in...  691 

conditions  following   influenza   873 

disorderly   action  of   594 

disturbances  of.  caused  by  low  grades  of 

astigmatism    447 


Page. 


Heart,  effect  of  arteriovenous  fistula  upon  960 

of  purgatives  on   48 

resuscitation  of    782 

secondary  syphilis  of   515 

weakness,  renal  manifestations  in   560 

Heat  and  infant  mortality   739 

hyperpyrexia    870 

Hecht-Weinberg-Gradwohl  modification  of 

Wassermann  test    559 

Heineberg,  Alfred.    Diseases  of  the  cervix 

uteri    706 

Heller,  Edwin  A.,  and  Steinfeld,  Edward. 
Nonleucotoxic    properties    of  benzyl 

benzoate    160 

Hematuria  in  pregnancy   742 

Hemeralopia,    epidemic,    due   to   lack  of 

vitamines    1005 

Hemiplegias,  transient,  of  doubtful  etiology  963 
Hemolysins,  production  of,  by  injection  of 

salts  of  rare  earth  metals   828 

Hemolytic  jaundice    307 

Hemoptysis,  treatment  of.  with  quinine.  .  817 

Hemorrhage,  accidental    742 

Hemorrhages  into  pelvic  cavity   607 

Hemorrhagic  diarrhea,  epidemic  of,  due  to 

streptococcus  mucosus    1008 

diseases,  diagnosis  of   693 

treatment  of    693 

Hemorrhoidectomy    613 

Hereditary  syphilis,  late   737 

study  of  incidence  of   1049 

Heredity    628 

Hernia,  amniotic    737 

inguinal,  radical   operation   for   21 

of  the  ileum  through  rent  in  mesentery  743 
operative  treatment  of,  value  of  position 

in    343 

sliding    561 

Herpes  iris   

zoster  and  chickenpox.  common  origin  of  739 
Heteroplastic  bone  formation  in  fallopian 

tube    828 

Hexamethylenamine,  arthritis  following  in- 
gestion of    560 

Hip,  congenital  dislocation  of   647 

joint,  diseases  of,  in  children,  differen- 
tial diagonosis  of    1046 

non  tuberculous,  arthrodesis  for   828 

Hirschsprung's  disease    1030 

Hirst,  Barton  Cooke.     Obstetrical  depart- 
ment of  a  modern  medical  school....  701 
Historical  notes  on  the  practice  of  medi- 
cine in  New  York  City   349 

History,  family  and  personal,  impairments 

regarding    579 

of  acidosis    246 

Holland,  Josiah  Gilbert,  physician  author  595 
Holmes.    Dr.    Oliver   \VendelI,  physician 

author    330 

Hood,   C.   T.    Hypertension   and  arterial 

fibrosis    152 

Hookworm  infection,  cure  of   959 

Hordeolum  or  stye   238 

Horovitz,    A.    S.     Biochemistry    of  drug 

addiction    585 

Hospital,  closing  of  British.   328 

prenatal  care  from  viewpoint  of   763 

service    388 

Hospitals,  future  of   418 

future  of  ■   772 

general,  tuberculosis  service  in   605 

Hubbard,  S.  Dana.    Industrial  medicine.  212 

Human  element  in  tuberculosis  work....  831 
Humerus,  motofacient  and  nonmotofacient 

cycles  in  elevation  of   963 

Hydrocephalus,  diagnosis  and  treatment  of  915 
Hydrogen    peroxide,    intravenous,    in  in- 
fluenzal pneumonia   869 

Hydrops,  intermittent,  of  parotid  due  to 

artificial  dentures    960 

Hydrotherapy    957 

in  constipation    50 

Hygiene,  dental  and  general   733 

International  Commission  on,  in  Mace- 
donia   603 

mental  childhood  the  period  for   1046 

new    818 

personal  and  community   425 

Hyman,    Albert    S.     Fatal  postarsphena- 

mine  jaundice    496 

Hyperchlorhydria  in  children   76 

Hyperpyrexia,  heat    870 

Hypertension    257 

arterial,  treatment  of   570 

in  relation  to  arterial  fibrosis   152 

venesection  in   _.  901 

Hyperthyroidism,  diagnosis  of  205,  827 

hypertension  due  to   153 

in  girl  nine  years  of  age   917 

Rontgen  treatment  of   827 

treatment  of   205 

Hypertonic    infant,    use    of    atropine  in 

treatment  of    971 

Hypertrophic  stenosis    1052 

Hypnotism  in  sixteenth  century   904 

Hysterectomy,  indications  for...   788 

severe  pelvic  infection  following     758 

Hysteria,    industrial,   national   morale  in 

relation  to    436 


IXDEX  TO  VOLUME  CXI  I. 


1059 


Interstitial  toxemia  and  benign  mammary 

43g        tumors   787 

43;  Intestinal  complications  of  measles   76 

intoxication,  acute,  treatment  of   40 

,0-     obstruction,    postoperative,  enterostomy 

l%l           for    41 

Lii     parasites  in  Filipino  children   107 

'        symptoms    in    malaria   632 

toxemia,  chronic   45 

'^•i     vertigo    331 

Cq",  Intestine,  small,  gangrene  of   744 

, n^c  Intestines,  diagnosis  of  nervous  disorders 

Yy.        of    429 

ii'.     intussusception  from  benign  tumor  of.  .  381 
Intoxication,  carbon  monoxide,  treatment 

l\[        of    916 

ggl    from  rectimi   916 

S-:,  Intracardiac  pressure  as  a  standard  in  car- 

2°^        diotherapy    781 

.^"Intracranial  complications  in  aural  suppu- 

qy'        rat. on  coupled  with  syphilis   341 

Intraligamentous  uterine  fibromyomata.  .  .  772 
07  Intramuscular,    combined    with  subcutan- 
y^c        eous.     antitoxin     administration  in 

jQjj       diphtheria    871 

Intravenous    administration    of  arsphena- 

jQQ(        mine,   reactions  following   498 

injections  of  hydrogen  pero-xide  in  in- 

jqq;           fluenzal  pneumonia   869 

ammoniacal  copper  sulphate  solution 

jQ4(              in  puerperal  sepsis   915 

12-        hypertonic  glucose  solution  in  chronic 

jQji              nephritis  with  azotemia   471 

of  mercuric  iodide  in  syphilis   471 

novarsenobillon,   severe  cerebral  tox- 

7g               emia  after   472 

35     medication    369 

JO:    treatment  of  malaria   366 

95lIntussusception  from  benign  tumor  of  in- 

29        testines    381 

in  typhoid  feser   108 

yglodide.  intravenous  mercuric,  in  syphilis.  .  471 

75lodine  absorption  from  human  skin   648 

75     fumes,  physiological  action  of   782 

in  oil,  intravenous  injection  of   691 

gglris,  herpes   693 

23lritis    245 

acute    239 

llron,  action  of,  in  chlorosis   1005 

69    dose  of   1005 

69lttelson.  M.  S.    Frequent  types  of  nasal 

64       obstruction  and  their  treatment   676 

105 

91IACOBY,  A.  Fibroma  of  the  mesentery  66 
3-*  Jaundice  and  fetid  rhinitis  with  Fried- 

34       lander  pleuropneumonia   785 

fatal  postarsphenamine   496 

21    hemolytic   307,  361 

78yejunocolic  fistula  after  gastrojejunostomy  960 
87jelliffe,  Smith  Ely.    Parathyroid  and  con- 

.    85       vulsive  states   877 

.    21  Joint,  hip,   diseases   of.   differential  diag- 

.    64       nosis  of   1046 

.    3S       nontuberculous,  arthrodesis  for   828 

.    23    knee,  arthroplasty  of   828 

.    68foints,  diseased,  advantages  of  extension  in  871 

34    tuberculous,    treatment    of   297 

J      .Fones,  E.  L.    Disturbances  of  the  heart 
8'        and  liver  caused   by   low  grades  of 

I-             astigmatism    447 

•  78fones.  Frank  A.    Clinical  significance  of 

I-             cardiac  murmurs   362 

.     86fones.  John  F.  X.    Surgery  of  prostate..  486 

78rournal.   new   332 

n         obstetrical    775 

69royce,  Thomas  F.    Treatment  of  drug  ad- 

n             diction    220 

"  AISER,  Albert  D.    Use  of  atropine  in 

•  Z^i      treatment  of  hypertonic  infant   971 

•  °^Caolin  as  substitute  for  bismuth  subnitrate  41 

,>ataphylactic  measures    406 

•  ''\earney,  J.  A.   Examination  of  eye  essen- 

,      tial  in  physical  examination   403 

•  •     *  ■Cellgren-Cyriax,  Mrs.    Treatment  of  per- 

sistent  vomiting  of  pregnancy   761 

•  •     ^'"Ceratitis    239 

,(  eczematosa    245 

■^    phlyctenular    245 

>c       -Cerley.    Charles   Gilmore.  Unappreciated 
4.      agencies  in  defective  development  of 

6  children    1016 

g-       Cidder,  Walter  H.    Mentality  in  epilepsy  889 

3.<idney,  colon  bacillus,  infections  of  '  652 

8.  diseases  of   94 

7  double,  resection  of   123 

9    function  test,  urea  output  as  practical..  483 

3    infections  of,  role  of  colon  bacillus  in..  694 

.  .     r  sarcoma  of   1052 

li_ transplantation  of   474 

ec-      Sidneys,    effect   of   therapeutic   doses  of 

6:      mercury  on   605 

7'  impairment  of  excretory  power  of,  and 

5^        an  unusual  case  of  alkalosis   966 

ur-      vnee  joint,  arthroplasty  of   828 

6   severe  sprain  of,  early  surgical  interven- 

rax               tion   in     268 

.  . .     4  strains,  chronic  '   337 

Cnife  cautery  in  surgery  of  thorax   673 


Page. 

Kohn,  L.  W'infield.    Gastrointestinal  dis- 
turbances   m    affections    of   the  ocular 

mechanism    91 

Koster.  H.    \'alue  of  abdominal  exercises 

before  and  after  delivery   722 

Kramer,   David  \V.    Venesection :   a  lost 

art    898 

Krauss,  Frederick.    A  case  of  unilateral 

choked  disc    157 

Krupp,  David  Dudley.  X  ray  as  an  essen- 
tial guide  for  producing  artificial 
pneumothorax   in   advanced   cases  of 

pulmonary    tuberculosis    670 

Kunstler,  M.  B.  Diagnosis  of  gastric  dis- 
eases   18 

Diseases  of  the  right  upper  quadrant ...  93 

LABOR,  analgesia  and  anesthesia  in...  562 

difficult    733 

induction  of  562,  563 

luxury,  and  the  surgeon   134 

prophylactic   forceps   operation    in   564 

rupture  of.  during  labor   742 

Laceration,  cervical   712 

Lane,  Harold  C.  New  method  for  detect- 
ing drug  habitues   222 

Langrock,    Edwin   G.     Caesarean  section 

for    eclampsia   718 

Langstroth.  Francis  Ward.    Severe  pelvic 

infection  following  hysterectomy   758 

Lankford,  J.  S.    Foods  and  races   845 

Lapenta,  Vincent  Anthony.    Treatment  of 

surgical  shock    296 

Laryngeal  stenosis,  cicatricial,  in  children  781 
tuberculosis,  therapeutic  tracheal  fistula 

in    869 

Laryngitides,  tubercfulous.  dysphagia  in..  101 
Laryngitis,     nondiphtheritic  pseudomem- 
branous   603 

Latent  sinusitis  in  children   1036 

Lateral  ventricles,  dilatation  of,  as  com- 
mon brain  lesion  in  epilepsy   913 

Laws,  new.  relating  to  inherited  syphilis..  299 
Lazarus,  David.     Early  diagnosis  of  preg- 
nancy   766 

Leg,  amputation  of   233 

Leiner,  Joshua  H.  Encephalitis  lethargica, 

clinical  aspects  of   178 

Leprosy,  some  conclusions  as  to   292 

Leptospira  icteroides  in  yellow  fever   785 

Lerch,  Otto.    Constipation  and  the  effect 

of  purgatives  on  heart  and  vessels ...  48 

Lesion,  brain,  common,  in  epilepsy   913 

Lesions,  common  puerperal,  pathology  of.  829 

in  midbrain   1050 

skin,  in  measles   949 

Lethal  aspects  of  artillery  fire   784 

Lethargic  encephalitis,  case  of   973 

disturbances  of  reflexes  in   341 

epidemic   <   1006 

ocular  manifestations  in   340 

polymorphism  of   926 

transmissibility   of   340 

trismus  in  ■.   341 

LETTERS  TO  THE  EDITORS: 

Carpi.  Prof.  U.  International  Associa- 
tion of  Pneiunothorax  Artificialis.  .  432 
Cans,  S.  Leon.  Venereal  prophylaxis.  140 
Joerg,  Oswald.  Morphine  poisoning...  44 
Kieman,  James  G.  Dr.  Benjamin  Rush.  236 
Knopf,  S.  Adolphus.  Medical  profession 

and  Hall  of  Fame   832 

Physicians  in  the  Hall  of  Fame   140 

Lydston.  G.  Frank.    Sex  gland  implan- 
tation   300 

Satterthwaite.  Thomas  E.  Venereal  dis- 
ease peril    172 

Leucemia   307,  360 

blood   changes    following    Rontgen  ray 

treatment  of    828 

splenic,  associated  with  pregnancy   787 

Leucoplasia  of  bladder  and  ureter   738 

Leucocytes,  in  study  of  blood  after  splen- 
ectomy   873 

Leucorrhea,  pathological,  treatment  of...  744 
Levin,    Oscar   L.    Modern   treatment  of 

syphilis   531 

Lichen  planus,  treatment  of,  by  x  ray....  839 

Life  insurance,  relationship  of  anemias  to  358 

Ligation  of  the  common  carotid   337 

Light,  steady,  for  workers   863 

Liposarcoma.  retroperitoneal    569 

Liver,  abcess  of    872 

cancerous,  sulphur  metabolism  in   785 

disease,  late  deaths  from  chloroform  in  339 

diseases    of    93 

cholesterinemia  in    34 

disturljances  of,  caused  by  low  grades  of 

astigmatism    447 

interesting  surgical  conditions  of   741 

Living  beyond  our  means   952 

Lloyd,  Ralph  I.     Stereoscopic  campimeter 

slate    944 

Lobsenz,  Moses.    Importance  of  prenatal 

care   765 

Locke,  John,  physician  author   507 

Love,  Louis  F.   Eye  conditions  of  interest 

to  the  general  practitioner   242 


Page. 

Lowenburg,  Harry.     Pleural  disease  in  in- 
fants and  children   124 

Luetic    involvement    of    optic  pathways, 

diagnosis  and  treatment  of   517 

Lumbar  puncture  in  diseases  of  children  1021 

Luminal,  epilepsy  treated  with   891 

Lunatic  asylums,  care  of  inmates  of   420 

Lung,  wounds  of   732 

Lungs,     disease    of,     physical  diagnosis 

versus  x  ray  in   841 

Lutein    cysts    accompanying  hydatiform 

mole    657 

Luteiun  extract    742 

Lyofi,     B.     B.     Vincent.  Choledochitis, 

cholecystitis  and  cholelithiasis  23,  56 

Lymph  propulsion,  control  of   406 

Lymphatic  diseases,  x  ray  treatment  of..  840 
Lynah,  Henry  Lowndes.    Series  of  foreign 

bodies  in  bronchi  and  esophagus   653 

McCRAE.  John,  phvsican  author   419 

McEvoy,  L.  Donald.    Heredity   62$ 

McGill  University    820 

McMurray,  T.  E.     Benzyl  benzoate  treat- 
ment of  whooping  cough   122 

McXair.  Robert  H.    Treatment  of  specific 

urethritis   490 

McXulty,  John  J.    Xew   therapy  in  the 

light  of  new  physiology   271 

Macedonian  campaign,  prophylaxis  against 

infectious  diseases  in   603 

Macht,  David  I.    Use  of  benzyl  benzoate 

in  circulatory  conditions   269 

Magnesium  in  blood,  determination  of...  605 

Major  trigeminal  neuralgias   740 

Malaria,  intestinal  symptoms  in   632 

intravenous  treatment  of   366 

tertian,    parasite    of   603 

Malignancy  in  diseases  of  gallbladder....  381 

Malignant  tumors  in  childhood   1046 

Malnourished  child  in  public  school   1031 

Malnutrition  in  children,  class  method  of 

treating    973 

Malposition  of  uterus   703 

Mammary  abscesses,  unopened,  aspiration 

and  pressure  treatment  of   735 

tumors,  benign,  and  interstitial  toxemia  787 

Mandeville,  Bernard  de,  physician  author.  1039 
Mania,  acute,  associated  with  plasmodimn 

vivax  infection    784 

Manifestations,  anaphylactic,  new  method 

of   preventing    693 

Marsh,  Chester  A.    Comparative  study  of 

phenomena  of  epilepsy   885 

Martin.  Sergeant  Price.  Disorders  of  func- 
tion of  urinary  bladder   544 

Mason,  Frederick  Raoul.    Bronchial  asth- 
ma in  childhood   399 

Massage  and  exercises  combined   1042 

Massey.  G.  Betton.  Rhythmic  electric  cur- 
rents in  treatment  of  abdominal  and 

pelvic  relaxation    441 

Maternal  blood    735 

welfare  work  of  American  Red  Cross 

in  Paris    607 

Measles,  intestinal  complications  of   76 

skin  lesions  in   949 

Meatus,  ulcerated,  in  circumcised  child...  1049 

Mediastinitis,  x  ray  in   842 

Medical  attention,  proper   997 

education    475 

in  Great   Britain   460 

of  women    316 

lectures  to  nurses   1043 

lunch    863 

men  in  American  Revolution ..  345.  410. 

455,  501 

practitioners,  unqualified    388 

problems  of  childhood  delinquency   964 

research  and  practice   384 

school,  modern,  obstetrical  department  of  701 

service,  report  on   387 

students,  increase  of,  in  Great  Britain . .  329 

work,  outpatient    586 

Medication,  intravenous    369 

Medicine,  American    316 

ancient  Greek    312 

Arabian    313 

Babylonian    312 

Chinese    312 

classical  period  of   312 

Hindu    312 

industrial    212 

gynecological  problem  in   606 

progress  of    860 

Japanese    312 

Jewish                                                 312,  313 

medieval    313 

modern,  evolution  of,  leading  to  group 

diagnosis    312 

philosophical    314 

practice   of,    in    Xew    York    City,  his- 
torical notes  on   349 

Roman    313 

scientific    315 

Megacolon,  congenital   1030 

Melanoma,  report  of  a  case  of....   252 

Meltzer,    Maurice.     When    is  gonorrhea 

cured  ?    492 


1060 


INDEX  TO  VOLUME  CXII. 


Page. 


Membranous  bones,  absorption  of   1051 

Memorial  of  regimental  surgeons  to  Con- 
gress   410 

Memory,  free  use  of   729 

Men  of  science  in  Russia   1038 

Menace  of  typhus  in  Europe   950 

Meningeal  symptoms,  significance  of   914 

syphilis,   influence  of  insufficient  treat- 
ment upon  appearance  of   515 

Meningitis,   anthrax    604 

lethargic    299 

meningococcus,    intravenous   and  intra- 

spinous  treatment  of   187 

Meningococcic  septicemia,  and  purpura..  1004 
Meningococcus  meningitis,  intravenous  and 

intraspinous  treatment  of   187 

Meningoencephalitis,    lethargic   299,  603 

Menorrhagia,  treatment  of,  with  radium.  736 
Menstruation,  functional  disturbances  of.  738 
Mensuration,   surgical,   standardization   of  109 
Mental  disease,  incipient,  periodical  exami- 
nations in    775 

disorders    of    old    age   604 

health  of  child   1018 

hygiene,  childhood  the  period  for   1046 

starvation    821 

states  in  relation  to  military  efficiency..  382 

Mentality  in  epilepsy   889 

Mercuric  iodide,  intravenous,  in  syphilis.  471 

Mercury,  duration  of  excretion  of   605 

effects  on  kidneys  of   605 

in  treatment  of  syphilis   474 

salicylate,    effects    of,    on  Wassermann 

reaction    518 

Mesenteric  vascular  occlusion   343 

vessels,  superior,  obstruction  of   744 

Mesentery,  fibroma  of   66 

hernia  of  ilium  through  rent  in   743 

Metabolism,  sulphur,  in  cancerous  liver.  .  785 
Metals,   salts   of    rare   earth,  therapeutic 

uses  of   518,  828 

Method,  new,  of  preventing  anaphylactic 

manifestations    693 

Potter's,  of  performing  version   742 

Metritis,  chronic,  treatment  of,  with  salts 

of  rare  earth  metals   518 

Meyer.  William  H.    Superficial  and  deep 

Rontgen   dose   estimation   936 

Mice,    primary    spontaneous    tumors  of 

ovary  in    738 

Micrococcus  catarrhalis    522 

Microscopical  examination  of  human  milk, 

importance  of    984 

Midbrain,  lesions  in   1050 

Military    efficiency,    mental    and  nervous 

states  in  relation  to   382 

Milk,  dangers  of  infection  from   728 

dried,  as  food   1036 

himian,  importance  of  microscopical  ex- 
amination   of    984 

in  treatment  of  tuberculosis   874 

injections  in  ocular  infections   234 

in  treatment  of  gonorrhea  and  vener- 
eal adenitis    496 

of  hypertrophied  mammary  glands.  297 

modifications,  calorie  as  unit  in   42 

situation    1005 

Miller,  Edwin  B.  A  word  to  general  prac- 
titioners about  handling  eye  cases.  .  .  237 

Report  of  five  operative  eye  cases   241 

Miller,  George  I.    Splenectomy,  with  re- 
port of  two  cases   304 

Mind  energy   .'   689 

Mitral  stenosis  associated  with  functional 

insufficiency  of  pulmonary  orifice.  .  .  .  740 

in  soldiers    172 

Mitchell,  Silas  Weir,  physician  author.  .  .  861 
Mole,    hydatiform,    lutein    cysts  accom- 
panying   651 

Monteith.   S.    R.     Report  of  a  case  of 

melanoma    252 

Montgomery,  E.  E.  Differential  diagnosis 
between  disorders  of  pelvic  organs  in 

women  and  of  abdominal  viscera.  .  .  .  752 
Morphine   narcosis,    combined   with  local 

anesthesia,  in  Caesarean  section   339 

poisoning    44 

Morse,  John  Lovett.    Unusual  case  of  al- 
kalosis and   impairment  of  excretory 

power  of  kidneys   966 

Mortality,  expected,  family  and  personal 

history  in  regard  to   579 

infant,  heat  in  relation  to   739 

in  Watertown,  N.  Y   1014 

variation  in  rate  of   1009 

neonatal    738 

Mucosus,  streptococcus,  epidemic  of  hem- 
orrhagic diarrhea  due  to   1008 

Miiller,   George   P.    Gunshot   injuries  of 

the  chest  in  civil  practice   614 

Multiple  fibromata    712 

Musculorum,  familial  dystonia,  of  Oppen- 

heim    920 

Musser,  John  H.    Treatment  of  arterial 

hypertension    570 

Mustard  gas,  toxicity  of,  to  human  eye.  .  739 

Mutism,  persistent  voluntary   433 

Myocarditis,  tuberculous    1047 


Pace. 


Myoclonic,  encephalitis,  acute   914 

Myoclonus  multiplex   917 

Myotonia  accusata    963 

■MASAL  obstruction,  types  of  676 

septum,  submucous  resection  of   474 

National   morale   in   relation   to  hysteria, 

military  and  industrial   436 

Nature  and  cause  of  stammering   435 

Neck,  treatment  of  tuberculous  glands  of  472 

Neighbors,  cleanliness  of    132 

Neoarsphenamine,  toxicity  of   516 

trypanocidal  activity  of   515 

Neonatal  mortality    738 

Nephrectomy,  operative  technic  of   233 

Nephritis                                                254,  283 

acute,  treatment  of   285 

chronic   286 

diffuse,  venesection  in   901 

hypertension  due  to   153 

nonprotein  nitrogen  of  blood  in   692 

phenolsulphonephthalein    test   in   692 

with   azotemia,   intravenous  injection 

of  hypertonic  glucose  solution  in  471 

influenza  as  etiological  factor  in   870 

Nerve  injuries,  peripheral   383 

splints  used  for,  at  U.  S.  Army  Gen- 
eral Hospital    474 

Nervous  and  mental  states  and  military 

efficiency    382 

disease,  early  symptoms  of   227 

disorders    546 

of  stomach  and  intestines   429 

patients  and  the  doctor   575 

states  in  relation  to  military  efficiency.  382 

system,  inflammations  of   340 

Neural  control    628 

Neuralgia,  coccygeal    925 

X  ray  treatment  of   649 

Neuralgias,  major  trigeminal   740 

Neurocirculatory    asthenia,    gastric  secre- 
tions in    42 

Neuropath  in  relation  to  doctor   575 

Neuropsychiatric    services    of    U.    S.  A. 
General   Hospital   No.   1,  analysis  of 

cases  admitted  to   961 

Neuroses,    in    relation    to    endocrines  in 

gynecology    697 

treatment  of    468 

Neurosyphilis,  results  in  treatment  of....  536 
Nicoll,    Alexander,    and    Rammol,  Harry 
M.  Clinical  notes  from  First  Surgical 

Division  of  Fordham   802 

Nitrogen,     nonprotein,     concentration  of 

blood  in  chronic  nephritis   692 

Norman,  N.  Philip.  Infections  of  the  gas- 
trointestinal tract  and  their  relation  to 

arteriosclerosis   13 

Types  of  carbonated  brine  baths   83 

Norris,    George   William.     Physical  diag- 
nosis versus  x  ray  in  disease  of  lungs  841 

Nova  Scotia,  women  workers  in   821 

Novarsenobillon,   intravenous,   severe  cer- 
ebral toxemia  after   472 

Nutrition    class,    six   months'  experience 

with   976 

clinics  and  tuberculosis   876 

value  of  vitamines  in   604 

vitamines  in   75,  375 

Nutritional  disorders  of  children   1008 

OBITUARY : 

Dyer,  Isadore,  M.D.,  of  New  Orleans  775 
Obstetrical  department  of  modern  medical 

school    701 

journal,  new    775 

patients,  foUowup  system  for   608 

practice,  blood  transfusion  in   951 

recent  advances  in   754 

Obstetrics,  role  of  rectal  examination  in..  716 
Obstruction  of  superior  mesenteric  vessels 

from  bands    744 

Occlusion,   mesenteric  vascular   343 

Occupation,   effects  of,  on  health  of  re- 
cruits   873 

Occupational  skin  diseases   1042 

Ocular   accidents   attributed    to  arsenical 

products   506 

manifestations  in  lethargic  encephalitis.  340 
Oliver,  James.    New  aspects  of  menstrua- 
tion   750 

Olives,  ripe,  bacteriological  study  of   222 

Ontario  medical  association   100 

temperance  law    685 

Operation,  complete  forceps   756 

for  inguinal  hernia,  radical   21 

for  spinal  fusion   827 

for  urethral  strictures   473 

high  forceps    473 

preparation    of    skin    for,    with  special 

reference  to  use  of  picric  acid....  829 
Operations,    gynecological,    embolism  fol- 
lowing  781 

pulmonary  infarction  following   781 

venous   thrombosis   following   781 

surgical,   convulsive  disturbances  cured 

by    691 

Operative  treatment  of  hernia,  value  of 

position  in    343 


INDEX  TO  VOLUME  CXII. 


1061 


Page. 


Physician  authors : 

244      Arbuthnot,  John    551 

Chekov,  Anton  Pavlovitch   951 

008      Clemenceau,  Georges  Benjamin  Eugene  463 

691      Coles,  Abraham    819 

Darwin,  Erasmus    773 

920      Doyle,  Conan    226 

517      Drimimond,  William  Henry   684 

553      Goldsmith,  Oliver    727 

719      Holland,  josiah  Gilbert   595 

Holmes,  Oliver  Wendell   330 

606      Locke,  John   507 

•McCrae,  John    419 

740      Mandeville,  Bernard  de   1039 

Mitchell,  Silas  Weir   861 

300      Rabelais,   Fiancois   194 

509      Ramsay,  David    260 

474      Schiller,  Johann  C.  F.  von   996 

649      Schnitzler,   Arthur    290 

Vaughan,  Henry    906 

234      Wight,  Orlando  Williams    374 

5g^      Young,  Francis  Brett   639 

724  Physician  in  Hall  of  Fame   775 

proper  equipment  for  a  rural   371 

697  Physicians,  seven  generations  of   277 

742  Physiological  action  of  iodine  fiunes   782 

78g      theories  of  Plato....   141 

738  Physiology,  new  therapy  in  the  light  of.  .  271 

719      of  ovulation   :   738 

750  Physiopathology  of  tendon  reflexes   818 

474  Physiotherapy,  plea  for   948 

Picrate  solutions,  effect  of  blood  on   1006 

914  Picric  acid,  use  of,  in  preparing  skin  for 

649         operation    829 

Pigmentation,  cutaneous,  etiology  of   640 

Pigmentosum,  xeroderma    985 

Pituitary  extract  in  labor   562 

syndrome  with  spinal  deformities   649 

4,;  Placental  extract    745 

gland    745 

Placentas,  large,  and  syphilis   906 

Plasmodium  vivax  infection,  acute  mania 

associated   with    784 

^f^.         tenue  phase  of   603 

Plastic  surgery  of  ear   828 

Plato,   anatomical   and  physiological  the- 

^°         ories  of    141 

Pleura,  disease  of,  in  infants  and  children  124 

X  ray  in   841 

5°      wounds  of    732 

Pleuropneumonia,   Friedlander,  with  fetid 

rhinitis  and  jaundice   785 

Pneuma,  theory  of,  in  Aristotle   833 

j/y  Pneumectomy.  experimental    1004 

^'  Pneumoconiosis,  therapeutic,  in  pulmonary 

°^         tuberculosis    691 

X  ray  in   842 

Pneumonia,  glucose  in  treatment  of   869 

y       in  children,  after  effects  of   597 

physical  signs  of   1032 

'  in   infants  and   children   during  recent 

^"         epidemics    1050 

,      influenzal,  intravenous  hydrogen  perox- 

!    i:           ide  in   869 

'    °'      lobar,  complicated  by  multiple  arthritis  161 

segregation  of    1006 

'            treatment  of    1004 

•  sodium  citrate  in:   1005 

^            venesection  in    899 

■  X  ray  in   841 

•  ^'  Pneumothorax,  artificial,  international  as- 

■  sociation  of   432 

•  rif.  X  ray  as  a  guide  for  producing,  in  ad- 
'    \i  vanced  cases  of  pulmonary  tuber- 

•  culosis    670 

•  'Poet  and  philosopher   996 

■  Poisoning,  gas,  digestive  disturbances  in .  43 

•  morphine    44 

•  '^Polak.  John  Osborn.    Recent  advances  in 

i.        obstetrical  practice    754 

'    'J  Polymorphism    of    epidemic  encephalitis 

•  ^'        lethargica    926 

"    44^°'^"'"'^  ,   1051 

•  V.  Popper,    Joseph.     Congenital  megacolon 

•  (Hirschsprung's  disease)    1030 

■  Portal  thrombosis,  case  of   1052 

•■     .Possession,  instinct  of   629 

•  Postarsphenamine  jaundice,   fatal   496 

•  Postmature  child,  treatment  of   140 

?J     .  -  Postmortem  examination  in  case  of  lethar- 

11    'i'      ggic  encephalitis    973 

-J  Postoperative  analgesia   903 

••     ^'Posture,  good,  underlying  factors  in.. 812,  852 

7;Potassium  borotartrate  in  epilepsy   913 

lie       Pottenger,   F.  M.    How  may  the  tuber- 

6'        culous   patient   secure  an  arrestment 

,d-       _     a"<l  avoid  becoming  an  invalid   389 

4  Potter's  method  of  performing  version...  742 
. .     3  Practice,  civil,  application  of  war  methods 

.  .     9              •  ■   473 

2     medical,  present  aspect  of   317 

••          obstetrical,  blood  transfusion  in   951 

jQ        recent  advances  in   754 

of  medicine  in  New  York  City,  histori- 

'se     ^        cal  notes  on   349 

-  Praecox  pubertas.  study  of   962 

;n-       Precipitinogen,  effects  of  serum  precipitin 

10        °°  animals  of  the  species  furnishing..  300 


Page. 


Pregnancy,  diagnosis  of   767 

early  diagnosis  of   766 

ectopic,  frequent  cause  of  hemorrhage.  607 

hematuria  in    742 

pyelitis  in,  preliminary  report  of,  with 

report  of  cases   786 

relation  of,  to  tumor  growth   738 

splenic  leucemia  associated  with   787 

syphilis  in  relation  to   162 

treatment  of  persistent  vomiting  of....  761 

Prenatal  care,  development  of,  in  Paris.  .  607 

from  viewpoint  of  hospital   763 

importance  of    765 

significance  of  syphilis  in   516 

Preoperative  treatment  of  diabetic  patients  871 
Pressure  and  aspiration  treatment  of  un- 
opened mammary  abscesses   735 

Problems,  medical  and  social,  of  childhood 

delinquency    964 

Professional  secrecy    287 

Progress  of  industrial  medicine   860 

Prohibition    in    Ontario   685 

Prolapsus  uteri    712 

in  elderly  women   706 

Prophylaxis   in   relation   to    treatment  of 

ven-real    disease   519,    682,  995 

Prostate  gland  in  arthritis,  treatment  of.  .  652 

surgery  of   486 

Prostatectomy    319 

relapses  after    516 

suprapubic   108,  338 

Protein  fever    325 

sensitization    115 

in  bronchial  asthma  and  hay  fever.  .  .  108 

Pseudocholecystitis    786 

Pseudomalarial  fever,  gonococcemic   916 

Pseudomyzoma  peritonei    108 

Psoriasis,  x  ray  treatment  of  838,  871 

Psychiatry  in  Germany   644 

progress  in    552 

Psychoanalytical  theory,  new   794 

Psychology  in  relation  to  commerce   166 

•in  relation  to  internationalism   70 

therapeutic  importance  of   462 

Psychotherapy  and  hypnotism  in  sixteenth 

century    904 

Pterygium    239 

Ptosis,  types  of   812 

Pubertas  praecox,  study  of   962 

Public  Health  Committee  of  New  York 
Academy  of  Medicine,  dispensary  rec- 
ords of    586 

Public  school,  malnourished  child  in   1031 

Puerperal  infection,  treatment  of   760 

lesions,  pathology  of  common   829 

sepsis,   intravenous  injection   of  ammo- 

niacal  copper  sulphate  solution  in..  915 
Puerperium  following   influenza,  cases  of 

thrombophlebitis    during   788 

Purpura    1004 

and   meningococcic  septicemia   1004 

Pulmonary  abscess,  x  ray  in   841 

infarction  following  gynecological  opera- 
tions   781 

orifice,  functional  insufficiency  of,  asso- 
ciated with  mitral  stenosis   740 

tuberculosis,  diagnosis  and  treatment  of  869 
relationship  of  diseased  tonsils  to....  902 
vital  capacity  constants  in  study  of..  .  873 
X  ray  as  an  essential  guide  for  pro- 
ducing artificial  pneumothorax  in  670 

Pupil,  action  of  chloral  on   740 

Puncture,  lumbar,  in  diseases  of  children.  1021 

of  superior  longitudinal  sinus   402 

Pyelitis  in  pregnancy   786 

Pyelotomy,  operative  technic  of   233 

Pylorus,  diseases  of   93 

new    299 

obstruction    of,    in    relation    to  gastric 

tetany   .'   76 


QUACKENBOS,     Maxwell.  Chronic 

peritonsillar  abscess    193 

Quadrant,  right  upper,  diseases  of   93 

Quinine  in  treatment  of  hemoptysis   817 

pABELAIS,  Dr.  Francois   194 

Rabies,  present  status  of   323 

Race,  effect  of,  on  health  of  recruits   873 

Races  and  foods   845 

Rachford,  B.  K.   Congenital  underdevelop- 
ment of  right  side  in  an  infant  three 

months   old   677 

Radiation,  regional,  study  of  relative  toxic 

effects  produced  by   871 

Radiculitis,  acute  descending   961 

Radium  in  disease    63 

in  esophageal  cancer  f   568 

in  operable  cancer  of  cervix   650 

in  treatment  of  eye  and  adnexa   959 

puncture  in  cancer   647 

treatment  of  cancerous  tumors   737 

of  cervical  cancer   608 

of   fibromata   782 

of  menorrhagia  with   736 

of  X  ray  epithelioma   871 

use  of,  in  gynecology   474 

value  of,  in  treatment  of  bladder  tumors  474 


Page. 


Radius,  dislocation  of  head  of,  in  treatment 

of  fracture  of  ulna   473 

Rales  after  expiration  and  cough  as  a 
means  to  early  diagnosis  in  tubercu- 
losis   361 

Ramirez,  Maximilian  A.  Report  of  some 
interesting  cases  of  protein  sensitiza- 
tion   115 

Rammol,  Harry  M.  and  Nicoll,  Alexander. 
Clinical  notes  from  First  Surgical  Di- 
vision of  Fordham   802 

Ramsay,  Dr.  David   260 

Ravdin,  I.  S.    Xeroderma  pigmentosum..  985 
Reactions   following   intravenous  adminis- 
tration of  arsphenamine   498 

Recruits,  effects  of  occupation  and  race  on 

health  of   873 

Rectal  administration  of  salvarsan   275 

examination,  role  of,  in  obstetrics   716 

Rectal  examination,  role  of,  in  obstetrics..  716 

surgery,  local  anesthesia  in   339 

Rectum,  intoxication  from   916 

Red  cross  societies  meeting   416 

Redfield,  Casper  L.    What  is  disease?....  572 
Reflexes,  disturbances  of,  in  lethargic  en- 
cephalitis   341 

tendon,  physiotherapy  of   818 

Regurgitation,  aortic,  venesection  in   901 

Rejuvenation,  Steinach's  work  on   612 

Relapses  after  prostatectomy   516 

Relaxation,  abdominal  and  pelvic,  rhythmic 

electric  currents  in  treatment  of   441 

Religion,  psychological  interpretation  of..  424 
Remer,  John,  and  Witherbee,  W.  D.  X 
ray  treatment  of  epithelioma  with  thin 

filter    935 

Renal  calculus,  with  negative  x  ray  find- 
ings   604 

function,  tests  of   5I8 

manifestations  in  heart  weakness   560 

Reparative  measures,  supplemental  action 

„     in,   404 

Reproduction,  relation  of,  to  tumor  growth  738 

Research,  medical,  and  practice   384 

work,  systemic,  plea  for,  in  endocrino- 
logy   382 

Resection,  submucous,  of  nasal  septum.  .  .  474 
Respiratory    diseases,    prevention    of,  in 

early  childhood   382 

Resuscitation  of  heart   782 

Retan,  George  M.     Child  health  work  in 

the  Solvay  schools   248 

Retina,  embolus  of  central  artery  of   172 

Retrovesical  hydatid  cysts,  diagnosis  of...  331 
Richardson,  Frank  Howard.  Simplified  in- 
fant feeding   977  - 

Rickets,  causation  of   994 

observations    on   1052 

Riddell,  William  Renwick.    An  early  view 

of  venereal  disease   540 

Venereal  disease  problem   500 

Ringworm,  x  ray  treatment  of   839 

Rivers,  W.  H.  R.    The  unconscious   789 

Riviere,  Joseph.    Plea  for  physiotherapy..  948 

Rhabdomyoma  of  ovary   750 

Rheumatism,  hypodermic  injections  of  sali- 
cylic acid  in   691 

Rhinitis,  fetid,  and  jaundice,  iFriedlander 

pleuropneumonia  with   785 

Rhodes.  William  L.  Relationship  between 
diseased  tonsils  and  pulmonary  tuber- 
culosis   902 

Rhythm,  gallop,  and  blood  pressure   784 

Rhythmic  electric  currents  in  treatment  of 

abdominal  and  pelvic  relaxation   441 

Rontgen  ray  in  disease   65 

standardized,  in  treatment  of  skin  dis- 
eases   837 

studies  of  bronchial  function   765 

in  obscure  conditions   338 

superficial  and  deep,  dose  estimation..  936 

treatment  of  hyperthyroid  sm   827 

of  leucemia,  blood  changes  following  828 

of  surgical  tuberculosis   298 

Rontgenotherapy    843 

Rohdenburg,  G.  L.  Historical  notes  on 
the  practice  of  medicine  in  New  York 

City    349 

Root,  Manly  B.  Diagnosis  of  pregnancy.  767 
Rose,   Robert  Hugh.     Weight,  diet,  and 

efficiency    27 

Rosenberger,    Randle    C.  Bacteriological 

study  of  ripe  olives   222 

Rout.  Ettie  A.  Conquest  of  venereal  in- 
fection  533 

Rubber  glov^  discarding  of   741 

Ruderman,  Louis  M.  Six  months'  experi- 
ence with  nutrition  class   976 

Rupture  of  bladder  during  labor   742 

Rush,  Dr.   Benjamin   236 

Russell,  Thomas  Hubbard.  Abdominal 
symptoms     in     influenza  simulating 

acute  surgical  lesion   216 

Russia,  men  of  science  in   1038 

Rutz,  Anthony  A.  Futility  of  examining 
filtrate  for  presence  of  occult  blood  in 
gastric  contents   619 


1062 


IXDEX  TO  VOLUME  CXI  I. 


Page. 

C  AJOUS.  Louis  T.  de  M.  Recent  glean- 

ings  in  diphtheria  prophylaxis   139 

Saligenin,  local  anesthetic  action  of   693 

Salts  of  rare  earth  metals,  injections  of.  to 

produce  hemolysins                518,  82S,  870 

Salvarsan,  administration  of,  by  rectum  in 

form  of  enteroclysis    273 

arsenical  poisoning  following  administra- 
tion of    559 

Sanatorium,  reforms  needed  in  manage- 
ment of    874 

treatment  of  tuberculosis   831 

Sanitation,  good  work  in  relation  to   70 

Sarcoma  of  kidney   1052 

of   stomach,    primary   9 

Satterthwaite.  Thomas  E.  Recent  in- 
creases in  venereal  diseases   678 

Scarlet  fever  mvsterv    550 

Scheimberg.  H.  Weak  foot  in  child. 988,  1026 
Scheppegrell,  William.   Diagnostic  tests  in 

hay  fever  and  asthma   112 

Schick  test,  its  control  and  active  immiini- 

zation    against    diphtheria   279 

Schiller,    Johann    C.    F.    von,  physician 

author    996 

Schnitzler,  Arthur,  physician-author  ....  290 
School  clinics,  public,  in  connection  with 

State  school  for  the  feebleminded....  1035 
Schroeder,   Theodore.     Christian  Science 

and  sex    851 

Schwartz.  Samuel.    Encephalitis  lethargica  182 

Science   and   spirits   464 

British  Association  for  Advancement  of  593 

imagination  in  relation  to   164 

men  of,  in  Russia   1038 

Sclerosis,  disseminated,  due  to  shell  con- 
cussion   603 

Scopolamine  narcosis,  combined  with  local 

anesthesia,  in  Caesarean  section   339 

Secretions,   internal    848 

of  sex  glands,  disturbance  of   694 

Section,  Cesarean,  under  local  anesthesia 
combined  with  morphine  and  scopola- 
mine narcosis    339 

Selfhealth  as  a  habit   602 

Sellard"s  alkali  tolerance  test   256 

Seminal  vesicles  in  arthritis,  treatment  of.  652 

Senses,    special    630 

Sepsis  complicating  treatment  of  abortion.  829 

Septicemia,   meningococcic    1004 

Septum,  nasal,  submucous  resection  of...  .  474 
Serum,  normal  bovine,  treatment  of  human 

anthrax  by    692 

precipitin,  effects  of.  on  animals  of  the 

species  furnishing  precipitinogen..  300 

Sex  extinction  and  feminism   469 

gland  implantation    300 

glands,  disturbance  of  internal  secretions 

of    694 

in  relation  to  Christian  Science   851 

instinct  of    630 

stimulation    848 

Sexual  characters,  acquired    527 

Shanahan,  William  T.  >[ore  adequate  pro- 
vision   for    epileptics   879 

Shapiro.  Isidor-F.  Instrument  for  simpli- 
fying tonsillectomy  by  snare   681 

Shock,  anaphylactic,  simple  means  of  ob- 
viating  1048 

anesthetics   in    338 

surgical,  treatment  of   267,  296 

Shoulder  joint,  dislocation  of   234 

Sigma  test   383 

Signs,  diagnostic,  in  tracheobronchial  ade- 
nopathy  1047 

Silver,   colloidal,  in  influenza   648 

Simulation  and  the  camera   729 

Sinus,   frontal,   drainage   471 

superior  longitudinal,  puncture  of   402 

Sinusitis,  latent,  in  children   1036 

Sippy  treatment  of  peptic  ulcer   75 

Skin  diseases    426 

occupational    1042 

standardized  Rontgen  rav  in  treatment 

of    837 

human,  iodine  absorption  from    648 

lesions  in  measles   949 

pigmentation   of   640 

preparation  of,  for  operation  with  special 

reference  to  use  of  picric  acid....  829 

Sleeping  sickness   506 

Smallpox  vaccination,  new  site  for   1035 

Smith,  Ethan  H.   Fractures  of  long  bones 

and  their  repair    301 

Sobel.  Jacob.    First  aid  in  infant  feeding.  442 

Social  problems  of  childhood  delinquency.  964 

SOCIETIES,  PROCEEDINGS  8f: 
American  Association   of  Obstetricians. 
Gynecologists,  and  Abdominal  Surg- 
eons  .741,  786,  829 

American  Gvnecol'>gical   Society ...  562, 

606.  650 

American  Pediatric  Society   1006,  1049 

British  Association  for  Advancement  of 

Science    S93 

British  Medical  Association. .  .384,  429,  475 
British  National  Association  for  the  Pre- 
vention of  Tuberculois  830,  874 


SOCIETIES,  PROCEEDINGS  OF: 

Medical  Society  of  the  State  of  New 

York  235.  343,  651, 

New  \ork  Neurological  Society ...  91 7, 
Society  for  the  Prevention  of  Venereal 

Disease   417, 

Sodium  citrate  in  treatment  of  pneumonia 
taurocholate  in  prophylaxis  of  gonorrhea 
Solis-Cohen,  Myer.  Some  interesting  pedi- 
atric cases   

Solomon.   Meyer.     Nature  and  cause  of 

stammering   

Sorrows  of  travel   

Special  numbers : 

Gastroenterological   1, 

Encephalitis  lethargica   

Genitourinary   477, 

Gynecological   697, 

Epilepsy   

Pediatric   965, 

Specific   for  tuberculosis   

treatment  of  tuberculosis  at  high  eleva- 
tion   

Spinal  analgesia   

cord,   middle   or   lower   dorsal  involve- 
ments of   

deformities,  with  pituitary  syndrome... 

fusion,  operation  for  

reflex  system,  diagnosis  of  chronic  con- 
ditions by   

system,  treatment  of  disorders  of  

t>-pe  of  epidemic  encephalitis  

Spirits  and  science   

discarnate   

Spirochetes,  different,  in  general  paralysis 

and  common  syphilis   

Spirocheticides   

Spirochetosis,  icterogenic   

Spleen,  malarial   

syphilis  of   

traumatism  of   

tuberculosis  of   

Splenectomy,  blood  study  after,  with  spe- 
cial reference  to  leucocytes   

technic  of   

with  report  of  two  cases  

Splenic  anemia  and  Banti's  disease  

leucemia  associated  with  pregnancy.... 
Splints  used  for  peripheral  ner\-e  cases  at 

Army  General  Hospital   

Sporotrichosis    of  genital  organs  

Sprain  of  knee,  severe,  early  surgical  in- 
tervention in   

Sputum,    tuberculosis,    chemical  disinfec- 
tion of   

Squint,  pseudo  or  apparent   

some  practical  considerations  of  

Stammering,   nature  and  cause  of  

Starvation,  fat,  cause  of  edema  in  children 

mental   

Steinach's  work  on  rejuvenation   

Steinfeld.  Edward,  and  Heller,  Edwin  A. 
Nonleucotoxic    properties    of  benzyl 

benzoate  

Stenosis,  cicatricial  laongeal,  in  children. 

hypertrophic   

mitral,  associated  with  functional  insuffi- 
ciency of  pulmonary  orifice   

tricuspid,  and  tricuspid  insufficiency . . . 

Stereoscopic   campimeter  slate   

Sterility   

in  females   606, 

from  gonorrheal  infection  

Stevens,  J.  Thompson.  Rontgenotherapy. 
Stewart-Cogill,  Lida.    Prenatal  care  froad 

viewpoint   of  hospital   

Stimulant,  overwork  a   

Stomach,  diseases  of,  diagnosis  of  

nervous   disorders  of   

sarcoma  of.  primary   

superacidity  of   

s>T)hilis  of  

ulcer  of,  operative  results  in  

Streptococcic  toxemia,  venesection  in.... 

Streptococcus      mucosus,      epidemic  of 
hemorrhagic   diarrhea  due  to  ...... 

Strickler,  Albert  A.    Reactions  following 
intravenous  administration  of  arsphe- 

namine   -  

Strictures,  urethral,  operation  for   

Student  and  faculty   

Stye,  or  hordeoltun   

Submucous  adenomyomata   

Subnormal  citizens  

Sugar,  blood,  studies  in   

Sulphur  metabolism  in  cancerous  liver.... 

Suprarenin.  general  effects  of.  

Suppuration*,  aural,  coupled  with  s>"philis, 
intracranial  complications  in  ....... 

Suppurative  dacryocystitis,  chromic  acid  in 

Suprapubic  prostatectomy   

Surgeon,   mind  of  a  

Surgeons,    regimental,    memorial    of,  to 

Congress   

Surgery,    biliary,    clinical    importance  of 

anatomical  anomalies  in   

bone  flap  in  cranial   

chest   


P.\GE. 


694 
961 

519 
1005 
517 

967 

435 
953 

45 
173 
521 
745 
877 
1009 
831 

783 
300 

914 
649 
827 

621 
691 
961 
464 

597 

498 
531 
68 
305 
305 
561 
305 

873 
308 
304 

305 
787 

474 

559 

268 

740 
453 
452 
455 
977 
821 
612 


160 
781 
1052 

740 
798 
944 
848 
778 
132 
843 

763 

553 
18 

429 
9 
5 

691 
84 
899 

1008 


498 
473 
921 
238 
742 
102 
1006 
785 
418 

341 
827 
338 
376 

410 

473 
871 
107 


Surgery  in  peptic  ulcer,  determinatiot 

need  of   

in  severe  dysentery   

of  gallbladder,  special   points   in . . 

of  prostate   

plastic   

of  ear   

rectal,  local  anesthesia  in   

vaginal,  certain  procedures  in  

Surgical  aspect  of  dysentery  

cases,  aftertreatment  in   

conditions,    interesting,    of    liver  I; 

biliary  tract   

division  of  Fordham,  clinical  notes  Ip 
mensuration,  standardization  of  .  .  i 
operations,  convulsive  disturbances  c  k 

by    . 

shock,  treatment  of   

treatment  of  acute  empyema  by  vfe 

drainage   '.  

of  infections  of  hand   

of  gastric  ulcer   

Sutton,  Sir  John  Bland,  retires  

Sycosis,  X  ray  treatment  of  

Symptoms,  delayed,  in  fracture  of  v  t 

bral  bodies   

S>-philis  and  large  placentas   

as  cause  of  delayed  healing  in  not 

fected   abdominal   incision    . . 
common,   different    spirochetes  in 

general  paralysis   

congenital,    in    infants    and  chile 

treatment  of   

hereditary,  dystrophies  resulting  frc 

late   

study  of  incidence  of   

transmission  of   

in  relation  to  pregnancy   

to  encephalitis  lethargica   

inherited,  new  laws  relating  to  

intracranial  complications  in  aural 

purations  coupled  with   

intravenous  mercuric  iodide  in.... 
meningeal,  influence  of  insufficient  t^l! 
ment  upon  appearance  of 

mercury  in  treatment  of   

modern  treatment  of   

of  spleen   

of  stomach   

pancreatic,   diabetes  due  to... 

precocious  malignant   

secondary,   of   the   heart  .... 
significance   of,    in    causation    of  |d 

death   

in  prenatal  care   

treatment  of   

Syphilitic  virus,  duality  of  

Sj-philoma  \'ulv3e   

System,  nervous,  inflammations  of 


'T  ABES  and  facial  paralysis. . 

*        early   signs  of   

Tartar  emetic  in  ulcus  tropicum. 
Taylor,  J.  Madison.    Filing  convenii^ 

for  physicians   

supplemental  action  in  reparative 

ures   

Taylor,  R.  Tunstall.     An  effort  to 
dardize  surgical  mensuration   . . 
Tempertaure,    high,    effect   of,  upon^ 

action  and  toxicity  of  digitalis. 
Tendon  reflexes,  physiopathology  of 
Test,  kidney  function,  urea  output  a: 
phenolsulphonephthalein,      in  ch^ 

nephritis   

influence  of  color  of  urine  on 

ings  of   

Sellard's  alkali  tolerance   

Sigma   

Testicle,  gangrene  of  

torsion  of   

Tests  of  renal  function   

Tetanus,   treatment  of   

Tetany,  gastric,  pyloric  obstruction  Utt 

lation  to  

in  adult  due  to  thyroid  apoplexy 
Theory,  new  psychoanal>-tical  ... 

of  pneuma  in  Aristotle   

Therapeutic  importance  of  psycholog 
study  of   whooping  cough    .  . . 
tracheal  fistula  in  laryngeal  tuberc 

Therapeutics,  cellular   

of  essential  epilepsy  

Therapy,  new,  in  light  of  new  phys 
Thom,  Burton  Peter.    Early  signs  of 

Thorax,  cholesterol   

knife  cautery  in  surgery  of... 
Thrombophlebitis   during  puerperiunfi. 
lowing  influenza,  cases  of  .  .  . 

Thrombosis,  case  of  portal   

venous,    following  gynecological 

tions   

Thymus  as  an  endocrine  organ  . 
Thyroid  and  other  endocrine  disturtjcs 

viewed  by  internist   

apoplexy,  tetany  in  adult  due  to 
feeding  action  on  pancreas   


.  m9 


» 


LWDEX  TO  VOLUME  CXI  I. 


1063 


'age.  Pace. 

Thyroid,  toxic  adenomata,  mild  types  of.  695 

1047  treatment   of   by   ether  oil  colonic 

40  anesthesia    744 

343  Tibia,  fissure  fracture  of   364 

486  Tissue  resistance  to  cancer,  factors  deter- 

688        mining    830 

828    sparing  amputations  of  foot   428 

339  Tolerance,  Sellard's  alkali,  test   256, 

742  Tonsils,  chronic  abscess  of   193 

771     diseased,  relationship  of,  to  pulmonary 

1048  tuberculosis    902 

Tonsillectomy,    new    instrument   for  sim- 

741        plifying    681 

802  Torsion  of  left  testicle   605 

109    of  spermatic  cord   596 

Tousey,  Sinclair.    Dental  infection   353 

691  Tovey,  Pavid  \V.    Female  pelvic  ureters.  720 
296 Toxemia,    cerebral,,  severe,    after  intra- 
venous novarse'nobillon   472 

471    interstitial,  and  benign  mammary  tumors  787 

663    streptococcic,  venesection  in   899 

385  Toxic  efTects  produced  by  regional  radia- 

417        tion    871 

839    thyroid,  treatment  of,  by  ether  oil  col- 
onic  anesthesia   744 

8731bxicity  of  arsphenamine  and  neoarsphe- 

906       namine    516 

of  digitalis,  eflFect  of  high  temperature 

539  upon    782 

of  mustard  gas  to  human  eye   739 

498    of  phenylacetic  acid   383 

Toxins,  diphtheria   994 

1049  Tracheal  fistula,  therapeutic,  in  laryngeal 

516  tuberculosis    869 

73  "Tracheobronchial    adenopathy,  diagnostic 

1049        signs   in   IO47 

^^'^Tract,  biliary,  interesting  surgical  condi- 

1°-       tions  of   741 

2QnTranslusion,  blood,  in  obstetrical  practice  951 

Transmissibility  of  lethargic  encephalitis..  340 

34 2 Transplantation  of  kidney  and  ovary   474 

471  Travel,  sorrows  of   953 

Trauma  and  other  nonluetic  influences  in 

S15       paresis    919 

474Traumatic  deformities,  treatment  of   960 

53irraumatism  of  spleen   561 

305Treatment,  ambulant,  of  diabetes  mellitus  427 

691  importance  of  early,  in  tuberculosis....  874 
561    influence  of  insufficient,  upon  appearance 

517  of  meningeal  syphilis   515 

515  intravenous,  of  malaria   366 

modern   individualized   dietarj-,    in  dia- 

516  betes    427 

516   of    abdominal    and    pelvic  relaxation, 

516  rhythmic  electric  currents  in   441 

943    of  bladder  tumors,  value  of  radium  in.  .  474 

828   of  borderline  carcinoma  01  cervix   786 

340  of   bronchial    fistulae    783 

of  cancerous  tumors  with  radium,  empi- 

2(,^  rical  results  of   737 

of  chronic  fatigue   428 

J  J.  I    of  displacement  of  uterus   702 

of   entropion   369 

620    °^  fracture  of  ulna  with  dislocation  of 

head  of  radius   473 

404   °f  gonorrhea,  injections  of  milk  in   496 

of  hemoptysis,  quinine  in   817 

JQ5   of  hemorrhagic  diseases   693 

ot  human    anthrax    by    normal  bovine 

782     ,  .  ^f"'"    692 

gjj   of  hydrocephalus    915 

483   °^  industrial  and  traumatic  deformities.  960 

of  lethargic  encephalitis   298 

692  injection  of  turpentine  oil  in   428 

of  luetic  involvement  of  optic  pathways  517 

47;  of  men^rhagia  with  radium   736 

of  pelvic  infection   298 

383  °^  penetrating  injuries  of  eyeball   871 

60=  °|  persistent  vomiting  of  pregnancy....  761 

gQ5  of  puerperal  infection   760 

5  J  J.  of  pulmonary  tuberculosis   869 

jg5  of  specific  urethritis   490 

of  surgical  shock   267,  296 

7(  of  syphilis   516 

mercury  in   474 

of  thyroid  and  other  endocrine  disturb- 

833         ances  as  viewed  by  the  internist...  428 
46         tox\c   thyroid    by   ether  oil  colonic 

g-l         anesthesia    744 

86'  °[  '"berculosis   830 

ant  °;  tuberculous  glands  of  the  neck   472 

gj    of  tuberculous  joints   297 

27    °[  ^'^""^^^  adenitis,  injections  of  milk  in  496 
■  of  Vmcent's  angina  and  other  similar 

affections  with  chromic  acid   297 

81    preoperative,  of  diabetic  patients   871 

6/    pressure   and   aspirations,   of  unopened 

mammary  abscesses   735 

78!  radium,  of  fibromata   782 

105.  sanatorium,  of  tuberculosis         831 

specific,  of  tuberculosis  at  high  elevation  783 

78  surgical,  of  acute  infections  of  hand   665 

87.  too  popular,  clinic   953 

training,  practical  experience  in,  of  epi- 

42i,  .      leptics    892 

73(ricuspid   insufficiency   798 

10:  stenosis  and  tricuspid  insufficiency..  ..  .  798 


Page. 

Tridon,     Andre.      New  psychoanalytical 

theory   794 

Trigeminal,  major,  neuralgias   740 

Trismus  in  lethargic  encephalitis   341 

Trypanocidal  activity  of  arsphenamine  and 

neoarsphenamine    515 

Tube,  fallopian,  heteroplastic  bone  forma- 
tion  in   828 

Tubercle  bacillus,   presence   of,   in  blood 

stream    1005 

Tucker,  Henry.     Comparative  anatomy  of 

genitourinary  organs  of  lower  animals  525 

Tuberculosis,  advanced,  x  ray  in   842 

alcoholism  in   876 

and  poverty   874 

chronic,  chemotherapy  of   647 

clinics,  crowding  in   831 

dust  in  spread  of   172 

experimental,  action  of  rare  earth  salts 

of  cerium  group  in   870 

German  periodical  on   911 

hospital,  outbreak  of  influenza  in   681 

ileocecal    768 

importance  of  early  treatment  of   874 

laryngeal,  therapeutic  tracheal  fistula  in  869 

miik    in   874 

new  books  on   600 

nutrition  clinics  in  treatment  of   876 

of  bladder   546 

of  spleen   305 

prevention  and  treatment  of   830 

prevention    of   876 

problem  of   378 

pulmonary,  diagnosis  and  treatment  of.  869 

relationship  of  diseased  tonsils  to.  .  .  .  902 

therapeutic  pneumoconiosis  in   691 

vital  capacity  constants  in  study  of...  873 
X  ray  a  guide  for  producing  artificial 

pneumothorax  in    670 

rales  after  expiration  and  cough  as  a 

means  to  early  diagnosis  in   361 

relation  of,  to  phlyctenular  ophthalmia.  1008 

sanatorium  treatment  of   831 

schemes,  difficulties  in  carrying  out ....  874 

service  in  general  hospitals   605 

social    problem   831 

specific  for   831 

specific  treatment  of.  at  high  elevation.  783 

sputum,  chemical  disinfection  of   740 

surgical,  Rontgen  ray  treatment  of.  .  .  .  298 

treatment  of  95,  127 

urogeni'..!    561 

Tuberculous  glands  of  neck,  treatment  of.  472 

laryngitides,  dysphagia  in   101 

myocarditis    1047 

patient,  in  regard  to  securing  an  arrest- 
ment and  avoid  becoming  an  in- 
valid   389 

women,  aid  for   328 

Tumor,  benign,  of  intestines,  intussuscep- 
tion  of   381 

brain,  two  cases  of                               .  918 

growth,  relation  of  pregnancy  to   738 

relation  of  reproduction  to...   738 

Tumors,  benign  mammary,  and  interstitial 

toxemia    787 

bladder    546 

value  of  radium  in  treatment  of   474 

cancerous,  empirical  results  of  treat- 
ment of.  with  radium   737 

fibrous,  of  palm   739 

malignant,  in  childhood   1046 

primary  spontaneous,  of  ovary  in  mice  738 
Turpentine  oil.  injection  of.  in  treatment 

of   lethargic   encephalitis   428 

Typhoid  fever,  epidemic  145,  189 

intussusception  in    108 

Typhus  fever,  clinical  diagnosis  of   872 

in  Serbia    1002 

in  Europe,  menace  of   950 

T  TLCER,  corneal   239 

^        duodenal,  operative  results  in ...  .  84 

perforated,  symptomatology  of   235 

gastric,  operative  results  in   84 

surgical  treatment  of   385 

of  esophagus   29 

peptic   60,  88,  116 

Sippy  treatment  of   75 

surgery  in,  determination  of  need  of.  1047 

tropical,  tartar  emetic  in   171 

varicose,  treatment  of,  with  salts  of  rare 

earth  metals   518 

Ulcerated  meatus  in  circumcised  child....  1049 
Ulna,  treatment  of  fracture  of,  with  dis- 
location of  head  of  radius   473 

Unconscious    789 

analysis  of   733 

Underdevelopment,  congenital   677 

Underbill,  B.  M.  Present  status  of  rabies  323 
Uniker.    T.    E.     Practical    experience  in 

training  treatment  of  epileptics   892 

Upham,  Roy.     Dietary  treatment  of  con- 
stipation   53 

Urea  output  as  kidney  function  test   483 

Uremia    259 

diagnosis  of   283 

venesection   in     901 


Page. 

Ureter,  hydronephrotic,  contraction  waves 

,    560 

leucoplasia  of   733 

normal,  contraction  waves  in   560 

Ureteral  calculi,  removal  of,  without  opera- 
tion   j[7 

Ureters,  female  pelvic  72b,  744 

Urethra,  male,  diagnosis  of  inflammations 

of    52] 

Urethral  strictures,  operation  'for.            !  473 

Urethritis,   chronic   593 

gonococcal  type  of  II  ......  ...  523 

specific,  treatment  of           490 

Urethrotomy,  external,  without  a  guide.  605 

Urinary  bladder,  disorders  of  function  of.  544 
Urme,  influenice  of  color  of,  on  readings 

of  phenolsulphonephthalein   test    ....  477 
of    children    suffering    from  nutritional 
disorders,  nature  of  reducing  sub- 
stance  in   1008 

Urogenital    tuberculosis   561 

Urological  diagnosis  in  practice  of  generai 

surgeon  ..      gji 

Uteri,  cervix,  diseases  of  ,   706 

prolapsus   '''  7^2 

Uterine  fibromyomata,  intraligamentous.   .  77' 

I  terovaginal   prolapse    705 

Uterus,  cervix,  amputation  of         710 

congenital  absence  of  ' 333 

displacement  of,  treatment  of           702 

fibromyomata  of,  x  ray  in       735 

malposition  of   7Q3 

method  of  covering  raw  surfaces  on.  .  .  .  650 

WACATIOXS,  need  for   164 

y     Vaccination,  smallpox,  new  site  for.  1035 

Vaccine  therapy  in  osteomyelitis   649 

treatment    gjQ 

Vaccines,  fresh,  in  whooping  cough!!  1051 

Vagina,  congenital  absence  of  383  742 

Vaginal   recurrences,    copper   sulphate*  in 

local  treatment  of   736 

surgery,  certain  procedures  in..!!!!  749 

Vaginouterine  prolapse    705 

Vandegrift,  George  W.    Binocular  single 

vision   

Vander   Veer,   Albert,  Jr."  The'asVhma 

problem    jg. 

Van    Paing,   John    F.     Knife   cautery  '  in 

surgery  of  the  thorax   673 

V  aricose  ulcers,  treatment  of,  with  salts  of 

rare  earth  metals   5]g 

Vascular  occlusion,  mesenteric.!!!! 343 

\  aughan,  Henry,  physician  author!!!!!!'  906 
Venereal   adenitis,    injections   of   milk  in 

treatment  of    496 

disease  clinics   !!!!!!!!!  163 

early  view  of  !!!!!!!!!  540 

increases  in    ^70 

peril  !!!!!!!!!!!■■•  172 

problem    5QQ 

prophylaxis   519    682  995 

_   society  for  the  prevention  of              '  417 

mfection,  conquest  of   533 

Venesection  :  a  lost  art  !!!!!!!!!  898 

in  aortic  regurgitation  !!!!!!!!!  901 

in  bronchopneumonia   ! !  !  900 

in  cardiac  dyspnea  !!!!!!!!  900 

in  chronic  diffuse  nephritis  !!!!!  901 

in  hypertension   !..!!  901 

in  pneumonia  ! !  ! !  899 

in  streptococcic  toxemia....!!!!!!!!!!  899 

in   uremia   '  ' '  '  ggi 

Ventricles,  lateral,  dilatation  of,  as  a'com- 

mon  brain  lesion  in  epilepsy   913 

Version  and  Cassarean  section  !!  473 

Dr.  Potter's  method  of  performing.!!!  742 

V  ertebral    bodies,    delayed    symptoms  in 

fracture  of    873 

Vertigo,  intestinal    331 

Vesical,  seminal,  in  arthritis   652 

Vesicovaginal  fistula,  operative  treatment 

,.    °f   108 

Vessels,  mesenteric,  superior,  obstruction 
of,  from  bands,  with  gangrene  of  in- 
testine   744 

Vincent's  angina  and  other  similar  affec- 

tions,  treatment  of,  with  chromic  acid  297 

Virus,  syphilitic,  duality  of   943 

Viscera,  abdominal,  disorders  of   752 

intraabdominal,   injury  of   915 

Visceroptosis,  cause  and  treatment  of! !  !  !  329 

vision,  binocular  single   320 

erysipelas  with  complete  loss  of  !  817 

monocular   and    binocular   240 

shifting  as  aid  to   158 

Vitamine  product,  stable,  preparation  of!  604 

Vitamines  in  relation  to  nutrition  75,  375 

lack  of,  epidemic  hemeralopia  due  to...  1005 
Vivax,  Plasmodium,  infection,  acute  mania 

associated   with    784 

Volvulus  complicating  appendectomy   22 

of  cfcum    32 

Vomiting,  cyclic   [  \  247 

from  surgical  viewpoint  !  64 

in  nurslings,  treatment  of  !  165 

persistent,  of  pregnancy,  treatment  of.  761 

V  ulvae,  syphiloma    828 


1064 


INDEX  TO  VOLUME  CXII. 


Page. 

yV/ALSH,  Joseph  W.   Treatment  of  sur- 

"     gical  shock    267 

War  methods,  application  of,  to  civil  prac- 
tice  244,  473 

Wartime,  diabetes  in   lOOS 

Wassermann  reaction    547 

effects  of  mercury  salicylate  on   518 

icebox  fixation  method  in   234 

value  of,  in  obstetrics   564 

test,  Hecht-Weinberg-Gradwohl  modifica- 
tion of   559 

Watkins,    Harvey    M.     Epilepsy  treated 

with  luminal    891 

Wealth  and  health   421 

Wechsler,  I.  S.  Symptoms  of  epidemic 
encephalitis  structurally  and  .function- 
ally considered    175 

Wehner,  William  H.  E.  Impairments  re- 
garding family  and  personal  history.  .  579 

Weight,  diet,  and  efficiency   27 

Weiss,  Samuel.    Ulcer  of  the  esophagus.  29 

Welfare  work  in  Paris   607 

West,  James   N.     Amputation   of  cervix 

uteri    710 

Whooping  cough,  benzyl  benzoate  treat- 
ment of   122 

therapeutic  study  of   959 

use  of  fresh  vaccines  in   1051 

Wight,  Dr.  Orlando  Williams   374 

Wile,  Ira  S.    How  to  protect  the  health 

of  school  children   407 

Wilensky,  Abraham  O.  Ileocecal  tuber- 
culosis   768 

Wiliams,  Tom  A.  National  morale  in 
relation  to  hysteria,  military  and  in- 
dustrial   436 

Witherbee,  W.  D.,  and  Remer,  John.  X 
ray  treatment  of  epithelioma  with  thin 

filter    935 

Wolbarsl^  Abr.  L.  Diagnosis  of  inflam- 
mations of  male,  urethra   521 

Woloshin,  Benjamin.  Treatment  of  asth- 
ma with  benzyl  benzoate  by  injection  403 


Page. 

Wood,  Horatio  C   308 

Women,  endocrine  influence,  mental  and 

physical,  in    742 

workers  in  Nova  Scotia   821 

Woodbury,  Frank  Thomas.   Cellular  ther- 
apeutics   809 

Woolsey,  George.    An  operation  for  the 

radical  cure  of  inguinal  hernia   21 

Results    of    operation    in    gastric  and 

duodenal  ulcers   84 

Work,  tuberculosis,  htmian  element  in...  831 

Workers,  women,  in  Nova  Scotia   821 

Wounds,  dry,  wet  and  ointment  dressings 

for    1048 

healings  of    575 

of  lung,  treatment  of   732 

suppurating,    following    abdominal  sec- 
tion   606 

Wright,  Jonathan.    Anatomical  and  physi- 
ological theories  of  Plato   141 

Theory  of  pneuma  in  Aristotle   833 

Wright,    V.   William    M.  Administration 
of  salvarsan  by  rectum  in  the  form  of 

enteroclysis    275 

Wyatt,  B.   S.    Intravenous  treatment  of 

malaria    366 

XANTHOCHROMIA    of  cerebrospinal 

fluid,   significance  of   1007 

Xeroderma  pigmentosum    985 

X  ray  as  an  essential  guide  for  producing 
artificial    pneumothorax    in  advanced 

cases  of  pulmonao'  tuberculosis   670 

differentiation  of  structures  by   428 

epithelioma,  radium  treatment  of....  871 

findings,  negative,  in  renal  calculus.  .  604 

generative  organs  treated  by   736 

in  acne    839 

in  adenitis   ,   842 

in  advanced  tuberculosis   842 


X  ray  in  bronchiectasis   

in  disease   

in  fibromyomata  of  uterus. .  .  . 

in  mediastinitis   

in  obscure  conditions  

in  pleural  disease  

in  pneumoconiosis   

1        in  pneumonia   

in  pulmonary  abscess  

manuals   

standardized,  in  skin  diseases, 
studies  of  vascular  system .  . . 

of  bronchial   functions  .... 
superficial  and  deep,  dose  estiil 

of   , 

therapy   

treatment  of  carcinoma  

of  eczema   

of  epithelioma  with  thin  filtei 

of  favus   

of  folliculitis   

of  foreign  bodies  in  bronchi . 

of  hyperthyroidism   

of  leucemia   

of  lichen  planus   

of  lymphatic  diseases   

of  neuralgia   

of  psoriasis   

of  ringworm   

of  sycosis   

of  universal  psoriasis   

of  surgical  tuberculosis  .... 
versus   physical   diagnosis  in 
of  lungs   


YELLOW  fever   

*     leptospira   icteroides   in .  . . 
Young,  Francis  Brett,  physician  au 
Young,  John  J.  and  Cotter,  Lawrer 
Tricuspid   stenosis"  and  tricusp 
sufficiency   


7  OSTER,  herpes  and  chickenpox  « 
^     mon  origin  of  


tr.  63i 


INDEX  TO  PAGES 


July  3rd   1- 

July  10th   45- 

July  17tli   77- 

July  24th  :   109- 

July  31st   141- 

August  7th   172- 

August  14th   205- 

August  21st    237- 

August  28th   269- 

September  4th   301- 

September  11th   345- 

September  18th   389- 

September  25ih   433- 


44    October  2nd . 


47 


76  October  9th   52 

108  October  16th   56 

140  October  23rd   60 

172  October  30th   65 

204  Xovember  6th   65 

236  November  13th   74 

268  November  20th   78 

300  November  27th   8, 

344  December  4th   8/ 

388  December  11th   9 

432  December  18th   9t 

476  December  25th  IOC 


53) 

& 
<^ 


New  York  Medical  Journal 


INCORPORATING  THE 


Philadelphia  Medical  Journal  the  Medical  News 

A  Weekly  Revieiv  of  Medicine,  Established  184S. 


Vol.  CXII,  Xo.  1. 


NEW  YORK.  SATURDAY.  JULY  3.  1920. 


Whole  No.  2170. 


Original  Communications 


THE   DIAGNOSIS   AXD   TREATMENT  OF 
GALLBLADDER  AFFECTIONS.* 
By  Max  Eixhorx,  M.  D., 
New  York, 

Professor  of  Medicine  at  the  New  York  Postgraduate  Medical 
School;  Visiting  Physician  to  the  Lenox  Hill 
Hospital,  New  York. 

In  a  paper  on  Ischochymia  Simulating  Gallstone 
Disease  (1),  published  a  number  of  years  ago,  I 
presented  reports  of  several  cases  in  which  the  pa- 
tients had  had  typical  attacks  of  what  was  appa- 
rently gallstone  colic,  some  with  slight  jaundice. 
The  real  trouble,  however,  was  not  in  the  gallblad- 
der, but  in  the  pylorus  or  the  duodenuin.  Later  I 
described  a  case  (2)  of  duodenal  ulcer,  in  which 
the  symptoms  and  previous  treatment  for  many 
years  had  been  those  of  distinct  cholelithiasis.  In 
this  patient  the  newer  methods  of  diagnosis  indi- 
cated that  we  had  to  deal  with  a  duodenal  ulcer. 
An  operation  disclosed  the  presence  of  the  ulcer  but 
failed  to  find  any  abnormal  condition  of  the  gallblad- 
der. It  is  thus  evident  that  a  correct  diagnosis  in 
gallbladder  lesions  is  not  always  an  easy  matter, 
and  their  characteristic  symptoms  are  sometimes 
misleading.  I  thought,  therefore,  it  would  be  of 
interest  to  broach  the  subject  of  gallbladder 
affections. 

Almost  all  gallbladder  diseases  are  intimately 
connected  with  gallstones ;  either  they  predispose 
to  the  formation  of  the  latter,  or  the  calculi  are  the 
cause  of  the  lesion.  It  will,  therefore,  be  appropriate 
to  state  a  few  well  known  facts  regarding  gall- 
stones. The  formation  of  gallstones  is  due,  accord- 
ing to  Naunyn,  to  bacterial  infections  of  the  gall- 
bladder. Aschoff  and  Bacmeister  (3)  accept  this 
view  in  a  general  way,  but  mention  that  some  choles- 
terin  stones  originate  without  the  aid  of  bacteria, 
but  are  solely  due  to  stagnation  of  bile  in  the  gall- 
bladder. 

Gallstones  are  found  in  ten  per  cent,  of  all  au- 
topsies performed  in  adults.  Not  all  gallstone  car- 
riers, however,  manifest  morbid  symptoms.  It  is 
generally  assumed  by  clinicians  that  about  five  per 
cent,  of  these  carriers  at  one  time  or  another  are 
troubled  with  mild  or  severe  lesions,  due  to  the 
biliary  calculi.  Kehr,  one  of  the  greatest  gallbladder 
surgeons,  maintains  that  but  one  per  cent,  of  the 
gallstone  carriers  ultimately  require  surgical  aid  to 
remedy  the  gallstone  disease.    In  contrast  to  this 


0         *Read  before  the  Medical  Society  of  the  Greater  City  of  New 
York,  April  19,  1920. 

4 

Copyright,  1920,  by  A.  R.  Elliott  Publishing  Company. 

18 


view  a  great  many  surgeons  believe  that  all  gall- 
stones are  pathological  and  accompanied  by  symp- 
toms, which  are  frequently  not  recognized.  Gall- 
stones are  much  more  frequently  found  in  women 
than  in  men,  and  principally  in  women  who  have 
gone  through  pregnancies. 

After  these  preparatory  remarks,  returning  to 
the  diseases  of  the  gallbladder,  we  can  practically 
divide  them  as  follows  :  1 ,  Acute  cholecystitis,  with- 
out and  with  jiaundice ;  2,  chronic  or  recurrent 
cholecystitis,  without  and  with  stones ;  3,  empyema 
of  the  gallbladder,  usually  with  ulcerations;  and  4, 
malignant  diseases  of  the  gallbladder. 

Inasmuch  as  the  diagnosis  must  be  based  on  the 
symptoms  in  conjunction  with  the  objective  find- 
ings, it  will  be  best  first  to  sketch  the  important 
symptoms  before  discussing  the  diagnosis  of  the 
diflferent  gallbladder  lesions. 

1.  Acute  cholecystitis. — There  are  present  full- 
ness and  distress  in  the  right  hypochondrium ;  ano- 
rexia and  sometimes  slight  icterus ;  no  fever  or  a 
moderate  rise  in  temperature  for  a  few  days. 

2.  Recurrent  or  chronic  cholecystitis. — There  ex- 
ists a  repetition  of  the  same  symptoms  with  increased 
severity  and  duration  or  typical  attacks  of  severe 
colicky  pains  of  comparatively  short  duration  oc- 
cur, usually  in  the  right  hypochondrium,  radiating 
to  the  back  and  upward.  Stones  in  the  cystic  duct 
are  ordinarily  accompanied  by  the  symptoms  of  re- 
current cholecystitis.  Here,  however,  the  attacks 
of  colicky  pain  play  a  more  predominant  part ; 
jaundice  of  a  mild  degree  may  occur.  Stones  in 
the  choledochus  and  common  duct  present  symp- 
toms similar  to  those  in  the  cystic  duct,  with  the 
addition  of  jaundice.  The  latter  is  present  in  vary- 
ing degree,  depending  upon  the  completeness  of  the 
obstruction  and  upon  the  length  of  time  the  stone 
became  incarcerated. 

3.  Enipycnta  of  the  gallbladder  presents  an  ir- 
regular septic  temperature ;  severe  pains  in  the  right 
hypochondrium ;  rigidity  of  the  right  rectus ;  ex- 
treme tenderness  on  pressure  of  the  right  upper  ab- 
domen ;  marked  swelling  of  liver.  The  blood  re- 
veals a  leucocytosis  and  an  increase  of  the  polynu- 
clear  cells.  In  addition  to  the  very  severe  colicky 
cramps  the  patient  suffers  almost  continuously  and 
presents  the  characteristics  and  appearance  of  gen- 
eral septicemia. 

4.  Malignant  disease  of  the  gallbladder. — Cancer 
of  the  gallbladder  is  present  for  a  considerable  time 
without  showing  symptoms.   The  latter  result  from 


2 


EIXHORX:    GALLBLADDER  AFFECTIONS. 


[\e\v  York 
Medical  Journal, 


complications  involving  other  organs,  namely  the 
bile  ducts,  causing  icterus,  or  the  pylorus,  or  duode- 
num, giving  rise  to  ischochymia. 

In  making  a  diagnosis  of  gallbladder  lesions  it 
is  of  first  importance  to  recognize  in  a  general  way 
the  organ  affected  and  then,  if  possible,  to  make 


Fig.  1. — GallUacder  of  patient  C.  A.,  and  two  stones,  natural  size. 

a  more  detailed  statement  with  regard  to  the  special 
disease  present.  The  diagnosis  is  comparatively 
easy,  when  the  affections  of  the  gallbladder  run  a 
typical  course,  but  extremely  difficult  when  they 
appear,  as  they  frequently  do,  in  disguised  forms. 
It  is  principally  in  these  latter  conditions  that  we 
must  avail  ourselves  of  all  the  more  refined  methods 
in  order  to  come  to  a  correct  conclusion. 

In  addition  to  a  consideration  of  the  subjective 
symptoms  and  a  physical  examination,  we  make 
use  of  the  x  ray  apparatus,  and  employ  the 
duodenal  tube  and  the  duodenal  bucket  and  string. 
The  rontgen  examination  consists  of  a  direct  inves- 
tigation of  the  gallbladder  region.  1,  to  determine 
whether  visible  shadows  can  be  detected :  2.  to  ascer- 
tain the  position  of  the  duodenal  cap  and  duodenum 
after  a  bismuth  or  barium  test  meal,  in  order  to 
see  whether  these  portions  of  the  intestinal  tract 
occupy  their  normal  positions  or  are  distorted  by 
the  interference  of  the  gallbladder  lesion;  3,  to 
ascertain  if  there  are  any  stones  in  the  gallbladder 
causing  a  depression  of  the  cap;  or  adhesions  be- 
tween the  former  organ  and  duodenum  and  pylorus 
producing  a  lengthening  of  the  pylorus  and  duo- 
denum with  a  dragging  away  to  the  right. 


Negative  x  ray  findings  with  regard  to  the  gall- 
bladder do  not  mean  much,  for  the  majority  of  gall- 
stones do  not  throw  shadows  on  the  screen.  Again, 
the  accidental  study  of  a  biliary  calculus  by  the  x  ray, 
in  a  patient  who  does  not  present  any  symptoms 
of  gallbladder  disease,  will  simply  show  that  the 
individual  in  question  is  a  gallstone  carrier. 

The  direct  examination  of  the  bile,  obtained  from 
the  duodenum,  in  the  fasting  condition  of  the  pa- 
tient, is  of  great  importance  for  the  diagnosis  of 
gallbladder  lesions. 

While  normalh'  the  bile,  as  found  in  the  duo- 
denum when  fasting,  has  a  golden  yellow  appear- 
ance and  is  clear,  in  pathological  conditions  of  the 
biliary  apparatus  it  is  turbid,  greenish  yellow  or 
dark  brown  in  color  and  contains  mucus,  pus,  fre- 
quently bacteria  and  cocci,  as  well  as  accumulations 
of  cholesterin  and  bilirubin  calcium  crystals.  The 
greater  the  deviations  from  the  normal,  golden  yel- 
low and  clear,  with  regard  to  the  turbidity  and  color, 
usually  the  more  severe  the  gallbladder  affection. 

In  cholecystitis,  without  the  presence  of  stones, 
turbidity  of  the  bile  with  mucus  and  pus  are  found. 
In  cholecystitis  with  stones,  microscopically,  numer- 
ous cholesterin  and  calciiun  bilirubin  crystals  are 
encountered  in  addition  to  the  mucus  and  pus. 

In  complete  obstruction  of  the  choledochus  and 
of  the  common  duct  there  is  no  bile  present,  even 
after  prolonged  aspiration  or  duodenal  lavage.  In 
common  duct  obstruction  the  pancreatic  secretion  is 
likewise  not  foimd. 

The  duodenal  bucket  and  string  test  are  useful  in 
the  differential  diagnosis,  especially  with  regard  to 
the  presence  or  absence  of  a  peptic  ulcer.  Clear  bile 
obtained  by  the  duodenal  tube  (or  found  as  such 
in  the  bucket)  and  a  distinct  blood  stain  on  the 
string  speak  for  peptic  ulcer  and  a  normal  gall- 
bladder. Turbid  bile  with  no  stain  on  the  string 
indicates  the  presence  of  a  gallbladder  affection. 
Turbid  bile  and  a  marked  blood  stain  on  the  string 
rather  point  to  a  double  affection,  namely  peptic 
ulcer  and  cholecystitis. 

As  examples  of  the  aid  these  newer  methods  fur- 
nish in  making  a  correct  diagnosis,  I  shall  describe 
the  following  three  cases,  which  I  have  recently 
observed ; 

Case  I.— B.  111-22-20.  In  October,  1916,  the  pa- 
tient had  an  irregular  heart  action  with  shortness  of 
breath  when  walking  for  the  previous  three  weeks ; 
he  had  no  pain.  The  next  attack  occurred  during 
October,  1918.  In  November,  1918,  the  patient  con- 
sulted me  on  account  of  distress  and  heartburn, 
which  occurred  one  to  two  hours  after  meals.  He 
also  complained  of  slight  diarrhea.  An  examination 
of  the  stomach  on  November,  1918,  showed :  hydro- 
chloric acid  -f ;  acidity,  80. 

Since  October,  1919,  the  patient  had  some  diffi- 
culty in  breathing,  principally  after  meals.  On 
March  8,  1920,  the  patient  woke  up  with  a  severe 
pain  in  the  upper  abdomen  and  he  vomited  for  five 
hours.  The  pain  radiated  to  the  left  shoulder  a'nd 
arm.  The  next  day  the  patient  had  a  similar  at- 
tack, for  which  he  required  a  hypodermic  injection 
of  morphine.  Almost  every  day  thereafter  the  pa- 
tient had  a  repetition  of  the  colic,  and  the  pain  radi- 


July  3,  1920.] 


EINHORX:    GALLBLADDER  AFFECTIOXS. 


3 


ated'to  the  back  and  left  shoulder.  On  March  16, 
1920,  the  patient  entered  the  hospital. 

On  March  16,  1920,  the  ph3-sical  examination 
showed  the  chest  to  be  in  good  condition ;  the  heart 
sounds  were  normal,  and  the  heart  was  not  en- 
larged. Palpation  of  the  abdomen  showed  an  area 
tender  to  pressure  below  the  right  costal  margin. 
The  stomach  was  not  dilated  and  the  liver  was  not 
markedly  swollen.  On  March  17,  1920,  an  exami- 
»  nation  of  the  gastric  contents  an  hour  after  a  test 
breakfast  showed  ;  hydrochloric  acid  +  :  acidity,  50 : 
no  blood.  The  duodenal  bucket  showed  no  signs  of 
ulceration  and  a  permeable  pylorus.  The  duodenal 
contents  obtained  on  March  20l:h,  in  the  fasting  con- 
dition, revealed  a  dark  brown  colored  fluid  of  great 
turbidity,  alkalinity,  40:  the  ferments  all  present; 
A  =  7;S  =  2;T  =  6;  microscopically  numerous 
small  cholesterin  crystals  and  pus  corpuscles  were 
found.  Blood,  hemoglobin.  80  per  cent. :  red  blood 
cells,  4,800,000;  white  blood  cells,  11,000;  polynu- 
clears,  60  per  cent. ;  lymphocjtes,  40  per  cent. 

A  diagnosis  of  severe  cholecystitis  with  probable 
stones  in  the  gallbladder  was  made.  An  x  ray  ex- 
amination confirmed  this  diagnosis.  It  showed  a 
large  shadow.  The  patient  was  then  operated  upon 
by  Dr.  J.  F.  Erdmann  on  March  25th.  The  gall- 
bladder was  found  enlarged,  filled  with  a  muco- 
purulent fluid  containing  no  bile.  The  cysticus  was 
dilated  and  contained  a  stone  the  size  of  a  half  wal- 
nut, hermetically  closing  up  this  branch  of  the  bile 
duct.  The  gallbladder  itself  was  almost  as  large 
as  a  goose  egg,  distended  with  fluid  and  ready  to 
burst. 

•  Case  II. — C.  A.,  aged  forty-two  years  (January 
6,  1920).  Patient  complained  for  the  last  six 
months  of  pain  over  the  right  hypochondrium, 
which  was  most  severe  after  midnight.  At  times 
vomiting  of  bile  occurred  in  the  morning.  Patient 
did  not  partake  of  alcohol  and  smoked  moderately. 
He  did  not  chew  tobacco,  slept  well,  appetite  was 
good,  bowels  were  always  regular.  The  present 
trouble  began  eighteen  years  ago  and  was  character- 
ized by  attacks  of  acute  indigestion,  pain  over  epi- 
gastrium, nausea  and  vomiting,  unaccompanied  by 
chills  or  fever.  The  attacks  used  to  occur  about 
three  times  a  year,  irrespective  of  the  food  taken. 
This  condition  assumed  greater  proportions  for  the 
past  year,  the  attacks  coming  on  more  frequently 
each  week  and  with  greater  severity.  For  the  last 
four  months  the  attacks  appeared  daily,  the  pain  was 
more  intense  and  lasted  longer.  The  patient  scarcely 
ever  had  chills  or  fever ;  vomiting  occurred  fre- 
quently. The  vomitus  consisted  principally  of  bil- 
ious matter.  The  pain  was  getting  worse,  espe- 
cially after  midnight.  For  the  last  three  months 
the  patient  would  wake  up  during  the  night  with 
pain.  He  would  get  up  during  the  night,  go  to  the 
cellar  and  chop  wood.  This  gave  him  partial  relief. 
The  ingestion  of  milk  would  frequently  allay  the 
pain  somewhat,  but  not  when  it  was  intense.  The 
patient  had  lost  over  twenty  jxjunds  in  weight. 
An  X  ray  examination  showed  a  deformity  of  the 
cap.  but  nothing  abnormal  otherwise. 

When  the  patient  consulted  me  on  January  6, 
1920,  he  was  in  great  pain.  The  examination  showed 
the  following :    The  stomach  was  not  enlarged ; 


the  liver  was  swollen ;  right  hypochondrium  pain- 
ful to  pressure,  with  slight  muscular  rigidity. 
The  duodenal  bucket  string  test  revealed  a  per- 
meable pylorus  and  no  distinct  ulceration  in  the 
stomach  or  duodenum.  The  duodenal  tube 
aspiration  in  the  fasting  state  furnished  a 
turbid  dark  green  vellow  bile ;  alkalinitv,  25 :  A=7 ; 
S  =:  0;  T  =  0.  "The  blood  showed  21,000  white 
blood  cells.  While  in  the  hospital  the  patient  was 
seized  with  a  violent  attack  of  pain  in  the 
region  of  the  liver  and  had  a  rise  of  temperature 
(102°  F.). 

Notwithstanding  the  x  ray  findings  of  duodenal 
ulcer,  a  diagnosis  of  severe  cholecystitis  with  proba- 
ble stones  and  empyema  of  the  gallbladder  was 
made.  The  patient  was  operated  upon  by  Dr.  Willy 
Meyer.  The  gallbladder  was  found  to  be  almost 
the  size  of  a  fist,  greatly  thickened,  filled  with  a 
mucopurulent  fluid  without  bile ;  toward  the  cystic 
duct  two  stones  the  size  of  a  pigeon  egg  were  lodged 
(Fig.  Ij. 

Case  III.— :March  14,  1920.  :\Irs.  I.  E.,  aged 
thirty-four  years,  had  always  enjoyed  good  health 
except  that  for  the  last  eight  years  she  had  been 
troubled  from  time  to  time  with  rheumatism.  Three 
years  ago  the  patient  began  to  suffer  from  attacks 
of  severe  pain  in  the  upper  abdomen,  radiating  to 
the  back  and  right  shoulder.  The  attacks  would 
come  on  first  about  once  a  month,  later  especially 
during  the  last  six  month,  every  two  weeks.  The  at- 
tacks varied  in  severity  and  duration.  Some  of  them 
were  relieved  by  hot  applications,  others  required  a 
hypodermic  injection  of  morphine ;  some  of  the  at- 


\ 

Fig.  2. — Microscopic  picture  of  the  duodenal  contents  (bile)  of 
Mrs.  E.     A,  big  cholesterin  crystals;  B,  pus  corpuscles;  C,  mucus. 

tacks  lasted  half  an  hour,  others  twenty-four  hours. 
The  attacks  had  no  relation  to  the  intake  of  food ; 
nor  were  they  relieved  by  food  or  alkalies.  For  the 
last  year  the  patient  complained  of  having  attacks 
of  sour  stomach,  belching,  poor  appetite,  and  con- 
stipation during  the  intervals.  She  frequently  had 
headaches,  and  suffered  from  nervousness,  dizziness 


4 


EI N HORN : 


GALLBLADDER  AFFECTIOXS. 


[New  Yorx 
Med€Cal  Journal. 


and  spots  before  her  eyes.  She  had  lost  about  ten 
pounds  in  weight. 

A  few  months  ago  an  x  ray  examination  had 
been  made  of  her  gastrointestinal  tract.  This 
showed  a  six  to  eight  hour  food  retention  in  the 
stomach  and  a  deformity  of  the  cap.  The  diagnosis 
of  the  rontgenologist  was  pyloric  obstruction  due 
to  duodenal  ulcer. 

The  examinations  performed  at  the  hospital 
showed :  The  chest  organs  apparently  normal.  Ab- 
domen :  Stomach  markedly  dilated,  the  greater 
curvature  was  a  hand's  width  below  the  navel.  Pal- 
pation showed  a  painful  area  beneath  the  liver 
under  the  right  costal  margin.  The  gastric  contents 
revealed  :  no  hydrochloric  acid ;  acidity,  6 ;  no  rennet 
present,  no  blood.  Lavage  in  the  fasting  condition  of 
patient  furnished  water  without  any  traces  of  food. 
The  duodenal  bucket  string  test  showed  a  permeable 
pylorus  and  no  signs  of  ulceration.  (Bile  at  nineteen 
inches,  no  blood  stains.)  The  duodenal  aspiration 
in  the  fasting  condition  revealed  a  yellow  slightly 
turbid  bile;  alkalinity,  25;  A=:8 ;  S=:8; 
T=4 ;  microscopically  many  cholesterin  crystals ; 
pus  corpuscles  and  mucus.  Two  blood  examina- 
tions were  made ;  one  on  March  18,  1920,  showed 
white  blood  cells,  6,000;  polynuclears,  59  per 
cent.;  lymphocytes,  41  per  cent.,  during  the  interval. 
The  other  on  April  5,  1920,  during  the  attack  showed 


Fig.  3. — Microscopic  picture  of  the  scrapings  of  Mrs.  E.'s  gall- 
stone, after  removal  by  operation.  The  same  cholesterin  crystals 
are  noted  as  found  in  the  duodenal  contents;  D,  chunk  of  calcium 
bilirubin  crystals. 

white  blood  cells,  10,000;  polynuclears,  66  per 
cent. ;  lymphocytes,  34  per  cent.  A  diagnosis  of 
severe  cholecystitis,  probably  due  to  a  biliary  calcu- 
lus, was  made  and  an  operation  on  account  of  the 
frequency  and  severity  of  the  attacks  was.  advised. 

Dr.' Willy  Meyer  operated  upon  the  patient  on 
April  7.  1920.  The  gallbladder  was  found  considera- 
bly enlarged  (the  size  of  a  goose  egg),  its  walls 
thickened  ;  the  mucosa  in  parts  corroded  and  almo.st 
necrotic;  toward  the  cysliciis  a  large  stone  (the  size 
of  a  walnut,  was  embedded;  the  contents  j)resen1ed 
a  mucous  fluid  without  bile  but  contained  ])us.  The 


gallbladder  was  resected.  Nothing  abnormal  was 
found  in  the  stomach  or  duodenum. 

A  microscopic  examination  of  a  tiny  piece 
scratched  from  the  surface  of  the  stone  showed 
the  same  typ*  of  cholesterin  crystals  found  in  the 
duodenal  contents  before  the  operation.  (Figs.  2 
and  3.) 

In  Case  I  the  diagnosis  had  been  made  of  angina 
pectoris  and  auricular  fibrillation.  The  direct  ex- 
amination showed  a  distinct  pathological  gallblad- 
der condition  and  led  to  a  correct  diagnosis. 

In  Case  II  duodenal  ulcer  appeared  to  be  the  dis- 
ease in  question  at  first,  the  deformity  of  the  cap 
revealed  by  the  x  ray  likewise  pointing  to  this.  The 
examination  of  the  bile,  again,  revealed  gallbladder 
disease,  while  the  string  test  negatived  the  pres- 
ence of  a  duodenal  ulcer. 

In  Case  III  the  symptoms  were  definite  enough 
to  make  a  diagnosis  of  gallstone  colic.  The  x  ray 
indicated  another  disease.  The  duodenal  bucket 
string  test  and  the  aspirated  bile,  however,  led  to  a 
correct  diagnosis,  which  found  full  corroboration 
at  the  operation. 

The  more  detailed  diagnosis  will  always  have  to 
be  made  by  a  combination  of  all  the  findings  (sub- 
jective and  objective)  present.  Thus,  turbid  bile, 
fever,  extensive  leucocytosis,  high  polynuclear 
count,  considerable  tenderness  in  the  right  hypo- 
chondrium,  in  conjunction  with  muscular  rigidity 
on  the  right  side,  will  point  toward  empyema  or  ul- 
ceration of  the  gallbladder  nearing  perforation. 
Severe  colicky  pains  in  the  right  hypochondrium. 
with  or  without  a  slight  rise  of  temperature,  fol- 
lowed a  few  hours  later  by  perfect  remissions  and 
freedom  from  pain,  will  speak  for  a  biliary  calculus. 
Turbid  bile  will  substantiate  the  diagnosis.  The 
same  symptom  complex,  with  jaundice  and  absence 
of  bile  in  the  duodenum,  will  indicate  a  stone  in  the 
choledochus  or  common  duct.  Intractable  jaundice, 
cachexia,  frequent  distress,  but  no  sharp  colicky 
pains,  preceding  the  icterus,  no  bile  in  the  duodenimi 
or  presence  at  times  of  clear  bile,  indicate  a  malig- 
nant disease  involving  the  choledochus,  or  the  hepa- 
tic ducts. 

The  treatment  of  gallbladder  diseases  can  be  di- 
vided into  that  of  the  acute  conditions,  and  that 
covering  chronic  states.  In  both  groups  medical  as 
well  as  surgical  therapy  have  their  special  fields. 

TREATMENT. 

In  acute  cholecystitis,  with  or  without  .stones,  the 
former  covering  all  colics  due  to  biliary  calculi,  treat- 
ment consists  of  absolute  rest,  hot  applications  and 
the  administration  of  an  opiate.  A  hypodermic  injec- 
tion of  morphine  with  or  without  atropine,  a  sup- 
pository of  opium  and  belladonna,  or  the  latter  with 
codeine,  \Vill  be  beneficial.  Hot  drinks  of  jilain 
water,  or  camomile  tea  are  useful.  Irrigation  of 
the  bowel  with  warm  .saline  and  the  addition  of 
essence  of  peppermint  (one  teaspoonful  to  a  quart), 
especially  when  there  has  been  no  defecation  for  a 
day  or  two — is  likewise  beneficial.  Usually  the 
acute  attack  subsides  in  from  one  to  three  days,  and 
there  is  either  a  return  to  the  normal  or,  more  fre- 
quently, to  a  kind  of  a  cjuicscent  or  latent  stage. 
-Acute  cholecystitis  of  great  toxicity,  giving  rise  to 


July  3,  1920.] 


HAYES:  GASTRIC  SUPERACIDITV. 


5 


empyema,  ulceration  or  a  perforation  of  the  gall- 
bladder, requires  immediate  surgical  intervention. 
Until  the  operation  is  performed  applications  of  ice 
over  the  right  hypochondrium,  the  administration 
of  opiates,  absolute  rest,  and  very  little  liquid  food 
form  the  principal  methods  of  treatment. 

The  treatment  of  recurring  cholecystitis,  with  or 
without  stones  during  the  latent  stage,  has  two  ob- 
jects, 1,  to  reduce  stagnation  of  bile,  and  2,  to  com- 
bat the  infection.  The  former  is  accomplished  by 
drinking  large  quantities  of  water.  Cures  at  Carls- 
bad, Kissingen,  Vichy,  Saratoga  or  French  Lick 
Springs  combine  the  advantages  of  water,  mild 
aperients,  and  restful  surroundings,  which  are  of 
benefit  for  establishing  a  healthy  liver  function. 
Frequent  and  small  meals  of  wholesome  food 
(mixed  diet,  with  plenty  of  green  vegetables  and 
fruits)  are  likewise  of  much  assistance  in  increas- 
ing the  flow  of  bile.  The  infection  is  best  com- 
batted  by  urotropine,  salicylic  acid,  salol,  aspirin, 
and  again  by  flushing  the  gastrointestinal  tract  with 
great  quantities  of  water.  I  found  that  glycerin 
given  in  teaspoonful  doses,  three  times  daily,  exerts 
an  antiputrefactive  action  on  the  bile.  Patients 
who  have  been  given  this  medicine  furnish  a  bile 
that  can  be  kept  from  one  to  two  days  without  de- 
composition, while  otherwise,  the  duodenal  secre- 
tion after  being  exposed  for  a  few  hours  in  the  air 
begins  to  smell  badly  and  in  about  six  hours  de- 
velops a  putrid  odor. 

This  led  me  ,to  prescribe  the  following  medica- 
tion which  I  frequently  give  in  these  cases  with  ad- 
vantage : 

Natr.  bicarbon   3ii 

Glycer.   pur   3" 

Aq.   dist   5v 

S.  5ss.  t.  i.  d.,  one  half  hour  a.  c. 

Antiseptic  and  astringent  solutions  can  likewise 
be  instilled  directly  into  the  duodenum,  in  order  to 
exert  a  beneficial  influence  in  this  locality,  which 
also  has  an  effect  on  the  biliary  passages.  Ichthyol 
(one  half  to  one  per  cent.)  or  argyrol  in  the  same 
strength  (blood  temperature)  can  be  thrown  into 
the  beginning  of  the  duodenum  in  amounts  of  from 
ten  to  twenty  c.  c.  daily  or  every  other  day  while 
the  patient  is  in  a  fasting  condition. 

When  biliary  calculi  are  known  to  exist  and  give 
rise  to  difficulties  through  their  migrations,  olive  oil 
administered  in  four  to  five  ounce  doses  once  or 
twice  daily,  has  been  believed  to  have  a  good  in- 
fluence on  the  passage  of  the  stones.  This  can  only 
refer  to  small  calculi ;  but  even  then,  the  effect  of 
the  oil  is  problematical.  Its  action,  however,  is 
never  harmful,  and  it  can  therefore  be  employed  in 
appropriate  cases. 

The  indications  for  surgery  in  chronic  cholecysti- 
tis (with  or  without  stones)  are  as  follows: 

1.  Comparatively  severe  recurrent  attacks  of 
cholecystitis,  whether  accompanied  by  fever  or  not, 
require  surgical  aid. 

2.  Mild  attacks  of  recurrent  cholecystitis  accom- 
panied by  a  moderate  leucocytosis  (especially  with 
an  increase  of  the  polynudear  cells)  likewise  re- 
quire operation. 

3.  Chronic  jaundice  due  to  obstruction  is  best 
handled  by  operative  measures. 


4.  Gallbladder  affections  in  which  there  is  suffi- 
cient reason  to  suspect  a  malignant  disease  should 
be  operated  upon  as  soon  as  possible. 

Contraindications  to  operative  measures  are  found 
in  severe  heart  or  kidney  lesions,  diabetes  mellitus, 
general  debility  and  old  age.  What  to  do  under  these 
circumstances  (whether  to  operate  or  not)  will  de- 
pend upon  the  severity  of  the  gallbladder  affection 
and  the  degree  of  involvement  of  other  organs.  No 
hard  and  fast  rules  can  be  laid  down.  A  careful 
consideration  of  the  danger  of  the  operation,  and 
the  benefit  to  be  obtained  by  it,  will  make  a  decision 
possible. 

REFERENCES. 

1.  EiNHORN,  Max:  Cases  of  Ischochymia  Simulating 
Gallstone  Disease,  American  Journal  of  Surgery,  June, 
1908. 

2.  Idem :  A  New  Method  of  Recognizing  Ulcers  of  the 
Upper  Digestive  Tract  and  Localizing  Them,  Medical  Rec- 
ord, April  3,  1909.  (Case  J.  F.  H.) 

3.  ASCHOFF  UND  Bacmeister  :  Cited  after  L.  Anspergr 
der  Gegenwartige  Stand  der  Pathologic  und  Therapie  der 
Gallenstein-Krankheit.  Albu :  Verdaimngs  und  Staffwcch- 
selkrankh.    Bd.  iii  H.  3,  1911. 

20  East  Sixty-Third  Street. 


GASTRIC  SUPERACIDITY. 
Causation  and  Treatment. 

By  William  Van  V.  Hayes,  M.  D., 
New  York. 

Formerly  Professor  of  Diseases  of  the  Digestive  System,  New  York 
Polyclinic  Hospital. 

Gastric  superacidity,  because  of  its  great  preval- 
ence, the  distress  or  pain  it  causes,  and  its  tendency 
to  progress  from  mild  to  severe  forms,  is  a  subject 
worthy  of  continued  study  as  to  its  causation  and 
treatment.  In  this  paper  the  various  forms  of 
gastric  superacidity  will  be  considered  as  a  group. 
This  includes  hyperchlorhydria,  in  which  the  gastric 
juice  is  too  rich  in  acid;  digestive  hyperchylia  (1), 
or  hypersecretion,  in  which  the  gastric  secretion  is 
excessive  in  amount,  and  usually  too  rich  in  hydro- 
chloric acid ;  also,  paroxysmal  hyperchylia  and 
chronic  hyperchylia  (gastrosuccorrhea  of  Reichman) 
(2)  in  which  there  is  a  continuous  gastric  secretion, 
even  when  the  stomach  does  not  contain  food.  These 
conditions,  intermittent  or  constant,  may  be  func- 
tional or  the  expression  of  organic  disease.  The 
milder  forms  are  likely  to  progress  to  the  severe 
ones.  Their  continuance  may  culminate  in  gastritis, 
the  production  of  gastric  or  duodenal  ulcer,  or 
marked  disturbance  of  intestinal  digestion. 

frequency. 

Einhorn  (3),  in  a  series  of  564  cases,  found  that 
286  had  an  acidity  of  sixty  or  over,  an  hour  after 
the  test  breakfast.  I  have  just  compiled  a  continu- 
ous alphabetical  series  of  300  cases,  in  which  the 
test  breakfast  was  used — 152  of  these  showed  a 
total  acidity  over  sixty;  eighty-seven  over  seventy; 
and  thirty-eight  over  eighty.  It  may  safely  be  con- 
cluded then,  that  about  half  the  private  patients 
complaining  of  indigestion,  presenting  themselves 
for  treatment  in  New  York,  have  an  excess  of  gas- 
tric acidity,  if  sixty  is  regarded  as  the  normal  limit. 

The  methods  which  I  usually  use  in  arriving  at  a 
diagnosis  of  gastric  superacidity  are : 


6 


HAYES:   GASTRIC  SUPERACIDITV. 


[Xew  York 
Medical  Journal. 


1.  The  Ewaid-Boas  test  breakfast.  One  roll, 
or  two  slices  of  bread  (about  seventy  gm.)  and  one 
and  a  half  glasses  of  w.ater  (350  c.  c.)  are  given  in 
the  morning  when  the  stomach  is  empty,  and  ex- 
pressed, or  preferably  aspirated,  with  a  bulb  spe- 
cially adapted  by  me,  an  hour  after  the  beginning 
of  the  meal  (Fig.  1).  When  the  aspiration  is  done, 
one  or  two  bulbs  of  air  are  injected  into  the  stomach 
to  smooth  out  the  rugae  before  the  gentle  suction 
is  employed.  After  a  portion  of  the  contents  is 
aspirated,  the  funnel  is  connected,  and  200  c.  c.  of 
water  thoroughly  mixed  with  the  remaining  con- 
tents, and  withdrawn.  This  permits  the  determi- 
nation of  the  total  quantity  of  contents.  (Method 
of  Mathieu  and  Reniond,  or  more  properly  fawor- 
ski)  (4). 

2.  Duration  test.  Two  soft  boiled  eggs,  seventy 
gm.  bread  with  butter,  and  a  glass  of  water,  are 


Fio.  1  — Dr.  Ha.ves's  a>i)irating  bull)  with  bevelled  glass  tip. 


given  in  the  morning.  Three  and  a  half  hours 
later  the  stomach,  which  should  be  empty,  is  tested 
as  in  the  case  of  the  Ewald-Boas  breakfast.  If 
for  any  reason  the  tube  is  not  used  at  this  time, 
splashing  or  gurgling  are  noted,  and  two  gm.  sodium 
bicarbonate  in  a  half  glass  of  water  is  given.  A 
notable  increase  in  gastric  tympany  points  to  high 
acidity. 

3.  The  introduction  of  the  tube  into  the  fasting 
stomach,  to  ascertain  if  there  is  continuous  secre- 
tion of  food  retention.  The  undiluted  and  diluted 
contents,  when  present,  are  obtained  and  the  deter- 
minations made  as  before.  Thus  the  acidity  is  de- 
termined in  the  early  stage  of  digestion — again  at  a 
time  when  after  stronger  stimulation  the  digestion 
should  be  completed ;  and  with  the  fasting  stomach 
— the  three  periods  of  special  importance  for  diag- 
nosis. Incidentally,  these  tests  give  valuable  infor- 
mation as  to  the  motor  function. 

ETIOLOGY. 

The  gastric  secretion  is  afifected  through  the 
nerves  by  mental  states,  nervous  diseases,  and  by 
reflexes  from  points  of  irritation,  especially  if  lo- 
cated in  the  abdomen,  and  of  these  particularly  by 
disturbance  in  the  gastrointestinal  tract  it.self.  or 
the  organs  directly  connected  with  it.  The  secretion 
is  also  directly  influenced  by  the  chemical  stimula- 
tion of  certain  food  elements  and  acid^  acting  on  the 
pyloric  mucous  membrane,  through  the  formation  of 
a  hormone  (5),  "which  acts  as  a  chemical  messenger 
to  all  parts  of  the  stomach,  being  absorbed  into  the 
blood  and  thence  exciting  the  activity  of  the  various 


secreting  cells  in  the  gastric  glands."  The  amount 
and  quality  of  the  gastric  juice  is  also  affected  by 
the  motor  function  of  the  stomach.  For  example : 
Food  held  back  in  the  stomach,  owing  to  spasm  or 
obstruction,  may  cause  an  abnormal  increase  in  se- 
cretion. The  endocrine  balance  and  other  factors 
also  have  a  bearing  upon  it. 

The  following,  therefore,  may  be  mentioned 
among  the  common  causes  of  gastric  superacidity : 

1.  Continued  mental  strain,  vexation  and  dis- 
turbing care,  have  long  been  held  by  leading  clin- 
icians to  be  important  etiological  factors.  This  is 
doubtless  true,  despite  the  fact  that  the  immediate 
effect  of  these  emotions  in  animals  (6)  and  man 
is  to  diminish  the  secretory  and  motor  activity  of  the 
stomach.  The  overworked  student,  the  worried 
broker,  and  the  sensitive  householder  who  cannot 
make  ends  meet,  are  ready  victims  of  superacidity. 
With  the  present  world  wide  conditions,  promoting 
a])prehension  and  mental  distress,  it  will  be  strange 
if  there  is  not  a  notable  increase  in  the  type  of  dis- 
ease we  are  considering. 

2.  Gastric  or  duodena!  ulcer,  cholecystitis,  chole- 
lithiasis and  chronic  appendicitis,  appear  to  cause 
supersecretion,  by  disturbing  the  vagosympathetic 
balance,  inducing  pyloric  spasm.  Troublesome 
hemorrhoids  may  act  in  the  same  way.  When 
these  conditions  are  painful,  there  is  also  a  mental 
element  in  aggravating  the  difficulty. 

3.  Rogers  (7)  and  his  coworkers  have  shown 
that  the  subcutaneous  administration  of  adrenal  ex- 
tracts, particularly  the  adrenal  nucleoproteids,  dimin- 
ishes the  secretion  of  the  gastric  juice,  presumably 
by  stimulating  the  sympathetic,  or  inhibiting  nerves, 
and  that  extracts  of  the  pituitary  gland  have  a 
similar  action  but  less  intense ;  whereas  certain  thy- 
roid, parathyroid,  thymus,  spleen,  liver  and  paCh- 
creas  extracts  increase  the  gastric  secretion,  ap- 
parently through  the  vagi,  or  activating  nerves. 
Rehfuss  (8)  reports  two  cases  of  total  achylia  in 
which  the  administration  of  parathyroid  was  partly 
responsible  for  a  definite  increase  in  secretion.  We 
may,  therefore,  infer,  that  any  condition  in  the  body 
disturbing  the  balance  of  these  important  internal 
secretions  will  markedly  influence  the  gastric  secre- 
tion. 

4.  Unsuitable  food  and  drink :  excess  of  nitro- 
genous food ;  thermal,  mechanical,  or  chemical  irri- 
tants, as  very  hot  and  very  cold  drinks,  coarse  foods 
which  are  not  or  cannot  be  properly  masticated ;  al- 
coholic beverages,  strong  tea  and  coffee ;  highly  sea- 
soned foods,  and  excess  of  sugar  may  induce  super- 
acidity. It  is  said  that  "in  the  United  States  the 
consumption  of  sugar  per  capita  a  year  has  gradu- 
ally increased  from  eighteen  to  over  eighty  pounds 
in  the  past  fifty  years."  May  this  not  be  a  potent 
factor  in  causing  such  widespread  superacidity? 

5.  Partial  obstruction  of  the  passage  of  food 
through  any  portion  of  the  gastroenteric  tract,  with 
the  associated  reflex  irritation  and  toxemia,  is  proba- 
1)1\'  responsible  for  a  large  group  of  overacid  condi- 
tions. There  may  be  adhesions  or  bands  between 
gallbladder  and  pylorus,  duodenum  or  colon ;  dense 
bands  at  the  duodenojejtmal  junction,  or  Lane  kinks 
in  the  ileum ;  or  bands  compressing  the  colon  or 
dragging  it  out  of  position.    Ptosis  of  the  stomach 


July  3,  1920.] 


HAYES:   GASTRIC  SUPERACIDITY. 


7 


or  transverse  colon,  or  a  too  free  movement  of  the 
cecum,  permitting  sagging  and  torsion,  may  bring 
about  the  saine  result. 

Lockwood  (9)  states :  "As  a  clinical  fact,  when- 
ever food  exit  is  delayed,  hyperacidity  appears,  and 
the  more  careful  is  our  examination  of  patients 
with  hyperacidity,  the  larger  is  the  number  of  gas- 
tric atonies  and  motor  errors  of  insufficiency  that 
are  discovered."  Any  condition  resulting  in  consid- 
erable delay  in  the  passage  of  food  through  the 
small  intestine,  I  believe  tends  to  induce  gastric 
superacidity  in  an  undamaged  stomach.  Associated 
toxemia  is  no  doubt  an  important  contributory  fac- 
tor. Pelvic  diseases  in  women  patients  should  not  be 
overlooked. 

TREATMENT. 

Gastric  superacidity,  if  at  all  prolonged,  should 
be  regarded  with  suspicion,  and  be  given  the  care- 
ful treatment  it  deserves.  The  tendency,  as  pre- 
viously stated,  is  for  the  mild  conditions  to  develop 
into  the  more  severe  forms,  and  a  neglected  hyper- 
chlorhydria  may  in  time  bring  on  a  gastric  or  duo- 
denal ulcer.  It  is  important  to  differentiate  between 
the  functional  cases  and  those  due  to  organic  dis- 
ease, in  planning  the  mode  of  treatment,  and  at  times 
it  is  extremely  difficult  to  do  this;  for  example, 
with  obscure  adhesions,  or  a  latent  chronic  appen- 
dicitis. Fenwick  (10)  believes  that  continuous  se- 
cretion invariably  indicates  organic  trouble  (gastric 
or  duodenal  ulcer,  gallstones  or  chronic  appendi- 
citis). Whether  or  not  this  is  true,  there  can  be 
no  doubt  that  with  cases  of  this  type,  painstaking 
and  persistent  search  should  be  made  for  structural 
disease.  Usually,  if  all  the  means  at  our  disposal 
including  the  x  ray  are  employed,  the  diagnosis  can 
be  made,  and  the  treatment  planned  accordingly.  As 
in  other  branches  of  medicine,  it  is  important  to 
correct,  if  possible,  the  cause  of  the  disturbance. 
If  there  is  a  serious  organic  difficulty,  gallstones, 
ulcer  too  severe  or  deepseated  for  medical  cure, 
pyloric  carcinoma  (an  occasional  cause  of  superacid- 
ity), bad  displacement,  or  other  mechanical  condi- 
tions not  controlled  by  suitable  support  of  the  abdo- 
men, or  other  remedial  measures,  surgery  is  clearly 
indicated.  For  the  borderline  cases,  marked  hyper- 
chylia,  intermittent  or  chronic,  including  continuous 
secretion,  medical  treatment  should  be  given  a  fair 
trial.  For  the  milder  cases,  the  treatment,  of  course, 
should  be  medical. 

It  must  be  made  clear  to  the  patient  at  the  out- 
set that  these  conditions  are  slow  in  developing 
and  that  it  will  take  persistence  and  honest  coopera- 
tion on  his  part  to  effect  a  cure.  The  essentials 
in  bringing  about  and  holding  improvement,  are 
the  maintenance  of  a  right  state  of  mind — calm, 
cheerful,  and  hopeful;  the  taking  of  a  correct  diet, 
at  the  right  times  and  in  the  right  way,  and  living 
in  a  physiological  manner  in  the  matter  of  suitable 
exercise,  sleep,  bathing,  and  dress.  It  is  a  matter  of 
common  experience  that  these  patients  are  often 
relieved  by  a  change  of  scene  and  occupation,  only 
to  have  their  symptoms  recur  on  resuming  their 
work,  with  its  attendant  cares.  At  times  they  recur 
with  added  force  because  of  indiscretions  in  diet 
while  the  patient  was  away.    Therefore,  the  treat- 


ment should  first  be  well  started,  and  the  patient 
intelligent  and  conscientious  in  carrying  out  instruc- 
tions, if  much  benefit  is  to  be  derived  from  travel. 

DIETETIC  MANAGEMENT. 

The  diet  must  be  prescribed  for  each  patient.  A 
theoretically  correct  diet  is  given,  and  this  is  then 
modified  according  to  special  indications,  the  re- 
sponse to  treatment  and  the  progress  toward  normal 
digestion,  particular  effort  being  made  to  reduce 
acidity,  maintain  comfort,  prevent  flatulence,  and 
keep  the  urine  indican  free. 

All  food  should  be  masticated  to  a  fine  pulp. 
For  patients  who  cannot  or  will  not  chew  thorough!} 
the  food  must,  in  preparation,  be  finely  subdivided. 
Even  then  it  must  be  eaten  slowly  so  as  to  be  well 
insalivated.  It  is  most  important  that  the  teeth  be 
free  from  caries  and  abscesses,  and  be  put  in  the 
best  possible  condition.  The  omission  of  this  may 
be  responsible  for  failure  to  improve.  While  it  is 
essential  to  give  food  of  the  right  quality,  proteids. 
carbohydrates,  fats,  salts,  and  vitamines,  in  such 
amounts  as  to  meet  the  nutritional  needs  of  the 
patient,  an  effort  is  made  to  avoid  irritants  in  the 
diet,  whether  chemical,  mechanical  or  thermal ; 
consequently,  mustard,  pepper,  horseradish,  radishes, 
vinegar,  sour  tomatoes,  strawberries,  meat  extrac- 
tives, strong  tea,  strong  coffee,  or  concentrated 
sweets  are  forbidden  or  greatly  restricted.  Vege- 
tables with  coarse,  firm  texture,  seeds  of  grapes 
and  berries,  skins  of  fruit  or  potato  skins,  fall  in 
the  group  of  mechanical  irritants,  and  while  Pavlov 
(11)  has  shown  that  mechanical  stimulation  of  a 
healthy  dog's  stomach  does  not  directly  stimulate 
secretion,  there  can  be  no  reasonable  doubt  that 
at  least  indirectly  coarse  foods  aggravate  the  trou- 
■bles  which  are  being  considered.  Under  thermal 
irritants  are  included  very  hot  and  very  cold  drinks, 
and  ices  if  taken  rapidly. 

Foods  should  be  chosen  which  do  not  remain  long 
in  the  stomach.  Usually  three  meals  are  given,  at 
five  to  six  hour  intervals ;  though  it  is  sometimes 
better  to  arrange  at  first  for  three  inoderate  meals, 
made  up  chiefly  of  milk,  cream,  whites  of  eggs, 
cereals,  dried  toasted  bread  and  butter,  at  eight,  one 
and  six-thirty,  and  then  give  a  cup  of  malted  milk, 
weak  cocoa  or  plain  milk  at  eleven,  four  and  bed- 
time. I  agree  with  Bassler  (12)  that  if  a  high  pro- 
teid  diet  is  employed,  it  should  only  be  as  a  tem- 
porary expedient,  to  be  gradually  diminished  to  a 
normal  percentage  as  soon  as  the  comfort  of  the  pa- 
tient permits  it.  Beginning  with  a  simple  diet,  the 
bill  of  fare  may  be  gradually  advanced  to  include 
most  of  the  articles  in  the  following  list : 

Egg  albumen,  raw  or  lightly  cooked ;  milk,  plain 
if  slowly  sipped,  or  made  into  soups  with  vegetable 
flavoring;  plain  junket  eaten  with  cream  and  a  little 
sugar ;  weak  cocoa,  or  digestible  cocoa,  made  with 
milk ;  malted  milk,  and  similar  preparations  added  to 
milk. 

Fine  wheat  cereals  and  rice  well  done ;  these  may 
be  cooked  in  water  or  may  be  given  in  milk.  Fine 
hominy,  oatmeal,  cornmeal,  macaroni  or  spaghetti, 
very  thoroughly  cooked,  may  be  used  in  suitable 
cases.  Bread  is  best  given  dried  and  toasted.  The 
addition  of  raw  whites  of  eggs  to  the  cereals  is  fre- 


8  HAVES:  GASTl 

quently  advantageous.  Sugar  should  be  taken  spar- 
ingly; salt  very  moderately. 

Cream,  good  butter  (without  butyric  odor),  and 
a  little  olive  oil  are  the  most  suitable  fats.  Yolks 
of  eggs  are  rich  in  fats,  but  should  be  used  spar- 
ingly as  they  often  cause  distress.  Fats,  while 
somewhat  diminishing  acidity,  tend  to  prolong  diges- 
tion, and  consequently  must  be  given  with  some 
caution.  Moreover,  there  is  no  advantage  in  giving 
fats  so  freely  that  they  disturb  the  intestinal  diges- 
tion, and  pass  off  in  large  quantities  by  rectum. 

Tender  flesh  foods ;  preferably  white  meated  fish, 
chicken  and  lamb  with  extractives  diminished  by 
boiling,  are  generally  the  best  foods  of  this  type. 
As  the  patient  improves,  these  may  be  given  roasted 
or  broiled,  and  to  enlarge  the  bill  of  fare,  beef,  freed 
from  fibre,  or  roast  beef  or  steak.  Tender  fresh 
vegetables,  such  as  string  beans,  peas,  celery,  spin- 
,  ach,  summer  squash,  tips  of  asparagus,  and  some- 
times young  carrots  well  stewed,  may  be  given  to  pa- 
tients who  can  and  will  masticate  thoroughly ;  other- 
wise, they  should  be  made  into  purees  or  cream 
soups.  Potatoes,  mashed,  baked,  or  twice  baked,  are 
allowed  when  flatulence  is  slight.  Simple  cereal  pud- 
dings; rice,  sago,  tapioca,  if  well  cooked,  or  cus- 
tard made  with  milk,  whites  of  eggs  and  about  half 
the  amount  of  egg  yolks  usually  employed;  and 
vanilla  ice  cream,  made  with  comparatively  little 
sugar  (to  be  eaten  very  slowly),  are  types  of  suit- 
able desserts. 

Stewed  fruits  (sweet  prunes,  peaches.  Bartlett 
pears),  the  pulp  of  a  sweet  orange,  or  sometimes 
half  a  grapefruit  (if  eaten  very  slowly)  may  be 
eaten  to  finish  the  meal. 

MEDICATION. 

Alkalies  are  surprisingly  helpful  as  a  rule  in  in- 
creasing comfort,  and  render  important  service  in  this 
way  and  by  protecting  the  mucous  membrane  from 
the  irritating  action  of  a  highly  acid  gastric  juice. 
Unfortimately,  in  some  cases  they  seem  to  heighten 
the  activity  of  the  gastric  glands,  so  that  after  weeks 
of  alkaline  medication  the  test  meal  may  show  dis- 
tinctly higher  figures.  Five  grains  each  of  bismuth 
subnitrate,  heavy  oxide  of  magnesia  and  sodium  bi- 
carbonate, stirred  into  a  glass  of  water,  may  be 
given  two  or  three  hours  after  meals,  or  about  fif- 
teen minutes  before  the  disagreeable  symptoms  usu- 
ally appear,  and  be  repeated  if  necessary.  From 
one  quarter  to  one  half  a  teaspoonful  of  a  mixture 
of  equal  parts  of  sodium  bicarbonate  and  sodium 
citrate  are  employed  in  the  same  manner.  Mag- 
nesia is  valuable  as  an  antacid  and  laxative,  but 
may  cause  intestinal  irritation  if  used  too  freely,  or 
for  a  long  time.  Precipitated  calcium  carbonate 
may  be  substituted  for  the  magnesia  if  the  bowels 
are  too  active.  Bismuth  subnitrate  given  in  dram 
doses,  in  water,  an  hour  before  breakfast,  is  very 
helpful ;  possibly  in  part  from  a  mechanically  protec- 
tive action. 

Adrenal  nucleoproteid  (13)  and  adrenal  extract 
(14)  seem  to  be  of  distinct  value  in  some  cases; 
but  my  experience  with  these  is  still  too  limited  to 
draw  definite  conclusions.  Belladonna,  one  to  five 
minims  of  the  tincture  before  meals,  often  definitely 
diminishes  distress ;  apparently  from  its  sedative  ac- 


C   SUPERACIDITY.  [New  York 

^[KDICAI,  Journal. 

tion,  reducing  the  tendency  to  pyloric  .-.pasm.  Stron- 
tuim  bromide,  in  five  to  ten  grain  doses,  is  some- 
tnnes  helpful  for  a  short  time.  Taka  diastase  five 
grams,  given  during  the  first  half  of  each  ineal, 
IS  often  highly  useful  in  aiding  the  action  of  the 
sahva,  before  it  is  checked  by  the  acid  secretion, 
resulting  in  better  digestion  and  greatlv  diminished 
gas  formation.  Opium  and  its  derivatives  should 
rarely  be  employed,  and  then  onl\-  in  the  severe  at- 
tacks for  a  very  brief  period. 

If  there  is  associated  constipation,  the  patient  is 
taught  to  massage  his  abdomen,  and  onlv  the  bland- 
est laxatives  should  be  prescribed,  such'  as  purified 
petrolatum  or  liquid  petrolatum  (heavvj.  a  half  to 
one  ounce  at  bedtime.    Agar,  finely  flaked,  plain  or 
medicated  with  cascara,  phenolphthalein  or  rhubarb, 
one  or  two  teaspoonfuls,  softened  in  water,  after 
meals.    Calcined  magnesia,  ten  to  twentv  grains, 
stirred  in  water,  at  bedtime:  compound  licorice 
water,  one  or  two  drams,  at  bedtime ;  or  fluid  extract 
of  cascara,  freed  from  the  bitter  principle,  a  half 
dram  at  bedtime.  Small  doses  of  calomel  are  occa- 
sionally prescribed,  or  if  need  be,  a  dose  of  castor  oil. 
Enemata  or  colonic  flushing  may  be  advantageous. 
If,  owing  to  dietetic  indiscretion,  or  unknown  cause, 
there  is  marked  nausea,  pain  and  vomiting,  the 
stomach  should  be  emptied  by  tube  if  necessary,  the 
bowels  cleansed  by  enema,  and  one  pint  of  water 
containing    glucose,    a    half    ounce,    and  sodium 
bicarbonate,  a  half  dram,  given  by  rectum.  Murphy 
drip  method,  two  or  three  times  daily;  no  food 
by  stomach  for  a  day  or  two ;  then  albumen  water ; 
later  milk  and  bland  soft  diet.    A  warm  compress 
over  the  stomach  may  also  be  employed  with  ad- 
vantage.   Lavage  is  not  necessary  in  the  mild  cases. 
\Mth  marked  hyperchylia  (gastrosuccorrhea) ,  bene- 
fit is  derived  from  washing  the  stomach  with  a  one 
per  cent,  sodium  bicarbonate  solution,  or  with  plain 
warm  water,  followed  by  a  one  to  two  thousandths 
solution  of  nitrate  of  .silver  (14),  or  a  nitrate  of 
silver  .spray  (method  of  Einhorn)  (15j.  EiYective 
abdominal  support  is  essential  for  patients  with  pto- 
sis.   This  is  given  by  means  of  a  spring  supporter, 
belt  or  corset,  as  is  most  suitable  for  the  patient. 

In  conclusion,  I  may  say  regarding  tlie  entire  sub- 
ject of  gastric  superacidity  that  although  the  meth- 
ods described  are  fairly  .satisfactory,  there  is  need 
for  continued  research  and  experimentation,  in  order 
that  the  treatment  may  be  established  on  more  scien- 
tific lines. 

REFERENCES. 

1.  Van-  Valz.ah  and  Nisbet:  Diseases  oi  the  Stomach 
pp.  295-299. 

2.  Reichman:  Berlin  kliiiische  wocheuschrift .  1882,  No. 
40,  p.  606  and  1887,  No.  12. 

3.  Einhorn  :  Medical  Record,  November  23,  1895,  p.  725. 

4.  Van  Valzah  and  Nisbet:  Diseases  of  the  Stomach. 
p.  133. 

5.  Starung,  Ernest  H.  :  Recent  Advances  in  the  Physi- 
ology of  Digestion,  Chicago,  1906,  p.  76.  Edkins,  J.  S. : 
The  Chemical  Mechanism  of  Gastric  Secretion,  Journal  of 
Physiology,  xxxlv,  1906,  p.  133. 

6.  Cannon:    Bodily  Changes  in  Pain,  Hunger,  Fear, 
and  Rage,  pp.  11  and  16. 

7.  Rogers  :  The  Stimulation  and  Inhibition  of  the  Gas- 
tric Secretion  with  Follows  the  Subcutaneous  Administra- 
tion of  Certain  Organic  E.xtracts.    John  Rogers,  Jessie 


July  i  1920.] 


BASCH  : 


SARCOMA   OF  STOMACH. 


9 


M.  Rabe,  and  Eliza  Ablehadian.  American  Journal  of 
Physiology,  Vol.  xlviii,  Xo.  1. 

8.  Rehfuss,  Martix  E.  :  An  Analysis  of  Achyha  Gas- 
trica,  American  Journal  of  the  Medical  Sciences,  July,  1915, 
No,  1,  Vol.  cl,  p.  72. 

9.  LocKWOOD,  George  R.  :  Diseases  of  the  Stomach,  p. 
463. 

lb.  Fenwick,  W.  S.:  Dyspcl>sia,  Its  l^aricties  and 
Treatment,  p.  61. 

11.  Pavlov:  The  IV ork  of  the  Digestive  Glands,  Second 
English  Edition,  p.  105. 

12.  Bassler:  Diseases  of  the  Stomach  and  Upper  Ali- 
mentary Tract.    1916,  p.  774. 

13.  Rogers,  Rabe,  Fawcett  and  Hackettj  The  Ameri- 
can Journal  of  Physiology.  1916,  xxxix.  345. 

14.  Reichmax  recommends  the  employment  of  nitrate 
of  silver  with  a  strength  of  1-1000  to  1-500.  Quoted  by 
EixHORX.    Diseases  of  the  Stomach,  p.  361.. 

722  Park  Avenue. 

PRIMARY  SACOMA  OF  THE  STOMACH.* 

Report  of  a  Successfully  Operated  Case. 

By  Seymour  Basch,  IM.  D.. 
New  York, 

Clinical  Professor  of  Medicine  at  Fordham  University  Medical 
School;  Attending  Physician  to  Lebanon  Hospital. 

The  subject  of  primary  sarcoma  of  the  stomach 
is  of  far  greater  cHnical  importance  than  is  gen- 
erally assumed.  A  careful  study  of  the  literature 
shows  it  to  be  of  more  frequent  occurrence  than 
individual  experience  would  lead  one  to  infer. 

Relatively  speaking,  gastric  sarcoma  has  more 
often  been  the  subject  of  mistaken  diagnosis  than 
perhaps  any  other  gastric  condition.  In  many  in- 
stances the  clinical  and  operative  diagnosis  has  been 
in  doubt  until  cleared  up  by  the  ultimate  histologi- 
cal examination.  In  such  cases  the  presumptive 
diagnosis  has  almost  invariably  l^een  cancer.  Gas- 
tric sarcoma  has,  however,  been  mistaken  also  for 
many  other  intragastric  and  extragastric  conditions, 
e.  g.,  neoplasms  of  the  spleen,  tuberculotis  abdominal 
glands,  abscess  of  the  liver,  stipptirative  peritonitis, 
pancreatic  growths,  benign  peptic,  ulcer  with  sec- 
ondary infiltrating  tumor,  and  many  other  condi- 
tions. 

The  character  of  this  neoplasm  varies  so  widely 
in  the  different  varieties,  from  extreme  malignancy 
down  to  almost  certain  promise  of  radical  cure, 
that  attention  to  the  possibility  of  its  occurrence, 
as  well  as  to  its  early  diagnosis,  are  matters  of 
the  utmost  importance.  In  numerous  instances  the 
diagnosis  has  been  made  so  late  in  the  cottrse  of 
the  disease  that  operative  interference  was  tanta- 
mount to  an  antemortem  procedure.  \Yhere,  how- 
ever, early  operation  was  undertaken,  radical  cure, 
or  at  least  freedom  from  recurrence  for  a  num- 
ber of  years,  has  frequently  been  obtained.  It 
has  been  my  fortune  to  have  encountered  such  an 
early  case,  and  I  present  it  herewith  in  the  hope 
of  stimulating  interest  in  this  comparatively  rare 
disease,  and  also  of  evoking  an  active  discussion  of 
the  various  phases  of  the  subject. 

Case  I. — The  patient,  C.  C,  aged  twenty-two 
years,  dressmaker,  was  first  seen  by  me  on  Janti- 
ary  1,  1919,  in  consultation  with  Dr.  Joshua  Leiner. 
The  family  history,  aside  from  the  death  of  her 

'Presented  before  the  American  Gastroenterological  Association, 
at  its  twenty-second  annual  meeting,  .Atlantic  City,  N.  J.,  June,  1919. 


father  from  gastric  carcinoma,  was  negative.  The 
patient  herself,  though  a  moderate  eater  and  some- 
what constipated,  had  always  been  stout  and  en- 
joyed excellent  health.  She  dated  her  present  ill- 
ness back  to  about  one  year  before,  when,  follow- 
ing a  dietary  error,  she  suffered  from  what  she 
termed  an  attack  of  acute  indigestion.  A  laxative 
was  followed  by  temporary  relief  for  about  three 
weeks,  when  she  began  to  experience  frequent  at- 
tacks of  sharp  cutting  pains  in  the  right  hypochon- 
drium  and  anterior  lumbar  regions.  These  began 
several  hours  after  meals  and  lasted  three  or  four 
hours  each  time.  They  were  associated  with  heart- 
burn and  freqtient  belching  of  sour  or  tasteless 
gases.  The  distress  was  so  acute  that  relief  was 
sought  through  forced  vomiting.  The  amounts 
vomited,  especially  of  late,  exceeded  those  ingested, 
although  food  from  previous  days  was  never  noted. 
Meat  and  other  heavy  foods  increased  the  pains, 
while  fltiids  often  gave  relief.  The  pains,  vomit- 
ing and  other  manifestations,  had  markedly  in- 
creased during  the  past  three  or  four  months,  dur- 
ing which  period,  too,  there  had  also  been  a  loss 
of  about  twenty-five  potinds  in  weight.  There  was 
no  history  of  fever,  cough,  sweats,  hematemesis  or 
melena. 

Examination  showed  a  thin,  anemic,  and  rather 
feeble  individual,  without,  however,  any  evidence 
of  systemic  or  central  nervous  disease.  The  ab- 
dominal wall  was  thin,  soft,  and  relaxed,  and  the  ab- 
domen therefore  readily  palpable.  In  the  right  hypo- 
chondriacal and  lumbar  regions,  somewhat  to  the 
right  of  the  usual  duodenal  area,  a  hard  globular 
mass,  about  three  inches  in  diameter,  could  be  eas- 
ily felt.  It  was  smooth  in  outline,  qtiite  tender 
to  the  touch,  and  freely  movable.  It  was 
especially  well  felt  when  the  patient  arched  her 
back  forward,  thus  stretching  the  anterior  abdom- 
inal wall.  Its  density  and  firmness  reminded  one 
forcibly  of  indurated  tuberctilous  abdominal  glands. 

The  stomach  was  considerably  enlarged  to  per- 
cussion, the  greater  curvattire  being  two  or  three 
inches  below  the  umbilicus.  There  was  no  visible 
peristalsis  or  gastric  stiffening,  no  resistance,  no 
other  points  of  tenderness,  or  any  other  palpable 
masses.  The  free  edge  of  the  liver  was  felt  about 
two  inches  below  the  costal  margin.  It  was.  how- 
ever, normal  to  the  touch.  The  spleen  and  left  kid- 
ney could  not  be  felt,  thotigh  the  right  kidney  was 
prolapsed  to  the  second  degree.  It  was  not  sensitive 
to  the  touch  and  apparently  normal. 

For  the  purposes  of  better  observation  and 
treatment,  the  patient  was  admitted  to  Lebanon 
Hospital  on  January  3rd.  Temperature,  pulse,  and 
respiration  were  normal :  the  blood  pressure  av- 
eraged 105  .systolic  and  75  diastolic.  Occasionally 
pains  of  moderate  severity  were  felt  in  the  right 
upper  quadrant.  She  was  placed  tipon  a  soft  diet 
which  was  for  the  most  part  retained,  although 
several  times  there  w-ere  attacks  of  slight  or  even 
profuse  vomiting,  which,  however,  never  was  san- 
guineous, btit  always  contained  rather  large  amounts 
of  mucus.  The  appetite  was  good.  The  Wasser- 
mann  reaction  was  negative.  Examination  of  both 
the  tirine  and  feces  proved  negative.  Two  string 
tests  were  attempted,  but  proved  tinsuccessiul  as  the 


10 


BASCH : 


SARCOMA  OF  STOMACH. 


[New  Y<*iK 
Medical  Journal. 


patient  vomited  each  time.  Retention  tests  were 
also  vomited,  but  one  or  two  successful  ones  showed 
evidences  of  partial  pyloric  obstruction,  viz.,  a  few 
ounces  of  stomach  contents,  containing  some  of 
the  barley  and  meat  from  the  previous  evening 
meal,  as  well  as  a  large  number  of  sarcinse.  There 
was  no  gastrosuccorrhea.  In  the  fasting  state  the 
free  hydrochloric  acid  was  ten  and  the  total  acid- 
ity sixty-four;  after  the  Ewald-Boas  test  breakfast 
there  was  thirty  free  hydrochloric  acid  and  eighty 
total  acidity.    Lactic  acid  was  never  present. 

Diagnostic  considerations. — It  was  seen  that  we 
were  dealing  with  an  indurated  tumor  mass  located 
in  the  middle  area  of  the  right  side  of  the  abdo- 
men ;  this  mass  was  definitely  circumscribed,  eas- 
ily palpable,  freely  movable,  and  rather  tender  to 
the  touch.  The  tumor  was  causing  a  partial  pyloric 
obstruction,  pronounced  abdominal  pains,  frequent 
attacks  of  vomiting  and  sitophobia,  and  was  asso- 
ciated with  a  rapid  loss  in  weight  and  strength. 
There  was  no  evidence  of  gastrointestinal  hemor- 
rhage. 

Two  pertinent  points  of  interest  presented  them- 
selves for  discussion,  viz.,  the  nature  of  the  tumor 
and  whether  it  was  of  intragastric  or  extragastric 
origin.  Although  the  patient  was  examined  by  a 
number  of  careful  and  experienced  observers,  no 
positive  conclusion  as  to  the  nature  of  the  tumor 
was  reached.  Neither  the  clinical  course  nor  the 
objective  findings  oftered  sufficiently  acceptable 
criteria  for  an  indisputable  diagnosis.  The 
history  of  the  case  and  the  presence  of  an 
indurated  tumor  were  strongly  indicative  of 
a  malignant  growth,  and,  in  an  older  individual, 
particularly  with  a  longer  history  of  gas- 
tric distress,  the  recent  and  rapidly  progressive 
downward  course,  such  a  diagnosis  would  have  been 
justified.  But  the  age  of  the  patient,  the  absence  of 
free  and  of  occult  blood,  the  presence  of  sarcinae 
and  of  a  high  degree  of  hydrochloric  acid,  were  fac- 
tors that  spoke  strongly  against  malignant  disease, 
and  favored  rather  the  existence  of  a  benign  pro- 
fess. It  was  felt  that  we  were  dealing  here  most 
probably  with  a  pyloric  ulcer  associated  with  pro- 
nounced inflammatory  changes.  Sarcoma  was  not 
even  thought  of.  The  tumor  itself  was  freely  mov- 
able;  its  situation  was  low  for  the  pylorus,  and  the 
obstruction  was  only  a  partial  and  not  a  constant 
one.  These  facts  led  the  greater  number  of  observers 
therefore  to  favor  the  diagnosis  of  an  extragastric 
lesion  with  inflammatory  changes,  resulting  adhe- 
sions and  partial  obstruction  to  the  pyloric  outlet. 
Among  the  other  diagnoses  suggested  were  omental 
tumor,  inflamed  adherent  gallbladder,  tuberculous 
peritoneal  glands,  indurated'  inflammatory  cyst,  and 
even  chronic  appendicitis,  situated  unusually  high. 
Discussion  of  the  pros  and  cons  for  these  various 
opinions  is  unnecessary. 

The  rontgenological  examination  pointed  de- 
cidedly to  an  intragastric  lesion.  The  report  stated 
that  the  stomach  was  enormou.sly  enlarged,  mark- 
edly ptosed  and  atonic,  with  extremely  sluggish  per- 
istalsis and  a  large  residue  after  six  and  even  after 
twenty-four  hours.  The  duodenum  was  difficult  to 
visualize,  but  the  first  portion  and  also  the  pyloric 
end  of  the  stomach  appeared  decidedly  pathological. 


The  rontgenological  diagnosis  was  "gastrectasy  with 
marked  pyloric  obstruction,  evidently  due  to  an  or- 
ganic lesion  involving  the  pyloric  end  of  the  stom- 
ach and  the  first  portion  of  the  duodenum." 

In  view  of  all  the  facts  mentioned  above  the  case 
was  regarded  unquestionably  as  a  surgical  one. 
Operative  interference  was  advised  and  consented 
to.  The  operation  was  performed  by  Dr.  Henry 
Roth  on  January  12th,  ten  days  after  the  patient's 
admission  to  the  hospital.  A  median  line  upper  ab- 
dominal incision  was  made.  The  stomach  was 
found  to  be  very  large  and  dilated  and  freely  mov- 
able. The  duodenum,  too,  was  freely  movable,  but 
apparently  normal.  In  the  pyloric  portion  of  the 
stomach  there  was  seen  and  felt  a  large  indurated 
mass,  occupying  the  greater  portion  of  the  antrum 
and  extending  down  close  to  the  pyloric  ring.  It 
was  situated  intramurally,  the  serous  coat  being  in- 
tact. The  tumor  surface  and  outline  were  smooth, 
and  while  the  mass  strongly  suggested  an  inflamma- 
torj-  infiltration,  such  as  one  so  often  finds  associ- 
ated with  chronic  ulcerative  obstruction,  Dr.  Roth 
was  decidedly  of  the  opinion  that  it  had  the  indura- 
tion of  a  malignant  process.  Because  of  this  fact,  and 
also  because  of  the  sharply  circumscribed  area  and 
free  mobility  of  the  tumor  mass,  a  complete  resec- 
tion was  decided  upon.  Thereupon,  a  typical  Mayo 
cautery  resection,  which  included  the  postpyloric 
portion  of  the  duodenum  and  the  stomach  antrum 
just  proximal  to  the  tumor  margin,  was  carried  out. 
This  procedure  was  followed  by  a  typical  posterior 
gastroenterostomy,  done  without  the  use  of  clamps. 
Careful  exploration  of  the  entire  abdomen  failed  to 
show  the  presence  of  any  other  growth.  The  wound 
was  closed  in  the  usual  manner,  leaving  a  rubber 
tissue  drain  in  the  duodenal,  stump. 

The  postoperative  course  during  the  first  two 
weeks  was  marked  by  fever  ranging  from  102°  to 
104°  F.,  and  a  disturbed  mental  state  (psychosis) 
manifesting  itself  through  extreme  loquaciousness, 
irritability,  distrustfulness  of  attending  nurses  and 
doctors,  and  a  fixed  stare  with  failure  to  reply  to 
direct  inquiries.  On  the  thirteenth  day  after  oper- 
ation there  was  a  sudden  profuse  discharge  of  a 
purulent  secretion  from  the  wound,  followed  by  a 
rapid  drop  in  the  temperature,  and  an  improvement 
in  the  mental  state^.  Thereafter  recovery  was 
progressive,  and  the  patient  was  discharged  from 
the  hospital  on  the  twentieth  postoperative  day. 
She  has  steadily  improved,  and  now.  five  months 
after  her  operation,  feels  well  and  has  gained  over 
thirty  pounds.  In  April,  1920.  fifteen  months  af- 
ter her  operation,  the  patient  was  feeling  very  well 
and  had  gained  fifty  pounds  in  weight. 

The  gross  appearance  of  the  tumor  has  already 
been  described.  It  was  a  rounded  mass,  three  by 
five  cm.  in  diameter,  having  a  density  exceeding 
somewhat  that  of  a  uterine  fibroid.  The  sarcoma- 
tous portion  was  adjacent  to  the  pylorus,  while  the 
rest  of  the  mass  was  made  up  of  dense  inflammatory 
tissues. 

The  specimen  was  microscopically  examined,  and 
reported  upon  as  follows  by  the  hospital  pathologist, 
Dr.  E.  P.  Bernstein :    The  mucous  membrane  di- 

1  The  rubber  tissue  drain  had  been  removed  rather  early  after  the 
operation  and  this  may  have  accounted  for  the  retained  exudate 
with  the  associated  fever  and  the  mental  condition. 


July  3,  1920.] 


BASCH:    SARCOMA   OF  STOMACH. 


11 


rectly  over  the  main  tumor  mass  is  comparatively 
normal,  showing  only  an  occasional  area  of  new 
growth  cells  between  its  ducts.  The  submucosa, 
which  is  the  apparent  origin  of  the  growth,  is  almost 
completely  replaced  by  tumor  cells — either  in  masses 
or  loosely  distributed  between  strands  of  connec- 
tive tissue.  The  cells  are  roughly  polygonal  in 
shape  with  a  fairly  large,  well  staining  nucleus  and 
surrounded  by  an  abundant  zone  of  clear  cypto- 
plasm.  Some  cells  show  active  mitotic  figures.  The 
tumor  cells  bear  no  relationship  to  the  blood  vessels 
present.  The  muscularis  is  but  sparsely  invaded  by 
tumor  cells  which  are  seen  in  the  innermost  portion 
of  the  circular  layer,  but  not  at  all  in  the  longitudinal 
layer.  The  serosa  is  normal.  The  microscopic 
picture  presented  is  that  of  a  malignant  tumor  (large 
round  celled  sarcoma)  which  has  not  progressed 
enough  to  invade  more  than  the  submucosa. 

In  this  case  as  in  so  many  others,  practically  all 
reported  sarcomata  of  the  stomach,  the  ultimate 
diagnosis  was  a  surprise.  Despite  an  increasing 
and  ably  discussed  literature  on  the  sub- 
ject, this  condition  is  still  regarded  as  one  of  extreme 
rarity,  so  rare,  indeed,  that  it  is  scarcely  ever 
thought  of  when  one  is  confronted  with  a  possible 
case.  Writer  after  v/riter  has,  however,  emphasized 
the  fact  that  sarcoma  of  the  stomach  is  a  much  more 
frequently  occurring  afifection  than  is  generally  as- 
sumed, and  has  urged  that  more  histological  exami- 
nations be  made  of  hastily  assumed  carcinomata. 

In  view  of  this  fact,  and  also  of  the  circum- 
stances mentioned  in  the  opening  remarks  of  this 
presentation,  it  is  felt  that  a  brief  discussion  of  the 
main  clinicopathological  features  will  be  of  interest. 
Those  desirous  of  obtaining  further  details  of  the 
subject  will  find  them  interestingly  discussed  in  the 
writings  of  Schlesinger  (3),  Kundrat  (4),  Fenwick 
(5),  Manges  (6),  Flebbe  (7),  Frazier  (8),  War- 
ner (9),  and  others. 

Sarcoma  may  be  either  a  primary  or  a  secondary 
growth  of  the  stomach.  Excepting  in  the  case  of 
the  lymphosarcomata,  the  primary  form  is  of  more 
frequent  occurrence. 

FREQUENCY. 

From  reports  of  cases  it  is  generally  assumed  that 
sarcomata  of  the  stomach  constitute  from  five  per 
cent,  to  eight  per  cent,  of  primary  malignant  gas- 
tric neoplasms,  and  about  twenty-five  hundredths  per 
cent,  of  sarcomata  in  general.  [Mikulicz  and  Kausch 
(1)  and  (2).]  These  and  all  other  statistical  fig- 
ures regarding  this  type  of  growth  are  relative  only, 
since  many  cases  of  assumed  cancer,  or,  on  the  other 
hand  (as  in  the  case  now  reported),  of  assumed 
chronic  inflammatory  infiltration,  associated  with 
chronic  gastric  ulcer,  have,  upon  subsequent  histo- 
logical examination,  proved  to  be  sarcomata.  Thus, 
Perry  and  Shaw  (11),  in  going  over  the  Guy's 
Hospital  series,  found  that  four  out  of  fifty  pre- 
viously reported  carcinomata  were  really  round 
celled  sarcomata. 

FORM  AND  SIZE. 

This  growth  may  occur  as  small  or  large,  nodular 
or  diffuse,  hard  flat  tumor  masses  within  the  wall 
of  the  stomach,  or  as  polypoidshaped  projections 
from  the  stomach  wall  either  into  its  lumen  or  into 
the  greater  or  lesser  peritoneal  cavity.    The  size 


varies  from  a  minute  nodule  to  an  enormous  mass 
that  may,  as  in  Baldy's  case  (12),  weigh  fifteen 
pounds,  and  almost  fill  the  entire  abdominal  cavity. 

TISSUE  ORIGIN  AND  TYPES. 

Sarcomata  being  a  nonepithelial  type  of  growth, 
never  orginate  from  mucous  membrane.  They  may, 
however,  develop  from  connective  tissue,  smooth 
muscle  fibre,  lymphoid  nodule,  or  from  the  endo- 
thelial cells  of  the  lymph  spaces  of  the  stomach. 
According  to  their  tissue  origin  they  form  respec- 
tively true  fibrosarcomata,  leiomyosarcomata  (ma- 
lignant leiomyoblastomata),  lymphosarcomata  (ma- 
lignant lymphoblastomata,  Hodgkin's  disease)  and 
endotheliomata.  According  to  their  cellular  struc- 
ture they  are  classified  as  small  and  large  round 
celled  and  small  and  large  spindle  celled  sarcomata. 

The  age  of  incidence  varies  widely.  Thus,  Find- 
layson  (13)  reports  a  case  observed  in  a  child  three 
and  a  half  years  of  age,  while  di  Giacoma  (14)  re- 
ported one  in  a  man  aged  ninety-one.  Contrary 
to  the  accepted  view  regarding  sarcomata  in  gen- 
eral, the  age  of  greatest  incidence  appears  to  be, 
not  that  of  younger  individuals,  but  that  between 
forty  and  fifty  years  (Corner  and  Fairbanks) 
(15).  The  connective  tissue  and  lymphoid  varieties 
occur  especially  in  young  individuals,  while  the 
smooth  muscle  type  is  seen  more  often  after  the 
age  of  thirty  to  fifty.  While  opinions  differ,  the 
majority  of  observers  agree  that  the  curvatures, 
especially  the  greater  curvature,  are  the  most  fre- 
quent seat  of  origin. 

COMPLICATIONS  AND  DEGENERATIONS 

The  complications  and  degenerations  are  numer- 
ous and  are  associated  with  the  more  advanced 
stages  of  the  growth.  They  include  ulceration, 
hemorrhage,  deformity  of  stomach  outline,  obstruc- 
tions, torsion,  cystic  and  purulent  changes,  adhe- 
sions to  neighboring  parts  and  metastases.  Meta- 
stases may  be  entirely  absent  or  may  occur  in  neigh- 
boring or  distant  organs,  particularly  the  skin. 

Symptoms. — Frequently  there  is  an  entire  ab- 
sence of  gastric  symptoms  throughout  the  entire 
course,  or  at  least  until  the  growth  is  far  ad- 
vanced. This  arises  from  the  fact  that  the  mucous 
membrane  is  not  involved  and  that  usually  there 
are  no  obstructive  changes.  In  many  other  cases 
the  predominant  manifestations  are  those  due  to 
the  complications,  or  to  secondary  changes  in  the 
growth  itself,  and  these  have  given  rise  to  great- 
est errors  in  diagnosis. 

The  gastric  symptoms  vary  from,  the  mildest 
expressions  of  gastric  dyspepsia  to  the  severest 
manifestations  of  gastric  cancer.  No  definite  diag- 
nostic signs  and  symptoms  can  be  stated.  In  al- 
most all  instances  of  sarcoma  of  the  stomach  the 
correct  diagnosis  has  never  been  made  previous 
to  direct  exploration.  In  a  few  exceptions  the 
diagnosis  was  ventured  through  the  examination 
of  tumor  particles  obtained  from  stomach  contents, 
[Riegel  (16),  Westphalen  (16),  or  through  excision 
of  a  metastatic  growth  in  the  rectum,  Schlesinger 

(17)  ],  skin,  glands,  etc.  That  even  this  latter  pro- 
cedure may  be  misleading  is  emphasized  by  Leube 

(18)  ,  who  instances  a  case  of  skin  sarcomatosis 
occurring  coincidentally  with  a  true  epithelial  gas- 


12 


BASCH:    SARCOMA   OF  STOMACH. 


[New 
Medical 


York 

JOL-RXAL. 


trie  cancer.  Dreyer  (19),  on  the  other  hand,  en- 
countered a  case  of  spindle  celled  pyloric  tumor 
coincidental  with  a  carcinomatous  ulcer  at  the 
pylorus.  The  metastases  in  this  ca.se  were  carci- 
nomatous. As  long  ago  as  1902,  Fen  wick  (20), 
in  his  well  known  monograpli  on  gastric  tumors, 
cites  a  nimiher  of  points,  attention  to  which  he 
states  makes  possible  the  diagnosis  of  round  celled 
sarcoma  of  the  stomach.  Despite  a  careful  search 
of  the  acctunulated  literature  since  that  date,  I  have 
failed  to  encounter  a  single  instance  in  which  a 
correct  preoperative  diagnosis  has  been  reported, 
excepting  through  the  examination  of  a  metastatic 
growth,  or  an  expelled  tumor  fragment. 

In  a  disea.sed  condition,  therefore,  such  as  the 
one  luider  consideration,  the  occurrence  of  which, 
even  in  a  most  typical  manner,  has  almost  invaria- 
bly baffled  the  diagnostic  acumen  of  so  many  care- 
ful observers,  it  would  be  an  idle  task  to  venture 
to  lay  down  definitely  drawn  lines  for  exact  diag- 
nosis. Until  the  di.scovery  of  a  specific  reaction  the 
diagnosis  will  probably  remain  a  matter  of  doubt. 
The  one  condition,  after  all,  from  which  it  is  most 
desirable  to  differentiate  sarcoma,  is  that  of  carci- 
noma of  the  stomach.  The  importance  of  this 
arises  from  the  fact  that  sarcoma  is,  on  the  whole, 
a  much  more  slowly  growing  tumor,  and,  in  the 
relatively  early  cases,  offers  a  far  better  chance 
for  a  radical  cure.  Both  affections  have  many 
characteristics  in  common,  such  as  the  earmarks 
and  accompaniments  of  malignancy,  the  alterations 
in  gastric  structure  and  functions,  the  occurrence 
of  hemorrhages,  metastases,  splenic  ttmior,  and 
febrile  states.  There  are,  however,  .some  definite 
distinguishing  features  which  may  serve  to  guide  us 
in  clinical  differentiation.  Thus,  carcinoma  arises 
from  the  epithelium,  and  though  it  may  involve 
the  rest  of  the  stomach  wall,  the  mucous  membrane 
is  always  also  affected.  Sarcoma,  on  the  contrary, 
as  already  stated,  arises  from  the  nonepithelial  tis- 
sues, and  does  not,  as  a  rule,  invade  the  mucous 
membrane.  When  it  does  injure  the  mucosa,  it 
does  so  throtigh  mechanical  force  (pressure  or  ero- 
sion). Carcinomata,  too,  are  most  frequently  lo- 
cated at  the  orifices  and  in  the  body  of  the  stomach  ; 
sarcomata,  along  the  curvatures.  Hence,  carcino- 
mata are  more  likely  to  cause  early  pyloric  obstruc- 
tion. In  most  instances  in  sarcoma  this  is  a  late 
complication,  and  is  due  not  so  much  to  narrow- 
ing of  the  pyloric  orifice,  as  to  massive  infiltration 
of  the  stomach  walls.  In  many  instances  this 
massive  infiltration  causes,  not  an  obstruction,  but 
a  gaping  of  the  pylorus.  Carcinoma  is  rapid  in 
its  growth  and  in  its  general  systemic  effect ;  sar- 
coma, on  the  contrary,  shows  quite  the  reverse 
characteristics,  especially  the  leiomyosarcomata  and 
the  endotheliomata,  which  are  very  slow  to  meta- 
-stasize.  Hence,  in  carcinoma  we  more  frequently 
find  early  local  gastric  symptoms  and  signs.  Round 
celled  sarcoma  is.  however,  as  a  rule,  a  rapidly 
growing  tumor,  and,  like  carcinoma,  very  prone 
to  metasta.ses.  Despite  the  fact  that  sarcoma  fre- 
(iuently  leaves  the  mucous  membrane  intact,  a 
number  of  observers  report  diminished  or  absent 
hydrochloric  acid,  and  even  the  presence  of  lactic 
acid  and  Boas-Oppler  bacilli.     Thus,  Schlesinger 


(17),  in  three  cases,  fotmd  free  hydrochloric  acid 
absent  and  lactic  acid  abundantly  present;  Mathieu 
found  hydrochloric  acid  absent  in  eleven  out  of 
seventeen  cases.  Indeed,  Harlow  Brooks  (21  ) 
reports  that  he  found  both  lactic  and  hydrochloric 
acid  present  in  his  cases,  and  instanced  this  simul- 
taneous presence  of  both  kinds  of  acids  as  one  of 
the  signs  that  "should  lead  at  least  to  the  serious 
consideration  of  the  possibility  of  gastric  sarcoma." 

Sarcomata  being  generally  less  malignant  than 
carcinomata,  we  find  that  their  average  duration  is 
longer  than  that  of  carcinomata.  Two  or  three 
years'  duration  after  the  onset  of  symptoms  is  not 
rare. 

Occult  blood  and  hemorrhages  are  relatively  less 
frequent  in  sarcoma  than  in  carcinoma.  Still,  at- 
tention has  been  drawn  by  Manges  (6)  to  a  group  of 
sarcomata  in  which  hematemesis  is  the  leading 
symptom.  These,  for  the  most  part,  were  advanced 
cases.  Splenic  timior  and  fever  are  more  frequent- 
ly encountered  in  sarcoma  than  in  carcinoma. 

Finally,  the  spindle  celled  sarcoma  may  progress 
to  even  quite  an  advanced  stage  withotit  giving  rise 
to  any  gastric  symptoms.  This  applies  more  espe- 
cially to  i)ediculated  subperitoneal  cases  that  pro- 
ject beyond  the  body  of  the  .stomach,  invading  the 
greater  or  lesser  peritoneal  cavities. 

PROGNOSIS. 

The  average  duration  of  untreated  round  celled 
types  is  reported  to  he  about  fifteen  months;  that  of 
the  spindle  celled  twenty-four  to  thirty-two  months, 
and  that  of  the  myosarcomata  three  and  a  half  years. 
The  lymphosarcomata  have  the  greatest  tendency  to 
metastasize,  and  the  endotheliomata  the  least.  Na- 
turally, the  earlier  the  removal,  the  less  danger  is 
there  of  recurrence.  Even  the  most  prolific  varie- 
ties, the  lympho.sarcomata  and  fibrosarcomata.  give 
a  better  prognosis  as  regards  recurrence  after  re- 
moval than  do  carcinomata. 

TREATMENT. 

This,  of  cour.se,  in  cases  not  too  far  advanced,  or 
even  in  those  where  the  diagnosis  is  in  doubt,  or 
mechanical  relief  is  indicated,  should  only  be  sur- 
gical. In  inoperable  cases  a  course  of  Coley's  se- 
rum might  be  tried.  In  cases  of  lymphosarcoma, 
especially  in  the  inflammatory  or  Hodgkin's  type, 
arsenic  therapy  is  decidedly  indicated. 

REFEREXCES. 

1.  Bergm.\nx,  Mikulicz  u.  v.  Brcxs  :  Handh.  d. 
prokt.  CItintrgic,  1903.    Vol.  iii,  p.  316. 

2.  Hoscn  :  Dcut.  Zcitschr.  f.  kliii.  incd..  1907,  vol.  xc, 
p.  98. 

3.  ScHLESixr.ER,  H. :  Zcitschr.  fl.  klin.  mcd.,  1898,  vol. 
xxxii,  supplement. 

4.  Kuxdr.at:    Wiener  kli.  Wochenschr,  1893,  No.  12. 

5.  Fexwick:  Lancet,  Feb.  16.  1901,  p.  463. 

6.  Maxces:  Medical  Nc'a:<:.  1905,  p.  201. 

7.  Flebbe  :  frankf.  Zcitschr.  f.  Pathol.  1913,  vol.  xii  p. 
311. 

8.  Fr.\zier  :  American  Journal  of  the  Medical  Sciences, 
June,   1914,  p.  781. 

9.  Warxer,  F.  :  Ohio  Medical  Journal.  117,  vol.  xiii, 
p.  647. 

10.  Hart,  \V.  J.:  Surgery.  Gxnecologx  and  Obstetrics. 
1918,  vol.  xvii,  p.  502. 

11.  Perrv  axd  Shaw:  Cited  from  Aaron,  Di.^cases  of 
the  Digestive  Organs. 

12.  Baldv:  Journal  A.  M.  A..  1898.  vol.  xxx,  p.  523. 

13.  FixnLAVsox  :  British  Medical  Journal,  1898.  p.  1535. 


July  3,  1920.]  NORMAX:   GASTROIXTESTIXAL  TRACT  AXD  ARTERIOSCLEROSIS. 


13 


14.  Di  Giacoma:  i?'.7or))((i  .Vrrf/Va,  Feb.  6,  1915. 

15.  Corner  and  Fairbanks:  Tnutsactioiis  of  the 
Pathological  Society,  London.  1905.  vol.  vii.  p.  20. 

16.  RiEGEL,  F. :  Die  Erkraiik.  d.  Magens.  1896,  part  2, 
p.  847. 

17.  ScHLE-^ixGER,  H. :  Loc.  cit.  also  Wicn.  kliii.  U'och- 
ciischr..  1916.  vol.  xxv,  p.  785. 

18.  Leube.  \V.  :  Diagnose  d.  iiiueren  Krankheiten,  4th 
edit.:  vol.  i.  p.  270. 

19.  Drever,  I.  D. :  Gottinger,  1894.  Cited  from  Ewing, 
Xeoplastic  Tumors.  Phila..  1919. 

20.  Fenwick  :  Cancer  and  Other  Tumors  of  the  Stom- 
ach. London,  102.  p.  274. 

21.  Brooks.  H.  :  Medical  Xez^'s,  1898,  p.  617. 

40  West  Eighty-Eighth  Street. 

IXFECTIOXS     OF    THE  GASTROIXTES- 
TIXAL TRACT  AXD  THEIR  RELA- 
TIOX  TO  ARTERIOSCLEROSIS.* 

Bv  X.  Philip  Xormax.  'SI.  D., 
New  York. 

Late  Major.  Medical  Corps,  U.  S.  Array. 

Arteriosclerosis,  because  of  its  frequency,  its  con- 
sequences and  tendencies  to  cause  complications, 
may  justly  be  called  the  most  important  degenera- 
tion incident  to  physical  ageing.  If  recognized  early, 
it  is  compartively  easy  to  impress  a  patient  with  the 
possibilities  of  the  situation  without  unduly  fright- 
ening him  and  to  institute  a  course  of  treatment 
which  will  materially  benefit  the  condition  as  well 
as  inhibit  the  insidious  process  in  its  development. 

In  this  essay  I  shall  present  my  own  ideas  of  ar- 
teriosclerosis as  well  as  my  classification  of  the 
various  types  and  phases  of  this  disease.  For  the 
moment  we  will  review  the  theories  now  current 
so  that  a  contrast  of  ideas  may  be  more  apparent 
and  that  the  reader  may  judge  impartially  of  the 
conclusions  reached  by  observers  of  this  disease. 
etiology. 

In  Gennany.  Thoma's  histomechanical  theory 
finds  favor,  this  view  being  founded  upon  the 
atonic  muscular  conception.  His  critics  state  that 
most  cases  of  endarteritis  or  arterial  degeneration 
due  to  faulty  or  deficient  nutrition  occur  before 
the  loss  of  muscle  tone,  as  would  be  evidenced  by 
vascular  dilatation.  In  France  and  America  the 
autointoxication  theory  of  Metchnikoff  is  generally 
accepted.  The  circulating  toxins  are  said  to  irri- 
tate or  inflame  the  endothelial  structures.  Oppon- 
ents of  this  theory  cite  that  feeding  animals  upon 
sterile  food  soon  produces  death :  that  vegetarians 
suffer  from  arteriosclerosis  and  that  the  degree  of 
arterial  degeneration  bears  no  proportional  relation 
to  the  amount  of  meat  ingested. 

The  endocrine  enthusiasts  believe  that  the  burden 
of  the  mischief  making  rightfully  belongs  to  a  hy- 
peradrenalism.  the  jihysiological  excess  of  adrenal 
.secretion  producing  a  vasoconstrictor  effect.  Pro- 
hibitionists have  not  neglected  the  opportunity  and 
insist  that  alcoholic  beverages  are  the  chief  causes. 
The  antitobacco  fanatic  is  equally  as  insistent  as  the 
prohibitionist  that  the  weed  deserves  the  honor. 
Other  cranks  include  coffee,  tea,  and  in  fact  every- 
thing that  is  likely  to  stimulate  our  senses  pleasantly. 

Weil  has  recently  suggested  a  new  theory ;  that  is. 

•Read  before  the  Sixth  District  liranch  of  the  Medical  Society  of 
the  State  of  New  York,  October  7.  1919. 


that  there  is  a  retention  of  the  lime  constituents  due 
to  some  fault  of  kidney  elimination.  He  conceives 
this  to  be  a  metabolic  perversion  akin  to  gouty  dia- 
thesis. L.  F.  Bishop  has  advanced  a  very  practical 
theory  of  arteriosclerosis.  He  calls  the  symptom 
complex,  cardiovascular  renal  disease.  He  believes 
that  the  disease  is  primarily  due  to  a  disturbance  of 
metabolism  that  has  extended  over  a  long  period  of 
time  before  manifesting  itself.  The  metabolic  per- 
version is  traceable  to  bacterial  invasion,  chemical 
poisoning,  food  poisoning,  psychic  traumas  or  a 
combination  of  these  factors.  This  metabolic  disturb- 
ance results  in  a  sensitization  of  the  body  cells  to 
particular  proteins  ordinarily  found  in  foods.  The 
three  kinds  of  food  found  most  irritating  to  the 
sensitized  cells  are  meat,  fish  and  eggs.  This  con- 
ception is  perhaps  the  broadest  of  all  the  theories 
advanced.  It  is  purely  clinical  and  the  results  ob- 
tained from  therapy  based  upon  this  theory  seem  to 
establish,  clinically  at  least,  the  logic  of  the  deduc- 
tions. 

However,  it  seems  be.st  to  consider  arteriosclero- 
sis as  part  of  a  general  involutional  process  occur- 
ring during  the  life  cycle  of  the  biological  unit.  It 
represents  a  normal  evolutional  consequence,  be- 
cause of  the  structural  complexity  of  the  cellular 
arrangement  not  allowing  of  proper  nutrition  or 
adequate  removal  of  waste  products  from  the  body 
cells. 

Weissmann  and  others  have  shown  that  protoplasm 
is  potentially  immortal.  Observing  infusoria  un- 
der a  favorable  environment  which  he  had  prepared 
for  them,  he  noticed  that  they  lived  for  genera- 
tions without  showing  any  tendency  to  degenera- 
tion or  death.  He  proved  that  infusoria  never  died 
except  as  a  result  of  an  accident,  improper  or  in- 
sufficient food,  the  improper  removal  of  waste 
products  or  by  the  radical  alteration  of  other  vital 
environmental  circumstances.  From  these  deduc- 
tions on  infusorial  life  scientists  began  to  inquire 
why  the  cells  should  lose  this  incapacity  for  po- 
tential immortality  when  aggregated  into  the  mak- 
ing of  a  multicellular  unit.  The  fact  that  infusoria 
degenerate  or  die  when  placed  in  unfavorable 
surroundings  supported  the  idea  that  the  multicell- 
ular organisms  owed  their  degeneration  and  death  to 
the  development  of  unfavorable  conditions  within 
and  without  themselves  rather  than  to  an  inherent 
propensity  to  die. 

The  human  organism,  like  the  infusoria,  began 
life  with  the  formation  of  a  one  cell  organism 
which  divided  into  two  cells  after  being  stimulated 
by  the  male  sperm.  Successive  division  into  two. 
four,  eight,  sixteen,  thirty-two,  sixty-four,  etc.,  oc- 
curred. Cnlike  the  infusoria,  each  cell  did  not 
spread  in  all  directions  and  take  up  an  isolated, 
individual  existence,  but  clustered  together  to  form 
a  larger  and  larger  cell  mass.  Soon  some  of  the 
cells  assumed  different  shapes  and  clustered  more 
compactly  at  different  points  to  form  the  various 
specialized  body  structures ;  muscles,  nerves,  blood 
vessels,  bones,  and  other  structures,  although  the\' 
all  originally  sprung  from  a  common  source.  How- 
ever, regardless  of  the  specialized  functional  char- 
acteristics which  they  may  develop,  they  all  retain 
the  most  primitive  of  cell  functions,  growth,  nutri- 


14 


NORMAN:   GASTROINTESTINAL  TRACT    AND  ARTERIOSCLEROSIS.     „  [New  York 

Medical  Journal. 


tion,  and  reproduction.  They  all  require  food  for 
their  growth  and  for  their  reproduction,  and  all 
excrete  waste  products,  the  chemical  ash,  so  to 
speak,  of  their  growth,  their  nutrition,  their  pro- 
ductive and  vital  activities.  Since  the  cells  have 
clustered  to  form  specialized  organs  with  special 
functions,  the  problem  of  adequate  nutrition  and 
proper  waste  removal  for  each  cell  of  these  units 
became  more  complex  than  when  each  individual 
cell  established  an  isolated  existence  after  the  fash- 
ion of  the  infusorial  cells. 

The  problem  of  getting  rid  of  waste  products  and 
of  getting  the  proper  amount  of  nutrition  to  each 
component  cell  of  a  multitudinous  aggregate,  such 
as  a  fish,  or  a  cow,  or  a  human,  was  facilitated 
by  an  evolutional  urge  which  established  channels 
through  which  nourishment  could  be  distributed 
to  isolated  cells  and  through  which  channels  these 
waste  products  could  be  removed.  These  tubular 
structures  are  the  gastrointestinal  tract,  the  blood 
vessels,  the  lacteals,  the  lymphatics,  the  bronchial 
tubes,  the  kidneys,  and  the  skin  glands.  These 
channels  either  supply  nourishment  or  remove 
waste  products  or  do  both.  As  long  as  the  food 
supply  is  properly  balanced  and  the  waste  removal 
adequate,  good  health  should  prevail,  assuming  that 
each  component  cell  is  treated  alike  in  a  multi- 
cellular organism.  However,  in  the  multicellular 
organism,  no  matter  how  well  the  unit  is  supplied 
with  channels  for  transporting  nutrition  and  for 
removing  waste  products,  there  are  numbers  of 
cells  that  cannot  be  reached  directly  by  these  chan- 
nels. For  this  reason,  there  is  a  constant  amount 
of  cellular  death  of  isolated  cells  which  is  taking 
place  within  our  body  and  which  is  being  replaced 
by  the  proliferation  of  adjacent  cells  more  fortu- 
nate than  its  neighbor,  as  regards  nutrition  and 
waste  removal,  to  the  take  the  place  of  the  dead 
cells. 

In  addition  to  these  defects  within  the  cellular 
arrangement,  our  chemical  laboratory,  the  gastro- 
intestinal tract,  which  prepares  the  nutrition  for 
the  body,  as  well  as  eliminating  a  very  great  pro- 
portion of  the  waste  products  of  the  body,  has 
been  imposed  upon  with  a  dietary,  the  cumulative 
product  of  the  culinary  fiendishness  of  generations 
of  crabbed  cooks  and  irrational  chefs,  as  well  as 
the  gourmandizi'ng  demands  of  gastronomic  per- 
verts, for  which  it  was  never  intended  to  deal. 

Modern  dietary  fuel  is  so  rankly  well  cooked, 
so  rottenly  pleasant  to  the  taste,  so  poisonously 
laden  with  highly  putrescent  protein,  and  so  vi- 
ciously full  of  harmful  bacterial  and  noxious  para- 
sites, that  it  simply  blocks  the  sewerage,  if  you 
please,  and  there  results  a  baneful  organic  reflex — 
disease.  When  this  occurs  intestinal  stasis  is 
brought  about  and  the  chemical  balance  in  the  colon 
is  lost  because  of  the  predominance  of  bacterial 
activity  that  produce  putrefactive  and  butyric  acid 
products.  These  predominate  because  the  food 
residue  of  the  average  person  is  so  rich  in  pro- 
teids,  and  is  so  excessive  in  quantity,  that  a  fertile 
and  inexhaustible  amount  of  pabulum  is  furnished 
for  the  growth  of  the  harmful  bacteria.  Because 
of  a  lack  of  starch  or  sugar  residue  the  helpful 
fermentative  bacteria  are  starved,  decrease  in  num- 


bers and,  finally,  are  not  capable  of  arresting  the 
growth  of  the  harmful  bacteria  as  well  as  neutral- 
izing the  harmful  products  which  they  elaborate 
during  their  functional  cycle.  When  this  occurs, 
the  intestinal  functions  become  impaired,  and  as  a 
result  the  food  molecules  are  inadequately  or  im- 
properly broken  up  and  are  carried  to  the  cells 
to  be  used  in  a  raw  state.  The  cells  have  to  fur- 
ther digest  the  raw  products  for  their  use. 

In  the  digestion  of  these  raw  products,  chiefly 
protein  derivatives,  a  sensitization  occurs  and  later 
an  unmistakable  anaphylactic  reaction  is  produced. 
Add  to  this  the  sensitization  which  is  produced 
by  the  food  toxins,  the  product  of  putrefaction, 
which  are  absorbed  directly  through  the  intestinal 
walls  and  into  the  circulation,  as  well  as  the  migra- 
tion of  bacteria  directly  into  the  circulation  and 
indirectly  into  the  circulation  through  the  lym- 
phatics, and  it  requires  but  little  intelligence  to 
grasp  the  significant  reaction  that  will  occur  in  the 
body's  effort  to  rid  itself  of  a  menace  which  is 
threatening  to  throttle  its  very  existence. 

Therefore,  it  seems  logical  to  believe  that  cellu- 
lar malfunction,  cellular  degeneration,  cellular  age- 
ing, and  cellular  death  are  caused  in  a  multicellular 
organism,  such  as  a  human  being,  by  the  following 
factors:  1,  Improper  dietary;  2,  focal  infection; 
3,  a  chemical  unbalance  of  gastrointestinal  func- 
tion ;  4,  intestinal  stasis ;  5,  gastrointestinal  infec- 
tion. 

The  reaction  of  the  cells  of  the  body  are  as 
follows:  1,  A  sensitization  to  raw,  nutritional  prod- 
ucts ;  bacterial  toxins  and  the  toxins  generated  in 
the  colon  because  of  a  disturbance  of  the  fermenta- 
tive-putrefactive balance ;  2,  a  resultant  improper 
cellular  digestion ;  3,  cellular  anaphylaxis  to  for- 
eign chemical  substances ;  4,  a  formation  of  waste 
residue  in  the  cellular  substance  that  is  difficult 
of  cellular  elimination ;  5,  an  irritation  of  the  waste 
removal  channels ;  6,  an  inflammatory  process  in- 
volving the  waste  removal  and  the  nutritional  bear- 
ing channels ;  7,  a  compensatory,  protective,  con- 
structive degeneration  of  the  waste  removal  channels 
and  8,  cellular  retention  of  toxic  materials,  the 
cumulative  effect  of  which  causes  death. 

These  toxins,  the  product  of  microbic  activity 
that  are  flourishing  in  the  intestines,  the  oral  cavity, 
the  gallbladder,  the  glandular  system  and  other 
tissues,  during  a  crisis,  somatic  or  psychical,  cor- 
relate their  energies,  become  kinetic  and  are  rapidly 
diffused  throughout  the  tissues,  their  clinical  display 
comprising  many  clinical  pictures  in  which  the 
circulatory  apparatus  always  bears  the  brunt  of  the 
attack  as  it  is  the  channel  through  which  these  toxins, 
food  poisons  and  cellular  waste  products  course 
throughout  the  body.  Therefore,  arteriosclerosis  is 
never  due  to  one  factor,  not  even  excepting  syphilis, 
but  to  a  combination  of  factors,  the  mobilized 
toxic  products  of  which  produce  the  arteriosclerosis. 

Nervous,  mental  and  emotional  stress,  the  end 
product  of  the  complexities  of  the  fast  changing 
social  order,  has  to  be  reckoned  with.  Psychic  con- 
flicts and  maladjustments  and  their  compensatory 
compromises  are  in  a  great  measure  absorbed  by  the 
phylogenetically  oldest  level,  that  is,  the  physio- 
chemical  level,  and  any  one  familiar  with  a  neurology 


July  3,  1920.]  NORMAN:   GASTROINTESTINAL  TRACT   AND  ARTERIOSCLEROSIS. 


15 


based  upon  an  evolutional  conception  cannot  fail 
to  understand  that  psychic  stress  is  capable  of  up- 
setting metabolic  or  endocrine  harmonies.  In  the 
battle  against  this  array  of  enemies  and  in  attempting 
to  intrench  themselves  the  cells  may  be  said  to 
undergo  a  constructive  or  protective  degeneration, 
thereby  attempting  to  protect  and  preserve  their 
function. 

PATHOLOGY. 

The  pathology  of  all  arteriosclerotic  degenerations 
is  essentially  the  same,  differing  one  from  the  other 
in  respect  to  etiology  and  the  anatomical  structures 
primarily  involved.  Three  types  are  usually  cited, 
known  as  the  inflammatory  type,  the  mechanical 
type,  and  the  nutritional  type.  It  is  doubtful  whether 
any  one  of  these  three  types  ever  occurs  alone. 

In  the  inflammatory  type  the  circulating  toxins 
jiroduce  a  local  endothelial  irritation  and  nature 
responds  to  this  irritation  by  a  protective  hyper- 
plasia of  endothelial  cells.  Thus,  endothelial  patches 
are  formed,  a  disturbance  of  the  circulation  in  the 
vasa  vasorum  results  and  from  lack  of  proper 
nutrition  the  patches  undergo  a  granular  or  fatty- 
degeneration.  A  thin  membrane  separates  the 
I)atches  from  the  circulating  blood  thus  hindering 
the  normal  bathing  of  endothelial  cells  in  blood 
plasma.  Further  degeneration  of  the  patches  forms 
a  nodule  filled  with  cholesterin  debris  and  fatty 
deposits.  The  phenomenon  is  completed  by  the 
deposition  of  lime  in  this  fatty  mass,  forming  a 
fatty  soap,  and  later  by  the  formation  of  the  in- 
soluble carbonate  and  phosphate  of  lime  by  chemi- 
cal action  of  acid  radicals  on  this  lime. 

Arterial  muscle,  being  a  highly  specialized  tissue, 
soon  breaks  down  after  adequate  vascularization  is 
interfered  with.  Connective  tissue  hyperplasia  is 
the  constructive  degeneration  planned  by  nature, 
because  it  requires  less  blood  supply  and  does  fairly 
well  substitute  the  action  of  arterial  muscle.  The 
degeneration  may  be  incomplete  or  complete,  de- 
pending upon  the  age  of  the  process. 

The  mechanical  type  begins  in  the  media  with 
a  loss  of  muscle  tonicity,  then  a  vascular  dilatation 
occurs  with  compensatory  tortuosity.  The  constant 
overstretching  of  the  muscle  of  the  arterial  wall  saps 
its  tone.  An  intimal  thickening  results  from  a  pro- 
liferation of  the  subendothelial  layer.  Disturbance 
of  vasa  vasorum  circulation  occurs  with  a  resultant 
additional  degeneration  of  muscle  and  of  prolifer- 
ated cellular  elements.  Lime  deposits  and  the  fatty 
masses  then  undergo  the  analogous  chemical  changes 
described  under  the  inflammatory  type. 

The  nutritional  type  dififers  in  that  proper  nutri- 
tion is  withdrawn  and  there  is  a  resultant  rapid 
muscular  degeneration  with  the  formation  of  minute 
atheromatous  abscesses  and  aneurysmal  sacs.  Con- 
nective tissue  replaces  the  muscle  and  elastic  tissue. 

On  analyzing  the  preceding  remarks  concerning 
the  pathology  of  arteriosclerotic  degenerations  wc 
are  impressed  with  the  fact  that  there  is  much  in 
common  in  all  types.  It  appears  that  there  is  first 
an  irritation  factor  at  work,  followed  by  a 
protective  reaction  on  the  part  of  the 
specialized  tissues  apparently  to  protect  the  most 
useful  coat  of  the  arterial  wall,  the  muscle 
and  elastic  tissue,  then  a  disturbance  of  vasa  vasorum 


circulation,  followed  by  a  degenerative  process  which 
forms  connective  tissue  to  replace  a  wasting  muscle 
and  elastic  tissue.  The  connective  tissue  substitutes 
for  the  muscle. 

Reasoning  that  arteriosclerotic  changes  are  normal 
phases  of  an  involutional  process,  it  would  appear 
that  these  changes  when  normal  or  abnormal  are 
brought  about  by  nature  in  a  conservative  attempt 
to  protect  the  biological  unit.  Therefore,  it  appears 
within  reason  to  consider  arteriosclerotic  changes 
compensatory  and,  therefore,  to  constitute  a  con- 
structive degenerative  process. 

SYMPTOMS. 

An  attempt  will  be  made  to  outline  only  the 
symptoms  that  are  associated  with  early  arterio- 
sclerotic changes.  Late  symptoms  are  so  manifestly 
indicative  that  diagnosis  is  practically  possible  by 
listening  to  the  complaints  alone.  Degenerating 
blood  vessels  give  rise  to  no  early  symptoms.  Sub- 
jective symptoms  and  sensory  disturbances  may 
arouse  our  suspicion  of  organic  disorder  long  before 
objective  findings  are  demonstrable.  There  may- 
be no  relation  of  disease  and  symptom. 

The  earliest  sign  of  arteriosclerosis  is  an  increase 
in  arterial  tension.  Bishop  has  called  attention  to 
exceptions  of  this  rule,  especially  found  in  arterio- 
sclerotics with  neurasthenic  states.  Occasionally, 
the  normal  difference  of  pulse  rate  when  standing 
and  when  in  a  recumbent  position  is  not  maintained. 
One  may  suspect  an  organic  process  if  the  rate 
standing  is  less  than  six  over  the  pulse  rate  when 
reclining.  Palpitation  after  eating,  smoking  or  sudden 
exertion  is  common.  Inability  to  lie  on  the  left 
side  without  producing  palpitation  or  cardiac  dis- 
comfort is  frequently  found.  Headache,  especially 
on  awakening  or  after  smoking,  is  a  symptom  often 
associated  with  early  sclerosis  of  the  cerebral  vessels. 
Muscular  twitchings ;  muscular  cramps  noctural  and 
after  exercise ;  tremors  of  the  face,  tongue  and 
fingers  ;  tinnitus ;  dizziness ;  diplopia ;  blurring  of 
vision ;  gastric  and  abdominal  distress,  as  flatulence, 
meteorism,  constipation  with  alternating  diarrhea 
are  significant  in  a  patient  of  forty  or  over. 

Sensory  disturbances,  such  as  flushings,  formica- 
tions, numbness  and  tingling,  head  pressures  and 
fainting  sensations,  are  common.  Nervous  dis- 
turbances, such  as  irritability,  intolerance  of  others, 
lack  of  vital  interest,  depression  and  phobias  often 
manifest  themselves.  Insomnia  is  a  distressing 
symptom  at  times. 

DIAGNOSIS. 

A  careful  study  of  the  individual's  symptoms  and 
an  attempt  to  explain  their  source  rationally  will 
justify  repeated  and  thorough  observations.  Per- 
haps the  earliest  physical  sign  is  a  hypertrophy  of 
the  left  ventricle  with  an  accentuation  of  the  second 
sound  and  increased  blood  pressure.  Functional 
tests  may  demonstrate  a  blood  pressure  rise  follow- 
ing exercise  and  later  a  rapid  fall  to  a  point  below 
the  initial  pressure,  evidencing  a  lack  of  integrity  in 
myocardial  tone  and  a  deficient  cardiac  reserve. 
Associated  with  these  physical  signs  may  be 
albuminuria  with  or  without  casts  and  indica- 
nuria. 

Ophthalmoscopic  examination  of  the  retina  often 


16 


NORMAX:  GASTROLXTESTIXAL  TRACT  AXD  ARTERIOSCLEROSIS.         [New  York 

Medical  Journal. 


demonstrates  early  vessel  change.  Increased 
tortuosity,  Ijeading  of  the  vessels,  increase  in  wall 
opacity,  widening  of  the  central  light  streak,  an 
interruption  of  the  continuity  of  the  veins  where 
they  cross  arteries  and  just  beyond  this  point  a 
dilatation,  and  evidences  of  punctate  hemorrhages 
are  diagnostic. 

Personal  observations  have  led  me  to  believe  that 
a  dilatation  of  the  skin  capillaries  along  the  course 
and  level  of  the  eighth  intercostal  space,  extending 
usually  from  a  point  midway  between  the  midsternal 
line  and  the  nipple  line  to  about  the  midaxillary  line, 
usually  bilateral,  but  in  early  cases  more  marked 
on  the  left  side,  is  practically  diagnostic  of  early 
sclerotic  changes.  It  is  at  this  point  that  a  ridging 
of  the  skin  occurs  when  stooping  or  sitting  in  a 
position  cramping  the  chest,  no  doubt  obstructing 
free  circulatory  movement,  and  results  in  this 
dilatation  because  of  a  loss  of  muscle  tone  in  these 
small  vessels.  I  have  repeatedly  made  this  observa- 
tion in  patients  who  presented  no  physical  signs  and 
complained  of  but  few  sensory  disturbances  but 
who  presented  definite  sclerotic  changes  upon  their 
return  a  year  or  so  later. 

A  pharmacodynamic  test,  using  nitroglycerin  as 
a  test  agent,  serves  to  solve  the  reason  for  subjective 
manifestations  in  many  instances.  ^lany  patients, 
with  no  physical  findings,  complaining  of  distressing 
symptoms,  are  promptly  relieved  with  this  drug. 

Because  of  the  meagreness  of  physical  signs  in 
early  arterial  disease,  one  must  resort  to  symptom- 
atic treatment,  being  very  watchful  to  anticipate  a 
premature  or  abnormal  sclerotic  degeneration  in 
patients  over  forty  years  of  age.  The  important 
point  to  be  remembered  is  that  arteriosclerosis  begins 
man\-  years  before  there  is  any  manifestation,  either 
subjective  or  objective,  of  this  disease.  Indeed,  many 
arteriosclerotic  patients  are  treated  for  several 
years  as  patients  suffering  from  indigestion  and  the 
dietary  in  these  cases  has  not  been  aimed  at  a 
correction  of  the  body  metabolism  but  rather  at  a 
local  effect  on  the  gastric  walls. 

TREATMENT. 

It  is  to  be  kept  in  mind  that  arteriosclerotic 
changes  are  part  of  a  normal  involutional  process. 
If  the  individual  survives  long  enough,  he  or  she  is 
certain  to  undergo  the  cellular  changes  common  to 
the  degeneracy  of  ageing  because  of  the  very 
structural  complexities  of  the  organized  multi- 
cellular unit.  Therefore,  arteriosclerosis  is  physio- 
logical as  long  as  the  tissue  age  of  the  cardiocir- 
culatory  apparatus  is  on  a  level  with  the  age  of  the 
rest  of  the  tissues  of  the  body.  However,  when 
from  the  various  causes  that  have  been  enumerated, 
the  bacterial  toxins,  the  food  toxins  and  the  products 
of  uneliminated  cellular  waste  become  mobilized 
and  kinetic,  producing  a  compensatory  change  in 
the  cardiocirculatory  apparatus,  which  is  simply  an 
ageing  of  these  nutritional  and  waste  product 
channels  in  advance  of  the  rest  of  the  tissues  of  the 
body,  the  resultant  disharmony  between  the  age 
levels  of  body  tissues  is  expressed  by  what  I  am 
pleased  to  call  physiopathological  arteriosclerosis. 
Therefore,  arteriosclerosis  is  abnormal  only  when 
there  is  an  acceleration  of  the  normal  mature 
arteriosclerotic  degeneracy  of  a  given  individual  or 


when  the  sclerotic  changes  are  premature  in  their 
manifestations  in  relation  to  the  age  of  the 
individual. 

If  recognized  early  we  may  hope  to  remove  the 
excitant  factors  or  at  least  to  hinder  or  inhibit  their 
manufacture  and  effect.  Cures  never  occur,  for 
they  would  be  abnormal  since  arteriosclerotic  de- 
generation is  essentially  a  compensatory  process  due 
to  the  structural  complexity  of  the  body.  We  strive 
to  limit  the  arterial  degeneration  to  the  extent  of 
conforming  its  age  level  to  that  of  the  other  tissues 
of  the  biological  unit.  So  to  speak,  we  strive  for 
age  harmony  of  tissues.  Premature  or  abnormal 
ageing  of  one  tissue  secondarily  excites  the  same 
process  in  a  correlated  tissue. 

Heretofore,  the  usual  therapeutic  efforts  have  been 
aimed  at  reducing  blood  pressure  by  the  nitrites  and 
potassium  iodide,  by  saline  purgation  and  a  restric- 
tion of  proteids.  If  an  infection  was  superficial 
enough  to  be  readily  obvious  and  especially  if  it 
produced  distressing  symptoms  it  was  routinely 
attended  to.  The  principle  of  this  therapy  is 
essentially  based  upon  elimination.  From  this 
theory  hydrotherapeutic  practice  originated,  and  the 
work  of  hydrotherapists,  until  recently,  has  been  the 
most  efficacious  in  eliminating  the  toxic  products  of 
the  causal  factors. 

However,  the  old  principles  of  arteriosclerotic 
therapy  are  fundamentally  incorrect,  because  they 
are  based  upon  a  very  imperfect  and  incorrect  con- 
ception of  the  disease.  Elimination,  per  sc,  is  of 
benefit  temporarily.  As  soon  as  one  neglects  this 
elimination  a  reaccumulation  of  toxic  products 
occurs  and  again  the  organism  anaphylactically 
reacts  and  the  disease  is  fully  manifested  again. 
And  who  can  question  the  stress  that  is  imposed 
upon  the  organism  by  these  strenuous  eliniinatory 
measures  ? 

Without  question,  the  most  logical  treatment 
would  be  first  to  find  the  causes,  remove  or  correct 
them,  and  then  allow  the  body  to  detoxicate  itself 
through  the  natural  avenues  and  through  its  own 
efforts.  If  the  causal  factors  are  removed  or  cor- 
rected a  metabolic  readjiistment  takes  place  and 
there  is  no  need  to  drug  a  patient  to  reduce  his 
pressure,  which  is  a  necessary  compensatory  re- 
action, but  the  pressure  will  adjust  itself  to  the 
metabolic  needs  of  the  organism  in  a  much  more 
exact  manner  than  is  possible  for  the  keenest 
therapeutist  to  discern.  Therapy  based  upon  this 
principle  is  certain  to  produce  results  and  the 
management  of  arteriosclerotic  patients  is  most 
gratifying  to  the  patient  and  to  the  physician.  Ar- 
teriosclerosis ceases  to  be  the  therapeutic  bugaboo 
of  the  old  days  when  one  grasps  the  significance  of 
its  clinical  display  and  understands  the  mechanism 
of  its  formation. 

Foci  of  infection  must  be  sought  for  diligently. 
The  gastrointestinal  tract  must  be  searched  for  foci 
of  infection  from  the  mouth  to  the  anus.  The 
intestines  contain  a  great  amount  of  lymph  tissue 
and  infection  of  this  tissue  is  particularly  likely  to 
occur  as  soon  as  the  composition  of  the  digestive 
juices  are  altered  by  a  faulty  metabolism.  Recent 
investigations  have  proved  that  bacteria  pass  through 
the  intestinal  mucosa  into  the  mesenteric  lymphoid 


July  3.  1920.]  XORMAX:  GASTROIXTESTIXAL  TRACT  AXD  ARTERIOSCLEROSIS. 


17 


tissue  and  are  just  as  much  a  source  of  infection 
as  an  abscessed  tooth  or  pyogenic  tonsil.  Routine 
blood  examination  to  determine  the  serology,  the 
c\tological  status,  and  other  conditions  is  very 
necessary.  Indeed,  much  information  may  be 
gained  from  the  blood  count.  The  stools  should  be 
examined  repeatedly  and  cultures  made  so  as  to  de- 
termine the  predominant  Ijacterial  flora.  It  is  well 
to  relieve  temporarily  such  patients  from  all 
nervous,  mental  or  occupational  tension  if  possible. 

To  begin  with,  we  know  that  the  dietary  has  been 
improper  and  that  a  great  part  of  the  general  cellular 
sensitization  has  been  brought  about  by  the  in- 
gestion of  an  excessive  amount  of  protein  food. 
Because  of  this  improper  dietary,  intestinal  stasis 
hai.  occurred.  Intestinal  stasis  alters  the  chemical 
composition  of  the  digestive  secretions,  lowering 
their  germicidal  activity  and  predisposing  the  in- 
testinal tissues  to  bacterial  invasion.  Poor  hygiene 
adds  to  the  misery,  and  the  teeth,  the  tonsils,  the 
nasal  passages  and  sinuses  may  become  the  seat  of 
infection.  From  these  foci  many  germs  escape, 
to  be  swallowed,  passed  on  to  the  small  intestines 
and  finally  reach  the  colon,  where  an  excess  of 
protein  food  residue  is  delayed  in  its  transit,  and 
supplies  a  fertile  pabulum  for  the  growth  of  patho- 
genic bacteria.  In  addition  to  these  bacteria,  think 
of  the  countless  number  that  are  ingested  with  food 
and  one  may  suspect,  at  least,  that  the  intestinal 
tissues  are  having  a  difficult  task  in  repelling  the 
bacterial  onslaught.  With  this  in  mind,  the  scheme 
of  treatment  becomes  apparent  and  assumes  a  logical 
aspect.  First,  diet ;  second,  colonic  hygiene ;  third, 
exercise:  fourth,  personal  hygiene:  fifth,  temporary 
palliative  therapeutics. 

Diet. — Exclude  rigidly  meat,  fish  and  eggs.  The 
proteins  necessary  for  the  dietary  balance  is  derived 
from  milk,  cheese,  breadstuffs  and  vegetables.  They 
are  nonirritating  proteids. 

Colon  hygiene. — My  method  is  to  begin  with 
ounce  doses  of  castor  oil  combined  with  ten  min- 
nims  of  tincture  of  iodine  and  two  grains  of  menthol, 
every  other  night  for  three  successive  nights,  then 
allowing  the  bowels  to  rest  for  forty-eight  hours. 
This  prepares  the  patient  for  the  cleansing  irriga- 
tions hygiene),  as  the  castor  oil  cleans  house  from 
above  downwards.  The  irrigations  are  begun  and 
are  given  daily  until  the  colon  has  been  thoroughly 
cleansed.  This  is  determined  by  the  bacteriological 
e.xamination  of  the  stool  and  by  the  character  of  the 
stool.  In  addition  to  the  irrigations  nightly  doses 
of  compound  licorice  powder  is  given  to  aid  the 
cleansing  process.  A  special  apparatus  is  used 
which  maintains  the  irrigating  solutions  at  a  con- 
stant temperature.  The  solutions  used  may  be  a 
mildly  antiseptic  solution,  or  perhaps  a  solution  of 
argyrol.  protargol  or  ichthyol.  After  the  colon  has 
been  thoroughly  cleansed  of  fecal  matter  and  harm- 
ful bacteria  one  is  then  ready  to  plant  the  colon. 
This  is  accomplished  by  first  washing  the  colonic 
tract  with  a  solution  of  lactose  so  as  to  furnish  cul- 
ture media  for  the  bacteria  that  are  to  be  injected  into 
the  cecum.  Then  a  pint  of  a  lactose  solu- 
tion containing  great  numberg  of  Bulgarian  bacilli 
and  the  Bacilli  acidophilus  are  introduced  through 
the  irrigating  tube  directly  into  the  cecum.  The 


patient  retains  the  plant  as  long  as  possible.  These 
two  bacteria  are  harmless,  if  given  after  the  colonic 
tract  has  been  thoroughly  cleansed  of  harmful 
bacteria.  The  success  of  the  treatment  depends  upon 
thoroughly  cleansing  the  colon  of  fecal  matter,  and 
harmful  bacteria  before  planting  the  Bulgarian  and 
acidophilus.  Unless  this  is  done,  it  is  possible  to 
do  much  harm.  This  technic  may  appear  to  be 
simple,  but  it  is  not.  It  requires  a  constant  study 
of  the  bacteriological  conditions  present,  in  order 
to  determine  when  it  is  safe  to  plant.  At  times, 
when  the  microscopical  picture  is  dominated  by 
pathogenic  bacteria,  an  autogenous  vaccine  will  l)e 
found  a  valuable  adjunct  to  the  treatment,  as  it 
clears  up  the  infection  in  the  intestinal  and  mesen- 
teric structures. 

This  treatment  is  not  to  be  confused  with  the 
high  enema  or  the  ordinary  high  irrigations  with 
which  every  one  has  had  more  or  less  experience. 
It  is  not  merely  a  means  to  introduce  bacteria  into 
the  colon,  but  an  efficacious  measure  in  treating- 
mfections  of  the  gastrointestinal  tract.  The  surgeon 
irrigates  infected  areas,  to  cleanse  the  tissues  of  the 
germ  products,  the  waste  tissue  products  and  because 
he  removes  many  harmful  bacteria,  thus  aiding  the 
tissues  in  the  process  of  resolution.  The  same  logic 
is  applied  to  the  colon  by  this  treatment. 

This  treatment  I  consider  the  best  and  most  rapid 
method  of  detoxication.  and  in  addition  to  its  de- 
toxicating  properties,  there  is  established  a  new 
chemical  balance  in  the  colon.  Putrefactive  pro- 
cesses are  inhibited  by  the  fermentation  products, 
chiefly  lactic  acid. 

Putrefactive  products  are  the  result  of  bacterial 
decomposition  of  protein  food  residue.  The 
character  of  the  food  residue  has  been  changed  by 
the  diet  and  favors  the  growth  of  such  favorable 
bacteria  as  the  Bulgarian,  the  acidophilus  and  the 
bifidus.  Thus  the  chemical  processes  have  changed 
from  putrefactive  to  fermentative,  and  there  is  no 
harmful  putrefactive  products  to  be  absorbed  to 
further  sensitize  the  body  cells.  Other  foci  of  in- 
fection are  treated  by  methods  which  are  (juite 
familiar  to  you  and  need  no  comment. 

E.vcrcisc. — Exercise,  graded  increasingly  to  a 
physiological  limit  determined  by  the  physician,  is 
very  necessary  because  it  promotes  skin  function, 
elimination  by  the  lungs,  a  better  oxygenation  of  the 
blood,  a  better  tissue  combustion,  heart  exercise, 
circulatory  exercise  and  the  formation  of  optimistic 
mental  attitudes.  It  is  to  be  emphasized  that  this 
exercise  is  not  prescribed  for  the  promotion  of 
pugnacious  muscular  proportions  but  chiefly  as  a 
heart  and  circulatory  exercise.  For  this  reason,  it  is 
well  to  discourage  all  forms  of  games  in  which  the 
match  element  is  well  developed,  as  the  patient  is 
likely  to  overstep  his  tonnage. 

Personal  hygiene. — The  patient  should  be  in- 
structed as  to  nasal,  tonsillar,  dental  and  sex  hygiene 
as  well  as  bathing.  Habits  should  be  modified.  No 
alcohol  and  moderate  smoking  unless  there  is  a 
distinct  reaction  to  tobacco. 

Temporary  palliative  therapeutics. — If  there  is 
insomnia  small  doses  of  chloral  hydrate  is  efficatious. 
If  there  is  precordial  distress  a  nitroglycerin  pellet 
symptomatically  used  is  indicated.    For  headaches 


18 


KUNSTLER:  DIAGNOSIS  OF  GASTRIC  DISEASES. 


[New  York 
Medical  Journal. 


a  small  dose  of  acetanilide  combined  with  cafTeine 
and  monobromated  camphor  usually  suffices.  Flat- 
ulence is  usually  combatted  by  resorcin,  sodium 
bicarbonate  and  pepsin.  Palpitation  may  be  helped 
by  atropin  or  very  small  doses  of  aconite  hydro- 
bromide,  or  by  a  cold  water  bag  to  the  precordia. 
Head  pressure  may  be  relieved  by  mustard  foot 
baths.  Nervousness  usually  responds  to  strontium 
bromide.  For  constipation  use  compound  licorice 
powder  or  castor  oil. 

There  are  a  few  don'ts  which  are  worthy  of  men- 
tion. First,  never  attempt  to  reduce  blood  pressure 
by  drugs  or  electricity.  Second,  never  prescribe 
salines.  They  do  nothing  but  irritate  an  already 
diseased  intestinal  wall  and  render  it  less  capable  of 
combatting  infectious  processes.  Third,  never 
deprive  your  patients  of  proteids,  except  those  con- 
tained in  meats,  fish  and  eggs. 

The  treatment  and  directions  that  I  have  outlined 
for  you  will  suffice.  Rid  the  body  of  the  patient 
of  the  products  of  food  poisoning,  the  products 
of  putrefaction  and  the  products  of  pathogenic 
i)acterial  activity,  and  by  changing  the  diet,  the  habits 
and  the  hygiene  of  the  patient  you  will  create  a  new 
metabolic  level  which  is  infinitely  more  potent  than 
any  drug  or  electrical  treatment  or  eliminative  treat- 
ment ever  devised  by  man,  for  the  purpose  of  arrest- 
ing the  development  of  the  most  insidious  of 
diseases,  arteriosclerosis,  which  is  being  increasingly 
recognized  as  the  most  dangerous  menace  that  is 
confronting  civilization  today. 

DIAGNOSIS  OF  GASTRIC  DISEASES.* 

By  M.  B.  Kunstler,  M.  D.. 
New  York. 

Attending   Gastroenterologist,   New   York   Diagnostic  Clinics. 

In  an  organ  so  accessible  to  all  diagnostic  meas- 
ures as  the  stomach  one  would  imagine  the  diag- 
nosis of  gastric  diseases  to  be  comparatively  easy. 
This,  however,  is  not  the  case,  for  even  after  a  most 
careful  and  complete  examination,  we  are  some- 
times in  a  quandary  as  to  the  underlying  pathologi- 
cal condition.  Among  the  reasons  for  this  the  most 
important,  perhaps,  are  the  facts  that  the  anamnesis 
is  so  often  misleading,  and  that  we  are  prone  at 
times  to  place  too  great  reliance  on  one  particular 
method  of  examination.  The  following  means  are  at 
our  disposal  in  arriving  at  a  diagnosis  :  1,  the  history  ; 
2,  physical  examination ;  3,  test  meal ;  4,  string  test ; 
5,  x  ray  examination ;  6,  stool  examination ;  7,  blood 
examination.  I  shall  discuss  each  method  separate- 
ly, endeavoring  to  point  out  its  particular  advant- 
ages and  disadvantages. 

HISTORY. 

Although  many  men  have  asserted  that  this  is  the 
most  important  means  at  our  disposal  in  diagnosing 
disease,  it  appears  to  me  to  be  very  uncertain  and 
of  little  value,  at  least  in  gastric  disease.  We  so 
often  find  patients  complaining  of  hyperacidity 
symptoms  where  a  normal  or  subacid  state  exists, 
that  after  a  time  we  are  prone  to  lose  faith  in  the 
patient's  statements.  And  again  there  are  numer- 
ous extragastric  causes  that  give  rise  to  symptoms 

^Presented  before  the  New  York  Diagnostic  Society,  May  26,  1920. 


SO  similar  to  the  intragastric  conditions  that  were 
we  to  rely  too  greatly  on  the  subjective  signs  we 
would  surely  start  with  an  incorrect  assumption.  I 
do  not  wish  to  give  the  impression  that  the  history 
is  altogether  unimportant,  for  many  useful  facts  can 
be  elicited  from  it.  In  a  textbook  case  of  gastric  ulcer 
the  history  of  pain  two  to  four  hours  after  meals 
relieved  by  eating,  sodium  bicarbonate  or  vomiting, 
with  frequent  attacks  of  pyrosis,  is  often  as  accu- 
rate in  diagnosing  the  condition  as  is  a  complete  and 
thorough  examination.  However,  I  have  found 
that  it  is  only  rarely  one  gets  so  typical  a  history 
and  so  the  anamnesis  proves  of  little  value  in  most 
cases.  An  ulcer  may  exist  without  any  of  the  usual 
gastric  symptoms,  the  patient  complaining  of  only 
constipation,  loss  of  weight,  or  what  he  calls  indi- 
gestion, with  nausea  at  times.  The  most  important 
point  in  the  history,  to  my  mind,  is  the  statement 
that  the  patient  has  a  good  appetite  but  is  afraid  to 
eat,  or  that  he  has  completely  lost  his  appetite.  The 
former  is  the  usual  case  in  ulcer,  the  latter  in  car- 
cinoma. The  time  element  is  another  important 
factor,  ulcer  cases  giving  a  history  of  long  duration, 
possibly  five  or  ten  years  with  periods  of  intermis- 
sion, whereas  carcinoma  dates  back  only  a  short 
time  and  is  progressive  and  constant.  This,  how- 
ever, is  not  nearly  so  valuable  as  the  previous  state- 
ment. The  fact  that  the  symptoms  are  aggravated 
by  the  taking  of  acids  usually  points  to  a  hyper- 
acidity, although  this  may  exist  with  a  normal  or 
subacid  condition.  Other  important  factors  to  be 
elicited  from  the  history  are  the  statements  pointing 
to  disease  of  other  organs,  for  a  mere  hint  that  some 
uterine  or  renal  disease  exists  may  prove  of  ex- 
treme value  in  the  final  cure. 

PHYSICAL  EXAMINATION. 

A  careful  physical  examination  is  perhaps  of  as 
great  value  as  any  other  one  diagnostic  method,  for 
by  it  we  learn  not  only  the  gastric  condition  but  also 
the  presence  or  absence  of  other  diseased  organs. 
Referring  to  the  stomach  the  physical  examination 
should  aim  to  elicit  the  following:  a,  points  of  ten- 
derness ;  b,  masses ;  c,  position ;  d,  size ;  e,  rigidity ; 
f,  peristalsis. 

a.  Tenderness. — Regarding  tenderness  one  must 
be  extremely  careful,  for  nothing  is  more  variable 
than  abdominal  tenderness.  Tenderness  over  the 
abdominal  nerve  plexuses,  particularly  the  celiac 
and  aortic,  may  lead  one  to  suspect  almost  any  path- 
ological condition  and  has  often  condemned  the 
patient  to  needless  surgical  intervention,  so  we  can- 
not be  too  painstaking  in  distinguishing  between  this 
type  of  tenderness  and  that  due  to  disease  of  the 
viscera.  Plexus  tenderness  is  always  deep,  usually 
bilateral,  and  exists  without  rigidity.  The  principal 
gastric  diseases  producing  tenderness  are,  of  course, 
ulcer  and  carcinoma.  In  the  former  there  exists, 
usually,  a  superficial  point  of  tenderness  in  the  epi- 
gastrium about  three  inches  above  the  umbilicus, 
which  may  be  elicited  by  gently  tapping  the  abdo- 
men in  this  region.  Another  tender  point  in  ulcer 
is  found  just  below  the  left  shoulder  blade,  pos- 
teriorly. The  tenderness  of  carcinoma  is  deeper 
and  is  not  localized  to  one  point  but  exists  over 
the  whole  area  involved.  In  duodenal  ulcer  the  ten- 
derness is  usually  lower,  being  situated  to  the  right 


July  3,  1920.] 


KUNSTLER:  DIAGXOSIS  OF  GASTRIC  DISEASES. 


19 


and  just  above  the  umbilicus.  This,  however,  re- 
sembles gallbladder  tenderness  and  it  becomes  diffi- 
cult at  times  to  distinguish  between  the  two  diseases. 
In  ulcer  pressure  inward  and  upward  is  the  most 
sensitive,  while  in  gallbladder  disease  the  most 
marked  tender  spot  is  elicited  by  pressure  upward 
and  to  the  right  in  a  line  from  the  umbilicus  to  the 
tip  of  the  right  shoulder.  In  appendicitis  we  some- 
times find  a  tender  spot  in  the  epigastrium,  but  pres- 
sure over  AIcBurney's  point  is  so  sensitive  as  to 
foreshadow  this. 

b.  Masses. — A  mass  in  the  epigastrium  should  al- 
ways arouse  our  suspicion  of  carcinoma  until 
proved  otherwise.  Carcinoma  cases  rarely  come  to 
us  so  early  that  a  mass  cannot  be  felt.  A  small 
nodule  only  may  exist  although  usually  the  mass  is 
diffuse,  superficial,  irregular,  and  freely  movable. 
The  principal  enlargements  from  which  carcinoma 
must  be  distinguished  are  liver,  splenic  masses,  and 
those  due  to  omental  or  peritoneal  diseases.  In  the 
two  fonuer  the  outlines  of  the  organs  can  often  be 
traced  by  palpation  or  percussion  and  it  will  usually 
be  seen  that  the  epigastric  mass  is  part  of  one  or  the 
other  organ.  In  peritoneal  or  omental  diseases,  such 
as  tuberculosis  for  instance,  the  growths  are  far 
more  diffuse  and  less  freely  movable  than  is  that  of 
gastric  carcinoma  and  we  get  the  other  signs  of 
general  peritonitis,  among  which  are  free  fluid  in 
the  abdomen,  temperature,  and  pulse  reaction. 

The  mass  in  benign  gastric  conditions,  such  as 
stenosis  or  chronic  ulcer,  is  very  much  smaller  and 
more  localized  than  that  of  carcinoma  and  besides 
does  not  give  the  general  signs  of  cancer.  Syphilis 
of  the  stomach  gives  no  mass  unless  it  exists  in  the 
form  of  a  gumma,  and  this  is  so  extremely  rare 
that  a  differential  diagnosis  from  cancer  presents 
many  difficulties.  Even  when  other  marked  signs 
of  lues  are  present  I  hesitate  to  call  a  gastric  mass  a 
gumma  until  cancer  has  absolutely  been  ruled  out. 
The  mass  of  pancreatic  cyst  is  situated  in  the  epi- 
gastric region  but  is  usually  regular  and  nonmobile. 
Here,  too,  cachexia  is  lacking. 

c.  Position. — Our  means  for  determining  the 
stomach  position  in  a  physical  examination  are 
percussion  and  the  eliciting  of  the  splash.  In  the 
fonner  we  may  inflate  the  stomach  or  not,  and  then 
outline  the  gastric  tympany  which  gives  some  idea 
as  to  position.  The  splash  of  the  gastric  contents 
is  heard  when  we  tap  the  abdomen  in  the  epigastric 
region  around  the  umbilicus.  Both  of  these  methods 
lack  the  accuracy  of  the  x  ray  in  showing  the  posi- 
tion but  for  general  purposes  may  prove  sufficient. 

d.  Sice. — This  is  shown  by  the  methods  used  in 
determining  position  and  the  same  may  be  said  as 
to  the  lack  of  accuracy. 

e.  Rigidity. — The  importance  of  rigidity  in  gas- 
tric diagnosis  lies  in  the  fact  that  in  a  perforated 
ulcer  this  is  perhaps  the  most  important  sign.  In 
these  cases,  if  seen  early,  there  is  marked  and  local- 
ized epigastric  rigidity.  Later  the  entire  abdomen 
becomes  rigid,  indicating  a  general  peritonitis.  In 
gallbladder  disease  there  usually  exists  a  mod- 
erate degree  of  rigidity  in  the  right,  upper  quad- 
rant, but  nothing  like  that  in  a  perforated  ulcer. 

/.  Peristalsis. — Visible  gastric  peristalsis  is  pres- 
ent in  malignant  or  benign  pyloric  obstructions  that 


have  existed  for  some  time,  allowing  the  stomach 
muscles  to  adjust  themselves  to  the  condition  by 
hypertrophy.  It  is  most  marked  in  the  benign  steno- 
sis, for  they  are  usually  of  longer  duration  and 
do  not  involve  the  stomach  wall  as  do  the  cancer 
cases.  In  thin  people  we  sometimes  are  able  to 
see  intestinal  peristalsis  through  the  abdominal  wall, 
but  this  is  much  more  indefinite  and  lacks  the  regu- 
larity of  the  peristalsis  in  pyloric  obstructions. 

THE  TEST  MEAL. 

This  is  of  equal  or  even  greater  importance  than 
the  phjsical  examination,  and  had  I  one  method 
only  to  choose  in  arriving  at  a  diagnosis  I  would 
take  the  test  meal,  for  by  it  we  get  a  wealth  of 
information.  It  is  perhaps  best  first  to  describe 
the  normal,  and  then  the  variations  in  the  test  meal. 
In  a  healthy  individual  we  find  that  the  stomach 
tube  enters  easily  to  about  nineteen  or  twenty 
inches.  This  is  important,  for  in  cases  of  cardiac 
spasms  or  esophageal  obstruction  (cancer,  aneur- 
ysm, etc.)  we  find  a  distinct  blocking  to  the  entry 
of  the  tube,  and  in  gastroptosis  the  tube  may  be 
inserted  to  twenty-five  inches  or  more  before  it  en- 
counters the  lower  border  of  the  stomach.  In  as- 
pirating, which  by  the  way  should  always  be  done 
in  taking  a  test  meal,  the  return  in  healthy  indi- 
viduals varies  between  five  and  thirty  c.  c.  (after 
one  hour)  and  is  of  the  consistency  of  well  cooked 
oatmeal  gruel,  being  rather  slimy  and  more  fluid 
than  solid.  It  comes  through  the  tube  easily,  is 
light  yellow  in  color,  and  odorless.  I  refer  to  the 
Ewald  test  breakfast,  consisting  of  a  slice  of  white 
bread  and  a  glass  of  water,  which  for  practical 
purposes  is  sufficient,  and  I  have  found  that  the 
one  hour  period  usually  gives  as  much  data  as  do 
the  newer  fractional  methods,  with  less  disturbance 
to  the  patient.  The  acidity  of  such  a  normal  meal 
is  about  thirty  or  forty  free  acid  and  fifty  or  sixty 
total  acid,  and  contains  some  starch  granules  with- 
out much  else  of  importance. 

The  most  common  deviations  from  this  are  found 
in  duodenal  or  gastric  ulcer,  carcinoma,  achylia  gas- 
trica,  and  gastrosuccorrhea.  In  ulcer  should  there 
be  no  obstruction  at  the  pylorus  the  return  is  usually 
small  in  amount,  varying  between  five  and  fifteen 
c.  c,  and  is  a  thin,  clear  fluid  containing  very  few 
food  particles.  This,  of  course,  means  that  there 
is  a  gastric  hypermotility,  the  meal  having  been 
rushed  through  the  pylorus.  Where  obstruction  at 
the  pylorus  exists  in  chronic  ulcer  the  return  is  ex- 
tremely large  (from  150  to  500  c.  c),  of  a  very 
foul  odor,  and  contains  not  only  all  of  the  test 
meal  taken  but  also  elements  of  previous  meals, 
such  as  carrots  or  spinach,  which  may  have  been 
eaten  two  or  three  days  before.  In  both  of  these 
cases,  either  with  or  without  obstruction,  there  is 
a  very  high  acidity,  the  free  acid  being  from  fortv 
to  eighty  and  the  total  acid  from  eighty  to  one 
hundred,  and  they  may  each  contain  traces  of  blood. 
With  obstruction  there  also  exists  varying  amounts 
of  lactic  acid  and  sarcinse.  I  have  also  found  the 
Boas-Oppler  bacilli  with  benign  obstructions,  so  this 
does  not  become  a  differential  point  from  cancer. 
The  test  meal  in  the  latter  is  also  large  in  amount 
but  differs  from  almost  every  other  condition  in  its 


20 


KUXSTLER:  DIAGXOSIS  OF  GASTRIC  DISEASES. 


[Xew  York 
Medical  Journal. 


color,  being  of  a  dark,  red  brown  hue,  having  the 
socalled  coffee  ground  appearance,  which  is  due  to 
the  presence  of  l)lood.  It  is  of  very  foul  odor  and 
almost  always  shows  an  absence  of  free  acid  with 
a  low  total  acidity  (fifteen  to  twenty).  Lactic  acid 
is  marked  as  is  blood,  and  we  usually  find  sar- 
cinse.  Boas  Oppler  bacilli  and  imdigested  meat  filjres. 
At  times  we  may  find  great  numbers  of  gastric 
epithelial  cells  and  pieces  of  the  neoplasm  rarely. 

The  meal  of  achylia  gastrica  is  also  individual  in 
appearance  and  a  diagnosis  can  usually  be  made  by 
the  way  it  returns  through  the  tube.  It  is  always 
small  in  amount  indicating  a  gastric  hypermotility, 
but  its  main  feature  lies  in  the  fact  that  it  is  glairy 
and  is  aspirated  with  great  difficulty.  The  food  par- 
ticles are  usually  large  and  undigested  and  are  cov- 
ered with  mucus.  It  is  perfectly  odorless  and  of 
normal  color,  contains  very  little  or  no  free  acid 
■and  about  thirty  total.  It  shows  an  absence  of  lac- 
tic acid,  sarcinie  and  Boas  Oppler  bacilli,  such  as 
are  found  in  cancer.  The  test  meals  in  pernicious 
or  secondary  anemias  often  show  an  achylia,  and 
in  these,  due  to  the  low  blood  state,  it  Ijecomes 
important  to  differentiate  from  cancer.  However, 
they  lack  the  characteristic  color  of  the  meal  in 
carcinoma  cases  and  show  no  signs  of  retention. 

In  gastrosuccorrhea  the  stomach  contents  are 
markedly  increased,  averaging  250  to  300  c.  c,  of  a 
thin  fluid  consistency,  and  contain  very  few  food 
l)articles.  If  colored  at  all  they  are  slightly  green 
from  the  presence  of  bile.  In  these  cases  there  is  the 
greatest  amount  of  acid,  about  eighty  free  and  one 
hundred  to  one  hundred  and  twenty  total.  There 
is  usually  nothing  else  of  importance  found.  The 
presence  of  bile  in  the  gastric  contents  means  a  pa- 
tent pylorus  with  a  regurgitation  from  the  duod- 
enum, and  is  often  found  in  atonia  gastrica.  So. 
taken  all  in  all,  I  think  that  it  will  easily  be  seen 
how  important  is  the  test  meal. 

STRING  TEST. 

Regardless  of  all  arguments  against  it  I  believe 
the  string  test  is  of  great  value.  In  a  normal  case 
the  string  shows  no  blood  stain  but  is  covered  with 
bile  from  about  the  twenty-three  inch  mark  onward. 
Ulcers  on  the  lesser  curvature  usually  show  a  marked 
blood  stain  at  about  twenty-one  to  twenty-two 
inches,  w^hile  those  on  the  walls  or  the  greater  curva- 
ture may  or  may  not  show  blood.  I  believe  the  stain 
must  be  fairly  well  marked  to  be  diagnostic  and  do 
not  think  tha't  a  very  small,  barely  visible  stain  is 
trustworthy  evidence  of  an  ulcer.  In  pyloric  ob- 
struction the  string  shows  no  bile  stain  and  in  carci- 
noma the  blood  stain  is  diffuse,  covering  eight  to  ten 
inches  of  the  string.  So  used  with  judgment  the 
string  test  becomes  of  great  importance. 

THE   X  RAY. 

A  peculiar  controversy  has  arisen  between  ront- 
genologists and  internists.  It  seems  to  me  that  the 
latter  accept  the  former's  statements  witli  necessary 
reservations  as  disclosed  by  clinical  findings,  while 
the  X  ray  specialist  is  neither  willing  to  accept  nor 
discuss  any  findings  except  his  own.  This  is  prob- 
ably due  to  the  fact  that  x  ray  findings  are  visual 
and  they  say:  "What  w^e  see  we  know."  The  fault 
lies  not  in  the  sen.se,  but  in  the  interpretation  there- 
of, And  if  the  rontgenologist  would  more  often  state 


what  was  visible  without  attempting  always  to  diag- 
nose, the  internist  would,  I  am  sure,  be  grateful. 
In  gastric  work  when  one  sees  cases  diagnosed 
rontgenologically  as  pyloric  cancer  or  perforating 
ulcer  where  no  such  condition  is  found  operatively, 
we  necessarily  become  a  little  skeptical  of  x  ray  find- 
ings.  The  only  true  method  is  to  put  all  of  our  data 

•into  the  form  of  a  brief  and  by  careful  study  to 
arrive  at  as  nearly  a  correct  diagnosis  as  possible. 

In  determining  the  size  and  position  of  the  stom- 
ach there  is  no  method  as  accurate  as  the  x  ray. 
It  is  also  definite  in  marked  duodenal  ulcer  with 
deformity  of  the  cap,  in  carcinoma  where  the  stom- 
ach wall  becomes  deformed  or  eroded,  and  in  pyloric 
obstructions.  However,  in  small  lesser  curvature 
ulcers  or  erosions,  where  gastric  hypermotility  and 
a  seeming  defect  are  the  only  x  ray  evidences,  we 
must  tread  very  carefully  before  accepting  such 
proof,  for  it  may  be  only  a  perigastric  adhesion  or  a 
slight  spasm  in  the  gastric  wall  that  causes  the  de- 
fect in  outline.  Rontgenological  retention,  unless 
marked  and  of  long  duration,  is  of  little  value  com- 
pared with  that  found  by  the  test  meal,  for  a  six 
hour  retention  may  be  ignored  and  the  other  types 
show  only  bismuth  stasis  without  giving  signs  of 
the  fluid  retention.  Early  carcinoma  at  the  pylorus, 
as  shown  in  the  rontgenogram,  must  never  be  ac- 
cepted unless  there  are  some  clinical  findings  to  sup- 

'  port  the  X  ray  for  we  may  get  a  flattening  of  the 
I^yloric  end  of  the  stomach  which  resembles  cancer 
without  such  being  the  case.  To  divert  from  the 
stomach  for  a  moment,  it  appears  that  the  gall- 
bladder is  often  accused,  rontgenologically,  of  en- 
largement where  no  such  enlargement  exists  and 
for  this  w^e  must  always  be  on  the  lookout.  And 
.so  I  use  the  x  ray  in  every  case,  but  with  reservation. 

STOOL  EXAMINATION. 

The  importance  of  stool  examinations  lies  in  the 
fact  that  in  a  duodenal  ulcer  blood  may  be  found 
in  the  stool  where  none  exists  in  the  gastric  con- 
tents. The  other  stool  findings  show  pathological 
conditions  of  the  intestines,  or  faulty  digestion  of 
certain  food  elements,  all  of  which  may  play  a  part 
in  the  diagnosis. 

BLOOD  EXAMINATION. 

This  must  always  be  done  in  a  complete  examina- 
tion for  any  gastric  condition.  The  secondary 
anemia  in  carcinoma  or  the  pernicious  anemia  found 
in  some  cases  of  achylia  is  of  utmost  importance. 
The  presence  of  a  positive  Wassermann  reaction 
may  change  the  complete  picture  and,  in  a  few  cases, 
a  marked  eosinophilia  may  put  us  on  the  track  of 
an  intestinal,  parasitic  disease.  In  some  extragastric 
conditions,  such  as  appendicitis,  where  all  signs 
point  to  the  stomach,  a  leucocytosis  is  important. 

I  have  purposely  omitted  mentioning  many  of  the 
conditions  causing  gastric  changes  for  the  sake  of 
clearness  and  simplicity  and  have  attempted  to 
present  briefly  the  methods  of  making  a  complete 
gastric  examination  with  the  interpretation  thereof. 
To  summarize,  examine  each  patient  completely, 
take  the  findings  for  what  they  are  worth,  and 
place  most  reliance  on  the  physical  examination  and 
the  test  meal. 

46  West  Eighty-third  Street. 


July  3,  1920.] 


irOOLSEY:    RADICAL    CURE    OF   INGUINAL  HERNIA. 


21 


AN  OPERATION  FOR  THE  RADICAL  CURE 
OF  INGUINAL  HERNIA.* 
Bv  George  Woolsev,  M.  D.,  F.  A.  C.  S., 

New  York. 

More  than  twenty  years  ago  I  settled  upon  a 
technic  for  operation  on  inguinal  hernise,  which 
proved  so  satisfactory  that  I  have  continued  to  use 
it  ever  since.  This  operation  was  a  gradual  de%^el- 
opment,  comljining  features  of  several  then  in  use. 
and  was  not  therefore  original,  except  as  to  this 
combination.  In  1896  I  published  a  clinical  lecture 
(1)  on  a  case  in  which  the  patient  was  operated 
upon  in  Bellevue  Hospital  in  1895  for  inguinal  her- 
nia and  urethrorectal  fistula.  The  method  then  em- 
ployed was  essentially  like  the  original  Halsted  op- 
eration, with  figure  of  eight  sutures  of  silkworm 
gut  through  the  edges  of  the  incision  in  the  skin 
and  of  the  external  oblique  aponeurosis,  the  cord 
lying  above  them.  A  year  or  so  later,  after  trying 
Bassini's  method  for  a  time.  I  adopted  my  present 
method  but  did  not  publish  it,  as  others  having 
similar  features,  such  as  Andrews's  method,  had 
recently  appeared.  I  did  not  see  Andrews's  publi- 
cation until  many  years  later  and,  until  I  read  it, 
supposed  that  his  operation  was  identical  with 
mine. 

My  method  has  been  demonstrated  in  numerous 
clinics  to  scores  of  hospital  interns,  one  of  w-hom, 
now  a  hospital  surgeon,  recently  asked  me  why  I 
never  published  it.  This  led  me  to  look  over  the 
literature  to  see  if  anything  exactly  like  it  had  been 
published.  I  have  found  one  publication  describ- 
ing an  operation  practically  identical,  which  I  had 
not  read  until  a  few  weeks  ago.  This  article  was 
by  E.  L.  Swift,  M.  D.,'  assistant  surgeon,  U.  S. 
Army,  and  was  entitled,  A  New  Form  of  Opera- 
tion for  the  Cure  of  Inguinal  Hernia.  It  was 
the  subject  of  a  special  report  to  the  Surgeon  Gen- 
eral of  the  U.  S.  Army  (2). 

The  main  features  of  my  method  of  operation 
are  obliteration  of  the  inguinal  canal  and  the  ex- 
ternal abdominal  ring,  and  fortifying  this  part  of 
the  abdominal  wall  by,  1,  suture  of  the  entire  thick- 
ness of  the  musculoaponeurotic  wall,  along  the 
upper  or  inner  margin  of  the  incision,  to  the  deep 
surface  of  Poupart's  ligament ;  2,  by  overlapping 
the  lower  flap  of  the  external  oblique  aponeurosis 
in  front  of  the  upper  flap,  and,  3,  transplanting  the 
cord  so  it  will  lie  superficially  to  the  aponeurosis.  I 
shall  describe  in  a  few  words  the  diflferent  steps  of 
the  operation  and  some  of  the  reasons  for  their  use. 

The  aponeurosis  of  the  external  oblique  is  split 
in  line  with  its  fibres  from  near  the  upper  margin 
of  the  external  ring  to  a  point  two  to  three  cm. 
above  the  position  of  the  internal  ring,  care  being 
•taken  to  avoid  injury  to  the  ilioinguinal  nerve.  It 
is  generally  recognized  as  most  important  to  ligate 
and  excise  the  sac  so  high  up  as  to  leave  no  infun- 
dibular depression  of  the  peritoneum  at  the  site  of 
the  internal  ring,  which  favors  recurrence.  This 
high  ligation  is  accomplished,  after  free  exposure 
of  the  neck  of  the  sac,  by  traction  on  the  sac  with 
or  without  twisting  it,  then  transfixing  and  ligating 

*Read  before  the  Bellevue  Hospital  Alumni  Societv,  December 
3,  1919. 


it  high  up.  When  the  traction  or  twisting  is  re- 
laxed the  site  of  the  ligature  is  flat  and  presents  no 
outward  bulging.  Twisting  is  also  useful  to  reduce 
the  contents,  like  the  omentum,  which  tends  to  slip 
by  the  finger,  introduced  into  the  sac  in  traction  to 
keep  the  contents  reduced.  If  the  operator  prefers 
he  may  excise  the  sac  high  up  and  close  the  open- 
ing b}-  a  continuous  suture.  Unless  the  neck  of  the 
sac  is  sutured  instead  of  ligated,  transfixion  is 
essential  to  prevent  the  ligature  slipping  of¥,  as  I 
have  learned  by  experience.  In  an  operation  for 
peritonitis,  due  to  an  injury  in  the  neighborhood  of 
a  hernia,  I  first  operated  on  the  hernia  and  then, 
finding  no  lesion  in  it,  opened  the  abdomen  and 
found  that  the  ligature  had  slipped  off  the  neck  of 
the  sac,  requiring  suture  of  the  opening.  I  rarely 
resect  the  veins  of  the  cord  unless  they  are  very 
markedly  varicose.  According  to  Hakstead  (3),  the 
advocate  of  this  procedure,  excision  of  the  veins 
with  transplantation  of  the  cord  results  in  atrophy 
of  the  testes  in  ten  per  cent,  of  the  cases  and,  not 
infrequently,  in  a  small  hydrocele.  This  atrophy 
usually  follows  a  considerable  swelling  of  the  epi- 
didymis. However,  all  extraneous  fat  and  con- 
nective tissues  are  removed  from  the  cord  to  re- 
duce its  size. 

In  case  the  muscular  portion  of  the  conjoined 
tendon  at  the  internal  ring  is  very  thin  and  weak, 
I  do  not  hesitate  to  incise  it  outward  and  upward 
one  to  two  cm.  into  thicker,  firmer  muscle,  to 
make  a  new  internal  ring,  as  in  Halsted's  original 
operation.    This  is  seldom  necessary,  however. 

In  suturing  the  internal  oblique  and  transversalis 
muscles  to  Poupart's  ligament,  in  Bassini's  opera- 
tion, I  found  that  the  sutures  in  the  muscle  had  a 
strong  tendency  to  cut  through.  Hence  I  included 
the  firm  inner  flap  of  the  external  oblique  aponeu- 
rosis. This  serves  to  take  the  cutting  strain  of  the 
sutures  off  the  muscles,  as  w^ell  as  to  add  to  the 
strength  of  the  abdominal  w-all  along  the  line  of  the 
old  canal.  When  this  is  done  there  is  nothing  left 
to  do  with  the  lower  or  outer  flap  of  the  external 
oblique  aponeurosis  except  to  overlap  it  in  front  of 
the  inner  or  upper  flap,  which  still  further  strength- 
ens this  w-eak  area  of  the  abdominal  wall.  Andrews 
has  well  pointed  out  that  when  the  conjoined  tendon 
is  sutured  to  Poupart's  ligament  it  leaves  the  aponeu- 
rosis relaxed  unless  it  is  overlapped. 

The  main  object  and  most'  important  result  of 
bringing  the  cord  out  at  the  upper  and  outer  end 
of  the  incision  is-  to  enable  one  to  obliterate  the 
external  ring  and  to  make  a  firm  closure  of  this 
potentially  weak  part  of  the  abdominal  wall,  by  car- 
rying the  suturing  of  the  musculoaponeurotic  flap 
to  Poupart's  ligament  and  the  imbrication  of  the 
aponeurosis  continuously  to  the  pubic  bone.  Toward 
the  inner  end  of  this  suture  line  the  sheath  of  the 
rectus  is  included  in  the  sutures,  and  in  direct  hernias 
it  may  be  necessary  to  relax  this  by  a  liberating 
incision,  or  to  turn  down  a  flap  from  it  to  allow 
satisfactory  approximation  to  the  inner  end  of  Pou- 
part's ligament.  The  outermost  suture  through  the 
conjoined  tendon  narrows  the  internal  ring,  care 
being  taken  not  to  compress  the  cord  too  snugly. 
The  cord  is  brought  out  forward  and  then  is  de- 
flected upward  by  the  overlapping  lower  flap  of  the 


22 


WOOLSEY:    RADICAL    CURE    OF   INGUINAL  HERNIA. 


[New  York 
Medical  Journal. 


external  oblique  aponeurosis,  so  that  it  passes  some- 
what obliquely  forward  and  upward  and  then  be- 
comes superficial.  Andrews  places  the  cord  between 
the  two  imbricated  layers  of  the  external  oblique 
aponeurosis  because  he  does  not  like  to  lose  "the 
valvular  arrangement  of  the  passage  of  the  cord." 
But  the  anatomical  "oblique  direction  of  the  cord 
can  benefit  nothing  when  the  posterior  wall  of  the 
canal  and  the  internal  ring  have  a  sufficient  resist- 
ing power  to  retain  the  abdominal  contents ;  when 
they  have  not,  it  can  afiford  no  assistance"  (3). 

Cabot  (4),  in  considering  the  radical  cure  of  in- 
guinal hernia,  says  that  we  should  make  a  new  canal 
running  upward  and  outward,  so  that  the  downward 
pressure  of  the  bowels,  coming  at  right  angles  to 
the  axis  of  the  canal  would  tend  to  force  its  walls 
together.  In  the  operation  I  am  describing  the  up- 
ward obliquity  serves  a  similar  purpose.  When  we 
imbricate  the  external  oblique  aponeurosis  the  part 
of  it  not  overlapped,  lateral  to  the  internal  ring,  will 
show  some  relaxation  when  the  patient  coughs  or 
strains,  unless  we  carry  the  incision  of  the  aponeu- 
rosis two  or  three  cm.  beyond  the  ring  and  gradu- 
ally taper  ofif  the  overlapping.  This  also  furnishes 
more  of  a  flap  to  deflect  the  cord  upward.  One, 
and  often  two,  sutures  are  always  placed  external 
to  the  cord  through  the  overlapping  aponeurosis. 
It  is  important  to  place  the  sutures  on  either  side 
of  the  cord  so  as  to  avoid  undue  pressure  on  the 
veins  of  the  cord.  This  passageway  of  the  cord 
nuist  be  tested  with  the  finger  and,  if  too  snug, 
must  be  eased  by  replacing  one  of  the  adjoining 
sutures.  There  is  no  more  danger  or  likelihood  of 
compressing  the  cord  here  than  at  the  external  ring 
in  other  operations ;  perhaps  less  danger. 

To  prevent  the  possible  adhesion  of  the  cutaneous 
cicatrix  to  the  structures  of  the  cord,  and  to  be  sure 
that  they  are  covered  by  the  entire  thickness  of 
the  subcutaneous  fat,  I  suture  this  fatty  layer  sepa- 
rately with  interrupted  sutures  of  plain  gut.  No.  1 
chromic  gut  is  used  for  the  other  buried  sutures. 
The  inclusion  of  the  external  oblique  aponeurosis 
in  the  suture  of  the  muscles  of  the  conjoined  tendon 
to  Poupart's  ligament,  described  above,  is  common 
to  Andrews's  operation  and  that  of  the  Mayo  clinic, 
as  described  by  Judd  (5).  Judd  speaks  of  includ- 
ing it  fo  help  hold  the  internal  oblique,  as  I  have 
done.  Both  of  these  operations  also  imbricate  the 
external  oblique  aponeurosis,  but  the  cord  is  placed 
between  the  layers.  Fowler  (6)  describes  an  opera- 
tion with  imbrication  of  the  aponeurosis,  but  with 
the  cord  beneath  both  layers  and  without  including 
the  aponeurosis  in  the  suture  of  the  conjoined  ten- 
don. Championniere  imbricated  the  aponeurosis  in 
the  reverse  direction  to  that  described  above,  but 
he  left  the  cord  undisturbed.  In  the  operation  de- 
scribed by  Halstead  in  1903  (3),  and  called  by  Bin- 
nie  (7)  the  Johns  Hopkins  operation,  there  is  a 
multiple  imbrication  of  the  separate  layers,  but  the 
vas  is  left  undisturbed. 

In  the  original  Halsted  operation  and  in  those 
described  by  J.  O'Connor,  Postempski,  and  others, 
the  cord  is  placed  superficially,  but  there  is  no  im- 
brication of  the  aponeurosis,  and  the  latter  is  not 
included  in  the  sutures  of  the  conjoined  tendon.  In 
hernia  associated  with  undescended  testis,  the  cord 


is  not  transplanted,  but  the  method  of  suture  and 
imbrication  described  above  is  employed. 

In  the  female  the  operation  is  very  simple  and 
should  give  no  recurrence.  The  round  ligament  is 
not  transplanted  and  is  included  in  one  or  more 
sutures  at  the  inner  end  of  the  incision,  to  fasten 
it  to  the  pubes  and  prevent  its  slipping  and  losing 
the  support  it  gives  to  the  uterus.  The  suturing  and 
imbrication  are  done  as  usual,  except  that  there  is 
no  opening  left,  the  abdominal  wall  being  completely 
closed.  My  experience  has  been  mostly  with  her- 
niae  in  adults  or  adolescents.  In  young  children 
hernia  can  be  cured  by  a  simple  operation. 

The  operation  I  have  described  is  peculiarly  ef- 
fective in  direct  herniae  for  it  enables  the  weak  por- 
tion of  the  abdominal  wall,  at  the  base  of  Hessel- 
bach's  triangle,  to  be  firmly  closed  by  the  overlap- 
ping of  firm  structures,  without  leaving  an  opening 
for  the  cord  to  pass  through  them,  as  in  most  opera- 
tions. It  is  also  as  serviceable  in  indirect  herniae 
as  any  operation  that  I  know  of.  There  are  a  num- 
ber of  good  hernia  operations.  I  do  not  assert  that 
this  is  by  far  the  best,  but  that  in  my  hands  it  has 
proved  at  least  as  good  as  any.  I  have  operated  on 
hundreds  of  herniae  with  most  satisfactory  results. 
I  cannot  give  statistics,  as  most  of  the  operations 
were  done  before  a  follow  up  system  was  intro- 
duced. I  have  seen  a  few,  but  very  few  recurrences. 
The  operative  mortality  is  practically  nil.  If  recur- 
rences were  frequent  the  chief  objection  to  the 
operation  would  be  in  reoperation,  by  one  who  did 
not  know  the  type  of  operation  done,  and  consists 
in  the  danger  of  injuring  the  cord,  lying  superfi- 
cially, by  making  the  incision  down  to  the  aponeu- 
rosis too  freely.  It  is  also  possible  to  compress  the 
cord,  so  as  to  result  in  thrombosis  of  the  spermatic 
veins,  but  there  is  no  more  danger  of  this  than  in 
Bassini's  or  any  other  operation. 

REFERENCES. 

1.  WooLSEY :  New  York  Medical  Journal,  July  18. 
1896. 

2.  Swift,  E.  L.  :  A  New  Form  of  Operation  for  the 
Cure  of  Inguinal  Hernia,  New  York  Medical  Journal. 
October  23,  1897. 

3.  Halsted  :  Johns  Hopkins  Hosp.  Bull.,  August,  1903. 

4.  Cabot  :  Boston  Medical  and  Surgical  Journal,  1896, 
p.  520. 

5.  Judd:    Northwest  Medicine,  February  15,  1908. 

6.  Fowler:    Treatise  on  Surgery,  Vol.  H,  pp.  181-183. 

7.  Binnie:    Operative  Surgery. 

117  East  Thirty-sixth  Street. 

Volvulus  Appearing  as  a  Late  Complication  in 
an  Appendectomy. — Gustave  Dardel  {Corrc- 
spondenc-Blatt  fur  Schweizer  Aerste,  December 
25,  1919)  reports  a  case  in  which  he  performed  an 
appendectomy  on  an  eight  year  old  girl.  Nearly  a 
month  later  the  child  presented  symptoms  of  ileus, 
which  could  not  be  ascribed  to  an  error  of  diet. 
The  condition  of  the  child  was  good  at  first,  but 
after  some  hours  became  bad.  Operation  seventeen 
hours  after  the  onset  of  the  symptoms  revealed  a 
gangrenous  loop  of  intestine  nearly  ready  to  rup- 
ture. This  loop  was  excised  and  the  child  recov- 
ered. The  prognosis  in  volvulus  is  very  grave. 
The  writer  states  that  with  the  single  exception  all 
previously  reported  cases  have  proved  fatal. 


July  3,  1920.] 


LYON:   GALLBLADDER  CONDITIONS. 


23 


CHOLEDOCHITIS,    CHOLECYSTITIS  AND 
CHOLELITHIASIS* 

The  Need  of  Early  Diagnosis  and  Treatment. 

By  B.  B.  Vincent  Lyon,  M.  D., 
Philadelphia, 

Associate  in   Medicine,   Jefferson   Medical  School;    Chief  of  Clinic, 
Gastro-Intestinal    Department,    Jefferson    Hospital,  Philadelphia. 

There  is  probably  no  six  inches  of  the  entire  aH- 
mentary  canal  in  which  states  of  organic  disease  are 
so  prone  to  develop  as  in  the  first  and  second  por- 
tions of  the  duodenum ;  nor  is  there  any  zone  into 
which  the  elements  of  differential  diagnosis  enter 
in  a  larger  and,  at  times,  more  perplexing  manner. 
This,  the  hot  bed  of  digestion,  has  emptying  into  it 
the  mixed  or  mixing  secretions  from  the  stomach, 
the  liver,  the  gallbladder,  the  pancreas  and  the  secre- 
tion from  the  dviodenal  mucosa  itself. 

The  physiology  of  the  digestive  secretions  in 
normal  people  from  these  various  sources  has  be- 
come better  understood  during  recent  years.  The 
pathological  physiology  of  states  of  disease  in  this 
zone  has  been  the  subject  of  much  profitable  inves- 
tigation during  a  still  more  recent  period.  Much 
light  has  been  thrown  upon  the  subject  by  means 
of  carefully  conducted  animal  experimentation.  The 
more  widespread  use  of  the  duodenal  tube  in  the 
hands  of  capable  students  of  ga.strointestinal  dis- 
ease is  contributing  greatly  to  our  knowledge  by 
clinical  experimentation  on  human  beings,  both  nor- 
mal and  those  suffering  from  disease.  We  have 
learned  how  to  interpret  our  findings  in  the  duod- 
enum much  more  clearly  and  accurately ;  we  can 
(juite  easily  determine  states  of  duodenitis  and  can 
differentiate  those  that  are  catarrhal,  those  that  are 
infected,  and  those  which  show  unusual  exfoliation 
of  dead  and  dying  epithelium ;  we  can  feel  reason- 
ably sure  of  separating  our  more  superficial  erosive 
states  from  those  of  true  ulceration  simply  because 
we  are  gradually  training  ourselves  to  make  better 
use  of  the  materials  recovered  by  means  of  the  duod- 
enal tube  for  more  painstaking  cytological.  bac- 
teriological and  chemical  studies. 

DifTerential  diagnosis  has  been  gradually  extended 
so  that  we  are  now  fairly  sure  of  the  soundness  of 
our  investigations  into  pancreatic  states  of  health  or 
disease,  although  there  remains  a  ver>-  great  deal  of 
work  to  be  done  in  this  field.  We  have  made,  too. 
considerable  progress  in  our  ability  to  diagnose  ac- 
curately many  of  the  states  of  disease  of  the  biliary 
system.  But,  unfortunately,  most  of  our  fruitful 
efforts,  as  in  the  cancer  problem,  have  resulted  in 
the  elaboration  of  various  methods  and  various  tests 
that  concern  themselves  in  the  proving  of  disease 
already  well  established. 

Furthermore,  our  methods  of  diagnosis  have  been 
more  largely  indirect  than  direct.  We  have  learned 
the  value  of  the  carefully  taken  and  searching  in- 
quiry into  the  presenting  symptoms,  we  have  learned 
to  interpret  more  clearly  the  transition  of  the  earlier 
symptoms  into  those  that  in  themselves  are  almost 
diagnostic,  we  have  extended  the  scope  and  the  ac- 
curacy of  our  methods  of  physical  examination,  and 

*Read  before  the  Twenty-Third  Annual  Meeting  of  the  American 
Gastroenterological  Society,  May  3  and  4,  1920. 


our  eyes  and  our  fingers  have  gradually  been  trained 
to  take  cognizance  of  more  minute  abnormalities 
than  would  have  been  thought  possible  a  generation 
ago.  Much  of  this  has  come  about  through  the 
pioneer  efforts  of  the  surgeons,  who  have  taught  us 
by  object  lessons  in  living  pathological  anatomy  at 
the  operating  table,  the  correct  interpretation  of  his- 
torical syndromes  and  of  data  gained  by  physical 
examinations. 

We  have  made  great  progress,  too,  in  the  art  of 
diagnosis  of  various  biliary  diseases,  as  we  have 
caught  the  importance  of  focal  infection  and  its 
march  from  primary  to  secondary  fields  of  activity. 
By  the  more  recently  accepted  methods  of  exami- 
nation of  blood  chemistry  we  have  learned  the  sig- 
nificance of  an  increased  amount  of  cholesterol  in 
the  blood  serum ;  we  have  connected  some  of  the 
clinical  links  regarding  the  incidence  of  pregnancy, 
tight  lacing,  and  other  conditions  with  gallbladder 
disease,  especially  in  relation  to  the  formacion  of 
gallstones.  As  a  more  direct  means  of  diagnosis 
we  have  turned  to  the  rontgenologist  for  the  im- 
portant aid  he  can  now  furnish  us  with  his  positive 
and  negative  shadows  of  formed  calculi  or  of  in- 
creased connective  tissue  formation  in  the  wall  of 
the  pathological  gallbladder.  But  direct  as  is  the 
evidence  given  by  the  x  ray,  it  fails  us,  perhaps,  in 
half  of  our  cases,  and  even  when  supplied  serves 
only  to  prove  a  pathological  state  already  well  estab- 
lished. In  other  words,  the  greater  part  of  our 
diagnosis  of  gallbladder  problems,  thus  far  made 
practical,  supplies  us  with  information  pointing  to 
disease  so  fully  developed  that  we  have  been  handi- 
capped in  applying  methods  of  treatment  which,  to 
be  successful  in  ultimate  cure,  have  become  more 
and  more  radical. 

The  field  of  treatment  by  almost  common  con- 
sent has  fallen  to  the  surgeon  because  our  accepted 
method  of  medical  management  have  woefully 
failed    to    bring    results    other    than  palliative. 

For  a  little  over  three  years  I  have  taken  great 
interest  in  developing  a  more  direct  means  of  dif- 
ferential diagnosis  of  diseases  of  the  biliary  system 
which  lends  itself  admirably  not  only  to  the  direct 
detection  of  organic  disease  well  established,  but 
also  gives  promise  of  a  better  understanding  of 
functional  disorders  of  the  liver  and  gallbladder  and 
the  recognition  of  pathological  physiology  which 
may  act  as  part  of  the  precursory  states  in  the 
development  of  the  later  full  blown  disease. 

We  have  known  for  some  time  that  it  is  possible 
to  drain  bile  from  the  common  duct  and  from  the 
liver  and  collect  it  by  means  of  the  duodenal  tube 
for  examinations  that  have  been  directed  largel}' 
to  the  estimation  of  pancreatic  efficiency.  (Einhorn, 
Gross,  Crohn).  But  a  great  step  forward  was 
made  when  Meltzer  suggested  to  us  a  means  of 
making  the  gallbladder  contract  and  discharge  its 
contents.  This  has  opened  an  entirely  new  field  of 
clinical  diagnosis  and  investigation  and  has  widened 
the  horizon  of  our  vision  for  the  recognition  and 
correction  of  the  early  states  of  disease  of  the  gall- 
bladder and  ducts  that  may  ultimately  lead  us  to 
the  goal  of  present  day  medicine,  namely,  the  pre- 
vention of  another  group  of  diseases  which  has 
claimed  a  heavy  toll  of  suffering  and  death.  I 


24 


LYON 


GALLBLADDER  COXDITIONS. 


fXEw  York 
Medical  Jourxai., 


allude  to  gallstones  and  serious  late  states  of  in- 
fection of  the  gallbladder,  liver  and  its  ducts. 

Meltzer  (1),  in  an  excellent  article  giving  his 
rational  conception  of  the  physiology  of  the  filling 
and  discharge  of  bile  from  the  gallbladder,  as 
governed  by  his  law  of  contrary  innervation,  ap- 
pended a  little  footnote  to  the  effect  that  he  found 
that  solutions  of  magnesium  sulphate,  when  locally 
placed  in  the  duodenum,  without  first  passing  over 
the  gastric  mucosa,  would  cause  a  relaxation  of  the 
tonus  of  the  duodenal  wall  and  would  thereby  relax 
Oddi's  sphincter  of  the  common  duct  and  permit 
the  discharge  of  bile  into  the  duodenum. 

Immediately  after  the  publication  of  Meltzer's 
paper,  in  April,  1917.  I  was  able  to  demonstrate 
that  the  use  of  magnesium  sulphate,  locally,  in 
solutions  of  various  strengths,  in  the  duodenum  of 
human  beings  would  very  promptly  deliver  bile 
through  the  duodenal  tube  in  varying  quantities 
and  of  varying  quality.  It  would  do  this  when  the 
duodenum  was  previously  bile  free,  indicating  that 
the  magnesium  sulphate  had  relaxed  the  sphincter 
action  of  Oddi's  muscle.  Further  than  this  it  was 
noticeable  that  the  character  of  the  bile  recovered 
by  means  of  the  duodenal  tube  underwent  certain 
definite  changes  in  color  and  viscosity,  first  a  light 
lemon  to  golden  yellow,  then  a  deeper,  richer,  more 
syrupy  golden  yellow,  finally  changing  to  a  very 
imiformly  light  lemon  yellow,  thinner  and  less 
syrupy  than  either  of  the  first  two ;  and  tlvit  this 
sequence  occurred  in  all  normal  cases. 

It  was  not  long,  however,  before  I  examined  a 
patient  suffering  from  symptoms  strongly  suggestive 
of  biliary  disease  in  whom  the  second  sequence  of 
delivery  of  the  deeper  golden  yellow  bile  was  re- 
placed by  the  recovery  of  over  five  ounces  of  deep 
greenish  black  bile  ver\"  viscid,  almost  tarry.  \\'hat 
did  this  mean  ?    \M'iere  was  this  bile  coming  from  ? 

The  natural  inference  was  that  it  was  coming 
from  the  gallbladder.  But  could  it  be  really  pos- 
sible to  drain  the  gallbladder  by  magnesium 
sulphate  and  the  duodenal  tube  and  get  it  out  in  a 
bottle?  Yet  the  cytology  of  this  bile  microscopically 
revealed  mucopurulent  particles  rich  in  pus  cells, 
large  masses  of  deepl}"  bile  stained  columnar 
epithelium,  inflammatory  debris,  masses  of  bile 
crystals  and  was  simply  swarming  with  bacteria, 
chiefly  cocci.  Culturally  the  latter  turned  out  to 
be  Streptococcus  viridans.  The  patient  was  oper- 
ated on  ten  days  later  and  the  gallbladder  found 
to  contain  bile  of  the  same  black  color  and  viscosity 
and  Streptococcus  viridans  was  isolated  from  the 
bile. 

This  case  and  several  that  had  preceded  it  were 
the  starting  point  in  the  use  of  a  method  which  I 
first  described  in  a  paper  (2)  and  published  seven 
months  ago  after  I  had  made  more  than  a  thousand 
observations  of  the  practicability  of  a  nonsurgical 
method  of  biliary  drainage.  With  certain  ex- 
ceptions, to  which  I  shall  later  call  your  attention, 
it  is  possible  to  drain  the  gallbladder  wholly  or 
partially  of  its  fluid  contents ;  to  drain  the  bile  ducts 
and  to' obtain  bile  freshly  secreted  from  the  liver 
cells.  Furthermore,  it  is  possible  to  segregate  these 
various  biles  from  their  numerous  sources  by  col- 
lecting them   in   individual  bottles   for  chemical, 


microscopical  and  bacteriological  examinations  that 
give  us  a  direct  method  of  differential  diagnosis 
between  various  diseases  of  the  biliary  system. 

In  the  direct  evidence  it  furnishes  us  it  far  sur- 
passes any  diagnostic  method  yet  •  available,  and 
materially  assists  our  correct  interpretation  of  the 
presenting  history,  the  physical  examination,  and 
the  information  furnished  by  the  rontgen  ray  and 
by  the  laboratory  examinations  into  the  state  of 
gastric  chemistry  and  motility,  and  of  the  stools' 
urine  and  blood  chemistry.  But  most  important  of 
all,  it  furnishes  direct  diagnostic  evidence  of  the 
beginnings  of  biliary  stasis,  of  masked  focal  infec- 
tion that  precede  the  more  florid  states  of  biliary 
disease  and  give  rise  later  to  the  symptoms,  the 
physical  and  laboratory  findings  that  are  usually 
so  clear  cut  as  to  make  a  tentative  diagnosis  of  gall- 
bladder disease  quite  tenable  and  to  warrant  the 
dictum,  "We  will  do  an  exploratory  operation  and 
find  out  what  the  trouble  really  is."  This  is  all 
very  well  for  the  doctor,  but  a  little  rough  on  the 
patient  if  there  is  another  reliable  and  direct  alterna- 
tive method  available.  In  other  words,  we  nuist 
learn  how  to  find  the  direct  evidence  in  the  early 
cases  exhibiting  the  chronic  but  vague  dyspeptic 
symptoms  and  not  leave  it  to  the  exploratory  opera- 
tion to  decide  whether  the  trouble  lies  in  the  upper 
right  or  the  lower  right  abdominal  quadrant.  Even 
with  the  stomach,  duodenum  and  gallbladder  well 
exposed  the  surgical  eye  and  finger  often  fails  to 
detect  the  presence  of  an  early  cholecystitis,  chole- 
dochitis  or  duodenitis  ( usually  the  forerunner  of 
ulcer),  because  there  is  no  recognizable  gross 
])athelogical  change  (quite  ignoring  the  pathologi- 
cal physiology  that  precedes  gross  pathology),  and 
the  appendix  is  then  removed  usually  because  it 
presents  a  sufliciently  pathological  condition  to  war- 
rant it,  but  not  infrequently  it  is  quite  innocent  and 
is  removed  simply  because  the  abdomen  is  open 
and  it  doesn't  increase  the  risk  of  the  operation. 

What  is  the  result  of  this?  If  there  is  present 
concomitant  disease  of  both  appendix  and  gall- 
bladder, as  Rosenow's  work  on  streptococci  leads 
many  to  suspect,  and  if  the  gallbladder  is  harboring 
streptococci,  but  in  a  state  of  masked  focal  in- 
fection, not  severe  enough  to  cause  diagnostic 
symptoms  with  a  parallel  gross  pathological  condi- 
tion, but  nevertheless  sufficient  to  produce  a 
pathological  biliary  physiology  and  a  positive 
bacteriology  to  be  found  by  him  who  looks,  the 
result  is  this.  The  surgeon  explores,  and  finds  no 
upper  abdominal  pathological  condition,  no  enlarged 
glands,  no  stones,  no  adhesions  and  the  gallbladder 
expels  its  contents  under  forcible  digital  pressure, 
(but  can  it  do  so  under  its  own  muscle  power?) 
and  because  there  is  no  gross  pathological  condition 
the  surgeon  says  everything  is  normal  here,  leaves 
a  gallbladder  harboring  streptococci,  and  proceeds 
to  account  for  the  symptoms  by  removal  of  the 
appendix.  The  patient  gets  well,  that  is  to  say,  he 
recovers  from  the  operation,  his  symptoms  improve 
temporarily,  aided  by  his  hospital  rest  and  the 
removal  of  his  appendix,  provided  it  was  in  a  truly 
pathological  condition ;  but  usually  between  six  and 
twenty-four  months  later  his  symptoms  recur, 
progress  in  frequency  and  severity,  and  change  in 


July  3,  1920.] 


LYON:  GALLBLADDER  COXDITIOXS. 


25 


character  until  finally  the  clinical  picture  of  full 
blown  gallbladder  or  duct  disease  presents  itself 
and  in  the  judgment  of  most  doctors  operative 
interference  again  becomes  imperative. 

This  is  not  to  be  wondered  at,  for  it  doubtless  is 
true  that  operative  interference  is  the  best  procedure 
at  the  present  time  in  the  properly  skillful  hands. 
The  surgeons  have  been  successful  pioneers  in  the 
field  of  gallbladder  therapy  because  the  indirect 
efforts  of  the  internist  with  his  cholagogues  and 
bile  disinfectants,  his  medicated  waters,  his  diets 
and  his  prescription  to  attend  expensively  famous 
foreign  spas  have  been  inadequate  and  uncertain, 
whereas  the  direct  attack  by  the  aseptic  scalpel  is 
productive  of  prompter  results  whether  good,  bad, 
or  indifYerent.  As  Dr.  John  B.  Deaver  (3),  so  apt 
always  in  his  quotations  and  epigrams,  says  in  a 
recent  paper,  "If  thy  right  hand  oflfend,  cut  it  off." 
But  let  us  pause  a  moment  and  consider.  Of  course 
it  is  easy  for  the  skillful  surgeon  to  cut  it  of?,  but 
it  is  quite  another  matter  to  put  it  on  again  if  the 
first  experiment  doesn't  work.  It  is  one  thing  to 
remove  with  impunity  the  appendix  which  possesses 
no  (or  an  unknown)  function,  (although  many  an 
innocent  one  has  been  removed  in  the  past,  as  have 
healthy  tonsils  and  teeth  during  their  respective 
crazes),  and  quite  another  thing  to  remove  ruthlessly 
and  routinely  every  gallbladder  because  some  har- 
bor streptococci  in  their  lymphatic  tissue  and  in 
their  walls.  As  I  have  said  it  is  all  very  well  with 
the  patient  if  it  works.  But  suppose,  and  we  know 
that  this  often  happens,  for  the  surgeons  tell  us, 
suppose  the  common  duct  remains  infected  after 
surgical  drainage  is  completed  and  later  becomes 
obstructed,  what  happens  then  when  the  distensible 
reservoir  for  liver  bile  has  been  removed  ?  The 
safety  valve  has  blown  oflf.  The  common  duct 
dilates  and  vicariously  tries  to  assume  the  duties 
of  the  gallbladder ;  cliverticuli  may  appear,  duct 
bile  becomes  static,  new  concretions  form,  and 
sooner  or  later  the  secreted  bile  dams  back  into  the 
liver  and  biliary  cirrhosis  has  begun.  Deaver's 
biblical  quotation  is  apt,  but  the  title  to  his  paper, 
Operation  and  Reoperation  for  Gallstone  Disease, 
is  still  more  apt,  besides,  the  mortality  table  is  not 
published 

Perhaps  if  the  careful  student  of  internal  medi- 
cine adopts  the  motto,  "Search  and  ye  shall  find," 
it  may  eventually  be  better  for  the  patient,  although 
the  work  may  be  slow  and  laborious  and  lacking 
in  spectacular  brilliance.  One  has  only  to  peruse 
.some  of  the  better  recent  papers  on  gallbladder 
surgery  to  realize  that  operation  means  facing  un- 
deniable risks.  Although  the  mortality  has  been 
-Steadily  reduced  it  was  nearly  six  per  cent,  in  the 
thousand  cases  recently  analyzed  by  Smithies  (4), 
with  thirty-five  per  cent,  of  associated  pathological 
lesions  of  the  upper  abdomen  found  at  operation, 
( enlarged  lymphatic  glands,  acute  and  chronic 
pancreatitis,  enlarged  liver  and  peptic  ulcer),  in- 
dicating late  diagnosis  with  well  established 
pathological  conditions.  Added  to  this  are  the 
complications  pictured  by  the  surgeon,  the  skilled 
full  time  operator  and  not  the  occasional  surgeon, 
of  damage  to  the  hepatic  and  common  ducts,  the 
recurring  adhesions,  the  persistent  fistulas,  the  oc- 


casional fatal  bleeding  from  the  liver  or  from  an 
accidentally  torn  blood  vessel,  the  occasional 
traumatic  puncture  of  the  gut  on  the  spilling  of 
infective  streptococci  bile  with  resultant  peritonitis, 
to  say  nothing  of  Nature's  recurrent  complications 
of  new  stone  formation  in  dilated  common  ducts 
again  obstructed,  necessitating  recurrent  operations, 
and  we  have  a  true  picture  of  the  gallbladder  pro- 
blem as  it  stands  in  the  light  of  our  present  methods 
of  diagnosis  and  treatment.  Certainly  it  is  far 
better  than  it  used  to  be,  but  is  it  as  good  as  we 
can  make  it  ? 

DESCRIPTION  OF  THE  METHOD. 

In  order  to  present  the  method  which  I  hope  can 
be  proved  in  other  hands  to  possess  the  merits  of 
early  or  late,  direct  diagnosis  in  gallbladder  and 
duct  disease,  and  of  potential  merit  in  the  treatment 
of  selected  patients  suffering  from  these  diseases, 
I  must  go  briefly  into  the  fundamental  principles 
which  underlie  the  method.  Much  of  this  has 
already  been  presented  in  four  previous  papers  on 
the  subject  (5,  6,  7,  8). 

The  biliary  system  consists  of  a  constantly  secret- 
ing organ,  the  liver,  passing  its  secretion  and  ex- 
cretion, the  bile,  down  a  series  of  tubes  guarded  at 
their  terminal  outlet  by  a  muscle  possessing  a 
sphincter  action.  Placed  between  the  liver  and 
Oddi's  muscle  sphincter  is  the  gallbladder  with 
elastic  walls  permitting  varying  degrees  of  physio- 
logical distensibility,  to  act  as  a  reservoir  for  excess 
bile  secreted  during  the  periods  when  the  duct 
sphincter  remains  closed.  Thus  we  have  a  me- 
chanism that  physiologically  consists  of  the  elabora- 
tion of  a  constantly  secreted  fluid,  which,  however, 
is  discharged  intermittently. 

Upon  what  does  the  mechanism  of  partially  or 
wholly  emptying  this  biliary  system  depend? 

Meltzer's  law  of  contrary  innervation  (9)  as 
he  applied  it  to  the  filling  and  discharge  of  the 
gallbladder  was  briefly  to  the  efifect  that  the 
sphincter  of  the  common  bile  duct  and  the  muscles 
of  the  gallbladder  were  supplied  with  inhibitory  and 
motor  nerve  fibres  from  the  splanchnic  and  vagus 
nerves  which  acted  antagonistically  to  one  another. 
That  when  the  inhibitory  fibres  relaxed  the  tone 
of  Oddi's  muscle  at  the  sphincter  of  the  common 
duct,  the  motor  fibres  to  the  gallbladder  caused  its 
muscle  to  contract  and  therefore  discharge  its 
stored  up  bile  into  the  duodenum  until  such  time 
as  the  sphincter  would  contract  again,  when,  auto- 
matically, the  inhibitory  fibres  to  the  gallbladder 
would  cause  a  relaxation  in  the  gallbladder  wall, 
thus  preventing  a  further  explusion  of  its  bile  and 
it  would  then  resume  its  passive  role  of  acting  as 
a  reservoir  for  the  bile  freshly  secreted  from  the 
liver.  Meltzer  pointed  out  that  the  normal  physio- 
logical stimulus  to  produce  biliary  discharge  lay  in 
the  character  of  the  food  chemistry  which  passes 
through  the  duodenum.  To  establish  this  he  quoted 
the  experimental  work  of  Bruns,  which  showed 
that  normally  no  bile  appeared  in  the  duodenum  as 
long  as  the  stomach  was  empty,  but  that  the  en- 
trance of  a  food  chyme  into  the  duodenum  was  the 
signal  for  the  ejection  of  bile  from  the  common 
duct.  He  further  quoted  the  experiments  of  Rost 
who  proved  that  injection  of  peptone  or  albumosis 


26 


Li  OX:   GALLBLADDER  CONDITIONS. 


[New  York 
Medical  Jourxal. 


through  a  duodenal  fistula  in  a  normal  dog  im- 
mediately caused  a  discharge  of  bile  from  the  com- 
mon duct  and  proved  that  this  took  place  by  a  reflex 
act  which  caused  a  contraction  of  the  gallbladder 
and  simultaneously  a  relaxation  of  sphincter  of  the 
common  duct.  Furthemiore,  Rost  had  previously 
established  the  fact  that  after  animal  cholecystotomy 
the  escape  of  bile  through  the  papilla  of  \'ater 
became  continuous,  whereas  in  normal  animals  it 
was  discharged  intermittently.  This  argued  strongly 
in  favor  of  Aleltzer's  law  of  contrary  innervation 
in  the  fact  that  simple  cutting  into  the  wall  of  the 
gallbladder  would  destroy  the  antagonistic  action 
of  the  nerve  supply  to  the  gallbladder  and  common 
duct  sphincter.  This  mechanical  l)reaking  of  the 
nerve  circuit  by  operation  can  be  easily  demonstrated 
in  postoperations  in  which  the  gallbladder  has  been 
either  opened  or  removed,  namely  that  bile  is  being 
discharged  continuously  into  the  duodenum  so  long 
as  the  common  duct  remains  unobstructed.  Fur- 
thermore, I  believe  this  break  in  nerve  conduction 
is  mimicked  in  disease  involving  the  wall  of  the 
gallbladder  or  in  the  wall  of  the  duodenum  adjacent 
to  Oddi's  muscle  (duodenal  ulcer,  duodenitis, 
duodenal  adhesions),  because  in  this  type  of  disease 
I  frequently  find  continuous  discharge  of  bile  into 
the  duodenum  with  a  reflux  of  grossly  recognizable 
bile  in  the  fasting  stomach  in  early  as  well  as  late 
pathological  states  of  the  duodenum  and  of  the  gall- 
bladder. This  observation  of  what  is  certainly 
pathological  physiology  appears  to  me  to  be  a  very 
important  diagnostic  factor  in  itself  and  useful 
because  it  may  be  indicative  of  early  changes.  The 
significance  of  fasting  and  digesting  biliary  regurgi- 
tation will  be  the  subject  of  a  future  communication. 

In  regard  to  magnesium  sulphate :  Although 
Aleltzer  did  not  specifically  state  in  his  footnote  that 
it  would  cause  explusion  of  gallbladder  bile,  but 
only  that  it  would  relax  the  duct  sphincter,  the  in- 
ference was  plain  that  if  his  law  of  contrary 
innervation  was  sound,  anything  which  would  cause 
inhibition  of  tonus  of  Oddi's  muscle  must,  ipso  facto, 
cause  contraction  of  the  gallbladder  musculature. 
This  is  not  so.  Yet  it  is  fortunate  for  the  progress 
of  this  work  that  Meltzer  was  experimenting  with 
magnesium  sulphate  for  it  will  call  into  action  this 
antagonistic  or  reciprocal  action  of  duct  sphincter 
and  gallbladder. 

But  there  are  other  substances  (  benzyl  benzoate, 
belladonna,  potassium  permanganate),  that  will 
relax  the  duct  sphincter  and  yet  will  not  produce 
expulsion  of  gallbladder  bile.  Similarly  there  ap- 
pears to  be  a  selective  gastric  food  chemistry  that 
will  electively  cause  expulsion  of  glallbladder  bile 
in  large  quantities  on  the  one  hand  and  discharge  of 
pancreatic  secretion  on  the  other.  For  instance, 
as  Rost  has  already  experimentally  shown,  pep- 
tones and  albumoses  fend  products  of  acid 
gastric  digestion),  will  call  forth  a  richer  and  larger 
quantity  of  bile  in  the  duodenum.  This  is  seen  in 
the  proteid  and  fat  test  meals.  Whereas,  a  carbo- 
hydrate meal,  although  bathed  in  the  sanie  acid 
gastric  juice,  will  call  forth  more  pancreatic  juice 
and  little,  if  any,  gallbladder  bile ;  although  naturally 
the  bile  in  the  common  duct  and  that  secreted  by 
the  liver  is  being  discharged  during  the  time  that 


pancreatic  secretion  is  being  poured  out.  This  ap- 
pears to  support  the  accepted  theory  of  the  physiol- 
ogy of  automatic  (or  reflex)  discharge  of  digestive 
secretions  or  enzymes  according  to  the  chemistry  of 
the  food  stufifs  to  be  digested.  What  the  exact  char- 
acter of  this  mechanism  may  be,  whether  nerve  reflex 
or  blood  reflex,  or  true  harmonic  action,  or  a  mixture 
of  them,  will  require  further  investigation  both  on 
animals  and  on  human  beings.  Btit  when  Ave 
remember  that  the  pancreatic  dtict  and  the  bile  ducts 
in  ninety  per  cent,  of  anatomical  subjects  discharge 
their  contents  through  a  common  ampulla  governed 
apparently  by  the  same  sphincter,  in  each  case  the 
sphincter  itself  must  relax  to  permit  stich  discharge, 
yet  the  gallbladder  may  not  necessarily  contract  each 
time,  certainly  not  with  the  same  degree  of  vigor. 
So  it  appears  that  while  Meltzer's  theory  of  the 
physiology  of  filling  and  discharge  of  the  gallbladder 
bile  is  thoroughly  worked  out,  and  while  his  law 
of  contrary  innervation  is  substantially  sound  as 
regards  magnesium  sulphate  (perhaps  in  this  direct 
duodenal  action  a  true  hormone  for  gallbladder 
contraction),  nevertheless  there  are  certain  sub- 
stances, while  they  relax  the  common  duct  sphincter, 
have  an  elective  action  on  the  gallbladder  or  on  the 
pancreas  individually,  and  no  doubt  certain  sub- 
stances may  have  a  dual  action. 

A  great  deal  of  this  problem  of  physiology 
remains  to  be  worked  otit  before  we  can  get  away 
from  a  certain  empiricism  in  the  tise  of  various 
diets  and  various  drugs.  The  method  of  direct 
clinical  investigation  in  health  and  disease  by  the 
duodenal  tube,  using  various  chemicals  and  food 
chymes,  opens  up  a  most  attractive  and  profitable 
field  of  work. 

To  return  to  the  subject  of  this  paper.  The 
method  that  I  have  suggested  permits  of  making 
direct  observations  on  the  bile  obtained  from  the 
several  sources  in  the  biliary  tract. 

To  make  possible  accurate  diagnosis  of  the  duo- 
denal biliary  zone  it  is  necessary  that  we  adojjt 
means  to  prevent  cytological  and  bacterial  contami- 
nations from  the  mouth,  teeth,  tonsils,  respiratory 
tract  and  stomach  from  confusing  us  in  our  inter- 
pretation of  duodenal  and  biliary  materials.  To 
avoid  this  as  far  as  possible  I  have  adopted  the  fol- 
lowing routine  method  in  diagnosis.  The  use  of 
proper  apparatus  will  aid  in  the  performance  of 
good  work.  The  patient  presents  himself  with  a 
twelve  hour  fasting  stomach.  He  then  brushes  his 
teeth  carefully,  rinses  and  gargles  his  mouth  and 
throat  thoroughly,  first  with  a  strong  solution  of 
potassium  permanganate  (one  grain  to  the  ounce), 
then  with  a  mildly  astringent  solution  of  zinc 
chloride.  The  duodenal  tube  which  has  stood  over- 
night in  a  two  per  cent,  solution  of  lysol  is  freshly 
sterilized  by  boiling  and  is  passed  to  the  stoiuach. 
The  fasting  residue  is  aspirated  and  set  aside  for 
chemical  cytological  and  bacteriological  examination 
for  comparison  with  the  findings  later  recovered 
from  the  duodenum.  The  stomach  is  then  rinsed  to 
sparkling  clearness,  using  gravity  douching  from 
250  c.  c.  irrigating  tanks  or  syringe  douching,  and 
recovering  the  wash  water  in  250  c.  c.  conical 
graduates  in  which  can  be  noted  how  clean  the 
stomach  is,  mucus,  shreds,  mucopurulent  plugs,  and 


July  3,  1920.] 


ROSE:   WEIGHT,  DIET  AND  EFFICIENCY. 


27 


other  material  which  microscopically  yields  much 
valuable  information.  After  the  wash  return  is 
sparkling  clear  the  stomach  is  made  astringent  with 
a  zinc  chloride  solution  (layoris),  and  then  re- 
washed  thoroughly.  It  is  surprising  to  observe  how 
often  a  stomach  apparently  washed  clean,  after  be- 
ing made  astringent,  will  press  out  from  the  mu- 
cosal tubules  mucopurulent  masses  which  plug  the 
ducts  and  which,  microscopically,  show,  in  true 
gastritis  cases,  masses  of  gastric  epithelial  cells  in- 
filtrated with  small  round  cells  and  polynuclear  leu- 
cocytes and  often  swarming  with  bacteria.  It  is 
to  be  noted  that  none  of  this  epithelium  is  ever  bile 
stained.  After  the  use  of  the  astringent  and  wash- 
ing clean  again,  the  stomach  is  then  disinfected 
with  250  c.  c.  of  potassium  permanganate,  one  to 
ten  thousand,  which  is  immediately  recovered  and 
the  stomach  again  washed  clean  to  crystal  clear- 
ness. This  requires  about  twenty  minutes  to  ac- 
complish. This,  so  far  as  it  is  possible,  prevents 
contaminated  material  from  the  upper  zones  con- 
fusing our  interpretations  of  material  later  obtained 
from  the  duodenal  biliary  zone.  After  diagnosis 
has  been  completed  and  local  treatment  has  been 
instituted  it  is  not  so  necessary  that  preparation  of 
the  mouth  and  stomach  should  be  so  carefully  car- 
ried out  except  when  indicated  in  patients  with  dirty 
mouths  and  dirty  stomachs.  A  little  water  is  then 
left  in  the  stomach  to  encourage  peristalsis,  the  pa- 
tient lies  down  and  turns  on  his  right  side  and  very 
slowly  swallows  an  additional  twenty  cm.  of  tubing 
to  a  total  distance  of  seventy-five  or  eighty  cm. 
from  the  teeth,  according  to  the  length  of  the  tho- 
rax. I  insist  that  they  take  twenty  minutes  to 
swallow  the  twenty  cm. ;  slow  swallowing  at  this 
point  is  often  the  secret  of  rapidly  entering  the  duo- 
denum. The  duodenal  tube  is  then  connected  to 
the  first  sterile  aspirating  bottle  and  the  duodenal 
secretion  is  aspirated  to  note  whether  the  common 
duct  sphincter  is  normally  closed.  The  duodenum 
is  then  douched  with  about  seventy-five  c.  c.  of  a 
thirty-three  per  cent,  solution  of  magnesium  sulph- 
ate. This  I  believe  to  be  the  optimum  strength  for 
good  sphincter  relaxation  and  gallbladder  contrac- 
tion. Where  the  gallbladder  is  found  atonic  it  is 
sometimes  necessary  to  restimulate  its  contraction 
discharge  by  douching  again  with  half  the  amount 
of  magnesium  sulphate  solution. 

Before  the  magnesium  sulphate  has  entirely  run 
in,  the  tubing  is  connected  to  the  bottle  and  gentle 
aspiration  started  and  the  magnesium  sulphate  re- 
turns at  first  uncolored  but  within  one  to  six  min- 
utes, normally,  the  sphincter  is  relaxed  and  the 
magnesium  sulphate  becomes  tinged  with  bile, 
which  becomes  steadily  deeper  until  pure  bile  alone 
is  being  recovered.  Another  bottle  is  then  attached 
and  observations  are  continued  through  the  glass 
cannula  window  inserted  in  the  tubing  about  eight 
meters  from  its  proximal  end.  When  the  first  bile, 
which  I  call  A  bile  and  believe  to  be  that  contained 
in  the  common  duct  plus  a  few  drops  from  the  cys- 
tic duct  and  a  few  mils,  perhaps,  of  freshly  se- 
creted liver  bile  passing  down  the  hepatic  ducts, 
deepens  to  a  distinctly  deeper  golden  yellow  or  be- 
comes in  any  way  off  color  and  more  syrupy  and 


of  heavier  viscosity,  this  bottle  is  detached,  another 
quickly  attached  and  drainage  of  this  darker  bile 
allowed  to  continue  until  the  third  transition  to  a 
very  much  lighter  yellow  and  thinner  bile  appears, 
when  a  final  bottle  is  attached  to  continue  the  bile 
collection  to  the  end  of  the  drainage  period. 

The  darker  bile  appearing  in  the  second  transi- 
tion I  call  B  bile  and  believe  it  to  be  derived  almost 
entirely  from  the  gallbladder,  mixed,  of  course, 
with  a  few  drops  or  mils  of  liver  bile.  My  reasons 
for  believing  this  bile  to  be  gallbladder  bile  I  have 
given  at  some  length  in  a  previous  paper  (8).  The 
third  type  of  very  light  yellow  limpid  bile  which 
appears  in  normal  cases  in  the  third  transition  I  call 
C  bile  and  believe  it  to  be  bile  recently  elaborated 
by  the  liver  cells  and  freshly  secreted.  It  has  in- 
variably appeared  at  the  termination  of  each  drain- 
age in  nearly  two  thousand  observations  which  I 
have  made  up  to  this  time.  Of  course,  one  cannot 
hope  to  segregate  these  several  biles  absolutely  un- 
mixed with  the  other,  but  if  one  is  careful  in  segre- 
gating them  it  is  surprising  how  accurately  they 
can  be  separated  with  a  little  practice,  and  I  feel 
safe  in  saying  that,  if  carefully  done,  the  majority 
of  A  bile  is  common  duct  bile,  that  by  far  the  ma- 
jority of  B  bile  is  derived  from  the  gallbladder  and, 
if  the  latter  has  emptied  completely,  that  practically 
all  of  C  bile  is  freshly  secreted  liver  bile. 

{To  be  concluded) 

WEIGHT,  DIET  AND  EFFICIENCY. 

By  Robert  Hugh  Rose,  M.  D., 
New  York. 

This  paper  will  discuss  the  following  three  sub- 
jects:  1,  Undernutrition;  2,  ovemutrition ;  3,  intes- 
tinal toxemia. 

The  role  of  malnutrition  as  a  factor  in  lessen- 
ing efficiency  has  not  escaped  notice.  Such  cases 
are  important ;  they  have  been  given  considerable 
attention,  but  are  far  more  numerous  than  has  been 
realized.  Some  persons  through  lack  of  appetite, 
are  unaccustomed  to  eat  a  sufficient  amount.  Others, 
while  they  may  consume  an  adequate  quantity,  do 
not  choose  a  properly  balanced  diet.  To  bring  the 
expenses  within  a  certain  income,  the  purchase  of 
food  is  limited.  Under  these  conditions  the  absence 
of  a  knowledge  of  food  values  may  prevent  the 
dietary  from  meeting  bodily  needs.  The  human 
body  is  the  most  efficient  engine  in  the  world.  How- 
ever, it  can  not  operate  without  fuel,  and  its  effi- 
ciency is  limited  by  the  fuel  supply.  Large  em- 
ployers of  labor  would  do  well  to  look  into  the  mat- 
ter of  the  proper  feeding  of  employees  in  order  to 
increase  their  efficiency.  This  could  be  accom- 
plished by  educational  methods. 

A  class  of  cases  receiving  less  attention  but  very 
frequently  encountered  and  of  great  importance  is 
composed  of  overnourished  patients.  Many  suf- 
ferers from  overnutrition  also  have  autointoxication 
of  intestinal  origin,  but  there  are  some  who  have 
no  indican  in  the  urine  and  no  sign  by  which  the 
presence  of  an  intestinal  toxemia  can  be  established. 
A  third  class  of  cases  and  probably  the  most  nu- 
merous, consists  of  intestinal  poisoning. 


28 


ROSE:   IV EIGHT,  DIET  AXD  EFFICIENCY. 


[New  York 
Medical  Journal. 


\'ery  little  will  be  said  regarding  the  first  class 
of  cases  because  they  have  receved  wide  discussion 
and  there  is  little  new  to  offer.  I  have  treated  a 
number  of  patients  who  were  underweight  and 
noticed  that  a  gain  of  a  few  pounds  was  nearly 
always  attended  l)y  an  improvement  in  their  general 
condition,  increased  energy  and  a  feeling  of  well- 
being.  An  explanation  which  seems  reasonable  is 
that  a  change  in  diet  sufficient  to  cause  even  a  slight 
gain  furnishes  some  reserve  for  the  patient  to  draw 
on.  Such  patients,  having  lived  on  an  insufficient 
diet,  had  no  reserve,  activity  was  reduced,  and  in  all 
probability  the  metabolism  of  the  body  had  adjusted 
itself  so  as  to  maintain  the  individual  on  a  diet  too 
low  for  the  development  of  an  average  amount  of 
energy.  The  increased  diet  changed  the  energy 
balance  of  the  patient  from  negative  to  positive. 

Cases  of  uncomplicated  overnutrition  undoubtedly 
exist.  After  a  certain  length  of  time  complications 
.occur,  such  as  high  blood  pressure,  fatty  heart, 
and  nephritis.  But  the  patients  become  inefficient 
even  before  these  complications  develop.  The  ef- 
fect of  a  weight  reduction  diet  in  such  cases  is 
sometimes  much  greater  than  would  naturally  be 
anticipated.  The  loss  of  a  few  pounds  is  followed 
by  an  improvement  in  breathing  and  relief  from 
palpitation.  The  loss  of  such  a  moderate  amount  as 
ten  pounds  so  markedly  increases  the  ability  to  climb 
stairs  that  the  patient  speaks  in  no  uncertain  terms 
regarding  the  improvement.  The  following  case 
well  illustrates  this  point : 

Case  I. — Mrs.  J.  S.,  aged  fifty-three,  housewife, 
complained  of  headaches,  dizziness,  ifainting  at- 
tacks (having  fallen  on  the  street  on  two  occa- 
sions), and  pain  in  the  right  arm.  The  patient  was 
not  constipated.  Physical  examination  showed 
heart  and  Itings  negative,  urine  negative,  even  to 
indican.  Blood  pressure  90-150.  The  patient  be- 
gan reduction  diet  March  21,  1920,  her  weight  at 
that  time  being  197  pounds,  12  ounces;  March  29th, 
weight  193  pounds  :  April  3rd,  191  pounds,  14  ounces, 
blood  pressure  90-144.  She  had  not  fainted  since 
starting  treatment  and  the  dizziness  and  rheumatic 
pains  had  decreased.  On  April  9th  her  weight  was 
190  pounds,  6  ounces.  Patient  stated  that  she 
climbed  stairs  more  easily.  On  April  23rd,  the 
weight  had  reached  186  pounds,  6  ounces.  Xo 
fainting  had  occurred  since  starting  the  diet  and 
dizziness  was  practically  gone.  No  rheumatic  pains 
remained  and  headaches  were  infrequent  as  well  as 
trifling,  though  formerly  they  had  been  severe. 

Case  II. — A  case  of  obesity  complicated  by  intes- 
tinal stasis.  Miss  B.  M.  K.,  aged  forty,  who  began 
treatment  on  April  22,  1916.  She  had  suffered 
from  fainting  spells,  unaccompanied  by  pain  or 
fever,  and  a  feeling  as  if  her  "heart  would  stop." 
These  attacks  had  been  going  on  for  two  months. 
There  was  'not  much  shortness  of  breath,  bowels 
moved  daily  without  medication.  There  was  a  bad 
taste  in  the  morning,  appetite  good  except  during 
the  attacks.  Though  the  patient's  bowels  were  regu- 
lar, the  stools  were  dark  green  at  times,  of  oflFensive 
odor,  and  comparatively  soft.  Physical  examina- 
tion showed  heart  and  lungs  negative,  blood  pres- 
sure 150,  slight  tenderness  over  the  right  hypochon- 
driac region.    X  ray  examination  by  Dr.  C.  W. 


Perkins  indicated  stasis  due  to  adhesions  between 
the  colon  and  the  gallbladder,  the  stomach  being 
pulled  to  the  right,  the  hepatic  flexure  of  the  colon 
lield  high,  the  ileum  dilated  and  ptosed,  bismuth 
being  present  in  the  cecum  and  ileum  in  the  forty- 
eight  hour  plate.  Colonic  irrigations  combined  with 
magnesia  usta  by  mouth  and  a  weight  reduction  diet 
comprised  the  treatment.  On  April  22nd  the  weight 
was  184  pounds,  15  oimces.  From  the  time  treat- 
ment was  instituted  no  further  fainting  spells  oc- 
curred._On  April  29th  her  weight  was  182  pounds ; 
^lay  27th,  172  pounds:  June  23rd,  164  pounds: 
July  22nd,  150  potmds,  12  ounces.  Blood  pressure 
dropped  to  120  by  July  1st. 

These  two  cases  represent  types  of  overnutrition 
causing  inefficiency.  The  former  patient  was  fast 
becoming  incapacitated  for  her  household  duties, 
l)ut  within  the  short  period  of  a  month  had  reached 
an  efficiency  which  was  only  slightly  below  normal. 
The  second  patient,  a  music  teacher,  was  able,  within 
two  weeks,  to  resume  her  full  duties,  and  lost  no 
time  thereafter. 

The  third  class,  intestinal  toxemia,  has  been  rec- 
ognized for  many  years  and  has  been  treated  with 
more  or  less  success.  However,  a  number  of  severe 
cases  fail  to  receive  the  correct  diagnosis  and  there 
are  many  mild  cases  that  go  unrecognized.  These 
patients  can  never  be  properly  treated  until  more 
attention  is  given  to  detail  in  diagnosis  as  well  as 
in  treatment.  The  dietetic  management  is  not  often 
sufficiently  careful,  and  there  is  a  tendency  to  relax 
it  far  too  soon. 

Indicanuria  or  scatol  and  indol  in  excessive  quan- 
tities in  the  stool  establish  the  diagnosis.  The  intes- 
tinal flora  is  never  normal,  the  gram  negative  or- 
ganisms (colon  bacilli)  Ijeing  replaced  in  whole  or 
in  part  by  gram  positive  organisms.  Constant  ab- 
sorption of  toxins  produces  the  symptoms  found  in 
such  cases.  The  most  prominent  symptoms  are 
lassitude,  depression,  feeling  of  melancholy,  and  in- 
ability to  concentrate.  The  patients  are  frequently 
unable  to  attend  to  business,  mental  processes  being 
almost  suspended.  \\'hen  this  condition  has  existed 
for  a  considerable  time,  kidneys,  arteries,  and  heart 
are  injured  by  the  toxemia.  A  couple  of  cases  may 
be  cited  to  illustrate : 

Case  III. — J.  F.,  aged  fifty-four,  a  heavy  eater  and 
drinker  all  his  life,  no  headaches  and  appetite  tinim- 
paired.  Several  years  previous  to  coming  under  my 
care  depression  had  been  extreme  so  that  business 
was  left  entirely  to  assistants  and  retirement  was 
intended.  Examination  of  the  test  breakfast  showed 
low  values  for  free  hydrochloric  acid,  the  urine 
showed  no  albttmin,  sugar  or  casts,  but  large  quan- 
tities of  indican.  The  stools  showed  the  follow- 
ing :  Color,  greenish  black ;  odor,  offensive ;  reac- 
tion, acid ;  indol  and  scatol  were  present  in  large 
amounts ;  meat  fibres  not  normally  digested,  and 
bacteria  almost  totally  gram  positive.  The  treat- 
ment by  irrigations,  implantations  of  colon  bacillus, 
the  exclusion  of  meat  and  eggs  and  the  prescrip- 
tion of  milk  as  the  chief  protein  food,  did  away  with 
the  indican  and  relieved  all  of  the  symptoms  of 
which  the  patient  complained.  The  patient's  pre- 
viously successful  business  life  was  restimed  and 
conducted  with  unabated  vigor. 


July  3,  1920.] 


iVEISS:   ULCER  OF  ESOPHAGUS. 


29 


Case  IV. — ^Ir.  J.  P.  H.,  aged  thirty-three.  His- 
tory of  diarrhea  while  in  the  army.  Since  that  time 
bilious  attacks  had  been  frequent  and  there  had  been 
complaint  of  nervousness,  dizziness,  lack  of  power 
to  concentrate,  depression,  drowsiness  and  constipa- 
tion. Stools  were  dark,  almost  black,  offensive  and 
hard.  Examination  showed  the  sigmoid  and  cecum 
not  well  emptied,  the  tongue  was  coated,  indican 
five  plus.  The  patient  had  been  variously  treated 
for  nervous  breakdown,  constipation,  and  stomach 
trouble.  The  following  treatment  caused  a  quick 
improvement  with  a  return  to  normal  within  six 
weeks.  This  patient  was  unable  to  perform  the 
duties  of  his  position  at  the  time  treatment  was 
started,  but  he  has  worked  steadily  since  going  back 
during  the  sixth  week.  Meat  and  eggs  were  re- 
moved from  the  diet  and  milk  substituted.  Other 
articles  of  food  were  allowed  freely.  Cathartics 
to  evacuate  the  colon  more  thoroughly  were  given 
and  bacillus  acidophilus  was  administered  by  mouth 
for  months.  Agar-agar,  bran,  Russian  oil,  and  fruit 
are  still  being  used,  as  the  constipation  is  a  diffi- 
cult feature  in  this  case. 

Although  there  is  nothing  new  involved  in  the 
diagnosis  and  treatment  in  the  four  cases  cited,  at 
least  two  of  them  had  been  unsuccessfully  treated 
for  a  long  time ;  one  more  than  a  year  and  the 
other  for  twenty  years,  and  they  represent  a  large 
class  of  patients  going  about  from  one  physician 
to  another,  receiving  various  diagnoses,  and  gen- 
erally grouped  as  neurasthenics.  Whether  these  pa- 
tients are  ill  through  dietetic  errors  alone  or  have 
some  mechanical  condition,  such  as  stasis,  the  con- 
trol of  diet  is  of  prime  necessity. 

40  East  Forty-first  Street. 

ULCER  OF  THE  ESOPHAGUS. 

Diagnosis  and  Treatment. 

By  Samuel  Weiss,  'SI.  D., 
New  York, 

Attending  Gastroenterologist,  Jewish   Memorial  Hospital. 

Appreciation  of  the  difficulties  in  diagnosing  ob- 
scure conditions  occurring  in  patients  who  complain 
of  vague  and  indefinite  sensations  behind  the 
sternum  has  prompted  me  to  pay  more  attention  to 
these  symptoms  with  the  express  purpose  of  obtain- 
ing a  more  definite  idea  of  the  various  underlying 
causes  producing  them. 

Possibly  none  of  the  many  striking  conditions 
that  are  revealed  by  the  x  ray  or  the  esophagoscope 
is  so  interesting  as  the  demonstration  of  esophageal 
obstruction.  A  dogmatic  positive  or  negative  diag- 
nosis is  expected  and  is  freely  given  by  the  radiogra- 
pher, and  is  usually  accepted  by  the  physician,  for 
it  is  a  generally  accepted  axiom  that  it  is  a  case  of 
either  guilty  or  not  guilty,  and  that  if  the  bismuth 
food  passes  freely  down  the  esophagus  there 
cannot  be  any  obstruction.  That  is  not  the  case, 
for  obstruction  is  a  relative  term  and  depends  on 
three  distinct  factors:  1,  the  consistency  of  the  food 
in  relation  to ;  2,  the  degree  of  obstruction,  and  3, 
the  power  of  the  esophageal  peristalsis,  aided  by  the 
action  of  gravity. 


Moreover  it  does  not  necessarily  follow  that  an 
obstruction  will  always  be  present.  Spasmodic  con- 
tractions of  the  esophagus  are  just  as  frequent  as  in 
other  parts  of  the  alimentary  tract.  Where  the 
mucous  membrane  is  inflamed  or  ulcerated  there 
will  be  a  considerable  spasmodic  contraction  that 
may,  of  itself,  give  rise  to  complete  obstruction, 
although  the  underlying  cause  may  be  simply  a 
small  source  of  irritation.  Perhaps  the  bismuth 
food  allays  the  irritation  and  no  obstruction  is 
noted,  whereas  later  a  hard  particle  may  set  up  the 
irritation  and  produce  a  spasm.  The  esophagus, 
unlike  the  rest  of  the  alimentary  tract,  has  approxi- 
mately only  one  function,  namely,  to  act  as  a  high- 
way from  the  mouth  to  the  stomach,  and  anything 
that  interferes  with  this  function  causes  the  symp- 
tom of  esophageal  obstruction,  which  may  arise 
from  a  variety  of  causes.  It  is  frequently  the  first 
and  only  sign  of  such  serious  conditions  as  new 
growths  and  aneurysms,  while  comparatively  inno- 
cent lesions  may  produce  the  same  trouble. 

AXATOMY. 

The  description  of  the  esophagus  as  a  tubular  or- 
gan of  definite  diameter  is  common  in  the  books 
of  descriptive  anatomy.  Like  the  rest  of  the  ali- 
mentary canal  it  is  a  potential  space  when  empty 
and  is  capable  of  considerable  distention.  The 
esophagus  is  divisible  into  three  parts:  1,  cervical, 
five  cm. ;  2,  thoracic,  eighteen  cm. ;  and  3,  abdominah 
two  to  three  cm.  Clinically  in  the  upper  portion  it 
is  in  relation  to  the  trachea ;  at  the  level  of  the  bi- 
furcation of  the  trachea,  to  the  left  bronchus,  the 
bronchial  glands,  the  pleura,  the  pericardium  and 
the  recurrent  larv-ngeal  nerves ;  and  lower  down, 
below  the  bifurcation,  to  the  aorta,  and  this  is  im- 
portant. The  diameter  of  the  lumen  increases  on: 
the  average  from  above  downward,  var\-ing  from 
seven  to  twenty-two  mm.  Xormally.  certain  con- 
strictions occur  at  dififerent  levels.  This  narrowing  is 
present  at  four  points  :  opposite  the  cricoid  cartilage  r 
above  the  arch  of  the  aorta ;  below  the  arch  of  the 
bifurcation  of  the  bronchi,  where  it  is  crossed  by  the 
left  bronchus,  and  at  the  diaphragm.  Besides  these 
there  may  be  other  points  of  narrowing  which  are 
without  pathological  significance. 

On  swallowing  corrosive  fluids,  or  when  there 
is  injury  on  passing  esophageal  bougies,  the  damage 
occurs  most  often  at  the  level  of  one  of  these  nor- 
mal constrictions ;  scars  are  more  common  in  these 
situations,  and  cancers  also  tend  to  develop  in  the 
same  region. 

In  the  anamnesis,  difficulty  in  swallowing,  pain  on 
swallowing,  a  localized  feeling  of  pressure  in  the 
course  of  the  tube,  or  regurgitation  of  food  makes 
an  examination  of  the  esophagus  necessary.  Dys- 
phagia may  set  in  suddenly  or  may  begin  insidiously 
and  increase  gradually.  In  esophageal  stenosis,  es- 
pecially, the  patients  state  that  they  have  been  com- 
pelled to  use  food  of  an  increasing  softness  of  con- 
sistency until  finally  only  liquids  could  be  swallowed. 
The  patients  either  regurgitate  food  immediately,  or 
they  feel  that  it  remains  in  the  esophagus  to  be 
regurgitated  later,  perhaps  in  a  decomposed,  foul 
smelling  state.  Such  patients  emaciate  rapidly. 
Where  there  is  great  variation  in  the  ability  to 


30 


PARIS  LETTER. 


[New  York 
Medical  Journal. 


swallow,  a  cardiospasm  or  a  diverticulum  of  the 
esophagus  may  be  suspected.  Pain  on  swallowing 
may  be  sharply  localized  (ulcer,  carcinoma),  or  may 
be  diffuse  throughout  the  whole  length  of  the  gullet 
(esophagitis) .  Regurgitation  of  food  is  character- 
ized by  the  absence  of  hydrochloric  acid ;  the  re- 
action is  usually  alkaline  and  contains  mucus. 
The  most  frequent  location  of  esophageal  ulcer, 
especially  in  males,  is  at  the  fourth  constriction. 
About  three  quarters  of  all  esophageal  ulcers  are 
found  in  this  location.  The  next  more  frequent 
location,  is  opposite  the  cricoid  cartilage,  and  finally 
it  is  found  in  the  narrowing  where  the  left  bronchus 
and  aorta  cross  the  esophagus. 

The  ulcers  may  be  round,  irregular  or  semicircu- 
lar. In  syphilis  they  are  circular.  Several  ulcers 
may  be  foimd  together  or  they  may  extend  up  and 
down  the  tube,  or  may  occur  at  both  ends  of  the 
esophagus.  The  right  posterolateral  wall  seems  to 
be  a  favorable  site  for  ulcers  occurring  at  the  fourth 
constriction.  etiology. 

The  etiologj'  in  many  cases  of  esophageal 
ulceration  seems  to  be  obscure.  Some  of  the  prob- 
able causes  may  be:  1,  pressure  of  the  cricoid  carti- 
lage on  the  esophagus,  or  to  pressure  from  a  struma, 
an  aneurysm,  or  a  neoplasm ;  2,  in  regurgitation  of 
the  gastric  juice,  to  esophagomalacia  or  peptic  ul- 
cer ;  or  3,  in  esophageal  varix  to  abrasion  over  the 
varix  with  formation  of  a  varicose  ulcer ;  4,  steno- 
sis of  the  pylorus  or  duodenum  or  an  hourglass 
stomach ;  5,  the  intake  of  quantities  of  hot  or  cold 
food  and  hurried  eating ;  6,  syphilis ;  7,  tuberculosis, 
malignancy;  9,  swallowing  of  foreign  bodies,  as  a 
fish  bone  or  chicken  bone,  or  piece  of  metal,  may 
cause  a  scratch  or  erosion  of  the  mucous  membrane 
and  generally  ulceration;  10,  injuries  of  esophagus 
in  attempted  suicide ;  ingestion  of  corrosive  fluids. 

SYMPTOMS. 

The  symptoms  of  superficial  ulceration  of  the 
esophagus  are  insignificant.  Usually  in  the  long 
standing  and  deepseated  ulcerations  marked  symp- 
toms are  produced.  Difficulty  in  swallowing  is 
present  and  is  one  of  the  chief  symptoms  in  differ- 
entiating it  from  gastric  ulcer.  When  a  patient 
complains  of  pain  immediately  on  swallowing  and 
also  has  marked  tenderness  over  the  sternum,  the 
internist  should  think  of  probable  ulcer  of  the  esopha- 
gus. Sometimes  pressure  over  the  lower  border 
of  the  spleen  may  cause  pain.  On  account  of  the 
difficulty  in  swallowing  and  because  of  the  pain,  pa- 
tients often  fear  to  take  food,  and  become  weak 
and  emaciated ;  some  have  nausea,  others  vomit. 

DIAGNOSIS. 

The  diagnosis  in  these  cases  depends  upon  the 
location  of  the  ulcer,  and  we  employ  several  meth- 
ods which  have  their  advantages  and  disadvantages. 
Rontgenoscopy  and  rontgenography  of  the  esopha- 
gus will  show  whether  or  not  there  is  a  lesion  or 
spasm  and  will  guide  us  in  reference  to  employing 
a  bougie.  The  use  of  the  bougie  should  never  be 
attempted  unless  the  bismuth  shadow  shows  a  defi- 
nite f  unnelshape  at  its  lower  end ;  a  bougie  may 
wander  in  an  amazing  fashion  far  away  from  the 
opening  into  the  passage.  Force  must  never  be  used, 
and  even  with  the  gentlest  manipulation,  a  round- 


nosed  bougie  may  pass  into  an  ulcer  and  down  be- 
tween the  mucous  and  muscular  coats,  giving  a 
sense  of  absence  of  obstruction. 

Einhorn's  string  test  for  determining  the  location 
of  the  ulcer  may  give  us  little  information,  because 
not  every  ulcer  bleeds,  and  even  if  it  does,  the 
thread  ma}-  not  come  in  contact  with  the  ulcer  and 
may  mislead  the  internist  who  depends  upon  finding 
the  red  stain  on  the  thread. 

The  most  reliable  instrument  for  making  the  diag- 
nosis, locating  the  lesion  and  the  kind  of  ulcer,  is  the 
esophagoscope.  This  instrument  in  the  hands  of  a 
capable  man  is  the  most  useful  aid  in  diagnosing 
esophageal  ulceration. 

TREATMENT. 

The  treatment  of  esophageal  ulcers,  when  prop- 
erly carried  out,  yields  gratifying  results.  I  employ 
the  duodenal  tube  for  feeding,  and  give  large  doses 
of  bismuth  and  magnesia  by  mouth.  For  the  thirst 
a  normal  saline  by  rectum,  preferably  in  the  form 
of  the  Murphy  drip,  is  given  once  or  twice  daily. 
The  patient  is  kept  in  bed  for  the  first  few  days, 
then  he  is  permitted  to  get  up,  and  for  ten  days 
or  longer  the  tube  is  kept  in  the  stomach  and  then 
withdrawn.  The  first  two  days  after  the  tube  is 
removed  the  patient  receives  milk  with  sweet  cream 
and  three  eggs  daily.  On  the  third  day,  toast  and 
butter  and  fine  cereals  are  allowed.  Should  the 
symptoms  recur  when  the  patient  goes  on  a  more 
liberal  diet,  we  go  back  to  the  fluid  diet,  and  if 
that  is  ineffective  another  course  of  duodenal  feed- 
ing should  be  inaugurated. 

CONCLUSIONS. 

In  making  a  diagnosis  it  is  the  internist  who  is 
usually  the  first  one  to  be  consulted,  and  therefore 
it  is  his  duty  to  analyze  carefully  the  symptoms  and 
determine  the  cause  of  the  ailment.  He  should 
not  merely  tell  the  patient  that  he  is  nervous  or 
some  such  makeshift  diagnosis  and  prescribe  a  pla- 
cebo. It  is  his  duty  to  employ  every  available  means 
to  come  to  a  definite  diagnosis,  and  in  many  cases 
prevent  future  trouble.  Should  he  be  incapable  of 
availing  himself  of  the  modern  methods,  it  is  no 
more  than  just  that  he  refer  the  patient  to 
someone  who  is  able  to  emplo}'  the  numerous  diag- 
nostic instruments  and  interpret  the  findings  in  a 
given  case. 

616  Madison  Avenue. 


PARIS  LETTER. 

(By  our  own  correspondent.) 

Paris,  May  30,  ig20. 
The  Offensive  of  the  Rockefeller  Mission  Against  Tuber- 
culosis. 

If  the  Rockefeller  Mission  for  the  Prevention  of 
Tuberculosis,  instituted  in  Paris  in  1917,  fails  to 
achieve  the  miracle  of  actually  stamping  out  tuber- 
culosis, it  will  at  least  have  succeeded  in  an  almost 
equally  difficult  task,  viz.,  that  of  drawing  together 
thousands  of  persons  to  Paris  to  hear  lectures  on 
the  prevention  of  the  disease. 

In  preparation  for  a  recent  gathering,  M.  Des- 
chanel,  President  of  the  French  Republic,  and  M. 
Leon  Bourgeois,  President  of  the  Senate,  were  in- 


July  3,  1920.] 


PARIS  LETTER. 


31 


duced  to  accept  the  honorary  presidency  of  the  con- 
vention, which  was  to  be  held  on  the  heights  of 
Menilmontant,  the  extensive  quarter  of  workmen's 
dweUings  in  the  east  of  Paris.  Some  doubts  had 
been  entertained  as  to  whether  the  affair  would 
prove  a  success  and  the  public  take  kindly  to  this 
new  kind  of  propaganda.  The  meeting,  however, 
was  a  splendid  success.  Although  the  daily  press 
had  hardly  made  mention  of  the  proposed  gathering, 
which  was  advertised  largely  by  posters  put  up 
in  the  workingmen's  quarter,  the  hall,  accommodat- 
ing three  thousand  persons,  was  completely  filled, 
and  hundreds  had  to  remain  standing. 

The  Ministry  of  Social  Hygiene  was  represented 
at  this  gathering  by  M.  Desmars,  the  chief  of  one 
of  its  services,  who  expressed  the  deepseated  grati- 
tude to  America  felt  by  France  for  its  campaign 
against  tuberculosis  and  the  large  funds  generously 
supplied  for  the  purpose.  "The  Americans,"  he 
said,  "have  organized  in  France  108  dispensaries 
for  tuberculous  patients,  arranged  for  a  great  num- 
ber of  lectures  and  motion  picture  demonstrations, 
saved  hundreds  of  lives,  and  brought  back  hope  to 
thousands  of  human  beings  afflicted  with  the  dread 
disease."  Special  praise  was  bestowed  upon  Dr. 
Stewart,  director  of  the  propaganda  against  tu- 
berculosis, and  upon  Mr.  Bernard  Wyatt,  of  New 
York  University,  who  represented  the  Mission  for 
the  Prevention  of  Tuberculosis  at  the  meeting. 

Mr.  Wyatt  having  thanked  the  speaker  in  a  brief 
speech  and  made  the  statement  that  "everyone  in 
America  would  be  glad  to  stand  by  the  side  of  our 
French  friends  in  combating  the  disease,"  the  floor 
was  given  in  succession  to  the  two  main  speakers. 
Dr.  Bezangon,  of  the  Academie  de  medecine,  and 
M.  Jean  Blaize,  special  lecturer  of  the  Mission  for 
the  Prevention  of  Tuberculosis. 

"Tuberculosis,"  said  Dr.  Bezangon,  "caused  86,- 
113  deaths  in  France  in  1911,  these  deaths  consti- 
tuting one  tenth  of  the  entire  mortality  in  the  coun- 
try. To  take  effectual  measures  against  it,  it  is 
necessary  to  be  familiar  with  its  causes  and  mode  of 
development.  Thirty  years  ago  tuberculosis  was 
commonly  thought  to  be  an  inherited  affection,  and 
this  idea  is  still  entertained  by  a  large  number  of 
persons.  Already  in  1865,  however,  Villemin,  the 
French  professor,  maintained  that  tuberculosis  was 
not  inherited  but  was  transmissible,  and  twenty  years 
later  this  view  was  confirmed  by  the  discovery  of 
Koch's  bacillus. 

"Thus,  the  question  as  to  the  manner  of  prevent- 
ing transmission  of  the  disease  presents  itself.  In  this 
connection  there  is  a  great  difference  between  tuber- 
culosis and  certain  other  diseases,  sucli  as  measles  and 
scarlet  fever.  Transmission  of  tuberculosis  com- 
monly occurs  only  after  prolonged  and  repeated 
contact  with  a  patient.  The  risk  of  transmission 
miist,  therefore,  not  be  overemphasized,  and  it 
would  be  inhuman  to  insist  upon  complete  isolation 
of  consumptives,  as  has  been  the  custom  in  the 
case  of  lepers.  One  need  not  hesitate  to  care  for 
and  bring  cheer  to  a  consumptive.  Children,  how- 
ever, being  extremely  sensitive  to  the  tubercle  ba- 
cillus, must  be  carefully  kept  away  from  such  pa- 
tients. On  the  other  hand,  the  risk  of  transmission 
among    adults    must    not    be    overlooked."  Dr. 


Bezangon  explained  how  uncleanliness,  tmwhole- 
some  dwelling  quarters,  and  badly  planned  work- 
shops favor  transmission  of  the  disease.  "We  are 
constantly  being  told  that  tuberculosis  is  a  poor 
man's  disease.  This  is  true  only  in  that  poverty 
compels  families  to  live  in  overcrowded  and  dirty 
quarters,  in  close  contact  with  patients  who  cannot 
be  placed  in  isolation."  Special  stress  was  laid 
on  the  absolute  efficacy  of  suitable  prophylactic 
measures.  The  sputum  being  the  vehicle  of  the 
tubercle  bacillus,  the  main  precaution  consists  in 
avoiding  contact  of  any  trace  of  the  sputum  with 
other  persons.  This  precaution  is  one  that  can  be 
instituted  in  a  thorough  manner,  and  in  a  well  or- 
dered sanatorium  there  has  been  no  instance  of 
transmission  of  the  disease  to  any  physician  or 
nurse.  In  concluding,  Dr.  Bezangon  spoke  of  the 
good  work  accomplished  in  the  dispensaries  and  es- 
pecially by  the  visiting  nurses. 

M.  Jean  Blaize  spoke  of  various  practical  meas- 
ures helpful  in  the  tuberculosis  prevention :  Dry 
sweeping  was  condemned ;  curtains  should  be  done 
away  with ;  one  should  sleep  with  the  windows 
open ;  tobacco  and  alcohol  should  be  discarded ; 
beans  constitute  a  useful  food.  These  various  items 
of  wholesome  advice  were  delivered  in  such  a  man- 
ner and  with  such  an  unexpected  choice  of  words 
that  the  listeners  were  moved  to  laughter  every  few 
minutes.  Thus,  speaking  of  tobacco,  he  said :  "Tu- 
berculosis, we  are  told,  is  trarismitted  by  the  sputum. 
But  why  do  we  spit  ?  Spitting  is  a  very  unattractive 
habit.  Women  don't  spit.  Why  not?  Mainly  be- 
cause they  don't  smoke.  Spitting  is  the  privilege 
of  men  who  smoke.  The  cigarette  smoker  spits 
a  little.  He  is  like  the  Petit  Morin  (a  small  affluent 
of  the  Seine  River).  The  cigar  smoker  spits  more, 
like  the  Grand  Morin.  The  pipe  smoker  is  like 
the  Seine  when  it  overflows  its  banks.  The  chewer 
of  tobacco — he  is  like  the  Black  Sea.  Man  is  the 
only  animal  who  smokes,  and  it  is  really  America's 
fault,  for  its  was  Christopher  Columbus  who 
brought  back  the  weed  with  him.  Fortunately,  at 
the  present  time  the  Americans  are  exporting  habits 
of  a  different  kind." 

As  was  to  be  expected,  the  managers  of  the  gather- 
ing also  brought  music  and  films  into  play.  A  com- 
plete Parisian  regimental  band  played  between  the 
lectures.  The  most  interesting  film  was  that  repre- 
senting the  open  air  school  at  Plessis-Robinson,  a 
school  originally  of  American  conception  and  man- 
aged by  the  Bureau  of  Hygiene  of  the  Department 
of  the  Seine.  In  this  institution  shelter  is  given  to 
children  predisposed  to  tuberculosis,  and  remarka- 
ble results  have  been  obtained.  The  sight  of  these 
children  playing  or  working  in  the  open  air,  well 
cared  for  and  watched,  could  not  fail  to  encourage 
parents  to  separate  themselves  for  awhile  from 
their  sickly  offspring.  Picture  propaganda  is  highly 
effective. 

The  Menilmontant  gathering  is  to  be  followed  by 
many  others.  The  medical  authorities  are  earnestlv 
supporting  the  Rockefeller  Mission.  The  large 
sums  expended  to  insure  continuity  of  endeavor  are 
far  from  being  wasted,  and  undoubtedly  this 
first  great  meeting  will  be  followed  by  material 
success. 


Editorial  Notes  and  Comments 


NEW  YORK  MEDICAL  JOURNAL 

INCORPORATING  THE 

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and  the  Medical  News 

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XEW  YORK.  SATURDAY.  JULY  3.  1920. 


NOTICE  TO  OUR  READERS. 
The  index  to  Volume  CXI  of  the  New  York 
Medical  Journal  will  be  printed  separately.  Copies 
of  this  index  can  be  obtained  by  writing  to  the 
editorial  department. 

PUBLISHER'S  ANNOUNCEMENT. 

At  no  time  since  the  founding  of  the  New  York 
Medical  Journal  in.  1843  has  the  situation  in  re- 
gard to  pubHshing  been  so  acute.  The  prices  of 
printing  and  paper  have  gradually  risen  and  in 
many  departments  expenses  have  increased  three 
fold  during  the  past  four  years.  Some  months  ago 
we  were  confronted  by  a  strike  of  the  printers,  but 
at  great  expense  and  trouble,  not  to  speak  of  loss, 
we  brought  out  the  Journal  with  regularity,  never 
missing  an  issue.  Following  this  there  was  a  short- 
age of  paper,  due  to  a  tie  up  of  transportation  fa- 
cilities, and  again  we  published  the  Journal  with- 
out the  loss  of  an  issue.  We  transported  paper  by 
automobile  from  a  great  distance.  In  spite  of  these 
difficulties  this  service  was  maintained  for  our  read- 
ers by  a  constant  struggle. 

Through  all  these  adverse  circumstances  we  have 
constantly  l^een  improving  the  quality  of  the 
Journal,  making  it  of  ever  increasing,  value  to  our 
readers.  Our  special  correspondents  in  foreign 
countries  have  been  on  the  alert  for  papers  by 
European  workers,  so  we  could  keep  our  readers  in- 
formed of  the  latest  advances  in  science  across  the 
sea. 


We  have  established  a  department  of  book  re- 
views, for  which  we  secure  the  services  of  workers 
in  the  various  fields  of  interest  to  the  physician. 
This  department  has  proved  to  be  a  guide  to  the 
medical  men  in  this  country.  We  had  felt  for  some 
time  prior  to  establishing  this  department  that  too 
little  attention  had  been  given  by  medical  journals 
to  the  textbooks  of  medicine.  In  these  books  are 
usually  found  the  most  careful  work  of  men  in 
medicine,  frequently  the  consummation  of  years  of 
study  and  work.  In  comparison  with  the  space 
given  to  hurriedly  written  papers,  frequently  a  re- 
hash of  things  published  many  times  before,  and 
to  extemporaneous  remarks  at  medical  meetings, 
under  the  head  of  proceedings  of  societies,  books 
received  scant  consideration. 

We  arranged  special  numbers  of  the  Journal  in 
order  to  group  together  under  one  cover  the  latest 
findings  of  leading  medical  men  in  each  particular 
specialty.  These  numbers  are  of  distinct  service, 
rendering  easily  available  information  concerning  a 
special  subject  for  which  one  may  be  looking.  So 
far  we  have  had  special  numbers  devoted  to  en- 
docrinology, neurology,  gynecology,  the  alcohol 
question,  dentistry,  diabetes,  ear,  nose  and  throat, 
and  gastroenterology. 

In  order  to  keep  things  moving  and  carry  out  our 
policies  we  shall  reduce  the  size  of  the  Journal 
slightly  dtiring  the  months  of  July  and  August, 
resuming  the  normal  size  with  the  first  issue  in 
September.  There  will  be  no  reduction,  however, 
in  the  amount  of  original  material.  The  high  stand- 
ard set  for  our  department  of  book  reviews  will 
be  maintained.  The  special  numbers  will  be  con- 
tinued. The  material  which  we  .shall  present  will 
be  chosen  with  great  care  and  only  those  things 
which  we  believe  will  be  of  interest  to  the  medical 
practitioner  will  be  given  space. 

THE  SYMPTOMATOLOGY  OF  VOLVULUS 
OF  THE  CECUM. 

The  onset  of  volvulus  of  the  ceciuu  occurs  in  one 
of  two  ways ;  the  process  either  commences  sud- 
denly with  violent  abdominal  pain  and  colic,  ac- 
companied by  vomitng,  or,  more  commonly,  the 
patients  are  constipated  and  suffer  from  abdominal 
pain,  particularly  in  the  right  iliac  fossa  where  true 
paroxysms  of  colic  are  complained  of.  These  pre- 
monitory phenomena,  the  result  of  movable  cecum, 
are  generally  regarded  as  due  to  the  appendix. 

The  pain  in  volvulus  is  intense,  all  the  greater 
the  tighter  the  constriction.  It  may  be  continuous, 


July  3,  1920.] 


EDITORIAL  ARTICLES 


33 


but  usually  it  takes  the  form  of  colic,  recurring  in 
paroxysms  at  the  time  of  intestinal  contraction.  As 
the  evolution  continues  the  intestine  becomes  dis- 
tended, paralysis  of  the  gut  ensues,  abolishing  per- 
i.stalsis.  The  colic  then  decreases  progressively  and 
is  replaced  by  a  more  hxed  pain,  due  to  beginning- 
peritoneal  reaction.  The  pain  is  usually  situated 
rather  low  in  the  right  iliac  fossa,  but  its  site  varies, 
and  it  has  been  known  to  occur  in  the  hepatic  re- 
gion or  on  the  left  side.  In  these  cases  the  loca- 
tion  of  the  pain  was  due  to  a  complete  dislocation 
of  the  cecum. 

The  pain  extends  progressively  throughout  the 
abdomen,  to  the  back  and  sacral  region.  It  is  spon- 
taneous, but  the  patient  can  lessen  it  by  changing 
his  position.  Abdominal  palpation  does  not  usual- 
ly reveal  any  point  of  exacerbation,  and  in  fact 
little  can  be  ascertained  by  it.  The  patients  com- 
pare the  pain  to  deep  crushing  or  a  sharp  constric- 
tion within  the  abdomen. 

\'omiting  appears  soon  after  the  onset  of  the  pain 
and  is  almost  always  a  constant  symptom,  statistics 
showing  that  it  is  absent  in  only  ten  per  cent,  of  the 
cases.  It  may  come  on  as  late  as  twenty-four  hours, 
after  the  onset  of  the  abdominal  pain,  but  this  is 
exceptional,  and  persists  with  tenacity,  although 
some  instances  have  been  recorded  where  it  tem- 
porarily subsided  or  even  completely  disappeared. 
It  is  intere.sting  to  note  that  the  vomiting  is  not  free, 
as  in  other  types  of  intestinal  obstruction,  and  it  is 
rarely  fecaloid. 

The  immediate  consequence  of  volvulus  is  an 
arrest  of  the  feces  and  gas,  and  this  is  likely  to  be 
complete  from  the  start ;  but  there  are  a  few  ex- 
ceptions to  the  rule.  When  once  the  obstruction 
is  realized  the  lower  portion  of  the  large  intestine 
may  empty  itself,  spontaneously  or  otherwise,  but 
only  during  the  first  few  hours  following  the  vol- 
vulus. The  paresis  of  the  large  intestine  is  the 
factor  of  its  reflex  paralysis. 

The  pain  which  existed  at  the  onset  declines  little 
by  little,  but  when  the  ]:»aroxysms  have  .subsided  a 
new  symptom  appears,  namely,  abdominal  disten- 
tion, which  renders  the  peristalsis  more  clearly  vis- 
ible. This  distention  appears  as  soon  as  the  pain  and 
vomiting  have  subsided  and  reaches  an  enormous 
degree,  but  its  principal  characteristic  is  that  it  is 
distinctly  localized  in  the  region  of  the  volvulus,  be- 
cause an  abundant  exudation  of  fermentable  fluid 
takes  place  at  that  point  which  results  in  the  pro- 
duction of  a  considerable  quantity  of  gas.  The  site 
of  the  distention  varies ;  it  may  occur  in  the  peri- 
umbilical region  or  in  the  left  hypochondrium.  In 
one  case  it  formed  a  sonorous  oval  tumor,  similar 
in  shape  to  an  ovarian  cyst.    Occasionally  the  tym- 


panic area  encroaches  upon  the  umbilical  region  and 
becomes  evident  in  the  right  hvpochondrium.  As 
operations  have  shown,  the  fundus  of  the  cecum  is 
above  and  to  the  left  and  ascites  is  present,  usually 
in  so  small  an  amount  that  it  cannot  be  detected  clin- 
ically. When  present,  it  is  a  cloudy  or  frankly  hem- 
orrhagic fluid.  Such  are  the  symptoms  peculiar  to 
volvulus  of  the  cecum.  The  general  symptoms, 
such  as  the  pulse,  and  normal  or  subnormal  tem- 
perature, are  the  same  as  those  encountered  in 
any  kind  of  intestinal  occlusion. 


THE  CHOLESTERIN  CONTEXT  OF  THE 
FECES. 

The  .study  of  the  cholesterin  content  of  the 
feces  is  interesting  because  it  forms  a  necessary 
complement  to  the  study  of  cholesterin  in  the  bile. 
In  the  feces  it  is  no  longer  found  in  the  form  of 
cholesterin  but  largely  in  the  form  of  a  product  of 
reduction,  namely,  coprosterin.  The  study  of 
cholesterin  in  the  feces  cannot  a  priori  furnish  any 
indication  relative  to  that  of  the  bile,  because  it  is 
now  a  well  established  fact  that  the  cholesterin 
thrown  into  the  intestine  by  the  bile  is  in  large 
part  absorbed  by  the  intestinal  epithelium.  The 
knowledge  of  this  important  datum  is  due  to  the 
splendid  researches  of  Doree  and  Gardner.  They 
first  showed  that  what  was  formerly  designated  un- 
der the  name  of  hippocoprostemia  is  nothing  else 
than  phytosterin  which  passes  untransformed 
in  the  intestine  of  the  horse.  As  far  as  the 
cholesterin  thrown  into  the  intestine  by  the  bile  is 
concerned,  the  feces  of  this  animal  do  not  contain  a 
trace.  Continuing  their  researches  in  the  dog  they 
note  during  different  diets  that  the  quantity  of 
cholesterin  eliminated  by  the  feces  of  the  ani- 
mals was  invariably  inferior  to  that  which  is 
normally  thrown  into  the  intestine  by  the  bile.  They, 
however,  remarked  that  this  fecal  elimination  of 
cholesterin,  very  minute  with  a  diet  poor  in  choles- 
terin— bread,  cream  and  white  of  egg — is  notably 
higher  following  a  meal  rich  in  cholesterin,  such  as 
brains. 

The  fecal  cholesterin  is  above  all  the  result  of 
the  (juantity  of  cholesterin  entering  into  the  compo- 
sition of  the  food  ingested.  It  is  largely  composed 
by  the  more  or  less  considerable  portion  of  choles- 
terin in  the  food  consumed  which  has  escaped  intes- 
tinal absorption.  In  reality,  the  cholesterin  ingested 
with  food  is  not  integrally  absorbed  hy  the  intes- 
tine. During  their  experiments  on  rabbits,  dogs 
and  cats  Doree  and  Gardner  observed  an  absorp- 
tion of  from  forty  to  sixty  per  cent,  of  the  total 
cholesterin    contained    in    the    food.  Chasoburo 


34 


EDITORIAL  ARTICLES 


[New  York 
Medical  Journal. 


Kusumoto  came  to  similar  conclusions  and  showed 
the  influence  of  diet  on  the  quantity  of  cholesterin 
eliminated  by  the  feces.  Klein  has  also  pointed  out 
that  intestinal  absorption  is  not  more  pronounced 
with  the  ethers  of  cholesterin  than  with  free  choles- 
terin and  that  in  all  circumstances  the  presence  of 
fats  is  necessary.  The  more  recent  elaborate  and 
remarkable  experiments  carried  out  by  Greze  con- 
finn  in  general  the  findings  and  conclusions  of  the 
former  observers. 

CHOLESTERINEMIA  IN  DISEASES  OF 
THE  LIVER. 
As  is  known,  hypercholesterinemia  is  absent  in 
the  hepatic  cirrhoses  and  congenital  or  acquired 
hemolytic  icterus  likewise  undergo  their  evolution 
without  an  increase  of  cholesterinemia  and  this  is 
still  another  element  which  opposes  the  hemo- 
lytic jaundice  to  all  other  kinds  of  icterus. 
On  the  other  hand,  Grigaut  has  found  hypercholes- 
terinemia frequently  in  those  states  which  accom- 
pany disturbances  of  the  biliary  secretion  and  here, 
as  in  cases  of  Bright's  disease,  it  may  attain  very 
high  percentages,  as  much  as  fifteen  grams  to  the 
litre. 

A  certain  relationship  exists  between  the  per- 
centage of  the  cholesterinemia  and  the  intensity  of 
the  reaction  of  the  other  elements  of  the  bile.  For 
example,  in  catarrhal  icterus  the  hypercholesterine- 
mia, cholemia  and  bilirubinemia  usually  follow  a 
parallel  evolution.  This  does  not  occur  of  neces- 
sity and  there  are  numerous  cases  in  which  there  is 
a  dissociation  between  the  retention  of  cholesterin 
and  that  of  other  elements  of  the  bile — bile  salts 
and  piginents.  It  is  known  that  during  cholemic 
states  the  bile  salts  and  pigments  may  be  retained 
independently  from  each  other  in  the  organism  and 
a  similar  dissociation  occurs  between  bilirubinemia 
and  cholalemia.  It  is  the  same  for  hypercholesterin- 
emia which,  although  appearing  generally  in  sub- 
jects accompanied  by  cholalemia,  may  nevertheless 
be  met  with  outside  of  an)-  bilirubinemic  or  chol- 
alemic  states,  thus  constituting  an  isolated  state  of 
biliary  retention.  This  is  what  is  encountered  in 
lithiasic  and  xanthelasmic  states  where  a  marked 
hypercholesterinemia  may  exist  without  any  jaun- 
dice being  evident. 

Inversely,  in  icterus  from  retention,  hypercholes- 
terinemia may  be  absolutely  wanting  regardless  of 
the  intensity  of  the  bilirubinemic  or  cholalemic  re- 
tention. The  dissociations  thus  observed,  even  in 
icterus  from  retention,  between  the  constituent  ele- 
ments of  cholelentia  cannot  l)e  explained  by  a 
simple  mechanical  phenomenon  which  obstructs  the 
flow  of  bile  at  some  part  of  the  liver,  but  supposes 


an  active  interference  of  the  hepatic  cell  in  every 
case.  This  is  an  important  point  as  regards  the  part 
played  by  the  hepatic  cell  in  the  metabolism  of 
cholesterin. 

One  of  the  clinical  consequences  of  hypercholes- 
terinemia in  hepatic  subjects  is  the  xanthelasma 
which  until  recently  has  been  empirically  attached 
to  cholemia  but  in  reality,  as  Chaufifard  and  La- 
roche  have  shown,  is  directly  related  to  an  increase 
of  the  cholesterin  in  the  serum.  The  nodules  formed 
by  the  fatty  ethers  of  cholesterin  which  are  ob- 
served to  develop  in  icteric  and  diabetic  subjects 
are  due  to  a  deposit  in  the  skin  of  the  cholesterin 
in  excess  in  the  blood. 

A  marked  hypercholesterinemia  is  likewise  at  the 
bottom  of  biliary  lithiasis  and  Chauffard  has  shown 
the  importance  belonging  to  this  hypercholesterine- 
mia in  the  pathogensis  of  this  other  local  deposit 
of  cholesterin.  The  relationship  between  cholelithi- 
asis and  pregnancy  and  typhoid  fever  can  be  ex- 
plained by  the  hypercholesterinemia.  Let  it  be 
added  that  the  hypercholesterinemia  which  is  usual 
in  cholelithiasis  is  an  excellent  differential  sign  for 
the  diagnosis  of  doubtful  forms  of  biliary  lithiasis. 

THE  PRESENCE  OF  HEAVY  METALS  IN 
FOOD. 

An  occasional  sensational  headline  in  the  papers 
about  a  man  having  died  through  eating  copper, 
creates  the  impression  that  in  most  canned  or  pre- 
served food  there  lurks  mortal  poison.  But  the  im- 
portant fact  should  be  noted  that  the  heavy  metals 
are  well  borne  for  a  long  time  if  taken  with  food, 
indicating  the  intestinal  canal  exerts  a  protective 
action  against  the  metals  and  their  salts.  Yet,  dis- 
turbance of  function  of  the  intestinal  canal  or  struc- 
tural changes  of  the  mucous  membranes  of  stomach 
and  intestines  may  occur;  the  protective  action  of 
these  organs  may  cease  and  the  metals  thus  gain 
access  to  the  different  organs,  causing  serious  dam- 
age. 

According  to  recent  analyses,  the  quantity  of  zinc 
in  oysters  may  reach  1.15  gm.  to  the  kilo;  in  baker's 
yeast  0.414  to  the  kilo.  Dried  eggs  may  have  2.4 
gm.  to  the  kilo.  Copper  in  oysters  varied  between 
52  and  53.9  a  kilo ;  canned  vegetables  may  have  up 
to  2.75  gm.,  0.25  gm.  of  nickel  sulphate  may  be 
present  in  green  peas.  Tin  has  been  found  up  to 
10  to  450  mg.  to  the  kilo.  Lead  is  often  present 
in  small  quantities. 

Dr.  Salant,  writing  on  this  subject  in  the  Journal 
of  Industrial  Hygiene,  June  1920,  says  that :  "The 
unreflective  will  point  out  the  very  small  quantities 
ingested.  The  analysts  admit  this,  but  produce 
cumulative  evidence  of  the  harm  from  small 
quantities  frequently  taken  yito  the  system,  and  at 
any  rate,  the  public  is  entitled  to  the  benefit  of  the 
doubt  in  the  case  of  metals  the  entire  harmlessness 
of  which  rests  in  the  fact  that  no  sure  results  have 
been  obtained." 


July  3,  1920.1 


NEWS  ITEMS. 


35 


News  Items. 

Bequests  to  Hospitals. — By  the  will  of  William 
F.  Armstrong,  the  Methodist  Episcopal  Hospital,  of 
Brooklyn,  will  receive  $25,000  to  establish  William 
O.  Armstrong  beds  ;  the  General  Hospital  Society  of 
Connecticut  will  receive  $25,000,  and  the  Bridge- 
port Hospital,  $10,000. 

Coordinating  Child  Health  Work.— The  Amer- 
ican Red  Cross  announces  that  a  council  of  coordi- 
nating child  health  activities  has  been  formed.  The 
societies  represented  in  the  council  are:  Ameri- 
can Child  Hygiene  Association,  American  Red 
Cross,  Child  Health  Organization  of  America,  Na- 
tional Child  Labor  Committee  and  the  National 
Organization  for  Public  Health  Nursing. 

National  Association  for  the  Study  of  Epilepsy. 
— At  the  nineteenth  annual  meeting  of  this  associa- 
tion, held  recently  in  New  York,  Dr.  G.  Kirby  Col- 
lier, of  the  Craig  Colony  of  Epileptics,  Sonyea, 
N.  Y.,  was  elected  president,  succeeding  Dr.  L. 
Pierce  Clark,  of  New  York.  Dr.  Joseph  J. 
Williams,  of  Woodstock,  Ontario,  was  elected  vice- 
president,  and  Dr.  Arthur  L.  Shaw,  of  Camden, 
N.  J.,  was  reelected  secretary-treasurer. 

New  Dean  of  Yale  School  of  Medicine. — 
Dr.  Milton  C.  Winternitz  has  been  elected  dean 
of  the  Yale  School  of  Medicine,  to  succeed  Dr. 
George  Blumer  who  resigned  recently.  Dr.  Winter- 
nitz was  graduated  from  Johns  Hopkins  Uni- 
versity in  1903  and  served  on  the  faculty  for  some 
time.  He  joined  the  Yale  faculty  in  1917  and  dur- 
ing the  war  was  in  charge  of  research  in  pathology 
and  bacteriology  at  the  University  for  the  Bureau 
of  Mines. 

Personal. — The  honorary  degree  of  doctor  of 
science  was  conferred  upon  Mr.  Herbert  C.  Hoover 
by  Tufts  College,  at  the  annual  commencement  held 
on  June  21st. 

Dr.  H.  Violle  has  been  appointed  by  the  League 
of  Red  Cross  Societies  as  medical  liaison  officer  be- 
tween the  central  committee  of  the. French  Red 
Cross,  the  League  of  Red  Cross  Societies,  and  the 
French  Ministry  of  Health. 

Dr.  Richard  P.  Strong,  of  Harvard  University, 
chief  medical  officer  of  the  League  of  Red  Cross 
Societies,  has  been  elected  to  honorary  membership 
in  the  Serbian  Medical  Society. 

New  York  and  New  England  Association  of 
Railway  Surgeons. — The  thirtieth  annual  session 
of  this  association  will  be  held  at  the  Hotel  McAl- 
pin.  New  York,  on  Tuesday,  October  19,  1920,  un- 
der the  presidency  of  Dr.  William  B.  Coley,  chief 
surgeon  of  the  New  York  Central  lines.  Special 
effort  is  being  put  forth  by  the  officers  to  make 
this  one  of  the  most  successful  meetings  of  the  asso- 
ciation. An  attractive  program  is  already  nearly 
completed.  Dr.  George  W.  Crile,  of  Cleveland,  has 
accepted  an  invitation  to  deliver  the  address  in 
surgery,  and  other  leading  surgeons  will  read  papers. 
Two  chief  claims  attorneys  will  present  papers,  and 
the  president  of  an  Eastern  trunk  line  is  expected 
to  be  present  and  address  the  members  of  the  asso- 
ciation. Dr.  George  Chaffee,  of  Binghamton, 
N.  Y.,  is  corresponding  secretary  of  the  associa- 
tion. 


Dr.  Hyslop's  Brain. — Dr.  James  H.  Hyslop, 
a  well  known  psychologist  and  editor  of  the  Jour- 
nal of  the  American  Society  for  Psychical  Research, 
died  at  his  home  in  New  York  on  June  17,  1920, 
of  cerebral  thrombosis,  and  his  brain  was  given  to 
Dr.  Edward  A.  Spitzka,  of  New  York,  for  scientific 
study.  The  brain  had  not  been  weighed  on  re- 
moval, but  when  received  by  Dr.  Spitzka,  after  five 
days'  immersion  in  five  per  cent,  formaldehyde  solu- 
tion, its  weight  was  1,290  grams,  or  45.5  ounces 
avoirdupois. 

Medical   Museum  Congress. — The  thirteenth 

annual  meeting  and  exhibition  of  the  American  and 
Canadian  Section  of  the  International  Association 
of  Medical  Museums  was  held  April  1st  and  2nd 
at  Cornell  University  Medical  College,  in  conjunc- 
tion with  the  meeting  of  the  American  Association 
of  Pathologists  and  Bacteriologists.  The  meeting 
was  under  the  presidency  of  Dr.  O.  Klotz,  of  Pitts- 
burgh. Officers  elected  for  the  ensuing  year  were 
as  follows :  President,  Dr.  W.  M.  L.  Coplin,  Phila- 
delphia ;  secretary  treasurer,  Maude  E.  Abbott,  Mon- 
treal ;  assistant  secretaries,  L.  Gross,  Montreal,  and 
H.  Goldblatt,  Cleveland. 

American  Laryngological,  Rhinological,  and 
Otological  Society. — At  the  annual  meeting  of 
this  society,  held  in  Boston,  on  June  2nd,  3rd  and 
4th,  the  following  officers  were  elected:  President, 
Dr.  Lee  Wallace  Dean,  of  Iowa  City,  Iowa;  vice- 
presidents.  Dr.  Harmon  Smith,  of  New  York,  chair- 
man of  Eastern  Section ;  Dr.  Joseph  C.  Beck,  of 
Chicago,  chairman  of  Middle  Section ;  Dr.  Joseph 
B.  Greene,  of  Asheville,  N.  C,  chairman  of  South- 
ern Section ;  Dr.  William  V.  Mullin,  of  Colorado 
Springs,  Colo.,  chairman  of  mid- Western  Section ; 
Dr.  Hill  Hastings,  of  Los  Angeles,  Cal.,  chairman 
of  Western  Section ;  Dr.  Ewing  W.  Day,  of  Pitts- 
burgh, Pa.,  treasurer ;  Dr.  William  H.  Haskin,  of 
New  York,  secretary;  Dr.  George  L.  Richards,  of 
Fall  River,  Mass.,  chairman  of  Publication  Commit- 
tee. The  next  annual  meeting  will  probably  be  held 
in  Atlantic  City,  N.  J.,  somewhere  about  the  first 
of  June,  1921. 

Plague  in  America. — In  accordance  with  fore- 
casts made  by  the  United  States  Public  Health 
Service  over  a  year  ago,  bubonic  plague  has  made 
its  appearance  in  the  United  States.  At  present, 
foci  of  the  infection  are  known  to  exist  at  New 
Orleans,  Pensacola  and  Galveston,  and  in  Tampico 
and  Vera  Cruz,  Mexico.  In  Vera  Cruz,  the  disease 
appears  to  have  assumed  the  proportion  of  an  epi- 
demic. Calling  attention  to  this  outbreak  of  plague 
and  renewing  his  warning  regarding  the  introduc- 
tion of  plague  from  Mediterranean  ports  which  are 
known  to  be  infected.  Surgeon  General  Hugh  S. 
Gumming  urges  communities  throughout  the  coun- 
try, and  especially  along  the  coast,  to  inaugurate 
rat  extermination  and  ratproofing  campaigns.  With 
the  definite  knowledge  now  possessed  regarding  the 
transmission  of  this  disease,  and  especially  as  to  the 
role  played  by  rats,  the  situation  should  cause  no 
alarm  or  panic  among  the  people  of  this  country. 
Nevertheless  the  very  real  menace  of  bubonic 
plague  calls  for  an  energetic  campaign  of  extermi- 
nation directed  against  the  rat,  and  other  rodent 
pests. 


Book  Reviews 


TEXTBOOK  OF  PHYSIOLOGY. 

A  Textbook  of  Phvsiolofjy.  By  Russell  Burton-Opitz, 
S.  M.,  M.  D.,  Ph.  D.  Illustrated.  Philadelphia:  W.  B. 
Saunders  Company,  1920.    Pp.  v-1185. 

This  work,  which  appeared  recently,  takes  a 
prominent  place  in  the  literature  of  medical  phy.si- 
ology.  It  is  a  valuable  book  of  reference  for  the 
medical  student  or  the  ph.ysician  who  has  main- 
tained his  interest  in  physiology.  The  essential 
point  in  which  this  book  differs  from  others  of  its 
type  lies  in  the  emphasis  which  is  given  to  the 
clinical  aspect  of  the  subject.  It  is  not  a  book  for 
the  research  worker.  On  every  page  there  is  evi- 
dence that  it  was  written  specifically  for  the  clinician- 

The  work  is  arranged  in  logical  sequence,  treat- 
ing in  turn  the  various  physiological  functions  of 
man.  There  is  enough  discussion  of  comparative 
physiology  to  give  the  reader  .some  idea  of  the  wide 
application  of  physiological  laws.  The  essential 
propositions  are  stated  with  brevity  and  simplicity, 
although  in  the  more  general  discussions  one  is  led 
into  rather  deep  waters.  There  are  many  references 
to  physiological  literature,  and  the  work  of  the  older 
foreign  physiologists  especially  is  cited.  Numerous 
diagrams  and  illu.strations  form  eflfective  graphic 
expositions  of  the  written  text.  The  tone  of  the 
book  is  conservative.  The  physician  who  is  too 
busy  with  his  practice  to  keep  abreast  of  the  ever 
increasing  literature  of  experimental  physiology, 
but  who  desires  to  keep  in  touch  with  the  standard 
physiological  doctrines,  will  do  well  to  refer  to  this 
book. 

BACTERIOLOGY. 

Pathogenic  Microorganisms.  By  William  Hallock  Park, 
.  M.  D.,  Professor  of  Bacteriology  and  Hygiene  University 
and  Bellevue  Hospital  Medical  College  and  Director  of 
the  Bureau  of  Laboratories  of  the  Department  of 
Health.  New  York  City,  and  Axxa  Wessels  Williams, 
\i.  D.,  Assistant  Director  of  the  Bureau  of  Labora- 
tories of  the  Department  of  Health ;  Consulting  Path- 
ologist to  the  New  York  Infirmary  for  Women  and 
Children.  Assisted  by  Charles  Krlmwiede,  Jr.,  M.  D., 
Assistant  Director  of  the  Bureau  of  Laboratories ;  As- 
sistant Professor  of  Bacteriology  and  Hygiene  in  the 
University  and  Bellevue  Hospital  Medical  College,  New 
York  City.  Seventh  Edition.  Enlarged  and  Revised. 
Illustrated.  Philadelphia:  Lea  &  Febiger,  1920.  Pp.  iii- 
786. 

This  book  is  the  outgrowth  of  the  original  first 
edition  which  was  called  Bacteriology  in  Medicine 
and  Surgery.  Since  the  publication  of  this  unas- 
suming first  edition  mtich  progress  necessitated 
many  changes  in  the  editions  that  followed.  This, 
the  seventh  edition,  presents  new  phases  of  the  work 
done  on  media.  Dr.  B.  v.  H.  Anthony  has  written 
the  chapter  and  he  has  incorporated  the  work  done 
on  hydrogen  ion  concentration.  Many  other  im- 
portant chapters  have  been  revised  including  those 
on  streptococci,  yeasts,  and  the  influenza  bacillus. 
The  entire  question  of  immunity  is  presented  in  a 
Iticid  and  well  written  manner  and  this  alone  would 
commend  the  book  to  the  practical  worker.  The 
nticletis  of  the  book  originated  in  the  bacteriological 
laboratories  of  the  city  of  Xew  York.  The  authors 
have  been  successful  in  presenting  the  ordinarily  dry 
subject  of  bacteriology  in  a  way  that  is  understand- 
able and  useful  to  the  general  practitioner. 


THE  ART  OF  PRESCRIBING. 
L'Art  de  prescrire.  Par  le  Professeur  Gilbert,  professeur 
de  clinique  medicale  a  THotel-Dieu  de  Paris,  Membre 
de  I'Academie  de  Medicine.    Paris:  Librairie  J.  B.  Bal- 
liere  et  Fils,  1920.    Pp.  x-373. 

This  book  is  no  simple  compilation,  no  mere  cook- 
book collection,  but  is  L'Art  de  prescrire  and  an  at- 
tempt has  been  made  to  change  this  dry  science 
and  make  it  charming  and  attractive.  Professor 
Gilbert,  lecturer  at  the  Hotel  Dieu,  Paris,  has  been 
rendering  the  subject  of  prescribing  interesting  to 
his  students  for  many  years.  The  General  Principles 
of  Therapeutics  is  a  fine,  lucid  exjwsition  ;  this  is 
followed  by  a  chapter  on  official  remedies,  and  their 
efficacy  according  to  mode  of  usage,  many  warnings 
being  given  as  to  haphazard  treatment.  The  pa- 
tient is  always  considered  as  an  individttal  first.  The 
supplement  has  an  historical  note  on  the  origin  of 
recipe,  on  tables  of  solubility,  and  the  incompatilMlity 
of  certain  drugs,  and  will  be  useful  to  those  who  do 
their  own  dispensing.  He  is  wise  on  not  going  deeply 
into  the  question  of  psychical  agents  in  such  a  book, 
but,  as  he  says,  every  good  doctor  is  unconsciously 
a  pyschotherapeutist.  "The  doctor's  speech,  his 
l)ious  lies  ])oth  help  to  raise  the  listless  morale  of  a 
patient.  The  sound  of  his  voice,  his  look,  his  smile, 
his  mere  presence  bring  joy  and  hope  and  favor  a 
right  action  of  the  treatment  he  prescribes." 

POSTMORTEM  TECHNIC. 

Postmortem  Manual.  A  Handbook  of  Morbid  .A.natomy 
and  Postmortem  Technic.  By  Charles  R.  Box.  ^L  D., 
B.  S.,  B.  Sc.,  Lond.,  F.  R.  C.  P.  Lond.,  F.  R.  C.  S.  Eng.; 
Physician  to  St.  Thomas's  Hospital  and  to  the  London 
Fever  Hospital ;  Late  Demonstrator  of  Morbid  Anatomy. 
St.  Thomas's  Hospital.  Second  Edition.  Illustrated. 
London:  J.  &  A.  Churchill,  119.    Pp.  vi-372. 

A  concise,  practical  mantial,  dealing  with  the 
gross  pathological  changes  to  be  found  at  autopsy. 
The  descriptions  of  the  various  technical  steps  are 
of  practical  value  and  their  observation  would  pre- 
vent the  mutilation  so  often  encountered,  dtie  large- 
ly to  lack  of  training  on  the  part  of  the  operator. 
Many  short  cuts  are  given  and  these  too  should  save 
time  and  energy.  Many  useful  hints  are  scattered 
throughout  the  text.  To  take  advantage  of  these 
wottld  save  many  a  tyro  from  em]:)arrassing  experi- 
ences. The  simplicity  of  the  style  and  the  direct 
handling  of  the  subject  make  it  an  easy  book  to 
study. 

ARTERIOSCLEROSIS  AND 
HYPERTENSION. 

Arteriosclerosis  and  Hypertension.  With  Chapters  on 
Blood  Pressure.  By  Louis  M.  Warfield,  A.  B..  M.  D., 
(Johns  Hopkins),  F.  A.  C.  P.  Formerly  Professor  of 
Clinical  Medicine,  Marquette  University  Niedical  School, 
etc.  Third  Edition.  Illustrated.  St.  Louis  :  C.  \' .  Mosby 
Co.,  1920.    Pp.  xv-265. 

In  no  field  of  medical  endeavor  has  more  work 
been  done  than  in  the  study  of  the  baffling  stibject 
of  hypertension  and  arteriosclerosis.  As  the  author 
says :  "Much  that  has  been  written  on  the  sul)ject  is 
of  little  value."  It  is  yet  a  bit  early  to  determine  just 
how  much  value  there  is  to  anything  that  has  been 
written  on  the  subject.  The  topics  have  been  ap- 
proached from  many  angles  and  much  information 


July  3,  1920.] 


BOOK  REVIEW  S. 


37 


secured,  but  for  the  major  part  we  are  still  very 
much  in  the  dark.  Xone  the  less  we  are  obliged  to 
make  the  most  of  the  material  we  have  at  hand. 
\\'arfield  has  approached  this  complex  subject  with 
great  candor  and  has  only  presented  the  findings 
of  which  he  is  reasonably  sure.  He  has  carefully 
avoided  the  presentation  of  the  many  involved 
theories  which  have  been  the  ground  of  so  much 
serious  controversy  and  has  clung  to  the  pathways  of 
empirical  medicine.  With  fearlessness  he  has  pre- 
sented his  ov.-n  findings  and  these  appear  to  be  ra- 
tional enough.  Where  he  has  lacked  boldness,  he 
has  made  up  in  good  sense.  ]Many  will  disagree 
with  him  but  all  will  respect  the  sincerity  with 
which  he  has  given  his  findings  to  the  medical  pro- 
fession. It  is  a  comfort  to  find  a  book  on  any  sub- 
ject which  is  not  a  rehash  of  all  that  has  gone  be- 
fore on  the  same  subject.  The  technic  of  blood 
pressure  observation  during  anesthesia  at  operation 
is  simple  and  it  seems  as  though  this  method  should 
be  used  more  generally  as  it  is  a  valuable  guide  in 
operative  procedures.  Aside  from  this  as  an  aid  to 
research  work  valuable  data  could  be  obtained. 

MANUAL  OF  AXATOMY. 

Cunningham's  Manual  of  Practical  Anatomy.  Revised 
and  Edited  by  Arthur  Robixsox,  Professor  of  Anatomy 
in  the  University  of  Edinburgh.  Seventh  Edition.  In 
Three  \"olumes.  Illustrated.  New  York :  William  Wood 
&  Co..  1919. 

There  have  been  no  changes  in  this  standard  an- 
atomy since  1914.  Three  impressions  were  taken 
of  the  sixth  edition  which  first  appeared  at  this 
time.  Many  new  changes  and  additions  have 
caused  the  publishers  to  publish  the  book  in  three 
volumes  in  place  of  the  usual  two,  \'olume  I  in- 
includes  the  superior  and  inferior  extremities;  \o\- 
ume  II,  the  thorax  and  abdomen,  and  \'olume  III, 
the  head  and  neck.  As  the  book  stands  today  it  is 
considered  one  of  the  most  valuable  class  room 
dissecting  manuals. 

CHRONIC  DISEASES. 

Originc,  evolution  ct  traitcmcnt  dcs  maladies  clironiqucs 
noncontaqicuscs.  Par  J.  D.wvsz.  Paris :  Librairie 
J.  B.  Balliepe  et  Fils,  1920.    Pp.  vii-130. 

For  many  centuries  the  list  of  incurable  diseases 
was  very  long  and  a  chronic  invalid  was  accepted 
without  question  by  the  family ;  nothing  was  done 
except  to  render  his  bartered  tent  as  impervious  to 
disease  as  possible.  In  fact,  an  invalid  was  sup- 
posed to  exert  a  good  moral  influence  by  his  pa- 
tience in  suffering  and  claim  to  selfsacrifice  on  the 
part  of  relations. 

But  inspired  by  success  learned  men  no  longer  tol- 
erate chronic  maladies,  but  fight  them,  and  among 
the  cheerfid  hopers  of  ultimate  victory  is  Profes- 
sor Danysz,  of  the  Paris  Pasteur  Institute,  whose 
studies  have  led  him  to  the  conclusion  that  all 
chronic  morbid  conditions,  with  their  acute  crises 
and  more  or  less  prolonged  intermissions,  have  an- 
tigens as  origin,  and,  as  determining  cause,  the  state 
of  anaphylactic  immunity  of  the  organism.  Experi- 
ence has  shown  that  antianaphylactic  treatment  has 
incontestable  efficacy  in  all  chronic  maladies,  except 
in  purely  mental  ones,  and  even  these  are  being  ef- 
fectively studied.    Results  laave  been  obtained  by 


nonspecific  antigens,  to  explain  whose  curative  ac- 
tion the  author  and  his  collaborators  have  been 
forced  to  admit  the  direct  and  predominating  in- 
tervention of  the  nervous  centres  on  the  curative 
reactions.  There  is  a  capital  resume,  followed  by 
an  exposition  of  the  general  theory  of  immimity, 
anaphylaxis,  and  antianaphylaxis  leased  on  the  struc- 
ture, properties,  the  functioning  of  the  organism, 
its  structural  units  and  the  functions  of  which  it  is 
composed. 

MEDICAL  EXAMINATION  OF  AVIATORS. 

Guide  pratique  pour  I'examen  medical  dcs  ai'iateurs,  des 
candidats  d  Variation,  et  des  pilotes.  Par  Le  Dr 
Maubl.^xc  et  le  Dr.  Ratie.  medicins  du  centre  d'aviation 
de  Chartres.  Preface  de  M.  le  Dr.  Axdre  Broca,  pro- 
fesseur  agrege  a  la  Faculte  de  Medicine  de  Paris. 
Illustrated.  Paris:  Librarie  J.  B.  Balliere  et  Fils, 
1920.    Pp.  vi-109. 

In  the  beginning  the  airman's  wings  were  pluck 
and  experience.  War  made  urgent  demands :  the 
men  flew  to  fulfil  them,  but  often  came  hurtling  to 
the  earth,  bruised,  dying,  because  of  some  little  fault 
in  their  physical  or  mental  condition. 

The  present  year  has  brought  time  for  a  scien- 
tific examination  of  all  government  aviators,  and 
few  of  them  will  be  properly  grateful  to  Maublanc 
and  Ratie  for  their  splendid  guide,  simply  l^ecause 
much  stress  is  laid  not  on  present  physical  condition 
but  on  past  history.  Yet  to  men  so  highly  placed  as 
examiners,  attention  must  be  given.  The  apparatus 
they  use  admits  of  no  arginnent  on  the  part  of  the 
candidate,  the  wicked  machine  heartlessly  records 
its  findings. 

They  reject  all  who  have  had  bacillosis  long  ago, 
or  recently,  pleurisy,  scarlatina,  articular  rheuma- 
tism, syphilis,  or  malaria,  woiuids  which  have  left 
functional  impotence  if  this  impairs  them  as  pilots, 
.slight  cardiac  lesions  though  there  seem  to  be  per- 
fect compensation  at  the  time  of  examination.  All 
suffering  from  tuberculous  affections,  of  whatever 
degree,  must  be  rejected,  also  the  dyspeptic,  nephritic 
or  enteritic.  "Who  then  can  be  saved?"  ask  the  re- 
jected. W  e  refer  them  to  the  excellent  guide  whose 
writers  declare  as  their  object  the  raising  of  the 
military  status  of  aviators  and  bringing  about  that 
appreciation  by  the  public  now  so  heavily  lacking. 

XOW  IT  CAX  BE  TOLD. 

Xozv  It     Can  Be   Told.    By   Philip  Gibbs.  Illustrated. 
New  York :  Harper  &  Brothers.  Pp.  iii-558. 

During  the  long  anxious  years  of  the  war  we  read 
with  interest  the  dispatches  of  Philip  Gibbs,  corre- 
spondent. Some  of  us,  the  more  or  perhaps  the  less 
fortunate,  who  saw  and  felt  some  of  the  things  he 
was  writing  about,  realized  at  the  time  that  he  was 
telling  the  truth — that  is,  as  much  of  the  truth  as 
cotdd  be  told. 

X'ow  he  has  told  us  the  story  all  over  again.  The 
officers  who  in  the  former  dispatches  were  gallant 
men  now  have  their  stupidity  revealed ;  they  are  no 
less  gallant  in  the  new  picture  but  the  picture  is 
completed.  We  are  told  again  of  the  heroism  of 
raw  recruits,  how  they  stormed  the  trenches,  and 
yet  in  their  hearts  they  had  no  hatred  for  the  much 
advertised  Hun.  He  shows  how  similar  in  appear- 
ance the  captured  boys  were  to  the  boys  who  caiv 
tured  them;  only  by  their  uniforms  could  they  be- 


38  BOOK  1 

told  one  from  the  other.  He  makes  it  seem  as 
though  they  came  from  the  same  common  stock,  that 
they  were  brothers  in  more  than  appearance,  settHng 
the  quarrels  of  short  sighted  rulers  who  followed 
old  traditions  which  had  long  since  become  useless 
except  as  a  means  of  perpetuating  their  own  worth- 
less class.  The  men  tell  us,  in  this  document  of 
Gibbs's,  that  they  did  not  want  to  kill  Germans. 
They  had  no  quarrel  with  them  and  they  didn't  like 
the  work  of  butchery. 

He  shows  how  in  the  actual  combat  the  men  were 
swept  ofif  their  feet  and  the  lust  for  killing  arose  in 
them  in  an  atavistic  fashion.  The  men  harked  back 
to  the  old  barbarities ;  the  old  savage,  sadistic  in- 
stinct came  to  the  fore ;  they  went  back  to  their 
archaic  past,  to  their  embryonal,  infantile  state.  We 
see  how  the  propaganda  of  blood  curdling  tales  of 
cruelty,  tales  from  Belgium  of  children's  hands  cut 
off,  old  men  murdered,  and  women  violated,  sent 
'  the  men  hurrying  to  the  army.  We  now  see  the  un- 
raveling of  the  red  tape  of  the  staff  and  the  suf- 
fering red  dawns  with  the  closing  red  toll.  And 
we  better  understand  the  fear  the  censor  had  in 
not  allowing  the  truth  to  be  told;  a  fear  of  their 
own  people,  not  of  the  enemy,  for  the  enemy  knew. 
In  a  graphic  way  we  are  made  to  realize  by  a  few 
cold  words  how  the  old  professional  army  came  to 
die  and  how  modern  warfare  opened  the  battlefield 
to  the  multitude.  There  could  no  longer  be  a 
group  watching  the  paid  gladiators.  .  .  .  H  there 
/  must  be  war  then  they  must  all  share  in  its  sac- 
rifices. .  .  .  There  would  have  to  be  victims  as 
well  as  victors.  Names  appear,  spelled  in  full,  in- 
itials included,  and  the  owners  are  given  full  credit 
for  their  sins,  both  of  omission  and  of  commission. 
No  one  escapes  in  this  fearless  telling,  not  even  the 
commander  in  chief  of  his  own  army — the  British. 

It  took  courage  to  tell  the  story  and  it  has  great 
value,  for  no  one  can  doubt  the  authenticity  of  an 
accredited  man  like  Gibbs.  He  was  there.  He  saw 
it  and  now  when  we  can  sit  back  in  a  relaxed  frame 
of  mind  we  will  do  well  to  hear  what  he  has  to  tell. 

It  may  be  said  that  we  are  weary  of  war  and 
stories  of  war,  but  we  who  were  through  what  some 
are  pleased  to  call  the  great  adventure,  see  it  in 
another  light.  We  can  more  truly  call  it  the  great 
crime,  or  many  more  harsh  sounding  names. 
It  may  be  that  we  have  had  enough  war.  We  did 
have  a  great  deal  of  it  and  it  was  a  bit  of  a  war — 
but  too  little  has  been  told — too  little  of  the  truth. 
The  books  have  told  us  more  of  the  heroics  and 
less  of  the  cold,  beastly,  mechanical  grind  of  the 
whole  maniacal  business.  Too  little  of  the  dia- 
bolic mess  and  too  nnich  of  the  heroes.  The  more 
we  read  of  true  stories  such  as  this  the  less  war  we 
will  have  to  write  about  in  the  future. 

This  book  will  takes  its  place  with  Zola's  Down- 
fall, Andreyev's  Red  Laugh,  Barbusse's  Under  Fire 
and  Latzka's  Men  in  War. 

Gibbs  is  bitter  in  his  denunciation  of  militaristic 
intervention  in  Russia.  He  states  that  England  and 
France  stood  by  when  the  old  Tzardom  with  which 
they  had  allied  themselves  committed  every  type 
of  cruelty  against  a  helpless  people,  and  when  these 
people  founded  a  new  order,  which  was  more  dan- 
gerous to  the  old  order  than  high  explosives,  they 
attempted  to  crush  their  newly  won  liberties.  He 


EVIEWS.  [New  York 

Medical  Journal. 

tells  how  the  French  mutinied  and  how  the  British 
soldiers  themselves  would  not  go  to  Russia. 

The  beauty  and  truth  of  his  closing  lines  allow 
for  their  repetition.  "Now  let  us  exorcise  our  own 
devils  and  get  back  to  kindness  toward  all  men  of 
good  will.  That  also  is  the  only  way  to  heal  the 
heart  of  the  world  and  our  own  state.  Let  us  seek 
the  beauty  of  life  and  God's  truth  somehow,  re- 
membering the  boys  who  died  too  soon,  and  all  the 
falsity  and  hatred  of  these  past  five  years.  By 
blood  and  passion  there  will  be  no  healing.  We 
have  seen  too  much  blood.  We  want  to  wipe  it  out 
of  our  eyes  and  souls.    Let  us  have  Peace." 

SCIENCE  IN  FICTION. 

The  Golden  Scorpion.  By  Sax  Rohmer.  Illustrated.  New 
York:  Robert  M.  McBride  &  Co.,  1920.  Pp.  v-308. 
The  writers  of  stories  of  mystery  and  crime  in 
1920  do  not  meet  such  responsive  thrills  as  here- 
tofore. The  improbabilities  of  an  earlier  age  are 
probabilized.  Verne  and  Haggard  would  be  certi- 
fied as  sane  by  any  alienist,  and  so  eager  are  writers 
to  show  their  prescience  that  they  despise  the  steady 
radiance  of  accepted  science  and  pen  their  stories 
by  the  as  yet  uncertain  light  of  marvels  to  be 
revealed. 

But,  on  the  whole,  we  are  grateful  to  Sax  Roh- 
mer and  his  kind  for  leading  us  away  for  awhile 
from  those  facts  "which  every  woman — every  man 
should  know,"  and  introducing  us  to  The  Golden 
Scorpion,  whose  real  name  is  Fo-Hi  and  who  is  so 
intimate  with  radium  and  really  scientific  methods 
of  getting  rid  of  enemies.  There  is  a  doctor,  too, 
superhuman  in  his  knowledge  of  poisons,  human  in 
his  knowledge  of  women,  and  triumphant  in  sav- 
ing the  heroine  Miska  from  the  fiendish  Fo-Hi.  We 
are  rather  sorry  when  "there  came  a  flash  of  blind- 
ing light,  an  intense  crackling  sound,  the  crash  of 
broken  glass,  and  a  dense  cloud  of  pungent  fumes 
rose  in  the  heated  air,"  because  that  means  the  story 
is  finished.  "The  complete  and  instantaneous  disin- 
tegration (of  Fo-Hi)  had  taken  place,"  the  mar- 
velous suicide  resulting  from  his  researches. 

THE  ETERNAL  QUESTION. 

Women's  Wild  Oats.  Essays  on  the  Refixing  of  Moral 
Standards.  By  C.  Gasquoine  Hartley.  Author  of  The 
Truth  About  Women,  Motherhood  and  the  Relation- 
ships of  the  Se.res,  etc.  New  York:  Frederick  A. 
Stokes  Company,  1920.    Pp.  vii-227. 

Over  two  thousand  years  ago,  three  young  men  of 
the  Persian  Royal  Guard  were  keeping  watch  one 
night  in  the  King's  antechamber.  There  had  been 
a  banquet  that  night ;  plenty  of  wine  and  beautiful 
women,  and  perhaps  they  found  it  difficult  to  keep 
awake,  so  to  pass  the  time  they  got  up  a  competi- 
tion. They  would  each  write  on  a  piece  of  paper 
that  which  they  esteemed  the  strongest  thing  in  the 
world  and  put  the  slips  under  the  King's  pillow.  In 
the  morning  he  would  find  them,  and,  to  the  wisest 
writer  he  would  be  asked  to  accord  the  award — 
an  award  of  privileges  and  gifts. 

But,  when  they  were  read.  King  Darius  sent  for 
the  royal  staff  and  said  the  young  men  should  de- 
fend their  own  statements  and  those  of  the  Court 
should  decide.  The  first  had  written :  "Wine  is  the 
strongest."    The  second.  "The  King  is  the  strong- 


July  3,  l§2n.] 


BOOK  REVIEWS. 


39 


est."  The  third,  "Women  are  the  strongest,  but, 
above  all  things.  Truth  beareth  away  the  victory." 

Each  statement  was  eloquently  defended,"  and 
the  King  and  the  princes  looked  one  on  another 
perhaps  approvingly)  for  women  had  a  good  advo- 
cate, but  suddenly  the  defender  boldly  said,  "Wine, 
is  wicked,  the  King  is  wicked,  women  are  wicked. 

as  for  the  Truth,  it  endureth  and  is  al- 
Avays  strong:  it  liveth  and  conquereth  for  ever- 
more." A  bold  statement,  when  it  was  not  wise  to 
displease  a  King  and  pretty  ladies  were  influential 
at  court  and  delighted  tlien.  as  now.  to  bewitch  men 
with  their  "tinkling  ornaments,  chains  and  brace- 
lets and  ornaments,  changeable  suits  of  apparel, 
mantles  and  wimples  and  crisping  pins,"  and  the 
Piccadilly  and  Broadway  ladies  of  those  days  lurked 
in  dusky  corners  to  beguile  young  men  at  night. 
There  was  a  moment's  silence,  then  a  mighty  shout 
went  up  from  all  present.  The  speaker  had  a  King- 
ly kiss  and  cousinship  bestowed,  and  far  more — 
politically — than  he  had  dared  to  hope. 

Gasquoine  Hartley  is  one  of  a  large  throng  who 
are  earnestly  trying  to  write  the  wisest  thing.  She 
has  studied  women  all  through  the  ages,  and,  while 
admitting  that  education,  suffrage,  larger  views,  and 
war  times  have  changed  woman's  position  and  rele- 
gated many  oldfashioned  views  to  the  kmiber  room, 
her  description^  and  opinions  as  to  moral  worth 
might  be  embodied  among  those  of  prophets  and 
reformers  thousands  of  years  ago. 

But  she  frankly  admits  that  old  world  cures  will 
not  cure,  and  has  plenty  of  sympathy  for  the  new 
girl.  She  deals  ably  with  the  question  of  woman's 
fitness  for  work,  for  her  home  duties,  her  attitude 
toward  marriage  and  lover,  the  unmarried  mother 
and  the  love  child,  divorce,  and  platonic  attach- 
ments. The  young  guardsman  who  won  the  royal 
kiss  also  spoke  frankly  concerning  the  ways  of 
women.  What  does  the  author  suggest?  It  is  hard- 
ly fair  to  pick  out  sentences  without  giving  the 
context,  but  a  few  gleanings  may  draw  more  atten- 
tion on  the  part  of  readers  to  a  closer  study  of  the 
whole. 

"There  are  many  without  the  gifts  that  make 
for  successful  parenthood  or  happy  permanent  mar- 
riage. I  would  recognize  this  frankly  and  let  those 
who  do  not  desire  marriage  be  openly  permitted  to 
live  together  in  honorable  temporary  union  .  .  . 
those  who  do  not  want  children  and.  not  wishing 
the  bondage  of  continuous  companionship,  desire 
to  pass  their  lives  in  liberty." 

"The  essential  fact  in  every  relationship  of  the 
sexes  is  the  woman's  power  over  the  man,  and  it  is 
the  misuse  of  that  power  which  leads  to  all  prosti- 
tution. For  the  lust,  men  are  held  responsible : 
the  chaste  character  of  women  held  up  in  contrast ! 
This  view  gives  women  all  the  pleasing  satisfac- 
tion of  a  virtue  that  is  realized  without  effort  and 
explains  why  they  object  to  repressive  measures. 

If  we  inquire  into  this  question  of  men's 
lust,  it  is  obvious  that  not  they,  but  women,  are 
the  more  responsible.  Man's  lust  is  a  necessity 
to  her  very  existence.  She  is  the  controller  of  the 
assault." 

The  foolishness  of  allowing  the  fallen  girls  to 
bring  up  their  babies,  and  of  continuing  in  un- 


happy wedlock  all  have  stormy  comments.  Again 
we  ask  with  her.  "What  is  the  cure?"  but,  unlike 
her,  we  shout  "Truth  is  the  strongest."  People 
do  not  abuse  the  moribund.  The  still  active,  open 
hostility  to  vice  exposure  or  to  changing  customs 
sliows  vigilant  interest,  an  undying  interest,  for.  as 
far  back  as  written  pages  tell  us.  zealous  men  have 
found  that  women  are  decadent,  rapidly  going  to 
the  devil,  enemies  of  men,  and  in  no  age  have  been 
as  bad  as  the  present  (their  own  day).  A  sorry 
lookout  for  the  men.  seeing  that  woman  stands  at 
the  very  gate  of  Life  and  all  men  must  humbly 
enter  by  her  permission. 

Meanwhile  sex  literature  is  flooding  the  mar- 
ket. It  is  a  case  of  "secrets  known  to  all,"  but,  to 
our  mind,  the  life,  not  the  writing,  of  one  good, 
open  minded  loving  woman  deters  more  girls  from 
evil  than  any  amoimt  of  books.  Xo  antivice  remedy 
will  be  curative  when  administered  in  the  septic, 
battered  spoon  of  pessimism.  Good  is  stronger  than 
evil.  W'ine  is  strong,  the  King  is  strong,  women  are 
strongest,  but,  above  all  things.  Truth  beareth  away 
the  victory." 


New  Publications  Received. 

[Wc  publish  full  lists  of  books  received,  but  zve  acknowl- 
edge no  obligation  to  rei'iew  than  all.  Neiyrtheless,  so 
far  as  space  permits,  we  review  those  in  which  we  think 
our  readers  are  likely  to  be  interested.] 

THE  LIGHT  HEART.     Bv  MaURICE  HEWLETT.     Xew  \*brk : 

Henry  Holt  &  Co.,  1920.    Pp.  xii-188. 

THE  PROBLEM  OF  NERVOUS  BREAKDOWN.     By  EdWIN  LaNXE- 

LOT  Ash,  M.  D.  New  York :  The  Macmillan  Company. 
1920.    Pp.  xii-299. 

THE   JOHNS    HOPKINS    HOSPITAL   REPORTS.      \'olume  XIX. 

Illustrated.  Baltimore :  The  Johns  Hopkins  Press,  1920. 
Pp.  i-358. 

BACKW.^TERS    OF    LETHE.      By    G.    A.    H.    BaRTON.    M.  D.. 

Anesthetist  to  the  Hampstead  General  and  Royal  X'ational 
Orthopedic  Hospital,  etc.  Illustrated.  London :  H.  K. 
Lewis  &  Co.,  1920.    Pp.  v-151. 

OUR  GREAT   W.\R  AND  THE   WAR  OF   THE   ANCIENT  GREEKS. 

By  Gilbert  Murray,  LL.D..  D.Litt.,  F.B..\..  Regius  Pro- 
fessor of  Greek  in  the  University  of  Oxford.  Xew  York : 
Thomas  Seltzer,  1920.    Pp.  v-85. 

BY-P.\THS  IN  HEBRAIC  BOOKLAND.     By  ISR.\EL  AbR.\HAMS. 

D.D.,  M.A.,  Author  of  Jezvish  Life  in  the  Middle  Ages. 
Chapters  on  Jewish  Literature,  etc.  Illustrated.  Philadel- 
phia: The  Jewish  Publication  Society  of  America,  1920. 
Pp.  v-371. 

ADULT  AND  CHILD — HOW  TO  HELP,  HOW  NOT  TO  HINDER  A 
STUDY    IN    DEVELOP.MENT    BY    COMR.\DESHIP.      By    JaMES  L. 

Hughes,  LL.D.,  for  forty  years  Inspector  of  Schools  in 
Toronto.  Author  of  Mistakes  in  Teaching,  Hoiv  to  Se- 
cure and  Retain  Attention,  etc.  Syracuse:  C.  W.  Bardeen. 
Pp.  ix-187. 

HEREDITY  AND  ENVIRONMENT  IN  THE  DEVELOPMENT  OF  MEN. 

By  Edwin  Grant  Conklix.  Professor  of  Biologj'  in  Prince- 
ton University.  Second  Printing  of  Revised  Third  Edition. 
Illustrated.  Princeton,  X'.  J. :  Princeton  University  Press. 
London:  Humphrey  Milford  (Oxford  University  Press), 
1920.    Pp.  xv-361. 

THE  HUMAN  COSTS  OF  THE  WAR.  By  Ho.MER  FoLKS,  Or- 
ganizer and  Director  of  the  Department  of  Civil  .\fFairs 
of  the  American  Red  Cross  in  France  and  later  Special 
Commissioner  to  Southeastern  Europe.  Illustrated  with 
Photographs  by  Lewis  W.  Hine.  American  Red  Cross 
Special  Survey  Mission.  New  York  and  London :  Har- 
per &  Brothers.    Pp.  i-326. 


Practical  Therapeutics  and  Preventive  Medicine 

A  Compendium  of  Treatment  and  Prophylaxis,  Original  and  Adapted 


Surgical  Intervention  in  Severe  Forms  of  Dys- 
entery.— ^Jacques  Leveuf  and  Georges  Heuyer 
{Paris  medical,  April  10,  1920)  state  that  in  acute 
gangrenous  dysentery  associated  with  grave  symp- 
toms, immediate  rest  for  the  ulcerated  intestine  by 
surgical  means  is  indicated.  Diverting  the  course 
of  the  fecal  flow  also  permits  of  intensive  feeding 
and  of  bringing  about  direct  remedial  action  on  the 
colonic  lesions  through  appropriate  lavage.  A  broad 
cecostomy  opening,  readily  made  and  constituting  a 
harmless  operation,  answers  the  requirements  and 
yields  highly  gratifying  results.  In  chronic  cachec- 
tic dysentery — essentially  a  protracted  gangrenous 
dysentery — the  same  indications  obtain;  the  main 
aim  should,  however,  be  to  prevent  such  a  condition 
by  insisting  upon  early  operation.  In  cases  of  dys- 
entery distinctly  improved  by  ordinary  measures 
but  not  cured  within  a  reasonable  time,  appendicos- 
tomy  followed  by  intestinal  lavage  is  a  useful  adju- 
vant to  the  medical  treatment.  Cecostomy  should 
be  considered  an  emergency  operation,  having  pre- 
cise indications  which  hardly  permit  of  temporizing. 
Appendicostomy  brings  to  medical  treatment  the 
added  assistance  of  the  direct  action  of  lavage  on 
the  proximal  portion  of  the  colon. 

Treatment  of  Acute  Intestinal  Intoxication 
with  and  without  Acidosis. — J.  S.  Weitzel  {Vir- 
ginia Medical  Monthly,  March,  1920)  states  that  in 
the  acute  intestinal  intoxication  of  young  children, 
prevalent  during  the  summer  and  early  fall  months, 
an  initial  dose  of  two  to  four  drams  of  castor  oil 
should  be  given  unless  there  is  persistent  vomiting, 
in  which  case  sodium  bicarbonate  should  be  begun 
at  once  and  given  in  sufficient  doses  to  keep  the 
urine  alkaline.  If,  however,  the  bowels  have  been 
very  active  and  only  serum  and  mucus  are  being 
evacuated,  the  initial  cathartic  is  unnecessary.  If 
vomiting  continues  after  administration  of  sodium 
bicarbonate,  one  or  more  stomach  washings  with 
bicarbonate  solution  will  usually  allay  it.  A  colonic 
irrigation  of  warm  saline  solution  once  or  twice  a 
day  proves  highly  beneficial  in  these  cases.  But  lit- 
tle pressure  should  be  used,  and  the  tube  should  be 
inserted  for  a  distance  of  four  or  five  inches.  Bis- 
muth subcarbonate,  ten  grains  every  three  hours  in 
children  under  six  months  of  age  and  every  two 
hours  after  six  months,  until  some  astringent  action 
is  noticed,  is  occasionally  beneficial.  Paregoric 
should  be  used  only  to  relieve  tenesmus  or  when 
large  watery  stools  persist,  and  should  not  be  given 
in  doses  large  enough  to  produce  stupor.  In  cases 
with  severe  prostration,  brandy,  caffeine  sodioben- 
zoate,  and  camphor  in  oil  are  satisfactory  stimu- 
lants. When  acidosis  arises,  sodium  bicarbonate 
must  be  given  promptly,  either  by  mouth,  subcu- 
taneously,  or  intravenously.  By  mouth,  fifteen  to 
thirty  grains  every  two  hours  should  be  given  until 
the  urine  is  alkaline,  and  then  enough  to  keep  it 
alkaline.  Subcutaneously  a  two  per  cent,  solution, 
and  intravenously  a  four  per  cent,  solution,  are 


used.  Boiling  of  the  solution  during  its  prepara- 
tion must  be  avoided.  The  intravenous  method  in 
infants  with  an  open  fontanel  is  very  satisfactory, 
and  is  simplified  by  use  of  the  Goldbloom  needle 
for  injection  into  the  longitudinal  sinus.  In  severe 
forms  in  which  the  intake  of  water  is  greatly  re- 
duced and  the  tissues  become  relatively  dry  owing 
to  the  frequent  watery  stools,  intraperitoneal  ad- 
ministration of  normal  saline  solution  is  the  most 
efficient  corrective  procedure.  A  spinal  puncture 
needle  is  inserted  through  the  abdominal  wall  in  the 
linea  alba,  one  half  inch  below  the  umbilicus,  and 
the  warm  saline  allowed  to  flow  in  by  gravity  to  the 
amount  of  seventy-five  to  150  mils,  according  to  the 
size  of  the  child.  The  procedure  is  repeated  daily 
until  the  tissues  lose  their  dry,  parched  appearance 
and  the  doughy  consistency  of  the  abdomen  dis- 
appears. After  the  initial  rest  of  the  stomach,  pro- 
tein milk  should  be  used  to  feed  the  child. 

Late  Results  of  Appendectomy  for  Chronic 
Appendicitis. — Enriquez  (Bulletin  de  I' Academic 
de  medecinc,  March  16,  1920)  asserts  that  in  over 
one  fourth  of  all  cases,  appendectomy  for  chronic 
appendicitis  fails  to  benefit  the  patient.  Surgeons 
have  often  found,  in  addition  to  appendiceal  dis- 
ease, such  conditions  as  adliesive  pericolitis,  more  or 
less  pronounced  omental  inflammation,  cecum  mo- 
bile, and  kink  of  the  distal  loop  of  the  ileum.  Often 
constipation  is  more  obstinate,  painful  attacks  more 
frequent,  and  nausea  a  more  marked  feature,  than 
before  the  operation.  In  one  group  of  cases  there 
is  pronounced  impairment  of  the  general  condition, 
with  anemia  and  slight  vesperal  fever,  ultimately 
ascribed,  as  a  rule,  to  a  latent  pulmonary  or  lym- 
phatic tuberculous  process.  Spontaneous  pain,  or 
pain  induced  by  certain  postures,  radiates  toward  the 
umbilicus,  liver,  or  right  lower  extremity.  Tender- 
ness is  greatest  between  the  operative  scar  and  the 
umbilicus,  and  palpation  may  give  the  impression  of 
rigidity,  a  cord,  or  even  a  tumor  in  this  region.  In 
a  second  group  of  cases  fever  is  wanting,  but  diges- 
tive symptoms  are  more  marked,  viz.,  late  pains 
and  eructations,  and  constipation  interrupted  by  mu- 
comembranous  diarrhea,  occurring  in  attacks  pre- 
ceded by  severe  headache.  To  forestall  such  at- 
tacks the  patients  reduce  their  diet  and  ultimately 
pass  into  inanition,  with  the  accompanying  asthenia, 
depression  of  spirits,  and  hypochondria.  General 
visceroptosis  is  the  rule  in  these  cases,  with  gurgling 
in  the  cecum  and  painful  spasm  of  the  descending 
colon.  Radioscopy  yields  definite  findings  in  these 
two  groups  of  cases.  In  the  first,  the  stomach  is 
tonic  or  hypertonic,  and  its  axis  no  longer  vertical ; 
the  hepatic  flexure  is  drawn  toward  the  midline ;  the 
ascending  and  transverse  colons  are  in  apposition ; 
the  lower  portion  of  the  cecum  fails  to  ascend  in 
the  horizontal  posture,  and  there  is  delayed  evacua- 
tion of  the  ileum.  In  the  second,  the  stomach  is 
hypotonic  or  atonic  ;  there  is  coloptosis  ;  the  cecum  is 
very  movable,  and  the  Lane  kink  is  present.  In 


July  3,  1920.] 


PRACTICAL  THERAPEUTICS  AND  PREVENTIVE  MEDICINE. 


41 


the  first  group  the  disturbance  is  mainly  inflamma- 
tory; in  the  second,  mainly  mechanical.  In  both 
instances  the  blood  shows  a  leucocytosis  of  10,000  to 
14,000;  the  large  mononuclears  are  increased  to  ten 
to  fourteen  per  cent.,  and  the  eosinophiles,  to  three 
to  eight  per  cent.  The  main  difficulty  is  that  hereto- 
fore chronic  inflammation  of  the  appendix  has  been 
regarded  as  constituting  practically  the  whole  of 
the  pathology  of  the  right  iliac  fossa.  The  remedy 
is  routine  x  ray  examination,  which  will  reveal  the 
various  coexisting  lesions  requiring  special  surgical 
procedures  if  recovery  is  to  be  obtained.  The  physi- 
cian should  himself  be  present  during  the  radioscopy, 
and  not  rely  on  plates  alone.  Examination  in  both 
the  standing  and  the  recumbent  postures  are  essen- 
tial. In  operating  the  surgeon  should  make  inci- 
sions sufficiently  long  to  permit  of  the  necessary 
exploration  of  the  ileocecal  region,  cecum,  hepatic 
flexure,  and  omentum.  Where  the  symptoms  sug- 
gest a  gallbladder,  pyloric,  or  duodenal  lesion,  the 
McBurney  incision  may  be  advantageously  replaced 
by  Walther's  median  incision,  or  better,  the  trans- 
verse supraumbilical  incision  employed  by  Gosset. 

Enterostomy  for  Postoperative  Intestinal  Ob- 
struction. —  A.  S.  Brinkley  {Virginia  Medical 
Monthly,  February,  1920)  emphasizes  the  harm 
done  by  extensive  operative  manipulations  in  these 
cases  and  recommends,  instead,  enterostomy  through 
a  small  incision  under  local  anesthesia.  Morphine 
is  given  hypodermically  half  an  hour  before  the 
operation,  a  McBurney  incision  usually  made,  and 
one  half  of  one  per  cent,  novocaine  solution  used 
to  infiltrate  the  tissues.  After  thorough  infiltration 
of  the  preperitoneal  fascia  the  peritoneimi  is  in- 
cised and  a  quick  exploration  carried  out  with  the 
middle  and  forefingers  to  locate  if  possible  the 
point  of  obstruction.  Then  a  loop  of  intestine  near- 
est this  point  on  the  proximal  side  is  brought  up 
and  an  enterostomy  done  on  the  principle  of  Cofifey, 
viz.,  of  forming  a  valve  of  the  intestinal  mucosa. 
After  packing  around  the  loop  with  gauze  mois- 
tened in  saline  solution,  an  incision  about  two 
inches  long  is  made  with  a  sharp  knife  down  to  the 
mucosa.  A  purse  string  suture  of  linen  is  placed  at 
one  end  and'  the  mucosa  within  the  grasp  of  this 
suture  punctured.  A  soft  rubber  catheter  is  quickly 
inserted  through  the  puncture,  the  purse  string  tied 
snugly,  an  end  of  the  suture  threaded  in  a  sharp 
needle,  and  the  catheter  transfixed  and  held  in 
place.  The  portion  of  the  catheter  over  the  incision 
is  then  buried  'with  a  right  angled  suture.  The 
bowel  is  sponged  off  with  saline  sheets  and  returned 
to  the  abdomen,  and  the  wound  closed  with  inter- 
rupted through  and  through  silkworm  gut  sutures. 
The  catheter  stays  in  position  at  least  five  or  six 
days,  and  when  it  is  removed  there  is  little  or  no 
leakage  of  fecal  contents ;  the  mucous  membrane  is 
thin,  pours  out  but  little  plastic  exudate,  acts  readily 
as  a  valve,  and  tends  to  close  the  opening.  Gastric 
lavage  with  soda  solution  is  ordered  every  four  to 
six  hours  until  no  longer  indicated.  Saline  solution 
with  glucose  and  soda  is  given  by  rectum  every  four 
hours.  Hypodermoclysis  is  also  practised  and  caf- 
feine sodiobenzoate  or  digalen  given  if  the  heart 
action  is  not  good.  The  catheter  is  connected  with 
a  longer  tube  and  the  drainage  collected  in  a  bottle 


tied  to  the  bed  rail.  Every  two  or  three  hours  the 
catheter  is  disconnected  from  the  longer  tubing  and 
about  one  ounce  of  warm  water  is  injected  into  the 
bowel,  to  keep  the  catheter  open.  AH  feeding  is 
withheld  for  at  least  forty-eight  hours,  then  liquid 
nourishment  given  every  two  hours  for  the  next 
five  or  six  days.  Mineral  oil,  one  ounce  three  times 
a  day,  is  started  on  the  fifth  or  sixth  day,  and 
enemas  given  according  to  indications.  The  cathe- 
ter could  usually  be  removed  in  five  to  seven  days, 
but  the  author  leaves  it  in  for  ten  days.  Three 
cases  of  postoperative  intestinal  obstruction  dealt 
with  by  this  method  are  reported.  All  the  patients 
recovered  and  left  the  hospital  in  from  three  to  six 
weeks  after  the  operation.  One  of  the  patients  was 
a  woman  seventy  years  of  age. 

A  New  Vehicle  for  Emetine  Bismuthos  Iodide. 

- — T.  J.  G.  Mayer  {Journal  of  Tropical  Medicine 
and  Hygiene,  May  1,  1920)  states  that  he  has 
found  a  new  vehicle  for  this  compound  which  will 
pass  through  the  stomach  unchanged  and  be  di- 
gested by  the  intestinal  juices.  The  drug  is  rubbed 
up  with  sixteen  parts  of  mutton  fat,  the  mass 
moulded  into  rounded  pills  weighing  about  seven 
grains,  and  each  pill  covered  with  a  layer  of  mut- 
ton fat,  applied  with  a  paint  brush.  The  mutton  fat 
being  solid  at  body  temperature,  it  is  not  digested 
until  it  is  too  far  beyond  the  pyloric  orifice  to  be 
regurgitated  and  cause  vomiting  or  even  nausea. 
Pills  containing  one  and  a  half  grains  of  the  drug 
and  about  seven  and  a  half  grains  of  mutton  fat 
are  about  as  large  as  may  be  conveniently  swal- 
lowed. Two  were  given  each  night  for  twelve  con- 
secutive nights.  The  pills  were  kept  in  the  ice  chest 
but  the  addition  of  thymol  might  serve  instead  as 
preservative.  That  the  emetine  bismuthos  iodide 
was  altered  by  the  intestinal  juices  was  shown  by 
the  discoloration  of  the  feces  and  the  cure  of  the 
dysentery. 

Kaolin  as  a  Substitute  for  Bismuth  Subnitrate. 

— Hayem  {Bulletin  de  I' Academic  dc  medecinc, 
April  13,  1920)  states  that  while  bismuth  subnitrate 
taken  on  an  empty  stomach  in  the  morning  in  a 
single  large  dose  of  twenty  grams  is  the  remedy  par 
excellence  for  gastric  pain  of  any  variety,  and  is  free 
from  the  risk  of  alkalinophagia  which  attends  the 
use  of  sodium  bicarbonate,  a  salt  of  good  quality  is 
now  hard  to  obtain,  and  the  price  of  bismuth  salts 
has  so  increased  as  to  render  them  unavailable  to 
a  large  proportion  of  patients.  In  1915  he  tried 
kaolin  as  substitute  in  a  case  of  gastric  ulcer, 
and  found  it  so  satisfactory  that  he  has  more  re- 
cently been  using  it  in  all  the  varieties  of  cases  in 
which  the  bismuth  salt  is  generally  given.  The 
kaolin  as  administered  is  an  impalpable  powder  con- 
sisting of  silica,  alumina,  and  the  oxides  of  iron 
and  magnesium.  It  is  practically  insoluble  in  water 
and  the  organic  fluids.  Well  washed  kaolin  is  al- 
most tasteless  and  may  be  given  with  water  like 
bismuth.  The  same  dose  is  used.  As  kaolin  is 
somewhat  lighter,  at  least  a  half  hour  should  be 
allowed  to  elapse  after  the  dose  before  breakfast 
is  taken.  To  provide  a  pleasant  flavor,  one  half 
drop  of  oil  of  anise  may  be  mixed  in  each  twenty 
gram  powder  of  kaolin ;  or,  one  third  drop  of  oil 


42 


PRACTICAL  THERAPEUTICS  AND  PREVENTIVE  MEDICINE.  [New  York 

Medical  Journal. 


of  peppermint  may  be  used  instead.  Like  bismuth 
subnitrate,  kaolin  acts  as  a  disinfectant  and  deo- 
dorant to  the  stools ;  in  fact,  it  is  even  preferable 
to  bismuth  in  its  effects  on  the  bowel,  tending  to 
allay  intestinal  disturbances  and  regularize  intestinal 
action.  It  should  not  be  looked  upon  as  a  com- 
plete substitute  for  bismuth  subnitrate,  as  its  effects 
are  less  regular  and  sustained.  It  is,  however,  reme- 
dially  sufficient  in  many  cases.  Internal  use  of 
kaolin  has  already  been  recommended  by  others  in 
Asiatic  cholera  and  chronic  diarrhea,  but  the  writer 
claims  priority  in  pointing  out  its  property  of  re- 
lieving pain,  as  well  as  of  acting  as  disinfectant,  in 
gastroenteropathic  patients. 

Gastric  Secretions  in  Neurocirculatory  Asthe- 
nia.— John  H.  Musser  (American  Journal  of  the 
Medical  Sciences,  May,  1920)  says  that  in  patients 
suffering  with  neurocirculatory  asthenia  there  is  a 
very  definite  increase  in  the  total  acidity  and  free 
hydrochloric  acid  as  compared  with  controls.  These 
figures  do  not  represent  abnormal  hyperacidity,  but 
they  do  show  that  almost  uniformly  soldiers  suffer- 
ing from  neurocirculatory  asthenia  as  contrasted 
with  apparently  normal  soldiers,  both  eating  the 
same  food,  under  identical  routine  and  under  the 
same  conditions  of  living,  show  a  higher  gastric 
acidity.  This  is  a  diagnostic  point  which  may  be 
of  value  in  differentiating  the  disorder  in  questiona- 
ble cases.  It  surely  seems  to  add  further  evidence 
to  that  already  accumulated  that  these  soldiers  are 
suffering  from  a  neurosis  with  which  is  probably 
associated  a  hyperirritable  vagus. 

Percussion  in  the  Detection  of  Tender  Points 
in  the  Abdomen. — G.  Hayem  (Bulletin  de  I'Aca- 
demie  de  medecine,  February  24,  1920)  emphasizes 
the  necessity  of  establishing  a  clear  clinical  distinc- 
tion between  pain  and  tenderness  in  abdominal  dis- 
orders. Induced  pain  is  a  better  term  tlian  pain 
upon  pressure,  for  tenderness  may  be  elicited  by 
means  other  than  pressure.  The  author  uses  special 
percussion  hammers  with  gauges  showing  the  force 
of  each  blow  delivered,  from  fifty  up  to  1,000 
grams.  When  the  customary  tender  points  are 
tapped  with  this  hammer,  patients  with  abdominal 
disorders  are  found  very  sensitive  to  the  procedure. 
Sometimes  even  very  light  percussion  will  bring  out 
tenderness  at  points  previously  found  insensitive  to 
firm  pressure ;  this  occurs  especially  in  cases  in 
which  the  abdominal  muscles  are  contracted.  In 
gastropathic  patients  the  tender  points  are  nearly 
always  the  same.  One  is  situated  on  the  linea  alba, 
somewhat  nearer  to  the  xiphoid  than  to  the  umbili- 
cus. One  or  two  other  sensitive  points  along  the 
linea  alba  are  not  infrequent,  and  such  points  should 
also  be  examined  for  both  to  the  right  and  the  left 
of  this  line.  Sensitive  points  can  often  be  detected 
along  the  right  costal  margin,  but  are  exceptional 
on  the  left  side.  In  many  patients  apparently  free 
of  intestinal  disorder,  and  even  oftener  in  those  ac- 
tually suffering  from  such  disorder,  percussion  over 
the  colon  is  more  or  less  painful,  especially  over 
the  cecum,  transverse  colon,  and  sigmoid.  Tender- 
ness to  percussion  or  pressure  is  sometimes  of  neu- 
rotic nature,  and  may  relate  to  a  dermatalgia  or  neu- 
ralgia— with  or  without  central  neurosis.    It  may 


also  be  of  muscular  origin.  Generally,  however,  it 
results  from  organic  disturbance.  Most  recent  au- 
thors ascribe  it  to  sensitiveness  of  the  abdominal 
nerve  plexuses,  but  it  is  actually  difficult  to  exert 
effective  pressure  on  these  plexuses,  and  under  ordi- 
nary circumstances,  especially  when  percussion  is 
used,  the  pain  induced  can  only  be  visceral  in  its 
location.  At  the  point  of  election  above  the  umbili- 
cus the  tender  point  may  be  situated  in  the  peri- 
toneum, the  liver,  or  the  stomach  wall  at  the  lesser 
curvature.  Aside  from  ulcer  and  cancer  cases,  the 
ordinary  pain  of  dyspeptics  is  probably  in  most  in- 
stances localized  in  the  liver,  at  least,  pain  on  per- 
cussion is  elicited  nearly  always  over  the  portion  of 
the  liver  covering  the  upper  portion  of  the  costo- 
umbilical  triangle.  Since  tender  points  are  often 
found  simultaneously  along  the  right  costal  margin 
and  along  the  course  of  the  large  bowel,  it  seems 
justifiable  to  conclude  that  in  chronic  gastric  affec- 
tions remote  reaction  upon  the  liver  and  bowel  is 
a  frequent  accompaniment. 

Results  of  Operations  for  Chronic  Appendicitis. 

— Charles  L.  Gibson  (American  Journal  of  the 
Medical  Sciences,  May,  1920)  recommends  the  fol- 
lowing in  order  to  avoid  disappointing  results,  bas- 
ing the  suggestions  on  a  study  of  555  cases :  1',  A 
comprehensive  and  detailed  history.  2.  A  complete 
and  thorough  physical  examination,  including  all  re- 
finements of  diagnosis.  3.  Exercise  caution  in  un- 
dertaking operations  on  women  as  compared  to 
men.  4.  Exercise  caution,  particularly  in  the  more 
mature  patients,  particularly  women ;  in  this  class 
other  lesions  may  coexist  or  may  be  mistaken  for 
appendicitis.  5.  Avoid  the  neurasthenics  of  any 
age  or  sex.  6.  Exercise  particular  restraint  when 
there  is  no  clear  and  reliable  history  of  well  de- 
fined attacks,  particularly  of  localized  pain  accom- 
panied by  nausea  and  vomiting.  7.  Make  a  good 
sized  incision,  and,  even  if  a  frankly  pathological 
appendix  is  found,  look  for  other  possible  lesions. 
8.  If  no  obviously  pathological  appendix  is  found, 
do  not  cease  looking  for  other  lesions  until  every 
other  possibility  has  been  exhausted. 

The  Calorie  as  a  Unit  in  Figuring  Milk  Modifi- 
cations.— Tracy  Jackson  Putnam  (Boston  Medical 
and  Surgical  Journal,  January  29,  1920)  asserts 
that  the  method  of  calculating  milk  modifications 
according  to  the  absolute  caloric  values  of  the  re- 
spective food  elements  is  as  rational  as  the  present 
methods  of  calculation  by  percentage  composition 
and  volume,  or  by  total  caloric  value.  The  use  of 
the  calorie  as  a  unit  in  expressing  the  composition 
of  milks  is  of  advantage  in  that  all  food  elements 
are  reduced  to  a  common  standard.  Such  a  view 
of  infant's  diet,  he  thinks,  might  lead  to  a  clearer 
comprehension  of  the  subect  by  some  practitioners. 
It  would  allow  of  easy  manipulation  of  the  fluid 
volume  apart  from  the  food  value  of  various  mix- 
tures, and  might  lead  to  the  accumulation  of  more 
data  concerning  the  effects  of  alterations  in  fluid 
volume,  and  would  facilitate  the  extension  of  the 
calculation  of  the  diet  into  late  infancy  v/hen  desira- 
ble. He  believes  that  the  calculation  of  modifica- 
tions would  be  simpler  in  many  ways,  and  more 
easily  understood,  than  many  of  the  present  systems. 


Miscellany  from  Home  and  Foreign  Journals 


Acidosis  in  Acute  Abdominal  Disorders. — Al. 

Lablee  {  Bulletin  dc  l Academic  dc  medecinc.  April 
6,  1920}  maintains  that  acidosis  is  a  condition  of 
Ijroad  clinical  interest  and  value  and  should  be  sys- 
tematically investigated  in  all  patients,  like  albu- 
minuria and  glycosuria.  He  is  in  the  habit  of  ap- 
plying the  Gerhardt,  Legal,  and  Lisben  tests  for 
this  purpose.  While  relatively  uncommon  in  the 
major  acute  infections,  acidosis  is  frequently  pres- 
ent in  acute  inflammations  of  the  abdominal  organs, 
e.  g.,  in  appendicitis,  cholecystitis,  salpingitis,  etc. 
In  appendicitis  of  intermediate  severity  or  with 
peritonitis  it  is  present  in  a  majority  of  cases  during 
the  acute  stage,  disappearing  after  a  few  days  but 
recurring  if  a  relapse  occurs.  It  is  particularlv 
marked  in  some  cases  without  very  high  tempera- 
ture but  with  probable  involvement  of  the  liver. 
The  same  condition  appears  in  salpingooophoritis 
with  pelvic  peritonitis,  and  especially  in  cholecystitis 
and  pericholecystitis.  Fasting,  operative  trauma, 
and  anesthesia  are  not  important  factors  in  the 
acidosis  in  such  cases.  Its  main  cause  is  functional 
disturbance  of  the  liver  secondary  to  the  infection. 
Evidences  of  hepatic  insufficiency  generally  coexist 
with  the  acidosis.  Generally  there  is  an  intense 
urol)ilinuria,  which  dwindles  and  disappears  along 
with  the  diaceturia.  \\'ith  H.  Bith,  Labbe  found 
ammoniuria  and  aminoaciduria  in  cases  of  appen- 
dicitis, even  in  the  presence  of  slight  acidosis.  In 
a  case  of  abdominal  infection  during  pregnancy  and 
in  one  of  fatal  acute  hepatic  insufficiency  in  a  preg- 
nant woman,  he  found  in  conjunction  with  positive 
acidosis  tests,  a  marked  aminoaciduria  and  all  evi- 
dences of  insufficient  proteolytic  activity. 

Chronic  Digestive  Disturbances  in  Gas  Poison- 
ing Cases. — Maurice  Loeper  (  Bulletin  dc  l Aca- 
demic dc  medecinc,  March  2,  1920)  states  that 
poisoning  with  chlorine  or  mustard  gas  causes 
chronic  digestive  disturbances  oftener  than  poison- 
ing by  pallete  or  benzyl  bromide.  Such  dis- 
turbances are  met  with  in  about  six  per 
cent,  of  the  chlorine  and  mustard  gas  cases. 
The  flatulent  type  of  disturbance  is  characterized 
by  anorexia,  gas  accimiulation,  discomfort  soon 
after  taking  food,  and  aerophagia;  the  painful  type, 
by  late  pains  and  symptoms  generally  suggestive  of 
pyloric  disease.  The  chief  pathological  disorder 
produced  is  probably  a  pyloritis.  There  is  often 
salivation,  nausea,  and  vomiting.  Either  hypo- 
chlorhydria  or  hyperclilorhydria  may  be  present, 
the  former  due  apparently  to  deep  initial  involve- 
ment, with  mucous  atrophy,  and  the  latter  to  more 
superficial  disturbances,  with  secretory  functional 
reaction.  That  the  condition  is  a  gastritis  and  not  a 
simple  dyspepsia  is  confirmed  by  cytological  exam- 
ination of  the  stomach  contents.  In  one  form,  such 
examination  reveals  a  marked  desquamative  gas- 
tritis ;  in  the  other,  the  presence  of  large  numbers 
of  polynuclear  leucocytes  or  lymphocytes,  indicat- 
ing a  persistent  infection  of  the  mucous  membrane. 
The  epitheliel  desquamation  often  coexists  with  in- 
creased gastric  acidity ;  the  diapedesis,  with  lowered 
acidity.    These  local  changes  produce  secondarily 


an  abnormal  sensitiveness  of  the  abdominal  nerve 
plexuses,  low  blood  pres.sure,  disturbances  of  car- 
diac rhythm,  and  variations  in  the  oculocardiac  re- 
flex. Tenderness  occurs  not  only  in  the  cehac  re- 
gion but  also  in  the  superior  and  inferior  mesenteric 
and  the  iliac  regions.  The  pulse  is  often  slowed,  or 
may  be  irregular  and  with  premature  beats.  Patho- 
logical studies  showed  in  three  cases  the  presence 
of  microscopic  hemorrhages  in  the  stomach  wall 
nine,  twelve,  and  sixteen  months,  respectively,  after 
the  poisoning.  No  true  ulcer  was  seen,  but  two 
cases  showed  permanent  deformity  of  the  greater 
curvature,  and  one  case,  partial  stenosis  of  the 
pylorus — all  ascribable  to  the  marked  lesions  in- 
duced at  the  onset. 

Gastrointestinal  Service  in  an  Army  Hospital. — 

John  A.  Kantor  {Military  Surgeon,  May,  1920j 
states  that  too  pessimistic  an  impression  as  to  the 
capacity  of  dyspeptics  to  qualify  as  fighting  men  is 
by  no  means  justifiable.  Now  that  such  evidence 
is  available,  more  than  one  ex-soldier  will  bear 
witness  that  his  dyspepsia  disappeared  almost  com- 
pletely during  his  period  of  service.  There  is  in- 
deed no  way  of  telling  in  advance  in  many  an 
instance  whether  the  disability  is  such  as  to  be 
benefited  or  aggravated  by  military  duties.  The 
policy  pursued  in  the  recent  mobilization  of  assign- 
ing trained  men  as  gastroenterologists  to  the  va- 
rious base  and  general  hospitals  is  decidedly  to  be 
recommended.  Such  men  can  readily  build  up 
special  services  that  will  be  properly  equipped  to 
dispose  adequately  of  all  cases  showing  digestive 
disturbance.  By  this  means  much  time  can  be 
saved  in  the  weeding  out  of  the  absolutely  unfit, 
the  distribution  of  the  moderately  disabled  to  re- 
stricted duties,  and  the  cure  of  those  suffering 
from  transient  disorders. 

Diverticulitis.— G.  G.  Turner  {Lancet,  January 
17,  1920)  reports  several  cases  of  diverticulitis, 
one  with  so  great  a  thickening  of  the  intestinal  wall 
that  a  new  growth  was  diagnosed  at  operation ;  an- 
other at  the  sigmoid  flexure  with  a  similar  hyper- 
plasia of  the  gut  wall  and  a  perforation  just  above 
it  through  which  a  large  gallstone  had  ulcerated, 
and  a  third  in  which  a  very  small  almost  isolated 
diverticulum  had  perforated  producing  a  peri- 
tonitis. The  etiology  is  considered  by  this  author  to 
be  congenital.  The  diagnosis  must  be  made  on  a  his- 
tory of  repeated  inflammatory  attacks  extending 
over  long  periods.  This  will  help  in  differentiating 
from  new  growth  after  the  inflammation  has  pro- 
duced the  thickened  tumorlike  mass  palpable 
through  the  abdominal  wall.  As  for  treatment,  the 
writer  has  had  success  with  temporary  colotomy  to 
rest  the  bowel,  with  subsequent  resolution  of  the 
inflammatory  process  so  that  the  colotomy  wound 
was  closed  and  the  lower  part  of  the  gut  was  able 
to  function  again.  He  has  also  inverted  the  pro- 
jections converting  them  into  polypi,  with  satisfac- 
tory outcome.  It  is  important  to  keep  the  bowels 
regular  and  to  have  the  patient  stop  eating  when 
symptoms  develop,  if  medical  treatment  is  used. 


44 


LETTERS  TO  THE  EDITORS. 


[New  York 
Medical  Journal. 


Congenital  Anomaly  of  Duodenum. — Leonard 
Freeman  (Surgery,  Gynecology  and  Obstetrics, 
May,  1920 )  states  that  partial  occlusion  of  the  duo- 
denojejunal angle,  simulating  pyloric  obstruction, 
occasionally  occurs  from  the  persistence  of  a  con- 
dition normally  existing  in  fetal  life.  In  this,  the 
duodenum,  instead  of  appearing  in  the  abdominal 
cavity  from  beneath  the  transverse  mesocolon  to 
the  left  of  the  spine,  as  it  should,  emerges  to  the 
right,  its  transverse  and  ascending  portions  possess- 
ing a  peritoneal  covering  and  mesentery  of  their 
own,  similarly  to  the  rest  of  the  small  intestine, 
instead  of  being  fixed  in  fibrous  tissue,  as  is  nor- 
mally the  case.  At  the  duodenojejunal  angle,  how- 
ever, the  bowel  is  hung  up  to  the  root  of  the  colonic 
mesentery  by  a  firm  adhesion  (duodenal  fold  of 
fetal  life),  the  kink  thus  produced  being  intensified 
by  the  downward  pull  of  the  free  duodenal  loop. 
This  kink  is  deeply  situated  and  in  freeing  it  care 
must  be  taken  not  to  injure  the  bowel,  the  inferior 
mesenteric  vein  or  the  left  colic  artery.  A  con- 
siderable denudation  of  the  gut  may  be  necessary, 
which  should  be  covered  either  by  reuniting  the 
peritoneum  or  by  means  of  a  free  omental  graft. 

Nonrotation  of  the  Colon. — Dudley  Roberts 
(American  Journal  of  Surgery,  June,  1920)  dis- 
cusses the  association  of  obscure  abdominal 
symptoms  with  nonrotation  of  the  colon  and 
presents  his  conclusions  as  follows : 

1.  It  seems  probable  that  the  anomaly  is  not  as 
rare  as  might  be  inferred  from  the  scarcity  of  lit- 
erature. The  condition  is  easily  overlooked  even 
at  operation  and  many  of  the  cases  have  not  been 
reported. 

2.  Failure  to  locate  the  cecum  in  its  usual  site 
should  immediately  arouse  a  suspicion  of  nonro- 
tation especially  if  small  intestines  present  them- 
selves in  the  right  iliac  fossa.  Most  frequently  the 
cecum  will  then  be  found  low  down  in  the  midline, 
even  in  the  pelvis.  Less  frequently  it  will  be  found 
high  in  the  middle  of  the  abdomen,  under  the  liver 
or  in  the  left  iliac  fossa. 

3.  Left  sided  or  midabdominal  pain  with  symp- 
toms suggestive  of  appendix  inflammation  suggests 
the  advisability  of  a  rontgen  examination  which  will 
positively  demonstrate  the  site  of  the  cecum. 

4.  Erroneous  conclusions  may  be  reached  in  a 
rontgen  study  of  these  cases,  particularly  if  the 
failure  of  rotation  is  only  partial  and  the  cecum  is 
foimd  on  the  right  side  of  the  abdomen.  If  the  end 
of  the  cecimi  is  seen  pointing  upward  or  inward  the 
inference  might  be  drawn  that  one  is  dealing  with 
a  lesion  and  not  an  anomaly. 

5.  The  fact  that  sixteen  cases  out  of  twenty-two 
collected  from  the  literature  showed  appendix  in- 
flammation associated  with  symptoms  regarded  as 
sufficient  to  justify  operation  suggests  that  non- 
rotation  increases  the  natural  predisposition  to 
pathological  conditions  in  the  appendix.  While  this 
is  not  a  proposition  that  can  be  proven  it -tends  to 
justify  the  inference  that  we  are  dealing  with  an 
abnormal  appendix  when  in  a  proven  nonrotation 
case  there  are  obscure  abdominal  symptoms.  Cer- 
tainly exploration  of  the  appendix  should  be  per- 
formed even  if  another  incision  is  required  for  the 
purpose. 


Letters  to  the  Editors. 

MORPHINE  POISOXIXG. 

Brooklvx.  April  28,  ig20. 

To  the  Editors : 

The  recent  report  in  the  newspapers  that  a  boy 
had  died  from  the  effects  of  swallowing  morphine 
recalls  a  case  which  came  to  my  notice  forty  years 
ago  and  which  shows  that  morphine  poisoning  need 
not  be  fatal  if  the  proper  remedy  is  applied. 

A  physician  who  wanted  to  commit  suicide  gave 
himself  120  subcutaneous  injections  of  one  sixth 
grain  of  morphinum  sulphurium  each,  or  a  total  of 
twenty  grains.  He  was  soon  found  in  a  comatose 
condition,  and  a  physician  was  immediately  called. 
He  sent  for  three  others,  among  whom  I  was  one. 
As  morphine  kills  by  paralyzing  the  respiratory  cen- 
tres, we  at  once  undertook  artificial  respiration.  We 
first  removed  the  patient's  clothing  and  two  of  us, 
one  standing  on  each  side,  effected  inspiration  by 
the  usual  method  of  raising  the  arms  high  above 
the  head,  and  expiration  by  lowering  them  and 
pressing  them  firmly  against  the  thorax,  the  other 
two  of  us  resting  in  the  meanwhile.  The  patient's 
pulse  was  a  little  weaker  and  slower  than  normal. 
We  had  no  time  to  take  the  blood  pressure  or 
make  other  observations.  The  only  symptoms  other 
than  the  lack  of  respiration  were  the  contraction 
of  the  pupils — greater  than  I  had  ever  seen  before 
— and,  of  course,  complete  muscular  paralysis.  Oc- 
casionally we  would  stop  for  a  few  seconds  to  see 
whether  he  could  breathe  by  himself,  but  he  could 
not.  Only  after  we  had  worked  over  him  for  eight 
hours  did  respiration  begin,  and  then  irregularly. 
After  an  hour  more  of  partial  continuation  of  our 
work  he  breathed  fully  and  regularly,  opened  his 
eyes  and  spoke.  He  soon  recovered  completely, 
and  after  some  weeks  took  up  his  practice  again. 
His  case  indicates  that  the  mortal  effect  of  mor- 
phine is  but  a  paralysis  of  the  respirator}-  centre. 

Oswald  Joerg,  M.  D. 
 ^  

Births,  Marriages,  and  Deaths. 

Died. 

Arxold. — In  Mexico,  on  Monday,  June  14th.  Dr.  G.  D. 
Arnold,  of  Cleveland,  Ohio,  aged  seventy-sLx  years. 

Chagxox. — In  Brooklyn,  X.  Y.,  on  Tuesday,  June  22nd, 
Dr.  Thelesphore  Chagnon,  aged  sixty-one  years. 

Deck. — In  Herkimer,  N.  Y.,  on  Sunday,  June  13th,  Dr. 
Otis  H.  Deck,  aged  fiftj'-six  years. 

Lyox. — In  New  Haven.  Conn.,  on  Monday,  June  14th, 
Dr.  Treby  \V.  Lyon,  aged  thirty-nine  years. 

McCarthy. — In  Maiden,  Mass.,  on  Tuesday,  June  22nd, 
Dr.  Charles  Daniel  McCarthy,  aged  sixty  years. 

Stoxe. — In  Frederick  Citj-,  Md.,  on  Sunday,  June  13th, 
Dr.  Daniel  E.  Stone,  of  Emmitsburg,  Md.,  aged  forty-four 
years. 

Wells. — In  Trenton,  X,  J.,  on  Friday,  June  11th,  Dr. 
Joseph  M.  Wells,  aged  sixty-three  years. 

Wood. — In  Bridgeport,  Conn.,  on  Wednesday,  June  I6th, 
Dr.  Eugene  H.  Wood,  aged  sixty-three  years. 


New  York  Medical  Journal 

INCORPORATING  THE 

Philadelphia  Medical  Journal     Medical  News 

A  Weekly  Revieiv  of  Medicine,  Established  181^3. 

Vol.  CXII,  No.  2.  NEW  YORK,  SATURDAY,  JULY  10,  1920.  Whole  No.  2171. 

Original  Communications 


CHRONIC  INTESTINAL  TOXEMIA.* 
A  Study  Based  on  One  Thousand  Cases. 
By  Anthony  Bassler,  M.  D., 

New  York. 

Professor  of  Gastroenterology,   Fordham  University  Medical  College 
and  New  York  Polyclinic  Medical  School  and  Hospital. 

It  gives  a  feeling  of  satisfaction  to  have  worked 
on  a  subject  in  any  of  the  learned  sciences  and  then 
to  see  an  awakening  of  interest  in  it  even  though 
this  may  take  years  to  come  about.  Ten  years  ago 
no  work  worth  while  was  being  done  on  intestinal 
toxemias.  A  paper  of  mine  at  the  time  ( 1 )  received 
no  recognition  until  recently,  and  now  many  men 
are  at  work  on  a  subject  that  unfortunately  is  far 
from  simple  and  requires  much  careful  study. 
There  have  been  debates  back  and  forth,  definite 
attitudes  for  and  against  certain  aspects  of  the 
subject,  but  the  consensus  of  belief  of  the  best 
workers,  is  that  such  conditions  exist,  and  that  food 
and  bacteria  make  up  the  important  etiological 
factors  in  their  production  and  therapeutics.  These 
may  have  been  my  beliefs  for  the  past  ten  years, 
during  which  time  many  cases  have  been  diagnosed 
and  treated  on  these  bases.  The  clinical  material 
comprised  in  all  of  these  cases  is  too  voluminous 
from  which  to  make  deductions,  so,  the  last  thou- 
sand cases  have  been  taken  and  the  best  possible 
brief  deductions  made  from  them. 

As  pointed  out  by  me,  chronic  excessive  intestinal 
toxemias  should  be  divided  into  two  main  groups, 
primary  and  secondary.  The  secondary  are  those 
that  are  due  to  intestinal  anchorings  from  adhesions 
or  bands,  angulations,  ptoses,  specific  infections 
within  the  gut  in  which  the  toxemia  is  part  of  a 
mixed  infection  (such  as  tuberculosis,  syphilis, 
streptococcic  infections  of  the  buccal  or  nasal 
cavities,  typhoid  carriers),  parasitic  conditions, 
advanced  age,  neglected  routine  of  life,  habitual 
constipation,  and  other  conditions.  Some  of  these 
patients  may  require  surgical  treatment,  others 
medical  treatment.  It  is  in  the  secondary 
toxemias  that  surgery  often  plays  an  important 
part,  not  the  sort  of  surgery  that  Lane  advises,  but 
such  surgery  as  is  logical  and  safe.  I  do  not  believe 
that  a  chronically  diseased  appendix  ever  causes 
a  secondary  toxemia,  because  it  is  the  toxemia  that 
causes  the  disease  of  the  appendix,  and  almost  the 
•same  thing  niay  be  said  of  the  gallbladder,  but  not 

•Read  by  invitation  before  the  Medical  Association  of  the  Greater 
City  of  New  York,  AprU  19,  1920. 


SO  definitely.  I  am  of  the  opinion  that  colitis, 
whether  sectional  or  general,  has  four  causes,  more 
or  less  mixed  in  parts,  in  all  cases.  These  are  un- 
fortunate heredity  and  improper  early  life,  endoc- 
rine disturbance,  a  neurological  tendency,  and  a 
chronic  intestinal  toxemia.  Such  conditions  always 
demand  medical  treatment  and  while  conservative 
surger>'  may  be  required  to  do  away  with  conditions 
that  come  secondarily,  this  is  often  only  incidental 
Primary  intestinal  toxemia,  which  is  most 
frequently  encountered,  is  a  biochemical  change  from 
normal  digestion  in  the  intestinal  canal.  It  takes 
place  in  the  contents  of  the  small  intestine  rather 
than  the  colon,  although  most  frequently  its  whole 
process  is  installed  in  the  ileum  and  in  the  colon  to 
the  hepatic  flexure.  In  my  opinion,  it  is  entirely 
bacterial  in  nature.  Whatever  the  food,  whatever 
any  other  condition,  it  is  the  change  from  a  normal 
bacteriology  of  the  intestinal  canal  that  figures  most 
prominently  as  the  cause.  An  examination  of  speci- 
mens of  the  stool  will  prove  this,  but  the  analyses 
must  be  more  complete  bacteriologically  and 
chemically  than  those  done  in  laboratories  today. 
Examination  of  the  urine  may  or  may  not  be 
valuable ;  with  normal  urine  the  stool  specimen 
often  will  be  positive.  To  mention  all  the  laboratory 
technic  and  findings  in  this  work  would  be  most 
uninteresting  and  out  of  place  in  a  short  paper  like 
this.  It  would  require  a  great  deal  of  space  and  is 
obtainable  by  a  study  of  the  literature  and  by 
laboratory  practice.  It  is  more  interesting  to  speak 
of  the  cases  from  a  clinical  viewpoint.  Clinically 
and  confirmed  by  laboratory  the  cases  occurred  as 
follows ; 

Secondary  toxemia. — Definite  anchoring  of  the 
gut,  27;  intestinal  obstruction  (incomplete),  19; 
carcinoma,  14 ;  marked  ptosis,  62 ;  tuberculosis, 
syphilis,  etc.,  20 ;  nasal  and  buccal  infections,  91 ; 
parasitic  infections,  43 ;  definite  gut  infections 
(specific),  6;  neglected  routine  of  life,  69;  other 
causes,  30;  total,  381. 

Primary  toxemia. — Putrefactive  (indolic),  180; 
fermentative  (saccharobutyric) ,  172;  mixed  form, 
224 ;  definite  streptococcal  or  staphylococcal,  43 ; 
total,  619. 

Although  a  little  theatrical  and  somewhat  over- 
drawn. Lane's  description  of  the  chronic  gut  case 
is  the  best  in  the  literature.  He  did  not  distinguish 
between  secondary  toxemia,  in  which  conservative 
surgery  might  be  required,  and  the  primary  forms. 
All  was  grist  to  the  mill  for  his  propaganda.  But 


Copyright,  1920,  by  A.  R.  Elliott  Publishing  Company. 


46 


BASSLER:   CHRONIC  INTESTINAL  TOXEMIA. 


[New  York 
Medical  Jourxal. 


you  no  doubt  remember  his  descriptions  of  typical 
cases,  and  you  have  all  had  so  many  of  them  in 
your  practice  that  I  need  not  detail  them  again.  I 
shall,  therefore,  mention  states,  disorders,  or  condi- 
tions that  you  may  not  have  thought  of  as  bound  up 
in  this  subject,  and  in  the  instances  recorded  be- 
low they  have  occurred  as  recorded  in  a  thousand 
case  records.  To  me  they  have  distinct  significance. 
While  the  figures  given  below  relate  only  to  primary 
toxemias,  the  conditions  occur  quite  as  often  in  sec- 
ondary toxemias. 

In  619  cases  of  primary  intestinal  toxemia  the 
conditions  listed  below  were  encountered  in  the  fol- 


lowing percentages : 

Excessive  fatigue    75 

Anemia    73 

Pernicious  anemia   ■   2 

Anorexia    37 

Insomnia    69 

Skin    condition     (eczema,    irritative  rashes, 

recurring  urticaria,  acne)    9 

Fatigue  neuroses  (neurasthenia)    67 

Psychic  disturbances    27 

Recurring  neuritis    7 

Recurring  headaches,  backaches,  etc   69 

Vagotonia    4 

Dementia  praecox    2 

Eye    symptoms    (color    bHndness,    spots  in 

vision)    6 

Asthma    3 

Myocarditis   (under  fi<fty  years)    7 

Functional  heart  conditions    27 

Chronic  arthritis  (nongouty  or  rheumatic)   . .  5 

Gastric  hyperacidity    54 

Gastric  or  intestinal  atony    69 

Gastric  hyperesthesia   89 

Ileal  or  colonic  stasis    91 

Chronic  disease  of  the  appendix    37 

Megacecum  (idiopathic)    11 

Chronic  colitis    69 

Intestinal  adhesions    32 

Ptosis    52 

Gallbladder   conditions    12 

Appendix  disease    31 

Abdominal  distress  (intestinal  indigestion)  . .  94 

Endocrine   disorders    61 

Nephritis    9 

Hypertrophic  rhinitis    36 

Loss  of  weight    51 

Arteriosclerosis  (under  forty)    43 

Functional  hypertension    27 

Functional  hypotension    39 


Even  this  array  of  disorders  might  not  be  so 
striking  were  it  not  for  the  fact  that  such  marked 
improvement  in  many  cases  was  met  with  while  the 
patients  were  under  treatment  solely  for  the  in- 
testinal condition.  While  it  is  the  consensus  of 
opinion  that  in  some  of  the  cases  no  permanent 
benefit  can  be  accomplished,  the  conditions  were 
ameliorated  markedly  or  cleared  up  entirely.  When 
one  has  gone  over  the  vast  amount  of  work  of  this 
kind  that  I  have  in  twelve  years'  time,  the  inevitable 
conclusion  is  that  these  conditions  are  a  factor  of 
importance  in  medicine,  and  I  believe  'that  no 
chronic  condition  is  accurately  judged,  etiologically, 
unless  the  status  of  the  intestinal  canal  is  taken  into 
consideration. 

I  have  been  asked  to  give  a  description  of  the 
,  methods  of  treatment  I  employ.  This  depends  upon 
whether  the  case  is  primary  or  secondary,  and  since, 
in  the  primary  case  the  accuracy  of  judging  the 
l)acterial  change,  the  method  of  bacterial  treatments 
and  diets  employed,  the  adherence  of  the  patient 


to  treatment  over  four  or  five  months'  time,  and 
other  measures  more  difficult  to  control,  only  a  few 
general  points  can  be  given.  Almost  daily  I  receive 
letters  from  colleagues,  asking  such  questions  as, 
"What  vaccine  do  you  use?  What  diet  do  you  use?" 
This  type  of  work  is  far  from  simple  and  is  largely 
individualistic  with  the  single  case.  Shifts  from 
one  vaccine  to  another,  or  one  bacterial  method  to 
another,  are  common,  and  sometimes  with  ideal 
conditions  no  benefit  or  apparent  results  are  brought 
about. 

One  might  begin  by  expressing  opinions  of  some 
of  the  methods  that  are  employed  in  an  aimless  way, 
both  by  members  of  the  profession  and  by  the 
laity.  Without  careful  investigation  of  the  case, 
socalled  colonic  irrigations  and  instillations  of  bac- 
teria into  the  rectum  are  being  employed.  Most 
of  this  effort  is  commercial  in  character  and  most 
unscientific.  The  intestinal  canal  was  not  intended 
for  irrigation  and  while  some  immediate  benefit 
may  come  from  it,  in  the  end  it  may  do  harm.  No 
irrigations  of  the  colon  have  ever  been  used  by  me. 
The  general  instillation  of  the  Bacillus  bulgaricus 
cultures  or  the  Bacillus  acidophilus  by  rectum  or 
mouth  is  of  no  value.  These  organistns  may  ac- 
complish certain  results  in  a  laboratory  but  do  not 
in  the  human  body.  They  never  have  acidified  a 
neutral  or  alkaline  intestinal  tract,  and  in  a  case  of 
acidity  (saccharobutyric  toxemia),  they  would  do 
harm,  if  they  could. 

A  year  after  the  publication  of  my  original  article, 
Turck  (2)  suggested  the  use  of  the  Bacillus  coli 
subcutaneously.  This  was  followed  by  Satterlee 
(3),  both  taking  the  stand  that  the  Bacillus 
coli  was  inimical  to  the  host  and  vaccination  against 
its  effect  was  helpful.  Connellan  (4)  took  Herter's 
and  my  own  beliefs  and  assumed  that  the  Bacillus 
coli  was  beneficial  and  that  more  should  be  added, 
using  my  rectal  method  but  modifying  it  by  count- 
ing the  bacilli.  Much  criticism  may  be  presented 
of  the  statements  of  these  workers  regarding  my 
original  method,  most  of  which  were  unfair,  un- 
scientific, and  proved  that  these  workers  had  had 
little  or  no  experience  with  the  method  I  advocated, 
and  were  an  effort,  principally,  to  present  an  original 
treattnent  or  method  of  their  own.  I  draw  your 
attention  to  Herter,  Connellan,  and  myself  who 
take  the  position  that  the  colon  bacilli  should  be 
increased  in  the  host,  and  to  Turck  and  Satterlee, 
who  say  that  they  should  be  decreased  and  im- 
munity against  them  secured.  The  truth  is  that  in 
certain  types  of  cases  either  one  of  these  is  correct, 
but  in  all  cases  either  one  is  more  often  wrong  than 
right.  More  than  that,  however,  to  use  one  bac- 
terium for  the  treatment  of  intestinal  toxemia  is 
like  employing  a  single  medication  for  everything 
in  medicine,  or  one  organism  to  treat  all  infections 
and  expect  their  cure  by  the  use  of  a  single  vaccine. 
There  are  many  organisms  and  groups  of  them 
that  are  the  causes  of  intestinal  toxemia  in  man. 
and  unless  laboratory  work  is  done  to  find  out  what 
the  status  of  affairs  is,  this  only  adds  to  the  un- 
scientific work  of  men  who  see  it  only  as  a  simple 
and  single  condition.  In  the  writings  of  Turck, 
Satterlee  and  Connellan  no  reference  is  made  to  any 
lal)oratory  procedure  to  prove  the  diagnosis  in  cer- 


July  10,  1920.] 


BASSLER: 


CHRONIC   INTESTINAL  TOXEMIA. 


47 


tain  cases,  and  inasmuch  as  much  investigation  is 
possible  of  being  carried  out,  even  though  it  may  be 
difficult  and  require  experience  and  time,  such  work 
cannot  be  of  permanent  value  even  though  some 
benefit  may  have  resulted.  More  than  that,  to  jump 
to  conclusions  from  a  clinical  case  to  the  use  of  a 
single  organism  as  the  cure  of  them  all  puts  just  op- 
probrium on  it.  for  such  hit  or  miss  medicine  makes 
for  commercialism,  and  inhibits  the  attention  and 
work  of  the  best  workers  in  medicine  in  a  field 
that  requires  the  closest  and  most  careful  study. 
This  slipshod  therapy  is  the  cause  of  advertising 
and  lay  institutions  engaging  in  it.  There  are  places 
in  this  city  run  by  lay  people  where  patients  wait 
in  line  for  colonic  irrigations  and  bacteria  implanta- 
tion at  so  much  a  visit. 

There  are  no  socalled  intestinal  antiseptics  that 
are  of  any  value,  or  any  medical  means  that  can 
change  the  biochemistry  or  bacteriology  within  the 
gut.  The  drinking  of  large  quantities  of  water  or 
fluid  during  the  day  (5)  is  of  some  value  but  not 
always  advisable,  difficult  to  keep  up  in  quantities 
of  3450  c.  c.  per  diem,  and  only  of  A  ery  moderate 
service  in  cases  of  putrefaction.  Up  to  the  present, 
fresh  air,  systematic  exercise,  temperate  living,  and 
an  anticonstipation  diet  would  accomplish  more  than 
any  or  all  so  far  mentioned. 

The  two  measures  I  would  present  as  of  the  most 
value  are  diet  and  bacterial  treatments.  The 
diet  should  be  a  carbohydrate  and  hydrocarbon  one 
in  the  putrefaction  (indolic)  case,  a  high  protein 
in  the  fermentation  (saccharobutyric)  case,  and 
one  of  carefully  weighed  foods  so  as  to  keep  down 
to  a  minimum  caloric  value  in  the  mixed  form. 
Lactose  by  mouth  is  of  no  value,  but  the  plan  of 
Chetham- Strode  and  Benjafield  (6)  of  feeding 
coarse,  uncrushed  grains,  somewhat  sustains  an 
acidity  if  a  suitable  bacteriology  is  present  in  the 
gut — which  unfortunately  is  seldom  met  with  in 
the  putrefaction  case ;  but  when  this  is  present  a 
lactic  acid  carbon  dioxide  result  can  easily  be  ac- 
complished. What  one  must  always  keep  in  mind, 
by  dietetic  treatment  alone,  is  that  most  of  the 
infecting  form^  of  bacteria  in  the  gut  are  faculta- 
tive, and  while  they  may  be  favorably  influenced 
by  diet,  this  is  transitory  and  not  dependable  in 
therapy  after  a  few  weeks'  time.  Since  no  purga- 
tion should  ever  be  permitted  in  these  cases,  the 
bowels  must  be  regulated  by  the  well  known  dietetic 
and  physical  measures,  and  not  even  by  irrigations 
or  enemata  of  any  sort. 

The  bacterial  treatments  are  based  upon  the  find- 
ings in  complete  examinations  of  the  stools  and 
urine  under  known  conditions  of  diet.  This  diet 
should  be  the  normal  one  for  the  age,  work,  and 
weight  of  the  individual.  One  suitable  for  a  man 
weighing  150  pounds  is  the  following: 

Morning. — Two  thin  slices  of  well  baked  bread 
with  butter  liberally  applied;  one  pint  of  oatmeal 
gruel,  made  of  about  forty  grams  or  one  and  a  half 
ounces  of  oatmeal :  ten  grams  or  one  third  ounce 
of  butter :  200  grams  or  six  and  two  thirds  ounces 
of  milk;  300  grams  or  ten  ounces  of  water  (all 
strained).    One  egg  cooked  in  any  form. 

11a.  m. — Milk,  half  a  pint  or  one  glass. 

Noon. — A  good  sized  piece  of  roast  beef  or  steak, 


chopped  or  cut  into  very  ,  fine  pieces  (about  120 
grams  or  four  ounces)  and  served  on  a  slice  of 
toast ;  one  bowl  (about  250  grams  or  eight  and  a 
third  ounces)  of  mashed  potato,  with  twenty  grams 
or  two  thirds  of  an  ounce  of  butter. 

4  p.  m. — Milk,  half  a  pint,  one  glass. 

Night. — Same  as  for  breakfast. 

Water  may  be  taken  as  desired. 

After  the  third  or  fourth  day  a  twenty-four  hour 
collection  of  urine  and  a  stool  specimen  passed  in 
the  same  day  are  examined.  In  addition  to  the 
routine  examination  of  the  urine,  the  uric  and 
oxalic  acids  are  estimated,  and  a  sulphate  partition 
is  made.  The  stool  is  examined  in  the  usual  way, 
and  in  addition  a  gram  differential  count  of  the  gram 
negative  and  gram  positive  organisms  and  a  study 
of  the  bacteria  are  made.  Food  detritus  is  separated 
from  bacteria  and  an  estimate  of  percentages  in 
dried  weights  is  made.  When  there  is  any  doubt, 
inoculation  observations  under  aerobic  and  anerobic 
conditions  and  different  media  are  performed. 
Complete  x  ray  examination  of  the  gastroenteric 
tract  is  done  almost  as  a  routine,  the  idea  being  to 
place  the  case  in  the  secondary  group  if  possible. 
Attention  is  also  paid  to  stasis,  ptosis  and  dilatation 
of  different  sections  of  the  digestive  tract  in  the  ab- 
domen. The  detail  in  these  examinations,  differing 
as  it  does  in  different  cases,  is  too  large  a  matter  to 
enter  into  here  and  may  be  found  in  the  literature, 
but  widely  scattered.  Suffice  it  to  say  that  all  of 
this  work  could  be  done  by  anyone  who  has  had 
some  practice  in  it.  but  it  means  work,  and  in  my 
opinion  the  diagnosis  of  intestinal  toxemia  should 
be  made  in  this  way  only  and  never  just  assumed 
from  clinical  aspects. 

If  bacterial  treatments  are  carried  out  they  should 
be  autogenous  if  possible.  It  is  not  always  easy  to 
decide  which  one  organism  or  what  combination  of 
organisms  is  infecting  the  canal.  Symbioses  rule 
high  in  intestinal  bacteriology.  Likewise  it  is 
not  always  possible  to  decide  in  advance 
whether  the  best  results  would  come  from 
the  vaccination  method,  that  of  antagonisms 
or  by  biochemic  alteration  (using  the  infecting 
organisms  but  changing  them  biochemically  by 
different  media).  Thus,  with  me  the  first  three  or 
tour  weeks  are  always  experimental,  with  one  week 
of  laboraton.-  observation.  By  close  attention  one 
gets  straightened  out.  Both  the  rectal  and  sub- 
cutaneous routes  are  used,  the  bacteria  being  killed 
in  the  subcutaneous,  but  left  viable  in  the  rectal. 
A  list  of  the  bacterial  treatments  I  have  used  in  the 
three  methods  are  the  following: 

RECT.\L   METHODS  BIOCHEMICAL  ALTERATIOXS. 

Occasionally  infecting  bacteria  can  be  changed 
biochemically  by  growing  under  different  media  and 
these  used  to  substitute  those  present  in  the  body. 
Successful  examples  of  this  have  been  found  in 
cases  of  infections  with  Bacillus  coli  aerogenes 
capsulatus,  mesentericus  and  putrificus. 

RECTAL    AXD    SUBCUTANEOUS    METHODS  BACTERIAL 

AXTAGOXISMS. 
Saccharobutyric   (high  protein  diet). 

Bacillus   aerogenes  capsulatus. 

Gram  positive  diplococci. 

Gram  positive  single  cocci. 

Bacillus  bifidus. 


48 


LERCH:  CONSTIPATION. 


[New  York 
Medical  Journal. 


Bacillus  coli  (many  different  strains  and  perhaps 
collected  from  different  sources).  For  the  first 
two  a  strains,  for  the  second  two  the  b  strains  are 
best. 

Indolic.    (Low  protein  and  high  carbohydrate  and  hydro- 
carbon diet). 
Bacillus  coli. 
Bacillus  mesentericus. 
Gram  negative  streptococci. 
Gram  negative  staphylococci. 
Bacillus  proteus  vulgaris  (Bacillus  Welch). 
Bacillus  cloaca  (Bacillus  coli,  polyvalent  strains). 
Bacillus  pyocyaneus  (Bacillus  coli,  a  strains). 
Bacillus  putrificus  (Bacillus  coli,  b  strains). 
Bacillus  acidophilus. 
Bacillus  bulgaricus. 
Bacillus   lactic  aerogenes. 
Mixed.   (Least  possible  amounts  of  foods,  no  cheese,  peel- 
ing of  fruits — mostly  boiled  foods). 
No  action  on  antagonisms  possible  by  rectal  or  sub- 
cutaneous methods  excepting  when  a  predominant 
type  of  bacteria  is  present. 
The  difference  between  the  a  and  b  strains  of  Bacillus 
coli  is  that  a  does  not  produce  gas  in  saccharose,  and  the  b 
does.    The  effects  are  the  same  on  all  the  other  sugars 
and  on  the  coagulation  of  milk. 

RECTAL     AND     SUBCUTANEOUS     METHODS  VACCINE 

IMMUNITY. 

Saccharobutyric. 

Bacillus  aerogenes  capsulatus  (rectal). 

Gram  positive  diplococci  (skin,  rarely;  rectal,  rarely). 

Gram  positive  single  cocci  (rectal). 

Bacillus  bifidus   (rectal,  rarely). 

Bacillus  putrificus   (rectal,  rarely). 
Indolic. 

Bacillus  coli  communis   (rectal;  skin). 
Bacillus  mesentericus  (rectal). 
Bacillus  liquefaciens  (rectal). 
Bacillus  proteus. 

Gram  negative  streptococci  (skin). 
Staphylococci  (skin). 
Mixed. 

Combination  of  methods  outlined  above  according  to 
predomination  of  fermentation  or  putrefaction  and 
types  of  organism.  The  rectal  method  is  used 
here  altogether,  and  effort  is  made  to  get  re- 
actions and  a  leucocytosis  of  from  ten  to  twenty 
thousand  within  eight  hours  after  the  injections. 

The  bacterial  treatments  are  kept  up  for  four  or 
five  months,  according  to  the  type  of  cases,  method 
employed,  and  bacteria  used.  After  the  first  month 
the  diet  is  no  longer  important.  Constructive  and 
tonic  additions  to  treatment  are  added,  and  at  the 
end  of  the  bacterial  treatments  the  stools  and  urine 
are  examined  each  month  for  six  months  to  see  that 
the  results  remain  permanent. 

These,  briefly  stated,  are  the  methods  I  have 
employed  for  over  ten  years,  the  total  number  of 
cases  now  comprising  close  to  five  thousand.  There 
may  be  easier  and  simpler  forms  of  treatiuent  but 
none  that  I  know  of  gives  the  results  that  have  been 
accomplished.  To  me  the  diagnosis  and  successful 
treatment  of  chronic  excessive  intestinal  toxemia  is 
far  from  a  simple  matter.  The  work  should  be 
done  as  dispassionately  and  as  far  from  assumption 
as  possible.  In  addition  to  the  clinical  aspects,  the 
work  should  be  done  in  both  diagnosis  and  therapy 
almost  entirely  from  the  laboratory,  and  the  closest 
sort  of  attention  is  required  all  the  way  through. 
I  wish  I  knew  of  an  easy  way.  The  therapeutic 
part  of  the  work  may  be  done  in  a  few  moments 
of  a  patient's  time  in  the  office,  but  to  conduct  the 
bacterial  treatments  as  I  believe  is  required  and 
treat  thirty  cases  at  a  time  requires  that  the  labora- 
tory must  be  actively  working  at  least  twelve  hours 


a  day  and  often  during  the  nights  and  on  Sundays. 
To  handle  these  cases  properly  requires  more  work 
with  proportionately  less  financial  remuneration  for 
the  expenditure  of  time,  attention  and  energy,  than 
any  I  know  of  in  medicine.  But  the  satisfaction 
experienced  in  the  results  obtained  repays  one, 
because  commonly  the  results  are  so  startling  that 
one  has  hesitancy  in  recording  them  in  the  literature. 

•REFERENCES. 

1.  Bassler,  Anthony:  A  New  Method  of  Treatment 
of  Chronic  Intestinal  Putrefaction,  by  Means  of  Rectal 
Instillation  of  Autogenous  Bacteria  and  Strains  of  Hu- 
man Coli  Communis.    Medical  Record,  September  24,  1910. 

2.  TuRCK  :  International  Clinics,  1911,  vol.  ii,  p.  45. 

3.  Satterlee  :  Transactions  of  the  Section  in  Pharma- 
cology and  Therapeutics,  Jour.  A.  M.  A.,  1916,  p.  100. 

4.  CoNNELLAN :  Treatment  of  Intestinal  Infections, 
Archives  of  Ophthalmology,  vol.  xviii,   No.  4,  1919. 

5    Blatherwick,   Shervvin,   and   Hawk  :   Journal  of 
Biological  Chemistry. 
6.    The  Lancet,  January  10,  1920.   ii,  2. 

CONSTIPATION   AND   THE   EFFECT  OF 
PURGATIVES  ON  HEART  AND  VESSELS. 
By  Otto  Lerch,  A.  M.,  Ph.  D.,  M.  D., 

New  Orleans,  La. 

We  speak  of  constipation  when  the  bowels  can- 
not be  evacuated  at  least  once  a  day  without  aid, 
that  is,  when  a  spontaneous  emptying  of  the  bowels 
has  partly  or  entirely  ceased  and  the  patient  has  to 
take  purgatives  or  enemas.  Some  patients  use 
•purgatives  for  years  apparently  without  bad  results, 
changing  the  remedies  as  they  are  recommended  to 
them  by  relatives  and  friends,  by  the  newspaper  and 
by  the  druggist.  However,  a  time  will  come  when 
medicines  lose  their  effect  and  the  patient  has  to  con- 
sult a  physician.  Long  before  this  we  find,  in  prac- 
tice, a  large  number  of  people  who  suffer  from  in- 
complete constipation  which  usually  precedes  the 
complete  form.  These  patients,  still  being  able  to  pro- 
cure an  evacuation  with  purgatives  or  enemas,  do 
not  trouble  about  their  ailment. 

Constipation  is  a  serious  disease  and  should  never 
be  neglected  when  discovered  during  an  examination 
or  treated  by  adding  another  purgative  to  the  list 
the  patient  has  already  used. 

Health  and  comfort  depend  largely  on  well  func- 
tioning bowels,  and  the  diseases  due  to  toxins  ab- 
sorbed from  putrefying  waste  retained  in  the  colon 
and  from  macroparasites  and  microparasites  which 
find,  under  these  conditions,  a  favorable  soil  in 
which  to  grow,  are  familiar  to  every  practitioner. 
Sufficiency  is  the  essential  feature  of  a  normal  stool 
and  though  it  is  impossible  to  detenuine  whether 
the  stool  corresponds  in  quantity  to  the  food  ingest- 
ed, we  can  estimate,  and  occasionally  by  giving  an 
enema  after  defecation  can  determine  with  some  ac- 
curacy, whether  the  bowels  have  been  emptied. 
A  constipated  stool  is  insufficient  in  quantity,  hard, 
and  delayed,  though  a  semisolid  and  even  liquid 
stool  is  constipated,  if  insufficient.  A  daily  sufficient 
evacuation  is  the  normal.  Several  factors  are 
necessary  to  produce  this. 

1,  A  free,  unobstructed  intestinal  canal;  2,  a 
normal  abdomen  and  normal  muscles ;  3,  a  sound 
and  well  functioning  nervous  system,  causing  in- 


July  10,  1920.] 


LERCH:  CONSTIPATION. 


49 


testinal  peristalsis,  relaxation  of  the  sphincter  and 
the  action  of  the  belly  press,  fixation  of  the  dia- 
phragm and  pressure  of  the  abdominal  walls  upon 
the  abdominal  contents ;  4,  a  sufficient  amount  of 
waste  matter  in  the  colon ;  5,  a  normal  consistency 
of  the  fecal  matter,  neither  too  hard  nor  too  soft. 

Next  of  importance  to  the  knowledge  of  the  cause 
of  the  constipation  is  the  diagnosis  of  the  exact  state 
when  first  seen ;  incomplete  or  complete,  atonic  or 
spastic.  Constipation  commences  with  atony  of  the 
bowels.  In  this  state  the  muscles  of  the  colon  are 
weak  and  relaxed.  This  condition  may  last  for 
years,  till  finally,  due  to  irritation  by  hard  scybala 
and  abuse  of  purgatives,  a  catarrh  is  established. 
Hard  scybala  and  flakes  of  mucus  make  the  diag- 
nosis of  catarrh  an  easy  matter.  Flatulence  and 
fine  particles  of  mucus  mixed  with  the  fecal  mat- 
ter indicate  an  involvement  of  the  small  intestines, 
and  icterus,  that  of  the  duodenum. 

The  constant  irritation  of  the  colon  causes  con- 
tractions ;  it  feels  like  a  smooth  cylinder  rolling 
under  the  palpating  fingers,  and  it  frequently 
gurgles.  This  manipulation  is  usually  painful  and 
the  accompanying  constipation  may  alternate  with 
attacks  of  diarrhea  and  gradually  pass  into  a  con- 
tinuous diarrhea.  Membranous  enteritis  is  an  ad- 
vanced state  of  catarrh.  In  this  condition  fecal 
matter  is  frequently  retained  for  several  days  in  the 
contracted  parts  of  the  colon,  and  the  decomposed 
mucus  acted  upon  by  the  acid  stool  is  expelled  in 
large  flakes  of  cylindrical  shape  or  like  jelly,  which 
under  water  take  the  form  of  membranes.  The 
expelling  of  the  mucus  is  accompanied  by  colic, 
after  which  the  patient  feels  better. 

CONDITIONS      CAUSING      INTESTINAL      STASIS  BY 
NARROWING  AND  OBSTRUCTING  THE  CANAL. 

Among  the  conditions  that  will  cause  stasis  are 
duodenal  or  rectal  strictures,  old  scarified  ulcers  of 
tuberculosis  and  syphilis,  malignant  growths,  par- 
tial torsion  and  moderate  invagination,  incomplete 
hernias,  adhesions  following  peritonitis,  appendici- 
tis, cholecystitis  and  laparotomy,  kinks,  pressure  of 
an  ovarian  cyst  and  gravid  uterus,  or  an  anal  fissure, 
which  due  to  pain  will  cause  an  excessive  contrac- 
tion of  the  sphincter.  If  the  obstruction  is  located 
in  the  small  intestines,  stasis  may  be  overlooked  for 
a  long  while.  The  liquid  contents  of  the  small  in- 
testines pass  the  narrowed  section  for  some  time. 
These  conditions  have  to  be  eliminated  and  a  careful 
examination  of  the  rectum,  uterus,  and  hernial  sites 
has  to  be  made. 

Inspection  should  never  be  neglected.  Large  sau- 
sagelike stools  indicate  atony  and  ribbonlike  stools 
spastic  conditions  or  obstructions.  Black  stools  are 
due  to  blood  or  medicaments  like  iron  and  bismuth. 
Calomel  colors  the  stools  green  and  grey  fatty  stools 
are  due  to  absence  of  bile  in  diseases  of  gallbladder 
and  duodenum,  in  severe  anemias  and  chronic  peri- 
tonitis. Fresh  blood  comes  from  the  end  of  the  tract. 
Black  stools,  if  the  coloring  is  due  to  blood,  may  be 
due  to  ulcers  of  stomach  and  duodenum,  enteritis 
and  malignant  tumors,  typhoid  fever  and  purpura. 
Pus  in  large  quantities  indicates  a  rupture  of  an  ab- 
dominal abscess  into  the  intestines.  If  the  pus  is 
mixed  with  the  stools,  usually  with  blood,  and  ac- 
companied by  diarrhea,  it  indicates  an  ulceration  of 


the  colon.  Tenesmus,  blood,  and  mucus  are  charac- 
teristic symptoms  of  dysentery.  Mucus  enveloping 
the  stools  indicates  a  catarrh  of  the  rectum,  and  if 
mixed  in  small  particles  with  the  fecal  matter,  ca- 
tarrh of  the  small  bowels. 

PATIENTS  WITH  ABNORMAL  ABDOMENS. 

Multipara  with  frequently  ruptured  perineums, 
and  most  enteroptotics,  furnish  the  vast  majority 
of  constipated  people.  The  enteroptotic  usually 
has  a  pendulous  abdomen  with  weak  and  relaxed 
abdominal  walls.  With  some,  however,  the  ab- 
dominal muscles  may  be  hard,  like  cords,  but  more 
or  less  widely  separated.  The  intestines  are  usually 
displaced  and  the  transverse  colon  sometimes 
approaches  the  V  shape  which,  of  course,  interferes 
with  a  normal  evacuation.  All  of  these  patients 
are  hysterical  and  neurasthenic  and  the  influence  of 
the  nervous  system  is  abnormal  and  adds  to  the 
trouble  caused  by  the  displacement  and  lack  of 
muscular  development. 

TREATMENT  OF  CONSTIPATION. 

This  should  be  directed  to  the  cause  of  the  con- 
stipation and  must  be  surgical  in  some  cases.  No 
cure  can  be  hoped  for  unless  the  cause  is  treated. 
If  the  constipation  is  due  to  lack  of  enervation  much 
can  be  done.  Young  girls  and  woinen  do  not 
respond  to  the  call  of  nature  on  account  of  false 
modesty,  and  business  men  neglect  it,  because  they 
are  too  busy.  They  commence  to  take  purgatives 
and  must  take  larger  and  larger  doses  to  produce 
results  and  invariably  end,  often  after  many  years, 
with  serious  difficulties. 

It  is  not  only  necessary  to  strengthen  and  regulate 
the  enervation  in  cases  like  these,  in  which  the 
failure  of  the  nervous  system  to  act  is  the  prime 
factor,  but  it  is  always  useful,  no  matter  what  the 
cause  may  be.  The  bowels  cannot  be  satisfactorily 
emptied  unless  the  nervous  system  is  intact  and 
functioning  properly.  This  is  illustrated  in  organic 
diseases  of  the  spine  and  brain  as  well  as  in 
toxemias.  In  these  cases  complete  stasis  or  in- 
voluntary movements  follow;  a  powerful  peristaltic 
wave  must  pass  down  the  intestinal  tract,  the 
sphincter  must  relax,  the  diaphragm  must  be  fixed 
and  the  abdominal  walls  press  upon  their  contents, 
when  the  brain  is  notified  that  the  rectum  is  filled 
and  evacuation  needed.  To  have  this  act  performed 
at  a  certain  time  and  place,  it  must  be  learned  until 
it  is  habitually  performed.  Infants  are  taught  by 
their  mothers  till  a  fixed  habit  is  established  which 
usually  lasts  during  life  and  is  interrupted  only  by 
disease,  change  of  place  and  later  on  by  occupation 
and  negligence.  The  taking  of  a  journey  on  rail- 
road or  steamship  interferes  with  it  and  people 
knowing  this  by  experience  provide  themselves  with 
purgatives  before  they  enter  on  such  a  trip.  Even 
moving  into  new  quarters  will  often  break  the  habit. 
The  accustomed  time  and  the  familiar  surroundings 
are  necessary  to  produce  prompt  action.  To  re- 
establish the  lost  habit  the  patient  must  be  advised 
to  go  to  stool  every  morning  at  the  same  hour 
whether  the  desire  is  present  or  not  and  the  im- 
portance of  this  measure  must  be  explained  to  them 
and  they  must  be  impressed  with  it.  Suggestion 
given  by  the  physician  or  practised  by  the  patient 


so 


LERCH:  CONSTIPATIOX. 


[Xew  York 
Medical  Journal. 


himself  will  assist  materially  and  often  this  alone 
is  sufificient  to  cure.  The  inhibition  which  is  present 
is  removed  by  it  and  a  powerful  peristaltic  wave 
will  pass  down  the  intestinal  tract  at  a  given  time. 
To  strengthen  the  habit  and  to  make  it  finn  it  is 
best  associated  with  another  act  habitually  per- 
formed at  the  same  time,  or  preceding  it  to  give 
as  it  were  a  time  signal  to  the  brain.  Most  people 
have  found  out  the  efficiency  of  this  measure  by 
experience.  They  go  to  stool  on  arising,  before  or 
after  the  bath,  before  or  after  breakfast.  Some 
have  to  smoke  a  cigar  or  pipe  and  some  tell  us  that 
they  cannot  have  an  evacuation  unless  they  take  an 
apple  at  night,  a  soft  boiled  egg  in  the  morning, 
a  spoonful  of  honey  and  the  like.  Defecation  is  an 
automatic  act  and  the  habit  must  not  be  interfered 
with  when  it  is  once  established. 

CONSTIPATION  DUE  TO  WEAKNESS  OF  MUSCLES. 

It  is  evident  that  nerve  stimulation  cannot  act 
efficiently  if  the  muscular  apparatus  is  not  intact. 
The  muscles  of  most  patients  suffering  from  con- 
stipation are  weak  and  flabby,  due  to  the  lack  of 
exercise.  Bookkeepers,  professional  men,  officials, 
sewing  girls,  tailors  and  all  who  lead  a  sedentary 
life  are  the  victims.  ]\Iassage  and  exercise  may  be 
used  to  strengthen  the  muscles.  Before  advising 
this,  all  inflammatory  processes  and  conditions  ob- 
structing the  intestinal  canal  must  be  excluded.  If 
a  tumor  is  palpable  the  intestines  have  to  be  cleansed 
thoroughly  with  enemas  and  castor  oil  and  if  after 
these  measures  the  tumor  can  still  be  felt,  mas- 
sage must  not  be  given.  Even  if  a  fecal  tumor 
is  diagnosed,  massage  is  contraindicated,  unless 
an  inflammatory  process  can  be  excluded.  In- 
testinal ulceration,  tuberculosis,  cancer,  syphilis, 
chronic  appendicitis,  and  cholecystitis,  contraindi- 
cate  massage. 

^Massage,  when  indicated,  is  commenced  with 
a  light  circular  stroke  from  right  to  left  around 
the  navel  to  treat  the  small  intestines,  to  be  followed 
by  a  firmer  stroke  along  the  colon.  The  masseur 
commences  in  the  right  iliac  fossa,  strokes  along 
the  ascending  colon  to  the  border  of  the  ribs,  across 
the  abdomen,  along  the  transverse  colon  and  down 
the  descending  colon  making  deeper  pressure  on 
reaching  the  flexure  and  following  it  to  the  begin- 
ning of  the  rectum.  This  stroking  has  to  be 
repeated  a  number  of  times  to  prepare  for  the 
rubbing.  The  left  hand  is  then  gently  but  deeply 
pressed  into  the  iliac  fossa  with  finger  tips  down, 
while  the  right  hand  rests  over  the  left,  the  fingers 
of  the  left  rub  the  ascending  colon  and  gently  but 
firmly  push  and  press  its  contents  onward  along 
the  course  of  the  colon.  This  manipulation  should 
be  repeated  a  few  times  only;  or  the  left  hand  is 
gradually  deeply  pressed  into  the  right  iliac  fossa, 
next  the  right  is  placed  before  the  left  in  the  same 
manner,  then  the  left  before  the  right  always  gently 
pressing  and  pushing  the  colon  contents  onward. 
The  rubbing  and  pushing  have  to  be  executed  with 
a  greater  force  along  fhe  flexure,  the  usual  place 
where  fecal  matter  collects.  In  some  cases,  especially 
in  the  obese  and  those  with  relaxed  abdominal  walls, 
the  abdominal  wall  may  be  grasped  with  both  hands 
and  pushed  from  side  to  side,  forward  and  back- 
ward, moving  the  whole  of  the  abdominal  contents. 


Tapotement  follows  with  the  hand  formed  lightly 
to  a  fist  or  with  the  whole  hand  slightly  made 
hollow  so  that  only  the  borders  strike.  \'ibration, 
best  with  an  instrument  (the  vibrator),  and  finally 
a  gentle  circular  effleurage  from  right  to  left  close 
the  procedure.  If  massage  is  given  at  all  in  the 
spastic  fomi  of  constipation  only  a  very  gentle 
effleurage  can  be  used  and  this  with  the  greatest 
caution.  A  contracted  colon  will  often  relax  under 
gentle  treatment  and  pain  may  be  stopped. 

Abdominal  massage  should  only  be  given  by  a 
physician  who  is  familiar  with  the  method  or  by 
a  well  trained  masseur  under  the  direction  and  ob- 
servation of  the  physician.  It  is  an  efficient  method 
and  often  will  cure  when  all  other  methods  have 
failed. 

EXERCISE  IN  CONSTIPATION. 

Outdoor  life  and  exercise  in  the  open  are  the  best 
methods  for  preventing  constipation  and  help  to 
cure  it  when  established.  Walking,  riding,  rowing, 
tennis,  golf,  work  in  the  garden,  and  other  pleasur- 
able exercises  which  divert  the  mind  are  the  most 
useful.  These  patients  are  depressed  and  constantly 
occupied  with  their  trouble  which  of  course  inter- 
feres with  the  evacuation.  If  these  pleasurable  ex- 
ercises cannot  be  had  or  not  in  sufficient  amount, 
then  the  patient  has  to  be  directed  to  walk  to  his 
place  of  business,  the  housewife  has  to  go  to  mar- 
ket, etc.  Room  exercises  are  useful  in  every  case. 
They  are  best  taken  in  the  morning  naked  before 
the  bath,  to  secure  an  airbath.  One  of  the  most 
useful  exercises  is  deep  breathing.  This  strengthens 
the  abdominal  muscles  and  exerts  a  powerful  pres- 
sure upon  the  abdominal  contents.  The  patient  lies 
on  the  floor  on  a  blanket  or  upon  a  hard  couch  with 
knees  flexed  and  mouth  slightly  opened.  He  then 
takes  a  deep  breath,  flattening  the  abdomen  and 
exerting  pressure  upon  its  contents.  He  has  to  re- 
peat this  five  times  with  a  pause  between  each  breath, 
a  longer  pause  follows  and  the  cycle  of  breathing 
has  to  be  repeated  five  to  six  times.  Bending  for- 
ward, going  into  the  bent  knee  position,  picking  up 
objects  from  the  floor  and  similar  exercises  should 
be  added. 

HYDROTHERAPY. 

Hydrotherapeutic  measures  are  always  helpful  in 
the  treatment  of  constipation.  A  warm  bath  in  the 
morning,  followed  by  a  cold  douche  or  ablution  and 
friction  with  a  rough  towel,  will  be  found  helpful. 
In  spastic  constipation,  warm  and  hot  applications, 
a  hot  sitzbath  or  a  full  prolonged  warm  bath  and 
hot  drinks  are  indicated.  Electricity  is  helpful,  the 
sinusoidal  current  causing  rhythmical  contractions 
of  the  abdomen.  The  faradic  current  may  be  used 
instead,  with  a  large  electrode  over  the  lumbar  por- 
tion of  the  spine  and  a  special  electrode  in  the  rec- 
tum. Before  introducing  the  electrode,  from  100 
to  150  c.  c.  of  lukewarm  water  should  be  injected 
to  make  contact  between  the  mucous  membranes  of 
the  rectum  and  the  electrode.  These  various  physio- 
logical measures  act  directly  upon  the  intestines  and 
improve  general  health  by  causing  a  better  blood 
distribution,  increase  organ  activity  and  free  the 
blood  from  impurities.  Muscles  gain  in  strength 
and  volume  and  the  bowels  commence  to  function. 


July  10,  1920.] 


LERCH :   CONSTIPA  TIOX. 


51 


DIET   IX  COXSTIPATIOX. 

Bulk  and  consistency  of  the  stools  depend  on  the 
diet.  A  suitable  diet  has  to  be  prescribed  in  every 
case.  The  exact  state  of  the  constipation,  atonic  or 
spastic,  complete  or  incomplete,  the  state  of  the 
nutrition  of  the  patient,  whether  fat  or  lean,  age, 
sex,  and  occupation,  indoor  or  outdoor  life,  the 
functioning  of  the  endocrine  glands,  diseases  which 
accompany  the  constipation,  climate  and  season,  all 
are  factors  which  have  to  be  carefully  considered 
in  prescribing  the  diet.  The  object  of  every  diet  is 
to  furnish  the  needed  amount  of  food  for  the  pro- 
duction of  energy  and  heat,  for  growth  and  repair. 
The  diet  must  be  sufficiently  bulky  and  mechanically 
stimulating  if  the  constipation  is  atonic,  and  non- 
irritating  and  stimulating  chemically  if  it  is  spastic. 
Going  to  the  toilet  is  best  accomplished  after  break- 
fast, when  the  food  of  the  preceding  day  has  passed 
the  intestinal  tract  and  the  morning  meal  excites  it 
to  act  (Osborne).  The  seat  of  the  toilet  should  be 
low  or  a  footstool  placed  under  the  feet.  The  squat- 
ting position  is  assumed  by  primitive  man  to  empty 
his  bowels  and  is  most  efficient.  People  may  know 
this  from  experience  on  hunting  and  fishing  expedi- 
tions. In  this  position  the  thighs  press  well  against 
the  abdomen  and  the  sphincter  is  stretched. 

Fats  and  starches  have  to  be  increased  or  de- 
creased according  to  the  state  of  nutrition,  occupa- 
tion, climate  and  season,  liquids  regulated  according 
to  the  consistency  of  the  stool  and  meat  allowed  in 
proportion  to  the  exercise  taken.  Meat  is  only  as- 
similated during  exercise  and  in  disease. 

In  atonic  constipation  articles  of  food  are  to  be 
preferred  which  excite  and  increase  peristalsis  and 
increase  bulk;  cold  water  in  the  morning,  lemon- 
ade, buttermilk,  cider  and  honey,  fresh  and  stewed 
fruits  like  prunes,  raisins,  figs  and  dates,  the  dried 
fruits  being  soaked  in  water  overnight  and  then 
well  stewed ;  graham  bread,  and  rye  bread,  the 
green  vegetables  like  spinach,  young  sprouts,  okra, 
snap  beans,  cauliflower  and  mustard  greens,  beet 
tops,  carrots  and  potatoes ;  the  coarser  vegetables, 
cabbage,  beans  and  peas,  in  selected  cases.  They 
produce  flatulence  and  increase  the  trouble,  if  they 
do  not  cause  an  evacuation. 

In  spastic  constipation  fats,  olive  oil,  butter  and 
cream  should  be  given  in  larger  quantities ;  fruit 
sugar,  honey,  buttermilk  and  clabber,  freshly  pressed 
fruit  juices,  apple  butter,  plum  butter,  fruit  jellies 
and  purees  of  the  tender  green  vegetables  in  butter 
act  chemically  and  increase  bulk  without  irritating 
the  inflamed  tract.  All  foods  should  be  given  in  the 
semisolid  state. 

The  following  table  may  serve  as  a  guide,  varied 
as  indications  demand : 

A  glass  of  cold  water  should  be  taken  on  arising. 
Breakfast :  A  cup  of  cofifee  with  cream ;  graham 
bread  or  rye  bread  with  butter  and  honey ; 
or  clabber,  buttermilk  or  cream  cheese.  Dinner :  Let- 
tuce and  olive  oil,  creamed  or  baked  potatoes  with 
butter,  the  green  vegetables  in  butter  and  fish  or 
meat  as  indicated ;  ripe  and  juicy  fruits,  stewed 
fruits  and  fruit  jellies.  Supper:  a  glass  of  butter- 
milk, a  plate  of  clabber,  a  soft  boiled  egg,  graham 
bread,  rye  bread  and  butter.    Fruit  on  going  to  bed. 


EXEMAS. 

Enemas  are  well  adapted  to  empty  the  colon  at 
once  of  stagnating  masses  of  fecal  matter.  A  large 
amount  of  water  injected,  to  which  soap,  salt  or 
castor  oil  has  been  added,  stimulates  the  intestinal 
peristalsis  powerfully,  and  an  evacuation  follows 
promptly.  Solution  of  the  stool  is  of  little  consid- 
eration. For  mild  stimulation  a  small  enema  of 
lukewarm  water  is  sufficient.  For  stronger  stimu- 
lation, the  temperature  of  the  water  has  to  be  cold, 
even  ice  cold,  if  a  small  enema  is  administered. 
If  the  higher  portions  of  the  colon  are  to  be  reached, 
the  rectal  tube  has  to  be  used  ( Xelaton  ) .  Oil  enemas 
are  of  great  importance  and  especially  useful  in  the 
treatment  of  spastic  constipation,  though  they  do 
not  act  in  every  case.  The  oil  may  creep  up  to  the 
ileum,  it  lessens  absorption  of  water,  acts  as  a  lubri- 
cant and  by  splitting  off  oil  acids  stimulates  peristal- 
sis. Inflammatory  processes  and  intestinal  ulcera- 
tion are  not  contraindications  to  the  method.  The 
enemas  are  best  given  at  night  and  consist  of  a 
half  to  one  pint  of  olive  oil  or  cottonseed  oil.  The 
patient's  hips  are  elevated  and  he  lies  on  his  right 
side.  The  colon  tube,  well  covered  with  petrolatum 
is  introduced  about  four  to  six  inches  and  the  oil 
allowed  to  flow  into  the  colon  under  low  pressure 
from  fifteen  to  twenty  minutes.  The  evacuation 
follows  the  next  morning,  though  occasionally  a 
watery  enema  may  have  to  be  added  in  the  morning 
to  produce  results.  A  daily  oil  enema  is  rarely 
necessary.  Enemas  are  useful  and  are  the  most 
harmless  remedy,  provided  the  technic  is  correct. 
Large  enemas,  too  frequently  repeated,  distend  the 
colon,  which  loses  its  tone,  and  this  increases  the 
trouble. 

THE  EXDOCRIXE  GLAXDS. 

It  has  been  mentioned  that  the  glands  of  in- 
ternal secretion  must  be  considered.  Their  func- 
tion is  disturbed  in  every  disease  and  their  failure 
to  act  may  be  the  cause  or  the  consequence  of  the 
constipation.  If  the\'  are  the  cause,  substitution  and 
homostimulation  alone  will  be  frequently  sufficient 
to  relieve  the  condition  .( 1 ) .  In  either  event  medi- 
cation in  this  direction  is  indicated.  The  obese  if 
suffering  from  constipation  due  to  poorly  function- 
ing thyroid  and  ovaries  need  the  extract  of  these 
glands.  However,  the  physiological  methods  must 
be  combined  with  this  medication  to  return  the  com- 
position and  distribution  of  the  blood  to  the  normal 
which  in  its  turn  will  secure  proper  functioning  of 
the  failing  glands.  People  finally  have  to  get  along 
with  air,  food,  rest  and  exercise.  The  same  may  be 
said  for  the  enteroptotics,  with  hypofunctioning  of 
the  pituitary,  thyroid  and  adrenals.  They  need  the 
substitute  to  get  relief,  and  together  with  rest,  diet, 
and  the  other  therapeutic  measures,  to  bring  about  a 
permanent  cure.  Rest  in  the  recumbent  posture 
secures  a  better  blood  supply  to  thyroid,  thymus  and 
pituitary  and  relieves  the  adrenals.  Hormonal,  a 
peristaltic  hormone,  is  stored  away  in  the  spleen  and 
has  been  successfully  used  to  relieve  chronic  con- 
stipation, and  biliary  salts  are  now  frequently  em- 
ployed for  the  same  purpose.  In  the  absence  or 
diminution  of  bile,  in  hepatic  disorders,  bile  and 
preparations  containing  it  in  some  form,  are  indi- 


52 


LERCH:  CONSTIPATION. 


[New  York 
Medical  Journal. 


cated,  of  which  a  number  are  on  the  market.  Bile 
acts  as  a  cholagogue  and  laxative,  and  neutralizes 
the  intestinal  ferment,  mucinase,  which  coagulates 
mucus.  Roger,  who  made  this  discovery,  recom- 
mends oxgall  in  the  treatment  of  membranous  en- 
teritis, and  Pauchet  recommends  adrenal  organo- 
therapy. 

THE    TREATMENT    OF    CONSTIPATION    WITH  PURGA- 
TIVES. 

With  drugs  we  can  meet  every  indication  and 
empty  a  clogged  bowel  in  short  time.  We  can  in- 
crease the  tone  of  nerves  and  muscles,  and  increase 
or  decrease  peristalsis.  We  can  influence  the  con- 
sistency of  the  stool  by  increasing  or  decreasing  in- 
testinal secretion,  soften  fecal  matter,  liquefy  it  or 
lubricate  and  increase  the  bulk. 

The  treatment  with  drugs  is  necessary  in  almost 
ever}^  case,  though  the  physiological  methods  should 
be  tried  and  drugs  added  and  gradually  withdrawn 
or  the  one  and  the  other  method  alternately  employed 
till  a  cure  is  perfected.  If  the  constipation  is  not  the 
main  trouble  but  only  a  companion  of  some  serious 
disease,  purgatives  are  indicated.  If  we  wish  to  act 
solely  upon  the  nervous  system,  we  give  prepara- 
tions of  nux  vomica  or  its  alkaloid  strychnine.  It 
stimulates  and  gives  tone  to  nerves  and  muscles. 
Belladonna  and  atropine  retard  peristalsis,  relax 
spasms  and  stop  pain,  and  are  indicated  in 
spastic  condition  of  the  intestines.  If  the  stools  are 
hard,  drugs  must  be  prescribed  which  increase  in- 
testinal secretion  or  strong  solutions  of  the  saline 
laxatives  which  liquefy  the  stools.  Liquid  petrolatum 
acts  as  a  lubricant  and  the  agar-agar  preparations 
increase  bulk,  stimulating  mechanically.  Bran  and 
similar  irritating  substances  should  not  be  used  for 
any  length  of  time  and  never  in  spastic  constipation. 

The  vegetable  purgatives  are  classified  as  aperi- 
ents, laxatives  and  drastics.  They  act  irritatingly 
upon  the  intestinal  mucous  membrane,  increase  peri- 
stalsis, produce  hyperemia  and  increase  secretions. 
The  effect  of  their  adininistration  is  a  more  or  less 
thorough  and  rapid  semisolid  evacuation  of  the  in- 
testinal contents.  Increased  .peristalsis  and  increased 
secretions  prevent  the  thickening  of  the  contents  as 
they  pass  rapidly  through  the  colon.  Some  of  these, 
like  podophyllin,  aloes,  and  senna,  act  when  given  by 
hypodermic  injection,  but  as  they  are  excreted  in 
the  intestines  it  is  probable  that  their  action  is  a  local 
reflex  one,  not  differing  from  that  when  given  by 
mouth.  Most  of  these,  especially  the  drastics,  cause 
pain  and  inflammation  when  given  in  larger  and 
repeated  doses,  due  to  the  violent  peristalsis  they 
produce.  Some  have  the  reputation  of  increasing 
bile  production  and  others  do  not  act  when  bile  is  ab- 
sent. Some  increase  the  peristalsis  of  the  whole 
intestinal  tract  and  others  affect  the  colon  only. 
Those  that  act  solely  upon  the  colon  are  preferable 
in  the  treatment  of  chronic  constipation  where 
change  of  remedy  and  a  prolonged  use  are  necessary. 
Purgatives  should  be  changed  if  a  continuous  use  is 
indicated,  to  prevent  intoxication,  irritation  of  the 
mucous  membrane  and  the  taking  of  larger  and 
larger  doses,  which  becomes  necessary  if  the  same 
drug  is  continuously  used.  Drastics  should  be  only 
occasionally  used  in  cases  without  complications. 


Castor  oil  and  calomel  are  most  frequently  em- 
ployed to  empty  the  bowels  thoroughly ;  they  may 
be  administered  every  eighth  or  tenth  day.  They 
affect  the  whole  tract  from  pyloric  orifice  to  rectum 
and  empty  the  gallbladder  by  mechanical  traction. 
The  violent  peristalsis  opens  the  papilla.  Croton  oil 
is  rarely  used,  and  only  in  severe  constipation  with- 
out complications  and  in  uremia  when  other  means 
have  failed.  Jalap  is  frequently  employed  to  pro- 
duce watery  stools  in  edema  and  ascites.  Podo- 
phyllin acts  as  a  cathartic  in  larger  doses  and  may 
be  used  in  small  doses  in  the  treatment  of  chronic 
constipation.  It  acts  well  in  hepatic  disorders.  A 
common  and  very  useful  household  remedy  is  a  jam 
made  of  raisins,  prunes,  dates  and  figs,  with  a  cup 
of  honey  or  molasses  to  which  senna  is  added.  The 
active  principles  of  rhubarb,  aloes,  cascara  sagrada 
and  others  when  given,  are  gradually  set  free  in  their 
passage  through  the  intestines  and  exert  their  action 
especially  in  the  colon.  Aloes  increases  tone  and  irri- 
tability of  the  colon  when  given  in  doses  of  one 
twelfth  to  one  grain,  three  times  daily,  sufficient  to 
produce  a  satisfactory  stool ;  the  dose  may  be  grad- 
ually decreased  and  finally  discontinued.  Rhubarb 
increases  intestinal  secretion  and  stimulates  peristal- 
sis. A  small  dose  at  night  may  be  given  for  a  long 
time  without  harm.  Cascara  sagrada  acts  upon  mus- 
cles and  tissues  of  the  intestines  through  the  sympa- 
thetic fibres  which  supply  them.  It  acts  well  as  a 
mild  laxative,  without  causing  pain  or  inconvenience. 
Phenolphthalein  is  effective  and  frequently  used. 
Black  alder  is  a  tonic  laxative  especially  useful  for 
continuous  employment  when  hemorrhoids  are 
present. 

The  saline  laxatives,  magnesium  sulphate  and 
the  sulphates,  phosphates,  tartrates  and  citrates  of 
sodium  and  potassium  attract  water  more  than  the 
cells  of  the  body  which  property  prevents  absorption 
during  their  passage  through  the  intestines,  keep  the 
intestinal  contents  in  a  liquid  condition,  and  by  slight 
local  irritation  increase  peristalsis,  which  is  aided 
by  the  hydrogen  sulphide  which  is  set  free.  The 
laxative  mineral  waters  contain  these  salts  and 
should  be  given  warm  an  hour  before  breakfast. 

The  use  of  purgatives  by  rectum  is  rare ;  they  do 
not  produce  a  thorough  evacuation  but  are  useful 
when  purgatives  by  mouth  and  enemas  are  contra- 
indicated;  glycerine  by  injection  or  as  a  suppository 
are  the  most  frequently  used.  Soap  suppositories 
are  useful  in  the  treatment  of  infants. 

PURGATIVES  IN  DISEASE. 

Disturbed  bowel  action,  frequently  constipation, 
usually  accompanies  organic  and  infectious  diseases. 
Prolonged  rest,  a  change  of  diet  and  the  intoxication 
produced  by  the  disease  itself,  are  the  cause.  It  is 
next  to  impossible  to  treat  constipation,  accompany- 
ing disease,  without  purgatives,  yet  it  is  far  more 
important  to  empty  the  bowels  of  the  sick  and  keep 
them  clean,  than  it  is  of  healthy  persons.  The  colon 
is  an  organ  of  absorption  as  well  as  a  waste  pipe. 
The  epithelial  cells  covering  the  absorbing  glands 
become  paralyzed  when  exposed  to  putrefying  waste 
too  long,  and  allow  toxins  to  pass  which  add  to  the 
toxins  produced  by  disease.  Normal  function  of  all 
organs  becomes  seriously  affected  on  account  of  in- 


July  10,  1920.] 


UPHAM:  DIETARY  TREATMENT  OF  CONSTIPATION. 


53 


sufficient  elimination  by  congested  kidneys,  impure 
blood  and  disturbed  circulation ;  under  such  condi- 
tions recovery  is  difficult.  "Blood  alone  cures,  and 
to  assist  nature  we  have  to  purify  it  and  bring  it 
where  it  is  needed.  Nature  repairs  and  cures  with 
hyperemia.  The  purer  the  blood,  the  better  the 
function  of  every  organ,  which  in  turn  produces 
a  perfect  blood,  hyperemia  and  recovery.  It  is  there- 
fore of  the  greatest  importance  to  commence  treat- 
ment by  thoroughly  emptying  the  bowels  and  keeping 
them  clean  with  purgatives  till  recovery  has  pro- 
gressed, then  the  physiological  methods  have  to  be 
substituted  till  the  bowels  function  without  aid."  (2) 
Purgatives  have  to  be  prescribed  according  to  the 
indications  previously  discussed.  The  acute  infec- 
tious diseases  commence  usually  with  a  chill,  the 
skin  is  cold  and  clammy  and  the  body  temperature  is 
high.  There  is  no  better  way  to  correct  the  faulty 
circulation  that  by  an  enema,  followed  by  a  purga- 
tive, a  hot  footbath  which  brings  the  blood  to  the 
surface  where  it  cools  and  returns  cooled,  and  an 
icebag  to  the  head  to  prevent  congestion.  The  chill 
ceases,  the  body  surface  becomes  warm  and  moist, 
the  temperature  drops,  the  high  blood  pressure  is 
lowered  and  a  dilated  heart  returns  to  the  normal 
size  and  gains  in  strength,  and  with  the  clean  bowels 
the  patient  has  a  better  chance  to  recover.  It  is 
probable  that  it  is  this  action  of  the  purgatives  on  the 
circulation,  which  acts  like  bloodletting,  together 
with  their  cleaning  effect,  which  has  led  to  the  almost 
universal  practice  of  commencing  the  treatment  of 
the  acute  infectious  diseases  with  a  purgative  and  re- 
peating the  dose  from  time  to  time  during  its  course. 
Whatever  is  done  to  relieve  the  patient,  a  permanent 
cure  can  only  be  secured  when  it  is  borne  in  mind 
that  nature  cures  with  hyperemia  and  that  a  pure 
blood — that  is,  a  perfect  composition  of  the  blood — 
will  assist  her  in  her  efforts.  All  therapeutic  meth- 
ods must  be  used  to  secure  it.  If  we  do  this  we 
assist  nature  and  practice  rational  therapy. 

references. 

1.  Strauss,  Spencer  G.  :  New  York  Medical  Journal, 
February  14,  1920. 

2.  Lerch  :  Rational  Therapv,  Southworth  Publishing 
Company,  Troy,  N.  Y.,  1919,  p."  1,  2,  272. 


DIETARY   TREATMENT   OF  CONSTI- 
PATION. 

By  Roy  Upham,  M.  D.,  F.A.C.S., 
Brooklyn,  N.  Y. 

The  part  played  by  dietetics  in  the  treatment  of 
constipation,  while  most  interesting,  is,  to  my  mind, 
subsidiary,  and  before  preaching  dogmatic  state- 
ments on  dietetics  I  shall  present  a  brief  considera- 
tion of  the  etiology  of  constipation,  for  if  practi- 
cal application  of  the  dietetic  treatment  as  outlined 
herein  were  attempted  without  an  investigation  of 
the  etiological  foundation  of  the  condition,  my  state- 
ments would  be  considered  inaccurate  and  be  cast 
aside  on  the  ground  that  they  were  not  applicable 
to  the  practical  work  as  seen  daily  in  the  office  of 
the  physician. 

In  discussing  the  dietetic  principles  it  is  necessary 
to  keep  clearly  in  mind  that  there  are  types  of  cases 


in  which  dietetic  principles  are  not  to  be  applied 
until  the  etiological  factor  has  been  corrected. 

Murray  (1),  in  a  clear  and  concise  paper  on  the 
subject  of  constipation,  takes  as  the  keynote  of  his 
discussion  the  fact  that  an  insufficient  intake  of 
water  is  the  therapeutic  factor  in  a  large  number  of 
cases.  We  know  that  the  daily  excretion  from  the 
kidneys  is  forty-eight  ounces ;  that  sixteen  ounces 
are  excreted  through  the  skin,  and  another  sixteen 
ounces  through  respiration.  Therefore,  there  must 
be  a  total  of  eighty  ounces  of  fluid  intake  in  order 
to  supply  nature's  wants,  and  this  is  the  first  dietetic 
measure  which  must  be  insisted  upon.  Very  few 
people  make  a  practice  of  drinking  water  other 
than  at  their  meal  times,  women  being  the  worst 
offenders  in  this  respect,  and  the  records  of  my 
office  show  that  there  are  three  cases  of  constipa- 
tion in  women  to  one  in  men.  I  believe  this  is  due 
to  two  faults :  First,  a  lack  of  fluid  intake,  as  pre- 
viously stated;  and,  secondly,  because  of  the  fact 
that  women  are  irregular  in  their  habits,  are  prone 
to  be  late  risers,  and  put  off  the  act  of  defecation 
until  the  defecation  reflex  has  become  so  benumbed 
that  it  no  longer  responds.  It  is  an  old  adage  that 
everybody's  business  is  nobody's  business,  and  it  is 
applied  in  constipation  that  any  old  time  to  go  results 
in  no  time  for  the  desire  to  do  so. 

Therefore,  in  the  treatment  of  constipation,  we 
prescribe  two  glasses  of  very  hot  water  on  arising, 
to  which  is  added,  in  some  cases,  a  teaspoonful  of 
salt,  in  others  two  teaspoonfuls  of  bicarbonate  of 
soda,  and  in  others  two  tablespoonfuls  of  milk  sugar, 
the  selection  of  the  soda  bicarbonate  being  made 
in  the  high  acid  cases  and  those  accompanied  with 
acidosis,  and  the  milk  sugar  used  in  cases  in  which 
these  factors  are  not  present  and  for  its  distinctively 
laxative  value.  Following  this  we  insist  upon  fif- 
teen minutes'  exercise,  and  then  the  patient,  after 
a  stimulating  cold  sponge,  is  dressed,  feeling  fit  and 
ready  for  his  breakfast,  which  should  consist  of 
some  fruit,  followed  by  a  cereal,  such  as  oatmeal  or 
grape  nuts,  with  which  one  or  two  tablespoonfuls 
of  agar-agar  are  mixed.  White  bread  should  be 
interdicted  in  these  cases  for  the  reason  that  it  does 
not  cause  sufficient  intestinal  stimulation ;  rye  or 
Boston  brown  bread  should  be  used  in  its  place. 
Do  not  forget  that  butter  is  distinctly  laxative,  and 
the  patient  should  be  encouraged  to  take  large 
amounts. 

We  have  a  special  bread,  the  recipe  for  which 
we  give  to  our  patients,  which  is  procurable  at  sev- 
eral bakeries  in  Brooklyn.  The  formula  for  this  is 
as  follows : 

bran  bread. 

Two  cups  of  wheat  bran. 

One  cup  of  flour. 

One  teaspoonful  of  salt. 

One  and  a  half  teaspoonfuls  of  baking  powder. 
Three  tablespoonfuls  of  molasses. 

Mix  bran,  flour,  baking  powder,  salt,  and  molasses. 
Then  add  enough  milk  to  make  a  dough.  Various  fruits, 
such  as  raisins,  figs,  and  dates,  may  be  added  if  desired. 
Bake  the  dough  in  the  form  of  a  loaf,  or  gems  to  vary  the 
monotony.  This  same  dough  can  also  be  steamed  as  a  pud- 
ding and  served  with  honey  or  other  syrup. 

We  encourage  our  patients  to  take  this  bread  in 
the  morning  with  honey  or  marmalade,  as  both  are 


54 


UPHAM:  DIETARY   TREATMENT  OF  CONSTIPATION. 


[New  York 
Medical  Journal. 


distinctly  laxative.  Bear  in  mind  that  smoked  foods 
are  distinctly  stimulating  to  the  bowels  because  of 
their  chemical  action,  and  for  this  reason,  bacon, 
ham,  and  smoked  fish  are  particularly  advised.  If 
the  patient  is  allowed  to  take  coffee,  there  is  no 
better  stimulant  to  intestinal  motility  than  a  cup  of 
coffee,  and  patients  are  encouraged  to  use  in  this 
large  quantities  of  condensed  milk,  as  this  is  dis- 
tinctly laxative. 

Immediately  after  breakfast  the  patient  is  en- 
couraged, if  a  male,  to  resort  to  a  pipe  of  tobacco, 
and  possibly  a  cigarette  for  women  may  do  as  well. 
This  will  stimulate  a  desire  for  movement,  and  the 
patient  is  told  that  time  must  be  spent  in  the  bath- 
room in  an  effort  to  produce  a  movement.  Regular- 
ity is  the  keynote  of  success,  and  if  a  definite  time 
of  daj^  is  set,  it  should  be  directly  after  breakfast, 
because  the  intake  of  food  on  an  empty  stomach 
should  stimulate  gastrointestinal  motility  and  bring 
'on  a  desire  for  movement. 

Neglecting  the  call  of  nature  should  never  be 
allowed,  as  the  rectum  is  a  very  delicate  structure, 
and  failure  to  respond  is  the  cause  of  the  majority 
of  cases  of  constipation.  A  great  aid  is  Kelly's 
suggestion  of  placing  a  box  in  front  of  the  toilet 
seat  so  as  to  lift  the  feet  from  the  floor,  thereby 
bringing  the  thighs  up  to  the  trunk  and  aiding 
greatly  in  the  expulsive  force. 

Patients  are  instructed  at  ten  o'clock  in  the  morn- 
ing to  drink  a  glass  of  buttermilk,  sour  milk,  or 
koumiss,  which,  due  to  their  chemical  action,  are 
a  great  stimulant  to  intestinal  movement,  and  as 
many  of  these  patients  have  a  proteid  type  of  intes- 
tinal intoxication,  the  lactic  acid  ferments  in  the  fer- 
mented milk,  while  they  may  not  fulfill  all  the 
claims  that  were  made  for  them  by  Metchnikoff,  do 
aid  in  the  return  of  the  intestinal  putrefaction  to 
a  more  normal  type.  They  should  be  instructed  to 
take  eight  oimces  of  water.  Before  luncheon  four 
tablespoonfuls  of  olive  oil  are  taken  for  its  laxa- 
tive action.  If  it  is  repulsive  it  can  often  be  taken 
exceedingly  cold  or  even  on  cracked  ice,  when  it 
can  be  tolerated. 

For  luncheon  the  patient  may  have  a  small  por- 
tion of  meat,  but  there  should  be  insistence  upon  a 
vegetable  intake.  Green  beans,  celery,  cabbage, 
onion,  cauliflower,  carrots,  and  beets  are  particu- 
larly insisted  upon,  and  with  limcheon  salad  should 
be  used  with  olive  oil  and  vinegar. 

The  bread  should  be  the  same  as  for  breakfast, 
and  a  dish  of  stewed  fruits,  figs,  pickled  peaches,  or 
apricots  taken  with  a  glass  of  cider,  which  is  dis- 
tinctly laxative,  with  a  tablespoonful  of  milk  sugar 
in  it.  At  four  o'clock  another  glass  of  buttermilk 
is  advised,  and  at  five  another  glass  of  water.  Din- 
ner should  be  preceded  by  the  olive  oil  and  should 
consist  of  meat  with  vegetables,  Brussels  sprouts  be- 
ing thought  of,  a  fruit  salad  with  much  oil  and 
vinegar,  and  a  dessert  of  stewed  prunes,  to  which 
a  tablespoonful  of  agar-agar  has  been  added.  Be- 
fore retiring  at  night,  if  it  does  not  disagree  with 
the  patient  (by  that  I  mean  if  it  does  not  prevent 
his  sleeping),  some  fruit  should  be  taken  along  with 
some  of  the  laxative  bread,  with  honey  on  it.  Car- 
bonated waters  are  stimulants  to  peristalsis,  and 
White  Rock  water  can  be  advised.      Ginger  ale 


should  always  be  interdicted  as  it  is  distinctly  con- 
stipating. Where  the  bowels  are  unusually  sluggish, 
some  time  during  the  day  a  half  cup  of  pure  wheat 
bran  taken  with  a  glass  of  milk  adds  to  the  intes- 
tinal content. 

The  great  point  to  be  Ijorne  in  mind  in  the  treat- 
ment of  cases  of  constipation  is  that  these  pa- 
tients because  of  intestinal  toxemia  are  constantly 
reducing  the  amount  of  their  food  until  such 
time  as  there  is  not  sufficient  intake  to  stimu- 
late the  intestinal  motility,  and  later  on  in  this  arti- 
cle a  method  will  be  presented  showing  how  this 
can  be  overcome.  The  difficulty  with  this  diet  is 
that  the  patients  become  tired  of  certain  articles,  of 
food,  and  your  success  will  be  enhanced  if  you 
are  able  from  time  to  time  to  offer  suggestions  which 
will  vary  the  monotony. 

Articles  which  will  be  particularly  spoken  of  as 
laxatives  are  as  follows :  ]\Iany  patients  are  aided  by 
the  use.  of  the  petroleum  oil.  This  can  be  taken  in 
doses  of  four  tablespoonfuls  three  times  a  day.  The 
difficulty  in  connection  with  the  use  of  the  oil  is 
that  often  a  patient  loses  control  of  the  sphincter  and 
the  oil  is  passed  when  gas  is  expelled.  To  overcome 
this  we  have  combined  the  oil  with  grape  juice  in  the 
preparation  of  equal  parts  of  grape  juice  and  oil, 
which  is  emulsified  by  the  use  of  mucilage  of  acacia 
in  the  proportion  of  one  ounce  of  mucilage  of  acacia 
to  the  pint.  If  this  is  shaken  up  directly  before 
taking  it  emulsifies  the  oil  in  a  measure  and  prevents 
this  disaster.  By  this  method  we  have  also  been 
able  to  disguise  the  oil,  and  patients  will  take  it  to 
whom  the  plain  oil  would  be  repulsive.  To  a  person 
who  has  no  repugnance  for  oil,  we  often  use  plain 
white  petrolatum,  a  teaspoonful  three  times  a  day. 
This  is  disguised  by  spreading  it  on  a  cracker  and 
covering  it  with  some  jelly  or  marmalade.  Honey 
has  been  referred  to  as  being  laxative,  and  molasses 
is  also  a  most  effective  remedy.  Patients  are  in- 
structed to  take  two  tablespoonfuls  of  molasses  three 
or  four  times  a  day,  which  can  be  diluted  with 
water  and  used  as  a  beverage  or,  if  the  patient  will 
take  it,  pure  cider  can  be  drunk  freely. 

There  are  numerous  cereals  and  laxative  biscuits 
of  various  kinds  on  the  market,  all  of  which  are  use- 
ful in  the  treatment  of  constipation.  One  of  the 
most  effective  breakfast  cereals  is  made  of  flaxseed 
and  is  easily  procurable.  Their  action  is  along  the 
same  lines  as  agar-agar  therapy.  Wheat  bran  has 
already  been  spoken  of  and  serves  to  supply  the  bulk 
but  does  not  hold  the  moisture  as  agar-agar  does. 
Our  aim  is  to  eliminate  entirely  the  use  of  drugs  with 
possibly  the  exception  of  various  liver  stimulants, 
such  as  oxgall,  sodium  succinate,  and  acid  sodium 
oleate.  which  are  effective  through  stimula- 
tion of  the  liver  and  not  as  direct  laxatives 
or  cathartics.  The  use  of  four  to  six  ounces  of 
oil  injected  into  the  rectum  at  night  the  last  thing 
and  held  until  morning  is  a  most  effective  measure, 
particularly  in  the  class  of  cases  due  to  dyschezia  of 
the  rectal  type  of  constipation. 

There  are  certain  articles  of  diet  in  which  pa- 
tients suffering  from  constipation  should  never  in- 
dulge and  among  those  which  are  particularly  in- 
terdicted are  puree  soups,  rice,  sago,  farina,  cream 
of    wheat,    cheese,    chocolate,    cocoa,  cranberries. 


July  10,  1920.] 


UFHAM:  DIETARY  TREATMENT  OF  CONSTIPATION. 


55 


huckleberries,  claret,  and  red  wines ;  white  wines 
may  be  used  in  moderation,  if  obtainable. 

Of  course,  before  going  to  bed  the  patient  is  in- 
structed to  exercise,  using  the  abdominal  exercises 
so  familiar  in  the  United  States  Army;  or  the  shot 
bag  principle  of  exercise.  One  important  point  to 
bear  in  mind  in  treating  these  patients  is  insistence 
upon  their  arising  at  the  same  time  every  day  and 
taking  their  meals  at  the  same  time,  thereby  allow- 
ing the  automatic  functions  to  become  once  more 
regular  in  their  activity.  As  has  been  hinted,  ex- 
tremes of  temperature,  either  hot  or  cold,  are  ex- 
tremely valuable  as  stimulants  to  bowel  motility. 

To  the  patient  who  has  difficulty  in  consuming  a 
sufficient  amount  of  food  we  have  found  that  the 
caloric  method  of  feeding  is  applicable.  By  these 
lists  the  amount  of  food  equal  to  100  calories  is 
readily  determinable,  and  then  the  patient  is  in- 
structed to  eat  a  unit  of  calories  a  day,  consum- 
ing 2,800  or  3,000  calories,  and  he  is  instructed  to 
keep  a  list  and  to  always  eat  the  exact  amount.  If 
the  patient  does  not  gain  weight  by  this  method,  or 
his  general  condition  does  not  improve,  by  an  in- 
crease of  200  calories  in  the  daily  intake  at  the  end 
of  each  week  an  increasing  amount  of  food  can  be 
forced  upon  him  until  a  sufficient  residue  is  left  in 
the  intestine  to  stimulate  bowel  movement. 

To  patients  who  are  somewhat  stubborn,  the  use 
of  a  rectal  dilator  inserted  when  they  begin  to  dress 
in  the  morning  and  left  in  the  rectum  until  a  desire 
for  bowel  movement  is  induced  is  .usually  very  ef- 
fective. This  is  particularly  so  in  cases  of  con- 
tracted spastic  sphincters.  Often  a  similar  result 
can  be  obtained  by  the  use  of  a  gluten  suppository ; 
and  often  we  have  large  suppositories  made  of  cocoa 
butter  which  produce  similar  results. 

In  all  work  on  dietetics  at  the  present  time  we 
should  not  forget  the  part  which  the  vitamines  play. 
In  the  diet  which  has  been  outlined  there  is  no  lack 
of  vitamines  because  of  the  fact  that  the  diet  is 
fairly  well  balanced  and  also  because  much  raw 
food  is  consumed  during  the  intake  of  the  meal. 
\^itamines  are  readily  supplied  to  the  body  in  yeast, 
and  we  sometimes  advise  patients  to  eat  half  a 
cake  of  yeast  three  times  a  day,  the  yeast  being 
stimulant  in  its  nature  to  intestinal  motility.  Cab- 
bage and  potatoes  are  other  splendid  sources  of 
vitamines  (2). 

In  all  cases  of  constipation  the  question  of  focal 
infection  in  any  part  of  the  body  should  not  be  for- 
gotten and  efforts  made  to  eliminate  any  foci  which 
may  be  present.  We  must  also  bear  in  mind  that 
venous  congestion  incident  to  improper  circulation 
in  the  intestine  allows  of  abnormal  invasion  of  the 
system  by  bacterial  products  and  bacteria.  There- 
fore, various  electric  modalities  applied  to  the  abdo- 
men are  extremely  valuable  in  the  way  of  stimu- 
lating the  circulation  and  improving  the  general  tone 
of  the  intestines.  However,  in  the  event  of  elabo- 
rate electrical  apparatus  not  being  at  hand,  the  in- 
creased intake  of  food  by  a  deposit  of  fat  in  the  ab- 
domen, aided  by  the  increased  vitality  of  the  an- 
terior abdominal  wall,  will  produce  a  condition  of 
increased  intraabdominal  pressure  which  will  tend 
to  return  the  circulation  to  normal. 

To  secure  any  success,  every  laxative  measure 


must  be  avoided,  and  ofl^n  it  must  be  insisted 
that  the  patient  go  for  even  forty-eight  hours  with- 
out a  movement,  at  the  end  of  which  time  a  desire 
usually  materializes,  and  from  that  time  on,  with 
a  large  bulky  diet,  frequently  a  normal  condition  of 
bowel  movements  results  at  once. 

Grahams  axioms  (3)  should  be  borne  in  mind. 
First,  no  case  of  chronic  constipation  is  diagnosed 
or  should  be  treated  until  a  thorough  proctological 
examination  has  been  made.  This  consists  not  alone 
in  the  use  of  the  proctoscope,  but  a  digital  exami- 
nation should  be  made  of  every  rectum,  the  whole 
secret  of  success  in  the  treatment  of  the  case  being 
found  at  this  time.  There  is  an  old  adage  that 
the  difference  between  a  gastrointestinal  specialist 
and  a  general  practitioner  is  the  fact  that  the  gas- 
trointestinal specialist  made  a  rectal  examination ; 
but  with  the  advances  which  are  constantly  being 
made,  we  realize  that  more  and  more  detail  and 
care  are  being  given  to  our  patients,  and  the  exami- 
nation of  the  rectum  is  not  overlooked  as  it  has  been 
in  the  past. 

The  previously  outlined  dietary  principles  are 
based  upon  broad  phases,  and  failing  in  success, 
the  diet  has  to  be  made  typically  applicable  to  vari- 
ous gastric  and  intestinal  conditions,  of  which  may 
be  mentioned  the  type  of  stomach  where  no  free 
hydrochloric  acid  is  secreted  with  the  attendant  lack 
of  activity  of  the  enzymes,  to  the  opposite  state  of 
affairs  where  pronounced  hyperacidity  is  present ; 
and  let  me  mention  the  fact  that  in  cases  of  gastric 
catarrh  with  diminished  acidity  a  tendency  of  diar- 
rheal conditions  is  prone  to  occur,  whereas  in  con- 
stipation there  is  more  likely  to  be  hyperacidity. 
This  will  not  follow  in  all  'cases,  but  we 
should  realize  that  with  the  falling  off  in  efficiency 
of  gastric  digestion  there  is  a  correspondingly  de- 
ficient function  of  the  liver  and  pancreas,  and  the 
absence  of  these  two  essential  digestive  factors  in 
the  intestine  promote  an  undue  fermentation,  and, 
as  a  result,  gastrogenic  diarrhea  occurs. 

Another  type  of  case  which  must  be  emphasized 
is  that  due  to  spasmodic  colitis  where  there  are  ab- 
normal spasmodic  contractions,  multiple  in  number, 
throughout  the  large  intestine.  This  condition  is 
usually  accompanied  by  an  increase  in  the  produc- 
tion of  mucus  and  gives  rise  to  the  condition  which 
is  known  as  mucous  colitis.  Formerly,  the  Aus- 
trian clinicians  felt  that  this  was  an  irritative  con- 
dition and  should  be  handled  by  an  extremely  bland 
diet,  no  irritative  foods  being  given,  and  a  diet  sim- 
ilar to  an  ulcer  diet  being  prescribed,  hoping  thereby 
that  the  points  of  irritation  would  disappear  and 
that  normal  peristalsis  would  occur.  After  exten- 
sive experiments  with  the  bland  diet  in  constipa- 
tion it  has  been  practically  discarded,  and  we  at- 
tack this  type  of  spasmodic  colitis  with  the  diet 
previously  outlined. 

These  cases,  as  is  true  of  many  other  cases  of 
constipation,  must  be  treated  intelligently,  and  the 
patients  should  be  informed  that  they  may  have  a  pe- 
riod of  a  few  days  of  increased  discomfort  while  their 
functions  are  becoming  regulated,  but  that  if  they 
will  have  the  courage  to  follow  your  instructions 
over  a  period  of  a  few  days  normal  results  will 
ensue. 


56 


LYON:   GALLBLADDER  CONDITIONS. 


[New  York 
Medical  Journal. 


The  only  auxiliary  measure  allowed  in  these  cases 
is  a  small  enema  in  the  morning  after  they  have 
passed  a  day  without  a  bowel  movement,  and  the 
important  factor  is  that  this  enema  should  be  given 
at  the  time  of  normal  bowel  movement ;  that  is, 
directly  after  breakfast.  With  this  enema  normal 
habits  are  usually  established,  and  it  is  to  be  re- 
sorted to  at  infrequent  intervals. 

COXCLUSIOXS. 

1.  Constipation  is  a  preventable  disease.  2.  The 
pronounced  causal  factors  are  carelessness  and 
laziness.  3.  Plenty  of  water  should  be  drunk 
to  supply  the  necessities  of  the  body.  4.  There 
should  be  absolute  regularity  in  the  time  of 
stool.  5.  Dietetic  principles  should  be  applied  with 
intelligence  and  the  etiological  causes  thoroughly  un- 
derstood. 6.  Cathartics  will  not  cure  constipation, 
but  are  positively  sure  to  aggravate  the  condition. 

REFERENCES. 

1.  MuRR-\v,  DwiGHT  H. :  Primary  Causes  and  Hygienic 
Treatment  of  Constipation,  New  York  Medical  Journal, 
November  8,  1919. 

2.  Mexdel,  L.  B.  :  Some  Relation  of  Diet  to  Disease, 
New  York  AIedical  Journal,  July  13,  1918. 

3.  Graham,  A.  B. :  Rectal  Conditions  in  Chronic  Con- 
stipation, New  York  Medical  Journal,  November  3,  1917. 

300  McDoNOUGH  Street. 

CHOLEDOCHITIS,   CHOLECYSTITIS  AND 
CHOLELITHIASIS.* 
The  Need  of  Early  Diagnosis  and  Treatment. 

By  B.  B.  Vixcext  Lyox,  M.  D., 
Philadelphia, 

Associate  in  Medicine,   Jeflferson    Medical   School;    Chief  of  Clinic, 
Gastrointestinal  Department,  Jefferson  Hospital,  Philadelphia. 

{Concluded  from  page  27) 

DIAGXOSIS. 

Diagnosis  is  then  developed  around  the  direct 
study  of  the  bile  and  the  manner  of  its  discharge — 
the  promptness  with  which  A  and  B  biles  appear, 
the  amount  of  B  bile  and  the  steadiness  or  the  in- 
termittency  of  its  discharge,  suggesting  normal 
tonus,  subtonus  or  hypertonus  of  gallbladder  mus- 
culature and  giving  inferences  as  to  its  capacity; 
on  the  gross  appearance  of  the  several  biles,  color, 
consistency,  viscosity,  transparency,  turbidity,  floc- 
culations,  mucus,  etc.,  and  especially  the  careful  ex- 
amination into  the  cytology  (epithelium,  whether 
bile  stained,  its  source,  pus,  leucocytes,  crystals, 
concretions,  red  blood  corpuscles,  inflammatory 
debris,  mucus,  bacteria)  ;  into  the  chemistry 
(lecithin,  cholesterin,  calcium,  pigments,  ef¥erves- 
cence  on  acidification)  ;  and  into  the  bacteriology 
by  culturation  of  each  of  the  segregated  samples  of 
bile. 

The  bacteriological  examination  must  be  care- 
fully conducted  and  promptly  done  to  prevent 
streptococci  and  other  less  hardy  organisms  becom- 
ing overgrown  with  the  more  rapidly  growing  colon 
groups,  Bacillus  pyocyaneus  and  Bacillus  subtilis. 
Cultures  should  be  made  at  the  time  of  the  with- 
drawal of  bile  in  the  office,  clinic  or  hospital,  and 
planted  in  glucose  broth  flasks,  blood  agar  tubes 

*Read  before  the  Twenty-Third  Annual  Meeting  of  the  American 
Gastroenterological  Society,  May  3  and  4,  1920. 


and  a  third  sample  put  in  a  sterile  test  tube,  labeled 
and  promptly  sent  to  the  pathologist  or  bacteriolo- 
gist unless  you  are  qualified  to  do  the  work  yourself. 

I  have  learned  that  I  get  more  reliable  cultures 
from  planting  the  mucopurulent  flakes,  especially 
when  heavily  bile  stained,  which  sink  down  to  the 
bottom  of  the  bottles,  particularly  those  of  B  bile. 
These  mucopurulent  flakes,  lifted  out  by  a  sterile 
pipette,  are  representative  of  material  from  the 
floor  or  walls  of  the  gallbladder,  ducts,  or  duo- 
denum. Microscopically  they  show  by  far  the 
most  interesting  and  conclusive  cjtological  condi- 
tion. If  more  cultures  were  taken  at  operation 
from  the  gallbladder,  from  the  mucopus  from  the 
floor  of  the  gallbladder  and  not  simply  from  the  su- 
pernatant bile,  I  believe  the  average  of  positive  cul- 
tures would  be  much  higher,  whether  the  gallblad- 
der showed  gross  pathological  changes  or  not. 
Withdrawing  bile  by  a  sterile  hypodermic  needle 
and  syringe  often  gets  the  supernatant  bile  only. 
I  wish  to  emphasize  the  need  for  careful  cultural 
technic  and  prompt  examination.  Much  important 
differential  diagnosis  hinges  on  this. 

Again  I  would  like  to  point  out  that  it  may  be 
possible  to  decide  where  the  source  of  the  maxi- 
mum infection  may  be,  even  though  A  and  B,  or  A 
and  B  and  C  biles  all  deliver,  say,  streptococcus 
and  colon  bacillus,  by  taking  advantage  of  colony 
counts.  For  instance,  if  you  plant  loopfuls  of  A 
and  B  biles  and  sow  them  through  blood-agar  petri 
plates  and  find  that  A  bile  grows  seven  colonies  and 
B  bile  ninety- four,  it  is  reasonable  to  conclude  that 
the  major  source  of  the  infection  is  the  gallbladder 
and  not  the  duct.  Similarly,  if  the  colony  counts 
from  C  bile  are  far  larger  than  A  or  B,  the  liver  is 
to  be  suspected  of  being  infected. 

This  plan  is  working  out  well  and  checking  up 
well  in  differential  diagnosis.  I  do  not  see  now, 
however,  how  we  can  ascertain  definitely  whether 
or  not  the  wall  of  the  gallbladder  or  of  the  ducts, 
or  the  duodenal  mucosa  is  definitely  infected  be- 
yond the  possibility  of  recovery  by  free  drainage 
and  topical  treatment  and  sensitized  vaccines. 
These  direct  diagnostic  findings  can,  therefore,  be 
used  to  amplify  or  to  interpret  the  information  se- 
cured from  the  history,  the  physical  examination 
and  from  special  examinations,  such  as  the  x  ray, 
stool,  stomach  and  blood. 

\\'e  can  thus  hope  progressively  to  modify  in 
the  future  the  one  time  true  statement  of  Stock- 
ton (10)  :  'Tt  is  difficult  to  reach  a  clinical  knowl- 
edge as  to  the  amount  of  bile  that  is  being  passed 
and  as  to  the  various  constituents  of  the  bile,"  and 
the  statement  of  Smithies  (11):  "The  average  text- 
book considers  cholecystitis  in  a  vague  uncertain 
way,  as  though  it  were  not  an  ailinent  second  in 
frequency  to  all  intraabdominal  disease  only  to  le- 
sions of  the  appendix.  Commonly  cholelithiasis 
meets  recognition  as  an  acute  dramatic,  abdominal 
crisis,  in  which  the  chief  roles  are  played  by  colic, 
chills,  fever,  sweats,  and  jaundice." 

The  differential  diagnosis  between  choledochitis 
and  cholecystitis  depends  to  a  large  extent  on  the 
bacteriology  and  cytolog>'  plus  the  gross  normality 
or  abnormality  of  the  bile.    This  will  be  referred 


July  10,  1920.] 


LYON:  GALLBLADDER  CONDITIONS. 


57 


to  in  greater  detail  when  the  diagnosis  of  atony  of 
the  gallbladder  is  discussed.  Of  course,  if  the  gall- 
bladder has  previously  been  removed  the  problem 
is  easier.  Empyema  of  the  gallbladder  is  easiest  to 
diagnose  directly,  provided  the  gallbladder  is  me- 
chanically able  to  discharge  a  specimen  of  its  con- 
tents. Dr.  Brown,  of  Montana,  recently  told 
me  that  he  had  examined  some  seventy  or  more 
suspected  gallbladder  cases  by  this  method.  Among 
them  w^ere  four  cases  of  empyema  successfully  and 
directly  diagnosed  and  two  of  the  four  he  had  suc- 
cessfully drained  and  tided  over  acute  complica- 
tions that  did  not  warrant  the  risk  of  surgery  at  the 
time. 

CHOLELITHIASIS. 

Regarding  the  diagnosis  of  cholelithiasis,  some 
helpful  points  can  now  be  suggested.  Of  course, 
the  recovery  of  gallstones  themselves  is  the  sine 
qua  non  of  this  diagnosis.  I  have  recovered  small 
concretions  through  the  duodenal  tube  in  one  in- 
stance, and  on  several  other  occasions  have  made 
stones  pass  either  out  of  the  gallbladder  or  out  of 
the  duct,  stones  too  large  to  be  recovered  by  tube 
but  found  on  sieving  the  stools.  In  none  of  these 
cases,  however,  do  I  feel  that  this  would  have  hap- 
pened at  the  time  of  diagnostic  drainage  if  mag- 
nesium sulphate  introduced  locally  did  not  possess 
the  power  to  relax  the  sphincter  and  to  contract  the 
gallbladder  wall.  Why  it  loses  much  of  its  power 
to  do  so  if  first  passed  across  the  gastric  mucosa, 
as  Meltzer  first  noted  and  which  I  have  confirmed, 
I  cannot  explain,  but  such  apparently  is  the  case. 

Next  in  importance  to  direct  recovery  of  definite 
gallstones,  gallsand  and  the  sense  of  grittiness  to  the 
finger  suggest  tlie  calculus  forming  possibility.  So 
does  the  microscopic  finding  of  large  agminated 
masses  of  precipitated  crystals  of  bile  salts  or  pig- 
ments, since  it  suggests  that  the  liver  cell  has  lost 
the  power  to  hold  these  substances  in  solution,  as 
occurs  in  the  formation  of  liver  or  hepatic  duct 
stones,  or  that  the  bile  in  the  gallbladder  has  be- 
come so  static  that  excessive  concentration  and 
crystallization  has  taken  place.  I  have  previously 
shown  that  the  sudden  dense  turbidity  that  one  sees 
taking  place  in  an  otherwise  perfectly  transparent 
bile  during  a  drainage  is  due  to  a  sudden  spurt  of 
acid  gastric  juice  entering  the  duodenum  and  mix- 
ing with  the  bile.  This  was  confusing  at  first  and 
is  still  annoying.  Dr.  Bartle,  working  with  me, 
found  that  this  turbidity  could  be  artificially  pro- 
duced in  the  case  of  every  clear  bile  by  artificially 
adding  dilute  hydrochloric  acid.  The  turbidity  va- 
ries according  to  the  strength  of  the  acid  and  the 
chemical  constituents  of  the  bile.  Later  certain 
clear  biles  were  encountered  in  which  an  efferves- 
cence as  well  as  the  turbidity  was  produced  on  add- 
ing hydrochloric  acid,  similar  to  the  reaction  of 
acetic  acid  and  calcium  carbonates  in  the  urine,  and 
the  question  has  been  suggested  as  to  whether  this 
might  mean  the  possibility  of  potential  or  formed 
calcium  carbonate  stones  in  the  gallbladder.  More 
work  must  be  done  on  this  point. 

ATOXY  OF  THE  GALLBLADDER. 

Relative  atony  of  the  gallbladder  is  something  I 
believe  we  can  diagnose  and  which  I  consider  to  be 


of  extreme  importance  because  I  believe  it  to  be  one 
of  the  earlier  phases  of  gallbladder  disease  and  the 
forerunner  of  gallstones  and  of  gallbladder  infec- 
tions.   This  diagnosis  is  suggested  in  three  ways : 

1.  The  recovery  of  static  or  off  color  bile,  rang- 
ing from  the  deeper  shades  of  golden  yellow,  into 
the  green  yellows,  green  blacks,  and  blacks,  and 
possessing  an  increasing  viscosity  from  that  of  a 
thick  syrup  to  that  of  tar.  Where  the  viscosity  is 
heavy  and  the  cytology  shows  much  mucus  and 
desquamating  masses  of  bile  stained,  high  colum- 
nar epithelium,  and  quantities  of  precipitated  crys- 
tals, I  consider  this  an  atonic  catarrhal  cholecystitis 
and  a  potential  forerunner  of  calculi.  I  have  seen 
this  type  alone  as  well  as  the  type  of  infected  chole- 
cystitis with  a  swarming  bacterial  flora  and  pus, 
blood  and  inflammatory  debris.  This  is  the  out- 
spoken type  giving  rise  to  well  marked  clinical 
symptoms.  But  I  have  also  frequently  seen  the 
masked  infective  cholecystitis  with  swarming  bac- 
teria and  static  bile,  but  no  cytological  inflammatory 
reaction  or  marked  cellular  destruction.  These  are 
the  cases  that  are  early,  do  not  show  interpretable 
clinical  symptoms,  but  give  rise  to  the  vague  atyp- 
ical dyspepsias,  and  these  too  are  the  cases  which 
operatively  are  passed  over  as  grossly  normal  and 
in  which  the  appendix  is  removed  and  the  masked 
focus  left  to  breed  pathological  conditions. 

2.  In  the  amount  of  static  bile  recovered.  If  a 
gallbladder's  normal  capacity  may  be  considered 
two  and  a  half  ounces,  and  if  four  ounces  of  this 
type  of  bile  can  be  recovered  in  bottles,  it  seems 
reasonable  to  assume  that  the  gallbladder  in  ques- 
tion must  be  functionally  atonic  and  unable  to  move 
its  contents  promptly  or  the  cystic  or  common 
ducts  must  be  partially  obstructed.  If  six  to  twelve 
or  more  ounces  of  this  static  bile  is  recoverable  (as 
in  my  series  of  cases),  it  must  appear  that  the  nor- 
mal distensible  sac  has  been  overdistended,  has  be- 
come dilated  and  has  perhaps  ruptured  some  of  its 
muscle  fibres  and  may  be  progressing  to  an  abso- 
lute atony.  The  functional  type  of  relative  atony 
seems  to  fit  in  well  with  many  of  the  cases  present- 
ing symptoms  of  socalled  biliousness  and  of  cyclic 
migraine  attacks.  These  also  are  groups  that  may 
be  the  forerunners  of  gallstones  and  pathological 
gallbladder  conditions. 

3.  In  normal  cases  when  B  bile  is  recovered  it 
comes  continuously  until  replaced  by  the  appear- 
ance of  C  bile  and  averages  from  one  to  three 
ounces  and  further  stimulation  with  magnesium 
sulphate  fails  to  recover  any  more.  Whereas, 
where  atony  is  suspected,  B  bile  appears,  the  bile 
is  static  to  varying  degrees  but  gallbladder  dis- 
charge may  be  intermittent,  that  is,  two  or  three 
ounces  of  B  bile  and  then  ten  to  thirty  c.  c.  of  C 
bile  and  again  two,  three  or  four  more  ounces  of 
static  B  bile.  Furthermore  it  is  possible  to  deliver 
more  of  this  type  of  bile  on  restimulating  with  mag- 
nesium sulphate.  "  It  is  reasonable  to  suppose  that 
such  gallbladder  musculatures  are  deficient  in  tone 
and  incapable  of  emptying  completely,  as  in  atony 
of  the  urinary  bladder,  with  its  residual  urine.  Of 
course,  there  are  limits  to  the  amounts  of  magne- 
sium sulphate  that  should  be  used.    I  think  a  safe 


58 


LYON:   GALLBLADDER  CONDITIONS. 


[New  York 
Medical  Journal. 


limit  might  be  placed  at  ninety  c.  c.  of  thirty-three 
per  cent,  representing  thirty  c.  c.  of  the  saturated 
sohition.  My  custom  is  to  start  with  seventy-five 
c.  c.  and  note  how  much  I  recover  in  the  first  bot- 
tle unmixed  with  bile.  If  I  recover,  say  forty  c.  c. 
I  can  then  restimulate  to  the  amount  of  fifty-five 
c.  c.  additional  and  still  keep  with  the  limit  of 
ninety  c.  c. 

It  may  be  as  well  to  mention  here  the  fact  that 
in  many  of  these  cases  we  are  draining  highly  in- 
fected material  from  the  biliary  passages  and  that 
some  of  this  fails  to  be  aspirated  into  the  bottles 
and  passes  down  the  intestines  possibly  to  infect 
susceptible  zones  lower  down.  There  are  two  log- 
ical ways  to  overcome  this.  First,  by  douching  the 
duodenum  with  various  disinfecting  solutions,  po- 
tassium permanganate,  silver  nitrate  or  possibly 
chloramine-T,  and  get  back  what  one  can.  I  per- 
sonally do  this,  but  do  not  advocate  it  for  any  one 
beginning  duodenal  work  of  this  kind,  for  it  has 
an  element  of  risk,  because  it  is  by  no  means  cer- 
tain that  you  can  get  out  again  what  you  put  in. 
Secondly,  to  hurry  along  the  infective  material  as 
rapidly  as  possibly  through  the  intestines.  To  do 
this  I  always  follow  each  biliary  drainage,  whether 
for  diagnosis  or  treatment,  with  a  duodenal  enema. 
I  prefer  Ringer's  solution,  for  its  healing  quahties, 
reinforced  by  a  five  tenths  per  cent,  or  twenty-five 
hundredths  per  cent,  sodium  sulphate  depending 
upon  how  much  magnesium  sulphate  solution  has 
failed  to  be  recovered.  The  total  amount  of  the 
duodenal  enema  I  keep  at  250  c.  c,  introduced  at 
105°  and  require  at  least  twenty  minutes  for  its 
introduction.  This  is  usually  effective  in  producing 
a  large  fluid  or  semifluid  bowel  movement  in  from 
fifteen  to  ninety  minutes.  Furthermore,  no  patient 
leaves  my  office  without  being  given  a  cup  of  bouil- 
lon and  some  crackers.  This  tides  them  over  the 
faintness  of  hunger  and  free  intestinal  evacuation. 

I  wish  to  refer  now  to  the  diagnostic  inferences 
that  might  be  possible  in  the  failure  to  obtain  B  or 
gallbladder  bile.  They  are  so  obvious  that  they 
merely  need  tabulation. 

It  might  indicate  any  of  these  possibilities:  1. 
Obstruction  of  cystic  duct,  by  a,  stone  or  stones, 
b,  adhesions  or  angulations  or  stricture,  c,  pressure 
from  without,  tumors,  lymphatic  glands,  or,  d,  in- 
spissated mucus,  hydrops.  2.  Gallbladder  contents, 
may  be  entirely  calculi  and  no,  or  relatively  little, 
bile.  3.  Weakness  of  gallbladder  musculature, 
atony,  dilatation,  too  weak  to  move  its  fluid  con- 
tents. 4.  Tarry  bile,  ultrastatic,  too  thick  to  flow. 
5.  Fibrosis  of  the  gallbladder. 

TREATMENT. 

This  method  during  the  past  three  years  has 
been  successfully  used  in  the  treatment  of  all  of 
the  states  of  biliary  diseases  mentioned  in  the  fol- 
lowing paragraphs.  Three  years  is  too  short  a  time 
to  predicate  an  opinion  as  to  the  ultimate  possibilities 
this  method  of  nonsurgical  biliary  drainage  may 
possess.  Its  principles  are  soundly  established  and 
are  logical.  Furthermore,  one  is  able  to  gauge 
progress  made  by  the  improvement  in  direct  ob- 
jective findings  in  addition  to  the  usual  method 
of  estimating  clinical  and  symptomatic  improve- 


ment. The  ultimate  criterion  of  a  cure  in  the  real 
sense  is  more  nearly  within  our  grasp. 

We  are  mechanically  applying  the  surgical 
principles  of  free  drainage  for  infected  sacs,  tubes 
and  tissues,  of  free  drainage  for  catarrhal  states  of 
inflammation  of  various  grades  but  without  in- 
fection, of  free  drainage  for  gallbladders  that  are 
atonic  and  contain  static  bile  in  which  sooner  or 
later  there  develop  stones  or  a  more  serious  patho- 
logical condition,  and  while  applying  surgical 
principles  we  are  doing  it  nonsurgically  and  avoid- 
ing certain  surgical  risks.  Besides  this,  and  even 
more  important,  we  are  preserving  tissue  which 
may  possess  a  power  of  recovery  of  function  beyond 
our  present  conception.  Patients  suitable  for  this 
method  of  treatment  should  be  selected.  Its  real 
sphere  of  usefulness  lies  in  giving  a  direct  method 
of  treatment  in  early  stages  of  disease,  diagnosed 
early,  before  gross  pathological  changes  have  taken 
place.  Removal  of  pathological  tissue,  of  gallstones, 
etc.,  must  be  left  to  the  surgeon.  Our  aim  should 
be  to  learn  better  to  diagnose  the  beginnings  of 
these  diseases  and  to  institute  promptly  direct,  ra- 
tional and  safe  measures  of  treatment.  We  may 
legitimately  hope  that  this  method,  if  intelligently 
applied,  may  decrease  the  number  of  cases  requir- 
ing serious  and  dangerous  surgery. 

TECHNIC. 

The  technic  of  treatment  is  not  difficult  and  can 
be  carried  out  by  hospital  interns  and  even  by 
nurses  after  a  little  practice.  It  does  not  require 
the  expert  supervision  of  the  highly  trained  special- 
ist, although  it  is  naturally  better  if  such  service 
can  be  secured.  Here  it  differs  at  once  from  the 
necessity  of  procuring  the  most  skillful  surgeon  for 
surgery  of  the  upper  right  quadrant  of  the  abdomen. 
This  is  not  the  field  for  the  occasional  operator. 
It  is  time  that  we  recast  some  of  our  accepted  views. 
To  operate  and  have  the  patient  live  and  to  operate 
and  make  the  patient  well  are  two  very  different 
things.  It  is  one  thing  to  cut  out  pathological  tissue 
and  quite  another  to  restore  pathological  physiology 
already  existent,  or  that  created  or  increased  by 
the  operative  procedure. 

The  technic  of  this  treatment  is  easy  but  it  is  the 
skill  in  the  general  diagnosis  and  the  technic  of 
handling  the  minutiae  of  special  diagnosis  that 
require  the  highly  trained  specialist,  and  the  better 
his  training  in  pathology  and  physiology  and  the 
keener  his  enthusiasm  for  the  use  of  the  microscope, 
the  test  and  culture  tube  the  more  valuable  will  be 
his  opinion. 

Simple  catharrhal  jaundice  may  be  treated  very 
satisfactorily  by  this  method.  The  duration  of 
jaundice  in  the  ordinary  case  may  be  cut  in  half 
and  potential  drainage  to  the  ducts,  gallbladder  and 
liver  may  be  prevented.  Recent  papers  (12)  have 
shown  what  can  be  done  in  the  treatment  of  this 
condition  by  this  method. 

Choledochitis  and  cholangeitis  may  be  successfully 
treated  in  favorable  cases,  especially  where  there 
has  not  been  any  surgical  interference.  That  means 
the  relatively  early  cases.  Even  in  late  cases  where 
there  has  been  well  established  pathology  and  several 
preceding  operations  this  method  may  give  an  un- 


July  10,  1920.] 


LVOX: 


GALLBLADDER  COXDITIOXS. 


59 


expected  brilliant  result.  This  was  evidenced  in 
one  young  girl  whose  case  I  have  reported  at 
length  (8j.  She  had  three  major  and  one  minor 
gallbladder  and  duct  operations  performed  in  three 
years  with  two  further  years  of  constant  suffering 
and  remittent  exacerbations  of  choledochitis,  finally 
culminating  in  a  ver\-  se\  ere  and  acute  attack,  with 
complete  duct  obstruction,  chills,  fever,  sweats,  high 
leucoc>-tosis  and  toxemia,  yet  her  condition,  with 
its  very  serious  aspects,  responded  splendidly  to 
this  method  of  attack,  and  today  the  girl  is  well  and 
has  remained  free  from  any  further  exacerbation 
for  nearly  three  years. 

I  have  within  the  week  seen  a  young  woman 
of  twenty-six  who  had  her  gallbladder  and  stones 
removed  twenty-three  months  ago ;  she  had  two 
weeks  of  surgical  tube  drainage  and  nearly  four 
months  of  dressing  drainage.  She  remained  free 
from  symptoms  for  just  two  months,  when  exacer- 
bations recurred  and  during  the  past  eighteen  months 
she  had  had  an  equal  number  of  attacks  of  severe 
colicky  pain  which  two  weeks  ago  culminated  in 
chills,  fever,  and  acute  obstructive  jaundice.  Unless 
her  common  duct  can  be  speedily  implugged  dilata- 
tion of  the  ducts  and  biliar\-  cirrhosis  may  develop 
because  her  safety  valve,  the  gallbladder,  has  been 
removed.  It  is  more  difficult  to  unplug  such  a  duct 
when  the  gallbladder  has  been  removed,  because  the 
contraction  of  the  bladder  supplies  a  good  part  of 
the  I'l^  d  tergo.  It  is  remarkable  to  what  extent  the 
gallbladder  can  distend,  as  witness  the  case  of  the 
little  girl  at  Johns  Hopkins  Hospital,  recently  re- 
ported upon,  whose  ver\-  distended  gallbladder  con- 
tained nearly  a  litre  of  bile. 

What  I  have  said  of  choledochitis  applies  to 
cholecystitis,  perhaps  if  an}-thing  more  favorably. 
Especially  so  in  the  early  cases,  such  as  those 
complicating  typhoid  fever,  and  masked  focal  in- 
fections of  the  gallbladder.  This  is  the  time  to 
diagnose  and  to  drain,  nonsurgically.  in  such  cases 
and  not  wait  for  the  development  of  a  full  blown 
pathological  condition. 

Empyema  of  the  gallbladder  has  been  success- 
fully treated  during  its  acute  phases  in  patients  who 
presented  severe  cardiorenal  contraindications  for 
surgery.  That  is  to  say.  their  gallbladders  have 
been  drained  successfully,  the  maximum  source  of 
their  toxemia  has  been  temporarily  removed,  and 
they  have  been  tided  over  to  a  point  where  corrective 
surger\-  for  the  removal  of  the  pathological  condi- 
tion could  be  more  safely  practised.  There  is 
nothing  to  prevent  the  success  of  nonsurgical 
drainage  in  empyema  provided  the  cystic  duct  is 
patulous.  This  is  by  no  means  recommended  as 
the  method  of  choice  but  as  a  possible  alternative 
measure  worthy  of  trial  in  selected  cases  presenting 
grave  surgical  contraindications. 

Cholelithiasis  remains  entirely  beyond  the  scope 
of  this  method,  although  stones  have  been 
made  to  pass  through  the  common  duct.  Our 
efforts  should  be  directed  to  the  detection  and 
treatment  of  the  early  states  of  pathological 
physiology  and  to  the  prevention  of  calculi.  The 
method  has,  however,  distinct  merit  as  a  postopera- 
tive follow  up  treatment  to  prevent  the  reformation 
of  stones  and  to  continue  to  drain,  cx  corporc,  still 


infected  bile  beyond  the  limits  afforded  by  surgical 
methods  of  drainage.  This  has  been  proved  a 
successful  measure. 

The  one  field  where  this  method  can  be  strongly 
recommended  is  in  the  treatment  of  biliary  stasis 
or  faulty  retention  of  gallbladder  bile.  If  more 
cases  of  biliousness  were  investigated  by  this  method 
it  would  surprise  many  of  you  to  find  the  gallbladder 
atonic  to  varying  degrees  and  unable  to  discharge 
its  static  bile.  These  are  the  patients  in  whom,  if 
they  are  left  to  themselves  and  their  cholagogues, 
a  quarry  of  stones  will  develop.  These  patients 
do  extremely  well  and  it  is  remarkable  to  see  their 
improvement  in  color,  digestion  and  bowel  function. 
They  lose  their  lethargy-  and  recover  their  sense  of 
wellbeing.  Many  of  these  atonic  gallbladders  are 
harboring  pathogenic  microorganisms  but  still  pre- 
serve sufficient  mucosal  resistance  to  prevent  in- 
fection of  their  walls.  This  is  the  time  to  treat  them 
energetically  by  frequent  drainage.  Baaerial  identifi- 
cation should  be  carefully  made  and  autogenous  vac- 
cines have  an  important  place  of  usefulness.  It  is 
ver\-  important  to  search  back  for  primar\-  foci  of 
matched  bacteriology  in  the  teeth,  tonsils,  sinuses, 
bronchial  tract,  stomach  or  duodenum  and  remove 
them.  Many  of  these  cases  of  biliary  stasis  are 
associated  with  various  forms  of  migraine.  Some 
of  them  respond  almost  miraculously  to  biliary 
drainage :  others  are  very  resistant,  suggesting  a 
different  causative  factor. 

SUMMARY. 

To  sum  up  in  a  few  words,  this  method  has  al- 
ready achieved  a  position  of  importance  in  the  diag- 
nosis of  biliary  diseases.  In  the  field  of  treatment 
it  is  certainly  the  method  of  choice  for  biliary  stasis, 
gallbladder  atony,  and  in  the  early  states  of  catarrh 
and  infection.  It  may  be  found  to  decrease  the 
incidence  of  stone  formation  and  thus  of  cancer  of 
the  gallbladder.  It  will  decrease  the  tendency  to  dam- 
age the  pancreas  and  liver.  It  may  decrease  the 
frequency  of  acute  and  chronic  pancreatitis,  of  bil- 
iary cirrhosis  and  possibly  diabetes.  It  may  have  a 
place  as  an  alternative  method  of  treatment  for 
some  of  the  surgical  groups  presenting  operative 
contraindication.  It  certainly  is  useful  as  a  post- 
surgical followup  plan  of  treatment  in  many  cases. 

^lore  time  must  elapse  to  prove  its  final  evalua- 
tion. Quite  true,  but  one  must  start  somewhere. 
It  has  had  a  good  beginning.  It  may  go  further. 
It  is  within  my  province  to  call  your  attention  to  it, 
and  within  yours  to  prove  that  it  has  the  merit  which 
I  believe  it  to  possess. 

As  to  future  possibilities,  it  offers  an  attractive 
opponunity  for  further  direct  clinical  investigation 
into  and  the  interpretation  of :  1 .  \Miat  are  the  cho- 
lagogues? How  do  they  act?  a.  By  increasing 
liver  secretion  of  bile  or  the  velocity  of  its  dis- 
charge ?  b.  Do  they  empty  the  gallbladder  ?  2.  Pre- 
cursory states  and  phases  of  gallstones  and  infec- 
tions, i.  e.  biliary  stasis  and  atony.  3.  Parallel 
studies  on  pancreatic  secretion,  velocity  of  elabora- 
tion of  ferments  and  their  discharge.  What  are  the 
elective  pancreatic  secretogogues  ?  Have  tliey  a  place 
in  the  prevention  and  treatment  of  diabetes?  4.  Ex- 
tending the  scope  of  chemical  investigations  into  the 
composition  and  physical  properties  of  bile. 


60 


DIAMOXD:  PEPTIC  ULCER. 


(New  York 
Medical  Journal. 


Here  are  many  usefully  important  problems 
awaiting  solution. 

REFERENXES. 

1.  Meltzer,  S.  J.:  American  Journal  of  the  Medical 
Sciences,  153:  469,  April,  1917. 

2.  Lyox,  B.  B.  \"ixcext:  Journal  A.  M.  A.,  September 
27,  1919,  Vol.  Ixxiii. 

3.  De.a,ver,  J.  B.:  Journal  A.  M.  A.,  April  17,  1920, 
Vol.  Ixxiv. 

4.  Smithies.  Fr.\xk,  Xorthn'cst  Medicine,  February. 
1920. 

5.  Lyox,  B.  B.  Vixcext,  Ibid.  cf.  Ref.  No.  2. 

6.  Idem:  Medical  Clinics  of  Xortli  America,  March, 
1920,  April,  1920. 

7.  Idem:  Medical  Clinics  of  Xortii  America,  March, 
1920. 

8.  Idem:  To  appear  in  American  Journal  of  Medi- 
cal Sciences. 

9.  Meltzer,  S.  J. :  Ibid. 

10.  Stocktox,  Charles  G.  :  Practical  Treatment  by 
Musser  and  Kelh',  vol.  iii,  p.  498. 

11.  Smithies,  Fr.\xk  :  Ibid. 

12.  Hopkins,  A.  G.,  Medical  Clinics  of  North  America, 
■March,  1920.    Lyon,  B.  B.  Vincent,  cf.  Ref.  No.  6. 


PEPTIC  ULCER. 

Clinically  and  Rdntgenologically  Considered. 

By  Joseph  S.  Diamond,  M.  D., 
New  York, 

Associate  Rontgenologist,   Beth   Israel  Hospital. 

The  refinements  in  diagnosis  of  peptic  ulcer  have 
not  only  facilitated  the  detection  of  this  intractable 
disease,  but  have  broadened  our  views  and  clarified 
our  understanding  of  the  varied  pathological  mani- 
festations. The  functional  gastric  neurosis  to 
which  our  older  textbooks  devote  chapters  are  today 
seen  in  a  different  light,  and  many  of  them  can 
presently  be  interpreted  on  pathological  bases.  The 
socalled  Reichman  disease,  spoken  of  as  a  functional 
hypersecretion,  is  today  better  understood  as  hyper- 
secretion concomitant  with  duodenal  ulcer.  Hyper- 
acidity is  no  longer  regarded  as  simple  or  functional 
hyperchlorhydria,  but  can  invariably  be  accounted 
for,  and  if  not  resulting  from  gastric  disease,  per- 
haps arises  reflexly  from  a  lesion  of  a  remote  ab- 
dominal organ.  Such  able  workers  as  Alayo, 
Smithies,  Einhorn,  Hamburger,  Case.  Cole,  and 
others  in  this  country ;  and  Moynihan,  Forsel,  Hau- 
deck,  Holzknecht,  Rieder,  and  Retzius  abroad,  have 
enriched  the  literature,  each  adding  something  to 
pathogenesis,  diagnosis,  or  treatment. 

The  symptomatology  of  ulcer  has  been  consider- 
ably popularized  at  present,  so  much  so  that  every 
physician  is  on  his  guard  when  confronted  with  a 
symptom  complex  of  gastric  complaints.  Moynihan 
has  said  that  a  diagnosis  of  duodenal  ulcer  can  be 
made  by  correspondence.  While  a  case  presenting 
classic  symptoms  may  be  recognized  with  ease,  yet 
it  is  only  by  careful  analytical  study  embracing  the 
subject  broadly  that  conclusions  approachnig  correct 
diagnosis  can  be  reached.  The  borderline  cases  are 
still  in  a  maze  of  complexity,  and  create  many 
doubts,  especially  so  when  the  conscientious  sur- 
geon is  confronted  with  exploratory  laparotomies 
in  these  obscure  cases. 

An  attempt  will  be  made  in  this  article  to  cover 
briefly  the  most  important  data  at  present  utilized 
in  the  diagnosis  of  peptic  ulcer  and  to  discuss  their 


merits,  as  well  as  the  modem  conception  of  etiology, 
pathology,  symptomatology,  and  disturbed  motor 
and  secretory  functions.  There  are  three  main  fac- 
tors to  be  considered.  Enumerated  in  the  order  of 
their  importance,  they  may  be  cited  as  follows: 
1,  anamnesis,  or  the  clinical  symptom  complex;  2, 
rontgen  examination ;  3,  chemistry  of  the  stomach 
and  intestines. 

ETIOLOGY   AND    PATHOLOGICAL  ANATOMY. 

The  etiology  of  peptic  ulcer  still  forms  a  fasci- 
nating chapter  in  medical  literature  and  though  shy 
of  complete  solution,  yet  it  is  nearer  the  compre- 
hensive goal.  Many  theories  have  been  advanced 
and  while  there  is  truth  in  some,  in  others  consider- 
able contradiction  outweighs  the  assertions.  The 
modern  conception  of  pathogenesis  of  peptic  ulcer 
includes  several  factors  which  may  be  cited  as  fol- 
lows: 1,  spasm  or  neurogenesis;  2,  infection,  and  3,. 
traumatism,  whether  mechanical,  physical  or  chem- 
ical. 

While  the  literature  abounds  in  numerous  data 
of  experimental  research  work  beginning  with  \'ir- 
chow  in  1885,  most  of  these  have  but  a  historical 
interest.  \'irchow's  theory  of  embolism  or  throm- 
bosis causing  circulatory  interference  in  localized 
areas  in  the  stomach  wall,  thus  causing  necrosis,  ul- 
ceration and  digestion,  did  not  stand  the  scrutiny  of 
later  studies.  The  gastric  vessels  are  not  terminal 
and  are  rich  in  anastomosis.  Furthermore,  the  age 
affected  by  ulcer  is  not  one  conducive  to  vascular 
changes.  Even  those  ulcers,  produced  by  Cohnheim 
and  later  by  ^IcCallum  by  the  injection  of  finely 
divided  suspension  of  lead  chromate  or  ultramarine 
blue  causing  hemorrhagic  ulcerations  in  the  mucous 
membranes,  apparently  on  the  theory  of  circulatory 
interference,  heal  promptly  like  all  other  traumatic 
ulcers  without  the  production  of  the  typical  round 
ulcer.  Other  experiments,  such  as  obstructing  the 
portal  circulation,  severing  the  vagi,  or  cutting 
various  segments  of  the  cord  at  various  levels,  have 
neither  produced  the  socalled  peptic  ulcer  nor  have 
been  conducive  to  any  logical  understanding  as  to 
the  causation  of  this  type  of  ulcer. 

The  problem  that  confronts  us  is  to  understand 
what  particular  pathological  process  takes  place 
which  leads  to  the  formation  of  the  typical  round, 
punched  out  ulcer,  with  sloughing  base  and  over- 
hanging edges,  the  socalled  classic  peptic  ulcer,  the 
ulcer  that  is  chronic  and  occurs  at  stated  intervals. 
It  must  possess  all  these  characteristics  before  it 
can  be  classed  as  peptic  ulcer.  It  is  well  known 
that  chemical  ulcers,  as  well  as  other  traumatic  ul- 
cers, do  occur  but  heal  rapidly  without  giving  any  of 
these  recognized  manifestations.  Such  cannot  be  re- 
garded as  peptic  ulcer.  As  we  shall  see  later  on, 
there  is  another  factor  to  be  considered  which  tends 
to  embrace  such  morbid  processes. 

Spasm. — The  theory  of  spasm  of  the  gastric  mus- 
cles as  a  forerunner  of  ulcer  has  been  mentioned  by 
Talma  and  his  pupil  \'on  Yzeren.  Strong  evidence 
has  been  accumulated  in  recent  years  that  place 
spasm  as  the  most  plausible  factor  in  the  causation  of 
gastric  ulcer.  Eppinger  and  Hess,  through  their 
elaborate  studies  of  the  autonomic  or  vegetative 
nervous  system  and  the  disturbances  attending  vago- 


July  10,  1920.] 


DIAMOXD:  PEPTIC  ULCER. 


61 


tonia  and  sympathicotonia,  have  shown  a  close  an- 
alogy between  the  symptom  complex  of  ulcer  and 
the  many  similar  manifestations  of  the  vagotonic 
state.  They  call  attention  to  the  local  vagotonia 
where  the  various  stimuli  act  upon  the  autonomic 
supply  to  the  smooth  muscle  and  secretory  appar- 
atus of  the  stomach  and  produce  pathological  states 
of  the  same  nature  as  are  found  when  the  autonomic 
system  is  in  an  increased  state  of  irritability.  These 
are  analogous  to  the  subjective  as  well  as  many  ob- 
jective manifestations  of  gastric  ulcer.  In  truth  do 
we  not  observe  clinically  the  S)-mptom  of  pyrosis, 
sour  eructations,  fullness  and  pressure  after  meals, 
hunger  pain  in  both  conclusions  ?  Do  we  not  see  un- 
der the  fluoroscope  the  .same  hyperkinetic  manifesta- 
tions of  deep  peristaltic  waves,  gastrospasm  with  in- 
cisures, pylorospasm,  and  cardiospasm?  Do  we  not 
find  the  same  chemical  changes  of  high  acidit)'  in 
both?  And  furthermore,  are  not  the  susceptibilities 
of  the  inherent  biological  properties,  their  reaction 
to  chemical  substances  (atropine,  pilocarpine)  alike 
in  both  states  ? 

Gross  and  Held  point  out  the  muscular  distribu- 
tion in  the  structure  of  the  stomach  emphasizing 
that  the  strongest  musculature  is  where  function  is 
greatest  and  where  spasm  most  abounds.  The 
groove  of  Retzius  is  strengthened  by  the  oblique 
bundle  of  fibres.  The  antrum  and  pylorus  as  well 
have  the  greatest  muscular  supply.  It  is  in  these 
regions  that  ulcer  most  frequently  occurs. 

Friedman  and  Hamburger  produced  acute  ulcers 
in  a  series  of  experiments  in  dogs  by  the  injection 
of  five  per  cent,  silver  nitrate  into  the  submucous 
tissue  of  the  stomach.  They  succeeded  in  retarding 
the  healing  of  these  ulcers  by  ligation  of  the  py- 
lorus and  thereby  rendering  them  chronic.  They  de- 
duce from  their  experiments  that  the  delay  in  heal- 
ing is  greater  when  the  food  and  gastric  juice  are 
ground  against  the  ulcer  with  unusual  violence. 
They  conclude  further  that  any  acute  ulcer  in 
man  which  may  be  produced  by  abrasion  of  a 
coarse  food  particle  or  other  form  of  traumatism 
will  become  a  chronic  ulcer  when  there  is  an  asso- 
ciated condition  of  spasm.  When  we  remember  that 
pylorospasm  results  from  an  increased  irritability  of 
the  autonomic  nerve  supply,  or  from  reflexes  of 
distal  organs,  supplied  by  the  same  nerves,  the  gall- 
bladder, appendix,  cecum,  proximal  colon,  liver, 
and  pancreas,  it  is  easy  to  conceive  how  an  abra- 
sion in  the  mucous  membrane  of  the  stomach  may 
become  a  chronic  ulcer.  Pylorospasm  is  usually  as- 
sociated with  hyperacidity,  hyperperistalsis.  and  im- 
paired motility,  and  these  are  the  factors  that  are 
the  forerunners  of  and  prepare  the  field  for,  the  de- 
velopment of  gastric  ulcer. 

Infection. — Rosenow  states  that  the  intravenous 
injection  of  streptococci  of  the  proper  grade  of  viru- 
lence (moderately  high  grade)  may  be  followed  by 
ulcer  of  the  stomach  and  duodenum.  The  culture 
obtained  was  usually  from  infected  tonsils  in  cases 
of  articular  rheumatism  or  from  the  base  of  an  in- 
durated chronic  ulcer  in  man.  These  various  strains, 
when  passed  a  number  of  times  through  various 
animals  until  the  proper  virulence  was  obtained, 
sometimes  produced  ulcer  after  the  fifteenth  injec- 
tion.   All  these  ulcers  appear  very  acute  and  show 


evidences  of  a  severe  grade  of  infection  by  the  in- 
flammatory reaction,  hemorrhages  and  rapid  slough- 
ing of  tissue — often  causing  perforation.  Simul- 
taneously with  these  ulcers  are  found  acute  arthri- 
tis, myositis,  nephritis  and  other  evidences  of  a 
septic  general  infection. 

From  the  foregoing  paragraph  one  must  conclude 
that  the  analogy  between  those  septic  conditions  and 
peptic  ulcers  in  man  is  still  very  remote.  The  link 
in  the  chain  from  this  type  of  experiments  has  as 
yet  not  established  the  relation  between  infection 
and  peptic  ulcer. 

John  B.  Deaver  perhaps  best  sums  up  the  infec- 
tion theory,  as  follows:  "The  action  of  bacteria  on 
the  capillaries  of  the  stomach  causes  an  irritation 
and  injury  to  the  endothelial  cells  with  an  escape  of 
blood  into  the  submucous  space.  This  later  forms 
a  localized  abscess  which  discharges  and  leaves  an 
ulcer  base.  The  constant  bathing  in  an  acid  medium 
tends  to  keep  the  ulcer  chronic." 

Traumatism. — Many  have  thought  that  trauma- 
tism in  all  forms,  whether  physical,  mechanical,  or 
chemical,  can  produce  ulcers.  \'iolence.  such  as  that 
produced  by  repeated  blows  over  the  abdomen,  has 
been  said  to  produce  ulcer.  Tight  lacing  and  occu- 
pations requiring  constant  pressure  over  the  upper 
abdomen  have  been  attributed  as  a  cause  of  ulcer. 
Leube  and  Decker  have  shown  that  burning  the 
mucosa  of  the  stomach  with  hot  food  caused  ulcer. 
W.  J.  ]Mayo  states  that  the  ingestion  of  hot  liquid 
foods  will  cause  ulcer.  Such  theories,  while  very 
plausible,  can  only  be  held  accountable  for  ulcers  on 
a  limited  area  on  or  about  the  groove  of  Retzius 
close  to  the  incisura  cardica  and  down  as  far  as  the 
pars  media.  The  temperature  of  the  food  is  surely 
lowered  by  the  time  it  reaches  the  pylorus  on  mix- 
ing with  the  secretions  of  the  stomach  and  the 
chyme.  When  we  further  consider  that  seventy- 
eight  per  cent,  of  all  the  peptic  ulcers  are  contained 
in  the  duodenum  within  the  postpyloric  regions, 
surely  this  form  of  trauma  cannot  be  held  responsi- 
ble for  the  large  field  of  peptic  ulcers. 

Hyperacidity  and  autodigestion. — Attention  has 
been  drawn  to  the  fact  that  peptic  ulcer  is  found 
only  in  that  portion  of  the  digestive  tract  where  the 
presence  of  hydrochloric  acid  is  found.  A  great 
deal  of  importance  has  been  attached  to  the  hyper- 
acid gastric  juice.  Pavy,  Samuelson,  and  Matthews 
have  retarded  the  healing  of  ulcer  by  irrigating  the 
stomach  of  a  dog  with  a  0.56  per  cent,  solution  of 
hydrochloric  acid.  The  action  thus  produced  would 
be  a  corrosion  of  the  superficial  layers  of  tissue  im- 
mediately followed  b}'  the  digestive  act  of  pepsin  in 
the  acid  media.  The  question  as  to  why  the  stomach 
does  not  digest  itself  in  toto  has  been  answered  by 
Weinland  who  attempted  to  prove  the  presence  of  a 
living  antiferment  in  the  living  cells  of  the  stomach 
thus  protecting  the  ferment  action  of  pepsin.  Wein- 
land thinks  that  the  inability  of  a  localized  area  of 
tissue  to  produce  antipepsin  in  a  hyperacid  medium 
causes  local  digestion  and  ulcer  formation. 

From  this  exposition  of  the  etiology  of  peptic 
ulcer  we  must  conclude  that  there  is  always  present 
a  predisposing  factor  consisting  of  an  increased  ir- 
ritability of  the  autonomic  nervous  system.  This 
state  is  a  forerunner  and  acts  as  a  receptive  back-* 


62 


DIAMOND:  PEPTIC  ULCER. 


[New  York 
Medical  Journal. 


ground.  The  inciting  factor  may  be  an  abrasion  in 
the  mucous  membrane  which  is  produced  either  by 
a  coarse  food  particle  or  any  other  mechanical,  ther- 
mal, bacterial  or  chemical  agent.  When  such  super- 
ficial abrasion  occurs  under  these  favorable  cir- 
cumstances when  bathed  by  the  hyperacid  and  pep- 
sin medium,  when  subjected  to  the  constant  grinding 
of  the  hyper  irritable  gastric  musculature,  and  where 
pylorospasm  and  gastrospasm  are  constant  factors, 
only  under  such  states  is  it  plausible  to  assmne  that 
a  peptic  ulcer  with  all  its  characteristics,  may  de- 
velop. 

CLINICAL   MANIFESTATIONS  OR  ANAMNESIS. 

^loynihan  says:  "First  and  foremost  (indeed  if 
not  exclusively)  the  anamnesis.  Great  importance 
must  be  attributed  to  a  good  clinical  history.  One 
should  learn  to  acquire  the  art  of  elucidating  the 
important  symptoms  of  the  patient's  complaint. 
Patients  often  dwell  on  the  least  significant  of  the 
symptom  complex  and  will  mention  subjective  symp- 
toms that  have  no  bearing  on  their  chief  com- 
plaint." A  great  teacher,  T.  C.  Janeway,  often  said : 
"Regard  your  patient  as  a  witness ;  cross  examine 
him  as  a  lawyer  would.  The  greater  the  art  of  your 
cross  examination  the  more  facts  will  you  be  able  to 
gather  from  your  patient."  The  type  of  patient, 
whether  hypersensitive  or  phlegmatic  as  well  as  the 
degree  of  intellect,  should  be  taken  into  considera- 
tion. His  ability  in  interpreting  and  imparting  his 
own  complaints  to  the  examining  physician  must 
likewise  be  considered. 

The  characteristic  symptom,  whose  presence  we 
must  aim  to  ascertain,  is  pain.  There  must  be  pain 
in  ulcer.  Without  pain  there  can  be  no  ulcer.  The 
pain  is  most  often  described  as  gnawing,  boring, 
or  burning.  The  pains  are  usually  so  spoken  of  at 
the  highest  stage  of  their  severity.  In  the  earlier 
stages  the  pain  may  not  be  so  characteristic.  A  his- 
tory can  be  obtained  of  an  insidious  onset,  of  a 
sense  of  distention  or  oppression,  of  fullness  or 
weight  in  the  epigastrium  after  meals.  Associated 
with  these,  other  symptoms  make  their  appearance, 
such  as  pyrosis,  eructation  and  waterl)rash  whose 
acrid  taste  often  burn  the  throat.  During  this  stage 
some  will  still  pay  little  or  no  attention  to  these 
symptoms ;  others  will  seek  relief  in  bicarbonate  of 
soda  which  stops  the  discomfort  by  the  expulsion  of 
gas  and  neutralization  of  the  acid.  A  sensation  of 
choking  in  the  throat  which  is  often  regarded  as  a 
neurosis  manifests  itself,  which  is  none  other  than 
an  indication  of  vagotonia  concomitant  with  the 
general  increase  in  the  irritabilit}-  of  the  autonomic 
nervous  system  occurring  in  ulcer.  The  periodicity 
of  these  symptoms,  their  seasonal  appearance  and 
disappearance,  is  rather  striking.  Patients  will  often 
say  that  they  feel  better  during  summer  and  are 
worse  during  early  spring  or  late  fall. 

As  the  disease  progresses  intense  pain  makes  its 
appearance,  coming  always  at  a  definite  interval  af- 
ter a  meal  and  may  be  accompanied  by  the  distress 
of  distention  or  a  'blown-out'  feeling.  At  times 
they  occur  in  the  form  of  abdominal  cratups  or  may 
even  simulate  an  attack  of  severe  colic,  necessitat- 
ing the  administration  of  a  hypodermic  injection  of 
■  morphine.  Several  such  cases  are  known  to  the 
writer  and  have  clinically  been  mistaken  by  good  ob- 


servers for  cholelithiasis  when  the  x  ray  examina- 
tion and  the  surgical  operation  revealed  a  pene- 
trating ulcer.  The  intense  burning  may  not  always 
be  spoken  of  by  the  patients  in  terms  of  pain.  As 
is  often  observed  in  duodenal  and  pyloric  ulcer, 
patients  are  awakened  at  night  by  an  intense  burn- 
ing sensation  in  the  stomach,  so  that  they  are  forced 
to  induce  vomiting  in  order  to  obtain  relief,  yet 
they  speak  of  this  as  burning  btit  not  pain. 

Time. — These  pains  bear  definite  relation  to  the 
time  of  the  intake  of  food.  The  time  varies  any- 
where from  one  to  three  or  five  hours  after  meals. 
The  nearer  the  ulcer  to  the  cardia  the  earlier  the  pain. 
There  are,  however,  exceptions  to  this  rule.  Late 
pains  speak  for  duodenal  ulcer ;  early  pain  coming 
on  three  quarters  to  one  hour  after  partaking  of  food 
indicates  an  ulcer  on  the  pars  media  of  the  stomach. 

Hunger  pains. — The  appetite  is  usually  good,  of- 
ten ravenous.  The  patients  eat  with  a  keen  relish 
and  enjoy  their  meals  after  which  they  experience 
for  the  first  few  hours  a  feeling  of  satiety  and  com- 
fort. When  the  disease  has  lasted  for  some  time, 
however,  these  patients  begin  to  shun  food  for  fear 
of  the  consequences.  It  is  a  daily  occurrence  to 
hear  them  remark  that  they  would  like  to  eat  but  are 
afraid  when  the  disease  has  existed  for  some  time. 
The  sensation  spoken  of  as  himger  pain,  which  I 
would  rather  designate  as  hunger  gnawing,  should 
be  differential  from  keen  appetite,  for  this  sensa- 
tion is  always  present  even  in  the  patients  who  have 
lost  their  appetites.  It  is  due  to  the  hypersecretion 
present  which  is  strongly  hyperacid  and  is  always 
present  luany  hours  after  a  meal  when  the  stomach 
is  ordinarily  emptied.  One  often  sees  patients  lean, 
haggard,  with  a  dyspeptic  facies,  who  have  trained 
themselves  to  inanition  and  who  have  lost  all  desire 
to  eat,  yet  in  whom  the  htmger  gnawing  is  always 
present  and  can  be  elicited  on  close  questioning. 
These  patients  will  then  freely  admit  that  they  carry 
a  few  biscuits  with  them  which  they  eat  whenever 
this  gnawing  arises  and  are  promptly  relieved.  Some 
patients  take  milk  at  night  for  the  same  reason,  this 
likewise  relieving  them  as  soon  as  the  acid  is  given 
an  opportunity  to  combine  with  the  food. 

Location  of  the  pain. — The  location  of  the  pain 
depends  on  the  location  of  the  ulcer.  In  duodenal 
and  pyloric  ulcers  the  pain  is  to  the  right  of  the 
midline  or  sometimes  at  the  midline,  and  is  referred 
upward  into  the  right  hypochondrium,  sometimes 
to  the  right  nipple,  but  never  to  the  shoulder  blade. 
When  the  ulcer  is  situated  on  the  pars  media  or 
about  the  lesser  curvature,  the  pain  is  referred  to 
the  left.  If  located  on  the  posterior  wall  the  pain 
is  always  referred  to  the  back,  and  to  the  left  of  the 
spine.  If  a  chronic  perforation  has  taken  place 
with  adhesion  to  the  pancreas  the  patient  will  always 
complain  of  a  localized  area  of  constant  boring  pain. 
(In  one  case  a  chauffeur  attributed  the  pain  to  the 
pressure  of  a  button  on  the  back  of  his  overcoat,  on 
the  left  of  his  belt  when  leaning  back  on  his  seat). 

Causation  of  the  pain. — The  belief  that  pain  in 
ulcer  is  directly  due  to  the  irritation  of  the  acid 
stills  holds  in  the  minds  of  many.  This  view  is 
further  strengthened  by  the  relief  obtained  by  the 
administration  of  alkalies.  It  is,  however,  of  com- 
mon knowledge  that  similar  pains  are  present  in 


July  10,  1920.] 


DIAMOND:  PEPTIC  ULCER. 


63 


conditions  of  hypoacidity  or  even  anacidity  as 
achylia.  Boas  and  others  have  long  called  attention 
to  cases  where  the  patients  had  obtained  relief  from 
alKaiies  and  who  had  low  acid  ^•alues.  The  pain 
may  also  be  relieved  by  the  ingestion  of  a  morsel 
of  food,  or  water,  or  milk.  Xumerous  experiments 
conducted  by  Hertz  proved  that  instillation  or  irri- 
gation with  acid  solution  in  ulcer  cases  in  concen- 
tration as  high  as  five  tenths  per  cent,  had  no  effect 
on  inciting  an  attack  of  pain  or  aggravating  the 
condition. 

From  these  observations  one  cannot  readily  associ- 
ate the  acid  with  the  primary  cause  of  pain. 

Modern  advances  in  gastric  physiology  tend  to 
the  conclusion  that  ulcer  pains  are  due  to  contrac- 
tion of  the  stomach,  pylorus  and  possibly  the  first 
portion  of  the  duodenum.  Hertz  attributes  epigas- 
tric pain  to  tension  of  the  gastric  musculature.  He 
demonstrated  that  inflation  of  the  stomach  by  means 
of  a  balloon  introduced  into  the  cardiac  end  of  the 
stomach,  leads  to  the  sensation  of  fulness  when  the 
intragastric  pressure  rises  to  ten  to  fifteen  mm.  of 
mercury.  Active  or  exaggerated  peristalsis  in  a 
hypertonic  organ  causes  increased  tension  and  ex- 
cessive intragastric  pressure.  The  increased  ten- 
sion of  the  musculature  of  a  stomach  rendered  irri- 
table by  disease  gives  rise  to  pain.  By  the  balloon 
and  X  ray  method  of  examination  it  has  been  ob- 
served that  pain  was  always  synchronous  with  the 
gastric  and  p\'loric  contractions.  The  subject  under 
observation  would  always  press  a  key  as  a  signal  of 
painful  sensation,  which  would  always  correspond 
with  the  height  of  the  contractions.  Physiologists 
have  further  proved  the  presence  of  tonus  changes 
and  rhythmic  contraction  in  the  fasting  stomach. 
Boldyreft  in  1905  reported  hunger  contractions  in 
dogs.  Cannon  and  Washburn  observed  the  same  in 
man.  Carlson  classified  the  various  types  of  con- 
tractions and  tonus  changes.  He  describes  hunger 
contractions  as  power  f  til  peristaltic  contractions 
which  arise  at  the  cardiac  sphincter  and  sweep  down 
to  the  pylorus,  increasing  in  strength  as  they  pro- 
ceed. Rogers  and  Hart  in  their  rontgen  examina- 
tions of  a  bismuth  coated  l)alloon  introduced  into 
the  fasting  stomach,  also  described  the  hunger  con- 
tractions as  vigorous  peristaltic  waves  beginning  at 
the  cardiac  end  and  sweeping  over  the  whole 
stomach.  The  rh>lhmic  contractions  would  occur 
at  intervals  of  twenty  minutes,  and  would  always  be 
associated  with  the  sensation  of  hunger.  We  thus 
see  that  the  pangs  of  hunger  in  the  normal  states  are 
due  to  the  periodical  contractions  and  are  synchro- 
nous with  them. 

The  similarity  of  moderate  ulcer  pains  to  the 
strong  hunger  pangs  in  the  normal  person  has  long 
been  observed  clinically  and  led  Moynihan  to  desig- 
nate them  as  hunger  pains.  In  diseased  conditions, 
such  as  ulcer,  the  stomach  is  in  a  hyperirritable 
state,  and  any  condition  that  will  give  rise  to 
increased  peristalsis  will  cause  an  increased 
tension  and  intragastric  pressure  resulting  in 
pain.  The  acid  plays  a  secondary  role  as 
it  merely  serves  to  stimtilate  contraction.  The 
ulcer  base  in  the  deeper  strata  of  the  stomach  con- 
tains sensory  nerves  which  are  not  found  in  the 


mucous  surface  of  the  stomach.  When  the  ulcer  is 
bathed  in  a  medium  containing  free  acid,  whether 
of  low  or  high  concentration,  increased  peristalsis 
will  result.  Any  other  irritant,  stich  as  alcohol  or  a 
coarse  food  particle,  will  do  the  same. 

An  excess  of  acid  in  the  duodenum,  as  emphasized 
by  Hertz,  prevents  relaxation  of  the  pylorus.  This 
induced  spasm  of  the  pylorus  and  first  portion  of 
the  duodenum  by  inhibiting  the  pyloric  reflex  adds 
to  the  increased  tension  resulting  in  hypertonus,  hy- 
perperistalsis  and  a  marked  increase  in  the  intra- 
gastric pressure  and  pain. 

The  time  of  the  occtirrence  of  the  pain  is  in- 
teresting as  it  adds  additional  weight  to  the  factors 
entering  into  the  causation  of  pain.  It  has  been  ob- 
served that  the  contractions  are  greater  when  most 
of  the  meal  has  passed  out  of  the  stomach  several 
hours  after  the  ingestion  of  the  meal,  the  stomach 
l)eing  more  than  half  empty.  With  the  small  calibre 
stomach  the  tonus  is  greater.  The  contractions  are 
greater  due  to  higher  concentrations  of  the  acid 
which  occur  at  this  time.  The  free  acid  remains 
uncombined,  as  most  of  it  has  already  combined 
and  passed  out.  In  cases  of  hypersecretion  the 
quantity  and  concentration  constantly  rise  and  one 
can  often  see,  late  in  the  digestion,  the  stomach  full 
of  secretion,  with  intense  spasm  and  all  the  other 
previously  mentioned  pain  producing  factors.  The 
relief  from  pain  by  alkalies  is  believed  to  be  brought 
about  in  several  ways.  Some  regard  alkalies  as  a 
direct  sedative  to  muscular  contractions,  that  con- 
trary to  the  acid,  inhibit  muscular  contractions. 
However,  it  is  well  known  that  by  neutralizing  the 
acid,  the  stimulus  to  contractions  is  at  once  stopped. 
The  pylorus  becomes  relaxed  and  the  first  portion 
of  the  duodenum  becomes  less  irritable  due  to 
changes  in  the  reaction  on  the  chyme. 

In  conclusion  it  may  be  said  that  pain  is  due  to : 
1,  muscular  contractions  when  the  stomach  is  in  a 
hyperirritable  state ;  2,  increased  tonus ;  3,  increased 
intragastric  pressure.  The  portion  most  irritated  is 
the  pylorus  and  the  first  portion  of  the  duodenum. 
The  time  of  most  marked  irritation  is  later,  during 
digestion,  when  the  stomach  has  more  than  half 
emptied  itself,  thus  approaching  the  tonus  changes 
and  rhythmic  contraction  of  the  hunger  state ;  4, 
the  acid  as  a  contributory  agent  causes  pain  indirectly 
by  stimulating  contraction ;  alkalies  control  pain  by 
inhibiting  contraction  and  neutralizing  the  chyme. 
{To  be  continued.) 


Radium  or  Rontgen  Ray  Treatment. — William 

J.  Young  {International  Journal  of  Surgery,  April, 
1920)  states  that  there  are  definite  fields  of  useful- 
ness for  radium  and  the  rontgen  ray  both  singly 
and  collectively.  Earlier  recognition  of  diseases 
amenable  to  these  agents  and  greater  proficiency 
in  their  employment  will  result  in  a  more  compre- 
hensive understanding  of  the  indications,  contra- 
indications and  limitations.  The  radiotherapeutist 
should  be  adequately  trained  in  the  diagnosis  and 
clinical  course  of  affections  responsive  to  these 
agents  as  well  as  the  technic  of  their  application 
and  the  reactions  which  may  be  expected. 


64 


HAMMER:   VOMITING  FROM  A  SURGICAL  VIEWPOINT. 


[New  York 
Medical  Journal. 


VOMITING   FROM    A    SURGICAL  VIEW- 
POIXT  * 

By  a.  Wiese  Hammer,  AI.  D., 
Philadelphia. 

Surgeon  to  the  American  Hospital  for  Diseases  of  the  Stomach; 
Instructor  in  Surgery,  Post-Graduate  School  of  Medicine, 
University  of  Pennsj-Ivania,  Polyclinic  Section. 

Thrown  daily  into  contact  with  many  surgical  con- 
ditions and  affections,  I  have  been  for  some  time 
past  impressed  with  the  fact  that,  while  medical  and 
surgical  literature  is  not  likely  to  regard  vomiting 
as  a  symptom  of  special  diagnostic  import,  my  ob- 
ject in  presenting  what  I  may  term  these  stray 
thoughts,  is  to  invite  attention  to  the  subject  of  vom- 
iting as  forming,  in  not  a  few  instances,  a  very  im- 
portant factor  in  the  symptom  complex  of  some  of 
the  major  surgical  maladies.  In  a  brief  exposition, 
such  as  this,  it  would  be  irrelevant  to  rehearse  the 
undisputed  facts  of  the  physiology  of  vomiting ;  and 
to  include  a  tabulated  list  of  diseases  engendering 
vomiting,  the  restilt  of  bacterial  toxines  in  the  blood, 
such  as  scarlatina,  or  diseases  caused  by  poisons  of 
nonbacterial  origin,  such  as  anemia,  or  to  dwell  upon 
the  vomiting  of  pregnancy  or  emesis  of  gastric 
origin,  would  be  superfluous. 

In  a  consideration  of  this  all  important  subject,  in 
taking  a  superficial  survey,  we  observe  vomiting  as 
merely  an  insignificant  symptom  at  one  end  of  the 
scale ;  at  the  other  end,  this  ominous  factor  is  a  fore- 
runner of  death.  Thus,  we  will  first  note  briefly  the 
nature  of  habitual  vomiting,  and  then  pass  in  rev'iew 
some  of  the  more  serious  maladies,  especially  of  a 
surgical  character,  in  our  effort  to  disprove  the  oft 
repeated  assertion  that  the  symptom  of  vomiting  has 
little  clinical  worth,  and  for  all  practical  purposes 
may  be  quite  disregarded. 

Let  us  first  consider  the  matter  of  habitual  vomit- 
ing, that  peculiar  condition  which  bafiles  explana- 
tion, usually  occurring  in  females,  apparently  with- 
out cause  and  independent  of  organic  disease.  Food 
may  be  ejected  in  the  midst  of  a  meal  or  in  the  inter- 
val between  meals.  There  is  no  esophageal  spasm 
and  no  regurgitation  of  the  stomach  contents.  Many 
clinicians  assert  that  the  condition  is  catching,  and 
they  place  this  peculiar  entity — or  perhaps  non- 
entity— in  the  same  category  as  habit  chorea.  This 
vomiting  is  to  be  differentiated  from  hysterical 
vomiting  and  from  gastric  neurasthenia.  Taking 
this  as  the  initial  form  of  vomiting,  and  omitting 
mention  of  its  occurrence  in  many  conditions  and 
maladies,  w^e  may  with  benefit  at  once  discuss  this 
symptoms  as  found  in  association  with  cerebral  dis- 
ease. 

In  acute  or  chronic  cerebral  lesions,  vomiting  may 
be  absent  or  appear  only  at  rare  intervals,  and  it 
may  not  be  attended  with  nausea.  When  it  does 
occur,  it  is  absolutely  independent  of  food  ingestion, 
is  projectile  in  character,  it  often  occurs  in  the  early 
morning  hours,  and  the  tongue  is  not  coated.  The 
head  cannot  be  raised  from  the  pillow  without  inces- 
sant vomiting,  although  other  symptorns  are  entirely 
dormant.  Vomiting  from  cerebral  conditions  may 
at  times  occur  when  digestion  is  at  its  height  and 

*Read  before  West  Philadelphia  Medical  Association,  February 
24,  1920. 


closely  simulate  a  case  of  indigestion,  as  in  a  sud- 
den apoplectic  seizure.  It  is  thus  almost  impossible 
to  determine  its  true  character ;  but  the  age  of  the 
patient  should  be  given  serious  consideration,  and 
this  important  practical  fact  should  always  be  borne 
in  inind — that  no  matter  how  apparently  simple  an 
attack  of  vomiting  may  be,  in  a  patient  over  the  age 
of  fifty,  its  oncoming  should  be  regarded  with  sus- 
picion. Sudden  vomiting  occurring  in  a  middleaged 
person,  or  in  a  patient  of  advanced  age,  the  emesis 
being  painless,  with  or  without  nausea,  with  no  evi- 
dence of  gastric  involvement,  the  ejected  matter 
being  made  up  of  mucus  or  a  watery  fluid,  should  at 
once  strongly  suggest  the  likelihood  of  the  occur- 
rence of  cerebral  hemorrhage. 

Such  vomiting  is  not  attended  by  the  usual  symp- 
toms of  relaxation,  but  the  sthenic  effects  which 
usually  attend  apoplexy  are  present.  If  the  usual 
collapse  symptoms  occur  in  persons  of  fifty  or  older, 
the  affection  is  more  likely  to  be  of  uremic  origin. 
If  the  respiration  be  altered  in  rhythm,  or  of  nor- 
mal frequenc}-,  or  slowed  because  of  the  intimate 
relation  of  the  vomiting  centre  and  the  pneumo- 
gastric  centre,  the  cause  is  more  likely  a  central 
hemorrhage.  Hurried  breathing  attends  vomiting 
from  other  causes.  Whether  vomiting  in  cerebral 
affections,  especially  the  incessant  vomiting  asso- 
ciated with  cerebral  tumors,  is  due  to  irritation  of 
a  special  centre  in  the  medulla,  whether  from  stimu- 
lation of  the  pneumogastric  centre  itself,  or 
engendered  by  vertigo,  the  result  of  the  auditory 
nerve  disturbance,  produced  by  stasis,  needs  further 
investigation. 

We  need  scarcely  be  reminded  of  the  peculiar 
nature  of  exophthalmic  goitre,  whose  three  cardinal 
symptoms  are  tachycardia,  goitre  and  exophthalmos. 
One  should  be  extremely  careful  in  pronouncing  a 
diagnosis  in  some  instances,  for  it  is  a  well  known 
fact  that  the  goitre  may  be  small  or  absent  and  the 
exophthalmos  may  be  late  in  developing.  In  recent 
cases,  before  treatment  is  instituted,  the  clinical  pic- 
ture is  fairly  uniform,  but  the  symptomatology  may 
be  most  misleading  if  the  affection  begins  suddenly 
or  develops  slowly.  This  may  be  especially  true 
when  the  gastrointestinal  symptoms  are  among  the 
earliest  and  are  in  the  ascendancy,  that  is,  when 
metabolism  is  increased,  with  subsequent  digestive 
changes,  nausea,  vomiting,  and  long  continued 
watery  stools.  This  vomiting  is  believed  to  be  partly 
of  nervous  origin.  There  are  quite  a  number  of 
cases  on  record  where  abdominal  pain,  watery 
dejecta,  nausea,  and  vomiting,  forming  part  of  a 
snnptom  complex  of  exophthalmic  goitre,  had  been 
hurriedly  diagnosed  by  practitioners  as  indiscretions 
in  diet. 

Intractable  vomiting  often  occurs  in  biliary  colic, 
often  no  other  symptom,  save  epigastric  pain,  being 
present  during  the  first  twenty-four  or  forty-eight 
hours.  In  other  cases,  the  patient  is  restless,  has 
an  anxious  expression,  the  skin  is  cold  and  moist, 
perhaps  cyanotic,  vomiting  soon  occurs — at  first 
the  contents  of  the  stomach,  and,  if  the  common 
bile  duct  is  not  obstructed,  bile  and  gallstones  follow. 
After-  the  stomach  contents  have  been  ejected, 
repeated  retching  usually  occurs. 


July  10,  1920.] 


HAMMER:   VOMITING  FROM  A  SURGICAL  VIEWPOIXT. 


65 


The  primary  nausea  and  vomiting  of  acute  ap- 
pendicitis is  reflex  in  character,  and  manifested 
early  in  the  invasion  of  the  disease.  Ahnost  in- 
variably it  is  the  second  symptom  of  the  develop- 
ment of  the  malady,  pain  being  the  first.  As  a  rule 
there  are  a  few  eflforts  at  emesis  and  the  nausea 
then  passes  away.  It  is  produced  by  an  overdis- 
tended  condition  of  the  appendix,  the  result  of  re- 
tained infected  matter  in  that  portion  of  the  gut. 
The  secondary  nausea,  and  often  persistent  vomiting, 
are  really  caused  by  peritoneal  involvement,  and  their 
nature  and  persistence  resemble  in  every  way  rup- 
ture of  the  stomach  or  intestine  into  the  peritoneal 
cavity. 

This  thought  invites  attention  to  the  peritoneum, 
and  in  acute  peritonitis,  distention,  or  meteorism  is 
one  of  the  earliest  signs.  It  is  Nature's  way  of 
splinting  the  intestines  to  minimize  the  pain  of  peri- 
stalsis. With  decrease  of  peristalsis  and  intestinal 
absorption,  putrefactive  changes  are  encountered, 
and  the  bowels  become  overdistended  with  gas.  In 
order  to  free  themselves  from  this  overdistention, 
reversed  peristalsis  occurs,  the  contents  of  the  upper 
intestine  forcing  their  way  into  the  stomach  to  be 
finally  disposed  of  by  vomiting.  This  vomiting, 
which  is  an  early  symptom,  often  continues 
through  the  course  of  the  disease — at  first  the  stom- 
ach contents  are  expelled,  then  bile,  and  later,  the 
contents  of  the  small  intestines,  giving  the  vomitus 
a  thin,  pale  yellow  appearance.  Frequently,  just 
before  the  oncoming  of  the  fatal  issue,  the  vomited 
matter  is  of  a  dark  brown  color,  although  at  times 
it  is  flocculent  and  resembles  partly  digested  food. 

The  importance  of  vomiting  as  a  cardinal  symp- 
tom is  well  illustrated  in  certain  cases  of  hernia, 
where  it  and  abdominal  pain  may  be  the  only  two 
factors  to  attract  the  diagnostician's  attention.  Thus, 
in  every  case  of  vomiting  associated  with  abdominal 
pain,  it  behooves  the  examiner  to  seek  carefully  for 
a  hernia,  as  a  small  knuckle  of  the  intestines  may 
have  become  nipped  in  the  hernial  sac  and  be  suffi- 
cient for  the  occurrence  of  these  two  appreciable 
symptoms.  In  incarcerated  or  obstructed  hernia, 
obstruction  takes  place  by  the  damming  of  feces  or 
undigested  food,  the  fecal  current,  but  not  the  blood 
current,  in  the  wall  of  the  bowel  being  arrested. 
Nausea  occurs,  constipation  that  is  not  absolute  is 
the  rule,  for  gas  is  passing  by  the  rectum  and  the 
vomiting  is  not  fecal.  In  strangulated  hernia,  both 
the  fecal  current  and  the  blood  current  in  the  wall 
of  the  bowel  are  arrested,  and  vomiting  is  an  early 
and  serious  symptom.  It  may  cease  for  a  day  or 
two,  and  especially  before  death,  the  result  of  pro- 
found prostration.  The  early  vomiting  is  reflex  in 
character,  later  it  is  regurgitant.  First,  the  alimen- 
tary contents  are  expelled,  then  the  bile,  and  lastly, 
the  vomited  matter  is  stercoraceous.  Vomiting  is 
seldom  encountered  in  inguinal  hernia,  more  often 
in  femoral  hernia,  and  still  more  frequently  in  ob- 
turator hernia. 

With  these  few  remarks  relative  to  occlusion  of 
the  bowels,  we  naturally  pass  to  the  consideration 
of  intestinal  obstruction,  recalling  for  the  moment 
that  acute  intestinal  obstruction  may  be  caused  by 
strangulation,  the  result  of  bands  or  cords,  intus- 


susception, twists  and  knots,  strictures,  peritoneal 
pouches,  slits  and  fissures,  also  abnormal  contents, 
as  biliary  calculi  and  enteroliths. 

The  stomach  contents  are  first  vomited,  then  the 
bile,  and  finally  the  duodenal  contents,  at  first  odor- 
less but  a  few  days  later  becoming  fecal  in  charac- 
ter. A  lesion  in  the  upper  part  of  the  small  intestine 
is  characterized  by  the  rapid  oncoming  of  vomiting 
of  a  violent  and  expulsive  nature,  while  obstruction 
of  the  large  intestine  exhibits  vomiting  as  a  later 
s\TOptom,  following  generally  tympanites,  or,  as  is 
often  the  case,  there  may  be  eructations  of  gas  with- 
out vomiting.  The  fecal  nature  of  the  vomitus  in 
obstruction  of  the  large  intestine  is  to  be  ascribed 
to  the  regurgitated  matter  from  the  upper  bowel, 
as  there  is  no  evidence  to  warrant  the  belief  that 
the  contents  of  the  large  intestine  are  ever  vomited. 
In  intussusception,  fecaloid  vomiting  is  the  rare  ex- 
ception and  certainly  never  the  rule. 

In  connection  herewith,  it  is  of  interest  to  note 
that  a  mere  narrowing  of  even  a  small  part  of  the 
intestine  is  only  necessary  to  offer  many  of  the  car- 
dinal signs  and  symptoms  of  total  intestinal  obstruc- 
tion. Many  years  ago.  Dr.  William  T.  Smith,  (1) 
professor  of  physiology  in  Dartmouth  College,  en- 
countered a  case  of  uncontrollable  emesis  in  the 
person  of  a  ^^oung  woman,  whose  history  at  the 
time  and  whose  past  history  failed  to  throw  any 
light  on  her  malady.  The  patient  had  no  fever, 
there  was  no  abnormality  found  upon  urinary 
analysis,  there  was  no  local  soreness;  physical  ex- 
amination of  all  the  organs  was  negative,  and  there 
was  neither  functional  disturbance  nor  organic  dis- 
ease of  the  uterus,  ovaries,  or  the  appendages. 
For  three  weeks,  nevertheless,  there  was  headache 
with  uncontrollable  vomiting  which  later  became 
fecal.  By  means  of  enemata,  slight  liquid  dis- 
charges were  noted.  Dr.  Charles  B.  Xancrede 
was  called  in  consultation,  a  laparotomy  was  de- 
cided upon,  but  the  operation  failed  to  disclose  the 
nature  of  the  suffering.  The  patient  died  the  next 
morning  and  at  the  postmortem  examination  a  por- 
tion of  the  ileum,  one  inch  long  and  five  feet  from 
the  ileocecal  valve,  was  found  somewhat  narrowed, 
apparently  by  cicatricial  contraction,  and  the  sur- 
face of  the  thickened  membrane  suggested  distinctly 
a  healed  ulcer. 

At  this  point  it  seems  pertinent  to  the  subject 
under  review  to  say  a  word  concerning  regurgitant 
vomiting,  followed  the  operation  of  gastroenteros- 
tomy. Because  of  improvements  in  surgical  technic 
and  a  better  understanding  of  abdominal  surgery, 
this  deplorable  sequela  is  much  rarer  today  than  in 
times  past.  It  is  the  result  of  one  of  several  causes, 
or  it  may  be  due  to  a  combination  of  factors,  which 
result  in  a  true,  acute,  intestinal  obstruction.  Promi- 
nent among  these  causes  we  may  mention  a  too  free 
and  careless  handling  of  the  intestine,  a  kinking  of 
the  bowel  at  the  point  of  anastomosis,  and  too  firm 
a  pressure  caused  by  faulty  clamping. 

In  concluding  this  subject  of  consuming  impor- 
tance, which  has  been  treated  very  superficially,  we 
should  regard  for  a  moment  the  varied  symptoma- 
tology complained  of  by  suffering  women.  The 
gynecologist  knows  only  too  well  that  diseases,  de- 


66 


JACOBY:  FIBROMA  OF  MESENTERY. 


[New  York 
Medical  Journal. 


formities  and  malpositions  of  the  female  generative 
organs  may  give  rise  to  chapters  of  symptoms,  not 
the  least  conspicuous  of  which,  in  many  instances, 
are  nausea  and  vomiting.  The  symptoms  may  not 
point  to  an  affection  of  the  generative  organs,  but 
are  often  of  a  more  general  character,  the  type  of 
which,  on  the  one  hand,  is  seen  in  neurasthenia  and, 
on  the  other  hand,  in  hysteria.  Such  nausea  and 
vomiting  occur  always  in  the  morning,  and  when 
alcoholism  and  Bright's  disease  are  excluded  from 
consideration,  these  symptoms,  when  occurring  in 
the  female,  often  indicate  affections  of  the  uterus, 
ovary,  or  appendages. 

In  this  all  too  brief  resume  of  a  most  important 
subject,  vomiting  has  been  shown  to  be  often  a  car- 
dinal symptom  of  the  first  magnitude.  I  have  only 
attempted  to  dispel  the  too  frequent  thought  that 
vomiting  is  an  unimportant  symptom,  and  to  point 
out  the  importance  of  using  care  in  the  interpreta- 
tion of  all  cases  of  vomiting,  suggesting  that  where 
the  causes  are  not  plainly  indicated,  an  investigation 
should  be  made  of  every  organ  and  bodily  function, 
so  as  to  determine  the  true  cause  of  this  important 
symptom. 

REFERENCE. 

1.  Smith,  William  T.  :  Medical  Xczi's.  1887,  vol.  li.  p. 
652. 

218  South  Fifteenth  Street.  * 


FIBROMA  OF  THE  MESEXTERY. 

Report  of  a  Case. 

By  a.  Jacoby,  M.  D.,  F.  A.  C.  S.,  . 
New  Orleans,  La. 

Solid  new  growths  of  the  mesentery  are  ex- 
tremely rare,  and  of  those  seen,  according  to  Vance, 
the  fibromata  are  the  most  frequent.  In  a  search 
of  the  literature  up  to  1906,  he  found  that  in 
twenty-seven  cases  of  solid  ttmiors  of  the  mesen- 
tery only  had  operation  been  performed,  and  of 
these  thirty-three  per  cent,  were  malignant.  Abdom- 
inal surgery  and  the  diagnosis  of  intraabdominal 
growths,  however,  have  shown  such  great  progress 
since  then,  that  more  cases  have  been  encountered 
and  been  successfully  treated  by  operation. 

In  his  report,  he  states  that  in  nine  cases  there 
was  a  mortality  of  twenty  per  cent,  which  would 
be  ver\-  much  too  high  in  this  present  operative  era. 
In  many  of  these  cases  the  growths  had  attained  a 
considerable  size,  because  the  patients  did  not  seek 
advice  until  their  attention  had  been  attracted  to 
the  growth  by  some  accident.  They  had  been  treat- 
ed for  a  long  time  for  indigestion  or  intestinal  dis- 
turbance, because  of  failure  to  receive  a  proper  ex- 
amination. In  the  particular  case  reported,  the 
patient,  who  was  a  tailor,  had  his  attention  attracted 
to  the  abdominal  growth  because  of  pain  in  that 
region.  He  pressed  his  hands  against'  his  abdomen 
hoping  to  obtain  relief,  when  he  felt  the  growth. 
In  reporting  this  case.  I  wish  to  call  attention  to  a 
method  of  anastomosis  of  the  intestines,  which  is 
not  original,  however,  but  I  am  not  able  to  give 
credit  to  the  one  to  whom  it  is  due. 

Case. — The  patient,  S.  P.,  was  referred  to  me 


by  his  physician  on  Xovember  15,  1918.  His  family 
history  was  negative.  Personal  historj-:  He  had 
had  gonorrhea,  otherwise  had  never  been  ill,  except 
with  indigestion  and  an  attack  of  jaundice  in  June, 
1915.  These  attacks  of  indigestion  were  more  of 
the  nature  of  gaseous  intestinal  disttirbances. 
The  attack  of  jaundice  came  on  rather  sud- 
denly, was  not  accompanied  by  pain,  and 
there  was  very  little  increase  of  temperature. 
The  jaundice  remained  for  twenty-one  days 
and  from  that  time  the  patient  stated  that  he  had 
suffered  from  indigestion  and  a  marked  degree  of 
constipation.  After  his  attention  had  been  attracted 
to  the  abdominal  mass,  he  saw  several  physicians 
who  treated  him  for  intestinal  disturbances  and  con- 
sidered the  mass  a  gas  ttimor. 

On  Xovember  16,  1918,  he  was  admitted  to  the 
Presb\terian  Hospital  and  after  the  usual  prelimin- 
ary laboratory  examinations  he  was  taken  to  the  op- 
erating room  on  Xovember  18th  for  operative  treat- 
ment. Under  ether  anesthesia,  a  right  rectus  incision 
was  made  and  the  tumor  mass  brought  out  of  the  ab- 
domen. It  was  located  in  the  mesenter\-  and  very 
close  to  the  ileum,  so  that  its  removal  could  be  con- 
sidered onh"  by  a  resection  of  that  part  of  the  ileum 
in  the  mesentery  of  which  it  was  located.  After 
determining  the  amount  of  ileum  to  be  resected,  the 
fecal  material  was  removed  from  the  points  of  ex- 
cision and  rubber  clamps  applied.  The  mesentery 
was  first  cut  away  from  the  bowel  to  be  excised, 
so  that  any  infection  along  that  line  might  be  avoid- 
ed. The  bowel  was  then  excised  with  the  cautery, 
tied,  and  inverted  with  several  rows  of  chromic 
catgut  and  one  of  silk.  The  ends  were  placed  side 
by  side  like  the  barrels  of  a  shot  gun  and  a  lateral 
anastomosis  done.  This  method  of  anastomosis 
does  away  with  the  danger  of  fecal  stasis  in  the 
blind  ends  of  the  gut,  one  of  the  objections  to  the 
lateral  anastomosis  by  the  ends  opposite  to  each 
other.  Closure  of  the  abdominal  wall  was  done  by 
the  usual  method  with  silkworm  gut  reinforcing 
sutures. 

The  patient  had  a  very  stormy  convalescence 
which  was  accompanied  by  a  severe  and  persistent 
hiccough  for  several  weeks.  The  only  relief  ob- 
tained was  from  the  almost  constant  use  of  mor- 
])hine  sulphate,  one  eighth  grain,  and  atropine  sul- 
phate, one  fifteenth  of  a  grain,  by  hypodermic  in- 
jections. An  infection  of  the  abdominal  wall  de- 
veloped that  also  delayed  his  convalescence.  He  was 
given  a  proctoclysis  of  glucose  five  per  cent,  and 
coffee  equal  parts,  to  make  one  pint,  every  six  hours 
for  nearly  three  days,  when  it  was  discontinued  and 
small  amounts  of  clear  meat  broth,  tea,  well 
sweetened  lemonade,  coffee,  and  fruit  tablets  were 
allowed.  On  Xovember  22nd  the  bowels  moved  vol- 
untarily, a  large  liquid  stool  resulting.  From  that 
time  on  the  diet  was  increased  until  on  Xovember 
25th  he  was  taking  a  full  diet.  On  January  15, 
1919,  he  was  discharged  as  cured.  Two  weeks  later, 
he  resumed  his  usual  occupations  and  remained 
well  until  April  1st  when  a  marked  jaundice  sud- 
denly developed  which  became  so  intense  that  a 
diagnosis  of  malignancy  was  made  and  an  explor- 
atory laparotomy  advised.  It  was  believed  that 
drainage  of  the  gallbladder  or  the  anastomosis  of 


July  10,  1920.] 


LONDON  LETTER. 


67 


the  gallbladder  to  the  duodenum  might  overcome 
the  jaundice  and  the  resulting  toxemia.  A  lap- 
arotomy was  performed  on  April  4,  1919,  at  the 
Hotel  Dieu  and  after  a  thorough  exploration,  only 
a  small  contracted  gallbladder  was  fotmd  without 
any  obstruction  of  the  ducts.  The  site  of  the 
anastomosis  of  the  intestines  was  found  to  be  very 
satisfactory.  After  his  recovery  from  the  opera- 
tion, though  Wassermann  reactions  had  always 
been  negative  when  made  by  different  observers, 
the  jaundice  yielded  to  three  injections  of  neosal- 
varsan  and  mercurial  inunctions.  He  has  remained 
well  ever  since,  with  the  exception  of  another  attack 
of  jaundice  which  yielded  to  the  salvarsan  treat- 
ment. The  report  of  the  pathologist  was :  Fibroma 
with  hyaline  changes;  tumor  measured  15  cm.  by 
12.5  cm.  by  8.75  cm.,  weight  132  grams ;  bowel 
length,  42.5  cm. 


LONDON  LETTER. 

{From  our  own  correspondent.) 

London  Association  of  the  Medical  Women's  Federation. — 
Death  of  Sir  Henry  Burdett. 

LoxDox.  May  4,  IQ20. 

A  meeting  of  the  London  Association  of  the 
Medical  Women's  Federation  was  held  at  the  rooms 
of  the  London  Society  of  Medicine,  11,  Chandos 
street,  W.,  on  April  20,  last.  Dr.  Helen  Boyle  was 
in  the  chair.  Dr.  Louisa  Garrett  Anderson, 
formerly  chief  surgeon  at  the  Military  Hospital, 
Endell  street,  gave  an  account,  illustrated  by  lantern 
slides,  of  the  work  at  that  hospital  from  1915  to 
1919.  She  said  that  the  surgical  work  might  be 
described  as  falling  under  three  heads.  In  1915 
to  1916  large  numbers  of  head  wounds  were  re- 
ceived, and  fractured  skulls,  with  every  kind  of 
complication,  were  treated.  In  1916  and  1917 
compound  fractures  of  the  thigh  were  numerous, 
while  in  1918  a  series  of  penetrating  wounds  of 
joints,  especially  the  knee  joint,  were  common. 

It  is  interesting  to  note  that  Dr.  Anderson  is 
enthusiastic  as  to  the  value  of  bipp,  which  from 
all  accounts  'seems  to  have  been  the  greatest 
antiseptic  success  of  the  war.  Dr.  Anderson  said 
it  was  first  tried  in  1916.  It  was  used  afterward 
in  a  large  number  of  cases  of  compound  fracture, 
and  always  with  the  best  results.  It  replaced  other 
disinfectants.  It  aided  in  ward  work  enormously, 
as  cases  which  had  previously  been  dressed  twice 
or  thrice  daily  were  left  undisturbed  with  bipp  for 
a  week  or  more.  It  apparently  altered  the  prog- 
nosis of  cases  and  shortened  the  time  of  treatment 
in  hospital.  Over  26,000  men  passed  through  the 
hospital,  and  7,000  operations  were  performed ;  300 
beds  were  set  aside  for  orthopedic  cases.  The 
speaker  drew  attention  to  the  fact  that  the  treatment 
of  fractured  thighs  and  wounds  complicating  joints 
had  been  revolutionized  by  Sir  Robert  Jones  and 
his  disciples,  Major  M.  Sinclair,  and  Major  J, 
Everidge.  In  1914  a  case  of  compound  fracture 
of  the  femur  was  a  source  of  infinite  anxiety  to  the 
surgeon  and  great  suffering  to  the  patient,  it  meant 
dressings  at  frequent  in.ter\-als,  drainage  tubes, 
constant  operations  for  the  removal  of  sequestra, 
and,  at  the  end  of  months  of  misery-,  a  weak  leg, 


considerably  shortened,  possibly  with  a  stiff  knee. 
The  modern  method  of  thorough  preliminary'  in- 
vestigation and  cleaning,  following  by  the  applica- 
tion of  bipp  to  the  wound,  suspension  on  a  net  bed 
or  a  Balkan  frame,  a  wellfitting  Thomas  splint,  and 
early  movement  of  the  knee,  was  incomparably 
better.  The  evoltttion  of  technic  for  dealing  with 
penetrative  wounds  of  joints  was  equally  striking. 
In  1918  it  was  not  uncommon  to  regain  a  full,  or 
almo.st  full  range  of  joint  mobility. 

^      ^  =i= 

A  great  organizer,  a  great  financier  and  a  great 
personality  has  just  passed  away  in  the  person  of 
Sir  Henry  Burdett  who  died  in  London  on  April 
29th  last,  at  the  age  of  seventy-three.  Although 
educated  for  the  medical  profession,  and  in  fact 
passing  all  his  professional  examinations,  he  never 
took  a  degree  or  qualification  in  medicine  or  surgery, 
and  yet  he  probably  did  more  for  medicine  than  any 
man  of  his  time.  For  the  first  six  years  of  his 
working  life,  and  it  was  indeed  a  working  life,  he 
was  supeinntendent  and  secretary  of  the  Queen's 
Hospital,  Birmingham,  and  for  the  next  six  years 
filled  a  similar  position  at  the  Seaman's  Hospital, 
London.  During  his  six  years'  term  of  the  latter 
post,  he  displayed  exceptional  financial  ability  and 
organizing  powers.  He  succeeded  in  raising  the 
income  of  that  institution  from  £7,000  to  £13,000 
a  year. 

His  chief  and  most  lasting  memorial  will 
be  his  work  in  aid  of  philanthropic  and  social 
causes.  He  was  the  founder  of  the  Royal  National 
Pension  Fund  for  Nurses,  which  proved  a 
conspicuous  success.  In  less  than  ten  years,  5,000 
nurses  joined  the  fund,  the  endowment  reached 
£73,000,  the  total  investment  amounted  to  £384,000; 
while  the  pensions  policies  numbered  nearly  six 
thousand,  and  the  sickness  policies,  nearly 
two  thotisand.  Nor  was  this  all  Sir  Henry 
Burdett  did  for  the  immediate  benefit  of  nurses. 
He  was  one  of  the  first  to  organize  a  system  of 
training  nurses  according  to  modern  ideas,  and  in 
many  other  directions  he  labored  to  raise  the  status 
of  their  profession.  He  did  almost  as  much  for 
the  hospitals  as  for  the  nurses  and  took  the  deep- 
est interest  in  the  Hospital  Sunday  Fund.  He  was 
always  a  firm  believer  in  the  voluntary-  hospital 
system  and  in  the  existing  hospital  crises,  although 
enfeebled  by  illness,  employed  his  pen  to  insist  that 
ample  ftinds  could  be  raised  to  continue  the 
voluntary  system.  He  founded  and  was  editor 
of  the  Hospital  and  he  established  Science  Progress 
and  a  nursing  journal.  He  published  many  volumes 
on  the  activities  and  organization  of  hospitals  and 
on  the  multiform  aspects  of  the  nurse's  life  and 
work.  He  is  best  known  in  America  and  all 
English  speaking  countries  by  his  Hospitals  and 
Charities,  a  year  book  of  philanthropy,  which 
contains  a  stupendous  amount  of  special  infomia- 
tion  and  is  recognized  as  a  leading  book  of  reference 
on  the  many  subjects  discussed  in  its  pages.  Sir 
Henry  Burdett  was  assuredly  one  of  the  great 
workers  of  the  age  and  like  '  several  other 
distinguished  men  and  intense  workers  did  a  large 
proportion  of  his  literary  labors  while  the  world 
in  general  was  sleeping. 


Editorial  Notes  and  Comments 


NEW  YORK  MEDICAL  JOURNAL 

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XEW  YORK.  SATURDAY.  JULY  10.  1920. 


GEX.EIL\L  GORGAS. 

The  death  of  Dr.  William  Crawford  Gorgas 
marked  the  passing  of  a  worker  in  the  field  of 
medicine  whose  achievements  did  much  to  show 
the  world  the  importance  of  medicine  in  relation 
to  human  progress.  Through  his  ability  as  an 
organizer  he  took  advantage  of  the  advances  that 
had  been  made  in  the  laboratory,  the  clinic,  and 
the  researches  in  sanitation,  and  applied  them  to 
the  practical  task  of  making  possible  the  construc- 
tion of  the  Panama  Canal.  He  thus  achieved  last- 
ing fame  and  did  great  service  to  humanity.  The 
painstaking  work  of  all  the  men  who  had  furnished 
the  material  for  him  was  not  lost.  The  pragmatic 
application  of  their  findings  gave  real  value  to 
their  results.  It  took  inedicine  into  the  realm  of 
national  achievement  and  into  every  avenue  of 
commerce.    His  was  a  really  great  work. 

He  brought  to  public  attention  the  power  of 
medicine  when  applied  on  a  large  scale.  The  re- 
sults of  his  operations  involved  cities  and  armies. 
He  cleaned  up  the  fever  laden  canal  zone ;  he 
eradicated  some  of  the  deadliest  diseases  known 
to  mankind ;  he  converted  the  most  loathsome  spot 
on  the  American  continent  into  a  place  of  beauty 
and  a  pleasure  resort.  He  was  triumphant  after 
the  French  had  twice  failed.  He  succeeded  in 
the  face  of  sceptical  criticism,  when  wise  men 
predicted  failure.  His  was  the  courage  of 
facing  an  apparently  hopeless  task.  Proud  should 
America  be  of  having  contributed  such  a  man  to  the 
field  of  medicine. 


His  peace  time  achievements  were  constructive. 
For  these  he  will  not  be  forgotten.  Many  of  the 
rules  he  set  in  the  construction  of  the  canal  were 
carried  over  and  used  during  the  war. 

Here  too  he  was  willing  to  learn  and  take  advan- 
tage of  the  work  done  by  medical  men  in  other 
armies.  Observers  were  stationed  with  the  Allied 
armies  in  the  field  and  their  findings  were  brought 
back  to  the  American  army  so  that  the  American 
troops  would  get  the  benefits.  In  the  meanwhile 
under  his  direction  the  organization  of  the  units 
was  rapidly  and  skillfully  accomplished  and  when 
hostilities  began  the  troops  had  the  best  care  of  any 
of  the  armies  in  Europe.  All  this  with  the  dis- 
advantage of  the  army  being  across  the  sea,  thou- 
sands of  miles  away.  All  medicines,  foods  and 
supplies  had  to  be  transported  from  America  to  the 
great  body  of  men  in  the  American  army.  Much 
of  this  success  was  due  to  the  close  harmony  be- 
tween the  Red  Cross  and  the  army.  Gorgas  made  this 
possible.  Lives  were  saved.  While  the  practitioner 
is  beloved  for  the  work  he  does  in  daily  contact  with 
his  patients,  the  admiration  of  a  nation  is  tendered 
General  Gorgas  for  the  work  he  did  for  the  masses 
and  a  permanent  place  in  the  annals  of  medicine. 

Born  in  Mobile,  Ala.,  in  1854,  General  Gorgas 
was  educated  at  the  University  of  the  South  and 
received  his  medical  training  in  New  York  at  Belle- 
vue.  In  1880  he  was  appointed  a  surgeon  in  the 
U.  S.  Army.  It  was  during  the  Spanish  war  that 
his  work  first  brought  him  general  attention.  He 
was  serving  as  health  officer  of  Havana  when  he 
seized  upon  the  discovery  of  the  transmission  of  yel- 
low fever  by  mosquitoes,  and  proceeded  to  clean  up 
the  city.  Then  followed  his  work  on  the  Panama 
Canal.  In  1913  General  Gorgas  went  to  South 
Africa  at  the  request  of  the  British  Government  to 
investigate  conditions  in  the  Rand  Mines,  where 
thousands  of  natives  were  dying  of  pneumonia.  In 
1914  he  was  appointed  Surgeon  General  of  the 
United  States  Army.  His  last  campaign  was  waged 
again  yellow  fever  strongholds  in  Ecuador,  under 
the  auspices  of  the  International  Health  Board  of 
the  Rockefeller  Foundation. 


ICTEROGEXIC  SPIROCHETOSIS. 
The  morbid  process  called  Weil's  disease,  whose 
pathogenic  agent  was  discovered  by  a  Japan- 
ese, shows  in  apyretic  cases  a  normal  coagulation 
while  in  others  the  coagulation  appears  in  from  five 
to  twenty  minutes,  but  it  never  appears  to  be  de- 
layed as  it  is  in  acute  red-yellow  atrophy  of  the  liver. 


July  10,  1920.] 


EDITORIAL  ARTICLES 


69 


Usually  the  globular  resistance  is  increased  but 
there  are  periods  when  this  resistance  is  decreased 
and  this  is  probably  the  cause  of  the  anemia 
observed  from  time  to  time  in  the  advanced  periods 
of  the  disease.  On  the  other  hand,  the  anemia  oc- 
curring at  the  onset  of  the  affection  is  due  to  a 
relaxed  hematopoiesis.  Examination  of  the  bone 
marrow  and  splenic  pulp  shows  that  the  er\-thro- 
phage  is  active  in  both  structures  and  the  manu- 
facture of  red  blood  corpuscles  is  lessened.  Xo 
myeloid  element  can  be  detected  in  the  spleen  al- 
though it  would  appear  that  some  megakar}-oc\1:es 
are  present  and  there  is  an  intense  production  of 
macrophagoc}-tes.  While  in  cases  undergoing  a 
rapid  evolution  the  size  of  the  spleen  varies  little, 
it  is  quite  otherwise  in  the  cases  with  a  slow  evolu- 
tion ;  the  latter  is  a  sclerosis  of  the  splenic  pulp. 
This  sclerosis  is  independent  from  the  lymphatic 
elements  and  seems  to  be  related  to  the  multiplica- 
tion of  the  macrophagocytes.  The  lymph  nodes 
usually  offer  a  follicular  hyperplasia  and  a  multi- 
plication of  the  large  mononuclears  without  macro- 
phagia,  but  with  cells  containing  basophile  grains. 
The  condition  of  the  lymphatic  lymph  node  of  the 
hilum  of  the  liver  is  different.  Here  necrosis  and 
bacilli  are  present.  It  would  seem  as  if  this  were 
consequent  upon  a  bacterial  infection  of  the  biliary 
tract  superadded  to  the  infection  by  the  spirochetes. 

The  liver  is  much  larger  than  normal,  varying 
between  1650  to  2350  grams,  while  its  color  varies 
between  a  yellowish  dark  green  to  that  of  Sienna 
earth.  The  bilian,-  tract  is  not  pathologically 
changed.  The  gallbladder  contains  little  bile  and 
may  contain  blood.  In  cases  where  death  occurs 
after  the  second  day.  the  tissues  near  the  central 
vein  are  greenish  while  those  near  to  the  Kernean 
spaces  are  brown.  The  greenish  tint  is  due  to  an 
accumulation  of  pigment.  ^Microscopically,  the 
icterogenic  spirocheta  produces  a  hyperplasia  of  the 
hepatic  parenchyma  with  hyperbiligenia.  A\'hen 
death  takes  place  at  the  onset  of  the  process  a  mul- 
tiplication of  the  trabecular  cells  may  be  the  only 
morbid  change  noted,  nevertheless  there  is  also  a 
moderate  steatosis — in  acute  red-yellow  atrophy 
the  steatosis  is  more  marked — the  dislocation  of  the 
cells  of  the  lobules  is  very  characteristic. 

All  these  lesions  are  found  in  the  acute  cases, 
while  those  arising  in  cases  having  a  slower  evolu- 
tion are  as  follows.  There  is  a  decrease  in  the 
size  of  the  cells,  a  slight  lymphoc\tic  infiltration,  a 
necrobiosis  of  certain  hepatic  cells,  which  are 
undergoing  multiplication,  slight  steatosis,  accumu- 
lations of  pigment  in  the  trabecular  cells  and 
dilatations  of  the  intercellular  canaliculae.  At  the 
onset  of  the  disease  the  spirochetes  are  numerous  in 


the  liver  and  this  is  in  relation  to  the  appearance  of 
the  icterus.  The  kidneys  are  usually  involved,  the 
weight  of  each  organ  varying  between  180  to  325 
grams.  There  is  an  interstitial  reaction  tending  to 
sclerosis  and  epithelial  degeneration.  The  glomerulse 
remain  intact,  while  the  tubuli  contorti  are  invaria- 
bly involved.  In  subjects  dying  from  aneuria  a  singu- 
lar fact  is  that  the  tubuli  contorti  are  free  from  bile 
pigment,  therefore  indicating  that  there  is  a  renal 
inhibition  and  in  these  cases  the  hepatic  lesions  are 
profound.  The  lesions  of  the  tubuli  contorti  are 
certainly  due  in  part  to  the  spirochetes  which  are 
eliminated  by  the  tubuli  and  indirectly  to  the  lesions 
of  the  hepatic  cells. 


CAXXER  OF  THE  MIDDLE  EAR. 

The  positive  diagnosis  of  malignant  disease  of 
the  middle  ear  and  the  external  auditory  canal  in 
its  bony  portion  may  be  difficult  at  the  onset  of  the 
process,  and  microscopical  examination  at  this  time 
is  the  only  means  at  our  disposal  of  ascertaining  the 
true  nature  of  the. granulations.  Later,  pain,  facial 
paralysis,  and  rapid  cachexia  will  lead  to  a  suspicion 
of  malignancy  and  a  biopsy  should  be  made.  It 
is  quite  possible  that  radiography  will  render 
assistance  when  a  more  perfect  technic  has  been 
devised,  as  it  is  hoped  that  by  this  means  will  be 
revealed  the  process  taking  place  in  the  bony  walls 
of  the  external  ear  as  well  as  in  advanced  neoplasia 
where  there  are  few  or  indefinite  symptoms. 

The  various  hearing  tests  will  show  the  state  of 
the  auditory  apparatus.  The  tests  for  nystagmus, 
in  particular,  will  give  useful  data  as  to  the  state 
of  the  vestibular  labyrinth,  from  which,  in  cases 
of  vertigo,  one  will  be  able  to  ascertain  how  much 
this  depends  upon  the  state  of  the  middle  ear  and 
how  much  it  may  depend  upon  central  compression 
only.  Caloric  and  rotatory  nystagmus  must  like- 
wise be  searched  for,  although  the  pathogenesis  of 
these  symptoms  is  still  a  moot  question.  It  may 
be  simply  stated  that  if  nystagmus  produced  by  the 
injection  of  cold  water  into  the  diseased  ear  does 
not  give  rise  to  rotatory  nystagmus  on  the  opposite 
side,  it  should  not  be  hastily  concluded  that  a 
destructive  process  is  going  on  in  the  labyrinth.  In 
point  of  fact,  the  neoplastic  masses  interposed  may 
form  a  kind  of  cushion  against  the  thermic  action 
and  thus  warp  the  result.  Consequently,  in  these 
cases  nystagmus  must  also  be  provoked  by  gyration. 
If  then  there  is  no  nystagmus  reaction  it  will  be 
perfectly  logical  to  conclude  that  there  is  destruc- 
tion of  the  vestibule.  The  search  for  voltaic 
nystagmus  must  not  be  overlooked  and  in  this  test 
Babinski's  method  should  be  followed. 


70 


NEWS  ITEMS. 


[New  York 
Medical  Journal. 


The  only  differential  diagnosis  to  make  is  that 
between  granulations  of  the  cavity  of  the  tympanum, 
polypi,  and  cholesteatoma,  but  the  latter  is  less  rapid 
in  evolution  and  does  not  bring  out  the  early 
cachexia  as  is  the  case  in  malignant  disease.  Mi- 
croscopically, in  cholesteatoma  the  cells  are  of  the 
pavement  type,  since  the  process  is  formed  by 
desquamation  of  the  epidermis  and  never  will  horny 
globes  be  found  which  are  characteristic  of  epi- 
thelioma. The  question  of  primary  cholesteatoma 
would  not  be  discussed  as  it  is  still  a  debatable  sub- 
ject, some  observers  maintaining  that  it  is  a  true 
neoplasia. 


PSYCHOLOGY  AND  INTERNATIONALISM. 

The  American  National  Research  Council,  based 
upon  forty  or  more  scientific  societies  to  promote 
the  interests  of  pure  and  applied  science,  numbers 
among  them  the  division  of  psychology  and  an- 
thropology, which  division  has  formulated  a  num- 
ber of  cooperative  projects.  Here  are  two:  The 
examination  of  four  alien  groups,  Mexicans,  Scan- 
dinavians, Sicilians  and  Japanese ;  some  two  thou- 
sand to  be  scientifically  examined  so  as  to  shed 
light  on  the  problem  of  assimilation  in  the  United 
States. 

The  second  plan  is  to  send  an  expedition  to  Cen- 
tral Africa  in  the  Congo  upper  regions  to  study  the 
aborigines  untouched  by  civilization.  A  language- 
learned  psychologist  will  head  the  expedition.  If 
the  aborigines  could  visit  Europe  at  present  they 
might  insist  on  the  incoming  scientists  being  exam- 
ined for  freedom  from  the  germs  of  that  exhausting 
disease — civilization. 


t 

SANITATION  AND  GOOD  WORK. 

Nothing  annoys  a  patient  who  has  made  an  auto- 
diagnosis  of  heart  disease,  brain  fag  or  lung  trouble, 
to  be  told  that  the  whole  source  of  mischief  lies  in 
constipation  or  his  kidneys.  It  is  the  same  with 
many  social  industrial  reformers.  They  study 
fatigue  and  efficiency,  mind  measuring,  better 
hours,  better  homes,  but,  if  told  that  toilet  rooms, 
revolting  in  appearance  and  difficult  of  access,  were 
often  accountable  for  faulty  work  and  discontent, 
they  would  not  believe.  But,  for  the  Safety  Insti- 
tute of  America  no  study  is  insignificant,  and  they 
consider  a  decent  sanitary  equipment  as  a  valuable 
asset  to  any  work  place.  Employees  reluctantly  yield 
to  Nature's  demands  when  the  toilet  is  imcleanly, 
and  it  is  hard  for  them,  when,  at  the  end  of  the  day, 
they  have  to  go  unwashed  among  the  people  in 
crowded  cars  and  ferries. 

Toilet  rooms  should  be  placed  where  they  are 
exposed  to  light  and  air.  Sunlight  is  a  powerful 
germicide  and  disinfectant.  If  artificial  light  has 
to  be  used  it  should  penetrate  to  every  corner  so 
showing  up  dirt  and  inducing  thorough  cleanliness 
by  flushing  or  scrubbing  the  floor.  It  should  be 
easily  accessible,  yet  not  too  prominent,  because 
some  false  modesty  still  exists,  many  girls  saying 


they  would  rather  die  than  walk  to  an  obvious  toilet 
through  a  room  crowded  with  men.  These  do  die* 
generally  of  architectural  blunders,  though  relations 
term  it  stomach  trouble,  and  vendors  of  patent 
medicines  grow  rich  from  the  sale  of  headache 
powders  and  liver  tonics,  the  necessity  for  which 
is  not  in  hard  work  but  wretched  sanitary  equipment. 


News  Items. 

Cambridge  University  Faculty.  —  Professor 
James  Thomas  Wilson  has  been  elected  professor  of 
anatomy  in  Cambridge  University  to  succeed  the 
late  Professor  Macalister. 

Diplomas  in  Psychological  Medicine. — The 
University  of  London  is  about  to  institute  a  diploma 
in  psychological  medicine,  the  standard  for  the  di- 
ploma being  about  that  required  by  the  University  of 
Cambridge. 

Medical  Journalism.  —  Professor  Giuseppe 
Guicciardi  of  Reggio  Emilia  has  succeeded  the  late 
Professor  Augusto  Tamburini  as  editor  of  the  well 
known  journal  of  psychiatry,  Kiz'ista  Sf'crimciitalc 
dc  Frcniairia. 

Royal  College  of  Surgeons  in  Ireland. — Mr. 
Edward  H.  Taylor,  regius  professor  of  surgery  in 
Trinity  College,  has  been  elected  president  and  Sir 
W.  I.  de  C.  Wheeler  has  been  elected  vice-president 
of  the  Royal  College  of  Surgeons  in  Ireland. 

Award  to  Dr.  Theobald  Smith.— The  M.  Doug-  ' 
las  Flattery  Medal  and  prize  of  $500  have  been 
awarded  by  the  Harvard  Corporation  to  Dr.  Theobald 
Smith,  formerly  of  Harvard  University,  in  recog- 
nition of  successful  scientific  research  resulting  in 
the  prevention  of  disease  and  the  conservation  of 
health. 

Correction. — The  statement  was  made  in  a  re- 
cent issue  that  the  proposed  International  Health 
Office  to  be  established  under  the  health  section  of 
the  League  of  Nations  would  be  located  in  London. 
The  International  Health  Office  is,  however,  to  be 
established  at  the  seat  of  the  capital  of  the  League 
of  Nations. 

North  Carolina  Medical  Meeting. — The  Medi- 
cal Society  of  the  State  of  North  Carolina  recently 
held  its  annual  meeting,  under  the  presidency  of  Dr. 
Carl  V.  Reynolds,  of  Asheville,  and  elected  the 
following  officers :  President,  Dr.  Thomas  E.  An- 
derson, Statesville;  vice-presidents.  Dr.  Charles  S. 
Lawrence,  Winston-Salem;  Dr.  William  H.  Ward, 
Plymouth;  Dr.  John  M.  Manning,  Durham;  secre- 
tary-treasurer. Dr.  Benamin  K.  Hays,  Oxford  (re- 
elected) . 

Venereal  Diseases  Conference. — A  Pan-Ameri- 
can conference  on  the  control  of  venereal  diseases 
will  be  held  in  Washington,  probably  in  December 
under  the  auspices  of  the  American  Red  Cross,  the 
United  States  Public  Health  Service,  the  United 
States  Interdepartmental  Social  Hygiene  Board, 
and  the  American  Social  Hygiene  Association.  The 
work  of  the  conference  will  deal  with  three  dififerent 
groups  of  problems  in  the  control  of  venereal  dis- 
eases, namely,  the  purely  scientific,  the  administra- 
tive, and  those  which  have  particular  public  interest. 


July  10,  1920.] 


NEWS  ITEMS. 


71 


Massachusetts    Medical    Meeting. — The  one 

hundred  and  thirty-ninth  annual  meeting  of  the 
Massachusetts  Medical  Society  was  held  on  June 
•8th  and  9th  in  Boston,  under  the  presidency  of  Dr. 
Alfred  Worcester.  The  officers  for  the  preceding 
year  were  reelected,  with  Dr.  Frederick  E.  Jones 
as  the  vice-president. 

West  Virginia  State  Medical  Conference. — The 
West  Virginia  State  Medical  Association  held  its 
annual  meeting  in  May,  when  the  following  officers 
were  elected :  President,  Dr.  J.  Howard  Anderson, 
of  Marytown ;  vice-presidents,  Dr.  Hubert  E.  Gay- 
no'r  of  Parkersburg ;  Dr.  S.  G.  Moore,  of  Elkins; 
Dr.  Charles  O'Grady,  of  Elkins ;  secretary.  Dr. 
Robert  A.  Ashworth,  of  Moundsville ;  treasurer,  Dr. 
H.  G.  Nicholson,  of  Charleston. 

Parkin  Prize  Offered. — The  Royal  College  of 
Physicians  of  Edinburgh  announces  a  competition 
for  the  Parkin  prize  of  100  pounds,  which  will  be 
awarded  for  the  best  essay  on  the  curative  effects  of 
carbonic  acid  gas  or  other  forms  of  carbon  in  cholera, 
for  different  forms  of  fever  and  other  diseases.  The 
prize  is  open  to  competitors  of  all  nations.  Essays 
must  be  in  the  hands  of  Dr.  J.  S.  Fowler,  the  secre- 
tary, not  later  than  December  31,  1920. 

Eugenics  Research  Conference. — The  eighth 
annual  meeting  of  the  Eugenics  Research  Associa- 
tion was  held  June  25th  at  Cold  Spring  Harbor, 
Long  Island,  under  the  presidency  of  Dr.  Stewart 
Paton,  of  Princeton.  Dr.  Irving  Fisher  was  elected 
president  for  the  ensuing  year,  and  plans  were  made 
for  the  transformation  of  the  Eugenical  News,  an 
eight  page  monthly,  into  a  quarterly  Journal  of 
Eugenics,  under  the  auspices  of  the  association. 

Greek  Hygienic  Congress. — The  first  Pan-Hel- 
lenic Congress  of  Hygiene  and  Demography  will 
"be  held  at  Athens  from  April  25  to  30,  1921,  under 
the  presidency  of  Professor  Phocas.  There  will  be 
sections  in  public  health,  individual  hygiene,  military 
and  naval  hygiene,  demography,  infant  hygiene,  and 
prophylactic  hygiene.  An  international  exhibition 
of  hygiene  and  medical  industry  will  be  opened  at 
the  same  time  as  the  congress  and  will  continue 
until  June  25th. 

Honorary  Degrees  for  Medical  Men. — In  con- 
nection with  the  annual  meeting  of  the  British 
Medical  Association  in  Cambridge,  the  council  of 
the  University  Senate  has  proposed  for  the  degree 
of  LL.  D.  honoris  causa  the  following  distinguished 
members  of  the  medical  profession :  Dr.  Harvey 
Cushing,  professor  of  svirgery.  Harvard  Univer- 
sity ;  Dr.  Simon  Flexner,  director  of  laboratories, 
Rockefeller  Institute  for  Medical  Research ;  the  late 
Major  General  William  C.  Gorgas,  former  presi- 
dent of  the  American  Medical  Association  and  Sur- 
geon General  of  the  U.  S.  Army;  Sir  T.  Clif- 
ford AUbutt,  K.  C.  B.,  regius  professor  of 
physics ;  Dr.  Jules  Bordet,  president  of  the  Faculty 
of  Medicine  and  director  of  the  Pasteur  Institute, 
Brus.sels ;  Dr.  A.  Calmette,  director  of  the  Pasteur 
Institute,  Lille ;  Dr.  P.  Giacosa.  professor  of  ma- 
teria medica  and  experimental  pharmacology,  Uni- 
versity of  Turin;  Sir  G.  H.  Makins,  G.  C.  M.  G., 
president  of  the  Royal  College  of  Surgeons  of 
England ;  Sir  Patrick  Man.son,  G.  C.  M.  G. ;  Sir 
Norman  Moore,  president  of  the  Royal  College  of 
Physicians  of  London. 


Association  of  American  Physicians. — At  the 

annual  meeting  of  the  Association  of  American 
Physicians,  held  in  Atlantic  City,  the  following 
officers  were  elected:  President,  Dr.  William  S. 
Thayer,  of  Baltimore;  vice-president,  Dr.  Herbert 
C.  Moffitt,  of  San  Francisco ;  secretary.  Dr.  Thomas 
McCrae,  of  Philadelphia;  recorder.  Dr.  Thomas  R. 
Boggs,  of  Baltimore;  treasurer,  Dr.  Joseph  A. 
Capps,  of  Chicago. 

Smallpox  in  Virginia. — During  the  first  four 
months  of  1920  there  were  1,821  cases  of  smallpox 
reported  in  the  State,  with  six  deaths,  compared 
with  770  reported  cases  in  the  same  period  of  1919 
and  ten  deaths  for  the  entire  year  of  1919.  Dur- 
ing 1917  the  disease  caused  but  two  deaths,  while  in 
1918  six  deaths  were  attributed  to  it.    In  January, 

1919,  there  were  129  cases  against  467  in  January, 

1920.  In  February,  1920,  the  disease  reached  its 
apex  for  the  season  with  703  cases  against  113  for 
the  corresponding  month  of  last  year.  In  March 
the  figures  were  326  against  261  for  March,  1919, 
while  in  April  they  were  325  and  267  cases,  re- 
spectively. During  April  of  this  year  smallpox  was 
reported  in  thirty-four  of  the  ten  counties  and  dur- 
ing the  year  it  has  appeared  in  approximately  half 
of  the  counties  of  the  State. 

Flechsig's  Jubilee. — Dr.  Paul  Flechsig.  the 
noted  Leipzig  anatomist  and  psychiatrist,  celebraf^ed 
the  fiftieth  anniversary  of  his  graduation  on  May 
23rd.  When  assistant  at  the  University  Physiologi- 
cal Institute  his  first  considerable  work  on  Conduc- 
tion Paths  in  the  Brain  and  Spinal  Cord  attracted 
attention.  In  1882  he  took  over  the  Neurological 
Clinic,  built  and  furnished  on  plans  drawn  up  by 
himself,  whose  chief  he  still  is.  Flechsig  holds  an 
honorary  doctorate  in  the  Faculty  of  Exact  Sciences 
at  Oxford  and  is  an  honorary  member  of  learned 
societies  in  Dorpat,  Dresden,  Florence,  Kieff,  Lon- 
don, Munich,  Paris,  Petrograd,  Rome  and  Vienna. 
On  the  day  of  his  jubilee  the  firm  of  Georg  Thieme, 
of  Leipzig,  issued  as  a  Festschrift  the  first  volume  of 
a  monumental  work  on  the  Anatomy  of  the  Human 
Brain  and  Spinal  Cord  on  a  Myelogenetic  Basis,  on 
which  the  veteran  psychiatrist  has  been  intensively 
engaged  for  ten  years. 

DIED. 

Blades. — In  Horiiell,  N.  Y.,  on  Monday,  June  28th,  Dr. 
John  Wesley  Blades,  aged  sixty-five  years. 

Davenport. — -In  Vancouver,  B.  C,  on  Monday,  May  31st, 
Dr.  George  Edwin  Davenport,  aged  fifty-seven  years. 

Fritchey. — In  Harrisburg,  Pa.,  on  Thursday,  June  24th, 
Dr.  Charles  Albert  Fritchey,  aged  forty-five  years. 

Gorgas. — In  London,  England,  on  Sunday,  July  4th, 
Major  General  William  C.  Gorgas,  U.  S.  Army,  aged 
sixty-six  years. 

MiLNOR. — In  Warrensville,  Pa.,  on  Thursday,  June  24th. 
Dr.  Robert  H.  Milnor,  aged  fifty-two  years. 

Price. — In  San  Francisco,  Gal.,  on  Saturday,  June  19th, 
Dr.  Thomas  Linton  Price,  aged  fifty-four  years. 

Schumann. — In  Oakland,  Cal.,  on  Saturday,  June  I9th, 
Dr.  H.  Schumann. 

Straughn. — In  Jersey  City,  N.  J.,  Dr.  Frederick 
Straughn,  aged  seventy-five  years. 

Tomes. — In  Brooklyn,  N.  Y.,  on  Monday,  June  28th,  Dr. 
William  Austin  Tomes,  aged  fifty-five  years. 


Book  Reviews 


ORGANIC  CHEMISTRY. 

The  Preparation  of  Organic  Compounds.  By  E.  De  Barry 
Barnett,  B.  Sc.  (Lond.),  A.  I.  C.  With  Fifty-four  Il- 
lustrations. -Second  Edition.  Philadelphia :  P.  Blakis- 
ton's  Sons  &  Co.,  1920.    Pp.  vi-273. 

In  this,  the  second  edition  of  The  Preparation  of 
Organic  Compounds,  the  atithor  has  made  no  funda- 
mental change  in  the  size  or  scope  of  his  book.  Sev- 
eral additions  have  been  made,  however,  which  in- 
crease its  usefulness.  The  inclusion  of  a 
short  description  of  larger  sized  apparatus  suit- 
able for  use  in  the  laboratory  resulted  from  the  au- 
thor's experience  during  the  war,  when  he  found 
that  few  chemists  had  any  idea  of  what  apparatus 
to  use  when  it  became  necessary  to  handle,  materials 
in  unusually  large  quantities.  Some  of  the  apparatus 
described  may  be  regarded  as  crude,  but  the  average 
manufacturing  plant  is  seldom  fitted  with  the  latest 
refineinents  and  the  practical  chemist  must  adapt 
himself  to  his  environment.  Chemical  preparations 
can  be  carried  out  in  saucepans  and  jam  pots  quite 
as  successfully  as  in  the  more  conventional  and  more 
expensive  beakers  and  basins.  The  description  of 
the  chemical  processes  is  less  full  than  in  most  books 
on  organic  preparations  but  the  details  given  are  suf- 
ficient to  enable  the  student  to  carry  out  the  prepa- 
ration successfully,  without  being  so  exhaustive  as 
to  reduce  the  work  to  mere  mechanical  routine.  The 
bibliography  will  appeal  to  the  more  serious  minded 
student.  The  selection  of  a  considerable  number 
of  preparations  from  the  patent  inedicine  literature, 
with  the  hope  of  familiarizing  the  student  with  this 
neglected  branch  of  the  literature,  is  to  be  com- 
mended. To  the  beginner  and  to  the  advanced  stu- 
dent in  organic  chemistry  the  present  vokune  will 
serve  as  a  valuable  laboratory  manual  and  as  a 
companion  volume  to  the  usual  theoretical  text- 
books. 

THE  PSYCHOLOGY  OF  THE  DOCTOR. 

Das  autistisch  undissipUniertc  Denkcn  in  der  Medizin  und 
seine  Uberwindung.  By  E.  Bleuler.  Berlin :  Julius 
Springer,  1919.    Pp.  iv-207. 

Some  time  ago  Bleuler  treated  of  autistic  thinking 
as  the  type  of  thinking  of  the  egoistic  psychoneu- 
rotic or  psychotic.  Now  he  comes  forward  to  apply 
the  term  to  the  prevailing  mental  attitude  in  medical 
conception,  treatment,  prophylaxis,  considerations 
of  etiology,  pathology  and  all  that  pertains  to  medi- 
cal practice.  He  uses  the  term  because  he  believes 
that  medical  thinking  lags  sadly  behind  in  the  pre- 
cision, accuracy  and  persistent  search  after  facts  and 
facts  only  on  which  to  base  all  activities  and  attitudes 
which  should  m.ark  a  profession  so  important  and 
presumably  scientific.  He  looks  upon  the  physician 
as  caught  unconsciously  in  the  desire  to  serve  the 
patient's  immediate  need,  to  conform  to  the  patient's 
wnsh  and  therefore  pressed  upon  by  the  force  of  his 
own  desire  to  maintain  himself  as  physician  and 
arise  at  once  to  the  demand  put  upon  him.  Thus 
more  and  more  he  has  become  enmeshed  in  elabo- 
rated and  meaningless  formuHstic  prescriptions  of 
various  sorts,  in  interference  with  Nature's  processes, 
a  godlike  assumption  even  of  her  activity,  which 


have  blinded  him  to  simplicity  and  actuality  of  facts 
as  the  governing  factors  of  practice  and  theory. 

Bleuler  makes  a  plea  for  a  humbler  and  more  truly 
scientific  position  on  the  part  •  of  the  profession, 
whether  in  the  physical  or  psychic  world,  whether  in 
the  realm  of  pharmacology  or  in  prescription  of 
whatever  sort,  in  understanding  the  reaction  of  in- 
dividuals to  any  part  of  the  environmental  world. 
The  physician  has  failed  in  this  in  physical  diseases 
as  in  the  mental.  The  quack  has  often  superseded 
him  because  he  has  had  naturally  a  better  intuitive 
appreciation  of  the  farreaching  psychology  of  inter- 
relation and  the  part  that  a  variety  of  facts  play 
in  the  lives  and  health  of  men.  The  physician  is  a 
victim  of  a  psychophobia  which  keeps  him  from  a 
clearer  investigation  of  actualities  which  are  both 
psychological  and  otherwise  scientific.  The  existing 
state  of  things  is  difficult  of  remedy,  but  Bleuler  asks 
that  a  new  type  of  disciplined  thinking,  investigat- 
ive and  constructive,  shall  become  the  rule.  He 
points  out  the  part  the  medical  school  and  medical 
publications  have  in  promoting  this  end. 

SMALLPOX  AND  VACCINATION. 

Half  a  Century  of  Smallpox  and  Vaccination.  Milroy 
Lectures  Before  the  Royal  College  of  Physicians,  1919. 
By  John  C.  McVail,  M.  D.,  LL.  D.,  Edinburgh:  E.  S. 
Livingstone,  1920.    Pp.  iii-86. 

A  book  from  a  Scotsman  generally  merits  atten- 
tion when  it  concerns  a  big  subject.  It  may  be  dry 
or  too  erudite,  but  is  reliable,  so  one  settles  down 
with  easy  mind  to  study  smallpox  as  it  was  and  is, 
vaccination  as  it  was  and  is,  and  the  control  of  small- 
pox in  the  present  day. 

The  second  lecture  rebuts  a  contention  that  infan- 
tile vaccination,  which  protects  the  individual,  makes 
smallpox  "so  difficult  to  recognize  where  it  is  not 
wholly  prevented  that  the  result  is  such  spread  of 
infection  froin  missed  cases  disadvantageous  to  the 
community." 

Careful  statistics  show  smallpox  to  have 
increased  gradually  in  power  in  the  eight- 
eenth centur}-;  to  have  reached  its  maximum 
in  1870-73,  and  since  then  to  have  "retro- 
gressed in  fatality,  infectivity,  and  prevalence." 
He  wisely  remarks  that  it  is  too  soon  after  the  war 
to  prophesy  that  we  have  seen  its  last  consequences 
with  regard  to  epidemic  disease,  but,  whether  it  be 
of  the  American  type  with  low  infectivity  or  the 
severe  type  of  the  seventies,  the  means  for  meet- 
ing it  are  at  hand. 

THE  MENDELIAN  THEORY. 

Mendelism.  By  Reginald  Crundall  Punnett,  F.  R.  S. 

Fifth  Edition.    London :  Macmillan  Co.,  Limited.  1919. 

A  straightforward  presentation  of  the  Mendelian 
theory.  In  this,  the  fifth  edition,  are  set  forth  the 
results  of  the  work  done  on  Drosphila,  the  fruit 
fly,  by  Professor  Morgan,  of  Columbia  University. 
These  researches  of  Morgan's  have  done  much  to 
shed  new  light  on  the  problem  of  heredity  and  many 
are  of  the  opinion  that  it  is  one  of  the  most  far- 
reaching  scientific  discoveries  of  late  years.  The 
working  out  of  hereditary  traits  up  through  man 
should  have  a  direct  practical  bearing  in  the  field  of 


July  10,  1920.] 


BOOK  REVIEWS. 


73 


medicine.  On  account  of  the  great  diversity  in  hu- 
mans it  is  at  times  difficult  to  trace  this.  However, 
new  work  which  has  been  done  recently  in  the 
transmission  of  endocrine  characteristics  has  opened 
a  new  field  in  the  study  of  heredity  and  medicine. 
In  order  to  realize  the  full  significance  of  the  work 
done  by  this  painstaking  monk  on  the  common  pea 
it  is  necessary  to  review  the  work  as  he  actually  did 
it.  The  extent  of  its  influence,  it  should  be  recalled, 
is  not  limited  to  man  and,  as  the  author  has  pointed 
out,  Mendel's  findings  have  an  economic  value  when 
applied  to  agriculture  and  the  breeding  of  animals 
for  live  stock  or  other  purposes. 

This  exposition  presents  the  problem  simply, 
tracing  each  step  with  care  and  leaving  a  cohesive 
picture  of  the  problem  of  heredity  as  we  understand 
it  today. 

HANDBOOK  OF  MEDICINE. 

IV heeler's  Handbook  of  Medicine.  By  Willi.\m  R.  Jack, 
B.Sc,  M.D.,  F.R.E.P.S.G,  Physician  to  the  Glasgow 
Royal  Infirma/y,  Lecturer  in  Clinical  Medicine  in  the 
University,  Glasgow.  Illustrated.  Sixth  Edition.  Edin- 
burgh :  E.  &  S.  Livingstone ;  New  York :  William  Wood 
&  Co.,  1920.   Pp.  V-56L 

Since  the  first  edition  of  Wlfeeler's  Handbook  of 
Medicine  it  has  been  found  on  the  bookshelves  of 
many  physicians.  This  small  compend  has  been 
more  widely  read  as  a  ready  reference  work  than 
many  of  the  more  unwieldy  volumes.  It  is  a  con- 
venient book  both  in  size,  composition,  and  brevity. 
Unfortunately,  the  present  edition,  the  sixth,  is 
badly  printed.  This  is  a  drawback  for  a  book  of  this 
type.  While  it  may  seem  an  unimportant  point  to 
criticize,  and  while  allowances  must  be  made  for 
difficulties  in  regard  to  labor  conditions  and  the 
scarcity  of  paper,  it  seems  as  though  an  unwise 
saving  has  been  attempted.  There  are  a  few  ad- 
ditions to  the  book  due  to  a  discussion  of  some  of 
the  diseases  more  commonly  found  during  the  war, 
but  on  the  whole  the  general  style  and  contents  have 
remained  unaltered. 

MODERN  PROGRESS. 

The  Story  of  Modern  Progress.  With  a  Preliminary 
Survey  of  Earlier  Progress.  By  Willis  M.^lson  West. 
New  York:-Allyn  &  Bacon,  1920.    Pp.  xvi-701. 

Fifty  years  ago  an  English  schoolboy  began  his 
history  composition  by  saying :  'When  Julius  Caesar 
landed  in  Britain  all  the  world  was  in  heathen  dark- 
ness." It  was — for  the  schoolboy.  Term  after  term 
he  plodded  through  his  history  of  England.  After 
that  came  the  history  of  Rome,  followed  by  that  of 
Greece.  There  were  no  small  histories  of  European 
countries,  so  that  when  he  began  the  large  ones,  he 
never  linked  up  dates  nor  made  any  connections,  so 
he  hazily  imagined  that  other  countries  became 
civilized  and  started  ofif  as  histories  some  time  after 
his  own,  and  he  wearily  took  up  Germany  or  said, 
thankfully,  he  had  done  France.  The  writers  of 
schoolbooks  made  them  as  dry  as  possible,  so  that 
an  anecdote  was  hailed  with  relief,  and  these  re- 
tained in  the  mind,  formed  the  basis  of  world 
knowledge. 

It  was  a  great  task  for  the  author  to  gather  con- 
temporary actors  on  the  world's  stage,  not  mak- 
ing its  tragedies  and  comedies  separately  but  all 
acting  and  reacting  on  each  other  as  nations. 
Teachers  will  welcome  its  teaching,  the  schoolboy 


will  unconsciously  benefit,  and  all  use  it  as  a  useful 
reference.  Naturally,  one  man  cannot  always  judge 
rightly  concerning  the  affairs  of  many  nations 
in  quite  modern  dealings  because  the  babble  of 
modern  historians  has  not  yet  quieted  down  for  the 
voice  of  Truth  to  be  heard,  but  the  reader  feels  that 
Professor  West  keeps  an  intent  ear  for  her  deci- 
sions, and  so  they  walk  together  in  glad  trust 
through  the  Stone  Age  right  away  to  the  present 
century. 

THE  DEATH  OF  TITIAN. 
The  Death  of  Titian.  By  Hugo  von  Hofm.\nnsthal.  A 
Dramatic  Fragment  Enacted  at  Munich  in  Memory  of 
Arnold  Bocklin.  Translated  from  the  German  by  John 
Head,  Jr..  Boston:  The  Four  Seas  Company,  1920.  Pp. 
ix-27. 

It  is  the  function  of  the  masters  in  art  and  litera- 
ture to  present  new  and  recreative  views  of  life. 
They  awaken  us  afresh  to  a  fuller  comprehension 
of  its  wealth  and  beauty  as  well  as  its  darker 
meanings.  This  fragment  reminds  us  of  the  depth 
and  richness  discovered  by  the  great  painter  and 
portrayed  permanently  for  the  world's  appreciation 
in  his  canvases.  The  poet  dramatist  who  had  dedi- 
cated to  him  this  memorial  has  added  to  all  this 
a  quickening  perception  and  lesson  of  his  own. 

The  melody  of  the  lines,  which  the  translator  has 
well  reproduced,  flows  deep  and  full  with  the  un- 
broken abundance  and  softness  of  a  Venetian  night 
in  the  master's  own  garden.  Even  the  stage  set- 
ting for  the  piece  is  indicative  of  the  warmth  of 
beauty  in  which  the  lines,  in  the  mouths  of  the 
master's  pupils,  express  more  fully  the  field  where 
Titian  found  his  inspiration  and  expression.  The 
poet  has  made  to  live  again  the  vitality  of  the  mind 
which  could  comprehend  the  sensuously  beautiful 
in  life  in  such  vivid  terms,  to  whom  these  things 
were  the  clothing  of  a  spirit  which  breathed 
through  them,  renewed  its  courage  and  expanded 
its  power  in  artistic  mastery  of  them.  The  artist's 
more  penetrating  eye  and  warmer  heart  seizes  and 
recreates  this  warmth  and  beauty  for  us. 

More  poignant  still  is  a  message  from  the  drama- 
tist's own  conception.  A  high  sustained  note 
throughout  this  dramatic  fragment  gives  a  consum- 
mating force  to  the  mere  description  of  the  paint- 
er's conception  and  expression.  It  lifts  the  reader's 
thought  continually  above  the  mere  beauty,  rich 
as  that  is,  and  above  the  sorrow  of  the  pupils  and 
members  of  the  household.  This  is  the  reiterated 
contrast  suggested  rather  than  spoken  between  Gia- 
nano,  young  and  handsome,  in  love  with  life  and 
afraid  of  death,  and  the  aged  master.  Gianano's 
fear  is  stronger  than  grief,  the  natural  egotistical 
fear  of  one  who  has  not  yet  found  life  and  tried 
his  powers.  It  arises  when  death  suggests  the  un- 
certainty of  all  this.  "Death !  Death !  .  .  .  I've 
never  stood  so  close  to  Death  before !"  Titian  on 
the  other  hand  has  revived  for  work  the  best  that 
he  has  yet  done.  "A  radiance  as  a  saint's  shines 
through  his  pallor,  as  he  paints  and  paints,"  eager 
only  to  secure  these  few  more  moments  of  crea- 
tive activity.  It  is  only  outside  that  they  mourn; 
the  master  is  quiet  and  busy  within.  The  sadness 
of  death  comes  to  those  at  the  other  side  of  life, 
where  its  achievements  exist  only  in  prospect  and 
in  uncertainty.  The  creator  who  has  exhibited  mas- 


74 


500a:  reviews. 


[New  York 
Medical  Journal. 


tery  of  his  powers  and  of  the  world  surrounding 
him  is  calm  and  even  gay.  His  work  is  not  torn 
from  him,  it  only  claims  him  up  to  the  last  moment 
when  smilingly  the  brush  is  laid  aside. 

WILLIAM  J.  LOCKE. 

The  House  of  Baltazar.  By  William  J.  Locke,  Author  of 
The  Rough  Road,  The  Red  Planet,  etc.  New  York: 
John  Lane  Company,  1920.    Pp.  ix-312. 

It  is  curious  how  men  depicting  things  by  pen  or 
brush  or  pencil  always  put  in  one  little  point  of  in- 
completeness to  make  it  look  more  natural,  more 
true  to  life.  On  a  library  shelf  one  book  is  aslant 
or  with  a  torn  binding;  in  drapery,  one  fold  hangs 
askew.  In  a  shop  whose  window  showed  marvels 
in  artificial  flowers,  I  noted  one  group  with  a  faded 
blossom,  some  petals  fallen  from  another  lay  on  the 
floor.  Some  such  deliberate  indication  of  imper- 
fection is  given  in  John  Baltazar  in  his  forcing  him- 
self to  do  what  he  has  purposed  without  looking  all 
round  the  question,  but  after  a  little  acquaintance 
you  feel  that  the  human  weakness  only  shows  up  the 
sturdy,  dogged,  cheerfulness  he  abundantly  pos- 
sesses. The  author  plays  on  the  feelings  of  his 
readers  in  the  same  way  as  the  skilled  acrobat  on  the 
sightseers,  who,  when  in  a  position  of  extreme  dan- 
ger nearly  loses  his  balance,  but  does  it  intentionally 
to  enhance  the  situation. 

John  Baltazar,  mathematical  professor  at  Cam- 
bridge, nearly  leaves  a  waspish  wife,  who  has  not 
told  him  of  her  approaching  motherhood,  to  go  away 
with  a  bonnie  pupil  but  flees  to  China  instead,  dis- 
appears, in  fact,  for  nearly  twenty  years,  and  re- 
turning sets  up  as  a  hermit  in  a  lonely  cottage  with 
his  priceless  Chinese  manuscripts  to  write  a  marvel- 
ous book  and  continue  mathematical  studies.  No 
news  of  the  outside  world  comes  to  him,  his  faithful 
Chinese  .  servant  pupil  is  bound  over  to  discreet 
silence,  and  only  a  Zeppelin  bomb,  destroying  the 
cottage  when  the  war  has  already  been  waging  two 
years,  brings  him  to  a  realization  of  the  war,  and 
knowledge  of  the  fact  of  his  possessing  a  motherless 
son,  already  war  wounded,  from  the  girl  pupil — 
now  over  thirty — who  is  a  hospital  nurse  and  recog- 
nizes the  son's  name  among  her  charges. 

The  erudite  labor  of  many  years  was  all  destroyed 
by  the  bomb,  but  the  countershock  of  his  coun- 
try's peril  arouses  him  to  devote  himself  wholly  to 
her,  a  golden  thread  of  love  in  the  way  of  a  deter- 
mination to  tenderly  coax  the  nurse,  ^larcelle,  to 
marry  him,  his  consolation.  Tremendous  success 
attends  his  politicomilitary  efforts.  He  is  one  of 
the  coming  men;  his  dream  of  helping  is  realized. 
But  his  new  found  soldier  son  becomes  entangled 
with  the  beautiful  wife  of  a  politician.  She  is  bent 
on  being  a  leader,  and  delights  in  political  secrets. 
She  has  induced  the  son  to  elope  with  her ;  his 
military  career  will  be  ruined.  They  are  on  the 
railway  platform ;  the  train  is  leaving  in  a  few 
minutes  but  toward  them  is  hastening  John  Baltazar, 
just  in  time  to  hurry  his  son  off  the  scene  and  face 
the  husband  of  Lady  Edna  Donnithorpe,  whom  he 
forces  to  believe  that  he — John — is  the  intending 
eloper.  The  snarling,  scandal  loving  politician  does 
not  really  believe,  but  is  greatly  glad  to  ruin  his 
enemy,  so  there  stands  the  hero  facing  the  third 
crisis  in  his  life.    Sweet  love  refused  for  the  honor 


of  a  girl ;  the  fruits  of  long  study  rudely  destroyed, 
a  dream  of  helping  his  country  vanishing,  all' his 
^ promises  fulfilled,  no  reward  to  the  promiser  save 
seeming  defeat.  He  will  return  to  China— alone. 
Then,  at  2:30  a.  m..  a  most  dismal  hour  to  be 
housed  with  disappointment  as  a  companion,  comes 
Xurse  Marcelle  to  give  him  what  he  has  so  patiently 
waited  for  and  scarcel}-  hoped  to  win.  She  will  go 
with  him,  and  life  shall  reblossom  in  the  land  of  his 
exile. 

In  one  part  of  the  book  he  deprecates  his  name 
of  John,  equally  so  its  diminutive  Jack  of  melodra- 
matic fame,  but,  from  much  reading,  the  reviewer 
guessed  a  John  could  not  go  wrong,  for  all  heroes 
socalled  in  fiction  are  invariably  strong,  and  in- 
domitable right  away  to  the  end  of  life  and  the  book. 


New  Publications  Received 


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


THE  FOOLISH  LOVERS.  By  St.  John  G.  Ervixe.  Author 
of  Changing  Winds,  John  Ferguson.  New  York :  The  Mac- 
millan  Company,  1920.    Pp.  iii-403. 

DIE   KINDERTUBERKULOSE   IHRE   ERKENNUXG   UXD  BEHAXD- 

LUXG.  Ein  Taschenbuch  fiir  praktische  Arzte  von  Prof. 
Haxs  Much.  Leipzig:  Verlag  von  Curt  Kabitzsch,  1920. 
Pp.  v-35. 

MASKS.  With  Jim's  Beast,  Tides,  Among  the  Lions, 
The  Reason,  The  House.  One  Act  Plays  of  Contemporary 
Life.  By  George  Middletox.  New  York:  Henry  Holt  & 
Co.,  1920.   Pp.  3-227. 

O.  HEXRV  MEMORIAL  AWARD  PRIZE  STORIES,  1919.  Chosen 

by  the  Society  of  Arts  and  Sciences.   With  an  Introduction 
by  Blaxche  Coltox  Williams.    Garden  Cit>'  and  New  . 
York:  Doubleday,  Page  &  Co.,  1920.    Pp.  xvii-298. 

THE    MICROBIOLOGY    AND    MICROAXALYSIS    OF    FOODS.  By 

Albert  Schxeider,  M.  D.,  Ph.  D.  (Columbia  University)  ; 
Professor  of  Pharmacognosy,  College  of  Pharmacy,  Uni- 
versity of  Nebraska,  etc.  Illustrated.  Philadelphia:  P. 
Blakiston's  Son  &  Co.    Pp.  v-262. 

EREWHOX   REVISITED  TWEXTY  YEARS  LATER.      Both   by  the 

Original  Discoverer  of  the  Country  and  by  His  Son.  By 
Samuel  Butler,  Author  of  Erezvhon,  The  Way  of  All 
Flesh,  Life  and  Habit,  etc.  With  an  Introduction  by 
MoREBY  AcKLOM.  Illustrated.  New  York :  E.  P.  Button  & 
Co.    Pp.  xxvii-304. 

LES  allures  CLIXIQUES  DE  LA  SYPHILIS  ET  LES  FORMES  DE 
PARALYSIE  GEXER.\LE  COXSECUTI\-E.     Par  Dr.  LuiGI  RoMOlJj 

Saxguixetti,  de  la  Faculte  de  Medicine  de  Paris  ;  de  la  Fac- 
ulte  de  Medicine  de  Sienne  (Italie)  ;  ex-interne  de  I'Asile 
d'Alienes  et  de  I'lnstitut  de  Pathologic  Generale.  Paris : 
Jouve  &  Cie,  1917.    Pp.  i-287. 

ESSEXTIjVLS  OF  PHARMACY,  WITH  QUESTIONS  AXD  ANSWERS. 

By  Clyde  M.  Snow,  Ph.  G.,  A.  M.,  Associate  Professor  of 
Pharmacy,  University  of  Illinois  School  of  Pharmacy ; 
Graduate  Instructor  in  Pharmacolog>'.  University  of  Illi- 
nois College  of  ^vledicine,  etc.  St.  Louis :  C.  V.  Mosby 
Company,  1919.    Pp.  xiv-734. 

LEHRBUCH    DER    SPEZIFISCHEX    DI.^GXOSTIK    UXD  THER.\PIE 

DER  TUBERKULOSE.  Fiir  Arztc  und  Studierende  von  Dr. 
Baxdelier,  Chefarzt  des  Sanatoriums  Schwarzwaldheim 
in  Schomberg  bie  Wildbad,  und  Prof.  Dr.  Roepke,  Chefarzt 
der  Heilstatte  Melsungen,  Facharzt  fiir  Lungen  und  Hals- 
krankheiten  in  Kassel.  Mit  einem  Vorwort  von  Wirkl. 
Geh.  Rat  Prof.  Dr.  R.  Koch,  Exzellenz.  Zehnte  .A.uflage. 
Mit  25  Temperaturkurven  auf  7  lithographischen  Tafeln,  2 
farb.  lith.  Tafeln,  und  6  Textabbildungen.  Leipzig  and 
Wurzburg:  Verlag  von  Curt  Kabitzsch,  1920.    Pp.  xi-501. 


Practical  Therapeutics  and  Preventive  Medicine 

A  Compendium  of  Treatment  and  Prophylaxis,  Original  and  Adapted 


Nutrition  and  Public  Health  with  Special  Ref- 
erence to  Vitamines. — J.  F.  McClendon  {Ameri- 
can Journal  of  the  Medical  Sciences,  April,  1920) 
believes  that  the  nutrition  of  some  individuals,  es- 
pecially infants,  is  not  ideal,  and  that  the  high  cost 
of  living  is  leading  to  worse  nutrition.  A  large 
part  of  the  population  has  unconsciously  depended 
on  the  presence  of  milk  in  an  otherwise  inadequate 
diet,  and  the  decrease  in  milk  consumption  that  is 
now  taking  place  is  to  be  viewed  with  alarm.  The' 
supply  of  fresh  green  vegetables  is  not  sufificient  to 
be  a  substitute  for  milk.  Grass  is  not  adapted  to 
human  alimentation  except  in  the  form  of  sprouted 
grass  seeds.  In  the  sprouting  of  seeds  vitamines 
are  synthetized  in  the  young  leaves  and  a  quick 
crop  of  vitamines  may  be  obtained  without  the 
necessity  of  planting  the  seeds  in  the  ground. 
Wheat  or  rye,  sprouted  until  the  shoot  extends  an 
inch  beyond  the  grain  and  heated  in  water  to  70° 
to  gelatinize  the  starch,  forms  a  cheap,  convenient, 
and  palatable  source  of  vitamines.  The  seeds  may 
be  freed  from  bacteria  before  sprouting.  Since 
beef  fat  is  about  as  valuable  a  source  of  vitamines 
as  is  butter,  beef  drippings  and  fat  should  be  eaten 
rather  than  thrown  away,  and  the  same  applies  to 
some  other  animal  fats.  Prolonged  cooking  of  fresh 
foods  should  be  discouraged,  but  all  canned  goods 
should  be  heated  to  boiling  before  they  are  served, 
to  destroy  toxins  of  bacillus  botulinus  that  might 
be  present,  unless  a  competent  inspection  of  the 
goods  has  been  made. 

The  Sippy  Treatment  of  Peptic  Ulcer. — Julius 
Friedenwald  and  Theodore  H.  Morrison  (Southern 
Medical  Journal,  May,  1920)  state  that  this  treat- 
ment has  yielded  most  gratifying  results  in  a  large 
number  of  cases.  Sippy's  treatment  consists  in 
protecting  the  ulcer  from  the  acid  corrosion  of  the 
gastric  juice  until  it  has  healed.  This  is  accom- 
plished by  maintaining  a  neutralization  of  the  free 
hydrochloric  acid  from  early  in  the  morning  until 
late  at  night.  The  neutralization  is  effected  by  fre- 
quent feedings  and  the  administration  of  alkalies, 
given  freely  and  at  frequent  intervals.  Nourish- 
ment is  given  from  the  start.  The  patient  remains 
in  bed  for  three  or  four  weeks.  Three  ounces  of 
a  mixture  of  equal  parts  of  milk  and  cream  are 
given  every  hour  from  seven  a.  m.  to  seven  p.  m. 
After  two  or  three  days  soft  eggs  and  well  cooked 
cereals  are  gradually  added  until  in  ten  days  the 
patient  receives  three  ounces  of  milk  and  cream  mix- 
ture every  hour,  three  or  four  boiled  eggs,  and  nine 
to  twelve  ounces  of  a  cereal  each  day.  Cream 
soups  of  various  kinds,  vegetable  purees,  and  other 
soft  foods  may  be  substituted  now  and  then  as  de- 
sired. One  egg  is  given  at  a  time  and  three  ounces 
of  a  cereal  at  a  single  feeding,  the  cereal  being  meas- 
ured after  it  has  been  prepared.  The  cereal  and 
eggs  are  given  alternately  and  taken  at  the  same 
time  as  the  three  ounce  mixture  of  milk  and  cream. 
The  total  bulk  of  each  feeding  should  not  be  over 


six  ounces.  After  a  longer  or  shorter  period,  ac- 
cording to  the  condition  of  the  patient,  a  large  va- 
riety of  soft  and  palatable  foods  may  be  used,  such 
as  jellies,  marmalade,  custards,  and  cream,  but  the 
basis  of  the  diet  should  be  milk  and  cream,  eggs, 
cereals,  vegetable  purees,  and  bread  and  butter.  Al- 
kalies are  administered  from  the  beginning  of  the 
treatment,  between  the  feedings,  to  neutralize  the  acid 
secretion ;  powders  of  heavy  calcined  magnesia,  ten 
grains,  with  sodium  bicarbonate,  ten  grains,  being 
alternated  with  powders  of  bismuth  subcarbonate, 
ten  grains,  and  sodium  bicarbonate,  thirty  grains. 
It  is  also  advisable  to  give  the  powders  every  half 
hour  after  the  last  night  feeding  for  a  number  of 
doses.  If  the  acidity  is  not  promptly  controlled  ten 
grains  of  sodium  bicarbonate  may  be  added  to  each 
powder  until  it  is  controlled. 

The  aftertreatment  of  these  patients  is  impor- 
tant. The  hourly  feedings  and  alkaline  powders 
must  be  continued  even  after  the  patient  is  pursuing 
his  regular  occupation.  If  this  is  impossible,  he 
may  be  allowed  a  light  breakfast  of  from  ten  to 
twelve  ounces  of  cereal,  eggs,  bread  and  butter, 
or  any  soft  food.  A  thermos  bottle  containing 
equal  parts  of  cream  and  milk  can  be  utilized  for 
supplying  the  hourly  feedings.  Three  or  four 
ounces  can  be  taken  hourly  until  noon,  when  a  light 
luncheon  may  be  eaten,  consisting  of  easily  digesti- 
ble meats.  During  the  afternoon  three  or  four 
ounces  of  milk  and  cream  should  be  taken  hourly 
until  the  evening  meal.  The  total  bulk  of  food 
should  not  be  sufficient  to  cause  a  greater  increase 
in  weight  than  is  desired.  If  hourly  feedings  can- 
not be  maintained,  the  three  usual  meals  should  be 
substituted  and  the  powders  taken  every  hour  for 
three  doses  after  a  light  breakfast ;  one  hour  after 
luncheon  a  powder  should  be  taken,  two  powders 
at  the  end  of  the  second  and  third  hours,  and  one 
at  the  end  of  the  fourth.  Aften  ten  to  twelve  weeks 
the  feedings  may  be  increased  to  two  hour  intervals 
and  the  powders  continued  midway  between  the 
feedings. 

About  twice  the  amount  of  food  should  be 
taken  at  each  feeding,  and  two  powders  midway 
between  the  feedings.  At  the  end  of  twenty  or  more 
weeks  the  patient  may  partake  of  three  meals  daily 
and  may  be  allowed  a  glass  of  equal  parts  milk  and 
cream  midway  between  breakfast  and  luncheon,  and 
between  luncheon  and  dinner ;  two  powders  should 
be  given  between  breakfast  and  the  milk  and  cream, 
two  between  the  milk  and  cream  and  luncheon. 
Powders  should  be  taken  similarly  in  the  after- 
noon, and  finally  two  powders  three  hours  after 
the  evening  meal.  The  writers  assert  that  this 
treatment  has  given  them  ninety-four  per  cent,  of 
cures  in  the  mild  cases ;  eighty-five  per  cent,  in  the 
moderately  severe ;  eighty  per  cent,  in  the  severe 
cases,  an  average  of  eighty-six  per  cent,  of  cures 
in  all  cases  and  the  results  were  better  than  those  ob- 
tained by  other  forms  of  treatment. 


76  PRACTICAL  THERAPEUTICS   AXD  PREVENTIVE  MEDICINE.  [New  York 

Medical  Journal. 


Treatment  of  Hyperchlorhydria  in  Children. — 

James  Hoyt  Kerley  {Medical  Record,  May  8,  1920) 
describes  this  condition  in  children  as  accompanied 
by  a  feeling  of  fullness  in  the  epigastric  region,  with 
indefinite  pains  radiating  from  the  region  of  the 
umbilicus ;  there  are  also  often  eructations  of  acid 
gas  and  heartburn.  A  powder  of  magnesium  car- 
bonate, one  grain,  sodium  bicarbonate,  two  grains, 
and  bismuth  subcarbonate,  two  grains,  may  be  given 
fifteen  minutes  before  each  meal.  For  the  consti- 
pation rhubarb  and  soda  mixture,  combined  with 
aromatic  cascara  sagrada,  may  be  given  in  one  or 
two  dram  doses  at  bedtime.  The  diet  should  be 
carefully  regulated.  Orange  juice,  if  allowed,  must 
be  taken  only  after  the  morning  meal ;  the  white 
of  egg  only  is  to  be  eaten,  as  the  yolk  excites  acid 
secretion.  Highly  seasoned  soups  should  be  for- 
bidden, and  red  meat  taken  only  once  a  week.  All 
excessive  sugar,  candy,  sodas,  ice  cream,  and  pas- 
try are  to  be  avoided,  and  tea,  coffee,  and  ice  water 
are  harmful.  Raw  fruit  is  not  permitted  until  the 
appetite  has  become  normal.  A  diet  of  farinaceous 
foods  with  milk,  potatoes,  green  vegetables,  stewed 
fruits,  with  wheat  bread,  toast  or  zwieback  is  to  be 
followed.  A  proper  amount  of  rest  is  to  be  insisted 
upon,  with  a  change  of  scene  in  the  worst  cases. 
This  condition  is  a  common  cause  of  defective  appe- 
tite in  children. 

Early  Lesions  in  the  Gallbladder. — William 
Carpenter  ^lacCarty  and  J.  R.  Corkery  {American 
Journal  of  the  Medical  Sciences,  May,  1920)  state 
that  the  early  changes  in  the  gallbladder  consist  of : 
1.  Congestion  and  edema  of  the  villi  frequently  as- 
sociated with  a  bulbous  appearance  which  makes 
them  look  cystic ;  occasionally  they  are  cystic.  2. 
Local  or  general  slight  degree  of  lymphocj-tic  infil- 
tration, which  manifests  itself  only  in  a  slight  en- 
largement of  the  villi  and  a  cloudy  or  duller  appear- 
ance. 3.  Local  or  general  slight  degree  of  lymphocy- 
tic infiltration  in  the  mucosa  alone,  which  may  be  nor- 
mal, but  when  seen  in  association  with  a  similar  infil- 
tration in  the  submucosa,  muscularis,  and  subserosa, 
probably  indicates  a  pathological  condition.  4.  The 
presence  of  fibrosis  in  the  villi,  which  usually  are 
not  thin  and  tentacular  in  sections  like  those  of  the 
perfectly  normal  organ.  The  fibrosis  sometimes  ex- 
tends into  the  submucosa,  muscularis,  and  subserosa. 
5.  The  presence  of  lymphocytic  infiltration  and 
fibrosis  plus  the  presence  of  a  finely  granular  or 
lipoid  substance  in  the  epithelium,  or  just  below  the 
epithelium  in  the  mucosa.  6.  The  presence  of  slight 
or  no  lymphocytic  infiltration  and  fibrosis  plus  the 
presence  of  large  spheroidal  cells  filled  with  finely 
granular  lipoid  substance  in  the  mucosa  and  some- 
times in  the  submucosa.  These  cells  are  similar  to 
those  which  have  been  described  in  the  socalled 
strawberry  gallbladder,  and  in  papillomas.  This  sub- 
stance may  not  be  visible  grossly,  but  may  some- 
times be  detected  with  the  high  power  dissecting 
microscope.  It  is  the  substance  which  gives  villi 
in  the  strawberry  gallbladder  and  papillomas  fheir 
yellow  or  white  appearance.  The  conditions  de- 
scribed do  not  alter  the  gross  exterior  of  the  organ, 
and  do  not  greatly  alter  the  internal  appearance  to 
the  naked  eye.  Therefore  a  careful  microscopic  ex- 
amination is  required. 


Intestinal  Complications  of  Measles. — Giulio 
Funaioli  {Gaczetta  dcgli  Ospedali  e  delle  Cliniche, 
December  7,  1919)  thinks  that  these  are  much  more 
frequent  than  is  ordinarily  supposed.  He  believes 
that  they  may  be  divided  into  three  classes:  1,  pro- 
dromal ;  2,  concomitant  or  primary,  and  3,  second- 
ary. The  primary  are  due  to  intestinal  enanthe- 
mata,  while  the  secondary  are  due  to  the  normal  in- 
habitants of  the  bowel.  The  prodromal  are  usually 
due  to  a  preexistent  enteritis,  as  at  this  time  the 
measles  virus  could  not  produce  any  noteworthy  in- 
testinal lesions. 

The  Effect  of  Pyloric  Obstruction  in  Relation 
to  Gastric  Tetany. — W.  G.  IMacCallum,  Joseph 
Lintz,  H.  N.  Vermilye,  T.  H.  Leggett  and  E.  Boas 
{Bulletin  of  Johns  Hopkins  Hospital,  January,  1920^1 
produced  pyloric  obstruction  in  dogs  and  found  that 
when  the  acid  gastric  juice  was  all  removed  and  no 
chlorides  were  given  in  the  food,  spontaneous 
twitching  and  usually  violent  convulsions  developed. 
A  constant  rapid  diminution  in  the  plasma  chlorides 
with  a  corresponding  rise  in  the  alkali  reserve  was 
noted,  together  with  a  heightened  electrical  excit- 
ability. It  was  possible  to  prevent  these  symptoms 
by  giving  the  animal  a  large  supply  of  chlorides  fol- 
lowing the  operation.  After  the  onset  of  the  symp- 
toms the  administration  of  chlorides  had  a  beneficial 
etfect. 

Carcinoma  of  the  Duodenum. — According  to 
J.  B.  Deaver  and  I.  S.  Ravdin  {American  Journal 
of  the  Medical  Sciences,  April,  1920)  carcinoma  of 
the  duodenum  is  a  rare  condition  found  in  0.033 
per  cent,  of  hospital  autopsies.  The  percentage  of 
carcinomas  of  the  entire  intestinal  tract  originating 
in  the  small  intestine  varies  from  2.5  per  cent,  to 
3.1  per  cent.  The  relative  proportion  between  car- 
cinoma of  the  duodenum  to  that  of  the  jejunum  and 
ileum  is  47.7  to  52.2  per  cent.  Inch  for  inch  the 
duodenum  is  much  more  likely  to  undergo  car- 
cinomatous change  than  the  jejunum  or  ileum. 
The  relative  frequency  at  various  sites  of  duodenal 
carcinoma  is:  First  portion,  22.15  per  cent.;  secbnd 
portion,  65.82  per  cent. ;  third  portion,  12.02  per 
cent.  Carcinomatous  degeneration  of  chronic  duo- 
denal ulcers  is  not  so  frequent  as  in  chronic  ulcers. 

Dietotherapy  in  Diseases  of  the  Pelvic  Bowel. 
— Charles  J.  Drueck  {Western  Medical  Times, 
February,  1920)  gives  the  following  plan  of  a  day's 
menu  to  serve  as  an  outline,  to  be  modified  ac- 
cording to  the  individual's  habits  and  the  seasons: 

Breakfast — Fruit  (one  orange,  or  a  bunch  of 
grapes,  half  a  grapefruit,  a  baked  apple,  or  a  dish 
of  cooked  fruit,  such  as  prunes,  peaches,  apricots)  ; 
two  slices  of  crisp  bacon  or  two  eggs,  with  two 
muffins  or  gems,  or  slices  of  toast  with  butter ;  or 
a  dish  of  porridge  with  cream ;  and  coffee,  black 
or  with  cream  and  sugar. 

Lunch — A  bowl  of  vegetable  soup  or  puree  with 
crackers ;  a  sandwich,  or  two  rolls  with  honey ;  a 
glass  of  buttermilk  or  fermented  milk. 

Dinner — A  bowl  of  soup;  one  lamb  chop,  or  a 
similar  sized  piece  of  beef  or  poultry ;  two  slices  of 
bread ;  one  potato ;  salad ;  green  vegetables,  such  as 
spinach,  string  beans,  asparagus  or  cauliflower ;  a 
dish  of  pudding  of  rice,  chocolate,  gelatine  or  tap- 
ioca with  fruit  or  a  fruit  sauce. 


New  York  Medical  Journal 

INCORPORATING  THE 

Philadelphia  Medical  Journal  thi  Medical  News 

A  Weekly  Review  of  Medicine,  Established  ISJ^S. 

Vol.  CXII,  No.  3.  NEW  YORK.  SATURDAY,  JULY  17,  1920.  Whole  No.  2172. 

Original  Communications 


REPORTS    OF   UNUSUAL  CASES. 
With  the  Anatomical  Diagnosis. 
By  Nellis  B.  Foster,  M.  D., 

New  York. 

It  not  infrequently  happens  that  our  most  obscure 
cases  remain  to  us  a  sealed  book,  because  of  the 
absence  of  a  postmortem  examination.  On  account 
of  the  autopsy  records  the  following  cases  of  un- 
usual or  rare  diseases  may  be  of  interest. 

Case  I. — The  patient  was  a  young  man  twenty- 
four  years  old,  who  came  to  the  hospital  on  account 
of  what  he  termed  severe  indigestion.  He  stated 
that  he  had  always  had  more  or  less  trouble  with 
his  stomach  and  had  had  to  be  careful  about  what 
he  ate,  and  he  was  subject,  at  irregular  intervals, 
to  attacks  of  abdominal  pain  accompanied  by  nausea. 
The  pain  had  been  in  the  upper  part  of  the  abdomen 
usually,  and  with  these  attacks  he  felt  nauseated, 
but  did  not  usually  vomit.  He  had  consulted 
several  physicians,  who  had  regarded  the  condition 
as  due  to  chronic  appendicitis.  The  particular  at- 
tack for  which  he  came  to  the  hospital  was  similar 
to  other  attacks  that  he  had  had.  It  began  rather 
suddenly  during  the  forenoon  and  was  ushered  in 
by  abdominal  cramps.  These  pains  had  increased 
in  intensity,  so  that  he  gave  up  work  and  went  to 
his  room  and  later  came  to  the  hospital.  He  had 
been  nauseated  and  had  felt  like  vomiting,  but  had 
not  done  so.  When  examined  he  was  found  to  be 
bordering  upon  collapse.  He  was  a  thin,  poorly 
nourished  man,  who  appeared  very  ill.  The  temper- 
ature was  normal  and  the  patient  was  bathed  in  a 
cold  sweat.  He  localized  the  pain  in  the  left  upper 
portion  of  the  abdomen.  The  examination  revealed 
a  tympanitic  note  over  the  left  chest,  extending  to 
the  fifth  rib  in  the  axillary  line.  Over  this  area 
the  breath  sounds  could  not  be  heard.  The  admis- 
sion diagnosis  v/as  pneumothorax  based  upon  these 
findings.  Examined  in  the  ward  by  one  of  our 
staff,  the  scaphoid  appearance  of  the  abdomen  and 
the  confirmation  of  these  physical  signs  suggested 
to  him  the  possibility  of  a  diaphragmatic  hernia. 
The  condition  of  the  patient  excluded  the  employ- 
ment of  any  methods  of  confirming  this.  The  pa- 
tient did  not  rally,  but  died  within  twenty-four 
hours  after  admission  to  the  hospital. 

The  anatomical  diagnosis  was  diaphragmatic 
hernia,  congenital ;  the  stomach  and  small  intestine 
were  in  the  left  thoracic  cavity,  the  displacement 
causing  a  volvulus  in  the  mid  portion  of  the  ileum 
and  secondary  gangrene  of  two  feet  of  intestine. 


Diaphragmatic  hernia,  although  uncommon,  is 
not  excessively  rare.  The  clinical  history  given  by 
this  patient  is  the  usual  one,  in  that  repeated  attacks 
of  abdominal  pain  associated  with  digestive  disturb- 
ance and  vomiting  are  characteristic.  Apparently, 
viscera  may  pass  in  and  out  of  the  thoracic  cavity 
under  these  circumstances,  resembling  in  this 
respect  the  spontaneous  reduction  of  usual  hernias, 
inguinal  for  example,  and  it  is  not  until  strangula- 
tion occurs,  due  often  to  volvulus  and  occlusion  of 
the  blood  supply,  that  serious  symptoms  arise.  If 
seen  early  the  diagnosis  may  be  confirmed  by  radio- 
logical examination.  The  condition  is  not  neces- 
sarily fatal,  a  number  of  patients  having  been  oper- 
ated upon  successfully  and  the  hernia  closed. 

Case  II. — A  young  Italian,  twenty-three  years 
of  age,  was  admitted  to  the  clinic  complaining  of 
precordial  pain,  cough,  hoarseness,  dyspnea  and 
difficulty  in  swallowing.  The  history  was  quite 
negative  up  to  the  onset  of  the  symptoms  for  which 
he  came  to  the  hospital.  Two  weeks  prior  to  this 
time  he  had  begim  to  have  pain  in  the  upper  part 
of  his  chest,  especially  on  the  left  side,  and  about 
this  time  he  began  to  be  short  of  breath  and  have 
some  cough.  The  hoarseness  and  difficulty  in  swal- 
lowing developed  later.  During  the  taking  of  the 
history  the  patient  had  several  paroxysms  of  cough- 
ing which  were  characterized  by  the  ward  surgeon 
as  "typically  brassy." 

The  patient  was  a  stockily  built  Italian,  with  some 
cyanosis  of  the  face.  There  was  definite,  visible 
pulsation  over  the  upper  portion  of  the  sternum, 
which  did  not  extend  into  the  cardiac  region.  Dul- 
ness  could  be  outlined  an  inch  and  a  half  to  the 
right  of  the  sternum  in  the  second  and  third  costal 
spaces,  and  there  was  a  definite  heave  over  this 
region  on  palpation.  There  seemed  no  question 
with  regard  to  the  diagnosis;  all  signs  and  every 
test  pointing  to  an  aneurysm  of  the  arch  of  the  aorta. 
There  was  a  distinct  difference  in  the  blood  pres- 
sure in  the  two  brachial  arteries.  Examination  of 
the  vocal  cords  indicated  probable  implication  of 
the  recurrent  laryngeal  nerve.  The  fluoroscopic 
examination  showed  a  pulsating  tumor  in  the  upper 
mediastinum  and  the  Wassermann  reaction  was 
four  plus.  The  patient's  downward  course  was 
very  rapid  and  death  took  place  from  aspiration 
pneumonia. 

The  postmortem  examination  disclosed  an  aneur- 
ysm, as  we  had  suspected,  not  of  the  aorta,  but 
of  the  pulmonary  artery.  Aneurysms  of  the  pul- 
monary artery  are  very  rare,  there  being  only  a  few 


Copyright,  1920,  by  A.  R.  Elliott  Publishing  Company. 


78 


POSTER:  UXi'SUAL  CASES. 


[N'ew  York 
Medical  Journal. 


reported  in  the  literature.  Differential  diagnosis 
is  almost  impossible  to  establish,  since  pnlmonarv' 
signs  which  might  be  supposed  to  develop  are  as  a 
matter  of  fact  not  infrequently  noted  with  thoracic 
aneurysms  on  account  of  pressure. 

Case  III. — Septicemia  taking  origin  in  the  geni- 
tourinary tract.  This  patient  contracted  urethritis 
the  latter  part  of  I\Iay  and  was  given  local  treat- 
ments, the  nature  of  which  are  not  known  further 
than  that  they  were  quite  painful.  On  the  fifth 
of  june  abdominal  pain  developed,  with  nausea 
and  chilly  sensations,  and  he  remained  at  home 
from  his  work.  The  following  day.  June  6th,  he  had 
diarrhea  and  severe  burning  on  urination.  The 
high  temperature  continued  and  he  felt  so  sick  that 
he  came  to  the  hospital.  On  admission  to  the 
hospital  he  had  a  temperature  of  103.6  degrees,  ap- 
peared very  uncomfortable  and  was  slightly  delir- 
ious. The  following  day,  June  7th.  it  was  noted 
at  the  morning  examination  that  the  patient  was 
drowsy  and  that  there  was  a  slight  ptosis  of  the 
right  eyelid,  the  right  pupil  being  larger  than  the 
left,  and  some  drooping  of  the  right  corner  of  the 
mouth.  The  reflexes  were  all  present  but  sluggish. 
Xo  muscular  weakness  could  be  determined  at  this 
time,  nor  changes  in  sensation. 

At  the  afternoon  rounds  it  was  noticed  that  the 
left  leg  was  definitely  weaker  than  the  right  and 
that  there  were  scattered  over  the  body,  a  few 
purpuric  spots.  The  eyegrounds  were  normal. 
Lumbar  puncture  was  done.  The  spinal  fluid 
containing  150  cells  to  the  c.  mm.  A  blood  culture 
had  been  done  earlier  in  the  day.  A  diagnosis  was 
made  of  a  primary  urethritis,  acute  posterior  ure- 
thritis and  prostatitis,  septicemia,  multiple  emboli 
in  the  central  nervous  system  and  meningitis. 

The  anatomical  diagnosis  at  autopsy  was  acute 
posterior  urethritis,  acute  prostatitis,  thrombosis  in 
the  prostatic  veins,  acute  vegetative  endocarditis  of 
the  aortic  valve,  multiple  cerebral  emboli,  multiple 
mycotic  abscesses  (kidney,  spleen,  liver).  The 
blood  cultures  showed  Streptococcus  hemolyticus. 

C.\SE  IW — This  patient  came  to  the  hospital  on 
account  of  an  inguinal  adenitis,  following  a  ure- 
thritis which  had  not  been  treated.  The  nodes  in 
the  right  groin  were  large  and  fluctuating  with 
considerable  local  reaction.  Following  free  incision, 
the  patient  did  well  for  two  days.  On  the  third 
day.  consultation  was  sought  of  the  medical  division 
on' account  of  considerable  rise  in  temperature,  pain 
in  the  left  chest  and  cough.  It  was  suspected  that 
pneumonia  might  have  developed.  Examination 
showed  that  there  was  undoubtedly  fluid  in  the 
left  chest  and  exploratory  puncture  demonstrated 
this  to  be  pus.  The  inguinal  wound  looked  clean. 
The  heart  appeared  to  be  dilated,  but  there  was  no 
evidence  of  an  endocarditis.  There  wjis  some  de- 
bate as  to  the  best  therapeutic  procedure,  opinion 
being  divided  as  to  the  necessity  of  immediate 
thoracotomy.  The  smear  from  the  pus  in  the  pleu- 
ral cavity  showed  chains  of  cocci,  probably  strepto- 
cocci. The  patient  was  operated  upon  for  empyema 
and  died  within  twenty-four  hours. 

The  anatomical  diagnosis  was  posterior  urethritis, 
acute  prostatitis,  thrombosis  of  the  prostatic  plexus, 


multiple  abscesses  involving  liver,  spleen,  kidneys 
and  lungs,  acute  suppurative  pleurisy  (right),  acute 
suppurative  pericarditis.  The  blood  cultures  report- 
ed after  death  showed  Streptococcus  hemolyticus. 

Generalized  blood  infections  as  a  sequel  to  acute 
posterior  urethritis  are  rather  more  common  than 
is  generally  supposed.  Two  factors  stand  out  as 
predisposing,  namely,  excessive  vigor  in  the  earlier 
stages  of  treatment  and  the  second  factor  is  neglect 
of  all  treatment.  Genitourinary  surgeons  appreci- 
ate, more  than  internists  are  likely  to,  the  important 
part  played  by  secondary  infections  in  urethritis ; 
indeed  the  late  complications  are  likely  to  be  due  to 
streptococci  rather  than  to  gonococci. 

Case  \'. — The  patient  was  a  woman  forty-two 
years  of  age,  who  was  admitted  to  the  ophthalmo- 
logical  service  on  account  of  rapidly  failing  vision. 
Her  history  was  that  she  had  always  enjoyed  good 
health,  until  about  six  weeks  before  admission  to 
the  hospital.  At  that  time  she  began  to  have  bleed- 
ing of  the  gums  and  this  had  continued  intermit- 
tently up  to  the  time  of  admission.  The  bleeding 
was  not  associated  with  any  soreness,  but  had  been 
persistent  and  she  thought  she  had  lost  a  good  deal 
of  blood  and,  of  cotirse,  the  bleeding  had  inter- 
fered with  the  taking  of  food,  because  it  de- 
stroyed her  appetite.  About  ten  days  before  ad- 
mission to  the  hospital  she  had  noticed  that  her 
vision  was  somewhat  dim.  Since  then  her  eyesight 
had  failed  steadily  until  she  was  unable  to  dis- 
tinguish any  object,  in  fact  could  only  see  sufficient- 
ly to  distinguish  light  from  dark.  The  ophthalmo- 
logical  examination  revealed  a  bilateral  optic  neu- 
ritis of  a  severe  degree.  There  had  been  at  no 
time  headaches,  nor  any  focal  symptoms  suggest- 
ing implication  of  other  cranial  nerves ;  no  symp- 
toms of  any  kind  in  fact,  except  the  bleeding  giuns 
and  gradually  failing  vision. 

The  examination  was  wholly  negative.  The  gums 
were  somewhat  spongy  and  were  exuding  blood 
constantl}-.  The  blood  count  was  normal.  The 
coagulation  time  of  the  blood  was  normal.  The 
patient  was  removed  to  the  medical  side  for  further 
observation.  A  few  days  after  the  transfer  signs 
developed  indicating  fluid  in  the  right  chest.  This 
fluid  was  withdrawn.  It  was  clear  and  had  the 
characteristics,  chemically  and  cj-tologically,  of  a 
transudate.  Only  one  abnormal  feature  was  noted 
in  the  pleural  fluid.  In  our  hunt  for  a  clue  to  ex- 
plain the  peculiar  condition  we  did  everything  that 
was  suggested  to  us  and,  among  other  things,  the 
albumin  globulin  ratio  was  estimated.  The  globulin 
was  considerably  increased,  and  to  this  we  attached 
a  significance  which  was  not  justified  by  subsequent 
disclosures.  Repeated  examinations  of  the  blood 
failed  to  detect  an}thing  except  severe  secondary 
anemia.  In  the  meantime  it  was  evident  that  the 
patient  was  losing  ground  on  account  of  the  per- 
sistent bleeding  from  the  gums  and  it  was  felt  by 
the  dental  consultant  that  this  could  be  checked  only 
by  removing  the  teeth.  Following  the  removal  of 
the  first  two  teeth  the  hemorrhage  was  so  persistent 
that  the  patient  nearly  died.  Several  weeks  later 
we  prepared  for  the  second  dental  operation  by 
transfusing  the  patient.  By  stages  in  this  way  all  of 
the  teeth  were  eventually  removed.  The  bleeding  of 


July  17,  1920.] 


FOSTER:  UNUSUAL  CASES. 


79 


the  gums  ceased ;  the  vision  gradually  returned.  The 
fluid  in  the  pleural  cavity  required  aspiration  on  two 
separate  occasions,  after  which  it  ceased  to  reaccu- 
niulate.  The  whole  period  of  treatment  in  the  hos- 
pital covered  about  four  months. 

When  the  patient  left  the  hospital  she  appeared  in 
good  health.  Her  eyesight,  while  not  normal,  was 
very  good  and  she  could  read  without  serious  diffi- 
culty. There  had  been  no  return  of  the  bleeding  of 
the  gums  or  of  loss  of  blood  elsewhere.  There  was, 
however,  very  little  change  notable  in  the  Ophthal- 
mol ogical  examination. 

The  patient  returned  home  and  remained  there  for 
two  months  apparently  improving  constantly.  Then, 
rather  suddenly,  she  began  to  have  shortness  of 
breath,  which  rapidly  increased  in  severity,  on  ac- 
count of  which  she  was  brought  back  to  the  hospital. 
It  was  found,  at  this  time,  that  both  pleural  cavities 
contained  considerable  liquid  and  aspiration  showed 
that  this  liquid  was  deeply  blood  tinged,  so  much 
so  that  a  blood  count  was  made,  and  it  was  found 
that  the, fluid  contained  about  a  million  red  cells  to 
the  c.  mm.  On  the  strength  of  this,  the  diagnosis 
of  neoplasm  was  made,  the  nature  and  location  of 
which  could  not  be  determined.  This  was  not  the 
first  suggestion  of  a  neoplastic  origin  for  the  symp- 
toms, one  of  the  members  of  the  staff  having  ex- 
pressed the  opinion  that  the  peculiar  atypical  symp- 
toms were  best  explained  by  the  h}-pothesis  of 
chloroma.  Following  removal  of  fluid  from  one 
chest  there  was  rapid  reaccumulation.  The  patient 
failed  rapidly  and  died  the  second  day  after  admis- 
sion to  the  hospital.    The  diagnosis  was  chloroma. 

Chloroma  is  a  peculiar  and  rare  malignant  dis- 
ease, primary  in  the  bone  marrow  and  giving  rise 
to  metastatic  growths,  chiefly  in  the  skull,  orbit, 
sinuses,  and  mediastinal  lymph  nodes,  found  also 
quite  often  in  the  sternum,  vertebrae  and  occasionally 
in  the  long  bones.  The  earliest  symptom  in  many 
cases  has  been  exophthalmus,  less  commonly  the 
earliest  symptom  is  blindness  or  deafness.  Hemor- 
rhages do  occur,  although  they  are  not  usual.  \'ari- 
ous  blood  pictures  have  been  described  and  two 
main  classifications  have  been  pointed  out,  lym- 
phemia  and  myelemia,  but  not  infrequently  leuco- 
cytic  increase  is  absent ;  in  other  words,  there  are 
leucemic  and  aleucemic  chloromas.  Certain  peculiar 
cells  have  been  noted  in  the  circulating  blood  in 
some  cases  and  these  chloroma  cells  were  for  a 
time  regarded  as  diagnostic,  but  this  opinion  is  no 
longer  held.  The  axillary  or  inguinal  nodes  are 
sometimes  enlarged.  In  brief,  chloroma  represents 
a  leucemic  process  of  a  definite  neoplastic  type. 

C.^SE  \T. — The  patient  was  a  young  man  who 
consulted  us  on  account  of  a  sense  of  compression 
in  the  chest  and  dyspnea.  He  stated  that  he  had 
always  been  in  good  health ;  had  had  no  sickness  of 
any  importance  that  he  could  recall.  Two  weeks 
prior  to  consultation  he  was  injured  while  playing 
football,  but  this  injury  at  the  time  was  regarded  as 
a  trivial  matter,  and  he  thought  nothing  of  it  for 
several  days,  when  he  began  to  be  troubled  by  a 
sense  of  oppression  and  slight  shortness  of  breath. 
On  examination  the  signs  presented  were  those  of 
liquid  in  the  left  chest,  with  displacement  of  the 


heart  to  the  right.  It  was  supposed  at  this  time 
that  the  case  represented  the  ordinary  type  of 
pleurisy  with  effusion,  probably  of  tuberculous  ori- 
gin. The  chest  was  aspirated  and  the  cell  count  on 
the  fluid  was  eighty-four  per  cent,  lymphocytes.  The 
patient  ran  a  fever  course  after  the  first  few  days, 
his  temperature  ranging  between  97°  and  102°,  with 
afebrile  periods  of  ten  days  or  two  weeks'  duration. 
The  fluid  rapidly  accumulated  after  aspiration  and 
paracentesis  was  repeatedly  necessary  in  order  to 
keep  the  patient  comfortable.  In  all  he  was  aspirat- 
ed thirty-four  times  and  forty-two  litres  of  fluid 
were  withdrawn.  The  fluid  was  never  blood  tinged. 
The  prompt  reaccumulation  of  fluid  after  the  earlier 
aspirations  led  to  a  revision  of  the  diagnosis  to 
endothelioma  of  the  pleura. 

At  autopsy  the  condition  was  found  to  be  primary 
sarcoma  of  the  pericardium,  w-ith  extension  to  the 
pleura  and  metastases  in  the  mediastinal  lymph 
nodes,  likewise  those  of  the  peritoneum. 

Case  VH. — The  first  patient  was  brought  to  the 
hospital  suffering  from  apparently  a  slight  infection 
("P.  U.  O.").  There  was  a  slight  rise  in  tempera- 
ture which  had  come  on  a  few  hours  before,  slight 
abdominal  pain  and  some  vomiting.  On  examination 
the  patient  presented  no  signs,  other  than  a  moderate 
degree  of  tympanitis.  Especial  care  was  given  to 
examination  of  the  lungs  on  account  of  the  tympa- 
nitis, suspecting  that  pneumonia  might  be  the  un- 
derlying disorder.  The  condition  of  the  patient  rap- 
idly grew  worse,  the  pulse  became  thready,  the 
blood  pressure  fell  and  in  twenty-four  hours  after 
he  entered  the  hospital  he  was  in  a  collapse  and 
comatose.    He  died  during  the  second  day. 

At  autopsy  no  lesion  of  any  sort  was  discovered, 
excepting  in  the  adrenal  glands.  The  architecture 
of  these  was  practically  destroyed  by  numerous 
hemorrhages  which  appeared  to  be  recent.  The 
blood  cultures  which  had  been  made  before  death 
yielded  a  diphtheroid  organism.  The  pathological 
diagnosis  was  hemorrhagic  suprarenitis. 

It  is  an  old  clinical  adage  that  rare  diseases  come 
in  pairs.  Our  first  case  of  suprarenitis  was  not 
recognized  before  death.  The  second  patient  came 
in  with  the  same  history  of  sudden  onset  of  fever, 
slight  abdominal  pain  and  vomiting.  The  examina- 
tion revealed  only  tympanitis.  A  few  hours  after 
he  was  admitted  to  the  hospital  he  had  a  series 
of  convulsive  seizures,  which  were  followed  by  col- 
lapse. The  hazardous  diagnosis  of  hemorrhagic 
suprarenitis  was  made,  because  of  the  similarity 
of  the  clinical  picture  to  our  first  case.  The  autopsy 
established  the  correctness  of  the  conjecture. 

Hemorrhages  into  the  adrenals  have  been  de- 
scribed with  a  number  of  infectious  diseases  and  I 
noted  them  quite  frequently  during  the  influenza 
epidemic  at  a  military  hospital.  Isolated  cases  of 
hemorrhagic  suprarenitis  must  be  regarded  as  a  local 
manifestation  of  an  overwhelming  infection.  The 
characteristic  features  are  the  onset,  resembling  the 
period  of  invasion  of  any  infection,  the  rapid  down- 
ward course,  the  tympanitis,  occasionally  convul- 
sions and  purpura.  Death  usually  occurs  within 
forty-eight  hours. 

121  East  Sixty-secoxd  Street. 


80 


BARR:  STIGMATA  OF  DEGENERATION. 


[New  York 
Medical  Journal. 


OBSERVATIONS  OX  THE  STIGMATA  OF 

DEGEXER.ATIOX  AS  FOUXD  IX 
I      '  THE  FEEBLEMIXDED. 

By  Martin  W.  Barr,  M.  D., 
Elw>-n,  Pa., 

Chief   Physician,   Pennsylvania   Training   School   for  Feebleminded 
Children. 

"A  fellow  b}"  the  hand  of  Nature  mark'd." 

King  John,  iv.,  2. 

That  stigmata  are  not  only  present,  but  prove  a 
valuable  aid  in  the  diagnosis  of  mental  defect,  there 
can  be  no  doubt.  But  one  cannot  point  to  any 
single  deviation  from  the  normal  and  say  positively 
that  it  alone  is  peculiar  to  any  special  defect.  It 
is  equally  true  that  many  perfectly  normal  people 
may  exhibit  some  stigmata ;  but  never  in  such 
combinations  as  do  defectives.  Thus  a  single 
anomaly  in  an  individual  is  not  indicative  of  de- 
generation ;  but  a  combination  of  three  or  more 
will  naturally  lead  the  investigator  to  look  for 
associated  mental  or  moral  defects,  as  in  accord- 
ance with  the  now  accepted  theor>%  the  individual 
exhibiting  from  three  to  five  stigmata  should  be 
classed  as  defective  beyond  a  peradventure. 

According  to  Dana  two  per  cent,  of  normal  males 
present  some  deviation ;  while  thirty  per  cent,  of 
the  neurasthenics,  insane  and  criminals  exhibit 
deviations  and  many  anomalies  are  found  among  the 
feebleminded.  Perfect  mental  and  physical  develop- 
ment usually  accord,  the  intelligence  having  a 
decided  influence  in  shaping  the  head,  limbs  and 
trunk. 

In  many  cases  there  is  moral  without  mental 
defect ;  indeed  the  former  may  be  so  marked  as  to 
completely  overshadow  mediocre  intelligence.  Sue- 
tonius's  description  of  The  Twelve  Ccesars  is  a 
nmning  commentary  'of  moral  without  mental 
degeneration. 

In  the  observation  and  careful  study  of  mental 
defectives  covering  a  period  of  thirty-three  years, 
numbering  many  hundreds  of  boys  of  all  grades,  I 
found  in  eagh  and  all  innumerable  anomalies  and 
in  not  one  case  were  these  absent.  Witliout  going 
into  percentages,  which  are  likely  to  prove  tiresome, 
I  briefly  note  some  of  the  principal  stigmata  of  de- 
generation found  among  the  feebleminded  : 

^lany  exhibit,  superficially,  a  good  physique,  but 
there  is  almost  always  a  lack  of  strength,  and  they 
tire  easily  and  succumb  readily  to  disease.  As  a 
class  the  feebleminded  are  undersized,  noticeably 
the  idiots,  Mongolians  and  microcephalics,  but  some 
of  the  brighter  ones  show  increasing  growth 
through  the  middle  grade  up  to  highest,  where  in 
many  cases  they  may  be  normal  in  height ;  the 
acromegalics  may  reach  seven  feet — or  indeed  even 
more. 

There  is  almost  invariably  a  lack  of  congruence 
between  the  appearance,  and  the  actual  or  chrono- 
logical age.  Before  the  age  of  forty  the  patients 
appear  much  younger ;  but  after  attaining  this  age 
(which  but  few  of  them  do.  the  actual  life  of  a 
mental  defective  being  from  twenty  to  twenty-five 
years)  they  exhibit  signs  of  rapid  decay.  Xot  in- 
frequently there  is  faulty  or  deficient  innervation  of 
the  different  muscles  and  hyperhidrosis  is  common. 
The  hands  and  feet  are  in  many  cases  cold  and 


clammy,  especially  among  those  of  the  low  and 
middle  grade. 

THE  HEAD. 

The  head  exhibits  many  peculiarities  in  regard  to 
shape.  In  addition  to  the  extremes  of  microcephaly 
and  hydrocephalus  there  are,  in  its  many  asym- 
metries, frequent  deviations  from  the  normal ;  this 
is  especially  noticeable  among  the  low  grades. 
(Xote. — The  term  low  grade  refers  to  the  imbecile 
of  that  type ;  when  the  plural  is  used  it  includes  not 
only  the  low  grade  imbecile  but  also  the  idioimbecile 
and  idiot.)  According  to  Peterson  (1),  all  length 
breadth  indices  between  seventy  degrees  and  ninety 
degrees  may  be  considered  as  physiological 
deviations. 

The  cephalic  indices  range  from  seventy  degrees 
to  ninety  degrees,  and  the  largest  number  in  all 
grades  is  eighty  degrees;  therefore  most  mental 
defectives  are  mesocephalic.  The  cephalic  indices 
in  accentuated  cases  of  mental  defect  are:  Mon- 
golians from  seventy-six  degrees  to  ninety  degrees, 
the  most  common  being  from  eighty-five  degrees 
to  eighty-eight  degrees,  this  class  being  for  the  most 
part  brachvcephalic ;  acromegalv  seventy-three 
de  grees,  dolichocephalic ;  dementia  praecox  from 
seventy-two  degrees  to  eighty-five  degrees,  the  most 
common  being  eighty  degrees,  therefore  mesoce- 
phalic; microcephals  from  seventy-two  degrees  to 
eighty-nine  degrees,  the  most  common  eighty-two 
degrees,  brachycephalic ;  moral  imbeciles  from 
seventy-three  degrees  to  eighty-five  degrees,  eighty- 
five  degrees  being  most  frequently  found,  and, 
therefore,  they  also  are  brachycephalic. 

Except  in  a  very  few  cases  the  length  and  maxi- 
mum width  of  the  skull  varies  but  little  in  the  dif- 
ferent grades.  The  longest  faces  are  found  most 
frequently  first  among  middle  grade  imbeciles,  next 
among  the  high  and  last  among  the  low  grades. 
Unusually  wide  faces  are  equal  in  the  high  and 
middle  grade,  and  least  frequent  among  the  low 
grades.  The  nasobregmatic  arc  is  most  pronounced 
in  the  high  grade,  next  in  the  middle  and  then  in 
the  low  grade.  The  craniofacial  angle  is  about 
eighty  degrees  in  the  middle  and  high  grade,  and 
sixty-nine  degrees  in  the  lower  grades,  including 
idiots  and  idioimbeciles.  Prognathism  is  most  com- 
mon in  the  low  grades,  and  opisthognathism  and 
orthognathism  in  the  middle  and  high  grade.  Fac- 
ial asymmetries  are  found  most  frequently  on  the 
right  side  in  the  high  grade,  and  on  the  left  side 
in  the  middle  and  low  grades,  including  idiots  and 
idioimbeciles.  Squints  and  tics  are  about  equally 
distributed  in  the  various  grades  except  in  the 
Mongolian  idiots  where  they  preponderate.  De- 
pressions over  the  glabella  are  equally  divided  in 
all  grades  and  are  most  frequently  found  among 
epileptics.  The  lemurian  hypothesis  is  rather  rare 
but  when  found  is  equally  divided  among  all  grades. 
Thick,  coarse  lips  predominate  in  the  low  grades — 
and  are  found  next  in  middle,  and  least  frequently 
in  the  high  grade.  Fissured  lips  occur  most  fre- 
quently in  the  high  grade,  then  in  the  middle  and 
last  in  the  low  grade.  Harelip,  which  is  extremelv 
rare,  is  practically  confined  to  the  high  grade ;  and 
is  almost  never  seen  below  the  middle  grade.  Per- 
leche is  common  in  the  middle  and  low  grades. 


July  17,  1920.] 


BARR:  STIGMATA   OF  DEGENERATION. 


81 


THE  TEETH  AND  PALATE. 

The  largest  number  of  decayed  teeth  are  found 
among  the  low  grade  and  idiots ;  this  of  course  for 
obvious  reasons.  Peculiar  and  badly  formed  teeth 
(especially  the  abnormal  length  of  the  canines)  are 
confined  to  low  grades.  The  notched  or  furrowed 
teeth  (Hutchinson's  teeth)  are  due  to  inherited 
syphilis,  and  are  common  to  all  grades ;  as  are  the 
rachitic  teeth,  and  also  the  continued  presence  of 
milk  teeth.  The  V  shaped  palate  is  found  most 
frequently  in  the  high  grade,  next  in  the  low,  and 
in  the  middle  least  of  all.  The  semi  V  is  found  in 
high  and  low  alike ;  the  saddle  is  most  frequent  in 
the  high,  then  middle  and  then  low.  Cleft  palate  is 
rather  rare,  but  is  evenly  distributed  between  the 
high  and  low  grades.  Asymmetries  of  the  hard 
palate  are  in  predominance  on  the  right  side  in  the 
high  and  middle  grade,  and  in  the  low  grades  they 
are  found  both  right  and  left.  The  uvula,  often 
short,  twists  to  the  right  most  frequently  in  the 
high  grade ;  in  the  middle  and  low  grades  the  twist 
to  the  left  predominates.  The  torus  palatinus  is 
commonly  seen  in  the  low  grades,  next  in  the  high, 
but  is  rarely  found  in  the  middle  grade. 

The  tongue  is  noticeably  large  and  thick,  and 
often  protruded  from  the  lips  of  the  low  grades, 
markedly  so  in  the  cretinoids.  Mongolians  and  mi- 
crocephals,  among  whom  it  is  almost  invariably 
fissured  deeply  with  greatly  enlarged  papillae.  The 
tongue  among  the  low  grades  is  likely  to  be  square, 
but  among  the  high  and  middle  grade  is  pointed. 
Broad  noses  are  found  most  frequently  in  the  mid- 
dle and  low  grades ;  while  long  narrow  noses  pre- 
dominate in  the  high  grade.  Asymmetries  of  the 
nose  are  most  frequent  on  the  right  side  in  all 
grades ;  as  are  deflected  septums. 

THE  EYE. 

The  eye  is  the  seat  of  many  deviations  from  the 
normal.  In  the  moral  imbeciles  we  find  the  red 
glint,  hard  look,  and  fleeting  shifty  expression, 
which  is  almost  impossible  to  describe.  In  the  low 
and  middle  grade  strabismus  is  not  uncommon ;  and 
in  the  Mongolian  type  there  are  the  oblique  eyelids 
peculiar  to  this  class.  Visual  defects  are  verj-  com- 
mon in  all  grades.  Xot  infrequently  there  is 
marked  asymmetry  of  the  eyes  in  middle  and  low 
grade ;  but  most  common  in  the  low.  Nystagmus 
is  found  in  the  high  and  middle  grade.  Photophobia 
is  frequent  among  idiots  and  low  grade  imbeciles ; 
and  congenital  cataract  is  rather  common  in  all 
grades. 

The  thyroid  gland  is  rudimentary  or  altogether 
absent  in  cretins ;  and  in  the  Mongolians  its  develop- 
ment is  frequently  arrested.  Goitre  is  not  very 
common  but  when  present  is  foimd  in  all  grades 
of  mental  defect. 

THE  EAR. 

The  external  ear  shows  a  greater  number  of 
anomalies  than  any  other  organ.  Blainville's  ear 
is  common  to  every  grade.  The  concha  is  largest 
in  the  high  grade,  and  sometimes  reaches  enormous 
size  in  the  moral  imbeciles ;  and  exhibits  rudi- 
mentary or  arrested  development  in  the  middle 
grade.  The  relation  of  the  concha  varies,  the  left 
being  usually  higher  in  the  high  grade.  Arrested 
development  of  the  helix  is  found  most  often  in  the 


high,  especially  in  moral  imbeciles ;  next  in  middle 
and  least  in  the  low  grades.  Excessive  develop- 
ment is  seen  most  frequently  in  middle,  then  in  the 
low  and  last  in  high  grade.  The  open  helix  occurs 
first  in  the  high,  next  in  the  low  and  last  in  the 
middle  grade.  Double  helix  is  evenly  distributed 
among  all  grades.  Darwin's  tubercles  are  common, 
and  are  found  most  frequently  among  the  high 
grade,  on  the  left  side  of  the  middle  third  of  the 
helix ;  in  the  upper  third  they  are  not  so  frequent ; 
in  some  cases  they  are  seen  on  both  ears.  In  the 
middle  and  lower  grades  they  are  about  equally 
distributed  between  the  middle  and  lower  third. 
The  antihelix  is  excessive  in  high,  next  in  middle 
and  least  in  the  low  grades.  The  tragus  is  excessive 
in  middle  and  high  grade ;  and  in  the  latter  is  very 
frequently  double,  especially  in  the  moral  imbeciles. 
When  arrested  it  is  confined  almost  exclusively  to 
the  middle  grade.  The  antitragus  when  either  ex- 
cessive or  rudimentary  is  found  in  the  high  grade, 
especially  in  the  moral  imbecile.  Double  hematoma 
is  found  in  middle  grade ;  and  when  single  is  con- 
fined almost  exclusively  to  the  left  ear.  The  lobules 
are  most  frequently  adherent  in  the  middle  grade ; 
and  next  in  the  high,  and  sometimes  they  are 
entirely  absent  (Wildermuth's  Aztec  ear),  rudi- 
mentary or  extremely  broad.  The  long  lobule  is 
peculiar  to  the  low  grades.  Morel's  ear  is  quite 
evenly  distributed  in  all  grades. 

THE  SKIN. 

The  skin,  while  usually  of  fine  texture  and 
normal  color  in  the  high  grade,  deteriorates  in  the 
descending  scale  of  intelligence.  In  the  cretins  and 
Mongolians  it  is  pallid  or  sallow  and  leathery,  and 
in  many  cases  prematurely  wrinkled.  Occasionally 
among  the  low  grade  imbeciles  and  idiots  there  are 
brachial  clefts,  preaural  sinuses  and  naevi  of  vary- 
ing size,  or  areas  of  pigmentation.  In  the  high  and 
middle  grade,  there  are  scars,  most  frequent  among 
epileptics,  due  to  their  numerous  falls  during 
paroxysms.  In  these  grades  also  is  seen  tattooing 
(especially  among  the  moral  imbeciles),  the  designs, 
often  of  women,  being  mostly  obscene  in  character  ; 
although  somewhat  favorite  devices  are  hearts  and 
gravestones  inscribed  with  mother,  or  the  names  of 
other  loved  ones.  Mental  defectives  of  every  grade 
are  prone  to  acquire  skin  diseases,  especially  the 
various  eczemas. 

It  may  be  of  passing  interest  to  note  that,  while 
not  a  stigmata  of  degeneration,  blondes  and 
brunettes  are  fairly  evenly  divided  among  the 
various  grades,  the  former  predominating  slightly 
in  the  high  grade,  and  the  latter  in  the  middle  and 
low  grades.  Brown  and  gray  eyes  are  found  in  all 
grades — the  largest  number  in  the  middle.  Black 
eyes  are  noted  most  frequently  among  the  high 
grade  and  blue  among  the  low  grade. 

THE  HAIR. 

Black  hair  is  distributed  equalh'  through  all 
grades.  While  yellow  and  red  hair  are  most  com- 
mon among  the  middle  grade,  red  hair  is  almost 
never  seen  among  the  low  grades.  In  the  high 
grade  brown  hair  is  most  frequent,  as  also  in  the 
low  grades.  The  beard  is  usually  heavy  in  all 
grades,  and  in  the  middle  and  low  grades  it  is  very 


82 


BARR:  STIGMATA   OF  DEGEXERATION. 


[New  York 
Medical  Jourxal. 


coarse :  but  in  some  cases  there  is  absence  of  beard. 
The  eyebrows  frequently  meet  and  may  be  heavy 
and  bushy  in  the  high  and  middle  grade ;  while  in 
the  low  grades  they  are  scanty  or  absent.  In  many 
of  the  high  and  middle  grade  there  is  a  lack  of  hair 
on  the  body;  but  not  infrequently  in  the  low  grades 
tufts  of  coarse  hair  are  found  in  the  sacrolumbar 
region,  and  on  the  abdomen. 

In  three  cases  I  have  seen  a  heavy  growth  of 
coarse,  curly,  black  hair,  enveloping  the  body  like 
a  jacket.  The  pubic  hair  in  all  grades  is  usually 
very  heavy  and  thick ;  but  occasionally  in  the  low 
grades  it  is  altogether  absent.  In  cases  of  dementia 
prsecox  and  microcephaly  I  find  an  absence  of  hair 
on  the  chest ;  which  according  to  Lanceraux  is  in- 
dicative of  a  tendency  to  tuberculosis.  This  I  have 
seen  verified  in  a  number  of  cases.  In  the  middle 
and  low  grades  there  are  sometimes  congenital  spofs 
of  baldness ;  and  hairy  moles  on  face  and  trunk ; 
and  patches  of  grav  hair  mav  appear  in  verv  early 
life. 

THE  EXTREMITIES. 

The  arms  are  found  to  be  asymmetrical  first  in 
the  middle,  and  next  in  the  low  grades ;  especialh' 
the  INIongolians.  Hands  are  largest  in  the  middle 
grade ;  and  are  asymmetrical  in  all  grades.  The  cre- 
tins and  Mongolians  invariably  have  short  clubbed 
fingers.  Polydactylism  and  webbed  fingers  are 
rather  rare,  and  are  confined  to  the  low  grade  and 
idiots  for  the  most  part.  Left  handedness  is  also 
rare,  and  confined  almost  exclusively  to  the  middle 
grade.  Occasionally  the  high  grade  are  ambidex- 
trous, especially  the  moral  imbecile. 

The  legs,  asymmetrical,  are  longest  and  shortest 
in  the  middle  grade.  Small  feet  are  found  most 
frequently  in  the  low  grade;  and  next  in  the  high. 
Large  feet  are  seen  often  in  middle  grade,  and  also 
in  low.  Flat  feet  are  verj-  common  in  the  middle 
grade,  and  in  Mongolians.  High  instep  is  found 
highest  in  high  grade,  and  lowest  in  low  grade.  The 
various  talipes  are  foimd  to  some  extent  among  all 
grades,  especially  talipes  planus,  as  are  hammer 
toes. 

Funnel  breast,  thorax  en  entonnoir,  is  found  in 
the  lower  grades,  especially  the  Mongolian :  and 
pectus  carinatuni  or  pigeon  breast  among  all  grades; 
but  most  often  among  the  middle  and  low. 

The  kyphotic  pelvis  is  seen  almost  exclusively 
among  the  lower  grades,  as  is  the  scoliorachitic 
pelvis ;  and  the  elongation  of  the  coccyx,  suggestive 
of  the  stump  of  a  tail,  is  found  among  the  lower 
grades,  especially  the  idiots. 

Heavy,  thickened,  pigmented  nails  are  very  com- 
mon among  the  middle  and  lower  grades,  and  many 
have  flat  furrows  extending  the  entire  length,  giv- 
ing a  rough  appearance.  When  heavily  ridged — 
generally  transverse — they  are  called  neurotic  nails, 
and  are  frequently  found  among  the  high  grade. 
IMany  are  addicted  to  onychophagy,  or  biting  of  the 
nails.  This  occurs  to  some  extent  among  the  middle 
and  high  grade,  but  rarely  among  the  low  grades. 

The  male  generative  organs  are  worthy  of  at- 
tention as  exhibiting  marked  deviations  from 
normal.  In  all  grades  the  penis  is  greatly  enlarged 
both  in  length  and  circumference.  Phimosis  is  the 
rule,  and  not  the  exception  in  all  grades,  as  are 


epispadias,  hypospadias,  and  cryptorchism.  Mas- 
turbation is  common  in  every  grade,  even  the  pro- 
found idiot.  Aspermia,  and  azoospermia  are  found 
mostly  among  epileptics  of  all  grades.  There  is 
retarded  genital  function,  as  well  as  sexual  desire, 
and  loss  of  sexual  power,  in  all  grades ;  but  when 
roused  there  is  excessive  exaggeration  which  in 
many  cases  exceeds  all  bounds  often  amounting  to 
satyriasis.  Atrophy  of  the  sexual  organs  is  not  very 
common.  In  rare  cases  there  is  socalled  herma- 
phrodism  among  the  high  grade,  especially  the 
moral  imbecile. 

Defective  vision,  hearing,  taste  and  smell,  as  well 
as  anosmia  are  found  most  frequently  in  the  middle 
and  low  grades,  especially  the  latter.  Defective 
hearts  are  found  in  all  grades,  but  most  frequently 
among  the  mi<Jdle  and  low ;  especially  are  they  to 
be  noted  among  the  Mongolians  and  microcephals. 
jMitral  and  aortic  regurgitation  are  common,  as  is 
tachycardia.  Hemophilia,  or  uncontrollable  bleed- 
ing, is  occasionally  encountered  in  the  middle  grade. 
Mirror  writing  is  not  infrequently  seen,  and  always 
in  the  high  grade.  Many,  especially  among  the  low 
grades,  are  insensitive  to  pain,  and  will  take  great 
delight  in  watching  the  setting  of  a  broken  bone 
or  the  amputation  of  their  own  fingers. 

Speech  is  retarded  in  all  grades.  Stammering 
occurs  mostly  among  the  high,  and  next  among  the 
middle  grade ;  while  among  the  low  grades  it  is  rare. 
There  is  defective  articulation  among  all  grades, 
but  it  is  most  pronounced  among  the  low.  Burring 
and  lisping  occurs  among  the  high  and  middle 
grade,  but  almost  never  among  the  low  grades. 
Semimutism  and  mutism  are  foimd  principally 
among  the  middle  and  low  grades.  Weak  digestion  is 
rare ;  and  all  grades  are  gormandizers  and  are  likely 
to  overeat.  Constipation  is  common  in  all  grades,  but 
markedly  so  in  the  low,  in  which  it  may  alternate 
with  diarrhea ;  and  many  are  persistently  unclean 
both  night  and  day.  In  a  large  number  of  cases, 
in  all  grades,  there  is  both  retarded  dentition  and 
locomotion ;  and  they  are  much  slower  in  learning 
to  dress  and  undress  than  normal  children ;  and  are 
awkward  in  the  use  of  their  hands ;  and  lack  of 
prehension,  as  well  as  poor  station  may  be  noted, 
especially  among  the  middle  and  low  grades.  Epi- 
lepsy and  chorea  are  common  in  all  grades. 

The  high  and  middle  grades  are  sometimes  difiident 
in  meeting  strangers ;  but  as  a  rule  they  are 
egotistical,  and  are  so  fond  of  attracting  attention 
that  they  will  go  to  almost  any  length,  even  resort- 
ing to  selfmutilation.  The  moral  stigmata  are 
always  prominent,  and  in  many  cases  exceed  the 
physical.  The  high  grade,  and  especially  the  tnoral 
imbecile,  are  veritable  artists  in  crime,  and  usually 
brutal  and  cruel,  and  always  crafty  and  cunning, 
deceitful  and  untruthful ;  mendacity  amounts  almost 
to  an  art,  their  lies  being  simply  wonderful. 

There  is  a  lack  of  true  affection ;  and  gratitude 
among  the  mentally  defective  is  by  no  means  a 
lasting  quality.  They  are  all  adroit  thieves,  and 
are  extremely  cunning  in  gaining  their  ends ;  but 
as  they  have  little  acquisitiveness,  and  only  a  very 
limited  appreciation  of  relative  values,  they  will 
steal  for  no  reason  whatsoever  except  the  excite- 
ment.   As  a  rule  they  are  not  revengeful,  but  are 


July  17,  IVJO.] 


NORM  AX:  THE  XAUHEIM  BATH. 


83 


generous  and  kindhearted  to  a  degree ;  their  emo- 
tions are  easily  stirred ;  and  they  are  lazy  and 
sluggish  in  habits.  In  sexual  perverts  a  mincing 
gait  is  noticeable,  and  feminine  appearance  and 
actions ;  and  there  is  a  peculiar  shuffling  walk 
among  the  lower  grades  which  is  often  a  mere 
lurching  forward.  All  grades  have  phenomenal 
memories  for  peculiar  things — dates  and  unim- 
portant events,  but  the  residual  or  practical  memory 
is  almost  always  very  deficient. 

The  following  deviations  from  normal,  common 
to  all  grades  of  the  feebleminded,  occur  so  rarely 
that  I  call  attention  to  them  simply  as  a  matter  of 
record ;  although  when  present,  especially  in  com- 
bination, they  are  indisputable  indications  of  de- 
generation. 

The  head. — Cephalones  without  hydrocephalus  ; 
trigonocephalus,  oxycephalus,  plagiocephalus,  sphen- 
ocephalus,  trochocephalus,  leptocephalus,  platy- 
cephalus. 

The  cvc. — ^legalophthalmus.  microphthalmus, 
microphepharon,  symblepharon,  colomba  palpebrse, 
coloboma  iridis,  coloboma  choroideae,  congenital ; 
coloboma  lentis.  congenital ;  epicanthus,  aniridia, 
polykoria.  corectopia.  staphyloma  posticum  scarpal, 
arteria  hvaloidea,  retinitis  pigmentosa,  hemeralopia, 
daltonism,  acrometropsia,  nyctalopia,  dermoid  ad- 
hesions on  cornea. 

The  far^.— Stahl's  ears  Xo.  1— Xo.  2— Xo.  3; 
faimonian  or  satanic  or  pointed  ear. 

Thorax. — Gynecomastia  or  excessive  develop- 
ment of  breasts. 

The  e.vtrcuiities. — Defective  extension  of  fingers; 
excessively  long  hands  and  fingers;  great  strength 
and  abnormal  development  of  left  hand  and  leg ; 
congenital  luxations,  aplasia  of  extremities,  hypo- 
plasia of  extremities,  micromelus.  apus  and  abrach- 
ius,  peropus  and  perobrachius,  ametus,  phocomelus, 
perometus.  sympus  apus  and  sympus  opus,  mono- 
brachius  and  monopus,  achinus  and  perochirus. 

REFERENCES. 

I.    Petersox:  American  Journal  of  Insanity,  July,  1893. 

THE    TYPES    OF    CARBOXATED  BRIXE 
BATHS  (XAUHEIM). 
A  Discussion  of  Their  Comparative  Values. 

By  X.  Philip  Xormax,  M.  D., 

New  York, 
Late  Major,  Medical  Corps,  U.  S.  Army. 

In  1857  Beneke  observed  that  carbonated  brine 
baths  had  a  very  decided  eitect  in  influencing  the 
course  of  diseases  of  the  heart  and  circulatory  appa- 
ratus. This  was  contrary  to  the  current  opinions 
held  by  the  medical  profession  at  large  and  the  physi- 
cians practising  at  Bad  Xauheim.  Prior  to  Beneke's 
observations,  which  he  subsequently  proved,  the  car- 
bonated brine  bath  was  held  to  be  dangerous  to 
heart  patients.  However,  the  treatment  had  been 
occasionally  risked  on  a  few  patients  with  heart 
disease  when  the  rheumatism  of  which  they  chiefly 
complained  was  so  painful  that  relief  was  impera- 
tive, despite  the  possibility  of  the  traditional  hazard 
of  life  involved  in  the  therapeutic  eflfort.  Beneke 


was  not  tardy  in  recognizing  that  the  beneficial  ef- 
fect of  the  baths  in  these  few  cases  was  due  not 
alone  to  the  effect  upon  the  rheumatic  condition, 
but  to  a  great  extent  to  the  general  tonic  ef¥ect 
upon  the  heart  and  circulation  which  indirectly  in- 
fluenced the  rheumatic  condition. 

This  briefly  outlines  the  history  of  the  develop- 
ment of  carbonated  brine  baths  as  a  therapeutic  agent 
for  cardiovascular  renal  diseases.  The  method  has 
been  developed  and  scientifically  elaborated  by  such 
men  as  the  Schotts  and  the  Groedels  in  Germany, 
and  by  Baruch  in  this  country.  From  the  time  that 
X'auheim  became  recognized  by  the  profession  as 
the  ]\Iecca  for  heart  patients,  attempts  have  been 
made  to  duplicate  this  bath  by  two  classes  of  indi- 
viduals, physicians  and  laymen,  with  two  definite 
purposes  in  view.  Physicians  have  labored  to  de- 
velop the  artificial  bath  that  their  patients  might 
have  the  advantages  of  this  form  of  therapy  with- 
out incurring  the  expense  of  a  trip  to  Xauheim  or 
without  necessitating  the  complete  separation  of 
themselves  from  their  domestic  and  community 
relations. 

The  other  set  of  individuals,  composed  of  lay- 
men, have  followed  in  the  development  of  the  arti- 
ficial bath,  not  actuated  so  much  by  the  scientific 
enthusiasm  of  the  therapeutist  but  rather  with  the 
purpose  of  profiting  financially  from  this  therapeu- 
tic venture  calculated  to  interest  the  hundreds  of 
heart  patients  in  this  country  by  methods  of  com- 
mercial advertising  at  once  insidious  in  its  sugges- 
tions and  ambiguous  in  its  promise  of  benefit.  An 
avenue  of  publicity  is  sought  that  is  contemplated 
to  reach  and  attract  the  public  eye  rather  than  the 
discriminating  judgment  of  the  profession  through 
the  popular  magazines.  An  ethical  way  is  offered 
to  reach  the  profession  directly,  and  the  public  indi- 
rectly, by  the  publication  of  scientific  observations 
through  the  pages  of  the  current  medical  journals. 
If  as  much  money  was  spent  on  developing  the 
scientific  methods  in  vogue  for  diagnostic  and  thera- 
peutic purposes  as  for  commercial  publicity  the  re- 
turn on  the  investment  within  a  few  years  would  be 
proportionally  commensurate  to  the  thoroughness 
of  the  work  accomplished. 

Because  of  the  claims  and  counterclaims  that  phy- 
sicians constantly  hear  concerning  this  and  that  kind 
of  Xauheim  bath  this  article  has  been  written  in  an 
endeavor  to  classify  properly  the  various  types  of 
baths  in  existence  and  to  evaluate  comparatively  the 
merits  of  each. 

Carbonated  brine  baths  (X'auheim  baths)  are  di- 
vided into  three  kinds,  as  follows : 

1.  The  natural  carbonated  brine  bath. 

2.  The  partially  natural  carbonated  brine  bath, 
a.  Using  natural  carbonated  water  and  artificially 
prepared  brine,  b.  Using  a  natural  brine  water  in 
which  the  carbonation  is  artificially  prepared. 

3.  The  artificially  carbonated  brine  bath. 

Type  1  is  to  be  found  only  at  Xauheim  and  is 
the  ideal  bath. 

Type  2,  a,  as  a  bath,  per  se,  is  on  a  par  with  X'au- 
heim,  as  it  possesses  the  most  important  constituent 
part  of  the  carbonated  brine  bath  in  its  natural  form 
of  occurrence.  It  is  a  matter  of  common  knowledge 
that  the  proper  physiological  action  of  the  bath  is 


84 


NORMAN:   THE  NAUHEIM  BATH. 


[New  York 
Medical  Journal. 


directly  dependent  upon  the  efficacy  of  the  carbonic 
acid  gas  saturation  throughout  the  brine  water.  In 
a  natural  carbonated  brine  bath  or  in  a  partially 
natural  carbonated  brine  bath  in  which  the  carbo- 
nation  is  natural  and  the  brine  artificial,  there  is 
such  an  ideal  distribution  of  the  carbonic  acid  gas 
throughout  the  water  as  to  permit  the  gas  bubbles 
properly  to  insulate  the  immersed  skin  area  against 
a  too  rapid  dissipation  of  body  heat  and  to  stimu- 
late the  skin  with  a  thermic  stimulus  of  heat  im- 
parted by  the  gas  bubble  because  of  the  difiference 
of  the  point  of  thermic  comfort  between  that  of 
carbonic  acid  gas  .and  the  water  of  thr  bath.  In 
a  bath  in  which  the  carbonation  is  natural  there 
are  successive  crops  of  gas  bubbles  that  adhere  to 
the  skin  and  provide  for  a  fresh  insulation  of  the 
immersed  skin  and  facilitate  more  adequately  the 
ph^-siological  action  of  the  gas  bubbles  than  in  the 
bath  in  which  the  carbonation  is  artificial. 

Type  2,  b.  is  on  a  par  with  the  artificial  bath. 
The  carbonation  is  artificial  and  it  is  obvious  that 
since  the  most  important  physiological  factor  of  this 
bath  and  of  the  artificial  bath  are  the  same,  that 
the  therapeutic  merit  must  necessarily  be  equal. 
Claims  have  been  made  that  the  natural  brine  was 
distinctly  advantageous  over  the  artificial  brine,  but 
the  observations  of  others,  as  well  as  my  own,  have 
failed  to  substantiate  this  clinically.  Assuming  a 
proper  proportion  of  calcium  and  sodium  chloride 
in  solution  for  each  bath  there  is  no  reason  known 
that  confirms  the  claim  of  superiority  of  natural 
brine  water  over  artificially  prepared  brine  water. 
Therefore,  an}'  claim  of  this  sort  is  to  be  discounted. 
It  is  merely  a  connivance  calculated  to  associate  in 
the  mind  of  the  reader  a  similarity  of  this  natural 
brine  water  to  the  natural  carbonated  brine  water 
of  Bad  Xauheim.  The  reader,  unlearned  in  hydro- 
therapeutic  lore,  is  misled  by  the  mental  processes 
of  logical  reasoning  sequence  to  ascribe  inferentially 
to  this  natural  brine  water  an  equivalent  value  to 
that  of  the  natural  carbonated  brine  water  of  Xau- 
heim, which  does  not  exist. 

Type  3  is  the  artificial  bath  and  is  the  equal  of 
Type  2,  b.    This  is  borne  out  by  clinical  results. 

Summing  up,  it  would  appear  that  Bad  Xauheim, 
in  point  of  the  bath  alone,  has  distinct  advantages 
that  have  not  been  exactly  duplicated  but  are  capa- 
ble of  duplication  at  Saratoga,  X.  Y.  The  bath 
of  Saratoga  Springs,  X^.  Y.,  represents  Type  2,  and 
when  the  "method"  has  been  more  scientifically 
elaborated  should  equal  Xauheim  as  a  heart  cure. 
It  has  no  rival  in  this  countr\-  in  point  of  natural 
assets  as  a  heart  cure. 

However,  at  this  point  it  is  well  to  call  attention 
to  a  handicap  existing  at  Saratoga  for  heart  patients. 
This  handicap  is  the  laxative  mineral  waters.  Laxa- 
tive mineral  waters  have  been  used  for  years  in  car- 
diacs, based  upon  a  time  honored  but  time  worn 
idea,  "elimination."  The  unpr escribed  use  and  abuse 
of  laxative  waters  by  cardiac  patients  is  dangerous, 
and  it  is  to  be  hoped  that  Saratoga  will  ever  exert 
a  restraining  influence  over  the  personal  inclination 
of  the  heart  patients  to  indulge  while  being  treated 
there. 

Type  2,  b,  having  no  advantages  over  the  artifi- 


cial or  Type  3  bath  deserves  discussion  in  associa- 
tion with  the  artificial  bath.  These  baths  are  capa- 
ble of  benefitting  cardiovascular  renal  disease,  and 
while  they  are  not  as  valuable,  per  sc,  as  Type  1 
and  Type  2,  a,  they  are  nevertheless  worthy  substi- 
tutes. 

There  are  a  few  places  in  this  country  where  a 
brine  water  similar  to  Bad  Xauheim's  is  to  be  found. 
It  is  to  be  hoped  that  in  the  event  of  the  develop- 
ment of  health  resorts  at  these  sites  that  it  will  not 
be  because  of  this  natural  brine,  but  becausie  of  a 
conscientious  attempt  to  establish  a  substitute  for 
those  patients  unable  to  journey  to  Xauheim.  The 
natural  brine  possesses  no  inherent  advantages  for 
the  carbonated  brine  bath.  That  it  renders  the  ad- 
ministration of  baths  less  troublesome  and  less  ex- 
pensive than  artificially  prepared  brine  is  quite  ob- 
vious. The  profession,  I  am  sure,  would  gladly 
support  an  establishment  whose  prime  interest  was 
directed  at  the  aggressive  development  of  a  health 
resort  for  heart  patients.  If  a  scientific  equipment 
of  such  an  establishment  was  kept  abreast  of  mod- 
ern medical  progress  there  would  be  no  need  for 
worry  about  its  financial  success.  However,  the 
profession  cannot  be  pledged  to  support  an  estab- 
lishment whose  atmosphere  scents  more  strongly  of 
commercial  interest  than  of  scientific  progressive- 
ness. 

I  have  attempted  to  classify  the  types  of  carbo- 
nated brine  baths  (X'^auheim  baths)  in  use,  basing 
this  classification  upon  the  results  of  recent  advances 
made  in  this  form  of  therapy  as  well  as  upon  per- 
sonal observations  extending  over  a  period  of  six 
years.  It  is  my  desire  to  give  to  those  of  the  pro- 
fession unfamiliar  with  this  therapy  a  correct  im- 
pression of  the  comparative  merit  of  the  different 
types  of  baths,  so  that  they  may  wisely  counsel  their 
heart  patients  as  to  the  advantages  of  this  treatment 
as  well  as  to  advise  correctly  some  despairing  pa- 
tient who  may  have  become  enthusiastically  con- 
fused by  advertisements  craftily  designed  to  attract 
his  interest  by  inferential  statements  which  are  so 
indeterminate  of  tangible  fact  as  to  lead  him  to 
question  the  accuracy  of  his  conclusions.  If  this 
has  been  accomplished  I  shall  indeed  be  repaid  for 
my  efforts. 

109  East  Sixty-first  Street. 

THE    RESULTS    OF    OPERATION  IN 
GASTRIC  AND  DUODEXAL  ULCERS.* 

By  George  Woolsey,  M.  D.,  F.A.C.S., 
New  York. 

The  following  study  of  the  results  of  operation  in 
gastric  and  duodenal  ulcer  is  based  upon  109  cases 
in  which  I  operated,  mostly  during  the  last  five  or 
six  years,  up  to  December,  1919.  This  does  not  in- 
clude acute  perforating  ulcers.  A  few  of  these  109 
cases,  principally  those  of  gastric  ulcer  for  which 
a  gastroenterostomy  or  an  excision  was  done,  date 
further  back,  but  are  included  for  a  comparison  of 
the  results,  as  I  have  done  relatively  few  opera- 
tions of  these  types  for  gastric  ulcer  in  recent  years. 

*Read  before  the  Surgical  Section  of  the  New  York  Academy  of 
Medicine,  May  7,  1920. 


July  17,  1920.] 


WOOLSEY:    GASTRIC  AXD  DUODEXAL  ULCERS. 


85 


Seventy-nine  of  these  operations  have  been  done 
since  January,  1916,  at  which  date  the  followup  sys- 
tem was  inaugurated  in  the  second  surgical  divi- 
sion of  Bellevue  Hospital.  Only  one  of  these  was 
done  in  1918,  so  that  the  period  covered  by  this 
group  was  three  years.  I  have  succeeded  in  get- 
ting return  or  late  records  in  seventy-six  of  these 
cases,  sixty-two  of  the  operations  having  been  per- 
formed since  January,  1916.  The  time  after  opera- 
tion of  these  return  records  varies  from  about 
three  months  to  110  months,  and  averages  16.4 
months.  Those  patients  who  had  no  gastric  symp- 
toms were  classed  as  excellent;  those  having  occa- 
sional vague  symptoms,  not  those  of  ulcer,  were 
classed  as  satisfactory.  The  remaining  class  of  un- 
satisfactory results  included  those  patients  who 
complained  of  considerable  abdominal  discomfort, 
though  it  was  rarely  suggestive  of  ulcer  and  proba- 
bly depended  for  the  most  part  on  adhesions  and 
other  extragastric  causes.  There  were  seven  post- 
operative deaths,  five  in  the  period  since  Januarv, 
1916. 

Naturally  the  largest  group  was  that  of  duodenal 
ulcer,  of  which  there  were  fifty-eight  cases,  but 
this  was  only  a  little  over  fifty  per  cent.,  a  low  ratio 
considering  the  average  run  of  duodenal  compared 
with  gastric  ulcers.  Two  of  these  patients  died 
after  operation,  one  of  pulmonary  embolism  and 
one  of  heat  prostration,  a  mortality  of  3.4  per  cent. 
The  heat  prostration  would  have  been  prevented  had 
we  recognized  how  hot  it  was ;  it  occurred  at  the 
beginning  of  an  intensely  hot  spell.  Of  the  re- 
maining fifty-six  cases  I  have  return  records  of 
forty-five.  A  number  of  these  patients  have 
come  back  to  the  return  clinic  several  times,  or  I 
have  seen  or  heard  from  them  repeatedly. 

The  immediate  results,  or  the  condition  on  leav- 
ing the  hospital,  was  excellent  in  seventy-five  per 
cent,  of  the  cases;  satisfactory  in  15.9  per  cent., 
and  unsatisfactory  in  nine  per  cent.  The  late  re- 
sults, which  are  the  real  test  of  the  value  of  the 
operation,  were  excellent  in  64.4  per  cent. ;  satis- 
factory in  26.6  per  cent.,  and  unsatisfactory  in  8.8 
per  cent.  Combining  the  excellent  and  satisfactory 
groups,  which  give  what  may  be  called  the  good 
results,  shows  that  the  immediate  good  results  were 
90.9  per  cent.,  and  the  good  results  nine  per  cent., 
which  are  practically  identical.  In  a  series  of  twenty 
cases  of  duodenal  ulcer  I  employed  pyloric  exclu- 
sion by  using  a  strip  of  fascia  from  the  rectus  sheath, 
according  to  \\'ilms's  method,  in  addition  to  gastro- 
jejunostomy, but  thinking  that  it  made  little  or  no 
difference  and  only  added  to  the  time  of  operation. 
I  discontinued  it.  However,  on  comparing  the  late 
results  in  cases  with  and  without  exclusion  I  unex- 
pectedly found  that  the  cases  with  exclusion  gave 
the  best  results.  Of  the  twenty  cases  I  have  late 
reports  of  nineteen,  giving  excellent  results  in  59.9 
per  cent. ;  satisfactory  in  36.8  per  cent.,  or  good 
results  in  94.7  per  cent.,  and  only  5.3  per  cent,  of 
failures.  Of  the  twenty-six  cases  without  exclusion, 
twenty-five  reported,  giving  excellent  results  in 
sixty-eight  per  cent. ;  satisfactory  in  twenty  per 
cent.,  or  good  results  in  eighty-eight  per  cent.,  with 
twelve  per  cent,  of  failures.  This  may,  however, 
be  too  small  a  number  of  cases  to  afford  a  fair 


comparison.  The  exclusion  is  only  intended  to  be 
temporary,  to  afford  the  ulcer  a  chance  to  heal 
without  being  irritated  by  the  passage  of  food ;  but 
in  one  case,  fluoroscoped  fifteen  months  later,  the 
pylorus  was  still  occluded. 

Suspicion  of  a  simultaneous  chronic  appendicitis 
led  to  the  removal  of  the  appendix  in  sixteen  out  of 
forty-eight  cases,  usually  through  the  median  inci- 
sion, though  in  three  cases  a  separate  muscle  split- 
ting incision  had  to  be  employed,  and  in  three  others 
the  appendix  could  not  be  delivered  in  the  epigas- 
tric wound.  In  six  rhore  cases  the  appendix  had 
been  removed  previously,  and  in  three  of  these  the 
patient  dated  the  epigastric  localization  of  the  symp- 
toms from  shortly  after  the  operation.  It  is  un- 
doubtedly true  that  a  number  of  patients  are  oper- 
ated upon  for  chronic  appendicitis  who,  in  addition 
to  or  instead  of  the  latter,  have  a  duodenal  or  gastric 
tilcer.  Appendectomy  coincident  with  gastrojeju- 
nostomy does  not  appear  to  influence  favorably  the 
final  result  in  the  cases  so  treated  in  this  series. 
The  gallbladder  was  removed  in  four  cases,  but 
only  once  for  stones,  the  other  three  times  because 
it  was  left  so  raw,  after  freeing  its  adhesions  to 
the  duodenum  or  -stomach,  that  fresh  massive  ad- 
hesions seemed  inevitable. 

A  symptom  or  condition  sometimes  mentioned  by 
patients  on  being  questioned  as  to  the  results,  is  con- 
stipation. In  several  the  bowels,  constipated  before, 
were  regular  after  operation ;  in  a  smaller  number 
the  reverse  condition  existed.  The  results  in  pa- 
tients who  were  constipated  after  the  operation, 
compared  with  the  nonconstipated  patients,  show 
this  difference,  that  there  are  more  excellent  re- 
sults, as  compared  with  satisfactory  results,  when 
the  bowels  are  regular  than  when  they  are  consti- 
pated. Eructations  of  gas  or  sour  fluid  is  another 
s3'niptom  of  frequent  occurrence.  It  was  noted 
before  operation  three  times  as  often  as  after.  It 
may  become  quite  a  matter  of  habit,  and  in  all  but 
one  of  the  cases  noted  after  operation  it  was  also 
noted  as  present  before. 

In  one  case  the  s\Tnptoms  of  ulcer  recurred  after 
twenty-one  months,  and  all  forms  of  diet  and  treat- 
ment had  no  effect.  On  operation  (gastrotomy) . 
two  years  after  the  first  operation,  about  three 
inches  of  silk  or  linen  thread  was  found  hanging 
from  the  inside  of  the  anastomosis.  Another  three 
inches  was  pulled  out  of  the  site  of  the  anastomosis. 
There  was  no  jejunal  ulcer.  The  symptoms  were 
entirely  relieved  aF~cmce.  This  thread  was  the 
outer  or  serous  suture.  This  was  a  symptomatic 
recurrence,  but  the  Mayos  have  shown  that  such 
nonabsorbable  sutures  are  probably  the  commonest 
cause  of  gastrojejunal  ulcer.  Since  that  time,  four 
and  a  half  years  ago,  I  have  used  no  nonabsorbable 
suture,  only  Xo.  0  chromic  gut,  so  that  nearly  all 
the  operations  in  this  present  series  have  been  so 
performed.  In  a  number  of  these  cases  we  had 
the  benefit,  in  diagnosis,  of  a  large  series  of  plates 
taken  by  Dr.  Cole,  in  clinical  cases  at  the  Cornell 
]\Iedical  School.  The  x  ray  diagnosis  was  in  each 
instance  confirmed  by  operation.  These  patients 
were  also  fluoroscoped  independently  b\-  Dr.  A.  L. 
Holland,  with  practically  identical  findings.  The 


86 


WOOLS Ey 


GASTRIC  AND  DUODENAL  ULCERS. 


[New  York 
Medical  Journal. 


great  A-alue  of  fluoroscopy  is  shown  in  one  of  the 
more  recent  cases  in  which  an  operation  had  been 
performed,  where  Dr.  Holland  was  able  to  diagnose 
a  duodenal  ulcer  only  after  forcibly  pressing  the 
stomach  aside.  The  hospital  plates  did  not  show  the 
ulcer. 

In  the  group  of  gastric  ulcer  cases  treated  by 
gastroenterostomy  I  have  included  all  that  I  have 
private  records  of,  going  back  to  1902,  as  the  group 
would  otherwise  be  too  small.  There  are  eighteen 
cases  in  this  group,  with  no  postoperative  deaths, 
making  a  mortality  of  2.6  per  cent,  for  all  cases 
of  peptic  ulcer  in  which  a  gastroenterostomy  only 
was  done.  Among  the  early  cases  were  three  of 
pyloric  stenosis,  with  dilatation  of  the  stomach,  giv- 
ing remarkably  successful  results  in  the  relief  of 
symptoms,  the  patients  putting  on  weight  and  re- 
turning to  a  normal,  active  life.  The  first  two 
operations  were  done  with  a  Murphy  button  by  the 
anterior  method.  The  second  patient  had  such  a 
large  indurated  mass  in  the  antrum  that  I  took  it 
for  a  carcinoma  and  told  his  family  that  I  did  not 
think  he  could  live  over  a  year.  Two  and  a  half 
years  later  I  saw  him  in  perfect  health  and  doing 
his  full  work,  having  gained  forty  pounds  in 
weight,  and  I  heard  of  him  fourteen  years  after 
operation  living  in  California  in  perfect  health. 

We  ordinarily  think  that  a  gastroenterostomy  is 
not  adequate  to  cure  a  gastric  ulcer,  except  those 
directly  at  the  pylorus.  That  some  at  least  of  the 
chronic  ulcers  can  be  cured  by  gastroenterostomy 
alone  is  shown  by  another  case,  in  which  the  pa- 
tient was  operated  upon  over  nine  years  ago  for  an 
ulcer  whose  crater  could  readily  be  felt  on  the 
posterior  surface,  near  the  middle  of  the  stomach, 
adherent  to  the  pancreas.  This  patient  I  heard 
from  recently.  He  is  not  sick  a  day,  has  done  hard 
physical  labor  since  operation,  and  is  nearly  sev- 
enty years  old.  In  this  case  a  posterior  gastroen- 
terostomy could  not  be  done  on  account  of  posterior 
adhesions,  so  I  brought  a  short  loop  of  the  jejunum 
through  the  mesocolon  and  then  through  the  gas- 
trocolic omentum  and  anastomosed  it  to  the  anterior 
surface  of  the  stomach,  making  what  may  be  called 
a  retrocolic  anterior  gastroenterostomy.  Since  then 
I  have  used  this  method  in  two  other  cases  of  this 
group  and  in  several  resections,  mostly  for  carci- 
noma. It  has  alwaj'S  given  most  satisfactory  re- 
sults ;  in  fact  the  best  results  that  I  have  had  in 
gastric  carcinoma  have  been  obtained  in  this  way. 

Another  patient  of  this  group  is  interesting  as 
having  been  operated  upon  at  another  hospital  for 
perforated  ulcer,  without  gastroenterostomy,  seven- 
teen months  before.  A  year  later  he  had  a  recur- 
rence for  which  the  gastroenterostomy  was  done, 
with  an  excellent  final  result.  There  is  considera- 
abie  dif¥erence  of  opinion  among  surgeons  as  to 
whether  a  gastroenterostomy  should  be  done^in  per- 
forated ulcer  if  the  patient's  condition  warrants  it. 
Though  this  is  one  of  only  two  cases  where  I  have 
seen  recurrence,  I  have  always  preferred  to  do  a 
gastroenterostomy  and  feel  that  the  reasons  for  this 
course  given  by  Pater  son,  of  London,  are  quite  suf- 
ficient. 

This  man  had  a  stormy  and  interesting  convales- 
cence.   Three  days  after  operation,  and  again  seven 


days  after,  he  had  a  large  hematemesis  with  melena. 
Nine  days  after  operation,  the  hemoglobin  being  ten 
per  cent,  and  the  blood  pressure  so  low  that  it  could 
not  be  counted,  he  was  reoperated  upon  after  a  trans- 
fusion of  1100  c.c.  On  opening  the  stomach  the 
edges  of  the  stroma  were  found  to  be  smoothly 
healed  and  the  source  of  the  hemorrhage  was  found 
to  be  the  ulcer.  There  was  no  further  serious  hem- 
orrhage and  he  made  a  good  recovery. 

In  this  series  of  gastric  ulcer  cases  treated  by  gas- 
troenterostomy the  late  results  are  known  in  four- 
teen, being  excellent  in  eight,  satisfactory  in  three, 
making  78.5  per  cent,  of  good  results.  In  the  three 
cases  marked  unsatisfactory  one  patient  when  last 
seen  four  months  after  operation,  gave  an  excellent 
report,  but  three  months  later  she  wrote  that  she  was 
hopelessly  sick,  without  specifying  in  what  way. 
Another  patient  was  well  for  eight  months  when  he 
began  to  have  stomach  symptoms  at  times,  especially 
vomiting,  but  no  gastric  pain.  He  was  operated 
upon  again  sixteen  months  after  the  first  operation 
and  the  pyloric  end  of  the  stomach  resected.  Since 
then  he  has  been  free  from  gastric  symptoms,  but  is 
still  neurotic  and  has  a  peculiar  pallor,  though  the 
blood  examination  is  quite  satisfactory.  The  third 
patient  was  entirely  well  for  nearly  three  years, 
when  gastric  symptoms,  with  hematemesis,  returned, 
His  habits  of  eating,  drinking,  and  smoking  were 
alone  enough  to  proA  oke  symptoms  of  recurrence  of 
ulcer.  On  resecting  the  pyloric  end  of  the  stomach 
the  stoma,  made  at  the  first  operation,  was  found 
entirely  closed,  the  only  case  of  the  kind  that  I  have 
met  with. 

A  rather  recent  case  was  that  of  a  hydrochloric 
acid  burn  where  the  ef?ects  of  the  acid  were  con- 
fined to  the  antrum,  the  distal  two  inches  of  which 
were  contracted  to  a  mass  with  thick  walls  and  nar- 
row lumen,  sharply  demarked  from  the  rest  of  the 
stomach.  The  symptoms  were  those  of  pyloric  sten- 
osis and  were  entirely  relieved  at  once  by  gastroen- 
terostomy. The  effect  of  the  acid  is  strikingly  dif- 
ferent from  that  of  a  strong  alkali,  which  is  exerted 
mostly  on  the  esophagus  and  the  cardia.  Apparently 
the  acid  caused  a  pyloric  spasm  which  retained  the 
acid  in  the  antrum  and  thus  concentrated  its  action 
on  this  portion. 

In  the  few  more  or  less  recent  cases  in  this  group 
the  ulcer  was  situated  at  or  close  to  the  pylorus  and 
in  five  cases  a  pyloric  exclusion  was  done,  proximal 
to  the  ulcer,  to  encourage  its  healing,  but  without 
affecting  the  final  result  very  favorably.  I  am  in- 
clined to  think  that  the  results  would  have  been  bet- 
ter if  most  of  these  later  cases  had  been  resected 
by  the  Polya-Reichel  method.  The  best  results  ob- 
tained by  gastroenterostomy  in  the  gastric  ulcer 
group  have  been  in  chronic  pyloric  stenosis  with  di- 
latation of  the  stomach.  The  group  of  gastric  ulcers 
treated  by  excision  is  a  small  one,  only  seven  cases. 
The  first  two  cases  were  treated  without  gastroenter- 
ostomy and  were  unsatisfactory.  A  gastroenteros- 
tomy was  performed  later  in  one  of  these  cases  to 
relieve  symptoms  and  a  good  result  was  obtained 
only  after  excluding  the  pylorus  at  a  later  operation. 

I  am  firmly  convinced  that  excision  alone  is  a 
poor  operation  for  gastric  ulcer.  It  seems  to  intef- 
fere  with  gastric  motility  and  does  not  relieve  hyper- 


July  17,  1920.] 


WOOLSEY:    GASTRIC  AND  DUODENAL  ULCERS. 


87 


acidity.  Combined  with  gastroenterostomy,  exci- 
sion, or  better  perhaps  the  Balfour  cautery  opera- 
tion, may  give  good  results.  Excision  comes  in  com- 
petition with  mesogastric  resection,  but  although  the 
postoperative  course  of  the  latter  has  been  very 
smooth,  the  final  results  have  not  been  as  good,  so 
that  my  early  enthusiasm  for  this  method  has  some- 
what abated.  There  are  also  a  few  cases  of  gastric 
ulcer,  well  toward  the  cardiac  end,  where  mesogas- 
tric resection  is  more  difficult.  At  least  two  in  the 
excision  group  were  of  this  type  and  both  gave 
good  results.  The  last  one  of  these  is  of  special  in- 
terest. A  woman  aged  sixty  years  had  been  ex- 
plored by  another  surgeon,  who  found  only  adhe- 
sions. The  stomach  symptoms  continuing  she  was 
fluoroscoped  by  Dr.  Holland,  who  found  a  very 
small  perforating  ulcer  posterior  to  the  lesser  curva- 
ture, about  five  inches  from  the  pylorus.  This  was 
seen  only  in  an  oblique  view  and  did  not  show  on 
the  hospital  x  ray  plates.  It  was  found  at  opera- 
tion, excised,  and  a  gastroenterostomy  done.  Owing 
to  its  posterior  position  I  could  not  reach  it  well 
with  the  cautery  and  it  was  not  suitable  for  meso- 
gastric resection. 

In  a  group  of  twenty-six  cases  of  gastric  ulcer 
treated  by  resection  of  the  stomach  four  patients 
died,  a  mortality  of  15.3  per  cent.  It  is  interesting 
to  study  these  four  fatalities,  all  done  by  the  Bill- 
roth II  method.  One  patient  took  the  anesthetic 
badly,  pneumonia  developed  and  death  occurred  on 
the  third  day.  Another,  a  man  of  sixty,  had  had  a 
gastroenterostomy  for  ulcer  three  and  a  half  years 
before  and,  though  a  hard  drinker,  had  been  well 
for  three  years  after  operation.  He  was  doing  and 
feeling  well  on  the  third  and  fourth  days  after  oper- 
ation, but  on  the  fifth  day  edema  of  the  lungs  de- 
veloped and  he  died.  A  postmortem  showed  seri- 
ous chronic  lesions  of  the  lungs,  kidneys  and  liver. 
The  other  two  patients  had  profound  anemia  from 
gastric  hemorrhage.  The  first  had  830,000  red 
cells  and  fifteen  per  cent,  of  hemoglobin.  He  was 
operated  upon  immediately  after  a  transfusion  of 
900  c.  c.  He  did  well  for  several  days  and  then 
became  weaker.  Efforts  to  obtain  a  second  trans- 
fusion failed  and  he  died  on  the  seventh  day.  The 
second  patient  had  1,900,000  red  cells,  thirty-five 
per  cent,  of  hemoglobin,  and  lived  twenty-five  days, 
finally  dying  of  progressive  anemia.  This  man, 
fifty-five  years  of  age,  had  cirrhosis  of  the  liver  and 
a  gritty  adherent  spleen,  of  approximately  normal 
size.  It  must  be  admitted  that  of  these  four  pa- 
tients three  were  very  poor  risks,  two  on  account  of 
profound  anemia  and  one  because  of  advanced 
chronic  visceral  disease.  It  would  have  been  wiser 
to  do  a  gastroenterostomy  only,  in  the  anemic  pa- 
tients, leaving  the  resection  to  a  second  stage. 

Of  the  remaining  twenty-two  patients  sixteen 
have  reported  the  late  result.  Of  these  six  gave  an 
excellent  result,  seven  a  satisfactory,  and  three  an 
unsatisfactory  one,  making  81.2  per  cent,  of  good 
results.  In  one  of  the  unsatisfactory  cases,  in  which 
a  mesogastric  resection  was  done,  the  patient  was 
reoperated  upon  six  months  later,  when  adhesions 
narrowing  the  distal  segment  Were  found  and  freed 
and  a  gastroenterostomy  done,  proximal  to  the  re- 
section.   Eight  months  later  the  result  was  excel- 


lent, making  87.5  per  cent,  of  good  results  and  12.5 
per  cent,  of  unsatisfactory  results.  The  two  re- 
maining unsatisfactory  cases  were  both  of  mesogas- 
tric resection.  One  was  moderately  successful  for 
over  two  years,  but  the  patient  was  a  heavy  drinker 
and  was  syphilitic.  Gastric  or  duodenal  symptoms 
had  recurred  after  alcoholic  excess,  when  the  pa- 
tient was  last  seen  two  and  a  half  years  after  oper- 
ation. Hematemesis,  occurring  repeatedly  before 
operation,  had  not  recurred.  The  other  patient  re- 
turned five  months  after  operation  with  gastric 
symptoms.  The  x  ray  suggested  a  new  growth  at 
the  pyloric  end,  although  no  evidence  of  this  had 
been  found  on  microscopic  examination  of  the  ulcer. 
He  refused  operation  and  was  lost  track  of. 

In  gastric  ulcers  situated  at  or  near  the  pyloric 
end  I  do  a  resection,  preferably  by  the  Polya- 
Reichel  technic.  If  the  antrum  is  normal  and  the 
ulcer  is  three  to  four  inches  or  more  proximal  to  the 
pylorus  I  have  done  a  mesogastric  resection.  Where 
the  ulcer  is  so  far  from  the  pylorus  as  to  make  this 
operation  quite  difficult,  an  excision,  or  the  Balfour 
cautery  method,  with  a  gastroenterostomy,  is  pre- 
ferable. 

This  group  includes  eight  mesogastric  resections 
with  no  deaths.  At  first  I  was  strongly  in  favor 
of  this  method,  which  has  the  advantage  of  not  re- 
quiring a  gastroenterostomy,  but  I  have  been  dis- 
appointed with  its  results.  The  convalescence  is 
usually  smooth  and  satisfactory.  Only  five  cases 
-have  been  heard  from  and,  after  reoperation  in  one 
case  and  the  addition  of  a  gastroenterostomy,  the 
satisfactory  results  comprise  only  sixty  per  cent. 
It  may  in  justice  be  said,  however,  that  many  of 
these  cases  presented  the  worst  types  of  chronic 
ulcer  in  unpromising  specimens  of  humanity.  I  be- 
lieve that  it  has  its  place  in  gastric  surgery.  Five 
out  of  the  eight  ulcers  were  situated  posteriorly  and 
adherent  to  and  sometimes  penetrating  the  pancreas. 
Excision  and  cautery  are  not  suitable  in  these  cases 
and  a  complete  resection  involves  the  removal  of  a 
large  segment  of  the  stomach.  In  such  cases,  ad- 
herent posteriorly,  I  believe  that  mesogastric  resec- 
tion is  indicated. 

Four  patients  were  operated  upon  by  the  Billroth 
II  method  and  both  of  the  cases  with  return  records 
gave  good  results,  one  satisfactory  and  one  excel- 
lent, the  latter  done  by  the  retrocolic  anterior  gas- 
troenterostomy method.  It  is  a  striking  fact  that  in 
four  cases  of  gastric  ulcer  in  which  this  method  was 
employed,  on  account  of  adhesions  posteriorly,  the 
end  result  has  been  excellent  in  all  in  which  it  is 
known.  But  the  number  of  cases  is  too  small  to 
justify  definite  conclusions.  The  Polya-Reichel 
method  was  used  in  nine  cases,  of  which  eight  re- 
ported, with  five  excellent  and  three  satisfactory  re- 
sults, or  100  per  cent,  of  good  results.  This  opera- 
tion has  given  much  satisfaction.  It  saves  time,  as 
compared  with  the  Billroth  II  method,  and,  accord- 
ing to  the  voluntary  testimony  of  the  house  staff  the 
postoperative  convalescence  is  smoother  and  more 
satisfactory.  The  Polya-Balfour  method  was  em- 
ployed with  satisfactory  results  on  one  patient  who 
had  previously  been  operated  upon  elsewhere,  and  in 
whom  the  Polya-Reichel  technic  could  not  be  used  on 
account   of   adhesions   posteriorly.    Carcinoma  is 


88 


DIAMOND:  PEPTIC  ULCER. 


[New  York 
Medical  Journal. 


known  to  have  developed  in  one  of  the  eighteen 
cases  of  gastric  ulcer,  not  resected,  after  five  and  a 
half  years  of  entire  absence  of  gastric  symptoms. 
The  operator  could  not  tell  whether  it  originated  in 
the  stomach  or  pancreas.  It  caused  persistent  jaun- 
dice. In  another  case  of  mesogastric  resection  the 
X  ray  gave  a  suspicion  of  malignancy.  It  is  notice- 
able that  the  results  in  private  practice  are  appreci- 
ably better  as  there  have  been  no  unsatisfactory  re- 
sults in  my  private  cases.  In  the  majority  (71.5 
per  cent.)  of  these  109  cases  the  ulcer  has  not  been 
removed  or  cured  by  the  operation.  The  latter 
merely  puts  the  stomach  in  such  a  condition, 
mechanically  and  chemically,  that  the  healing  of  the 
ulcer  is  favored.  In  addition  then  these  patients 
should  have  a  dietetic  cure  and  the  postoperative 
period  offers  ideal  conditions  for  this  regimen.  A 
few  patients,  after  obtaining  complete  relief,  have 
so  abused  their  stomach  by  alcoholic  and  dietetic  ex- 
cesses as  to  bring  on  recurrence  of  ulcer  or  of  gas- 
tric symptoms. 

Again,  if  bacteria  from  the  gums  and  teeth  sockets 
are  an  etiological  factor  in  producing  ulcer,  we  can 
not  expect,  much  less  obtain,  continuous  satisfac- 
tory- oral  conditions  in  the  majority  of  hospital  pa- 
tients. In  the  matter  of  diet  or  oral  sepsis  condi- 
tions may  continue  or  recur  which  caused  the  for- 
mation of  the  original  ulcer  and  which  favor  the 
development  of  a  new  one.  This  applies  particular- 
ly to  hospital  patients,  and  in  this  class  it  is  im- 
portant, by  education,  the  follow  up  system,  social 
service,  and  similar  means,  to  secure  such  condi- 
tions that  the  good  results  may  be  permanent.  In 
a  given  case  of  gastric  or  duodenal  ulcer  we  cannot 
guarantee  a  good  result  from  operation,  but  we  can 
assure  such  patients  that  in  a  very  large  proportion 
of  cases,  eighty-five  to  over  ninety  per  cent., 
suitable  operation  offers  good  results,  both 
immediate  and  lasting.  This  holds  where  medical 
cures  have  been  tried  and  failed.  In  fact,  in  many 
of  these  cases,  relapses  have  occurred  after  one  or 
several  such  cures,  and  ulcer  patients  should  be 
urged  to  first  take  such  cures  if  they  can  give  the 
time  for  thorough  treatment  by  rest  and  diet.  The 
relapses  after  such  treatment  will  leave  many  pa- 
tients who  should  be  urged  to  try  operative  treat- 
ment. 

117  East  Thirty-sixth  Street. 

PEPTIC  ULCER. 
Clinically  and  Rdntgenologically  Considered. 
By  Joseph  S.  Diamond,  M.  D., 
New  York, 

Associate  Rontgenologist,  Beth  Israel  Hospital. 

{Continued  from  page  63.) 

VOMITING  IN  ULCER. 

Vomiting  is  not  a  common  factor  in  the  ordinary 
uncomplicated  peptic  ulcer.  It  occurs  rarely  in  the 
duodenal  ulcer  and  is  more  common  in  the  gastric 
ulcers.  When  stenosis  takes  place,  due  to  cicatricial 
pyloric  ulcers,  then  vomiting  may  become  a  daily 
occurrence  and  will  depend  upon  the  degree  of  ste- 
nosis. The  vomitus  in  the  severe  grades  of  stenosis 
is  large  and  has  the  classical  appearance  of  a  gas- 


trectasia  vomitus  presenting  several  layers  of  food 
secretion  and  containing  food  ingested  a  day  or  so 
before  the  vomiting. 

Such  vomitus  is  pathognomonic  of  stenosis  and 
when  associated  with  symptoms  of  ulcer,  a  diag- 
nosis of  callous  ulcer  of  the  pylorus  can  promptly 
be  made.  In  minor  grades  of  obstruction  vomiting 
takes  place  at  longer  intervals.  In  the  gastric  ulcers 
situated  about  the  lesser  curvature  forming  the  so- 
called  Haudeck  niche,  vomiting  occasionally  takes 
place  at  the  height  of  digestion  and  is  due  to  the 
irritation  set  up  by  the  hyperacid  contents  as  well 
as  by  coarse  food  particles  being  rubbed  against  the 
ulcer  base.  The  gastrospasm  is  so  intense  that 
vomiting  takes  place  in  the  attempt  on  the  part  of 
the  stomach  to  rid  itself  of  the  irritating  agents. 
In  this  type  of  ulcer  vomiting  takes  place  without 
any  obstruction  being  present,  the  ulcer  usually  be- 
ing several  inches  away  from  the  pylorus.  In  one 
case  of  chronic  perforating  ulcer  situated  high  up 
near  the  cardia  on  the  posterior  wall,  the  gastro- 
spasm was  so  intense  that  vomiting  took  place  im- 
mediately after  the  introduction  of  food  into  the 
stomach  before  it  had  a  chance  to  reach  the  caudal 
portion.  In  simple  duodenal  ulcer  vomiting  is  the 
exception  and  will  only  occur  during  an  attack  of 
marked  pylorospasm  with  retention  of  hyperacid 
secretion.  Here  the  pain  and  burning  is  so  intense 
that  reverse  peristalsis  sets  in  and  the  irritating 
contents  are  brought  up.  When  vomiting  does  not 
take  place  spontaneously  these  patients  often  induce 
vomiting  by  introducing  the  fingers  in  back  of  the 
pharynx.  There  are  of  course  cases  when  a  tem- 
porary obstruction  is  brought  about  by  pylorospasm. 
In  vomiting  without  pyrosis  or  without  any  definite 
relation  to  meals  and  other  factors  other  conditions 
must  be  looked  for  to  account  for  its  cause. 

HEMORRHAGE. 

Gastric  hemorrhage  due  to  ulcer  is  computed  to 
take  place  in  about  thirty-five  per  cent,  of  the  cases. 
It  may  occur  at  any  time  during  the  course  of  the 
disease.  It  may  often  be  the  first  symptom  in  a 
case  of  ulcer  with  an  ill  defined  ulcer  history  elicited 
from  the  patient  only  after  the  hemorrhage  has  oc- 
curred. The  hemorrhage  is  usually  severe  in  the 
deeply  eroded  ulcers  when  larger  arteries  are  in- 
volved. Often  a  blood  transfusion  may  be  neces- 
sary to  save  life.  In  duodenal  hemorrhage  there 
may  be  no  vomiting  of  blood.  Syncope  may  be  the 
first  symptom,  followed  by  abdominal  pains,  pallor, 
rapid  pulse  and  all  the  characteristic  phenomena  of 
acute  bleeding.  Later,  melena  develops.  There  may 
appear  at  first  a  bright  red  movement  when  there 
is  a  rapid  peristalsis  and  evacuation  takes  place  im- 
mediately. This  will  invariably  be  followed  by  tarry 
stools.  If  the  blood  continues  to  be  bright  red  then 
the  bleeding  is  from  the  lower  bowel.  When  hem- 
orrhage takes  place  in  gastric  ulcer,  vomiting  occurs 
which  is  bright  red  and  is  large  in  quantity.  In  the 
duodenal  ulcer  when  regurgitation  of  blood  occurs 
in  the  stomach,  the  vomitus  may  be  dark  red  or 
coffee  ground  due  to  retention  and  admixture  with 
hydrochloric  acid. 

CHEMISTRY. 

In  the  consideration  of  the  chemistry  of  the 
stomach  as  a  diagnostic  factor  in  ulcer,  one  must 


July  17,  1920.] 


DIAMOND:  PEPTIC  ULCER. 


89 


relegate  this  method  considerably  behind  all  others. 
Taken  alone  it  has  no  value,  for  who  would  dare 
to  commit  himself  definitely  as  to  the  diagnosis  of 
an  ulcer  upon  the  chemistry  alone?  It  surely  can 
be  done  in  fifty-five  per  cent,  of  the  cases  by  the 
anamnesis  and  in  as  many  cases  by  the  study  of 
the  rontgen  plates.  Even  a  study  of  the  gastric 
contents  in  all  its  phases  by  the  Rehfuss  method  of 
fractional  titration  at  fifteen  minute  intervals  con- 
tinued for  two  hours  will  not  per  se  settle  the  diag- 
nosis. The  continued  late  hyperacidity  is  present 
in  all  duodenal  irritations  whether  due  to  gallbladder 
disease,  or  appendicitis,  or  even  epigastric  hernia 
when  adhering  and  pinching  the  omental  tissue. 
Even  carcinoma  is  not  immune  from  late  hyperacid- 
ity. With  all  that,  however,  it  has  its  place  and 
is  of  definite  value  as  an  adjuvant.  Aside  from 
the  chemical  reaction  there  is  other  valuable  infor- 
mation to  be  obtained  from  an  examination  of  the 
gastric  contents,  such  as  quantity,  consistency — or 
the  degree  of  chymification,  color,  the  presence  of 
mucus,  blood,  and  if  on  a  fasting  stomach,  the 
presence  of  food  particles  whether  macroscopical  or 
microscopical.  Again  the  finding  of  a  hypoacidity 
or  an  anacidity  such  as  in  achylia  gastrica,  will  at 
once  help  us  to  rule  out  an  ulcer.  It  may  be  safely 
stated  that  this  negative  anacid  phase  is  of  greater 
value  than  the  positive  hyperacid  phase;  for  while 
the  latter  can  only  be  a  hint  of  the  possibility  of 
ulcer,  the  former  will  exclude  it  and  indicate  the 
presence  of  another  disease.  Truly  it  may  be  stated 
that  ulcer  may  sometimes  occur  in  the  presence  of 
achylia.  These  cases  are  extremely  rare  and  can 
always  be  differentiated  by  the  Gluczinsky  test,  con- 
sisting in  the  administration  of  a  meat  meal  and  re- 
moving the  contents  at  the  height  of  digestion  when 
some  free  acid  will  invariably  be  found  when  ulcer 
is  present. 

The  interest  centered  about  gastric  analysis  is 
still  of  greater  physiological  than  diagnostic  im- 
portance. To  quote  from  Rehfuss :  "In  a  resume 
of  842  complete  curves  on  various  food  stuffs  with 
more  than  twenty  thousand  titrations  we  found  that 
forty-five  per  cent,  exceeded  one  hundred  total  acid- 
ity and  after -a  study  embracing  three  years'  work  we 
are  prepared  to  state  that  no  acid  figures  occurred  in 
disease  which  could  not  be  duplicated  in  health.  In 
other  words  we  found  that  forty-five  per  cent,  of  all 
responses  in  health  showed  socalled  hyperacidity, 
while  forty-two  per  cent,  of  my  ulcer  series  showed 
the  same  thing.  In  other  words  there  is  no  greater 
incidence  of  high  acid  figures  in  ulcer  or  in  any 
other  gastric  diseases  than  in  health,  a  fact  that 
raises  the  extremely  important  question  as  to 
whether  an  actual  demonstrable  hyperacidity  ever 
does  occur." 

Physiologically,  however,  gastric  analysis  imparts 
to  ITS  the  knowledge  of  events  of  gastric  digestion 
as  follows :  1,  The  response  of  the  organ  to  the  direct 
stimulus  of  food  as  well  as  the  psychic;  2,  the 
change  from  the  fasting  secretion  to  a  secretion  of 
higher  acidity ;  3,  the  control  mechanism  of  the  acid 
content  by  the  duodenal  regurgitation.  This  latter 
is  evidenced  by  the  finding  of  trypsin  and  bile  at 
certain  phases  of  the  digestive  cycle.  To  compare 
the    merits    of    the    Rehfuss    fractional  method 


of  examination  with  the  older  Ewald  method  is  not 
within  the  province  of  this  paper.  Suffice  it  to 
state  that  both  possess  meritorious  advantages.  The 
Rehfuss  method  informs  us  of  every  phase  of  diges- 
tion at  fifteen  minute  intervals  from  the  time  of 
ingestion  of  the  meal  up  to  the  end  of  digestion, 
comprising  about  two  hours. 

Rehfuss  has  constructed  a  curve  of  the  normal 
secretion  where  the  maximum  rise  of  acidity  is 
reached  at  the  end  of  an  hour  and  then  gradually 
declines  to  zero  at  the  end  of  digestion.  He  fur- 
ther attempted  to  classify  the  pathological  depar- 
tures from  this  normal  curve  and  impart  to  them 
diagnostic  significance.  For  instance,  a  sharp  rise 
within  the  hour  would  indicate  a  gastric  ulcer.  A 
rise  which  continues  high  and  is  sustained  to  the 
end  of  the  second  hour,  he  designated  as  duodenal 
ulcer.  Neither  of  these  is  pathognomonic  and  may 
be  found  in  all  cases  of  increased  irritability  of  the 
autonomic  nervous  system,  the  lesion  residing  in 
any  one  of  the  abdominal  organs.  The  fractional 
method  also  indicates,  with  a  fair  degree  of  accur- 
acy, the  time  of  tryptic  regurgitation  and  if  occult 
blood  is  found  simultaneously  with  tryptic  regurgi- 
tation it  may  point  to  a  duodenal  ulcer.  The  signifi- 
cance of  occult  blood  with  the  old  method  of  ex- 
traction is  perhaps  valueless  as  the  larger  tube  may 
produce  sufficient  capillary  traumatism  to  give  a 
Benzidin  reaction.  The  advantages  from  the  Ewald 
method  of  examination  are  first,  that  a  better  knowl- 
edge can  be  obtained  as  to  the  rate  of  emptying  of 
the  stomach,  and  second,  by  withdrawing  larger 
quantities,  its  physical  characteristics  as  well  as  the 
amount  of  mucus  can  be  better  studied.  By  at- 
tempting half  hourly  extractions  with  an  Ewald 
tube  we  can  approach  the  Rehfuss  method. 

Occult  blood  in  the  feces. — The  presence  of  oc- 
cult blood  in  the  feces  when  the  examination  is  car- 
ried out  under  proper  precautions  is  significant. 
There  are  too  many  factors  of  safety  which  mini- 
mize the  value  of  the  test.  The  patient  must  be 
on  a  meat  free  diet  for  three  days.  Precaution  as 
to  bleeding  gums,  hemorrhoids,  or  any  other  ano- 
rectal bleeding  is  to  be  observed.  Such  extreme 
care  can  only  be  followed  in  an  institution.  Finally 
the  presence  of  occult  blood  in  carcinoma  is  a  con- 
stant factor. 

PHYSICAL  EXAMINATION. 

Physical  examination  offers  only  the  most  mea- 
gre information  in  the  diagnosis  of  peptic  ulcer. 
The  socalled  tender  point  upon  which  the  older  text- 
books lay  so  much  stress  cannot  be  relied  upon  to 
corroborate  the  diagnosis.  It  is  not  always  present 
and  if  too  much  importance  be  attached  to  it  one 
would  miss  the  diagnosis  in  the  majority  of  cases 
of  peptic  ulcer.  It  manifests  itself  only  when  the 
ulcer  is  in  an  active  stage,  during  an  exacerbation 
of  symptoms.  When  the  ulcer  is  large  and  deep 
enough;  when  in  the  course  of  ulceration  it  has 
reached  or  closely  approximated  the  visceral  peri- 
toneum; when  it  is  in  an  active  inflammatory  con- 
dition and  an  exudate  is  being  thrown  out;  when 
there  is  an  associated  perigastritis  or  periduodenitis 
present,  only  under  such  conditions  is  the  tender 
point  manifest. 


90 


DIAMOND:  PEPTIC  ULCER. 


[New  York 
Medical  Journal. 


ROXTGENOLOGICAL  EXAMINATION. 

Next  in  importance  to  the  anamnesis  in  the  diag- 
nosis of  peptic  ulcer  is  the  rontgenological  exami- 
nation ;  in  fact,  so  closely  associated  has  it  become 
with  the  routine  gastroenterological  examination, 
and  so  dependable,  that  scarcely  a  clinician  today 
will  commit  himself  to  a  definite  diagnosis  until  it 
has  been  substantiated  by  the  rontgenological  find- 
ings. 

History. — Rapid  strides  have  been  made  in  the 
progress  of  the  rontgenological  interpretation  of 
gastrointestinal  lesions.  The  development  of  the 
rontgen  ray  in  the  diagnosis  of  gastrointestinal  dis- 
eases dates  back  to  1906  when  Hemmeter  first  at- 
tempted to  demonstrate  the  site  of  an  ulcer  by  the 
adherence  of  a  fleck  of  bismuth.  He  was  then 
called  a  visionary.  With  the  advent  of  the  Rieder 
meal,  however,  Riecher  succeeded  in  1909  in  visual- 
izing the  cavity  of  an  ulcer  and  Hemmeter's  dream 
•  ckme  true.  Shortly  after,  in  1910,  Haudeck  de- 
scribed in  detail  the  penetrating  and  perforating  gas- 
tric ulcer  and  called  it  nischen  symptom,  to  which 
his  name  has  since  been  attached,  and  it  is  now 
known  as  the  Haudeck  niche.  Simultaneously 
Schlesinger  was  enabled  to  set  down  definite  classi- 
fications of  the  various  types  of  stomachs  according 
to  their  morphology  as  seen  by  the  aid  of  the  con- 
trast meal,  and  Holzknecht,  in  studying  functional 
manifestations  in  health  and  disease  was  able  to 
formulate  the  hypothesis  of  group  symptom  com- 
plex in  the  various  forms  of  ulcer  which  has  since 
been  called  the  Holzknecht  symptom  complex.  A 
host  of  observers  abroad,  Kaestle,  Rosenthal,  Groe- 
del  and  others  added  gradually  to  the  morphology, 
biology  and  motility  of  the  stomach  under  normal 
and  abnormal  conditions.  Simultaneously  in  this 
country  Pfahler,  Carman,  Case,  Hirsch  and  others 
continued  independently  along  similar  lines  of  sign 
complexes.  In  1911,  Lewis  Gregory  Cole,  in  this 
country,  by  the  aid  of  serial  rontgen  examinations 
introduced  the  epoch  making  studies  of  deformities 
of  the  duodenal  cap  which  has  since  been  estab- 
lished as  an  absolute  sign  of  duodenal  ulcer. 

With  the  visualization  of  the  Haudeck  niche,  and 
especially  so  with  Cole's  demonstrations  of  duodenal 
defects,  dates  the  birth  of  the  direct  method  of  inter- 
pretations of  peptic  ulcer.  The  advent  of  this  dem- 
onstration threw  a  new  light  on  the  method  of  ront- 
genological examinations  and  placed  its  accuracy  on 
firmer  foundations.  It  tended  to  revolutionize  the 
older  method  of  indirect  examination  by  the  direct 
method  of  studying  organic  structural  changes.  The 
trend  in  this  country  of  late  has  -been  to  rely  chiefly 
on  the  latter  method,  so  much  so  that  many  ront- 
genologists and  gastroenterologists  have  totally  dis- 
carded the  symptom  complex.  The  fallacy  of  dis- 
regarding the  expression  of  a  disturbed  physiologi- 
cal function  of  an  organ  under  abnormal  influences 
will  be  pointed  out  later  on.  The  unbiased  observer 
cannot  fail  to  regard  the  direct  method  as  of  primary 
importance  and  the  indirect  method  as  of  secondary 
or  contributory  value.  Unfortunately,  however,  the 
direct  method  is  not  adaptable  to  all  types  of  cases. 
Certain  localizations  of  the  ulcer  cannot  be  directly 
visualized.   Ulcers  in  the  posterior  wall  of  the  vesti- 


Ijule  and  pars  pylorica  cannot  be  seen.  A  fair  pro- 
portion of  ulcers,  if  too  small  or  if  situated  on  the 
posterior  wall,  are  also  missed  if  followed  only  by 
the  direct  method.  In  the  latter  type  of  cases  the 
secondary  or  indirect  method  is  employed  to  very 
good  advantage,  and  the  percentage  of  diagnoses  is 
largely  increased. 

Before  entering  into  a  detailed  description  of  the 
various  methods  of  examinations,  it  is  important 
to  possess  a  full  knowledge  of  the  normal  rontgen 
ray  anatomy  of  the  stomach,  as  well  as  its  normal 
physiological  functions  as  observed  with  the  ront- 
gen rays.  The  following  factors  have  to  be  con- 
sidered: 1,  Type  of  the  stomach  (size,  shape,  posi- 
tion, axis)  ;  2,  tonus  (the  response  or  the  behavior 
of  the  gastric  musculature  to  the  introduction  of 
food);  3,  outline;  4,  mobility  and  flexibility;  5, 
peristalsis ;  6,  gastric  secretion ;  7,  motility. 

Type  of  stomach. — The  type  of  stomach  varies 
with  the  habitus  of  the  individual,  i.  e.,  with  the 
bony  framework,  the  muscular  development,  and 
the  degree  of  intraabdominal  pressure,  which  regu- 
lates the  tone,  shape,  size,  and  position  of  the 
stomach.  There  are  several  types  of  stomachs. 
Adopting  the  Schlesinger  classification  according  to 
tone  they  are  as  follows :  a,  hypertonic ;  b,  ortho- 
tonic  ;  c,  hypotonic,  and  d,  atonic.  While  dissimilar 
in  their  rontgen  appearance,  varying  in  length, 
breadth,  capacity,  position,  axis  and  tone,  all  are 
considered  normal,  each  corresponding  to  the  dif- 
ferent status  of  the  individtial. 

a.  The  hypertonic  type,  called  by  Holzknecht 
the  steerhorn  stomach  from  its  configuration,  fits 
the  individual  of  the  status  apoplecticus,  i.  e.,  the 
individual  with  robust  frame,  short  and  wide  thorax, 
and  wide  epigastric  angle.  The  position  of  the 
stomach,  lik^  all  abdominal  organs,  in  this  habittis 
is  high,  assuming  an  extreme  oblique  to  a  trans- 
verse axis.  Relatively  small  in  size  it  is  broadest 
at  the  fundus  and  tapers  down  at  the  pylorus  which 
is  the  most  dependent  portion.  Forsel  explains  the 
hypertonic  type  somewhat  as  follows :  The  influence 
exerted  by  the  strong  abdominal  muscles  and  the 
surrounding  abdominal  organs  causes  an  increased 
intraabdominal  pressure  which  accentuates  the  tone 
of  the  musculature  of  the  most  active  part  of  the 
stomach,  the  socalled  sinus  (Forsel)  or  vestibule 
(Cannon)  or  antrum  pylori.  The  stimulus  thus 
exerted  from  without,  as  well  as  the  high  diaphrag- 
matic and  liver  attachments,  causes  the  lower 
portion  of  the  stomach  to  straighten  out  assuming 
a  transverse  position.  The  pylorus  reaches  con- 
siderably to  the  right  of  the  median  line  and  the 
greater  curvature  is  displaced  upward  about  four 
to  six  inches  above  the  umbilicus.  This  type  of 
stomach  is  generally  found  in  males  and  is  less  com- 
monly met  with  than  the  other  types.  When  the 
intraabdominal  pressure  is  increased  from  Other 
sources,  such  as  pregnancy,  obesity,  and  ascites,  the 
steerhorn  type  is  also  encountered. 

b.  The  orthotonic  or  fishhook  type  of  stomach 
is  the  most  common  form  of  stomach.  It  occurs 
in  the  medium  slender  individual.  It  is  the  so- 
called  syphon  form  of  Rieder  and  resembles  the 
letter  J.  It  descends  vertically  downward  from 
the  diaphragm  to  the  level  just  below  the  umbilicus. 


July  17,  1920.]  KOHN:   OCULAR  DISORDER    WITH  GASTRIC  SYMPTOMS. 


91 


The  pylorus  then  rises  upward  for  several  inches 
forming  a  pronounced  incisura  angularis.  The  py- 
lorus usually  overlies  the  middle  or  the  right  border 
of  the  spinal  column.  It  has  the  capacity  of  main- 
taining its  contents  in  a  tubular  form.  The  diameter 
of  its  lumen  is  equal  throughout.  The  stimulus  ex- 
erted here  from  a  uniform  intraabdominal  pres- 
sure causes  an  even  contraction  of  the  entire  gastric 
musculature,  assuming  the  vertical  or  fishhook  type. 

c.  The  hypotonic  stomach  occurs  in  the  individual 
of  the  status  asthenicus  (habitus  enteroptoticus 
of  Stiller)  with  weak  abdominal  muscles,  flat  abdo- 
men, poor  panniculus,  long  narrow  chest  with  low 
diaphragm,  and  correspondingly  low  position  of  all 
the  abdominal  viscera.  The  stomach  exhibits  a  re- 
laxation of  its  longitudinal  muscular  fibres  and  is 
therefore  increased  in  length  and  is  more  capacious. 
It  lies  entirely  to  the  left  of  the  median  line  and  its 
most  dependent  portion  sags  down  into  the  pelvis. 
The  upper  part  is  narrowed  by  an  approximation  of 
its  walls.  The  deficient  intraabdominal  pressure 
robs  the  stomach  and  all  the  abdominal  viscera  of 
support,  resulting  in  the  stretching  of  the  liagment- 
ous  attachments  as  well  as  the  musculature  of 
the  hollow  viscera. 

d.  The  atonic  type  shows  the  muscular  relaxation 
to  an  extreme  degree  and  manifests  an  exaggera- 
tion of  all  the  weaknesses  of  the  hypotonic  stom- 
ach. It  forms  a  borderline  between  the  normal 
and  the  pathological  stomach.  It  is  met  with  in 
the  literature  under  various  names ;  the  hubhohe 
of  Haudeck  or  the  water  trap  stomach  of  Sat- 
terlee  and  Le  Wald.  Variations  and  transition 
forms  between  the  various  types  are  common.  Mod- 
ifications between  the  orthotonic  and  hypertonic  or 
orthotonic  and  subtonic  types  are  very  often  met. 

Tonus. — Tonus  characterizes  the  muscular 
tonicity  of  the  organ  and  is  evidenced  by  the  mode 
of  filling  when  food  is  introduced.  It  signifies  the 
behavior  of  the  gastric  musculature  when  a  morsel 
of  food  enters  the  cardia  or  represents  the  con- 
tractility of  the  muscular  walls  to  direct  stimulus 
of  food  introduced  into  the  stomach.  The  stomach 
in  the  empty  state  lies  collapsed  into  a  narrow  sau- 
sageshaped  tub'e,  the  walls,  barely  approximating 
each  other.  In  its  uppermost  portion  under  the  left 
diaghragm,  overlies  the  gas  bubble  or  magen  blase 
whose  size  and  shape  vary  according  to  tone  and 
to  the  presence  of  a  fasting  secretion.  In  the 
hypertonic  and  orthotonic  stomach  it  is  usually 
small.  It  increases  in  size  in  the  hypotonic  and 
is  largest  in  the  other  type.  In  the  collapsed  organ 
it  assumes  a  pearshaped  form  with  the  apex  below. 
The  magen  blase  in  cases  of  the  latter  type  may 
be  so  large  as  to  cause  an  eventration  of  the  left 
diaphragm  exerting  considerable  pressure  upon  the 
heart.  When  secretions  are  present  the  magen  blase 
is  supported  by  the  fluid  level  and  appears  with  a 
broad,  flattened,  horizontal  base.  When  food  is 
taken  the  first  portion  of  it  comes  down  through 
the  cardiac  sphincter  and  stops  just  below  the 
magen  blase  for  several  seconds.  The  duration  va- 
ries according  to  the  state  of  muscular  contrac- 
tility or  peristole  of  the  stomach.  It  is  largest 
in  the  hypertonic  and  orthotonic  types  of  stomachs. 
It  then  slowly  slides  down  tapering  below  to  the 


apex  of  a  triangle.  Shortly  after  it  is  seen  to 
come  down  along  the  lesser  curvature  in  a  narrow 
cylindrical  form  until  it  reaches  the  caudal  portion. 
As  food  continues  to  enter,  it  keeps  to  the  lesser 
curvature  and  fills  excentrically,  i.  e.,  from  the 
lesser  curvature  outward,  the  gtreater  curvature 
being  pushed  downward  and  outward,  the  stomach 
distending  chiefly  in  width.  The  lesser  curvature 
in  virtue  of  its  anatomical  muscular  arrangement 
forms  a  groove  called  the  groove  of  Retzius  or  the 
road  of  the  stomach  (magenstrasse) .  In  the  hypo- 
tonic stomach  the  temporary  delay  is  lessened  and 
is  totally  absent  in  the  atonic  type.  The  meal  is 
seen  to  drop  rapidly  into  the  caudal  portion  filling 
the  stomach  from  below  up,  only  the  lower  half 
remaining  filled,  the  walls  in  the  tubular  portion 
collapsed  and  approximating  each  other,  differing 
strikingly  from  the  orthotonic  form  wherein  the 
muscular  walls  possess  the  power  of  sustaining  its 
contents  uniformly  in  a  tubular  or  cylindrical  form. 

Outline. — The  outline  of  the  stomach  when  filled 
is  smooth  and  regular,  broken  only  by  the  incisura 
cardiaca  just  at  the  junction  of  the  esophagus  with 
the  stomach  and  low  down  by  the  incisura  angularis 
at  the  junction  of  the  pars  media  and  pars  pylorica. 
One  even  sees  frequently  a  broad  indentation  at 
the  greater  curvature  under  the  left  costal  arch  due 
to  pressure. 

(To  be  continued) 

GASTROINTESTINAL  DISTURBANCES  IN 
AFFECTIONS    OF    THE  OCULAR 
MECHANISM. 

By  L.  WiNFIELD  KoHN,  M.  D., 
New  York, 

Formerly  Chief  of  the  Gastrointestinal  Department,  Temple 
University,  Philadelphia. 

The  more  thoroughly  we  become  acquainted  with 
gastrointestinal  manifestations,  the  more  convinced 
do  we  become  of  the  fact  that  their  creation  often 
has  its  generic  stimulus  in  dysfunction  of  other  ap- 
parently remote  organs.  This  stimulus  through 
the  medium  of  the  nervous  system  affects  the  ali- 
mentary apparatus  in  such  a  manner  as  to  give  rise 
to  the  many  symptoms  commonly  ascribed  to  the 
stomach  and  bowels. 

For  years  I  have  from  time  to  time  suspected  in 
many  stomach  sufferers  the  existence  of  visual  dis- 
turbances by  inference,  after  having  noted  care- 
fully the  facial  expression  or  facial  carriage.  Upon 
investigation  I  elicited  that  the  ocular  apparatus  was 
more  or  less  unsuccessful  in  its  eff'orts  properly  to 
adapt  itself  to  an  adequate  appreciation  of  the  en- 
vironment. This  visual  disturbance  was  found  in 
many  instances  in  individuals  who  had  no  suspicion 
of  its  presence.  Upon  questioning  them  regarding 
their  vision  they  invariably  remarked  that  their  eye- 
sight was  faultless  or  that  they  never  experienced 
any  ocular  difficulty.  In  just  such  cases  does  this 
unconscious  ocular  disturbance  emphasize  its  im- 
portance and  frequency  as  a  cause  of  visceral  dis- 
order. The  intermediary  part  that  the  nervous  sys- 
tem plays  in  this  condition  is,  of  course,  most  im- 
portant and  essential  in  the  creation  of  the  symptoms 
under  consideration. 


92 


KOHN:  OCULAR  DISORDER    iriTH  GASTRIC  SYMPTOMS. 


[New  York 
Medical  Journal. 


The  ocular  conditions  ordinarily  encountered  in 
the  production  of  these  disturbances  are  anomalies 
of  the  eye  muscles  and  refractive  errors.  Either  of 
these  types  of  eye  affections  are  capable  of  inducing 
profound  reflex  or  referred  visceral  manifestations. 

The  recognition  of  the  dependence  of  abnormal 
body  poise  and  abnormal  body  expression  upon  ab- 
normal adjustments  of  the  eyes  was  forcibly  brought 
out  by  Stevens  (1)  a  few  years  ago.  The  resulting 
development  of  peculiar  facial  expression,  of  de- 
cidedly improper  body  carriage  and  of  improper 
physiological  chest  action  was  stressed,  and  the  dis- 
tinct association  of  diseases  of  the  muscles  of  the 
neck  and  face,  diseases  of  the  nervous  system,  such 
as  chorea,  epilepsy  and  other  neuroses  with  ocular 
affection  had  been  established.  It  had  even  been 
taken  for  granted  that  as  a  consequence  of  these  dis- 
turbances other  secondary  diseases,  such  as  pulmon- 
ary tuberculosis,  diseases  of  the  blood  and  other 
diseases,  followed.  We  are  not  absolutely 
certain  in  stating  how  eyestrain  lowers  an  individ- 
ual's resistance  to  the  extent  of  rendering  him 
susceptible  to  dreaded  disease,  but  it  seems  not 
improper  to  suppose  that  the  nervous  system  is  the 
great  medium  wherein  the  damaging  stimulus  takes 
its  profound  hold.  It  is  in  this  manner,  I  feel  cer- 
tain, that  original  disturbances  of  the  stomach  and 
bowels  are  created  from  set  up  excitation  in  the 
eyes.  Through  the  medium  of  the  nervous  system, 
either  as  a  conveyor  of  abnormal  stimulation  or  as 
a  creator  of  remote  disease  through  its  abnormal 
responsiveness  to  stimuli,  the  function  of  the  gas- 
trointestinal tract  suffers  and  as  a  result  for  a  time 
our  patient  suffers  from  symptoms  of  neuroses  af- 
fecting the  organs  of  that  tract.  These  symptoms 
are  commonly  found  and  exist  for  long  periods  of 
time  as  purely  functional  expressions  until  as  a  re- 
sult of  their  overaction  definite  organic  disease  estab- 
lishes itself.  This,  in  my  opinion,  is  the  probable 
manner  of  creation  of  visceral  disease,  not  only 
from  the  eyes  as  a  source  of  original  irritation,  but 
also  from  irritation  in  almost  any  distant  organ. 

In  this  paper,  however,  we  are  concerned  with 
the  eyes  as  disturbers  of  gastrointestinal  poise,  and 
it  seems  that  emphasis  upon  a  condition  known  as 
ocular  declination  is  indicated.  Often  patients  hav- 
ing no  other  errors  of  vision  will  upon  dbse  inves- 
tigation show  declinations  of  the  vertical  meridians 
of  the  eyes.  This  condition  must  always  be  borne 
in  mind  and  looked  for  else  its'  presence  will  escape 
detection.  This  alone  may  often  be  the  causative 
factor  back  of  a  profound  gastrointestinal  neurosis. 
The  strain  to  which  the  eyes  are  subjected  in  this 
condition  is  of  sufficient  moment  reflexly  to  arouse 
alimentary  disruption.  Of  course,  other  eye  anoma- 
lies that  are  commonly  present  and  more  easily  rec- 
ognized, such  as  refractive  and  heterophoric  errors, 
will  also  very  often  set  up  digestive  disturbances. 
Before  continuing,  it  might  be  well  to  emphasize  the 
fact  that  any  of  these  ocular  disturbances  need  only 
be  developed  to  an  apparently  slight  extent  and  yet 
may  reflexly  create  severe  gastrointestinal  symptoms. 
These  eye  conditions  may  consist  of  either  a  refrac- 
tive error  alone  or  a  muscle  anomaly,  and  may  also 
at  times  occur  in  combination.    Following  are  the 


records  of  two  cases,  each  typifying  a  distinct  ocular 
anomaly : 

Case  I. — Young  lady,  aged  twenty,  was  referred 
to  me  by  her  brother,  who  is  a  physician.  This  pa- 
tient had  been  undergoing  observation  and  treat- 
ment at  the  hands  of  a  number  of  physicians  for 
months.  She  was  being  treated  for  gastric  disease. 
She  gave  no  evidence  of  improvement  under  their 
care.  Her  chief  complaint  was  nausea  and  vomit- 
ing. She  is  of  slightly  nervous  temperament,  ate 
rapidly  and  drank  considerable  tea  and  coffee;  had 
typhoid  fever  eight  years  ago.  Her  present  illness 
began  eight  months  ago  with  headaches.  She  had 
had  these  terrific  headaches  off  and  on  for  eight 
months,  for  which  she  had  been  treated  by  a  num- 
ber of  physicians.  During  the  seven  weeks  prior 
to  my  seeing  her  she  had  suffered  from  attacks  of 
vertigo,  nausea  and  vomiting,  which  occurred  as  a 
rule  while  eating  the  first  morsel  of  food  or  immedi- 
ately after  finishing  her  meal.  She  never  vomited 
during  a  total  abstinence  from  food.  The  vomiting 
attacks  would  often  continue  as  long  as  four  hours 
at  a  time.  These  vomiting  attacks  would  most  often 
be  followed  a  few  hours  later  by  a  profuse  diar- 
rhea. These  gastrointestinal  attacks  would  occur 
every  few  days  and  would  leave  the  patient  in  a 
highly  irritable,  discouraged  mood,  as  a  result  of 
which  she  would  have  crying  spells.  She  also  gave 
a  history  of  irregular  menstrual  function.  She  had 
lost  fourteen  pounds  during  the  past  three  months, 
and  she  presented  an  emaciated  appearance.  Physi- 
cal examination  was  practically  negative,  except  for 
a  palpable  right  kidney  and  slight  refractive  error. 
The  eyes  showed  O.  D.  -f-  .50  —  O.  S.  +  .50. 
Upon  inquiry  regarding  her  vision,  she  contended 
that  her  vision  was  fine  and  always  had  been  good. 
Testing  her  eyes  with  a  Snellen  chart  convinced 
me  that  my  suspicion  of  ocular  error  was  correct. 
She  was  fitted  with  proper  glasses  and  as  a  result 
all  symptoms  disappeared  immediately.  She  has  been 
free  from  all  symptoms  for  over  seven  months. 

Case  II. — Young  lady,  aged  twenty-seven.  Her 
chief  complaint  was  nervousness  and  epigastric  sore- 
ness. Except  for  frequent  attacks  of  tonsillitis,  no 
further  history  of  important  past  illness.  She  was 
also  treated  by  a  number  of  physicians  before  I  saw 
her  for  this  condition.  The  last  diagnosis  made 
was  that  of  gallstones.  Her  present  illness  began 
about  a  year  ago  with  a  feeling  of  general  nervous- 
ness, a  sensation  of  heaviness  in  the  epigastrium 
after  meals,  and  attacks  of  cold  hands  and  feet. 
She  was  nervous  most  of  the  time.  Experienced 
a  shaking  sensation  in  the  epigastrium  frequently^ 
with  no  relationship  to  her  meals.  She  often  had  a 
feeling  of  profound  faintness  in  the  epigastrium,, 
at  times  excessive  sweating  and  cardiac  palpitation. 
The  appetite  was  poor,  breath  offensive,  excessive 
gaseous  eructations,  and  the  abdomen  was  distended 
most  of  the  time  after  a  milk  diet.  Lately  had  had 
many  diarrheic  movements  and  attacks  of  frequent 
urination.  There  was  a  slight  loss  of  weight.  The 
foregoing  symptoms  plainly  indicated  disturbance  of 
the  vegetative  nervous  system  (vagal  portion). 
Physical  examination  was  practicall}'  negative.  There 
certainly  was  nothing  about  her  physical  condition 


July  17.  1920.] 


KUXSTLER:  THE  RIGHT  UPPER  QUADRANT. 


93 


to  suggest  a  diagnosis  of  gallstone  disease.  Her  eyes 
evinced  the  existence  of  a  slight  refractive  error  and 
a  declination  of  the  eyes.  The  eyes  showed,  as  in 
the  first  case,  O.  D.  +  .50  and  O.  S.  +  .50  and 
a  declination  of  the  retinal  meridians  to  the  right, 
of  only  slight  degree,  however,  and  affecting  only 
the  vertical  meridians  of  the  eyes.  The  simple  cor- 
rection of  these  ocular  difficulties  has  ameliorated 
the  condition  of  this  patient  to  such  a  vast  extent 
as  to  make  me  feel  that  the  original  cause  of  the 
vagal  neurosis  was  in  the  eyes.  Just  as  in  the 
former  case,  this  patient  had  no  knowledge  what- 
ever of  the  existence  of  these  anomalies  in  her  eyes 
and  thought  it  very  strange  that  I  should  lay  so 
much  stress  upon  her  organs  of  vision.  The  im- 
provement, however,  speaks  for  itself. 

It  is  very  evident  from  the  foregoing  that  sub- 
jective gastrointestinal  complaints  often  result  from 
eye  disturbances,  and  it  would  seem  to  me  that 
almost  any  eye  disturbance  is  capable  of  produc- 
ing enough  irritation  to  reflexly  bring  about  these 
complaints,  but  those  most  common  are  anomalies 
of  accommodation,  refractive  errors  and  disturb- 
ances of  the  eye  movements.  It  would  also  seem, 
here,  that  a  reemphasis  of  the  importance  of  look- 
ing into  the  question  of  declination  of  the  meridians 
of  the  eyes  is  indicated.  ]Many  eyes  are  constantly 
being  examined  by  specialists  who  seldom  look  into 
the  condition  of  the  meridians,  and  as  a  result  a 
very  important  factor  in  the  probable  creation  of 
reflex  disease  is  overlooked.  !Many  patients,  again, 
owing  to  the  fact  that  they  subjectively  experience 
no  trouble  with  their  eyes  often  lead  the  physician 
away  from  his  path  of  proper  diagnosis.  Instead 
of  anomalous  eyes  in  these  cases  setting  up  eye 
symptoms,  they  set  up  reflex  visceral  manifestations. 
To  this  condition,  in  which  ocular  anomalies  give 
rise  to  no  subjective  eye  symptoms,  I  have  ascribed 
the  title  unconscious  ocular  disease.  Eyestrain, 
conscious  or  unconscious,  is  a  rather  common  condi- 
tion and  by  all  means  requires  attention,  for  through 
its  removal  or  mitigation  the  general  welfare  of  the 
patient  can  be  decidedly  improved.  It  seems  that 
eyestrain  so  conditions  the  reflex  visceral  arcs  as  to 
result  in  the  establishment  of  many  untoward  body 
symptoms,  and  these  symptoms  often  show  a  pre- 
dominating relationsliip  to  the  vagus,  hence  the 
condition  is  spoken  of  as  a  vagal  neurosis.  The 
above  cited  cases  were  pure  neuroses,  yet  the  physi- 
cians in  attendance  were  prone  to  view  the  symp- 
toms from  an  organic  viewpoint.  After  an  exten- 
sive study  of  gastrointestinal  complaints  I  feel  cer- 
tain that  most  of  us  would  agree  that  the  occur- 
rence of  gastrointestinal  neuroses  far  outnumbers 
organic  diseases  of  this  tract.  For  that  reason  let 
us  eliminate  eye  difficulties  in  our  search  for  a 
cause  of  gastrointestinal  disease.  Attention  to 
this  matter  in  my  practice  has  ameliorated  the 
condition,  if  not  entirely  cured  many  of  these 
disorders.  \ 

REFERENCES. 

1.  Ste\-ens,  George  T.  :  A  Series  of  Studies  of  Nervous 
Affections  in  Relation  to  the  Adjustments  of  the  Eyes. 
New  York  Medical  Journal,  September  2,  1911. 

768  West  End  Avexue. 


DISEASES     OF     THE     RIGHT  UPPER 
QUADRANT.* 
Medical  Aspect. 
By  ^I.  B.  Kunstler,  :M.  D., 

Gastrocnterologist  to  the  New  York  Diagnostic  Clinics. 
New  York. 

We  may  consider  the  right,  upper  quadrant  from 
either  the  subjective  or  the  objective  point  of  view. 
The  latter  is  by  far  the  more  accurate,  for 
frequently  the  patient  complaining  of  trouble  in  this 
region  upon  further  examination  will  reveal  a  far 
distant  lesion;  on  the  other  hand,  one  must  also  be 
wary  of  objective  findings  since  we  may  get  many 
signs  pointing  to  right,  upper  quadrant  disease, 
when  in  reality  no  such  trouble  exists.  Right  sided 
pleurisy  or  pneumonia,  subphrenic  abscesses,  herpes 
zoster,  and  many  other  diseases  may  cause  symp- 
toms in  the  right  quadrant  resembling,  in  every 
way,  diseases  of  the  organs  in  this  region  and  may 
even  bring  the  patient  to  the  operating  table. 

The  organs  included  in  the  region  under  dis- 
cussion are  the  pylorus,  duodenum,  pancreas,  liver, 
gallbladder,  kidney,  colon  and  at  times  the  appendix. 
To  discuss  all  diseases  of  each  organ  would  mani- 
festly be  impossible,  so  I  propose,  simply,  to 
mention  the  most  common  disorders  and  then  to 
discuss,  briefly,  the  subjective  and  objective  symp- 
tomatology. 

The  pylorus. — The  most  frequent  conditions  met 
with  at  the  pylorus  are  ulcer  and  carcinoma,  the 
former  being  by  far  the  commonest.  Stenosis  of 
the  pylorus,  also  quite  common,  give^  symptoms 
in  the  epigastrium  rather  than  the  right  quadrant. 

The  duodenum. — The  only  common  disease  here 
is  uker  although  strictures,  dilatation  and  carcinoma 
arising  from  the  ampulla  of  Vater  have  been 
described. 

The  pancreas. — Here  we  get  carcinoma,  cysts  and 
calculi.  All  of  these  are  rather  rare  and  give 
symptoms  more  in  the  umbilical  and  epigastric 
regions  than  in  the  upper,  right  quadrant.  A  rather 
common  condition,  however,  is  pancreatitis,  either 
acute  or  chronic  and  most  often  associated  with 
gallbladder  disease. 

The  liver. — Such  common  conditions  as  cirrhosis, 
congestion  and  syphilis  of  the  liver  being  more 
general  than  local  disease  need  no  discussion  here, 
although  they  often  complicate  other  conditions. 
Of  the  local  diseases  we  have  tumors  and  cysts  and 
abscesses.  The  cysts  are  almost  always  due  to  the 
echinococcus  and  the  abscesses  to  the  ameba  but 
may  also  be  caused  by  colon  bacillus. 

TJie  gallbladder. — Since  gallstones  were  found  by 
Mitchell  (1)  in  three  per  cent,  of  sixteen  hundred 
postmortems  and  by  others  in  five  to  ten  per  cent, 
of  cases  we  must  realize  how  extremely  common 
gallbladder  conditions  are.  Cholecystitis  and  chole- 
lithiasis are  the  most  fiequent,  and  it  appears  that 
females  are  afifected  much  more  than  males,  and 
those  past  forty  in  the  majority  of  cases.  Gee  says : 
"In  women  past  middle  age  gallstones  are  so  com- 
mon that  one  is  not  wrong  to  be  always  suspecting 
them."     The   other   gallbladder   disease   of  any 

*Presented  before  the  New  York  Diagnostic  Society,  May  26,  1920. 


94 


KUNSTLER:   THE  RIGHT  UPPER  QUADRANT. 


[New  York 
Medical  Journal. 


importance,  to  be  considered,  is  carcinoma  and  this 
is  so  rare  as  compared  to  the  previously  mentioned 
diseases  as  to  be  almost  negligible. 

The  kidneys  and  adrenal  glands. — It  becomes  im- 
portant at  times  to  differentiate  kidney  diseases  from 
the  others.  Calculi  and  infections  of  the  kidneys 
are  perhaps  the  most  fpequent  conditions,  but 
tumors  and  hydronephrosis  must  be  kept  in  mind, 
as  well  as  perinephric  abscesses. 

Colon. — Carcinoma  is  the  only  disease  in  this 
portion  of  the  colon  that  needs  consideration  but 
we  must  not  forget  the  frequency  of  reflected 
symptoms  when  other  portions  of  the  colon  are 
affected. 

The  appendix. — A  high  appendix,  at  times,  gives 
symptoms  entirely  localized  to  the  right,  upper 
quadrant  and  must  be  differentiated  from  the  other 
acute  diseases  in  this  region. 

In  considering  the  symptomatology  of  the  right, 
upper  quadrant  I  propose  taking  up  the  principal 
subjective  and  objective  signs  and  point  out  a  few 
differential  points. 

The  cardinal  symptom  and  the  one  causing  the 
patient  to  seek  medical  advice  is  pain,  and  the 
principal  finding  in  diseases  of  this  region  is  tender- 
ness. We  may  divide  pain  into  several  classes  as : 
1,  the  pain  of  carcinoma,  whatever  its  location;  2, 
the  colics ;  3,  the  pain  of  ulcer ;  4,  that  of  pancre- 
atitis, and  5,  of  liver  diseases.  In  carcinoma  the 
pain  is  more  stationary  and  constant,  usually  worse 
at  night,  and  of  a  dull,  boring  character.  There  is 
no  relief  except  by  opiates,  the  one  exception  being 
in  those  ra^e  cases  of  carcinoma  of  the  stomach 
with  hyperacidity,  when  alkalies  may  relieve  it 
somewhat.  Gallstones  and  renal  colics  cause  an 
agonizing  pain  that  has  a  tendency  to  radiate,  the 
former  to  tlie  right  scapular  region,  and  the  latter 
toward  the  pubis.  Relief  may  be  spontaneous  with 
the  passage  of  the  stone  but  usually  opiates  are 
required.  Appendicular  colic  is  neither  so  severe 
nor  so  steady  as  the  former  and  has  not  the  tendency 
to  radiate.  The  pain  in  ulcer  is  sharp,  gnawing 
and  burning  and  usually  bears  a  distinct  relation  to 
the  taking  of  food  which  relieves  it  as  do  vomit- 
ing and  alkalies.  At  times  it  shows  a  tendency  to 
radiate  toward  the  left  scapular  region.  Acute 
pancreatitis  gives  one  of  the  most  severe  pains, 
being  cutting  in  character  and  prostrating  the  pa- 
tient. The  pain  in  liver  disease  (cyst  or  abscess) 
in  which  I  include  cholecystitis  is  more  of  a  dull 
pressure  and  is  localized  to  the  liver  region.  It  is  at 
times  made  worse  by  taking  a  deep  breath  and  by 
bending. 

In  this  case,  I  believe,  the  subjective  signs  are 
worth  more  than  the  objective  signs  for  the  tender- 
ness in  these  diseases  is  quite  indefinite,  except  in 
cholecystitis  and  ulcer.  In  the  latter  it  is  usually 
superficial  and  localized  to  the  epigastrium,  while 
in  the  former  it  is  deep  and  corresponds  to  the 
position  of  the  gallbladder  or  on  a  line  between 
the  umbilicus  and  the  right  shoulder.  In  kidney 
diseases  the  tenderness  exists  in  the  costovertebral 
angle  and  carcinomas  cause  tenderness  wherever 
they  exist.  With  tenderness  we  may  consider  rigid- 
ity of  the  right  rectus  muscle,  which  is  present  in 
almost  all  conditions  in  this  region,  and  is  of  little 


diagnostic  value.  Masses  rtiay  also  be  felt  including 
enlarged  gallbladders,  kidney  tumors,  pancreatic 
cysts  or  carcinomas  and  gastric  tumors.  Of  these 
the  gastric  tumors  are  the  most  mobile  and  those  of 
the  pancreas  least  so. 

Indigestion  is  next  in  frequency  to  pain  and  in- 
cludes belching,  heartburn,  loss  of  appetite  and  nau- 
sea and  vomiting.  The  principal  diseases  causing 
loss  of  appetite  are  gallbladder  conditions  or  car- 
cinomas, regardless  of  their  location.  The  dift'er- 
ence  is  that  in  carcinoma  tlie  patient  has  an  absolute 
aversion  to  food,  especially  meat,  while  in  gall- 
bladder trouble  the  loss  of  desire  is  due  to  a  rather 
constant  nausea.  In  the  latter  it  is  surprising  how 
well  nourished  the  patient  remains,  even  though  the 
anorexia  has  existed  for  some  time,  while  in  carci- 
noma a  rapid  loss  of  weight  occurs.  Ulcer  patients 
do  not  eat  simply  because  they  are  afraid,  but  we 
find  that  the  desire  for  food  is  present.  They  are 
usually  spare  and  anxious  looking,  but  show  no 
evidence  of  any  marked  or  rapid  loss  of  weight. 

Vomiting  may  occur  in  any  disease,  being  of  most 
frequent  occurrence  in  gallbladder  or  renal  colic, 
appendicitis,  ulcer,  carcinoma  of  the  stomach  and 
pancreatitis.  The  vomiting  is  probably  reflex  due 
to  pain,  but  in  ulcer  or  carcinoma  it  may  be  due 
to  obstruction.  In  carcinoma  it  is  of  almost  daily 
occurrence  and  is  of  a  foul,  coffeeground  character, 
while  in  the  former  it  occurs  only  rarely  and  gives 
immediate  relief  from  the  pain,  a  phenomenon  that 
liappens  in  none  of  the  other  conditions.  Heart- 
burn is  often  complained  of,  but  the  cause  is  not 
so  frequently  corroborated  by  stomach  analysis. 
Thus,  gallbladder  patients  may  complain  of  it,  but 
I  have  found  that  they  more  often  have  a  tendency 
to  achylia,  due,  probably,  to  a  gastritis.  Ulcer  and 
chronic  appendicitis  most  frequently  give  a  hyper- 
acidity, the  latter  being  much  less  in  degree  than 
the  former. 

Constipation  is  another  frequent  accompaniment 
of  the  diseases  under  consideration  and  is  most 
marked  in  ulcer,  gallbladder  diseases,  appendicitis 
and  carcinoma  of  the  colon.  In  the  latter  the  stool 
becomes  small  and  may  contain  blood  and  mucus. 

Jaundice  occurs  in  carcinoma  of  the  pancreas,  gall- 
stones, cholecystitis  and  some  of  the  liver  diseases. 
In  the  former  it  is  constant,  progressive,  and  of  a 
greenish  hue.  In  gallstones  it  is  more  variable  and 
of  a  yellow  color.  In  cholecystitis,  while  jaundice 
is  not  so  marked  we  commonly  get  an  icteroid  tint 
to  the  skin,  which  usually  exists  in  the  various  liver 
diseases. 

I  wish  to  call  attention  to  certain  general  points 
which  may  bear  a  part  in  the  diagnosis.  The  pres- 
ence of  a  secondary  anemia  is  of  importance  in  diag- 
nosing carcinoma,  providing  the  other  signs  are  pres- 
ent and  a  positive  Wassermann,  or  a  pernicious 
anemia,  as  shown  by  blood  examination  may  be  of 
extreme  value.  The  consideration  of  age  and  sex 
are  of  value  for  gallstones  are  most  frequent 
in  elderly  females,  while  ulcer  is  found  mostly  in 
young  males.  Wlien  carcinoma  develops  on  an  ulcer 
the  change  of  symptoms,  rather  suddenly,  is  quite 
characteristic  and  should  always  be  considered. 

46  West  Eighty-third  Street. 


July  17,  1920.] 


PASCHALL:    TREATMENT  OF  TUBERCULOSIS. 


95 


TREATMENT  OF  TUBERCULOSIS. 

Clinical  Case  Reports. 

By  Bexjamix  S.  Paschall,  M.  D., 
Xew  York. 

Some  one  has  aptly  said  that  it  would  take  a 
lifetime  to  prove  or  disprove  the  usefulness  of  any 
new  method  of  treatment  in  tuberculosis.  How- 
ever that  ma}'  be,  we  think  that  twehe  years  is  a 
sufficient  length  of  time  to  get  a  fair  degree  of 
accuracy  in  the  case  of  the  stibstance  we  are  about 
to  describe.  The  results  have  been  so  accurate  and 
consistent  in  both  animals  and  man  and  the  obser- 
vations have  extended  over  such  a  comprehensive 
series  in  both  groups  that  the  conclusions  reached 
will  be  found  to  approach  very  closely  the 
statements  made  in  the  following  pages.  It  was 
shown  in  the  animal  experiments  that  one  could  pre- 
dict to  a  remarkable  degree  of  accuracy  just  how 
a  given  group  of  guineapigs  would  appear  at  au- 
topsy as  soon  as  the  standardization  valties  of  a 
given  strain  of  tubercle  bacilli  had  been  learned, 
and  that  these  results  could  be  predicted  with  the 
same  degree  of  acctiracy  as  can  be  obtained  in  the 
usual  toxin  antitoxin  measurements  obtained  in  the 
standardization  of  diphtheria  antitoxins. 

We  began  using  mycoleum  as  far  back  as  1908, 
but  were  soon  stopped  by  our  first  disastrous  labor- 
atory fire,  which  put  a  check  on  our  supply  for  near- 
ly a  year.  Even  at  that  time  it  was  sufficiently  per- 
fected to  be  entirely  satisfactory  on  experimental 
animals  and  so  far  as  we  could  see  in  its  clinical 
results,  the  only  draXvback  being  our  utter  inability 
to  prodtice  an  adequate  amount  even  for  the  few 
patients  who  were  then  taking  it. 

A  consideration  of  the  pathology  of  tuberculosis 
is  essential  in  connection  with  its  treatment  by  any 
specific  means,  since  the  commonest  or  caseotis  form 
of  this  disease  corresponds  to  a  similar  condition 
seen  in  syphilis  in  the  tertiary  stage,  the  stage  of 
gumma.  Primary  and  secondary  stages  are  seldom 
seen  in  tuberculosis  but  they  exist  nevertheless  and 
they  may  be  very  clearly  demonstrated  in  the  ex- 
perimental animal.  Pulmonary  forms  of  tubercu- 
losis are  particularly  comparable  to  the  tertiary 
forms  of  syphilis,  so  that  we  might  say  first,  second, 
third,  and  fourth  stages  of  tertiary  tuberculosis 
when  referring  to  the  usual  physical  lung 
findings  plus  the  pathological  realizations.  In  at- 
tempting to  gain  an  insight  into  what  our  expecta- 
tions should  be  in  the  case  of  a  new  and  valuable 
therapeutic  agent  to  be  added  to  our  annamentarium 
let  us  not  lose  sight  of  this  pathological  vision  lest 
we  expect  things  to  happen  in  a  ditTerent  manner 
from  what  will  actually  prove  to  be  the  case. 

In  the  first  place  antibodies  particularly  lipases 
penetrate  very  slowly  into  walled  off  or  partly  walled 
off  areas  of  necrosis  or  into  areas  of  caseation, 
while  tubercle  bacilli  can  lie  in  these  areas  without 
being  destroyed  for  long  periods  of  time.  So  closely 
do  these  caseous  areas  resemble  the  gumma  that 
their  separate  identity  was  unproved  until  the  dis- 
covery of  the  bacillus  by  Koch. 

In  the  second  place,  wax  lipases  of  a  specific  na- 
ture obey  the  physiological  laws  commonly  recog- 
nized as  governing  the  action  of  fat  lipases  and  are 


not  called  forth  and  activated  except  when  one  of 
these  areas  softens  down  and  liberates  natural  tu- 
bercle bacillus  waxes  into  the  surrounding  tissues 
or  blood  stream,  or  when  mycoleum  is  injected  to 
increase  artificially  the  quantity  of  these  antibodies 
already  present,  that  is  either  the  real  wax  or  the 
wax  modified  as  I  have  already  described  (2j  must 
be  present  to  activate  these  antibodies.  Therefore  de- 
struction of  tubercle  bacilli  can  proceed  only  when 
there  is  first  an  adequate  amount  of  \yax  splitting 
antibodies  present  in  the  tissues  and  second  when 
there  is  physical  contact  between  the  bacilli  and 
the  enzymes  in  question. 

Upon  these  facts,  by  the  way,  rests  the  great  di- 
vergence of  results  reported  by  various  investigators 
on  the  reliability  of  certain  complement  deviation 
tests  in  the  diagnostic  field  in  tuberculosis,  for  while 
the  nonwaxy  portions  of  the  bacillus  play  such  an 
important  role  in  these  serological  reactions  the 
strictly  waxy  portions  themselves  are  exceedingly 
irregular  and  uncertain  in  their  results  for  the  rea- 
sons stated.  Of  course  the  wax  lipoid  proteid  carbo- 
hydrate complex  when  used  as  an  antigen  is  not  sep- 
arated in  its  entirety  by  purely  physical  methods, 
which  further  complicates  the  already  complex  de- 
viation aspect  of  the  case. 

From  the  foregoing  remarks  it  will  be  readily  ap- 
preciated that  the  rules  for  treatment  must  closely 
follow  our  present  understanding  of  the  most  mod- 
ern methods  for  treating  syphilis.  That  the  time  of 
treatment,  the  alternation  between  active  courses  of 
treatment  and  periods  of  rest  between,  and  the  indi- 
cations for  more  active  courses  or  longer  periods 
of  intermission  mtist  bear  a  striking  resemblance  to 
this  pathologically  similar  disease,  with,  the  single  ex- 
ception that  in  the  case  of  tuberculosis  treated  with 
mycoletim  we  are  raising  the  immunity  dose  by  dose 
steadily  and  surely  to  a  higher  and  higher  level 
until  finally  there  comes  a  time  when  the  patient 
fails  to  react  any  further  and  is  apparently  cured. 

Sometimes  this  high  level  is  not  maintained  and 
reactions  will  reappear  after  a  sufficient  interval 
but  it  is  surprising  to  note  the  number  of  patients 
who  once  they  are  brought  to  this  level  will  hold  it 
to  such  a  degree  that  a  dose  administered  one,  two, 
and  three  years  later  will  fail  to  elicit  the  slightest 
response  even  in  some  patients  who  reacted  so  con- 
tinuously and  so  violently  that  it  sometimes  seemed 
as  if  we  never  were  to  arrive  at  the  end  of  the  dis- 
ease process.  These  are  in  general  the  old  chronic 
fibroid  types  of  the  down  and  out  class.  Of  course, 
we  do  not  like  to  treat  them  and  we  avoid  them  as 
much  as  possible,  but  they  occur  too  frequently  and 
are  too  insistent  in  their  claims  upon  us  to  be  en- 
tirely ignored.  For  the  first  year  or  so  there  does 
not  seem  to  be  an\-thing  happening  of  an  encour- 
aging nature.  They  are  just  patiently  hanging  on  of 
their  own  accord  because  we  do  not  encourage  them, 
since  we  never  know  in  this  class  which  ones  have 
enough  lung  tissue  left  and  which  have  not.  After 
the  first  year,  but  more  often  after  the  second,  it  be- 
comes unmistakably  apparent  that  the  patient  is 
getting  well. 

And  at  the  end  of  the  third  and  fourth  and  fifth 
years  they  are  still  going  up,  steadily  climbing  and 
never  slipping  backward.   One  can  only  wonder  how 


96 


PASCHALL:   TREATMENT  OF  TUBERCULOSIS. 


[New  York 
Medical  Journal. 


much  punishment  the  human  body  can  stand  and 
then  recover,  if  given  the  right  chance  to  do  it  and 
time  enough  to  do  it  in.  We  cannot  ignore  these 
men  and  women  in  the  future.  They  will  insist  that 
we  treat  them  through  the  long  and  weary  years. 
They  are  the  most  patient  and  the  hardest  to  discour- 
age and  they  are  satisfied  with  so  little,  but  let  us 
try  in  the  future  not  to  have  them  get  this  way  if 
we  can  avoid  it,  and  I  think  that  we  can. 

There  is  nothing  so  common  in  the  world  as  the 
practice  of  selfdeception  in  nearly  all  human  af- 
fairs. That  we  avoided  this  from  the  first  was  due 
to  the  extreme  difficulty  in  producing  an  adequate 
amount.  It  takes  from  three  to  six  months  to  pre- 
pare a  dose  and  a  few  seconds  to  give  it,  and  the 
number  of  doses  which  can  be  prepared  at  a  given 
time  or  in  one  lot  is  exceedingly  limited.  There 
has  never  been  an  adequate  amount  for  us  to  use 
in  our  own  practice,  and  there  is  not  at  the  pres- 
ent time  enough  to  treat  more  than  a  very  limited 
number  of  patients,  so  limited  that  the  taking  on 
of  a  single  new  patient  should  have  long  and  seri- 
ous consideration  as  to  whether  or  not  we  can 
manage  it. 

Every  effort  is  being  made  at  the  present  time  to 
make  mycoleum  available  by  going  into  quantity 
production  methods,  which  will  be  an  engineering 
task  of  large  and  expensive  proportions. 

The  difficulties  in  producing  mycoleum  were  so 
great  that  in  the  beginning  we  actually  hoped  against 
hope  that  some  substance  easier  and  cheaper  to 
prepare  would  turn  out  to  be  the  proper  immuniz- 
ing substance.  At  first  we  discounted  the  very 
positive  reports  which  a  considerable  group  of  pa- 
tients began  to  turn  in,  some  of  them  exceedingly 
glowing  reports  on  their  sudden  and  unmistakable 
improvement.  We  discounted  them  on  the  grounds 
of  anything  new.  Then  the  laboratory  burned  out 
again  and  we  were  again  without  mycoleum  for 
several  months.  I  made  a  frantic  search  over  the 
United  States  for  any  quantity  of  dried  tubercle 
bacilli  at  that  time,  and  I  want  to  take  this  occa- 
sion to  thank  the  biological  laboratories  and  the  state 
experiment  stations  which  helped  me  out. 

Owing  to  our  inability  to  obtain  more  than  a 
few  ounces  of  dried  tubercle  bacilli  at  the  best  from 
the  whole  country,  we  tried  to  put  our  patients 
back  on  tuberculin.  They  refused  and  decided  to 
wait  for  the  new  laboratory.  Some  of  them  waited 
too  long  and  when  we  again  had  it  they  no  longer 
were  capable  of  reacting.  Others  reacted  once  more 
and  again  began  to  make  that  same  unmistakable 
climb  back  toward  health.  It  was  the  first  clear 
cut  indication  I  had  that  whatever  difficulties 
there  might  be  in  the  way  of  producing  this  sub- 
stance and  whatever  its  cost  of  production  might  be, 
some  way  must  be  found  to  make  it  available  to 
sufferers  from  this  disease. 

Some  of  these  patients  had  been  with  us  during 
the  previous  fires,  and  so  we  had  seen  patients  who 
were  failing  on  tuberculin  in  1908  start  gaining 
on  mycoleum  in  1909,  begin  losing  again  in  1910 
when  our  first  fire  happened  and  tuberculin  was 
resumed,  gain  again  in  1911  on  retreatment  with 
mycoleum,  lose  ground  again  in  1912  on  resuming 
tuberculin  once  more  on  account  of  our  second  fire 


and  again  start  improving  in  1913  on  mycoleum, 
when  they  were  finally  treated  to  ultimate 
recovery. 

Prior  to  1910  the  doses  of  mycoleum  were  small 
as  compared  to  those  given  at  a  later  date.  It  was 
plainly  seen  that  even  these  doses  had  a  distinct 
retarding  action  on  the  course  of  the  disease  in  the 
severe  forms  and  a  markedly  beneficial  effect  in  the 
milder  forms.  It  was  only  after  we  had  very 
greatly  enlarged  our  incubator  facilities  that  the 
doses  could  be  increased,  and  the  dose  at  present 
given  was  finally  determined  to  be  the  mini- 
mum amount  which  would  prove  sufficient  to  pro- 
voke a  lasting  immunity  in  the  largest  majority  of 
cases.  It  has,  however,  been  determined  that  if  this 
standard  dose  does  not  provoke  a  reaction  no  amount 
of  increase  will  have  the  slightest  effect.  It  has 
already  been  shown  that  it  is  harmless  on  the  experi- 
mental animal  in  practically  any  amount.  I  have 
given  the  human  dose  of  three  c.c.  to  a  tuberculous 
guineapig  without  harm. 

There  are  a  number  of  complications  and  sequelae 
which  deserve  a  moment's  attention,  though  they 
might  well  be  reserved  for  a  future  discussion  in 
which  methods  of  treatment  are  more  fully  taken 
up.  Accumulations  of  pus  from  bone  tuberculosis 
must  be  evacuated  at  the  earliest  possible  moment. 
There  is  no  danger  of  secondary  infections  and 
sinuses  discharging  over  long  periods  of  time.  My- 
coleum will  take  care  of  this  feature  with  prompt- 
ness and  accuracy.  On  the  other  hand  failure  to 
evacuate  pus  promptly  keeps  mycoleum  from  exert- 
ing its  specific  action  and  may  cost  the  patient  his 
life. 

Patients  with  intestinal  tuberculosis  may  make  a 
splendid  recovery  and  die  from  a  subsequent  ob- 
struction due  to  adhesions  caused  by  the  disease. 

Renal  tuberculosis  is  quite  as  amenable  to.  treat- 
ment as  are  other  forms,  but  a  contracted  bladder 
remains  a  constant  discomfort  and  does  not  improve 
much  as  years  go  on.  It  is  not  advisable  to 
treat  renal  tuberculosis  where  the  injected  bladder 
does  not  hold  six  ounces,  unless  the  patient  is  highly 
intelligent  and  understands  thoroughly  that  there  is 
going  to  be  less  and  less  capacity,  even  an  almost 
immediate  cessation  of  the  process.  Long  contin- 
ued toxemia  may  have  left  permanent  changes  in 
the  organs  of  metabolism  and  elimination,  and  these 
degenerations  are  not  capable  of  regeneration. 

Immunity  does  not  often  take  place  before  the 
age  of  three,  but  recovery  as  late  as  seventy-five  is 
not  uncommon.  Alcohol  and  tobacco  depress  the 
blood  capability,  and  excessive  smoking  may  oblit- 
erate the  power  of  the  formation  of  immune  bodies 
just  as  surely  as  does  excessive  alcoholism. 

Acute  miliary  tuberculosis  does  not  react  except 
in  comparatively  early  stages  of  the  disease,  and  if 
the  first  three  doses  do  not  cause  a  reaction  there  is 
no  use  of  giving  any  further  injections.  The  same 
thing  may  be  said  of  tuberculous  meningitis.  I  have 
seen  a  number  of  these  cases  and  so  far  have  not 
been  able  to  elicit  reactions  in  any  one  of  them.  Some 
of  them  have  been  children  and  some  adults.  There 
may  be  histological  reasons  for  this  though  it  would 
seem  as  if  there  should  be  reaction  to  the  disease 
which  undoubtedly  exists  in  other  parts  of  the  body 


July  17,  1920.] 


PASCHALL:   TREATMENT  OF  TUBERCULOSIS. 


97 


— still  the  rule  of  no  reaction  no  recovery  holds 
good  in  these  cases.  There  are,  it  is  true,  some 
cases  of  synovitis  in  which  the  reaction  is  satisfac- 
tory and  the  improvement  exceedingly  slow  in  pro- 
portion, due  to  the  difficulty  of  penetration  of  wax 
lipases,  but  cases  are  rare  in  which  the  clearing  up 
is  not  in  keeping  with  the  reaction. 

As  a  diagnostic  test  mycoleum  is  more  accurate 
than  tuberculin  and  there  is  never  a  tolerance  pro- 
duced toward  it  as  there  is  to  tuberculin  with  evi- 
dences of  the  disease  still  present.  Continued  neg- 
ative reactions  at  spaced  intervals  indicate  that  the 
disease  has  been  eradicated  or  else  is  so  thoroughly 
encapsulated  that  none  of  the  antibodies  can  pene- 
trate the  encapsulated  area. 

The  effect  of  the  wax  splitting  enzymes  often 
shows  splendidly  if  samples  of  sputum  are  stained 
and  compared  at  monthly  intervals.  A  description 
of  these  changes  deserves  a  separate  chapter  and 
will  be  treated  at  a  later  time  but  in  general  it  may 
be  said  that  there  are  several  ways  in  which  the  phe- 
nomena may  manifest  themselves.  There  may  be  a 
peculiar  irregular  or  moth  eaten  appearance  of  the 
tubercle  bacillus  as  a  whole  where  a  portion  of  wax 
is  eaten  away,  leaving  the  rest  of  the  bacillus,  or 
there  may  be  a  marked  swelling  of  the  whole  bacillus 
with  a  hyaline  appearance  which  takes  the  stain 
badly,  or  at  a  further  stage  of  the  process  there  may 
be  a  pale,  yellowish  structure  with  the  characteristic 
shape  and  size  of  the  bacillus  but  with  little  or  no 
affinity  for  aniline  dyes. 

This  last  is  evidently  the  membranous  portion  of 
the  cell  wall  whose  composition  is  at  present  un- 
known. These  last  structures  often  show  a  trace  of 
pink  color  remaining  and  are  the  last  bodies  seen 
until  the  patient  reports  the  absence  of  sputum. 

Our  experiences  with  mycoleum  extend  over 
twelve  years  and  record  many  hundreds  of  cases 
of  human  beings  and  over  a  thousand  experimental 
animals,  beside  those  experiments  done  under  the 
auspices  of  the  U.  S.  Public  Health  Service. 

We  have  administered  several  thousand  doses  dur- 
ing this  period  in  every  known  form  of  the  disease 
and  have  refrained  from  publishing  these  results 
until  every  important  phase  of  the  subject  was  com- 
pletely covered  and  every  side  of  the  question  thor- 
oughly worked  out.  The  following  case  reports 
have  been  selected  to  illustrate  in  general  these 
forms.  Nearly  all  of  them  were  diagnosed  by 
other  physicians  and  referred  to  me  for  mycoleum 
treatment. 

Case  I. — In  1908  a  young  lady  (J.  C.)  was  sent 
to  me  suffering  with  lupus  of  the  face.  Examina- 
tion revealed  similar  areas  on  the  chest,  on  the  nasal 
mucous  membranes,  and  on  the  scalp.  There  was 
evidence  of  an  early  choroiditis  and  the  chest  was 
pretty  well  scarred  up.  Xo  particular  area,  just  a 
diffuse  fibrosis,  corroborated  by  the  x  ray.  She 
was  aged  twenty -three  and  gave  a  history  of  mal- 
nutrition from  early  childhood,  was  not  underweight 
but  her  tissues  had  a  corklike  feel.  I  mention  this 
because  it  is  common  in  tuberculosis  of  the  toxic  or 
latent  variety. 

It  is  the  scrofulous  child  grown  up,  carrying 
along  with  it  all  the  early  infection,  all  the  intoxi- 
cation, all  the  pathological  changes  caused  by  this 


constant  poisoning  going  on  year  after  year,  and  yet 
because  the  patient  is  not  emaciated  or  underweight 
we  have  to  content  ourselves  with  the  unsatisfactory 
assertion  that  her  tissues  are  bad,  which  does  not 
give  the  picture  in  the  slightest  degree.  The  Was- 
sermann  was  negative.  I  gave  her  a  thorough 
course  of  tuberculin  in  the  accepted  way,  with  no 
improvement.  Instead,  she  grew  gradually  worse 
until  in  1913  I  saw  her  in  bed  with  a  typical  tuber- 
culous enteritis  of  the  typhoid  type,  an  average 
daily  temperature  of  101''  to  103°  and  a  pulse  of 
120  to  130,  which  condition  they  told  me  had 
been  going  on  for  several  months.  I  told  the  family 
that  the  prognosis  was  absolutely  unfavorable,  but 
they  begged  me  to  do  what  I  could  for  her.  I  ac- 
cordingly gave  her  full  doses  of  mycoleum  (three 
c.  c.)  at  three  week  intervals  for  the  first  six  doses 
and  once  a  month  thereafter  until  she  had  received 
thirty  doses.  She  made  a  prompt  and  uninterrupt- 
ed recovery  and  has  remained  well  since.  This  case 
is  reported  to  illustrate  the  effect  on  a  patient  long 
under  observation  and  known  to  be  slowly  but  sure- 
ly going  down  hill  with  a  fatal  ending  clearly  in 
sight. 

What  has  been  said  of  other  tuberculous  condi- 
tions applies  to  eye  cases  also.  In  all  instances  the 
patient  had  been  to  a  competent  specialist  and  had 
received  appropriate  treatment  from  him  or  from 
some  one  familiar  with  tuberculin  therapy  and  was 
finally  turned  over  to  me  in  the  hope  that  mycoleum 
would  prove  of  some  value.  We  succeeded  in  ob- 
taining favorable  results  in  all  of  them  and  will 
briefly  report  a  few  selected  at  random  from  our 
records. 

Case  II. — E.  B.,  aged  eighteen,  ran  a  ma- 
chine in  a  clothing  factory.  She  was  poor  and 
mycoleum  was  expensive  and  scarce.  She  there- 
fore took  treatment  only  when  driven  to  it  by  the 
ravages  of  the  disease.  She  had  iritis,  episcleritis 
and  corneal  ulcers  with  intense  photophobia.  Every 
time  she  took  a  few  doses,  the  condition  improved  to 
such  an  extent  that  she  was  able  to  work  with  com- 
fort and  the  clinical  signs  rapidly  cleared  up.  Every 
time  she  left  off  treatment,  she  remained  well  for 
about  six  months  when  the  condition  slowly  began 
to  return  again,  but  the  promptitude  and  complete- 
ness with  which  it  always  cleared  up  left  no  doubt 
in  the  mind  of  either  patient  or  physician  that  mj'- 
coleum  offered  an  absolutely  reliable  therapeutic 
weapon  and  left  no  doubt  that  the  eye  condition  was 
progressive  untreated.  The  Wassermann  and  gono- 
coccic  complement  deviation  tests  were  negative.  The 
patient  had  been  treated  several  years  with  tuber- 
culin without  improvement,  and  her  condition 
had  become  so  bad  at  the  time  of  her  first 
dose  that  there  was  every  indication  that  she 
would  have  to  have  the  eye  removed,  and  she 
had  been  told  that  this  would  have  to  be  done  in  a 
short  time.  She  made  a  complete  recovery  with  a 
perfectly  useful  eye.  The  time  of  treatment  was 
from  1914  to  1916  and  the  number  of  doses  six- 
teen in  all. 

Case  III. — Dr.  G.,  aged  forty-five,  tuberculous 
iritis  with  intense  photophobia  confining  him  to  a 
darkened  room  during  the  intermittent  attacks. 
Three  doses  of  mycoleum  in  1914  and  one  in  1916. 


98 


LONDON  LETTER. 


[New  York 
Medical  Journal. 


No  return  of  symptoms  since  that  time  and  thinks 
the  improvement  entirely  due  to  its  action.  There 
was  no  doubt  about  the  diagnosis,  as  there  were 
sclerocorneal  ulcers  containing  tubercle  bacilli. 

Pharyngeal  ulcers  are  of  peculiar  interest  in  that 
they  are  so  spectacular.  This  case  was  Wasser- 
mann  negative  and  had  been  diagnosed  and  treated 
with  tuberculin  very  thoroughly  without  any  great 
improvement. 

C.^SE  IV. — Mrs.  A.  O.  T..  aged 'thirty-five,  mar- 
ried; husband  tuberculous.  First  seen  in  1911 ;  con- 
dition was  diagnosed  as  diphtheria  by  the  attend- 
ing physician  and  three  doses  of  antitoxin  were 
given  without  effect,  except  to  produce  such  an  ery- 
thema as  to  be  rediagnosed  by  another  physician  as 
scarlet  fever.  Indeed  the  suddenness  of  the  onset, 
the  high  fever  and  pulse  and  apparently  well  nour- 
ished condition  made  a  tuberculous  ulcer  a  remote 
consideration,  but  it  persisted  and  continued  to 
spread  as  weeks  went  on,  and  I  saw  her  at  a  later 
date.  Scrapings  of  the  ulcer  edges  revealed  the 
presence  of  tubercle  bacilli,  and  later  tubercle  bacilli 
were  obtained  in  the  sputum  coming  presumably 
from  the  lungs,  which  showed  distinct  lesions.  I 
wanted  to  give  her  mycoleum  at  once,  but  she 
looked  upon  it  as  an  experiment,  and  as  she  had 
been  sent  to  me  for  ttiberculin  treatment,  I  gave 
her  tuberculin  for  a  year  with  no  results,  as  at  the 
end  of  the  year  the  ulcer  was  greatly  increased  in 
size  and  had  involved  the  fauces  and  was  so  painful 
that  she  was  unable  to  take  any  solid  food.  At 
this  time  she  became  discouraged  and  refused  fur- 
ther treatment  of  an)-  kind.  I  did  not  see  her 
again  for  about  five  months,  when  things  had  be- 
come so  bad  that  she  could  not  even  take  liquids 
and  her  pulmonary  lesions  were  rapidly  increasing. 
She  had  lost  weight,  thirty  or  forty  pounds,  and 
her  outlook  was  absolutely  unfavorable.  I  gave 
her  mycoleum  and  forced  it  at  close  intervals,  giv- 
ing her  in  all  twelve  doses.  She  made  a  complete 
recovery;  the  throat  healed  and  at  the  end  of  six- 
months  she  returned  to  her  normal  weight.  I  heard 
from  her  from  time  to  time  for  several  years,  and 
when  last  heard  from  she  was  still  in  good  health 
with  no  return  of  her  tuberculosis.  She  finished 
mycoleum  treatment  in  1912  and  reported  as  late 
as  1917.  • 

Case  V. — C.  D..  aged  thirteen,  had  suf¥ered  from 
cervical  adenitis  for  five  years,  and  already  had  sev- 
eral chains  of  glands  removed  by  operation.  They 
seemed  to  appear  in  crops  first  on  one  side  and 
then  on  the  other,  but  she  was  never  free  from 
them.  She  was  given  ten  doses  of  mycoleum  in 
1914,  and  there  were  a  nuinber  of  small  calcified 
nodules  left  which  were  removed  the  following  year 
b\-  a  surgeon.  I  was  told  afterward  that  the  appear- 
ance was  retrogressive  as  far  as  the  disease  was 
concerned.  The  surgeon  left  drainage  and  was 
surprised  to  see  the  sinus  heal  immediately. 

Case  VI. — M.  F.  had  cervical  adenitis,  was 
treated  w-ith  tuberculin  without  any  particular  benefit, 
and  the  Wassermann  was  negative.  She  was  twelve 
when  put  on  treatment  and  received  twenty  doses  in 
1913-1914.  She  had  a  very  severe  eczema  over 
the  whole  body,  which  had  been  there  since  she  was 
a  baby,  and  which  constantly  increased  in  intensity. 


This  entirely  cleared  up  by  the  time  she  was  ready 
for  discharge,  and  the  cervical  glands  disap- 
peared though  they  were  never  large.  Her  general 
health  changed  in  a  very  noticeable  manner.  She 
was  the  typical  sickly  scrofulous  child  and  belonged 
to  a  sickly  scrofulous  family.  She  suddenly  shot 
up  to  womanhood  and  at  fourteen  was  a  patient  to 
be  proud  of.    She  has  remained  well  since. 

Genitourinary  tuberculosis  without  undue  blad- 
der contraction  is  a  satisfactory  form  to  treat.  I 
have  seen  old  chronic  pulmonary  cases  drag  their 
weary  way  along  for  months  before  any  definite 
improvement  could  be  seen.  I  have  had  desperate 
cases  of  general  miliary  tuberculosis  give  a  definite 
clear  reaction  to  mycoleum,  indicating  that  they 
were  still  capable  of  being  immunized,  and  then  keep 
one  guessing  as  to  whether  or  not  the  positive  reac- 
tion was  a  safe  prediction  of  ultimate  recovery.  Yet 
a  patient  with  genitourinary  tuberculosis  whose 
bladder  must  be  emptied  every  hour  or  oftener,  day 
and  night,  and  who  is  titterly  worn  out  from  lack  of 
sleep,  suffering  from  pain  and  a  constant  desire  to 
urinate,  makes  as  already  indicated  an  ideal  one 
for  the  uninitiated  to  observe  for  the  first  time. 
Following  the  first  dose  in  a  local  involvement  of 
this  kind,  there  is  usually  no  setback.  The  patient 
simply  makes  a  steady  and  uninterrupted  recovery 
if  he  follows  directions.  The  following  report  il- 
lustrates a  failure  to  carry  out  our  instructions  on 
the  part  of  the  patient. 

(To  be  concluded) 


LONDOX  LETTER. 
(From  our  ozi'ti  correspondent.) 
Annual  Lady  Priestly  Memorial  Lecture. 

London,  May  4,  1930. 
Sir  George  New-man,  chief  medical  officer  of  the 
Ministry  of  Health,  delivered  on  April  22d,  for 
the  National  Health  Society,  at  Robert  Barnes  Hall, 
in  the  building  of  the  Royal  Society  of  Medicine, 
the  annual  Lady  Priestly  Memorial  Lecture,  which 
was  instituted  for  the  purpose  of  organizing  an- 
ntially  a  public  lecture  on  whatever  subject  connect- 
ed with  ptiblic  health  might  be  considered  most 
important  at  the  time.  No  better  man  could  have 
been  found  to  deliver  a  lecture  dealing  with  public 
health  than  Sir  George  Newman  and  his  choice  of 
subject.  The  Place  of  Public  Opinion  in  Preventive 
Medicine,  was  peculiarly  apt.  He  pointed  out  that 
some  kind  of  public  opinion,  had  no  doubt  existed 
from  the  earliest  history  of  mankind.  Sir  Robert 
Peel  defined  that  opinion  as  consisting  of  "a  great 
compound  of  folly,  weakness,  prejudice,  right  feel- 
ing, obstinacy  and  newspaper  paragraphs."  That 
definition  contained  at  least  some  ideas  which  were, 
perhaps,  characteristic  of  public  opinion  today. 
Whether  or  not,  the  world  was  moved  today,  as 
never  before,  by  the  indefinable  power  of  public 
opinion,  governments,  as  well  as  national  habit 
and  custom,  were  impelled  or  moulded  by  the  man 
in  the  street.  He  was  master,  the  government  was 
his  servant.    Referring  to  preventive  medicine  the 


July  17,  1920.] 


LONDON  LETTER. 


99 


lecturer  said  that  during  the  last  half  century,  the 
increase  of  physiological  and  pathological  knowl- 
edge, including  that  of  infection,  had  been  one  of 
the  outstanding  features  of  the  age.  He  now  knew 
two  certain  facts  about  disease ;  first,  that  it  is  not 
something  arbitrary,  capricious,  occult  or  accidental 
but  is  an  effect  of  definite  causes  and  conditions ; 
secondly,  that  these  causes  and  conditions  are  in  a 
large  and  increasing  measure  controllable  by  man. 
Today,  for  the  first  time,  public  and  personal  health 
had  become  purchasable.  There  were  two  things 
we  desired,  health  and  long  life,  in  other  words,  to 
reduce  and  if  possible  to  abolish  invalidism  and 
physical  disability  and  to  postpone  the  event  of 
death.  It  was  to  make  human  life  better,  larger, 
more  capable  and  useful,  happier,  and  to  prolong 
our  days. 

The  coming  of  the  Ministry  of  Health  meant  a 
new  sort  of  attack  on  the  strongholds  of  disease. 
It  meant,  of  course,  increased  intervention  by  the 
State,  improved  organization,  central  and  local,  a 
bolder  policy.  But  there  was  a  further  factor  in 
reform  which  was  in  some  ways  more  important 
than  all  these,  namely,  an  educated  community  and 
an  enlightened  public  opinion.  "As  the  science  of 
government  becomes  more  representative  of  the 
aspirations  of  the  people  as  a  whole,  so  also  its  prac- 
tice becomes  more  dependent  upon  their  educa- 
tion and  equipment.  Only  ah  educated  people  is  an 
effective  and  healthy  people."  The  education  re- 
quired was  not  technical  instruction  in  hygiene 
alone,  but  an  informed  humanism  which  welcomes 
and  understands  the  growth  of  medicine  and  accepts 
its  results  boldly  and  gladly  on  behalf  of  all  man- 
kind. In  the  opinion  of  the  lecturer  England 
would  not  get  much  further  in  perfecting  her  na- 
tional health  organization  until  the  average  citizen 
has  been  educated  to  think,  and  to  act  as  knowledge 
demands.  This  statement  applies  with  equal  force 
to  America  and  all  countries. 

The  elements  of  health  for  the  body  were  nutri- 
tion, fresh  air  and  exercise,  and  he  pointed  out  that 
the  food  of  the  working  classes  in  Great  Britain  was, 
generally  speaking,  unsuitable,  unnutritious  and 
badly  cooked  and  served.  The  reason  was  not  pov- 
erty, but  lack  of  knowledge  of  the  right  food  to  buy 
and  how  to  cook  it.  Emphasis  was  laid  on  the 
need  for  well  ventilated  factories,  workshops  and 
dwelling  rooms.  The  great  value  of  games  and 
recreation  was  also  dwelt  upon.  And  with  regard 
to  games  and  recreation  for  women,  the  source  of 
the  new  race,  he  said  that  if  music  and  dancing, 
golf,  hockey  and  tennis  were  good  for  any  young 
woman  they  were  good  for  all.  Sir  George  pro- 
ceeded to  show  how  knowledge  necessary  for  the 
maintenance  of  health  and  prom.otion  of  sound 
physique  was  equally  necessary  for  the  prevention 
of  disease.  Invalidism,  disease  and  premature 
death  were  due  to  a  relatively  small  number  of 
morbid  conditions.  A  large  proportion  of  these 
diseases  were  directly  preventable. 

The  chief  hindrance  in  the  practice  of  preven- 
tion was  lack  of  knowledge  on  the  part  of  the 
public.  It  was  now  known,  for  example,  that  four 
principal  diseases,  namely,  pulmonary  tuberculosis, 
influenza,    poliomyelitis    and    cerebrospinal  fever. 


were  conveyed  from  person  fo  person  by  the  inhal- 
ation of  the  causal  microbe.  Protection  could  be 
secured  only  by  safeguarding  one  person  from 
another  on  the  individual  scale.  A  clean  mouth, 
clear  breathing  passages,  abstinence  from  spitting, 
sneezing,  coughing  or  shouting  would  go  a  long  wa). 
toward  the  prevention  of  these  diseases.  The 
lecturer  went  on  to  show  how  considerably  other 
groups  of  maladies,  such  as  dyspepsia,  septic 
wounds  and  diseases  contracted  by  infection,  infant 
mortality,  etc.,  could  be  lessened  by  the  dissemina- 
tion of  some  simple  knowledge  as  to  their  causation. 

A  further  purpose  of  an  enlightened  public  opinion 
in  regard  to  preventive  medicine  was  that  the 
assent  of  the  community  might  be  won  for  sanitary 
reform  and  its  consent  secured  for  sanitary  govern- 
ment, imperial  and  local.  Hygiene  could  only  be- 
come an  expression  of  the  national  life  if  the  people 
consented  and  were  willing  to  advocate  and  carry 
out  its  reform.  Mere  legislation  in  this  as  in  other 
fields  would  prove  abortive  if  not  supported  by 
an  intelligent  public  opinion.  The  lecturer  re- 
capitulated the  principal  items  of  a  national  policy 
in  preventive  medicine  as  follows:  1.  Importance 
of  rearing  a  healthy  race.  2.  Maternity  and  the 
care  and  encouragement  of  the  function  of  mother- 
hood. 3.  Infant  welfare.  4.  The  health  and 
physique  of  the  school  child  and  adolescent.  5. 
Sanitation  and  an  improved  personal  and  domestic 
environment,  including  food,  water  supply  and 
housing.  6.  Industrial  hygiene.  7.  The  prevention 
and  treatment  of  infectious  disease.  8.  The  pre- 
vention and  treatment  of  noninfectious  disease.  9. 
The  education  of  the  people  in  hygiene.  10.  Re- 
-search.  and  the  extension  of  knowledge. 

In  discussing  the  means  of  educating  public 
opinion  Sir  George  Newman  dealt  first  with  the 
young.  What  was  needed  was  to  give  the  child  and 
adolescent  population  of  all  social  classes  and  grades, 
first,  a  body  of  facts  concerning  personal  health,  and 
secondly,  an  experience  in  the  practice  of  hygiene,  the 
habit  of  healthy  living.  The  two  elements  must  be 
taught  together  and  the  subject  pressed  home  every 
week  in  every  school  in  the  land.  Arrangements 
must  be  made  in  all  schools  for  physical  training* 
and  instruction.  To  appear  to  the  youth  and 
adolescent  of  the  country,  however,  was  not  suf- 
ficient. We  needed  much  wider  methods  of 
propaganda.  We  must  avail  ourselves  of  the 
services  of  all  who  know  in  behalf  of  all  who  do 
not  know.  All  doctors,  nurses,  midwives,  health 
visitors,  sanitary  inspectors  and  welfare  workers 
should  be  missionaries  of  hygiene.  The  admirable 
work  of  the  voluntary  health  societies  could  hardly 
be  overestimated.  Particularly  valuable  was  such 
a  campaign  as  that  represented  in  national  health 
work.  Why  not  have  a  Health  Day  as  well  as  an 
Empire  Day  or  Hospital  Day,  as  a  regular  feature 
of  our  national  life?  Again  it  was  impossible  to 
exaggerate  the  significance  of  the  newspaper  press 
as  an  educational  health  agency.  The  press  had  done 
much,  but  it  might  do  more.  It  was  after  all  the 
daily  literature  of  the  people.  Lastly,  the  govern- 
ment itself  could  not  be  absolved  from  its  share 
of  responsibility  in  begetting  a  wise  public  opinion 
in  health  matters. 


Editorial  Notes  and  Comments 


NEW  YORK  MEDICAL  JOURNAL 

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NEW  YORK,  SATURDAY,  JULY  17,  1920. 


CLINICAL  FORMS  AND  TREATMENT  OF 
BILIOUS  HEMOGLOBINURIC  FEVER. 

There  are  two  forms  of  bilious  hemoglobinuric 
fever,  each  having  a  distinct  symptomatology.  The 
first,  which  breaks  out  at  the  time  of  a  violent  at- 
tack of  malaria,  commences  with  a  severe  chill. 
The  temperature  attains  103°  to  105°  F,  accom- 
panied by  restlessness,  occasionally  by  delirium,  and 
attempts  at  vomiting.  The  urine  is  scanty  and  light 
red  in  color.  There  is  a  mild  yellow  tinge  to  the 
skin,  the  pulse  is  rapid  but  regular,  the  spleen 
hyper trophied,  and  the  liver  slightly  enlarged. 

In  the  second  form  of  the  process,  which  arises 
'  in  chronic  malarial  patients  when  some  secondary 
cause  intervenes,  there  is  no  chill,  the  temperature 
never  goes  as  high  as  in  the  first  form  of  the  pro- 
cess, while  the  restlessness  and  vomiting  are  absent. 
The  urine,  which  is  voided  in  large  amount,  is 
melanic,  the  tint  of  the  skin  is  frankly  icteric,  and 
the  pulse  depressible.  The  heart  sounds  are  dimin- 
ished in  clearness  and  the  spleen  and  liver  are  hy- 
pertrophied.  This  is  the  more  dangerous  of  the 
two  forms  because  the  patients  have  been  weakened 
by  long  continued  malaria,  the  cardiac  muscle  is 
wanting  in  tonicity,  while  the  hemoglobinuria 
reaches  its  maximum  degree  from  the  onset. 

The  general  treatment  consists  of  an  enema  given 
at  a  temperature  of  99°  F.  followed  by  a  dose  of 
sodium  sulphate.  This  should  be  repeated  every 
morning.  In  the  first  form  twenty  centigrams  of 
sulphate  or  hydrochlorate  pf  quinine  should  be  in- 
jected at  once  and  after  this  has  been  done  the  urine 


should  be  collected  at  least  everv  two  hours  and  the 
tube  containing  the  sample  held  against  a  sheet  of 
white  paper  in  order  to  appreciate  the  color.  The  red 
tint  of  the  urine  slowly  decreases  in  intensity.  The 
temperature  is  simultaneously  taken  with  each  urine 
examination  and  is  compared  with  the  successive 
notations  of  the  colorimetric  scale  of  the  urine.  The 
quinine  injection  should  be  repeated  only  when 
there  is  a  drop  in  the  temperature  and  a  decrease  in 
the  intensity  of  the  color  of  the  urine.  When  the 
proper  time  has  come,  whicli  may  be  delayed  for 
eight,  ten  or  even  twelve  hours,  it  is  better  to  give 
two  injections  of  ten  centigrams  each  at  one  or  two 
hour  intervals  than  a  single  injection  of  twenty 
centigrams.  When  the  temperature  has  become  nor- 
mal and  the  urine  clear,  the  patient's  condition 
should  be  followed  and  the  heart  especially 
watched. 

In  the  second  form  of  the  process  a  very  large 
dose  of  camphorated  oil  should  be  injected  at  the 
onset  and  the  urins  and  temperature  examined 
and  compared,  as  stated  above.  The  hemoglobin- 
uria is,  in  this  case,  regarded  as  a  secondary  process 
by  Houssian,  and  he  believes  that  the  cardiac  dis- 
turbances are  the  all  important  feature  of  the  con-  • 
dition.  If  they  subside,  the  hemoglobinuria  will  have 
a  tendency  to  disappear  spontaneously.  Diuretics 
are  useless  in  this  form  and  quinine  will  only  activate 
the  destruction  of  the  red  blood  corpuscles.  It  is  only 
later  on,  when  the  hemoglobinuria  has  become  less 
intense,  that  quinine  and  arsenic  may  be  exhibited 
to  control  the  paludism. 


THE  ONTARIO  MEDICAL  ASSOCIATION. 

On  May  25,  1920,  and  the  three  following 
days,  the  annual  meeting  of  the  Ontario  Medical 
Association  convened  in  Toronto  under  the  presi- 
dency of  Dr.  Fred  W.  Marlow.  It  is  said  to  have 
been  one  of  the  most  successful  meetings  in  the 
history  of  the  organization.  Perhaps  the  direct 
contributory  cause  of  this  may  be  assigned  to  the 
rather  extensive  and  ambitious  efforts  of  recent 
years  in  the  formation  of  county  societies  and  dis- 
trict societies  which,  along  with  the  city  societies, 
have  now  representation  on  a  body  styled  the  Com- 
mittee of  General  Purposes.  This  arrangement 
gives  widespread  and  rather  close  connection  with 
medical  men  in  all  parts  of  the  province  of  On- 
tario— and  where  is  the  man  who  does  not  like  to 
have  a  seat  in  the  inner  circle? 

Immigration  and  alcohol  were  live  topics. 
Regarding  the  former,  the  special  committee  on 


July  17,  1920.] 


EDITORIAL  ARTICLES 


lOI 


legislation  recommended  that  classes  be  established 
by  school  boards  for  the  training  of  mentally  de- 
fective children ;  that  stringent  immigration  laws 
against  bringing  mental  defectives  into  Canada  be 
enacted ;  that  there  be  legislation  to  prevent  their 
marriage ;  and  that  students  in  medicine  be  more 
intensively  educated  in  psychopathology.  There  are 
seven  government  vendors  of  liquor  in  Ontario — 
two  in  Toronto,  and  one  each  in  Ottawa,  Hamilton, 
Windsor,  London  and  Kingston.  It  was  the  opinion 
that  the  number  of  these  should  be  increased  and 
that  their  offices  should  remain  open  on  Saturday 
afternoons  and  Sundays.  It  was  also  suggested 
that  doctors  should  refuse  to  write  prescriptions  for 
government  vendors,  as  all  such  prescriptions  should 
go  to  druggists.  That  the  Ontario  Temperance  Act 
is  a  very  unpopular  measure  was  evidenced ;  and 
it  is  even  so  considered  by  the  Government  of  the 
province  itself,  which  has  appointed  a  special  com- 
mittee of  the  legislature  to  inquire  into  the  ad- 
ministration of  the  act.  There  is  a  growing  feel- 
ing that  not  a  quart  but  an  eight  ounce  bottle  should 
be  the  maximum  for  prescriptions. 

President  Marlow  felt  strongly  that  there  should 
be  some  system  for  checking  up  the  general  prac- 
titioner. Particularly  was  he  caustic  in  his  re- 
marks on  the  man  who  was  too  busy  to  take  a 
few  days  off  to  attend  the  meeting  of  the  provin- 
cial medical  organization.  This,  however,  was  an 
old  topic  even  before  the  president  came  into  active 
propaganda  work  on  this  topic.  Dr.  Marlow's  spe- 
cial designation  of  the  shirkers  was  chronic  fossils. 
It  takes  a  long  time  to  become  a  fossil,  but  what 
would  an  acute  fossil  be  like?  Dr.  Marlow  would 
give  the  Medical  Council  of  Ontario  power  to  ex- 
pel, suspend,  or  order  further  courses  of  study 
where  a  practitioner  was  found  incompetent.  Con- 
sider what  is  ahead  of  one -as  an  old  man!  The 
great  lack  of  hospital  accommodation  and  of  pro- 
fessional nurses  was  another  subject  dealt  with  by 
Marlow.  He  thought  that  the  extension  of  hos- 
pitals must  be  faced  by  the  municipality  in  the 
future,  and  that  there  was  a  particular  need  for 
women  trained  as  nurses  and  with  a  good  knowl- 
edge of  domestic  science.  His  pronouncement  on 
medical  education  against  the  six  year  course  was 
wise,  in  that  the  student  was  stuffed  and  would  be 
better  for  having  opportunity  for  postgraduate 
study. 

Dr.  Charles  W.  Service,  of  West  China,  pressed 
upon  the  association  the  needs  of  the  West  China 
Medical  School.  In  China  lack  of  sanitation  was  the 
greatest  problem.  Mortality  was  probably  forty 
to  fifty  to  the  thousand  in  adults  and  fifty  to 
seventy  to  the  thousand  in  children.  The  medical 
and  surgical  fields  were  enormous.  He  said  that  it 


was  intended  to  make  the  West  China  Medical 
School  a  Canadian  institution. 

A  very  interesting  address  was  that  of  Dr.  Ariel 
W.  George,  of  Tufts  Medical  College,  Bos- 
ton. It  was  on  the  use  of  the  x  ray  in  the  in- 
terpretation of  symptoms  referable  to  the  biliary 
system,  and  was  illustrated  with  lantern  slides.  Prof. 
N.  W.  Percy,  of  the  University  of  Illinois, 
dealt  with  the  subject  of  the  transfusion  of  whole 
blood,  which  should  be  carried  out  only  after  care- 
ful selection  of  the  donor.  Its  use  in  pernicious 
anemii  occupied  a  good  part  of  his  address.  Evi- 
dence was  forthcoming  that  the  high  cost  of  living 
was  affecting  the  medical  practitioner  in  Ontario. 
Indeed,  in  some  cities  and  towns  fees  have  already 
been  advanced  from  two  dollars  to  three  dollars  a 
call  and  five  dollars  for  emergency  visits  and  visits 
after  six  o'clock  p.  m.  Additional  advance  in  fees 
for  insurance  examinations  was  a  live  topic,  and 
larger  fees  for  workman's  compensation  injuries 
were  demanded.  Dr.  Gwyn,  Toronto,  in  reading 
a  paper  on  influenza,  said  that  this  disease  generally 
came  in  three  successive  waves,  that  last  fall 
witnessed  the  final  wave  and  that  Ontario  was 
not  likely  to  be  visited  again  in  the  fall  of  1920. 


THE  TREATMENT  OF  DYSPHAGIA  IN 
TUBERCULOUS  LARYNGITIDES. 

Dysphagia  is  one  of  the  most  common  symptoms 
of  tuberculosis  of  the  larynx,  at  least  at  the  terminal 
phase  of  the  process,  and  is  one  of  the  difficulties 
encountered  in  the  care  of  those  unfortunate  pa- 
tients who  are  unable  to  eat.  and  contributes  toward 
making  tuberculosis  of  the  larynx  one  of  the  most 
distressing  affections  with  which  we  have  to  deal. 
Its  cause  resides  in  the  edema,  or  rather  the  infiltra- 
tion of  the  upper  structures  of  the  larynx — epiglottis, 
arytenoids,  and  ar}'tenoepiglottic  folds,  with  or 
without  ulceration. 

The  sensory  nerve,  whose  territory  corresponds 
with  the  laryngeal  vestibulum,  is  exclusively  the  su- 
perior laryngeal  which,  before  penetrating  into  the 
cavity  of  the  larynx,  passes  very  superficially  be- 
tween the  lower  border  of  the  os  hyoid  and  the  up- 
per border  of  the  thyroid  cartilage.  If  the  exam- 
iner pushes  the  left  side  of  the  larynx  with  a  finger  of 
the  right  hand,  the  thumb  of  the  same  hand  will  dis- 
tinctly feel  the  large  horn  of  the  hyoid,  the  horn  of 
the  thyroid  and  the  free  thyrohyoid  space.  A  little 
stronger  pressure  over  this  area,  especially  on  the 
diseased  larynx,  will  at  once  give  rise  to  rather  sharp 
pain,  shooting  to  the  external  auditory  canal,  on 
account  of  the  superior  laryngeal  nerve  being  di- 
rectly under  the  examiner's  finger. 

The  dysphagia  can  be  controlled  in  most  cases  by 


102 


NEIJ'S  ITEMS. 


[New  York 
Medical  Journal. 


regional  anesthesia  and  the  best  procedure  consists 
in  pricking  the  nerve  at  the  point  where  it  underUes 
the  skin,  and  injecting  a  few  drops  of  eighty-five 
per  cent,  alcohol  along  the  nerve.  There  is  a  sharp 
pain  at  first,  extending  to  the  ear,  which  proves  that 
the  injection  has  reached  the  proper  structures.  The 
pain  lasts  for  but  a  few  seconds  and  is  followed  by 
a  complete  analgesia  and  the  entire  disappearance 
of  the  dysphagia.  The  eflFect  on  both  the  mental 
state  and  the  physical  condition  of  the  patient  is  nat- 
urally considerable.  It  is  curious  to  note  that  the 
edema  and  infiltration  diminish  and  the  mucosa  as- 
sumes its  normal  volume.  On  the  other  hand,  the 
laryngeal  lesions  can  be  directly  treated  and  the 
patient  properly  fed. 

This  anesthesia  may  last  for  several  months  f ol- , 
lowing  a  single  injection,  in  other  subjects  the 
amelioration  is  for  only  a  few  days,  but  it  often 
happens  that  after  six  or  seven  injections  a  perma- 
nent anesthesia  ensues.  This  treatment  is  practically 
devoid  of  danger,  if  the  operator  exercises  a  little 
care,  and  does  not  require  any  special  technical 
knowledge  other  than  the  requisite  amount  of  knowl- 
edge of  regional  anatomy  which  every  practitioner 
should  possess. 


ILLINOIS  AND  HER  SUBNORMAL 
CITIZENS. 

"I  am  convinced  that  thousands  of  persons  daily 
walk  the  streets  of  Chicago  who,  because  of  their 
mentality,  are  not  fit  to  be  at  large.  Should  they 
be  arrested  for  petty  larceny  they  may  be  impris- 
oned two  or  three  years,  but  imprisonment  or  psych- 
ological care  will  not  create  brains  and  a  man  can- 
not be  always  in  prison  in  case  he  should  commit 
some  crime  when  released."  J.  L.  Whitman,  super- 
intendent of  prisons  for  Illinois,  in  saying  this  wel- 
comes the  new  parole  law  of  from  two  to  five  years 
for  the  subnormal  prisoner. 

Even  with  all  that  societies  can  do  for  these 
and  for  defective  children  they  remain  a  care 
to  the  State,  even  a  menace  to  society.  At  the 
end  of  1919,  Illinois  alone  had  19,194  cases  classed 
under  mental  in  her  penal  institutions. 

Of  course  if  they  could  always  be  kept  impris- 
oned for  fear  of  what  they  might  do,  matters  would 
be  more  simple,  but  it  is  only  when  a  paroled  person 
feverishly  and  gustatorily  commits  some  horrible 
crime  that  shocked  normals  concur  in  the  advan- 
tages to  be  gained  from  institutional  life  run  on  a 
scientific  and  humane  basis.  But  it  will  be  costly, 
for  beside  those  actually  committed  as  subnormal, 
preventive  work  beginning,  one  might  almost  say, 
at  a  prenatal  stage,  must  have  more  and  more  recog- 
nition. Illinois  is  now  building  a  large  graded  prison 
offering  opportunities  by  a  progressive  merit  sys- 
tem, and  the  Department  of  Public  Welfare  is  well 
staffed  with  clever  men,  but  will  leading  citizens  on 
its  opening  day  give  due  reflection  to  the  horrible 
necessity  such  a  building  suggests  in  any  State? 


FAMILY  TREES. 

There  are  many  men  in  the  United  States  who, 
when  in  America,  will  loudly  proclaim  their  con- 
tempt for  aristocrats,  blue  blood,  and  lordly  castles, 
but  such  men  are  often  found  in  the  British  Mu- 
seum or  the  Royal  College  of  Arms  seeking  to  trace 
their  family  back  to  some  denounced  aristocrat  or 
old  county  family  in  England. 

When  compiled  such  a  document  is  of  great  in- 
terest to  all  relations,  but  names,  dates,  and  titles 
do  not  enthuse  the  physician  or  the  student  of 
eugenics,  who  would  gain  more  interesting  facts 
from  the  family  tree  of  Mark  Twain,  which  had. 
as  the  owner  remarked,  only  one  branch  (with  a 
noose  attached). 

The  Eugenics  Record  Ofiice  rather  fancies  such 
one  branched  trees ;  at  any  rate,  it  is  offering 
four  leaved  ones  to  those  who  will  follow  instruc- 
tions given  and  chart  in  four  generations  giving  as 
much  as  possible  concerning  their  character.  The 
Family  Tree  Folder,  when  filled  in,  will  be  a  com- 
plete modern  eugenic  record.  It  will  give  natural, 
physical,  mental,  and  temperamental  traits,  so  that 
their  segregation  and  recombination  may  be  traced 
in  a  definite  manner. 

 ^>  

News  Items. 


Yellow  Fever  in  Vera  Cruz. — A  press  dispatch 
from  Vera  Cruz  states  that  several  new  cases  of 
yellow  fever  have  occurred  there. 

Irish  Medical  Meeting. — The  annual  meeting 
of  the  Irish  Medical  Association  was  held  June  17th 
under  the  presidency  of  Dr.  J.  Marshall  Day.  Dr. 
E.  Magennis  was  elected  president. 

United  States  Hospital  No.  28  to  Close. — An- 
nouncement has  been  made  that  U.  S.  General 
Hospital  No.  28,  at  Fort  Sheridan,  111.,  will  probably 
be  closed  on  October  1st. 

Dr.  E.  P.  Lyon  Honored.— Dr.  E.  P.  Lyon, 
dean  of  the  medical  school  of  the  University  of 
Minnesota  and  formerly  dean  of  the  St.  Louis 
University,  has  been  awarded  the  honorary  degree 
of  LL.  D.  by  the  latter  institution. 

Dr.  S.  Josephine  Baker  Appointed. — Dr.  S.  Jo- 
sephine Baker,  director  of  the  Bureau  of  Child 
Hygiene  of  the  Department  of  Health  of  New  York 
City,  has  been  appointed  consultant  in  child  hygiene 
for  the  United  States  Public  Health  Service  and 
has  also  received  a  commission  as  surgeon  in  re- 
serve of  the  Public  Health  Service. 

Plague  Increasing  in  Southern  Regions. — Re- 
ports of  cases  of  bubonic  plague  continue  to  come 
in  from  Texas  and  Florida.  Last  advices  were  to 
the  effect  that  eight  cases  have  occurred  in  Austin. 
Tex.,  with  three  deaths ;  at  Galveston  there  have 
been  three  cases  of  plague,  with  two  deaths,  and 
there  have  been  four  cases  in  Pensacola,  Fla. 

Health  Bureaus  Coordinated. — A  coordination 
of  the  work  of  the  U.  S.  Public  Health  Service  and 
that  of  the  Bureau  of  War  Risk  Insurance  in  car- 
ing for  sick  and  disabled  veterans  of  the  war  is 
shortly  to  be  achieved  by  placing  the  two  bureaus 
under  the  direction  of  one  assistant  secretary  of  the 
treasury. 


July  1",  1920.] 


NEWS  [TE}fS. 


103 


Appointment  of   Dr.   Benjamin   White. — Dr. 

Benjamin  White  has  been  appointed  director  of 
the  division  of  biological  laboratories  of  the  Massa- 
chusetts State  Department  of  Public  Health,  to 
succeed  Dr.  Milton  J.  Rosenau.  resigned. 

Honor  to  Dr.  Alonzo  E.  Taylor. — Dr.  Alonzo 
E.  Taylor,  professor  of  physiological  chemistry  at 
the  University  of  Pennsylvania,  has  been  awarded 
the  honorary  degree  of  Doctor  of  Laws  by  the 
University  of  Wisconsin. 

Brazilian  Hospital  Given  to  France. — The  Bra- 
zilian hospital  installed  during  the  war  at 
Vaugirard,  France,  at  a  cost  of  ten  million  francs, 
has  been  offered  by  the  Brazilian  government  to  the 
French  faculty  of  medicine.  Although  the  hospital 
will  serve  for  the  study  of  general  medicine  and 
surgery,  it  will  be  used  more  particularly  for  teach- 
ing practical  surgery  to  Brazilian  medical  students 
in  Paris. 

United  States  Civil  Service. — The  United 
States  Civil  Service  Commission  announces  exami- 
nations on  October  1st  for  the  following  positions: 
Medical  intern,  St.  Elizabeth's  Hospital,  $1,200  a 
year  and  maintenance ;  bacteriologist,  U.  S.  Public 
Health  Service.  $130  to  $180  a  month ;  assistant 
bacteriologist,  $70  to  $90  a  month  :  junior  bacteri- 
ologist, $70  a  month;  junior  bacteriologist,  part 
time  $30  to  $50  a  month. 

New  York  State  Civil  Service. — The  Civil 
Service  Commission  of  the  State  of  New  York 
announces  examinations  on  July  31st  for  the  fol- 
lowing positions  of  interest  to  medical  men :  As- 
sistant medical  examiner.  State  Industrial  Commis- 
sion (write  for  special  circular)  ;  physician  and 
assistant  physician,  state  institutions,  $1,500  to 
$1,800  and  maintenance;  physician  (psychiatrist), 
Syracuse  State  School  for  Mental  Defectives, 
$2,000  and  maintenance. 

Appointments  and  Promotions  at  the  Rocke- 
feller Institute. — The  board  of  scientific  directors 
of  the  Rockefeller  Institute  for  Medical  Research 
announces  the  election  of  Dr.  Winthrop  J.  V.  Os- 
terhout  as  a  member  of  the  board  to  succeed  Dr. 
Theodore  C.  Janeway,  deceased. 

The  following  promotions  and  appointments  are 
announced :  Dr.  Alfred  E.  Cohn,  hitherto  an  asso- 
ciate member  in  medicine,  has  been  made  a  member. 
Dr.  Peyton  Rous,  hitherto  an  associate  member  in 
pathology  and  bacteriology,  has  been  made  a  mem- 
ber. Dr.  Donald  D.  Van  Slyke,  hitherto  an  associate 
member  in  chemistry,  has  been  made  a  member. 
Dr.  Francis  G.  I^ake,  hitherto  an  associate  in  medi- 
cine, has  been  made  ^n  associate  member. 
Dr.  John  H.  Xorthrup,  hitherto,  an  associate  in 
experimental  biology,  has  been  made  an  associate 
member.  Dr.  James  H.  Austin,  hitherto  an  as- 
sistant in  medicine,  has  been  made  an  associate.  Dr. 
Harry  W.  Graybill,  hitherto  an  assistant  in  the  de- 
partment of  animal  pathology,  has  been  made  an  as- 
sociate. Dr.  William  C.  Stadie,  hitherto  an  as- 
sistant in  medicine,  has  been  made  an  associate. 

The  following  have  been  made  assistants :  Miss 
Helen  L.  Fales  (chemistry),  Dr.  Philip  D.  Mc- 
Master  (pathology  and  bacteriology),  and  Miss 
Marion  L.  Orcutt  (animal  pathology). 

The  following  new  appointments  are  announced ; 


Dr.  Harry  Clark,  associate  member  in  pathology 
and  bacteriology ;  Dr.  Pierre  L.  du  Nouy,  asso- 
ciate member  in  experimental  surgery ;  Dr.  Paul 
H.  de  Kruif,  associate  in  pathology  and  bacteri- 
ology; Dr.  Lloyd  D.  Felton,  associate  in  pathology 
and  bacteriology ;  Dr.  Rudolph  W.  Glaser,  asso- 
ciate in  the  department  of  animal  pathology ;  Dr. 
Carl  A.  L.  Binger,  assistant  in  medicine ;  Dr.  Ralph 
H.  Boots,  assistant  in  medicine ;  Dr.  Louis  A.  Mi- 
keska,  assistant  in  chemistry ;  Dr.  Charles  P.  Miller. 
Jr.,  assistant  in  medicine;  Dr.  Eugene  V.  Powell, 
assistant  in  x  ray ;  Dr.  Leslie  T.  Webster,  assistant 
in  pathology  and  bacteriology :  Dr.  Goronwy  O. 
Broun,  fellow  in  pathology  and  bacteriology ;  Miss 
Katharine  M.  Dougherty,  fellow  in  pathology  and 
bacteriology ;  Dr.  Andre  L.  E.  Gratia,  fellow  in 
pathology  and  bacteriology ;  Mr.  Thomas  J.  Le 
Blanc,  fellow  in  pathology  and  bacteriology ;  Dr. 
Giovanni  Martinaglia,  fellow  in  the  department  of 
animal  pathology;  Mr.  Henry  S.  Simms,  fellow  in 
chemistry. 

Dr.  Marshall  A.  Barber,  hitherto  an  associate 
in  pathology  and  bacteriology,  has  accepted  a  posi- 
tion with  the  U.  S.  Public  Health  Service  to  do 
field  work  in  the  Malaria  Research  Laboratory. 
^Memphis.  Tenn.  Miss  .\ngelia  M.  Courtney, 
hitherto  an  associate  in  chemistry,  has  accepted  an 
appointment  to  do  chemical  research  work  in  the 
Medical  School  of  the  University  of  Toronto.  Dr. 
Carl  Ten  Broeck,  hitherto  an  associate  in  the  de- 
partment of  animal  pathology,  has  accepted  an  ap- 
pointment as  associate  professor  of  bacteriology, 
with  the  Peking  Union  Medical  College.  Mr.  Earl  P. 
Clark,  hitherto  an  assistant  in  chemistry,  has  ac- 
cepted a  position  with  the  Bureau  of  Standards, 
Washington,  D.  C.  Dr.  Ferdinand  H.  Haessler, 
hitherto  an  assistant  in  pathology  and  bacteriology, 
has  accepted  an  appointment  as  resident  pathologist 
in  the  department  for  nervous  and  mental  diseases 
in  the  Pennsylvania  Hospital  at  Philadelphia.  Dr. 
Arthur  B.  Lyon,  hitherto  an  assistant  in  medicine, 
has  resigned  to  enter  private  practice. 

 <$>  

DIED. 

Browx. — In  Boston,  Mass.,  Dr.  Frank  Byron  Brown, 
aged  fifty-seven  years. 

C.\RPEXTER. — In  Pottsville,  Pa.,  on  Sunday,  July  4th,  Dr. 
James  Stratton  Carpenter,  aged  sixty-one  years. 

CoxKLix. — In  New  York,  N.  Y.,  on  Monday,  July  5th, 
Dr.  Fanny  Donovan  Conklin,  aged  seventy-four  years. 

Cope. — In  Nazareth,  Pa.,  on  Sunday,  June  27th,  Dr. 
Thomas  Cope,  aged  seventy-three  years. 

Curtis. — In  New  Britain,  Conn.,  on  Saturday,  June 
26th,  Dr.  John  Henry  Curtis,  aged  fifty-six  years. 

Gray. — In  New  York,  N.  Y.,  on  Saturday,  July  3rd, 
Col.  William  W.  Gray,  aged  sixty-nine  years. 

Holdridge. — In  New  York,  N.  Y.,  on  Saturday,  July  3rd, 
Dr.  Walter  Henry  Holdridge,  aged  forty  years. 

Kellogg. — In  Sacramento,  Cal..  on  Tuesday,  June  22nd, 
Dr.  Donald  A.  Kellogg,  aged  fifty-five  years. 

L.A.XE. — In  Philadelphia,  Pa.,  on  Wednesday,  July  7th, 
Dr.  Peter  Henry  Lane,  aged  forty-one  years. 

Pausox. — In  San  Francisco,  Cal.,  on  Tuesday,  June  29th, 
Dr.  Charles  Arthur  Pauson,  aged  thirty-eight  years. 

ScoFiELD. — In  Dalton,  Mass.,  on  Tuesday,  July  6th,  Dr. 
\\'alter  W.   Scofield,  aged  sixty-six  years. 

Thompsox. — In  Snohomish,  Wash.,  on  Sunday,  June 
20th,  Dr.  Thomas  F.  Thompson,  aged  se\enty-one  years. 


Book  Reviews 


THE  SIX  OF  WEAKNESS. 
Peter  Middleton.    By  Hexry  K.  Marks.    Boston :  Rich- 
ard G.  Badger  (The  Gorham  Press),  1919.    Pp.  v-370. 

There  have  been  noveUsts  of  the  past  who  in- 
tuitively and  unconsciously  used  the  tools  of  psy- 
choanalysis to  represent  their  characters  more 
truly  than  the  superficial  observer  would  appraise 
them.  The  writers  of  the  present  with  a  conscious 
appreciation  of  psychoanalytical  investigation  have 
usually  handled  the  subject  rather  clumsily.  Here, 
X  however,  is  a  writer  who  has  revealed  the  uncon- 
scious side  of  his  hero's  character  with  the  clearness, 
the  interpretation,  the  convincingness  of  a  technical 
psychoanalysist,  and  yet  no  awkward,  inartistic  tool 
work  is  visible. 

One  wonders  whether,  as  such  truer  representa- 
tion of  human  lives  becomes  more  common,  litera- 
ture will  have  to  substitute  some  other  name  than 
hero  for  the  chief  character  of  a  story.  Literature 
has  gradually  descended  from  gods  to  demigods, 
from  demigods  to  heroes,  and  now  to  what?  Will 
it  not  be  a  truer,  more  helpful  revelation  of  a  weak 
and  struggling  fellow  man,  and  the  reason  for  suc- 
cess and  failure  ?  As  the  field  of  knowledge  regard- 
ing ourselves  and  others  is  thus  enlarged  we  shall 
lose  nothing  of  a  genuine  appreciation  of  human 
nature  and  be  better  able  to  develop  a  genuine  hero- 
ism which  meets  successfully  the  actualities  of  lov- 
ing and  living. 

Peter  ^liddleton  was  sufficient  for  neither  of 
these.  He  did  not  know  what  it  was  to  discover 
and  realize  himself,  he  did  not  know  what  was  ex- 
pected of  a  genuine  masculine  self.  He  cherished 
a  lovely  idealism,  a  temperamental,  dreamy  ap- 
preciation of  beauty.  He  called  it  artistic  but  it  had 
none  of  the  true  artist's  strong  creative  tendency. 
It  was  rather  an  escape  from  healthy  activity  upon 
external  things  and  deeper  still  from  a  recognition 
of  inner  vmfailing  fountains  of  power.  The  repei- 
lant  austerity  of  his  mother  must  have  early  driven 
those  deeply  within  and  fixed  them  for  Peter  where 
they  were  incapable  of  being  tapped.  At  least  only 
a  woman  in  later  life  who  comes  first  as  a  wiser 
mother,  deeper  in  tender  creative  wish  and  yet  with 
an  ability  to  become  the  eqv:al  adult  companion,  suc- 
ceeds in  awakening  any  healthy  outward  reaction 
on  the  part  of  Peter.  That,  however,  was  too  late 
for  him  to  escape  the  bonds  which  his  weaknesses 
had  woven  about  him  so  that  the  abject  failure  of 
his  life  could  not  be  stayed. 

Until  it  was  too  late  Peter  had  never  learned 
what  it  was  psychically  and  physically  to  be  a  man. 
His  idealism  was  not  only  a  substituted  escape  from 
the  sterner  facts  of  reality,  it  actually  also  turned 
him  back  to  feed  upon  himself.  There  is  no  escape 
from  the  results  of  a  morbid  absorption  in  self  ex- 
cept through  an  outgiving  relation  to  the  external 
world.  Peter  could  sustain  such  a  relationship  only 
for  a  brief  time  and  in  an  incomplete  ineffectual  way. 
The  products  of  introversion  are  self  pity,  of  which 
Peter  bore  a  heavy  load,  shameful  inadequacy  in 
confronting  insincerely  aggressive  types  of  men, 
spinelessness  and  indecision  in  the  face  of  the  cling- 
ing afifection  and  desires  of  another,  which  form  his 


final  entanglements  and  lead  to  his  complete 
undoing. 

The  author  discloses  with  an  artistic  suggestive- 
ness  and  reserve  the  fundamental  disturbance  in  the 
hero's  nature.  He  was  radically  inef¥ectual  because 
the  sexual  -fountain  of  power  and  interest  in  life 
was  blocked  and  distorted  from  its  true  development. 
He  was  psychically  and  physically  incapable  of  giv- 
ing to  his  first  wife  the  love  which  her  more  healthy 
nature  demanded.  His  imagined  love  for  her  was 
only  a  phantasied  ideal  as  unreal  as  his  dreamy  en- 
joyment of  all  external  beauty.  His  relation  to  his 
second  wife  was  only  the  helpless  reaction  of  a  man 
utterly  incapable  of  thinking  or  acting  for  himself, 
too  ignorant  of  either  his  rights  or  his  duties  to 
avoid  the  marriage  or  to  make  something  workable 
out  of  it  once  he  had  entered  into  the  relationship. 
His  attempts  to  set  things  right  as  well  as  he  can  are 
as  infantile  as  all  his  actions.  His  clumsy,  unsophis- 
ticated method  of  releasing  his  first  wife  from  her 
marriage  bonds  brings  upon  him  a  seemingly  un- 
deserved nemesis  in  the  venereal  infection  which 
later  reappears  twice  in  horrible  form,  first  to  mark 
another  attempted  sexual  outbreak  and  then  finally 
to  ruin  his  second  married  life  and  precipitate  his 
end.  He  has  to  learn  that  the  race  is  not  to  the  weak. 

The  book  is  a  strong  and  fearless  study  of  the  in- 
ner nature  of  a  man  whose  conscious  ideals  and  good 
intentions  could  never  have  furnished  explanation 
for  his  cumulative  failure.  Deeper  study  was 
necessary.  The  writer  has  multiplied  the  details 
of  this  failure  somewhat  unnecessarily.  This 
seems  to  be  a  temptation  to  the  modern  analytical 
type  of  novelist.  It  will  doubtless  be  easier  in 
time  to  handle  the  vast  field  of  unconscious  motives 
more  simply  as  readers  and  writers  grow  better 
acquainted  with  its  features  and  mechanisms. 

Physicians  will  recognize  the  clearcut  clinical 
pictures  of  the  symptoms  of  syphilis.  As  an  object 
lesson  in  the  dangers  of  venereal  disease  it  is  one  of 
the  most  graphic  stories  that  has  ever  been  told. 
While  it  serves  as  a  vehicle  to  convey  the  horrors 
and  farrcaching  effects  of  disease  and  portrays  with 
clarity  the  follies  and  weaknesses  of  men  and  the 
webs  of  their  own  weaving  into  which  they  fall,  it 
does  not  lose  its  artistic  value  at  any  part  of  the 
story. 

HEREDITY  AND  ENVIRONMENT. 

Heredity  and  Environment  in  the  Development  of  Man. 
By  Edwin  Grant  Conklin,  Professor  of  Biology  in 
Princeton  University.  .Second  Printing  of  Revised 
Third  Edition.  Illustrated.  Princeton,  N.  J. :  Princeton 
University  Press;  London:  Humphrey  Milford  (Oxford 
University  Press),  1920.    Pp.  xv-361. 

A  third  edition  of  Conklin's  lectures  delivered  at 
the  Northwestern  and  Princeton  universities  pre- 
sents the  subject  of  the  biology  of  the  human  race 
with  its  chief  theme  of  heredity  in  a  form  enlarged 
and  revised  according  to  recent  advance.  This  is 
an  advance  not  only  in  biological  investigation,  af- 
fording therefore  a  wider  and  surer  basis  for  the 
study  of  heredity  and  development,  but  represents 
also  a  growing  and  broadening  interest  in  these 
problems.    The  latter  is  due  in  part  to  the  growing 


July  17,  1920.] 


BOOK  REVIEWS. 


recognition  of  the  interrelation  of  structure  and 
function,  upon  which  the  writer  lays  emphasis.  It 
rests  also  upon  present  greater  surety  in  regard  to 
the  problems  of  heredity  and  its  fundamental  facts 
with  realization  of  their  importance  in  the  under- 
standing of  the  evolution  and  development  of  both 
mind  and  body.  This  means  a  possibility  of  control 
of  man's  development  toward  a  better  future  ph\si- 
cally  and  in  all  the  departments  of  his  psychic  life. 
The  author  maintains  throughout  his  discussions 
such  an  all  embracing  view  reaching  back  through 
all  development  as  well  as  forward  through  the 
present  responsibility  toward  future  improvement. 
He  recognizes  the  unalterableness  of  heredity,  the 
fixity  of  its  principles  and  facts,  and  at  the  same 
time  the  influence  in  the  unfolding  of  the  race  or  of 
each  individual  in  response  to  the  stimuli  of  the 
environment. 

He  seeks  to  present  practically  and  clearly  the  so- 
ciological implications  of  these  facts,  to  present  the, 
dynamic  relation  of  structure  and  function,  as  well 
as  to  make  plain  the  facts  of  biology  upon  which  all 
this  rests  as  far  as  these  facts  have  been  discovered. 
He  enters,  therefore,  with  a  simplicity  and  definite- 
ness  which  make  the  book  of  practical  value  to  every 
reader,  into  the  subject  of  the  factors  and  stages  of 
development  of  the  body,  particularly  of  the  germ 
cells,  and  of  the  mind  in  its  parallel  growth  and 
development.  Particular  space  is  given  to  the  dis- 
cussion of  heredity  as  it  depends  on  these  elemen- 
tary facts  of  development  and  as  it  in  itself  forms 
a  basis  for  all  further  development  and  conscious 
social  efi^ort  toward  improvement.  The  book  is  pro- 
fusely illustrated  by  figures  taken  from  the  experi- 
mental work  on  germ  cells  and  of  human  and  other 
forms  of  life. 

MODERN  METHODS  OF  ANESTHESIA. 

Handbook  of  Anesthetics.     By  J.   Stuart  Ross,  M.  B., 
Ch.  B.,    F.  R.  C.  S.  E.     With   an    Introduction   by  Hy. 
Alexis  Thomson,  C.  M.  G.,  M.  D.,  F.  R.  C.  S.  E.,  and 
Chapters  upon  Local  and  Spinal  Anesthesia,  by  William 
Quarry  Wood,   M.  D.,   F.  R.  C.  S.  E.,  and  upon  Intra- 
tracheal Anesthesia,  bv  H.  Torrance  Thomson,  M.  D., 
F.  R.  C.  S.  E.     Edinburgh  :  E.  &   S.  Livingstone ;  New 
York:  William  Wood  &  Co.,  1919.    Pp.  214. 
"This  little  book,"  says  Ross  in  his  preface,  "is  an 
attempt  to  present  to  the  student  and  practitioner  a 
condensed  account  of  modern  anesthetic  views  and 
practice."   Let  it  be  said  at  once  that  the  attempt  has 
been  eminently  successful.    The  first  four  chapters 
are  devoted  to  the  factors  that  modify  the  physiology 
of  the  patient  during  an  operation  under  a  general 
anesthetic.    The  author  has  very  wisely  refrained 
from  describing  in  detail  the  technic  of  administer- 
ing the  volatile  anesthetics  and  has  limited  himself 
to  a  consideration  of   the  underlying  principles. 
Throughout  the  volume  emphasis  has  been  laid  on 
the  relations  of  anesthesia  to  general  medical  science 
rather  than  upon  elaborate  descriptions  of  anesthetic 
apparatus  which  a  few  years  hence  may  be  super- 
seded.   The  account  of  the  use  of  nitrous  oxide  and 
oxygen  is  deservedly  full,  for  a  just  appreciation  of 
this  mixture  was  arrived  at  through  the  experiences 
of  the  war.    Gas  and  oxygen  are  the  safest  of  all 
general  anesthetics  and  for  major  operations  should 
be  preceded  by  a  hypodermic  injection  of  morphine 


and  atropine.  During  the  latter  part  of  the  in- 
duction stage,  it  is  well,  especially  for  the  tyro,  to 
give  a  trace  of  ether  A-apor  and  to  maintain  it  until 
the  operation  is  well  under  way.  Gas  oxygen  an- 
esthesia is  indicated  in  minor  operations  lasting  five 
to  fifteen  minutes,  particularly  if  performed  on  out 
patients ;  operations  of  any  variety  upon  the  subjects 
of  severe  shock ;  the  removal  of  tonsils  and  adenoids, 
and  may  be  employed  as  an  adjuvant  to  gas  or  gas 
and  oxygen  and  as  a  help  to  the  speedy  induction  of 
closed  ether.  The  discussion  of  the  accidents  and 
sequelae  of  anesthesia  is  brief,  lurid,  helpful.  In 
the  chapter  on  choice  of  anesthetics  Ross  points 
out  that  the  selection  of  the  drug  and  the  method  de- 
pend on  the  age,  sex,  physical  type,  and  temperament 
of  the  patient,  the  possible  presence  of  some  definite 
pathological  lesion,  and  the  nature  and  duration  of 
the  operation.  Each  of  these  factors  is  expound- 
ed so  clearly  that  the  selection  of  the  proper  anes- 
thetic ought  to  be  relatively  easy.  The  chapter  on 
local  anesthesia  was  written  by  William  Quarry 
Wood.  'The  section  dealing  with  regional  anesthesia 
will  prove  especially  valuable  to  the  surgeon.  The 
chapter  on  spinal  anesthesia,  also  contributed  by 
Wood,  leaves  nothing  to  be  desired.  No  one  who 
has  read  this  very  valuable  little  volume  can  fail  to 
agree  with  Alexis  Thomson,  who  writes  the  intro- 
duction:  "I  feel  on  perfectly  safe  ground  in  recom- 
mending this  book  as  ...  a  reliable  manual  of 
instruction  ...  to  both  the  student  and  the  prac- 
titioner." 

THE  SUPERJOURNALIST. 

Woman  Triumphant.  By  V^.  B.  Ibanez.  Translated  from 
the  Spanish  by  Hayvvard  Reniston.  With  a  Special 
Introductory  Note  by  the  Author.  New  York :  E.  P. 
Button  and  Companj-,  1920.    Pp.  v-322. 

This  novel  has  gone  into  fifteen  editions  in  two 
months.  That  is  its  outstanding  feature,  and  to 
one  who  does  not  take  fifteen  editions  too  seriously 
the  fact  is  suggestive.  It  is  singularly  appropriate 
to  Sefior  Ibanez's  largeness  of  gesture,  his  fertility, 
the  muscularity  of  his  books.  Any  smaller  circula- 
tion for  such  an  expansive  piece  of  writing  would 
be  like  condemning  a  sunflower  to  a  hotbed.  We 
are  glad  the  reading  public  has  a  sense  of  the  fitness 
of  things. 

In  telling  this  story  the  author  invests  with  an 
air  of  romantic  improbability  events  which  are  not 
entirely  improbable.  His  main  character  is  a  figure 
greatly  like  himself — healthy,  frank,  theatrical,  and 
objectively  minded — a  sort  of  superjournalist  in 
painting.  Mariano  is  deflected  from  artistic  sincer- 
ity by  his  wife,  who  will  neither  allow  herself  to  be 
painted  nude  nor  permit  her  husband  to  use  models. 
Ibanez  does  not  quite  dare  to  say  that  prudery  and 
evasiveness  are  fatal  to  good  painting  of  any  kind, 
whether  of  the  human  body  or  of  a  collection  of 
fruit.  Paul  Gauguin,  who  left  his  sympathetic,  re- 
spectable wife  to  go  to  the  South  Sea  Islands  and 
paint,  was  aware  of  this  truth.  But  Mariano  Reno- 
vales  does  not  do  anything  so  indecorous.  Instead 
he  devotes  himself  to  his  wife,  paints  portraits  of 
fashionable  ladies  with  plenty  of  clothing,  and  earns 
a  great  deal  of  money.  And  most  of  the  portraits 
are  bad — Ibanez  at  least  admits  that. 


io6 


BOOK  REVIEJVS. 


[New  York 
Medical  Journal. 


Josephina.  the  wife,  is  left  an  invalid  by  the  birth 
of  a  daughter,  and  the  ugliness  of  ill  health  em- 
bitters both  her  life  and  that  of  ^lariano.  It  is  not 
surprising  that  the  painter  enters  upon  an  affair 
with  a  woman  as  healthy  as  himself  and  that  Jose- 
phina, discovering  it,  grows  more  hostile  and  bitter 
and  ugly,  finally  dying  of  accumulated  resentment. 
Here  is  where  Senor  Ibanez  falls  back  upon  one 
of  those  dexterous  twists  of  the  wrists  which  ac- 
count for  the  fifteen  editions.  The  Countess  of  Al- 
berca,  coming  to  reproach  Mariano  for  his  neglect, 
finds  him  "in  love  with  his  wife — and  after  she 
was  dead  ! '  Shut  up  like  a  hermit  in  order  to  paint  her 
with  a  beauty  which  she  never  had."  "It  is  the  wife 
who  triumphs,"  comments  our  author  in  his  preface, 
"resurrecting  in  spirit  to  exert  an  overwhelming  in- 
fluence over  the  life  of  a  man  who  wished  to  live 
without  her.  .  .  .  Renovales,  the  hero,  is  simply 
the  personification  of  human  desire,  this  poor  desire 
which,  in  reality,  does  not  know  what  it  wants,  eter- 
nally fickle  and  unsatisfied." 

To  Ibanez  this  character  may  be  the  personifica- 
tion of  human  desire,  but  to  the  reviewer  he  is  a 
horrible  example  of  what  happens  to  those  who 
temporize.  Mariano  sacrifices  his  art  first  to  ro- 
mantic love  and  second,  when  that  love  has  van- 
ished, to  a  sense  of  duty,  and  when  he  does  break 
away  it  is  not  toward  freedom  but  only  to  a  hectic 
relationship  with  an  indiscriminate  woman.  The 
outcome  is  the  only  possible  one  :  Mariano  at  the  end 
of  his  career  is  alone,  his  talent  fading,  and  all  that 
he  has  left  is  the  delusion  that  he  has  always  loved 
his  wife  and  that  she  has  always  loved  him  !  A  more 
ironic  situation  could  not  be  imagined,  but  the 
trouble  is  that  Ibanez  has  taken  it  with  entire  seri- 
ousness as  regards  the  external  events  and  with  a 
total  want  of  psychological  understanding.  He  has 
neither  the  sensuality  of  Mr.  Robert  \V.  Chambers 
nor  the  sentimental  morality  of  Mr.  Harold  Bell 
Wright  and  he  is  less  insular  than  either,  yet  he 
stands  on  the  same  plane.  He  writes  astonishingly : 
the  story  is  unfolded  with  an  overflowing  ampli- 
tude ;  the  author  has  a  detailed  and  dramatic  knowl- 
edge of  many  sorts  of  human  beings,  and  a  seeming- 
ly endless  store  of  energy  with  which  to  write  about 
them.  Nevertheless,  his  observation  is  essentially 
that  of  the  journalist — alive  to  dramatic  possibili- 
ties and  the  pageantry  and  color  of  life,  recording 
itself  with  facility,  and  not  concerned  with  what 
lies  beneath  the  surface.  He  might  in  fact  be  called 
the  super  journalist. 

ADVENTURES  IN  SOUTH  AIMERICA. 

The  Purple  Land.  By  W.  H.  Hudson.  Author  of  Green 
Mansions,  etc.  With  an  introductory  note  by  Theodore 
Roose\t:lt.  New  York :  E.  P.  Button  and  Company, 
1916.    Pp.  v-355. 

The  modern  man,  though  he  may  now  travel 
imder  or  above  the  land,  has  little  time  to  travel 
back  to  satisfy  his  curiosity  concerning  the  begin- 
nings of  civilization  and  still  less  to  dream  of  the 
possibilities  of  natural  wealth  in  coimtries  still  not 
wholly  known.  What,  then,  should  be  known  of 
the  romance,  the  customs,  the  manners  of  those  who 
inhaliit  them  ?  Any  encyclopedia  will  tell  him  that 
"The  Purple  Land"  (Banda  Orient^)  was  dis- 
covered by  Alagellan  in  1500;  and  in  1515,  Juan 


Diaz  da  Solis,  while  searching  for  passage  into- 
the  Great  South  Sea,  entered  the  Rio  de  la  Plata;, 
that  in  1535  Buenos  Aires  was  founded,  a  city 
which,  in  conjunction  with  its  own  colony,  Mon- 
tevideo, virtually  monopolized  the  history  of  a  re- 
gion equal  in  extent  to  Western  Europe.  It  re- 
mains for  the  gentle  but  determined  adventurer,, 
the  scientist,  the  novelist,  and  the  poet  to  entrance 
our  restlessness  with  the  real  story  of  a  country. 

So  one  is  glad  that  W.  H.  Hudson  gives  us  "The 
narrative  of  one  Richard  Lamb's  Adventures  in  the- 
Banda  Oriental,"  glad  that  his  book,  first  issued  in 
1885,  has  seen  a  new  edition,  for  the  disappointed 
stay-at-home  traveler,  the  naturalist,  and  those  whc 
love  stories  of  hairbreadth  escapes,  will  find  satis- 
faction and  delight  in  sharing  Richard  Lamb's: 
journey  of  perils  and  astonishments  and  learn  with 
him  the  curious  unwritten  legends  and  stories  in 
which  the  people  delight.  Those  who  know  some- 
thing of  this  vast  country  will  recognize  many 
places  he  mentions  and  the  true  portraiture  he  gives ; 
those  who  hardly  hope  to  go  ajourneying  will  have 
their  imagination  so  stimulated  that  pale  thought 
will  almost  seem  vital  reality,  even  as  it  happened  tO' 
the  low  salaried  clerk,  who  at  holiday  time  bought  a 
railway  guide  and  spent  a  few  hours  at  a  crowded 
London  terminus.  Imagination  furnished  the  rest 
of  the  vacation. 

 ^  

New  Publications  Received. 


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


WHISPERS.  By  Louis  Dodge.  New  York :  Charles  Scrib- 
ner's  Sons,  1920.    Pp.  i-261. 

WARD  T.\iJES.  By  E.  C.  Davies,  V.  A.  D.  New  York  and" 
London:  John  Lane  Company,  1920.    Pp.  i-211. 

jo.\x  OF  THE  ISLAND.  Bv  Ralph  Hexry  Barbour  and 
H.  P.  Holt.    Boston:    Small,  Maynard  &  Co.    Pp.  i-292. 

THE  WHITE  MOLL.  By  Frank  L.  Packard,  Author  of 
From  Now  On,  The  Night  Operator,  etc.  New  York. 
G.  H.  Doran  &  Co.    Pp.  v-306. 

PROCEEDINGS  OF  THE  MEDIC.\L  CONFERENCE  HELD  .A.T  THE 
INVIT.-VTION    OF    THE    COMMITTEE    OF    RED    CROSS  SOCIETIES,. 

Cannes,  France,  April  1  to  11,  1919.  Illustrated.  Geneva^ 
Switzerland :  The  League  of  Red  Cross  Societies,  1919. 
Pp.  vi-179. 

FEDER.\L  INCOME  TAX.  War  Profits  and  Excess  Profits. 
Taxes.  Including  Stamp  Ta.xes,  Capital  Stock  Tax,  ^  Tax 
on  Employment  of  Child  Labor.  By  George  E.  Holmes 
of  the  New  York  Bar.  Illustration.  Indianapolis :  The 
Bobbs-Merrill  Co.,  1920.   Pp.  xv-1151. 

THE  BEST  PSYCHIC  STORIES.  Edited,  with  a  Preface  by 
Joseph  Lewis  French.  Editor  of  Great  Ghost  Stories,  Mas- 
terpieces of  Mystery,  etc.  Introduction  by  Dorothy  Sc.\r- 
BOROUGH,  Ph.D.,  Lecturer  in  English,  Columbia  University. 
Author  of  The  Supernatural  in  English  Literature,  From 
a  Southern  Porch,  etc.  New  York:  Boni  &  Liveright. 
Pp.  xv-299. 

A  DICTIONARY  OF  TREATMENT  INCLUDING  MEDICAL  AND' 
SURGICAL     THERAPEUTICS.       Bv      SiR      WiLLIAM  WhITL.\, 

M.A.,  M.D.,  LL.D.,  M.P..  Late  Professor  of  Materia 
Medica  and  Therapeutics  in  Queen's  University,  Belfast, 
Consulting  Physician  to  Royal  Victoria,  Belfast  Ophthal- 
mic and  the  Ulster  Hospitals  for  Women  and  Children. 
Sixth  Edition.  Chicago:  Chicago  Medical  Book  Company, 
1920.    Pp.  viii-1083. 


Miscellany  from  Home  and  Foreign  Journals 


Thyroid  Feeding  Action  on  the  Pancreas. — 

Hirotoshi  Hoshimoto  (Endocrinology,  January- 
March,  1920)  says  that  nine  normal  male  and  five 
normal,  nonpregnant  female  whit^  rats  were  fed 
for  several  weeks  on  bread  and  milk.  The  diastase 
content  of  the  pancreas  varied  ( Wohlgemuth's 
method)  from  25,000  to  35,000  units  in  males  and 
16,700  to  50,000  in  females.  The  average  for  both 
sexes  was  24,717.  Feeding  dry  thyroid  in  doses 
of  0.5  to  0.1  gm.  resulted  in  a  marked  decrease  of 
the  diastatic  activity  of  the  pancreas  varying  from 
forty  to  ninety-two  per  cent.  This  was  accom- 
panied by  a  diminution  of  the  acidophile  granules  of 
the  pancreas  cells.  Large  doses  of  thyroid  were 
more  effective  than  small,  but  the  effects  in  different 
animals  were"  A-ariable.  The  diastase  content  of  the 
intestinal  /nice  was  also  decreased  in  some  cases  by 
the  thyroid.  In  such  positive  cases  the  appetite  was 
markedly  depressed  and  the  feces  were  soft ;  in  ex- 
treme cases  they  contained  considerable  quantities 
of  fat.  Thyroid  feeding  frequently  resulted  also  in 
marked  enlargement  of  the  pancreas.  In  such  cases 
the  pancreatic  diastase  was  often  decreased  even 
when  the  amount  of  food  consumed  and  the  intes- 
tinal diastase  were  augmented.  The  decrease  can- 
not be  ascribed  to  general  metabolic  perturbation 
since  it  frequently  antedated  any  evidence  of  such : 
it  is  rather  ascribed  to  stimulation  of  diastase  dis- 
charge from  the  pancreas. 

Intestinal    Parasites   in   Filipino    Children. — 

F.  G.  Haughwout  and  F.  S.  Horrilleno  {Philippine 
Journal  of  Science,  January,  1920)  studied  100  sick 
Filipino  children  with  regard  to  intestinal  parasit- 
ism. Ninety-two  per  cent,  were  foimd  infested 
with  one  or  more  parasites.  Under  one  year  the 
incidence  was  66.6  per  cent.,  and  between  the  first 
and  second  years,  73.6  per  cent.  All  the  children 
between  two  and  thirteen  years  were  found  para- 
sitized. No  protozoon  of  proved  pathogenicity  was, 
however,  encountered  in  the  series.  It  is  suggested 
that  an  apparent  immunity  of  children  to  forms 
such  as  Entamoeba  histolytica  and  Balantidium  may 
have  a  physiological  basis  in  the  child.  The  inci- 
dence of  infection  with  Spirochsta  eurygyrata  was 
high — sixty-one  per  cent.  The  authors'  experience 
coincides  with  that  of  other  workers  who  have 
failed  to  record  any  definite  train  of  symptoms 
attributable  to  intestinal  parasites  other  than  those 
that  are  specifically  pathogenic.  Concomitant  in- 
festation with  Trichuris  and  Ascaris,  however,  is 
accompanied  by  an  almost  characteristic  train  of 
symptoms  referable  to  the  digestive  tract.  Combin- 
ation of  these  two  helminths  is  especially  serious, 
the  entire  alimentary  tract  being  involved.  Chil- 
dren occasionally  purge  themselves  of  Ascaris  in- 
fections, particularly  if  complicated  by  Trichuris 
infection,  through  vomiting  or  defecation  of  the 
worms,  or  both.  Helminthal  infections  were  re- 
stricted to  the  nematodes.  ^  Respiratory  diseases 
Other  than  tuberculosis,  influenza,  and  pleurisy 
were  met  in  thirty-three  per  cent,  of  the  children 
studied.  The  lung  stages  of  Ascaris  may  be  re- 
sponsible   for    much    of    the    respiratory  disease 


among  Filipino  children.  Hookworm  infection  was 
found  in  twelve  per  cent,  of  the  series ;  only  one 
severe  case  was  recorded.  Sanitary  conditions  are 
a  heavy  factor  in  the  infection  of  children,  but  the 
weak  link  lies  in  the  failure  to  educate  mothers  in 
the  principles  of  domestic  hygiene.  A  given  city 
may  be  clean  to  educated  people  but  insanitary  with 
respect  to  the  child.  Campaigns  through  the  schools, 
visiting  nurses,  and  physicians  should  be  instituted. 
Parasitism  starts  coincidently  with  bottle  or  artifi- 
cial feeding  and  even  breast  fed  children  do  not 
escape  in  all  cases.  Intestinal  parasitism  contributes 
heavily  toward  the  high  death  rate  of  young  Fili- 
pino children.  Endolimax  nana  and  Dientamoeba 
fragilis  are  reported  for  the  first  time  from  the 
Philippine  Islands.  Eutrichomastrix  is  provisional- 
ly reported. 

Surgery  of  the  Chest. — Berkeley  Moynihan 
(British  Journal  of  Surgery,  i\.pril,  1920)  gave  the 
results  of  his  experiences  as  follows :  Forty-nine 
cases  were  treated  by  operation ;  two  patients  died, 
one  from  hemorrhage  following  the  removal  of  a 
projectile  from  the  root  of  the  lung,  and  one  from 
sepsis  after  the  removal  of  an  infected  foreign 
body  and  a  piece  of  clothing.  The  late  history 
has  been  obtained  in  forty-three  cases.  Twenty- 
four  patients  are,  they  say,  in  perfect  health,  and 
are  able  to  do  heavy  work.  Fourteen  of  these  pa- 
tients are  better  than  before  operation,  but  still 
have  some>'5hortness  of  breath,  or  unusual  respira- 
tory trouble  when  having  a  cold,  or  in  bad  weather. 
Some  are  a  little  better  since  the  operation.  Two 
patients  died ;  three  are  unable  to  do  any  work, 
or  have  serious  respiratory  trouble,  shortness  of 
breath,  cough,  etc.  All  but  five  were  operated  on 
by  the  ordinary  anterior  method.  The  five  operated 
on  by  direct  attack  from  behind  show  four  with 
good  ultimate  results,  one  with  fair  result.  Eigh- 
teen of  the  foreign  bodies  were  examined  bacterio- 
logically;  eleven  were  infected  with  Staphylococcus 
aurus,  or  Streptococcus  brevis  in  equal  numbers,  or 
by  these  organisms  together  with  coliform  bacilli ; 
seven  were  sterile.  Empyema  after  operation  devel- 
oped in  five  cases,  and  in  each  of  these,  when  the 
foreign  body  was  examined,  it  was  found  to  be 
infected.  In  twelve  cases  blood  collected  after 
operation  in  sufficient  quantity  to  require  aspira- 
tion. In  all  these  the  adhesions  were  dense,  and 
were  widely  separated.  These  twelve  include  the 
five  reported  above  in  which  empyema  subsequently 
developed.  Of  the  seven  which  did  not  suppurate, 
only  once  was  the  foreign  body  examined,  and  it 
was  sterile.  In  ten  cases  the  original  injury  had 
been  followed  by  empyema.  The  only  effect  this 
had  at  the  time  of  removing  the  foreign  body  was 
that  adhesions  were  found  to  be  very  dense  and 
extensive.  Three  cases  were  reported  as  having 
had  hemothorax  at  the  time  of  the  original  injury  ; 
at  the  operation  for  removing  the  foreign  body, 
adbesions  were  dense ;  in  two  of  these  three  cases 
an  exceedingly  thick  blanketlike  membrane  had  to 
be  removed  by  scissors  to  allow  the  expansion  of 
the  lung. 


Io8  MISCELLANY  FROM  HOME  AND  FOREIGN  JOURNALS.  [N'ew  Vork 

Medical  Tourxal 


Intussusception    in    Typhoid    Fever. — A.  L. 

Moreton  (British  Journal  of  Surgery,  April,  1920) 
came  to  the  following  conclusions : 

1.  Acute  intussusception  is  one  of  the  rare  ab- 
dominal complications  of  typhoid  fever. 

2.  It  may  occur  at  any  time  during  the  progress 
of  the  disease,  but  usually  late  or  during  a  relapse. 

3.  It  may  be  caused  by  irregular  peristalsis  due 
to  inflammatory  changes  in  the  wall  of  the  gut, 
or  an  enlarged  Peyer's  patch  may  start  the  process 
of  intussusception. 

4.  The  intussusception  is  more  commonly  of  the 
enterocolic  type.  If  of  the  enteric  type,  there  may 
be  more  than  one  lesion. 

5.  The  differential  diagnosis  from  perforation 
may  be  difficult. 

6.  The  prognosis  is  goo<T  if  the  patient  is  sub- 
mitted to  operation,  and  the  results  of  operative 
treatment  are  better  than  those  of  perforation. 

7.  In  reducing  the  intussusception  at  operation, 
it  should  be  borne  in  mind  that  diseased  bowel  is 
being  dealt  with,  and  that  the  utmost  gentleness 
should  be  used  in  all  manipulations. 

Protein  Sensitization  in  Bronchial  Asthma  and 
Hay  Fever. — Charles  X.  Hensell  (Minnesota 
Medicine,  April,  1920)  states  that  foreign  proteins 
may  enter  the  body  chiefly  through  three  different 
channels,  i.  e..  inhalation,  ingestion,  and  infection. 
In  the  inhalation  type  there  are  four  sources,  name- 
ly, 1,  animal  hair  and  dandruff':  2.  pollens:  3.  flodr, 
and  4,  dust.  In  the  ingestion  type  there  is  but  one 
source,  namely,  food.  The  chief  food  offenders  in 
order  of  importance  are,  1,  cereals,  such  as  wheat, 
com,  rice,  rye ;  2.  eggs ;  3,  fish,  such  as  lobster,  sal- 
mon, mackerel,  and  cod :  4,  casein ;  5,  beef ;  6, 
chicken;  7,  cocoa.  Walker's  proportion  of  the 
various  causative  factors  is  twenty  per  cent,  sen- 
sitive to  horse  dandruff,  fifteen  per  cent,  to  wheat, 
fifteen  per  cent,  to  staphylococcus  pyogenes  aureus, 
fifteen  per  cent,  to  early  pollens,  ten  per  cent,  to  late 
pollens,  five  per  cent,  to  cat  hair,  three  per  cent,  to 
staphylococcus  pyogenes  albus,  and  seventeen  per 
cent,  to  miscellaneous  proteins. 

Distant  Foci  of  Infection  in  Chronic  Arthritis. 

— Herbert  S.  Chapman  (Annals  of  Surgery,  May. 
1920)  states  that  fifty  per  cent,  of  the  cases  of 
chronic  arthritis  treated  at  the  Stanford  University 
clinics  by  the  removal  of  foci  of  infection,  ac- 
cording to  clinical  observation,  showed  definite  im- 
provement. From  personal  observation  of  twenty- 
one  cases,  the  following  was  concluded :  Seventy- 
six  and  two  tenths  per  cent,  of  the  cases  showed  no 
definite  improvement  or  change ;  four  and  eight 
tenths  per  cent,  were  worse  after  treatment.  Although 
the  proportion  of  improvement  did  not  vary  greatly 
in  the  different  groups,  the  most  striking  results  were 
obtained  in  those  cases  in  which  the  focus  was 
situated  in  the  genitourinary  tract.  Long  continued 
faithful  treatment  is  necessary  before  improvement 
can  be  expected  in  the  cases  in  which  the  focus  is 
located  in  the  genitourinary  tract.  Very  rapid  re- 
covery with  very  few  treatments  was  obtained  in 
those  cases  in  which  the  teeth  were  the  seat  of  in- 
fection. Removal  of  the  tonsils  in  several  cases 
was  followed  in  a  few  days  by  loss  of  pain,  and 
later  by  return  of  function  to  the  injured  joint. 


Pseudomyxoma  Peritonei. — M.  H.  Biggs 
(Annals  of  Surgery,  May,  1920)  states  that 
pseudomyxoma  peritonei  is  much  more  frequent 
than  is  generally  recognized.  It  is  caused  by  cel- 
lular implantation.  It  is  histologically  benign,  but 
may  be  clinically  malignant.  If  it  is  considered  to 
be  a  form  of  cancer,  it  must  be  assumed  that 
pseudomucin  inhibits  its  destructive  power.  It  may 
originate  in  the  ovary  or  the  intestinal  tract;  ovar- 
ian origin  being  by  far  the  most  frequent.  If  it 
is  appendiceal  in  origin,  the  appendix  has  been  the 
seat  of  chronic  inflammation.  Early  invasion  of  the 
peritoneum  is  characterized  by  a  pebbly  appearance. 
In  early  cases  the  condition  will  sometimes  be  cured, 
and  at  any  stage  it  may  be  inhibited,  by  operation. 

Operative  Treatment  of  Vesicovaginal  Fistulae. 
— E.  S.  Judd  (Surgery,  Gynecology  and  Obstetrics, 
May,  1920)  concludes  as  follows: 

1.  Vesicovaginal  fistulae  are  now  more  common 
following  operations  than  following  childbirth. 

2.  All  vesicovaginal  fistulae  should  be  considered 
operable  as  long  as  the  sphincter  muscle  of  the  blad- 
der is  intact  or  can  he  repaired.  If  the  sphincter 
has  been  completely  destroyed  it  will  be  necessary 
to  consider  some  other  procedure. 

3.  Suprapubic  extraperitoneal  operations  seem  to 
be  indicated  if  the  cystoscopic  examination  reveals 
injury  to  a  ureter  as  well  as  to  the  bladder,  or  it 
may  be  indicated  if  the  fistulous  tract  is  adherent 
to  the  nubic  b-  ne. 

4.  The  plastic  vaginal  operation  consists  in  com- 
pletely separating  the  bladder  from  the  vagina,  and 
closing  the  two  separately  and  obliterating  all  dead 
space. 

5.  A  large  proportion  of  complete  and  permanent 
cures  follow  such  operations. 

Suprapubic  Prostatectomy.— J.  Thomscm 
Walker  (British  Journal  of  Surgery,  April,  1920) 
in  discussing  prostatectomy  presented  the  follow- 
ing findings  in  the  operation  he  describes : 

1.  Two  objections  may  be  raised  to  this  opera- 
tion. It  requires  a  longer  incision  than  the  usual 
prostatectomy,  and  more  time  is  required  for  its 
performance. 

2.  The  longer  incision  suggests  the  possibility  of 
a  hernia  of  the  scar ;  but  hernia  depends  upon  the 
ability  of  the  surgeon  to  repair  the  abdominal  wall 
and  to  keep  the  wound  clean. 

3.  The  incision  should  heal  up  to  the  tube^  chan- 
nel by  first  intention.  With  efficient  repair  of  the 
abdominal  wall,  a  hernia  need  not  be  feared. 

4.  The  length  of  time  spent  on  the  operation 
from  start  to  finish  is  about  thirty  minutes,  and 
there  is  no  increase  in  the  shock  after  the  opera- 
tion. Shock  in  prostatectomy  is  partly  due  to  hem- 
orrhage and  partly  to  rough  handling  in  enuclea- 
tion.   Both  of  these  causes  can  be  avoided. 

5.  An  unexpected  feature  of  the  open  method  is 
the  absence  of  a  great  part  of  the  spasmodic  pain 
after  operation.  This  pain,  which  lasts  for  twenty- 
four  or  forty-eight  hours,  is  due  partly  to  the  large 
tube,  but  mostly  to  the  accumulation  of  clots  in  the 
bladder,  with  consequent  spasm  of  the  bladder  mus- 
cle in  the  attempt  to  expel  them.  The  latter  factor 
is  abolished  where  the  bleeding  can  be  efficiently 
combated. 


New  York  Medical  Journal 


INCORPORATING  THE 


Philadelphia  Medical  Journal  ?he  Medical  News 

A  Weekly  Review  of  Medicine,  Established  18Jf3, 


Vol.  CXII,  No.  4. 


NEW  YORK.  SATURDAY.  JULY  24.  1920. 


Whole  No.  2173. 


Original  Communications 


AX  EFFORT  TO  STANDARDIZE  SURGICAL 
MENSUR-\TIOX.* 

By  R.  Tuxstall  Taylor,  M.  D..  F.A.C.S., 
Baltimore, 

Late  Lieutenant  Colonel,  M.  C,  L'.  S.  Army,  and  Chief  of  Orthopedic 
Service,  L'.  S.  Army  General  Hospital  No.  2,  Fort 
McHenry,  Maryland. 

Many  different  methods  have  been  suggested  for 
making  measurements  for  both  miHtary  and  civilian 
clinical  records,  and  it  is  with  a  desire  of  obtaining 
a  standardization  of  these  that  the  present  paper 
is  concerned,  as  well  as  to  encourage  recording  by 
a  simple  method.  In  the  majority  of  hospitals,  no 
measured  record  of  affected  bones  and  joints  is 
kept.  In  these  hospitals  the  only  instruments  for 
routine  anthropometric  record  are  usually  the  tape- 
measure,  the  X  ray  and  possibly  the  photographic 
camera.  In  a  small  number  of  hospitals,  chiefly 
orthopedic,  an  endless  number  of  devices  are  to  be 
found,  many  inaccurate  and  unscientific,  for  meas- 
uring the  range  of  motion  or  angle  in  joints.  It 
can  almost  literally  be  said  that  no  two  of  them  use 
the  same  appliance  for  recording  motion  and  each 
has  a  different  apparatus  for  each  joint  in  the  body. 

It  is  conceded  that  for  the  most  thorough  work, 
full  bedside  clinical  records  should  be  detailed  on 
the  chart,  not  only  to  give  data  as  to  the  condition 
of  a  patient  when  first  seen,  but  also  to  note 
progress  under  treatment  and  the  end  result.  In  the 
standardization  of  hospitals,  proposed  by  the 
American  College  of  Surgeons,  full  clinical  records 
are  insisted  on. 

It  is  advisable  that  any  device  adopted  for  re- 
cording motion  should  be  of  universal  application  to 
all  joints  to  render  use  general,  and  not  require  one 
for  each  joint.  The  device  should  be  simple  in  con- 
struction, inexpensive,  and  easy  to  use,  so  that  the 
readings  of  different  individuals  should  give  mini- 
mum variations  in  the  hands  of  the  different  ob- 
servers, and  thus  the  personal  equation  be  elimi- 
nated, as  far  as  possible. 

RECORDS  REQUIRED. 

Three  and  possibly  four  comparative  records  are 
required  in  the  involved  and  uninvolved  extremities 
and  joints  on  the  two  sides,  viz :  a.  length  of  ex- 
tremities ;  b,  circumference  of  extremities ;  c,  motion 
of  each  joint;  d,  position  of  angle  of  malposition  in 
ankylosis  or  partial  ankylosis.  In  the  spine,  devia- 
tions in  an  anteroposterior  or  lateral  direction  and 

'Published  by  permission  of  the  Surgeon  General,  U.  S.  Army. 


limitation  of  motion  in  the  different  regions  are  to 
be  recorded  as  to  extent.  The  amount  of  rotation 
in  scoliosis,  as  to  degrees,  is  necessary  for  record. 

It  is  essential  for  accuracy  that  a  fixed  position  of 
the  body  be  maintained  for  immediate  and  future 
observations.  This  can  only  be  attained  when  the 
body  is  supine  or  prone,  centred  on  a  horizontal  ex- 
aming  table  with  the  extremities  symmetrically 
placed,  unless  the  disability  itself  prevents,  except  in 
pronation  and  supination  of  the  forearm  and  mo- 
tions at  carpus  metacarpophalangeal  and  interpha- 
langeal  joints.  In  a  standing  attitude  a  patient 
may  consciously  and  intentionally  or  unconsciously 
tilt  or  lean  forward,  backward,  sideways  or  in  a 
twisted  position  and  no  records  at  stated  intervals 
should  be  made  thus  with  any  idea  of  accuracy. 

APPARATUS  REQUIRED. 

1.  Table.  An  ordinary  horizontal  rectangular 
wooden  top  examining  table,  six  feet,  six  inches 
long  and  three  feet  wide  with  legs  three  feet  high 
is  necessary.  The  centre  of  this  table  at  top  and 
bottom  is  marked  with  a  thumb  tack.  An  imaginary 
line  joining  these  will  constitute  what  we  may  call 
our  base  line.  In  the  region  that  will  correspond 
with  the  location  of  shoulder  and  hips  of  patients 
to  be  measured,  two  lines  are  ruled  on  each  side 
parallel  with  the  table's  edge,  and,  of  course,  with 
the  base  line  and  three  inches  apart.  These  we 
speak  of  as  parallel  lines.    (See  Figure  1). 

We  know  from  geometry  that  when  a  line  crosses 
two  parallel  lines,  the  alternate  interior  angles  are 
equal  and  any  line  at  right  angles  to  the  first  line 
crossing  the  parallel  lines  produces  also  alternate  in- 
terior equal  angles.  (See  Figures  2  and  3). 

Therefore,  any  angle  made  by  an  extremity  in 
relation  to  the  base  line  or  upon  which  we  have  the 
axis  of  the  patient's  body  or  a  joint  resting,  is  iden- 
tical with  that  angle  obtained  from  the  table's  edge 
or  any  line  parallel  to  it,  w^hen  the  patient  is  prop- 
erly centred.  Take  for  example,  adduction  of  the 
humerus.  (See  Figure  4).  AB  equals  the  line  of  axis 
of  humerus.  The  angles  BGH  and  BFD  are  not 
measurable  as  the  patient  is  lying  on  them,  but  the 
angle  EC  A  (or  BCJ)  is  identical  and  equal  to  them, 
easily  sighted  and  accessible.  (See  Figure  4).  It 
would  be  manifestly  incorrect  to  put  any  instrument 
on  top  of  the  rounded  shoulder  or  hip,  and  expect  to 
obtain  an  accurate  reading.  These  readings,  how- 
ever, from  the  parallel  lines  are  readily  made  by  a 
graduated  semicircle  and  protractor. 


Copyright,  1920,  by  A.  R.  Elliott  Publishing  Company. 


110 


TAYLOR:  SURGICAL  MENSURATION. 


[New  YojiK 
Medical  Jolr.nal. 


2.  The:  semicircle  with  a  protractor  at  its  cqntre 
made  in  our  orthopedic  shop  at  Fort  McHenry  is 
graduated  in  degrees  to  measure  the  range  of  mo- 
tion. This  is  made  of  aluminum,  and  has  two 
forklike  legs,  which  may  be  attached,  if  it  is  desired 
to  use  it  vertically,  as  well  as  .horizontally  without 
them. 

3.  The  ordinary  cotton  spring  tape  measure.  This 
is  preferable  to  the  steel  tape  measure,  as  will  be 


■  Fic.   1. — Examiniiifr  Table 

seen  under  measurement  of  circumference.  (Figure 
5)- 

4.  The  lead  tape  consists  of  a  strip  of  sheet  lead 
three  mm.  thick,  two  cm.  wide  and  one  metre  long, 
and  is  to  be  molded  over  curves  and  used  then  as  a 
ruler  to  trace  these  data  on  the  history.   (Figure  6). 

5.  A  rectangular  drawing  triangle. 

6.  A  yard  stick. 

STANDARD  POSITIONS  OF  PATIENTS  TO  BE  MEASURED. 

In  order  that  all  subsequent  measurements  may 
be  comparative,  it  is  essential  that  a  standard  posi- 
tion be  agreed  upon  in  which  all  individuals  are 
measured  and  as  in  all  upright  positions,  inclination 
of  the  trunk  in  relation  to  itself  or  to  the  extremi- 
ties are  lit^ely  to  vary,  the  position  in  recumbency 
becomes  the  natural  standard.  The  centre  of  the 
table  in  the  region  of  the  head  and  the  heels  is  used 
as  the  guide  in  placing  the  patient  in  the  supine  or 
prone  position.  The  arms  are  to  be  at  the  sides, 
fully  extended,  and  the  forearms  in  neither  prona- 
tion nor  supination,  and  the  fingers  fully  extended. 


)i  Z  X  Z  -X  Z  -X  Z      X  =  X'=X-  'X'" 

Fir,.  2.  Fig.  3. 

Geometric  fifures  us  d  as  a  basis  for  making  the  records. 

The  line  joining  the  anterior  superior  spines  of  the 
patient  must  be  at  right  angles  with  the  base  line. 
The  legs  are  fully  extended  with  the  toes  pointed 
vertically  upward,  and  the  heels  equally  distant  from 
the  central  base  line. 

For  records  of  spinal  deviation  or  knee  flexion, 
the  patient  is  similarly  to  be  centred  in  the  prone 
position.  The  recording  angle  of  rotation  in  scoliosis 
is    demonstrated    by    yard    stick    and  graduated 


semicircle  and  protractor.  Figure  .6  shows  the  re- 
cording angular  deformity  in  Pott's  disease  by  the 
lead  tape,  which  is  to  be  used  as  a  ruler  in  tracing 
curve  on  the  history.  Figure  7  shows  method  of 
recording  flexion  of  knee.  A  method  is  demon- 
.strated  of  measuring  bv  means  of  Yardstick  and 


Fig.  4. 

The  readings  are  determined  by 
graduated  semicircle  and  protractor. 


Fig.  5. 

the    parallel    lines   made    by  a 


rectangular  triangle  amount  of  deviation  of  spine 
from  base  line  in  lateral  curvature.  For  records  of 
pronation  and  supination  of  the  arm  and  flexion  of 
the  metacarpophalangeal  joints  and  wrist,  the  pa- 
tient sits  beside  the  table  with  the  entire  fore- 
arm supported.  (See  Figure  8).  For  tests 
of  flexion  of  terminal  phalanges  or  second  joints 


Fig.  6. — The  had  tape  being  molded  over  curves. 

the  palm  surface  of  the  hand  is  placed  on  the  table 
up  to  the  joint  and  the  reading  made. 

LANDMARKS. 

The  following  landmarks  are,  as  a  rule,  easily 
and  accuratelv  located  in  all  individuals  in  order  to 


July  24,  1920.] 


TAYLOR:  SURGICAL  EXSURATION. 


Ill 


measure  length  of  bones:  1,  Suprasternal  notch; 
2,  tip  of  the  xiphoid  cartilage ;  3,  symphysis  pubis ; 
4,  anterior  superior  spines;  5,  anterior  tibial  tuber- 
cles ;  6,  malleoli ;  7,  acromion  processes ;  8,  olecranon 
processes ;  9,  styloid  processes  of  the  ulnse ;  10,  ver- 
tebra prominens ;  11,  posterior  superior  spines;  12, 


Fir..     — Method  for  recording  flexion  of  the  knee. 


ischial  tuberosities;  13,  greater  trochanters,  and  14. 
gluteal  notch. 

When  the  patient  is  in  position,  1 ,  2  and  3  are  on 
the  base  line,  and  the  line  joining  the  two  anterior 
superior  spines  should  be  at  right  angles  to  the 
base  line.  The  distance  from  the  anterior  superior 
spine  to  the  internal  malleolus  oa  each  side  gives 
the  comparative  measurement  of  the  two  legs.  If 
one-  is  found  shorter  than  the  other,  and  it  is  de- 
sired to  determine  the  bone  at  fault,  this  may  be 
done  by  measuring  from  the  anterior  superior  spine 
to  the  anterior  tibial  tubercle  and  from  there  to  the 
malleolus  on  each  side. 

Similarly  the  arms  may  be  measured  from  the 
acromion  processes  to  the  styloid  processes  of  the 
ulnae,  and  to  and  from  the  olecranons. 

The  anterior  superior  spine,  the  greater  trochanter 
and  the  ischial  tuberosity  are  normally  on  Nekton's 
line.  Departure  of  the  trochanter  from  this  line 
indicates  dislocation  or  fracture  or  bending  of  the 
femoral  neck  of  so  much  displacement,  depending 
on  the  amount  of  this  departure.  This  is  an  ac- 
cepted measurement  for  record. 

The  vertebra  prominens,  the  spine  and  the  gluteal 
notch  in  the  normal  prone  individual  constitute  a 
straight  line  parallel  to  our  base  line.  Departures 
laterally  to  one  or  the  other  or  both  sides  consti- 


tute a  lateral  curvature,  and  backward  or  forward, 
an  anteroposterior  curvature,  and  must  be  measured 
as  must  be  rotations  or  twists  in  the  spine  in  the 
cervical,  dorsal  or  lumbar  regions.    (See  Figure  6). 

COMPARATIVE  MEASUREMENT  OF  LENGTH  OF  LIMBS. 

After  accurately  marking  the  landmarks  needed 
with  ink  or  skin  pencil,  it  is  quite  easy  to  measure 
the  lengths  desired.  It  is  better  not  to  press  the 
scale  of  the  tape  measure  on  the  skin,  as  the  latter  is 
like!}'  to  slip,  but  simply  place  the  scale  lightly  on 
the  parts  and  make  the  reading. 

]Major  Robert  D.  Maddox,  C,  U.  S.  Army, 
suggested  that  the  tape  be  stretched  tight  beyond 
the  two  points,  with  the  figure  10  at  the  first  point 
and  the  number  noted  at  the  other  fixed  point,  when 
the  reading  could  be  recorded  less  10.  This  would 
obviate  error  from  undue  or  unequal  stretching  of 
the  tape  or  slipping  of  the  skin. 

COMPARATIVE     MEASUREMENT     OF  CIRCUMFERENCE 
OF  LIMBS. 

It  can  easily  be  appreciated  that  owing  to  the 
conical  shape  of  limbs,  circumferential  measurements 
must  vary  considerably,  if  made  at  different  levels ; 
it  is  essential,  therefore,  th^t  identical  points  be 
chosen  on  the  two  limbs  for'  comparison,  and  these 
points  should  be  marked  with  ink  or  skin  pencil  at 
a  measured  distance  below  a  fixed  bony  landmark. 
Thus  in  the  thighs  the  points  chosen  should  be  a 


Fig.  8. — Method  of  securing  readings  of  wrist  flexion  with  entire 
forearm  supported. 


given  nimiber  of  inches  or  cms.  below  the  anterior 
superior  spines ;  in  the  calves,  below  the  anterior 
tibial  tubercles ;  in  the  arms,  below  the  acromions ; 
and  in  the  forearms,  below  the  olecranons.  IMajor 
Maddox  also  suggested  that  in  order  to  get  even 
tension  on  the  tape  that  the  free  end  be  held  in  one 
hand,  then  the  part  be  encircled  and  the  tape  case 


112 


SCHEPPEGRELL:   HAY  FEl'ER. 


[New  York 
Medical  Journal. 


be  allowed  to  fall  vertically  as  a  plumb  bob.  The 
number  10  is  used  as  the  first  point,  and  where  the 
tape  passes  the  10  after  encircling,  is  read  and  re- 
corded less  10. 

MEASUREMENT   OF  ANGLES   OF   POSITION    OR  RANGE 
OF  MOTION  IN  JOINTS. 

The  desire  to  record  these  observations  on  charts 
has  led  in  private  practice  and  hospitals,  where  a 


Fig.  9. — Method  of  recording  dorsal  flexion  at  the  ankle  joint. 

sincere  eftort  has  been  made  to  keep  accurate  prog- 
ress charts,  to  an  endless  number  of  complicated  and 
expensive  appliances.  Many  records  were  inaccu- 
rate, owing  to  the  necessity  of  application  to  the 
patient  when  the  latter  was  in  what  might  be  termed 
an  unstable  position,  or  one  in  which  from  time  to 
time,  or  one  may  even  say  from  one  minute  to  the 
next,  variations  in  readings  might  be  observed  with 
proportionate  errors.  It  is  therefore  essential  to 
accuracy  that  the  positions  descril^ed  above  be  in- 
sisted on,  and  all  measurements  of  angles  be  made 
with  relation  to  the  base  line  or  one  of  its  parallel 
lines  on  the  horizontal  table. 

.  It  is  further  important  that  all  readings  of  the 
position  of  extremities  or  their  components  be  made 
from  a  zero  position,  i.  e.,  neither  flexed  nor  ex- 
tended, rotated  in  nor  out,  pronated  or  supinated.  etc. 
It  is  necessary  for  this  basis  to  be  agreed  on  in 
comparing  results  in  diflPerent  clinics.  For  exam- 
ple, it  is  manifestly  confusing  for  an  author  to  speak 
of  flexion  of  the  elbow  of  70°,  when  he  means  110°. 
that  is,  starting  from  zero  or  full  extension.  Sim- 
ilarly semipronation  should  be  pronation  of  90°,  or 
supination  of  90°. 

It  is  therefore  patent,  I  believe,  that  the  method 
herewith  introduced  is  accurate  to  all  intents  and 
purposes,  sound,  practical  and  simple,  and  may  be 
applied  to  all  the  joints  with  but  slight,  if  any,  dif- 
ferent findings,  if  obtained  by  different  observers. 
This  we  have  proved  to  our  satisfaction  by  testing 
the  findings  of  several  assistants  seriatim  and  com- 
paring the  very  negligible  error. 

Figure  5  shows  the  recording  of  adduction  of  the 
hip  joint,  and  Figure  9.  recording  dorsal  flexion  at 
the  ankle  joint. 

1102  North  Charles  Street. 


DIAGNOSTIC  TESTS  IN  HAY  FEVER  AND 
ASTHMA. 

By  William  Scheppegrell,  A.  M.,  M.  D., 
New  Orleans, 

President,   American   Hay   Fever   Prevention   Association;  Ex-Presi- 
dent, American  Academy  of  Ophthalmology  and  Otolaryngology; 
Chief  of  Ha>   Fever  Clinic,  Charity  Hospital. 

As  the  immunizing  methods  of  treating  hay 
fever  and  hay  fever  asthma  are  becoming  recognized 
as  the  most  practical  means  of  controlling  these  dis- 
eases, it  is  important  that  accurate  methods  be  em- 
ployed in  order  to  obtain  successful  results. 

GEOGRAPHICAL  DISTRIBUTION. 

In  the  majority  of  diseases,  such  as  smallpox, 
diphtheria  and  tuberculosis,  the  causative  factor  is 
a  pathogenic  microorganism,  which  is  the  same  re- 
gardless of  the  geographical  distribution  of  the  dis- 
ease. In  hay  fever,  however,  in  spite  of  the  ap- 
parent similarity  of  the  symptoms,  the  cause  is  a 
pollen  which  varies  materially  in  different  locations. 
In  Europe,  for  instance,  the  cause  of  hay  fever  is 
the  pollen  of  the  grasses,  Gramineae,  to  the  exclu- 
sion of  the  ragweed  (Ambrosiaceae)  group.  In  the 
United  States,  however,  while  the  grass  pollen  is 
the  most  common  cause  of  spring  hay  fever  (some- 
times erroneously  called  rose  cold),  the  pollens  of 
the  ragAveed  group  form  the  principal  cause  of  fall 


Fig.  1. — The  grasses,  Grarainea  group,  form  the  principal  cause 
of  spring  summer  hay  fever  in  Europe  and  most  sections  of  the 
United  States.  The  illustration  shows  the  following  grasses:  Mea- 
dow, redtop,  timothy,  perennial  rye,  orchard,  foxtail  and  Johnson. 

hay  fever  (1).  In  view  of  this,  it  is  important, 
before  commencing  immunizing  methods,  to  deter- 
mine the  incriminating  pollens ;  cr,  what  is  usually 
sufficient  and  more  practical,  the  group  to  which 
biologically  the  pollen  belongs. 


July  24,  1920.] 


SCHEPPEGRELL:   HAY  FEVER. 


113 


BIOl^OGICAL  GROUPS. 

From  the  viewpoint  of  immunization,  we  have  di- 
vided the  principal  hay  fever  pollens  into  four 
groups,  which  include  eighty-five  per  cent,  of  all  hay 
fever  pollens.   These  groups  are  as  follows  (2)  : 

1 .  Graminea?  ( Fig.  1 ) .    All  species  and  families 


Fig.  2. — Marsh  elder,  Iva  ciliata,  belonging  to  the  ragweed  (Am- 
brosiaccs)  group.  Found  in  moist  soil,  Illinois  to  Nebraska,  south 
to  Louisiana  and  New  Mexico. 


of  the  grasses,  including  the  cultivated  varieties 
(cereals). 

2.  Ambrosiaceae  (Fig.  2).  This  includes  the  va- 
rious varieties  of  ragweeds.  Ambrosias,  cockle  burs, 
Xanthium,  marsh  elders,  Iva,  and  false  ragweeds, 
Gaertnerias. 

3.  Artemisias  (Fig.  3).  The  wormwoods,  of 
which  there  are  about  sixty  species  in  the  western 
parts  of  North  America,  and  which  are  important 
factors  in  hay  fever  in  the  Pacific  and  Rocky  Moun- 
tain States. 

4.  Chenopodiaceae  (Fig.  4).  This  group  includes 
the  chenopods,  docks,  Rumex,  amaranths,  Ama- 
ranthus,  and  Russian  thistle,  Salsola  pestifer  and 
glauca,  which,  although  botanically  not  as  closely 
related  as  the  three  other  groups,  are  similar  in  their 
hay  fever  reaction. 

In  the  application  of  pollen  therapy,  the  extracts 
of  the  pollens  of  any  one  of  these  groups  are  inter- 
changeable, and  may  be  used  singly,  or  a  combina- 
tion of  several,  for  testing  and  immunizing  methods. 
As  an  indication  of  the  more  scientific  methods  in 
the  treatment  of  hay  fever  demanded  by  the  medical 
profession,  the  majority  of  the  biological  houses 
now  prepare  these  pollen  extracts  of  single  pollens. 


or  of  the  same  biological  group,  instead  of  the  shot- 
gun method  formerly  in  vogue,  in  which  many  kinds 
of  pollen,  and  belonging  to  different  biological 
groups,  as  the  grasses  and  ragweeds,  were  used, 
and  recommended  for  immunizing  purposes. 

ATMOSPHERIC  POLLENS. 

An  important  feature,  which  seems  not  yet  well 
recognized,  is  the  fact  that  hay  fever  is  due  to  atmos- 
pheric pollens,  and  that  only  these  are  needed  for 
testing  and  immunizing  purposes  (3).  We  are  still 
receiving  frequent  inquiries  regarding  such  plants  as 
clover,  daisies,  golden  rod,  oleanders  and  jasmines, 
as  a  cause  of  hay  fever,  and  these  are  still  referred 
to  as  furnishing  hay  fever  pollens,  in  otherwise  ex- 
cellent articles  published  in  the  medical  journals. 
The  persistence  of  placing  blame  on  the  golden  rod 
is  especially  remarkable,  in  view  of  the  well  known 
fact  that  the  most  brilliant  bloom  of  the  golden  rod, 
Solidago  canadensis,  is  in  October,  when  practically 
all  of  the  hay  fever  attacks  have  subsided  by  the 
end  of  September  (4). 

DIAGNOSTIC  TESTS. 

In  making  the  diagnostic  test  for  hay  fever,  we 
are  guided,  in  the  selection  of  the  pollen  extract, 
by  the  location.  It  is  therefore  necessary  to  know 
the  hay  fever  plants  to  which  the  patient  is  exposed, 
the  representative  biological  group  being  sufficient 
in  most  cases.  East  of  the  hundredth  meridian,  we 


Fig.  3. — Wormwood  sage,  .\rtcmisia  frigida,  artemisia  group.  On 
dry  plains  and  on  rocky  soil,  Minnesota  to  Saskatchewan,  Yukon, 
Idaho,  Nebraska,  Texas  and  Arizona. 


must  test  for  the  grasses,  ragweeds  and  chenopods. 
West  of  this  meridian,  the  tests  should  in  addition 
include  the  artemisias.  The  ragweed  test  should 
also  be  made  in  the  Rocky  Mountain  and  Pacific 


114 


SCHEPPEGRELL:   HAY  FEVER. 


[New  York 
Medical  Journal. 


States,  since,  although  the  ragweeds  are  uncommon, 
there  are  other  members  of  the  ragweed  or  Ambro- 
siaceae  group,  such  as  the  gsertnerias,  marsh  elders, 
Iva,  and  cockle  burs,  which  respond  to  the  same 
test  and  similar  immunizing  methods. 

In  making  the  diagnostic  test,  we  have  standard- 


FlG.  4. — Curly  dock,  Rumex  crispus,  Chenopodiacese  group.  Found 
•throughout  the  United  States  and  Southern  British  America. 


ized  the  method,  which,  in  a  series  of  over  a  thou- 
sand cases,  has  given  us  results  which  are  accurate 
as  regards  the  nature  and  degree  of  the  sensitiza- 
tion, and  reliable  as  a  guide  to  the  immunizing  doses. 
Five  units  of  the  extract  of  the  selected  pollen,  of 
the  strength  of  one  hundred  vmits  to  the  c.c,  are 
injected  into  the  skin,  and  the  reaction  determined 


Fig.  5. — 'False  wormwood,  Parthenium  hysterophorus.  From 
southern  Pennsylvania  to  Illinois,  Missouri,  Florida  and  Texas, 
and  throughout  tropical  America.  In  warm  climates,  the  parthenium 
blooms  every  month,  and  is  a  minor  cause  of  perennial  hay  fever. 


in  twenty  minutes,  and  recorded  on  a  percentage 
basis.  A  marked  wheal,  two  or  more  centimetres 
in  diameter,  is  recorded  as  one  hundred  per  cent., 
one  centimetre  fifty  per  cent.,  etc.    While  this  is 


an  arbitrary  scale,  it  is  valuable  for  gauging  the 
size  of  the  dose  and  for  purposes  of  comparison, 
and  is  much  more  definite  than  such  terms  as  mild, 
marked  or  severe.  , 

TESTS  AS  A  GUIDE  TO  DOSE. 

The  record  of  the  diagnostic  test  is  placed  at 
the  head  of  the  clinical  chart  for  each  patient,  so 
as  to  form  a  constant  guide  in  administering  the 
immunizing  doses.  A  mild  ruction  indicates  a  pro- 
portionate tolerance  of  .the  pollen  extract,  and  a 
marked  reaction  that  ca^lfion  should  be  used  in 
increasing  the  doses  of  *the  pollen  extracts.  In  one 
of  our  patients,  whose  test  is  registered  ninety-five 
per  cent.,  the  limit^of  his  dose  is  one  hundred  and 
seventy-five  units>  of  ragweed  pollen  extract.  As 
soon  as  this  dose  is  exceeded,  a  miliary  eruption  de- 
velops and  sometimes  a  typical  hay  fever  reaction. 

The  record  of  the  test  also  indicates  the  probable 
maximum  dose  required  for  desensitization.  In  pa- 
tients of  ninety  per  cent,  reaction  or  over,  two  hun- 
dred units  is  the  maximum  dose,  and  should  be 
reached  by  gradually  increasing  closes.     In  those 


Fig.  6.- — Flowers  (floiescence)  of  marsh  elder,  showing  enormous 
pollen  production  of  wind  pollinated  plants. 


marked  sixty  per  cent,  the  maximum  dose  is  six 
hundred  units,  and  others  in  proportion  (5). 

TESTS   FOR   PATHOGENIC  GROUPS. 

In  our  last  series  of  cases,  in  addition  to  the 
tests  for  sensitization  to  the  various  groups  of  pol- 
lens to  which  the  patient  is  exposed,  we  include  the 
test  for  a  vaccine  composed  of  the  following  micro- 
. organisms:  Bacillus  Friedlander,  Micrococcus  ca- 
tarrhalis,  pneumoccoccus,  Streptococcus  pyogenes. 
Staphylococcus  aureus  and  albus.  If  there  is  a 
marked  reaction  to  the  intradermal  injection  of  this 
vaccine,  it  is  used  as  a  part  of  the  immunizing 
process,  and  the  degree  of  the  reaction,  as  in  the 
case  of  the  pollen  extracts,  forms  a  guide  to  the 
size  of  the  injections. 

IMPORTANCE  OF  ACCURATE  TESTS. 

We  believe  that  the  relatively  high  degree  of  suc- 
cess in  the  treatment  of  hay  fever  in  our  hay  fever 
clinic  ,at  the  Charity  Hospital  (6)  is  due  to  the 
fact  that  each  case  is  individualized,  and  a  course 
of  treatment  followed  that  is  based  on  the  character 


July  24,  1920.] 


RAMIREZ:  PROTEIX  SENSITIZATIOX. 


115 


and  degree  of  the  diagnostic  test,  and  regulated 
by  the  records  of  the  atmospheric  pollen  plates  and 
the  reaction  of  the  patient.  To  inject  large  doses 
of  extract  in  order  to  immunize  a  patient,  when  he 
is  already  absorbing  the  protein  of  numerous  atmos- 
pheric pollens,  tends  to  develop  an  anaphylactic 
shock  that  explains  many  failures  in  the  treatment 
of  these  cases. 

Naturally,  this  is  avoided  if  the  immunizing  is 
commenced  before  the  attack  is  due.  Unfortu- 
nately, however,  the  majority  of  patients  apply  for 
treatment  only  when  they  are  already  suffering  from 
hay  fever.  This  complication  requires  much  greater 
delicacy  in  the  application  of  the  treatment ;  but, 
unless  due  attention  is  given  to  these  details,  the 
results  will  be  discouraging  to  the  physician  and 
disappointing  to  his  patient. 

REFEREXCES. 

1.  \V.  ScHEPPEGRELL :  Hav  Fever  and  Its  Prevention, 
United  States  Public  Health  Reports,  July  21,  1916. 

2.  Idem  :  The  Classification  of  Hay  Fever  Pollens  from 
a  Biological  Standpoint,  Boston  Medical  and  Surgical 
Journal,  July  12,  1917. 

3.  Idem  :  Hay  Fever  and  Hay  Fever  Pollens,  Archives 
of  Internal  Medicine,  June,  1917. 

4.  Idem  :  Hay  Fever  and  Its  Relation  to  One  Hundred 
of  the  Most  Common  Plants,  Trees  and  Grasses,  Medical 
Record,  August  11,  1917. 

5.  Idem  :  The  Treatment  of  Hay  Fever,  United  States 
Public  Health  Reports,  August  1,  1919. 

6.  Idem :  Anaphylaxis  Due  to  Pollen  Protein,  with  a 
Report  of  the  Results  of  Treatment  in  the  Hay  Fever 
Clinic  of  the  New  Orleans  Charity  Hospital,  The  Laryngo- 
scope, December,  1918. 


A    REPORT    OF    SOME  IXTERESTIXG 
CASES  OF  PROTEIX  SEXSITIZATIOX. 

By  Maximilian  A.  Ramirez.  M.  D., 
New  York, 

Associate   Attending    Physician   to   the    French    Hospital,  Assistant 
Attending  Physician  to  City  Hospital. 

Case  I. — A.  J.,  female,  aged  thirty-six,  married. 
Family  history :  Father  has  chronic  asthma,  other- 
wise negative.  Previous  history :  Has  had  several 
attacks  similar  to  present  illness,  lasting  two  to 
three  weeks.  Present  history:  The  attack  began 
four  days  ago  with  severe  pain  in  the  right  eye. 
The  eye  became  very  red.  Examination  established 
the  diagnosis  of  a  definite  scleritis  of  an  unknown 
etiology.  Patient  had  been  taking  salicylates  and 
colchicum  without  any  relief.  A  protein  test  was 
performed  and  a  positive  three  plus  reaction  to 
white  of  egg  was  obtained.  The  patient  was  in- 
structed to  abstain  from  taking  white  of  egg  in  any 
form ;  all  other  tnedication  was  discontinued.  Three 
days  later  she  returned  feeling  perfectly  well.  There 
was  no  pain  and  the  eye  was  absolutely  normal. 

■  I  believe  this  to  be  a  true  case  of  protein  sensibility 
in  view  of  the  previous  history  in  which  we  note 
the  long  duration  of  previous  attacks,  the  lack  of 
relief  under  large  doses  of  salicylates  and  the  rapid 
improvement  after  removal  of  a  protein  which  gave 
a  definite  skin  reaction.  I  have  tested  three  other 
cases  of  scleritis  giving  positive  skin  tests  and  re- 
covering rapidly  after  removal  of  the  offending  pro- 
tein. 

Case   II. — Female,   aged  twenty-seven ;  family 


hi --tor}-  and  previous  history  negative.  Present  his- 
tory ;  The  difficulty  began  eight  days  ago  with  itch- 
ing and  burning  of  right  eye,  profuse  lachrymation. 
marked  photophobia  and  intense  redness  of  palpe- 
bral and  ocular  conjunctiva.  The  patient-  had  been 
receiving  local  treatment  for  the  eye  without  ap- 
parent relief.  A  ■  protein  test  performed  on  the 
ninth  day  of  her  illness  showed  a  positive  reaction 
to  mustard,  wheat  and  crab,  of  which  the  patient 
had  partaken  freely  for  several  days  preceding  the 
present  attack.  The  diagnosis  was  an  acute  con- 
junctivitis of  anaphylactic  origin.  On  removal  of 
the  oft'ending  proteins  the  conjunctivitis  rapidly 
subsided  and  within  three  days  the  eye  was  abso- 
lutely normal. 

Case  III. — L.  H..  female,  aged  forty.  Family 
history,  negative.  During  the  past  few  years  the 
patient  had  had  repeated  attacks  of  sudden  decided 
swelling  of  lips  and  tongue  during  or  immediately 
following  a  meal.  Examination  showed  the  lower 
lip,  gums,  tongue  and  soft  palate  to  be  markedly 
swollen  and  edematous.  A  diagnosis  of  angioneu- 
rotic edema  was  made.  The  protein  test  showed 
a  very  marked  reaction  to  white  of  egg.  The  reac- 
tion measured  two  cm.  in  diameter.  The  patient 
was  desensitized  against  white  of  egg  and  can  now 
take  one  egg  a  day  without  symptoms  appearing. 

Case  IV. — B.  ]\IcG.,  aged  seven.  Had  had  severe 
attacks  of  bronchial  asthma  for  two  years,  espe- 
cialh'  severe  during  the  summer  months.  The  fam- 
ily history  was  negative ;  physical  examination,  nega- 
tive. The  protein  test  showed  a  positive  reaction 
to  potato,  white  of  egg  and  rabbit  hair.  The  pa- 
tient had  two  rabbits  in  the  house.  Removal  of  the 
potato  and  white  of  egg  from  the  diet  and  removal 
of  the  rabbits  resulted  in  a  complete  recovery  in  sev- 
eral days.  The  patient  has  not  had  an  attack  of 
asthma  in  seven  months  and  skin  tests  with  potato, 
egg  white  and  rabbit  hair  are  now  negative. 

Case  V. — L.  K.,  aged  ten.  Had  had  asthma  for  . 
two  years  with  persistent  cough  and  expectoration. 
Physical  examination  showed  the  presence  of  a 
chronic  bronchitis.  The  protein  test  gave  a  positive 
reaction  to  banana,  potato  and  chicken.  Also  posi- 
tive to  parrot  feathers.  Staphylococcus  aureus  and 
slightly  positive  to  goose  feathers.  The  offending 
proteins  were  removed  from  the  diet,  the  parrot 
was  disposed  of  and  a  suitable  Staphylococcus  aureus 
vaccine  injected  by  Dr.  L.  B.  MacKenzie,  who  re- 
ferred this  patient  for  protein  examination.  The 
patient  has  made  a  complete  recovery  and  is  now 
absolutely  free  from  asthmatic  symptoms. 

Case  VI. — A.  B.,  aged  forty-seven.  Persistent 
asthmatic  attacks  every  night  for  past  six  years ; 
could  not  lie  in  bed  at  night ;  free  of  symptoms  dur- 
ing the  day.  Protein  tests  showed  a  strongly  posi- 
tive reaction  to  goose  feathers.  Patient  has  been 
free  of  all  symptoms  since  the  substitution  of  a 
hair  pillow,  and  is  sleeping  comfortably  in  bed  all 
night. 

Case  VII. — J.  \'.,  aged  seven.  Complained  of 
repeated  attacks  of  severe  epigastric  pain.  Pain 
came  on  three  to  four  hours  after  eating  and  lasted 
for  about  thirty  minutes.  Duration  of  present  ill- 
ness about  six  months.    The  previous  history  was 


116 


DIAMOXD:  PEPTIC  ULCER. 


[New  York 
Medical  Journal, 


negative ;  the  physical  examination  was  negative. 
Gastric  analysis  showed  free  hydrochloric  acid, 
40 ;  total,  70 ;  blood  negative.  X  ray  examination 
showed  a  decided  pylorospasm.  Negative  for  nicer 
of  stomach,  colon  and  pathological  gallbladder  con- 
dition. Protein  test  showed  a  strongly  positive  re- 
action to  whole  egg.  All  egg  was  removed  from 
diet  and  patient  has  only  had  an  occasional  attack 
of  pain  since  day  of  testing,  four  months  ago. 

1  believe  these  occasional  attacks  were  due  to 
the  presence  of  some  egg  in  his  food.  Skin  test 
four  months  later  still  gave  a  slightly  positive  reac- 
tion. I  have  seen  four  cases  of  pylorospasm  with 
moderate  increase  in  gastric  acidity  of  definite  ana- 
phylactic origin  in  which  the  spasm  completely  dis- 
appeared on  removal  of  the  offending  protein.  Two 
of  these  cases  were  in  children  imder  ten.  and  the 
other  two  in  adidts  over  twenty. 

Case  VIII. — Rev.  H.  G.,  aged  twenty-seven.  Se- 
vere dermatitis  extending  over  both  hands  and 
arms.  Family  history,  mother  has  had  hay  fever 
for  twenty  years.  Previous  history,  hay  fever  com- 
ing on  about  August  20th  for  past  six  years.  Had 
never  had  a  skin  eruption  before  present  illness, 
and  never  had  hay  fever,  except  after  middle  of 
August.  The  present  illness  began  two  weeks  ago 
(]^Iay  5,  1919),  with  burning  and  itching  of  both 
hands  and  arms  and  the  appearance  of  the  eruption, 
which  was  characteristic  of  dermatitis,  followed  in 
two  days  by  an  attack  of  hay  fever.  The  protein 
tests  gave  a  negative  reaction  to  all  the  common 
foods,  bacteria  and  animal  emanations,  but  gave  a 
four  plus  to  ragweed  and  three  plus  to  timothy,  and 
two  plus  to  sunflower.  Believing  that  the  dermatitis 
was  due  to  timothy  sensitization,  and  it  already  be- 
ing the  timothy  pollen  season,  I  advised  this  patient 
to  go  on  a  sea  trip,  as  it  was  too  late  to  obtain  bene- 
ficial results  from  active  immunization.  A  few  days 
after  leaving  on  this  sea  voyage  the  dermatitis  dis- 
appeared completely.  The  patient  returned  to  me 
in  June  for  immunization  against  ragweed  and  sun- 
flower, free  from  all  signs  of  the  previous  attack 
of  dermatitis. 

2  West  Eighty-eighth  Street. 


PEPTIC  ULCER. 
Clinically  and  Rdntgenologically  Considered. 
By  Joseph  S.  Diamond,  M.  D., 

New  York, 
Associate  Rontgenologist,  Beth  Israel  Hospital. 

(Concluded  from  page  91) 
Mobility  and  fle.vibility. — The  supporting  anchor- 
age of  the  stomach  are  the  esophagus  and  the 
gastrophrenic  ligament  at  the  cardiac  region  and 
the  duodenohepatic  ligament  about  one  inch  beyond 
the  pylorus.  Between  these  parts  the  body  of  the 
stomach  has  considerable  range  of  movement  and 
by  palpation  can  be  lifted  or  shifted  to  either  side. 
It  moves  with  respiration.  By  forcibly  contracting 
the  abdominal  muscles  it  can  be  drawn  upward 
distorting  its  outline.  If  the  abdomen  is  relaxed 
the  gastric  walls  are  flexible  and  can  be  indented 
on  palpation. 


Gastric  secretions. — In  the  normal  stomach  the 
fasting  secretions  are  negligible  and  cannot  ordi- 
narily be  seen  unless  under  pathological  conditions. 

Peristalsis. — Considerable  attention  has  been 
devoted  to  gastric  peristalsis.  The  ringlike  con- 
traction w-aves  passing  over  the  stomach  at  definite 
intei^-als  represents  its  physiological  motor  phenom- 
enon of  churning  of  the  food  and  its  expulsion  into 
the  duodenum.  Viewed  fluoroscopically  we  notice 
an  initial  contraction,  soon  after  the  introduction  of 
the  meal,  best  seen  after  a  sediment  mixture  con- 
sisting of  barium  and  water.  This  appears  as  an 
indentation  on  the  lesser  curvature  in  the  vestibule 
just  below  the  incisura  angularis.  Simultaneously 
there  appears  a  corresponding  wave  at  the  greater 
curvature.  These  are  of  short  duration.  If  the  full 
meal  is  now  administered,  there  occurs  a  delay  of 
from  about  five  to  ten  minutes  during  which  time 
no  peristaltic  contractions  are  seen,  due  to  the  sud- 
den distention  of  the  muscular  walls.  Soon,  how- 
ever, the  regular  peristaltic  contraction  sets  in.  A 
shallow  wave  first  appears  on  the  greater  curvature 
below  the  level  of  the  incisura  cardiaca  in  the  pars 
media.  A  wave  similarly  shallow  but  even  less 
perceptible  is  seen  on  the  lesser  curvature.  They 
travel  down  gathering  but  little  in  depth  until  they 
reach  a  point  just  beyond  the  incisura  angularis, 
when  the  waves  suddenly  increase  in  depth,  the 
contractions  producing  the  maximum  indentations 
in  the  vestibule  or  antrum  pylori,  from  whence  they 
travel  sharply  toward  the  pylorus.  At  times  the 
depth  of  the  wave  is  so  intense  that  the  stomach 
appears  to  be  divided  into  two  parts.  This  has 
aroused  considerable  discussion  in  the  past  as  there 
was  believed  to  exist  a  sphincter  antri  separating  the 
stomach  into  two  compartments.  By  the  animal 
experimentations  of  Cannon  and  the  biorontgeno-  ^ 
graphic  studies  of  Rieder,  Kaestle,  and  Rosenthal, 
it  has  been  definitely  proved  that  there  is  no  cleav- 
age of  the  stomach.  Cannon  explains  these 
augmented  contractions  as  the  necessary  requisite 
for  the  churning  and  chymification  of  the  food. 
The  energy  of  the  wave  varies  with  the  type  of. 
stomach,  being  greatest  in  the  hypertonic  and 
orthotonic  stomachs  and  less  in  the  subtonic  types. 
It  is  influenced  by  the  deep  respiratory  movements 
and  by  abdominal  massage  and  is  greater  in  the 
prone  and  oblique  postures.  The  waves  succeed 
each  other  at  regular  intervals,  the  traversing  of 
each  wave  throughout  the  entire  length  of  the 
stomach  consumes  about  twenty-two  seconds  and  is 
spoken  of  by  Cole  as  a  gastric  cycle.  Several  waves 
are  often  seen  simultaneously  and  are  spoken  of  as 
the  one,  two,  three,  or  four  cycle  stomach. 

Motility. — It  is  an  established  fact  that  the  ront- 
genological  examination  offers  conclusive  evidence 
of  gastric  motility.  The  findings  in  a  given  case  are 
taken  as  a  definite  index  of  the  power  of  the 
stomach  to  empty  itself  within  normal  or  abnormal 
limits.  When  a  definite  standard  of  meal  is  used, 
the  carbohydrate  (  Rieder)  meal  or  its  modifications, 
it  has  been  found  that  the  longest  time  for  a  normal 
stomach  to  empty  itself  is  six  hours.  The  steer- 
horn  stomach  empties  sooner,  between  two  and  a 
half  to  three  hours.  The  orthotonic  type  empties 
between  four  and  five  hours  and  for  the  subtonic 


July  24,  1920.] 


DIAMOND:  PEPTIC  ULCER. 


117 


types  six  hours  are  allotted.  In  the  Haudeck  hub- 
hohe  or  the  Satterlee  and  Le  W'ald  water  trap 
stomachs,  which  are  -  nothing  but  markedly  exag- 
gerated subtonic  stomachs  with  the  acute  incisura 
angularis,  the  pylorus  rising  sharply  upward,  a 
longer  time  than  six  hours  is  required.  Eight  hours 
may  still  be  considered  normal.  If  it  exceeds  this 
period  we  must  regard  the  condition  as  pathological. 
Carmen  and  Miller  in  a  series  of  950  cases  at  the 
Mayo  clinic,  which  were  examined  by  means  of 
both  the  rontgen  rays  and  the  test  meal,  and  went 
to  operations,  state :  "Our  own  series  indicates  the 
six  hour  bariumized  carbohydrate  meal  is  a  more 
sensitive  test  of  gastric  motility  than  the  method 


Fig.  1. — Large  penetrating  ulcer  on  the  lesser  curvature.  The 
deep  forward  projection  from  the  lesser  curvature  simulating  a 
diverticulum  shown. 


used  by  the  gastroenterologist."  The  rontgen  ray 
.showed  approximately  seventy  per  cent,  more  re- 
tention in  pathological  cases  than  the  clinical 
methods  of  extraction  about  fourteen  hours  after 
a  Riegel  meal  and  raisins  partaken  the  night  before. 

In  taking  up  the  rontgen  interpretation  of  peptic 
ulcer  we  shall  consider  them  in  the  two  main  classi- 
fications :    Gastric  and  duodenal  ulcers. 

Gastric  ulcer. — The  accuracy  of  the  rontgen  diag- 
nosis of  gastric  ulcer  today  cannot  be  overempha- 
sized. Carman  and  Miller  state :  "From  our  sta- 
tistics we  can  say  that  nine  tenths  of  the  ulcers  of 
the  stomach  give  distinct  rontgenological  indications 
of  gastric  disease,  and  in  an  overwhelming  majority 
of  these  the  signs  are  either  pathognomonic  or 
strongly  presumptive." 

Gastric  ulcers  may  be  classified  according  to  loca- 


tion and  depth.  According  to  location  we  may  con- 
sider:  1,  Ulcers  on  or  about  the  lesser  curvature 
(on  the  posterior  and  anterior  walls  approximating 
the  lesser  curvature)  ;  2,  pyloric  ulcers  in  the  pre- 
pyloric region ;  3,  ulcers  situated  at  the  cardia. 
Classified  according  to  depth:  1,  Mucous  or  simple 
ulcers  involving  the  superficial  layers ;  2,  penetrating 
or  callous  ulcers,  when  the  ulcer  is  of  long  stand- 
ing and  has  ulcerated  into  the  deeper  strata  of  the 
muscular  walls  producing  deep  craters,  spoken  of 
also  as  saddle  ulcers  when  overriding  the  lesser 
curvature;  3,  perforating  ulcer,  the  ulcer  extend- 
ing outside  the  stomach  walls  beyond  the  visceral 
coat  forming  at  times  an  accessory  pocket  in  the 
surrounding  tissue. 

The  rontgen  methods  of  diagnosis  of  gastric  ul- 
cer are  as  follows:  1,  Direct  method,  which  consists 
of  the  visualization  of  the  niche,  accessory  pockets 
and  pyloric  craters ;  2,  indirect  method,  consisting  of 
secondary  or  contributory  signs  indicating  the  de- 
parture from  the  normal  morphology  and  from  the 
normal  physiological  function,  plus  the  appearance  of 
adventitious  signs  which  give  expression  to  the  dis- 
turbed functions.  * 
DIRECT  SIGNS. 

Penetrating  ulcer  (Haudeck  niche),  Fig.  1,  on 
ihe  lesser  curvature  is  seen  as  a  forward  projec- 
tion from  the  contour  of  the  stomach  appearing  as 
if  it  were  a  diverticulum  filled  with  barium.  It  is 
best  seen  when  situated  above  the  incisura  angu- 
laris. It  varies  in  size  and  shape ;  usually  rounded 
in  outline,  it  may  assume  any  irregular  form.  The 
size  varies  according  to  the  depth  of  the  penetra- 
tion, from  a  few  mm.  to  an  inch  or  more.  When 
on  the  posterior  or  anterior  wall  it  is  best  seen  when 
using  the  sediment  mixture.  At  times  it  may  be 
completely  missed  when  the  buttermilk  mixture  is 
at  once  administered.  I  have  had  many  opportunities 
to  verify  this  and  use  the  sediment  mixture  to  good 
advantage.  All  positions  must  be  utilized,  especial!}' 
l;oth  obliques. 

2.  The  perforating  ulcer  with  the  accessory  pocket 
shows  the  diverticulum  with  a  supervening  layer  of 
air  simulating  a  miniature  stomach  pouch.  Here  the 
base  of  the  ulcer  has  gradually  perforated  through 
the  visceral  layer  of  the  peritoneum  into  the  neigh- 
lioring  organs  such  as  the  pancreas  or  liver,  becom- 
ing firmly  adherent.  The  niche  with  the  accessory 
air  pocket  is  often  seen  after  the  stomach  has  com- 
pletely emptied  itself.  A  niche  must  be  diflferentiated 
from  a  filled  loop  of  small  intestine,  usually  the  duo- 
denojejunal junction  jutting  above  the  gastric 
line ;  also  from  an  apparent  elevation  on  the  gastric 
walls  intervening  between  two  closely  following  peri- 
staltic waves.  Both  of  these  waves,  while  persisting 
for  a  time,  are  not  constant.  The  differentiation 
will  be  made  fluoroscopically. 

3.  Callous  ulcer  of  the  pylorus  when  occurring 
close  to  the  pyloric  sphincter  gives  the  appearance  of 
a  filling  defect  and  not  as  a  projection.  When  of 
long  standing  it  may  simulate  an  early  carcinoma 
defect.  Fig.  8  illustrates  the  persistent  filling  defect 
of  a  callous  ulcer  about  half  an  inch  away  from  the 
pyloric  sphincter  as  seen  in  the  multigraph  exposure. 
The  case  was  one  of  extreme  interest.    It  occurred 


118 


DIAMOND:  PEPTIC  ULCER. 


[New  York 
Medical  Journal. 


in  a  young  woman  about  twenty-eight  years  of  age 
with  gastric  symptoms  of  rather  short  duration,  in 
whom  a  fairly  large  tender  mass  was  felt  extend- 
ing downward  toward  the  right  iliac  region.  The 
clinical  diagnosis  was  that  of  a  possible  hyperne- 
phroma.   The  rontgenological  examination  at  once 


Fig.  2. — Organic  hourglass  stomach  of  several  years'  duration 
following  penetrating  ulcer  of  the  lesser  curvature.  Large  doses  of 
belladonna  left  condition  unchanged. 


made  the  diagnosis  of  calloiis  ulcer  of  the  pylorus 
with  pyloric  stenosis.  Operation  corroborated  the 
diagnosis.  The  mass  which  was  nothing  but  a  large 
inflammatory  exudate  disappeared  shortly  after  the 
gastroenterostomy  operation. 

INDIRECT  METHOD. 

The  secondary  or  contributory  manifestations  of 
gastric  ulcer  will  be  more  easily  understood  if  we 
consider  the  same  phenomena  governing  the  normal 
stomach,  such  as  the  type,  tonus,  outline,  motility 
and  peristalsis,  and  how  they  are  influenced  in  the 
pathological  states.  In  addition  several  new  factors 
make  their  appearance — the  socalled  spastic  manifes- 
tations. 

Hyperacidity  and  hypersecretion  are  the  main 
fimctional  disturbances  in  ulcer.  A  study  of  the 
rontgenological  appearance  of  these  functional 
changes  and  of  their  influence  upon  the  stomach 
constitutes  the  indirect  method  of  interpretation. 
These  changes  are  differently  expressed,  depending 
upon  the  location  of  the  ulcer  and  the  underlying 
type  of  stomach.  In  speaking  of  the  normal  stom- 
ach, stress  was  laid  upon  the  relation  of  the  mor- 
phology of  the  stomach  to  the  status  of  the  indi- 
vidual. In  diseased  conditions,  however,  the  relation 
becomes  disturbed  so  that  an  individual  normally 
the  possessor  of  a  subtonic  stomach  may  have  a 
hypertonic  stomach,  and  vice  versa.   The  alterations 


in  form  are  due  to  changes  in  the  tone  of  the  mus- 
culature of  the  stomach  in  response  to  the  stimu- 
lus of  an  existing  lesion.  The  changes  thus 
wrought  will  vary  with  the  location  and  duration 
of  the  ulcer.  There  may  also  occur  alterations  in 
size,  capacity  and  position,  the  stomach  rising 
higher  within  the  abdomen  or  descending  lower. 
Similarly  there  may  occur  disturbances  in  the  mo- 
tor phenomena,  as  seen  by  the  changes  in  the  peri- 
stalsis and  motility  of  the  stomach.  Changes  in 
outline  are  likewise  encountered,  resulting  from  in- 
creased muscular  irritability,  which  distort  the  con- 
tour diffusely  or  specifically.  These  functional 
changes  in  outline  are  spoken  of  as  spasm,  and  the 
stomach  may  assume  either  the  hourglass  form  or 
may  be  diffusely  distorted.  Organic  changes  aris- 
ing from  connective  tissue  infiltrations  around  ulcer 
areas  will  cause  adhesions  and  will  anchor  the 
stomach  in  abnormal  shapes  and  positions,  such 
as  is  seen  in  the  snail  form,  or  organic  hourglass 
(Fig.  2).  Pressure  from  without,  such  as  gas  in 
the  splenic  colon,  enlarged  spleen,  and  tumors  may 
likewise  produce  distortion  in  outline. 

Tone. — In  gastric  ulcer  loss  of  tone  is  the  rule. 
When  situated  at  the  lesser  curvature  the  hypo- 
tonic or  stretched  out  fishhook  type  is  invariably 
encountered.  In  the  administration  of  the  meal, 
while  there  may  be  a  temporary  delay  at  the  site 
of  the  ulcer,  it  soon,  however,  is  seen  to  drop  into 
the  lower  gastric  pole,  which  appears  distended  and 
sagging.  In  pyloric  ulcer  with  long  continued  ob- 
struction the  loss  of  tone  is  considerable  and  all 
the  muscle  fibres  are  stretched  out,  the  stomach 
appearing  uniformly  enlarged,  taking  on  the  ap^- 
pearance  of  ectasia.  The  upper  as  .well  as  the 
lower  gastric  pole  and  pylorus  are  uniformly 
widened. 

Peristalsis. — Altered  peristalsis  is  not  an  out- 
standing feature  of  ulcer  situated  in  the  pars  media. 
Pyloric  ulcers,  however,  when  associated  with  vari- 
ous degrees  of  stenosis,  exhibit  an  increase  in  depth 
and  number  of  the  waves.  The  waves  rise  abnor- 
mally high  and  bite  deep  into  the  lumen  of  the 
stomach,  often  giving  the  appearance  of  three  or 
four  segmented  round  balls.  Later  on  when  ectasia 
has  occurred  from  the  continued  weakening  of  the 
musculature,  the  peristaltic  contractions  are  inter- 
mittent, with  long  inter\^ening  periods  of  atony,  the 
contents  lying  dormant  in  the  basinlike  low  stom- 
ach. When  strongly  stimulated  by  abdominal 
massage  the  stomach  will  suddenly  stiffen  up  and 
be  thrown  into  a  violent  convulsive  standing  con- 
traction which  may  last  but  a  moment  and  then  sud- 
denly relax  into  the  previous  ectatic  atonicity. 

Spastic  manifestation. — The  visualization  of  the 
inherent  characteristics  of  the  gastric  musculature 
to  undergo  spastic  or  standing  contractions  when 
subjected  to  irritations  from  within,  or  reflexly 
from  without,  only  became  apparent  when  the  ront- 
gen  ray  was  first  used  in  examinations  of  dis- 
eases of  the  alimentary  tract.  The  finding  of  a 
spastic  contraction  is  of  great  value  and  cannot  be 
disputed  even  by  those  who  base  their  information 
on  direct  findings  alone,  for  a  spastic  contraction 
will  often  denote  the  presence  of  ulcer  in  the  ab- 


July  24,  1920.] 


DIAMOND:  PEPTIC  ULCER. 


119 


sence  of  any  other  evidence.  All  parts  of  the  diges- 
tive tract  are  subjected  to  spasm,  the  stomach, 
however,  is  the  ground  where  n  anifestations  of 
insult  from  within  or  from  distal  abdcKTiinal  vis- 
cera most  frequently  make  themselves  foil. 

Spasm  in  gastric  ulcer  may  assume  the  following 
forms,  dependent  upon  location  and  general  char- 
acteristics:  1,  The  incisura  or  spastic  hourglass;  2, 
dif¥use  or  general  gastrospasm;  3,  spasm  of  the 
pylorus. 

1.  The  incisura  is  due  to  a  contraction  of  the 
circular  muscle  fibres  occurring  in  the  plane  of  the 
ulcer.  It  is  manifested  by  a  narrow,  smooth,  and 
regular  indentation  of  the  greater  curvature.  It  va- 
ries in  depth  and  width,  depending  upon  the  size  of 
the  ulcer.  They  are  usually  seen  in  the  pars  media  in 
the  vertical  portion  of  the  stomach,  but  may  occur 
anywhere.  When  deep  enough  it  may  bisect  the 
stomach  into  two  sacs  giving  the  appearance  of  the 
hourglass  stomach.  The  two  sacs  are  connected  by 
a  very  narrow  canal  often  assuming  the  shape  of 
the  letter  B.  The  incisura  is  a  persistent  standing 
contraction,  especially  when  the  ulcer  is  in  the  florid 
stage.  It  does  not  disappear  under  active  bella- 
donna administration.  While  the  incisura  is  not  a 
constant  accompaniment  of  gastric  ulcer  it  may, 
however,  at  times  be  the  only  evidence  of  ulcer.  An 
incisura  may  likewise  manifest  itself  from  reflex 
causes  when  diseased  conditions  exist  in  other  ab- 
dominal viscera.  It  can,  however,  be  differentiated 
by  its  transient  nature,  by  its  inconsistency  in  posi- 
tion, and  by  its  disappearance  under  active  bella- 
donna administration. 

2.  Diffuse  gastrospasm  is  a  frequent  accompani- 
ment of  gastric  ulcer.  It  may  be  remote  from  the 
seat  of  an  ulcer,  differing  from  the  incisura,  and 
involves  the  most  active  portion  of  the  stomach,  the 
pyloric  segment  as  far  as  the  incisura  angularis.  It 
causes  considerable  distortion  of  the  pars  pylorica, 
often  simulating  carcinoma.  The  contour  may  ap- 
pear angular  or  choppy  or  may  simulate  a  cork- 
screw. Fig.  3  gives  a  fair  indication  of  its  appear- 
ance. The  rhythmic  peristaltic  waves  fail  to  pass 
over  and  very  'often  the  rontgenologist  encounters 
great  difficulty  in  the  differentiation  from  malignant 
infiltrations.  Only  good  doses  of  belladonna  and 
the  clinical  picture  will  solve  this  problem.  The 
spasm  will  interfere  with  gastric  motility. 

3.  Spasm  of  the  pyloric  sphincter  arises  from  ir- 
ritation of  an  ulcer  situated  in  the  pyloric  segment 
at  or  close  to  the  sphincter.  The  pylorospasm  may 
be  so  intense  as  to  cause  marked  interference  with 
the  emptying  time  and  the  six  hour  examination 
will  reveal  a  large  residue,  the  stomach  often  not 
emptying  until  the  next  day.  How  the  mechanism 
of  retention  is  brought  about  and  how  the  state  of 
the  pyloric  sphincter  governs  the  exit  of  the  food 
under  abnormal  conditions  will  be  discussed  below. 

Motility. — Disturbances  in  motility  as  manifested 
by  retention  at  the  end  of  six  hours  is  present  in 
about  fifty-five  per  cent,  of  gastric  ulcers.  The 
closer  the  ulcer  to  the  pyloric  sphincter  the  greater 
will  be  the  six  hour  residue.  Ulcers  situated  in 
the  pars  media  may  not  be  accompanied  by  reten- 
tion. If  so,  the  retention  is  small  and  is  situated 
to  the  left  of  the  median  line.    In  pyloric  ulcers 


the  residue  is  large,  crescentic  in  outline,  and  is 
centrally  located,  the  retention,  lying  closest  to  the 
seat  of  the  ulcer.  The  size  of  the  residue  varies 
from  one  quarter  to  three  quarters  or  more  of  the 
meal  partaken.  Large  retentions  are  also  met  with 
when  the  ulcer  is  in  the  active  stage  and  is  associated 
with  an  inflammatory  exudate.  These  often  simu- 
late organic  stenosis.  When  the  active  stage  sub- 
sides the  six  hour  retention  becomes  considerably 
lessened  or  may  totally  disappear.  In  ulcers  situ- 
ated at  the  pyloric  sphincter  the  stenosis  may  be 
complete,  and  the  meal  may  then  be  retained  for 
several  days,  the  ectatic  stomach  finally  relieving 
itself  by  vomiting  large  quantities  of  food.  The 
characteristic  three  layers  of  vomitus  in  gastrectasia 
are  then  observed.  The  incidence  of  gastric  re- 
tention is  not  always  due  to  the  mechanical  factor 
of  stenosis,  for  retentions  are  continually  encoun- 
tered when  the  ulcer  is  situated  remotely  from  the 
sphincter.  Retentions  may  likewise  arise  from  dis- 
tant lesions  of  abdominal  organs,  such  as  appen- 
dicitis, cholecystitis,  and  renal  calculi.  Such  reten- 
tions are  due  to  disturbances  in  function  of  the 
pyloric  sphincter,  disturbances  which  arise  from 
disordered  vagus  innervation  manifesting  itself  in 
hyperacidity  and  hypersecretion.  The  pylorus  be- 
comes irritable  and  spastic  and  gives  rise  to  the 
condition  spoken  of  as  pylorospasm.  When  lesions 
exist  in  a  hypertonic  or  orthotonic  stomach  the  re- 
tention due  to  pylorospasm  will  be  greater  than 
hypotonic  lesions  due  to  greater  muscular  strength. 
Under  the  fluoroscope  the  pylorus  is  seen  to  take 
on  a  sheared  off  or  notched  appearance.  The  meal 
is  at  first  delayed  in  its  passage  and  later  on  is 
seen  to  pass  through  in  a  very  narrow  stream, 
never  filling  the  duodenum  completely.  Such  spasm 
usually  indicates  ulcer  at  or  near  the  pylorus.  In 


Fig.  3. — Penetrating  gastric  ulcer.  Note  the  intense  accom- 
panying spasm  in  the  pyloric  region  simulating  a  canalization  of 
carcinoma  defect. 


ulcers  situated  distally  from  the  pylorus  the  re- 
flex spasm  is  only  present  in  the  first  hours  of 
digestion  when  food  still  fills  the  pars  media.  Later 
on,  however,  when  the  local  irritation  has  disap- 
peared the  reflex  pylorospasm  will  let  up  and  the 
stomach  will  empty  on  time. 


120 


DIAMOND:  PEPTIC  ULCER. 


[New  York 
Medical  Journai.. 


Ulcer  situated  at  the  cardia  is  a  rare  occurrence. 
It  cannot  be  visualized  on  direct  examination.  The 
diagnosis  must  .rest  on  the  presence  of  indirect 
signs  of  cardiospasm,  the  lower  end  of  the  esopha- 
gus remaining  filled  and  assuming  a  sausageshaped 
appearance,  tlie  food  only  occasionally  dropping 
through  in  a  thin  stream.  An  incisura  high  up  at 
the  cardia  may  also  be  present.  While  cardiospasm 
may  be  the  result  of  other  conditions,  a  careful 
clinical  history  will  aid  in  the  diagnosis. 

The  rontgen  methods  of  diagnosis  of  duodenal 
ulcer,  like  those  of  gastric  ulcer,  consist  of:  1. 
Direct  signs — visualization  of  the  duodenal  defect. 
2.  Indirect  signs — hypertonus,  hyperperistalsis,  hy- 
permotility.  hypersecretion,  spastic  manifestations, 
and  tender  i^oints. 

DIRECT  SIGNS. 

Before  entering  into  a  description  of  the  duodenal 
defect  it  would  not  be  amiss  to  mention  briefly  the 
rontgen  anatomy  of  the  duodenum.  The  duodenum 
is  made  up  of  four  portions :  First,  pars  ascen- 
dens  superioris,  also  called  duodenal  bulb  or  cap ; 
second,  pars  descendens;  third,  pars  horizontalis. 


gular  shape,  as  is  seen  in  the  fishhook  or  the  other 
forms. 

Duodenal  defect  consists  of  a  distortion  in  the 
contour  of  the  duodenum.  The  irregularity  may 
assume  any  form  or  size,  and  may  be  seen  on  any  of 
the  borders,  most  often  on  the  mesial  border.  The 
duodenal  defect  is  due  to  organic  structural  changes 
in  the  walls  of  the  duodenum.  It  may  also  be  due 
to  associated  spasm.  Carman  states  that  the  defect 
always  appears  larger  under  the  rontgen  examina- 
tion than  when  seen  at  the  operation,  which  he  ex- 
plains is  due  to  the  associated  spasm.  Figs.  4,  5, 
6  and  7  give  a  fair  idea  of  the  different  types  of 
duodenal  defects.  They  usually  appear  as  craters 
which  may  be  very  small,  Fig.  7,  or  sufficiently 
large  to  distort  the  entire  surface  of  the  duodenum, 
as  is  seen  in  the  large  clover  leaf  defect  in  Figs. 
4  and  6.  Sometimes  the  defect  may  appear  as  a 
niche,  similar  to  gastric  ulcer,  and  occasionally  an 
accessory  pocket  is  encountered.  An  incisura  oc- 
curring in  the  plane  of  an  ulcer  is  often  seen.  At 
times  no  defect  may  be  visible  but  the  duodenum 
appears  small  and  contracted.    When  such  obser- 


Fk,. 


Fig. 


Fig 


Figs.  4,  5.  6. — Various  types  of  duodenal  ulcers  showing  the  defect  of  the  first  portion  of  the  duodenum.     Note  the  persistent  defect  in  the 

raultigraph  exposure. 


and  fourth,  pars  ascendens  inferioris.  The  first 
portion  or  duodenal  cap  is  the  one  of  most  interest 
to  the  rontgenologist.  Nine  tenths  of  all  duodenal 
ulcers  occur  in  the  fir.st  portion.  The  duodenal  bulb 
varies  in  size  and  somewhat  in  shape  with  the  type 
of  stomach.  Rising  above  the  pylorus,  the  duo- 
denum comnninicates  directly  with  the  sphincter. 
The  cap  is  one  inch  to  an  inch  and  a  half  in  size 
and  is  triangular  in  outline,  with  the  base  below 
and  the  apex  above.  It  presents  a  smooth  and 
regular  appearance.  The  duodenohepatic  ligament 
anchors  the  summit  of  the  first  portion  of  the 
duodenum.  In  the  subtonic  type  of  stomach  the 
duodenum  is  larger  in  size  and  is  seen  filled  most 
of  the  time.  This  is  due  to  the  low  and  sagging 
lower  pole  of  the  subtonic  stomach,  which  causes 
traction  in  the  duodenohepatic  ligament,  thus  in- 
creasing the  bend  between  the  first  and  second  por- 
tions. In  the  steerhorn  stomach  it  is  often  with 
difficulty  visualized,  appearing  small  and  situated 
posteriorly  to  the  pylorus,  and  may  also  be  directed 
downward.    It  does  not  assume  the  typical  trian- 


vation  is  continually  noted  the  rontgenologist 
should  be  on  his  guard,  for  there  may  be  a  small 
mucous  ulcer  present.  Distortion  in  contour  may 
sometimes  occur  from  adhesions  arising  from  the 
gallbladder.  Such  defects,  however,  do  not  present 
the  regularity  or  constancy  of  an  ulcer.  Pressure 
on  the  outer  border  of  the  duodenum  from  an 
enlarged  gallbladder  does  not  offer  any  difiicuhy 
or  differentiation.  Finally  a  sufficient  number  of 
exposures  must  be  taken  to  satisfy  the  observer 
as  to  the  presence  of  a  normal  or  abnormal  duo- 
denum. All  positions  should  he  utilized,  including 
the  first  and  second  oblique. 

INDIRECT  SIGNS. 

Hypertonus. — In  duodenal  ulcers  the  stomach  as- 
sumes the  hypertonic  form.  The  alteration  in  type 
is  due  to  the  increase  in  tonus  which  may  either  he 
due  to  reflex  stimulation  arising  from  the  irritable 
ulcer  or  from  the  more  energetic  contractions  in 
the  effort  to  overcome  a  spastic  duodenum.  Thus 
we  often  see  a  stomach  of  the  fishhook  type  with 
a  vertical  axis  change  in  position  and  form.  The 


Jul..-  24,  1920.J 


DIAMOND:  FEFTIC  ULCER. 


121 


stomach  rises  higher  in  the  abdomen  and  assumes 
an  oblique  to  a  transverse  axis.  These  changes  in 
form  and  axis  are  due  to  the  increased  state  of 
tonicity  of  the  vestil)ular  portion  of  the  stomach. 
In  long  standing  callous  ulcers  of  the  duodenum 
with  stenosis  the  stomach  will  gradually  assume 


trie  musculature  in  the  effort  to  compensate  the 
ol)struction.  With  moderate  degrees  of  obstruction 
the  antrum  appears  distended  and  is  a  significant 
finding  in  duodenal  ulcer.  When  the  ulceration  has 
extended  to  the  pyloric  sphincter  the  picture  of  the 
ectatic  stomach  of  the  pyloric  ulcer  with  stenosis 
will  repeat  itself. 

Hypcniioti!it\. — Hypermotility  is  another  factor 
in  duodenal  ulcer,  j)rovided  marked  obstruction 
does  not  exist.  As  mentioned  ])efore,  rapid  evacu- 
ation is  continually  observed  during  the  fluoroscopic 
examination,  the  meal  passing  with  great  rapidity 
through  the  duodenum  often  never  allowing  the 
duodenum  to  fill  completely.  The  advance  of  the 
meal  through  the  intestinal  canal  is  also  rapid.  Nor- 
mally the  head  of  the  contrast  meal  is  seen  at 
the  hepatic  flexure  at  the  end  of  six  hours,  being 
evenly  distributed  in  the  terminal  ileum,  cecum  and 
ascending  colon.  In  duodenal  ulcer,  however,  the 
advance  of  tlie  meal  is  more  rapid  and  the  head 
of  the  advancing  column  is  beyond  the  midportion 
of  the  transverse  colon  and  may  be  seen  as  far 
as  the  sigmoid  (Fig.  8),  very  little  remaining  in 
the  terminal  ileum.  The  stomach  empties  early. 
In  uncomplicated  duodenal  ulcers  it  may  empty 
within  two  or  two  and  a  half  hours  or  even  earlier. 
\\'hen  hyperacidity,  hypertonus,  and  associated  py- 
loro^asm  supervene  a  small  six  hour  retention  is 


Fig.  7. — Defect  under  rontgen  examination  due  to  associated  spasm. 
The  surface  of  the  duodenum  is  distorted. 

the  hypotonic  and  atonic  forms  from  exhaustion 
of  the  nuiscular  fibres,  spoken  of  then  as  loss  of 
compensation. 

Hyper  peristalsis. — Hyperperistalsis  is  character- 
istic of  duodenal  ulcer  and  occurs  in  a  large  per- 
centage of  cases.  There  occurs  not  only  an  in- 
crease in  the  wave  depth  but  also  in  their  number. 
The  wave  begins  high  up  at  the  cardia  on  both 
curvatures.  Several  waves  simultaneously  travel 
briskly  toward  the  pylorus.  The  four  to  five  cycle 
stomach  is  most  often  seen.  When  a  meal  is  given 
it  is  retained  somewhat  longer  in  the  cardia  on  ac- 
count of  the  increased  perisystole.  When  reach- 
ing the  caudal  portion  the  initial  peristaltic  wave 
is  more  intense  and  the  meal  is  at  once  seen  to  pour 
out  copiously  through  the  duodenum.  The  normal 
five  to  ten  minutes  period  of  delay  is  shortened 
and  the  regular  waves  soon  set  in.  The  energy  and 
depth  of  the  waves  are  marked  not  only  in  the 
antrum  pylori  but  high  up  in  the  pars  media,  the 
antrum  however  exhibiting  several  large  deep  in- 
dentations. As  digestion  progresses  short  periods 
of  rest  are  noted,  the  stomach  becoming  completely 
relaxed  and  no  peristaltic  waves  being  seen.  If  gentle 
abdominal  massage  is  used  the  stomach  will  at  once 
stiffen  up  and  again  repeat  the  violent  -convulsive 
contractions.  These  periods  of  intermission  in- 
crease with  the  size  and  extent  of  the  ulcer  and 
are  due  to  an  increasing  exhaustion  of  the  gas- 


FiG.  8. — Callous  ulcer  of  the  duodenum  on  the  indirect  evi- 
dence. Retention  and  colonic  hypermotility  at  the  end  of  six  iiours. 
Incidentally  the  ulcer  defect  of  the  duodenum  is  also  seen. 


met  with.  This  retention  is  made  up  mostly  of 
gastric  secretion  holding  little  of  the  contrast  sub- 
stance in  suspension.  If  a  tube  is  introduced  no 
food  particles  are  withdrawn  but  a  large  quantity 
of  clear  secretion  with  a  little  barium  are  obtained. 
Later,  however,  when  stenosis  takes  place  the  six 


122 


McMURRAY 


BENZYL  BEN ZO ATE  IN  WHOOPING  COUGH. 


(New  York 
Medical  Journal. 


hour  residue  will  vary  with  the  degree  of  the  steno- 
sis and  will  simulate  pyloric  ulcer.  In  such  cases, 
aside  from  the  duodenal  defect,  the  presence  of  ex- 
aggerated peristalsis  will  always  help  in  the  differ- 
entiation of  the  two  conditions. 

Hypersecretion. — Hypersecretion  is  the  fourth  and 
final  "hyper"  characteristic  of  duodenal  ulcer.  It 
should  be  looked  for  only  in  the  fasting  stomach 
or  at  the  six  hour  examination  when  using  the 


Fig.  9. — Note  the  intense  spasm  on  the  pars  pylorica,  both  on  the 
lesser  and  greater  curvatures  accompanying  duodenal  ulcer. 

double  Haudeck  meal  and  can  then  be  demonstrated 
by  the  presence  of  the  horizontal  base  line  of  the 
magen-blasc,  and  fluoroscopically  by  the  visual  suc- 
cussion  of  the  fluid.  If  the  meal,  is  administered 
in  the  presence  of  secretion  it  does  not  hug  the 
lesser  curvature  but  is  seen  to  drop  through  the 
fluid  like  molasses  through  water.  When  the  stom- 
ach is  full  with  the  buttermilk  barium  mixture,  if 
secretions  are  present  they  will  rise  to  the  top  and 
form  a  layer  of  a  lesser  grayish  density  interven- 
ing between  the  magen-blase  and  the  meal.  This  is 
not  due  to  sedimentation  of  the  meal,  for  it  be- 
comes at  once  apparent,  and  furthermore  the  butter- 
milk mixture  does  not  settle. 

Spastic  manifestations. — Gastrospasm  is  usually 
a-.i  accompanying  factor  in  duodenal  ulcer.  It  may 
occur  in  the  form  of  an  incisura  or  less  commonly 
as  a  diffuse  gastrospasm.  Fig.  9  represents  a  con- 
stant defect  in  the  pyloric  segment  due  to  reflex 
gastrospasm  from  duodenal  ulcer  simulating  malig- 
nant infiltration.  A  reexamination  after  active  bel- 
ladonna administration  relaxed  the  spasm  and  the 
distortion  in  contour  disappeared. 

Tender  Points. — Tender  points  in  duodenal  ul- 
cer are  not  a  dependable  sign.    The  writer  has  seen 


many  outspoken  duodenal  ulcers  without  tender 
points.  When  the  ulcer  is  large  enough,  however, 
or  is  in  the  acute  stage,  or  when  periduodenitis  is 
present,  then  tenderness  is  quite  manifest.  Simi- 
larly, in  gastric  ulcer  the  niche  along  the  lesser 
curvature  is  invariably  tender  and  is  always  due 
to  the  accompanying  perigastritis. 

The  indirect  signs  of  hypertonus,  hyperperistal- 
sis,  hypermotility  and  hypersecretion  are  spoken  of 
as  duodenal  irritation  and  are  not  pathognomonic 
of  duodenal  ulcer.  Pathological  conditions  in  dis- 
tant viscera  are  frequently  manifested  in  reflex  duo- 
denal irritation.  In  the  presence  of  a  normal  duo- 
denal bulb  one  should  hesitate  to  regard  the  case 
as  one  of  duodenal  ulcer.  While  a  small  ulcer  may- 
exist,  under  the  circumstances  it  is  not  commonly 
seen,  and  a  careful  investigation  of  other  possible 
lesions  should  be  made.  It  is,  of  course,  superfluous 
to  state  that  such  examinations  should  be  routinely 
performed.  The  efforts  of  the  examiner  will  then 
be  amply  rewarded. 

BIBLIOGRAPHY. 

McCallum  :  Pathologj-  of  Chronic  Gastric  Ulcer,  Jour- 
nal A.  M.  A.,  September  10,  1904. 

Hertz,  A.  F. :  The  Sensibility  of  the  Alimentary  Canal, 
Chapter  VI,  London. 

Carlson,  A.  J. :  Epigastric  Pain,  American  Journal  of 
Physiology,  xlv. 

Hart,  L.  J. :  Pain  in  Active  Pathological  Processes  in 
Stomach  and  Duodenum,  Journal  A.  M.  A.,  March  23,  1918. 

Kast  and  Meltzer:  Sensibility  of  Abdominal  Organs, 
Medical  Record,  December  29,  1906. 

Rogers  and  Hardt. 

Dragstedt:  Contribution  to  the  Physiology  of  the  Stom- 
ach, Gastric  Juice  in  Duodenutn,  and  Gastric  Ulcer,  Jour- 
nal A.  M.  A.,  February,  1917. 

45  St.  Mask's  Place. 


THE    BENZYL    BENZOATE  TREATMENT 
OF  WHOOPING  COUGH. 
By  T.  E.  McMurray,  M.  D., 

Wilkinsburg,  Pa. 

Satisfactory  and  immediate  results  can  be  ob- 
tained in  the  treatment  of  whooping  cough  by  the 
use  of  benzyl  benzoate.  The  dose  given  was  from 
five  to  thirty  minims  every  four  hours,  depending 
upon  results.  In  some  cases  decided  improvement 
was  noticed  from  the  smaller  dose,  in  other  cases 
larger  doses  were  employed.  In  almost  every  in- 
stance the  treatment  determined  subsidence  of  the 
paroxysms. 

The  effect  usually  made  itself  felt  within  forty- 
eight  hours  and  in  one  instance  there  was  relief 
after  the  second  dose.  As  a  rule  the  relief  is  im- 
mediate and  complete.  Although  it  is  necessarily 
somewhat  difficult  to  estimate  the  efficacy  of  a 
remedy  in  such  a  capricious  disease  as  whooping 
cough,  I  think  I  am  entitled  to  conclude  from  my 
experience  that  it  not  only  does  in  many  cases  af- 
ford immediate  relief  of  severe  spasms  of  coughing, 
but  it  also  seems  to  lengthen  the  interval  between 
attacks.  As  far  as  my  experience  goes,  this  treat- 
ment gives  rise  to  no  undesirable  results.  I  gave 
twenty  minims  to  a  child  twelve  months  of  age 
with  no  evidence  of  gastric  or  any  other  disturbance. 

553  Trenton  Avenue. 


Jul,-  24,  1920.] 


PALEFSKI:  STUDY  OF  GASTROINTESTINAL  CONDITIONS. 


12.; 


.5 


DIAGNOSTIC  CHARTS  AS   A  GUIDE  IN 
THE  STUDY  OF  GASTROINTESTINAL 
CONDITIONS. 

By  I.  O.  Palefski,  M.  D., 
New  York. 

The  correct  diagnosis  of  abdominal  conditions 
necessarily  requires  observation  based  upon  the  re- 
sults of  extensive  clinical  and  rontgenological 
examinations.  From  the  cases  studied  by  us  within 
recent  years,  we  observed  that  errors  in  diagnosis 
were  most  frequently  the  result  of  brief  histories 
or  hasty  examinations.  Another  common  cause 
was  the  overemphasizing  of  one '  procedure  at  the 


Fig.    1. — Filled  stomach,   erect  posture;   A,   moderately   dilated  and 
drawn  to  right  of  spine;  B,  duodenum  not  properly  filled. 


expense  of,  or  even  to  the  exclusion  of,  other  equal- 
ly important  ones. 

Such  studies  must  not  only  be  made  from  every 
angle  but  the  diagnostic  data  gathered  must  be 
properly  recorded  for  reference.  Gastrointestinal 
disturbances  are  sometimes  the  expression  of  an 
organic  disease  outside  the  gastrointestinal  tract 
and  which  makes  itself  apparent  months  or  years 
later.  Hence  all  evidence  must  be  noted  and  re- 
corded. Again,  the  recording  of  such  data  must 
not  entail  too  much  clerical  work  as  it  is  not  prac- 
tical in  private  practice.  On  the  other  hand, 
loosely  kept  records  and  prints  of  x  ray  negatives 
are  likely  to  be  misplaced  and  the  record  of  the 
whole  case  soon  becomes  a  matter  of  memory. 

We  have,  therefore,  devised  a  folding  card  sys- 
tem comprising  four  printed  forms  for  the  history, 
physical,  clinical,  and  rontgenological  findings. 
Prints  of  the  reduced  x  ray  negatives  are  attached 
and  the  whole  can  be  conveniently  kept  in  a  record 


Fig.  2. — Filled  stomach,  prone;  normal  appearance. 


cabinet  or  bookcase.  These  charts  require  the  least 
amount  of  writing  as  only  abnormal  or  unusual 
findings  need  be  recorded,  while  the  unfilled  parts 
represent  the  normal.  A  duplicate  of  this  card 
is  sent  as  a  report  to  the  physician. 

The  printed  form  for  the  history  permits  a  de- 


Fig.  3. — Six-hour  plate;  A,  appendix  well  visualized. 


124  LOIVEXBURG:  EMPYEMA  IX   IXFAXTS  AXD  CHILDREN.  [New  York 

Medical  .Tournau 


tailed  description  of  the  personal  habits,  character 
of  meals,  menstrual  and  marital  history,  and  a 
careful  analysis  of  the  symptoms  of  the  present 
complaint.  Improper  habits,  indiscretions,  in  diet, 
gynecological  disorders  and  previous  pregnancies 
and  labors,  have  a  direct  bearing  upon  the  present 


Fig.  4. — Forty-eight  hour  plate;  A,  appendix  still  visualized. 


complaint  in  a  large  number  of  patients  with  gas- 
trointestinal disturbances. 

The  printed  form  for  the  physical  examination 
provides  for  a  general  examination  and  detailed 
description  of  the  abdomen  and  fluoroscopy  of  the 
gastrointestinal  tract.  The  findings  elicited  in  the 
physical  examination  of  the  abdomen,  are  repre- 
sented by  their  initials  inserted  at  the  correspond- 
ing areas  in  the  diagram. 

\Ye  believe  that  these  folding  charts^^  ofTer  not 
only  a  convenient  and  timesaving  method  for  the  re- 
cording of  data  but  will  prove  a  guide  to  the  busy 
practitioner  in  obtaining  careful  histories  and  phy- 
sical examinations  essential  for  correct  diagnosis 
in  abdominal  conditions. 

156  West  Eighty-sixth  Street. 


Resection  of  Double  Kidney. — Frederick  C. 
Herrick  (Sitrgcry.  Gynecology  and  Obstetrics,  June, 
1920),  presents  his  conclusions  in  the  treatment  of 
double  kidney  :  1.  Resection  of  a  diseased  double  kid- 
ney or  the  diseased  portion  of  a  single  kidney  may  be 
advisable  in  order  to  save  a  necessary  amount  of 
kidney  sulDstance  for  the  individual.  2.  The  resected 
end  surface  should  be  covered  with  fatty  capsule.  3. 
There  were  found  in  the  literature  four  other  re- 
ported cases  of  resection  of  double  kidneys. 

^The  folding  charts  will  be  included  in  the  author's  reprints. 


PLEURAL  DISEASE  IN  INFANTS  AND 
CHILDREN.* 
With  Special  Reference  to  Empyema. 
By  H.\RRY  LowEXBURG,  A.  M.,  M.  D., 

Philadelphia, 
Pediatrist  to  the  Mount  Sinai  and  Jewish  Hospitals. 

Dry  pleurisy  is  common  in  infancy  and  child- 
hood. It  occcurs  as  a  primary  disease  but  more 
often  is  secondary  to  lobar  or  bronchopneumonia, 
forming  a  part  of  the  complete  clinical  picture  of 
nearly  every  case  of  the  first.  Nonpurulent  pleural 
effusion  is  more  often  a  primary  disease  than  dry 
pleurisy.  It,  too,  more  often  follows  lobar  pneu- 
monia. Purulent  pleuritic  empyema  commonly  fol-* 
lows  pneumonia  and  may  rarely  be  a  primary  dis- 
ease, or  rather  it  occurs  as  a  sequence  to  or  is  a 
secondary  stage  of  primary  nonpurulent  effusion. 
In  infants  and  young  children  tuberculosis  as  an 
etiological  factor  plays  comparatively  a  minor  role. 

DIAGNOSIS. 

Years  ago  I  drew  attention  to  the  fact  that  on  the 
left  side  in  infants  and  children  the  breath  sounds 
are  harsher  and  louder  than  they  are  on  the  right 
side.  This  fact  is  too  little  recognized  and  leads 
to  the  suspicion  of  fluid  on  the  right  side  when  no 
fluid  exists.  It  must  further  be  borne  in  mind  that 
the  breath  sounds,  especially  in  infants  but  also  in 
young  children,  are  sometimes  not  at  all  interfered 
with  as  to  their  transmissibility  and  in  the  majority 
of  cases  but  little.  This  is  due  to  many  cattses — 
the  thinness  of  the  chest  wall  and  frequently  be- 
cause there  is  either  a  compressed  (carnified)  or  con- 
solidated lung  from  which  bronchial  breathing  em- 
anates. This,  being  loud,  is  more  readily  trans- 
mitted. Hence  reliance  for  a  conclusive  diagnosis 
may  not  be  placed  upon  ausctiltatory  phenomena. 

Percussion  yields  the  best  results.  Two  percus- 
sion phenomena  are  of  particular  value,  as  fol- 
lows: 1.  There  is  a  widespread  area  of  impaired 
resonance  or  dullness  (depending  on  the  amount  of 
effusion)  which  is  out  of  proportion  to  the  degree 
of  dyspnea.  In  other  words,  if  the  same  area  of  im- 
pairment depended  upon  solid  lung  there  should  and 
would  be  very  difficult  breathing,  perhaps  orthopnea 
and  cyanosis.  Impairment  in  the  axillary  spaces 
or  the  lateral  aspect  of  the  chest  is  always  highly 
suggestive.  2.  Just  as  important  is  the  widespread 
area  of  a  sense  of  increased  resistance  which  is 
revealed  by  what  may  be  termed  light  massive  per- 
cussion or,  perhaps  better,  light  palpatory  percus- 
sion. This  is  practised  by  lightly  tapping  the  thorax 
with  the  tips  of  five  fingers  of  the  outspread  hand. 
The  difference  experienced  between  the  two  sides  in 
onesided  effusion  is  extremely  well  marked.  With 
these  two  signs  in  evidence  the  results  of  thoracic 
puncture,  the  concluding  evidence  of  fluid,  if  posi- 
tive, but  not  of  the  absence  of  fluid,  if  negative, 
may  be  predicted  with  almost  absolute  surety. 

A  word  as  to  which  interspace  should  be  the  one 
of  preference  for  thoracic  puncture  may  not  be 
amiss.  On  this  topic  textbooks  should  be  rewritten. 
No  special  interspace  may  be  named.  Puncture 

*Read  before  the  Northern  Medical  Society,  as  part  of  a  sym- 
posium on  pleural  disease,  January  23.  1920. 


July  24,  1920.] 


LOIVENBURG:  EMPYEMA  IX    IXJ  AXTS  AXL)  CHILDKEX. 


125 


should  be  made  where  pliysical  signs  indicate  the 
presence  of  fluid.  Space  for  discussing  the  value 
of  X  ray  studies,  whicli  should  always  be  made  in 
hospital  cases,  if  for  no  other  reason  than  for  purely 
pedagogical  purposes,  is  not  available,  and  for  the 
same  reason  discussion  of  the  treatment  of  nonpuru- 
lent pleural  effusion  will  be  omitted. 

\\'hen  asked  to  participate  in  this  symposium  I 
eagerly  accepted  mainly  for  two  reasons.  First,  it 
gave  me  a  formal  opportunity  to  say  something 
frankly,  and  I  trust  w-ithout  ofifense,  to  the  sur- 
geons ;  second,  it  gave  opportunity  to  express,  with 
due  humility,  in  the  capacity  of  pediatric  internist, 
certain  views  as  to  the  surgical  treatment  of  this 
serious  and  death  dealing  condition.  These  views,  in 
my  judgment,  in  principle  at  least,  offer  encourage- 
ment as  to  the  possibility  of  a  greater  number  of 
cures.  I  desire  it  to  be  borne  in  mind  that  the 
opinions  here  expressed  are  personal  ones,  given, 
how^ever,  as  a  pediatrist  and  are  born  of  the  disas- 
trous results  experienced  in  many  cases,  handled  by 
competent  surgeons.  If  any  of  my  hearers  desire 
to  apply  these  views  to  the  adult  they  do  so  on  their 
own  responsibility. 

CRITICISMS   OF   SURGERY   AND   OF  SURGEONS. 

The  surgeon  has  taken  from  the  medical  man, 
one  by  one,  his  right  to  treat  disease  after  disease, 
and  perhaps  justly  so.  His  conquests,  however, 
have  made  him  arrogant  (shall  we  say  egotistical?) 
and  even  at  times  insolent  and  abusive  toward  his 
medical  colleagtie,  who  conscientiously,  and  not  al- 
ways wrongly,  may  differ  from  him.  Appendicitis, 
gallbladder  and  pancreatic  disease,  malignancy  in  its 
protean  manifestations,  hernia,  gastric  and  duodenal 
ulcer,  pyloric  obstruction,  goitre,  uterine  fibrosis, 
tonsillar  disease,  prostatic  hypertrophy,  etc.,  have 
rightly  been  removed  from  the  realm  of  the  medical 
idler,  the  therapeutic  procrastinator,  and  have  been 
preempted  by  the  surgeon.  Woe  to  that  medical 
philosopher  who  presumes  to  take  sides  against  his 
chirurgical  brother  in  dealing  with  the  conditions 
aforementioned  !  How  scathing  his  chastisement ! 
How  humiliating  his  ridicule !  How  damning  his 
censure !  But  unlike  Duncan,  the  illustrious  king 
of  Scots  in  Shakespeare's  Macbeth,  he,  the  surgeon, 
hath  not  borne  his  great  ofiice  so  meekly.  To  mis- 
quote further  the  bard  of  Avon,  he  assuines  a  vir- 
tue and  he  has  it  not,  with  reference  to  this  disease, 
empyema.  He  has  taken  this  disease  to  his  bosom 
as  his  own.  Like  the  ubiquitous  traffic  officer  auto- 
matically he  raises  his  warning  hand  and  says  "Thou 
shalt  not.  This  is  the  acreage  for  angels'  feet  to 
tread  and  fools  may  not  enter.  You  have  no  opin- 
ion worthy  our  contemplation  or  consideration.  Do 
not  forget  ye  are  but  medical  men  and  in  matters 
surgical  ye  dare  not  speak.  Content  ye  therefore 
yourselves  with  making  mistakes  in  diagnosis  and 
with  telling  us  where  pus  lies  concealed  after  we  re- 
sect the  wrong  rib  and  we  will  do  the  rest.  And 
verily  so  it  comes  to  pass.  The  rest  is  done  and  of- 
ten it  is  for  long  and  frequently  it  is  a  rest  eternal 
and  everlasting !" 

To  face  facts,  may  one  not  ask  what  in  all  honesty 
has  the  surgeon  done  for  empyema?  Do  his  re- 
sults warrant  his  right  to  assume  dictatorship  over 


this  disease  or  to  refuse  the  advice  and  counsel  of 
his  medical  colleague?  Has  he  provided  us  with  a 
clear  cut  reliable  method  of  procedure  based  upon 
old  well  tried  principles  or  enunciated  upon  a  new 
but  demonstrable  hypothesis?  In  my  experience  he 
has  done  neither.  He  can  approach  no  single  case 
with  a  reasonai)le  degree  of  definiteness  that  this 
will  follow  that.  His  results  fall  all  but  short  of 
being  a  reproach  to  himself  and  his  profession.  The 
salvation  of  both  lies  in  the  fact  that  there  is  prob- 
ably a  limit  to  himian  effort.  But  the  surgeon  fails 
to  recognize  that  this  applies  to  himself  and  to  sur- 
gery but  (shall  we  say  generously?)  grants  this  dis- 
tinction to  his  medical  coworker.  The  fact  remains, 
however,  that  both  the  surgeon  and  surgery  have 
failed  to  solve  this  problem.  The  former  has  been 
myopic  in  his  viewpoint.  He  has  not  made  the  best 
tise  of  the  means  at  hand.  He  has  limited  the  ap- 
plication of  simple  principles  which  are  limitless  in 
their  scope.  Hence  the  total  morbidity  and  total 
mortality  of  empyema  remain  unchanged.  Hence 
the  surgeon  is  helpless  in  so  far  as  he  is  forced  to 
seek  mformation  and  to  accept  advice  in  spite  of 
himself  irrespective  of  its  source,  be  this  even  from, 
in  his  judgment,  the  mind  of  the  avirile  medical 
man. 

ADVICE  TO  THE  SURGEON"  INCLUDING  THE  EXPRES- 
SION OF  THE  VIEWS  OF  A  PEDIATRIC  INTERNIST 
AS  TO  SOME  OF  THE  PRINCIPLES  UNDERLY- 
ING  THE  SURGICAL   TREATMENT  OF 
EMPYEMA. 

The  pediatrist  has  no  quarrel  with  the  surgeon  as 
to  the  necessity  for  the  surgical  treatment  of  em- 
pyema. Neither  has  he  nor  has  any  sane  physician 
an}-  quarrel  with  anyone  who  advocates  thorough 
drainage  as  the  conditio  sine  qua  nan  in  the  treat- 
ment of  this  disease.  Anyone  who,  however,  has 
witnessed  the  poor  and  uncertain  results  already 
referred  to  which  commonly  follow  costatectomy, 
which  are  served  up  to  the  medical  man  and  his 
patient  with  a  monotony  worthy  of  the  effrontery 
and  calm  stoicism  of  the  proverbial  boarding  house 
mistress,  as  the  piece  dc  resistance  of  the  meal,  must 
seriously  differ  from  the  surgeon  as  to  how  best 
drainage  is  to  be  induced. 

Costatectomy,  in  my  experience  at  least,  is  respon- 
sible for  no  more  recoveries  than  is  simple,  well 
conducted,  and  intelligently  performed  thoracot- 
omy. In  truth,  it  has  not  given  as  good  results, 
for  I  have  witnessed  more  recoveries  and  prompter 
ones  from  this  procedure  than  from  costatectomy. 
Hence  it  is  my  conviction  that  costatectomy  never 
saved  a  case  of  empyema  that  would  not  have  been 
saved  by  thoracotomy.  Surgeons  are  to  blame  for 
this.  They  do  not  conduct  the  aftertreatment  in 
their  cases  w-ith  the  patience  and  care  which  are 
required,  and  it  is  but  a  few  days  after  the  costa- 
tectomy is  performed  that  the  same  conditions  ob- 
tain which  call  forth  and  warrant  the  surgeon's 
criticism  of  the  average  thoracotomy,  viz.,  a  walled 
off  sinus  of  the  chest,  leading  to  where  no  one 
knows,  and  probably  draining  an^-thing  but  the 
proper  area.  It  is  no  argument  in  favor  of  costatec- 
tomy to  say  that  a  larger  opening  may  be  made 
than  by  thoracotomy.    This  larger  opening  is  of  no 


126 


LOW  EN  BURG:  EMPYEMA  IN  INFANTS  AND  CHILDREN. 


[New  York 
Medical  Journal. 


avail  if  it  does  not  drain  the  proper  area,  and  this 
often  happens,  because  most  good  surgeons  are  poor 
diagnosticians.  Better  a  small  opening  made  by  a 
thoracotomy  over  the  area  to  be  drained  than  a 
larger  one  made  by  costatectomy  over  a  dry  area. 
However,  the  truth  about  the  proper  treatment  of 
empyema  will  never  be  reached  by  arguing  the  re- 
spective merits  and  demerits  of  these  two  surgical 
procedures.  Both  may  give  good  results  if  properly 
performed,  and  both  may  give  poor  results  if  im- 
properly conducted.  What  is  needed  first  is  a  proper 
diagnosis  of  the  exact  location  of  the  pus.  After 
this  the  crux  of  the  situation  lies  in  securing  the 
greatest  amount  of  thorough  drainage  and  disin- 
fection with  the  minimum  amount  of  trauma.  If  a 
thoracotomy  will  do  it,  that  is  the  procedure  of 
choice ;  if  not,  a  costatectomy  must  be  performed. 
Here  is  where  good  judgment  is  necessary.  In  my 
experience,  simple,  well  conducted  thoracotomy  done 
in  a  manner  to  be  described  will  give  the  best  results. 

WHEN  TO  OPERATE. 

No  empyema  should  be  operated  upon  as  soon  as 
diagnosis  is  made,  unless  the  mechanical  disturb- 
ance resulting  from  the  efifusion  itself  is  so 
great  as  to  cause  alarming  symptoms :  at  least,  no 
radical  step  should  be  undertaken.  Simple  aspira- 
tion may  be  done  at  first,  purely  as  a  measure  of 
relief.  The  reasons  for  this  are  plain.  No  open- 
ing in  the  chest  may  be  made  and  maintained  with- 
out the  development,  at  least  subsequently,  of  pneu- 
mothorax. Clinically  it  has  been  experienced  that 
pneumothorax,  within  certain  limits,  is  a  bugaboo 
of  the  past  and  may  be  ignored,  inasmuch  as  its 
influence  is  negligible  as  far  as  retardation  of  re- 
covery is  concerned.  Nevertheless  the  work  of 
Major  E.  A.  Graham  and  Captain  Richard  D.  Bell 
clearly  indicates  the  lethal  influence  of  pneumo- 
thorax, due  to  a  large  opening  in  the  chest  wall, 
in  cases  where  the  entrance  of  air  into  the  lung  is 
impeded  by  obliteration  of  the  alveoli  or  bronchi, 
i.  e.,  where  the  pressure  of  the  air  entering  the 
thorax  through  the  artificial  opening  exceeds  that 
which  enters  through  the  normal  channels.  As- 
phyxia promptl}'  supervenes.  These  conditions  ob- 
tain in  nearly  every  case  of  empyema,  inasmuch  as 
acute  pneumonia  precedes  or  accompanies  the  dis- 
ease. Hence  at  this  stage  the  danger  from  acute 
pneumothorax  is  real  and  readily  apparent.  Later, 
after  the  pneumonia  has  subsided,  the  influence  of 
the  pneumothorax  within  certain  limits,  as  that  in- 
duced by  the  average  thoracotomy  or  costatectomy, 
may  be  ignored. 

Further,  patients  in  whom  the  temperatvire  re- 
mains high  are  poor  operative  risks  and  frequently 
become  extremely  septic  and  succumb  to  this  con- 
dition. Those  in  which  the  temperature  has  struck 
a  lovtfer  level  or  even  becomes  normal,  and  those  in 
which  the  efifusion  is  in  fact  not  only  purulent  but 
thick,  give  the  best  prognosis.  Cases  in  which  the 
fluid  is  "on  the  turn"  often  do  badly.  The  former 
may  be  said  to  be  ripe.  Hence  cases  in  which  the 
diagnosis  is  made  late  or  when  the  diagnosis  was 
missed  do  best  of  all.  To  summarize,  therefore,  it 
may  be  said  that  no  empyema  should  be  operated 
upon  until  the  evidences  of  acute  pneumonia  and 


of  hyperpyrexia  have  disappeared  and  until  the  pus 
has  become  thick. 

The  following  method  of  handling  empyema  cases 
is  followed  in  my  private  work  and  in  that  portion 
of  the  pediatric  service  under  my  control  at  the 
Mt.  Sinai  Hospital : 

The  diagnosis  is  made  by  physical  signs.  It  is 
confirmed  by  exploratory  puncture  over  the  area  as 
indicated  by  these  signs.  The  pus  is  studied  physi- 
cally (most  important)  and  bacteriologically.  An 
X  ray  examination  of  the  chest  is  made  and  care- 
fully studied  with  the  rontgenologist  for  evidences 
of  lung  consolidation.  If  this  is  present  and  the 
fever  is  high  nothing  is  done,  or  aspiration  is  prac- 
tised if  indicated.  When  these  have  disappeared 
an  ordinary  curved  or  straight  adult  sized  trocar 
and  cannula,  such  as  that  used  to  do  paracentesis 
abdominis,  is  pushed  between  the  ribs,  where  a  care- 
ful study  of  the  physical  signs  and  of  the  x  ray 
plate  and  the  results  of  puncture  indicate  the  best 
situation  for  drainage,  and  as  much  pus  as  will  is 
permitted  to  flow  into  a  pus  basin,  the  entrance  of 
air  being  ignored.  The  cavity  is  gently  washed  with 
a  warm  Dakin's  solution,  the  volume  entering  the 
chest  at  one  time,  never  being  'permitted  to  equal 
or  to  exceed  the  amount  of  pus  removed,  otherwise 
excessive  coughing  ensues.  A  rubber  tube  large 
enough  to  fit  the  opening  is  fixed  in  place,  and 
through  this  once  or  twice  a  day  the  cavity  is  irri- 
gated. I  have  treated  many  cases  this  way,  having 
the  patients  brought  to  the  office.  When  the  tem- 
perature subsides  the  washings  are  gradually  dis- 
continued, and  finally  the  tube  is  removed  and  re- 
covery ensues.  The  success  of  this  method  depends 
upon  the  proper  placing  of  the  drainage  tube  so  that 
it  drains  the  bottom  of  the  cavity,  and  it  must  be 
carefully  considered  which  is  the  bottom,  when  the 
child  is  sitting  or  reclining.  Hence  it  is  important 
to  indicate  which  position  is  the  best  for  the  patient. 

If  the  temperature  rises  again  careful  physical 
and,  if  necessary,  an  x  ray  examination  is  again 
made,  and  if  the  needle  reveals  pus  this  area  is 
treated  in  exactly  the  same  manner.  It  may  be  well 
to  make  x  ray  studies  with  the  tubes  in  position 
to  see  that  they  are  properly  placed.  Fenestrated 
tubes  are  employed.  If  more  than  one  tube  is  in 
the  chest  at  one  time  it  is  desirable  to  secure  through 
and  through  drainage,  in  other  words,  to  see  the 
fluid  leave  the  thoracic  cavity  by  one  or  more  tubes, 
inserted  at  various  places  between  the  ribs,  after 
the  fluid  has  been  gently  injected  through  any  one 
of  them.  This  would  indicate  that  communication  is 
established  between  the  areas  drained  and  that  ad- 
hesive bands  are  few. 

To  summarize  again,  it  may  be  said  that  our  stud- 
ies lead  us  to  believe  that  multiple  thoracotomy, 
or,  if  you  will,  multiple  costatectomy,  to  satisfy 
the  obsession  of  the  "costatectomatized"  surgeon, 
done  at  different  levels  of  the  chest  wall  or  over 
the  areas  where  it  is  positively  revealed  that  pus 
exists  and  that  these  areas  are  not  drained  by  the 
original  opening,  will  be  the  primary  operation  of 
choice,  even  in  cases  of  empyema  where  it  is  known 
that  a  large  free  effusion  exists.  Thus  with  two 
or  three  or  more  tubes  inserted  between  various  ribs, 
some  just  within  the  cavity  and  some  placed  deeper 


July  24,  1920.] 


PASCHALL:   TREATMENT  OF  TUBERCULOSIS. 


127 


as  the  X  ray  may  reveal  the  necessity  therefor,  every 
hour,  or  every  two  hours,  or  every  three  hours,  or 
more,  thorough  irrigation  of  the  entire  cavity  may 
be  done  with  warm  Dakin's  solution  with  scarcely 
any  disturbance  to  the  patient.  When  discharge 
ceases  and  when  the  culture  reports  become  negative 
irrigation  may  be  discontinued  and  the  tubes  re- 
moved. This  method  is  thought  to  be  decidedly 
more  practical  and  thorough  and  scientific  than  that 
advocated  by  a  prominent  surgeon  who  does  a  large 
single  thoracotomy  and  places  a  series  of  tubes  in 
the  thoracic  cavity  in  a  hit  or  miss  fashion,  i.  e.,  ad- 
mittedly he  does  not  know  exactly  what  direction 
they  will  take  but  hopes  they  will  drain  the  areas 
affected.  Through  these  tubes  he  practises  frequent 
irrigation. 

The  advantage  of  the  method  proposed  over  this 
is  that  in  encysted  cases  the  definite  diseased  area 
is  drained,  and  where  free  fluid  exists  the  danger 
of  encystment  is  lessened,  since  the  whole  cavity  is 
irrigated  and  drained  thoroughly  because  the  fluid 
enters  and  leaves  at  various  levels,  from  the  lowest 
to  the  highest,  and  drainage  takes  place  whether  the 
patient  is  either  prone  or  erect. 

CONCLUSIONS. 

1.  Surgeons  and  surgery  have  failed  to  give  a 
definite  method  for  the  treatment  of  empyema. 

2.  Their  right  to  preempt  this  disease  is  therefore 
denied. 

3.  A  correct  diagnosis  as  to  the  location  of  pus 
must  precede  all  methods  of  treatment. 

4.  No  patient  should  be  operated  upon  until  the 
evidences  of  pneuinonia  have  passed  and  until  the 
temperature  has  subsided  and  the  pus  has  become 
thick. 

5.  Aspiration  should  precede  permanent  drainage, 
if  there  is  mechanical  interference  with  breathing, 
until  the  conditions  mentioned  above  have  been  met. 

6.  Neither  thoracotomy  nor  costatectomy  per  se 
offer  any  special  advantage  to  the  patient  if  indif- 
ferently performed. 

7.  The  size  of  the  opening  is  not  nearly  so  im- 
portant as  the  position  of  the  opening. 

8.  Thorough  drainage  with  propet  irrigation  of 
the  infected  area  or  areas,  with  a  minimum  amount 
of  trauma,  is  desirable. 

9.  For  this  reason  alone  thoracotomy  is  to  be 
preferred  to  costatectomy. 

10.  Personal  experience  would  seem  to  indicate 
that  multiple  thoracotomy  is  the  operation  of  choice. 

11.  A  reasonable  amount  of  pneumothorax  in  the 
absence  of  pneumonia  is  negligible. 

2011  Chestnut  Street. 


The  Nutritive  Value  of  Commercial  Corn  Glu- 
ten Meal. — Carl  O.  Johns,  A.  J.  Finks,  and  Mabel 
S.  Paul  (Journal  of  Biological  Chemistry,  March, 
1920)  found  that  eighteen  per  cent,  of  whole, 
ground,  yellow  corn  meal  furnished  an  adequate 
supply  of  water  soluble  vitamine  to  rats.  Commer- 
cial corn  gluten  meal  supplemented  by  dried  brew- 
er's yeast,  whole,  ground,  yellow  corn,  or  cocoanut- 
press  cake  furnished  the  necessary  protein  for  nor- 
mal growth. 


TREATMENT  OF  TUBERCULOSIS. 
Clinical  Case  Reports. 

By  Benjamin  S.  Paschall,  M.  D., 
New  York. 
{Concluded  from  page  98) 

Case  VII. — D.  K.  is  a  patient  of  whom  I  was 
particularly  proud  for  a  long  time.  He  made 
a  wonderful  record  for  himself  and  was  apparently 
well  at  the  end  of  his  twentieth  dose.  He  was  a 
young  man  twenty-five  years  of  age  with  both 
kidneys  infected  and  numerous  definite  pulmonary 
lesions.  There  appeared  to  be  considerable 
activity  in  the  lungs  though  tubercle  bacilli  were 
not  demonstrated  in  the  sputum.  They  were 
repeatedly  found  in  the  urine.  After  the  twentieth 
dose  he  concluded  to  stop.  We  warned  him  em- 
phatically that  the  disease  would  return  unless  he 
was  treated  to  the  point  of  three  negative  reactions, 
but  we  did  not  know  till  afterwards  that  he  had 
taken  up  Christian  Science.  He  discontinued  treat- 
ment in  1916.  For  three  years  he  did  very  well 
and  then  the  disease  began  to  return.  The  last 
year  has  been  a  bad  one  for  him  but  he  is  still 
sticking  valiantly  to  his  cult. 

Case  VIII. — L.  E.  E.  is  interesting  because  he 
had  genitourinary  tuberculosis  in  addition  to 
acute  nephritis.  He  was  a  marine  engineer  aged 
forty,  and  had  numerous  sinuses  from  old  tuber- 
culous abscesses,  all  of  which  promptly  healed  on 
mycoleum.  He  was  treated  in  an  extremely  irregu- 
lar way  because  of  his  occupation  but  we  seemed 
to  keep  him  alive  year  after  year  by  giving  him  an 
occasional  dose.  He  had  tubercle  bacilli  in  his  urine 
and  albumin.  These  finally  disappeared  and  his  al- 
bumin dropped  from  four  per  cent,  to  five  per  cent, 
to  a  trace  when  last  seen.  I  put  him  on  treatment 
in  1911  and  saw  him  last  in  1917.  A  case  of  this 
kind  is  interesting  because  it  illustrates  the  effect  of 
mycoleum  over  long  periods  of  time  in  the  most 
hopeless  kind  of  a  patient  who  is  in  too  bad  condi- 
tion to  work  and  who  still  manages  somehow  to  hang 
on  to  his  position.  There  is  nothing  to  be  done  to 
improve  the  hygienic  conditions  and  the  patient  him- 
self is  and  has  been  for  years  a  wreck  and  a  dere- 
lict, just  holding  on  to  life  by  a  thread. 

Of  one  thing  I  am  convinced  and  it  is  the  thing 
I  am  trying  to  make  clear  in  this  paper.  If  we 
cannot  cure  many  of  these  old,  hopeless,  long  stand- 
ing chronic  cases,  we  can  at  least  patch  them  up 
so  that  they  can  live  along  in  comfort  and  support 
themselves  and  their  families  and  feel  well  enough 
to  enjoy  life  at  the  same  time. 

Case  IX — O.  O.,  aged  twenty-two.  He  was  long 
suffering,  and  had  a  long  standing,  tuberculin  treat- 
ed prostatitis  and  epididymitis.  He  was  placed  on 
treatment  in  1915  and  given  fifteen  doses  of  my- 
coleum. His  symptoms  disappeared,  his  prostate 
subsided  as  did  his  right  epididymis.  His  left  had 
previously  suppurated,  leaving  a  sinus  which  closed. 
His  Wassermann  was  negative  and  he  had  never 
had  gonorrhea.  During  his  treatment  he  did  heavy 
work  as  machinist  in  railroad  shops. 

Case  X. — W.  I.,  colored,  aged  thirty-six,  ship's 
steward,  was  an  interesting  patient.  He  had  genito- 
urinary tuberculosis ;  the  kidney,  bladder  and  pros- 


128 


PASCHALL:   TREATMENT  OF  TUBERCULOSIS. 


[New  York 
Medical  Journal. 


tate  were  involved.  The  Wassermann  was  nega- 
tive but  he  probably  had  a  latent  gonorrhea  of  long 
standing.  After  the  sixth  dose  of  mycoleum  an 
enormous  abscess  developed  in  the  lower  hypogas- 
tric region,  supposedly  from  a  tubercle  in  the  anterior 
bladder  wall.  He  was  taken  to  the  hospital  but  the 
abscess  broke  before  he  reached  there  and  there 
was  nothing  for  the  surgeon  to  do  but  make  the 
observation  that  it  was  evidently  tuberculous  and 
that  it  had  pointed  both  ways,  since  the  urine  was 
pouring  freely  through  the  torn  bladder  wall. 

Accordingly,  he  sutured  up  the  rent  in  the  bladder 
wall  in  the  forlorn  hope  that  it  might  hold.  Three 
weeks  later  the  patient  left  the  hospital  with  the 
area  completely  healed  and  in  apparently  excellent 
condition  and  when  last  heard  from  three  years 
later  had  remained  well.  The  surgeon  then  wanted 
to  know  if  it  was  the  rule  that  my  cases  of  tuber- 
culous abscesses  healed  without  sinus  formation 
and  he  was  told  that  it  was  the  invariable  rule 
provided  the  patient  had  received  six  doses  of 
mycoleum. 

When  one  comes  to  tuberculosis  of  the  bones 
and  joints,  a  consideration  of  their  pathological 
conditions  becomes  necessary.  Here  the  disease 
invades  two  main  structures  and  confines  itself  so 
exclusively  to  them  that  the  surgeon  takes  constant 
advantage  of  the  facts  elaborated  by  the  pathologist. 
Tuberculosis  of  the  bones  invades  the  synovial 
structures  and  the  red  lymphoid  cellular  spongy  or 
cancellous  portion  of  the  marrow  of  the  bone.  If 
it  invades  the  epiphyses  first  from  the  blood  stream 
and  then  finds  its  way  to  the  joints  by  extension, 
it  is  in  its  earlier  stages  easy  to  control,  because  it 
is  the  portion  of  bone  which  is  most  perfectly  sup- 
plied with  circulation  and  into  which  wax  splitting 
ferments  most  thoroughly  and  quickly  penetrate  fol- 
lowing mycoleum  injections.  If,  however,  it  invades 
the  synovial  membranes  and  joint  cavities  primarily, 
as  it  frequently  does  in  adults,  the  picture  then  be- 
becomes  just  the  opposite. 

Here  we  have  about  the  worst  structures  in  the 
body  for  exchange  of  fluids,  and  wax  splitting  fer- 
ments being  of  the  peculiar  physicochemical  compo- 
sition described  it  is  easy  to  understand  how  they 
would  penetrate  into  this  particular  area  of  disease 
with  great  difficulty  until  the  disease  had  pro- 
gressed to  a  stage  where  the  synovial  structures 
had  become  sufficiently  disintegrated  for  the  wax 
ferments  once  more  to  exert  their  characteristic  ac- 
tion. This  puzzled  me  for  a  number  of  years  be- 
cause my  early  cases  with  synovial  afifections  did 
badly  while  the  later  ones  began  to  clear  up  from 
the  very  first  dose,  in  the  majority  of  cases.  Adult 
forms  of  bone  and  joint  tuberculosis  also  recover 
less  rapidly  than  they  do  in  children  no  matter  in 
what  form  the  disease  appears. 

In  tuberculosis  of  the  bones  and  joints  of  chil- 
dren, the  immunizer  must  realize  that  while  the 
advice  and  help  of  the  surgeon  is  invaluable,  the 
necessity  of  administering  from  six  to  twelve  doses 
of  mycoleum  is  of  paramount  importance  before 
any  drastic  surgical  measures  are  thought  of,  after 
which  they  will  be  imnecessary.  If  this  can  be 
accomplislied  first,  the  surgeon,  if  he  does  anything 
at  all,  can  proceed  as  if  the  involved  bone  or  joint 


were  a  sterile  cavity.  Necrotic  material  or  sequestra 
may  be  removed  and  the  rest  may  be  safely  left 
to  take  care  of  itself. 

Case  XI. — H,  S.  was  sent  to  me  early  in  1909 
with  a  tuberculous  knee  of  two  years'  standing. 
He  was  four  years  old.  His  mother  and  sister 
were  tuberculous  and  received  treatment.  This  is 
one  of  those  cases  which  had  been  observed  over 
a  long  period  of  time  but  not  treated  with 
mycoleum  until  late  in  the  process.  During  the 
first  five  years,  with  plaster  casts  and  other  suitable 
orthopedic  appliances,  the  knee  was  kept,  as  we 
thought,  in  fairly  good  condition.  It  was  necessary 
to  keep  some  sort  of  apparatus  on  most  of  the  time 
to  prevent  undue  contracture,  but  it  was  evident 
that  the  child  was  growing  up  without  showing  any 
tendency  to  throw  of?  the  disease  constitutionally 
even  with  the  best  of  treatment,  which  he  certainly 
had.  He  was  first  treated  with  tuberculin,  ex- 
cept three  years  when  the  family  was  in  an- 
other city.  In  1914  he  returned  and  we  started 
to  give  him  mycoleum,  but  it  immediately  became 
apparent  that  its  use  had  been  postponed  too  long 
and  that  the  necrosis  in  the  knee  joint  was  too 
extensive  to  be  longer  ignored,  and  accordingly  he 
was  turned  over  to  the  surgeon.  As  soon  as  they' 
opened  the  knee,  it  was  evident  that  the  dam- 
age had  become  so  great  that  it  was  doubtful  if 
excision  would  be  feasible,  thotigh  it  could  be  tried, 
with  a  subsequent  amputation  if  this  failed.  We 
decided  that  he  had  not  been  treated  thoroughly- 
enough  with  mycoleum  and  also  argued  against  ex- 
cision, on  the  ground  that  even  this  could  be  done 
later.  For  this  I  was  properly  rebuked  by  the 
surgeons,  but  the  boy's  mother  and  I  reftised  to  be 
moved.  There  was  a  cavity  where  the  knee  joint 
properly  belongs  into  which  one  could  have  in- 
serted a  small  sized  orange  after  it  had  been  curetted. 
Eighteen  months  later  I  had  an  almost  perfect  func- 
tional result,  a  straight  leg  which  could  bend  to  a 
right  angle,  and  less  than  one  quarter  inch  of 
shortening,  and  the  x  ray  showed  complete  bone 
replacement.  At  the  present  time  after  six  years 
it  would  be  hard  to  convince  anyone,  even  the  most 
experienced,  of  what  the  boy  has  been  through  in 
the  way  of  damage  done,  taking  into  consideration 
the  causative  factor  of  tubercle  bacillus.  The  sur- 
geons were  my  friends  and  they  knew  some  very 
good  things  about  mycoleum,  but  they  could  see  no 
possible  chance  for  the  bone  to  fill  in  in  the  first 
place  or  the  prevention  of  ank\-losis  in  the  second. 

We  did  have  to  keep  working  to  prevent  the 
second  complication,  but  we  managed  to  get  a 
fibrous  covering  that  answers  very  well  for  a  joint 
in  the  knee. 

Case  XII. — Mrs.  H.  C.  developed  a  tuberculous 
synovitis  in  the  right  hip  which  terminated  in  ab- 
scess formation.  The  pus  was  evacuated  by  simple 
incision  and  she  was  sent  to  me  for  treatment.  She 
received  twelve  doses  of  mycoleum;  the  sinus 
promptly  healed  and  she  was  discharged  apparently 
cured.    She  has  remained  well  since. 

Case  XIII. — B.  V.  W.  came  from  a  country  hos- 
pital, took  her  doses  and  returned  from  whence  she 
came.  She  was  aged  twenty-seven  and  suffered 
from  tuberculosis  of  the  hip.    She  also  had  intes- 


July  24,  1920.] 


PASCHALL:    TREATMENT  OF  TUBERCULOSIS. 


129 


tinal  tuberculosis.  Both  had  been  of  many  years 
standing  and  she  had  been  a  pubhc  charge  for  a 
long  time.  Somehow  ^  she  heard  of  me  and  the 
county  authorities  allowed  me  to  treat  her.  After 
nine  doses  of  mycoleum  she  was  apparently  well 
and  returned  to  work  ior  the  first  time  in  many 
years  as  maid  in  domestic  service.  I  do  not  know 
whether  or  not  she  relapsed. 

Case  XIV. — J.  O.  N.,  aged  thirty,  farmer,  was 
operated  on  a  number  of  times  for  tuberculosis  of 
the  elbow.  It  had  involved  the  joint  and  there  was 
considerable  ankylosis  when  I  first  saw  him.  He 
was  absolutely  unable  to  use  arm  or  hand  and  his 
pain  was  so  great  and  so  constant  that  he  spent  most 
of  his  time  in  the  -barn  so  that  his  wife  and  chil- 
dren could  not  hear  him  moaning  in  his  sulYering. 
When  I  first  saw  him,  he  could  not  hold  an  empty 
tumbler  in  the  right  hand  and  his  surgeon  sent  him 
to  me  as  a  sort  of  a  forlorn  hope  before  doing  an 
excision  of  the  elbow.  He  received  sixteen  doses 
of  mycoleum,  made  the  usual  recovery  and  since  he 
lived  where  it  was  impossible  to  have  the  surgeon 
constantly  limber  up  the  stilTened  arm,  I  suggested 
that  he  rig  up  an  orthopedic  appliance  in  the  barn 
with  the  crank  of  the  grindstone  which  would  work 
free  the  elbow  joint.  I  did  not  see  him  for  several 
months  after  that  but  when  I  did  I  asked  him  about 
it.  He  said  he  had  not  used  it  because  loading  the 
team  with  two  hundred  pound  milk  cans  twice  a  day 
had  the  same  beneficial  eflfect  and  driving  a  team 
of  spirited  horses  tandem  over  rough  roads  twice 
a  day  had  a  straightening  effect.  His  course  of 
treatment  extended  over  fourteen  months.  I  might 
add  that  the  pain  stopped  si.x  hour,s  after  the  first 
dose  had  been  administered  and  never  returned.  He 
has  remained  well  since  that  time. 

What  has  been  said  before  in  regard  to  the  im- 
portant points  in  differential  diagnosis  particularly 
applies  to  intestinal  tuberculosis.  Gonorrhea  must 
be  excluded  in  women.  Typhoid  fever  sometimes 
simulates  tuberculosis,  l)ut  repeated  attacks  with 
suspicious  pulmonary  findings  aid  in  making  a  pro- 
visional diagnosis.  Usually  the  appendix  has  long 
since  been  removed  by  an  earlier  observer  of  one 
of  these  intestinal  attacks.  Care  must  be  taken  to 
differentiate  the  acute  flare  up  with  stenosis  or  ob- 
struction plus  tlie  recurring  attack.  The  gas,  the  ex- 
quisite tenderness,  the  constipation,  the  rigidity,  the 
distention  and  the  vomiting,  sometimes  fecal,  to- 
gether with  the  extremely  severe  paroxysms  of  pain, 
and  often  the  fluid  in  the  flanks,  should  immediately 
arouse  suspicion  of  this  form  of  tuberculosis,  and 
when  there  is  in  addition  a  rapid  pulse  and  mod- 
erate temperature  the  disease  is  usually  well  ad- 
vanced with  considerable  accompanying  peritonitis. 

If  one  gives  a  dose  of  mycoleum  to  a  patient  in 
the  midst  of  an  attack  of  this  character  and  a  reac- 
tion follows  (characterized  by  the  occurrence  of 
immediate  soreness  and  swelling  at  the  point  of 
injection  which  continues  to  increase  in  size  and 
soreness  for  several  days  together  with  constitu- 
tional symptoms  accompanied  by  fever)  one  may 
then  expect  to  see  an  immediate  subsidence  of  the 
symptoms  of  the  disease  within  a  few  hours  and 
continuing  to  decrease  in  severity  until  they  have 
disappeared  entirely.  The  patient  then  goes  about  his 


business  and  provided  he  takes  his  doses  within  rea- 
sonable limits  of  the  prescribed  intervals,  there 
will  be  no  further  trouble  and  he  will  make  a  per- 
fectly monotonous  record  for  himself  from  this 
time  on.  There  is  nothing  more  dramatic  than  to 
see  a  bad  case  of  this  kind  after  the  first  dose. 

Case  XV. — Mrs.  S.  E.  B.  was  a  patient  of  seven- 
teen years'  standing.  She  had  been  operated  on 
and  the  peritoneum  was  seen  to  be  studded  with 
tubercles.  She  was  sent  home  and  continued  to 
become  worse  in  spite  of  good  hygienic  surround- 
ings. Tuberculin  was  tried  in  competent  hands 
A'ithout  benefit.  She  was  thirty-five  years  old  and 
a  confirmed  invalid  with  a  constantly  elevated  tem- 
perature and  pulse.  I  put  her  on  mycoleum  in 
May,  1912,  as  a  sort  of  last  resort,  in  the  hope 
that  it  might  do  her  some  good  but  that  at  least 
it  would  not  do  her  any  harm.  She  gave  me  one 
of  those  early  surprises  by  getting  up  out  of  bed 
at  the  end  of  the  first  week  and  never  going  back 
to  it.  Please  do  not  think  that  this  is  a  miracle  story 
until  the  rest  is  told.  She  also  never  ceased  to  tell 
about  that  first  reaction  and  what  it  did  to  her 
leg.  It  is  perfectly  true  that  this  is  not  an  enjoy- 
able form  of  treatment  and  no  living  human  being 
would  take  it  if  were  not  for  the  overwhelming 
evidence  to  the  sufferer  of  the  subsequent  benefit. 
She  received  fifteen  doses  during  the  succeeding 
three  years,  made  a  perfect  recovery  and  has  re- 
mained entirely  well  since  that  time. 

Pulinonary  tuberculosis  deserves  a  separate  con- 
sideration altogether  from  the  forms  hitherto  dis- 
cussed. The  histology  of  the  lung  tissue  must  be 
kept  constantly  in  mind  when  considering  the  feasi- 
bility of  bringing  wax  substances  and  wax  antibodies 
into  intimate  contact  with  the  tissues,  and  the  classi- 
fication of  the  three  main  forms  of  pulmonary  in- 
fection into  fibrous,  caseous,  and  general  miliary 
does  not  materially  alter  the  present  description  of 
seciuences.  Of  course  the  fibrosis  is  the  least  perme- 
able and  the  acute  miliary  form  the  most  permeable 
to  antibodies  of  this  nature,  while  the  caseous 
processes  stand  midway  between. 

Acute  miliary  is  the  most  favorable  form  of  pu'- 
monary  tuberculosis  to  treat,  up  to  a  certain 
sharply  defined  point,  when  the  picture  becomes 
reversed  and  the  prognosis  becomes  absolutely  un- 
favorable. This  occurs  as  soon  as  the  blood  stream 
is  sufficiently  overloaded  with  toxins  to  disturb 
the  antibody  forming  functions  of  the  infected  host, 
and  in  acute  miliary  forms  it  happens  with  great 
suddenness.  Of  course  each  case  is  usually  more 
or  less  of  a  mixture  of  all  three  forms  with  one 
or  the  other  predominating,  but  the  encapsulating 
tendency  is  shown  nuich  earlier  in  the  pulmonary 
than  in  other  forms  of  tuberculosis,  or  else  symp- 
toms which  make  themselves  known  to  the  patient 
are  prone  to  occur  so  much  later  in  pulmonary 
forms  that  the  therapeutic  application  of  mycoleum 
becomes  more  difficult.  There  is  a  peculiarity  of 
ferments  of  the  lipase  class  before  mentioned 
whereby  they  diffuse  into  infected  areas  with  ex- 
treme slowness,  which  is  an  exceedingly  important 
one,  since  the  immediate  action  of  the  wax  anti- 
bodies produced  by  an  injection  of  mycoleum  can 
only  be  successfully  directed  against  those  tubercle 


130 


PASCHALL: 


TREATMENT  OF  TUBERCULOSIS. 


[New  York 
Medical  Journal. 


bacilli  which  are  actually  free  in  the  tissues  or  blood 
stream.  Those  organisms  which  are  much  more 
deeply  seated  and  surrounded  by  the  usual  inflam- 
matory area,  including  connective  tissue,  are  only 
reached  by  degrees,  and  in  some  instances  not  until 
there  has  been  an  actual  softening  of  the  area  in 
question.  Since  the  number  of  free  organisms  at 
any  time  is  small  in  comparison  to  those  more  or 
less  deeply  buried,  it  follows  that  the  immediate 
reaction  is  always  less  than  would  be  expected, 
while  the  length  and  ultimate  degree  of  the  reaction 
is  of  paramount  importance.  The  reason  for 
monthly  intervals  between  doses  is  determined  by 
these  considerations.  It  is  not  uncommon  in  cer- 
tain cases  to  observe  a  marked  inflammatory  local 
reaction  keeping  up  for  two  and  often  three  weeks 
after  the  injection  has  been  given.  In  this  report 
of  pulmonary  cases  we  will  describe  only  those 
which  present  features  of  more  than  ordinary 
interest. 

Case  XVI.— M.  A.,  aged  nine,  pure  American 
Indian,  was  brought  to  me  with  acute  pulmonary 
tuberculosis.  Both  lungs  were  well  dotted  with  tu- 
bercles of  moderate  size,  and  there  was  a  running 
temperature  of  104°  in  the  afternoon  and  a  pulse 
of  130  all  the  time.  She  had  been  treated  with 
tuberculin  for  nine  months  without  benefit.  I  put 
her  on  mycoleum  in  December,  1914,  and  gave  her 
twelve  doses  in  the  following  year.  She  made  an  ap- 
parently perfect  recovery  and  was  discharged  with  a 
normal  temperature  and  pulse.  Three  months  later 
she  relapsed  and  the  whole  condition  seemed  as  bad, 
even  if  not  worse;  her  temperature  was  104°,  and 
sometimes  as  high  as  105°,  with  an  average  pulse  of 
160.  Of  course  her  age  was  in  her  favor,  but  her 
race  was  against  her,  as  none  of  these  children 
from  Alaska  down  to  lower  California  have  ever 
been  reported  to  recover  if  pulmonary  tuberculosis 
set  in.  Her  sputum  was  swarming  with  tubercle 
bacilli  and  it  was  evident  that  she  held  her  immunity 
badly.  Accordingly  I  put  her  back  on  treatment  and 
gave  her  twelve  more  doses  during  the  second  year. 
I  did  not  dare  to  space  the  doses  for  fear  of  relapse, 
but  at  the  end  of  this  second  course  she  seemed 
so  well  that  I  decided  to  space  to  ninety  day  inter- 
vals. Since  that  time  she  has  received  two  doses 
a  year  until  this  year,  when  she  was  finally  put  off 
treatment.  She  is  at  the  present  writing  normal 
and  healthy  in  every  way.  There  is  absolutely  and 
positively  no  doubt  but  that  this  patient  would  have 
died  without  mycoleum.  She  had  been  sick  two 
years  when  I  treated  her,  and  was  in  very  bad  con- 
dition when  first  seen. 

Case  XVII. — J.  A.  is  another  patient  of  the  same 
type.  He  was  thirty  years  of  age  and  suffered 
from  acute  miliary  tuberculosis.  He  was  constantly 
being  treated  with  a  few  doses,  not  enough  to  im- 
munize him,  but  just  enough  to  put  him  on  his 
feet  again  when  he  relapsed,  so  that  he  could  re- 
turn to  work.  I  first  saw  him  in  1909  and  treated 
him  with  tuberculin  in  addition  to  rest  in  bed  in 
my  sanitarium  until  his  acute  symptoms  had  sub- 
sided, but  he  did  not  improve  much,  as  his  case  was 
of  the  acute  type  from  the  first.  His  exacerbations 
were  always  most  severe  with  exceedingly  high 
temperatures.    He  was  an  engineer  and  spent  most 


of  his  time  going  from  place  to  place,  unless  he 
had  to  come  in  and  be  patched  up.  When  he  was 
out  of  work  and  out  of  money  at  the  same  time 
he  would  go  without  food  for  days. 

These  facts  did  not  aid  in  the  treatment,  but  it 
is  necessary  to  mention  them  because  every  tuber- 
culosis specialist  knows  how  injurious  these  things 
are,  and  to  show  that  mycoleum  has  not  been  used 
under  conditions  which  were  ideal  but  under  such 
handicaps  as  physicians  encounter  in  general  practice 
among  patients  uffering  from  this  disease.  He  had  a 
bad  relapse  in  1913,  received  three  doses,  cleared  up 
and  went  to  work.  There  was  another  relapse  in 
1914,  and  both  lungs  showed  scattered  lesions  over 
both  sides  to  such  an  extent  that  I  have  him  marked 
III  on  my  records.  During  this  time  his  tempera- 
ture reached  105°,  and  once  or  twice  went  over  this 
mark.  During  the  next  two  years  he  received  fifteen 
doses,  and  the  disease  apparently  became  arrested. 
He  received  five  doses  in  1916  and  the  lung  findings 
cleared  up.  I  saw  him  in  1918  and  heard  from 
him  in  1920  when  he  seemed  to  be  in  good  health. 
He  weighed  135  when  first  seen  in  1909,  and  weighs 
155  at  present. 

Case  XVIII. — M.  B.  was  seventeen  when  first 
seen.  He  had  been  raised  in  ideal  home  surround- 
ings, and  there  developed  a  rather  acute  miliary 
tuberculosis  about  a  year  before  he  was  sent  to 
me.  The  x  ray  showed  perihilar  fibrocaseous  tuber- 
culosis somewhat  bilateral,  one  side  active  and  one 
side  quiescent,  which  indicated  considerable  dura- 
tion. He  is  marked  II  on  the  records.  Tempera- 
ture, 100°;  pulse,  110.  He  was  not  under  weight 
at  the  beginning  but  gained  fifteen  pounds  on  treat- 
ment and  ten  pounds  subsequently.  Received 
twenty-seven  doses  during  1914  and  1915,  and  has 
not  shown  the  slightest  tendency  to  relapse  since 
that  time.  No  change  was  made  in  his  habits  or 
mode  of  living.  After  the  first  six  doses  •there 
was  a  complete  disappearance  of  symptoms,  which 
never  reappeared.  We  did  not  get  a  final  radio- 
graph because  the  physical  signs  were  perfectly  sat- 
isfactory and  he  had  to  pass  through  other  hands 
than  mine.  Tubercle  bacilli  were  found  in  the  spu- 
tum several  times  before  I  put  him  on  treatment. 
This  young  man  has  been  recently  examined  in 
the  east  and  told  that  it  is  impossible  to  under- 
stand how  he  could  have  had  a  lesion  from  the 
present  findings,  although  had  a  recent  skiagraph 
been  taken  the  old  scars  would  have  been  quite 
apparent,  since  they  are  permanent.  One  must 
never  forget  to  warn  the  patient  if  he  has  a  second 
stage  case  that  a  subsequent  examiner  may  be  to- 
tally unable  to  make  out  a  previous  tuberculous  in- 
fection treated  with  mycoleum  unless  this  physical 
test  is  checked  up  by  skiagraphic  findings. 

REFERENCES. 

1.  Paschall  :  •  New  York  Medical  Journal,  February 
28,  1920. 

2.  Idem:  New  York  Medical  Journal,  January  31, 
1920. 

NOTE:  Mycoleum  is  the  name  given  to  the  preparation  described 
in  this  article  in  the  same  way  that  tuberculin  is  applied  to  those 
proteid  derivatives  of  the  tubercle  bacillus  with  which  we  are  familiar. 

Mycoleum  indicates  a  fatty  or  oily  preparation  from  organisms  of 
the  genus  mycobacteraceae,  or  the  acid  fasts,  to  which  belong  the 
tubercle  bacillus  leprosy  bacillus  and  many  saphrophytes  widely  dis- 
tributed throughout  the  world. 

The  Waldorf  Astoria. 


July  24,  1920.] 


LONDON  LETTER. 


131 


LONDON  LETTER. 
{From  our  own  correspondent.) 

Problems  of  Parenthood. — Venereal  Disease. — Clinics  and 
Professional  Secrecy. 

London,  May  22,  1920. 

A  second  report  of  the  National  Birth  Rate  Com- 
mission has  been  issued  recently  in  book  form. 
The  commission  was  instituted  in  October,  1913, 
by  the  British  National  Council  of  PubHc  Morals, 
and  its  first  report,  which  has  been  referred  to  in 
this  correspondence,  and  in  which  the  causes  and 
effects  of  the  declining  birth  rate  were  amply  and 
frankly  discussed,  was  published  in  1916.  The 
book  had  a  wide  circulation  and  was  popular,  in 
that,  it  was  generally  recognized  that  its  contents 
were  extremely  valuable,  and  the  demand  was  per- 
sistently made  from  numerous  quarters  that  in  view 
of  the  fact  that  the  great  war  had  exerted  much  in- 
fluence upon  vital  problems  of  population,  the  com- 
mission should  pursue  its  work.  The  commission 
was  reconstituted,  its  members  being  drawn  from 
various  classes  of  the  community.  Among  the 
many  well  known  and  eminent  men  and  women 
who  gave  evidence  before  the  commission  may  be 
mentioned  the  following :  Professor  A.  Keith,  Dr. 
Amand  Routh,  Dr.  Mary  Gordon,  Inspector  of 
Prisons,  Mr.  Sidney  Webb,  Mr.  Bramwell  Booth, 
Major  Leonard  Darwin,  Sir  A.  Conan  Doyle,  Sir 
William  Osier,  Sir  H.  Bryan  Donkin,  Dr.  C.  W. 
Saleeby,  Dr.  C.  B.  Turner,  Dr.  Marie  Stopes,  Sir 
Rider  Haggard,  Professor  Leonard  Hill,  and  Mr. 
Harold  Cox. 

In  the  first  place  the  commission  discussed 
the  fall  in  the  birth  rate  during  the  war  years,  the 
reduction  amounting,  in  1918,  to  twenty-six  per 
cent.,  in  England  and  Wales.  They  estimate  that 
in  the  period  1915-18  the  loss  of  births  attributable 
to  the  war  was  543,000.  In  commenting  upon  vol- 
untary restriction,  which  is  denominated  as  one  of 
the  most  important  causes  of  the  decline  in  the  birth 
rate,  the  comrhission  states:  "At  present  the  de- 
cline of  the  birth  rate  is  greater  where  the  quality 
of  the  children  might  be  expected  to  be  better.  The 
childbearing  is  at  present  relatively  the  greatest 
among  families  and  in  homes  in  which  the  economic 
and  social  conditions  do  not  allow  of  the  healthy 
and  proper  upbringing  of  so  many  children.  The 
reduction  is  taking  place  in  the  average  size  of  the 
families,  in  always  greater  degrees  in  those  classes 
where  the  condition  for  the  welfare  and  education 
of  the  children  are  the  best.  This  disproportion  in 
relative  birth  rates  is  an  ominous  sign  for  the  future 
of  the  nation  and  the  Empire.  The  duty  of  par- 
enthood needs  to  be  urged  upon  the  well-to-do,  who 
can  provide  the  more  favorable  conditions  for  the 
bringing  up  of  a  family.  The  commission  points 
out  that  the  responsibility  of  the  country  to  parents 
in  the  discharge  of  their  obligations  must  equally  be 
asserted.  If  the  community  desires  an  adequate 
number  of  children  of  good  quality,  its  members 
must  be  prepared  to  see  that  the  burdens  which 
weigh  too  heavily  upon  many  parents  are  relieved. 
Among  the  reforms  which  have  been  proposed  are : 
Proper  housing,  a  living  wage,  training  for  and 
care  of  motherhood  and  infancy,  facilities  for  edu- 


cation, and  relief  from  taxation  proportionate  to 
the  responsibilities  involved.  The  need  for  a  prop- 
erly regulated  redistribution  of  the  population  of 
the  sexes  in  the  Empire  may  be  mentioned  as  one 
of  the  most  important  methods  of  relieving  the  bur- 
den of  parenthood  in  large  families.  Various 
schemes  for  the  endowment  of  motherhood  were 
considered,  but  having  regard  to  the  economic  and 
other  difficulties  of  the  question,  the  commission 
did  not  recommend  any  of  them  for  adoption. 

As  for  the  problem  of  illegitimacy,  to  which  ref- 
erence has  been  made  in  a  previous  letter,  the  com- 
mission found  that,  although  the  decline  in  legiti- 
mate births   had  alarmed   the   country,   and  the 
illegitimate  child  has  come  to  be  regarded  as  help- 
ing to  make  up  for  the  deficiency  of  births  in  wed- 
lock, there  is  no  evidence  that  public  opinion  has, 
as  a  whole,  undergone  any  fundamental  change  of 
attitude  toward  the  unmarried  mother,  nor  are 
there  any  signs  of  such  a  change  coming  about  in 
the  near  future.     Statistics  for  1918  show  that 
illegitimate  births  had  increased  by  11.6  per  cent, 
while  legitimate  births  have  decreased  by  1.6  per 
cent.    As  a  result  of  these  changes  the  proportion 
of  illegitimate  to  total  births,  which  fell  to  a  mini- 
mum of  3.95  per  cent,  in  1901-05,  has  now  risen  to 
6.26  per  cent.,  the  highest  ratio  reached  during  the 
past  fifty  years.    The  commission  drew  attention 
to  the  fact  that  by  no  means  the  least  of  the  reasons 
for  regarding  the  illegitimate  child  as  a  national 
problem  are  these :  a,  The  number  of  illegitimates 
shows   no   sign  of   decreasng;   b,   the  mortality 
among  illegitimate  is  double  that  of  legitimately 
born  children ;  c,  the  nation  cannot  acquiesce  in  the 
destruction  of  children,  legitimate  or  illegitimate. 
The  neglect  and  ill  nourishment  of  the  unmarried 
mother  and  her  child  tend  to  increase  prostitution, 
poverty,  crime  and  disease  and  are  a  source  of  con- 
tinual recruitment  of  the  undesirable  class  by  poten- 
tially worthy  citizens.     Summing  up  the  national 
and  international  aspects  of  restriction  the  commis- 
sion said :  "Grave  issues  for  the  nation  and  the 
Empire  are  involved  in  the  steady  decline  of  the 
birth  rate.    In  the  event  of  a  war  similar  to  that 
just  experienced,  what  would  happen  to  us  with  a 
greatly  reduced  birth  rate?   As  it  is,  the  position  is 
most  disquieting,  both  here  and  there,  for  the  indi- 
cations are  that  in  the  homeland  the  population  may 
not  continue  to  increase,  while  in  the  Dominions 
oversea,  without  the  aid  of  immigration,  it  will  not, 
at  the  present  rate,  increase  greatly,  at  least  from 
additions  of  the  British  stock.    All  these  enormous 
lands,  with  their  countless  native  races,  we  hold 
with  less  than  60,000,000  white  people,  of  whom 
45,000,000  dwell  in  these  little  islands.    But  unless 
we  add  to  our  numbers  how  long  shall  we  be  able 
to  fulfill  our  obligations  in  the  face  of  recent  de- 
velopments of  race  ambitions?    Extensive  settle- 
ment upon  the  land  would  mitigate  the  evil,  but 
modern  men  and  women  will  not  settle  in  numbers 
on  the  land.    As  our  experience  and  that  of  Aus- 
tralia show,  they  prefer  the  city  and  the  cinema. 
The  commission  pointed  out  that  the  outcome  rested 
largely  upon  the  women  as  having  votes  they  now 
held  the  balance  of  power. 

{To  be  continued) 


Editorial  Notes  and  Comments 


NEW  YORK  MEDICAL  JOURNAL 

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NEW  YORK,  SATURDAY,  JULY  24,  1920. 


OUR  NEIGHBORS. 

Bernard  Shaw  once  made  the  remark  that  we 
should  not  be  concerned  about  the  bodily  cleanliness 
of  our  neighbors.  He  said  that  we  did  not  see 
their  bodies,  and  went  on  to  say,  reasoning  in  the 
same  fashion,  that  they  should  keep  their  faces 
clean.  Popular  wits  often  get  to  the  heart  of  things, 
but  just  as  frequently,  by  making  the  surface  attrac- 
tive, they  keep  away  from  the  vital  spots.  So  it  may 
be  well  to  stop  and  analyze  and  not  be  misled  by  our 
own  silly  laughter. 

Epidemics  have  shown  us  that  once  disease  is 
started  in  a  lowly,  filthy  quarter  it  spreads  like  a 
prairie  fire  and  sweeps  everything  before  it.  In 
most  instances  the  mortality  rates  in  epidemics  are 
as  high  among  the  rich  as  among  the  poor;  among 
the  clean  as  among  the  dirty.  We  know  that  the 
majority  of  people  do  not  realize  the  value  of  per- 
sonal cleanliness  and  hygiene.  The  proportion  of 
those  ignorant  in  these  matters  in  our  own  country 
is  not  as  great  as  in  many  other  countries.  We 
must  be  interested  in  the  cleanliness  of  our  neigh- 
bors in  order  to  protect  ourselves.  We  must  spread 
our  knowledge  so  that  the  less  informed  may  be 
better  educated.  As  a  matter  of  selfpreservation 
we  have  the  right  to  enforce  measures  of  sanitation 
among  our  neighbors. 

With  the  advent  of  rapid  means  of  communica- 
tion, the  airplane,  fast  ocean  steamships,  and  the 
many  links  that  are  forged  by  international  commerce 
and  free-for-all  wars,  the  inhabitants  of  the  most 
remote  quarters  of  the  globe  are  brought  to  our 


own  firesides.  These  people  have*  become  our 
neighbors,  though  we  may  never  see  them.  And 
so  we  have  the  right  to  guide  the  education  and 
look  after  the  health  of  the  Senegalese,  the  Eskimo, 
the  African  natives;  they  are  all  our  neighbors. 

Health  Commissioner  Royal  S.  Copeland  has 
returned  from  Europe  with  a  report  of  the  sanitary 
conditions  there.  He  tells  how  travelers  returning 
from  a  holy  journey  to  Mecca  filter  through  Persia 
and,  passing  up  the  Russian  rivers,  carry  cholera 
to  Russia  and  Poland ;  and  how,  through  the  Baltic 
ports  the  disease  may  eventually  reach  the  rest  of 
Europe  and  even  America,  unless  we  are  watchful. 
He  states  that  typhus  is  prevalent  in  Poland,  Russia, 
Ukrainia,  Lithuania,  Rumania,  and  Hungary. 
Filtration  plants  have  been  destroyed,  water  sup- 
plies are  contaminated,  sewage  systems  are  blocked. 
Plague  is  found  in  Egypt  and  adjoining  countries. 

It  is  not  alone  our  duty  to  watch  our  ports  to  pro- 
tect ourselves.  Disease  can  not  be  combatted  ef- 
fectually in  this  way.  We  need  only  recall  the 
influenza  epidemic.  There  was  not  a  remote  nook 
in  the  entire  world  that  was  not  reached  by  this 
disease.  We.  should  do  everything  in  our  power 
to  clean  up  the  dirty  corners  of  the  world.  Through 
the  bait  of  commerce  we  cleaned  the  Panama  Canal. 
A  good  example.  Why  should  we  not  extend  this 
work  to  the  more  remote  regions,  for  the  people 
there  are  our  neighbors.  We  owe  it  to  our.selves, 
to  protect  ourselves.  We  shall  not  make  this  an 
issue  of  altruism  and  pretend  we  are  doing  our 
neighbors  a  good  turn,  even  if  this  is  true.  The 
cleanliness  of  our  neighbors  is  a  vital  afifair  to  us, 
and  the  wit  of  Shaw  will  not  help  them  in  main- 
taining their  privacy. 


STERILITY   IN  THE  FEMALE  FROM 
GONORRHEAL  INFECTION. 

There  are  two  types  of  sterility  of  uterine  origin 
in  the  female,  the  septic  form  which  is  the  most 
serious  and  frequent,  and  that  due  to  a  mechanical 
cause  which  is  far  less  serious.  The  most  important 
of  the  septic  uterine  sterilities  is  unquestionably 
gonorrheal  infection,  giving  rise  to  metritis,  usually 
of  the  corpus  uteri.  From  here  the  process  may 
follow  an  ascending  extension,  invading  the  tubes 
and  periuterine  cellular  tissue.  In  some  rare  cases 
a  virulent  infection  may  result  in  rapid  invasion  of 
the  uterine  mucosa,  adnexa,  and  peritoneum  with 
rapidly  occurring  suppuration  in  all  these  structures. 
In  cases  where  uterine  and  periuterine  lesions 
exist  simultaneously  the  explanation  of  sterility  is 


July  24,  1920.] 


EDITORIAL  ARTICLES 


133 


simple,  but  the  same  cannot  be  said  when  the  in- 
fection is  localized  to  the  cervix.  It  is,  however, 
certain  that  a  gonorrheal  cervical  endometritis  is 
one  of  the  most  frequent  causes  of  sterility  as  is 
proved  by  proper  treatment  of  this  lesion,  the  wom- 
an becoming  pregnant  afterwards. 

The  puffing  up  of  the  cervical  mucosa,  the  morbid 
changes  undergone  by  the  mucosa  of  the  corpus 
uteri  and  purulent  secretions  prevent  the  spermato- 
zoon from  progressing  upward.  It  is  either  ar- 
rested by  a  collection  of  secretions  which  forms  a 
mucopurulent  plug  or  is  destroyed  by  the  too  great 
acidity  of  the  discharge  or  the  toxin  it  contains.  It 
is  probable  that  some  importance  must  be  attached 
to,  slight  tubal  reactions  that  are  usually  unrecog- 
nized. Clinically  gonorrheal  metritis  is  met  with 
in  three  forms,  viz.,  acute,  subacute,  and  chronic,  the 
latter  being  by  far  the  most  common  cause  of  steril- 
ity. During  the  first  year  of  married  life  the  woman 
presents  a  leucorrhea  resisting  all  kinds  of  treat- 
ment, resulting  from  an  old  gonorrheal  infection  in 
the  husband.  The  process  in  the  wife  develops 
quietly,  without  giving  rise  to  any  general  reaction 
or  pain.  The  discharge  is  free,  composed  of  thick, 
sticky,  yellow  mucus.  The  body  of  the  uterus  is 
normal  in  size,  the  cervix  enlarged,  swollen  at  its 
middle  portion  and  with  an  os  surrounded  by  a  red 
cuff  formed  hy  entropion  of  the  cervical  mucosa 
through  which  a  large  drop  of  pus  will  be  seen  ex- 
uding. But  even  when  the  corpus  uteri  is  infected 
the  lesions  are  always  more  pronounced  in  the  cervix 
and  becoming  localized  are  difficult  to  overcome. 

The  gonococcus  is  not  likely  to  show  itself 
very  much.  Hidden  in  the  folds  of  the  mucosa, 
or  lodged  within  it,  the  organism  does  not  appear  in 
the  pathological  secretions  excepting  at  the  advent 
of  the  menses.  Completely  sheltered  in  the  recesses 
of  the  mucous  membrane  or  in  its  glandular  struc- 
tiues,  the  organism  produces  a  progressive  increase 
in  the  size  of  the  cervix,  an  increase  and  occlusion 
of  the  glands,  thickening  on  account  of  the  develop- 
ment of  sclerous  periglandular  bands  and,  when  it 
comes  forth  from  its  lair,  the  result  will  be  a  re- 
inoculation  which  clinically  is  made  manifest  by  an 
unlooked  for  relapse  and  a  contamination  of  the 
husband,  who  tardily  receives  the  results  of  his 
own  work.  Hence  a  vicious  circle  is  established  in 
which  a  marital  gonorrheal  infection  passed  on  to 
the  wife  is,  at  the  exit  of  the  gonococcus,  transferred 
to  the  husband. 

Treatment  is  purely  medical  and  above  all  should 
be  mild.  Nothing  but  prudent  intracervical  applica- 
tions should  be  attempted.  Under  no  pretext  should 
a  sound  or  curette  be  resorted  to  unless  an  experi- 
mental inoculation  of  the  mucosa  of  the  corpus  uteri 
is  desired.    When  the  infection  is  of  long  standing 


and  the  applications  are  insufficient,  it  will  be  nec- 
essary, in  order  to  overcome  the  infection  completely, 
to  deal  radically  with  the  diseased  structures  by 
cauterization  which  is  renewed  every  ten  or  twelve 
days.  Usually,  when  properly  done,  from  four  to 
five  treatments  are  enough.  During  the  treatment  the 
mucopurulent  discharge  will  increase  in  intensity, 
but  from  one  treatment  to  the  next  the  diseased 
structures  will  be  seen  to  become  eliminated,  the 
cervix  gradually  assuming  its  normal  aspect  and 
color,  and  pus  no  longer  coming  from  the  external  os. 
Cure  is  usually  complete  if  the  patient  does  not  re- 
ceive a  reinoculation  and  if,  during  the  treatment, 
she  remains  recumbent  the  greater  part  of  the  time. 


THE  COLLOIDS  IX  GENERAL  PR.'\CTICE. 

Colloidal  therapy  has  progressed  apace  and  a  be- 
lief in  its  virtues  appears  to  be  based  upon  a  sound 
foundation.  However,  it  is  well  to  remember  that, 
although  the  use  of  colloids  was  introduced  many 
years  ago,  colloidal  therapy  is  really  in  its  infancy. 
The  average  general  practitioner  as  a  matter  of  fact 
knows  little  concerning  the  colloids,  and  reading 
and  hearing  of  successful  treatment  by  this  method 
of  administering  medicine  is  likely  to  be  led  astray. 
He  is  prone  to  believe  that  all  colloidal  preparations 
have  an  equal  or  similar  therapeutic  value,  whereas 
this  is  far  from  the  truth,  and  acted  upon  will  pro- 
duce very  unsatisfactory  results. 

As  pointed  out  in  the  Prcscrihcr,  June,  1920,  the 
preparation  of  colloids  is,  in  many  instances,  no  very 
difficult  matter ;  the  difficulty  begins  in  the  attempt 
to  make  them  therapeutically  valuable.  The  general 
practitioner  should  satisfy  himself  that  he  is  using 
colloids  of  the  right  strength,  those  whose  thera- 
peutic properties  are  sufficiently  known,  and  those 
which  are  suitable  for  internal  administration, 
orally  or  by  intravenous  injection  as  the  case  may  be. 
Further,  the  colloidal  preparation  used  must  be 
stable,  that  is,  "protected,"  for  if  it  is  not  it  is  no 
longer  colloidal  and  its  therapeutic  value  vanishes. 
Also  the  preparation  must  be  fresh,  the  colloidal 
state  being  obviously  essentially  unstable  and  subject 
to  disintegration  by  certain  substances  existing  in 
the  atmosphere. 

Provided  that  all  these  principles  are  complied 
with,  it  is  argued  by  the  advocates  of  colloidal 
therapy,  that  it  is  easily  the  most  effective  method  of 
employing  medicinal  measures  in  the  treatment 
of  certain  diseases.  Colloidal  mercury  may  be  given 
wherever  the  employment  of  mercury  is  indicated ; 
in  this  state  it  is  only  feebly  toxic  and  is  rapidly 
absorbed.  The  other  colloidal  preparations,  accord- 
ing to  many  who  have  tested  them  clinically,  possess 
merits  of  a  like  nature  and  in  the  case  of  coUosol 


134 


NEWS  ITEMS. 


[New  York 
Medical  Journal. 


manganese  Mr.  J.  E.  R.  McDonagh,  F.  R.  C.  S.,  has 
recorded  some  remarkable  results. 

Perhaps  it  is  too  early  as  yet  to  attempt  to  place 
an  estimate  on  the  value  of  colloidal  therapy.  It 
will  sufifice  to  say  that  so  far  the  results,  on  the 
whole,  have  been  satisfactory  and  encourage  the 
belief  that  there  is  a  great  future  for  this  method  of 
medication.  It  is  necessary  to  state,  however,  that 
when  employing  colloidal  therapy  it  is  essential  to 
use  preparations  which  have  been  properly  stabilized 
and  are  isotonic  with  the  blood.  Those  which  do  not 
possess  these  characteristics  are  not  only  useless  but 
may  be  dangerous. 


LABOR,  LUXURY  AXD  THE  SURGEON. 

Most  people  would  imagine  that  the  condemna- 
tion of  harmful  luxuries  by  doctors  would  happen 
most  frequently  in  the  office  with  rich  patients, 
but  surgeons  attached  to  large  industries  could  tell 
that  neither  fines  nor  thought  of  others  seems  able 
to  eradicate  the  love  of  finery.  Three  cases  of 
finger  or  hand  crushing  have  happened  recently  in 
laundries  owing  to  rings  being  worn.  The  law  de- 
crees that  all  flatiron  workers  must  be  equipped  with 
guards  in  front  of  the  feed  rolls  to  prevent  the 
hands  of  feeders  from  being  drawn  into  the  rollers, 
and  ringed  fingers  were  found  especially  danger- 
ous, yet  nothing  seems  able  to  instill  the  idea  of 
self  preservation  at  the  small  cost  of  giving  up 
some  finery  in  work  hoUrs. 

It  is  not  only  the  girls  but  the  men  who  sometimes 
put  adornment  before  safety.  Do  they  realize — - 
just  to  give  one  instance — that  the  rim  of  a  circular 
saw  is  moving  at  the  rate  of  one  to  two  miles  a 
minute?  Perhaps  not,  but  the  printed  warnings 
against  wearing  rings  or  gloves  are  before  their 
eyes.  All  the  same,  smashed  fingers  and  hands 
appear  with  horrible  frequency,  and  the  public  blame 
the  employer  for  what  was  in  reality  contributory 
negligence  on  the  part  of  the  worker. 


THE  SEAPORT  DOCTOR. 
Psychology  is  preparing  ever  increasing  tasks  for 
doctors,  not  intentionally,  but  she  is  working  with 
medicine  concerning  the  permitted  entry  of  aliens 
into  America,  sa3-s  the  Journal  of  Applied  Psychol- 
ogy, IMarch,  1920.  proving  that  a  sound  industrial 
democracy  must  be  built  on  racial  psychology  and 
putting  the  right  man  in  the  right  place.  We  no- 
tice the  French  Canadians  drifting  to  the  cotton 
factories,  copper  mining,  smelting  and  leather  works  ; 
Croatians  toward  the  mines,  steel  and  kindred  trades  ; 
Danes  favoring  leather  and  furniture  factories ;  Ar- 
menians, cigarette  making  and  peddling ;  Greeks  lik- 
ing blacksmithing,  baking,  shoemaking;  Hebrews 
get  into  small  manufactures  of  the  sweat  shop  va- 
riety. The  Chinese  love  to  import;  the  French 
Swiss  take  to  hotel  and  restaurant  business,  silk 
industries,  embroideries,  etc.  There  are  also  the 
big  questions  of  nostalgia  and  the  adaptability  to 


climatic  conditions.  Truly  the  life  of  the  doctor 
in  a  seaport  city  will  not  be  attractive  until  civic 
governments,  local  boards  and  employers  under- 
stand the  nature  and  cost  of  that  which  they  de- 
mand in  the  way  of  careful  judgment  concerning 
incoming  workers.  ' 

 <^  

News  Items. 


Fund  for  Spanish  Hospital. — The  will  of  the 

late  Mrs.  Luisa  de  Xavarro,  of  Xew  York,  leaves 
the  greater  portion  of  her  estate  to  establish  a  hos- 
pital in  Xew  York  for  Spanish  speaking  peoples. 

Medicine  in  Holland. — The  Dutch  medical  cor- 
respondent of  the  Presse  medic  ale  comments  on  the 
unity  of  organization  among  Dutch  physicians.  Of 
3,300  medical  men  in  Holland,  3,200  are  members 
of  the  Society  of  Medicine. 

Northwestern  University  Buildings.  —  The 
schools  of  medicine,  dentistry,  commerce,  and  law 
of  Northwestern  University  will  be  housed  in  new 
buildings  which  are  to  be  erected  at  Chicago  Avenue 
and  Lake  Shore  Drive,  Chicago. 

Bequest  to  Bowdoin  Medical  School. — Dr.  Ad- 
dison S.  Thayer,  dean  of  Bowdoin  Medical  School, 
Brunswick,  j\Ie.,  announces  that  the  late  Dr.  Frank 
Byron  Brown,  of  Boston,  of  the  class  of  '87,  has 
bequeathed  to  the  school  $1,000. 

Police  Hospital  Fund  Campaign. — A  campaign 
for  $5,000,000  for  a  police  hospital  for  Xew  York 
City  is  under  consideration  b}"  a  committee  interested 
in  the  project.  The  proposed  hospital,  w'hich  will 
have  300  beds,  will  probably  be  located  in  Brooklyn. 

Dr.  Carrel  Honored. — An  honorary  degree  was 
conferred  on  Dr.  Alexis  Carrel,  of  the  Rockefeller 
Institute,  by  Brown  University,  at  its  recent  com- 
mencement. He  also  received  the  honorary  degree 
of  doctor  of  science  from  Princeton  University  at 
the  recent  annual  commencement. 

Vacancies  on  the  Staff  of  the  Psychiatric  Insti- 
tute.— The  Xew  York  State  Civil  Service  Com- 
mission announces  examinations  to  be  held  on  July 
31st  to  fill  the  following  positions  at  the  Psychiatric 
Institute,  Ward's  Island,  Xew  York,  of  which  Dr. 
George  H.  Kirby  is  director ;  assistant  in  neuro- 
pathology, $2,160;  associate  in  bacteriology,  $2,- 
360 ;  associate  in  internal  medicine  and  clinical  path- 
olog}',  $2,360;  senior  physician,  $2,000.  Applica- 
tions must  be  received  at  the  office  of  the  commis- 
sion on  or  before  July  26th. 

Health  Commissioner  Copeland  Returns. — Dr. 
Royal  S.  Copeland,  health  commissioner  of  X'^ew 
York,  has  returned  from  a  trip  abroad  to  attend  the 
International  Housing  Conference  in  London  and 
the  Royal  Institute  of  Public  Health  Conference  in 
Brussels.  In  a  published  interview  following  his  ar- 
rival, Dr.  Copeland  gave  it  as  his  opinion  that  in  the 
protection  of  the  milk  supply,  food  inspection,  health 
supervision,  infant  welfare,  school  inspection,  and 
protection  of  the  public  against  disease,  Xew  York 
is  superior  to  European  cities,  but  that  Europe  has 
much  to  teach  us  in  the  matter  of  garbage  disposal, 
and  also  that  in  Europe  the  question  of  housing  is 
regarded  from  the  viewpoint  of  a  public  utility. 


July  24,  1920.] 


XEIVS  ITEMS. 


135 


Sonsonate    Cleared    of    Yellow    Fever. — The 

quarantine  against  the  city  of  Sonsonate,  in  the 
southwestern  part  of  San  Salvador,  has  been  lifted, 
and  Dr.  Bailey,  of  the  Rockefeller  Institute,  has  in- 
formed the  Committee  on  Public  Health  that  yellow 
fever  has  been  eradicated  there. 

Smallpox  in  Glasgow. — Smallpox  is  still  re- 
ported as  being  epidemic  in  Glasgow.  The 
disease,  however,  does  not  appear  to  be  spreading 
with  any  increase  of  rapidity,  as  the  number  of  new 
cases  remains  about  the  same — four  to  six  a  day. 
Since  its  commencement  the  epidemic  has  been 
almost  entirely  confined  to  Glasgow. 

Death  of  Professor  Kretz. — Professor  Kretz, 
one  of  the  last  living  pupils  of  Kundrat,  died 
recently  in  \'ienna  after  a  protracted  illness.  He 
was  born  in  1865,  and  after-  studying  in  Vienna, 
became  the  professor  of  pathological  anatomy  in 
Prague  and  later  in  Wiirzburg.  His  investigations 
were  directed  to  the  physiology  and  patholog}-  of 
the  liver,  and  dealt  also  with  diphtheria  and  sero- 
therapeutics.  His  papers  on  antibodies  and  immu- 
nity, on  disturbances  of  metabolism  and  the  pan- 
creas, as  well  as  on  embolism  of  the  lung,  are  most 
instructive  and  afford  a  clear  insight  into  the 
problems  of  these  conditions. 

Cambridge  Honors  Medical  Men. — At  the  an- 
nual meeting  of  the  British  Medical  Association  at 
Cambridge,  the  honorary  degree  of  LL.D.  was  con- 
ferred upon  the  following  gentlemen :  Sir  Clifford 
Allbutt,  regius  professor  of  physic  in  the  University 
and  president  of  the  British  Medical  Association ; 
M.  Jules  Bordet,  president  of  the  Faculty  of  ]Medi- 
cine  and  director  of  the  Pasteur  Institute  at  Brus- 
sels ;  Dr.  Simon  Flexner,  director  of  the  Rockefeller 
Laboratories ;  Dr.  Pietro  Giacosa,  professor  of 
experimental  pharmacology  at  the  University  of 
Turin ;  Sir  George  Makins,  president  of  the  Royal 
College  of  Surgeons  of  England ;  and  Sir  Xorman 
Moore,  president  of  the  Royal  College  of  Physicians 
of  London. 

Examination  for  Associate  in  Psychiatry  and 
Psychotherapy. — The  United  States  Civil  Service 
Commission  announces  an  examination  on  August 
24th  for  associate  in  clinical  psychiatry  and  psycho- 
therapy, from  which  a  vacancy  at  Saint  Elizabeth's 
Hospital,  Washington,  D.  C,  at  $2,500  a  year  and 
maintenance  will  be  filled.  The  appointee  will  act  as 
consultant  to  the  different  medical  services  of  the 
hospital,  and  instruct  the  younger  members  of  the 
staff  in  psychological  methods  and  in  the  technic  of 
case  analysis  and  presentation.  He  will  undertake 
analytical  and  therapeutic  measures  in  special  func- 
tional cases  and  will  be  expected  to  avail  himself 
of  the  clinical  material  and  laboratory  oppor- 
tunities for  special  observation  and  research.  It  is 
desired  to  secure  the  services  of  a  person  familiar 
with  the  modern  therapeutic  movements  in  the  prac- 
tice of  mental  medicine,  particularly  those  that  have 
to  do  with  functional  conditions  and  involve  the  ap- 
plication of  psychotherapeutic  principles. 

A  bachelor's  degree  and  an  M.  D.  degree  or  its 
equivalent  from  institutions  of  recognized  standing, 
at  least  one  year's  resident  hospital  experience,  and 
at  least  three  years'  experience  in  the  care  and  treat- 
ment of  the  insane  are  required. 


Otorhinolaryngologists  Meet. — At  the  annual 
meeting  of  the  American  Laryngological,  Rhino-, 
logical  and  Otological  Society,  which  was  held  June 
2nd  to  4th  in  Boston,  the  following  officers  were 
elected:  president,  Dr.  Lee  Wallace  Dean,  of  Iowa 
City;  vice-presidents.  Dr.  Harmon  Smith,  of  New 
York;  Dr.  Joseph  C.  Beck,  of  Chicago;  Dr.  Joseph 
B.  Greene,  of  Asheville,  N.  C. ;  Dr.  William  V. 
^lullin,  of  Colorado  Springs,  Colo.,  and  Dr.  Hill 
Hastings,  of  Los  Angeles ;  secretary,  Dr.  William 
H.  Haskin,  of  New  York;  treasurer.  Dr.  Ewing  W. 
Day,  of  Pittsburgh. 

New  Jersey  Medical  Meeting. — The  ^Medical 
Society  of  New  Jersey  held  its  annual  meeting  June 
16th  to  19th  at  Spring  Lake,  under  the  presidency 
of  Dr.  Gordon  K.  Dickinson,  of  Jersey  City.  The 
following  officers  were  elected :  president.  Dr. 
Philander  A.  Harris,  of  Paterson ;  vice-presidents. 
Dr.  Henry  B.  Costill,  of  Trenton ;  Dr.  James 
Hunter,  Jr.,  of  Westville;  Dr.  Wells  P.  Eagleton, 
of  Newark;  corresponding  secretary.  Dr.  Harry  A. 
Stout.  Wenonah  (reelected)  ;  recording  secretary. 
Dr.  William  J.  Chandler,  of  South  Orange  (re- 
elected) ;  treasurer,  Dr.  Archibald  Mercer,  of  New- 
ark.   The  next  meeting  will  be  in  Atlantic  City. 

Annual  Meeting  of  the  Public  Health  Associa- 
tion.— The  American  Public  Health  Association 
will  meet  in  San  Francisco,  Cal.,  September  13th  to 
17th.  Special  cars  will  leave  Boston  and  New  York 
on  Tuesday,  September  7th,  connecting  with  a  spe- 
cial train  leaving  Chicago  on  September  8th.  The  pro- 
gram will  include  the  following :  A  symposium  on 
the  relative  functions  of  official  and  nonofficial 
health  organizations  ;  Western  health  problems  ;  nar- 
cotic control ;  food  poisoning ;  organization  for  child 
hygiene ;  mental  hygiene ;  health  centres.  The  fore- 
going subjects  and  others  will  be  distributed  among 
the  following  ten  sectional  groups :  General  sessions, 
public  health  administration,  laboratory,  vital  sta- 
tistics, sociological,  sanitary  engineering,  industrial 
hygiene,  food  and  drugs,  personal  hygiene,  and  child 
hygiene.  Detailed  information  may  be  obtaised 
from  the  secretary  of  the  association,  Dr.  A.  W. 
Hedrich,  169  Massachusetts  Avenue,  Boston. 

 ^  ■ 

DIED. 

Buchanan. — In  Toms  River,  N.  J.,  on  Tuesday,  July 
13th,  Dr.  Thomas  J.  Buchanan,  aged  sixty-one  years. 

Ellingwood. — In  Pasadena,  Cal.,  on  Sunday,  July  4th, 
Dr.  Finley  Ellingwood,  of  Evanston,  111.,  aged  sixty-eight 
years. 

GuixxooK. — In  Philadelphia,  Pa.,  on  Friday,  July  9th, 
Dr.  William  H.  Guinnook,  aged  forty-two  years. 

HiRSCHFELDER. — In  San  Francisco,  Cal.,  on  Saturday, 
July  3rd,  Dr.  Joseph  Oakland  Hirschfelder,  aged  sixty-six 
years. 

MacGrath. — In  Quincy,  Mass.,  on  Sunday,  July  4th,  Dr. 
Thomas  H.  MacGrath,  aged  seventy-three  years. 

Parker. — In  Springfield,  Mass.,  on  Thursday,  July  8th, 
Dr.  Ernest  K.  Parker. 

Pelham. — In  New  York,  N.  Y.,  on  Friday,  July  16th,  Dr. 
!Mathilde  Annette  Pelham,  aged  fifty-six  years. 

RoBixssoN. — In  Alaska,  on  Sunday,  June  27th,  Dr.  J.  T. 
Robinson,  of  Columbia  Falls,  Mont. 

Steely. — In  Pocatello.  Idaho,  on  Sunday,  June  27th,  Dr. 
Oscar  B.  Steely,  aged  fifty-eight  years. 


Book  Reviews 


DISCOVERED  BY  THE  CENSOR. 

The  Cream  of  the  Jest.  Bv  James  Branch  Cabell.  Xew 
York :  Robert  M.  McBride  &  Co.,  1920.    Pp.  ix-280. 

Bexond  Life.  Bv  James  Br.xnxh  C.a.bell.  New  York : 
Robert  M.  :McBride  &  Co..  1920. 

These  strange  seekers  of  impurity  who  from  time 
to  time  tell  us  what  we  should  not  read,  deserve 
much  credit.  Xot  that  they  tell  us  what  we  should 
read  or  suggest  that  we  read  at  all  for  that  matter, 
but  this  time  they  have  discovered  an  American 
writer  who  has  spoken  too  freely  of  things  that 
they  insist  should  remain  unsaid.  And  so  the  censor 
has  finally  proved  his  value,  for  he  has  rendered  a 
service  to  those  of  us  who  managed  to  secure  a  copy 
of  the  much  discussed  Jurgcn.  This  led  on  to  the 
discovery  of  the  other  books  of  this  young,  yet  pro- 
lific writer.  It  was  with  amazement  that  we  found 
ourselves  deeply  buried  in  the  master  works  of 
American  literature. 

Slowly,  reluctantly,  the  critics,  in  spite  of  their 
good  training,  have  come  to  acknowledge  Cabell  as 
one  of  the  really  great  writers  of  the  present  day. 
They  attempted  to  trace  back  to  their  source  the 
singing  lines  of  subtle  phantasy  and  a  galaxy  of 
writers  from  \'oltaire  to  Shaw  have  been  as- 
signed as  the  foster  parent.  For  if  credit  were 
to  be  given  an  ancestor  should  be  found,  for  even 
critics  seek  legitimacy.  And  so  they  took  the  oppor- 
tunity of  showing  their  erudition  and  all  the  really 
good  books  they  had  read.  Meredith.  Anatole 
France  and  a  host  of  others  were  given  due  credit. 
But  why  stop  by  the  wayside  and  discuss  the  critics  ? 
Cabell  does  this  very  thoroughly  in  Beyond  Life. 
^^'ithout  attempting  an  analysis  one  can  discern  a 
varicolored  literary  backgroimd  in  the  work  of  this 
newly  discovered  American  genius. 

His  earlier  works,  charming  creations  of  phantasy, 
yet  built  on  a  solid  conscious  foundation,  send  the 
mind  scampering  batk  to  the  historical  and  literary 
works  of  the  time  of  chivalry  and  gallantry,  and 
prove  to  us  that  he  has  made  use  of  much  that  we 
have  forgotten.  Here,  too,  we  find  a  promise  of 
what  is  to  come,  and  indeed  they  are  a  fitting  pro- 
logue to  his  greater  works,  The  Cream  of  the  Jest 
and  Jurgen.  One  immediately  forgets  the  ornate 
trappings  of  the  holida\'  editions  of  Harper's  and 
spends  refreshing  hours  with  the  charming  figures 
created  by  Cabell.  The  Line  of  Love,  CJiivalry  and 
Gallantry  comprise  this  series.  These  tales  are  fit- 
tingly dedicated  to  that  kindly  old  lady  Mrs.  Grundy. 
He  probably  had  his  early  childhood  difficulties  with 
her  and  had  the  feeling  that  he  should  at  least  be 
polite  to  her,  even  if,  in  his  maturity,  he  has  dis- 
covered her  not  to  be  a  kindly  old  lady  but  a 
blatant  humbug. 

When  Cabell  becomes  critic,  as  he  does  in  Be- 
yond Life,  he  for  the  first  time  lays  himself  open 
to  criticism,  ^^'hile  the  book  is  one  of  the  keenest 
observations  on  literature  and  a  masterly  defense  of 
the  use  of  phantasy  in  fiction,  he  attempts  to  rational- 
ize his  method  of  procedure  by  proving  that  true 
literature  should  be  about  things  as  they  should 
be  and  not  about  things  as  they  are.  If  he  would  only 


go  a  step  farther  and  show  that  the  phantasies  of 
man.  whether  they  are  the  nnihs  of  the  people,  the 
tales  in  the  Bible,  or  the  legends  that  have  been 
handed  down  in  the  folk  tales  for  generations  and 
lost  in  the  mists  of  antiquity,  are  only  the  wishes 
that  man  has  symbolized  because  he  has  not  been 
able  to  bring  them  into  being  in  the  world  of  reality. 
To  defend  these  as  the  ultimate  goal  of  literature  is 
only  defending  human  weakness.  True,  man 
in  the  past  has  grown  by  being  an  ape  to  his  dreams, 
but  the  process  has  been  one  of  a  blind  groping  in 
a  little  understood  world — the  unconscious.  Now 
that  we  can  explore  this  world  and  bring  it  into  the 
world  of  reality,  a  tangilile.  useful  thing,  how  much 
more  rapid  should  our  progress  be.  The  magic 
worlds  woven  by  the  imconscious  to  satisfy  the  cen- 
sor will  always  remain  a  source  of  supply  for  the 
poet  and  creator  of  literature,  but  by  the  very  act  of 
his  bringing  them  to  us  he  enters  into  the  world  of 
reality,  and  we  go  a  step  ahead,  understanding 
their  creations  better,  and  yet  never  losing  sight 
of  their  beauty :  indeed  they  will  have  a  new  charm, 
for  then  they  will  be  both  music  and  food  to  us. 

It  may  all  be  true  that  realism  is  not  art.  Be 
that  as  it  may,  whether  we  agree  or  not  is  small 
matter,  but  we  have  often  seen  that  reality  graphi- 
cally portrayed  frequently  causes  changes  by  which 
things  l)ecanie  more  nearly  what  they  should  be 
instead  of  what  they  were.  W  e  might  mention  Har- 
riet Beecher  Stowe's  Uncle  Tom's  Cabin  or  Upton 
Sinclair's  Jungle,  or  Chekhov's  Sakalinc,  the  story 
of  Rus.sia's  Siberian  prison  camp. 

After  all  Cabell's  works  need  no  apology  nor  his 
own  adroit  rationalization.  They  are  quite  capa- 
ble of  standing  by  themselves  just  as  many  other 
symbolic  masterpieces  have  stood  through  the  centu- 
ries. The  question  of  realism  we  shall  only  bring 
up  by  alluding  to  a  concrete  example.  In  the  Bible, 
which  we  are  told  by  Cabell  is  a  master  work  of 
phantasy  and  which  he  rightly  chooses  to  find  more 
easy  of  belief  than  many  of  the  events  in  everyday 
life,  we  find  the  story  of  the  betrayal  of  Christ  by 
one  named  Judas.  A  Russian  writer,  Andreiff,  has 
made  bold  and  written  the  story  of  Judas  Iscariot 
as  he  interpreted  the  character  from  the  biblical 
version.  The  story  of  Andreift  may  well  be  called 
nearer  realism  than  that  of  the  biblical  version.  His 
Judas  lives  and  breathes,  becomes  a  powerful  char- 
acter, an  unforgettable  man,  and  yet  be  is  the  dream 
Judas  of  Andreiflf,  a  creature  formed  in  his  own 
unconscious,  his  interpretation  of  the  symbolic 
Judas  of  the  Bible.  He  is  presented  to  our  conscious 
minds  for  reinterpretation.  This  same  sort  of  thing 
Cabell  has  done  when  he  has  woven  together  the 
dream  stuff  in  his  unconscious — the  dream  material  he 
he  gathered  from  the  world's  m\ths  and  legends,  re- 
grouped them  in  a  new  symphony  of  phantasy  and 
presented  them  to  the  cadence  of  a  new  music  with 
a  new  rh}thm.  But  all  these  dreams  are,  as  he 
strives  to  tell  us,  a  method  of  escape  from  the  world 
of  reality  which  he  found  sordid  and  uninviting. 
But  always  he  returns  from  his  world  of  phantasy 
and  brings  back  his  wanderings  to  the  world  of 


July  24,  19:0.] 


BOOK  REVIEWS. 


137 


reality  from  which  there  is  no  escape.  He  does  this 
in  the  Cream  of  the  Jest  and  again  in  Jurgcn.  The 
skill  lies  in  his  ability  to  do  this  and  not  create 
an  anticlimax.  Is  it  escape  that  he  seeks  in 
his  journeys  in  the  realm  of  phantasy  and  does  he 
try  to  justify  his  retreat  by  pointing  the  utility  of 
his  wanderings?  By  recalling  our  ability  to  ape 
our  dreams  and  so  make  progress?  Or  does  he 
knowingly  enter  into  this  semisomnolent  dream 
world  in  a  conscious  endeavor  to  find  what  his  un- 
conscious is  creating,  to  bring  it  to  us  as  a  dream  of 
what  men  should  be  instead  of  what  they  are?  A 
little  of  both,  perhaps. 

In  Bexond  Life  Cabell  carelessly  dismisses  Rus- 
sian literature  as  dull.  Without  doubt  he  made 
an  tmfortunate  choice  and  selected  examples 
from  a  limited  field,  for  they  more  nearly  present 
the  things  Cabell  most  earnestly  pleads  for.  He 
defends  symbolic  writing  and  little  realizes  that 
many  Russian  writers  also  have  their  mo- 
ments of  retreat  which  are  marked  by  the  produc- 
tion of  some  of  the  finest  symbolic  productions 
known  in  literature.  They  too  have  found  realism 
hard  to  face,  and  perhaps  they  are  more  justified 
in  their  complaint  than  those  living  in  more  fortu- 
nate surroundings.  They  had  a  censorship  to  face 
more  powerful  than  the  one  that  suppressed  Jurgen. 
They  were  forced  to  resort  to  a  subtle,  somewhat 
conscious  symbolization  in  their  literature.  We  find 
AndreifF  writing  plays  of  power  and  flexibility  of 
almost  pure  symbolism,  such  as  Savva.  The  Life 
of  Man,  The  Black  Maskers.  Checkhov  has  given  us 
Uncle  Vanya  and  The  Sea  Gull  and  other  plays  sim- 
ilar to  those  of  Dunsany.  We  find  Korolenko's 
phantasy  tale.  Makar's  Dream,  and  Dostoievsky's 
Dream  of  a  Queer  Fcllozc  and  the  dream  tales  in 
Tchernechevsky  in  his  book  on  What's  To  Be 
Donef  and  then  the  story  of  Grigorovitch,  Kara- 
lin's  Dream.  In  all  of  these  tales  the  authors  make 
use  of  carefully  worked  out  symbolisms  to  de- 
scribe the  world  as  it  should  be  and  not  as  it  is. 
In  spots  they  do  come  to  earth,  even  as  Cabell,  and 
for  the  advantage  of  contrast  tell  of  the  world 
as  it  is.  All  these  men,  and  a  host  of  other  writers, 
have  handled  symbolisms  with  an  understanding 
that  many  psychological  students  of  the  present  day 
find  difficult  to  grasp.  If  Cabell  had  read  as  deeply 
of  the  Russian  as  he  had  of  the  French  and  Eng- 
lish he  would  not  so  hastily  bring  up  the  issue,  and 
he  would  not  seek  so  vainly  for  the  things  he  com- 
plains at  not  finding. 

In  his  attempt  to  explain  that  true  art  is  an  escape 
from  reality  he  proves  that  an  understanding  of 
reality  is  necessary  to  art.  For  it  is  only  when  we 
fail  to  face  reality  that  we  seek  an  escape  in  the 
world  of  phantasy.  Here  we  can  soar  to  our  heart's 
delight  and  hurl  our  darts  against  the  world  we 
call  distorted.  We  are  likely  to  forget  that  if  we 
did  not  carefully  consider  and  appraise  this  world 
of  reality  and  make  our  judgments  after  contact 
we  could  not  fling  our  satirical  darts  with  any  de- 
gree of  accuracy.  In  the  continuous  change  occa- 
sioned by  evolutionary  processes  and  with  the  many 
interrelated  complexities  there  are  bound  to  be  many 
maladjustments.    These  incongruities  will  always 


serve  as  receptors  for  the  art  and  criticism  of  the 
maladjusted.  We  will  find  at  every  turning  these 
warriors,  deriding  the  world  as  they  find  it,  behind 
a  shield  of  wit  with  their  weapons  of  irony.  They 
find  the  many  weak  sf)ots  without  difficulty  and  so 
cover  their  own  inferiorities.  The  compensatory 
process  is  obvious.  But  withal  we  owe  them  much, 
for  with  their  sharpened  wits  they  hold  the  mirror 
to  our  deficiencies.  And  so  we  owe  a  debt  to  the 
Molieres.  the  Xietzsches  and  the  Cabells.  More  suc- 
cessful beings  blinded  by  the  easy  adjustments  they 
have  made — satisfied  with  the  world  they  find  no  dif- 
ficulty in  facing — even  for  a  mediocre  existence — 
satiated  with  simple  pastimes,  fit  in  their  flexible 
souls  in  an  order  that  could  well  be  improved. 

So  we  find  socalled  psychologists  busily  branding 
as  abnormal  all  those  who  do  not  conform — all  those 
who  rebel.  Perhaps  they  are  right,  but  these 
moulded  pedagogues  forget  the  debt  they  owe  these 
malcontents  in  the  world  of  science  and  literature. 
The  very  things  these  learned  men  hurl  at  the  heads 
of  the  malcontents  are  the  findings  of  predeces- 
sors of  these  same  grumblers,  for  it  is  by  the  keen 
wits  of  the  maladjusted  that  progress  is  made.  Smug 
critics  from  their  mediocre  pathways,  often  by  sheer 
force  of  number,  bear  down  upon  the  seekers  of 
change,  for  the  majority  find  it  more  comfortable 
to  conform,  and  so  the  conflict  goes  on.  Many  take 
up  the  popular  cry  against  progress  to  gain  popu- 
larity. They  travel  the  easy  pathway  of  conform- 
ity. We  find  these  parrots  in  the  pulpit  and  read 
them  in  the  press,  and  then  a  new  outburst  from 
the  maladjusted  and  a  new  series  of  popular  cries. 

So  we  hail  Cabell  and  bid  him  sing  on.  We  will 
try  to  follow  his  melodious  lines  and  interpret  as 
best  we  can  the  world  as  it  should  be — or  as  he 
thinks  it  should  be.  But  we  will  always  enjoy  and 
be  grateful  for  the  things  he  has  given  us.  We 
greet  Cabell  and  place  him  in  a  field  alone  in  Eng- 
lish literature.  A  place  of  his  own  creation  and 
far  above  any  of  his  nearest  contemporaries.  For 
he  is  a  true  artist.  Perhaps  the  censor  may  some- 
time have  another  surprise  for  us.  He  may  "discover 
another  artist  who  will  rival  Cabell. 

PRIMITIVE  SOCIETY. 

Primitive  Society.  _  By  Robert  H.  Lowie.  Ph.  D.,  Asso- 
ciate Curator  of  Anthropology-,  American  Museum  of 
Natural  History.  Author  of  Culture  and  Ethnology.  New 
York:  Boni  and  Liveright,   1920.   Pp.  v-463. 

The  luminousness  of  Dr.  Lowie's  study  of  social 
foundations  is  the  more  remarkable  since  he  has 
undertaken  so  vast  a  subject.  The  social  scheme 
of  primitive  races  engages  each  student  in  a  differ- 
ent fashion.  But  by  far  the  majority  limit  them- 
selves to  a  single  phase,  or  when  their  range  of 
interests  happens  to  be  wider,  present  a  report 
which  deteriorates  into  instances  and  observations. 
Tribal  peculiarities  and  customs,  privileges  and 
taboos  conspire  to  impress  us  with  the  social  com- 
plexities surrounding  the  savage,  yet  the  why  and 
wherefore  is  nowhere  touched  upon.  This  Dr. 
Lowie  does  not  seek  to  do  either,  in  fact  he  feels 
that  psychologists  and  Freudian  students  should 
keep  their  impious  hands  oflt  the  simple,  untram- 
melled savage  in  their  efforts  at  world  analysis. 


138 


BOOK  REVIEWS. 


[New  Vork 
Medical  Journal. 


"(Freud)  paints  the  subjective  state  of  mother-in- 
law  and  son-in-law  with  the  lurid  colors  that  tinge 
our  modern  family  life  but  are  wholly  lacking  in 
the  savage  relationship,"  says  Dr.  Lowie,  but  he 
himself  is  still  content  to  note  that  such  peculiar 
antagonisms  exist  among  the  peoples  he  is  study- 
ing and  does  not  seek  to  explain  traditions  at 
least  as  complicated  as  our  modern  ones. 

For  the  students  of  cultural  history,  for  the  lay 
reader  who  cares  to  read  something  a  little  dif- 
ferent from  the  popular  history  or  a  heavy,  scien- 
tific treatise  on  primitive  man's  eccentricities,  and 
for  all  specialists  in  the  study  of  human  develop- 
ment, a  textbook  and  inspiring  guide  is  here  of- 
fered. Dr.  Lowie's  concept  of  society  is  that  of 
an  interrelation  between  individuals  and  groups, 
therefore  to  him  society  is  a  living,  moving  whole, 
as  vital  as  the  living  beings  comprising  it.  The 
anatomical  structure,  marriage,  the  family,  kinship 
and  the  sib,  law  at  its  very  source,  the  club,  caste, 
and  government,  all  these  he  presents  to  us,  em- 
bryos, as  it  were,  of  the  social  structure  that  we 
know  today. 

The  time  will  come  when  the  anthropologist  will 
find  that  the  material  he  has  been  classifying  and 
pigeonholing  has  more  than  a  historical  value.  When 
he  begins  to  explore  the  human  mind,  primitive  or 
modern,  it  is  all  the  same,  he  will  find  his  obser- 
vations and  stores  of  data  strangely  interpretive, 
not  of  cultural  trends,  borrowings  of  custom  be- 
tween tribes,  but  of  psychic,  universal  growth. 
Then  perhaps  he  will  be  able  to  tear  down  the  sta- 
tistics laden  structure  of  modern  anthropology  and 
acknowledge  himself  ready  to  learn  to  construct 
from  fundamental  causes  rather  than  to  distribute 
his  findings  under  convenient  headings.  Lowie  is 
still  distributing.  But  he  at  least  believes  in  a 
society  that  is  alive. 

INSTRUMENTAL  ORTHOPEDY. 

De  I'Orthopedie  instrurncntale.  By  Dr.  Gabriel  Bidou. 
Twenty  Full  Page  Illustrations.  Paris,  France :  The 
Orphan-Apprentice-School,  1919.    Pp.  x-132. 

The  secret  of  Dr.  Bidou's  instrumental  orthopedy 
is  coadaptation,  cooperation,  and  a  thorough  knowl- 
edge of  anatomy  on  the  part  of  the  orthopedist. 
Most  frequently  the  disabled  man  has  to  adapt  his 
whole  anatomy  to  the  new  limb,  often  creating  a 
contortion  nonexistent  before.  By  the  aid  of  the 
arthromometer  the  aid  becomes  a  normal  part  of 
the  body  and  demands  no  extraordinary  muscular 
exertion.  He  deprecates  the  use  of  any  stock  mech- 
anism, for  that  which  will  help  one  man  may  be 
totally  unfitted  for  another.  The  mechanician  begins 
his  work  when  the  mechanical  physiology  has  been 
thoroughly  studied.  Some  psychology  is  necessary 
to  earn  the  good  will  of  the  patient  toward  instru- 
mental aid  and  to  teach  him  to  collaborate  with  the 
surgeon,  to  conquer  inertia,  persevere  in  spite  of 
fatigue,  and  overcome  mental  apathy,  because  this 
resignation  to  impotency  is  itself  a  fault.  He  relies 
on  compassion,  help,  from  family  or  State,  as  on  a 
crutch  and  no  longer  exerts  himself.  It  is  impos- 
sible to  give  evidence  by  words  only.  Let  those 
who  want  to  understand  that  which  is  a  hopeful 
remedial  attempt  to  scientifically  help  our  disabled 
study  the  lucid  book  by  Dr.  Bidou. 


BRITISH  MEDICAL  ASSOCIATION. 
British    Medical    Association.     Proceedings    of  Special 
Clinical   and    Scientific   Meeting,    London,   April  8-11, 
1919.    London:    The  British  Medical  Association,  1919* 
Pp.  vii-403. 

The  papers  presented  here  are  those  of  a  special 
clinical  and  scientific  meeting  held  by  the  British 
^ledical  Association  April  8  to  11,  1919.  in  Lon- 
don, under  the  presidency  of  Sir  Clifford  Allbutt. 
The  last  of  the  custoiuary  general  meetings  had 
been  in  1914,  and  after  the  armistice  it  was  decided 
to  hold  a  meeting  with  a  smaller  number  of  sec- 
tions than  usual  and  at  an  early  date,  so  that  foreign 
medical  ofiicers  might  attend  before  their  return 
home.  The  material  is  given  under  three  heads, 
medicine,  surgery,  and  preventive  medicine  and 
pathology.  Reports  of  discussions  are  included. 
There  are  two  general  addresses,  one  by  Sir  Clif- 
ford Allbutt  on  the  New  Birth  of  Medicine,  and 
the  other  by  Sir  Cuthbert  Wallace  on  the  Rise  of 
the  Casualty  Clearing  Station.  Various  war  rec- 
ords are  appended, 

 €>  

New  Publications  Received. 


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

GREEX  RUST.  By  Edg.\r  Wall.\ce.  Boston :  Small,  May- 
nard  &  Co.    Pp.  i-299. 

THE  PATHWAY  OF  ADVENTURE.     By   RoSS   TyRRELL.  New 

York:  Alfred  A.  Knopf,  1920.    Pp.  vii-310. 

THE  PARADISE  MYSTERY.  By  J.  S.  Fletcher.  New  York: 
Alfred  A.  Knopf,  1920.    Pp.  ix-306. 

FOLLOW  THE  LITTLE  PICTURES !  By  Alan  Graham.  Bos- 
ton:    Little,  Brown  &  Co.,  1920.    Pp.  iii-299. 

THE   VANISHING    MEN.      By   RiCHARD   WaSHBURN  ChiLD. 

Author  of  Velvet  Black,  etc.  New  York:  E.  P.  But- 
ton &  Co.    Pp.  i-324. 

woman.  By  Magdeleine  Marx.  Introduction  by 
Henri  Barbusse.  Translated  by  Adele  Szold  Seltzer. 
New  York:   Thomas  Seltzer,  1920.    Pp.  vii-228. 

sex  and  society — studies  in  the  social  PSYCHOLOGY  OF 

SEX.  By  William  I.  Thomas.  Seventh  Edition.  Bos- 
ton :    Richard  G.  Badger.    Pp.  vii-325. 

THE  ivory  disc.  By  Percy  James  Brebner.  Author  of 
A  Gallant  Lady,  The  Turbulent  Duchess,  The  Little  Grey 
Shoe,  etc.    New  York:  Dufiield  &  Co.,  1920.    Pp.  iii-254. 

THE    mystery    in    THE    RITSMORE.      By    WiLLIAM  JoHN- 

STON.  With  Illustrations  by  Harold  James  Cue.  Boston :. 
Little,  Brown  &  Co.,  1*920.    Pp.  i-293. 

sane  sex  life  and  sane  SEX  living — some  THINGS  THAT 
ALL  SANE  PEOPLE  OUGHT  TO  KNOW  ABOUT  SEX  NATURE  AND 
SEX  functioning;  its  PLACE  IN  THE  ECONOMY  OF  LIFE,  ITS 
PROPER  TRAINING  AND  RIGHTEOUS  EXERCISE.     AlsO,  A  Study 

of  How  to  Cultivate  and  Practise  the  Art  of  Love,  and 
How  to  Master  the  Science  of  Procreation.  By  H.  W. 
Long,  M.D.,  Captain,  M.  R.  C.  Boston :  Richard  G. 
Badger.    Pp.  xxii-151. 

HELMETS  AND  BODY  ARMOR  IN  MODERN  WARFARE.    By  BaSH- 

ford  Dean,  Ph.D.,  Curator  of  Armor,  Metropolitan  Mu- 
seum of  Art,  formerly  Major  of  Ordnance,  U.  S.  Army, 
in  Charge  of  Armor  Unit,  Equipment  Section,  Engineering 
Division,  Washington ;  formerly  chariman  of  the  Com- 
mittee of  Helmets  and  Body  Armor,  Engineering  Division 
of  the  National  Research  Council.  Illustrated.  New- 
Haven  :  Yale  University  Press.  London :  Oxford  Uni- 
versity Press,  1920.    Pp.  xxiii-32S. 


Practical  Therapeutics  and  Preventive  Medicine 

A  Compendium  of  Treatment  and  Prophylaxis,  Original  and  Adapted 


RECENT  GLEANINGS  IN  DIPHTHERIA 
PROPHYLAXIS. 

By  Louis  T.  de  M.  Sajous,  B.  S.,  M.  D., 
Philadelphia. 
(Continued  from  page  917,  Fo/.  CXI.) 

What  of  the  administration  of  antitoxin  in  an  at- 
tempt to  rid  diphtheria  carriers  of  their  infection? 
The  generally  accepted  view  of  the  action  of  anti- 
toxin is  that  it  is  limited  to  the  neutralization  of 
diphtheria  toxin  and  that  the  remedy  has  no  direct 
effect  on  the  diphtheria  bacilli  themselves.  Such 
being  the  case,  antitoxin  should  be  valueless  in  the 
treatment  of  carriers.  Yet  it  has  been  noted,  ac- 
cording to  McCollom  and  Place,  191 3,  that  chronic 
nasal  diphtheria  will  often  clear  bacteriologically 
as  soon  as  the  existing  slight  toxin  irritation 
has  been  eliminated  through  antitoxin  adminis- 
tration. From  personal  experience  I  am  not 
convinced  that  antitoxin  is  wholly  useless  in  the 
treatment  of  the  average  carrier.  Indeed,  the 
impression  has  been  gained  that,  in  some  in- 
stances at  least,  antitoxin  administration  even  in 
small  doses  may  result  in  some  change  in  the  mor- 
phological features  of  the  organism  and  its  re- 
moval from  the  group  of  highly  virulent,  culturally 
positive  bacilli.  If  such  is  actually  the  case,  anti- 
toxin administration  might  be  considered  at  least 
worth  trying  in  troublesome  carrier  cases. 

Again,  attempts  have  been  made  to  overcome  the 
carrier  state  by  awakening  an  active  immunity  in 
the  carrier  through  injection  of  killed  diphtheria 
bacilli  or  toxin.  Thus,  in  1912,  Petruschky  treated 
a  small  series  of  cases,  including  some  convalescents 
from  diphtheria,  with  injections  of  diphtheria  bacilli 
killed  by  chloroform  vapor.  The  majority  of  the 
cases  soon  became  negative — in  five  to  twenty-nine 
days — but  in  one  instance  negative  cultures  were  ob- 
tained only  after  intermittent  treatment  occupying 
over  a  year. 

In  an  attempt  to  overcome  protracted  carrier  in- 
fection in  diphtheria  convalescents  by  inducing  a 
further  defensive  reaction  in  the  body  tissues  and 
fluids,  Hewlett  and  Nankiwell,  1912,  administered 
injections  of  diphtheria  endotoxin,  prepared  by  col- 
lecting a  growth  of  virulent  diphtheria  bacilli  from 
culture  media,  removing  the  toxin  by  washing  the 
growth  two  or  three  times  in  sterile  saline  solution, 
grinding  the  bacterial  mass  in  the  presnce  of  intense 
cold,  and  filtering  the  ground  mass  through  a  Berke- 
feld  filter.  The  resulting  filtrate,  which  contained 
the  endotoxin,  was  then  standardized  by  addition 
of  sterile  saline  solution  in  such  amoimt  that  the 
product  contained  from  two  to  five  milligrams  of 
the  endotoxin  per  mil  of  fluid.  The  most  effective 
plan  of  administration,  clinically,  was  found  to  be 
to  give  an  initial  dose  of  two  milligrams  of  the 
endotoxin  and,  if  the  cultures  remained  positive  for 
a  week  or  ten  days,  to  give  another  dose  of  five 
milligrams,  to  be  repeated  later  if  necessary.  Of 


twenty-four  diphtheria  carriers  in  whom  this  meas- 
ure wa?  applied,  all  showed  improvement  after  one 
or  more  endotoxin  injections.  Many  of  these  per- 
sons had  continued  to  be  carriers  for  a  number  of 
weck^  or  months  after  the  acute  attack  of  diph- 
theria. After  the  endotoxin  injections  the  carrier 
infection  ceased  entirely  in  many  cases,  while  among 
those  in  which  complete  success  was  not  attained 
there  was  at  least  a  reduction  in  the  number  of 
bacilli  in  all  instances.  Reaction  following  tfie  in- 
jections was  limited  to  some  local  redness  and  ten- 
derness, and  in  one  case  only,  malaise  and  an 
evanescent  rise  of  temperature.  The  doses  of  the 
endotoxin  administered  to  adults  and  children  were 
the  same.  On  the  whole,  it  must  be  admitted  that 
no  completely  satisfactory  procedure  for  eliminating 
carrier  infection  has  as  yet  been  discovered. 

In  some  instances  the  inconvenience  of  isolation 
rendered  necessary  by  carrier  infection  may  be  cut 
short  by  the  use  of  the  guineapig  test,  performed 
to  ascertain  whether  the  germs  continuously  har- 
bored in  a  given  case  are  actually  of  high  virulence 
or  are  of  so  low  a  grade  as  to  constitute  no  menace 
to  susceptible  contacts.  Where  the  guineapig  into 
which  the  germs  are  injected  fails  to  succumb,  the 
infection  is  considered  to  be  one  of  low  virulence 
and  isolation  of  the  carrier  no  longer  insisted  upon. 

Administration  of  immunizing  doses  of  antitoxin 
to  the  house  contacts  in  clinical  diphtheria  cases  is 
generally  considered  an  important  step  in  prophy- 
laxis. Although  some  authorities  would  Hmit  such 
immunization  to  contacts  in  special  institutions  for 
children  and  in  hospitals,  and  depend  upon  careful 
watching  of  the  contacts  for  signs  of  incipient  clin- 
ical diphtheria,  to  supply  the  necessary  indications 
for  early,  curative  antitoxin  administration,  the  fact 
remains  that  in  the  average  household  such  expert 
watching  is  impracticable,  and  proper  prophylaxis 
imperatively  requires  antitoxin  injection  in  the  other 
members  of  the  household,  particularly  children,  and 
in  less  degree  young  adults.  Although  secondary 
cases  of  diphtheria  in  a  household  are  not  very  com- 
mon, they  do  occur,  and  by  prophylactic  immuniza- 
tion of  the  other  members  of  the  family  the  num- 
ber of  these  cases  can  be  very  markedly  reduced. 
Results  from  antitoxin  immunization  in  hospitals 
and  other  institutions  preclude  all  doubt  as  to  its 
preventive  value.  Thus,  McCollom  and  Place,  191 3, 
note  that  before  immunization  was  applied,  out- 
breaks of  diphtheria  were  very  frequent  among  the 
young  children  in  the  Infants'  Hospital,  Boston,  as 
well  as  among  the  nurses  and  nursery  maids.  In 
a  number  of  years  after  the  institution  of  immuni- 
zation, on  the  other  hand,  but  one  case  of  diphtheria 
probably  originating  in  the  hospital,  developed 
among  the  infant  inmates ;  a  number  of  nurses  and 
nursery  maids  did  contract  diphtheria,  but  these 
were  all  comprised  among  those  who  had  declined 
to  be  immunized.  The  same  authors  note  that  in 
another  institution,  in  which  scarlet  fever  patients 


140 


LETTERS  TO  THE  EDITORS. 


[New  York 
Medical  Journal. 


are  cared  for,  antitoxin  immunization  brought  about 
cessation   of   diphtheria   outbreaks   in  the  wards. 

These  represent  typical  instances  of  experience 
with  antitoxin  immunization,  though  some  observers 
appear  to  have  been  less  fortunate — possibly  owing 
to  the  use  of  an  inferior  quality  of  antitoxin,  insuf- 
ficient dose,  or  certain  unusual  circumstances  among 
the  classes  of  patients  immunized.  Thus  Markuson 
and  Agopoff,  191 1.  reported  disappointing  results 
among  1,178  children  suffering  from  measles,  in 
whom  antitoxin  was  given  to  prevent  diphtheria. 
Brown.  Allen,  and  Lupton,  1907,  stated  that  among 
129  tuberculous  and  forty-nine  nontuberculous  indi- 
viduals to  whom  400  immunizing  doses  of  antitoxin 
had  been  given  during  an  epidemic,  four  patients 
had  developed  diphtheria  between  the  fourteenth 
and  sixteenth  days  following  the  first  antitoxin  in- 
jection, and  in  one  case  four  days  and  in  another 
one  day  after  a  second  injection.  Blumenau,  191 1, 
stated  that  among  348  children  with  measles  or  scar- 
let fever  to  each  of  whom  two  injections  of  500  or 
600  units  of  antitoxin  had  been  given  in  nineteen, 
or  5.5  per  cent.,  diphtheria  had  developed  later,  and 
the  procedure  of  immuniation  had  been  changed  to 
active  immunization  with  diphtheria  toxin. 

{To  be  continued.) 


Treatment  of  the  Postmature  Child. — Charles 
A.  Reed  (Surgery.  Gynecology  and  Obstetrics,  June, 
1920)  states  that  when  diagnosis  of  maturity  or  post- 
maturity has  been  made  it  is  too  late  to  influence 
the  size  of  the  child  by  Prochownick's  diet  except  in 
those  rare  cases  of  habitual  postmaturity  described 
by  Moisnard.  Here  perhaps  the  conditions  could 
be  anticipated.  The  principle  of  management  must 
be  based  on  the  results  of  regular  and  painstaking 
examinations  of  the  child  with  a  merely  subsidiary 
interest  in  the  subjective  history.  If  the  child  is 
mature  and  the  pelvis  not  seriously  contracted,  sev- 
eral days  or  a  week  may  be  permitted  to  elapse,  and 
then  if  Nature  fails  in  her  duty,  a  day  should  be  set 
and  the  labor  induced.  The  induction  may  be 
brought  about  easily,  safely,  and  expeditiously  by 
castor  oil  and  quinine,  or  by  the  Voorhees  bag,  or 
by  both.  Castor  oil  and  quinine  are  effective  in  pos- 
sibly two  cases  out  of  five  but  the  \'oorhees  bag  is 
always  highly  dependable. 

If  the  attendant  has  not  been  watchful  or  if  through 
the  weight  of  tradition  he  has  allowed  the  child  to 
become  postmature,  a  careful  revision  of  the  pelvic 
diameters  must  be  undertaken.  This  examination 
may  show  that  the  transit  of  the  child  through  the 
maternal  passages  would  be  highly  questionable  and 
possibly  accompanied  by  more  than  ordinary  danger. 
In  such  a  case  the  Csesarean  operation  will  suggest 
itself  as  the  most  conservative  way  of  terminating 
the  pregnancy.  On  the  other  hand  if  the  delivery 
by  the  pelvic  route  seems  feasible,  even  though  diffi- 
cult, labor  may  be  induced  by  the  bag  with  a  reser- 
vation that  if  the  natural  powers  are  insufficient,  de- 
livery may  be  completed  by  version  and  extraction 
or  forceps,  depending  on  the  conditions  and  preceded 
if  necessary  by  pubiotomy.  To  foresee  difficulties 
that  impend  and  to  anticipate  them  by  proper  and 
judicious  means  is  called  by  rhetoricians  a  pro- 


lapsus. To  foresee  the  obstacles  and  dangers  which 
attend  and  follow  the  birth  of  a  large  or  postmature 
child  and  to  avert  them  by  intelligence  and  skill  is 
good  obstetrics.  Unhappily  or  otherwise  we  all  have 
an  ingrained  reluctance  to  intervene  in  the  course  of 
what  is  apparently  a  regularly  advancing  pregnancy. 
It  is  much  easier  to  let  the  business  slip  along  under 
the  impression,  born  of  our  hopes  rather  than  of 
our  knowledge,  that  the  problem  may  solve  itself. 

 ^  

Letters  to  the  Editors. 


PHYSICIANS  IN  THE  HALL  OF  FAME. 

New  York,  July  6,  1920. 

To  the  Editors: 

You  were  good  enough  to  publish  my  letter  in 
reference  to  the  election  of  the  names  of  Morton, 
McDowell,  and  Sims  to  the  Hall  of  Fame  in  your 
issue  of  June  26th.  In  my  letter  I  stated  that  the 
election  would  take  place  on  July  1st.  I  have  since 
learned  that  the  electors  have  until  October  1st  to 
make  their  decision,  which  gives  all  those  who  are 
interested  time  and  opportunity  to  send  their  en- 
dorsement of  all  or  any  one  of  the  candidates  men- 
tioned to  the  electors  or  to  the  Senate  of  the  New 
York  University. 

Since  the  publication  of  my  last  letter  I  have  re- 
ceived a  number  of  requests  to  include  in  the  list 
of  America's  immortals  the  great  Benjamin  Rush, 
whom  Roswell  Park  in  his  History  of  Medicine 
calls  "the  most  conspicuous  medical  character  of 
the  centur>'."  American  internists  will  always  hold 
Rush  in  grateful  admiration  as  an  acute  observer  of 
disease.  His  description  of  clinical  phenomena  is 
today  as  authentic  as  when  published,  and,  of 
course,  I  am  glad  to  include  the  founder  of  Rush 
Medical  College  among  those  of  our  profession  who 
should  have  a  place  in  the  Hall  of  Fame. 

S.  Adolphus  Knopf,  M.  D. 


VENEREAL  PROPHYLAXIS. 

Pexxsvlvaxia  Dep.^rtmext  of  He.\lth, 
Harrisburg,  June  ig,  igzo. 

To  the  Editors: 

A  word  of  appreciation  for  the  editorial  on  the 
venereal  peril  published  in  the  June  12th  issue  of 
the  New  York  Medical  Journal.  Notice  is 
taken  of  the  mention  made  of  sixteen  prophylaxis 
stations  established  by  the  Department  of  Health. 

The  Pennsylvania  State  Department  of  Health 
does  not  centre  its  activity  in  the  matter  of  venereal 
prophylaxis  upon  stations  where  prophylaxis  may 
be  given  but  upon  the  individual  prophylaxis  pack- 
age, which  is,  or  should  be,  obtainable  at  all  drug 
stores.  The  department  puts  its  approval  upon 
preparations  which  come  up  to  specifications  as  re- 
gards bactericidal  properties,  nonirritative  effects, 
contents  of  the  tube,  character  of  the  container,  etc. 
Letters  have  gone  out  to  all  druggists  in  the  state 
asking  them  to  keep  in  stock  those  preparations 
which  come  up  to  the  requirements  of  the  depart- 
ment. I  wish  to  say  that  the  prophylaxis  stations 
are  not  doing  much  in  this  line  of  work. 

S.  Leon  Cans,  M.  D. 
Director,  Genitourinary  Division. 


New  York  Medical  Journal 

INCORPORATING  THE 

Philadelphia  Medical  Journal  "2  Medical  News 

A  Weekly  Revieiv  of  Medicine,  Established  18^3. 

Vol.  CXII.  No.  5.  NEW  YORK.  SATURDAY.  JULY  31.  1920.  Whole  No.  2174. 

Original  Communications 


THE     .ANATOMICAL      AXD  PHYSIO- 
LOGICAL THEORIES  OF  PLATO. 

By  Joxathax  Wright.  ^I.  D. 
Pleasantville,  X.  Y. 

It  is  quite  evident  (  8)  that  the  Homeric  Greeks 
entertained  ideas  in  regard  to  the  pneuma  and  the 
soul  of  man  but  little  removed  from  the  accounts 
travelers  give  of  those  of  primitive  man.  Man  was 
in  relationship  with  his  environment  by  virtue  of 
it.  His  ideas  were  essentially  pantheistic.  It  was 
the  pneuma  within  the  body  which  not  only  com- 
manded its  activities  but  translated  its  impressions. 
It  played  the  part  not  only  of  the  sensory  nerves, 
but  of  the  motor  nerves  as  well.  It  went  in  and 
out  of  the  body  in  respiration.  In  the  phenomenon 
of  death,  it  escaped  permanently  through  the  air 
passages  or  through  any  gaping  wound  of  the  body 
that  let  it  out.  What  the  Homeric  idea  of  dis- 
ease was  cannot  be  exactly  demonstrated.  It  was 
evidently  to  a  large  extent,  one  of  demonology, 
evolving  toward  a  differentiation  which  in  the 
course  of  a  few  centuries  almost  entirely  submerged 
the  primitive  etiology,  for  there  is  no  demonology  in 
Hippocrates.  Herodotus  (484-424  B.  C.)  was 
about  twenty-five  years  old  when  Hippocrates  was 
born  (460  B.  C.J,  according  to  commonly  accepted 
chronology,  and  he  said  Homer  lived  about  four 
hundred  years  before  his  time.  Some  of  the  Ho- 
meric poems  are  supposed  to  have  been  composed 
earlier  than  this,  but  we  are  perhaps  not  far  wrong 
in  allowing  four  centuries  in  which  this  striking 
change  took  place.  Puccinotti  ( 1 )  has  written  one 
of  the  most  readable  of  all  the  histories  of  medi- 
cine. The  prominence  he  gives  to  the  Chiron 
School  of  Medicine  from  which  Achilles  and  some 
other  Homeric  heroes  graduated,  and  the  still  more 
vague  emphasis  he  places  on  the  University  of  Or- 
pheus, more  recent  archeology  has  failed  to  justify. 

^-Esculapius  may  have  had  an  honorary  LL.D.  of 
the  former,  for  he  sent  his  two  sons  to  the  Trojan 
War,  not  as  warriors  alone,  but  as  physicians.  One 
has  to  be  a  little  cautious  in  seeing  any  affiliation 
of  the  doctrine  of  the  pneuma  with  the  deification 
of  ^sculapius,  to  be  inferred  from  a  story  of  the 
traveler  Pausanias  (2)  written  in  the  latter  part 
of  the  second  century  of  our  era,  when  the  glories 
of  ancient  Greece  were  long  since  things  of  the 
past.  He  relates  (YII,  23)  that  a  Sidonian  told 
him  that  at  Tyre  ^Esculapius  was  worshipped  as 
the  symbol  of  air,  because  that  element  is  the  father 


of  health  and  Pausanias  told  him  the  same  idea 
prevailed  in  Greece.  This  all  may  very  well  have 
been  adapted  from  the  then  greatly  expanded  doc- 
trine, springing  from  the  faddist  teachings  of  Diog- 
enes Apollonius  in  the  time  of  Hippocrates.  In 
the  verses  of  Oqpheus,  according  to  Aristotle  (On 
the  Sold)  the  soul  is  described  as  moved  to  and 
fro  by  the  winds  and  it  is  drawn  into  the  body  in 
respiration,  perhaps  with  the  first  inspiration  after 
birth.  Xow  we  infer  from  Diogenes  Laertius  (3) 
that  Orpheus  was  a  barbarian  and  that  those  who 
believed  that  the  knowledge  of  philosophy  came  to 
the  Greeks  from  barbarians  called  him  a  philoso- 
pher. Diogenes  calls  him  a  barbarian  because  he 
was  a  Thracian.  but  Thrace  sent  forth  many  min- 
strels and  prophets  in  the  time  of  Homer  and  doubt- 
less in  the  earlier  time  of  the  Trojan  War.  This  is 
b)"  no  means  the  chief  intimation  we  have  of  the 
external  source  of  Greek  theories,  but  despite  the 
association  of  Pythagoras  with  Egyptians  and  other 
Asiatics  we  may  imagine  that  as  heir  of  Orphic  re- 
ligious enthusiasm  he  may  have  had  from  Orpheus 
the  view  he  had  of  the  Cosmos  "always  inhaling 
and  exhaling  infinite  breath  or  void  (ether)  which 
surrounds  it  on  every  side." 

We  need  not,  however,  seek  in  the  baffling  tra- 
ditions of  half  mythical  persons  for  the  origin  of 
such  ideas.  It  was  from  the  -\siatic  Greeks,  from  the 
nature  philosophers  of  Ionia  and  Caria,  from  Colo- 
phon and  Miletus,  from  Cnidos  and  Cos  and  the 
islands  that  fringe  the  shores  of  the  Asiatic  littoral, 
in  contact  with  the  sea  and  land  routes  between 
Egypt  and  Asia  Minor,  over  which  commerce  trav- 
eled, that  history  records  Greek  philosophy  sprang. 
Xenophanes  (flourished  536-496  B.  C.)  seems  to 
have  dissented  from  the  view  of  P\i:hagoras  (born 
608  B.  C.)  and  he  is  thought  by  Gomperz  (6). 
with  true  Teutonic  modesty  ascribing  the  origin 
of  the  pneuma  to  the  inventive  minds  of  the  skin 
clad  barbarians  of  the  Danube,  to  have  received  it 
undiluted  from  these  or  more  northern  Aryans. 
According  to  Xenophanes  the  soul  returns  to  celes- 
tial space.  A  line  of  Epicharmus  of  Cos,  a  con- 
temporary of  Xenophanes.  has  been  preserved  to 
us,  bearing  the  same  sentiment,  strangely  modern 
in  form :  "Dust  to  dust  and  breath  of  Heaven." 

This  brings  it  direct  to  Cos,  the  birthplace  of 
Hippocrates  who  was  ten  years  old  at  the  reported 
time  of  the  death  of  Epicharmus  (450  B.  C). 
Though  it  is  first  found  sur\-iving  in  the  text  of 
Herodotus,  Xenophanes  of  Colophon  is  said  to  have 


Copyright,  1920,  by  A.  R.  Elliott  Publishing  Company. 


142 


WRIGHT:   THEORIES  OF  PLATO. 


[New  York 
Medical  Journal. 


been  the  first  to  employ  the  word  pneunia  in  this 
connection.  We  have  Fuchs's  (6)  word  for  it  that 
in  Homer  the  substantive  form  is  not  used.  Dar- 
emberg  (7)  though  asserting  the  existence  of  the 
idea  of  the  pneuma  in  Homer,  which  we  have  veri- 
fied (8),  supposes  the  word  to  have  been  derived 
from  that  which  in  Homer  inchided  a  reference  to 
both  lungs  and  pleura.  Anaximenes  of  Miletus 
must  have  belonged  to  this  epoch  also.  The  single 
fragment  of  his  philosophy  which  has  come  down 
to  us  in  his  own  words  concerns  us  at  once.  "Just 
as  our  soul,  being  air,  holds  us  together,  so  do 
breath  and  air  encompass  the  whole  world."  (9) 
We  might  trace  this  doctrine  through  its  modifica- 
tion into  the  nous  by  Anaxagoras,  the  pupil  of  An- 
aximenes, and  to  Athens  through  Diogenes  Apol- 
lonius,  who  may  have  written  the  book  on  The 
Winds  in  the  Hippocratic  Corpus,  where  it  is  car- 
ried to  absurdity. 

In  Plato  the  fire  of  Heraclitus,  which  in  Aris- 
totle became  the  vital  heat,  is  wc^ked  into  a  won- 
derful cosmic  theor}-  with  the  air  and  water,  which 
few  can  comprehend.  Perhaps  Plato  took  some  of 
the  obscurity  of  Heraclitus  into  this  part  of  his 
writings,  most  of  which  are  as  clear  as  crystal. 
At  any  rate  we  get  the  trail  from  the  nature  philos- 
ophy of  Anaximenes  and  Heraclitus,  straight  into 
the  dark  shadows  of  the  Thnwiis,  where  we  find  the 
pneuma  theory  which  was  transmitted  from  this 
work  of  Plato,  rather  than  from  any  genuine  trac- 
tate of  Hippocrates,  into  later  medical  literature. 
It  flourished  in  the  time  of  Hippocrates,  but  de- 
spite the  easily  found  traces  of  nature  philosophy 
which  probably  came  through  .Aicmseon  and  Em- 
pedocles,  we  get  no  distinct  formulation  of  the 
pneuma  idea  in  his  genuine  works  and  but  little 
incidental  indication  that  he  was  seriously  influ- 
enced by  it.  For  these  reasons  I  for  the  present 
pass  over  the  older  Hippocrates  to  his  younger  con- 
temporary Plato  and  the  latter 's  great  pupil, 
Aristotle.  In  Plato  the  fire  still  retains  the  mark 
of  its  protagonist,  Heraclitus,  and  this  part  of  his 
doctrine  we  may  well  associate  with  that  of  the 
Persian  Zoroaster.  According  to  Martin  (10) 
Galen  or  the  author  of  the  tract  on  philosophy, 
usually  incorporated  in  his  works,  and  the  ancient 
critics,  Proclus,  Chalcidius  and  others  asserted  the 
meaning  of  Plato  was  that  the  soul  was  incor- 
poreal. Hence  it  had  to  be  separated  from  the  air. 
Unless  that  is  the  meaning  of  Plato's  tendency  to 
give  prominence  to  the  ether,  I  cannot  see  it  in  that 
light.  The  idea  of  the  air  as  a  corporeal  body, 
perhaps  only  emphasized  by  the  experiment  oi 
Empedocles  and  long  admitted,  was  still  invisible 
and  mysterious.  Later  the  stoics,  especially  Chry- 
sippus,  placed  themselves  firmly  on  the  basis  of 
primitive  man  and  identified  the  soul  with  the  air, 
claiming  the  support  of  Plato.  In  his  view  it  was 
allied  with  fire  and  ether,  one  of  which  was  grossly 
misconceived  and  the  latter  still  is  a  theory.  It 
seems  to  me  that  Plato  nowhere  frankly  separates 
either  the  fire  or  the  ether  or  the  soul  from  the  air. 
Rigid  analysis  had  not  become  a  habit  of  mind. 
There  are  passages  in  Plato  which  later  philoso- 
phers were  accustomed  to  read  as  though  they  refer 
to  the  corporeality,  to  the  reality  of  the  air.  In 


their  time,  doubtless  they  felt  justified  in  excluding 
the  soul  from  the  congeries  of  conceptions  still 
adherent  to  the  air,  but  there  is  in  Plato  no  clearly 
cut  idea  that  it  had  nothing  to  do  with  the  air. 
Galen  (18)  declares  the  Tiiiiccus  was  read  only 
to  a  few  friends  capable  of  understanding  it.  He 
intimates  that  the  pantheistic  doctrine  it  contains 
was  unknown  to  the  common  people  and  might  of- 
fend them.  Galen  refers  rather  to  this  doctrine 
of  the  soul  as  puzzling  than  to  Plato's  remarkable 
conception  of  the  animal  body. 

Importance  in  medicine  was  first  given  to  the 
pneiuna  by  Philistion  of  the  Sicilian  School  (11). 
From  him  Plato  may  have  derived  his  doctrines 
when  he  went  to  Sicily  on  his  unfortunate  errand 
as  tutor  of  Dionysius  II,  though  the  Timceus  and 
many  of  his  earlier  works  may  have  been  written 
before.  Wellmann  attributes  to  Diodes  the  first  dis- 
tinction made  between  arteries  and  veins,  both  car- 
rying air  as  well  as  blood  according  to  the  view 
of  the  Sicilian  School.  For  Diodes,  younger  than 
Hippocrates,  and  to  a  less  extent  for  Plato,  the 
pneuma  disturbances  were  combined  with  disturb- 
ances in  the  equilibrium  of  the  humors  as  the  cause 
of  disease.  Thus  early  the  hvuiioral  doctrines  and 
those  of  the  pneuma  were  combined  in  medical 
conceptions  of  etiology.  Plato  repeats  the  age  old 
conception  in  the  Timceus  of  the  impressions  on 
the  body  being  distributed  by  the  blood  vessels,  but 
it  is  not  clear  whether  they  are  inherent  in  the 
blood  or  in  the  air  mixed  with  it.  The  importance 
we  ascribe  to  finding  such  a  discrimination  (12)  is 
perhaps  not  very  consistent  since  in  modern  times 
we  see  no  difficulty  in  ascribing  a  lot  of  properties 
to  the  blood  in  serotherapy,  without  considering  or 
without  knowing  in  chemical  terms  just  what  for- 
mula represents  any  specific  attribute. 

To  discuss  further  Plato's  ideas  in  regard  to  the 
soul  would  involve  the  exertion  of  higher  powers 
than  my  own.  They  receive  an  enormous  expan- 
sion in  his  dialogues,  taken  as  a  whole,  and  libra- 
ries of  books  have  subsequently  been  filled  with 
comments  on  them.  I  must  confine  myself  to  the 
bearing  these  ideas  have  upon  the  pneuma  chiefly 
in  its  relation  to  the  conceptions  of  the  anatomy 
of  his  time  and  briefly  in  its  influence  on  the  suc- 
ceeding epochs  in  physiological  science.  I  may 
make  an  exception  to  this  limitation  by  briefly  al- 
luding to  the  threefold  partition  of  the  soul — the 
noble  cogitations  of  the  intellect  being  seated  in 
the  brain,  a  relic  of  the  ancient  doctrine  of  Alc- 
maeon,  the  noble  emotions  in  the  heart  and  the 
animal  appetites  and  passions  in  the  abdomen  be- 
tween the  diaphragm  and  the  navel.  We  see  thus 
the  multiple  souls  of  the  primitive  African  philoso- 
phers finding  in  the  human  frame  a  separate  habi- 
tation. It  was  into  Sicily  years  before  Plato  and 
two  thousand  years  after  him  that  Africa  contin- 
ued to  -pour,  by  invasion  and  by  commerce,  her 
hordes  from  Carthage  and  the  neighboring  shores 
of  her  Mediterranean  coasts.  Plato  is  said  to  have 
traded  with  Egypt  in  olive  oil.  as  Solon  did  before 
him.  I  think  I  have  shown  (13)  that  we  have  suf- 
ficiently clear  evidence  in  the  Papyrus  Ebers  that 
pneuma  ideas  dominate  its  anatomy  and  physiology. 


July  31,  1920.] 


WRIGHT:  THEORIES  OF  PLATO. 


143 


and  I  have  elsewhere  (14)  cited  at  some  length 
from  the  copious  evidence  ethnology  offers  of  the 
widespread  belief  in  multiple  souls  by  primitive  peo- 
ple. This  is  especially  abundant  in  savage  Africa 
in  modem  times,  ^^'ith  these  primitive  conceptions 
of  the  soul  we  find,  added  to  that  of  the  pneuma 
from  Egypt,  Plato's  obligations  to  Heraclitus  for 
the  Asiatic  theories  of  fire  and  perhaps  of  the  ether, 
the  former  finally  evolving  into  a  form,  that  of 
heat,  which  in  Aristotle  allies  it  more  definitely  with 
the  principles  of  modern  science.  These  facts  stand 
forth,  thanks  to  the  labors  of  many  commentators, 
ancient  and  modern,  in  an  attentive  study  of  the 
Thnccus.  This  book  has  baffled  the  most  skillful 
of  translators  and  the  most  profound  of  critics. 
Perhaps  its  obscurity  is  one  reason  for  the  influence 
it  had  on  the  subsequent  evolution  of  medicine.  The 
literature^  which  has  grown  up  around  the  Timccus 
has  displayed  the  unequalled  scope  and  power  of 
the  imagination  of  Plato. 

Xo  imagination  is  purely  imaginary.  Every 
castle  in  Spain  has  its  foundation  in  the  solid  facts 
of  real  life.  Every  dream,  we  are  told  by  those 
not  devoid  of  an  ill  controlled  imagination  them- 
selves, has  its  root  in  the  impressions  made  on 
the  mind  by  the  senses  of  men  when  awake.  We 
may  be  sure  that  Plato  did  not  evolve  from  his 
inner  consciousness  alone  that  fantastic  idea  of 
anatomy  and  physiolog}'  in  those  parts  exhibiting 
the  involvement  of  the  pneuma,  set  forth  in  the 
Timccus,  to  which  I  can  scarcely  do  more  than 
allude.  Cicero's  far  less  profound  mind  adopted 
much  of  it  in  his  essay  on  the  Xature  of  the  Gods 
(Lib.  II,  54-56),  and  it  is  there  somewhat  incom- 
pletely but  more  clearly  set  forth.  Professor 
Jowett  conferred  a  great  benefit  on  medicine  by 
opening  to  modern  readers  the  dialogues  of  Plato 
in  an  English  translation.  Of  this  Sir  William 
Osier  (15)  took  advantage  many  years  ago  in  order 
to  offer  to  the  attention  of  medical  men  those  points 
of  medical  interest  which  they  contain.  Unfortu- 
nately the  brilliant  performance  of  Jowett  is  ob- 
scured in  the  inadequate  and  often  incoherent  ren- 
dering of  this  part  of  the  Timccus.  Martin  (10  )  is 
considerably  more  successful,  but  a  comparison  of 
either  the  English  or  the  French  interpretation  with 
the  Greek  text  will  easily  reveal  an  inexactitude 
which  is  not  compensated  for  by  their  plausibility 
and  which  evidently  arose  from  bewilderment  in 
both  translators,  partly  due  doubtless  to  their  insuf- 
ficient acquaintance  with  the  general  outlines  of 
human  anatomy  and  physiology  and  the  history  of 
their  evolution.  Chiefly,  however,  one  must  realize 
it  is  due  to  the  remarkable  scope  of  Plato's  thought 
and  the  wide  expansion  of  his  imagination.  Pos- 
sibly by  approaching  it  from  a  viewpoint  formed 
by  a  better  knowledge  of  medicine  and  by  a  better 
understanding  of  the  course  of  medical  thought  be- 
fore and  after  Plato,  the  medical  reader,  despite 

'  Leon  Robin  has  recently  published  an  interesting  study  on  the 
physics  of  Plato  (Etudes  sur  la  signification  et  la  place  de  la  physique 
dans  la  philosophic  de  Platan)  which  has  come  to  my  notice  since 
this  article  has  been  written,  but  there  seems  to  be  little  in  it  in 
regard  to  matters  of  our  especial  interest — nothing,  I  think,  which  I 
have  failed  at  least  to  allude  to  here.  I  cannot,  however,  too  highly 
recommended  it  4o  the  students  of  physics  proper  in  the  Timaus  and 
to  lovers  of  Plato  in  general. 


his  vastly  inferior  philological  knowledge,  may  ar- 
rive at  a  more  satisfying  if  not  a  more  accurate  and 
teclinical  understanding  of  Plato's  thought. 

In  the  spurious  book  on  the  Aliment  we  have  seen 
(16)  the  idea  existent,  probably  at  least  as  early  as 
Plato's  years  of  activity,  that  the  air  is  a  food  when 
inspired.  \\'e  must  bear  in  mind  that  however 
faulty  the  idea  of  the  circulation  of  the  blood  was 
for  the  contemporaries  of  Plato  and  for  those  liv- 
ing nearly  2000  years  after  him,  it  did  surge  with 
the  air  through  the  veins  and,  for  some,  through 
the  arteries.  If  the  air  is  a  food  to  the  tissues 
it  must  get  to  them  by  channels  at  that  time,  undis- 
covered either  in  the  lung  or  the  system  generally. 
Xo  such  mind  as  Plato's  could  rest  satisfied  with 
this  gap  of  nutrition  in  the  continuity  of  the  ever 
changing  flood  of  existence  as  conceived  by  Hera- 
clitus. We  may  imagine  that  in  the  Timccus  Plato 
followed  the  old  Egyptian  conception  of  channels 
(or  metie)  running  everywhere  through  the  body. 
A\'e  are  able  to  help  ourselves  out  with  the  lymph 
spaces  and  call  them  channels  (or  metie j.  But 
Plato  had  no  such  knowledge  as  we  possess.  What 
must  have  occurred  to  him  was :  "It  seems  evi- 
dent tliat  thus  the  nutrition  and  the  life  is  carried 
throughout  the  body,  but  how  does  it  reach  the 
flesh  lying  between  the  vessels  we  see?"  Plato 
therefore  conceived  of  the  life — of  the  air  and  fire 
(heat?)  passing  through  the  veins,  but  also  God 
wove  "together  of  fire  and  air  like  basket  nets" 
[78] — a  sort  of  reticular  tissue  we  may  call  it 
for  a  moment  in  order  to  encourage  modern  anato- 
mists. We  shall  find  this  tissue  of  Plato's  imagi- 
nation dissolving  and  flowing  through  itself.  Mod- 
ern histologists  know  of  the  cells  wandering  off  from 
the  walls  of  the  lymph  spaces,  and  know  that  it  is 
a  structure  in  which  the  constituents  flow  away  and 
are  replaced  by  others,  the  ever  changing  river  of 
life,  as  old  Heraclitus  thought  of  it,  which  is  never 
the  same — "man  never  steps  twice  in  the  same 
river."  I  am  not  trying  so  much  to  force  a  parallel 
of  things  as  to  exhibit  the  underlying  parallelism 
of  thought  between  Platonic  and  modern  mental 
concepts. 

In  the  discourse  of  Plato  we  get  a  hint  of  this 
transmutation  of  tissue — of  the  flesh  into  liquid 
"which  generates  all  sorts  of  bile  and  Ij-mph  and 
phlegm,"  in  the  process  of  disease.  It  is  perhaps 
not  necessary  to  use  modern  parlance  in  tracing  the 
genesis  of  mucus  and  pus.  Something  happens  in 
the  retiform  tissue ;  a  blow,  a  foreign  body,  a  bac- 
terium, whose  potentiality  is  so  interesting  to  us, 
cause  the  network  to  break  down  into  a  fluid,  which 
flows  away  along  lymph  channels  if  no  surgeon  is 
at  hand.  The  pathological  change  as  well  as  the 
physiological  change  which  took  place  was  thought 
of  by  Plato.  "Xow  everyone  can  see  whence  dis- 
eases arise.  There  are  four  natures  out  of  which 
the  body  is  compacted — earth  and  fire  and  water 
and  air,  and  the  unnatural  excess  and  defects  of 
these,  or  the  change  of  any  of  them  from  their 
own  natural  place  into  another,  or  again,  the  as- 
sumption on  the  part  of  these  diverse  natures  of 
fire  and  the  like  of  that  which  is  not  suitable  to 
them,  or  an}lhing  of  the  sort,  produces  diseases 


144 


ir RIGHT:   THEORIES  OF  PLATO. 


[New  York 
Medical  Journal. 


and  disorders ;  for  each  being  produced  or  changed 
in  a  manner  contrary  to  nature,  the  elements  which 
were  previously  cool  grow  warm,  and  those  which 
were  dry  become  moist,  and  the  light  becomes 
heavy,  and  the  heavy  light ;  all  sorts  of  changes 
occur."  I  doubt  if  my  readers  will  think  it  worth 
while  to  follow  the  thought  in  this,  but  it  is  little 
worse  than  the  mist  which  hangs  about  the  be- 
ginnings of  bacteriology  or  serology.  It  is  less  dif- 
ficult to  seize  the  conclusion  which  is  to  be  drawn 
from  this  picture  of  tlie  processes  in  the  living 
body,  if  one  gets  the  drift  of  the  thought  of  them 
through  the  mind  of  Plato  and  sees  how  out  of  it 
arises  his  discrimination  of  the  pathological  from 
the  physiological.  "For  we  affirm  that  only  the 
same,  in  the  same  and  like  manner  and  proportion 
added  or  subtracted  to  or  from  the  same,  will  allow 
the  body  to  remain  in  the  same  state,  whole  and 
sound,  and  that,  whatever  is  taken  away  or  added 
in  violation  of  these  rules  causes  all  manner  of 
changes  and  infinite  diseases  and  disorders." 

Now  this  gives  us  a  glimpse  of  the  grasp  Plato 
had  of  the  many  theories  of  the  nature  of  man 
and  his  diseases  prevalent  in  his  day.  which  is  a 
little  aside  from  the  subsidiary  theme  of  the  reticu- 
lar tissue  which  has  led  us  in  sight  of  it.  The 
modern  reticular  network  like  the  Platonic  has  a 
tieed  for  renovation  and  repair.    Everything  wore 
out  in  his  day  as  it  does  in  our  own.  Everything 
now,  as  in  the  days  of  Heraclitus,  is  in  a  state  of 
flux,  but  it  is  a  proposition  hard  for  us  to  grasp 
when,  as  we  shall  note,  we  realize  that  Plato  made 
his  air  and  fire  framework  to  flow  along  the  chan- 
nels of  the  body  to  aid  in  vivifying  and  renewing  it. 
somewhat  as  we  make  our  wandering  cells  perform 
their  functions.    After  Plato  we  find  Erasistratus 
busy  with  the  thought  of  the  connective  tissue.  He 
it  was  who  gave  it,  in  the  lungs,  the  name  of 
parenchyma.    I  do  not  know  if  the  cryptic  sayings 
of  Plato  in  the  Timaus  had  their  influence  on  him. 
As  for  the  antecedents  of  Plato's  own  thought,  no 
fact  or  fancy  can  be  seized  by  the  intellect  of  man 
which  is  unassociated  with  anything  that  is  already 
familiar  to  him.    The  only  previous  hint  in  an- 
tiquity known  to  me  of  the  body  made  as  a  net- 
work is  derived   from  an  incidental  remark  of 
Aristotle  (Generation  of  Animals  IT.  cap.  1)  who 
says  that  the  organs  of  an  animal  are  generated 
either  simultaneou.sly  or  in  successive  order  as  de- 
scribed "in  the  verses  of  Orpheus.    For  it  is  there 
said  that  an  animal  is  generated  similarly  to  the 
knots  of  a  net."    I  recognize  that  the  thought  of 
Aristotle  is  not  in  line  with  our  present  concern, 
but  we  get  from  Orpheus  at  least  the  simile  of  a 
fish  basket  or  net.    In  Jowett's  translation  Plato 
proceeds  thus  in  continuation  of  the  sentence  quoted 
above,  as  to  a  basket  network  of  fire  and  air.  hav- 
ing in  mind  perhaps  a  basket  such  as  is  used  to  cap- 
ture lobsters  or  fish. 

"The  network  he  took  and  spread  over  the  newly 
formed  animal  in  the  following  manner:  he  let  one 
of  the  openings  pass  into  the  mouth;  this  opening 
was  twofold,  and  he  let  one  part  of  it  descend  by 
the  air  pipes  into  the  lungs,  the  other  by  the  side 
of  the  air  pipes  into  the  belly.    (The  laryngo- 


trachea  and  the  esophagus).  The  other  opening 
(the  pharynx?)  he  divided  into  two  parts,  both 
of  which  he  made  to  communicate  with  the  chan- 
nels of  the  nose,  so  that  when  there  was  no  way 
through  the  mouth  the  streams  of  the  mouth  were 
replenished  from  the  nostril.  But  the  other  cav- 
ity (?)  of  the  network  he  placed  around  so  much 
of  the  body  as  was  hollow,  and  the  entire  recep- 
tacle which  was  composed  of  air  he  made  to  flow 
into  the  passage  of  the  network,  which  then  flowed 
back ;  the  tissue  of  the  lung  found  a  way  in  and  out 
of  the  pores  of  the  body,  and  the  rays  of  fire  which 
were  interlaced  followed  the  passage  of  the  air 
either  way;  this  continuing  as  long  as  the  mortal 
being  holds  together.  These,  as  we  affirm,  are  the 
phenomena  which  the  imposer  of  names  called  res- 
piration and  expiration."  We  must  pause  to  recol- 
lect that  air  is  passing  not  alone  into  the  arteries 
from  the  modern  air  passages,  but  the  process  in- 
cludes the  passage  of  air  through  the  pores  of  the 
body,  which  not  only  channel  it  but,  in  the  sense  of 
Empedocles,  pierce  the  integument  and  communi- 
cate with  the  outside  air.  "And  all  this  process  of 
cause  and  effect  took  place  that  the  body  might  be 
watered  and  cooled,  and  thus  have  nourishment  and 
life ;  for  when  the  respiration  is  going  in  and  out, 
and  the  fire  (heat?),  which  follows  at  the  same 
time,  is  moving  to  and  fro,  and  entering  through 
the  belly,  reaches  the  meat  and  drink,  it  liquefies 
them,  and  dividing  them  into  small  portions  and 
guiding  them  through  the  passages  where  it  goes, 
draws  them  as  from  a  fountain  into  the  channels  or 
veins,  and  makes  the  stream  of  the  veins  flow- 
through  the  body  as  through  a  conduit." 

Reflecting  on  the  vicissitudes  of  the  text,  pass- 
ing through  hands  entireh-  unskilled  and  inter- 
preted by  minds  entirely  void  of  any  idea  of  an- 
atomy and  physiology,  we  may  easily  conceive  how 
such  a  passage  may  have  become  so  mutilated  as 
to  be  now  almost  undecipherable  by  the  ablest  of 
philologists  and  paleographers,  but  by  keeping  the 
central  idea  of  the  necessity  for  the  interchange  we 
now  know  goes  on  in  the  lymph  channels,  we  get  in 
hailing  distance  of  Plato's  thought.  How  are  we 
going  to  account  for  the  birth  of  this  stupefying 
conception  in  the  mind  of  Plato?  The  mind  of 
Plato,  we  may  grant,  explains  no  inconsiderable 
part  of  it.  Its  fertility  can  be  gauged  only  by 
reading  all  his  dialogues.  For  many  readers  of  this 
article  this  is  an  impracticable  suggestion,  but  they 
can  at  least  assume  that  he  had  a  mind  of  excep- 
tional imaginative  power.  As  has  already  been 
pointed  out  no  imagination  is  purely  imaginary.  It 
grows  by  what  it  feeds  upon.  So  far  as  space  ad- 
mits, I  have  attempted  to  trace  some  connection 
between  Plato  and  the  thought  of  his  time.  He 
mentions  Heraclitus  and  it  is  quite  clear  he  was 
profoundly  influenced  by  his  philosophy.  Burnet 
(9a)  guided  by  Proclus,  believes  Plato  knew  noth- 
ing of  Democritus  and  his  atoms.  He  does  not 
mention  him,  but  one  can  scarcely  believe  he  was 
not  familiar  with  his  doctrines.  Since  Aristo- 
phanes (17)  in  the  Clouds  refers  to  the  Vortex, 
the  atomic  theory  must  have  been  familiar  to  the 
Athens  of  the  days  of  Plato.  The  expression  used 
by  Empedocles  to  describe  the  movement  of  the 


July  31,  1920.] 


CORNIVALL  AND  CRAWFORD:    TYPHOID  FEVER  EPIDEMIC. 


145 


elements  is  that  thev  run  through  each  other  (fr. 
17-34). 

The  anatomy  and  physiology  of  Plato,  whatever 
may  have  been  the  sources  from  which  he  drew  his 
inspiration,  were  figments  of  his  imagination.  On 
it  he  drew  for  his  mental  pictures  of  the  structure 
and  forces  of  the  body.  The  fire  being  an  attenu- 
ated form  of  matter  as  compared  to  the  coarser 
particles  of  air,  he  made  his  connective  tissue  out 
of  them.  The  reason  for  the  network  was  not 
only  to  permit  air  and  fire  and  food  to  flow  through 
the  body  but  to  permit  the  disengaged  particles  of 
air  and  fire  to  escape  while  the  food  and  the  drink 
[78  A],  the  chief  nutrition  of  the  body  is  retained. 
Their  intimate  relation  to  one  another  while  in  the 
body  is  made  plain,  the  air  being  thought  of  as  con- 
stituting the  outer  layers  of  the  network  and  the 
fire  or  the  heat  the  inner  lining,  presumably  in 
contact  with  the  digested  food  and  drink,  but  their 
state  of  flux  we  recognize  as  greatly  exaggerated 
in  Plato's  thought,  evidently  owing  to  the  emphasis 
of  Heraclitean  doctrine.  We  see  also  in  the 
mingling  of  the  humors  and  the  pneuma  the  trace 
of  Sicilian  medicine  and  we  realize  that  like  Diodes, 
Plato  was  not  purely  a  pneumatist  nor  purely  a 
humoralist,  but  admitting  the  equilibrium  of  the 
four  elements  as  a  state  of  health  and  its  disturb- 
ance as  disease  in  accord  with  Alcmaeon,  he  left 
the  way  open  to  conjecture  that  the  cause  of  that 
disturbance  of  equilibrium  might  be  sought  in  the 
pneuma. 

REFERENCES. 

1.  PuccixoTTi,  Francesco:  Storia  dclla  Mcdecina. 
Livorna,  1850. 

2.  Pausanias's  Description  of  Greece,  translated  by  J. 
G.  Fraser.    London,  Macmillan,  1898. 

3.  Diogenes,  Laertius  :  Lives  and  Opinions  of  Eminent 
Philosophers,  translated  by  C.  D.  Yonge.  London,  Bohn, 
1853. 

4.  Adam,  James:  The  Religious  Teachers  of  Greece. 
Edinburgh,  Clark,  1908. 

5.  GoMPERZ,  Theodor  :  Greek  Thinkers,  translated  by 
Laurie  Magnus,  four  volumes.  New  York,  Scribner's, 
1908-1912. 

6.  FucHS,  Robert:  In  Handbuch  dcr  Geschiehte  der 
^ledizin,  begriindet  von  Dr.  Med.  Th.  Puschmann. 

7.  Daremberg,  Charles:  La  Medcciuc  dans  Homerc. 
Paris,  Didier  et  Cie,  1865. 

8.  New  York  Medical  Journal,  Alay  22,  1920. 

9.  Burnet,  John:  Early  Greek  Philosophy,  second  edi- 
tion.   London,  Adam  &  Black,  1908. 

9a.    Greek  Philosophy,  London,  Macmillan,  1914. 

10.  Martin,  Henri:  Etudes  sur  le  Timee  de  Platon, 
second  volume.    Paris,  1841. 

11.  Wellmann,  M.  :  Fragmentsamnilung  der  Griesch- 
ichen  Aertze.  Band  L  Die  Fragmente  dcr  Sikelischen 
Aertzte.  Akron,  Philistion  nnd  des  Diokles  von  Karystos, 
1901. 

12.  Beare,  John  L:  Greek  Theories  of  Elementary 
Cognition  from  Alcmaeon  to  Aristotle.    Oxford,  1906. 

13.  New  York  Medical  Journ.^l,  December  7.  1918. 

14.  New  York  Medical  Journal,  July  20,  191 8. 

15.  Osler,  William:  Boston  Medical  and  Surgical 
Journal,  cxxviii,  Nos.  6  and  7,  February  2  and  9,  1893. 

16.  New  York  Medical  Journal,  December  13,  1919. 

17.  Aristophanes  :  Comedies  translated  by  T.  Mitchell, 
vol.  ii,  London,  Murray,  1822. 

18.  Galen  :  Fragment  on  the  Substance  of  the  Natural 
Faculties  (Kiihn,  IV,  p.  757). 


AN   EPIDEMIC   OF  TYPHOID  FEVER 
OF  WATER  BORNE  ORIGIN  AND 
CARRIER  TRANSMISSION. 

At  Camp  Hosptial  Xo.  10,  Praiitliay.  Haute  Manic, 
American  Expeditionary  Forces,  France. 

Bv  Leon  H.  Cornwall,  M.  D., 

New  York, 

Pathological   Laboratories,   City  Hospital,   Blackwell's  Island; 
Captain,  Medical  Corps,  U.  S.  Army, 

And  James  P.  Crawford,  M.  D., 
San  Francisco, 

Captain  Medical  Corps,  U.  S.  Army. 

On  January  20,  1919,  a  case  of  clinical  typhoid 
fever  was  discovered  at  Camp  Hospital  No.  10, 
located  at  Prauthoy,  Haute  Marne,  France.  The 
tenth  area  from  which  this  hospital  received  its 
])atients  was  occupied  by  the  Eighty-second  divi- 
sion and  a  few  casual  organizations.  This  patient 
was  admitted  on  January  i6th,  and  for  the  first  few 
days  the  condition  was  diagnosed  as  bronchopneu- 
monia. On  January  24th  a  crop  of  rose  spots  ap- 
peared and  on  the  following  day  a  blood  culture 
was  taken.  At  that  time  the  cultural  bacteriolog}' 
for  Camp  Hospital  No.  10  was  done  at  the  central 
medical  department  laboratory  at  Dijon,  France,  a 
distance  of  some  thirty  kilometres.  Within  forty- 
eight  hours,  however,  the  clinical  diagnosis  was 
confirmed  by  a  positive  report  of  Bacillus  typhosus. 

The  case  originated  in  Battery  E  of  the  321st 
Field  Artillery  and,  as  the  number  of  men  being 
hospitalized  from  that  organization  indicated  a  high 
sick  rate,  a  careful  watch  was  kept  of  all  admis- 
sions from  that  command.  To  facilitate  the  early 
diagnosis  of  typhoid  or  paratyphoid  fever  a  special 
building  was  designated  as  a  gastroenteric  ward. 
By  the  improvisation  of  temporary  partitions  this 
building  was  subdivided  into  sections  for:  i,  Clin- 
ical typhoid  fever,  2,  typhoid  fever  suspects,  3, 
typhoid  carriers,  and  4,  other  conditions  such  as 
gastritis,  gastroenteritis,  diarrhea,  dysentery,  acute 
catarrhal  jaundice  and  acute  cholecystitis.  All  en- 
teric patients  in  the  hospital  were  immediately  col- 
lected here  and  all  new  admissions  for  such  condi- 
tions were  sent  to  this  building  for  observation. 

As  a  result  of  a  conference  between  Major  John 
W.  Emhardt,  commanding  officer  of  the  hospital, 
Major  Victor  C.  Vaughan,  Jr.,  epidemiologist  from 
the  division  of  laboratories  and  infectious  diseases 
of  the  office  of  the  chief  surgeon,  A.  E.  F.,  and  the 
laboratory  officer  assigned  to  the  hospital,  the  fol- 
lowing hospital  order  was  issued : 

"A  blood  culture  for  typhoidlike  organisms  will 
be  taken  in  the  case  of  all  typhoid  suspects  on  ad- 
mission. If  negative  two  more  blood  cultures  will 
be  taken  at  the  end  of  forty-eight  and  ninety-six 
hours  respectively.  A  blood  culture  will  then  be 
taken  every  seven  days  throughout  the  illness,  with- 
out regard  to  previous  findings.  An  additional 
blood  culture  will  be  taken  at  the  onset  of  a  relapse. 

'Tn  cases  of  fevers  of  an  unknown  origin  three 
successive  blood  cultures  will  be  taken  at  forty- 
eight  hour  intervals  following  admission  to  the 
hospital. 

"Fecal  cultures  for  typhoidlike  organisms  will 


146 


CORNWALL  AND  CRAWFORD: 


TYPHOID  FEVER  EPIDEMIC. 


[New  York 
Medical  Journal. 


be  made  in  all  cases  of  typhoid  suspects  or  fevers 
of  unknown  origin  of  forty-eight  hours'  duration 
and  in  such  cases  of  gastrointestinal  derangement 
as  gastritis,  gastroenteritis,  diarrhea,  dysentery, 
acute  catarrhal  jaundice,  and  acute  catarrhal  cho- 
lecystitis, with  or  without  fever,  when  occurring  in 
a  command  from  which  cases  of  typhoid  fever  have 
been  reported.  If  cultures  from  any  of  the  above 
mentioned  gastrointestinal  derangements  from  nor- 
mal stools  are  negative  a  saline  purge  will  be  ad- 
ministered and  a  second  culture  will  be  made  from 
the  resulting  movement. 

"Patients  in  whose  stools  typhoid  or  typhoidlike 
organisms  have  been  discovered  will  not  be  dis- 
charged from  the  hospital  to  a  duty  status  until 
three  successive  negative  fecal  and  urine  cultures 
have  been  obtained,  the  same  to  be  taken  at  weekly 
intervals. 

"A  quantitative  Widal  reaction  will  be  deter- 
mined at  seven  day  intervals  in  each  suspected  and 
proved  case  of  typhoid  or  paratyphoid  fever." 

This  necessitated  laboratory  facilities  beyond 
those  possessed  by  the  hospital  at  that  time  so  a 
U.  S.  Army  transportable  laboratory  equipment 
was  requisitioned  and  immediately  secured  from 
the  advance  medical  supply  depot  at  Is-sur-Tille. 
A  portion  of  one  of  the  hospital  buildings  was  taken 
over  and  divided  into  four  small  rooms.  These 
were  furnished  with  water,  electricity  and  other 
equipment,  and  with  the  assistance  of  a  sergeant  of 
the  medical  department,  who  was  a  graduate  phar- 
macist, and  two  trained  technicians  assigned  from 
the  central  medical  laboratorj',  the  laboratory 
studies,  under  the  direction  of  Captain  Cornwall, 
were  commenced.  Later  this  laboratory  personnel 
was  increased  by  the  assignment  of  Captain  Craw- 
ford and  four  enlisted  men,  who  had  comprised 
the  personnel  of  the  Eighty-second  divisional  la- 
boratory. 

Before  February  i,  1919,  eleven  patients  had 
been  admitted  to  the  hospital  from  Battery  E,  321st 
Field  Artillery  with  either  clearly  marked  or  very 
suggestive  clinical  symptoms  of  typhoid  fever.  On 
February  3rd,  two  more  patients  were  admitted, 
on  the  "th  one,  on  the  9th  two,  on  the  14th  one,  and 
on  the  15th  one,  making  a  total  of  eighteen  cases 
of  clinical  typhoid  fever  from  the  same  organiza- 
tion within  a  month. 

EPIDEMIOLOGY. 

Investigation  for  the  purpose  of  ascertaining  the 
possible  source  of  the  epidemic  lead  first  to  an  in- 
quiry as  to  the  movements  of  the  organization  be- 
fore it  reached  the  area.  It  had  come  from  the 
Argonne  region  with  the  other  units  of  the  Eighty- 
second  division  and  had  arrived  in  the  tenth  area 
on  December  19,  1918.  While  in  the  Argonne 
there  had  been  a  considerable  amouftt  of  diarrhea 
among  the  members  of  the  command  but  no  cases 
of  typhoid  fever.  The  absence  of  typhoid  in  the 
other  batteries  of  the  regiment  and  in  the  other 
units  of  the  division,  together  with  the  interval  that 
elapsed  after  leaving  the  Argonne  before  the  ap- 
pearance of  the  first  case,  seemed  to  render  it  im- 
probable that  the  infection  had  been  brought  from 
there. 

r 


CIVILIAN  POPULATION. 

Battery  E  was  billeted  in  Rosoy,  a  small  French 
town  of  400  to  500  inhabitants.  The  sanitary  con- 
ditions of  the  town  were  fair  and  the  billets  as  good 
as  the  average.  According  to  information  obtained 
from  the  French  civilian  physician  there  had  been 
an  epidemic  of  typhoid  fever  in  this  town  ten 
3'ears  previously.  This  epidemic  comprised  about 
sixty  cases ;  sixteen  of  the  patients  died  and  were 
buried  on  the  hillside  overlooking  the  town.  The 
assurance  was  given  that  there  had  been  no  typhoid 
in  the  vicinity  for  at  least  two  years  but  this  infor- 
mation was  later  negatived  by  the  discovery  by 
Captain  Crawford,  during  the  first  week  in  Feb- 
ruary, of  a  case  of  clinical  typhoid  fever  in  a  young 
French  girl,  at  whose  home  a  cook  and  two  other 
men  from  Battery  E  were  billeted.  The  members 
of  the  kitchen  force  were  accustomed  to  congre- 
gate frequently  at  this  billet.  A  specimen  of  feces 
from  this  French  girl  was  sent  to  the  laboratory  at 
Camp  Hospital  Xo.  10  and  an  organism  isolated 
that,  in  its  serological  reactions,  resembled  the 
Bacillus  paratyphosus  B  from  which  it  was  concluded 
that  we  were  dealing  with  two  disease  entities  that 
had  no  immediate  relation  to  each  other.  More 
detailed  study  of  this  organism  with  different 
batches  of  diagnostic  sera  resulted  in  its  identifi- 
cation as  the  Bacillus  typhosus.  The  sugar  reac- 
tions were  confirmatory  for  typhoid  rather  than 
paratyphoid.  None  of  the  men  billeted  at  the  home 
of  this  French  girl  contracted  typhoid.  The  onset 
of  her  illness,  so  far  as  could  be  determined,  oc- 
curred about  January  20th,  which  lead  us  to  the 
conclusion  that  she  was  not  the  cause  of  the  epi- 
demic but  more  probably  contracted  the  infection 
from  the  same  source  that  the  soldiers  did  or  by 
contact. 

FOOD. 

All  of  the  food  was  prepared  at  the  same  kitchen 
and  consisted  of  issue  rations  with  the  exception 
of  milk  which  was  purchased  locally  and  presum- 
ably boiled  before  use.  although  this  was  not  con- 
firmed to  the  satisfaction  of  the  division  sanitary 
inspector.  IMany  of  the  men  admitted  that  they 
had  drunk  unboiled  milk  after  their  arrival  in  the 
area.  The  cooks  had  been  permanent  but  there 
had  been  a  shifting  kitchen  police.  French  civilians 
assisted  in  handling  the  food  when  it  was  trans- 
ferred from  the  ration  truck  to  the  kitchen.  The 
meals  were  served  from  a  low  field  range  and  it 
was  customary  to  remove  the  covers  of  the  food 
containers  and  stand  them  against  the  wall  of  an 
adjacent  stone  building  while  mess  was  served. 
The  ease  with  which  mud  could  be  spattered  upon 
these  covers  as  the  mess  line  passed  and  thence 
get  into  the  food  rendered  this  a  dangerous  pro- 
cedure that  was  immediately  remedied.  Fruits  and 
other  edibles  were  on  sale  at  the  civilian  stores  in 
the  neighborhood  and  probably  some  food  from 
these  sources  was  consumed  by  the  soldiers.  Green 
vegetables  were  not  available  at  the  market  at  this 
season  of  the  year.  Beer  and  wines,  all  of  which 
were  said  to  be  grossly  diluted  with  water,  were  on 
sale  at  several  places.  Members  of  the  kitchen 
force  admitted  having  purchased  eggs  and  chickens 


July  31,  1920.] 


CORNWALL  AND  CRAWFORD: 


TYPHOID  FEVER  EPIDEMIC. 


147 


from  outside  sources  for  their  own  consumption. 
Orders  were  issued  strictly  prohibiting  the  purchase 
or  consumption  of  food,  wine,  or  beer  from  civiHan 
sources. 

KITCHEN  AXD  L.\TRIXE. 

The  kitchen  was  located  but  a  short  distance, 
fifty  feet,  from  the  battery  latrine.  Owing  to  the 
fact  that  soldiers,  when  not  continually  under  sur- 
veillance, become  negligent  in  their  personal  habits 
as  to  the  use  of  latrines  and  the  care  of  their  hands 
after  visiting  the  latrine  this  situation  had  in  it  an 
undesirable  element  of  danger  and  consequently 
the  kitchen  was  removed  to  another  locality.  This 
made  more  remote  the  possibility  of  fecal  matter 
being  tracked  from  the  latrine  to  the  neighborhood 
of  the  low  field  range  where  it  could  be  easily  spat- 
tered into  the  food. 

WATER  SUPPLY. 

The  town  was  supplied  with  water  from  two 
sources,  both  of  w^hich  were  brought  in  pipes  from 
springs  located  some  distance  from  the  village. 
Although  the  bacteriological  examinations  of  sam- 
ples from  both  sources  did  not  show  either  to  be 
badly  contaminated  they  had  been  labeled  as  non- 
potable  and  the  men  had  been  cautioned  against 
using  any  but  chlorinated  water.  Previous  to  the 
outbreak  of  typhoid  the  water  had  been  chlorinated 
in  the  Lyster  bags  after  they  had  been  filled  from 
the  water  carts.  Men  were  observed  to  fill  their 
canteens  directly  from  the  water  carts,  hence  it 
■was  ordered  that  thereafter  the  chlorination  should 
be  done  before  the  removal  of  any  water  from  the 
carts.  A  cook  was  observed  to  dip  water  from  the 
cart  and  then  place  the  dipper  on  the  muddy 
ground.  This  was  remedied  by  having  the  dipper 
hung  at  all  times  on  the  water  cart.  A  demonstra- 
tion of  the  method  employed  for  chlorination 
showed  it  to  be  satisfactory. 

The  Lyster  bags,  which  were  the  only  source  of 
chlorinated  water,  were  located  at  the  geographical 
centre  of  the  town  and  it  was  suspected  that  men 
billeted  in  the  more  remote  sections  used  water 
from  some  of  the  more  conveniently  situated  hy- 
drants. This  was  confirmed  by  personal  interviews 
with  the  men  in  the  hospital.  Although  they  appre- 
ciated that  the  raw  water  was  unfit  for  consump- 
tion they  nevertheless  used  it  many  times  in  pref- 
erence to  the  chlorinated  water.  Two  men  ad- 
mitted that  they  habitually  drank  water  from  street 
hydrants  or  pumps  in  their  billets.  Two  others 
depended  almost  entirely  upon  beer  which,  the}"^ 
stated,  was  grossly  diluted  with  w^ater.  Three  men 
used  water  from  a  hydrant  for  cleansing  their 
teeth. 

Within  fifty  feet  from  the  kitchen  was  a  well, 
the  water  from  which  had  been  exclusively  used 
for  kitchen  purposes  from  December  19,  1918,  to 
January  I,  1919,  at  which  time  it  became  dry.  A 
few  days  later  water  reappeared  in  this  well  and  it 
was  again  used  until  the  cooks  noticed  that  it  had 
a  disagreeable  odor.  This  was  called  to  the  atten- 
tion of  the  battery  commander  about  January  7th 
and  from  that  date  he  prohibited  its  use.  The  prox- 
imity of  this  well  to  the  latrine  and  the  odor  of  the 
water  furnish  ample  proof  of  fecal  contamination. 


It  does  not  require  any  great  imagination  to  recog- 
nize the  possibility  of  a  carrier,  either  soldier  or 
civilian,  having  deposited  the  infecting  bacilli  in 
the  latrine.  This  leads  one  strongly  to  the  pre- 
sumption that  this  was  the  source  of  the  epidemic. 
Although  examinations  of  the  water  from  this  well 
were  negative  for  typhoid  bacilli  it  was  heavily 
contaminated  with  colon  bacilli,  which  is  again 
strong  presumptive  evidence  of  its  guilt.  Guards 
were  stationed  at  all  water  points  and  strict  orders 
were  issued  against  the  use  of  any  but  chlorinated 
water. 

TYPHOID  INOCULATIOX. 

.  All  members  of  the  command  had  been  inoculated 
against  typhoid  and  paratyphoid  A  and  B  from  six 
to  sixteen  months  previously.  Two  men  gave  his- 
tories of  illness  in  infancy  during  which  they  were 
confined  to  bed  for  several  weeks  but  in  all  prob- 
ability they  had  not  had  typhoid.  Aside  from  these 
two  men  there  were  none  who  had  had  typhoid  fever, 
therefore  it  was  quite  certain  that  we  did  not  have 
a  chronic  carrier  to  deal  with.  The  two  men  re- 
ferred to  were  kept  under  observation  for  a  month 
at  Camp  Hospital  Xo.  10  but  repeated  examina- 
tions of  gastric  and  duodenal  contents  and  feces 
were  negative. 

CARRIER  EXAMINATIONS. 

On  February  10,  1919,  a  systematic  examination 
of  the  feces  of  every  member  of  Battery  E  for 
organisms  of  the  typhoid  dysentery  group  was 
commenced.  A  single  examination  was  made  upon 
every  man  and,  with  the  exception  of  twenty-six 
men,  a  second  examination  was  made  of  the  whole 
battery.  This  was  deemed  necessary  as  in  the  early 
examinations,  made  for  the  purpose  of  selecting  a 
permanent  kitchen  force,  two  were  negative  on  the 
first  and  positive  on  the  second  examination,  the 
interval  being  one  week.  Three  hundred  and  six 
feces  examinations  Avere  made  for  the  purpose  of 
detecting  carriers  and,  in  addition  to  this,  the  actual 
typhoid  cases  as  well  as  every  member  of  Battery 
E,  admitted  to  Camp  Hospital  No.  10  for  any  treat- 
ment, had  from  two  to  ten  feces  examinations.  A 
total  of  390  such  examinations  were  made  on  mem- 
bers of  this  battery.  As  a  result  three  men  were 
found  with  typhoid  bacilli  in  their  feces  and  were 
sent  to  the  hospital  as  carriers.  In  one  of  them  the 
condition  was  later  diagnosed  as  mild  typhoid 
fever.  The  other  two  were  kept  under  observation 
for  over  a  month  but  subsequent  feces  examina- 
tions at  intervals  of  from  three  to  five  days  were 
negative.  Before  release  from  the  hospital  both 
of  these  men  had  seven  consecutive  negative  labora- 
tory reports. 

■  INCIDENCE. 

A  study  of  the  sick  book,  together  with  personal 
interviews  with  all  of  the  men  who  had  been  sick 
during  the  month  of  January,  revealed  some  in- 
teresting information.  It  became  apparent  imme- 
diately that  we  were  dealing  with  three  distinct 
groups  of  cases  as  indicated  by  the  dates  of  onset. 
(Table  i.)  The  first  case  was  hospitalized  on  Jan- 
uary 1 6th,  nine  days  after  he  had  first  reported  at 
sick  call  (January  7th).  This  date,  therefore,  was 
taken  to  be  the  time  of  the  onset  of  his  first  symp- 


148 


CORXIVALL  AND  CRAWFORD: 


TYPHOID  FEVER  EPIDEMIC. 


[New  York 
Medical  Journal. 


toms  and  consequently  the  beginning  of  the  epi- 
demic. 

TABLE  I. 

Showing  group  incidence  as  determined  by  dates  of  onset. 
Group  I. 


1918581 
1356770 
2228981 
404010 
1357379 
2234057 
2143735 


=5^ 
Jan .  7 
Jan .  1 2 
Jan .  14 
Jan.  16 
Jan.  17 
Jan.  17 
Jan .  20 


IS 

24 
16 
24 


26 
29 
38 
29 


II  29  38 


Death  26 
Death  29 
Death  30 
Death  29 
Death  25 
Recovery 
Recovery 


On  K.  P.  until  Jan.  15 

On  K.  P.  until  admis- 
sion 


Group  II. 


8  1357517  Jan.  27 

9  191 6614  Jan.  27 

10  1356718  Jan.  28 

11  2998785  Jan.  28 

12  1916505  Jan.  29 

13  2142582  Jan.  30 

14  1916605  Jan.  31 


Recovery 
Recovery 
Recovery 
Recovery 
Death  30 
Recovery 
Recovery 


19 


1S12542 
1918457 
1639452 
1916479 


1357136 
1356893 


Feb. 
Feb. 
Feb. 
Feb. 


Group  III. 

8    25  Recovery 

2    24  Recovery 

II    24  Recovery 

2    II  Recovery 

Carriers. 


On  K.  P.  until  admis 
sion 


Cook 


Feb.  6 
Feb.  10 


On  K.  P.  until  admission 
On  K.  P.  until  admission 


Suspected  Clinical  Cases 

21  2233966    Feb.  22      2      o      7  Recovery 

22  Feb.  25      2      o      4  Recovery 

The  interval  between  the  onset  of  the  first  and 
last  case  in  Group  I  was  thirteen  days  and  the 
intervals  between  the  onset  and  admission  to  the 
hospital  varied  from  three  to  twelve  days.  The 
high  mortality  of  this  group  suggests  two  things :  a 
massive  infection  and  a  relation  between  mortality 
and  delayed  hospitalization.  We  believe  that  both 
factors  were  concerned  in  this  instance.  We  feel 
quite  certain  that  the  well  water  was  the  source  of 
the  massive  infection.  It  had  been  used,  with  the 
exception  of  a  few  days  when  the  well  went  dry, 
from  December  19th  to  January  7th,  at  which  time 
the  odor  became  so  objectionable  that  it  was  reported 
to  the  battery  commander  and  at  this  same  time 
the  first  man,  who  was  later  diagnosed  as  having 
typhoid  fever,  reported  at  sick  call.  In  view  of  the 
interval  of  thirteen  days  between  the  onset  of  symp- 
toms in  the  first  and  last  case  in  Group  I,  it  is  not 
improbable  that  the  seven  men  were  infected  at 
different  times.  Statements  from  the  men  in  the 
hospital  substantiated  this  view.  Some  admitted 
that  they  had,  at  different  times,  washed  their  mess 
kits  in  this  well  water  and  that  they  had  drunk  it. 
On  at  least  one  occasion  it  was  reported  that  the 
cooks  had  used  water  from  this  well  to  dilute  the 
coffee.  Two  of  the  men  in  Group  I,  No.  2  and  No. 
5,  were  kitchen  police. 

The  onset  of  the  first  case  in  Group  II  was 
twenty  days  after  the  first  and  seven  days  after 
the  last  in  Group  I.  The  interval  between  the 
first  and  last  cases  in  Group  II  was  only  four  days. 
It  is  our  opinion  that  this  group  resulted  from  car- 
rier or  contact  transmission.  The  two  kitchen 
police  in  the  first  group  could  easily  have  been  the 
source  of  infection  for  the  second  group.  In  ad- 
dition to  this  nearly  all  of  the  kitchen  force  lived 
together  in  a  room  just  in  the  rear  of  the  kitchen. 
There  was  a  member  of  the  kitchen  force  in  the 


second  group  (No.  14).   Two  other  men  in  Group 

II  lived  together  and  one  man  from  Group  II  occu- 
pied a  room  with  a  man  in  Group  III. 

The  four  cases  in  Group  III  originated  within  a 
period  of  three  days,  February  7th,  8th,  and  9th, 
and  the  intervals  between  the  first  case  in  Group 

III  and  the  first  and  last  cases  in  Group  II  were 
eleven  and  seven  days  respectively. 

In  the  third  wave  the  kitchen  force  was  not 
spared.  No.  15  being  a  codk.  Directly  upon  the 
confirmation  of  the  first  typhoid  fever  case  among 
the  kitchen  personnel  (No.  2  positive  feces  Feb- 
ruary 5th)  the  entire  kitchen  force  was  reorgan- 
ized, but  on  February  9th  and  lOth,  two  men  from 
the  new  kitchen  force  (No.  19  and  No.  20)  were 
found  to  have  typhoid  bacilli  in  their  feces  and 
were  sent  to  the  hospital  for  observation.  Neither 
of  these  men  had  positive  fecal  findings  after  the 
first  examination  and  they  were  recorded  as  car- 
riers. In  the  sense  that  they  harbored  typhoid 
bacilli  in  their  intestinal  tracts  without  being  ill 
with  the  disease  they  were  unquestionably  carriers 
but  the)'  were  not  chronic  carriers.  On  the  other 
hand  we  consider  these  as  examples  of  the  failure 
to  develop  the  disease  l)ecause  of  the  immunity 
established  by  inoculation,  natural  immunity,  the 
ingestion  of  a  limited  amount  of  infectious  mate- 
rial, or  other  similar  factors.  One  of  these  so- 
called  carriers,  on  at  least  four  occasions  had  a 
slight  fever  without  any  other  symptoms,  and  we 
are  not  convinced  but  that  it  would  have  been  more 
accurate  to  classify  him  as  a  mild  case  of  typhoid 
fever. 

It  was  anticipated  that  a  fourth  group  might 
present  itself  but  such  was  not  the  case  so  far  as 
could  be  determined.  Two  cases  were  regarderl 
with  suspicion  and  carefully  observed  (No.  21  and 
No.  22),  but  it  was  not  possible  to  establish  a 
diagnosis  of  typhoid  fever  in  either  instance.  Al- 
though the  agglutinin  content  of  their  sera  was  high 
and  one  (No.  22)  had  a  positive  complement  fixa- 
tion with  typhoid  antigen,  these  findings  had  a 
limited  significance  because  both  men  were  inocu- 
lated with  French  triple  tvphoid  lipovaccine  on  Jan- 
uary 31,  1919. 

After  the  recognition  of  the  first  cases  as  typhoid 
fever  a  careful  watch  was  kept  of  the  temperature 
of  each  member  of  the  battery  and  notes  were  made 
of  the  symptoms  complained  of  by  those  reporting 
at  sick  call.  The  following  were  the  complaints  in 
the  order  of  their  f  requeue}- :  Headache,  eight : 
weakness  or  malaise,  eight ;  anorexia,  seven ;  fever, 
six ;  generalized  pains,  six ;  constipation,  five ;  chills, 
one,  and  diarrhea,  one. 

Further  study  of  the  sick  book  revealed  the  fact 
that  at  the  time  that  the  typhoid  cases  were  taken 
sick,  there  was  a  coincident  increase  in  the  total 
sick  of  this  organization.  Chart  I  illustrates  this 
graphically.  This  suggests  that  some  of  these  men 
may  have  had  mild  attacks  of  typhoid  fever,  per- 
haps modified  by  their  previous  inoculations,  the 
symptoms  not  having  been  considered  severe 
enough  to  cause  them  to  be  hospitalized. 

Although  there  may  be  a  reasonable  doubt  as  to 
the  source  of  this  epidemic  we  believe  that  the 
evidence  points  strongly  to  the  well  as  the  primary 


July  31,  1920.] 


CORXU  ALL  AXD  CRAU  FORD: 


TYPHOID  FEVER  EPIDEMIC. 


149 


source  of  infection.  The  two  most  probable  meth- 
ods of  transmission  were :  food  contamination  and 
contact.  Members  of  the  kitchen  force  might  have 
been  passing  off  typhoid  bacilli  for  days  without 
detection  had  it  not  been  for  the  routine  daily 
record  of  temperatures.  By  this  means  four  men 
were  discovered  in  the  beginning  of  the  disease 
that  otherwise  would  have  not  been  hospitalized 
until  several  days  later.  A  circumstance  that  mili- 
tated against  the  early  discovery  of  any  of  the 
cases  from  subjective  complaints  was  the  fact  that 
it  was  generallv  known  that  the  division  was  sched- 
uled for  early  return  to  the  United  States  and  for 
fear  of  being  left  behind  in  a  hospital,  the  men 
would  not  report  at  sick  call  unless  the^■  were  verv 
ill. 

CASES. 

The  following  cases  are  briefiv  related  in  order 
to  emphasize  some  features  of  clinical  interest : 

Case  L— (11)  Private  Battery  E.  321  F.  A.  Ad- 
mitted Februar\-  i.  19 rp,  complaining  of  headache, 
cliillv  sensations,  pains  in  back  and  legs,  vomiting 


at  sick  call  and  said  that  he  felt  feverish  and  had 
experienced  some  abdominal  discomfort.  The  ex- 
amination by  the  battalion  surgeon  revealed  no 
cause  and  he  received  symptomatic  treatment.  His 
name  appeared  on  the  sick  book  again  on  Febru- 
ary 3rd  and  5th  but  no  record  was  made  of  his 
complaints.  He  did  not  report  sick  again  but  on 
February  8th  he  was  discovered  with  a  tempera- 
ture of  99.2°  F.  On  the  following  morning  it  was 
normal  but  in  the  afternoon  was  100°.  On  Febru- 
ary loth  and  nth  there  was  no  fever.  On  Febru- 
ar\-  1 2th  he  was  sent  by  his  battalion  surgeon  to 
the  regimental  dental  surgeon  for  an  opinion  re- 
garding the  presence  of  pyorrhea  alveolaris  suffi- 
cient to  account  for  the  intermittent  fever.  On 
February  14th.  his  temperature  suddenly  rose  to 
102°  and  on  the  following  day  he  was  sent  to  the 
hospital.  On  admission  he  complained  only  of 
slight  malaise  and  poor  appetite.  The  spleen  was 
palpable.  On  the  third,  fourth  and  twelfth  days 
there  was  abdominal  pain.. sharp  and  severe  on  the 
twelfth  day.    Four  days  after  admission  a  crop  of 


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Chart  I. — Showing  the  incie;ise  in  the  number  of  sick  in  Battery  £,  321st  Field  Artillery,  coincident  with  the  onset  of  the  group 
of  typhoid  fever  cases.     Light  line  represents  total  sick  lor  the  organization  exclusive  of  typhoid  fever  cases;   heavy  line  represents  the 

typhoid  fever  cases. 


and  nose  bleed.  Onset  January  28.  1919.  The 
diagnosis  of  influenza  was  made.  There  were  no 
objective  symptoms  of  typhoid  fever  but  on  the  thir- 
teenth day  the  Bacillus  typhosus  was  isolated  from 
the  feces.  The  temperature  was  between  102°  and 
103^  F.  for  the  first  two  days  after  admission,  then 
99°  to  101°  F.  for  fourteen  days  when  it  dropped 
by  lysis  to  normal.  The  pulse  averaged  80  and  the 
respiration  20.  There  was  no  malaise.  On  the 
eighteenth  day  al)dominal  pain  was  complained  of 
Xo  rose  spots  were  noted  at  any  time  but  on  the 
eighteenth  day  the  spleen  was  palpable.  No  blood 
culture  was  made.  The  diagnosis  was  based  on  a 
positive  feces,  a  positive  typhoid  complement  fixa- 
tion, and  a  rise  in  the  agglutination  titre  of  the 
serum  for  typhoid  bacilli.  Inoculated  with  U.  S. 
triple  typhoid  vaccine  July  20,  1918.  Febrile 
period  twenty  davs. 

Case  H.— (12)  Corporal  Battery  E,  321  F.  A. 
.\dmitted  February  15.  1919,  complaining  of  nothing 
but  slight  malaise  and  poor  appetite.  Onset  Janu- 
ary 29,  1919,  at  which  time  the  patient  reported 


rose  spots  appeared.  On  the  fifth  day  there  was 
vomiting.  The  blood  and  feces  were  positive  on 
the  day  after  admission.  The  urine  was  cultural!}' 
negative  but  gave  a  positive  diazo  reaction.  The 
typhoid  complement  fixation  was  positive  and  the 
agglutination  titre  of  the  serum  high.  Both  of 
these  serological  findings,  however,  would  have 
been  insufticient  for  a  positive  laboratory  diagnosis 
in  the  absence  of  the  positive  bacteriological  results 
as  the  patient  had  been  inoculated  with  French 
triple  typhoid  lipovaccine  on  January  31.  1919. 
The  temperature  averaged  101°  to  104°,  the  pulse 
90  to  100  and  the  respiration  24.  On  the  twelfth 
day  there  was  sharp,  severe  abdominal  pain  with 
some  abdominal  rigidity  and  tenderness.  The  tem- 
perature dropped  from  104°  to  normal,  the  pulse 
became  rapid  and  thready,  134  a  minute,  and  the 
respiration  went  up  to  50.  On  the  thirteenth  day 
after  admission  the  patient  died  as  the  result  of 
perforation.  The  probable  period  of  illness  was 
thirty  days,  hospitalization  being  aftected  on  the 
seventeenth  day. 


150 


HART:  ADMIXISTRATIOX  OF  DIGITALIS. 


[New  York 
Medical  Journal. 


Case  III. —  (14)  Private  Battery  E  321  F.  A.  Ad- 
mitted Februar)^  3,  1919,  complaining  of  headache, 
constipation  and  poor  appetite.  Onset  January  31, 
1 91 9,  and  attributed  to  exposure  after  a  long  rail- 
road journey.  The  patient  had  been  a  permanent 
member  of  the  kitchen  police.  Constipation  was 
present  for  the  first  three  days,  on  the  fourth  day 
some  abdominal  pain  was  complained  of  and  on 
the  fifth  day  there  was  diarrhea.  A  crop  of  rose 
spots  appeared  seven  days  after  admission  and  the 
spleen  was  palpable  on  the  twelfth  day.  On  the  eight- 
eenth day  signs  of  bronchopneumonia  were  noted. 
The  temperature  ranged  from  99°  to  101°,  the  pulse 
from  70  to  80,  and  the  respiration  from  18  to  20. 
Blood,  feces  and  urine  cultures  were  negative. 
There  was  a  positive  typhoid  complement  fixation 
and  a  moderate  rise  in  the  agglutination  titre  of 
the  serum  but  the  significance  of  these  findings  was 
relatively  slight  because  of  inoculation  on  January 
31,  1919,  with  French  triple  typhoid  lipovaccine. 
The  febrile  period  was  thirty-four  days  ending  by 
lysis.  The  diagnosis  w&s  based  on  clinical  obser- 
vations but  not  confirmed  by  the  laboratory. 
(To  be  concluded.) 


THE  ADMIX! STR.-\TIOX  OF  DIGITALIS.* 

'  By  T.  Stuart  Hart,  M.  D., 

New  York, 
Visiting  Physician  to  the  Presbj-terian'^Hospital. 

Digitalis  is  a  real  drug.  It  is  worth  thinking 
about,  worth  talking  about  and  worth  using  prop- 
erly. Digitalis  will  relieve  suflFering.  It  will  make 
efficient  and  prolong  the  activity  of  man)'  a  dam- 
aged heart ;  often  it  actually  saves  life.  Also,  be- 
cause it  is  a  real  drug  it  has  its  dangers.  ^lany  a 
man  with  a  diseased  heart  does  not  need  it.  In 
a  considerable  number  its  administration  is  dis- 
tinctly detrimental.  I  have  seen  more  than  one 
case  in  which  I  am  quite  sure  it  actually  shortened 
life. 

I  shall  not  spend  time  in  discussing  at  length  the 
indications  and  contraindications  for  the  adminis- 
tration of  digitalis.  There  are  certain  groups  of 
cardiac  cases  in  which  its  use  is  positively  indi- 
cated; there  are  others  in  which  it  is  just  as  cer- 
tainly contraindicated,  and  there  is  a  very  large 
group  in  which,  in  the  present  stage  of  our  knowl- 
edge, it  is  impossible  to  make  a  dogmatic  state- 
ment, and  our  only  recourse  is  to  try  digitalis  in 
effective  doses  under  close  observation  and  watch 
for  its  effects.  It  seems  to  me  that  one  of  the 
promising  fields  for  study  for  the  individual  mem- 
bers and  for  groups  in  this  Association  of  Car- 
diac Clinics,  composed  of  men  who  are  every  day 
seeing  so  many  patients  suffering  from  disordered 
circulation  of  all  types,  would  be  to  study  the  effect 
of  digitalis  on  these  large  groups  in  which  our 
knowledge  is  so  inadequate,  to  tabulate  the  results 
obtained  with  all  the  evidence,  and  attempt  to  formu- 
late further  rules  for  the  use  of  this  drug.  We 
might  thus  make  some  advance  and  a  real  contri- 
butiota  to  our  knowledge  of  this  important  subject. 

•■Read  before  the  Association  of  Cardiac  Clinics  May  11,  1920. 


It  seems  to  me  that  there  are  just  two  satisfac- 
tory methods  of  administering  digitalis,  by  mouth 
and  intravenously.  Personally  I  never  use  digitalis 
subcutaneously.  The  active  glucosides  have  a  very 
irritating  effect  on  the  soft  tissues  and  invariably 
when  given  subcutaneously,  produce  an  area  of  ten- 
derness and  redness  which  may  be  very  sore  and 
cause  the  patient  a  great  deal  of  unnecessary  dis- 
comfort. When  I  meet  one  of  my  physician 
friends  who  is  using  digitalis  subcutaneously,  I  al- 
ways ask  him  whether  it  does  not  produce  this 
reaction ;  frequently  he  will  reply  that  he  has  found 
a  new  preparation  which  he  is  now  using  subcu- 
taneously and  which  causes  no  subsequent  discom- 
fort. In  my  experience  this  means  just  one  thing, 
he  is  using  atn  inactive  preparation.  When  a  subcu- 
taneous injection  of  digitalis  gives  satisfactory  re- 
sults it  also  produces  local  irritation,  when  there  is 
no  local  irritation  I  have  failed  to  obtain  a  physio- 
logical effect.  The  local  effect  of  the  subcutaneous 
administration  is  in  a  wa\-  the  measure  of  the  po- 
tency of  the  particular  preparation.  We  have  a 
number  of  preparations  which  are  suitable  and  con- 
venient for  intravenous  use,  the  method  is  simple, 
it  is  the  quickest  and  surest  way  to  obtain  physio- 
logical results  and  it  causes  no  local  irritation.  It 
is  obvious  that  comparatively  few  patients  are  in 
such  an  urgent  condition  that  the  intravenous  route 
is  necessary  or  advisable;  most  of  our  digitalis  will 
be  given  by  mouth. 

At  the  risk  of  stating  what  today  should  be  obvi- 
ous to  every  physician  I  want  to  speak  a  word  in 
regard  to  the  dose  of  digitalis.  It  must  be  given 
in  quantities  sufficient  to  produce  physiological  ef- 
fects. It  is  distressing  to  me  to  see  how  frequently 
today  one  meets  physicians  of  large  experience  and 
who  are  in  most  respects  skillful  practitioners,  who 
seem  to  have  no  conception  of  the  amount  of  digi- 
talis which  should  be  administered.  They  tell  you 
that  they  have  tried  digitalis  and  can  get  no  satis- 
factory results.  On  inquiry  one  often  finds  that 
the}'  are  administering  an  inadequate  quantity  of 
a  good  preparation  or  that  they  are  giving  consid- 
erable quantities  of  a  preparation  which  has  little 
real  activity.  It  is  often  extremely  difficult  to  get 
physicians  to  give  digitalis  in  effective  quantities 
and  to  persuade  patients  who  need  it  to  take  it 
continuous!}'.  There  are  all  sorts  of  traditions  in 
regard  to  digitalis  which  seem  to  die  hard.  For 
example,  I  am  frequently  told  by  patients  and  physi- 
cians too  that  digitalis  may  be  all  right  while  the 
patient  is  in  bed  or  sitting  in  a  chair,  but  tliey  fear 
disaster  if  he  takes  it  when  walking  about.  I  need 
not  comment  on  this  point  of  view.  Another  much 
dreaded  attribute  of  digitalis  is  that  it  unduly  raises 
blood  pressure.  In  some  cases  with  broken  compen- 
sation the  effect  of  the  administration  of  digitalis  is 
certainly  to  raise  blood  pressure.  One  sees  this  fre- 
quently in  cases  of  auricular  fibrillation  with  low 
pressure,  and  in  certain  cases  of  hypertension  with 
hearts  unable  to  maintain  tlie  pressure  which  is 
adequate  for  the  individual  needs  of  the  patient, 
in  both  of  these  groups  the  blood  pressure  rises 
as  the  patient  improves.  I  believe  that  the  favora- 
ble results  are  obtained  in  these  patients  by  a  direct 


July  31,  1920.] 


HART:  ADMINISTRATION  OF  DIGITALIS. 


151 


action  of  the  digitalis  on  the  heart  muscle  and  not 
by  a  contraction  of  the  peripheral  blood  vessels.  In 
hypertension  without  decompensation  I  have  re- 
peatedly administered  full  doses  of  digitalis  with- 
out perceptibly  affecting  the  blood  pressure. 

One  of  the  most  difficult  notions  to  combat  is 
the  idea  that  even  tiie  smallest  doses  of  digitalis 
produce  nausea.  I  believe  there  is  an  occasional 
patient  who  has  an  idiosyncrasy  to  digitalis  in  whom 
the  vomiting  centre  is  exceedingly  sensitive  to  the 
drug.  These  are  so  rarely  seen  and  so  inconsidera- 
ble in  number  that  they  need*scarcely  be  considered, 
and  yet  it  sometimes  seems  to  me  that  nurses  and 
physicians  vie  with  one  another  in  their  efforts  to 
impress  upon  the  patient  that  nausea  is  one  of  the 
early  toxic  symptoms  of  digitalis,  then  when  a  pa- 
tient has  nausea  from  the  force  of  suggestion  or 
from  some  other  cause  bearing  no  relation  to  the 
administration  of  the  drug,  the  physician  at  once 
orders  it  discontinued  or  more  often  the  pacient 
refuses  to  take  it.  A  patient  in  whose  mind  this 
idea  has  been  thoroughly  implanted  is  sometimes 
extremely  difficult  to  convince  that  the  digitalis 
which  he  regards  as  his  eneni}-  is  really  his  best 
friend.  I  very  rarely  see  nausea  which  is  caused 
by  too  much  digitalis.  Far  more  frequent  is  it  to 
meet  with  nausea  due  to  chronic  passive  conges- 
tion of  the  digestive  viscera  which  the  proper  ad- 
ministration of  digitalis  will  entirely  abolish. 

Through  the  careful  studies  of  Eggleston  and 
others  we  are  now  able  to  calculate  approximately 
the  total  amount  of  a  digitalis  preparation  of  known 
strength  which  it  will  be  necessary  to  administer  to 
obtain  complete  cardiac  digitalization.  Such  a  calcu- 
lation permits  us  to  produce  complete  digitalization 
much  more  rapidly  than  before  these  formuke  had 
been  worked  out.  The  method  advocated  by  Eggle- 
ston is  to  give  at  once  half  of  the  amount  calcu- 
lated as  necessary  to  produce  complete  digitaliza- 
tion, six  hours  later  there  is  given  an  amount  equal 
to  half  of  the  initial  dose  and  at  two  subsequent 
six  hour  intervals  a  dose  half  of  the  second  dose. 
By  this  plan  of  administration  full  effects  can  be 
obtained  in  a  majority  of  instances  in  from  twelve 
to  thirty-six  hours. 

I  have  found  that  when  digitalis  is  administered 
in  these  amounts  one  may  not  infrequently  exceed 
the  dose  desired  and  to  say  the  least  may  make  a 
considerable  number  of  his  patients  quite  uncomfort- 
able. There  is  rarely  the  necessity  of  thus  hasten- 
ing the  production  of  full  effects,  and  except  in 
the  exceptional  case  1  feel  that  the  slower  method 
of  administration  is  much  to  be  preferred.  If  the 
Eggleston  method  is  to  be  used  certain  precautions 
must  be  borne  in  mind.  In  calculating  the  dose 
due  allowance  must  be  made  for  fluid  in  the  subcu- 
taneous tissues.  One  must  be  sure  that  the  patient 
has  not  been  recently  taking  digitalis,  and  to  quote 
Eggleston's  own  words,  "the  use  of  such  large  doses 
...  is  not  a  safe  procedure  unless  the  patient 
can  be  under  nearly  constant  observation  and  un- 
less the  effects  of  the  treatment  can  be  graphically 
recorded  at  frequent  intervals." 

After  a  heart  is  thoroughly  digitalized  and  one 
has  found  out  just  the  amount  of  a  given  prepa- 


ration which  is  necessary  to  keep  it  under  proper 
control,  intervals  of  administration  are  of  very 
slight  importance,  if  a  man  needs  twenty  minims  of 
a  certain  tincture  of  digitalis  each  twenty-four  hours 
it  makes  no  difference,  except  as  a  matter  of  con- 
venience, whether  he  gets  a  single  dose  of  twenty 
minims  a  day  or  ten  doses  of  two  minims  each. 
There  is  one  factor  in  the  administration  of  fluid 
preparations  which,  while  seemingly  trivial,  is  of 
considerable  practical  importance,  and  that  is  the 
exact  measurement  of  the  dose.  On  account  of  the 
inaccuracy  of  the  medicine  dropper  patients  should 
invariably  be  instructed  to  use  a  minim  glass,  even 
thus  administered  a  considerable  variation  may  oc- 
cur, and  for  this  reason  I  feel  that,  the  solid  stand- 
ardized preparations  put  up  in  tablets  or  in  capsules 
permit  of  a  more  precise  dose.  The  uneven  or 
jerky  administration  is  to  be  avoided  as  far  as 
possible ;  one  can  most  plainly  see  the  undesirable 
effects  of  such  a  procedure  in  cases  of  auricular 
fibrillation  where  the  heart  rate  is  a  fair  indicator 
of  the  degree  of  digitalization.  The  drug  is  com- 
menced with  doses  of  considerable  size,  the  heart 
rate  begins  to  fall,  and  after  a  few  days  perhaps 
reaches  a  rate  of  sixty,  then  digitalis  is  stopped; 
none  is  given  for  a  few  days  and  the  rate  rises  to 
one  hundred ;  then  considerable  doses  are  again 
given  and  the  rate  again  drops  to  sixt}'  and  the 
drug  is  again  discontinued.  A  better  way  is  to 
allow  the  rate  to  reach  sixty,  then  discontinue  the 
drug  for  twenty-four  hours,  and  begin  again  with 
a  small  daily  dose.  If  it  appears  that  this  dose  is 
insufficient  to  hold  the  heart  at  the  desired  rate 
the  daily  dose  is  slightly  increased  until  we  find 
the  exact  dose  which  keeps  the  heart  at  its  most 
efficient  level ;  by  this  method  the  heart  is  much 
better  controlled  and  a  great  deal  of  time  is  saved. 

It  is  well  known  that  in  a  large  number  of  car- 
diac conditions  we  have  no  such  simple  guide  to 
the  degree  of  digitalization  as  is  furnished  by  the 
heart  rate  in  auricular  fibrillation.  It  is  true  that 
such  evidence  is  furnished  by  the  electrocardiograph, 
Ijut  few  of  us  have  the  opportunity  to  follow  the 
routine  of  our  cases  by  this  method.  It  would, 
therefore,  be  greatly  to  our  advantage  if  we  were 
able  to  use  preparations  which  were  carefully  stand- 
ardized so  that  when  we  had  given  a  definite  amount 
of  one  of  these  preparations  we  would  be  morally 
sure  that  we  had  secured  effective  digitalization. 

It  appears  to  me  that  it  would  be  a  very  valuable 
function  for  the  Association  of  Cardiac  Clinics 
to  assume  the  oversight  of  the  standardization  of 
preparations  of  digitalis,  and  I  would  like  to  present 
this  thought  for  your  consideration.  This  could 
be  accomplished  by  appointing  a  committee  from 
among  the  many  distinguished  members  of  the  as- 
sociation who  could,  in  the  first  place,  formulate 
standards  and  later  could  supervise  the  examina- 
tion of  preparations  on  the  market  much  in  the 
same  manner  that  the  ^Nlilk  Commission  of  the 
Covmty  Medical  Society  supervises  the  milk  sup- 
ply. I  should  like"  to  see  marked  authoritatively 
on  every  bottle  containing  digitalis  the  amount  in 
cubic  centimetres  or  grams  to  the  kilo  of  body 
weight  which  should  effect  complete  digitalization. 


152 


HOOD :  HYPliRTEKSION. 


[New  York 
Medical  Journal. 


The  aggregate  amount  of  digitalis  used  by  the 
members  of  the  association  must  be  very  great.  I 
think  we  should  soon  find  that  a  number  of  manu- 
facturers would  be  willing  to  submit  their  digitalis 
preparations  to  a  committee  of  this  association  for 
standardization  and  would  gladly  defray  the  ex- 
pense of  the  necessary  biological  tests  for  the  sake 
of  a  suitable  endorsement  of  their  products  by  this 
association. 

160  West  Fiftv-xinth  Street. 


HYPERTENSION  AND  ARTERIAL 
FIBROSIS. 
A  Preliminary  Report. 

By  C.  T.  Hood,  M.  D., 
Chicago, 

Consulting  Physician,  Cook  County  Hospital. 

There  are  several  reasons  for  this  preliminary 
report.  First,  there  still  remain  some  unsolved 
problems,  if  the  hypothesis  is  to  be  proved  beyond 
dispute,  and  it  is  with  the  hope  that  others  who 
are  interested  in  research  work  will  take  up  this 
problem,  and  under  better  conditions  and  surround- 
ings complete  the  findings.  Second,  clinical  evi- 
dence, to  be  of  value,  in  hypertension  and  arterial 
fibrosis,  must  extend  over  years  of  time,  and  the 
writer  trusts  that  many  of  his  colleagues  will  thor- 
oughly test  the  clinical  facts  related  in  this  paper, 
and  report  their  results.  Third,  at  the  present  time, 
the  profession  has  practically  nothing  to  ofifer  to  in- 
dividuals suffering  from  hypertension  and  arterial 
fibrosis.  Fourth,  and  most  important,  the  clinical 
results  warrant  this  preliminary  report.  The  details 
of  the  experimental  work  covering  now  more  than 
five  years  will  be  reported  at  another  time. 

Perhaps  it  may  seem  to  the  reader  that  the  sub- 
ject is  too  broad  and  covers  too  much  ground,  to  be 
considered  at  one  time,  but  I  believe  that  the  stereo- 
typed methods  of  considering  hypertension  and  ar- 
terial fibrosis,  each  as  an  entity,  is  responsible  for 
much  of  the  present  poor  conception  of  these  con- 
ditions, and  the  present  uncertainty  of  their  treat- 
ment. 

Hypertension  and  arterial  fibrosis  are  no  re- 
specter of  persons.  They  are  found  in  the  rich, 
the  poor,  the  middle  class  and  in  the  alcoholic ;  and 
yet,  many  old  bums  whose  bodies  have  been 
pickled  in  alcohol  almost  from  boyhood,  have  neither 
of  them.  One  man,  whose  business  requires  intense 
mental  attention,  has  both.  In  another  person,  under 
the  same  conditions,  they  never  develop.  Many 
of  the  women  of  the  street  go  free,  while  in  the 
woman  of  the  home,  under  the  most  favorable  con- 
ditions possible,  they  develop.  One  man  is  habitually 
constipated  and  has  been  all  his  life,  and  never 
presents  one  positive  finding.  Another  succumbs  to 
them.  In  other  words,  so  far  as  we  know,  we  have 
no  definite  data  as  to  the  etiology  of  hypertension 
and  arterial  fibrosis.  Therefore,  if  he  who  causes 
two  blades  of  grass  to  grow  where  only  one  grew 
can  be  called  a  philanthropist,  then  if  we  can 
throw  but  a  passing  shadow  across  the  path  of  this 
condition,  which  is  taking  a  greater  death  toll  than 


any  other  disease,  not  excluding  tuberculosis  and 
I)neumonia,  if  we  can  but  hold  the  light,  while  some 
ray  penetrates  these  obscure  conditions,  we  will 
have  done  all  we  hope  to  do. 

In  presenting  this  paper  to  the  profession,  we 
are  well  aware  that  we  are  laying  ourselves  open 
to  severe  criticism,  but  thirty-five  years  of  active, 
intensive  study  and  practice  have  made  us  immune 
to  criticism,  and  knowing  that  we  have  obtained  re- 
sults, and  that  others  are  obtaining  results,  work- 
ing along  the  same  lines,  prompts  us  to  present 
the  results  of  these  ye^rs  of  intensive  study  to  the 
profession.  In  a  way  the  hypothesis'  to  be  pre- 
•sented  is  not  new  to  the  profession,  yet,  the  work- 
ing out  of  the  pathology  is.  With  the  exception  of 
the  cancer  problem,  hypertension  and  arterial  fibro- 
sis are  two  of  the  greatest  unsolved  medical  prob- 
lems of  the  day. 

We  must  ask  the  reader's  indulgence,  while  we 
recapitulate  some  well  known  facts  which  are 
necessary,  in  order  that  we  may  understand  the 
subject  under  consideration.  I  believe  that  there 
are  five  types  of  hypertension : 

PHYSIOLOGICAL  HYPERTENSION. 

In  this  type,  the  individual  in  whom  it  is  found 
is  from  sixty  to  seventy-five  years  of  age.  The  sys- 
tolic pressure  is  170  to  190,  or  even  200,  with  some 
increase  in  the  diastolic  pressure  above  the  normal. 
The  left  ventricle  is  enlarged  to  some  extent,  and 
the  aortic  second  sound  somewhat  snappy,  the  urine, 
while  of  comparatively  low  gravity  and  may  at 
times  contain  a  trace  or  a  considerable  quantity  of 
albumin  and  a  few  casts,  yet,  the  specific  gravity 
is  not  fixed,  and  the  night  urine  is  of  small  volume. 
In  this  type  of  hypertension,  the  increase  in  the  sys- 
tolic pressure  is  due  to  the  wrinkling  of  the  skin, 
the  contraction  of  the  liver,  kidneys  and  spleen, 
the  result  of  age.  This  contraction  necessarily 
obliterates  an  extensive  amount  of  the  capillaries. 
Therefore,  if  the  circulatory  balance  is  to  be  main- 
tained, and  the  increased  capillary  resistance  over- 
come, hypertension  must  result.  This  increased 
capillary  resistance  is  of  gradual  onset.  For  some 
time,  years  perhaps,  the  left  ventricle  is  able  to 
maintain  the  increased  pressure  necessary  to  keep 
up  a  normal  circulation,  but  by  degrees,  the  back- 
pressure from  the  capillaries  causes  some  thick- 
ening of  the  arterial  walls,  not  a  true  arterial  fibro- 
sis, but  sufficient  thickening  to  enable  the  left 
ventricle  to  maintain  the  required  hypertension. 
In  this  type  of  cases,  the  individual  presents  none 
or  but  few  of  the  clinical  symptoms  of  arterial 
fibrosis.  They  are  able  to  go  about  their  life,  and 
while  not  performing  a  full  day's  work,  are  capable 
of  doing  from  a  half  to  two  thirds  of  a  day's  work, 
and  as  a  rule,  are  rested  in  the  morning.  They 
rarely  die  of  heart  failure,  but  as  a  rule,  from 
some  acute  infection,  to  which  they  are  more  sus- 
ceptible, owing  to  their  lowered  resistance. 

We  wish  it  to  be  understood  that  we  are  not  con- 
sidering true  atheroma,  for  true  atheroma  is  a  much 
more  rare  condition  than  was  formerly  supposed, 
and  than  the  laity  understand  when  they  speak  of 
liardening  of  the  arteries,  but  in  true  atheroma,  the 
hypertension  which  is  present  is  a  necessary  physio- 
logical process  to  maintain  a  normal  circulation. 


July  31.  1920.] 


HOOD:  HYPERTENSION. 


153 


IIYPERTEXSIOX    IX    THE  YOUNG. 

The  second  type  of  hypertension  is  that  type 
found  in  comparatively  yotmg  people,  from  thirty- 
five  to  forty-five  year.s"  of  age.  The  systolic  pres- 
sure is  from  160  to  190,  with  some  increase  in  the 
diastolic  pressure,  the  left  ventricular  impulse, 
while  somewhat  increased  in  its  muscular  action, 
has  not,  as  yet,  hypertrophied,  the  urine  is  increased 
in  amount.  It  may  contain  casts  or  even  a  plain 
trace  of  al1)umin,  but  the  specific  gravity  is  good, 
and  the  night  urine,  if  there  is  any  at  all,  is  small 
in  amount.  The  secretion  of  urea  may  be  somewhat 
l)elow  the  normal,  but  the  secretion  of  chlorides  is 
low. 

ARTERIAL  FIBRO.SIS. 

The  third  type  of  hypertension  is  due  to  true 
arterial  fibrosis,  and  is  not  due  to  a  physiological 
process,  not  due  to  atheroma,  and  not  the  result 
of  chronic  nephritis  or  hyperthyroidism,  btit  the 
condition  begins  by  an  increased  resistance  in  the 
capillaries,  that  ultimately  results  in  left  ventricular 
hypertrophy  and  arterial  fibro.sis.  The  pathological 
condition  found  in  this  type,  we  shall  consider  later. 
These  individuals  are  from  thirty-five  to  fifty-five, 
or  may  even  be  sixty  years  of  age.  The  sy.stolic 
pressure  is  from  175  upward,  with  a  marked  in- 
crease in  the  diastolic  pressure. 

CHRONIC  NEPHRITIS. 

The  fourth  type  of  hypertension  is  the  result  of 
chronic  nephritis.  Here,  the  hypertension  is  due 
to  the  increased  resistance  in  the  kidney.  The  left 
ventricle  hypertrophies  to  meet  this  increased  resist- 
ance, and  the  l)ack  pressure  from  the  kidney  re- 
sults in  actual  arterial  fibrosis,  with  more  hyper- 
trophy of  the  left  ventricle,  dilatation  and  rough- 
ening of  the  aortic  arch,  and  a  systolic  murmur  at 
the  base,  a  snappy  aortic  second  sound.  If  the  left 
ventricular  hypertrophy  becomes  extensive,  or  if 
from  nutritional  changes,  the  left  ventricular  walls 
stretch  the  mitral  opening,  a  mitral  systolic  murmur 
will  be  found.  The  urinary  findings  are  those  of  a 
chronic  nephritis,  or,  more  properly,  a  chronic 
inter-stitial  nephritis.  They  are  a  low  fixed  specific 
gravity,  a  trace  of  albumin  up  to  one  per  cent.,  casts, 
both  hyaline  granular  and  sometimes  epithelial. 
If  the  chronic  nephritis  is  the  result  of  an  acute 
and  subacute  glomerular  nephritis,  fatty  casts  or 
fatty  globules  will  be  found.  The  volume  of  the 
night  urine  is  equal  to  or  greater  than  the  day 
urine.    The  Urea  is  low,  as  well  as  the  chlorides. 

HYPERTHYROIDISM. 

The  fifth  type  of  hypertension  is  due  to  hyper- 
thyroidism, which  is  never  extensive,  and  never 
causes  death,  and  is  due  to  the  thyrotoxicosis,  which 
])roduces  a  spasm  of  the  arterial  walls,  but  never 
true  arterial  fibrosis. 

In  order  that  we  may  have  an  intelligent  concep- 
tion of  the  subject,  we  must  understand  the  factors 
concerned  in  the  production  of  normal  blood  pres- 
sure, and  how  these  factors  may  be  influenced.  We 
believe  that  we  are  absolutely  correct,  when  we  say 
that  it  is  the  heart  muscle  which  maintains  the 
normal  systolic  blood  pressure,  and  that  it 
is    the    resistance    of    the    coats    of    the  ar- 


teries, supplemented  by  the  capillary  resist- 
ance, that  produces  the  diastolic  blood  pres- 
sure. The  factors  then  concerned  in  the  production 
of  normal  blood  pres.sure  are,  first,  the  contraction 
of  the  heart;  second,  the  volume  of  blood  in  the 
body ;  third,  the  resi.stance  offered  by  the  coats  of 
the  arteries ;  fourth,  the  capillary  resistance. 

That  the  contraction  of  the  heart  muscle  is  the 
first  and  most  important  factor  in  the  production 
of  the  systolic  blood  pres.sure  is  selfevident.  That 
the  volume  of  blood  plays  an  important  part  in  the 
ability  of  the  heart  muscle  to  maintain  the  systolic 
blood  pressure  is  easily  understood.  Much  has  been 
written,  regarding  the  velocity  of  the  blood  stream, 
in  maintaining  the  systolic  blood  pressure.  The 
velocity  of  the  blood  stream  depends  upon  three 
factors ;  first,  the  size  of  the  stream  of  blood,  which 
is  governed  by  the  size  of  the  arteries ;  second,  the 
contraction  of  the  muscular  coats  of  the  arteries, 
and,  third,  the  force  of  the  contraction  of  the 
heart  muscle.  With  these  facts  in  mind,  I  am  un- 
able to  see  how  the  velocity  of  the  blood  stream 
can  present  any  factors  in  the  production  of  blood 
pressure  not  already  considered. 

The  resistance  offered  by  the  muscular  coats  of 
the  arteries  must  influence  the  contraction  of  the  left 
ventricle,  for  if  the  contraction  of  the  left  ventricle 
is  to  empty  its  contents  into  the  aorta,  it  must  first 
overcome  the  weight  of  the  volume  of  blood  in 
the  aorta,  and  the  resistance  offered  by  the  muscular 
coats  of  the  aorta,  and  the  resistance  of  the  blood 
stream  ahead  of  the  aorta.  But  why  is  it  neces- 
sary that  in  the  normal  person,  the  heart  muscle 
must  overcome  a  resistance  equal  to  from  120  to 
140  mm.  of  mercury?  Surely  it  is  not  to  over- 
come the  weight  of  blood  in  the  aorta  and  the  re- 
sistance in  the  muscular  coats  of  the  aorta.  No,  the 
resistance  offered  by  the  blood  in  the  aorta  and  the 
coats  of  the  aorta  is  due  to  the  back  pressure  of  the 
blood  stream  ahead  of  the  aorta.  To  what  is  this 
back  pressure  due?  First,  to  capillary  resistance; 
second,  to  the  coats  of  the  arteries.  As  is  well  known, 
the  function  of  the  mucular  coats  of  the  arteries  is 
to  change  the  interrupted  flow  of  blood  in  the  ar- 
teries into  a  continuous  flow  in  the  capillaries.  In 
other  words,  that  the  flow  of  blood  may  be  main- 
tained in  the  capillaries  in  a  normal  manner,  name- 
ly, a  continuous  stream,  constant  pressure  must  be 
maintained  upon  the  blood  stream.  Capillary  re- 
sistance, then,  is  the  real  reason  for  the  normal 
diastolic  blood  pressure,  and  the  diastolic  pressure 
is  the  reason  for  the  systolic  pressure. 

What  practical  deductions  can  we  derive  from 
the.se  facts?  First,  any  condition  that  increases  or 
decreases  the  force  of  the  contraction  of  the  heart 
muscle  will  raise  or  lower  the  systolic  blood  pres- 
sure. Second,  any  increase  or  decrease  in  the 
volume  of  blood  will  raise  or  decrease  the  blood 
pressure,  both  systolic  and  diastolic.  Third,  any 
condition  which  will  increase  or  decrease  the  size 
of  the  arteries  will  raise  or  lower  the  systolic  blood 
pressure.  Fourth,  any  condition  which  will  increase 
or  decrease  the  velocity  of  the  flow  of  blood  through 
the  capillaries,  or,  in  other  words,  raise  or  decrease 
the  capillary  resistance,  will  increase  or  decrease  the 


154 


HOOD :  HYPER TEXSION. 


[New  York 
Medical  Journal 


diastolic  blood  pressure,  and  thus  increase  or  lower 
the  systolic  blood  pressure.  Many  experiments  have 
been  carried  on  to  prove  these  statements,  but  I 
believe  them  to  be  correct.  Clinical  examples  illus- 
trating these  facts  are  common. 

When,  from  any  cause,  the  heart  muscle  degene- 
rates or  dilates,  the  systolic  blood  pressure  falls,  as 
does  also  the  diastolic  pressure,  but  the  diastolic 
pressure,  does  not  fall  to  the  same  degree  that 
the  systolic  does.  When  hypertrophy  of  the 
left  ventricle  occurs,  independently  of  aortic 
valve  disease,  the  systolic  blood  pressure  is  de- 
creased, as  in  hemorrhage  the  systolic  blood  pressure 
falls,  and  it  may  be  raised  by  transfusion,  especially 
the  intravenous  saline  transfusion.  If  the  capil- 
lary walls  suddenly  relax,  the  systolic  blood  pres- 
sure falls.  Such  a  condition  we  have  when  a  patient 
faints,  and  such  a  condition  exists  to  a  large  ex- 
tent in  what  is  called  shock,  following  the  long  con- 
tinued administration  of  an  anesthetic,  while  the 
contraction  of  the  capillaries,  as  in  a  chill  of  the  sur- 
face of  the  body,  the  systolic  blood  pressure  will 
be  raised.  If  a  chronic  nephritis  exists,  and  the 
capillary  resistance  in  the  kidney  is  raised,  the  sys- 
tolic blood  pressure  must  be  raised,  in  order  that 
kidney  function  may  be  carried  on.  If  the  heart 
muscle  fails,  the  kidney  function  fails  or  ceases  in 
proportion  as  the  systolic  pressure  falls. 

From  these  facts,  we  conclude,  first,  that  capil- 
lary resistance  is  responsible  for  the  diastolic  blood 
pressure;  second,  that  the  diastolic  blood  pressure, 
or  the  capillary  resistance  is  the  reason  for  the 
systolic  blood  pressure :  third,  that  the  heart  muscle 
is  responsible  for  the  systolic  pressure. 

With  these  facts  in  mind,  let  us  see  if  we  can 
deduce  a  probable  hypothesis  for  hypertension  and 
arterial  fibrosis.  Considerable  time  has  been  given 
to  the  part  the  vasomotor  nerves  play  in  the  produc- 
tion of  hypertension  and  arterial  fibrosis.  I  do  not 
believe  that  the  vasomotor  nerves  play  any  part 
whatever  in  the  production  of  permanent  hyperten- 
sion or  arterial  fibrosis.  If  this  fact  is  kept  dis- 
tinctly in  mind,  namely,  that  the  reserve  power  of 
the  heart  or  that  heart  power  which  is  employed 
when  effort  is  made,  this  reserve  power  of  the  heart 
is  capable  of  wonderful  variations,  and  as  we  know, 
it  is  the  contraction  of  the  heart  muscle  which  pro- 
duces the  systolic  blood  pressure.  Then,  when  we 
recall  how  varied  the  force  of  the  heart  muscle  is, 
under  exertion,  we  must  know  that  the  systolic  pres- 
sure would  vary  to  a  great  extent,  if  the  calibre  of 
the  arteries  remained  the  same,  but  the  vasomotor 
nerves  regulate  the  size  of  the  arteries  to  meet  the 
force  of  the  heart  muscle.  This  we  believe  to  be 
the  function  of  the  vasocontractor  and  vasodilator 
tierves.  In  other  words,  the  vasomotor  nerves  are 
the  governors  upon  circulation,  and  by  their  action 
upon  the  coats  of  the  arteries  maintain  the  circula- 
tory equilibrium.  But  physiology  teaches  us  that 
nerve  force  cannot  be  continually  applied;  there- 
fore, the  vasomotor  nerves  cannot  be  a  factor  in 
the  production  of  permanent  hypertension  or  arterial 
fibrosis. 

What,  then,  will  produce  permanent  hypertension 
and  arterial  fibrosis? 


We  have  already  spoken  of  physiological  hyper- 
tension, due  to  contraction  of  the  capillaries,  the 
result  of  old  age.  We  know  that  it  is  on  account 
of  the  capillary  resistance  that  a  systolic  pressure  is 
necessary,  but  what  causes  the  capillary  resistance? 
First,  the  resistance  offered  by  the  splitting  up  of 
the  arteriorles  into  extensive  and  exceedingly  small 
vessels ;  second,  the  pressure  of  the  body  fluids  upon 
the  capillaries. 

The  first  proposition  is  self  evident ;  the  second 
requires  some  explanation.  We  know  that  the  hu- 
n)an  body  contains  eighty  per  cent,  fluid,  and  that 
this  fluid  state  is  absolutely  necessary  for  life.  We 
also  know  that  hydraulic  pressure  is  equal  in  all 
directions ;  therefore,  the  pressure  of  the  body  fluids 
is  exerted  as  much  upon  the  walls  of  the  capillaries 
as  it  is  upon  the  body  tissue.  If  this  is  true,  and 
we  believe  that  it  is,  then,  'the  fluid  pressure  of  the 
body  is  responsible,  entirely  or  in  most  part,  for 
the  capillary  resistance,  and  any  variation  in  the 
fluid  pressure  of  the  body  will  influence  the  capillary 
resistance.  If  the  capillary  resistance  is  raised,  by 
reason  of  an  increase  in  the  body  fluids,  the  blood 
stream  is  held  back  in  the  arterioles,  backed  up  from 
the  arterioles  into  the  large  arteries.  Finally,  the 
pressure  is  exerted  upon  the  aorta,  and  by  increas- 
ing the  resistance  in  the  aorta,  the  left  ventricle 
must  increase  its  force  to  overcome  this  aortic  re- 
sistance. In  other  words,  while  the  vasomotor 
nerves  may  be  able  to  accommodate  the  size  of  the 
arteries  to  meet  the  increased  resistance  in  the  capil- 
laries, if  this  increased  capillary  resistance  be  con- 
tinued beyond  the  physiological  time  for  vasomotor 
activity,  the  back  pressure  is  referred  to  the  heart 
muscle,  and  hypertrophy  of  the  left  ventricle  results. 
If  the  capillary  resistance  is  continued  over  years, 
the  left  ventricle  hypertrophies,  and  so  long  as  it 
can  maintain  the  circulatory  equilibrium  with  the 
arteries  at  a  normal  size,  this  is  all  the  changes  re- 
quired. But  if  the  capillary  resistance  continues,  and 
the  left  ventricle  finds  itself  unable  to  maintain  the 
circulatory  equilibrium,  then,  the  coats  of  the  arter- 
ies, which  have  already  felt  the  strain  of  the  in- 
creased systolic  blood  pressure,  become  fibrosed 
from  necessity,  in  order  to  decrease  the  size  of  the 
arteries,  and  thus  assist  the  heart  muscle  in  main- 
taining the  systolic  pressure.  And  it  is  such  patho- 
logical changes  that  we  find  at  the  postmortem  table. 
We  find  hypertrophy  and  dilatation  of  the  heart, 
with  fibrosis  and  dilatation  of  the  aortic  arch. 

Remember,  we  are  not  considering  true  atheroma 
with  infiltration  of  the  arterial  walls^  but  the  much 
more  common  condition  of  arterial  fibrosis.  Again, 
we  may  find  arterial  fibrosis  extending  along  the 
large  arteries,  and  sometimes,  but  rarely,  in  the 
smaller  arteries.  But  you  ask  if  the  small  arterioles 
are  the  first  to  feel  the  back  pressure  from  the  in- 
creased capillary  resistance,  why  do  we  not  have 
arterial  fibrosis  present  more  frequently  in  the 
smaller  arteries?  For  a  purely  physiological  rea- 
son. It  is  the  law  of  nature  that  when  increased 
work  is  required  of  any  part  of  the  body,  so  long 
as  that  part  can  obtain  sufficient  blood  supply  it 
will  increase  its  working  power  sufficient  to  meet 
the  requirement. 


July  31,  1920.] 


HOOD:  HYPERTENSION. 


155 


The  back  pressure  in  the  individual  arteriole  is 
small,  but  the  aggregate  back  pressure  in  many  ar- 
terioles and  small  arteries  is  great,  and  the  full  force 
of  the  back  pressure  is  exerted  upon  the  aorta  and 
the  left  ventricle.  Thus,  we  have  hypertrophy  of 
the  heart,  first  of  the  left  ventricle,  and  so  long  as 
the  left  ventricle  can  hypertrophy  to  meet  the  in- 
creased resistance,  the  rest  of  the  heart  enlarges 
but  little,  but  when  the  left  ventricle  begins  to  dilate 
and  the  mitral  ring  is  stretched,  and  the  blood  begins 
to  be  pumped  back  into  the  lungs,  then,  the  right 
ventricle  hypertrophies  to  lend  its  assistance  to  the 
left  ventricle,  in  maintaining  the  circulatory  equi- 
librium. Ultimately,  if  the  capillary  resistance  con- 
tinues, the  coronary  arteries  will  fail  to  supply  the 
heart  muscle  with  sufficient  nutrition,  or  the  coro- 
naries  may  be  fibrosed,  and  the  heart  muscle  will 
dilate  with  resulting  passive  congestion. 

SUMMARY. 

Increased  tissue  fluid  pressure  causes,  first,  in- 
creased capillary  resistance;  second,  hypertrophy  of 
the  heart ;  third,  fibrosis  of  the  arteries. 

Therefore,  the  practical  application  of  these  facts 
is,  what  can  and  does  increase  the  body  fluid  pres- 
sure in  the  capillaries?  Without,  at  this  time,  de- 
tailing the  experiments  which  have  convinced  us  of 
of  this  hypothesis,  we  believe  that  it  is  the  presence 
of  sodium  chloride  in  the  tissue  that  brings  about 
this  condition.  That  salt  will  hold  back  the  body 
fluids  has  been  abundantly  proved,  and  the  clin- 
ical results  obtained  from  this  fact  can  be  proved 
by  anyone. 

Sodium  chloride  is  used  in  the  human  body  for 
two  and  possibly  three  purposes.  First,  it  is  from 
the  sodium  chloride  that  the  hydrochloric  acid  of 
the  gastric  juice  is  made.  Of  this  we  have  abun- 
dant proof.  Second,  sodium  chloride  probably 
plays  some  part,  although  this  is  questionable,  in 
the  alkalinity  of  the  blood  stream.  Third,  sodium 
chloride  holds  back  or  retains  the  fluids  in  the  tis- 
sues of  the  body.  It  is  plain  that  if  the  body  fluids 
contain  an  abnormal  amount  of  sodium  chloride  for 
the  individual,  the  intratissue  fluid  pressure  is 
increased,  capillary  resistance  is  raised,  and  ulti- 
mately we  have  hypertrophy  of  the  heart,  with  ar- 
terial fibrosis. 

I  am  convinced  of  the  truth  of  these  statements. 
When  we  remember  that  the  human  body  requires 
from  thirty  to  sixty  grains  of  sodium  chloride  in 
twenty-four  hours  for  perfect  health,  and  then  re- 
call how  much  sodium  chloride  is  as  a  rule  con- 
sumed by  the  ordinary  individual  in  twenty-four 
hours,  it  is  not  hard  to  see  how  capillary  resistance 
is  increased.  But  it  is  not  necessary  that  the  in- 
dividual be  an  excessive  salt  eater.  The  question  is, 
To  what  extent  is  the  sodium  chloride  eliminated 
from  the  body  ?  Sodium  chloride  is  eliminated  from 
the  body,  aside  from  that  used  in  the  manufacture  of 
hydrochloric  acid  for  the  gastric  juice,  first,  by  the 
skin  and  tears ;  second,  by  the  lungs,  to  a  very  small 
extent ;  and  third  and  principally,  by  the  kidneys. 

Now  for  the  clinical  application  of  these  facts.  In 
the  first  type  of  hypertension,  the  physiological  type, 
it  must  be  kept  distinctly  in  mind  that  these  indi- 
viduals who  have  a  physiological  hypertension  re- 


quire an  increased  systolic  pressure,  in  order  to 
maintain  a  circulatory  equilibrium.  Many  of  these 
persons  die  of  some  acute  infection,  owing  to  their 
lowered  resistance,  but  if  they  do  not  die  from  the 
acute  infection,  they  die  from  heart  failure,  and  they 
all  have  a  secondary  anemia  to  a  greater  or  less  de- 
gree. By  putting  these  people  upon  a  salt  poor  diet, 
and  keeping  them  on  this  diet  for  a  time,  their  ex- 
cess sodium  chloride  becomes  filtered  out.  This  re- 
lieves the  kidney  of  the  work  of  eliminating  the 
chlorides,  and  permits  the  elimination  of  more  nitro- 
gen and  urea,  thus  making  it  possible  to  allow  these 
people  a  more  liberal  protein  diet,  but  keeping  them 
upon  a  salt  poor  diet  also  lowers  the  systolic  pres- 
sure, and  to  some  extent  the  diastolic  pressure,  to 
the  normal  for  the  individual. 

In  the  second  type  of  hypertension,  the  pseudo 
fibrosis,  if  the  individual  is  comparatively  young, 
from  thirty-five  to  forty-five  years  of  age,  the 
most  of  them  are  overweight.  They  have  been 
good  feeders,  and  have  drunk  a  large  amount  of 
liquid,  and  strange  as  it  may  seem,  by  far  the  greater 
number  of  them  have  eaten  an  excess  of  salt. 
The  urine  may  show  a  normal  amount  of  chlorides, 
for  it  must  be  remembered  that  the  blood  stream 
can  hold  only  so  much  sodium  chloride ;  therefore, 
the  kidney  rarely  elirriiii&tes  an  excessive  amount 
of  chlorides,  although  this  may  occur  for  a  short 
time,  but  in  these  cases,  even  with  their  excessive 
liquid  drinking,  the  volume  of  urine  is  but  little 
above  the  normal.  Placing  these  persons  upon  a 
salt  free  diet  for  a  few  weeks  or  two  or  three 
months,  with  a  restricted  diet  in  amount,  will  work 
wonders.  They  will  do  better  to  dispense  with  tea, 
cofiee,  and  tobacco,  but  they  may  use  these  in 
moderate  amounts.  By  the  withdrawal  of  the  salt 
from  their  diet,  they  will  at  once  cut  practically 
all  the  meats  out  of  their  diet,  as  they  will  have 
no  taste  for  unsalted  meats  for  some  time,  and  no 
salt  meats  are  permitted.  The  amount  of  liquids 
they  require  is  reduced  to  the  minimum, 
but  the  volume  of  the  urine  will  be  increased,  in 
some  instances  enormously  increased  for  a  time. 
They  will  lose  weight  for  a  few  weeks,  at  a  rapid 
rate,  then  more  slowly.  By  degrees,  the  volume  of 
urine  becomes  normal,  the  gravity  is  usually  above 
the  normal,  the  systolic  pressure  will  drop  rapidly, 
and  if  the  diastolic  pressure  has  been  increased,  it 
will  also  come  down.  The  dyspnea  upon  exertion 
will  disappear,  the  sleep  will  become  better,  and 
they  will  get  up  in  the  morning  refreshed. 

In  the  third  type,  the  true  arterial  fibrosis,  the  re- 
sults are  not  so  marked,  but  the  kidney  efficiency  will 
be  increased,  the  systolic  pressure  will  be  reduced 
as  well  as  the  diastolic  pressure.  The  elimination 
of  the  amount  of  nitrogen  and  urea  will  be  in- 
creased. The  aortic  second  sound  will  lose  some  of 
its  snap,  and  the  general  condition  of  the  patient 
will  be  much  improved. 

In  the  fourth  type  of  hypertension,  that  due  to 
chronic  nephritis,  not  so  much  can  be  accomplished, 
although  it  is  perfectly  wonderful  what  the  salt  free 
diet  will  do  for  these  patients,  if  it  is  persevered  in 
for  months,  and  they  are  permitted  to  take  a  well 
balanced  diet.  For  it  must  be  distinctly  borne  in 
mind  that  besides  the  uremic  symptoms,  the  most 


156 


HOOD:  HYPERTEXSIOX. 


[New  York 
Medical  Journal. 


important  symiitonis  are  those  due  to  heart  failure 
and  the  coexisting  secondar\-  anemia.  The  heart 
must  be  closely  watched,  and  gi\  en  what  assistance 
it  requires. 

In  the  fifth  type  of  hypertension,  that  accompany- 
ing exophthabiiic  goitre,  we  have  had  some 
excellent  results  by  putting  these  people  upon  a 
salt  poor  diet,  the  use  of  the  ice  bag  over  the 
thyroid,  the  hydrobromate  of  quinine,  and  some 
heart  assistants,  as  sparteine  or  strophanthus.  The 
sweating  quickly  subsides  and  the  kidney  function 
is  increased,  although  the  diarrhea  ceases. 

As  has  been  said,  the  hypothesis  we  present  is  in 
many  ways  not  new  to  the  profession,  and  we  make 
no  assertion  that  a  salt  poor  or  a  salt  free  diet  will 
cure  true  arterial  fibrosis  or  chronic  nephritis,  for 
we  know  full  well  that  when  fibrous  changes  have 
once  taken  place  in  the  arterial  walls,  these  changes 
will  continue  for  the  life  of  the  indi\ndual,  but  we 
are  assured,  after  more  than  five  years  of  observa- 
tion in  a  goodly  number  of  cases,  that  such  a  diet, 
so  far  as  we  can  find  out,  apparently  stops  the 
further  extension  of  the  fibrous  changes,  and  the 
individual,  if  he  continues  to  take  only  the  necessary 
amoimt  of  sodium  chloride,  may  live  out  his  days. 
W  e  know  that  in  chronic  nephritis,  where  actual 
pathological  changes  have  occurred,  nothing  can 
replace  the  kidney  structure,  but  by  withdrawing 
the  salt  from  the  diet  of  these  individuals  for 
months,  and  then  pennitting  them  only  ten  to  fifteen 
grains  a  day,  relieves  the  kidney  of  much  work, 
permits  a  much  richer  protein  diet,  and  thus  pro- 
longs the  patient's  life. 

REMEDIES  TO  ASSIST  IX   THE  ELIMIXATIOX  OF  THE 
CHLORIDES. 

This  is  one  of  the  unsolved  problems.  So  far, 
we  have  found  but  one  drug,  potassium  nitrate, 
which  in  any  way  increases  the  elimination  of  the 
chlorides,  and  this  drug  is  eflfective  in  not  more 
than  seventy-five  per  cent,  of  the  cases.  Large 
doses  of  potassium  nitrate  increases  the  volume  of 
the  urine,  but  not  the  twenty-four  hour  output  of 
the  chlorides,  while  smaller  doses  of  the  drug,  as 
five  grains  to  the  ounce,  and  fifteen  drops  in  a 
half  glass  of  water,  three  times  a  day,  will  not  in- 
crease the  volume  of  urine,  but  will  increase  the 
amount  of  chlorides  up  to  the  normal,  and  maintain 
this  imtil  the  individual  is  filtered  of  his  excess 
chlorides.  In  chronic  nephritis,  potassium  nitrate 
is  of  little  avail,  except  in  the  true  arteriosclerotic 
nephritis.  In  chronic  nephritis,  other  than  the 
arteriosclerotic  type^  when  the  urine  is  of  a  low  fixed 
specific  gravity,  with  the  kidney  function  from  five 
to  fifteen  per  cent.,  the  administration  of  eserine, 
one  fortieth  of  a  grain  three  times  a  day  will  increase 
the  chloride  elimination  for  several  weeks,  then  the 
chlorides  will  fall  to  almost  nothing,  and  the 
nitrogen  and  urea  elimination  will  increase,  often 
to  a  marked  extent.  The  question  of  nephritis  of 
the  acute  type  and  what  part  sodium  chloride 
plays  in  making  it  possible  for  secondary  changes 
to  occur  is  an  exceedingly  interesting  subject,  and 
one  fraught  with  great  possibilities, 

I  believe  that  it  is  now  considered  by  the  pro- 
fession that  the  iodides  or  iodine  has  no  place  in 


the  treatment  of  hypertension  or  arterial  fibrosis, 
that  they  have  no  influence  whatever  upon  the 
course  of  the  disease,  that  the  nitrates,  while  of 
service  in  temporarily  reducing  the  hypertension,  to 
relieve  the  anginal  attacks,  are  of  service,  but  so 
far  as  influencing  the  course  of  the  disease  or  pro- 
ducing any  permanent  results,  they  are  not  produc- 
tive of  good. 

The  salt  poor  and  salt  free  diet  have  been  used 
for  some  years  by  many  clinicians,  in  the  treatment 
of  chronic  nephritis,  but  salt  free  diet  has  never,  so 
far  as  we  know,  been  pushed  to  the  point  of  the 
removal  of  the  surplus  sodium  chloride  from  the 
body,  and  keeping  the  tissue  sodium  chloride  con- 
tent at  the  physiological  amount.  Herein  lie  the 
possibilities. 

EXDOCRIXOLOGY. 

There  has  been  considerable  discussion  recently 
regarding  the  part  that  the  internal  secretions  play 
in  the  production  of  hypertension  and  arterial  fibro- 
sis. We  know  some  facts  regarding  the  functions  of 
the  internal  secretions. 

The  thyroid  may  cause  some  increase  in  the  sys- 
tolic blood  pressure,  as  we  find  in  many  cases  of 
exophthalmic  goitre,  but  in  other  ,cases  of  exoph- 
thalmic goitre  there  is  a  low  systolic  blood  pressure. 
Simple  goitres  which  become  toxic  are  more  likelv 
to  increase  the  systolic  pressure.  So  far  as  I  have 
observed,  and  the  observation  has  been  fairly  ex- 
tensive, overacting  thyroids  may  increase  the  sys- 
tolic pressure,  but  do  not  increase  the  diastolic  pres- 
sure. 

The  administration  of  adrenalin  will  raise  the  sys- 
tolic pressure  for  a  short  time,  and  the  lack  of  supra- 
renal secretion  in  the  circulation  will  result  in  a  low 
systolic  pressure.  We  know,  from  the  ability  of 
adrenalin  to  control  capillary  hemorrhage,  that  it 
causes  contraction  of  the  capillary  walls;  hence, 
when  there  is  a  lack  of  adrenalin  in  the  circulation, 
the  capillary  walls  are  relaxed  beyond  normal.  That 
the  secretion  of  the  adrenalins  have  something  to 
do  with  maintaining  a  normal  capillary  calibre  is 
self  evident,  but  so  far  as  our  knowledge  goes,  it 
has  nothing  to  do  with  the  production  of  hyperten- 
sion or  arterial  fibrosis. 

In  the  few  cases  of  Addison's  disease  that  I 
have  had  the  privilege  of  studying  and  observing 
some  facts  were  common  to  all.  First,  the  chlor- 
ides were  below  normal  in  the  urine.  Second,  with- 
out exception,  individuals  suffering  from  Addison's 
disease  were  light  salt  eaters.  We,  therefore,  are 
led  to  conclude  that  internal  secretions  do  not  in 
any  way  alter  our  hypothesis :  namely,  that  sodium 
chloride  holds  back  the  tissue  fluids ;  that  an  increase 
in  the  sodium  chloride  content  of  the  tissue  fluids 
increases  capillary  resistance;  that  increased  capil- 
lary resistance  requires  an  increased  systolic  pres- 
sure; that  an  increased  systolic  pressure  demands 
extra  eflfort  on  the  part  of  the  left  ventricle,  which 
may  result  in  hypertrophy  of  the  left  ventricle  or 
even  hypertrophy  of  the  entire  heart,  and  that  ar- 
terial fibrosis  is  an  effort  on  the  part  of  Nature 
to  assist  the  heart  muscle  in  maintaining  the  re- 
quired systolic  pressure. 

2959  Washixgtox  Boulevard. 


July  31,  1920.] 


KRAUSS:   U XI LATERAL  CHOKED  DISC. 


157 


A  CASE  OF  UNILATERAL  CHOKED  DISC. 

By  Frederick  Krauss,  M.  D., 
Philadelphia, 

Eye  Surgeon  to  the  Hospital  of  the  Protestant  Episcopal  Church. 

Case. — X.  A.,  aged  ten,  came  to  the  outpatient 
department  of  the  Episcopal  Hospital  on  April  28, 
1919,  with  the  history  of  increasing  blindness  in  the 
right  eye,  following  an  attack  of  intense  pain  over 
the  right  forehead  accompanied  by  a  scaly  rash  over 
both  sides  of  the  face.  He  had  had  no  ocular  treat- 
ment except  glasses  at  the  Eye  Hospital  two 
years  before. 

Upon  examination,  the  right  eye  was  absolutely 
blind  to  strong  light  stimulus.  The  pupil  was  in- 
active to  light,  but  reacted  consensually  with  the 
fellow  eye.  The  right  eye  was  slightly  divergent  and 
perhaps  a  shade  more  prominent,  but  the  muscle 
movements  of  both  eyes  were  normal.  The  tension 
was  normal.  Ophthalmoscopically  the  right  eye 
showed  a  choked  disc  with  apex  best  seen  with  plus 
6  D  the  periphery  of  retina  with  no  lens.  The  disc 
was  intensely  swollen,  the  vessels  were  completely 
hidden  appearing  again  on  the  retina,  with  many 
hemorrhages  along  the  course  of  the  vessels.  The 
left  eye  had  normal  vision  and  practically  normal 
ej^eground,  the  nerve  being  too  grey  for  his  age. 
The  Wassermann,  \*on  Pirquet  test  and  urine  were 
found  negative.  The  x  ray  examination  showed  a 
normal  pituitary  and  normal  nasal  sinuses.  The 
nasal  examination  was  negative.  The  general  med- 
ical examination  l)y  Dr.  Hooker  was  negative. 

He  was  then  placed  on  increasing  doses  of  iodide 
of  potassium.  There  was  a  gradual  decrease  of  the 
edema  beginning  in  tlie  periphery  of  the  retina,  until 
the  nerve  alone  appeared  swollen,  with  evidences  of 
chorioidal  changes  appearing  on  the  temporal  and 
lower  sides  of  the  disc. 

The  vessels  were  first  visible  in  the  periphery  with 
outlines  of  the  disc  appearing  about  two  months  af- 
ter the  beginning  of  the  treatment.  For  the  vision 
there  was  light  perception  about  two  weeks  after 
treatment  was  inaugurated,  gradually  increasing  to 
fingers  counted  in  five  weeks  and  20/100  in  two 
months.  At  the  present  time  his  vision  is  15/70 
plus.  His  fields  of  vision  are  contracted,  uniformly 


urr 


Fig.  1. — Perimeter  charts  of  X.  A.,  October  13,  1919.  Light  lines, 
red;  heavy  lines,  white. 


in  the  left  eye  and  greatly  narrowed  in  the  right  eye. 
except  to  the  temporal  side. 

The  ophthalmic  appearance  of  the  right  eye  is  as 
follows:  Media  clear,  disc  is  oval — 90°,  quite  pale  in 
tint.    Running  directly  across  the  nerve  at  axis  105° 


is  a  semitransparent  menilirane,  which  may  be  a 
remnant  of  the  hyaloid  or  more  likely  exudate  re- 
sulting from  the  intense  inflammation.  The  vessels 
are  of  good  size.  The  chorioid  is  disturbed  with 
partial  absorption  of  pigment  for  a  distance  of  near- 
ly a  disc  diameter  to  the  temporal  and  lower  sides  of 
the  disc.    There  are  no  indications  of  previous  hem- 


FiG.  2.— Perimeter  charts  of  X.  A.,  January  14.  1920:  O.  D.,  LXX  — 


orrhages.  The  disc  of  the  left  eye,  seems  too  grey — 
i)ut  no  gross  changes  are  marked. 

The  patient  has  always  held  his  head  at  an  angle. 
L'pon  close  fixation  the  right  eye  tends  to  turn  out. 
When  the  fixing  hand  is  carried  to  the  left,  the  right 
eye  ttirns  inward  and  tipward.  Inferior  oblique). 
When  fixing  above  the  horizontal  meridian  the  right 
eye  turns  upward  and  otitward.  (Superior  oblique.) 
The  excessive  action  of  the  oblique  muscles  is  prob- 
ably due  to  a  central  cause,  following  the  convulsive 
seizures. 

In  the  further  study  of  this  case  we  have  the  fol- 
lowing history :  His  father  and  mother  are  well.  He 
has  an  older  sister  and  a  younger  brother.  Previous 
to  patient's  birth,  the  mother  had  had  two  miscar- 
riages. 

The  patient  had  convulsions  up  to  his  sixth  year 
and  especially  with  the  oncoming  of  the  following" 
infectious  diseases,  measles,  chicken  pox  and  pneu- 
monia. The  patient  has  been  apparently  healthy 
until  three  weeks  before  his  appearance  in  our  clinic 
when  he  had  intense  headaches,  not  relieved  by 
aspirin  tablets  given  him  by  his  mother. 

The  eyesight  was  bad  immediately  with  the  head- 
aches, but  gradually  became  worse,  until  he  had  no 
vision.  In  establishing  the  etiological  factor  in  this 
case,  the  miscarriages  of  the  mother  above  noted 
are  suggestive.  The  patient  showed  much  improve- 
under  potassium  iodide  taking  forty-five  grains  three 
times  daily  without  general  symptoms,  thus  demon- 
strating the  socalled  therapeutic  test  for  syphiHs. 
The  W'assermann  test  was  negative.  This  in  itself 
does  not  prove  the  absence  of  syphilis,  though  I  am 
constrained  to  believe  that  a  positive  Wassermann 
is  proof  of  its  presence.  Though  marked  neuro- 
retinitis  was  present  only  in  the  right  eye,  an  in- 
volvement of  the  left  eye  is  seen  in  the  accompanv- 
ing  fields,  which  show  the  left  field  considerably  af- 
fected, indicating  an  optic  atrophy.  The  specific 
character  of  the  inflammation  is  also  suggested  by 
the  improvement  possible  after  severe  involvement 
of  the  optic  nerve  (shown  in  the  choked  disc). 

The  retinal  vessels  instead  of  being  contracted  as 
one  ought  to  expect,  were  nearly  normal  in  size  in 
the  cases  examined. 

1701  Chestnut  Street. 


158 


BATES: 


AIDS  TO  riSJOX. 


[New  York 
Medical  Journal. 


SHIFTING  AS  AX  AID  TO  VISION. 

By  W.  H.  Bates,  D.. 
New  York. 

When  the  eye  regards  a  letter  with  normal  vision 
either  at  a  near  point  or  at  a  distance,  the  letters 
appear  to  pulsate,  or  move  in  various  directions, 
from  side  to  side,  up  and  down,  or  obliquely.  When 
it  looks  from  one  letter  to  another  on  the  Snellen 
test  card,  or  from  one  side  of  a  letter  to  another, 
not  only  the  letters,  but  the  whole  line  of  letters  and 
the  whole  card,  appear  to  move  from  side  to  side. 
This  apparent  movement  is  due  to  the  shifting  of 
the  eye  and  is  always  in  a  direction  contrary  to  its 
movement.  If  one  looks  at  the  top  of  a  letter,  the 
letter  is  below  the  line  of  vision,  and,  therefore, 
appears  to  move  dow-nw-ard.  If  one  looks  at  the 
bottom,  the  letter  is  above  the  line  of  vision  and 
appears  to  move  upward.  If  one  looks  to  the  left 
of  the  letter,  it  is  to  the  right  of  the  line  of  vision 
and  appears  to  move  to  the  right.  If  one  looks  to 
the  right,  it  is  to  the  left  of  the  line  of  vision  and 
appears  to  move  to  the  left.  Persons  with  normal 
vision  are  rarely  conscious  of  this  illusion,  and  may 
have  difficulty  in  demonstrating  it ;  but  in  every 
case  that  has  come  under  my  observation  the  pa- 
tients have  always,  in  a  longer  or  shorter  time,  be- 
come able  to  do  so.  When  the  sight  is  imperfect 
the  letters  may  remain  stationary,  or  even  move  in 
the  same  direction  as  the  eye. 

It  is  impossible  for  the  eye  to  fix  a  point  longer 
than  a  fraction  of  a  second.  If  it  tries  to  do  so,  it 
begins  to  strain  and  the  vision  is  lowered.  This  can 
readily  be  demonstrated  by  trying  to  hold  one  part 
of  a  letter  for  an  appreciable  length  of  time.  No 
matter  how  good  the  sight,  it  will  begin  to  blur,  or 
even  disappear,  very  quickly,  and  sometimes  the 
efiFort  to  hold  it  will  produce  pain.  In  the  case  of  a 
few  exceptional  people  a  point  may  appear  to  be  held 
for  a  considerable  length  of  time ;  the  subjects  them- 
selves may  think  that  they  are  holding  it ;  but  this 
is  only  because  the  eye  shifts  unconsciously,  the 
movements  being  so  rapid  that  objects  seem  to  be 
seen  all  alike  simultaneously,  just  as  the  parts  of  a 
moving  picture  appear  to  be  seen  as  one. 

The  shifting  of  the  eye  with  normal  vision  is 
usually  not  conspicuous,  but  by  direct  examination 
with  the  ophthalmoscope,  it  can  always  be  demon- 
strated. If  one  eye  is  examined  with  this  instru- 
ment while  the  other  is  regarding  a  small  area 
straight  ahead,  the  eye  being  examined,  w-hich  fol- 
lows the  movements  of  the  other,  is  seen  to  move 
in  various  directions,  from  side  to  side,  up  and 
down,  in  an  orbit  which  is  usually  variable.  If  the 
vision  is  normal,  these  movements  are  extremely 
rapid  and  unaccompanied  by  any  appearance  of 
effort.  The  shifting  of  the  eye  with  imperfect  sight, 
on  the  contrary,  is  slower,  its  excursions  are  wider 
and  the  movements  are  jerky  and  made  with  ap- 
parent eflfort. 

It  can  also  be  demonstrated  that  the  eye  is  capable 
of  shifting  with  a  rapidity  which  the  ophthalmoscope 
cannot  measure.  The  normal  eye  can  read  four- 
teen letters  on  the  bottom  line  of  a  Snellen  test 
card,  at  a  distance  of  ten  or  fifteen  feet,  in  a  dim 


light,  so  rapidly  that  they  seem  to  be '  seen  all  at 
once.  Yet  it  can  be  demonstrated  that  in  order  to 
recognize  the  letters  under  these  conditions  it  is 
necessary  to  make  about  four  shifts  to  each  one.  At 
the  near  point,  even  though  one  part  of  the  letter 
is  seen  best,  the  rest  may  be  seen  well  enough  to  be 
recognized ;  but  at  the  distance,  in  a  dim  light,  it 
is  impossible  to  recognize  the  letters  unless  one 
shifts  from  the  top  to  the  bottom  and  from  side  to 
side.  One  must  also  shift  from  one  letter  to  an- 
other, making  about  seventy  shifts  in  a  fraction  of 
a  second.  A  line  of  small  letters  on  the  Snellen  test 
card  may  be  less  than  a  foot  long  by  a  quarter  of  an 
inch  w'ide,  and  if  it  requires  seventy  shifts  to  a 
fraction  of  a  second  to  see  it  apparently  all  at  once, 
it  must  require  many  thousands  to  see  an  area  of 
the  size  of  the  screen  of  a  moving  picture,  with  all 
its  detail  of  people,  animals,  houses,  or  trees,  and  to 
see  sixteen  such  areas  to  a  second,  as  is  done  in 
viewing  moving  pictures,  must  require  a  rapidity  of 
shifting  that  can  scarcely  be  realized.  Yet  it  is 
admitted  that  the  present  rate  of  taking  and  pro- 
jecting moving  pictures  is  too  slow.  The  results 
would  be  more  satisfactory,  authorities  say,  if  the 
rate  were  raised  to  twenty,  twenty-two,  or  twenty- 
four  a  second. 

The  human  eye  and  mind  are  not  only  capable 
of  this  rapidity  of  action,  but  it  is  only  when  the 
eye  is  able  to  shift  thus  rapidly  that  the  eye  and 
mind  are  at  rest  and  the  efficiency  of  both  at 
their  maximum.  It  is  true  that  every  motion  of  the 
eye  produces  an  error  of  refraction ;  but  when  the 
movement  is  short  this  is  very  slight,  and  usually 
the  shifts  are  so  rapid  that  the  error  does  not  last 
long  enough  to  be  detected  by  the  retinoscope,  its 
existence  being  demonstrable  only  by  reducing  the 
rapidity  of  the  movements  to  less  than  four  or  five 
a  second.  Hence,  when  the  eye  shifts  irormally  no 
error  of  refraction  is  manifest.  The  more  rapid 
the  unconscious  shifting  of  the  eye  the  better  the 
vision,  but  if  one  tries  to  be  conscious  of  a  too 
rapid  shift  a  strain  will  be  produced. 

Perfect  sight  is  impossible  w-ithout  continual 
shifting,  and  such  shifting  is  a  striking  illustration 
of  the  mental  control  necessary  for  normal  vision. 
It  requires  perfect  mental  control  to  think  of  thou- 
sands of  things  in  a  fraction  of  a  second,  and  each 
point  of  fixation  has  to  be  thought  of  separately,  be- 
cause it  is  impossible  to  think  of  two  things,  or  two 
parts  of  one  thing,  perfectly  at  the  same  time.  The 
eye  with  imperfect  sight  tries  to  accomplish  the 
impossible  by  looking  fixedly  at  one  point  for  an 
appreciable  length  of  time,  that  is.  by  staring.  When 
it  looks  at  a  strange  letter,  and  does  not  see  it,  it 
keeps  on  looking  at  it,  in  an  effort  to  see  it  better. 
Such  efforts  always  fail,  and  are  an  important  fac- 
tor in  the  production  of  imperfect  sight. 

One  of  the  best  methods  of  improving  the  sight, 
therefore,  is  to  imitate  consciously  the  unconscious 
shifting  of  normal  vision,  and  to  realize  the  appar- 
ent motion  produced  by  shifting.  Whether  one  has 
imperfect  or  normal  sight,  conscious  shifting  and 
swinging  are  a  great  help  and  advantage  to  the  eye ; 
for  not  only  may  imperfect  sight  be  improved  in 
this  way,  but  normal  sight  may  also  be  improved. 


July  31,  :920.] 


BATES:  AIDS  TO   r  I  SI  OX. 


159 


The  eye  with  normal  sight  never  attempts  to  hold 
a  point  more  than  a  fraction  of  a  second,  and  when 
it  shifts  it  always  sees  the  previous  point  of  fixa- 
tion worse  (1).  When  it  ceases  to  shift  rapidly, 
and  fails  to  see  the  point  shifted  from  worse,  the 
sight  ceases  to  be  normal  and  the  swing  is  either  pre- 
vented or  lengthened :  occasionally  it  is  reversed. 
These  facts  are  the  keynote  of  the  treatment  by 
shifting. 

In  order  to  see  the  previous  point  of  fixation 
worse,  the  eye  with  imperfect  sight  has  to  look  far- 
ther away  from  it  than  does  the  eye  with  normal 
sight.  If  it  shifts  only  a  quarter  of  an  inch,  for 
instance,  it  may  see  the  previous  point  of  fixation 
as  well  or  better  than  before :  and  instead  of  being 
rested  by  such  a  shift,  its  strain  will  be  increased, 
there  will  be  no  swing  and  the  vision  will  be  lowered. 
At  a  couple  of  inches  it  may  be  able  to  let  go  of  the 
first  point ;  and  if  neither  point  is  held  more  than 
a  fraction  of  a  second,  it  will  be  rested  by  such  a 
shift,  and  the  illusion  of  swinging  may  be  produced. 
The  shorter  the  shift,  the  greater  the  benefit ;  but 
even  a  very  long  shift — as  much  as  three  feet  or 
more — is  a  help  to  those  who  cannot  accomplish  a 
shorter  one.  When  the  patient  is  capable  of  a  short 
shift,  on  the  contrary,  the  long  shift  lowers  the 
vision.  The  swing  is  an  evidence  that  the  shifting  is 
being  done  properly;  and  when  it  occurs  the  vision 
is  always  improved.  It  is  possible  to  shift  without 
improvement,  but  it  is  impossible  to  produce  the 
illusion  of  a  swing  without  improvement,  and  when 
this  can  be  done  with  a  long  shift  the  distance  can 
be  gradually  reduced  till  the  patient  can  shift  from 
the  top  to  the  bottom  of  the  smallest  letter  on  the 
Snellen  test  card,  or  elsewhere,  and  maintain  the 
swing.  Later  he  may  be  able  to  be  conscious  of  the 
swinging  of  the  letters  without  conscious  shifting. 

Xo  matter  how  imperfect  the  sight,  it  is  always 
possible  to  shift  and  produce  a  swing,  so  long  as 
the  previous  point  of  fixation  is  seen  worse.  Even 
diplopia  and  polyopia  do  not  prevent  swinging  with 
some  improvement  of  vision.  Usualh*  the  eye  with 
imperfect  vision  is  able  to  shift  from  one  side  of  the 
card  to  the  other,  or  from  a  point  above  the  large 
letter  to  a  point  below  it,  and  observe  that  in  the 
first  case  the  card  appears  *to  move  from  side  to 
side,  while  in  the  second  the  letter  and  the  card 
appear  to  move  up  and  down. 

In  some  cases  the  eyes  are  under  such  a  strain 
that  tio  matter  how  far  a  patient  looks  away  from 
a  letter  he  sees  it  just  as  well,  so  long  as  he  sees  it 
at  all,  as  if  he  were  looking  directly  at  it.  In  these 
extreme  cases  of  eccentric  fixation  considerable 
ingenuity  is  sometimes  required,  first  to  demonstrate 
to  the  patient  that  he  does  not  see  best  where  he  is 
looking,  and  then  to  help  him  to  see  an  object  worse 
when  he  looks  away  from  it  than  when  he  looks 
directly  at  it.  The  use  of  a  strong  light  as  one  of 
the  points  of  fixation,  or  of  two  lights  five  or  ten 
feet  apart,  has  been  found  helpful.  In  such  cases 
the  patient,  when  he  looks  away  from  the  light,  is 
able  to  see  it  less  bright  more  readily  than  he  can 
see  a  black  letter  worse  when  he  looks  away  from 
it.  It  then  becomes  easier  for  him  to  do  the  same 
thing  with  the  letter.   The  highest  degrees  of  eccen- 


tric fixation  occur  in  the  high  degrees  of  myopia, 
and  in  these  cases,  since  the  sight  is  best  at  the 
near  point,  the  patient  is  benefitted  by  practising 
seeing  worse  and  producing  the  illusion  of  a  swing 
at  this  point.  The  distance  can  then  be  gradually 
extended  until  it  becomes  possible  to  do  the  same 
thing  at  twenty  feet.  Usually  such  patients  can 
begin  shifting  at  the  near  point  with  the  letters  of 
the  Snellen  test  card,  but  occasionally  it  is  necessary 
to  use  a  light,  or  lights.  In  hypermetropia,  too,  the 
sight  is  often  best  at  the  near  point,  when  the  same 
methods  can  be  used  as  in  myopia. 

After  resting  the  eyes  by  closing,  or  by  covering 
with  the  palms  of  the  hands  in  such  a  way  as  to 
exclude  all  the  light,  shifting  and  swinging  are  often 
more  successful.  By  this  method  of  alternately 
resting  the  eyes  and  then  shifting  persons  with  very 
imperfect  eyesight  have  sometimes  obtained  a  tem- 
porary or  permanent  cure  in  a  few  weeks. 

Shifting  may  be  done  slowly  or  rapidly,  accord- 
ing to  the  state  of  vision.  At  the  beginning  the 
patient  will  be  likely  to  strain  if  he  shifts  too 
rapidly,  and  then  the  point  shifted  from  will  not 
be  seen  worse,  and  there  will  be  no  swing.  As  im- 
provement is  made  the  speed  can  be  increased.  It 
is  usually  impossible,  however,  to  realize  the  swing 
if  the  shifting  is  more  rapid  than  two  to  three  times 
a  second. 

A  mental  picture  of  a  letter  can  be  made  to  swing 
precisely  as  can  a  letter  on  the  test  card.  For 
most  patients  mental  swinging  is  easier  at  first  than 
visual  swinging,  and  when  they  become  able  to 
swing  in  this  way  it  becomes  easier  for  them  to 
swing  the  letters  on  the  test  card.  By  alternating 
mental  with  visual  swinging  and  shifting  rapid  prog- 
ress is  sometimes  made.  As  relaxation  becomes 
more  perfect  the  swing  can  be  shortened,  until  it 
becomes  possible  to  conceive  and  swing  a  letter  of 
the  size  of  a  period  in  a  newspaper.  This  is  easier, 
when  it  can  be  done,  than  swinging  a  larger 
letter,  and  many  patients  have  derived  great  benefit 
from  it. 

All  persons,  no  matter  how  great  their  error  of 
refraction,  when  they  shift  and  swing  successfully, 
correct  their  error  of  refraction  partially  or  com- 
pletely, as  demonstrated  by  the  retinoscope,  for  at 
least  a  short  fraction  of  a  secnd.  This  time  may 
be  so  short  that  the  patient  is  not  conscious  of  im- 
proved vision,  but  it  is  possible  for  him  to  imagine 
it,  and  then  it  becomes  easier  to  maintain  the  relaxa- 
tion long  enough  to  become  conscious  of  improved 
sight.  For  instance,  the  patient,  after  looking  away 
from  the  card,  may  look  back  to  the  large  letter  at 
the  top,  and  for  a  fraction  of  a  second  the  error  of 
refraction  may  be  lessened  or  corrected,  as  demon- 
strated by  the  retinoscope.  Yet  he  may  not  be  con- 
scious of  improved  vision.  By  imagining  that  the 
C  is  seen  better,  however,  the  moment  of  relaxation 
may  be  sufficiently  prolonged  to  be  realized. 

When  swinging,  either  mental  or  visual,  is  suc- 
cessful, the  patient  may  becme  conscious  of  a 
feeling  of  relaxation  which  is  manifested  as  a  sensa- 
tion of  universal  swinging.  This  sensation  com- 
municates itself,  to  any  object  of  which  the  patient 
is  conscious.  The  motion  may  be  imagined  in  any 


160 


HELLER  AXD  STEIN  FIELD:    BENZYL  BENZOATE. 


[New  YoaK 
Mkdical  Journal. 


part  of  the  l)ody  to  which  attention  is  directed.  It 
may  be  communicated  to  the  chair  in  which  the 
patient  is  sitting,  or  to  any  object  in  the  room,  or 
elsewhere,  which  is  remembered.  The  building,  the 
city,  the  whole  world,  in  fact,  may  appear  to  be 
swanging.  When  the  patient  becomes  conscious  of 
this  universal  swinging  he  loses  the  memory  of  the 
object  with  which  it  started,  but  so  long  as  he  is 
able  to  maintain  the  movement  in  a  direction  con- 
trary to  the  original  movement  of  the  eyes,  or  the 
movement  imagined  by  the  mind,  relaxation  is 
maintained.  If  the  direction  is  changed,  however, 
strain  results.  To  imagine  the  universal  swing  with 
the  eyes  closed  is  easy,  and  some  patients  soon  be- 
come able  to  do  it  with  the  eyes  open.  Later  the 
feeling  of  relaxation  which  accompanies  the  swing 
may  be  realized  without  consciousness  of  the  latter, 
just  as  the  letters  may  swing  without  consciousness 
of  the  fact,  but  the  swing  can  always  be  imagined 
when  the  patient  thinks  of  it. 

Associated  with  all  failures  to  produce  a  swing 
is  strain.  Some  people  try  to  make  the  letters  swing 
by  efifort.  Such  efforts  always  fail.  The  eyes  and 
mind  do  not  swing  the  letters ;  they  swing  of  them- 
selves. The  eye  can  shift  voluntarily.  This  is  a 
muscular  act  resulting  from  a  motor  impulse.  But 
the  swing  comes  of  its  own  accord  when  the  shifting 
is  normal. 

REFERENCES. 

1.  B.\TEs :  The  Cure  of  Defective  Eyesight  by  Treatment 
Without  Glasses,  New  York  Medical  Tourxai.,  May  8, 
1915. 

40  E A. ST  Forty-first  Street. 


NONLEUCOTOXIC  PROPERTIES  OF 
BENZYL  BENZOATE.* 

By  EDWftv  A.  Heller,  M.  D., 

Philadelphia, 
AND  Edw.\rd  Steinfield,  !M.  D., 
Philadelphia. 

Through  pharmacological  studies  of  the  opium 
alkaloids,  Macht  was  able  to  separate  them  into 
two  classes :  the  pyridin  phenanthrene  group  and 
the  benzyl  isoquinolin  group,  with  morphine  as  the 
principal  representative  in  the  former  and  papa- 
verin,  the  typical  member  of  the  latter  group.  He 
further  noted  that  the  alkaloids  of  the  papaverin 
group  were  able  to  effect  the  relaxation  of  smooth 
muscle  and  were  able  to  antagonize  the  tonus  in- 
creasing properties  of  the  morphine  group.  This 
relaxing  effect  was  demonstrated  to  be  due  to  benzyl 
grouping  in  their  molecules  and  in  the  search  for 
similar  bodies  of  a  simple  and  nonnarcotic  nature, 
benzyl  benzoate  and  benzyl  acetate  were  investi- 
gated. These  were  found  to  produce  the  same  tonus 
lowering  effects  and  appeared  to  be  eminently  safe 
for  clinical  use,  with  the  exception  that  the  acetate 
was  irritating  when  taken  by  mouth. 

Following  these  investigations,  benzyl  benzoate 
has  come  into  widespread  use  in  nearly  all  conditions 
indicating  the  relaxation  of  smooth  muscle.  Because 
of  its  close  chemical  derivation  from  benzol,  it  has 

*From  the  Clinical  Laboratories  of  the  Jewish  Hospital. 


appeared  to  us  to  be  of  interest  and  even  advisable 
to  investigate  any  possible  analogy  to  the  toxic  ef- 
fects of  the  latter.  Though  the  untoward  manifes- 
tations of  benzol  are  varied,  we  have  selected  its 
destructive  action  on  leucoc\tes  as  being  capable  of 
more  accurate  determination  and  comparison  with 
the  benzoate.  The  studies  of  various  observers  have 
shown  the  leucotoxic  effect  of  benzol  and  for  this 
reason  it  was  formerly  used  as  a  therapeutic  agent  in 
leucemia.  The  problem  could  not  be  approached 
very  well  from  the  clinical  side,  since  it  was  not 
justifiable  to  use  larger  doses  than  recommended  by 
Macht,  and  becau.se  conditions  could  not  be  so  thor- 
oughly controlled  as  in  an  experimental  study  using 
animals.  We  have  therefore  used  rabbits,  which 
were  the  animals  usually  used  by  investigators  upoia 
Ijenzol  in  the  past.  Certain  precautions  were  used 
to  ensure  accuracy.  That  is,  several  preliminary 
leucocyte  counts  were  made  to  recognize  tendency  to 
variation  in  the  counts,  since  this  variability  exists 
in  these  animals. 

The  animals  were  then  given  subcutaneous  injec- 
tions of  benzyl  benzoate  in  eciual  parts  of  olive  oil 
into  the  loose  tissues  of  the  flanks,  the  preparation 
used  being  the  full  strength  benzyl  benzoate  and  not 
the  alcoholic  dilution,  which  will  not  mix  with  oil. 
The  doses  used  varied  from  one  cubic  centimetre  to 
two  and  five  tenths  cubic  centimetres  to  the  kilo  of 
body  weight,  these  being  given  in  one  injection,  with 
the  exception  that  one  rabbit  received  four  doses  of 
twenty-five  hundredths  c.  c.  each.  Two  rabbits  were 
used  as  controls  to  demonstrate  the  destructive  ef- 
fects of  benzol,  so  that  comparisons  could  be  made 
with  the  same  lot  of  animals  under  similar  condi- 
tions. As  can  be  noted,  the  doses  used  were  con- 
siderably larger  in  comparison  than  those  used  clin- 
ically. Leucocyte  counts  were  then  made  daily  until 
a  tendency  for  the  figures  to  remain  constant  was 
noted,  and  then  made  every  other  day.  The  results 
are  shown  in  the  accompanying  table,  and  as  can 
be  noted,  doses  of  one  quarter  c.  c.  to  the  kilo  for 
four  days,  and  doses  of  one,  one  and  five  tenths, 
two,  and  two  and  five  tenths  c.  c.  to  the  kilo  ap- 
parently had  no  appreciable  effect  in  lowering  the 
leucocyte  count.  However,  the  animals  ^iyen  the 
largest  amounts  showed  the  ill  effects  of  the  drug  by- 
lethargy,  weakness  and  in  one  case  death  was  not 
preceded  by  leucopenia. 

In  contrast  with  these  animals,  the  two  control 
animals  receiving  benzol  in  doses  of  one  and  five 
tenths  c.  c.  and  two  c.  c.  to  the  kilo,  showed  definite 
evidences  of  depression  of  the  leucoc>1;e  icount, 
which  later  came  back  to  approximately  formal. 

For  convenience  in  reading  the  table,  the  data 
cerning  the  various  animals  may  be  summarized  as 
follows : 

Rabbit  I. — Female,  weight  1,200  grams;  four  injections 
of  twenty-five  hundredths  c.  c.  each  of  benzyl  benzoate 
to  the  kilo. 

Rabbit  II. — Male,  weight  1,500  grams;  one  injection 
of  a  cubic  centimetre  of  benzyl  benzoate  to  the  kilo. 

R.\BBiT  III. — Male,  weight  1,450  grams;  one  injection  of 
one  and  five  tenths  c.  c.  of  benzyl  Ijenzoate  to  the  kilo. 

Rabbit  IV. — Male,  weight  1,630  grams;  one  injection  of 
2  c.  c.  benzyl  benzoate  to  the  kilo. 

Rabbit  V. — Male,  weight  1,350  grams;  one  injection  of 
two  and  five  tenths  c.  c.  l^enzyl  benzoate  to  the  kilo. 


July  31,  1920.] 


GKEEXBERG:  LOBAR  PNEUMONIA  AND  MULTIPLE  ARTHRITIS. 


161 


Rabbit  VI. — Male,  weight  i,68o  grams;  one  injection  of 
one  and  five  tenths  c.  c.  benzol  to  the  kilo. 

Rabbit  VII. — ^Male.  weight  1,340  grams;  one  injection  of 
2  c.  c.  benzol  to  the  kilo. 

LEUCOCYTE   COUNTS   AFTER   IXJECTIOX    OF   BEXZYL  BEXZOATE 
AND  BEXZOL. 

Days  After     ,  Rabbit  No.-  s 

Injection  j  2  3  4  5  ^7 

Preliminary  9,100   11,200  8.500  12,600  8,100  8,400  7,800 

1  9,200   11,400  8,100  12,100  7,400  5,000  6,100 

2  8,600   11,100  8,000  13,400  7,800  4,000  4,100 

3  8,800   10,900  9,100  12,500  7,000  7,000  4,200 

4  8,500   11,200  8,700  12,300  8,200  8,400  3,100 

5  9,600  11.500  8,500  12,800  8,200  8,100  3.200 
7  9,400   11,100  8,600  13,200  8,100  8,500  3,800 

9    8,400  12,500  8,400  8,200  5,100 

II    dead  8,700  8,100  7,200 

Rabbits  6  and  7  received  benzol. 

COXCLUSIOXS. 

1.  Benzyl  benzoate  was  found  to  be  without  toxic 
effects  upon  the  leucocytes  of  rabbits. 

2.  Controls  of  benzol  showed  the  well  known  de- 
pression of  the  leucocyte  count. 

3.  A  wide  margin  of  safety  is  present  between 
the  therapeutic  doses  and  the  toxic  doses  of  benzyl 
benzoate,  based  upon  observations  on  rabbits. 


LOBAR  PNEUMONIA  COMPLICATED  BY 
MULTIPLE  ARTHRITIS.* 

Report  of  a  Case. 
By  David  Greexberg,  M.  D., 
New  York, 

Chief  cf  Medical  Clinic  and  Assistant  in  Pathology, 
Lebanon  Hospital. 

The  occurrence  of  two  or  more  diseases,  espe- 
cially of  the  acute  febrile  type,  simultaneously  in 
the  same  individual,  is  of  interest  because  of  its 
bearing  on  diagnosis,  prognosis,  and  treatment. 
Early  during  the  onset  the  presence  of  multiple 
infections  renders  a  diagnosis  difficult  or  impossi- 
ble. When  a  diagnosis  is  established  because  of 
of  signs  and  symptoms  characteristic  of  one  dis- 
ease, manifestations  of  another  disease  may  errone- 
ously be  regarded  as  a  complication  of  the  first. 
Then,  when  the  j^resence  of  two  distinct  entities 
is  recognized,  the  prognosis  becomes  more  uncer- 
tain on  account  of  the  complexity  of  the  factors  to 
be  taken  into  consideration.  Lastly,  should  there 
arise  complications,  it  may  be  almost  impossible  to 
decide  which  of  the  diseases  is  responsible,  which 
often  means  the  difference  between  surgical  inter- 
vention and  absolute  rest. 

With  the  difficulty  thus  encountered  in  separat- 
ing two  diseases,  and  with  the  justifiable  hesitancy 
one  has  in  diagnosing  two  diseases  when  one  dis- 
ease may  possibly  account  for  all  the  symptoms,  it 
is  evident  what  a  problem  it  is  to  estimate  the  fre- 
quency of  such  double  affections.  From  the  pub- 
lished reports  and  Board  of  Health  figi.ires  one  is 
led  to  believe  them  rather  uncommoM.  Yet  it  is 
only  logical  to  assume  that  many  double  infections 
arc  probably  overlooked,  because  when  the  attention 
is  centered  on  a  particular  disease  one  is  likely  to 
overlook  the  appearance  of  another,  regarding  it 

*Read  before  the  Alumni  of  the  Lebanon  Hospital,  New  York, 
-March  2,  1920. 


as  a  complication,  unless  ushered  in  with  violent 
or  characteristic  symptoms.  This  tendency  to  focus 
our  attention  on  one  problem  only  perhaps  explains 
the  comparative  decrease  in  the  incidence  of  ordi- 
nary diseases  during  the  prevalence  of  an  epidemic 
disease.  Many  of  the  ordinary  diseases  are  then 
overlooked  and  are  regarded  as  atypical  cases  of 
the  epidemic  disease. 

From  a  theoretical  viewpoint  one  may  assume 
that  in  the  event  of  two  or  more  infectious  organ- 
isms together  in  the  same  host  there  is  a  certain 
interrelationship,  and  they  have  either  a  deleteri- 
ous or  a  beneficial  effect  on  each  other.  In  vitro, 
one  species  of  organisms  may  have  an  inhibitory 
influence  on  the  growth  and  development  of  the 
other.  The  reverse  is  true  in  other  instances,  when 
the  presence  of  one  organism  may  help  the  develop- 
ment of  the  other,  as  in  the  case  of  an  aerobe,  which 
is  often  necessary  to  facilitate  the  development  of 
an  anaerobe.  Bacteriologists  speak  of  it  as  symbi- 
osis and  enentobiosis  or  synergism  and  antagonism. 
Clinically,  while  the  phenomenon  of  synergism 
may  be  said  to  be  rather  common,  as  in  the  case 
of  secondary  invaders  in  tuberculosis  and  strepto- 
coccus, in  measles  the  phenomenon  of  antagonism 
is  rather  rare.  A  critical  analysis  of  cases  where 
double  infection  occurred  would  be  interesting  if 
such  record  were  available.  In  the  case  here  re- 
ported there  seems  to  have  been  a  shortening  of 
the  febrile  course  by  the  appearance  of  polyarthri- 
tis during  the  course  of  pneumonia. 

Case. — S.  C.  H.,  male,  born  in  the  United  States. 
His  family  history  was  irrelevant.  Previous  his- 
tory: He  had  the  ordinary  diseases  of  childhood. 
His  habits  were  good;  denied  venereal  disease. 
Three  months  previously  he  had  had  an  attack  of 
appendicitis  with  an  abscess,  for  which  he  was 
operated  upon  at  St.  Francis  Hospital.  During 
his  convalescence  pneumonia  developed  (postop- 
erative), and  after  that  he  suffered  from  pain  in 
the  right  shoulder,  which  disappeared  after  about 
three  weeks. 

His  present  illness  began  on  May  7,  1919,  with 
a  chill  and  fever.  The  patient  stated  that  for  two 
days  previous  he  felt  somewhat  tired,  but  he  went 
to  work  on  the  morning  of  the  7th  and  had  to 
come  home  in  the  afternoon  because  he  felt  too  sick 
to  hold  out  longer.  I  saw  him  late  that  afternoon, 
when  he  had  the  appearance  of  a  man  acutely  ill, 
with  eyes  and  throat  congested,  face  flushed,  tem- 
perature 105.2°,  pulse  130,  respiration  20.  There 
were  no  definite  lung  signs  then  except  slightly 
diminished  breathing  and  relative  dullness  at  left 
base,  with  a  few  sibilant  rales  at  right  base.  The 
next  day  there  were  signs  of  lobar  pneumonia  at 
the  left  base  posteriorly  and  in  the  left  axilla.  The 
temperature  remained  at  about  104.5°,  and  pulse 
about  120.  The  respiration  became  more  frequent, 
between  35  and  40.  The  blood  count  at  that  time 
was  30,000,  with  eighty  polymorphonuclears  and 
twenty  lymphoc}tes.  The  urine  contained  a  slight 
amount  of  albumin,  but  no  casts,  pus,  or  blood. 
Sputum  was  blood  tinged  and  later  became  rusty. 
A  culture  of  sputum  showed  the  predominating  or- 
ganism to  be  Type  R'. 


162 


GREEXBERG :   LOBAR  PXEUMOXIA  AXD  MULTIPLE  ARTHRITIS.  ln^'v  Vork 

Medical  Journal. 


On  the  third  day  of  illness  the  patient's  condi- 
tion was  very  serious.  He  had  signs  of  extensive 
involvement  of  the  entire  lower  and  part  of  upper 
left  lungs,  as  well  as  a  small  patch  over  right  angle 
of  scapula.  He  was  cyanotic  and  there  were  some 
moist  rales  over  both  lungs.  He  was  given  atro- 
pine and  digalen  intravenously.  Toward  evening 
some  pain  in  the  left  shoulder  developed  which 
was  thought  to  be  the  result  of  extensive  pleuritic 
involvement. 

The  following  day  the  patient  complained  of 
pain  in  his  left  knee,  and  later  in  the  day,  in  the 
right  ankle.  On  examination,  the  ankle  and  knee 
were  found  to  be  red,  swollen,  and  tender.  About 
the  same  time  the  temperature  began  to  fall,  and 


kles,  both  knees,  both  elbows,  the  left  hip,  left 
shoulder,  and  left  first  and  right  second  metacarpo- 
phalangeal joints  had  been  involved.  During  the 
course  there  were  also  present  small  areas  of  ery- 
thematous patches  around  these  joints.  They  were 
thickened  and  tender  and  varied  in  size  from  one 
to  three  cm.  The  patient  eventually  recovered  com- 
pletely. 

In  the  case  here  reported  there  seems  to  have 
been  a  decided  shortening  of  the  usual  acute  course 
in  lobar  pneimionia.  A  glance  at  the  temperature 
chart  shows  a  drop  in  the  fever  coincident  with  the 
appearance  of  articular  symptoms,  although  there 
was  no  change  in  the  physical  signs  in  the  lungs 
at  that  time.    This  calls  to  mind  the  recent  attempts 


Chart — Temperature  chart  of  S.  C.  H. 


in  twenty-four  hours  was  100.2".  The  left  elbow 
and  right  shoulder  became  red  and  swollen  next 
day.  The  whole  clinical  picture  was  that  of  an 
acute  polyarthritis  of  rheumatic  origin.  There  was 
marked  redness,  much  tenderness  and  swelling  and 
inability  to  move  the  joints,  either  actively  or  pas- 
sively. When  the  first  joints  became  involved  there 
was  a  doubt  as  to  whether  we  were  dealing  \vith 
a  pneumococcus  arthritis.  The  blood  count,  which 
had  gone  up  then  to  48,000,  with  eighty-three  poly- 
morphonuclears, would  have  been  in  favor  of  that 
assumption.  However,  the  patient  looked  much 
better  despite  his  joint  involvement.  The  subse- 
quent manifestations  in  other  joints  and  the  ready 
response  to  salicylates  eliminated  pneumococcus  ar- 
thritis, which  is  usually  monoarticular,  is  associated 
with  a  septic  temperature,  and  does  not  respond 
to  salicylates. 

The  course  of  the  pneumonia  was  rather  unus- 
ual. After  the  temperature  became  normal  the  ex- 
tensive lung  signs  remained  about .  the  same  from 
nine  to  ten  days,  when  signs  of  resolution  slowly 
began  to  appear.  At  the  end  of  about  three  weeks 
the  patient  still  had  some  dullness  over  the  left 
base  posteriorly. 

The  joint  manifestations  ran  a  clinical  course 
typical  of  an  ordinary  attack  of  acute  articular 
rheumatism.  The  migratory  tendency  of  the  joint 
involvement  was  very  decided.  Within  a  week 
after  the  first  appearance  of  the  arthritis  both  an- 


that  have  been  made  to  shorten  the  course  of  cer- 
tain diseases  by  the  introduction  of  nonspecific  bac- 
teria, such  as  polyvalent  vaccines  intravenously. 
The  success  with  chronic  arthritis  in  the  hands  of 
some  observers  by  the  intravenous  injection  of  ty 
phoid  vaccines  received  considerable  attention  four 
or  five  years  ago,  and  only  last  year  there  were 
similar  attempts  made  to  influence  the  course  of 
influenza  by  the  injection  of  streptococci  and  staphy- 
lococci, in  order  to  raise  or  bring  about  a  leucocy-' 
tosis.  Certainly,  some  of  the  favorable  results  that 
some  observers  claim  to  have  obtained  by  polyvalent 
vaccines,  or  sera,  and  phylacogens,  may  not  be  en- 
tirely due  to  a  nonspecific  protein  reaction,  but 
may,  in  some  measure,  be  due  to  the  phenomenon 
of  symbiosis  and  enentobiosis.  It  would  be  worth 
while  to  study  this  subject  from  a  clinical  as  well 
as  a  bacteriological  viewpoint. 
1220  Grand  Concourse. 

Syphilis  and  Pregnancy. — William  J.  Young 
(Surgery,  Gynecology  and  Obstetrics,  May,  1920) 
in  a  study  syphilis  and  pregnancy  came  to  the 
following  conclusions:  Routine  Wassermann  ex- 
amination should  be  made  in  obstetrical  wards  of 
charity  institutions  when  patients  are  admitted. 
It  should  be  just  as  much  the  duty  of  the  obstetri- 
cian to  ascertain  evidence  or  history  of  lues  in  his 
patient  as  to  conduct  delivery. 


July  31,  1920.] 


LONDON  LETTER. 


163 


LONDON  LETTER 

{From  our  own  correspondent) 

Venereal  Disease  Clinics  and  Professional  Secrecy. — Next 
Year's  Census. — Dinner  to  Sir  George  Watkins. 

London,  May  22,  igao. 

In  other  chapters  the  commission  dealt  with  the 
problems  of  infant  mortaHty,  and  conspicuous  con- 
tributory causes  of  loss  of  population  as,  for  ex- 
ample, venereal  disease  and  alcoholism.  With  re- 
spect to  the  treatment  of  venereal  disease  they  re- 
cord their  opinion  that  taking  into  consideration 
the  gravity  of*  the  situation,  the  Ministry  of  Health 
would  be  justified  in  calling  the  attention  of  the 
public  to  the  fact  that  abstinence  from  promiscuous 
intercourse  is  the  only  thoroughly  effective  method 
of  preventing  the  spread  of  disease,  and  that  it  is 
the  urgent  duty  of  every  citizen  who,  in  disregard 
of  the  claims  of  morality  and  citizenship,  exposes 
himself  to  the  risk  of  infection,  to  use  some  method 
of  disinfection  either  personal  or  by  private  medical 
treatment  or  by  attendance  at  an  early  treatment 
centre  at  the  earliest  opportunity.  Further,  if  on 
later  investigation  the  methods  of  selfdisinfection 
should  prove  to  be  more  effecutal  in  preventing  the 
spread  of  venereal  disease  than  the  methods  of  disin- 
fection at  early  treatment  centres,  then  the  National 
Birth  Rate  Commission  think  that  any  difficulties  of 
an  administrative  kind  which  may  now  prevent 
registered  chemists  from  selling  such  disinfectants 
should  be  removed,  provided  such  preparations  are 
only  to  be  sold  when  accompanied  by  a  notice  that 
they  are  to  be  used  for  disinfection  only  and  are 
useless  for  treatment. 

The  report  commented  on  is  an  exceedingly  valu- 
able one,  inasmuch  as  it  discusses  with  the  utmost 
frankness  the  two  outstanding  obstacles  to  a  fr^iitful 
birth  rate.  Also  it  may  be  noted  the  suggestions 
and  findings  of  the  commission  apply  with  almost 
equal  force  to  America  as  to  this  country.  Birth  re- 
striction is  prevalent  in  all  civilized  countries,  and 
of  course,  America  is  not  exempt.  The  most  de- 
plorable feature  of  the  case  is  that  it  is  a  survival  of 
the  least  fit,  or,  at  any  rate,  not  of  the  most  fit, 
The  class  that  is  most  likely  to  bring  forth  progeny 
of  the  type  from  which  the  most  desirable  citizen  is 
evolved,  refuse  to  have  even  decent  sized  families. 
The  inexorable  consequence  must  be  that  if  such  a 
course  be  continued,  the  undesirable  class  will  pre- 
dominate and  will  swamp  the  desirable  class  and 
will  rule  the  world.  This  is  a  very  serious  situation 
and  one  which  must  be  squarely  and  resolutely 
faced. 

Dr.  x\ddison,  the  Minister  of  Health,  received  at 
the  office  of  the  Ministry  on  May  6th,  last,  a  depu- 
tation from  the  London  and  Counties  Medical  Pro- 
tection Society,  Ltd.  The  chairman  of  the  London 
and  Counties  Protection  Society  Dr.  C.  M.  Fegen, 
on  behalf  of  the  deputation,  urged  upon  the  ^Minister 
of  Health,  the  necessity  for  early  legislation  to  pro- 
tect the  medical  officers  of  venereal  disease  clinics 
from  being  compelled  in  the  witnessbox  to  violate 
the  established  principles  of  professional  secrecy, 
and  to  give  information  of  their  patients'  ailments 
and  of  anything  else  which  came  to  their  knowledge 
in  their  professional  capacity.    He  said  that  the 


medical  officers  of  venereal  clinics  were  being  com- 
pelled in  the  law  courts,  under  penalty  of  imprison- 
ment for  contempt  of  court,  to  reveal  what  their 
patients  had  communicated  to  them,  believing  that 
the  information  would  be  regarded  as  absolutely 
confidential.  It  was  pointed  out  that  the  effect  of  this 
would  be  disastrous  to  the  working  of  the  venereal 
disease  clinics.  The  Minister  of  Health  expressed 
his  complete  concurrence  with  the  views  of  the 
deputation,  and  promised  to  do  what  he  could  to 
promote  legislation  as  suggested  by  the  deputation. 
He  said,  moreover,  that  he  felt  certain  that  public 
opinion  would  support  the  maintenance  of  profes- 
sional secrecy  in  connection  with  venereal  disease 
clinics. 

^    ^  ^ 

In  1921  the  decennial  census  of  Great  Britain  is 
to  be  taken.  Viscount  Astor,  secretary  to  the  Min- 
istry of  Health,  has  introduced  into  the  House  of 
Lords  a  bill  making  the  necessary  provision  for  the 
purpose.  Hitherto,  it  has  been  necessary  to  pass  a 
bill  on  the  occcasion  of  each  enumeration,  but 
should  the  present  measure  become  law,  special 
legislation  will  be  dispensed  with  in  future,  and  the 
necessary  arrangements  will  be  provided  for  by 
order  in  council.  Power  is  also  sought  to  direct 
the  taking  of  a  census  every  five  years.  In  future 
enumerations  British  householders  will  be  required 
to  state  the  following  particulars:  1.  Names,  sex, 
age.  2.  Occupation,  profession,  trade  or  employ- 
ment. 3.  Nationality,  birthplace,  race,  language.  4. 
Place  of  abode  and  character  of  dwelling.  5.  Edu- 
cation. 6.  Infirmity  or  disability.  7.  Condition  as 
to  marriage,  relation  to  head  of  family,  parentage, 
issue.  8.  Any  other  matters  with  respect  to  which 
it  is  desirable  to  obtain  statistical  information 
with  a  view  to  ascertaining  the  social  or  civil  con- 
dition of  the  population.  Provision  is  made  for 
the  enumeration  to  be  carried  out  by  the  Registrar 
General  under  the  direction  of  the  Minister  of 
Health,  and  for  the  issue  of  regulations  prescribing 
the  procedure  to  be  followed. 

A  complimentary  dinner  to  Sir  George  Watkins, 
president  of  the  Royal  College  of  Surgeons,  and 
late  consulting  surgeon  to  the  British  Expeditionary 
Forces,  was  held  in  the  Hotel  Great  Central,  Lon- 
don, on  the  evening  of  May  10th,  last.  A  large 
company  was  present,  including  Sir  John  Goodwin, 
Director  General  of  the  Army  Medical  Depart- 
ment; Sir  James  Porter,  late  Director  General  of 
the  Naval  Medical  Services;  Sir  John  Bland  Sut- 
ton, vice-president  of  the  Royal  College  of  Sur- 
geons ;  Sir  William  Fletcher,  representing  the  Medi- 
cal Research  Council ;  Sir  John  MacAlister,  for  the 
Royal  Society  of  Medicine;  Dr.  Alfred  Cox,  for 
the  British  Medical  Association  and  Mr.  F.  G. 
Hazzett,  for  the  Conjoint  Examination  Board  of 
the  Royal  Colleges.  Sir  Cuthbert  Wallace  gave  the 
toast  of  the  evening  which  was  seconded,  if  such  a 
term  is  applicable,  by  no  fewer  than  four  persons. 
Sir  John  Goodwin,  Mr.  E.  F.  White,  Sir  John 
Bland  Sutton  and  Sir  George  Savage,  the  well 
known  alienist,  who  in  the  course  of  his  speech  gave 
a  humorous  sketch  of  Bedlam  some  forty  years  ago. 
The  dinner  was  a  success  from  all  points  of  view. 


Editorial  Notes  and  Comments 


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SCIENCE  AND  IMAGINATION. 
While  it  is  true  that  scientific  knowledge  repre- 
sents the  grasping  of  hard  facts,  this  by  no  means 
signifies  that  the  scientific  man  should  be  devoid  of 
imagination  or  that  imagination  has  no  place  in  the 
building  of  science.  The  discoverer,  the  pioneer  of 
science,  is  notoriously  a  man  of  imagination  or  he 
would  not  be  a  discoverer.  His  is  the  speculative 
mind;  he  theorizes  and  then  sets  himself  to  prove 
that  his  theories  are  right.  In  his  remarkably  able 
and  fascinating  .address  a  few  weeks  ago  as  presi- 
dent of  the  British  Medical  Association,  that  grand 
old  man  of  medicine,  Sir  T.  Clifford  Allbutt,  regret- 
ted the  fact  that  the  schools  are  teaching  too  much 
detail,  and  that  the  universities  do  not  stimulate  the 
imagination  as  in  times  gone  by.  The  true  scientist 
is  born,  not  made;  a  person  can  have  an  abso- 
lutely scientific  mind  without  knowing  one  science 
and  conversely  an  individual  can  have  a  hopelessly 
unscientific  mind  although  his  brain  may  be  gorged 
with  scientific  facts.  Accurate  knowledge  is  essen- 
tial, but  the  gaining  of  such  knowledge  may  be  car- 
ried too  far  and  become  narrow  specialization,  exact 
knowledge  on  one  subject,  but  no  broad  outlook. 
The  human  mind  does  not  need  monuments  of  la- 
borious research  so  much  as  the  play  of  imagination 
of  the  master  mind  which  regards  the  subject  as  a 
whole.  Therefore  Sir  Clifford  insisted  that  sci- 
ence and  imagination  should  go  hand  in  hand  and 
that  detail  should  be  the  complement  of  imagination. 
It  is  obvious  that  science  cannot  make  great  pro- 
gress without  the-  aid  of  imagination.   The  highest 


type  of  man  is  the  theoretical  and  contemplative, 
and  he  only  reaches  perfection  when  these  gifts 
are  allied  with  the  genius  for  bringing  them  into 
effect. 

The  imaginative  genius  frequently  lacks  the  prac- 
tical instinct  and  must  rely  on  the  common  sense 
plodder  to  reduce  his  theories  to  utilitarian  pur- 
poses. But  the  imaginative  man  rs  essential  if 
scientific  medicine  is  to  continue  to  advance,  and 
consequently  the  warning  to  the  modern  schools  and 
universities  not  to  dwell  too  much  on  detail  but  to 
leave  plenty  of  scope  for  the  exercise  of  the  imagi- 
nation is  altogether  justified. 


VACATION  TIME. 
During  evolutionar}-  processes  man  tries  to  fit  into 
the  various  niches  which  are  created  through  his 
own  efforts.  At  times  progress  is  more  rapid  in 
one  field  than  another  and  it  requires  great  effort 
to  maintain  a  balance.  During  all  this  manipulation 
the  struggle  for  existence  makes  itself  manifest  by 
the  continuous  grind  to  which  we  are  subjected. 
The  physician  is  especially  aware  of  these  factors 
which  he  must  face.  He  is  required  to  fit  himself 
into  the  modern  world  with  its  rapidly  changing 
molds,  to  struggle  along  in  a  competitive  race  to 
make,  his  living,  serve  mankind  by  administering 
to  the  sick,  making  his  own  adjustments.  In  this 
constant  striving  he  is  obliged  to  observe  and  give 
back  to  medicine  his  own  findings  and  so  pay  his 
debt  to  science.  He  is  obliged  to  study  the  findings 
of  other  men,  making  use  of  them  for  the  benefit  of 
his  patients. 

Frequently  the  medical  man  does  not  realize  in 
the  course  of  his  constant  endeavor  to  alleviate  suf- 
fering that  he  owes  to  himself  a  period  of 
rest  and  recuperation.  His  responsibilities  are 
greater,  however,  than  those  of  many  other  work- 
ers, for  he  cannot  stop  the  incidence  of  disease  while 
he  leaves  his  practice  and  seeks  a  retreat  from  its 
cares  and  anxieties.  From  time  to  time,  however, 
he  should  think  of  the  duty  he  owes  to  himself. 
We  have  found  that  the  ideal  condition  for  the 
human  body  is  alternate  work  and  rest.  This  holds 
also  for  the  mind.  Many  physicians  do  more  read- 
ing during  their  vacation  time  than  during  the  rest 
of  the  year.  Many  of  them  who  do  not  have  time 
for  study  during  the  busy  months  of  active  prac- 
tice take  the  opportunity  for  study.  They  review 
the  literature  that  has  accumulated  and  in  the 
peace  and  quiet  of  the  country  they  can  assimilate 
and  make  use  of  the  material  they  find.    To  be 


July  31,  1920.] 


EDITORIAL  ARTICLES 


165 


able  to  cast  aside  the  responsibilities  of  their  every- 
day tasks  and  revel  in  the  medical  literature  con- 
stitutes a  real  vacation  for  these  men.  They  are 
refreshed  and  return  to  their  work  with  a  new 
vigor.  Other  physicians,  who  are  able  to  combine 
their  studies  with  their  practical  work,  require  a 
change  which  they  find  in  the  more  vigorous  out 
of  door  sports,  and  the  most  exciting  thing  many  of 
them  do  during  their  vacation  days  is  to  lie  on  the 
banks  of  some  quiet  stream  tending  a  fishing  rod 
and  dreaming  of  the  time  they  ran  away  from  school 
to  enjoy  a  similar  day's  sport. 

In  any  event,  the  physician  is  entitled  to  a  vaca- 
tion. He  deserves  it  and  owes  it  to  himself  and  to 
his  patients.  He  returns  to  his  work  with  a  new 
outlook  upon  life  and  can  give  more  of  himself, 
for  the  life  of  the  physician,  more  than  that  of  any 
other  occupation,  consists  in  giving.  But  he  must 
keep  himself  fit,  in  body  and  in  mind. 


THE  TREATMENT  OF  VOMITING  IN 
NURSLINGS. 

A  problem  of  almost  daily  occurrence  to  be  solved 
by  the  physician  is  that  of  the  treatment  of  vomit- 
ing in  nursing  infants.  In  the  first  place  regurgi- 
tation, where  the  infant  rejects  the  excess  of  milk 
which  it  has  ingested,  must  not  be  mistaken  for 
vomiting.  This  takes  place  immediately  after  nurs- 
ing, the  milk  rejected  being  liquid  and  without  any 
change  having  occurred.  Vomiting  arises  some  time 
after  nursing  and  the  milk  is  coagulated.  In  the 
newly  born  hematemesis,  melena  and  incoercible 
vomiting  due  to  pyloric  stenosis  or  from  a  congenital 
intolerance  for  all  kinds  of  milk  are  encountered. 
These  cases  are  exceptional,  so  that  the  vomiting 
due  to  an  alimentary  cause  or  to  some  intrinsic 
pathological  factor  alone  will  be  considered.  In  the 
former  the  vomiting  is  produced  either  by  irregu- 
larity in  feeding,  by  overfeeding  or  underfeeding 
or  something  defective  in  the  food.  The  causes  are 
to  be  looked  for  in  the  hygiene  or  defective  diet  of 
the  infant,  its  general  state  of  health  and  in  a  too 
great  richness  of  butter  or  casein  in  the  milk.  If 
the  child  is  bottle  fed  the  cause  may  be  bad  feeding 
of  the  cow  furnishing  the  milk,  various  changes  of 
the  milk  occurring  during  transportation  or  to  un- 
cleanliness  of  the  instruments— bottle  and  rubber 
nipple — or  an  excess  of  butter  or  casein. 

In  a  weaned  infant  the  abuse  of  feculents  may 
lead  to  the  same  result,  like  any  other  food  dispro- 
portionate to  the  age  of  the  child.  Various  path- 
ological states  may  produce  vomiting.  Thus  it  is 
in  aflfections  of  the  digestive  tract — dyspepsia,  en- 
teritis, infantile  cholera,  appendicitis,  intestinal  oc- 


clusion or  invagination,  hernia  and  aft'ections  of 
other  systems — meningitis,  encephalitis,  various  in- 
fectious states,  etc.  If  the  infant  is  breast  fed  the 
feedings  should  be  regulated  and  given  at  proper  in- 
tervals, frecjuent  if  there  is  reason  to  suppose  that 
the  baby  is  underfed.  The  health  and  diet  of  the 
nurse  must  be  examined  into  and  an  analysis  of  the 
milk  should  always  be  made  when  the  vomiting  per- 
si.sts.  Before  each  feeding  a  teaspoonful  of  the 
nurse's  milk  should  be  given  to  which  has  been 
added  a  pinch  of  chymosin,  pegnin  or  lab  ferment. 
Maternal  milk  should  not  be  regarded  defective  un- 
til the  sterile  milk  test  has  been  made.  Stop  maternal 
feeding  for  two  days,  during  which  time  the  nurs- 
ling is  fed  on  cow's  milk  properly  diluted  and 
sugared ;  if  the  vomiting  ceases  or  decreases  it  is 
due  to  the  nurse's  milk. 

If  the  infant  is  bottle  fed  the  origin  of  the  milk 
must  be  watched,  as  well  as  cleanliness  of  the  bot- 
tles and  nipples.  Aerophagy  is  avoided  by  holding 
the  bottle  so  that  the  neck  is  always  filled  with  milk 
during  the  feeding.  After  the  fourth  month  begin 
to  concentrate  the  milk  according  to  the  infant's 
tolerance.  Light  vegetable  broth  and  maltose  bouil- 
lon can  also  be  given.  Anhydric  diet  is  indicated  in 
vomiting  resulting  from  acute  diseases  for  twelve 
to  twenty-four  hours  and  should  it  still  persist  a 
dry  diet  may  be  resorted  to  for  two  or  three  days. 
If  the  baby  is  weaned  the  feedings  must  be  regu- 
lated and  the  abuse  of  feculents,  meat  and  fats 
avoided.  Other  therapeutic  measures  such  as  hot 
packs  over  the  epigastric  region  can  be  applied  in 
appendicitis,  while  i.f  the  vomitus  has  a  butyric  odor 
or  if  there  is  a  gastrointestinal  intoxication,  gastric 
lavage  may  be  done.  A  teaspoonful  of  sodium 
citrate  or  dilute  hydrochloric  acid  in  proper  dose 
can  be  given  before  each  feeding.  Operation  is 
urgently  required  if  the  case  is  one  of  pyloric  ste- 
nosis, appendicitis  or  invagination. 


INSOMNIA  DUE  TO  DYSPEPTIC  STATES. 

Dyspeptic  subjects  frequently  suft'er  from  dis- 
agreeable forms  of  insomnia  presenting  certain 
characteristics  which  individualize  them  and  facili- 
tate their  diagnosis.  In  these  forms  of  insomnia 
the  patients  are  nervous,  overwrought,  and  in  a 
state  of  depression  quite  incompatible  with  a  nor- 
mal life.  In  the  end  a  true  neuropathic  condition 
exists. 

There  aie  three  principal  varieties  of  insomnia 
due  to  digestive  disturbances.  In  the  first  and 
most  common  form  the  patient  falls  asleep  easily 
l)ut  is  awakened  regularly  at  a  certain  hour  by  a 
gastric  paroxysm,  accompanied  by  pain,  pyrosis, 


166 


XEJrS  ITEMS. 


[Xe\v  YoRr; 
Medical  Journal. 


and  belching,  sometimes  relieved  by  a  change  of 
position.  This  pain  follows  the  movements  of  the 
patients  to  a  certain  extent  and  becomes  localized 
on  the  side  upon  which  they  lie.  It  is  sufficiently 
severe  to  prevent  sleep  and  only  subsides  toward 
morning,  allowing  the  patient  to  fall  into  a  heavy 
sleep  from  which  he  arises  in  a  state  of  fatigue, 
without  energy,  possibly  suffering  from  vertigo, 
and  quite  incapable  of  physical  or  intellectual  effort. 

In  the  second  variety  of  insomnia,  the  patient 
always  experiences,  at  about  the  same  hour  every 
night,  a  feeling  of  malaise  which  seems  in  no  way 
to  be  due  to  the  stomach.  After  a  period  of  rest- 
lessness, haunted  by  disagreeable  dreams,  he 
awakens,  drenched  with  perspiration,  with  a  rapid 
pulse,  a  difficult,  anxious  respiration,  and  a  sensa- 
tion of  distress  and  painful  weight  in  the  cardiac 
region.  Assuming  the  sitting  posture  and  belching 
up  considerable  gas  affords  some  relief,  but  the 
patient  is  often  unable  to  fall  asleep  for  hours,  and 
as  a  consequence  in  the  morning  he  is  fagged  out 
and  only  by  the  greatest  effort  is  able  to  leave 
his  bed. 

In  the  third  variety  tlie  patients  are  wakeful  all 
night  and  lose  consciousness  only  during  brief 
periods.  The  best  way  to  prevent  these  cases  of 
insomnia,  which  are  frequently  encountered  in 
practice  and  often  misunderstood,  as  well  as  the 
nervous  states  engendered  thereby,  is  to  treat  the 
digestive  disturbances  which  are  the  underlying 
cause. 


CO^IMERCE  AXD  PS\''CHOLOGY. 

A  few  years  ago  a  narrow  minded  commercial 
man  would  have  enjoyed  an  article  which  recently 
appeared  in  a  Xew  York  paper  on  the  mistakes 
and  failures,  even  the  cruelty,  of  those  doctors  who 
undespairingly  wrestle  against  tuberculosis.  "Waste 
of  time ;  waste  of  Government  funds,"  his  com- 
ment. Today  he  pricks  up  his  ears ;  psychology  can 
teach  him  how  to  get  the  best  value  from  employ- 
ees; can  save  him  many  a  compensation  and  pen- 
sion. Here  is  one  of  his  helpers,  a  gentleman  who 
puts  E.  P.  R.  I.  after  his  name,  which  simply  means 
he  is  an  employment  psychologist  in  the  rubber 
industry,  and  the  results  of  his  work  are  an  enor- 
mous saving  to  the  company.  This  is  explained  in 
the  Journal  of  Applied  Ps\cholog\  for  ^^larch. 
1920. 

But  those  who  cannot  appreciate  the  ramifications 
of  medical  science  certainly  will  not  understand  the 
work  which  is  being  added  yearly  to  the  tired  doc- 
tors' crowded  day.  Indirectly,  even  the  general 
practitioner  must  be  able  to  meet  and  discuss  cases 
with  a  real  or  partly  assumed  interest.  He  must 
agree  with  or  fight  the  law  court  verdict  as  to 
mental  conditions,  and  a  dual  personality  case  in 
an  employee  does  not  mean  a  dual  fee ;  perhaps, 
even  none  at  all. 


CANADA'S  WORK  FOR  DISABLED 
SOLDIERS. 

In  a  splendid  pamphlet  just  published  by  the  De- 
partment of  Soldiers'  Civil  Reestablishment,  in  Ot- 
tawa, is  described  the  work  that  is  being  done  for 
the  disabled  soldiers  in  Canada.  From  a  careful 
reading  of  the  book  it  will  be  seen  that  this  work 
has  been  done  with  energy  and  thoroughness.  Xo 
department  has  been  neglected.  Careful  attention 
has  been  given  to  the  physiotherapeutic  fields,  a 
branch  of  therapeutics  which  has  come  to  the  fore 
during  the  war,  showing  that  more  progress  can  be 
made  by  carefully  directed  physical  methods  than 
by  surgery  or  medicine.  In  fact,  it  has  grown  to  be 
one  of  the  most  dependable  and  most  widely  used 
methods  of  treatment. 

The  work  done  has  been  of  a  very  high  order  and 
every  effort  made  to  secure  comfortable  and  cheerful 
surroundings  for  the  men.  Many  needs  have  received 
attention  that  were  neglected  in  former  postwar 
methods  of  treatment.  Modern  dentistry  has  re- 
ceived the  attention  it  deserves.  Workers  in  this 
field  will  read  this  valuable  book  with  a  feeling  of 
great  satisfaction. 


News  Items. 


Virginia  Medical  Meeting. — The  Medical  Soci- 
ety of  \'irginia  will  hold  its  next  meeting  October 
26th  to  29th  in  Petersburg. 

Married. — Dr.  Albert  Ernest  Gallant,  of  Forest 
Hills.  X.  v.,  and  ]Mrs.  ^Vlary  Claire  Parsons  were 
married  June  14th.    They  will  live  in  Forest  Hills. 

Death  of  Dr.  Zander. — Dr.  Gustav  Zander,  the 
originator  of  the  Zander  system  of  mechanical 
therapeutics,  is  dead  at  Stockholm  at  the  age  of 
eighty-five. 

Proposed  American  Hospital  in  Philippines. — 

A  campaign  to  raise  funds  for  the  establishment  of 
an  American  hospital  is  being  conducted  by  Ameri- 
can residents  of  the  Philippines. 

Royal  College  of  Surgeons  Elects  Officers. — 
Sir  Anthony  Bowlby  has  been  elected  president  and 
Sir  Charles  A.  Ballance  and  Sir  John  Bland  have 
been  elected  vice-presidents  of  the  Royal  College  of 
Surgeons. 

Italian   Congress  of   Medical   Radiology. — A 

congress  under  the  auspices  of  the  Societe  Italiana 
di  Radiologia  Aledica  will  be  held  October  28th  to 
30th  in  Rome,  under  the  presidency  of  Professor 
Francesco  Ghilarducci. 

Appointment  of  Dr.  Geiger. — Dr.  Jacob  Geiger 
has  been  appointed  director  of  the  pathological 
laboratories  of  the  Xew  York  Diagnostic  Clinics 
and  after  a  survey  of  the  better  American  labora- 
tories will  reorganize  the  present  laboratories  of  this 
institution. 

Dinner  to  Dr.  Mayo. — A  dinner  was  held  in 
London  on  Tuesday,  July  6th,  with  the  double  ob- 
ject of  honoring  Dr.  Charles  H.  Mayo  and  of  in- 
troducing to  public  notice  the  movement  for  found- 
ing an  American  Hospital.  The  speakers  included 
Lord  Reading,  Dr.  Mayo,  Mr.  Balfour,  Mr.  John 
W.  Davis,  and  Sir  Arbuthnot  Lane. 


July  31,  1920.] 


XEU'S  ITEMS. 


167 


Major  General  Gorgas  to  Lie  in  Arlington. — 

The  body  of  Major  General  Gorgas,  who  died  re- 
cently in  London,  will  be  buried  in  Arlington  Na- 
tional Cemetery. 

Appropriation  to  Fight  Disease. — An  appropri- 
ation of  380,000  has  been  made  to  the  Xew  York 
City  Health  Department  by  the  Board  of  Estimate 
for  the  purpose  of  preventing  the  invasion  of 
cholera,  bubonic  plague,  smallpox,  and  typhus,  which 
are  now  ravaging  sections  of  Europe. 

Iowa  Medical  Meeting. — The  Iowa  State  Med- 
ical Society  held  its  sixty-ninth  annual  meeting  May 
12th  to  14th  in  Des  Moines.  The  following  officers 
were  elected:  President.  Dr.  Alanson  M.  Pond,  of 
Dubuque ;  vice-presidents.  Dr.  C.  P.  Howard,  of 
Iowa  City;  Dr.  J.  \V.  Osborn,  of  Des  Moines.  The 
next  meeting  will  be  held  in  Des  Moines. 

Ontario  Medical  Meeting. — The  Ontario  Med- 
ical Association  at  a  meeting  held  the  latter  part  of 
May  elected  the  following  officers :  President,  Dr. 
J.  H.  Mullin,  of  Hamilton :  vice-presidents.  Dr.  F. 
J.  Farley,  of  Trenton,  and  Dr.  F.  A.  Clarkson,  of 
Toronto ;  secretary.  Dr.  T.  G.  Routley,  of  Toronto ; 
treasurer,  Dr.  G.  Stewart  Cameron,  of  Peterboro. 

Medical  Society  of  Northern  Virginia  and  the 
District  of  Columbia. — At  a  meeting  held  at  Al- 
exandria on  May  19th  this  society  elected  the  fol- 
lowing officers :  President,  Dr.  George  Tully 
Vaughan,  Washington ;  vice-president.  Dr.  Arthur 
Hooe,  Washington ;  recording  secretary.  Dr.  Wil- 
liam T.  Davis,  \\'ashington ;  corresponding  secre- 
tary, Dr.  Joseph  D.  Rogers,  Washington ;  treasurer. 
Dr.  Robert  S.  Lamb,  Washington. 

Arkansas  Medical  Society. — The  Arkansas 
State  Medical  Association  met  recently  in  Eureka 
Springs  and  elected  the  following  officers :  Presi- 
dent, Dr.  G.  A.  Warren,  of  Black  Rock ;  vice- 
presidents.  Dr.  Robert  H.  Huntington,  of  Eureka 
Springs ;  Dr.  A.  J.  Clinton,  of  Lockesburg,  and  Dr. 
Thad  Cothern,  of  Jonesboro ;  secretary  editor.  Dr. 
William  R.  Bathurst,  of  Little  Rock  (reelected)  ; 
treasurer.  Dr.  Henry  R.  Kirby,  of  Little  Rock. 
The  next  meeting  will  be  held  in  Hot  Springs. 

Virginia  Commission  on  Medical  Education. — 
The  following  medical  men  have  been  appointed  to 
the  Commission  on  Medical  Education  in  Virginia, 
the  body  which  has  been  created  to  make  recom- 
mendations leading  to  the  establishment  of  a  single 
state  supported  medical  school  in  Virginia :  Dr. 
Beverley  R.  Tucker,  of  Richmond;  Dr.  James  H. 
Dillard,  of  Charlottesville ;  Dr.  Julian  A.  Burrus, 
of  Blacksburg;  Dr.  Stuart  ]^IcGuire,  of  Richmond, 
and  Dr.  Theodore  Hough.  University  of  Virginia. 

Massachusetts  Central  Health  Council. — A 
Central  Health  Council  for  the  purpose  of  promot- 
ing cooperation  between  the  various  health  agencies 
throughout  the  state  has  been  organized  in  !Massa- 
chusetts.  In  the  new  organization  are  represented 
public  health  nursing,  child  welfare,  medical  and 
dental  groups,  tuberculosis,  cancer,  state  and  local 
health  officials,  the  Red  Cross,  and  the  American 
Public  Health  Association.  Dr.  Enos  H.  Bigelow, 
of  Framingham,  is  president.  It  is  expected  that 
by  means  of  this  organization  duplication  aYid  over- 
lapping of  duties  may  be  eliminated. 


Police  Department  Sanitarium. — Plans  are 
under  way  for  the  erection  of  a  sanitarium  in  the 
Catskills  or  in  the  Adirondacks  for  members  of  the 
Xew  York  City  police  department  who  become  ill. 

United  Hospitals  Report. — According  to  an  an- 
nouncement by  a  member  of  the  executive  com- 
mittee, the  United  Hospitals  Fund  of  New  York 
last  year  provided  2,438,811  hospital  days,  of  which 
1,203,728  were  free  days.  Free  treatment  was  given 
to  698.335  persons. 

Sanitary  Code  Amended  to  Prevent  Anthrax. 
— The  Sanitary  Code  of  Xew  York  City  has  been 
amended  to  provide  for  sterilization  of  hair  used 
in  toilet  articles,  in  order  to  prevent  anthrax.  The 
sterilization  must  be  according  to  rules  laid  down 
by  the  Board  of  Health. 

Complete  Medical  Course  at  Wisconsin  Uni- 
versity.— The  medical  course  of  the  University 
of  Wisconsin,  heretofore  only  two  years,  will  be 
expanded  to  a  complete  four  year  course,  by  the 
terms  of  legislation  recently  enacted.  The  teaching 
of  the  third  year  will  probably  be  offered  in  the  fall 
of  1923  and  that  of  the  fourth  year  in  the  fall  of 
1924.  A  state  hospital  will  also  be  established  at 
Madison. 

United  States  Civil  Service.  —  The  United 
States  Civil  Service  Commission  announces  exami- 
nations on  December  1,  1920,  for  the  positions  of 
bacteriologist  at  $130  to  $180  a  month,  associate  bac- 
teriologist at  $90  to  $130  a  month,  assistant  bacter- 
iologist at  $70  to  S90  a  month,  junior  bacteriologist 
at  $70  a  month,  and  junior  bacteriologist  fpart  time) 
at  S30  to  $50  a  month.  Announcement  is  also  made 
of  an  examination  on  August  31st  for  the  position 
of  pharmacologist  in  the  Public  Health  Service,  at 
$3,000  a  vear. 

 ^  

Died. 

BR.A.XDEXBURG. — In  New  York,  N.  Y.,  on  Saturday.  July 
17th,  Dr.  Charles  Wesley  Brandenburg,  aged  sixty-nine 
years. 

Campbell. — In  New  York,  N.  Y.,  on  Sunday,  July  2Sth, 
Dr.  Harry  E.  Campbell,  of  Pittsburgh,  Pa.,  aged  sixty-one 
years. 

Cook. — In  West  Stockholm,  N.  Y.,  on  Friday,  July  9th, 
Dr.  Martin  Button  Cook,  aged  eighty  years. 

EiDEXMULLER. — In  San  Francisco,  Cal.,  on  Saturday,  July 
10th,  Dr.  William  Cooper  Eidenmuller.  aged  sixty-four 
years. 

Flagg. — In  Hyde  Park,  Vt.,  on  Friday,  July  9th,  Dr. 
Rowley  Smith  Flagg,  aged  thirty-two  years. 

Kix  MOUTH. — In  Belmar,  X.  J.,  on  Wednesday,  July  21st, 
Dr.  Hugh  S.  Kinmouth,  aged  seventy-three  years. 

Lester. — In  Seneca  Falls,  N.  Y.,  on  Sunday,  July  18th, 
Dr.  Elias  Lester,  aged  eighty- four  years. 

LoxG. — In  Haddonfield,  N.  J.,  on  Wednesday,  July  14th, 
Dr.  William  Sumner  Long,  aged  sixty-five  years. 

McCuRDY. — In  Bangor,  Me.,  on  Thursday,  July  8th,  Dr. 
Charles  L.  !McCurdy,  aged  sixty-six  years. 

Parker. — In  Willimantic,  Conn.,  on  Saturday,  July  17th, 
Dr.  Theodore  Raymond  Parker,  aged  sixty-four  years. 

Parsoxxet. — In  Newark,  N.  J.,  on  Tuesday,  July  20th, 
Dr.  Victor  Parsonnet,  aged  forty-nine  years. 

Smith. — In  Bridgeport,  Conn.,  on  Wednesday,  July  14th, 
Dr.  Edwards  M.  Smith,  aged  sixty  years. 

Yax  Wert. — In  New  York,  N.  Y.,  on  Sunday,  July  25th, 
Dr.  John  Irving  Van  Wert,  of  Patton,  Pa.,  aged  fifty-five 
years. 


Book  Reviews 


FOLKLORE  IN  THE  OLD  TESTAMENT. 

Folklore  in  the  Old  Testament.  Studies  in  Comparative 
Religion,  Legend  and  Law.  By  Sir  James  George 
Frazer,  Hon.  D.  C.  L.,  Oxford;  Hon.  LL.D.,  Glasgow; 
Hon.  Litt.  D.,  Durham  Fellow  of  Trinity  College,  Cam- 
bridge. In  Three  \^olumes.  London :  Macmillan  and 
Company,  Limited,  1919.  Pp.  xxv-569;  xxi-569;  xviii- 
566. 

"The  proper  study  of  mankind  is  man."  IMan 
is  no  less  the  proper  study  of  that  branch  of  human 
interests  which  pertains  to  the  discovery  and  the 
maintenance  of  the  principles  upon  which  his 
health  rests,  namely  medicine.  Sir  James  G.  Frazer 
has  been  one  of  the  chief  servants  in  the  past  in 
furnishing  an  extensive  backgrotjnd  for  any  branch 
of  study  of  man's  needs,  a  background  whose  chief 
theme  has  been  man  and  man  only.  For  his  works 
are  concerned  with  gathered  material  from  the 
records  of  humanity  itself,  records  engraved  in 
folklore,  custom,  superstition,  religious  belief  and 
practice,  in  the  actions  and  modes  of  thought  dis- 
coverable among  all  races  and  all  conditions  of 
men  still  to  be  found  upon  the  face  of  the  earth  and 
in  whatever  traces  of  former  times. 

Psychological  medicine  at  least  has  come  to  find 
such  material  indispensable  in  investigation  of  the 
reactions,  the  archaic  modes  of  thought  and  feeling, 
the  residue  of  experiences  which  still  linger  in  the 
unconscious  of  each  individual.  These  have  left 
their  mark  in  deeply  fixed  tendencies  which  lie  in 
the  hidden  mental  life  of  man  and  play  an  enormous 
part  in  determining  outer  reactions,  still  influencing 
man's  attempts  to  deal  with  the  social  world  in  which 
he  lives  today.  Frazer  himself  says  in  the  preface 
to  these  recent  volumes :  "The  instrument  for  the 
detection  of  savagery  under  civilization  is  the  com- 
parative method,  which,  applied  to  the  human  mind, 
enables  us  to  trace  man's  intellectual  and  moral 
evolution,  just  as,  applied  to  the  human  body,  it 
enables  us  to  trace  his  physical  evolution  from  lower 
forms  of  animal  life.  There  is,  in  short,  a  com- 
parative anatomy  of  the  mind  as  well  as  of  the 
body,  and  it  promises  to  be  no  less  fruitful  of  far- 
reaching  consequences,  not  merely  speculative  but 
practical,  for  the  future  of  humanity." 

The  author  has  at  his  command  such  a  vast 
amount  of  this  material  gathered  and  sorted  and 
compared  by  him  through  many  years  of  scholarly 
work  that  he  can  bring  to  bear  an  overwhelming 
force  of  fact  upon  any  theme  of  man's  develop- 
ment and  man's  interest  which  he  chooses  as  his 
starting  point.  The  title  of  these  volumes  suggests 
at  once  a  pathway  into  human  history  where  the 
comparative  method  must  yield  rich  results  and  at 
the  same  time  grant  new  and  deeper  appreciation 
of  the  introductory  topics  themselves.  These  be- 
long to  the  ancient  Hebrew  religion,  which  in  its 
turn  is  of  fundamental  interest  to  all  Christendom. 
From  the  study  of  these  topics  there  comes  an  illu- 
mination of  still  more  fundamental  psychological 
facts  out  of  which  these  larger  formulas  of  religion 
have  sprung.  The  author's  spirit  of  reverent  ap- 
preciation of  truths  and  modes  of  thought  and  be- 
lief which  have  rendered  tremendous  service  to 


humanity,  as  well  as  his  fearless  seeking  of  the 
fundamental  human  psychology  underneath,  are 
warrant  for  the  true  value  of  these  books.  He 
has  moreover  a  literary  style  of  more  than  usual 
grace  and  beauty  which  has  its  basis  in  a  genuine 
spirit  of  kindly  con.structive  comparison  and  criti- 
cism, an  ability  not  only  to  see  two  sides  of  a  ques- 
tion but  to  bring  these  harmoniously  into  a  mutual 
service  in  the  search  for  underlying  fact.  Through 
all  this  there  runs  a  bubl^ling  stream  of  humor 
which  lends  to  the  reader  a  quicker  appreciation 
of  the  absurdities  and  false  logic  of  much  of  the 
primitive  affective  form  of  thinking  and  the  results 
to  which  such  thinking  leads.  At  the  same  time  it 
makes  the  reader  more  tolerant,  reaching  as  it  does 
unawares  into  his  unconscious  symjjathy  with  the 
infantile  reactions  of  our  ancestors.  When  we  con- 
sider the  etiological  factors  our  judgments  are  tem- 
pered. 

Frazer  has  taken  for  the  arrangement  of  his  work 
certain  important  or  certain  strangely  obscure  topics 
pertaining  to  the  Old  Testament  religion  and  then 
has  given  himself  license  to  range  freely  over  the 
face  of  the  earth  for  similar  material.  He  thus 
illustrates  the  fuller  meaning  of  these  things  as  the}" 
lie  in  the  origin  and  development  of  the  Hebrew 
faith.  He  shows  the  inherent  value  and  significance 
of  these  factors  as  they  appear  different  merely  in 
outward  form  in  the  religions  and  customs,  the 
hopes  and  fears,  of  men  over  the  wide  world  and 
through  dififerent  times.  Thus  he  also  clears  up  man}- 
an  obscurity  and  gives  meaning  where  the  orig- 
inal pragmatic  value  had  been  covered  over  through 
the  distortions  of  reinterpretation  and  redirection 
of  the  underlying  significance. 

For  the  literary  and  the  theological  critic  he  has 
an  interesting  opening  discussion  of  the  twofold 
record  embodied  in  the  Old  Testament,  the  earlier 
traditional  one,  the  more  picturesque,  rich  in  redo- 
lent folklore,  as  Frazer  himself  describes  it,  and 
the  later  intellectualized  version  of  the  same  ma- 
terial made  by  the  priestly  cult.  He  discusses  the 
creation  and  fall  of  man  with  the  paiticipation  of 
the  serpent  in  the  latter,  his  bringing  of  the  mes- 
sage, the  fatal  interpretation  of  which  led  to  death, 
to  all  of  which  rich  parallels  are  foimd  in  widely 
different  parts  of  the  earth.  The  discussion  of  the 
mark  put  upon  Cain  and  the  reason  for  this  mark 
is  a  significant  chapter  for  the  earliest  history  of 
legal  conceptions  and  the  faint  foreshadowings  of 
legal  code. 

Comparative  study  leaves  the  reader  with  a 
far  different  regard  for  Cain  and  a  very  dif- 
ferent understanding  of  his  position  in  early  society 
than  the  orthodox  theological  or  legal  one  would 
afford.  Some  confusing  discrepancies  in  the  nar- 
rative are  also  resolved  when  we  learn  that  Je- 
hovah was  really  kindly  disposed  to  Cain,  this  "first 
Mr.  Smith,  for  Cain  means  Smith,"  as  the  author 
considerately  tells  us.  He  was  probably  protected 
by  the  mark  set  upon  him  from  his  victim's  ghost, 
not  branded  with  a  sign  of  f rightfulness  and  shame, 
the  former  according  better  with  the  primitive  esti- 
mate of  a  murderer's  status  in  society.    Feeling  is 


July  31,  1920.] 


BOOK  REVIEWS. 


169 


altered  also  in  regard  to  the  apparent  scheming  of 
Jacob  against  his  older  brother  when  it  is  learned 
that  there  was  once  a  widespread  existence  of  ulti- 
mogeniture which  preceded  the  custom  of  primo- 
geniture known  to  more  recent  society.  The  latter 
has  been  so  long  accepted  that  the  memory  of  a 
reverse  principle  in  society  has  fallen  to  the  level 
of  the  distorted  tale  by  which  Jacob's  character  has 
long  been  defamed. 

Great  interest  attaches  to  the  comparative  study 
of  the  legend  of  the  flood.  This  long  chapter  is 
a  reprint  of  the  annual  Huxley  lecture  delivered  by 
the  author  and  therefore  is  especially  characterized 
by  the  writer's  charm  of  literary  production,  his 
gracious  handling  of  opposing  views,  his  delicate 
humor  with  which  he  makes  merry  with  his  readers, 
though  never  discourteously  to  the  childish  thinkers 
of  the  past,  over  their  infantile  type  of  thought  and 
narrative  which  he  in  such  manner  more  fully 
reveals.  This  chapter  would  form  a  valuable  mono- 
graph in  itself  upon  a  much  investigated,  much  con- 
tested subject  and  one  upon  which  Frazer's  studies 
3-ield  vast  stores  of  material  illustrative  of  uncon- 
scious modes  of  thought  and  the  content  of  this 
deeper  mental  life.  Perhaps  still  more  important 
in  questions  of  medical  psychology,  in  the  light  of 
Freud's  investigations  in  the  relations  of  the  indi- 
vidual to  the  family  group,  is  the  extensive  chapter 
dealing  with  the  slow  development  of  social  feeling 
and  custom  in  regard  to  cousin  marriages  and  the 
marriage  of  a  wife's  sister  or  of  a  deceased  brother's 
wife.  The.se  subjects  are  introduced  l)y  the 
pastoral  tale  of  Jacob's  wooing  of  the  two 
sisters,  Leah  and  Rachel,  the  older  necessarih'  be- 
fore the  younger  more  desired  one.  The  chapter 
consists  of  a  long  discussion  of  the  gradual  altera- 
tion of  social  feeling  and  custom  in  regard  to  these 
marriages.  It  is  full  of  illustrative  material  but  falls 
almost  into  the  category  of  extremely  technical  mat- 
ter, for  the  details  which  regulate  and  belong  to 
these  customs  among  different  peoples  and  at  dif- 
ferent times,  as  social  feeling  and  custom  pass  from 
one  stage  to  another,  would  require  special  time  and 
application  for  their  .study.  It  forms  nevertheless 
a  valuable  chapter  for  such  reference  and  in  its 
general  revelations  throws  light  upon  the  problems 
lying  within  the  present  day  unconscious  "family 
complex"  with  its  place  in  social  history  as  well  as 
in  individual  conflict. 

The  literary  background  in  which  all  these  col- 
lected details  of  comparative  matter  are  woven  to- 
gether, through  the  author's  ripe  scholarship  and 
power  as  a  writer,  is  never  one  to  tempt  to  idle 
self  enjoyment.  It  stimulates  to  thought  and  specu- 
lation of  many  sorts.  He  revives  a  fading  interest 
in  the  Old  Testament,  one  which  ought  not  to  pass 
away  but  one  which  should  grow  to  a  wider  and 
deeper  appreciation  of  its  stores  of  material  because 
of  his  treatment.  Frazer's  three  volumes  deserve 
a  place  on  the  shelves  of  the  library,  those  shelves 
which  stand  closest  to  the  retreat  of  an  idle  hour 
and  those  most  accessible  for  the  busy  student.  They 
should  form  part  of  the  indispensable  equipment  of 
the  special  worker  in  the  mysteries  and  complexities 
of  the  mental  disturbances  of  the  men  and  women 
of  today. 


IRISH  FOLKLORE. 

Visions  and  Beliefs  in  the  West  of  Ireland.  Collected  and 
Arranged  by  Lady  Gregory.  With  Two  Essays  and 
Notes  by  W.  B.  Yeats.  In  Two  Series.  Illustrated.  New- 
York  and  London:  G.  P.  Putnam's  Sons  (The  Knicker- 
bocker Press),  1920.    Pp.  vii-293;  iii-343. 

Oh,  to  live  in  the  enchanted  land  of  Ireland,  to 
share  the  hospitable  mood  of  its  people  which  freely 
welcomes  to  their  daily  life  the  strange  images  of 
the  dream  world !  One  can  steep  oneself  in  Lady 
Gregory's  volumes  until  the  partitions  between  this 
world  and  some  other  are  fairly  dissolved — for  the 
moment,  until  one  again  awakes.  It  is  perhaps  too 
bad  that  most  of  us  on  both  sides  of  the  Atlantic 
have  been  so  trained  in  scientific  thought,  we  have 
kept  ourselves  so  well  afloat  in  the  world  of  logical 
sequence,  because  it  seemed  useful  and  workable  so 
to  do,  that  we  cannot  be  satisfied  with  continual 
wandering  on  such  uncertain  boundaries.  Some  ad- 
vanced thinkers  have  even  dug  out  from  the  work- 
ings of  the  human  mind  a  single  unifying  formula, 
they  call  it  "wish  fulfilment,"  which  sets  all  these 
strange  beings  to  scampering  into  the  realm  of 
unsubstantiality  and  accounts  for  all  their  strange 
forms  and  trickeries.  J\Ir.  Yeats  in  his  labored 
comments  has  no  such  simple  satisfying  explana- 
tion. His  attempts  to  explain  and  to  locate  these 
beings,  essences,  whatever  they  may  be,  show  a  lack 
of  logic  which  may  satisfy  a  puerile  animistic  style 
of  thinking  but  which  hardly  accords  with  the  sim- 
ple, logical  directness  of  evolution.  Cause  as  a 
fundamental  background  gradually  unfolding  out 
of  itself  has  no  place  for  him.  Therefore  he  tells 
us  only  that  souls,  spiritual  beings,  exist  and  take 
all}'  shape  they  will  and  appear  as  and  how  they 
will.  Yet  sometimes  they  are  limited  and  forced 
to  other,  or  partly  other  appearances,  a  confusion 
of  shapes.    Is  this  evolutionary  logic? 

Although  the  Irish  know  it  not  they  are  oftener 
nearer  to  the  more  simple  scientific  formula  than 
that.  "They  can  do  nothing  without  some  live 
person  is  looking  at  them."  "It  is  something  in  our 
own  eyes  makes  them  big  or  little."  They  all  but 
acknowledge  the  root  of  wish  fulfilment  or  its  dis- 
tortion. Of  the  latter  the  mind  permitting  a  wish 
to  come  through  from  the  uncritical  unconscious 
into  the  light  of  conscious  requirements  is  easily 
capable.  No  wonder,  if  these  visions  and  beliefs  are 
products  of  their  own  minds,  that  they  take  familiar 
shape  and  form,  manifest  desires  similar  to  those  of 
their  creators.  The  latter  lead  a  hard  existence  with 
an  absence  or  a  severe  limitation  of  the  joys  and 
beauties  they  so  often  ascribe  to  these  beings.  It  is 
not  a  peculiarity  of  the  Irish  to  be  able  to  dream  and 
express  their  desires  thus  even  in  waking  belief  in 
these  dreams.  "There's  no  doubt  at  all  but  that 
there's  the  same  sort  of  things  in  other  countries ; 
but  you  hear  more  about  them  in  these  parts  be- 
cause the  Irish  do  be  more  familiar  in  talking  of 
them."  Not  only  so  but  they  have  maintained  to  an 
unusual  degree  a  childlike  spirit  of  beauty  and  de- 
light, as  an  ambivalence  toward  their  environment. 
At  all  events  they  hold  to  the  kindly  and  lovely  side 
of  these  beings  and  ascribe  to  even  the  distorted, 
ugly  forms  a  desire  to  do  no  harm  except  under  pro- 
vocation.   They  give  testimony  frequently  in  their 


170 


BOO  A'  REJ-IEUS. 


iKp.w  Yor.-: 
Medical  Journal. 


own  Statement  of  their  belief,  to  which  Lady  Greg- 
ory has  adhered  throughout,  to  A-arious  phases  of 
mental  condition  in  which  deliria  and  dreams  are 
prominent.  There  are  the  periods  of  being  "away," 
suggestions  of  epileptic  or  other  fits,  and  the  not  in- 
quent  "drop  too  much."  Stress  of  loss  of  dear  ones 
plays  a  large  part.  The  two  volumes  form  a  rich 
and  charming  addition  to  the  study  of  the  products 
of  the  vast  unconscious  world  of  phantasy  which 
fomis  the  greater  part  of  all  of  us  and  to  the  pecu- 
liar power  of  all,  particularly  of  this  race,  to  pro- 
ject the  unconscious  material  outside  jhe  self  and 
there  reinterpret  it.  There  is  shrewd  testimony  on 
the  part  of  some  of  the  harder  hearted,  more  real- 
istic inhabitants,  "Walking  Coole  demesne  I  am 
these  forty  years,  days  and  nights,  and  never  met 
anj-thing  worse  than  myself."  Have  we  or  shall 
we  ever,  any  of  us? 

TR.WEL  FOR  THOSE  WHO  STAY  AT 
HOME. 

White  Shadoii-s  in  the  South  Seas.  By  Frederick  0"Briex. 
With  many  illustrations  from  photographs.  New  York: 
The  Centura-  Company,  1919.  Pp.  iii-450. 
Thirty-seven  days'  sail  from  Tahiti  lie  the  Mar- 
quesas, those  tragic  islands  of  the  South  Seas  where 
the  last  members  of  a  race  are  dying.  "Here  in 
these  islands,"  says  the  author,  "the  brothers  of  our 
long  forgotten  ancestors  have  lived  and  bred  since 
the  Stone  Age,  cut  of?  from  the  main  stream  of  man- 
kind's development.  Here  they  have  kept  the  child- 
hood customs  of  our  white  race,  savage  and  wild, 
amid  their  primitive  and  savage  life.  Here,  three 
centuries  ago,  they  were  discovered  by  the  people 
of  the  great  world,  and  rudely  encountering  a  civili- 
zation they  did  not  build,  they  are  dying  here." 
There  is  much  of  easy,  simple  living  in  these  islands ; 
there  are  many  "sun-steeped  days  on  white  beaches," 
but  there  is  also  much  of  degradation.  A  hundred 
years  ago  there  were  160,000  Marquesans ;  the  num- 
ber today  is  estimated  by  the  author  at  less  than 
2,100.  Tuberculosis  and  taxes,  smallpox  and  syphi- 
lis, leprosy  and  opitxm,  the  cupidity  of  the  trader 
and  the  strange  gods  of  the  missionary  have  been 
brought  to  die  islands  by  the  white  men.  and  the 
Poh-nesian  is  dying  under  them.  As  Titihuti,  she 
of  the  tattooed  legs,  says:  "We  will  all  be  gone 
soon,  and  the  cocoanut  groves  of  our  islands  will 
know  us  no  more.  We  come,  we  do  not  know 
whence,  and  we  go,  we  do  not  know  where.  Only 
the  sea  endtires,  and  it  does  not  remember." 

The  reader  who  elects  to  journe}-  with  Mr. 
O'Brien  will  be  well  repaid,  for  this  book  is  dif- 
ferent from  most  travelers'  tales.  It  is  not  scenery 
or  customs  or  atmosphere  that  the  autlior  is  trying 
to  reproduce,  but  the  life  of  which  these  form  a 
part,  and  life  in  the  Marquesas  is  shot  through 
with  simplicity  and  beauty  and  melancholy.  Our 
white  author,  with  his  Golden  Bed  and  The  Iron 
Fingers  That  Make  \\^ords,  was  treated  by  the  na- 
tives as  one  of  themselves,  and  in  return  he  has 
done  them  the  honor  of  not  being  sociological  about 
them.  Perhaps  it  is  because  he  lived  their  life  in- 
stead of  merely  observing  it,  and  because  he  ap- 
proached them  with  their  own  friendliness,  that 
his  book  is  rich  in  the  comprehension  which  so 


few  white  men  feel  for  others  not  of  their  own 
color. 

It  is  one  thing  to  travel ;  it  is  another  to  re- 
create far  places  so  perfectly  that  the  reader  has  the 
illusion  of  having  been  there  himself.  Mr.  O'Brien 
does  this,  and  even  more — he  recreates  the  en- 
chantment that  travel  has  for  those  imprisoned 
against  their  will  by  the  coil  of  circumstances.  This 
book,  written  "for  those  who  stay  at  home  yet 
dream  of  foreign  places."  should  be  read  by  all 
those  in  whom  the  daily  routine  has  not  quite 
buried  the  dreams  of  the  romance  that  lies  over  the 
world's  rim. 

MYSTERY  AND  MEDICINE. 

The  Pathway  of  Adientnrc.    By  Ross  Tyrrell.  Xew 
York:    Alfred  A.  Knopf.  1920.    Pp.  vii-310. 

The  individual  reader  borne  breathlessly  along 
this  Borzoi  Mystery  highroad  on  coming  to  the 
end  will  say,  "An  unlikely  story,"  half  ashamed  that 
he  had  really  enjoyed  the  journey.  But,  should  that 
man  ever  be  in  lazy  chat  with  some  dozen  com- 
panions, he  will  find  that  nearly  all  can  tell  stories 
as  strange  and  confirm  the  daily  probability  of  the 
improbable.  The  beguilement  of  such  beolcs  as 
those  by  Ross  Tyrrell  lies  in  the  fact  that  they 
gratify  the  love  of  adventures  which  every  man 
secretly  longs  for,  and  that  hope  of  ultimate  justice 
in  that  the  hero  always  triumphs  in  the  end  over 
the  forces  of  wrong  arrayed  against  him.  As  in 
this  story,  fotir  villains,  armed  with  deadly  weap- 
ons, are  of  no  avail  against  the  virttious  hero  armed 
with  a  broken  bladed  penknife  or  a  table  leg.  They 
may  leave  him  wounded  and  gagged  in  a  dank 
cellar  or  throw  him  out  of  a  window  or  crack  his 
skull,  but  he  revives  in  a  manner  which  should  in- 
spire every  surgeon  who  figtires  in  the  Annals  of 
Surgery  with  his  "tmique  cases." 

Such  literature  used  to  be  advertised  as  "rail- 
way fiction"  for  travelers,  but  it  is  rather  to  be 
recommended  in  this  day  for  reading  in  breezy, 
qtiiet  holiday  resorts,  where  the  reader  will  have 
a  chance  of  regaining  a  normal  pulse  rate  after 
wild  adventuring  through  its  pages. 



New  Publications  Received. 


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


THE   WHISPERIXG  DE.\D.     Bv   ALFRED   GaXACHILLY.  New 

York:   Alfred  A.  Knopf,  1920.    Pp.  xi-279. 

THE   HISTORY   AXD  POWER  OF    MIXD.     Bv   RlCH.\RD  IXGA- 

lese.  New  York:  Dodd.  Mead  &  Co..  1920.  Pp.  xxiv- 
329. 

the    E.\RTH0M0T0R   AXD   OTHER    STORIES.      By    Dr.    C.  E. 

LixTox.  Illustrated  by  Murr.\y  Wade.  Salem.  Oregon : 
Statesman  Publishing  Co.    Pp.  xiii-231. 

the    real    C.\USE    of    STAMMERIXG    AXD    ITS  PERM.\XEXT 

CURE.  A  Treatise  on  Psychoanalytical  Lines.  By  Alfred 
Appflt.  Second  Edition.  London :  Methuen  &  Co.,  Ltd. 
Pp.  xi-234. 

TRAXSACTIOXS     of     the     AMERICAN"     PEDIATRIC  SOCIETY. 

Thirt\-first  Session,  held  in  Atlantic  Cit>',  N.  J.,  June 
16,  17  and  18,  1919.  Edited  by  Osc.\r  M.  Schloss.  M.D., 
Yol.  31.    Pp.  xv-270. 


Miscellany  from  Home  and  Foreign  Journals 


Coccygodynia. — Charles  J.  Drueck  {Western 
Medical  Times,  March,  1920)  says  that  coccygo- 
dynia is  to  be  thought  of  in  every  patient  with  anal 
or  sacral  pain.  In  every  rectal  examination  the 
coccyx  should  be  carefully  palpated  and  manipu- 
lated to  determine  any  faulty  position,  undue  sensi- 
tiveness, abnormal  mobility  or  rigidity,  or  infiltra- 
tion of  tissue  about  the  region.  In  mild  cases  noth- 
ing may  be  found  but  a  tender  spot  on  one  or  the 
other  surface  or  at  the  tip  of  the  coccyx.  In  other 
cases  dislocation  or  fracture  may  be  found,  or  a 
projecting  bony  spicule.  In  severe  cases  the  pa- 
tient may  writhe  or  scream  during  the  examination. 
A  further  examination  of  all  the  pelvic  organs  is 
necessary  in  order  to  exclude  disease  elsewhere,  and 
sometimes  this  is  impossible  without  an  anesthetic. 
The  prognosis  in  general  is  good.  In  many  cases 
cure  is  spontaneous,  though  it  may  require  months, 
so  recent  cases  should  be  treated  conservatively. 
Rest  and  hygiene  are  indicated  until  the  acute  symp- 
toms subside ;  local  medication  and  bandages  are 
worthless.  Sedative  drugs  and  analgesics  should  not 
be  used  for  fear  of  inducing  a  drug  habit.  The 
bowels  should  be  kept  open.  A  hot  rectal  douche 
at  105°  F.  for  five  minutes  twice  a  day  is  sedative 
and  relaxing  to  the  tissues.  External  heat  with 
the  therapeutic  lamp  one  hour  night  and  morning 
is  also  of  much  value.  Faradism,  one  pole  over 
the  coccyx  and  the  other  above  the  sacrum,  or  with- 
in the  rectum,  according  to  the  location  of  the  pain- 
ful spots,  is  good.  The  injection  of.  eighty  per 
cent,  alcohol  into  and  about  the  sensory  nerves 
often  is  satisfactory.  The  point  of  maximum  ten- 
derness is  determined  by  digital  examination.  The 
index  finger  is  retained  within  the  rectum  as  a 
guide,  a  two  inch  needle  is  introduced  through  the 
skin  in  the  posterior  raphe,  is  carried  to  this  sensi- 
tive area,  and  ten  to  twent}'  minims  of  eighty  per 
cent  alcohol  is  slowly  injected.  The  injections  may 
be  repeated  in  five  to  seven  days.  They  may  be 
given  without  anesthesia,  but  most  careful  asepsis 
must  be  observed.  If  the  suffering  continues  after 
a  thorough  trial  of  palliative  treatment,  excision  of 
the  coccyx  is  required. 

Experiments  on  the  Eye  with  Gas  Mantles  of 
Different  Compositions. — C.  E.  Ferree  and  G. 
Rand  {American  Journal  of  Ophthalmology,  Jan- 
uary, 1920)  reports  experiments  made  with  Wels- 
bach  mantles  of  known  size  and  composition  as  to 
the  effect  of  the  light  they  furnish  upon  the  loss  of 
efficiency  and  discomfort  caused  by  a  certain 
amount  of  eye  work  done  under  such  illumination. 
The  conspicuous  variables  in  these  experiments  were 
composition  of  light,  a  physical  variable,  and  color 
value,  a  sensation  variable,  which  are  not  synony- 
mous and  do  not  always  go  hand  in  hand.  It  is  a 
natural  inference  that  the  results  obtained  were  due 
to  differences  in  the  color  value  of  the  illuminants 
used,  but  it  is  conceivable  that  differences  in  com- 
position of  light  may  aifect  the  power  of  the  eye  to 
sustain  clear  and  comfortable  seeing.  They  may 
affect  the  resolving  power  of  the  eye ;  they  may 
exert  an  immediately  deleterious  or  irritating  action 


OP  the  delicate  structures  of  the  eye;  they  may  have 
an  effect  on  acuity  through  the  color  of  the  sensa- 
tion aroused.  If  one  were  willing  to  draw  conclu- 
sions with  regard  to  composition  and  color  value 
of  light  at  this  stage  of  the  investigation,  he  would 
be  inclined  to  say  that  in  case  of  a  given  color  the 
power  of  the  eye  to  sustain  clear  and  comfortable 
seeing  decreases  with  the  saturation  of  the  color ; 
but  that  independent  of  saturation  some  colors  af- 
fect the  eye  more  than  others.  A  displacement 
from  white  toward  a  dominance  of  the  short  wave 
lengths  of  the  spectrtnn  affects  the  eye  more  than  a 
similar  displacement  toward  the  long  wave  lengths. 
In  considering  the  relative  merits  of  illuminants 
the  comparatively  low  surface  brilliancy  of  the  gas 
mantle  should  not  be  forgotten,  it  is  of  practical 
importance  in  the  problem  of  providing  adequate 
shading  for  the  eye.  In  connection  with  the  prob- 
lem of  shading  the  writers  recommend  that  the  0.75 
per  cent,  ceria  mantle,  and  other  mantles  of  low 
ceria  content,  be  used  with  shade  so  selected  that 
its  color  effect  is  corrective  of  the  greenish  colora- 
tion of  the  light  given  by  these  mantles.  The  amber 
shade  should  exert  in  some  measure  such  a  correc- 
tive action  on  the  greenish  light  of  the  "standard" 
mantle. 

Tartar  Emetic  in  Ulcus  Tropicum. — A.  Mei 

{Journal  of  Tropical  Medicine  and  Hygiene,  Febru- 
ary 2,  1920)  states  that  tropical  ulcer  is  very  prev- 
alent among  the  natives  of  Cyrenaica.  In  most  of 
the  cases  seen,  the  Spirochasta  schaudinni  was  found 
in  the  lesion.  The  known  value  of  tartar  emetic  in 
various  protozoal  diseases  led  the  author  to  try  it  in 
this  aft'ection,  with  marked  success.  Even  when  the 
drug  is  merely  applied  externally,  the  patient  must 
be  kept  at  perfect  rest  in  bed.  The  copious  secretion 
from  the  ulcer  is  removed  with  dry  sterile  gauze. 
The  tartar  emetic  is  applied  only  in  small  amount  to 
the  surface  of  the  ulcer  and  beneath  its  margins, 
and  the  lesion  then  covered  with  sterile  gauze  and  a 
light  bandage.  Applications  are  made  at  first  twice 
and  then  once  daily,  according  to  the  amount  of  se- 
cretion. The  average  duration  of  treatment  is  one 
month.  Only  occasionally,  among  children  and 
European  patients,  is  there  intolerance  to  the  rem- 
edy ;  iodoform  is  then  substituted.  Tartar  emetic 
acts  strongly  on  the  spirochetes.  After  two  or  three 
days  they  are  reduced  to  small  numbers,  in  a  de- 
generated condition,  whereas  the  Vincent  bacilli  and 
various  cocci  are  still  present  in  large  numbers.  By 
the  fifteenth  day,  all  Vincent  bacilli  and  spirochetes 
are  gone,  and  only  a  few  cocci  remain.  The  ulcer 
improves  coincidently  with  the  diminution  and  dis- 
appearance of  the  spirochetes,  suggesting  that  these 
organisms  constitute  the  true  etiological  agent  in 
ulcus  tropicum.  In  two  native  boys,  intravenous 
injections  of  0.06  grain  of  tartar  emetic  were  given. 
Distinct  but  slow  improvement  followed,  and  later 
local  treatment  was  substituted,  with  very  good  re- 
sults. Treatment  by  intravenous  injections  of  the 
remedy  may  prove  useful  in  cases  in  which  external 
application  gives  very  severe  pain,  but  is  otherwise 
unnecessary. 


172 


LETTERS  TO  THE  EDITORS. 


[New  Yof.k 
Medical  Journal. 


Action  of  Curara  on  the  Output  of  Epinephrine 
from  the  Adrenals. — G.  X.  Stewart  and  J.  M. 
Rogoff  (Journal  of  Pharmacology  and  Experu 
mental  Therapeutics,  December,  1919).  found  in  ex- 
periments on  cats  that  curara  in  doses  sufficient  to 
paralyze  the  skeletal  muscles  markedly  repressed  the 
output  of  epinephrine  from  the  adrenals.  The  de- 
pression begins  promptly,  and  may  be  still  well 
marked  when  the  paralysis  of  the  muscles  has  be- 
gun to  wear  off.  No  attempt  was  made  to  compare 
exactly  the  doses  of  curara  required  to  paralyze  the 
epinephrine  secretory  fibres  and  the  cardioinhibitory 
fibres,  but  a  marked  diminution  in  the  epinephrine 
output  was  observed  in  samples  of  blood  collected 
from  the  adrenals  at  a  time  when  stimulation  of  the 
vagus  caused  inhibition  of  the  heart.  In  general, 
curara  should  not  be  employed  in  experiments  on 
the  epinephrine  output. 

Mitral  Stenosis  in  Soldiers. — T.  F.  Cotton 
[British  Medical  Journal.  December  27,  1919)  re- 
ports observations  on  seventy-five  patients  with 
signs  of  mitral  stenosis,  and  analyzes  the  histories 
of  fifty  of  these.  Tests  with  the  exercise  tolerance 
of  the  patients  led  the  writer  to  conclude  that  the 
increase  in  pulse  rate  is  a  useful  sign  in  estimating 
the  exercise  tolerance,  but  it  is  not  of  value  in  dis- 
tinguishing between  early  and  developed  mitral 
stenosis.  The  average  early  mitral  stenosis  showed 
better  exercise  tolerance  than  the  disordered  action 
of  the  heart,  but  when  the  distress  after  exercise  was 
as  great  in  stenosis  as  in  D.  A.  H.  the  pulse  rate 
rose  as  high  after  exercise  in  the  one  as  in  the  other. 
It  is  pointed  out  that  the  symptoms  of  cardiac  fail- 
ure may  be  observed  in  patients  with  no  signs  of 
structural  disease  of  the  heart  and  in  particular  in 
cases  of  D.  A.  H.  The  suggestion  is  made  that  the 
same  cause  produces  the  symptoms  in  early  mitral 
disease  as  in  D.  A.  H.  Prognosis  is  discussed  and 
emphasis  is  placed  on  the  importance  of  any  consid- 
erable enlargement  as  an  unfavorable  sign. 

Pupillary  Symptoms  in  Embolus  of  the  Cen- 
tral Artery  of  the  Retina. — John  Dunn  {Archives 
of  Ophthalmology,  March,  1920)  reports  a  case  of 
embolus  of  the  central  artery  which  is  of  peculiar 
interest  because  the  direct  reflex  response  of  the 
pupil  to  light  was  absent  as  long  as  the  edema  of  the 
retina  persisted,  but  returned  after  the  edema  liad 
disappeared.  Dunn  has  maintained  for  several  years 
that  the  direct  response  of  the  pupil  to  light  is  an 
extracerebral  reflex  and  that  its  -nervous  pathways 
are  from  the  retinal  cells  to  the  retinal  pigment  cells, 
along  this  pigment  layer  to  the  ciliary  region,  where 
sensory  impulses  are  aroused  in  the  sensory  nerves 
to  the  ciliary  ganglion  from  this  region,  thence  along 
these  ciliary  sensory  nerves  to  the  ciliary  ganglion,  in 
the  substance  of  which  impulses  are  aroused  in  the 
motor  cells  of  the  ganglion,  which  impulses  passing 
outward  result  in  contraction  of  the  pupil.  Thus  he 
explains  the  phenomena  of  the  Argyll-Robertson  pu- 
pil, the  behavior  of  the  pupil  in  the  second  stage  of 
anesthesia,  the  pupillary  phenomena  that  precede 
death,  and  he  believes  this  case  to  be  confirmatory 
of  his  theory.  Another  interesting  point  was  the 
preservation  of  a  tonguelike  projection  of  normal- 
ly pink  retina  from  the  outer  margin  of  the  disc 
nearly  to  the  cherry  spot. 


The  Relation  of  Dust  to  the  Spread  of  Tuber- 
culosis.— H.  C.  Sweany  and  C:  C.  Mac  Lane 
(Illinois  Medical  Journal,  December,  191 9)  report 
that  of  134  samples  of  dust  taken  from  rooms 
where  open  cases  of  tuberculosis  were  being  treated, 
twelve  were  positive.  Of  eighteen  samples  taken 
from  the  Cook  County  jail,  three  were  positive. 
Seven  positive  cases  were  found  in  single  and 
double  rooms  facing  north,  while  only  two  were 
found  in  rooms  facing  south.  The  greatest 
percentage  of  positive  samples  was  found 
in  places  where  the  greatest  number  of  open 
cases  were  being  treated.  A  suspension  of 
tubercle  bacilH  in  salt  solution  was  killed  in 
twenty  minutes  in  direct  sunlight  with  the  sun's 
rays  at  an  angle  of  fifty  degrees ;  five  hours  in  a 
film  of  dust  in  direct  sunlight,  five  days  in  a  south 
room,  and  seven  days  in  a  north  room. 

 <$>  

Letters  to  the  Editors. 

VENEREAL  DISEASE  PERIL. 

New  York,  July  22,  jg20. 

To  the  Editors: 

In  your  issue  of  April  3rd  last,  it  was  stated  by  an 
Australian  that  the  ratio  of  venereal  infection  among 
the  British  forces  was  never  so  high  as  in  their  army 
of  occupation  during  the  early  part  of  1919.  In  an 
editorial  in  your  issue  of  June  12th  last  it  was  also 
stated  that  the  increase  had  been  much  greater  in 
Europe  than  in  the  United  States,  and  that  the  aug- 
mentation in  cases  of  venereal  infection  in  Canada 
had  been  "almost  incredible,"  in  fact,  that  the  ven- 
ereal problem  was  the  "outstanding  problem  of  the 
day."  We  have  also  been  told  by  Dr.  Joseph  E. 
Moore,  one  of  our  military  men  on  duty  in  Paris 
(Journal  of  the  American  Medical  Association, 
April  24,  1920),  that  at  one  time  he  found  the  inci- 
dence of  infection  there,  among  our  men,  four  times 
that  of  any  other  locality  in  the  zone  of  warfare.  As 
many  as  70,000  prostitutes  plied  their  trade  actively 
in  that  city,  and  almost  unmolested  by  the  police. 

Morel,  also  in  the  Daily  Herald  (London)  in  its 
issue  of  April  10th,  tells  of  practices  by  the  colored 
troops  which  were  even  more  shocking.  While 
thirty  to  forty  thousand  of  them  were  occupying  the 
enemy  coimtry,  girls  and  women  were  raped  and 
there  was  such  wholesale  infection  that  the  hospitals 
were  filled  to  overflowing  with  their  victims.  The 
details  which  he  has  given  of  practices  controlled  by 
the  military  authorities,  in  the  zone  of  occupation,  I 
will  not  give.    Perhaps  they  still  prevail  there. 

As  these  amazing  statements  have,  so  far  as  I 
know,  not  been  contradicted,  is  it  not  our  duty,  as 
civilized  beings,  to  have  them  verified  or  disproved? 

If  we  as  Americans  are,  as  it  seems,  face  to  face 
with  a  real  venereal  peril,  should  we  not  recognize 
at  once  the  menace  of  such  European  conditions,  to 
ward  them  ofif  as  far  as  we  can,  and  fix  the  respon- 
sibility for  them,  even  if  it  should  be  shown  that  our 
sanitary  authorities  abroad  were  lax  in  their  duties. 
Otherwise  this  subject  would  properly  merit  a  con- 
gressional inquiry. 

Thom.as  E.  Satterthwaite,  M.  D. 


New  York  Medical  Journal 


INCORPORATING  THE 


Philadelphia  Medical  Journal     Medical  News 

A  Weekly  Review  of  Medicine,  Established  184-3. 


Vol.  CXII,  No.  6. 


NE\A'  YORK,  SATURDAY,  AUGUST  7,  1920. 


Whole  No.  2175. 


Original  Communications 


THE  BORDELAISE  CONCEPTION  OF 
ENCEPHALITIS  LETHARGICA. 

By  Rene  Cruchet,  M.  D., 
Bordeaux,  France, 

Adjunct    Professor,    Faculty    of    Medicine,     Bordeaux,  Attending 
Physician,  Hospital   St.  Andre. 

I  recall  that  from  Septembei-  to  the  end  of  De- 
cember, 1915,  first  at  Commercy,  then  at  Verdun 
from  December  to  the  middle  of  February,  1916, 
and  finally  at  Bar-le-duc,  and  at  various  successive 
medical  military  centres,  where  I  had  charge  of 
important  neuropsychiatrical  services,  I  noticed  that 
the  type  of  encephalomyelitis  which  we  observed 
was  dififerent  from  the  forms  we  had  habitually  en- 
countered. In  April,  1917,  and  prior  to  von  Eco- 
nomo  and  Netter,  we  isolated  with  Montier  and 
Calmette  forty  of  these  cases.  These  observations 
were  published  under  the  name  of  subacute  enceph- 
alomyelitis ( 1 )  and  the  disease  described  was  iden- 
tical with  the  syndrome  described  since  that  time 
under  the  name  of  encephalitis  lethargica.  The 
following  is  the  exact  text : 

Formerly  it  was  fairly  easy  to  diagnose  the  ordi- 
nary lesions  of  the  order  of  cerebral,  protuberential, 
cerebellar,  bulbar,  medullary,  but  the  hypothesis  of 
hemorrhage  or  softening,  of  tumor,  diabetes  or 
uremia,  of  tuberculosis  or  syphilis,  were  successive- 
ly discarded.  There  were  the  central  lesions,  called 
polioencephalitis,  studies  by  Medin  and  American 
workers,  which  clearly  had  the  character  of  an 
epidemic  with  the  characteristic  abrupt  inception, 
an  elevated  temperature,  vomiting,  marked  pain, 
and  an  extensive  dissemination  of  the  paralytic  dis- 
turbances, which  eventually  limited  themselves  to 
certain  muscle  groups,  followed  by  more  or  less 
atrophy. 

In  various  cases  the  febrile  reaction  was  not  in- 
tense. At  times  it  would  seem  that  we  were  con- 
fronted with  a  more  or  less  attenuated  form  of 
typhoid  or  paratyphoid  fever,  but  the  examination 
of  the  blood  did  not  corroborate  this.  The  hvpothe- 
sis  of  a  fruste  form  of  cerebrospinal  meningitis  did 
not  lead  to  a  more  clear  diagnosis,  for  the  examina- 
tion of  the  cephalorachidian  fluid,  even  if  it  fre- 
quently gave  a  lymphocytic  or  albuminose  reaction 
did  not  reveal  anything  in  the  way  of  microbes. 

Whereas  it  was  impossible  not  to  be  impressed 
by  a  certain  similarity  between  the  various  cases, 
one  was  tempted  to  classify  this  disease  with  the 
attenuated  affections  of  the  central  nervous  system. 


The  general  clinical  characters  of  the  disease  were 
as  follows. 

ONSET. 

At  the  onset  the  subjects  manifest  an  extreme 
lassitude,  a  physical  and  mental  asthenia ;  in  place 
of  a  violent  headache  they  complain  of  a  feeling 
of  heaviness.  The  fever,  which  occurs  infrequent- 
ly, is  at  times  manifested  by  a  feeble  elevation  of 
temperature,  between  37.5°  and  38°  C,  for  a  few 
days.  In  some  cases  the  elevation  is  more  marked, 
and  this  is  interpreted  as  an  accident  in  the  evolu- 
tion of  the  clinical  signs,  ictus,  convulsions,  or 
bulbar  asphyxia.  The  age  of  the  patients  varies 
between  twenty-five  and  forty-five  years.  Their 
inert  facies,  emotional  indifiference,  semicomatose 
state,  loss  of  weight,  earthy  appearance,  at'  times 
subicteric,  their  lack  of  appetite,  give  the  patients 
the  appearance  of  being  profoundly  infected  or 
toxic. 

CLINICAL  FORifS. 

In  a  general  way  there  are  a  complete  series  of 
clinical  forms  which  are  as  follows : 

1.  A  mental  form,  in  which  the  cerebral  torpor, 
the  amnesia,  the  disorientation,  the  pupillary  man- 
ifestations, the  tremor,  the  dysarthria,  even  the  par- 
aphasia and  the  reaction  of  the  cephalorachidian 
liquid,  give  the  impression  of  a  general  paralysis  of 
one  type  or  another. 

2.  A  convulsive  form,  in  which  the  crises  create 
a  veritable  convulsion,  which  generally  subsides. 

3.  A  chronic  form,  with  all  the  characters  of  the 
adult  form  of  an  infectious  chorea. 

4.  A  meningitic  form,  in  which  the  meningeal  re- 
actions (stififness,  Kernig,  rachialgia,  somnolence 
and  vasomotor  phenomena)  are  always  associated 
with  profound  and  tenacious  encephalitic  disturb- 
ances, which  are  not  explained  by  any  of  the  known 
agents. 

5.  A  hemiplegic  form,  or  rather  hemiparetic, 
which,  by  its  rapid  regression  and  stabilization  at  a 
certain  stage  of  its  evolution,  is  clearly  differenti- 
ated from  the  ordinary  hemiplegia  of  the  adult. 

6.  A  pontocerebellar  form,  with  ptosis,  paralysis 
of  accommodation,  titubation,  and  a  simple  cere- 
bellar form,  recall  the  symptomatology  of  tumors 
of  the  cerebellum. 

7.  A  bulboprotuberential  form  with  various  nu- 
clear lesions  of  the  nerves  of  this  region,  trigeminal, 
facial,  vagospinal. 

8.  A  mild  ataxic  form,  which  in  certnin  ways  re- 
calls the  polyneuritis  of  toxic  infections. 


Copyright,  1920,  by  A.  R.  Elliott  Publishing  Company. 


174 


CRUCHET:  EXCEPHALITIS  LETHARGICA. 


[New  York 
Medical  Journal, 


9.  An  anterior  poliomyelitis  form,  in  which  the 
initial  characters,  at  least,  make  one  think  of  infan- 
tile paralysis.    This  is  an  exceptional  form. 

EVOLUTIOX. 

In  their  evolution  these  clinical  types,  which  are 
frequently  associated  with  one  another  in  their  de- 
velopment, go  side  by  side  in  spite  of  their 
polymorphisms.  Aside  from  two  cases  of  sudden 
death  (one  during  a  convtilsive  seizure  and  the 
other  by  bulbar  asphyxia)  the  regression  in  these 
subjects  was  slow,  and  the  subjects,  asthenic  and 
somnolent,  progressively  regained  their  health.  The 
sequelae  drag  along  and  manifest  themselves  in  re- 
lation to  their  anatomical  lesions,  paralysis  or  spas- 
modic states,  cerebral  fatigue,  muscular  atrophy, 
and  other  manifestations. 

Plating  of  cultures  and  inoculation  of  the  blood 
of  the  guineapig,  as  well  as  the  examination  of  the 
cephalorachidian  fluid,  was  systematically  practised 
with  no  results.  From  the  patient  who  died  stid- 
denly  from  bulbar  asphyxia,  a  quantity  of  the  ma- 
terial nearest  the  bulb  was  mixed  with  one  c.  c. 
of  physiological  senun  and  injected  into  the  brain 
of  a  rabbit  withotit  any  result.  We  were  badly 
situated  to  conduct  any  pathogenic  researches,  for 
most  of  the  patients  on  their  arrival  were  entering 
into  the  period  of  stabilization  of  their  disease, 
and  when  the  infection  was  in  the  state  of  reces- 
sion. The  disease  which  was  not  well  known  would 
frequently  be  entirely  overlooked,  and  often  the 
symptoms  would  be  attributed  to  the  exaggeration 
of  a  constant  fatigue. 

Therefore  in  our  first  communications,  we  in- 
sisted upon  the  polymorphism  of  this  disease  which 
recalled  in  many  ways  INIedin's  disease,  but  was  dif- 
ferentiated at  the  same  time  by  the  in  frequency  of 
the  medullary  localizations  and  the  frequency  of 
the  attenuated  encephalitis,  the  irregularity  of  the 
temperature,  which  was  usually  moderate,  the  ordi- 
nary absence  of  pain,  and  the  persistence  of  the 
cerebral  torpor.  We  have  emphasized  the  inert 
facies  of  the  patients,  their  asthenia,  their  somno- 
lence, which  always  indicated  a  slow  convalescence. 

At  the  end  of  1917  (1)  we  again  called  atten- 
tion to  this  little  known  disease  which  neverthe- 
less continued  to  pass  unrecognized  in  France  until 
the  communication  of  M.  Xetter  in  iNIarch.  1918, 
upon  encephalitis  lethargica. 

We  have  never  ceased  to  consider  this  name  as 
being  inexact.  We  have  shown  by  the  foreign 
documents,  notably  English,  that  the  trilogy  of 
symptoms  cited  by  Xetter — lethargy,  fever,  and 
ocular  paralysis — could  not  be  applied  in  all  cases. 
We  have  always  contended  that  encephalitis  le- 
thargica was  a  particular  form  oi  diffuse  encephalo- 
myelitis, which  we  isolated  in  April,  1917  (1). 

Our  understanding  or  idea  of  encephalitis  ap- 
proved of  at  Bordeaux  not  long  before,  in  all  other 
respects  appeared  to  be  in  accordance  with  the 
scope  of  a  number  of  communications  on  encepha- 
litis lethargica  which  have  appeared  in  France  since 
the  end  of  1919;  at  Lyon,  IMontpellier,  Xancy,  An- 
gers and  notably  at  Paris,  where  MM.  ChaufJard, 
Pierre  Marie,  Achard,  Widal,  Sicard,  and  others 
specifically  agreed    on  all  points  we  demonstrated 


(clinical  anatomicopathological,  nosographical)  and 
our  interpretation. 

Concerning  the  details  of  certain  clinical  forms, 
such  as  the  myoclonic  of  the  type  of  electric  chorea 
of  Dubini,  the  ideas  set  forth  by  AI.  Sicard  tend 
to  reinforce  the  original  ideas  we  had  some  time  ago. 
In  1907,  I  insisted  upon  the  rhythmic  character  of 
the  chorea  of  Dubini,  and  definitely  separated  the 
movements,  classifying  them  under  the  name  of 
rhythmic  rather  than  the  more  vague  term  of  my- 
oclonia. 

These  marked  rhythms,  as  we  indicated  in  the  be- 
ginning, are  always  symptomatic  of  serious  cere- 
brospinal lesions ;  especially  in  tuberculous  menin- 
gitis, and  in  the  complications  of  central  localiza- 
tion in  typhoid  fever,  alcoholism,  measles,  broncho- 
pneumonia, and  other  infectious  diseases.  One  of 
their  essential  characters  is  their  p>ersistence  in 
sleep  or  coma,  contrary  to  those  occurring  in  true 
chorea.    The  prognosis  is  invariably  fatal  (1). 

These  particular  manifestations  are  encountered 
in  rhythmic  encephalitis  and  actual  myoclonias,  as 
have  been  described  in  a  number  of  cases  seen  in  Bor- 
deaux, Lyon  and  Paris. 

COXCLUSIOXS. 

1.  Encephalitis,  called  lethargica  in  May,  1917,  at 
\'ienna  and  in  [March,  1918,  at  Paris,  was  con- 
sidered and  described  on  the  27th  of  April,  1917, 
as  one  of  the  forms  of  subacute  or  diffuse  encepha- 
lomyelitis. 

2.  The  Bordelaise  concept  of  encephalitis  le- 
thargica, or  better  called  epidemic  encephalomyelitis 
or  the  disease  of  Cruchet  (as  it  is  called  in  the 
Girondine  region)  is  that  which  is  adopted  in  Eng- 
land, in  the  United  States,  in  Italy.  Spain  and  in 
the  South  American  countries,  and  is  also  accepted 
in  France  in  the  large  centres  like  Lyon,  X^ancy, 
and  Bordeaux,  and  was  finally  accepted  in  Paris. 

REFERENXES. 

1.  Quarante  cas  d'encephalomyelite  subaigue,  Societe 
medicale  des  hopitaux  de  Paris.  25  avril,  1917. 

2.  Revue  Neurologiquc  (Travaux  des  centres  neurolo- 
giques  d'armee,  October,  november,  december,  1917,  p.  457). 

3.  L'encephalomyelite  diffuse  at  I'encephalite  lethar- 
gique,  Paris  medical,  14  juin,  1919.  See  also  my  communi- 
cations and  discussions  in  Societe  de  Medicine  et  de  Chirur- 
gie  de  Bordeaux,  especially  the  sessions  from  the  7th  to  the 
27th  of  February-,  1919,  and  the  6th,  13th,  and  20th  of 
Februarj-,  1920. 

4.  Communications  de  \"erger  et  iloulinier.  de  Coquet, 
X  erger  et  Anglade,  Lacroix,  de  Teyssieu,  etc.  (Soc.  de 
Medicine  et  de  Chirurgie  de  Bordeaux,  1919  et  1920)  : 
Creyz,  L'encephalomj'elite  diffuse,  epidemique.  Journal  de 
Medicine  tie  Bordeaux.  10  avril.  1920:  Arnozan,  Un  cas 
d'encephalite  lethargique,  30  janvier,  1920.  Concours  medi- 
cal mai,  1920. 

5.  Traite  des  tdrticolis  spasmodiques  (Masson  et  Cie, 
editeurs,  Paris,  1907,  pp.  514  a  516;  et  pp.  444  a  459).  See 
also  the  article  Rj-thmose  in  maladies  du  systeme  nerveux 
de  la  Pratique  des  maladies  des  enfants.  t.  v.  pp.  605  a  607. 
Bailliere  &  Fils,  editeurs,  1912. 


Early  Diagnosis  of  General  Paralysis  of  the 
Insane. — Egbert  W.  Fell  (Souflicrn  Medical  Jour- 
nal, March,  1920)  saj's  that  a  change  in  disposition 
or  habits  in  a  middle  aged  man  should  always  cause 
suspicion  of  paresis.  A  diagnosis  of  paresis  is  pos- 
sible even  in  the  early  stage  b)'  a  careful  considera- 
tion of  the  mental,  neurological,  and  serological  find- 
ings. 


August  7,  1920.] 


WECHSLER:  SYMPTOMS  OF   EPJDEMIC  ENCEPHALITIS. 


175 


THE  SYMPTOMS  OF  EPIDEMIC  ENCEPHA- 
LITIS STRUCTURALLY  AND  FUNC- 
TIONALLY CONSIDERED.* 
•    By  I.  S.  Wechsler,  M.  D., 
New  York, 

Associate'  in  Neurology,  Columbia  University  and  Adjunct  Neurol- 
ogist to  Mt.  Sinai  Hospital. 

Most  of  the  reports  which  have  appeared  on  the 
subject  of  epidemic  encephalitis  have  been  limited 
mainly  to  a  description  of  the  symptomatology  and 
pathology  of  the  disease.  The  epidemic  furnished 
extremely  rich  and  varied  material  for  accurate  ob- 
servation, and  clinicians  have  been  atforded  ample 
opportunity  for  the  exhibition  of  their  diagnostic 
acumen.  Indeed,  the  multiplicity  of  symptoms  which 
have  been  recorded  and  the  new  clinical  entities 
which  have  been  described  almost  make  one  feel  as 
if  the  clinical  side  has  been  just  a  bit  overemphasized, 
while  other  lessons  have  not  been  sufficiently  pointed 
out.  Without  in  the  least  trying  to  minimize  the 
value  of  the  clinical  and  pathological  studies,  and 
they  are  perhaps  most  valuable  from  an  immediately 
practical  viewpoint,  an  attempt  might  be  made  to 
interpret  the  clinical  signs  and  symptoms  in  the  light 
of  anatomy  and  physiology  and  to  inquire  whether 
any  new  lessons  may  be  drawn  as  to  the  structure 
and  function  of  the  nervous  system. 

The  disease  has  afforded  one  of  the  rarest  oppor- 
tunities for  the  study  of  the  functions  of  the  nervous 
system  and  possibly  may  throw  some  light  on  the 
more  obscure  causes  of  chronic  degenerative  diseases 
of  the  nervous  system,  such  as  paralysis  agitans, 
multiple  sclerosis  and  others.  Some  S3'mptoms,  too, 
such  as  chorea,  myoclonic  movements,  lethargy,  cata- 
tonia or  the  Argyll-Robertson  pupillary  phenomenon 
and  symptoms  referring  to  the  extrapyramidal  sys- 
tem, will  bear  further  consideration  in  the  light  of 
our  experience  with  the  epidemic. 

Our  knowledge  of  the  structur'^  and  function  of 
the  brain  is  based  on  the  study  of  its  anatomy  and 
embryology  (ontogenesis,  myelinization),  on  com- 
parative anatomy,  on  congenital  anomalies,  on  meth- 
ods of  degeneration,  on  direct  physiological  experi- 
mentation such  as  electrical  stimulation  and  on  the 
correlation  of  clinical  signs  and  symptoms  with 
structural  changes  caused  by  disease.  A  number  of 
names  occur  as  one  scans  the  list  of  great 
anatomists,  neurologists  and  physiologists  who  have 
contributed  to  our  knowledge :  Gall,  Flourens,  Bocra, 
Hammarberg,  Goltz,  Elliott  Smith,  Bevan  Lewis, 
Campbell,  Bolton,  Hitzig,  Flechsig,  Brodman,  Mey- 
nert,  Bechterew,  Wernicke,  Sherrington,  Cajal, 
Dejerine,  Head,  and  others. 

The  works  of  these  men  have  helped  us  to  under- 
stand the  structure  and  function  of  the  brain  and 
aided  us  in  the  intelligent  interpretation  of  clinical 
findings.  Neurology,  more  than  any  other  branch  of 
medicine,  lends  itself  particularly  well  to  study  of 
disease  in  terms  of  anatomy  and  physiology  patho- 
logically affected.  Instead,  therefore,  of  merely 
enumerating  symptoms  as  parts  of  a  picture  it  might 
be  wiser  wherever  possible  to  focus  one's  attention 
on  the  structure  and  function  of  an  affected  part  and 

•Observations  based  on  material  in  the  service  of  Dr.  B.  Sachs 
-at  the  Mt.  Sinai  Hospital. 


correlate  with  that  the  resuhing  symptoms.  For  in- 
stance, instead  of  enumerating  a  dozen  different 
forms  of  tabetic  crises,  we  may  explain  them  by  the 
underlying  pathology  and  merely  state  that  involve- 
ment of  the  lowest  sacral  roots  will  cause  vesical  and 
rectal  crises,  of  the  lumbosacral  roots  lancinating 
pains  in  the  legs,  of  the  vagus  gastric  symptoms  and 
so  on  with  the  girdle  pains,  laryngeal  crises,  renal 
crises,  lachrymal  crises,  etc.  From  the  practical 
viewpoint  the  important  thing  with  reference  to  epi- 
demic encephalitis  is  to  determine  the  etiological  fac- 
tor and  to  make  sure  that  we  are  dealing  with  one 
clinical  entity.  The  work  of  Strauss  and  Loewe  bids 
fair  to  establish  the  former  and  the  whole  course  of 
epidemic  has  given  conviction  on  the  latter. 

It  has  been  shown  that  the  disease  is  a  meningo- 
myeloencephalitis  with  the  last  greatly  predominat- 
ing. Whether  the  peripheral  nerves  have  been  at  all 
affected  is  difficult  to  say,  as  no  definite  pathological 
reports  have  been  recorded,  and  whatever  peripheral 
palsies  have  been  observed  can  more  readily  be  ex- 
plained by  nuclear  or  central  involvement.  If,  how- 
ever, one  accepts  the  cases  reported  as  acute  infec- 
tious polyneuritis  and  infective  neuronitis  the  peri- 
pheral nervous  system  may  be  said  to  have  been  in- 
volved. In  some  cases  there  have  been  undoubted 
involvement  of  the  anterior  horn  cells  of  the  cord 
resulting  in  paralyses  such  as  are  seen  in  poliomye- 
litis. The  involvement  of  the  roots  of  the  nerves, 
probably  in  a  localized  meningitic  process,  explains 
the  frequent  onset  of  the  disease  with  a  sciatica,  a 
pleurisy,  a  trifacial  neuralgia,  and  some  recognized 
but  at  first  uninterpreted  radiculitis.  The  hemi- 
plegias, diplegias,  facial  paralyses,  ptoses,  strabismus, 
are  easily  explained  by  lesions  involving  the  pyra- 
midal tracts,  the  nuclei  of  the  seventh,  third,  fourth 
or  sixth  nerves.  Involvement  of  the  phrenic  nerve 
which  has  been  clinically  observed  was  no  doubt  due 
to  a  lesion  in  the  cervical  cord,  but  most  of  the  res- 
piratory symptoms  were  secondary  to  lesions  in  the 
bulbar  centres. 

However,  there  are  other  symptoms  and  signs 
which  stand  in  need  of  explanation.  The  Argyll- 
Robertson  pupil  has  been  encountered'  o^:casionally, 
although  paralysis  of  accommodation  alone  and  no 
loss  of  pupillary  reaction  to  light  was  much  the  more 
frequent.  Now,  an  A-R  pupil  is  a  sigji  of  neuro- 
syphilis, more  particularly  the  tabetic  or  paretic  type, 
and  yet  it  was  undoubtedly  seen  in  epidemic  en- 
cephalitis. We  have,  therefore,  an  acute  Argyll- 
Robertson  coming  on  in  an  acute  disease,  persisting 
for  a  while  then  disappearing.  The  pathology  of 
the  phenomenon  is  not  as  yet  known,  but  we  may 
infer  that  a  minute  hemorrhage  or  inflammatory 
focus  in  the  midbrain,  either  in  the  nucleus  of  the 
third  nerve  or  the  Edinger-Westphal  nucleus,  or 
superior  quadrigeminal  or  the  connections  between 
them  is  responsible  for  the  phenomenon.  Marina's 
suggestion  that  the  lesion  of  an  A-R  pupil  is  in  the 
ciliary  ganglion  seems  to  be  made  untenable.  The 
cases  reported  early  in  the  epidemic  as  exhaustion 
pseudoparesis  may  possibly  have  been  of  epidemic 
form  and  point  to  difficulty  originally  encountered  in 
properly  interpreting  the  Argyll-Robertson  phenome- 
non.   Paralysis  of  accommodation  which  occurred. 


176 


WECHSLER:  SYMPTOMS  OF   EPIDEMIC  ENCEPHALITIS. 


[New  York 
Medical  Journal. 


SO  frequently,  at  times  as  the  only  symptom  and  more 
commonly  as  the  only  persisting  symptom,  must  be 
attributed  to  injury  of  the  socalled  accommodation 
nucleus  which  lies  farthest  forward  at  the  tip  of 
the  third  nerve  nucleus  in  the  floor  of  the  aqueduct 
of  Sylvius.  It  is  not  likely  to  be  due  to  involvement 
of  individual  fibres,  although  it  is  known  that  par- 
alysis of  accommodation  occurs  in  acute  infections, 
for  instance  in  diphtheria,  in  which  peripheral  neu- 
ritides  are  not  uncommon. 

A  curious  phenomenon  which  has  been  observed 
in  the  course  of  the  epidemic  was  the  localized  mass 
movements  of  groups  of  muscles,  particularly  of  the 
abdomen,  by  some  grouped  under  chorea  and  by 
others  as  special  myoclonic  movements.  Indeed,  the 
attempt  has  been  made  to  make  of  the  symptoms  a 
distinct  clinical  entity  or  at  least  to  endow  it  with 
special  significance.  As  commonly  interpreted  the 
symptom  was  said  to  be  due  to  involvement  of  the 
lower  motor  neurons,  that  is  the  lower  motor  cells 
supplying  the  muscles.  This  seems  unlikely,  as  the 
most  common  symptom  attributable  to  an  irritative 
lesion  of  that  sort  is  fibrillation.  This  is  a  slow,  ver- 
micular movement  of  parts  of  a  muscle  and  not  the 
complete  movement  of  a  whole  muscle  or  group  of 
muscles.  The  irritative  phenomenon  must  therefore 
be  explained  by  a  lesion  higher  up.  It  is  probable 
that  minute  hemorrhagic  or  inflammatory  foci  in  the 
higher  motor  cells  were  responsible  for  the  myo- 
clonic movements. 

Peculiar  champing  movements  of  the  jaws  have 
been  observed  and  they  too  have  been  included  under 
the  myoclonic  movements.  These  can  perhaps  be 
explained  by  lesions  in  the  midbrain.  Experimental 
studies  in  Bechterew's  laboratory,  particularly  by 
Jiirman,  and  studies  on  degeneration,  etc.,  go  to 
prove  that  the  substantia  nigra  governs  the  functions 
of  chewing  and  swallowing.  Indeed,  direct  stimula- 
tion of  the  substantia  nigra  Soemmeringii  caused  just 
such .  movements  as  were  observed  during  the  epi- 
dernic.  The  substantia  nigra  was  also  shown  to  have 
connections  with  the  caudate  and  lenticular  nuclei 
and  opercular  cortex.  In  view  of  the  affinity  of  the 
encephalitie  virus  for  the  midbrain  and  basal  ganglia 
and  in  view  of  the  presumed  function  of  the  sub- 
stantia nigra  and  of  its  connections  it  may  not  be  too 
farfetched  to  attribute  the  champing  movements  to 
an  irritative  lesion  in  it. 

With  reference  to  the  tremors,  choreic  and  athetoid 
movements,  we  stand  on  somewhat  firmer  anatomical 
and  physiological  ground.  The  tegmentum  of  the 
midbrain  evidently  is  the  concentrated  associational 
centre  for  these  nonvolitional  movements.  The  red 
nucleus  of  Monakow  connects  with  the  cerebellum 
by  way  of  the  superior  peduncle;  it  sfends  fibres 
down  to  the  cord  by  way  of  the  rubrospinal  tract, 
and  also  connects  with  structures  higher  up,  particu- 
larly with  the  striate  body.  A  thalamic  lesion,  also, 
may  give  rise  to  choreoathetoid  movements.  A 
lesion,  therefore,  in  any  one  of  these  structures  may 
be  followed  by  tremors,  choreic  and  athetoid  move- 
ments. This  is  all  the  more  hkely  in  view  of  the 
well  known  cerebellar  or  ataxic  component  of  choreic 
movements.  It  is  difficult  of  course  to  dissociate  the 
cerebellar  component  of  speech,  but  the  musculature 


involved  stands  in  associational  relation  with  the 
cerebellum  and  a  lesion  in  some  of  the  pathways  will 
account  for  the  disturbances  of  speech,  particularly 
the  slow  and  scanning  variety.  Acute  chorea  fre- 
quently illustrates  the  cerebellar  disturbance  to  a 
marked  degree.  The  lesion  here  as  well  as  in  cases 
showing  pure  ataxia  need  not  be  in  the  cerebellum, 
but  may  well  be  in  any  of  the  numerous  pathways. 
The  absence  of  reports  on  cerebellar  foci  would  tend 
to  confirm  this  view. 

The  whole  striatal  or  extrapyramidal  system  has 
been  held  to  account  for  the  tremors,  rigidity  and 
catatonic  symptoms.  (With  reference  to  the  last 
more  will  be  said  later. )  The  acute  paralysis  agitans, 
the  general  rigidity,  the  loss  of  associated  move- 
ments, the  tremors,  etc.,  have  hitherto  been  attributed 
to  lesions  in  the  extrapyramidal  system.  Striimpell 
tried  to  correlate  Wilson's  disease,  pseudosclerosis  of 
Westphal  and  paralysis  agitans  and  described  what 
he  calls  an  amyostatic  symptom  complex  on  the 
basis  of  disturbance  of  that  system.  He  stresses  the 
disturbance  of  posture  and  of  the  associational  ac- 
tivity not  directly  involved  in  motion ;  this  has  also 
been  emphasized  by  other  workers,  particularly  Ram- 
say Hunt.  Many  cases,  however,  of  acute  epidemic 
encephalitis  exhibited  apparent  loss  of  associational 
movements  but  showed  neither  the  rigidity  nor  the 
tremors,  so  that  other  factors,  more  likely  thalamic, 
must  be  taken  into  account.  The  great  importance 
of  the  acute  paralysis  agitans  and  the  involvement  of 
the  extrapyramidal  system  lies  in  the  light  it  throws 
upon  the  possible  genesis  of  chronic  Parkinson's  dis- 
ease. The  disease  may  be  inflammatory  at  the  start 
and  later  on  degenerative.  The  complete  or  partial 
recoveries  which  have  been  observed  and  the  pro- 
gressive conditions  also  throw  light  on  the  patho- 
genesis. Parenthetically  it  may  be  added  that  some 
patients  showed  simultaneous  involvement  of  the 
pyramidal  and  extrapyramidal  systems,  as  evidenced 
by  a  Babinski,  absent  abdominal  reflexes,  and  a  typi- 
cal paralysis  agitans  syndrome. 

The  facial  expression,  or  rather  loss  of  facial  ex- 
pression, has  been  attributed  to  striatal  involvement. 
This  seems  to  the  writer  to  be  too  sweeping  a  gen- 
eralization. Omitting  the  pseudobulbar  type,  there 
are  three  different  kinds  of  facial  expression.  First, 
there  is  the  actual  Parkinsonian  facies  with  rigidity 
which  becomes  masklike.  There  is  no  loss  of  motor 
power,  but  the  movements  are  slow,  dissociated,  and 
involve  only  that  muscle  or  group  of  muscles  which 
are  absolutely  necessary  for  the  execution  of  a  cir- 
cumscribed movement.  Other  associational  activity, 
such  as  movements  of  the  eyes  in  smiling  and  speak- 
ing or  that  of  the  forehead  muscles  in  opening  the 
eyes,  and  other  similar  movements  are  altogether 
wanting.  Secondly,  there  is  complete  bilateral  par- 
alysis, probably  nuclear  in  origin,  of  the  facial 
nerves.  It  is  not  a  question  of  associational  loss,  but 
of  absolute  paralysis.  Not  a  muscle  can  be  moved, 
the  wrinkles,  curves  and  lines  disappear,  the  face  is 
flattened,  ironed  out.  The  want  of  expression  is  not 
due  to  inherent  absence  of  expression  but  to  the  in- 
ability to  lend  motor  power  to  its  execution.  Thirdly, 
and  what  seems  to  the  writer  to  be  more  significant 
of  epidemic  encephalitis,  is  the  listless,  dull,  expres- 


August  7,  1920.] 


IVECHSLER:   Sl\]JrTOMS  OF    EPJDEMIC  ENCEPHALITIS. 


\77 


sionless,  not  quite  waxlike  face  which  simulates 
double  facial  paralysis.  There  is  no  rigidity  as  in 
Parkinson's  disease  and  no  paralysis  as  in  the  double 
facial  form.  The  patient  can  move  all  the  muscles 
and  even  associated  motor  activit}-  is  present,  but 
there  is  no  emotional  life  behind  it,  no  intellectual 
background.   It  is,  if  you  will,  a  face  without  a  soul. 

The  last  type  of  facial  expression  probably  be- 
trayed an  involvement  of  the  thalamus.  The  affec- 
tive life  seemed  to  have  ebbed  out.  Head  has  in- 
sisted upon  the  afifective,  emotional  aspect  of  the 
optic  thalamus,  and  it  is  quite  possible  epidemic  en- 
cephalitis attacked  that  side  of  it  without  hitting  the 
special  sensory  end  stations.  But  in  the  facial  ex- 
pression it  would  seem  as  if  the  conative  side  of 
thought  has  been  hardest  hit.  Intellectual  activity 
seeks  expression  in  motor  activity;  this  is  most 
marked  in  the  face  and  there  any  interference  is 
most  easily  detected.  Other  motor  activities  such  as 
gestures  and  postures  also  form  part  of  the  conative 
tendency;  a  general  inhibition  of  all  of  them  was 
noted  in  epidemic  encephalitis.  There  seems  to  have 
been  a  dissociation  between  thought,  emotion  and 
motor  activity  and  a  considerable  slowing  down  of 
each.  The  thalamic,  affective  disturbance  in  epi- 
demic encephalitis  often  dominated  the  whole  clinical 
picture  or  furnished  the  background  against  which 
were  silhouetted  motor,  sensory  and  psychic  dis- 
turbances. 

Other  syndromes  were  observed  from  time  to 
time  and  they  are  equally  interesting  although  their 
explanation  is  less  speculative.  Unilateral  tremor 
and  paralysis  of  the  oculomotor,  the  socalled  Bene- 
dict syndrome,  owed  its  existence  to  a  lesion  in  the 
tegmentum  which  involved  the  red  nucleus  and  the 
third  nerve  nucleus  or  its  fibres  which  traverse  the 
nucleus  ruber.  A  true  Weber's  syndrome  paralysis 
of  the  oculomotor  causing  ptosis,  external  strabis- 
mus, fixed,  dilated  pupil,  etc.,  on  the  same  side  of 
the  lesion,  and  hemiplegia  on  the  other  side — was  oc- 
casionally encountered.  This  of  course  was  due  to 
a  lesion  in  the  crus  which  compromised  the  cortico- 
spinal fibres  and  its  traversing  oculomotor  nerve. 

In  a  few  instances  one  noticed  conjugate  deviation 
of  the  eyes.  It  is  fair  to  assume  that  the  lesion  was 
most  frequently  in  the  midbrain  and  pons  although 
there  are  numerous  locations  in  the  brain  which 
might  account  for  conjugate  deviation,  and  in  view 
of  the  numerous  inflammatory  or  hemorrhagic  foci 
which  were  found  scattered  in  pathological  sections 
such  an  assumption  is  not  out  of  place.  In  the  sec- 
ond frontal  convolution  there  is  one  centre  which  if 
afifected  may  give  uncomplicated  deviation  of  the 
eyes  to  one  side.  The  same  result  may  follow  upon 
lesions  at  the  knee  of  the  internal  capsule,  but  pyra- 
midal tract  signs  would  be  associated  with  the  ocular 
symptoms.  Some  authors  maintain  that  there  is  a 
centre  for  conjugate  deviation  in  the  parietal  lobe 
and  a  few  clinicians  have  diagnosticated  lesions,  such 
as  tumor  and  abscess,  in  virtue  of  that  symptom. 
This,  however,  is  still  a. matter  of  dispute.  A  fourth 
place  causing  paralysis  of  gaze  is  in  the  hypothalamic 
region  involving  the  fibres  to  the  oculomotor,  but 
here  we  get  a  vertical  paralysis.  Involvement  of  the 
pes  lemniscus  superficialis  and  profundus  also  gives 


paralysis  of  gaze.  A  lesion  in  the  sixth  nerve  nucleus 
which  controls  not  only  the  external  rectus  of  one 
side  but  the  internal  rectus  of  the  ^other  results  in 
paralysis  of  lateral  gaze.  This  form  of  conjugate 
deviation  is  frequently  called  the  syndrome  of 
Foville.  Finally,  lesions  in  the  posterior  longitudinal 
bundle  and  the  Deitero  (vestibular)  oculomotor 
pathways  will  also  give  conjugate  deviation.  In  each 
instance,  however,  the  presence  or  absence  of  other 
symptoms  helps  to  determine  the  site  of  the  lesion. 
For  instance,  nystagmus  and  ataxia  accompany 
lesions  in  the  vestibular  pathways,  a  facial  paralysis 
in  the  case  of  the  posterior  longitudinal  fasciculus 
and  so  on  with  the  others. 

Attempts  have  been  made  to  explain  the  bladder 
disturbances,  particularly  retention,  by  means  of 
lesions  in  the  midbrain.  There  is  some  ground  for 
believing  that  there  is  a  centre  there  which  controls 
the  bladder  function,  but  more  definite  observations 
are  required  to  establish  the  fact  beyond  peradven- 
ture.  The  same  may  be  said  of  some  disturbances 
of  function  of  the  sympathetic  system,  such  as  vaso- 
motor changes,  sweating,  etc.,  which  have  been  ob- 
served. Certainly  the  midbrain  and  bulb  and  very 
likely  the  cortex  stand  in  intimate  connection  with 
the  general  sympathetic  and  autonomic  systems.  In 
the  case  of  urinary  retention  it  is  quite  possible  that 
the  brain,  because  of  the  general  affection,  is  unable 
properly  to  receive  and  interpret  afferent  sensory 
stimuli  or  send  out  efferent  motor  impulses. 

The  question  of  catatonia,  catalepsy  or  flexibilitas 
cerea,  has  been  variously  interpreted.  It  is  doubtful 
whether  one  can  altogether  explain  it,  as  has  been 
attempted,  by  involvement  of  the  extrapyramidal 
system.  There  is  not  that  mimic  and  other  rigidity 
which  one  is  accustomed  to  see.  One  might  invoke 
the  cerebellar  mechanism  (particularly  in  view  of 
the  asthenia,  which  could  be  so  interpreted)  but 
that,  too,  does-  not  give  the  desired  explanation. 
More  likely  is  it  that  we  are  dealing  with  a  true  cere- 
bral condition,  or  rather  interference  with  cerebral 
function  and  the  consequent  liberation  of  uncontrol- 
led, unconscious  activity.  Theoretically,  dissociative 
hypnotic  catalepsy  furnishes  a  parallel.  But  there 
are  some  pathological  facts  which  may  explain  the 
catatonia.  Southard  has  demonstrated  lesions  in  the 
supracortex  or  neopallium  in  the  parietal  regions  of 
brains  of  patients  who  suffered  from  catatonic  de- 
mentia prascox.  Whether  minute  lesions  or  general 
toxic  affection,  edema,  etc.,  can  explain  the  catatonic 
conditions  in  encephalitis  cannot  be  definitely  stated, 
as  Southard's  work  has  not  been  altogether  con- 
firmed; but  inferentially  one  may  speak  of  the  cortex 
as  the  probable  seat  of  the  lesion  in  catatonia.  It 
should  be  recalled  that  Alzheimer  speaks  of  a  gliosis 
in  the  lower  layers  of  the  cortex  in  catatonia. 

The  coma  in  epidemic  encephalitis  has  given  rise 
to  a  good  deal  of  discussion.  The  fact  is  that  it 
differs  from  the  comas  with  which  one  is  familiar. 
Indeed,  it  may  be  doubted  whether  the  patients  are 
either  sleepy  or  comatose.  What  strikes  one  most 
forcibly  is  a  want  of  attention  even  after  momentary 
well  coordinated  responses  to  stimuli,  an  indiffer- 
ence, an  utter  absence  of  emotional  response.  There 
seems  to  be  a  paralysis  of  the  emotions.    There  is 


178 


f 

LEINER:  ENCEPHALITIS  LETHARGICA. 


[New 
Medical 


York 
Journal. 


general  apathy,  a  seeming  indifference  to  general 
sensory  stimuli.  Even  at  the  risk  of  riding  the  thal- 
amic hobby  horse  too  hard  one  might  invoke  the  aid 
of  a  disturbance  in  affective  control  of  the  thalamus 
as  an  explanation  for  the  puzzling  condition.  Cer- 
tainly the  corticothalamic  connections  are  affected. 
In  very  severe  cases,  the  patient  is  a  vegetating  au- 
tomaton w^ithout  either  intellectual  or  emotional  life, 
barely  showing  a  human  flicker  and  not  betraying  the 
slightest  sign  of  struggle,  physically  or  psychically. 

Some  have  attributed  somnolence  to  disturbance 
of  the  pituitary;  others  referred  it  to  the  pineal 
gland.  All  these  suggestions  are  interesting  but  have 
little  to  recommend  them.  Nobody  has  observed 
actual  signs  or  symptoms  of  involvement  of  either  of 
the  hypophysis  or  epiphysis  cerebri.  It  may  be  urged 
that  the  functions  of  the  brain,  more  particularly  the 
higher  function,  are  not  limited  to  any  particular  part 
and  that  a  general  disturbance  accounts  for  the  alter- 
ation in  the  psychic  and  emotional  life  of  a  person 
suffering  from  epidemic  encephalitis.  Perhaps  dis- 
turbance in  the  neuroglia  may  account  for  some  of 
the  general  symptoms.  Achucarro's  view  that  the 
neuroglia  is  a  structure  or  organ  of  internal  secretion 
may  satisfy  those  who  are  speculatively  inclined, 
although  few  pathological  changes  have  been  re- 
ported in  the  glia  structure  of  brains  which  have 
been  studied  closely. 

The  term  manic  has  been  frequently  employed  to 
describe  the  mental  condition  of  patients  with  en- 
cephalitis. In  most  instances  the  term  was  very  un- 
fortunate. What  the  patient  suffered  from  was  de- 
lirium— an  infectious  or  toxic  delirium  such  as  is 
seen  in  other  diseases.  They  did  not  have  a  true 
psychosis  despite  the  fact  that  they  seemed  to  have 
delusions  or  hallucinations.  To  be  maniacal  in  a  de- 
lirium does  not  mean  that  the  patient  has  a  psychosis. 
It  is  only  when  mental  symptoms  persist  after  the 
acute  febrile  condition  has  subsided  that  one  may 
speak  of  a  psychosis  as  the  result  of  epidemic  en- 
cephalitis. Such  cases  have  occurred,  it  is  true,  but 
they  have  been  extremely  rare.  The  same  thing  may 
be  said  of  convulsions  in  the  course  of  the  disease. 
The  common  term  epilepsy  is  not  strictly  applicable. 

The  whole  course  of  the  disease  proves  that  it  is 
a  general  infection  with  selective  affinity  for  the  cen- 
tral nervous  system.  The  fever  is  in  favor  of  such  a 
conception.  The  fact  that  most  of  the  pathological 
changes  are  mesodermal — meningeal  inflammation, 
perivascular  infiltration,  small  hemorrhages,  occa- 
sional thrombosis  with  secondary  necrosis,  edema, 
etc. — also  points  in  that  direction.  Finally  the  suc- 
cessful reproduction  of  the  disease  in  animals  by 
intravenous  inoculation  (Strauss  and  Loewe)  fur- 
nishes very  strong  evidence.  The  morbid  changes 
resemble  those  found  in  other  infectious  diseases  of 
the  nervous  system.  The  similarity  in  the  pathology 
of  many  diseases  of  the  nervous  system  of  different 
etiology  suggests  that  it  is  the  underlying  histological 
structure  of  the  cerebrospinal  axis  which  mostly  de- 
termines the  reaction  and  not  the  individual  causative 
factor.  The  histopathological  picture  seems  to  de- 
pend more  upon  the  question  of  whether  the  meso- 
dermal or  ectodermal  structure  is  mainly  involved. 

1291  Madison  Avenue. 


ENCEPHALITIS  LETHARGICA.* 

A  Study  of  Its  Clinical  Aspects. 

By  Joshua  H.  Leiner,  M.  D., 
New  York, 

Adjunct  Attending  Neurologist,   Lebanon   Hospital;   Attending  Neu- 
rologist, Central  Neurological  Hospital,  Blackwell's  Island. 

In  the  early  part  of  1917,  Von  Economo  and  Von 
Wiesner  (1),  of  Vienna,  reported  a  disease  affect- 
ing the  central  nervous  system,  of  which  lethargy 
was  the  most  prominent  symptom.  Von  Economo 
thereupon  coined  the  syndrome,  encephalitis  leth- 
argica.  This  name  is  incorrect  and  has  other  short- 
comings, but  for  the  present  at  least  the  disease 
will  have  to  be  socalled.  It  has  been  found,  how- 
ever, that  eighty  per  cent,  of  the  cases  have  shown 
lethargy. 

That  this  is  not  an  entirely  new  disease  is  shown 
by  Crookshank  (2),  who  pointed  out  that  epidemics 
of  disease  resembling  encephalitis  lethargica  oc- 
curred at  various  times  and  under  different  names 
in  medical  literature,  going  back  at  least  450  years. 
It  seems  that  whenever  it  appeared,  it  was  always 
thought  to  be  a  new  disease.  Linnaeus  called  it 
raphania,  and  thought  it  was  due  to  radish  seeds ; 
the  Germans  thought  it  was  due  to  contaminated 
meats,  such  as  sausages.  Albrecht,  in  1695,  de- 
scribed it  as  the  lethargica  fever  with  disseminated 
eye  signs.  In  the  sixteenth  century  it  was  seen  in 
Italy,  and  called  mal  maazucc,  or  sickness  of  sleep. 
In  1890  epidemic  encephalitis  swept  over  the  Lom- 
bardy  Plains  of  Italy,  and  even  Hungary,  where  it 
was  called  nona.  In  1917  it  was  called  the  mys- 
terious disease,  in  Australia. 

The  relationship  of  epidemic  encephalitis  to  in- 
fluenza has  been  pointed  out  by  Jelliffe  (3),  Men- 
ninger,  and  others.  It  has  been  linked  with  botulism 
and  atypical  poliomyelitis  in  the  early  days.  Bassoe 
(4)  thought  the  histology  bore  some  resemblance  to 
the  trypanosome  infection.  However,  it  is  a  dis- 
ease entity,  with  its  own  peculiar  pathology  and 
bacteriology. 

Next  to  the  protean  clinical  symptomatology  dis- 
played as  a  result  of  the  syphilitic  virus  involving 
the  central  nervous  system,  in  the  variety  of  clinical 
symptoms  engendered  in  this  disease  it  easily  ranks 
second.  Because  of  this  fact  for  the  present  at  least, 
each  writer  establishes  his  own  classification  as  a 
working  hypothesis,  in  recording  his  cases. 

AGE  AND  SEX. 

A  case  of  congenital  epidemic  encephalitis  was 
reported  by  Harris  (5).  The  mother,  aged  twenty- 
eight,  was  a  victim  of  this  disease,  and  gave  birth 
to  a  child  that  seemed  excessively  drowsy.  On 
the  third  day,  a  lethargic  condition  set  in.  This 
lasted  for  several  days  with  subsequent  recovery. 
The  youngest  patient  recorded  as  having  this  mal- 
ady was  four  months  old,  the  oldest  was  aged 
ninety-six  years.  The  greatest  number  of  cases 
are  found  in  those  who  seem  robust  and  healthy. 
Its  most  frequent  occurrence  is  between  the  ages 
of  twenty  and  thirty,  which  bears  this  out.  Males 
are  more  often  affected  than  females. 

*Read  before  the  Bronx  County  Medical  Society,  May  19,  1920. 


August  7,  1920.] 


LEINER:  ENCEPHALITIS  LETHARGICA. 


179 


GENERAL  SYMPTOMS. 

Lethargic  encephalitis  is  an  acute  disease  affect- 
ing the  central  nervous  system.  Like  all  acute  in- 
fectious diseases,  it  may  appear  as  a  fulminating 
type  and  the  patient  dies  within  a  few  days,  or,  as 
in  the  majority,  as  a  long  drawn  out  illness. 

The  general  symptoms  begin  with  the  patients 
being  either  apathetic  and  drowsy  or  showing  an 
initial  exhilaration.  They  may  continue  ro  be 
drowsy  and  walk  about  in  this  way.  In  two  cases 
of  this  variety  the  patients  walked  into  the  Lebanon 
hospital  clinic,  showing  acute  Parkinsonian  symp- 
toms, i.  e.,  in  their  gait  and  attitude,  and  they  had 
tremor,  rigidity,  and  rise  in  temperature.  One  of 
the  patients  in  addition  showed  an  involvement  of 
the  right  sixth  nerve.  This  condition  may  then 
become  stationary,  or  take  the  form  of  pathological 
sleep  and  lethargy.  The  exhilarating  type  shows 
an  excessive  energy  at  work  or  at  play,  which  may 
later  merge  into  the  drowsy  or  sleeping  state.  Dr. 
Richman,  who  had  epidemic  encephalitis  in  1918, 
showed  periodical  states ;  either  he  was  asleep  or 
very  restless.  He  showed  the  most  marked  rest- 
lessness that  I  have  ever  seen.  He  kept  turning 
continuously  in  bed  pleading  for  opiates.  Head- 
aches are  severe  in  some  cases ;  vomiting  and  gid- 
diness in  others.  Many  patients  complain  of  neu- 
ralgic pains,  and  pain  in  back  of  the  neck,  to- 
gether with  suboccipital  tenderness.  In  these  cases 
Kernig's  sign  could  often  be  elicited.  Coarse  trem- 
ors were  often  found  in  the  fingers  early  in  the 
infection.  A  severe  chorea  would  at  times  usher  in 
the  disease.  The  temperature  would  rarely  rise 
above  101°  F.  Someone  has  characterized  this 
infection  as  a  low  smoldering  fire.  The  terminal 
states  were  often  marked  by  higher  temperature, 
which  was  frequently  a  complication  and  not  a  pic- 
ture of  the  disease  proper.  A  good  many  patients 
died  from  hypostatic  pneumonia. 

LOCAL  SYMPTOMS. 

The  local  symptoms  are  dependent  upon  the  area 
involved.  The  disease  seems  to  have  a  predilection 
for  the  mesencephalon,  and  the  basal  ganglia.  This 
fact  accounts  for  the  frequency  of  third  nerve  in- 
volvement, with  ophthalmoplegias  resulting  in  early 
diplopia ;  the  red  nucleus,  and  superior  peduncular 
fibres,  showing  the  chorea,  athetoid  movements  of- 
ten remaining  as  residual  symptoms;  the  tremors. 
Parkinsonian  rigidities,  a  picture  of  corporastri- 
atel  invasion,  particularly  of  the  pallidal  system, 
which  controls  the  automatic  and  associated  move- 
ments ;  and  finally  the  cutting  off  of  all  centripetal 
stimuli  to  the  thalamus,  resulting  in  sleep.  Cli- 
menko  (6)  tries  to  explain  this  phenomenon  on  the 
basis  of  a  toxic  involvement  of  the  pituitary  which 
leads  to  a  temporary  suspension  of  function,  sim- 
ilar to  hibernation,  which  was  first  noted  by  Gush- 
ing. If  the  neighboring  internal  capsule  is  affected 
with  -involvement  of  the  corticospinal  tracts,  we 
have  hemiplegia  and  other  similar  manifestations. 
Again  the  pontine  and  medullary  nuclear  implica- 
tions give  rise  to  their  respective  symptoms. 

The  toxic  involvement  of  the  endocrines.  auto- 
nomic, sympathetic  systems  is  striking  adrenals  be- 
ing particularly  affected  and  showing  the  severe  con- 
stitutional toxemia.    Hypoadrenia  with  exhibition 


of  Sergent's  white  line  has  been  noted  by  Cli- 
menko  (6),  Goldmark,  and  myself.  I  have  wit- 
nessed its  disappearance  in  a  patient  with  marked  as- 
thenia after  the  administration  by  mouth  of  whole 
adrenal  gland.  In  the  service  of  Dr.  Goldmark  at 
the  Lebanon  Hospital,  hypodermic  injections  of 
adrenalin  led  to  an  improvement  in  blood  pressure, 
pulse,  and  the  disappearance  of  Sergent's  white  line. 
Alexander  and  Allen  (7)  observe  strange  vaso- 
motor phenomena.  A  child,  aged  five  and  a  half 
years,  who  had  epidemic  encephalitis,  shovyed 
half  of  the  ear  flushed,  while  the  remaining  half 
was  blanched  white,  also  flushing  of  only  one  cheek 
at  a  time  and  a  sudden  cyanosis  of  one  hand,  while 
the  radial  pulse  was  equal  on  both  sides. 

PSYCHIC  TYPE. 

Case  I. — I  was  asked  by  Dr.  Gitlow  to  see  a 
male  patient,  aged  forty-five.  For  three  weeks  his 
temperature  never  exceeded  101°  F.  No  patho- 
logical changes  were  found  in  the  viscera.  Neu- 
rologically  he  showed  a  marked  suboccipital  tender- 
ness, a  slight  facial  droop  on  the  right  side,  and  a 
right  Babinski  that  was  not  constant.  Psychically 
his  memory  and  retention  were  poor.  He  showed 
an  incomplete  Korsakoff  syndrome.  In  addition  he 
had  delusions  of  persecution,  of  a  sexual  accusa- 
tory character.  I  performed  a  lumbar  puncture, 
and  the  fluid  came  out  under  very  high  pressure. 
The  fluid  was  clear.  The  Wassermann  was  negra- 
tive.  The  patient  recovered  completely  in  a  few 
weeks. 

There  are  now  two  girls  at  the  neurological 
clinic  of  Mt.  Sinai  Hospital,  one  aged  twenty  and 
the  other  twenty-one.  Both  gave  a  hitory  of  hav- 
ing had  colds,  accompanied  by  fever,  extreme  rest- 
lessness, and  insomnia.  Both  show  a  psychosis  of 
the  manic  depressive  type,  one  belonging  to  the  cy- 
clothymics with  alternating  periods  of  depression 
and  excitement.  Both  patients  showed  a  suppres- 
sion of  their  menstruation,  one  not  having  menstru- 
ated for  five  months  and  the  other  for  three. 
Neurological ly  they  showed  negative  findings.  ■ 

Here  we  have  cases  of  a  toxic  psychosis,  which 
gave  rise  to  hallucinations,  delusions,  catatonic 
states  with  flexibilitas  cerea,  reminding  one  of  the 
catalepsies  in  dementia  prsecox.  Kinnier  Wilson 
reported  a  patient  who  showed  a  typical  witzelsucht 
(8),  Climenko's  (6)  case  showed  a  true  Korsakoff 
syndrome.  It  must  be  observed,  however,  that 
as  a  general  rule,  even  at  the  height  of  the  disease, 
during  pathalogical  sleep,  the  memory  is  surprising- 
ly accurate,  and  the  mental  attitude  one  of  abso- 
lute indifference.  The  facies  depict  no  emotional 
play,  due  perhaps  in  some  cases  to  facial  nuclear, 
supranuclear,  or  nerve  involvement,  and  in  others 
to  striatal  tract  implication  as  in  Parkinson's  dis- 
ease, with  its  rigid  masked  features. 

CEREBROCEREBELLAR  TYPE. 

Alexander  and  Allen,  who  have  collected  the  data 
up  to  date,  state  that  the  oldest  patient  who  con- 
tracted this  disease  was  aged  sixty-two. 

Case  I. — This  female  patient  was  sixty-five  years 
of  age.  The  history  shows  that  four  grown  up 
children  had  socalled  influenza.  They  recovered, 
when  the  mother,  who  was  nursing  them,  contracted 
the  disease.    She  had  pneumonia,  was  cared  for 


180 


LEINER:  ENCEPHALITIS  LETHARGIC  A. 


[New  York 
Medical  Journau 


by  Dr.  Handleman,  and  was  up  for  a  week,  when 
she  became  listless  and  drowsy.  When  I  saw  her 
she  was  in  bed,  the  face  was  masked,  the  eyelids 
were  closed ;  she  would  raise  them  half  way  when 
requested.  When  she  was  requested  to  do  this  a 
number  of  times  in  succession,  this  effort 
would  be  followed  by  an  inability  to  open  the  lids, 
reminding  one  of  the  observation  made  by  Hall  (9) 
and  Foster  Kennedy  (10),  that  the  condition  re- 
sembled myasthenia.  The  pupils  reacted  to  light. 
I  could  not  elicit  any  other  test  that  required  the 
patient's  cooperation.  Her  pharyngeal  and  uvular 
reflexes  were  absent.  The  neck  and  both  upper 
extremities  were  rigid.  The  radial  and  triceps  re- 
flexes were  obtainable.  The  lower  extremity  on 
the  right  side  was  drawn  up  and  rigid.  The  knee 
jerk  on  this  side  could  not  be  obtained  because  of 
an  anomalous  condition  of  the  quadriceps  tendon 
on  that  side.  The  left  knee  jerk  was  present,  but 
the  extremity  was  rigid.  The  right  ankle  jerk  was 
absent. 

She  was  admitted  four  weeks  later  to  Lebanon 
Hospital,  where  she  presented  a  typical  lethargic 
encephalitis.  There  were  double  facial  involvement, 
tremor  of  digits  of  both  hands,  and  rigidity  of  both 
upper  and  lower  extremities,  together  with  stupor. 
Repeated  questioning  would  sometimes  elicit  a 
whispering  monosyllabic  reply.  Her  temperature 
was  never  above  101.5°  F.  She  died  of  a  terminal 
hypostatic  pneumonia,  after  a  ten  weeks'  illness. 

Case  H.— This  case  is  of  the  fulminating  variety. 
The  patient  was  seen  by  Dr.  Bennet  three  days  be- 
fore I  saw  her.  She  was  a  young  married  woman 
aged  twenty-four,  who  first  showed  some  catarrhal 
symptoms,  headache  and  insomnia.  She  showed  an 
acute  Parkinson's  disease  with  marked  rigidity, 
tremors,  suboccipital  tenderness  and  Kernig's  sign. 
The  same  day  she  was  admitted  to  Lebanon  Hos- 
pital, where  she  died  in  eighteen  hours.  A  postmor- 
tem examination  was  performed.  The  piaarachnoid 
showed  marked  congestion  over  the  convexity  and 
base.  A  slight  exudate  was  seen.  The  ependyma  of 
the  fourth  ventricle  was  found  congested.  When  I 
cut  down  into  the  tissue  to  examine  the  basal  ganglia, 
I  found  nothing  upon  gross  examination.  The  brain 
was  left  to  be  sectioned,  but  unfortunately  the  porter 
in  trying  to  obtain  new  jars  threw  it  away.  Perhaps 
we  could  have  confirmed  Dr.  Ramsay  Hunt's  find- 
ings that  the  lenticular  nucleus,  especially  the  globus 
pallidas,  is  involved  in  those  cases  that  manifest 
acute  Parkinsonian  syndrome. 

Case  IIL — This  case  is  of  interest  because  of 
acute  onset  of  cerebellar  involvement.  Male,  aged 
thirty-six,  had  a  cold  for  three  days,  together  with 
insomnia  and  restlessness  followed  by  drowsiness. 
I  saw  him  three  weeks  later.  He  then  showed  a  par- 
tial ptosis  of  the  left  eye,  a  nystagmus,  with  greater 
amplitude  to  the  left,  and  a  dysdiadokokinesia  of  the 
left  upper  extremity,  together  with  a  certain  amount 
of  hypermetria  in  performing  the  heel  to  knee  test, 
on  the  left  side.  When  standing  he  fell  to  the  left. 
When  walking  he  reeled  to  the  left.  Dr.  Luttinger, 
his  family  physician,  stated  that  his  temperature  hov- 
ered between  99°  F.  and  100°  F.,  and  never  above 
this.  There  was  no  visible  sign  of  involvement  of 
the  corticospinal  pathways. 


MYELONEURITIC  TYPE. 

Here  the  central  grey  and  the  white  matter,  the 
root  ganglion  and  nerves  show  involvement. 

On  May  4,  1920,  Dr.  Walter  Kraus  presented  a 
case  before  the  New  York  Neurological  Society, 
which  showed  a  distinct  involvement  of  the  fifth  and 
sixth  nerves  of  the  cervical  region  of  the  cord,  in- 
volving the  ainterior  horn  cells,  with  a  resulting 
winged  scapula,  and  atrophy  of  the  muscles  of  the 
arm  and  forearm.  The  early  symptoms  were  those 
of  epidemic  encephalitis.  This  case  showed  the  pro- 
tean nature  of  the  disease,  and  the  thin  ice  we  were 
treading  in  trying  to  differentiate  this  from  a  classi- 
cal case  of  acute  anterior  poliomyelitis. 

Case  IV. — This  is  a  case  of  the  radicular  type. 
H.  S.,  twenty-three  years  old,  became  sick  the  early  . 
part  of  January,  1920,  his  teeth  pained  him  and  he 
had  pains  in  his  ear.  Five  days  later  when  I  saw 
him  he  complained  of  severe  pain  in  both  arms  and 
hands,  and  in  the  cervicodorsal  region  of  his  back. 
He  presented  wild  choreiform  movements  of  both 
upper  extremities  and  of  the  lower  extremities  to  a 
lesser  degree.  Accompanying  this  there  were  con- 
tinuous chewing  movements,  and  also  swallowing. 
His  speech  became  nasal  in  character,  and  he  often 
stammered.  On  examination,  his  pupils  were  con- 
tracted, the  right  larger  than  the  left,  and  reacted 
to  light  sluggishly.  Nystagmoid  movements  were 
present,  and  the  left  sixth  nerve  was  paretic.  A 
history  of  diplopia  was  elicited.  A  distinct  right 
facial  paralysis  was  observed.  Suboccipital  tender- 
ness was  present,  together  with  a  slight  stiffness  of 
the  neck.  The  right  abdominal  reflexes  were  absent. 
Knee  and  ankle  jerk  were  diminished.  A  slight  Ker- 
nig  was  elicited ;  no  Babinski  nor  Oppenheim  at  this 
time.  On  February  10,  1920,  I  was  told  that  he  was 
drowsy  for  three  days  during  the  preceding  week, 
his  temperature  was  101°  F.  He  complained  bitterly 
of  pain  which  prevented  him  from  sleeping.  This 
was  present  in  the  forearms  above  his .  wrists  and 
external  surface  of  his  arm  and  forearm,  correspond- 
ing to  C5  and  C6,  the  right  being  more  painful  than 
the  left.  The  chorea  had  ceased,  and  a  coarse  tremor 
with  occasional  jactitations  was  present  in  the  digits 
of  both  hands.  His  facial  paralysis  was  less  appar- 
ent. The  knee  jerks  and  ankle  jerks  were  more  ac- 
tive. No  Babinski  was  present,  but  an  Oppenheim 
was  obtainable  for  the  first  time,  i.  e.,  four  weeks 
after  the  onset  of  the  illness.  He  showed  a  distinct 
level  of  hyperalgesia  from  the  fifth  to  the  seventh 
cervical. 

On  February  20,  1920,  his  pupils  were  more  di- 
lated, reacted  readily  to  light  and  in  convergence. 
But  he  now  saw  objects  one  above  another.  The 
facial  paresis  was  greatly  improved,  the  abdominal 
reflexes  were  all  present;  knee  jerks  were  lively,  the 
Oppenheim  was  present,  and  a  Gordon  reflex  was 
also  elicited  on  the  left  side,  but  at  no  time  was  a 
Babinski  plantar  reflex  present.  He  now  complained 
of  pain  only  in  the  right  hand,  limited  to  the  ulnar 
nerve  distribution.  He  showed  no  tenderness  of  the 
nerve  trunks.  On  February  26th  his  status  was 
about  the  same,  but  his  sensory  cord  lev^el  was  now 
down  to  the  first  dorsal.  In  the  middle  of  March, 
1920,  his  double  vision  had  entirely  disappeared; 


August  7,  1920.] 


LEINER:  ENCEPHALITIS  LETHARGICA. 


181 


the  optic  discs  were  not  involved.  Coarse  tremors 
were  still  present,  and  an  Oppenheim  of  the  left 
lower  extremity  was  elicited.  He  still  complained 
of  burning  pain  in  the  back  of  his  neck. 

Case  V.— This  case  showed  both  a  radicular  and 
a  myeloneuritic  involvement.  A  married  woman 
thirty-two  years  of  age  was  sick  for  seven  weeks 
before  I  saw  her.  There  was  a  history  here  of  diplo- 
pia, and  of  having  been  in  a  lethargic  state.  The 
patient's  pupils  were  equal  and  moderately  dilated, 
reacting  promptly  to  light  and  accommodation. 
Ankle  jerks  were  present  bilaterally,  but  the  left 
knee  jerk  was  diminished.  She  showed  an  atrophy 
of  the  left  thigh  group  and  a  trophic  skin  disturb- 
ance. Severe  pain  was  complained  of  in  the  cervical 
region,  and  a  level  of  C5  and  C6  hyperesthesia  was 
present.  There  was  segmental  hyperesthesia  corre- 
sponding to  this  level,  involving  the  right  deltoid  and 
external  surface  of  right  arm.  A  Lesegue  sign  was 
present  in  the  left  lower  extremity,  together  with 
tenderness  along  the  sciatic.  Another  line  of  radicu- 
litis was  found  at  the  lower  lumbar  and  upper  sacral 
region.  The  bladder  was  involved  and  this  led  to  a 
cystitis. 

Case  VI. — L.  L.,  female,  aged  seventeen,  a  patient 
in  the  neurological  clinic,  in  Dr.  Climenko's  service, 
of  Mt.  Sinai  Hospital.  She  came  in  with  her  head 
resting  on  her  left  shoulder.  A  history  of  having 
been  five  weeks  in  bed  was  given,  together  with  rest- 
lessness and  insomnia.  For  the  past  three  weeks  she 
had  had  pain  in  the  left  side  of  her  head  and  in  her 
left  arm.  This  arm  had  a  pulling  sensation ;  an  oc- 
casional twitch  was  visible.  Examination  revealed  a 
weakness  of  the  left  side  of  the  face,  a  weakness  of 
left  upper  extremity,  and  the  head  was  deviated  to 
the  left.  Pain  was  present  in  both  upper  extremities 
on  passive  motion.  There  was  a  distinct  line  of 
hyperalgesia  of  C5  and  C6.  This  girl  improved 
gradually,  and  she  is  holding  her  head  erect  again. 
She  had  not  had  her  menses  for  the  past  three 
months. 

PATHOLOGY. 

The  basic  pathological  condition  can  be  epitomized 
to  a  vascular  congestion  and  perivascular  infiltration 
especially  around  the  veins.  A  predominating  num- 
ber of  lymphoc^-tes  are  present,  but  plasma  cells  and 
polynuclear  cells  are  also  present.  These  hemor- 
rhagic areas  may  be  minute  in  size,  and  can  hardly 
be  detected  macroscopically.  The  changes  in  the  sur- 
rounding nervous  parenchyma  show  different  grades 
of  degeneration,  even  neurophagia  being  noted, 
but  to  a  far  less  extent  than  in  poliomyelitis,  as  noted 
by  Marenesco ;  another  point  is,  there  is  less  destruc- 
tion of  the  parenchymatous  tissue  than  in  poliomye- 
litis. This  has  also  been  noted  in  poliomyelitis. 
This  pathological  condition  has  been  noted  in  every 
portion  of  the  affected  nervous  tissue. 

BACTERIOLOGY. 

Von  Weissner  recovered  a  gram  positive  diplo- 
streptococcus,  which,  it  is  stated,  will  produce  som- 
nolence when  it  is  injected  in  monkeys.  Wegeforth 
and  Ayer  have  inoculated  monkeys  with  cord  in- 
filtrates from  the  infected  human  as  well  as  spinal 
fluid  injections,  and  their  results  were  negative. 

The  most  promising  work  in  this  field  of  investi- 


gation, which  is  of  the  highest  type  of  scientific  en- 
deavor, and  is  bringing  results  that  are  most  convinc- 
ing, is  the  work  of  Strauss  and  Loewe  (13,  14). 
They  have  fulfilled  Koch's  law  in  every  respect. 
They  have  produced  lesions  in  monkeys  that  are 
characteristic  of  the  disease,  by  means  of  the  emul- 
sion of  the  human  infected  brain,  by  filtrates  derived 
from  the  nasopharynx  of  sufferers  of  this  disease, 
and  isolated  an  organism  that  is  small  and  globular 
in  shape,  appearing  in  diploforms,  chains  or  in 
clumps.  The  inoculation  of  this  organism  has  pro- 
duced the  disease.  The  organisms  were  then  recov- 
ered, and  passed  through  generations  of  monkeys 
and  rabbits.  I  have  personally  seen  these  globoid 
bodies,  observed  the  stuporous  animals,  and  the 
macroscopic  and  microscopic  lesions,  engendered  by 
the  organism.  For  diagnostic  methods  in  the  detec- 
tion of  this  malady  they  have  lately  introduced  a 
Shick  epidermal  reaction.  The  observation  should 
be  made,  that  the  organism  in  some  characteristics, 
resembles  the  one  found  by  Flexner  and  Noguchi 
in  poliomyelitis. 

In  consideration  of  the  residual  symptoms  that 
this  malady  leaves  behind,  it  is  too  early  to  see  if 
they  will  remain  permanent.  On  the  neurological 
service  of  Dr.  W.  Leszynsky  in  Lebanon  Hospital 
there  is  a  man  who  has  shown  attacks  of  petit  mal 
following  encephalitis.  At  the  Montefiore  Hospital 
there  are  two  cases  of  residual  postencephalitis,  one 
patient  showing  a  Parkinsonian  and  the  other  a 
hemiplegic  syndrome.  The  patient  with  cerebellar 
involvement,  whose  case  is  mentioned  in  this  paper, 
still  shows  vertigo,  when  looking  upward.  One  must 
therefore  be  guarded  in  the  prognosis.  The  patient 
with  a  radiculitis  with  a  sciatic  neuritis  showing 
atrophy  of  her  muscles  is  a  case  in  point.  There  is 
no  true  cerebral  type  nor  any  pure  type  in  this 
affection.  The  cerebral  form  may  combine  with 
the  radicular  but  it  is  the  same  disease. 

In  conclusion  I  wish  to  point  out  a  rather  obscure 
type  of  this  malady  wliich  Dr.  Reilly  mentioned,  and 
one  case  of  which  was  seen  on  the  neurological  serv- 
ice of  Dr.  Leszynsky,  in  the  Lebanon  Hospital.  This 
male  patient  gave  the  clinical  picture  of  a  man  in 
coma,  either  of  the  nephritic  form  or  of  the  diabetic 
type.  In  addition  to  this  he  showed  glycosuria.  We 
know  that  a  great  proportion  of  sufferers  of  this  af- 
fection have  shown  sugar  in  the  urine.  Dr.  Reilly 
mentioned  a  few  cases  of  this  type  that  came  under 
his  observation.  This  patient  showed  very  marked 
spasmodic  abdominal  muscular  contractions.  These 
contractions  have  been  noted  in  different  parts  of  the 
body,  resembling  myoclonic  muscular  contractions. 
Dr.  Abrahamson  has  pointed  out  that  the  muscles 
so  affected  always  corresponded  to  the  line  of  spinal 
hyperesthesia  elicited. 

TREATMENT. 

The  treatment  is  purely  symptomatic.  Some  ef- 
forts have  been  made  in  the  use  of  serums  and  vac- 
cines, but  no  success  has  attended  this  field  of  en- 
deavor. Lumbar  puncture  at  times  seemed  to 
afford  some  relief  for  the  symptoms,  but  this  was 
short  lived.  It  should  only  be  used  where  there  is 
marked  meningeal  irritation.  Good  nursing  is  the 
best  treatment. 


182 


SCHWARTZ:  EXCEPHALITIS  LETHARGICA. 


[New  York 
AIedical  Journal. 


In  the  residual  symptoms  that  this  disease  en- 
genders, massage,  which  should  be  applied  lightly,  is 
often  indicated.  In  those  cases  that  show  contrac- 
tures, the  earlier  the  immobilization  with  overcorrec- 
tion the  better  the  prognosis.  I  wish  to  take  this 
opportunity  for  thanking  Dr.  William  Leszynsky, 
Dr.  Hymen  Climenko  and  Dr.  Carl  Goldmark  for 
allowing  me  to  quote  some  of  their  cases. 

REFEREXCES. 

1.  V.  EcoxoMO :  Wiener  Klin.  Woch.,  July  26,  1917. 

2.  Crookshaxk:  Proceedings  Royal  Society  of  Medi- 
cine, vol.  12,  Section  History  of  Medicine,  1919. 

3.  Menxinger,  K  :  Archives  of  Neurology  and  Psychia- 
try, January,  1920. 

4.  B.\ssoE  and  Hassin  :  Archives  of  Neurology  and  Psy- 
chiatry, July,  1919. 

5.  Harris,  W.  :  Lancet,  1-508,  April  20  1919. 

6.  Climexko,  H.  :  New  York  Medical  Jourxal,  1920. 

7.  Alexander  and  Allex  :  Archives  of  Neurology  and 
Psychiatry,  May,  1920,  p.  492. 

8.  Wilson,  Kixxier:  Lancet,  July  6,  1918. 

9.  Report  on  an  Inquiry  into  an  Obscure  Disease.  En- 
cephalitis Lethargica,  Local  Government  Rd^oorts  on  Pub- 
lic Health..  N.  S.  121,  Lond.  H.  M  Stationer's  Office 

10.  Kexxedy,  Foster:  Epidemic  Stupor,  Medical  Rec- 
ord, 191 9,  p.  631-633 

11.  Wegeforth  and  Aver:  Journal  A.  M.  A.,  July  5. 
1919. 

12.  RiCE-OxLEY  :  Report  on  an  Inquiry,  etc.  (9) . 

13.  Strauss,  Hirschfield  and  Loewe  :  New  York 
Medical  Jourxal,  May  3,  1919. 

14.  Loewe  and  Strauss:  Journal  A.  M.  A.,  October  4, 
1919. 

1187  Boston  Road. 


ENCEPHALITIS  LETHARGICA.* 
Report  of  Eleven  Cases. 
By  Samuel  Schwartz,  M.  D., 

New  York. 

Through  the  courtesy  of  Dr.  Neff,  I  beg  to  pre- 
sent before  you  a  paper  reviewing  the  cases  of 
encephalitis  lethargica  at  the  Harlem  Hospital.  Be- 
fore proceeding  with  our  own  cases,  I  shall  first 
give  a  resume  of  the  literature  on  the  subject. 

DEFINITION. 

Accepting  Sainton's  definition  we  may  classify  it 
as  "a  toxic  infectious  epidemic  syndrome  char- 
acterized clinically  by  triad  lethargy — ocular  palsies 
and  a  febrile  state — and  anatomically  by  a  more 
or  less  diffuse  encephalitis  most  marked  in  the  gray 
matter  of  the  midbrain." 

HISTORY. 

In  the  middle  of  1917  \'on  Economo  reported  a 
number  of  cases  appearing  in  Vienna  in  epidemic 
proportions  characterized  by  somnolence — almost 
simulating  sleeping  sickness,  and  very  illogically 
called  it  encephalitis  lethargica,  for  not  all  the  pa- 
tients are  lethargic.  Many  of  them  really  suffer 
from  insomnia  and  are  very  restless.  In  March, 
1918,  Breinl  reported  nine  cases  observed  in  Aus- 
tralia. About  the  same  time  that  these  observations 
were  being  made  in  Australia,  similar  cases  were 
under  investigation  in  France  and  England,  and 
later  reports  from  Italy  and  Uruguay  give  evidence 
that  the  disease  was  worldwide  in  its  distribution. 
This  disease  is  not  a  new  one,  as  similar  epidemics 

•Read  before  Harlem  Hospital  Medical  Society,  April  6,  1920. 


have  been  reported  as  early  as  1712  and  others  in 
1891,  following  pandemics  of  influenza.  So  we  see 
that  the  present  epidemic  first  appeared  in  eastern 
Europe  and  in  Australia,  then  it  spread  westward 
reaching  France  and  England  early  in  1918,  and  in 
this  country  in  the  fall  of  the  same  year.  The  first 
case  in  this  country-  was  observed  in  Major  Tasher 
Howard's  serv-ice  at  Camp  Lee,  Va.,  in  November, 
1918. 

PATHOLOGY. 

We  have  had  opportunity'  to  examine  the  brains 
in  two  cases  in  which  complete  necropsies  were  per- 
formed. The  appearance  of  these  two  brains  was 
very  similar.  The  gross  changes  consisted  of  edema 
and  marked  congestion.  The  histological  changes 
were  also  similar  in  the  two  cases  and  were  mainly 
found  in  the  basal  ganglions  and  brain  stem.  They 
consisted  principally  of  dense  accumulations  of 
mononuclear  cells  around  the  vessels  and  of  small 
hemorrhages.  There  was  little  evidence  of  necrosis 
or  of  extensive  tissue  destruction,  in  which  respect 
this  disease  differs  from  poliomyelitis. 

SYMPTOMS. 

The  outset  of  the  symptoms  was  always  insidious. 
The  first  suggestive  symptom  has  been  blurring  of 
vision,  with  more  or  less  definite  diplopia,  together 
with  progessive  listlessness  which  when  pronounced 
has  been  called  lethargy.  The  facies  gradually  be- 
comes extremely  characteristic  with  masklike  im- 
mobile features,  half  open  eyes  and  a  fixed,  more  or 
less  distorted  position  of  the  mouth.  The  patient 
does  not  sleep  as  much  as  is  indicated  by  the 
sleepy  expression.  In  fact,  some  of  the  patients 
actually  suffer  from  insomnia.  Thus  we  see  that 
the  lethargic  appearance  is  only  a  sign  of  the 
involvement  of  the  cerebral  mechanism.  In  one 
of  our  patients  there  developed  distinct  choreiform 
movements  with  labored  respiration  and  weak,  rapid 
])ulse.  Retention  of  urine  was  a  common  symptom 
observed  in  our  cases.  The  urinary  apparatus  has 
its  centre,  according  to  recent  investigation,  in  the 
basal  ganglion,  which  is  the  favorite  site  of  the 
inflammatory  changes  in  this  disease.  Fever  is  usu- 
ally present  to  a  variable  extent,  but  like  the  lethargy 
floes  not  bear  a  direct  relation  to  the  amount  of 
infection  present.  Headache,  malaise  and  weakness 
are  common  symptoms,  noticed  in  the  early  stage 
of  the  disease.  Orientation  was  usually  unaffected 
just  until  death,  and  a  very  important  symptom  was 
a  sense  of  euphoria  which  almost  all  of  our  pa- 
tients had  when  aroused  and  questioned  as  to  their 
condition. 

REPORT  OF  CASES. 

Our  own  experience  at  Harlem  Hospital  with  en- 
cephalitis lethargica  dates  back  to  September,  1919. 

Case  I. — P.  S.,  male,  white  Russian,  aged  thirty- 
eight,  was  admitted  to  the  institution  September 
28,  1919.  Chief  complaint  was  headache  of  two 
weeks'  duration.  His  daughter  was  at  that  time  at 
Mount  Sinai  Hospital,  ill  with  encephalitis  lethar- 
gica. His  headache  came  on  with  an  upset  stomach, 
felt  very  weak,  was  sleepy,  and  could  not  see  with 
the  right  eye.  Physical  examination  revealed  the 
patient  in  lethargic  state.  Bilateral  ptosis  was 
present,  the  tongue  and  mouth  deviated  to  the  right. 


August  7,  1920.] 


SCHWARTZ:  ENCEPHALITIS  LETHARGICA. 


183 


there  was  diminished  power  in  upper  extremities, 
Kernig  and  Babinski  were  positive.  There  was  left 
facial  weakness  and  the  neck  was  rigid. 

The  laboratory  findings  were  as  follows :  Blood, 
white  blood  corpuscles  10,000,  polynuclears  sixty- 
one  per  cent. ;  lymphocytes  thirty-nine  per  cent., 
blood  pressure  140,  95,  urine  negative,  blood  and 
spinal  Wassermann  negative,  spinal  fluid  came  out 
under  no  pressure,  was  contaminated  with  blood, 
twenty-two  cells  per  mm.,  Fehling  slightly  positive, 
Noguchi  slightly  positive,  no  organisms  were 
found;  temperature  103°  to  99.4°,  pulse  112  to  90, 
respiration  24  to  20. 

His  eyes,  examined  by  Dr.  Cohen,  showed  myopic 
changes  in  the  left  eye,  with  internal  strabismus, 
dislocated  right  calcareon  lens  with  complete  retinal 
detachment.  The  pupils  were  equal  and  reacted  to 
light  and  accommodation.  There  was  a  calcareous 
deposit  in  right  anterior  chamber  of  the  eye.  Later 
findings  showed  ocular  paresis,  urinary  retention, 
left  abdominal  muscles  less  active  than  right.  The 
patient  was  discharged  as  cured  October  22,  1919. 
In  this  case  the  early  tendency  to  oculomotor  dis- 
turbance indicates  primary  involvement  of  the  up- 
per part  of  the  brain  stem  around  the  aqueduct 
of  Sylvius  and  the  third  ventricle. 

In  reviewing  the  literature  of  encephalitis  le- 
thargica  complicating  pregnancy  I  find  only  eight 
cases  reported.  The  mortality  is  far  higher  in 
females  than  in  males.  The  mortality  rate  in  preg- 
nant women  is  very  'high. 

Out  of  the  eight  cases  reported  five  of  the  pa- 
tients died,  one  recovered,  and  in  the  other  two  the 
outcome  was  not  reported.  In  the  Harlem  Hos- 
pital we  had  four  cases  complicating  pregnancy ; 
three  patients  died,  one  recovered. 

Case  II. — B.  M.,  aged  twenty-six,  white,  Hun- 
garian. Admitted  January  5,  1920,  to  Dr.  Broad- 
head's  service  for  delivery  of  second  child.  On 
January  6th,  the  patient  complained  of  headache, 
pain  in  neck  and  vomiting.  Dr.  Langrock  examined 
the  patient  and  stated  that  her  pregnancy  did  not 
account  for  her  condition.  Spinal  puncture  was 
performed  and  twenty  c.  c.  of  clear,  colorless  fluid 
under  moderate  pressure  was  withdrawn ;  twenty 
cells  to  the  c.  mm.,  Noguchi  positive,  Fehling 
negative,  no  organism  was  demonstrated.  The 
urine  was  negative.  The  patient  became  irrational. 
The  reflexes  were  exaggerated.  The  Kernig  was 
positive,  Babinski  positive.  The  patient  had  uri- 
nary retention  and  died  January  8,  1920. 

Case  III. — L.  F.,  female,  aged  twenty  three, 
white,  Hungarian.  Admitted  February  7,  1920,  be- 
cause of  pain  in  back.  Was  sick  at  home  for  a 
week,  and  on  admission  a  diagnosis  of  pneumonia 
was  made.  Physical  examination  revealed  well  de- 
veloped physique  in  lethargic  state.  There  was  no 
evidence  of  consolidation  in  the  lungs.  The  pos- 
terior pharynx  and  tonsils  were  the  seat  of  a 
marked  inflammatory  process  with  large  amount  of 
mucus  exudate.  The  neck  was  rigid,  Kernig  posi- 
tive, left  sided  facial  paralysis.  On  February  10th, 
there  were  automatic  movements  of  left  upper  ex- 
tremities, and  a  clonic  convulsive  action  of  right 
lower  extremity. 

The  fundus  of  the  bladder  reached  to  the  umbili- 


cus. The  patient  was  catheterized  and  sixty-eight 
ounces  of  urine  withdrawn.  The  fundus  of  the 
uterus  was  about  three  fingers  below  the  umbilicus, 
and  Dr.  Broadhead  believed  that  she  was  probably 
four  months  pregnant. 

Laboratory  findings :  Blood — red  blood  cells,  4,- 
200,000,  white  blood  cells,  13,200,  polynuclears 
eighty-six  per  cent,  lymphocytes,  fourteen  per  cent., 
urine  negative.  The  spinal  fluid  came  out  under 
moderate  pressure  clear  and  colorless.  There  were 
thirty  cells  to  the  c.  c,  lymphocytes  100  per 
cent.,  Fehling  positive,  Noguchi  negative,  no  or- 
ganism demonstrated.  Temperature  103°  to  98°, 
pulse  122  to  138,  respiration  26  to  34.  The  patient 
died  February  11,  1920. 

Case  IV. — C.  D.,  white,  aged  20,  married,  preg- 
nant, was  sent  in  by  Dr.  Cherry  to  Dr.  Hayne's 
service,  March  18,  1920,  with  tentative  diagnosis 
of  toxemia  of  pregnancy.  The  patient  had  enjoyed 
good  health  throughout  her  pregnancy.  Two  weeks 
ago  she  began  to  have  severe  headaches,  sleepless- 
ness, and  vomited  once.  She  also  noticed  that  her 
vision  was  defective.  For  past  five  days  she  has  been 
extremely  drowsy,  and  hard  to  waken ;  and  for  last 
forty-eight  hours  has  been  picking  at  the  bed 
clothes,  and  was  irrational.  Dr.  Garretson  examined 
the  patient  and  reported  the  following: — "Cranial 
nerves  negative.  Can  open  both  eyelids,  left  ap- 
pears slightly  paretic,  extrinsic  ocular  muscles  ap- 
parently balanced.  Reflexes,  upper  extremity  nor- 
mal and  equal,  lower  extremities,  patella  reflexes  ab- 
sent, plantar  present  and  normal,  sensation  responds 
to  tactile  and  pain  normally."  The  patient  gave  no 
history  of  convulsions  and  there  was  no  edema  of 
the  lower  extremities.  Laboratory  findings :  Urine, 
3  plus  albumin,  blood  pressure  systolic  175,  blood, 
white  blood  corpuscles  16,600,  polynuclears,  eighty- 
five  per  cent.,  lymphocytes  fifteen  per  cent,  a  spinal 
puncture  was  performed  and  gave  a  clear,  color- 
less fluid  under  slight  pressure.  There  were  no 
cells,  Noguchi  was  slightly  positive,  Fehling  posi- 
tive, no  organism  was  demonstrated.  The  patient 
died  March  21,  1920. 

Case  V. — A.  G.,  white,  single,  eight  months 
pregnant.  Admitted  February  13,  1920.  Com- 
plained of  headache,  pain  in  back  of  neck  and  fever 
which  began  two  weeks  ago.  She  became  drowsy 
and  felt  so  weak  thdt  she  had  to  stay  in  bed.  Physi- 
cal examination  revealed  adult  female  in  lethargic 
state.  The  pupils  were  equal  and  regular,  reacted 
to  light  and  accommodation,  no  strabismus,  ro- 
tatory nystagmus  of  right  eye,  with  weakness  of 
right  levator  palpebrae  muscle.  The  uterus  was  en- 
larged to  the;  size  of  an  eight  months'  pregnancy. 
The  knee  jerks  were  present,  Kernig  present,  Ba- 
binski ankle  clonus  and  Brudzinsky  not  obtained. 
Lumbar  puncture  performed  and  twenty-five  c.  c. 
of  clear  spinal  fluid  obtained  under  no  pressure. 

The  laboratory  findings  were,  thirteen  cells  to  the 
c.  m.,  Noguchi  negative,  Fehling  positive,  no  or- 
ganism was  demonstrated.  The  urine  showed  a 
weak  trace  of  albumin,  no  sugar,  granular  casts 
with  red  and  white  blood  cells.  The  patient  was 
transferred  to  the  obstetrical  ward,  pronounced 
cured,  where  she  gave  birth  to  a  baby  boy  March 
26,  1920. 


184 


SCHWARTZ:  ENCEPHALITIS  LETHARGICA. 


[New  Yo>k 
Medical  Jouesal. 


Case  VI. — M.  B.,  aged  nineteen,  white,  married, 
Austrian.  Admitted  January  19,  1920,  because  of 
marked  headache  and  weakness,  loss  of  appetite  and 
general  malaise.  Physical  examination  revealed  a 
poorly  developed  female,  anemic,  and  in  a  lethargic 
state.  The  muscles  of  the  neck  were  rigid,  Kernig 
positive.  A  clinical  diagnosis  of  tuberculous  men- 
ingitis was  made  and  spinal  tap  was  performed, 
twenty  c.  c.  of  clear  colorless  fluid  under  pressure 
was  withdrawn.  The  laboratory  findings  were,  twenty 
cells  to  the  c.  mm.,  Fehling  negative  'Noguchi 
slightly  positive,  no  organism  was  demonstrated. 
The  temperature  was  102°  to  104.5°,  pulse  150  to 
155,  respiration  thirty-four  to  fortv.  The  patient 
died  January  22,  1920. 

Case  VII. — M.  G.  aged  thirty-two,  U.  S.,  mar- 
ried, admitted  January  27,  1920.  Ten  days  prior 
to  admission  she  complained  of  headache  and  pain 
in  orbital  region.  She  also  complained  of  diplopia 
which  lasted  four  days.  On  the  fifth  day  the  di- 
plopia disappeared  and  the  patient  went  into  a 
lethargic  state.  Three  days  ago  there  was  noticed 
a  muscular  twitching  of  the  face  and  tongue,  and 
the  protruding  tongue  was  deviated  to  right  side. 
This  condition  kept  up  till  February  3rd.  when  the 
temperature  came  down  by  lysis  from  102°  to  nor- 
mal and  the  patient  was  discharged  as  cured. 

Case  VIII. — This  case  differs  from  the  others  by 
the  absence  of  somnolence  and  the  presence  of 
choreiform  jerking  movements.  The  patient  was 
irritable  and  had  an  anxious  expression.  The  pa- 
tient was  a  young  girl,  white,  fifteen  years  of  age, 
admitted  February  18,  1920,  because  of  pain  over  the 
head  which  had  continued  for  two  weeks.  Had 
diplopia  ten  days  ago.  Physical  examination  revealed 
3'oung  girl  well  developed,  with  labored  breathing. 
Herpes  were  present  on  the  lips,  ptosis  of  right  eye- 
lid, pupils  were  equal,  Kernig  positive,  no  Babinski 
or  Brudzinsky.  The  next  day  the  patient  became  vio- 
lently delirious  which  necessitated  restraining  her  in 
bed.  She  had  many  absurd  illusions.  While  the  lum- 
bar puncture  was  done  the  patient  seemed  to  pay  no 
attention  to  the  entrance  of  the  needle.  A  clear, 
colorless  fluid  under  moderate  pressure  was  with- 
drawn. 

The  laboratory  findings  were  350  cells  to  the  c. 
mm.,  Xoguchi  positive,  Fehling  positive,  no  organism 
was  demonstrated.  Blood,  while  blood  cells  23,000, 
polynuclears  84  per  cent.,  lymphoc)1:es  16  per  cent., 
temperature  103°-100°,  pulse  120-145,  respiration 
42-20.  On  February  21st  the  patient  went  into 
coma  and  died  February  22nd. 

The  necropsy  was  performed  by  Dr.  Cassasa,  and 
he  found  the  following :  scalp  negative ;  skull  nega- 
tive: dura  normal.  Brain:  Extreme  congestion  of 
brain :  vessels  in  the  sulci  markedly  dilated  and 
branches  over  the  convolutions  markedly  congested. 
The  congestion  was  of  a  crimson  color.  The  sulci 
and  convolutions  were  very  well  marked.  There 
was  no  free  fluid  in  the  pia  arachnoid  meshwork 
over  the  cortex  of  brain.  The  knife  was  passed  in 
a  horizontal  plane  in  a  lateral  direction  over  corpus 
collosum.  The  first  three  or  four  cervical  segments 
of  brain  were  also  removed.  The  brain  and  cord 
were  put  in  formalin  to  be  examined  for  epidemic 
encephalitis. 


The  right  pleural  sac  was  completely  obliterated 
by  old  adhesions.  The  right  lower  lobe  was  firmly 
adherent  to  the  chest  wall  and  diaphragm.  In  the 
left  pleural  sac,  over  lower  lobe  there  were  old  ad- 
hesions;  section  of  right  lung;  upper  and  middle 
lobes  normal,  showed  no  congestion  or  edema. 
The  right  lower  lobe  over  its  entire  extent  was 
markedly  congested  and  consistency  increased.  There 
was  no  distinct  granulation  on  section.  The  upper 
lobe  of  the  left  lung  was  normal :  no  congestion  or 
edema.  Along  the  costal  vertebral  border  of  the 
lower  left  lobe  there  was  an  area  of  congestion  about 
an  inch  deep;  on  section  this  area  was  black,  not 
granular  and  slightly  firm. 

There  was  no  dilatation  of  the  right  heart.  The 
pericardial  sac  was  normal,  heart  muscle  good  color. 
Right  and  left  heart  contained  a  soft,  dark  red 
blood  clot.  Stomach,  intestines,  and  appendix 
normal.  The  liver  was  yellowish  red,  and  showed 
large  areas  of  a  lighter  yellow,  giving  it  a  mottled 
appearance.  The  spleen  was  slightly  enlarged.  On 
section,  the  pulp  was  slightly  exaggerated.  The 
pancreas  was  normal.  The  cortex  of  the  kidneys 
was  smooth,  grayish  yellow ;  slightly  dull  and  intra- 
lobular vessels  markedly  injected.  The  bladder  was 
contracted  and  empty.  The  entire  mucous  surface 
showed  a  hemorrhagic  cystitis.  The  uterus,  tubes 
and  ovaries  were  normal.  Sections  were  taken 
from  the  bladder,  spleen,  liver,  heart  muscle  and 
brain.    The  final  report  was  encephalitis  lethargica. 

Case  IX. — M.  G..  aged  forty-five,  colored,  mar- 
ried. Admitted  ]March  6th,  complaining  of  headache 
and  pain  throughout  body.  Patient  later  became 
drowsy  and  fell  into  a  lethargic  state.  Had  ptosis 
of  both  eyelids  and  slight  rigidity  of  the  muscles  of 
the  neck.  The  Kemig  was  positive  :  Babinski  and 
Brudzinsky  negative.  Spinal  puncture  performed 
and  twenty  c.  c.  of  clear,  colorless  fluid  under  mod- 
erate pressure  withdrawn.  The  laboratory  findings 
were  twenty  cells  to  the  c.  mm..  Xoguchi  positive. 
Fehling  positive,  no  organism  was  found.  The 
blood  showed,  white  blood  corpuscles,  14,400,  poly- 
nuclears 76  per  cent.,  lyinphocytes  24  per  cent.  The 
temperature  was  100° -102°,  pulse  100-124.  respira- 
tion 30^0.  The  urine  was  negative,  blood  pressure 
was  122/100.  .The  patient  is  still  in  the  hospital 
convalescing. 

Case  X. — One  of  the  most  interesting  cases  we 
had  was  that  of  J.  L..  aged  thirty,  white,  Italian. 
Admitted  February  22nd,  with  chief  complaint  of 
headache.  Headache  lasted  seven  days,  and  then 
the  patient  became  drowsy ;  had  pain  in  legs,  and 
then  became  semiconscious. 

Physical  examination  revealed  a  well  developed 
and  nourished  young  Italian,  semiconscious,  answer- 
ing questions  intelligently.  When  roused  from  his 
lethargy,  having  a  sense  of  euphoria  and  manifest- 
ing twitching  of  arms,  fingers,  eyelids,  and  occasion- 
ally of  the  face,  ptosis  of  both  eyelids ;  no  ocular 
paresis,  knee  jerks  exaggerated  bilaterally,  no  definite 
Kernig,  positive  Baiiinski,  no  ankle  clonus.  Spinal 
puncture  was  done  February  23rd.  The  specimen 
was  contaminated  with  blood  and  came  under  slight 
pressure. 

The  laboratory  findings  were,  Fehling  positive. 
Xoguchi  positive,  and  the  sediment  showed  encap- 


August  7,  19iU.] 


CUMSTON:  EXCEPHALITIS  LETHARGICA. 


185 


sulated  diplococci  resembling  pneumococci.  A  diag- 
nosis of  pneumococcic  meningitis  was  made  with 
the  feehng  that  the  organism  demonstrated  was 
merely  a  contamination. 

February  28th,  lumbar  puncture  was  done,  ten  c.  c. 
of  the  fluid  slightly  contaminated  with  blood  was 
removed  under  slight  pressure  and  eight  c.  c.  of 
patient's  own  serum  injected  intraspinally.  The 
specimen  showed,  Fehling  positive,  Noguchi  posi- 
tive. No  organism  was  demonstrated  this  time  and 
the  sediment  culture  was  also  negative,  so  we 
changed  our  diagnosis  to  encephalitis  lethargica. 

In  looking  over  the  literature  on  this  subject,  I 
find  that  no  one  adequately  explains  the  cause  of  the 
lethargy  seen  in  this  disease.  I  beg  to  offer  the  fol- 
lowing explanation  and  invite  your  opinions  on  this 
matter.  In  disorders  of  the  hypophysis  we  find  that 
lethargy  is  a  very  important  symptom,  and  by  admin- 
istering the  extract  of  the  anterior  lobe  of  the  gland 
we  can  at  times  cure  a  case  of  lethargy  due  to  hypo- 
pituitism.  Now  since  the  pathology  of  encephalitis 
lethargica  shows  a  perivascular  infiltration  of  the 
pons  and  medulla,  I  feel  that  by  virtue  of  its  anatom- 
ical relationship  to  the  hypophysis  by  means  of  the 
infundibuliform  process,  it  is  rational  to  theorize 
that  the  lethargy  is  due  to  a  hypopituitism  resulting 
from  the  pathological  condition  extending  to  it. 

The  early  occurrence  of  lethargy  points  to  its  being 
a  focal  symptom  rather  than  an  expression  of  intoxi- 
cation of  the  higher  brain  centres.  In  otherwise 
mild  cases  with  good  complexion  and  clear  tongue 
the  lethargy  may  be  well  marked.  In  other  words 
the  lethargy  bears  no  relation  to  the  amount  of  in- 
fection. Hence,  it  is  safe  to  assume  that  the  letharg}- 
sets  in  just  as  soon  as  the  hypophysis  becomes  in- 
volved. 

SUMMARY 

In  summarizing  I  wish  to  state  that  while  the  lit- 
erature reports  that  the  disease  is  more  common  in 
males  than  in  females,  our  experience  has  been  other- 
wise. Of  our  eleven  cases,  there  were  seven  females 
and  four  males.  Five  of  the  female  patients  died — 
(three  were  pregnant).  Out  of  the  four  male  cases, 
one  patient  died  and  three  recovered,  which  bears 
out  the  experience  that  the  disease  is  more  fatal  to 
females.  All  of  our  cases  may  be  classified  as  en- 
cephalitis lethargica.  The  onset  was  always  in- 
sidious, with  headache,  malaise,  weakness,  vertigo, 
sore  throat,  diplopia  and  fever  as  common  symp- 
toms. Drowsiness  occurred  in  almost  every  case, 
frequently  developing  into  coma,  and  at  times  alter- 
nating with  irritability  and  anxiety.  Long  projection 
fibre  tracts  to  the  arms  and  legs  showed  disturbances 
in  some  of  our  cases  as  indicated  by  spasticities,  and 
Babinsky  reflexes.  The  symptoms  and  signs  refer- 
able to  the  brain  stem  were  found  in  all  our  cases, 
together  with  oculomotor  palsy.  Weakness  of  the 
facial  muscles  was  also  characteristic.  The  path- 
ology and  symtomatology  in  our  series  corresponded 
very  clpsely  to  that  described  by  the  men  abroad  and 
here.  As  to  the  etiology  of  lethargy  I  offer  in  ex- 
planatk)n  disturbances  of  the_  pituitary  body-  due  to 
the  -extension  of  pathological  condition  from  the 
pons  and  medulla  by  mpans.af  the.  infundibuliform 
process  which  extends,  from; the  base  of  the  brain  to 
the  hypophysis. 


EXCEPHALITIS  LETHARGICA  IN  FIL^NCE 
AND  SWITZERLAND. 
By  Charles  Greene  Cumston,  M.  D., 

Geneva,  Switzerland. 

The  clinical  aspect  of  this  morbid  process  since 
cases  have  become  more  numerous  may,  perchance, 
cause  its  name  to  be  changed,  but  until  we  possess 
more  information  concerning  it,  I  think  the  term  en- 
cephalitis lethargica  may  be  retained,  although  it  is 
not  quite  correct,  because  most  of  the  press  com- 
munications have  been  printed  under  this  heading. 
The  history  of  this  morbid  process  is,  up  to  date, 
rather  brief.  It  was  observed  by  Camerarius  and 
also  by  Sydenham,  while  in  1889-1890  the  Italians 
referred  to  it  by  the  name  of  nona,  but  it  was  von 
Economo,  of  Vienna,  who,  with  other  workers,  de- 
scribed the  disease  in  1916-1917.  In  1918  the  dis- 
ease appeared  in  England  and  France,  and  after  a 
period  of  quiescence,  it  again  developed  in  Italy, 
France  and  Switzerland,  where  cases  have  become 
more  numerous  ever  since.  First  encountered  in  the 
Parisian  suburbs,  it  extended  over  vast  territories, 
especially  Alsace,  Cherbourg,  in  the  Loire  and  Bor-. 
deaux.  Nearly  all  the  Swiss  cities  have  been  af- 
fected by  it  and  at  Geneva  to  date  we  have  had  more 
than  twenty-two  cases,  which  is  a  fair  number  for 
a  city  of  one  hundred  and  forty  thousand. 

It  may  be  assumed  to  be  an  infectious  disease,  its 
morbid  agent  as  yet  unknown  and  producing  lesions 
preferably  in  the  mesocephalon.  The  symptomatol- 
ogy is  regarded  as  being  represented  by  three  princi- 
pal phenomena,  namely,  fever,  paralysis  of  the  third 
cranial  nerve,  and  somnolence,  but,  as  I  shall  show, 
this  is  subject  to  revision.  The  prognosis  is  variable 
and  treatment  uncertain.  Although  moderately  con- 
tagious the  disease  is  unquestionably  transmissible  ,by 
the  intermediary  of  the  bucconasopharyngeal  mucus, 
a  transmission  similar  to  that  of  influenza,  and  it  is 
remarkable  that  epidemics  of  the  latter  affection  ap- 
pear coincidentally  with  the  appearance  of  enceph- 
alitis lethargica. 

The  symptomatology  as  encountered  in  France  has 
been  well  described  by  Netter.  The  disease  is  usual- 
ly febrile,  commencing  with  headache  and  occasion- 
ally vomiting.  Somnolence  rapidly  supervenes  and 
becomes  progressively  accentuated.  At  first  there  is 
drowsiness  only  and  this  is  followed  by  a  true  sleep 
from  which  the  patient  can  be  aroused,  will  reply  to 
questions,  and  walk  about,  but  as  soon  as  he  is  left 
alone  he  will  relapse  into  sleep.  At  a  more  advanced 
phase  sleep  may  be  interrupted  by  delirium,  tremor, 
and  exceptionally  convulsions.  Usually,  however, 
there  is  only  sleep.  The  muscular  system  of  the 
eyes  is  almost  always  involved — paralysis  of  eye- 
lids, nystagmus  and  rarely  diplopia.  Somnolence, 
headache,  and  ocular  disturbances  naturally  lead  one 
to  suspect  meningitis,  simple,  cerebrospinal  or  tuber- 
culous. However,  the  ordinary  signs  of  meningitis 
are  wanting  or  only  slightly  marked.  The  menin- 
geal line  can  be  readily  provoked  and  although  pres- 
sure of'  the  globes  is  painful,  irregularity  of  both 
pulse  and  respiration  is  generally  absent.  StiflFness  of 
the  neck  and  Kernig's  sign  are  slight  or  absent. 
Lumbar  puncture  gives  a  clear  fluid  containing  a  nor- 
mal .percentage  of  albumin  and  from  two  to  three 
cell  elements,  rarely  as  many  as  seven.    Cultures  of 


186 


CUMSTOX:  ENCEPHALITIS  LETHARGICA. 


[New  York 
Medicai.  Journal. 


the  cerebrospinal  fluid  remain  negative.  Therefore, 
if  the  physician  is  not  on  his  guard,  a  diagnosis  of 
cerebral  tumor  and  especially  tuberculosis  of  the 
cerebellum  will  be  made.  If  the  affection  is  pro- 
longed and  the  subject  recovers,  such  a  presumption 
might  seem  justified,  but  if  death  ensues  no  trace  of 
tubercle  will  be  found.  Both  the  surface  and  sec- 
tions of  the  brain  appear  normal  or  simply  injected 
•  with  a  diminished  consistency.  The  evolution  of 
the  process  is  variable.  Some  subjects  die  within  a 
few  hours  of  the  onset,  others  as  late  as  the  seven- 
teenth day.  Some  recover  in  a  few  days,  others 
after  several  weeks. 

This  describes  the  type  of  encephalitis  lethargica 
most  frequently  observed,  but  the  significance  of  the 
symptoms  presented  should  be  given  careful  consid- 
eration. Let  us  consider  the  three  principal  symp- 
toms separately. 

The  fever  denotes  an  infection  of  the  organism  but 
it  is  irregular  in  the  intensity  of  its  manifestations. 
In  a  large  number  of  cases  the  temperature  remains 
in  the  neighborhood  of  100.5°  to  101.5°  F.  In  others 
it  goes  to  102°,  103°  or  even  104°  F.,  and  it  seems 
now  logical  to  assume  that  the  height  of  the  tempera- 
ture is  in  direct  relation  to  the  gravity  of  the  infec- 
tion. There  are  instances  where  no  thermic  rise  has 
been  observed.  When  there  is  fever  the  morning 
remission  is  sonietimes  very  trifling. 

The  fever  is  accompanied  in  most  cases,  and  occa- 
sionally preceded  by,  other  evidences  of  infection, 
among  which  slight  chills,  an  increased  pulse  rate, 
vomiting  and  coated  tongue  are  to  be  noted.  It  is 
usually  these  symptoms  with  a  rise  in  temperature 
that  mark  the  onset  of  the  disease  but  at  the  same 
time  they  appear  the  patient  will  complain  of  head- 
ache. This  clinical  picture  is  quite  constant  and 
those  patients  too  sleepy  to  reply  to  questions  keep 
their  hands  on  their  foreheads  thus  indicating  ceph- 
alalgia. 

The  somnolence  which  is  present  has  given  its  name 
to  the  affection  and  it  would  consequently  seem  that 
it  exists  in  all  cases,  but  instances  are  reported  in 
which  it  was  absent.  However,  it  may  be  regarded 
as  one  of  the  most  constant  symptoms.  It  varies 
greatly  in  degree,  duration  and  time  of  appearance, 
but  it  should  be  regarded  as  one  of  the  earliest  signs 
and  when  the  general  symptoms  are  not  marked  it  is 
the  first  one  to  be  manifested.  Therefore,  in  those 
cases  where  the  diagnosis  has  been  made  from  som- 
nolence alone  it  will  probably  be  correct  in  the  ma- 
jority of  instances. 

In  a  large  proportion  of  cases  the  somnolence  is 
continuous,  the  subject  appearing  like  one  in  ordi- 
nary sleep.  If  he  is  called  or  an  attempt  made  to 
arouse  him  from  his  stupor  he  will  awake,  but  if 
left  alone  sleep  returns.  When  the  subject  replies 
to  questions  he  does  so  in  the  weary  way  of  a  per- 
son who  wants  to  sleep.  In  other  cases  the  somno- 
lence is  less  profound,  the  patients  having  the  look  of 
one  merely  tired  and  attempting  to  do  no  more  than 
possible.  In  reality,  they  are  fighting  against  sleep— 
and  some  subjects  resist  it  to  such  a  degree  that  they 
try  to  get  up  and  be  about  in  order  to  overcome  the 
somnolence. 

If  they  accomplish  their  end  they  stagger  about 
and,  obliged  to  give  up.  fall  into  a  state  of  lethargy. 


Patients  in  hospitals  have  been  known  to  get  up, 
make  their  beds  and  then  fall  asleep.  Finally,  cer- 
tain patients  present  a  true  narcolepsia,  more  like 
coma  than  ordinary  sleep.  The  muscular  system  is 
absolutely  relaxed,  the  eyelids  remain  closed,  and  if 
they  are  raised  the  pupils  will  be  found  turned  up- 
ward as  in  normal  sleep.  This  fact  has  been  re- 
ferred to  by  F.  Levy,  who  has  also  observed  an  in- 
continence of  urine  and  feces  in  complete  coma.  The 
duration  of  the  somnolence  is  variable,  lasting  from 
a  few  hours  only  to  several  weeks  if  not  months. 
It  frequently  continues  after  the  disappearance  of 
the  general  symptoms,  especially  the  rise  in  tempera- 
ture. 

In  the  earlier  descriptions  of  the  ocular  phe- 
nomena of  encephalitis  lethargica,  the  paralysis  was 
said  to  involve  almost  exclusively  the  motor  muscles 
of  the  eye,  but  of  late  they  have  been  singularly  in- 
creased and  they  are  unquestionably  very  valuable 
diagnostic  signs.  Morax  and  Pollack  have  given 
particular  attention  to  their  study.  These  observers 
have  pointed  out  the  integrity  of  the  sensory  and 
sensitive  functions  of  the  visual  apparatus  to  which 
is  opposed  an  intrinsic  or  extrinsic  involvement  of  the 
motor  apparatus  of  the  ocular  globe.  Bilateral  in- 
complete ptosis  is  an  almost  constant  symptom,  al- 
though sometimes  quite  fleeting.  Strabismus  is  less 
constant  and  generally  convergent,  appears  at  the 
onset  of  the  disease,  and  quickly  disappears.  Diplo- 
pia is  variable,  often  atypical  and  should  be  looked 
for  in  extreme  movements.  There  is  an  almost 
constant  presence  of  disturbances  of  the  associated 
movements,  especially  the  vertical.  These  disturb- 
ances are  to  be  opposed  to  the  rarity  of  a  limited  in- 
volvement of  one  oculomotor  nerve. 

The  frequency  of  unequal  pupils  and  the  constancy 
of  paralysis  of  accommodation  should  also  be  noted. 
It  is  common  to  observe  that  some  of  the  ocular 
signs,  particularly  nystagmiform  disturbances  in  the 
movement  of  elevation,  persist  after  the  clinical  re- 
covery from  the  disease,  or  at  least  subside  very 
>lowly.  But  the  paralyses  are  not  confined  to  the 
muscles  of  the  eye  and  other  nerves  originating  in 
the  mesocephalon  may  be  involved,  such  as  the  com- 
mon oculomotor,  facial,  hypoglossus,  glossopharvTi- 
geal  and  pneumogastric.  Facial  paralysis  has  been 
especially  observed  and  Sainton  had  a  case  of  com- 
plete immobility  of  the  expression. 

It  may  be  proper  here  to  refer  to  paralyses  met 
with  in  the  territories  of  entirely  different  nerves, 
such  as  fleeting  paralysis  of  the  limbs,  epileptiform 
convulsions  reported  by  Khoury  and  Chauffard, 
clonic  movements  referred  to  by  Halbron,  and  su- 
doral paroxysms  mentioned  by  Khoury. 

Among  accessory  symptoms  may  be  mentioned  as- 
thenia which,  although  almost  constant,  may,  when 
existing  alone,  be  regarded  as  an  outcome  of  somno- 
lence. Retention  of  urine  has  been  mentioned  by 
Halbron,  Souques,  and  Lereboullet,  multiple  neu- 
ralgia by  Xetter,  Salmont  and  Leri.  rather  durable 
confiisional  states  by  Claude,  tremors  and  exagger- 
ated reflexes  by  Lhermitte  and  Babinski's  sign. 

The  evolution  of  encephalitis  lethargica  is  extreme- 
ly variable.  There  are  subacute  cases  with  a  small 
thermic  rise  or  even  none  whatsoever,  where  all  the 
symptoms  are  little  marked  and  result  in  rapid  re- 


August  7,  1920.] 


GOLDBLATT: 


MEXIXGITIS. 


187 


covery.  There  are  hyperacute  forms  ending  in  death 
in  a  few  days.  The  ordinary  acute  types  end  in 
death  by  a  progressive  aggravation  of  the  symptoms 
or,  on  the  contrary,  by  a  remission  of  the  symptoms 
announcing  a  favorable  issue,  ahhough  this  may  take 
several  months.  The  prolonged  cases  reported  by 
Netter  and  Sainton,  where  it  took  two,  three  or 
more  months  for  recovery  to  take  place,  were  par- 
ticularly numerous  in  the  Vienna  epidemic  of  1917. 
Chauffard  and  others  have  described  ambulatory 
forms  which  did  not  prevent  the  subject  from  con- 
tinuing his  ordinary  duties,  but  Lortat-Jacob  states 
that  in  them  there  was  diplegia,  nystagmus  and  a  per- 
petual tendency  to  sleep.  Sicard  and  Kudelski  have 
described  types  particularly  distinct  from  the  typical 
cases,  which  they  propose  to  call  acute  myoclonic  en- 
cephalitis, characterized  at  the  onset  by  lancinating 
pain,  moderate  fever  and  headache,  while  in  the 
phase  of  full  development  short,  rapid,  explosive 
muscular  jerkings  are  noted — having  the  electrical 
fh\-thm — located  in  the  muscles  of  the  limbs,  face, 
and  diaphragm  or  localized  to  a  section  of  the  body, 
sometimes  with  a  tendency  to  generalize.  There  are 
no  ocular  symptoms  or  somnolence.  Then  delirium 
appears,  usually  the  oneiric  type,  and  coma  super- 
venes, although  the  jerkings  continue.  These  ob- 
servers have  also  described  relapsing  forms  in 
Avhich  the  patient,  rather  seriously  ill,  presented  a 
remission  for  a  couple  of  weeks  during  which  he 
returned  to  work  and  then  relapsed  for  several 
months. 

Achard,  of  Paris,  and  Cramer  and  Koch,  of  Gen- 
eva, have  referred  to  the  clinical  diversity  of  this 
morbid  process.  The  modalities  of  the  intensity  of 
the  somnolence,  the  symptoms  of  excitement  replace 
those  of  depression,  etc..  so  that  we  must  con- 
clude that  the  disease  is  both  polymorphous  and  acy- 
clical.  The  Paris  and  Geneva  observers  have  shown 
that  the  microscopic  lesions  are  seated  in  the  cerebral 
cortex  and  especially  the  ganglia,  in  the  protuberance 
and  bulb.  The  vessels  are  surrounded  by  cuflFs  of 
cells  particularly  in  the  gray  matter  of  the  third  ven- 
tricle, the  aqueduct  of  Sylvius  and  in  the  nuclei  of 
the  motor  nerves  of  the  eye.  The  nerve  cells  under- 
go morbid  changes.  From  the  quite  considerable 
number  of  autopsies  made  to  date  it  is  evident  that 
the  lesions  of  encephalitis  lethargica  are  seated  in  the 
niesocephalon  surrounding  the  ventricles  and  are 
microscopically  of  little  import,  the  conjunctivovas- 
cular  changes  being  the  most  marked.  Netter  and 
others  who  just  described  this  disease  maintained 
that  the  cerebrospinal  fluid  was  normal  but  we  now 
know  that  such  is  not  the  case  and  that  a  mild  lym- 
phoc\-tosis  is  common  in  the  advanced  phases  of  the 
affection  and  even  a  marked  one  may  be  found,  but 
the  percentage  of  albumin  remains  normal.  Let  me 
add  that  there  are  still  some  observers  who  are  in 
■doubt  on  the  subject  of  lymphoc\tosis  so  that  more 
work  along  these  lines  must  be  forthcoming  befq^-e 
any  exact  conclusion  can  be  reached. 

Of  the  diagnosis  and  prognosis  of  encephalitis 
lethargica  it  is  quite  unnecessary  for  me  to  speak, 
likewise  of  treatment  which  is  still  a  matter  of  study, 
tut  in  conclusion  I  would  briefly  refer  to  the  nature 
of  this  interesting  morbid  process.  I  have  considered 
encephalitis  lethargica  so  far  as  a  perfectly  distinct 


affection  due  to  an  infectious  agent  belonging  to  the 
class  of  filterable  virus  and  as  yet  unidentified.  This 
is  the  opinion  of  most  observers  on  the  continent  but 
in  this  respect  opinion  is  not  uniform  and  perhaps  it 
is  not  devoid  of  interest  to  refer  to  this  aspect  of  en- 
cephalitis lethargica. 

In  1917,  Cruchet  described  a  diffuse  encephalo- 
myelitis which  assumed  divers  clinical  forms :  men- 
tal, convulsive,  choreic,  meningitic,  pontocerebellar, 
bulboprotuberantial,  etc.,  and  he  believed  that  en- 
cephalitis lethargica  was  one  of  the  types  of  this  en- 
cephalomyelitis. Lhermitte  and  some  others  main- 
tain that  encephalitis  lethargica  is  simply  a  syndrome, 
the  expression  of  an  infectious  process  in  the  meso- 
cephalon.  Page  recalls  that  Sainton's  cases  seem  to 
be  related  to  an  influenzal  infection,  that  one  of  Lor- 
tat-Jacob's  was  related  to  syphilis,  and  that  Lesage 
and  Abrami  have  described  a  somnolent  type  of  tu- 
berculous meningitis.  Comparing  these  facts  with 
two  cases  of  his  own  in  which  the  encephalitis  leth- 
argica was  merely  an  episode  in  the  evolution  of 
tuberculosis.  Page  believes  that  several  toxins — one 
being  that  of  tuberculosis — are  susceptible  of  adul- 
terating the  h'ypnic  centre  which  appears  to  be  located 
in  the  mesocephalon  and  whose  involvement,  although 
temporary,  produces  the  syndrome  of  encephalitis 
lethargica. 

What  is  more  important,  however,  as  Cruchet  has 
pointed  out,  is  the  cause  of  this  involvement  of  the 
nervous  centres.  Netter,  who  sees  an  unquestionable 
analogy  between  encephalitis  lethargica  and  poliomye- 
litis, maintains  that  the  former  is  a  specific  morbid 
process  with  a  well  defined  virus  of  its  own  and  he 
opposes  the  opinion  which  has  been  expressed  upon 
several  occasions  that  the  disease  under  consideration 
occurs  with  epidemics  of  influenza  and  assumes  that 
the  former  process  is  due  to  influenzal  virus  or  some 
associated  microbe,  such  as  those  giving  rise  to  influ- 
enzal pneumonia.  This  opinion  is  also  opposed  by 
Cruchet  and  Claude,  the  latter  observer  pointing  to 
the  fact  that  the  cause  may  not  be  universal.  All  this 
i■^  to  come  back  to  the  conception  of  an  encephalitis 
syndrome  that  several  toxins  may  be  capable  of  pro- 
ducing. 


IXTRAVEXOUS     AND  INTRASPINOUS 
TREATMENT    OF  MENINGOCOCCUS 
MENINGITIS.* 
By  David  Goldblatt,  M.  D., 

New  York. 

The  one  outstanding  contribution  to  the  study  of 
meningococcus  meningitis  during  the  past  two  years 
is  the  conception  of  the  infection  as  a  generalized 
one  primarily,  with  secondary  localization  in  the 
meninges.  The  disease  had  previously  been  studied 
carefully  by  Flexner  and  his  associates  at  the  Rocke- 
feller Institute,  and  they  have  demonstrated  that 
the  infection  was  the  result  of  direct  transmission 
of  the  organism  into  the  meninges  by  way  of  the 
cribriform  plate  of  the  ethmoid. 

But  it  was  mainly  through  the  work  of  Herrick 
and  his  associates  at  Camp  Jackson,  where  many 
cases  of  meningitis  have  been  studied,  that  we  came 

*Read  before  the  Harlem  Hospital  Clinical  Society. 


188 


GOLDBLATT: 


MENINGITIS. 


[New  York 
Medical  Journal. 


to  recognize  the  disease  as  a  generalized  infection. 
Workers  at  other  camps  and  especially  Haden,  at 
Camp  Lee,  have  confirmed  this  view.  Of  coiu-se 
it  had  been  long  known  that  there  was  a  type  of 
the  disease,  fulminating  in  character,  in  which  the 
infection  was  evidently  generalized.  But  it  had 
been  held  by  most  observers  that  the  majority  of 
cases  were  primarily  a  localization  from  the  outset. 

Coupled  with  the  conception  of  the  disease  as  a 
generalized  one  there  have  been  new  ideas  brought 
forward  for  treatment.  It  has  been  shown  that  in- 
travenous therapy  markedly  influences  the  course  of 
the  disease.  This  result  is  well  illustrated  in  the 
Camp  Jackson  series,  where  with  intraspinous 
treatment  alone  the  mortality  was  34.3  per  cent., 
and  in  the  combined  intravenous  and  intraspinous 
treatment  the  mortality  was  14.8  per  cent.  Her- 
rick  also  emphasizes  that  it  is  in  the  more  severe 
cases  that  the  newer  method  is  more  effectual.  In- 
travenous therapy  also  decreases  the  number  of  in- 
traspinous treatments,  and  the  harmful  results 
from  continued  intraspinous  treatment  have  not 
been  sufficiently  emphasized. 

The  majority  of  bad  sequellae  following  intra- 
spinous treatment  are  due  to  a  myelitis  of  the  cauda 
equina,  the  direct  result  of'  trauma  incidental  to  a 
lumbar  puncture  and  the  introduction  of  serum  in- 
traspinally ;  and  these  explain  the  pain  and  stiff- 
ness of  the  back  and  legs.  Rosanoff  from  a  study 
of  twenty-six  cases,  describes  what  he  calls  a  uni- 
form postmeningitic  syndrome. 

Objection  has  been  raised  to  the  intravenous  treat- 
ment by  several  workers,  especially  by  Neal,  who 
states  that  intravenous  therapy  neutralizes  the  tox- 
ins and  destroys  the  organisms  circulating  in  the 
blood  stream,  and  since  the  ability  of  the  choroidal 
plexus  in  filtering  through  antibodies  is  still  ques- 
tionable, it  would  not  influence  the  localized  condi- 
tion. But,  I  believe,  we  are  justified  in  assuming 
that  by  destroying  the  organisms  in  the  blood 
stream  and  meninges  by  the  combined  therapy,  we 
preclude  the  possibility  of  a  reinfection,  which  is 
not  as  uncommon  as  one  would  think.  Herrick  re- 
ports seven  cases  of  reinfection  occurring  within 
several  weeks  or  months  of  the  primary  infection. 

Prompted  by  the  good  results  obtained  at  the 
army  camps,  we  decided  to  try  the  combined  treat- 
ment at  the  Harlem  Hospital  and  prove  for  our- 
selves the  value  of  it.  We  cite  the  following  case 
in  confirmation  and  corroboration  of  the  treatment 
outlined  above: 

C.\SE. — Patient  A.  S.  D.,  aged  eighteen,  female, 
was  brought  into  the  hospital  February  15,  1920, 
complaining  of  headache,  pain  in  the  back  of  the 
neck,  and  fever  of  two  days'  duration.  Her  mother 
and  father  were  well  and  living  in  Porto  Rico,  her 
native  land.  She  had  no  infectious  diseases  during 
childhood  or  thereafter,  and  no  operations.  The 
menstrual  cycle  first  appeared  at  twelve,  being  of 
the  monthly  type  and  flowing  for  two  or  three  days. 
She  had  been  married  for  two  years  and  had  no 
children  or  miscarriages.  Venereal  .diseases  were 
denied  by  name  and  symptoms.  Her  habits  were 
irrelevant.  .  Her  present  illness  dated  back  to  three 
weeks  prior  to  admission  to  the  hospital,  when 
she  experienced  a  chill  which  wakened  her  from 


sleep  and  lasted  for  about  half  an  hour.  Follow- 
ing this  she  was  delirious  for  several  hours,  and 
remained  in  bed  for  a  week,  at  the  end  of  which 
time  she  felt  well  enough  to  go  to  work.  This  she 
did  for  about  a  week.  At  the  end  of  this  time, 
while  at  work,  she  experienced  a  sudden  severe 
headache,  vomited  and  was  feverish.  She  immedi- 
ately went  home  where  she  remained  for  two  days 
until  her  admission  to  the  hospital.  The  pain  in 
the  head  persisted,  and  associated  with  it  were 
pains  in  the  back  of  the  neck  and  upper  part  of  the 
back.  There  was  no  history  of  cough,  expectora- 
tions, sweats,  or  hemoptysis. 

The  physical  examination  revealed  a  well  devel- 
oped and  well  nourished,  apathetic,  young  white 
woman,  appearing  acutely  ill,  and  apparently  un- 
concerned about  what  was  going  on  about  her. 

Temperature,  105°;  pulse,  116;  respiration,  24. 
On  touching  the  neck  or  upper  portion  of  the  back 
she  complained  of  pain.  The  skin  was  soft,  warm, 
moist  and  free  from  rashes.  The  examination  of 
the  head  and  eyes  were  negative,  with  the  excep- 
tion of  weakness  of  the  right  internal  rectus.  The 
breath  had  a  foul  odor,  the  lips  were  dry  and 
crusted,  the  tongue  was  coated  with  white  fur,  and 
the  throat  was  injected.  The  neck  was  markedly 
rigid,  there  being  limitation  of  motion  from  side 
to  side  as  well  as  from  before  backward.  The  ex- 
amination of  the  chest,  lungs  and  heart  proved 
negative;  the  pulses  were  equal,  full  and  bounding, 
but  rapid.  Blood  pressure,  120-70.  The  abdom- 
inal findings  were  negative,  with  the  exception  of 
slight  tenderness  in  the  hypogastrium ;  the  liver  and 
spleen  were  not  enlarged ;  the  kidneys  were  not  pal- 
pable. The  superficial  lymph  glands  were  not  en- 
larged. The  knee  jerks  were  equal,  very  active, 
and  no  Babinski  or  its  modifications  could  be  elicited. 
Brudzinsky's  and  Kernig's  signs  were  both  strongly 
positive. 

The  urine  was  negative  with  the  exception  of  a 
few  red  and  white  blood  cells.  The  white  blood 
count  was  12,400,  with  78  per  cent,  polynuclears 
and  22  per  cent,  lymphocytes.  The  blood  culture  was 
negative  on  two  occasions.  The  spinal  fluid  was 
cloudy,  and  under  pressure  had  850  cells  to  the  c.  c. 
with  61  per  cent,  polynuclears  and  39  per  cent, 
lymphocytes.  The  Noguchi  test  was  positive  and 
the  Fehling  test  negative.  No  organism  was  dem- 
onstrated in  this  first  examination.  Subsequent 
spinal  fluid  examinations  showed  a  variation  of  total 
cell  count  from  500  to  1100  cells  to  the  c.  c,  with 
75  per  cent,  to  99  per  cent,  polynuclears. 

On  February  25th  a  gram  ■  negative  intracellular 
diplococcus,  having  many  of  the  mor_phological 
characteristics  of  the  meningococcus,  was  demon- 
strated.   This  was  the  sixth  spinal  puncture. 

Reviewing  the  history  and  bearing  in  mind  the 
mode  of  inception  of  the  disease  in  this  case,  I  be- 
lieVe  we  can  rightly  assume,  that  the  condition  ap- 
parently began  as  a  generalized  infection  which  was 
rather  mild,  not  prostrating  the  patient,  but  later 
localizing  in  the  meninges  and  there  manifesting  its 
virulence.  The  interval  of  apparent  freedom  from 
symptoms  as  demonstrated  in  this  case  has  been  viv- 
idly brought  to  notice  by  many  of  the  cases  in  the 
army,  where  soldiers  were  ill  and  incapacitated  for 


August  7,  1920.]  CORNWALL  AND  CRAWFORD: 


TYPHOID  FEVER  EPIDEMIC. 


189 


several  days,  to  return  to  duty  at  the  end  of  this 
time,  and  two  to  three  weeks  later  be  readmitted 
with  frank  manifestations  of  a  meningitis. 

Considering  the  case  as  one  of  meningococcus 
meningitis,  although  the  first  spinal  fluid  examina- 
tion did  not  show  the  organism,  treatment  was  in- 
stituted as  follows : 

The  patient  was  first  tested  for  sensitization  to 
horse  serum  and  at  the  end  of  a  half  hour,  the  re- 
action being  negative,  100  c.  c.  of  antimeningococ- 
cus  serum  were  given  intravenously.  This  was 
followed  eight  hours  later  by  a  lumbar  puncture 
with  the  injection  of  fifteen  c.  c.  of  serum  intra- 
spinally.  Twenty-four  hours  after  the  first  intra- 
venous injection,  100  c.  c.  were  again  administered 
intravenously.  Twenty-four  hours  later  ten  c.  c. 
of  serum  were  given  intraspinally.  Thus  intra- 
venous and  intraspinous  treatments  were  alternated 
for  four  doses,  at  time  intervals  ranging  from  eight 
to  twenty-four  hours,  and  the  temperature  coming 
down  to  100°  F.,  the  patient  was  left  alone  to  see 
what  would  happen.  At  the  end  of  this  free  from 
treatment  interval  the  temperature  rose  to  103.5°  F., 
and  an  intraspinous  treatment  of  twenty-five  c.  c. 
was  given.  The  next  day  the  temperature  dropped, 
but  within  twenty-four  hours  rose  again  and  as- 
sumed a  definitely  septic  character  for  three  days. 
During  these  three  days  intraspinous  treatment  alone 
were  used  to  see  the  effect  of  this  treatment.  We 
now  decided  upon  an  energetic  intravenous  treatment 
alone,  to  see  what  effect  this  route  of  treatment 
would  have  upon  the  disease.  For  four  days  a  daily 
injection  of  serum  was  given  intravenously,  begin- 
ning with  eighty  c.  c.  the  first  day  and  sixty  c.  c. 
every  following  day.  At  the  end  of  this  treatment 
the  temperature  came  down  to  100°  F.,  and  did 
not  go  any  higher  for  six  days.  On  the  seventh  day 
a  lumbar  puncture  was  made  and  the  fluid  was  re- 
ported as  being  almost  normal,  there  still  being  a 
slightly  positive  Noguchi.  On  this  day  following 
the  intraspinous  administration  of  serum,  a  routine 
after  each  spinal  puncture,  the  temperature  rose  to 
102.5°  F.,  and  came  back  to  normal  within  twenty- 
four  hours.  I  believe  this  rise  in  temperature  was 
due  to  a  partial  injection  of  the  serum  into  the  con- 
nective tissue  between  the  dura  and  the  bone,  as  the 
patient  complained  of  pain  during  the  administra- 
tion. 

In  closing  I  would  like  to  emphasize  the  salient 
features  of  this  treatment  and  although  I  am  aware 
that  one  case  is  not  sufficient  to  draw  conclusions 
from,  I  cannot  help  being  impressed  by  the  marked 
improvement  in  this  patient  after  energetic  intra- 
venous therapy. 

CONCLUSIONS. 

1.  Intravenous  therapy  combined  with  intraspin- 
ous treatment,  aims  at  a  rapid  sterilization  of  the 
blood  and  meninges  and  thus  shortens  the  period  of 
morbidity. 

2.  Intravenous  therapy  reduces  the  required  num- 
ber of  intraspinous  treatments,  and  if  started  early 
may  abort  the  disease. 

3.  With  a  moderate  amount  of  care  the  intra- 
venous therapy  is  free  from  danger  and  should  be 
used  in  cases  that  clinically  indicate  a  severe  type 
of  the  disease.  (,.t;<v>»Ci  '<KVi. 


AN  EPIDEMIC  OF  TYPHOID  FEVER 
OF  WATER  BORNE  ORIGIN  AND 
CARRIER  TRANSMISSION. 

At  Camp  Hospital  No.  10,  Prauthoy,  Haute  Marne, 
American  Expeditionary  Forces,  France. 

By  Leon  H.  Cornwall,  M.  D., 

New  York, 

Pathological  Laboratories,  City  Hospital,  Blackwell's  Island;. 
Captain,  Medical  Corps,  U.  S.  Army, 

And  James  P.  Crawford,  M.  D., 
San  Francisco, 
Captain,  Medical  Corps,  U.  S.  Army. 

{Continued  from  page  150) 

CARRIERS. 

Case  1.(19)  Private  Battery  E,  320  F.  A.  Ad- 
mitted February  9,  1919,  as  a  result  of  the  isola- 
tion of  Bacillus  typhosus  from  the  feces  during  the 
search  for  carriers.  He  had  been  on  kitchen  police 
since  December  18,  1918.  On  February  6th  this 
man  had  a  temperature  of  100.2°.  For  three  days 
following  it  was  normal.  On  February  loth  it  was 
again  100.2°  but  normal  for  the  succeeding  five 
days.  On  the  i6th  it  was  101.6°  and  on  the  17th 
99.6°.  There  was  no  fever  after  that.  All  subse- 
quent laboratory  examinations  were  negative  ex- 
cept for  the  presence  of  diazo  bodies  in  the  urine 
on  the  seventeenth  day.  The  typhoid  complement 
fixation  was  positive  but  the  agglutination  titre  of 
the  serum  was  not  high.  Inoculated  with  U.  S. 
triple  typhoid  vaccine  October  15,  1917,  and  with 
French  triple  typhoid  Hpovaccine  January  31,  1919, 
It  is  an  open  question  if  this  was  not  a  case  of  mild 
typhoid. 

Case  II. —  (20)  Cook  Battery  E,  321  F.  A.  Ad- 
mitted February  12,  1919  as  a  result  of  the  isola- 
tion of  Bacillus  typhosus  from  the  feces  during 
the  search  for  carriers.  He  was  kept  under  obser- 
vation for  over  a  month  during  which  time  there 
were  eight  negative  feces  examinations.  There  was 
a  positive  complement  fixation  and  the  agglutination 
titre  of  the  serum  was  moderately  high.  Inoculated 
with  U.  S.  triple  typhoid  vaccine  January  3,  1918, 
and  with  French  triple  typhoid  Hpovaccine  January 
31,  1919- 

SUSPECTED  CLINICAL  CASES. 

Case  I.— (21)  Private,  Battery  E,  321  F.  A.  Ad- 
mitted February  23,  1919,  complaining  of  slight 
bronchitis,  headache,  pains  in  back  and  legs,  weak- 
ness and  poor  appetite.  Onset  February  22,  1919. 
A  palpable  spleen  was  noted  on  the  day  after  ad- 
mission. Epistaxis  occurred  at  the  same  time. 
Headache  was  complained  of  on  the  fourth  and 
sixth  days.  The  temperature  ranged  from  99°  to 
101°  for  seven  days.  The  pulse  averaged  80  and 
the  respiration  20.  There  were  no  laboratory  find- 
ings upon  which  could  be  based  a  positive  diag- 
nosis of  typhoid  fever.  Four  blood  cultures,  five 
fecal  cultures  and  three  urine  cultures  were  nega- 
tive. There  was  a  positive  complement  fixation  and 
only  a  moderately  high  agglutination  titre  for  the 
serum.  Inoculated  with  U.  S.  triple  typhoid  vac- 
cine October  11,  1917  and  with  the  French  triple 
typhoid  Hpovaccine  January  31,  1919. 

Case  II.— (22)  Private.  Battery  E,  321  F.  Ar'Ad-^' 


190 


CORNWALL  AND  CRAWFORD: 


TYPHOID  FEVER  EPIDEMIC. 


[New  York 
Medical  Journal. 


mitted  February  26,  1919,  complaining  of  slight 
bronchitis,  chilly  sensations,  headache  and  meteor- 
ism.  Onset  recorded  as  February  24,  1919.  On 
January  28th,  29th  and  30th  and  February  5th,  6th 
and  7th  this  man  reported  at  sick  call  with  practi- 
cally the  same  group  of  symptoms  as  those  com- 
plained of  on  admission  but  there  was  no  rise  in 
temperature  at  any  of  these  times.  He  had  been 
on  kitchen  police  since  January  i,  1919.  During 
the  interval  between  January  28th  and  February 
26th  he  performed  full  duty.  He  had  a  rise  in  tem- 
perature for  four  days  as  follows :  February  26th, 
100.5°,  February  27th  99.6°,  February  28th  and 
March  1st,  101.6°.  There  were  no  other  clinical 
symptoms  of  typhoid  fever.  Blood,  feces  and  urine 
were  negative  bacteriologically.  The  diazo  reaction 
was  positive  in  the  urine  on  the  second  day  after  ad- 
mission. The  complement  fixation  was  positive  and 
the  agglutination  titre  of  the  serum  was  sufficiently 
high  to  be  very  significant.  Inoculated  with  French 
triple  typhoid  lipovaccine  January  31,  1919. 

On  the  evening  of  January  26th  a  patient  was 
admitted  to  Camp  Hospital  No.  10  from  Battery  E, 
321st  Field  Artillery  with  a  temperature  of  100.6°, 
pulse  of  90  and  respiration  of  16.  He  gave  a  his- 
tory of  acute  generalized  abdominal  pain,  which  be- 
gan on  the  previous  day,  but  stated  that  he  had  been 
tired  and  had  felt  weak  for  three  or  four  days. 
The  admission  diagnosis  was  acute  appendicitis  and 
he  was  immediately  evacuated  to  Base  Hospital  No. 
53  at  Langres.  The  diagnosis  was  confirmed 
there  and  an  appendectomy  was  performed  that 
evening.  The  appendix  was  described  as  being 
postcecal  with  adhesions.  It  was  acutely  inflamed 
and  had  ruptured.  There  was  free  fluid  in  the  ab- 
dominal cavity  and  pus  in  the  right  illiac  fossa.  For 
the  first  few  days  after  the  operation  there  was 
some  abdominal  distention,  pain  and  vomiting,  and 
the  temperature  remained  around  102°,  pulse  80  to 
116,  and  respiration  20  to  24.  In  the  patient  there 
developed  an  apathetic  state  suggestive  of  typhoid 
but  there  were  no  rose  spots,  splenic  enlargement 
nor  diarrhea.  The  leucocyte  count  averaged  6,500 
with  forty  per  cent,  lymphocytes.  Blood,  feces  and 
urine  cultures  were  made  at  the  laborator\-  of  Base 
Hospital  No.  53  but  were  all  negative  for  the  Bac- 
illus typhosus  and  paratyphosus.  The  temperature 
and  general  condition  of  the  patient  remained  ap- 
proximately the  same  until  the  fifth  week,  when 
the  temperature  dropped  to  normal  by  lysis. 

During  convalescence  this  patient  admitted  hav- 
ing drunk  unchlorinated  water  at  Rosoy.  His  serv- 
ice record  was  not  available  but  he  states  that  he 
had  been  inoculated  six  times  before  leaving  the 
United  States.  It  is  probable  that  this  was  another 
case  of  typhoid  and  that  it  belonged  to  Group  i. 
This  record  was  not  available  at  the  time  that  the 
cases  were  being  studied  at  Camp  Hospital  No.  10, 
hence  it  was  not  included  in  the  tabulations.  The 
data  concerning  this  case  were  placed  at  our  dis- 
posal through  the  courtesy  of  Major  C.  E.  S.  Web- 
ster. M.  C. 

CLINICAL  OBSERVATIONS. 

Onset. — In  approximately  sixty  per  cent,  of  the 
cases  the  onset  was  gradual  and  more  or  less  insid- 
ious.   Four  men  (Nos.  12,  14,  15  and  18)  were 


hospitalized  as  a  result  of  taking  the  temperatures 
of  all  of  the  men  in  Battery  E  daily.  They  would 
not  otherwise  have  been  discovered  so  early.  One 
of  these  men  (No.  15),  liowever,  had  rose  spots, 
a  palpable  spleen  and  a  temperature  of  102°  on 
admission.  IDespite  the  fact  that  his  temperature 
continued  high  he  denied  malaise  until  the  eleventh 
day.  Careful  interrogation  of  the  patients  after 
their  arrival  at  the  hospital,  for  the  purpose  of  as- 
certaining the  earliest  subjective  symptoms  elicited 
the  information  recorded  in  Table  II,  as  follows: 

TABLE  III. 

No.  Percentage. 

Headache    ii  6i 

Fever    9  50 

Malaise    7  39 

Anorexia    7  39 

Bronchitis    5  28 

Constipation    4  22 

Chilly  sensations    4  22 

Pains   in   back    4  22 

Pains   in    legs   4  22 

Generalized  pains    4  22 

Vomiting   2  11 

Epistaxis   2  11 

.\bdominal   difv;omfort    i  5.5 

Diarrhea    i  5.5 

Vertigo   o  o 

Pain  in  right  iliac  fossa    o  o 

When  the  epidemic  originated  the  intervals  be- 
tween the  onset  and  hospitalization  were  quite  long. 
These  intervals  varied  from  three  to  twelve  days  in 
the  first  group.  With  the  exception  of  one  case 
(No.  15)  the  others  were  admitted  before  the  sixth 
day.  This  was  due,  in  large  measure,  to  the  search 
for  febrile  cases.  It  serves  to  emphasize  the  diffi- 
culty of  early  diagnosis  of  typhoid,  in  persons  who 
have  been  inoculated,  by  attention  to  subjective 
symptoms  alone.  Several  men,  during  the  first  few 
days  of  their  illness,  could  not  be  convinced  that 
they  were  sick  enough  to  be  kept  in  the  hospital 

DIAGNOSIS. 

Fever  was  the  most  constant  early  objective  symp- 
tom, all  of  the  patients  having  some  hyperpyrexia. 
It  was  extremely  irregular,  however,  and  to  be  ap- 
preciated required  that  it  be  taken  and  charted  at 
frequent  intervals. 

Headache  was  a  pretty  constant  early  complaint 
(sixty-one  per  cent.)  and  was  present  at  some  time 
in  sixty-six  per  cent,  of  the  patients. 

Bronchitis,  though  not  especially  prominent  as 
an  early  complaint,  was  noted  on  physical  exami- 
nation before  the  third  day  in  thirty-nine  per  cent, 
and  at  some  period  of  the  illness  in  sixty-six  per 
cent,  of  the  cases. 

Anorexia  was  only  noted  as  an  early  complaint 
in  thirty-nine  per  cent,  and  in  only  forty-four  per 
cent,  of  all  cases  during  the  illness. 

Malaise  was  complained  of  early  in  thirty-nine 
per  cent,  but  during  the  illness  only  fifty  per  cent, 
acknowledged  that  they  had  it. 

Constipation  was  not  prominent,  being  noted  in 
only  four  cases. 

Early  diarrhea,  persisting  from  the  second  to 
the  seventeenth  day  was  present  in  one  case.  An- 
other man  had  diarrhea  from  the  third  to  the  fifth 
day  and  one  had  it  for  four  days  in  the  fourth 
week.  As  an  early  symptom  of  diagnostic  value, 
therefore,  it  was  noted  only  once  in  this  series. 

Pains  in  back,  pains  in  legs,  and  generalized  pains 
were  each  noted  four  times  but  abdominal  pain  was 
infrequent,  never  prominent  as  a  nearly  symptom. 


August  7,  1920.] 


CORNWALL  AND  CRAWFORD: 


TYPHOID  FEVER  EPIDEMIC. 


191 


and  only  severe  in  two  cases,  one  of  which  perfo- 
rated.   Right  iliac  pain  was  never  noted. 

Epistaxis  was  present  twice  in  the  first  week  and 
twice  in  the  second  (twenty-two  per  cent.)  of  the 
cases. 

Vomiting  occurred  three  times  in  the  first  week 
and  whereas  it  occurred  in  three  other  cases  in  the 
third  or  fourth  week,  it  was  never  persistent  or 
troublesome.    Total  incidence  thirty-three  per  cent. 

Among  the  objective  findings  rose  spots  were  the 
most  constant,  being  present  in  fifteen  cases 
(eighty-three  per  cent)  ;  six  times  in  the  first  week  ; 
four  times  in  the  second ;  three  times  in  the  third ; 
once  in  the  fourth ;  and  once  in  the  fifth. 

A  palpable  spleen  was  recorded  twelve  times 
(sixty-six  per  cent.)  ;  three  times  in  the  first  week; 
five  times  in  the  second ;  three  times  in  the  third ; 
and  once  in  the  fifth. 

Meteorism  was  noted  five  times  (twenty-eight 
per  cent.)  in  the  first  week  and  at  some,  period  of 
the  illness  ten  times  (fifty-six  per  cent.) 

Delirium  occurred  but  once  before  the  fourth 
week.  Four  patients  (twenty-two  per  cent.)  were 
delirious  at  some  time. 

Jaundice  was  present  only  in  one  case. 

COMPLICATIONS. 

Bronchopneumonia  was  noted  clinically  four 
time  (Nos.  1,  3,  4,  15),  and  was  discovered  at 
autopsy  in  two  other  cases.  It  was  not  present 
until  the  third  week.  Lobar  pneumonia  was  diag- 
nosed once  clinically  and  was  confirmed  by  autopsy. 

Intestinal  hemorrhage  occurred  in  three  cases 
(Nos.  I,  5,  12).  It  caused  complete  exsanguination 
and  was  the  immediate  cause  of  death  in  one  case 
(No.  5).  In  the  other  two  cases  the  intestinal 
hemorrhage  was  not  in  itself,  the  cause  of  death. 
It  was  a  contributing  factor  in  No.  i  and  incidental 
in  No.  12,  death  being  due  in  the  latter,  to  perfora- 
tion followed  by  general  peritonitis. 

Nephritis  was  present  in  two  cases  (Nos.  i  and 
16).  In  the  former  it  was  a  contributing  factor  in 
producing  death  but  the  latter  case  recovered.  It  is 
worthy  of  notice  that  the  Bacillus  typhosus  was 
only  isolated  from  the  urine  of  this  one  case  (No. 

Phlebitis  of  the  le-ft  leg  occurred  in  one  case  (No. 
13),  acute  catarrhal  otitis  media  once  (No.  8)  and 
perforation  once  (No.  12). 

RELAPSES. 

In  only  two  cases  was  the  clinical  course  sugges- 
tive of  a  relapse.  In  No.  7  the  temperature  ranged 
from  102°  to  104.6°  for  six  days,  then  fell  by  lysis 
reaching  normal  on  the  eleventh  day  after  admis- 
sion. After  remaining  normal  for  twenty-four 
hours  it  gradually  ascended  to  104°  and  ranged  be- 
tween that  point  and  101°  for  twelve  days,  when  it 
fell  to  normal  by  crisis.  In  case  No.  16  the  tem- 
perature was  104°  on  admission.  It  gradually  fell 
by  lysis,  reaching  normal  the  fifth  day  after  admis- 
sion. It  remained  normal  for  twenty-four  hours, 
then  ranged  from  normal  to  99.6°  for  three  days, 
then  rose  to  102.4°.  It  remained  between  102°  and 
103°  for  five  days  and  then  fell  by  lysis,  again 
reaching  normal  on  the  twenty-second  day  after  ad- 
mission. 


DURATION. 

The  shortest  duration  \Vas  eleven  days,  the  longest 
forty-seven  days,  and  the  average  twenty-nine  days. 

TERMINATION. 

Death  terminated  six  cases.  Five  of  the  deaths 
occurred  in  the  first  group  of  seven  cases,  which, 
there  is  reason  to  believe,  received  the  most  massive 
infections.  Three  of  the  patients  were  hospitalized 
in  the  first  week,  two  in  the  second,  and  one  in  the 
third.  There  were  twelve  recoveries ;  one  by  crisis, 
two  by  rapid  lysis,  and  nine  by  the  usual  lysis. 

PATHOLOGICAL  ANATOMY. 

An  opportunity  was  afforded  to  study  the  gross 
pathology  in  six  cases  and  several  features  were 
noted  that  deserve  attention  because  of  the  possible 
relationship  between  antityphoid  inoculation  and 
the  pathological  anatomy  that  was  observed. 

Intestinal  lesions.- — In  every  case  that  was  au- 
topsied  there  were,  in  the  upper  intestines,  lesions 
having  the  typical  shaven  beard  appearance  of 
healed  typhoid  ulcers.  These  lesions  extended  rather 
high  in  the  duodenum,  in  two  cases  being  noted  with- 
in six  inches  of  the  pyloric  opening  of  the  stomach. 
One  case  showed  a  very  acute  duodenitis  of  the 
upper  twelve  inches  of  the  duodenum.  The  mucous 
surface  of  the  gut  was  roughly  granular  due  to  the 
hyperplasia  of  the  lymphatic  tissue  in  the  submu- 
cosa.  There  was  an  intense  congestion  of  the 
blood  vessels  of  the  mucosa  and  submucosa  giving 
to  the  gut,  a  bright  red  color.  With  regularity  the 
lesions  became  more  extensive  and  severe  as  one 
proceeded  with  the  examination  of  the  intestines 
from  the  upper  to  the  lower  portions.  First  one 
would  encounter  in  the  lower  duodenum  or  upper 
jejunum  sometimes  right  at  the  side  of  a  healed 
lesion,  a  round  or  oval  swollen  avascular  lymphatic 
patch ;  then  an  acutely  inflamed,  bright  red,  swollen 
patch  ;  then  a  similar  partch  with  a  small  central  ex- 
cavation ;  and  then  still  lower  down,  usually  in  the 
lower  ileum  or  ileocecal  region,  the  typical  large, 
deep,  round  or  oval  ulcerations,  extending  through 
the  mucosa,  submucosa  and  musculature.  The  ul- 
cerations extended  into  the  colon  in  three  instances  ; 
once  in  the  ascending;  once  in  the  ascending  and 
transverse ;  and  once  in  the  ascending,  transverse 
and  descending.  In  one  case  (No.  2)  the  intestinal 
lesions  were  all  either  healed  or  rapidly  healing. 
Death  was  due  to  an  intercurrent  lobar  pneumonia. 

Pancreas. — The  pancreas,  in  every  case  that  was 
autopsied  was  very  firm  and  grossly  suggestive  of 
an  interstitial  pancreatitis.  Microscopically  those 
examined  showed  a  cellular  infiltration  and  fibrous 
tissue  proliferation  between  the  glandular  acini  and 
in  the  interlobular  tissue.  This  indicates  that  the 
infection  extended  from  the  duodenum  up  through 
the  pancreatic  ducts,  causing  diffuse  interstitial  pan- 
creatitis. 

Gallbladder. — There  was  an  acute  catarrhal  cho- 
lecystitis in  five  of  the  six  cases. 

Spleen  and  mesenteric  lymphatics.- — In  no  case 
was  there  more  than  moderate  hyperplasia  of  the 
spleen,  and  the  hyperplasia  of  the  mesenteric  lymph 
glands  with  the  accompanying  distension  of  the 
lymph  channels  seemed  to  parallel  the  splenic  hy- 
perplasia. 


192 


CORNWALL  AND  CRAWFORD:   TYPHOID  FEVER  EPIDEMIC.  [New  York 

Medical  Journal. 


Kidneys. — Acute  focal  glomerulitis  was  noted 
once  (No.  i).  In  no  other  case  was  there  more 
than  a  moderate  cloudy  swelling  of  the  kidneys. 

Lungs. — Lobar  pneumonia  was  present  once  ( No. 
2),  very  late  terminal  bronchopneumonia  twice 
(Nos.  I  and  12),  a  generalized  lobular  pneumonia 
three  times  (Nos.  3,  4  and  5).  Healed  or  chronic 
inactive  pulmonary  tuberculosis  was  noted  in  three 
cases  (Nos.  4,  5  and  12). 

CAUSES  OF  DEATH. 

The  immediate  causes  of  death  were  as  follows : 
Lobular  pneumonia,  two  cases  ;  terminal  broncho- 
pneumonia and  focal  nephritis,  one  case ;  lobar  pneu- 
monia, one  case ;  fatal  hemorrhage,  one  case ;  per- 
foration, one  case. 

LABORATORY  EXAMINATIONS. 

Technic. — Blood  cultures  were  made  by  placing 
two  to  three  c.  c.  of  blood  after  puncture  of  the 
median  basilic  vein  into  fifteen  c.  c.  of  bile  me- 
dium contained  in  a  test  tube.  The  use  of  small 
amounts  was  necessitated  for  the  conservation  of 
materials.  These  were  incubated  for  eighteen  to 
twenty- four  hours  and  examined  for  the  presence 
of  typhoidlike  organisms.  Final  identification  was 
made  by  subcultures  on  endo  medium,  Russell's 
triple  sugar  and  agglutination  with  diagnostic  sera 
prepared  at  the  Central  Medical  Laboratory,  Di- 
jon, France.  Subcultures  of  all  of  the  strains  iso- 
lated were  sent  to  the  central  laboratory  for  com- 
plete biological  and  immunological  study. 

Feces  cultures  were  made  by  taking  swabs  di- 
rectly from  the  stools  and  sending  them  to  the 
laboratory  in  sterile  test  tubes.  Fifteen  c.  c.  of 
ordinary  peptone  broth  medium  was  inoculated 
from  the  swabs  and  after  standing  for  two  hours 
at  room  temperature  a  drop  of  this  broth  was  trans- 
ferred to  an  end  plate  and.  smeared  with  a  metal 
rod.  A  second  end  plate  was  made  from  the  first. 
Subsequent  subcultures  were  made  as  for  blood. 
Urine  was  obtained  in  sterile  test  tubes  and  was 
added  in  the  proportion  of  one  to  three  to  peptone 
broth  and  incubated  eighteen  to  twenty-four  hours. 
Examination  was  then  made  for  organisms  of  the 
typhoid  group.  If  present  subcultures  were  made 
upon  end  medium  and  then  regular  routine.  All 
original  cultures  from  blood,  feces  and  urine  were 
incubated  and  subcultured  for  five  successive  days 
before  the  rendition  of  negative  reports. 

Agglutination  reactions  were  done  by  a  slightly 
modified  Dreyer  technic.  The  diagnostic  sera  were 
obtained  from  the  central  laboratory  and  the  same 
sera  were  employed  throughout.  The  following  is 
the  history  of  the  diagnostic  sera :  Paratyphoid  A 
(C.  M.  D.  L.  399),  prepared  from  culture  of  Bacil- 
lus paratyphosus  A  (New  York  Health  Depart- 
ment strain  228  as  antigen)  ;  paratyphoid  B  (CM. 
D.  L.  78),  prepared  from  culture  of  Bacillus  para- 
typhosus B  (New  York  Health  Department  strain 
225  as  antigen).  Typhoid  (C.  M.  D.  L.  429),  pre- 
pared from  culture  of  Bacillus  typhosus  (Mt.  Sinai 
Hospital,  New  York  city,  strain  i  as  antigen).  The 
bacterial  emulsions  employed  for  the  Widal  reac- 
tions were  obtained  from  the  central  medical  de- 
partment laboratory.  The  same  batch  of  emulsions 
was  used  for  all  of  the  reactions. 


The  following  is  the  history  of  the  bacterial 
emulsions:  Paratyphosus  A  prepared  from  New 
York  Health  Department  strain  228;  paratyphosus 
B  prepared  from  New  York  Health  Department 
strain  225.  Typhosus  prepared  from  Central  Med- 
ical Department  Laboratory  strain  11,  a  Rawlings 
strain  from  the  U.  S.  Army  Medical  School. 

RESULTS. 

The  di  agnosis  of  typhoid  fever  were  confirmed 
by  positive  laboratory  findings  in  seventeen  of  the 
eighteen  clinical  cases,  ninety-four  and  one  half- 
per  cent. 

Blood. — -Positive  blood  cultures  were  obtained  in 
fourteen  cases,  seventy-eight  per  cent.  The  fol- 
lowing data  applies  to  the  four  cases  in  which 
positive  blood  cultures  were  not  obtained:  (No.  6) 
Admitted  on  the  eleventh  day  of  illness.  The  first 
blood  culture  was  taken  on  the  twenty-fourth  day. 
The  typhoid  course  was  mild.  (No.  11)  Admitted 
on  the  third  day  of  the  illness.  The  original  diag- 
nosis was  influenza  but  was  changed  to  typhoid 
fever  on  the  thirteenth  day,  after  the  isolation  of 
typhoid  bacilli  from  the  feces.  No  blood  culture 
was  made.  (No.  14)  Admitted  to  the  hospital  on 
the  third  day  of  the  illness.  First  blood  culture 
was  taken  on  the  tenth  day.  No  other  confirmatory 
laboratory  findings  except  a  positive  complement 
fixation.  (No.  18)  Admitted  on  the  fifth  day  as 
a  carrier  after  the  isolation  of  typhoid  bacilli  from 
the  feces.   First  blood  culture  made  on  the  tenth  day. 

The  earliest  positive  blood  culture  was  ob- 
tained on  the  fifth  day  and  the  latest  on  the  forty- 
third  day.  The  diagnosis  was  first  confirmed  by 
blood  cultures  in  nine  cases,  fifty  per  cent. 

Feces. — Positive  feces  cultures  were  obtained  in 
eleven  cases,  sixty-one  per  cent.,  the  earliest  on  the 
second  day  and  the  latest  on  the  twenty-ninth  day. 
The  diagnosis  was  first  confirmed  by  the  feces  ex- 
amination in  seven  cases,  thirty-nine  per  cent. 

Urine. — A  positive  urine  culture  was  obtained 
from  but  one  case.  No.  16.  The  urinary  findings 
gave  evidence  of  nephritis  on  the  third  day  of  the 
illness.  The  diazo  reaction  was  not  significant 
enough  to  attach  much  importance  to  it.  It  was 
positive  in  two  clinical  cases.  No.  12  and  No.  15, 
on  the  twenty-fifth  and  sixteenth  days  respectively, 
in  one  carrier.  No.  19,  on  the  seventeenth  day  and 
in  one  suspected  case.  No.  22,  on  the  third  day. 

Blood  counts. — The  lowest  total  leucocyte  count 
was  4,200  on  the  twenty-seventh  day  and  the  high- 
est was  10,800  on  the  fortieth  day.  Normal  counts 
were  the  rule.  The  lymphocytes  averaged  thirty- 
seven  per  cent.  The  leucopenia  ordinarily  expected 
in  typhoid  cases  was  notable  by  its  absence. 

Complement  fixation. — The  complement  fixation 
was  positive  in  all  of  the  cases. 

Widal  reactions. — Seven  of  the  cases  showed 
an  increase  of  the  agglutinin  content  of  the  sera 
from  nine  to  over  4,500  units.    No  agglutination 
reactions  were  done  on  the  sera  of  four  cases  and 
in  four  others  but  one  estimation  was  made  of  the  ; 
agglutinins.    In  one  case  the  agglutinins  remained 
constant  and  two  cases  showed  a  diminution  after  the 
first  titration,  indicating  that  the  peak  of  the  curve, , 
or  maximum  agglutinin  response  had  been  reached  , 
and  that  the  titration  was  again  falling.    The  low- 


August  7,  1920.] 


QUACKEXBOS:  CHRONIC   PERITOXSILLAR  ABSCESS. 


193 


est  agglutinin  content  was  nine  units  and  the  high- 
est 9,000.  The  bacterial  emulsions  employed  for 
the  Widal  reactions  were  standardized  to  a  Dreyer 
emulsion,  hence  the  tabulated  results  represent 
standard  agglutinin  units. 

Had  it  not  been  our  good  fortune  to  obtain  bac- 
teriological confirmation  of  the  cHnical  diagnoses 
in  so  large  a  proportion  of  the  cases  the  agglutina- 
tion reactions  would  have  been  of  incalculable  diag- 
nostic value,  and  would  have  confirmed  the  clinical 
diagnoses  in  over  fifty  per  cent,  of  the  cases.  The 
last  five  cases  of  clinical  typhoid  admitted  to  the 
hospital  and  the  two  carriers  had  been  reinoculated 
with  triple  typhoid  lipovaccine  (French)  on  Janu- 
ary 31,  1919,  and  this  had  to  be  considered  in  at- 
taching importance  to  the  agglutinin  content  of  the 
sera.  By  comparing  the  results  in  these  cases  with 
two  other  series,  one  a  group  of  men  one  month  af- 
ter inoculation  with  the  same  vaccine  and  the  other 
a  group  who  had  not  been  recently  inoculated,  it 
will  be  seen  that  the  relative  values  were  as  sig- 
nificant as  in  the  other  cases. 

In  its  biological  characteristics  the  strain  of  Ba- 
cillus typhosus  isolated  from  this  epidemic  is  not 
identical  with  the  strain  which  is  employed  for  the 
U.  S.  Army  vaccine,  dift'ering  in  its  fermentation 
reaction  with  xylose.  From  an  immunological 
viewpoint  this  is  of  importance  as  it  suggests  these 
queries : 

1.  Are  all  strains  of  the  Bacillus  typhosus,  which 
fulfill  all  of  thfe  requirements  for  an  immunizing 
antigen  equally  efficient  for  protective  inoculation? 

2.  Is  a  given  strain,  which  fulfills  all  the  require- 
ments for  an  immunizing  antigen,  as  efficient  in 
producing  immunity  against  another  strain  with 
slightly  different  biological  characteristics,  as  an 
immunizing  antigen  homologous  to  the  latter  strain  ? 

3.  Should  not  the  ideal  immunizing  antigen  con- 
tain all  strains  that  differ  in  their  biological  reac- 
tions? The  immunological  aspects  of  this  problem 
will  probably  be  the  subject  of  later  publications 
from  the  Army  Medical  School  as  it  is  now  under 
extensive  investigation. 

CONCLUSIONS. 

1.  The  probable  source  of  this  epidemic  was  pol- 
luted water. 

2.  It  was  further  transmitted  by  carriers  among 
food  handlers. 

3.  The  early  diagnosis  of  typhoid  fever  among 
inoculated  persons  requires  more  attention  to  the 
objective  than  to  the  subjective  symptoms. 

4.  Fever  may  be  the  only  early  objective  symp- 
tom and  may  be  present  when  no  subjective  symp- 
toms are  complained  of. 

5.  Headache  was  the  most  constant  early  sub- 
jective symptom  of  this  series  of  cases. 

6.  Malaise,  anorexia  and  diarrhea  were  not 
prominent  among  the  early  symptoms  in  this  series. 

7.  Antityphoid  inoculation  will  not  protect  indi- 
viduals against  the  ingestion  of  massive  doses  of 
typhoid  bacilH. 

8.  The  gross  pathological  anatomy  of  typhoid 
fever  in  inoculated  persons  shows  some  diflferences 
from  that  ordinarily  observed.  The  intestinal 
lesions  show  evidence  of  a  vigorous  fight  on  the 


part  of  the  natural  defenses  of  the  body  before 
succumbing  to  the  infection.  The  extreme  splenic 
hyperplasia  ordinarily  observed  does  not  occur. 
Our  experiences  indicate  that  interstitial  pan- 
creatitis is  a  common  result  of  typhoid  infection 
in  inoculated  persons. 

CHRONIC  PERITOXSILLAR  ABSCESS. 

By  Maxwell  Quackenbos,  M.  D.,  M.  R.  C.  S. 
(Eng.) 
New  York. 

The  etiology  of  this  comparatively  rare  lesion  is 
obscure.  Those  textbooks  which  mention  the  con- 
dition voice  the  opinion  that  chronic  peritonsillar 
abscess  if  encysted  may  be  tuberculous  in  origin 
but  attribute  the  malady  most  frequently  to  a  caseous 
crypt  of  the  tonsil.  In  many  instances  the  abscess 
must  be  entirely  overlooked,  as  for  example  when 
the  operation  of  enucleation  is  performed  by  the 
digital  method  or  the  operative  field  concealed  by 
hemorrhage  with  the  swallowing  reflex  present.  I 
do  not  see  how  the  small  pocket  of  pus  can  be  pos- 
sibly recognized  and  the  diagnosis  confirmed  unless 
the  deeply  anesthetized  supine  patient's  tonsils  are 
enucleated  by  some  dissection  method  as  that  of 
Waugh's  technic,  in  which  procedure  a  sandbag 
is  placed  under  the  shoulders  and  the  head 
hyperextended  so  that  the  point  of  the  chin,  the 
neck  and  the  chest  are  in  a  straight  line.  With 
the  tongue  drawn  out  by  a  suture  through  its 
dorsum  and  the  chin  held  forward,  this  position 
gives  an  unobstructed  view,  a  free  air  way  and  con- 
verts the  nasopharynx  into  a  dependent  reservoir; 
no  blood  will  then  enter  the  larynx.  In  the  six  cases 
of  chronic  peritonsillar  abscess  herewith  recorded 
the  age  incidence  was  between  twelve  and  twenty- 
six  years,  four  being  female  patients,  three  of  whom 
gave  history  and  showed  evidence  of  tonsillotomy 
many  months  previousl^^  All  patients  had  suffered 
from  the  prevailing  endemic  of  influenza.  The  syni- 
tom  presented  by  the  patients  was  the  usual  debility 
and  its  attendant  secondary  anemia.  Two  of  the 
younger  patients  had  superimposed  renal  symptoms 
of  albuminuria.  There  was  no  history  of  throat 
trouble  and  no  acute  stage  of  inflammation.  Enuclea- 
tion of  the  small  embedded  tonsils  was  advised  be- 
cause of  the  palpable  enlargement  of  the  afferent 
cervical  (tonsil)  hmiph  node.  The  diagnosis  of 
chronic  peritonsillar  abscess  is  dependent  upon  the 
observation  of  grayish  pus  of  thick  consistency  in 
its  cavity  situation  under  the  capsule  in  the  region 
of  the  supratonsillar  fossa.  The  largest  abscess  was 
the  size  of  a  split  pea  and  all  were  located  on  the  left 
side.  The  condition  might  be  aptly  described  as  an 
encysted  abscess  although  the  patients  were  not 
tuberculous.  The  abscess  was  not  due  to  a  crypt  of 
the  tonsil.  There  is  no  anatomical  foundation  for 
the  belief  that  it  arose  as  an  adenitis  of  a  lymph  node 
in  that  region.  I  am  of  the  opinion  that  this  focal 
septic  lesion  is  a  sequella  of  constitutional  infection 
(as  empyema  or  an  epiphysitis  probably  as  a  re- 
sult of  a  bacterial  embolus.  Following  enucleation 
the  patient's  condition  rapidly  returned  to  normal. 

175  West  Fifty-eighth  Street. 


Editorial  Notes  and  Comments 


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PHYSICIAN  AND  AUTHOR. 

\\'hat  has  been  described  as  "the  most  baffling 
bit  of  Hterature  ever  set  down  on  paper"  was  writ- 
ten by  Dr.  Francois  Rabelais — old  Dr.  Rabelais — 
upon  whose  head  has  been  heaped  more  anathema 
than  upon  the  head  of  any  other  writer.  Those 
who  are  displeased  with  his  coarse  language  and 
smutty  yarns  call  him  a  filthy  old  blackguard,  and 
will  have  none  of  him.  On  the  other  hand,  Dr. 
Rabelais  has  his  host  of  tolerant  admirers  through- 
out the  world,  and  he  has  long  been  rated  as  a 
classic.  The  French  have  raised  him  to  a  pinnacle 
of  fame,  and  unquestionably  he  was  a  humorist  of 
the  first  rank,  the  father  of  ridicule,  and  merciless 
in  flaying  the  customs  of  courts  and  convents,  of 
schools  and  camps,  of  processes  and  wars,  of  ro- 
mances and  legends.  The  influence  of  Rabelais 
upon  English  literature  has  been  greater  than 
many  persons  would  willingly  admit ;  but  the  fact 
is  that  numerous  authors  studied  and  imitated  him, 
as  their  work  amply  testifies.  A  shoal  of  minor 
humorists,  poets  and  essayists  have  pillaged  right 
and  left  from  the  stores  of  wit  and  humor  in  his 
Gargantua  and  Pantagruel,  and  English  novelists 
have  availed  themselves  of  all  sorts  of  plots  and 
episodes  from  the  same  prolific  source. 

Rabelais  was  born  about  the  year  1483  at  Chinon, 
an  ancient  little  town  in  the  province  of  Touraine, 
France.  The  details  of  his  life  are  enshroiided  in 
uncertainty,  but  it  is  fairly  definitely  established 
that  he  spent  at  least  twenty-five  years  in  the 
cloister,  first  as  a  Franciscan  monk,  later  as  a  Bene^ 


dictine,  and  finally  gave  up  the  cloistered  life  to 
enter  Montpellier  University,  where  he  took  all  his 
degrees  as  a  physician  and  gained  a  considerable 
reputation  as  a  practitioner.  During  this  practice 
he  began  writing  medical  tracts,  and  translated  the 
Aphorisms  of  Hippocrates  and  some  of  the  works 
of  Galen,  published  first  in  1532  by  the  famous 
Gryphius,  of  Lyons,  and  reprinted  many  times. 

There  is  no  clear  record  of  how  Rabelais  came 
to  leave  Montpellier,  but  the  supposition  is  that  he 
probably  was  sent  by  the  university  to  Paris  to  in- 
tercede for  it  at  court,  and  was  invited  to  remain  at 
the  capital,  for  he  was  a  delightful  fellow  to  have 
around.  The  generally  accepted  version  is  that, 
due  to  some  mischievous  pranks  on  the  part  of 
students,  the  university  had  been  deprived  of  some 
of  its  privileges,  and  Rabelais  so  effectually  pleaded 
the  cause  of  the  school  that  the  chancellor  imme- 
diately restored  the  privileges.  Thus  it  is  that,  in 
gratefulness  to  the  incorrigible  old  doctor,  no  one 
today  is  admitted  to  the  degree  of  M.  D.  at  Mont- 
pellier who  has  not  first  put  on  the  cap  and  gown 
of  Rabelais,  which  are  preserved  'in  the  castle  of 
Morac  in  that  city. 

Rabelais  did  not  end  his  days  as  a  physician. 
John,  Cardinal  du  Bellay,  Bishop  of  Paris,  who  had 
been  Rabelais'  friend  from  boyhood,  employed  him 
in  a  diplomatic  position.  It  was  at  this  period, 
some  say,  that  he  composed  his  Gargantua  and 
Pantagruel.  It  seems  to  be  fairly  well  established, 
however,  that  in  addition  to  his  practice  as  a  physi- 
cian at  ^Montpellier  he  also  served  two  years  at 
^letz  as  the  town  ph3-sician,  at  the  princely  salary 
of  one  hundred  and  twenty  livres  a  year.  A  livre 
was  about  twenty  cents.  And  he  also  was  physician 
for  a  time  to  the  Hotel  Dieu  at  Lyons,  at  the  still 
lesser  compensation  of  forty  livres.  They  were 
generous  to  their  physicians  in  those  old  days. 

Rabelais'  Gargantua  and  Pantagruel  has  been 
described  as  "a  vast  ocean  of  pure  and  impure  tom- 
foolery and  laughter  surrounding  a  few  solid 
islands  of  sense  and  reason  and  devotion." 
The  greater  part  of  these  books  is  burlesque  ro- 
mance into  which  was  introduced  a  vein  of  buf- 
foonery quite  in  accordance  with  the  spirit  of  the 
age.  In  it  he  delighted  to  make  merry  with  the 
impertinences  of  mankind,  and  nothing  was  able 
to  allay  his  mirth.  It  is  wholly  on  this  satirical 
work  that  the  fame  of  Rabelais  rests.  His  Latin 
versions  of  Hippocrates'  Aphorisms  and  Galen  are 

much  esteemed  also  for  their  faithfulness  and 
purity  of  style ;  but  their  circle  of  readers  is  small. 


August  7,  1920.] 


EDITORIAL  ARTICLES. 


195 


He  also  wrote  several  French  and  Latin  epistles  in 
excellent  style  to  numerous  great  and  learned  men, 
and  he  wrote  a  book  called  Sciomachia,  printed  in 
Lyons  in  1549.  An  Almanak  for  the  year  1553, 
calculated  by  him  for  the  meridian  of  Lyons,  shows 
that  he  was  an  astronomer  of  great  ability.  Dr. 
Rabelais  was  also  a  poet,  philosopher,  grammarian 
and  theologian,  and  a  great  linguist,  skilled  in 
French,  German,  Italian,  Spanish,  Greek  and  the 
Hebrew  tongues,  and  his  letters  prove  that  he  also 
understood  Arabic,  which  he  learned  at  Rome. 

Rabelais  died  in  a  house  in  the  street  called  La 
Rue  des  Jardins,  in  St.  Paul's  parish  at  Paris,  about 
the  year  1553,  aged  scA^enty  years.  But  his  fame 
will  never  die.  The  best  pens  of  his  age  honored 
his  memory  with  epitaphs,  and  since  that  time  his 
name  has  appeared  times  without  number  in  the 
literature  of  all  lands.  As  he  lived,  so  he  died, 
jesting.  Just  before  his  demise  he  wrote  a  will, 
which,  when  opened,  is  said  to  have  contained 
these  three  articles :  "I  owe  much,  I  have  nothing. 
I  give  the  rest  to  the  poor." 


HOURS  OF  WORK  AND  HEALTH. 
The  relation  of  hours  of  work  to  fatigue  con- 
cerns the  preservers  of  health ;  the  relation  of  hours 
of  work  to  production  concerns  the  managers  of 
industry.  Thus  far  most  of  the  latter  have  gone 
ahead  on  the  theory  that  the  more  hours  the  more 
production,  without  any  great  thought  as  to  the  ef- 
fect on  the  individual  workman.  Now  and  then  it 
was  bruited  abroad  that  such  a  policy  involved  an 
immense  waste  of  human  material,  but  this  did  not 
worry  many  people  except  those  who  were  being 
wasted.  Then  the  war  came  with  its  need  for  in- 
tensified production,  leading  to  an  unparalleled  pub- 
licity campaign  for  physical  fitness.  Even  work- 
men were  included,  for  the  truth  came  out  that 
people  cannot  work  too  long  and  too  hard  without 
suffering. 

England  was  one  of  the  first  countries  to  conduct 
scientific  investigations  into  the  question  of  fatigue 
and  hours  of  work.  England  tried  to  speed  up  her 
munition  workers  until  she  discovered  that  they 
were  breaking  under  the  strain;  then  studies 
of  the  munition  industry  were  made,  with  the  re- 
sult that  hours  of  work  were  shortened  and  both 
the  health  and  effectiveness  of  the  workers  were 
increased.  Now  comes  our  own  Public  Health 
Sendee  with  a  report  {Public  Health  Bulletin  No. 
106,  Studies  in  Industrial  Physiology)  proving  the 
superiority  of  the  eight  over  the  ten  hour  day.  The 
findings  are  based  on  a  comparison  of  an  eight  and 
a  ten  hour  plant,  each  a  huge  industrial  establish- 


ment prominent  in  the  metal  working  industry. 
Superiority  of  the  eight  hour  day  was  proved  from 
the  economic  standpoint — that  is,  in  respect  to  main- 
tenance of  output,  lost  time,  and  labor  turnover. 
But  the  eight  hour  day  was  also  proved  more  bene- 
ficial to  the  workman  and  this  in  a  way  that  the 
employer  could  appreciate  because  it  touched  his 
pocketbook — it  was  found  to  reduce  the  rate  of 
industrial  accidents. 

Ordinarily  accidents  may  be  expected  to  vary 
directly  with  speed  of  production,  owing  to  in- 
creased exposure  to  risk,  but  when  fatigue  is  taken 
into  consideration  there  is  a  marked  modification  of 
this  rule.  When  there  is  a  reduction  of  output  due 
to  fatigue  there  is  a  rise  in  the  number  of  accidents ; 
that  is,  in  the  last  hours  of  the  ten  or  twelve  hour 
day,  in  spite  of  employees  slowing  up  in  work,  more 
accidents  occur.  If  for  any  reason  production  is 
speeded  up  in  the  last  hours,  when  the  laborers  are 
fatigued,  the  number  of  accidents  rises  so  rapidly 
as  to  leave  no  room  to  doubt  that  the  higher  acci- 
dent risk  accompanies  the  decline  in  working  capac- 
ity of  the  employee.  In  general,  the  plant  exhibiting 
the  indications  of  heavier  fatigue  in  output  is  also 
the  plant  subject  to  the  higher  accident  risk. 

Where  does  all  this  investigating  lead?  A  few 
forward  looking  employers  have  been  able  to  see 
for  themselves  that  sodden  drudges  are  not  as 
desirable  as  workers  who  have  leisure  for  recrea- 
tion, for  study,  for  health ;  organized  labor  is  bring- 
ing the  recalcitrant  into  line.  But  the  duty  of  the 
scientist  is  clear.  "To  humanize  working  condi- 
tions, to  reassert  the  value  of  the  individual,  to 
study  all  ways  of  releasing  in  work  the  best  en- 
ergies of  the  worker,  instead  of  as  now  so  prodigally 
wasting  them,  this  should  be  the  practical  role  of 
science  in  industry.  And  it  is  as  a  contribution  to 
this  new  era  of  intensive  study  devoted  to  large 
ends  that  this  report  has  been  aimed." 


TREATMENT  OF  TETANUS. 

Castaigne  and  Paillard  have  recently  given  some 
complete  and  up  to  date  data  concerning  tetanus 
when  the  disease  has  declared  itself,  and  their  re- 
marks on  the  treatment  are  well  worth  considering. 
They  point  out  that  there  are  a  certain  number  of 
conditions  present  which  should  guide  the  treatment 
when  the  disease  has  been  confirmed.  For  instance, 
the  subject  has  a  wound  which  requires  surgical 
care ;  he  suffers  from  painful  permanent  contrac- 
ture, to  which  intermittent  paroxysms  are  added ; 
a  specific  intoxication  exists,  as  well  as  inanition 
and  dehydration. 

The  first  step  in  the  treatment  is  the  adminis- 


196 


NEWS  ITEMS. 


[New  York 
Medical  Journal. 


tration  of  sedatives,  keeping  the  patient  absolutely 
quiet,  preferably  in  a  darkened  room,  and  the  avoid- 
ance of  all  unnecessary  examinations.  Hot  baths 
(lOr  to  104°  F.),  lasting  from  half  an  hour  to 
forty  minutes  and  repeated  every  three  or  four 
hours,  will  lessen  the  contracture  and  result  ulti- 
mately in  a  very  pleasant  sedation  and  occasionally 
sleep,  which  should  be  carefully  guarded.  The 
patient  should  be  moved  from  place  to  place  with 
the  utmost  care. 

Of  sedative  medicines,  chloral  is  recommended 
administered  in  doses  varying  from  six  to  ten,  or 
even  fifteen  grams,  either  in  combination  or  not 
with  four  to  eight  grams  of  potassium  iodide,  by 
mouth  or  rectum.  Chemically  pure  neutral  sodium 
persulphate,  preserved  in  closed  ampoules,  should 
be  given  intravenously  in  doses  of  five  grams  in  one 
hundred  cubic  centimetres  of  sterile  distilled  water. 
Intraspinal  injections  of  magnesium  sulphate  in  a 
twenty-five  per  cent,  solution — one  cubic  centimetre 
for  every  twenty  kilograms  of  body  weight — may 
be  given  once  a  day,  or  it  may  be  given  subcutane- 
ously,  in  which  case  ten  cubic  centimetres  of  the 
twenty-five  per  cent,  solution  are  given  four  times 
daily. 

Morphine  and  chloroform  are  not  so  highly 
recommended,  but  the  latter,  when  inhaled  in  small 
quantities,  will  relieve  the  pain  of  hyperacute  te- 
tanus. 

The  second  aim  of  treatment  is  specific  medica- 
tion and  its  basis  is  serotherapy.  Regardless  of 
the  lack  of  irrefutable  proof,  Castaigne  and  Paillard 
believe  that  clinical  experience  is  decidedly  in  favor 
of  this  form  of  treatment.  In  the  acute  and  sub- 
acute forms  of  tetanus  a  daily  injection  of  twenty 
to  thirty  cubic  centimetres  of  serum  should  be 
given  during  the  first  week,  after  which  one  every 
twQ  or  three  days  will  suffice.  The  injection  may 
be  given  subcutaneously  or  in  the  epidural  space, 
but  the  latter  route  does  not  seem  to  offer  any  ad- 
vantages over  the  former.  Baccelli's  method,  which 
consists  of  fort)'  centigrams  to  one  gram  of  car- 
bolic acid  dissolved  in  oil  or  ghxerin,  according  to 
the  gravity  of  the  infection  and  the  patient's  weight, 
is  still  a  moot  subject,  but  it  can  be  resorted  to  in 
combination  with  other  therapeutic  measures.  The 
injections  should  be  given  daily  during  the  first 
week  and  afterward  every  second  or  third  day. 

Feeding  is  a  most  important  factor- in  the  treat- 
ment of  tetanus,  on  account  of  the  inanition  and 
dehydration  of  these  patients.  Feeding  by  mouth 
is  often  impossible,  or  at  best  difficult,  on  account 
of  the  trismus  and  dysphagia,  so  that  rectal  feed- 
ing must  be  resorted  to.  Rehydration  is  obtained 
by  the  same  route.    Two  rectal  feedings  and  two 


glucose  serum  rectal  injections  are  to  be  given  in 
twenty-four  hours.  One  cleansing  enema  will  be 
required  daily.  Glucose  serum  or  salt  solution  can 
also  be  administered  subcutaneously.  The  latter 
will  be  the  ultimate  resource  when  dysphagia  exists 
and  rectal  intolerance  is  present.  Lastly,  accessory 
medicaments,  such  as  camphorated  oil  as  a  tonic — 
one  to  three  grams  of  camphor  in  twenty-four 
hours,  subcutaneously,  sparteine  for  the  heart,  and 
subcutaneous  injections  of  oxygen,  when  contrac- 
ture of  the  inspiratory  muscles  exists,  must  never 
be  overlooked. 


EDITORIAL  ANNOUNCEMENT. 

Beginning  with  this  issue  we  shall  publish  a 
series  of  editorials  about  medical  men  in  literature. 
Strange  as  it  may  seem,  some  of  the  greatest  men 
in  the  literary  world  were  physicians.  Many  of 
them  were  Americans.  Rabelais  will  be  the  first 
physician  author  described,  others  will  follow. 
A  great  deal  of  research  was  necessary  to  com- 
plete this  work,  which  has  been  done  by  Jefferson 
Williamson  especially  for  the  New  York  Medical 
Journal. 

These  editorials  will  be  intensely  interesting.  It 
will  be  well  worth  your  while  to  read  tine  entire 
series. 


News  Items. 


Tampico  Quarantined. — Quarantine  against 
bubonic  plague  has  been  established  in  Tampico, 
Mexico. 

Addition  to  Rockaway  Hospital. — Plans  are 
under  way  to  erect  a  Soldiers'  and  Sailors'  Build- 
ing as  an  adjunct  to  the  Rockaway  Beach  Hospital, 
in  memory-  of  Rockaway  boys  who  served  during 
the  war. 

Dr.  William  O.  Pitt  to  Red  Cross  League.— 
Dr.  William  O.  Pitt  has  been  appointed  chief  of 
the  Department  of  Child  Welfare  of  the  League 
of  Red  Cross  Societies.  He  has  been  active  in 
child  welfare  work  in  England  since  1910. 

War  Invalids  in  Government  Hospitals. — The 
Bureau  of  War  Risk  Insurance  is  embarking  on  a 
plan  to  concentrate  convalescent  veterans  in  hos- 
pitals owned  and  controlled  by  the  Government. 
There  are  17,981  disabled  exservice  men  and 
women  being  cared  for  in  more  than  1,000  hospitals 
scattered  throughout  the  United  States,  of  this  num- 
ber 8,123  are  in  Government  hospitals  and  9,858 
in  private  or  state  and  county  hospitals  and  san- 
itoria. 

Radium  Soon  Available. — On  and  after-  Octo- 
ber 15th,  the  New  York  State  Institute  for  the 
Study  of  Malignant  Diseases,  in  Buffalo,  will  ad- 
minister the  two  and  one  quarter  grams  of  radium 
which  the  state  legislature  recently  enabled  it  to 
purchase  by  an  appropriation  of  $225,000.  Any 
citizen  of  the  United  States  will  be  treated  free  of 
charge  at  Buffalo,  but  preference  will  be  given  to 
residents  of  New  York  State.  Dr.  Harvey  R. 
Gaylord  is  director  of  the  Institute. 


August  7,  1920.] 


NEWS  ITEMS. 


197 


Award  to  Dr.  Pende. — The  Balbi-Valier  prize 
offered  by  the  Venice  Reale  Istituto  has  been 
awarded  to  Dr.  Nicola  Pende,  professor  of  pathol- 
ogy in  the  University  of  Palermo,  for  his  works 
on  the  organs  of  internal  secretions. 

Honorary  Degrees. — Cambridge  University  has 
conferred  the  honorary  degree  of  Doctor  of  Laws 
upon  Dr.  John  Jacob  Abel,  professor  of  pharma- 
cology at  Johns  Hopkins  Medical  School,  and  Dr. 
Harvey  Gushing,  professor  of  surgery  at  Harvard 
Medical  School. 

Maryland  Health  Department  Enlarged. — A 
department  of  bacteriology  has  been  established  by 
the  Maryland  State  Board  of  Health,  under  the 
direction  of  Dr.  R.  C.  Salter,  and  a  new  venereal 
disease  department  under  the  direction  of  Dr. 
Walter  Brunet. 

Woman  Physician  Decorated. — Dr.  Blanche 
Norton,  of  Eldon,  Iowa,  has  been  awarded  the 
Order  of  King  George  I  by  King  Alexander  of 
Greece.  Dr.  Norton,  a  physician  of  the  American 
Committee  for  Relief  in  the  Near  East,  distin- 
guished herself  at  Kerrassunde,  Anatolia,  by  treat- 
ing Greek  orphans  with  trachoma.  She  contracted 
the  disease  herself  but  has  since  recovered. 

Florida  State  Medical  Association. — The  Flor- 
ida State  Medical  Association  met  May  12th  and 
13th  at  Daytona  and  elected  the  following  officers : 
President,  Dr.  William  E.  Ross,  of  Jacksonville ; 
vice-presidents,  Dr.  Clyde  C.  Bohannon,  of  Day- 
tona; Dr.  George  A.  Davis,  of  DeLand ;  Dr.  James 
H.  Fellows,  of  Pensacola ;  secretary-treasurer,  Dr. 
Graham  E.  Henson,  of  Jacksonville.  Pensacola  was 
selected  as  the  next  place  of  meeting. 

Municipal  Milk. — The  city  council  of  Man- 
chester, England,  has  voted  to  municipalize  the  dis- 
tribution of  milk. 

The  health  committee's  arguments  in  support  of 
the  proposal  were  that  as  supplied  at  present  Man- 
chester milk  would  all  be  classed  C3  according  to 
American  grading,  and  would  be  allowed  for  use 
only  for  cooking  and  for  manufacturing  purposes; 
that  impure  milk  was  largely  responsible  for  tuber- 
culosis in  children,  and  that  one  third  of  the  deaths 
of  children  under  five  years  of  age  could  be  at- 
tributed to  bovine  infection.  Adulteration  was  so 
common  that  Manchester  citizens  paid  £35,000 
yearly  for  water. 

Tuberculosis  Research  Fellowship. — To  en- 
courage study  of  the  means  for  the  prevention  and 
cure  of  tuberculosis,  the  Hennepin  County  Tubercu- 
losis Association  of  Minneapolis,  has  set  aside  a 
fund  for  the  support  of  a  tuberculosis  research  fel- 
lowship in  the  graduate  school  of  the  University  of 
Minnesota.  The  candidate  for  the  fellowship  must 
be  a  graduate  of  a  Class  A  medical  college.  He 
will  be  expected  to  devote  himself  to  research  in 
some  problem  concerned  with  the  causes,  prevention 
or  cure  of  tuberculosis.  No  teaching  or  other  serv- 
ice will  be  required.  The  fellowship  yields  $750 
the  first  year  and  progressively  increasing  amounts 
to  be  appropriated  for  the  second  and  third  years 
as  conditions  warrant. 

Inquiries  and  requests  for  application  blanks 
should  be  addressed  to  the  dean  of  the  graduate 
college.  University  of  Minnesota,  Minneapolis. 


Dr.  Villard  Elected  to  Faculty  of  Lyon.— Dr. 

Villard,  surgeon  to  the  Hotel-Dieu  and  an  editor 
of  the  Lyon  medical,  has  been  amed  professor  of 
operative  medicine  at  the  University  of  Lyon,  to 
succeed  Prof.  Maurice  Pollosson,  resigned. 

International  Health  Journal. — The  Interna- 
tional Journal  of  Public  Health,  which  makes  its 
first  appearance  with  the  July  number,  is  the  offi- 
cial scientific  organ  of  the  League  of  Red  Cross 
Societies.  Dr.  Thomas  R.  Brown  is  the  editor. 
Dr.  W.  W.  Francis  is  the  associate  editor,  and 
the  assistant  editors  are  Miss  Harriet  Bailey,  Mr. 
Marshall  Balfour,  Dr.  Garcia  Banus,  Mr.  Walter 
Clarke,  Dr.  E.  F.  Ducasse,  and  Dr.  Lina  M.  Potter. 
The  Journal  will  be  published  every  two  months 
and  will  appear  in  four  editions,  English,  French, 
Italian  and  Spanish.  It  will  be  devoted  to  all  phases 
of  public  health  and  preventive  medicine. 

New  Medical  Journal  in  Palestine. — Palestine's 
first  medical  journal,  a  quarterly  entitled  Harc- 
foosli  (Medicine)  has  just  made  its  appearance, 
published  by  the  Jewish  Medical  Association  of 
Palestine.  Medical  work  in  Palestine  has  been 
greatly  stimulated  during  the  past  two  years  by 
the  physicians  and  nurses  with  the  American 
Zionist  Medical  Unit,  who  have  taught  the  native 
members  of  the  profession  modern  methods.  The 
hospitals  and  clinics  established  by  the  American 
unit  in  Palestine  are  planned  as  the  beginning  of 
the  Medical  College  of  the  Hebrew  University  at 
Jerusalem. 

Hookworm    and    Tuberculosis. — Information 

with  regard  to  mistaken  diagnosis  in  the  case  of 
tuberculosis  and  hookworm  is  contained  in  a  pre- 
liminary report  received  by  the  War  Department  on 
a  study  conducted  by  army  medical  men  at  General 
Hospital  No.  19,  at  Oteen,  N.  C,  where  tuberculous 
patients  are  treated.  The  report  says  that  many 
cases  which  had  been  diagnosed  as  tuberculosis  on 
further  examination  showed  signs  of  hookworm, 
and  under  treatment  for  hookworm  the  patient  im- 
proved greatly.  Accurate  figures  as  to  the  number 
of  hookworm  cases  which  had  shown  all  the  evi- 
dences of  tuberculosis  will  soon  be  compiled.  It  is 
estimated  that  about  ten  per  cent,  of  the  patients 
suffer  from  hookworm  at  the  time  of  admission  and 
that  about  two  per  cent,  do  not  have  tuberculosis. 

 «^  

Died. 

Baker. — In  Dennison,  Ohio,  on  Sunday,  August  ist.  Dr. 
Charles  Wesley  Baker,  of  Kilgore,  aged  forty-seven  years. 

CoNCANNON. — In  New  York,  N.  Y.,  on  Sunday,  August 
1st,  Dr.  James  J.  Concannon,  aged  sixty-four  years. 

Crowley. — In  Potsdam,  N.  Y.,  on  Sunday,  July  25th, 
Dr.  William  H.  Crowley,  of  Chicago,  aged  fifty-three  years. 

Harding. — In  Topeka,  Kan.,  on  Tuesday,  July  27th,  Dr. 
Eva  Harding,  aged  sixty-three  years. 

Hughes. — In  Boston,  Mass.,  on  Friday,  July  30th.  Dr. 
Laura  Ann  Cleophas  Hughes,  aged  sixty  years. 

Jones. — In  St.  Louis,  Mo.,  on  Tuesday,  July  27th,  Major 
D.  C.  Jones,  of  Leavenworth,  Kan.,  aged  eighty-two  years. 

Kenny. — In  New  York.  N.  Y.,  on  Saturday,  July  24th, 
Dr.  John  Joseph  Kenny,  aged  thirty-seven  years. 

Parker. — In  Southampton,  Pa.,  on  Saturday,  July  24th, 
Dr.  George  Albertson  Parker,  aged  sixty-six  years. 

Quint. — In  Boston,  Mass,,  on  Monday,  July  26th,  Dr. 
Norman  Perkins  Quint,  of  West  Medway. 


Book  Reviews 


FRIEDRICH  HEBBEL 

Friedrich  Hcbbcl.  Ein  psychoanalytischer  Versuch.  By  Dr. 
J.  Sadger,  Schriften  zur  angewandten  Seelenkunde.  Ed- 
ited by  Prof.  Dr.  Sigmund  Freud.  No.  18.  Vienna: 
Franz  Deuticke,  1920.     Pp.  374. 

"My  purpose  is  to  write  an  entirely  sincere  book 
— the  reader  will  judge  if  I  have  succeeded — that  is, 
to  draw  the  man  Friedrich  Hebbel  as  he  appears  to 
me,  not  merely  in  his  merits  and  his  great  accom- 
plishments but  also  with  all  his  many  weaknesses. 
This  will  be  seen  not  to  be  due  to  a  lack  of  appre- 
ciation of  the  genius  which  has  given  the  world 
such  great,  such  immortal  gifts.  It  seems  to  me  that 
genius  is  little  served  when  one  pours  out  only 
psalms  of  praise,  for  it  is  only  to  the  gods  that  in- 
cense is  not  a  poison ;  it  befogs  and  stupefies  earth- 
bound  man,  veiling  the  truth.  And  to  find  the 
truth,  with  favor  to  no  one,  but  also  with  injury  to 
no  one,  seems  to  me  the  first  task  of  the  investi- 
gator." 

This  latest  volume  in  the  psychoanalytical  series 
of  the  Schriften  zur  angewandten  Seelenkunde  is 
thus  introduced  by  the  author.  This  author  has 
written  earlier  (Von  der  Pathographic  zur  Psycho- 
graphic.  Imago  Vol.  1,  No.  2,  p.  158)  explaining 
the  difference  between  such  scientifically  psycho- 
logical search  for  truth  through  understanding  of 
a  human  life  and  its  work  and  that  of  the  blind  and 
pointless  method  of  applying  a  certain  amount  of 
superficial  psychological  skill  to  the  study  of  a  writer 
and  exercising  perhaps  a  prurient  delight  in  destroy- 
ing the  world's  idols.  The  sincere  purpose  of  the 
author  and  the  thoroughly  openminded  and  faithful 
manner  in  which  he  has  carried  it  to  fulfillment 
show  how  far  genuine  psychoanalytical  study  stands 
above  a  superficial  dabbling  with  human  lives  or 
human  achievements.  If  one  reads  again  thought- 
fully the  words  quoted  above  from  the  author's 
preface,  one  will  find  full  justification  for  present- 
ing this  study  even  to  a  group  of  readers  outside 
Hebbel's  own  country  and  where  his  works  are 
comparatively  little  known.  This  justification  is 
made  more  complete  by  an  examination  of  the  con- 
tents of  the  book. 

In  the  first  place,  the  author's  point  of  view  shows 
us  the  value  that  such  a  study  of  any  life  may  have. 
For  the  reader  finds  here  what  is  promised,  a  study 
of  the  characteristics  of  a  man,  the  strong  and  the 
weak,  and  of  his  performances  in  the  light  of  his 
entire  life,  with  particular  emphasis  upon  his  child- 
hood. In  this  way  the  contradictions  of  his  per- 
sonal life,  the  power  of  his  creative  work,  as  well 
as  its  limitations,  become  comprehensible.  To  sub- 
mit any  life,  its  character  and  its  products,  to  such 
careful  and  penetrating  scrutiny  yields  rich  results 
for  enlarging  psychoanalytical  knowledge.  Such  is 
the  case  with  this  book.  So  keen  and  faithful  is 
the  search  for  underlying  psychic  facts  and  the  por- 
trayal of  these  as  discovered,  the  discussion  of  the 
elements  of  environment  which  play  upon  a  life 
and,  more  important  still,  the  reactions  of  such  a 
life  to  these  environmental  factors,  that  the  reader 
is  compelled  also  to  a  persistent  probing  and  analysis 
of  self  throughout  the  reading. 


The  subject  of  this  book  affords,  moreover,  spe- 
cially rich  material  for  such  investigation,  material 
which  is  peculiarly  fitted  to  bring  home  these 
searching  and  therefore  wholesome  truths.  Hebbel 
is  a  poet  who  attracts  psychoanalytical  study.  In 
the  first  place,  he  himself  has  given  much  informa- 
tion concerning  his  own  inner  life  and  the  feelings 
and  experiences  of  his  childhood  in  his  reminis- 
cences and  his  diaries.  Moreover,  in  doing  so  he 
has  revealed,  just  as  he  has  in  all  his  creative  writ- 
ing, an  acknowledged  belief  in  the  unconscious  with 
its  storehouse  of  creative  impulses  and  its  reserve 
material  of  phantasies.  Along  with  this  he  reveals 
a  striking  appreciation  of  the  dream,  of  its  close 
relation  to  artistic  creation,  and  of  its  function  in 
the  life  of  the  dreamer.  Besides,  the  creative  works 
of  the  poet  reveal  the  close  relation  of  these  to  his 
own  unconscious  content,  the  limitations  and  imper- 
fections of  this  poetry  revealing  the  infantile  com- 
plexes which  to  a  large  extent  always  dominated 
him. 

These  are  plainly  traceable,  largely  through  the 
testimony  he  himself  has  given,  to  the  infantile 
period  of  his  life  and  to  the  sexual  difficulties  which 
there  built  themselves  around  both  parents  and 
around  other  objects  of  his  environment.  These 
were  not  necessarily  directly  sexual  in  the  adult 
sense  of  the  word  but  richly  illustrative  of  the  in- 
fantile sexuality  which  it  has  been  discovered  played 
such  an  enormously  important  part  in  determining 
his  later  life  and  production.  The  writings  of  the 
poet  testify  to  the  power  bound  with  these  com- 
plexes which  in  part  found  sublimation  into  works 
of  force  and  strength,  serving  thus  to  discharge  in 
really  great  form  these  infantile  libido  trends  and 
thus  furnish  release  for  the  poet  and  for  his  audi- 
ences. At  the  same  time  they,  too,  largely  filled  his 
plots  and  their  developments  and  therefore,  because 
of  their  often  too  insistent  and  too  grossly  exag- 
gerated infantile  character,  they  failed  to  establish 
the  hold  upon  the  world  that  they  otherwise  might 
have  had.  In  his  personal  life  they  played  a  still 
more  disturbing  part.  The  man  Hebbel  was  gov- 
erned too  strongly,  too  compulsively,  by  these  fac- 
tors to  fulfill  his  part  as  lover,  husband,  father, 
friend,  in  the  best  way.  His  inability  to  free  him- 
self from  the  infantile  bondage  to  either  parent 
seriously  marred  his  relations  with  his  fellow  beings 
and  brought  suffering  to  many  in  his  train. 

The  details  of  his  character  and  of  its  develop- 
ment from  its  early  determinants  are  largely  those 
of  the  compulsive  neurotic.  The  elements  of  his 
partial  success,  great  and  imposing  as  far  as  it  was 
attained,  as  well  as  his  weaknesses  and  failures, 
serve  to  throw  much  light  upon  the  makeup  of  such 
a  neurosis,  the  difficulties  with  which  such  a  charac- 
ter must  contend,  its  manner  of  meeting  these  diffi- 
culties in  overcoming  or  succumbing  to  them,  and 
upon  the  infantile  experience  out  of  which  such  a 
form  of  character  arises.  Therefore  the  study  of  a 
man  who  reveals  in  such  large  measure  the  elements 
of  both  greatness  and  weakness,  bound  together  in 
such  a  condition,  is  an  invaluable  human  document. 
Added  to  these  revelations  of  human  character,  of 


August  7,  1920.1 


BOOK  REVIEWS. 


199 


the  striving  of  human  elements  which  speak  through 
his  writings,  is  his  definite  teaching  regarding  psychic 
material  and  the  mechanisms,  such  as  the  dream, 
through  which  it  reveals  itself.  English  readers 
must  acknowledge,  therefore,  beyond  the  general 
psychoanalytical  debt  to  Sadger,  their  indebtedness 
to  him  for  the  opportunity  to  become  better  ac- 
quainted with  this  poet  of  the  unconscious  of  an- 
other land  and  tongue. 

OPHTHALMOLOGY. 

A  Practical  Treatise  on  Ophthalmology.  By  L.  Webster 
Fox.  M.  D..  LL.  D..  Professor  of  Ophthalmolog>-. 
^ledico-Chirurgical  College  Graduate  School ;  University 
of  Pennsylvania,  etc.  Illustrated.  New  York:  D.  Ap- 
pleton  &  Co.,  1920.  Pp.  i-831. 

This  new  edition  of  Fox's  follows  the  older  edi- 
tion fairly  well.  The  new  technic  which  the  author 
devised  for  the  relief  of  conical  ulcer  has  been  add- 
ed to  the  original  test.  The  author's  experience 
with  this  operation  causes  him  to  recommend  it 
highly.  His  description  is  given  in  detail  and  can 
be  followed  with  ease.  He  also  describes  an  opera- 
tion of  great  simplicity  which  he  uses  for  the  ex- 
cision of  the  tarsal  cartilage  in  trachoma.  He  has 
described  the  Elliot  operation  for  glaucotna  with 
the  Fox  modifications  for  comparison.  Some  space 
has  been  given  to  the  use  of  biological  tests  in  diag- 
nosis and  treatment.  This  is  important  and  care- 
fully worked  out  and  should  prove  of  great  interest. 
Much  work  has  been  done  in  this  field  experiment- 
ally and  it  is  encouraging  to  find  it  incorporated 
in  a  textbook  with  the  merits  of  this  one. 

HUMAN  COSTS  OF  WAR. 

The  Human  Costs  of  the  War.  By  Homer  Folks.  Or- 
ganizer and  Director  of  the  Department  of  Civil  Af- 
fairs of  the  American  Red  Cross  in  France  and  Later 
Special  Commissioner  to  Southeastern  Europe.  Illus- 
trated with  photographs  by  Lewis  W.  Hine.  Ameri- 
can Red  Cross  Special  Survey  Mission.  New  York 
and  London :  Harper  &  Brothers.  Pp.  i-326. 

Homer  Folks  is  qualified  to  write  about  the 
Human  Costs  of  the  War.  After  all  there  are 
only  two  things  to  consider:  The  human  costs  and 
the  eflfect  of  the  war  on  human  progress.  If  those 
who  say  they  are  so  weary  of  war  stories  would 
spend  the  same  amount  of  energy  in  decrying  war, 
wars  would  be  at  an  end.  But  it  seems  consistent 
with  human  folly  to  refuse  to  face  the  products  of 
our  own  making,  so  that  we  may  be  able  to  repeat 
our  crimes  with  a  clear  conscience. 

This  survey  is  a  rather  extensive  one  and  covers 
most  of  Europe.  The  horrors  of  the  country  that 
suffered  most,  Serbia,  are  told  clearly  and  dispas- 
sionately. These  rather  primitive  people  were  able 
to  stand  their  hardships  better  than  any  other  Euro- 
peans. We  are  shown  how  typhus  ravaged  the 
country  and  overflowed  from  the  hospitals  into  the 
cemeteries.  Typhtis,  while  the  most  deadly  enemy 
of  the  Serbians  was  not  the  only  one.  Tuberculosis, 
syphilis,  typhoid,  dysentery  and  malaria  were  en- 
countered on  every  hand.  Other  barbarities  of  hu- 
man making  are  also  described  and  some  of  the  re- 
corded deeds  of  Serbia's  neighbors  are  none  too 
esthetic — some  of  the  acts  of  the  Serbians,  how- 
ever, are  not  given.  When  the  cultural  level  of  these 
Balkan  people  is  considered  their  acts  should  cause 


less  wonderment  than  those  of  some  of  the  more 
civilized  countries.  Xone  of  the  little  games  of 
revenge  played  by  people  at  war  can  bear  close 
scrutiny. 

We  are  also  shown  the  gruesome  pictures  of  Bel- 
gium, France  and  Italy  and  finally  wavering  Greece 
holding  out  for  more  gain.  Then  comes  the  summing 
up  with  the  question:  What  is  our  civilization,  what 
has  it  done?  It  has  caused  epidemic  and  death  by 
violence,  misery,  and  unhappiness — all  through  the 
maneuvering  of  a  few  senile  statesmen.  There  were 
nine  million  soldier  dead,  ten  million  homeless,  fifty 
million  manless  homes,  ten  million  einpty  cradles, 
disease,  death,  desolation.  How  can  one  face  these 
figures  and  favor  war?  How  much  can  we  who 
remain  do  to  retrieve  the  results  of  this  madness 
and  folly?  Perhaps  we  here  in  America  have 
grown  so  accustomed  to  large  figures  that  these  will 
mean  little ;  perhaps  a  few  months  in  a  vermin  in- 
fested dugout  decorated  by  decaying  bits  of  our 
former  comrades  would  be  a  more  effective  lesson ; 
perhaps — but  it  is  so  difficult  to  measure  sorrow  and 
count  the  broken  souls  who  suffered  and  were  left 
behind.  Is  it  fair  to  forget  this  bloody  lesson  in  the 
joys  and  comforts  that  surround  us? 

THE  PRIMITIVE  IN  POETRY. 

The  Golden  Whales  of  California.  And  other  rhymes  in  the 
American  language.  By  Vachel  Linds.w.  New  York : 
The  Macmillan  Company,  1920.    Pp.  iii-181. 

Poems  by  a  Little  Girl.  By  Hilda  Coxkling.  With  a 
Preface  by  Amy  Lo\\t;ll.  A  Portrait  by  James  Chapin. 
New  York:  Frederick  A.  Stokes  Company.  Pp.  v-120. 

These  two  books  of  poetry  are,  at  first  glance,  as 
far  apart  as  they  can  be,  yet  when  more  closely 
e.xamined  they  present  an  analogy  that  may  be  well 
worth  recording — Vachel  Lindsay,  a  poet  of  stand- 
ing, well  known  to  followers  of  American  verse, 
and  Hilda  Conkling,  a  little  girl  of  nine,  the  one 
writing  about  all  manner  of  things,  most  of  them 
familiar  to  all  of  us,  and  the  child  telling  her  im- 
pressions to  her  mother. 

Now  where,  you  may  ask,  do  we  find  common 
ground?  On  the  one  hand  we  find  the  crude  primi- 
tive cadences  used  to  describe  the  passing  puppet 
shows,  while  the  child  gives  voice  to  her  musings 
Httle  touched  by  the  adult  knowingness  which  comes 
from  contact  with  the  world.  The  one  makes  use 
of  the  infantile  expressions  of  the  race,  while  the 
other  uses  the  lyrical  images  of  her  infantile  life. 
Both  use  the  lower,  more  primitive  levels  for  their 
medium  of  expression. 

Vachel  Lindsay  has  popularized  the  booming 
melodies  of  negro  chants ;  he  has  used  them  to  de- 
scribe prize  fights,  political  conventions,  and  camp 
meetings.  He  has  felt  the  throbbing  pulse  of  the 
unsuppressed  rhjthmic  heart  beats  of  those  un- 
shackled by  culture;  he  has  woven  these  into  strong 
stanzas  which  carry  one  away  in  a  wild  ecstasy. 
The  child,  unrestricted  by  the  continual  don'ts  of 
nursemaids,  as  Amy  Lowell  so  carefully  ex- 
plains, has  presented  her  phantasies  to  her  under- 
standing mother.  She,  too,  has  clung  rather  tena- 
ciously to  reality  and  her  phantasy  has  served  to 
harmonize  and  make  beautiful  the  little  things  about 
her  and  not  as  a  retreat  wherein  she  can  escape 
from  the  world  of  reality.    In  both  instances  free- 


200 


BOOK  REVIEirS. 


[New  Vork 
Medical  Iovrxal. 


doni,  unrestraint  and  wholesomeness,  are  expressed. 

The  argument  may  be  raised  that  all  rh\i:hmic 
expression  is  more  or  less  primitive  and  has  an 
imderlying  sex  motive  which  it  seeks  to  express. 
But  there  is  a  vast  difference  in  the  way  it  is  used. 
We  find  the  Chinese  with  their  delicate  fragments 
dating  back  to  antiquity,  Keats  with  his  sophistica- 
tion. Browning  in  his  mystic  intricacies,  Maeterlinck 
in  his  symbolic  musings,  Longfellow's  sentimental- 
it)-,  the  self  pity  of  Oscar  Wilde,  and  the  ponder- 
ousness  of  Wordsworth.  Few  are  content  with  the 
purely  primitive. 

In  Russia  poetry  and  other  means  of  expression 
in  children  have  received  more  attention  than  in 
many  other  countries.  The  drawings,  verses,  and 
writings  of  children  have  been  collected  there  for 
many  years  and  much  original  material  revealed. 
They  have  shown  that  frequently  the  phantasy 
minds  of  the  children,  prior  to  the  time  that  their 
minds  are  pressed  in  the  great  conventional  mold, 
give  rise  to  man\-  creations  of  rare  beauty.  Perhaps 
we,  too,  would  find  much  of  interest  and  not  a  little 
instruction  if  we  were  to  give  more  encouragement 
to  the  thoughts  and  productions  of  children,  if  we 
would  try  to  teach  them  less  of  the  dry  material  we 
have  to  offer  them,  and  learn  more  from  them  when 
they  sing  to  us  the  melodies  of  their  child  souls  or 
try  to  paint  life  as  they  see  it  before  the}'  are  crushed 
in  the  mold  of  our  making. 

MYSTERY  AND  THE  NEUROTIC. 

The  Vanishing  Men.  By  Rich.\rd  \V.\shburx  Child, 
Author  of  Velvet  Black,  etc.  New  York:  E.  P.  Button 
&  Co.    Pp.  i-324. 

Most  mystery  stories  are  rather  flimsy  affairs. 
They  are  written  with  the  object  of  putting  down 
enotigh  words  on  paper,  using  a  rather  circtilar  plot 
and  then  trusting  that  the  nm  of  the  book  will  be 
up  to  the  average  and  so  prove  a  successful  business 
venture.  This  does  not  apply  in  the  case  of  Van- 
ishing Men.  CarefuU)-  written,  so  as  to  hold  atten- 
tion to  the  last  page;  many  thrills,  and  all  the 
trimmings  demanded  of  a  worthy  rrn-stery  tale  and 
yet  there  is  something  more.  The  author  has  taken 
advantage  of  the  little  bypaths.  The  descriptive  bits 
are  very  real  and  very  beautiful.  Most  worthy  of 
all,  however,  is  his  description  of  fear.  One  of  the 
chief  characters  in  the  book  is  a  man  with  a  remnant 
of  worth  tr\-ing  to  disclose  itself  through  a  mass 
of  less  worthy  characteristics.  With  great  precision 
we  find  portrayed  a  hypochondriacal  person  who  in 
the  shifting  of  life's  scenes  makes  a  monetary  suc- 
cess, but  is  a  bankrupt  in  soul.  Gradually  the 
hj^ochondria  becomes  replaced  by  an  anxiet)"^  neu- 
rosis and  here  Child  draws  a  convincing  clinical 
picture.  He  makes  use  of  the  dramatic  material 
presented  and  handles  it  exceedingly  well.  Another 
point  of  interest  is  the  projection  of  the  fears  to  a 
harmless  individual,  the  heroine.  This  is  so  subtly 
done  that  in  time  she  herself  feels  that  through  some 
supernatural  power  she  brings  destruction  to  those 
who  know  her.  But  in  the  solving  of  the  human 
riddle  we  find  here  as  always  these  mystic  forces  are 
nothing  but  the  interpretation  of  man's  fears  and 
weaknesses.  There  are  many  of  these  in  the  book 
and  not  until  it  is  finished  do  w'e  see  them  clearly. 


New  Publications  Received. 


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


m.\n's  uxcoxsciors  conflict.  A  Popular  Exposition  of 
Psvchoanab'sis.  Bv  Wilfred  Lav,  Ph.  D.  New  York : 
DcKld,  Mead  &  Co.  1919. 

THE  child's  uncoxscious  mixd.  The  Relations  of  Psycho- 
analysis to  Education.  Bv  Wilfred  L.w,  Ph.  D.  New 
York:  Dodd.  Mead  &  Co.,  1920. 

HELLEXic  ARCHiTECTL"RE.  Its  Gcnesis  and  Growth.  By 
Edward  Bell,  M.  A.»  F.  S.  A.  Illustrated.  London  :  G. 
Bell  &  Sons.  Ltd.,  1920.    Pp.  xx-185. 

kxowledge  exhaxced.  Phenomenon  of  Sleep  Solved. 
Bv  LcTHER  Stocktox  Fish.  Illustrated.  Cleveland,  Ohio : 
Published  by  the  Author,  1920.    Pp.  viii-297. 

mort.\lity  statistics,  1918.  Department  of  Commerce, 
Bureau  of  the  Census.  S.\ii  L.  Rogers,  Director.  Nine- 
teenth Annual  Report.  Washington :  Government  Printing 
Office,  192a    Pp.  iii-603. 

GEXER.\L  ixtroductiox  TO  psvcH0.\x.\LYSis.  By  Prof. 
SiGMUXD  Freud,  LL.D.  Authorized  Translation,  with  a 
Preface  by  G.  Staxlev  H.^ll,  President,  Clark  University. 
New  York :    Boni  &  Liveright.    Pp.  i-402. 

MIXISTRY  of   the  IXTERIOR.  EGYPT — DEPARTMENT  OF  VXTB- 

uc  HEALTH.  Sixth  Annual  Report  on  the  Ophthalmic  Sec- 
tion, 1918.  By  the  Director  of  Ophthalmic  Hospitals. 
Cairo,  Eg>  pt :    Government  Press,  1919.    Pp.  viii-30. 

THE  VSE  OF  COLLOIDS  IX  HE.\LTH  .\XD  DISEASE.  By  AL- 
FRED B.  Searle.  With  Foreword  by  Sir  Malcolm  Mor- 
ris, E.C.V.O.  Illustrated.  London:  Constable  &  Co., 
Ltd.,  1920;  New  York:    E.  P.  Dutton  &  Co.    Pp.  vii-120. 

da\s'x  of  the  .\\v.\kexed  mixd.  By  John*  S.  Kind.  M.  D., 
Founder  and  President  of  the  Canadian  Society  for  Psy- 
chical Research  for  the  eight  years  of  its  existence.  Illus- 
trated. New  York :  James  A.  McCann  Company.  1920. 
Pp.  xxix-451. 

the  facltty  of  the  college  of  physicians  .\xd  sur- 
geons. Columbia  L'niversity  in  the  City  of  New  York., 
Twent\--four  Portraits  by  Doris  U.  Jaeger.  With  a  Fore- 
word by  Samu-el  W.  Lambert,  M.D.,  A.B.,  A.M..  Ph.B. 
New  York:    Paul  B  Hoeber,  1919. 

the  principles  of  .\xtexatal  and  postnatal  child 
physiology,  pure  and  .applied.  By  W.  M.  Feldmax, 
M.B.,  B.S.  (Lond.),  Assistant  Physician  to  and  Lecturer 
on  Child  Physiolog)'  at  the  Infants'  Hospital.  Illustrated. 
London  and  New  York:  Longmans,  Green  &  Co..  1920. 
Pp.  xxvii-694. 

alb.^xy  :  THE  CRISIS  IX  GOVERNMENT.  The  Histoiy  of 
the  Suspension,  Trial  and  Expulsion  from  the  New  York 
State  Legislature  in  1920  of  the  Five  Socialist  Assembly- 
men by  Their  Political  Opponents.  By  Lolts  Waldmax. 
With  an  Introduction  by  Seymour  Stedman.  Illustrated. 
New  York :    Boni  &  Liveright.    Pp.  xx-233. 

DISE.\SES    OF    THE    IXTESTIXES    .A.ND    LOWER  ALIMENT.\RY 

TR.\CT.  By  Anthony  B.\ssler,  M.D.,  Professor  of  Gas- 
troenterologj',  Fordham  University  Medical  College  and 
New  York  Polyclinic  Medical  School  and  Hospital;  Visit- 
ing Phj-sician,  New  York  Polyclinic  Hospital,  etc.  Illus- 
trated. Philadelphia:  F.  A.  Davis  Co.,  1920.  Pp.  xvi- 
660. 

ADVANCED  LESSOXS  IX  PRACTICAL  PHYSIOLOGY  FOR  STU- 
DEXTS    OF    MEDICINE.      By    RuSSELL    BuRTOX-OpITZ,  S.M., 

M.D.,  Ph.D.,  Associate  Professor  of  Physiolog>',  Colum- 
bia Universin- ;  Professional  Lecturer  in  Physiology^  in 
Teachers'  College  and  the  Extension  Department  of  Co- 
lumbia University.  Illustrated.  Philadelphia  and  London : 
W.  B.  Saunders' Co.,  1920.    Pp.  xiii-238. 

HUMAX  p.\R.\siT0L0GY.  With  Notcs  ou  Bacteriologj",  My- 
cology', Laboratory  Diagnosis.  Hematology'  and  Serology*. 
By  Damaso  Riv.\s,  B.  S.  Biol.,  M.  S.,  M.  D.,  Ph.  D..  As- 
sistant Professor  of  Parasitology;  Assistant  Director  of 
the  Course  in  Tropical  Medicine  and  of  the  Laboratory^  of 
Comparative  Pathology-  and  Tropical  Medicine  in  the  Uni- 
versity of  Pennsylvania,  etc.  Illustrated.  Philadelphia  and 
London  :  W.  B.  Saunders  Company,  1920.    Pp.  vii-715. 


Miscellany  from  Home  and  Foreign  Journals 


Epidemic  Encephalitis. — L.  P.  Stephen  and 
K.  M.  Bulchandani  (Indian  Medical  Gazette, 
March,  1920)  thus  describe  this  disease  as  observed 
in  Karachi.  The  onset  may  be  acute  and  fulmi- 
nant, or  be  insidious  and  take  a  more  or  less  be- 
nign course.  Very  young  children  are  rarely  at- 
tacked; most  patients  are  from  fifteen  to  forty 
years  of  age.  Five  out  of  six  are  males.  Cases 
are  found  in  all  grades  of  society.  The  onset  is 
mostly  insidious,  with  generally  a  stage  of  excite- 
ment at  first.  The  patient  may  show  nothing  but 
a  marked  eccentricity  and  an  easy  excitability  on 
slight  provocation,  and  may  have  hallucinations  and 
delusions.  In  other  cases  a  sudden  diplopia  is  the 
first  symptom.  Sooner  or  later  the  subject  be- 
comes lethargic  and  looks  very  sleepy.  He  lies 
with  drooping  eyelids,  unconcerned  about  himself 
and  his  surroundings,  has  little  or  no  initiative, 
and  at  the  height  of  the  disease  may  show  a  com- 
plete lack  of  spontaneous  motion.  If  questioned 
a  short  intelligent  response  can  generally  be  elicited, 
after  a  delay.  Various  types  of  paralysis  appear, 
always  related  to  cranial  nerves  and  apparently  of 
nuclear  origin.  Sensory  nerves  are  rarely  involved. 
Among  other  symptoms  are  general  rigidity  of  the 
limbs,  not  always  present,  slight  retraction  of  the 
head,  tremors  of  the  muscles  of  the  face  and  limbs, 
sometimes  restless  movements  of  the  latter.  Mus- 
cular power  is  weak.  Sugar  may  appear  in  the 
urine.  Reflexes  are  present  as  a  rule.  There  is 
little  or  no  tendency  to  bed  sores.  In  fulminant 
cases  the  patient  may  be  struck  down  suddenly,  be- 
come unconscious,  and  die  sooner  or  later.  Con- 
stipation is  another  definite  feature.  The  tongue 
has  a  thin  whitish  coating  and  is  large,  thick  and 
slightly  indented  at  the  edges.  The  breath  is  foul, 
the  appetite  unimpaired,  the  liver  and  spleen  not 
enlarged.  Retention  of  urine  may  be  one  of  the 
first  symptoms,  or  may  appear  later,  to  be  still  later 
replaced  by  involuntary  passage  of  urine.  Fever 
is  generally  present,  the  temperature  ranging 
from  100°  to  101°  F.,  but  rising  to 
104°  or  105°  in  unfavorable  cases.  The  skin  is 
usually  moist  and  there  may  be  profuse  perspira- 
tion. A  rash,  either  rose  or  purpuric,  may  appear 
early  or  not  until  the  thirteenth  day. 

In  favorable  cases  the  temperature  falls  by  lysis, 
the  patient  begins  to  take  interest,  and  his  symp- 
toms improve.  Ptosis  is  generally  the  last  symp- 
tom to  disappear.  In  unfavorable  cases  with  high 
temperature  and  acute  toxemia  the  patients  die  of 
asthenia  or  edema  of  the  lungs.  The  pathological 
changes  described  are  those  of  hemorrhagic  encepha- 
litis. There  may  be  pin  point  aggregate  foci  of 
hemorrhage  more  frequently  in  the  mesoencephalon 
than  elsewhere.  A  sort  of  patchy  dififuse  meningi- 
tis with  cellular  exudate  has  also  been  found.  All 
cases  showed  a  moderate  amount  of  leucocytosis 
and  were  negative  to  blood  parasites.  The  cerebro- 
spinal fluid  was  clear  and  under  no  pressure.  Con- 
cerning the  nature  of  the  disease,  the  writers  do 


not  believe  it  to  be  connected  with  influenza,  but 
refuse  to  venture  an  opinion  as  to  whether  it  is 
a  new  disease  or  not.  As  regards  treatment,  cal- 
omel in  fractional  doses  and  salines  are  useful  to 
relieve  constipation  and  lessen  intestinal  autointoxi- 
cation. Eserine  was  found  to  be  of  little  use.  Uro- 
tropin  in  gram  doses  was  given  without  noteworthy 
results,  but  its  use  is  recommended  as  the  only  use- 
ful antiseptic  in  cerebrospinal  infections.  Three 
patients  were  treated  with  an  intravenous  injection 
of  salvarsan,  after  which  the  improvement  was 
very  rapid  and  striking. 

The  Virus  of  Lethargic  Encephalitis. — C.  Le- 

vaditi  and  P.  Harvier  (Presse  medicale,  March  31, 
1920)  have  succeeded  in  reproducing  encephalitis  in 
a  rabbit  by  intracerebral  inoculation  of  an  emul- 
sion of  gray  matter  from  a  human  case  of  the  dis- 
ease. Upon  repeated  passage  through  rabbits  the 
virus  became  a  fixed  virus  and  exhibited  the  prop- 
erty of  killing  the  animal  in  from  four  to  six  days. 
The  animal  showed  a  torpid  state,  myoclonic  man- 
ifestations, and  symptoms  of  meningeal  irritation. 
Postmortem  there  were  found  typical  encephalitic 
lesions  analogous  to  those  described  in  man.  The 
virus,  which  is  not  cultivable  by  the  ordinary 
methods,  may  be  kept  in  glycerine.  It  is  a  filterable 
virus,  easily  passing  through  No.  1  and  No.  3 
Chamberland  filters.  It  can  be  inoculated  into  the 
rabbit  not  only  by  the  cerebral  route  but  also  by 
way  of  the  peripheral  nerves.  After  repeated 
passage  through  rabbits  it  becomes  pathogenic  for 
the  lower  catarrhine  ape.  The  general  conclu- 
sion reached  is  that  the  virus  is  a  specific,  filterable 
virus,  plainly  distinct  from  that  of  epidemic  polio- 
myelitis. 

Lethargic  Encephalitis. — Combemale  and  Du- 
hot  {Bulletin  de  I'Academie  de  medicine,  April  13, 
1920),  among  twelve  cases  of  lethargic  encephalitis 
seen  at  Lille,  found  a  considerable  variation  in  the 
earlier  symptoms,  some  cases  exhibiting  a  sudden 
onset  with  vomiting  and  distinct  constitutional  re- 
action and  others  beginning  insidiously  with  som- 
nolence, at  first  intermittent  and  later  continuous. 
In  some  cases  visual  disturbances  constituted  the 
initial  symptom,  leading  the  patient  to  consult  an 
oculist.  Hypersomnia  ranged  from  simple  apathy 
to  profound  lethargy.  Delirium  and  restlessness 
sometimes  developed  at  night.  At  times  there  was 
distinct  catatonia,  and  two  patients  presented,  espe- 
cially during  convalescence,  certain  features  sug- 
gesting Parkinson's  disease.  Most  cases  showed 
at  least  temporary  diplopia.  One  third  of  the 
cases  had  internal  ophthalmoplegia,  and  the  possi- 
bility of  facial  or  velopalatine  paralysis  was  also 
noted.  The  knee  jerks  were  generally  exaggerated, 
sometimes  unequally  on  the  two  sides ;  in  two  cases 
they  were  absent.  Fever  was  variable,  constipation 
frequent  and  obstinate,  and  marked  loss  of  weight 
generally  observed.  Low  blood  pressure  was  found 
to  be  an  important  feature.  The  cerebrospinal  fluid 
generally  issued  at  high  pressure ;  albumin  was 


202 


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[New  York 

Medical  Journal. 


normal  or  slightly  raised,  and  sugar  rather  in- 
creased than  diminished.  Lymphocytosis  in  the 
cerebrospinal  fluid  was  constant  but  slight ;  some- 
times it  persisted  even  after  disappearance  of  the 
clinical  signs.  Urea  in  the  blood  and  cerebrospinal 
fluid  was  high  in  the  grave  cases.  In  the  diagnosis, 
the  cerebrospinal  fluid  should  always  be  taken  into 
account.  Marked  lymphocytosis  and  hyperalbu- 
minosis  suggest  rather  a  meningeal  reaction  due  to 
tuberculous  or  syphilitic  infection  or  to  mumps, 
while  slight  lymphocytosis  and  slight  or  absent  hy- 
peralbuminosis  confirm  the  suspicion  of  lethargic 
encephalitis,  excluding  from  the  start  a  neurosis  or 
ordinary  infection.  The  prognosis  may  be  based 
upon  the  same  series  of  factors.  Death  seems  to 
occur  in  two  ways.  In  some  instances  there  are 
evidences  of  infection  and  fever,  which  may  be  very 
high ;  the  rise  in  the  temperature,  either  progressive 
or  following  a  remission,  is  the  most  important 
sign.  In  the  other  group  death  takes  place  through 
secondary  intoxication,  gradual  increase  of  the 
blood  urea  occurring  as  an  indication  of  oncoming 
tissue  disintegration. 

Intraspinal  Injection  of  Antitetanic  Serum  in 
Lethargic  Encephalitis. — Laubie  (Bulletin  de 
V Academic  dc  mcdecine,  March  16,  1920),  having 
treated  some  cases  of  lethargic  encephalitis  with  uro- 
tropin  and  collargol,  without  benefit,  administered,  in 
two  subsequent  cases,  intraspinal  injections  of  anti- 
tetanic  serum,  previously  used  with  success  by  De 
Coquet  in  a  case  of  encephalitis  with  pronounced 
rigidity,  suggesting  tetanus.  In  Laubie's  fir-st  case 
thus  treated,  the  injection,  given  on  the  fourth  day, 
was  followed  in  thirty-six  hours  by  marked  improve- 
ment, the  temperature  descending  and  the  dyspnea, 
ptosis,  photophobia,  neck  rigidity  and  somnolence 
passing  off.  In  this  case  lumbar  puncture  had  yield- 
ed clear  fluid  showing  a  little  albumin,  a  few  lymph- 
ocytes, no  bacteria,  and  negative  Noguchi  and  Bor- 
det-Wassermann  tests.  The  second  patient  exhibited 
somnolence,  slow  speech  and  movements,  rigidity  of 
the  neck,  and  positive  Kernig's  sign.  Lumbar  punc- 
ture yielded  fluid  containing  a  few  erythroc\-tes,  0.78 
of  allDumin,  no  bacteria,  and  a  weakly  positive  No- 
guchi. Injection  of  tetanus  antitoxin  was  followed 
by  disappearance  of  rigidity  and  Kernig's  sign  in 
forty-eight  hours,  and  subsequently,  of  the  otlier 
manifestations  of  the  disease. 

Lethargic  Encephalitis. — G.  Marinesco  {Bulle- 
tin de  I'Academie  dc  medccinc.  March  16,  1920) 
notes  that  the  more  recent  epidemic  of  this  affec- 
tion appears  to  include  a  considerable  number  of 
mild  and  atypical  cases,  in  particular  the  ambula- 
tory, myoclonic  and  meningeal  forms,  which  were 
not  seen  in  previous  epidemics.  He  reports  a  case 
in  a  woman  aged  twenty-two,  with  pronounced 
lethargic  and  cataleptic  symptoms  but  with  preser- 
vation of  the  functions  of  the  sensorium.  The  spinal 
fluid  at  first  showed  a  marked  lymphocytosis,  and 
the  temperature  eventually  rose  above  41°  C.  The 
patient  died  twenty  days  after  the  onset.  Post- 
mortem examination  showed  as  the  chief  pathologi- 
cal disturbance  an  inflammation  of  the  small  and 
precapillary  veins,  the  lymphatic  sheaths  of  which 
were  infiltrated  with  numerous  lymphocytes,  mon- 


onuclears, plasma  cells,  and  fibroblasts.  Where 
destruction  of  medullated  fibres  or  hemorrhagic  foci 
occurred,  macrophages  laden  with  fat  or  pigment 
were  seen.  New  formation  of  capillary  vessels  was 
likewise  detected.  Disseminated  foci  of  hemor- 
rhage were  found  in  the  gray  substance  of  the  floor 
of  the  fourth  ventricle  and  of  the  aqueduct  of 
Sylvius.  No  corresponding  inflammation  of  the 
arteries  could  be  found.  The  infundibulum  was  but 
slightly  involved  and  the  hypophysis  not  at  all. 
The  pathological  changes  were  not  limited  to  the 
corpora  quadrigemina  and  cerebral  peduncles,  but 
had  extended  to  the  thalamus  and  metathalamus, 
the  telencephalon,  the  corpus  striatum,  and  even 
the  cerebral  cortex.  In  the  medulla,  pons  and 
peduncle  there  was  marked  infiltration  of  the  ves- 
els  of  the  raphe.  The  raphe  and  even  the  nerve 
roots  of  the  hypoglossal,  glossopharyngeal,  and 
pneumogastric  showed  foci  containing  not  only 
mononuclear  lymphoc}i;es  and  plasma  cells  but  also, 
and  chiefly,  enlarged  and  proliferated  neuroglia 
cells  of  the  fibrous  type.  Inflammation  of  the  neu- 
roglia about  the  blood  vessels  was  manifest  in  all 
the  cases  of  lethargic  encephalitis  examined  post- 
mortem by  the  author.  Attention  is  called  to  the 
similarity  of  the  pathological  changes  in  lethargic 
encephalitis  to  those  found  in  African  sleeping  sick- 
ness, general  paralysis,  and  infantile  paralysis.  i)n 
the  whole,  no  pathological  peculiarity  completely 
distinctive  of  lethargic  encephalitis  is  as  yet  known. 
Neuroglia  nodules  have  been  found  in  the  dentate 
nuclei,  white  matter,  and  other  portions  of  the  cere- 
bellum by  the  author  as  well  as  by  Charles  Box. 
The  pathogenic  agent  is  asserted  to  be  different 
from  those  of  influenza  and  of  infantile  paralysis. 
It  is  probably  propagated  by  the  throat  secretions. 
It  is  carried  by  the  lymphatic  vessels  to  the  mid- 
brain and  medulla,  where  the  most  ]jronounced 
pathological  changes  are  found. 

Serpiginous  Character  of  Lethargic  Encephali- 
tis.— C.  Achard  {Bulletin  dc  I'Academie  de  medc- 
cinc, April  6,  1920)  points  out  that  the  protean 
character  of  the  clinical  picture  in  lethargic  en- 
cephalitis applies  not  only  to  different  cases  but 
likewise  to  the  individual  case,  in  which  widely  di- 
vergent clinical  manifestations  may  follow  one  an- 
other in  close  succession.  One  patient  had  had  the 
characteristic  somnolence  for  one  week  before  ad- 
mission to  a  hospital.  Upon  admission  he  talked 
volubly,  showed  interest  in  his  surroundings,  moved 
without  difficulty,  and  sat  up  in  bed,  but  complained 
of  left  frontal  headache.  Next  day  the  tempera- 
ture rose  to  39.2°  C.  and  lumbar  puncture  yielded 
a  hemorrhagic  fluid  which  remained  yellow  upon 
centrifugation.  Three  days  later  fluid  presenting 
these  same  features  was  withdrawn.  The  tempera- 
ture remained  above  38°  C.  for  a  week.  Suddenly, 
after  defervescence  and  marked  diminution  of  the 
headache,  complete  paralysis  of  the  left  oculomotor 
nerve  appeared.  Had  the  initial  disturbance  not  been 
known,  independent  diagnoses  of  meningeal  hemor- 
rhage and  later  of  oculomotor  paralysis,  both  of  ob- 
scure origin,  might  have  been  made.  The  left  pupil 
was  dilated  and  unresponsive  to  light  in  this  case. 
Reference  is  made  to  a  similar  case,  with  initial  som-- 


August  7,  1920.]  MISCELLANY  FROM  HOME  AND  FOREIGN  JOURNALS.  203 


nolence,  reported  by  Achard  and  Paisseau  in 
1904,  which  was  probably  one  of  lethargic  encepha- 
litis. Stress  is  laid  on  successive  stages  marked  by 
different  clinical  phenomena  as  a  diagnostic  feature 
in  this  disease.  This  variation  of  the  symptoms  may 
be  correlated  with  present  knowledge  of  the  pathol- 
ogy of  the  disorder.  The  brain  lesions,  chiefly  vas- 
cular in  their  localization,  may  affect  different  nerv- 
ous structures  to  a  varying  extent  and  for  variable 
periods  of  time,  passing  from  one  point  of  the 
midbrain  to  another,  and  also  to  the  cerebral  hemi- 
spheres and  spinal  cord.  The  course  followed  by 
the  lesions  is  serpiginous,  and  this  is  perhaps  the 
most  singular  feature  of  the  disease,  for  no  other 
form  of  encephalitis,  whether  acute  or  chronic,  pre- 
sents it  to  such  a  high  degree. 

Clinical  Signs  and  Meningeal  Reaction  in 
Lethargic  Encephalitis. — Jeanselme  [Bulletin  dc 
I'Academie  de  medecine,  April  6,  1920)  reports  a 
case  of  lethargic  encephalitis  in  which  the  initial 
soporose  and  paretic  stage  of  the  disease  was  fol- 
lowed by  a  stage  of  myoclonic  movements  and  a 
third  stage  of  choreiform  manifestations  and  athe- 
tosis. He  discusses  the  question  whether  these  later 
manifestations  should  be  looked  upon  as  sequelae  or 
as  the  expression  of  a  recrudescence  of  the  encepha- 
litis. Three  lumbar  punctures  carried  out  at  succes- 
sive intervals  of  two  weeks  and  one  week  proved 
highly  significant  in  this  connection.  The  first  punc- 
ture showed  thirteen  lymphocytes  and  1.5  grams  of 
albumin ;  the  second,  three  lymphocytes  and  0.5 
gram  of  albumin,  and  the  third,  twelve  lymphocytes, 
0.8  gram  of  albumin  and  0.38  gram  of  sugar.  Thus, 
during  the  soporose  and  paretic  stage  there  was 
slight  but  distinct  meningeal  irritation.  During  the 
remission  which  preceded  the  manifestations  of  in- 
coordination the  meningeal  reaction  was  perceptibly 
lessened.  Finally,  upon  appearance  of  the  myo- 
clonia and  chorea,  a  recrudescence  of  the  meningeal 
reaction  took  place.  In  view  of  the  close  agreement 
l)etween  the  clinical  symptoms  and  these  puncture 
findings,  the  myoclonia  and  chorea  need  not  be  con- 
sidered as  sequelse  appearing  during  convalescence 
but  as  a  new  stage  in  the  active  course  of  the  dis- 
ease, doubtless  associated  with  migration  of  the 
pathogenic  agent  to  different  structures. 

Increased  Cerebrospinal  Sugar  Content  in 
Epidemic  Encephalitis. — C.  Dopter  {Bulletin  de 
I'Academie  de  medecine,  March  2,  1920)  refers  to 
the  case  of  a  man,  aged  twenty-five  years,  com- 
])laining  of  slight  frontal  headache  and  general  lassi- 
tude, dull  pain  in  the  right  scapular  and  cervical 
regions,  diplopia,  accommodative  asthenopia,  slight 
external  strabismus,  mydriasis,  paresis  of  the  lips 
on  one  side,  doubtful  Kernig  sign,  and  slight  fever. 
Ten  months  before,  this  patient  had  had  a  chancre 
and  had  been  treated  with  novarsenobenzol ;  hence 
a  tentative  diagnosis  of  syphilitic  meningitis  was 
made,  though  the  Bordet-Wassermann  test  uas 
negative.  The  cerebrospinal  fluid  was  clear  and 
contained  twelve  lymphocytes  per  cubic  millimetre 
and  some  albumin.  Sugar,  however,  was  found 
present  in  the  unusual  amount  of  0.85  gram  per 
litre.   This  finding  was  taken  to  exclude  botli  syphi- 


litic and  tuberculous  meningitis,  and  lethargic  en- 
cephalitis was  suspected.  Next  day  the  patient 
showed  marked  restlessness  and  delirium,  followed 
by  myoclonic  twitchings  and  somnolence;  death 
took  place  a  week  later.  From  previous  personal 
cases  and  the  present  case,  as  well  as  from  the 
observations  of  other  clinicians,  Dopter  concludes 
that  increase  of  sugar  in  the  cerebrospinal  fluid  is 
of  value  in  differentiating  lethargic  encephalitis  from 
meningitis  in  its  various  forms.  This  increase 
doubtless  results  from  hyperglycemia,  due  in  turn 
to  disturbance  of  the  floor  of  the  fourth  ventricle. 
In  tuberculous  meningitis  sugar  in  the  cerebro- 
spinal fluid  is  diminished  or  entirely  absent,  while 
in  syphilitic  meningitis  it  is  generally  normal  in 
amount  and  only  exceptionally  in  excess.  It  should 
be  borne  in  mind  that  increased  sugar  content  may 
occur  also  in  affections  other  than  epidemic  enceph- 
alitis, e.  g.,  diabetes,  uremia,  pneumonia,  Malta 
fever,  rabies,  pertussis,  brain  tumor,  amyotrophic 
lateral  sclerosis,  cerebral  hemorrhage,  and  occa- 
sionally in  chronic  nervous  syphilis.  Furthermore, 
the  sign  is  not  constant  in  epidemic  encephalitis. 
In  one  case  examined  late  in  the  course  of  the 
disease,  the  sugar  content  was  subnormal.  Possi- 
bly in  cases  of  encephalitis  high  vip,  without  in- 
volvements of  the  bulbopontine  region,  excess  of 
su2;ar  is  not  to  be  expected. 

Lethargic  Encephalitis. — A.  Pic  {Lyon  medical, 
]\Iarch  25,  1920)  reports  a  case  of  epidemic  encepha- 
litis unattended  with  soinnolence,  and  thinks  the 
term  lethargic  encephalitis  might  with  advantage  be 
replaced  by  acute  epidemic  superior  poliomyelitis, 
at  least  in  some  cases.  By  way  of  prophylaxis, 
antisepsis  of  the  mouth  and  pharynx  of  patients 
and  convalescents,  as  well  as  among  the  contacts 
and  ordinary  influenza  cases,  is  indicated,  the  patho- 
genic agent  apparently  entering  through  the  naso- 
pharynx and  persisting  there.  In  the  treatment, 
lumbar  puncture  may  be  of  service  in  a  few  cases 
with  meningeal  reaction,  and  hexamethylenamine 
is  also  useful.  To  stimulate  the  leucocytes,  col- 
loidal metals  and  the  fixation  abscess  are  availa- 
ble, as  are  also  subcutaneous  injections  of  oxygen 
for  detoxicatory  purposes.  Warm  baths  or  the 
hot  pack,  together  with  an  icebag  to  the  head,  may 
be  used  for  sleeplessness,  nerve  pains,  restlessness, 
and  meningitic  symptoms.  Adrenalin  is  useful  for 
heart  weakness  and  low  blood  pressure,  as  in  ordi- 
nary influenza.  For  insuflicient  diuresis,  rectal  in- 
jections of  isotonic  glucose  solution  by  the  Murphy 
method  may  be  employed.  By  such  means  the 
mortality — so  far  reported  as  twenty-five  to  thirty- 
five  per  cent. — may  be  lowered. 

Experimental  Research  on  the  Virus  of  Leth- 
argic Encephalitis. — C.  Levaditi  and  F.  Harvier 

{Bulletin  de  I'Academie  de  medecine,  April  20, 
1920)  note  that  on  February  10,  1920,  they  were  suc- 
cessful for  the  first  time  in  inoculating  a  rabbit  with 
the  disease,  usjng  an  emulsion  of  brain  tissue  from 
a  case  of  encephalitis  in  a  woman  aged  forty-five. 
The  tissue  was  obtained  aseptically  from  the  cortex, 
midbrain  and  medulla,  and  was  inoculated  in  the 
dose  of  0.2  mil  into  the  brains  of  two  rabbits  and 


204 


MISCELLAXY  FROM  HOME  AND  FOREIGN  JOURNALS. 


[New  York 
Medical  Journal. 


one  monkey.  One  of  the  rabbits  died  on  the  eighth 
day.  Cultures  of  the  brain  and  cardiac  blood  were 
sterile,  and  the  nerve  centres  showed  the  typical 
lesions  of  meningoencephalitis  of  the  cortex  and 
midbrain.  The  two  other  animals  showed  no  dis- 
turbance whatever.  An  emulsion  of  brain  tissue 
from  the  dead  rabbit  was  inoculated  in  the  same 
dose  into  two  other  rabbits,  which  died  on  the  sixth 
and  sevenths  days,  respectively,  and  showed  identi- 
cal brain  lesions.  The  virus  from  one  of  these  rab- 
bits was  subsequently  passed  through  a  number  of 
other  animals  in  succession.  The  experiments 
showed  that  the  incubation  period  of  the  disease 
after  intracerebral  inoculation  averages  four  or  five 
days.  Symptoms  appear  only  a  few  hours  before 
death  and  consist  of  a  torpid  condition  with  signs 
of  meningeal  irritation  and  epileptoid  and  myoclonic 
spasms  in  the  limbs  or  choreic  movements.  The 
virus  can  be  preserved  in  glycerin,  and  is  a  filterable 
virus,  readily  passing  through  the  Chamberland  fil- 
tres  Nos.  1  and  3.  The  virus  may  be  inoculated 
into  the  rabbit  through  the  sciatic  nerve  as  well  as 
through  the  anterior  chamber  of  the  eye.  The  virus 
does  not  seem  to  be  pathogenic  for  monkeys  when 
directly  obtained  from  man,  but  becomes  so  after 
having  passed  a  certain  number  of  times  through 
rabbits.  It  then  becomes  pathogenic  likewise  for 
guinea  pigs.  The  virus  retains  its  virulence  after 
desiccation  in  vacuo  in  the  presence  of  sulphuric 
acid  and  after  desiccation  in  a  watch  glass  in  con- 
tact with  caustic  potash.  The  virus  is  present  in  the 
spinal  cord  of  animals  inoculated  by  the  cerebral 
route.  The  serum  of  "patients  convalescent  one 
month  from  lethargic  and  myoclonic  encephalitis  has 
no  neutralizing  action  upon  the  virus.  Experiments 
upon  crossed  immunity  with  the  virus  of  poliomye- 
litis, upon  vaccination  of  animals,  and  upon  serum 
treatment  are  now  being  carried  out. 

The  Oculocardiac  Reflex  in  Lethargic  En- 
cephalitis.— A.  Litvak  (Presse  medicate,  February 
14,  1920)  states  that  in  lethargic  encephalitis  the 
oculocardiac  reflex  is  rather  active.  The  more  deeply 
somnolent  the  patient,  the  more  readily  the  reflex 
is  elicited.  In  syphilitic  meningitis,  this  reflex  is  al- 
ways absent,  while  in  tuberculous  meningitis  it  is 
only  uncommonly  present  and  is  feeble.  In  lethar- 
gic encephalitis  there  may  be  observed  a  condition  of 
dissociation  between  the  tone  of  the  circulatory  cen- 
tre, which  may  be  lowered,  and  the  oculocardiac  re- 
flex, which  may  be  rather  pronounced. 

Syphilis  and  Lethargic  Encephalitis. — E.  Jean- 
selme  {Bulletin  dc  rAcadeinie  de  niedecine,  March 
2,  1920)  states  that  lethargic  encephalitis  may  read- 
ily be  overlooked  in  cases  of  suspected  syphilis  of  the 
central  nervous  system.  Many  symptoms  are  com- 
mon to  both  disorders,  from  dissociated  paralysis 
of  the  cranial  nerves  and  the  Argyll-Robertson  pupil 
to  convulsive  seizures  and  apoplectoid  coma.  The 
author's  case  was  characterized  by  persistent  som- 
nolence from  which  the  patient  could  readily  be 
roused,  complete  mental  clearness,  and  a  diifuse 
paretic  condition  with  motor  incoordination  reflect- 
ing cerebellar  involvement.  The  tendon  reflexes 
were  markedly  disturbed,  ankle  clonus  was  present, 


and  bulbar  involvement  was  shown  by  tachycardia, 
dissociation  of  the  pulse  and  temperature,  and  polyp- 
nea on  slight  exertion.  Lumbar  puncture  at  first 
showed  1.5  grams  of  albumin  per  litre,  positive  Bor- 
det-Wassermann,  and  thirteen  lymphocytes  per  cubic 
millimetre.  Sixteen  days  later  the  lymphocytes  had 
dropped  to  three  and  the  albumin  nearly  to  normal, 
and  the  Wassermann  was  negative.  The  blood  Was- 
sermann  had  been  negative  on  two  occasions.  The 
initial  positive  cerebrospinal  Wassermann  is  thought 
to  have  been  due  to  the  hyperalbuminosis.  A  posi- 
tive reaction  has  already  been  occasionally  noted  in 
nonsylphilitic  persons  in  the  presence  of  marked 
hyperalbuminosis  and  xanthochromia  of  the  cerebro- 
spinal fluid. 

Late    Sequelae    of   Lethargic    Encephalitis. — 

Henri  Claude  {Bullein  de  I'Acadeuiie  de  niedecine, 
March  2,  1920)  reports  four  cases  illustrating  the 
fact  that  encephalitis  patients  may  continue  for  a 
long  period  after  apparent  recovery  to  be  troubled 
with  asthenia,  inability  to  work,  and  the  recurrence 
upon  fatigue  of  particular  symptoms,  such  as  motor 
paresis,  choreiform  movements  and  visual  disturb- 
ances. Altered  disposition  may  also  persist  for  some 
time.  These  seqtielae  are  explainable  on  the  basis 
of  the  vascular  and  perivascular  pathological  changes 
found  in  cases  studied  postmortem. 

Prognosis  and  Treatment  of  Epidemic  En- 
cephalitis.— T-  Chalier  (Lyon  medical.  April  25, 
1920)  estimates  the  mortality  rate  of  lethargic  en- 
cephalitis as  forty  to  fifty  per  cent.  Rise  of  the 
temperature  to  40°  C.  is  an  unfavorable  prognostic 
feature,  as  are  also  tachycardia — with  or  without 
fever — and  polypnea,  which  suggest  bulbar  involv- 
ment.  Cases  manifesting  excitement  are  more 
dangerous  than  those  exhibiting  somnolence  alone. 
An  unfavorable  meaning  attaches  to  the  dissemina- 
tion and  progression  of  certain  symptoms,  such  as 
myoclonic  movements,  particularly  with  participa- 
tion of  the  diaphragm,  and  more  or  less  diffuse 
choreic  manifestations.  Regarding  treatment, 
Chalier  considers  the  administration  of  serum  from 
convalescents  the  most  rational  measure.  In  a  re- 
cent severe  case  its  use  was  followed  by  recovery. 

Epidemic  Encephalitis  and  Catatonic  Symp- 
toms.— Earl  D.  Bond  (American  Journal  of  Insan- 
ity, January,  1920),  in  a  review  of  three  cases  found 
that  mild  and  transient,  but  definite,  symptoms  are 
usually  missed  in  excited,  seclusive  or  indifferent  pa- 
tients. In  one,  strabismus  went  unrecognized  at 
home ;  another,  because  she  had  no  psychosis,  was 
able  to  give  information  which  would  have  been 
lost  in  a  person  less  clear.  Some  facts  came  out 
in  retrospective  accounts  which  few  can  give  satis- 
factorily. The  author  has  elsewhere  emphasized 
that  fevers  are  usually  overlooked  in  difficult  and 
chronic  patients.  There  is  a  great  reward  for  the 
first  hospital  for  mental  diseases  which  can  carry  out 
good,  thorough  and  repeated  physical  examinations 
on  all  its  patients.  A  catatonic  episode  in  a  chronic 
mental  patient  demands  and  rewards  the  same  skill- 
ful medical  and  nursing  care  which  is  given  to  the 
general  hospital  patient  with  acute  encephalitis. 


New  York  Medical  Journal 

INXORPORATING  THE 

Philadelphia  Medical  Journal     Medical  News 

A  Weekly  Review  of  Medicine,  Established  18Jf3. 

Vol.  CXir.  Xo.  7.  XEW  YORK.  SATURDAY.  AUGUST  14.  1920.  Whole  Xo.  2176. 

Original  Communications 


DIAGNOSIS  AND  TREATMEXT  OF 
HYPERTHYROIDISM.* 

By  M.  H.  Fussell,  D., 
Philadelphia. 

The  great  difficulty  in  the  treatment  of  many  dis- 
eases is  that  we  are  constantly  confronted  with  the 
end  results  of  the  disease,  when  the  chances  of 
bringing  about  a  cure  are  almost  nil.  A  patient 
with  diphtheria  who  dies  today  does  so  because 
diphtheria  antitoxin  has  either  been  used  in  too 
small  doses,  or  used  too  late.  Thousands  of  pa- 
tients with  tuberculosis  present  themselves  with  ex- 
tensive disease  of  the  lungs  that  can  never  be  cured. 
Early  diagnosis,  which  spells  cure,  has  been  missed. 

Hyperthyroidism  is  frequently  not  diagnosed 
until  the  patient  has  all  the  characteristics  described 
in  the  case  quoted  by  Graves  (1).  He  thus  de- 
scribes his  case  of  exophthalmic  goitre,  said  to  be 
the  first  in  the  literature : 

"A  lady,  aged  twenty,  became  aflFected  with  some 
symptoms  which  were  supposed  to  be  hysterical. 
•This  occurred  more  than  two  years  ago ;  her  health 
previously  had  been  good.  After  she  had  been 
in  this  nervous  state  about  three  months,  it  was 
observed  that  her  pulse  had  become  singularly 
rapid.  This  rapidity  existed  apparently  without 
any  cause  and  was  constant,  the  pulse  being  never 
under  120.  and  often  much  higher.  She  next  com- 
plained of  weakness  on  exertion,  and  began  to 
look  pale  and  thin.  Thus  she  continued  for  a 
year,  but  during  this  time  she  manifestly  lost 
ground  on  the  whole,  the  rapidity  of  the  heart's 
action  having  never  ceased.  It  was  now  ob- 
ser^-ed  that  the  eyes  assumed  a  singular  appear- 
ance, for  the  eyeballs  were  apparently  enlarged,  so 
that  when  she  slept  or  tried  to  shut  her  eyes,  the 
eyes  were  incapable  of  closing.  When  the  eyes 
were  open  the  white  sclerotic  could  be  seen  to 
a  breadth  of  several  lines  all  round  the  cornea." 

While  it  is  true  that  many  patients  with  well 
marked  exophthalmic  goitre  recover  under  rest  and 
other  measures,  it  is  equally  true  that  every  pa- 
tient who  has  the  marked  characteristics  of  the 
disease  has  vmdergone  a  change  in  the  heart  muscle, 
and  other  organs  of  the  body,  which  may  cause 
death  or  prolonged  invalidism.  For  this  reason 
chiefly,  I  have  selected  hyperthyroidism  for  this 
paper,  that  we  may  discuss,  first,  early  diagnosis 
and  dififerential  diagnosis  and  then  treatment  of  the 

*The  references  to  this  article  will  appear  in  the  reprint. 


condition  in  the  early  stages,  and  finally  the  treat- 
ment of  cases  in  the  later  as  well  as  the  latest 
stages. 

The  symptoms  of  well  developed  exophthalmic 
goitre  as  described  by  Graves  ( 1 ) ,  and  those 
which  usually  are  described  in  textbooks  are  so 
striking  that  he  who  runs  may  read.  Mental  alert- 
ness, tachycardia,  muscular  tremor,  exophthalmos, 
visible  pulsation  of  the  vessels,  tumultous  action  of 
the  heart,  sweating,  warm  hands  and  feet,  fre- 
quently cardiac  murmurs,  enlarged,  usually  pul- 
sating thyroid  gland,  tendency  to  flushing  of  the 
skin,  an  erythematous  rash  following  handling  of 
the  skin,  weakness,  emaciation,  diarrhea  and  vomit- 
ing, sometimes  arthritis ;  all  of  these  symptoms  may 
be  present  in  the  advanced  case  of  exophthalmic 
goitre,  or  Graves's  disease.  Of  these,  the  pro- 
truding eyes,  the  appearance  of  fright,  and  the 
enlarged  thyroid  are  the  symptoms  which  attract 
the  physician  as  the  patient  enters  his  examining 
room  or  even  when  he  meets  such  a  person  on  the 
street.  We  must  always  keep  in  mind  the  ex- 
treme cases  of  hyperthyroidism  which  may  occur 
with  little  or  no  thyroid  enlargement.  Such  a  pa- 
tient always  has  decreased  sugar  tolerance ;  un- 
usual reaction  to  the  injection  of  adrenalin ;  is 
made  worse  by  taking  preparations  of  the  thyroid 
gland,  and  has  an  increased  metabolic  rate. 

Unfortunately,  many  or  all  of  the  symptoms  are 
present  before  active  treatment  is  considered, 
either  by  the  patient,  or  the  examining  physician. 
It  is  the  patient  in  this  condition,  showing  end  re- 
sults of  the  disease,  who  is  in  danger,  and  upon 
whom  surgical  operation  is  a  serious  procedure, 
and  upon  whom  the  recognized  medical  treatment  is 
so  frequently  a  failure.  It  is  a  condition  fairly 
comparable  to  that  of  a  patient  in  the  second  week 
of  an  active  appendicitis. 

A  condition  which  is  often  indistinguishable  from 
the  one  described,  which  demands  somewhat  the 
same  treatment,  occurs  in  the  hypertrophic  atoxic 
goitres,  as  described  by  Plummer  (3). 

\\\\y  do  patients  not  present  themselves  for 
treatment  before  reaching  this  extreme  condition? 
Why  are  they  not  treated  sooner? 

First,  because  patients  consider  themselves  nerv- 
ous, and  delay  treatment,  or  the  physician  to 
whom  they  apply  in  the  early  stage  of  the  disease 
considers  the  patient  as  neurasthenic,  as  having  an 
irritable  heart,  or  heart  disease,  until  the  unmis- 
takable signs  of  advanced  Graves's  disease,  exoph- 
thalmic goitre,  present  themselves. 


Copyright,  1920,  by  A.  R.  Elliott  Publishing  Company. 


206 


FUSSELL:  HYPERTHYROIDISM. 


[New  York 
Medical  Journal. 


Thanks  to  the  intensive  studies  of  Charles  Mayo, 
H.  S.  Plnmmer,  Louis  Wilson  and  Kendall  (4), 
the  condition  of  hyperthyroidism  and  other  condi- 
tions due  to  disturbance  of  the  thyroid  gland,  have 
been  brought  so  prominently  before  the  profession 
that  we  are  beginning  to  realize  the  condition  in 
its  early  stages,  and  hence  the  selected  treatment 
is  more  effectual  and  less  dangerous. 

A  short  description  of  some  of  the  later  labora- 
tory methods  which  help  in  the  differentiation  of 
these  conditions,  particularly  in  the  early  stage, 
seems  desirable  at  this  point.  Hereafter  they  will 
be  referred  to  as : 

1.  Increased  metabolic  rate;  2,  thyroid  feeding; 
3,  adrenalin  test,  Goetsch  test,  and  4,  decreased 
sugar  tolerance. 

INCREASED  :\IETABOLIC  RATE. 

Dubois  (5)  in  a  paper  on  the  Respiratory  Cal- 
orimeter in  Clinical  Medicine  says  that  the  normal 
average  basal  metabolism  is  34.7  calories  an  hour 
to  the  square  metre  of  the  surface  of  the  body. 
He  also  states  that  in  forty-four  cases  of  exoph- 
thalmic goitre,  the  increase  of  metabolism  is 
the  most  striking  effect  of  thyroid  activity,  and 
is  strictly  proportionate  to  the  activity  of  the 
disease. 

Means  and  Aub  (6)  state  that  in  224  observations 
on  toxic  goitre,  and  eighteen  cases  of  nontoxic 
goitre,  the  toxicity,  judged  clinically,  runs  nearly 
parallel  with  the  rise  in  metabolism.  I  believe  that 
the  estimation  of  the  metabolic  rate  of  a  patient  is 
the  most  accurate  laboratory  method  in  differenti- 
ating mild  cases  of  hyperthyroidism  from  conditions 
which  simulate  it.  The  great  drawback  at  present 
to  this  valuable  test  is  that  it  has  to  be  made  in  an 
institution  which  possesses  the  proper  apparatus  for 
the  work,  hence  it  is  not  as  practicable  as  the  second 
test — thyroid  feeding.  The  value  of  estimation  of 
the  metabolism  test  is  shown  in  the  following  im- 
portant case. 

Case  I. — Mrs.  L.  This  lady  was  sent  for  a  diag- 
nosis as  to  whether  an  evident  goitre  was  the  cause 
of  her  symptoms. 

Her  chief  complaint  was  palpitation  of  the  heart 
and  throbbing  of  her  neck,  she  had  headache,  was 
extremely  nervous,  had  gained  much  weight.  She 
was  in  the  midst  of  her  menopause ;  was  extremely 
neurasthenic.  She  had  had  a  goitre  for  several 
years.  She  had  tremor  and  attacks  of  diarrhea. 
Her  weight '  was  205  pounds.  There  was  an  en- 
larged thyroid  gland  which  was  rather  soft.  Auscul- 
tation over  the  gland  did  not  reveal  pulsation  or 
thrill  or  murmur.  There  was  a  slight  tremor  of 
her  hands.  Examination  of  her  heart  showed  a 
rate  of  about  100.  She  was  quite  hysterical.  Her 
blood  count,  except  for  a  slight  anemia,  was  normal, 
and  the  differential  count  was  normal.  Her  blood 
pressure  was  200  systolic  and  110  diastolic.  Her 
urine  was  normal.  Her  metabolic  rate  was  twenty- 
seven  calories  to  the  cubic  metre  of  her  body. 
This  latter  fact  caused  the  case  to  be  classed  as 
neurasthenia  accompanying  menopause,  and  not  one 
of  hyperthyroidism  which  it  simulated.  The  subse- 
quent history  of  the  case  showed  this  view  to  be 
correct. 


THYROID  FEEDING. 

It  is  generally  recognized  that  a  person  who  is 
suffering  from  an  increased  activity  of  the  thyroid 
gland  will  suffer  an  exacerbation  of  all  of  the 
symptoms  when  given  desiccated  thyroid  gland. 

Smith  (20)  used  this  test  in  the  examination  of 
thirty  cases  among  soldiers  at  .Fort  Travis,  Texas, 
with  the  idea  of  differentiating  between  this  condi- 
tion and  the  effort  syndrome.  Six  of  the  patients 
responded  to  the  test  and  were  diagnosed  upon 
thi«i  and  upon  other  grounds  as  having  hyperthy- 
roidism. Lewis  (10)  believes  that  cases  of  effort 
syndrome  are  not  due  to  hyperthyroidism  and  that 
use  of  thyroid  feeding  will  differentiate  between  the 
conditions. 

Case  II. — Several  years  ago  Miss  P.  was  seen 
with  Dr.  Merscher  of  Germantown,  Pa.  She  had 
not  been  well  for  five  or  six  years.  Violent  attacks 
of  gastric  pain,  with  much  diarrhea.  Her  pulse  was 
80  to  94.  Blood  pressure  135  diastolic  and  180 
systolic.  The  eyes  were  prominent ;  palpebral  an- 
gle wide.  The  thyroid  was  enlarged.  There  was 
much  muscular  tremor.  She  was  put  upon  thyroid 
feeding  with  an  immediate  exacerbation  of  her 
symptoms.  In  October,  1914,  the  upper  pole  of  the 
right  lobe  of  the  thyroid  was  ligated.  There  was  a 
temporary  improvement.  In  January,  1915,  the 
diarrhea  had  disappeared,  her  weight  was  118 
pounds,  there  was  much  perspiration.  On  May  10, 
1915,  she  was  nervous,  her  weight  was  still  118. 
A  ligation  of  the  other  lobe  was  done.  A  great 
improvement  followed.  On  October  10,  1919,  she 
weighed  134  pounds,  was  the  picture  of  health,  all 
signs  of  hyperthyroidism  had  disappeared. 

Smith  (20)  describes  a  method  of  thyroid  feed- 
ing as  follows : 

"The  men  were  put  to  bed  and  isolated  in  one  ^ 
end  of  the  ward.  Other  convalescent  patients  were 
instructed  not  to  disturb  them.  The  desiccated 
thyroid  gland  of  sheep  was  used,  Lilly  preparation. 
The  initial  dose  was  one  fourth  grain  morning  and 
evening.  This  dose  was  increased  one  fourth  grain 
each  day  and  was  continued  until  there  was  a  re- 
sponse or  the  patient  was  getting  five  grains  a  day. 
The  pulse  was  taken  four  times  a  day.  The  nurse 
was  instructed  to  take  the  pulse  whenever  possible 
when  the  men  were  asleep.  A  definite  increased 
pulse  rate  while  the  patient  was  asleep,  associated 
with  increased  nervousness  and  irritability,  was  re- 
garded as  a  positive  reaction,  and  the  thyroid  feed- 
ing was  discontinued. 

THE   GOETSCH    ADRENALIN  TEST. 

This  was  described  by  Goetsch  (7)  in  July,  1918. 

"On  the  day  of  the  test  the  patient  is  placed  as 
nearly  as  possible  under  normal  conditions.  By  this 
we  mean  in  a  warm  room  without  the  appliances 
such  as  hot  water  bottles,  heating  devices,  which  are 
common  in  the  outdoor  treatment  of  tuberculosis. 
The  patient,  of  course,  is  to  take  his  meals  in  bed. 
We  emphasize  these  precautions  because  of  the  well 
known  hypersensitiveness  and  irritability  of  hyper- 
thyroid  and  tuberculous  patients.  Because  of  the 
tendency  of  the  thyroid  to  hyperactivity  at  the 
menstrual  period,  the  test  is  not  given  during  this 
time. 


August  14,  1920.] 


FUSSELL:  HYPERTHYROIDISM. 


207 


"We  proceed  with  the  test  as  follows:  Two 
readings  are  taken,  at  five  minute  intervals,  of  the 
lilood  pressure,  systolic  and  diastolic,  pulse  rate  and 
respiration.  The  notes  are  made  of  subjective  and 
objective  condition  of  the  patient.  This  includes  the 
state  of  the  subjective  nervous  manifestations — the 
throbbing,  heat  and  cold  sensations,  asthenia,  and 
the  objective  signs  such  as  pallor  and  flushing  of 
the  hands  or  feet,  the  size  of  the  pupils,  throbbing  of 
the  neck  vessels,  and  precordial  tremor,  tempera- 
ture of  the  hands  and  feet,  perspiration  and  any 
other  characteristic  signs  or  symptoms  noticed. 
These  signs  are  all  noted  previous  to  the  injection 
of  the  adrenalin,  so  that  comparison  may  be  made 
after  the  injection. 

"A  hypodermic  syringe  armed  with  a  fine  needle 
which,  when  inserted,  causes  little  discomfort,  is 
then  used  to  inject  0.5  c.  c.  of  the  1/1000  solution 
of  adrenalin  chloride  into  the  deltoid  region,  sub- 
cutaneously.  Intramuscular  and  intravenous  in- 
jections are  not  given.  Readings  are  then  made 
every  two  and  a  half  minutes  for  ten  minutes,  then 
every  five  minutes  up  to  an  hour,  and  then  every 
ten  minutes  for  a  half  hour  longer.  At  the  end 
of  one  and  a  half  hours  the  reaction  has  usually 
entirely  passed  ofif,  sometimes  earlier.  The  repeated 
early  readings  are  made  in  order  not  to  miss  cer- 
tain reactions  on  the  part  of  the  pulse  and  blood 
pressure  that  may  come  on  in  less  than  five  minutes 
after  the  injection  is  made.  This  is  particularly 
true  of  cases  of  active  hyperthyroidism. 

"In  a  positive  reaction  there  is  usually  an  early 
rise  in  blood  pressure  and  pulse  of  over  ten  points ; 
ther^  may  be  a  rise  of  as  much  as  fifty  points  or 
even  more.  In  the  course  of  from  thirty  to  thirty- 
five  minutes  there  is  a  moderate  fall,  then  a  second 
slight  secondary  rise,  then  a  second  fall  to  the  nor- 
mal in  about  one  and  a  half  hours.  Along  with 
tliese  one  sees  an  exaggeration  of  the  clinical  picture 
of  hyperthyroidism  brought  out,  especially  the 
nervous  manifestations.  The  particular  symptoms 
of  which  the  patient  has  complained  are  usually 
increased,  and  in  addition  there  are  brought  out 
many  symptoms  which  have  been  latent.  Thus  it  is 
not  uncommon  to  have  extra  systoles  brought  out 
after  the  injection  of  the  adrenalin.  The  patient  is 
usually  aware  of  them,  and  may  tell  one  that  she 
has  felt  this  same  thing  a  year  or  two  previously, 
at  which  time  the  symptoms  of  the  disease  were 
more  active. 

"The  following  may  all  or  in  part  be  found ;  in- 
creased tremor,  apprehension,  throbbing,  asthenia, 
and  in  fact  an  increase  of  any  of  the  symptoms  of 
which  the  patient  may  have  complained.  Vaso- 
motor changes  may  be  present ;  namely,  an  early 
pallor  of  the  face,  lips  and  fingers,  due  to  vasomo- 
tor constriction,  to  be  followed  in  fifteen  or  thirty 
minutes  by  a  stage  of  vasodilation  with  flushing  and 
sweating.  There  may  be  a  slight  rise  of  tempera- 
ture and  a  slight  diuresis. 

"In  order  to  interpret  a  test  as  positive  we  have 
regarded  it  as  necessary  to  have  a  majority  of  these 
signs  and  symptoms  definitely  brought  •  out  or  in- 
creased." 

From  a  review  of  the  literature  it  would  seem 
that  this  reaction  is  practically  always  present  in 


hyperthyroidism,  but  that  it  may  occur  in  other 
conditions,  noticeably  in  the  effort  syndrome.  Pea- 
body  (13)  and  his  coworkers  examined  sixty-five 
soldiers  with  irritable  hearts  by  this  method  for 
the  presence  of  hyperthyroidism,  with  a  positive  re- 
sponse to  the  test  in  sixty  per  cent,  of  the  cases, 
a  doubtful  response  in  thirty  per  cent.,  and  a 
negative  response  in  ten  per  cent.  That  is,  there 
was  a  positive  result  from  the  adrenalin  test  in 
sixty  per  cent,  of  the  cases  which  did  not  show 
hyperthyroidism  by  other  tests.  Therefore,  the 
adrenalin  test  is  of  less  value  than  the  metabolic  rate 
or  thyroid  feeding.  According  to  the  article  from 
which  the  abstract  was  made,  however,  the  test  is 
never  positive  in  tuberculosis  alone. 

SUGAR  TOLERAXCE. 

For  a  long  time  it  has  been  known  that  patients 
with  exophthalmic  goitre  had  a  low  sugar  tolerance. 
Harriman  and  Hirschman  (8)  and  Wilder  and 
Sansum  believe  that  increase  of  thyroid  function 
is  accompanied  by  a  decrease  in  sugar  tolerance, 
and  these  authors  in  addition  express  the  opinion 
that  the  hypodermic  use  of  epinephrin  is  followed 
by  a  marked  hyperglycemia — sugar  will  appear  in 
the  urine  also  after  the  Goetsch  test.  This  test  is 
of  undoubted  value,  but  like  the  adrenalin  test  is 
probably  corroborative  and  not  absolute. 

Examination  of  the  blood. — Kocher  announced 
that  the  differential  count  was  of  considerable  value 
in  the  dififerentiation  of  hyperthyroidism,  while 
Plummer  (11)  in  the  tabulation  of  578  cases  of  ex- 
ophthalmic goitre,  found  that  while  the  neuro- 
philes  are  low  and  the  lymphocytes  high,  the  blood 
count  is  of  relatively  little  value  in  diagnosis. 

The  conditions  for  which  hyperthyroidism  in  any 
stage  may  be  mistaken,  or  which  may  be  mistaken 
for  hyperthyroidism,  are  numerous.  Among  them 
are:  1,  Neurasthenia;  2,  irritable  heart,  or  its  syn- 
onyms, effort  syndrome,  functional  papitation, 
3, _  organic  heart  disease;  4,  tuberculosis;  5,  inter- 
stitial nephritis;  6,  gastrointestinal  disturbances;  7, 
arthritis;  8,  local  conditions  of  the  eye,  and  9, 
hypertrophic  atoxic  goitre. 

Upon  decision  as  to  whether  the  patient  is  suf- 
fering from  one  or  another  of  these  conditions  the 
treatment  absolutely  depends.  A  differentiation  is 
therefore  necessary.  The  limit  of  time  which  can 
be  devoted  to  this  paper  will  of  necessity  demand 
a  rather  superficial  review.  Enough  will  be  at- 
tempted, however,  to  make  the  points  intelligible. 

DIFFERENTIATION  OF  HYPERTHYROIDISM. 

Neurasthenia  is  constantly  confused  with  hyper- 
thyroidism. The  most  serious  mistake  is  to  con- 
sider a  case  of  mild  hyperthyroidism  as  a  simple 
neurasthenia  until  the  patient  has  Graves's  disease 
in  a  well  advanced  form.  The  neurasthenic  may 
have  muscular  tremor  even  when  the  arm  is  held 
horizontally  with  the  fingers  spread  apart,  but  this 
tremor  is  intermittent,  and  is  not  continuous  as  in 
hyperth3-roidism. 

The  mental  characteristic  of  the  neurasthenic  is 
an  introspective  one,  and  not  the  alert  apprehensive 
mind  of  the  hyperthyroid  patient.  The  neurasthenic 
does  not  have  the  flushing  characteristic  of  dis- 
ease of  the  thyroid. 


208 


F  US  SELL :  HYPER  THVROIDISM. 


[New  York 
Medical  Journal. 


The  rapid  heart  of  the  neurasthenic  frequently 
becomes  slower  when  the  patient  is  recumbent  for  a 
short  time,  as  opposed  to  the  continuous  tachycardia 
of  the  hyperthyroid  patient.  The  heart  is  not  di- 
lated in  the  neurasthenic  individual  as  it  is  in  the 
moderate  or  advanced  hyperthyroid  patient. 

The  thyroid  of  the  neurasthenic  if  enlarged 
may  pulsate,  but  the  pulsation  is  evidently  transmit- 
ted from  the  vessels  below  the  gland  is  not  the  seat 
of  a  murmur,  or  a  thrill.  The  eyes  do  not  protrude, 
and  there  are  none  of  the  other  characteristic  eye 
symptoms. 

Increased  appetite  is  a  characteristic  of  hyper- 
thyroidism (14)  ;  the  neurasthenic  usually  has  a  loss 
of  appetite.  Finally,  the  neurasthenic  does  not 
respond  to  thyroid  feeding ;  the  metabolic  rate  is 
not  increased ;  the  Goetsch  test  is  not  positive,  and 
sugar  tolerance  is  normal. 

Irritable  heart. — This  is  a  condition  frequently 
seen  in  civil  practice,  and  was  first  described  by  Da 
Costa.  It  was  very  frequently  noticed  in  examina- 
tion of  draftees  by  draft  boards  and  by  the  cardiac 
boards  of  the  army,  1917-18.  It  is  characterized 
by  the  inability  to  withstand  exertion,  by  tachycardia 
which  is  increased  by  exercise,  by  a  soft  murmur 
over  the  apex  or  the  base,  which  may  disappear  on 
exercise,  and  by  muscular  tremor. 

These  symptoms  notoriously  resemble  those  of 
hyperthyroidism,  but  the  eye  symptoms  of  exoph- 
thalmic goitre  are  wanting,  the  thyroid  gland  is 
normal,  or  if  hypertrophied  is  not  the  seat  of  in- 
trinsic pulsation  or  thrill.  There  is  no  erythematous 
rash.  The  laboratory  signs  of  thyroid  feeding  and 
increased  metabolism  rate  are  wanting,  while  the 
adrenalin  test  may  be  present  in  sixty  per  cent,  of 
the  cases  (13),  and  the  sugar  tolerance  test  is  nega- 
tive except  in  rare  instances  (3). 

Organic  heart  disease,  particularly  mitral  sten- 
osis, is  frequently  mistaken  for  hyperthyroidism, 
and  the  opposite  mistake  is  often  made.  Close  at- 
tention to  the  actual  condition  of  the  heart,  the 
presence  of  a  confirmed  murmur  due  to  endocard- 
itis, the  charactertistic  murmur  of  mitral  stenosis, 
the  fact  that  the  rate  of  the  rapid  heart  of  organic 
heart  disease  is  reduced  upon  rest,  the  absence  of 
the  peculiar  alertness  of  hyperthyroidism  with  its 
wavelike  exacerbation  (14),  the  absence  of  the  eye 
symptoms,  the  negative  findings  in  the  four  labora- 
tory tests,  mark  the  case  as  one  of  organic  valvular 
disease. 

Myocarditis  in  older  persons  may  also  be  mistaken 
for  hyperthyroidism,  but  attention  to  the  actual  con- 
dition of  the  heart,  and  the  absence  of  characteristic 
symptoms  of  hyperthyroidism,  will  mark  the  case. 

The  following  case  shows  the  difficulties  some- 
times encountered  in  making  the  diagnosis. 

Case  II. — Mrs.  G.  S.,  wife  of  physician,  seen 
March  14,  1918.  Felt  weak,  no  cough,  no  dyspnea, 
but  palpitation  of  the  heart,  ner\'ous  spells,  vomit- 
ing in  the  morning,  bowels  rather  loose,  much  wor- 
ried, marked  tache,  no  exophthalmos  or  other  eye 
signs.  There  was  some  tremor  of  the  hands.  The 
thyroid  was  decidedly  enlarged,  but  there  was  no 
pulsation  or  thrill.  The  heart  dullness  reached  to 
one  inch  to  the  right  of  the  sternum,  the  nipple  line, 
and  the  upper  third  rib.  There  was  a  suspicion  of  a 


presystolic  murmur.  On  rest  in  bed  the  heart  dull- 
ness decreased,  the  presystolic  murmur  be- 
came very  evident,  the  thyroid  gland  decreased  in 
size.  The  progress  of  the  case  marked  it  as  a  true 
mitral  stenosis,  notwithstanding  the  first  appearance 
of  exophthalmic  goitre. 

Tuberculosis. — Symptoms  indicative  of  hyper- 
thyroidism may  frequently  complicate  certain  cases 
of  frank  tuberculosis,  or  cases  in  which  there  is  a 
suspicion  of  tuberculosis,  but  in  which  the  physical 
signs  are  not  marked.  Of  course  the  physical  ex- 
amination and  history  of  the  case  must  be  the  sheet 
anchors  in  making  a  diagnosis,  but  it  is  these 
borderline  cases  in  which  Goetsch  (7)  claims  so 
much  for  his  test.  He  says :  "It  should  be  men- 
tioned furthermore  that  the  adrenalin  hypersensi- 
tiveness  reaction  affords  us  a  means  of  early  diag- 
nosis of  hyperthyroidism  at  a  stage  before  the  dis- 
ease has  seriously  damaged  the  individual  or  per- 
haps incapacitated  him.  It  thus  allows  us  to 
appreciate  an  early  mild  hyperthyroid  element  in 
tuberculosis  should  the  two  diseases  exist  con- 
comitantly." 

It  is  in  these  cases  also  that  thyroid  feeding  and 
metabolic  rate  should  be  of  greatest  value. 

Interstitial  nephritis. — Barker  (15)  described  the 
presence  of  exophthalmos  in  interstitial  nephritis, 
and  calls  attention  to  the  danger  of  mistaking  certain 
cases  of  nephritis  for  hyperthyroidism.  The  con- 
stant high  blood  pressure,  polyuria  and  urinary  find- 
ings, and  the  absence  of  findings  of  hyperthyroidism 
other  than  the  eye  symptoms,  and  the  negative  find- 
ings, should  make  the  diagnosis  simple. 

Gastrointestinal  conditions. — In  rare  cases  of  hy- 
perthyroidism, the  outstanding  symptom  of  the  dis- 
ease, is  diarrhea.  The  following  case  illustrates 
this  condition  in  a  typical  way. 

C.\SE  III. — Mrs.  W.  For  years  had  an  intrac- 
table diarrhea.  She  appeared  for  treatment  Aug- 
ust 26,  1909,  with  the  following  complaints: 

Diarrhea  for  three  years,  eight  to  ten  bowel 
movements  a  day ;  lost  thirteen  pounds  in  two 
years;  always  nervous;  some  palpitation  of  the 
heart  and  some  dyspnea.  There  was  a  large  cystic 
goitre.  The  second  piilmonary  sound  was  accen- 
tuated. At  this  time  the  goitre  was  not  considered 
in  relation  to  her  diarrhea. 

On  May  3,  1913,  she  returned  with  evident  signs 
of  a  toxic  goitre,  including  diarrhea  and  arthritis. 
Her  elbows,  shoulders,  hands  and  feet  had  been  in- 
termittently painful  and  swollen  during  the  exist- 
ence of  the  goitre.  Since  the  removal  of  the 
goitre  five  years  ago  the  joint  pains  have  disap- 
peared and  never  returned. 

Her  goitre  was  removed  with  no  untoward  re- 
sults, and  the  condition  of  the  patient  immediately 
improved — the  diarrhea  and  arthritis  disappeared. 
In  1919  she  reappeared  at  the  office  having  gained 
thirty  pounds  and  was  the  picture  of  health. 

Arfliritis. — I  am  not  aware  that  arthritis  has  ever 
been  considered  as  a  symptom  of  hyperthyroidism, 
but  in  the  case  of  Mrs.  W.  and  Mrs.  T.  whose  his- 
tory follows,  in  both  instances  the  arthritis  dis- 
appeared with  the  removal  of  the  thyroid  gland. 
Whether  this  was  a  mere  coincidence  I  am  not  cer- 
tain, but  the  facts  are  accurate,  and  I  wish  to  put 


August  14,  1920.] 


FUSSELL:  HYPERTHYROIDISM. 


209 


them  on  record.  Unfortunately  there  is  no  note  as 
to  any  of  the  laboratory  methods,  and  therefore  one 
cannot  express  a  positive  opinion  as  to  whether  the 
hyperthyroidism  which  existed  intermittently  was 
the  cause  of  the  arthritis.  Certainly,  however,  the 
arthritis  disappeared  upon  the  removal  of  the  gland. 

Case  IV. — Mrs.  T.,  aged  thirty,  was  examined  by 
Dr.  Corson  of  Cynwyd,  January  15,  1915.  When 
she  was  thirteen  years  of  age  a  goitre  developed 
with  toxic  symptoms.  Tliis  attack  of  hyperthroid- 
ism  disappeared,  to  reappear  three  times  in  the  last 
seventeen  years.  For  the  past  twelve  years  has 
had  painful,  enlarged  joints  in  various  parts  of 
the  body ;  for  the  last  five  years  these  were  much 
worse,  until  now  she  is  an  invalid  from  the  painful 
joints,  arthritis  or  periarthritis. 

On  examination  she  had  a  large  goitre  which  ap- 
parently was  not  toxic  unless  her  arthritis  was  an 
indication  of  toxicity.  Her  joints  are  the  seat  of 
swelling,  pain  and  stiffness.  She  was  seen  by  Dr. 
Halstead,  of  Baltimore,  and  her  thyroid  was  re- 
moved. I  based  the  reason  for  the  operation  on 
the  fact  that  Mrs.  W.  who  had  had  arthritis  and 
hyperthyroidism  was  cured  of  the  arthritis  after 
thyroidectomy. 

A  letter  from  her  physician  dated  December  4, 
1919,  states  that  since  her  thyroidectomy  she  was 
completely  relieved  of  her  arthritis  and  muscular 
pains,  which  she  had  continuously  for  twelve  years. 

Local  conditions  of  the  eye  giving  rise  to  exoph- 
thalmos.— Such  conditions  might,  of  course,  give 
rise  to  the  appearance  of  hyperthyroidism,  but  the 
entire  absence  of  other  signs  would  negative  that 
diagnosis. 

Hypertrophic  atoxic  goitre. — Whenever  a  case  of 
simple  hypertrophic  goitre  presents  itself,  the  ques- 
tion as  to  its  toxic  character  must  always  be  taken 
into  consideration.  An  atoxic  goitre  is  entirely  void 
of  all  of  the  symptoms  of  hyperthyroidism.  The 
fact  that  in  the  patient  there  may  later  develop  toxic 
symptoms,  so  well  described  by  Dr.  H.  S.  Plummer, 
must  always  be  taken  into  consideration. 

As  a  diagnostic  sign  between  a  hypertrophic 
atoxic  goitre  in  which  there  develops  toxic  symp- 
toms, and  a  toxic  hyperplastic  goitre,  true  Graves's 
disease,  H.  S.  Plummer  cites  figures  to  show  that 
the  hypertrophic  goitre  develops  symptoms  after  an 
interval  of  fourteen  and  a  half  years,  while  the 
true  exophthalmic  goitre  is  observed  only  nine 
tenths  of  a  year  before  the  toxic  symptoms  (13). 

It  will  be  seen  that  while  there  are  a  number  of 
conditions  which  simulate  hyperthyroidism  the  chief 
difficulties  in  differentiation  occur  in  the  early 
stages.  It  is  scarcely  possible  to  mistake  a  well  de- 
veloped case  of  exophthalmic  goitre  for  any  other 
condition,  and  the  opposite  mistake  is  likewise  un- 
likely to  'occur.  It  therefore  is  important  that  all 
of  us  have  in  our  minds  the  possibility  of  making 
mistakes  in  the  early  stages,  and  do  all  we  can  to 
avoid  them.  The  laboratory  methods  which  have 
been  described  are  of  the  utmost  value  in  differen- 
tiating difficult  cases,  especially  the  metabolic  rate 
which  is  always  increased  in  exophthalmic  goitre. 

TREATMENT. 

Unfortunately  the  ultimate  cause  of  hyperthy- 
roidism is  not  yet  certain.    The  researches  of  Can- 


non (16)  and  Wilson  (17)  point  to  some  irritation 
of  the  sympathetic  as  the  possible  actual  cause. 
Certainly  Cannon  has  proved  that  the  nerve  supply 
of  the  thyroid  is  from  the  sympathetic,  and  Wilson 
has  found  that  "certain  bacteria  may  cause  histologi- 
cal pictures  in  the  sympathetic  ganglia  and  in  the 
thyroid  gland  which  parallel  those  found  in  pro- 
gressive and  regressive  exophthalmic  goitre." 

For  these  reasons,  and  due  to  the  fact  that  we 
are  attributing  many  general  conditions  to  local  in- 
fections (frequently  I  believe  without  sufficient 
grounds,  especially  many  teeth  and  numerous  ton- 
sils are  removed  without  sufficient  grounds),  the 
search  for  tooth  abscesses,  infected  foci  in  tonsils, 
and  other  localities  should  be  made.  If  found  they 
should  be  corrected  in  order  that  we  may  do  pos- 
sible good,  and  in  order  that  we  may  not  later  ac- 
cuse ourselves  of  negligence. 

Kendall's  (2)  epoch  making  investigations  appear 
to  prove  that  the  iodine  containing  compound,  thy- 
roxin, is  the  positive  cause  of  the  toxic  symptoms 
found  in  hyperthyroidism,  whether  it  is  that  of 
true  exophthalmic  goitre,  or  the  toxic  symptoms  in 
cases  of  hypertrophic  atoxic  goitre.  Hence  meas- 
ures both  medical  and  surgical  which  will  pre- 
vent the  increase  and  absorption  of  this  substance 
must  be  adopted. 

Perhaps  it  is  the  uncertainty  of  the  cause  which 
causes  so  many  and  often  opposite  views  as  to 
method  of  treatment.  Still  more  likely  the  different 
methods  of  treatment  may  be  due  to  the  fact  that 
in  many  cases  of  hyperthyroidism,  and  even  in  some 
cases  of  well  developed  exophthalmic  goitre  the 
symptoms  disappear  and  the  patients  entirely  re- 
cover without  any  accurately  directed  treatment. 
Whatever  methods  have  been  used  in  these  cases 
are  heralded  as  a  cure. 

The  positive  knowledge  which  we  now  possess 
that  the  iodine  containing  compound,  thyroxin,  is 
the  cause  of  the  toxic  symptoms  (18)  puts  us  on 
firm  ground  from  which  we  may  direct  our  treat- 
ment, for  whatever  the  cause  of  the  hypersecretion 
of  this  substance,  we  know  that  long  continued 
secretion  will  lead  to  invalidism  and  death. 

The  problem  then  is,  what  is  the  best  treatment 
for  the  condition  of  hyperthyroidism?  Discussion 
of  this  most  important  phase  of  the  subject  must  in- 
clude the  socalled  medical  treatment,  surgery,  ront- 
gen  ray,  and  injection  methods. 

The  physician  who  recognizes  that  there  is  no 
one  plan  of  treatment  for  all  patients,  is  the  safest 
one  for  the  patient,  because  he  is  the  one  most  likely 
to  bring  about  a  cure  of  the  condition.  Some  pa- 
tients are  fit  for  one  kind  of  treatment  alone, 
others  demand  the  combination  of  two  or  more 
forms  of  treatment.  The  knowledge  and  ability  to 
select  the  proper  patient  for  a  special  treatment 
or  combination  of  treatments  is  the  acme  of  attain- 
ment. Each  one  of  us  must  bring  all  the  knowledge 
we  have  to  bear  upon  each  case.  A  careful  study 
should  be  made  of  each  case  and  all  of  the  possibili- 
ties considered. 

The  subject  of  treatment  is  best  considered  by  in- 
cluding hypertrophic  atoxic  goitre  or  simple  col- 
loidal goitre,  and  thyroid  enlargement  common  at 
the  age  of  puberty,  with  that  of  toxic  goitres. 


210 


FUSSELL:  HYPERTHYROIDISM. 


[New  York 
Medical  Journal. 


HYPERTROPHIC  ATOXIC  GOITRES. 

Much  discussion  of  this  subject  has  taken  place. 
The  use  of  iodine  in  minute  doses  has  been  recom- 
mended, and  other  drugs  without  number,  but  in 
my  opinion,  based  on  experience  and  upon  the  ht- 
erature,  surgery  is  the  treatment  of  choice  of  non- 
toxic, long  standing  goitres.  Certainly  all  goitres 
which  are  increasing  in  size,  all  which  have  not  re- 
sponded to  small  doses  of  iodide  of  potassium,  one 
grain  three  times  a  day,  all  which  are  giving  pres- 
sure symptoms,  all  which  are  the  seat  of  tumors, 
should  be  removed.  As  one  reason  for  removing 
all  large  goitres,  Balfour's  statistics  may  be  quoted. 

Cancer  of  the  thyroid  according  to  Balfour  (19) 
occurred  in  103  cases  of  6,359  cases  operated  in 
the  Mayo  Clinics,  with  a  mortality  of  six  per  cent, 
from  operation,  forty-seven  and  six  tenths  per  cent, 
early  recurrence,  eleven  per  cent,  are  living,  a  total 
of  sixty-five  and  six  tenths  per  cent.  This  arbitrary 
view  from  an  internist  comes  from  the  practical  lack 
of  mortality  in  operation  of  simple  goitres,  and  the 
decided  risk  of  toxic  symptoms  and  malignancy  in 
long  standing  simple  goitres,  as  well  as  the  decided 
uselessness  of  any  medical  treatment  with  which  he 
is  familiar. 

GOITRES  WHICH  APPEAR  AT  PUBERTY. 

These  patients  should  be  given  either  small  doses 
of  iodide  or  let  alone,  as  in  the  experience  of 
everyone  those  enlargements  usually  disappear  as 
the  person  becomes  older.  Of  course  if  the  goitres 
become  toxic  or  undergo  changes  which  render 
them  dangerous,  they  should  be  removed. 

HYPERTHYROIDISM    AND    EXOPHTHALMIC  GOITRES. 

Four  methods  of  treatment  will  be  discussed : 
First,  rest;  second,  rontgen  ray;  third,  surgery; 
fourth,  injection  methods. 

Means  and  Aub  (6)  have  made  some  useful  ob- 
servations on  the  influence  of  the  metabolism  rate 
by  single  and  combined  treatments  of  the  above 
methods.  Their  conclusions  are :  a,  rest  alone  usu- 
ally causes  a  marked  decrease  in  toxicity ;  b,  drugs 
in  addition  to  rest  do  not  materially  accelerate  the 
decrease  of  toxicity ;  c,  the  rontgen  ray  in  some 
cases  produces  a  decided  improvement,  while  in 
others  it  has  no  effect ;  d,  the  usual  immediate  effect 
of  surgery  is  a  marked  decrease  of  toxicity  but 
there  is  a  very  definite  tendency  to  recurrence. 

Rest. — All  patients  with  mild  hyperthyroidism 
should  at  once  be  put  upon  rest  treatment.  This 
should  as  nearly  as  possible  approach  in  detail  the 
principles  long  since  recommended  by  Weir  Mit- 
chell for  neurasthenia.  The  patient  must  be  away 
from  home,  in  bed,  in  the  hands  of  a  competent 
nurse,  and  be  given  superalimentation.  The  treat- 
ment at  home  cannot  be  considered  except  as  a 
makeshift.  The  father  or  mother  cannot  possibly 
separate  themselves  from  their  many  worries  when 
surrounded  by  familiar  scenes  and  sounds.  The 
ordinary  medical  ward  must  also  be  considered  a 
makeshift,  as  pointed  out  by  Alfred  Stengel  in  a 
discussion  at  a  recent  meeting  of  the  Medical  Ses  - 
sion of  the  College  of  Physicians  of  Philadelphia. 

Many  of  the  patients  with  beginning  hyperthy- 
roidism will  respond  to  a  properly  conducted  rest 
treatment,  and  will  go  on  to  complete  cure.  Re- 


sponse occurs  occasionally  even  with  the  makeshift 
trials. 

The  rest  is  particularly  important  in  cases  which 
occur  as  the  apparent  result  of  extreme  fright,  ex- 
citement and  nervous  strain.  The  removal  of  these 
apparent  exciting  causes  in  certain  cases  of  Graves's 
disease  will  often  be  all  that  is  necessary  to  bring 
about  a  cure.  Rest  is  also  imperative  in  the  very 
toxic  cases  before  thought  of  operation  is  enter- 
tained. 

The  following  case  is  an  example  of  what  rest 
and  change  of  surroundings  will  do. 

Case  V. — Mrs.  M.  B.,  New  York,  on  September 
11,  1914,  complained  of  diarrhea  without  assignable 
cause.  There  was  no  abnormality  of  the  heart, 
blood  vessels  or  thyroid.  During  March,  1915, 
she  complained  of  cardiac  palpitation  and  some 
tremor.  The  heart's  action  was  tumultuous.  There 
was  no  enlargement  of  the  thyroid.  The  next  week 
the  tumultuous  action  of  the  heart  with  tremor  of 
the  hands  was  still  present.  During  July,  1915,  she 
had  much  less  tremor  and  cardiac  palpitation.  For 
the  first  time,  the  enlargement  of  the  thyroid  was 
noticed.  Before  this  the  true  character  of  the  disease 
was  not  recognized.  Her  eyes  were  prominent. 
There  was  a  tremor  of  the  hands,  fullness  of  the 
thyroid,  which  pulsated  and  was  the  seat  of  a  to 
and  fro  murmur.  The  heart  was  enlarged  to  the 
left. 

She  was  sent  away  from  the  family  to  Atlantic 
City  and  kept  at  rest,  and  belladonna  was  admin- 
istered. In  two  months  she  was  much  improved. 
The  neck  had  decreased  four  centimetres  in  cir- 
cumference. Five  months  later  (after  seven 
months  at  the  seaside)  there  was  no  cardiac  palpi- 
tation, the  pulse  was  88  and  she  had  gained  twelve 
pounds  in  weight.  There  were  no  signs  of  the  ex- 
ophthalmos which  was  so  prominent  in  July,  1915. 

It  will  be  seen  that  in  this  patient  after  the  use 
of  belladonna  and  her  separation  from  all  her  for- 
mer surroundings,  all  the  symptoms  disappeared. 
On  January  5,  1920,  her  husband  reported  her  as 
entirely  well. 

Of  drugs,  belladonna  given  in  full  doses  to  the 
physiological  limit,  bromide  of  potassium  in  ten  to 
fifteen  grain  doses  three  times  a  day  to  quiet  the 
patient,  veronal  at  night  the  first  few  days  to 
procure  sleep,  and  morphine  hypodermically  in  pa- 
tients who  are  highly  toxic,  are  helpful  and  often 
efficient.  But  the  use  of  this  method  of  rest  and 
drugs  must  not  be  persisted  in  if  the  symptoms 
are  not  distinctly  ameliorated  after  a  period  of  ob- 
servation, differing  in  each  case.  Surely  surgery 
must  be  used  if  the  patient  does  not  improve  in  a 
few  weeks.  The  patient  should  not  be  allowed  to 
drag  on  in  a  condition  of  no  improvement. 

Charles  Mayo  repeatedly  calls  attention  to  the 
fact  that  the  operation  for  toxic  goitre  is  not  an 
emergency  one.  We  all  know  that  the  chief  danger 
in  surgery  in  hypothyroidism  is  in  its  employment  in 
patients  who  are  highly  toxic.  We  are  also  aware 
that  before  surgery  is  employed  in  patients  with 
very  toxic  goitres,  the  metabolism  rate  must  be  re- 
duced by  rest,  drug  treatment,  and  possibly  by  the 
use  of  the  rontgen  ray. 

Without  personal  experience  in  the  use  of  x  ray. 


August  14,  1920.] 


FUSSELL:  HYPERTHYROIDISM. 


211 


but  basing  my  opinion  on  the  work  of  Pfahler,  Pan- 
coast  and  Manges,  I  believe  that  in  selected  cases 
of  great  toxicity,  and  in  patients  suitable  for  sur- 
gery, but  who  will  not  submit  to  this  treatment,  the 
rontgen  ray  will  be  of  use  if  it  is  applied  by  an 
expert  but  it  is  highly  dangerous  if  not  applied 
according  to  well  known  safeguards.  Not  every 
man  who  runs  an  x  ray  machine  is  competent  to 
treat  toxic  goitres,  any  more  than  every  man  who 
can  wield  a  scalpel  is  competent  to  ligate  the  ves- 
sels or  resect  a  thyroid  gland  affected  by  thyroid 
hyperactivity. 

I  am  not  a  surgeon,  and  hence  cannot  give  any 
direct  advice  as  to  how  to  do  a  thyroid  operation. 
But  being  an  internist  I  can  have  an  opinion  as  to 
which  operations  have  been  of  the  greatest  value 
to  my  patients.  First  as  to  the  method  of  Crile  in 
the  use  of  anociassociation. 

I  have  seen  patients  treated  by  the  expert  use  of 
this  method  at  the  hands  of  Dr.  Charles  Frazier, 
have  the  thyroid  resected  or  the  vessels  ligated  and 
the  patient  leave  the  hospital  without  the  knowledge 
that  an  operation  had  been  performed.  Surely  a 
method  which  will  relieve  the  patient  of  the  worry, 
the  fright,  and  the  distress  caused  by  the  thought 
of  an  operation,  is  of  the  greatest  value.  It  fails  in 
the  hands  of  many  because  the  surgeon  does  not 
realize  or  carry  out  the  necessary  details. 

In  every  severely  toxic  case,  the  patient  must  be 
given  a  thorough  rest  cure,  with  proper  drugs,  and 
perhaps  the  use  of  the  x  ray  until  the  patient  is 
as  much  improved  as  possible.  Even  ligation,  as 
usually  performed,  is  sometimes  dangerous.  I  have 
seen  severe  exacerbation  and  occasionally  death 
follow  ligation. 

The  following  technic  is  described  by  Charles 
Mayo  (21)  and  is  quoted  as  the  best  and  usual 
method : 

"Greater  operative  experience  upon  cases  of  hy- 
perthyroidism has  led  to  a  great  reduction  in  mor- 
tality. This  has  come  about  through  many  changes 
in  the  earlier  operation,  better  operative  technic, 
more  careful  preparation  of  the  patients,  choosing 
the  operation  to  suit  the  case,  and  the  graduated 
operation. 

"Operation. — A  transverse  incision  gives  the  best 
working  space  as  well  as  the  least  disfiguring  scar. 
It  is  made  two  and  a  half  inches  in  length,  crossing 
the  central  part  of  the  thyroid  cartilage.  The  in- 
cision should  be  made  in  a  natural  skin  crease  if 
possible,  and  should  include  the  platysma  myoides, 
this  one  incision  being  better  than  two  lateral  ones. 
The  inner  border  of  the  sternomastoid  is  tracted 
laterally.  This  exposes  the  omohyoid  muscle  which 
is  tracted  up  and  in  toward  the  midline.  Beneath 
this  muscle  is  the  upper  pole  of  the  gland  with  the 
superior  thyroid  artery  and  vein. 

"The  ligating  material  is  linen  passed  by  an 
aneurysm  needle.  Should  a  vein  be  pierced  and  a 
hemorrhage  follow  the  placing  of  the  ligature,  it  is 
tracted  upon  and  a  second  loop  is  passed  around 
including  more  tissue." 

There  are  certain  patients  who  are  so  desperately 
ill  that  surgical  intervention  is  full  of  danger,  but 
where  a  delay  seems  certainly  fatal.  Dr.  A.  C. 
Wood  has  performed  the  operation  of  ligation  un- 


der such  conditions  with  the  result  of  great  improve- 
ment, allowing  later  on  a  partial  thyroidectomy  and 
the  cure  of  the  patient. 

I  have  had  Dr.  Wood  put  down  his  method.  His 
note  I  quote  in  full : 

"Assuming  a  condition  of  extreme  thyroidism  in 
which  medical  measures  have  failed  to  relieve  the 
urgent  symptoms,  and  in  which  it  is  necessary  to 
promptly  reduce  the  thyroid  activity,  the  control 
in  the  circulation  of  the  gland  suggests  itself  as  one 
of  the  most  promising  measures.  This  can  be  ac- 
complished by  ligating  one  or  more  of  the  four 
principal  arteries  supplying  the  gland.  It  is  usually 
advisable  to  tie  one  or  both  superior  thyroid  ves- 
sels, as  they  are  more  accessible.  The  operation  is 
a  simple  one,  and  may  easily  be  done  with  local 
anesthesia.  A  two  inch  incision  along  the  anterior 
border  of  the  sternocleidomastoid  muscle,  through 
skin  and  platysma,  exposes  the  muscle.  The  deep 
fascia  is  incised  in  the  same  line,  the  sternomastoid 
gently  retracted  outward,  which  exposes  the  sheath 
of  the  great  vessels.  The  sheath  is  opened  and  the 
vessel  sought  is  readily  found  just  above  the  bifur- 
cation of  the  common  carotid  artery.  The  ligature 
should  be  of  thread  rather  than  of  catgut. 

"In  many  cases  not  a  single  vessel  is  divided  that 
needs  a  ligature,  and  it  is  rarely  necessary  to  tie 
more  than  one  or  two  bleeding  points.  No  drainage 
is  required. 

"This  technic  may  be  carried  out  without  the 
least  trauma  or  interference  with  the  thyroid  gland, 
without  any  general  anesthesia,  and  hence  without 
adding  any  additional  burden  to  the  load  the  patient 
is  already  struggling  with.  If  both  vessels  have 
been  tied,  the  blood  supply  to  the  gland  has  been 
reduced  by  half.  In  the  most  extreme  cases,  it  may 
be  desirable  to  ligate  but  one  vessel  at  a  time." 

So  many  modifications  of  the  original  suggestion 
of  arresting  a  part  of  the  blood  supply  to  the  gland 
have  been  made  and  carried  out,  that  one  reading 
the  literature  might  be  in  doubt  as  to  just  what  is 
intended  by  the  term  ligation. 

The  following  case  illustrates  the  extreme  illness 
of  some  of  these  patients,  in  which  any  increase 
of  metabolism  would  seem  to  be  quickly  fatal,  and 
in  which  the  method  of  ligation  employed  by  Wood 
is  highly  advantageous.  It  is  jlist  such  cases  or  even 
less  dangerous  ones  in  which  x  ray  may  be  used. 

Case  VI. — Mrs.  C,  aged  thirty-five.  Seen 
with  Dr.  W.,  Hightstown,  N.  J.,  July  18,  1919.  For 
many  years  she  had  recognized  a  goitre  which  had 
given  her  no  trouble  except  from  its  appearance 
and  size.  There  was  no  pulsation  inherent  in  the 
gland  and  there  was  no  murmur  except  as  trans- 
mitted. Marked  exophthalmos  was  present ;  the 
pulse  was  135 ;  heart  dilated  and  a  murmur  over 
the  body  of  the  heart ;  blood  pressure  160  and  80. 
Seen  December,  1915,  there  was  distinct  loss  of 
health,  dyspnea,  pulsation  of  the  vessels,  and  pal- 
pitation of  the  heart.  On  July  14,  1918,  there  was 
sudden  severe  vomiting,^  diarrhea  and  rapid  emacia- 
tion. The  patient  seemed  at  death's  door.  She  was 
put  on  more  strict  rules  of  rest,  a  nurse  was  ob- 
tained, but  the  symptoms  gradually  increased  in 
severity.  At  the  end  of  this  period,  Dr.  Wood  tied 
both  superior  thyroid  arteries  with  almost  imme- 


212 


HUBBARD: 


IXDUSTRIAL  MEDIC  I XE. 


[New  York 
Medical  Journai- 


diate  improvement.  In  six  months  there  was  a  re- 
turn of  the  symptoms  of  hyperthyroidism.  The 
right  lobe  and  isthmus  were  removed.  Since  then 
the  patient  has  regained  her  health. 

As  to  the  question  of  choice  between  ligation  and 
resection.  The  rule  that  seems  best  is  first  ligation 
of  one  or  both  arteries  in  every  severe  case,  then 
ligation  of  the  pole,  then  a  partial  resection.  It  is 
better  to  do  too  little  than  too  much.  A  second  op- 
eration can  be  done.  A  patient  cannot  be  recalled 
from  the  grave. 

INJECTION  METHODS. 

I  have  not  had  experience  with  these  methods, 
but  with  access  to  certain  methods  of  surgery, 
injection  seems  cumbersome  and  uncertain.  The  fol- 
lowing succinct  plan  may  be  followed  in  treating 
hyperthyroidism  with  the  minimum  of  fatality : 

First.  An  early  diagnosis  is  imperative  b}-  the 
methods  here  detailed. 

Second.  Every  patient  should  be  put  to  rest  in 
order  to  reduce  the  metabolism  rate.  Many  patients 
will  be  cured  rby  this  means. 

Third.  Patients  who  cannot  give  the  time  to  a 
thorough  trial  of  rest  should  be  operated  upon  early, 
after  a  partial  rest. 

Fourth.  Patients  who  are  very  toxic  must  al- 
ways be  put  at  rest  and  given  other  appropriate 
treatment  before  any  form  of  surger}^  is  attempted. 

Fifth.  If  patients  fail  to  improve  under  rest, 
ligation  should  be  done,  or  the  rontgen  ray  should 
be  used  tentatively  to  reduce  the  metabolism  rate, 
until  a  resection  can  be  done. 

Sixth.  In  ven,-  severe  cases  in  which  the  patients 
appear  to  be  approaching  death,  and  the  x  ray  can- 
not be  used,  a  ligation  after  the  method  of  Wood 
may  be  done. 

The  writer  thoroughly  believes  that  in  patients 
who  do  not  promptly  respond  to  rest,  surgery  by 
all  odds  is  the  proper  procedure. 

INDUSTRIAL  MEDICINE.* 

Its  Proper  Relation  to  Industry. 

By  S.  Dana  Hubbard,  M.  D. 
New  York. 

Fundamentally,  the  science  of  medicine  is  applic- 
able to  industry^  for  its  principes  may  be  applied  to 
the  selection  and  assignment  of  applicants  for  work, 
to  the  supervision  of  laborers  when  at  work,  that 
they  may  produce  with  greatest  effectiveness  and 
with  least  harm  to  the  individual  worker.  Labor 
may  be  controlled  scientifically ;  the  principles  of  the 
prevention  of  accidents  and  of  illnesses  ma}^  be  prac- 
tically applied,  so  that  production  may  not  be  dimin- 
ished by  injur}^  unnecessaril}^  inflicted  upon  workers 
or  these  laborers  made  ill  and  unable  to  work,  thereby 
causing  loss  of  time,  waste  of  material  in  the  raw 
product  and  unnecessar}'  expense  to  the  producer. 

Industrial  medicine  in  practical  application  must 
naturally  be  a  compromise  between  the  ideal  and  the 
commonplace,  the  medical  ideal  being  that  medical 
service  in  industry  to  be  of  the  greatest  possible  use- 
fulness  must   primarily   benefit   the   worker  and 

*Read  before  the  Academy  of  Pathological  Science,  New  York, 
April  23,  1920. 


through  increased  capacity,  ability  and  usefulness 
react  to  the  benefit  of  industry  and  through  these 
to  public  health.  The  policy  of  good  management 
is  to  assist  workers  to  the  greatest  possible  degree 
of  production,  and  to  do  this  successfully  workers 
must  be  selected,  assigned,  tried  out,  intensively 
trained,  and  compared  so  that  those  best  suited  may 
be  employed.  Once  employed  their  work  should  be 
supervised  in  order  that  they  may  continue  to  per- 
form the  maximum  of  work  with  the  least  possible 
wear,  much  the  same  as  does  the  machine  when  prop- 
erly adjusted  and  working  at  its  highest  efficiency 
under  intelligent  supervision. 

THE  DUTY  OF  EMPLOYER  TO  HIS  EMPLOYEES. 

Generally  speaking,  it  is  the  duty  of  the  manage- 
ment to  provide  for  the  worker  the  following  essen- 
tials :  1,  A  safe,  healthy  place  in  which  to  work  and 
which  is  kept  clean  and  well  ventilated ;  2,  tools,  ma- 
chinery, and  methods  which  permit  of  rapid  work  of 
good  quality;  3,  careful,  competent  and  helpful 
supervision ;  4,  if  work  is  monotonous,  exhausting, 
or  requires  concentration,  time  for  rest  and  recrea- 
tion ;  5,  opportunities  for  education  and  advance- 
ment ;  6,  fair  and  adequate  wages  with  regular  pay- 
ments ;  7,  medical  and  nursing  supervision,  with  in- 
struction on  how  to  keep  well  and  avoid  injuries ;  8, 
special  facilities  for  training  inexperienced  workmen ; 
9,  reduction  of  all  hazards  to  the  minimum ;  10,  en- 
couragement of  thrift,  domesticity,  morality,  and 
sobriety.  The  fulfillment  of  these  duties  makes  em- 
ploj-ers  expect  that  their  workers  will  be  healthier, 
happier,  their  services  more  stable,  and  production 
at  the  maximum  of  capacity.  These  results  are  ben- 
eficial to  the  worker,  to  the  manufacturer  and  to 
the  public. 

THE  DUTY  OF  THE  EMPLOYEE  TOWARDS  HIS  EMPLOYER 

1 ,  That  he  shall  be  interested  and  enthusiastic  about 
his  job ;  2,  that  he  shall  be  loyal  to  his  work  and 
exert  every  possible  effort  to  have  others  so ;  3,  that 
he  shall  give  a  full  day's  labor  for  a  day's  pay;  4, 
that  he  shall  conserve  material,  prevent  waste,  be 
honest,  and  play  fair ;  5,  that  he  shall  report  dangers 
of  all  kinds,  whether  it  is  his  duty  or  the  duty  of 
another ;  6,  that  he  shall  take  due  precaution  to  aid 
his  fellow  worker  and  prevent  sickness  or  accident ; 
7,  that  he  shall  willingly  and  cheerfully  cooperate 
best  to  serve  his  employer  and  aid  his  fellow  workers. 

health  and  INDUSTRY. 

Employers  are  beginning  to  realize  that  the  sub- 
ject of  health  vitally  concerns  their  industrial  prob- 
lems. Industrial  medical  and  surgical  supervision 
of  work  is  essential  in  order  to  produce  efficiently, 
as  capacity  depends  probably  more  largely  on  the 
physical  and  mental  condition  of  the  workmen  than 
on  any  one  single  factor.  To  reduce  hazards,  espe- 
cially those  which  occasion  illness  or  injury,  re- 
quires medical  attention.  If  we  are  to  secure  and 
maintain  high  efficiency  in  a  working  force  both 
health  and  safety  must  receive  necessary  and  proper 
consideration. 

The  first  step  in  the  conservation  of  energy  and 
health  is  to  learn  the  facts  of  the  physical  condition 
of  the  workmen.  False  modesty  and  sham  must  be 
turned  aside  and  those  industrially  employed  taught 


August  14,  1920.] 


HUBBARD:  INDUSTRIAL  MEDICINE. 


213 


how  to  live  good  clean  lives,  employers  must  be 
taught  the  error  of  overdriving  workers  to  the  point 
of  exhaustion,  the  public  made  to  stop  exploiting 
labor,  and  profiteering  eliminated. 

THE  FACTOR  OF  PREVEXTIOX  AXD  EDUCATIOX. 

Individual  plants  often  have  accidents  which  cost 
both  money  and  lives.  ^Many  of  these  manufacturers 
are  indiiterent  because  they  are  protected  from  loss 
by  insurance.  The  man  who  is  ignorant  of  the  cause 
of  these  conditions  thinks  that  by  posting  bulletins 
he  may  remove  the  cause.  He  hopes  that  people  will 
remember  his  words  and  their  safety  but  he  permits 
the  hazards  to  remain  instead  of  accepting  the  prin- 
ciple, "Conditions  shall  be  such  that  workmen  may 
pursue  safely  their  normal  activities  without  abnor- 
mal care."  There  is  no  use  talking  in  high  brow 
phrases  and  then  neglecting  essentials.  The  wise  and 
prudent  man  knows  what  are  the  prolific  causes  of 
both  sickness  and  accident  and  governs  his  actions 
accordingly.  Workmen  are,  as  a  rule,  unaware  of 
these  and  it  is  necessary  that  they  be  apprised  by 
repeated  cautioning,  by  careful  education  and  by 
proper  protection. 

THE  IXDUSTRIAL   MEDICAL  OFFICER. 

To  reiterate,  medical  aid  almost  specifically  con- 
cerns industry.  It  is  not  sufficient  simply  to  have 
a  dispensary  in  the  plant  with  hours  for  advising  or 
treating  such  employees  as  may  from  time  to  time 
need  medical  advice,  or  to  have  first  aid  applied. 
Industrial  medicine  demands  not  only  a  knowldege  of 
the  human  body,  a  knowledge  of  the  conditions  which 
impair  it,  as  well  as  the  means  for  restoration  when 
impaired,  but  also  the  more  necessary  measures  that 
will  enable  workmen  to  reach  and  maintain  their 
greatest  capacities  for  good  work.  The  ability  of 
medical  officers  to  participate  in  this  plan  establishes 
the  logical  relation  of  medicine  to  industry. 

Since  the  value  of  medical  service  will  be  measured 
by  its  effect  on  production,  the  most  useful  industrial 
medical  departments  are  those  best  able  to  avoid  ac- 
cident and  prevent  absence  incident  to  illness 
which  means,  loss  of  time,  unnecessary  expense  to 
both  management  and  worker,  as  well  as  increased 
labor  turnover,  diminished  production,  and  in  fre- 
quent instances  waste  of  material.  The  human  ele- 
ment must  be  known  and  evaluated.  The  long  way 
is  the  safe  way,  but  it  io  the  short  way  which  usually 
is  taken  and  is  the  dangerous  way  because  human 
nature  loves  to  take  a  chance.  Managements  and 
labor  both  seem  today  to  object  to  the  long  way.  If 
time  is  so  essential  a  factor  that  the  long  way  must 
be  sacrificed,  how  can  labor  be  speeded  up  without 
actually  occasioning  a  breakdown  or  heating  up  of 
the  human  mechanism? 

This  is  the  problem  of  the  medical  officer  of  the 
plant.  A  man  applies  for  the  position  of  watchman. 
This  applicant  has  flat  feet,  but  no  physical  examina- 
tion is  made  and  so  every  one,  even  the  applicant 
himself,  is  unaware  of  the  defect.  In  time,  however, 
he  finds  walking  painful  and  instead  of  walking  and 
watching,  he  sits  and  eases  himself,  neglecting  his 
duty,  and  giving  opportunity  for  depredation  by 
thieves  with  attending  loss  of  property.  This  is 
the  forbidden  way  and  the  inevitable  happens.  The 
workman's  neglect  is  discovered  and  he  is  discharged. 


which  is  like  locking  the  stable  door  after  the  horse 
has  been  stolen.  Had  the  defect  been  remedied  in 
the  first  place  a  man  would  not  have  lost  his  job, 
labor  turnover  would  have  been  reduced,  and  prop- 
erty would  not  have  been  lost.  Is  not  this  contribu- 
tory negligence  on  the  part  of  the  management? 
Can  such  management  be  considered  efficient?  To 
ascertain  the  presence  of  defects,  in  order  that  em- 
ployment departments  may  know  the  limitations 
of  employees,  is  a  true  function  of  the  industrial 
medical  officer.  . 

Monotonous,  concentrative  or  exhausting  opera- 
tions are  known  to  be  hazardous  to  health.  Who 
appreciates  this  better  than  does  the  medical  officer, 
and  who  is  there  to  detect  this  physical  stress  and 
resulting  inefficiency  better  than  the  plant  physician? 
If  no  physician  is  employed  or  if  one  is  employed 
who  does  not  appreciate  his  position,  there  is  none 
to  aid  the  management  in  stopping  this  costly  leak 
to  production. 

The  plant  physician  comes  into  intimate  contact 
with  almost  every  branch  of  the  industrv,  more 
especially  with  the  employment  office  and  the  divi- 
sions of  medicine,  safety  and  welfare.  If  the  plant 
physician  is  efficient,  he  fulfills  the  various  demands 
made  upon  him.  He  needs  must  know  intimately 
and  well  the  workings  of  each  branch  of  the  plant 
and  by  making  physical  examinations  and  periodical 
reexaminations  of  the  workers,  and  supervising  the 
sanitation  of  the  plant,  he  can  exert  a  direct  influ- 
ence upon  the  essential  elements  of  production.  If 
he  examines  applicants  for  employment  he  uses  the 
knowledge  obtained  for  proper  placement  with  re- 
gard to  capacity  and  fitness.  The  perfect  man  is 
not  to  be  found,  but  with  medical  guidance  the 
man  with  defects  may  be  guided  and  directed  so 
that  he  may  serve  most  efficienth'  and  with  the  least 
harm  to  himself.  The  plant  physician  attending  ac- 
cident cases  and  investigating  the  causes  leading  up 
to  them  is  in  a  position  to  recommend  measures  to 
prevent  the  repetition  of  such  incidents. 

If  the  plant  physician  has  the  proper  idea  of 
medical  supervision  of  industry,  he  attends  the  sick 
workmen  at  their  homes  and  becomes  familiar  with 
their  domestic  and  communit\-  problems.  He  knows 
whether  this  workman  or  that  is  spending  his  earn- 
ings wisely ;  whether  this  man  is  rearing  his  family 
so  as  to  be  an  asset  to  the  community ;  which  one 
is  thrifty  and  is  looking  ahead  and  preparing  for 
the  proverbial  rainy  day,  or  whether  in  a  more  or 
less  short  time  another  liability  will  be  thrust  upon 
society.  Through  the  careful  plant  physician  the 
problem  of  communicable  diseases  may  be  studied 
and  their  introduction  into  the  plant,  with  the  en- 
suing disastrous  effects  upon  production,  loss  of 
time,  and  waste  of  material,  may  be  prevented. 

By  proper  use  of  the  plant  physician,  the  worker 
is  adapted  to  his  job,  accidents  are  prevented,  sick- 
ness is  diminished,  absence  reduced,  labor  turn- 
over minimized  and  the  workman  made  to  feel 
that  there  is  some  one  influential  with  the  man- 
agement interested  in  his  personal  welfare.  This 
raises  morale  and  increases  interest  in  the  work.  A 
full  knowledge  of  the  physical  and  temperamental 
limitations  of  the  worker  is  of  much  assistance  to 
managements  and  in  all  instances  of  direct  benefit 


214 


HUBBARD:   INDUSTRIAL  MEDICINE. 


[New  York 
Medical  Journal. 


to  the  worker  himself.  Does  the  ordinary  plant 
apply  this  knowledge  to  the  aid  of  production? 
Only  in  exceptional  instances  is  this  done.  Why? 
Has  not  the  misuse  of  the  physician  as  an  eliminator 
of  bad  material  or  improper  use  of  the  plant 
physician  made  labor  distrustful  of  a  service  that 
when  properly  used  is  labor's  greatest  aid  to  effici- 
ency and  health?  No  doubt  the  contract  doctor 
with  his  limitation  of  service  and  abilities  has  also 
had  a  bad  if  not  actually  a  vicious  influence  which 
has  resulted  in  much  misinformation  regarding  in- 
dustrial medical  service. 

The  modern  industrial  physician  knows  under 
what  conditions  people  may  engage  in  hazardous 
occupations  and  what  precautions  are  essential  to 
both  safety  and  health.  He  instructs  his  aids,  drills 
his  staff,  and  informs  his  workers  so  that  when 
danger  appears  or  accidents  occur  the  medical  serv- 
ice is  prepared  and  acts  promptly.  Industrial  phy- 
sicians meet  many  opportunities  to  clear  up  differ- 
ences between  employer  and  employee  and  even 
among  employees  themselves.  By  succssfully  avail- 
ing themselves  of  the  opportunities  afforded  by  a 
modern  industrial  medical  service,  managements 
know  intimately  the  physical  limitations  of  their  in- 
dustrial staff.  Without  this  information  some  are 
overworked  and  others  are  underworked. 

NECESSITY  FOR  MEDICAL  GUIDANCE  IN  INDUSTRY. 

Statistics  regarding  health  in  industry  are  replete 
with  interesting  correlating  facts.  From  the  United 
States  Department  of  Labor  we  learn  that  there  are 
about  forty  million  people  engaged  in  industry.  Of 
this  army  of  workmen  there  are  about  750.000  who 
sustain  accidents  which  disable  them  for  a  period  of 
more  than  four  weeks'  duration.  There  are  about 
22,500  industrial  workers  killed  annually,  and  be- 
tween 15,000  and  18,000  who  suffer  permanent  dis- 
ability. The  economic  waste  from  these  accidents 
means  the  loss  of  working  time  of  over  60,000  la- 
borers or  18,000,000  work  days  a  year. 

Sickness  in  industry  likewise  exacts  a  heavy  toll. 
We  are  informed  from  the  same  source  that  the 
average  worker  loses  about  nine  days  a  year.  This 
means  a  loss  of  one  million  workers  a  year  or  360,- 
000,000  days  a  year,  both  of  which  estimated  at  an 
average  per  diem  wage  means  a  stupendous  amount 
in  dollars  and  cents.  This  is  the  loss  simply  from 
sickness  and  accident :  to  this  there  must  be  added 
the  loss  of  production,  the  cost  of  medical  and  nurs- 
ing service  and  medical  supplies,  and  sundry  ex- 
penses which  make  a  sum  running  into  the  billions. 
There  is  no  greater  problem  before  the  coun- 
try today  than  that  of  caring  for  the  industrial 
worker.  There  is  no  one  in  this  country  who  can 
better  cope  with  this  situation  than  the  properly 
trained  and  equipped  industrial  physician. 

AIMS  OF  INDUSTRIAL  MEDICINE. 

1.  Devising  ways  and  means  of  improving  the 
health  of  workmen ;  2,  preventing  losses  to  employ- 
ers due  to  the  poor  health  of  employees ;  3,  prevent- 
ing losses  to  employees  due  to  their  own  poor  health ; 
4,  demonstrating  the  advantages  of  health  super- 
vision ;  5,  preventing  sickness,  accidents,  and  deaths 
incident  to  poor  health ;  6,  removing  hazards  which 
occasion  poor  health  or  cause  injuries  to  workmen. 


APPLICATION  OF  INDUSTRIAL  MEDICAL  SUPERVISION. 

1.  Plan  a  daily  program  so  that  there  will  be  a 
healthful  balance  between  work  and  outdoor  activ- 
ities ;  2,  develop  habits  of  cleanliness  in  person, 
food,  dress  and  environment ;  3,  instruction  so  that 
there  will  be  intelligent  cooperation,  hygienic  rules 
carried  out  willingly,  at  work,  in  the  home,  and  in 
the  community ;  4,  education  as  to  the  necessity  of 
appreciating  early  signs  of  illness  and  of  seeking 
medical  assistance ;  5,  preserving  eyesight,  demon- 
strating proper  and  improper  lighting,  avoidance  of 
glare  and  direct  light  ray  irritation,  protective  de- 
vices ;  6,  teaching  the  employed  what  is  a  suitable 
and  well  balanced  diet ;  advice  concerning  luncheons, 
and  meals  generally;  meeting  the  physical  needs  of 
diet ;  7,  avoidance  of  exposure  to  heat  or  cold,  getting 
wet,  chilled,  cooling  off  too  rapidly,  dressing  to  meet 
weather  conditions;  8,  cleanliness,  necessity  of  clean 
clothing,  clean  and  safe  work  garments,  bathing, 
washing  hands,  clean  habits ;  necessity  for  cleanli- 
ness about  children  to  avoid  sickness  in  the  home  and 
escape  the  stress  and  strain  of  home  worries ;  9, 
vermin,  the  cause,  the  dangers ;  characters  of  vermin 
and  destruction  of  such  pests ;  10,  precautions  to  be 
observed  regarding  the  communicable  diseases;  11, 
necessity  for  rest,  recreation,  days  of  rest,  taking 
time  to  eat  and  resting  after  meals ;  amount  of  sleep 
required;  signs  of  fatigue,  of  debility,  loss  of  flesh, 
and  too  early  advancing  age ;  12,  avoidance  of  ex- 
cesses, what  constitute  excesses ;  dangers  of  over  in- 
dulgence in  sweets,  tea  or  coffee,  drinks,  excessive 
smoking,  late  hours ;  13,  necessity  for  the  use  of 
safe,  strong,  suitable  tools,  ladders  and  protecting 
devices  ;  14,  keeping  articles  out  of  the  mouth ;  neces- 
sity for  keeping  fingers  out  of  ears,  nose,  mouth,  etc. ; 
15,  necessity  for  safe  and  sane  habits  about  shop; 
the  need  for  looking  out  not  only  for  self  but  exer- 
cising consideration  for  others  in  regard  to  yards, 
toilets,  sinks,  urinals ;  keeping  aisles  clear  and  un- 
obstructed. 

Industrial  strength  equals  the  sum  of  individual 
physical  efficiency.  Every  person  employed  in  an  in- 
dustrial plant  is  a  determining  factor  in  the  strength 
and  efficiency  of  production.  Siiccess  is  not  deter- 
mined by  the  brains  and  physical  energy  of  the  man- 
agement but  by  the  earnest  zealous  enthusiasm  of 
every  individual  employed  in  the  works.  The  field 
therefore  of  industrial  medicine  is  limitless.  En- 
thusiasm for  the  job  depends  upon  proper  adapta- 
tion of  man  to  work  and  the  participation  of  that 
man  in  the  requirements  of  his  work. 

There  must  be  working  enthusiasm — there  must  be 
a  desire  for  health — if  there  is  it  will  do  much  to  give 
the  worker  strength,  virility,  and  above  all  a  reason 
to  live.   No  factor  in  living  is  so  important  as  health. 

Actually  to  enjoy  life,  we  must  be  free  from  the 
burden  of  poverty  and  sickness  as  well  as  free  from 
the  fear  of  future  want  and  be  able  to  appreciate 
the  present  good.  The  problem  of  industrial  medi- 
cine is  how  can  we  make  men  eager  to  work  and 
eager  to  live.  We  must  teach  them  how  to  take 
proper  care  of  themselves  and  make  the  most  of 
their  opportunities.  Brains  are  paid  for  and  com- 
mand a  ready  market. 

143  West  103d  Street. 


August  14,  1920.] 


HAMMOND:  THE  CHEST  IN  INFLUENZA. 


215 


THE  CONDITION  OF  THE  CHEST  IN 
INFLUENZA* 

Surgical  Aspect. 

By  L.  J.  Hammond,  M.  D. 
Philadelphia. 

The  surgical  phase  of  postinfluenzal  chest  condi- 
tions lends  itself  mainly  to  a  discussion  of  thoracic 
effusions.  These  are  primary  in  only  a  limited  num- 
ber of  instances,  the  vast  majority  of  them  being 
secondary,  occurring  either  as  part  of  the '  clinical 
picture  of  some  general  infection,  such  as  was  so 
commonly  met  with  during  the  epidemic,  or  an  ex- 
tension of  local  processes  in  neighboring  organs, 
especially  those  affecting  the  lungs.  And  yet,  while 
secondary,  the  physiological  conditions  that  exist  in 
the  thoracic  cavity  are  such  that  an  independent 
clinical  picture  is  produced  by  the  effusion,  requiring 
special  treatment  not  independent  of,  but  in  conjunc- 
tion with,  the  medical  treatment.  The  effusions  that 
occurred  during  the  epidemic  of  1918  were  excep- 
tional only  in  that  they  were,  more  often  than  is 
usual,  sudden  in  occurrence  and  massive  in  quantity, 
and  associated  frequently  with  extensive  effusion 
into  other  serous  cavities. 

The  more  usual  occurrence  of  these  effusions  is 
late,  during  the  period  of  recovery  from  inflamma- 
tory disease  of  other  organs.  All  pathological  effu- 
sions demand  special  treatment  independent  of  the 
primary  disease,  hence  it  becomes  at  once  of  special 
surgical  interest.  The  effusions  differ  greatly  both 
as  to  extent  and  characteristics  and  may  be  anything 
from  a  mere  transudate,  a  clear  serous  exudate,  a 
cloudy  exudate,  on  through  transitions  to  pure  pus, 
serohemorrhagic  fluid,  pure  blood  and  chyle.  The 
mere  presence  of  effusions  in  sufficient  quantity 
causes  disturbance  of  respiration  and  circulation  pro- 
portionate to  the  quantity,  and  the  systemic  disturb- 
ance is  directly  dependent  on  the  virulence  of  its 
toxicity  by  absorption  of  the  invading  organisms. 
Not  all  serous  effusions,  however,  have  toxicity. 
Even  during  the  epidemic  pyogenic  organisms  were 
absent  in  fluid  that  was  early  aspirated.  In  conse- 
quence, then,  of  the  mechanical  factor  and  the  toxic 
possibilities  the  symptoms  must  be  considered  as 
arising  from  two  causes,  first,  those  of  a  purely  me- 
chanical disturbance  and,  second,  those  from  the  ab- 
sorption of  toxicity.  Owing  to  the  limited  space, 
sudden  and  massive  serous  effusions  without  the 
presence  of  pyogenic  organisms  may  so  affect  the 
neighboring  organs  as  to  necessitate  immediate 
evacuation,  at  least  in  part,  for  the  relief  of  pressure. 
The  changes  produced  by  these  effusions  affect,  first 
the  chest  wall,  then  the  lungs,  then  the  organs  in 
the  mediastinum,  and  finally  the  abdominal  organs. 
Early  in  the  streptococci  form  of  infection  the  pleura 
presents  oh  its  surface  a  granular  or  strawberry  ap- 
pearance, which  is  not  met  with  in  the  pleura  where 
the  effusion  is  from  less  virulent  types  of  organism. 
In  the  latter  the  condition  is  often  more  chronic  and 
the  pleura  is  found  to  be  dense,  presenting  the  ap- 
pearance of  fibrous  membrane. 

In  massive  effusions  the  involved  chest  wall  be- 

*Presente<l  before  the  South  Branch  of  the  Philadelphia  County 
Medical  Society,  April  30,  1920. 


comes  distended,  the  sternum  may  he  pulled  over  to 
the  affected  side,  and  the  lung,  if  not  bound  by  pre- 
vious adhesions  to  the  parietal  pleura,  is  forced  in- 
ward and  rests  against  the  side  of  the  vertebra.  The 
respiratory  cycle  is  seriously  interfered  with  both  by 
reason  of  pressure  against  the  lung  and  downward 
displacement  of  the  diaphragm.  The  displacement 
and  pressure  on  the  heart  is  often  marked  and  always 
serious  and  the  viscera  in  the  mediastinum — esoph- 
agus, descending  aorta,  the  pulmonary  vessels  and 
the  vena  cava — are  pressed  down  and  embarrass 
respiration  and  circulation  in  proportion  to  the  mas- 
siveness  of  the  effusions. 

The  unaffected  lung  is  compelled  to  perform  the 
work  of  both  though  seldom  itself  entirely  free  in 
action.  The  classic  picture,  therefore,  of  marked 
dyspnea,  cyanosis,  and  feeble  rapid  pulse  is  readily 
accounted  for  by  the  mechanical  interference ;  the 
heart  is  overworked  and  death  may  ensue  merely 
from  change  of  position  from  the  recumbent  to  erect 
or  sitting  posture.  The  depression  of  the  displaced 
vena  cava  or  the  large  vessels  arising  from  the  heart 
prevents  the  blood  entering  the  heart  and  indirectly 
the  brain,  causing  syncopal  attacks.  Then,  too.  there 
is  difficulty  in  swallowing  from  compression  of  the 
esophagus. 

While  symptomatology  in  detail  belongs  to  the 
realm  of  physical  diagnosis,  certain  disturbances  in 
the  physiological  performance  of  the  anatomical 
structure  in  the  thorax  cause  clinical  signs  and  symp- 
toms so  definite  that  they  must  be  considered  equally 
from  'a  surgical  viewpoint.  These  are  dullness  over 
the  affected  area,  displacement  of  the  heart,  absence 
of  respiratory  signs,  and  vocal  fremitus.  When 
there  are  no  adhesions  to  prevent  it,  a  large  amount 
of  effusion  separates  the  lung  from  the  chest  wall. 
When  such  do  exist  multiple  pockets  and  irregular 
compression  of  the  lung  are  found.  Some  of  these 
pockets  may.  contain  pure  serum,  others  pus,  and 
others  serohemorrhagic  fluid.  Such  complications 
as  these  offer  difficulties  both  in  diagnosis  and  surgi- 
cal treatment.  The  effusions  which  occurred  during 
the  epidemic  were  usually  treated  before  changes  in 
the  pleura  could  take  place.  These  changes,  such  as 
thickening  and  contracture,  which  often  pull  together 
and  diminish  the  circumference  of  the  thoracic  wall, 
are  often  encountered  in  old  effusions. 

The  variety  and  characteristics  of  the  pathological 
effusions  that  occurred  during  the  epidemic  differed 
only  in  their  suddenness  and  massiveness  and  great 
toxicity,  the  Streptococcus  hemolyticus  furnishing 
the  gravest  constitutional  disturbances  because  it 
produced  the  most  sudden  and  overwhelming  effu- 
sions. They  were  all,  however,  secondary  to  general 
streptococcic  infection,  influenzal  pneumonia,  and 
similar  conditions,  and,  in  a  few  instances,  I  be- 
lieved them  due  to  hemorrhagic  infarcts  the  result 
of  a  general  systemic  bacteremia. 

There  seems  to  have  arisen  a  diversity  of  opinions 
as  to  the  best  surgical  treatment  of  pleural  effusions, 
growing  out  of  the  findings  of  the  various  emp3^ema 
commissions.  At  the  beginning  of  the  epidemic  the 
effusion  was  so  sudden  and  massive  as  to  prove  fatal 
before  any  operative  treatment  could  be  employed. 
Later  on  early  rib  resection  was  practised  with  an 


216 


RUSSELL:  ABDOMINAL   SYMPTOMS  IK  INFLUENZA. 


[New  York 
Medical  Journal. 


eighty  per  cent,  mortality ;  still  later,  delayed  opera- 
tion with  early  aspiration  was  practised  with  a  fur- 
ther improvement  in  lowering  the  mortality,  though 
it  was  still  high,  while  further  along  in  the  course  of 
the  epidemic  all  operative  treatment  was  delayed 
with  a  yet  greater  number  of  recoveries.  Therefore, 
if  one  examines  these  findings  of  the  commissions 
at  the  several  military  camps  and  studies  the  vol- 
uminous literature,  he  is  disposed  to  conclude  that 
the  particular  operative  procedure  played  a  less  im- 
portant part  in  the  reduction  of  the  mortality  than 
the  spent  virulence  of  the  toxic  process,  because,  as 
the  epidemic  drew  to  a  close,  delayed  thoracotomy 
with  or  without  rib  resection,  with  or  without  irri- 
gation, resulted  in  a  percentage  of  recoveries  equal 
to  that  in  civil  practice  and  before  the  occurrence  of 
the  epidemic. 

The  report  clearly  suggests  the  wisdom  of  return- 
ing to  the  fundamental  rule  in  the  treatment  of  pyo- 
thorax,  that  is,  to  remove  the  pus  as  soon  as  its  pres- 
ence can  be  determined,  for  effusion  is  seldom,  if 
ever,  purulent  early ;  then  secure  and  maintain  ade- 
quate drainage  from  the  most  dependent  part  of  the 
abscess  as  long  as  suppuration  persists.  Thoraco- 
tomy with  or  without  rib  resection  is  the  method  of 
choice. 

The  addition  of  irrigation  has  not  been 
proved  valuable  since  a  much  larger  number  of  pa- 
tients so  treated  have  been  and  are  actually  now 
requiring  some  form  of  collapsing  operation  and 
decortication  because  of  the  extensive  adhesions  that 
appear  to  have  been  directly  caused  by  its  use. 
Therefore,  neither  the  influenza  epidemic  nor  the 
empyema  commission  has  disproved  the  merits  of 
the  fundamental  rule  that  governs  the  operative  pro- 
cedure in  thoracic  effusion  before  their  occurrence, 
viz.,  paracentesis,  either  with  or  without  suction 
drainage,  when  serothorax  is  so  massive  as  to  affect 
by  its  mere  mechanical  presence  the.  physiological 
functions  of  the  organs  in  the  thoracic  cavity,  and 
thoractomy,  should  be  performed,  wi'th  or  without 
rib  resection  for  pyothorax  as  soon  as  its  presence 
can  be  determined. 

Rib  resection  is  generally  necessary  when  there 
are  marked  narrowing  of  the  intercostal  spaces  and 
pleural  adhesions  with  pockets ;  otherwise  most  un- 
complicated abscesses  require  only  intercostal  incision 
and  drainage.  For  the  relief  of  pain  analgesia  with 
novocaine  or  ethyl  chloride  is  usually  all  sufficient. 
Inhalation  anesthesia  is  seldom  needed  and  always 
an  added  danger.  Not  rarely  during  the  epidemic 
there  were  instances  where  both  a  serothorax  and  a 
pyothorax  became  infected  with  mixed  pyogenic 
organisms  resulting  in  gangrene  of  the  lung  and 
osteomyelitis  of  the  ribs.  These  were  fatal  in  most 
cases. 

When  the  empyema  is  encapsulated  the  x  ray 
will  best  determine  the  most  dependent  point  of  the 
abscess.  In  all  other  instances  the  eighth  or  ninth 
interspace  external  to  the  long  muscles  of  the  back 
is  found  the  favorite  site.  Chest  and  arm  ex- 
ercises intelligently  directed  are  always  included  in 
the  convalescent  treatment  in  all  these  cases  and  the 
results  are  beneficial. 

1222  Spruce  Street. 


ABDOMINAL  SYMPTOMS  IN  INFLUENZA 
SIMULATING  AN  ACUTE  SURGICAL 
LESION.* 

By  Thomas  Hubbard  Russell^  M.  D. 
New  Haven,  Conn. 

My  interest  in  this  subject  was  aroused  by  the  fact 
that  I  have  personally  seen  five  cases  of  influenza 
presenting  pronounced  abdominal  symptoms,  suffi- 
cient in  every  case  to  have  caused  the  possibility  of 
an  acute  surgical  lesion  in  the  abdomen  to  have  been 
entertained.  The  first  patient  diagnosed  her  own 
condition  as  appendicitis,  on  account  of  the  severity 
and  predominance  of  the  abdominal  pain,  and  came 
to  me  for  an  operation.  Three  of  the  patients  I 
saw  in  consultation  with  Dr.  Standish  and  Dr.  Sea- 
bury,  of  New  Haven,  and  Dr.  Per r ins,  a  naval  sur- 
geon stationed  in  New  Haven  during  the  war.  The 
fifth  patient  I  saw  in  the  New  Haven  Hospital  by 
courtesy  of  Dr.  Blumer  and  Dr.  Tileston,  on  whose 
service  it  occurred.  All  of  these  cases  were  in  adults, 
and  all  of  the  patients  recovered  uneventfully  with- 
out an  operation.  I  hope  to  report  the  cases  in 
greater  detail  at  some  future  time.  This  paper  does 
not  permit  of  it  at  present. 

The  subject  I  believe  to  be  of  considerable  impor- 
tance at  the  present  time  on  account  of  the  serious- 
ness of  the  recent  epidemic,  and  the  probability  of 
our  seeing  sporadic  cases  for  some  time  to  come, 
and  also  on  account  of  the  frequency  of  abdominal 
symptoms,  and  the  great  difficulty  so  often  encoun- 
tered in  arriving  at  a  correct  estimate  of  their  true 
significance,  as  well  as  the  danger  of  an  unnecessary 
operation  during  the  course  of  an  influenza.  It  is 
now  possible  to  formulate,  on  the  basis  of  the  avail- 
able literature,  an  accurate  estimate  of  their  meaning. 

We  must  depend  principally  on  the  literature  em- 
bodied in  the  periodicals  printed  during  the  past  two 
years,  for  two  reasons.  In  the  first  place,  the  char- 
acter of  the  cases  encountered  in  the  epidemic  of 
1888-1889  varied  somewhat  from  those  found  in  the 
recent  epidemics.  In  the  former  epidemic,  people  of 
all  ages  having  been  almost  equally  affected,  and  a 
relatively  large  number  having  had  the  gastrointes- 
tinal form,  characterized  by  nausea,  vomiting,  diar- 
rhea, and  hemorrhages  into  the  intestinal  tract,  which 
have  been  rare  in  the  recent  epidemic.  Also  the 
acute  surgical  abdomen  and  particularly  the  path- 
ology of  appendicitis  were  not  nearly  as  well  known 
at  that  time  as  they  are  now.  One  does,  however, 
find  references  to  typhlitis  in  the  literature  of  that 
time.  Articles  on  influenza  in  the  standard  textbooks 
of  today  give  scant  or  no  attention  whatever  to  the 
symptoms  and  signs  frequently  occurring  in  influ- 
enza, which  would  ordinarily  suggest  an  acute  surgi- 
cal abdomen. 

The  abdominal  lesion  most  often  simulated  is  ap- 
pendicitis, and  a  differential  diagnosis  here  is  made 
more  difficult  by  the  fact  that  the  two  conditions,  at 
least  during  the  recent  epidemic,  have  occurred  most 
frequently  at  the  same  time  of  life,  young  adults 
having  been  chiefly  aflected.  One  must,  of  course, 
always  consider  the  possibility  of  a  coexistence  of  the 

Read  before  the  Connecticut  State  Medical  Societv,  Mav  19, 
1920. 


August  14,  1920.] 


RUSSELL:  ABDOMLNAL    SYMPTOMS  IN  INFLUENZA. 


217 


two  conditions.  It  would  be  strange  indeed  if  they 
did  not  occasionally  coexist. 

Let  us  consider  for  a  moment  what  lesions  are 
known  to  occur  in  the  abdomen  secondarily  to  in- 
fluenza. One  of  the  most  frequent  is  peritonitis, 
which  may  be  either  local  or  general.  When  local  it 
occurs  most  frequently  in  the  upper  abdomen,  adja- 
cent to  the  diaphragm.  In  a  large  proportion  of 
these  cases  it  appears  to  be  a  direct  extension  from 
an  adjacent  empyema.  When  general  it  usually  is 
of  "a  fibrinous  character.  When  purulent  it  is,  as  a 
rule,  part  of  a  general  pyemic  infection.  It  is  not 
due  to  an  extension  from  an  infection  of  the  appen- 
dix or  gallbladder.  In  some  cases  a  localized  col- 
lection of  serosanguinous  fluid  is  found  among  the 
coils  of  intestine.  The  causative  organism  may  be 
the  Streptococcus  hemolyticus,  pneumococcus  or 
staphylococcus.  Where  peritonitis  is  a  complication, 
it  almost  always  comes  on  during  convalescence  from 
pneumonia. 

Rupture  of  the  rectus  abdominis  muscle  has  fre- 
quently occurred  during  the  recent  epidemic,  and 
still  more  frequently  during  the  epidemic  of  1888- 
1889.  It  occurs  in  muscles  showing  a  Zenker's  de- 
generation, probably  due  to  a  spasmodic  contraction 
of  the  weakened  muscle  during  coughing.  It  may  re- 
sult in  a  hemorrhage  within  the  sheath  of  the  muscle, 
which  not  infrequently  becomes  secondarily  infected, 
resulting  in  a  deep  abscess.  The  rupture  is,  rarely 
complete,  and  usually  occurs  midway  between  the 
symphysis  pubis  and  umbilicus.  One  writer  reports 
eight  cases,  another  has  seen  twenty.  These  patients 
have  frequently  been  operated  upon  for  a  supposed 
appendicitis. 

Multiple  abscesses  of  the  kidney,  and  perinephritic 
abscesses  occur  infrequently.  A  thrombophlebitis 
of  the  large  abdominal  vessels  has  occasionally  been 
reported.  Also  a  general  congestion  of  the  intes- 
tines, with  submucous  hemorrhages,  occasionally 
occurs.  One  case  of  rupture  of  the  colon  has  been 
reported. 

These  lesions'  are  about  the  only  ones  at  all  likely 
to  appear  in  the  abdomen.  In  the  great  majority  of 
cases  they  have  come  on  during  convalescence,  or 
as  a  terminal  process,  and  an  operation  would  have 
been  useless,  or  merely  hastened  the  end. 

There  are  a  few  who  believe  that  there  is  a  close 
relationship  between  appendicitis  and  influenza,  but 
their  statistics  are  not  convincing.  The  general  opin- 
ion seems  to  be,  on  the  contrary,  that  appendicitis  is 
a  very  rare  complication,  although  a  train  of  symp- 
toms which  would  ordinarily  substantiate  such  a 
diagnosis  is  exceedingly  common.  The  best  sta- 
tistics available  are  from  the  military  camps  and 
base  hospitals,  as  here  tremendous  numbers  of  men 
suffering  from  influenza  were  under  observation  and 
excellent  control.  Let  me  quote  freely  from  a  few 
of  those  which  describe  the  frequency  and  the  puz- 
zling nature  of  the  abdominal  symptoms. 

Camp  Dix. — During  the  twenty-two  days  of  the 
epidemic  there  were  -6,000  cases  of  influenza  in  the 
hospital,  and  800  deaths  due  to  the  epidemic.  Synott 
and  Clark  report :  "In  the  abdomen,  meteorism  oc- 
curred in  some  cases ;  in  certain  lethal  cases  it  was 
excessive.    Abdominal  pain  and  tenderness  were 


present,  possibly  not  entirely  due  to  pleurisy,  but  in 
the  light  of  necropsy  findings  to  infection  and  hem- 
orrhages in  the  rectus  muscles." 

Camp  Logan. — A  daily  average  of  24,000  men 
were  in  camp  and  4,126  were  admitted  to  the  hos- 
pital with  a  diagnosis  of  influenza  in  addition  to  567 
with  a  diagnosis  of  pneumonia.  The  report  states : 
"An  interesting  feature  of  the  respiratory  epidemic 
was  the  great  number  of  patients  admitted  to  the 
hospital  with  a  diagnosis  of  acute  appendicitis,  in 
whom,  after  a  few  hours  of  observation,  we  changed 
the  diagnosis  to  either  influenza  or  pneumonia. 
About  fifty  cases  were  received  whose  previous  diag- 
nosis was  wrongly  given  as  appendicitis." 

U.  S.  Naval  Hospitals  in  Philadelphia. — Daland 
reports  on  the  basis  of  3,000  cases  of  influenza :  "Re- 
flex pleuritic  pains  have  been  erroneously  diagnosed 
as  cholecystitis  or  appendicitis — usually  interlobar 
and  diaphragmatic  seroplastic  and  purulent  pleurisy 
are  not  diagnosed,  but  the  latter  may  be  suspected 
when  friction  sounds  are  heard  over  the  borders  of 
the  lung  or  when  referred  pain  occurs  in  the  upper 
abdominal,  gallbladder  or  appendix  regions.  . 
Autopsies  showed  no  pronounced  gastrointestinal 
pathological  change.  .  .  .  Referred  pleuritic 
pain  is  often  mistaken  for  cholecystitis  or  appendi- 
citis." Billings  states :  "In  the  majority  of  instances 
there  was  some  abdominal  distension  and  pain  on 
palpation,  particularly  in  the  right  iliac  fossa.  This 
latter  symptom  cleared  up  rapidly,  however,  but 
during  its  presence  markedly  simulated  appendicitis." 

Great  Lakes  Naval  Training  Station. — McNally 
reports  that  he  saw  a  considerable  number  of  cases 
which  taxed  his  diagnostic  ability  and  that  of  his  col- 
leagues on  the  surgical  service.  He  states:  "The 
onset  of  acute  chest  conditions  gave  us  concern  in 
many  instances.  They  were  confused  most  often 
with  acute  appendicitis  although  we  were  occasion- 
ally confronted  with  symptoms  resembling  acute 
gallbladder  disease.  I  have  come  to  have  a  whole- 
some respect  for  the  difficulties  encountered  in  mak- 
ing an  early  diagnosis  in  these  cases."  Autopsy 
findings  showed  in  some  cases  a  moderate  amount  of 
turbid  liquid  in  the  peritoneal  cavity,  but  the  appen- 
dix and  gallbladder  showed  no  changes  which  could 
be  connected  with  the  recent  condition.  "To  have 
operated  upon  these  cases  would  have  been  a  fatal 
mistake." 

Royal  Naval  Hospital,  Plymouth. — Smith  reports: 
"In  the  earlier  days  patients  were  constantly  being 
sent  in  to  the  surgical  service  with  the  diagnosis  of 
l^erf orated  gastric  or  duodenal  ulcer,  l^ss  frequently 
as  an  acute  appendicitis — the  true  diagnosis  is  often 
difficult." 

Camp  Dodge. —  Manson  reports  that  at  one  time 
there  were  a  total  of  8,000  cases  in  the  hospital.  The 
total  number  diagnosed  as  influenza  from  September 
16  to  December  15,  1918,  was  10,041.  He  states: 
"In  about  thirty  patients  with  pneumonia  symptoms 
developed  strongly  suggestive  of  surgical  lesions  of 
the  abdomen,  which  were  seen  in  consultation  with 
the  medical  service;  so  closely  did  some  of  these 
cases  with  chest  pathology  simulate  appendicitis  that 
three  of  the  patients  were  transferred  to  the  surgical 
wards  with  the  diagnosis  of  appendicitis,  but  the  true 


218 


RUSSELL:  ABDOMINAL   SYMPTOMS  IN  INFLUENZA. 


[New  York 
Medical  Journal. 


condition  was  discovered  in  time,  and  none  of  them 
were  operated  upon.  There  were  two  patients  with 
appendicitis  who  were  operated  upon,  and  gan- 
grenous appendicitis  was  found,  each  patient  giving 
a  history  of  previous  attacks  of  appendicitis." 

University  of  lotva  R.  O.  T.  C. — Rowan  states 
tliat  among  1,030  cases  of  influenza,  appendicitis  was 
not  a  common  compHcation,  there  having  been  two 
cases.  In  quite  a  number  of  patients  there  were  pain, 
tenderness  and  rigidity,  locaHzed  in  the  right  lower 
abdominal  quadrant.  He  states :  "This  was  marked 
enougi:  in  some  cases  to  have  led  to  the  diagnosis 
of  acute  appendicitis  and  to  have  indicated  operation 
in  ordinary  times."  He  felt  that  it  was  extremely 
important  to  avoid  unnecessary  operations  in  these 
influenza  cases. 

Cai)ip  Zachary  Taylor. — Meyer  states:  "In  many 
instances  patients  were  sent  to  the  surgical  depart- 
ment, in  whom  the  condition  was  diagnosed  as  ap- 
pendicitis because  of  the  history  of  abdominal  pain 
and  vomiting." 

Camp  Custer. — Beals  and  others  state:  "A  num- 
ber of  patients  were  either  admitted  to  the  surgical 
wards  or  seen  in  consultation  in  the  medical  wards 
for  pain  in  the  right  lower  quadrant.  Pain  of  a  dull, 
aching  character,  referred  to  the  right  lower  quad- 
rant was  the  most  prominent  feature.  .  .  These 
abdominal  signs  and  symptoms  might  ordinarily  be 
diagnosed  as  appendicitis.  However,  it  was  re- 
peatedly observed  that  the  local  abdominal  signs  dis- 
appeared in  a  short  time ;  more  rarely  they  persisted 
and  increased  in  severity  so  that  operation  was 
deemed  imperative.  This  group  occurred  in  in- 
fluenza patients,  nearly  all  of  whom  later  showed 
demonstrable  signs  of  bronchopneumonia."  Four 
and  two  tenths  per  cent  of  the  cases  coming  to 
autopsy  showed  peritonitis,  usually  localized  in  the 
upper  abdomen,  and  never  secondary  to  any  demon- 
strable abdominal  lesion.  Abdominal  rigidity  and 
tenderness  of  the  upper  abdomen  were  usually  a  re- 
flex from  pneumonia. 

Camp  Lewis. — Based  on  their  experience  with 
7,088  cases  of  influenza  and  1,126  cases  of  broncho- 
pneumonia, Kerr  and  others  state :  "While  abdom- 
inal symptoms  have  been  rather  infrequent  during 
the  course  of  the  disease,  they  are,  when  present,  the 
source  of  great  annoyance.  In  two  instances  these 
symptoms  led  to  operative  procedures.  At  operation 
one  patient  was  found  to  have  a  normal  appendix 
and  pneumonia  developed  later.  The  other  presented 
an  acute  gangrenous  appendicitis,  although  the  leuco- 
cyte count  prior  to  operation  was  6,000.  Pneumonia 
was  not  found  in  either  case  prior  to  operation.  In 
another  instance  abdominal  pain,  leucocytosis  and  a 
slight  jaundice  suggested  acute  cholecystitis.  Pneu- 
monia with  a  resulting  empyema  on  the  right  side 
was  found  and  apparently  produced  the  abdominal 
picture." 

Camp  Beauregard. — Frick  reports  that  many  pa- 
tients "had  vomiting ;  some  l^ecame  tender  over  the 
abdomen,  imitating  an  intraabdominal  condition." 

Abrahams,  Hallows  and  French  report  that  in 
several  thousand  cases  of  influenza  occurring  in  the 
British  army,  about  400  of  which  came  to  autopsy 
"Adominal  pain    .    .    .    has  existed  of  sufficiently 


severe  character  to  lead  to  a  provisional  diagnosis  of 
appendicitis,  and  even  to  some  solicitude  as  to  a 
differentiation  from  an  acute  abdominal  condition 
urgently  needing  operation."  Under  postmortem 
findings,  they  state :  "The  vermif oi  m  appendix  has 
not  shown  any  noticeable  change.  We  mention  this 
because  there  has  been  a  tendency  elsewhere,  we 
have  been  told,  for  certain  of  these  influenzopneu- 
monic  patients  to  develop  acute  appendicitis." 

Brooks  and  Gillette  state  that  out  of  about  29,000 
deaths  in  the  American  Expeditionary  Force  due  to 
influenza  only  three  were  recorded  as  due  to  other 
conditions  than  pneumonia.  Dr.  Lewis  Connor 
states  on  the  strength  of  a  study  of  reports  to  the 
surgeon  general  from  seventy-two  base  hospitals 
scattered  throughout  the  country:  "Abdominal  pain 
was  of  rare  occurrence.  Abdominal  tenderness  was 
sometimes  encountered,  but  seemed  usually  to  be 
either  a  part  of  a  general  hyperesthesia  or  related 
to  inflammation  in  the  chest  which  involved  the  dia- 
phragmatic pleura.  Very  rarely  it  was  caused  by  a 
local  or  general  peritonitis." 

Henderson  and  Billington,  basing  their  statements 
on  an  experience  with  about  5,000  cases  of  influenza 
in  a  large  base  hospital,  say:  "In  some  cases  the 
abdominal  signs  and  symptoms  are  such  as  to 
strongly  suggest  an  acute  appendicitis,  and  quite  a 
number  of  cases  have  been  operated  upon  on  this 
diagnosis.  On  the  other  hand,  during  the  latter  part 
of  the  epidemic,  numbers  of  patients  were  sent  into 
the  hospital  with  a  provisional  diagnosis  of  influenza 
of  the  abdominal  type,  in  which  the  condition  was 
actually  one  of  acute  appendicitis.  In  one  week  we 
had  three  such  cases  in  which  operation  was  neces- 
sary. One  does  not  regard  influenza  in  an  ordinary 
sense  as  a  cause  of  appendicitis,  but  it  can  be  readily 
understood  that,  with  such  a  catarrhal  condition  of 
the  bowel  as  is  often  met  with  in  abdominal  influ- 
enza, an  acute  appendix  inflammation  may  be  read- 
ily set  up." 

Mann,  from  his  experience  at  a  base  hospital,  states 
that  the  abdominal  symptoms  were  frequent,  might 
occur  before  other  symptoms,  and  frequently  lead 
to  a  diagnosis  of  appendicitis ;  that  true  appendicitis 
in  influenza  was  rare,  but  did  occasionally  occur. 
"Acute  appendicitis  was  so  rare  that  we  had  only 
one  case.  .  .  .  The  cases  simulating  appendicitis 
gave  us  a  great  deal  of  anxiety." 

That  the  abdominal  symptoms  are  not  confined  to 
military  practice,  and  that  cases  are  not  infrequently 
operated  upon  for  a  supposed  abdominal  lesion  in 
civilian  life  is  illustrated  by  the  following  abstract 
and  quotations :  Bloomfield  and  Harrod  state  from 
their  experience  at  the  Johns  Hopkins  Hospital :  "In 
a  few  instances,  acute  abdominal  pain,  vomiting,  or 
diarrhea,  ushered  in  the  disease." 

William  R.  Williams  states :  'Another  group  of 
cases  showed  chiefly  abdominal  symptoms.  .  .  One 
such  patient  was  admitted  to  the  New  York  Hospital 
with  fever  and  a  good  history  of  acute  appendicitis. 
The  abdomen  was  rigid  and  sensitive  in  the  region 
of  the  appendix.  Because  she  had  a  little  cough  and 
influenza  was  so  prevalent  at  the  time,  operation  was 
delayed  for  a  little  time.  Later  there  developed  a 
double  bronchopneumonia,'  and  the  patient  recovered 


August  14,  1920.] 


RUSSELL:  ABDOMINAL    SYMPTOMS  IN  INFLUENZA. 


219 


without  surgical  treatment.  There  were  other  pa- 
tients who  had  both  an  operation  and  pneumonia  to 
get  over.  .  .  .  Another  patient  was  operated  upon 
for  acute  cholecystitis.  The  gallbladder  was  normal 
and  later  pneumonia  developed." 

Dubs  operated  upon  two  patients  with  supposed- 
ly ruptured  appendix  during  influenza.  In  both  cases 
no  surgical  condition  was  found,  and  no  real  lesion 
of  the  appendix,  but  a  slight  congestion  of  this 
region.  In  other  cases  he  states  that  individuals 
have  lain  in  the  hospital  for  twenty-four  hours  with 
a  diagnosis  of  abdominal  grippe,  and  the  patients 
were  then  operated  upon  and  a  ruptured  appendix 
located. 

Manges  states :  "Another  symptom  referable  to 
the  abdomen  is  pain.  At  times  this  may  be  so  severe 
that  acute  abdominal  conditions  may  be  suspected. 
In  the  case  of  a  child  recently  admitted  to  the  Mt. 
Sinai  Hospital,  the  abdominal  pain  was  so  severe 
and  cramplike  and  the  rigidity  of  the  abdomen  was 
so  great,  that  in  the  presence  of  fever,  and  the  ab- 
sence of  other  symptoms  and  signs,  a  diagnosis  of 
acute  appendicitis  was  made.  As  nothing  was  found 
at  the  operation,  the  true  diagnosis  of  influenza  be- 
came apparent.  I  have  seen  a  number  of  patients  in 
my  own  service  in  whom  the  main  symptom  was 
intense  abdominal  pain,  which  was  especially  referred 
to  the  epigastrium." 

Delbet  has  described  two  patients  in  his 
private  practice  in  whom  there  were  all  the  symptoms 
ordinarily  found  in  an  appendicitis  with  abscess  for- 
mation, including  a  palpable  mass.  The  first  was 
operated  upon  and  died,  the  appendix  having  been 
found  normal,  but  there  having  been  a  collection  of 
serosanguinous  fluid  between  the  loops  of  intestines. 
In  the  second  case,  profiting  by  his  experience  in  the 
first,  he  did  not  operate,  but  used  medical  treatment, 
especially  antistreptococcic  serum,  with  rapid  im- 
provement and  restoration  to  health.  In  both  of 
these  cases  the  abdominal  symptoms  developed  dur- 
ing convalescence  from  influenza.  He  is  firmly  con- 
vinced that  these  patients  should  be  treated  medically, 
and  that  it  is  poor  judgment  to  operate.  He  makes 
the  suggestion  that  the  streptococci  are  carried 
through  the  intestinal  wall  by  the  lymphatics  of 
Peyer's  patches.  He  states  that  one  must  be  on  the 
lookout  for  these  cases  during  convalescence  from 
the  grippe. 

Reissman  states:  "Pain  and  tenderness  in  the 
right  iliac  fossa  suggesting  appendicitis  were  noted 
in  several  instances,  but  in  my  personal  experience 
none  of  these  cases  were  appendicitis ;  virtually  all 
were  examples  of  pain  referred  from  the  chest." 

Villard  has  reported  four  cases  of  influenza  closely 
simulating  appendicitis,  two  of  which  were  referred 
for  an  operation.  All  recovered  within  a  few  days 
without  operation.  He  states  that  the  most  impor- 
tant part  of  the  treatment  is  to  abstain  from  opera- 
tion, which  is  very  dangerous,  and  treat  the  patient 
with  an  ice  cap  and  enemas. 

From  a  thorough  examination  of  the  literature,  at 
least  since  the  recent  epidemic,  and  from  my  own 
limited  experience  there  is,  I  believe,  sufficient  evi- 
dence to  warrant  the  statement  that  the  complication 
of  surgical  appendicitis  or  cholecystitis  or  any  other 


surgical  lesion  within  the  abdomen  requiring  opera- 
tion is  very  infrequent,  but  that  abdominal  pain  and 
tenderness  are  extremely  frequent,  and  are  in  the 
majority  of  cases  either  reflex,  when  present  in  the 
upper  abdomen  being  due  to  irritation  in  the  course 
of  the  9th  and  10th  intercostal  nerves,  and  when 
present  in  the  lower  abdomen  to  irritation  of 
the  11th  and  12th  intercostals  or  due  to  a  more  or 
less  general  congestion  of  the  intestines.  Less  fre- 
quently there  is  a  collection  of  serosanguinous  fluid 
in  the  abdomen ;  in  these  cases  the  condition  of  the 
patient  is  not  benefited  by  operation,  but  rather 
harmed.  This  fluid  will  be  absorbed  in  time  if  the 
patient  survives.  Occasionally  there  is  a  purulent 
local  or  general  peritonitis,  most  often  present  in 
the  upper  abdomen,  which  is  generally  a  terminal 
l^icture  of  a  general  pyemia,  or  the  extension  through 
the  diaphragm  of  an  empyema.  One  must  always 
bear  in  mind  the  frequency  of  a  hemorrhage  or 
abscess  within  the  rectus  muscle,  which  has  often 
been  mistaken  for  a  ruptured  appendix.  In  these 
latter  cases  simple  evacuation  under  local  anesthesia 
is  sufficient  to  affect  a  rapid  cure. 

One  should  be  especially  cautious  in  making  a 
diagnosis  of  acute  appendicitis  or  gallbladder  dis- 
ease during  or  immediately  following  influenza. 
During  the  course  of  an  epidemic,  it  should  always 
be  borne  in  mind  that  there  is  a  possibility  of  the 
abdominal  symptoms  being  the  first  to  appear.  If 
the  patient  has  other  symptoms  of,  or  is  convalescing 
from  influenza  or  influenzal  pneumonia,  one  should 
be  extremely  conservative  in  recommending  an  op- 
eration for  appendicitis  or  gallbladder  disease.  It 
is  certain  that  a  large  number  of  unnecessary  opera- 
tions were  performed  during  the  recent  epidemic. 

The  following  points  should  be  remembered  in 
making  a  diagnosis  of  appendicitis  in  these  cases : 

In  uncomplicated  influenza,  there  is  almost  always 
a  leucopenia.  In  surgical  appendicitis  complicating 
influenza  there  is  usually  a  considerable  leucocytosis. 
A  leucocytosis  of  over  20,000  in  the  first  eight  hours 
or  so  of  an  appendicitis  is  rare,  and  would  be  strongly 
suggestive  of  pneumonia.  It  is  possible  to  have  an 
appendicitis  without  any  increase  in  the  leucocytes. 

In  chest  conditions,  the  pain  is  most  often  referred 
to  the  upper  abdomen,  and  in  most  cases  is  rather 
more  diffuse  than  in  appendicitis  or  cholecystitis.  In 
chest  conditions,  also,  the  facial  expression  does  not 
indicate  that  the  patient  is  suffering  as  acutely  as 
would  be  the  case  if  a  real  surgical  condition  were 
present  in  the  abdomen,  but  is  resigned  or  lethargic. 
The  rigidity  of  the  recti  is  more  likely  to  be  equal, 
where  the  condition  is  due  to  a  chest  lesion,  and  light, 
superficial  palpation  is  apt  to  cause  the  patient  almost 
as  much  pain  as  deep  palpation,  which  is  not  usually 
true  where  a  real  surgical  condition  is  present  within 
the  abdomen. 

A  movement  of  the  alse  nasae  with  respiration  is 
very  suggestive  of  a  chest  lesion,  usually  being  ab- 
sent in  surgical  lesions  of  the  abdomen,  unless  ex- 
tremely advanced.  Cyanosis  and  rapid  breathing 
are  suggestive  of  a  chest  lesion.  Jaundice  and 
vomiting  occur  so  frequently  in  influenzal  condi- 
tions that  their  presence  should  not  be  construed  as 
indicating  a  surgical  lesion. 


220 


JOYCE:  DRUG  ADDICTION. 


[New  York 
Medical  Journal. 


In  concluding,  I  want  to  emphasize  the  following 
points : 

1.  Influenza  is  a  protean  disease. 

2.  Abdominal  symptoms  which  would  ordinarily 
indicate  the  need  of  an  urgent  surgical  operation  are 
commonly  present  during  influenza,  and  their  fre- 
quency is  not  sufficiently  brought  out  in  the  text- 
books. 

3.  Conditions  requiring  an  abdominal  operation 
during  influenza  or  its  convalescence  are  exceedingly 
rare. 

4.  While  in  some  cases,  a  differential  diagnosis  is 
extremely  difficult,  the  safest  procedure  in  doubtful 
cases  is  to  adopt  an  expectant  treatment. 

5.  In  case  an  exploratory  operation  is  decided 
upon,  a  local  anesthetic  is  advisable. 

6.  A  surgical  abdominal  lesion  and  influenza  may 
occasionally  coexist. 

7.  Many  unnecessary  and  harmful  operations 
have  been  performed  during  the  course  of  influenza, 
due  to  the  lack  of  appreciation  of  the  frequency  with 
which  abdominal  symptoms  occur  in  influenza. 

8.  The  great  majority  of  cases  showing  abdominal 
symptoms  have  no  surgical  basis,  but  are  either  re- 
flex, or  due  to  some  condition  which  would  not  be 
benefited,  but  rather  harmed  by  a  laparotomy. 

9.  The  chest  should  always  be  carefully  examined 
before  operating  for  a  supposed  acute  surgical  lesion 
of  the  abdomen. 

BIBLIOGRAPHY. 

1.  Manges,  M.  :  Symptomatology  of  the  Prevailing  Epi- 
demic Influenza,  New  York  AIedical  Journal,,  108 :722, 
October  26,  1918. 

2.  Reilly,  T.  F.  :  Sequelae  of  Influenza,  New  York 
Medical  Journal,  110:454,  September  13,  1919. 

3.  Report  on  the  Influenza  Epidemic  in  the  British  Army 
in  France,  British  Medical  Journal,  1918,  2:505. 

4.  MacNeal.  W.  J.:  The  Influenza  Epidemic  of  1918 
in  the  A.  E.  F.,  Archives  of  Internal  Medicine,  23 :657, 
June,  1919. 

5.  Blumgarten,  a.  S.,  and  Voss,  F.  H. :  Clinical  An- 
alysis of  Influenza  Cases,  New  York  Medical  Journal, 
111  :146,  January  24,  1920. 

6.  LoNGCOPE,  W.  F. :  Survey  of  the  Epidemic  of  In- 
fluenza in  the  A.  E.  F.,  Journal  A.  M.  A.,  73:189,  July  19, 
1919. 

7.  Lyon,  L.  P.,  and  Others :  Some  Clinical  Observa- 
tions on  the  Influenza  Epidemic  at  Camp  Upton,  Journal 
A.  M.  A.,  72:1726,  1919. 

8.  Delbet,  p.  :  Accidents  Typhoappendiculaires  consecu- 
tifs  a  la  Grippe,  Paris  Chir.,  10:475,  1918. 

9.  Hall,  J.  N.,  and  Dyas,  F.  G.  :  Appendicitis  at  Camp 
Logan  -as  a  Sequel  to  Influenza  and  Pneumonia,  Journal 
A.  M.  A.,  72  -.726,  March  8,  1919. 

10.  Synott,  M.  J.,  and  Clark,  E.  :  The  Influenza  Epi- 
demic at  Camp  Dix,  N.  J.,  Journal  A.  M.  A.,  71  :1816,  1918. 

11.  Smith,  R.  E.  ;  Intraabdominal  Catastrophes  in  In- 
fluenza, Lancet,  1919,  1 :421,  March  25. 

12.  Beals,  L.  S.,  and  Others  :  Abdominal  Complications 
of  the  Influenza  Epidemic  at  Camp  Custer,  Mich.,  Journal 
A.  M.  A.,  72:850,  March  22,  1919. 

13.  Manson,  F.  M.  :  Report  of  the  Surgical  Service, 
U.  S.  A.  Base  Hospital,  Camp  Dodge,  on  the  Epidemic  of 
Influenza,  American  Journal  of  the  Medical  Sciences, 
158:244,  August,  1919. 

14.  Greenberg,  D.  :  Some  Unusual  Symptoms  and  Signs 
Observed  in  the  Last  Influenza  Epidemic,  Medical  Record, 
97:188,  January  31,  1920. 

15.  Dalanp,  J.:  The  Epidemic  of  Influenza  ...  in  the 
U  S.  Naval  Hospitals  in  Philadelphia,  Medical  Record, 
97:173,  January  31,  1920. 

16.  Gage,  H.  :  Postinfluenzal  Abscess  of  the  Sheath  of 
the  Rectus  Muscle,  Annals  of  Surgery, _  70:188,  1919. 

17.  Rowan,  C.  G.  :  Surgical  Complications  in  1,030  Cases 
of  Influenza,  Western  Surgical  Transactions,  1918,  159. 


18.  Brooks,  H.,  and  Gillette,  C.  :  The  Argonne  In- 
fluenza Epidemic,  New  York  Medical  Journal,  110:925, 
1919. 

19.  Conner,  L.  A. :  Symptomatology  and  Complications 
of  Influenza,  Journal  A.  M.  A.,  73:321,  August  2,  1919. 

20.  Balgarnie,  W.  :  Ruptured  Rectus  Abdominis  in  In- 
fluenza, Lancet,  1919,  1  :843,  May  17. 

21.  Behrend,  M.  :  Appendicitis  as  a  Sequel  to  Influenza, 
with  Report  of  Cases,  Surgery,  Gynecology,  and  Obstetrics, 
26:601,  June,  1919. 

22.  McNealy,  R.  W.  :  Conditions  Arising  in  Recent  In- 
fluenza Epidemic  that  Simulated  Acute  Abdomen,  Illinois 
Medical  Journal,  35  :192,  April,  1919. 

23.  Frick,  D.  J. :  Influenza  at  Camp  Beauregard,  La., 
American  Journal  of  the  Medical  Sciences,  158:68,  July, 
1919. 

24.  Dubs,  J. :  Ueber  einige  Chirurgische  Kompliksionen 
der  Influenza,  Cor.  Bl.  f.  scliiveiz.  Aerzte,  49  :438,  April  19, 
1919. 

25.  Kaufman,  J. :  Gastrointestinal  Disturbances  in  In- 
fluenza, New  York  Medical  Journal,  June  29,  1907. 

26.  Marvel,  P. :  Has  Influenza  Been  a  Causative  Factor 
in  the  Increase  of  Appendicitis?  Journal  A.  M.  A.,  July  30, 
1904. 

27.  Mann,  A.  T. :  Surgical  Sequelae  of  Influenza, 
Lancet,  39:284,  June,  1919. 

28.  Williams,  W.  R.  :  Clinical  Aspects  of  Influenza, 
New  York  State  Medical  Journal,  19:393,  1919. 

29.  Bloomfield,  A.,  and  Harrop,  G.  A. :  Clinical  Ob- 
servations on  Epidemic  Influenza,  Johns  Hopkins  Hospital 
Bulletin,  30:1,  1919. 

30.  Clifford,  H.  B.,  Billings,  and  Others :  Report  on 
Influenza  .  .  .  U.  S.  Naval  Hospital,  Philadelphia,  U.  S. 
Naval  Medical  Bulletin,  13:637,  1919. 

31.  Kerr,  W.  J.,  and  Others:  Influenza  and  Broncho- 
pneumonia at  Camp  Lewis,  New  York  Medical  Journal, 
110:133,  184,  July  26-August  2,  1919. 

32.  Henderson,  J.,  and  Billington,  S.  C.  :  Review  of 
Complications  of  Influenza,  Glasgoiv  Medical  Journal,  May, 
1919,  91 :257. 

33.  Riessmann,  D.  :  Influenza  .  .  .  Symptoms,  Pre- 
vention, and  Treatment,  Medical  Clinics  of  North  America, 
2  :903,  1918. 

34.  Villard,  E.  :  Les  fausses  appendicitis  grippales, 
Lyon  Mcdicale,  127:534,  December,  1918. 

35.  Deaver,  J.  B. :  Surgical  Sequelae  of  Influenza,  Med- 
ical Clinics  of  North  America,  2:699,  November,  1918. 

36.  Meyer,  J. :  Clinical  Picture  of  Influenzal  Pneumonia 
and  Its  Complications,  International  Clinics,  Series  29,  3  :112, 
1919. 

37.  Warfield,  L.  M.  :  Appendicitis  as  a  Sequel  to  In- 
fluenza, Wisconsin  Medical  Journal,  18:129,  September, 
1919. 

38.  Veyrassat  :  Perforation  appendiculaire  d'origine 
grippae.  Rev.  Med.  d.  I.  Suisse  Rom.,  39  :78,  February,  1919. 

57  Trumball  Street. 


THE  TREATMENT  OF  DRUG  ADDICTION. 

By  Thomas  F.  Joyce,  M.  D., 
New  York, 

Resident  Physician  in  Charge,   Riverside  Hospital, 
North  Brother  Island 

Drug  addicts  may  be  divided  into  two  general 
classes.  The  first  class  is  composed  of  people  who 
have  become  addicted  to  the  use  of  drugs  through 
illness,  associated  probably  with  an  underlying  neu- 
rotic temperament.  The  second  class,  which  is  over- 
whelmingly in  the  majority,  is  at  the  present  time 
giving  municipal  authorities  the  greatest  concern. 
These  people  are  largely  from  the  underworld  or 
channels  leading  directly  to  it.  They  have  become 
addicted  to  the  use  of  narcotic  drugs  largely  through 
association  with  habitues  and  they  find  in  the  drug 
a  panacea  for  the  physical  and  mental  ills  that  are 
the  result  of  the  lives  they  are  leading.    Late  hours. 


August  14,  1920.] 


JOYCE:  DRUG  ADDICTION. 


221 


dance  halls,  and  unwholesome  cabarets  do  much  to 
bring  about  this  condition  of  body  and  mind  and  in 
a  great  many  cases  these  people  are  found  far  below 
the  standard  mentally. 

On  August  25th  last  a  hospital  for  the  treatment 
of  drug  addiction  was  opened  at  Riverside  Hospital 
on  North  Brother  Island.  While  a  few  isolated 
cases  had  been  treated  there  previously,  up  to  that 
time  it  was  found  practically  impossible  to  give  cases 
withdrawal  treatment  in  large  numbers.  Beginning 
September  1st  an  organization  was  established 
whereby  we  were  enabled  to  treat  successfully  one 
hundred  cases  a  week  when  required. 

When  a  drug  addict  reached  the  hospital  his  pedi- 
gree was  taken  and  he  was  admitted  to  the  receiving 
ward,  where  all  his  clothing  and  belongings  were 
checked  up  and  an  entire  new  outfit  given  him,  in- 
cluding hospital  shoes.  From  this  building  he  was 
taken  to  what  we  term  the  preparatory  ward,  where 
after  a  period  of  six  days  he  was  brought  down  to 
the  lowest  amount  of  narcotic  that  would  hold  him 
without  the  usual  signs  of  drug  deprivation.  Our 
experience  has  taught  us  the  absolute  uselessness  of 
ascertaining  the  amount  of  daily  consumption 
before  treatment.  For  the  majority  of  cases  the 
amount  is  very  much  increased  for  fear  of  a  too 
sudden  reduction. 

We  have  been  taught  that  in  the  vast  majority  of 
cases  they  are  using  much  larger  amounts  than  is 
necessary  for  their  bodily  comfort,  in  other  words, 
most  of  our  patients  have  come  to  the  hospital  not 
only  feeling  comfortable  but  actually  intoxicated 
from  excessive  doses  of  the  drug.  We  have  been 
taught  that  after  two  or  three  days  in  the  hospital  the 
oldest  offender  can  be  made  reasonably  comfortable 
on  from  two  to  three  grains  in  twenty-four  hours, 
notwithstanding  the  fact  that  most  of  them  have  told 
us  that  they  were  consuming  from  twenty  to  sixty 
grains  of  morphine  or  heroine  in  twenty-four  hours. 
Four  fifths  of  the  2,300  patients  treated  at  Riverside 
Hospital  were  addicted  to  heroine  while  about  one- 
fifth  were  addicted  to  morphine,  opium  pipe  smok- 
ing, laudanum,  or  paregoric.  About  twelve  and  one- 
half  per  cent,  of  the  heroine  addicts  were  continual 
users  of  cocaine  while  five  per  cent,  would  be  termed 
occasional  indulgers.  The  fact  of  the  addiction  be- 
ing complicated  by  the  use  of  cocaine  made  little  or 
no  difference  with  us  during  the  period  of  prepara- 
tion, they  just  simply  did  not  get  it  and  did  without 
it.  The  use  of  cocaine  itself  gives  none  of  the  symp- 
toms of  deprivation  as  do  the  products  of  opium. 
During  this  period  of  six  days  reduction  we  gave 
them  a  full  amount  of  catharsis  but  there  was  no 
drastic  purgation.  We  employed  a  system  of  gastro- 
intestinal elimination  on  the  fourth  day  by  giving 
capsules  of  calomel,  ipecac,  rhubarb,  atropine  and 
strychnine,  supplemented  by  a  series  of  colonic  saline 
irrigations.  The  free  catharsis  that  this  treatment 
caused  was  usually  quite  effectual  and  on  the  fifth 
day  elimination  by  this  method  was  discontinued, 
to  be  resumed  again  on  the  sixth  day. 

At  six  o'clock  on  the  morning  of  the  seventh  day 
the  patients  are  given  a  large  dose  of  castor  oil 
followed  shortly  afterwards  by  a  small  dose  of  mor- 
phine,  the   last   they   receive    in   the  institution 


unless  otherwise  indicated.  About  four  hours  later 
the  first  signs  of  drug  deprivation  are  usually  expe- 
rienced. This  is  a  signal  to  start  using  a  therapeutic 
anesthetic.  At  Riverside  Hospital  we  use  the  hyo- 
scine  hydrobromate.  I  may  say  here  that  we  use 
hyoscine  internally  practically  with  the  same  object 
in  view  that  the  general  anesthetist  employs 
ether,  in  other  words,  as  these  various  symptoms 
reappear,  small  but  adequate  doses  of  hyoscine  are 
given  at  irregular  intervals,  depending  upon  the 
physiological  action  in  the  particular  case.  Person- 
ally I  find  hyoscine,  when  used  with  reasonable 
care  and  in  small  doses,  and  particularly  after  thor- 
ough and  satisfactory  elimination,  a  perfectly  safe 
therapeutic  agent,  wonderfully  adapted  to  this  stage 
of  the  treatment.  During  this  period,  which  we  have 
termed  the  period  of  therapeutic  anesthesia,  we  are 
combating  all  the  phenomena  attending  narcotic  de- 
privation, such  as  vomiting,  general  restlessness,  in- 
testinal colic,  cramps  in  the  legs,  and  a  rapid,  feeble 
pulse.  These  characteristic  symptoms  are  held  in 
check  by  the  frequent  administration  of  small  doses 
of  hyoscine,  usually  hypodermically.  At  the  end  of 
thirty-six  hours,  under  favorable  conditions  the 
hyoscine  is  discontinued  and  we  arrive  at  the  period 
of  convalescence.  Before  considering  this  period  it 
might  be  well  to  mention  some  of  the  difficulties  en- 
countered in  connection  with  the  hyoscine  period. 
During  the  period  of  hyoscine  administration  no 
food  whatever  is  given  but  plenty  of  alkaline  waters. 

In  the  first  place,  no  two  cases  ever  present  the 
same  symptoms  at  the  same  time,  consequently  every 
case  presents  an  individual  problem.  In  one  case 
it  may  require  only  nine  or  ten  doses  of  1/300  of  a 
grain  to  keep  the  patient  comfortable,  while  in  an- 
other case  thirteen  or  fourteen  doses  of  1/250  of  a 
grain  may  be  required  to  combat  the  symp- 
toms of  deprivation.  Again,  the  patient  may  have 
been  a  habitual  cocaine  user  and  we  find  this  type 
gives  considerable  trouble  during  the  withdrawal 
treatment ;  they  very  frequently  after  eighteen  to 
twenty- four  hours  of  hyoscine  anesthesia  become 
maniacal  and  often  go  into  convulsions.  We  have 
found  that  a  single  dose  of  morphine  at  this  stage 
will  counteract  these  symptoms  and  in  no  way  inter- 
fere with  the  hyoscine  treatment,  which  is  resumed 
two  or  three  hours  later.  At  this  stage  of  the  treat- 
ment we  produce  what  might  be  properly  termed  a 
modified  twilight  sleep.  After  thirty-six  to  forty- 
eight  hours  of  withdrawal  treatment  the  patients  are 
found  to  be  moderately  intoxicated  by  the  accumu- 
lative action  of  hyoscine ;  even  after  a  period  of 
twelve  hours  they  experience  all  the  customary  signs 
of  their  intoxication  and  we  describe  this  period  as 
the  posthyoscine  hysteria.  This  is  followed  in  twelve 
hours  by  a  general  feeling  of  depression  and  weak- 
ness which  lasts  from  two  to  seven  days,  depending 
upon  the  recuperative  powers  of  the  individual  and 
the  duration  of  the  addiction.  During  this  early  con- 
valescent period  they  are  given  hot  baths  and  mild 
hypnotics,  if  indicated,  and  a  restricted  diet. 

Forty-eight  hours  after  the  last  dose  of  hyoscine 
is  given  the  majority  of  patients  are  ready  to  be 
transferred  to  a  building  which  we  term  the  first 
convalescent  ward.     When  patients  are  not  quite 


222 


LANE:  DETECTING  DRUG  HABITUES. 


[New  York 
Medical  Journal. 


ready  to  be  sent  to  the  ward,  they  are  transferred  to 
a  building  known  as  the  infirmary,  for  the  reception 
of  patients  whom  we  term  laggards.  These  laggards 
comprise  patients  who  through  long  years  of  ad- 
diction and  numerous  treatments  have  become  de- 
vitalized and  their  convalescence  is  usually  prolonged 
and  tedious.  After  a  week  or  ten  days  in  the  first 
convalescent  ward  the  patients  are  transferred  to 
the  final  convalescent  ward,  where  their  physical 
reconstruction  begins.  They  are  given  light  exer- 
cise in  the  gymnasium  and  they  are  taught  the  use- 
ful lessons  of  clean  living.  After  a  week  of  walk- 
ing around  and  indulging  in  light  exercise  they  are 
assigned  to  some  work  which  we  have  included  in 
our  program  under  the  name  of  occupational  thera- 
py. The  application  of  this  treatment  is,  I  might 
say,  tile  most  trying  in  the  entire  course,  for  the 
average  drug  addict  of  this  type  is  lazy,  to  say  the 
least,  but  we  have  been  able  at  Riverside  Hospital 
to  prove  to  them  the  necessity  for  their  physical 
upbuilding,  if  they  are  to  abstain  from  drug  addic- 
tion. For  after  all  we  can  bring  them  to  a  state  of 
physical  balance  where  the  future  use  of  the  nar- 
cotic drug  is  unnecessary  to  their  physical  needs ; 
we  can  keep  them  long  enough  to  show  them  the 
folly  of  their  addiction,  we  can  impress  upon  them 
the  fact  that  they  do  not  need  the  temporar}^  mental 
exhilaration  that  goes  with  its  use,  but  as  yet  we 
have  found  nothing  that  will  remove  the  psychic 
trauma  that  its  prolonged  use  has  inflicted. 

The  prognosis  in  drug  addiction,  to  my  mind,  is 
one  of  the  most  difficult  in  the  entire  field  of  medi- 
cine, and  in  venturing  upon  one  we  must  take  into 
consideration  the  etiological  factors  that  led  to  the 
addiction,  the  type  of  the  individual,  the  environment 
to  which  the  patient  will  return,  and  the  encourage- 
ment that  society  in  general  will  mete  out  to  this 
unfortimate  sutferer  upon  his  discharge  from  our 
institution. 


A  XEW  METHOD  FOR  DETECTING  DRUG 
HABITUES. 

Bv  Harold  C.  Laxe,  M.  D., 
Denver,  Colo. 

The  finger  of  a  suspected  opiophagic  patient  is 
stabbed  with  an  automatic  lance.  The  blood  is  drawn 
into  a  Gowers's  blood  pipet  holding  two  cm.  This 
is  expelled  into  a  small  test  tube  five  by  five-eighths 
cm.,  containing  one  c.c.  of  normal  saline  sohition. 
This  is  repeated  for  five  more  saline  tubes.  The 
tubes  are  numbered  1-2-3-4-5-6.  Shake  each  tube 
gently  immediately  after  the  blood  is  introduced. 
Prepare  two  more  saline  tubes  and  number  them  7 
and  8.  If  any  shreds  or  clots  of  blood  should  be 
present,  remove  them  with  a  sterile  platinum  wire. 
As  a  rule  they  will  not  be  present. 

Tubes  1  and  2  are  controls,  containing  only  saline 
solution  and  blood.  To  tubes  3  and  4  add  .2  c.c.  of  a 
1-100  solution  of  morphine  sulphate  in  distilled 
water.  The  solution  should  be  neutral,  it  must  not 
be  either  acid  or  alkaline  therefore  it  should  be  tested 
with  red  and  blue  litmus  paper  and  with  phenolph- 
thalein  and  methyl  orange  indicators.  To  tubes  5 
and  6  add  .2  c.c.  of  a  1-200  solution  of  morphine  sul- 


phate made  with  a  good  grade  of  the  drug  in  dis- 
tilled water.  Tubes  7  and  8  contain  the  blood  of 
normal  individuals. 

RESULT  OF  TEST. 

After  standing  at  room  temperature  out  of  the  light 
for  from  twelve  to  twenty-four  hours  or  even  less, 
tubes  1  and  2  (controls)  show  complete  inhibition 
of  hemolysis  with  a  clear  supernated  fluid.  Tubes  3 
and  4  show  almost  complete  inhibition  of  hemolysis 
with  a  very  cloudy  supernated  fluid.  This  flocculent 
flaky  appearance  is  the  positive  test  for  a  drug 
habitue.  Tubes  5  and  6  show  a  modified  flocculent 
appearance  of  supernated  fluid.  Tubes  7  and  8  (true 
controls  of  normal  blood)  show  a  clear  supernated 
fluid  with  complete  inhibition  of  hemolysis.  I  would 
like  to  caution  the  investigator  that  upon  agitation 
of  the  tubes,  the  flocculent  deposits  settle  to  the  bot- 
tom of  the  tubes.  The  tubes  should  be  placed  against 
a  black  background  in  order  to  accurately  interpret 
the  results,  as  a  clear  bright  light  obscures  the 
readings. 

It  is  also  possible  that  the  reaction  takes  place  with 
any  of  the  narcotic  drugs  such  as  heroine,  codeine, 
and  others.  The  blood  of  a  drug  user  has  amboceptor 
with  at  least  one  narcophore  binding  cell  which  has 
an  affinity  for  the  drug  the  patient  is  taking.  This  is  a 
rapid  method  of  testing  the  blood  of  a  dri:g  addict 
as  the  blood  does  not  have  to  be  passed  through  the 
lower  animals  to  secure  antiserum.  All  the  glass- 
ware should  be  sterile,  the  technic  is  simple  and  any- 
one can  do  the  test.  The  test  may  also  be  done  with 
rabbit  serum  which  has  been  sensitized  with  the 
blood  serum  of  a  drug  habitue.  I  do  not  state  that 
this  test  is  perfect  but  in  the  course  of  time  it  should 
be  made  an  aid  to  diagnosis. 


A   BACTERIOLOGICAL   STUDY   OF  RIPE 
OLIVES. 

By  R.\xdle  C.  Rosenberger,  M.  D., 
Philadelphia. 

Professor  of  Hygiene  and  Bacteriology,  Jefferson  Medical  College. 

This  Study  of  ripe  olives  was  made  under  the  au- 
spices of  the  Dairy  and  Food  Commission  of  the 
State  of  Pennsylvania  following  several  epidemics 
of  botulism  (attributed  to  ripe  olives)  with  fatal 
results  in  dilTerent  parts  of  the  United  States.  In 
all,  there  were  more  than  two  hundred  and  fifty 
samples  examined,  including  loose  olives,  canned 
varieties,  and  a  large  number  in  bottles.  Combi- 
nations of  ripe  olives  with  pimento  (sandwichola) 
were  also  included. 

All  specimens  of  olives  examined  were  in  per- 
fect condition  regarding  canning,  that  is,  there  were 
no  swelled  cans,  none  buckled  or  leaky,  and 
those  in  jars  and  bottles  presented  no  leaks  what- 
soever. Some  of  the  cans,  however,  were  dirty 
and  shopworn.  There  were  never  any  offensive 
odors  of  putrefaction  or  decomposition,  and  in  the 
majorit}-  of  samples,  the  flavor  was  good,  though 
in  a  few  an  insipid  taste  was  noted.  The  con- 
sistency of  the  fruit  was  extremely  variable,  as 
was  the  color,  which  varied  from  yellowish  green 
to  dark  green  and  to  a  reddish  purple,  and  a  num- 
ber of  cans  contained  olives  of  variegated  colors. 


August  14,  1920.] 


ROSEXBERGER:  BACTERIOLOGY   OF  RIPE  OLIVES. 


223 


When  placed  in  a  mortar  and  crushed  with  a 
pestle,  some  were  so  ripe  or  intensively  treated  chem- 
cally  that  the  pulp  was  immediately  reduced  to 
a  paste,  the  pit  being  expressed  at  once.  In  others 
a  great  deal  of  pressure  was  needed  even  to  crush 
the  pulp  and  the  pit  was  never  cleanly  removed. 
Taking  the  olive  between  the  fingers  and  thumb, 
XJressing  in  the  longitudinal  axis  and  exerting  but 
gentle  pressure,  was  all  that  was  necessary  to  make 
the  pit  fly  out  in  some  specimens  and  crush  the 
pulp.  In  twenty-two  specimens  this  pasty  condi- 
tion was  noted.  In  other  lots  of  fruit  no  amount 
of  pressure  between  the  fingers  and  thumb  could 
crush  the  olive  or  expel  the  pit. 

Thus  it  can  be  seen  that  even  in  the  same  cans, 
olives  exhibiting  several  degrees  of  ripeness  or 
various  stages  of  chemical  treatment  were  present, 
especially  in  the  small  variety.  In  three  instances 
an  actual  blemish  was  seen  upon  the  fruit;  in 
these  specimens  almost  every  olive  in  the  can  was 
marked  with  small  white  specks,  about  the  size  of 
a  pin  head,  resembling  an  insect  bite.  Removing 
several  of  these  small  spots,  there  were  observed, 
upon  microscopical  examination,  numerous  bacteria, 
resembling  in  morphology  and  staining  character- 
istics Bacillus  proteus.  .  When  these  olives  were 
squeezed  a  iet  of  fluid  squirted  from  the  little 
specks. 

In  two  specimens,  Grecian  ripe  olives,  the  fruit 
was  of  a  reddish  purple  color,  showed  longitudinal 
fissures  (cuts),  and  while  the  pulp  was  extremely 
soft,  the  pit  was  adherent.  The  olives  that  were 
collected  in  bulk,  when  allowed  to  stand  in  the 
bottles  for  a  day  or  two  after  examination,  soon 
became  covered  with  mold  fungi.  When  first  re- 
ceived they  were  moist,  showing  that  they  had  been 
covered  with  liquor  when  offered  for  sale.  One  or 
two  samples  presented  fruit  with  part  of  the  skin 
peeling  off,  and  these  were  distinctly  sour  to  the 
taste.  The  technic  employed  in  the  bacteriological 
examination  of  these  olives  was  as  follows : 

After  numbering  the  specimens,  the  top  of  the 
can  or  jar  was  cleaned  with  a  rag,  and  then  ex- 
posed to  the  flame  of  a  bunsen  burner,  or  placed  in 
boiling  water,  to  remove  any  bacteria  from  the  sur- 
face of  the  receptacle.  The  can  or  jar  was  next 
opened  with  a  can  opener,  which  was  always  kept 
in  a  bath  of  boiling  water.  Upon  opening  the 
can.  the  first  several  layers  were  removed  with  a 
sterile  forceps,  and  from  the  depths  of  the  can  at 
least  four  large  or  six  small  olives  were  placed  in  a 
sterile  mortar  and  then  cut  with  a  sterile  scissors 
or  crushed  with  a  sterile  pestle.  After  crushing 
the  pulp,  about  thirty  c.  c.  of  sterile  salt  solution 
was  added,  and  the  pulp  thoroughly  ground  in  this 
solution.  Then  with  a  long  sterile  needle  (made 
•expressly  for  anerobic  cultures)  at  least  one  to 
two  c.  c.  of  suspension  were  drawn  into  a  sterile 
ten  c.  c.  syringe  and  injected  into  deep  tubes  of  cul- 
ture media,  the  surface  of  the  medium  covered  with 
sterile  oil  and  the  tubes  kept  at  ordinary  room  tem- 
perature. The  culture  media  used  were  alkaline 
litmus  glucose  agar,  alkaline  gelatin  and  a  medium 
made  with  pumpkin  as  a  basis,  solidified  with  agar. 
These  inoculations  were  kept  under  observation  for 
at  least  two  or  three  weeks.  No  evidence  of  growth 


or  liquefaction  occurred  up  to  this  time.  Sterile 
bouillon  was  also  inoculated,  using  ten  c.  c.  of  the 
liquor  from  the  cans  or  jars.  In  almost  every  in- 
stance, at  body  temperature  (370°  C.)  in  an  aerobic 
atmosphere,  a  firm  pellicle  developed  within 
twenty-four  to  thirty-six  hours.  These  inocula- 
tions were  made  into  bouillon  to  determine  if  the 
liquor  contained  living  aerobic  organisms. 

Regarding  the  investigation  of  the  toxicity  of 
the  olives,  the  salt  solution  suspension  made  of  the 
pulp  was  injected  intraperitoneally  into  guineapigs 
and  white  mice.  One  c.  c.  was  injected  into  the 
white  mice  and  two  c.  c.  into  the  guineapigs.  (In 
the  white  mice  the  dose  injected  was  about  one 
twentieth  of  the  body  weight  of  the  animal.)  It 
is  asserted  by  ^'on  Ermengem  and  others  that  .0005 
c.  c.  of  toxin  is  fatal  to  guineapigs  and  mice,  so 
these  animals  surely  would  have  received  an  amount 
sufiicient  for  poisoning,  if  present  in  samples.  These 
animals  were  kept  under  observation  for  a  number 
of  days. 

In  another  set  of  animals,  feeding  experiments 
were  conducted  upon  white  mice.  The  .  salt  sus- 
pensions of  the  olives  were  placed  upon  bread  and 
this  was  all  the  animals  were  given  for  twenty-four 
hours.  It  is  said  that  the  most  pronounced  symp- 
tom of  botulism  in  the  lower  animals  is  paralysis  of 
the  posterior  extremities.  Xo  animal  under  obser- 
vation presented  these  symptoms. 

Three  mice  (3883,  3865,  1263)  died  of  traumatic 
peritonitis  following  inoculation  (six  hours,  twelve 
hours,  twenty-four  hours)  ;  one  mouse  (6675)  was 
killed  as  a  result  of  a  fight;  two  others  died  (3865. 
1264)  from  inoculation,  but  no  lesions  were  observed 
at  autopsy,  and  the  heart  blood  was  free  from  bac- 
teria. One  mouse  died  within  twenty-four  hours 
after  being  fed  on  soaked  bread.  Xo  lesions  were 
demonstrable  at  autopsy,  and  its  blood  was  sterile. 
One  guineapig  (3862)  died  after  four  days,  but 
autopsy  showed  few  adhesions  in  peritoneal  cavity 
and  the  blood  was  sterile. 

As  none  of  the  animals  died  of  botulism  it  was 
thought  that  by  allowing  the  suspension  to  stand 
for  a  day  or  two  in  the  ice  box  more  toxin  (if 
present)  would  be  brought  into  solution.  But  even 
after  standing  this  length  of  time,  and  inoculating 
and  feeding  mice  and  guineapigs.  no  ill  results  were 
noticed.  In  examining  the  sediment  of  the  salt  sus- 
pension, organisms  of  some  sort  were  observed  in 
all  specimens.  A  number  contained  hyphae  and 
spores  of  mold  fungi;  quite  a  number  contained 
yeasts  and  molds,  while  the  greatest  number  showed 
gram  negative  bacilli.  A  few  others  showed  gram 
positive  baciUi.  Some  contained  gram  positive 
micrococci,  arranged  in  short  chains,  and  in  a  few 
the  chains  of  micrococci  were  gram  negative.  In 
two  specimens  a  bacillus  was  encountered  which 
possessed  the  characteristics  of  the  Bacillus  tetani. 
i.  e.,  about  the  same  size  and  with  a  terminal  round 
spore.  It  was  generally  gram  negative,  however. 
Long  filaments  resembling  leptothrices,  and  bacilli 
corresponding  in  morphology  to  lactic  acid  bacilli 
were  also  encountered.  In  some  specimens,  even 
though  the  consistency  of  the  fruit  was  pasty,  verv 
few  organisn-is  were  found,  and  in  others,  every  field 
of  the  slide  was  well,  filled  with  microorganisms. 


224 


ROSEXBERGER:  BACTERIOLOGY    OF  RIPE  OLIVES. 


[New  York 
Medical  Jourxal 


If  the  ripe  olives  would  cause  botulism,  there  was 
abundant  opportunity  for  the  production  t)f  the 
disease,  as  there  were  three  of  us  working  upon  the 
specimens,  each  eating  at  least  twelve  to  twenty 
olives  a  morning,  during  examinations  lasting  sev- 
eral weeks.  On  one  occasion,  several  people  ate  at 
least  one  quart  of  the  olives  in  the  course  of  two 
hours  and  no  untoward  symptoms  resulted. 

To  determine  whether  the  fruit  would  undergo 
any  putrefactive  changes  after  being  kept  for  a 
certain  time,  a  number  of  olives  were  placed  in 
sterile  bottles  and  placed  in  -  various  parts  of  the 
laboratory.  Some  had  a  small  quantity  of  the  orig- 
inal liquor  upon  them  while  others  were  kept  with- 
out liquor.  Some  were  kept  at  ordinary  room  tem- 
perature upon  the  window  sill  of  the  laboratory, 
some  in  a  dark  closet,  while  others  were  kept  in  the 
refrigerator.  One  can  was  kept  half  full  of  olives 
with  some  of  the  original  liquor  upon  them.  (The 
ordinary  room  temperature  during  these  observa- 
tions varied  from  18°  to  21°  C).  At  the  end  of 
four  months  no  disagreeable  odor  was  noticeable 
and  except  in  those  where  no  liquor  was  left  on 
specimens,  slight  shrinkage  of  the  fruit  was  ob- 
served, otherwise  there  was  no  change  in  the  ap- 
pearance or  consistency.  In  all  specimens,  how- 
ever, a  mold  fungus  developed. 

In  one  bottle,  holding  500  c.  c,  olives  of  various 
brands  were  placed  with  liquor  completely  covering 
the  fruit,  and  on  the  surface  of  the  liquor  a  pellicle 
of  mold  fungus  developed  and  one  or  two  olives 
on  the  surface  were  found  quite  soft  and  mushy, 
but  the  majority  of  the  fruit  was  as  good  as  when 
placed  in  the  jar.  In  all  specimens  where  the  mold 
odor  was  not  predominant,  the  agreeable  aromatic 
odor  of  the  ripe  fruit  was  noticeable.  In  the  can 
which  was  kept-  unsealed  on  the  window  sill  for  four 
months  a  rather  tough  mold  pellicle  developed  but 
the  fruit  for  the  most  part  was  intact  and  absolutely 
odorless.  In  a  sterile  flask  holding  the  liquor  of 
several  containers  which  stood  around  the  lab- 
oratory for  over  three  months,  complete  evaporation 
of  the  liquor  occurred  and  the  residue  gave  off  an 
oily  odor  but  lacked  anything  of  a  disagreeable 
nature. 

Four  months  after  date  of  preliminary  examina- 
tions, specimens  that  were  kept  upon  the  window  sill 
and  working  table,  exposed  to  daylight,  and  those 
from  inside  a  dark  closet,  were  ground  up  in  a  sterile 
mortar  and  sterile  salt  solution  added.  This  salt  sus- 
pension was  inoculated  into  guineapigs  in  amounts 
of  0.5  c.c.  subcutaneously.  None  of  the  animals  ex- 
hibited the  slightest  ill  effects,  showing  an  entire 
absence  of  the  development  of  any  poisonous  sub- 
stances in  olives  that  were  originally  sound  and 
which  had  been  left  standing  at  ordinary  room  tem- 
perature for  a  period  of  several  months  (under 
various  conditions  of  sunlight).  All  the  olives 
examined,  as  stated  before,  gave  off  a  pleasant, 
aromatic  odor,  and  even  when  kept  for  a  long  pe- 
riod of  time  (four  months)  with  and  without  the 
preserving  liquor,  the  same  aroma  was  noticeable 
and  in  some  an  oily  odor  was  observed. 

Tubes  containing  sterilized  macerated  ripe  olives 
were  inoculated  with  a  strain  of  Bacillus  botulinus 


obtained  from  the  Department  of  Agriculture  in 
\\'ashington,  and  though  no  difference  in  the 
consistency  of  the  olives  was.  noted,  yet  a 
disagreeable,  rancid,  heavy  penetrating  odor  devel- 
oped anaerobically  which  persisted  for  a  number  of 
days  following  the  removal  of  the  oil  making  the 
anaerobic  seal.  Regarding  the  strength  of  the  liquor 
upon  these  olives  as  originally  prepared,  it  was 
found  by  La  Wall  that  "the  density  of  the  brine  of 
the  moist  packed  olives  was  investigated  and  found 
to  vary  greatly.  The  lowest  figure  was  1.75  per 
cent,  of  salt  present  and  the  highest  was  9.3  per 
cent.,  the  average  being  slightly  less  than  four  per 
cent."  In  the  unripe  olive  the  salt  content  of  the 
liquor  is  usually  about  six  to  seven  per  cent.  With 
reference  to  the  preparation  of  the  olives  in  glass, 
it  has  been  found  that  the  temperature  to  which 
these  packages  are  exposed  in  preparation  was  far 
lower  than  that  where  the  olives  were  packed  in 
cans.  In  those  instances  where  deaths  occurred 
from  botulism  it  was  stated  that  the  fruit  gave  off 
an  offensive,  putrid  odor. 

In  my  opinion  ripe  olives  when  packed  should  be 
sound  and  placed  in  a  six  or  seven  per  cent,  solution 
of  salt  and  sterilized  as  thoroughly  as  any  other 
canned  fruit  or  vegetable.  Where  glass  packages 
are  used,  naturally  the  glass  must  be  of  a  suitablv 
tempered  nature  to  withstand  heating  to  a  high 
degree ;  the  commercial  glass  used  will  not  stand  this 
high  temperature  without  cracking. 

It  is  probable  that  the  olives  which  caused  the 
death  of  individuals  partaking  thereof  were  un- 
clean, putrid  or  decomposing  when  packed,  and  the 
heat  to  which  they  were  exposed  was  not  high 
enough  nor  prolonged  sufficiently  to  destroy  the 
toxins  or  spores  already  developed.  Dickinson  (1) 
and  his  coworkers  proved  that  the  spores  of  the 
Bacillus  botuHnus  resist  the  temperature  of  boiling 
water  for  two  hours,  and  a  temperature  of  95 °C. 
for  more  than  three  hours.  According  to  earlier 
observers,  especially  Von  Ermengem,  a'  temperature 
of  80° C.  for  one  hour  effectively  destroyed  the 
spores  of  the  organism.  The  work  of  Burke  (2) 
demonstrates  the  ubiquity  of  the  Bacillus  botulinus. 
She  found  in  five  localities  in  Central  California 
fifty  or  more  miles  distant  from  each  other.  Bacillus 
botulinus  in  bruised  and  bird  pecked  cherries,  crop, 
gizzard,  and  intestinal  contents  of  birds,  hay,  leaves, 
insects,  spiders,  bush  beans,  etc.  She  concludes 
that  the  Bacillus  botulinus  is  widely  distributed  in 
nature,  and  that  it  is  present  in  the  garden  and  on 
fruit  and  vegetables  when  they  are  picked  and  not 
necessarily  associated  with  active  decay.  The  ob- 
servations of  Cheyney  (3)  proved  that  an  average 
of  eight  per  cent,  of  canned  foods  examined  con- 
tained living  organisms,  and  that  the  usual  methods 
of  processing  are  inefficient  in  that  they  do  not  re- 
sult in  a  complete  sterilization. 

What  is  desirable  is  a  sterile  product,  whether 
this  product  be  meat,  olives,  or  vegetables  of  any 
kind,  and  until  this  end  is  attained,  there  will  occur 
outbreaks  of  food  poisoning  of  one  type  or  another 
with  perhaps  some  fatal  results.  The  work  of  \\'ein- 
zirl  (4)  upon  canned  foods  is  also  instructive  in 
demonstrating  the  care  exercised  by  commercial 


August  14,  1920.] 


LOXDOX  LETTER. 


225 


industries   in   the   canning   of    many  foodstuffs. 

From  the  examinations  made  of  various  brands 
and  varieties  of  ripe  oHves,  no  evidence  of  Bacillus 
botulinus  or  its  toxin  was  found.  Bacteria  were 
present  in  all  preparations  but  no  anaerobic  organ- 
isms developed  in  the  gelatin  or  litmus  lactose  agar 
or  pumpkin  agar  (which  were  made  alkaline  in 
reaction). 

From  the  rancid,  offensive  odor  developed  in  the 
macerated  olives  by  the  growth  of  Bacillus  botulinus 
intentionally  added,  it  would  appear  that  where  any 
canned  foodstuff  gave  off  this  odor  it  should  imme- 
diately be  rejected.  The  number  and  variety  of 
organisms  found  in  spreads  demonstrate  that  gross 
carelessness  was  exercised  in  a  sanitary  sense  in 
preparation  of  the  fruit,  or  that  these  bacteria  prob- 
ably represent  the  organisms  found  in  overripe  or 
decaying  fruit. 

REFERENCES. 

1.  Archives  of  Internal  Medicine,  December  15,  1919. 

2.  Journal  of  Bacteriology,  1919,  iv,  541. 

3.  Journal  of  Medical  Research,  xl,  177,  July,  1919. 

4.  Ibid:  xxxix,  349,  Januarj-,  1919. 


LOXDOX  LETTER. 

Smoke  Ei'ils  in  London. — Disabled  Ex-Service  Men. 
(From  our  ozvn  correspondent) 

LoxDOX,  June  23,  1920. 

On  June  18th  the  Ministry  of  Health  issued  an 
interim  report  of  the  Department  Committee  of 
Smoke  and  Xoxious  \^apors  Abatement,  in  which 
it  is  stated  that  means  which  produce  little  or  no 
smoke  are  available  and  practicable  for  cooking, 
heating  water,  and  warming  rooms,  and  among  rea- 
sons for  issuing  an  interim  report  is  that  the  great 
housing  schemes  now  being  undertaken  with  the 
aid  of  the  Government  subsidy  afford  a  unique  op- 
portunity for  securing  these  means  in  the  new 
houses.  The  committee  profess  themselves  as 
satisfied  that  domestic  smoke  from  the  burning  of 
raw  soft  coal  is  not  only  a  serious  menace  to  health 
and  a  damage  to  property,  but  also  wasteful,  as  all 
the  valuable  byproducts  are  lost.  Central  hot  wa- 
ter installation  is  strongly  advocated,  from  the 
standpoint  of  health,  comfort,  and  economy.  Among 
the  conclusions  and  recommendations  made  by  the 
committee  are  the  following :  Whenever  a  supply  of 
gas  is  available  a  gas  stove  shall  be  installed  instead 
of  a  coal  range. 

The  cheapest  and  most  efficient  way  of 
providing  hot  water,  where  a  central  supply 
is  not  practicable,  is  by  a  coke-fired  boiler.  As  far 
as  practicable  gas  fires,  hot  water  radiators,  or  elec- 
tric radiators  should  entirely  supersede  the  old 
fashioned  open  coal  fire,  adequate  means  for  ven- 
tilation being  provided.  In  none  of  the  houses  built 
with  the  assistance  of  the  Government  subsid)- 
should  more  than  one  or,  in  exceptional  circum- 
stances, two  coal  grates  be  installed.  Whenever 
coal  ranges  and  coal  grates  are  installed  they  should 
be  of  a  type  adapted  to  the  use  of  coke  as  well  as 
of  coal. 


Adequate  means  for  regulating  the  draught 
should  in  all  cases  be  provided.  The  cen- 
tral housing  authority  should  decline  to  sanction  any 
housing  scheme  submitted  by  a  local  authority  or 
public  utility  society  unless  special  provision  is 
made  in  the  plans  for  the  adoption  of  smokeless 
methods  for  supplying  the  required  heat.  The  only 
exception  to  this  should  be  when  the  central  author- 
ity is  fully  satisfied  that  the  adoption  of  such  meth- 
ods is  impracticable.  The  Government  should  en- 
courage the  coordination  and  extension  of  research 
into  domestic  heating  generally. 

^    ^  ^ 

On  June  16th  evidence  was  given  before  the 
House  of  Commons  Select  Committee  on  Pensions 
with  regard  to  the  employment  of  exservice  men, 
and  particularly  disabled  men.  Mr.  T.  W.  Phillips, 
principal  assistant  secretary  to  the  Ministry  of 
Labor,  who  has  charge  of  the  employment  depart- 
ment, stated  that  there  were  420  employment  ex- 
changes and  1,196  branch  employment  offices  in 
the  United  Kingdom.  In  the  period  since  the  armis- 
tice to  Mav  last  the  exchanges  had  found  employ- 
ment for  1,612,000  individuals,  824,000  men  and 
490,000  women,  of  whom  about  403,000  were  ex- 
service  men  who  were  placed  in  employment  for  the 
first  time  since  leaving  the  forces.  In  addition, 
there  were  large  numbers  of  exservice  men  whose 
return  to  preservice  employment  was  arranged  by  the 
exchange  under  the  demobilization  scheme  period. 
During  the  same  period  about  £988,200  was  paid 
out  in  unemployment  benefit  under  the  national  in- 
surance acts,  and  about  £52,534,000  in  out  of  work 
donations. 

In  August,  1918.  there  was  established  at 
Catherine  Street,  Aldwych,  a  special  exchange  to 
deal  with  disabled  men  only,  the  staff  itself  consist- 
ing almost  entirely  of  disabled  men.  A  member  of 
the  exchange  staff  attended  the  office  of  the  Xeuro- 
logical  Board  at  Lancaster  Gate  and  took  particu- 
lars of  the  neurasthenic  men.  About  1,700  cases 
had  been  registered  and  thirty-three  placed  monthly, 
while  337  had  been  submitted  for  training.  These 
cases  presented  exceptional  difficulty,  as  most  em- 
ployers declined  to  take  neurasthenic  men..  The 
manager  was  submitting  a  scheme  for  coordinating 
curative  treatment  and  placing.  On  June  4th  last, 
the  number  of  firms  on  the  national  roll  was  16,- 
989,  employing  an  aggregate  of  2,496,677  work 
people,  of  whom  140,759  were  disabled.  The  total 
number  of  disabled  men  placed  in  employment 
through  the  exchanges  since  the  armistice  up  to 
May  28,  1919,  was  71,983. 

An  analysis  which  was  compiled  of  the  types 
of  disability  of  the  disabled  men  who  had  applied 
to  the  exchanges  for  assistance  in  obtaining 
employment  from  June  17,  1918,  to  the  end  of  May, 
1920,  showed :  Injuries  to  arms,  40,569  men :  in- 
juries to  legs,42,610  men;  lung  affections,  16,967; 
hea4-t  affections,  16,581;  neurasthenia,  12,406;  in- 
ternal injuries,  14,090;  rheumatism,  10,009;  debil- 
ity and  weakness,  8,040 ;  injuries  to  head,  7,801  ; 
injuries  to  eyes,  6,811;  muscular  ailments.  4,407; 
epilepsy,  2,099;  mental  derangements,  1,425;  deaf- 
ness, 3,127;  various  minor  ailments,  25,881. 


Editorial  Notes  and  Comments 


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NEW  YORK.  SATURDAY.  AUGUST  14,  1920. 


AUTHOR  PHYSICIANS— DR.  CONAN 
DOYLE. 

Although  Sir  Arthur  Conan  Doyle,  the  creator 
of  Sherlock  Holmes,  was  for  several  years  a  prac- 
tising physician,  it  was  foreordained  from  the  very 
beginning  of  his  career  that  literature  rather  than 
medicine  should  be  his  life  work.  He  began  writ- 
ing stories  of  adventure,  his  biographers  tell  us,  at 
the  feeble  old  age  of  six.  Against  such  precocity 
what  chance  was  there  for  mere  medicine?  Alto- 
gether Dr.  Doyle's  medical  activities  covered  a 
period  of  about  ten  years,  not  counting  .the  time 
he  spent  in  South  Africa  during  the  Boer  War, 
when  he  was  honorary  senior  physician  and  regis- 
trar in  the  Langman  Field  Hospital. 

Dr.  Doyle  was  born  in  Edinburgh  on  May  22, 
1859,  and  was  graduated  from  Edinburgh  Uni- 
versity in  1881  as  an  -\I.  D.  A  year  later,  after  a 
voyage  to  South  Africa,  he  began  practicing  in 
Southsea,  but  the  practice  of  medicine  to  him  was 
more  of  a  makeshift  than  anything  else,  despite  the 
elaborate  preparation  he  had  made  for  it  at  Edin- 
burgh and  in  Germany.  All  through  his  student 
days  he  devoted  his  leisure  hours  to  writing,  and 
in  one  of  the  professors  at  Edinburgh,  Dr.  Joseph 
Bell,  a  man  of  astonishing  analytical  and  deduc- 
tive powers,  he  found  the  original  from  whom 
Sherlock  Holmes  was  subsequently  drawn. 

It  was  in  1878  that  his  first  story  was  published 
in  Chambers'  Journal — a  romance  based  on  an  old 
Kafifir  superstition,  but  it  was  not  until  nine  years 


later,  when  he  was  attending  patients  in  Southsea, 
that  his  Study  in  Scarlet  came  out.  It  was  in  this 
volume  that  Sherlock  Holmes  and  Dr.  Watson 
made  their  first  appearance,  but  the  popularity  of 
the  book  was  not  astonishingly  great  nor  the  royal- 
ties from  it  large.  Dr.  Doyle  continued  the  practice 
of  medicine.  In  1890  his  The  White  Company  and 
TJic  Firm  of  Girdlcstonc  were  published,  and  he 
left  Southsea  and  went  to  London  as  an  eye  special- 
ist. Soon  thereafter  the  royalties  from  his  books 
and  the  checks  for  his  serials  and  short  stories 
began  to  pour  in,  and  he  forsook  the  medical  pro- 
fession forever. 

W'hat  the  loss  to  the  medical  profession  may 
have  been  is  uncertain,  but  there  is  no  doubt  that 
the  gain  to  literature  Avas  considerable.  As  a  writer 
Dr.  Doyle  has  firmly  established  himself  in 
English  literature.  Few  writers  have  been  more 
versatile  than  he.  We  think  of  him  mainly  in  con- 
nection with  the  Sherlock  Holmes  stories.  Prob- 
ably on  these  his  greatest  fame  will  rest,  though 
critics  contend  that  from  a  literary  standpoint  his 
best  work  was  done  in  the  field  of  the  historical 
novel — The  White  Company,  Micah  Clark,  The 
Refugees  and  others,' tales  of  olden  times  full  of 
action  and  hairbreath  escapes,  good  description, 
convincing  atmosphere,  and  painstaking  fidelity  to 
detail. 

Dr.  Doyle  is  also  a  poet  and  historian.  Two 
vokmies  of  poems — Songs  of  Action  and  Songs  of 
the  Road — stand  to  his  credit,  and  in  the  field  of 
history  he  gave  us  two  volumes  on  the  Boer  War 
and  was  Britain's  official  historian  of  the  British 
campaigns  in  France  and  Flanders  during  the 
world  war.  The  British  Government  gave  him 
sole  access  to  official  records  and  other  sources, 
from  which  he  compiled  the  six  volumes  which  tell 
of  the  British  army's  part  in  the  struggle  against 
Germany. 

As  if  this  were  not  versatility  enough.  Dr.  Doyle 
also  has  won  laurels  in  the  playwriting  field.  Per- 
haps the  best  known  of  his  work  in  this  line  is 
Waterloo,  a  one  act  play  written  in  1894,  in  which 
Sir  Henry  Irving  played  the  leading  part,  hoxh  in 
this  country  and  in  London. 

However,  it  was  Sherlock  Holmes  who  gave  Dr. 
Doyle  his  tremendous  popularity,  a  popularity  that 
has  had  few  parallels  in  literature.  With  these 
stories  of  crime  detecting  he  set  a  vogue  which 
brought  out  a  host  of  imitators.  As  for  detective 
stories  today  on  the  Holmes  model,  their  name  is 
legion.    This  is  not  to  say  that  Dr.  Doyle  was  the 


August  14,  1920.] 


EDITORIAL  ARTICLES. 


227 


first  to  write  a  detective  story.  The  controversy 
over  whether  he  or  Edgar  Allan  Poe  created  the 
detective  story  is  a  literary  cause  cclcbrc  which  has 
raged  for  many  years.  Certainly  Poe  wrote  the 
first  detective  stories,  but  just  as  certainly  Dr. 
Doyle  created  the  rnodern  detective  as  he  exists  in 
the  literature  of  our  time. 

In  all  Dr.  Doyle's  stories  there  is  a  masculine, 
healthful  and  courageous  spirit.  His  pages  are 
stimulating  from  first  to  last.  He  sees  life  as  a 
whole,  and  his  outlook  is  broad  and  genial.  His 
is  a  sane  philosophy  of  life,  and  one  does  not  have 
to  be  a  good  guesser  to  size  him  up  for  a  man  of 
action,  an  outdoor  man,  a  devotee  of  all  outdoor 
sports,  who  has  been  whaling  in  the  Arctic  seas, 
has  made  balloon  and  airplane  flights,  has  been 
skiing  in  the  Swiss  Alps,  and  is  a  crack  rifle  shot 
and  an  inveterate  golfer.  Time  was  when  he  was 
a  formidable  foe  at  football  and  cricket,  but  ad- 
vancing years  have  crowded  those  activities  into 
the  background. 

In  recent  years  Dr.  Doyle  has  become  greatly 
interested  in  the  occult  science,  and  is  one  of  the 
staunchest  upholders  of  the  theory  of  spiritism. 
In  all  Dr.  Doyle's  writings  only  one  volume  is  of 
a  medical  nature  and  that  in  no  wise  technical — 
Round  the  Red  Lamp,  Being  Facts  and  Fancies  of 
Medical  Life,  published  in  1895.  Dr.  Doyle  was 
knighted  in  1902. 


EARLY  SYMPTOMS  OF  NERVOUS 
DISEASE. 

The  trend  of  medicine  seems  to  be  in  the  direc- 
tion of  preventive  treatment.  Sir  James  Mac- 
kenzie, the  great  specialist,  has  retired  while  at 
the  height  of  his  fame  to  the  small  city  of  St. 
Andrews  in  Scotland  to  endeavor  to  carry  out 
his  views  with  regard  to  the  early  symptoms  of 
disease.  His  idea  is  to  teach  the  general  prac- 
titioner how  to  recognize  and  treat  the  early  symp- 
toms of  disease,  for  the  general  practitioner  is  the 
only  man  who  is  likely  to  have  the  opportunity  of 
observing  early  symptoms.  This  is  the  essence 
of  preventive  medicine.  This  seemingly  most  ra- 
tional conception  of  the  practice  of  medicine  has 
caught  the  imagination  of  the  British  medical  pro- 
fession;  at  the  meeting  of  the  British  Medical  As- 
sociation the  subject  was  referred  to  at  every  turn, 
and  in  the  papers  read  the  necessity  for  early 
diagnosis  was  dwelt  upon.  If  a  disease  can  be 
diagnosed  before  it  has  gained  a  foothold,  proper 
treatment,  though  not  necessarily  always  thera- 
peutic, will  generally  prevent  it  from  progressing. 
Perhaps  cancer  is  the  most  selfevident  example  of 
this  truth.    If  cancer  can  be  diagnosed  at  an  early 


stage,  treatment  can  be  applied  whicli  promises 
most  satisfactory  results.  As  with  cancer  so  with 
most  other  diseases  early  diagnosis  ensures  suc- 
cessful treatment. 

Dr.  Henry  Head  at  the  recent  meeting  of  the 
British  Medical  Association  opened  a  discussion  in 
the  section  of  neurology  and  psychiatry  by  reading 
a  paper  dealing  with  the  early  signs  and  symptoms 
of  nervous  disease  and  their  interpretation.  He 
pointed  out  that  the  experience  and  outlook  of 
the  family  physician  leads  him  of  necessity  to  a 
different  attitude  toward  early  signs  and  symptoms 
than  that  of  the  specialist.  The  former  sees  so 
many  apparently  serious  conditions  pass  away  that 
he  tends  to  become  sceptical  with  regard  to  the 
minor  manifestations  which  often  lead  to  perma- 
nent disability.  On  the  other  hand,  the  knowl- 
edge of  the  consultant  leads  him  confidently  to 
anticipate  the  worst.  Moreover,  early  symptoms 
frequently  produce  so  little  discomfort  that  a 
medical  man  is  not  consulted.  Nearly  all  histories 
of  illness  taken  from  the  laboring  population  start 
from  the  moment  when  the  patient  was  forced  to 
leave  his  work.  Among  the  well  to  do,  the  story 
usually  begins  with  the  first  visit  of  the  doctor. 
Such  symptoms  as  precipitate  inactivation  or  slight 
changes  in  articulation,  though  trivial  manifesta- 
tions, may  be  of  profound  diagnostic  importance. 
Again,  early  signs  are  not  only  neglected  because 
they  seem  trivial,  but  the  physician  frequently  omits 
to  establish  their  true  nature  during  the  siiort 
period  of  their  existence.  Frequently  the  signifi- 
cance of  some  symptom  or  'sign  is  not  appre- 
ciated owing  to  the  adoption  of  a  misleading  gen- 
eral diagnosis.  The  early  pains  of  spinal  syphilis 
are  thought  to  be  due  to  fibrositis.  Disseminated 
.■■clerosis  frequently  begins  with  short  attacks  of 
what  is  called  influenza,  the  temperature  is  raised 
little  if  any,  but  the  patient  feels  ill,  with  a  general 
sense  of  powerlessness.  This  may  be  accompanied 
by  transitory  loss  of  vision,  diplopia,  or  inconti- 
nence of  urine.  But  the  diagnosis  of  influenza  has 
blinded  the  physician  to  the  condition  with  which 
he  has  to  deal.  Sometimes  the  history  though  ac- 
curate in  every  particular  may  be  almost  perverse- 
ly misleading.  A  cervical  rib  is  a  congenital  ab- 
normality and  yet  ihe  symptoms  and  signs  it  pro- 
duces may  become  manifest  for  the  first  time  at 
almost  any  age. 

The  war  has  taught  us  much  concerning  both 
functional  and  organic  nervous  disease  and  perhaps 
especially  concerning  the  different  varieties  of 
headache.  The  question  of  headache  alone  provides 
a  difficult  diagnostic  problem  to  the  medical  man, 
and  while  the  specialists  in  nervous  diseases  are 
far  from  comprehending  the  significance  of  the 


228 


EDITORIAL  ARTICLES. 


[New- 
Medical 


York 

JOVRNAL 


various  forms  of  headache,  they  can  be  classed 
roughly  according"  to  certain  broad  rules.  Dr. 
Head  does  this  in  the  paper  referred  to.  Many 
medical  practitioners  do  not  differentiate  between 
the  different  kinds  of  headache,  or  at  least  do  not 
apply  to  them  their  diagnostic  significance..  Some 
even  treat  a  headache  as  if  all  pains  in  the  head  were 
of  similar  diagnostic  import.  It  goes  without  say- 
ing that  early  diagnosis,  diagnosis  early  enough  to 
prevent  the  affection  from  going  farther,  is  very 
difficult,  frequently  impossible  even  when  the  gen- 
eral practitioner  is  sufficiently  well  trained  in  early 
s\inptoms  and  signs  and  their  significance.  But  it 
seems  that  a  good  deal  can  be  done  in  that  direc- 
tion. Early  diagnosis  and  proper  treatment  is  the 
really  scientific  preventive  medicine,  which  is  said 
to  be  the  medicine  of  the  future. 


INGUINAL  EPIDERMOPHYTIA. 

Since  the  war  a  dermatosis  has  become  singular- 
ly frequent,  namely,  the  mycosis  first  described  by 
Hebra  under  the  name  of  eczema  marginatum,  or 
tinea  cruris,  whose  causal  agent  is  the  epidermo- 
phyton  discovered  by  Sabouraud.  The  affection 
has  a  predilection  for  the  inguinal  region,  but  is 
not  confined  to  it,  because  it  is  also  frequently  found 
in  the  folds  of  the  axilla.  The  process  may  also 
develop  around  the  umbilicus  and  even  in  various 
degrees  on  the  trunk  and  limbs,  principally  the 
lower  limbs.  . 

When  it  occurs  in  the  inguinal  folds,  it  begins 
on  the  thigh,  in  the  immediate  neighborhood  of  the 
fold,  in  the  form  of  a  red,  dry,  irregularly  rounded 
spot,  extending  over  the  thigh  and  the  genitalia  and 
presenting  a  variable  aspect  after  fifteen  or  twenty 
days.  At  times  it  is  of  an  intense  red  color,  dry, 
smooth,  and  glistening,  slightly  desquamated  at  the 
centre  and  marked  off  by  a  slightly  raised  border, 
and  presents  a  thin  white  squamous  area  about  two 
millimetres  within  the  border  concentric  to  it.  At 
other  times  the  color  of  the  central  portion,  much 
less  marked,  is  slightly  fawn  yellow,  the  borders 
rose  colored  and  less  projecting,  and  immediately 
within  the  borders  a  continuous  zone  two  to  three 
millimetres  broad  is  seen,  made  up  of  fine,  thin, 
white  scales  that  are  more  or  less  detached.  Some- 
times instead  of  one  squamous  border  there  are 
two  concentric  ones  about  two  millimetres  apart, 
thus  forming  a  cockade. 

Usually  round,  the  patch  may  be  bilobate  or 
trilobate,  and  sometimes  at  a  short  distance  from  it 
will  be  found  clustered  together  regularly  shaped 
circles  having  the  same  appearance  and  varying  in 
size  from  a  pea  to  a  ten  cent  silver  piece.  On  the 
scrotum  and  labia  majora  the  lesion  assumes  a  dif- 


ferent aspect.  On  account  of  its  pale  rose  color  it 
is  hardly  noticeable,  but  it  manifests  itself  by  a  thin, 
fine  grayish  white  desquamation,  fomiing  a  rounded 
sinuous  outline,  recalling  the  gray  tint  which  char- 
acterizes cutaneous  lesions  in  the  negro. 

The  plaques  extend  to  the  suprapubic  region  only 
exceptionally  and  join  together  on  the  median  line. 
Less  infrequently  they  extend  to  the  posterior  aspect 
of  the  scrotum,  over  the  perineum  and  around  the 
anus,  and  cease  at  the  upper  portion  of  the  inter- 
gluteal  fold.  In  all  these  regions  the  lesions  are 
superficial,  pale  red  in  color,  and  their  limit  usually 
marked  by  a  border  of  desquamation.  They  are 
invariably  dry. 

The  second  site  of  election  for  epidermoph}-tia 
is  the  axillary  region,  where  the  spots,  rather  bright 
red  in  color,  rounded,  distinctly  limited,  with  a 
marked  desquamative  aspect,  are  frequently  mul- 
tiple and,  by  their  cohesion,  form  plaques  having  a 
polycjlical  contour.  They  occupy  the  axillary  hol- 
low. Localization  around  the  umbilicus  is  much 
less  common.  It  manifests  itself  by  a  rounded 
patch,  with  a  distinctly  limited  border,  with  or  with- 
out fine  desquamation,  often  measuring  as  much  as 
twenty  or  more  centimetres  in  diameter,  sometimes 
concentric  to  the  umbilicus,  at  other  times  more  or 
less  eccentric  to  it.  The  plaques  developing  on  the 
trunk  and  segments  of  the  limbs  are  also  rounded  in 
outline,  with  a  bright  red  surface,  and  slightly  raised 
distinctly  marked  edges  closely  surrounded  by  a 
more  or  less  marked  collar  of  desquamation.  Epi- 
dermophytia is  always  accompanied  by  pruritus, 
especially  nocturnal,  which  occurs  at  the  onset  of 
the  lesion  and  persists  while  recovery  is  taking 
place.  The  process  may  last  a  year  if  not  treated 
with  regularity,  but  after  a  certain  time  it  ceases  to 
spread.  Appropriate  treatment  results  in  a  rapid 
recovery. 

The  diagnosis  is  usually  easy,  but  in  doubtful 
cases  recourse  should  be  had  to  the  microscope.  The 
intertrigo  set  up  by  perspiration  occupies  the  in- 
guinal folds,  but  the  lesion  has  a  less  regular  con- 
figuration, undergoes  evolution  quickly,  and  is 
accompanied  b}-  a  manifest  oozing.  The  same  may 
be  said  of  eczema  of  the  region.  Psoriasis,  when 
it  develops  in  the  inguinal  area,  is  covered  by 
desquamation  which  is  made  more  distinct  by 
scratching,  and  if  this  is  continued  characteristic 
minute  droplets  of  blood  will  be  seen  to  appear.  In 
circumscribed  lichen  the  color  is  paler,  the  surface 
of  the  lesion  is  more  brilliant  and  typically  plaided. 
In  erythrasma,  the  long  duration  of  the  affection, 
the  yellow  color  of  the  plaques,  their  irregular  con- 
figuration with  finely  insular  borders,  and  the  ab- 
sence of  any  raised  surface  make  the  diagnosis  easy. 


August  14,  1920.] 


NEWS  ITEMS. 


229 


In  doubtful  cases  the  epidermis  should  be  super- 
ficially scraped  at  the  border  of  the  lesion,  the 
product  placed  on  a  slide  and  a  few  drops  of  a 
forty  per  cent,  potash  solution  added.  Cover  with 
a  slide,  beat  slightly  and  the  mycelian  filaments  can 
be  seen  composed  of  quadrangular  cells  having  a 
double  contour.  These  elements  are  seen  in  the 
midst  of  the  epidermic  cells  and,  contrary  to 
trichoph}1:osis,  they  are  invariably  absent  on  the 
hairs. 

Epidermophytia  is  rare  in  ordinary  times  but 
during  the  war  it  was  frequent.  It  was  often  trans- 
mitted by  direct  contagion,  sometimes  during  coitus. 
Lack  of  bodily  cleanliness  is  also  a  factor  in  its 
production,  and  it  would  seem  that  the  disease  can 
be  transmitted  by  the  underclothing  when  not  prop- 
erly dried.  Treatment  consists  of  repeated  applica- 
tions of  tincture  of  iodine  diluted  to  one-third 
strength  with  friction  over  the  surface  of  the 
plaques.  It  should  be  repeated  every  second  day 
for  ten  to  twelve  days.  As  to  the  pruritus,  it  can 
be  relieved  by  a  lotion  of  menthol  in  alcohol  diluted 
with  a  one  per  cent,  watery  solution  of  carbolic 
acid. 



News  Items. 


Dr.  Robinson  and  Dr.  Turner  Elected. — Dr.  G. 

Ernest  Robinson  and  Dr.  John  P.  Turner  were 
elected  associate  chief  surgeons  of  the  Frederick 
Douglass  Hospital,  Philadelphia,  at  a  staff  meeting 
on  July  30th. 

Award  of  Riberi  Prize. — The  Riberi  prize  of 
the  Royal  Medical  Academy  of  Turin  has  been 
awarded  to  Dr.  Giuliano  Vanghetti  for  his  work 
in  connection  with  the  utilization  of  the  muscle  of 
a  stump  to  actuate  an  artificial  limb"  (cineplastic 
operation) . 

Austrian  Children  in  Desperate  Condition.— 

Austria  has  asked  Switzerland  to  feed  45,000  Aus- 
trian children  for  six  weeks.  The  children,  it  is 
declared  by  medical  men,  will  either  perish  out- 
right or  grow  up  weaklings  unless  they  get  a  change 
and  proper  food. 

Jewish  Memorial  Hospital  to  Move. — The  Jew- 
ish Memorial  Hospital,  formerly  the  Philanthropin 
Hospital,  has  purchased  the  Inwood  House  at 
202nd  Street  and  Broadway,  New  York.  This  in- 
stitution will  be  renovated  to  accommodate  150  pa- 
tients and  is  expected  to  be  open  by  June  1,  1921, 
when  it  will  demonstrate  the  possibilities  of  an  open 
hospital. 

Vera  Cruz  Port  to  Reopen. — The  port  of  Vera 
Cruz  has  been  reopened  under  a  modified  quarantine 
against  bubonic  plague.  Regulations  were  drawn 
up  by  Dr.  Carl  Michel,  of  the  U.  S.  Public  Health 
Service,  and  Mexican  health  authorities.  A  cam- 
paign against  yellow  fever  will  be  begun  at  Vera 
Cruz  under  the  advisory  supervision  of  Dr.  Michel, 
along  the  lines  of  the  United  States  campaign  in 
Cuba  and  Panama. 


Royal  College  of  Surgeons  Fellowship  to 
Americans. — The  Honorary  Fellowship  of  the 
Royal  College  of  Surgeons  was  formally  pre- 
sented on  July  8th  to  four  distinguished  surgeons: 
Professor  John  Finney,  of  Johns  Hopkins  Univer- 
sity; Dr.  Charles  H.  Mayo,  of  Rochester,  Minn.; 
Professor  A.  Depage,  of  Brussels,  and  M.  Pierre 
Duval,  of  Paris. 

School  of  Rontgenology. — The  special  commit- 
tee of  the  New  York  Association  for  INIedical  Edu- 
cation has  drawn  plans  for  a  course  of  instruction 
in  rontgenology.  The  July  15th  Bulletin  of  the 
Association  states  that  one  of  our  universities  has 
expressed  a  willingness  to  open  and  develop  such 
a  department ;  one  of  the  leading  physicists  of  the 
country  and  a  staff"  of  the  best  rontgenologists  of 
New  York  have  agreed  to  serve  as  a  teaching  body 
and  that  provision  of  a  comparatively  small  sum 
of  money  to  purchase  equipment  and  start  the  work 
is  all  that  is  necessary  to  launch  this  excellent  and 
sorely  needed  new  department  of  medical  education. 

American  Hospitals  in  Near  East. — An  Ameri- 
can hospital  of  one  hundred  beds  has  been  estab- 
lished in  Stamboul,  the  Turkish  section  of  Constanti- 
nople. Dr.  A.  R.  Hoover,  a  resident  of  Turke}-  for 
many  years,  will  be  the  director,  and  Dr.  Elfie  Rich- 
ards Graff,  formerly  physician  to  Vassar  College  and 
a  member  of  the  Wellesley  unit  of  the  American 
Committee  for  Relief  in  the  Near  East,  will  be  his 
assistant.  Equipment  for  the  hospital  will  be  sup- 
plied by  the  American  Red  Cross  and  the  personnel 
by  the  Red  Cross  and  the  American  Committee  for 
Relief  in  the  Near  East.  Constantinople  College 
for  Women  will  open  a  school  for  nurses  in  connec- 
tion with  the  hospital  and  within  a  year  will  open  a 
woman's  medical  college. 

An  open  air.  hospital  for  tuberculous  children  has 
also  been  established  on  the  shores  of  the  Bosporus, 
a  few  miles  north  of  Constantinople,  under  the  direc- 
tion of  the  American  Committee  for  Relief  in  the 
Near  East.    Dr.  Elfie  Richards  Graff  is  the  director. 

 ^  • 

Died. 

Althans.— In  New  York,  N.  Y.,  on  Tuesday,  August 
3d,  Dr.  Charles  H.  Althans,  aged  eighty-three  years. 

AsHER. — In  New  Orleans,  La.,  on  Monday,  July  5th,  Dr. 
Philip  Asher,  aged  fifty-three  years. 

BoRNio. — In  New  Orleans,  La.,  on  Saturday,  July  17th, 
Dr.  Domingo  Bornio,  aged  sixty  years. 

FuRTNEY. — In  Orosi,  Cal.,  on  Wednesday,  July  21st,  Dr. 
Henry  Furtney,  aged  sixty-three  years. 

Henry. — In  Lecompte,  La.,  on  Wednesday',  July  7th,  Dr. 
Eugene  L.  Henry,  aged  forty-six  years. 

Lewix.- — In  Buffalo,  N.  Y.,  on  Saturday,  July  31st,  Dr. 
William  C.  Lewin,  aged  fifty-seven  j'ears. 

Lewis. — In  Harrington,  Del.,  on  Sunday,  August  ist, 
Dr.  Beniah  L.  Lewis,  aged  seventy-two  years. 

McVea. — In  Baton  Rouge,  La.,  on  Monday,  July  5th, 
Dr.  Charles  J.  ^IcVea,  aged  fifty-one  years. 

INIeierhof. — In  New  York,  N.  Y.,  on  Thursday.  August 
Sth,  Dr."  Harold  Lee  Aleierhof,  aged  twenty-six  years. 

MoYER. — In  Lansdale,  Pa.,  on  Tuesday,  August  3d,  Dr. 
Samuel  C.  Moyer,  aged  seventj-four  years. 

RoBix. — In  New  Orleans,  La.,  on  Saturday,  July  loth, 
Dr.  Ernest  A.  Robin,  aged  fifty-one  years. 

Sever.axce. — In  Keeseville,  N.  Y.,  on  W^ednesday,  July 
28th,  Dr.  Karl  J.  Severance,  aged  fifty-four  years. 


Book  Reviews 


LOCAL  ANESTHESIA. 

Die  drtlichc  Betdubung,  ihre  ivissenschaftUchen  Gnind- 
lagen  und  praktische  Anwcndung.  Ein  Handbuch  und 
Lehrbuch.  Von  Prof.  Dr.  Heinrich  Braun,  Geh. 
Medizinalrat,  Direktor  des  Krankenstiftes  in  Zwickau. 
Fiinfte,  erganzte  und  teilweise  umgearbeitete  Auflage. 
Mit  208  Abbildungen.  Leipzig:  Joiiann  Ambrosius  Barth, 
1919.    Pp.  xvi-507. 

This  fifth  edition  contains  two  new  chapters  deal- 
ing with  operations  on  the  throat  and  on  the  ver- 
tebral column  and  thorax.  In  the  chapter  on  throat 
operations,  the  most  extensive  operative  procedures 
are  described,  including  strumectomy,  laryngectomy, 
adenectomy,  and  resection  of  the  pharynx  and 
esophagus  under  conductive  local  anesthesia.  The 
details  of  paravertebral  anesthesia  are  given  in  the 
chapter  on  thoracic  surgery  and  it  promises  to  be 
of  great  value  in  abdominal  operations.  Breast 
cancers  may  be  removed  under  local  anesthesia. 
The  chapters  on  operations  of  the  abdomen  and  on 
the  genitourinary  organs  and  rectum  have  been  re- 
written and  the  whole  work  has  been  brought  up 
to  the  minute  in  conformity  with  the  most  modern 
practice. 

The  first  half  of  the  book  deals  with  the  history, 
theory  and  physiological  principles  of  local  anesthe- 
sia, the  use  of  cocaine  and  its  toxicology,  and  also 
•of  the  other  local  anesthetics,  such  as  tropacocaine, 
■eucaine,  holocaine,  the  orthoform  group,  stovaine, 
alypine,  novocaine,  phenol,  quinine  and  urea  hydro- 
chloride, and  other  preparations  not  so  well  known 
or  used  in  this  country.  The  author  prefers  the  use  of 
novocaine  with  adrenalin  as  the  most  useful  of  them 
all.  The  various  methods  of  local  anesthesia  are 
described  in  detail.  '  It  is  the  author's  opinion  that 
the  belief  that  children  and  nervous  .adults  are  not 
amenable  to  local  anesthesia  is  no  longer  tenable 
because  of  the  improved  modern  technic.  He  has 
operated  upon  children  four  years  old  under  local 
anesthesia  with  the  aid  of  cajolery  and  bribery.  The 
indications  and  technic  of  infiltrative  and  conductive 
anesthesia  are  fully  described. 

The  illustrations  are  profuse  and  illuminating, 
in  many  cases  being  actual  photographs  of  opera- 
tive field.  The  bibliography  is  most  exhaustive 
and  up  to  date.  On  the  whole,  the  book  is  a 
valuable  adjunct  to  the  armamentarium  of  the  gen- 
eral surgeon  and  the  specialist,  and  of  distinct 
value  as  an  aid  to  the  student. 

HEREDITY. 

Heredity  and  Social  Fitness.  Study  of  Differential  Mat- 
ing in  a  Pennsylvania  Family.  By  Wilhelmixe  E. 
Key.  With  Charts.  Washington,  D.  C. :  Carnegie  In- 
stitute, 1920.    Pp.  102. 

More  than  a  century  ago,  there  came  to  Western 
Pennsylvania  a  German  with  his  wife  and  three  chil- 
■dren,  and  about  the  same  time,  three  married  Ger- 
man brothers.  They  all  acquired  land :  there  seemed 
no  obstacle  to  their  proving  a  blessing  to  their  adop- 
ted country.  Some  have  ;  but  tracing  the  defectives, 
as  they  drifted  from  place  to  place  in  Pennsylvania, 
these  have  been  found  to  constitute  the  dregs  of 
every  community.  The  author  has  undertaken  the 
tremendous  task  of  tracking  some  1,822  members 
of  the  two  families,  not  with  a  view  to  exhibit  her 


talent  for  such  research  or  to  prove  the  depravity 
of  man,  but  simply  to  show  how  the  histories  of 
the  various  branches  af¥ect  the  immigration  problem 
of  today,  and  how  far  these  two  branches  assimi- 
lated and  amalgamated,  seeing  they  were  planted  in 
a  progressive,  pioneer  community  where  democratic 
ideals  prevailed  and  opportunities  for  education 
were  fair.  There  was  amalgamation,  but,  then  as 
now,  the  defective  members  married  defective  na- 
tives or  incoming  itnmigrants,  while  the  superior 
ones  had  wives  from  the  better  native  strains.  The 
modern  inrush  of  immigrants  meets  conditions  far 
less  favorable  than  it  did  a  century  ago ;  Ellis 
Island,  after  all,  can  only  judge  superficially,  and 
the  need  for  colonization  schemes  for  the  unfit  is  in- 
creasing. The  author  suggests  five  main  remedial 
measures :  segregation  and  even  sterilization  of  the 
grossly  defective ;  state  control  of  marriage  through 
a  eugenics  board ;  Federal  control  of  immigration : 
creation  of  an  enlightened  public  sentiment  in  favor 
of  eugenic  mating,  and  eugenic  education  of  pros- 
pective couples.  All  this  ought  to  be  supplemented 
by  studies  abroad  to  prevent  the  transplanting  of 
strains  seriously  defective,  and  by  studies  here  to 
secure  the  locating  and  registration  of  the  increas- 
ingly unfit.  One  reads  of  vital  statistics,  and  the 
reader  of  this  book  will  find  the  facts  very  alive, 
very  impressive,  even  tragic,  not  inclining  the  flip- 
pant to  say  with  the  Irishman,  "What  has  posterity 
done  for  me  that  I  should  do  anything  for  pos- 
terity?" 

LEONARD  MERRICK. 

When  Loves  Flies  Out  o'  the  Windoii'.  By  Leonard  Mer- 
rick. With  an  Introduction  by  W.  Robertson  Nicoll. 
New  York :  E.  P.  Dutton  &  Co.,  1920.    Pp.  x-309. 

77!^  Worldlings.  By  Leonard  Merrick.  With  an  Intro- 
duction by  Neil  Munro.  New  York :  E.  P.  Dutton  & 
Co.,  1919.    Pp.  v-334. 

Leonard  Merrick  is  a  writer  who  for  a  long  time 
was  not  appreciated  by  anyone  but  the  literary 
critics  and  who  is  now  being  pushed  into  public 
favor  by  the  cumulative  acclaim  of  his  fellow  crafts- 
men. His  works  are  being  brought  out  in  a  new 
American  edition  with  prefaces  by  various  writers 
attesting  to  Mr.  Merrick's  artistry,  and  the  public 
is  finding  out  that  in  spite  of  this  they  are  splendid 
entertainment.  IMerrick's  stories — and  the  two 
novels  mentioned  are  preeminently  stories — are 
light  in  theme,  -expert  in  workmanship,  and  dis- 
illusioned in  mood.  There  is  no  padding  in  them 
and  no  undigested  psychology.  They  might  be 
used  as  models  for  college  courses  in  composition. 

Mr.  Merrick  is  most  at  home  in  the  theatrical  and 
literary  worlds  and  his  novel  When  Love  Flies  Out 
o'  the  Window  bears  the  earmarks  of  experience. 
There  is  more  than  a  touch  of  irony  in  his  depic- 
tion of  the  noted  author  who  was  lauded  by  all  the 
critics  but  whose  sales  did  not  warrant  his  pub- 
lishers advancing  fifty  pounds  on  account.  He 
knows,  too,  the  precarious  life  of  the  chorus  girl — 
one  day  with  an  engagement,  the  next  without — 
and  the  hopelessness  which  makes  her  snatch  at  an\^ 
sort  of  chance.  When  Love  Flies  Out  o'  the  Win- 
dow details  the  story  of  a  stranded  writer  and  a 
stranded  singer — how  he  rescued  her  from  the  cab- 


August  14,  1920.] 


BOOK  REVIEWS. 


231 


aret  in  Paris  where  she  was  singing,  how  they  were 
married  on  the  strength  of  the  two  guineas  weekly 
furnished  by  his  causcric  for  a  London  paper,  and 
how  the  two  guineas  suddenly  stopped.  Mr.  Merrick 
has  done  a  fine  piece  of  work  in  the  portrayal  of 
Lingham's  endeavor  to  prevent  his  wife's  returning 
to  the  stage,  of  his  struggle  when  circumstances 
finally  compelled  her  to,  and  of  the  bitterness  which 
caused  their  parting — all  because  Lingham  could 
not  see  her  as  a  comrade  to  share  the  downs  as  well 
as  the  ups  of  their  economic  life.  The  book  is 
written  with  a  fine  economy  of  means :  there  is  not 
an  unnecessary  incident  to  mar  the  course  of  the 
narrative,  not  a  shade  too  much  interest  on  the 
part  of  the  author  in  any  one  character  or  situation, 
and  the  happy  end  is  not  an  afterthought. 

The  IVorldling.';  is  a  melodrama  in  which  the  hero 
and  the  villain  are  the  same  person.  There  is  noth- 
ing new  about  the  theme — the  impersonation  of  the 
prodigal  son  by  an  adventurer  who  succeeds  in  his 
blufif,  marries  the  beautiful  daughter  of  a  neighbor- 
ing countess,  and  is  discovered  only  because  his 
partner  in  the  plot  turns  upon  him.  But  Mr. 
Merrick's  people  are  not  thus  easily  disposed  of : 
they  cannot  be  sharply  separated  into  the  sheep  and 
the  goats.  The  original  prodigal  son  is  a  waster, 
and  the  man  who  takes  his  place  is  a  rather  fine 
fellow  who  had  neither  the  luck  nor  the  hard- 
headedness  to  succeed  in  life.  The  countess's  daugh- 
ter is  a  cool,  artificial  beauty,  but  when  the  veneer 
cracks  she  is  much  the  same  as  other  women.  Even 
Blake's  fellow  plotter  is  moved  by  much  the  same 
springs  of  ambition  as  distinguish  more  laudable 
enterprises.  The  IVorldings  should  appeal  to  many 
readers.  Those  who  demand  incident  will  find  it  a 
compact,  quickly  moving  story  which  holds  the  in- 
terest from  cover  to  cover,  while  those  who  can 
see  beyond  the  plot  will  admire  the  skill  with  which 
Mr.  Merrick  has  clothed  a  conventional  theme  with 
the  flesh  and  blood  of  reality. 

WAR  NEUROSIS  IX  FICTION. 

Fctcr  Jameson.     Bv  Gilbert  Fraxkal'.    New  York :  Al- 
fred A.  Knopf.  1920.   Pp.  i-431. 

Gilbert  Frankau's  novel  fulfills  the  requirements 
of  the  postwar  fiction  readers.  It  describes  the 
■war  not  too  attractively,  yet  not  too  uncomfortably, 
and  the  characters  of  the  book  are  just  such  whole- 
some, fine  individuals  as  the  secretly  self  discon- 
tented reader  would  like  to  be.  The  business  man 
and  woman  will  delight  in  reading  of  the  adventures 
of  a  man,  essentially  a  business  man,  who  tottered 
on  the  brink  of  ruin  because  he  answered  the  call 
of  war,  and  yet  just  survived — not  in  his  business, 
from  which  he  escaped  unscathed,  however,  but  in 
his  comfort  and  future.  The  longing  for  adventure 
and  romance  in  business  that  has  not  found  achieve- 
ment in  us,  animates  the  pages,  rendering  the  hero's 
tobacco  industry  so  absorbing  to  him  that  his  wife 
and  family  are  forced  into  the  background. 

Returning  from  the  war,  a  war  neurosis  victim, 
Peter  Jameson  has  to  pass  through  the  conventional 
struggle  of  adjustment  to  a  world  where  business 
has  lost  its  urgency,  where  the  human  beings  in 
the  tale  have  a  romance  and  value  of  their  own. 
Peter's  father-in-law,  the  skilled  neurologist,  is  able, 


by  psychoanalysis  to  suspect  and  guide  him  through 
this  period  of  adjustment,  and  the  story  ends  with 
Peter's  gratifying  response  to  the  call  of  the  soil. 

England,  we  foresee,  is  safe,  with  her  sons  re- 
turning to  mother  earth.  This  amateur  farmer, 
probably  because  he  knows  his  business,  somehow 
succeeds  on  the  large  scale  of  his  other  business 
enterprises.  Romance  and  adventure  even  though 
it  be  only  in  the  growing  of  crops  once  more  lend 
the  scene  a  rosy  glow. 

NIETZSCHE. 

The  Antichrist.  By  F.  W.  Nietzsche.  Translated  from 
the  German.  With  an  Introduction  by  H.  L.  Mencken. 
New  York :  Alfred  A.  Knopf,  1920.    Pp.  vii-182. 

Poor  Nietzsche !  How  he  hated  those  who  in- 
cluded the  word  pity  in  their  vocabulary  and  yet  how 
can  one  help  pitying  him !  The  cause  of  this  was 
the  turn  of  circumstance,  his  ill  fitting  personality, 
a  heritage  of  ministerial  ancestors,  and  the  curse 
of  syphilis.  No  wonder  he  stood  on  the  edge  of 
the  world  and  howled.  With  his  inferiority  which 
he  strove  to  overcome  his  wit  sharpened,  and  often 
while  he  was  baying  at  the  harmless  moon  he  told 
of  things  we  knew  were  true.  He  spoke  of  the 
moon's  dull  light  and  of  how  it  differed  from  the 
sun.  j\Iany  were  struck  by  his  obvious  truths, 
others  were  convinced  by  his  keen  judgments  and 
attempted  to  swallow  his  creed,  but  they  found 
more  condiment  than  meat  in  the  dose. 

We  are  indebted  to  Neitzsche  for  many  bright 
and  truthful  sayings,  boldly  told.  When  we  ex- 
amine his  bravery  with  a  bit  of  care  we  find  it  no 
more  than  coward's  courage.  The  only  way  his 
works  can  be  read  with  profit  is  by  an  impartial 
separation  of  the  grain  from  the  chaff.  All  pre- 
judice must  be  cast  aside  and  we  must  soften  our 
judgments  and  consider  how  he  labored  under  many 
handicaps,  ever  seeking  an  external  cause  for  his 
own  misery  and  a  reason  for  his  insolvent  soul.  He 
found  little  good  in  man  and  even  less,  by  his  own 
confession,  in  woman.  Had  he  looked  more  into 
his  own  egotistical  being  he  would  perhaps  have 
found  the  causes  for  his  shortcomings  and  refrained 
from  damning  the  world,  its  inhabitants,  and  their 
ideas,  even  if  many  of  them  were  erroneous  and 
childish.  We  must  also  search  for  the  motive  of 
fear  that  prevented  him  from  finding  the  good  in 
man.  Was  it  that  he  trembled  at  losing  the  protec- 
tive armor  that  prevented  him  from  coming  into 
contact  with  his  fellow  man?    ]\Iost  likely. 

With  all  this  we  owe  the  man  a  debt.  Just  as 
Napoleon's  weakness  led  him  on  to  a  tremendous 
striving  without  peace  to  himself  and  to  great  cre- 
ative achievements,  so  it  was  with  Nietzsche.  We 
cannot  afford  to  cast  him  aside  and  let  his  little  liked 
mannerisms  keep  us  from  the  many  fundamental 
teachings  he  left.  It  is  only  a  question  of  realization 
that  many  beautiful  flowers  and  useful  foods  owe 
their  existence  to  manure.  The  difficulty  is  that 
few  of  us  relish  the  task  of  the  horticulturalist, 
especially  when  the  fertilizer  has  a  strong  stench  as 
of  ground  bone  dust.  We  must  not  make  the  error 
of  calling  him  Teutonic  and  carelessly  cast  him  aside. 
He  was  of  Polish  origin.  This  should  not  influence 
us  one  way  or  another  for  the  seekers  after  truth 


232 


BOOK  REVIEWS. 


[New  York 
Medical  Jourxai, 


have  no  scruples  in  borrowing  their  material  wher- 
ever they  find  it. 

Just  what  Alenken's  idea  was  in  writing  an  elab- 
orate preface  is  a  bit  difficult  to  determine.  Per- 
haps he  wished  to  identify  himself  with  a  really 
great  man  and  immortalize  himself  by  being  bound 
into  one  volume  with  the  pugnacious  Nietzsche. 
He  can  best  answer  this  himself,  for  he  is  still 
among  the  living. 

O.  HENRY  PRIZE  STORIES. 

0.  Henry  Memorial  Azmrd  Price  Stories  iQig).  Chosen  by 
the  Society  of  Arts  and  Sciences.  With  an  Introduction 
by  Blanche  Coltox  Willi.\ms.  Garden  City  and  New 
York:  Doubleday,  Page  &  Co.,  1920.    Pp.  xvii-298. 

This  volume  of  stories  has  been  selected  as  the 
best  short  stories  that  have  appeared  in  American 
publications.  Aside  from  the  interest  they  offer  and 
the  pleasure  one  may  get  from  reading  carefully 
selected  short  stories  they  oft'er  an  added  value  in 
being  a  permanent  index  for  reference  of  what 
American  writers  are  doing.  It  is  stated  that  there 
has  been  a  dearth  of  short  stories  during  the  past 
year.  This  should  be  referred  to  as  being  relative, 
for  in  no  country  are  there  so  many  short  stories 
written.  The  demands  made  by  the  numerous  mag- 
azines are  tremendous  and  they  must  be  filled.  The 
editors  find  it  difficult  to  secure  enough  copy  and 
yet  keep  a  high  standard.  It  may  be  well  16  amend 
the  statement  and  say  that  the  number  of  good  short 
stories  is  limited,  that  the  standard  is  none  too  high. 
It  may  seem  strange  where  so  many  are  being  pro- 
duced that  so  few  are  of  a  really  high  standard.  In 
view  of  these  facts  it  is  commendable  that  we  have 
a  volume  containing  the  cream  of  what  has  been 
produced. 

Worthy  of  note  are  the  prize  story,  England  to 
America,  by  Margaret  Prescott  ]\Iontague,  and  the 
Porcelain  Cups  by  James  Branch  Cabell.  Cabell 
has  come  to  the  fore  and  he  has  received  recognition 
from  his  much  discussed  Jurgen.  He  has  great 
charm  and  more  depth  than  is  apparent  at  first 
glance,  both  from  the  material  which  he  handles 
in  a  masterly  way,  material  that  he  has  culled  from 
the  literature  little  appreciated  in  America,  and 'from 
the  subtle  irony  which  he  weaves  into  his  stories. 

This  is,  indeed,  a  splendid  book  for  vacation  read- 
ing, or  for  whiling  away  an  idle  half  hour.  We 
are  presented  with  stories  of  good  workmanship, 
wide  interests,  and  not  too  banal. 

 ^  

New  Publications  Received. 


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


FAIRY  TALES  FROM  FRANCE.  Retold  by  WiLLIAM  TROW- 
BRIDGE Larned.  Illustrations  in  Full  Color.  By  John  Rae. 
New  York,  Chicago,  and  Toronto :  P.  F.  VoUand  Company. 

travaux  neurologiques  de  GUERRE.  Par  Georges  Guil- 
lain,  Professor  agrege  a  la  Faculte  de  medicine  de  Paris ; 
Medicin  de  I'hopital  de  la  Charite ;  ct  J.  A.  Barr)!;,  Pro- 
fesseur  de  Neurologic  a  la  Faculte  de  medicine  de  Stras- 
bourg. Preface  de  Professeur  Pierre  M.\rie.  Paris :  Mas- 
son  &  Cie,  1920.    Pp.  xii-463. 


WHEN  L0\-E  flies  OUT  o'  THE  WINDOW.     By  LEONARD  MeR- 

RiCK.  With  an  Introduction  by  W.  Robertson  Nicoll. 
New  York :  E.  P.  Button  &  Co.,  1920.    Pp.  x-309. 

BARNS  UTSATTANDE  FOR  TUBERKULOS  SMITTA.     Av  EmaN- 

UEL  Bergman;  Medicine  Licentiat  av  Goteborgs  Nation. 
Uppsala :  Appelbergs  Boktryckeri  Aktiebolag.    Pp.  vii-126. 

GENERAL  psvcHOLOGV.  By  Walter  S.  Hunter,  Profcs- 
sor  of  Psycholog>%  University  of  Kansas.  Illustrated. 
Chicago:   The  University  of  Chicago  Press.    Pp.  xiii-351. 

NUEVAS,  ORIENT.^CIONES  SOBRE  L.A.  P.\T0GENI.A.  Y  TR.\TA- 
MIENTO  DE  LA  DI.\BETES  INSIPIDA.     Par  Dr.  GrEGORIO  MaRAS- 

NON,  de  Hospital  General.  Madrid :  Editorial  Saturnino 
Calleia,  S.  A.,  1920.    Pp.  xiii-174. 

RADIOGRAPHY  IN  THE  EXAMIN.\TI0N  OF  THE  LI\"ER,  GALL- 
BL.\DDER,  AND  BILE  DUCTS.  By  RoBERT  Knox,  M.  D.,  Hon. 
Radiographer,  King's  College  Hospital,  London.  A  Series  of 
Articles  Reprinted  from  Archives  of  Radiology  and  Electro- 
therapy. Illustrated.  St.  Louis :  C.  V.  ^losby  Company, 
1920.    Pp.  i-64. 

A  MANUAL  OF  KEUR.\STHENij\.  (Nervous  Exhaustion.) 
By  Ivo  Geikie  Cobb,  M.  D.,  M.  R.  C.  S.,  Neurologist,  Min- 
istry of  Pensions ;  Late  Assistant  to  Out  Patient  Physician, 
the  Middlesex  Hospital ;  Formerly  Neurologist,  Brinning- 
ton  Section,  Second  Western  General  Hospital.  New  York : 
William  Wood  &  Co.,  1920.    Pp.  xvi-366. 

X  KAY  OBSERVATIONS  FOR  FOREIGN   BODIES  AND  THEIR  LO- 

c.\LLZATioN.  By  Captain  H.'vrold  C.  Gage,  A.  R.  C,  O.  I.  P., 
Consulting  Radiographer  to  the  American  Red  Cross  Hos- 
pital of  Paris;  Radiographer  in  Charge,  Military  Hospital 
\'.  R.  76,  Ris  Orangis,  and  Complementary  Hospitals.  Il- 
lustrated.  St.  Louis :  C.  V.  Mosby  Company,  1920.   Pp.  i-83. 

EPIDEMIC  ENCEPHALITIS.  (Encephalitis  Lethargica).  By 
Frederick  Tilney,  M.  D.,  Ph.  D. ;  Professor  of  Neurology, 
Columbia  University ;  Attending  Neurologist,  the  Presby- 
terian Hospital  and  the  New  York  Neurological  Institute ; 
Consulting  Neurologist,  Roosevelt  Hospital,  New  York, 
and  Hubert  S.  Howe,  A.  M.,  M.  D. ;  Instructor  in  Neu- 
rologA-,  Columbia  University ;  Assistant  Visiting  Neurol- 
ogist, the  Presbyterian  Hospital,  New  York.  Illustrated. 
New  York:   Paul  B.  Heeber,  1920.    Pp.  xv.-252. 

DISEASES  OF  CHILDREN.  Presented  in  Two  Hundred  Case 
Histories  of  Actual  Patients  Selected  to  Illustrate  the 
Diagnosis,  Prognosis  and  Treatment  of  the  Diseases  of 
Infancy  and  Childhood,  with  an  Introductory  Section  on 
the  Normal  Development  and  Physical  Examination  of 
Infants  and  Children.  By  John  Lovett  Morse,  A.  M., 
M.  D. ;  Professor  of  Pediatrics,  Harvard  Medical  School; 
Visiting  Physician  at  the  Children's  Hospital,  and  Con- 
sulting Physician  at  the  Infants'  Hospital  and  at  the 
Floating  Hospital,  Boston.  Third  Edition.  Illustrated. 
Boston :  W.  M.  Leonard,  1920.    Pp.  v-639. 

ORAL  surgery.  A  Treatise  on  the  Diseases,  Injuries,  and 
Malformations  of  the  Mouth  and  Associated  Parts.  By 
Truman  W.  Brophy,  M.  D.,  D.  D.  S.,  LL.  D.,  Sc.  D., 
F.  A.  C.  S.,  President  and  Professor  of  Oral  Surgery,  Chi- 
cago College  of  Dental  Surgery;  Oral  Surgeon  to  St. 
Joseph's,  Michael  Reese,  and  other  Chicago  Hospitals :  Con- 
sulting Oral  Surgeon  to  the  Presbyterian  Hospital,  etc. 
With  Special  Chapters  by  Matthew  H.  Cryer,  M.  D.,  G. 
Hudson  Makuen,  M.  D.,  William  J.  Younger,  M.  D.,  F. 
W.  Belknap,  M.  D.,  C.\lvin  S.  Case,  M.  D.,  D.  D.  S.  With 
Nine  Hundred  and  Nine  Illustrations,  Including  Thirty- 
nine  Plates  in  Colors.  Philadelphia:  P.  Blakiston's  Son  & 
Co.,  1918.    Pp.  xvi-1090. 

tr.\ite  d'an.'VTOmie  humaine.  Par  P.  Poirier-A.  Charpy. 
Nouvelle  Edition  Entierement  Refondue.  Par  A.  Nicol.\s, 
Professeur  d'Anatomie  a  la  Faculte  de  Medicine  de  Paris. 
Avec  la  Collaboration deMM.O.AMOEDO,.ARGUAD,A.BRANCA, 
R.  Collin,  C.  Guneo,  G.  Delamare,  Paul  Delbert,  Dieu- 
lafe,  a.  Druault,  P.  Fredet,  Glantenay,  A.  Gosset,  M. 
Guide,  A.  Hovel.\cque,  P.  Jacques,  A.  Prenant,  H.  Rief- 

FEL,  ROUVIERE,  Ch.  SiMON,  A.  SoULIE,  B.  DE  FrIESE,  WeBER, 

Tome  Deuxieme,  Troisieme  Fascicule  Angeiologiee.  Capil- 
laires:  P.  J.\cqu-es  (revision  R.  Arguad).  Developpement 
des  veines :  A.  Ho\-el.\cque.  Systeme  veineux :  A.  Charpy 
(revision  A.  Hovelacque).  Structure  des  veines:  P. 
J.A.CQUES  (revision  R.  Arguad).  Veines:  A.  Charpy  (re- 
vision A.  Hovelacque).  Troiseme  Edition  Revue,  .^vec 
99  Figures  dans  le  Texte,  en  Noir  en  Couleurs.  Paris : 
Masson  et  Cie,   Pp.  i-278. 


Miscellany  from  Home  and  Foreign  Journals 


General  Anesthesia  with  Ethyl  Chloride  in 
Fractional  Amounts. — Paul  Lutaud  {Journal  de 
medccine  dc  Paris,  January  20,  1920),  from  ex- 
perience in  war  surgery,  comments  on  the  disad- 
vantages of  ether,  chloroform,  anesthetic  mixtures, 
and  other  procedures,  in  particular  as  regards  slow- 
ness of  induction,  ten  or  fifteeen  minutes  always 
elapsing  before  the  operation  could  be  started. 
Ethyl  chloride  is  highly  advantageous  in  this  and 
other  respects,  but  as  applied  hitherto,  yields  only 
a  brief  anesthesia.  Lutaud  uses  a  metallic  mask  of 
medium  size,  closely  adjusted  to  the  face  with  an 
inflatable  rubber  margin,  and  provided  within  with 
wire  netting  to  which  gauze  is  fastened,  and  above 
with  a  small  funnel  shaped  projection,  open  at  the 
top  and  communicating  with  the  interior  of  the 
mask.  The  mask  is  placed  in  firm  contact  with  the 
face,  the  patient  directed  to  breathe  out  completely 
two  or  three  times,  and  an  ordinary  ethyl  chloride 
or  kelene  tube  passed  into  the  funnel  shaped  open- 
ing. The  stream  of  ethyl  chloride  moistens  the 
gauze  within.  Anesthesia  is  generally  obtained  in 
one  minute ;  the  ethyl  chloride  tube  is  then  re- 
moved and  the  funnel  shaped  opening  closed  with 
the  finger  tips.  For  prolonged  anesthesia  only 
about  one-fifth  of  a  twenty  mil  tube  of  anesthetic 
is  at  first  used.  The  anesthetist  then  closes  the 
opening,  while  keeping  the  mask  firmly  against  the 
face,  and  later  renews  the  dose  of  ethyl  chloride 
according  to  requirements.  With  this  procedure 
the  patient  shows  much  less  cyanosis  than  where  a 
larger  amount  is  used  at  the  outset,  and  the  anes- 
thesia can  readily  be  kept  up  for  ten  or  fifteen 
minutes,  a  little  air  being  allowed  between  succes- 
sive doses  of  the  anesthetic,  provided,  however, 
complete  resolution  has  been  obtained  at  the  outset. 
Under  this  type  of  anesthesia  the  author  removed 
over  a  thousand  projectiles  with  the  x  ray  screen, 
and  did  several  htindred  operations  on  wounds,  in- 
cluding short  bone  operations,  such  as  compound 
fractures  and  ligations.  In  abdominal  work  the  in- 
cision was  made  under  ethyl  chloride,  the  ab- 
dominal cavity  explored,  and  the  anesthesia  then 
discontinued  during  such  maneuvers  as  intestinal 
suture,  being  later  resumed  for  closure  of  the  in- 
cision. A  gastrostomy,  two  gastroenterostomies, 
two  artificial  anus  operations,  acute  and  chronic 
appendicitis  procedures,  and  even  removal  of  a 
malignant  ovarian  cyst  in  a  countrywoman,  were 
successfullv  performed  under  ethyl  chloride. 

Pyelotomy  and  Nephrectomy.  —  Daniel  X. 
Eisendrath  (Annals  of  Surgery,  June,  1920)  from 
a  study  of  the  variations  and  anomalies  of  the  renal 
vessels  suggests  the  following  changes  in  operative 
technic : 

1.  During  nephrectomy  or  even  nephrotomy  the 
poles  of  the  kidney  should  be  most  carefully  ex- 
posed. The  mobilization  of  the  kidney  should  be 
gradual,  care  being  taken  both  at  the  lower  and 
upper  poles  never  to  tear  or  divide  adhesions  or 
strands  of  fibrous  tissue  before  they  have  been 
inspected  and  also  palpated  (for  a  possible  pulsa- 
tion) to  exclude  the  presence  of  a  supernumerary 


vessel.  I  have  found  the  suggestion  of  Kolisher 
an  excellent  one,  namely,  to  divide  the  ureter  in 
nephrectomy  before  attempting  to  mobilize  the 
kidney. 

2.  In  pyelotomy  one  must  bear  in  mind  the 
anomalies  of  the  retropelvic  vessels  which  I  believe 
have  been  reported  for  the  first  time  in  this  paper. 
Careful  exposure  of  the  pelvis  before  the  incision 
for  delivery  of  a  calculus  is  made  will  greatly  lessen 
the  chances  of  encountering  an  anomalous  vein  or 
arten,-. 

Treatment  of  the  Acute  Abdomen. —  J.  P  Run- 

yan  (Southern  Medical  Journal,  February,  1920) 
has  formulated  the  following  conclusions  from  the 
answers  received  to  a  questionnaire  sent  to  a  num- 
ber of  prominent  surgeons : 

1.  It  is  a  safe  and  sane  procedure  to  operate 
early  in  an  attack  of  acute  suppurative  peritonitis. 

2.  After  the  stage  of  contamination  comes  the 
stage  of  diff^use  peritonitis,  in  which  the  Ochsner 
treatment  offers  the  largest  proportion  of  recov- 
eries. 

3.  The  exceptions  to  rule  two  are  perforation  of 
duodenal  ulcer  and  gunshot  wounds  of  the  hollow 
viscera. 

4.  Do  not  hurry  too  much  to  operate  once  the 
Ochsner  treatment  has  been  started. 

5.  Following  the  Ochsner  treatment,  an  opera- 
tion should  be  done  and  Crile's  principles  applied 
in  the  aftertreatment  of  all  cases  of  septic  peri- 
tonitis. 

6.  Where  there  are  large  areas  of  denuded  peri- 
toneum, from  which  may  be  expected  a  considera- 
ble flow  of  pus  and  serum,  gauze  drainage  after 
the  manner  of  Mikulicz  or  Price  may  be  expected 
to  give  the  most  satisfactory  results. 

7.  In  cases  in  which  no  peritoneal  denudation  has 
occurred,  rubber  tube  drains  will  suffice. 

Amputation  of  the  Leg. — O.  Borchgrevink 
{Annals  of  Surgery,  June,  1920)  describes  the 
operation  which  he  follows  for  the  amputation  of 
the  leg  as  follows : 

From  a  point  eight  cm.  above  the  line  where 
the  tibia  is  to  be  divided,  make  a  longitudinal  incision 
through  the  skin  and  superficial  fascia  three  cm. 
behind  and  parallel  with  the  fibula.  The  incision  is 
curved  forward  above  the  head  of  the  fibula.  Place 
clips  on  the  edges  of  the  superficial  fascia.  Divide 
the  peroneal  nerve  behind  the  head  of  the  fibula, 
expose  it  upward;  reflect  its  divided  end  and  push 
it  upward  behind  the  biceps  tendon.  Divide  the  ten- 
don of  the  biceps  and  the  collateral  fibular  ligament 
as  close  to  the  fibula  as  possible  without  injuring 
its  periosteum.  Open  the  tibiofibular  joint  and  free 
the  head  of  the  fibula,  which  is  removed  after  divi- 
sion of  the  neck  of  the  bone.  Do  not  injure  the 
insertion  of  the  biceps  tendon  into  the  external 
tuberosity  of  the  tibia.  To  prevent  injury  of  the 
anterior  tibial  artery  and  vein,  expose  them  at  their 
passage  under  the  fibula.  Separate  the  interosseous 
membrane  from  the  shaft  of  the  fibula.  Be  careful 
neither  to  injure  its  periosteum  nor  the  main  vessels. 


234 


MISCELLAXY  FROM  HOME  AXD  FOREIGN  JOURNALS. 


[New  York 
Medical  Journ.u- 


Divide  the  fibula  at  the  lower  end  of  the  incision. 
From  the  inner  and  front  side  of  the  leg  make  a  flap 
consisting  of  skin  and  superficial  fascia.  The  flap 
must  at  least  be  five  cm.  longer  than  the  diameter 
of  the  leg  at  the  joint  chosen  for  the  division  of  the 
tibia.  At  the  same  level  join  the  upper  ends  of  the 
flap  incision  by  a  horizontal  incision  around  the 
outer  and  posterior  part  of  the  leg.  Divide  the  fibula 
two  to  three  cm.  above  the  last  incision.  Treat  both 
ends  of  the  left  piece  of  the  fibula  according  to 
Hirsch-Bunge.  Divide  the  muscles  at  the  line  chosen 
for  the  section  of  the  tibia.  Divide  the  tibia  and 
remove  its  periosteum  and  marrow  for  one  and  five 
tenths  to  two  cm.  upward.  With  the  standing  pa- 
tient the  sawn  surface  of  the  tibia  must  form  accu- 
rately a  horizontal  plane.  Its  edges  should  be 
rounded  with  a  file.  Every  point  of  the  end  of  the 
tibial  stump  must  bear,  and  bear  equally  much. 
Carefully  close  the  incision  of  the  superficial  fascia 
by  a  separate  catgut  suture.  Only  when  the  leg 
stump  has  a  length  of  at  least  fifteen  cm.  there 
can  become  a  question  of  leaving  a  piece  of  the 
fibula. 

In  case  of  reamputation  the  fibula  is  removed  in 
the  way  above  described.  If  the  stump  is  nonend- 
bearing,  a  part  of  the  tibia  if  sufficiently  large  for 
treatment,  according  to  Hirsch-Bunge,  is  amputated. 
If  the  stump  is  covered  with  healthy  and  movable 
skin  and  superficial  fascia,  these  should  be  separated 
from  the  bone,  but  otherwise  left  as  they  are.  Has 
the  end  of  the  stump  a  tender  and  immovable  scar, 
an  amputation  is  sufficient  for  the  covering  of  the 
stump  with  superficial  fascia  and  normal  skin  is 
necessary. 

Intravenous  Injections  of  Pancreas  Emulsions 
in  Experimental  Diabetes. — Israel  S.  Kleiner 
{Journal  of  Biological  Chemistry,  November, 
1 919)  adnunistered  to  dogs  rendered  diabetic  by 
depancreatization  slow  intravenous  injectioiis  of 
unfiltered  water  extracts  of  fresh  pancreas,  diluted 
with  0.9  per  cent,  sodium  chloride  solution.  In 
nearly  all  the  experiments  a  substantial  reduction 
in  the  blood  sugar  occurred  lasting  from  half  an 
hour  to  an  hour  and  three  quarters.  There  was 
also  a  diminution  in  the  excretion  of  sugar  in  the 
urine.  Controls  of  other  gland  extracts  failed  to 
produce  similar  results.  The  author  believes  that 
his  experiments  support  the  internal  secretion  the- 
ory of  experimental  diabetes  and  also  thinks  that 
the  pancreas  emulsions  might  be  used  as  a  thera- 
peutic agent  in  human  beings,  although  more  work 
will  have  to  be  done  on  this  problem  before  such 
injections  can  be  carried  out  safely. 

The  1918  Pandemic  of  Influenza  in  Canton. — 
— \\'illiam  W.  Cadbury  {China  Medical  Journal, 
Tanuary,  1920)  says  that  three  definite  epidemics  of 
influenza  appeared  in  Canton  during  the  spring,  fall, 
and  winter  of  1918,  co'inciding  in  time  with  the  ap- 
pearance of  the  disease  in  Europe  and  America.  In 
Canton  foreigners  were  but  slightly  affected.  The 
spring  epidemic  was  mild,  the  fever  lasting  but  two 
to  four  days ;  the  second  and  third  epidemics  were 
more  severe,  the  fever  usually  lasting  four  or  five 
days  and  complicated  in  some  cases  by  pneumonia. 
Males  suffered  more  than  females  .  At  the  Christian 
College,  Canton,  the  majority  of  the  patients  were 


boys  between  eleven  and  twenty  years  of  age ;  the 
older  students,  the  faculty,  and  the  servants  were 
affected  in  relatively  much  smaller  numbers.  Leu- 
copenia  was  generally  present.  The  fever  curve 
often  presented  two  high  peaks  from  one  to  four 
days  apart.  One  attack  of  the  disease  tended  to 
immunize  against  further  attacks.  The  disease 
tended  to  run  through  a  household,  affecting  ever)' 
member.    The  mortality  in  Canton  was  low. 

Injection  of  Cow's  Milk  in  Ocular  Infections. 

— D.  S.  Garcia  jNIansilla  (Revista  de  Medicina  V 
Cirugia  Practicas,  December  14,  1919)  states  that 
this  method  of  using  cow's  milk  by  injection  was 
first  used  by  Miiller  and  Thanner  in  Vienna  in 
1916,  not  only  for  the  treatment  of  ocular  infec- 
tions but  also  general  infections  such  as  influenza,, 
bronchopneumonia,  gonorrhea,  and  articular  rheu- 
matism. The  eye  infections  where  the  method  has 
been  found  of  value  are  acute  iritis,  infected  ulcers, 
of  the  cornea,  postoperative  infections,  purulent 
ophthalmia,  trachoma,  and  eczematous  keratitis. 
The  injections  are  given  intravenously,  subcon- 
junctivally,  or  intramuscularly;  the  quantity  being 
about  five  c.c.  and  the  interval  averaging  two  days. 

Icebox  Fixation  Method  in  the  Performance  of 
the  Wassermann  Reaction. — R.  G.  Owen  and 
F.  A.  Martin  {Journal  of  Laboratory  and  Clinical 
Medicine,  January,  1920)  believe  that  a  simple  alco- 
holic extract  of  human  heart  with  the  first  phase 
of  the  reaction  carried  out  at  7  to  10°  C.  for  four 
to  six  hours  gives  the  most  reliable  Wassermann 
results.  Like  other  observers,  they  obtained  false 
positives  in  a  considerable  munber  of  cases  when 
cholesterinized  antigens  were  used.  The  sera  from 
I.I  13  patients  was  examined  with  plain  antigen  at 
7  to  10°  C.  fixation  for  four  hours,  and  with  in- 
cubation at  37.5°  C.  for. one  hour  with  both  plain 
and  cholesterinized  antigen.  Fewer  doubtful  re- 
actions were  obtained  bv  the  icebox  fixation  method 
than  with  the  older  methods. 

Dislocation  of  the  Shoulder  Joint  and  Its  Treat- 
ment.— Alan  H.  Todd  {Practitioner,  March,  1920) 
asserts  that  the  present  aftertreatment  of  disloca- 
tions of  the  shoulder  by  fixation  of  the  arm  to  the 
side  is  irrational,  unscientific,  and  unsuccessful,  re- 
sulting in  limitation  of  abduction  and  osteoarthritis. 
In  rectangular  abduction  the  rent  in  the  capsule  is 
closely  coaptated,  whereas  in  adduction  the  capsule 
is  crowded  together  in  a  crinkly  lump  and  coheres 
in  that  position,  thus  limiting  abduction  and  causing 
pain.  The  arm  is  no  more  likely  to  redislocate  when 
placed  in  rectangular  abduction  than  when  it  is  tied' 
to  the  side.  If  abduction  is  adopted,  the  resulting 
movements  are  much  better ;  they  are  obtained 
much  more  quickly  and  less  painfully. 

New  Treatment  of  Chronic  Suppurating  Otitis, 
with  Dakin's  Solution. — D.  A.  Ramos  Acosta 
{Revista  de  Medicina  y  Cirugia  Practicas,  January 
28,  1920)  has  found  that  Dakin's  solution  is  an  ex- 
cellent agent  for  the  rapid  cure  of  chronic  suppu- 
rating ears.  Having  eliminated  all  nasopharyngeal 
causes  of  ear  discharge,  this  method  should  be  the 
one  of  choice ;  further,  it  has  no  contraindications. 
To  avoid  irritation  of  the  auricle  it  should  be 
anointed  with  vaselin. 


Proceedings  of  National  and  Local  Societies 


MEDICAL  SOCIETY  OF  THE  STATE  OF 
XEW  YORK. 

One  Hundred  and  Fourteenth  Annual  Meeting, 
Held  in  New  York,  March  23  to  25,  1920. 

The  President,  Dr.  Claude  C.  Lytle,  of  Geneva,  in  the 
Chair. 

{Continued  from  page  1054,  Vol.  CXI.) 

SECTION  IX  SURGERY. 

Abdominal  Incisions. — Dr.  Charles  W.  Hen- 
xiXGTOX,  of  Rochester,  stated  that  there  was  still  a 
great  difference  of  opinion  in  reference  to  abdom- 
inal incisions.  The  final  decision  as  to  which  was 
best  would  be  reached  by  a  further  study  of  the 
normal  healing  of  tissues.  In  general,  the  location 
and  direction  of  the  incision  ought  to  be  determined 
by  its  effect  on  the  muscles  and  innervation.  The 
approach  to  this  question  depended  upon  anatomical 
and  embryological  considerations.  He  felt  that 
many  of  the  objections  recently  raised  to  the  Mc- 
Burney  incision  would  vanish  if  attention  were  paid 
to  the  complete  and  orderly  separation  of  the  layers. 
Whether  the  high  or  low  McBurney  incision  was 
to  be  employed  must  be  determined  by  examination 
and  final  palpation  when  the  patient  was  under  the 
anesthetic.  The  low  incision  was  preferable,  in  his 
opinion,  as  it  gave  better  access  to  the  abdomen. 
The  occurrence  of  hernia  after  the  McBurney  in- 
cision was  due  to  needless  destruction  of  the  in- 
nervation. The  other  lateral  incision  was  that 
through  Petit's  triangle,  with  a  similar  spreading  of 
the  muscles.  This  afforded  a  good  approach  to  the 
retroperitoneal  appendix  and  to  the  kidneys  and 
ureter.  This  incision  had  the  advantage  that  it 
admitted  of  excellent  closure  and  disturbance  of 
the  innervation  could  be  avoided  with  moderate 
care.  The  transverse  incision  had  been  slow  in 
gaining  favor,  and  justly  so,  in  his  opinion.  Al- 
though the  transverse  incision  permitted  a  wider 
exposure, '  the  muscle  fibres  of  the  rectus  muscle 
were  longitudinal ;  furthermore,  the  transverse  in- 
cision did  not  readily  lend  itself  to  enlargement  of 
alteration,  and  the  difficulties  of  closure  outweighed 
those  encountered  when  the  muscle  was  divided 
longitudinally.  The  best  way  of  closing  the  trans- 
verse incision  was  by  the  crossbuck  mattress 
suture.  The  best  approach  to  the  lower  abdomen 
was  by  the  classical  longitudinal  midline  incision. 
There  was  of  course,  greater  danger  to  the  innerva- 
tion from  a  long  than  from  a  short  incision.  The 
toxicity  absorbed  might  be  just  as  great  from  a 
short  incision  as  from  a  long  one.  A  wound  with 
bruised  edges,  even  if  short,  might  give  a  greater 
degree  of  toxicity  than  a  long  one  with  clean,  un- 
bruised  edges.  In  closing  any  incision,  emphasis 
was  to  be  laid  on  the  exact  approximation  of  similar 
structures.  The  explanation  of  painful  scars  w^s 
dependent  upon  one  of  two  factors,  the  inclusion 
of  nerves  in  the  scar,  or  traction  produced  by 
tension  on  the  scar.  He  had  had  a  special  oppor- 
tunity of  observing  scars  in  France,  as  where  he 
was  located,  a  considerable  number  of  soldiers  had 


been  sent  back  from  base  hospitals  because  of 
painful  abdominal  scars,  and  these  men  proved  a 
serious  problem.  It  was  a  question  whether  they 
could  be  sent  back  as  Class  A  men.  ^Many  hernia 
operations  had  been  done  in  camps  in  the  United 
States  and  it  would  be  interesting  to  know  the 
exact  proportion  of  these  men  who  were  really 
fitted  for  Class  A  military  service.  He  was  con- 
fident that  a  large  number  of  these  repairs  had 
failed  to  make  Class  A  men.  and  he  thought  they 
should  be  placed  in  Class  B  limited  service.  The 
fact  that  many  men  who  had  had  operations  for 
hernia,  as  well  as  those  having  undergone  other 
abdominal  operations,  complained  of  painful  scars 
gave  weight  to  the  idea  that  excessive  scar  forma- 
tion was  to  be  avoided.  In  closing  an  abdominal 
wound,  the  aim  should  be  not  merely  the  avoidance 
of  hernia  but  actual  normal  anatomical  and  physio- 
logical restitution  of  the  abdominal  covering. 

The  Symptomatology  of  Perforated  Duodenal 
Ulcer. — Dr.  Robert  S.  IMacDoxald,  of  Plattsburg. 
said  that  of  all  the  acute  abdominal  catastrophies, 
perforated  duodenal  ulcer  was  the  most  painful. 
In  subacute  and  chronic  perforations  there  was 
a  gradual  increase  in  the  symptoms,  but  in  acute 
perforation  the  onset  was  absolutely  sudden  and 
the  signs  pointed  toward  the  duodenum.  In  non- 
perforating  duodenal  ulcer  the  symptom  complex 
was  so  complete  that,  as  Doctor  Deaver  said,  the 
diagnosis  could  be  made  over  the  telephone.  In 
the  t}-pical  duodenal  case  there  was  a  history  of 
gastric  disturbance  extending  over  a  series  of  j^ears. 
and  often  a  history  of  a  feeling  of  fullness  in  the 
chest,  with  eructation  of  gas,  corrected  to  a  certain 
extent  by  alkalies.  In  point  of  time  it  was  im- 
portant to  remember  that  the  distress  occurred 
several  hours  after  meals  and  was  worse  at  night ; 
food  seemed  to  relieve  the  distress.  There  was  a 
typical  loss  of  weight,  mostly  in  the  spring  and  fall. 
Vomiting  and  hematemesis  or  blood  in  the  stools 
occurred  in  eighty  per  cent,  of  the  cases.  There 
were  gastric  hyperacidity  and  hyperperistalsis.  and 
often  there  was  a  too  rapid  expulsion  of  the  barium 
if  no  obstruction  was  present.  In  many  cases  the 
time  when  perforation  would  occur  could  be  pre- 
dicted with  considerable  accuracy.  The  anatomical 
location  of  the  perforation  was  uncertain.  At  the 
time  of  perforation  it  was  frequently  impossible  to 
tell  whether  it  was  in  the  stomach  or  the  duodenum. 
Often  the  right  side  was  affected  more  than  the 
left  and  this  might  lead  to  a  mistaken  diagnosis  of 
appendicitis,  gallstones,  or  renal  colic.  The  site  of 
the  ulcer  seemed  to  make  no  difference  as  to  the 
probability  of  perforation.  C.  H.  Mayo  reported 
2113  cases  of  all  types,  in  84.9  per  cent,  of  which 
the  perforations  were  duodenal  and  in  15. i  gastric. 
The  statistics  of  the  Massachusetts  General  Hospi- 
tal showed  that  sixty-nine  per  cent,  of  the  perfora- 
tions were  duodenal,  while  Dr.  Charles  L.  Gibson 
reported  that  in  his  cases  the  majority  of  perfora- 
tions were  gastric.  Doctor  Stanton  reported  seventy 
per  cent,  gastric  perforation.    Of  his  own  ten  cases. 


236 


LETTERS  TO  THE  EDITORS. 


[New  York 
Medical  Journal 


three  were  gastric,  five  duodenal,  and  two  were 
in  the  pyloric  area.  There  was  an  interval  between 
the  early  crisis  and  the  later  rigidity  when  it  might 
be  possible  to  get  some  idea  as  to  the  location  of 
the  perforation.  He  felt  convinced  that  seventy 
per  cent,  of  perforations  would  be  found  to  occur 
in  the  duodenum.  The  greatest  aid  in  diagnosis 
was  afforded  by  a  well  recorded  history  and  a  series 
of  X  ray  findings. 

Diagnosis  of  Cholecystitis  and  Indications  for 
Cholecystectomy. — Dr.  Alexander  E.  Garrow,  of 
Montreal,  said  a  patient  might  give  a  history  of 
cholecystitis  and  yet  the  gallbladder  show  little 
evidence  of  disease  either  to  the  eye  or  by  palpa- 
tion. Often  such  a  gallbladder  when  opened  may 
show  a  typical  strawberry  mucous  membrane. 
Frequently  the  peritoneum  in  the  region  of  the 
colon  may  show  hyperemia,  and  there  may  be  en- 
largement of  the  lymph  glands  in  the  vicinity  of  the 
gallbladder.  In  fact  it  might  be  said  that  contigu- 
ous disease  often  offered  a  better  criterion  for  the 
removal  of  the  gallbladder  than  the  appearance  of 
the  organ  itself.  The  evidence  seemed  to  show  that 
inflammation  of  the  gallbladder  was  infective  in  ori- 
gin. We  had  been  taught  that  infection  probably 
occurred  through  the  bile  or  from  the  duode- 
num by  way  of  the  common  duct.  Drain- 
age of  the  gallbladder  had  seemingly  benefited  a 
number  of  patients,  but  he  doubted  whether  the 
good  results  were  due  to  drainage  per  sc ;  probably 
they  were  due  to  rest  and  the  withdrawal  of  a  small 
amount  of  bile.  Appendicitis,  ulcer  of  the  stomach 
and  duodenum,  and  cholecystitis  were  largely  of 
embolic  origin.  Rosenow  had  shown  the  selective 
affinity  of  the  streptococcus  for  this  region,  and  the 
bile  might  be  sterile  though  the  wall  of  the  gall- 
bladder was  infected.  He  agreed  with  those  who 
held  that  cholecystectomy  was  the  operation  of 
choice,  even  though  there  was  little  pathology 
limited  to  the  gallbladder  itself.  When  there  was 
a  clinical  history  of  recurrent  attacks  or  of  a  chronic 
type  of  inflammation,  it  was  safe  to  assume  the 
presence  of  an  infective  process  which  became  active 
when  the  resistence  of  the  body  was  lowered. 
Doctor  Garrow  described  various  types  of  chole- 
cystitis and  spoke  of  the  difficulty  in  some  instances 
of  differentiating  it  from  duodenal  ulcer. 

In  differentiating  perforated  duodenal  ulcer  from 
acute  cholecystitis  it  might  be  well  to  remember 
that  retraction  of  the  abdomen  was  never  seen 
•  except  in  duodenal  ulcer.  Fever  in  acute  cholecys- 
titis varied  with  the  acuteness  of  the  infection; 
chills  were  unusual,  being  rather  more  frequent  in 
common  duct  infection ;  routine  examination  of  the 
blood  showed  a  leucocytosis ;  frequent  vomiting  was 
not  usual.  The  indication  for  the  treatment  of  an 
acute  attack  of  cholecystitis  was  drainage,  provided 
bile  was  found ;  as  long  as  the  bile  drained  away 
one  might  look  for  recovery,  but  in  many  of  these 
cases  treated  by  drainage  there  were  sequelaa  and 
hence  many  surgeons  preferred  cholecystectomy. 
The  gallbladder  was  not  essential  to  life,  though 
it  might  be  a  factor  in  the  well  being  of  the  individ- 
ual. The  symptoms  of  chronic  cholecystitis  were  a 
distressing  sensation  in  the  epigastrium,  pSin 
beneath  the  right  scapvila  and  over  the  eighth,  ninth 


and  tenth  ribs,  a  bad  taste  in  the  mouth  in  the  morn- 
ing, and  loss  of  appetite;  some  individuals  were 
thin  and  others  obese.  Inspection  of  the  abdomen 
was  negative,  but  usually  there  was  marked  pain 
on  deep  pressure  in  the  gallbladder  region.  Ex- 
amination of  a  test  breakfast  showed  about  normal 
acidity.  The  gastric  symptoms  had  no  direct 
relation  to  meals  and  usually  occurred  late  at  night. 
These  patients  were  often  quite  comfortable  for 
weeks  between  attacks.  In  the  ordinary  chronic 
forms  of  cholecystitis  the  gallbladder  was  thickened, 
milky  white  in  color,  and  tenderness  and  rigidity 
were  present ;  occasionally  there  was  a  tumor  when 
the  cystic  duct  was  obstructed.  Doctor  Garrow 
reported  a  series  of  eighty  patients  operated  on  for 
gallbladder  disease  during  the  past  two  years;  of 
these  sixty  were  women.  The  average  age  was 
forty-four  and  a  half  years.  In  forty-five  the  chief 
symptom  was  sour  stomach ;  fifty  vomited ;  twenty- 
seven  were  jaundiced;  only  eleven  showed  definite 
rigidity ;  forty  had  stones  in  the  gallbladder.  A 
reliable  foUowup  was  conducted  which  showed  that 
one  had  recurrence  of  symptoms. 

 <i>  

Letters  to  the  Editors. 

DR.  BENJAMIN  RUSH. 

Chicago,  July  28,  ig20. 

To  tlic  Editors: 

Dr.  S.  Adolphus  Knopf  is  in  error  in  assummg 
that  Benjamin  Rush  was  the  founder  of  Rush  Med- 
ical College.  Benjamin  Rush  died  in  1813.  He 
was  the  greatest  physician  of  the  five  medical  signers 
of  the  Declaration  of  Independence,  and  the  first 
and  one  of  the  greatest  of  American  alienists.  His 
work  On  the  Mind  is  still  quoted  by  the  foremost 
European  alienists.  Next  to  Chiarrugi  and  Pinel 
he  was  the  greatest  reformer  of  the  treatment  of 
the  insane.  Dwight  in  his  Lives  of  the  Signers  says 
of  Rush :  "Although  in  the  political  department  in 
which  he  was  called  to  act  there  was  nothing  that 
furnished  occasion  for  splendid  achievements,  yet 
the  services  he  rendered  to  the  country  were  numer- 
ous and  valuable ;  and  not  less  so  for  being  of  that 
humble,  unobtrusive  character  which  will  not  nec- 
essarily emblazon  his  name  on  the  pages  of  history. 
With  the  ardent  feelings  of  an  enlightened  and  in- 
flexible patriot,  he  espoused  the  cause  of  his  coun- 
try, and,  with  a  zeal  worthy  of  such  a  character, 
he  devoted  his  best  talents  to  the  promotion  of  its 
highest  interests.  And  while  he  is  esteemed  as  a 
benefactor  of  mankind,  in  the  valuable  contribu- 
tions he  has  made  for  improving  and  advancing  the 
medical  sciences,  he  will  be  esteemed  no  less  so  by 
future  generations  who  will  learn  his  real  merits  ' 
from  history,  for  the  benefits  he  conferred  on  his 
fellow  citizens,  in  the  valuable  services  he  rendered 
his  country  as  a  politician  and  a  statesman."  As 
a  statesman,  a  patriot,  a  clinician  and  an  alienist 
Benjamin  Rush  peculiarly  deserves  a  place  in  the 
Hall  of  Fame. 

Very  sincerely, 

James  G.  Kiernan,  M.  D. 


New  York  Medical  Journal 


INCORPORATING  THE 


Philadelphia  Medical  Journal  the  Medical  News 

A  Weekly  Review  of  Medicine,  Established  181^2. 


Vol.  CXII,  No.  8. 


NEW  YORK.  SATURDAY.  AUGUST  21.  1920. 


Whole  No.  2177. 


Original  Communications 


A    WORD    TO    THE    GENEIL\L  PRACTI- 
TIONER ABOUT  THE  HANDLING 
OF  EYE  CASES.* 

By  Edwin  B.  Miller,  M.  D., 
Philadelphia, 

Associate  in  Ophthalmology,  Temple  University;  Assistant  Professor 
of  Ophthalmology,  Graduate  School,  University  of  Penn- 
sylvania; Ophthalmologist  to  Roosevelt  Hospital. 

There  are  two  reasons  for  presenting  a  paper  of 
this  character.  First,  fifteen  or  twenty  years  ago  the 
medical  student  received  a  very  inadequate  course 
in  ophthalmology.  Most  of  these  men  are  poorly 
equipped  to  handle  eye  cases  and  are  so  engrossed 
with  their  daily  tasks  that  they  spend  little  or  no  time 
in  study.  Therefore,  we  receive  frequent  inquiries 
in  reference  to  the  treatment  of  eye  diseases  and  we 
see  many  cases  in  private  practice  and  in  the  dis- 
pensaries which  have  not  heen  properly  diagnosed 
and  treated.  Secondly,  while  students  nowadays 
receive  a  fairly  comprehensive  course,  hy  the  time 
they  get  into  practice  they  seem  to  forget  a  large 
part  of  their  teaching,  as  is  evidenced  by  the  way  in 
which  many  of  their  eye  cases  are  treated  and  by 
conversation  with  patients  who  have  been  under 
their  care.  If,  therefore,  this  paper  will  enlighten 
the  first  class  and  refresh  the  memory  of  the  second, 
it  will  be  of  service  to  both  physician  and  patient. 

RELATIONSHIP   BETWEEN   THE   SPECIALIST  AND  THE 
GENERAL  PRACTITIONER. 

It  is  often  difficult  to  send  patients  to  a  specialist, 
and  probably  not  one  in  five  go  after  they  are  sent, 
the  fear  of  an  excessive  fee  usually  being  the  factor 
which  keeps  them  from  going.  The  fault  lies  with 
both  the  general  practitioner  and  the  specialist.  The 
medical  man  does  not  attach  enough  importance  to 
such  an  examination  and  frequently  uses  it  for  moral 
support  only  while  the  specialist  often  overestimates 
the  value  of  his  services.  Both  must  play  fair  to 
each  other  and  to  the  patient. 

I  am  perfectly  sure  that  many  general  practition- 
ers hold  on  to  cases  which  they  do  not  fully  under- 
stand too  long  before  referring  them  to  a  specialist. 
Many  patients  have  asked  me,  "Why  did  not  the 
doctor  send  me  to  you  sooner?"  Sometimes  this 
places  us  in  an  embarrassing  position  and  we  give 
evasive  answers,  but  it  is  still  perfectly  obvious  to 
the  patient  that,  had  an  early  diagnosis  been  made 

*Read  before  the  Kensington  branch  of  the  Philadelphia  County 
Medical  Society,  March  12,  1920. 


and  appropriate  treatment  given,  it  would  have 
saved  him  time,  money  and  discomfort.  I  have,  on 
the  other  hand,  had  patients  say  to  me  that  they  ap- 
preciated the  promptness  of  their  physician  in  send- 
ing them  to  a  specialist  and  he  would  not  lose  any- 
thing by  it.  I  believe  it  pays  to  be  perfectly  frank 
and  open  and  above  board  with  your  patients.  I 
do  not  believe  it  does  any  harm  to  tell  patients  that 
you  do  not  know  what  is  the  matter  with  them  but 
will  study  up  their  cases,  or  call  in  a  consultant,  or 
refer  them  to  someone  in  the  line  of  work  in  which 
you  think  their  case  belongs. 

There  are,  however,  two  sides  to  every  question 
and  many  men  who  profess  to  be  specialists  violate 
the  code  of  medical  ethics  and  take  advantage  of  the 
general  practitioner.  I  have  had  men  tell  me  that 
when  they  send  a  patient  to  a  specialist  they  never 
see  him  again.  W'hen  I  was  doing  general  work,  I 
sent  patients  to  specialists  who  treated  them  for  other 
conditions  which  I  could  have  done  just  as  well.  I 
sent  a  woman  to  a  gynecologist ;  she  was  under  treat- 
ment for  some  months.  She  told  me  she  had  had 
two  attacks  of  tonsillitis  while  under  his  care  and 
he  treated  her  for  it ;  when  I  questioned  him  he  said 
she  was  in  the  office  and  he  thought  he  might  as  well 
treat  her,  admitting  that  he  had  forgotten  I  had  sent 
her  to  him.  That  was  all  wrong  and  needless  to  say 
he  received  no  more  of  my  work.  If  it  is  an  eve 
case  and  the  sinuses  need  looking  into,  the  man  who 
sent  the  patient  should  at  least  be  asked  to  suggest 
a  nose  specialist  or  should  be  informed  of  the  con- 
dition. 

We  can  avoid  such  tendency  toward  forgetfulness 
by  having  on  our  cards  the  name  of  the  doctor  who 
referred  the  case  to  us.  Even  when  patients  are  sent 
me  by  opticians,  I  try  to  find  out  who  is  their  family 
doctor  and  record  it  with  the  optician's  name.  I  fre- 
quently find  that  the  doctor  has  sent  them  to  some 
specialist,  and  they  have  wandered  off  to  the  opti- 
cian. Recently  an  optician  referred  a  patient  to  me 
who  also  needed  medical  treatment.  I  called  up  her 
family  doctor  and  explained  the  situation  to  him, 
when  he  frankly  told  me  that  he  had  sent  the  patient 
to  another  oculist  but  was  glad  that  the  optician  was 
honest  enough  to  refer  her  to  me.  He  was  pleased 
that  I  had  the  case  and  promised  me  his  cooperation. 

I  feel  that  the  general  practitioner  would  greatly 
increase  his  knowledge,  improve  his  prestige,  and 
add  to  his  income  if  he  would  spend  three  months 
each  year  working  in  the  special  clinics  throughout 


Copyright,   1920,  by  A.  R.  Elliott  Publishing  Company- 


238 


MILLER:  EYE  AND  GENERAL  PRACTITIONER. 


[New  York 
Medical  Journal 


the  city.  It  would  help  him  to  diagnose  properly 
many  special  cases ;  it  would  show  him  those  he 
could  treat  successfully ;  it  would  give  him  a  differ- 
ent viewpoint  df  dispensary  work,  and  cause  him  to 
discriminate  in  the  cases  which  he  sends  to  the  dis- 
pensary. Most  clinical  chiefs  would  welcome  the 
coming  of  physicians  to  their  clinics  in  this  spirit 
and  it  would  bring  about  better  cooperation  between 
medical  men  throughout  the  city.  I  have  advised  a 
number  of  men  to  do  this  and  the  few  who  took  ad- 
vantage of  the  plan  tell  me  that  the  knowledge  gained 
has  been  of  great  value  to  them. 

Now  a  word  or  two  about  the  special  cases  coming 
to  the  family  doctor  for  treatment : 

Catarrhal  conjunctivitis. — There  are  two  forms, 
acute  and  chronic.  In  acute  conjunctivitis  the  symp- 
toms are  pronounced  and  the  bulbar  conjunctiva  is 
involved,  while  in  the  chronic  form,  the  inflammation 
is  usually  limited  to  the  palpebral  conjunctiva.  The 
objective  symptoms  are  swelling  of  the  lids,  abnor- 
mal secretion,  mucoid  or  mucopurulent  conjunctiva, 
with  redness.  The  lids  are  glued  together  in  the 
morning  and  the  patient  complains  of  burning  and 
itching  and  a  gritty  feeling.  There  is  no  involve- 
ment of  the  cornea  and  the  increased  blood  supply 
is  confined  to  the  first  system  of  blood  vessels — the 
posterior  conjunctival.  The  congestion  is  greatest 
at  the  periphery  and  diminishes  as  it  approaches  the 
cornea,  the  vessels  being  easily  emptied  on  pressure. 

Just  a  word  with  reference  to  the  blood  vessels 
in  the  conjunctiva,  a  knowledge  of  which  will  enable 
the  practitioner  to  distinguish  at  a  glance  between 
serious  and  benign  inflammation  involving  the  eye- 
ball. There  are  three  systems  of  blood  vessels  in 
the  conjunctiva.  The  first,  or  posterior  conjunctival 
system  of  blood  vessels  are  always  seen  in  health ; 
they  enter  at  the  periphery  and  travel  toward  the 
corneoscleral  margin ;  they  are  of  a  bright  red  vel- 
vety color  and  are  easily  compressible ;  they  can  be 
emptied  by  pressing  the  fingers  over  the  closed  lids ; 
the  congestion  is  more  marked  at  the  periphery  and 
lessens  as  it  approaches  the  cornea.  Congestion  of 
this  system  is  indicative  of  a  simple  process  and  is 
usually  accompanied  by  increased  secretion.  The 
anterior  ciliaries,  or  second  system  of  blood  vessels, 
consist  of  the  anterior  ciliary  perforating  and  non- 
perforating  arteries  and  veins.  They  are  not  visible 
in  health,  except  the  perforating  which  in  dark  com- 
plexioned  persons  appear  as  small  brown  dots  on 
the  conjunctiva  about  five  millimetres  from  the  cor- 
neoscleral margin.  When  they  are  inflamed  there  is 
a  brick  red  congestive  band  beginning  about  five 
millimetres  from  the  corneoscleral  margin  which 
extends  toward  the  periphery.  The  greatest  con- 
gestion is  near  the  cornea  ;  they  cannot  be  emptied  on 
pressure.  This  is  indicative  of  a  severe  inflammation 
of  the  eye  such  as  iritis,  cyclitis,  or  glaucoma.  The 
third  system  is  the  anterior  conjunctival,  which  are 
not  seen  in  health  and  when  inflamed  extend  into 
the  cornea  from  the  corneoscleral  margin.  They 
are  not  compressible  and  this  is  indicative  of  a  se- 
vere process,  such  as  keratitis  phlyctenula. 

In  a  case  of  conjunctivitis,  if  you  wish  to  deter- 
mine the  cause  accurately,  make  a  smear  on  a  micro- 
scopic slide  and  have  it  examined.   The  pneumococ- 


cus  is  probably  the  germ  most  frequently  found ; 
streptococcus  and  diphtheria  bacillus  may  be  present. 
The  Koch- Weeks  bacillus  is  the  cause  of  epidemic 
catarrhal  conjunctivitis  or  pink  eye. 

Treatment. — Warm  local  applications  of  boric 
acid  or  normal  saline  are  indicated.  In  the  office 
the  conjunctiva  can  be  touched,  with  a  solution  of 
silver  nitrate.  If  the  case  does  not  clear  up  promptly 
the  patient  should  be  sent  to  a  specialist  or  eye  dis- 
pensary for  more  exhaustive  study. 

Chronic  catarrhal  conjunctivitis. — There  is  little 
or  no  secretion.  While  it  otherwise  presents  the  pic- 
ture of  acute  conjunctivitis,  the  lids  may  be  much 
thickened.  Sometimes  it  is  confounded  with  tra- 
choma but  the  presence  of  trachoma  bodies,  scars 
and  atrophic  areas  makes  the  picture  clear.  Spring 
catarrh,  or  vernal  conjunctivitis,  is  a  condition  which 
occurs  in  youth.  Its  appearance  in  the  warm  season, 
the  elevations  resembling  cobble  stone,  and  the  film 
of  bluish  white  secretion  serve  to  differentiate  it. 

Gonorrheal  ophthalmia. — Every  general  practi- 
tioner should  be  thoroughly  conversant  with  the 
preventive  and  prophylactic  measures  used  in  oph- 
thalmia neonatorum.  Unless  he  sees  the  treatment 
carried  out  in  a  lying-in  hospital  or  an  eye  dispensary, 
he  is  not  competent  to  do  anything  except  give  first 
aid  treatment.  A  year  ago  a  baby  was  brought  to 
my  office  after  three  weeks  treatment  for  ophthalmia 
neonatorum  by  the  family  doctor,  who  then  told  the 
mother  to  wash  the  eyes  with  boric  acid  solution 
until  the  discharge  stopped,  as  nothing  further  could 
be  done  and  the  baby  would  probably  be  blind.  The 
Lord  was  with  him,  for  the  infection  was  of  a  mild 
type.  Although  there  was  a  great  swelling  and  pro- 
fuse purulent  secretion,  the  corneas  were  not  in- 
volved. How  they  escaped  I  do  not  know.  The 
child  made  a  good  recovery  without  loss  of  vision 
by  strenuous  and  persistent  treatment. 

Hordeolum  or  stye. — Suppuration  of  the  glands 
of  Zeiss  and  iVIoll  is  called  external  hordeolum. 
They  are  single  or  multiple  and  are  often  recurrent. 
The  treatment  is  quite  simple.  Hot  applications  in 
the  form  of  a  poultice  or  gauze  pad  dipped  in  hot 
water  and  the  application  of  a  salve  composed  of  the 
yellow  oxide  of  mercury  gr.  1 — petrolatum  album 
drams  11,  usually  hastens  the  process  and  brings  it 
to  a  head.  The  pus  may  be  evacuated  with  a  sharp 
scalpel,  after  which  the  salve  is  continued  and  the 
hot  compresses  omitted,  until  recovery  takes  place. 

It  is  well  to  remember  that  hordeoli  are  frequently 
produced  by  eyestrain,  even  though  the  vision  ap- 
pears to  be  normal.  Every  physician  should  have  in 
his  ofiice  eye  test  cards,  both  for  distance  and  for 
near  vision,  but  must  understand  that  the  ability  to 
read  the  finest  print  is  no  indication  that  there  is  not 
eye  trouble.  There  may  be  low  refractive  errors 
which  frequently  produce  a  great  variety  of  reflex 
nervous  symptoms.  Prescribing  glasses  may  put  an 
end  to  the  trouble. 

Chalazion — internal  stye. — It  is  evident  that  there 
is  a  close  relationship  between  a  hordeolum  and  a 
chalazion  as  a  chalazion  is  simply  a  blocked  up  mei- 
bomian gland,  causing  a  tumor  of  the  eyelid.  The 
sac  is  filled  with  gelatinous  or  cheesy  material.  Oc- 
casionally it  may  go  on  to  suppuration,  usually  point- 


August  21,  1920.] 


MILLER:  EYE  AND  GENERAL  PRACTITIONER. 


239 


ing  inward,  and  rupturing  forms  a  granulating  area 
on  the  under  surface  of  the  Hds.  Occasionally  the 
orifice  of  the  gland  may  open  and  the  contents  grad- 
ually be  expelled ;  then  in  a  few  months  it  fills  up 
again.  There  is  no  treatment  of  permanent  value 
but  excision.  If  this  is  not  carefully  done  and  the 
sac  entirely  removed,  the  trouble  recurs.  Salves, 
hot  applications,  and  massage  are  of  very  little  serv- 
ice. This  condition,  like  hordeolum,  is  frequently 
caused  by  eyestrain. 

Foreign  bodies  on  the  cornea. — These  are  of  con- 
siderable importance  and  the  practitioner  will  do 
well,  in  these  times  of  workmen's  compensation,  to 
handle  them  with  kid  gloves.  It  is  of  the  utmost  im- 
portance that  a  correct  history  of  the  character  of 
the  injury  be  obtained  and  the  size  and  location 
of  the  foreign  body  noted.  The  best  way  to  record 
the  location  of  a  foreign  body  is  to  consider  the 
cornea  in  the  aspect  of  a  clock  face.  The  upper  part 
is  at  twelve  o'clock,  the  lower  at  six  o'clock,  and  the 
intervening  points  approximate  to  the  numbers  on 
the  dial.  The  distance  of  the  foreign  body  from  the 
centre  of  the  cornea  or  from  the  corneoscleral  mar- 
gin is  then  noted.  You  record  a  foreign  body  on  the 
cornea,  for  example,  at  six  o'clock  three  millimetres 
in  from  the  corneoscleral  margin  or  the  limbus,  and 
you  have  its  exact  location  for  future  reference. 
The  size  of  the  foreign  body  is  also  noted  in  milli- 
metres. Many  very  small  sharp  foreign  bodies  may, 
because  of  the  speed  which  they  attain  in  flying 
through  the  air,  upon  striking  the  eyeball  penetrate 
and  hardly  leave  a  mark  at  the  point  of  entrance. 

A  case  in  point  may  be  cited.  A  man  was  struck 
in  the  eye  by  a  foreign  body,  but  as  far  as  could  be 
seen  there  was  no  evidence  of  injury.  He  suffered 
pain  and  on  very  close  examination,  with  oblique 
illumination,  a  faint  gray  pin  point  area  was 
noticed  on  the  cornea  near  the  limbus  at  three 
o'clock.  When  a  magnet  was  applied  to  this  area 
the  iris  pulled  toward  it,  showing  that  the  foreign 
body  was  imbedded  in  the  iris.  Under  cocaine  anes- 
thesia, a  small  incision  was  made  at  the  point  of 
entrance,  the  tip  of  the  magnet  applied,  and  a  piece 
of  steel  less  in  size  than  a  pin  head  was  removed 
without  any  very  great  injury  to  the  iris.  The  x  ray 
did  not  show  this  minute  piece  of  steel.  More  skill 
is  required  to  remove  foreign  bodies  from  the  cor- 
nea than  in  doing  more  serious  operations. 

In  the  past  we  saw  many  bad  scars  following  cor- 
neal ulcerations  and  even  lost  eyes,  because  some 
workman  was  supposed  to  be  specially  clever  in 
removing  foreign  bodies  from  the  eye.  All  cases 
occurring  in  the  shop  were  sent  to  him.  Even  now, 
under  present  conditions,  I  find  that  many  company 
physicians,  nurses,  and  many  general  practitioners 
are  hardly  more  skillful.  I  presume  they  do  not  un- 
■  derstand  the  technic,  have  not  the  proper  instru- 
ments, and  do  not  appreciate  the  danger  of  careless 
handling. 

I  usually  instil  four  per  cent,  cocaine  in  the  eye, 
put  in  a  clean  eye  speculum,  seat  the  patient  with  a 
bright  light  over  his  head,  put  on  a  head  mirror, 
and  throw  a  beam  of  light  on  the  cornea.  With  a 
magnifying  lens  in  one  hand  and  a  sterile  eye  spud  in 
the  other,  the  foreign  body  is  gently  removed. 


Occasionally  a  few  drops  of  sterile  boric  or  saline 
solution  are  dropped  into  the  eye  and  the  area  is 
wiped  with  a  cotton  tipped  probe  dipped  in  boric 
or  saline  solution.  It  is  better  not  to  attempt  to 
remove  all  the  rust  stain  from  the  bed  on  which  the 
foreign  body  has  rested.  Nature  will  take  care  of 
this. 

Prescribe  a  boric  wash,  and  if  the  injury  is 
extensive  instil  one  drop  of  one  per  cent,  atropine 
solution.  Be  sure  to  apply  a  sterile  bandage ;  if 
you  do  not  the  eye  may  become  infected  and  you 
are  liable  to  suit.  Instruct  the  patient  to  return 
the  next  day  for  observation ;  in  this  way  the  best 
results  may  be  obtained. 

Corneal  ulcers,  phlyctenular  disease  and  kera- 
titis.— These  fall  in  the  realm  of  the  specialist. 
The  general  practitioner  will  get  best  results  by 
not  handling  these  cases,  but  there  is  no  reason  why 
he  should  not  have  charge  of  them,  see  them  occa- 
sionally and  take  charge  of  their  general  treatment 
and  dietetic  regulation. 

Pterygium. — This  occurs  in  teamsters,  builders, 
farmers  and  other  workers  exposed  to  air  and  dust. 
It  is  frequently  due  to  exposure  and  to  foreign 
bodies,  as  dust  or  sand,  getting  into  the  eye.  I  have 
never  seen  any  good  results  from  local  treatment, 
although  I  know  there  are  some  men  who  are  en- 
thusiastic about  the  application  of  alcohol.  Opera- 
tion is  the  procedure  of  choice. 

Every  practitioner  should  at  least  know  how  to 
diagnose  iritis  and  glaucoma  and  also  how  to  pre- 
scribe the  initial  treatment,  especially  where  the  pa- 
tient cannot  get  to  a  specialist  promptly.  I  will  give 
you  the  differential  diagnosis  between  iritis  and  glau- 
coma and  say  a  word  about  the  immediate  treatment, 
because  in  these  conditions,  unless  we  are  alert,  irre- 
parable damage  may  be  done. 

DIFFERENTIAL  DIAGNOSIS. 


Acute  Iritis. 
Intense  bright  redness 
of    bulbar  conjunctiva, 
intense  pericorneal  infec- 
tion. 

Cornea  clear,  very  sen- 
sitive. Anterior  cham- 
ber normal  or  deep. 

Pupil  contracted  im- 
mobile, synechia  often 
present. 

Iris  discolored,  mark- 
ings obliterated. 

No  contraction  of 
fields. 

No  cupping  of  disc. 

Usually  no  increase  of 
tension. 

Intense  pain  radiating 
to  side  of  face. 


Acute  Glaucoma. 

Rather  dusky  bluish 
redness  of  bulbar  con- 
junctiva ;  rapidly  failing 
vision. 

Cornea  steamy,  anes- 
thetic. 

Anterior  chamber  very 
shallow. 

Pupil  dilated,  immo- 
bile, greenish  in  appear- 
ance. 

Iris  markings  present 
not  discolored. 

Contraction  of  fields. 

Rainbows  seen  around 
lights  and  flashes  of 
light ;  disc  cupped. 

Tension  greatly  in- 
creased. 

Sick  stomach  and 
vomiting  often  occur ; 
violent  pain  coming  on 
frequently  at  night. 


240 


MILLER:  EYE  AXD  GEXERAL  FRACTITIOSER. 


[New 
Medical 


York 

JOL'RNA. 


'  IMMEDIATE 

Iritis. 

Instil  one  or  two  drops 
of  one  per  cent,  solution 
of  atropine  three  times  a 
da}-  or  more  often  as  oc- 
casion requires  to  dilate 
the  pupil. 

Hot  compresses,  leech- 
ing. 

Xo  operation. 


TREATMENT. 

Glaucoma. 
Instil  one  or  two  drops 
of  solution  eserine  grain 
one-eighth  to  one-fourth 
to  the  dram  three  times 
a  day.  or  more  often  as 
required  to  contract  the 
pupil. 

Hot  compresses,  leech- 
ing. 

Operation  in  twenty- 
four  hours  unless  tension 
decreases  and  s3-mptoms 
subside. 

In  iritis  unless  immediate  and  strenuous  treatment 
is  begun  early  the  eye  is  badly  damaged,  but  in  glau- 
coma, unless  remedial  measures  are  instituted  at  once 
to  combat  it,  the  eye  is  lost.  Therefore,  it  behooves 
the  general  practitioner  to  familiarize  himself  with 
these  two  important  conditions. 

Patients  with  glaucoma  will  often  prevent  a  good 
result  by  refusing  operation  and  sometimes  the 
ophthalmologist  will  assist  in  this,  as  in  a  case  which 
I  shall  cite.  A  woman  called  in  her  family  doctor 
for  violent  pain  and  a  red  eye.  Thinking  it  was 
iritis  he  instilled  atropine.  The  next  morning  the 
eye  was  worse,  so  he  sent  her  to  me.  I  immediately 
used  eserine.  hot  compresses,  leeching,  and  advised 
immediate  iridectomy,  which  was  refused.  I  took 
her  to  another  ophthalmologist  who  advised  the 
same  operation,  but  it  was  refused,  so  I  dropped  the 
case.  Then  they  went,  as  they  said,  to  a  good  eye 
doctor  who  was  going  to  cure  her  with  medicine ; 
later  I  learned  that  she  went  to  a  prominent 
oculist  in  Philadelphia  who  continued  the  eserine 
and  saw  her  three  times  a  week  for  three  months 
at  five  dollars  a  visit.    Result,  a  totally  blind  eye. 

Here  I  w^ish  to  say  a  word  about  hot  and  cold 
compresses.  Cold  compresses  are  indicated  for 
acute  conditions  and  should  be  applied  constantly 
and  are  of  very  little  value  after  forty-eight  hours. 
Hot  compresses  are  of  use  in  many  cases  from  the 
beginning  and  can  often  follow  cold  compresses  after 
fortv-eight  hours.  They  are  usually  applied  from 
fifteen  to  thirty  minutes  every  three  hours  or  at 
longer  intervals.  It  will  pay  every  general  practi- 
tioner to  own  an  artificial  leech,  by  which  he  can 
withdraw  blood  from  any  congested  area.  I  ain 
surprised  to  find  that  in  many  hospitals  it  is  not 
available.  Natural  leeches  are  hard  to  get  and  are 
not  nearly  so  satisfactory. 

This  paper  would  not  be  complete  without  calling 
your  attention  to  a  condition  which  means  a  great 
deal  to  the  patient  from  a  cosmetic  and  economic 
standpoint,  namely,  the  recognition  of  the  condition 
known  as  squint  or  strabismus  and  the  proper 
method  of  handling  it.  Every  physician  should  at 
least  know  that  there  is  a  fusion  centre  which  enables 
us  to  fuse  the  images  which  fall  on  corresponding 
parts  of  the  retinas,  and  the  difference  between  a 
phoria,  which  is  a  tendency  of  the  eyes  to  deviate 
from  parallelism,  and  a  tropia,  which  is  an  actual 
deviation  or  turning  of  the  eyes  from  parallelism  and 


is  manifest  to  the  most  casual  observer.  To  demon- 
strate a  phoria  have  the  patient  look  at  an  object  in 
the  distance  with  one  eye  while  you  cover  the  other 
eye  with  a  card.  Look  behind  the  card  and  if  the 
eye  is  not  looking  straight  ahead,  you  have  a  phoria 
or  latent  squint.  Remove  the  card  and  the  eye  will 
quickly  return  to  its  original  position  of  parallelism. 
Many  intractable  eye  conditions  and  reflex  nervous 
symptoms  are  due  to  this  anomaly. 

MONOCULAR  AND  BINOCULAR  VISION. 

It  has  been  said  that  one  eye  is  a  necessity,  two 
eyes  a  luxury.  Cross  eyed  persons  can  shoot  ac- 
curately because  they  only  use  one  eye  in  sighting; 
they  can  tell  direction,  but  cannot  measure  distance 
so  well.  They  cannot  thread  a  needle  or  direct  the 
hand  to  a  small  object  accurately.  Binocular  vision 
measures  distance  and  speed  more  accurately  than 
monocular  vision.  The  development  of  binocular 
vision  is  one  of  the  most  important  epochs  in  a 
child's  life.  We  watch  their  dentition.  We  look 
after  their  tonsils  and  adenoids  and  yet  when  a 
child  is  brought  to  us  with  a  squinting  eye,  we  physi- 
cians pass  it  up  and  tell  the  parents  the  child  will 
grow  out  of  it.  Why?  Because  we  often  forget 
or  do  not  know  about  fusion  sense  or  fail  to  recog- 
nize the  importance  of  binocular  vision. 

Every  physician  knows  the  approximate  date  of 
the  coming  of  the  first  tooth  and  when  a  baby  should 
walk  and  talk,  but  he  fails  to  study  the  sight  of  the 
child.  Every  babe  at  birth  has  only  light  perception. 
In  a  few  weeks  it  can  recognize  large  objects ;  later 
small  objects,  and  during  this  time  one  eye  may 
wander  out  or  in  while  the  other  eye  is  straight. 
This  is  not  harmful  in  the  first  six  months.  When 
a  child  directs  both  eyes  to  the  same  obfect,  it  is  be- 
ginning to  acquire  binocular  vision.  This  it  does  in 
the  second  half  of  the  first  year.  Five  years  or  more 
are  necessary  to  complete  the  establishment  of  bin- 
ocular vision  which  lasts  through  life. 

Remember,  binocular  vision  begins  in  the  first 
year  and  is  completely  established  by  the  sixth  or 
seventh  year  and  cannot  be  acquired  after  the  seventl" 
year.  If  the  squint  develops  during  this  time  or 
double  vision  occurs,  the  child  learns  to  suppress  one 
image  and  becomes  amblyopic  or  blind  in  the  squint- 
ing eye.  Therefore  these  cases  should  all  be  sent  tc 
the  oculist  for  study,  treatment  or  operation  and 
many  eyes  will  in  this  way  be  saved. 

A  knowledge  of  this  special  work  and  the  ability 
at  least  to  give  intelligent  advice  in  these  eye  cases 
will  be  of  great  service  to  the  general  practitioner, 
especially  in  these  times  of  advanced  knowledge  and 
I  think  the  patients  have  the  right  to  demand  it.  I 
am  sure  it  will  not  harm  but  will  assist  the  specialist 
in  getting  better  results  as  the  proper  treatment  will 
have  been  started  and  no  valuable  time  will  be  lost. 

SOLUTIONS. 

Atropine  is  used  in  eye  work,  mostly  in  solutions 
of  four  grains  to  the  ounce:  eserine  solution,  one 
grain  or  less  to  the  ounce ;  argyrol.  ten  per  cent,  to 
twenty-five  per  cent. ;  nitrate  of  silver,  one  to  four 
grains  to  ounce,  and  in  some  special  cases  as  high 
as  twenty  grains  to  the  ounce ;  cocaine,  twenty  grains 
to  the  ounce.    Cocaine  should  not  be  used  much  in 


August  21,  1920.] 


MILLER:  REPORT  OF  EYE  CASES. 


241 


ulceration  of  cornea,  as  it  will  dissolve  the  cement 
stibstance  in  the  corneal  tissue  and  cause  maceration. 
Holecaine  in  about  the  same  strength  can  be  used  in- 
stead of  cocaine.  Zinc  sulphate,  as  an  astringent,  one 
grain  to  the  ounce  ;  saline  (normal )  salt  solution  and 
a  saturated  solution  of  boric  acid  are  the  usual  collyra 
in  simple  forms  of  congestion.  For  quick  results 
adrenaline  1  in  1,0(X)  may  be  added,  five  minims  to 
the  ounce.  Every  man  doing  compensation  work 
should  have  an  oimce  of  fluorescein  solution  on  hand 
to  stain  the  cornea  to  determine  breaks  in  its  con- 
tinuity. The  following  is  the  formula :  Fluorescein 
eight  grains ;  sodium  bicarbonate,  eight  grains ;  dis- 
tilled water,  one  ounce.  One  drop  is  placed  on  the 
cornea  and  it  is  immediately  washed  off  with  boric 
acid  or  saline  solution.  It  will  leave  a  greenish  stain 
on  the  broken  corneal  surface,  but  will  not  stain 
healthy  tissue. 

2028  Chestnut  Street. 


REPORT  OF  FIVE  OPERATIVE  EYE  CASES. 

By  Edwix  B.  ]\Iiller,  M.  D. 
Philadelphia, 

Associate  in  Ophthalmology,  Temple  University;  Assistant  Professor 
of    Ophthalmology;    Graduate    School,    University    ot  Pennsyl- 
vania;  Ophthalmologist  to  Roosevelt  Hospital,  Philadelphia. 

In  looking  over  the  journals  from  time  to  time, 
we  find  reports  of  many  rare  and  interesting  cases 
and  interesting  accounts  of  new  operations.  I  am 
going  to  depart  from  this  and  report  a  few  cases 
from  the  ordinary  group  in  which  there  appeared  in- 
teresting features  requiring  somewhat  diflferent  tech- 
nic in  handling.  The  first  three  cases  were  due  to 
known  injuries,  the  fourth  probably  to  unknown 
injury  and  the  fifth  due  to  a  disturbance  in  meta- 
bolism which  produces  cataract — in  this  case  prob- 
ably glycosuria. 

Case  I. — March  26,  1917.  J.  F.  was  admitted  to 
the  Roosevelt  Hospital  with  the  following  history : 
While  at  work  in  a  bottling  establishment  was  struck 
in  the  right  eye  by  a  flying  piece  of  glass  from  an 
exploding  soda  water  bottle.  Thirty  minutes  after 
the  accident,  his  eye  presented  the  following  appear- 
ance :  There  was  an  irregular  linear  incised  wound 
©f  the  cornea  extending  from  just  below  the  limbus 
at  7  o'clock  to  the  centre  of  the  cornea  and  then  up 
and  out  to  the  limbus  at  11  o'clock;  the  anterior 
chamber  was  empty  and  the  iris  was  prolapsed  into 
the  wound  at  the  upper  and  lower  margins. 

Under  cocaine  anesthesia  after  cleansing  the  con- 
junctival sac,  I  ctit  off  the  iris  at  both  places  and  re- 
placed the  cut  edges,  instilled  atropine,  applied  ice 
compresses  and  kept  the  patient  in  bed  for  a  week, 
when  he  left  the  hospital  in  good  shape  and  one 
month  later  refraction  showed  the  following  result : 
Right  eye+2.50+2.00  ax  75=20/70;  left  eye+.50 
ax  90=20/20.  He  had  vision  in  all  directions,  ex- 
cept up  and  out  where  there  was  quite  an  extensive 
leucoma.  The  interesting  points  in  this  case  are  the 
escape  of  the  other  structures  of  the  eye  from  injury 
and  the  rapidity  with  which  recovery  took  place.  In 
all  cases  of  this  character,  I  now  perform  conjunc- 
tivokeratoplastv. 

Case  II.— February  17,  1919.    I.  K.,  colored, 


aged  thirty-four,  sustained  an  accident  similar  to 
that  in  the  first  case.  While  working  in  a  bottling 
establishment  he  was  struck  in  the  right  eye  with  a 
piece  of  flying  glass  from  an  exploding  soda  water 
bottle.  An  hour  later  I  saw  him  at  the  Roosevelt 
Hospital  and  found  the  following  condition :  A 
wound  of  the  cornea  semilunar  in  shape  extending 
from  the  limbus  at  11  o'clock  to  just  above  the  centre 
of  tlie  cornea,  then  up  to  the  limbus  at  2  o'clock.  The 
anterior  chamber  was  empty  and  the  iris  was  pro- 
lapsed at  11  o'clock.  Atropine  was  instilled  and  ice 
compresses  were  applied.  Under  cocaine  anesthesia, 
I  cut  off  the  prolapsed  iris,  replaced  the  pillars, 
smoothed  down  the  wound  with  a  spatula  and  cov- 
ered the  entire  area  by  .a  conjunctival  flap.  Five 
days  later  when  the  stitches  had  sloughed  ottt  and 
the  conjunctiva  had  retracted,  I  noticed  that  the  lens 
had  become  entirely  opaque.  There  was  no  infec- 
tion and  on  April  2nd,  when  the  eye  was  entirely 
quiet,  I  evacuated  the  lens  material  with  a  keratome. 
He  made  a  good  recovery.  When  the  e\e  was  en- 
tirely quiet.  I  performed  a  V  shaped  capsulotomy 
and  secured  a  large  black  pupil ;  with  the  correcting 
lens  his  vision  was  20/30  for  distance  and  .75  D  type 
for  near.  The  refractive  error  in  the  left  eye  was 
corrected  giving  him  20/20  distance  and  37  D  type 
for  near.  A  plain  glass  was  placed  over  the  right  eye. 

The  interesting  point  in  this  case  was  that  the  in- 
jury while  very  much  less  than  in  the  preceding  case, 
produced  a  rapidly  forming  traumatic  cataract,  there 
being  probably  a  slight  break  in  the  anterior  lens 
capsule. 

Case  III.— J.  B..  aged  sixty-five,  March  7,  1919, 
was  removing  a  tire  when  the  wrench  slipped, 
striking  him  in  the  left  eye.  I  saw  him  at  the 
Roosevelt  Hospital  several  hours  after  the  accident 
and  the  eye  presented  the  following  appearance : 
There  was  a  slight  abrasion  on  the  forehead  above 
the  left  eye,  also  a  small  cut  below  the  lower  lid ;  the 
cornea  was  uninjured,  the  anterior  chamber  was 
deep,  the  iris  was  badly  torn  at  6  oclock  and  there 
was  partial  dislocation  of  the  lens  down  and  in  ;  a 
small  amount  of  blood  was  visible  in  the  anterior 
chamber.  Vision  was  3/200.  His  right  eye  had 
been  injured  in  childhood ;  the  pupil  was  irregular 
and  about  three  millimetres  in  diameter.  There  were 
some  remains  of  the  lens  capsule  around  the  pupillary 
margins,  the  lens  having  been  absorbed :  the  central 
area  was  clear.    \Tsion  was  1/200. 

This  man  was  kept  in  bed  for  a  week,  atropine  was 
instilled  and  ice  compresses  were  applied.  All  the 
inflammatory  symptoms  promptly  cleared  up  and  on 
the  fifteenth  day  the  eye  was  quiet.  On  ^March  31st 
I  removed  the  lens  with  some  loss  of  vitreous.  A 
few  days  later,  there  developed  a  slight  infection  at 
the  lower  outer  corner  of  the  wound.  Under  treat- 
ment this  rapidly  cleared  up  and  some  weeks  later 
refraction  showed,  right  eye4-9.00+1.00  ax  180= 
20/30;  left  eye  +11.00+2.50  ax  165=20/20.  Add 
+2.50  for  near=50  D  type.  Before  the  accident  he 
only  had  protective  vision  in  the  right  eye,  never 
having  obtained  a  suitable  glass.  Xow  he  has  two 
good  eyes  for  distance  and  close  work. 

The  interesting  features  in  this  case  were  the 
absence  of  injury  to  the  cornea  In  view  of  the  severe 


242  LOVE:  EYE  DISEASES  AND    GENERAL  PRACTITIONER.  [New  York 

Medical  Journai. 


injury  behind  it,  and  the  rapid  clearing  up  of  the 
vitreous  cloud  which  was  present  during  the  slight 
infection. 

Case  IV. — An  Italian  woman  referred  to  nie  by 
Dr.  M.  E.  Smukler  presented  phthisis  bulbi  in  the 
right  eye  following  injury  in  childhood  and  a  mature 
cataractous  lens  in  the  left  eye,  which  was  partially 
dislocated  into  the  anterior  chamber,  being  tilted 
backward  above.  The  patient  had  light  perception 
and  projection  down,  up  and  in.  Under  narco  and 
cocaine  anesthesia  I  made  the  usual  corneal  incision 
with  a  conjunctival  flap  and  immediately  the  woman 
turned  her  eye  up.  Because  of  her  ignorance,  even 
with  the  aid  of  an  interpreter,  we  could  not  induce 
her  to  roll  the  eye  down,  and  therefore  it  w^as  im- 
possible to  do  an  iridectomy.  As  the  pupil  was  well 
dilated  and  the  lens  was  tilted  backward  above,  I 
decided  to  deliver  the  lens  in  its  capsule.  Using  two 
Smith  lid  elevators.  Dr.  Smukler  holding  the  lids 
well  up  and  open,  by  the  use  of  hook  and  spatula  the 
lens  was  tumbled  without  difficulty  and  came  out 
under  the  upper  lid,  without  loss  of  vitreous  or  pro- 
lapse of  the  iris.  The  toilet  of  the  wound  was  then 
made  and  the  eye  closed.  On  examination  of  the  lens, 
we  found  it  was  a  distinctly  black  cataract,  Morgag- 
nian in  character  with  the  capsule  loosely  attached,  so 
that  one  could  lift  the  capsule  up  from  the  lens  with 
a  forceps.  The  patient  made  an  uneventful  recovery 
and  left  the  hospital  in  eight  days.  Unfortunately 
there  was  an  old  retinal  detachment  including  a  good 
part  of  the  nasal  side,  thus  explaining  the  absence  of 
temporal  light  projection  and  changing  what  would 
have  been  a  perfect  result  into  a  case  of  only  useful 
protective  vision.  The  interesting  point  in  this  case  is 
the  good  clean  simple  extraction  obtained  in  an  illit- 
erate unruly  patient  while  working  under  difficulties. 

Case  V. — Wm.  A.,  aged  seventy-nine,  had  mature 
lenticular  cataract  in  both  eyes,  light  perception  and 
projection  being  good.  The  patient  had  an  old 
chronic  diabetes.  Operation  was  refused  by  another 
oculist,  because  of  his  age  and  the  amount  of  sugar 
present,  but  as  he  wanted  to  see  and  was  willing  to 
take  a  chance,  I  agreed  to  operate  without  promising 
him  any  result  and  told  him  of  the  danger.  I  thought 
it  wise  to  do  a  preliminary  iridectomy  in  his  left  eye 
to  thoroughly  test  the  advisability  of  an  extraction. 
Under  narco  and  cocaine  anesthesia  a  small  iridec- 
tomy was  performed.  This  operation  was  a  per- 
fect success ;  there  was  prompt  healing  and  hardly 
.any  reaction.  Thus  encouraged  I  attempted  to  ex- 
tract the  lens.  Before  my  corneal  incision  was  fin- 
ished the  zonule  ruptured  below  and  some  fluid  vitre- 
ous began  to  come  out.  When  I  attempted  to  rupture 
the  capsule,  the  lens  moved  with  the  cystatome  in  all 
directions.  I  eventually  got  a  fair  opening  but  the 
lens  was  soft  and  sticky  and  when  about  half  of  the 
lens  substance  was  expressed  so  much  vitreous  was 
lost  that  I  decided  to  stop.  Replacing  the  remaining 
capsule  and  lens  and  replacing  the  iris  pillars  I  closed 
the  wound.  I  should  have  covered  the  entire  in- 
cision with  a  conjunctival  flap. 

The  next  day  I  took  a  look  at  the  eye  and  it  seemed 
all  right  although  the  entire  pupillary  area  was  filled 
with  lens  substance  and  capsule.  When  I  paid  my 
second  visit  I  found  that  the  wound  had  burst  open 


and  the  remaining  lens  and  capsule  was  in  the  open 
wound.  There  also  was  leaking  of  the  aqueous  at 
the  outer  corner  but  after  looking  at  it  from  every 
angle,  I  decided  to  leave  it  alone  and  take  a  chance. 
This  I  explained  to  the  family.  I  watched  it  for 
fifteen  days.  No  infection  occurred.  On  the  fif- 
teenth day  the  anterior  chamber  closed,  the  lens 
absorbed  rapidly  down  and  out  and  there  was  a  clear 
area  3x5  mm.  through  which  I  could  see  the  faint 
disc  outline.  He  has  good  protective  vision ;  I  held 
a  -|- 12.00  condensing  lens  before  his  eye  and  found' 
he  could  read  1.50  D  type.  I  intend  to  do  a  capsulo- 
tomy  and  hope  to  get  a  good  result.  The  interesting 
features  in  this  case  are  first,  the  corneal  flap  was 
sufficiently  nourished  even  though  two-thirds  of  it 
was  cut  off  from  its  blood  supply  for  at  least  ten 
days ;  second,  there  was  no  infection  in  spite  of  the 
fact  that  the  anterior  chamber  remained  unclosed 
above  and  no  increase  in  tension  occurred  after  the 
wound  closed,  even  though  there  was  considerable 
debris  in  the  upper  angle ;  third,  the  remarkable  man- 
ner in  which  the  wound  healed  in  an  old  diabetic  is 
worthy  of  note ;  fourth;  of  great  interest  is  the  useful 
vision  obtained  in  spite  of  the  loss  of  a  large  amount 
of  vitreous. 

There  are  numerous  questions  that  arise  as  we 
survey  a  series  of  cases  like  this,  but  time  will  not 
permit  of  their  full'  discussion.  Reports  of  difficult 
cataract  cases  and  how  the  operator  meets  the  diffi- 
culties would  be  both  interesting  and  instructive. 

2028  Chestnut  Street. 


EYE  CONDITIONS  OF  INTEREST  TO  THE 
GENERAL  PRACTITIONER.* 
By  Louis  F.  Love,  M.  D., 

Philadelphia, 

Surgeon,    Ophthalmological    Department,    St.    Mary's  and 
Misericordia  Hospitals. 

The  general  practitioner  is  frequently  called  upon 
to  diagnose  and  treat  ailments  of  the  visual  organ 
that  are  either  emergency  cases  or  diseases  of  such 
minor  importance  as  to  make  the  services  of  the  eye 
specialist  unnecessary.  It  is  apparent,  therefore, 
that  in  order  to  institute  proper  treatment  and 
achieve  results  he  must  have  a  thorough  knowledge 
of  the  eye  conditions  most  likely  to  come  under  his 
care  and  at  least  a  general  familiarity  with  the  more 
serious  ocular  afifections  that  he  may  encounter  in 
the  course  of  his  practice.  This  paper  aims  to  give 
to  the  busy  physician,  in  succinct  form,  the  informa- 
tion he  may  require  in  his  work,  and  aid  him  in 
treating  intelligently  conditions  that  too  often  are 
neglected  because  of  insufficient  knowledge  of  the 
subject,  particularly  that  pertaining  to  the  differen- 
tial diagnosis  of  the  commoner  eye  affections. 

CONJUNCTIVITIS. 

Perhaps  the  most  frequent  condition  encountered 
in  general  practice  is  conjunctivitis.  The  physician 
will  be  called  upon  to  diflferentiate  between  a  simple 
inflammation  of  the  conjunctiva  and  a  disease  of 
the  deeper  structures  of  the  eye,  such  as,  for  ex- 

•Read  before  the  Kensington  Branch  of  the  Philadelphia  Countj- 
Medical  Society,  November  7,  1919. 


August  21,  1920.] 


LOVE:  EYE  DISEASES  AND    GENERAL  PRACTITIONER. 


243 


ample,  iritis  and  glaucoma.  In  order  to  make  a 
careful  distinction  between  these  conditions  the 
practitioner  should  recall  something  of  the  structure 
of  the  visual  organ.  The  conjunctiva  or  delicate 
membrane  that  lines  the  eyelids  (palpebral  conjunc- 
tiva) and  covers  the  front  of  the  globe  (ocular  con- 
junctiva) receives  its  blood  supply  from  two  sources 
— the  posterior  conjunctival  and  the  anterior  ciliary 
vessels.  In  marked  inflammations  of  the  anterior 
section  of  the  eye  both  the  ciliary  and  the  conjunc- 
tival vessels  are  injected.  As  a  rule,  however,  the 
differentiation  between  the  two  forms  of  injection 
is  readily  made.  When  the  conjunctival  vessels  are 
injected  there  is  clearly  visible  a  superficially  dis- 
posed vascular  network  that  can  be  moved  easily 
along  with  the  conjunctiva.  The  diseased  structures 
take  on  a  vivid  scarlet  or  brick  red  color.  In  ciliary 
injection  the  individual  vessels  cannot  be  clearly 
made  out,  and  when  the  conjunctiva  is  displaced, 
the  vessels  do  not  move  along  with  the  membrane. 
The  latter  is  an  important  point  in  differentiating 
an  inflammation  of  the  conjunctiva  from  diseases 
of  the  deeper  structures  of  the  eye,  as  for  example, 
iritis  and  glaucoma.  The  redness  is  prone  to  be 
more  diffuse  than  in  conjunctival  inflammations, 
and  there  is  a  rose  red  or  pale  violet  zone  about  the 
cornea — circumcorneal  injection. 

In  differentiating  these  diseases  one  from  the 
other  we  have  as  valuable  diagnostic  aids  the  dis- 
coloration of  the  iris,  the  presence  of  which  should 
be  ascertained  by  careful  comparison  with  the  nor- 
mal eye.  In  conjunctivitis  the  iris  remains  unaf- 
fected, whereas  in  iritis  and  in  glaucoma  the  iris  is 
discolored.  The  diagnosis  is  influenced  also  by  the 
size  of  the  pupil,  which  is  contracted  in  iritis,  dilated 
in  glaucoma,  and  unaffected  in  conjunctivitis.  In 
conjunctivitis  there  are  pain  and  tenderness,  but  the 
pain  is  not  neuralgic,  as  in  iritis  and  glaucoma. 

An  inflammatory  glaucoma  is  often  mistaken  for 
an  iritis  by  the  presence  of  ciliary  injection  and  dis- 
coloration of  the  iris,  symptoms  common  to  both 
diseases,  a  mistake  which  is  rendered  doubly  grave 
by  the  fact  that  although  we  use  atropine  freely  in 
the  treatment  of  iritis,  we  know  that  it  must  never 
be  instilled  in  a  glaucomatous  eye.  In  glaucoma  the 
injection  is  decidedly  venous  in  character  or  dusky 
red  in  color ;  the  episcleral  veins  are  large  and  tor- 
tuous, owing  to  the  pressure  on  the  vasa  vorticosa 
throwing  greater  work  on  the  anterior  ciliary  veins. 
In  iritis  the  injection  is  general  and  intense,  espe- 
cially circumcorneal  injection  of  the  ciliary  vessels. 
In  conjunctivitis  the  injection  is  velvety  and  in- 
creases away  from  the  cornea  and  toward  the  fornix. 
In  acute  glaucoma  a  characteristic  symptom  is  the 
loss  of  vision,  frequently  coming  on  suddenly  and 
being  out  of  all  proportion  to  the  apparent  in- 
flammatory condition ;  in  iritis  the  loss  of  vision 
greatly  depends  on  the  cloudiness  of  the  aqueous  or 
the  exudation  in  the  pupillary  space.  In  simple 
conjunctivitis  the  vision  is  unimpaired,  depending 
on  the  photophobia  or  the  amount  of  mucus  or  pus 
which  may  float  over  the  cornea. 

Diseases  of  the  conjunctiva  form,  on  an  average, 
thirty  per  cent,  of  all  eye  affections ;  in  epidemics, 
of  course,  this  percentage  is  much  higher.    For  gen- 


eral clinical  purposes  conjunctivitis  may  be  divided 
into  three  forms,  the  hyperemic  (and  congestive), 
the  catarrhal,  and  the  purulent.  There  are,  how- 
ever, many  subdivisions,  such  as  croupous,  diph- 
theritic, traumatic,  trachomatous  and  scrofulous,  but 
in  these  forms  the  conjunctivitis  is  merely  a  symp- 
tom of  a  special  exciting  cause.  In  the  majority  of 
cases  of  acute  conjunctivitis  the  morbific  matter 
is  brought  into  contact  with  the  conjunctiva  through 
the  medium  of  the  atmosphere;  this  has  been  proved 
in  a  form  of  conjunctivitis  by  the  discovery  of  a 
special  bacillus  by  Koch-Weeks,  Morax-Axenfeld, 
Hansell,  and  others.  But  there  are  also  instances 
in  which  a  poisonous  element,  circulating  in  the 
blood,  has  been  the  cause  of  the  conjunctivitis.  In 
measles,  before  the  rash  appears  upon  the  body, 
there  is  frequently  observed  a  conj'unctivitis,  this 
constituting,  therefore,  a  prominent  symptom  of  a 
beginning  rubeola. 

The  prognosis  of  acute  catarrhal  conjunctivitis 
is  favorable  in  uncomplicated  cases,  the  disease  dis- 
appearing spontaneously  in  from  eight  to  fourteen 
days.  The  complications  that  arise  in  conjunctival 
catarrh  consist  for  the  most  part  of  corneal  ulcers. 
The  onset  of  these  complications  is  manifested  by 
an  increase  in  the  pain  and  heightened  photophobia. 
These  complications  are  often  the  result  of  attempts 
at  treatment  of  the  catarrh  by  the  laity,  who  do  not 
hesitate  to  apply  bread  and  milk  poultices,  tea  leaves, 
raw  meat,  urine,  or  even  a  bit  of  placenta.  The 
transmission  of  the  secretion  from  one  individual 
to  another  plays  an  important  part  in  spreading  the 
disease;  for  this  reason  the  indiscriminate  use  of 
towels,  handkerchiefs,  and  the  like  should  be  care- 
fully guarded  against.  Search  should  always  be 
made  for  foreign  bodies,  for  atoms  of  dirt  or  dust 
may  have  become  lodged  in  the  cornea  or  in  the  con- 
junctiva of  the  upper  lid.  Indeed,  a  conjunctivitis 
is  frequently  brought  on  by  a  foreign  body  creating 
a  condition  that  may  give  entrance  to  an  infective 
germ  ;  a  type  of  this  form  frequently  seen  is  the 
socalled  pink  eye. 

The  treatment  of  acute  conjunctival  catarrh  is 
very  simple :  Frequent  flushings  of  the  conjunctival 
sac  with  a  saturated  solution  of  boric  acid,  with  a 
little  cocaine  or  sulphate  of  zinc  combined,  anoint- 
ing the  edges  of  the  lids  with  borated  petrolatum  to 
prevent  agglutination,  and  the  instillation  of  a  few 
drops  of  a  solution  of  one  of  the  silver  salts,  such 
as  a  twenty  per  cent,  solution  of  argyrol,  re- 
peated at  intervals.  Applications  of  a  solution  of 
nitrate  of  silver,  about  one  grain  to  the  ounce,  to 
the  upper  and  lower  lids  once  daily  should  also  be 
used  if  necessary.  The  patient  should  be  instructed 
to  avoid  dust,  smoke,  and  vitiated  air  in  general,  and 
pass  as  much  of  his  time  as  possible  in  the  open  air. 
At  the  onset  a  purge  should  always  be  administered. 
Stimulants,  as  a  rule,  should  be  avoided.  The  naso- 
pharynx should  be  carefully  looked  after,  and  re- 
fractive errors  corrected.  The  use  of  atropine  can- 
not be  too  strongly  condemned.  In  a  simple  con- 
junctivitis the  drug  is  useless,  ^nd  in  some  cases 
may,  indeed,  do  much  harm.  It  should  never  be 
used  unless  there  are  decided  indications  for  its 
employment. 


244 


LOVE:  EYE  DISEASES  AND    GENERAL  PRACTITIONER. 


[New  York 
Medical  Journal 


OPHTHALMIA  NEONATORUM. 

All  authorities  are  now  agreed  that  ophthalmia 
neonatorum  is  due  to  but  one  cause,  and  that  is  in- 
fection. Statistics  also  show  that  the  disease  is  an 
easily  preventable  one,  and  one  that  is  readily  cured 
if  recognized  in  time.  It  is  with  the  general  prac- 
titioner that  the  early  diagnosis  of  this  disease  rests, 
for  it  is  on  prompt  treatment  in  the  early  stages 
that  the  preservation  of  sight  depends.  The  disease 
is  readily  recognized,  for  all  physicians  are  familiar 
with  the  congested  eyes,  the  swollen  conjunctivae, 
the  overlapping  lids,  from  which  thick  pus  exudes, 
and  the  dim  and  embedded  cornea. 

For  the  prevention  of  this  disease  the  Crede 
method  should  be  universally  adopted.  In  fact  a 
national  law,  instead  of  depending  on  certain  States 
for  the  adoption  of  such  a  law,  should  be  passed 
compelling  every  physician,  midwife,  and  nurse  to 
use  a  drop  of  one  or  two  per  cent,  solution  of  silver 
nitrate  in  the  infant's  eyes  as  soon  as  possible  after 
birth.  In  fact  I  am  convinced  that  the  invariable  em- 
ployment of  the  Crede  method  would  almost  entirely 
eliminate  ophthalmia  neonatorum  and  its  dreadful 
consequences.  It  is  reasonably  certain  that  at  the 
present  time  there  is  no  remedy  that  can  take  the 
place  of  nitrate  of  silver,  either  in  the  prevention  of 
this  disease  or  its  treatment. 

In  a  recent  communication  to  the  different  health 
boards  of  the  large  cities  of  the  United  States,  it 
was  astonishing  to  find  the  wide  diversity  of  opinion 
and  legislation  in  the  different  cities  regarding  the 
prevention  of  blindness  in  the  newborn ;  but  in  the 
cities  where  the  free  distribution  of  nitrate  of  silver 
was  made  to  the  midwives  and  nurses,  cases  of  oph- 
thalmia neonatorum  had  been  reduced  considerably. 
The  superintendent  of  the  Philadelphia  Lying-in 
Hospital  says  that  in  her  eight  years'  experience  in 
that  institution  she  has  never  seen  a  patient  who 
was  harmed  or  injured  by  the  instillation  of  silver 
nitrate,  and  this  experience  has  been  repeated  again 
and  again  in  many  lying-in  institutions.  It  has 
been  stated  that  one  fifth  of  all  the  blind  asylums 
in  the  United  States  could  be  eliminated  if  the 
Crede  method  were  universally  adopted  by  obstet- 
ricians, nurses  and  midwives. 

ETIOLOGY. 

It  is  now  generally  conceded  that  ophthalmia 
of  the  newborn  is  acquired  in  the  great  majority  of 
cases  by  the  infection  of  the  eyes  of  the  infant  with 
the  vaginal  secretions  of  the  mother  during  the 
passage  of  the  child  along  the  birth  canal.  A  few 
cases  of  antepartum  infection  have  been  found,  and 
infants  have  been  born  with  bennorrhea  fully  de- 
veloped, or  the  cornea  already  destroyed,  but  these 
cases  are  extremely  rare,  only  105  I  believe,  having 
been  reported  up  to  the  present  time. 

In  a  large  majority  of  cases  the  gonococcus  has 
been  found  present  in  the  pus  from  the  affected  eyes. 
Streptococci,  staphylococci,  pneumococci,  and  other 
pathogenic  organisms  have  been  detected  microscopi- 
cally, but  when  these  have  been  the  cause  of  the 
infection,  the  malady  with  proper  treatment  has 
usually  run  a  mild  course  and  gone  on  to  ultimate 
recovery.  When,  however,  infection  by  the  gon- 
ococcus takes  place,  the  course  of  the  disease  is  usu- 


ally a  virulent  one  and  may  progress  until  sight  is 
destroyed. 

Sidney  Stephenson,  in  his  valuable  essay  on  oph- 
thalmia neonatorum,  sums  up  the  four  main  factors 
in  the  etiology  of  the  disease.  He  says:  1.  That  a 
majority  of  mothers  of  ophthalmic  babies  are  af- 
fected with  vaginal  discharge  at  the  time  of  de- 
livery. 2.  That  in  most  of  these  cases  gonococci 
could  be  found  not  only  in  the  pus  from  the  ma- 
ternal passages,  but  also  in  pus  from  the  inflamed 
eyes.  3.  That  microorganisms  other  than  the  gon- 
ococcus could  occasionally  be  demonstrated  in  the 
nongonococcal  forms  of  ophthalmia.  4.  That  the 
serious  cases  of  ophthalmia,  that  is,  such  as  were 
likely  to  impair  the  sight,  were  almost  invariably 
due  to  the  specific  microbe  of  Neisser.  Neisser 
found  the  gono'coccus  present  in  68.47  per  cent,  of 
ninety-two  cases  of  ophthalmia,  and  in  a  total  of 
1,658  cases  reported  by  forty-one  observ'ers  gon- 
ococci were  demonstrated  in  67.14  per  cent. 

It  has  been  shown  and  confirmed  by  numerous 
investigators  that  most  pregnant  women  suffer  from 
catarrh  of  the  vagina,  with  a  mucous  or  purulent 
discharge,  and  hence  are  in  a  condition  to  infect 
the  eyes  of  their  babies.  While  this  is  so,  it  must 
be  remembered  that  gonorrhea  is  often  a  latent 
disease,  and  that  acute  symptoms  may  be  absent  or 
remain  quiescent.  It  is  well  known  that  pregnancy, 
labor,  and  the  puerperal  state  are  likely  to  cause  a 
recrudescence  of  an  old  Neisserian  infection,  and 
the  chronicity  of  this  disease  has  been  demonstrated 
by  the  fact  that  the  gonococci  have  shown  renewed 
activity  after  lying  dormant  in  the  genital  tract  for 
years.  All  this  goes  to  show  that  the  genital  dis- 
charges of  seemingly  healthy  women  may  convey 
infection  to  the  eyes  of  the  newborn,  and  thus  the 
innocent  offspring  be  deprived  of  their  most  valu- 
able faculty. 

The  indications  in  the  treatment  consist  of :  1,  the 
employment  of  agents  known  to  have  a  destructive 
effect  on  the  gonococci ;  2,  the  use  of  antiseptic  or 
cleansing  washes  to  keep  the  eyes  free  from  in- 
fective matter.  For  the  former  indications  the  eyes 
should  be  carefully  washed  with  a  boric  acid  solu- 
tion and  a  two  per  cent,  silver  nitrate  solu- 
tion applied  to  the  surface  of  the  everted  lids  by 
means  of  a  cotton  probe.  Both  lids  should  be  care- 
fully gone  over  quickly  and  thoroughly,  paying  par- 
ticular attention  to  the  little  folds  in  the  conjunc- 
tiva. The  eyes  should  be  subsequently  washed  at 
frequent  intervals  with  a  boric  acid  solution. 

Let  me  emphasize  that  the  treatment,  to  be  ef- 
fective, must  be  prompt.  The  second  application 
of  the  silver  solution  should  follow  in  from  eight 
to  twelve  hours  after  the  first.  Too  much  stress 
cannot  be  laid  on  the  necessity  for  keeping  the  eyes 
free  from  pus  accumulations.  This  can  only  be 
accomplished  by  repeated  washings,  at  fifteen  min- 
ute intervals  if  necessary,  both  night  and  day,  using 
a  boric  acid  solution,  as  previously  directed,  or 
potassium  permanganate  or  solution  of  bichloride  of 
mercury,  although  mercury  solution  may  prove  ir- 
ritating. In  order  to  secure  the  most  complete  at- 
tention, it  is  generally  necessary  to  use  two  nurses, 
one  for  night  duty  and  the  other  for  day.  Too 
mucli  stress  cannot  be  laid  on  the  necessity  for 


August  21,  1920.] 


LOl'E:  EYE  DISEASES  AXD   GENERAL  PRACTITIONER. 


245 


observing  the  strictest  asepsis  regarding  everything 
coming  in  contact  with  the  child.  The  newer  silver 
salts,  argyrol  and  protargol,  in  my  opinion,  possess 
certain  advantages  and  should  be  used  in  conjunc- 
tion with  nitrate  of  silver  but  under  no  circum- 
stances should  the  nitrate  of  silver  be  omitted. 

KERATITIS  ECZEMATOSA,  PHLYCTENULAR  KERATITIS,/ 
OR  PHLYCTEXULAR  CONJUNCTIVITIS. 

This  condition  is  characterized  by  the  formation 
of  single  or  numerous  vesicles  (phlyctenules)  on 
some  portion  of  the  cornea  or  conjunctiva,  and  is 
accompanied  by  photophobia  and  blepharospasm.  It 
is  seen  in  scrofulous  subjects — most  frequently  in 
children  before  the  age  of  puberty,  and  less  often  in 
adults.  It  occurs  in  connection  with  inflammatory 
diseases  of  the  nasal  passages  and  adenoid  vegeta- 
tions. "'The  affection  often  follows  measles  or  other 
acute  exanthemata." 

The  phlyctenules  appear  upon  the  comea,  usually 
at  or  near  the  corneoscleral  junction.  At  first  gray, 
they  rapidly  break  down,  forming  the  phlyctenular 
ulcer,  with  vessels  running  to  it.  Their  appearance 
is  accompanied  by  an  exacerbation  of  all  symptoms. 
When  the  ulcer  heals,  the  blood  vessels  disappear, 
but  a  strip  of  opacity  remains.  A  microscopic  ex- 
amination of  the  epithelium  of  the  aft'ected  areas 
reveals  the  presence  of  microorganisms — Staphy- 
lococcus pyogenes  aureus  and  albus. 

The  treatment  of  simple  phlyctenular  keratitis 
consists  of  instilling  atropine  in  sufficient  strength 
to  maintain  dilatation  of  the  pupil,  thus  putting  the 
eye  at  perfect  rest,  and  allaying  inflammation.  Hot 
stupes  are  useful  in  relieving  pain  and  in  promoting 
healing.  Good  hygiene  should  be  maintained  and 
sanitary  surroundings  looked  into.  Local  cleanli- 
ness should  be  assured  by  the  free  use  of  boric 
acid  solution.  Diet  and  outdoor  exercise  are  im- 
portant factors.  Of  drugs,  yellow  mercuric  oxide 
ointment  may  be  used,  and  when  the  inflammatory 
conditions  are  subsiding,  dusting  the  eye  with  calo- 
mel is  a  useful  procedure.  Codliver  oil,  iron,  qui- 
nine, minute  doses  of  calomel,  and  arsenic  should 
be  prescribed  to  meet  the  individual  constitutional 
requirements.  Refractive  errors  should  be  corrected 

IRITIS. 

In  inflammations  of  the  iris  the  symptoms  de- 
pend largely  upon  the  degree  of  hyperemia  and  the 
character  and  location  of  the  exudate.  Hyperemia 
of  the  iris  is  not,  properly  speaking,  a  disease,  but 
merely  a  symptom,  and  it  is  only  when  the  hyper- 
emia becomes  so  extreme  that  an  exudate  is  formed 
that  a  true  inflammation — an  iritis — can  be  said  to 
exist.  In  iritis  the  acuity  of  vision  is  diminished  in 
proportion  to  the  amount  of  effusion  and  accom- 
panying cloudiness  of  the  aqueous  or  the  exudate 
in  the  pupillary  space.  If  the  pupil  is  occluded,  the 
eye  is,  for  the  time  being,  almost  totally  blind. 

Among  other  symptoms  must  be  mentioned,  first, 
the  pain.  This  is,  as  a  rule,  very  characteristic.  It 
begins  as  a  dull,  deep  seated  pain,  as  if  the  eyeball 
were  being  pressed  upon.  This  increases  in  severity 
as  the  inflammation  progresses,  and  is  accompanied 
by  sharp  twinges,  usually  along  the  course  of  the 
fifth  nerve.  Thus  it  is  that  supraorbital  neuralgia 
is  a  conspicuous  s\-mptom.  Paroxysms  of  intense 
pain  occur,  gradually  increasing  in  severity  and 


number  as  night  approaches.  This  pain  is  different 
from  that  due  to  any  inflammation  external  to  the 
eye,  and  is  throbbing  and  stabbing  in  character. 

Another  important  symptom  in  iritis  is  the  change 
in  the  color  of  the  iris,  in  addition  to  the  loss  of  its 
nautral  lustre.  This  is  due  to  hyperemia,  which 
causes  a  normally  blue  or  gray  iris  to  appear  green- 
ish— a  change  particularly  marked  when  compari- 
son is  made  with  the  unaffected  eye. 

Iritis  may,  in  certain  cases,  resemble  glaucoma, 
but  the  severity  of  the  symptoms  will  easily  differ- 
entiate it  from  simple  conjunctivitis.  The  physician 
may,  however,  occasionally  be  misled  by  symptoms 
common  to  many  inflammations  of  the  deeper  tis- 
sues, such  as  photophobia  and  injection  of  the  con- 
junctiva. Yet  of  all  inflammations  of  the  eye  iritis 
is  that  most  readily  recognized.  The  iris  is-  at  first 
discolored  and  contracted,  and  its  power  of  move- 
ment impaired.  The  pupil  loses  its  glossy  blackness, 
there  is  a  deep  ciliary  injection,  and  the  cornea  is 
dull.  When  the  disease  has  progressed  to  the  for- 
mation of  an  exudate  and  the  iris  has  apparently 
become  fixed,  the  nature  of  the  disease  can  positively 
be  diagnosed. 

Rheumatic  or  gouty  iritis  occurs  most  commonly 
in  middle  life,  and  may  be  present  along  with  other 
rheumatic  affections.  In  rheumatic  or  gouty  iritis 
the  treatment  should  be  directed  toward  relieving 
the  pain  and  maintaining  mydriasis.  The  custom- 
ary treatment  of  rheumatism  and  gout  should  also 
be  prescribed. 

In  my  opinion  gonorrhea  is  a  frequent  cause  of 
iritis  and  we  can  usually  obtain  a  history  of  gon- 
orrhea when  we  fail  absolutely  to  get  one  of  lues. 
It  is  well,  therefore,  in  suspected  cases,  in  the  males, 
at  least,  to  examine  the  urethra  and  urine.  Gen- 
erally however,  the  history  of  gonorrhea  is  not  of 
recent  date.  In  the  majority  of  cases  the  suspicion 
that  syphilis  is  the  cause  of  iritis  is  well  founded. 
In  the  secondary  or  tertiary  stage  of  syphilis  a  form 
of  iritis  is  occasionally  seen,  evidenced  by  the  in- 
flamed iris  and  the  presence  of  yellowish  or  reddish 
brown  nodules — gummata  or  condylomata — situ- 
ated generally  at  the  pupillary  border.  A  Wasser- 
mann  should  always  be  made. 

The  treatment  consists  essentially  of  the  free  ex- 
hibition of  mercury,  perhaps  salvarsan,  local  seda- 
tives, and  as  in  other  forms  of  iritis,  atropine  freely. 
Dilatation  of  the  pupil  should  be  maintained  until 
all  irritation  has  subsided.  Local  measures  to  re- 
lieve the  pain  and  congestion,  such  as  Swedish 
leeches  or  the  heurteloup  to  the  temple,  are  useful, 
as  are  hot  water  fomentations  applied  at  frequent 
intervals,  and  dionin  also  may  be  used. 

GLAUCOMA 

\\'e  shall  now  consider  that  most  serious  of  eye 
diseases,  glaucoma,  a  name  applied  to  several  vari- 
eties of  a  disease  of  which  increased  intraocular 
tension  and  dilated  pupil  are  likely  to  be  the  most 
prominent  symptoms.  The  tension  of  the  eye  may 
be  estimated  by  palpating  the  eyeball  through  the 
closed  lids  with  the  index  fingers,  just  as  when  test- 
ing for  fluctuation  in  any  other  part  of  the  body. 
It  should  be  done  with  deliberation  and  care.  A 
tonometer  may  be  used. 


246 


DOXXELLV:  HISTORY  OF  ACIDOSIS. 


[New  York 
Medical  Journal 


In  making  a  diagnosis  of  glaucoma  the  sound  eye 
should  always  be  used  for  purposes  of  comparison. 
Under  normal  conditions  the  intraocular  pressure 
is  quite  constant,  but  in  morbid  conditions  consid- 
erable variations  occur.  It  should  be  remembered 
that  the  eyeballs  of  elderly  persons  are  generally 
harder  than  those  of  the  young.  The  early  recogni- 
tion of  glaucoma  by  the  general  practitioner  is  of  the 
greatest  importance,  for  in  this  disease,  more  than 
in  any  other,  prompt  and  proper  treatment  may  save 
an  eye  that  a  mistaken  diagnosis  or  improper  treat- 
ment wotild  invariably  destroy.  Inflammatory 
glaucoma  is  frequently  mistaken  for  iritis,  and  as 
a  consequence,  is  treated  with  atropine — which  has 
a  most  disastrous  effect  upon  a  glaucomatous  eye. 

Glaucoma  as  an  idiopathic  disease  usually  attacks 
those  of  fifty  or  over,  although  younger  persons  are 
not  immune.  During  the  early  stages  the  conjunc- 
tiva is  seen  to  be  hyperemic.  the  cornea  slightly 
smoky  and  anesthetic,  the  aqueous  cloudy,  and  the 
pupil  moderately  dilated.  The  association  of  in- 
flammation and  dilatation  is  seen  in  no  other  disease 
of  the  eye,  while  the  peculiar  sombre  redness  of  the 
inflammation  has  its  own  significance.  In  glaucoma 
vision  is  usually  much  worse  than  in  iritis — except 
in  iritis  with  occluded  pupil.  The  patient  complains 
that  he  does  not  see  well — as  if  a  cloud  of  smoke 
were  obscuring  things.  If  there  is  a  light  in  the 
room,  it  may  be  encircled  by  a  halo  of  rainbow 
hues.  If  the  physician  examines  the  eye  during  the 
attack,  he  finds  the  cornea  somewhat  dull,  anes- 
thetic, and  diffusely  clouded,  resembling  ground 
glass.  After  such  an  attack  which  usually  lasts 
several  hours,  the  eye  may  assume  an  apparently 
normal  condition.  As  the  disease  progresses  these 
attacks  become  frequent,  and  the  patient  complains 
of  pain  in  the  head,  ears,  and  even  in  the  teeth. 
The  pain  is,  in  fact,  intolerable.  An  examination 
at  this  time  shows  all  the  evidences  of  a  violent  in- 
flammation— edema  of  the  lids  and  of  the  conjunc- 
tiva, the  latter  being  greatly  congested.  The  in- 
jection, being  preeminently  of  a  venous  character, 
is  of  a  dusky  red  color.  The  cornea  is  dotted  and 
presents  an  appearance  of  smoky  cloudiness.  It  is 
almost  or  quite  insensitive  to  the  touch.  These  are 
the  symptoms  of  an  acute  attack.  In  the  third  stage 
the  eye  is  completely  blind.  \'omiting  frequenth" 
occurs,  a  symptom  that  has  often  led  to  errors  in 
diagnosis,  the  patient  being  treated  for  gastric  dis- 
turbances, while  the  ocular  symptoms  were  re- 
garded as  neuralgia  or  conjunctivitis. 

Every  case  of  glaucoma  if  allowed  to  go  un- 
treated will  probably  end  in  complete  and  incurable 
blindness,  and  the  necessity  for  an  early  recognition 
is  thus  at  once  made  apparent. 

Treatment  should  be  directed  toward  the  reduc- 
tion of  tension.  For  the  relief  of  pain  and  in  the 
hope  of  curing  the  disease  iridectom}'  or  trephining 
is  without  an  equal.  Morphine  hypodermically  is 
invaluable,  as  likewise  is  eserine.  The  coal  tar  pro- 
ducts are  also  useful.  When  all  is  said,  however, 
early  operation  is  the  treatment.  ^Mental  depression 
must  be  overcome.  Glaucoma  cannot  be  cured,  but 
in  favorable  cases  acute  attacks  may  be  cut  short  by 
pilocarpine  or  eserine. 
1305  Locust  Street. 


THE  HISTORY  OF  ACIDOSIS.* 

By  William  Hexry  Doxiselly,  M.  D., 
Brooklyn,  X.  Y.,  . 

Instructor  in  Pediatrics  in  the  Xew  York  Postgraduate  Medical 
School  and  Hospital;   Chief  of  Children's  Nutrition  Clinic, 
Brookl>n  Hospital. 

While  the  subject  of  acidosis  as  we  now  know  it 
is  of  comparatively  recent  development,  an  investi- 
gation of  the  literature  on  the  subject  shows  that 
it  had  its  origin  seventy  years  ago.  The  term  acid- 
osis was  first  used  by  Xaunyn  (1)  in  1906,  and  was 
applied  by  him  to  an  abnormal  metabolic  condition 
in  which  hydroxybutyric  acid  was  formed.  The 
broader  use  of  the  term  has  been  the  rule  since  the 
writings  of  Henderson  in  1909,  Sallards  in  1914, 
Peabodv  in  1914,  and  Howland  and  Marriott  in 
1916. 

The  theory  of  acidosis  had  its  inception  in  1850 
when  a  French  investigator  named  Boussingault  (2) 
made  the  discovery  that  large  amounts  of  ammonia 
frequently  appeared  in  the  urine  of  advanced  dia- 
betic patients.  Modern  writers  frequently  ascribe 
this  discovery  to  a  German  observer  named  Haller- 
vorden  (3),  who  in  1880  repeated  and  confirmed 
Boussingault's  work,  and  so  stated  in  his  writings. 
The  reason  for  this  is  evidently  the  highly  unfavor- 
able criticism  of  Boussingault's  German  contem- 
poraries as  to  his  methods  and  technic.  However, 
Schaffer  (4)  has  shown  that  Boussingault's  technic 
was  distinctly  superior  to  that  of  all  of  his  con- 
temporaries. In  the  meantime  A.  Kussmaul  (5) 
in  1874  made  the  first  clinical  observation  in  noting 
the  dyspnea  in  advanced  diabetic  patients  which  he 
named  air  hunger.  His  description  was  classical, 
describing  the  expansion  of  the  thorax  in  all  direc- 
tions, the  following  of  complete  inspiration  by  com- 
plete expiration,  with  absence  of  cyanosis,  and  of 
congestion  of  the  veins  of  the  neck. 

In  1883  E.  Stadelmann  (6),  in  the  search  for 
acid  radicals  to  account  for  the  presence  of  am- 
monium salts  in  the  urine,  discovered  betaoxybuty- 
ric  acid.  In  this  paper  he  set  forth  the  acid  intoxi- 
cation theory  and  indicated  the  logical  alkali  therapy 
as  it  is  used  at  the  present  day.  In  the  same  year 
Von  Jaksch  published  a  paper  (7)  describing  the 
substance  which  gave  Gerhardt's  ferric  chloride  test 
in  diabetic  urine,  and  positively  identified  it  as 
acetoacetic  or  diacetic  acid.  He  included  diacetic 
acid  in  his  acetone  theory  of  diabetic  coma,  having 
proved  definitely  while  working  in  his  father's  lab- 
oratory that  the  volatile  substance  obtained  from 
the  distillation  of  fever  and  diabetic  urine  is  acetone. 
Soon,  however,  acetone  was  proved  to  be  negligible 
in  its  toxic  eft'ects,  and  \'on  Jaksch  was  unable  to 
substantiate  his  contention  that  acetone  was  the 
mother  substance  of  the  other  socalled  acetone 
bodies. 

On  the  other  hand,  Walter  (8)  in  1877  had  dem- 
onstrated that  mineral  acids  were  capable  of  com- 
bining with  basic  groups  in  the  blood,  and  that 
ingestion  of  these  acids  by  animals  proved  fatal, 
although  the  blood  serum  remained  faintly  alkaline 
to  litmus.  2^Iagnus-Levy  (9)  in  1899  showed  that 
the  chief  alkali  robber  in  dyspneic  coma  was  beta- 

•Read  before  the  Brooklyn  Pediatric  Society,  April  28,  1920. 


August  21,  1920.] 


DONNELU 


HISTORY  OF  ACIDOSIS. 


247 


oxybutyric  acid.  Knoop  of  Strassburg  (10),  in  the 
opinion  of  Folin  made  in  1905  the  most  important 
advance  since  Stadehnann,  namely,  demonstrating 
that  fatty  acids  are  the  main  source  of  supply  of 
the  acetone  bodies.  Folin  (11)  states  that  these 
fatty  acids  which  contain  an  even  number  and  not 
less  than  four  carbon  atoms  can  be  oxidized  to  oxy- 
butyric acid. 

Walter  had  found  a  uniformity  of  symptoms  in 
the  administration  of  hydrochloric  acid  to  rabbits. 
If  the  quantity  inserted  into  the  rabbit's  stomach 
exceeded  .9  gram  to  the  kilo  of  body  weight,  death 
came  within  a  few  hours.  The  phenomena  were 
ushered  in  by  increased  frequency  of  respiration, 
each  respiratory  movement  being  more  labored, 
deeper  and  accompanied  by  forcible  heaving  of  the 
body  walls.  The  animal  lost  the  power  of  motion 
and  lay  in  one  position.  Fifteen  minutes  after  this 
stage  was  reached  the  dyspnea  ceased,  blood  pres- 
sure fell,  the  heart  action  weakened  and  stopped, 
although  respiration  ended  before  the  heart  ceased 
to  beat  entirely. 

Up  to  this  period  in  the  literature  nothing  had 
been  done  on  the  carbon  dioxide  tension  either  of 
the  blood  or  of  the  alveolar  air.  Haldane  and 
Priestley  (12)  in  1905  devised  a  method  of  getting 
alveolar  air  by  means  of  a  three  quarter  inch  hose 
with  a  glass  mouth  piece.  Lindhard  (13)  in  1911 
reported  a  method  of  getting  the  alveolar  air  by  a 
Krogh  glass  valve  with  a  small  flexible  lead  ttibe 
with  an  interior  bore  of  one  mm.  which  was  passed 
as  far  as  comfortable  into  the  pharynx.  Then 
Plesch  (14)  in  1909  suggested  the  rebreathing  of  a 
limited  amount  of  air  until  it  was  in  equilibrium 
with  the  air  in  the  alveoli. 

In  1914  Peabody  and  Boothby  (15)  working 
in  the  Peter  Bent  Brigham  Hospital  in  Boston 
evolved  an  apparatus  with  a  three  way  valve  by 
which  the  patient  breathed  into  a  bag  for  a  given 
length  of  time.  They  filled  the  bag  with  1,000  c.  c. 
of  air  so  as  to  allow  of  a  deep  inspiration  on  the 
part  of  the  patient.  Their  apparatus  was  a  modifi- 
cation of  one  described  by  Porges  (16)  and  they 
agree  with  him  that  the  optimum  time  of  breathing 
into  the  bag  is  twenty-five  seconds,  and  the  average 
carbon  dioxide  tension  is  about  forty-five  mm. 

Rowland  and  Marriott  (17)  warn  us  that  ace- 
tonuria  and  acidosis  are  not  synonymous  terms. 
The  acetonuria  of  starvation  or  increased  food  re- 
quirement rarely  results  in  acidosis.  Acidosis  prob- 
ably depends  on  the  same  underlying  cause  as  most 
cases  of  cyclic  vomiting.  ]\Iarriott  (18)  in  1916 
brought  out  a  colorimeter  of  standard  phosphate 
solution  colored  with  phenolsulphonphthalein.  This 
was  primarily  meant  for  use  in  children  and  the 
child  was  made  to  breathe  into  a  bag  twenty-eight 
to  thirty-two  seconds,  avoiding  collapse  of  the  bag, 
and  then  the  air  was  passed  through  a  test  solution 
colored  in  the  same  way  as  the  standard  tubes  and 
then  compared  with  them.  The  colorimeter  tubes 
are  arranged  in  series  with  a  ground  glass  back- 
ground and  are  calculated  so  as  to  give  at  once  the 
carbon  dioxide  index  in  the  same  way  as  a  hemo- 
globinometer.  With  this  test  set  the  normal  carbon 
dioxide  tension  in  the  adult  is  shown  to  be  forty 
to  forty-five  mm.;  in  children  three  to  five  mm. 


lower.  A  tension  of  thirty  to  thirty-five  shows  a 
mild  degree  of  acidosis,  one  of  twenty  imminent 
danger,  while  in  coma  with  acidosis  it  may  be  as 
low  as  eight  to  ten  mm. 

The  first  adaptation  of  a  clinical  method  of  esti- 
mating the  carbon  dioxide  given  off  from  the  blood 
plasma  or  the  carbon  dioxide  tension  of  the  blood 
was  reported  by  Van  Slyke  in  1915  (19).  He 
found  that  the  results  attained  were  the  same  as 
those  with  the  alveolar  air  methods  and  this  has 
been  repeatedly  verified  since  that  time. 

The  prophylaxis  of  acidosis  in  intestinal  condi- 
tions in  children  is  advised  by  Schloss  (  20)  using 
in  severe  cases  the  veins  or  longitudinal  sinus  with 
a  four  per  cent,  bicarbonate  of  soda  solution,  or  a' 
two  per  cent,  solution  subcutaneously.  In  March, 
1920,  in  a  lecture  before  the  Harvey  Society  at  the 
New  York  Academy  of  Medicine,  Marriott  ex- 
pressed his  belief  in  the  causation  of  acidosis  by  the 
anhydremia  produced  by  the  loss  of  body  fluids  in 
diarrhea,  and  stated  that  he  had  found  the  most 
rapid  and  efficacious  method  of  combating  the 
acidosis  in  intraperitoneal  injections  of  normal  sa- 
line which  promptly  corrected  the  dehydration  of 
the  blood. 

CYCLIC  VOMITING. 

While  there  is  a  definite  and  serious  difference  of 
opinion  among  pediatric  observers  as  to  the  con- 
nection between  cyclic  or  recurrent  vomiting  and 
acidosis,  it  must  inevitably  be  considered  in  any 
history  or  investigation  of  acidosis. 

It  seems  that  the  first  important  description  of 
the  disease  was  bv  Gruere  (21)  in  France  in  1838- 
1841.  Marfan  (22)  in  1905  and  other  French 
writers  have  associated  recurrent  vomiting  with  ace- 
tonemia, and  have  even  called  it  acetonemic  vom- 
iting, on  the  ground  that  acetone  is  so  constantly 
present  in  the  urine.  There  is  no  evidence,  as  Mar- 
fan admits,  that  acetonemia  produces  the  attack, 
since  acetonuria  is  seen  in  so  many  other  affections. 
D.  L.  Edsall  (23)  in  1903  pointed  out  that  the 
presence  of  betaoxybutyric  acid  indicated  the  pos- 
sibility of  the  condition  being  an  acidosis,  and  ad- 
vised full  doses  of  sodiitm  bicarbonate  even  in  the 
intervals.  Griffith  (26)  thinks  this  has  much  in  its 
favor,  but  is  wanting  in  certain  proofs,  and  the  dif- 
ference between  acetonuria  and  acidosis  is  to  be 
borne  in  mind,  as  was  pointed  out  by  Howland  and 
.Alarriott  (17)  in  1916.  Mellanby  (24)  in  1911 
and  Sedgwick  (25)  in  1912  foimd  a  urinary  secre- 
tion of  creatin  at  the  time  of  the  attack,  and  believed 
that  this  was  due  to  abnormal  metabolic  changes. 
Sedgwick  also  thinks  that  adenoids  are  a  powerful 
etiological  factor.  Richardiere  (27)  in  1905  be- 
lieved that  the  occasional  coexistence  of  icterus  was 
an  evidence  of  the  involvement  of  the  liver  in  the 
disease  process.  Charles  Hunter  Dunn  (28)  is  so 
convinced  of  the  connection  between  this  condition 
and  acidosis,  that  he  divides  the  latter  subject  into 
recurrent  vomiting  and  acid  intoxication. 

REFERENCES. 

1.  Nauxvx,  B.  :  Dcr  Diebetes  Mellitus,  Zweite  Auflage, 
Wien,  1906. 

2.  BoussiXGAULT :  Recherches  sur  la  quantite  d'ammoni- 
aque  contenue  dans  I'urine,  Annales  de  Chitnic  ct  Physique, 
1850,  3me,  No.  29,  p.  472. 

3.  Hallervorden,  E.  :Ueber  Ausscheidung  von  Ammo- 


248  RET  AX:  CHILD 


niak  im  Urin  bei  pathologischen  Zustanden.  Archiv.  fiir  Ex- 
pcrhnciit.  Path,  iind  Pharmak..  1879-80.  No.  12.  p.  237. 

4.  Schaffer:  American  Journal  of  Physiology,  1903, 
vol.  viii,  p.  345. 

5.  Kussmaul:  Deutsche  Archiv.  fiir  klinische  Medizin, 
1874,  vol.  xiv.  p.  1. 

6.  Stadelm.\xx,  E.  :  Archiv.  fiir  E.vperitncnt.  Path,  und 
Pharmakol,  1883.  vol.  xvii,  p.  419. 

7.  \'ox  Taksch  :  Zeitschrift  fiir  phxs.  Chcmie,  1883,  p. 
487. 

8.  W.\LTER,  F. :  Archiv.  fiir  Experiment.  Path,  und 
Pharmakol.  1877,  vol.  vii,  p.  148. 

9.  Magxts-Levv:  Archii:  fiir  Experiment.  Path,  und 
Pharmakol,  1899.  No.  42.  p.  148.  No.  45,  p.  389. 

10.  KxooP :  Zeitschrift  fiir  die  qesammte  Biochemic. 
1905,  vol.  vi,  p.  150. 

11.  FoLix",  Otto:  Transactions  of  Association  of  Ameri- 
can P/iv.rfVifl'iJ,  1907,  vol.  xxii.  p.  256. 

12.  Haldaxe  and  Priestley:  Journal  of  Physiology, 
1905,  vol.  xxxii,  p.  225. 

13.  Lixdhard:  Journal  of  Physiology,  1911,  vol.  xlii,  p. 
337. 

14.  Plesch  :  Zeitschr.  fiir  Experiment.  Path,  und  Tliera- 
pie.  1909.  vol.  iii,  p.  380. 

15.  Pfabodv,  W.  M.,  and  Boothbv.  F.  \\'. :  Archives  of 
Internal  Medicine,  vol.  xiii,  1914,  p.  499. 

16.  Porges  :  Zeitschrift  fiir  klinische  Med.,  vol  Ixxiii. 

17.  HowLAXD,  J.,  and  Marriott,  \V.  McK.  :  American 
Journal  of  Diseases  of  Children,  1916,  vol.  xii,  p.  459. 

18.  Marriott,  W.  McK.  :  Journal  A.  M.  A.,  vol.  Ixvi. 
May  20.  1916. 

19.  V.\x  Slyke,  D.  D.  :  Proceedings  of  Society  of  Ex- 
perimental Biology  and  Medicine.  1915,  vol.  xii,  p.  165. 

20.  ScHLOSS,  Osc.\R  :  .V.  }'.  State  Journal  of  Medicine. 
August.  1918. 

21.  Gri'ere  :  Precis  dcs  travau.v  de  la  Soci-ete  medicate 
dc  Diion.  1838-1841. 

22.  M.\rfax,  a.  :  Bull.  soc.  de  Pediat.,  1905.  vii,  p.  41. 

23.  Eds.\ll,  D.  L.  3  American  Journal  of  the  Medical 
Sciences.  1903,  cxxv,  p.  629. 

24.  Mellaxby  :  Lancet,  1911,  vol.  ii,  p.  8. 

25.  Sedgwick,  J.:  American  Journal  of  Diseases  of 
Children,  1912.  vol.  iii,  p.  209. 

26.  Griffith,  J.  P.  C. :  Diseases  of  Infants  and  Chil- 
dren, vol.  i.  1919,  p.  702. 

27.  Richardiere:  Ann.  de  med.  et  chir.  inf.,  1905,  vol. 
ix,  p.  150. 

28.  Duxx.  C.  H.:  Pediatrics,  1917,  vol.  ii.  Second  Edi- 
tion, p.  54. 

178  Woodruff  Avenue. 


CHILD  HEALTH  WORK  IX  THE  SOLVAY 
SCHOOLS. 

By  George  M.  Retax.  ^l.  D., 
Syracuse,  N.  Y.. 

Instructor  in   Pediatrics,  College  of  Medicine,   Syracuse  University. 

The  objects  sought  in  our  health  work  in  the 
Solvay  schools  are  threefold :  First,  to  lower  mor- 
tality rate;  second,  to  prevent  sickness,  and  third, 
to  encourage  the  best  possible  mental  and  physical 
development  in  each  individual  child.  The  work  is 
divided  into  four  general  heads:  1,  the  prenatal 
clinic ;  2,  the  infant  welfare  clinic :  3,  the  preschool 
clinic  which  fills  the  gap  between  the  age  of  infancy 
and  the  school  age,  and  4,  the  school  welfare  work 
which  takes  the  child  from  kindergarten  through 
high  school. 

The  conditions  at  Solvay  have  been  unusually 
favorable  for  the  success  of  this  plan.  Solvay  is  an 
incorporated  village  of  6,000  inhabitants.  It  has 
fifty-one  per  cent,  of  foreign  population.  The  vil- 
lage is  a  suburb  of  the  city  of  Syracuse.  It  has  its 
own  water  supply  and  sewerage  plant.  Practically 
all  of  the  streets  are  paved.    The  school  system  con- 


HEALTH    WORK.  [New  York 

Medical  Journ.kl 

sists  of  a  high  school,  two  graded  schools  and  one 
rural  school.  There  are  1,588  pupils.  There  are 
no  hospitals  but  we  have  access  to  the  wards  of  the 
Syracuse  hospitals  and  to  the  free  dispensary  con- 
nected with  S>Tacuse  Universit}-. 

The  entire  work  is  under  the  supervision  of  the 
school  physician.  The  staiT  consists  of  the  school 
physician,  an  ophthamologist,  a  dentist,  a  dental 
assistant,  two  school  nurses,  one  baby  welfare 
nurse,  a  visiting  housekeeper,  a  nutrition  worker, 
and  a  physician  who  conducts  the  prenatal  clinic. 
The  prenatal  clinic  is  held  each  week.  We  have  at 
present  ten  women  registered.  This  clinic  is  held  by 
Dr.  Clara  Gregory  assisted  by  our  baby  welfare 
nurse.  A  maternity  history  is  taken  and  physical 
examination  including  pelvimetry  is  made.  Urine 
and  blood  pressure  examinations  are  made  each 
month  during  the  early  part  of  pregnancy.  This 
is  done  every  two  weeks  during  the  later  months 
of  pregnancy.  The  doctor  advises  the  expectant 
mother  regarding  her  diet  and  mode  of  living.  The 
teeth  are  filled  and  a  mouth  wash  prescribed.  The 
women  are  encouraged  to  go  to  the  hospital  foi 
their  confinement. 

The  infant  welfare  work  is  divided  into  two 
general  headings,  work  in  the  clinics  and  field  work. 
It  is  done  in  cooperation  with  the  State  Child  Wel- 
fare Department.  The  clinics  are  held  each  ^^londay 
afternoon.  At  these  clinics  any  mother  in  the  town 
is  allowed  to  bring  her  infant.  From  September  1, 
1918,  to  September  1,  1919.  we  cared  for  522  babies. 
The  general  form  in  each  new  case  is  filled  out  by 
the  nurse  and  any  additional  facts  suggested  are 
added  by  the  physician.  The  babies  are  weighed  at 
each  visit  by  the  nurse  and  a  weight  record  made. 
The  chief  purpose  of  this  clinic  is  to  teach  mothers 
to  feed  their  babies  properly.  Every  attempt  is 
made  to  induce  mothers  to  nurse  their  infants.  In 
spite  of  our  efforts  we  find  that  thirty-one  per  cent, 
of  the  babies  are  bottle  fed.  This  percentage  should 
be  much  lower  and  we  are  making  the  greatest  ef- 
fort to  bring  it  down.  This  high  percentage  is  in 
part  due  to  the  mothers  and  in  part  due  to  the  family 
physicians.  ^lany  mothers  seem  anxious  to  take 
their  babies  from  their  breast  for  insufficient  rea- 
sons and  doctors  often  advise  this  without  careful 
investigation.  Breast  fed  babies  may  have  digestive 
disturbances  when  the  breast  milk  is  normal.  These 
disorders  are  due  to  irregularities  in  the  intervals  of 
feeding,  to  the  manner  of  living  on  the  part  of  the 
mother  and  to  insufficient  length  of  single  feedings. 
It  should  be  the  duty  of  the  attending  physician  to 
insist  that  the  mother  nurse  her  baby  at  stated  in- 
tervals and  also  that  she  nurse  the  baby  for  a  definite 
number  of  minutes  as  the  conditions  warrant.  Fur- 
ther than  this  the  mother  should  be  instructed  in 
regard  to  the  manner  of  her  living  and  hygiene  dur- 
ing this  period. 

The  problems  of  infant  feeding  form  a  large 
proportion  of  the  problems  presented  in  infant  wel- 
fare work.  We  insist  that  our  babies  shall  be  fed 
with  certified  milk.  The  bacterial  counts  of  all 
milk  used  are  obtained  at  least  once  a  month.  For 
a  year  we  supplied  a  certified  cow's  milk  at  a  re- 
duced cost  to  mothers  who  were  using  bottle  feed- 


August  21,  1920.] 


RETAN:  CHILD  HEALTH  WORK. 


249 


ings.  The  milk  was  distributed  directly  from  the 
school  at  a  cost  of  nine  cents  a  quart.  At  that  time 
grade  A  milk  was  selling  for  eleven  cents  a  quart. 
We  did  this  in  order  to  demonstrate  to  them  the 
superiority  of  certified  milk  for  infant  feeding. 
We  feel  that  this  demonstration  was  a  success  for 
since  we  have  stopped  distributing  milk  we  have 
no  trouble  in  inducing  mothers  to  use  the  best  grade 
of  milk.  I  think  that  it  is  important  for  the  physi- 
cian in  charge  of  an  infant  welfare  station  to  keep 
himself  informed  regarding  the  bacterial  counts  of 
all  milk  used  by  the  mothers.  In  private  pediatric 
practice  infant  feeding  presents  a  different  problem 
than  in  a  baby  welfare  clinic.  A  pediatrist  has 
many  difficult  feeding  cases  to  care  for,  while  in 
the  welfare  clinics  the  large  proportion  of  patients 
are  normal  babies  and  are  not  difficult  to  feed.  We 
use  dilutions  of  whole  milk  basing  the  amount  on 
the  caloric  requirements.  Cane  sugar  is  used  in 
most  cases.  I  am  convinced  that  it  is  not  necessary 
to  ask  mothers  to  buy  the  more  expensive  sugars 
used  in  infant  feedings.  In  our  feeding  both  breast 
and  bottle  babies  we  insist  that  our  infants  be  fed 
at  a  regular  stated  interval  and  I  feel  that  we  are 
successful  in  getting  the  mothers  to  do  this. 

After  instructing  the  mothers  regarding  the  new 
formula,  the  nurse  is  sent  to  the  home  to  show  the 
mother  how  the  formula  should  be  made  up,  the 
proper  care  of  the  milk  and  how  to  cleanse  and  care 
for  nursing  bottles  and  nipples.  The  home  visits 
of  the  nurse  are  of  vital  importance  in  conducting 
a  baby  welfare  clinic.  Without  this  work  the  clinic 
could  not  succeed.  Our  nurse  makes  a  visit  each 
month  to  the  town  registrar  for  a  list  of  the  births 
and  infant  deaths  during  the  preceding  month. 
The  nurse  calls  at  the  home  to  interest  the  mothers 
in  the  welfare  clinic  and  asks  them  to  bring  the 
babies  to  the  clinic  for  examination.  The  list  of 
infant  deaths  is  used  by  the  physician  in  his  attempt 
to  lessen  cases  of  preventable  sickness.  The  nurse 
is  instructed  to  advise  that  the  family  physician  be 
summoned  to  care  for  any  sick  infant  who,  in  her 
opinion,  requires  medical  aid.  This  is  of  advantage 
since  many  cases  are  thus  placed  under  a  physician's 
care  earlier  than  would  otherwise  be  true.  The 
nurse  continually  advises  mothers  in  matters  of 
cle'anliness,  diet,  in  the  care  of  milk  and  in  the  care 
of  nursing  bottles  and  nipples. 

Cases  of  respiratory  diseases  are  often  seen  at 
the  clinic  and  if  these  are  of  a  benign  nature  rem- 
edies are  prescribed.  I  feel  that  this  is  better  than 
allowing  the  mother  to  use  household  or  drug  store 
remedies  as  these  cases  would  rarely  be  taken  to  a 
physician  for  treatment.  No  attempt  is  made  to 
treat  the  more  serious  diseases  as  bronchitis  or  pneu- 
monia. The  mothers  are  always  instructed  to  dis- 
continue all  feedings  and  give  the  baby  plain  water 
or  barley  water.  If  the  nurse  considers  the  case  of 
any  possible  serious  nature  the  family  physician  is 
summoned  at  once.  The  early  treatment  of  intes- 
tinal diseases  especially  in  the  summer  months  is  of 
the  first  importance  and  we  feel  that  by  stopping 
the  feedings  and  by  placing  the  case  early  in  the 
hands  of  a  physician,  the  high  mortality  rate  can 
be  materially  diminished. 


Another  idea  that  we  have  developed  and  which 
we  feel  is  of  distinct  advantage  is  the  manner  in 
which  our  clinics  are  held.  The  patients  are  seen 
and  examined  by  the  doctor  in  the  same  room  and 
in  the  midst  of  the  mothers  who  are  waiting  and 
each  point  explained  to  the  mother  is  also  heard  by 
those  mothers  waiting.  All  mothers,  in  this  way, 
receive  repeatedly  the  principles  of  infant  care  and 
hygiene.  The  annoyance  caused  by  the  infants  and 
children  in  the  room  is  ofifset  when  mothers  see 
these  principles  successfully  applied.  I  believe  that 
this  is  the  reason  that  we  are  able  to  have  prac- 
tically all  of  the  babies  fed  at  regular  intervals. 

The  infant  mortality  in  Solvay  has  steadily  de- 
creased since  the  clinic  has  been  in  operation.  Last 
year  we  had  enrolled  in  our  clinic  seventy  per  cent, 
of  the  infants  in  the  village.  This  year  that  per- 
centage has  been  increased.  The  mortality  rate  for 
1916  was  156.  For  1917  the  mortality  rate  was 
ninety-seven.  For  1918  it  was  eighty-three.  The 
infant  welfare  clinic  in  its  present  form  was  or- 
ganized in  1917.  Before  that  time  we  were  holding 
clinics  but  without  a  nurse  who  devoted  all  of  her 
time  to  the  work.  I  believe  that  in  order  for  a 
baby  welfare  clinic  to  be  successful  it  is  necessary 
for  the  physician  to  be  paid.  One  of  the  first  re- 
quisites of  a  successful  clinic  is  the  regular  and 
prompt  attendance  of  the  physician  in  charge.  Since 
most  physicians  gain  their  livelihood  through  the 
recompense  they  receive  from  their  private  prac- 
tice, it  is  necessary  for  them  to  respond  to  their 
calls  and  consequently  they  are  often  late  to  the 
clinics  or  are  not  able  to  attend.  If  they  receive 
sufficient  compensation  for  the  work  the  clinic  could 
demand  their  prompt  attendance. 

The  preschool  clinic  cares  for  children  between 
the  ages  of  two  and  five  years.  From  the  viewpoint 
of  preventive  medicine  this  is  an  extremely  impor- 
tant period.  It  is  the  period  during  which  the  child 
forms  faulty  food  habits.  Many  children  who  have 
been  properly  fed  during  the  first  two  years  of  life 
are  allowed  to  select  their  own  diet  during  this 
period.  ]\Iany  children  begin  at  these  ages  to  eat 
whatever  diet  their  fancy  dictates.  Faulty  food 
habits  once  formed  are  extremely  difficult  to  change. 
This  is  also  the  age  in  which  many  children  learn 
to  drink  coffee  and  to  eat  candy  before  meals. 
These  habits  sadly  afifect  their  nutrition  and  their 
resistance  to  infection.  If  the  nutrition  is  decreased 
seven  per  cent,  below  the  normal  their  rate  of 
growth  is  retarded.  The  teeth  during  this  period 
should  receive  attention.  Carious  teeth  should  be 
filled  since  the  decay  and  early  loss  of  the  primary 
set  afifects  the  development  and  formation  of  the 
jaw. 

This  is  also  the  period  during  which  the  adenoids 
should  be  removed.  The  changes  in  the  face,  the 
retarded  development  of  the  nose,  the  high  arched 
palate,  the  flat  chest  and  the  middle  ear  complica- 
tion produced  by  adenoid  growths  could  largely  be 
prevented  if  the  adenoids  could  be  removed  before 
the  age  of  five.  All  children  attending  school  re- 
ceive at  least  one  physical  examination  a  year.  This 
includes  an  examination  of  the  height,  weight,  nu- 
trition, eyes,  ears,  nose,  teeth,  throat,  glands,  heart 


250 


RET AN: 


CHILD  HEALTH  WORK. 


[New  York 
Medical  Journal 


and  lungs.  All  children  are  examined  with  the 
chest  exposed. 

The  routine  examination  is  made  in  the  following 
manner.  The  height  and  weight  are  taken.  The 
mouth  is  inspected,  examining  the  pharynx  first, 
then  the  teeth.  The  hands  are  now  passed  along 
the  sternomastoid  muscle  to  determine  the  condi- 
tion of  these  glands  and  along  the  back  of  the  neck 
for  the  same  purpose.  The  heart  is  then  examined 
oscillating  each  of  the  four  valvular  areas.  Ex- 
amination of  the  lungs  consists  of  at  least  six  oscil- 
lations in  front  and  the  same  number  in  the  back. 
The  forced  cough  at  the  end  of  expiration  is  used 
in  making  examinations.  The  chest  is  also  ex- 
amined for  D'Espine's  sign.  By  these  methods 
efforts  are  being  made  to  detect  the  early  stages  of 
tuberculosis.  This  examination  is  made  in  an  aver- 
age of  three  minutes.  Without  using  the  forced 
cough  at  the  end  of  expiration  and  the  D'Espine 
sign  the  examination  can  be  made  in  an  average  of 
two  m.inutes.  If  school  children  are  to  be  examined 
at  all  and  a  careful  examination  can  be  made  in  this 
time  I  see  no  reason  why  it  should  not  be  done. 

I  believe  that  there  is  a  close  relationship  between 
the  work  of  the  school  physician  and  the  prevention 
of  tuberculosis  among  children.  Until  more  exact 
methods  of  diagnosing  early  cases  have  been  worked 
out,  I  feel  that  we  can  accomplish  much  in  the  way 
of  prevention  by  applying  our  present  knowledge. 
During  my  first  year  in  Solvay  T  found  children 
with  pulmonary  tuberculosis,  who  showed  positive 
signs  and  tubercle  bacilli  were  found  in  the  sputum. 
The  conditions  in  a  school  room  with  children  closely 
associated  for  five  hours  each  day  are  ideal  for  con- 
tinuous infection.  For  these  reasons  I  believe  that 
it  is  not  safe  for  children  to  attend  public  schools 
in  which  children  are  allowed  who  do  not  have  their 
chests  examined  at  least  once  a  year.  Further  than 
this  I  believe  that  many  cases  of  tuberculosis  among 
children  could  be  prevented  were  this  universally 
done. 

I  have  thought  that  we  could  go  farther  and 
find  the  earlier  cases  and  with  this  idea  in  view  we 
are  making  a  list  of  the  children  who  come  in  con- 
tact in  their  homes  with  known  patients  with  tuber- 
culosis. Patients  who  show  suspicious  physical 
signs  are  listed  and  reexamined  and  if  these  signs 
persist  on  the  second  and  third  examination  we  will 
attempt  to  have  an  x  ray  taken  and  an  examination 
made  by  a  specialist. 

The  nutrition  of  each  child  is  measured  by  a 
scale  (1)  which  I  have  prepared  which  divides  nu- 
trition into  four  classes:  1,  overnutrition ;  2,  excel- 
lent nutrition;  3,  passable  nutrition;  4,  malnutrition. 
The  observations  made  each  year  are  placed  on  a 
separate  chart  for  each  child  and  these  observations 
connected  by  a  line  form  a  curve  of  the  child's  nu- 
trition during  school  period.  If  a  child  is  found  to 
be  malnourished  he  is  placed  in  one  of  our  malnutri- 
tion classes  where  an  effort  is  made  to  correct  his 
nutrition. 

The  principal  causes  of  malnutrition  may  be 
classified  as:  Physical  defects,  1,  adenoids,  2,  hyper- 
trophied  tonsils;  3,  decayed  teeth;  4,  eyestrain;  hab- 
its, 1,  food  habits,  coffee,  tea  and  alcohol  and  candy 


between  meals;  2,  lack  of  rest;  hygiene,  1,  sleeping 
in  congested,  unventilated  rooms;  disease,  1,  any 
actual  diseased  condition  as  tuberculosis  or  syphilis. 

During  the  past  year  an  attempt  was  made  to 
correct  our  malnutrition  cases  after  the  plan  of  Dr. 
Emerson  of  Boston.  A  special  nutrition  worker 
was  engaged  who  was  trained  by  Dr.  Emerson. 
This  year  we  have  divided  the  malnutrition  cases 
into  two  sections.  One  section  is  cared  for  by  this 
nutrition  worker  after  the  plan  of  Dr.  Emerson,  the 
other  section  is  in  charge  of  our  dietitian  who  is  a 
graduate  of  Mechanics  Institute  at  Rochester.  The 
majority  of  all  malnutrition  cases  are  either  caused 
by  infected  tonsils  and  adenoids  or  by  faulty  diet 
and  often  a  combination  of  the  two. 

The  result  of  tonsillectomy  on  nutrition  is  shown 
by  the  following  data.  This  gives  a  summary  of 
the  weights  of  ninety-five  children  who  have  had 
their  tonsils  removed  for  at  least  a  year.  These 
children  have  lived  under  the  same  conditions  fol- 
lowing tonsillectomy  and  have  received  the  same 
diet.  Six  pounds  was  used  as  an  average  yearly 
gain  for  a  basis  of  comparison.  Sixty-eight  patients 
or  seventy-one  per  cent,  gained  more  than  six 
pounds.  Three  children  failed  to  gain  during  the 
year  and  two  cases  lost  weight.  One  of  the  two 
children  that  lost  weight  had  active  pulmonary 
tuberculosis. 

We  have  made  an  investigation  to  determine  the 
diet  of  530  scliool  children  between  the  ages  of  five 
and  twelve  years.  The  diets  were  separated  into 
three  classes. 

This  data  showed  that  nearly  half  of  our  chil- 
dren receive  insufficient  food  and  that  over  half  of 
these  children  are  in  the  habit  of  drinking  coffee. 
You  can  see  the  importance  of  considering  diet  in 
relation  to  any  nutrition  problem. 

No  child  is  allowed  in  either  class  whose  malnu- 
trition is  obviously  due  to  any  physical  defect  as 
adenoids,  tonsils,  etc.  The  Emerson  system  as 
practised  by  our  nutrition  worker  mainly  works 
through  the  child.  The  interest  of  the  child  is 
obtained  in  his  own  physical  growth.  He  is  asked  to 
fill  out  a  note  book  showing  the  amount  and  char- 
acter of  the  food  he  eats.  His  diet  is  corrected  and 
the  approximate  number  of  calories  he  consumes 
each  day  is  placed  on  the  chart  each  week.  He  is 
asked  to  take  a  daily  extra  lunch  and  if  he  does  so 
a  red  star  is  placed  on  the  chart  each  week.  He  is 
also  requested  to  take  a  rest  period  each  day.  If 
this  is  done  a  blue  star  is  added.  A  weight  curve 
is  kept  showing  the  progress  in  weight.  The  chart 
also  shows  his  normal  weight  curve.  When  he  has 
reached  the  normal  curve  he  is  graduated.  He  is 
also  asked  to  give  up  drinking  coffee  and  requested 
to  slip  with  the  windows  open  nights.  The  classes 
of  malnutrition  are  held  once  every  week.  In  these 
classes  the  nutrition  worker  teaches  the  children 
what  food  is  for,  the  kinds  of  food  that  are  best 
suited  for  growth,  the  harm  done  by  drinking  coffee 
and  tea  and  matters  of  hygiene.  The  case  of  each 
child  is  then  considered  separately.  In  the  event 
the  child  has  gained  the  reasons  for  this  are  brought 
forward  and  the  child  is  encouraged.  In  case  he 
has  not  gained  the  reason  for  this  lack  of  gain  is 


August  21,  1920.] 


RETAN:  CHILD  HEALTH  WORK. 


251 


sought  and  he  is  stimulated  to  greater  efforts. 
The  physician  regularly  visits  the  class  and  adds 
his  influence  toward  gaining  the  cooperation  of 
the  child.  Food  models  are  used  to  aid  in  teaching 
the  children  a  balanced  diet  and  food  values. 

The  dietetian  conducts  her  work  by  using  the 
class  method  of  teaching  the  children  diet  and 
hygiene  and  by  visiting  the  home  and  teaching 
mothers  proper  methods  of  cooking  and  preparing 
food,  what  foods  to  buy  to  keep  within  their  in- 
come. She  advises  the  parents  to  allow  the  chil- 
dren to  drink  no  coffee  and  to  sleep  with  windows 
open.  She  also  uses  extra  rest  periods  for  the  badly 
nourished.  The  results  of  these  two  experiments 
will  be  of  interest. 

The  following  list  gives  the  defects  found  from 
September  1,  1918.  to  June  30.  1919: 


Defects  Treated 

Vision    149  149 

Hearing    14  11 

Teeth    510  508 

Nasal  breath    160  92 

Tonsils    273  138 

Nutrition    215'  130 

Cardiac    16  16 

Pulmonary    12  12 

Nervous    13  13 

Orthopedic    13  13 

Skin  disease    151  151 


Through  the  operation  of  the  Boyd  School  Den- 
tal Clinic,  this  condition  has  been  practically  eradi- 
cated. A  summary  of  the  work  done  in  the  dispen- 
sary from  February  15,  1917,  to  April  8,  1919,  is  as 


follows : 

Treatments    1,329 

Extractions    1,895 

Cement  fillings    920 

Amalgam  fillings    2,890 

Silicate  cement  F   254 

Cleanings    1,255 

Extractions    1.017 


Total    9,560 


The  value  of  this  work  estimated  at  the  rates 
charged  in  dental  offices  is  $10,242.  The  fees  paid 
by  the  patients  were  $455.15.  The  actual  cost  of 
equipment  and  salaries  was  $5,679.  The  value  of 
the  work  to  the  community  is  apparent.  The  com- 
munity, realizing  the  value  of  this  work,  has  this 
year  assumed  the  expense  of  the  dental  department. 

We  are  now  carrying  on  a  plan  of  preventive 
dentistry.  After  a  molar  tooth  has  become  decayed 
many  treatments  are  needed  before  this  tooth  can 
be  filled.  If  the  dentist  could  fill  this  tooth  when 
the  carious  process  first  begins,  much  time  would  be 
saved  the  dentist,  and  many  extractions  would 
be  prevented.  Under  a  plan  of  preventive  dentis- 
try a  large  proportion  of  the  1895  extractions  which 
we  were  forced  to  do  could  be  prevented  and  very 
little  treatment  work  would  be  needed. 

The  success  of  preventive  dentistry  can  be  shown 
by  the  fact  that  from  February,  1917,  when  the 
dental  clinic  began  to  August,  1918,  including  the 
first  seventeen  months  of  its  operation,  we  treated 
on  an  average  of  eleven,  six  year  molar  teeth  each 
month.  From  September,  1918,  to  June,  1919,  a 
period  of  nine  months,  we  treated  on  an  average  of 
four,  six  molar  teeth  each  month.  And  from  Sep- 
tember, 1919,  to  December,  1919,  the  past  four 


months,  we  treated  on  an  average  of  but  2.4  each 
month.  The  six  year  molar  is  the  first  permanent 
tooth  and  as  you  will  remember  we  found  twenty- 
five  per  cent,  of  the  children  with  these  teeth  so 
nearly  decayed  that  they  required  treatment  before 
filling.  If  we  could  work  only  on  our  own  children 
and  those  who  enter  school  at  kindergarten  ages,  we 
could  entirely  eliminate  this  tooth  destruction,  but 
we  will  always  have  some  children  with  badly  de- 
cayed molars  who  come  to  us  from  other  schools. 

We  have  been  unusually  successful  in  correcting 
errors  of  refraction.  In  149  cases  found  the  last 
school  year  we  corrected  one  hundred  per  cent. 
Much  credit  is  also  due  the  nurses  in  the  follow  up 
work.  They  did  not  rest  content  until  these  chil- 
dren were  provided  with  proper  glasses.  After 
glasses  have  been  provided  it  is  necessary  to  see 
that  they  are  worn. 

The  enlarged  tonsils  and  adenoids  present  a  diffi- 
cult problem  to  the  school  physician.  We  have  been 
extremely  cautious  in  selecting  cases  in  which  we 
advise  operation.  Our  opinion  has  not  always  been 
substantiated  by  the  family  physician.  Unfortu- 
nately there  is  some  difference  of  opinion  among 
the  doctors  in  regard  to  what  kind  of  tonsils  should 
be  operated.  I  feel  that  doctors  should  consider  a 
case  carefully  before  giving  advice.  From  our  273 
cases  we  were  able  to  have  138  operated,  which  is 
fifty  per  cent. 

In  concluding  I  want  to  correct  an  impression 
that  I  have  heard  advanced  many  times  regarding 
this  work  at  Solvay.  I  hear  that  this  manner  of 
work  is  not  practical  since  we  have  unlimited  funds 
of  money  at  our  disposal.  One  would  think  that 
at  Solvay  resided  a  Midas  with  a  golden  touch. 
This  is  not  true.  We  can  spend  money  only  when 
we  can  show  that  the  expenditure  will  bring  suffi- 
cient results  to  warrant  it.  Every  dollar  spent  must 
show  at  least  a  dollar's  worth  of  results.  It  is 
purely  a  business  proposition  and  we  are  spending 
no  more  money  than  any  community  ought  to  spend 
in  proportion  to  its  population.  If  the  conservation 
of  children  is  of  importance,,  money  must  be  spent 
to  put  methods  of  conservation  into  successful  op- 
eration. It  cannot  be  done  in  any  other  way.  Com- 
pare the  expense  of  child  education  with  the  expense 
of  child  welfare  work.  We  are  spending  but  one 
dollar  for  health  to  every  eighteen  dollars  spent  for 
education.  It  is  not  sound  business  to  spend  large 
sums  to  educate  a  poorly  nourished  child  with 
adenoids,  enlarged  tonsils,  flat  chest,  retarded  phys- 
ically one  or  more  years.  Figure  the  loss  of  time 
and  money  in  attempting  to  teach  a  child  to  read 
whose  eyes  will  allow  him  to  see  the  printed  page 
but  imperfectly.  And  shall  we  allow  our  educators 
to  spend  their  time  on  a  child  with  tuberculosis,  not 
to  mention  the  other  children  he  will  start  along 
the  same  highway  to  chronic  diseases? 

None  of  this  work  described  costs  too  much  for 
any  community  if  we  expect  to  train  a  future  gen- 
eration of  virile,  healthy,  energetic  men  and  women. 

REFERENCES. 

1.    The  Measure  and  Development  of  Nutrition  in  Child- 
hood, New  York  Medical  Jourxal,  Novemljer  19,  1919. 

705  Keith  Building. 


252 


MOXTEITH: 


MELANOMA. 


[New  York 
Medical  Journal 


REPORT  OF  A  CASE  OF  INIELANOMA  * 

From  Gouvcrncnr  Hospital,  X .  Y .,  Medical  Service. 

By  S.  R.  MoxTEiTH,  M.  D., 
New  York. 

There  are  three  features  of  the  case  under  con- 
sideration which  lead  us  to  report  it :  First,  the 
volcanic  rapidity  of  its  clinical  course ;  secondly,  the 
distribution  of  the  metastases  as  shown  at  autopsy, 
and  the  comparatively  minute  quantity  of  pigment 
seen  in  the  tumor  masses. 

Case. — Patient,  M.  K.,  an  adult  white  female 
aged  twenty-three  years,  admitted  to  the  wards  of 
Gouverneur  Hospital,  October  25,  1919,  at  8:40  a.  m. 
The  patient  while  thin  and  undernourished  did  not 
evidence  a  marked  degree  of  cachexia.  She  was 
markedly  dyspneic,  somewhat  cyanotic  and  jaun- 
diced. The  jaundice,  while  marked,  was  of  a  lemon 
yellow  tint  but  not  bright  yellow.  On  the  right 
back,  at  the  lower  part  of  the  neck,  above  the  scapula, 
was  a  large  firm  reddish  cauliflower  mass,  raised 
above  the  surface  of  the  skin  three-eighths  of  an 
inch  and  measuring  one  and  a  half  inches  trans- 
versel}-  by  an  inch  vertically.  This  mass  was  slough- 
ing, and  from  it  exuded  a  bloody  discharge.  Ex- 
tending outward  from  this  mass  was  a  scar  which 
reached  the  shoulder.  In  the  line  of  this  scar,  and 
attached  to  the  skin,  were  two  firm  hard  masses. 
There  were  other  masses  palpable ;  these  will  be 
described  later. 

The  following  history  was  obtained :  The  family 
history  was  negative  for  chronic  diseases.  The  pre- 
vious history  was  negative  for  any  disease  except 
measles  in  childhood.  In  reference  to  the  masses 
described,  they  were  first  noticed  by  the  patient  five 
years  previously,  but  gave  her  no  concern.  She  had 
been  in  good  health  until  four  weeks  prior  to  admis- 
sion to  the  hospital.  At  that  time  the  hard  masses 
on  the  right  shoulder  began  to  itch ;  later,  they  ached 
and  pained  her.  About  a  week  after  the  beginning 
of  this  trouble  ( three  weeks  before  admission  to 
the  hospital )  her  doctor  had  incised  the  most  painful 
of  tlie  masses.  From  this  woimd  the  cauliflower 
mass  had  grown.  It  was  fiery  red  in  color,  bled 
easily,  and  appeared  to  be  bubbling  over  on  top  of 
the  skin.  The  next  symptom  noticed  by  the  patient 
was  a  severe,  nonproductive  cough ;  next,  pain  in  the 
right  upper  abdomen.  Later  there  were  chills  and 
fever,  the  cough  became  productive  of  a  thick  tena- 
cious sputum,  and  a  few  days  before  admission  the 
patient  began  to  suffer  from  attacks  of  severe 
dyspnea. 

In  addition  to  these  masses,  there  were  other 
nodules  as  follows :  Over  the  right  side  of  the  back, 
just  within  the  inner  border  of  the  scapula,  was  a 
firm  mass  in  the  subcutaneous  tissue,  not  attached 
to  the  skin,  about  one  half  by  one  quarter  inch  in 
extent.  Over  the  left  side  of  the  back,  on  a  level 
of  the  ninth  dorsal  vertebra,  was  a  firm  swelling  not 
attached  to  the  skin,  but  which  seemed  to  be  attached 
to  the  ribs  for  about  three  quarters  of  an  inch.  Over 
the  right  side  of  the  neck  posteriorly,  on  a  level  with 
the  sixth  cervical  vertebra,  and  adjacent  to  the  cauli- 

*Read  before  Section  in  Medicine,  New  York  Academy  of  Medi- 
cine, February  17,  1920. 


flower  mass,  was  a  nodule  one  half  inch  long.  This 
mass  was  present  in  the  subcutaneous  tissue,  but  not 
adherent  to  the  skin.  Below  this  area  and  somewhat 
to  the  right  was  another  similar  nodule  but  smaller 
in  extent.  Posteriorly,  in  line  with  the  posterior 
cervical  lymph  nodes  was  felt  a  large,  firm  mass  re- 
sembling in  consistency  a  large  lymph  node.  This 
also  was  not  attached  to  the  skin.  Here  also,  there 
were  a  few  very  small  lymph  nodes.  In  the 
left  supraclavicular  region  there  was  a  large  nodule. 
The  axillary  lymph  nodes  were  not  palpable.  The 
inguinal  lymph  nodes  were  not  palpable.  It  is  well, 
in  view  of  the  fact  that  there  was  no  postmortem 
examination  of  the  cranium,  to  emphasize  the  fact 
that  no  neurological  disturbance  was  noted ;  the  eyes 
seemed  normal  in  reaction  and  in  movement.  There 
was  no  history  nor  evidence  of  ocular  disturbance. 

The  heart  was  normal  in  size  and  position,  the 
action  was  rapid  with  a  harsh  systolic  murmur  heard 
at  the  apex  and  transmitted  to  the  axilla. 

In  view  of  the  postmortem  findings  I  wish  to  call 
especial  attention  to  the  lung  signs :  Motion  was  im- 
paired more  on  the  left  side  than  on  the  right.  Per- 
cussion showed  flatness  below  the  clavicle  on  the 
right  lung  anteriorly;  auscultation  gave  low  pitched 
tubular  breathing,  amphoric  in  character,  over  the 
same  area  with  no  rales  present.  Posteriorly,  percus- 
sion and  auscultation  were  negative.  Over  the  left 
lung  anteriorly  there  was  flatness  to  percussion,  and 
on  auscultation  low  pitched  tubular  breathing  below 
the  clavicle.  On  inspiration  there  were  many  loud 
leathery  rales.  Posteriorly,  there  was  complete  flat- 
ness to  percussion  over  the  upper  half  of  the  lung. 
Auscultation  gave,  over  the  same  area,  marked  tubu- 
lar breathing,  bronchophony,  and  coarse  rales  on  in- 
spiration and  expiration.  The  left  lung,  clinically, 
was  more  markedly  involved  than  the  right  lung. 

In  the  abdomen  the  liver  was  palpable  an  inch  be- 
low the  costal  margin.  In  the  gallbladder  area  there 
was  a  round,  hard  mass,  palpable  over  the  liver  just 
below  the  costal  margin.  This  mass  was  the  size  of 
an  egg  and  moved  with  expiration  and  inspiration. 
The  uterus  was  palpable ;  the  fundus  being  felt  just 
below  the  umbilicus.  Vaginal  examination  showed 
that  the  cervix  was  soft,  the  external  os  admitted 
one  finger,  the  internal  os  being  closed.  There  was 
no  uterine  bleeding. 

Other  features  of  the  physical  examination,  in- 
cluding the  reflexes,  were  negative. 

THE  CLINICAL  COURSE. 

On  admission  the  patient  had  a  temperature  of 
99°  F.,  pulse  140,  respiration  44.  The  cyanosis 
and  dyspnea  continued,  and  became  progressively 
more  marked.  There  were  frequent  stools,  those 
of  the  first  day  being  brown  in  color.  On  the  fol- 
lowing day  the  stools  were  clay  colored  and  sticky. 
A  small  amount  of  urine  was  passed,  not  over  400 
c.  c.  in  twenty-four  hours.  This  urine  was  of  a 
dark  amber  color  and  smoky.  Tests  for  albumin 
and  glucose  were  negative.  Microscopical  ex- 
aminations showed  an  occasional  granular  cast, 
with  a  few  pus  cells  and  erythrocytes.  The 
blood  examination  showed  erythroc}tes  4,750,000; 
leucocytes,  23,500 ;  eighty-five  per  cent,  polynu- 


August  21,  1920.] 


MOXTEITH:  MELANOMA. 


253 


clears;  twelve  per  cent,  small  mononuclears;  three 
per  cent,  large  mononuclears ;  hemo.s^lobin  seventy 
per  cent.  (Sahli). 

Suspecting  the  possibility  of  a  melanotic  tumor, 
the  test  for  melanin  was  applied  to  the  urine  and 
was  positive.  This  excretion  of  pigment,  which  is 
one  of  the  many  interesting  features  of  melanotic 
tumors,  is  brought  about  as  follows :  By  the  meta- 
bolic processes  of  its  chromatophore  cells  the  tumor 
produces  an  excess  of  melanin.  This  pigment  en- 
ters the  blood.  It  is  excreted  by  the  kidney  glo- 
meruli as  pigment  granules ;  or  as  others  hold  the 
melanin  in  the  blood  is  changed  by  the  liver  to  color- 
less melanogen,  which  is  in  turn  excreted  by  the 
kidney.  The  test  used  to  determine  the  presence 
of  melanogen  in  the  urine,  to  quote  from  Wells,  is 
as  follows :  "True  melanogen  may  be  considered  to 
be  present  in  the  urine.  First,  if  the  careful  addition 
of  ferric  chloride  causes  the  development  of  a  black 
precipitate.  Secondly,  if  this  precipitate  dissolves 
in  sodium  carbonate  forming  a  black  solution. 
Thirdly,  if  from  this  solution  mineral  acids  pre- 
cipitate a  black  or  brownish  black  powder.  All  three 
of  these  reactions  must  be  followed  out  for  there 
are  substances  other  than  "melanin  which  will  give 
the  first  two  reactions."  As  you  will  see  from  the 
specimens  presented  urine  containing  melanogen  will 
in  time  turn  deep  brown  or  black  through  the 
action  of  the  oxygen  of  the  air  or  other  oxidizing 
agents. 

Within  a  few  hours  after  admission,  the  patient's 
respirations  had  increased  to  sixty  a  minute,  and  the 
pulse  rate  to  160.  She  became  progressively  weak- 
er and  finally  died  at  2.10  a.  m.,  October  27th,  hav- 
ing been  in  the  hospital  forty  hours. 

Autopsy  was  performed  in  the  afternoon  of  Oc- 
tober 27th  by  Dr.  Schwartz  of  the  Gouverneur  staff. 
Interest  in  the  autopsy  centres  largely  around  the 
distribution  of  the  metastatic  processes.  I  shall  quote 
largely  from  the  autopsy  protocol.  The  first  gen- 
eral autopsy  incision  revealed  the  liver  slightly  en- 
larged, extending  a  finger's  breadth  below  the  cos- 
tal margin.  The  gallbladder  was  distended  and 
extended  about  three  inches  below  the  ribs.  The 
peritoneal  cavity  was  free  from  fluid ;  omentum  ad- 
herent to  the  lower  part  of  the  right  side  of  the 
uterus  and  the  pelvis.  The  pleural  sacs  were 
practically  obliterated,  apparently  by  adhesion.  The 
pericardial  sac  was  distended  and  contained  over 
an  ounce  of  clear  yellow  fluid.  The  heart  valves 
were  normal. 

Over  the  left  ventricle  and  projecting  from  the 
surface  were  four  firm  masses  about  three  eighths 
of  an  inch  in  extent,  which  on  section  were  raised 
above  the  cut  surface,  grayish  white  in  color,  homo- 
geneous, firm  and  well  circumscribed.  One  nodule 
extended  through  almost  the  entire  thickness  of  the 
left  ventricle.  The  anterior  mediastinal  lymph 
nodes  were  the  seat  of  a  metastasis.  The  right 
lung  was  separated  with  great  difficulty  from  the 
chest  wall  on  account  of  the  infiltration  of  the 
costal  pleura  and  intercostal  muscles  with  tumor 
growth.  The  right  lung  was  lumpy  in  consistency, 
and  projecting  beyond  the  pleural  surface  and  into 
the  substance  of  the  lung  were  numerous  large, 
well  circumscribed,  oval  tumor  masses ;  these  were 


grayish  white  in  color,  firm,  and  homogeneous,  some 
being  three  inches  in  diameter.  The  left  lung 
showed  similar  processes,  but  to  a  lesser  degree. 
However,  in  the  centre  of  the  tumor  mass  of  the 
left  lung  were  two  blackish  circumscribed  nodules 
about  three  eighths  of  an  inch  in  extent.  Let  me 
emphasize  this,  for  these  were  the  onlv  ones  of 
the  enormous  number  of  tumor  masses  which 
showed  any  black  pigmentation  macroscopically. 
There  was  a  large  tumor  mass  in  the  vault  of  the 
diaphragm. 

The  pancreas  was  hard,  nodular,  and  was 
the  seat  of  extensive  tumor  growth,  only  a 
small  portion  of  the  gland  remaining  uninvolved. 
The  liver  was  normal  in  size ;  surface  smooth  and 
on  section  was  slightly  softened  in  consistency,  and 
of  a  brownish  color,  studded  with  red  markings 
throughout.  There  were  no  macroscopic  metatases 
to  the  liver. 

The  gallbladder  was  distended  and  contained  black 
bile.  Its  mucous  membrane  and  that  of  the  ducts 
were  normal.  The  spleen  was  normal,  there  were  no 
metastases.  Thus  there  were  two  organs  commonly 
the  seat  of  secondary  tumor  growth  in  this  case  ap- 
parently uninvolved.  The  right  adrenal  gland  was 
much  enlarged  and  the  centre  contained  a  large 
tumor  mass,  grayish  white  in  color,  about  two  inches 
in  width.  This  mass  was  soft  and  easily  disinte- 
grated.   The  left  adrenal  gland  was  normal. 

The  kidneys  were  normal  in  form  and  size,  and 
contained  numerous  circumscribed  grayish  nodules ; 
capsule  stripped  easily,  surface  smooth  with  the  ex- 
ception of  the  areas  where  the  tumor  masses  pro- 
jected beyond  the  surface.  The  peritoneal  coat  of 
the  bladder  contained  several  small  growths.  The 
bladder  itself  was  normal.  The  uterus  was  much 
enlarged  measuring  ten  inches  in  length,  seven  and 
a  half  inches  in  width  and  three  and  a  half  inches 
in  thickness.  It  contained  a  fetus  of  about  six 
months  and  a  placenta.  It  might  be  of  passing  in- 
terest to  mention  that  the  test  for  melanin  applied 
to  the  amniotic  fluid  was  negative.  The  right  ovary 
was  enlarged  and  contained  a  tumor  mass  two  inches 
in  diameter  which  completely  obscured  any  ovarian 
tissue ;  left  ovary  and  both  tubes  were  normal. 

There  was  a  firm  tumor  at  the  cardiac  end  of  the 
stomach  an  inch  in  diameter.  This  was  ulcerated 
through,  and  over  it  the  mucous  membrane  was  ab- 
sent. 

The  mesentery  contained  numerous  nodules  of 
varying  size  and  of  the  same  grayish  white  homo- 
geneous material.  The  retroperitoneal  lymph  nodes 
were  enlarged  and  numerous;  on  section  they  were 
pink  in  color. 

The  large  tumor  mass  on  the  back  was  incised  and 
was  found  to  be  surrounded  by,  and  to  lodge  entirely 
in  muscle  tissue.  In  the  muscle  of  the  lower  right 
chest  wall  there  were  two  small  firm  grayish  areas 
about  one  half  inch  in  diameter.  There  was  also 
an  extensive  infiltration  of  the  intercostal  muscles 
as  described  previously. 

Permission  to  open  the  cranium  could  not  be  se- 
cured, thus  valuable  information  as  to  the  possible 
seat  of  the  original  tumor  or  of  extensions  to  the 
central  nervous  system  could  not  be  obtained. 


254 


GOLDSTEIN: 


NEPHRITIS. 


[N'ew  York 
Medical  Journal 


SUMMARY. 

Here  is  a  young  woman  who  carried  a  tumor 
growth  five  years,  without  subjective  symptoms. 
Then  some  event  which  we  can  only  conjecture  ap- 
plied the  torch.  Within  four  weeks  from  her  first 
discomfort,  she  is  brought  into  the  hospital  so  acutely 
ill  that  the  diagnosis  on  admission  was  pneumonia. 
The  picture  presented  was  not  unlike  many  seen  in 
fatal  pneumonia :  cyanosis,  jaimdice,  rapid  pulse, 
and  extreme  dyspnea.  Considering  the  colossal  hmg 
changes  can  we  wonder  at  these  symptoms  ? 

In  reference  to  the  distribution  of  the  tumor 
masses :  The  absence  of  inacroscopical  change  in 
liver  and  spleen  was  striking.  Interesting  features 
are  the  degree  of  involvement  of  the  heart,  pancreas 
and  right  adrenal.  And  the  findings  in  the  muscles 
were  rather  unusual. 

The  lack  of  pigmentation  also  is  a  point  worthy  of 
note.  Only  one  of  the  tumor  masses,  that  in  the 
left  lung,  showed  black  deposits  to  the  naked  eye 
or  under  the  microscope. 


NEPHRITIS. 

By  Hymax  I.  Goldstein,  jM.  D., 
Camden,  N.  J. 

During  the  past  eleven  years  I  have  met  with 
many  interesting  cases  of  nephritis — especially  those 
occurring  in  children  and  young  adults  following 
slight  and  severe  infections,  such  as  tonsillitis,  ap- 
pendicitis, and  other  aflfections.  In  calling  attention 
to  this  type  of  kidney  disturbance,  I  shall  also  in- 
clude a  general  review  of  renal  disease  as  ordinarily 
found  in  the  every  day  practice  of  the  internist. 

It  is  much  easier  to  gain  a  general  understanding 
of  nephritis  and  its  complications  by  having  in  mind 
some  simple  classification  of  the  various  types  of 
renal  disease.  Many  classifications  have  been  put 
forward — based  on  clinical,  pathological,  chemical 
and  etiological  factors.  Such  classifications,  after 
all,  must  necessarily  lead  to  a  more  thorough  study 
and  analysis  of  cases  and  the  result  is  a  better  un- 
derstanding of  renal  conditions  as  they  are  present- 
ed to  the  internist. 

Before  reporting  some  of  my  own  cases,  I  will 
mention  some  of  the  classifications  of  kidney  dis- 
ease. 

Christian  prefers  to  classify  nephritis  according 
to  renal  fimction  as:  1.  Patients  wath  hypertension 
without  definite  cardiac  or  renal  insufficiency — 
primary  or  essential  hypertension  (hyperpiesia). 
In  some  of  these  cases  albuminuria  and  cylinduria 
are  only  occasionally  present.  2.  Patients  with  hy- 
pertension with  renal  insufficiency — most  of  these 
cases  in  later  stages  show  cardiac  insufficiency — 
cardiorenal  cases  in  the  later  stages.  3.  Patients  with 
renal  insufficiency  with  or  without  hypertension — ■ 
the  latter  when  present  having  developed  second- 
arily to  the  renal  insufficiency — chronic  nephritis 
with  or  without  hypertension. 

In  group  1  considerable  edema  does  not  occur;  in 
group  2  edema  is  frequently  met  with  and  when 
present  is  usually  of  cardiac  origin,  though  it  may 
be  of  combined  cardiac  and  renal  origin.    In  group 


3  considerable  edema  occurs,  but  is  not  frequently 
met  with ;  when  it  occurs  it  is  of  renal  origin.  In 
the  cases  where  hypertension  is  present,  signs  of 
chronic  myocarditis  usually  appear  later  until  myo- 
cardial insufficiency  becomes  an  important  factor. 
Edema  with  fair  renal  function  is  almost  always  of 
cardiac  origin  (these  cases  respond  to  digitalis 
promptly)  ;  on  the  other  hand,  edema  with  poor 
renal  function  is  usually  of  renal  origin  (these  cases 
do  not  respond  to  digitalis  or  diuretics).  Christian 
does  not  approve  of  the  use  of  the  tenns  interstitial, 
parenchymatous  or  glomerular  nephritis. 

It  is  bold  and  one  hesitates  to  suggest  that  we  try 
to  diminish  the  use  of  the  name  of  Guy's  Hospital's 
famous  physician,  but  the  term  Bright's  disease  is 
not  a  good  one.  It  has  no  set  meaning  and  is  a  bad 
term  to  use  to  tell  a  patient  his  trouble — to  many 
this  gives  a  hopeless  prognosis  and  life  of  short 
duration  is  predicted,  and  is  as  bad  a  term  as  rheu- 
matism. 

Riesman  classifies  nephritis  as;  1,  Parenchyma- 
tous— a,  acute ;  b,  subacute ;  c,  chronic  nephrosis. 
2.  Tubuloglomerular  nephritis — a,  acute :  b,  sub- 
acute;  c,  chronic  (the  chronic  tubuloglomerular 
type  being  the  old  chronic  interstitial  nephritis.  3. 
The  arteriosclerotic  kidney. 

Stengel's  classification  is:  1.  Acute;  a,  mild  tubu- 
lar; b,  severe  ttibular;  c,  glomerular,  always  severe. 
2.  Chronic — a,  tubular,  mild  ;  b,  glomerular,  severe ; 
c,  renal  sclerosis  or  arteriosclerotic  kidney  (senile 
kidney). 

Stengel's  acute  mild  tubular  nephritis  is  due  to 
infections,  etc.  There  is  no  severe  renal  (func- 
tional) disturbance,  no  kidney  symptoms,  no  eleva- 
tion of  blood  pressure.  The  urine  may  show  some 
albumin  and  some  casts ;  the  specific  gravity  is  con- 
stant. In  the  severe  tubular  form,  there  is  consid- 
erable dropsy,  no  elevation  of  blood  pressure,  no 
blood  changes.  In  the  acute  glomerular  type,  the 
disease  is  always  severe,  there  is  high  blood  pres- 
sure, and  marked  nitrogen  retention  in  the  blood. 

The  chronic  tubular  cases  are  nearly  always  mild, 
and  go  on  for  many  years,  the  patients  are  of  an 
alabaster  white  complexion,  have  no  marked  eleva- 
tion of  blood  presstire  and  no  marked  nitrogen 
retention  in  the  blood  (no  other  marked  blood 
changes).  There  is  some  albiunin  and  casts;  dropsy 
is  present ;  no  marked  renal  inadequacy  present. 

The  chronic  glomerular  type  presents  an  alto- 
gether different  picture ;  these  cases  are  usually  se- 
vere ;  this  is  the  most  severe  type  we  meet  with. 
The  urine  is  of  a  high  specific  gravity ;  albumin  and 
casts  may  or  may  not  be  present ;  there  is  early 
nitrogen  retention  in  the  blood ;  there  is  marked 
renal  insufficiency,  and  a  markedly  low  phenolsul- 
phonepthalein  excretion.  These  patients  die  in 
uremia,  and  live  only  one  or  two  years. 

The  renal  sclerosis  cases  are  even  more  mild,  and 
even  more  so  than  the  chronic  tubular — without 
danger  to  health  and  may  go  on  for  many  years 
(senile  kidney).  The  patients  are  arteriosclerotic; 
renal  tests  show  more  functional  activity;  blood 
nitrogen  retention  is  not  great.  The  blood  pressure 
is  high,  because  these  cases  occur  in  elderly  people 
with  arteriosclerosis. 

Fischer  states  that  there  is  really  only  one  type 


August  21,  1920.] 


GOLDSTEIN: 


NEPHRITIS. 


255 


of  nephritis — parenchymatous  nephritis.  He  calls 
them  generalized  and  focal  nephritis,  primarily  and 
secondarily  contracted  kidneys. 

Aschoff  divides  nephritis  into  acute  inflamma- 
tions: 1,  chronic  inflammatory  nephropathies;  2, 
chronic  degenerative  nephropathies,  and,  3,  chronic 
circulatory  nephropathies. 

\'olhard  and  Fahr  classify  the  nephritides  as  fol- 
lows: 1.  Nephrosis  (^degenerative) — a,  acute;  b, 
chronic ;  c,  terminal  contracted  kidney ;  2,  nephritis 
(inflammatory) — A,  difftise  glomerular  nephritis; 
a,  acute,  b,  chronic,  c,  terminal ;  B.  focal  nephritis — 
a,  focal  glomerular ;  b,  acute  interstitial ;  c.  embolic : 
3.  arteriosclerotic  kidney — a.  pure  arteriosclerotic 
(benign  hypertension)  ;  b,  combination  form  (ma- 
lignant hypertension). 

Senator's  classification  is  practical  and  most 
familiar  to  the  profession:  1.  Acute  nephritis;  2. 
chronic  nephritis;  A,  chronic  parenchymatous;  B. 
chronic  interstitial ;  a,  primary  chronic  interstitial 
nephritis ;  b,  secondary  chronic  interstitial  nephritis ; 
c,  arteriosclerotic  kidney;  3,  diffuse  nephritis — a 
combination  of  parenchymatous  and  interstitial. 

Widal  suggested  three  groups  of  renal  cases:  1. 
salt  retention;  2,  nitrogen  retention,  and,  3,  mixed 
salt  and  nitrogen  retention  cases.  The  combined 
type  is  more  common  than  the  simple  salt  or  nitro- 
gen retention  cases.  The  pure  salt  retention  tjpe 
of  nephritis  show  only  edema.  There  is  an  entire 
absence  of  serious  symptoms  and  signs  such  as 
twitchings,  coma,  convulsions.  Cheynes- Stokes 
breathing,  marked  hypertension  (200  mm.,  or  over, 
of  mercury,  systolic),  acidosis  (Kussmahl  breath- 
ing), retinitis,  anemia,  hardened  arteries,  enlarged 
heart,  loss  of  weight.  Any  severe  symptoms  as 
these  with  or  without  edema  represent  nitrogen 
retention  type  of  nephritis.  Frequent  weighing  of 
an  edematous  patient  gives  us  a  guide  as  to  the 
retention  or  excretion  of  fluids  in  the  study  of  these 
cases. 

The  general  symptoms  and  diagnosis  of  neph- 
ritis need  not  be  dwelt  upon  in  this  paper — they 
are  well  known  and  described  in  detail  in  all  text- 
books of  medicine.  To  make  a  careful  study  of  a 
case  of  nephritis,  one  must  know  the  functional  ca- 
pacity of  the  kidneys  and  the  various  tests  proposed. 
All  of  these  help  to  make  a  decision  as  to  the  proper 
treatment  and  the  indication  or  contraindication  to 
the  use  of  drugs. 

As  mentioned,  weighing  an  edematous  patient  (if 
the  condition  warrants  this  with  safety)  is  of  con- 
siderable help  as  a  guide  as  to  retention  or  excre- 
tion of  fluids ;  the  study  of  salt  excretion ;  tests  for 
acidosis ;  study  of  the  excretion  of  nitrogen  waste 
products  by  chemical  examination  of  the  blood  for 
urea.  Study  of  the  amount  of  phenolsulphone- 
phthalein  output  and  finally  studies  of  the  concen- 
trating ability  of  the  kidneys  over  a  twenty-four 
hour  period  by  the  socalled  renal  test  meal  will  show 
whether  there  is  a  true  hyposthenuria  (constant  low- 
specific  gravity),  and  whether  the  kidneys  can  ex- 
crete concentrated  urine  with  normal  amounts  of 
solids  or  not. 

If  renal  function  as  measured  by  our  functional 
tests  is  poor  and  the  patient's  condition  indicates 
no  serious  disturbance  in  any  other  organ  than  the 


kidneys,  the  probability  of  any  great  improvement 
in  renal  function  is  slight,  except  in  cases  of  acute 
nephritis.  Where  the  phenolsulphonephthalein  test 
can  be  done,  it  is  of  service  for  the  general  prac- 
titioner. In  the  mild  cases  the  phthalein  excretion 
is  normal  or  slightly  depressed.  In  mild  cases,  too, 
blood  urea  X  is  normal  or  almost  normal  in  value 
(  unless  the  patient  is  on  a  high  proteid  diet )  and 
therefore  offers  much  help.  It  serves  as  a  check  on 
the  phthalein  test.  The  McLean  or  Ambard  co- 
efficient index  in  such  cases  is  sometimes  normal — 
often,  however,  this  helps  in  making  a  prognosis. 
In  the  mild  cases  the  two  hour  test  is  particularly 
useful,  and  in  these  cases  if  phthalein  excretion  is 
normal,  the  patient  is  placed  on  a  diet  containing 
seventy-five  grams  of  protein  and  four  grams  of 
salt  for  two  days  and  on  the  third  day  special  meals 
— Mosenthal  or  Christian — the  Frothingham  or 
Schlayer  and  Hedinger  diets  are  given,  and  the 
urinary  collections  of  the  two  hour  test  are  made. 

A  patient  showing  an  excretion  of  thirty-five  to 
forty-five  per  cent,  phthalein  is  classed  as  a  mod- 
erate renal  case.  ]\Iany  of  these  cases,  however, 
have  cardiac  disturbances  with  edema.  In  this  type 
of  case,  in  addition  to  the  phthalein  test,  the  renal 
function  can  be  further  learned  by  the  administra- 
tion of  a  diuretic  such  as  agurin,  theocin  or  theo- 
phyllin,  diuretin  or  theophorin  and  if  the  edema  im- 
proves with  prompt  diuresis,  renal  function  is  good, 
if  not.  renal  function  is  poor  and  the  prognosis  is 
not  so  good. 

Patients  with  less  than  thirty-five  per  cent,  phtha- 
lein excretion  have  poor  renal  function  and  if  pa- 
tients do  not  have  any  cardiac  disturbances,  it 
usually  means  a  severe  kidney  disease  and  offers  a 
poor  prognosis.  Properly  used  tests  of  renal  func- 
tion are  an  aid  in  the  treatment  and  management 
of  renal  cases  and  help  in  giving  a  more  nearly  ac- 
curate prognosis. 

Thus,  where  the  blood  urea  nitrogen  continues  to 
rise,  we  may  be  reasonably  certain  and  so  inform 
the  relatives  of  the  patient,  that  uremia  is  impend- 
ing. Xormally,  the  blood  contains  about  twenty  per 
cent,  total  solids ;  total  nitrogen  three  per  cent. ; 
sugar  .012  per  cent. ;  chlorides  as  sodium  chloride 
.65  per  cent,  and  cholesterol  .15  per  cent.;  nonpro- 
tein nitrogen  twenty-five  to  thirty  mgms.  to  the  one 
hundred  c.  c.  of  blood ;  urea  nitrogen  twelve  to  fif- 
teen mgms. ;  uric  acid  one  to  three  mgms.,  creatinine 
one  to  two  and  a  half  mgms.,  creatine  five  to  ten 
mgms.  to  the  one  hundred  c.  c.  of  blood. 

In  chronic  nephritis  the  blood  may  show  thirty 
to  eighty  mgms.  nonprotein  nitrogen  and  fifteen  to 
fifty  mgms.  to  the  one  hundred  c.  c.  blood  of  urea 
nitrogen ;  in  uremic  nephritis  yoti  may  get  120  to 
350  mgm.  nonprotein  n,  and  eighty  to  300  mgm. 
urea  n,  to  the  one  hundred  c.  c.  of  blood — in  these 
absolutely  fatal  cases  you  may  have  five,  ten  or  fif- 
teen mgins.  uric  acid  per  one  hundred  c.  c.  and 
creatinine  up  to  thirty  mgm.  or  more  in  one  hundred 
c.  c.  of  blood. 

]\Iyers  and  Lough  and  Gradwohl  contend  that 
the  presence  of  over  five  mgms.  of  creatinine  in  one 
hundred  c.  c.  of  blood  indicates  an  absolutely  fatal 
prognosis.  Blood  chemical  tests  will  help  in  differ- 
entiating so  called  cardiovascular  disease  from  cases 


256 


GOLDSTEIN: 


NEPHRITIS. 


[New  York 
Medical  Journai, 


of  primary  renal  disease  with  secondary  cardiac 
disturbance  and  lack  of  compensation.  Blood  tests 
in  cardiovascular  disease  show  practically  no  reten- 
tion of  nitrogen  waste  products,  whereas  nephritics 
with  failing  hearts  show  nitrogen  retention. 

Another  point  to  be  emphasized  is  that  even  in 
bad  cases  of  nephritis  urinary  findings  may  be  nega- 
tive or  scant  so  far  as  albumin  and  casts  are  con- 
cerned, yet  an  undue  accumulation  of  urea  n, 
uric  acid,  and  creatinine  will  be  found  in  the  blood, 
and  therefore  the  chemical  blood  work  becomes  at 
once  a  valuable  method  of  estimation  for  true 
kidney  function.  Uric  acid  is  the  most  difficult  of 
all  three  (urea  n,  uric  acid,  and  creatinine)  for 
the  kidneys  to  get  rid  of,  urea  next,  and  creatinine 
is  eliminated  with  the  least  difficulty  by  the  kidneys. 
Therefore,  the  staircase  effect  of  Myers  and  Chase, 
emphasized  by  Gradwohl  and  others,  is  easily  un- 
derstood ;  first,  uric  acid  is  retained  in  early  chronic 
nephritis,  next  as  the  case  advances,  urea  n  is 
retained,  and  finally  creatinine.  The  uric  acid  re- 
tention occurs  early  in  chronic  interstitial  nephritis, 
this  is  similar  to  the  uric  acid  retention  which  oc- 
curs in  gout.  The  urea  is  estimated  by  the  Mar- 
shall method,  the  uric  acid  by  the  Folin  method. 
(The  Hellige  colorimeter  is  used  in  all  cases  by 
Gradwohl).  The  Duboscq  colorimeter  is  used  by 
others. 

The  blood  for  these  tests  should  be  collected  be- 
fore breakfast,  similar  to  the  manner  in  which  blood 
is  taken  for  the  Wassermann  reaction.  Potas- 
sium oxalate  solution  or  a  few  crystals  of  the  ox- 
alate are  put  in  the  tube  and  the  blood  is  well 
shaken.  Amylase  (amylolytic  action)  of  urine  is 
reduced  in  nephritis. 

Uric  acid  is  the  first  of  the  nitrogenous  substances 
to  be  retained  in  interstitial  nephritis. 

Since  gout  and  very  early  interstitial  nephritis 
are  characterized  by  essentially  the  same  blood 
picture,  it  is  necessary  to  employ  every  possible  test 
to  exclude  nephritis  before  a  high  blood  uric  acid 
may  be  regarded  as  evidence  of  gout  in  the  absence 
of  the  classical  clinical  manifestations. 

Mosenthal  and  Lewis  place  considerable  import- 
ance on  the  Ambard  coefficient  of  urea  excretion  in 
their  comparison  of  this  method  and  the  renal  test 
meal  with  the  Geraghty  and  Rowntree  functional 
kidney  test  by  means  of  subcutaneous  injection  of 
phenolsuphonephthalein.  Others,  while  they  admit 
that  there  seems  to  be  something  advantageous  in 
this  estimation  of  the  ratio  between  the  amount  of 
itrea  in  the  blood  and  the  amount  of  rate  or  urea  ex- 
cretion in  the  urine,  quote  the  conclusions  of  Addis 
and  Watanabe,  that  the  rate  of  urea  excretion  in 
man  varies  under  physiological  conditions  in  a  man- 
ner that  cannot  be  explained  by  the  concentration  of 
urea  in  the  blood  and  urine.  The  normal  Ambard 
coefficient  is  .08 ;  however,  with  the  Doremus  urea- 
meter,  Gradwohl  finds  this  test  to  be  unreliable. 
McLean  and  Selling,  with  the  Marshall  method  of 
urea  N,  estimation,  have  worked  out  another  co- 
efficient, which  is  more  exact  (the  index  of  100  is 
normal  for  McLean's  coefficient). 

Folin  and  Denis,  Fritz  and  Frothingham  showed 
(in  experimental  uranium  nephritis  in  rabbits)  that 
the  retention  of  the  nonprotein  nitrogenous  blood 


constituents  represented  the  difference  between  the 
quantity  eliminated  and  the  amount  produced, 
whereas  the  Geraghty-Rowntree  phenolsulphone- 
phthalein  test  served  as  an  indicator  of  elimination 
alone.  Therefore,  the  blood  chemical  examination 
(for  urea  nonprotein)  is  the  most  valuable  of  all 
renal  tests.  The  amount  of  nonprotein  and  urea 
in  the  blood  is  a  measure  of  accumulating  differ- 
ence between  the  waste  produced  in  metabolism  and 
the  amount  eliminated  by  the  kidneys. 

ACIDOSIS. 

By  Van  Slyke's  estimation  of  the  combining 
power  of  the  blood  plasma  for  carbon  dioxide  we 
may  find  exactly  how  much  carbon  dioxide  a  pa- 
tient's blood  plasma  may  take  up  and  in  that  way 
determine  the  onset  of  uremic  (nephritic)  or  dia- 
betic acidosis.  Normally,  in  the  state  of  relative  al- 
kalinity of  blood  plasma,  about  sixty-five  per  cent, 
of  the  carbon  dioxide  will  be  taken  up.  As  the  acid 
bodies  form  which  are  part  of  the  chemical  changes 
seen  in  the  blood  acidosis,  the  blood  loses  this  power 
to  combine  with  carbon  dioxide  so  that  when  the 
figure  of  fifty  or  less  is  reached,  the  patient  is  in 
danger  of  impending  acidosis.  This  is  more  im- 
portant than  the  finding  of  acetone,  diacetic  acid, 
or  other  constituents  in  the  blood.  The  plasmas  of 
normal  adults  contain  from  fifty-five  to  seventy- 
eight  volumes  per  cent,  of  combined  carbon  dioxide 
as  determined  by  Van  Slyke's  method.  As  stated, 
the  bicarbonate  content  of  the  plasma  is  determined 
by  measuring  the  carbon  dioxide  given  off  after 
the  addition  of  an  excess  of  acid.  In  the  determin- 
ation of  the  bicarbonate  reserve  of  the  plasma,  it 
is  found  that  in  infants  the  normal  values  average 
about  ten  per  cent,  lower  than  in  adults.  Figures 
lower  than  fifty  in  adults  and  forty-five  in  infants 
are  indicative  of  acidosis.  The  results  if  multiplied 
by  seven  tenths  approximate  alveolar  carljon  diox- 
ide tension  in  millimetres  determined  according  to 
the  Marriott  method  (Van  Slyke). 

The  determination  of  the  carbon  dioxide  tension 
in  the  alveolar  air  (Marriott's  method)  may  be 
carried  out  at  the  bedside.  In  normal  children  at 
rest,  the  carbon  dioxide  tension  in  the  alveolar  air 
varies  from  forty  to  forty-five.  Tensions  of  be- 
tween thirty  and  thirty-five  millimetres  are  indica- 
tive of  a  mild  degree  of  acidosis.  When  the  tension 
is  as  low  as  twenty  millimetres,  the  patient  is  in 
imminent  danger.  In  coma,  with  acidosis,  the 
tension  may  be  as  low  as  eight  or  ten  millimetres. 
In  infants  the  tension  of  carbon  dioxide  is  from 
three  to  five  millimetres  lower  than  in  older  children 
or  adults. 

sell.\rd's  alkali  tolerance  test. 
When  the  bicarbonate  content  of  the  plasma  is 
within  normal  limits,  the  administration  of  a  small 
amount  of  sodum  bicarbonate  by  mouth  raises  the 
amount  in  the  blood  and  brings  about  an  alteration 
of  the  reaction  of  the  urine.  The  excess  of  bi- 
carbonate is  excreted  and  the  normally  acid  urine 
becomes  amphoteric  or  alkaline.  \Mien  there  is 
acidosis,  the  bicarbonate  of  the  plasma  and  of  all 
of  the  body  tissues  is  diminished.  This  must  be 
replenished  before  bicarbonate  by  mouth  will  be 
excreted  by  the  kidney.  Therefore,  the  amount  of 


August  2],  1920.]  GOLDSTEIN:  NEPHRITIS.  257 


sodium  bicarbonate  that  must  be  given  to  produce 
an  amphoteric  or  alkaline  urine  is  a  measure  of  the 
depletion  of  the  bicarbonate  reserve  of  the  body. 
With  infants  two  or  three  grams  of  sodium  bi- 
carbonate is  sufficient  to  cause  an  alkaline  reaction 
of  the  urine;  with  older  children  and  adults  five 
grams  are  required.  When  acidosis  is  present  much 
larger  amounts  of  soda  are  necessary  to  bring  about 
this  change — sometimes  five  or  ten  times  as  much 
may  be  required.  I  take  this  opportunity  to  include 
these  tests  for  acidosis,  because  we  may  have 
acidosis  of  renal  origin. 

The  ability  of  the  kidneys  to  excrete  acid, 
especially  acid  phosphate,  is  one  of  the  chief  de- 
fensive mechanisms  of  the  body — and  failure  of 
this  mechanism  leads  to  acidosis.  In  nephritis, 
when  acidosis  is  present,  there  is  an  accumulation 
of  unexcreted  phosphate  in  the  blood  plasma.  In 
these  cases  of  acidosis,  hyperpnea  is  present,  the 
carbon  dioxide  tension  in  the  alveoli  is  lower  than 
normal,  the  alkali  reserve  of  the  blood  is  depleted 
and  there  is  an  increased  alkali  tolerance.  No 
acetone  bodies  are  detected  in  the  urine  and  the 
ammonia  nitrogen  excretion  in  normal  or  dimin- 
ished in  cases  of  the  acidosis  of  nephritis. 

W.  W.  Palmer  and  L.  J.  Henderson  have  shown 
that  nephritis  commonly  involves  a  state  of  acidosis. 
They  conclude  that  the  urinary  concentration  of 
ionized  hydrogen  is  increased  in  the  various  forms 
of  nephritis ;  and  that  acidosis  is  frequently  present 
in  renal  cases — because  when  alkali  (sodium  bi- 
carbonate) is  administered  it  is  in  these  cases  re- 
tained by  a  kidney  capable  of  the  rapid  elimination 
of  an  excess  of  alkali. 

Marriott  and  Howland  have  shown  that  acidosis 
occurs  in  nephritis  and  the  kidneys  fail  to  excrete 
acid,  especially  acid  phosphates,  and  they  found  an 
accumulation  of  unexcreted  phosphate  in  the  blood 
I)lasnia.  Henderson  and  Palmer  have  also  shown 
that  in  every  case  of  nephritis  in  which  the  condi- 
tion of  diminished  ammonia  excretion  was  detected, 
there  has  been  a  real  retention  of  alkali.  This  is 
also  commonly  the  case  in  other  types  of  nephritis, 
even  with  heightened  ammonia  excretion. 

Other  methods  used  in  the  study  of  acidosis  are 
the  Marriott  method  for  the  determination  of  the 
hydrogen  ion  concentration  of  the  blood  or  the 
indicator  dialysis  method  for  the  determination  of 
reserve  alkali  and  the  Barcroft  and  Peters  quanti- 
tative method  for  the  detection  of  acidosis — this 
latter  test  has  for  its  basis  the  fact  that  the  combin- 
ing power  of  hemoglobin  for  oxygen  is  dependent 
upon  the  reaction  of  the  blood.  In  acidosis  the 
combining  power  is  regularly  diminished. 

The  Fredericia  Plesch  method  may  be  used  for 
the  determination  of  the  carbon  dioxide  in  alveolar 
air. 

Sellards'  serum  test  consists  in  the  precipitation 
of  the  proteins  of  one  c.c.  of  serum  by  twenty-five 
c.  c.  of  neutral  absolute  alcohol.  The  mixture  is 
shaken  and  filtered  through  a  dry  acid — free  filter 
jjaper.  To  the  filtrate  a  drop  of  phenolphthalein 
solution  is  added  and  the  fluid  is  evaporated  to  dry- 
ness on  a  water  bath.  Normally,  a  deep  reddish 
purple  color  develops.  In  severe  acidosis,  there  is 
a  faint  pink  color  or  no  color  at  all,  but  the  addition 


of  a  drop  of  water  brings  out  a  red  color.  In 
extreme  acidosis  the  residue  is  colorless  and  remains 
colorless  on  adding  water. 

In  acidosis  due  to  an  overproduction  of  acetone 
bodies,  acetone,  oxybutyric  and  acetoacetic  acid 
appear  in  the  urine  in  sufficient  amount  to  be  de- 
tected by  qualitative  tests. 

But  these  are  not  enough  to  serve  as  a  basis  for 
the  diagnosis  of  acidosis.  Acetonuria  is  exceedingly 
common  with  sick  children ;  it  is  almost  regularly 
present  in  febrile  disease  and  in  any  condition  in 
which  temporary  inanition  or  starvation  occurs. 
Very  seldom  is  the  production  of  the  acetone  bodies 
sufficient  to  cause  a  depletion  of  the  alkali  reserve. 
From  acetonuria  alone  the  diagnosis  of  acidosis 
should  not  be  made,  though  where  the  amount 
in  the  urine  is  very  large,  it  should  inspire 
a  careful  examination  for  additional  evidence  of 
acidosis.  Severe  and  fatal  acidosis  may  occur  with 
no  overproduction  of  the  acetone  bodies.  Their 
absence  from  the  urine  is  no  evidence  that  acidosis 
is  not  present.  Recently  Marriott,  Hoessler  and 
Howland  have  called  attention  to  a  method  of  de- 
termination of  acidosis  that  occurs  with  the  nephritic 
state.  They  state  that  the  acidosis  met  with  in 
nephritis  is  unlike  that  of  diabetes;  namely,  an 
accumulation  of  acetone  bodies ;  it  is  rather  due  to 
a  failure  to  regulate  the  formation  of  acid  sub- 
stances by  the  kidneys,  a  failure  to  eliminate  acid 
phosphates.  Their  method  looks  to  the  estimation 
of  the  inorganic  phosphates  in  the  blood.  The 
normal  figure  expressed  in  terms  of  phosphorus  va- 
ried from  one  to  three  and  a  half  mg.  to  the  one 
hundred  c.  c.  of  blood.  In  nephritic  acidosis,  they 
found  it  increased  invariably  to  many  times  the 
normal,  as  much  as  twenty-three  mg. 

The  definition  proposed  by  Henderson  and 
quoted  by  Austin  and  Jonas  for  acidosis — is  any 
condition  in  which  the  bufifer  substances  of  the 
blood  and  body  fluids  are  reduced  below  the  normal. 
Henderson  calls  the  sodium  phosphate  and  sodium 
carbonate  (phosphoric  acid  and  carbonic  acid)  of 
the  blood  and  body  fluids  bufifer  substances. 

Finally,  Christian  states  the  most  delicate  test  of 
renal  damage  that  we  possess  is  the  presence  of 
albumin  and  casts,  leucocytes  or  red  blood  cells  in 
the  urine  in  varying  combination.  They  are  never 
absent  in  all  of  several  specimens  on  dififerent  days 
if  there  is  renal  damage — though  single  examin- 
ations may  fail  to  reveal  any  even  in  patients  with 
severely  damaged  kidneys.  Their  presence  does 
not  justify  the  diagnosis  of  nephritis  unless  sup- 
ported by  other  data,  though  their  continued 
absence  justifies  the  conclusion  that  the  kidney  is 
free  from  nephritis  (a  diffuse,  progressive,  degener- 
ative, proliferative  lesion  of  renal  parenchyma  or 
interstitial  tissue  or  both). 

HYPERTENSION. 

Hypertension,  as  shown  by  Schneider,  may  be 
due  to  many  causes.  We  are  now  interested  in 
only  one  phase  of  the  subject — namely,  that  type  of 
chronic  vascular  hypertension  which  has  been  called 
primary  vascular  hypertension,  essential  benign 
hypertension,  essential  hyperpiesia  of  Albutt,  Gull 
and  Sutton's  disease.  These  cases  nay  show  a  high 
blood  pressure  for  many  years   without  definite 


258 


GOLDSTEIN: 


NEPHRITIS. 


[New  York 
Medical  Joursai, 


urinary  findings,  and  with  surprisingly  few  symp- 
toms. Eventually  after  many  years,  these  patients 
do  show  some  capillar}-  fibrosis,  with  an  increase 
in  cardiac  failure  and  increase  in  renal  insufficiency, 
and  at  autopsy  show  extensive  thickening  of  the 
small  arteries  and  the  changes  in  the  kidney  look 
as  if  they  had  come  as  the  result  of  the  arterial 
disturbance.  Many  other  patients  with  hyperpiesia 
appear  to  die  with  the  same  combination  of  signs 
and  symptoms  before  the  peripheral  vessels  (except 
the  larger  ones)  show  any  appreciable  change. 
Gull  and  Sutton's  disease  probably  represents  the 
advanced  or  late  stages  of  Christian's  primary 
vascular  hypertension. 

In  a  study  of  one  hundred  cases  of  hypertension, 
Schneider  found  twenty-six  arteriosclerotic,  sixteen 
diffuse  nephritic,  twenty-five  granular  kidney,  two 
climacteric,  seventeen  benign,  one  surgical  kidney, 
two  cystic  kidney,  four  vascular  syphilis,  three 
thyrotoxic  and  four  were  asphyxial. 

Riesman  and  Hopkins  have  recently  emphasized 
the  cases  of  hypertension  occurring  in  women  be- 
tween forty  and  fifty  years  of  age.  Some  of  these 
women  have  had  many  children,  some  none  at  all, 
some  showed  urinary  findings  and  had  symptoms, 
others  had  no  complaints  traceable  to  the  high 
blood  pressure — and  got  along  very  well  on  a 
regulated  diet  and  rest.  Some  of  these  climacteric 
patients  were  relieved  by  the  administration  of 
benzyl-benzoate.  (Macht),  corpus  luteum  and 
thyroid.  The  nitrates  and  iodides  are  not  beneficial. 
The  blood  chemical  tests  in  these  cases  are  normal 
or  nearly  normal — the  urea  X,  uric  acid,  and 
creatinine  are  not  noticeably  increased.  At  times 
the  hyperpiestic  heart  becomes  decompensated  and 
then  some  medical  treatment  is  necessarily  indicated. 
It  is  to  be  remembered,  therefore,  that  the  chronic 
nephropathies  are  not  to  be  held  accountable  for 
all  cases  of  vascular  hypertension — although  nearly 
all  cases  of  persistent  high  blood  pressure  eventu- 
ally do  show  some  renal  sclerosis  and  cardiorenal 
disturbance. 

Clifford  Albutt.  in  1903,  called  attention  to  the 
fact  that  the  hypertension  in  a  certain  proportion 
of  cases  was  primary  and  the  sclerosis  secondary, 
although  the  prevailing  opinion  held  at  that  time 
was  that  hypertension  was  alwaj'S  secondary  to 
arteriosclerosis  or  nephritis. 

Stengel,  in  1914,  dwelt  on  the  occurrence  of  cases 
of  arteriocapillary  fibrosis  (Gull  and  Sutton's 
Disease)  and  noted  cases  of  primary  arterial  or 
arteriolar  disease  with  insidious  onset.  Meara  (1), 
described  cases  of  essential  hypertension  occurring 
in  ruddy,  stocky  patients  with  plethoric  habits, 
and  active  temperament. 

Essential  hypertension,  or  Albutt's  hyperpiesia,  is 
essentially  chronic  in  course  and  ends  ultimately  in 
a  definite  nephritis  with  sclerosis  of  the  renal  ves- 
sels, cardiac  hypertrophy,  and  arteriosclerosis,  the 
end  result  being  either  cardiac  failure,  or  an  arterial 
accident,  cerebral  or  coronary.  These  patients 
rarely  die  of  uremia.  Usually  they  are  ap- 
parentl}"  in  robust  health,  have  a  florid  complex- 
ion, are  plethoric,  and  have  excellent  appetites. 
These  cases  usually  begin  in  late  middle  life.  The 
earliest  complaints  are  increasing  dyspnea  on  exer- 


tion and  sometimes  precordial  pain.  INIeara  reports 
a  case  of  this  type  in  a  boy  eight  and  one  half  years 
old,  in  whom  the  trouble  began  at  the  age  of  five 
years.  After  all,  these  cases  may  be  in  the  preal- 
buminuric  stage  of  chronic  interstitial  nephritis 
(]Mahomed)  or  the  presclerotic  stage  of  arterio- 
sclerosis (Huchard). 

OTHER  TESTS. 

Indigocarmin  and  methylene  blue  (from  five  to 
fifteen  minims)  in  five  per  cent,  solution  when 
injected  into  a  patient  will  under  normal  circum- 
stances color  the  urine  blue  in  an  hour  and  in 
twenty-four  to  twenty-eight  hours  the  dye  is  com- 
pletely eliminated.  In  nephritis  the  excretion  begins 
later  and  lasts  much  longer — several  days. 

Iodide  of  potassium,  seven  and  one  half  grains, 
when  given  the  excretion  of  iodine  in  the  urine 
lasts  about  twenty-four  to  thirty-six  hours  in 
healthy  persons,  while  in  nephritics  this  may  last  for 
four  or  five  days  (F.  Miiller). 

Rowntree  and  Geraghty's  phenolsulphonephthal- 
ein  test  has  now  becomes  the  one  most  commonly 
used.  Phthalein  ampoules  containing  the  monoso- 
dium  salt,  in  sterile  solution  (.006  in  1  mil.)  can 
now  be  obtained,  and  the  Dunning  colorimeter  is  on 
the  market.  For  the  rapid  estimation  of  urea,  in  the 
urine  and  in  the  blood,  urease  tablets  (twenty-five 
mgm.  may  be  used).  Rapid  acidosis  testing  outfits 
for  estimating  the  alkali  reserve  of  the  blood,  the 
alveolar  air  carbon  dioxide  tension,  and  the  hydro- 
gen ion  concentration  can  also  be  obtained  at 
moderate  cost. 

The  electric  conductivity  in  nephritic  urine  is 
often  diminished,  and  the  same  is  true  of  the  blood. 
The  resistance  to  electric  conductivity  of  a  fluid 
depends  upon  the  amount  of  electrolytes — i.  e.,  dis- 
sociated ions  of  inorganic  salts  contained  therein. 
Increased  concentration  of  the  salts  adds  to  the 
electric  conductivity. 

The  freezing  point  and  boiling  point  of  a  solution 
are  dependent  upon  the  number  of  molecules  present 
in  it.  The  fewer  solid  constituents  the  kidney 
excretes,  the  less  will  the  freezing  point  of  the 
urine  be  below  the  freezing  point  of  distilled  water. 
Under  normal  conditions  this  lowering  is  about  1° 
to  2.3°  C.  below  0°.  If  it  is  less  than  1°  C,  an  insuf- 
ficiency of  the  kidneys  is  probable. 

The  freezing  point  of  blood  normally  is  about 
0.56°  C.  below  that  of  water.  In  disease  of  the 
kidneys  it  sinks  lower.  In  uremia  it  is  as  low  as 
0.70°— 75°  C. 

BLOOD  PRESSURE. 

In  estimating  the  blood  pressure  in  my  cases  I 
always  use  the  aviscultatory  method  of  Korotkow. 
This  is  the  simplest,  most  satisfactory  and  accurate 
method.  In  cases  where  the  heart  is  irregular  in 
force  and  rhythm  it  becomes  impossible  to  make 
accurate  observations  of  systolic  and  diastolic  pres- 
sure. In  such  cases  Warfield  advises  taking  the 
average  reading  between  the  point  where  the  strong- 
est beat  is  heard  and  the  point  where  practically 
all  beats  are  heard  as  the  systolic  pressure.  The 
diastolic  pressure  is  best  taken  at  the  point  where 
no  sound  is  heard  except  the  occasional  sound  pro- 
duced by  an  excessively  strong  beat.     The  first 


August  21.  1920.] 


GOLDSTEIN 


XEPHRITIS. 


259 


audible  sound  occurs  at  systolic  pressure ;  the 
diastolic  pressure  should  be  read  at  the  sudden 
transition  of  the  third  clear  tone  to  the  dull  fourth 
tone  and  just  before  the  disappearance  of  all  sound. 

Diastolic  pressure  is  important  as  it  measures  the 
peripheral  resistance ;  the  pulse  presstire  measures 
the  actual  head  of  propulsive  force  in  the  arteries 
at  the  base  of  the  heart.  Normally,  the  pulse 
presstire  is  forty  to  forty-five  mm.  of  mercury.  The 
catise  of  hypertension  is  not  exactly  known.  Macht 
and  \'oegtlin  have  isolated  a  crystalline  substance 
from  human  blood  which  they  regard  as  a  lipoid 
and  related  to  cholesterin.  This  substance  was 
recovered  from  the  conex  of  the  adrenal  gland. 
There  may  be  something  in  the  circulation,  there- 
fore, that  produces  constriction  of  the  vessels. 
Speaking  of  hypertension  in  women  Riesman  says 
it  may  be  set  down  as  a  general  rule  that  hyper- 
tension in  women  under  thirty-five  years  of  age 
is  practically  always  nephritic,  it  gives  a  bad 
prognosis,  much  worse  than  any  other  form  of 
hypertension. 

UREMIA. 

There  are  two  forms  of  uremia.  Chloridemia, 
eclampsia  of  \'olhard,  is  due  to  arterial  hyperten- 
sion, and  edemas  caused  by  retention  of  water 
salines — i.  e..  mechanical  in  origin.  This  is  a 
pseudouremia.  Azotemia,  or  true  uremia,  is  due 
to  some  excess  accumulation  of  toxic  substances. 
These  poisons  are  largely  nervous  poisons.  Uremia 
holds  the  same  relation  to  nephritis  as  coma  to 
diabetes.    The  real  cause  of  uremia  is  not  known. 

Traube  believed  uremic  symptoms  were  depend- 
ent upon  an  acutely  developing  edema  of  the  brain 
and  consequent  cerebral  anemia.  Frerichs  assumed 
that  through  fermentation,  the  urea  in  the  blood  of 
nephritics  was  converted  into  carbonate  of  am- 
monia. Some  experiments  seem  to  point  to  potas- 
sium salts  as  the  poisonous  agents.  Some  workers 
laid  the  blame  for  the  condition  on  extractive  mat- 
ters, as  creatinin.  Bouchard,  Acoli  and  others 
thought  that  the  urotoxins  (alkaloid  substances), 
nephrolysin,  nephrotoxins,  caused  the  kidney  cells 
to  break  down  and  act  as  poison  (product  of  dis- 
integration of  the  tissues)  Brown-Sequard.  Some 
traced  the  uremia  to  a  disturbance  in  renal  internal 
secretion. 

Xoncoagulable  nitrogen,  the  nitrogen  remaining 
in  the  blood  after  the  complete  precipitation  of  allni- 
min,  may  play  a  part.  Hughes  and  Carter  con- 
clude that  the  poison  is  of  an  albtmiinous  nature. 
Rose  Bradford  showed  an  extarordinary  increase  in 
the  production  of  urea  of  the  nitrogenous  bodies 
like  creatinin  and  creatin,  and  that  it  profoundly  in- 
fluenced the  metabolism  of  muscle  tissue. 

Fleischer  found  urea  in  the  saliva  and  sputum  of 
a  uremic  patient.  Schottin  first  described  a  coating 
(lustry  scaly)  of  urea  on  the  skin  and  the  sides  of 
the  nose  in  uremia.  Urea  does  not  cause  uremia. 
Widal  thinks  it  does.  Ammonia  nitrogen  does  not 
cause  uremia.  Martin  Fischer  states  that  an  acid 
intoxication  of  the  brain  caused  edema  of  the  brain 
cells  and  uremic  symptoms  resulted. 

There  is  an  accumulation  of  rest  nitrogen  (non- 
coagulable  nitrogen)  in  the  blood,  in  uremia  with 
convulsions,  but  it  has  not  been  proved  to  be  the 


catise  of  uremia.  Foster  thinks  he  has  discovered  the 
causal  toxic  crystalline  substance  in  uremia.  Indica- 
nemia  is  not  the  cause.  Foster  describes  several  types 
of  uremia:  1.  Retention  type  of  uremia,  due  to  ob- 
struction of  ureters  (complete  occlusion)  or  if  a 
surgeon  by  mistake  removes  an  only  kidney,  or  if 
both  kidneys  do  not  functionate,  death  occurs  in 
stupor  and  without  convulsions.  2.  Cerebral  edema 
type  occurs  in  acute  parenchymatous  and  glome- 
rular nephritis.  Symptoms  of  cerebral  compres- 
sion due  to  edema  of  the  brain,  and  death  occurs 
without  convulsions.  3.  Toxic  or  epileptiform  or 
classical  or  convulsive  type,  occurs  with  local  and 
general  twichings  and  convulsions.  It  is  in  this 
tvpe  that  Foster  thought  he  discovered  the  causal 
poison  of  uremia. 

SYMPTOMS  OF  UREMIA. 

The  pulse  is  often  very  slow,  forty  to  fifty,  be- 
fore the  appearance  of  severe  symptoms.  There  is 
a  disturbance  of  the  cerebral  visual  centres,  par- 
ticularly of  the  occipital  cortex,  resulting  in 
amaurosis.  Delirum  and  maniacal  or  melancholic 
states  occasionally  follow  uremic  coma.  Uremic 
vomiting  is  often  persistent,  it  may  be  central  in 
origin,  but  it  is  also  due  to  gastric  irritation  from 
eliminated  urea. 

Uremic  diarrhea  is  provoked  by  the  carbonate  of 
ammonia  arising  from  the  urea  in  the  intestines. 
The  disturbances  in  uremia  are  almost  exclusively 
cerebral  and  in  the  main  located  in  the  cortex  of 
the  brain.  They  are  probably  due  to  a  direct  injury 
of  the  nervous  elements,  possibly  also  to  spasm  of 
the  blood  vessels. 

The  most  characteristic  symptom  of  severe 
uremia  is  the  uremic  convulsion.  Headache,  pre- 
cordial distress,  vomiting,  peculiar  restlessness,  itch- 
ing of  the  skin,  are  important  symptoms  in  milder 
fonns  of  uremia.  Uremic  amaurosis  usually  re- 
mains after  recovery  from  the  convulsions  and  usu- 
ally develops  quite  rapidly.  A  lustry  scaly  coating 
of  urea  may  be  observed  on  the  sides  of  the  nose 
in  these  uremic  cases. 

Fischer  says  the  "consequences  of  kidney  disease 
are  not  consequences  but  are  the  same  thing  as  the 
kidney  disease  manifested  in  the  different  organs  of 
the  body  and  all  due  to  the  same  poison  which 
originally  produced  the  kidney  change."  He  at- 
tributes the  headache,  stupor,  coma,  and  convulsions 
of  uremia  to  an  edema  of  the  brain,  the  changes  in 
sight  to  an  edema  of  the  optic  nerve  or  retina,  the 
vomiting  to  an  edema  of  medulla  and  the  general 
edema  to  a  swelling  of  the  body  tissues  generally, 
all  induced  through  the  same  poison  circulating 
through  the  body  and  responsible  for  the  edema  of 
the  kidney  (nephritis).  He  believes  water  is  the 
only  true  diuretic. 

Xervous  s\Tnptoms. — Uremic  hemiplegia  is  char- 
acteristically transient,  changes  may  occur  in  a  few 
hours.  These  cases  must  be  dift'erentiated  from 
cerebral  hemorrhage  and  thrombosis.  Aphasia 
which  is  renal  in  origin  clears  up  commonly,  with 
an  improvement  of  the  condition.  It  must  be  re- 
membered, however,  that  a  uremic  patient  may  also 
have  a  cerebral  hemorrhage. 

(To  be  continued.) 


Editorial  Notes  and  Comments 


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NEW  YORK.  SATURDAY.  AUGUST  21,  1920. 


PHYSICIAN  AUTHORS— DR.  DAVID 
RAMSAY. 

It  is  said  that  Napoleon  during  his  exhaustive 
military  campaigns  was  able  to  thrive  on  five  hours' 
sleep  a  night,  and  sometimes  less,  and  deemed 
more  than  that  amount  of  slumber  unnecessary. 
There  have  been  those  who  required  even  less  sleep, 
and  one  of  these  was  that  indefatigable  patriot 
of  the  RevoKitionary  period,  Dr.  David  Ramsay.  It 
is  related  that  Dr.  Ramsay  would  sleep  only  four 
hours  a  night,  arising  before  daylight  and  devoting 
his  entire  time  to  hard,  systematic  work.  It  is  not 
surprising  that  with  all  this  intensive  industry  Dr. 
Ramsay  was  able  to  take  care  of  a  large  medical 
practice  and  at  the  same  time  dash  of?  soinething 
like  thirty  volumes  of  history  and  miscellaneous 
writings,  in  addition  to  taking  an  active  part  in  all 
public  and  philanthropic  enterprises  in  his  home 
city,  Charleston,  South  Carolina. 

Dr.  Ramsay's  numerous  volumes  of  Revolution- 
ary history  are  not  only  excellent  narratives  in 
themselves,  but  they  have  also  been  veritable  store- 
houses of  information  from  which  succeeding  his- 
torians have  been  able  to  gather  a  vast  amount  of 
material.  He  was  peculiarly  fitted  to  give  to 
America  its  first  written  accounts  of  the  War  of 
Independence,  for  he  was  not  only  an  exceptional 
man,  but  also  one  who  enjoyed  exceptional  ad- 
vantages. As  a  member  of  the  Continental  Con- 
gress he  had  access  to  all  official  documents,  and 
he  tells  us  in  his  preface  that  he  went  carefully 


through  these,  gathering  notes  and  data.  Similarly, 
he  made  a  careful  perusal  of  all  Washington's  let- 
ters and  those  of  the  other  general  officers  and 
members  of  Congress.  Throughout  the  Revolution, 
despite  his  numerous  patriotic  activities,  he  busily 
gathered  material  for  the  volumes  of  history  which 
he  wrote  after  freedom  had  been  attained.  As  a 
further  help  in  the  compilation  of  his  histories.  Dr. 
Ramsay  was  blessed  with  a  retentive  memory  and  a 
fine  sense  of  discrimination,  and  he  was  a  keen 
observer  of  men  and  events.  As  a  writer  he  was 
lucid,  direct  and  forceful,  and  his  descriptions  of 
battles  and  characterizations  of  men  were  clear 
cut,  vivid  and  exact. 

In  a  way.  Dr.  Ram'say  had  been  a  sort  of  child 
prodigy.  Born  on  a  farm  in  Lancaster  County, 
Pennsylvania,  on  April  2,  1749,  of  Irish  parents,  he 
displayed  rare  talents  at  an  early  age,  and  was  un- 
commonly proficient  in  his  studies  at  school. 
When  he  was  twelve  years  old  he  became  a  tutor 
in  an  academy  at  Carlisle,  Pa.,  and  after  a  year 
in  that  occupation  he  entered  the  College  of  New 
Jersey,  now  Princeton  University,  from  which  he 
was  graduated  in  the  class  of  1765.  He  then  be- 
gan teaching  school  in  Maryland,  and  it  was  not 
until  after  several  years  of  this  that  he  decided  to 
become  a  physician.  He  was  graduated  from  the 
University  of  Michigan  as  an  M.  D.  in  1773,  and 
settled  in  Charleston,  where  he  rapidly  built  up  a 
large  practice. 

Although  Dr.  Ramsay  had  been  an  ardent  patriot 
in  his  younger  years,  it  was  in  Charleston  that  he 
gained  prominence  throughout  the  colonies  by  rea- 
son of  his  unflinching  advocacy  of  the  colonies' 
rights.  The  part  he  played  in  the  Revolution  was 
a  large  one — as  member  of  the  South  CaroHna 
Senate,  as  member  of  the  Continental  Congress,  as 
field  and  hospital  surgeon,  and  in  various  other 
capacities.  When  the  British  captured  Charleston 
in  May,  1780,  Lord  Cornwallis  ordered  that  Dr. 
Ramsay  be  put  in  prison  at  St.  Augustine,  Fla.,  to 
curb  his  anti-British  activities.  As  a  public  speaker 
and  member  of  the  Council  of  Safety  at  Charleston, 
Dr.  Ramsay  had  long  been  a  thorn  in  the  side  of 
the  British.  He  was  detained  at  St.  Augustine 
eleven  months.  Two  years  later  he  was  elected  to 
the  Continental  Congress  and  reelected  in  1785. 
During  his  second  term  he  served  for  one  year  as 
president  pro  tempore  during  the  illness  of  the 
famous  John  Hancock. 

The  History  of  the  Revolution  in  South  Carolina 
was  Dr.  Ramsay's  first  published  work,  issued  in 


August  21,  1920.] 


EDITORIAL  ARTICLES 


261 


two  volumes  in  1785,  followed  four  years  later  by 
his  History  of  the  American  Revolution.  Dr. 
Ramsay  wrote  the  first  Life  of  Washington  (pub- 
lished in  1807),  with  whom  he  was  personally 
acquainted,  and  the  biography  stands  today  as  one 
of  the  best  and  most  authentic  of  the  numerous 
biographies  of  the  Father  of  His  Country. 

The  most  pretentious  of  Dr.  Ramsay's  works 
was  his  Universal  History  Americanized,  in  twelve 
volumes,  which  included  three  volumes  of  his 
History  of  the  United  States  from  the  First  Settle- 
ment in  i6o/  to  i8o8. 

Dr.  Ramsay's  writings  included  three  works  of 
more  or  less  direct  interest  to  the  medical  profes- 
sion— one  entitled  The  Means  of  Prcsen'ing  Health 
in  Charleston  and  Vicinity,  published  in  1790;  a 
ReviezL'  of  the  Improvements,  Progress  and  State 
of  Medicine  in  the  Eighteenth  Century,  published 
in  1802,  and  a  Eulogium  of  Dr.  Benjamin  Rush, 
published  in  1813. 

Despite  his  literary  activities.  Dr.  Ramsay  con- 
tinued his  professional  practice  in  Charleston  from 
1786  until  his  death  in  1815.  His  influence  seems 
to  have  been  great  in  every  department  of  life.  He 
was  always  in  demand  to  address  public  gatherings, 
and  is  reputed  to  have  been  a  forceful  speaker.  He 
was  twice  married,  his  first  wife  being  Frances,  the 
daughter  of  the  Rev.  John  Witherspoon,  president 
of  Princeton  University,  and  the  second  wife 
Martha,  daughter  of  Henry  Laurens,  of  Charles- 
ton, a  woman  of  rare  accomplishments,  as  extracts 
from  her  diary,  included  in  Dr.  Ramsay's  Memoirs 
of  Mrs.  Martha  Laurens  Ramsay,  show. 

Dr.  Ramsay,  notwithstanding  a  tremendous  ex- 
penditure of  energy  throughout  his  life,  was  said 
to  be  ni  vigorous  health  when  he  was  shot  by  a 
lunatic  against  whom  he  had  testified  as  an  alienist. 
He  died  as  a  result  of  his  wounds  on  May  8,  1815. 
at  the  age  of  sixty-six. 


THE  TRUE  BASIS  FOR  PEXAL 
REGULATION. 
Genuine  self  interest  can  never  stand  in  antag- 
onism to  the  best  and  mo.st  workable  altruism.  It 
is  rather  the  basis  of  the  latter.  Honest  and  thor- 
ough investigation  of  an  individual  self  or  of 
society  would  not  fail  to  recognize  this.  But  the 
individual  self  has  lazily  and  timidly  stopped  short 
of  such  investigation,  and  so  has  collective  social 
understanding.  Stopping  less  than  half  way,  both 
have  failed  to  penetrate  to  real  motives  or  to  the 
basis  out  of  which  all  motives  primarily  arise.  Here 
their  sincerity  must  be  put  to  the  test,  and  their 
genuine  self  interest  find  not  only  its  natural  justi- 


fication, but  its  origin  as  a  spring  for  all  service 
rendering  behavior.  In  the  sphere  of  penal  regula- 
tions and  activities  we  are  slowly  realizing  how 
seriously  the  race  has  allowed  certain  partial  con- 
ceptions to  obstruct  the  more  honest  penetration 
which  involves  time  and  trouble,  a  good  deal  of 
both.  Such  partial  conceptions  dominate  the 
thought  and  the  method  of  civilized  society. 

Enrico  Ferri.  writing  of  The  Reform  of  Penal 
Justice  in  Italy  (Archivio  di  Antropologia  criininalc, 
Psichitria   c   Medicina   legale,   Vol.  XL.    Xo.  1, 
1920),  says  that  two  principles  have  formed  the 
basis  of  the  administration  of  jtistice.    X'either  of 
these  has  truly  served  the  principles  of  self  in- 
terest,   for    the\-    have    been    only    blindly  ap- 
plied to  this  end.    The  two  principles  which  are 
in    play,    the    writer    says,    are    that    of  de- 
fense  of   the  state  against  the  individuals  who 
threaten  it  and  that  of  penalty  measured  only  ac- 
cording to  the  gravity  of  the  offense.    Society  in 
its  attitude  toward  penal  questions  has  forgotten  or 
completely  lost  sight  of  its  own  best  defense,  its 
own  best  interest,  as  contained  in  an  imderstand- 
ing  of  the  real  nature  of  the  criminal  and  of  the 
crime   from   his   point   of   view.    The   time  and 
trouble  involved  in  this  are  more  than  society  is 
in  the  habit  of  spending  upon  any  of  its  ques- 
tions or  upon  any  one  of  its  individuals,  except  in 
the  negative  way  of  patching  tip  damages  done,  re- 
pairing the  ravages  due  to  a  crime,  and  putting  into 
action   the   extensive   machinery   of  apprehension 
and  punishment  of  the  ofTender.    The  trouble  of 
investigation  that  would  lead  to  preventive  action 
in  the  case  of  the  individual  delinquent  and  to  a 
thorough  apportionment  of  the  treatment  of  each 
delinquency  in  order  to  get  the  best  positive  re- 
turns in  the  long  rim  for  society  itself  has  not 
seemed  worth  while.    This  study  from  Italy  re- 
minds us  again  that  such  unreasonableness  and 
lack  of  real  self  interest  on  the  part  of  society  are 
coming  to  be  recognized  as  the  starting  point  for 
some  more  effective  manner  of  viewing  the  question. 

The  writer  refers  to  Christ's  injunction  that  one 
man  shall  not  judge  another.  The  logic  of  this 
command  lies  in  the  fact  that  one  man  cannot  judge 
another.  He  has  not  possession  of  the  elements  on 
which  such  judgment  could  be  based.  It  is  neces- 
sary to  know  the  internal  world  which  belongs  to 
the  offender  really  to  pass  sentence  that  should  fit 
the  crime.  This  includes  a  knowledge  of  the  in- 
dividual's heredity,  of  the  environment,  intrauter- 
ine and  extrauterine,  by  which  his  early  life  was 
surrounded,  and  of  all  his  later  family  and  social 
surroundings.  Could  this  all  be  known,  the  ques- 
tion for  social  regulation  would  not  yet  lie  one  ot 


262  EDITORIAL  ARTICLES  [New  Vork 

Medical  Journal 


punishment.  Who  is  even  society,  one  might  ask, 
to  mete  out  measure  for  measure,  the  payment  for 
a  social  crime?  The  crime  itself  and  its  injury  to 
society  are  not  something  which  can  be  put  in  the 
balance  and  compensated  for.  The  practical  duty, 
one  which  serAJ^es  the  interests  of  every  one,  and  by 
this  alone  protects  society,  is  to  determine  how  best 
to  redirect  these  tendencies,  these  psychological  de- 
terminants, which,  in  addition  to  environmental 
pressure,  have  resulted  in  criminal  acts.  Enacted 
laws  against  crime  can,  as  the  writer  states,  only 
partially  eliminate  the  effects  of  crime.  They  do 
nothing  toward  its  causes,  and  therefore  do  not 
defend  against  repetition. 

Alteration  of  causes  can  be  attained  only  by  the 
larger  psychological  knowledge ;  l)y  providing  better 
social  conditions,  and  aiding  the  individual  in  his 
adaptation  to  these.  There  can  also  be  more  direct 
and  efficient  prevention  through  police  agencies  and 
special  educational  provision  for  those  who  are  de- 
ficient in  adaptive  power,  because  of  deficient  in- 
tellect or  otherwise.  There  should  also  be  per- 
sonal attention  directed  toward  the  condemned  from 
the  time  of  their  apprehension  to  that  of  the  carrying 
out  of  their  sentence  and  at  their  return  to  society. 
Agricultural  and  other  colonies  are  suggested  as 
wise  provision  for  those  under  punishment.  A 
strong  plea  is  made  for  special  educational  train- 
ing for  the  officials  who  have  the  penal  work  in 
hand.  Psychology,  medicine,  anthropology,  and 
criminology  should  be  in  their  course  of  study. 

  « 

TABES  AND  FACIAL  PAR,-\LYSIS. 

When  facial  paralysis  occurs  during  tabes  a  cer- 
tain number  of  questions  are  to  be  considered  if  a 
correct  diagnosis  and  prognosis  are  to  be  made. 
The  first  question,  is  there  really  facial  paralysis, 
simple  as  it  appears  may  necesitate  a  long  and 
minute  examination,  and  for  making  a  conclusion 
the  state  of  contracture  of  the  face,  the  exaggera- 
tion of  the  asymmetry  on  the  slightest  movement, 
the  deviation  of  the  tongue,  and  spasmodic  twitch- 
ing of  the  eyes  and  lips  must  be  looked  into.  In 
some  cases  the  asymmetry  that  one  is  prone  to  attach 
to  the  paralysis  may  be  the  efifect  of  ataxia  of  the 
face.  The  patient  may  also  limit  the  movements 
on  the  side  of  the  face,  either  because  of  the  violent 
pain  occurring  with  each  motion  or  because  of  a 
true  paresis  indirectly  related  to  the  involved  sensi- 
tive portion  of  the  trigeminus.  Finally,  tabetic 
hemiplegias  exist,  but  their  description  is  too  well 
known  to  require  comment. 

If  facial  paralysis  really  exists,  the  second  ques- 
tion is  whether  the  paralysis  is  really  tabetic.  In 


some  cases  paralytic  associations  may  distort  the 
face  so  that  a  pseudobulbar  paralysis  may  be  con- 
sidered, in  which  case  the  reflexes  are  not  abolished. 
A  glossolabiolaryngeal  paralysis  might  also  be 
diagnosed,  but  here  there  are  no  ocular  manifesta- 
tions or  sensitive  or  sensory  phenomena.  But  con- 
fusion generally  is  not  possible  and  the  real  point  to 
settle  is  whether  the  facial  paralysis  is  tabetic  or  is 
a  facial  paralysis  occurring  in  an  ataxic  subject. 
A  tabetic  is  both  a  nervous  and  syphilitic  subject 
and  each  of  these  conditions  is  susceptible  to  facial 
paralysis. 

As  a  nervous  subject  he  may  be  hysterical  and 
a  true  hysterical  paralysis  may  develop,  although 
this  is  rare.  A  careful  study  will  always  detect 
some  peculiarity,  such  as  irregular  distribution  oc- 
casionally supplanted  hx  true  spasmodic  paroxysms 
almost  constantly  accompanied  by  sensory  manifes- 
tations. On  the  other  hand,  hysterical  facial  par- 
alysis is  a  manifestation  of  a  hysterical  syndrome, 
always  serious  and  frequently  giving  rise  at  the 
same  time  with  the  facial  hemiplegia  to  a  total 
hemiplegia  or  a  hemianesthesia.  In  the  ataxic  there 
may  develop  a  facial  paralysis  a  frigore  from  the 
most  trivial  causes.  It  is  usually  easy  to  recognize 
a  nuclear  paralysis  and  to  dififerentiate  it  from  a 
])urely  neuritic  paralysis ;  the  distribution  is  not  the 
same,  the  evolution  is  in  every  way  different ;  the 
extent  and  the  intensity,  especially  at  the  onset,  may 
be  infinitely  more  marked  in  a  frigore  type.  On 
the  contrary,  it  is  a  delicate  matter  to  differentiate  a 
preatoxic  paralysis  from  facial  paralysis.  The  be- 
nign characters  and  the  rapidity  of  evolution  are 
not  the  appanage  of  tabetic  paralysis  only;  they  are 
merely  presumptive  characters.  But  always  when 
a  tabes  is  distinctly  evident  as  well  as  the  symptoms 
of  the  onset — fulgurating  pains,  the  Argyll  Robert- 
son, Westphall.  and  so  on  and  above  all  if  the  tabes 
appears  to  claim  this  somewhat  special  character 
that  Brissaud  has  described  under  the  name  of 
paralytic  tabes — the  physician  will  be  authorized  to 
relate  every  instance  of  nonsymptomatic  facial  par- 
alysis to  the  tabes  in  evolution. 

The  tabetic  being  a  syphilitic,  there  are  several 
good  reasons  for  a  facial  paralysis  developing  dur- 
ing the  secondary  phase  of  syphilis,  as  tabes  is  al- 
ways a  late  manifestation,  but  during  the  tertiary 
phase  syphilis  has  multiple  means  of  producing 
functional  impotency  of  the  facial  nerve.  First, 
there  is  the  basal  meningitis  which  involves  the  third 
and  fourth  cranial  pairs.  The  auditory  nerve  fre- 
quently gives  rise  to  hemianosmia  with  preservation 
of  tactile  sensibility  of  the  nasal  mucosa  on  the 
same  side ;  it  also  provokes  an  extremely  marked 
leucocytosis  as  revealed  by  examination  of  the  cere- 


August  21,  1920.] 


NEirS  ITEMS. 


263 


brospinal  fluid.  Luetic  meningeal  gummata  may  be 
seated  at  the  point  of  exit  of  the  facial  nerve,  more 
rarely  over  the  convexity  of  the  brain ;  occasionally 
even  a  large  surface  of  the  meninges  is  involved  by 
the  gummatous  or  sclerogummatous  process.  Much 
more  rarely  the  nerve  itself  appears  to  be  directly 
involved,  but  gummatous  neuritis  is  so  exceptional 
that  from  the  viewpoint  of  diagnosis  it  need  scarce- 
ly be  taken  into  consideration.  Great  consideration 
should  be  given  to  bone  lesions — exostoses,  gum- 
matous periostides — compressing  the  seventh  pair  in 
its  course  along  the  Fallopian  aqueduct.  Such 
cases  are  easy  to  eliminate  because  tabetic  facial 
paralysis  is  exceptionally  isolated.  However,  the 
fact  that  the  patient  has  tabes  will  be  greatly  in 
favor  of  a  diagnosis  of  facial  hemiplegia  and  above 
all  the  test  by  treatment — positive  in  syphilitic  le- 
sions, negative  in  tabes — will  be  conclusive. 

As  to  the  third  question,  namely  the  nature  and 
origin  of  the  parah'sis,  there  will  be  no  difficulty  in 
typical  cases.  The  rapidity  of  evolution,  the  gen- 
eral involvement  of  the  face,  the  appearance  of  the 
paralysis  at  the  onset  of  the  tabetic  symptoms,  the 
suddenness  of  appearance  and  disappearance,  and 
their  benign  course  are  all  characters — although 
relative — which  assign  them  to  a  neuritic  origin. 
Their  incurability,  progress,  the  exclusive  involve- 
ment of  the  lower  territory  of  the  face,  the  asso- 
ciation especially  with  other  paralyses  of  nuclear 
origin,  are  elements  of  almost  certain  nuclear  origin. 


News  Items. 


Tri-State  Medical  Meeting. — The  Tri-State 
District  Medical  Society  of  Iowa,  Illinois  and  Wis- 
consin will  be  held  October  4th  to  7th  at  Waterloo, 
Iowa. 

Minnesota  Medical  Meeting. — The  annual 
meeting  of  the  Minnesota  State  Medical  Association 
will  be  held  September  29th  to  October  1st  in  St. 
Paul. 

Southwest  Medical  Meeting. — The  Medical 
Association  of  the  Southwest  will  hold  its  fifteenth 
annual  session  September  27th  to  29th  at  Wichita, 
Kan.,  under  the  presidency  of  Dr.  E.  F.  Day,  of 
Arkansas  City,  Kan. 

Dysentery  in  Poland. — Dispatches  from  abroad 
state  that  dysentery  is  epidemic  in  the  Polish  army. 
At  one  Red  Cross  station  where  about  4.000  men 
are  received  daily,  four  fifths  of  the  arrivals  are 
said  to  be  suffering  from  dysentery. 

Fiske  Fund  Prize  Avi^arded. — The  Fiske  Fund 
Prize  of  the  Rliode  Island  Medical  Society  has  been 
awarded  to  Dr.  Allen  G.  Rice,  of  Springfield,  Mass., 
for  his  dissertation  on  Surgical  Lessons  of  the 
Great  War. 


Death  of  Professor  Guyon. — Word  has  come 
from  Paris  of  the  death  of  Professor  Feliz  Guyon, 
senior  surgeon  of  the  Hopital  Xecker.  and  a  former 
president  of  the  Academy  of  Sciences  and  the 
Academy  of  Medicine,  Paris. 

Child  Hygiene  Conference. — The  American 
Child  Hygiene  Association  will  hold  its  annual 
meeting  October  11th  to  13th  in  St.  Louis.  The 
Central  States  Pediatric  Society,  which  also  meets 
in  St.  Louis  October  13th  and  14th,  will  hold  a 
joint  session  with  the  first  mentioned  association. 

Death  of  Professor  Politzer. — Professor  Abame 
Politzer,  the  noted  otologist  of  the  Lniversity  of 
Vienna,  died  on  Thursday,  August  12th,  in  his 
eighty-fiftli  year.  Dr.  Politzer  was  the  teacher  of 
many  American  postgraduate  students  in  Vienna. 

Archives  of  Surgery. — The  first  number  of  the 
ArcJiives  of  Surgery  has  recently  been  issued  by 
the  American  ^Medical  Association.  It  will  contain 
papers  which  have  been  read  before  the  surgical 
section  of  the  Association  and  also  original  articles 
pertaining  to  research  and  investigation  in  the  field 
of  stirgery. 

Award  of  Cameron  Prize. — The  Cameron  prize 
of  the  University  of  Edinburgh  has  been  awarded 
to  Sir  Robert  Jones  in  recognition  of  the  highly  im- 
portant advances  he  has  made  in  orthopedics  and  his 
many  valuable  contributions  to  the  literature  of  the 
subject  during  the  past  five  years.  The  prize  has 
not  been  awarded  since  1915,  when  it  was  given  to 
the  late  Sir  Lauder  Brunton. 

French  Asylum  Transformed. — The  National 
Asylum  at  Charenton,  France,  is  to  be  gradually 
transformed  to  a  giant  maternity  home  and  creche. 
At  present  500  mental  patients  occupy  the  asylum, 
which  has  accommodation  for  1,500.  These  500 
will  remain  in  one  wing  of  the  vast  building,  and 
as  they  die  out — the  mortality  rate  is  high — their 
places  will  not  be  filled.  From  now  on  1,000  beds 
will  be  reser\-ed  for  the  Institute  of  Puericulture, 
providing  accommodation  for  about  that  number  of 
recently  confined  women,  who  will  stay  there  with 
their  infants  for  an  average  of  two  months.  The 
number  of  these  occupants  will  gradually  increase 
in  proportion  as  the  others  disappear. 

Personal. — Dr.  John  M.  Finney,  of  Baltimore, 
has  recently  returned  from  Europe,  where  he  at- 
tended the  Interallied  Surgical  Congress  at  Paris. 

Dr.  V.  J.  Harding,  associate  professor  of  bio- 
logical and  physiological  chemistry  at  ^IcGill  L'ni- 
versity,  has  been  appointed  professor  of  patho- 
logical chemistry  in  the  University  of  Toronto. 

Dr.  W.  Thurber  Fales,  of  Maiden,  Mass..  has 
been  appointed  instructor  of  biolog)-  and  public 
health  in  the  medical  school  of  the  Johns  Hopkins 
L'niversit)-. 

Dr.  S.  Burt  \\'olbach,  professor  of  pathology  and 
bacteriology  at  Harvard  Medical  School,  has  re- 
turned from  Poland,  where  he  spent  six  months 
studying  typhus. 

Dr.  Sebastian  Recasens.  of  Spain,  is  on  a  visit  to 
this  country  for  the  purpose  of  studying  radium 
treatment  of  malignant  diseases. 


Book  Reviews 


MARK  TWAIN  ANALYZED. 

The  Ordeal  of  Mark  Ttvaiit.  By  Van  Wyck  Brooks, 
Author  of  Letters  and  Leadership,  etc.  New  York :  E. 
P.  Button  &  Co.   Pp.  vii-267. 

Two  questions  force  themselves  upon  the  reader 
of  this  book.  How  many  countrymen  of  Mark 
Twain  would  subscribe  to  Brooks's  conviction  of 
the  beloved  writer's  failure  and  recognize  in  him  a 
pessimistic  sense  of  defeat  struggling  with  his  na- 
turally cheerful  nature?  This  presses  the  second 
question :  Who  among  us  would  be  roused  to  con- 
scientious selfexamination  to  see  if  he  too  had  fallen 
Mnder  the  spell  of  public  opinion  to  the  detriment 
of  creative  ability?  No  thoughtful  person  can  deny 
the  realization  of  a  manysidedness  in  the  attitude 
of  Mark  Twain,  the  acknowledged  humorist  of 
the  American  people,  which  discloses  traits  that  are 
not  those  of  the  satisfied  man.  When  his  life  and 
work  are  closely  studied  it  is  discovered  that  his 
uncertainty  of  attitude  is  apparent  not  only  in  the 
latter  years  of  life  that  suffered  many  external 
losses,  not  alone  at  times  of  financial  collapse.  It 
has  been  present  in  the  man  all  through  his  per- 
sonal career.  It  has  made  of  the  external  griefs, 
of  the  losses  and  successes  only  episodes  which 
represent  the  attitude  with  which  the  man  took  up 
his  life  and  work.  They  are  the  results  in  large 
part  at  least  of  his  confused  position  in  regard  to 
himself  and  the  world  about  him. 

There  is  something  that  puzzles  the  admirer  of 
Mark  Twain ;  something  that  detracts  from  the 
power  that  should  be  foimd  in  his  work.  One  who 
had  such  ability  to  win  the  attention  of  a  people,  to 
hold  and  extend  it  into  wider  circles  should  have 
left  many  a  stimulating  message.  There  were  times 
when  ]\Iark  Twain  stirred  his  readers  to  such  ex- 
pectation, there  were  writings  which  suggested  that 
the  contented  would  have  to  don  their  armor  of 
protective  convention.  Those  restless  for  advance 
almost  found  a  leader  in  him  but  the  promises  were 
little  fulfilled.  Instead  of  this  evidences  of  a  hin- 
dering of  his  vast  powers  are  found  in  his  writ- 
ings in  his  populace  winning  speeches  in  his  busi- 
ness ventures  in  his  successes  as  well  as  his  con- 
spicuous failures.  His  works  reveal  themselves  for 
the  most  part  as  only  a  vast  flood  of  effort  to 
please  to  satisfy  an  uncritical  public.  The  public 
to  which  he  catered  cared  more  for  its  fixed  con- 
ventions under  which  it  obtained  its  material  suc- 
cess and  maintained  its  established  literary  com- 
placencies than  to  be  roused  to  new  development. 

Brooks  shows  that  this  is  largely  the  result  of 
the  period  to  which  Mark  Twain  belonged,  the 
era  of  a  tremendous  effort  and  a  too  engulfing  type 
of  success.  Material  standards  were  those  of  the 
nation  and  individuals  bent  themselves  toward 
them.  Mark  Twain  and  his  associates  almost  for- 
got the  urgency  of  the  creative  instinct.  They 
overlooked  the  fact  that  it  represents  the  more  ur- 
gent need  of  the  individual  as  well  as  his  chief 
avenue  of  service  to  society.  But  no ;  Mark  Twain 
himself  did  not  entirely  forget.  Again  and  again 
he  gives  evidence  of  this.    In  the  reports  of  his 


bigrophers  as  well  as  through  the  often  uttered 
thought  in  his  own  writings,  in  his  letters,  wherever 
Mark  Twain  spoke,  this  man  of  such  apparent  suc- 
cess revealed  the  suffering  of  an  impaired  spirit. 
His  testimony  was  constantly  that  of  a  house  di- 
vided against  itself,  the  house  of  his  inner  soul. 
"You  observe  that  under  a  cheerful  exterior  I  have 
got  a  spirit  that  is  angry  with  me  and  gives  me 
freely  its  contempt."  This  he  writes  to  his  mother. 
It  is  to  her  that  Brooks  points  his  readers  to  wit- 
ness the  heavy  hand  of  pressure  laid  by  this  im- 
pressive woman  upon  the  child  soul.  Brooks  touches 
slightly  upon  the  elements  of  libido  fixation  which 
led  the  boy  to  accept  such  a  strong  limitation  by 
another  person.  He  tells  us  of  the  mother's  ca- 
pacity for  loving  which  her  husband  failed  to 
satisfy.  He  mentions  the  sensitive  boyhood  op- 
pressed by  the  boy  knew  not  what  sense  of  naughti- 
ness and  guilt.  At  any  rate  these  things  rendered 
him  so  impressionable,  so  heartbrokenly  sensitive  at 
his  father's  cofffn  that  he  permitted  the  signing  of 
himself  away  to  his  mother's  wishes.  He  sub- 
scribed to  the  fixed  conventionality  which  she  rep- 
resented and  stifled  the  freedom  to  create  and  to 
express  according  to  the  sincere  dictates  of  his 
own  nature.  His  later  life  throughout  his  varied 
career  was  a  successive  repetition  of  such  acknowl- 
edgment of  the  force  of  convention.  He  sub- 
mitted to  the  authority  of  money  or  of  accepted 
literary  taste.  He  was  a  life  long  victim  of  all 
.sorts  of  worshipped  statidards.  These  failed  to 
encourage,  they  actually  forbade  the  launching  of 
new  thoughts.  A  soul  inwardly  aware  of  its  own 
power  could  not  permit  itself  the  free  expression 
of  its  convictions  and  send  them  forth  as  regener- 
ating ideas. 

Such  are  the  secrets  of  Mark  Twain's  luirest  with 
himself  and  of  his  failure  in  vigorous  messages. 
His  artist's  spirit  had  been  turned  aside  from  its 
service  to  his  own  age  and  the  future.  He  himself 
valued  most  that  time  in  his  life  when  in  the  po- 
sition of  river  pilot  on  the  Mississippi  he  stood 
above  public  opinion  and  was  able  for  once  to  be 
himself.  Here  and  there  in  his  later  life  he  tried 
to  attain  again  this  freer  exercise  of  himself  but 
it  was  with  only  partial  success.  He  revealed  a 
pathetically  imdue  exaggeration  of  the  furor  that 
such  possible  free  expression  would  produce  about 
the  heads  of  his  descendants.  Great  he  was.  l)ut 
his  genius  never  dared  find  and  exercise  itself. 
Hence  its  flooding  in  many  directions  where  it 
stood  at  a  high  water  mark  but  never  flowed  on  to 
wear  new  channels.  He  dared  not  upheave  the  calm 
exterior  of  society.  Thus  he  could  do  little  to  ease 
the  pain  of  a  hindered  life.  He  dared  not  at- 
tack the  system  of  things  and  so  he  remained, 
Brooks  says,  "the  playboy  to  the  end.  divided  be- 
tween rage  and  pity,  cheerful  in  his  selfcontempt, 
an  illusionist  in  the  midst  of  his  disillusion."  In 
this  he  is  the  typical  American  unappreciative  of 
the  selfresponsble  soul  of  the  artist.  Thus  Brooks 
arraigns  America  itself  in  this  presentation  of  Mark 
Twain.    The  latter  was  partially  just  disturbingly 


August  21,  1920.] 


BOOK  REl'IEU'S. 


265 


aware  of  his  creative  spirit.  Too  many  of  his 
fellow  citizens  are  unaware  of  power  and  respon- 
sibility and  to  too  great  an  extent  this  is  true  of 
American  society  in  general.  This  w'ell  written 
study  therefore  of  this  national  literary  hero  is  a 
wholesome  stimulus  to  sober  selfconsideration  and 
national  testing,  as  regards  the  freedom  of  the 
creative  spirit  from  without  and  from  within. 

OR.\L  SURGERY. 

Oral  Surffcry.  A  Treatise  on  the  Diseases.  Injuries,  and 
Malformations  of  the  Mouth  and  Associated  Parts.  By 
Truman  W.  Brophv,  M.  D.,  D.  D  S.,  LL.  D.,  Sc.  D., 

F.  A.  C.  S.,  President,  and  Professor  of  Oral  Surgery, 
Chicago  College  of  Dental  Surgery;  Oral  Surgeon  to  St. 
Joseph's,  Michael  Reese,  and  Other  Chicago  Hospitals : 
Consulting  Oral  Surgeon  "to  the  Presbyterian  Hospital. 

.  With  Special  Chapters  by  M.\tthew  H.  Cryer,  M.  D.  ; 

G.  Hudson  Makuen,  M.  D.  ;  William  J.  Younger, 
M.  D.;  F.  W.  Belknap,  M.  D.  ;  Calvin  S.  Case,  M.  D., 
D.  D.  S.  With  Nine  Hundred  and  Nine  Illustrations,  In- 
cluding Thirty-nine  Plates  in  Colors.  Philadelphia:  P. 
Blakiston's  Son  &  Co.,  1918.    Pp.  xvi-1090. 

The  history  of  oral  surgery  as  a  specialized 
J)ranch  of  medicine  and  as  the  first  specialty  of 
dentistry  is  comparatively  short  and  dates  back  to 
the  influence  of  James  Edmund  Garrettson,  who 
at  the  height  of  his  career  about  seventy  years  ago 
commanded  the  attention  of  the  world  with  his 
very  important  work  in  surgery  of  the  mouth.  Al- 
though the  care  in  avoiding  mutilation  of  the  ex- 
ternal features  while  performing  intraoral  opera- 
tions emanates  from  Garrettson  there  is  today  a 
great  deal  of  mutilation  produced  by  members  of 
the  medical  profession,  who  find  it  a  much  simpler 
.technic  to  lift  away  the  cheek  for  the  removal  of 
the  superior  maxilla  than  to  work  through  the  nat- 
.ural  opening. 

Truman  \X.  Brophy  received  his  early  training 
from  Dr.  Garrettson,  whose  influence  is  imme- 
•diately  shown  in  the  preface  of  his  book  when  he 
says  that  the  important  principle  to  be  observed  is 
to  operate  so  that  the  parts  will  be  left  in  as  nearly 
.a  normal  anatomical  condition  as  possible.  That 
of  course  is  an  underlying  principle  of  general 
surgery,  but  in  no  branch  of  the  work  is  the  exe- 
♦cution  of  this  principle  as  vital  as  in  surgery  of  the 
mouth  and  the  surrounding  parts. 

Most  important  in  the  crowded  material  of  over 
'900  pages  is  the  original  contribution  of  Brophy's 
on  the  cleft  palate.  There  are  few  more  ugly  con- 
•ditions  than  the  congenital  condition  of  the  harelip 
and  cleft  palate,  regarding  which  there  has  been  so 
little  understanding.  To  definitely  establish  the 
truth  about  the  cleft,  which  had  long  been  regarded 
as  a  condition  of  atrophy,  was  the  first  move.  "A 
cleft  palate,"  says  Dr.  Brophy,  "is  a  fissure,  a  sep- 
aration of  well  developed  parts,  not  the  result  of 
arrested  development  nor  failure  of  the  normal 
quantity  of  tissue  to  enter  into  its  structure."  Upon 
the  recognition  of  that  fact,  Dr.  Brophy  attempted 
to  bring  the  parts  of  the  superior  maxilla  together 
under  pressure.  The  complete  success  of  the  op- 
eration depends  entirely  upon  the  age  of  the  patient 
at  the  time  of  operation,  the  first  three  months  of 
life  being  the  most  favorable  period.  The  opera- 
tion today  is  generally  used.    It  was  for  a  long  time 


contended  that  speech,  the  mechanism  of  which  is 
largely  dependant  upon  the  palate,  would  not  be 
rectified,  and  that  an  obturator  would  have  to  be 
employed  but  time  and  the  results  of  the  operation 
have  since  disproved  the  belief  of  the  skeptics.  The 
technic  of  the  operation  with  its  many  variations 
is  carefully  outlined  and  aided  by  the  many  photo- 
graphic representations. 

IMuch  more  can  be  said  about  the  remaining  ma- 
terial, the  first  part  of  which  concerns  itself  with 
a  consideration  of  the  general  conditions  of  surgery 
and  the  second  half  with  those  of  the  buccal  cavity 
and  the  surrounding  parts — material  that  Dr.  Brophy 
began  to  collect  in  1886  and  which  he  did  not  pub- 
lish until  1915,  replete  with  data  and  photographic 
and  diagrammatic  representations  to  help  the  student 
and  the  practitioner  to  a  better  imderstanding  of 
the  subject.  Since  1915  six  editions  of  the  book 
have  been  published ;  the  seventh  is  now  being  issued. 

MODERN  ADVENTURE. 

Hills  of  Hail.    By  Samuel  Merwix.    Illustrated.  Indian- 
apolis :  The  Bobbs-Merrill  Company.    Pp.  i-365. 

Mr.  Merwin  has  done  a  thing  which  we  have 
always  maintained  there  was  no  reason  for  not 
doing — he  has  compounded  a  thrilling  adventure 
story  out  of  persons  and  situations  which  do  not 
strain  anyone's  credulity.  He  has  done  even  more, 
for  there  is  some  shrewd  psychology  in  the  depic- 
tion of  his  characters.  It  is,  however,  not  a  book 
which  the  missionaries  will  care  to  read,  for  one  of 
its  chief  figures  is  a  missionary,  and  one  of  its 
author's  preoccupations  is  with  showing  how  the 
rigor  of  a  missionary  compound  denies  fundamental 
human  needs — joy,  spontaneity,  colorful  expression. 

This  book  is  interesting  as  showing  w-hat  can  be 
done  by  a  writer  who  does  not  actually  shut  his 
eyes  and  ears  to  what  is  going  on  in  the  world.  As 
a  tale  of  adventure  Hills  of  Han  is  full  of  exciting 
incidents,  mostly  violent — the  revolt  of  the  Chinese 
against  foreign  capital,  leading  to  attacks  on  all 
foreigners ;  the  heroics  of  the  rebel  student  Li 
Hsien ;  the  creeping  by  night  through  mysterious 
dangers ;  the  fighting  about  Ping  Yang ;  the  back- 
ground of  political  intrigue,  and  the  teeming  life 
of  the  Orient.  In  addition,  however,  Mr.  Merwin 
has  given  us  several  characters  who  denote  struggle. 
There  is  Griggsby  Doane  who,  after  years  of  mili- 
tant faith  as  a  missionary,  finds  that  at  forty-five  he 
is  full  of  energy  and  in  the  wrong  work,  and  whose 
bitter  struggle  against  doubt  ends  in  his  deciding 
to  begin  over  again  in  a  primitive,  satisfying  exist- 
ence as  a  common  workman.  On  the  other  hand 
there  is  Jonathan  Brachey,  the  journalist  who,  em- 
bittered by  an  unhappy  marriage,  tries  to  solace  him- 
self with  solitude  and  Nietzschean  self  sufficiency. 
He,  too,  finds  after  he  has  met  Betty  Doane,  Griggs- 
by's  daughter,  that  he  has  to  start  afresh.  There  is 
Betty  herself,  an  aflfectionate,  impulsive,  artistic 
temperament,  among  people  who  associate  joy  with 
vice.  The  psychological — and  in  one  place  physical 
— struggle  between  Doane  and  Brachey  is  quite  as 
exciting  as  the  shooting  up  of  the  missionaries. 

One  thing  more  Mr.  Merwin  has  done.  He  has 
caught  something  of  the  ancient  wisdom  and  the 
new  turbulence  of  China ;  there  is  a  rumbling  pro- 


266 


BOOK  REVIEWS. 


[New  York 
Medical  Journal 


phecy  of  the  student  revolt  to  come,  of  the  begin- 
nings in  China  of  the  class  warfare  that  today  is 
encircling  the  globe.  A  very  modern  adventurer, 
Mr.  Merwin.  He  seems  to  have  read  Freud,  and 
he  probably  has  read  something  about  the  class 
struggle.  So  many  writers  of  thrilling  fiction  re- 
fuse to  know  anything  about  either. 

MYSTERY. 

The  Paradise  Myslerv.    By  J.  S.  Fletcher.    Xew  York : 
Alfred  A.  Knopf,  "l920.    Pp.  ix-306. 

In  these  days,  when  a  doctor  can  be  condemned 
for  culpable  negligence  or  exonerated  by  a  learned 
j'ury  numbering  the  butcher,  baker  and  artisan,  it  is 
refreshing  to  read  of  one  accused  of  murdering  a 
man,  poisoning  another  and  betraying  a  friend, 
calmly  going  on  with  his  work  with  the  hot  breath 
of  slander  full  on  him,  and  his  former  associate 
unkindly  running  all  over  the  country  to  prove  him 
guilty.  Certainly  the  poisoned  man  died  of  hydro- 
cyanic; acid  poisoning ;  certainly  the  hero  —  Dr. 
Ransford — had  given  him  some  digestive  pills,  but 
he  had  died  immediately,  whereas  a  fellow  practi- 
tioner explains  that,  as  the  pills  were  sugar  coated, 
they  could  not  take  effect  instantly.  (Science  usu- 
ally appears  as  the  guardian  angel  in  mystery 
stories.)  In  the  end  an  aged  citizen  who  is  highly 
esteemed  is  proved  the  murderer,  but  he  is  so  angry 
with  the  treacherous  associate,  thinking  he  has  be- 
trayed him  to  the  police  that  he  shoots  him  dead  and 
poisons  himself — no  sugar  coating  this  time — leaving 
nothing  for  the  police  to  do  but  rush  away  for  Dr. 
Ransford  to  come  and  say  the  men  are  dead.  Not 
a  difficult  task,  nor  was  that  of  reinstating  himself 
in  the  neighborhood's  esteem  any  harder.  The 
story  is  well  told,  because  the  mystery  is  kept  up 
right  to  the  end. 

THE  ORIENT. 

Civilization.  Tales  of  the  Orient.  By  Ellen  N.  La  Motte. 
New  York:  George  H.  Doran  Company,  1919.  Pp.  231. 

Tuberculosis  is  an  insidious,  often  an  unrecog- 
nizable disease,  and  many  years  of  Miss  La  Motte's 
life  were  spent  in  directing  national  efforts  to  fight 
it,  and  the  habit  of  thoughtful  consideration  of  an 
evil  cannot  be  suddenly  broken  nor  small  indica- 
tions— negligible  to  the  laitj- — be  ignored.  So  it 
came  about  that  when  working  in  the  French  War 
hospitals,  when  traveling  in  Japan  she  saw,  under- 
neath the  pomp  and  glory  of  war,  underneath  the 
picturesqueness  of  the  East,  much  that  was  reme- 
diable especially  in  military  camps  and  the  evils  of 
the  opium  trade,  therefore  much  to  be  not  only 
deplored,  but  exposed  to  the  sterilizing  light  of 
publicity. 

In  the  book  giving  tales  of  the  Orient  she  is,  in  re- 
ality, attacking  a  morbid  condition,  which  with  grim 
sarcasm,  she  calls  civilization.  The  stories  she  tells 
are  good,  not  a  few  bare  facts  with  scenery  spread 
over  to  hold  them  together.  Canterbury  Chimes 
and  Homesick  are  especially  good,  but  the  under- 
tone in  all  asks  What  has  civilization  done  to  place 
the  peoples  of  the  Orient  on  a  higher  level  and 
induce  that  sympathy  and  understanding  too  long 
withheld  by  the  Western  world? 


New  Publications  Received. 


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


THE  life  of  ROBERT  owEX.  By  HiMSELF.  With  ail  Intro- 
duction by  M.  Beer,  Author  of  A  History  of  British  So- 
cialism.   New  York:  Alfred  A.  Knopf,  1920.    Pp.  xiii-352. 

GOTTFRIED  KELLER.  Psychoanalyse  des  Dichters  Seiner 
Gestalten  und  Motive.  Von  Dr.  Eduard  Hxtschmaxn. 
W'icn  :  Internationaler  Psvchoanalytischer  \'erlag,  G.  M.  B 
H.,  1919.  Pp.  vii-125. 

YOUTH  AND  ECOL.A.TRV.  Bv  Pio  B.\RojA.  Translated  from 
the  Spanish  by  Jacob  S.  Fassett,  Jr.,  and  Frances  L. 
Phillips.  Edited,  with  Introduction,  by  H.  L.  Mencken. 
New  York :  Alfred  A.  Knopf,  1920.    Pp.  v-265. 

columbi.\  university  bulletin  OF  INFORMATION.  An- 
nual Report  of  the  President  and  Treasurer  to  the  Trustees 
with  Accompanying  Documents  for  the  Year  Ending,  June 
30,  1919.    Illustrated.    New  York,  1920.    Pp.  v-499. 

electric  ionization,  a  Practical  Introduction  to  Its 
Use  in  Medicine  and  Surgerj'.  By  A.  R.  Friel,  M.  A , 
M.  D.  (Dub.),  F.  R.  C.  S.  I.,  Aural  Specialist,  Ministry  of 
Pensions,  London  District,  etc.  Illustrated.  New  York : 
\\'illiam  Wood  &  Co.,  1920.   Pp.  ix-78. 

the  new  physiology  in  surgical  and  general  practice. 
By  A.  Rendle  Short,  M.  D.,  B.  S.,  B.  Sc.  (Lond.), 
F.  R.  C.  S.  (Eng.)  ;  Examiner  in  Physiology-  for  the 
F.  R.  C.  S.,  etc.  Fourth  Edition,  Revised  and  Enlarged. 
Illustrated.  New  York:  William  Wood  &  Co..  1920.  Pp. 
xi-291. 

diagnostischer  leitfaden  fur  sekret-und  blutunter- 
sucHUNGE^.  (Theoretisches  und  Praktisches.)  Von  Dr. 
C.  S.  Engel,  Sanitatsrat,  Arzt  und  Laboratoriumsleiter  in 
Berlin.  Mit  144  Abbildungen  •  und  1  farbigen  Tafel. 
Zweite,  vollig  umgearbeitete  Auflage.  Leipzig :  \"erlag  von 
George  Thieme,  1920.    Pp.  xv-303. 

THE    DUODEXAL    TUBE    AXD    ITS    POSSIBILITIES.      By  Max 

Eixhorx,  'M.  D.  ;  Professor  of  Medicine  at  the  New  York 
Postgraduate  Medical  School ;  Visiting  Physician  to  the 
Lenox  Hill  Hospital,  New  York.  Illustrated.  Philadel- 
phia and  London :  W.  B.  Saunders  Company,  1920.  Pp. 
xiii-122. 

HEART  TROUBLES  :  THEIR  PREVENTION  AND  REUEF.    By  LoUIS 

Faugeres  Bishop,  M.  A.,  M.  D.,  Sc.  D.,  F.  A.  C.  P.,  Pro- 
fessor of  the  Heart  and  Circulatory  Diseases,  Fordham  Uni- 
versity School  of  Medicine,  New  York ;  President  of  the 
Good  Samaritan  Dispensary ;  Physician  to  the  Lincoln 
Hospital,  etc.  Illustrated.  New  York  and  London :  Funk 
&  Wagnalls  Company,  1920.    Pp.  xvi-422. 

AN  index  of  SYMPTOMS.  With  Diagnostic  Methods.  By 
Ralph  Winnington  Leftwich,  M.  C,  Late  Assistant 
Physician  to  the  East  London  Children's  Hospital ;  Author 
of  Tabular  Diagnosis,  etc.  Seventh  Edition,  Revised  by 
H.  N.  Warner  Collins,  B.  Sc.,  M.  R.  C.  S.,  L.  R.  C.  P., 
Radiographer  to  the  Putney  and  Chiswick  Hospitals ; 
Deputv'  Radiographer  to  the  Evelina  Hospital.  New  York : 
William  Wood  &  Co.,  1920.    Pp.  xii-595. 

LEHRBUCH  DER  VOLKSERNAHRUNG  NACH  DEM  piRQwex'- 
SCHEN   SYSTEM.     BeARBEITET  VON  J.  HeUSSLER,  E.  MaYER- 

HOFER,  Frau  R.  Miari,  E.  Nobel,  Er.  Oberleitner,  Cl. 
PiRQUET,  R.  ScHNEEWEis,  R.  Wagner.  Herausgegeben 
von  Priv.  Doz.  Dr.  E.  Mayerhofer,  Assistant  der  Univer- 
sitats-Kinderklinik ;  und  Prof.  Dr.  C.  Pirquet,  Vorstand 
der  Universitats-Kinderklinik  in  Wien.  Mit  32  Abbildun- 
gen im  Texte.  Wien  und  Berlin :  Urban  &  Schwarzen- 
berg,  1920.    Pp.  vi.-299. 

dementia  praecox  AND  PAR.\PHRENiA.  By  Professor 
Emil  Kraepelin,  of  Munich.  Translated  by  R.  Mary 
Barclay,  M.  A.,  M.  B.,  from  the  Eighth  German  Edition 
of  the  Textbook  of  Psychiatry,  vol.  iii.  Part  II.,  section  on 
the  Endogenous  Dementias.  Edited  by  George  M.  Robert- 
son, M.D.,  F.  R.  C.  P.  (Edin.),  Lecturer  on  Mental  Dis- 
eases in  the  University  of  Edinburgh  and  Physician  to  the 
Royal  Asylum,  Morningside.  Illustrated.  Edinburgh: 
E.  &  S.  Livingstone,  1919.    Pp.  x-331. 


Practical  Therapeutics  and  Preventive  Medicine 

A  Compendium  of  Treatment  and  Prophylaxis,  Original  and  Adapted 


THE  TREATMENT  OF  SURGICAL  SHOCK. 

By  Joseph  W.  Walsh,  M.  S.,  M.  D., 
Brooklyn,  X.  Y. 

The  condition  of  shock  was  known  to  the  an- 
cients, but  the  term  shock  was  introduced  in  1795 
by  James  Latta  to "  designate  the  condition  follow- 
ing severe  injury.  Shock  is  really  a  general  de- 
pression of  the  vital  powers,  the  result  of  an  injury 
or  profound  emotion.  It  may  be  slight  or  transient 
or  severe  and  prolonged.  It  is  usually  sudden  in 
onset,  but  may  come  on  gradually,  and  possibly 
may  produce  almost  instant  death.  There  are 
many  theories  as  to  the  cause  and  nature  of  shock, 
none  of  which  is  entirely  satisfactory.  I  shall, 
however,  discuss  only  its  treatment. 

There  are  various  forms  of  shock  and  some 
cases  call  for  special  methods  of  treatment.  We 
have  apathetic  shock,  also  delayed  shock  which 
comes  on  several  hours  after  an  injury  or  a  vioknt 
emotional  disturbance.  This  latter  form  is  often 
seen  in  people  who  have  passed  through  a  railroad 
accident.  It  is  often  the  sign  of  a  concealed  hem- 
orrhage and  is  sometimes  encoimtered  after  the  ad- 
ministration of  ether  or  chloroform.  Erethistic  or 
delirious  shock  is  said  to  exist  but  I  do  not  believe 
the  condition  is  true  shock,  but  rather  a  traumatic 
or  toxic  delirium  added  to  or  following  shock. 
There  are  also  shock  from  bullet  wounds,  shock  in 
anesthesia,  local  shock  peculiar  to  gunshot 
woimds.  shock  during  operation,  shell  shock  and 
war  shock.  The  treatment  in  all  these  forms  is 
not  identical. 

In  treating  ordinary  apathetic  shock,  raise  the 
feet  and  lower  the.  head,  unless  cyanosis  is  caused 
by  such  position.  The  head  should  be  lowered 
and  the  body  recumbent,  maintain  body  heat, 
wrap  the  patient  in  hot  blankets,  surroimd  him 
with  hot  bottles,  hot  bricks  or  hot  water  bags :  al- 
ways have  your  bottle,  bag  or  brick  wrapped  in 
some  material  such  as  flannel,  to  avoid  burning 
the  patient.  Stimulants  are  of  little  value,  when 
given  by  stomach.  They  are  not  absorbed.  Nor- 
mal salt  solution  should  be  infused  into  a  vein, 
if  the  blood  pressure  is  below  eighty.  If  the  blood 
pressure  is  higher  give  the  solution  by  rectum  or 
subcutaneously.  Intravenous  infusion  is  beneficial 
in  hemorrhage.  The  infusion  may  be  mixed  with 
adrenalin  chloride:  one  teaspoonful  of  the  1-1,000 
solution  of  the  adrenalin  chlorid  is  added  to  one 
litre  of  the  salt  solution,  one  half  to  two  pints 
being  given  at  a  temperature  of  105°  F.  or  over 
as  it  enters  the  vein.  This  degree  of  heat  will  not 
damage  the  corpuscles.  If  salt  solution  is  given 
too  rapidly  or  in  too  great  a  quantity  it  may 
gather  in  the  chambers  of  the  right  heart  and 
arrest  a  heart  already  weakened.  It  has  been 
stated  that  the  best  way  to  use  adrenalin  in  severe 
shock  is  by  Crile's  method,  to  introduce  it  into 
the  arterial  system  and  toward  the  heart.  Occa- 
sionally resuscitation  from  apparent  death  may  be 


accomplished  by  this  means.    The  technic  by  this 
method  is  as  follows :     Place  the  patient  in  the 
prone  position.    He  is  then  subjected  at  once  to 
rapid,  rh\-thmic  pressure  upon  the  chest  on  each 
side  of  the  sternum.    This  pressure  produces  ar- 
tificial respiration  and  a  moderate  amount  or  de- 
gree of  artificial  circulation.     A  cannula  is  then 
inserted  in  the  direction  of  the  heart  into  an  ar- 
tery.   Normal  salt.  Ringer's,  or  Lock's  solution  or 
in  their  absence  sterile  water  or  in  the  greatest 
extremity  tap  water  is  infused  by  means  of  a  fun- 
nel and  rubber  tubing.    As  soon  as  the  flow  has 
begtm,   the   rubber   tubing   near   the   cannula  is 
pierced  with  the  needle  of  the  hypodermatic  sy- 
ringe with  1-1,000  adrenalin  chloride  solution  and 
fifteen  to  thirty  minims  are  injected.  Repeat  this 
injection  in  a  minute  if  needed.  Synchronously 
with  the  injection  of  the  adrenalin  the  rh}thmic 
pressure  upon  the  thorax  is  increased.    The  result 
is  an  artificial  circulation  distributing  the  adrenalin. 
This  causes  a  stimulating  contact  with  the  arteries, 
bringing   a   wave   of   powerful   contractions  and 
producing  a  rising  arterial  and  consequently  cor- 
onary   pressure.    When    the    coronary  pressure 
rises    to    forty    m.    m.    or    more,    the  heart 
is  likely  to  resume  action.     The  first  result  of 
this  action  is  to  spread   still   further  the  blood 
pressure  raising  adrenalin  causing  a  further  rise 
in  blood  pressure.     Such  pressure  favors  tissue 
resuscitation    especially    of    the    central  nervous 
system.    When  the  heart  beat  is  well  established 
withdraw  the  cannula  because  there  is  no  longer 
need  for  it.    L'nless  there  has  been  hemorrhage, 
the  only  reason  for  using  saline  infusion  is  to 
introduce   adrenalin    into   the   circulation  toward 
the  heart.    Bandaging  the  abdomen  and  extremi- 
ties tightly  over  masses  of  cotton  is  an  excellent 
addition  to  this  treatment.    In  prolonged  shock 
and    shock    accompanied    by    hemorrhage,  direct 
transfusion    of    blood    is    indicated.     Hot  and 
stimulating  rectal  enemata  are  important  agents 
of  treatment  also.    Enemata  of  hot  coffee  or  hot 
nomial    salt    solution    are    beneficial.    In  giving 
such  enemata  carry  the  tube  as  high  as  possible 
and  inject  so  as  to  distend  the  colon.  Another 
effective  method  of  treatment  is  hypodermoclysis 
of  normal  salt  solution  into  the  cellular  tissue  of 
the  loin,  scapular  region  or  under  the  breast  after 
thorough  disinfection  of  the  point  of  injection 
with  iodine.    The  syringe  holding  the  salt  solution 
being  two  or  three  feet  above  the  bed,  a  pint  or 
more  of  the  solution  will  be  absorbed  in  an  hour's 
time.     Strychnine,  hypodermatically.  is  of  doubt- 
ful value  in  collapse,  in  fact  it  may  be  harmful 
by  increasing  the  heart  action  when  the  heart  has 
not  enough  blood  passing  into  it  to  enable  it  to 
contract  firmly  and  strongly.    Atropine  is  bene- 
ficial in  shock,  especially  if  the  skin  is  moist.  This 
drug  acts  upon  the  vasomotor  system,  combats 
vascular  dilatation,  maintains  vascular  tone,  op- 
poses blood  stagnation  and  increases  the  amount 


268  PRACTICAL   THERAPEUTICS  AXD  PREVENTIVE  MEDICINE.  [New  York 

Medical  Journal 


of  moving  blood.  Senn  recommended  a  hy- 
podermatic syringeful  of  sterile  campliorated  oil 
every  fifteen  minutes  imtil  reaction  begins.  In- 
halation of  oxygen  frequently  serves  well  and 
artificial  respiration  may  be  necessary. 

Opiates  are  contraindicated  in  shock.  Mustard 
plasters  over  the  heart,  spine  and  shins  are  used. 
A  turpentine  enema  is  useful.  Pituitrin  is  valu- 
able to  restore  blood  pressure.  Intramuscular 
pituitrin  injections  in  ten  to  thirty  minim  doses 
or  intravenously  in  saline  solution  are  often  given. 
In  severe  cases  of  shock  bandage  the  extremities. 
Bandaging  for  the  relief  of  shock  is  called  auto- 
transfusion  and  causes  an  increased  peripheral 
resistance,  enabling  the  body  to  utilize  to  the  best 
advantage  the  small  amount  of  circulating  blood, 
sending  most  of  it  to  the  brain,  where  it  will 
activate  the  vital  centres  and  maintain  respiration 
and  circulation.  It  is  well  to  massage  the  abdo- 
men also  and  drive  out  the  blood  imprisoned  in 
the  splanchnic  area,  after  which  a  compress  and 
binder  are  applied  to  prevent  a  quick  return  of 
the  intraabdominal  circulation.  With  very  low 
blood  pressure  and  continued  bleeding  immediate 
transfusion  of  blood  is  imperative.  Artificial 
respiration  and  stimulation  of  the  diaphragm  may 
be  used  with  good  effect.  When  death  without 
prompt  operation  is  certain  it  is  proper  to  oper- 
ate during  shock,  the  shock  itself  being  treated 
vigorously  by  assistants  not  concerned  in  the  op- 
eration. 

Treat  delayed  shock  as  you  do  apathetic  shock 
if  hemorrhage,  sepsis  and  fat  embolism  are  ex- 
cluded. If  hemorrhage  exists,  arrest  the  bleed- 
ing and  give  a  blood  transfusion  or  a  saline  in- 
fusion into  the  vein,  using  adrenalin  as  in  apa- 
thetic shock  if  the  hemorrhage  is  firmly  checked. 
In  delirious  shock  due  to  sepsis  the  treatment  is 
that  of  the  sepsis  or  if  due  to  uremia,  the  other 
most  common  cause  for  the  socalled  delirious 
shock,  the  treatment  is  the  same  as  for  uremia. 
Shock  from  bullet  wounds  may  result  from  deep- 
ly concealed  hemorrhages  and  calls  for  treatment. 

Local  shock  from  gimshot  wounds  relates  to 
the  devitalization  of  the  tissues  in  the  immediate 
vicinity  of  the  wounds  and  the  treatment  of  this 
condition  is  to  rest  in  asepsis :  it  is  further  stated 
that  "antiseptics  will  tend  to  maintain  this  state  of 
lowered  vitality  and  to  favor  microbic  attack,"  (1). 
The  hypertonic  saline  treatment.  Sir  Almroth 
Wright's  method  in  gunshot  wounds,  has  many  ad- 
vocates, while  some  consider  it  inefiicient.  For  irri- 
gation or  immersion  a  five  per  cent,  solution  of 
sodium  chloride,  in  extremely  septic  cases  a  ten  per 
cent,  solution  is  used  and  when  the  woimd  becomes 
clean  normal  salt  solution  is  substituted.  In  a 
short  time  this  is  abandoned  and  the  wound  is 
then  merely  dressed  with  gauze  moistened  in 
normal  saline  solution.  Free  drainage  and  removal 
of  foreign  matter,  destroyed  tissue  and  blood 
clots  are  necessary.  Shock  in  anesthesia  is 
treated  by  diminishing  the  amount  of  the  anes- 
thetic. Atropine  is  given  hypodermically,  espe- 
cially when  there  is  a  profuse  perspiration.  Hot 
saline  by  rectum,  heat  to  the  body  and  lowering 
the  head  of  the  bed  are  all  important  in  treat- 


ing shock  of  anesthesia.     The  syncope  of  this 
condition  is  caused  by  a  sudden  cerebral  anemia 
and  calls  for  lowering  the  head  and  giving  a  hy- 
podermic injection  of  strychnine.  In  extreme  syn- 
cope, more  likely  to  occur  from  chloroform,  sus- 
pend the  anesthetic  entirely,  lower  the  head,  open 
the  mouth  with  a  gag,  catch  the  tongue  and  make 
rhythmic   traction   while   an   assistant   is  making 
slow  artificial  respiration.     If  no  improvement  is 
noted  invert  the  patient  completely,  holding  him 
by  the  legs,  and  continue  artificial  respiration  by 
compressing   the    sternum    (Xelaton).  Atropine, 
ether  or  ammonia  by  hypodermic  injection,  also 
mustard  to  the  heart  and  spine,  and  faradism  to 
the  phrenic  nerve  are  recommended.     Fresh  air 
should  be  admitted  into .  the  room.    In  some  cases 
of   anesthetic   poisoning   direct    massage    of  the 
heart  has  been  successfully  employed.    This  was 
first    suggested   by    Schliff    in    1874.  Hysteria 
found  in  men  at  the  front  is  called  war  hysteria 
or  war  shock.    Many  writers  have  called  it  shell 
shock,  a  wrong  term  because  this  implies  a  shock 
due  to  shell  explosions,  an  incorrect  idea.    Yet  an 
explosion  may  cause  a  ruptured  ear  dnmi  and 
bleeding  from  the  ear.    From  war  shock  or  shell 
shock    temporary    conditions    such    as  deafness, 
blindness,   dumbness,   convulsions,    forms   of  pa- 
ralysis, states  not  unlike  cerebral  concussion,  symp- 
toms of  neuritis,  zones   of  anesthesia,  muscular 
contractures,  delirium,  mania,  tremor  and  spinal 
conditions  may  arise.    War  shock  or  shell  shock 
should  be  treated  by  a  neurologist,  not  by  a  sur- 
geon. 

REFERENXE. 

1.    Hull,  Alfred  J. :  Surgery  of  War. 

698  St.  Marks  Avenue. 


Early  Surgical  Intervention  in  Severe  Sprain 
of  the  Knee. — Leriche  and  Santy  {Lyon  medical, 
April  25,   1920)   maintain  that  in  certain  severe 
sprains  of  the  knee,  with  some  degree  of  dislocation 
due  to  complete  tearing  of  the  infrapatellar  fibrofas- 
cial  tissues  or  with  loosening  of  the  crucial  ligaments, 
it  is  well  to  intervene  surgically  as  soon  as  possi- 
ble in  order  to  repair  the  tissues  before  definite 
retraction  has  set  in.     In  a  recent  case,  arising 
through  a  tramway  accident,  there  was  complete 
dislocation  and  flaillike  condition  of  the  knee  ioint, 
together  with  contusion  of  the  abdomen  and  injury 
to  the  scrotum.     Two  hours  after  the  accident, 
the  abdomen  having  been  opened  and  found  nega- 
tive, and  the  scrotal  wound  excised  and  sutured, 
a  U  shaped  arthrotomy  of  the  knee  was  performed 
and  a  piece  of  contused  skin  of  the  size  of  the  palm 
of  the  hand  removed.    The  torn  infrapatellar  ten- 
don was  trimmed  with  scissors,  and  likewise  a 
large  tear  in  the  lateral  fascial  tissues.    The  free, 
torn  portions  of  the  crucial  ligaments,  the  loosened 
cartilages,  and  bone  fragments  from  the  tibia  were 
removed,  and  the  synovial  membrane,  capsule  and 
infrapatellar  tendon  returned.    Three  days  later  a 
few  additional  sutures  were  placed  in  the  tendons 
and  the  skin  wound  closed.    The  patient  recovered 
with  a  firm  knee  joint,  without  dislocation.  Ten 
weeks  after  operation  the  patient  walked  about. 


New  York  Medical  Journal 


INCORPORATING  THE 


Philadelphia  Medical  Journal  the  Medical  News 

A  Weekly  Review  of  Medicine,  Established  18Jt.3. 


Vol.  CXII,  No.  9. 


NEW  YORK.  SATURDAY.  AUGUST  28,  1920. 


Whole  No.  2178. 


Original  Communications 


ON  THE  USE  OF  BENZYL  BENZOATE  IN 
SOME  CIRCULATORY  CONDITIONS  * 

By  D.  I.  Macht,  M.  D., 
Baltimore,  Md. 

In  a  communication  presented  in  February,  1918, 
before  the  Society  for  Experimental  Biology  and 
Medicine,  I  described  my  work  on  the  relationship 
of  the  chemical  structure  of  some  opium  alkaloids 
to  their  effect  on  smooth  muscle  and  the  discovery 
of  a  new  therapeutic  agent,  benzyl  benzoate,  as  a 
consequence  thereof  (1).  I  showed  that  the  pecu- 
liar and  interesting  effects  of  the  opium  alkaloid, 
papaverin,  on  the  tonus  and  contractions  of  smooth 
muscle  must  be  ascribed  to  the  benzyl  portion  of 
its  molecule  and  that  the  same  effects,  pharmacolog- 
ical and  therapeutic,  can  be  produced  by  the  use  of 
a  simple  benzyl  ester.  A  complete  pharmacological 
and  therapeutic  study  on  the  subject  was  published 
(2).  The  conditions  in  which  the  benzyl  effect  was 
anticipated  to  produce  therapeutic  results,  and  in 
which  such  results  were  actually  obtained  by  subse- 
quent clinical  trials,  were  those  exhibiting  either 
excessive  peristalsis  or  excessive  spasm  of  plain 
muscle  viscera.  Among  such  conditions  were  men- 
tioned the  following :  Excessive  peristalsis  and 
colic  of  the  intestines,  as,  for  instance,  in  diar- 
rhea and  dysentery ;  spasm  or  colic  of  ureteral  mus- 
cle, or  renal  colic ;  spasmodic  contractions  of  the 
gallbladder,  or  biliary  colic ;  spasmodic  contractions 
of  the  uterus,  or  uterine  colic ;  spasmodic  con- 
tractions of  the  urinarv-  bladder ;  spastic  consti- 
pation, due  to  powerful  tonic  contraction  of  the  in- 
testine ;  pylorospasm ;  bronchial  spasm,  and  arterial 
spasm. 

I  am  happy  to  state  that  during  the  two  and  a 
half  or  more  years  since  the  first  announcement  of 
this  work,  I  have  gathered  a  large  amount  of  ad- 
ditional pharmacological  and  clinical  data  concern- 
ing benzyl  benzoate  and  that  all  my  original  obser- 
vations have  been  fully  confirmed  and  the  therapeu- 
tic results  obtained  have  more  than  corroborated  my 
most  sanguine  expectations.  In  the  present  paper 
I  wish  to  call  attention  to  a  therapeutic  use  of 
benzyl  benzoate  which  I  have  already  described,  but 
which  is  not  so  well  known  as  yet  to  the  general 
practitioner,  namely,  its  employment  in  the  treat- 
ment of  certain  circulatory  conditions. 

'From  the  Pharmacological  Laboratory  of  the  Johns  Hopkins 
University. 


PHARMACOLOGICAL  DATA 

The  action  of  benzyl  benzoate  on  circulation  has 
already  been  described.  The  most  striking  effect 
of  the  drug  is  exerted  upon  the  vascular  system. 
After  injections  of  benzyl  esters,  a  fall  in  blood 
pressure  is  noted  which  can  be  shown  to  be  due 
to  a  peripheral  vasodilatation,  the  fall  being  a  re- 
sult of  the  depressor  action  of  the  drug  on  the 
smooth  muscle  cells  of  the  arterial  walls.  The 
effect  on  the  vasomotor  centre  after  ordinary  doses 
is  negligible  and  unimportant.  The  effect  upon 
the  heart  itself,  after  small  doses  of  ben?yl  ben- 
zoate, is  negative;  so  that  after  injections  of  the 
drug  there  is  a  marked  fall  in  blood  pressure  with- 
out any  depressant  effect  upon  the  heart  muscle 
itself.  Such  an  action  is  well  illustrated  by  the 
subjoined  curve,  which  shows  the  effect  of  an  in- 
travenous injection  of  benzyl  benzoate  in  the  form 
of  an  emulsion  in  a  dog  (Fig.  1).  It  will  be 
noted  that  while  the  pressure  had  fallen  the  respir- 
ation and  the  heart  beat  were  not  at  all  impaired. 
Furthermore,  it  is  interesting  to  note  the  long  dur- 
ation of  the  fall  in  blood  pressure,  with  the  gradual 
recovery  to  normal.  Even  an  injection  of  a  small 
dose  of  epinephrine  was  not  completely  effective  in 
bringing  the  pressure  level  back  to  normal.  All  that 
adrenalin  did  was  to  cause  an  immediate  sharp  rise 
in  the  blood  pressure,  which  then  fell  again  and 
only  gradually  rose  to  the  original  level  as  the  benzyl 
effect  wore  out.  Even  toxic  doses  of  benzyl  ben- 
zoate have  been  found  by  me  to  produce  little  effect 
upon  the  heart,  a  fatal  dose  killing  the  animal 
through  paralysis  of  the  medulla,  and  not  of  the 
heart. 

THERAPEUTIC  INDICATIONS. 

In  view  of  the  marked  vasodilator  properties  of 
benzyl  benzoate,  .a  therapeutic  application  of  the 
drug  naturally  suggested  itself.  The  indication  for 
its  administration  was  obviously  a  spastic  contrac- 
tion of  the  arteries,  or  angiospasm ;  and  the  drug 
was  given  to  patients  exhibiting  such  a  condition 
with  very  satisfactory  results.  I  have  collected  a 
large  number  of  data  concerning  the  use  of  benzyl 
benzoate  in  cases  of  hypertension  observed  by  my 
self  and  by  many  other  physicians.  The  best  re- 
sults, of  course,  were  obtained  in  cases  of  idiopathic 
or  essential  hypertension,  or  high  blood  pressure 
without  demonstrable  involvement  of  the  kidneys. 
The  drug,  however,  was  found  effective  in  cases  of 
high  blood  pressure,  irrespective  of  its  etiology. 


Copyright,  1920,  by  A.  R.  Elliott  Publishing  Company. 


270  MACHT:  BEX. 

wherever  the  arteries  were  not  calcified  and  were 
anatomically  capable  of  dilatation. 

It  was  found  that  benzyl  benzoate  reduced  both 
systolic  and  diastolic  blood  pressures.  The  follow- 
ing are  a  few  illustrations  of  the  clinical  results 
obtained : 

Patient,  A.  K.,  blood  pressure  on  examination  212/132. 
After  five  days'  administration  blood  pressure  was  182/110. 

Patient,  I."  L.,  blood  pressure  before,  210/130;  after, 
180/120. 

Patient,  M.  S.,  blood  pressure  before,  194/110;  after, 
164/98. 

Patient,  H.  M.,  blood  pressure  before,  230/120;  after, 
175/105. 

Patient,  A.,  blood  pressure  before,  315/160;  after, 
240/148. 

Patient,  B.,  blood  pressure  before,  194/100;  after,  178/80. 
Patient,  C.  blood  pressure  before,  170/98;  after,  150/80. 
Patient,    D.,    blood    pressure    before,    212/132;  after, 
182/110. 

Patient,  E.,  blood  pressure  before,  225/200;  after, 
165/120. 

Patient,  R.  L.,  blood  pressure  on  examination  225/200; 
after  administering  twenty-five  drops  of  a  twenty  per  cent, 
solution  of  benzvl  bensoate  for  two  days,  the  blood  pressure 
fell  to  165/140,  and  by  the  end  of  the  week  it  became  165/120 ; 
after  two  weeks  the  pressure  in  this  patient  was  reduced  to 
160/98. 

Patient,  A.  W.,  blood  pressure  on  examination  220/114; 
after  five  days'  treatment  with  benzyl  benzoate,  twenty  per 
cent,  solution,  three  times  a  day,  the  pressure  fell  to  165/100. 

Patient,  L.  L.,  blood  pressure  on  examination  194/100; 
after  five  days'  treatment,  178/80. 

COMMENT. 

I  have  found  few  cases  of  high  blood  pressure  in 
which  that  condition  was  not  relieved,  at  least  tem- 
porarily, by  benzyl  benzoate.  Most  of  the  cases 
treated  with  the  drug  were  ambulant  patients  who 
attended  to  their  daily  occupations  while  taking  the 
drug  while  all  the  other  conditions  were  the  same. 
The  only  difference  being  the  taking  of  benzyl  ben- 
zoate, the  effect  of  the  drug  in  reducing  the  blood 
pressure  was  indisptttable.  In  most  of  the  patients 
the  reduction  of  the  blood  pressure  was  accom- 
panied by  an  improvement  in  their  general  condi- 
tion. Thus,  patients  who  complained  of  precordial 
pain  or  oppression  showed  decided  improvement  in 
that  respect. 

The  most  convenient  and  effective  form  of  ad- 
ministration of  the  drug  was  fotind  by  the  author 
to  be  the  one  originally  used  in  his  earlier  experi- 
ments. A  twenty  per  cent,  alcoholic  solution  of 
benzyl  benzoate  was  administered  by  mouth,  either 
in  cold  water  or  milk.  The  ordinary  dose  was  found 
to  be  twenty  or  thirty  drops  of  such  a  solution, 
taken  three  or  four  times  a  day.  The  administration 
of  benzyl  benzoate  in  the  form  oi  a  sohttion  was 
found  to  be  especially  useful  becaitse  it  allowed  of 
a  convenient  reduction  of  the  dose  whenever  desir- 
able. I  have  found  that  after  administering  to  a 
patient  full  doses  of  benzyl  benzoate  and  obtaining 
a  desirable  therapeutic  effect,  the  reduced  pressure 
could  be  maintained  by  keeping  a  patient  on  very 
small  doses  of  the  drug,  sometimes  no  more  than 
five  minims  of  the  twenty  per  cent,  solution. 

The  effect  of  benzyl  benzoate  on  the  blood  pres- 
sure was  demonstrable  even  in  such  cases  in  which 
nitrites  failed  to  produce  a  vasodilatation.  Thus,  1 
have  been  able  to  reduce  a  high  blood  pressure  in 
patients  who  have  become  habituated  to  nitroglycerin 


1 

X   BENZOATE.  [New  York 

Medic.\l  Joukkai. 

and  sodium  nitrite.  The  onset  of  the  benzyl  effect, 
however,  is  not  as  rapid  as  in  the  case  of  nitrites, 
although  sometimes  the  vasodilator  effect  was  ap- 
preciable within  thirty  minutes.  The  duration  of 
the  benzyl  elfect.  on  the  other  hand,  was  much 
longer  than  that  in  the  case  of  the  nitrites,  with  the 
possible  exception  of  erj-throl  tetranitrate.  The 
blood  pressure  sometimes  remained  at  a  low  level 
for  several  days  after  discontinuing  the  drug. 

In  my  experience  no  toxic  effects  have  been  noted 
after  administration  of  benzyl  benzoate  by  mouth. 
The  drug  has  been  given  to  some  patients  repeatedly 
for  periods  of  over  a  year  or  more,  without  pro- 
ducing any  untoward  symptoms.  So  far  as  I  have 
been  able  to  ascertain  from  examinations  of  urine 


Fig.  1. — Dog,  8  Kilos.  Paraldehyde  anesthesia.  Upper  curve 
shows  respiration;  middle  curve  shows  blood  pressure;  lower  curve 
the  time  in  five  seconds.  At  BB,  twenty  mg.  of  benzyl  benzoate  in 
the  form  of  an  emulsion  was  injected  into  the  femoral  vein.  At  Ep, 
one  mg.  of  epinephrine  solution  was  injected.  Note  the  fall  in  blood 
pressure  and  the  lack  of  depression  in  the  respiration  and  heart  beat. 
Note  also  the  prolonged  duration  of  the  benzyl  eflfect  on  the  blood 
pressure,  with  a  gradual  return  to  the  normal  level. 

and  functional  tests  of  the  kidneys,  benzyl  benzoate 
does  no  harm  to  the  latter  organs,  and  may  therefore 
be  administered,  if  desired,  to  patients  sutfering 
from  nephritis. 

As  in  the  case  of  nitrites,  however,  I  have  noted, 
after  observations  extending  over  a  period  of  more 
than  two  years,  that  patients  will  become  habituated 
to  benzyl  benzoate  and  will  not  react  as  promptly 
to  it  as  at  the  beginning  of  the  treatment.  Such 
patients,  however,  were  generally  of  the  nephritic 
type,  whose  condition  was  expected  to  become  ag- 
gravated in  the  course  of  time. 

While  benzyl  benzoate  acts  as  a  vasodilator  and 
will  therefore  reduce  excessively  high  blood  pressure, 
the  indications  for  its  clinical  use  are  precisely  the 
same  as  for  the  use  of  other  vasodilators,  such  as 
the  nitrites.  Its  action  is  a  purely  symptomatic  one, 
that  is,  in  redticing  the  blood  pressure.  It  is  of 
cotirse  well  known  that  a  reduction  of  the  blood 
pressure  in  many  cases  of  renal  disease  and  other 
conditions  is  not  indicated  and  may  even  be  harm- 
ful. In  such  cases,  of  course,  benz3-l  benzoate  is 
not  to  be  used  any  more  than  nitroglycerin  or  sodium 
nitrite. 

EFFECT  ON  CORONARY  ARTERIES. 

I  have  noted  a  beneficial  elfect  following  the  use 
of  benzyl  benzoate  in  patients  with  hypertension 
who  stiffer  more  or  less  from  precordial  pain.  I 
have  also  given  the  drug  successfully  in  a  few  cases 


August  28,  1920.] 


McNULTY:   THERAPY  AND  PHYSIOLOGY. 


271 


of  angina  pectoris.  If,  as  is  generally  supposed, 
anginal  attacks  are  due  to  paroxysmal  spasm  of  the 
coronary  arteries,  the  favorable  effects  of  benzyl 
benzoate  may  be  explained  by  its  vasodilator  action 
on  those  vessels.  Dr.  A.  B.  Spach,  of  Chicago,  col- 
lected a  series  of  such  cases,  which  is  published  else- 
where, and  is  of  great  interest.  The  pharmacological 
action  of  benzyl  benzoate  certainly  warrants  a  more 
extensive  trial  of  that  drug  in  the  treatment  of  this 
condition.  The  best  method  of  employing  it  would 
seem  to  be  to  administer  it  between  the  acute  anginal 
attacks.  For  the  acute  attacks  the  effect  of  benzyl 
benzoate  by  mouth  would  be  too  slow,  and  in  order 
to  relieve  the  patient  it  would  either  have  to  be  given 
by  subcutaneous  injection  in  oil  or,  still  better,  the 
attack  should  be  combated  with  a  whiff  of  amyl 
nitrite. 

SUMMARY. 

Benzyl  benzoate  has  been  shown  to  be  a  powerful 
vasodilator,  without  being  depressant  to  the  heart 
when  administered  by  mouth  in  small  doses. 

Owing  to  this  property  it  has  been  found  effective 
in  the  treatment  of  hypertension  and  angina  pectoris. 

The  best  method  of  administering  the  drug  in 
such  cases  is  in  alcoholic  solution,  which  admits  of 
rapid  absorption  and  a  control  of  the  dose. 

REFERENCES. 

1.  Macht:  Proceedings  Society  Experimental  Biology 
and  Medicine,  xv,  63,  1918. 

2.  Idem:  Journal  Pharmacology  and  Experimental 
Therapy,  xi,  389  and  419,  1918. 


NEW  THERAPY  IN  THE  LIGHT  OF  NEW 
PHYSIOLOGY. 
By  John  J.  McNulty,  M.  D., 

New  York. 

"Medicine  needs  a  new  physiology  which  will 
teach  what  health  really  means,  and  how  it  main- 
tains itself  under  the  ordinary  varying  conditions 
of  environment.  We  also  need  a  pathology  which 
will  teach  how  health  tends  to  reassert  itself  under 
totally  abnormal  conditions,  and  a  pharmacology 
which  will  teach  us  not  merely  the  actions  of  drugs, 
but  how  drugs  can  be  used  rationally  to  aid  the 
body  in  the  maintenance  and  reestablishment  of 
health.  The  new  physiology,  new  pathology,  and 
new  pharmacology  are  growing  up  around  us  just 
now." — J.  S.  Haldane. 

In  clinical  medicine  we  can  be  guided  in  our  ser- 
vice by  the  larger,  more  inclusive  vision.  xA.s  help- 
ful physicians  we  must  consider  the  whole  rather 
than  the  mere  local  aspect.  If  we  are  to  serve  in  a 
social  complex  we  must  serve  as  those  who  have 
caught  glimpses,  at  least,  of  a  new  biology,  a  new 
physiology,  a  new  therapy.  Let  us  hear  and  let  us 
hold  one  thematic  note,  the  note  of  the  rhythm  of 
the  normal.  Until  we  think  the  rhythm,  hear  the 
rhythm,  see  the  rhythm  of  the  normal  we  are  unfit 
to  enter  into  the  presence  of  biology.  The  ineffec- 
tiveness of  past  therapy  and  much  present  therapy  is 
the  result  of  ignorant  interference  with  Nature's 
law  of  maintenance  and  her  law  of  repair.  There 
is  a  beneficent,  a  helpful  cooperation  the  physician 
can  offer  if  he  has  caught  a  glimpse  of  Nature's 
law. 


We  are  on  the  threshold  of  fuller  revelation ;  a 
clearing  away  of  the  mist  of  false  concepts.  We 
seem  to  be  ready  for  a  higher  understanding  of  that 
which  appears  ready  to  reveal  itself ;  a  vision  of 
truer  perspective.  Man  is  too  delicately  adjusted 
in  his  physiology,  in  his  interrelations  and  interde- 
pendencies  of  function,  for  the  unskilled  to  meddle 
with  this  delicate  adjustment.  As  we  see  more 
clearly  the  phenomenon  of  human  life,  we  begin  to 
perceive  how  wonderfully  and  fearfully  this  organ- 
ism is  made  in  its  interrelated  and  interdependent 
functioning.  Sensitive  adjustment  is  a  requisite  of 
its  continuance.  The  uninformed  should  not  tamper 
with  it. 

It  now  appears  as  though  the  normal  of  physical 
man  is  dependent  largely  for  its  rhythm  upon  the 
functioning  of  the  socalled  autoprotective  mechan- 
ism— the  endocrine  chain  or  cycle — an  internal  or- 
ganism whose  intelligence  so  transcendently  sur- 
passes our  cerebral  intelligence  that  it  endeavors  to 
protect  itself  against  unskilled  interference.  This 
autoprotective  mechanism  stands  only  partly  re- 
vealed, but  now  enough  understood  in  its  character 
and  activities  that  we  may  approach  it  interroga- 
tively and  ask  if  we  can  aid  in  conditions  of  embar- 
rassment. 

Insufficiencies  and  sometimes  deficiencies  in  this 
endocrine  cycle  seem  to  be  a  cause  of  modification 
of  function  and  disorder  of  physiological  rhythm. 
In  this  line  of  research  there  seems  to  be  a  real 
reason  to  feel  that  we  can  often  come  to  Nature's 
aid  through  contributing  from  without  substances 
like  those  which  are  insufficient  or  deficient.  These 
substances — ductless  gland  substances — when  ad- 
ministered, find  their  place  of  selection  and  by  their 
presence,  as  catalysts,  awaken,  activate  the  in- 
herent, the  resident  reaction.  We  have  been  so  awk- 
ward, so  clumsy  in  our  use  of  endocrine  substances 
in  endocrine  therapy,  in  thinking  that  gland  sub- 
stances owe  their  efficacy  to  volume  and  stimulation 
rather  than  understanding  that  internal  secretions 
and  enzymes  aid  only  through  the  properties  of  vital 
catalysis  to  maintain  a  more  normal  "concentration 
and  velocity  of  reaction." 

A  wonderful  cycle  of  activities  is  the  socalled 
endocrine  system.  The  rhythm  of  the  normal  is 
delicately  sensitive,  notwithstanding  a  toxic  environ- 
ment. It  is  probable  that  the  first  deviation  from  the 
normal  and  its  rhythm  is  due  to  a  fatigue  of  the 
glandular  system,  especially  the  suprarenal  glknds — ■ 
suprarenal  fag;  for  the  suprarenals  seem  to  have 
most  of  the  work  to  do  in  the  autoprotective 
mechanism.  We  do  not  understand  enough  as  yet 
of  the  endocrines  to  say  which  is  the  initiative, 
which  is  the  receptive  centre  that  receives  and  di- 
rects, but  the  suprarenal  function  seems  to  have  no 
rest. 

"Costa  stated  that  nice  distinctions  between  con- 
ditions due  to  various  ductless  gland  disorders  are 
very  difficult  to  make.  He  does  not  attempt  the 
differentiation  suggested  by  Claude  and  Gougerot 
and  others  to  determine  in  which  gland  the  hypo- 
function  (or  hyper  function)  predominates,  and 
which  is  essentially  responsible  for  the  disturbance. 
This  undertaking  appears  to  him  much  too  difficult, 
at  present,"  states  Luciani. 


272 


McNL'LTY:   THERAPY  AND  PHYSIOLOGY. 


[New  York 
Medical  Journal 


We  are  commencing  to  perceive  enough  of  new 
physiology  to  know  that  the  endocrines  are  vitally 
interrelated  and  interdependent  in  a  unified  f  unction^. 
With  increasing  knowledge  of  how  the  endocrines 
are  interrelated  and  interdependent,  we  are  not 
justified  in  a  hazardous  adventure  of  thinking  we 
know,  from  obvious  symptoms,  which  gland  is 
primarily  affected,  and  upon  this  evidence  admin- 
ister a  seemingly  indicated  single  gland  substance. 

Until  our  knowledge  of  the  endocrines — their  re- 
lations and  reactions — becomes  much  clearer  and 
more  complete,  we  should  administer  small  quanti- 
ties of  associated  gland  substances  as  they  seem  to 
be  associated  and  act  in  the  living  human  organism. 
Haldane  stated :  "A  living  organism  differs  in  this 
respect  from  any  mechanism  which  we  can  construct 
or  conceive,  that  it  forms  itself  and  keeps  itself  in 
working  order  and  activity."  This  is  what  new 
therapy  should  seek  to  do  to  aid  an  embarrassed 
living  organism  to  form  itself  and  keep  itself  in 
working  order  and  activity.  This  is  all  the  new 
therapist  intelligently  desires  or  attempts  to  do.  We 
hope  the  old  superficial  and  harmful  interference 
with  the  living  organism's  selfworking  is  rapidly 
passing  in  the  light  of  new  physiology  and  new 
therapy.  Again  refering  to  Haldane:  "Stated  gen- 
erally, therefore,  the  problem  of  physiology  is  not 
to  obtain  piecemeal  physicochemical  explanations  of 
physiological  processes,  but  to  discover  by  observa- 
tion and  experiment  the  relation  to  one  another  of 
all  the  details  of  structure  and  activity  in  each  or- 
ganism as  expressions  of  its  nature  as  an  organism. 

"What  is  the  practical  object  of  medicine?  It  is 
to  promote  the  maintenance  and  assist  in  the  rees- 
tablishment  of  health.  But  what  is  health?  Surely 
it  is  what  is  normal  for  an  organism.  By  normal  is 
meant,  not  what  is  the  average,  but  what  is  the 
normal  in  the  biological  sense — the  condition  in 
which  the  organism  is  maintaining  in  integrity  all 
the  interconnected  normals  which  .  .  .  manifest 
themselves  in  both  bodily  structure  and  bodily  ac- 
tivities." 

In  the  light  we  now  have  to  work  in  we  can  aid 
in  the  maintenance  and  assist  in  the  reestablishment 
of  health.  The  physician  equipped  with  the  new 
physiology  and  new  therapy  can  abstain  from  stig- 
matizing his  patient  with  incurable  terms,  for  he 
knows  with  a  clearer  understanding  that  he  can  aid 
in  the  reestablishment  of  the  normal,  the  normal 
with  its  rhythm.  He  can  approach  the  embarrassed 
organism  which  manifests  faulty  functioning  and, 
with  a  scientific  understanding  of  qualitative  and 
quantitative  endocrine  therapy,  aid  in  the  reform  of 
conditions  which  have  been  considered  incurable. 

Endocrine  therapy,  and  by  endocrine  therapy  we 
mean  associated  gland  substances,  is  not  a  wand  we 
can  credulously  pass  over  the  afflicted  and  say, 
Presto  change.  Associated  gland  therapy  is  a  pro- 
gressive, an  improved  effort  to  scientifically  assist 
the  organism  manifesting  weariness  or  even  disease. 

It  is  the  holding  of  the  physiologically  normal  in 
thought  that  protects  us  and  our  patients  from  er- 
rors in  prognosis.  The  physician  who  today  is  ser- 
viceable in  his  socioprofessional  relations  is  the  prac- 
tical physiological  therapist  who  holds  in  thought 
the  physiologically  normal :  the  rhythm  of  the  nor- 


mal even  in  the  face  of  the  powerful  influence  of 
old  pathological  concepts.  The  physician  who  thinks 
and  acts  only  in  terms  of  pathology  is  today  unac- 
ceptable. I  have  been  approached  by  old  patients 
who  state  that  twenty  years  or  more  ago  I  was 
called  to  see  them  in  uremic  coma,  that  examination 
of  the  urine  showed  large  hyaline  casts,  and  still 
further  informed  that  they  had  enjoyed  twenty  or 
more  years  of  health  with  efficiency.  I  have  an- 
swered that  I  hoped  I  would  never  again  condemn 
with  terms  of  fatality,  for  I  now  knew  somewhat 
of  Nature's  law  of  repair ;  we  should  understand- 
ingly  cooperate  with  this  law  of  reestablishment. 
!Most  physicians  desire  and  try  to  help  but  in  their 
effort,  guided  by  old  therapy,  they  add  embarrass- 
ment to  embarrassment.  Xew  physiology  and  new 
therapy  direct  our  desires  and  efforts  more  wisely, 
more  serviceably,  more  reparably. 

"But  medicine,  as  we  have  seen,  is  supremely 
interested  in  the  physiological  normal.  What  a  man 
sees  at  the  bedside  is  a  perversion  of  the  normal, 
and  Nature's  attempts  to  restore  it  with  what  as- 
sistance medicine  can  give.  For  medicine  it  is  nec- 
essary to  know  the  normal  in  its  elastic  and  active 
organization,"  states  Haldane.  Old  therapy  is  often 
so  helpless.  New  therapy  does  not,  like  the  old, 
seek  to  interfere  but  with  a  new  understanding  co- 
operates effectively  with  Nature  in  her  law  of  return 
to  the  normal — to  elastic  and  active  organization. 

Let  us  here  state  that  if  the  full  benefits  of  en- 
docrine therapy  are  to  be  obtained  the  care  of  the 
entire  organism  must  be  considered.  Rhythm  of 
the  normal ;  let  us  think  it,  see  it,  hear  it  and,  as 
physicians,  cooperate  with  it. 

The  time  is  now  here  when  the  intelligence  of 
the  socalled  laity  will  not  tolerate  the  physician  who 
is  only  thinking  in  terms  of  pathology  and  its  grue- 
some cortege  of  fatal  terms.  Society  today  needs 
the  new  physiologist,  the  new  therapist  who,  to  some 
working  degree,  understands  the  constant  endeavor 
of  the  organism  to  maintain  the  normal  rhjthm.  We 
find  this  reflected  in  Haldane :  "My  intellectual  as 
well  as  my  moral  sympathies  are  all  with  the  cheery 
general  practitioner  whose  moral  is  'Never  say  die.' 
and  who  flashes  defiance  at  this  dismal  ghost." 

" .  .  .  biological  conception  of  organic  regula- 
tion"— this  is  our  theme,  and  this  our  desire.  May 
we  more  fully  understand  it  and  more  helpfully  co- 
operate with  it  as  general  practitioners  and  as  broad- 
ly equipped  endocrinologists.  "To  whatever  part  of 
physiology  one  turns  one  finds  evidence  accumulat- 
ing of  the  fineness  and  omnipresence  of  organic 
regulation."  Let  us  work  with  this  "fineness  of 
organic  regulation."  "Treatment  can  only  be  se- 
curely founded  on  the  correct  and  full  diagnosis  of 
what  is  amiss  in  organic  regulation,  and  how  nature 
can  be  aided  in  restoring  this  regulation." 

The  men  who  have  blazed  a  trail  in  the  wilder- 
ness of  the  unknown  are  those  who  have  contributed 
the  greatest  blessings  to  afflicted  humanity. 

In  endocrine  therapy  the  temptation  may  come  to 
see  only  the  obvious,  and  treat  only  the  obvious. 
This  is  the  origin  of  monoglandular  therapy.  The 
one  gland  therapist  does  not  understand  that  thyroid 
imbalance,  hyperthyroidism  or  hypothyroidism,  is 
rarely  if  ever  a  primary  thyroid  disorder.    It  may 


August  28,  1920.] 


THOM:  EARLY  SIGNS  OF  TABES. 


273 


be  and  usually  is  an  objectification  of  suprarenal, 
or  pituitary,  or  gonadal  primarv-  disorder  or  disease. 
This  is  why  associated  gland  therapy  is  not  only 
more  scientific  but  more  efficacious  than  single  gland 
therapy.  The  law  that  the  associated  gland  thera- 
pist works  with  is  the  organism's  law  of  accurate, 
intelligent  selection ;  selecting  what  is  insufficient  or 
deficient  and  appropriating  it.  Until  our  knowledge 
of  physiology  more  clearly  and  perfectly  approaches 
the  intelligent  selection  of  the  autonomic  mechan- 
ism, organic  regulation,  we  should  administer  in- 
ternal secretions  and  enzymes  in  associations,  as- 
sociated as  they  seem  to  be  associated  and  act  in 
the  living  human  organism,  confident  that  the  resi- 
dent intelligence  will  select  needed  supplies  wisely. 

I  desire  to  quote  here  a  paragraph  from  one  of 
my  former  articles :  Internal  Secretions  and  En- 
zymes, Their  Interrelation  and  Interdependence, 
Their  Value  and  Application  in  Modern  Therapy : 

"Physiologically  associated  internal  secretions  and 
enzymes,  endocrine  therapy,  has  created  a  new 
therapeutic  era.  We  can  now  treat  disorders  that 
we  formerly  and  even  recently  called  incurable, 
with  greater  confidence.  No  physician  with  present 
day  understanding  should  allow  a  fatal  prognosis 
to  take  possession  of  his  thought  nor  should  he 
voice  a  fatal  prognosis.  We  now  have  sufficient 
understanding  of  a  fixed  and  certain  biological 
principle  to  apply  it  in  curative  therapy.  The  dawn 
is  appearing  over  the  domain  of  biological  phenom- 
ena and  we  are  beginning  to  understand  their  in- 
fluences and  utilize  them  beneficently.  The  old 
idea  of  the  futility  of  treating  socalled  incurable  dis- 
eases is  rapidly  giving  place  to  definite  and  compe- 
tent therapy  based  on  successful  issue." 

We  desire  to  quote  the  following  from  a  recent 
article  by  Dr.  S.  W.  Handler: 

"New  things  are  always  treated  with  scepticism, 
but  each  thinking  physician  may  observe  in  his  prac- 
tice abundant  material  for  research.  By  working 
together  we  may  soon  prove  beyond  doubt  that 
while  heredity  shapes  our  ends  there  is  an  endo- 
crinity  that  runs  parallel." 

New  therapy  based  on  new  physiology  is  an  im- 
proved therapy,  a  therapy  that  obtains  results  im- 
looked  for  in  old  methods  of  treatment. 

REFERENCES. 

1.  Handler,  S.  W.  :  New  York  Medical  Journal,  Feb- 
ruary 7,  1920. 


THE  EARLY  SIGNS  OF  TABES. 
By  Burton  Peter  Thom,  M.  D., 

New  York, 

Visiting  Syphilologist  to  the  Hospitals  of  the  Department  of  Cor- 
rection, Blackwell's  Island. 

With  the  exception  of  paresis,  the  most  desperate 
symptom  complex  of  which  the  spirochetal  invasion 
of  the  nervous  system  is  the  cause,  is  tabes.  Paresis 
is  the  same  pathological  manifestation  as  tabes  only 
at  a  higher  level ;  paresis  involves  the  brain,  whereas 
tabes  involves  the  cord.  It  can  therefore  be  as- 
serted that  every  tabetic  is  a  potential  paretic.  Until 
quite  recently  tabes  could  not  be  cured,  its  pro- 
gress stayed  or  its  symptoms  mitigated  except  by  the 
relief  which  opium  afifords.   This  was  due  to  wrong 


conceptions  of  its  pathology  but  more  especially  to 
inadequate  methods  of  treatment.  But  since  the 
discovery  of  the  Spirochseta  pallida,  the  Wasser- 
mann  reaction  and  the  advent  of  salvarsan  all  this 
is  changed  and  now  this  dread  disease,  like  many 
others,  if  attacked  in  its  earliest  stages  is  amenable 
to  treatment.  For,  if  it  cannot  be  cured  as  some 
still  believe — I  am  not  among  the  number — its  mor- 
bid processes  can  at  least  be  stopped  and  its  victim 
saved  from  its  impending  terrors. 

Unfortunately,  however,  most  of  those  suffering 
with  tabes  when  they  resort  to  the  neurologist  or 
syphilologist  have  reached  the  stage  when  such  help 
cannot  be  given  or  only  to  a  slight  degree.  Of 
these,  many,  I  regret  to  say,  are  so  because  of  faulty 
or  careless  diagnosis.  If  a  correct  diagnosis  had 
been  made  at  the  beginning  this  melancholy  pro- 
cession would  not  be,  or  perhaps  I  had  better  say, 
it  would  not  be  so  long. 

The  proper  time  to  treat  tabes  is  before  it  starts. 
This  may  seem  a  paradox  but  no  more  so  than  the 
ancient  saw  that  "an  ounce  of  prevention  is  worth 
a  pound  of  cure."  The  importance  of  this  state- 
ment I  cannot  emphasize  too  strongly  and  I  will 
give  reasons  why  it  cannot  be  denied.  It  is  well 
known  that  the  Spirochasta  pallida  in  common  with 
all  trypanosomes  has  a  decided  predilection  for  ner- 
vous tissue;  and  further,  this  predilection  is  in  evi- 
dence at  the  very  commencement  of  its  onslaught. 
The  researches  of  Dreyfus,  Leishman,  Ravaut,  For- 
dyce  and  many  others  present  ample  testimony  of 
this.  They  have  shown  that  the  specific  reaction 
of  lues  is  present  in  the  spinal  fluid  of  from  twenty 
to  thirty-five  per  cent,  of  all  the  syphilitics  examined 
by  them  in  the  first  year  of  the  disease.  If  we 
strike  an  average  of  the  percentages  noted  by  the 
various  observers  it  can  be  assumed  that  fully  one 
fourth  of  all  syphilitics  in  the  first  year  of  the  dis- 
ease show  an  invasion  of  the  cerebrospinal  axis. 
This  invasion  is  independent  of  any  nervous  lesion 
being  manifest.  Be  this  as  it  may,  it  cannot  be 
denied  that  any  individual  with  a  positive  Wasser- 
mann  in  the  spinal  fluid  is  perforce  a  candidate  for 
nervous  syphilis.  We  also  know  with  equal  cer- 
tainty that  in  nothing  like  twenty  to  thirty-five  per 
cent,  of  syphilitics  cerebral  or  spinal  syphilis  devel- 
ops. It  must  therefore  follow  that  the  major  por- 
tion of  the  potential  neural  syphilitics  either  get 
well  spontaneously  or  as  the  result  of  treatment. 
But  it  is  also  true  that  a  definite  percentage  do  not 
resolve  in  this  manner  and  nervous  lesions  follow 
early  or  late.  It  is  variously  estimated  that  in  from 
fifteen  to  twenty  per  cent,  of  syphilitics  who  acquire 
the  disease  tertiary  symptoms  develop.  In  approxi- 
mately one  third  of  these  the  nervous  system  is  in- 
volved.   Tabes  is  by  far  the  most  prevalent  form. 

Since  we  know  that  the  seeds  of  the  disease  are 
sown  many  years  before,  it  must  follow  if  they  are 
not  allowed  to  grow,  tabes,  and  for  that  matter,  all 
other  syphilitic  nervous  diseases,  can  in  most  in- 
stances be  prevented.  Knowing  this  no  case  of 
syphilis  in  the  early  cycle  of  its  development  should 
be  pronounced  cured  until  a  lumbar  puncture  had 
been  made  and  the  spinal  fluid  found  to  be  normal. 
This  should  be  in  addition  to  repeated  negative 
findings  in  the  blood.    Should  the  spinal  fluid  be 


274 


THOM:  EARLY  SIGXS  OF  TABES. 


[New  York 
Medical  Journal 


positive,  even  if  the  blood  is  negative,  which  not 
infrequently  happens,  energetic  intraspinal  treat- 
ment should  at  once  be  instituted  and  kept  up  until 
the  findings  in  the  spinal  fluid  have  returned  normal. 
This  procedure  should  admit  of  no  exception  if  we 
are  to  insure  our  patients,  as  far  as  is  humanly  pos- 
sible in  our  present  state  of  knowledge,  against  the 
future  raid  of  the  spirochetae  upon  the  nervous  sys- 
tem. If  this  were  made  an  inflexible  rule  in  every 
case  of  early  syphilis,  tabes  as  a  disease  entity  would 
almost  disappear,  or  at  least  be  lowered  to  the  irre- 
ducible minimum  common  to  all  preventable  diseases. 

I  realize  that  it  is  not  alwa\s  possible  to  control 
every  case  of  early  syphilis  in  the  manner  just  de- 
scribed. Also,  the  majority  of  tabetics  do  not  pre- 
sent themselves  until  well  marked  symptoms  are 
present.  It  is  not  my  purpose  here  to  discuss  these 
cases  but  rather  those  in  which  the  subjective  and 
objective  symptoms  are  just  beginning  and  in  which 
the  element  of  doubt  as  to  the  diagnosis  of  the  con- 
dition still  exists  in  the  mind  of  the  physician. 
There  are  many  such  and  if  their  malady  is  diag- 
nosed correctly  they  would  be  spared  much  suffer- 
ing. Tabes,  like  its  congener,  paresis,  is  an  insidious 
disease.  It  is  therefore  most  difficult  to  diagnose 
at  the  onset  but  it  is  at  this  period  when  the  damage 
done  is  still  slight  that  it  offers  the  best — I  may  say 
the  only — opportunity  for  arrest. 

One  of  the  first  of  the  premonitory  symptoms  of 
tabes  is  impotence.  ]Many  times  it  is  this  loss  of 
sexual  power  that  causes  the  patient  to  first  seek 
medical  advice.  This  sexual  decadence  is  never 
sudden.  The  patient  usually  states  that  he  has  been 
noticing  a  decrease  of  sexual  power  for  a  year  or 
more.  If  it  is  found  that  in  conjunction  with  the 
impotence  the  testicles  are  insensible  to  pain  when 
compressed  it  is  almost  certain  that  it  is  due  to  be- 
ginning tabes. 

Another  early  symptom  of  tabes  is  slowness  in 
emptying  the  bladder.  In  many  instances  if  the 
patient  has  ever  had  gonorrhea  he  may  consult  the 
physician  for  what  he  thinks  is  a  stricture.  In  these 
cases  there  is  always  a  lack  of  sensibility  of  the 
bladder,  which  may  contain  a  large  amount  of  urine 
without  the  patient  being  at  all  aware  of  it.  Should 
the  urine  show  evidences  of  decomposition,  which 
will  be  shown  by  its  odor  and  appearance,  a  low 
grade  of  fever  will  almost  invariably  be  present  due 
to  absorption  and  a  possibly  existing  pyelonephritis. 

According  to  Osier  ten  per  cent,  of  all  tabetics 
have  the  ocular  form  of  the  disease ;  that  is  amau- 
rosis caused  by  atrophy  of  the  optic  nerve.  Failing 
vision,  therefore,  which  cannot  be  helped  by  gjasses, 
or  the  gradual  or  sudden  appearance  of  scotoma, 
central,  homonymous  or  heteronymous,  should  al- 
ways cause  suspicion  of  beginning  tabes.  An 
ophthalmoscopic  examination  should  be  made  at 
once  to  determine  the  presence  of  choked  disc ;  al- 
though as  Hughling  Jackson  observed  long  ago 
there  may  be  considerable  choking  of  the  disc  with- 
out impairment  of  vision.  Choked  disc  is  not  al- 
ways due  to  tabes,  however ;  atrophy  of  the  optic 
nerve  from  pressure  due  to  a  pachymeningitis  in 
the  vicinity  of  the  optic  chiasm,  neuritis  of  the  nerve, 
an  embolism  of  the  lenticulate  artery  or  an  aneurysm 
of  the  same,  a  thrombus  of  the  central  retinal  vein, 


or  glaucoma  must  also  be  considered.  Smallness 
of  the  pupils — spinal  myosis — may  precede  the 
classic  Argyll-Robertson  pupils  for  a  considerable 
period  and  this  condition  of  the  eyes  should  always 
arouse  suspicion.  Diplopia  or  double  vision  is 
sometimes  encountered  in  early  tabes,  as  well  as  the 
slow  and  painless  development  of  paralysis  of  the 
external  muscles  of  the  eye.  Moebius  is  of  the 
opinion  that  these  symptoms  are  as  significant  of 
tabes  as  the  Argyll-Robertson  pupil. 

A  symptom  which  is  highly  suggestive  of  begin- 
ning tabes  is  loss  of  bone  conductivity  as  exemplified 
by  Egger's  test  with  the  tuning  fork.  It  is  not  in- 
frequently the  very  first  objective  symptom  of  the 
disease.  Sudden  deafness,  a  condition  which  has 
been  compared  by  Hermet  with  primary  optic 
atrophy,  is  also  a  sign  of  beginning  tabes.  Sudden 
or  gradual  loss  of  hearing  in  a  middle  aged  man 
where  no  other  cause  can  be  assigned  should  cause 
a  suspicion  of  tabes. 

The  socalled  lightning  pains  which  are  present  in 
the  early  as  well  as  the  later  stages  of  the  disease 
are  very  often  mistaken  for  rheumatism  or  sciatica. 
To  treat  them  as  such,  as  so  often  happens,  is  to 
lose  much  precious  time.  There  are  certain  peculi- 
arities about  the  pains  of  tabes  which  should  give 
pause  before  they  are  lightly  dismissed  as  due  to 
sciatica  or  rheumatism.  One  is  the  intensity  of  the 
pains.  The  pains  of  rheumatic  arthritis  or  sciatica 
cannot  possibly  compare  with  these  agonizing  flashes 
which  come  and  go  with  the  rapidity  of  lightning — 
hence  their  name.  Rheumatic  pains,  if  of  the 
muscles,  are  diffuse  and  if  of  the  joints,  as  they 
usually  are,  there  is  stiffness.  There  is  no  stiffness 
of  the  joints  in  incipient  tabes.  Sciatica  is  often 
extremely  painful  but  the  pain  is  constant,  it  does 
not  come  and  go  as  in  tabes.  It  may  be  so  severe 
as  to  cause  the  patient  to  limp,  but  it  is  never  as 
intense  as  the  shooting  pains  of  tabes.  It  follows 
a  definite  tract — the  course  of  the  sciatic  nerve.  The 
pains  of  tabes  are  not  definite  in  so  far  as  any  par- 
ticular nerve  distribution  is  concerned.  When  they 
leave,  the  skin  over  where  the  pains  have  been  is 
sore  and  tender  to  the  touch  for  some  time  after. 
As  pointed  out  by  Strauss,  spots  of  purpura  not 
infrequently  follow  these  attacks  over  where  the 
pains  have  been.  Sometimes  there  is  a  herpetiform 
eruption  not  unlike  that  observed  in  shingles. 

Loss  of  the  patellar  reflex  is  one  of  the  early 
signs  of  tabes.  For  many  years  it  may  be  the  only 
objective  sign  of  the  disease.  With  loss  of  the 
patellar  reflex  it  will  almost  invariably  be  noted 
that  the  triceps  reflex  is  also  absent.  In  examining 
for  loss  of  reflexes  however,  I  desire  to  call  the 
reader's  attention  to  the  fact  that  the  first  reflex  to 
be  lost  is  that  of  the  tendo  achillis — the  ankle  re- 
flex. In  determining  the  presence  or  absence  of 
the  reflexes,  most  examiners  test  the  patella  or  knee 
reflex  first  and  if  it  is  present,  in  many  instances  the 
possibility  of  tabes  is  dismissed.  This  is  wrong. 
The  first  reflex  to  be  tested  should  be  that  which  is 
the  first  to  disappear  and  that  is  the  ankle  reflex. 
This  reflex  is  determined  by  placing  the  patient  in  a 
kneeling  position  and  lightly  tapping  the  Achilles 
tendon. 

The  socalled  crises,  gastric,  vesical  or  laryngeal, 


August  28,  1920.] 


WRIGHT:  ADMINISTRATION  OF  SALVARSAN  BY  RECTUM. 


275 


are  sometimes  present  in  the  beginning  of  the  dis- 
ease. Usually,  however,  they  do  not  occur  until  it 
is  well  established  and  the  diagnosis  is  certain.  A 
sudden  attack  of  indigestion,  especially  if  the  patient 
complains  of  a  peculiar  feeling  of  weight  in  the 
epigastrium,  or  a  sudden  attack  of  diarrhea  where 
there  has  been  in  neither  instance  no  dietary  indis- 
cretion and  which  persists  for  several  days  should 
always  cause  tabes  to  be  considered. 

Perforating  ulcers  of  the  soles  of  the  feet  are 
usually  late  manifestations  of  the  disease  but  oc- 
casionally they  occur  as  a  premonitory  sign.  I  can 
recall  a  case  in  which  this  condition  was  present 
for  a  number  of  years  before  ataxia  developed. 
The  same  is  true  of  the  socalled  Charcot's  joint — 
usually  a  late  sign  but  sometimes  appearing  early. 

A  feature  of  tabes  not  often  mentioned  in  the 
textbooks  is  the  frequent  presence  of  cardiac  lesions, 
although  attention  was  called  to  this  thirty  years 
ago  by  Striimpell.  All  forms  of  cardiopathies  are 
to  be  noted  but  it  would  seem  that  aortic  lesions 
predominate.  This  is  not  strange,  however,  when 
we  consider  that  aortic  disease  is  almost  invariably 
caused  by  syphilis.  So  frequently  are  cardiac  lesions 
coexistent  with  tabes  that  their  presence  where 
rheumatism  or  endocarditis  can  be  excluded  should 
always  cause  a  search  for  the  incipient  signs  of  tabes. 

Any  individual  in  whom  tabes  is  suspected  should 
have  a  Wassermann  test  of  the  blood  and  of  the 
spinal  fluid.  A  cell  count  and  the  globulin  reaction 
and  the  redticing  power  for  Fehling's  solution 
should  also  be  ascertained  of  the  spinal  fluid.  The 
colloidal  gold  test  to  show  the  tabetic  curve  can. 
in  my  opinion,  be  ignored.  If  present,  it  of  course 
helps  to  confirm  the  other  findings.  These  two 
examinations  should  be  made  even  if  there  is  no 
history  of  syphilis.  For,  as  every  syphilologist  well 
knows,  the  disease  may  present  in  the  blood  and 
spinal  fluid  and  yet  be  otherwise  asymptomatic.  The 
absence  of  scars  due  to  gross  external  lesions  should 
not  deter  the  examiner,  for  in  the  majority  of  in- 
stances they  are  not  present.  Should  the  blood  be 
returned  negative  it  does  not  by  any  means  follow 
that  the  physician's  suspicions  are  incorrect.  It  has 
been  said  that  one  swallow  does  not  make  a  summer, 
neither  does  a  single  negative  \\'assermann  reaction 
preclude  syphilis.  The  blood  is  not  infrequently 
negative  in  tabes  and  yet  the  disease  may  be  present. 
Several  tests  should  be  made  and  if  a  doubt  still 
exists  a  provocative  salvarsan  injection  should  be 
given  and  the  blood  tested  repeatedly  thereafter  for 
at  least  ten  days. 

The  c}lological  findings,  however,  are  by  far  the 
most  important.  For,  while  syphilis  may  not  be 
manifest  serologically  it  will  invariably  give  indi- 
cations of  its  presence  in  the  spinal  fluid.  I  desire 
to  emphasize  this  because  it  has  been  asserted  and 
is  quite  generally  believed  that  the  Wassermann  is 
negative  in  approximately  fifty  per  cent,  of  tabetic 
spinal  fluids.  In  spite  of  its  wide  circulation  this 
statement  in  my  opinion  is  incorrect.  The  reason 
for  this  seemingly  large  number  of  negative  findings 
in  tabes  is»due  to  the  fact  that  too  small  an  amount 
of  fluid  is  used  in  making  the  test.  If  instead  of 
two  tenths  c.  c.  of  fluid,  three  or  four  c.  c.  were 
used  the  Wassermann  would  be  found  positive  as 


often  as  in  paresis,  i.  e.,  one  hundred  per  cent.  The 
cell  count  in  early  tabes  is  always  increased  which 
is  indicative  of  a  more  or  less  acute  process.  It  is 
only  when  the  disease  is  in  a  state  of  arrest  or  has 
progressed  so  far  that  the  nerve  tracts  are  completely 
destroyed  that  the  cell  count  sinks  to  normal  or 
nearly  so,  that  is  to  ten  or  twelve  cells  to  the  count- 
ing chamber.  The  fluid  also  usually  flows  out  under 
pressure.  The  globulin  index  is  increased  and  there 
is  reduction  of  Fehling's  solution. 

It  is  not  my  purpose  here  to  discuss  the  treatment 
of  tabes  in  this  early  stage.  I  believe  treatment — 
salvarsan  intravenously  and  intraspinally — will  ar- 
rest and  in  not  a  few  instances  cure  the  disease  at 
this  stage.  One  thing  at  least  is  certain ;  this  early 
stage  is  the  only  stage  where  treatment  offers  such 
a  hope.  It  is  the  patient's  hour  of  fate — his  only 
opportunity,  and  it  is  the  duty  of  his  physician  to 
grasp  it  boldly  and  try  to  save  him  from  what  means 
eventually,  as  expressed  by  Heine,  a  '"mattress 
grave." 

1632  Avenue  A. 


ADMIXISTJLATIOX    OF    SALVARSAX  BY 
RECTUM  IX  THE  FORM  OF 
EXTEROCLYSIS.* 
Preliminary  Report. 
Bv  \'.  William  M.  Wright.  M.  D., 
Philadelphia. 
Philadelphia  General  Hospital. 

During  my  service  in  the  venereal  wards  of  the 
Philadelphia  General  Hospital  under  Dr.  Siter  and 
Dr.  Alexander  Randall,  I  had  occasion  to  treat 
syphilitic  patients  who  for  various  reasons  could 
not  be  given  salvarsan  intravenously.  It  was  essen- 
tial that  they  receive  it  in  some  way  or  other  as 
merctiry  and  the  iodidee  were  inadequate.  Realiz- 
ing that  they  would  be  benefited  by  it  if  they  could 
get  it  I  decided  to  find  some  way.  Textbooks  and 
journals  were  searched  for  other  methods,  but  those 
given  did  not  seem  satisfactory  and  imiformly  safe. 

In  Warbasse's  Surgery  there  appears  the  follow- 
ing statement :  "The  patient  comes  to  the  operation 
empty,  hungry,  and  thirsty.  The  patient  lies  on  his 
right  side ;  an  adult  is  given  morphine,  a  child  pare- 
goric." With  this  as  a  nucleus  salvarsan  by  entero- 
clysis  was  begun. 

Following  the  basic  principles  that  the  patient 
should  be  empty,  thirsty,  and  hungry,  the  patient 
was  made  empty  and  hungry  by  starvation  and  pur- 
gation and  thirsty  by  withholding  liquids  and  giving 
a  few  doses  of  atropine.  In  a  series  of  fifty  cases 
the  following  routine  was  followed : 

If  the  administration  was  to  take  place  at  1  :30 
p.  m.  the  patient  was  given  a  very  light  supper,  one 
fluid  ounce  of  a  saturated  solution  of  magnesium 
sulphate  and  one  or  two  compound  cathartic  pills 
at  5  or  6  p.  m.  of  the  preceding  day.  The  next 
morning  they  were  denied  the  regular  breakfast  but 
were  given  two  cups  of  black  coflfee  and  one  piece  of 
soft  toast.    At  7  a.  m.  they  received  1/150  gr. 

*Read  before  the  Blockley  Medical  Society.  February  2.  1920, 
and  February  23,  1920  (by  invitation)  before  the  Genitourinary 
Society.  Philadelphia. 


276 


WRIGHT:  ADMINISTRATIOX  OF  SALVARSAX  BY  RECTUM. 


[New 
Medical 


York 
Journal 


of  atropine,  at  10  a.  m.  another,  and  went  to  bed 
where  they  remained  until  that  evening  or  next 
morning.  At  1  p.  m.  they  were  given  one  quarter 
grain  of  morphine  and  1/150  grain  atropine  hypo- 
dermically.  During  the  entire  day  they  were 
denied  liquids,  except  in  some  instances  a  half  glass 
of  milk  at  noon.  At  1  p.  m.  a  "1-2-3"  enema  was 
given,  consisting  of  magnesium  sulphate  one  ounce, 
glycerine  two  ounces  and  hot  water.  By  this  time 
the  condition  of  the  patient  was  such  that  the  ab- 
sorption of  the  enteroclysis  by  a  dried  up  bowel  was 
an  easy  matter, — this  is  what  we  wished  to  accom- 
plish. At  1  ;30  p.  m.  the  enteroclysis  was  given  and 
continued  at  a  rate  of  forty-five  to  fifty-five  drops 
a  minute. 

The  solutions  used  varied  according  to  whether 
salvarsan  or  arsenobenzol,  neosalvarsan  or  neoar- 
senobenzol  was  given.  If  arsenobenzol  was  used  it 
was  prepared  as  usual  and  dihited  with  hot  normal 
saline  to  260-320  c.  c.  and  the  enteroclysis  bag  kept 
hot  by  hot  water  bags  or  electrical  appliances.  The 
neoarsenobenzol  was  dissolved  in  sixty  c.  c.  of  water 
at  room  temperature  and  diluted  to  200-260  c.  c. 
with  normal  saline  and  required  no  heat.  As  stated, 
the  rate  of  flow  ran  from  fortN'-five  to  fifty-five 
drops  a  minute  and  generally  required  one  and  a 
half  to  two  hours.   At  first  the  patients  were  not  al- 

Dilution  used              200  c.  c.  230  c.  c.  260  c.  c. 

Time                 Time  Time 

Rate  of  flow         hours  minutes  hours  minutes  hours  minutes 

40  gtt.  per  min..      1        15  1        27  1  38 

42  gtt.  per  min..      1         11  1        22  1  33 

45  gtt.  per  min..      1          7  1         17  1  27 

47  gtt.  per  min.  .1          4  1         14  1  23 

50  gtt.  per  min..      1          0  1          9  1  18 

52  gtt.  per  min..     0        58  1          7  1  15 

55  gtt.  per  min..     0        55  1          3  1  10 

lowed  to  eat  any  supper  that  night,  but  later  it  was 
found  that  some  could  eat  a  light  lunch  and  experi- 
ence no  after  effects ;  those  who  could  not  went 
without  food.  That  night  they  were  allowed  a  few 
liquids  and  the  following  morning  the\-  resumed 
ordinary  conditions  and  diet. 

The  imtoward  efifects  have  been  negligible  and 
only  once  has  an}'thing  imusual  occurred,  except 
now  and  then  slight  headache.  If  the  patient  cheats 
on  the  fasting  she  is  likely  to  have  nausea,  perhaps 
vomiting  and  headache.  One  patient  was  given  the 
enteroclysis  with  only  a  preliminary  enema  and  mor- 
phine and  atropine.  That  night  she  experienced 
pain  across  the  abdomen,  diarrhea,  painful  defeca- 
tion and  nausea.  Bismuth,  opium,  plenty  of  water, 
rest  in  bed  and  liquid  diet  with  several  enemata 
benefitted  the  patient.  There  were  no  later  mani- 
festations. Another  patient  complained  of  dizzi- 
ness, and  a  silly  feeling  which  were  traced  out  as 
an  idiosyncrasy  to  atropine  and  morphine. 

The  dose  varies  between  0.6  gram  and  0.9  gram. 
Nearly  all  were  started  with  0.6  grarn  of  arseno- 
benzol for  the  first  one,  two  or  three  doses,  which 
was  increased  to  0.9  gram  as  the  treatment  pro- 
gressed. With  neoarsenobenzol  0.9  gram  was  given 
for  four  or  five  doses  and  then  1.0  gram.  Of  course 
it  is  not  presumed  that  salvarsan  by  this  method  is 
an\'^  more  beneficial  than  when  administered  in 
other  ways  and  mercury  and  iodides  are  to  be  used 
in  exactly  the  same  way  as  in  treating  syphilis  by 
the  intravenous  injections  of  salvarsan. 


Indications  for  rectal  administration  are  as  fol- 
lows : 

1.  Fat  patients  with  small  or  no  visible  superficial  veins. 

2.  Scrawny  patients  with  poor  veins. 

3.  Children. 

4.  Women  for  whom  needlemarks  in  the  arm  would  prove 

inconvenient  in  evening  dress. 

5.  Patients  with  knotted  veins  from  previous  intravenous 

injections. 

6.  Hysterical  and  highly  nervous  types  of  patients. 

REMARKS. 

1.  It  is  thought  that  by  this  method  the  solution 
is  picked  up  by  the  blood  vessels  and  lymphatics  of 
the  rectuin  and  sigmoid  and  the 

greater  proportion  of  the  solu- 
tion conveyed  directly  to  the 
liver  whence  it  is  meted  out, 
and  that  mtich  more  salvarsan 
enters  the  liver  and  is  stored 
there  by  this  method  than  by 
the  intravenous  method. 

2.  It  has  been  questioned 
whether  atropine  should  be 
used.  The  method,  however,  has 
proved  successful  in  the  pres- 
ence of  atropine,  the  drug  which 
the  researches  of  Novi  have 
proved  to  be  of  greatest  avail  in 
the  prophylaxis  of  nitritoid 
shock. 

3.  iVIorphine  tends  to  quiet 
the  patient  and  put  him  in  a 
mental  and  physical  state  of  ac- 
quiescence. This  is  especially 
helpful  in  the  case  of  excitable 
and  hysterical  women,  in  whom 
an  extra  injection  of  morphine 
is  frequently  indicated. 

4.  The  saturated  solution  of 
magnesium  sulphate  given  by 
mouth  has  a  hydragogue  action, 
and  desiccates  the  patient  as  well 


I 


as  cleansing  out  the  gastrointes- 


FiG.  1.  —  A.  Hot 
water  bottle  or  glass 
container.  B.  Drop- 
cock.  C.  Murphy 
dropper.  E.  Glass 
Y.  F.  20  French 
rubber  catheter.  G. 
Gas  pressure  release. 
H.    Safety  pin. 

Dr.  Morrison's  ap- 
paratus for  enterocly- 
sis.    (Modified  by  the 


tinal  tract. 

5.  Any    preparation    of  ars 
phenamine      or  neoarsphena 
mine  lends  itself  readily  to  this    '^"vhln    no  escape 
method    of    administration.  In 
our  hands,  however,  the  neoars- 
phenamine  has  given  the  better 
results.    It  is  less  toxic  and  far    dropcock.   The  rectal 

catheter    is  therefore 

less  troublesome  to  prepare  and 
administer. 

6.  More  concentrated  solu- 
tions might  be  used,  but  the 
above  dilution  has  proved  entire- 
ly satisfactory. 

7.  Critics  prejudiced  in  fa- 
vor of  the  intravenous  admin- 
istration of  these  drugs  have  raised  the  objection  that 
much  of  the  dose  might  be  ejected  by  defe- 
cation. They  fail  to  taken  into  consideration  the 
fact  that  owing  to  the  large  doses  of  atpopine  and 
morphine  given,  with  the  resulting  bowel  atony  and 
inhibition  of  peristalsis,  there  will  be  no  bowel 
movement  for  manv  hours.    During  this  interval 


tube  is  used,  gas 
forming  can  find  no 
outlet  owing  to  the 
construction  of  the 
single     tube    by  the 


expelled  by  the  intra- 
rectal pressure.  The 
same  is  prone  to  oc- 
cur if  the  rate  of  flow 
is  too  fast  and  no 
adequate  bypass  is 
provided.  This  diffi- 
culty is  entirely  obvi- 
ated by  the  use  of  the 
glass  Y  and  escape 
tube  featured  in  tlie 
above  diagram. 


August  28,  1920.] 


BANGERT:   THE  SHIPPEN  FAMILY. 


277 


ample  time  is  afforded  for  the  slow  and  complete 
absorption  of  all  the  drug  administered.  On  the 
other  hand,  it  is  well  known  that  a  fair  proportion 
of  the  dose  of  these  drugs  administered  intraven- 
eusly  is  excreted  during  the  first  few  hours  by  the 
kidneys.  As  yet  there  has  been  no  time  for  the 
laboratory  study  of  the  excretions  after  the  adminis- 
tration of  salvarsan  by  rectum.  But  it  would  seem 
that  by  this  method  the  kidney  waste  should  be 
reduced.  For,  when  a  given  dose  of  arsenobenzol 
is  injected  directly  into  the  blood  stream  the  con- 
centration in  the  blood  rises  immediately  to  above 
its  kidney  threshold  value,  and  is  only  reduced  to 
below  this  value  after  the  liver  has  had  time  to  effect 
a  balance  between  storage  and  circulation.  Mean- 
while much  of  the  drug  has  been  lost  by  the  kidney 
excretion.  In  injections  by  rectum  absorption  is 
slow,  and  the  absorbed  product  passes  directly  to 
the  liver,  so  that  the  latter  is  probably  able  to  eft'ect 
the  balance  between  the  storage  and  circulation  be- 
fore the  concentration  of  the  drug  in  the  blood  ever 
reaches  the  kidney  threshold.  For  this  reason  the 
kidney  threshold  is  probably  never  exceeded  in  the 
blood  and  none  of  the  drug  is  lost  in  the  urine. 

CONCLUSION. 

Inasmuch  as  we  have  been  able  to  clear  up  or 
modify  the  secondary  stages  of  syphilis  and  the 
reaction  of  the  patients'  blood  to  the  Wassermann 
test  by  the  rectal  administration  of  salvarsan  in  the 
form  of  enteroclysis,  without  the  use  of  mercury  or 
iodides,  we  believe  this  to  be  a  satisfactory  method 
for  its  administration  to  those  who  are  in  need  of 
it  and  who  cannot  receive  it  intravenously. 


SEVEN  GENERATIONS  OF  PHYSICIANS. 

By  George  Schuyler  Bangert,  Ph.  G.,  M.  D., 
East  Orange,  N.  J., 

Late  Acting  Assistant  Surgeon  L^.  S.  P.  H.  S.;  Assistant  Surgeon 
U.  S.  P.  H.  S.  (Reserve);  Officers'  Reserve  Corps;  U.  S.  Army; 
Member   New  Jersey  Historical  Society. 

An  interesting  family  leaning  towards  medicine  is 
shown  in  the  Shippen  family.  In  the  first  genera- 
tion appears  the  name  of  Edward  Shippen,  M.  A., 
M.  D.,  the  son  of  Rev.  Robert  Shippen,  B.  A., 
M.  A.,  D.  D.,  and  a  nephew  of  Edward  Shippen 
(first  mayor  of  Philadelphia),  and  a  brother  of 
Downright  William  Shippen,  B.  A.,  LL.  B.,  M.  P., 
and  a  brother  of  Rev.  Robert  Shippen,  B.  A.,  M. 
A.,  D.  D.  (vice  chancellor  of  Oxford).  He  was 
born  in  Methley,  England,  in  1671  and  married 
Frances  Leigh,  daughter  of  Peter  Leigh  of  Lynne. 
He  received  his  degrees  from  Brasenose  College, 
Oxford,  and  subsequently  succeeded  his  brother 
Robert  as  professor  of  music  at  Gresham  College. 
He  was  also  a  physician. 

In  the  second  generation  we  find  the  name  of  Dr. 
William  Shippen,  Sr.  (member  of  Continental  Con- 
gress). He  was  the  son  of  Joseph  Shippen  and 
Abigail  Gross,  and  a  grandson  of  Edward  Shippen 
(first  mayor  of  Philadelphia).  (There  is  an  India 
ink  sketch  of  him  by  Mrs.  Frances  B.  Pierce  in  the 
possession  of  the  Pennsylvania  Historical  Society, 
Philadelphia,  together  with  an  etching  of  the  same 
by  Albert  Rosenthal,  1884.)    He  was  born  in  Phila- 


delphia October  1,  1712.  He  applied  himself  early 
in  life  to  the  study  of  medicine  for  which  he  had  a 
remarkable  genius,  possessing  that  instinctive  knowl- 
edge of  diseases  which  cannot  be  acquired  from 
books.  He  seems  to  have  inherited  his  father's 
eager  desire  to  explore  the  domains  of  physical 
science  and  no  doubt  the  Junto  (American  Phil- 
osophical Society)  had  its  influence  in  shaping  his 
course  in  life.  It  is  not  known  what  university 
granted  him  his  M.  D.,  but  it  is  thought  that  he 
received  his  early  training  under  one  of  the  Welsh 
Chirurgeons  who  were  brought  to  this  country  by 
William  Penn.  He  received  his  literary  education 
and  medical  instruction  in  Philadelphia  where  he 
studied  with  Dr.  Cadwalader  and  under  Dr.  John 
Kearsley,  Jr.  He  was  a  colleague  of  Dr.  Zachary. 
L'pon  Dr.  Cadwalader's  return  from  Europe,  1730, 
he  made  dissections  and  demonstrations  for  the  in- 
struction of  Dr.  William  Shippen,  Sr.  These  in- 
structions were  given  in  the  building  where  the 
bank  of  Pennsylvania  stood  in  1809.  In  1903  the 
United  States  bonded  warehouse  was  built  there. 
It  is  on  the  west  side  of  Second  Street  above  Wal- 
nut Street. 

Dr.  Shippen  is  recorded  as  being,  besides  a  physi- 
cian, a  chemist  and  an  apothecary.  (1)  He  speedily 
obtained  a  large  and  lucrative  practice  which  he 
maintained  throughout  a  long  and  respected  life. 
He  was  especially  liberal  towards  the  poor  and  not 
only  gave  his  professional  aid  and  medicines  with- 
out charge  but  often  assisted  with  donations  from 
his  purse.  He  was  very  successful  in  his  practice 
but  did  not  by  any  means  think  that  medicine  was 
advanced  to  perfection.  It  is  said  when  he  was  con- 
gratulated by  someone  on  the  number  of  cures  he 
effected  and  the  few  patients  he  lost,  he  said,  "My 
friends,  nature  does  a  great  deal  and  the  grave  cov- 
ers up  our  mistakes."  Because  he  was  conscious  of 
the  deficiencies  of  medical  education  in  America  and 
was  animated  by  a  patient  desire  to  remedy  them 
Dr.  Shippen  trained  his  son  William,  Jr.,  and  sent 
him  to  the  University  of  Edinburgh,  where  he  had 
every  opportunity  to  obtain  a  knowledge  of  the 
various  branches  of  medicine.  On  his  return.  May 
1678,  he  commenced  a  series  of  lectures  on  anatomy 
in  one  of  the  large  rooms  of  the  State  House  and 
thus  was  begun  the  first  medical  school  in  America 
(L'niversity  of  Pennsylvania).  Dr.  William  Ship- 
pen,  Sr.,  was  not  much  interested  in  politics  but  at 
the  close  of  1778  when  the  outlook  for  the  Ameri- 
cans was  very  dark  he  was  called  upon  to  take  part 
in  the  convention  of  the  nation.  On  November  16, 
1778  (2)  he  was  elected  to  the  Continental  Congress 
by  the  Assembly  of  Pennsylvania  by  a  vote  of 
twenty-seven.  He  was  elected  to  a  second  term 
November  13,  1779.  Throughout  both  terms  he  was 
constant  in  his  attendance  (3).  His  advanced  years 
and  his  professional  duties  would  have  furnished 
ample  excuse  to  a  less  patriotic  citizen  for  declining 
the  thankless  position.  Dr.  Shippen  was  always  at 
his  post  and  his  vote  was  that  of  an  honest,  intelli- 
gent, highminded,  patriotic  gentleman  who  thought 
always  of  his  country's  welfare.  Dr.  Shippen  took 
an  earnest  part  in  the  Junto  from  which  probably 
sprang  the  American  Philosophical  Society.  He 
was  elected  to  this  society,  November,  1767,  and  was 


278 


BANGERT:   THE  SHIPPEN  FAMILY. 


[New  York 
Medical  Journai. 


made  vice-president  1768-9,  and  was  a  member  for 
many  years.  He  was  elected  physician  to  the  Penn- 
sylvania Hospital  for  twenty-five  years  from  1753- 
1778.  He  was  one  of  the  five  prominent  physicians 
serving  on  the  board  of  trustees  from  1755-79. 

He  was  also  one  of  the  trustees  of  the  Academy 
in  1749.  He  helped  found  the  Second  Presbyterian 
Church  of  Philadelphia,  1742,  and  was  a  member  of 
it  for  nearly  sixty  years.  He  was  one  of  the  foun- 
ders and  for  thirty  years  a  trustee  of  the  College  of 
Xew  Jersey  (Princeton).  (One  of  the  stained 
windows  at  that  University  contains  the  Shippen 
coat  of  arms.)  He  possessed  a  powerful  frame  and 
vigorous  health  for  which  his  race  was  noted.  At 
the  age  of  ninety  he  rode  horseback  from  German- 
town  to  Philadelphia  in  the  coldest  weather  without 
an  overcoat ;  and  but  a  short  time  before  his  death 
he  took  a  walk  of  six  miles  from  Germantown  to 
his  son's  house  in  Philadelphia.  His  mode  of  liv- 
ing was  simple  and  unostentatious.  His  tempera- 
ment was  so  very  serene  and  forbearing  that  tradi- 
tion says:  "It  was  never  ruffled."  His  benevolence 
was  without  stint. 

He  was  married  in  Philadelphia,  September  19, 
1735,  to  Susanna  Harrison,  the  eldest  daughter  of 
Joseph  Harrison  and  Catherine  Noble  of  Philadel- 
phia. She  was  the  granddaughter  of  John  Harrison 
and  his  wife,  Mary.  Dr.  Shippen  lived  beloved  and 
on  November  4,  1801,  in  Germantown,  Pa.,  at  the 
age  of  ninety  bowed  his  head,  regretted  and  la- 
mented, and  was  buried  in  the  graveyard  of  the 
church  to  which  he  had  been  so  useful  in  Philadel- 
phia. His  summer  home  which  he  built  in  Oxford 
Furnace,  N.  J.,  about  1742,  is  still  standing  well 
preserved.  Dr.  Shippen  owned  10,000  acres  of 
land  in  what  is  now  Sussex  and  Warren  counties, 
N.  J. 

In  the  third  generation  we  find  two  brothers,  both 
sons  of  Dr.  William  Shippen,  Sr.,  and  Susanna 
Harrison,  i.  e..  Dr.  William  Shippen,  Jr.,  and  Dr. 
John  Shippen.  Dr.  John  Shippen,  A.  B.,  A.  M., 
M.  D.,  was  born  in  Philadelphia,  Pa.,  January  23, 
1740.  He  was  a  graduate  of  the  College  of  New 
Jersey,  1758;  studied  with  his  father  and  at  the 
Medical  Department  of  the  University  of  Rheims, 
France.  He  received  the  degree  of  M.  D.  there. 
On  his  return  to  America,  April  5,  1770,  he  began 
a  course  of  lectures  on  fossils.  He  died  unmarried 
in  Baltimore,  Md.,  November  26,  1770.  Dr.  Wil- 
liam Shippen,  Jr.,  B.  A.,  M.  A.,  M.  D.,  the  father 
of  scholastic  medicine  in  America,  was  surgeon 
general  of  the  United  States  during  the  Revolution 
and  the  first  professor  of  anatomy  in  America  and 
the  founder  of  the  first  medical  school  in  America, 
i.  e.,  the  University  of  Pennsylvania. 

Dr.  William  Shippen,  Jr.,  was  born  in  Philadel- 
phia December  21,  1736,  and  died  in  Germantown, 
Pa.,  July  11,  1808.  He  was  married  in  London, 
England,  to  Alice  Lee  of  Virginia,  daughter  of 
Col.  Thomas  Lee,  Governor  fo  Virginia.  Dr.  Ship- 
pen  was  one  of  the  founders  of  the  first  medical 
school  in  America,  the  University  of  Pennsylvania. 
He  delivered  the  first  course  of  lectures  in  America 
on  anatomy  November  16,  1762,  and  was  mobbed  by 
the  public  when  he  first  introduced  dissection.  He 
continued  to  lecture  on  anatomy  and  obstetrics  until 


December  23,  1765.  He  was  elected  professor  of 
anatomy  and  surger\-  in  the  Medical  School  Col- 
lege of  Philadelphia,  September  23,  1765.  He  was 
chief  physician  of  the  Flying  Camp  during  the 
Revolution.  He  laid  before  Congress  a  plan  for 
the  organization  of  the  Medical  Department  which 
with  some  modifications  was  adopted.  On  April 
11,  1777,  he  was  unanimously  elected  director  gen- 
eral of  all  the  military  hospitals  of  the  United  States 
army. 

He  was  president  of  the  University  of  Pennsyl- 
vania, Medical  Department,  from  1805  until  his 
death.  He  was  a  graduate  of  the  College  of  New 
Jersey  and  valedictorian  of  the  class  of  1754.  From 
that  institution  he  received  the  degrees  A.  B.,  M.  A. 
and  received  his  M.  D.  from  the  University  of 
Edinburgh,  class  1761.  He  studied  under  Senac, 
John  Hunter,  McKenzie,  and  Smellie.  After  study- 
ing in  Eftrope  he  returned  to  America,  1762.  He 
was  a  member  of  the  American  Philosophical  So- 
ciety, also  one  of  the  first  physicians  appointed  to 
the  Philadelphia  Hospital.  A  eulogy  on  Dr.  Ship- 
pen  was  delivered  by  request  by  C.  Wistar  as  an 
introductorv  lecture  to  the  medical  class  in  the 
autumn  of' 1808  (Portfolio  Third  Series,  Vol.  1, 
No.  2,  February,  1813).  He  was  noted  for  his 
graceful  personality,  polite  manners,  power  of  con- 
versation, sociability,  conciliatory  nature. 

iTe  reviewed  a  lecture  not  by  interrogation  but 
by  recapitulation.  His  portrait  by  Gilbert  Stuart 
is  in  Corcoran  Art  Gallery,  Washington,  D.  C.  one 
in  Independence  Hall,  Philadelphia,  one  at  the 
University  of  Pennsylvania  and  one  at  the  Penn- 
sylvania Historical  Society. 

In  the  fourth  generation  we  find  Edward  Ship- 
pen,  A.  B.,  M.  D.,  a  son  of  the  Chief  Justice,  Ed- 
ward Shippen,  and  Margaret  Francis,  and  a  brother 
of  Peggy  Shippen,  who  married  Major  General 
Arnold  while  an  officer  in  the  American  army.  Dr. 
Shippen  was  born  in  Philadelphia,  December  11, 
1758,  and  died  in  Burlington,  N.  J.,  October  22, 
1809.  He  married  Elizabeth  Julianna  Footman, 
November  23,  1785,  at  Christ  Church,  Philadelphia. 
He  studied  medicine  at  Edinburgh  and  afterwards 
took  a  course  in  London  and  Paris.  He  removed 
to  Burlington,  N.  J.,  in  1795,  after  having  studied 
under  Dr.  Bond.  In  Burlington  he  became  the 
partner  of  Dr.  Mclllvain,  his  brother-in-law.  He 
was  a  man  of  agreeable,  hearty  manner  and  fond 
of  horses.  He  had  an  excellent  practice.  A 
picture  of  him  taken  in  London  shows  him  as  a 
student,  a  handsome  youth,  with  powdered  hair,  lilac 
colored  coat,  gold  waistcoat. 

Also  in  the  fourth  generation  we  find  his  first 
cousin,  Joseph  Galloway  Shippen,  M.  D.,  who  was 
the  son  of  Col.  Joseph  Shippen,  A.  B..  and  Jane 
Galloway.  He  was  born  in  Plumley,  Pa.,  Decem- 
ber 25.  1783,  and  died  September  6,  1857.  He  mar- 
ried Ann  Martha  Buckley,  November  10,  1814, 
daughter  of  Daniel  and  Sarah  (Brooke)  Buckley. 
He  graduated  from  the  University  of  Pennsylvania 
with  the  degree  of  ]\I.  D.  and  was  a  practicing 
physician. 

In  the  fifth  generation  is  the  name  of  Joseph 
Shippen,  M.  D.,  who  was  a  son  of  Dr.  Joseph 
Galloway  Shippen  and  Ann  Maria  Buckley.  Also 


August  28,  1920.] 


BLAU:   THE  SCHICK  TEST. 


279 


in  this  generation  was  William  Shippen,  A.  B., 
M.  D.,  who  was  a  son  of  Thomas  Lee  Shippen  and 
Elizabeth  Carter  Farley  Bannister  and  a  grandson 
of  Dr.  William  Shippen,  Jr.  He  was  born  in  Far- 
ley, Pa.,  January  29,  1792,  and  was  married  in 
Petersburg,  Va.,  February  13,  1817,  to  Mary  Louise 
Shore,  daughter  of  Thomas  and  Jane  Gray  (Wall) 
Shore  of  Violet  Bank,  Va.  Dr.  Shippen  was  vice 
president  of  the  Pennsylvania  Historical  Society, 
trustee  of  the  College  of  Xew  Jersey  (1841-1867), 
graduate  of  the  University  of  Pennsylvania,  M.  D., 
1814.  He  studied  medicine  under  Dr.  Wistar.  He 
was  a  demonstrator  of  anatomy  in  the  university. 
He  died  in  Philadelphia,  June  5,  1867. 
~In  the  sixth  generation  are  two  of  the  same  name. 
The  first,  Edward  Shippen,  A.  B.,  A.  M.,  M.  D., 
United  States  Army,  was  a  son  of  \\'illiam  Shippen, 
;M.  D.,  and  Mary  Louise  Shore.  He  was  born  in 
Farley,  Pa.,  June  23,  1827.  He  was  a  graduate  of 
the  University  of  Pennsylvania,  class  of  1846,  and 
received  his  M.  D.  with  the  class  of  1857.  He 
married  Rebecca  Lloyd  (Nicholson)  Post,  the 
granddaughter  of  Judge  Hooper  Nicholson  and 
Rebecca  Lloyd,  December  3,  1878.  Dr.  Shippen 
was  a  distinguished  surgeon  during  the  Civil  war 
and  among  other  services  had  charge  of  the  Capitol 
at  Washington,  D.  C,  when  it  was  used  as  a  hos- 
pital. He  had  1,000  wounded  men  luider  his  care. 
Later  he  was  with  General  Griffin  as  surgeon  in 
chief  of  the  Fifth  Army  corps,  and  then  as  medical 
director  of  the  Twenty-third  Army  corps  under 
General  Scofield  where  he  remained  during  the 
rest  of  the  war.  He  died  April  22,  1895,  in  Bal- 
timore, Md. 

The  second  name  in  the  sixth  generation  is  that 
of  Edward  Shippen,  A.  B.,  A.  ^NL,  M.  D.  (rear 
admiral  United  States  Navy).  He  was  a  son  of 
Richard  Footman  Shippen  and  Ann  Elizabeth 
Farmer.  He  was  a  grandson  of  Dr.  Edward  Ship- 
pen  of  the  fourth  generation.  He  was  born  at 
Singletree.  Bordentown.  N.  J..  June  18,  1826,  and 
died  at  Chestnut  Hill,  Pa.,  Jime  16,  1911.  He 
graduated  from  Princeton  in  1845  and  the  L'niver- 
sity  of  Pennsylvania  in  1848.  He  entered  the 
United  States  Navy  from  Pennsylvania  as  assistant 
surgeon,  August  7,  1849,  was  made  surgeon,  April 
26,  1861,  and  sent  to  the  coast  of  China  and  Africa 
and  South  America  and  on  the  European  station  for 
four  years.  He  was  on  the  Congress  when  she  was 
destroyed  by  the  Mcrriiiiac  at  Newport  News,  \'a., 
]\Iarch  8,  1862,  and  was  injured  by  a  shell.  He  was 
on  the  ironclad  Xcw  Ironsides  in  both  the  attacks 
on  Fort  Fisher  and  the  operation  of  Bermuda  Hun- 
dred. He  made  a  Russian  cruise  under  Admiral 
Farragiit,  1870-1.  He  was  chief  surgeon  at  the 
Naval  Academy,  Annapolis,  Md.,  and  medical  in- 
spector in  1871  ;  fleet  surgeon  of  the  European 
Squadron,  1871-3 ;  medical  director  at  the  Naval 
Asylum,  1876;  president  of  the  ^ledical  Examining 
Board  of  Philadelphia,  1880-2,  and  for  nearly  seven 
years  in  charge  of  the  Naval  Hospital  at  Philadel- 
phia. He  was  a  writer  on  medical  topics.  He 
was  retired  in  1888  and  in  1907  made  rear  admiral 
on  the  retired  list.  He  was  a  Fellow  of  the  College 
of  Physicians  and  Surgeons  of  Philadelphia ;  presi- 
dent of  the   Pennsylvania  Genealogical   Society ; 


member  of  the  Pennsylvania  Historical  Society ; 
commander  of  the  Military  Order  of  the  Loyal 
Legion,  Deputy  Governor  of  the  Society  of  Colonial 
Wars  of  Pennsylvania;  one  of  the  vice  presidents 
of  the  University  Club.  He  married  ]Mary  Cather- 
ine Paul  on  January  13,  1853,  daughter  of  Dr.  John 
Rodman  Paul  and  Elizabeth  Duffield  Neill  of  Phila- 
delphia. She  was  born  in  Philadelphia.  Tulv  23, 
1829,  and  died  there  January  18,  1905. 

In  the  seventh  generation  we  find  three  names  of 
men  who  are  first  cousins,  i.  e.,  Lloyd  Parker  Ship- 
pen,  M.  D.,  U.  S.  N.,  M.  R.  C.,  who  is  the  son  of 
Edward  Shippen  and  Rebecca  Lloyd  Post.  He  mar- 
ried Florence  Hawley  Brush.  He  graduated  from 
the  University  of  Pennsylvania  (1907)  and  is  a 
member  of  the  Pennsylvania  Commandery  of  the 
Military  Order  of  the  Loyal  Legion.  Charles 
Carroll  Shippen,  M.  D.,  A.  B.,  was  the  son  of 
William  Shippen,  A.  B.,  A.  M.,  LL.  B.,  and  Achsah 
Ridgley  Carroll.  He  was  born  in  Philadelphia,  Pa., 
October  29,  1856,  and  died  in  Baltimore,  Md., 
November,  1905  (unmarried).  He  graduated  from 
the  University  of  Maryland  in  1879.  William 
Shippen,  M.  D.,  U.  S.  A.,  son  of  Thomas  Lee 
Shippen  and  Jane  Gray  Gilliam,  and  grandson  of 
Dr.  John  Gilliam,  was  born  in  Arrowfield,  \'a.. 
May  21,  1861,  and  died  (immarried)  November 
17,  1913,  at  his  home  in  Petersburg,  W.  Va.  He 
served  twenty  years  in  the  United  States  army  as 
a  surgeon. 

REFEREXCES. 

1.  Peiiiisylz'aiiia  Magazine  of  History  and  Biography. 

2.  Colonial  Records,  vol.  ii,  12. 

3.  Journal  of  Continental  Congress. 


THE  SCHICK  TEST,  ITS  CONTROL,  AND 
ACTIVE  IMMUNIZATION  AGAINST 
DIPHTHERIA. 

By  Arthur  I.  Blau,  M.  D.. 

Xew  York, 

Diagnostician,  Department  of  Health 

I  shall  endeavor  to  give  a  brief  outline  of  the 
salient  features  of  the  Schick  test  and  active  im- 
munization against  diphtheria.  The  summary  pre- 
sents a  working  knowledge  of  the  test  and  immuniz- 
ation, as  practised  in  the  Stuyvesant  Branch  of 
the  Department  of  Health.  Personal  observations 
from  the  work  carried  on  in  the  Stuyvesant 
Branch  Clinic  are  noted  in  full.  This  article  should 
be  of  particular  value  to  the  physicians  of  the 
Department,  who  are  doing  the  Schick  test  for  the 
Department's  patients,  and,  secondarily,  to  physi- 
cians desiring  a  concise  description  of  the  test  and 
immunization. 

The  Schick  test  is  a  practical  and  reliable  test 
by  which  the  antitoxic  immunity  of  a  person 
against  diphtheria  can  be  determined.  The  im- 
munization is  for  the  purpose  of  protection  against 
diphtheria.  In  the  progress  of  modern  medicine 
the  Schick  test  and  active  immunization  against 
diphtheria  occupy  a  most  prominent  and  impor- 
tant place.  In  the  determination  of  the  antitoxic 
immunity  of  a  person  against  diphtheria  the  Schick 


280 


BLAU:   THE  SCHICK  TEST. 


[New  York 
Medical  Journal 


test  is  as  reliable  a  diagnostic  aid  as  the  Widal 
is  in  typhoid  fever,  or  as  the  Wassermann  is  in 
lues.  When  we  realize  the  prevalence  of  diph- 
theria among  children,  and  the  high  degree  of  mor- 
tality we  will  appreciate  the  importance  of  the  Schick 
test  and  active  immunization  in  the  prophylaxis  and 
final  eradication  of  diphtheria.  Since  the  ages  of 
one  to  five  years  is  the  period  in  which  children 
are  most  susceptible  to  diphtheria  and  the  mor- 
tality greatest,  the  necessity  of  the  application  of 
the  test  and  active  immunization  early  in  the 
child's  life,  before  the  age  of  eighteen  months,  so 
that  the  child  may  be  protected  against  diphtheria  in 
that  crucial  period,  becomes  apparent. 

THE  SCHICK  TEST. 

Supplies. — The  supplies  used  are  those  furnished 
by  the  Health  Department.  Either  of  two  outfits 
may  be  used  for  the  test,  namely,  the  capillary  or 
the  stock  solution. 

1.  The  capillary  outfit  consists  of  a  capillary 
tube  in  a  thin  wooden  box.  This  tube  contains  the 
unheated  diphtheria  toxin.  A  second  capillary  tube 
in  a  thin  wooden  box.  This  tube  has  a  black  mark 
at  one  end  and  contains  the  heated  diphtheria 
toxin,  for  use  in  the  control  test.  The  toxin  in  this 
capillary  tube  is  the  same  as  that  in  the  first  tube, 
but  has  been  heated  to  75°  C.  for  five  minutes.  The 
heating  destroys  the  diphtheria  toxin,  which  is  the 
active  agent  in  the  positive  Schick  test,  but  does 
not  effect  the  protein  substance  of  the  diphtheria 
bacillus,  which  produces  the  pseudoreaction.  The 
black  mark  on  the  capillary  tube  is  designed  for 
differentiating  the  heated  from  the  unheated  toxin. 
Two  small  vials,  each  containing  ten  c.  c.  of  normal 
saline  solution,  to  be  used  as  diluents  for  the  toxin 
in  the  capillary  tubes,  one  vial  for  the  Schick  test, 
and  the  other  for  the  control.  Two  small  rubber 
bulbs,  one  for  each  capillary  tube.  The  contents 
of  both  vials,  with  the  toxin  introduced,  are  suf- 
ficient for  thirty-five  tests  and  if  kept  on  ice  are 
good  for  use  only  twenty-four  hours. 

2.  The  stock  solution  outfit:  Since  the  capillary 
Schick  test  outfit  can  only  be  used  for  twenty-four 
hours,  a  stock  solution  can  be  made  which  is  good 
for  a  longer  period.  The  supplies  and  the  method 
of  preparation  of  the  toxin  solutions  are  as  fol- 
lows :  One  vial  containing  two  c.  c.  of  original  diph- 
theria toxin,  from  which  all  stock  solutions  are 
made.  This  toxin  is  not  ready  for  use.  To  be  used 
it  has  to  be  diluted.  If  kept  on  ice,  this  toxin  is 
good  for  two  months.  From  the  original  diph- 
theria toxin,  (a),  a  primary  stock  solution  is  made 
as  follows :  One  c.  c.  of  this  toxin  is  added  to  six 
and  a  half  c.  c.  of  normal  saline  solution  and  the 
mixture  shaken.  This  primary  stock  solution  is  not 
ready  for  use.  To  be  used  it  has  to  be  further 
diluted.  If  kept  on  ice,  this  primary  stock  solution 
is  good  for  two  weeks.  One  c.  c.  of  the  primary 
stock  solution,  (b),  is  added  to  ninety-nine  c.  c.  of 
normal  saline,  or  1  c.  c.  of  the  primary  stock  solu- 
tion, (b),  is  added  to  9.9  c.  c.  of  normal  saline,  or 
.1  of  saline  solution  is  withdrawn  from  the  10 
c.  c.  saline  vial,  and  that  amount  (.1)  is  replaced 
with  a  similar  amount  of  the  primar>-  stock  solu- 
tion, (b),  and  the  mixture  is  shaken.    This  latter 


solution  is  the  secondary  stock  solution.  It  is  the 
final  dilution  and  ready  for  use  in  the  Schick  test. 

TECHNIC  OF  THE  TEST. 

Directions  for  the  use  of  the  capillary  outfit  in 
the  Schick  test: 

1.  Break  off  one  end  of  the  capillary  tube  not 
having  the  black  mark. 

2.  Push  the  broken  end  of  the  tube  through  the 
neck  of  the  rubber  bulb,  until  it  punctures  the  dia- 
phragm and  enters  the  cavity  of  the  bulb. 

3.  Break  off  the  other  end  of  the  tube. 

4.  Expel  the  contents  of  the  capillary  tube  into 
one  of  the  vials  containing  ten  c.  c.  of  saline  solu- 
tion by  placing  the  index  finger  over  the  opening 
in  the  larger  end  of  the  bulb. 

5.  Rinse  the  capillary  tube  by  drawing  up  saline 
solution  several  times. 

6.  Cork  the  saline  vial  and  shake  the  diluted  toxin. 

7.  Inject  0.2  c.  c.  of  the  diluted  toxm,  repre- 
senting one  fiftieth  M.  L.  D.  for  the  guineapig,  in- 
tracutaneously  on  the  flexor  surface  of  the  left 
forearm. 

The  procedure  for  the  use  of  the  capillary  outfit  in 
the  control  test  is  identical  with  that  employed  in 
the  Schick  test,  but  using  the  capillary  tube  with 
the  black  mark,  and  making  the  injection  on  the 
flexor  surface  of  the  right  forearm. 

Directions  for  the  use  of  the  secondary  stock 
solution  in  the  Schick  test :  Inject  0.2  c.  c.  of  the 
final  dilution,  i.  e.,  the  secondary  stock  solution, 
intracutaneously  into  the  flexor  surface  of  the  left 
forearm,  the  same  way  as  is  used  with  the  capillary 
toxin.  Whenever  possible  the  capillary  toxin  should 
be  used  in  preference  to  the  stock  toxin  in  making 
the  Schick  tests,  as  the  capillary^  toxin  requires  no 
dilution  and  no  preparation,  being  ready  for  use  as 
it  is.  The  stock  solution  should  only  be  used  when 
Schick  tests  are  infrequently  made,  and  the  number 
of  cases  to  be  tested  but  few.  In  other  words  when 
we  wish  to  have  a  reserve  supply  of  Schick  toxin, 
to  be  used  as  occasion  arises,  the  stock  solution  is 
preferred.  However,  for  the  general  practitioner 
the  capillary  toxin  is  recommended  for  all  occasions. 
For  the  control  test  the  capillary  control  outfit  is 
used  in  either  case,  whether  the  Schick  test  is  made 
with  the  toxin  in  the  capillary  tube  or  with  the  toxin 
from  the  stock  solution. 

METHOD  OF  INJECTION. 

This  is  the  same  in  all  tests,  in  the  capillary 
Schick  test,  in  the  capillary  control  test  and  in  the 
stock  solution  Schick  test.  The  procedure  should 
be  uniform  in  all  tests,  and  conducted  as  follows: 
Sterilize  the  skin  with  cotton  soaked  with  alcohol  and 
then  insert  the  needle  into  the  skin.  An  efficient 
guide  for  the  introduction  of  the  needle  into  the 
proper  layer  of  the  skin  is  to  be  able  to  see  the 
oval  opening  of  the  needle  through  the  superficial 
layers  of  skin  cells.  A  definite,  blanched,  circum- 
scribed, wheellike  elevation,  the  size  of  a  dime,  with 
the  markings  of  the  openings  of  the  hair  follicles 
distinct,  shows  that  the  injection  is  properly  made. 
An  ordinary  one  c.  c.  hypodermic  syringe,  with  a 
fine  half  inch  steel  needle  can  be  used  for  the 
injections.  The  site  of  the  injection  need  not  be 
covered. 


August  28,  1920.] 


BLAU:   THE  SCHICK  TEST. 


281 


THE  REACTIONS. 

The  reactions  should  be  observed  at  the  end  of 
twenty-four  and  forty-eight  hours,  basing  the  final 
judgment  on  the  last  reading.  In  case  of  doubt,  a 
reading  should  also  be  made  at  the  end  of  four 
days. 

1.  The  positive  (-|-)  reaction  becomes  apparent 
at  the  end  of  from  one  to  four  days,  generally  at 
the  end  of  two  days,  at  a  time  when  the  pseudo 
element  of  the  reaction  has  disappeared.  It  con- 
sists of  a  definitely  circumscribed  area  of  redness, 
from  one  to  two  and  a  half  cm.  in  diameter,  with  a 
superficial  scaling  and  a  beginning  brownish  pig- 
mentation. A  strongly  positive  reaction  will  occa- 
sionally show  vesiculation  of  the  surface  layers  of 
the  epithelium.  The  reaction  gradually  disappears 
in  from  one  to  four  weeks,  going  through  various 
stages  of  scaling  and  pigmentation.  After  about 
two  weeks  a  distinct  brownish  area  is  seen  at  the 
site  of  the  injection. 

2.  The  negative  ( — )  reaction.  In  most  cases 
nothing  is  seen  at  the  site  of  the  injection.  In  a 
small  proportion  of  cases  a  pseudoreaction  is  man- 
ifest. 

3.  The  pseudoreaction  shows  an  indefinite  area 
of  redness  of  varying  size,  surrounded  by  a  sec- 
ondary areola,  which  shades  into  the  surrounding 
skin.  The  pseudoreaction  appears  earlier  than  the 
positive  reaction,  in  from  six  to  eighteen  hours, 
reaches  its  height  in  from  twenty-four  to  thirty-six 
hours,  and  has  disappeared  by  the  end  of  from 
two  to  four  days,  at  a  time  when  the  positive  re- 
action becomes  apparent,  and  may  leave  a  poorly 
defined  area  of  pigmentation,  but  generally  no  scal- 
ing. 

4.  The  combined  reaction  is  a  reaction  showing 
a  positive  and  a  pseudoreaction  in  one.  The  posi- 
tive element  of  the  reaction  becomes  apparent  at  the 
end  of  from  two  to  four  days,  at  a  time  when  the 
pseudo  element  of  the  reaction  has  disappeared.  The 
appearance  of  the  positive  element  of  the  reaction  is 
that  described  under  1.  The  appearance  of  the 
pseudo  element  of  the  reaction  is  that  described 
under  3.  and  reseipbles  the  reaction  at  the  site  of 
the  control  test,  if  there  is  a  reaction  at  the  control, 
with  which  it  should  be  compared. 

5.  The  doubtful  (+  — )  reaction.  At  times 
doubt  arises  as  to  what  the  reaction  really  is.  The 
reaction  may  not  be  typically  positive,  or  typically 
negative,  or  typically  a  pseudoreaction.  In  such 
cases  the  leaning  should  be  toward  a  positive  read- 
ing. 

6.  In  the  control  reaction,  as  a  rule,  nothing  is 
manifest  at  the  site  of  the  control  test.  Occasional- 
ly the  control  test  shows  a  pseudoreaction. 

INTERPRETATIONS  OF  THE  REACTIONS. 

1.  A  positive  reaction.  If  the  person  tested  is 
not  immune  to  diphtheria,  the  toxin  in  the  Schick 
test  will  exert  its  irritant  action,  and  the  reaction 
is  positive.  A  positive  reaction  shows  that  the  indi- 
vidual has  no  antitoxin  in  his  blood,  showing  that 
he  is  not  immune  to  diphtheria,  and  that  he  needs 
active  immunization  against  diphtheria  to  render 
him  immune  against  the  disease. 

2.  A  negative  reaction  shows  that  the  individual 


is  immune  against  diphtheria,  and,  therefore,  needs 
no  active  immunization.  It  also  indicates,  in  chil- 
dren over  eighteen  months  of  age,  the  development 
of  a  natural  immunity  against  diphtheria,  which  ap- 
parently is  permanent. 

3.  A  pseudoreaction  has  the  same  significance  as 
a  negative  reaction. 

4.  A  combined  reaction  has  the  same  significance 
as  a  positive  reaction. 

5.  A  doubtful  reaction  should  be  considered  as  a 
positive  reaction,  and,  therefore,  requires  immuniz- 
ation. 

The  Schick  test  is  positive  between  the  ages  of 
one  and  four  years  in  about  thirty-two  per 
cent,  of  normal  children.  It  is  positive  in  a  slight- 
ly larger  proportion  of  measles  cases,  in  twice  as 
many  cases  of  scarlet  fever,  and  in  nearly  three 
times  as  many  cases  of  poliomyelitis.  Susceptibility 
to  one  of  the  less  contagious  diseases,  like  polio- 
myelitis, indicates  that  the  child  is  more  likely  to  be 
susceptible  to  other  contagious  diseases.  After  the 
sixth  year  the  proportion  of  positive  reactions 
rapidly  decreases,  being  positive  in  from  four  to 
ten  per  cent.  only.  In  adults  eighty-five  to  ninety- 
five  per  cent,  of  the  tests  are  negative. 

ACTIVE  IMMUNIZATION. 

For  active  immunization  against  diphtheria  a 
solution  of  undiluted  diphtheria  toxin  and  antitoxin 
is  used.  This  mixture  of  toxinantitoxin  is  slight- 
ly toxic  and  represents  about  eighty-five  per  cent, 
of  an  L-|-  dose  of  toxin  to  each  unit  of  antitoxin, 
there  being  three  units  of  antitoxin  in  one  c.  c.  of  the 
mixture.  The  immunity  produced  is  probably  per- 
manent. Three  injections,  of  one  c.  c.  each,  irre- 
spective of  the  age  of  the  individual,  of  the  toxin- 
antitoxin  mixture  are  given  at  seven  days'  interval, 
the  first  being  given  as  soon  as  a  positive  reaction  is 
noted.  The  injections  are  made  subcutaneously  in 
the  arm  at  the  insertion  of  the  deltoid  muscle, 
after  having  painted  the  skin  where  the  injection  is 
to  be  made  with  iodine.  The  first  injection  is  made 
in  the  right  arm,  the  second  in  the  left,  and  th€ 
third  in  the  right. 

The  development  of  an  active  immunity  is  de- 
termined with  the  Schick  test  at  the  end  of  three 
months,  i.  e.,  all  completed  injected  cases  are  tested 
three  months  after  the  last  injection,  to  see  whether 
they  are  then  immune  against  diphtheria.  If  the 
test  is  negative,  the  person  has  been  made  im- 
mune against  the  disease  and  the  case  requires  no 
further  attention.  If  the  test  is  positive  the  person 
is  not  yet  immune  and  has  to  be  reinjected  and 
tested  again  after  three  months.  By  reinjecting 
those  who  still  give  a  positive  Schick  test  an  active 
immunity  can  be  developed  in  almost  all  susceptible 
persons. 

Figures  compiled  at  the  Willard  Parker  Hospital 
show  that  from  ninety  to  ninety-nine  per  cent,  of 
the  retests  are  negative;  after  one  injection,  about 
sixty  per  cent,  are  negative;  and  after  two  injec- 
tions eighty  per  cent,  are  negative.  As  the  im- 
munity arising  from  the  injection  of  toxinantitoxin 
does  not  develop  until  the  lapse  of  from  two  to 
twelve  weeks,  active  immunization  with  toxinanti- 


282 


BLAU:   THE  SCHICK  TEST. 


[New  Vork 
Medical  JofRx.u, 


toxin  cannot  be  utilized  to  protect  persons  from 
exposure  within  that  period. 

Children  between  three  and  eighteen  months 
should  be  actively  immunized  with  toxinantitoxin, 
irrespective  of  the  Schick  test,  so  that  an  efficient 
immunity  is  produced  during  the  ages  of  from  one 
to  five  years,  when  the  susceptibility  of  children  to 
diphtheria  is  the  greatest.  This  is  necessarj-  be- 
cause the  protection  of  the  infant  from  the  mother 
is  only  temporary,  and  usually  lasts  only  from  about 
six  to  nine  months.  All  children  over  eighteen 
months  of  age  should  be  tested  with  the  Schick 
test,  and  only  those  giving  a  positive  reaction  should 
be  immunized". 

PERSOXAL  OBSERVATION. 

I  have  conducted  a  practical  study  of  the  Schick 
test  and  active  immunization  against  diphtheria  with 
toxinantitoxin  in  my  work  in  the  Stuyvesant  Clinic 
of  the  Department  of  Health.  The  obstacles  en- 
countered in  my  studies  were  numerous.  The  diffi- 
culties experienced  were  due.  primarily,  to  the  lack 
of  enlightenment  on  the  subject  on  the  part  of  the 
parents.  The  general  public  knows  but  little  about 
the  Schick  test,  and  about  the  efficiency  of  active 
immunization  as  a  preventive  against  diphtheria. 
Those  of  the  public  who  do  know  something  about 
the  subject  are  indifferent  about  it  and  are  reluctant 
to  subject  their  children  to  what  they  believe  un- 
necessary inconvenience,  especially  in  the  face  of 
perfect  health.  People  are,  of  necessity,  well  versed 
in  the  indispensability  of  curative  medicine,  but  are 
as  yet  unappreciative  of  the  value  of  preventive 
medicine. 

'  Ignorance  and  indifference  were,  however,  not 
the  only  barriers  in  the  successful  completion  of 
the  studies  undertaken.  Having  with  great  labor 
convinced  a  large  number  of  the  parents  of  the  ad- 
visability of  bringing  their  children  to  the  clirric 
for  the  Schick  tests,  we  were  much  less  successful 
in  having  these  children  brought  to  the  clinic  often 
enough  to  complete  the  tests  and  the  injections.  Ire 
spite  of  the  frequent  and  persistent  home  visits 
bv  our  nurses  to  urge  prompt  attendance  we  were 
only  successful  in  a  very  small  proportion  of  the 
cases. 

Sometimes  the  child  would  stay  away  on  account 
of  illness,  other  times  attendance  at  school  or  other 
scholastic  duties  would  detain  the  child;  in  still 
other  instances,  and  not  so  rarely  at  that,  it  \ras 
fear  that  kept  the  children  away.  A  good  many 
of  the  mothers  having  consented  to  one  injection, 
would  withhold  permission  for  further  injections. 
Then  again,  a  large  proportion  of  our  patients 
moved  before  the  tests  and  injections  were  com- 
pleted, and  no  trace  could  be  found  of  their 
destination. 

On  account  of  these  unfavorable  influences  our 
research  studies  could  not  be  complete  in  all  the 
cases.  Of  a  total  of  434  cases  Schick  tested,  seventy 
never  returned  for  a  reading.  Of  111  positive 
Schick  cases,  only  nineteen  received  the  full 
series  of  three  injections,  and  of  these  nineteen 
cases  we  were  able  to  retest  only  twelve.  Almost 
half  of  our  positive  cases  only  received  one  injec- 
tion as  they  never  returned  subsequently. 


RECORD  OF  THE  CASES  STUDIED, 

Total  number  of  cases  Schick  tested   434 

Number  of  cases  not  returned  for  reading   70 

Balance    364 

Reactions  : 

Negative    227 

Positive    Ill 

Combined    3 

Doubtful    23 

Total    364 

Positive  Cases  : 

Not  injected    28 

One  injection    49 

Two  injections    15 

Three  injections    7 

Retested  cases    12 

Total    Ill 

Retested  Cases  : 

Not  returned  for  reading   2 

Positive    2 

Negative    8 

Total    12 

Combined  Reaction  Cases  : 

Not  injected    3 

Total    3 

Doubtful  Reaction  Cases  : 

Not  injected    19 

Three  injections,  not  retested   4 

Total    23 

ANALYSIS   OF   THE   CASES   ACCORDING   TO  AGES. 
Positive  Schick  tests  : 

Age  :  To  2  years   20 

2-4  years   18 

4-6  years   24 

6-14  years   48 

14  years  and  over   1 

Total    Ill 

Xegative  Schick  tests : 

Age  :  To  2  years   18 

2-  4  years   33 

4-  6  years   37 

6-14  years   136 

14  years  and  over   3 

Total   227 

Doubtful  Schick  tests  : 

Age  :  To  2  years  '.   2 

2-  4  years   2 

4-  6  years   3 

6-14  years   16 

14  years  and  over   0 

Total    23 

Combined  Schick  tests  : 

Age  :  6-14  years   3 

Total    3 

Positive  Retested  Cases    (after  three  months)  : 

Age  :  2-  4  years   1 

14  years  and  over   1 

Total    2 


Note:  These  two  positive  retest  cases  received  one  injec- 
tion each  after  the  retest,  but  never  returned  for  the  subse- 
quent injections. 

Negative  Retested  Cases  (after  three  months)  : 


Age  :  To  2  years   1 

2-  4  years   1 

4-  6  years   1 

6-14  years   5 

Total    8 


August  28,  1920.] 


GOLDSTEIX:  NEPHRITIS. 


283 


DEDUCTIOXS  FROM  OUR  STUDIES. 

It  is  evident  from  these  figures  that  more  than 
a  third  of  the  children  under  fourteen  years  of  age 
are  susceptible  to  diphtheria,  that  is,  have  no 
natural  immunity  against  the  disease.  The  great- 
est susceptibility  is  found  between  one  and  six 
years.  After  the  age  of  six  years,  the  degree  of 
susceptibility  gradually  diminishes,  as  shown  by  our 
negative  Schick  tests.  Of  a  total  of  227  negative 
Schick  tests,  136  were  between  the  ages  of  six  and 
fourteen  years. 

Although  the  immunity  produced  by  active  im- 
munization with  toxinantitoxin  was  not  quite  100 
per  cent,  in  our  series,  we  can  safely  deduce  that 
\vith  repeated  tests  and  injections,  immunity  against 
diphtheria  could  be  produced  in  100  per  cent,  of  the 
cases.  Naturally  such  results  require  the  diligent 
cooperation  of  the  patients. 

Of  our  ten  retested  cases,  eight  were  negative, 
and  only  two  were  positive,  showing  that  with  only 
one  series  of  three  injections  of  toxinantitoxin,  we 
were  able  to  produce  an  immunity  against  diphtheria 
in  eighty  per  cent,  of  the  cases.  Had  our  two 
positive  retested  cases  returned  for  further  injec- 
tions, there  is  no  doubt  in  my  mind  that  we  could 
have  made  them  react  negatively  to  the  Schick 
test,  giving  us  an  active  immunity  in  one  hundred 
per  cent,  of  the  cases. 

Whether  the  immunity  is  permanent  in  all  cases, 
we  cannot  positively  state  at  the  present  stage  of 
our  investigations.  Judging  from  the  studies  con- 
ducted at  the  Willard  Parker  Hospital,  once  an  im- 
munity is  established  it  is  probably  permanent. 

Advances  in  the  knowledge  of  the  medical  sci- 
ences should  be  applied  for  the  benefit  of  mankind. 
What  could  benefit  humanity  more  than  the  pre- 
vention of  disease?  That  is  really  what  mod- 
em medicine  is  striving  for.  The  motto  now  is 
"not  to  cure,  but  to  prevent." 

Considering  the  extent  of  the  morbidity  and 
mortality  of  diphtheria,  it  would  be  almost  criminal 
not  to  utilize  to  the  fullest  possible  degree  the 
means  at  our  disposal  to  curtail  and  check  the 
disease.    This  can  and  should  be  done. 

To  have  success  crown  our  endeavors  it  is  neces- 
sary to  popularize  the  Schick  test  and  active  immu- 
nization both  among  the  profession  and  the  lay 
public.  To  begin  with,  doctors  have  to  familiarize 
themselves  with  the  technic  of  the  test  and  the  in- 
jections. Once  that  is  done,  they  can  urge  upon 
their  patients  the  advantages  to  be  derived  from 
the  application  of  the  test  and  active  immunization. 
The  Department  of  Health  is  conducting  clinics  in 
the  different  sections  of  the  city,  where  doctors  are 
instructed  on  the  theory  and  practice  of  the  test 
and  immunization. 

It  is  not  sufficient  to  merely  educate  the  profes- 
sion on  this  important  subject,  the  general  public 
also  has  to  be  enlightened.  This  can  be  accom- 
plished by  means  of  lectures,  films,  and  popular 
advertisements  both  in  the  newspapers  and  on  bill 
posters.  By  such  systematic  and  generalized  dis- 
tribution of  knowledge  and  information,  our  en- 
deavors surely  cannot  fail. 

417  East  Eighty-third  Street. 


NEPHRITIS. 
By  Hyman  I.  Goldstein,  M.  D., 
Camden,  X.  J. 
{Concluded  from  page  259) 

Headaches  occur  which  are  often  severe,  com- 
monly occipital  or  on  top  of  head,  may  be 
associated  with  vomiting  and  twitchings  or  convul- 
sions, and  must  be  differentiated  from  brain  tu- 
mor. Convulsions  and  coma  are  frequently  late 
scenes.  Forms  of  insanity  may  develop,  such  as 
uremic  psychoses,  delirium,  melancholia,  confusion- 
al  insanity,  and  uremic  narcolepsy.  There  may  be 
much  difficult)-  in  diagnosing  these  cases.  Xo  al- 
bumin and  very  few  casts  may  be  present  in  many 
of  these  uremic  states. 

The  gastrointestinal  symptoms  are  many  and 
varied.  Sali\'ation  may  occur.  Long  continued 
hiccough  without  fever  and  if  not  hysterical  may 
often  be  uremic.  Hiccough  with  fever  occurs  in 
pneumonia,  typhoid  fever,  infections  below  the  dia- 
phragm, and  abscess  of  liver.  Riesman  emphasizes 
the  fact  that  vomiting  without  headache  may  be  due 
to  intestinal  obstruction.  Dysentery  is  not  uncom- 
mon. 

Eczema,  severe  and  distressing  pruritis,  purpura, 
hemorrhagic  diathesis  are  some  of  the  more  com- 
mon cutaneous  manifestations. 

The  uremic  eye  changes  consist  of  albuminuric 
retinitis,  depreciation  of  vision,  blue  blindness,  violet 
blindness.  The  retinitis  may  be  degenerative  (gran- 
ular kidney)  or  exudative  and  inflammatory  (pa- 
renchymatous nephritis).  Recurring  subconjunctival 
hemorrhages  may  be  uremic  (nephritis  and  arterio- 
sclerosis) in  origin.  Iritis  may  occur  alone,  or  with 
albuminuric  choroditis.  Retinal  hemorrhages  and 
white  spots  (  star  shaped )  are,  of  course,  the  most 
characteristic.  The  white  or  yellowish  white  spots 
occur  near  the  macula,  and  often  form  a  striking 
wide  white  area  about  the  papilla  (nerve  head)  or 
snow  bank  appearance  of  the  retina  (de  Schwein- 
itz).  The  retinal  vessels  are  tortuous  .and  beaded  in 
appearance  and  less  translucent  and  show  whitish 
stripes  (degeneration  of  walls). 

DIAGNOSIS   OF  UREMIA. 

The  urine  itself  may  fail  as  a  diagnostic  sign. 
Riesman,  Christian  and  others  have  repeatedly 
pointed  out  that  uremia  cannot  be  diagnosed  by 
the  urine.  Christian  says  no  single  renal  test  is 
pathognomonic  of  nephritis  or  uremia.  The 
whole  case,  the  history,  the  symptoms  and  repeated 
uranalysis  must  all  be  considered  in  reaching  a 
diagnosis  of  real  nephritis  and  the  condition  of  the 
renal  tissue.  Tests  of  renal  function  may  aid  in 
diagnosis,  and  in  the  treatment  as  they  measure  the 
extent  and  severity  of  the  renal  lesion. 

The  functional  tests,  such  as  the  Rowntree,  Ger- 
aghty  phenolsulphonephthalein  test,  the  blood  urea 
nitrogen  estimation  and  the  renal  test  meals  all 
help  to  a  correct  diagnosis  of  acute  and  chronic 
uremia.  There  is  present  polyuria,  urine  is  of  low 
specific  gravity,  traces  only  of  albumin  at  times,  and 
few  casts.  Casts  are  nearly  always  present.  There 
may  be  a  fixed  low  level  specific  gravity  or  hy- 
postenuria.    Indican  has  been  demonstrated  in  the 


284 


GOLDSTEIX:  NEPHRITIS. 


[New  York 
Medical  Journal 


blood  in  uremia  by  Moraczewski,  Herzfeld  and  G. 
Domer. 

Finally,  the  hypertension,  which  may  show  a 
blood  pressure  as  high  as  300  mm.  of  mercury 
systolic,  and  other  characteristic  cardiovascular 
changes,  such  as  hypertrophy  of  the  left  ventricle, 
sclerosis  and  hardening  of  the  vessels,  with  the 
frequent  presence  of  systolic  murmur  and  an  ac- 
centuated aortic  second  sound  without  true  organic 
valvular  disease,  and  the  eye  ground  examination 
complete  the  diagnosis. 

The  uremic  vomiting  must  be  distinguished  from 
other  causes  of  toxic  vomiting  such  as  those  ac- 
companying migraine  and  hyperthyroidism,  preg- 
nancy, cyclic  or  paroxysmal  vomiting ;  and  from 
the  vomiting  due  to  gastric  crisis  of  tabes  dorsalis 
.  and  strangulated  hernia,  and  alcoholism. 

Hyperthyroidism,  tuberculosis,  diabetes,  and  other 
diseases,  must  be  ruled  out  in  cases  of  uremic  psy- 
choneurosis.  Eclampsia,  alcoholism,  meningitis, 
hysteria,  and  epilepsy  must  be  ruled  out  in  cases 
of  uremic  convulsions  and  nephritic  meningism. 
The  very  important  and  almost  constant  symptom 
of  headache  in  uremic  patients  must  be  differenti- 
ated from  the  headaches  occurring  in  various 
chronic  intoxications,  constipation  and  biliousness, 
eyestrain,  psychoneurosis,  sinusitis,  meningitis,  mi- 
grane,  gout,  lues,  syphilitic  periostitis,  and  brain 
tumor. 

Uremic  pericarditis  occurs  as  a  not  uncommon 
complication  in  chronic  interstitial  nephritis.  Of 
course,  pericarditis  is  most  commonly  due  to  rheu- 
matism, tonsillitis,  and  pneumonia,  and  any  of  these 
conditions  may  coexist  in  a  uremic  patient. 

E.  C.  Segun  (2)  has  emphasized  occipital  head- 
ache as  a  sj-mptom  of  uremia.  Intermittent  head- 
aches have  also  been  mentioned  as  occurring  in 
uremia  by  Von  Leube.  Bronchitis  and  asthmatic 
attacks  often  form  part  of  the  symptomatology  of 
chronic  and  acute  uremia.  While  bronchitis  is 
most  frequent,  pericarditis  is  the  most  fatal. 

Sudden  blindness,  amblyopia,  with  ringing  in  the 
ears  with  dizziness  and  more  or  less  deafness  have 
occurred  in  some  of  my  cases  early  in  the  attack 
and  have  helped  ward  off  more  serious  complicating 
s>Tnptoms  by  warning  the  patient ;  my  resort- 
ing to  venesection  and  the  prompt  use  of  depletory 
remedies  have  saved  life  at  least  at  the  time.  The 
uremic  deafness  is  probably  of  central  origin;  as 
in  the  sudden  blindness,  it  is  of  short  duration, 
lasting  only  a  few  days. 

Curschmann  states  that  in  threatened  uremia,  the 
Babinski  reflex  often  becomes  positive  before  in- 
creased tendon  reflexes  or  mental  disturbance  occur. 
Insomnia  of  several  days  duration,  followed  by  hemi- 
plegia, monoplegia  or  aphasia  and  paraplegia  with 
pains  in  the  calf  muscles,  have  occurred  most  unex- 
pectedly in  some  doubtful  cases,  with  only  slight 
sjTnptoms  referable  to  the  kidne3-s  and  practically 
negative  urine. 

CONVULSIONS. 

Uremic  or  renal  asthma  is  a  most  constant  symp- 
tom in  uremia  and  Cheyne-Stokes  breathing  may  oc- 
cur. These  attacks  are  likely  to  occur  at  night.  The 
attacks  of  renal  dyspnea  are  due  to  acidosis  and 


may  be  excited  or  made  worse  by  the  associated 
cardiac  weakness  or  pulmonary  edema.  One  of  my 
patients  nearly  died  recently  from  the  pulmonary 
edema.  The  breathing  may  be  that  of  air  hungrer 
or  Kussmaul  type.  This  hyperpnea  may  be  consid- 
ered as  pathognomonic  of  acidosis.  The  acidemia 
breathing  is  deep,  pauseless,  not  usually  increased  in 
rate,  though  the  respirations  may  vary  in  depth,  Iik« 
a  modified  Cheyne-Stokes  breathing,  the  excursions 
of  the  abdomen  and  thorax  are  nearly  the  same  with 
succeeding  respirations.  Drowsiness  may  accom- 
pany this  condition.  The  convulsions  themselves,  as 
stated,  are  the  most  characteristic  symptoms  of 
uremia.  They  are  epileptiform  in  type,  and  they 
may  be  local  or  unilateral.  Osier  says  they  are 
supposed  to  be  due  to  a  local  or  general  edema  of 
the  brain  and  are  probabl}-  allied  to  the  apoplexia 
serosa  of  early  writers.  They  may  come  on  sud- 
denly or  be  preceded  by  nausea,  vomiting,  insomnia, 
vertigo,  headache  or  dropsy.  After  the  toxic  rigid- 
ity, clonic  spasms  with  fever  and  cyanosis  and  ar- 
terial spasm  may  follow  at  short  intervals.  The 
diagnosis  cannot  be  made  by  the  convulsions  alone. 
In  epilepsy  convulsions  are  preceded  by  an  aura,  and 
unconsciousness  is  total  and  complete;  the  patient 
may  bite  the  tongue  and  urinate  :  there  is  a  history  of 
previous  convulsions  occurring  in  younger  patients. 
Clonic  convulsions  are  present,  after  the  rigidity 
subsides.  The  epileptic  cry  or  shriek  is  character- 
istic. 

Jacksonian  epilepsy  consists  of  convulsions  which 
are  usually  unilateral  and  due  to  a  focus  of  irri- 
tation on  opposite  side  of  brain.  The  unconscious- 
ness is  not  total.  General  paralysis  of  the  insane 
is  manifested  by  convulsions  which  have  a  ten- 
dency to  repeat  themselves  one  after  another.  The 
\\'assermann  reaction  would  be  positive,  the  test 
should  be  made  with  the  cerebrospinal  fluid  and 
the  blood.  Acute  infectious  diseases,  such  as  menin- 
gitis, scarlet  fever,  pneumonia,  especially  in  children, 
may  begin  with  convulsions. 

Convulsions  may  be  due  to  drugs  such  as  strych- 
nine. They  are  painful  and  are  started  by  the  slight- 
est irritation.  They  are  not  accompanied  by  loss 
of  consciousness.  The  jaw  muscles  may  also  be- 
come affected.  The  muscles  of  respiration  are  in- 
volved. Death  occurs  suddenly,  due  to  respiratory 
spasm.  Intervals  of  complete  relaxation  occur.  Al- 
cohol may  cause  convulsions  very  similar  to  epi- 
lepsy. There  is  a  history  of  ingestion  of  some 
drug.  Strychnine  convulsions  begin  with  gastric 
disturbance  or  tetanic  contraction  of  the  extremi- 
ties. Objects  appear  green  and  hyperesthesia  of 
retina  occurs.  The  convulsions  are  violent  from 
the  onset.  The  gastric  contents  show  strychnine ; 
the  course  is  brief. 

Tetanus  begins  with  lockjaw.  The  first  convul- 
sive spasm  aft'ects  the  jaw  muscles,  and  conscious- 
ness is  preserved.  The  convulsions  later  spread 
downward,  the  arms  and  hands  escaping.  Rigid- 
ity is  persistent  except  in  the  chronic  form.  The 
course  is  prolonged  for  days  or  weeks.  Cultures 
made  from  a  discoverable  wound  may  show  tetanus 
bacilli. 

In  hysteria  convulsions  seldom  occur  when  pa- 


August  28,  1920.] 


GOLDSTEIN: 


NEPHRITIS. 


285 


tient  is  alone.  Usually  the  patient  cries  continu- 
ally. There  is  no  total  loss  of  consciousness.  The 
patient  is  erratic  and  has  a  dramatic  attitude. 
Opisthotonus  is  sometimes  present ;  it  lasts  a  long 
time,  a  half  hour  or  so.  The  patient  is  often  emo- 
tional, crying  or  laughing.  Stigmata  may  be  pres- 
ent. The  pupils  are  dilated.  Spasms  of  hysterical 
laughing  or  crying  may  precede  the  convulsions. 
An  aura  is  present,  as  in  epilepsy.  Globus  hysteri- 
cus, clavus  hystericus  with  vertigo  and  tinnitus 
aurium  and  localized  areas  of  tenderness  or  hystero- 
genous  zones  may  be  present.  Reflex  convulsions 
from  parasites,  eclampsia,  myotonia,  muscle  spasm 
of  a  ticlike  character,  and  Adams-Stokes  disease 
are  other  conditions  which  must  be  differentiated. 

Uremic  unconsciousness  coming  on  sud- 
denly may  simulate  cerebral  tumor,  cerebral  hem- 
orrhage or  a  stroke  of  apoplexy,  alcoholism  or  men- 
ingitis. In  uremia  there  is  an  indicanemia  and  not 
in  pseudouremia,  and  there  is  no  nitrogen  reten- 
tion in  pseudouremia.  In  diabetic  coma  the  presence 
of  sugar  in  the  urine  with  acetone,  the  history,  and 
the  odor  of  the  breath  help  make  the  diagnosis. 

Opium  poisoning  must  also  be  ruled  out.  Here 
the  pupils  are  contracted  and  do  not  respond  to 
light ;  the  patient  may  answer  rationally  when 
aroused.  In  uremic  coma  consciousness  is  entirely 
abolished  and  pupils  are  generally  dilated.  In  cere- 
bral hemorrhage  the  pupils  may  be  vmequal  or 
dilated ;  stertorous,  flapping  respiration  is  present ; 
there  is  paralysis,  and  the  urine  may  be  negative. 

SOME  PHYSIOLOGICAL  FACTS. 

The  secretion  of  urine  is  probably  controlled 
through  chemical  stimuli.  Certain  substances  in 
the  blood,  when  in  excess  of  a  certain  concentra- 
tion, are  secreted,  because  in  some  way  they  stimu- 
late the  activity  of  the  kidney  cells.  The  increased 
amount  of  urine  that  occurs  when  there  is  an  in- 
creased blood  flow  through  the  kidneys  is  due  to 
the  greater  amount  of  these  chemical  stimuli  that 
pass  through  the  kidneys. 

Schaefer  and  Herring  (3)  have  shown  that  a 
substance  is  contained  in  extracts  of  the  posterior 
lobe  of  the  pituitary  gland  which  acts  as  a  stimu- 
lating hormone  to  the  kidneys,  and  it  may  be  that 
this  hormone  may  function  normally.  Cow  (4) 
has  stated  that  a  stimulating  diuretic  hormone  is 
formed  in  the  mucous  membrane  of  the  intestine. 
When  water  is  taken  this  hormone  is  carried  into 
the  blood  with  the  absorbed  water  and  is  responsi- 
ble for  the  resulting  diuresis.  It  is  stated  that 
water  taken  by  mouth  causes  diuresis,  when  a  sim- 
ilar amount  injected  directly  into  the  blood  may 
have  no  effect. 

The  excretion  of  the  kidney  varies  with  the  quan- 
tity of  blood  flowing  through  it.  Landergren  and 
Tigerstedt  (5)  have  shown  that  when  the  kidney  is 
in  strong  functional  activity,  as  may  be  produced  by 
the  action  of  diuretics,  it  is  a  vascular  organ. 
They  estimate  that  in  a  minute's  time,  under  the  ac- 
tion of  diuretics,  an  amount  of  blood  flows  through 
the  kidney  equal  to  the  weight  of  the  organ ;  this  is 
an  amount  from  four  to  nineteen  times  as  great  as 
occurs  in  the  average  supply  of  other  organs  in  the 
systemic  circulation.    In  strong  diuresis,  both  kid- 


neys taken  into  account,  five  and  six  tenths  per  cent, 
of  the  total  quantity  of  blood  sent  out  of  the  left 
heart  may  pass  through  the  kidneys  in  a  minute,  al- 
though the  combined  weight  of  the  kidneys  makes 
only  fixty-six  hundredths  per  cent,  of  that  of  the 
body.  Any  vascular  dilatation  of  the  small  renal 
vessels  will  tend  to  increase  the  blood  flow  through 
it,  unless  there  is  at  the  same  time  such  a  general 
fall  of  blood  pressure  as  is  sufficient  to  lower  the 
pressure  in  the  renal  artery  and  reduce  the  driving 
force  of  the  blood. 

As  to  the  urinary  secretion,  the  weight  of  evi- 
dence favors  the  Bowman-Heidenhain  theory, 
namely,  that  in  the  glomeruli  water  and  inorganic 
salts  are  produced  as  an  act  of  secretion,  while  the 
urea  and  related  bodies  are  elhninated  through  the 
activity  of  the  epithelial  cells  in  the  convoluted 
tubules. 

Some  diuretics  may  cause  a  genuine  secretion 
while  others  influence  the  amount  of  urine  through 
mechanical  or  physical  influences  alone.  Saline  diu- 
retics probably  attract  water  from  the  tissues  into 
the  blood  and  thus  cause  a  condition  of  hydremic 
plethora,  and  an  increased  amount  of  urine  is  the 
result.  According  to  Magnus  (6),  each  inorganic 
salt  has  a  secretion  threshold. 

TREATMENT  AND  PROGNOSIS. 

Prognosis  should  be  based  chiefly  on  the  history 
of  the  case,  the  symptoms  and  accidents  the  patient 
has  had,  and  the  results  of  the  functional  tests.  The 
phenolsulphonephthalein  test,  as  described  by  Rown- 
tree  and  Geraghty,  with  the  use  of  either  the  Dun- 
ning or  modified  Hellige  colorimeter  and  an  am- 
poule of  the  monosodium  salt  of  phthalein  (.006  to 
1  c.  c.)  given  either  intraniuscularly  or  intravenous- 
ly. The  average  normal  eliminations  after  intra- 
muscular injections  are  fifty  per  cent,  the  first  hour 
and  eighty-five  per  cent,  after  two  hours.  Follow- 
ing intravenous  administration,  thirty-five  to  forty- 
five  per  cent,  in  fifteen  minutes;  fifty  to  sixty-five 
per  cent,  in  thirty  minutes  and  sixty-five  to  eighty 
per  cent,  in  the  first  hour.  The  bladder  should  be 
completely  emptied  and  one  measured  cubic  centi- 
metre of  the  phthalein  solution  injected  into  the 
lumbar  muscles  or  intravenously.  If  it  is  injected 
intramuscularly,  collect  the  urine  excreted  during 
an  hour  and  ten  minutes,  also  during  a  second  hour, 
and  estimate  the  amount  of  phthalein  excreted,  by 
the  colorimeter.  If  given  intravenously,  collections 
and  estimations  may  be  made  at  the  end  of  fifteen 
or  thirty  minutes,  or  an  hour  (7). 

Urease  may  be  used  for  the  estimation  of  urea 
in  the  urine  and  in  the  blood.  This  preparation, 
soy  bean,  comes  in  twenty-five  mgm.  tablets.  By 
the  use  of  these  two  tests,  a  fairly  accurate  prog- 
nosis can  be  given  in  the  majority  of  the  renal  cases. 
Urine  analysis  alone  is  not  reliable. 

TREATMENT  OF  ACUTE  NEPHRITIS. 

Acute  nephritis  is  a  curable  condition  in  the  ma- 
jority of  the  cases.  Acute  or  subacute  glomerulo- 
nephritis occurs  in  scarlet  fever,  endocarditis,  strep- 
tococcic infection,  tonsillitis,  appendicitis,  influenza, 
exposure  to  cold,  and  other  affections.  Edema  of 
the  face,  eyelids,  fingers  and  hands  are  early  symp- 
toms, and  treatment  should  be  instituted  promptly. 


286 


GOLDSTEIN:  NEPHRITIS. 


[New  York 
Medical  Journal. 


There  may  be  trembling  of  the  fingers,  muscular 
twitchings  and  paralysis  of  one  limb. 

In  Hughes  shifting  paralysis  a  foot,  an  eye.  or  a 
hand  may  be  afifected.  Moisture  is  absent  in  the 
axillae  in  all  cases  of  acute  nephritis.  The  kidneys 
must  be  activated  because  the  patient  may  not  void 
any  urine.  Water,  which  is  the  best  diuretic,  should 
be  given  in  quantities  of  one,  two,  or  three  quarts  a 
day,  and  water  may  be  given  by  the  Murphy  drip. 
Diuretics,  such  as  theocin,  cafifeine,  agurin,  and  dig- 
italis, should  be  avoided  in  acute  nephritis.  Orange 
juice  or  lemonade  should  be  given. 

EDEMA. 

In  Fischer's  opinion,  diuretics  decrease  edema, 
not  because  the  secretory  organs  of  the  body  have 
been  stimulated  to  pull  water  out  of  the  tissues, 
but  because  the  diuretics  act  upon  all  the  tissues  of 
the  body,  and  decrease,  directly  or  indirectly,  their 
hydration  capacity  and  cause  shrinking.  The  water 
is  then  thrown  off  by  the  kidneys,  bowel,  skin  or 
lungs.  Cohnheim's  theory  as  to  the  edema  is  that 
it  is  due  to  increased  permeability  of  the  capillary 
vessels,  which  is  caused  by  malnutrition  or  poison- 
ing" on  account  of  the  nephritis. 

Widal  believes  that  the  kidneys  have  a  deficient 
capacity  to  eliminate  sodium  chloride  and  the  accu- 
mulation of  salt  in  the  body  causes  a  retention  of 
water,  causing  anasarca.  Fischer's  theory  that  the 
edema  is  due  to  an  acidosis  has  not  received  con- 
firmation. All  of  these  workers  attribute  the  edema 
to  a  retention  of  salt  and  water  caused  by  kidneys' 
inability  to  eliminate  them  adequately. 

Epstein,  of  New  York,  presented  a  hypothesis 
for  the  production  of  edema  in  chronic  parenchy- 
matous nephritis.  He  stated  that  the  loss  of  protein 
incurred  by  the  blood  serum  through  the  continuous 
albuminuria  caused  a  decrease  in  osmotic  pressure 
of  the  blood,  which  favored  absorption  or  inhibition 
and  retention  of  fluid  by  the  tissues.  Through  a 
change  in  the  protein  composition  of  the  blood  plas- 
ma a  condition  was  produced  which  was  capable 
of  causing  the  retention  of  fluid  in  the  tissues.  The 
increase  in  the  lipoid  content  of  the  blood,  the  de- 
crease in  the  globulin  content  of  the  blood  serum, 
and  the  excessive  accumulation  of  lipoids 
constitute  additional  factors  which  contribute  to 
the  causation  of  edema  in  chronic  paren- 
chymatous nephritis,  and  interfere  with  the  elimi- 
nation of  salt  and  water  by  the  kidneys. 

As  stated,  it  is  well  to  give  the  patient  who  is 
suffering  from  acute  nephritis  plenty  of  water  to 
drink.  The  bowels  and  the  skin  should  be  acti- 
vated. Citrate  of  magnesia  is  given.  The  patient 
is  sponged  with  hot  water ;  a  hot  pack  consisting  of 
a  wet  hot  blanket  is  given  for  twenty  minutes. 
Fortify  your  patient  before  the  sweating  by  stimu- 
lation with  aromatic  spirits  of  ammonia.  Perntit 
him  to  sweat  for  at  least  twenty  minutes,  then  use 
dry  blankets.  A  glass  or  two  of  cold  lemonade 
or  ice  water  might  make  him  perspire.  Potassium 
citrate  may  be  given  as  a  mild  alkaline  diuretic. 
Enemata  and  a  slow  drip  of  sodium  bicarbonate 
may  be  administered  by  rectum.  Later,  after  re- 
covery, Basham's  mixture  or  infusion  of  digitalis 
U.S.P.,  freshly  prepared,  may  be  prescribed.  If 


the  patient  is  comatose  eight  to  ten  ounces  of  blood 
or  more  may  be  removed,  and  water  given  by  stom- 
ach tube  or  sodium  bicarbonate  solution  by  rec- 
tum or  salt  solution  by  hypodermoclysis.  Do  not 
give  the  sodium  bicarbonate  solution  by  skin.  Soda 
solution  should  be  given  intravenously,  by  rectum, 
or  by  mouth.  Nature  has  a  tendency  to  cure  acute 
nephritis,  and  we  should  not  be  too  meddlesome  or 
too  active  in  the  treatment.  Many  patients  with 
acute  nephritis  following  tonsillitis,  influenza,  scar- 
let fever,  recover  nicely  without  much  treatment, 
other  than  by  the  avoidance  of  exposure,  keeping 
the  patient  well  covered,  out  of  draughts,  and  the 
use  of  the  mildest  kinds  of  laxatives. 

In  the  case  of  scarlet  fever  prophylaxis  is  most 
important.  "Make  the  diagnosis  of  acute  nephritis 
in  scarlatina  before  you  can  see  it,"  says  Riesman. 
Watch  the  urine.  If  you  find  some  red  blood  cells 
and  a  little  increase  in  the  albumin  in  the  urine, 
tell  the  family  and  predict  a  probable  kidney  com- 
plication. 

In  bad  cases  with  nuich  dropsy,  either  one  quart 
skimmed  milk  or  buttermilk  can  be  given  a  day. 
As  the  patient  improves  cereals  and  cocoa  with 
sugar  and  various  milk  preparations ;  potatoes 
and  rice  may  be  ordered ;  no  eggs  until  later. 
Either  powdered  digitalis  or  the  fresh  infusion  may 
be  used  as  a  diuretic.  I  find  the  use  of  a  freshly 
made  U.S. P.  preparation  of  the  infusion  of  digi- 
talis, after  the  real  acuteness  of  the  attack  subsides, 
of  great  help  in  many  of  the  cases.  In  very  bad 
cases  one  may  try  thirty  grams  of  digitalis  leaves 
in  a  poultice  over  the  kidneys  or  a  hot  flaxseed 
poultice  may  be  applied. 

After  recovery  the  patients  all  have  some  sec- 
ondary anemia.  In  these  cases  Basham's  mixture 
may  be  given.  At  the  expiration  of  three  to  five 
weeks  the  urine  should  be  free  from  albumin. 
Iron  is  not  of  as  much  value  in  acute  nephritis  as  it 
is  in  the  chronic  forms. 

CHRONIC  NEPHRITIS. 

Since  the  blood  shows  a  marked  decrease  in  pro- 
tein and  an  increase  in  lipoids  and  since  the  lipoid 
content  increase  gives  evidence  of  a  grave  nutritional 
disturbance  and  its  effect  on  the  pathological  con- 
dition of  kidney  tissue  itself,  Epstein  advises  to 
increase  the  protein  content  of  blood  and  thus  help 
regain  its  normal  osmotic  power  and  to  remove 
or  cause  reabsorption  by  the  tissues  of  the  exces- 
sive lipoids.  He  advises,  therefore,  a  removal  of 
quantities  of  blood  from  the  patient  and  massive 
infusions  or  transfusions  of  healthy  blood  in  equal 
quantities.  1.  The  removal  of  the  patient's  blood 
avoids  circulatory  embarrassment  and  removes 
some  excessive  lipoids  in  the  cases  of  chronic 
parenchymatous  nephritis.  2.  A  proper  adminis- 
tration of  a  high  protein  and  fat  poor  diet  is  most 
important.  It  should  consist  of  1280  to  2500  cal- 
ories daily.  Fats  should  be  excluded.  Lean  veal, 
lean  ham,  whites  of  eggs,  oysters,  lima  beans,  len- 
tils, green  peas,  oatmeal,  rice,  skimmed  milk,  cocoa, 
split  peas  may  be  ordered.  Large  quantities  of 
selected  proteins  are  listed  with  a  minimum  of 
carbohydrates  and  exclusion  of  fats.  Carbohy- 
drates are  restricted  in  order  to  allow  for  a  maxi- 


August  28,  1920.] 


GOLDSTEIN :  XEPHRITIS. 


287 


mum  assimilation  of  protein  and  to  exclude  the 
greater  production  and  retention  of  water  which  is 
incidental  in  the  metabolism  of  carbohydrates.  The 
fats  are  excluded  because  of  the  marked  increase 
of  faulty  substances  in  the  blood.  The  fluid  in 
edema  is  made  up  principally  of  salts  and  water. 
The'  decrease  in  protein  content  of  the  serum  is 
chiefly  due  to  a  loss  of  protein  in  the  urine.  Chauf- 
ford,  Rechit  and  Grigaut  in  1911  reported  an  in- 
crease in  lipoid  content  of  the  blood  in  chronic 
parenchymatous  nephritis. 

I  speak  of  the  diet  first  in  the  treatment  of 
chronic  nephritis  because  it  is  the  most  important 
single  factor  in  the  handling  of  these  cases.  In 
the  usual  case  of  chronic  nephritis  with  edema  very 
slight  or  absent,  and  without  any  of  the  other  more 
or  less  acute  disturbances,  and  with  the  patient 
feeling  fairly  well,  I  allow  the  following  diet : 

For  breakfast 

Grapefruit ;  cream  of  wheat  and  cream ;  cocoa, 
toast  and  butter. 

or 

Apple    sauce ;    wheatena    with    cream ;  zweiback 
and  butter  or  prunes ;   farina  and  cream ;  sliced 
oranges  ;  apricots  ;  rolled  oats,  etc. 
For  dinner  and  supper  a  selection  is  made  from  the  fol- 
lowing list : 

Mashed  potatoes;  rice  and  cream;  cream  of  onion 
soup ;  baked  sweet  potatoes ;  pineapple ;  buttered 
beets ;  creamed  carrots ;  brussels  sprouts  with  but- 
ter sauce ;  chocolate  cornstarch  pudding ;  stewed 
corn ;  chicken  fricassee ;  orange  ice ;  cream  of 
tomato  soup ;  hominy  grits ;  lamb  chop  and  a  little 
sauerkraut  for  dinner ;  cream  of  asparagus  soup ; 
berries  ;  small  broiled  chicken  ;  celery  ;  lettuce  ;  two 
ounces  of  roast  beef  or  none  at  all ;  baked  squasn 
or  salmon ;  spinach ;  fruit  salad ;  cream  of  celerj^ 
soup ;  broiled  trout ;  all  kinds  of  vegetables ;  fresh 
and  stewed  fruits ;  fish,  perch,  cod,  haddock,  etc. 
No  eggs  are  allowed.  No  salt.  Meats  in  great 
moderation  or  none  at  all. 

Some  physicians  advise  the  use  of  all  kinds  of 
fats,  butter,  cream  and  olive  oil,  in  liberal  quanti- 
ties. Some  advise  the  use  of  carbohydrates  and 
sugar  in  abundance  and  eliminate  the  proteins, 
while  still  others,  like  Epstein,  forbid  the  ttse  of 
fats  and  restrict  the  use  of  carbohydrates  and  push 
the  proteins,  especially  in  chronic  parenchymatous 
nephritis.  I  believe  that  a  conservative  happy 
medium  of  the  three  is,  after  all,  the  most  satis- 
factory for  all  concerned. 

If  the  patient  becomes  dropsical,  order  him  to 
bed.  Protect  him  with  warm  flannels.  Order  a 
milk  diet  and  fruit  juices.  Fruit  juices  are  very 
good  in  chronic  cases  of  nephritis.  Some  diuretic 
should  be  used  with  caution ;  first,  it  is  advisable 
to  start  with  digitalis.  Later,  if  necessary,  three 
to  five  decigrams  of  theobromine  may  be  used  with 
the  digitalis. 

Agurin,  theophorin,  theophyllin,  theocin,  theocin- 
sodium  acetate,  diuretin  and  others  may  be  tried  in 
different  cases,  as  needed,  if  the  ordinary  milder 
diuretics  fail.  The  dropsy  often  disappears,  with- 
out the  use  of  any  of  these  active  diuretics.  The 
bowels  should  be  opened  by  elaterium  or  elaterine 
and  the  patient  sweated  by  means  of  vapor  bath, 
hot  bricks  and  hot  blankets,  or  electric  lamps,  and 
if  necessary  pilocarpine  hydrochlorate  a  few  min- 
utes before  the  hot  pack  is  administered  hypodermi- 
^ally.     In  these  cases  if  there  is  danger  of  pul- 


monary edema  or  marked  cardiac  weakness  do  not 
use  pilocarpine.  A  salt  free  diet  helps  dispel  the 
dropsy. 

Southey  tubes  are  useful  for  the  removal  of  large 
quantities  of  fluid  from  the  legs  and  thighs ;  by 
their  use  I  have  removed  a  half  gallon  or  more 
fluid  in  twenty-four  hours.  Multiple  incisions 
throtigh  the  skin,  in  both  legs  may  also  be  made. 

For  the  nervousness  and  insomnia  I  have  used 
sedobrol,  as  a  cup  of  hot  soup  or  bouillon.  Dial 
(Ciba),  barbital  or  chloral  hydrate  have  given  good 
resvilts.  In  bad  cases  if  the  heart  requires  stimula- 
tion I  use  digitan  and  cafifein — sodium  benzoate,  hy- 
podermically.  In  the  uremic  cases  abstinence  from 
nitrogenous  and  animal  foods  is  urged.  In  these 
cases  a  lactovegetarian  diet  is  best,  with  fruit,  ce- 
reals and  oysters  allowed  on  improvement. 

In  the  uremia,  convulsions  and  coma,  active 
treatment  of  the  most  vigorous  kind  is  demanded  and 
necessary. 

It  is  most  important  to  bleed  the  patient ;  the  blood 
pressure  is  the  guide.  The  skin  and  bowels  must 
be  kept  working.  Croton  oil,  2  min.,  in  olive  oil  or 
butter  may  be  given,  as  well  as  elaterium.  and  later 
epsom  salts  with  lemonade.  Make  the  patient  per- 
spire freely  and  then  stimulate  the  kidneys  if  possible. 

In  some  of  the  cases  with  simple  hypertension, 
without  much  demonstrable  trouble  in  the  kidneys, 
the  arterial  spasm  and  high  blood  pressure  may  be 
relieved  by  the  use  of  benzyl  benzoate,  twenty 
minims  in  alcoholic  solution  every  three  or  fottr 
hours.  In  some  of  the  cases  of  the  type  known  as 
climacteric  hypertension,  I  have  in  a  few  cases  seen 
surprisingly  good  results  from  the  use  of  benzyl 
benzoate,  and  corpus  lutettm  or  ovarian  extract;  in 
others  ovarian  extract  or  lutein  tablets  were  used 
with  thyroid  extract  with  favorable  results.  The 
iodides  and  nitrites  do  not  do  much  good  in  the 
cases  of  essential  Benign  hypertension.  Bromides 
relieve  the  nervousness,  and  with  tincture  of  vera- 
tnun  viride  relieve  the  dizziness  and  headache. 

Anemia  is  always  present ;  this  can  be  treated  by 
the  administration  of  wine  of  iron  citrate, 
Basham's  mixture,  or  Blaud's  mass  or  by  the  hypo- 
dermic injections  of  citrate  of  iron,  starting  with 
small  doses  to  avoid  vomiting  and  faintness  after  its 
use. 

Sometimes  the  patient's  embarrassment  of  the 
heart  suddenly  increases  and  persists,  due  to  a  hy- 
drothorax — this  is  likely  to  occur  in  dropsical  cases. 
Here  we  must  tap  the  chest,  and  if  necessary  the  ab- 
dominal ascites  should  also  be  relieved  by  tapping. 
Pulmonary  edema  and  albuminous  expectoration 
after  thoracentesis  may  be  prevented  by  the  adinin- 
istration  of  one  sixth  grain  of  morphine  sulphate 
and  one  one  hundred  and  fiftieth  grain  of  atropine. 
The  aspiration  should  be  performed  slowly  and 
thoracentesis  should  be  stopped  as  soon  as  the  pa- 
tient begins  to  cough  persistently  or  becomes  mark- 
edl\-  dyspneic.  Open  pleural  puncture  as  described 
by  Schmidt  may  be  tried  instead  of  the  usual 
method  of  thoracentesis. 

ACIDOSIS. 

This  condition  is  relieved  and  reduced  by  the  use 
of  bicarbonate  of  soda  solution.  In  all  forms  of 
acidosis,  alkalies  are  indicated.    They  may  be  ad- 


288 


GOLDSTEIN: 


NEPHRITIS. 


[New  Yokk 
Medical  Journal. 


ministered  by  mouth,  or  intravenously,  or  by  rec- 
tum. Avoid  the  subcutaneous  administration  of 
bicarbonate  of  soda  solution.  When  a  solution  of 
bicarbonate  of  soda  solution  is  boiled  carbon  dioxide 
is  given  off  and  sodium  carbonate  is  formed.  This  is 
irritating.  It  has  therefore  been  advised  to  pass  a 
current  of  carbon  dioxide  through  the  solution  until 
it  is  no  longer  colored  by  phenolphthalein.  Oscar 
Schloss  has  found  that  bicarbonate  of  soda  in  bulk 
is  always  sterile.  It  is  probably  therefore  sufficient 
to  add  the  bicarbonate,  with  proper  precautions,  to 
sterile  water  according  to  Howland  and  Marriott. 

In  adults  and  older  children  300  to  400  c.  c.  of  the 
bicarbonate  solution  may  be  injected;  in  small  in- 
fants not  more  than  75  to  100  c.  c.  Alkalosis  must, 
however,  be  avoided.  Edema  may  occur,  but  is  usu- 
ally of  no  serious  consequence.  Sometimes  in  young 
children  tetany  may  occur  following  administration 
of  soda  solution — where  such  condition  is  feared 
administer  a  solution  of  magnesium  sulphate  subcu- 
taneously — when  large  doses  of  the  sodium  bicar- 
bonate solution  are  to  be  given  (just  as  in  idiopathic 
tetany),  a  four  per  cent,  glucose  solution  can  also  be 
used. 

In  conclusion  every  patient  with  kidney  disease 
must  be  carefully  studied,  and  treated  as  an  indi- 
vidual. No  set  rules  apply  to  any  one  case.  It  is 
to  be  remembered,  and  it  has  been  emphasized  by 
Christian  and  others,  that  in  nephritis  as  such,  in 
uncomplicated  nephritis  of  all  types,  diuretics  are 
either  not  indicated  because  there  is  no  need  for 
increased  urinary  output,  or  where  there  is  need 
for  diuresis  to  remove  edema  or  toxins,  they  do  no 
good.  In  other  words,  in  nephritis,  as  such,  diuretics 
should  not  be  pushed. 

Reduction  of  fluid  intake,  salt  poor  diet,  sweat- 
ing, purging,  and  the  use  of  alkaline  remedies,  with 
Southey  tubes,  or  punctures,  are  far  better  for  re- 
moving the  edema.  For  toxic  symptoms,  bleeding, 
purging,  sweating,  and  alkaline  treatment  are  more 
efficacious  than  diuretic  drugs.  On  the  other  hand, 
in  patients  with  cardiac  insufficiency  and  relatively 
little  organic  lesion  diuretics  are  extremely  useful  to 
aid  in  the  removal  of  fluid  accumulated  in  the  body. 
They  are  most  efficient  when  given  after  a  short 
period  of  digitalis  (digitan,  digalen,  digipuratum,  or 
powdered  digitalis)  therapy.  In  cases  of  edema  of 
renal  orgin  without  cardiac  insufficiency,  digitalis 
alone  produces  no  diuresis  and  when  followed  by  a 
diuretic  drug  little  or  no  increased  urine  flow  re- 
sults. 

Theocin,  with  or  without  pulv.  scillae  or  fluid  ex- 
tract apocynum  cannabinum  or  cymarin,  was  in 
some  of  my  cases  more  effectual  than  theobromin 
sodium  salicylate,  caffein,  and  potassium  acetate  in 
producing  diuresis.  However,  when  edema  is  in 
large  part  due  to  renal  insufficiency,  theocin,  or 
agurin,  or  theophyllin  or  any  other  diuretic  drug, 
fails  to  remove  the  fluid.  They  are,  however,  ef- 
fectual in  increasing  urine  output  in  cases  associ- 
ated with  cardiac  insufficiency. 

ARRHYTHMIA. 

In  some  of  my  nephritic  cases,  patients  who 
were  troubled  with  arrhythmia,  paroxysmal  or  pe- 
riodical attacks,  and  at  times  anginal  spells,  I  used 
cactus  graildiflorus,  fresh  tincture  and  convallaria 


majalis,  fresh  fluid  extract  with  or  without  tincture 
of  prunus  Virginia.  Bromides  and  chloral  hy- 
drate in  small  doses  do  good,  especially  in  older 
patients. 

What  I  want  to  emphasize  is  the  importance  of 
infection  in  many  of  our  cases  of  nephritis,  especial- 
ly in  children.  Such  diseases  as  tonsillitis,  appendi- 
citis, sinusitis,  and  suppurative  otitis  media ;  chronic 
tooth  infection  and  other  focal  infections ;  influenza, 
scarlet  fever,  and  various  septic  conditions  are  im- 
portant factors  in  the  causation  of  acute  and  even 
subacute  and  chronic  nephritis.  I  have  seen  a  fair- 
ly large  number  of  cases  of  nephritis  in  children 
following  influenza,  tonsillitis,  and  other  acute  in- 
fections of  the  nose,  throat,  ear,  and  appendicitis 
and  enterocolitis.  I  could  make  a  formidable  list 
of  these  cases  that  would  make  interesting  reading, 
but  this  is  unnecessary  in  a  paper  of  this  kind,  ex- 
cept to  call  attention  to  the  fact  that  we  must  in 
the  future  take  more  interest  in  the  cases 
of  apparent  slight  acute  infections,  because 
of  the  frequent  occurrence  of  a  nephritis 
which  may  start  as  an  acute  condition,  con- 
tinuing into  a  chronic  nephritis.  Many  cases  of 
chronic  nephritis  in  children  are  often  of  such  mild 
character,  and  present  such  a  totally  different 
picture  from  chronic  nephritis  in  the  adult,  that  we 
often  do  not  see  these  cases  until  long  after  the 
attack  of  a  mild  scarlet  fever  or  a  touch  of  diph- 
theria, or  a  quinsy  tonsillitis  or  a  touch  of  grippe  or 
influenza.  When  these  children  happen  to  pick  up 
another  mild  attack  of  an  acute  infection  of  some 
sort,  there  is  an  exacerbation  of  the  chronic  neph- 
ritic condition.  Then  it  is  that  a  flood  of  light  strikes 
us  and  we  discover  we  were  dealing  with  a  case  of 
chronic  nephritis  in  a  child. 

Most  often  the  blood  pressure  is  not  elevated,  but 
I  have  seen  cases  in  children  with  blood  pressure 
varying  from  140  to  244  systolic  and  up  to  130  and 
140  diastolic.  The  urine  often  only  shows  a  small 
quantity  of  albumin  and  possibly  a  few  casts  of  the 
granular  and  hyaline  varieties.  There  is  an  absence 
of  cardiac  hypertrophy,  although  I  reported  a  case 
some  time  ago  in  a  girl  with  an  enormous  heart 
complicating  a  case  of  nephritis — here  the  cardiac 
condition  was  primary.  Of  course,  as  Tyson  has 
stated,  prognosis  is  much  more  favorable  if  the  heart 
disease  is  primary,  and  the  renal  disease  secondary, 
even  if  there  is  extreme  dropsy.  Ordinarily  cardiac 
hypertrophy  following  primary  renal  disease,  is 
more  marked  than  in  primary  heart  disease.  In 
primary  renal  disease,  even  in  some  of  the  cases 
occurring  in  children,  the  hypertrophy  is  principally 
of  the  left  heart,  whereas  if  heart  disease  is  pri- 
mary we  get  enlargement  (and  dilatation)  also  to 
the  right. 

There  are  many  characteristic  findings  in  adult 
renal  disease  which  are  totally  absent  in  children.  I 
have  used  in  children,  especially  when  acidosis  may 
appear  imminent,  four  per  cent,  bicarbonate  solu- 
tion by  rectum  and  small  doses  of  bicarbonate  of 
soda  and  sodium  citrate  by  mouth  with  splendid 
results.  In  these  cases  (infants  and  children) 
water  should  be  given  by  mouth,  by  rectum,  or  in- 
traperitoneally.  The  injection  of  water  can  best  be 
made  with  a  short  needle,  slowly,  with  all  aseptic 
precautions,  in  the  median  line  below  the  umbilicus ; 


August  28,  1920.] 


GOLDSTEIN:  NEPHRITIS. 


289 


as  much  as  300  c.  c.  may  be  given  to  a  small  infant. 
The  fluid  is  absorbed  gradually  without  throwing 
any  strain  on  the  circulation. 

RESUME  AND  SUMMARY. 

1.  The  importance  of  focal  infection  in  the  pro- 
duction of  systemic  disease  has  been  emphasized  by 
the  work  of  Frank  Billings  and  others.  The  rela- 
tion of  foci  of  infection  such  as  appendicitis,  gall- 
bladder disease  (cholecystitis  and  cholelithiasis), 
tonsillitis,  endocarditis,  prostatitis,  otitis  media  and 
osteomyelitis,  to  nephritis,  especially  of  the  paren- 
chymatous type,  must  be  remembered. 

2.  The  previous  history  of  the  patient  and  espe- 
cially a  history  of  any  recent  ailments  and  infec- 
tious disease  such  as  scarlet  fever,  pneumonia,  ty- 
phoid fever,  influenza,  has  an  important  bearing  on 
the  diagnosis  and  prognosis  and  treatment  of  the 
renal  condition  in  each  particular  case  under  study. 
One  must  not  forget,  however,  that  many  cases  of 
albuminuria  are  due  to  local  sources  of  infection, 
which  clear  up  entirely  after  the  focus  of  infection 
is  removed.  In  these  cases  medication  and  dietetics 
have  no  important  place.  The  cases  show  no  evi- 
dences of  disturbed  renal  function  and  no  definite 
renal  disease  is  present  in  these  symptomatic  albu- 
minurias. Barker  and  Smith  (8).  Riesman  (9), 
Thomas,  Cabot  and  others,  have  called  attention  to 
the  importance  of  focal  conditions  to  these  socalled 
innocent  and  harmless  albuminurias. 

3.  Diagnosis  must  be  made  from  cyclic  and  or- 
thostatic albuminuria,  another  allied  condition — the 
diagnosis  and  prognosis  can  be  made  more  ac- 
curately by  blood  chemical  test  and  by  renal  func- 
tion tests  than  by  urine  analysis.  By  determining 
the  proportion  of  the  urea  in  the  blood  to  that 
excreted  in  the  urine  according  to  Ambard's  laws 
and  formula  derived  therefrom,  an  idea  as  to  the 
power  of  the  body  to  excrete  urea  can  be  obtained 
(10).  As  the  urea  in  the  blood  increases  it  ex- 
ercises a  correspondingly  greater  diuretic  stimulus, 
and  the  urinary  urea  rises  proportionately.  That 
is,  in  any  given  person  Ambard's  constant  does 
not  change  even  though  the  blood  urea  fluctuates 
very  markedly.  Therefore,  this  gives  us  a  means 
of  determining  very  accurately  the  degree  of  renal 
function  present.  Blood  urea  (the  resultant  of 
dietetic  regulation  and  renal  function)  varies  wide- 
ly. Ambard's  constant  remains  fixed  unless  the 
disease  process  changes  and  renal  function  either 
improves  or  deteriorates. 

4.  Dietetic  treatment  is  of  the  greatest  impor- 
tance in  the  handling  of  cases  of  nephritis.  The 
blood  urea  and  creatinin  content  gives  us  indica- 
tions for  dietetic  therapy.  Ambard's  constant  fur- 
nishes information  as  to  the  progress  of  nephritis 
and  indicates  renal  function  when  the  blood  urea 
may  be  as  low  as  the  result  of  dietetic  therapy : 
0.09  or  less  equals  normal,  0.351  or  over  is  a  sign 
of  impending  danger  (11).  McLean's  normal 
figure  is  80  or  higher  and  a  change  for  the  worse 
is  indicated  by  a  lowering  of  the  constant  (12). 

5.  Drug  therapy  is  only  occasionally  of  consid- 
erable help  in  true  chronic  nephritis.  Diuretics  and 
digitalis  do  good  in  cardiac  cases  where  the  kidneys 
fail.    Digitalis,  theocin,   diuretin,  cat¥ein  sodium 


benzoate,  potassium  citrate,  and  other  drugs  may 
prolong  life  and  stimulate  the  kidneys  to  increased 
action  for  a  brief  period  only  in  chronic  renal 
cases  with  poor  kidney  function,  but  sooner  or 
later  fail  absolutely.  Frequently  patients  with 
serious  primary  renal  disease  fail  to  respond  to 
any  medication — and  it  is  important  to  keep  this 
in  mind,  because  more  harm  than  good  may  be 
done  by  overmedication  and  meddlesome  therapy  in 
these  cases.  The  phthalein  test  is  an  indication  of 
progress  in  nephritis,  and  reveals  the  course  of  the 
disease  as  affected  by  therapeutic  measures.  Its 
prognostic  value  as  to  immediate  and  ultimate 
outlook  and  as  to  advancement  of  disease  of  the 
kidney  as  far  as  its  function  is  concerned,  is  great, 
and  an  aid  in  the  supervision  of  such  cases. 
Chronic  interstitial  nephritis  is  an  incurable  disease. 
An  active,  comfortable  life,  however,  is  often  com- 
patible with  this  disease  for  many  years.  Chronic 
parenchymatous  nephritis,  on  the  other  hand,  is  a 
very  grave  and  serious  condition  which  kills  in 
two  or  three  or  four  years.  Change  of  climate, 
change  of  occupation,  may  help  to  prolong  life. 
T.  C.  Janeway  (13)  says:  "Caffein  in  small  doses 
may  give  good  results  in  edema  cases." 

In  uremic  cases  the  total  amount  of  fluid  ad- 
ministered should  be  at  least  2,500  to  3,000  c.  c. 
in  twenty-four  hours.  You  may  give  a  ten  per 
cent,  glucose  solution  by  mouth  or  by  the  stomach 
tube  if  the  patient  is  unconscious.  W.  W.  Palmer 
(14)  has  shown  that  acidosis  occurs  in  many  cases 
of  severe  nephritis  as  a  result  of  kidney  deficiency 
— here  there  is  a  deficient  elimination  of  acid.  Mar- 
riott and  Rowland  have  suggested  the  administra- 
tion of  calcium  as  an  aid  to  the  elimination  of 
phosphates  which  are  increased  in  nephritis.  Bi- 
carbonate of  soda  may  be  used  with  caution.  The 
kidney  holds  back  the  alkali  and  therefore  alkalosis 
may  result.  Note  the  depth  of  breathing  and  car- 
bon dioxide  tension  in  the  alveolar  air,  and  the 
quantity  of  carbonate  in  the  blood  as  to  the  amount 
of  alkali  to  be  administered.  Frothingham  and 
Smillie  (15)  have  shown  how  the  nonprotein  nitro- 
gen could  be  diminished  in  the  blood  by  a  low 
protein  diet.  Finally,  uric  acid  concentration  of 
the  blood  is  the  most  delicate  test  of  renal  function 
at  our  disposal.  The  first  to  increase  in  the  blood 
is  uric  acid,  next  urea — while  creatinin  (16)  in- 
creases in  the  blood  only  after  considerable  re- 
tention of  urea  had  taken  place  and  the  nephritis 
was  rather  far  advanced ;  that  cases  with  five 
mg.  of  creatinin  or  luore  almost  invariably  have  a 
bad  prognosis  and  when  the  blood  nitrogen  reaches 
sixty-five  to  the  100  c.  c.  the  patient  is  in  serious 
danger.  Five  mg.  creatinin  and  sixty  to  sixty-five 
mg.  urea  nitrogen  in  100  c.  c.  blood  is  a  death  ver- 
dict for  the  patient — the  prognosis  being  absolutely 
hopeless  in  many  of  these  cases. 

REFERENCES. 

1.  Mara:  Medical  Clinics  of  North  America. 

2.  Seguin  :  Archives  of  Internal  Medicine,  vol.  iv,  No. 
1,  August,  1880. 

3.  ScHAFER  AND  Herring  :  Philosophical  Transactions, 
London,  B.  199,  1,  1906. 

4.  Cow:  Journal  of  Physiology,  48,  1,  1914. 

5.  Landergren  and  Ticerstedt:  Svcndinarischcs  Ar- 
chiv.  f.  Physiologie,  4,  241,  1892. 


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NEW  YORK.  SATURDAY,  AUGUST  28,  1920. 


PHYSICIAN  AUTHORS— DR.  ARTHUR 
SCHNITZLER. 

As  a  rule,  when  physicians  become  eminently 
successful  in  literature  and  the  rewards  from  the 
product  of  their  pen  mount  to  flattering  heights, 
they  give  up  the  practice  of  medicine  and  devote 
their  whole  time  to  writing,  feeling,  no  doubt,  that 
circumstances  do  not  warrant  their  serving  two 
masters.  There  are  always  exceptions  to  prove 
every  rule,  and  Dr.  Arthur  Schnitzler  of  Vienna  is 
one  of  these.  Despite  the  position  he  has  won  as 
a  playwright  and  novelist  throughout  Europe  and, 
in  lesser  degree,  in  America,  he  still  clings,  at  the 
age  of  fifty-eight,  to  his  first  love,  unremittingly 
attending  to  his  activities  as  a  general  practitioner 
and  maintaining  his  connection  with  the  Clinical 
Hospital  of  Vienna,  in  which  city  he  was  born  in 
1862. 

To  the  bulk  of  Americans  Dr.  Arthur  Schnitzler 
is  not  very  well  known,  but  there  is  every  reason 
to  believe  that  in  course  of  time  he  will  be  a  familiar 
literary  figure.  For  Dr.  Schnitzler  is  one  of  the 
few  great  masters  in  modern  literature.  It  is  his 
frankness  in  dealing  with  some  aspects  of  life,  per- 
haps, that  has  retarded  his  introduction  to  the  gen- 
eral reading  public  of  America,  but  this  handicap 
is  being  steadily  overcome  and  Dr.  Schnitzler's 
audience  in  this  country  is  rapidly  widening.  For 
many  years  his  plays  have  been  produced  in  foreign 
language  theaters  and  a  start  has  been  made  with 
them  on  the  English  speaking  stage,  the  first  of  such 
productions    being   his    Anatol,    in    which  John 


Barrymore  played  the  title  role.  The  vogue  of  the 
printed  play  has  also  helped  to  introduce  Dr. 
Schnitzler  here,  and  translations  of  many  of  his 
twenty-five  plays  and  playlets  are  obtainable.  His 
plays  are  mostly  of  the  one  act  type,  full  of  shrewd 
wit  and  displaying  a  wonderful  grasp  of  hiunan 
nature.  The  critics  are  agreed  that  Dr.  Schnitzler 
is  the  finest  psychologist  of  the  theater  today,  rank- 
ing on  a  par  with  Hauptman  and  Wedekind.  All 
his  plays,  and  the  novels,  too,  have  their  satiric  and 
comic  side,  even  those  in  which  tragedy  is  the  pre- 
dominant note,  and  as  for  those  in  which  comedy 
is  uppermost,  there  is  always  a  vein  of  tragedy. 
There  is  no  man  writing  today  who  gives  us,  in 
plays,  novels  and  short  stories,  a  more  incisive  dis- 
section of  human  yearnings  and  foibles  than  Dr. 
Schnitzler. 

The  atmosphere  of  Vienna  permeates  all  Dr. 
Schnitzler's  work,  for  he  has  an  unbounded  love  for 
the  once  gay  old  capital  of  the  Austrian  empire,  and 
it  will  be  interesting  to  watch  his  future  treatment 
of  the  life  of  the  city  now  that  it  has  fallen  on  evil 
days.  When  what  was  formerly  Austria-Hungary 
was  fretsawed  into  an  economic  picture  puzzle, 
Vienna,  with  a  population  of  more  than  two  millions, 
was  left  suspended,  as  it  were,  in  midair.  Where 
once  it  was  the  twin  capital  of  a  vast  empire,  it  is 
now  the  centre  of  a  tiny  country  that  is  hardly  more 
than  a  suburb,  and  the  consequences  are,  to  say  the 
least,  distressing.  But  that  it  will  continue  to  be  a 
source  of  inspiration  to  Dr.  Schnitzler  there  is  no 
doubt,  for  he  is  still  there  in  the  midst  of  the  new 
life  with  an  observant  mind  and  a  rich  storehouse 
of  memory. 

When  Dr.  Schnitzler  adopted  the  practice  of 
medicine  he  followed  in  the  footsteps  of  his  father, 
Dr.  Johann  Schnitzler,  who  was  a  famous  laryngol- 
ogist.  He  got  his  medical  degree  in  1885  at  the 
University  of  Vienna  and  four  years  later  began 
that  connection  with  the  Clinical  Hospital  which  he 
still  maintains.  Meanwhile  he  contributed  to  Wcinar 
Klinische  Rundschau,  a  medical  review  of  which  his 
father  was  editor  and  publisher,  and  also  contributed 
sketches,  stories  and  poems  to  other  publications. 
His  hobby  at  this  period  seems  to  have  been  the  in- 
vestigation of  psychic  phenomena,  for  he  published 
an  article  of  comprehensive  scope  on  the  treatment 
of  certain  diseases  by  hypnotism  and  suggestion.  He 
then  went  to  London  and  there  wrote  his  London 
Letters,  exclusively  devoted  to  medical  subjects  of 
wide  range  and  variety.  His  original  writings  on 
medical  subjects  and  occasional  excursions  into  the 
byways  of  medicine  are  exceedingly  voluminous. 


August  28,  1920.] 


EDITORIAL  ARTICLES. 


291 


They  culminated  in  an  exhaustive  reference  work 
compiled  by  him  and  his  father,  entitled.  Clinical 
Atlas  of  Laryngology  and  Rhinology. 

Although  Dr.  Schnitzler  numerically  is  fifty-eight 
years  old,  he  is  said  to  possess  an  aliveness  that 
would  mean  youth  at  any  age.  He  is  one  of  those 
men  who  seem  to  defy  old  age.  An  interviewer 
who  chatted  with  him  recently  in  his  beloved  A'ienna 
tells  us  that  his  gray  blue  eyes  are  warm  and  bright, 
and  that  his  ample  brown  hair  and  trimmed  beard 
give  no  hint  of  his  years,  in  spite  of  the  gray  in 
them.  He  is  rather  square  in  build  and  therefore 
looks  shorter  than  he  is,  and  his  muscles  are  as  hard 
as  iron.  He  gives  the  impression  of  a  man  who 
has  taken  the  best  bodily  care  of  himself  and  his 
appearance  gives  him  dominance  in  any  group.  But 
although  Dr.  Schnitzler  seems  to  defy  time,  we 
know  that  he  has  given  it  considerable  profound 
thought,  for  his  latest  work,  a  novel,  Casanova's 
Homegoitig,  is  founded  on  the  horror  of  growing 
old.  "A  merciless  soul  vivisection"  this  book  has 
been  called,  flawless  both  as  a  work  of  art  and  as  a 
grim  human  document.  The  verdict  is  that  of  a 
European  critic.  We  may  have  to  wait  a  few  years 
before  we  in  America  are  able  to  verify  it. 


PRODIGIOUS    MENTAL  CALCULATORS. 

The  first  prodigy  in  mental  calculation  was 
Xichomachos,  about  whom  little  is  known.  It  has 
also  been  stated  that  the  African  slave  traders 
were  apt  mental  calculators,  but  no  particular  ex- 
ample has  been  reported  in  old  literature.  !Mathieu 
le  Coq,  who  lived  in  Italy  about  1660,  appears  to 
have  solved  the  most  difficult  rules  of  arithmetic 
at  the  age  of  six  years  although  he  did  not  write 
or  read.  If  this  statement  is  not  completely  leg- 
endary it  places  in  evidence  two  characteristics  al- 
most constantly  found  in  families  of  prodigious 
mental  calculators — precocity  and  ignorance. 

Tom  Fuller,  surnamed  the  negro  calculator,  is  a 
curious  example  of  an  ignorant  mental  calculator. 
He  knew  neither  how  to  read  nor  write  and  died 
at  the  age  of  eighty  years  without  having  learned. 
A  contemporary  of  the  negro  was  Jedediah  Bux- 
ton, who  lived  in  England  from  1702  to  1762.  He 
was  a  poor  laborer  who,  although  the  son  of  a 
schoolmaster,  had  never  received  any  instruction 
and  could  not  even  write  his  name.  It  is  said  that 
he  was  far  below  the  average  intellectually  and  it 
was  with  the  greatest  difficulty  that  he  could  main- 
tain his  numerous  family.  He  fished  in  summer 
and  worked  as  a  thresher  in  winter.  He  pushed 
his  mania  for  calculation  to  such  an  extent  that 
when  he  came  to  London  to  be  examined  bv  the 


Royal  Society  and  was  taken  to  see  the  play  of 
Richard  III  he  fixed  his  attention  during  the 
dances  on  the  number  of  steps  executed.  There 
were  5,202  of  them  but  he  only  occupied  himself 
in  counting  the  number  of  words  spoken  by  the  ac- 
tors, 12,445,  and  this  was  found  exact.  He  had 
learned  the  multiplication  table  and  this  was 
the  only  instruction  he  had  ever  received.  Beside, 
he  preserved  in  his  memor\-  a  certain  number  of 
products  which  facilitated  his  calculation  and  were, 
so  to  speak,  landmarks.  He  always  reduced 
lengths  to  a  peculiar  scale,  the  thickness  of  a  hair, 
and  he  well  knew  how  many  of  these  thicknesses 
there  were  to  a  mile.  Finally,  he  had  a  very  re- 
markable coup  d'ocil  and  judgment  of  space,  for 
he  had  only  to  walk  over  extensive  grounds,  taking 
long  steps,  after  which  he  could  give  the  exact 
surface.  Like  Fuller,  he  died  at  an  advanced  age, 
showing  that  these  prodigies  do  not  die  young,  as 
some  have  maintained. 

Mathematicians  who  have  been  remarkable  cal- 
culators represent  a  type  distinct  from  prodigious 
calculators.  Calculators  like  Fuller  or  Buxton 
remain  such  all  their  lives.  They  have  not  a  mind 
open  to  mathematics  and  profit  little,  if  at  all, 
from  any  instruction  given  them.  From  infancy, 
mathematicians  show  a  remarkable  disposition  for 
mental  calculation,  but  for  them  this  is  simply  an 
accident  in  their  existence  and  they  are  destined  to 
soar  higher.  Such  is  the  case  of  Ampere,  who 
from  the  age  of  four  carried  out  long  operations 
of  mental  calculation  with  the  use  of  small  pebbles, 
although  he  did  not  know  the  alphabet  or  figures, 
De  Gausse,  regarded  as  the  greatest  geometrician 
of  the  century,  was  a  prodigious  calculator  when 
hardly  three  years  old.  In  1810,  Zerah  Colburn 
gave  exhibitions  in  the  large  cities  of  America  and 
Europe.  He  was  an  individual  of  mean  intelli- 
gence and  yet  he  maintained  that  he  should  be  re- 
garded as  the  greatest  mind  of  the  times.  He  was 
backward  mentally,  incapable  of  any  practical  ap- 
plication and,  like  his  predecessor,  a  specialist  at 
figures,  but  obdurate  to  all  else.  His  faculties  as 
a  calculator  developed  spontaneously  before  he 
could  write  or  read.  Mangiamele.  a  little  Sicilian 
shepherd,  was  ten  years  old  when  he  came  to  Paris 
to  be  examined  by  Arago  in  1837.  He  had  dis- 
covered procedures  of  calculation  which  he  used  to 
solve  intricate  problems.  On  all  other  questions  his 
knowledge  was  more  than  rudimentary.  Dase,  born 
in  1824,  was  a  mental  calculator  of  great  note  who 
not  only  was  a  prodigy  but  was  also  useful  to  sci- 
ence. To  him  is  principally  due  the  calculation  of 
natural  logarithms  or  numbers  from  one  to  a  mil- 
lion.   Yet  he  was  a  calculator  in  the  strict  sense 


292 


NEWS  ITEMS. 


[New  York 
Medical  Journal. 


of  the  word ;  he  would  never  learn  the  simplest 
geometrical  proposition  and  in  general  had  a  very 
obtuse  intellect. 

Henri  Wondeux,  a  young  shepherd  of  Touraine, 
who  was  the  object  of  a  report  by  Cauchy  at  the 
Paris  Academy  of  Science,  easily  carried  out  men- 
tally the  most  varied  arithmetical  operation.  He 
devised  procedures,  sometimes  remarkable,  for 
solving  many  problems  usually  treated  by  algebra. 
His  memory  for  figures  was  highly  developed  and 
he  could  remember  numbers  composed  of  twenty- 
four  figures.  In  everything  else  his  memory  was 
faulty.  Bidder  is  a  type  by  himself  in  the  family 
of  calculators.  Born  in  most  modest  conditions 
he  became  through  his  intelligence  one  of  the  most 
distinguished  men  of  science  of  his  day.  At  no 
time  in  his  life  did  he  lose  his  aptitude  for  mental 
calculation,  which  increased  with  years,  a  fact  that 
distinguished  him  from  other  calculators.  His 
mental  gifts  were  in  part  transmitted  to  his  son 
and  grandsons.  This  is  the  only  case  in  which 
hereditary  influence  has  been  noted.  In  1892, 
Jacques  Inandi  was  presented  at  the  Paris  Academy 
of  Science  and  Charcot  was  one  of  the  commis- 
sion designated  to  examine  him,  while  more  re- 
cently another  case  has  been  studied  in  France  by 
Desrulles.  The  subject,  Fleury  by  name,  was 
born  blind,  and  although  not  so  prodigious  as  In- 
andi still  he  can  be  placed  in  the  call  of  subjects 
under  consideration. 

The  most  recent  work  on  the  subject  is  Hunt- 
ziger's  thesis  (Paris,  1913).  This  writer  points 
out  that  there  is  a  congenital  disposition  in  these 
subjects,  affirmed  by  the  precocity  of  the  phenome- 
non. Neither  heredity  nor  environment  plays  any 
part,  at  least  in  most  instances.  The  subject  de- 
velops only  a  single  memory,  that  of  figures,  and 
this  special  mnemic  faculty  attains  extraordinary 
proportions  in  some.  They  all  have  almost  identi- 
cal procedures  for  carrying  out  their  mental  cal- 
culations but  they  are  not  those  of  ordinary  arith- 
meticians, and  Huntziger  finds  that  almost  all  nat- 
ural calculators  remain  ignorant  during  their  lives. 


SOME  CONCLUSIONS  AS  TO  LEPROSY. 

While  the  complacently  resigned  were  pronounc- 
ing leprosy  incurable,  scientists  and  medical  mis- 
sionaries, great  hearted  men,  have  been  and  are 
incessantly  toiling  over  its  prevention  and  cure.  The 
findings  of  the  Leper  Mission  Conference  in  In- 
dia last  month  are: 

That  leprosy  is  contagious,  but  slowly.  It  is  not 
directly  hereditary,  children  being  free  at  birth,  but 
susceptible  at  an  early  age.  It  is  necessary  to  pro- 
mote the  earliest  possible  separation  of  infants  from 
infected  leper  parents.    The  Conference  believes 


leprosy  could  be  stamped  out  in  India  if  all  lepers 
were  segregated,  but  as  this  presents  many  initial 
difficulties  the  segregation  of  pauper  lepers  should 
be  first  vmdertaken.  The  present  type  of  mission 
asylum  with  sympathetic  Christian  management  af- 
fords the  best  means  of  effecting  a  voluntary  seg- 
regation. 

For  amending  the  Indian  Lepers  Act  of  1908  the 
training  of  medical  assistants  in  diagnosis  and  treat- 
ment was  urged ;  the  equipping  of  all  leper  insti- 
tutions with  a  suitable  laboratory ;  when  the  sepa- 
ration of  the  sexes  is  impracticable,  the  couple 
should  be  allowed  to  live  together  only  on  the  under- 
standing that  any  children  born  shall  be  separated 
from  them  as  early  as  possible  also  that  one  parent, 
if  presenting  good  prospects  of  recovery,  should  be 
separted  from  the  leprous  one.  It  was  added  that 
the  method  of  treatment  with  the  salts  of  fatty  acid 
introduced  by  Sir  Leonard  Rogers  had  been  lately 
tested  by  fourteen  medical  officers  and  assistants 
on  lepers  throughout  India  with  most  favorable  re- 
sults, seventy-two  advanced  cases  showing  marked 
improvement,  but  much  research  into  this  is  still 
needed.  The  amendments  are  approved  by  foremost 
men  such  as  Sir  Ronald  Ross.  Sir  Leslie  Rogers,  of 
the  School  of  Tropical  Medicine,  referred  recently  to 
the  shabby  treatment  the  Medical  Service  in  India 
had  received  from  the  bureaucratic  Government  in 
regard  to  special  research,  saying  his  own  expenses 
were  far  in  excess  of  his  income.  The  appeal 
comes  from  men  fighting  daily,  the  ignorance  of  it 
from  men  who  have  only  met  lepers  in  the  pages 
of  Blue  Books  and — to  them — tiresomely  long  re- 
ports. 

■  <$>  ■ 

News  Items. 


Honor  for  Dr.  Biggs. — Dr.  Hermann  M.  Biggs, 
health  commissioner  of  New  York  State,  has  been 
awarded  the  honorary  degree  of  Doctor  of  Science 
by  Harvard  University. 

Huebner  Prize  Awarded. — The  Huebner  Prize 
for  the  best  work  on  pediatrics  has  been  awarded 
to  Dr.  Arvo  Ylppo  of  Helsingfors,  assistant  at  the 
Kaiserin-Augusta-Viktoria  Haus  at  Charlottenburg, 
Germany. 

Georgia  Medical  Association  Officers. — At  its 

annual  meeting  held  in  Macon  in  May,  the  Medical 
Association  of  Georgia  elected  the  following  offi- 
cers :  president,  Dr.  Edward  T.  Coleman,  of  Gray- 
mont ;  vice-presidents,  Dr.  Theodore  E.  Oertel,  of 
Augusta,  and  Dr.  Fred  L.  Webb,  of  Macon;  sec- 
retary-treasurer, Dr.  Allen  H.  Bunce,  of  Atlanta. 

Changes  in  Mercy  Hospital  Staff. — The  follow- 
ing appointments  have  been  made  to  the  staff  of 
Mercy  Hospital,  Baltimore :  Superintendent,  Dr. 
Irwin  O.  Ridgely;  Dr.  L.  H.  Brumback,  Dr.  Hazen 
G.  Chamberlain,  Dr.  J.  A.  darkens.  Dr.  John  J. 
Erwin,  Dr.  Andrew  J.  Gillis,  Dr.  Benjamin  Gold, 
Dr.  W.  F.  Martin,  Dr.  E.  L.  Kaufman,  Dr.  W.  K. 
McGill,  Dr  J.  W.  Martindale,  Dr.  William  J.  B. 
Orr,  Dr.  Daniel  J.  Pessagno,  Dr.  J.  M.  Robinson, 
Dr.  Sanford  M.  Rosenthal,  Dr.  Vernon  I.  Smith, 
and  Dr.  Robert  B.  White. 


August  28,  1920.] 


NEWS  ITEMS. 


293 


United  States  Civil  Service. — The  United 
States  Civil  Service  Commission  announces  exami- 
nations for  district  medical  officer  ($l,800-$3,000) 
and  assistant  medical  officer  ($l,800-$2,750)  in 
the  rehabilitation  division  of  the  Federal  Board  for 
Vocational  Education. 

John  B.  Murphy  Memorial. — It  is  proposed  to 
erect  a  memorial  to  the  late  Dr.  John  B.  Murphy, 
of  Chicago,  in  the  form  of  the  John  B.  Murphy 
Memorial  Hall  of  the  American  College  of  Sur- 
geons, on  a  site  in  Chicago  and  at  an  estimated 
cost  of  $500,000.  The  building  would  furnish  a 
meeting  place  for  medical  societies,  and  it  is  also 
proposed  to  maintain  there  a  pantheon  of  Ameri- 
can medicine  and  surgery.  The  John  B.  Murphy 
Memorial  Association  is  undertaking  to  raise  sub- 
scriptions for  the  amount.  One  hundred  thousand 
dollars  has  already  been  pledged  provided  the  bal- 
ance of  the  requisite  sum  is  obtained. 

Gift  from  English  to  American  Surgeons. — 

Word  comes  from  London  that  a  silver  gilt  mace 
is  to  be  presented  by  British  surgeons  to  the  Ameri- 
can College  of  Surgeons  (which  includes  Canada) 
as  a  memento  of  the  work  done  in  cooperation  by 
British  and  American  surgeons  during  the  war.  The 
gift  is  the  suggestion  of  Sir  Berkeley  Moynihan, 
who  has  worked  in  collaboration  with  Sir  Anthony 
Bowlby  and  Sir  D'Arcy  Power.  The  mace  is  the 
work  of  Mr.  Omar  Ramsden,  who  has  modeled  the 
head  of  the  mace  on  the  lines  of  a  surgeon's  mortar 
dug  up  in  a  Salonika  trench.  The  design  includes 
maple  leaves  and  American  eagles,  the  badges  of 
the  British  and  American  Army  Medical  Corps,  and 
the  serpents  of  ^sculapius,  while  the  name  is  in- 
troduced of  Philip  Syng  Physick  (1768-1837),  the 
father  of  American  surgery,  who  was  a  pupil  of 
John  Hunter  and  an  ex-house  surgeon  at  St. 
George's  Hospital.  An  inscription  reads :  "From 
the  consulting  surgeons  of  the  British  Armies  to  the 
American  College  of  Surgeons  in  memory  of  mu- 
tual work  and  good  fellowship  in  the  Great  War." 

New  York  State  Vital  Statistics.— The  May 

death  rate  in  New  York  state  was  12.7,  which  is  the 
lowest  May  death  rate  on  record  for  the  state  as  a 
whole  and  is  2.3  points  lower  than  the  May  average 
in  the  five  years  1913-17.  The  infant  mortality,  88 
deaths  under  one  year  in  1,000  live  births,  is  9  points 
below  the  May  average  in  the  five  year  period 
mentioned. 

The  communicable 'diseases  which  showed  a  case 
incidence  in  the  state  as  a  whole  of  100  or  more  in 
100,000  population  were  measles  1,175.1,  syphilis 
315.4,  tuberculosis  (all  forms)  247.1,  diphtheria 
221.5  ,  pneumonia  (all  forms)  198.6,  whooping 
cough  172.9,  scarlet  fever  156.1,  mumps  140.3,  and 
chickenpox  133.8.  The  communicable  diseases 
which  showed  a  death  rate  of  10  or  more  in  100,- 
000  population  were  tuberculosis  (all  forms)  127.8, 
pneumonia  (all  forms)  125.9,  measles  14.5,  diph- 
theria 14.5,  and  epidemic  influenza  13.1. 

Syphilis  continues  to  show  the  notably  high  case 
rate  which  prevailed  during  the  first  quarter  of 
1920.  The  May  rate  of  312.6  represents  the  dis- 
covery during  that  month  of  2,930  cases  of  the 
disease. 


Dr.  Gorgas  Buried  in  Arlington. — The  body  of 
Major  General  William  C.  Gorgas  was  buried 
August  16th  at  Arlington  National  Cemetery.  Pre- 
ceding the  army  ritual  at  the  grave,  services  were 
held  at  the  Church  of  the  Epiphany,  attended  by 
Cabinet  members,  members  of  the  diplomatic  corps, 
and  representatives  of  American  and  foreign  scien- 
tific societies.  Among  the  pallbearers  were  Col.  Sir 
William  Smith,  of  the  Royal  Institute  of  Public 
Hygiene;  Major  General  Merritte  W.  Ireland; 
Rear  Admirals  W.  C.  Braisted  and  Gary  T.  Gray- 
son, and  former  Surgeon  General  Rupert  Blue  of 
the  Public  Health  Service. 

Rural  Consultation  Clinic. — The  New  York 
State  Department  of  Health  recently  held  at  Goshen 
the  first  rural  consultation  clinic  in  the  country,  to 
assist  local  physicians  in  difficult  diagnoses.  It  is 
planned  to  establish  visiting  clinics  in  other  locali- 
ties which  are  without  x  ray  machines  and  needed 
laboratory  apparatus.  In  conductng  the  clinic  the 
following  subdivisions  were  used :  diseases  of  chil- 
dren, diseases  of  adult  life,  diseases  of  women,  men- 
tal and  nervous  disorders ;  orthopedic  surgery, 
venereal  diseases,  and  oral  surgery.  Among  the 
physicians  who  were  to  take  part  in  the  clinic  are : 
Dr.  T.  Ordway,  dean  and  professor  of  medicine, 
Albany  Medical  College;  Dr.  H.  L.  K.  Shaw,  presi- 
dent-elect, American  Child  Hygiene  Association, 
and  professor  of  diseases  of  children,  Albany  Medi- 
cal College ;  Dr.  J.  F.  Nagle,  attending  physician, 
Bellevue  Hospital ;  Dr.  E.  J.  Wynkoop,  profes- 
sor of  diseases  of  children,  Syracuse  Medical  Col- 
lege ;  Dr.  G.  W.  Partridge,  Bellevue  and  Post 
Graduate  Hospitals,  New  York  City ;  Dr.  C.  D. 
Post,  professor  of  medicine,  Syracuse  Medical 
College;  Dr.  Charles  INI.  Dunne,  Norwich,  N.  Y. ; 
Dr.  F.  W.  Barrows,  state  medical  instructor  of 
schools;  Dr.  L.  W.  Hubbard,  Dr.  M.  F.  Lent  and 
Dr.  W.  E.  Youland,  State  Health  Department;  Dr. 
A.  S.  Moore,  Dr.  W.  E.  Kelly  and  Dr.  W.  A. 
Schmitz,  Middletown  State  Hospital;  Dr.  W.  O. 
Sandv  and  Dr.  E.  W.  Fuller,  State  Commission  for 
Feeble  Minded,  and  Dr.  C.  B.  Witter. 

 <^  

Died. 

Bell. — In  Williamsport,  Pa.,  on  Monday,  August  9th,  Dr. 
G.  Franklin  Bell,  aged  fifty-nine  years. 

Cooper. — In  New  York,  N.  Y.,  on  Monday,  August  9th, 
Dr.  Sherman  Cooper,  aged  eighty-eight  years. 

Davis. — In  Mackinac,  Mich.,  Dr.  Olga  Davis,  of  Chicago, 
aged  forty-five  years. 

Heist. — In  Philadelphia,  Pa.,  on  Sunday,  August  8th,  Dr. 
George  David  Heist,  aged  thirty-five  years. 

Heuel. — In  New  York,  N.  Y.,  on  Wednesday,  August 
11th,  Dr.  Emil  Heuel,  aged  fifty-five  years. 

Hoev. — In  San  Francisco,  Cal.,  on  Sunday,  August  1st, 
Dr.  Matthew  J.  Hoey,  aged  thirty-eight  years. 

Karlsloe. — In- New  York,  N.  Y.,  on  Sunday,  August  8th, 
Dr.  William  J.  Karlsloe,  aged  seventy-one  years. 

Mereness. — In  Albany,  N.  Y.,  on  Wednesday,  August 
4th,  Dr.  Henry  E.  Mereness,  aged  seventy-one  years. 

Sherman. — In  Rochester,  N.  Y.,  on  Wednesday,  August 
4th,  Dr.  James  F.  Sherman,  aged  fifty-eight  yer.rs. 

Tillapaugh. — In  Wolcott,  N.  Y.,  on  Friday,  August  6th, 
Dr.  James  J.  Tillapaugh,  aged  sixty-three  years. 


Book  Reviews 


PSYCHOANALYSIS. 

A  General  Introduction  to  Psychoanalysis.  By  Prof.  Sic- 
MUND  Freud,  LL.  D.  Authorized  Translation.  With  a 
Preface  bv  G.  Stanley  H.\ll.  \'e\v  York :  Boni  &  Live- 
right,  1920.    Pp.  i-402. 

A  book  of  this  sort  is  a  rare  acquisition. 
Whether  its  readers  are  psychoanalysts  or  not  does 
not  alter  the  unique  value  of  the  work.  Naturally 
their  interest  will  depend  upon  their  point  of  view, 
but  the  inherent  worth  of  the  book  lies  outside 
this  consideration.  Perhaps  never  before  has  a 
man  of  high  authority  in  his  field  so  taken  the 
public  into  his  confidence,  so  patiently  invited  them 
into  the  scientific  details  and  the  broader  implica- 
tions of  his  subject.  Freud's  authority  has  been 
won  through  an  unremitting  toil  by  which  alone  he 
has  mastered  the  field  which  today  may  truthfully 
be  acknowledged  his.  One  may  not  agree  with  his 
conclusions,  one  may  dispute  the 'wisdom  of  choos- 
ing such  a  field  as  his  upon  which  to  expend  a  life's 
labor,  yet  one  cannot  read  this  book  with  an  open 
mind  and  not  perceive  that  in  so  far  as  this  has 
been  his  realm  he  has  become  master  within  it. 
Here  he  spares  no  pains  to  share  generously  the 
•results  of  his  experience  with  other  thinking  men 
and  women. 

One  might  even  go  so  far  as  to  admit  that  it  is  an 
actual  field  of  service  and  because  of  his  faithful- 
ness and  skill  he  has  performed  a  unique 
work  in  the  history  of  mankind.  He  himself 
makes  no  boastful  suggestion.  He  is  content  with 
lesser  claims,  his  contentment  that  of  the  worker 
too  absorbed  in  his  task  to  dream  vain  dreams.  He 
merely  points  out  the  steps  he  has  taken  and  calls 
attention  to  the  lanes  and  bypaths  of  future  pos- 
sibilities both  in  psychotherapy  and  other  psycho- 
logical fields  which  temptingly  open  out  of  the 
narrower  way  already  trod.  At  any  rate  the  con- 
tent of  this  book  is  worthy .  of  close  reading  in 
order  first  to  know  psychoanalysis  in  the  author 
himself  and  then  in  order  to  determine  on  what 
its  assertions  to  practical  success  are  founded. 
Psychoanalysis  is  obtaining  ever  wider  recognition 
from  all  circles  of  interest.  The  least  that  one  can 
do  in  an  endeavor  to  keep  abreast  of  progress  is  to 
understand  the  simple  rudiments  of  a  system  which 
is  taking  such  a  prominent  place. 

Of  course  the  book  has  an  especial  value  to  those 
closely  concerned  in  the  study  and  treatment  of 
psychic  disorders,  and  for  that  matter  for  any 
physician  who  is  continually  being  brought  face  to 
face  with  all  sorts  of  mental  difficulties  in  his  gen- 
eral professional  contact  with  the  sick.  Here  again 
it  is  of  greatest  advantage  to  approach  this  method 
of  study  of  mental  disorders  through  the  direct 
teaching  of  the  leader  in  psychoanalysis.  For  the 
acknowledged  psychoanalyst  this  presentation  of 
the  subject  is  a  detailed  study  of  still  greater  value. 
It  af¥ords  a  summary  of  the  essential  principles  of 
psychoanalysis.  It  reviews  the  various  elements  in 
the  approach  to  the  unconscious  mental  life  and  its 
niechani.-^ms  in  unified  and  consecutive  order.  Any 
worker  in  this  field  admits  at  once  the  advantage 
of  frequent  review  of  these  fundamental  facts  and 


repeated  discussion  of  their  mutual  relations.  It  is 
both  stimulating  and  instructive  to  enter  again  in 
this  simple  manner  into  the  author's  own  practical 
approach  to  the  unconscious. 

The  often  repeated  objections  of  arbitrariness, 
narrow  resistance  to  opponents,  the  insisting  upon 
unfounded  speculations,  with  which  Freud's  work 
has  long  been  met,  grow  feeble  before  the  patient 
explanations  with  which  Freud  has  expounded  the 
principles  upon  which  he  works  and  his  experi- 
ence in  developing  and  applying  them.  His  cour- 
tesy is  manifest  toward  those  who  oppose  and,  more 
difficult  still,  toward  those  who.  going  part  way, 
have  then  taken  certain  hard  won  hypotheses  and 
twisted  them  to  new  meanings,  which  in  some  in- 
stances at  least  lack  the  directness  and  simplicity  of 
Freud's  own  thought  and  practice.  His  openmind- 
edness  toward  the  real  contributions  of  others  as 
well  as  toward  the  possibilities  of  which  he  counts 
his  life  work  only  the  beginning  also  win  the  re- 
spect of  the  reader  and  incite  him  to  a  more  than 
passing  interest  in  the  subject  presented.  Freud 
has  proceeded  with  such  careful  steps  and  his 
manner  of  presentation  is  so  scientifically  sincere 
that  criticism  is  disamied. 

It  is  not  possible  to  do  justice  to  the  various 
positive  elements  of  the  book  and  this  for  two  rea- 
sons. Anything  more  than  a  brief  survey  of  the 
topics  discussed  would  only  crudely  represent  what 
the  author  has  accomplished  in  so  more  complete 
a  form.  The  value  of  the  book  can  only  be  reached 
by  a  close  perusal  of  its  pages.  In  the  second  place 
the  book,  aside  from  this  instructive  sequence  of 
presentation,  contains  many  rich  nuggets  of  psycho- 
logical truth,  especially  such  as  pertain  directly  to 
the  subjects  peculiar  to  psychoanalysis.  The  main 
subjects  might  be  hastily  enumerated  in  the  order 
in  which  Freud  presents  them,  the  psychology  of 
errors  as  his  introduction  to  the  unconscious, 
then  the  study  of  dream  content  and  dream 
mechanisms,  passing  from  this  on  to  the  relations 
of  psychoanalysis  and  psychiatry  with  the  definite 
application  of  the  former  to  interpretation  and 
treatment  of  the  forms  of  neurotic  illness.  He 
touches  briefly  upon  the  relation  of  psychoanalysis 
to  the  actual  psychotic  manifestations  but  con- 
siders this  field  one  of  those  in  which  advance  is 
still  mostly  a  matter  of  future  rather  than  of 
present  accomplishment.  Certamly  no  one  can  leave 
the  reading  of  the  work  without  a  far  profounder 
knowledge  of  the  psychic  life,  an  understanding  en- 
riched both  by  this  wide  and  profound  survey  of 
mental  life  and  its  mechanisms  and  by  these  many 
words  of  revelation  with  which  Freud's  interpre- 
tation abounds. 

Was  there  not  an  ancient  objection  to  psycho- 
analysis and  to  Freud  based  on  resistance  to  the 
sexual  content  of  his  work?  Any  one  with  such 
a  repugnance  would  find  this  a  wholesome  study. 
Let  him  not  be  deceived,  sex  is  mentioned  and  in 
frank  detail.  It  is  handled,  however,  with  all  the 
dignified  unreserve  of  a  conscientious  handling  of 
facts.  Again  the  reader  has  a  straightforward  op- 
portunity to  question  himself  whether  the  assertions 


August  28.  1920.] 


BOOK  REVIEWS. 


29S 


of  psychoanalysis  are  wildly  made.  If  he  discovers 
they  are  not  he  finds  himself  at  the  end  of  his 
reading  in  possession  of  a  clearer  knowledge  of  the 
entire  sex  life  of  man  and  of  its  importance  in 
mental  disturbances.  He  gains  an  appreciation  of 
its  developmental  history-  in  each  individual.  He 
is  able  to  re\-iew  thus  closely  in  its  various  forms 
the  appearances  of  sex  throughout  childhood  and 
adult  life.  He  gains  also  a  clearer  appreciation  of  its 
part  in  sublimation  as  well  as  in  partial  sublima- 
tions and  compromise  reactions  and  in  determining 
per\'er5ities.  He  comes  to  understand  the  neces- 
sit\'  of  a  balance  between  the  ego  and  the  sex  libido 
and  the  difficulties  which  present  themselves  in 
making  such  a  balance.  Whatever  one's  medical 
or  psychological  faith,  one's  knowledge  of  human 
psychic  life  is  greatly  increased  by  a  careful  study 
of  this  work.  At  the  same  time  it  has  its  special 
function  as  the  most  complete  and  comprehensive 
book  on  psychoanalysis  yet  produced. 

A  CHILD'S  MIXD. 

The  World  ai  Se^en.  By  Burxett  Steele  Ivey.  Boston: 
The  Stratford  Company.  1920. 

This  little  book  of  verse  is  interesting,  as  are  all 
the  productions  of  children.  The  world  of  this 
child  was  a  real  world,  a  ver\-  real  world  inhabited 
by  policemen.  grocer\"men.  candymen.  and  soldiers. 
Unlike  the  poetical  works  of  many  children  the  pro- 
duction of  phantasy  is  not  evident.  One  might 
recite  the  poems  which  are  called  historical,  the 
ones  about  Jack  the  Giant  Killer.  Cinderella  and 
King  Alfred,  but  in  all  of  these  he  is  onlv  giving 
back  the  things  he  has  read  about.  He  does  not 
aspire  to  create  new  worlds.  He  is  content  to  live 
in  the  worlds  in  which  he  finds  himself,  or  at  least  to 
accept  another  world  which  has  been  created  for 
him  by  someone  else.  He  made  his  adjustments 
with  ease.  Either  he  has  had  his  own  way  about 
things  or  he  encountered  few  difficulties.  A  safe 
prophecy  would  be  that  he  will  find  little  difticulrj- 
in  his  studies,  but  unless  a  radical  revolution  takes 
place  he  will  never  be  an  artist.  He  may  become  a 
poet,  but  he  will  travel  the  ways  of  mediocrity. 

A  PRIZE  NOVEL. 

Atlatttid*:  (L'Atlantide) .  By  Pierre  Bexoit.  Translated 
bv  M.ARY  S.  T.\MPE  and  M.\ry  Ross.  New  York :  Duffield 
&  Co. 

In  France  Benoit  was  awarded  a  prize  of  5,000 
francs  for  having  written  this  highly  graphic  ad- 
venture stor}-.  On  the  whole  it  recalls  H.  Rider 
Haggard.  Benoit,  no  doubt,  has  done  archeological 
work  in  the  region  and  used  the  material  he  found 
in  making  his  story.  His  portrayal  of  the  desert 
leaves  a  distinct  feeling  of  its  solitude  and  mysterv-. 
The  country  he  has  selected  is  well  adapted  for  the 
tale  which  he  has  told.  So  con\-incingly  has  he 
written  that  one  stops  to  wonder  about  the  signifi- 
cance of  the  rites  which  are  described.  Then  there 
is  the  strange  woman,  powerful  and  beautiful,  lur- 
ing men  to  destruction.  Of  two  comrades,  one  holds 
out  and  the  other  succumbs  to  her  lures.  The  pas- 
sion of  the  weaker  man  is  so  great  that  he  slays  his 
comrade  in  order  to  gain  the  woman,  knowing  full 
well  that  when  she  tires  of  him  he  will  be  put  in  a 
neatly  numbered  coffin  to  be  placed  in  a  great  hall 


where  she  keeps  the  souvenirs  of  her  conquests.  In 
order  to  prolong  the  story  or  to  show  more  com- 
pletely the  weakness  of  man,  he  is  allowed  to  es- 
cape. After  this  stormy  adventure  he  is  not  con- 
tented and  is  ever  seeking  to  find  his  way  back  to 
the  arms  of  the  woman  and  the  niche  which  has 
been  reser\-ed  for  him.  Such  efforts  must  be  re- 
warded in  story  books,  and  the  reader  is  content 
to  know  that  finally  the  fatal  woman  has  learned 
his  whereabouts  and  sent  her  henchman,  the  unpro- 
nounceable Cegheir-ben-Chetkh  after  him ;  if  it  is 
what  he  really  wants,  after  knowing  all  about  it, 
let  him  have  it  by  all  means. 

VEXGEAXCE  WITHOUT  IXDIAXS 

Indian  T'eiigcancL.  By  LmxGSTOX  Frexch  Joxes.  Boston : 
The  Stratford  Company,  1920. 

In  this  little  book  one  would  expect  to  find  ma- 
terial of  value  to  the  anthropologist  or  at  least  in- 
teresting data  in  regard  to  Indian  customs.  From 
this  viewpoint  it  is  disappointing.  Instead,  we  find 
an  ordinary  story  that  might  have  been  told  about 
any  grotip  of  people  in  any  locality  by  changing  the 
scenery.  The  telling  of  a  tale  that  has  little  value 
to  science  might  be  forgiven,  but  when  we  find  the 
author  stating  it  badly  and  approaching  simple 
problems  in  a  school  boy  manner  it  is  more  difficult 
to  overlook  the  transgression. 

 <$>  

NJew  Publications  Received. 


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


PR0CEEDIXG5    OF    THE    XEW    YORK    PATH0L0GIC-\L  SOCIETY. 

New  Series,  Volume  xix.  1919.  Illustrated.  New  York, 
1919.    Pp.  xc-173. 

BIEX  XI.AI.  REPORT  OF  THE  BOARD  OF  HEALTH  FOR  THE  PARISH 
OF    ORLEAXS    AXD    THE    CITY'    OF    XEW    ORLEAXS,  1918-1919. 

Illustrated.  New  Orleans :  Brandao  Printing  Co.  Pp. 
vii-1 33. 

FORESTS.  WOODS  AXD  TREES  IX  RELATIOX  TO  HYGIEXE.  By 

AuGL  STiXE  Hexrv,  M.  A.,  F.  L.  S.,  M.  R.I.A.;  Professor 
of  Forestry-,  Royal  College  of  Science,  Dublin.  Illustrated. 
New  York :   E.  P.  Dutton  &  Company.    Pp.  xii-314. 

THE   life  of  BEXJAMIX"   DISRAELI,  EARL  OF  BEACOXSFIELD. 

By  Geo.  Earl  Buckle.  In  Succession  to  W.  F.  Moxey'- 
PEXXY.  Volume  5  and  6.  1868-1876.  With  Portraits  and 
Illustrations.  New  York:  The  Macmillan  Co.,  1920.  Pp. 
xii-558. 

THE     SOL'L     OF     R.\TI0X.\L     PSYCHOLOGY.       By  Em.\XL"EL 

SwEDEXBORG.  Translated  and  Edited  by  Fraxk  Sew.aI-l, 
A.M.  From  the  Latin  Edition  of  Dr.  J.  F.  Immanuel 
Taiel.  Tubingen.  1849.  Third  and  Revised  Edition.  New 
York :  The  New-Church  Press.    Pp.  xxxiii-388. 

HE.\LTHY  LivixG.  By  Charles-Edward  Amory  W'ix- 
SLOW.  D.P.H. :  Professor  of  Public  Health.  Yale  Medical 
School,  and  Curator  of  Public  Health.  American  Museum 
of  Natural  Historj-.  Enlarged  Edition.  Illustrated.  In 
two  volumes.  New  York  and  Chicago :  Charles  E.  Mer- 
rill Co.    Pp.  iii-405. 

THE  MECHAXISM  AXD  GRAPHIC  REGISTRATIOX  OF  THE 
HEART  BEAT.     By  TfaOMAS  Le\\ts,  M.  D..  F.  R.  S..  F.  R.  C. 

p..  D.  Sc. :  Honorarj'  Consulting  Physician,  Ministry  of 
Pensions ;  Late  Consulting  Physician  in  Diseases  of  the 
Heart  (Eastern  Command)  :  Physician  of  the  Staff  of  the 
Roval  Medical  Research  Committee,  etc.  Illustrated.  New 
Yo'rk:   Paul  B.  Hoeber,  1920.    Pp.  xx-452. 


Practical  Therapeutics  and  Preventive  Medicine 

A  Compendium  of  Treatment  and  Prophylaxis,  Original  and  Adapted 


TREATMENT  OF  SURGICAL  SHOCK. 

By  Vincent  Anthony  Lapenta,  A.  M.,  M.  D., 
Indianapolis,  Ind. 

The  Structure  of  the  question  as  framed  natu- 
rally excludes  any  consideration  of  the  several 
theories  advanced  for  the  explanation  of  this  strik- 
ing phenomenon.  Much  progress  has  been  made  in 
the  elucidation  of  this  question  and  while  limiting 
this  contribution  to  treatment,  some  brief  reference 
will  occasionally  be  made  to  some  physiological  and 
physicochemical  facts  on  which  my  treatment  of 
shock  is  based. 

Answering  the  question,  "How  do  you  treat 
shock?"  it  seems  that  the  personal  method  and  ideas 
of  the  contributor  are  what  is  sought.  Adhering  to 
this,  no  academic  reference  will  be  made  to  the 
many  therapeutic  opinions  in  vogue,  but  these  re- 
marks will  be  strictly  limited  to  my  personal  ex- 
perience and  practice. 

It  does  not  seem  out  of  place  in  the  consideration 
of  the  treatment  of  surgical  shock,  to  say  a  few 
words  about  its  prevention.  The  occurrence  of 
surgical  shock  can  be  largely  prevented  in  the  ma- 
jority of  operations  of  election  and  in  many  in- 
stances greatly  minimized.  Traumatic  shock  re- 
sulting from  severe  injuries  is  usually  treated  in 
the  same  manner  as  surgical  shock  following  op- 
erations. In  the  general  scheme  of  prevention, 
particular  attention  is  paid  to  the  type  of  patient 
that  is  to  undergo  a  major  operation.  Patients  ex- 
hibiting neuropathic  tendencies,  especially  when 
afflicted  with  diseases  associated  with  disturbances 
of  the  central  or  sympathetic  nervous  system,  such 
as  exophthalmic  goitre,  are  prepared  for  operation 
by  a  preliminary  rest  cure.  Great  attention  is  paid 
at  this  time  to  all  the  metabolic  functions  and  any 
disorders,  especially  acidosis,  are  corrected  before 
operation.  The  good  to  be  derived  from  mental 
suggestion  is  never  to  be  overlooked  and  a  great 
deal  can  be  done  by  allaying  the  fear  that  some 
patients  feel  to  an  exaggerated  degree. 

The  choice  of  the  anesthetic  is  of  g^reat  impor- 
tance. For  the  sake  of  brevity,  I  would  say  that 
the  anesthesia  necessary  in  a  given  case  is  in  direct 
ratio  to  the  severity  of  the  operation  and  the  physi- 
cal and  neurological  condition  of  the  patient. 

The  anesthesia  must  be  sufficient  to  block  as  much 
as  possible  the  conduction  of  pain  stimuli  to  the 
vasomotor  centre.  A  preanesthetic  injection  of 
morphine  is  essential  and  beneficial.  In  painful 
operations,  especially  on  sensitive  subjects,  I  be- 
lieve that  the  addition  of  one  one  hundredth  grain 
of  scopolamine  is  of  distinctive  value.  I  have  no 
hesitancy  in  affirming  that  it  positively  diminishes 
the  likelihood  of  true  shock.  Among  the  factors 
tending  to  the  prevention  of  shock  the  importance 
of  gentle  manipulations  must  not  be  overlooked.  In 
operations  on  the  abdominal  viscera,  especially  when 
complicated  by  extensive  and  firm  adhesions,  proper 
protection  of  the  exposed  peritoneal  surfaces  by 


warm,  moist,  gauze  pads,  sharp  dissection  of  the 
adhesions  and  gentle  handling  of  the  viscera  will 
greatly  aid  in  minimizing  shock.  Rough  handling 
of  the  viscera,  severe  pulling  on  mesenteries,  force- 
ful tearing  of  adhesions  and  undue  prolongation  of 
the  operation  are  potent  agencies  for  the  produc- 
tion of  deep  and  severe  shock.  The  duration  of 
an  operation  is  intimately  connected  with  the  pro- 
duction of  shock.  I  consider  it  one  of  the  most 
important  elements.  A  rapidly  performed  opera- 
tion is  less  likely  to  result  in  shock  even  in  the  ab- 
sence of  precautionary  measures  than  a  long  slow 
one,  even  when  performed  under  ideal  conditions. 
A  moderate  degree  of  speed  is  an  essential  virtue  of 
a  true  surgeon. 

TREATMENT  OF  SHOCK. 

The  treatment  must  necessarily  be  adjusted  to 
the  degree  of  shock  present  and  to  any  complicating 
factors  requiring  attention.  It  is  necessary  there- 
fore to  individualize  and  it  is  thus  that  the  best  re- 
sults are  obtained.  "Patients  exhibiting  a  mild  de- 
gree of  shock  evidenced  by  a  rapid,  but  not  weak 
pulse,  with  increased  respiratory  movements,  will 
usually  respond  to  applications  of  external  heat  to 
the  entire  surface  of  the  body.  Morphine  at  prop- 
er intervals  should  be  administered.  An  agent  cap- 
able of  increasing  the  contractions  of  the  rijjht  ven- 
tricle, thereby  overcoming  and  preventing  venous 
stasis,  is  of  distinctive  value.  I  believe  that 
pituitrin  is  the  best  agent,  and  I  use  it  in  doses 
of  one  c.  c.  every  three  or  four  hours  in  conjunction 
with  morphine,  until  the  pulse  shows  increased  pres- 
sure and  reduced  number  of  pulsations.  Digipura- 
tum  and  other  potent  digitalis  principles  are  often 
of  great  value.  Where  it  is  desired  to  administer 
a  larger  amount  of  fluid,  physiological  saline  solu- 
tion is  administered  by  hypodermocylsis.  With  in- 
creasing experience  I  have  come  to  reg^ard  the  saline 
proctoclysis  as  quite  vinreliable  and,  I  might  add 
of  very  uncertain  value.  If  a  patient's  condition 
demands  the  administration  of  even  small  amounts 
of  saline  solution,  it  is  obvious  that  this  can  effectu- 
ally be  accomplished  by  the  hypodermoclysis,  avoid- 
ing thereby,  the  uncertainty  of  results  from  the  rec- 
tal route  which  often  amounts  to  nothing  more  than 
a  lavage  of  the  anus. 

In  patients  exhibiting  severe  shock  and  particu- 
larly where  there  has  been  considerable  loss  of 
blood,  intravenous  administration  of  physiologic  sa- 
line solution  is  of  paramount  importance.  How- 
ever, the  following  precautions  must  be  observed. 
The  amount  must  not  be  too  large.  Seldom  should 
it  exceed  750  c.  c.  It  should  always  be  administered 
slowly,  as  too  rapid  administration  may  cause  a 
rapid  dilatation  of  the  right  ventricle.  The  tempera- 
ture of  the  solution,  at  the  point  of  entrance  into 
the  vein,  must  never  be  below  98.6°  F.  It  is  ex- 
ceedingly easy  to  add  to  the  shock  of  the  patient  by 
injudicious  intravenous  medication.  Intravenous 
shock  is  not  a  myth  and  can  be  induced  very  read- 


August  28,  1920.] 


PRACTICAL   THERAPEUTICS  AND  PREVEXTIVE  MEDICINE. 


297 


ily  by  rapid  administration  of  the  fluid  of  low  tem- 
perature, or  of  imperfect  isotonicity.  Through  sev- 
eral years  of  observation,  I  have  become  convinced 
that  in  cases  of  shock  requiring  intravenous  medi- 
cation a  physiological  fluid  of  colloidal  nature  ap- 
proaching that  of  human  plasma  would  be  of  great 
value,  and  far  superior  to  the  ordinary  saline  solu- 
tion.   The  formula  I  prefer  is  as  follows: 


Gelatine  grams  5 

Purified  acacia  grams  2 

Sodium  chloride  grams  8.5 

Potassium  chloride,   grams  2.5 

Calcium  chloride,   grams  3 

Distilled  water  1000 


Dissolve  the  acacia  and  gelatine  in  the  water  at 
80°  C,  filter  through  hard  paper,  add  salts  and  re- 
filter,  sterilize  in  autoclave.  When  hermetically 
sealed  this  solution  will  keep  for  some  time.  In 
hospital  practice  it  is  best  to  prepare  it  fresh  weekly, 
in  expectation  of  it  being  needed. 

In  patients  exhibiting  a  tendency  to  acidosis,  four 
gms.  of  glucose  and  eight  gms.  of  sodium  bicar- 
bonate are  added  to  the  solution  before  filtering. 
Extreme  cases  of  shock  which  have  been  pre- 
ceeded  by  severe  hemorrhage  may  demand  blood 
transfusion,  which  we  practice,  using  the  citrate 
method.  With  judicious  use  of  this  solution, 
transfusion  will  seldom  be  found  necessary. 

In  summing  up,  I  wish  to  state  that  the  bodily 
temperature  must  be  protected  by  external  heat ; 
that  in  extreme  cases  bandaging  of  the  extremities 
is  useful ;  that  morphine  must  be  used  fearlessly ; 
that  the  respiratory  centre  can  be  sustained  by  small 
doses  of  strychnine  and  atropine  when  indicated, 
that  acidosis  must  be  prevented  by  timely  alkaliniz- 
ation ;  that  intravenous  medication,  while  highly 
beneficial  must  be  judiciously  employed;  and  that 
last  but  not  least,  a  hopeful,  cheerful  demeanor  is 
essential  in  the  presence  of  the  patient  and  that  it  is 
conducive  to  rapid  reestablishment  of  the  vasomotor 
sensory  equilibrium.  A  nervous,  anxious,  fretful 
conduct  on  the  part  of  the  surgeon  and  attendants 
cannot  fail  to  react  on  the  patient  and  create  the 
impression  of  imminent  danger  resulting  in  further 
exhaustion  of  sympathetic  inhibition  with  its  at- 
tedant  vasomotor  failure. 

347  Newton  Clavpool  Bldg. 


Milk  Injections  in  the  Treatment  of  Hyper- 
trophied  Mammary  Glands. — Patel  {Lyon  medi- 
cla,  April  25,  1920)  reports  the  case  of  a  young 
woman  of  twenty-four  years  with  enormous  en- 
largement of  the  breasts,  of  sixteen  months'  stand- 
ing. The  patient  was  married  but  had  had  no  child 
nor  miscarriage  nor  any  signs  of  beginning  preg- 
nancy. The  breasts  enlarged  after  an  attack  of 
influenza  in  October,  1918,  and  were  estimated  to 
weigh  five  kilograms  each.  Aspiration  with  Bier  cups 
and  deep  cauterizations  were  without  result,  and 
when  first  seen  by  the  author  the  patient  was  seek- 
ing radical  treatment.  On  the  advice  of  Mouri- 
quand  Patel  administered  ten  subcutaneous  in- 
jections of  five  mils  each  of  human  milk  on  alter- 
nate days.  On  the  fifteenth  day  the  breasts  began 
to  recede,  and  thereafter  rapidly  decreased  in  size 
until  they  resembled  deflated  balloons. 


Treatment  of  Tuberculous  Joints. — Gustav 
Schwyzer  {Surgery,  Gynecology  and  Obstetrics, 
June,  1920)  give  the  following  procedure  for  the 
treatment  of  tuberculous  joints :  As  to  the  methods 
of  operating,  incision  and  so  on,  we  can  briefly  say 
that  we  generally  followed  Kocher's  ways.  We  al- 
ways were  impressed  that  through  his  incisions  good 
access  could  be  gained  to  the  entire  diseased  area, 
and  it  is  most  important  that  all  the  tuberculous  tis- 
sue be  carefully  excised  by  exact  dissection.  If  the 
disease  is  confined  purely  to  the  synovial  membrane 
of  the  joint  we  limit  our  work  entirely  to  the  re- 
moval of  this  membrane,  thus  avoiding  complete  an- 
kylosis. But  if  the  bone  is  involved,  the  bone  ends 
are  exposed  by  energetic  dislocation.  We  strip  back 
the  healthy,  outer  integuments  and  turn  them  back 
like  the  cuff  of  a  sleeve.  Now  the  diseased  part  of 
the  bone  is  cleanly  removed.  If  we  aim  at  a  com- 
plete ankylosis,  a  good  apposition  of  the  bones  is 
imperative. 

In  every  case  we  have  used  idoform  powder.  Con- 
trary to  the  general  routine,  we  prepared  the  iodo- 
form powder  previously  by  boiling  the  same  for  half 
an  hour  in  a  1  :500  bichloride  solution.  This  powder 
is  rubbed  into  the  entire  wound  surface,  the  bone, 
and  the  soft,  tissues.  The  superfluous,  loose  part 
of  it  is  washed  away  with  saline  solution.  Thus  we 
always  have  avoided  dangerous  degrees  of  iodoform 
intoxication.  In  all  our  resections  we  drained  the 
wound  cavities  with  rubber  tube  surrounded  by 
washed  out  iodoform  gauze  strips.  Our  buried  suture 
material  consisted  of  silk  and  linen.  Silkworm  gut 
is  the  best  material  for  the  surface.  An  abundant 
amount  of  absorbent  gauze  and  cotton  is  used  for 
dressing.  A  plaster  of  paris  cast  is  put  on  before 
the  Esmarch  bandage  is  released.  The  drains  are 
removed  through  windows  in  the  cast  within  a  week. 

Though  the  bleeding  into  the  cast  was  often  con- 
siderable, we  never  noticed  any  alarming  hemor- 
rhage. The  first  cast  was  always  made  quite  heavy 
with  the  intention  to  leave  it  on  from  four  to  six 
weeks.  After  that  time  the  wounds  were  closed  and 
in  affections  of  the  lower  extremity  the  patient  was 
allowed  to  leave  the  bed  in  a  lighter  cast.  None  of 
our  patients  with  hip  or  knee  resections  remained  in 
bed  longer  than  six  weeks.  The  patient  was  sent 
home  in  the  second  cast  with  the  advice  to  return  in 
two  or  three  months.  A  much  shorter  time  is  needed 
following  operation  on  the  upper  extremities.  For- 
tunately in  all  our  cases  we  did  not  have  to  resort 
to  amputation.  Only  one  patient  left  with  a  fistula 
after  a  resection  of  the  elbowjoint.  A  second  resec- 
tion eleven  months  later  brought  on  a  definite  cure 
also  in  this  case. 

Treatment  of  Vincent's  Angina  and  Other 
Similar  Infections  with  Chromic  Acid. — W.  Du- 
breuilh  {Journal  de  niedecine  de  Bordeaux,  March 
25,  1920)  found  the  local  use  of  arsenobenzol  in 
Vincent's  angina  painful  and  not  particularly  effec- 
tive. Methylene  blue  proved  less  painful  but  acted 
relatively  slowly.  Chromic  acid  solution  proved  more 
satisfactory  than  either  of  these  agents.  The  satu- 
rated solution  of  this  acid,  such  as  is  produced 
spontaneously  when  a  bottle  of  the  acid  is  left  un- 
stoppered  for  a  few  days,  is  employed,  or,  a  few 
drops  of  water  may  be  placed  in  a  bottle  of  the 


298 


PRACTICAL  THERAPEUTICS  AXD  PREVEXTIJ-R  MEDICINE. 


[New  York 
Medical  Journal. 


acid  SO  that  a  few  crystals  of  the  acid  remain  at  the 
bottom.  The  solution  is  applied  with  cotton  tightly 
wound  around  a  small  stick  of  wood ;  a  metallic  ap- 
plicator or  glass  rod  will  not  do,  as  the  cotton  soon 
loosens  and  drops  ofiF.  The  cotton  should  be  merely 
moistened  and  not  thoroughly  wet  with  the  solution. 
The  ulcers  are  immediately  rubbed  rather  firmly 
with  the  cotton,  so  as  to  detach  the  false  membranes 
and  bring  the  drug  in  direct  contact  with  the  ulcer- 
ated surface.  The  patient  is  then  at  once  requested 
to  gargle  with  water,  being  cautioned  not  to  swal- 
low any  saliva  before  doing  so.  The  resulting  pain 
is  moderate.  The  patient  should  thereafter  gargle 
several  times  a  day  with  hydrogen  dioxide  solution 
diluted  one  in  ten  or  with  a  one  per  cent,  solution 
of  resorcinol.  Next  day  the  ulcer  is  usually  found 
clean,  odorless,  and  without  false  membrane.  By 
the  third  day  it  is  red  and  undergoing  repair.  In 
occasional  instances  a  second  application  on  the 
fourth  or  fifth  day  is  required.  This  treatment  may 
be  employed  in  all  lesions  similarly  produced.  In 
severe  mercurial  stomatitis  it  is  a  useful  adjuvant. 
It  does  not  act  on  the  attending  diffuse  stomatitis 
but  merely  on  the  ulcers,  which  are  perhaps  due  to 
added  infection.  In  the  rather  frequent  form  of 
gingivitis  manifested  in  a  linear  ulceration  about 
the  necks  of  the  teeth,  especially  of  the  lower  jaw, 
forming  a  grayish,  gangrenous,  and  rather  painful 
linear  depression,  cauterization  with  concentrated 
chromic  acid  cures  the  condition  in  a  few  days.  This 
disorder  occurs  rather  frequently  during  mercurial 
treatment,  but  may  also  develop  independently.  In 
applying  the  acid  in  these  cases  a  pointed  match- 
stick,  or  better  a  fine  Japanese  toothpick  with  a 
minute  amount  of  cotton  wound  about  it  should  be 
used. 

Treatment  of  Lethargic  Encephalitis. — A.  Net- 

ter  {Bulletin  de  1' Academic  dc  medccine.  March  30, 
1920)  estimates  at  1,500  the  number  of  recent 
cases  of  this  disorder  in  the  city  of  Paris,  and  at 
10,000  in  the  whole  of  France.  Italy  and  Austria 
are  known  likewise  to  have  suffered  heavily  from 
it.  The  author  reports  the  results  from  various 
forms  of  treatment  in  seventy-two  cases.  Con- 
sidering the  disease,  like  epidemic  poliomyelitis,  to 
be  due  to  a  filterable  virus  present  both  in  the  nerv- 
ous tissues  and  in  the  nose,  throat  and  mouth,  he 
thinks  the  treatment  should  be  conducted  along 
three  particular  lines,  viz.,  neutralization  of  the 
virus  directly  in  the  nerve  centres  by  the 
use  of  a  specific  or  nonspecific  bactericidal 
preparation ;  elimination  of  the  poison  by  various 
routes,  and  stimulation  of  the  general  defensive 
activity  of  the  organism.  The  first  of  these  ob- 
jects would  be  attained  by  intraspinal  injection  of 
serum  from  persons  already  recovered  from  the 
disease,  but  such  a  procedure  cannot  yet  be  recom- 
mended in  this  disorder,  partly  because  the  pres- 
ence of  a  neutralizing  principle  in  convalescent 
blood  has  not  yet  been  demonstrated  and  partly 
because  the  course  of  the  disease  is  so  prolonged 
that  a  very  large  number  of  injections  would  have 
to  be  given.  Administration  of  hexamethylena- 
mine  by  mouth  is,  on  the  other  hand,  always  to  be 
recommended,  though  its  exact  utility  is  still  in 
doubt.    Neosalvarsan    injections    seemed    to  do 


harm  in  one  case.  Enlargement  of  the  salivary 
glands  and  salivation  having  been  noted  in  some 
cases,  administration  of  jaborandi  or  pilocarpine  to 
hasten  elimination  of  the  virus  with  the  saliva  is 
indicated.  Adrenalin  is  always  combined  with  it 
to  antagonize  heart  depression  by  the  pilocarpine, 
as  well  as  to  combat  the  asthenia  commonly  present 
in  these  cases  and  probably  dependent  upon  fixation 
of  the  virus  by  the  nerve  cells  of  the  endocrine 
organs.  The  measure  most  strongly  advised  by  the 
author  is  the  fixation  abscess,  instituted  by  inject- 
ing one  or  two  mils  of  oil  of  turpentine  in  the 
outer  aspect  of  the  thigh.  Hippocrates  had  already 
noted  that  in  patients  who  recovered  from  letJiargus 
a  spontaneous  abscess  generally  developed  in  some 
part  or  other  of  the  body.  Out  of  twenty-seven 
cases  in  which  Netter  injected  turpentine,  in  nine- 
teen an  incisable  abscess  formed,  and  of  these  nine- 
teen patients  only  one,  a  pregnant  woman,  suc- 
cumbed to  the  disease,  although  fourteen  of  them 
had  the  myoclonic  form  of  encephalitis,  considered 
more  deadly  than  other  forms.  Two  patients  out  of 
the  eight  who  did  not  form  an  incisable  abscess 
succumbed  before  collection  of  pus  had  occurred, 
and  the  other  six,  in  whom  the  turpentine  had 
caused  no  local  reaction,  likewise  succumbed.  Out  of 
twenty-five  patients  who  received  no  turpentine  in- 
jections, thirteen,  or  over  fifty  per  cent.,  died. 
Fochier's  theory  that  a  fixation  abscess  draws  away 
virulent  matter  from  the  general  circulation  to  the 
point  of  injection  has  not  been  confirmed  by  experi- 
mental work,  but  the  abscess  does  in  some  way 
yield  benefit,  probably  by  awakening  a  reaction  in 
the  organs  in  which  the  materials  for  defence 
against  the  disease  are  formed.  Netter's  pupil, 
Mozer,  has  shown,  at  least,  that  the  bone  marrow 
participates  in  the  reaction,  throwing  out  myelocytes 
into  the  blood  stream. 

Treatment  of  Pelvic  Infection.— Theodore  J. 
Doederlein  {Surgery,  Gynecology  and  Obstetrics, 
June,  1920)  emphasizes  the  following  points  in  the 
classification  and  treatment  of  types  of  pelvic  infec- 
tions : 

1.  The  classification  of  pelvic  infections  into  as- 
cending and  descending  is  not  merely  academic  but 
of  practical  value  for  better  analysis  of  the  cases, 
especially  with  regard  to  prognosis. 

2.  Operations  for  descending  pelvic  infections  are 
rarely  connected  with  grave  danger,  once  the  in- 
fection has  reached  the  quiescent  or  elective  period. 

3.  One  should  seek  to  make  a  differential  diagnosis 
in  the  ascending  type,  i.  e.,  between  puerperal  and 
gonorrheal  infections,  before  operation,  as  the 
prognosis  depends  on  proper  diagnosis. 

4.  Judicious  conservatism  is  productive  of  best  re- 
sults. 

Rontgen  Ray  Treatment  of  Surgical  Tubercu- 
losis.— Hans  Iselin  {Schwcizcrische  medizinische 
Wochenschrift,  June  17,  1920)  says  that  as  a 
chronic  infectious  disease  surgical  tuberculosis  is 
not  suited  for  radical  operative  treatment,  even 
though  the  extirpation  of  a  single  primary  focus 
might  be  an  ideal  procedure.  He  extols  the  value 
of  the  rontgen  rays  as  being  preferable  in  the 
treatment  of  this  disease. 


Miscellany  from  Home  and  Foreign  Journals 


New  Laws  Relating  to  Inherited  Syphilis. — 

Carle  (Prcssc  medicalc.  April  24,  1920j  notes  that, 
according  to  the  law  of  Colles,  a  syphilitic  child  pro- 
created by  a  syphilitic  father  generally  does  not 
infect  the  apparently  healthy  mother,  who  may 
nurse  the  child  without  risk.  This  law,  thus  word- 
ed, should  be  abandoned  as  subject  to  erroneous  and 
dangerous  interpretation,  and  should  be  replaced  by 
the  following :  A  mother  giving  birth  to  a  syphilitic 
child  who  exhibits  secondary  manifestations  of 
syphilis  soon  after  birth  is  always  syphilitic  her- 
self, even  if  apparently  healthy;  she  may  therefore 
nurse  the  child  in  safety,  but  should  be  at  once 
subjected  to  specific  treatment  which  should  there- 
after be  systematically  continued.  Profeta's  law  is 
as  follows :  An  admittedly  healthy  child  born  of  a 
syphilitic  mother  cannot  contract  syphilis  through 
being  nursed  or  through  any  other  contact  with  her ; 
such  immunity  is  not  perpetual.  For  this  wording 
Carle  would  substitute  the  following  more  com- 
prehensive statement :  A  child  born  of  a  syphilitic 
mother  is  himself  generally  s\-philitic,  in  spite  of  his 
apparent  normal  condition  at  birth ;  he  therefore 
has  every  chance  of  not  being  contaminated  through 
lactation ;  this  is  not  an  absolute  rule,  however,  and 
all  children  born  under  such  conditions  should  be 
carefully  watched,  and  the  Bordet-Wassermann  re- 
action carried  out  if  possible  before  they  are 
declared  to  be  healthy.  As  a  corollary  to  Profeta's 
law  the  author  would  state  that  the  manifestations 
of  socalled  late  inherited  syphilis  are  only  the  ter- 
tiary expression  of  ordinary  congenital  syphilis, 
the  secondary  symptoms  of  which,  manifested  in  the 
usual  way  in  the  course  of  the  first  few  years  of  life, 
have  been  overlooked  or  otherwise  diagnosed.  There 
is  no  such  thing  as  late  inherited  syphilis,  but  there 
are  late  symptoms  of  an  overlooked  inherited  syph- 
ilis. The  third  law,  that  of  conceptional  syphilis, 
is  to  the  ef¥ect  that  syphilitic  fetus  in  utero  may, 
through  the  placental  vessels,  contaminate  its 
mother,  in  whom  there  may  appear  in  the  course  of 
pregnancy  secondary  manifestations,  without  there 
having  ever  been  noted  any  primary  manifestations. 
Evidence  tending  to  substantiate  this  law  is  prac- 
tically nil.  Blood  analyses  have  plainly  shown  that 
where  two  of  the  three  parties  are  infected  with 
syphilis,  the  third  is  likewise  infected.  The  svph- 
ilitic  pregnant  woman  has  in  all  likelihood  con- 
tracted her  infection  in  the  usual  way,  the  chancre 
having,  however,  been  overlooked — a  common  oc- 
currence in  the  female  sex.  The  socalled  law  of 
conceptional  syphilis  should  be  deleted  from  our 
textbooks. 

A  New  Pylorus. — G.  Gore  Gillon  {Practitioner, 
June,  1920 )  says  that  when  one  sets  about  alter- 
ing the  mechanism  of  the  alimentary  tract  it  be- 
hooves him  to  do  so  in  a  manner  that  will  produce 
no  secondary  liability.  When  we  want  to  do  awav 
with  the  old  pyloric  gatewa\-  we  must  make  certain 
that  the  new  gateway  is  situated  at  the  lower  end 
of  the  stomach,  and  by  a  jejunojejunostomy  some 
three  and  a  half  inches  away  from  the  new  pylorus 
we  can  make  sure  that  the  food  stream  does  not 


mingle  with  the  bile  and  pancreatic  fluids  till  the 
proper  time.  He  holds  the  no  loop  operation  to  be 
physiologically  incomplete ;  the  bile  and  pancreatic 
fluids  find  their  way  into  the  stomach,  and  he  be- 
lieves that  the  subsequent  complaints  are  due  to 
this  result,  while  after  the  operation  he  describes 
digestion  goes  on  naturally.  He  thus  describes  his 
operation :  After  opening  the  abdomen  and  exposing 
the  part  of  the  stomach  required,  he  put  in  his 
right  hand  and  brought  up  from  the  left  of  the 
spine  ten  inches  of  jejtmum,  counting  from  the 
duodenojejunal  junction,  immediately  at  the  left  of 
the  second  lumbar  vertebra ;  three  inches  of  this 
proximal  loop  were  used  to  make  the  first  anastomo- 
sis, leaving  seven  inches  for  the  second.  The  gas- 
trojejunostomy opening  is  made  three  inches  in 
length.  He  and  his  assistant  now  change  their 
gloves  and  then  make  the  anastomosis  between  the 
two  descending  legs  of  the  jejunum  at  a  distance 
of  three  and  one  half  inches  below  the  stomach 
opening.  The  anastomotic  opening  itself  should 
measure  one  and  a  half  inches  vertically.  The  gas- 
trocolic omentum  is  attached  to  the  jejunum  near 
the  stomach  by  two  iliches,  and  any  veins  in  the 
omentum  tied.  The  abdomen  is  then  sewn  up  in  the 
usual  way.  The  patient  can  lie  in  a  recimibent 
position  a  few  hours  after  the  operation  and  need 
not  be  propped  up;  hence  there  is  less  strain  on  the 
abdominal  stitches.  He  is  fed  with  tablespoonfuls 
of  water  for  a  day,  then  peptonized  milk  in  the 
usual  way  for  a  few  days,  and  in  a  week  is  taking 
a  fair  amount  of  light  food.  On  the  twelfth  day 
he  gets  two  or  three  grains  of  calomel ;  prior  to  that 
his  bowels  are  cpen;-d  b>  recial  injections  if  rc- 
'";Liir.''d.  He  should  !:e  on  his  back  for  the  first 
three  weeks  and  leave  hospital  on  the  24th  to  28th 
day.  He  claims  that  the  results  are  uniformly  good 
and  that  the  patients  are  not  only  well,  but  very 
well.  They  put  on  weight  and  acquire  a  great  ca- 
pacitv  for  swallowing  large  quantities  of  liquids 
without  discomfort. 

Lethargic  Meningitis,  Meningoencephalitis, 
and  Encephalitis. — Beriel  and  Branche  [^Lyon 
medical,  March  25,  1920)  state  that  they  have  been 
struck  by  the  occurrence,  during  the  past  year,  of 
an  unusual  number  of  infectious  states  with  special 
involvement  of  the  nervous  centres  and  presenting 
all  intermediate  types  from  radiculitis  to  radiculo- 
myelitis,  meningitis,  and  meningoencephalitis.  Bj 
their  consentaneous  occurrence  and  curability  these 
cases  seemed  to  be  allied.  The  most  pronotmced 
cases  simulated  tuberculous  meningitis  in  their  sub- 
acute course,  cerebrospinal  fluid  reactions,  tempera- 
ture curve,  and  admixture  of  meningeal  and  en- 
cephalic manifestations,  but  recovery  took  place. 
Lethargic  encephalitis  is  but  a  single  peculiar  ex- 
pression of  an  infection  of  the  nervous  centres  that 
may  appear  in  various  localizations,  though  doubt- 
less due  to  a  single,  as  yet  unknown,  cause.  One 
patient  presented  violent  myoclonic  seizures,  and 
death  took  place  in  a  continuous  epileptoid  parox- 
ysm :  the  autopsy  showed,  histologically,  a  diffuse 
meningoencephalitis. 


300 


LETTERS  TO  THE  EDITORS. 


[New  York 
Medical  Journal. 


Effects  of  a  Serum  Precipitin  on  Animals  of 
the    Species   Furnishing   the   Precipitinogen. — 

Peyton  Rous,  George  W.  Wilson,  and  Jean  Oliver 
(Journal  of  Experimental  Medicine,  Alarch,  1920) 
attempted  to  determine  whether  serum  used  as  anti- 
gen gives  rise  to  injurious  principles  in  the  anti- 
serum, as  the  serum  of  infected  individuals  would 
form  a  convenient  antigen  in  many  diseases.  They 
found  that  there  is  present  in  serum  of  high  pre- 
cipitin titer,  which  was  produced  by  the  repeated 
injection  of  rabbits  with  the  blood  free  serum  of 
guineapigs  or  dogs,  a  principle  highly  toxic  for  ani- 
mals of  the  species  furnishing  the  antigen.  After 
intravenous  injection  of  the  serum  severe  shock  or 
sudden  death  occurred,  and  there  were  produced 
locally  acute  inflammatory  changes  and  profuse 
capillary  hemorrhages.  The  serum  was  exposed 
repeatedly  to  washed  red  cells  to  remove  the  hemo- 
lysins and  hemagglutinins  with  only  a  slightly  less- 
ened toxicity  resulting,  and  the  removal  of  precip- 
itin by  specific  precipitation  in  vitro  had  no  detoxi- 
fying effect.  The  symptoms  produced  in  guineapigs 
and  dogs  after  intravenous  injections  of  the  treated 
and  untreated  sera  were  similar  to  those  of  anaphy- 
laxis, but  attempts  at  desensitization  failed.  It  must 
still  be  determined  whether  the  toxic  principle  is  a 
hitherto  unrecognized  antibody,  or  a  toxic  product 
of  the  interaction  of  precipitin  and  precipitinogen. 
Evidently  the  fluids  of  infected  human  beings  can- 
not be  practically  utilized  for  the  production  of  anti- 
serum unless  the  obstacle  of  the  presence  of  the  in- 
jurious principles  can  be  somehow  overcome. 

Orthostatic  Cardiac  Acceleration  of  Abdominal 
Origin. — Preval  (Presse  medicale,  April  21,  1920) 
believes  that  acceleration  of  the  heart  rate  upon  ris- 
ing from  the  recumbent  to  the  standing  position 
is  an  abnormal  and  not  a  physiological  phenomenon. 
It  is  due  generally  to  disturbed  equilibrium  of 
the  abdominal  organs,  particularly  the  stomach,  and 
is  the  result  of  a  reflex  mechanism  in  which 
probably  participate  the  gastric  branches  of  the 
solar  plexus.  This  reflex  may  be  clinically 
demonstrated  by  the  application  of  a  hypogastric 
belt,  which  causes  the  orthostatic  acceleration  to  dis- 
appear when  it  is  dependent  upon  gastroptosis. 
Orthostatic  cardiac  acceleration  may  and  should  be 
treated  by  better  hygiene  of  the  stomach  and  by 
physiological  reeducation  of  the  abdominal  wall. 
Such  treatment  is  especially  necessary  where  there 
is  tachycardia  on  exertion,  a  condition  often  partly 
due  to  the  operation  of  the  abdominocardiac  reflex. 

Availability  of  Carbohydrate  in  Certain  Vege- 
tables.— W.  H.  Olmstead  (Journal  of  Biological 
Chemistry,  January,  1920),  by  the  use  of  diastase 
and  copper  reduction,  and  by  feeding  to  phloridzin- 
ized  dogs,  determined  the  sugar  forming  material 
in  certain  vegetables  which  are  commonly  used  in 
dietaries  of  diabetics.  Nearly  all  the  carbohydrates 
may  be  washed  out  of  the  vegetables  by  cooking. 
Cabbage  showed  4.4  per  cent,  of  available  carbo- 
hydrate or  glucose  by  the  takadiastase  method,  and 
five  per  cent,  by  the  phloridzinized  dog,  while  thrice 
cooked  cabbage  showed  corresponding  figures  of 
0.4  and  0.5  per  cent.  Cauliflower  by  the  diastase 
method  gave  2.8  per  cent,  of  available  carbohydrate, 
and  thrice  cooked  cauliflower  0.8  per  cent. 


Spinal  Analgesia. — A.  E.  Halstead  (Interna- 
national  Journal  of  Surgery,  April,  1920)  asserts 
that  the  indications  for  the  use  of  spinal  analgesia 
are  in  general:  1,  Those  cases  where  for  any  rea- 
son a  general  anesthetic  is  not  considered  safe,  e.  g., 
in  intestinal  obstruction  with  fecal  vomiting.  In 
general  peritonitis,  for  the  same  reasons.  Also  in 
strangulated  hernias,  and  in  operations  in  old  people, 
such  as  prostatectomy.  2,  In  traumatic  surgery  of 
the  lower  extremities,  in  crushing  injuries.  The  so- 
lution injected  into  the  spinal  canal  not  alone  pro- 
duces analgesia,  but  in  doing  so  also  blocks  the  sen- 
sory tracts  of  the  cord  and  lessens  shock.  3,  In 
disarticulations  of  the  hip  or  in  high  amputations 
for  conditions  not  depending  upon  trauma.  These 
operations  can  be  carried  out  with  much  less  shock 
than  if  a  general  anesthetic  is  employed. 



Letters  to  the  Editors. 

SEX  GLAND  IMPLANTATION. 

Chicago,  August  10,  i()20. 

To  the  Editors: 

The  public  press  of  this  country  recently  has  been 
flooded  with  articles  regarding  the  alleged  work  in 
sex  gland  implantation  of  Dr.  Serge  Voronoff  of 
Paris.  The  New  York  Tribune  of  July  19,  1920, 
quoted  him  as  saying  that  he  had  concluded  that 
human  glands  were  preferable  to  ape  glands,  which 
he  had  been  using.  He  also  said  that  glands  from 
electrocuted  criminals  and  from  bodies  dead  of 
accident  were  available  sources  of  material.  He 
further  said  that  if  the  New  York  profession  would 
furnish  patient  and  material,  he  would  teach  them 
how  to  do  the  work.  How  a  man  of  VoronolT's 
scientific  training  could  have  overlooked  my  work 
I  cannot  understand.  In  the  Bulletin  of  the  Chicago 
Medical  Society,  March  7,  1914,  and  New  York 
Medical  Journal,  March  21,  April  4,  July  11, 
October  17-24-31,  and  November  7,  1914,  I  publish- 
ed a  large  series  of  cases  of  human  implantations  of 
testes  and  ovaries  taken  from  dead  bodies.  Most 
of  these  cases  were  successful.  I  made  sections  of 
implanted  glands  showing  the  hormone  producing 
cells  and  new  blood  vessels.  I  have  done  up  to  date 
a  large  number  of  implants  with  most  astonishing 
results  as  to  rejuvenation  and  effects  on  various 
bodily  functions.  I  also  have  done  some  animal 
experimentation.  Some  of  my  later  work  was  pub- 
lished in  the  Journal  of  the  American  Medical  As- 
sociation. My  work  antedated  any  claims  of  Vor- 
onoff by  six  years.  I  challenge  Voronoff  to  show 
that  he  has  even  seen,  much  less  performed,  a  single 
human  testicle  or  ovarian  implant  up  to  date.  In 
his  book,  published  this  year,  not  a  single  such  case  is 
recorded.  Why  is  it  that  the  press  of  this  country 
exploits  foreigners  who  have  done  nothing  and  ig- 
nores the  work  of  American  workers,  who  have 
done  much?  And  when  will  the  chauvinistic  for- 
eigner discover  America?  I  expect  at  any  moment 
to  learn  that  some  foreigner  has  just  written  the 
Constitution  of  the  United  States  or  discovered 
Cape  Cod. 

Very  fraternally, 

G.  Frank  Lvdston,  M.  D. 


New  York  Medical  Journal 


INCORPORATING  THE 


Philadelphia  Medical  Journal  u"' Medical  News 

A  Weekly  Review  of  Medicine,  Established  ISJ^S. 


Vol.  CXII,  No.  10. 


XKW  YOKK.  SATURDAY.  SEPTEMBER  4,  1920. 


Whole  No.  2179. 


Original  Communications 


FRACTURES  OF  THE  LONG  BONES  AND 
THEIR  REPAIR.* 

By  Ethan  H.  Smith,  M.  D., 
San  Francisco. 

The  type  of  fracture  of  any  long  bone  has  much 
to  do,  first,  with  the  matter  of  reduction,  second, 
with  the  heahng  of  the  fracture.  Formerly  we  were 
taught  to  fear  oblique  fractures.  Since  the  com- 
mon use  of  the  radiograph  we  find  that  but  re- 
latively few  fractures  are  strictly  transverse.  We 
also  find  that  the  transverse  fracture,  when  dis- 
placed, is  likely  to  be  difficult  to  reduce.  This  is 
because  the  muscles  will  not  stretch  without  great 
force  beyond  the  normal  length  of  the  part  of 
which  the  bone  is  a  portion.  Oblique  fractures 
slide  readily  into  place  with,  perhaps,  a  shortening 
so  slight  as  to  be  of  no  consequence. 

Longitudinal  fractures  if  not  widely  separated 
or  complicated  by  more  or  less  transverse  frac- 
tures can  usually  be  replaced  without  much  diffi- 
culty. When  complicated  as  mentioned,  they  are 
as  a  rule  most  difficult  to  replace.  Comminuted  and 
multiple  fractures  are  always  difficult  to  handle, 
both  as  to  replacement  and  securing  union.  Open 
fractures  are  always  to  be  regarded  as  presenting 
problems  to  be  handled  one  at  a  time  as  each  one 
occurs.  On)y  general  rules  can  be  laid  down,  but 
these  few  rules  are  well  nigh  absolute  if  we  are 
to  expect  success. 

Gentle  handling  of  all  fractures  is  an  absolute 
necessity  if  we  wish  good  results.  Rope  and  tackle, 
Hawley  tables  and  such  paraphernalia  are  a  retro- 
gression of  a  century  at  least  in  handling  fractures. 
They  substitute  unnecessary  brute  force  and 
thoughtlessness  for  skill  and  intelligence.  To  reduce 
fractures,  all  muscles  concerned  in  the  fracture  must 
be  relaxed.  This  can  not  be  done  by  putting  a  por- 
tion of  them  on  the  stretch  as  is  done  by  the  rope 
and  tackle  or  the  Hawley  table.  Recent  fractures, 
gotten  quickly  in  the  hands  of  the  surgeon,  rarely 
present  great  difficulty  in  reduction.  Great  swelling, 
huge  extravasation  of  blood  or  rapid  edema  of  the 
muscles  may  make  reduction  difficult.  Any  or  all 
of  these  conditions  make  forcible  reduction  a  reck- 
less procedure.  Increased  hemorrhage  and  the 
probable  rupture  of  muscular  fibrillae  are  to  be 
expected  from  such  work.  More  than  that,  they 
increase  the  difficulty  of  retaining  the  fracture  in 

"Read  before  the  North  Western  Pacific  Railroad  Surgeons  Asso- 
ciation. April  24,   1920,  San  Francisco,  California. 


apposition  and  increase  the  tendency  to  slough.  Pain 
afterward  is  also  augmented  and  unnecessarily  so. 

In  the  repair  of  bone  new  material  is  thrown  out 
between  the  periosteum  and  the  shaft  of  the  bone 
and  also  from  the  medulla  through  the  cancellous 
portion  of  the  bone.  Some  reparative  material  is 
thrown  out  over  a  goodly  portion  of  the  broken 
surface  providing  the  circulation  has  not  been  too 
seriously  impaired.  The  periosteum  does  not  form 
bone.  It  limits  its  formation  and  protects  the 
bone.  Strip  the  periosteum  off  a  portion  of  the 
sound  bone  and  prevent  infection,  and  an  exostosis 
will  form  which  will  be  limited  when  again  covered 
by  the  repair  of  the  periosteum.  Periosteum  strip- 
ped loose  from  the  shaft  of  bone  will  many  times 
heal  back  in  place,  but  it  will  never  adhere  to  the 
end  grain  of  cut  or  broken  bone.  An  oblique  frac- 
ture makes  a  quicker  repair  than  a  transverse  frac- 
ture. There  is  a  much  larger  surface  to  furnish 
material  for  repair,  and  the  union  does  not  have 
to  be  so  complete  in  order  to  support  the  broken 
parts. 

A  notch  out  of  the  cylinder  of  the  shaft  of  a 
long  bone,  due  to  a  widely  displaced  small  fragment, 
makes  an  awkward  fracture  to  handle.  The  time 
required  to  fill  in  the  space  due  to  this  displaced 
fragment  may  be  so  long  as  to  prevent  the  calcium 
salts  from  being  deposited  and  lead  to  a  partial 
fibrous  union.  Widely  separated  fragiuents  undergo 
the  same  process  quite  often. 

In  delayed  union  or  nonunion,  we  have  the  ends 
of  the  fragments  united  by  preliminary  soft  tissue. 
This  if  not  reinforced  by  the  mineral  salts  soon 
partakes  of  the  nature  of  scar  tissue,  coats  over  the 
broken  surface  and  blocks  out  the  mineral  salts. 
The  ends  of  the  fragments  become  sclerosed  and 
harder  than  normal.  Operating  on  these  adjacent 
ends  of  bone  and  merely  fastening  them  together 
by  any  device  whatsoever,  is  a  waste  of  time  and 
a  reckless  surgical  risk.  We  must  go  above  and 
below  the  fracture  into  normal  bone  and  open  up  a 
channel  through  which  reparative  material  may  be 
brought  in  to  complete  the  union.  Do  not  cut  into 
or  through  excessively  denuded,  bruised  or  lacerated 
tissue  to  reach  a  fracture  in  operating  upon  it. 
Wait  until  the  soft  parts  have  recuperated.  "Haste 
makes  waste"  in  many  illadvised  operations  on  frac- 
tures. 

All  metal  contrivances  for  the  repair  of  bone  are 
bad,  and  if  used  at  all  are  to  be  regarded  as  a 
choice  between  evils.    They  are  seldom  required 


Copyright,  1920,  by  A.  R.  Elliott  Publishing  Company. 


302 


SMITH:  REPAIR  OF  FRACTURES. 


[New  York 
Medical  Journal. 


at  all.  Tfie  plate  is  one  of  the  worst  of  all  inven- 
tions. It  does  more  harm  than  good,  is  a  weak 
device,  and  has  been  largely  discarded  in  the 
operative  treatment  of  bone.  Staples  are  justly 
obsolete  and  never  should  have  been  used.  Silver 
wire  has  a  limited  use,  and  is  valuable  occasionally, 
not  because  it  is  silver,  but  because  it  is  pliable  and 
can  be  pulled  into  place  and  cannot  bear  enough 
strain  to  do  much  harm  by  cutting  through  the 
bone,  thus  hindering  repair. 

Kangaroo  tendon  offers  the  best  material  for 
binding  fractures  in  place,  but  requires  perfect  tech- 
nic to  prevent  infection.  If  it  is  infected  it  makes 
a  bad  mess.  It  should  be  placed  in  1  :1000  bi- 
chloride of  mercury  solution,  not  for  the  antiseptic 
effect  of  the  solution,  but  to  render  it  readily  pliable 
so  that  it  can  be  accurately  placed  and  tied. 

BONE  GRAFTS. 

Do  not  put-  in  an  intermedullary  bone  graft.  It 
fills  up  the  medullary  canal  and  prevents  restora- 
tion of  the  intermedullary  repair  and  nutritive  cir- 
culation of  blood  in  the  bone.  It  prevents  a 
sufficient  deposition  of  callus  and  often  prevents 
union  of  the  fractured  shaft.  The  graft  unites 
within  the  medullary  canal  leaving  only  the  graft 
itself  at  the  site  of  fracture.  Refracture  is  sure  to 
follow.  It  also  frequently  causes  a  throbbing  pain 
at  the  site  of  fracture  until  the  medullary  canal  is 
cleared  of  obstruction.  In  case  of  refracture  it 
must  be  removed  before  union  can  take  place  as  the 
result  of  further  operative  procedures. 

Do  not  take  a  graft  from  the  crest  of  the  tibia. 
The  bone  is  too  compact  and  does  not  readily  unite 
with  the  less  dense  bone  into  which  it  is  inserted. 
It  does  not  allow  of  the  necessary  flow  of  reparative 
material  to  the  site  of  fracture.  It  leaves  a  damaged 
tibia  that  will  not  make  a  good  repair. 

Do  not  reverse  the  longitudinal  axis  of  a  bone 
transplant  in  taking  it  from  one  position  to  another. 
If  you  do,  you  will  reverse  all  the  nutritive  chan- 
nels within  the  transplant  and  perhaps  have  the 
transplant  perish  and  the  operation  fail. 

Never  try  to  use  damaged  bone  for  a  transplant. 
It  will  perish  every  time.  Fit  the  transplant  ac- 
curately into  a  carefully  prepared  seat.  Do  not  jam 
it  too  tightly  into  place.  Do  not  bruise  or  batter 
any  of  the  bone.  Do  not  place  it  in  any  solution. 
Do  as  little  handling  as  possible  and  place  it  in  site 
as  quickly  as  possible.  Do  as  little  trauma  as  pos- 
sible in  handling  any  part  of  the  work. 

Do  not  leave  periosteum  on  a  bone  peg  to  be 
placed  within  the  bone  as  in  the  neck  of  the  femur. 
Do  not  place  a  bone  transplant  in  the  central  axis 
of  the  femoral  neck,  as  it  will  lie  in  a  bed  composed 
largely  of  fat,  which  is  a  semimedullary  tissue  and 
the  transplant  will  be  wasted.  The  upper  portion 
of  the  femoral  neck  is  the  most  advantageous  site 
for  the  transplant.  Remember  that  the  adult  fe- 
moral neck  from  the  greatest  convexity  of  the  tro- 
chanter major  to  the  attachment  of  the  ligamentum 
teres,  is  from  three  and  three  eighths  inches  to 
three  and  five  eighths  inches  in  length.  It  is  never 
necessary  to  turn  a  round  peg  for  this  transplant. 
Use  a  quarter  or  three  eighths  inch  bone  chisel, 
graduated  in  quarter  inches  on  one  side.  Cut  a 
square  hole  in  the  shell  of  the  trochanter.  Gently 


drive  the  chisel  into  the  neck,  loosening  it  gently 
from  time  to  time.  Drive  it  in  about  three  inches 
in  the  adult  bone.  Lay  the  chisel  bit  on  the  anterior 
wall  of  the  shaft  of  the  exposed  tibia  and  mark  out 
a  three  and  one  quarter  inch  long  transplant,  the 
width  of  the  chisel  bit,  with  a  scalpel.  Saw  out  the 
graft  right  into  the  medullary  canal.  Gently  detach 
it  after  sawing  a  point  on  the  lower  end.  Carefully 
shave  off  the  medullary  tissue  and  strip  off  the 
periosteum  and  shove  it  home  through  the  pre- 
viously prepared  chisel  hole.  Nip  off  the  short 
protruding  end  and  the  job  is  neatly  and  quickly 
done.  This  method  does  away  with  an  unsafe  ma- 
chine that  cannot  be  well  sterilized,  prevents  unnec- 
essary trauma,  preserves  the  vitality  of  the  trans- 
plant and  saves  valuable  time. 

In  fracture  of  the  neck  of  the  femur,  when  the 
line  of  fracture  is  near  the  head  of  the  bone,  re- 
placement of  the  fragments  is  more  difticult  than 
when  the  fracture  occurs  nearer  the  trochanter.  If 
the  ligamentum  teres  is  ruptured,  thus  destroying 
the  artery  which  enters  the  head  of  the  bone  at  the 
attachment  of  the  ligament  this  fragment  may 
be  rapidly  absorbed.  Bony  union  between  the  frag- 
ments is  also  doubtful.  If  there  are  two  lines  of 
fracture,  one  near  the  head  of  the  bone  and  one 
near  the  trochanter,  the  intervening  fragment  may 
absorb  leading  to  fibrous  union,  or  in  fortunate 
cases  a  very  much  shortened  neck  of  the  bone. 
Whether  or  not  the  fracture  is  intracapsular  or 
extracapsular  has  practically  nothing  to  do  with 
the  healing  of  the  bone,  except  that  it  makes  a  dif- 
ference in  the  adjustment  of  the  fracture.  The 
disturbance  of  the  blood  supply  is  the  controlling 
factor  in  the  matter  of  repair,  providing  we  know 
how  to  treat  the  fracture. 

The  terms  intracapsular  and  extracapsular  are 
rather  ridiculous  as  usually  applied  to  the  neck  of 
the  femur.  As  an  anatomical  fact  the  neck  of  the 
femur  is  wholly  intracapsular,  except  a  small  tri- 
angular portion  near  the  digital  fossa,  posteriorly 
situated. 

If  an  overriding  fracture  of  the  shaft  of  a  long 
bone  cannot  be  reduced  by  careful  manipulation 
under  an  anesthetic,  do  not  attempt  to  make  a  forc- 
ible reduction  by  means  of  ropes  and  pulleys,  or  a 
machine  like  the  Hawley  table,  as  you  will  do  in- 
finite harm  to  the  soft  parts.  Although  you  may 
apply  plaster  of  par  is  with  the  parts  on  the  stretch 
while  in  position  on  the  table,  there  is  no  certainty 
of  the  bone  remaining  in  place  when  the  patient  is 
released  from  the  table.  The  pain  afterwards  is 
unjustifiable.  Pressure  sores  are  common.  Par- 
alysis of  the  bladder  has  occurred  and  persisted  for 
an  indefinite  time  from  the  pressure  on  the  perineum, 
the  forcible  reduction  of  fracture  of  the  femur 
by  means  of  the  Hawley  table.  A  much  easier  and 
by  far  better  method  is  to  make  an  incision,  and  by 
use  of  the  simple  device  known  as  a  bone  skid,  the 
fracture  can  be  reduced  quickly  and  easily  and  with- 
out harm.  The  part  can  then  be  put  up  in  appro- 
priate dressings  with  the  muscles  relaxed  and  'with 
the  certainty  that  the  patient  is  not  going  to  suffer 
unnecessary  pain. 

Bones  cut  smoothly  and  transversely  to  the  long 
axis  of  the  shaft  unite  slowly  or  perhaps  not  at  all 


September  4,  1920.] 


SMITH:  REPAIR  OF  fRACTURES. 


303 


even  in  the  absence  of  any  deleterious  influence. 
Bones  cut  obliquely  or  longitudinally  and  spliced  in 
that  manner  will  unite  very  quickly  under  favorable 
conditions.  One  reason  for  this  is  that  in  the  latter 
condition  much  wider  surface  is  exposed  and  on 
account  of  the  peculiar  structure  of  the  bone,  larger 
nutritive  channels  are  opened  up,  through  which 
bone  building  material  can  be  brought  to  the  site 
of  union. 

Do  not  attempt  reparative  work  on  open  frac- 
tures until  after  the  soft  parts  have  iTealed  and  all 
infection,  latent  or  active,  has  ceased.  Do  not  plate 
these  fractures.  Do  not  operate  on  any  fracture 
under  a  week  or  ten  days  unless  it  is  the  patella, 
which  may  sometimes  be  sutured  in  five  days.  You 
invite  infection  by  too  early  operation.  By  wait- 
ing, much  extravasated  blood  is  absorbed,  many 
blood  vessels  have  been  restored  and  the  lymph 
spaces  occluded,  rendering  the  operation  nearly  as 
safe  as  a  clean  operation  on  the  soft  parts.  Other- 
wise, infection  is  the  rule. 

Never  undertake  to  do  a  bone  graft  or  operative 
repair  of  any  fracture  when  there  is  pus  in  the 
woinid  or  necrosed  bone  or  active  or  latent  infection 
in  the  tissues.  That  is  an  invitation  to  the  most 
destructive  infection  with  possible  loss  of  life  or 
limb.  It  certainly  means  a  failure  as  far  as  repair 
of  the  fracture  is  concerned. 

Do  not  use  an  unnecessary  piece  of  catgut  in 
fracture  work.  Heavy  hemostats  left  in  place  for 
a  few  minutes  will  stop  hemorrhage  from  small 
vessels  and  prevent  infection  fr9m  too  much  catgut. 
Bones  and  ligaments  do  not  readily  dispose  of  catgut. 

Most  fractures  of  the  femur  can  be  treated  with 
absolutely  satisfactory  results  by  the  modified 
Hodgen  splint  or  by  weight  and  pulleys  and  long 
sand  bags. 

Never  use  any  sort  of  zinc  oxide  adhesive  plaster 
for  traction.  It  is  not  strong  enough.  It  wrinkles 
and  makes  sores.  It  is  irritating  to  the  skin  and  is 
a  most  unsatisfactory  material.  Most  surgeons  use 
whatever  adhesive  material  is  handed  them.  Shiver's 
moleskin  adhesive  plaster  is  the  only  material  fit 
to  use  for  this  purpose.  This  statement  may  not 
get  much  consideration,  but  Sayre  would  never 
have  made  the  great  record  he  did  without  moleskin 
adhesive  plaster.  He  was  absolute  in  his  teaching 
on  this  point  and  he  was  right. 

It  is  superlative  folly  for  any  surgeon  to  state 
that  a  fracture  of  the  femoral  neck  cannot  be  suc- 
cessfully handled  by  straight  traction  and  the  proper 
use  of  sand  bags.  This  method  is  vastly  superior 
to  all  others  if  properly  applied,  better  as  to  the 
safety  and  comfort  of  the  patient,  puts  the  bones  in 
better  apposition  than  any  other  method  and  gives 
unexcelled  results.  A  small  sand  bag  behind  the 
trochanter  is  the  factor  added  to  the  rest  that  keeps 
the  broken  surfaces  from  rotating  apart.  The 
method  must  be  seen  to  be  learned  and  moleskin 
adhesive  plaster  is  essential. 

All  fractures  of  the  leg,  including  fractures  in- 
volving the  ankle,  should  invariably  be  reduced  with 
the  knee  semiflexed  and  never  in  the  extended  posi- 
tion. They  should  always  be  put  on  a  splint  or  in 
plaster  with  the  knee  held  in  semiflexion  and  the 
thigh  included  to  the  hip  in  the  dressing.  This 


excludes  the  Hawley  table  and  obviates  the  use  of 
brute  force  in  handling  these  fractures. 

Colles's  fractures  should  be  put  up  in  a  dressing- 
including  the  arm  so  as  to  prevent  pronation  and 
supination.  The  fingers  and  thumb  should  be  free 
and  movement  of  the  digits  encouraged.  Splints 
are  bad  as  they  cause  clamplike  pressure  and  favor 
adhesions.  Tenosynovitis  is  all  too  common  in 
these  fractures.  It  happens  in  persons  of  all  ages 
and  by  any  method  of  treatment.  Some  biological 
product  is  liberated  into  the  tissues  in  fractures 
near  joints,  causing  adhesions  and  thickening  of 
epiphyseal  structures.  Some  day  someone  will  ex- 
plain what  happens. 

Do  not  do  passive  movements  with  joints  when 
there  is  free  movement  between  fractured  parts 
near  by.  Pain  and  irritation  and  damage  will  re- 
sult. Do  not  bake  any  bone  or  joint  unless  you 
want  it  for  food.  It  means  devitalization  of  tis- 
sue and  permanent  damage.  Do  not  massage  in- 
fected tissue  until  all  infection  has  ceased. 

Do  not  use  sheet  wadding  under  plaster  of  paris 
or  to  pad  splints.  It  does  not  pad  a  part  sufficient- 
ly. It  wrinkles  and  makes  sores.  It  irritates  the 
skill.  It  stinks.  It  is  unpardonably  bad.  Use  a 
good  quality  of  absorbent  cotton. 

Frequently  large  hemorrhages  take  place,  some- 
times deeply  in  the  limb,  sometimes  under  the  gu- 
taneous  structures.  In  uninfected  cases  these  hem- 
orrhages rapidly  form  clots  which  are  absorbed 
within  a  few  days  or  weeks.  The  absorption  of 
this  blood,  together  with  that  escaping  from  the 
broken  bone,  often  causes  a  rise  in  temperature  of 
from  one  to  several  degrees.  In  compound  frac- 
tures it  makes  us  apprehensive  as  to  whether  the 
rise  of  temperature  is  due  to  this  cause  or  to  a  be- 
ginning infection.  A  large  clot  of  blood  which  is 
capable  of  being  demonstrated  should  be  carefully 
watched.  Sometimes  five  or  six  or  even  more  weeks 
after  the  occurrence  of  a  fracture,  even  after  the 
union  of  the  bone,  one  of  these  large  clots  will  begin 
to  liquefy.  Through  a  small  opening,  evacuate  the 
broken  down,  liquefied  blood  clot,  of  course  with 
strict  surgical  precautions.  The  liquefaction  of  the 
blood  clot  is  evidence  of  infection  which  will  cer- 
tainly result  in  an  abscess  and  widespread  infection 
unless  the  disorganized  blood  is  promptly  evacu- 
ated. Place  a  wet  compress,  preferably  one  to  two 
thousand  solution  of  permanganate  of  potassium, 
over  the  part  and  bandage  rather  firmly.  This  will 
prevent  refilling  of  the  evacuated  cavity. 

701  Phel.an  Building. 


Measurements  of  Goitre  on  the  Living. — H. 

Hunziker  {Schweizcrischc  medizinische  Wochen- 
schrift,  January  29,  1920)  proposes  as  a  standard 
scale  of  measurements  by  means  of  which  the  si?e  of 
goitres  in  different  regions  and  countries  may  be 
compared,  the  square  area  obtained  by  multiplying 
the  breadth  of  the  palpable  thyroid  by  its  height  in 
centimetres.  When  the  thyroid  cannot  be  felt  the 
recond  would  be  0 ;  when  it  is  one  cm.  broad  and  one 
cm.  high,  the  record  would  be  one ;  measuring  six 
by  five  cm.  it  would  be  thirty ;  measuring  .seventeen 
by  twelve  cm.  it  would  be  204,  and  so  on. 


304 


MILLER:  SPLEXECTOM) 


[New  York 
Medical  Journal. 


SPLENECTO^IY.  WITH  REPORT  OF  TWO 
CASES.* 
By  George  I.  Miller,  M.  D., 

Brooklyn. 

The  rarity  of  articles  on  the  diseases  of  the  spleen 
and  their  treatmeht,  compared  with  the  legions  of 
essays  on  other  anatomical  parts,  invites  interest 
and  enthusiasm  in  the  study  of  this  mysterious 
ductless  organ.  Organs  in  the  body  richly  supplied 
with  blood  vessels  and  lymphatics  and  not  provided 
with  ducts  are  necessarily  regulators  of  the  complex 
human  mechanism.  These  organs  exert  this  sys- 
temic influence  through  the  blood  stream.  To  what 
extent  the  spleen  is  of  value  to  the  body  cannot  be 
determined  by  direct  studies,  since  the  spleen  has 
no  external  secretion  and  no  known  internal  secre- 
tion, and,  furthermore,  the  removal  of  the  normal 
spleen  causes  no  serious  bodily  change. 

Historically,  splenic  surgery  is  of  great  interest. 
As  early  as  1500,  spleens  were  removed  from  ani- 
mals without  affecting  their  health.  Krumbhaar 
says  Aristotle  suspected  that  the  spleen  was  not 
essential  to  life.  In  1549  Zaccarelli  was  said  to 
have  removed  the  spleen  from  a  patient,  with  satis- 
factory results. 

The  earliest  splenectomy  in  this  country  was  done 
by  Browne  in  1814,  the  patient  living  and  re- 
maining in  good  health  after  the  operation.  In 
1866,  Ouittenlaum,  Spence,  and  Wells  (1)  removed 
spleens  not  only  in  cases  of  injury,  but  also  from 
patients  suffering  with  constitutional  disturbances 
and  splenomegaly.  The  revolutionary  period  of 
splenic  surgery,  however,  must  be  considered  from 
1894,  when  Banti  (loc.  cit.,  77)  described  the  disease 
which  bears  his  name. 

The  operations  performed  on  the  spleen  are  most- 
ly splenectomy,  splenorrhaphy,  splenopexy,  aspira- 
tion, and  splenotomy.  Splenectomy  is  advocated  in 
a  great  variety  of  diseases  and  conditions,  especially 
when  the  spleen  is  enlarged  to  twice  or  more  its 
normal  size.  Clinically,  the  enlargement  of  the 
spleen  is  to  be  considered  the  barometer  of  sys- 
temic disturbance,  since  the  spleen  itself  is  seldom 
the  cause  of  the  disease. 

Physiologically,  the  spleen  enlarges  following 
food  intake  and  resumes  its  normal  size  after  sev- 
eral hours.  This  enlargement  may  be  due  to  the 
influx  of  blood  from  the  celiac  axis,  during  the 
process  of  digestion,  the  same  source  which  supplies 
the  stomach,  the  duodenum,  the  liver,  and  the  pan- 
creas with  blood.  Enlarged  spleens  caused  by  dis- 
ease show  constant  pathological  changes,  irrespec- 
tive of  the  clinical  phenomenon.  The  spleen,  on 
examination,  reveals  marked  fibrosis,  degeneration 
of  the  blood  vessels  and  malpighian  bodies,  or 
swelling,  or  atrophy  of  the  splenic  pulp. 

Elliot  and  Kanavel  state  that  the  intramuscular 
injection  of  epinephrine  contracts  the  spleen  one 
third  the  size. 

The  function  of  the  spleen  has  not  been  definitely 
established.  It  is  known  to  have  phagocytic  prj)per- 
ties,  to  develop  hemolytic  ferments,  to  act  as  a 

•Read  before  the  Clinical  Spciety  of  the  People's  Hospital,  N.  Y. 
Citv,  February  11.  1920,  and  before  the  Kings  County  Medical 
Society,  April  20,  1920. 


mechanical  strainer,  and  to  divert  a  large  volume  of  >• 
blood  from  the  general  to  the  portal  circulation.  It 
also  directs  bacteria  and  protozoa,  toxic  products, 
and  worn  out  red  cells  from  the  blood  to  the  liver 
for  destruction.  The  spleen,  therefore,  in  health  is 
to  be  considered  a  desirable  organ,  while  under  cer- 
tain conditions  in  disease  it  proves  to  be  an  untrust- 
worthy, dispensable  traitor,  causing  destruction  of 
blood  ingredients,  the  loss  of  which  eventually  kills 
the  patient.  Its  timely  removal,  therefore,  stops 
the  progressive  destruction  and  the  patient  recovers. 

Traumatism  of  the  spleen  may  result  in:  1,  Sub- 
cutaneous rupture,  usually  produced  by  falls,  kicks, 
or  the  passage  of  a  wheel  across  the  abdomen. 
Congenital  syphilis  prediposes  to  rupture  of  the 
spleen  during  birth.  2,  Open  wounds  of  the  spleen 
such  as  are  caused  by  stab  wounds  and  gunshot 
injuries.  3,  Accidental  injuries  of  the  spleen  have 
occurred  by  a  trocar  thrust  into  the  abdomen  for 
the  relief  of  ascites  or  by  a  trocar  thrust  into  the 
chest  for  empyema.  The  sypmptoms  pathogno- 
monic of  injury  of  the  spleen  will  be  illustrated  by 
the  following  case. 

April  3,  1919,  I  was  summoned  in  great  haste  to 
a  private  hospital,  by  a  surgeon.  He  asked  me  to 
explain  the  collapsed  condition  of  his  patient,  R.  S., 
a  married  woman,  forty-five  years  of  age.  She  had 
been  sick  in  bed  about  four  weeks  with  pneumonia, 
followed  by  empyema.  The  physician  had  decided 
to  treat  the  patient  by  introducing  a  large  cannula 
into  the  chest  and  leaving  it  in  situ  for  continued 
drainage,  instead  of_  by  an  open  operation.  About 
three  hours  before  my  arrival  he  thrust  the  cannula 
in  the  axillary  line  of  the  left  ninth  intercostal 
space.  The  patient  experienced  considerable  pain 
and  shortly  afterward  collapsed.  I  found  her  in 
bed,  looking  very  pale,  her  Hps  were  white,  and  the 
pulse  was  faintly  perceptible.  Abdominal  percus- 
sion revealed  dulness  in  both  flanks.  She  showed 
all  the  evidences  of  abdominal  hemorrhage. 

I  suggested  a  laparotomy,  and  on  opening  the 
abdomen  we  saw  a  typical  picture  of  a  ruptured 
ectopic  gestation.  After  removing  about  two 
quarts  of  fluid  and  clotted  blood,  I  demonstrated  a 
ragged  rent  in  the  convex  surface  of  the  spleen, 
caused  by  the  thrust  of  the  cannula.  I  repaired  the 
torn  spleen  with  two  mattress  sutures  and  closed 
the  abdomen.  I  transfused  the  patient,  while  she 
was  still  on  the  table,  with  500  c.  c.  of  whole  blood. 
She  made  an  uneventful  recovery. 

Movable  and  ptosed  spleens  can  be  anchored  in 
position,  except  when  torsion  and  strangulation  of 
the  pedicle  have  taken  place ;  then  splenectomy  is 
indicated. 

^Nlaclaren  relates  the  case  of  a  woman,  aged  fifty- 
one,  who  suffered  from  palpitation,  dyspnea  and 
depression.  The  examination  revealed  an  irregular 
tumor  in  the  pelvis.  Operation  showed  the  tumor 
to  be  a  wandering  spleen  with  two  complete  turns 
in  a  pedicle  ten  inches  long.  Johnston  collected 
eighteen  cases  of  ectopic  spleen  from  1900  to  1908. 
MacDonald  and  Mackay,  Solieri,  Paterson  reported 
cases  of  spleen  in  the  pelvis,  with  acute  torsion  of 
the  pedicle.  In  all  cases  splenectomy  was  per- 
formed with  recovery.  Benign  growths  and  non- 
parasitic cysts  of  the  spleen  have  been  resected  by 


September  4,  1920.] 


MILLER:  SPLENECTOMY. 


305 


Bircher.  Splenectomy,  however,  proved  to  be  the 
safer  operation.  A  lymphangioma  of  the  spleen 
was  removed  by  R.  H.  Fowler.  A  case  of  multi- 
locular  cystic  spleen  removed  hy  splenectomy  by 
Coenen  was  considered  by  him  of  lymphangiectatic 
origin.  Johnston  reported  twelve  cases  of  splenec- 
tomies for  sarcoma  with  three  recoveries.  Bush 
recorded  the  case  of  a  man  whose  spleen  showed 
some  whitish  elevations  on  its  surface  suggesting 
sarcoma.  Splenectomy  was  performed  with  recov- 
ery from  the  operation,  but  the  patient  died  a  few 
months  later  from  metastasis. 

Tuberculosis  of  the  spleen. — Burke,  in  1889,  was 
the  first  to  remove  the  spleen  for  splenic  tubercu- 
losis. Cases  of  splenectomy  for  primary  tubercu- 
losis of  the  spleen  have  been  collected  by  Fisher 
showing  twelve  cases  with  four  recoveries.  W.  J. 
Mayo  reported  a  case  of  prol^able  tuberculosis  of  the 
spleen,  that  of  a  young  girl  who  died  six  months 
later  from  generalized  tuberculosis.  Bland  Sutton 
believed  tuberculosis  of  the  spleen  to  be  secondary 
to  tuberculous  foci  elsewhere  in  the  body.  The 
spleen  is  frequently  involved  in  children  who  die 
from  tuberculosis. 

Syphilis  of  the  spleen. — Syphilitic  spleens  have 
been  removed,  with  remarkable  results,  from  pa- 
tients who  failed  to  improve  under  persistent  anti- 
syphilitic  treatment  with  salvarsan,  neosalvarsan 
and  mercurial  remedies.  The  removed  spleens 
showed  encapsulated  spirochetes.  Splenomegaly 
is  common  in  syphilitic  children  and  is  considered 
second  in  frequency  to  rickets.  Gummata  of  the 
spleen  are  rare  in  both  children  and  adults.  Giffin 
in  1916  reported  6  cases  of  syphilitic  splenomegaly 
showing  marked  anemia,  a  positive  W'assermann  and 
failure  to  improve  under  antisy]:)hilitic  treatment. 
The  patients  had  changes  in  the  liver  and  one  pa- 
tient had  a  gumma.  Splenectomy.  I)y  removing  the 
spirochetes  within  the  organ,  cured  the  patient. 

Malarial  spleen. — The  removal  of  the  spleen  for 
chronic  malarial  splenomegaly  is  not  generally 
recommended,  although  Finkelstein  and  Jonesco  and 
others  performed  splenectomy  with  gratifying  re- 
sults. 

Splenic  anemia  and  Banti's  disease. — Splenic 
anemia  with  splenomegaly  and  leucopenia  is  a 
chronic  intoxication  of  unknown  cause  occurring  in 
children  and  adults ;  at  times  in  one  third  to  one  half 
of  the  cases  it  is  accompanied  with  hemorrhage, 
especially  from  the  stomach,  and  often  terminates  in 
Banti's  disease  with  cirrhosis  of  the  liver,  jaundice 
and  ascites.  Balfour  states  that  forty-two  pa- 
tients showing  this  type  of  disease  were  operated 
upon  in  the  Mayo  Clinic  up  to  May,  1917.  Spleno- 
megaly usually  preceded  the'  anemia.  The  weight  of 
the  spleen  in  some  of  these  cases  has  been  in- 
creased from  the  normal  195  grams  to  5,280 
grams  (Giffin).  The  enlargement  was  due  to 
thrombophlebitis  of  the  splenic  and  portal  veins 
which  occurred  as  a  primary  condition.  Banti's 
disease  is  considered  the  advanced  stage  of  splenic 
anemia — cases  which  have  cirrhosis  of  the  liver 
with  ascites. 

A.  G.  Gibson  offers  triple  evidence  that  the 
disease  is  of  parasitic  orgin :  Splenectomy  cures 
or  alleviates  the  condition,  the  disease  simulates 


kala  azar,  and  salvarsan  acts  beneficially.  The  pre- 
ascitic  stage  lasts  several  years.  Gastric  disturb- 
ance, abdominal  pain,  pallor  and  increasing  weak- 
ness may  be  the  attracting  clinical  symptoms.  There 
may  be  a  slight  leucopenia  and  increased  urobilin. 
As  the  disease  progresses,  the  urine  is  diminished, 
high  colored,  with  excess  of  urobilin.  There  may 
be  diarrhea.  Finally,  cirrhosis  of  the  liver  and 
ascites  are  present.  Some  jaundice  and  emacia- 
tion can  be  observed.  Splenectomy  is  a  specific 
remedy  in  whatever  stage  of  the  disease  the  patient 
is  found. 

I  operated  in  the  following  two  cases  belonging  to 
this  group : 

Case  L — G.,  D.,  aged  forty-eight  years.  Rus- 
sian. Admitted  to  the  Jewish  Hospital,  Brooklyn, 
N.  Y.,  September  8,  1915,  and  discharged  October 
8,  1915. 

Family  history,  negative.  Previous  personal 
history,  married  twenty-eight  years.  Gave  birth  to 
six  healthy  children ;  never  aborted ;  menstruation 
regular.  Had  typhoid  fever  at  the  age  of  twenty. 
For  the  past  eight  years  she  had  had  myalgia. 

Present  illness :  Six  years  ago  she  was  admitted 
to  the  \'ienna  General  Hospital  for  pain  in  the  ab- 
domen and  left  side.  She  remained  in  this  in- 
stitution for  four  weeks  and  left  feeling  well.  She 
arrived  in  America  two  years  ago.  Six  months 
previously  the  patient  noticed  a  hard  mass  in  the 
left  hypochondrium,  which  gradually  increased  in 
size.  Two  months  before  admission  to  the  hospital, 
she  had  an  attack  of  abdominal  cramps  which  last- 
ed twenty-four  hours.  Since  then  she  had  felt  a 
sensation  of  weight  and  a  sticking  pain  in  the  left 
side  of  the  abdomen.  She  did  not  cough  or  vomit. 
She  had  lost  about  fifty  pounds  in  weight  in  the 
past  eight  years. 

Pliysical  examination,  adult  female ;  well  de- 
veloped :  anemic ;  not  dyspneic ;  appeared  chronical- 
ly ill.  There  were  no  glandular  enlargements.  The 
abdomen  showed  a  firm  mass  in  the  left  side,  ex- 
tending from  the  tenth  rib  to  the  pelvis  and  to  the 
linea  alba  anteriorly.  The  mass  was  somewhat  ten- 
der. There  were  varicose  veins  of  legs.  Reflexes 
normal.  Temperature,  101°;  pulse,  100:  respir- 
ation, 20. 

Urine  examination,  specific  gravity,  1020 :  acid ; 
negative.  Blood  examination,  red  blood  cells,  3,- 
260,000;  leucocytes,  7,400;  neutrophiles,  61  :  lymph- 
ocytes, 34 ;  mononuclears,  3 ;  basophiles,  1  ;  eosino- 
philes,  1  ;  hemoglobin,  70  per  cent. 

Operation,  September  20,  1915.  Ether  anes- 
thesia. Left  upper  rectus  incision,  peritoneum 
opened.  Adhesions  above  and  to  left  of  the  spleen 
separated  without  difficulty.  Spleen  delivered ;  ten 
by  six  inches  in  size.  Pedicle  tied  with  double  liga- 
ture and  cut.  The  spleen  was  removed.  The  abdo- 
minal wall  was  closed.  Immediately  following  the 
operation,  I  transfused  350  c.  c.  of  unmodified 
blood.  Four  to  five  accessory  spleens,  about  the 
size  of  walnuts,  were  present.  The  patient  made 
an  uneventful  recovery  and  has  since  gained  about 
twenty  pounds  in  weight  and  is  in  perfect  health. 
She  has  been  absolutely  cured  by  the  operation. 

Case  II. — H.  K.,  real  estate,  aged  sixty-four 
years,  Russian;  lived  in  New  York  forty  years.  He 


306 


MILLER:  SPLENECTOMY 


[New  York 
Medical  Journal. 


had  eleven  healthy  children.  His  wife  never 
aborted.  The  patient  entered  the  Jewish  Hospital 
of  Brooklyn,  October  9,  1919,  for  the  relief  of 
weakness,  pallor,  loss  of  weight  and  a  large  mass 
in  the  abdomen.  The  family  history  '  was 
negative. 

Previous  personal  history :  Had  typhoid  fever 
thirty-eight  years  ago ;  had  had  no  malaria  or  syph- 
ilis. The  patient  suffered  from  chronic  articular 
and  muscular  rheumatism  for  several  years  prior  to 
ten  years  ago.  He  was  never  subject  to  colds  or 
tonsillitis  ;  never  had  gallstone  colic  or  abdominal 
pain.  His  cervical,  axillar}'  or  inguinal  glands 
were  never  enlarged.  The  patient  lost  his  left  eye 
forty-three  years  ago  from  a  bullet  shot.  His  habits 
were  good ;  occasionally  drank  several  glasses  of 
prewar  beer.  Denied  venereal  disease.  Slept  well ; 
appetite  good  until  four  months  ago ;  constipated. 

Present  illness :  Four  months  ago  the  patient 
noticed  a  painless  mass  in  the  left  side  of  his  ab- 
domen. In  the  course  of  a  few  weeks  the  mass 
grew  much  larger.  He  lost  about  twenty-five 
pounds  in  weight  since  he  became  sick  and  noticed 
a  progressive  loss  in  strength  and  marked  pallor. 
He  had  no  nausea  or  vomiting.  No  gastric  hemor- 
rhages or  blood  at  stool.  The  patient  consulted 
several  physicians  and  was  treated  medically  with 
large  quantities  of  liquids,  powders  and  pills  with- 
out relief.  He  went  to  the  Catskills  for  three 
weeks,  which  seemed  to  have  improved  his  strength 
and  color.  The  abdominal  mass,  however,  re- 
mained the  same  size.  On  returning  to  the  city  he 
was  referred  to  a  specialist  on  internal  diseases,  who 
informed  him  that  his  spleen  was  enlarged,  and 
recommended  x  ray  treatment.  He  received  seven  x 
ray  exposures  at  intervals  of  four  days,  each  ex- 
posure lasting  from  fifteen  to  twenty  minutes.  After 
the  first  four  exposures  the  spleen  seemed  to  have 
shrunk  to  about  one  half  the  size,  but  later  became 
even  larger  than  before  the  treatment.  He  was  then 
advised  to  have  his  spleen  removed. 

Physical  examination  showed  an  elderly  man,  five 
feet,  five  inches  in  height,  with  sallow  skin,  anemic, 
pale;  left  eye  missing;  right  sclera  not  jaundiced; 
pupils  normal.  The  patient  was  lying  in  bed.  He 
appeared  chronically  ill.  Most  of  his  teeth  were 
missing.  Those  remaining  were  carious  and  loose ; 
tongue  was  coated;  tonsils,  negative;  neck,  sym- 
metrical ;  no  glandular  enlargement ;  the  skin  was 
faintly  jaundiced.  There  was  no  pruritis,  no  blebs, 
and  no  pigmentation.  The  heart  was  not  enlarged. 
There  was  a  faint  systolic  murmur  at  the  apex, 
which  was  transmitted  toward  the  left  axilla.  There 
was  no  angina.  The  pulses  were  of  small  volume 
and  low  tension.  The  arteries  showed  moderate 
thickening;  somewhat  tortuous.  The  lungs  were 
negative.  He  did  not  cough ;  was  never  dyspneic  or 
cyanotic.  The  abdomen  showed  a  slight  fulness  in 
the  flanks  and  shifted  with  change  of  position.  The 
liver  edge  was  felt  two  inches  below  the  costal 
margin.  The  spleen  filled  the  entire  left  half  of  the 
abdominal  cavity,  extending  from  underneath  the 
left  costal  margin  to  the  left  iliac  fossa  and  to  the 
right  of  the  linea  alba.  The  glands  of  the  groin 
were  not  enlarged. 

Patient  admitted  to  the  Jewish  Hospital,  Brook- 


lyn, October  9,  1919.  Temperature,  lOr  F. ; 
pulse,  104;  respiration,  24;  blood  pressure,  130  sys- 
tolic ;  78  diastolic.  Blood  examination,  red  blood 
cells,  3,328,000;  white  blood  cells,  3,000;  polymor- 
phonuclears, 64;  lymphocytes,  36;  hemoglobin,  55 
per  cent.  The  Wassermann  was  negative ;  urine 
examination,  specific  gravity,  1,015;  hyaline  and 
granular  casts,  few  pus  cells. 

October  10,  1919,  I  gave  him  a  blood  transfusion 
of  400  c.  c.  of  whole  blood.  October  13,  1919, 
blood  examination  showed  red  blood  cells,  3,808.- 
000 ;  white  blood  cells,  3,200 ;  polymorphonuclears, 
70 ;  lymphocytes,  30 ;  hemoglobin,  65  per  cent. 

October  20,  1919,  I  gave  him  a  second  blood 
transfusion  of  400  c.  c.  of  whole  blood.  The  blood 
examination  showed,  red  blood  cells,  3,840,000 ; 
white  blood  cells,  3,200;  polymorphonuclears.  61; 
lymphocytes,  30 ;  hemoglobin,  65  per  cent. 

October  22,  1919,  under  gas,  oxygen  and  ether 
anesthesia,  in  the  presence  of  a  number  of  surgeons 
who  attended  the  Congress  of  the  American  Col- 
lege of  Surgeons,  I  opened  the  abdomen  of  the 
patient  by  making  an  incision  in  the  linea  alba,  from 
the  ensiform  cartilage  down  to  two  inches  below 
the  umbilicus.  On  opening  the  peritoneum  I 
evacuated  about  six  ounces  of  serous  fluid.  The 
liver  was  smooth  and  extended  three  inches  below 
the  normal  line.  The  gallbladder  and  appendix 
were  normal. 

The  spleen  filled  the  entire  left  portion  of  the  ab- 
dominal cavity.  It  was  smooth  and  hard.  Extensive 
adhesions  bound  it  firmly  to  the  diaphragm,  to  the 
parieties  and  to  its  own  bed.  The  adhesions  were 
easily  destructible  so  that  I  succeeded  in  breaking- 
through  them,  without  injuring  the  spleen.  I  enu- 
cleated the  organ  by  lifting  the  lower  extremity 
through  the  incision  and  then  the  middle  and  upper 
part  until  it  was  entirely  out  of  the  abdominal 
cavity.  The  spleen  was  then  turned  over  to  the 
left,  which  exposed  the  internal  surface  and  its 
pedicle.  Without  much  traction  on  the  pedicle,  I 
divided  it  between  two  ligatures.  I  clamped  and 
ligated  the  splenic  vessels.  After  breaking  up  the 
adhesions  and  before  removing  the  spleen,  I  packed 
several  abdominal  pads  in  the  splenic  bed  to  pre- 
vent hemorrhage.  These  pads  were  removed  and 
the  splenic  bed  and  the  pillar  of  the  diaphragm  in- 
spected. Bleeding  from  the  oozing  points  had 
stopped.  There  were  no  mesenteric  glandular  en- 
largements. The  stomach  and  intestines  were  normal. 

The  abdominal  wall  was  closed  by  four  layers 
of  sutures,  without  drainage,  using  bolsters,  silk- 
worm and  silk  for  the  skin.  The  dressings  were 
compressive  and  elastic  Si3  as  to  fill  up  the  void 
left  by  the  removal  of  the  spleen.  While  still  under 
the  anesthetic,  I  gave  the  patient  a  postoperative 
blood  transfusion  of  500  c.  c.  of  whole  blood  to 
overcome  the  shock,  to  increase  his  resisting  power 
and  to  return  the  blood  he  had  lost.  Time  of  both 
operations,  forty  minutes. 

The  following  day  the  patient  appeared  bright 
and  cheerful  and  showed  no  sign  of  reaction.  He 
had  no  chill.  Temperature,  101°;  pulse,  110;  res- 
piration, 24.  During  the  second  night  he  was  rest- 
less ;  slept  at  intervals.  Temperature,  102°  ;  pulse, 
130;  respiration,  28. 


September  4,  1920.] 


MILLER:  SPLEXECTOMi 


307 


October  24,  1919,  I  gave  him  the  fourth  blood 
transfusion  of  400  c.  c.  of  unmodified  blood.  From 
that  day  on  he  showed  signs  of  gradual  improve- 
ment. The  suture  line  had  to  be  opened  on  account 
of  a  stitch  infection.  Eleven  days  after  operation 
he  was  in  a  wheel  chair  on  the  porch,  and  every 
day  thereafter,  the  weather  permitting. 

Blood  examination,  November  1,  1919,  red  blood 
cells,  4,200,000:  white  blood  cells,  8,000;  hemoglo- 
bin, 65  per  cent.  November  6,  1919,  temperature, 
100°  ;  pulse,  90 ;  respiration,  20.  During  the  early 
morning  of  November  7,  1919,  he  suddenly  had 
a  copious  intestinal  hemorrhage  of  venous  blood. 
November  9.  1919.  he  had  several  hemorrhages 
from  the  bowel  which  exhausted  him.  The  pulse 
became  soft  and  empty.  He  was  drowsy  and 
muttering,  but  could  be  easily  aroused  by  loud  ques- 
tions. He  complained  of  no  pain.  November  10. 
1919,  he  became  imconscious  and  remained  so  until 
he  died  the  following  day.  No  autopsy  was  held. 
The  spleen  weighed  five  pounds  and  was  smooth 
and  hard. 

Histologically,  it  showed  no  perivascular  inflam- 
mation or  thickening.  There  was  no  increase  in  in- 
terstitial fibrous  tissue.  It  did  show  lymph  granu- 
loma denoting  evidence  of  Hodgkin's  disease. 

Osier  (2)  states,  "In  Hodgkin's  disease,  whether 
or  not  there  is  a  type  involving  the  spleen  alone 
without  the  lymph  glands,  is  still  a  question.  The 
disease  may  originate  in  the  lymphoid  tissues  of  the 
spleen.  It  is  very  difiicult  to  distinguish  such  cases 
clinically  from  the  early  stages  of  Banti's  disease.'" 
Pool  collected  four  cases  of  splenectomy  for  the 
anemia  of  von  Jaksch.  Considering  the  fact  that 
from  a  third  to  a  half  of  the  cases  of  splenic 
anemia  have  gastrointestinal  hemorrhages  without 
evidence  of  existing  ulcer  in  the  stomach  or  the 
duodenum,  and  that  the  removal  of  a  small  or 
slightly  enlarged  spleen  from  a  patient  .with  obscure 
gastric  hemorrhage  cures  the  patient,  we  are  justi- 
fied in  believing  such  patients  to  be  victims  of  un- 
recognized cases  of  splenic  anemia. 

Therefore  after  excluding  every  causative  lesion 
which  may  cause  gastric  he'morrhage  and  bearing 
in  mind  the  fact  that  the  spleen  is  the  root  of  infec- 
tion which  gives  unaccounted  toxic  hemorrhage,  I 
believe  that  such  cases  should  be  considered  splenic 
anemia  per  sc. 

Hemolytic  jaundice. — Nonobstructive  hemolytic 
icterus  with  anemia  and  splenomegaly  may  be  the 
congenital  familial  type  of  Minkowski  and  the  ac- 
quired type  of  Hyam  and  Widal.  The  blood  in  these 
cases  shows  increased  fragility  of  the  red  blood  cells, 
which  is  to  be  considered  the  most  important  diag- 
nostic sign.  Bile  pigment  is  also  constant  in  the 
blood  and  urobilin  in  the  urine. 

Elliot  and  Kanavel  were  the  first  to  report  splen- 
ectomy in  this  disea.se  in  1915.  Nineteen  cases  of 
hemolytic  icterus  operated  on  in  the  Mayo  Clinic 
are  reported  with  gratifying  results.  The  jaundice 
which  existed  for  years  disappeared  within  four 
days.  About  sixty  per  cent,  of  these  cases  had  com- 
plicating gallstones  due  to  thickened  bile,  the  result 
of  pigment  derived  from  the  disintegrated  red  cells. 
The  patients  showed  chronic  jaundice  of  a  mild 
degree,  not  accompanied  with  itching  or  the  clay 


stools  usually  associated  with  jatmdice  due  to  ob- 
struction of  the  common  duct.  Bile  is  always  present 
in  the  stool.  The  spleen  and  liver  w-ere  usually 
enlarged  and  often  painful.  Anemia  was  present. 
The  patients  with  congenital  and  acquired  types  suf- 
fered more  and  were  more  likely  to  seek  relief. 

jNIinkowski,  Eppinger,  and  Banti  believe  that  the 
spleen  is  the  destroying  agent  of  the  red  cells  and  the 
fact  that  the  removal  of  the  organ  cures  the  patient 
is  convincing  evidence  to  support  this  view.  The  re- 
ported cases  of  splenectomy  in  this  disease  with  uni- 
formly excellent  results  must  be  looked  upon  as  a 
therapeutic  measure  well  warranted  in  every  case 
of  the  congenital  and  acquired  type. 

Pernicious  anemia. — The  removal  of  the  spleen  in 
cases  of  pernicious  anemia  effects  a  remission  of 
symptoms  to  some  extent.  Percy  suggests  the  re- 
moval of  the  gallbladder  and  the  appendix  as  addi- 
tional possible  foci  of  infection  which  may  be  thes, 
causative  factor  of  the  disease.  There  is,  however, 
thus  far,  no  proof  that  splenectomy  will  cure  the 
disease  or  permanently  check  the  symptoms.  The 
operation  has  proved  of  empirical  value  when  per- 
formed early  in  the  disease  and  before  destructive 
changes  have  taken  place  in  the  cord.  The  anemia 
of  the  pernicious  type  is  due  to  destruction  of  the 
red  blood  cells  and  not  to  inhibition  of  blood  forma- 
tion, and  in  the  absence  of  any  other  evidence  as  to 
the  cause  of  this  destruction,  the  enlarged  spleen 
should  be  considered  a  crematory,  which,  when  re- 
moved in  time,  proves  to  be  the  best  therapeutic 
remedy  at  our  command.  Its  removal  is  followed 
by  absolute  improvement  if  not  by  actual  cure. 

Leucemia. — In  splenomedullary  leucemia,  radium, 
the  X  ray  and  benzol  temporarily  exert  specific  ef- 
fects on  the  spleen  and  on  the  blood  picture,  but 
remissions  occur.  The  spleen  under  radium  treat- 
ment is  often  reduced  to  a  nonpalpable,  normal 
sized  organ  and  disappears  behind  the  left  costal 
margin.  The  several  hiuidred  thousand  white  cells 
disappear  to  the  point  of  a  leucopenia.  In  a  short 
time,  however,  the  spleen  gradually  increases  again 
in  size,  the  white  cells  increase  in  niunber,  the  red 
cells  decrease  and  the  patient  is  a  physical  bankrupt. 

In  the  Mayo  Clinic  in  nineteen  cases  of  this  class 
the  patients  were  splenectomized  after  the  blood 
picture  had  first  been  brought  to  normal  by  the  use 
of  radium,  x  ray  and  benzol.  All  patients  recovered 
but  thus  far  we  have  no  knowledge  of  the  end 
result. 

The  leucemic  spleen  is  not  adherent  and  after  re- 
duction by  radium  is  easily  removed.  The  removal  of 
the  spleen  in  cases  of  cirrhosis  of  the  liver  is  justi- 
fied on  the  theory  that  the  spleen  stimulates  the 
liver  to  overactivity  and  to  excessive  hemohtic 
power.  It  is  well  established  that  the  liver  destroys 
bacteria  and  protozoa  and  detoxicates  poisons 
brought  to  it  from  the  portal  circulation.  In  portal 
cirrho>is  the  liver  is  apparently  exhausted  and  un- 
able to  eliminate  all  the  poisons  directed  to  it  b\' 
the  spleen,  and  there  is  an  ultimate  formation  of  con- 
nective tissue  about  the  portal  radicals.  The  spleen, 
which  is  always  enlarged  in  portal  cirrhosis,  sug- 
gests that  the  source  of  the  poisons  is  in  the  spleen 
and.  furthermore,  splenectomy  improves  the  condi- 
tion of  the  patient. 


308 


BEATES:  HORATIO  C.  WOOD. 


[New  Yokk 
Medical  Journal. 


TECHNIC  OF  SPLENECTOMY. 

The  removal  of  the  spleen  is  not  a  difficult  opera- 
tion. A  median  incision,  or  one  to  the  outer  edge 
of  the  left  rectus  muscle  down  to  the  peritoneum, 
four  to  five  inches  long,  is  made  and,  if  necessary, 
supplemented  by  a  transverse  incision  through  the 
rectus.  The  peritoneum  is  opened.  The  intestines 
are  pushed  aside  and  the  spleen  exposed.  The 
liver,  the  gallbladder  and  the  appendix  are  examined. 
Adhesions  when  present  are  stripped  with  the  fin- 
gers or  clamped  and  ligated. 

After  lifting  the  spleen  out  of  its  bed,  a  large 
gauze  pack,  as  suggested  by  Balfour,  is  introduced 
into  the  space  formerly  occupied  by  the  spleen.  This 
will  aid  materially  in  the  checking  of  all  oozing  points 
and  at  the  same  time  support  the  spleen.  The  spleen 
is  elevated  and  drawn  toward  the  midline  and  the 
pedicle  ligated.  Care  must  be  taken  not  to  include 
the  tail  of  the  pancreas  in  the  ligature.  This  can  be 
avoided  by  isolating  the  arterial  and  venous  branches 
in  the  pedicle  and  ligating  them  separately.  If  the 
procedure  is  found  inadvisable,  ligation  cn  mcssc 
by  two  clamps  is  easily  carried  out. 

In  cases  where  the  splenic  adhesions  are  excessive, 
the  liberation  is  at  times  followed  by  profuse  venous 
bleeding.  This  bleeding  can  be  controlled  in  three 
ways:  1,  ligation;  2,  clamping  the  bleeding  mass 
and  leaving  the  clamp  in  situ  for  three  days,  then 
loosening  it  for  about  twelve  hours,  and  if  no  ooz- 
ing follows,  the  forceps  are  removed;  3,  the  placing 
of  a  gauze  pack,  as  suggested  by  Balfour,  and  leav- 
ing it  in  place  for  a  few  days. 

In  pernicious  anemia  the  spleen  is  removed  with- 
out difficulty.  In  hemolytic  jaundice  the  spleen  is  at 
times  very  large,  but  the  operation  for  its  removal 
is  without  danger.  Greater  operative  risk  is  en- 
countered in  cases  of  splenic  anemic  and  in  hepatic 
cirrhosis  and  particularly  in  leucemia,  since  the 
blood  of  a  leucemic  patient  possesses  less  than  the 
normal  power  of  agglutination. 

Blood  transfusion  preliminary  to  splenectomy  is  a 
therapeutic  remedy  of  great  value  by:  1,  improving 
the  impoverished  and  diminished  quantity  of  the 
blood ;  2,  by  toning  up  the  system  and  preparing  it 
for  the  shock  of  the  operation;  3,  by  gauging  the 
effect  of  the  transfusion  on  the  health  of  the  patient. 

When  a  patient  responds  favorably  to  two  or  three 
transfusions  prior  to  operation,  the  removal  of  the 
spleen  will  probably  effect  a  cure.  On  the  other 
hand,  if  no  improvement  follows  repeated  trans- 
fusion, splenectomy  may  be  of  no  value.  Consider- 
ing the  great  quantity  of  blood  present  in  the  spleen, 
its  removal  necessarily  withdraws  from  the  patient 
a  volume  of  blood  which  should  be  replaced  by  post- 
operative transfusion.  The  usual  amount  transfused 
is  from  500  to  750  c.  c,  and  I  consider  whole  blood, 
as  nature  has  provided,  preferable  to  modified,  medi- 
cated blood.  Changes  in  the  blood  picture  following 
splenectomy  were  studied  and  recorded  by  Pearce,  of 
Philadelphia,  and  his  coworkers.  There  is  a  slow 
progressive  anemia  which  appears  soon  after  re- 
moval of  the  spleen  and  reaches  its  height  between 
the  fourth  and  sixth  week  and  then  the  blood  gradu- 
ally reaches  normal  about  the  fourth  month,  but  the 
hemoglobin  continues  to  increase  up  to  the  tenth 


month.  The  white  cells  show  polymorphonuclear 
leucocytosis  soon  after  operation  and  then  gradually 
fall  to  normal  at  about  the  fourth  month.  There  is 
also  a  transient  eosinophilia,  but  no  increase  in  the 
lymphocytes  was  observed. 

The  postoperative  course  of  splenectomized  pa- 
tients is  equal  to  that  of  other  major  abdominal  op- 
erations. This  depends  mainly  on  the  disease  and 
the  condition  of  the  patient  at  the  time  of  the  oper- 
ation. If  a  patient  is  brought  to  the  operating  table 
as  a  last  resort,  very  little  can  be  expected,  unfair 
advantage  is  taken  of  the  surgeon,  and  surgery  is 
reflected  upon  when  the  result  is  unsuccessful.  Time- 
ly surgical  interference,  after  brief  medical  treat- 
ment has  failed  to  improve  or  cure,  will  bring  grati- 
fying results  to  both  patient  and  physician. 

REFEREXCES. 

1.  QuiTTEXLAUM,  SpEXCE  and  Wells:  Medical  Times 
and  Gaaette,  1866. 

2.  Osler:  Te-xtbook,  p.  749. 

700  St.  Mark's  Avenue. 


HORATIO  C.  WOOD. 

By  Henry  Beates,  Jr.,  M.  D.,  Sc.  D., 
Philadelphia. 

By  the  death  of  Professor  Horatio  C.  Wood  the 
medical  profession  and  mankind  in  general  have 
suffered  an  irreparable  loss.  His  life  was  an  ex- 
ample of  sincerity  of  purpose,  diligence,  honest  en- 
deavor and  justice,  and  an  exceptionally  powerful 
influence  for  the  uplift,  growth  and  development 
of  those  sciences  with  which  he  was  identified.  En- 
dowed with  an  unusual  mind  and  insatiable  in  the 
acquisition  of  knowledge,  the  ever  conspicuous 
power  and  faculty  of  learning  were  demonstrative 
of  his  great  intellect.  Indefatigable  as  an  investi- 
gator, utilizfition  of  time  and  opportunity  found 
him  ever  active  in  the  study  and  solution  of  prob- 
lems presented  by  the  various  natural  sciences  to 
which  his  life  was  dedicated. 

The  eagerness  with  which  he  engaged  in  study, 
a  conspicuous  characteristic,  is  illustrated  by  the 
following  incident  that  occurred  when  a  mere 
youth :  Visiting  the  Philadelphia  Academy  of  Nat- 
ural Sciences,  he  stood  before  a  locked  cabinet  con- 
taining specimens  in  which  he  was  deeply  interested, 
and  being  unable  to  handle  and  examine  them,  his 
disappointment  found  expression  in  tears.  The 
great  Leidy  passed  by  and,  noticing  the  distress  of 
the  youthful  Wood,  inquired  the  cause.  Being  in- 
formed and  doubtless  recognizing  the  impulses  of 
genius,  he  had  the  cabinet  unlocked  and  the  speci- 
mens placed  at  the  student's  disposal. 

Dr.  Wood  was  an  enthusiastic  student  of  botany. 
In  1860,  when  but  nineteen  years  of  age,  he  pre- 
sented his  first  scientific  paper.  Contributions  to  the 
Carboniferous  Flora  of  the  United  States.  From 
then  until  1873  fourteen  papers,  each  of  which  was 
an  authoritative  classic,  appeared  in  the  Proceedings 
of  the  Academy  of  Natural  Scieytces,  American 
Philosophical  Society,  Queckett  Microscopical  Club 
Journal,  American  Journal  of  Science  and  the 
Smithsonian  Institute.  In  1872  the  Smithsonian 
Institute  published  Dr.  Wood's  monograph  The 


September  4,  1920.] 


BEATES:  HORATIO  C.  WOOD. 


309 


Fresh  Water  Algcc  of  North  America.  This  paper 
contained  nineteen  colored  and  two  uncolored  plates 
prepared  from  360  original  microscopic  drawings 
which  for  accuracy  of  detail  and  perfection  are  un- 
surpassed. It  remained  the  authoritative  work  on 
this  subject  for  twenty-five  years. 

The  following  botanical  papers  may  be  mentioned 
as  demonstrating  Dr.  Wood's  phenomenally  acute 
powers  of  observation:  Life  History  of  Some  Si- 
phonaceous  Fresh  Water  Algse;  Manner  in  Which 
Schizomeris  Leibleinii  Produces  Its  Zoosphores ; 
New  Species  of  Desmids ;  New  Species  of  the  Genus 
Sirosiphon,  the  S.  lignicola,  S.  phloiophilum,  S. 
disjunctum. 

Entomology  also  engaged  his  attention  during 
these  years,  and  his  achievements  in  this  branch  of 
science  culminated  in  fourteerw  papers  characterized 
by  that  thoroughness  and  masterful  research  which 
stamped  each  as  an  authoritative  contribution  and 
an  acquisition  to  knowledge.  Of  these  studies, 
which  want  of  time  prevents  naming,  that  entitled 
The  Myriapoda  of  North  America  was  published  in 
the  American  Philosophical  Society  Transactions  in 
1865.  It  was  a  brochure  of  112  pages— with  sixty- 
one  figures  in  the  text  and  three  plates.  The  draw- 
ings, true  to  nature,  were  exponent  of  his  skill. 
The  excellence  and  reliability  of  his  work  was  rec- 
ognized by  Louis  Agassiz,  who  in  1865  headed  a 
large  naturalizing  expedition  to  Brazil  and  after  his 
return  wrote  the  following  letter  to  Dr.  Wood : 

Dear  Sir  : 

While  in  Brazil  I  have  collected  a  good  many  myriapods 
in  every  part  of  the  Empire  visited  and  I  will  gladly  put 
the  whole  at  your  service  as  soon  as  the  specimens  can  be 
picked  out,  but  I  cannot  say  how  soon  this  will  be  possible 
as  I  cannot  make  a  beginning  with  the  arrangement  of  my 
collections  before  I  can  secure  the  means  of  buying  about 
5.000  gallons  of  alcohol  to  carry  the  work  through. 

Very  truly  yours, 

Ag-'^ssiz. 

Dr.  Wood  was  an  indefatigable  worker.  He 
would  frequently  concentrate  his  mind  upon  the 
subject  in  hand  for  thirty  consecutive  hours,  then 
relax  and  indulge  in  uninterrupted  sleep  for  from 
twelve  to  eighteen  hours,  when  his  insatiable  thirst 
for  knowledge  found  him  again  active  in  the  pursuit 
of  investigation  and  discovery,  with  that  intensity 
of  interest  and  painstaking  care  in  obser^-ing  the 
minutest  details  which  crowned  his  labors  with 
phenomenal  success.  Profound  learning  necessarily 
established  a  high  plane  from  which  to  observe 
conventional  standards  of  achievement,  enabling  Dr. 
W'ood  to  enter  his  chosen  profession  of  medicine 
with  a  mind  exceptionally  well  informed  'and  an 
intellect  of  superior  power. 

As  professor  of  botany  in  the  auxiliary  medical 
course  of  the  University  of  Pennsylvania,  his  ability 
as  a  teacher  was  highly  cultivated,  and  later  his 
occupancy  of  the  chair  of  materia  medica  and  thera- 
peutics in  the  major  faculty  of  medicine  constituted 
one  of  the  strongest  and  most  influential  of  the  then 
famous  centre  of  medical  education.  He  was  a 
brilliant  and  impressive  lecturer  and  a  teacher  of 
great  renown. 

His  career  in  the  natural  sciences  rendered  him 
extremely  alert  in  recognizing  the  inevitable  conse- 
quences of  cause  and  effect.    He  was  painfully  con- 


scious of  the  imperfections  and  limitations  of  em- 
pirical medicine,  and  the  measure  thereof  found  ex- 
pression in  the  fearless  manner  in  which,  then 
almost  single  handed,  he  entered  the  arena  in  a 
struggle  having  for  its  aim  the  establishment  of 
physiological  or  rational  medicine  upon  a  firm  and 
scientific  basis.  With  an  open  mind  ever  alert  to 
recognize  and  acknowledge  truth,  he  did  not  belittle 
the  knowledge  of  means  to  end  that  empirical  medi- 
cine had  established,  but  sought  to  add  thereto  eluci- 
dation and  explanation.  His  sincere  willingness  to 
entertain  and  accept  demonstration  of  mistake  or 
error  was  parallel  with  his  eagerness  and  desire  to 
guide  and  instruct  and  guard  against  error  wherever 
and  whenever  encountered,  and  the  measure  of  his 
true  greatness. 

To  Professor  Wood  belongs  the  distinguished 
honor  of  having  been  a  pioneer  in  establishing  the 
epoch  of  rational  medicine.  The  courage  of  con- 
viction that  found  him  alone  championing  rational 
medicine,  therapeusis  based  upon  knowledge  and 
logical  conclusion,  was  conditioned  upon  his  recog- 
nition of  the  defects  of  empirical  medicine.  From 
the  first  edition  of  his  epochmaking  treatise  on 
therapeutics,  published  in  1874  and  antedating  that 
of  Lauder  Brunton  by  ten  years,  of  which  fourteen 
editions  were  printed  and  served  as  a  model  for 
textbooks  on  therapeutics  in  European  countries  as 
well  as  the  United  States,  the  following  quotations 
from  the  preface  serve  to  emphasize  the  firm 
foundation  upon  which  he  stood :  "There  are  a  num- 
ber of  excellent  treatises  upon  materia  medica  and 
therapeutics,  yet  in  various  attempts  at  original  re- 
search as  well  as  in  the  ward  and  lecture  room  of 
the  hospital  I  have  keenly  felt  the  want  of  some- 
thing more.  The  old  and  tried  method  in  thera- 
peutics is  that  of  empiricism  or  if  the  term  sounds 
harsh,  of  clinical  experience.  The  best  possible  de- 
velopment of  this  plan  of  investigation  is  to  be 
found  in  a  close  and  careful  analysis  of  cases  be- 
fore and  after  the  administration  of  a  remedy,  and 
if  the  results  be  favorable  the  continued  use  of  the 
drug  in  similar  cases.  That  very  much  has  been 
thus  accomplished  it  were  folly  to  deny.  Therapeu- 
tics developed  in  this  inanner  cannot  rest  however 
upon  a  secure  fotmdation.  Looking  at  the  revolu- 
tions and  contradictions  of  the  past,  listening  to 
the  therapeutic  Babel  of  the  present,  is  it  a  wonder 
that  men  should  take  refuge  in  nihilism  and,  like 
the  lotus  eaters,  dream  that  all  alike  is  folly — that 
rest  and  quiet  and  calm  are  the  only  human  fruition  ? 
A  primary  knowledge  of  the  end  to  be  accom- 
plished, and  a  secondary  acquaintance  with  the  in- 
struments are  a  necessitj^  for  human  effort  and  until 
the  sway  of  this  law  is  acknowledged  by  physicians, 
medicine  can  never  rise  from  the  position  of  an 
empirical  art  to  the  dignity  of  applied  science.  The 
work  of  the  therapeutist  is  with  the  second  portion 
of  the  law.  Evidently,  it  is  his  special  province  to 
find  out  what  are  the  means  at  his  command,  what 
the  individual  drugs  in  use  do  when  put  into  a 
human  systetn."  Thus  did  this  champion  and 
pioneer  of  rational  medicine  enter  the  arena  of  con- 
troversy and  withstand  the  attacks  of  relatively 
ignorant  and  emotional  antagonists  who  sought  by 
all  means  available,  social,  financial  and  political,  to 


BEATES:  HORATIO  C.  WOOD. 


[New  York 
Medical  Joi  rxai.. 


prevent  scientific  investigation  and  the  establishment 
of  the  era  of  rational  medicine. 

Animal  experimentation  was  a  sine  qua  iwii  which 
was  most  bitterly  opposed.  Xo  less  an  authority 
than  the  famous  Xiemeyer.  an  authority  however  in 
another  sphere,  asserted  that  experiments  made  with 
medicaments  upon  lower  animals  or  upon  healthy 
human  beings  have  as  yet  been  of  no  direct  service 
to  our  means  of  treating  disease,  and  that  a  continu- 
ance of  such  experiments  gives  no  prospect  of  such 
service.  The  antagonists  asserted  that  medicines 
did  not  affect  lower  animals  as  they  did  human 
beings.  Apparently  the  contention  was  well  taken, 
but  Dr.  Wood  demonstrated  that  while  apparently 
this  was  true,  in  reality  it  was  erroneous  and  a 
misinterpretation.  He  proved  that  while  it  required 
as  much  morphine  to  kill  a  pigeon  of  a  pound  weight 
as  to  destroy  a  man,  it  was  not  a  different  action 
but  on  the  contrary  an  identical  one,  the  seemingly 
different  eft'ects  being  dependent  upon  varied  de- 
grees of  susceptibility,  and  that  the  modus  operandi 
was  identical.  This  physiological  law  or  truth  Dr. 
Wood  further  demonstrated  by  a  study  of  atropine. 
An  animal  which  may  be  exceedingly  sensitive  to 
the  spinal  action  of  atropine  in  contradistinction  to 
that  of  its  eft'ects  upon  the  conducting  fibres,  the 
nerve  trunks,  will  result  in  convulsion  on  the  one 
hand  and  paralysis  on  the  other.  This  law  makes 
understandable  wh\-  so  many  drugs  seemingly  exert 
an  antagonistic  action.  Dr.  Wood,  by  conclusively 
demonstrating  that  degree  and  quality  are  two  sep- 
arate and  distinct  things  and  should  never  be  con- 
founded, successfully  combatted  the  efforts  of  ig- 
norance and  emotionalism  to  make  it  a  crime  to 
pursue  scientific  research.  \\  hat  may  properly 
be  designated  the  opus  major  of  Wood,  the  achieve- 
ment of  having  instituted  an  epoch  in  medicine 
characterized  by  the  relinquishment  of  the  empirical 
and  the  adoption  of  the  rational  and  of  establishing 
an  era  conspicuous  for  achievements  in  preven- 
tive as  well  as  curative  medicine,  is  of  itself  sufifi- 
cient  to  place  his  name  side  by  side  with  those  of  the 
immortal  Hippocrates,  Galen,  Sydenham,  Hunter. 
Lister.  Laennec.  Jenner,  Pasteur,  and  Koch. 

In  1810  Majendie.  studying  the  effects  of  nux 
vomica,  recognized  the  vital  importance  of  knowing 
how  medicines  aft'ected  the  human  system,  but  to 
Horatio  C.  Wood  belongs  the  credit  of  having 
i)rought  to  the  recognition  of  the  medical  world  the 
necessity  of  adopting  rational  medicine  as  the  one 
essential  means  of  acquiring  that  skill  and  art  in  the 
prevention  and  treatment  of  disease  upon  which  hu- 
manity depends. 

Dr.  Wood  consecrated  himself  to  medicine.  In 
1869  he  made  his  famous  experiments  upon  himself 
with  American  grown  cannabis,  the  details  of  which 
appear  in  his  work  on  therapeutics.  The  following 
year  his  first  paper  on  the  Physiological  Action  of 
Drugs  was  publi<;hed  in  the  American  Journal  of  the 
Medical  Sciences.  His  studies  of  the  action  of 
veratrum  viride  led  to  its  adoption  in  practice  by 
clinicians  generally.  In  1871  Dr.  Wood's  papers 
treating  of  the  physiological  action  of  amyl  nitrite 
were  published.  Two  years  previously  Lauder 
Brunton  published  his  paper  which  set  forth  the 
value  of  amyl  nitrite  in  angina  pectoris,  but  the 


contribution  of  Dr.  Wood  was  the  first  description 
of  the  physiological  action  of  the  drug  upon  the 
nervous  system.  His  investigations  of  chloroform, 
ether  and  other  anesthetics  are  so  well  known  that 
mention  onh"  is  necessary.  These  results  were  pub- 
lished in  1890  and  the  following  year  found  him 
honored  with  being  selected  to  make  the  principal 
address  before  the  general  session  of  the  Interna- 
tional Medical  Congress  (at  Berlin).  These  studies 
have  probably  been  responsible  more  than  the  work 
of  any  other  scientist  for  the  general  adoption  of 
ether  as  an  anesthetic  by  the  entire  surgical  world. 
It  was  while  pursuing  the  studies  of  anesthetics  and 
the  treatment  of  their  toxic  effects  that  Dr.  Wood 
discovered  the  value  of  strychnine  as  a  respiratory 
stimulant  and  its  importance  in  averting  threatened 
death. 

Of  5.000  scientists  present  at  the  Berlin  Congress 
the  Duke  of  Bavaria,  a  physician,  selected  and  en- 
tertained twent\--five  who  were  noted  for  excep- 
tional achievements.  Of  these  Professor  Wood  was 
one  and  when  about  to  be  seated  the  Duke  removing 
his  crown  placed  it  upon  Dr.  Wood's  head  and  fur- 
ther honored  him  by  requesting  him  to  occupy  the 
chair  pro  tern.  Thus  Professor  Wood  was  Duke  of 
Bavaria  for  almost  an  hour. 

In  1903  Dr.  Wood  represented  the  United  States 
Government  at  the  International  Conference  held  at 
Brussels  for  the  purpose  of  unifying  the  more  im- 
portant preparations  of  the  various  Pharmacopccias. 
Early  in  its  session  this  conference  became  so  in- 
volved in  an  acrimonious  dispute  as  to  the  proper 
percentage  of  alcohol  to  be  used  in  making  tinctures 
that  the  whole  usefulness  of  the  meeting  was  seri- 
ously threatened.  Dr.  Wood,  by  his  personality  and 
well  known  advocacy  of  justice  and  right,  succeeded 
in  convincing  the  delegates  of  the  foolishness  of 
quibbling  over  minor  details  and  they  finally  adopted 
tlie  present  regulation  for  ten  per  cent,  tinctures 
and  various  other  standards  which  are  recognized  by 
the  Phannacopa~ias  of  practically  all  civilized  na- 
tions. This  busy  clinician,  investigator,  teacher  and 
author  published  his  textbook  on  Xervous  Diseases 
and  their  Diagnosis  in  1887. 

Of  240  medical  papers  each  one  of  which  was  a 
classic  and  an  addition  to  the  knowledge  of  the 
science  and  art  of  medicine,  the  treatise  on  thermic 
fever  or  sunstroke  has  especial  value.  Published  in 
1872.  it  was  accorded  the  Boylston  Prize.  What 
this  work  has  contributed  to  the  saving  of  thousands 
of  lives  annually,  is  testimony  of  one  of  thp  great 
services  this  man  of  genius  has  accorded  to  many. 
His  investigations  of  fever  culminated  in  a  work  of 
250  pages  which  was  published  by  the  Smithsonian 
Institute  in  1880.  It  is  a  monument  to  his  learning 
and  a  most  valuable  contribution  to  medical  science. 
Dr.  Wood  discovered  the  alkaloid  hyoscine  while 
studying  the  effects  of  hyoscyamine  and  in  1885 
demonstrated  its  value  for  certain  nervous  diseases. 

His  researches  in  experimental  pharmacology. 
ph}siology  and  pathology  embody  more  than  fifty 
contributions  to  the  science  and  art  of  medicine. 
Twelve  conscientiously  elaborated  subjects  of  med- 
ical jurisprudence  and  toxicology  were  contributed 
from  the  years  1873  to  1899.  As  a  clinician,  his 
studies   of   pathology,   medicine   and  therapeutics 


Septenibfr  4,  1920.] 


BEATES:  HORATIO  C.  WOOD. 


311 


comprise  139  papers  which  for  originality  and  pro- 
fundity of  learning  are  invaluable.  Thirty-six  pub- 
lished lectures  and  addresses  appeared  in  various 
journals  during  the  years  1874  to  1900  and  extended 
his  beneficial  influence  throughout  the  continent. 

Nine  magazine  articles  from  the  year  1872  to 
1879  brought  to  the  lay  mind  information  and 
knowledge  which  proved  of  great  value  in  securing 
popular  cooperation  with  efforts  instituted  by  the 
profession  for  the  betterment  of  standards  of  med- 
ical efficiency.  In  1875  there  appeared  in  Lippiw 
cott's  Magazine  an  article  contributed  by  Dr.  Wood 
entitled  Medical  Education  in  the  United  States. 
This  paper  brought  to  a  crisis  the  agitation  which 
had  been  active  for  many  years  concerning  this  mat- 
ter, which  was  and  is  of  such  vital  importance  to  the 
profession  of  medicine  as  well  as  the  greatest  and 
highest  interests  upon  which  human  welfare  is  con- 
ditioned. It  caused  radical  changes  in  the  medical 
department  of  the  University  of  Pennsylvania,  and 
indirectly  compelled  other  colleges  of  medicine  to 
reform  their  curricula.  It  advocated  State  Board 
examinations  and  was  a  powerful  influence  for  the 
establishment  of  the  legal  supervision  of  the  qualifi- 
cations and  rights  to  practice  the  healing  art. 

In  1889  Yale  University  conferred  upon  Pro- 
fessor Wood  the  degree  of  LL.D.  The  occasion 
was  made  an  opportimity  by  Dr.  Wood  to  use  his 
influence  in  promoting  and  intensifying  interest  in 
higher  medical  education.  The  title  of  his  address, 
The  Medical  Profession,  the  Medical  Sects,  the 
Law,  emphasized  the  necessity  of  demanding  for 
the  doctorate  men  of  proper  preliminary  education 
and  the  administration  of  an  ample  curriculum.  The 
too  commonly  encountered  unfitness  of  clinicians 
upon  whom  colleges  had  conferred  the  medical  de- 
gree and  the  fearful  consequences  he  emphasized  by 
the  astounding  statement  that  the  horrible  disasters 
of  the  Johnstown  flood  were  insignificant  when 
compared  with  those  resulting  from  the  ill  pre- 
pared and  unqualified  practitioner.  So  strongly 
was  Dr.  Wood  convinced  of  this  seriously  defective 
but  then  prevalent  system  of  medical  education  that 
the  comparison  was  unhesitatingly  presented  to  the 
interested  audience  with  that  vehemence  which  al- 
ways characterized  his  advocacy  of  higher  ideals. 

It  is  the  habit  of  action  that  individualizes  man 
and  imparts  special  qualities  to  his  character.  That 
"nature  never  rhymes  her  children  nor  makes  two 
men  alike"  is  a  fact  that  explains  why  men  of  genius 
constitute  a  centre  from  which  emanate  influences 
for  either  good  or  evil  which  powerfully  modify  the 
lives  of  all  within  their  range.  That  Dr.  Wood  was 
keenly  alive  to  this  great  truth  is  made  manifest  by 
his  definition  of  character:  "Character  is  the  estab- 
lished equilibrium  existing  between  the  emotional, 
the  intellectual  and  the  volitional."  To  establish 
and  possess  that  equilibriimi  is  an  achievement 
which  few  attain.  It  taxes  to  the  utmost  the  noblest 
and  best  qualities  with  which  a  man  is  endowed, 
and  that  Dr.  Wood  was  ever  alert  to  so  do  was 
evidenced  by  his  every  action.  Once  while  in  con- 
versation he  suddenly  stooped  down  and  caught  a 
large  roach  that  was  crossing  the  floor  and,  holding 
it  in  his  hand,  fondled  it.  Being  asked  why,  his 
reply  was  that  to  master  a  foundationless  dislike  of 


anything  harmless  was  invaluable  and  when  it 
caused  one  to  overcome  empty  prejudices  it  con- 
tributed to  the  usefulness  of  being  and  did  much 
to  give  force  to  one's  influence  for  the  betterment 
of  fellow  man. 

Dr.  Wood  was  profoimdly  conscious  of  the  value 
of  time,  and  as  a  superficial  glance  into  his  active 
life  shows,  every  moment  was  advantageously  occu- 
pied. As  an  example  of  untiring  and  continual 
work  he  stands  preeminent,  and  the  fundamental 
principles  imderlying  his  achievements  are  well 
shown  by  the  subject  of  his  inaugural  address  be- 
fore the  trustees,  faculty  and  student  body  of  the 
University  of  Pennsylvania  when  as  professor  of 
materia  medica  and  therapeutics  his  wonderful 
career  in  that  capacity  began.  He  urged  upon  every 
one  that  a  definite  object  in  life  is  the  goal  for 
which  to  strive,  and  that  substantial  progress  is  con- 
ditioned upon  a  thorough  mastery  of  each  involved 
factor.  In  that  manner  by  which  he  had  the  happy 
faculty  of  impressing  great  truths  upon  the  minds 
of  his  pupils,  he  drove  home  these  principles  by 
quoting  from  Mother  Goose,  how  "leg  over  leg  the 
dog  got  to  Dover,"  and  all  who  were  privileged  to 
hear  him  proclaim  that  the  dream  of  his  life  was 
to  become  a  professor  and  that  by  a  conscientious 
mastery  of  minute  and  upbuilding  details  the  goal 
was  reached,  were  doubtless  stimulated  to  emulate 
the  great  teacher  and  strive  to  do  their  best. 

As  Emerson  so  impressively  states,  character  is 
the  moral  order  seen  through  the  mediiun  of  an  indi- 
vidual nature.  An  individual  is  an  enclosure.  Time 
and  space,  liberty  and  necessity,  truth  and  thought 
are  left  at  large  no  longer.  All  things  exist  in  the 
man  tinged  with  the  manners  of  his  soul.  With 
what  quality  is  in  him  he  infuses  all  nature  that  he 
can  reach,  nor  does  he  ten  to  lose  himself  in  vast- 
ness.  He  animates  all  he  can,  and  he  sees  only  what 
he  animates.  He  encloses  the  world  as  the  patriot 
does  his  country,  as  a  natural  basis  for  his  character 
and  a  theatre  for  action.  A  healthy  soul  stands  with 
the  just  and  the  true  as  a  magnet  arranges  itself 
with  the  pole,  so  that  he  stands  to  all  beholders  like 
a  transparent  object  between  them  and  the  sim,  and 
who  journeys  toward  the  sun  journeys  toward  that 
person.  He  is  thus  the  medium  of  the  highest  in- 
fluence to  all  who  are  not  on  the  same  level.  Thus 
men  of  character  are  the  conscience  of  the  society 
to  which  they  belong.  To  the  honor  and  memory 
of  the  first  president  of  the  American  Therapeutic 
Society  may  be  ascribed  the  consummation  of  a  life 
conspictious  for  moral,  intellectual  and  physical  ex- 
cellence, the  influence  of  which  for  betterment  will 
continue  on  and  on.  His  example  will  ever  serve 
the  thousands  whom  he  influenced  as  a  guide  and 
stimulus  for  right  living  and  constitute  a  power  for 
good  in  the  uplift  of  humanity  as  enduring  as  time. 


Analysis  of  Blood  of  Insane  Patients. — Paul  G. 

W'eston  {Archives  of  Neurology  and  Psycliiatry, 
February,  1920)  states  that  the  blood  of  epileptic, 
dementia  praecox  and  manic  depressive  patients 
shows  no  deviation  from  the  normal  content  of  total 
nitrogen,  nonprotein  nitrogen,  uric  acid,  urea,  creat- 
inin,  creatin,  glucose,  chlorine  or  calcium. 


312 


GOLDSTEIN:   GROUP  DIAGXOSJS. 


[Nkw  York 
Medical  Journal. 


EVOLUTION     OF     MODERN  MEDICINE 
LEADING  TO  GROUP  DIAGNOSIS. 
By  Hyman  Goldstein,  M.  D., 
New  York, 

Assistant   Medical    Director   and    Pediatrist,    New    York  Diagnostic 
Clinics;  Visiting  Physician,  Home  of  the  Sons  and  Daughters 
of    Israel;    Assistant    Physician,    Pediatric  Clinic, 
Lenox  Hill  Hospital,  O.  P.  D. 

In  reviewing  the  evolution  of  modern  medicine 
three  periods  are  noted : 

1.  Ancient:  a,  Prehistoric  medicine  before 
Hippocrates ;  b,  classical  or  Greek  and  Roman 
medicine,  460  B.  C.  to  476  A.  D. 

2.  Medieval:  a,  476  A.  D.  to  Paracelsus,  1493; 
b,  philosophical  medicine,  1493  to  Pasteur,  1822. 

3.  Modern  or  scientific  medicine,  1822  to  the 
present. 

The  earliest  historical  fact  in  the  heal- 
ing art  is  that  it  was  in  the  hands  of 
the  priests  attending  in  the  temples  of  certain  dei- 
ties. The  earhest  known  physician  Hved  in  the 
third  Egyptian  dynasty  about  4500  B.  C.  He  had  a 
temple  erected  in  his  honor  on  the  Island  of  Philje 
and  was  worshipped  at  Memphis.  Engravings  de- 
picting surgical  operations,  dated  about  2500  B.  C., 
have  been  found,  and  also  a  vase  of  an  Egyptian 
Queen  of  the  eleventh  dynasty  containing  dried 
drugs.  In  the  edicts  of  Hammurabi,  2500  B.  C., 
there  are  regulations  for  medical  practice,  rewards 
for  success  and  punishment  for  failure.  The  first 
known  surgical  instruments  were  copper  knives 
found  in  a  tomb  near  Thebes,  dating  from  abour 
1500  B.C.  It  is  interesting  to  note  how  medicine 
was  practised  then  in  the  different  localities. 

ANCIENT  MEDICINE. 

Egyptian  Medicine. — The  Egyptian  physicians 
appear  to  have  been  specialists.  According  to 
Homer,  they  were  particularly  skillful  in  com- 
pounding drugs.  They  were  familiar  with  the  use 
of  castor  oil,  opium,  colchicum,  gentian,  squill  and 
other  drugs,  which  they  usually  compounded  with 
excreta,  blood,  etc.  The  physicians  were  divided 
into  three  classes,  as  follows : 

1.  The  lower  class  or  military  physicians. 

2.  The  next  upper  class  were  the  Pastophora, 
who  studied  the  last  six  books  (Hermatic)  dealing 
with  anatomy,  pathology,  pharmacy,  ophthalmology 
and  gynecology. 

3.  The  highest  class  of  physicians  were  the  sages 
or  soothsayers,  who  acquired  their  learning  from 
the  thirty-six  Hermatic  books  of  Thoth. 

Models  in  gold  or  silver  of  the  diseased  parts 
(anathemata)  were  given  by  sufferers  to  priests 
who  hung  them  before  shrines,  and  later  sold  them 
to  other  invalids.  Medicine  as  practised  those  days 
was  largely  sacerdotal. 

Babylonian  Medicine.  —  The  people  of  Babylon 
were  their  own  physicians,  bringing  all  who  were 
sick  to  the  market  place,  where  every  passerby 
could  stop  and  express  his  opinion,  diagnose,  and 
treat  the  case.  Later  on  came  the  physician  priest. 
Nearly  every  disease  was  attributed  to  the  liver, 
and  medicines  were  given  internally  to  dispossess 
demons. 

Jewish  Medicine. — The  sources  of  this  knowledge 
are  the  Bible  and  Talmud.    The  Jews  excelled 


in  anatomy  and  hygiene.  They  advocated  the  earli- 
est operation  of  circumcision,  and  also  described 
bubonic  plague  and  syphilis.  Medical  education 
among  the  ancient  Hebrews  was  very  progressive. 

Medicine  of  the  Hindus. — This  is  a  history  of 
elaborate  error.  The  Hindus,  however,  excelled  in 
surgery,  their  cataract  operation  being  used  today. 
Susruta  in  the  fifth  century  attributed  the  cause 
of  malaria  to  the  mosquito. 

Chinese  Medicine. — Medicine  in  China  is  the  es- 
sence of  conservatism.  It  has  been  practically  sta- 
tionary for  thousands  of  years,  and  is  now  about 
on  the  level  of  European  medicine  in  the  thirteenth 
century.  The  Chinese  still  believe  that  the  larynx 
opens  up  into  the  heart,  the  spinal  cord  into  the 
testicles,  and  that  the  spleen  and  heart  are  organs 
of  reason. 

Japanese  Medicine. — In  medicine  as  in  other 
sciences  Japan  has  shown  a  remarkable  capacity 
for  assimilating  European  knowledge.  Before  96 
B.  C.  all  her  medical  science  was  superstition  and 
mythology.  From  that  time  to  700  A.  D.  it  was 
that  of  the  Chinese,  when  she  began  gradually  to 
absorb  outside  ideas  and  to  keep  pace  with  Euro- 
pean medicine. 

Ancient  Greek  Medicine.  —  Medicine  of  ancient 
Greece  is  supposed  to  have  originated  with  ^scu- 
lapius,  the  god  of  medicine  among  the  Greeks,  sub- 
sequently adopted  by  the  Romans  and  usually  said 
to  have  been  a  son  of  Apollo.  He  was  worshipped 
in  particular  at  Epidaurcis  in  Peloponnesus,  where 
a  temple  with  a  grove  was  dedicated  to  him.  The 
sick  visiting  his  temple  had  to  spend  one  or  more 
nights  in  the  sanctuary,  after  which  remedies  to 
be  used  were  revealed  in  a  dream.  Those  who 
were  cured  offered  a  sacrifice  to  ^sculapius.  There 
were  two  sets  of  physicians  of  the  temple,  i.  e., 
those  who  were  priests  of  ^Hsculapius  and 
^-Esclepiadse,  who  were  physicians  but  not  priests 
and  who  learned  medicine  from  their  fathers  or 
foster  fathers. 

Pythagoras  (580-489  B.  C.)  founded  the  school 
of  philosophers  in  Crotona,  where  he  was  driven 
from  Samos  by  the  tyranny  of  Polycrates.  He  was 
the  first  to  suspect  the  functions  of  the  brain,  and 
devised  a  system  of  numbers  in  diagnosing  dis- 
eases, namely,  unity  as  the  symbol  of  God  and  per- 
fection, and  twelve  for  the  universe.  This  he  ap- 
plied to  abnormal  conditions  for  comparison.  Then 
came  Plato  and  Aristotle,  who  taught  four  princi- 
ples or  qualities — heat,  dry,  moist,  and  cold,  and 
formulated  them  as  follows :  Heat  plus  dry  equals 
fire;  cold  plus  dry  equals  earth;  heat  plus  moist 
equals  air;  cold  plus  moist  equals  water.  From 
these  arose  the  humoral  pathology  of  Galen,  the 
basis  of  which  was  that  the  body  was  made  up  of 
four  humors :  blood,  phlegm,  yellow  bile  and  black 
bile,  i.  e.,  heat  and  moist  equals  blood;  cold  and 
moist  equals  phlegm ;  heat  and  dry  equals  yellow 
bile ;  cold  and  dry  equals  black  bile. 

THE  CLASSICAL  PERIOD.  • 

The  classical  period  began  with  Hippocrates,  460 
B.  C,  and  lasted  to  the  fall  of  the  Western  Em- 
pire in  476  A.  D.  Hippocrates  was  born  on  the 
Island  of  Cos.    He  was  one  of  the  family  of  the 


September  4,  1920.] 


GOLDSTEIN: 


GROUP  DIAGNOSIS. 


313 


^sclepiadse  and  the  contemporary  of  Socrates  and 
Plato.  He  was  educated  by  his  father  Heroclides 
and  by  Hiradicus.  He  was  the  real  father  of  medi- 
cine. His  methods  were  similar  to  those  of  the 
modern  practitioner,  and  his  description  of  diseases 
is  still  of  value.  He  was  the  first  physician  to 
commit  his  teachings  to  writing,  and  therefore  was 
the  father  of  medical  literature.  His  great  achieve- 
ments were  the  writing  of  the  Hippocratic  oath  and 
the  description,  known  as  the  Hippocratic  facies,  of 
one  approaching  death.  He  wrote  on  prognosis,  epi- 
demics, diet  in  acute  disease,  wounds  of  the  head,  air, 
water  and  place.  He  also  wrote  medical  aphorisms 
and  described  tuberculosis,  puerperal  convulsions, 
mumps,  and  epilepsy.  He  observed  the  pulse,  tem- 
perature, respiration,  facies,  sputum,  pain,  and 
movements  when  predicting  the  outcome  of  a  case. 
His  great  merit  lay  in  the  fact  that  he  believed 
in  giving  nature  her  chance,  and  dispensed  with 
drugs  as  far  as  possible.  He  relied  chiefly  on  fresh 
air,  good  diet,  purgation,  tisanes  of  barley,  wine, 
massage,  and  hydrotherapy.  His  clinical  histories 
were  the  only  ones  for  1700  years.  His  other  great 
a<^hievements  were :  First,  the  separation  of  medi- 
cine from  theurgy  and  philosophy ;  second,  the  mak- 
ing of  a  connected  and  symmetrical  science  from 
a  mass  of  disconnected  teachings ;  third,  the  ex- 
ercise of  a  beneficial,  moral  influence  upon  the  prac- 
titioner of  his  time.  After  Hippocrates  there  were 
no  great  medical  teachers  until  Aristotle,  whose 
contributions  to  medicine  were  studies  of  compara- 
tive anatomy,  embryology,  and  formal  logic.  He 
named  the  aorta  and  probably  had  an  accurate  idea 
of  the  function  of  the  blood.  The  empirical  school 
of  medicine  flourishing  then  rejected  all  etiology 
and  anatomy  and  laid  weight  on  the  empirical  tri- 
pod: I,  History  of  the  particular  case;  2,  its  anal- 
ogy to  similar  cases,  and  3,  its  accidental  surround- 
ings. 

Roman  Medicine. — Before  Galen,  Roman  medi- 
cine was  a  riot  of  theories.  Thus,  Asclepiades  of 
Bithyma,  124  B.  C,  believed  in  a  relaxed  or  con- 
stricted state  of  the  body,  or  solidism,  as  a  cause 
of  disease.  Celsus  wrote  on  malarial  fever,  gout, 
and  insanity.  Diascordes  is  said  to  have  originated 
the  materia  medica  and  Arctacus  ranked  next  to 
Hippocrates  as  a  clinician  and  writer.  His  accounts 
of  pneumonia,  diabetes,  lockjaw,  elephantiasis,  and 
diphtheria  are  classical.  Galen  (131-201)  was  one 
of  the  greatest  physicians  in  ancient  medicine.  He 
believed  that  disease  was  abnormal  and  that  health 
might  be  conserved  by  the  upbuilding  of  the  body. 
He  believed  in  the  four  humors  mentioned  above, 
and  was  a  great  user  of  drugs.  He  was  an  anato- 
mist and  an  experimental  physiologist,  and  de- 
scribed the  infectious  character  of  tuberculosis, 
treating  it  with  fresh  air,  change  of  climate,  and 
good  diet.  He  also  described  and  recognized  the 
distinction  between  pleurisy  and  pneumonia,  and 
described  aneurysm.  But  he  also  believed  in  the 
efficiency  of  amulets,  the  doctrine  of  vitalism,  i.  e., 
that  the  blood  received  natural  spirits  from  the 
liver,  vital  spirits  from  the  heart,  animal  spirits 
from  the  brain,  and  that  the  blood  poured  from 
the  right  heart  into  the  left  through  invisible  pores : 
that  pus  served  a  good  purpose  in  wounds.   He  was 


the  originator  of  the  famous  anodyne  necklace 
which  was  so  long  used  in  England.  These  er- 
rors were  hardly  questioned  for  about  1500  years. 
He  was  also  a  voluminous  writer  on  medical  and 
philosophical  subjects ;  very  interesting  were  his 
writings  on  Anatomical  Administrations  and 
the  Use  of  the  Parts  of  the  Human  Body. 
He  was  also  a  practical  dissector  of  lower  animals. 
Quackery  was  rampant  in  Rome  because  the  Roman 
citizens  were  not  encouraged  to  study  medicine. 
Many  slaves  became  doctors.  The  Servi  Medici 
were  doctors  who  were  prisoners  but  had  to  serve 
in  their  professional  capacity. 

MEDIEVAL  MEDICINE. 

There  was  but  little  progress  made  in  medicine 
during  the  middle  ages,  as  Galen  seemed  to  have 
said  the  last  words  on  the  subject,  and  most  of 
the  writers  compiled  from  his  works.  The  Byzan- 
tine Empire  produced  four  medical  writers,  Ari- 
basins  (326-403),  who  wrote  an  encyclopedia  of 
over  seventy  volumes;  ^tius  of  Aniida  (sixth 
century),  wrote  well  of  disease  of  the  eye,  nose, 
mouth,  and  teeth;  Alexander  of  Tralles  (526-605), 
wrote  on  worms  and  vermifuges,  and  Paul  yEgin- 
eta  wrote  an  epitome  of  medicine  in  seven  books. 

Arabian  Medicine. — Rhazes  (860-932),  a  physi- 
cian of  the  Eastern  Caliphate,  gave  the  first  au- 
thentic account  of  smallpox  and  measles.  Avicenna 
(980-1037),  wrote  the  Canon,  a  system  of  medicine 
in  which  theorizing  took  the  place  of  experimenting. 
The  most  renowned  physicians  of  the  Western  Ca- 
liphate were  Avenzaar,  who  described  the  itch  mite 
and  was  the  first  parasitologist,  and  Moses  ben 
Maimon,  who  wrote  a  book  on  hygiene.  They  de- 
scribed the  heart  as  the  prince  of  the  body;  the 
lungs  as  the  fan  of  the  heart ;  liver  as  its  guard 
and  habitat  of  the  soul ;  pit  of  the  stomach  as  the 
seat  of  pleasure ;  and  gallbladder  the  seat  of  cour- 
age. Their  hospitals  were  excellent.  The  Alman- 
sur  Hospital  at  Cairo  perhaps  surpassed  many 
present  day  institutions  in  its  humanitarian 
practices. 

Jewish  Medicine. — At  this  time  Jewish  medicine 
was  just  like  Arabian.  The  ancient  Hebrews  were 
banished  in  1412  from  the  Western  Caliphate,  and 
were  not  allowed  to  study  medicine  at  European 
universities  until  the  time  of  the  French  revolu- 
tion. In  spite  of  that,  much  of  the  progress  from 
hypothetical  to  scientific  medicine  was  due  to  this 
race. 

The  famous  medical  school  at  Salerno  arose 
from  a  little  health  resort.  The  school  lasted  sev- 
eral centuries,  after  Robert,  son  of  William  the 
Conqueror,  was  treated  successfully  for  a  wound  in 
the  head,  in  iioi,  and  was  abolished  by  Napoleon 
in  181 1.  The  ceremonies  used  for  conferring  medi- 
cal degrees  at  Salerno  are  copied  even  today.  The 
degree  of  doctor  of  medicine  was  conferred  upon 
the  graduates  of  Salerno  by  Gilles  de  Corbeil  in 
the  twelfth  century. 

Other  great  schools  were  at  Palermo,  Naples  and 
Montpelier.  Toward  the  close  of  the  medieval 
period  medical  science  began  to  free  itself  from 
the  doctrines  of  Galen,  and  received  the  benefit  of 
some  independent  thinking.  The  leader  of  the  in- 
tellectual   revolution   was   Henri   de  Mondeville 


314 


GOLDSTEIN:  GROUP  DIAGNOSIS. 


[New  York 
Medical  Journal. 


(1260-1320),  who  advocated  clean  surgery,  and  in  a 
measure  was  the  first  asepsist.  In  1140  Roger  of 
Sicily  formulated  some  admirable  hygienic  regula- 
tions. In  the  middle  of  the  fourteenth  century 
a  series  of  epidemics,  such  as  leprosy,  St.  Anthony's 
fire,  scurvy,  influenza,  and  bubonic  plague,  ravaged 
Europe.  It  is  estimated  that  about  one  quarter  of 
the  earth's  inhabitants  or  over  60,000,000  people 
perished  in  a  period  of  two  years.  Syphilis  ap- 
peared in  Europe  in  1495  siege  of  Naples. 

PHILOSOPHICAL  MEDICINE. 

Superstition  still  reigned  during  this  period,  and 
what  is  known  as  signatures  was  practised,  i.  e., 
using  drugs  that  have  a  resemblance  to  a  disease 
to  treat  it;  for  instance,  yellow  plants  for  jaun- 
dice; red  ones  for  anemia;  trefoil  for  heart  dis- 
ease ;  thistle  for  a  stitch  in  the  side ;  walnuts  for 
diseases  of  the  head,  etc.  Paracelsus  (1493-1541), 
whose  real  name  was  Van  Hohenheim,  was  the 
earliest  prominent  physician  of  this  period.  He 
boldly  attacked  Galen,  Avicenna  and  others, 
publicly  burned  their  writings  and  prepared  the  way 
for  modern  medicine.  He  was  the  only  asepsist 
between  Mondeville  and  Lister.  He  wrote  also  on 
occupational  diseases,  cretinism  and  goitre,  and  lec- 
tured in  his  native  tongue,  a  startling  innovation 
not  repeated  for  over  three  hundred  years.  Thomas 
Linacre  (1460- 1524)  established  the  medical  de- 
partment of  the  universities  of  Oxford  and  Cam- 
bridge. Due  to  his  influence  Henry  VHI  made  it 
obligatory  for  candidates  to  pass  examinations  in 
medicine  to  secure  a  degree  from  one  of  the  uni- 
versities. Andreas  Vesalius  (1514-1564)  was  the 
first  great  anatomist,  and  published  Dc  Fabrica 
Humana  Corporis^  the  first  anatomy  worth  its  name. 
He  ridiculed  Galen's  description  of  the  heart,  taught 
artificial  respiration,  and  held  that  the  brains  of 
lower  animals  functionated  the  same  as  man's.  Two 
of  his  pupils  became  famous:  Fallopius  (1523- 
1562),  who  named  the  Fallopian  tube,  and  Eustach- 
ius  (1524-1603),  who  named  the  Eustachian  canal. 
Vesalius  through  anatomical  drawings  hinted  at  the 
circulation  of  the  blood,  and  Servetus  (1509-1553) 
also  suspected  it. 

During  the  sixteenth  century  much  progress  was 
made  in  medicine.  Andreas  Cesalpino  (1524-1603), 
an  Italian,  formulated  a  theory  closely  approximat- 
ing the  true  circulation  of  the  blood,  later  proved 
by  Harvey.  The  famous  Bedlam  Asylum  was 
started  in  1547.  Leprosy,  cholera,  and  sweating 
sickness  practically  disappeared  from  Europe  by 
the  middle  of  this  century,  syphilis  and  bubonic 
plague  remaining. 

The  greatest  physician  of  the  seventeenth  century 
was  Harvey  (i 578-1657),  who  discovered  the  true 
circulation  of  the  blood.  His  other  great  contribu- 
tion to  medicine  was  his  theory  of  generation  that 
overthrew  the  ancient  assumption  that  life  was  de- 
rived from  a  sort  of  putrefaction.  Although  he 
stated  that  the  heart  was  a  muscular  force  pump, 
he  did  not  know  its  source  of  power,  and  attributed 
it  to  innate  heat,  celestial  in  nature  and  identical 
with  the  essence  of  stars.  Later,  Malpighi  (1628- 
1694),  with  the  aid  of  the  microscope,  discovered 
how  the  terminations  of  the  arterial  and  venous 
blood  vessels  empty  into  each  other,  and  he  supplied 


the  last  link  to  Harvey's  chain.  Thomas  Syden- 
ham (1624-1689)  and  John  Garut,  who  pubUshed 
the  first  book  on  vital  statistics,  were  great  physi- 
cians of  that  day.  There  was  still  much  supersti- 
tion in  medicine  and  materia  medica,  which  had 
reference  to  worms,  dried  vipers,  fox's  lungs, 
powder  of  jewels,  moss  from  the  skull  of  a  mur- 
dered man,  crab's  eyes,  oil  of  bricks,  etc. 
Charles  II  gave  $50,000  for  the  formula  of  God- 
flard  drops  recommended  by  Sydenham,  made  from 
raw  silk. 

The  eighteenth  century  was  filled  with  systems 
and  theories.  George  E.  Stahl  (1660-1734)  wrote 
on  the  liver  and  tear  duct  and  on  a  theory  of  aii 
imaginary  component  of  the  body  he  called  phlogis- 
ton, which  he  considered  necessary  to  all  vital  proc- 
esses. Herman  Boerhoave  (1668-1738),  the  great- 
est physician  of  the  eighteenth  century,  was  the 
first  to  prove  that  smallpox  was  contagious  and 
that  pleurisy  was  confined  to  the  pleura.  Morgagni. 
(1682-1771)  when  seventy-nine  years  old  pub- 
lished a  work  which  proved  to  be  the  basis  of  mod- 
ern pathology.  Sir  John  Floyer  ( 1649-1734)  timed 
the  pulse  rate  with  a  one  minute  watch.  Dr.  G. 
Martini  (1702-1741),  a  Scotchman,  discovered  the 
clinical  thermometer.  Dr.  Van  Haller  was  noted 
for  his  surgical  treatment  of  aneurysm.  Dr. 
Auenbrugger  (1722-1809)  introduced  percussion  of 
the  chest  as  a  means  of  diagnosis.  Toward  the  end 
of  the  eighteenth  century  came  Dr.  Jenner's 
great  discovery  of  vaccination,  a  preventive  against 
smallpox.  The  hospitals  of  the  eighteenth  century 
were  kept  so  filthy  that  operation  practically  meant 
death.  There  was  really  no  clean  surgery  until 
Lister's  time,  and  no  humane  treatment  for  the  in- 
sane until  William  Turke,  in  1793,  started  the 
Yorke  treatment.  The  charlatans  of  the  eighteenth 
century  were  numerous  and  picturesque.  The  most 
notorious  were  Sir  William  Reed,  known  as  Spot 
W^ard,  and  Joanna  Stevens. 

About  1800  the  Royal  College  of  Surgeons  was 
incorporated,  connected  with  some  of  the  hospitals 
in  London,  as  Guy's,  St.  Bartholomew,  St.  Thomas, 
and  St.  George  at  that  time  were  medical  schools, 
in  which  the  teachers  were  the  attending  physicians 
and  surgeons  of  the  respective  hospitals.  Scotland 
antedates  England  in  the  matter  of  medical  educa- 
tion. The  medical  school  of  St.  Andrews  was 
founded  in  141 1,  and  that  of  the  University  of 
Edinburgh  in  1582. 

The  first  half  of  the  nineteenth  century  was 
largely  a  continuation  of  the  theorizing  of  the  eigh- 
teenth century;  the  chief  progress  was  made  by  the 
French  physician  Francois  Victor  Broussais  (1772- 
1838),  whose  theory  was  that  disease  was  caused 
by  too  much  heat  concentration  on  one  particular 
organ.  He  bled  his  patients  profusely,  so  that 
France  in  1883  imported  over  forty-three  million 
leeches.  Soon  after  Lewis  proved  through  statis- 
tics that  leeches  were  harmful,  and  this  practice 
was  stopped.  He  was  the  founder  of  medical  sta- 
tistics. Parkinson  (1755-1824)  reported  the  first 
case  of  appendicitis  in  England,  and  gave  his  name 
to  paralysis  agitans.  Laennec  (1781-1826)  invented 
the  stethoscope  and  in  1823  wrote  a  textbook  on 
thoracic  diseases.   Pinel  (1745-1826)  risked  his  life 


September  -4.  1920.] 


GOLDSTEIN:  GROUP  DIAGNOSIS. 


315 


for  the  insane,  who  up  to  this  time  were  treated 
worse  than  criminals.  Pelletier  and  Conventon  dis- 
covered quinine  in  1820,  and  thereby  malaria  was 
cured.  The  greatest  English  clinician  of  that  day 
was  Dr.  Richard  Bright  (1789-1858),  who  distin- 
guished between  the  various  forms  of  kidney  lesions 
and  classified  kidney  diseases,  a  classification  which 
is  used  even  today  by  such  great  clinicians  and 
surgeons  as  the  Mayos.  Kidney  disease  is  com- 
monly known  as  Bright's  disease  ever  since  his 
writings  on  this  subject.  Thomas  Addison  (1793- 
1860)  wrote  a  monograph  on  the  local  and  con- 
stitutional effects  of  disease  of  the  suprarenal  cap- 
sules, and  opened  the  field  for  the  study  of  the 
ductless  glands  and  their  internal  secretions.  Sem- 
melweiss  (1818-1865)  and  Oliver  Wendell  Holme^ 
(1809-1894)  discovered  the  true  cause  of  puerperal 
fever.  S.  C.  F.  Hahnemann  (1755-1843)  founded 
a  new  cult  called  homeopathy,  on  theories  akin  ( in- 
tellecttially)  to  the  doctrine  of  signatures,  the  first 
tenet  being  that  "like  cures  like,''  a  generaliza- 
tion dating  back  to  650  B.  C.  The  second  tenet  was 
that  infinitesimal  doses  should  be  given  which  were 
supposed  when  shaken  violently  to  develop  mysteri- 
ous powers — probably  to  correct  a  defect  in  those 
days  of  overdosing  patients  with  drugs.  Hahne- 
mann claimed  divine  inspiration.  It  had  an  im- 
mense vogue  for  a  number  of  years.  Homeopathy 
of  today  has  departed  widely  from  the  original 
teachings  of  the  founder.  John  Himter,  a  British 
surgeon  and  physiologist,  in  1760  wrote  on  the 
blood,  inflammation,  and  gunshot  wounds.  His 
museum  contains  wonderful  anatomical  and  surgi- 
cal specimens  now  with  the  Royal  College  of  Sur- 
geons. William  Hunter  (1718-1783),  an  older 
brother,  wrote  an  Anatomical  Description  of  the 
Human  Gravid  Uterus  and  Its  Contents.  He  was 
an  obstetrician. 

SCIEXTIKIC  MEDICINE. 

Scientific  medicine  began  about  the  middle  of 
the  nineteenth  century.  It  was  about  this  time, 
1845,  that  Darwin  and  \\'allace  promulgated  their 
views  on  evolution.  Magendie  (  1783- 1855)  was  a 
pioneer  in  experimental  physiology ;  Schleiden 
(1804-1881)  and  Schumann  (1810-1882)  developed 
the  knowledge  of  cell  growth.  Rudolph  Virchow 
(1821-1859)  began  in  1847  the  publication  of 
Archiv  fiir  pathologisclie  Anato)nie.  now  Vir- 
chozv's  Archives.  His  first  number  took  a  stand 
against  improved  hypothesis  and  the  infallibility  of 
any  one  man.  thus  striking  the  keynote  of  modern 
medicine.  In  1858  he  published  a  book  on  cellu- 
lar patholog)'.  with  which  began  the  European  pe- 
riod of  modern  medicine.  His  fatuous  epitaph  was 
oninis  cellule  e  cellula;  that  is,  where  there  is  growth 
of  cells  there  must  have  been  cells  preceding  them. 
Henle  (1809-1885)  was  one  of  the  greatest  anato- 
mists of  all  time.  In  1840  he  published  his  ob- 
servations which  were  the  nucleus  of  the  germ  the- 
ory of  disease.  Louis  Pasteur  (1822-1895),  who 
was  originally  a  chemist,  was  the  father  of  bacteri- 
ology. The  whole  field  of  preventive  inoculations 
is  due  directly  to  him,  and  he  is  credited  with  dis- 
covering the  preventive  treatment  of  hydrophobia. 
Emil  von  Behring  in  1894  discovered  diphtheria 
antitoxin.    Asepsis  and  antisepsis  in  surgery  was 


the  epoch  making  work  of  Lister  (1827-1912),  and 
due  directly  to  Pasteur's  teachings.  Claude  Bern- 
ard (1813-1878),  the  leading  physiologist  of  the 
century,  discovered  the  glycogenic  function  of  the 
liver,  which  proved  that  the  body  could  build  up  or 
break  down  substances  itself.  Von  Baers  (1792- 
1876)  discovered  the  mammalian  ovum,  and  did  for 
embryology  what  Cuvier  did  for  anatomy — made 
it  comparative.  Von  Friedreich  in  1857  was  the 
first  to  describe  acute  myelogenous  leucemia. 
Friedlebens  in  1858  in  a  monograph,  Die  Physiol- 
ogic dcr  Thymusdruse,  described  the  thymus  gland 
perfectly.  Hubner  wrote  on  endarteritis  in 
1874.  Cannon,  Harvey,  and  Cushing  of  America, 
and  Pavlow  of  Russia  continued  along  fines  laid 
down  by  Bernard  Laveran  in  1881,  who  discovered 
the  malarial  parasite.  Robert  Koch  in  1882  discov- 
ered the  tubercle  bacillus  and  formulated  the  Koch 
postulates  to  prove  a  germ  disease.  Schaudinn  in 
1905  discovered  the  Spirochaeta  pallida;  Wasser- 
mann,  Neisser.  and  Bruck  in  1906  discovered  the 
serum  diagnostic  Wassermann  test;  Plant  in  1908 
tested  the  spinal  fluid  for  the  Wassermann  reaction. 
Ehrlich  (1854-1919)  did  an  immense  amount  of 
woric  on  metabolism,  and  promulgated  and  theo- 
rized the  side  chain  theory  of  disease.  After  a 
series  of  experiments  he  discovered,  in  1909,  sal- 
varsan  or  606  for  the  treatment  of  syphilis,  and 
later  on  neosalvarsan.  His  pupil  Abderhalden  in 
1877  studied  metabolism  and  evolved  the  biochem- 
ical test  for  pregnancy.  Swift,  Ellis,  and  Byrnes 
in  191 2  perfected  salvarsanized  serum  and  treated 
nervous  syphilis  by  injecting  salvarsan  directly  into 
the  spinal  canal.  Quincke  in  1891  described  the 
technic  of  lumbar  puncture;  and  cytodiagnosis  of 
the  cerebrospinal  fluid,  as  described  by  Ravaut,  Si- 
card,  Xageotti,  and  Widal,  in  1901.  was  classical. 
In  1903  they  described  the  albttmin  significance  of 
the  cerebrospinal  fluid.  Roux  and  MetchnikoflF  in 
1903  experimented  with  the  transmission  of  syphilis 
to  apes.  In  1904  Alzheimer  wrote  on  the  histopath- 
ology  of  brain  syphihs.  Noguchi  and  Moore  found 
spirochetes  in  brain  tissues  of  paresis  in  191 3,  and 
Lange  described  the  gold-sol  test  in  191 3. 

Anesthesia. — Crawford  W'.  Long,  of  Georgia,  in 
1842-43  used  ether  in  several  cases.  Horace  Wells, 
a  dentist  of  Connecticut,  in  1844  began  the  use  of 
laughing  gas  or  nitrous  oxide,  and  communicated 
this  to  his  friend,  W.  T.  G.  Alorton,  who  later 
experimented  with  it  and  with  the  aid  of  J.  C. 
Warren  and  H.  J.  Bigelow,  made  the  dis- 
covery known  to  the  medical  profession. 
In  1 83 1,  Guthrie,  Liebig,  and  Soubieran 
introduced  chloroform,  purified  and  named 
by  Dumas  in  1834,  and  used  by  Sir  J.  Young  Simp- 
son (1811-1870)  in  1847  in  obstetrics.  Cocaine  was 
first  isolated  by  Niemann  in  Wohler's  laboratory 
in  1858,  but  not  used  in  medicine  until  1884,  when 
Carl  Coller  called  attention  to  its  advantage  as  a 
local  anesthetic.  The  discovery  of  anesthesia  revo- 
lutionized surgery,  and  as  W^eir  Mitchell  remarked, 
it  was  the  death  of  pain.  Hypodermic  injection  for 
the  relief  of  pain  was  first  administered  and  intro- 
duced to  the  profession  by  Francis  Rynd,  of  Dub- 
lin, and  Dr.  Provaz  in  1845-1852.  The  laryngo- 
scope was  first  used  by  \'.  von  Bruns  in  1862. 


316 


GOLDSTEIN:  GROUP  DIAGNOSIS. 


[New  York 
Medical  Journal 


Poiselli  in  1828  introduced  the  first  U  tube  mer- 
curial manometer,  and  shortly  afterward  Ludwig 
devised  the  kymographion.  which  connected  directly 
to  an  open  artery,  recording  tlie  pulse  wave  on  a 
revolving  cylinder.  Dr.  ]Marey  in  1876  orig- 
inated the  first  useful  blood  pressure  apparatus  or 
sph}"gmomanometer  by  which  he  could  determine 
both  the  systolic  and  diastolic  blood  pressures  and 
the  pulse  pressure.  Riva-Rocci  in  1896  devised  the 
first  sphygmomanometer  with  cuff  arrangement  as 
used  at  the  present  time,  only  the  cuff  was  too  nar- 
row and  gave  rise  to  various  modifications  for 
greater  accuracy  and  better  results.  This  led  to 
the  discover}-  of  the  electrocardiograph,  a 
great  aid  in  the  diagnosis  of  abnormal  conditions 
of  the  heart. 

Electrotherapy  was  first  used  in  modem  medicine 
by  Duchenne.  The  x  ray  was  discovered  by  Dr. 
William  Conrad  Rontgen  in  1893.  ^lental  medi- 
cine was  in  a  chaotic  state  until  Emil  Kraepelin  in 
1856  brought  order  into  its  study.  Sigmund  Freud 
in  1895  promulgated  a  new  psychologj'  known  as 
psychoanalysis.  His  two  chief  disciples,  C.  G.  Jung 
and  Alfred  Adler,  started  schools  of  their  own. 
Alfred  Binet  and  Th.  Simon  in  1905  and  1908  de- 
vised tests  for  measuring  the  intellectual  capacities 
of  children.  Goddard,  Yerks,  Fernald,  and  Healy 
did  similar  work  in  America.  In  1856  Sir  William 
H.  Perkins  obtained  aniline  dyes  from  coal  tar 
products  and  marked  the  beginning  of  the  manu- 
facture of  phenacetin.  acetanilid,  and  similar  drugs. 

In  1910  R.  G.  Harrison  demonstrated  that  nerve 
cells  could  be  preserved  and  grown  outside  of  the 
body.  Then  Alexis  Carrel  proceeded  to  preserve 
other  tissues  outside  of  the  body,  and  even  trans- 
planted organs  and  limbs  from  man  to  man.  He 
also  did  wonderful  work  of  this  kind  during  the 
world  war,  and  where  these  astonishing  feats  will 
end  it  is  indeed  difficult  to  say.  Dr.  G.  W.  Crile 
elaborated  the  theory  of  anociassociation  or  block- 
ing of  harmful  stimuli,  and  hence  preventing  shock 
during  operations.  He  accomplishes  this  by  admin- 
istering local  and  general  anesthesia  together  with 
psychological  handling  before  operating.  Sir 
AMlliam  Osier  (1839),  Canadian  by  birth,  was  a 
good  clinician  and  teacher  whose  works  here  were 
similar  to  Strumpell's  in  Europe.  He  added  much 
to  medical  science  through  his  admirably  classified 
Practice  of  Mcdicittc.  Dr.  Abraham  Jacobi  was  a 
pioneer  in  -American  medicine,  and  well  deserves 
the  name  of  the  Xestor  of  American  pediatrics. 
Tinel  and  Mme.  Athenassio  Benisty.  of  Paris,  did 
wonderful  ners'e  repair  work  during  the  world 
war.  Carrel  and  Dakin  treated  all  kinds  of  wounds 
and  infections  siv:cessfully  with  frequent  irrigations 
of  chlorinated  lime  solution  named  after  them.  The 
paraffin  and  ambrine  treatment  of  extensive  burns 
and  surface  wounds  were  developed  also  during 
the  war  and  is  giving  good  results.  Trench  foot, 
trench  fever,  and  trench  nephritis  are  new  condi- 
tions for  diagnosis  brought  on  by  the  war. 

American  Medicine. — -The  first  American  medical 
books  were  published  in  ^lexico  City  in  I570I595- 
Dr.  J.  Morgan  and  \\"illiam  Shippen  in  1765 
founded  the  medical  department  of  the  College  of 
Philadelphia,  known  later  as  the  Cniversity  of 


Pennsylvania.  In  1767  the  medical  department  of 
King's  College  of  New  York,  now  known  as  Colum- 
bia University,  was  founded ;  the  medical  depart- 
ment of  Harvard  University  was  organized  in  1782, 
and  of  Dartmouth  in  1798.  Prior  to  the  establish- 
ment of  these  schools,  medical  instruction  was 
given  by  practitioners  to  their  private  pupils,  ex- 
cept those  who  studied  abroad  in  foreign  medical 
schools.  There  was  no  real  American  medi- 
cal literature  until  after  the  revolution,  when  Ben- 
jamin Rush  (1745-1813)  came  into  prominence. 
Five  medical  schools  were  started  in  the  United 
States  before  1800. 

With  the  rapid  expansion  of  the  population  in 
the  nineteenth  century,  it  required  a  much  larger 
number  of  physicians  than  the  schools  supplied. 
In  the  absence  of  restricted  law,  numerous  private 
schools  (medical)  were  established  for  profit  and 
gain.  A  precedent  was  fotmd  in  the  London  medi- 
cal schools,  which  were  independent  of  the  univer- 
sities. But  in  London  the  medical  school  was 
part  and  parcel  of  its  respective  hospital  and 
could  not  confer  a  degree.  The  American  medical 
school  had  no  hospital  connection  or,  in  rare  in- 
stances, an  inadequate  hospital,  and  it  obtained 
the  right  to  confer  medical  degrees,  which  for  many 
years  carried  with  it  the  right  to  practise  medicine. 
Well  up  into  the  eighties  demoralization  was  prac- 
tically complete ;  in  spite  of  that,  medicine  and  es- 
pecially surgery  made  marvelous  strides  in  Amer- 
ica in  tlie  short  time  they  have  been  practised  here. 
Much  research  work,  such  as  animal,  bacteriologi- 
cal, pathological,  and  cellular  is  being  carried  on 
and  is  constantly  adding  to  progressive  medi- 
cine new  discoveries  too  numerous  to  mention.  The 
discovery  of  anesthesia  and  most  operative  tech- 
nic in  surgery  is  distinctly  American.  Today  Amer- 
ica is  quite  as  progressive,  if  not  more  so,  in  many 
departments  of  medicine,  surgery,  and  laboratory 
work.  as  Europe.  The  world  war  has 
helped  greatly  to  bring  together  medical  ideas 
of  all  lands  and  dift'use  this  knowledge  about  evenly 
in  worldly  medical  events.  It  will  probably  be 
many  years  before  all  the  new  discoveries  will  be 
known  that  were  made  in  medicine  during  the  war. 

Medical  Education  of  JVoincn.  —  The  admission 
of  women  into  medical  schools  was  more  bitterly 
opposed  in  Europe  than  in  the  United  States.  Until 
1900  the  medical  colleges  of  Germany  were  closed 
to  women,  and  not  until  1876  did  Parliament  pass 
a  bill  admitting  women  into  the  medical  schools 
of  Great  Britain;  in  Paris,  in  1871.  Xow  they  are 
permitted  to  studv  medicine  in  Stockholm.  Upsala. 
Madrid.  Valladolid,  Barcelona,  Berne,  Zurich,  and 
Geneva.  In  Russia  the  war  department  conducts 
medical  schools  for  women  at  Petrograd  and 
^loscow.  In  the  United  States  in  1848  there  was 
the  Boston  Homeopathic  ^Medical  School  for 
Women;  in  1850,  the  Women's  College  of  Phila- 
delphia ;  in  1868,  the  Medical  College  of  the  New 
York  Infirmary ;  in  1870,  the  Free  IMedical  College 
for  Women.  \\'omen  now  are  permitted  to  study 
medicine  in  Johns  Hopkins  University,  the  Uriver- 
sity  of  Pennsylvania,  and  Cornell  University.  In 
191 T  only  two  colleges  were  exclusively  for  women. 

In  general,  within  the  past  fifty  years  great  prog- 


September  4,  1920.] 


GOLDSTEIN:   GROUP  DIAGNOSIS. 


317 


ress  has  been  made  in  medicine.  Undoubtedly  in 
the  future  preventive  medicine  will  prevail  rather 
than  curative,  and  therefore  the  subject  of  diag- 
nosis will  be  the  prominent  topic,  which  we  shall 
describe  more  fully  later. 

Practical  or  applied  hygiene  and  sanitation,  physi- 
cal culture,  health  education  of  the  laity  in  matters 
pertaining  to  sexual  hygiene,  the  regulation  of  con- 
tagious diseases  and  inoculations,  together  with  the 
rising  standard  of  medical  education  and  stricter 
laws  governing  practice,  will  improve  the  condition 
of  the  race  until  disease  will  be  rare.  Many  mal- 
adies now  obscure  will  be  found  to  be  due  to  one 
or  more  perverted  functions  of  the  ductless  glands, 
and  extracts  therefrom  will  be  used.  The  discov- 
ery of  infecting  agents  in  such  diseases  as  scarlet 
fever  is  only  a  matter  of  time.  For  the  past 
one  hundred  years  experiment  has  been  taking  the 
place  of  theorizing,  and  where  the  early  days  of 
medical  science  present  the  picture  of  a  few  Titans 
standing  out  from  a  background  of  ignorance,  the 
nineteenth  and  twentieth  centuries  show  workers 
in  many  fields,  collecting  and  collating  facts  in  biol- 
ogy, chemistry,  physics,  physiology,  endocrinology, 
pharmacology,  psychology,  accepting  nothing  as  ab- 
solute truth,  but  ever  seeking  results  which  shall  be 
truer  than  former  ones,  gradually  finding  out  the 
causes  of  disease  and  elaborating  a  system  of  pre- 
ventive medicine  which  is  the  hope  of  the  future. 
Nothing  is  taken  for  granted  in  medicine  now ;  no 
high  flown  theorist  will  be  tolerated  unless  proofs 
are  produced.  The  patient  work  of  thousands  of 
observant  clinicians  and  painstaking  laboratory  men 
is  gradually  exposing  the  light  of  science,  and  some 
day  empiricism  will  be  entirely  eliminated. 

Looking  ahead  as  to  the  possible  further  develop- 
ment of  medicine,  it  seems  to  us  that  the  future 
of  this  .science  lies  in  specialization.  Although 
specialization  in  the  strict  sense  was  not  practised 
in  ancient  times,  still  we  find  a  hint  of  it  in  the 
history  of  Egyptian  medicine.  Hippocrates  also 
gave  definite  descriptions  of  disease  and  facies,  and 
wrote,  the  Hippocratic  oath,  his  main  specialty  be- 
ing dietetics.  Diascorides  originated  the  materia 
medica,  and  .'Ertius  was  the  first  real  specialist  who 
wrote  on  diseases  of  the  eye,  nose,  mouth,  and 
teeth.  Later  on.  as  medicine  assumed  a  scientific 
aspect,  it  became  quite  impossible  for  any  one  man, 
no  matter  how  brilliant,  to  master  more  than  a 
fraction  of  the  existing  field  of  medicine ;  speciali- 
zation therefore  became  necessary.  Among  the 
theoretical  specialists  we  find  Gilles  de  Corbeil,  who 
was  the  first  to  confer  the  degree  of  doctor  of  medi- 
cine upon  graduates  of  Salerno,  in  the  twelfth 
century.  Roger,  of  Sicily,  was  the  first  hygienist ; 
Paracelsus  wrote  intelligently  on  occupational  dis- 
eases and  ductless  glands ;  Henri  de  Mondeville  ad- 
vocated clean  surgery  ;  Vesalius  wrote  on  anatomy  ; 
Fallopius  as  anatomist  and  gynecologist ;  Eustach- 
ius  as  anatomist  and  otologist ;  Linacre  as  intern- 
ist and  the  first  to  introduce  license  examinations 
to  be  permitted  to  practise  medicine ;  Harvey,  the 
physiologist;  Malpighi,  the  great  pathologist  and 
microscopist ;  John  Gaunt,  the  first  to  write  a  book 
on  vital  statistics,  in  the  seventeenth  century;  Von 
Haller,  the  great  surgeon ;  Auenbrugger,  on  per- 


cussion of  the  chest;  Sir  John  Floyer,  who  dis- 
covered the  pulse  rate;  George  Martini,  and  the 
clinical  thermometer;  Dr.  Jenner  and  vaccina- 
tion ;  Turke  on  care  and  treatment  for  the  insane ; 
and  Lister,  who  introduced  antiseptics  and  antisep- 
tic surgery.  But  the  more  practical  medicine  began 
to  agree  with  scientific  research,  the  more  speciali- 
zation became  necessary,  and  in  the  second  half 
of  the  nineteenth  century  division  of  labor  became 
an  established  factor  in  the  practice  of  medicine, 
bringing  forth  discoveries  from  the  time  of  Lister 
down  to  the  present  time. 

PRESENT  ASPECT  OF  MEDIC.VL  PR.\CTICE. 

Not  so  very  long  ago  the  family  physician  was 
numerically  the  predominating  type  of  practitioner ; 
at  the  present  time,  partly  because  of  the  growth 
of  specialization  in  medicine  and  partly  on  account 
of  the  great  mobility  and  complexity  of  our  popu- 
lation and  of  modern  life  itself,  the  family  physi- 
cian who  treats  a  particular  family  continuously 
and  is  in  close  touch  with  all  the  members  is  fast 
^disappearing.  Expenses  for  equipment,  x  ray  labo- 
ratory accessories,  etc.,  are  too  great  for  the  average 
physician,  and  health  department  and  commercial 
laboratories  are  valuable  but  limited.  This  applies 
not  only  to  equipment  but  also  to  the  physician's 
special  skill  and  training.  Even  those  physicians 
who  have  had  modern  training  in  diagnosis  on  en- 
gaging in  private  practice  often  do  not  have  the  facil- 
ities for  using  their  training  effectively  for  the  av- 
erage patient,  or  for  securing  for  their  patients 
the  services  of  specialists,  because  the  patient  can- 
not aft'ord  their  rates.  This  method  of  having  the 
patient  travel  from  doctor  to  doctor  or  from  one 
specialist  to  another  is  used  in  all  classes,  but  is 
more  prevalent  among  the  well  to  do  and  the 
wealthy.  The  system  is  necessarily  expensive  and 
is  time  consuming  to  the  patient,  as  well  as  to  the 
physician,  who  has  to  be  present  at  the  respective 
consultations  at  the  patient's  rec^uest,  and  therefore 
is  not  able  to  work  continuously.  Besides,  the  doc- 
tor and  the  patient  (separately  or  together)  get 
independent  opinions,  often  contradictory,  and  in 
consequence  the  physician  is  frequently  at  a  loss 
to  know  the  exact  diagnosis  or  how  to  treat  him. 
This  chaotic  state  of  affairs  leads  the  public  to 
seek  other  means  of  relief,  which  accounts  for  its 
falling  into  the  hands  of  charlatans,  osteopaths, 
chiropractors,  and  other  pseudomedical  cults.  The 
remedy  for  that  condition  is  naturally  evolving  in 
the  form  of  group  medicine  practice.  The  organi- 
zation of  cooperative  or  group  medicine  practice 
is  gradually  replacing  individualism  in  order  to  give 
the  maximum  of  efficiency  of  equipment  and  or- 
ganization of  skilled  specialists,  in  order  to  get 
correlated  medical  opinions  of  trained  diagnosti- 
cians and  as  near  as  possible  correct  diagnoses  of 
diseases  and  abnormal  conditions. 

A  number  of  instances  of  this  tendency  are  the 
Mayo  Clinics,  in  Rochester,  Minn.,  the  New  York 
Diagnostic  Clinics,  the  Boston  Dispensary,  and 
others  scattered  over  the  country.  These  have 
added  valuable  data  to  the  medical  literature  of  this 
century  and  are  in  reality  institutions  for  the  train- 
ing of  specialists  of  the  highest  type,  and  are  also 


318 


GOLDSTEIN:  GROUP  DIAGNOSIS. 


[New  York 
Medical  Journal. 


examples  of  practical,  self  supporting  pay  clinics, 
diagnosing,  correlating  data  and  opinions,  and  in 
some  cases  treating  cases  and  getting  results.  At 
the  time  of  the  present  writing  there  are  about  sixty 
institutions  established  in  America  with  the  group 
medicine  idea.  Yet  it  is  not  surprising  that  the 
real  teachers  of  medicine,  the  faculties  and  pro- 
fessors of  medical  colleges,  who  should  have  been' 
the  first  to  advocate  anj'  methods  that  are  pro- 
gressive, fail  to  recognize  this  need  ?  It  may  be 
expensive  to  have  the  proper  building,  complete 
diagnostic  equipment  for  every  department,  and  a 
proper  personnel  and  staff.  This  mav  require  out- 
side help  or  large  donations,  but  the  group  medi- 
cine practice  plan  can  be  established  on  a  smaller 
basis  with  full  equipment  and  trained  per- 
sonnel. Before  dwelling  on  this  further,  we  will 
define  a  pay  clinic  and  special  dispensary,  and  then 
continue  with  the  requisites  of  a  cooperative  or 
group  diagnostic  medical  clinic. 

PAY  CLINICS. 

A  pay  clinic  is  one  in  which  a  fee  is  charged 
to  patients,  this  fee  corresponding  to  the  cost  of 
the  service  rendered.  It  should  therefore  be  made 
self  supporting.  Most  of  the  dispensaries  deal  with 
specialty  diseases,  such  as  eye,  ear,  nose,  and  throat 
diseases,  pediatrics,  orthopedics,  neurological  dis- 
eases, etc.  The  large  special  dispensaries,  existing 
chiefly  in  great  cities,  have  contributed  substan- 
tially to  the  advancement  of  specialties  in  medicine, 
bringing  together  a  group  of  physicians  or  surgeons 
interested  in  a  particular  phase  of  medical  work, 
and  providing  excellent  equipment  for  the  advance- 
ment of  special  technic; 

The  essential  weakness  of  a  large  or  small  dis- 
pensary limited  to  one  specialty  consists  in  an  in- 
ability to  take  an  all  around  view  of  the  patient 
and  to  relate  special  conditions  to  general  condi- 
tions. If  the  patient  presents  himself  at  a  special 
ophthalmological  dispensary,  for  in.stance,  all  the 
general  conditions  which  may  influence  a  disease 
of  the  eye  or  which  may  be  influenced  by  eye 
disease,  must  be  referred  to  another  institution  for 
diagnosis  and  treatment.  The  general  pay  clinic 
or  group  diagnostic  clinics  will  solve  this  problem, 
in  which  all  departments  are  w'ell  represented  in  one 
building  for  diagnosis.  The  maintenance  of  high 
scientific  standards  and  a  spirit  of  public  service, 
such  as  generally  characterizes  private  medical  prac- 
tice, are  essential  in  pay  clinics. 

The  group  medicine  diagnostic  idea  —  self  sup- 
porting philanthropy — or  pay  clinics  established  as 
a  public  service  enterprise,  is  a  recent  development. 
Patients  can  be  admitted  only  when  referred  by  a 
physician,  who  requests  an  opinion  and  report  of 
the  case.  The  charge  to  the  patient  should  be  a 
flat  rate  for  the  examinations,  plus  extra  fees  for 
x  ray  plates,  special  tests,  such  as  blood  chemistry, 
complete  kidney  function,  etc.,  consistent  with  the 
circumstances  of  the  patient,  but  not  to  be  gratis. 
Free  service  has  a  tendency  to  lower  the  standard 
of  the  clinics  and  their  purposes. 

Group  medicine  practice  or  group  diagnostic  clin- 
ics should  be  so  organized  as  to  be  essentially  a 
cooperative  association  of  a  large  number  of  physi- 


cians, to  prevent  skepticism  and  distrust  by  the 
general  practitioners  of  such  progressive  ideals. 
This  will  also  greatly  broaden  the  services  of  the 
clinics. 

The  pa}-  clinic  may  be  viewed  or  appraised  from 
three  aspects:  1,  the  institution;  2,  the  doctors,  and 
3,  the  public. 

The  Institution. — There  is  a  stinnilus  to  efficient 
service  arising  out  of  the  new  psychological  rela- 
tion between  doctor  and  patient  and  between  doc- 
tor and  institution. 

The  Doctor. — His  fees  received  are  gross  and  not 
net  incomes,  considering  expenses  such  as  rent, 
equipment,  lighting,  heat,  records,  automobile,  etc.  In 
the  clinics  the  physician  is  supplied  with  assistants, 
equipment,  plant,  and  therefore  his  salary  is  a  net 
income. 

The  Public. — It  pays  less  in  the  end  and  gets 
better  and  more  accurate  service  and  results.  The 
diagnosis  from  correlated  opiniojis,  collaborated 
data  and  laboratory  findings  is  of  the  greatest  bene- 
fit to  the  public. 

Why  should  not  cooperative  pay  clinics  be  estab- 
lished by  a  group  of  physicians  or  specialists  com- 
ing together  for  cooperative  work  and  having  their 
offices  so  situated  that  joint  equipment  can  be  ar- 
ranged? The  difficulty  would  be  a  defective  cen- 
tralized administration.  This,  as  the  experience 
of  all  acquainted  with  dispensary  organization  and 
management  has  shown,  is  vital  to  the  best  coopera- 
tive work  among  physicians,  and  to  the  efficient 
management  of  the  records,  laboratory,  etc.  Where 
a  group  of  physicians  actually  established  an  organi- 
zation with  adequate  equipment  and  complete  ad- 
ministrative machinery,  the  difficulty  would  be 
overcome,  and  we  should  have  pay  clinics  like  the 
Mayo  Clinics  for  diagnostic  purposes,  or  combined 
diagnostic  and  therapeutic.  The  latter  plan  may 
interfere  with  the  practitioner,  in  that  his  patients 
may  ultimately  wander  from  his  office  into  the  clin- 
ics, whereas  in  the  former  or  group  diagnostic 
clinics,  the  patients  are  referred  back  to  the  physi- 
cian who  recommended  the  case,  with  full  data  of 
diagnosis  and  suggestions  as  to  proi)er  treatment. 
The  ])hysician  may  report  from  time  to  time  the 
])rogress  of  his  case,  for  follow  up  work  and  tabu- 
lating i-esults.  The  fee  should  be  scheduled  so  that 
those  of  small  means,  as  well  as  the  rich  and  well 
to  do,  might  benefit.  In  general  medicine  and 
most  of  the  specialties,  especially  in  diagnosis,  there 
seems  to  be  a  considerable  field  for  cooperative 
medical  clinics.  The  encouragement  of  pay  clinics 
of  either  type  is  a  measure  of  progress  in  the  de- 
velopment of  cooperative  or  group  medicine  prac- 
tice on  a  democratic  basis. 

The  efficient  dispensary  of  the  present  day  needs 
correction  of  three  faults:  i,  A  medical  organiza- 
tion not  sufficiently  centralized  so  that  the  patient 
is  divided  up  between  clinics  without  adequate 
central  medical  control  and  interpretation ;  2,  too 
much  hurry,  too  many  patients  for  the  time  allotted 
for  the  examining  physician,  hence  too  little  com- 
fort and  too  little  dignity  for  the  patient ;  3,  lack 
of  adaptation  to  the  needs  of  a  clientele  of  wage 
earners.  The  group  medicine  clinics  obliterate  all 
these  defects. 


September  4^  1920.] 


GOLDSTEIN:   GROUP  DIAGNOSIS. 


319 


NEEDS  FOR  AN   EFFICIENT  DISPENSARY. 

1.  A  medical  staff  properly  remunerated  for  its 
services. 

2.  A  medical  organization  facilitating  cooperative 
diagnosis  and  treatment,  providing  central  medical 
control,  interpreted  data  for  reference  of  the  at- 
tending physician. 

3.  Central  administrative  control  of  all  its 
branches  of  dispensary  service,  carried  out  by  an 
efficient  executive  officer,  under  a  board  of  com- 
mittees in  which  the  medical  interests  of  the  staff' 
and  the  interests  of  the  laity  are  both  represented. 

4.  Administrative  organization  to  secure  reason- 
able comfort,  privacy,  and  dignity  for  the  individual 
])atient. 

5.  Building  and  equipment  of  proper  standard, 
good  nursing,  good  clerical  staff,  and  a  good  social 
service  department. 

Although  ideals  are  seldom  if  ever  attained,  still 
the  nearest  to  the  ideal  seems  to  be  the  type  of 
the  Mayo  Clinics,  of  Rochester,  Minn. ;  New  York 
Diagnostic  Clinics,  New  York,  and  the  Boston  Dis- 
])ensary,  Boston,  Mass.  We  shall  give  a  brief  de- 
scription of  the  New  York  Diagnostic  Clinics,  since 
it  is  of  the  latter  we  have  direct  personal  knowl- 
edge. 

These  clinics  were  organized  by  the  New  York 
Diagnostic  Society  to  provide  facilities  for  group 
diagnosis  of  cases  among  all  classes.  For  this  pur- 
pose the  clinic  is  divided  into  nineteen  separate 
clinics  or  departments  of  modern  medicine.  These 
are  adequately  equipped  with  all  modern  diagnostic 
devices  and  instruments,  including  complete  mod- 
ern laboratories  for  pathological,  bacteriological, 
^nd  animal  research  work. 

The  medical  staff'  consists  of  one  chief  and  two 
assistants,  on  a  six  months'  service  in  each  of  the 
nineteen  departments,  and  several  full  time  men 
who  are  in  the  laboratories,  general  x  ray  and  den- 
tal X  ray  departments,  and  the  anamnestiologist. 
Physicians  receive  final  appointment  only  after  the 
expiration  of  a  year's  satisfactory  service.  They 
must  be  of  the  highest  type,  as  to  their  experi- 
ence and  knowledge  in  their  respective  specialties, 
as  well  as  their  character  and  standing  in  the  medi- 
cal profession  and  medical  societies.  The  institu- 
tion is  in  fact  a  composite  of  the  diagnostic  facili- 
ties to  be  found  in  the  leading  hospitals  and  dis- 
pensaries of  the  United  States  and  Europe.  It  is 
worthy  of  study  for  those  interested  in  model  clin- 
ical and  dispensary  work  as  an  inspiration  for  the 
establishment  of  similar  clinics  elsewhere. 

CONCLUSIONS. 

The  advantages  of  cooperative  or  group  medicine 
practice  for  all  social  classes  become  more  gen- 
erally perceived.  Is  the  practical  situation  of  the 
medical  profession  satisfactory?  Would  a  larger 
and  more  general  preparation  in  the  work 
of  cooperative  clinics  improve  the  financial 
outlook  and  status  of  the  rank  and  file  of 
the  medical  profession  ?  The  answer  is  de- 
cidedly, yes.  A  higher  average  income  and  more 
stable  income  and  a  larger  professional  opportunity 
for  the  average  physician,  who  has  had  a  good 
training  to  start  with,  are  desiderata  which  can 


only  arise  out  of  more  comprehensive  organization, 
which  means  essentially  more  work  done  in  medical 
institutions  and  more  cooperative  and  collaborative 
practice. 

The  world  will  not  fail  to  remember,  however, 
that  the  advances  in  modern  medicine  which  have 
been  made  during  the  world  war  could  only  be 
brovight  about  by  cooperation  of  the  medical  fra- 
ternity in  all  fields  of  military  medicine  and  sur- 
gery, hygiene,  and  sanitation.  Hence  the  advan- 
tage and  necessity  of  pay  clinics  with  the  group 
medicine  idea,  which  should  be  the  future  pro- 
gressive way  for  successful  practice  of  medicine. 

Twenty-eight  years  ago  Dr.  Stephen  Smith,  a 
well  known  clinician  who  has  added  much  to  medi- 
cine in  our  country,  remarked  at  a  meeting  of  the 
Academy  of  Medicine :  "I  predict  that  in  twenty- 
five  years  the  United  States  will  be  the  medical 
Mecca  of  the  world."  Therefore,  one  of  two  things 
is  necessary,  either  that  a  combination  of  men  inter- 
ested in  the  various  sides  of  medicine  club  together 
primarily  to  arrive  at  diagnoses,  so  that  any  one  of 
them  can  cover  any  scope  in  therapy  demanded  in 
a  case,  or  that  we  develop  a  new  department, 
namely,  that  of  the  diagnostician,  to  whom  medicine 
will  eventually  look  in  the  future. 

The  sins  of  omission  and  commission  on  the  part 
of  different  men  in  the  various  branches  of  medi- 
cine naturally  prompt  us  to  seek  for  diagnosti- 
cians. In  the  future,  this  want  will  become  more 
and  more  urgent,  and  it  will  not  be  many  years 
before  the  people  will  demand  such  service.  Let 
us  in  this  instance  be  progressive  enough  to  supply 
this  need  when  it  arrives. 

I  am  greatly  indebted  to  Dr.  M.  J.  Mandelbaum, 
medical  director.  New  York  Diagnostic  Clinics, 
for  his  valuable  suggestions  and  material  aid. 

125  West  Seventy-second  Street. 


Prostatectomy. — Henry  G.  Bugbee  {Boston 
Medical  and  Surgical  Journal,  July  15,  1920)  em- 
phasizes the  following:  1.  The  study  of  pros- 
tatic obstruction  has  had  slow  evolution,  extending 
back  over  two  thousand  years.  2.  Not  until  it  be- 
came possible  to  inspect  the  interior  of  the  bladder 
were  measures  for  its  relief  placed  upon  a  definite 
footing.  3.  With  the  advance  in  the  study  of  cases, 
operative  measures  suggested  during  the  period  of 
obscurity  were  brought  forward  and  perpetrated 
with  renewed  zeal.  4.  Anatomical  and  pathological 
study  of  cases  has  resulted  in  a  certain  classifica- 
tion. 5.  The  objects  of  relief  will  best  be  at- 
tained by  a  thorough  analysis  of  the  individual,  by 
procedures  instituted  to  remove  step  by  step  and 
with  the  least  possible  .shock  to  the  patient  the 
causes  of  the  symptoms.  Prostatectomy  for  fibro- 
adenomatous  enlargement  can  best  be  accomplished 
by  preliminary  suprapubic  drainage,  the  removal  of 
the  gland  being  an  incident  of  the  convalescence 
from  the  drainage.  The  most  important  phase  in 
its  removal  is  the  control  of  hemorrhage,  with  a 
careful  attention  to  details  during  the  healing,  in- 
suring a  rapid  functional  cure  free  from  compli- 
cations. 


VAXDEGRIFT:  BIXOCVLAH  SIXGLE  VISIOX. 


<i  [New  York 

*     aIedical  Journal. 


BINOCULAR  SINGLE  VISION. 
By  George  W.  Vandegrift,  M.  A.,  M.  D., 

New  York, 

Instructor  in  Ophthalraology,   Cornell  University   Medical  College. 

Binocular  single  vision,  or  the  fusion  of  two 
retinal  images  of  an  object  into  a  single  perception, 
offers  a  subject  for  investigation  of  more  than  ordi- 
nary interest.  Many  investigators  consider  it  a 
visual  function  rather  than  a  secondary  result  of 
ocular  activities.  Its  utility  cannot  be  gainsaid  but 
a  little  thought  will  show  that  it  plays  a  minor  role 
to  the  prime  purposes  of  vision,  that  of  perception 
of  the  external  world  and  protection  from  its  vicis- 
situdes. Binocular  single  vision  far  from  being  a 
purposeful  function  is  a  compromise  in  the  play 
of  evolutionary  processes.  The  proof  of  this  lies 
in  the  study  of  the  biogenetic  development  of  the 
visual  apparatus  and  in  the  study  of  the  factors  by 
which  binocular  vision  is  harmonized  and  antag- 
onism prevented. 

It  is  established  that  the  visual  field  is  divided  into 
two  purposeful  areas,  that  of  the  fovea  or  central 
area  which  is  concerned  with  the  nice  distinction  of 
details  and  form,  and  that  of  the  periphery  which 
is  to  a  high  degree  sensitive  to  movement  and  to 
the  differences  of  illuminations.  In  the  lower  ver- 
tebrates the  fovea  is  absent  and  visual  acuity  is  low 
so  that  the  search  for  food  and  protection  must 
depend  largely  upon  the  movement  of  objects. 
Birds  and  higher  monkey's  are  supplied  with  a  fovea 
and  keenness  of  central  vision  is  added  to  the  quick 
perception  of  movement. 

Among  the  invertebrates  a  binocular  field  of 
vision  must  be  extremely  rare  as  the  eyes  possessed 
by  the  different  species  vary  enormously  both  in 
number  and  position,  though  in  most  animals  that 
propel  themselves  the  eyes  are  in  the  anterior  seg- 
ment of  the  body.  In  the  cuttlefish  and  crusta- 
ceans the  paired  eyes  occupy  a  position  that  possibly 
may  produce  an  uncertain  amount  of  binocular  field. 
Among  the  vertebrates  a  binocular  field  is  generally 
present  except  in  fish  where  it  is  found  exceptional- 
ly, only  among  some  of  the  deep  sea  varieties. 

Depending  upon  the  relative  positions  of  the 
orbital  axes  for  its  limitations,  and  upon  the  stage 
of  development  of  the  ocular  muscles  for  its  range, 
the  binocular  field  varies  markedly  in  the  various 
subdivisions.  Throughout  the  animal  series  the 
biorbital  axial  angle  varies  widely.  In  man  and  the 
higher  apes  the  binocular  field  is  large,  approxi- 
mately 120° ;  but  with  increase  of  the  biorbital 
angle  in  lower  animals  the  extent  diminishes.  In 
the  carnivora  it  approaches  more  nearly  the  size 
found  in  man,  being  approximately  100°,  while  in 
ruminants  it  decreases  to  50°,  and  in  birds  to  30°. 
The  binocular  field  is  not  limited  necessarily  to  an 
anterior  position  for  with  an  upward  or  backward 
displacement  of  the  eyes  a  binocular  field  may  de- 
velop superiorly  as  in  a  few  amphibia  and  rodents, 
or  posteriorly  as  in  the  albino  rabbit.  In  a  few  of 
the  lower  animals  such  as  the  carnivora  and  her- 
bivora  the  increase  of  the  biorbital  angle  appears 
to  be  counteracted  by  the  increased  size  of  the  cor- 
neal surface  by  which  the  monocular  visual  angle  is 
enlarged  and  the  binocular  field  maintained. 


In  all  classes  of  vertebrates  the  extraocular 
muscles  are  well  developed  except  in  reptijes  and 
birds,  in  which  the  movements  of  the  eyeballs  are 
much  restricted.  Animals  in  which  the  head  nio-^'e- 
ments  are  restricted,  such  as  the  fish,  possess  ^ 
highly  developed  extraocular  muscular  system,  and 
those  in  which  the  head  movement  is  free,  as  in 
birds,  have,  as  a  rule,  a  more  limited  extraocular 
muscular  activity.  This  rule  is  not  without  excep- 
tion, however,  as  many  animals  requiring  a  quickly 
shifting  field  of  view  for  the  detection  of  prey 
and  for  protection,  as  the  carnivora,  are  supplied  not 
only  with  muscles  of  rotation  which  at  times,  in 
addition  to  the  ordinary  movements  as  found  in 
man,  may  possess  the  power  of  projecting  the  cor- 
nea beyond  the  lids,  but  also  are  supplied  with  a 
muscular  system  not  found  in  man,  which  allows 
translation  of  the  globe. 

Whereas  the  extent  of  the  binocular  field  depends 
upon  the  size  of  the  biorbital  angle  and  the  range 
upon  the  external  musculature,  the  perceptive  in- 
tensity within  the  field  varies  with  the  acuity  of 
vision,  central  and  peripheral,  and  with  the  degree 
of  development  of  the  functions  of  convergence 
and  accommodation.  Central  visual  acuity  varies 
widely  among  the  vertebrates.  In  the  higher  groups 
only,  such  as  birds,  apes  and  man,  does  a  fovea  exist 
and  a  powerful  accommodative  apparatus.  The 
lower  vertebrates,  having  no  fovea,  must  be  visually 
guided  by  the  movements  of  the  external  world. 
Tracing  the  development  of  the  ocular  apparatus  we 
find  no  valid  reason  to  judge  the  human  eye  as  the 
highest  or  most  perfect  type.  Anatomically  and 
physiologically  it  occupies  in  development  a  place 
below  that  of  birds.  With  the  evolution  of  mental 
characteristics  a  perfection  of  other  functions  is 
not  so  requisite  as  in  lower  animals  not  so  endowed. 
The  ocular  apparatus  displays  throughout  the  ani- 
mal kingdom  a  demoilstrable  and  excellent  adapt- 
ation of  form  and  function  to  en\nronment.  The 
lowest  vertebrates,  such  as  fish  and  reptiles,  apjjear 
to  orient  themselves  largely  by  external  movement. 
The  herbivora  also  appear  to  have  a  visual  acuity 
available  for  a  short  distance  and  protection  and 
the  search  for  food  must  depend  visually  upon  a 
keen  perception  of  movement.  The  carnivora  are 
better  endowed  with  a  perceptive  retina  and  accom- 
modative apparatus  though  the  fovea  is  absent.  The 
monkeys  nearly  approach  man  in  the  development 
of  the  eye,  while  the  birds,  in  which  the  retina  is 
highly  developed  and  possesses  one  or  more  fovea, 
have  a  visual  acuity  and  accommodative  apparatus  of 
a  degree  unapproached  by  any  member  of  the  ani- 
mal kingdom. 

The  complete  visuality  of  the  external  world  de- 
mands not  only  orientation  and  the  perception  of 
objects  but  also  the  realization  of  their  spatial  re- 
lations of  distance,  depth  and  comparative  sizes. 
For  this  psychological  conception  are  necessary  not 
only  the  factors  previously  described  but  also  that 
factor  derived  from  the  muscle  sense  produced  by 
accommodation  and  convergence. 

An  accommodative  apparatus  is  not  exclusively  a 
property  of  the  vertebrates.  A  functioning  lens  is 
found  in  many  invertebrates.  In  very  simple  forms 
such  as  the  snail  it  is  in  contact  with  the  retinal  cells 


September  4,  1920.] 


VAI^DEGRIFT:  BIXOCULAR  SINGLE  VISION. 


321 


and  refraction  and  accommodation  are  practically 
negative.  Such  a  primitive  apparatus  determines  only 
the  direction  of  the  light  source.  For  the  forma- 
tion of  an  image,  indistinct  as  it  may  be,  an  eye 
fashioned  upon  the  principle  of  the  camera  is  nec- 
essary. Such  a  compound  apparatus  is  found 
among  many  invertebrates  as  crustaceans,  insects 
and  worms.  Among  the  worms  the  first  details  of  a 
ciliary  body  appear  as  a  group  of  small  pigment 
cells  between  the  lens  and  the  retina.  In  the  cuttle 
fish  a  distinct  ciliary  body  is  discoverable  which  is 
attached  to  the  lens  and  moves  with  its  excursions. 
In  other  shell  fish  such  as  the  pecten  the  ciliary  body 
consists  of  a  muscular  apparatus  so  arranged  as  to 
increase  by  contraction  the  convexity  of  the  lens. 

While  the  accommodative  act  is  present  in  all  ver- 
tebrates its  mode  of  accomplishment  differs  in  many 
species.  In  fish  the  anteroposterior  excursions  of 
the  lens  vary  refractivity.  In  the  bird  the  act  of 
accommodation  is  performed  secondarily  by  a  simi- 
lar excursion  of  the  lens  and  primarily  by  an  in- 
crease in  curvature  of  the  cornea.  Alammals,  apart 
from  man,  have  a  weak  accommodative  apparatus, 
the  mode  of  activity  of  which  is  the  same  through- 
out the  subkingdom,  and  needs  no  elucidation  here. 

All  these  factors,  the  multiplicity  of  eyes  in  the 
invertebrates  and  their  varied  positions,  the  varia- 
tions in  the  direction  of  the  orbital  axis  of  the  binoc- 
ular invertebrates  and  vertebrates,  the  irregular  de- 
velopment of  the  visual  angle  and  of  the  external 
and  internal  musculature,  are  directed  to  the  ac- 
complishment of  a  visual  acuity  and  orientation 
demanded  by  environmental  exigencies  of  protection 
and  search,  and  not  to  the  creation  of  a  binocular 
single  field.  The  latter  describes  no  regularity  of 
development,  and  results  secondarily  when  these 
factors  are  so  coordinated  as  to  bring  it  into  exist- 
ence. As  we  shall  see  a  true  conception  of  the  vis- 
ible world  and  its  spatial  relations  is  as  possible 
monocularly  as  binocularly,  the  latter  furnishing 
only  an  increased  precision  and  nicety.  Finally, 
considering  the  high  psychological  laws  involved  in 
spatial  apprehension  it  is  a  debatable  question 
whether  the  binocular  field  plays  any  but  an  adven- 
titious role  in  the  animal  kingdom  below  man. 

We  have  traced  briefly  the  anatomical  and  physi- 
ological factors  that  develop  the  binocular  field. 
Before  studying  the  factors  that  maintain  single 
vision  within  this  field  a  psychological  analysis  is 
requisite  of  the  mental  concept  that  produces  in 
consciousness  the  knowledge  of  the  external  world 
as  a  material  entity  of  three  dimensions.  Observ- 
ers generally  look  upon  binocular  single  vision  as  a 
necessary  function  in  the  production  of  this  concept. 
The  apprehension  of  spatial  relations  is  not,  how- 
ever, dependent  upon  binocular  single  vision  for  it 
is  present  though  distorted  in  pathological  diplopia, 
and  also  in  those  individuals  whose  vision  is  per- 
formed monocularly.  The  concept  of  space  is  a 
compound  of  qualitative  and  intensive  sensations 
dependent  not  only  upon  visual  but  also  upon  tactile 
and  muscular  perceptions.  Such  sensations  are. 
however,  of  themselves  not  sufficient  to  produce  a 
true  knowledge  of  the  external  world.  Upon  these 
must  rest  a  power  of  consciousness  that  is  construc- 
tive, so  that  the  apprehension  of  space  is  the  product 


of  experience  through  the  interaction  of  the  asso- 
ciation of  ideas  upon  the  qualitative  sensations. 
Otherwise  the  concept  is  intuitional.  The  spatial 
errors  of  young  children  and  of  the  blind  restored 
to  sight  appear,  however,  to  refute  this  latter  hy- 
pothesis. Based  thus  as  it  is  upon  highly  developed 
psychological  interactions  this  concept  of  spatial 
relations  can  be  present  but  dimly,  if  at  all,  in  the 
low  orders  of  the  animal  kingdom  which  may  pos- 
sess a  binocular  field  even  more  extensive  than 
man's.  The  processes  of  evolution  appear  to  have 
produced  adventitiously  the  overlapping  fields  by 
placing  the  ocular  apparatus  in  the  position  that  gives 
the  widest  outlook.  In  the  higher  animals,  in  which 
the  apprehension  of  spatial  relations  begins  to  enter 
consciousness,  secondary  factors  have  been  evolved 
to  refine  and  to  maintain  the  concept  undistorted 
within  the  binocular  field.  Were  binocular  single 
vision  and  its  refining  and  maintaining  factors  a 
primary  rather  than  a  secondary  process  we  would 
expect  to  find  young  children  and  the  blind  restored 
to  sight  endowed  at  the  incipiency  of  visual  activity 
with  a  full  and  exact  apprehension  of  spatial  rela- 
tions. The  earliest  apprehension  of  distance  and  of 
surface  extension  however  depends  upon  the  tactile 
sensations.  In  the  first  few  months  of  life  the  bi- 
nocular movements  are  incoordinated  and  the  power 
of  accommodation  undeveloped.  When  the  size 
of  objects  and  their  distances  apart  are  apprehended 
by  grasping  visual  apprehension  develops  and  ob- 
jects and  distances  previously  acknowledged  con- 
sciously through  the  sense  of  touch  become  the 
foundation  of  visual  apprehension.  With  full  de- 
velopment of  the  latter  the  conception  of  space  is 
further  clarified  by  the  muscular  sense  produced  by 
accommodation,  convergence  and  orientation. 

Analyzing  the  concept  still  further  we  find  that 
the  apprehension  of  space  is  extensive  while  the 
sensations  giving  rise  to  it  are  successive.  Both  the 
tactile  and  visual  images  are  connected  continuously 
and  without  interruption  though  the  tactile  and 
visual  organs  lack  this  relative  continuity,  the  retina 
in  fact  containing  the  blind  spot  which  is  not  pro- 
jected into  consciousness.  Again  we  are  lead  to  the 
conclusion  that  the  concept  of  spatial  relations  is 
the  product  of  a  power  of  consciousness  that  is  con- 
structive, and  that  binocular  single  vision  while  a 
contributing  factor  cannot  be  the  controlling  in- 
fluence in  its  creation. 

To  maintain  this  concept  clear  and  undistorted 
within  the  binocular  single  field  certain  psychological 
and  physiological  factors  must  functionate  har- 
moniously. The  primary  psychological  factors  are 
the  faculty  of  fusion  by  which  the  two  retinal  images 
are  merged  into  one  perception,  and  the  faculty  of 
projection  by  which  the  retinal  impression  is  pro- 
jected along  the  line  of  direction  into  the  visual  field, 
passing  through  the  nodal  point,  and  thereby  fur- 
nishing the  knowledge  of  direction  and  position. 
These  functions  are  undoubtedly  mental.  They  do 
not  produce  the  concept  but  refine  it  and  prevent 
antagonism  within  the  overlapping  fields.  Were 
the  spatial  concept  based  upon  innate  ideas  the 
fusion  and  projection  faculties  would  be  found  com- 
pletely developed  at  the  first  visual  act.  The  first 
evidence  of  their  presence  is  not  m.anifested  how- 


322 


VANDEGRIFT:  BIXOCULAR  SINGLE  I'lSIOX. 


[New  York 
Medical  Journal. 


ever  until  several  months  after  birth  and  they  are 
not  fully  developed  for  five  or  six  years. 

Within  the  binocular  field  the  sensations  received 
at  the  two  foveae  are  projected  to  the  same  place 
in  space  if  the  two  eyes  functionate  normally.  If 
the  gaze  of  the  two  eyes  is  directed  through  two 
openings  of  interpupillary  distance  in  a  sheet  of 
paper  held  close  to  the  face  the  two  openings  appear 
as  one  lying  in  the  median  line.  Impressions  re- 
ceived upon  peripheral  retinal  parts,  however,  are 
fused  only  when  they  fall  upon  identical  retinal 
points. 

Under  the  impulse  of  the  spatial  perceptions  the 
will  controls  the  actions  of  the  two  eyes  as  though 
they  were  a  single  organ ;  and  the  nervous  impulses 
that  produce  ocular  movements  are  of  ecpial  binocu- 
lar intensity.  Each  eye  is  the  duplicate,  anatomically 
and  physiologically,  of  the  other.  Each  macula  has 
a  common  brain  cell  connection  with  the  other,  and 
every  perceptive  point  in  each  retina  has  a  corre- 
sponding perceptive  point  in  the  other  retina  an- 
atomically connected.  Thus  two  images  may  be 
fused  into  one  when  the  images  are  j)roduced  by 
these  corresponding  points.  Corresponding  points 
are,  therefore,  anatomical  and  physiological  facts 
upon  which  the  psychological  factors  of  fusion  and 
projection  develop. 

A  perceptive  point  in  one  retina  corresponds  with 
a  perceptive  point  in  the  other  when  images  upon 
them  of  the  same  external  object  are  projected  as 
one.  When,  however,  the  images' are  not  blended 
diplopia  results,  for  the  perceptive  points  are  not 
identical. 

Every  visual  act  embraces  a  field  of  view  that  is 
complex.  Objects  occupy  every  possible  plane  in 
relation  to  the  visual  line.  The  eyes  rapidly  pass 
from  point  to  point,  orienting  themselves,  converg- 
ing and  accommodating.  In  each  visual  act,  there- 
fore, a  large  number  of  objects  do  not  fall  upon 
identical  points.  For  every  direction  of  the  gaze 
certain  objects  which  lie  in  space  so  as  to  fall  upon 
identical  points  appear  single,  while  all  other  objects 
falling  upon  nonidentical  points  produce  a  physio- 
logical diplopia.  This,  however,  does  not  caust 
confusion,  but  rather  adds  to  the  delicacy  of  the 
spatial  concept.  The  blurred  peripheral  images  act 
as  directors  of  the  visual  line  so  that  the  eyes  easily 
pass  from  point  to  point  estimating  distance  and 
direction.  A  complete  concept  of  the  field  of  view 
combining  perspective  and  stereopsis  is  thus  ob- 
tained, and  the  double  images  being  closely  asso- 
ciated and  falling  upon  retinal  parts  of  low  per- 
ceptivity do  not  produce  diplopia  in  consciousness 
imtil  the  attention  is  drawn  to  it  voluntarily. 

While  the  sense  of  direction  depends  uj)on  the 
faculty  of  projection  the  realization  of  form  size 
and  distance  rests  largely  upon  the  nuiscular  sense. 
Muscular  perception  arises  not  only  from  the  inter- 
play of  tlie  conjugate  muscles  but  also  from  the 
action  of  convergence  and  accommodation.  The 
muscle  sense  is  complicated,  being  compounded  of 
the  sensations  derived  from  mliscular  activity  and 
from  their  mental  interpretation.  The  tension  or 
efifort  of  the  nuiscular  action  and  the  result  or  the 
muscular  contraction  accompany  the  voluntary  men- 
tal control  and  produce  in  consciousness  a  knowledge 


of  the  intensity  of  impulse  demanded  for  a  particu- 
lar action.  The  knowledge  of  direction,  therefore, 
and  indirectly  of  the  size  and  distance  of  objects, 
depends  upon  the  consciousness  of  the  degree  of 
energy  required  to  bring  the  visual  line  into  that 
direction.  Once  again  we  perceive  that  the  spatial 
concept  is  not  innate  but  founded  upon  knowledge 
derived  from  experience. 

The  previous  discussion  has  dwelt  largely  with 
the  apprehension  of  the  first  and  second  dimensions 
of  space.  We  have  seen  that  the  spatial  concept 
does  not  rest  entirely  upon  ocular  sensations,  and 
that  binocular  single  vision  is  not  so  essential  that 
its  absence  would  prevent  the  production  of  the 
concept.  The  apprehension  of  depth  and  relief, 
the  realization  of  the  third  dimension  of  space,  like- 
wise is  not  exclusively  a  binocular  ftmction.  Mon- 
ocularly  the  apprehension  of  the  third  dimension 
may  be  derived  in  many  ways.  Stereopsis  or  the 
sense  of  relief  ma}'  be  produced  monocularly  by 
the  efifects  of  shadows  and  shades  and  by  mathe- 
matical and  aerial  perspective.  From  accommoda- 
tion and  from  parallactic  movements  of  objects 
when  the  eye  or  head  is  moved  the  knowledge  of 
distance  and  anterior  posterior  extension  is  derived. 
.Solidity  is  thus  realized. 

Binocularly  stereopsis  and  perspective  vision  are 
more  exquisite  and  refined.  As  an  object  may  now 
I)c  perceived  from  two  dif¥erent  aspects  the  sense 
of  solidity  is  heightened.  This  con.stitul:es  stereo- 
scopic vision.  Perspective  vision  is  the  perception 
of  objects  at  varying  distances,  the  knowledge  de- 
rived from  the  muscular  actions  of  convergence 
and  accommodation  furnishing  a  sense  of  depth. 

It  is  not  essential  in  this  brief  review  to  enumerate 
the  various  factors  existent  in  the  external  world, 
such  as  shadow  play  and  relative  sizes  and  distances 
of  objects,  that  enhance  the  sense  of  depth  and 
relief  ;  nor  is  it  esseiuial  to  analyze  more  fully  the 
subjective  elements  of  stereopsis  and  perspective. 
The  purpo.^e  of  this  paper  is  to  analyze  the  spatial 
concept  and  show  that  it  is  not  entirely  an  ocular 
])roduction;  and  that  while  the  function  of  vision 
is  a  primary  factor  the  concept  may  rest  upon  mon- 
ocular as  well  as  binocular  perceptions.  Biogenet- 
ically  the  binocular  field  and  its  manifestations  have 
been  evolved  not  to  produce  the  concept  but,  hav- 
ing been  evolved  secondarily,  have  been  developed  to 
conform  to  and  not  to  antagonize  the  concept. 

The  sense  of  solidity  and  dejith  are  neither  es- 
sentially octilar,  tactile  nor  muscular  but  a  complex 
of  these  sensations  acted  upon  by  the  association 
of  ideas,  in  which  memory  and  experience  play  an 
imjjortant  role.  The  completed  concept  is  the  result 
of  a  constructive  mental  function. 


Treatment  of  Tuberculosis  Epididymitis.— H. 

\\  ildbolz  i  Sclnvciccrisclic  iiicdicinischc  IVochen- 
sclirift,  June  17,  1920)  discusses  the  advantages 
and  disadvantages  of  excision  of  the  epididymis  in 
this  condition,  and  seems  on  the  whole  to  favor  this 
operation.  Yet  the  psychical  injury  produced  on 
a  young  man  by  a  double  castration  is  so  great  that 
it  cannot  be  recommended.  In  a  great  many  cases 
also  the  disease  is  too  far  advanced  for  an  excision 
of  the  epididymes  to  be  effective  in  checking  it. 


September  4,  1920.  J 


UXDERHILL:  RABIES. 


PRESENT  STATUS  OF  IL\BIES  * 

Clinical  and  Microorganisinal. 

By  B.  M.  Underbill,  V.  M.  D., 
Philadelphia. 

As  to  the  present  status  of  rabies,  I  can  bring  little 
before  you  but  what  is  of  common  knowledge  to 
medicine,  for  I  am  not  aware  of  anything  new  hav- 
ing been  reported  from  research  in  this  line  during 
the  past  two  or  three  years.  Probably  all  warm 
blooded  animals  are,  in  varying  degree,  susceptible 
to  this  disease  which  has  been  termed  rabies,  lyssa, 
canine  madness,  or  hydropholMa.  all  of  wliich  terms, 
except  the  last,  may  properly  apply  to  it  in  lower 
animals,  the  dread  or  fear  of  water  never  having 
been  observed  in  these,  though,  whether  or  not  a 
true  specific  symptom,  it  does  appear  in  man. 

So  far  as  I  know,  Noguchi,  of  the  Rockefeller 
Institute  laboratories,  has  made  the  most  recent  re- 
port upon  investigations  with  Xegri  bodies.  This 
deals  with  the  cultivation  of  the  i)arasite,  as  he 
terms  it,  of  rabies.  Xoguchi  undertook  to  cultivate 
the  virus  of  rabies  from  the  brain  and  medulla  of 
rabbits,  guineapigs,  and  dogs  infected  with  street 
virus,  passage  virus,  and  fixed  virus.  His  results 
were  obtained  by  methods  employed  for  the  culti- 
vation of  spirochetes  of  relapsing  fever  ( 1  ) .  His 
cultures  were  minute  granular  bodies  which,  on 
transplantation,  reappeared  in  new  cultures  through 
many  generations.  He  observed  that  in  the  cul- 
tures from  passage  and  fixed  virus,  round  or  oval 
nucleated  bodies  surrounded  by  membranes  ap- 
peared. He  demonstrated  the  cultivated  nucleated 
bodies  actively  multiplying  by  division  and  budding, 
and  exhibiting  the  appearance  of  protozoa.  In  size 
they  were  one  micron  to  twelve  niicra.  By  inocu- 
lating cultures  containing  the  granular  or  nucleated 
bodies  he  has  produced  rabies  in-  dogs,  rabbits  and 
guineapigs  with  typical  symptoms  and  positive  ani- 
mal inoculations. 

It  might  be  said  here  as  to  the  terms  street  and 
fixed  virus  that  street  virus  is  from  rabid  dogs  nat- 
urally infected.  When  street  virus  is  inoculated  into 
a  rabbit  it  reproduces  the  disease  in  fourteen  to 
twenty-one  days  or  more.  This  street  virus  is  then 
conveyed  from  rabbit  to  rabbit  through  a  number 
of  transfers.  It  thus  becomes  more  virulent  for 
rabbits  and  the  period  of  incubation  of  the  passage 
virus  is  progressively  shortened.  Finally  the  rab- 
bits invariably  sicken  on  the  sixth  or  seventh  day 
and  die  on  the  ninth  or  tenth.  When  the  virus  has 
reached  this  degree  of  virulence  for  rabbits  it  is 
said  to  be  fixed,  that  is  its  potency  remains  constant. 
Fixed  virus,  which  has  obtained  a  high  degree  of 
virulency  for  rabbits,  has  lost  much  of  its  virulence 
for  dogs,  and  is  probably  avirulent  for  man. 

For  the  Pasteur  treatment  the  fixed  rabbit  virus 
is  used.  The  rabbits  are  injected  with  the  fixed 
\irus  under  the  dura  mater.  A  rabbit  thus  inocu- 
lated should  begin  to  show  symptoms  in  six  to  seven 
days  and  die  on  the  ninth  or  tenth  day.  The  spinal 
cord  is  then  removed  and  hung  in  a  jar  containing 
Ijotassium  hydroxide.  Jars  containing  the  cords  are 
kept  in  a  dark  place  at  a  temperature  of  20°  to 

*Reail  b-?fore  the  Pathological  Societv  of  Philadelphia.  March  25, 
1920. 


22°  C.  Under  these  conditions  the  cords  gradually 
desiccate  and  the  virus  diminishes  in  virulence  until 
the  fourteenth  day,  when  it  is  no  longer  infective. 
Pasteur  started  treatment  with  a  cord  fourteen  days 
old.  A  small  portion  of  the  cord  is  ground  in  sterile 
salt  solution  and  injected  into  the  subcutaneous  tissue 
of  the  abdomen. 

The  original  method  of  attenuation  of  virus  and 
treatment  of  Pasteur  has  been  modified  in  many 
ways.  Many  Pasteur  Institutes  now  start  treatment 
with  an  eight  day  instead  of  a  fourteen  day  cord. 
"Ferran  in  Barcelona,  Proescher  in  Pittsburgh,  and 
others  inject  patients  with  the  unaltered,  fresh,  fixed 
virus.  The  advantages  in  using  the  virus  as  fresh 
and  as  strong  as  possible  are  that  an  active  immunity 
is  produced  more  quickly,  and  this  is  of  considerable 
importance  in  wounds  of  the  face,  also  in  wolf  and 
cat  bites,  which  frequently  have  a  short  period  of 
incubation.  Further,  onh"  one  or  two  injections  of 
the  fresh  virus  are  necessary  to  produce  an  immu- 
nity, and  this  shortens  and  simplifies  the  treatment 
very  much."  (2) 

Proescher  (3)  injected  into  himself  the  entire 
I)rain  and  medulla  of  a  rabbit  (fixed  virus),  and 
another  entire  brain  into  a  volunteer  with  no  ill 
effects  in  either  case.  A  control  rabbit  injected  with 
a  0.02  dilution  of  the  same  emulsion  died  in  seven 
days  with  experimental  rabies. 

In  the  laboratory  of  the  Pennsylvania  State  Bu- 
reau of  Animal  Industr}'  our  method  of  examining 
material  sent  in  for  diagnosis  where  rabies  is  sus- 
pected is  as  follows :  The  brain  and  ganglion 
nodosum,  (  the  second  ganglion  of  the  pneumogas- 
tricj  are  removed.  Impressions  are  made  upon 
slides  from  the  transected  hippocampus  major  and 
from  the  cerebelltim,  and  portions  of  each,  with  the 
ganglion  nodosum,  are  placed  in  eighty  per  cent, 
alcohol  for  sectioning.  Portions  of  the  hippocam- 
pus and  cerebellum  are  also  placed  in  glycerine  for 
animal  inoculation  should  it  be  desired  that  this  be 
carried  out.  The  impressions  are  fixed  in  methyl 
alcohol  for  a  few  minutes,  dried,  and  stained  with  : 

Sat.  alcoholic  sol.  carbol  fuchsiii   1  c.  c. 

Loeffler's  methylene  blue   30  c  c. 

Water,  q.  s  100  c.  c. 

Heat  upon  slide,  simmer  and  allow  warm  stain  to  remain 
tor  about  thirty  seconds. 

Examined  with  oil  immersion  lens,  the  nerve 
cells,  if  properly  stained,  will  be  blue,  the  Negri 
l)odies  a  maroon  red  with  one  or  more  dark  stained 
inner  bodies.  Careful  impressions  show  the  bodies 
within  the  cytoplasm  of  the  nerve  cells.  If  the 
lirain  material  is  more  or  less  smeared  upon  the 
slide  many  of  the  bodies  will  appear  as  extracellular 
in  the  spread  cytoplasm.  Sections  are  stained  with 
hematoxylineosin  or  with  the  Mann  stain. 

During  twelve  months  in  1915-16  thirty-three 
brains  of  dogs  dead  from  causes  known  to  be  other 
than  rabies  were  examined  in  our  laboratory.  All 
were  treated  in  the  routine  outlined  for  examination 
for  Negri  bodies.  A  thorough  search  of  this  mate- 
rial failed  to  reveal  any  intracellular  or  extracellular 
structure  that  cotild  be  regarded  as  a  Negri  bodv. 
and  in  no  case  were  there  changes  in  the  ganglion. 

As  to  the  reliability  of  changes  in  the  ganglion  in 
the  diagnosis  of  rabies,  some  investigations  were 
carried  out  in  our  laboratory  for  a  period  covering 


324 


UNDERBILL:  RABIES. 


[New  York 
Medical  Journal. 


two  years  in  1914-16.  Four  hundred  and  fifty-three 
brains  of  dogs  were  examined,  sections  of  the  gang- 
Hon  nodosum  being  made  in  each  case.  In  223  of 
these  both  brain  and  ganghon  were  positive,  in  187 
both  brain  and  ganghon  were  negative,  in  nine  the 
brain  was  positive,  ganghon  negative ;  in  thirty- 
four  the  brain  was  negative,  ganghon  positive.  In 
the  last  case  it  is  probable  that  the  Negri  bodies 
escaped  observation  in  the  brain  examination,  or 
that  the  material,  through  decomposition,  mutila- 
tion or  other  cause,  was  in  unsatisfactory  condition 
for  preparation  and  staining.  From  these  findings 
we  concluded  that  in  all  cases  submitted  for  diag- 
nosis the  ganglion  nodosum  should  be  preserved 
and,  in  the  event  of  negative  brain  findings,  ex- 
amined. If  the  sectioned  ganglion  showed  diffuse 
or  distinct  localized  proliferative  changes  it  war- 
ranted a  diagnosis  of  rabies. 

To  the  practiced  laboratory  worker  frequent  ob- 
servation of  Negri  bodies  stamps  them  with  such 
morphological  and  staining  characteristics  as  to 
make  it  unlikely  that  he  will  confuse  them  with 
other  corpuscular  elements.  Accepting  it  as  true 
that  these  bodies  are  only  present  in  the  central 
nervous  tissue  of  animals  which  were  suft'ering 
from  rabies  at  the  time  of  their  death,  the  case  is 
at  once  returned  as  positive  to  rabies  where  the 
bodies  are  found. 

It  is  not  within  our  province  to  advise  as  to  the 
treatment  of  persons  bitten  by  animals  suspected  of 
rabies ;  that  is  a  matter  at  the  disposal  of  the  physi- 
cian in  charge.  In  the  event  of  advice  being  asked 
for,  we  would  suggest  the  following : 

1.  While  the  presence  of  Negri  bodies  is  proof 
positive  of  rabies,  failure  to  find  them  does  not  war- 
rant a  negative  diagnosis.  If  an  animal  has  ex- 
hibited symptoms  of  rabies  treatment  should  be 
given,  though  no  Negri  bodies  and  no  ganglion 
changes  have  been  found  in  the  material  submitted. 
This  is  especially  true  if  the  animal  has  shown 
changes  in  disposition,  expression  and  voice,  a  ten- 
dency to  roam,  an  unusual  disposition  to  bite,  or 
jmrtial  dropping  of  the  lower  jaw. 

2.  If  a  person  has  been  bitten  by  an  animal,  and 
the  animal  is  securely  confined  so  it  can  do  no  fur- 
ther harm,  it  should  not  be  killed  unless  distinctly 
rabid.  If  killed  before  or  during  the  initial  symp- 
toms it  is  probable  that  changes  in  the  central  ner- 
vous system  will  not  have  had  time  to  develop ; 
laboratory  examination  cannot  aid,  therefore,  in 
removing  the  uncertainty.  If  the  confined  animal 
lives  and  remains  normal,  Pasteur  treatment  of  the 
bitten  person  will  be  unnecessary.  If  rabies  de- 
velops in  the  animal  within  a  week  or  ten  days 
following  the  bite,  treatment  of  the  bitten  person 
is  advisable  as  the  saliva  may  already  have  become 
infective.  The  confinement  and  observation  should 
extend  over  a  period  of  at  least  two  weeks.  Dogs 
usually  die  in  a  few  days  from  the  inauguration 
of  symptoms. 

3.  While  the  period  of  incubation  is  in  any  case 
of  natural  infection  far  from  exact,  clinical  experi- 
ence has  shown  that  this  period  is  shortened  relative 
to  the  proximity  of  the  seat  of  inoculation  to  the 
brain.  Face  bites,  therefore,  call  for  more  prompt 
and  intensive  treatment  than  those  upon  the  hand 


or  leg  in  order  that  immunity  may  be  established 
before  expiration  of  the  incubation  period. 

In  any  review  of  rabies  a  case  is  made  out  against 
the  dog  as  the  principal  offender.  Through  his 
susceptibility  and  tendency  to  roam  and  to  bite,  he 
is  the  reservoir  and  disseminator  of  the  disease.  In 
general,  the  dog  has  certain  qualities  which  tend  to 
make  him  attractive  to  man,  while,  on  the  other 
hand,  he  has  characteristics  of  habit  which,  to  sane 
minds,  brand  him  as  a  disgusting  nuisance.  Re- 
stricted and  properly  cared  for  by  a  responsible 
owner,  he  may  well  be  tolerated ;  unclean  and  with- 
out restrayit,  he  is  a  menace  to  public  health.  He 
harbors  more  intestinal  parasites  than  any  of  our 
other  domestic  animals,  and  certain  of  these  can 
readily  be  conveyed  to  man.  Through  the  dog's 
intimate  association,  especially  with  children,  he  runs 
a  close  second  with  the  house  fly  as  a  direct  trans- 
mittor  of  pathogenic  bacterial  and  parasitic  organ- 
isms. It  is  well  known  that  the  dog  furnishes 
essential  hostage  to  stages  in  the  life  history  of  cer- 
tain parasites  of  man,  as  well  as  parasites  to  other 
animals  used  as  human  food. 

Echinococcosis  occurs  in  man,  cattle,  sheep, 
horses,  hogs,  and  numerous  other  animals.  The 
hydatid  is  derived  from  ingested  material  contami- 
nated with  eggs  from  a  three  segmented  tapeworm 
(Echinococcus  granulosus)  about  three  sixteenths 
of  an  inch  long,  which  may  inhabit  the  small  intes- 
tine of  a  dog  by  the  hundreds.  The  dog  is  practi- 
cally the  only  carrier  of  this  tapeworm.  In^omestic 
animals  the  cysts  are  commonly  found  in  the  liver, 
usually  multiple,  and  may  reach  the  size  of  an 
orange,  or  maybe  larger.  In  these  animals  the 
hydatids  are  seldom,  if  ever,  fatal.  The  longevity 
of  lower  animals,  especially  those  used  for  human 
food,  is  relatively  short,  and  the  cyst,  a  slow  grower, 
probably  does  not  reach  its  full  development.  In 
man,  where  the  development  has  not  been  checked, 
the  hydatids  are  said  to  reach  the  size  of  a  child's 
head.  A  common  tapeworm  of  the  dog,  Dipylidium 
caninum,  may  also  infest  man,  principally  children. 
Hall  speaks  of  a  case  in  which  as  many  as  two  hun- 
dred and  thirty-eight  of  these  worms  were  found  in 
a  single  person.  The  intermediate  host  of  the  worm 
is  the  dog  flea  or  louse,  probably  in  most  cases  the 
flea.  Infestation  with  the  tapeworm  is  by  ingestion 
of  the  flea  containing  the  larva  (Cryptocystis  trich- 
odectes).  Children  in  their  intimate  association 
with  dogs,  especially  if  they  have  food,  as  sticky 
candy,  about,  may  easily  have  a  flea  or  two  con- 
veyed to  the  stomach.  The  larval  worm  is  there 
set  free  and,  passing  to  the  intestine,  attaches  to  the 
mucosa  by  its  armed  rostrum  and  sucker  disks  and 
proceeds  to  develop  the  strobila  which  may  reach  a 
length  of  about  fourteen  inches. 

A  round  worm  of  the  dog,  Toxascaris  limbata, 
may  find  hostage  in  man's  intestine.  The  infesta- 
tion is  direct  by  ingesta  contaminated  with  the 
worm's  eggs.  Dogs  are  also  accused  of  playing  a 
part  in  the  spread  of  diseases  due  to  fungi,  such 
as  ring  worm  and  favus. 

REFERENCES. 

1.  NoGUCHi:  Journal  of  Experimental  Medicine,  1912, 
xvi,  199. 

2.  RosENAU  :  Preventive  Medicine  and  Hygiene. 

3.  Proescher  :  N.  Y.  Medical  Journal,  Oct.  9,  1909. 


September  4,  1920.] 


COTT:  PROTEIN  FEVER. 


325 


k  PROTEIN  FEVER. 

1  •  By  George  F.  Cott,  M.  D., 

Buffalo,  N.  Y., 

Professor  of  Otolaryngology,  University  of  Buffalo. 

At  various  times  and  places  the  otologist  sees 
patients  with  suspected  sinus  thrombosis,  or  mas- 
toiditis ;  whichever  it  may  be,  it  needs  draining ;  then 
the  patient  recovers,  or  succumbs,  or  hangs  in  the 
balance  indefinitely.  These  balance  cases  are  en- 
countered in  other  diseases  besides  those  found  in 
otology.  We  will,  however,  consider  only  those 
which  would  interest  us  most,  namely,  diseases  of 
the  ear. 

My  observations  on  these  balance  cases  extending 
over  a  period  of  fifteen  years  were  mostly  on  post- 
operative cases,  but  they  occur  just  as  often  before. 
I  have  found  that  patients  often  have  a  vacillating 
temperature  of  such  extreme  variations  that  it  makes 
the  physician  worry,  not  as  to  cause,  but  as  to  re- 
sult. When  a  patient  is  seen  but  once  a  day  the 
thermometer  may  read  from  104°  to  106°  F.  every 
day  for  a  week  or  more.  If  a  record  were  taken 
every  three  or  four  hours  he  would  find  that  the 
temperature  recedes  after  a  short  high  spurt,  and  re- 
peats that  performance,  usually  every  day  or 
so.  A  physician  with  considerable  experi- 
ence will  at  once  think  of  sinus  thrombosis. 
So  typical  a  temperature  will  only  be  found 
where  the  channels  are  peculiarly  situated  as 
those  within  the  skull  cavity.  There  are 
sharp  as  well  as  obtuse  angles  in  the  various 
brain  sinuses,  such  as  obstructions  foimd  at 
the  jugular  bulb  and  veins  entering  the  sinus 
at  right  angles.  All  these  further  the  for- 
mation of  clots.  Particles  are  then  swept 
into  the  blood  stream  causing  certain  dis- 
turbances which  will  be  described  later. 

A  thrombus  is  always  a  pathological  con- 
dition but  may  not  be  septic.  Bacterial  in- 
vasion may  be  checked  spontaneously  before  op- 
eration or  afterwards.  Bacteria  may  not  be  patho- 
genic unless  they  are  able  to  propagate  by  feeding 
on  the  surrounding  medium.  While  growth  con- 
tinues proteolytic  enzyme  is  being  formed,  or  the 
icell  is  being  sensitized  (which  we  will  designate  as 
the  period  of  incubation)  and  as  the  poison  in  the 
^•irculation  comes  within  the  sphere  of  the  cell  it  is 
digested  with  the  evolvement  of  heat.  When,  how- 
ever, the  bacterial  cell  protein  is  overwhelming,  in- 
stead of  a  rising  temperature  we  may  have  a  falling 
temperature  and  a  consequent  depression.  The 
severity  of  the  symptoms  depends  entirely  upon 
the  degree  of  infection. 

On  the  other  hand,  if  the  foreign  protein  is  not  in- 
fectious and  is  introduced  at  frequent  intervals  then 
there  are  often  no  marked  symptoms  except  a  high 
and  low  temperature,  rising  during  digestion  and 
gradually  dropping  again  to  normal  at  its  conclusion. 
A  marked  chill  may  also  occur  though  usually  there 
is  only  a  rise  of  temperature.  Chilly  sensations  up 
and  down  the  back  are  quite  common.  Unless  pro- 
tein from  a  thrombophlebitis  is  infectious  it  is  di- 
gested with  the  elimination  of  heat,  but  there  are 
no  symptoms  of  depression.  When  the  foreign  body 
is  large  enough  it  may  obstruct  certain  vessels,  be- 


coming an  embolus.  This  condition  is  out  of  the 
category  of  this  discussion. 

When  we  come  in  contact  with  different  zymotic 
diseases  such  as  typhoid,  scarlet  fever,  or  spotted 
fever,  we  at  once  paint  a  mental  picture,  not  only 
of  the  causative  factor,  but  also  of  the  destruction 
in  progress.  We  know  the  effect  produced  in  ty- 
phoid fever  in  the  spleen ;  the  skin  in  scarlet  fever, 
and  the  meninges  in  spotted  fever,  and  because  of 
these  ocular  manifestations  we  are  accustomed  to 
follow  the  ancient  observers  and  apply  a  name  to  an 
effect.  If  we  would  investigate  closely  we  would 
find  that  all  poisons  of  infection  are  the  same.  Dif- 
ferent bacterial  proteins  manifest  their  predilection 
for  certain  cells  only,  and  then  we  may  have  hay 
asthma  affecting  the  air  passages ;  typhoid,  the 
spleen ;  rheumatism,  the  joints,  etc.  A  protein,  not 
being  a  toxin  in  itself,  does  not  develop  or  propagate 
in  the  surrounding  medium  and  therefore  is  easily 
disposed  of  by  digestion  and  fever,  without  much 
more  general  disturbance.  For  that  reason  one  can 
usually  give  a  favorable  prognosis  and  not  subject 
the  patient  to  unnecessary  worry  which  produces 
no  good,  but  perhaps  a  tedious  convalescence. 

For  a  number  of  years  I  have  contended  that 


Chart  I. — Radical  mastoid  operation.  Sinus  thrombosis,  which 
had  broken  down  and  formed  pus  in  centre;  epidural  abscess.  After 
operation  temperature  fell  to  normal;  after  the  seventh  day  tempera- 
ture rose  and  continued  to  rise  and  fall  for  a  week,  then  gradually 
recovered.  At  the  height  of  the  fever,  which  reached  104.5°,  the 
consulting  surgeon  said  the  patient  would  die;  I  disagreed.  The 
patient  recovered. 

typical  temperature  of  protein  digestion  is  not  septic 
or  due  to  infection.  My  remarks  were  greeted  with 
a  smile  of  incredulity  in  certain  quarters.  There- 
fore, I  thought  it  best  to  make  a  somewhat  more 
elaborate  statement  and  emphasize  the  difference 
between   infectious   and  noninfectious  substances. 

Many  of  us  have  encountered  cases  with  temper- 
atures simulating  sinus  thrombosis  and  have  oper- 
ated upon  the  patients  and  found  practically  nothing. 
If  we  would  take  into  account  that  it  requires  more 
than  temperature  to  prove  the  existence  of  a  septic 
clot  in  one  of  the  brain  sinuses,  we  should  hesitate 
before  coming  to  conclusions.  I  do  not  wish  to 
convey  the  impression  that  one  runs  much  risk  in 
opening  the  sigmoid  sinus,  but  it  may  cause  much 
delay  in  a  patient's  recovery. 

My  attention  was  first  attracted  to  such  a  condi- 
tion in  a  physician.  My  impulse  was  to  open  the 
sinus  and  this  course  also  met  the  approval  of 
a  surgeon  and  an  internist,  both  men  of  large  expe- 
rience.  I  hesitated  because  the  patient's  temperature 


326 


COTT:  PROTEIN  FEVER. 


[New  York 
Medical  JouRNAr,, 


after  five  or  six  days  remained  normal  for  twenty- 
four  hours  and  then  took  another  sprint  upwards. 
I  counseled  watchful  waiting.  Then  scrutinizing 
accompanying  symptoms  I  decided  that  I  could 
safely  take  a  chance,  and  the  patient  recovered. 


constant,  but  remitting  from  time  to  time.  This 
fever  is  caused  by  the  sweeping  into  the  circulation 
of  infinitesimal  particles  of  the  new  clot,  causing  a 
rise  in  temperature.  Each  succeeding  particle  pro- 
duces the  .same  effect.  If  bacterial  invasion  con- 
tinues and  thrives  within  the  clot  they  will 
be  swept  into  the  circulation  producing  not 
only  spurts  of  high  temperature  but  also  de- 
lirium, nausea,  chills,  .sweats  and  in  general 
marked  to  profound  depression,  as  in  bac- 
teremia. On  the  other  hand,  when  bacterial 
])ropagation  has  been  checked  or  become 
arrested,  from  some  cause  or  other,  it 
happens  at  times  that  the  particles  keep  on 
being  swept  into  the  circulation  as  before 
until  the  clot  is  finally  set.  This  is  not  an 
occasional  occurrence  but  I  believe  quite  common. 
Fever  is  produced  which  causes  alarm.  It  is  just 
this  latter  class  of  cases  that  .seems  to  bother  the 
otologist  and  the  surgeon  from  time  to  time.  They 
occur  before  an  operation  or  after  one,  but  always 
cause  concern.    Before  considering  the  cause  and 


Chart  II. — Radical  mastoid  operation.  Caries.  Fifth  day  after 
operation,  temperature  rose  and  continued  to  rise  and  fall  for  a 
week.  At  the  end  of  that  time,  in  consultation  with  two  eminent 
men,  an  internist  and  a  surgeon,  it  was  decided  to  explore  the 
lateral  sinus.  But  the  next  day  the  temperature  returned  to  normal 
and  I  put  off  operation.     Final  recovery. 

Since  then  I  have  had  a  number  of  such  experi- 
ences and  in  every  instance  I  gave  a  favor- 
able prognosis  without  further  operation,  and 
all  of  the  patients  eventually  recovered. 
Some  years  ago  I  presented  a  paper  on  this 
subject  before  a  local  society,  in  the  discus- 
sion of  which  Dr.  Bentz,  a  Bufifalo  patholo- 
gist, said  I  might  find  a  solution  of  the  prob- 
lem in  the  experiments  of  Vaughan  which  he 
conducted  during  a  period  of  fifteen  years 
and  which  can  be  found  in  .his  book  (1). 
The  conclusions  given  here  are  entirely  drawn 
from  Vaughan's  work.  Although  it  is  only 
theory  it  is  so  palpable  and  his  experiments 
so  exhaustive  that  I  can  but  accept  the  con- 
clusion drawn  therefrom. 

Let  us  draw  a  mental  picture  of  a  case 
with  suppuration  of  the  middle  ear  and 
phlebitis  o(  a.  sigmoid  sinus,  or  symptoms 
which  which  would  lead  us  to  think  the  sinus 
was  involved.  First  we  have  irritation  of 
the  wall,  its  endothelium  becomes  desqua- 
mated,   its   walls   .softened,    thickened  and 

cnmf>timp«  HiQintporatpfl  rnnpnlatinn  of  blood  OCCUrs  Chart  IV. — Mastoid  disease.  Patient  thought  to  have  typhoid 
SOmetmieS  aiSmiegraieCl,  coagulation  OI  UIOOU  OCCUl.^  ^^^^^  ^^^^^  ^^^^  ruptured  and  discharged  pus  for 

in  the  vessel.     Up  to  this  time  we  may  have  had  no  about  ten  days,  when  I  saw  him.     His  trouble  was  supposed  to  be 

r       t-1      i        •  i-1  1       ■  acute  mastoiditis.     Found  sclerosis  due  to  recurrent  attacks;  mother 

symptoms  reierable  to  sinus  thrombosis.  denied  previous  ear  disease,  but  acknowledged  boy  had  complained 

\!r-m-    lTr>Tirf»Tf>r    fhf^  natif>n1-  hpcrinc  tn   sliriw   sirrn^  "f  earache  off  and  on.     Red  cells,  4,250,000;   white  cells,  10,000. 

.\OW,   nowever,   tne  patient   OegmS  to   snow   signs  j  ;,,^^^^^  ^^^^^  ^^^^^       l^ft  hospital,  then  recovered. 

of  fever,  that  is,  bursts  of  fever,  not  continuous  or 

giving  a  valid  and  plausible  explanation  for 
it,  I  want  to  emphasize  the  fact  that  these 
cases  are  not  septic  and  do  not  end  disas- 
trotisly.  But  to  differentiate  one  must  notice 
that  although  the  temperature  is  of  the  reces- 
sional type  the  patient  does  not  become  worse 
from  his  fever,  is  not  nauseated,  delirious 
nor  depressed.  His  leucocyte  count  is  seldom 
over  10,000;  he  feels  comfortable,  .smiles, 
eats  with  considerable  relish,  and  sleeps  three 
or  four  hours  at  a  stretch.  In  fact  he  com- 
plains of  little.  Some  have  chills,  to  be  sure, 
and  perspire  afterwards  while  others  ])er- 
spire  only  af'ter  their  spurt  of  temperattire 
.,  ,.         T.,         T-     .        ,  1  but  they  all  eventually  recover.    The  tem- 

Chart   III. — Mastoid   disease.     The   peculiar  temperature   caused                                                       ,  •      i  i 

an  examination  by  the  physician  and  a  surgeon,  and  they  concluded  peraturc   differs    frOm    the  Virulently  SeptlC  type  111 

the  patient  had  endocarditis.     The  only  murmur  heard  was  over  the  .  •                        .                  f  .U,.^         rfmai'nc  nnrnnl 

left  scapula  toward  the  vertebra.    Recovery.  l"'^    Way,   tnat   CVCry    tCW  (la>  S   It   remaiUS  nomiai. 


September  4,  1920.] 


COTT:  PROTEIN  FEVER. 


327 


to  resume  its  flight  again  after  this  period  of  rest. 
When  a  septic  temperature  comes  down  to  stay  it 
means  either  recovery  or  death.  This  is  not  so  in 
protein  fever.  Now  let  us  look  into  the  cause  of 
this  peculiar  phenomenon. 

A  protein  molecule  introduced  into  the  circulation 
whether  enteral  or  parenteral  is  a  foreign  body  and 
must  be  removed.  It  is  the  business  of  a  similar 
]>rotein  cell  to  perform  that  duty.  When  the  foreign 
protein  attacks  or  is  attacked,  a  ferment  is  formed 
l)y  the  body  cell  and  the  invader  is  digested.  The 
foreign  protein  is^not  a  toxin,  it  is  a  cause  of  the 
formation  of  the  antibody  and  consequently  the 
cell  is  now  in  a  state  of  anaphylaxis.  In  other 
words,  the  cell  having  been  warned  gets  its  ferment 
ready  for  the  next  invasion  of  a  similar  protein.  If 
in  the  intervals  there  should  be  introduced  other 
foreign  material  dissimilar  in  character  the  same 
])repared  cell  will  not  act,  but  other  cells  will  be- 
come sensitized. 

A  toxin  is  always  a  protean.  All  these  proteans 
contain  a  jwisonous  group  tliat  ordinarily  proves 


once  been  attacked,  is  forewarned  and  gathers  re- 
serve force  in  the  shape  of  more  ferment,  and  is 
ready  for  any  future  attacks.  If  these  attacks  come 
early  and  often  each  is  disposed  of  gradually.  On 
the  other  hand  if  there  is  an  interval  of  several 
weeks  there  may  be  so  much  ferment  stored  up 
that  the  protein  is  overwhelmingly  attacked  and 
thus  sets  free  the  poisonous  group  of  the  molecule 
of  foreign  protein,  often  causing  such  disastrous  re- 
sults. Now  to  analyze  further :  All  proteins  con- 
tain a  poison  group  but  remain  harmless  until  sep- 
arated from  their  secondary  groups  and  thus  the 
intensity  depends  upon  the  thoroughness  and  prob- 
able rapidity  of  isolation.  Foreign  protein,  as  for 
instance  taken  from  a  forming  thrombus,  may  not 
be  infected  with  bacteria  yet  in  its  ultimate  destruc- 
tion cause  a  rise  in  temperature.  This  phenomenon 
is  what  I  mean  by  protein  fever. 

How  may  we  differentiate  between  protean  di- 
gestion and  sepsis?  The  patient's  life  may  depend 
upon  your  action.  Your  attention  is  first  attracted 
to  the  rising  and  falling  temperature  taken  every 


ST  VINCENT  S  HOSPITAL  ~. 


ST.  VINCENT'S  HOSPITAL  n. 


ST.  VINCENT'S  HOSPPTAL    n   ST.  VINCENT  S  HOSPITAL 


^^a,£^^^.^^  •u4^!^4i*..AAi-.uj._  (^t^__3_^_  o^u^ 


Chart  \  .— On  .September  3d,  four  days  after  the  operation,,  the  patient  had  a  chill,  and  immediately  afterward  the  temperature  per 
axilla  was  107.6°,  pulse  could  not  be  positively  counted,  respiration  60.  Had  a  consultation  and  decided  to  take  blood  cultures  in  an  effort 
to  determine  whether  the  lateral  sinus  was  involved.  Agar,  gelatin,  and  broth:  cultures  were  negative.  Took  another  blood  culture  Sep- 
tember 10th,  and  it  also  proved  negative.  On  September  19th  the  temperature  rose  to  106.6°;  pulse  125,  and  respiration  35.  Had  another 
consultation  and  decided  that,  further  blood  cultures  proving  negative,  we  would  not  int-rfere  with  the  patient,  who,  in  his  extremely  pre- 
carious condition  and  pneumonic  state,  would  not  well  stand  the  anesthetic  nor  operative  investigation  of  the  lateral  sinus.  Three  days 
after  this  the  temperature  dropped  from  104.4°  to  98.6°.  and  has  remained  normal  ever  since,  and  the  patient's  convalescence  was 
uninterrupted. 


harmless.  They  may  act  as  a  virulent  poison  under 
certain  conditions.  Let  us  lead  up  to  such  a  con- 
dition. A  minute  particle  of  the  thrombus,  which 
may  be  microscopical,  is  swept  into  the  circulation. 
How  small  a  particle  is  necessary  cannot  be  stated. 
Many  chemical  poisons  cannot  be  found  with  the 
microscope  yet  their  symptoms  are  plainly  manifest. 
It  immediately  becomes  a  foreign  body  and  the  cir- 
culating fluid  must  get  rid  of  it,  so  it  is  brought 
within  the  sphere  of  the  cell,  which  being  stimulated 
to  activity  evolves  a  ferment  and  gradually  digest> 
the  intruder.  This  process  is  always  accompanied 
by  heat  and  consequently  there  is  a  rise  in  tempera- 
ture. As  the  process  is  completed  the  temperature 
falls  again.  This  occurs  after  each  successive  in- 
vasion of  the  circulating  fluid  by  a  foreign  protein. 
The  cell  now  having  become  sensitized,  or  having 


four  hours.  In  protean  fever  besides  the  peculiar 
temperature  there  may  be  chills,  sometimes  severe, 
followed  by  perspiration,  seldom  headache.  There 
is  no  pain  in  the  mastoid  region.  The  patient  sleeps 
fairly  well,  feels  well,  has  a  good  appetite,  leucocy- 
tosis  may  be  high.  Some  cases  reported  showed 
thirty  thousand  or  forty  thousand  but  usually  ten 
thousand  or  twelve  thousand  only.  The  per- 
centage of  the  mononuclear  cells  increases  or 
the  number  remain  stationary  for  a  time  and  does 
not  decrease.  Sepsis  also  shows  high  and  low  tem- 
perature with  severe  rigors  and  sweating  and  ano- 
rexia. The  patient  sleeps  badly,  and  there  is  an  in- 
creasing depression.  These  symptoms  gradually 
grow  worse  to  dissolution.  The  blood  count  is 
helpful  in  both  cases ;  in  sepsis  look  for  bacteremia, 
rising  leucocytosis  with  increased  polynuclear  per- 


328 


LONDON  LETTER. 


[New  York 
Medical  Journal, 


centage  and  a  falling  percentage  of  mononuclear 
cells.  When  hemolytic  streptococci  are  found,  the 
case  must  always  be  treated  energetically.  A  decep- 
tive class  of  cases  is  that  following  some  kind  of 
epidemic,  like  the  socalled  influenza.  For  instance, 
patients  may  go  on  with  mild  symptoms  for  several 
weeks  and  possibly  end  disastrously  but  in  these 
cases  pain  over  the  mastoid  is  always  present  and 
always  deep  seated.  The  temperature  seldom  runs 
very  high,  but  these  cases  are  treacherous.  How- 
ever, the  blood  picture  will  usually  tell  the  story. 

There  are  many  case  reports  appearing  in  litera- 
ture in  which  a  tentative  diagnosis  is  made  of  sinus 
thrombosis  with  recovery  because  they  do  not  show 
a  septic  chart.  A  thrombus  does  not  necessarily  mean 
danger  whether  it  is  in  the  cranial  sinuses  or  other 
veins  in  the  body.  This  may  be  noticed  in  many 
cases  of  thrombophlebitis  in  the  lower  limbs;  if  all 
sinuses  were  opened  postmortem  we  might  be  sur- 
prised to  find  thrombi  that  were  never  suspected. 
We  remove  a  thrombus  because  it  is  septic,  never 
because  it  is  present.  A  septic  thrombosis  is  often 
rapidly  fatal,  even  when  removed  early.  Sepsis  is 
often  profound  and  it  may  take  the  patient  weeks 
to  recover.  A  slow  forming  thrombus  gives  a  far 
more  favorable  prognosis,  especially  if  the  tempera- 
ture does  not  reach  105°  or  106°  F.  repeatedly.  I 
have  never  found  these  to  be  fatal  when  a  remission 
lasted  oyer  twenty  four  hours.  My  experience  has 
been  with  suppurating  otitis  only,  and  therefore 
cannot  be  equally  positive  in  zymotic  diseases.  (In 
endocarditis  a  similar  temperature  may  occur.) 

A  case  reported  by  Dr.  Alter,  of  Toledo,  seems  to 
be  fairly  typical  of  protein  digestion.  Alter  states, 
in  summing  up,  "we  abstained  from  further  inter- 
ference, being  well  aware  of  the  fact  that  had  this 
been  a  case  of  sinus  thrombosis  we  would  very 
likely  have  lost  our  patient." 

The  doctor  unfortunately  assumes  that  all  cases 
of  sinus  thrombosis  are  fatal  while  the  fact  remains 
that  only  in  septic  cases  do  the  patients  fail  to 
recover. 

I  believe  it  is  quite  common  to  regard  sinus 
thrombosis  in  otology  as  extremely  dangerous.  My 
object  in  this  paper  is  not  to  regard  it  lightly  but 
to  call  attention  to  the  many  patients  who  recover 
without  further  operative  interference  and  give  a 
possible  explanation  of  the  prominent  symptoms. 

REFERENCES. 

1.  Vaughax  :  Protein  Split  Products. 

2.  Alter:  Ohio  State  Medical  Journal,  September,  1915 
1001  Main  Street. 


Clinical  Signs  of  Cancer  of  the  Esophagus. — 

Guisez  (Presse  medicalc,  May  5,  1920),  on  the 
basis  of  cases  subjected  to  esophagoscopy  and  sub- 
sequendy  kept  under  observation,  lays  stress  on 
certain  clinical  signs,  viz.,  frequently  very  insidious 
onset,  selective  dysphagia  as  regards  bread  •and 
meats,  preservation  of  the  appetite  to  an  advanced 
.stage,  expectoration  of  small  amounts  of  blood- 
stained mucus,  malodorous  breath,  and  a  white  coat- 
ing at  the  base  of  the  tongue.  Differentiation  from 
inflammatory  strictures  and  pseudocancers  is 
sometimes  difficult;  in  this  event  esophagoscopy 
settles  the  diagnosis. 


LONDON  LETTER. 
(From  our  own  correspondent.) 

Aid  for  Tiibcrcidous  Women. — British  Hospital  Closes. — 
Cause  and  Treatment  of  Visceroptosis. — More  Medical 
Students  in  Great  Britain. 

London,  June  6,  ig^o. 

The  committee  of  medical  men  appointed  by  the 
Minister  of  Health  to  advise  his  department  in  ref- 
erence to  tuberculous  diseases  have  during  the  past 
two  months  been  engaged  in  the  selection  of  sites 
for  the  ten  village  settlements  which  are  to  be  estab- 
lished in  Great  Britain  for  ex-service  men.  The 
committee  are  able  to  report  great  progress,  as  they 
have  settled  upon  six  sites  out  of  the  eight  to  be 
allotted  in  England.  These  are  in  Norfolk,  Cam- 
bridgeshire, Essex,  Kent,  Yorkshire,  and  Cheshire. 
One  settlement  is  to  be  provided  in  Wales  and  an- 
other in  Scotland ;  and  it  is  probable  that  an  eleventh 
will  be  established  in  Ireland. 

It  was  pointed  out  recently  in  the  Daily  Telegraph 
that  while  the  various  training  colonies  and  indus- 
trial centres  for  tuberculous  ex-soldiers  and*  ex-sail- 
ors are  still  developing,  and  likely  to  be  of  great  help 
to  the  men,  no  provision  has  been  made  for  women 
suffering  from  tuberculosis,  of  whom  there  are 
many  in  England  who  are  obliged  to  work  for  a 
living,  and  yet,  on  account  of  their  health,  are  un- 
able to  work  in  towns.  It  is  suggested  that  the 
State  provide  institutions  or  sanatoriums  in  which 
these  women  can  work  at  various  industries  and 
earn  enough  to  support  themselves.  Attention  is 
drawn  to  the  fact  that  so  frequently  one  sees  young 
women  just  commencing  a  career  smitten  with 
tuberculosis.  They  have  sanatorium  treatment  for 
about  three  months  and  are  then  told  that  they  must 
on  no  account  go  back  to  their  former  employment 
if  they  wish  to  keep  well.  They  are  faced  with  the 
difficulty  of  learning  a  new  occupation  and  finding 
ideal  conditions  of  labor,  generally  a  sheer  impo^- 
sibility.  Some  are  fortunate  enough  to  have  people 
on  whom  they  can  depend,  others  go  from  one 
sanatorium  to  another  costing  the  State  at  least  two 
guineas  a  week ;  others  again  leave  the  sanatorium 
to  take  up  some  work,  but  have  to  return  in  the 
course  of  a  few  months  for  further  treatment.  If 
an  institution  could  be  provided  where  the  stronger 
subjects  could  live  under  ideal  conditions,  and  thus 
continue  their  treatment,  they  could  work  at  one  or 
another  of  the  occupations  provided,  and  at  least 
help  to  earn  their  board  and  lodging.  If,  in  addition 
to  providing  the  institution  and  bearing  the  initial 
cost,  the  State  were  prepared  to  offer  a  small  wage 
to  each  worker,  possibly  repayable  from  the  sale  of 
her  work,  it  would  enable  the  women  to  provide 
themselves  with  clothing  and,  to  some  extent,  free 
their  mind  from  worry.  It  is  urged  that  all  the 
women  should  be  insured  under  the  National  Health 
Insurance  Act,  so  that  if  they  break  down  and  draw 
sick  benefit  they  will  be  treated  in  the  same  way  as 
the  men. 

An  illustration  of  the  financial  stress  of  British 
hospitals  was  afforded  recently  by  the  announce- 
ment of  the  decision  to  close  the  inpatient  depart- 
ment of  the  National  Hospital  for  the  Paralyzed 
and  Epileptic,  Queen's  Square,  Bloomsbury,  Lon- 


September  4,  1920.] 


LOXDOX  LETTER. 


329 


don.  It  was  stated  some  little  time  ago  that  the 
hospital  was  sadly  lacking  in  funds,  but  it  was 
hoped  that  in  view  of  the  reputation  of  the  institu- 
tion and  the  splendid  work  it  was  doing  and  had 
done,  an  appeal  to  the  generosity  of  the  public 
might  have  the  result  of  raising  sufficient  money  to 
tide  over  the  existing  difficulties.  However,  the 
aid  has  not  been  forthcoming,  and  there  is  no  al- 
ternative but  to  curtail  expenses  in  every  possible 
way.  The  greatly  increased  cost  of  living  has 
weighed  heavily  on  all  charitable  institutions.  The 
expenditure  of  the  hospital  in  question  has  risen 
during  the  past  five  years  from  £i6,ooo  to  £32,000 
on  which  an  annual  deficit  of  £7,000  has  been  in- 
curred, and,  as  said  before,  the  committee  have 
come  to  the  conclusion  that  the  only  course  left  is 
to  close  the  wards.  The  outpatient  department  will 
remain  open,  but  no  more  patients  will  be  admitted 
for  treatment,  and  a  long  waiting  list  has  been  can- 
celled. Dr.  Addison,  the  minister  of  health,  stated 
in  the  House  of  Commons  a  few  days  ago  that  he 
had  been  given  to  understand  that  the  King  Ed- 
ward Hospital  Fund  was  prepared  to  consider  the 
application  from  the  hospital  for  an  immediate 
emergency  g^rant. 

^    ^  ^ 

At  a  meeting  of  the  Edinburgh  Medico-Chiru- 
gical  Society,  held  on  June  2d.  enteroptosis  and  as- 
sociated conditions  were  discussed.  Among  those 
who  took  part  in  the  discussion  was  Sir  Harold 
Stiles,  who  said  that  of  all  the  subjects  in  the  bor- 
derland of  medicine  and  surgery  that  of  viscerop- 
tosis probably  interested  him  most.  In  the  majority 
of  cases  the  patient  had  been  treated  by  the  physi- 
cian, the  gynecologist,  and  ear  and  throat  specialist 
before  coming  to  the  surgeon.  The  surgeon,  there- 
fore, saw  the  late  cases,  but  the  important  point 
was  the  origin  of  the  condition.  There  must  be 
an  anatomical  and  developmental  cause  for  the  con- 
dition. The  perfectly  normal  person,  in  the  sense 
of  the  anatomist  or  sculptor,  was  the  exception 
rather  than  the  rule  ;  but  within  certain  limits  of 
variation  many  persons  might  be  regarded  as  nor- 
mal, and  there  might  be  considerable  departures 
from  this  and  yet  no  symptoms  might  arise.  There 
were  often  physical  defects  which,  in  the  first  in- 
stance, did  not  lead  to  disease.  There  were  varia- 
tions in  the  skeleton,  and  the  long  and  slender  type 
supplied  the  cases  of  visceroptosis.  In  certain 
families  it  was  not  difficult  to  understand  from  the 
configuration  why  there  might  be  displacements  of 
the  stomach,  kidney,  ovary,  colon,  or  uterus.  Di- 
versity must  be  expected  in  the  number  and  position 
of  folds,  because  of  the  complexity  of  development 
of  the  intestine  and  peritoneum.  Certain  children 
were  born  with  a  degree  of  visceroptosis,  and  it 
was  only  a  question  of  time  before  symptoms  would 
arise.  The  proximal  part  of  the  colon,  because  of 
the  way  in  which  it  was  slung  and  because  of  its 
greater  absorptive  function,  gave  rise  to  symptoms 
much  more  readily  than  the  distal  part.  The  forma- 
tion of  various  bands  was  described.  The  absorption 
of  toxins  led  to  faulty  muscular  tone,  involving 
both  voluntary  and  involuntary  muscle.  Innerva- 
tion was  interfered  with,  adipose  tissue  was  lost. 


and  the  viscera  tended  to  slip  downward.  An  es- 
sential in  treatment  was  physical  education,  and  if 
this  was  carried  out  in  children  of  predisposing 
type,  the  visceral  and  associated  clinical  conditions 
would  not  occur.  Enteroptosis  affected  more  women 
than  men.  It  was  more  common  among  the  un- 
married and  the  married  without  children,  and  it 
was  possible  that  there  was  a  subtle  something, 
perhaps  of  a  sexual  character,  which  detennined  the 
onset  of  symptoms.  In  bad  cases  a  plaster  cast 
should  be  taken  and  supports  made  from  it.  Ex- 
ercises were  essential.  In  the  neurasthenic  patients, 
presenting  severe  symptoms,  removal  of  the  prox- 
imal part  of  the  colon  was  of  benefit  in  carefully  se- 
lected cases.  Sir  Harold  Stiles  said  that  he  had  done 
the  operation  in  sixty  cases.  He  had  been  able  to  fol- 
low twenty-seven,  and  in  a  third  of  these  there 
had  been  great  improvement,  in  one  third  some  im- 
provement, and  only  in  two  cases  had  there  been 
no  benefit.  I\Ir.  Dowden  agreed  with  him  that 
symptoms  often  did  not  arise  until  what  he  also 
has  noted  as  a  "subtle  something"  had  occurred. 
This  was  sometimes  a  mental  shock  or  worry.  Dr. 
Edwin  Bramwell  said  that  emotional  conditions 
often  determined  the  onset  of  symptoms,  and  re- 
ferred to  the  danger  of  setting  up  an  anxiety  neu- 
rosis by  the  search  for  an  insistence  on  a  physical 
cause  for  symptoms.  Perhaps,  after  all,  viscerop- 
tosis is  more  of  a  neurosis  than  due  to  physical 
causes,  or  is  it  the  physical  cause  with  its  attendant 
or  subsequent  toxemia  that  brings  about  the  neuro- 
sis ?  Sir  Arbuthnot  Lane  insists  that  the  neurosis 
is  the  effect  and  not  the  cause  of  visceroptosis,  and 
his  opinion  carries  great  weight. 

^    ^  ^ 

At  a  recent  meeting  of  the  General  Medical 
CoiHicil,  Sir  Donald  MacAlister,  the  president, 
said  that  while  on  the  home  list  only  872  practition- 
ers were  registered  in  1919,  no  fewer  than  450 
were  registered  in  the  Colonial  and  foreign  list. 
The  result  was  that  the  total  number  of  new  names 
was  higher  than  in  any  year  since  1915.  The  pro- 
portion of  woman  practitioners  had  increased  and 
was  likely  to  increase  dtiring  the  next  year  or  two. 
It  was  said,  however,  on  good  authority, 
that  their  services  were  in  less  demand  than  during 
the  war,  and  that  newly  qualified  women  were  find- 
ing difficulty  in  obtaining  suitable  opportimities  for 
professional  work.  Supply  and  demand  would  no 
doubt  adjust  themselves  in  time  but  in  view  of  the 
large  entry  of  woman  students  it  was  proper  to 
warn  those  concerned  that  in  the  meantime  indi- 
vidual disappointments  might  be  encountered.  The 
Aledical  Sttidents'  Register  indicated  that  the  de- 
pletion of  their  professional  ranks  by  the  wastage 
of  war  would  in  a  few  years  be  much  more  than 
made  good  by  the  addition  of  newly  qtialified  men. 
Xo  fewer  than  3,420  medical  students,  men  and 
women,  were  registered  in  1919,  as  compared  with 
1.600  in  1914.  The  number  of  registrations  ex- 
ceeded by  over  1,000  the  highest  previously  re- 
corded, namely  2.405  in  1891.  The  strain  thrown 
upon  the  medical  schools  of  the  cotmtr\^  was  for 
the  time  excessive,  and  most  of  the  schools  wotikl 
welcome    an    ebb    in    the    tide    of  applican*^- 


1., 


Editorial  Notes  and  Comments 


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NEW  YORK,  SATURDAY.  SEPTEMBER  4.  1920. 


PHYSICIAN  AUTHORS— DR.  OLIVER 
WENDELL  HOLMES. 

America's  greatest  physician  author,  Dr.  OHver 
Wendell  Holmes,  was  a  gentleman  and  scholar  of 
the  old  school  whose  poems  and  essays  stand  high 
among  the  classics  of  the  literature  of  this  country. 
He  was  a  novelist,  too,  but  his  fame  as  a  novelist 
proved  to  be  somewhat  ephemeral.  Nevertheless, 
his  Elsie  Vcnncr  was  the  most  lauded  novel  written 
in  America  during  the  decade  of  1860-70.  "Medi- 
cated fiction"  Dr.  Holmes  called  it,  chatty,  dis- 
cursive and  brilliant,  but  hardly  a  novel  in  the  strict 
sense  of  the  word.  Elsie  is  a  mere  case  of  antenatal 
impression.  The  plot  is  what  the  critics  are  wont 
to  call  extravagant  and  unconvincing.  Sad  to  say, 
a  vast  majority  of  fiction  plots  are  of  that  very  cal- 
ibre. But  Dr.  Holmes's  object  in  the  writing  of 
Elsie  Venncr,  as  he  pointed  out,  "was  to  bring  the 
dogma  of  inherited  guilt  and  its  consequences  to  a 
clearer  point  of  view,"  and  there  is  no  gainsaying 
that  this  object  was  adequately  achieved. 

In  Elsie  Vernier  many  subjects  that  are  not  ger- 
mane to  the  story  are  discussed  with  the  same  bril- 
liant wit  and  kindly  humanity  that  characterize  The 
Autocrat  of  the  Breakfast  Table,  and  its  companions 
of  the  breakfast  table  series,  The  Professor  and  The 
Pact.  It  is  on  these  three  volumes,  and  especially 
on  The  Autocrat  and  The  Professor,  that  the  fame 
of  Dr.  Holmes  chiefly  rests.  The  Autocrat  was  the 
first.  The  first  installment  of  it  was  published  in 
the  first  isstie  of  the  Atlantic  Monthly  and  leaped 


into  general  popularity  overnight.  The  Autocrat 
appeared  in  the  first  twelve  numbers  of  the  Atlantic 
and  served  to  keep  that  new  literary  venture  on  its 
feet  during  the  panic  of  1857.  The  name  Atlantic, 
incidentally,  was  Dr.  Holmes's  suggestion  when  he 
and  the  editor,  James  Russell  Lowell,  discussed  a 
name  for  the  new  publication.  Lowell  had  accepted 
the  editorship  of  the  magazine  only  on  condition 
that  he  could  have  Dr.  Holmes  as  his  assistant. 

The  Autocrat  papers  were  followed  by  The  Pro- 
fessor papers,  which  rivalled  the  former  in  popu- 
larity. It  was  not  until  twelve  years  later  that  Dr. 
Holmes  wrote  The  Poet  at  the  Breakfast  Table,  but 
this  series  did  not  meet  with  the  success  that  accom- 
panied the  earlier  efforts.  However,  in  all  three 
there  is  a  brilliancy  of  wit  and  humor  that  has  sel- 
dom if  ever  been  equalled. 

In  all  Dr.  Holmes  wrote  three  volumes  of  poems 
and  ten  volumes  of  prose.  Many  of  his  poems  were 
published  while  he  was  yet  a  student  at  Harvard, 
froiTi  which  university  he  was  graduated  with  the 
"famous  class  of  '29."  In  obedience  to  the  tradi- 
tions of  his  mother's  family.  Dr.  Holmes,  following 
his  graduation  from  Harvard,  began  the  study  of 
law,  but  he  found  law  uncongenial  and  after  a  year 
gave  it  up  and  turned  his  attention  to  the  study  of 
medicine,  and  soon  found  that  he  liked  it.  Mean- 
while he  dabbled  in  literature  and  it  v/as  at  this  time 
that  he  wrote  those  fervent  verses.  Old  Ironsides, 
which  saved  the  historic  frigate  Constitution  from 
destruction.  Old  Ironsides  was  what  Dr.  Holmes 
called  "an  impromptu  otitbiirst  of  feeling"  inspired 
by  a  Navy  Department  order  that  the  Constitution 
be  destroyed.  The  verses,  still  popular,  were  sung 
all  over  the  country  and  created  such  a  weight  of 
public  opinion  that  the  Navy  Department  had  to 
countermand  its  order.  Dr.  Holmes's  first  volume 
of  poems  was  published  in  1836,  and  in  it  was  his 
Last  Leaf,  accounted  one  of  the  finest  pieces  of 
poetry  in  the  English  language. 

After  a  brief  experience  in  medicine  in  Boston, 
Dr.  Holmes  went  to  Paris  in  1833  and  studied  under 
many  famous  physicians  and  surgeons.  He  re- 
turned to  Boston  two  years  later  and  established 
himself  there  permanently,  with  this  as  his  motto: 
"The  smallest  fevers  thankfully  received,"  as  he 
put  it  humorously  in  conversation  with  friends. 
He  already  had  a  wide  reputation  as  a  brilliant  wit 
and  this  seeined  to  cause  the  sober  minded  Boston- 
ians  to  doubt  his  medical  skill.  Regardless  of  this 
skepticism  of  the  Bostonians,  Dr.  Holmes  was  a 
very  advanced  physician  who  made  many  contribu- 
tions to  medical  knowledge.    In  1843  he  published 


ft 


September  4,  1920.] 


EDITORIAL  ARTICLES 


an  essay  on  The  Contagiousness  of  Puerperal  Fever 
and  a  fierce  controversy  arose  over  this  publication, 
in  which  Dr.  Holmes  was  assailed  by  those  who 
disagreed  with  him.  In  time,  however,  he  came  to 
be  honored  as  the  discoverer  of  this  truth.  In  his 
earlier  years  Dr.  Holmes  won  many  prizes  for  pro- 
fessional papers  and  eked  out  his  income  by  lec- 
turing on  anatomy  at  Dartmouth  College.  His 
volume  of  medical  essays,  although  not  so  well 
known  to  the  general  public  as  his  other  work,  con- 
tains some  of  his  most  sparkling  wit,  his  shrewdest 
observations  and  kindliest  humanit}-.  In  1847  he 
/  was  appointed  professor  of  anatomy  and  physiology 
in  the  Har\-ard  Medical  School  and  continued  this 
professorship  until  1883,  when  he  was  seventy-four 
years  old.  From  about  1860  onward  this  was  aboi.it 
his  only  link  with  the  profession,  for  following  the 
publication  of  The  Autocrat  in  book  form  he  de- 
voted himself  wholly  to  literature. 

As  a  writer  Dr.  Holmes  was  active  almost 
up  to  the  day  of  his  death,  in  1894,  at 
the  age  of  eighty-five.  His  third  and  last  novel. 
A  Moral  Antipathy,  was  published  when  he  was 
seventy-five  and  he  wrote  his  Life  of  Emerson  when 
he  was  past  three  score  and  ten.  His  last 
volume,  Over  the  Teacups,  after  the  manner  of 
The  Autocrat,  was  begun  in  1888  when  he  was 
nearly  four  score.  His  place  is  among  the  bright 
and  happy  spirits  of  literature  and  there  is  fair 
assurance  that  he  will  forever  hold  that  place. 


THE  DIAGNOSIS  OF  RETROVESICAL 
HYDATID  CYSTS. 

Retrovesical  localizations  of  hydatid  cysts  in  man 
are  relatively  rare.  The  cyst  develops  in  the  sub- 
peritoneal connective  tissue  between  the  bladder 
and  rectum,  and  being  supported  by  the  pelvic  floor 
the  cyst  grows  to  the  sides  of  the  pelvis  and  up- 
ward, compressing  all  the  structures  surrounding  it. 
Usually  its  evolution  is  slow,  but  as  soon  as  urin- 
ar\-  disturbances  accrue  the  consequences  may 
quickly  become  fatal.  The  rounded  shape  of  the 
growth,  its  situation  in  the  midline  and  the  fluctua- 
tion frequently  lead  to  the  diagnosis  of  an  over- 
distended  bladder,  as  its  upper  outline  may  reach 
the  umbilicus.  Passage  of  a  catheter  shows  that 
the  bladder  is  empty  or  at  least  contains  an  ordinary 
amount  of  urine  and  the  tumor  will  be  found  by 
rectal  examination,  showing  its  pelvic  development. 

In  Saxahausty's  case  the  diagnosis  of  sarcoma 
of  the  prostate  was  made  and  after  incision  of  the 
perineum  hydatid  cysts  were  seen  to  issue  forth. 
Tillaux  likewise  made  the  same  diagnostic  error, 
while  Wood  performed  a  suprapubic  cystotomy  for 
what  he  supposed  was  a  hypertrophied  prostate.  In 


Kean's  case — reported  by  Jendy  (Thesis.  Paris. 
1913) — the  patient  was  a  boy  of  seven  years:  the 
diagnosis  at  first  wavered  between  a  cyst  of  the 
mesentery  and  a  cold  abscess  developing  in  the  hori- 
zontal branch  of  the  pubis,  the  latter  conclusion 
having  been  agreed  upon.  An  exploratory  punc- 
ture was  consequently  made  and  revealed  the  true 
nature  of  the  tumor. 

L'sually  the  clinical  diagnosis  of  these  cysts  is 
not  made  unless  exploratory  punctures  or  incisions 
are  resorted  to,  but  in  some  cases  a  correct  diag- 
nosis is  possible  without  these  means.  The  func- 
tional symptoms  are  not  sufficient  to  make  a  diag- 
nosis, although  they  may'  lead  the  surgeon  to  sus- 
pect the  real  condition  of  affairs,  but  the  phw-ical 
signs  are  all  important.  The  tuinor  is  hard,  round- 
ed, and  smooth.  These  signs  are  constant  and  al- 
though they  are  not  pathognomonic  when  met  with 
singly,  when  they  are  all  present  in  the  case  of  a 
tiunor  of  the  pelvis  they  offer  strong  presumption 
in  favor  of  a  diagnosis  of  hydatid  cyst.  Unfortiuiate- 
ly,  the  only  truly  pathognomomic  sign — hydatid 
thrill — is  absent  and  we  only  know  of  one  instance  in 
which  it  was  present,  that  of  Tuftier  referred  to  by 
Getten  in  his  thesis  (Paris,  1898  ).  When  by  punc- 
ture perfectly  clear  fluid  is  withdrawn  the  diagnosis 
can  be  made,  but  sometimes  the  fluid  does  not  come 
away,  although  in  these  circumstances  the  possi- 
bilitv  of  a  hydatid  cyst  must  not  be  eliminated.  \Mien 
the  needle  does  not  give  issue  to  the  fluid  it  is  be- 
cause the  cyst,  filled  by  daughter  vesicles,  flees  from 
the  instrument  just  like  the  intestine  in  cases  of 
ascites.  If  fluid  does  not  exist  or  has  become  col- 
lected in  the  parts  it  cannot  be  withdrawn,  as  for 
example,  in  Legrand's  case,  where  a  cyst  existed 
tightly  packed  with  hydatids.  Briefly,  a  diagnosis 
can  be  made  if  hydatid  thrill  can  be  made  out  or 
when  the  exploratory  puncture  is  positive ;  it  can 
only  be  one  of  probability  when  the  physical  signs 
exist.  Research  for  the  deviation  of  the  comple- 
ment and  eosinophilia  should  be  resorted  to. 


INTESTINAL  VERTIGO. 
Like  the  stomach,  the  intestine  may  be  the  cause 
of  the  phenomena  of  vertigo.  Glenard,  Sigaud, 
Vincent,  not  to  mention  others,  have  met  with  them 
in  instances  of  prolapse  of  the  transverse  colon 
with  bending  of  the  angle,  in  distention  of  the 
colon  by  gas,  and  typhlectasis,  while  Pron.  Men- 
del, and  others  have  reported  instances  of  vertigo 
in  cases  of  chronic  enterocolitis  interspersed  with 
acute  painful  paroxysms.  Special  credit  is  due  to 
Loeper,  of  Paris,  for  the  report  of  numerous  cases 
with  radioscopic  verification,  examination  of  the 


332 


.NEIVS  ITEMS. 


[New  York 
Medical  Journal. 


blood  pressure,  etc.,  as  well  as  the  development  of 
a  brilliant  pathogenic  theory. 

All  types  of  vertigo  may  be  met  with  in  intestinal 
disturbances,  from  simple  indecision  in  walking  to 
the  state  of  )ual  vcrtigincux,  and  even  Meniere's 
vertigo  with  falling  and  vomiting  has  been  known 
to  occur.  Loeper  records  the  case  of  a  male  thirty- 
nine  years  of  age  who  had  been  constipated  for 
years  and  who  complained  of  an  emptiness  in  the 
head,  cephalic  malaise  and  fainting  whenever  he 
went  two  days  without  a  stool.  For  several  months 
the  constipation  had  increased,  likewise  the  other 
symptoms,  to  which  an  ataxic  gait  became  added. 
He  also  suffered  from  beating  in  the  head,  tinnitus 
aurium  and  dizziness.  All  these  symptoms  disap- 
peared after  the  intestine  had  been  emptied  by  oil 
enemata.  Abdominal  palpation  was  negative,  the 
appetite  good  and  the  general  state  perfect.  The 
ears  were  absolutely  normal,  the  pupils  reacted  to 
light  although  greatly  dilated,  and  the  patellar  re- 
flexes were  exaggerated.  Blood  pressure  was  usu- 
ally found  below  normal,  the  urine  rich  in  indican. 

Another  case  recorded  by  Loeper  which  we  give 
as  an  example  of  intestinal  vertigo  was  that  of  a 
male  who  had  followed  a  farinaceous  diet  on  ac- 
count of  a  long  standing  enteritis.  He  suffered 
frequently  from  meteorism.  pain,  palpitation,  nau- 
sea, tinnitus  aurium,  and  vertigo  and  twice  he  fell 
although  consciousness  was  not  lost.  Colonic  dis- 
tention was  verified  by  radioscopy  while  the  blood 
pressure  reached  twenty-one  and  more  when  the 
meteorism  was  marked  and  vertigo  appeared. 
There  were  appreciable  lesions  of  the  circulatory 
system  and  by  a  less  exclusive  diet,  combined  with 
pancreatin,  the  blood  pressure  dropped  to  sixteen 
and  the  vertigo  disappeared. 

Intestinal  vertigo  in  young  subjects  is  not  seri- 
ous ;  it  is  a  troublesome  symptom  but  is  usually  re- 
covered from  by  proper  treatment.  In  elderly 
people,  on  account  of  the  resulting  high  tension,  it 
may  be  the  prelude  to  cerebral  hemorrhage.  Ac- 
cording to  Loeper,  the  vertigo  is  due  to  a  variation 
of  pressure  in  the  semicircular  canals,  which  may 
or  may  not  be  independent  of  the  general  circula- 
tion. In  the  first  case  the  blood  pressure  is  nor- 
mal or  below  normal  and  a  spasm  or  localized  flux 
comes  into  play ;  in  the  second  case  there  is  a  sudden 
hypertension  of  the  entire  circulator}-  system. 

All  these  phenomena  may  be  provoked  in  patients 
with  intestinal  disturbances  by  four  principal 
causes,  namely :  The  congestion  of  the  digestive 
apparatus  during  intestinal  digestion;  blood  ple- 
thora; absorption  of  toxic  products  or  at  all  events 
vasotonic  substances,  and,  lastly,  abdominal 
reflex.     The     hypotensive     action     of  certain 


toxic  products  elaborated  in  the  intestine 
of  constipated  subjects  and  the  passage  into  the 
urine  of  a  hypotension  of  intestinal  origin  has  been 
experimentally  demonstrated  by  Loeper.  Vertigo 
from  hypertension  is  of  reflex  origin. 


A  NEW  JOURNAL. 

Decrease  of  working  hours  must  bring  increased 
leisure  for  reading  of  all  the  marvels  around  us. 
Some,  of  course,  are  satisfied  with  a  jerky  articfe  in 
the  Sunday  paper,  or  the  report  of  a  discovery,  con- 
densed to  absurdity,  in  the  daily  news.  In  Discov- 
ery, which  is  a  popular  journal  of  knowledge,  pub- 
lished by  Murray  in  London,  the  opinion  is  given 
that  the  specialist,  when  he  has  told  of  his  results 
to  fellow  workers  in  the  usual  way,  should  make 
those  same  results  plain  to  the  ordinary  man  in 
books,  pamphlets  or  articles.  Certainly,  those  pa- 
pers in  the  first  number  are  extraordinarily  clear 
and  well  chosen,  but  this  was  to  be  expected,  for 
all  the  leaders  in  science — including  medicine,  sur- 
gery and  pathology — are  on  the  writing  staff.  The 
journal  is  maintained  under  a  deed  of  trust;  the 
Presidents  of  the  Royal  Society  and  the  British 
Academy  being  two  of  the  trustees,  and  the  British 
Psychological  Society  and  the  Royal  Society  of 
Economics  on  the  committee  of  management, 
along  with  every  learned  society  of  note.  Its  good 
paper  and  large  print  are  not  minor  virtues  in  these 
days  of  expensive  light  and  efforts  to  read  during 
the  daily  ricle  on  rail  and  road. 

 ^  

News  Items. 

Mount  Sinai  Hospital  Receives  Gift. — The  late 
Henry  L.  Einstein,  of  New  York,  bequeathed  $25,- 
000  to  Mount  Sinai  Hospital. 

Additions  to  University  of  Maryland  Hospital. 

— The  L'niversity  of  Maryland  Hospital  is  under- 
taking to  raise  funds  to  provide  an  obstetrical  de- 
partment and  a  nurses'  home. 

Prize  for  Ambidexterity. — The  ^ledical  School 
of  Guayaquil,  Ecuador,  has  offered  a  prize  of  100 
piastres  to  the  schoolmaster  who  trains  the  largest 
number  of  ambidextrous  pupils. 

Plague  at  Galveston. — The  eighth  case  of  bu- 
bonic plague  is  reported  at  Galveston  by  surgeons 
of  the  United  States  Public  Health  Service,  and 
another  case  is  under  observation. 

Death  of  Professor  Guyon. — Jean  Casimir  Felix 
Guyon,  word  of  whose  death  has  recently  been 
received,  was  professor  of  genitourinary  surgery  at 
the  Hopital  Necker,  Paris,  and  for  many  years  edi- 
tor Avith  Lancereaux  of  Annales  des  maladies  des 
organcs  genito-urinaircs.  He  was  a  member  of  the 
Institute  and  of  the  Academy  of  Medicine. 

Radium  Service  at  Hotel-Dieu. — The  municipal 
council  of  Paris  has  decided  to  add  to  the  Hotel- 
Dieu  a  radiotherapeutic  department  for  the  treat- 
ment of  cancer.  A  gift  of  40.000  francs  has  been  of- 
fered by  the  Ligiic  franco-anglo-americaine,  and 
the  remainder  of  the  cost  will  be  defrayed  by  the 
mtmicipality. 


September  4.  1920.] 


XEJIS  ITEMS. 


333 


Dysentery  in  Baltimore. — An  unusually  large 
amount  of  dysentery  has  been  reported  during  the 
present  summer  in  Baltimore,  and  the  infant  death 
rate  has  been  increasing. 

Chicago  Polyclinic  to  Build. — The  Chicago 
Polvclinic  is  endeavoring  to  raise  funds  for  a  hos- 
pital building,  to  be  erected  on  a  site  adjoining  the 
present  Henrotin  Hospital. 

Harvard  Medical  School  Receives  Gift. — The 
Rockefeller  Foundation  has  given  the  Harvard 
Medical  School  $350,000  for  the  development  of 
psychiatry  and  $300,000  for  the  teaching  of  ob- 
stetrics. 

Canadian    Anesthetists    Form    Society. — The 

Canadian  Society  of  Anesthetists  was  recently 
formed,  with  the  object  of  promoting  the  science, 
practice,  and  teaching  of  anesthesia.  Dr.  Samuel 
Johnston,  of  Toronto,  is  president. 

Physical  Education  in  France. — A  bill  provid- 
ing for  compulsory  physical  education  of  children 
has  been  passed  by  the  French  Senate.  The  train- 
ing will  begin  at  the  age  of  six  and  in  the  case  of 
boys  will  continue  until  their  period  of  military 
training. 

Alcoholic  Cases  Increasing  at  Bellevue. — A  re- 
port of  Commissioner  of  Charities  Bird  S.  Coler 
states  that  cases  of  alcoholism  at  Bellevue  Hospital 
have  increased  in  frequency  during  the  last  few 
weeks  until  the  number  virtually  equals  that  before 
prohibition. 

Dr.    Huffman    Receives    Appointment. — Dr. 

Otto  V.  Huffman,  formerly  dean  and  acting  pro- 
vost of  Long  Island  College  Hospital,  has  been  ap- 
pointed a  member  of  the  faculty  of  the  New  York 
Post-Graduate  College  and  Hospital  and  chief  of 
the  medical  clinic. 

Resignation  of  Dr.  Hyman. — Dr.  Albert  S.  Hy- 
man,  resident  physician  at  the  Long  Island  Hos- 
pital, has  resigned  to  become  superintendent  of  the 
Mt.  Sinai  Hospital  in  Philadelphia.  His  successor 
is  Dr.  Albert  B.  !Murphy.  formerly  assistant  resi- 
dent physician  at  the  hospital. 

Kings  County  Almshouse  to  Be  a  Hospital. — 
The  Kings  County  Almshouse,  N.  Y.,  has  been 
closed  and  will  be  turned  into  a  hospital  for  chronic 
cases,  to  be  administered  by  the  city.  About  600 
chronic  cases  will  be  transferred  to  the  new  insti- 
tution from  the  Kings  County  Hospital. 

Personal. — Dr.  L.  Duncan  Bulkley,  of  lo  East 
Sixty-first  Street,  New  York,  has  retired  from  the 
active  practice  of  dermatology  and  will  devote  his 
attention  to  consultation  practice  in  the  same  and 
to  the  treatment  of  cancer. 

Dr.  Harry  Plotz,  of  the  U.  S.  Public  Health 
Service,  has  recentlv  returned  to  this  country  from 
Poland. 

Honorary  Degrees. — The  University  of  St. 
Andrews  has  awarded  the  degree  of  LL.D.  to  the 
following  men :  Mr.  W.  J.  Matheson.  president  of 
the  biological  laboratory  of  the  Brooklyn  Institute 
and  chemical  adviser  to  the  New  York  City  Board 
of  Health ;  Dr.  Leon  Frederick,  professor  of  pathol- 
ogy in  the  University  of  Liege,  Belgium,  and  Dr. 
Norman  Walker,  inspector  of  anatomy  for  Scotland 
and  representative  of  the  profession  in  Scotland 
on  the  General  Medical  Council. 


Interallied  Conference. — The  fourth  interallied 
conference  for  the  study  of  questions  pertaining  to 
war  invalids  will  be  held  September  19th  to  24th 
in  Brussels. 

New  Westchester  Hospital. — A  new  hospital 
to  be  known  as  the  \'alhalla  Neurological  Hospital 
will  be  opened  October  1st  at  Valhalla,  Westchester 
County,  N.  Y.  The  institution  will  be  located  on 
a  site  covering  twenty-five  acres  and  include  a 
tennis  court  and  athletic  grounds.  There  are  eight- 
een buildings.  Among  those  on  the  medical  execu- 
tive committee  are :  Dr.  Max  G.  Schlapp,  professor 
of  neuropathology  at  New  York  Post-Graduate 
^Medical  School  and  Hospital ;  Dr.  Tohn  P.  Grant, 
Dr.  John  J.  McPhee,  Dr.  Emil  Altman,  Dr.  W.  I. 
Sirovich  and  Dr.  Julius  Broder. 

Regional  Health  Conference  in  Washington. — 
The  first  of  a  series  of  regional  health  conferences 
authorized  by  the  International  Health  Conference 
in  Cannes  is  to  be  held  in  Washington,  D.  C,  De- 
cember 6th  to  13th.  It  will  be  devoted  to  a  con- 
sideration of  venereal  disease. 

The  conference  is  being  organized  under  the  joint 
auspices  of  the  United  States  Interdepartmental 
Social  Hygiene  Board,  the  United  States  Public 
Health  Service,  the  American  Red  Cross,  and  the 
American  Social  Hygiene  ^Association.  Professor 
William  H.  W'elch  of  Johns  Hopkins  will  serve  as 
president. 

The  conference  will  review  past  experiences  and 
existing  knowledge  as  to  the  causes,  treatment,  and 
pt-evention  of  venereal  diseases,  and  will  formulate 
recommendations  relating  to  a  practicable  three 
year  program  for  each  of  the  North  and  South 
American  countries  participating.  In  addition  it  will 
make  suggestions  for  putting  such  programs  into 
effect. 



Died. 

Boone. — In  Troutville,  Va.,  on  Friday,  July  9th,  Dr. 
George  A.  Boone,  aged  seventy  years. 

Churchill. — In  New  York,  N.  Y.,  on  Friday,  August 
20th.  Dr.  Frank  Churchill,  aged  sixtj'-six  j-ears. 

Classen. — In  Albany,  N.  Y.,  on  Thursday,  August  12th, 
Dr.  Frederick  Luke  Classen,  aged  sixty-three  years. 

Cracraft. — In  Wheeling,  W.  Va.,  on  Monday,  July  26th, 
Dr.  William  A.  Cracraft,  aged  seventy-six  years. 

Florence. — In  New  York,  N.  Y.,  on  Sunday,  August  8th, 
Dr.  William  Steed  Florence,  aged  twenty-three  years. 

Furness. — In  Wallingford,  Pa.,  on  Wednesday,  August 
11th,  Dr.  William  Henrj'  Furness,  aged  fifty-four  years. 

Gelixeau. — In  Eastliampton,  Mass.,  on  Wednesday. 
August  18th,  Dr.  Joseph  Homer  Gelineau,  aged  thirty-eight 
years. 

Harrison. — In  Enfield,  N.  C,  on  Thursday,  August 
19th,  Dr.  Aristides  Smith  Harrison,  aged  fifty-six  years. 

Laase. — In  New  York,  N.  Y.,  on  Saturday,  August  21st, 
Dr.  Christian  Frederick  John  Laase,  aged  fifty-one  years. 

McDowell. — In  Butternut,  Va.,  on  Thursday,  July  29th, 
Dr.  Ivan  W.  McDowell,  of  Savannah,  Ga.,  aged  thirty-five 
years. 

Murphy. — In  Elmira,  N.  Y.,  on  Tuesday,  August  7th, 
Dr.  Daniel  P.  Murphy,  aged  forty-six  years. 

Wagner. — In  Warrensburg,  N.  Y.,  on  Sunday,  August 
8th,  Dr.  Edward  Wagner,  aged  fifty-one  years. 

Wesselhoeft. — In  Cambridge,  Mass.,  on  Tuesday, 
August  17th,  Dr.  Walter  Wesselhoeft,  aged  eighty-two 
years. 


Book  Reviews 


PRINCIPLES  OF  ANTEXATAL  AND  POST- 
NATAL PHYSIOLOGY. 

The  Principles  of  Antenatal  and  Postnatal  Child  Physi- 
ology, Pure  and  Applied.  By  W.  M.  Feldmax,  M.  B.. 
B.  S.  (Lond.),  Assistant  Physician  and  Lecturer  on  Child 
Physiology  at  the  Infants'  Hospital.  Illustrated.  London 
and  New  York :  Longmans,  Green  &  Co.,  1920.  Pp. 
xvii-691. 

This  is  a  comprehensive  study  of  the  physiology 
of  the  fetus  and  child.  Too  little  has  been  ofifered 
in  this  field,  but  now  we  are  rewarded  by  a  splen- 
did textbook  that  may  be  said  to  be  a  solid  founda- 
tion for  further  building.  Perhaps  our  studies  of 
physiology  originated  from  a  curious  introspection 
similar  to  that  revealed  in  the  life  of  Leonardo  da 
Vinci  and  we  did  not  readily  realize  the  importance 
of  the  study  of  the  infant  and  fetus.  Here,  indeed, 
if  we  are  to  build  a  rational  structure,  should  the 
beginning  be  made.  Another  reason  for  lack  of 
study  in  this  domain  has  been  the  lack  of  financial 
remuneration  in  treating  an  unborn  fetus.  It  w^ould 
seem  that  at  best  the  study  was  an  abstract  one. 
But  this  is  not  true,  for  a  comprehensive  under- 
standing of  the  underlying  dynamics  would  clarify 
many  of  the  obscure  phenomena  encountered  in 
later  life. 

Until  recent  years  pediatrics  was  not  considered 
a  special  subject.  Jacobi,  in  this  tountry,  was  one 
of  the  pioneers  who  gave  pediatrics  a  separate  place 
in  the  world  of  medicine.  At  present  we  are  awase 
that  the  physiology  of  childhood  diflfers  from  that 
of  adult  life.  The  pathological  conditions  are 
different.  The  bodily  proportions,  and  bodily 
changes  in  growth  and  nutrition  are  not  the  same. 
Then  we  also  have  the  transitory  stages  at  the  time 
of  birth  and  during  the  period  of  adolescence. 
During  these  times  vast  physiological  changes  oc- 
cur. As  physicians  it  is  our  duty  to  try  and  know 
more  about  them.  In  Feldman's  book  many  of 
these  processes  are  described,  among  them  some  to 
which  we  have  given  little  consideration  in  the 
past. 

Heredity  and  the  germinal  stages  are  considered, 
as  well  as  the  physiology  of  conception.  A  broad 
working  concept  of  heredity  is  presented.  This  is 
then  followed  by  the  postconceptional  or  intrauter- 
ine stage.  Of  vital  importance  are  the  chapters  on 
general  physiology,  metabolism,  and  the  mechanics 
of  development.  New  light  is  shed  upon  fetal 
secretions,  excretions,  and  the  biodynamics  of 
growth.  The  physiology  of  pregnancy  is  discussed 
in  detail,  and  this  portion  of  the  book  should  inter- 
est the  obstetrician  and  gynecologist,  for  the  con- 
comitant changes  in  the  maternal  organs  are  also 
considered.  Then  comes  a  detailed  and  well  pre- 
sented account  of  the  latest  findings  of  the  post- 
natal stage.  The  various  systems  are  considered 
one  by  one  and  in  their  relation  to  one  another. 
At  no  time  does  the  author  lose  sight  of  the  organ- 
ism as  a  whole.  This,  unfortunately,  is  a  too  fre- 
quent occurrence  when  laboratory  workers  attempt 
to  present  their  findings.  The  special  senses  are 
taken  up  separately  and  are  given  the  emphasis  they 
require. 


For  the  endocrinologist,  there  is  a  chapter  de- 
voted to  the  internal  secretions.  This  is  followed 
by  an  account  of  the  changes  during  puberty  and 
postnatal  growth.  The  book  is  written  in  an  in- 
teresting manner  and  this  brief  survey  should  show 
the  many  fields  in  which  the  book  will  be  found 
of  Aalue. 

AUTOEROTIC  PHENOMENA. 

Autoerofic  Phenomena  in  Adolescence.  An  Analytical 
Study  of  the  Physiology  and  Psychopathology  of  Onanism. 
By  K.  Menzies.  With  a  Foreword  by  Ernest  Jones, 
M.  D.    New  York :  Paul  B.  Hoeber,  1920. 

This  is  a  most  valuable  monograph.  The  sub- 
ject of  masturbation  has  usually  been  discussed 
with  more  reluctance  than  that  of  any  other  phase 
of  sex.  Menzies  shows  that  not  until  Freud's  an- 
alytical approach  was  it  possible  to  give  a  correct 
interpretation  to  the  general  subject  of  autoerotic 
phenomena.  Many  ills  of  mankind  have  been  at- 
tributed to  masturbation,  and  men  accredited  with 
wisdom  by  virtue  of  their  position  or  of  degrees 
given  them  have  spoken  of  masturbation  as  a  vice. 
In  the  light  of  the  new  psychology,  we  are  shown 
that  autoerotic  manifestations  are  phases  of  human 
development  and  not  perversions.  There  are  many 
erogenous  zones  besides  the  genitals  and  in  early 
infancy  these  are  made  the  region  of  autoerotic  en- 
joyment. Thumb  sucking,  the  retention  of  feces 
and  urine,  rubbing  the  thighs  together,  and  many 
similar  performances  are  all  a  part  of  the  process. 
Much  sufi^ering  and  shame  have  been  caused  by  the 
lack  of  knowledge  surrounding  this  subject;  neu- 
rotic symptoms  are  a  common  result  of  the  fearful 
warnings  and  of  the  quack  literature  that  has  dealt 
with  this  subject  in  the  past.  We  are  now  able  to 
consider  the  autoerotic  manifestations  as  one  of  the 
primary  or  infantile  states  in  sexual  development. 
Then  comes  the  homosexual  phase,  which  is  finally 
supplanted  by  the  heterosexual  or  complete  love 
life.  Menzies  shows  that  ma.sturbation  continued 
over  a  long  period  is  injurious  inasmuch  as  it  in- 
terferes with  the  appreciation  of  the  normal  sex  life 
in  later  years.  In  women  the  zone  of  the  clitoris 
predominates  and  it  is  only  with  difficulty  that  the 
transfer  of  the  zone  of  excitation  is  made  to  the 
vagina.  This  accounts  for  the  number  of  socalled 
anesthetic  women.  In  the  male  the  habit  leads  to 
premature  ejaculation  and  does  not  allow  for  the 
full  enjoyment  of  the  normal  sex  act.  This  in 
turn  is  harmful  to  the  female,  for  it  does  not  per- 
mit her  the  degree  of  excitation  necessary  to  pro- 
duce an  orgasm.  This  condition  may  lead  to  vari- 
ous neuroses,  anxiety  neurosis  being  a  common 
sequel. 

Max  Hiihner  is  quoted  at  some  length.  He  be- 
lieves masturbation  to  be  caused  luainly  by  an  ir- 
ritation of  the  deep  urethra.  This  sounds  plausible 
but  is  not  true  in  the  majority  of  cases.  Hiihner 
cites  many  cures  which  have  been  efi^ected  by  mas- 
sage and  instillations  of  silver  nitrate  in  the  deep 
urethra.  He  may  have  found  this  condition  in  a 
number  of  patients,  but  surely  he  cannot  logically 
believe  that  the  great  proportion  of  inales  who 


September  4,  1920.] 


BOOK  REVIEWS. 


335 


masturbate  have  an  irritation  of  the  deep  urethra. 
If  he  were  to  give  the  subject  further  considera- 
tion and  observe  the  situation  outside  his  treatment 
room,  he  would  find  that  he  was  considering  only  a 
small  number  of  masturbators.  In  order  to  under- 
stand the  process  in  its  entirety  he  would  be  obliged 
to  accept  the  broader  psychological  concept  of  an 
evolutionary  process  in  the  development  of  the 
sexual  cycle. 

The  "monograph  is  an  excellent  one,  for  Menzies 
has  quoted  freely  from  Pfister,  Freud,  Jung,  Hall, 
Jones,  Ferenczi,  Forel,  and  Havelock  Ellis  and 
has  presented  their  views  in  an  understanding 
fashion.  In  fact  he  has  done  little  else  but  quote, 
but  he  has  done  it  well.  The  book  is  timely  and 
worthy  of  study. 

A  PSYCHOLOGICAL  STUDY  OF  LIFE  IN 
THE  GHETTO. 

Sarah  and  Her  Daughter.    By  Bertii.\  Pe.ari..    New  York  : 
Thomas  Seltzer,  1920. 

There  is  much  of  the  sordid  side  of  New  York 
life  in  this  book.  The  stor>',  however,  is  lifted  to 
the  level  of  compelling  interest  by  its  truth  and  the 
fine  appreciation  of  the  individual  struggle  with 
which  tragedy  is  met.  To  refuse  to  enter  into 
such  painful  realism  is  to  .shirk  the  responsibility 
of  its  existence. 

There  are  two  sweeping  forms  of  difficulty  that 
lie  at  the  bottom  of  the  tragic  experiences  dragged 
through  the  lives  of  Sarah  and  the  daughter.  One 
is  the  economic  maladjustment  of  society  which 
permits  of  crushing  pressure  upon  lives  that  ask 
merely  free  opportunity  for  themselves  in  their 
toil  and  in  a  modest  selfdevelopment.  Sarah  and 
her  family  failed  to  find  even  such  freedom  to  work 
until  she  was  tempted  to  a  misappropriated  freedom 
in  money  making  which  again  made  slaves  of  her- 
self and  children.  Poverty,  sickness,  dirt — these 
things  were  made  to  press  their  weight  upon  a 
spirit  originally  of  too  fine  material  to  breathe  be- 
neath them.  The  only  aid  society  was  able  or 
willing  to  render  was  to  compress  this  already  un- 
bearable load  under  a  falsely  constructed  protec- 
tiveness  where  individual  expansion  was  the  last 
thing  to  be  conceived.  It  is  an  oft  repeated  tale, 
alas,  this  careless  method  of  throwing  an  occasional 
sop  to  conditions  fundamentally  wrong.  In  this 
story  Sarah  and  her  daughter  and  all  their  associ- 
ates are  in  one  way  or  another  victims  of  bad  in- 
dustrial conditions.  Some  of  them  achieve  a  vic- 
tory of  selfdevelopment  which  raises  them  aljove 
their  original  environment,  but  each  one  bears  in 
one  way  or  another  the  marks  of  social  compression 
and  attains  a  hampered  success. 

Below  the  broad  economic  basis  for  these  indi- 
vidual histories  is  the  profound  psychology  of  the 
struggles  which  issue  partially  in  defeat,  par- 
tially in  victory.  Bertha  Pearl's  touch  has  the 
sureness  of  the  artist  who,  while  not  always  con- 
scious of  the  psychological  implications  of  her 
words,  yet  touches,  however  fleetingly,  those  ulti- 
mate sources  which  the  clumsier  scientist  labors  to 
define.  The  name  of  the  book  itself  carries  sugges- 
tiveness.  The  mother  daughter  theme  here  bears 
its  own  interpretation.     Sarah's  native  refinement 


is  blunted  by  the  duller  religiosity  of  her  inefficient 
husband  and  is  pierced  by  reproach  deeper  than  that 
of  having  been  untrue  to  herself  in  the  fact  that  she 
did  not  follow  the  true  lover  in  the  homeland. 
Such  a  nature  with  such  a  history  is  especially 
sensitive  to  the  rivalry  of  a  daughter  like  herself, 
whom  she  both  loves  and  fears.  The  embittered 
woman  possesses  in  Minnie  a  daughter  of  rare 
sweetness  of  character  but  of  a  greater  sincerity 
than  Sarah  had  been  able  to  maintain.  From 
Minnie's  early  childhood  mother  and  daughter  pre- 
sent a  touching  interplay  of  love.  The  mother  de- 
pends upon  the  child's  native  tenderness  and  helpful- 
ness and  yet  throws  up  that  stubborn  defense  with 
which  such  natures  shield  their  own  deficiencies. 
The  hatred  of  selfdefense  and  self  accusation  by  the 
time  the  girl  has  reached  puberty  comes  to  separate 
hopelessly  mother  and  daughter.  The  latter  devel- 
ops a  brave  endurance  under  hardship  and  tempta- 
tion ;  the  mother  to  the  end  is  torn  between  blame  to 
herself  and  perplexity  over  a  need  for  independence 
in  her  child  which  she  cannot  quite  define. 

No  less  finely  suggestive  is  the  psychology  that 
touches  the  other  characters  of  the  book.  The  story 
in  its  study  of  these  struggles  through  a  sordid  en- 
vironment and  with  vmderlying  psychic  burdens  is 
so  realistically  human  that  one  need  not  seek  in 
it  the  register  of  either  complete  success  or  com- 
plete failure.  Its  review  of  social  facts  as  well  as 
of  the  human  conflict  in  which  the  rich  share  with 
the  poor  should  recall  the  reader  to  a  double  need. 
One  cannot  lay  down  the  book  as  indifferent  as 
before  to  the  defects  of  our  world  with  its  hardest 
pressure  upon  such  lives  as  these.  Neither  can  one 
remain  unappreciative  of  the  necessity  of  deeper 
psychological  knowledge.  There  are  such  sensitive 
souls  as  these  on  the  East  Side  as  on  the  West.  The 
psychic  maelstrom  of  hidden  antagonisms  and  mis- 
understandings as  well  as  of  hidden  powers  sweeps 
beneath  many  such  poignant  situations  as  that  of 
Sarah  and  her  daughter.  One  must  to  a  certain  ex- 
tent sufifer  with  them  in  reading  these  pages.  One 
will  be  rewarded,  however,  by  finding  two  characters 
especially  worth  knowing.  One  may  not  pity  them 
too  much  or  find  cause  to  blame,  but  one  will  love 
both  Sarah  and  her  daughter. 

INDUSTRIAL  PSYCHOLOGY. 

Lectures  on  Industrial  Psychology.  By  Bern.\rd  Aluscio, 
M.  A.  (Sydney);  M.  A.  (Conville  and  Caius  College, 
Cambridge)  ;  Late  University  Demonstrator  in  Experi- 
mental Psychology,  Cambridge,  etc.  Second  Edition, 
Revised.  New  York:  E.  P.  Dutton  &  Co.,  1920.  (Lon- 
don: George  Routledge  &  Sons,  Ltd.)    Pp.  iv-30G. 

The  intelligent  young  artisan,  who  reads  such 
works  as  these  much  more  than  is  imagined,  is  be- 
ginning to  cast  a  suspicious  eye  on  those  learned 
men  who  want  him  to  work  in  the  position  best 
fitted  to  his  ability  and  to  grant  him  all  those 
recreationary  periods  which  Nature  has  declared 
necessary  for  sagging  nerves  and  the  mischief 
wrought  by  noise  and  the  ghastly  monotony  of 
repetition.  Is  it,  he  asks,  that  he  may  know  the  gor- 
geousness  of  life,  may  conquer  the  daily  task  him- 
self unconquered  ?  Or  has  the  economy  of  mercy 
been  discovered,  have  the  future  returns  of  scientific 
management  been  seen  as  more  profitable  than  the 


336 


BOOK  REVIEWS. 


[New  York 
Medical  Journal. 


immediate  ones  of  continuous  work  at  high  pres- 
sure? 

Then  again,  in  his  irrational  way,  he  asks  what 
will  be  done  with  the  incompetent  whom  it  will  take 
a  long,  long  time  to  convince  that  the  new  is  the 
best,  who  is  wholly  bent  on  contesting  each  inch  of 
ground  with  the  insistent  monster,  machinery?  Is 
it  not  possible  that  a  few  competent  may  do  the 
work  of  many  stunted  in  mind  and  body  and  the 
question  of  employment  prove  a  tougher  one  than 
ever  for  philanthropists  and  employers?  Labor 
saving,  energy  saving  must  be  translated  into  the 
workman's  own  language.  Our  next  step  must  be 
to  prove  that  all  the  gain  will  not  be  on  the  em- 
ployer's side,  nor  behind  the  apparent  relief  from 
hard  labor  will  there  lie  ambushed  the  same  old 
enemies  of  want  and  sickness  and  old  age.  A  feel- 
ing of  fear,  leading  to  hostility,  has  come.  "Or- 
ganized labor  has  declared  that  scientific  manage- 
ment is  essentially  autocratic,  a  reversion  to  indus- 
trial autocracy  which  forces  the  workers  to  depend 
on  the  employer's  conception  of  fairness  and  jus- 
tice, and  limits  the  democratic  safeguards  of  the 
workers." 

Now  for  an  absolutely  fair  discussion  of  what 
psychology  can  do  in  the  labor  world,  of  what  it 
can  do  in  the  way  of  obviating  accidents  to  the 
public  and  to  workmen,  of  increasing  the  amount 
of  work  while  diminishing  fatigue  and  time  taken, 
it  would  be  difficult  to  find  a  wiser  volume  than 
this,  for  no  point  is  too  small  to  discuss  and  eluci- 
date when  it  will  lead  to  a  clearer  understanding 
of  all  that  seems  so  obvious  to  us,  so  entangled  to 
the  working  man. 

THE  WORK  OF  THE  RED  CROSS. 

The  American  Red  Cross  in  the  Great  W ar.  By  Henry  P. 
Davison,  Chairman  of  the  War  Council  of  the  American 
Red  Cross.  Illustrated.  New  York :  The  Macmillan 
Company,  1920.    Pp.  i-302. 

It  is  so  often  thought  that  everyone  knows  about 
the  Red  Cross,  that  no  one  thinks  it  worth  while  to 
let  anyone  know  how  things  began.  Who  knows 
that  the  American  National  Red  Cross  was  per- 
manently incorporated  in  1905  with  the  President 
as  president?  Who  knows  of  the  eager,  tempestti- 
ous  giving  which  formed  its  early  share  in  the  war, 
or  the  generous  help  given  the  troops  on  the  Mexi- 
can border,  where  75,000  men  rehearsed  the  drama 
and  learnt  a  few  of  the  hardships  awaiting  them 
overseas  ? 

The  author  has  wisely  kept  the  work  in  each 
country  separate,  for  this  is  a  work  of  reference, 
not  merely  a  collection  of  anecdotes  or  things  re- 
membered, and  the  last  chapter  reminds  us  that  the 
Red  Cross,  now  figuring  as  a  section  of  the  League 
of  Red  Cross  Societies,  fovtnded  May  5,  1919,  is 
toiling  away  at  the  weary  task  of  clearing  up  after 
the  war.  The  still  greater  task  awaits  it  of  pro- 
moting the  welfare  of  mankind  by  furnishing  the 
medium  for  bringing  within  the  reach  of  all  peoples 
the  benefits  to  be  derived  from  present  known  facts 
and  new  contributions  to  science  and  medical 
knowledge  and  their  application,  and  to  coordinate 
relief  work  in  case  of  great  national  or  international 
calamities. 


New  Publications  Received. 


[JVe  publish  full  lists  of  books  received,  but  we  acknotvl- 
eage  no  obligation  to  review  them  all.  Nevertheless,  so 
far  as  space  permits,  we  revieiv  those  in  zvhich  we  think 
our  readers  are  likely  to  be  interested.] 


RELIGION  AND  THE  NEW  PSYCHOLOGY.  A  Psychoanalytic 
Study  of  Religion.  By  Walter  Samuel  Swisher,  B.D. 
Boston:  Marshall  Jones  Company,  1920.    Pp.  xv-261. 

report  for  the  year  1919  OF  THE  CANTON  HOSPITAL.  Can- 
ton, China:  Canton  Medical  Missionary  Society  and  the 
Canton  Medical  Missionary.    Pp.  v-120. 

BIBLICAL  STUDIES.  Moses  the  Founder  of  Preventive  Med- 
icine. By  Percival  Wood,  M.  R.  C.  S.,  L.  R.  C.  P.,  Captain, 
R.  A.  M.  C,  Author  of  The  Whole  Duty  of  the  Regimental 
Medical  Officer.  New  York:  The  Macmillan  Company, 
1920.  (London:  Society  for  Promoting  Christian  Knowl- 
edge.)   Pp.  xi-116. 

TUBERCULOSIS     AND    PUBLIC     HEALTH.       By     H.  HySLOP 

Thomson,  M.  D.,  D.  P.  H.,  County  Medical  Officer  of 
Health,  County  Tuberculosis  Officer  and  School  Medical 
Officer  for  Hertfordshire ;  Formerly  Tuberculosis  Officer 
for  Newport  and  East  Monmouthshire,  etc.  New  York  and 
London :  Longmans,  Green  &  Co.,  1920.    Pp.  xi-104. 

AN  EPITOME  OF  HYDROTHERAPY.  For  Physiciaus,  Archi- 
tects and  Nurses.  By  Simon  Baruch,  M.  D.,  LL.  D.,  Con- 
sulting Physician  to  Knickerbocker  and  Montefiore  Hos- 
pitals ;  Hydrotherapeutist  to  Sea  View  Hospital  for  Tuber- 
culosis, etc.  Illustrated.  Philadelphia  and  London:  W.  B. 
Saunders  Company,  1920.    Pp.  ii-205. 

MARINE  HYGIENE  AND  SANITATION.  A  Manual  for  Ships' 
Surgeons  and  Port  Health  Officers.  By  Gilbert  E.  Brooke, 
M.A.  (Cantab.),  L.R.C.P.  (Edin.),  D.P.H.,  F.R.G.S.;  Chief 
Health  Officer,  Straits  Settlements  Medical  Department ; 
Port  Health  Officer,  Singapore,  etc.  Illustrated.  New 
York:  William  Wood  &  Co.,  1920.    Pp.  ix-409. 

THE  SYMPATHETIC  NERVOUS   SYSTEM   IN  DISEASE.     By  W. 

Langdon  Brown,  M.  A.,  M.  D.  (Cantab.),  F.  R.  C.  P. 
(Lond.),  Physician  with  Charge  of  Outpatients,  St.  Bar- 
tholomew's Hospital ;  Physician  to  the  Metropolitan  Hos- 
pital, etc.  Illustrated.  London :  Henry  Frowde,  Hodder 
&  Stoughton,  Ltd.  (Oxford  University  Press),  1920.  Pp. 
xi-16I. 

TREATMENT  OF  THE   NEUROSES.     By  ErNEST  JoNES,  M.D. 

(Lond.),  M.R.C.P.  (Lond.)  ;  President  of  the  British  Psy- 
choanalytical Society ;  Member  ( for  England  and  Amer- 
ica) of  the  Council  of  the  International  Congress  for  Medi- 
cal Psychology  and  Psychotherapy;  Honorary  Member  of 
the  American  Psychopathological  Association.  New  York : 
William  Wood  &  Co.,  1920.    Pp.  viii-233. 

FUNCTIONAL  NERVE  DISEASE.  An  Epitome  of  War  Ex- 
perience for  the  Practitioner.  Edited  by  H.  Creighton 
Miller,  M.  A.,  M.  D.,  Formerly  Medical  Officer  in  Charge 
Functional  Cases,  No.  21  General  Hospital,  Alexandria : 
Late  Consulting  Neurologist,  Fourth  London  General  Hos- 
pital. London :  Henry  Frowde,  Hodder  &  Stoughton.  Ltd., 
(Oxford  University  Press),  1920.    Pp.  xi-208. 

SELF   HEALTH   AS   A   HABIT.      By    EuSTACE   MiLES,   M.  A., 

Formerly  Scholar  of  King's  College,  and  Honors  Coach 
and  Lecturer  at  Cambridge  University;  Assistant  Master 
at  Rugby  School ;  Amateur  Champion  at  Racquette  and 
Tennis ;  Author  of  How  to  Prepare  Essays,  How  to  Rc- 
mcmber,  etc.  Illustrated.  New  York :  E.  P.  Dutton  &  Co., 
1919.  (London  and  Toronto:  J.  M.  Dent  &  Sons,  Ltd.) 
Pp.  v-341. 

A    STUDY   IN   THE  EPIDEMIOLOGY   OF   TUBERCULOSIS.  With 

Especial  Reference  to  Tuberculosis  of  the  Tropics  and  of 
the  Negro  Race.  By  George  E.  Bushnell,  Ph.D.,  M.D. ; 
Colonel,  United  States  Army  Medical  Corps  (retired)  ; 
Honorary  Vice-President  and  Director  National  Tuber- 
culosis Association  of  the  United  States ;  Member  Ameri- 
can Climatological  and  Clinical  Association.  Illustrated. 
New  York:  William  Wood  &  Co.,  1920.    Pp.  v-221. 


Practical  Therapeutics  and  Preventive  Medicine 

A  Compendium  of  Treatment  and  Prophylaxis,  Original  and  Adapted 


Chronic  Knee  Strains. — H.  Page  Manck  (Vir- 
ginia Medical  Monthly,  April,  1920)  comments  on 
the  frequency  with  which  acute  knee  strains  remain 
inadequately  treated,  chronic  sensitiveness  of  the 
joint  resulting.  The  joint  should  be  fixed  for  four 
or  five  weeks,  preferably  on  a  posterior  splint,  so 
that  after  the  first  week  daily  massage  of  the  thigh 
muscles  can  be  practised.  Exercises  of  these  mus- 
cles, care  being  taken  to  allow  no  lateral  motion,  are 
very  beneficial  after  the  second  week.  Such  treat- 
ment of  the  acute  injuries  would  result  in  far  fewer 
ychronic  traumatic  knee  joints.  In  the  chronic  cases 
the  subjective  symptoms  are  recurrent  attacks  of 
synovitis  with  or  without  locking,  and  the  important 
objective  symptoms,,  increased  lateral  mobility,  ten- 
derness over  the  injured  ligament  or  cartilage,  pos- 
sibility of  palpation  of  the  cartilage  in  some  cases, 
and  atrophy  of  the  muscles  of  the  thigh.  Of  159 
cases  collected  by  the  author,  of  which  only  twenty- 
one  apparently  received  any  greater  amount  of 
treatment  than  rest  and  bandaging  with  or  without 
local  applications  for  a  few  days,  136  showed  an 
atrophy  of  over  half  an  inch  of  the  thigh  on  the 
aflfected  side.  In  cases  with  a  history  of  repeated 
locking,  operation  for  removal  of  a  loose  cartilage 
or  loose  body  is  indicated,  with  aftertreatment  the 
same  as  in  cases  without  locking.  This  treatment 
aims  first  at  protection  against  recurrence,  allowing 
the  lateral  ligament  and  synovia  to  recover  and  de- 
veloping the  supporting  muscles.  Eflfusion  indi- 
cates rest  in  bed  with  snug  bandaging  until  it  has 
subsided.  After  this  it  is  essential  to  prevent  lateral 
mobility,  an  object  secured  by  elevation  of  the  shoe 
on  the  inner  side  and  the  application  of  a  properly 
fitting  brace,  such  as  the  Campbell  knee  brace  or  the 
knee  cage  devised  by  Robert  Jones. 

To  prevent  muscular  atrophy  and  thus  stabilize  the 
joint  there  must  be  daily  massage  with  systematic 
exercises,  especially  of  the  quadriceps ;  the  latter  is 
readily  carried  out  by  having  the  patient  sit  on  a 
table  with  his  legs  hanging  over  the  edge,  simple 
flexion  and  extension  bringing  the  muscles  into 
play;  a  weight  on  the  foot  may  be  added.  Bristow 
recommends  graduated  contractions  of  the  thigh 
muscles  with  the  Bristow  coil.  The  elastic  kneecap 
often  prescribed  in  these  cases  is  useless  and  even 
harmful  in  that  it  does  not  prevent  lateral  mobility 
but  interferes  with  free  use  of  the  muscles.  Cases 
with  extreme  lateral  mobility  require  an  operation 
on  the  internal  lateral  ligament,  which  is  to  be  rein- 
forced with  the  semimembranous  or  sartorius.  as 
advised  by  McMurray.  In  cases  with  a  bruised  or 
hypertrophied  infrapatellar  pad  the  principal  symp- 
toms are  recurrent  synovitis  with  pain  on  complete 
extension  and  definite  tenderness  over  the  pad.  Con- 
servative treatment  consists  of  fixation  in  slight 
flexion  for  a  few  weeks,  followed  by  elevation  of 
the  heel  of  the  shoe  by  one  inch,  which  prevents 
pinching  of  the  pad  during  locomotion.  Good  re- 
sults have  followed  operative  removal  of  the  hy- 
pertrophied and  bruised  pad. 


Ligation  of  the  Common  Carotid. — John  Ho- 
mans  (Amials  of  Surgery,  June,  1920)  in  describ- 
ing a  case  of  ligation  of  the  carotid  and  in  a  review 
of  the  literature  on  the  subject  presents  the  follow- 
ing conclusions.  If  an  injury  to  the  common  caro- 
tid is  suspected,  the  patient  should  be  studied  with 
a  view  to  determining  the  quality  of  the  emergency 
collateral  circulation ;  that  the  operator  should  con- 
sider the  strength  of  the  arterial  circulation,  as  dem- 
onstrated by  the  blood  pressure  and  the  apparent 
degree  of  shock,  or  its  absence ;  that  he  should  not 
undertake  the  procedure  in  the  absence  of  signs  of 
dangerous  extension  of  the  local  hematoma  and  in 
the  absence  of  external  hemorrhage,  unless  all  the 
circumstances  appear  favorable  for  the  resumption 
of  a  collateral  cerebral  circulation ;  that  he  should 
be  prepared  for  the  temporary  or  permanent  repair 
of  the  common  carotid  in  case  temporary  occlusion 
induces  immediate  cerebral  symptoms ;  that  he 
should  ligate  the  jugular  vein  before  or  during 
occlusion  of  the  artery;  that  he  should  be  prepared 
to  give  blood  transfusion  to  the  patient ;  that  he 
should  use  an  anesthetic  the  least  disturbing  to  the 
heart  and  to  the  brain — in  other  words,  that  local 
anesthesia  should  be  used  wherever  possible ;  and 
that  in  case  immediate  operation  is  for  any  reason 
delayed,  he  may  properly  expect  a  greater  likeli- 
hood of  injury  to  adjacent  nerves,  but  a  far  lower 
incidence  of  cerebral  complications. 

The  Treatment  of  Empyema. — Evarts  A.  Gra- 
ham (Surgery,  Gynecology  and  Obstetrics^  July, 
1920)  states  that: 

The  extensive  recent  literature  on  empyema  re- 
veals both  a  striking  tendency  toward  a  more  or 
less  standardized  treatment  and  a  radical  departure 
from  methods  in  use  prior  to  the  war.  The  cardinal 
principles  of,  1,  the  avoidance  of  an  open  pneu- 
mothorax during  the  acute  pneumonic  stage  of  the 
disease,  2,  early  sterilization  and  obliteration  of  the 
cavity,  and  3,  the  maintenance  of  the  nutrition  of 
the  patient,  are  discussed  in  this  article.  It  is  shown 
that  the  former  prevalent  conceptions  of  the 
mechanism  of  action  of  an  open  pneumothorax  are 
incorrect. 

In  the  normal  thorax  the  mediastinal  structures, 
instead  of  constituting  a  more  or  less  rigid  partition 
between  the  two  pleural  cavities,  are  in  reality  so 
mobile  that  to  air  pressure  they  offer  a  resist- 
ance which  is  equivalent  to  the  pressure  ex- 
erted by  a  column  of  water  only  one  half  centi- 
metre to  one  centimetre  high  (.4  millimetre  to  .8 
millimetre  of  mercury).  This  resistance  is  there- 
fore negligible  and  from  the  point  of  pressure 
relationships,  the  thorax  can  be  considered  as  one 
cavity  instead  of  two.  Any  change  of  pressure, 
therefore,  in  one  pleural  cavity  will  manifest  itself 
to  practically  the  same  degree  in  the  other  pleural 
cavitv  with  the  result  that  both  lungs  will  be  about 
equally  compressed.  The  situation  in  this  respect 
is  the  same  in  the  dog  as  in  the  human,  and,  there- 


338 


PRACTICAL   THERAPEUTICS   AXD  PREVEXTH'E  MEDICIXE. 


[New  York 
Medical  Journal. 


fore,  experimental  results  obtained  on  the  dog  can 
be  directly  applied  to  the  human. 

The  likelihood  of  a  fatal  asphyxia  as  a  result  of 
an  open  pneumothorax  depends  upon  a  number  of 
factors,  important  ones  of  which  are  the  size  of  the 
opening  and  the  vital  capacity  of  the  individual.  A 
mathematical  expression  has  been  devised  by  which 
it  is  possible  in  a  given  case  to  approximate  the 
maximum  nonfatal  opening  in  the  chest  wall  if 
the  vital  capacity  is  known.  One  who  has  an 
average  vital  capacity  and  a  normal  thorax  can 
withstand  an  opening  in  the  thoracic  wall  of  fifty- 
one  square  centimetres,  but  the  individual  of  ex- 
ceptional vital  capacity  can  live  with  an  opening  of 
one  hundred  and  one  square  centimetres.  A  bi- 
lateral open  pneumothorax  is  practically  no  more 
dangerous  to  life  than  a  unilateral  opening  provided 
that  in  each  case  the  areas  of  the  openings  are  the 
same.  If  the  vital  capacity  is  so  low  as  to  ap- 
proximate the  tidal  air,  even  a  very  small  opening 
may  be  fatal. 

As  shown  in  the  text,  these  observations  have  a 
very  important  bearing  on  the  question  of  open 
drainage  of  cases  of  empyema,  particularly  during 
the  acute  pneumonic  stage  when  the  vital  capacity 
is  low.  After  adhesions  have  formed  and  the 
mediastinum  has  become  somewhat  stabilized,  both 
by  adhesions  and  inflammatory  induration,  then  the 
pressure  relationships  may  be  materially  different 
on  the  two  sides. 

Effects  of  an  open  pneumothorax  other  than 
those  directly  upon  the  lungs  are  briefly  considered, 
such  as  heat  loss,  changes  in  the  systemic  circula- 
tion and  danger  of  infection.  The  value  of  Dakin's 
solution  in  sterilizing  and  obliterating  empyemic 
cavities  is  shown,  as  well  as  its  power  to  decorticate 
lungs.  Collapsing  thoracoplastic  operations  have 
the  disadvantage,  even  when  successful,  of  appar- 
.ently  permanently  reducing  the  vital  capacity.  The 
-maintenance  of  the  nutrition  of  the  patient  is  of 
fundamental  importance. 

Suprapubic  Prostatectomy. — T.  L.  Deavor 
{American  Journal  of  Surgery,  July,  1920)  men- 
tions the  following  points  in  favor  of  suprapubic 
prostatectomy :  The  entire  field  is  open  to  inspec- 
lion.  and  within  easy  reach.  Reflected  light  may 
be  used.  Rectal  pressure  elevates  the  prostatic 
region.  In  case  of  marked  sepsis,  it  is  the  first  step 
in  a  two  stage  operation.  Complications,  as  hem- 
orrhage, stone  and  prostatic  bar,  are  more  easily 
managed.  The  gland  is  just  as  accessible,  and  per- 
haps more  so.  Enucleation  is  very  simple.  The 
rectum  may  be  as  safely  protected.  Xo  more  dam- 
age need  be  done  to  the  prostatic  urethra,  if  due 
^re  is  exercised.  Drainage  both  ways  is  readily 
applied.  Retrograde  catheterization  may  be  used, 
when  it  is  impossible  to  reach  the  bladder  by  the 
ordinary  way.  A  catheter  may  be  fixed  in  position, 
to  remain  for  the  entire  period  of  drainage.  Dur- 
ing the  process  of  recover)-,  the  wound  is  well  placed 
for  subsequent  treatment  away  from  the  rectum, 
adding  much  to  the  comfort  of  the  patient.  Except 
in  carcinoma,  a  fistula  following  this  method  is 
almost  unknown.  Should  it  occur,  obliteration  is 
always  possible.  The  mortality  should  not  be  in- 
creased. 


Rontgen  Rays  in  Obscure  Conditions. — George 
E.  Pfahler  {International  Journal  of  Surgery,  June, 
1920)  gives  the  following  conclusions  as  to  the 
uses  of  the  x  ray  in  diagnosis : 

1.  The  rontgen  rays  are  useful  in  the  diagnosis 
of  practically  all  obscure  conditions  in  the  body. 

2.  The  organ  involved  is  not  always  indicated 
by  the  character  of  the  symptoms,  and  frequently 
an  X  ray  study  must  include  more  than  the  organ 
to  which  the  symptoms  refer. 

3.  For  accurate  diagnosis  it  is  essential  that  good 
rontgenograms  be  made,  but  much  greater  skill  and 
a  wider  scope  of  knowledge  are  needed  in  their  in- 
terpretation than  in  their  making. 

4.  The  purchase  of  an  x  ray  outfit  no  more 
makes  the  rontgenologist  than  does  the  purchase  of 
a  set  of  surgical  instruments  make  a  surgeon. 

Anesthetics  in  Shock. — AIcKeen  Cattell  {Ameri- 
can Journal  of  Surgery,  July,  1920)  gives  the  fol- 
lowing simimary  of  the  experimental  studies  which 
were  conducted  on  the  effect  of  anesthetics  in  shock : 

1.  In  the  normal  animal,  ether,  rapidly  admin- 
istered, causes  a  moderate  fall  in  blood  pressure, 
followed  immediately  by  a  recovery,  so  that  by  the 
time  a  degree  of  anesthetization  is  reached  sufficient 
to  cause  a  disappearance  of  the  eye  reflex,  the  pres- 
sure is  normal.  In  shock  the  animal  becomes  very 
sensitive  to  ether,  the  same  degree  of  anesthesia 
produced  under  exactl)-  similar  conditions  result- 
ing in  a  marked  drop  in  blood  pressure. 

2.  An  increased  sensitiveness  to  ether  is  brought 
about  by  any  circumstances  which  tend  to  depress 
the  general  condition  of  the  animal  such  as  low 
blood  pressure,  hemorrhage,  severe  operation,  or  the 
injection  of  acid  into  the  circulation. 

3.  In  a  shocked  animal,  sensitive  to  ether,  nitrous 
oxide  and  oxygen  may  be  given  in  the  most  favorable 
proportions,  so  as  to  produce  the  same  degree  of 
anesthesia  produced  by  ether  without  causing  a  fall 
in  blood  pressure. 

4.  Experiments  on  the  heart  volume  in  intact 
cats,  and  on  contractions  of  the  isolated  turtle  heart, 
together  with  deductions  from  blood  pressure,  show 
that  ether,  from  the  very  beginning  of  its  admini- 
stration, results  in  a  depression  of  the  heart  and  a 
decrease  in  its  output,  which  is  sufficient  to  account 
for  the  fall  in  pressure  in  both  the  normal  and  the 
shocked  animal. 

5.  Large  doses  of  adrenalin  injected  intraven- 
oush'  in  shocked  animals  usually  result  in  the  dis- 
appearance of  the  sensitiveness  to  ether  for  a  period 
of  an  hour  or  more.  The  evidence  indicates  that 
adrenalin  acts  on  the  heart  in  a  manner  which  an- 
tagonizes the  effects  of  ether.  Pituitrin  does  not  in- 
fluence the  pressure  drop  produced  by  ether  in  the 
shocked  animal. 

6.  Determinations  of  leg  volume  with  a  plethys- 
mograph,  perfusion  experiments,  and  results  ob- 
tained from  the  injection  of  ether  directly  into  the 
circulation,  together  with  the  form  of  the  blood  pres- 
sure curves,  indicate  that  ether  causes  a  contraction 
of  the  peripheral  vessels  in  the  normal  animal.  This 
construction  is  caused,  a,  by  a  direct  stimulation  of 
the  vasomotor  centre  and,  b,  by  a  reflex  to  the  fall  in 
pressure  resulting  from  depression  of  the  heart. 
In  shock  no  evidence  of  a  vasoconstriction  produced 


September  4,  1920.]  PRACTICAL  THERAPEUTICS   AND  PREVENTIVE  MEDICINE. 


339 


by  ether  was  obtained,  and  pressor  eifects  from 
asphyxia  or  sensory  nerve  stimulation  become  less 
or  are  entirely  absent. 

7.  The  cause  of  the  greater  depressing  influence 
of  ether  on  the  blood  pressure  in  shock  is  a  dis- 
turbance of  the  vasomotor  system.  The  usual  com- 
pensatory constriction  no  longer  occurs  to  oflfset 
the  decreased  output  of  the  heart,  so  that  there  is 
no  recovery  of  the  blood  pressure  during  the  in- 
halation of  -  ether,  but  instead,  the  pressure  con- 
tinues to  fall.  This  might  be  due  to  a  depression 
of  the  vasomotor  centre  or  to  an  already  existing 
maximum  constriction,  so  that  there  would  be  no 
compensation. 

Local  Anesthesia  in  Rectal  Surgery. — E.  Jay 

Clemons  [Medical  Council.  April,  1920)  considers 
the  postoperative  advantages  of  quinine  urea  hydro- 
chloride anesthesia  in  anorectal  surgery  to  be  as 
follows :  First,  being  nontoxic  there  is  no  reac- 
tion. Secorid,  as  there  is  no  interference  with  blood 
pressure  there  is  no  need  to  use  drugs  to  block 
oflE  absorption.  Third,  the  drug  being  a  mechanical 
irritant  it  causes  the  production  of  a  plastic  exudate 
which  helps  repair  and  prevents  postoperative  ooz- 
ing. Fourth,  this  exudate  having  been  thrown  out 
and  absorbed,  a  barrier  is  produced  which  enables 
the  operator  to  get  his  patient  on  his  feet  while 
the  repair  is  taking  place.  Fifth,  there  is  produced 
a  postoperative  anesthesia  for  a  week  to  ten  days 
which  is  very  grateful  to  the  patient. 

Caesarean  Section  Under  Local  Anesthesia 
Combined  with  Morphine  and  Scopolamine  Nar- 
cosis.—  Frederick  C.  Irving  (Boston  Medical  and 
Surgical  Journal.  June  3,  1920 )  says  that  Caesarean 
section  under  local  anesthesia  combined  with  mor- 
phine and  scopolamine  narcosis  is  a  useful  and 
successful  method  of  delivery  in  some  of  the 
graver  complications  of  pregnancy.  Among  these 
are  cardiac  disease  where  one  or  more  attacks  of 
decompensation  have  occurred,  diabetes,  nephritis 
and  cardiorenal  disease,  pulmonary  tuberculosis, 
and  bronchial  asthma.  In  general  it  finds  its  ap- 
plication in  those  cases  where  we  wish  to  avoid  the 
pain  and  physical  exertion  of  labor,  the  possible 
shock  of  an  operative  pelvic  delivery,  and  the  dan- 
ger of  a  general  anesthetic.  Plenty  of  time  must 
be  allowed  for  both  the  general  medication  and  the 
local  anesthetic  ^o  act.  Deliberate  operating,  with 
studious  avoidance  of  roughness,  is  essential  to 
success. 

Benzylcarbinol  as  a  Local  Anesthetic. — A.  M. 

Hjort  and  J.  T.  Eagan  (Journal  of  Pharmacology 
and  Experimental  Therapeutics,  November,  1919) 
describe  an  investigation  of  benzycarbinol,  or 
betaphenylethylol,  also  known  as  rose  oil  or 
orange  oil.  It  is  a  volatile  oil  with  a  roselike  odor 
occurring  in  nature  in  the  volatile  oils  of  roses, 
orange  flowers,  and  pine  needles.  Its  local  anes- 
thetic properties  were  studied  by  comparative  tests 
with  phenmethylol  (benzyl  alcohol)  and  w-ith  pro- 
caine (novocaine.)  As  determined  by  the  wheal 
method,  the  local  anesthetic  power  of  rose  oil 
seemed  slightly  superior  to  that  of  benzyl  alcohol 
and  procaine.  It  is  more  stable  than  benzyl  alco- 
hol.   Its  toxicity  in  white  mice  and  the  dog  is  about 


the  same  as  that  of  benzyl  alcohol.  One  of  the 
authors  injected  one  mil  of  a  one  per  cent,  solu- 
tion of  rose  oil  subcutaneously  in  the  volar  surface 
of  the  forearm.  The  area  became  anesthetic  to 
needle  pricking  for  a  period  of  five  minutes.  The 
solubility  of  rose  oil  is  relatively  low — about  two 
per  cent. — but  is  sufficient  for  its  therapeutic  use. 
It  is  cheaper,  less  toxic,  and  more  stable  than  pro- 
caine. It  is  a  commercial  product  found  on  the 
market  regularly,  being  used  in  the  manufacture 
of  perfumes.  It  anesthetized  the  skin  in  a  one 
fortieth  per  cent,  solution  in  thirteen  out  of  twenty- 
one  cases. 

Ethyl  Chloride  Anesthesia,  Brief  or  Prolonged. 

— H.  Abrand,  (Presse  medicale,  May  5,  1920) 
recommends  the  use  of  Camus's  mask  foi*  ethyl 
chloride  anesthesia,  but  supplements  it  with  a  new 
device  to  permit  precise  regulation  of  the  dose  of 
anesthetic  as  well  as  the  use  of  a  single,  graduated 
ethyl  chloride  ampoule  of  any  desired  size.  No  cool- 
ing device  is  required  and  the  anesthesia  may  be 
begun  with  small  amounts  and  later  pushed  as  re- 
quired. The  patient,  even  if  an  inveterate  alcoholic, 
goes  under  without  any  period  of  excitement  and 
only  rarely  vomits  upon  awakening.  Ethyl  chloride 
anesthesia  should  be  induced  gradually  to  avoid 
choking  sensations  and  possible  acute  toxic  eft'ects. 
Administration  of  small  amounts  may  be  repeated 
indefinitely,  as  the  product  is  of  relatively  low  tox- 
icity and  is  quickly  eliminated.  Anesthesia  should 
be  obtained  with  a  dose  not  exceeding  one  to  three 
mils  in  children  and  three  to  five  mils  even  in 
large  adults.  The  anesthesia  is  maintained  more 
and  more  easily  as  it  is  prolonged.  The  dose 
after  induction  in  prolonged  anesthesia  is  only 
about  one  half  a  mil  a  minute.  ]Many  extensive  op- 
erations, such  as  arthrotomy,  Estlander  operations, 
arm  and  thigh  amptitations,  and  radical  hernia  op- 
erations, have  been  successfully  performed  tmder 
prolonged  ethyl  chloride  anesthesia  by  the  author 
and  others.  The  anesthesia  is  not  as  deep  as  with 
chloroform,  yet  is  wholly  sufficient.  The  patients 
do  not  strain  and  radical  cure  of  hernias  is  in  no 
wise  hindered.  About  eight  to  ten  minutes  after 
the  induction  the  patient's  face  begins  to  perspire. 
The  mask  is  then  slightly  raised  to  admit  a  little 
air.  The  color  of  the  lips  and  ears  is  used  as  a 
guide.  Xot  infrequently  after  ten  to  fifteen  min- 
utes the  anesthetic  may  be  completely  suspended 
and  the  mask  removed  for  a  minute  or  two.  At 
the  first  signs  of  returning  consciousness,  the  pa- 
tient is  soon  brought  back  into  complete  anesthesia. 
The  final  awakening  is  rapid  and  is  at  times  at- 
tended with  regurgitation  of  bile  which,  however, 
does  not  recur.  The  patient  is  always  completely 
conscious  when  put  back  in  his  bed.  One  patient 
with  an  arm  amputation  wanted  to  walk  back  to 
bed. 

Late  Deaths  from  Chloroform  in  Liver  Disease, 
Especially  Cirrhosis  of  the  Liver. — Fr.  Brunner 
{SclnvcizcriscJie  mediziniscJie  Woclicnschrift,  June 
17,  1920)  urges  a  careful  testing  of  the  functions 
of  the  liver  and  kidneys  by  the  usual  methods 
before  entering  upon  an  operation  on  the  biliary 
{passages,  especially  when  there  is  any  suspicion 
that  these  functions  have  been  diminished. 


Miscellany  from  Home  and  Foreign  Journals 


Inflammations  of  the  Nervous  System. — Lew- 
ellys  F.  Barker,  Ernest  S.  Cross,  and  Stewart  V. 
Irwin  (American  Journal  of  the  Medical  Sciences, 
March,  1920)  in  discussing  epidemic  acute  and  sub- 
acute nonsuppurative  inflammations  of  the  nervous 
system  prevalent  in  the  United  States  in  1918-1919, 
encephalitis,  encephalomyelitis,  polyneuritis,  and 
meningoencephalomyeloneuritis,  state  that  the  on- 
set may  be  sudden  or  gradual,  with  or  without  pro- 
dromata.  The  most  striking  symptom,  when 
present,  is  a  drowsiness,  which  may  vary  in  degree 
from  apathy  to  coma.  Some  patients  do  not  have 
this  symptom.  A  patient  may  be  drowsy  in  the 
day  and  wakeful  and  restless  at  night.  Other  dis- 
turbances include  mental  depression,  anxiety,  de- 
lirium, headache,  vertigo,  tachycardia  and  vomiting. 
Fever  may  or  may  not  be  present.  A  slight  optic 
neuritis  may  occur,  but  choked  disc  was  not  seen. 

Focal  symptoms  are  motor  rather  than  sensorv. 
Commonest  are  bilateral  nuclear  and  radicular  par- 
alyses of  the  eye  muscles,  with  ptosis  and  oph- 
thalmoplegia externa  et  interna,  but  pontile  and 
bulbar  nuclear  and  radicular  paralyses,  with  facial 
paralysis,  dysmasesis,  dysphagia,  or  dysarthria, 
are  common,  as  are  symptoms  that  point  to  par- 
alysis of  part  of  the  extrapyramidal  motor  system. 
The  lesions  that  are  most  frequent  as  causes  of 
motor  focal  symptoms  must  be  located  in  the  mid- 
brain about  the  aqueductus  cerebri ;  the  pons  and 
upper  medulla  oblongata,  and  the  basal  ganglia. 
Less  common  are  monoplegias,  hemiplegias,  diple- 
gias, aphasias,  contractures,  choreatic  and  athetotic 
disturbances  of  motility  and  general  or  circum- 
scribed convulsive  seizures.  Only  in  relatively 
few  cases  are  there  clinical  signs  of  an  outspoken 
meningeal  irritation.  The  cerebrospinal  fluid  is 
clear  and  may  or  may  not  be  under  increased  pres- 
sure. In  the  writer's  experience,  a  cell  count  in 
the  cerebrospinal  fluid  of  from  ten  to  one  hundred 
small  mononuclears  along  with  a  positive  globulin  re- 
action, with  negative  Wassermann.  and  negative 
bacteriological  smears  and  cultures  is,  at  the  time  of 
an  epidemic  of  encephalitis,  strong  corroborative 
evidence  of  the  disease  in  a  patient  in  whom  the 
process  is  for  any  other  reason  suspected  to  exist. 

The  blood  usually  presents  a  slight  Ieucoc\tosis.  A 
trace  of  albumin  and  a  few  casts  are  sometimes 
found  in  the  urine,  but  the  renal  function  appears 
to  be  unimpaired.  Whether  the  disease  terminates 
in  death  or  in  recovery,  the  course  may  be  either 
brief  or  prolonged.  In  fulminant  cases  death  may 
occur  in  a  few  days  or  hours.  In  many  instances, 
both  mild  and  severe,  recovery  has  been  rapid,  the 
symptoms  lasting  from  a  few  days  to  a  month,  but 
in  the  majority  the  disease  is  protracted,  extending 
over  several  weeks  or  months.  The  prognosis  as 
regards  life  is  better  than  might  have  been  ex- 
pected. The  mortality  has  varied  in  different  coun- 
tries and  seems  to  have  been  greatest  in  Austria 
and  France ;  in  the  series  reported  here  there  were 
no  deaths.  No  definite  statement  can  yet  be  made 
as  to  residues  and  sequelae.  The  bacteriology  of 
the  disease  is  uncertain  as  yet.    As  regards  treat- 


ment tlie  writers  state  that  at  the  onset  rest  in 
bed,  protection  from  external  stimuli  of  all  kinds, 
laxatives,  bland  diet,  and  relief  of  headache  and 
pains,  would  seem  to  be  desirable.  In  their  expe- 
rience lumbar  puncture,  done  for  diagnostic  rea- 
sons, relieved  the  symptoms  so  markedly  in  several 
instances  that  it  was  repeated  at  intervals  as  a  thera- 
peutic measure.  During  convalescence,  prolonged 
rest,  careful  nursing,  a  nutritious  diet,  and  mild  hy- 
drotherapy, electrotherapy,  and  massage  have  been 
the  only  measures  made  use  of.  Complete  recovery 
without  residuals  seems  to  be  common. 

Transmissibility  of  Lethargic  Encephalitis. — • 
A.  Netter  (Bulletin  de  1' Academic  dc  medecinc, 
April  27,  1920)  reports  a  number  of  instances  in 
which  the  source  of  infection  in  lethargic  encepha- 
litis could  be  definitely  traced,  and  concludes  that 
the  disorder  is  certainly  a  transmissible  disease, 
though  the  risk  attending  contact  with  such  cases 
is  relatively  slight.  The  virus  is  probably  carried 
in  the  salivary  secretion.  In  view  of  the  prolonged 
persistence  of  the  virus  in  the  nerve  centres,  the 
patient  must  retain  for  a  long  time  the  capacity  to 
transmit  the  disease.  Considerable  evidence  is  at 
hand  to  the  effect  that  encephalitis  may  be  trans- 
mitted to  another  person  by  a  convalescent.  There 
is  also  reason  for  believing  that  the  disease  may  be 
acquired  through  contact  with  a  subject  harboring 
an  incomplete — fruste — or  larval  form  of  the  dis- 
ease, or  even  from  a  healthy  person  who  has  been 
in  contact  with  a  patient.  All  these  considerations, 
some  established  and  others  merely  probabilities, 
render  advisable  an  attempt  to  detect  and  record  all 
actual  or  suspected  cases  of  the  disease.  Persons 
in  contact  with  patients  should  be  warned  of  the 
possibility  of  direct  or  indirect  acquisition  of  the 
disease.  Isolation  of  all  patients  is,  however,  diffi- 
cult to  secure  at  the  present  time. 

Ocular  Manifestations  in  Lethargic  Encepha- 
litis.— F.  de  Lapersonne  (Bulletin  de  I'Academie  de 
medecinc,  April  27,  1920)  insists  that  ocular  paraly- 
ses are  equally  as  important  as  somnolence  from 
the  standpoint  of  diagnosis.  Frequently,  however, 
the  eye  symptoms  are  difficult  to  detect,  requiring 
a  special  ophthalmological  examination.  In  pa- 
tients confined  to  bed  when  first  seen,  the  ocular 
paralyses  may  have  already  disappeared — being 
fugacious  and  migratory — only  to  reappear  a  little 
later  on ;  or,  the  seriousness  of  the  general  condition 
may  not  permit  of  the  functional  examination  re- 
quired for  the  detection  of  diplopia  or  paralysis  of 
accommodation.  Ambulatory  patients  nearly  always 
consult  ophthalmologists  because  of  their  eye  dis- 
turbances, yet  seldom  reach  the  oculist  when  the 
disease  is  in  its  incipiency,  the  infection  having  been 
overlooked  and  the  disorder  ascribed  to  grippe  or 
food  intoxication.  In  some  instances  the  infection 
has  been  duly  recognized  and  treated,  and  the  pa- 
tients come  because  of  visual  disturbances  persist- 
ing as  sequelae  to  the  disease.  Ptosis  and  some- 
times diplopia  are  the  most  striking  manifestations. 
Xeuroretinal  lesions  have  never  as  yet  been  ob- 


September  4,  1920.] 


M  ISC  ELLAS  y  FROM  HOME   .-iXD  FOREIGN  JOURNALS. 


341 


served,  save  in  cases  of  coincident  syphilis  and 
encephalitis.  The  oculomotor  nerve  is  that  most 
commonly  affected,  a  special  feature  being  that  its 
involvement  is  of  a  fragmentary,  partial  type.  A 
single  muscle  may  be  alone  involved,  and  incom- 
pletely at  that.  Chauffard  has  laid  stress  on  an 
incomplete  unilateral  or  bilateral  ptosis,  only  part 
of  the  cornea  being  covered.  The  patients  do  not 
attempt  to  react  to  the  ptosis  by  throwing  the  head 
back  or  contracting  the  frontalis  muscle.  The  in- 
ternal rectus  is  often  only  incompletely  involved  and 
external  strabismus  is  not  always  apparent,  crossed 
diplopia  resulting.  Nystagmoid  jerks  rather  than  true 
nystagmus  are  present.  At  times  limitation  of  ver- 
tical movements  of  the  eye  may  be  observed.  In 
several  instances  the  author  noted  tmilateral  internal 
ophthalmoplegia,  evidenced  by  mydriasis  and  paraly- 
sis of  accommodation.  Complete  or  incomplete  par- 
alysis of  accommodation,  unilateral  or  bilateral,  may 
likewise  be  present  alone ;  this  condition  may  strik- 
ingly reproduce  certain  paralyses  of  accommoda- 
tion witnessed  after  diphtheria  or  in  botulism.  The 
external  oculomotor  is  more  rarely  involved,  though 
the  author  has  seen  one  apparent  case  of  such  in- 
volvement. Xo  instance  of  independent  paralysis 
of  the  patheticus  has  been  reported.  Apart  from 
the  manifestations  dtie  directly  to  nuclear  or  infra- 
nuclear  involvement  of  the  motor  nerves  there  may 
also  occur  other  forms  of  paralysis.  One  patient 
showed  paralysis  of  convergence  in  spite  of  preser- 
vation of  motor  power  in  the  two  internal  recti. 
Cantonnet  saw  a  patient  with  conjugate  deviation 
of  the  eyes.  These  cases  show  that  the  pathological 
lesions  of  encephalitis  may  involve  the  oculomotor 
pathways  in  their  corticomesocephalic  or  supranu- 
clear course. 

Disturbances  of  the  Reflexes  in  Lethargic  En- 
cephalitis.— G.  Guillain  {Bulletin  dc  V Academic  de 
mcdecine,  February  24,  1920)  found  the  tendon 
reflexes  greatly  disturbed  in  three  out  of  six  well 
marked  cases  of  lethargic  encephalitis.  The  patel- 
lar, Achilles,  medioplantar,  posterior  tibiofemoral 
and  posterior  peroneofemoral  reflexes  were  all  abol- 
ished in  these  patients.  In  the  upper  extremities, 
the  styloradial,  radiopronator,  ulnopronator,  flexor, 
biceps,  and  olecranon  reflexes  were  likewise  lost. 
In  one  of  the  other  cases,  dissociation  of  the  ten- 
don reflexes  of  adjacent  spinal  segments  was  noted. 
The  right  lower  limb  showed  merely  diminution  of 
the  patellar,  Achilles,  medioplantar,  and  posterior 
tibiofemoral  reflexes,  while  the  posterior  peroneo- 
femoral reflex  was  alone  abolished.  In  the  left 
lower  limb,  the  latter  reflex  was  likewise  lost,  but 
•the  other  fotir  were  normal.  In  the  upper  extremi- 
ties of  the  same  patient  the  olecranon  and  stylora- 
dial reflexes  were  normal,  but  the  radiopronator  and 
ulnopronator  reflexes  were  abolished.  This  disso- 
ciation of  reflexes  in  a  single  limb  is  analogous  to 
the  frequently  noted  dissociation  of  eye  paralyses, 
as  well  as  of  the  dissociation  of  the  signs  suggest- 
ing pyramidal  tract  involvement.  The  skin  reflexes 
were  normal  in  all  the  patients.  The  defensive  or 
spinal  automatic  reflexes  were  never  very  marked. 
In  no  patient  was  there  observed  the  contralateral 


flexion  reflex  to  pinching  of  the  femoral  quadri- 
ceps— a  reflex  frequently  positive  in  acute  menin- 
geal reactions.  Even  where  all  the  tendon  reflexes 
in  the  extremities  were  abolished,  the  nasopalpebral 
or  trigeminofacial  reflex,  resulting  in  closure  of 
the  lids  upon  percussion  at  the  root  of  the  nose, 
was  preserved.  In  two  cases  the  reaction  of  the 
pupils  to  light  was  sluggish,  but  not  abolished.  In 
two  ■  patients  all  tendon  and  skin  reflexes  remained 
unaffected,  and  both  patients  recovered.  The  re- 
flex disturbances  as  a  whole  betoken  diffuse  involve- 
ment of  the  neuraxis  in  lethargic  encephalitis,  the 
lesions  being  therefore  not  limited  to  the  bulbo- 
pontopeduncular  region.  The  frequency  of  mani- 
festations of  cerebral  excitation  with  mental  con- 
fusion indicates  also  a  participation  of  the  cortex 
in  the  morbid  process.  Early  abolition  of  reflexes 
seems  to  be  of  prognostic  import ;  the  four  patients 
showing  diffuse  loss  of  reflexes  all  succumbing  to 
the  disease,  while  the  other  two  recovered. 

Trismus  in  Lethargic  Encephalitis. — Audry 
and  J.  Froment  (Presse  inedicale,  May  5,  1920) 
report  two  cases  of  lethargic  encephalitis  attended 
with  trismus  but  no  other  form  of  contracture.  The 
first  patient  was  a  pregnant  woman  who  succumbed 
early  with  ophthalmoplegia,  dysarthria,  polypnea, 
and  disttirbances  of  deglutition.  The  second  was  a 
farmer  who,  after  a  blow  on  the  head,  developed 
headache,  dysarthria,  masklike  face,  and  prostration. 
Tetanus  might  have  been  thought  of,  btit  the  par- 
alysis of  accommodation,  few  myoclonic  contrac- 
tions, and  moderate  somnolence  suggested  rather  an 
epidemic  encephalitis,  a  conclusion  subsequently 
confirmed  by  the  marked  success  which  followed 
administration  of  injections  of  hexamethylenamine. 
In  both  these  cases,  as  in  the  case  reported  by  Cher- 
mitte  and  Saint-Martin,  the  distinctly  predominant 
involvement  of  the  midbrain  leads  to  the  conclusion 
that  the  trismus  was  due  to  irritation  of  the  motor 
nucleus  of  the  fifth  pair,  in  the  absence,  however, 
of  any  sign  of  involvement  of  the  sensory  portions 
of  these  nerves. 

Intracranial  Complications  in  Aural  Suppura- 
tion Coupled  with  Syphilis.- — E.  J.  Moure  (Bulle- 
tin de  V Academic  dc  medecine,  ^lay  11,  1920) 
states  that  while  in  most  cases  of  intracranial  com- 
plication in  actue  suppurative  otitis  media  the 
symptomatology  is  sufficiently  sitggestive  to  per- 
mit of  a  proper  diagnosis,  in  some  cases  the  func- 
tional disturbances  presented  are  so  indefinite  as 
to  mislead  the  physician.  Some  patients  with  ear 
suppuration  develop  pain  on  the  affected  side,  with 
swelling  and  tenderness  of  the  mastoid.  In  addi- 
tion to  these  customary  indications  of  mastoiditis 
the  patient  is  a  little  more  prostrated  than  usual, 
sometimes  presents  bilateral  spontaneous  nystag- 
mus upon  lateral  vision,  has  more  or  less  disturb- 
ances of  equilibration,  and  even  at  times  a  begin- 
ning Kernig.  In  short,  in  addition  to  the 
mastoiditis  there  are  presented  the  appearances  of 
an  indefinite  intracranial  complication.  If  there  is 
acute  otitis  media,  antrotomy  is  practised  or  if 
the  case  is  one  of  long  standing  otorrhea,  the 
radical  mastoid  operation  is  done  from  the  start. 
The  wound  heals  as  usual  and  the  bone  lesions  are 


342  MISCELLAXY  FROM  HOME   A.\D  FOREIGN  JOURNALS.  l^'^*  Vork 

Medical  Journal. 


recovered  from,  but  the  headache,  nystagmus,  dis- 
turbed equilibration,  and  Kernig  persist  and  often 
become  even  more  marked.  At  a  second  opera- 
tion cerebrum  and  cerebellum  are  explored  in  vain 
with  the  needle,  merely  yielding  in  some  instances 
clear  cerebrospinal  fluid  under  pressure  which,  upon 
laboratory  examination,  affords  no  special  indica- 
tion or  points  simply  to  a  meningeal  reaction  of 
varying  intensity.  Nor  is  this  second  operation 
followed  by  any  improvement.  In  such  cases  iMoure 
thought  of  the  possibility  of  complicating  syphilitic 
manifestations.  The  Wassermann  reaction  usually 
confirmed  this  suspicion,  being  negative  only  once, 
and  all  the  patients  recovered  under  systematic 
antisyphilitic  treatment.  One,  however,  succumbed 
to  a  subsequent  recurrence :  the  autopsy  showed  a 
gumma  of  the  cerebellum  undergoiHg  softening, 
whence  an  acute  meningitis  which  killed  the  patient. 

Influenza  in  the  United  States  Army. — Howard 
and  Love  {Military  Sitrf/coii,  May,  1920)  from  a 
study  of  the  reports  of  influenza  in  the  army  give 
the  following  conclusions : 

1.  Influenza  prevailed  much  more  extensively  in 
the  army  in  1917  and  during  the  early  months  of 
1918  than  has  been  commonly  recognized.  There 
were  40,512  cases  of  this  disease  reported  in  the 
army  for  the  year  1917. 

2.  Unrecognized  influenza  was  probably  the 
primary  and  underlying  cause  of  many  of  the  atypi- 
cal and  fatal  pneumonic  infections  occurring  in  the 
army  camps  during  1917  and  the  early  months  of 
1918,  in  addition  to  the  cases  known  to  have  been 
associated  with  measles. 

3.  Influenza  in  1917  and  the  early  months  of 
1918  was  relatively  mild  in  type  as  compared  with 
the  virulent  type  of  the  disease  which  appeared  in 
army  camps  in  September,  1918. 

4.  The  extension  of  the  virulent  influenza  from 
Camp  Devens  to  other  camps  south  and  west  in 
September,  1918,  can  be  traced  in  many  instances 
directly  to  the  interchange  of  military  personnel 
from  infected  to  noninfected  camps.  The  conta- 
gion was  transferred  by  persons  either  themselves 
infected  or  who  were  carriers  of  the  disease,  and 
the  extension   followed  ordinary   lines   of  travel. 

5.  The  height  of  the  September  outbreak  of  the 
disease  in  the  United  States  extended  over  a  period 
of  about  nine  weeks  (September  13  to  November 
15,  1918).  During  this  period  over  20,000  deaths 
occurred  among  troops  in  the  United  States  alone 
in  excess  of  the  number  that  would  have  occurred 
if  the  disease  death  rate  for  the  corresponding  period 
of  the  preceding  year  had  prevailed. 

6.  The  height  of  the  epidemic  in  France  extended 
over  the  same  period  of  time  as  in  the  United  States. 

7.  Influenza  and  pneumonia  were  less  prevalent 
and  less  fatal  among  our  troops  in  France  than  in 
the  United  States. 

8.  The  cantonment  group  of  stations  gave  a  much 
higher  death  rate  from  influenza  and  its  complica- 
tion than  other  groups. 

9.  For  the  entire  army  (approximately  3,500,000 
men)  there  were  688,869  admissions  charged  to  in- 
fluenza for  the  year,  or  twenty  per  cent,  of  the 
command.  This  record  does  not  represent  the  full 
incidence  of  the  disease  during  this  period. 


10.  There  were  47,384  deaths  from  all  diseases 
for  the  year  1918,  of  which  23,007  were  attributed 
to  influenza.  In  addition,  16,364  were  due  to  pneu- 
monic infections,  bronchitis  and  pleurisy,  many  of 
which,  it  is  certain,  should  have  been  charged  to 
influenza,  making  a  total  of  39,371  due  to  acute 
respiratory  diseases,  or  eighty-two  per  cent,  of  the 
total  deaths  from  disease  for  the  year.  Influenza 
with  its  complications  is  charged  with  48.5  per  cent, 
of  total  deaths  from  disease  for  the  year. 

11.  Influenza  was  more  prevalent  among  white 
troops  than  among  colored. 

12.  White  soldiers  from  the  south  had  much 
higher  admission  and  death  rates  for  influenza, 
pneumonia  and  other  acute  respiratory  diseases  than 
white  soldiers  from  other  sections.  The  lowest  rates 
for  these  diseases  were  among  white  soldiers  from 
the  Pacific  Coast  and  Rocky  Mountain  States. 

13.  The  negroes  stationed  in  the  United  States 
had  lower  admission  rates  than  the  whites  for  the 
country  at  large. 

14.  The  incidence  rate  for  all  forms  of  pneu- 
monia was  nearly  three  times  as  high  for  the  colored 
as  for  the  whites  for  the  entire  country. 

15.  The  death  rate  for  all  pneumonic  infections 
was  more  than  twice  as  high  for  colored  troops  as 
for  whites. 

16.  The  case  mortality  for  all  pneumonia  infec- 
tions for  the  colored  was  about  twenty  per  cent, 
lower  than  for  the  whites. 

A  Contribution  to  the  Study  of  Cerebellar 
Localizations. — Alfred  Gordon  (Journal  of  Ner- 
z'oiis  and  Mental  Disease,  ]\Iarch,  1920)  reviews 
the  literature  on  cerebellar  localizations  and  four 
case  histories  supporting  Bolk's  localizations.  The 
author  finds  from  these  four  cases  that  the  func- 
tion of  certain  muscular  groups  is  affected  in  dis- 
eases of  the  cerebellum.  The  selectivity  of  af- 
fection indicates  that  the  cerebellum  possesses  dis- 
tinct centres  for  the  extremities  and  for  the  head 
and  trunk.  These  primary  centres  are  composed  of 
secondary  centres  controlling  segments  of  limbs  as 
to  their  stability  and  orientation.  Clinical  findings 
show  that  the  cerebellar  centres  for  the  upper  and 
lower  extremities  are  located  in  the  hemispheres  on 
the  homolateral  side.  The  head,  neck,  and  trunk 
are  under  the  influence  of  the  vermis. 

A  Consideration  of  the  Nature  of  Aurae. — L.  B. 
Alford  (Archives  of  X curology  and  Psychiatry, 
February,  1920)  has  attempted  to  point  out  anew 
the  analogy  between  aurae  and  the  hallucinations 
occurring  in  connection  with  sleep,  hypnosis,  crys- 
tal gazing,  etc.  According  to  this  view,  aurse  should 
be  regarded  not  as  the  result  of  discharges  of  an 
epileptic  nature  in  some  part  of  the  cortex,  but  as 
deficiency  reactions,  like  -dreams,  occurring  when 
there  is  a  disturbance  of  consciousness  of  a  certain 
type.  Their  relation  to  the  loss  or  disturbance  of 
consciousness  in  epilepsy  and  migraine  is  assumed 
to  be  the  same  as  that  of  dreams  to  drowsy  or 
sleep  states,  and  their  content  should  be  regarded 
as  being  determined  by  the  same  factors  that  deter- 
mine the  content  of  dreams  and  similar  hallucina- 
tions which  develop  in  connection  with  disease  of 
the  organs  of  special  sense  or  of  the  nerves  con- 
necting them  with  the  brain. 


Proceedings  of  National  and  Local  Societies 


MEDICAL   SOCIETY  OF  THE   STATE  OF 

NEW  YORK. 
0)ic  Hundred  and  Fourteenth  Annual  Meeting^ 
Held  in  Nczu  York,  March  23  to  25,  1920. 

The  President,  Dr.  Claude  C.  Lytle,  of  Geneva,  in  the 
Chair. 

{Continued  from  page  236) 

SECTION  IN  SURGERY. 

The  Value  of  Position  in  the  Operative  Treat- 
ment of  Hernia. — Dr.  Henry  H.  M.  Lyle,  of 
Xew  Yorl:,  with  the  aid  of  lantern  slides,  described 
the  anatomical  relationship  of  tlie  abdominal  and 
thigh  muscles  to  Poupart's  ligament  and  showed 
that  when  this  ligament  was  relaxed  the  conjoined 
tendon  would  be  relaxed.  In  operating  for  hernia 
he  employed  a  simple  procedure  consisting  of  high 
ligation  and  transplantation  of  the  cord,  during 
which  the  patient  was  in  the  dorsal  position.  After 
putting  in  the  first  suture  through  the  conjoined 
tendon,  Gimbernat's  ligament  and  out  through  the 
lower  portion  of  Poupart's  ligament,  the  patient's 
knees  were  propped  up  with  the  leg  in  internal 
rotation.  The  shoulders  were  also  elevated.  The 
hinged  bed  that  had  come  into  use  during  the  war 
was  useful  in  maintaining  this  relaxed  position 
which  was  maintained  for  seven  days  and  insured 
firm  union. 

Mesenteric  Vascular  Occlusion. — Dr.  Ross  G. 
Loop,  of  Elmira,  said  that  this  subject  from  the 
viewpoint  of  prognosis  and  treatment  had  received 
scant  attention  in  our  literature,  and  in  the  text- 
books it  was  accorded  little  notice.  In  the  French 
and  German  literature  it  had  received  much  more 
complete  discussion.  Mesenteric  vascular  occlusion 
was  not  as  rare  a  condition  as  was  supposed  and 
quite  frequently  it  was  mistaken  for  intestinal  ob- 
struction. He  had  seen  seven  proved  cases  within 
the  last  two  years  and  was  convinced  that  in  the 
past  he  had  failed  to  recognize  many  more.  Its 
existence  or  nonexistence  in  obstruction  cases 
spelled  a  bad  or  a  good  prognosis  and  influenced 
treatment.  Mesenteric  vascular  occlusion  presented 
two  well  defined  forms.  In  the  primary  form  the 
symptoms  were  not  associated  with  other  abdominal 
lesions.  The  process  was  one  of  thrombosis  or  em- 
bolism due  to  remote  causes  from  the  heart  valves. 
Its  practical  interest  lay  in  the  fact  that  the  surgeon 
might  operate  for  the  relief  of  intestinal  obstruction, 
and  at  operation  he  had  to  deal  with  a  selfreduced 
volvulus.  If,  on  the  other  hand,  a  frank  gangrene 
was  found  (a  rare  finding  in  early  cases),  he  might 
resect  the 'intestine  without  suspecting  the  cause  of 
the  condition.  The  second  form  occurred  as  a  com- 
plication of  various  septic  conditions  and  might  be 
associated  with  the  common  forms  of  intestinal 
obstruction.  As  a  complication  of  clean  or  aseptic 
surgery,  it  was  responsible  for  many  deaths  that 
were  attributed  to  postoperative  ileus.  The 
symptomatolog>-  in  these  cases  was  susceptible  of 
another  classification  into  fulminating  and  phleg- 
matic, both  of  which  might  be  either  primary  or 
secondary.    There  might  be  considerable  free  fluid 


in  the  abdominal  cavity,  ranging  in  color  from  a 
light  yellowish  to  a  dark  brown.  The  blood  vessels 
were  cyanosed  and  dark.  Gangrene  might  be 
present,  or  there  might  be  mottled  segments  of  in- 
testine alternating  with  dark  red  ones.  At  times 
there  might  be  small  oval  areas  of  necrosis.  The 
peritoneum,  except  in  areas  where  there  might  be 
local  death,  had  not  lost  its  glistening  appearance. 
The  involved  coils  were  not  distinct  and  lay  inert 
and  half  filled  with  liquid,  looking  very  much  like 
a  rubber  glove  with  a  little  water  in  it.  If  handled 
the  coils  gave  a  peculiar  sensation  of  weight  and 
thickness.  The  mesentery  was  heavy  and  soggy, 
and  thrombosed  vessels  might  be  seen  if  not  obscured 
by  tumefaction.  One  or  two  folds  of  the  mesentery 
might  hang  down  over  the  sacral  promontory  and 
give  the  impression  of  being  adherent,  but  this  was 
produced  by  the  weight  of  the  liquid  contents.  In 
all  of  his  cases  the  middle  third  of  the  small  in- 
testine was  involved  and  the  mesentery  appeared 
as  a  low  attachment,  and  whether  this  had  anything 
to  do  with  the  production  of  the  condition  he  was 
unable  to  say.  The  fulminating  cases  presented  a 
symptom  complex  which  constituted  a  disease 
entity.  The  phlegmatic  types  were  less  easily 
recognized,  especially  if  they  were  associated  with 
preexisting  trouble.  The  fulminating  type  was 
characterized  by  pain,  sudden  and  violent,  if 
primary,  or  if  secondary  by  the  same  kind  of  pain 
in  connection  with  the  preexisting  symptoms.  The 
pain  was  worse  on  the  left  side.  In  the  phlegmatic 
type  the  pain  was  not  sudden  or  severe,  but  varied 
from  a  vague  unrest  to  a  severe  cramp,  and  when 
this  form  was  superimposed  on  another  lesion  it 
was  insidious.  Vomiting  occurred  in  all  the  forms, 
was  coincident  with  the  pain,  and  tended  to  cease 
spontaneously  in  a  few  hours  when  the  pressure 
above  the  lesion  had  been  relieved  by  the  vomiting. 
The  muscle  rigidity  was  not  to  be  compared  with 
that  found  in  other  equally  severe  conditions.  The 
abdomen  was  not  distended  as  in  peritonitis.  The 
condition  was  afebrile  and  the  pulse  soft  and  ir- 
regular. In  the  fulminating  cases  the  patient  was 
more  or  less  in  shock.  ^Mesenteric  vascular  occlu- 
sion was  a  disease  of  adult  life,  more  than  seventy 
per  cent,  of  the  cases  being  in  individuals  over 
forty-five  years  of  age.  The  condition  might  be 
mistaken  for  pancreatitis  or  rupture  of  a  viscus. 
Moynihan  stated  that  in  this  condition  no  surgeon 
could  show  a  mortality  of  less  than  fifty  per  cent. 
The  treatment  was  purely  surgical,  consisting  of 
wide  excision  of  the  involved  coils  of  intestinal 
anastomosis. 

Special  Points  in  th<;  Surgery  of  the  Gallblad- 
der.— Dr.  George  \V.  Crile,  of  Cleveland,  Ohio, 
described  the  experience  of  his  associates  and  him- 
self in  1325  operations  on  the  gallbladder  and  ducts 
from  the  viewpoint  of  the  difficulties  and  failures 
that  they  had  met  with.  Among  the  questions 
considered  were  how  they  might  increase  the  cer- 
tainty of  reHef,  how  they  might  decrease  the  risk 
from  hemorrhage;  what  was  the  incision  of  choice, 


344 


PROCEEDIXGS  OF  XATIOXAL   AXD  LOCAL  SOCIETIES. 


[New  York 
Medical  Journal. 


and  when  the  common  duct  should  be  drained. 
Hemorrhage  might  be  met  by  transfusion.  The 
best  incision  in  operating  on  the  common  duct  was 
parallel  to  the  costal  border ;  this  did  not  divide 
many  nerve  fibres  and  secured  against  ppstoperative 
hernia.  The  incision  should  be  long  enough  to  in- 
sure adequate  exposure.  In  cholecystostomy  the 
best  drainage  was  from  the  dependent  point,  and 
frequently  this  was  obtained  by  a  counter  incision 
at  the  bottom  of  ^Morrison's  pouch.  In  fulminating 
acute  cases  the  only  immediate  procedure  was  to 
establish  gallbladder  drainage.  It  was  very  desir- 
able to  carry  the  acute  gallbladder  to  the  subacute 
stage  before  final  operation.  When  this  acute  con- 
dition subsided  and  the  patient's  condition  was 
stabilized,  cholecystectomy  was  the  procedure  of 
choice  in  those  cases  giving  a  historj-  of  recurrent 
attacks  of  cholecystitis.  In  severe  cases  of  acute 
cholecystitis  he  used  a  short  incision,  a  round  tube, 
plenty  of  gauze  about  the  opening  and  no  stitches. 

The  general  principle  of  adequate  exposure  held 
for  operations  on  the  common  duct  as  for  those  on 
the  a1)domen.  In  dicussing  cholecystectomy  versus 
cholecystostomy.  Doctor  Crile  said  that  in  the  ab- 
sence of  the  gallbladder  the  common  duct  compen- 
sated by  storing  bile  and  this  predisposed  to  the  for- 
mation of  stones  and  a  recurrence  of  symptoms,  so 
that  the  removal  of  the  gallbladder  was  not  without 
some  imfavorable  consequences.  If  the  mucous 
membrane  of  the  gallbladder  was  gangrenous,  if 
the  wall  was  thickened,  or  if  stones  were  imbedded 
and  after  drainage  there  had  been  a  recurrance  of 
periodical  attacks  of  cholecystitis  with  obstruction 
and  infection,  then  cholecystectomy  was  indicated. 
If  the  gallbladder  and  cystic  duct  were  normal,  no 
matter  what  the  size  of  the  stone,  there  would  rarely 
be  a  cycle  of  recurrent  attacks  and  cholecystostomy 
would  fulfill  the  requirements.  In  removing  the 
gallbladder  there  should  be  free  exposure  through 
an  ample  incision  so  as  to  give  free  access  to  its 
base.  The  gallbladder  should  be  dissected  free  by 
sharp  dissection,  without  injury  to  the  liver.  The 
entire  gallbladder  should  be  freed  from  its  attach- 
ments so  that  ample  opportunity  might  be  given 
for  determining  where  it  ended.  The  cystic  duct 
should  likewise  be  dissected  free  so  that  the  exact 
point  of  division  between  the  gallbladder  and  the 
cystic  duct  could  be  determined.  The  cj'Stic  duct 
should  be  taken  oft  near  the  common  duct.  The 
clinical  results  following  cholecystectomy  were  as 
much  better  than  those  following  cholecystostomy  as 
were  those  of  nephrectomy  better  than  those  of 
nephrotomy.  They  were  now  doing  about  sixty 
cholecystectomies  to  forty  cholecystostomies.  In 
doing  a  cholecystectomy  a  careful  dissection  should 
be  done  so  that  the  surgeon  would  not  be  at  a  dis- 
advantage later  if  he  were  called  upon  to  operate 
upon  the  common  duct. 

Liver  shock  was  a  common  cause  of  death  after 
gallbladder  operations  and  was  due  to  failure  of 
the  liver  cells  to  perform  their  function.  Its  pre- 
vention was  secured  by  the  avoidance  of  liver  cell 
depression.  The  depression  of  the  liver  cells  was 
increased  by  trauma  and  by  low  blood  pressure,  and 
that  meant  suboxidation.  To  prevent  this  light  gas 
anesthoia  should  be  employed,  the  operation  should 


be  as  brief  as  was  compatible  with  good  surgery, 
blood  transfusion  should  be  given  early,  and  heat 
should  be  applied  over  the  whole  abdomen. 

Application  of  the  Methods  Developed  during 
the  War  to  the  Fractures  of  Civil  Life. — Dr.  Jo- 
seph A.  Blake,  of  New  York,  presented  a  lantern 
slide  demonstration  of  the  overhead  suspension  and 
traction  treatment  of  fractures  now  being  used  in 
the  treatment  of  fractures  at  Bellevue  Hospital. 
At  the  beginning  of  the  war  they  had  treated  frac- 
tures by  the  application  of  plaster  of  Paris,  but  they 
soon  found  that  they  would  have  to  develop  some 
method  which  would  permit  of  better  access  to 
the  wounds  and  which  would  be  more  susceptible 
of  variation,  so  they  came  to  use  wire  splints,  and 
in  1917  and  1918  these  were  well  established  in  the 
French  and  Engli.sh  armies.  They  were  at  first 
much  hampered  by  the  old  opinions  as  to  the  treat- 
ment of  fractures,  namely,  that  these  should  be 
fixed  as  much  as  possible.  However,  the  further 
they  got  away  from  the  old  idea  of  fixation  the 
better  were  the  results  obtained.  In  fractures  of 
the  long  bones  it  was  easy  to  fix  the  distal  frag- 
ment, but  the  difficulty  came  in  fixing  the  upper 
or  proximal  fragment  to  the  lower  fragment. 

The  principles  upon  which  the  newer  method 
was  based  was  that  when  the  proximal  frag- 
ment w'as  at  ])hysiological  rest,  it  was  in  the  posi- 
tion in  which  antagonistic  muscles  had  brought  it ; 
it  would  not  have  much  tendency  to  move  in  either 
direction,  and  if  the  upper  fragment  was  in  that 
position,  the  other  fragment  could  be  readily 
moved.  Having  placed  the  upper  fragment  in  the 
position  of  physiological  rest,  the  distal  frag- 
ment was  brought  into  line  with  it  and  then  the 
whole  extremity  could  be  moved  without  moving 
the  fracture.  Doctor  Blake  then  demonstrated  the 
use  of  the  overhead  suspension  frame  in  high  frac- 
tures of  the  humerus.  He  said  it  gave  uniformly 
good  results,  the  only  objection  to  it  being  that  the 
patient  had  to  remain  in  bed,  and  this  was  not  an 
objection,  considering  the  rapidity  with  which  re- 
pair took  place.  He  left  the  arm  free  during  the 
day  and  put  it  back  in  the  suspension  apparatus  at 
night,  and  in  this  way  union  was  often  obtained  in 
eighteen  or  twenty  days.  In  fractures  of  the  fore- 
arm the  fragments  were  not  suspended  in  the  same 
plane,  one  being  suspended  mesial  to  the  other.  In 
the  application  of  traction  they  made  use  of  the 
glued  cotton  glove  with  curtain  rings  sewed  to  each 
finger  tip.  This  permitted  of  even  traction,  or  trac- 
tion might  be  applied  to  individual  fingers.  The 
Blake-Keller  half  ring  thigh  and  leg  splint 
was  shown.  This  splint  had  proved  of  great  value 
in  the  transportation  of  men  with  fractured  femur, 
and  with  the  Thomas  arm  splints  should  form  a 
part  of  the  equipment  of  every  ambulance.  He 
hoped  that  they  would  be  able  to  extend  some  of 
these  methods  which  had  been  so  valuable  in  the 
treatment  of  fractures  during  the  war  to  the  treat- 
ment of  industrial  injuries  of  which  there  were  at 
least  three  quarters  of  a  million  in  this  countr}' 
every  year.  They  shortened  the  period  of  con- 
valescence and  did  away  with  at  least  five  per  cent, 
of  the  incapacity  resulting  from  other  methods. 
{To  be  continued.) 


New  York  Medical  Journal 


INXORPORATIXG  THE 


Philadelphia  Medical  Journal  ?he  Medical  News 

A  Weekly  Revieiv  of  Medicine,  Established  184S. 


Vol.  CXII.  No.  11. 


XEW  YORK.  SATURDAY.  SEPTEMBER  11.  1920. 


Whole  Xo.  21S(). 


Original  Communications 


MEDICAL  MEX  IN  THE  A^IERICAX 
RE\'OLUTIOX.* 
The  Xctc  ]'ork  Campaign  of  1776. 
By  Louis  C.  Duncan,  M.  D., 

Washington,  D.  C, 

Lieutenant  Colonel.  Medical  Corps.  I'.  S.  Army. 

The  siege  of  Boston  had  ended  in  March  with 
complete  success  for  the  Colonists,  a  sticcess  to 
be  followed  by  a  long  sticcession  of  dismal  failures 
before  victory  wottld  again  cheer  their  hearts.  Bos- 
ton had  been  captured  with  little  loss  in  battle  casual- 
ties, and,  what  is  even  more  surprising,  with  even 
less  from  sickness  in  the  camps.  This  happy  event 
was  also  not  to  be  repeated ;  henceforth  the  army 
was  to  be  dogged  by  disease,  the  camps  to  be  clogged 
with  thotisands  of  miserable  sick.  There  men  not 
only  died  by  htindreds,  but,  scattering  to  their  homes, 
carried  disease  and  death  to  the  inhabitants  of 
every  colony.  Btit  all  this  was  in  the  web  of  the 
future,  and  the  Continental  Army,  cheered  by  its 
recent  easy  victory,  marched  confidently  on^its  way 
to  where  the  enemy  next  threatened  battle  before 
the  city  of  X"ew  York. 

General  Charles  Lee  had  been  despatched  to  Xew 
York  in  February,  1776.  Raising  a  force  of  twelve 
hundred  men  in  Connecticut,  he  marched  into  the 
city  and  assumed  the  principal  authority  there,  in 
conjunction  with  three  members  of  the  Continental 
Congress.  X'ew  York  was  threatened  throttghout 
the  spring,  but  not  actually  attacked  until  July. 
Washington  did  not  believe  that  the  place  could  be 
held ;  there  were  so  many  points  to  be  fortified  and 
defended  with  his  loosely  organized  and  poorly  sup- 
plied army  that  it  seemed  next  to  impossible  to 
maintain  all  of  them.  He  proposed  to  retire  to 
the  Highlands  of  the  Hudson  and  defend  the  Col- 
onies there ;  but  the  Congress  decided  that  Xew 
York  must  be  held,  and  he  promised  his  "'titmost 
exertions,  under  every  disadvantage."  When  the 
British  entered  the  river  with  men  of  war  and 
threatened  to  cut  off  his  forces,  it  was  quickly 
proved  to  be  a  place  that  could  not  be  defended  in 
the  face  of  command  of  the  sea. 

General  Lee  projected  works  on  Long  Island, 
at  the  Harlem,  and  at  various  points  along  the 
shores  of  the  island.  In  F'ebruary  he  was  succeeded 
by  Lord  Stirling.    When  Boston  was  evactiated  in 

*This  article,  which  will  appear  in  four  instalments,  is  a  chapter 
from  a  book  to  be  published  shortly. 

Copyright.  1920,  by  A.  R. 


^larch,  a  large  part  of  the  Continental  Army  was 
moved  to  Xew  York,  and  King's  College  was  taken 
for  a  hospital  on  April  6th.  Washington  himself 
arrived  on  April  16th:  going  on  to  Philadelphia 
to  visit  the  Congress  in  May.  he  left  Putnam  in 
command  in  X'ew  York,  and  Greene  in  charge  of 
the  works  on  Long  Island.  These  generals  held 
their  respective  commands  until  shortly  before  the 
Battle  of  Long  Island.  Washington  found  about 
eight  thousand  men  in  and  about  Xew  York,  poorly 
armed  and  equipped.  On  leaving  Boston,  five  of 
the  Xew  England  regiments  had  Seen  left  behind, 
and  some  had  been  sent  to  join  the  X'orthern  Army, 
but  the  brigades  of  Heath.  Sullivan.  Spencer  and 
one  other  had  marched  to  Xew'  York.  These  bri- 
gades were  of-  about  five  regiments  each  and  may 
have  numbered  twelve  to  fifteen  hundred  men  to 
a  brigade.  At  Xew  York  the  army  was  joined 
for  the  first  titne  by  regiments  from  the  middle 
states. 

The  camps  at  Xew  York  were  marked  by  much 
serious  sickness,  especially  by  typhus,  which  had 
scarcel}  been  seen  at  Boston.  There  was  also  much 
dj'sentery.  though  this  disease  was  seldom  fatal. 
Dr.  James  Tilton  said  of  the  camps  at  this  time: 

The  ignorance  and  irregularities  of  our  men  in  the  new 
scene  of  life  subjected  them  to  numberless  diseases.  The 
sick  flow  in  a  regular  current  to  the  hospitals :  these  are 
overcrowded  so  as  to  produce  infection,  and  mortality 
ensues  too  affecting  to  be  described. 

Our  Revolutionary  Army  exemplified  this  misfortune 
in  a  shocking  manner.  The  Flying  Camp  of  1776  melted 
like  snow  in  a  held ;  dropped  like  rotten  sheep  on  their 
.struggling  route  home,  where  they  communicated  the  camr 
infection  to  their  friends  and  neighbors,  of  whom  ni;in\- 
died. 

Rush  said  afterward : 

^  It  is  very  remarkable  that  while  the  American  Army  at 
Cambridge,  in  the  year  1775.  consisted  only  of  New  Eng- 
land men  (whose  habits  and  manners  were  the  same), 
there  was  scarcely  any  sickness  among  them.  It  was  not 
until  the  troops  of  the  eastern,  middle,  and  southern  states 
met  at  New  York  and  Ticonderoga,  in  1776.  that  the 
typhus  became  universal,  and  spread  with  such  mortality 
in  the  army  of  the  United  States. 

Dr.  Schoepfif.  chief  medical  ofificer  of  the  Hes- 
sian force.  whiclT  reached  Staten  Island  in  fune. 
.said  that  scarcely  a  man  escaped  sickness  dtiring  that 
first  sttmmer.    The  principal  disease  was  dysenterv. 

The  officers  of  the  army  were  not  ignorant  or 
entirely  careless  of  sanitation,  but  the  state  of  gen- 
eral knowledge  and  prevailing  discipline  made  en- 
forcement of  orders  difficult  or  impossible.  On 

Elliott  Publishing  Company. 


346 


DUNCAN:  MEDICAL  MEN  IN   THE  AMERICAN  REVOLUTION. 


[New  York 
Medical  Journal. 


July  28th  the  following  order  was  issued  from 
Headquarters  of  the  camp  on  Long  Island: 

The  General  is  pained  to  observe  inattention  to  the  dig- 
ging and  filling  of  vaults  for  the  Regts  &,  the  General  di- 
rects camp  colourmen  (colored  men?)  of  the  several  regi- 
ments to  dig  vaults  and  fill  up  the  old  ones  every  three 
days ;  and  that  fresh  dirt  be  thrown  in  every  day  to  the 
vaults;  and  that  all  filth  in  and  about  the  camp  be  buried 
daily. 

This  order,  if  enforced,  would  have  resulted  in 
camps  as  sanitary  as  those  of  the  Spanish- Ameri- 
can War,  one  hundred  and  twenty-two  years  later. 
Unfortunately  it  was  poorlv  enforced,  as  it  was  in 
1898. 

In  February,  General  Lee,  in  a  letter  to  Con- 
gress, suggested  that  a  hospital  be  established  in 
New  York  without  loss  of  time.  The  work  of 
building  a  hospital  in  New  York  (the  second  in 
America)  had  been  commenced  in  1771  and  finished 
in  1774,  to  be  burned  down  and  rebuilt  in  1775.  But 
the  necessity  for  barracks  preceding  that  for  a  hos- 
pital, the  unfinished  hospital  building,  at  the  recom- 
mendation of  the  Committee  of  Safety,  was  occu- 
pied by  the  troops  as  quarters.  It  was  afterward 
used  by  the  British  troops,  but  chiefly  as  barracks. 
Private  homes  were  taken  and  (with  King's  Col- 
lege) formed  the  principal  reliance  for  hospitals. 
They  were  safer,  on  account  of  the  consequent  sep- 
aration of  the  sick,  during  the  prevalence  of  dysen- 
tery and  typhus.  On  April  3rd,  while  still  in  Bos- 
ton, Medical  Director  Morgan  received  the  follow- 
ing letter  from  the  General : 

As  the  Grand  Continental  Army  .  .  .  will,  as  soon 
as  it  is  practicable,  be  assembled  at  New  York,  you  are. 
with  all  convenient  speed,  to  remove  the  general  hospital 
to  that  city.  As  the  sick  in  the  different  houses  cannot 
be  moved,  but  must  be  attended  to  until  they  are  able  to 
march,  you  will  leave  such  surgeons,  surgeons'  mates, 
apothecaries,  and  attendants  under  the  direction  of  (Sur- 
geon to  be  selected  by  Dr.  Morgan)  as  are  necessary-  for 
the  care  of  the  sick  now  in  the  general  hospital.  The 
medicine,  stores,  bedding,  etc.,  etc.,  not  immediately  want- 
ed in  the  general  hospital,  should  be  loaded  in  carts,  that 
will  be  provided  next  Saturday  by  the  Asst.  Q.  M.  Gen- 
eral, and  sent  under  the  care  of  a  proper  ofiicer,  or  officers 
of  the  hospital,  to  Norwich,  Connecticut.  Upon  their  ar- 
rival there  they  will  find  his  Excellency's  orders,  and  how 
and  in  what  manner  to  proceed  from  thence,  whether  b> 
land  or  water. 

The  medicines  ordered  upon  his  Excellency's  applica- 
tion, by  the  honorable  the  General  Court  of  this  Province, 
to  be  taken  out  of  the  town  of  Boston,  should  be  sent 
with  the  first  of  the  hospital  stores  that  go  to  Norwich, 
a  careful  person  having  order  to  take  charge  of  the  same. 

The  fixing  and  completing  of  the  regimental  chests,  ac- 
cording to  your  plan,  had  better  be  deferred  until  your 
arrival  at  New  York,  when  they  may  be  set  about  under 
your  inspection. 

Before  you  leave  Cambridge  it  will  be  necessary  to  see 
a  proper  regimental  medicine  chest  provi4ed  and  delivered 
to  each  of  the  surgeons  of  the  four  regiments  left  in  gar- 
rison there  under  the  immediate  command  of  Major  Gen- 
eral Ward ;  also  a  chest  for  Colonel  Glover's  regiment,  on 
command  at  Beverly. 

Reposing  entire  confidence  in  your  care,  diligence  and 
zeal  for  the  service,  I  remain  satisfied  of  your  best  exer- 
tions for  the  public  benefit. 

Given  at  Cambridge  Headquarters,  3rd  day  of  April, 
1776.  George  Washington. 

To  Dr.  John  Morgan. 

This  letter  is  quoted  to  show  the  interest  taken  by 
the  General  even  in  the  details  of  the  medical  de- 
partment of  the  army. 


Dr.  Morgan,  in  his  Vindication,  gives  some  in- 
formation as  to  the  sick  left  behind  in  the  Boston 
hospitals,  and  also  of  the  supplies  that  he  had  col- 
lected. They  seem  pitifully  meagre  now,  but  he 
evidently  was  proud  of  them.  Many  of  these  sup- 
plies had  been  abandoned  by  the  British,  on  leav- 
ing Boston. 

When  the  troops  marched  from  Cambridge  for  New 
York,  all  the  sick  were  left  behind  in  the  General  Hos- 
pital, amounting  to  upwards  of  300  men.  In  less  than 
six  weeks,  during  'which  time  but  few  died,  I  was  able 
to  discharge  the  hospital  of  every  man,  to  settle  and  pay 
every  account,  insomuch  as  never  to  have  had  anv  further 
demands  from  that  quarter. 

During  this  time,  with  little  or  no  expense  to  the  public, 
but  for  package  and  transportation,  I  collected  medicines, 
furniture,  and  hospital  stores,  worth  many  thousand 
pounds,  and  sent  them  on  to  New  York.  The  like  quan- 
tity I  apprehended  could  not  be  procured  in  any  (other) 
part  of  America.  Besides  these,  I  was  able  by  means  of 
the  subaltern  officers  in  the  hospital,  some  of  whom  I 
employed  continually  at  this  work,  likewise  to  collect  near 
to  the  amount  of  two  thousand  rugs  and  blankets,  near  as 
many  bedsacks  and  pillows,  which  were  taken  up  from 
docks,  and  were  gathered  from  hospitals  and  barracks, 
etc.,  etc.  These  being  washed  and  aired,  served  the  last 
campaign,  when  none  other  could  be  got,  and  many  of 
them  are  yet  in  good  preservation  (1777).  In  New  York 
I  collected  some  hundred  sheets,  fracture  boxes,  and  other 
useful  articles. 

It  may  be  thought  that  I  place  a  higher  value  on  these 
acquisitions  than  they  merit;  be  that  as  it  may,  I  am  per- 
suaded that  the  like  could  not  be  obtained  for  much  less 
than  thirty  thousand  dollars :  which  is  equal  to  the  whole 
amount  of  what  I  have  drawn  or  expended,  for  the  gen- 
eral hospital  in  the  space  of  twelve  months,  including  the 
pay  of  all  the  officers,  and  all  the  expenses  of  every  kind ; 
and  for  the  faithful  expenditure  of  the  same  I  am  ready 
to  produce  my  accounts,  receipts,  and  vouchers,  whenever 
called  upon  for  a  settlement.  Yet  the  general  hospital  has 
had  the  constant  charge  of  a  number  from  two  to  three 
hundred  to  a  thousand  sick  and  upwards  to  provide  for. 

Economy  seems  to  have  been  one  of  Morgan's 
virtues,  as  it  was  Washington's.  He  did  well  to 
retain  his  vouchers,  for  long  after  the  war  ended  he 
was  wrestling  with  Congress  over  these  very  ex- 
penses.   He  went  on  to  say: 

I  am  persuaded  that  of  the  sick  who  have  been  drawn 
(rations)  for  in  the  general  hospital,  if  none  of  them 
have  been  drawn  for  at  the  same  time  with  the  well  men 
in  their  regiments,  the  stoppage  of  their  rations  will  go  a 
long  way  toward  paying  the  whole  of  the  expenses  the 
hospital  has  been  to  on  their  accounts  for  provisions  and 
stores  of  whatever  kind. 

Washington  found  time,  in  the  month  of  June, 
probably,  to  inqtiire  into  the  expenses  of  the  general 
hospital.  He  learned  from  some  unnamed  persons 
what  the  expenses  of  a  similar  establishment  should 
be  in  the  British  Army.    Morgan  says : 

In  a  conference  with  the  General,  he  (Washington) 
stated  that  the  expenses  of  the  general  hospital  should  not 
exceed  ten  thousand  pounds  per  annum,  as  some  experi- 
enced persons  had  intimated. 

Morgan  feared  it  could  not  be  done,  but  resolved 
to  employ  strict  economy  to  keep  it  within  those 
bounds.  He  mentions  "the  advanced  price  of  every 
article  of  living  and  hospital  stores,"  which  it  seems 
accompanied  that  war  as  well  as  later,  and  earlier, 
ones. 

Wishing  to  know  the  basis  of  this  estimate  of  the 
General's,  he  wrote  to  the  person  who  made  it, 
probably  Dr.  John  Jones.  He  was  informed  that 
the  estimate  of  ten  thousand  pounds  was  made  for 
a  force  of  ten  thousand  men,  for  six  months.  Mor- 


September  11.  1920.]       DCXCAX :  MEDICAL  MEN  IN   THE  AMERICAN  REVOLUTION. 


347 


gan  estimated  that  the  expense  for  the  Army,  on 
that  basis,  should  be  forty  thousand  pounds  for  one 
year — for  twenty  thousand  men,  the  number  then 
kept  on  foot.  Morgan's  administration  was  ex- 
tremely economical,  as  will  be  better  understood 
when  the  hundreds  of  thousands  expended  by  his 
successors  are  considered. 

At  the  same  time  he  inquired  of  this  person,  who 
doubtless  had  been  in  the  IBritish  service,  to  clear  up 
all  doubts  as  to  the  manner  in  which  the  regimental 
surgeons  were  supplied  with  instruments  and  medi- 
cines in  that  service.  He  seems  to  have  been  in- 
formed that  such  supplies  were  not  drawn  from  the 
general  hospital.    He  goes  on  to  say : 

The  Congress,  or  your  Excellency  should  give  orders 
for  a  different  mode  to  be  pursued ;  I  considered  mj-self 
to  be  bound  in  duty  to  keep  the  British  establishment  con- 
stantly in  my  eye,  as  a  directory,  making  allowances  for 
the  nature  and  differences  of  the  ser^-ice. 

At  another  conference  with  Washington  over  dif- 
ficulties, he,  Washington,  had  said:  "What  is  the 
practice  in  the  British  Army  ?  Why  should  we  think 
of  improving  upon  their  system,  founded  upon  long 
experience?"  It  is  clear  that  both  the  General  and 
the  Medical  Directors  were  following  the  customs 
and  regulations  of  the  British  Army,  in  so  far  as 
they  could  be  applied  to  the  Continental  Army. 

On  June  3rd  Congress  called  for  thirteen  thou- 
sand eight  hundred  militia  from  the  New  Eng- 
land Colonies,  and  ten  thousand  from  Pennsylvania, 
Delaware  and  Maryland.  These  latter  were  to  fur- 
nish what  was  designated  as  The  Flying  Camp,  for 
the  protection  of  the  Jerseys,  threatened  with  in- 
vasion by  the  British  forces.  General  Hugh  Mercer 
was  given  the  command  of  this  doubtful  force,  and 
Dr.  W^illiam  Shippen  was  made  its  Medical  Director 
on  July  15th.  Shippen  had  been  ^lorgan's  colleague 
in  founding  the  Medical  College  at  Philadelphia,  and 
was  later  to  supplant,  if  not  undermine,  him.  Mer- 
cer was  a  Scotch  physician,  a  graduate  of  Aberdeen, 
who  had  followed  Prince  Charlie  to  Derby  and 
escaped  from  the  slaughter  of  Culloden.  He  had 
served  in  many  Indian  campaigns,  where  he  was 
often  wounded.  He  commanded  a  companv  in 
Braddock's  dismal  expedition,  was  severely  wounded 
and  left  on  that  field  of  death,  but  escaped  and  made 
his  way  back  through  three  hundred  miles  of  wil- 
derness. In  1756  he  was  both  commanding  officer 
and  surgeon  at  McDowell's  Fort  in  Pennsylvania, 
and  was  there  twice  wounded.  In  1758  he  was  an 
officer  under  Forbes,  fighting  with  the  redcoats  now. 
He  entered  the  war  as  Colonel  of  the  Third  Vir- 
ginia Line  early  in  1776.  He  was  made  a  briga- 
dier on  June  5th  and  given  command  of  the  Flying 
Camp.  He  was  to  die  by  British  bayonets,  fighting 
to  the  last,  before  the  year  was  out.  Of  the  many 
heroes  of  the  Revolution  none  merited  that  title 
more  than  did  Dr.  Hugh  Mercer. 

By  July,  Morgan  had  established  his  hospitals  in 
Xew  York,  provided  them  with  stores,  and  was  as 
he  supposed  fairly  well  prepared  for  the  coming 
storm.  But  as  to  the  regimental  surgeons  he  was 
in  dismay.  They  had  next  to  nothing,  and,  most  of 
all,  seemed  careless  or  ignorant  of  their  own  help- 
less state.    He  says : 

I  am  well  off  in  the  general  hospital,  except  in  a  few 
particulars.    I  have  provided  ten  thousand  bandages,  have 


some  hundred  old  sheets,  and  a  stock  of  medicine  (though 
iinassorted).  I  have  of  capital  instruments  nearly  enough 
for  hospital  use.  But  in  the  meantime  what  is  to  become 
of  the  regimental  surgeon?  Should  I  divide  my  stores 
among  them,  they  would  be  dissipated  and  ourselves  left 
destitute.  To  observe  a  medium  I  have  orders  to  be  is- 
sued from  the  general  hospital  stores,  sixty  bandages,  two 
sheets,  four  tourniquets,  a  quantity  of  lint  and  tow,  and 
a  chest  of  medicines.  .  .  .  But  of  instruments  I  have 
none  to  spare,  and  I  begin  to  want  some  capital  medicines. 
Moreover,  symptoms  of  a  putrid  fever  begin  to  appear. 
[Typhus.] 

At  this  time  there  were  about  forty  regiments 
with  the  Army.  The  hospitals  in  Xew  York  then 
were:  King's  College,  City  Hospital,  City  Bar- 
racks, and  whole  streets  of  houses  appropriated  by 
the  convention  of  Xew  York.  Country  seats  at  a 
distance  of  some  miles  were  also  taken.  King's 
College  was  the  principal  hospital,  the  others  were 
subsidiary.  General  Greene  complained  of  the  ne- 
glect of  the  sick  on  Long  Island.  Dr.  John  War- 
ren (1),  of  Boston,  was  made  stirgeon  of  that  part 
of  the  General  Hospital,  established  on  Long  Island 
for  the  troops  there.  Dr.  Isaac  Foster  was  his  as- 
sistant. Morgan's  letter  of  instructions  (2)  to  War- 
ren is  full  and  comprehensive. 

The  hospitals  about  Xew  York  were  an  improve- 
ment on  those  hitherto  established,  yet  left  much  to 
be  desired.  Especially  were  the  regimental  sur- 
geons lacking ;  not  only  in  tents  and  bedding,  but 
also  in  instruments  and  dressings,  of  which  they  had 
next  to  none.  Morgan  inquired  into  these  short- 
ages and  took  what  he  considered  the  proper  steps 
for  remedying  them.  While  most  of  his  proposed 
measures  were  excellent,  in  one  principal  one  he 
appears  to  have  failed  to  hit  upon  a  proper  remedy. 
The  regimental  surgeons  were  always  short  of  sup- 
plies and  were  continually  applying  for  them  to  the 
general  hospital.  He  always  maintained  that  he  had 
none  to  spare,  which  was  true.  But,  instead  of 
proposing  a  general  supply  officer,  under  his  own 
jurisdiction,  he  proposed  a  system  of  continental 
druggists,  located  some  place  and  imder  no  control. 
This  was  the  point  on  which  he  failed.  He  himself 
admitted  afterward  that  this  was  the  rock  on  which 
he  foundered,  but  never  admitted  that  he  was  in 
error.  His  letters  and  papers  at  this  period, 
though  not  always  clearly  composed,  give  a  com- 
plete picture  of  the  difficulties  of  the  general  hos- 
pital at  that  time. 

In  a  letter  to  Congress,  in  July,  1776,  he  stated 
his  own  case.  ^Morgan  may  be  allowed  to  tell  his 
own  story  of  his  efforts  to  supply  the  regimental 
surgeons  and  put  them  on  a  proper  working  basis. 
He  says : 

A  powerful  fleet  and  army  from  Great  Britain  intended 
for  the  reduction  of  Xew  York,  being  likewise  already 
arrived  on  the  coast;  and  having  prepared  everything  in 
my  department  that  was  in  my  power,  I  then  considered 
the  unsettled  state  of  the  regimental  surgeons.  In  order 
to  bring  them  by  degrees  into  greater  regularity,  and  to 
make  them  more  useful  in  case  of  action  (as  many  of 
them  had  newly  entered  the  ser\-ice  and  most  of  them 
from  want  of  experience  were  yet  novices  in  the  duties 
of  a  military  surgeon).  I  thought  it  advisable  to  give  them 
some  instruction  which  might  open  their  minds  to  a  sense 
of  what  their  duty  required  of  them,  as  regimental  sur- 
geons, in  time  of  action,  which  it  could  not  be  supposed 
was  very  distinct.  I  therefore  drew  up  the  following  di- 
rections and  communicated  them  to  the  General.  He  ap- 
proved of  them  in  the  orders  of  the  day;  and  commanded 


348 


DUNCAX:  MEDICAL  MEN  IX   THE  AMERICAX  REVOLUTION.  [New  York 

Medical  Jolrxal. 


the  several  surgeons  of  the  regiments  to  wait  upon  me 
for  copies,  and  to  regulate  themselves  according  to  tiie 
proposed  plan.  Each  surgeon  was  allowed  a  copy,  and 
commonly,  at  the  same  time,  I  gave  him  an  order  on  the 
apothecary  of  the  general  hospital  for  a  medicine  chest, 
for  every  battalion  :  which  he  also  obtained  if  he  was  not 
already  provided :  together  with  a  number  of  tourniquets, 
and  a  quantitj-  of  lint,  tow,  and  old  linen  for  surgical 
dressings. 

The  order  and  instructions  are  worth  repeating 
here  in  full : 

Order  and  Instructions  Given  to  the  Regimental  Surgeons 
in  Case  of  Action. 

New  York.  July  j.  /77A. 

It  is  proposed  by  the  director  general,  and  ordered  by 
his  Excellency,  the  Commander  in  Chief,  that  the  regi- 
mental surgeons  and  mates  may  be  the  better  prepared  for 
the  discharge  of  their  duty,  in  case  of  action,  to  hold 
themselves  in  immediate  and  constant  readiness  for  ser- 
vice ;  and,  in  the  first  place,  to  make  a  return  to  the  direc- 
tor general  of  the  hospital,  of  those  names  and  stations, 
and  of  the  instnnnents  and  bandages,  etc.,  they  have  on 
hand,  agreeable  to  the  following  form : 

A  regimental  return  of  surgeon's  instruments  and  ban- 
dages, etc.,  now  in  readiness  for  medical  service :  belonging 

to  Colonel    Regiment,  in  Brigadier  General 

  Brigade,  encamped  at   

July  3.  1776. 

Xiiinber  an  i  kind 
Instruments  on  of  bandages.  Old  linen  and 

Name.        hand  for  use.  ligatures,  etc.        other  implements. 

Surgeou     Amputating  instru-      Simple  rollers  Quantity  of  linen 

ments  Double  rollers  or  weight  of 

Trepanning  instru-      Foliated  bandages  rags 

ments  Splints  Weight  or  quan 

Incision  knives  Tourniquets  tity  of  lint 

Mate         Pocket  instruments     Ligatures  Tow  or  sponges 

Ballet  forceps  Tape 
Crooked  needles  Thread 

Straight  needles,  

Pins  Signature. 

As  the  general  hospital  will  not  admit  of  the  hospital 
surgeons  and  mates  being  divided  or  detached,  .  .  . 
and  may  require  occasional  assistance  from  the  regi- 
mental surgeon,  in  case  of  many  wounded  being  sent  to  it, 
.  .  .  the  following  regulations  are  to  be  observed  for 
the  present,  and  till  any  change  of  circumstances  may  re- 
quire an  alteration. 

Part  of  the  general  hospital  is  now  fixed  at  Long  Island, 
for  the  reception  of  sick  and  wounded  persons,  whose 
cases  may  require  it ;  which  John  Warren,  Esq.,  Surgeon 
in  the  General  Hospital,  is  appointed  to  superintend  and 
direct,  with  the  assistance  of  three  hospital  surgeons  and 
mates,  and  such  other  regimental  surgeons  and  mates, 
belonging  to  that  part  of  the  army  stationed  at  Long 
Island,  as  may  be  required.  In  case  of  evident  necessity, 
arising  from  an  attempt  being  made  on  Fort  Defiance 
(afterwards  called  Fort  Washington),  two  of  the  hospital 
mates  with  Dr.  McHenry,  now  at  Montressor  Island,  and 
whom  he  is  to  superintend  and  direct,  are  to  repair  to  that 
post,  with  a  proper  assortment  of  medicines  and  bandages. 

The  remainder  of  the  surgeons  and  mates  of  the  general 
hospital  are  to  continue  at  King's  College  and  New  York 
Hospital,  for  the  reception  of  such  wounded  as  are  sent 
to  them,  from  whatever  part. 

It  being  the  duty  of  the  regimental  surgeon  and  mates, 
in  case  of  action  in  the  field,  to  attend  the  corps  to  which 
they  belong,  in  order  to  dress  the  wounded  in  battle ;  they 
are  to  take  post  in  rear  of  the  troops  engaged  in  ac- 
tion, at  the  distance  of  three,  four  or  five  hundred  yards, 
behind  some  convenient  hill,  if  at  hand,  there  to  dress  the 
wounded  who  require  to  be  dressed,  on  or  near  the  field 
of  battle. 

If  the  regiment  or  corps  to  which  they  belong  are  en- 
gaged within  a  fort,  or  lines  thrown  up  for  defense,  that 
fort  or  place  of  defense  is  then  the  proper  station  for 
the  regimental  surgeons.  But  as  a  regiment  may  be  divided, 
and  distributed  into  different  posts,  so  as  to  render  it  im- 
practicable for  the  regimental  surgeon  and  mate  belonging 
to  that  regiment  to  be  near  some  part  of  their  corps,  it  is 
necessary  that  an  account  of  the  number  of  surgeons  and 
mates  in  any  brigade  or  any  division  of  the  army  that  oc- 
cupies one  or  more  detached  posts  be  taken,  and  delivered 
to  the  commanding  officer  of  said  posts  or  divisions.    It  is 


to  be  considered  as  the  duty  of  each  regimental  surgeon 
and  mate  respectively,  wherever  stationed,  to  regard  him- 
self as  having  a  joint  charge  of  the  whole  brigade,  with 
the  rest  of  the  surgeons  of  that  brigade,  rather  tnan  as  if 
his  care  was  to  be  confined  onlj'  to  those  officers  and  sol- 
diers who  are  of  the  regiment  to  which  he  belongs.  It 
must  unavoidably  happen,  at  times,  that  both  officers  and 
soldiers  may  be  wounded  in  action,  and  their  particular 
surgeons  be  elsewhere  employed,  so  as  not  to  be  able  to 
attend  them. 

The  amputation  of  a  limb,  or  performance  of  any 
capital  operation,  cannot  well  take  place  in  the  heat  of  a 
brisk  action.  It  is  seldom  possible  or  requisite.  What  the 
surgeon  has  chiefly  to  attend  to,  in  cases  of  persons  being 
much  wounded  in  the  field  of  battle,  is  to  stop  any  flow 
of  blood,  either  by  tourniquet,  ligature,  lint  and  compress, 
or  a  suitable  bandage,  as  the  case  may  require ;  to  remove 
any-  extraneous  body  from  the  wound ;  to  reduce  fractured 
bones ;  to  apply  proper  dressings  to  wounds ;  take  care  on 
the  one  hand  not  to  bind  up  the  parts  too  tightly,  so  as  to 
injure  the  blood  circulation,  increase  inflammation,  and 
excite  a  fever;  or,  so  loosely  as  to  endanger  the  wounds 
bleeding  afresh,  or  to  allow  broken  bones,  after  they  are 
properly  set.  to  be  again  displaced.  The  wounded  being 
thus  dressed  by  the  regimental  surgeons,  are  next  to  be 
removed  to  the  nearest  hospital  belonging  to  the  brigade, 
or  to  the  general  hospital,  as  may  be  most  convenient. 

As  the  general  hospital  may  at  times  be  fully  crowded 
with  sick  persons,  or  in  the  time  of  action,  so  many 
wounded  may  be  sent  there,  as  to  require  a  greater  num- 
ber of  hands  than  that  part  of  the  general  hospital,  where 
many  of  the  wounded  are  sent,  is  furnished  with,  it  may 
be  absolutely  necessary  for  the  superintending  surgeon,  be- 
sides the  proportion  allowed  him  from  the  general  hos- 
pital, to  call  for  the  assistance  of  a  number  of  surgeons 
and  mates  from  the  brigade,  division,  or  post  of  the  army 
where  he  is,  either  before  an  engagement,  or.  when  the 
number  of  wounded  persons  sent  to  him  becomes  very 
great,  making  such  assistance  needful.  For  this  purpose 
he  is  to  apply  to  the  commander  of  the  brigade,  or  any 
part  of  the  army,  who  is  hereby  ordered  to  send  him  as 
many  regimental  surgeons  and  mates,  for  that  purpose,  as 
are  required  and  can  be  spared  from  their  posts. 

To  prevent  confusion,  and  that  the  regimental  surgeons 
may  know  the  better  what  part  of  duty  is  expected  from 
them,  some  one,  at  least,  of  the  surgeons,  especially  those 
fixed  at  outposts,  are  directed,  as  soon  as  possible,  to  call 
upon  and  arrange  matters,  in  time,  with  the  hospital  sur- 
geons nearest  at  hand,  in  behalf  of  the  brigade,  or  corps 
acting  together,  that  no  disorder  may  arise,  in  time  of 
action,  for  want  of  so  necessary  a  precaution.  The  regi- 
mental surgeons  ought  to  call  on  the  officers  of  the  corps 
to  which  they  belong,  to  settle  with  them,  what  persons 
are  to  be  employed  in  carrying  off  the  wounded,  and  for 
a  supply  of  wheelbarrows,  or  more  convenient  biers,  for 
conveying  them  from  the  field  of  battle  to  the  place  ap- 
pointed for  reception  of  the  wounded,  or  general  hos- 
pital. Each  regimental  surgeon  and  mate  ought  to  have 
a  portable  box,  with  suitable  divisions  for  containing  his 
lint,  bandages,  instruments,  and  other  implements  of  sur- 
gery, which  ought  to  be  well  provided  with  every  nec- 
essary. 

In  applying  a  common  tourniquet  to  stop  the  flow  of 
blood  from  any  principal  artery  in  a  limb,  till  it  can  be 
otherwise  properly  secured,  care  must  be  taken  not  to 
twist  it  too  tightly  above  the  limb;  and  to  prevent  the 
tourniquet  from  slipping,  so  as  to  endanger  a  fresh  loss 
of  blood,  it  must  be  fortified  with  a  ligature  of  thread  or 
tape.  John  Morgan, 

Director  General. 

This  circular  of  instruction,  though  in  places 
most  clumsily  worded,  contains  much  useful  infor- 
mation and  directions.  The  direction  as  to  placing^ 
the  dressing  station  behind  a  convenient  hill  is  naive. 
The  reminder  that  a  surgeon  should  not  confine  his 
attention  to  his  own  organization,  but  should  at- 
tend any  man  in  need  of  help,  his  own  proper  sur- 
geon being  absent,  was  very  necessary.  The  fear 
of  too  tight  a  tourniquet  causes  him  to  refer  to  it 
twice.    The  mention  of  wheelbarrows  and  biers  for 


September  11,  1920.] 


KOHDENBURG:  MEDICINE  IX  XEli'  YORK. 


349 


the  wounded  makes  it  apparent  that  no  real  standard 
Htters  were  then  in  use.  The  Dr.  McHenry  men- 
tioned was  he  for  whom  Ft.  McHenry  at  Baltimore 
was  afterward  named. 

He  attempts  to  overcome  the  difficulty  of  re- 
quiring regimental  surgeons  to  assist  at  the  general 
hospital,  whicli  they  then,  as  now,  did  not  desire 
to  do,  but  the  scheme  is  involved  and  lacking  in 
force.  Throughout  the  circular  there  is  much  ming- 
ling of  what  will  be  done  and  what  ought  to  be  done. 
Yet,  on  the  whole,  this  circular  shows  that  Dr. 
^lorgan  had  a  clear  conception  of  the  situation  and 
what  should  be  done :  that  he  was  attempting,  under 
the  greatest  difficulties  and  inertia,  to  get  these 
things  done.  He  states,  later,  what  success  or  lack 
of  success  he  had  in  his  endeavors.  His  statements 
list  the  complete  surgical  armamentarium  of  the 
regimental  surgeons  of  the  Continental  Army  at 
that  time.  It  was  meagre  beyond  imagination. 
There  were  then  about  forty  small  regiments  in  the 
Army  at  New  York.  They  averaged  little  more 
than  300  men  each. 

In  consequence  of  the  foregoing  plan  and  orders,  some 
reports  were  inade,  although  they  came  in  but  slowly. 
Xear  a  fortnight  passed  over  before  I  received  them  from 
more  than  fifteen  regimental  surgeons.  It  is  to  be  ascribed, 
if  not  to  that  backwardness  which  the  regimental  surgeons 
ever  showed  to  comph'ing  with  general  orders,  perhaps 
to  a  conscious  shame  of  being  entirely  destitute  of  any 
necessary  articles,  but  what  they  had  previously  indulged 
to  draw  from  the  general  hospital :  Some  of  them,  whom 
I  afterwards  met.  and  inquired  into  the  cause  of  their 
neglect,  confessed  this  to  be  the  truth. 

As  my  intention  in  desiring  these  reports  to  be  made 
to  nie,  was  to  lay  them  before  the  General  and  Congress, 
with  remarks  on  their  insufficiency,  that  the  medical  com- 
mittee might  be  incited  to  use  more  diligence,  than  here- 
tofore, to  fall  cui  some  measures  for  supplying  the  regi- 
mental surgeons  with  every  necessary  to  qualify  them  for 
greater  usefulness  in  their  station.  I  drew  up,  from  the 
separate  reports  delivered  to  me.  one  general  return  of  the 
state  of  the  above  mentioned  fifteen  regiments.  All  the 
instruments  were  reputed  to  be  private  property,  and 
amounted  to : 

Six  sets  of  amputating  instruments. 
Two  sets  of  trepanning  instruments. 
Fifteen  cases  of  pocket  instruments. 
Twenty-five  crooked  and  six  straight  needles. 
Among  the  whole  fifteen  surgeons  there  were  only  four 
scalpels  or  incision  knives,  for  dilating  wounds,  or  any 
other  purpose :  three  pairs  of  forceps  for  extracting  bul- 
lets;  half  a  paper  and  seventy  pins  and  but  few  bandages, 
ligatures,  or  tourniquets :  and  as  little  old  linen,  lint  or 
tow.  but  what  they  had  procured  from  the  general  hos- 
pital :  and  only  two  ounces  of  sponges  in  all.  .^mazing 
deficiency  for  fifteen  surgeons  and  as  many  mates ! 

Upon  inquiry  how  thej-  could  think  of  marching  with 
their  regiments,  without  at  least  providing  old  linen  for 
dressings;  or  of  joining  the  army  without  the  necessary 
instruments,  as.  if  ever  they  reflected  at  all  they  must  be 
sensible  of  the  impropriety  of  so  doing,  and  of  its  being 
much  easier  for  each  man  to  procure  those  articles,  within 
the  sphere  of  his  acquaintance,  connexions,  or  neighbor- 
hood, than  to  obtain  them  in  an  army,  in  general  destitute 
of  necessary  supplies,  of  what  was  not  to  be  procured  in 
America,  but  with  great  difficulty :  Their  constant  answer 
was,  whenever  they  applied  to  their  superior  officers  for 
those  things,  they  were  always  told,  they  would  be  fur- 
nished with  everything  they  wanted,  as  soon  as  they  should 
have  joined  the  army.  Upon  being  informed  that  I  had 
only  a  sufficiency  of  those  things  for  the  general  hospital, 
and  that  I  would  by  no  means  unfurnish  it  to  supply  them, 
they  appeared  quite  confounded,  and  expressed  great  un- 
easiness, at  having  no  proper  establishment ;  and  said,  they 
knew  not  how.  or  where  to  obtain  the  necessary  articles, 
to  be  anyways  useful  in  the  army,  if  I  did  not  assist  them. 


As  I  was  not  ignorant  of  the  many  inconveniences  under 
which  they  had  hitherto  labored,  from  a  want  of  attention 
in  the  Congress  to  relieve  or  place  them  on  a  better  foot- 
ing, and  as  I  felt  for  their  distress.  I  assured  them  of  my 
readiness  to  assist  them,  all  in  my  power,  confidently  with 
my  proper  duty,  and  the  orders  I  had,  or  should  receive 
from  Congress.  I  asked  them  to  meet  in  a  body;  to  con- 
verse on  the  matter  with  each  other :  and  then  to  choose 
one  or  more  deputies  from  each  brigade,  to  state  their 
helpless  situation,  and  'pray  for  relief ;  in  which  I  was 
willing  to  second  their  application,  with  all  the  influence 
of  which  I  was  master. 

As  they  complained  much  of  not  being  allowed  proper 
regimental  hospitals,  and  as  I  had.  in  opposition  to  what 
appeared  to  me  to  be  the  sentiments  of  both  the  Congress 
and  the  General,  ever  uniformly  given  it  as  my  opinion, 
that  regimental  surgeons  and  regimental  hospitals,  under 
proper  regulations,  and  due  subordination  to  the  general 
hospital,  might  be  very  useful.  I  took  that  matter  under  my 
consideration.  I  likewise  drew  up  a  memorial,  and  projiosals, 
to  be  shown  to  the  General,  for  his  approbation  and  con- 
currence, to  be  laid  before  Congress.  At  the  same  time  I 
penned  for  the  use  of  the  regimental  surgeons,  a  form 
and  directions  for  keeping  a  proper  register  of  the  sick, 
and  for  making  every  kind  of  necessarj-  returns  of  sick, 
provisions,  etc..  etc..  also  tables  of  the  various  kinds  of 
diet  used  in  the  general  hospital,  as  are  examples  for 
themselves  to  copy  after ;  under  the  heads  of :  full  diet, 
half  diet,  low  diet,  milk  diet,  and  fever  diet;  with  the 
method  of  calculating  the  difference  betwixt  these,  and  the 
amount  of  the  well  rations  ;  to  enable  them  to  draw  the 
value  of  the  difference,  whether  in  cash  or  refreshments, 
but  for  the  use  of  the  sick  only :  And  I  showed  them  a 
list  of  what  instruments.  l)andages.  ligatures,  lint,  tow.  old 
linen,  and  other  articles  I  esteemed  necessary  for  a  Regi- 
ment;  which  I  shall  subjoin  to  the  substance  of  the  memo- 
rial and  petition  to  Congress,  and  the  proposals  I  had 
sketched  out  for  their  consideration  (3). 

.\t  an  appointed  meeting  with  the  regimental  surgeons, 
before  producing  the  papers  referred  to.  the  director  ad- 
dressed them  in  a  prepared  speech,  which  he  had  the  fore- 
thought to  preserve  (3). 

{To  be  continued ) 

HLSTORICAL  NOTES  OX  THE  PRACTICE 
OF  MEDICINE  IN  NEW  YORK  CITY. 

Bv  G.  L.  ROHDENBURG,  M.  D.. 
New  York. 

It  has  recently  been  niy  good  fortune  to  be  per- 
mitted to  search  the  Whitehead  Library  of  the  Lin- 
coln Hospital  and  Home  of  New  York  for  iteins  of 
historical  interest  in  medicine.  This  library  w^as 
founded  by  Dr.  Whitehead,  and  consists  not  only  of 
his  own  library  but  also  the  libraries  of  Dr.  Living- 
stone, one  of  the  founders  of  the  long  defunct 
Queen's  Medical  School,  and  of  Dr.  Sabine,  who  wai 
for  many  years  a  member  of  the  faculty  of  the  Col- 
lege of  Physicians  and  Surgeons,  New  York.  Many 
of  the  volumes,  particularly  the  older  ones,  are  im- 
portations from  England,  and  are  either  the  works 
of  English  authorities  now  more  or  less  forgotten, 
or  translations  from  some  other  European  language. 
A  fair  number  are  early  American  works  dating 
from  1778  to  1804.  In  a  survey  of  these  volumes  I 
have  gleaned  a  numlier  of  somewhat  disconnected 
items  which  are  perhaps  of  more  than  passing  inter- 
est at  the  present  time. 

Among  the  things  of  interest  which  have  been 
found  are  a  series  of  facts  having  to  do  with  the 
early  history  of  medicine  in  the  City  of  New  York. 
During  the  supremacy  of  the  Dutch  West  Indian 
Company  in  New  Am.sterdam.  the  names  of  Johan- 


350 


ROHDENBURG:  MEDICINE  IN  NEW  YORK. 


[New  York 
Medical  Journal. 


nes  Megapolensis  and  of  his  son  Samuel  appear  as 
the  prominent  physicians  of  the  period.  A  Httle  later 
the  names  of  Johannes  La  Montague,  also  a  promi- 
nent physician,  and  of  Abraham  Staes  and  Hans 
Kierstede,  both  of  much  repute  as  surgeons,  are 
found  in  the  records.  The  last  named  had  a  daugh- 
ter, Tryn  Jansen,  who  was  a  famous  midwife.  At  a 
still  later  period,  Gerardus  Be'ekman  is  mentioned. 

The  first  postmortem  occurring  in  the  city  was 
performed  on  the  body  of  Governor  Slaughter,  who 
died  under  suspicious  circumstances  in  1691 ;  and  it 
is  recorded  that  the  physicians  performing  it  were 
paid  eight  pounds  six  shillings  for  their  investigation. 
The  first  anatomical  dissection  was  performed  by 
John  Bard  and  Peter  Middleton  in  1750;  and  the 
first  medical  school  was  founded  in  1767  by  the 
group  consisting  of  Samuel  Bard,  Middleton,  Glossy, 
Smith,  Tennant,  and  Jones.  Middleton  was  selected 
as  the  first  professor  of  pathology  and  physiology  in 


physicians  displayed  great  discretion  by  remaining 
within  doors. 

In  1807  the  College  of  Physicians  and  Surgeons 
was  founded;  and  in  1814  this  institution  united  with 
the  Medical  School  of  Columbia  College.  The  equip- 
ment of  the  institution  was  exceptionally  poor,  for 
it  is  recorded  that  in  1814  the  three  students  used 
umbrellas  in  the  lecture  halls  on  rainy  days.  The 
course  in  anatomy  consisted  of  the  dissection  of  one 
body  a  year. 

The  deficiencies  in  education  were  to  some  extent 
corrected  by  the  formation  of  medical  societies  for 
the  exchange  of  .views  on  medical  matters  and  for 
the  development  of  sociability;  thus  the  Physico 
Medical  Society  was  founded  in  August,  1815,  and 
in  1823  the  New  York  Kappa  Lambda  Society  of 
Hippocrates  was  started. 

The  New  York  Pathological  Society  was  founded 
in  June,  1844,  the  first  meeting  taking  place  in  the 


PENNSYLVANIA  HOSPITAL,  1820 


the  medical  school  of  King's  College,  which  in  1784, 
after  the  Revolution,  became  Columbia  College.  The 
first  medical  degrees  were  granted  in  1769,  when 
Samuel  Kissam  and  Robert  Tucker  were  made 
Bachelors  of  Medicine. 

The  medical  school  having  been  founded,  the 
troubles  of  the  faculty  began  in  their  inability  to  ob- 
tain anatomical  material,  for  which  reason  the  stu- 
dents and  faculty  acted  as  their  own  resurrectionists. 
Even  Valentine  Mott  confessed  to  his  share  in  such 
proceedings.  This  resurrectionist  habit  led  to  the 
famous  Doctors'  Riot,  which  occurred  on  April  13, 
1788,  lasted  two  days,  and  cost  ten  lives,  troops  be- 
ing called  out  to  repress  the  disturbance.  Numerous 
prominent  individuals  were  injured,  among  them 
Baron  Steuben  of  Revolutionary  fame.  The  inciting 
cause  of  the  disturbance  was  the  incautious  exposure 
of  a  pair  of  freshly  varnished  and  dissected  legs 
hung  out  of  the  college  window  to  dry.  Dr.  Cocks 
states  that  for  the  period  of  the  disturbance  the 


office  of  Dr.  Lewis  Sayre  at  the  corner  of  Broadway 
and  Spring  Street,  but  a  short  distance  from  the  old 
quarters  of  the  Queen's  Medical  School  at  Duane 
and  Hudson  Streets.  The  College  of  Physicians  and 
Surgeons,  which  subsequently  became  the  meeting 
place  of  the  society,  was  at  that  time  located  on 
Crosby  Street.  Dr.  Sayre  had  the  doubtful  honor  of 
disposing  of  specimens  after  the  meetings  by  throw- 
ing them  into  the  Hudson  River.  At  one  time  he 
was  almost  caught  by  the  police,  and  at  the  next 
meeting  his  confreres  urged  him  to  be  more  circum- 
spect— this  not  in  the  tenth  century,  but  in  1847. 

Even  in  those  days  civic  pride,  which  is  now  typi- 
fied by  a  statue  atop  of  the  Municipal  Building,  was 
a  fully  developed  and  vigorous  movement.  Some  of 
the  inaugural  addresses  before  the  Academy  of  Med- 
icine, which  was  founded  in  1847,  are  almost  taunt- 
ingly boastful  of  the  achievements  of  the  medical 
men  of  New  York  City. 

Dr.  McGrath,  the  first  hydrotherapeutist  in  th 


September  11,  1920.] 


ROHDENBURG:  MEDICINE  IN  NEW  YORK. 


351 


city,  has  been  immortalized  by  Smollett.  Vaccina- 
tion against  smallpox  was  first  introduced  into  the 
city  by  Dr.  Seeman,  and  inmates  of  city  institutions 
were  first  vaccinated  by  Dr.  Beekman  Van  Buren. 
The  New  York  Hospital,  first  located  on  Bedloe's 


RUDOLF  VIRCHOW 

Island,  was  founded  in  1771  and  incorporated  in 
1790.  James  Stringham  was  the  first  professor  of 
legal  medicine,  and  Governor  Eddy  of  New  York 
authorized  the  establishment  of  the  first  insane  hos- 
pital in  the  United  States. 

Among  other  causes  for  civic  pride,  as  having  been 
first  performed  by  residents  of  the  city,  were  the 
following  operations :  Ligature  of  the  arteria  in- 
nominata,  ligature  of  the  left  subclavian  artery 
within  the  scaleni,  division  of  the  esophagus  for  the 
relief  of  impermeable  stricture,  extirpation  of  the 
upper  and  lower  jaw,  excision  of  the  elbow  joint, 
and  scarification  of  the  interior  of  the  larynx.  To 
us  of  the  present  day  these  may  not  seem  to  be  won- 
derful ;  but  in  those  days  aseptic  surgery  was  not 
dreamed  of,  and  antiseptic  surgery  had  not  yet  been 
born ;  even  anesthesia  was  but  in  its  very  infancy. 
In  fact.  Dr.  Valentine  Mott  was  so  impressed  by  the 
fact  that  he  had  seen,  in  1818,  a  case  of  compound 
fracture  of  the  femur  in  which  recovery  had  actually 
occurred  that  he  thought  it  worth  while  to  report  it 
in  detail. 

There  are  before  the  profession  today  problems 
which  had  their  counterpart  in  the  older  days  under 
different  names,  and  since  history  is  but  the  expe- 
rience of  bygone  generations,  the  terse  and  forcible 


Anglo-Saxon  in  which  they  described  their  troubles 
may  also  interest  us.  In  1849,  the  three  most  prom- 
inent patent  medicine  dealers  in  the  city  were  an  in- 
solvent drygoods  store  keeper,  a  clerk  in  a  lamp 
store,  and  a  bookbinder.  In  denouncing  these  para- 
sites. Dr.  Francis  remarked : 

"In  a  few  instances  the  powers  of  quack  medicine 
have  been  so  highly  esteemed,  that  large  sums  of 
money  have  been  given  to  the  owners  to  reveal  their 
secret  composition ;  but  as  soon  as  the  mystery  has 
been  unraveled  the  charm  has  disappeared,  and  the 
remedy  which  was  once,  regarded  as  so  important 
has  been  consigned  to  oblivion,  the  common  grave 
of  quacks.  The  remedies  which  are  now  so  much 
esteemed  on  account  of  their  working  powers,  will 
undergo  the  same  fate,  and  other  Swains,  and  Mor- 
risons, and  Grandfathers,  will  appear  in  other  days 
to  reap  an  income  from  the  credulity  of  the  ages  in 
which  they  shall  live,  and  like  those  who  have  gone 
before  them  will  in  their  turn  be  forgotten." 

In  the  early  years  of  the  last  century  the  question 


of  cults  and  isms  was  also  a  crying  problem.  The 
chief  of  the  new  fads  at  that  time  was  homeopathy, 
and  from  a  scathing  arraignment  of  the  entire  fad 
the  following  quaint  doggerel  is  copied.  It  was 
quoted  as  being  a  typical  application  of  the  principle 


352 


ROHDENBl'RG:  MEDICINE  IX  XEW  YORK. 


[New  York 
Medical  Journal. 


of  infinitesimal  dosage  carried  to  the  point  of  rcdiictio 

ad  obsurdiitii. 

Take  a  little  rum.  the  less  you  take  the  better. 
Pour  it  in  the  Lakes  of  Wenner  and  of  Wetter. 
Dip  a  spoonful  out.  mind  you  don't  get  grogg>  : 
Pour  it  in  the  Lake  of  Winnepissigogge. 
Stir  the  mLxture  well,  lest  it  prove  inferior ; 
Then  put  half  a  drop  into  Lake  Superior. 
Every  other  day  take  a  drop  in  water. 
You  il  be  better  soon,  or  at  least  you  ought  to. 

In  a  discussion  of  the  necessity  for  higher  educa- 
tion preliminary  to  the  study  of  medicine.  Alexander 
Stevens  put  his  finger  tipon  an  extremely  sore  spot, 
one  in  existence  even  today.  "The  defect  of  Ameri- 
can character,  as  regards  scientific  requirements,  is 
overweening  selfconfidence.  or  an  undervaluing  the 
necessity  of  technical  knowledge  for  the  successful 
pursuit  of  the  learned  professions,  and  consequently 
a  lamentable  deficiency  or  superficiality  in  their  ac- 
quirement." 

Dr.  Francis  in  the  same  year  conmiented  rather 
acidulously  upcm  the  action  of  the  State  Legislature 
in  letting  down  the  requirements  for  the  right  to 
practise  medicine:  " Nothing  but  the  poverty  of  lan- 
guage debars  me  from  a  suitable  expression  of  opin- 
ion of  that  calamitous  proceeding  of  our  State  Legis- 
lature which  has  broken  down  the  door  of  the 
temple  for  all  who  please  to  enter  and  administer.'' 

The  ethics  of  newsf>aper  publicity  also  aroused  a 
considerable  storm  in  the  early  meetings  of  the  Xew 
York  Academy  of  Medicine.  Isaac  Wood  in  a  vig- 
orous discussion  drawing  the  attention  of  the  mein- 
bers  to  the  fact  that,  "so  far  a<  they  have  been  made. 


JOHN  BROWN 


the  reports  oi  our  proceedings  in  the  public  prints 
have  not  advantaged  us  either  collectively  or  indi\'i- 
dually."'  Ale.xander  Stevens  at  the  same  time  warned 
the  newspaper  reporters  that  they  should  "be  cau- 
tious in  giving  cretlence  to  alleged  facts  which  are  in 


opposition  to  established  principles,  for  it  is  rare 
that  time  does  not  prove  them  to  have  been  without 
foundation:  especially  do  not  be  misled  by  reports 
of  wonderful  cures  or  the  efiicacy  of  new  opera- 
tions." Well  might  the  opening  phrase  of  the  sen- 
tence be  emblazoned  upon  the  editorial  page  of  every 
newspaper  in  America. 

The  more  jovial  aspects  of  the  profession  are 
exemplified  by  the  accompanying  cartoon  drawn  by 


Cartoon  depicting  a  quiz  in  the  office  of  Dr.  Willarc  Parker. 


Dr.  Sabine  and  depicting  a  quiz  in  the  ottice  of  Dr. 
Willard  Parker.  Prohibition  was  not  then  in  vogue, 
though  Dr.  \'alentine  Mott  publicly  protested 
against  the  rum  ration  of  medical  students  as  too 
large,  a  half  pint  f^cr  diem  l>eing  allowed.  Whether 
the  large  pot  in  the  foreground  is  a  receptacle  for 
tobacco  cuds  or.  as  might  be  deduced  from  the  title 
of  the  cartoon,  a  precaution  against  gastric  up- 
heaval, the  artist  leaves  to  our  imagination.  The 
other  illustrations  of  the  present  article  are  present- 
ed because  of  the  excellent  work  of  the  engraver. 
One  is  of  John  Hunter,  best  known  to  the  younger 
generation  because  of  his  association  with  the  rec- 
ognition of  chancre.  Another  is  of  John  Brown. 
A  third  is  a  hitherto  unpublished  photograph  of 
\'irchow.  the  founder  of  cellular  pathology :  while 
the  fourth  will  l>e  readily  recognized  by  the  inhabit- 
ants of  the  City  of  Brotherly  Love. 

From  a  scientific  viewpoint  the  old  volumes 
record  the  alert  mentatities  and  acute  powers  of 
observation  of  bygone  generations.  To  those  who 
passed  through  the  influenza  epidemic  of  1918  it 
may  be  of  interest  to  know  that  almost  one  himdred 
years  ago  Graves  described  a  similar  epidemic  in  Ire- 
land. His  description  of  the  gross  pathology  fits 
the  condition  so  exactly  that  with  the  addition  of  the 
lal)el :  "From  the  laboratory  of  the  XYZ  Hospital." 
it  might  have  been  written  but  yesterda\-.  The 
bronchiolitis,  the  absence  of  complicating  empyemas, 
the  intense  congestion,  the  {persistent  cough,  the  fol- 
lowing incidence  of  tubercle,  the  alopecia,  are  all 
wonderfully  clearly  described,  as  Graves  says,  for 
the  benefit  of  posterity,  so  that  eventually  the  cause 
of  the  disease  may  be  discovered.  He  states  that 
such  epidemics  have  been  known  for  over  200 
years,  and  points  out  the  differences  between  in- 
fluenza and  bubonic  plague. 

Another  item  of  interest  is  the  preface  to  the 


Scpiember  11,  1920.] 


TOUSEV:  DENTAL  INEEC'l'lON. 


353 


first  English  edition  of  Koch's  The  Infectious  Trau- 
matic Fevers.  Cheyne,  who  wrote  the  preface  to 
the  translation,  betrays  his  origin  by  his  conserva- 
tism, for  one  sentence  reads  as  follows :  "The  reader 
of  the  following  work  cannot  fail  to  admit  the 
]:)eauty  and  importance  of  tlie  observations  which 
it  records  provided  he  can  be  satisfied  of  their 
authenticity."  Thus  was  the  demonstration  of  the 
cause  and  mechanism  of  sepsis  greeted  upon  its 
translation  into  the  English  language. 

The  ©pinion  of  the  older  American  surgeons  upon 
the  surgery  of  cancer  is  well  represented  by  Alex- 
ander Stevens,  who  in  a  report  of  cases  of  fungus 
haematodes  of  the  eye  (melanosarcomaj  appearing  in 
the  Medical  and  Surgical  Register  of  the  New  York 
Hospital  for  1818,  mournfully  concludes : 

"From  these  gloomy  details  not  one  ray  of  con- 
solation can  be  derived.  The  occurrence  of  disease 
in  parts  distant  from  the  primary  atTection  (meta- 
stasis) in  the  last  two  cases  is  too  remarkable  to  pass 
without  notice.  It  naturally  tends  to  the  conclusion 
that  the  disease  is  not  local,  and  ofifers  a  strong  in- 
ducement to  the  surgeon  to  limit  his  views  to  the 
smoothing  of  the  avenues  to  the  grave  from  which 
he  can  neither  free  nor  respite  his  unhappy  patient." 

905  West  End  Avenue. 


DEXTAL  INFECTION. 

By  Sinclair  Tousey,  A.  M.,  M.  D., 
New  York. 

Dental  infection  is  no  new  thing.  Benjamin 
Rush  over  a  hundred  years  ago  cured  cases  of 
rheumatism  by  ordering  the  extraction  of  infected 
teeth.  It  is  now  known  that  infection  may  exist  for 
years  without  local  symptoms,  pain,  or  swelling. 
Probably  in  many  cases  the  infected  teeth  could 
have  been  found  by  the  dentist  before  the  days  of 
the  X  ray,  but  now  this  examination  shows  the  con- 
dition in  many  cases  as  clearly  as  it  shows  a  fracture 
of  the  bones  of  the  leg. 

A  dead  and  putrified  nerve  or  tooth  pulp  is  full 
of  germs  from  which  poison  is  al)sorbed  into  the 
system.  This  may  go  on  for  years,  since  the  pulp 
chamber  in  the  tooth  cannot  collapse  like  the  walls 
of  any  ordinary  boil  or  abscess  and  the  lesion  un- 
dergo spontaneous  cure.  The  amount  of  absorp- 
tion from  an  abscess  at  the  apex  of  the  root  of  a 
tooth  is  not  indicated  by  the  small  size  of  the 
abscess  cavity  but  by  the  rapidity  with  which  the 
poison  is  generated  and  the  freedom  with  which 
it  is  communicated  to  the  blood.  The  free  bleeding 
which  ordinarily  ensues  when  a  tooth  is  extracted 
illustrates  the  anatomical  fact  that  the  tooth  is  not 
like  an  inanimate  glass  ])lug  in  the  tooth  socket  but 
is  a  vital  organ  with  blood  vessels  which  must  be 
torn  in  order  to  extract  it.  Through  this  free  blood 
supply  the  poison  from  a  blind  abscess  is  poured 
into  the  sy.stem  at  a  speed  of  which  we  can  obtain 
some  idea  from  the  other  class  of  dental  infection, 
pyorrhea.  In  the  latter  case  we  may  be  able  to 
press  a  large  ^Irop  of  pus  from  the  pocket  surround- 
ing the  root  of  a  tooth  every  five  minutes. 

Two  kinds  of  poison  are  absorbed ;  the  germs 
themselves  and  toxins  or  their  poisonous  products. 


The  germs  enter  the  lilood  but  there  they  are  ordi- 
narily destroyed  by  certain  white  blood  cells  called 
phagocytes,  and  even  in  many  cases  of  seriou.s  or 
fatal  disease  unmistakably  due  to  dental  infection, 
the  germs  do  not  grow  and  multiply  in  the  blood 
and  may  not  be  discoverable  in  it.  This  is  true  in 
regard  to  certain  other  germ  diseases.  For  instance, 
in  a  case  of  tuberculosis  we  look  in  the  sputum, 
not  in  the  l)lood,  for  the  tubercle  bacilli.  When  the 
normal  resistance  of  the  blood  to  invasion  by  the 
germs  from' a  focus  of  infection  has  been  lost  or 
greatly  reduced,  then  the  germs  may  multiply  in  the 
blood  and  usually  with  a  fatal  result.  A  pint  of 
blood  drawn  from  the  body,  cooled  and  therefore 
devitalized,  may  be  experimentally  infected  with  the 
pus  from  an  extracted  abscessed  tooth  and  if  kept 
at  a  temperature  of  about  100°  F.  will  in  a  few 
days  become  a  mass  of  living  and  multiplying  germs 
sufficient  if  divided  up  in  hypodermic  doses  to  kill 
a  company  of  one  hundred  soldiers. 

In  many  cases  where  the  germs  never  succeed  in 
growing  and  multiplying  in  the  blood,  some  of  them, 
are  carried  by  the  blood  and  lymph  to  places  where 
they  form  a  secondary  focus  of  infection.  A  clot 
or  vegetation  may  form  in  the  heart  valves,  ful!  of 
the  living  and  multiplying  germs.  This  occurrence 
is  commonly  the  beginning  o-f  a  lingering  and  pain- 
ful death.  Fragments  of  the  infected  vegetations 
break  away  and  are  carried  by  the  blood,  anu 
blocking  up  small  arteries  cause  paralysis,  pneu- 
monia, and  a  host  of  other  complications  affecting 
every  organ  and  function  of  the  body.  This  pain- 
ful and  hopeless  illness  often  lasts  many  months 
and  all  that  time  there  is  a  possibility  of  sudden 
death  from  blocking  of  a  large  artery  in  the  brain. 

Hap])ily  a  dental  abscess  almost  always  produces 
symptoms  due  to  absorption  of  poisons  before  any 
direct  germ  extension  takes  place.  These  symp- 
toms are  as  manifold  as  the  different  organs  to 
which  the  blood  carries  the  poison.  Two  persons 
seldom  are  affected  in  exactly  the  same  way.  Some 
of  the  subjects  have  high  blood  pressure  with  a 
tendency  to  result  in  arteriosclerosis  and  finally 
apoplexy  and  death.  Others  have  one  or  other  of 
the  different  lesions  and  symptoms  called  rheuma- 
tism. Others  have  neuritis,  neuralgia,  and  various 
eye  troubles  which  formerly  seemed  to  be  due  to 
rheumatism,  one  eye  even  having  been  saved  by 
the  treatment  of  a  tooth  al).scess  di.scovered  too  late 
to  save  the  other.  Indigestion  is  a  common  effect. 
And  there  is  a  general  agreement  with  the  Mayos 
that  ulcer  and  cancer  of  the  stomach  and  cancer 
of  the  gallbladder  are  usually  due  to  dental  infec- 
tion. Skin  diseases  and  insanity  are  in  many  cases 
due  to  dental  infection.  A  complete  list  of  condi- 
tions which  may  be  cau.sed  by  dental  infection 
would  be  a  very  long  one. 

We  often  hear  it  said  that  this  is  a  temporary 
fad.  like  removing  the  tonsils  for  rheumatism.  And 
again  the  physician  who  recognizes  the  possibility 
and  even  the  strong  probability  that  the  patient's 
symi:)toms  indicate  the  presence  of  dental  infection 
too  often  is  asked,  "You  want  me  to  have  all  mv 
teeth  out  ?"  It  is  true  that  many  cases  of  rheuma- 
tism and  other  diseases  are  due  to  infected  tonsils. 
That  was  not  a  temporary  fad  but  is  today  the 


354 


TOUSEY: 


DENTAL  INFECTION. 


(New  York 
Medical  Journal, 


means  of  restoring  health  and  saving  Hves.  We 
know  that  the  teeth  also  are  a  sofurce  of  infection 
and  we  know  that  a  focus  of  infection  may  some- 
times be  found  in  the  sinuses  and  that  sometimes 
autointoxication  ma\-  develop  from  primary  intes- 
tinal conditions. 

These  facts  do  not  make  it  a  fad  to  examine  the 


Fig.  1 — Radiograph  of  jaw  of  skeleton  showing  mental  foramen. 

tonsils  or  the  teeth  or  the  sinuses  or  the  intestines 
and  to  cure  any  focus  of  infection  that  is  discovered. 
Particularly  in  regard  to  the  teeth,  the  x  raj-  enables 
one  to  acquit  the  healthy  teeth  and  it  certainly 
would  be  a  fad  to  go  ahead  and  blindly  extract  all 
the  teeth,  good  and  bad,  in  a  case  of  rheumatism. 

That  the  different  diseases  and  symptoms  re- 
ferred to  are  often  caused  by  a  focus  of  infection 
and  that  many  of  them  if  taken  in  time  are  cured 
by  the  eradication  of  the  focus  of  infection  is  not 
the  theory  of  one  person  or  of  any  group  of  per- 
sons. It  has  been  tested  and  proved  by  many 
physicians,  surgeons,  and  dentists  in  many  dif- 
ferent countries.  The  tests  as  to  causation  have 
been  similar  to  those  establishing  the  fact  that  ty- 
phoid fever  is  caused  by  typhoid  bacilli  and  cholera 
by  the  cholera  bacillus. 

A  great  variety  of  symptoms  are  known  to  have 
dental  infection  as  their  frequent,  common  or  even 
usual  cause.  These  symptoms  may  not  be  serious 
in  themselves  and  if  they  are  due  to  dental  infec- 
tion that  cause  may  be  left  undiscovered  and  un- 
treated for  years.    Delay  in  the  discovery  of  the 


dental  infection  may  occur  because  the  idea  had  not 
occurred  to  the  physician,  or  the  patient  may  delay 
the  X  ray  examination  because  of  a  fear  that  one 
or  more  teeth  may  have  to  be  extracted.  This  de- 
lay cannot  possibly  enable  the  infected  tooth  or 
teeth  to  become  normal.  It  simply  results  in  their 
getting  worse  and,  whereas  at  an  early  stage  the 
dentist  is  often  able  to  treat  and  cure  and  preserve 
an  infected  tooth,  an  advanced  stage  may  be  reached 
where  only  extraction  is  possible.  The  sooner  an 
infected  tooth  is  discovered  and  cured  the  greater 
is  the  hope  that  others  may  not  become  infected. 

The  idea  used  to  be  that  an  old  snag  of  a  root 
ought  to  be  preserved  at  all  hazards  to  prevent  ab- 
sorption of  the  alveolar  process  and  falling  in  of 
the  cheek.  This  is  a  dangerous  theory  and  in  actual 
practice  many  a  patient  has  been  poisoned  by  pus 
from  an  infected  retained  root.  And  the  x  ray  has 
often  demonstrated  extension  of  pyorrhea  from 
such  a  root  as  the  cause  of  destruction  of  the 
alveolar  process  of  a  neighboring  tooth.  A  per- 
fectly good  tooth  may  be  sacrificed  by  clinging  to 
a  dangerous  and  useless  root. 

The  lower  bicuspid  apices  are  close  to  the  mental 
foramen,  an  opening  in  the  lower  jaw  through 
which  a  nerve  passes  to  the  chin  and  lower  lip. 
A  radiograph  (Figs.  1  and  2)  of  the  lower  jaw  of 
a  skeleton  shows  this  opening  in  an  unmistakable 
way,  but  the  foramen  has  no  such  characteristic 
appearance  in  a  radiograph  of  a  living  person.  In- 
deed it  often  looks  very  much  like  a  periapical  ab- 
scess of  the  second  lower  bicuspid  and  has  doubt- 
less been  frequently  mistaken  for  one.  It  is  only 
necessary  to  be  on  one's  guard  against  this  error 
and  in  case  of  doubt  to  make  a  radiograph  of  the 
second  lower  bicuspid  on  the  other  side  of  the  face. 
An  identical  appearance  of  the  right  and  left  lower 
second  bicuspids  would  be  the  strongest  indication 
that  the  appeara^ice  was  a  normal  one  due  to  the 
mental  foramen. 

It  has  long  been  known  to  the  author  that  a 
vital  tooth  may  show  periapical  infection  and  he 
has  made  a  radiographic  diagnosis  of'  periapical 
infection  in  teeth  which  were  vital,  some  with  and 
some  without  pain.  A  lower  molar  pulp  may  die 
in  one  root  canal  and  be  alive  in  the  other  and  in 
the  pulp  chamber.  As  a  rule  if  the  radiographic 
appearance  is  doubtful  it  is  recommended  that  the 
vitality  of  the  tooth  be  tested  by  heat  or  cold  or  by 
faradism.  And  if  found  to  be  vital  the  tooth  is 
given  the  benefit  of  the  doubt.  Where,  however, 
the  X  ray  appearance  is  unmistakable,  even  though 
the  tooth  may  respond  to  heat  and  cold  and  farad- 
ism and  be  exquisitely  sensitive  when  drilled  into, 
then  the  interests  of  the  patient  require  that  the 
ner\'e  be  killed  or  the  tooth  extracted.  The  latter 
would  be  called  for  if  the  radiograph  showed  such 
a  bending  of  the  root  that  disinfection  of  the  root 
canal  and  of  the  periapical  abscess  cavity  would 
be  impossible.  With  pain  and  swelling,  in  fact  with 
the  ordinary  sj^mptoms  of  a  dying  nerve,  the  dentist 
has  never  been  at  a  loss  as  to  the  proper  treatment. 
But  without  the  x  ray  it  is  not  alwa}-»  possible  to 
determine  promptly  which  tooth  is  affected  and  I 
have  walked  the  floor  twelve  nights  while  a  tooth 
four  spaces  from  the  affected  one  was  being  treated. 


Septcmb;r  11,  1920.] 


TOUSEY 


DENTAL  INFECTION. 


355 


It  was  a  case  of  the  shoemaker's  children  going 
barefoot,  and  the  moment  a  radiograph  was  made 
the  error  was  discovered.  And  even  in  the  right 
tooth  the  X  ray  will  sometimes  be  required  to  trace 
the  root  canal  and  the  way  into  the  abscess  cavity. 
Guided  by  the  radiograph  the  dentist  presses  his 
drill  in  the  right  direction,  it  enters  the  abscess  and 
pus  wells  into  the  pulp  chamber. 

It  is  the  cases  of  a  vital  pulp  without  pain  or 
swelling  but  with  unmistakable  x  ray  evidence  of 
periapical  abscess  th3t  are  the  most  difficult  for  the 
dentist  to  decide  about  and  he  may  very  probably 
ask  to  have  another  corroborative  radiograph  made 
before  reaching  a  decision. 

An  important  discovery  has  just  been  announced 
by  Hartzell  and  Henrici  to  the  effect  that  patho- 
genic germs  are  often  found  in  the  vital  pulps  of 
the  teeth  affected  by  pyorrhea  or  having  carious 
cavities.  Their  experiments  were  conducted  in  such 
a  way  as  apparently  to  prevent  artificial  infection 
of  the  pulp,  and  in  twenty-six  healthy  teeth  ex- 
tracted and  opened  in  the  same  way  the  pulps  were 
all  found  aseptic.  This  agrees  with  my  own  ob- 
servation of  many  vital  teeth  with  periapical  in- 
fection. 

From  some  cause  the  radiograph  of  a  dead  tooth 
which  has  been  treated  and  filled  may  show  the  root 
canal  only  partly  filled.  This  appearance  may  be 
due  to  the  use  of  a  transparent  filling  material  or 
to  the  filling  being  actually  incomplete.  In  the  latter 
case  a  space  remains  permanently  which  is  exceed- 
ingly prone  to  infection.  And  when  there  are 
symptoms  of  infection  it  is  often  necessary  for  the 
dentist  to  treat  the  root  canal  and  fill  it  completely. 

Many  authorities  favor  the  extraction  of  every 
dead  tooth,  but  there  are  many  others  who  believe 
that  a  dead  tooth  can  often  be  sterilized  and  be 
kept  in  that  condition  for  many  years  and  for  all 
that  be  a  harmless  and  useful  member.  A  dead 
tooth  is  of  course  always  under  suspicion  and  to  be 
kept  under  occasional  x  ray  observation.  At  the 
first  indication  of  its  being  infected  treatment 
through  the  root  canal  should  be  instituted  and  if  it 
becomes  infected  time  after  time  for  a  period  of 
years,  the  rule  seems  to  be  that  what  can't  be  cured 
must  be  extracted.  Of  course  many  a  time  the 
radiograph  reveals  such  an  extent  of  necrotic  bone, 
or  the  symptoms  of  systemic  poisoning  are  so  se- 
vere that  one's  effort  should  be  not  to  save  the 
tooth  but  to  save  the  patient. 

The  condition  in  which  the  tooth  is  found  after 
extraction  is  an  important  subject  for  considera- 
tion. The  tooth  itself  may  in  some  cases  appear 
normal  or  close  scrutiny  may  show  a  small  area  at 
the  foramen  where  the  natural  smooth  surface  is 
lacking.  We  know  that  an  infected  root  canal  and 
an  infected  periapical  space  causing  systemic  in- 
fection do  not  necessarily  involve  any  marked 
change  in  the  gross  appearance  of  the  extracted 
tooth.  The  dentist  and  the  patient  should  not  for 
a  moment  suppose  that  the  tooth  was  harmless  or 
even  a  desirable  possession  because  it  looks  prac- 
tically normal  after  removal.  We  can  tell  from  the 
radiograph  before  extraction  whether  the  root  has 
been  denuded  or  eroded,  and  if  so,  to  what  extent. 
And  changes  in  the  tooth  itself  are  not  the  decisive 


factor  in  deciding  that  a  focus  of  infection  exists 
which  if  not  capable  of  cure  by  treatment  through 
the  root  canal  requires  extraction. 

The  fang  of  a  rattlesnake  or  the  needle  of  a  hypo- 
dermic syringe  may  be  perfectly  smooth  and  still 
convey  an  active  poison.  The  putrescent  pulp  of 
a  tooth  may  poison  the  system  through  the  apical 
foramen  without  any  necessary  change  in  the  gross 
appearance  of  the  root. 

We  sometimes  hear  that  some  dentist  has  told 
a  patient  that  a  blind  dental  abscess  will  some- 
times exist  for  years  without  causing  illness.  The 
inference  is  intended  to  be  drawn  that  if  you  have 
symptoms  or  lesions  which  all  dental,  medical, 
and  surgical  authorities  state  are  often  caused  by 
dental  infection,  it  is  just  as  well  not  to  have  an 
x  ray  examination  and  when  one  is  made  and  shows 
the  existence  of  a  blind  abscess  the  inference  these 
people  suggest  is  that  it  may  just  as  well  be  left 
untreated  and  uncured. 

I  do  not  believe  that  at  the  present  time  any  dentist 
would  make  the  statement  unqualifiedly  or  would 
draw  these  conclusions  from  it.  But  years  ago 
this  was  the  case  and  the  following  history  shows 
the  natural  result  of  such  beliefs. 

Case  I. — Dr.  S.  was  referred  to  me  for  the  treat- 
ment of  neuritis  of  the  shoulder  and  forearm  by 


Fig.  2 — Radiograph  of  lower  jaw  of  skeleton  showing  mental 
foramen. 

high  frequency  currents  applied  from  ultraviolet 
ra}'  vacuum  electrodes.  At  the  same  time  he  was 
under  treatment  elsewhere  for  high  blood  pressure, 
by  X  ray  flashes,  a  method  in  which  I  fail  to  see 
any  special  virtue,  as  compared  with  a  continuous 
application  of  the  rays.  He  also  complained  of 


356 


TO  USE] 


DEXTAL  I X PEC T ION. 


[New  York 
Medical  Jourkal. 


severe  headache.  Systemic  infection  from  dental 
foci  without  local  symptoms  had  not  then  been 
discovered.  I  had  made  thousands  of  dental  radio- 
graphs in  cases  presenting  local  indications  and  it  oc- 
curred to  me  to  make  radiographs  of  all  the  teeth 
to  see  if  the  headache  was  a  reflex  from  an  infected 
tooth.    The  radiograph  showed  extensive  destruc- 


Fn;.  ,1 — Radiograph  showing  gouty  tophus  of  the  hand  of  a  patient 
with  pyorrhea 

tion  of  bone  about  the  apices  of  several  upper 
teeth.  That  report  and  the  radiographs  were 
taken  by  the  patient  to  two  different  dentists  who 
examined  the  teeth  by  their  usual  methods  and  pro- 
nounced them  all  right.  The  doctor  did  not  want 
to  hurt  my  feelings  by  telling  me  their  report  and 
the  teeth  remained  untreated  until  two  years  later 
when  he  was  in  a  serious  condition  at  Battle  Creek. 
Then  the  affected  teeth  were  extracted  and  there 
was  some  improvement,  but  the  proper  treatment 
had  been  applied  too  late  to  prevent  death  b\- 
apoplexy  at  the  age  of  fifty-six. 

Another  fatal  case  occurred  just  at  the  transi- 
tion period  in  our  knowledge  of  dental  infection. 

C.\SE  II. — The  patient,  ^Irs.  T.,  complained  of  a 
lame  lower  first  bicuspid  tooth,  and  a  radiograph 
showed  an  area  of  rarefaction  diagnosed  by  the 
author  as  periapical  infection.  The  dentist,  how- 
ever, thought  the  tooth  was  not  infected  but  sim- 
ply irritated  by  impact  with  the  corresponding  up- 
per tooth.  His  treatment  was  not  to  open  the 
tooth  and  make  applications  through  the  root  canal 
but  to  grind  the  two  opposing  teeth.  A  year  later  a 
frank  abscess  developed  causing  great  pain  and 
some  swelling  and  recurrences  during  a  long  course 
of  treatment.  Later  rheumatic  symptoms  ensued 
and  septic  endocarditis  with  infarctions  in  the 
.spleen,  kidneys.  lungs,  pleura  and  brain.  This  ill- 
ness lasted  seven  months  with  pain,  convulsions, 
paralysis  and  complications  affecting  the  eye,  ear 
and  nearly  every  other  organ.  All  the  twenty-five 
general  and  special  physicians  and  dentists  who  saw 
her  as  occasion  arose  attributed  the  illness  and 
death  to  dental  infection. 

The  natural  way  now  is  for  an  x  ray  e.xartiina- 
tion  to  be  marie  upon  the  occurrence  of  the  first 


local  or  constitutional  symptoms  and  for  radical 
treatment  to  be  applied  to  an\-  dental  infection  re- 
vealed. I  do  not  believe  that  a  person  is  often 
well  for  years  with  a  blind  abscess  of  a  tooth.  I 
have  known  many  persons  who  were  up  and  about 
with  a  variety  of  painful  if  not  disabling  symptoms 
who  all  this  time  had  a  dental  focus  of  infection 
and  who  got  well  after  the  latter  had  been  dis- 
covered and  treated.  To  my  mind,  this  indicates 
not  the  harmlessness  of  such  a  focus  ljut  that  very 
often  the  system  is  able  to  resi.st  the  infection  long 
enough  for  the  symptoms  to  be  recognized  and 
proper  methods  of  diagnosis  and  treatment  to  be 
applied. 

When  a  dentist  or  a  physician  says  that  the  dental 
infection  idea  is  often  overdone.  1  have  sometimes 
found  on  inquiry  that  he  refers  to  a  case  in  which 
he  knows  all  the  teeth  of  say  a  thirty-six  year  old 
woman  to  have  been  extracted.  He  naturally  thinks 
that  many  of  these  were  probably  not  infected  and 
might  better  have  been  preserved.  And  that  is  ex- 
actly the  reason  for  an  x  ray  examination.  The 
strongest  reason  to  suspect  dental  infection  does 
not  afford  an  indication  for  e.xtracting  all  the  teeth 
l)ut  for  locating  the  infected  ones  and  acquitting 
the  harmless  and  useftil  teeth.  Another  dentist  may 
refer  to  the  fact  that  the  radiographer  has  told  the 
])atient  that  if  the  abscesses  revealed  had  been  left 
undi.scovered  and  untreated  some  of  the  .serious 
symptoms  or  lesions  described  above  would  prob- 
ably have  ensued.  The  dentist  thinks  his  patient 
has  been  unduly  alarmed,  and  it  really  would  have 
been  the  part  of  wisdom,  as  long  as  the  examina- 
tion had  been  made  and  the  trouble  and  its  remedy 
discovered,  to  omit  the  list  of  the  dangers  that  had 
l)een  averted. 

A  patient,  who  is  a  great  grandmother  but  is 
very  active  bodily  and  mentally,  has  practically  all 
her  natural  teeth  but  has  a  di.scharging  abscess  of 
an  upper  bicuspid.  Her  dentist  referred  her  for  an 
X  ray  examination  of  all  her  teeth  and  many  chronic 
infections  were  shown  with  the  bone  so  extensively 
involved  that  several  teeth  could  not  apparently  be 
restored  to  a  healthy  condition.  Only  the  lower 
front  teeth  could  be  given  a  clean  bill  of  health. 
On  asking  the  patient  herself  whether  this  had 
affected  her  general  health  she  said' not  at  all.  And 


Fh..    4 — Radiograph    showing    marked    pyorrheal    destruction  about 
one  of  the  lower  incisors. 


yet  she  had  had  two  strokes  of  paralysis,  still  has 
])aralysis  of  the  trigeminal  nerve,  has  a  bad  knee 
for  which  the  author  applied  high  frequency  cur- 
rent by  vacuum  electrode  several  years  ago.  and 
has  some  asthmatic  trouble.  .Such  a  case  and  the 
numerous  cases  of  arthritis  or  myositis  causing 
torture   or   disability    for   years    from  untreated 


Septsmb-T  11,  1920.  J 


TOLSEy:   DEXTAL  IXIECTIOS. 


357 


dental  infection,  show  how  slow  it  is  to  produce 
death  by  its  own  poison.  The  more  terrible  cases 
alluded  to  were  rapidly  fatal  from  secondary  lesions 
which  are  always  to  be  feared.  But  just  as  the 
rattlesnake  always  gives  warning,  these  fatal  com- 
plications of  dental  infection  are  practically  always 
preceded  by  signs  which  he  who  runs  may  read. 
But  unlike  the  rattlesnake,  the  warning  is  not  empty 
noise  but  some  real  injury,  though  the  latter  is  for- 
tunately temporary  as  a  rule  if  the  warning  is 
heeded. 

These  patients  could  not  be  said  to  be  well  for 
\ears  in  spite  of  dental  infection,  the  truth  is  mani- 
festly that  they  have  been  ill  for  years.  And  it  is 
my  belief  that  if  the  dentist  knew  all  about  the 
patient,  few  patients  with  dental  infection  would  l)e 
considered  well  for  years. 

Case  III. — An  illustrative  case  is  that  of  a  lady 
about  sixty  years  old  who  came  a  couple  of  years 
ago  for  dental  radiography  because  of  constitu- 
tional symptoms.  A  space  was  seen  at  the  apex  of 
a  dead  and  treated  tooth  occupied  either  by  pus  or 
by  a  granuloma.  The  dentist  was  especially  skill- 
ful and  experienced  in  the  subject  of  dental  in- 
fection and  his  judgment  was  to  leave  the  tooth 
alone  as  long  as  it  did  not  make  the  patient  sick. 
This  advice  was  taken  and  for  two  years  the  pa- 
tient was  able  to  be  about  and  to  enjoy  life,  which 
was  the  basis  for  the  supposition  that  the  tooth 
was  not  causing  illness.  All  this  time,  how- 
ever, the  indigestion  continued  and  there  was  a 
gradual  increase  in  the  high  blood  pressure  and  the 
sense  of  fullness  in  the  brain  and  the  pain  in  the 
knee  (with  a  negative  radiographic  appearance)  and 
especially  a  gouty  swelling  ancl  redness  and  pain  in 
the  nose.  An  extended  series  of  inoculations  with 
extracts  of  every  conceivable  article  of  food  and 
drink  showed  no  reaction  to  indicate  that  any  of 
these  caused  the  symptoms.  Then  a  radiograph 
showed  the  affected  tooth  to  be  in  the  same  condi- 
tion as  two  years  previously.  It  could  not  be  cured 
by  treatment  and  the  dentist  extracted  it.  A  sac 
was  adherent  to  the  root.  The  symptoms  includ- 
ing the  high  blood  pressure  were  all  improved  im- 
mediately and  the  final  result  was  that  the  blood 
pressure  became  normal  and  remained  so,  and  the 
other  symptoms  all  disappeared. 

The  burden  of  proof  should  not  l)e  thrown  upon 
the  patient  to  jjrove  that  he  is  actually  sick  and 
more  especially  to  prove  that  his  sickness  is  due  to 
the  infected  tooth.  Such  a  course  gives  the  in- 
fected tooth  too  great  an  opportunity  to  do  irre- 
\  ocable  harm.  The  burden  of  proof  that  the  tooth 
is  actually  infected  should  not  be  thrown  upon  the 
patient  who  is  manifestly  ill  and  has  a  manifest 
periapical  cavity,  which  might  look  very  much  the 
same  whether  it  contained  pus  or  an  infected  or 
uninfected  granuloma,  or  who  has  a  dead  tooth 
from  which  the  nerve  has  not  been  removed  in 
whole  or  in  part  or  the  root  of  which  has  been  only 
partially  filled  leaving  a  space  prone  to  infection. 

Whenever  it  is  a  question  between  saving  the 
rooth  and  saving  the  patient,  the  latter  must  have 
the  benefit  of  any  doubt.  In  many  cases  both  the 
patient  and  the  tooth  can  be  saved  by  the  treatment 
of  the  latter.    But  if  conditions  are  such  that  the 


tooth  cannot  be  treated  and  it  manifestly  may  be  a 
focus  of  infection  and  the  patient  has  symptoms 
well  known  to  be  often  due  to  dental  infection,  the 
patient  and  not  the  tooth  should  have  the  benefit 
of  any  doubt. 

In. a  case  of  disease,  say  rheumatism,  an  x  ray 
examination  of  the  teeth  is  made  not  chiefly  to  find 
out  the  cause  of  the  disease  and  a  possible  or  prob- 
able cure ;  but  far  more  to  find  out  whether  there 
is  tooth  infection  which  may  well  be  a  much  more 
important  matter  than  the  symptom  or  lesion  which 
has  suggested  its  possible  presence.  Supposing 
there  is  an  infected  tooth  in  a  case  of  arthritis,  how 
are  we  going  to  prove  that  it  is  the  cause?  Sup- 
posing there  are  tubercle  bacilli  in  a  patient's 
sputum  or  diphtheria  bacilli  in  a  culture  from  a 
patient's  throat,  how  are  we  going  to  prove  that 
the  germs  are  the  cause  of  the  patient's  illness? 
Observations  and  experiments  by  the  world's  great- 
est scientists,  with  every  hospital  and  laboratory 
facility  and  extending  over  years,  were  required 
to  prove  that  these  germs  are  the  cause  of  these 
two  diseases.  To  prove  it  in  an  individual  case  might 
well  be  impossible  and  even  the  attempt  would  cer- 
tainly subject  the  patient  to  experiments,  and  de- 
lays and  dangers.  The  usual  custom  is  to  proceed 
with  measures  of  treatment  and  prevention  of  con- 
tagion just  as  if  Koch  or  Klebs  and  Loeffler  had 
made  the  actual  demonstration  of  the  causative  re- 
lation in  our  particular  patient. 

There  are  cases  where  the  secondary  lesion  is  of 
so  serious  or  permanent  a  character  that  no  radical 
improvement  seems  to  be  expected  from  the  dis- 
covery and  cure  of  the  primary  cause.  Even  here 
an  infected  tooth  is  not  a  benefit  to  the  patient,  and 
is  a  very  probable  cause  of  still  more  painful  and 
serious  lesions  and  of  nonsuccess  of  remedial 
measures. 

Dental  infection  sometimes  shows  how  severe  it 
has  been  by  the  reaction  which  ensues  where  the 
tooth  is  extracted  or  the  abscess  opened  into  through 
the  root  canal.  This  is  a  reason  for  not  initiating 
treatment  of  more  than  one  or  two  foci  at  once. 

When  the  dental  infection  is  the  cause  of  the 
symptoms  or  lesions  an  immediate  ciu^e  is  not  al- 
ways to  be  expected.  A  condition  of  the  system 
which  has  lasted  for  years  may  not  instantly  re- 
spond to  the  removal  of  the  cause,  though  the 
ultimate  result  may  be  perfect.  In  fact,  if  there  is 
instant  benefit  the  patient  had  better  be  warned  that 
this  may  be  temporary  and  that  lasting  benefit  may 
come  gradually. 

Pyorrhea. — This  is  practically  always  known  to 
the  patient  and  the  dentist.  In  England  it  is  con- 
sidered to  be  the  most  common  cause  of  arthritis. 
Xo  X  ray  examination  is  required  to  detect  its  pres- 
ence. It  is  only  necessary  to  realize  that  it  can 
cause  the  same  troubles  as  a  blind  abscess  and  that 
the  primary  infection  is  controllable  by  treatment 
in  most  cases  and  immediately  cured  by  extraction 
in  the  most  advanced  cases.  Fig.  3  shows  a 
large  gouty  tophus  on  a  man's  hand  and  Fig.  4 
marked  pyorrheal  destruction  about  one  of  his  low- 
er incisor  teeth. 

Even  without  any  belief  in  the  causative  rela- 
tion and  regarding  it  merely  as  a  coincidence  that 


358 


GIFFIN:  ANEMIA  AND  LIFE  INSURANCE. 


[New  York 
Medical  Journal. 


dental  abscesses  and  other  dental  infections  are  fre- 
quently found  on  x  ray  examination  in  cases  of  ar- 
thritis and  a  good  many  other  diseases,  no  one  but 
a  Christian  Scientist  would  for  a  moment  doubt  the 
desirability  of  discovering  and  curing  a  dental  in- 
fection. 

Coming  now  to  Christian  Scientists,  the  author 
has  explained  to  them  that  whether  from  an  error 
or  from  a  physical  cause  over  which  the  mind  has 
no  control,  carious  cavities  develop  in  teeth  which 
only  the  dentist's  tool  can  clean  out  and  which 
only  filling  with  suitable  physical  substance  can 
protect  from  further  decay  and  infection.  When 
germs  have  passed  through  the  exposed  canaliculi  or 
pores  of  the  tooth  substance  like  water  through  a 
filter,  they  often  cause  putrefaction  of  the  dead 
nerve  just  as  germs  cause  putrefaction  of  dead 
animal  or  vegetable  substances  entirely  outside  the 
human  body.  In  the  latter  case  we  know  that 
toxins  or  poisonous  substances  are  produced  which 
will  injure  or  kill  animals  absorbing  them,  and 
when  we  see  twenty-three  persons  out  of  a  cooking 
class  of  twenty-seven  die  after  eating  from  the 
same  supply  of  canned  string  beans  containing,  as 
subsequent  analysis  disclosed,  the  Bacillus  botu- 
linus,  we  cannot  avoid  the  conclusion  that  it  was 
a  grave  error  for  them  to  eat  the  infected  vegetable 
matter.  Whatever  the  best  treatment  for  the  re- 
sulting poison  common  prudence  would  prompt  the 
scientist,  no  less  than  the  nonbeliever,  to  sterilize  the 
home  made  canned  beans  by  the  physical  agency  of 
boiling  before  eating  them  and  so  avoid  the  poison- 
ing. ■ 

A  putrescent  tooth  pulp  has  been  shown  by 
animal  experiment  to  contain  germs  and  toxins 
which  will  cause  in  animals  the  various  lesions  and 
symptoms  which  occur  in  human  beings  with  den- 
tal infection.  The  putrescent  tooth  pulp  is  in  a 
cavity  with  hard  walls  which  can  neither  collapse 
and  so  obliterate  nor  produce  granulation  or  cure 
itself  by  any  other  natural  process  whether  under 
influence  of  the  mind  or  not.  Like  dislocation  of 
the  shoulder  it  is  a  physical  condition  which,  with 
our  present  knowledge,  cannot  be  cured  without  the 
use  of  physical  agents.  Whatever  may  be  the 
treatment  of  a  burn,  common  prudence  would  sug- 
gest to  the  scientist  no  less  than  to  the  unbeliever 
the  unwisdom  of  cleaning  gloves  with  crasoline  near 
an  open  fife.  Common  prudence  would  indicate 
the  unwisdom  of  allowing  to  remain  undiscovered 
and  unremoved  a  physical  cause  for  trouble.  No 
matter  what  one's  belief  might  be  he  would  not 
leave  on  the  surface  of  the  body  a  quantity  of  acid 
or  caustic  alkali  accidentally  spattered  there  but 
would  promptly  wash  it  off.  He  would  remove  the 
physical  cause  of  trouble  as  soon  as  possible,  re- 
gardless of  his  belief  and  regardless  of  the  treat- 
ment to  be  adopted  for  the  resulting  burn. 

I  am  not  a  Christian  Scientist  and  do  not  believe 
they  are  able  to  help  every  sufferer,  and  it  is  my 
belief  that  this  is  one  of  the  cases  where  the  aid  of 
physical  agents  is  required.  The  fact  of  our  present 
dependence  in  some -cases  upon  physical  agents  is 
illustrated  by  the  case  of  air,  water  and  food,  with- 
out which  life  itself  ceases, 

8.S0  Seventh  Avenue. 


THE  RELATIONSHIP  OF  THE  ANEMIAS 
TO  LIFE  INSURANCE* 
By  H.  Z.  Giffin,  M.  D., 
Rochester,  Minn., 
Division  of  Medicine,   Mayo  Clinic. 

The  general  mortality  in  this  country,  according  to 
the  ^Mortality  Statistics  of  the  Department  of  Com- 
merce for  1916,  was  approximately  1,400  for  every 
100,000  population.  In  these  statistics  no  attempt 
has  been  made  to  differentiate  the  various  types  of 
anemia.  Under  the  headings  anemia  and  chlorosis 
are  combined  evidently  the  many  types  of  primary 
and  secondary-  anemia,  with  the  exception  of  leu- 
cemia  which  is  considered  separately.  Two  of  every 
100,000  persons  are  reported  to  have  died  of 
leucemia.  The  death  rate  in  100,000  for  the  various 
forms  of  anemia  was  5.3.  Peptic  ulcer  is  reported 
to  have  caused  death  in  4.6  in  100,000  persons  and 
biliary  calculi  in  3.4  in  100,000.  It  appears  then 
that  with  respect  to  mortality  the  various  forms  of 
anemia,  leucemia  and  diseases  of  the  spleen  (7.5  in 
100,000)  are  equal  in  importance  to  ulcer  and  biliary 
calculi  combined  (8  in  100,000). 

One  death  in  700  deaths  is  attributed  to  leucemia. 
This  disease  is  less  common  in  rural  districts  than 
in  cities ;  for  instance,  in  Massachusetts,  in  cities 
of  more  than  10,000  population  the  rate  is  2.3  in 
100,000,  in  the  rural  districts  1.2.  There  seems  to 
be  little  variation  throughout  the  United  States ; 
the  rate  for  Kentucky,  however,  is  low  (1.1  in  100,- 
000  in  cities  and  1.2  in  the  rural  districts).  With 
such  a  definite  difference  the  question  of  diagnosis 
in  this  state  naturally  arises.  The  total  number  of 
deaths  attributed  to  leucemia  in  the  registration  area 
of  the  United  States  was  1424,  of  which  males  pre- 
dominated (males  876;  females  548).  There  seems 
to  be  a  gradual  increase  in  the  number  of  deaths 
attributed  to  leucemia  up  to  the  ages  between  fifty 
and  fifty-four.  There  is  not  a  great  variation,  how- 
ever, in  the  death  rates  during  any  period  between 
the  ages  of  forty-five  and  sixty-four.  At  all  ages 
approximately  twice  as  many  cases  in  males  as 
in  females  are  reported.  Leucemia  seems  to  be  a  rare 
disease  among  the  colored  race. 

One  death  in  approximately  three  hundred  deaths 
is  attributed  to  some  form  of  severe  anemia. 
Throughout  the  registration  area  for  1916,  3785 
deaths  were  attributed  to  anemia,  the  number  in 
females  exceeding  that  in  males;  females  2,101; 
males,  1,684.  The  number  of  deaths  attributable 
to  the  anemias  shows  a  marked  variation 
in  different  portions  of  the  country.  In  general, 
there  is  less  anemia  in  the  rural  districts.  Massa- 
chusetts has  approximately  equal  distribution  (6.8 
in  100,000  in  cities  and  6.9  in  rural  districts). 
Kentucky  again  shows  a  wide  difference,  especially 
among  the  colored  race  (for  the  colored  race  12.6 
in  ciFies  and  2.8  in  rural  districts ;  for  the  white  race 
6.1  in  cities  and  2.0  in  rural  districts.)  The  average 
for  the  United  States  is  5.3  in  100,000.  The  ques- 
tion of  diagnosis  is  so  involved  with  respect  to  the 
anemias  that  very  few  deductions  can  be  drawn 
from  these  statistics. 

*  Presented  before  the  Medical  Section  of  the  American  Life 
Convention,  March  11,  1920,  French  Lick,  Indiana. 


September  11,  1920.] 


GIFFIX:  AXEMIA  AND  LIFE  IXSURAXCE. 


359 


In  the  medicoactuarial  mortality  investigation  I 
have  found  no  report  on  pernicious  anemia  alone. 
From  0.3  to  0.8  per  cent,  of  the  total  number  of 
deaths,  with  variation  according  to  the  age  of  entry, 
are  attributed  to  anemia  and  chlorosis.  For  appli- 
cants between  the  ages  of  fifteen  and  twenty-nine, 
0.3  per  cent,  of  the  total  number  of  deaths  are  at- 
ributed  to  some  form  of  anemia ;  for  applicants 
between  the  ages  of  thirty  and  forty-four  0.8  per 
cent. ;  and  for  applicants  at  the  age  of  forty-five 
or  more,  0.7  per  cent. 

I  have  not  been  able  to  find  in  the  literature  a 
discussion  of  the  relationship  of  diseases  of  the 
blood  and  spleen  to  life  insurance.  The  question  has 
been  regarded  evidently  of  little  importance  for 
two  reasons :  First,  the  total  number  of  deaths  from 
any  one  disease  of  the  group  is  small,  with  the  ex- 
ception of  pernicious  anemia,  and  second,  the  in- 
surance companies  have  not  accepted  applicants  who 
were  anemic  or  who  were  reported  to  have  a  large 
spleen  or  to  have  been  splenectomized.  This  is, 
of  course,  a  ver\-  safe  attitude  from  the  viewpoint 
of  the  insurance  company,  but  is  likely  to  be  un- 
just from  the  viewpoint  of  the  individual  appli- 
cant. Much  inconvenience,  worry,  and  a  definite 
financial  loss  are  occasionally  due  to  rejection  for 
life  insurance.  I  believe  that  the  medical  depart- 
ments of  life  insurance  companies  should  give  a 
ver\-  full  consideration  to  the  applicants  who  may 
be  rejected  in  order  that  they  do  not  receive  false 
impressions  of  their  condition. 

It  is  possible  to  state  definitely  that  several  t\-pes 
of  anemias  are  curable:  1,  Secondary  anemias, 
which  are  due  to  hemorrhage,  in  which  the  cause  of 
hemorrhage  is  benign  and  can  be  eliminated  entire- 
ly :  2,  secondary  types  of  anemia  which  are  dietetic 
in  origin  or  due  to  hysterical  dysphagia ;  3,  splenic 
anemias  in  which  an  exploration  at  the  time  of 
operation  shows  no  evidence  of  cirrhosis  of  the 
liver,  portal  or  splenic  thrombosis,  or  gallbladder 
disease,  and  for  which  a  splenectomy  results  in 
satisfactory  convalescence ;  and  4,  anemias  which 
are  associated  with  the  clinical  entit\%  hemolytic 
jaundice,  after  the  patient  has  satisfactorily  re- 
covered from  splenectomy. 

Pernicious  anemia. — J.  W.  Fisher,  of  the  Xonh- 
westem  Mutual  Life  Insurance  Company,  has  fur- 
nished me  with  information  concerning  claims  paid 
in  cases  of  death  due  to  pernicious  anemia.  In 
1919,  thirty-six  of  a  total  of  4.234  deaths  from  all 
causes  were  from  pernicious  anemia :  this  is  .85 
per  cent.  None  of  the  thirty-six  patients  had 
been  listed  on  the  books  less  than  three  years,  and 
the  average  duration  of  their  insurance  was  nine- 
teen and  six  tenths  years.  Of  a  total  of  18,878 
deaths  from  all  causes  in  persons  insured  by  this 
company  during  the  last  five  years,  191  were  as- 
cribed to  pernicious  anemia,  approximatelv  1  per 
cent. 

F.  H.  Rockwell,  of  the  Equitable  Life  Assur- 
ance Society,  found  in  reviewing  his  statistical  ma- 
terial that  172  of  27,784  deaths,  from  May  1,  1917, 
to  Jan.  31,  1920,  were  due  to  pernicious  anemia. 
This  is  a  percentage  of  0.6.  The  policies  of 
these  persons  had  been  in  force  less  than  five  years 
in  only  5.2  per  cent. 


X.  W.  Muhlberg,  of  the  Union  Central  Life  In- 
surance Company,  has  furnished  me  with  the  sta- 
tistics of  this  company.  For  the  five-year  period 
1915  to  1919  there  were  7,474  deaths,  of  which 
seventy-three  were  attributed  to  pernicious  anemia, 
a  percentage  of  .97. 

The  statistics  of  the  Northwestern  National  Life 
Insurance  Company  furnished  by  H.  W.  Cook  for 
the  years  1915  to  1919  show  seventeen  deaths  of 
1,589  from  pernicious  anemia,  a  percentage  of  1.06. 

The  statistics  of  these  insurance  companies  may 
be  compared  with  the  general  mortality  statistics  of 
one  death  in  three  hundred  ascribed  to  anemias. 
The  statistics  of  the  insurance  companies  show  ap- 
proximately three  times  as  many  deaths  from  per- 
nicious anemia  as  those  of  the  Department  of  Com- 
merce. This  may  be  explained  by  the  fact  that 
the  cause  of  death  in  insured  persons  is  always 
carefully  investigated  by  the  companies,  while  many 
deaths  from  pernicious  anemia  are  undoubtedly 
listed  under  other  conditions  in  the  general  mortal- 
ity statistics.  It  is  likely  that  the  actual  death  rate 
from  pernicious  anemia  is  about  one  for  each  one 
hundred  deaths  rather  than  one  for  each  three 
hundred  deaths. 

Dr.  Fisher  states  that  his  company  does  not  issue 
insurance  to  persons  suflFering  from  anemia  in  any 
form  and  consequently  special  examinations  of  the 
blood  are  not  required.  Evidently  insurance 
companies  in  general  assume  this  attitude  \\-ith  re- 
spect to  applicants  with  severe  anemia,  and  so  far 
as  pernicious  anemia  is  concerned  it  is  very  proper. 
Of  all  patients  with  a  severe  grade  of  anemia  the 
smaller  proportion  are  those  suffering  from  per- 
nicious anemia.  Applicants  with  severe  anemia  un- 
doubtedly should  not  be  accepted  for  life  insurance. 
It  seems  no  more  than  just,  however,  to  recon- 
sider their  applications  for  insurance  after  a  period 
of  four  years.  The  average  life  of  persons  with 
pernicious  anemia  is  less  than  two  and  one  half 
years :  occasionally  patients  have  been  reported  to 
have  lived  for  longer  periods ;  a  few  for  twelve 
years  and  longer  are  on  record.  An  examination  of 
the  blood  smear  in  the  laboratory  of  the  medical 
director  would  be  a  protection  to  the  insurance  com- 
pany. The  smears,  in  cases  of  pernicious  anemia, 
show  many  large  red  cells  which  stain  rather  deep- 
ly, as  well  as  deformed  cells  and  cells  with  poly- 
chromatophilic  degeneration.  These  characteristic 
findings,  especially  if  associated  with  normoblasts 
or  megaloblasts,  would  be  sufiicient  evidence  for  the 
rejection  of  the  applicant.  Patients  with  secondary 
types  of  anemia,  which  are  in  many  instances  en- 
tirelv  recoverable,  present  a  blood  smear  showing 
rather  small,  pale  red  cells  without  the  presence  of 
abnormal  marrow  cells.  Two  features  occur  al- 
most constantly  in  tlie  history  of  patients  with  per- 
nicious anemia ;  recurrent  attacks  of  glossitis  with 
the  gradual  development  of  a  shiny  glistening 
tongue,  devoid  of  papillae,  and  the  complaint  of 
numbness,  tingling,  and  other  paresthesias  in  the 
hands  and  feet.  These  neurological  complaints  are 
the  result  of  the  cord  changes  which  are  present  to 
a  certain  degree  in  eighty-five  per  cent,  of  the  cases. 
Applicants  with  blood  smears  characteristic  of  the 
secondary  types  of  anemia  could  be  advised  to  seek 


360 


(ill'l-JX:  ANEMIA  AXU  LIFE  INSL'RAXCE. 


I  New  York 
Mkdic.m.  Journal. 


diagnosis  and  treatment  by  a  competent  clinician, 
and  to  reapply  for  insurance  in  from  two  to  four 
years. 

Lcuccmia. — In  the  Northwestern  Mutual  Life 
Insurance  Company  five  of  4,234  deaths  from  all 
causes  in  1919  were  attributed  to  leucemia,  approx- 
imately 0.1  per  cent.  During  a  five  year 
period  among  18.878  deaths  from  all  causes  0.2 
per  cent,  were  due  to  leucemia.  In  the  year 
1919  there  was  only  one  death  from  leucemia  during 
the  members'  first  year  of  insurance,  and  this  seems 
to  have  been  a  ca.se  of  acute  leucemia  with  an  ill- 
ness of  very  short  duration.  The  five  applicants 
who  died  had  been  insured  in  the  company  on  an 
average  of  ten  and  six  tenths  years. 

A  review  of  the  statistics  of  the  Equitable  Life 
Assurance  Society  shows  eighty-four  out  of  27,784 
deaths  to  be  due  to  leucemia,  a  percentage  of 
0.3 :  of  the  Union  Central  Life  In.surance  Com- 
pany, ten  of  7.474  deaths,  a  percentage  of  0.13. 
L.  F.  Mackenzie,  of  the  Prudential  Insurance  Com- 
pany, has  furnished  me  with  statistics  on  industrial 
insurance  from  which  I  calculate  a  percentage  of 
0.12  for  deaths  due  to  leucemia.  , 

It  is  evident  from  the.se  statistics  that  in  a  com- 
pany with  a  well  organized  medical  department 
leucemia  is  a  disease  which  demands  little  special 
attention.  It  is  conceivable  that  a  patient  with  leu- 
cemia might  occasionally  be  accepted  by  mistake 
as  a  life  in.surance  risk.  I  have  seen  at  least  half 
a  dozen  cases  in  which  the  patients  were  not  anemic 
and  the  diagnosis  was  made  as  the  result  of  a  blood 
cotmt  taken  becau.se  of  the  pre.sence  of  spleens 
which  were  barely  ]ialpable  and  might  easily  have 
been  overlooked.  The  patients  themselves  came 
with  complaints  of  a  neurotic  nature.  There  is 
no  means  of  excluding  this  group  of  mistakes,  how- 
ever, without  very  careful  clinical  study,  but  in 
such  cases  the  blood  smear  would  disclose  definite 
evidence  of  the  disease. 

Secondary  t\pcs  of  anemia. — I  would  like  to 
draw  your  attention  especially  to  the  types  of  sec- 
ondary anemia  from  which  patients  may  definitely 
recover  and  becau.se  of  which  it  would  apparently 
be  an  injustice  to  deny  an  applicant  the  privilege 
of  obtaining  insurance  at  some  later  date.  We  have 
been  surprised  to  find  that  very  severe  anemias  may 
result  from  slight  and  at  times  almost  unrecogniz- 
able bleeding  from  hemorrhoids  which  may  have 
lasted  for  two  or  three  years  without  evidence  of 
anemia.  Finally,  however,  the  hemopoietic  organs 
fail  to  respond  to  the  demand  placed  on  them  ;  and 
imder  these  circumstances  a  very  slight  hemorrhage 
is  sufficient  to  maintain  a  severe  grade  of  anemia. 
In  fact,  the  organism  may  be  said  to  develop  the 
"anemia  habit,"  so  that  at  the  time  the  patient  is  ex- 
amined a  marked  anemia  may  be  present  without 
hemorrhage.  Patients  who  have  developed  the  so- 
called  anemia  habit  usually  require  one  transfusion, 
after  which  the  blood  improves  with  medical  treat- 
ment. Proper  operative  measures  for  the  hemor- 
rhoids obviate  the  possibility  of  further  bleeding 
and  the  patient  is  permanently  cured. 

Secondary  types  of  anemia  due  to  profuse  men- 
struation over  a  period  of  years  are  similarly  re- 


coverable. The  increase  in  the  number  of  policies 
issued  to  women  makes  this  a  noteworthy  consid- 
eration. It  is  not  necessary  that  uterine  bleeding 
should  be  excessive  to  result  eventually  in  a  severe 
grade  of  anemia.  If  anemia  is  due  to  a  hyper- 
trophic endometritis,  it  can  usually  be  checked  per- 
manently by  means  of  radium.  Removal  of  a  be- 
nign polyp  is  also  frequently  necessary.  An  im- 
l)rovement  in  the  condition  of  the  blood  will  occur 
and  within  one  year  or.  at  the  most,  two  years  a 
reapplication  for  insurance  should  be  acceptable. 

Applicants  with  .severe  anemia  due  to  obscure 
])leeding  from  ulcer  of  the  duodenum  should  have 
the  same  consideration  that  is  given  to  applicants 
with  duodenal  ulcer  when  an  operative  cure  has 
been  effected. 

Dietetic  anemias  of  adults  have  not  received  the 
attention  they  deserve.  An  im]>roperly  balanced 
diet.  cs])ecially  one  low  in  protein  or  green  vege- 
tal)les,  may  result  in  seveje  secondary  anemia.  In 
addition  to  these  simple  forms  of  dietetic  anemia 
H.  S.  Plummer  has  demonstrated  a  new  clinical 
.syndrome,  of  which  the  cardinal  clinical  features 
are  anemia,  very  slight  enlargement  of  the  spleen, 
and  a  hysterical  block  of  the  ui)per  end  of  the 
eso])hagus.  Patients  with  this  condition  frequently 
choke  on  pills  and  certain  kinds  of  food,  especially 
meat.  Phey  consequently  avoid  foods  which  can- 
not be  finely  divided.  After  the  passage  of  an 
olive,  regardless  of  its  size,  they  are  able  to  eat 
normally.  Following  this  the  anemia  promptly  im- 
])roves.  the  .spleen  becomes  normal  in  size,  and  the 
])atient  completely  recovers. 

Ap])licants  for  insurance  who  may  be  shown  to 
have  severe  secondary  types  of  anemia  due  to  such 
conditions  as  hemorrhage  from  hemorrhoids,  pro- 
fuse menstruation,  and  hysterical  dysphagia  should, 
it  seems  to  me,  be  allowed  the  privilege  of  re- 
application  two  or  three  years  later  when  a  suffi- 
cient length  of  time  has  elapsed  to  ])ermit  recovery 
in  favorable  cases. 

The  medical  examiner  must  constantly  be  on 
guard  in  order  that  he  may  not  overlook  the  simple 
anemia  of  such  .serious  di.sea.ses  as  tuberculosis, 
nejihritis,  and  cancer.  It  is  very  well  known  that 
even  moderately  severe  grades  of  anemia  may  be 
difficult  of  recognition  on  inspection  alone.  In  fact 
the  use  of  the  Tallquist  scale  should  be  required 
in  the  examination  of  every  applicant.  Special 
mention  should  be  made  of  the  severe  degree  of 
anemia  which  sometimes  occurs  in  association  with 
carcinoma  of  the  fundus  of  the  stomach,  and  also 
of  the  colon,  especially  of  the  cecum  and  a.scending 
colon.  Indeed  the  diagnosis  of  cancer  of  the  colon 
in  these  cases  may  be  reached  with  extreme  diffi- 
culty. 

Sf^loiir  anemia. — Applicants  who  have  had  sple- 
nic anemia  should  l)e  considered  for  acceptance 
when  all  other  conditions  that  may  simulate  splenic 
anemia  have  been  excluded,  if  cirrho.sis  of  the  liver 
and  portal  or  splenic  thrombosis  were  not  demon- 
strated at  the  time  of  splenectomy,  provided  that 
recovery  has  been  prompt  and  the  person  has  been 
well  for  a  period  of  four  or  five  years.  Spleno- 
megaly in  simple  splenic  anemia  occurs  with  a  pure- 


Sept. ml). r  II.  1920.] 


GIPFIN:  ANEMIA  AM)  LIFE  ISSURAXCE. 


361 


ly  secondary  type  of  anemia  which  in  many  in- 
stances is  associated  with,  and  probably  the  resuh 
of,  gastro-intestinal  hemorrhages  caused  by  the  en- 
gorgement of  splenogastric  yessels.  Patients  with 
unconiphcated  sjjlenic  anemia  who  survive  opera- 
tion are  cured.  In  our  series  of  seventy-one  cases 
of  splenic  anemia  in  which  splenectomy  was  per- 
formed, thirty-two  were  found  to  be  uncomplicated 
cases ;  portal  cirrhosis  and  ascites  were  not  present, 
the  exploration  of  the  gallbladder  was  negative,  and 
there  was  no  evidence  of  splenic  thrombosis.  In 
thirty  of  the  thirty-two  uncomplicated  cases  the 
patients  recovered  following  operation,  and  all,  so 
far  as  can  be  ascertained,  are  well. 

Hemolytic  jaundice. — The  cure  of  hemolytic 
jaundice  by  splenectomy  is  one  of  the  conspicuous 
therapeutic  triumphs  in  diseases  of  the  hemopoietic 
system.  Hemolytic  jaundice  is  a  rare  disease  with 
distinctive  clinical  characteristics.  Elliott  and  Ka- 
navel  in  their  very  careful  review  of  the  literature 
(1915)  collected  forty-seven  cases  (one  case  of 
their  own)  in  which  splenectomy  had  been  done.  In 
1917  I  reviewed  the  cases  of  seventeen  patients 
.splenectomized  at  the  Mayo  Clinic.  Since  then 
fifteen  more  patients  have  been  examined,  making  a 
total  of  seventy-nine.  The  actual  incidence  of  the 
disease  is  difficult  to  determine.  We  have  observed 
approximately  fifty  cases  (medical  and  surgical)  in 
five  3'ears,  or  ten  cases  each  year  among  fifty  thous- 
and or  more  patients.  This  incidence,  therefore,  is 
about  one  in  five  thou.sand  patients.  The  results 
following  splenectomy  were  uniformly  good;  re- 
covery was  prompt  and  permanent.  In  every  in- 
stance in  which  the  diagnosis  of  hemolytic  jaundice 
was  indisputable  the  ])atient  was  cured  if  he  .sur- 
vived the  operation. 

There  is,  however,  one  exception  to  this  gen- 
eral rule :  A  patient  who  has  had  hemolytic  jaim- 
dice  for  many  years  may  develop  anemia  in  which 
the  blood  picture  of  ])ernicious  anemia  is  simulated, 
at  least  a  blood  coimt  of  high  color  index  ( ).  In 
this  type  of  case  the  anemia  may  persist  to  a  cer- 
tain degree  after  splenectomy. 

The  first  splenectomy  for  hemolytic  jaundice  was 
performed  by  Spencer  Wells  in  1887;  Dawson,  in 
1914.  twenty-.seven  years  later,  reported  this  ])atient 
to  be  cured.  Bland-Sutton  operated  on  a  patient  in 
1895.  Ten  years  later  this  patient  was  well.  Banti, 
in  1903,  operated  on  a  patient  who  was  rejiorted 
cured  eight  years  later.  The  first  patient  operated 
on  at  the  Mayo  Clinic  is  now  in  excellent  health, 
nine  years  after  the  operation.  The  clinic's  experi- 
ence in  a  series  of  thirty-two  splenectomies  for  hemo- 
lytic jaundice  has  demonstrated  remarkable  re- 
sults. There  is  no  doubt  in  the  minds  of  surgeons 
and  physicians  in  general  who  observe  the  remark- 
able improvement  in  the  condition  of  patients  who 
have  been  .splenectomized  for  hemolytic  jaundice, 
that  some  very  important  factor  is  either  neutral- 
ized, removed,  or  so  influenced  that  a  cure  results. 
It  is  impossible  at  present  to  determine  life  ex- 
pectancy for  applicants  for  life  insurance  who  have 
had  splenectomy  for  hemolytic  jaundice.  However, 
they  may  at  least  be  entitled  to  consideration  for 
term  insurance  at  a  special  rate,  and  indeed  could 
be  safely  granted  a  more  liberal  form  of  policy. 


SUMMARY. 

1.  The  increase  in  the  incidence  of  pernicious 
anemia  makes  it  advisable  to  consider  this  disease 
separately  in  mortality  statistics,  rather  than  to  in- 
clude it  among  anemias  in  general. 

2.  Medical  examiners  should  be  required  to 
report  a  hemoglobin  estimation  of  each  applicant 
(the  use  of  a  simple  .scale  would  be  sufficient). 
Blood  smears  forwarded  to  the  laboratory  of 
the  central  offices  by  examining  physicians  would 
be  of  great  assi.stance  in  eliminating  for  insurance 
applicants   with  pernicious  anemia  and  leucemia. 

3.  The  refusal  of  all  applicants  with  anemia  with- 
out a  definite  imderstanding  concerning  the  possi- 
bility of  later  reapplication  and  acceptance  may  be 
a  serious  inju.stice  to  the  individual. 

4.  Aj)plicants  with  anemia  from  chronic  recur- 
rent hemorrhage,  anemia  from  insufficiencies  of 
diet,  or  as  a  result  of  functional  dy.^phagia.  may  htt 
expected  to  recover  within  one  year  at  most  after 
proper  treatment,  and  should  be  given  the  privilege 
of  reapjjlication  at  a  subsequent  time. 

5.  A])plicants  who  have  had  splenectomy  for 
splenic  anemia,  provided  cirrhosis  of  the  liver,  gall- 
bladder disease,  and  thrombosis  of  splenic  vessels 
are  not  present,  might  be  considered  acceptable  risks 
for  term  insurance  after  having  been  well  for  five 
years  following  operation. 

6.  Applicants  who  have  recovered  following 
splenectomy  for  hemolytic  jaundice  may  safely  be 
con.^^idered  for  a  more  liberal  form  of  policy  if  they 
have  remained  well  for  five  years. 

BIBLIOGRAPHY. 

1.  Banti,  G.  :  La  spenomegalia  emolitica.  Scniamc  mcd.. 
1912,  xxxii.  265-268. 

2.  Bland-Sutton.  J. :  Three  successful  splenectomies. 
Lancet.  1895.  ii.  974-975.  Observations  on  the  surgery  of 
the  spleen,  British  .founial  of  Surgery,  1913-1914.  i.  157-172. 

3.  Dawson,  B.  :•  Discussion,  Proceedings  Ko\al  Socielv 
of  Medicine,  1914,  vii,  Clin.  Sec,  84-85. 

4.  Elliott,  C.  A.,  and  Kanavel.  A.  B. :  Splenectomy  for 
hemolytic  icterus,  a  discussion  of  the  familial  aiirl  r.c- 
(|uired  types,  with  a  report  of  splenectomized  case.;,  .V.rr- 
iicry.  Gynecology,  and  Obstetrics,  1915.  xxi,  21-37. 

5.  GiFFiN.  H.  Z. :  Hemolytic  jaundice,  a  review  of  sev- 
enteen cases.  Sitrgcrv.  Gxnccologv  and  Ob.<:tctrics.  1917, 
XXV,  152-161. 

6.  Medicoactuarial  Mortality  Investigation.  New  York. 
.Association  Life  Insurance  Medical  Directors  and  t!u-  .Ac- 
tuarial Society  of  America,  1913,  ii.  27-29. 

7.  Mortality  Statistics.  1916.  Seventeenth  Annual  Re- 
)u)rt.  Department  of  Commerce,  Washington,  Government 
Printing  Office,  1918. 


Rales  after  Expiration  and  Cough  as  a  Means 
to  Early  Diagnosis  in  Tuberculosis. —  1!.  L.  Talia- 
ferro [I'lrginia  Medical  Monthly,  January.  1920) 
has  the  patient  breathe  out,  cough,  and  quickl\' 
breathe  in.  Rales  not  heard  on  ordinary  or  deep 
breathing  are  often  thus  elicited.  Where  the  patient 
is  unable  to  carry  out  what  is  required  of  him.  the 
author  demonstrates  the  procedure  himself.  The 
patient  is  told  to  cover  the  mouth  with  a  gauze  hand- 
kerchief, imagine  that  it  is  a  window  pane  on  a  cold 
morning,  blow  the  breath  out  as  fast  as  possible, 
next  give  a  quick  hack  or  cough  into  the  gauze,  im- 
mediately take  a  fairly  deep  breath,  and  repeat  the 
process  each  time  the  examiner  moves  the  stetho- 

SCOJT*. 


362 


JOXES:  CARDIAC  MURMURS. 


[New  York 
Medical  Journal. 


CLINICAL    SIGNIFICANCE    OF  CARDIAC 
MURMURS* 
By  Frank  A.  Jones,  M.  D., 

Memphis,  Tenn. 

The  English  school  has  been  and  is  still  the  leader 
in  the  study  of  cardiac  diseases.  Since  the  days  of 
Walsh  and  Corrigan  down  to  the  present  time,  with 
such  men  as  INIacKenzie  and  Lewis,  there  has  been 
a  gradual  evolution  and  change  regarding  the 
value  of  the  presence  of  a  murmur  in  studying  heart 
disease.  In  presenting  this  paper  I  shall  not  attempt 
to  review  the  literature  nor  add  anjthing  specially 
new.  The  object  of  the  paper  is  to  present  the  sub- 
ject matter  in  such  a  way  as  to  be  of  benefit  to  both 
the  specialist  and  the  general  practitioner.  As  a 
teacher  of  physical  diagnosis  in  the  hospital  wards, 
in  the  amphitheatre  and  in  the  out  clinic  for  more 
than  twenty  years  I  have  reached  some  definite  con- 
clusions.   Perhaps  some  of  them  may  seem  radical. 

The  question  naturally  arises,  especial!)-  where  the 
clinician  has  had  a  broad  experience  in  observing 
diseases  of  the  heart,  when  is  a  murmur  of  value 
in  making  a  diagnosis?  When  is  it  significant  and 
when  is  it  to  be  dismissed  in  making  a  diagnostic 
estimate?  In  my  consultation  work  I  have  been 
much  impressed  with  the  fact  that  entirely  too  much 
value  has  been  attached  to  the  presence  of  this  mystic 
something  we  are  pleased  to  call  murmur. 

Too  often  incorrect  diagnoses  are  made,  improper 
treatment  is  instituted  and  many  subjects  made  in- 
trospective. Do  not  attach  too  much  importance  to 
finding  a  murmur.  If  you  go  back  to  the  days  of 
Corrigan  and  Walsh  and  in  this  country  to  the  time 
of  Da  Costa  and  Flint,  you  will  observe  that  all 
hinged  upon  the  location,  the  time  and  quality  of 
the  murmur,  that  the  diagnosis,  prognosis  and  treat- 
ment rested  almost  entirely  upon  the  stethoscopic 
findings.  Fortunately  that  day  is  passing,  but  it 
has  not  passed  rapidly  enough.  Let  us  go  back  to 
our  college  days,  say  thirty  or  thirty  five  years  ago 
and  remember  what  we  were  taught.  The  classifi- 
cation of  murmurs  hitherto  has  been  burdensome. 
We  have  been  told  about  endocardial  murmurs, 
extracardial  murmurs,  cardiorespiratory  murmurs, 
dynamic  murmurs,  anemic  murmurs,  accidental 
murmurs  and  others.  There  is  no  classification  that 
is  really  satisfactory,  but  in  time  we  trust  cardiolo- 
gists will  reach  a  standard  as  to  classification.  For 
a  working  basis  AlacKenzie  has  classified  murmurs 
as  ph3-siological,  functional  and  organic. 

In  studying  cardiac  aftections  I  wish  to  impress 
upon  you  that  the  presence  of  a  murmur  is  the  least 
important  of  all  of  our  findings.  It  does  not  matter 
whether  the  murmur  is  physiological,  functional  or 
organic.  Perhaps  the  question  might  arise  in  the 
minds  of  some,  can  we  have  a  murmur  where  the 
heart  is  perfectly  normal  ?  Can  we  have  a  functional 
murmur  when  there  is  no  evidence  of  organic  dis- 
ease? Can  we  have  an  organic  murmur  in  which 
the  prognosis  is  good  and  in  which  case  the  patient 
may  live  out  his  allotted  time  and  die  from  some 
intercurrent  trouble?  All  these  questions  can  be 
readily  answered  in  the  affirmative.    Perhaps  some 

•Read  before  the  Mississippi  State  Medical  Association,  May  12, 
1920. 


may  ask  what  we  mean  by  a  physiological  mur- 
mur. We  are  able  to  answer  this  question  by  citing 
the  presence  of  a  murmur  in  young  adults  in 
whom  there  has  been  no  history  of  previous  infec- 
tion ;  where  the  patient  is  in  the  pink  of  health, 
and  is  not  conscious  of  the  presence  of  a  mur- 
mur until  informed  by  the  physician.  These  physio- 
logical murmurs  have  their  analogue  in  the  high 
pitch  respiration  so  frequently  found  particularly 
over  the  apex  of  the  right  lung  in  children  and 
young  adults.  The  question  of  physiological  mur- 
murs in  young  people  perhaps  is  a  question  of  biol- 
ogy, biochemistry;  a  physiological,  anatomical,  his- 
tological, embryological  question.  In  proportion  to 
the  degree  that  the  arteries,  myocardium  and  valves 
develop  into  maturity  the  murmur  will  disappear. 

We  are  hearing  a  great  deal  today  about  func- 
tional tests.  The  whole  medical  world  has  turned 
on  its  head  with  reference  to  functional  activity, 
to  the  detriment  of  pathology.  When  we  use  the 
term  functional  murmur  the  thought  intrudes  itself 
as  to  its  nature.  In  truth  it  seems  that  functional 
murmurs  in  a  measure,  in  many  instances  can  be 
used  as  a  synonym  of  physiological  murmurs.  In 
other  words  if  we  test  out  carefully  through  a  sys- 
tem of  exercise  the  heart  muscle,  estimate  the  size 
and  condition  of  the  heart  by  palpation  and  auscul- 
tation and  find  everything  working  well,  for  the 
want  of  a  better  term  we  can  use  the  generic  term, 
functional  murmur.  I  have  been  accustomed  to 
classify  these  physiological  and  functional  murmurs 
as  benign  in  that  they  are  are  of  but  little  importance 
and  have  slight  bearing  on  the  cardiac  state. 

It  will  not  be  necessary  to  dwell  upon  organic 
murmurs  except  to  say  that  when  found,  the  history 
of  the  case  together  with  other  physical  findings 
will  place  the  value  of  a  murmur  where  it  belongs. 

Graham  Steele,  another  eminent  English 
cardiologist,  has  said :  "No  one  ever  dies  from 
mitral  regurgitation."  He  stated  that  when  the 
heart  failed  where  there  was  a  mitral  systolic  mur- 
mur present,  heart  failure  had  occurred,  not  because 
of  the  regurgitation,  but  because  there  were  present 
other  factors  which  provoked  it,  such  as  some  myo- 
cardial disease  or  impairment.  "This  was  so  op- 
posed to  the  conception  of  heart  failure  by  back 
pressure  which  I  had  been  taught  to  accept  that  I 
carefully  observed  my  patients  to  see  whether  or  not 
it  was  true ;  and  now  I  can  fully  endorse  Graham 
Steele's  diction." — MacKenzie.  What  Graham 
Steele  has  said  about  mitral  lesions  can  as  well  be 
said  about  aortic  lesions.  Hitherto  we  have  laid  too 
much  stress  on  the  term  and  diagnosis  valvular 
lesion.  How  often  do  we  see  death  certificates 
signed,  "organic  valvular  lesion  of  the  heart."  In 
any  given  case  of  heart  disease  the  results  of  pre- 
vious infections,  whether  the  condition  be  of  long 
duration  and  chronic  or  acute,  the  condition  at  the 
valve  has  but  little  to  do  with  the  death  of  the  pa- 
tient. In  other  words  the  valve  lesion  per  se  is  merely 
a  part  of  the  general  p>athological  cardiac  condition. 
MacKenzie  has  well  said  in  any  infection  of  the 
heart  no  one  tissue  is  absolutely  attacked.  The  in- 
fection frequently  spends  its  force  on  the  entire 
cardiac  structure,  namely  valvulitis,  endocarditis, 
pericarditis,  myocarditis  blended  to  make  the  sum 


Septsmbrr  11,  1920.] 


JONES:  CARDIAC  MURMURS. 


363 


total  of  the  cardiac  pathological  condition  carditis. 
Our  whole  attention  must  be  directed  in  the  man- 
agement of  any  given  case  to  the  heart  muscle  and 
its  sac,  the  pericardium,  and  its  lining  membrane, 
the  endocardium.  From  our  accumulative  knowl- 
edge of  cardiac  disease  where  there  is  a  pathological 
condition  in  the  valves  associated  with  changes 
taking  place  in  the  cardiac  structure,  when  compen- 
sation fails,  we  can  use  the  hyphenated  term,  myo- 
cardial valvular  insufficiency.  Reverting  to  the 
clinical  significance  of  cardiac  murmurs  their  only 
significance  is  determining  what  valve  is  affected,  if 
organic;  how  much  enlargement  there  is  of  the 
heart ;  what  symptoms  are  present ;  the  nature  of  the 
infections  that  lead  to  the  valvular  defect ;  the  age 
and  general  nervous  makeup  of  the  patient. 

Given  a  case  we  will  say  of  mitral  insufficiency 
the  result  of  rheumatic  endocarditis,  in  either  adult 
or  child,  if  we  find  a  systolic  murmur  at  the  apex 
possibly  not  transmitted  further  than  the  axillary 
line,  with  the  apex  beat  in  the  normal  line,  the  apex 
beat  not  diffusable  nor  tumultuous,  with  the  pulse 
normal,  the  pulmonic  second  sound  not  mark- 
edly accentuated,  with  no  symptoms  of  dyspnea, 
no  enlargement  of  the  liver,  nor  evidence  of 
stasis  an)"svhere,  we  can  assure  the  patient  that  the 
condition  is  of  but  little  moment  and  not  to  be  re- 
garded with  too  much  disquietude.  It  is  well  in  this 
type  of  case  to  put  the  patient  through  a  strenuous 
gymnastic  exercise  and  test  the  heart  after  the  ex- 
ercise to  estimate  the  reserved  integrity  of  the  heart 
muscle.  Where  the  heart  responds  and  shows  no 
evidence  of  a  weak  myocardium,  making  this  dem- 
onstration to  the  patient  is  quite  often  a  valuable  aid 
in  reassuring  him  that  his  condition  is  not  serious.  A 
great  many  of  these  patients  come  to  me  either  with 
strychnine  tablets  or  with  tincture  of  digitalis.  In 
such  cases  giving  strychnine  and  digitalis  or  any  car- 
diac tonic  or  stimulant  is  like  handicapping  a  well 
bred  race  horse  on  a  smooth  track.  How  often  have 
I  seen  these  patients'  nervous  systems  tuned  to  high 
C  by  the  strjxhnine  they  are  taking  and  the  heart 
muscle  made  irritable  by  the  injudicious  use  of 
digitalis.  In  such  cases  there  is  no  indication  what- 
soever for  medical  agencies.  The  psychic  condition 
needs  more  treatment  and  attention  than  the  heart 
needs  medicine.  Too  often  these  patients  are  put 
to  bed  to  take  rest  treatment  without  due  considera- 
tion and  weighing  all  the  evidence.  They  become 
markedly  introspective  while  in  bed  and  are  con- 
stantly watching  the  heart.  Exercise  and  mental 
diversion  are  what  they  need  and  not  rest. 

Now  as  to  physiological  murmurs,  they  are  nearly 
always  systolic  in  time  and  at  the  apex.  They  may 
be  distributed  over  the  entire  precordium.  The  heart 
is  never  enlarged  and  the  history  as  to  infection  is 
nearly  always  negative.  There  is  not  much  area  of 
transmission ;  the  heart  responds  to  all  tests.  These 
physiological  murmurs  are  too  often  confused  with 
the  true  organic  mitral  regurgitation,  merely  by  the 
findings  of  a  systolic  apex  murmur.  A  careful 
physical  examination  of  the  patient,  however,  can 
easily  decide  the  question  in  many  instances.  The 
late  war  has  taught  us  some  valuable  lessons  with 
reference  to  cardiac  diagnosis.  Some  of  the  long 
accepted  views  have  been  reversed.    Since  the  war 


I  have  examined  numbers  of  patients  coming  out  of 
base  hospitals  with  a  diagnosis  of  mitral  regurgita- 
tion, when  upon  a  most  searching  stripped  examina- 
tion and  a  thorough  review  of  their  history  I  could 
find  nothing  to  justify  the  diagnosis  except  a  slight 
systolic  whiff  at  the  apex.  I  am  quite  satisfied  that 
numbers  of  men  on  examining  boards  making  these 
examinations  were  young  amateurs,  who  had  not 
been  sufficiently  trained  in  physical  diagnosis.  I 
quite  agree  with  MacKenzie  when  he  says,  "Per- 
fectly healthy  men  have  been  rejected  from  the  army, 
or  invalided  out  of  it,  because  a  murmur  was  de- 
tected in  their  hearts.  Others  who  present  them- 
selves for  life  insurance  are  rejected  or  made  to 
pay  a  higher  premium  for  the  same  reason,  while 
innumerable  individuals  are  subjected  to  prolonged 
treatment  and  great  restrictions  in  their^  mode  of  life 
because  these  early  superficial  observations  have 
misled  the  profession."  The  question  of  fife  insur- 
ance in  its  relation  to  heart  murmurs  concerns  all 
medical  examiners.  Were  I  the  chief  medical  ex- 
aminer of  any  life  insurance  company  the  detecting 
of  a  murmur  without  other  findings  would  not  deter 
me  from  issuing  a  policy  without  extra  premium. 

Diastolic  murmurs  are  practically  always  organic. 
Just  why  this  is  true  no  cardiologist  has  yet  been 
able  to  give  a  reason.  We  have  for  a  working  basis 
but  two  diastolic  murmurs  of  consequence,  namely, 
that  of  aortic  insufficiency  and  the  late  diastolic  mur- 
mur of  mitral  stenosis.  So  far  as  I  am  personally  con- 
cerned I  have  never  been  convinced,  from  the  quality 
of  the  murmur  upon  auscultation  in  mitral  stenosis, 
that  it  is  diastolic.  Personally,  I  am  content 
to  classify  the  murmur  so  typical  and  characteristic 
in  mitral  stenosis  as  presystolic.  I  have  been  much 
amused  of  late  in  reading  the  superabundance  of 
literature  upon  the  subject  in  army  and  base  hos- 
pitals as  to  the  question  of  this  lesion.  I  read  an 
article  not  long  since  in  which  the  statement  was 
made  that  the  author  did  not  consider  the  presys- 
tolic murmur  of  any  consequence,  that  he  had 
discarded  its  significance,  and  that  it  was  not  con- 
sidered at  all  in  a  diagnosis  of  mitral  stenosis.  I 
do  not  think  that  any  cardiologist  of  broad  experi- 
ence can  accept  this  dictum.  In  fact,  the  presystolic 
murmur,  or  as  some  call  it  the  late  diastolic  murmur, 
is  as  characteristic  of  mitral  stenosis  as  the  diastolic 
murmur  is  of  aortic  insufficiency.  Personally,  I 
would  not  be  satisfied  with  the  diagnosis,  particu- 
larly where  there  is  perfect  compensation,  without 
the  presence  of  this  distinctive  murmur.  In  fact, 
the  presystolic  thrill  over  the  apex  on  palpation  and 
the  presystolic  murmur  on  auscultation  clinch  the 
diagnosis.  In  aortic  insufficienc}-,  whether  endo- 
cardial or  arteriosclerotic,  the  diastolic  murmur  at 
the  base  is  just  as  distinctive  as  the  presystolic  mur- 
mur at  the  apex  in  mitral  stenosis. 

In  conclusion,  let  us  remember  that  in  organic 
cardiac  lesions  the  finding  of  a  murmur  is  merely 
an  aid  to  the  diagnosis  and  is  to  be  considered  as 
the  least  important  of  all  of  our  findings ;  that 
physiological  and  functional  murmurs  are  of  but 
little  consequence  and  must  not  be  confused  with 
organic  murmurs.  Let  us  be  careful  and  painstaking 
in  history  taking  and  in  a  thorough  physical  exam- 
ination of  the  patient  in  making  any  estimate. 


3C)4  GROSSMJX:  FRAC 

FISSURE  FRACTURE  OF  THE  TIBIA. 
II' i til  Reports  of  Cases. 

By  Jacob  Grossman,  'M.  D., 
New  York, 

Chief   of   the   Orthopedic    Clinic,    Lebanon    Hospital;    Chief   of  the 
Orthopedic   Clinic,    Stuyvesant   Polyclinic:   Instructor  of  Ortho- 
pedics, Xcw  York  Postgraduate  Medical  School. 

Fissure  fracture,  also  known  as  subperiosteal,  in- 
traperiosteal,  linear  and  oblique  fracture,  is  one  in 
which  the  bone  breaks  or  cracks  inside  the  thick 
periosteum,  as  a  willow  bough  cracks  without  tear- 
ing its  bark.  The  commonest  site  of  this  type  of 
fracture  is  in  the  tibia.  Only  one  was  found  else- 
where and  that  was  in  the  fibula.  This  case  was  re- 
ported by  me  (1)  in  1916.  Fissure  fracture  is  espe- 
cially found  in  children  and  results  from  direct 
trauma,  such  as  a  falling  object  striking  the  leg,  or  a 
fall  striking  upon  the  leg. 

,  ETIOLOC.Y 

In  this  series  there  were  twenty-one  cases.  Of 
these  sixteen  or  eighty  per  cent,  were  in  males  and 
five  or  twenty  per  cent,  in  females.  Ten  were  in  the 
left  tibia  and  eleven  in  the  right.  Nineteen  or  almost 
ninety-five  per  cent,  occurred  in  children  who  were 
below  ten  years  of  age.  One  occurred  in  a  boy  of 
thirteen  and  the  other  in  a  boy  of  fifteen.  The 
yoimgest  child  was  twelve  months  of  age.  The  com- 
monest cause  was  a  fall,  the  patient  striking  upon 
the  affected  leg.  The  distance  of  the  fall  varied.  In 
some  instances  the  patient  fell  from  a  high  chair,  in 
others  down  the  stairs,  a  distance  of  one  or  twti 
steps,  in  others  they  fell  on  level  ground.  In  a  nwm- 
ber  of  instances  the  trauma  was  very  mild. 

S  V  M  PTO  M  .\TOLOG  Y 

The  subjective  symptoms  varied  from  mild  cases 
to  verv  severe  ones.  In  some  instances  the  pain  and 
disabilitv  were  slight.  The  pain  was  especially 
evident  when  the  child  attempted  to  walk  or  when 
the  affected  liml)  was  manipulated.  The  subjective 
symptoms  in  a  number  of  instances  were  so  niild 
that  the  mothers  were  surprised  to  learn  of  the 
presence  of  a  fracture.  In  others  the  pain  and  dis- 
ability were  so  severe  that  the  patients  refused  to 
walk  and  would  not  permit  the  slightest  manipula- 
tion of  the  affected  leg.    Disability  was  marked. 

The  diagnostic  objective  symptom  is  pencil  ten- 
derness. It  is  excruciating  in  character  and  can  be 
mapped  out  by  means  of  the  rubber  tip  of  a  pencil, 
which  is  made  to  exert  pressure  over  the  area  of 
trauma.  The  line  of  fracture  can  be  traced  by  this 
means  in  a  large  number  of  instances.  This  symp- 
tom may  persist  for  months.  There  may  be  slight 
swelling  and  ecchymosis  around  the  site  of  frac- 
ture, "a  limp  f)n  the  affected  side  was  ustially 
present.  Crepitus,  false  mobility  and  deformity 
were  always  lacking. 

DIAGN'OSIS 

The  diagnosis  is  usually  made  by  mapping  out 
the  pencil  tenderness  and  confirmed  by  subsequent 
X  ray  pictures.  It  is  essential  that  the  x  ray  pic- 
tures be  taken  in  sevefal  planes  as  the  fracture  may 
show  in  one  plane  only.  This  plane,  as  has  often 
been  the  case,  may  be  omitted,  and  the  fracture  may 
))e  overlooked. 


TURE    OF    TIBIA.  ,    f^^w  York 

llEDic.\L  Journal. 

In  sprains  and  contusions  the  tenderness  is  as  a 
rule  more  generalized  than  it  is  in  fissure  fractures. 
There  are  no  areas  of  pencil  tenderness  in  the  for- 
mer conditions.  Tenderness  and  pain  in  sprains 
and  contusions  do  not  persist  for  as  long  a  period 
of  time  as  they  do  in  fracture. 

In  one  of  our  cases  the  fissure  fracture  was  ac- 
companied by  a  luetic  osteoperiostitis  of  the  tibia. 
The  luetic  infection  was  responsible  for  the  per- 
sistence of  the  symptoms  for  months  after  the  injtiry 
had  been  sustained.  The  history  of  the  case  in 
point  follows : 

Case  I. — The  patient  was  a  boy.  ten  years  of 
age.  who  had  met  with  an  accident  in  which  his  leg 
was  injured.  He  was  taken  to  a  clinic  where  a 
diagnosis  of  fracture  of  the  tibia  was  made  and 
proper  treatment  instituted.  His  leg  was  encased 
in  plaster  of  Paris  bandages  and  maintained  in  this 
fashion  for  several  weeks.  In  spite  of  this  im- 
mobilization the  pain  persisted.  He  came  to  our 
clinic  several  months  later  complaining  of  pain  and 
a  limp.  Examination  disclosed  slight  swelling 
about  the  centre  of  the  shaft  of  the  tibia.  Tender- 
ness in  the  same  region  was  marked  and  localized. 
Ecchymosis.  crepitus,  false  iiK^bility  and  deformity 
were  lacking. 

It  was  quite  evident  that  something  be- 
side the  old  injury  was  responsible  for  the  symp- 
toms. Exannnation  of  the  eyes  disclosed  that  the 
pupils  were  une(|tial  and  irregular,  responding  rather 
sluggishly  to  light.  The  teeth  showed  humpy 
molars,  dental  interspacing  and  fluting  (Roberts). 
These  latter  findings  suggested  a  possible  luetic  in- 
fection. Closer  questioning  of  the  mother  disclosed 
the  history  of  a  primary  infection  about  the  time 
that  the  patient  was  four  months  of  age.  As  she 
ntirsed  the  child  at  the  time  the  infection  was 
traced  to  that  source.  Subsequent  blood  examina- 
tions of  both  child  and  mother  were  made  and  the 
AX'assermann  was  four  plus.  An  x  ray  picture  of 
the  affected  leg  was  taken  and  it  showed  an  old 
fissure  fracture  and  a  syphilitic  osteoperiostitis  of 
the  tibia. 

The  subsequent  course  of  the  case  tmder  treat- 
ment further  confirmed  our  findings.  The  pain 
and  disability  disappeared  under  mixed  treatment. 
This  case  is  mentioned  to  emphasize  the  necessity 
of  bearing  in  mind  the  possibility  of  hies  being 
responsible  for  persistent  pain  and  disability  fol- 
lowing an  injury. 

COURSE  AND  PROGXOSIS 

The  prognosis  is  excellent.  The  patient  usually 
recovers  within  a  few  weeks.  The  pencil  tender- 
ness persists  for  an  indefinite  time  after  the  pain 
and  disability  have  subsided. 

TREATMEXT 

The  treatment  consists  of  immobilization  by 
means  of  plaster  of  Paris  bandages.  The  bandages 
are  retained  for  a  period  of  two  weeks  when  they 
are  removed  and  baking  and  mas.sage  are  given. 
The  average  length  of  treatment  was  four  weeks. 

It  is  lumecessary  to  report  in  detail  the  entire 
series  of  cases.  The  following  .six  reports  jiresent 
the  main  features  occurring  in  fis.sure  fractures. 


.September  U,  1920.] 


CROSSMAX:  FRACTURE  Of  TIBIA. 


365 


Case  II.— C.  R..  three  and  a  half  years  of  age. 
Three  weeks  before  coming  to  our  clinic,  the  child 
tripped  and  fell.  She  was  taken  to  her  family  physi- 
cian and  local  applications  with  rest  were  prescribed. 
In  spite  of  faithfully  carrying  out  these  directions, 


Fig.   1 — Fissure  frattun-  of  the  tihia.     (Case  II.) 


the  pain  and  disability  persisted.  It  was  for  these 
symptoms  that  the  child  was  referred  to  us. 

The  child  was  unable  to  walk,  having  been  carried 
to  the  clinic  by  her  father.  Her  leg  was  slightly 
swollen  in  the  region  of  the  tibial  crest.  Ecchy- 
mosis,  crepitus,  false  mobility  and  deformity  were 
lacking.  There  was,  however,  a  line  of  pencil  ten- 
derness localized  to  the  tibia  and  e.xtending  for  a 
distance  of  about  two  inches.  .\  diagnosis  of  fi.s- 
sure  fracture  of  the  tibia  was  made  and  a  subse- 
quent X  ray  picture  confirmed  the  diagnosis  (Fig. 
1).    The  patient  made  an  uneventful  recovery. 

Case  III. — M.  O.,  .seven  years  of  age,  fell  strik- 
ing upon  his  leg.  He  was  brought  to  our  clinic 
several  days  later,  on  account  of  pain  and  slight 
disability.  The  patient  walked  with  a  slight  limp  on 
the  affected  side.  Ecchymosis,  false  mobility  and 
deformity  were  lacking.  There  was  slight  swelling 
over  the  affected  area.  Pencil  tenderness  extending 
for  a  di.stance  of  about  three  inches  was  traced  along 
the  tibia.  .\  diagnosis  of  fissure  fracture  was  made 
and  a  subsequent  .x  ray  picture  confirmed  the  diag- 
nosis (Fig.  2). 

Case  IV. — J.  F.,  three  years  of  age.  A  few  days 
before  being  brought  to  the  orthopedic  clinic  of 
Lebanon  Hospital,  the  patient  fell,  striking  upon 
his  left  leg.  No  attention  was  paid  to  the  accident 
as  he  was  able  to  get  about.  For  the  following  few 
days  the  child  complained  of  pain  esj^ecially  evident 
when  he  walked.  The  ])atient  walked  with  a  slight 
limp  on  the  left  side.  The  leg  was  swollen,  there 
was  no  deformity,  ecchymosis,  crepitus  or  false 
mobility.  .\  line  of  jiencil  tenderness  was  traced 
along  the  shaft  of  the  tibia  for  a  distance  of  two  and 


a  half  inches.  A  diagnosis  of  fissure  fracture  of 
the  til)ia  was  made  and  proper  treatment  instituted. 
A  suljsecjuent  x  ray  picture  confirmed  the  diagnosis. 
The  patient  made  an  uneventful  recovery. 

C.\SE  V. — S.  R.,  eight  years  of  age,  fell,  strik- 
ing upon  his  left  leg.  Complained  of  pain  and  a 
limp.  There  was  slight  swelling  and  ecchymosis 
over  the  upper  part  of  the  leg.  Crepitus,  false  mo- 
bility and  deformity  were  lacking.  A  line  of  pencil 
tenderness  was  traced  for  about  two  inches,  along 
the  upper  part  of  the  tibia.  A  diagnosis  of  fissure 
fracture  of  the  tibia  was  made  and  a  subsequent  x 
ray  jjicture  confirmed  the  diagnosis.  The  patient 
made  an  imeventful  recovery. 

C.\SK  VI. — H.  S..  fifteen  years  of  age.  About 
five  weeks  before  coming  to  our  clinic,  the  patient 
fell  and  hurt  his  right  leg.  Disability  and  severe 
pain  followed.  Ecchymosis  and  swelling  localized  in 
the  centre  of  the  leg  were  evident.  Pencil  tenderness 
was  traced  along  the  shafr  of  the  tibia  for  a  distance 
of  about  three  inches.  A  diagnosis  of  fissure  frac- 
ture of  the  tibia  was  made  and  a  subse(|uent  x  ray 
])icture  confirmed  the  diagnosis.  The  patient  made 
an  uneventful  recovery. 

Case  VII. — S.  S.,  four  years  of  age,  fell,  striking 
upon  his  right  leg.  For  a  few  days  thereafter  he 
complained  of  pain  only  when  walking.  The 
mother  noticed  that  he  limped.  The  patient  walked 
with  a  limp  on  the  right  side.  There  were  slight 
swelling  and  ecchymosis  over  the  lower  part  of  the 


Fic.  1 — Suliperiosteal  fissure  fracture  of  the  tibia.     (Case  III.). 

right  leg.  -\  line  of  pencil  tenderness  was  traced 
along  the  tibia  for  about  an  inch.  A  diagnosis  of 
fissure  fracture  of  the  tibia  was  made  and  a  subse- 
quent X  ray  picture  confirmed  the  diagnosis.  This 
patient  fell  again  a  few  weeks  after  he  was  dis- 
charged and  injured  the  .same  leg.  Examination 


366 


U'YATT:   TREATMENT  OF  MALARIA. 


[New  York 
Medical  Jovrnal. 


again  disclosed  a  fissure  fracture  a  little  higher  than 
the  previous  one  had  been. 

SUMMARY  AXD  COXCLUSIOXS  : 

1.  Fissure  fracture  occurs  mostly  in  children. 

2.  The  tibia  is  usually  the  site  of  the  fracture, 
only  one  case  having  been  seen  in  the  fibula. 

.  3.  The  subjective  symptoms  and  the  disability 
may  be  mild. 

4.  Fissure  fracture  should  be  differentiated  from 
sprains  and  contusions. 

5.  The  presence  of  a  luetic  infection  in  the  bone, 
as  a  factor  prolonging  the  duration  of  the  symp- 
toms, should  not  be  overlooked. 

6.  False  mobilit}-,  crepitus  and  deformity  are 
always  lacking  in  this  type  of  fracture. 

7.  The  diagnostic  objective  symptom  is  pencil 
tenderness.  It  is  always  present  and  persists  for 
an  indefinite  period  of  time  after  the  accident  has 
occurred. 

8.  The  recognition  of  the  type  of  fracture  is  im- 
portant, not  only  from  a  scientific  viewpoint,  but 
also  from  a  medicolegal  viewpoint. 

REFERENCES. 

1.    Grossman:  Medical  Record,  July  8,  1916. 
1182  Jackson  Avenue. 


THE  INTRAVENOUS  TREATMENT  OF 
MALARIA. 

By  B.  S.  Wyatt,  M.  D., 
Piano,  Tex. 

Evolution  is  a  law  of  nature.  Evolution  in  the 
science  and  art  of  medicine  has  changed  funda- 
mentally methods  of  treating  disease.  From 
the  primitive  method  of  drug  administration 
per  OS  to  the  giving  of  medicine  by  the  hypodermic 
syringe,  was  a  long  step  forward.  From  the  sub- 
cutaneous injection  to  the  intramuscular  injection 
was  a  logical  evolution.  From  the  intramuscular 
injection  to  the  intravenous  injection  was  inevitable. 
It  had  to  come.  It  is  here  to  stay.  There  is  every 
argument  for,  no  argument  against  intravenous 
therapy.  Once  admitted  that  the  blood  is  the  me- 
dium in  which  medicine  is  carried  to  every  organ, 
tissue  and  cell  of  the  body,  there  is  nothing  to  con- 
tradict the  conclusion  that  to  introduce  medicine  di- 
rectly into  the  blood  is  simpler,  svirer  and  even  safer 
than  to  depend  upon  its  reaching  the  circulating 
medium  after  having  run  the  gauntlet  of  digestion, 
alteration,  and  modification  by  its  passage  along  the 
gastrointestinal  tract.  There  is  a  saving  of  time  and 
effort  and  a  prevention  of  imperfect  action  and 
uncertain  effect. 

At  the  present  time  and  under  modern  conditions 
there  is  absolutely  no  logical  or  actual  argument  or 
objection  to  the  intravenous  method  of  drug  ad- 
ministration. The  work  of  certain  pharmaceutical 
chemists  has  made  possible  the  preparation  and  sup- 
ply of  solutions  containing  indicated  drugs  in  a 
form  entirely  safe  for  intravenous  administration. 
Thousands  of  physicians  all  over  the  world  are 
taking  up  and  employing  the  intravenous  method. 
As  the  result  of  an  extended  experience  I  can  defi- 
nitely state  that  dangerous  reactions  or  uncertain  or 
negative  results  are  conspicuous  by  their  absence, 


providing  properly  prepared  solutions  are  employed. 
Their  technic  is  simple,  so  simple,  in  fact,  that  a 
physician  who  is  not  qualified  or  able  to  make  an 
intravenous  injection  is  not  qualified  to  practise 
medicine  at  all. 

The  number  of  physicians  who  depend  and  insist 
upon  the  intravenous  method  for  administering 
iron  and  arsenic  in  anemia  is  steadily  increasing. 
The  same  is  true  of  the  intravenous  use  of  iodides, 
especially  of  sodium  iodide.  Furthermore,  and  as 
would  naturally  and  logically  be  expected,  the  intra- 
venous method  was  quickly  applied  to  the  adminis- 
tration of  quinine  in  malaria.  As  a  matter  of  fact, 
it  is  in  malaria  that  the  proof  of  the  superiority  of 
intravenous  therapy  over  all  other  methods  is  being 
conclusively  established. 

The  treatment  of  malaria  in  its  various  fofms  is 
by  no  means  simple,  and,  if  one  may  judge  from  the 
literature  regarding  it,  in  many  cas^  unsatisfactory. 
Quinine,  while  it  was  long  ago  hailed  as  a  specific 
for  malaria,  does  not  always  act  as  such.  IMore- 
over,  there  is  in  malaria  another  element  always 
present  which,  in  a  general  way,  may  be  referred  to 
as  anemia,  which  complicates  matters,  and  which 
almost  always  requires  careful  treatment.  There 
has  been  a  change  in  recent  years  in  the  interpreta- 
tion of  the  meaning  of  the  classic  symptoms  of 
malaria — the  chill,  the  fever  and  the  sweat.  These 
used  to  be  attributed  to  the  development  of  the 
Plasmodium  and  the  hatching  out  of  a  brood  of 
Plasmodia  in  the  blood  stream.  Recent  observations, 
however,  go  to  show  that  at  this  stage  the  er>1;hro- 
cyte  is  hemolyzed.  Hence  the  destruction  of  the 
er3-throc}-te  with  the  resulting  hemolysis  is  probably 
the  cause  of  the  reaction  rather  than  the  digestion 
of  the  protein  of  the  plasmodium.  Hemolyzed  ery- 
throcyte is  known  to  cause  serious  reaction  and  to 
have  even  caused  death.  Hence,  conclusion  points 
to  the  resistance  of  the  erythrocyte  to  the  malarial 
Plasmodium  as  the  factor  that  determines  the  extent 
and  severity  of  the  malarial  attack.  It  is  known 
that  each  malarial  attack  is  followed  by  evidence  of 
great  destruction  of  erythrocytes,  followed  by  per- 
sistent and  in  many  cases  profound  anemia.  Re- 
covery from  anemia  means  practically  recovery 
from  malaria.  Every  study  of  malaria  indicates 
that  tJie  destruction  of  the  red  cells  and  hemoglobin 
and  the  recovery  from  such  a  condition  is  a  true 
index  of  the  status  and  severity^  of  infection.  That 
this  is  true  is  indicated  by  the  fact  that  arsenic,  long 
recognized  as  a  valuable  remedy  in  malaria,  par- 
ticularly^ in  chronic  forms,  owes  its  therapeutic  value 
to  its  physiological  action  in  preventing  the  de- 
struction of  the  erythrocyte. 

The  red  corpuscle  is  the  chief  actor  in  malaria. 
It  is  not  alone  the  site  of  infection,  but  it  is  the  most 
active  agent  in  resisting  the  infection.  Observers 
have  reported  favorable  results  in  severe  malarial 
infection  from  the  use  of  salvarsan,  and  there  has 
been  placed  on  record  a  report  in  which  the  use  of 
mercury  was  followed  by  beneficial  results.  Con- 
sequently, in  the  consideration  of  the  effective 
treatment  of  malaria,  it  may  be  divided  into  two 
heads — first,  the  proper  and  most  effective  method 
of  administering  quinine  in  order  to  secure  its 
maximum  effect  upon  the  malarial  organism,  and 


September  11,  1920.] 


WYATT:   TREATMEXT  OF  MALARIA. 


367 


second,  and  quite  as  important,  the  administration 
of  iron  and  arsenic  (iron  cacodylate)  in  order  to  re- 
plenish the  supply  of  erythrocytes  and  hemoglobin. 
One  does  not  have  to  go  far  into  medical  literature 
before  finding  many  references  to  the  drawbacks  and 
inefficiency  of  the  administration  of  quinine,  in 
malaria,  by  the  mouth,  e.  g.,  ^lacGilchrist  (1)  de- 
clares that  very  little  quinine  is  absorbed  by  the 
stomach,  and  that  any  absorption  is  due  to  the 
fact  that  quinine  is  a  very  diffusible  substance. 

In  the  attempt  to  get  better  results  from  quinine 
than  are  obtainable  from  its  administration  per  os, 
numerous  observers  recommend  its  use  by  subcu- 
taneous or  intramuscular  injection.  Definite  proof, 
clinical,  as  well  as  experimental,  showed,  however, 
that  when  a  concentrated  solution  of  a  quinine  salt, 
e.  g.,  five  or  ten  grains  in  thirty  minim  syringe,  is  in- 
jected into  the  muscles  or  under  the  skin,  most  of 
the  quinine  is  precipitated  at  the  site  of  the  injection, 
and  remains  there  for  many  hours.  The  tissues  at 
the  seat  of  injection  are  killed,  giving  rise  to  so- 
called  abscesses  and  fibrous  nodules,  or,  if  the  injec- 
tion is  made  very  superficially,  to  sloughing  and 
ulceration. 

It  was,  of  course,  inevitable  that  the  suggestion 
should  arise  that  the  intravenous  use  of  quinine  in 
malaria  would  prove  of  great  advantage.  Several 
surgeons  in  the  ^Medical  Corps  of  the  United  States 
Navy  resorted  to  the  intravenous  method  and  re- 
ported excellent  results. 

Thomson  (2)  made  still  further  contributions  to 
this  important  subject.  He  pointed  out  that  the  in- 
travenous route  for  the  administration  of  quinine 
in  m.alaria  was  first  used  almost  exclusively  in 
emergency  cases,  especially  those  in  which  the  pa- 
tients were  suffering  from  what  has  been  termed  per- 
nicious comatose  ren'iittent  malaria.  He  explained 
that  the  intravenous  method  had  other  advan- 
tages to  recommend  it ;  that  it  is  the  only  route 
by  which  one  can  concentrate  upon  the  parasite  and 
thereby  obtain  the  maximum  effect  at  the  optimum 
time.  Thomson  employed  the  twenty  per  cent, 
solution  of  the  bihydrochloride  of  quinine.  He 
concluded  that  the  intravenous  route  has  special 
advantages  in  the  treatment  of  malaria  during  the 
active  periods  of  the  disease.  By  this  means,  the 
full  quantity  of  quinine  given  can  be  concentrated 
against  the  parasite  at  the  moment  when  it  is  most 
susceptible  to  such  action  and  the  maximum  effect 
obtained. 

In  eighteen  consecutive  cases  of  malignant  ter- 
tian malaria  with  remittent  fever  and  with  ring 
forms  of  Plasmodium  falciparum  present  in  the 
peripheral  blood  a  single  intravenous  injection  of 
fifteen  grains  of  quinine  bihydrochloride  was  suf- 
ficient to  break  the  attack  in  every  case.  All  stages  of 
the  schizogenous  cycle  of  Plasmodium  vivax  present 
in  the  circulating  blood  were  directly  affected  by 
the  injection.  The  mature  gametoc}tes  of  Plasmo- 
dium vivax.  unlike  those  of  Plasmodium  falciparum, 
disappear  from  the  peripheral  blood  under  the  di- 
rect action  of  quinine  bihydrochloride  given  intra- 
venously. In  cases  of  benign  tertian  malaria,  the 
patient's  comfort  will  be  considered  without  the 
parasite  being  spared  if  the  first  intravenous  injec- 
tion be  given  at  the  very  end  of  a  severe  stage. 


Subsequent  intravenous  injections  should  be  timed 
to  be  given  at  what  would  have  been  about  the  be- 
ginning of  the  severe  stage  in  the  paroxysms  next 
in  order  had  the  cases  remained  untreated. 

In  an  original  communication  John  C.  Clark  (3) 
of  ^Memphis,  Tenn.,  discusses  the  intravenous  in- 
jection of  quinine  bihydrochloride  and  cacodylate 
of  iron  in  treatment  of  chronic  malaria.  He  re- 
ported his  experience,  both  as  to  the  results  obtained 
and  the  reactions  which  were  manifested.  In  fifty- 
seven  cases  of  chronic  malaria  seen  in  private  prac- 
tice in  the  year  1917,  467  intravenous  injections  of 
quinine  bihydrochloride  in  combination  with  caco- 
dylate were  given.  The  author  states  that  he  never 
saw  a  reaction  which  did  not  right  itself  within  the 
time  expected.  The  results  were  gratifying.  Of 
fifty-seven  patients  reported,  thirty-two  were  under 
treatment  for  forty  days  or  more ;  the  remaining 
twenty-five  patients  were  given  from  one  to  five 
injections  for  relief  only.  Of  the  thirty-two  pa- 
tients, twenty-seven  were  kept  under  observation 
and  in  only  two  instances  was  there  any  evidence  of 
a  relapse.  There  was  an  average  increase  of  red 
blood  cells  of  1,125,000  with  a  hemoglobin  increase 
of  about  forty  per  cent.  At  the  time  treatment  was 
discontinued,  it  was  impossible  to  demonstrate  the 
malarial  organism  in  any  form,  or  to  detect  any 
other  evidence  of  malaria. 

Carnot  (4)  commends  the  intravenous  route  as 
simple  and  not  at  all  dangerous,  when  it  is  a  ques- 
tion of  striking  quick  and  striking  hard.  He  states 
that  the  sterilizing  effect  of  the  quinine  is  reenforced 
by  this  route. 

L.  Rogers  (5)  states  that  the  intravenous  admin- 
istration of  quinine  in  primary  attacks  of  malaria 
appears  to  be  worthy  of  careful  trial,  because  a 
further  material  advantage  of  such  intravenous  ad- 
ministration is  likely  to  be  that  dangerously  large 
infections,  which  may  terminate  at  any  moment  in 
fatal  coma  under  oral  administration  of  quinine,  are 
likely  to  be  rapidly  controlled.  He  predicts  that  by 
this  method,  the  present  mortality  from  malaria 
should  be  reduced  to  practically  nothing. 

Knowles  (6)  asserts  that  the  intravenous  ad- 
ministration of  quinine  in  concentrated  solution  is 
the  quickest  and  surest  method  of  immediately  cut- 
ting short  a  febrile  attack  of  malaria.  It  appears  to 
be  a  perfectly  safe  method,  and  is  infinitely  pre- 
ferable to  intramuscular  injections  from  ever\-  point 
of  view.  He  declares  that  there  is  quite  a  sufficient 
amount  of  evidence  now  available  to  justify  the 
routine  and  extensive  use  of  quinine  intravenously. 

Barbary  (7)  reports  that  he  has  been  treating 
malaria  during  the  last  ten  months  by  intravenous 
injection.  He  has  treated  899  patients  at  the  mili- 
tary hospital  at  Xice,  and  comments  most  favor- 
ably on  the  prompt  and  effectual  action  of  this  route. 
The  injections  were  given  every  third  day  at  first 
and  then  at  five  day  intervals.  Hence,  it  will  be 
appreciated  that  the  use  of  quinine  intravenously 
in  the  treatment  of  malaria  has  long  passed  the  ex- 
perimental stage  and  is  coming  to  be  regarded  as 
the  most  efficient,  least  dangerous,  and  therefore, 
most  to  be  preferred  method.  It  may  be  assumed, 
however,  that  in  the  treatment  of  malaria,  whether 
in  the  acute  or  chronic  form,  the  intravenous  ad- 


3(j8 


iDjyy;    TREATMEXT  U/  MALARIA. 


LNf.w  Voric 
Medical  Journal. 


ministration  of  quinine  should  he  employed  with 
even-  exi)ectation  of  success,  so  far  as  any  effect 
upon  the  malarial  parasite  is  concerned.  There  re- 
mains, however,  the  element  of  anemia  which  is 
always  present  and  which  always  demands  or  should 
demand  careful  treatment. 

R.  Lawson  (8)  shows  that  nuiltiple  infection 
of  red  corpuscles  with  young  parasites  is  seen  in 
all  malarial  infections,  hut  is  found  most  frequently 
in  estivoautumnal  infections.  The  anemia  in  ma- 
larial infections  is  explained  in  Lawson's  opinion, 
hy  the  fact  that  each  parasite  destroys  several  red 
hlood  cells.  Reduction  (jf  hemoglohin  out  of  pro- 
])ortion  to  the  loss  of  red  corpuscles  is  explained  hy 
the  fact  that  there  is  always  a  ])artial  loss  of  hemo- 
glohin in  certain  of  the  surviving  corpuscles  due  to 
parasitic  action. 

Deilille  and  his  coworker  (9)  report  that  the 
hndings  in  the  malaria  contracted  hy  the  French 
troops  in  Macedonia  show  a  relative  frequency  of 
hemoglobinuria,  indicating  massive  destruction  of 
blood  corpuscles.  probal)ly  in  the  blood  stream,  as 
the  first  phase.  This  may  he  accom])anied  by  hem- 
orrhages from  the  mucosa. 

Xetter  (10)  reports  that  in  thirty-seven  malaria 
patients,  the  blood  corpuscles  displayed  greater  re- 
sisting powers  during  the  malarial  attacks  than  at 
other  times.  He  queries  whether  it  might  not  be 
possible  to  sustain  and  prolong  this  hy  other 
measures  to  combat  hemolysis.  The  query  \s 
answered  in  part  by  NefT.  He  reports  five 
cases  of  tertian  malaria  treated  with  arsenic  in- 
travenously. Neflf  states  that  there  is  room 
for  improvement  in  the  treatment  of  malaria  and 
that  the  disease  is  often  resistant  to  permanent  cure 
by  the  administration  of  quinine  alone.  Disappear- 
ance of  fever  is  often  taken  as  evidence  of  a  cure. 
Given  rapid  destruction  of  red  blood  corpuscles  and 
marked  reduction  in  hemoglobin,  the  suggestion  im- 
mediately presents  itself  that  in  iron  and  arsenic  a 
remedy  capal)le  of  accomplishing  the  second  indi- 
cation in  the  treatment  of  malaria,  viz.,  to  overcome 
the  anemia  and  restore  the  blood  to  its  normal  con- 
dition. It  has  long  been  known  and  recognized 
when  given  by  the  mouth  in  postmalarial  anemia. 


C 


In  view  of  recent  clinical  reports,  as  well  as  from  the 
theoretical  view  point,  there  is  every  reason  to  ex- 
pect better  results  in  a  shorter  length  of  time  when 
iron  and  arsenic  are  given  by  the  intravenous  route. 
Iron  and  arsenic  given  intravenously  have  been 
found  of  special  value  in  the  treatment  of  non- 
malarial  anemia;  e.  g.,  Geyser  (12)  reports  ten  cases 
treated  with  a  combination  of  iron  and  arsenic  given 
intravenously,  pointing  out  that  it  is  possible  to 
demonstrate  a  positive  increase  of  red  cells  after 
each  infection  and  that  results  occur  with  a  cer- 
tainty and  rapidity  that  all  their  efforts  have  hereto- 
fore failed  to  bring  about.  He  states  that  positive 
clinical  results  can  be  obtained  by  stimulating  the 
white  and  red  cells,  providing  a  remedy,  the  phar- 
macological action  of  which  is  known,  is  adminis- 
tered by  this  direct  method  into  the  blood  stream. 
Stern  (13  )  re])orts  over  100  cases  treated  with  iron 
and  arsenic  intravenously. 

pell.\(;k.\. 

AMiat  is  true  of  the  anemia  which  forms  such  a 
])rominent  feature  in  malaria  also  holds  true  of 
])ellagra,  which  is  invariably  accompanied  by  a  di- 
minished amount  of  hemoglobin  and  impaired  re- 
sistance on  the  part  of  the  erythrocyte.  Recovery 
from  pellagra  is  invariably  associated  with  recovery 
from  the  anemia,  which  is  its  characteristic  feature. 
Perhaps  the  main  object  of  treatment  is  to  increase 
the  number,  quality  and  resisting  power  of  the 
erythrocytes,  together  with  an  increase  in  hemoglobin 
and  the  bringing  the  blood  back  to  normal.  For  ol)- 
vious  reasons,  iron  and  arsenic  may  be  relied  upon 
to  do  this,  provided  they  can  be  introduced  into 
the  body  in  such  a  way  as  to  enable  them  to  exert 
a  thorough  and  free  physiological  and  therapeutic 
efl^ect.  This  means,  naturally,  by  the  intravenous 
route. 

Perhaps  the  greatest  objection  that  has  l)een  raised 
to  the  employment  of  quinine,  iron  or  arsenic,  in- 
travenously, has  had  to  do  with  the  difficulty  and 
possible  danger  incurred  in  the  extemporaneous 
])reparation  of  solutions  of  these  drugs  for  such 
tise.  Experience  with  the  administration  of  sal- 
varsan  and  others  of  this  group  has  impressed 
upon  the  minds  of  many  physicians  the  fact  that 


E  I. — Tertian  Malaria  : 
Patient  had  been  having  cliills  six  weeks,  very  ema- 
ciated. Intravenous  injection  ciuinine  May  25th,  26th, 
27th,  28th.  29th,  June  Lst.  3rd,  9th,  16th,  23rd,  alter- 
nating with  5  c.  c.  iron  and  arsenic  solution  at  inter- 
vals twice  a  week  until  .\ugust  9.  1919. 
Case  II. — Quotidian  Type  : 

Intravenous  injection  5  c.  c.  quinine  every  day  for  seven 
days.    Alternating  twice  a  week  each  with  5  c.  c.  iron 
and  arsenic  solution  vintil  .\ugust  7.  1919. 
C.\SE  III. — Quartan  Type: 

Intravenous  injection  every  day  for  seven  days;  every 
other  day  for  fourteen  days  alternating  with  iron  and 
arsenic,  5  c.  c.  solution,  until  August  27th. 
C.\SE  IV. — Quartan  Type: 

Intravenous  injections  5  c.  c.  quinine  solution  every  day 
for  seven  days,  every  other  day  for  twelve  days.  Then 
alternating  twice  a  week  with  5  c.  c.  solution  iron  and 
arsenic  until  July  19,  1919. 
C.\SE  V. — Quartan  Type  : 

Intravenous  injection  5  c.  c.  quinine  every  day  for 
eight  days,  every  other  day  for  sixteen  days.  Then 
twice  a  week,  alternating  with  iron  and  arsenic  solution 
5  c.  c.  once  a  week  until  .\ugiLst  27.  1919. 


May  25.  1919. 
red  cell  count,  3,000,000 
hemoglobin,  60  per  cent, 
white  cell  count,  18.000 


June  2,  1919. 
red  cell  count,  4,500,000 
hemoglobin,  70  per  cent, 
white  cell  count,  3,500 

June  5.  1919. 
red  cell  count,  3.400,000 
hemoglobin,  40  per  cent, 
white  cell  count,  2,000. 

June  7,  1919. 
red  cell  count.  4,100,000 
hemoglobin.  75  per  cent, 
white  cell  count,  4,000 

June  6,  1919. 
red  cell  count.  4,200,000 
hemoglobin,  55  per  cent, 
white  cell  count,  10,000 


August  27,  1919. 
5,200,000 
98  per  cent. 
6,500 


August  7,  1919. 
6,180,000 
95  per  cent. 

8,000 
August  27,  1919 
5,000,000 
100  per  cent. 
6,000 


19,  1919. 
5,400,000 
95  per  cent. 
7,000 


July 


August  27,  1919. 
6,000,000 
90  per  cent. 
6,000 


Sfi>tcmb'.r  il.  1920. J 


CUMSTOX:   I XTRAJ'EXOUS  MEDICATION. 


309 


unless  special  precautions  are  observed  and  correct 
technic  followed,  dangerous  reactions  are  to  be 
expected. 

My  experience'  with  the  intravenous  method  ex- 
tends over  a  period  of  two  years,  during  which  time 
I  have  treated  thirty-two  cases  of  malaria.  Quinine 
was  administered  in  the  form  of  a  five  c.  c.  solution 
containing  five  tenths  grain  of  quinine  bihydro- 
chloride.  The  iron  and  arsenic  were  contained  in 
tlie  five  c.  c.  solution  representing  sixty-four  nig. 
The  number  of  cases  treated  with  iron  and  arsenic 
alone  and  the  results  that  I  observed,  justify  me 
in  stating  that  not  alone  is  the  intravenous  method 
indicated  in  the  treatment  of  malaria,  but  the  results 
obtained  lead  one  to  conclude  that  •  the  ac- 
tion of  quinine  in  malaria  is  due  to  its  effect  upon  the 
red  corpu.scle  rather  than  to  a  plasmoidal  action. 
The  fact  that  iron  and  arsenic  stimulate  an  increase 
in  the  number  of  er\throcytes  and  their  resistance, 
is  well  founded  in  medical  experience.  However, 
the  prominently  positive  and  imiform  results  from 
the  intravenous  administration  of  iron  and  ar.senic 
as  indicated  in  my  experience  cause  me  to  state  that 
this  is  the  ideal  treatment  of  malaria.  The  case 
histories  given  indicate  the  results  I  have  obtained. 

These  cases  were  selected  out  of  a  total  of  thirty- 
two.  Twenty-seven  similar  cases  treated  by  the 
same  method  have  convinced  me  that  the  action  of 
quinine  given  intravenously  upon  the  plasmodium  is 
evident  during  every  stage  of  the  life  cvcle  in  man. 
The  ettect  of  the  drug  varies  with  the  time  of  ad- 
ministration and  the  size  of  dose  given.  If  quinine  is 
continued,  the  blood  being  examined  at  regular  in- 
tervals, it  will  be  found  the  plasmodia  diminished 
greatly  in  number  up  to  the  time  of  sporulation, 
])roving  that  in  every  stage  of  the  growth,  quinine  is 
capable  <\i  destroying  them.  To  combat  the  anemia, 
and  re?tore  the  individual  to  his  normal  tone,  I  have 
always  given  intravenously,  five  c.  c.  .solution  of 
iron  and  arsenic  until  hemoglobin  and  blood  count 
hecome  normal.  kekerf.xces. 

1.  M.«icGii.rnKiST :  Indian  Medical  Gazelle.  October. 
1917.  _ 

2.  iHiiMsox:  Journal  of  Ihc  Royal  Anny  Medical 
Corps. 

^.  r^ARK.  John  C.  :  Tlieraf'eulic  Gazette.  July  15.  1918. 

4.  Carnot  :  Paris  medical. 

b.  RtRiERS.  L. :  British  Medical  Journal,  September  15. 
1919. 

6.  Knowlks  :  Indian  Journal  of  Medical  Research.  Jan- 
uary, 1919. 

7.  B.^RB.^RV  :  Bulletin  de  V Academic  de  Medicine .  Paris. 

8.  L.wvsox.  M.  R.  :  Journal  of  E.rperimental  Medicine. 
June,  1918. 

9.  Deilille  :  Bulletin  of  the  Medical  Association  of 
Hospitals.  Paris. 

10.  X'elter  :  Rcvista  Medica  dc  Bogota.  Januarv-March. 
1919. 

11.  Xeff:  Journal  .1.  M.  A..  October  7,  1916. 

12.  Geyser:  New  York  Medic.\l  Journal.  Tune  7,  1919. 

13.  Sterx:  Medical  Record.  Tuly  5.  1919. 


Treatment  of  Entropion. — Jacqueau  (Lyoii 
medical.  March  25,  1920)  reports  a  case  of  spas- 
modic entropion  by  the  use  of  a  Michel  clamp  fixed 
in  a  vertical  position  above  the  eyelid.  The  meas- 
ure is  recommended  as  very  simple,  practically 
j)ainless.  requiring  no  dressing,  and  giving  the  best 
results,  notably  in  postoperative  spasmodic  entro- 
pion. 


IXTILAVEXOUS  MEDICATION. 
Bv  Charles  Greene  Cumston,  M.  D., 
Geneva,  Switzerland. 

Given  the  great  interest  shown  in.  and  the  con- 
siderable progress  made  of  late  in  intravenous  medi- 
cation, I  propose  to  offer  a  brief  review  of  the  sub- 
ject as  it  stands  on  the  Continent.  It  is  true  that 
many  physicians  are  perplexed  by  the  simple  phe- 
nomena following  intravenous  injections  of  various 
substances,  given  under  the  names  of  hemoclasic 
crisis,  peptonic  or  anaphylactic  shock,  but  in  order 
not  to  confuse  the  subject  still  further  by  discussing 
the  differential  reactions,  the  experimental  results 
shall  not  be  referred  to — although  many  are  of  un- 
questionable interest — and,  therefore,  only  the  clin- 
ical aspects  need  be  examined,  passing  in  review 
the  simplest  to  the  most  complex  injectable  sub- 
stances with  the  opinions  of  the  observers  most  com- 
petent in  the  matter. 

In  septicemias  resulting  from  wounds,  especially 
war  injuries,  Audain  and  Masmonteil  have  em- 
ployed intravenous  injections  of  an  isotonic  solution 
of  sugar — glucose,  saccharose  or  lactose — as  a  leu- 
cogenous  procedure  which,  by  increasing  the  num- 
ber of  leucocytes,  heightens  the  organic  resistance  to 
infection.  During  the  past  year,  Humbert,  of 
Geneva,  has  also  resorted  to  intravenous  injections 
of  sugar  in  pulmonarv  tuberculosis  with  good  re- 
sults. 

The  leucogenous  action  of  sugar  given  intraven- 
ously is,  in  reality,  quite  remarkable,  because  within 
thirty  minutes  after  the  injection  the  leucocyte 
count  reaches  from  seven  to  twenty-five  thousand 
and  remains  at  this  figure  for  two  to  three  hours, 
afterwards  falling  to  about  fifteen  thousand.  Ac- 
cording to  Audain  and  Masmonteil.  the  injections 
produce  quite  as  marked  reactions  as  the  colloid 
metals,  sodium  nucleinate,  etc.  The  leucogenous 
action  manifests  itself  clinically  shortlv  after  the  in- 
jection by  a  transitory  rise  of  temperature  of  a  few 
tenths  of  one  degree,  ushered  in  by  a  severe  chill 
and  followed  by  a .  sudoral  crisis  similar  to  a 
paroxysm  of  malaria.  The  thermic  maximum  cor- 
responds with  the  maximal  phase  of  hyperleucocy- 
tosis.  but  these  phenomena  are  those  met  with  fol- 
lowing the  injection  of  any  leucogenous  substance, 
es])ecially  when  given  intravenously.  The  phenom- 
ena of  reaction  are  proof  of  leucocytic  changes  and 
are  consequent  upon  the  sudden  and  massive  intro- 
duction of  foreign  bodies  into  the  circulation. 

It  is  not  to  our  purpose  to  enter  here  into  a  dis- 
cussion of  the  scientific  aspects  of  the  leucogenous 
action.  Suffice  it  to  say  that  intravenous  injections 
of  sugar  first  produce  a  chill,  a  slight  rise  of  tem- 
j)erature  and  sudation,  accompanied  by  leucocytosis 
and  afterwards  by  a  fall  in  the  temperature,  with  a 
normal  pulse  rate,  profuse  diuresis,  and  an  ameliora- 
tion of  the  principal  symptoms,  but  sometimes  fol- 
lowed by  a  painless  abacterial  abscess.  These  results 
may  be  permanent,  but  usually  the  injections  must 
be  repeated  several  times. 

In  a  lecture  delivered  at  the  Paris  Faculty  of 
Medicine  last  year  on  intravenous  injections  of  pep- 
tone in  infectious  diseases.  Professor  Nolf,  of  Liege, 
pointed  out  the  phenomena  which  resulted,  as  fol- 
lows.  "The  immediate  result  depends  upon  the  dose 


370 


CUMSTON 


INTRAVENOUS  MEDICATION. 


[New  York 
Medical  Journal. 


injected.  If  it  is  equal  tc  or  less  than  one  centigram 
for  each  kilogram  of  the  patient's  weight — a  patient 
of  medium  build  receiving  from  five  to  six  c.  c. 
of  a  ten  per  cent,  peptone  solution — a  rise  of  tem- 
perature usually  occurs  one  or  two  hours  after  the 
injection  and  lasts  for  several  hours.  If  the  dose 
is  a  little  stronger — from  seven  to  ten  c.  c.  of  a  ten 
per  cent,  solution — the  same  initial  rise  is  observed 
and  may  be  ushered  in  by  a  more  intense  chill,  the 
onset  being  usually  about  one  hour  following  the 
injection.  The  chill  lasts  from  twenty  to  thirty 
minutes  and  is  followed  by  a  phase  of  heat  of  ioi° 
to  102°  F.,  after  which  a  phase  of  sudation  is  prone 
to  occur.  When  the  sweating  takes  place,  the  tem- 
perature will  have  already  fallen  a  little,  but  con- 
tinues to  drop  rapidly  as  the  sudation  increases,  so 
that  within  three  or  four  hours  after  the  onset  of 
the  sweat  it  will  have  become  normal  or  nearly  so, 
and  remains  normal  for  some  time." 

The  thermic  drop  referred  to  by  Nolf  is  accom- 
panied by  a  general  amelioration;  in  typhoid  fever 
especially,  the  abdominal  distention,  prostration,  de- 
lirium, insomnia,  and  signs  of  bronchitis  diminish 
or  even  disappear.  It  is  hardly  necessary  to  say  that 
in  two  or  three  days  the  phenomena  of  the  infec- 
tious process  return,  but  if  the  injections  are  given 
every  second  day  a  marked  drop  in  the  temperature 
will  be  maintained  which  in  itself  is  advantageous 
to  the  patient. 

Nolf  does  not  insist  upon  the  leucocytic  reaction, 
but  it  is  known  that  it  exists,  both  by  experimental 
work  and  direct  clinical  examination  of  patients 
having  received  peptone  injections.  On  the  other 
hand,  Nolf  refers  to  certain  disadvantages  of  the 
injections  when  they  are  given  too  often  or  in  too 
large  doses  in  profoundly  infected  subjects.  A  syn- 
drome develops  consisting  of  dyspnea,  tachycardia, 
hypotension,  distress,  and  sometimes  a  more  or  less 
extensive  urticaria,  which  Nolf  compares  to  ana- 
phylactic shock,  but  which  he  nevertheless  designates 
under  the  term  of  peptonic  shock. 

Peptonic  shock  is,  in  reality,  a  German  invention, 
which  was  put  forth  by  Schinidt-lMuhlheim  if  cre- 
dence is  to  be  placed  on  German  assertion.  At  all 
events,  it  has  been  studied  in  France  by  Gley,  Hedon 
and  especially  Delezenne,  the  latter  showing  that  the 
shock  may  be  brought  about  by  very  different  sub- 
stances— toxins,  vaccines,  extracts  of  organs.  But 
why  peptonic  shock,  since  Nolf  himself  admits  that 
intravenous  injections  of  colloidal  metals  give  rise 
to  similar  phenomena?  To  this  Nolf  replies  that 
the  colloidal  metals  are  stabiHzed  with  organic  sub- 
stances— gelatin,  serum,  peptone — and  it  is  these 
substances  and  not  the  colloidal  metals  which  give 
rise  to  the  accidents  which  follow.  Unfortunately 
this  argument  is  not  acceptable,  as  Laumonier  justly 
points  out,  because  Bredig's  colloids — which  contain 
nothing  but  the  powdered  metal  and  pure  water — 
produce  reactions  in  every  point  comparable  to  those 
resulting  from  stabilized  colloids,  but  also  to  pep- 
tones and  sera. 

Briefly,  as  to  the  nature  of  peptonic  shock,  all 
that  is  essential  to  remember  is  that  intravenous  in- 
jections of  peptone  first  give  rise  to  a  chill,  then  to 
a  rise  of  temperature  and  sudation,  as  well  as  to 
various  forms  of  distress,  hypotension,  and  tachy- 


cardia, grouped  under  the  name  of  peptonic  shock, 
and  accompanied  by  a  hemoclasic  crisis — leucopenia, 
hemolysis,  etc. — which  shall  be  referred  to  later  on ; 
then  a  thermic  drop  and  an  improvement  in  the  gen- 
eral symptoms  lasting,  in  the  average  case,  for  two 
to  three  days.  It  is  also  to  be  observed  that  the 
peptone  injected  is  soluble  and  assimilable  as 
an  ordinary  food,  but  it  is  supposed  to  have  the 
property  of  an  antigen,  that  is  to  say,  when  injected 
into  the  organism  it  produces  new  specific  antagon- 
istic bodies,  a  conception  whose  insufficiency  shall  be 
shown  later  on. 

Of  late,  serotherapy,  autoserotherapy  and  plasmo- 
therapy  have  been  frequently  resorted  to.  They 
have  been  utilized  especially  during  the  epidemic  of 
influenza  in  1918.  Among  these  various  trials, 
whose  results  are,  in  reality,  absolutely  comparable, 
that  of  Lesne,  Brodin  and  Saint-Girons  may  be 
selected,  since  it  is  one  of  those  which  offers  the 
broadest  field  for  interesting  consideration.  It  con- 
sists in  intravenous  injections  of  from  fifty  to  two 
hundred  and  fifty  c.  c.  (maximum  dose)  of  blood 
plasma  of  convalescent  subjects,  normal  subjects  or 
even  autoplasma,  in  patients  presenting  complica- 
tions during  influenza  or  typhoid.  When  the  patient 
reacts,  which  does  not  always  happen,  the  phenom- 
ena already  referred  to  develop. 

Most  observers  maintain  that,  in  a  general  way, 
at  the  end  of  from  fifteen  to  sixty  minutes  there  is 
a  general  chill  and  a  sensation  of  cold  with  head- 
ache. Then  the  rectal  temperature  goes  up  to  101° 
to  102°  F.,  even  to  106°  F.,  the  pulse  rate  at  the 
same  time  increases,  while  the  blood  pressure  de- 
creases. This  state  lasts  from  twenty  to  forty  min- 
utes, then  the  chill  subsides,  the  headache  disap- 
pears, sudation  takes  place,  and  the  patient  has  a 
sense  of  wellbeing.  The  temperature  quickly  drops 
below  its  former  level  and  ranges  around  98.6°  F., 
where  it  will  remain  or  not,  according  to  the  case. 
This  reaction  is  identical  with  that  following  the 
injection  of  horse  serum  in  septicemia.  It  is  also 
like  Nolf's  peptone  reaction  and  near  to  anaphylactic 
shock,  whose  vascular  blood  manifestations  have 
been  comprised  under  the  name  of  hemoclasic  crises 
by  Widal,  Abrami  and  Brissard  It  is  to  be  re- 
marked that  Lesne,  Brodin  and  Saint-Girons  admit 
that  their  injections  of  plasma  are  in  no  way  ana- 
phylactic and  they  believe  that  the  plasma  is  less 
toxic  than  the  serum  and  is  to  be  preferred  to  total 
blood,  whose  red  blood  corpuscles  act  as  foreign 
bodies.  This  interpretation  is,  so  far  as  it  goes, 
exact,  but  should  be  extended  to  heteroplasma,  as 
well  as  to  autoplasma  and  autoserum,  the  mere  fact 
of  being  extracts  of  the  organism  making  these 
bodies  different  from  living  plasma  from  the  phy- 
sicochemical  viewpoint. 

Briefly,  what  is  to  be  remembered  is  that  intra- 
venous injections  of  plasma  first  produce  a  chill, 
then  headache  and  hypotension,  a  rise  in  tempera- 
ture, sudation,  then  a  drop  in  the  temperature  with 
general  improvement  of  the  patient's  general  condi- 
tion of  variable  duration — sometimes  permanent. 
The  observers  last  mentioned  do  not  seem  to  have 
specially  considered  the  leucocytic  reaction,  but  it 
exists  since  they  regard  the  reaction  observed  after 
injection  of  plasma  as  similar  to  peptonic  shock  and 


September  11,  1920.J 


HAYS:  EQUIPMENT  FOR  RURAL  PHYSICIAN. 


371 


hemoclasic  crisis,  in  which  the  blood  undergoes  lytic, 
and  afterwards,  hematopoietic  changes. 

Without  referring  to  many  other  substances,  such 
as  sodium  nucleinate,  quinine,  the  newer  arsenical 
products,  specific  sera,  etc.,  and  their  reactions  fol- 
lowing intravenous  injection,  the  reactions  to  which 
intravenous  injections  of  more  or  less  fine  particles 
of  insoluble  products  give  rise  will  next  receive  our 
attention. 

It  is  known  that  the  colloids,  Bredig's  for  ex- 
ample, are  heterogenous  systems  formed  by  ultra- 
microscopic  particles  carrying  an  electric  charge  of 
ionic  origin  in  stable  suspension  in  water,  and  that 
when  introduced  into  the  veins  they  produce  reac- 
tions identical  with  those  already  mentioned  and  in 
particular,  a  hematic  and  leucocytic  reaction  of  high 
grade.  In  this  respect  the  pure  colloids,  stabilized 
colloids  and  collobiases — which  are  not  true  colloids 
but  suspensions  of  finely  powdered  bodies  in  a 
gummy  colloid — act  in  exactly  the  same  fashion. 
Consequently,  Audain  and  ^^lasmonteil  could,  with 
perfect  propriety,  regard  the  leucogenous  action  of 
sugar  given  intravenously  as  the  same  as  that  of  col- 
loidal metals.  Xolf  compares  the  reactions  of 
intravenous  injections  of  colloids  to  peptonic 
shock,  reactions  which  he  attributes — wrongly 
according  to  Laumonier — to  the  presence  of  stabil- 
izing bodies.  Even  if  these  were  of  peptonic  nature, 
their  quantity  would  be  foo  small  to  cause  any  eflfect 
from  the  peptone  which  exacts,  in  order  to  occur, 
from  fifty  centigrams  to  one  gram  of  peptone  to 
each  kilogram  of  the  weight  of  the  subject.  How- 
ever, let  it  be  said  that  the  reactions  to  which  the 
collobiases  give  rise  are  usually  more  severe  than 
those  produced  by  the  colloids — stabilized  or  not — 
and  this  difference  seems  to  be  due  to  the  inequality 
of  the  particles  of  the  collobiases.  Nevertheless,  the 
phenomena  of  reaction  are,  in  all  cases,  quite  alike, 
whether  they  are  colloids,  collobiases,  sugar,  pep- 
tones, sera,  or  plasma. 

Of  the  work  done  in  the  United  States  with  emul- 
sions of  dead  bacteria  by  Cowie,  Beaven,  and  others 
I  shall  not  speak,  as  you  have  first  hand  information 
on  the  subject,  neither  need  mention  be  made  of 
Drinkler  and  Brittingham's  work  with  transfusion 
of  citrated  blood  for  the  like  reason.  I  would  point 
out,  how-ever,  that  Cowie  and  Beavan  give  the  name 
of  proteinotherapy  to  their  procedure  and  attribute 
a  large  part  to  proteinic  shock — in  other  words  to 
the  effects  of  peptone.  But  in  the  former  case  the 
protein  is  injected  in  the  form  of  normally  insoluble 
bacterial  bodies ;  nevertheless,  both  reactions  and 
therapeutic  effects  are  and  remain  quite  the  same. 

In  conclusion,  I  would  refer  to  tlic  pathogenesis 
of  malarial  paroxysms,  in  the  light  of  recent  studies 
made  by  Abrami  and  Senevet.  These  observers 
have  showm  that  the  malarial  paroxysm  is  the  conse- 
quence of  a  hemoclasic  shock  identical  with  that 
resulting  from  the  sudden  intravenous  introduction 
of  any  foreign  matter  and  especially  of  metallic  col- 
loids. In  both  cases  a  vasculosanguineous  crisis 
takes  place,  composed  of  leucopenia  with  inversion 
of  the  leucocytic  formula,  rarefaction  of  the  hemat- 
oblasts,  hypercoagulability  of  the  blood  and  hypoten- 
sion, soon  followed  by  chills,  then  fever,  and  finally 
sudation.    The  satellite  symptoms  of  the  paroxysm 


— or  of  a  colloidal  injection — paleness,  nausea,  col- 
lapse and  urticaria,  result  in  reality  not  from 
specific  intoxication,  but  from  the  hemoclasic  crisis 
whose  vulgar  manifestations  it  merely  expresses, 
and  this  crisis  occurs  under  the  influence  of  the  sud- 
den innoad  of  the  merozoites  at  the  time  when  fission 
of  the  schizont  occurs.  This  pathogenesis  of  the 
malarial  paroxysm  appears  to  be  quite  logical,  while 
clinically  there  is  a  perfect  similarity  between  this 
paroxysm  and  the  colloidal  reaction. 

No  matter  what  substance  is  injected  into  the 
blood  there  always  follows  an  identical  vasculosan- 
guineous crisis  with  nervous  and  febrile  manifesta- 
tions, followed  by  a  hematic  and  leucocytic  reaction, 
then  a  return  to  the  normal  state.  It  is  a  reaction 
of  defense  against  the  sudden  introduction  of  for- 
eign bodies  into  the  blood.  This  diaphylaxis  occurs 
no  matter  what  foreign  body  enters  the  circulation. 
There  is  no  peptonic,  seric  or  proteinic  shock,  but 
simply  a  hemoclasic  crisis  common  to  all,  against 
which  the  organism  reacts  always  in  the  same 
fashion. 

Intravenous  injections  do  not  always  result  suc- 
cessfully, first,  because  the  subject  may  not  react 
because  he  is  worn  out  by  the  infectious  process 
from  which  he  is  suft'ering — his  diaphylaxis  is  abol- 
ished. Therefore,  the  intravenous  injection  is  use- 
less. Secondly,  certain  individuals  are  either  very 
sensitive  or  very  refractory  to  such  bodies ;  conse- 
quently the  reactions  are  very  violent,  even  fatal  at 
times  or  else  they  are  nil,  although  the  defenses  of 
the  organism  are  not  completely  inhibited.  In  these 
circumstances,  experience '  shows  that  by  changing 
the  nature  of  the  substance  injected,  better  results 
may  be  obtained. 


PROPER    EQUIPMENT    FOR    A  RUIL\L 
PHYSICIAN. 

By  MEL\^LLE  A.  Hays,  M.  D., 
New  York. 

Aside  from  the  office  furniture  (including  ex- 
amining chair  or  table)  which  every  physician  re- 
quires, the  equipment  of  a  rural  physician  will 
depend  entirely  on  whether  he  is  going  to  rely  on 
his  own  ability  to  practice  medicine  fully  and  con- 
scientiously, or  is  going  to  depend  largely  on 
laboratories,  specialists,  and  hospitals  (near  or  re- 
mote) for  a  great  deal  of  assistance;  it  will  also  be 
partly  governed  by  the  presence  or  absence  of  a 
reliable  drug  store  where  prescriptions  may  be  prop- 
erly compounded.  In  the  absence  of  a  drug  store, 
the  physician  wall  be  compelled  to  carry  and  dis-- 
pense  his  own  medicines.  These  can  be  secured, 
largely  in  tablet  form  to  be  dispensed  as  such  or 
to  be  made  into  solutions,  from  one  of  the  large 
drug  supply  houses.  The  variety  of  remedies  car- 
ried and  used  will  depend  entirely  on  the  average 
type  of  diseases  to  be  treated,  and  the  physician's 
own  views  on  therapeutics. 

If  the  physician  is  going  to  depend  for  assistance 
on  laboratories,  specialists,  and  hospitals,  he  will 
require,  aside  from  necessary  medicines,  only  the 
ordinary  diagnostic  instruments  (including  stetho- 
scope, sphygmomanometer,  etc.),  a  pocket  case  of 


372 


LONDOX 


LETTER. 


[New  York 
Medical  Journal. 


surgical  instruments,  and  a  full  supply  ot  surgical 
dressings — gauze.  absorbent  cotton,  bandages, 
splints,  antiseptics,  ointments  and  dusting  powders : 
his  serious  or  puzzling  cases  will  be  sent  to  a  spe- 
cialist or  a  hospital,  and  his  income  will  be  reduced. 

The  up  to  date  physician  will  do  most  of  his 
own  work,  and  will  only  refer  exceptional  or  very 
serious  cases  to  specialists  or  hospitals.  His  equip- 
ment will  necessarily  include  the  following : 

Diacpwstic. — Stethoscope  :  standard  sphygmo- 
manometer: headlight  (electric  battery),  or  mirror, 
with  necessary  specula,  for  exaiuining  nose,  throat, 
ears,  vagina,  and  rectum  :  microscope  with  •  neces- 
sary slides,  cover  glasses,  and  stains :  uranalysis  out- 
fit with  a  suitable  centrifuge  :■  outfit  for  W  idal  re- 
action and  outfit  for  examining  gastric  contents : 
suitable  aspirating  syringe  and  needles ;  materials 
for  special  tests  for  tuberculosis ;  and  other  aids  as 
the  occasion  arises. 

Medical. — If  there  is  a  reliable  drug  store  near 
by.  the  medical  equipment  will  include  only  hypoder- 
mic syringe  and  needles,  with  necessary  tablets  for 
emergency  and  other  use :  in  the  absence  of  such 
drug  store,  the  physician  will  necessarily  be  com- 
pelled to  carry  and  dispense  a  full  line  of  thera- 
peutic agencies. 

Obstetrical  and  (jynecological. — This  will  include 
suitable  obstetrical  forceps :  ether  and  chloroform  : 
pituitrin  in  ampoules ;  ergot ;  needles,  sutures,  and 
ligatures;  disinfectant  for  hands:  dilating  bag  for 
use  in  placenta  pra?via :  compact  gynecological  oper- 
ating set :  vaginal  specula :  special  remedies  for 
local  use :  and  gauze  packing  strips. 

Surgical. — This  will  include  a  small  portable  and 
comjiact  operating  set  for  general  use  (similar  to 
the  one  furnished  by  the  U.  S.  Army)  ;  pocket 
case  for  emergencies ;  needles,  sutures,  and  liga- 
tures:  gauze  (plain  and  medicated):  bandages 
(gauze,  cotton,  and  plaster  of  Paris)  and  absorbent 
cotton:  splints:  antiseptics;  special  instruments  for 
nose  and  throat  work  ( tonsillotomes.  adenoid  cur- 
ettes, etc. )  :  anesthetics  ( local  and  general )  and  ap- 
pliances for  administering  or  using  them  ;  special 
liypodermic  syringe  and  needles  for  administration 
of  mercury  preparations  in  the  treatment  of  syphi- 
lis; irrigating  appliances  for  treatment  of  gonor- 
rhea :  apparatus  for  administration  of  salvarsan : 
apparatus  for  transfusions :  and  an  aspirating  set 
for  general  use. 

Special. — Spray  apparatus  (  either  hand  atomiz- 
ers or  compressed  air  tank )  is  necesary  for  the 
treatment  of  nose  and  throat  afTections.  A  small 
<)])tical  trial  set  is  another  essential  which  will  add 
to  the  efficiency  and  income  of  the  physician  ;  its 
use  my  be  easily  learned.  If  there  is  an  available 
supply  of  electric  current,  there  can  be  secured  and 
used  a  cabinet  which  is  supplied  with  the  appli- 
ances for  diagnostic  and  therapeutic  work,  includ- 
ing an  X  ray  outfit.  Special  work  should  be  sent 
to  a  reliable  laborat')ry. 

The  entire  ecjuipment  as  eniunerated  will  not 
necessarily  be  required  itumediately  upon  beginning 
jiractice,  iDut  the  essentials  should  be  secured,  and 
the  other  items  added  as  the  occasion  arises.  Some 
means  of  quick  transportation,  either  horse  or  auto- 
mobile, is  a])solutelv  neces.sarv  in  all  rural  practice. 


LONDOX  LETTER. 
(I'roiii  our  oti'H  correspondent ) 

The  McctiiKj  of  the  British  Medical  Associntion  at 
Coinhridiie. 

London",  July  ^,  igso. 

The  last  time  the  British  Medical  Association 
met  was  in  the  far  northern  L'niversity  town  of 
Aberdeen  in  the  fateful  year  of  1914,  shortly  be- 
fore the  outbreak  of  the  world  war,  immediately 
after  the  Congress  of  Surgeons'of  North  America 
was  held  in  London  under  the  j^residency  ■  of  Dr. 
|.  I).  Murphy,  of  Chicago.  I  attended  that 
meeting  and  how  well  I  recall  that  the  air  seemed 
charged  with  electricity. 

The  meeting  of  1920  took  place  under  very  dif- 
ferent conditions.  In  fact,  no  meeting  of  this 
association  has  been  held  under  more  favorable 
auspices  than  the  eighty-eighth  annual  meeting. 
Everything  seemed  to  conspire  to  render  this 
gathering  a  conspicuous  success.  The  long  inter- 
val since  the  last  annual  meeting,  the  ideal  place 
of  meeting.  Cambridge  with  its  colleges  and 
halls  and  lecture  rooms,  only  fifty  miles  from 
London  and  a  railway  centre,  and  last  but  not 
least,  the  choice  as  president  of  Sir  Clifford 
Allbutt,  the  grand  old  man  of  medicine,  whose 
medical  scientific  knowledge  is  only  e(]ualled  by 
bis  personal  luagnetism,  his  charm  of  manner, 
and  his  gift  of  oratory.  The  attendance  w^as 
large  and  while  fully  representative  of  the  Brit- 
ish medical  profession  included  also  distinguished 
men  from  other  countries.  Dr.  Simon  Flexner 
and  Dr.  Alfred  Hess  represented  research  and 
clinical  medicine  in  New  York.  Dr.  Charles  H. 
Mayo,  of  Rochester,  Minn.,  and  Dr.  J.  M.  T.  Fin- 
ney, of  Baltimore,  surgery  in  the  United  States, 
and  Dr.  Brown  and  others  from  Johns  Hopkins 
Medical  School. 

The  comfort  and  entertainment  of  the  visitors 
were  well  looked  after  and  there  was  so  much  of 
interest  to  see  in  Cambridge  that  one  did 
not  quite  know  what  to  see  and  what  not  to  see. 
Tours  through  the  colleges  were  arranged  and 
although  Oxford  is  generally  pointed  to  a>  offer- 
ing more  in  the  way  of  architectural,  historical 
and  archeological  delectation,  yet  Cambridge, 
even  if  second  in  this  respect,  is,  at  least,  a  very 
good  second.  Indeed  Oxford  has  nothing  to 
show  to  compare  with  the  wonderful  King's  Col- 
lege chapel  at  Cambridge  and  the  (|uadrangles 
and  hall  of  Trinity  College  are  certainly  not  sur- 
])assed  by  those  of  any  (3xford  College,  (harden 
parties  were  held  at  Downing  College,  Newton 
Hall,  the  Bishop's  Palace,  Ely.  Christ's  College. 
Croxton  Park,  and  Madingley  Hall  and  organ  re- 
citals were  given  by  college  organists  at  King's 
College  chapel.  Numerous  excursions  were  also 
a\ailable,  including  one  to  the  Cambrid.geshire 
tuberculosis  colony,  Papworth  Hall,  situated 
about  twelve  miles  from  Cambridge.  The  mu- 
seums with  which  Cambridge  abounds  were,  of 
course,  all  thrown  open. 

A  congregation  for  the  conferring  of  honorary 
degrees  was  held  in  the  Senate  House  on  June 
29th  when  the  degree  of  LL.D.,  was  conferred 
upon  six  distinguished  medical  men  of  two  con- 


September  II,  1920.] 


LOXDOX  LETTER. 


tinents.  The  degree  was  first  conferred  upon 
Sir  Clifford  Allbutt.  K.C.B..  M.D..  Fellow  of 
Gonville  and  Cains  College,  regius  professor  of 
physic  at  Cambridge  University.  In  his  oration 
which,  as  is  always  the  case,  was  delivered  in 
Latin.  Rev.  C.  E.  Raven,  dean  of  Emmanuel  Col- 
lege, referred  to  Sir  Clifford,  as  one  whose  wide 
study,  admirable  writing,  and  inspiring  zeal  had 
lifted  him  to  a  position  in  which  l)oth  the  medical 
faculty  and  the  university  looked  jointly  upon  him 
as  their  own.  It  may  be  mentioned  that  Sir  Clif- 
ford Allbutt  is  in  his  eighty-fourth  year.  The 
other  recipients  of  the  degree  were:  M.  Jules 
Bordet,  president  of  the  Facultv  of  Medicine  and 
director  of  the  Institute  Pasteur  at  Brussels : 
Simon  Flexner.  director  of  the  laboratories  of  the 
Rockefeller  Institute  for  Medical  Research.  Xew 
York :  Dr.  Piero  Giacos.  a  professor  of  materia 
medica  and  experimental  pharmacolog}"  at  the 
University  of  Turin:  Sir  George  Henry  Makins, 
G.C.M.G.,  C.B..  president  of  the  Royal  College  of 
Surgeons,  and  Sir  Xorman  Moore.  I'.art..  M.D.. 
Honorary  Fellow  of  St.  Catherine's  College,  Cam- 
bridge, and  president  of  the  Royal  College  of 
Physicians.  Four  gentlemen  were  unable  to  at- 
tend to  receive  their  degrees,  viz..  Mr.  Albert 
Calmette,  subdirector  of  the  Institute  Pasteur 
of  Paris.  Dr.  Harvey  Cushing.  professor  of  sur- 
gery at  Harvard  University.  Major  General  \\\\- 
liam  Crawford  Gorgas.  and  Sir  Patrick  Manson. 

On  the  evening  of  June  28th,  Sir  Clifford  Allbutt 
delivered  his  address  as  president  of  the  asso- 
ciation. The  gold  medal  of  the  association  was 
presented  to  the  Bishop  of  Liverpool,  as  the 
father  of  the  late  Captain  Xoel  Godfrey  Chavasse. 
\'.C.,  M.C..  R.A.M.C..  to  whom  the  \'ictoria  Cross 
was  awarded  in  1916,  for  extraordinary  acts  of 
bravery. 

The  Stewart  Prize  was  j)resented  to  Miss 
Harriette  Chick,  D.  Sc.,  in  recognition  of 
her  own  work  and  that  of  the  band  of  scientific 
women  as.sociated  with  her  in  the  investigations 
into  the  means  for  preventing  scurvy  and  l)eri 
beri  in  armies  and  among  populations  suft'ering 
privations.  The  Middlemore  Prize  was  pre- 
sented to  Harry  Moss  Pragnair.  M.D.,  F.R.C.P.. 
D.P.H.,  for  his  essay  on  perimetry,  inclusive  of 
scotometry.  its  methods,  and  its  value  to  the 
ophthalmic  surgeon. 

After  the  presidential  address  the  visitors. 
♦  ntmibering  about  one  thousand,  were  received  on 
the  grounds  of  King's  College  by  the  Master.  Dr. 
Grove,  and  members  of  the  Cambridge  Hunting- 
don Branch  of  the.  British  ^Medical  Association. 
At  10  p.m.  the  company  assembled  in  the  hall  of 
King's  College,  where  Sir  Clifford  Allbutt  was 
presented  with  a  large  portrait  painted  by  Sir 
William  ( )rpen.  Sir  Xorman  Moore  made  the 
presentation  in  a  fitting  speech. 

The  evidence  afforded  of  the  trend  of  medicine 
of  the  present  day.  was  the  most  significant  feature 
of  the  meeting.  Judging  from  the  prominence 
given  to  preventive  medicine  there  would  seem  to 
be  little  doubt  of  what  the  future  of  medical  prac- 
tice would  be.  All  the  meetings  concerned  with 
preventive  medicine  were  largely  attended  and  it 


was  somewliat  curious  and  in  a  way  disheartening 
to  note  that  the  attitude  of  the  medical  men  present 
appeared  to  be  defensive.  The  medical  profession 
seemed  to  fear  state  control.  Sir  George  Xewman, 
in  his  opening  speech  in  the  section  in  sociology, 
fully  recognized  this  and  endeavored  to  reassure 
the  profession.  While  the  chief  medical  adviser 
to  the  Ministry  of  Health  undoubtedly  meant  what 
he  said,  he  was  quite  imable  to  control  or  perhaps 
even  greatly  to  influence  the  situation.  As  he  said, 
he  was  after  all  only  a  servant,  and  it  was  to  be 
feared  that  politics  would  rule  the  situation.  It  is 
obvious  that  the  medical  profession  is  impotent 
politically,  while  the  Labor  Party  is  powerful. 
Therefore,  it  is  logical  to  argue  that  if  the  Labor 
Party  desires  state  control  of  the  medical  profes- 
sion they  are  not  unlikely  to  get  it.  It  is  useless 
to  evade  probabilities  because  they  are  unpleasant 
and  it  was  of  sinister  import  that  the  labor 
representative  who  spoke  at  the  meeting  was 
wholly  in  favor  of  state  control. 

Another  much  discussed  suljject  and  one  that 
is  involved  in  the  question  of  state  control  was 
that  of  the  voluntary  hospitals  and  what 
is  to  become  of  them.  The  medical  profession 
here  as  a  whole  are  imalterably  opposed  to  the 
hospitals  passing  into  the  hands  of  a  bureaucracy. 
Why  is  it  necessary  to  rely  upon  the  state  for  the 
maintenance  of  hospitals  when  an  obvious  way  out 
of  the  difficulty  is  ready  at  hand?  Wh}-  not  in- 
troduce a  pay  system  or  a  modified  pay  system  ? 
It  is  fair,  and  should  provide  sufticient  fimds  to 
support  the  hosj^itals.  partially  at  least.  The  state 
or  municipalities  might  aid  l)ut  there  seemed  to  be 
no  valid  reason  for  the  state  having  complete  con- 
trol. At  any  rate,  the  state  should  pay  for 
insurance  patients  which,  since  the  passing  of  the 
Insurance  Act.  had  ]ilaced  a  great  strain  upon  the 
resources  of  hospitals.  If  everyone  paid  for 
hospital  treatment  according  to  his  or  her  means 
it  would  go  a  long  wa\-  toward  solving  the  problem. 
In  the  words  of  Sir  Wilmot  Herringham.  who  in 
discussing  the  future  of  the  medical  profession, 
dealt  with  the  question  from  the  viewpoint  of  the 
consultant.  "'The  only  sotind  remedy,  as  far  as 
I  can  see,  is  to  extend  to  private  patients  the 
benefit  and  convenience  of  treatment  at  a  hospital. 
Paying  hospitals  are  one  of  the  greatest  needs  of 
the  time."  Mr.  E.  W.  Morris,  who  is  house  governor 
of  the  London  Hospital,  and  one  of  the  greatest 
authorities  on  the  management  of  hospitals  in  the 
world,  in  the  same  di.scussion  gave  it  as  his  opinion 
that,  considering  the  enormously  increased  cost  of 
running  the  volimtary  hospitals,  the  time  had  come 
when  patients  should  as  a  matter  of  dtity  contribute 
to  the  cost  of  their  treatment.  From  all  this  it  will 
be  gathered  that  the  medical  profession  in  Great 
Britain  is  in  a  critical  condition  It  is  at  the  parting 
of  the  ways  and  it  is  earnestly  hoped  that  in  attempt- 
ing to  avoid  the  Scylla  of  unorganized  practice 
it  will  not  be  forced  into  the  Charybdis  of  state 
control.  Sir  George  X'ewman  said  that  individual- 
ism was  the  genius  of  British  medical  practice  and 
it  would  be  nothing  short  of  a  national  disaster  if 
that  were  to  be  lost  or  allowed  to  be  destroAed. 


Editorial  Notes  and  Comments 


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NEW  YORK,  SATURDAY,  SEPTEMBER  11,  1920. 


PHYSICIAN  AUTHORS  —  DR.  ORLANDO 
WILLIAMS  WIGHT. 

A  many  sided  man  was  Dr.  Orlando  Williams 
Wight,  author,  physician,  lecturer,  theologian,  edu- 
cator, linguist  and  traveler — a  man  who  had  an  in- 
teresting and  varied  career  in  many  lines  of  en- 
deavor and  who  was  a  success  in  all.  Dr.  Wight 
seems  to  have  had  some  difficulty  in  making  up  his 
mind  definitely  as  to  just  what  course  in  which  to 
shape  his  destiny.  He  began  by  being  an  instructor 
in  Eastern  academies  and  when  he  was  only  twenty- 
three  years  old  he  became  president  of  the  Auburn 
(N.  Y.)  Female  Academy.  Here  was  a  field  in 
which  he  seemed  destined  to  make  a  name  for  him- 
self, but  it  was  not  to  his  liking  and  so  he  gave  it 
up  and  went  to  New  York  city,  where  he  began 
doing  free  lance  work  for  newspapers  and  maga- 
zines. This  was  in  1847.  At  about  that  period  he 
thought  of  becoming  a  minister  of  the  gospel,  and 
so  studied  theology  and  was  ordained  as  a  Uni- 
versalist  minister,  but  his  religious  activities  ended 
there.  He  never  entered  the  pulpit,  but  went  to 
Europe  in  1853,  where  he  spent  several  years,  re- 
newing his  literary  work  upon  his  return. 

As  a  physician  Dr.  Wight  was  of  the  late  bloom- 
ing type.  He  was  well  along  in  his  middle  thirties 
when  he  began  the  study  of  medicine  at  the  Long 
Island  College  Hospital,  and  was  turned  forty  when 
he  received  his  degree.  He  found  the  practice  of 
medicine  more  fascinating  than  any  pursuit  he  had 
yet  attempted  and  he  maintained  his  connection 
with  it  throughout  the  rest  of  his  life.    His  first 


work  as  a  practicing  physician  was  done  at  Ocon- 
omowoc,  Wis.,  and  subseqtiently  in  Milwaukee.  In 
1874  he  was  appointed  surgeon  general  of  Wis- 
consin and  four  years  later  became  chief  health  offi- 
cer of  Milwaukee,  in  which  position  he  sen^e'd  two 
years.  When  the  board  of  health  of  the  city  of 
Detroit  was  recorganized  in  1882  he  became  the 
chief  health  officer  there  and  served  until  his  death 
six  years  later. 

It  would  take  a  five  foot  shelf  with  a  roomy  ad- 
dition to  hold  all  the  volumes  of  original  works  and 
translations  that  came  from  Dr.  Wight's  pen,  not 
counting  the  volumes  he  edited  and  revised,  for  he 
was  an  indefatigable  worker.  We  hear  little  of 
him  today  because  he  chose  literary  paths  that  do 
not  lead  to  heights  of  fame.  His  work  was  largely 
translating  and  he  made  of  it  a  fine  art.  But  trans- 
lation is  a  difficult  art  and  a  thankless  one,  filled 
with  empty  honors.  To  Dr.  Wight  translation  came 
naturally,  for  he  had  a  gift  for  languages.  He  spoke 
French,  German,  Spanish  and  Italian  fluently,  and 
there  was  none  in  his  time  better  versed  in  Latin 
and  Greek  than  he.  He  had  received  a  classical 
edtication  at  W^estfield  Academy  and  at  the  Roches- 
ter Collegiate  Institute  and  before  he  had  reached 
his  maj'orit)'  was  teaching  Latin  and  Greek  at  Genoa 
Academy  and  mathematics  and  modern  languages 
in  Aurora  Academy.  It  was  because  of  his  remark- 
able proficiency  as  a  linguist  that  Yale  University 
in  1861  conferred  on  him  the  degree  of  A.  M.  and 
later  the  degree  of  LL.  D. 

The  translations  made  by  Dr.  Wight  are  standard 
today.  They  have  stood  the  test  of  time  because 
they  reproduce  the  spirit  and  style  of  their  originals ; 
because  they  were  the  labor  of  love  of  a  gifted  man 
who  was  thoroughly  familiar  with  the  manifold 
complexities  of  the  languages  from  which  and  into 
which  he  translated.  Six  volumes  of  Balzac,  Pas- 
cal's Thoughts,  the  Lives  and  Letters  of  Ahelard 
and  Heloise,  Victor  Cousin's  History  of  Modern  ' 
Philosophy,  a  history  of  France  in  several  volumes, 
fourteen  volumes  of  the  Standard  French  Classics, 
the  works  of  Montaigne — these  were  some  of  the 
works  translated  by  Dr.  Wight.  He  also  edited  and 
did  most  of  the  translating  of  the  Household  Li- 
brary in  eighteen  volumes.  This  consisted  of  a 
series  of  portraits  of, the  world's  most  famous  his- 
torical spirits,  the  first  volume  being  devoted  to  Joan 
of  Arc,  translated  from  Jules  Michelet's  brilliant 
history  of  France.  Other  volumes  in  the  series 
translated  by  Dr.  Wight  included  the  lives  of  Peter 
the  Great,  Mahomet,  Martin  Luther,  and  Socrates. 


September  11,  1920.] 


EDITORIAL  ARTICLES. 


375 


Dr.  Wight  had  a  strong  preference  for  biography 
and  beHeved  that  the  study  of  the  Hves  of  great  men 
and  women  made  more  stimulating  and  wholesome 
reading  for  the  American  public  than  what  he  called 
"the  bloodless  personages  of  mere  fiction." 

"Life  and  histor>%"  he  said,  "are  always  stronger 
than  the  day  dreams  of  fancy ;  they  can  satisfy  the 
cravings  of  the  imagination  while  they  feed  the 
heart  and  instruct  the  mind." 

Dr.  Wight's  own  life  was  written  by  his  brother, 
Dr.  Jarvis  Sherman  Wight,  who  was  an  authority 
on  craniologj'  and  author  of  several  medical  works, 
including  Suggestions  to  Medical  Witnesses.  He 
was  for  many  years  professor  of  surgery  and  dean 
of  the  faculty  of  Long  Island  College  Hospital, 
and  it  was  largely  through  his  influence  that  Dr. 
Orlando  Wight  decided  to  adopt  a  medical  career. 

Dr.  Wight's  contributions  to  magazines  and  news- 
papers would  fill  half  a  dozen  volumes.  His  best 
known  medical  work  was  his  Maxims  on  Public 
Health,  published  in  1884.  One  of  his  most  suc- 
cessful volumes  was  his  Lectures  on  The  True,  The 
Beautiful  and  the  Good.  His  last  book,  A 
Winding  Journey  Around  The  World,  was  pub- 
lished the  year  of  his  death. 

Dr.  Wight  came  of  an  old  colonial  family.  He 
was  born  in  Centerville,  N.  Y.,  on  February  19, 
1824,  the  son  of  Thomas  and  Caroline  Van  Buren 
Wight,  and  was  a  descendant  of  Thomas  Wight 
who  emigrated  to  the  American  colonies  from  the 
Isle  of  Wight  in  the  year  1635.  He  died  on  Oc- 
tober 19,  1888. 


VITAMINES  IX  THE  NUTRITION. 
Not  long  ago,  A.  Lumiere,  of  Lyons,  demon- 
strated that  the  majority  of  phenomena  which  con- 
stitute what  may  be  called  physiological  insolvency 
can  be  explained  by  inanition.  It  then  remained  to 
show  what  part  the  want  of  vitamines  played  in 
the  inanition.  This  has  been  accomplished  by 
Lumiere,  who  recently  demonstrated  that  pigeons 
fed  on  decorticated  rice — a  food  deprived  of  vita- 
mines — ceased  to  eat  after  a  few  days.  If  the 
birds  were  fed  by  gavage  they  regurgitated  all  food 
given.  These  phenomena  are  dependent  upon  the 
fact  that  the  alimentary  bolus  thus  constituted  is 
incapable  of  passing  through  the  pylorus  and  re- 
mains in  the  upper  portion  of  the  digestive  tract, 
especially  in  the  crop,  then  in  the  gizzard.  When 
pigeons  thus  fed  are  opened  it  will  be  found  that 
with  a  complete  alimentation  the  grains  are  abun- 
dantly impregnated  with  the  secretions,  the  bolus 
formed  by  polished  rice  being  drier.  This  alimen- 
tary bolus  is  found  in  the  shape  of  a  compact  mass 
in  the  gizzard,  in  which  gravel  is  present  and  in  nor- 


mal conditions  crushes  the  grains  which  are  as  hard 
as  plaster. 

In  these  circumstances,  it  is  evident  that  digestion 
cannot  be  carried  out.  Quite  independent  of  the  me- 
chanical action  which  causes  the  food  to  progress 
onward  in  the  digestive  tract,  the  aliments  ingested 
should,  in  the  first  place,  undergo  a  phase  of  elabora- 
tion, consisting  of  their  dislocation,  disaggregation, 
and  hydrolysis  in  order  to  give  rise  to  substances 
whose  simplified  molecules  may  be  able  later  to  form 
by  synthesis  the  complex  albuminoid  matter  and 
other  organic  combinations  which  make  up  the  ele- 
ments of  animal  tissues.  Now,  this  first  act  of  nu- 
trition can  only  be  assured  by  the  ferments  derived 
from  the  glands  of  external  secretion  whose  secre- 
tion is  completely  absent  when  decorticated  rice  is 
used  as  food. 

The  consequence  of  these  data — which  have  been 
corroborated  by  the  very  ingenious  experiments  of 
Lumiere — is  that  in  the  case  of  decorticated  rice 
the  necessary  substances  for  setting  up  the  glandu- 
lar secretion  of  the  upper  digestive  tract  are  lacking 
and  these  substances  are  the  very  ones  called  vita- 
mines  Now,  if  to  a  pigeon  which,  following  gavage, 
has  reached  the  phase  of  intolerance,  some  drops  of 
oil  be  given  or  even  a  very  minute  quantity  of  ex- 
tract of  malt  yeast,  the  glands  of  external  secretion 
will  commence  their  functions,  the  alimentary-  bolus 
will  progress  through  the  digestive  tract,  and  a 
copious  stool  will  demonstrate  that  the  digestive  act. 
has  been  carried  out  thoroughly.  This  is  unques- 
tionably a  discovery  of  the  utmost  import  and  sin- 
gularly enlightens  the  problem  of  vitamines  and 
physiological  insolvency  which,  until  now,  has  been 
most  obscure. 


THE  CLINICAL  FORMS  AND  DIAGNOSIS 
OF  ARTHRITIC  CELLULITIS. 
The  clinical  forms  of  cellulitis  are  numerous 
and  vary  according  to  the  region  in  which  the  con- 
nective tissue  is  involved.  The  principal  modali- 
ties are  above  all  met  with  in  the  neuralgic  domain. 
In  the  upper  limb  an  intercostal  pseudoneuralgia 
will  be  complained  of  by  the  patient,  with  pain 
seated  in  the  cutaneous  ramuscules  which  supply  the 
skin  of  the  thoracic  walls  and  extend  to  the  shoul- 
der, arm  and  lumbar  region.  That  the  patient  is  not 
suffering  from  intercostal  neuralgia  will  be  made 
evident  by  pinching  the  skin  over  a  nerve  filament. 
This  will  elicit  sharp  pain,  while  compressing  the 
skin  over  a  rib  will  cause  characteristic  pain.  Next 
in  frequency  as  a  clinical  form  of  cellulitis  comes 
sciatica,  in  which  Valleix's  points  can  be  brought 
into  evidence,  which  are  obtained  not  only  by  com- 


376 


XEIIS  ITEMS. 


[New  York 
Medical  Journal. 


pressing-  the  nerve  on  the  tinderlying  hone  hut  also 
])y  pinching  the  skin  over  a  corresponding  area 

Beside  these  neuralgias  the  trigeiuinus  is  the  seat 
of  pain  when  cellulitis  is  present  at  the  point  of 
emergence  of  this  nerve.  The  neuralgias  of  the 
arm,  forearm,  and  shoulder  are  freqtient  and  often 
mistaken  for  joint  disturhances :  rheumatoid  pain 
in  the  neck  or  shoulders  is  encountered,  especially 
in  women  who  are  insufficiently  protected  hy  their 
clothing"  Lumhosacral  localization  of  cellulitis 
gives  rise  to  neuralgia  simulating  hunhago  and  may 
lead  to  the  erroneous  diagnosis  of  a  muscular  af- 
fection. Celkilitis  in  the  ahdominal  wall  near  the 
right  iliac  fossa  has  been  known  to  simulate  appen- 
dicitis, not  only  in  the  female  hut  in  males  as  well. 
Cellulitis  around  the  joints  gives  rise  to  periarthri- 
tides  characterized  by  a  thickening  of  the  tissues 
which  aid  in  the  protection  and  support  of  the 
joint,  as  well  as  general  soreness  of  the  joint  and 
muscles. 

By  its  symptomatology,  as  well  as  by  its  etiology, 
gout,  another  manifestation  of  arthritism.  shows 
bonds  of  relationship  to  cellulitis.  The  presclerous 
edema  of  the  subcutanous  connective  tissues  may 
extend  to  the  tissue  of  the  same  nature  surround- 
ing the  veins  and  produce  a  periphlebitis,  which  ac- 
companies and  invariably  follows  phlebitis,  but  can 
exist  without  the  latter.  It  produces  a  feeling  of 
weight  in  the  lower  limbs  and  abdominal  region  with 
cold  and  warm  sensations. 

In  abdominopelvic  cellulitis  neuralgias  occur 
which  are  due  to  the  onset  of  the  process  in  the 
connective  tissue,  although  by  palpation  little  can 
be  detected.  When  the  cellulitis  becomes  more 
marked,  however,  a  doughy  feeling  is  imparted  to 
the  organs  in  the  ti^ue  pelvis  which  may  lead  to 
a  diagnosis  of  tumor,  and  should  the  cellulitis  be 
accompanied  b\-  fever  a  suppurating  process  may  be 
suspected. 

Among  all  these  clinical  forms  the  diagnosis  is 
sometimes  a  matter  of  some  difficulty  at  first.  The 
diagnosis  of  cutaneous  celkilitis  is  not  hard  to  make : 
the  symptoms  may  not  all  be  present  but  are  very 
distinct  when  they  exist.  As  far  as  cellulitic  tume- 
factions are  concerned,  the  continual  change  in 
their  size,  or  even  in  their  localization,  makes  the 
diagnosis  easy.  In  subcutaneous  cellulitis  the  ex- 
citing of  superficial  pain  will  ])revent  diagnostic  con- 
fusion, for  example  pseudoappendicitis  or  sciatica. 
The  presence  of  several  foci  of  cellulitis  in  various 
parts  of  the  body  will  also  aid  in  diagnosis.  Thus 
should  there  be  any  hesitancy  as  to  whether  a  tumor 
or  neuralgia  is  due  to  cellulitis  and  another  focus 
is  found,  for  instance  in  the  arm  or  shoulder,  the 
real  condition  becomes  clear. 


THE  MIND  OF  A  SURGEOX. 
Professor  J.  L.  Faure,  the  distinguished 
French  surgeon,  has  written  a  brochure,  L'amc 
dii  ChiriirgicH,  showing  the  triumphs  and  diffi- 
culties of  the  surgeon's  life.  He  says:  "There 
is  not  a  man  in  the  world  who  receives 
more  often  than  the  surgeon  the  impress  of  power- 
ful emotions,  sometimes  pleasant,  often  tragic  and 
sorrowful,  but  of  an  infinite  variety  and  of  which 
perhaps  only  the  diversity  permits  him  to  endure 
without  faltering  the  incessant  repetition.  In  the 
battles  which  he  fights  each  day  and  of  which  the 
stake  is  a  human  life,  he  knows  one  by  one  the 
pangs  of  imminent  clanger  and  the  satisfaction  of 
difficulty  overcome.  Abruptly  and  without  transi- 
tion he  passes  from  the  tranquillity  of  mind  result- 
ing from  an  ordinary  operation  to  the  sudden 
discjuietude  which  springs  from  some  unforeseen 
accident.  His  soul  is  engrossed  in  these  constant 
struggles  and  sudden  shocks.  There  is  not  an  act 
of  his  professional  life  which  for  the  surgeon  does 
not  entail  grave  responsibilities.  From  each  of  his 
decisions,  each  of  his  thoughts,  each  of  his  acts,  and 
sometimes  even  from  his  gestures  may  arise  the 
most  fortunate  results  or  the  most  tragic  conse- 
(|uences.  It  is  a  grave  and  serious  function,  that  of 
the  man  who  each  instant  holds  life  or  death  in  his 
hand,  and  the  role  of  the  surgeon  is  often  of  sin- 
gular grandeur." 

 %  ■ 

News  Items. 


Personal. — Dr.  Harry  J.  Moss,  superintendent 
of  the  Hebrew  Hospital.  Baltimore,  has  been  ap- 
pointed superintendent  of  the  Brownsville  and  East 
Xew  York  Hospital.  Brooklyn. 

New  York  City  Acquires  Milk  Stations. — The 
Xathan  Strauss  milk  stations  and  laboratory,  estab- 
lished in  1892.  were  taken  over  by  Xew  York  on 
September  1st.  Dr.  Royal  S.  Copeland,  health  com- 
missioner, accepted  the  ])lant  on  behalf  of  the  city. 

Death  of  Professor  Wundt. — Word  has  been 
received  from  Leipsic  of  the  death  there  on  A^ugust 
31st  of  Professor  Wilhelni  Wundt,  at  the  age  of 
eighty-eight.  Professor  Wundt  held  the  chair  of 
philosophy  at  Leipsic,  where  he  had  foimded  an  in- 
stitute for  experimental  psychology. 

Southwestern  Medical  Meeting. — The  fifteenth 
annual  meeting  of  the  Medical  Association  of  the 
South\\-est,  composed  of  the  States  of  Missouri, 
Kansas,  Oklahoma,  Arkansas  and  Texas,  will  be 
held  Xovember  22nd  to  24th  at  Wichita.  Kan., 
under  the  presidency  of  Dr.  E.  E.  Day.  of  Ar- 
kansas City,  Kan. 

New  Plan  for  Poliomyelitis  Patients. — The  500 
or  more  children  suffering  from  poliomyelitis  who 
have  been  receiving  treatment  three  times  a  week 
in  the  clinics  of  city  hospitals  in  charge  of  the 
Department  of  Public  Welfare  are  to  be  put  under 
a  new  plan  of  treatment.  They  are  to  be  admitted 
to  resident  patients,  and  a  public  school  teacher  will 
be  provided  for  each  hospital.  ^lany  of  the  chil- 
dren have  been  unable  to  attend  school,  and  the  plan 
to  be  followed  will  prevent  neglect  of  their  educa- 
tion. 


Sepf,ml._r  11,  1920.] 


XEUS  ITEMS. 


377 


Red  Cross  Public  Health  Chair. — A  chair  of 
public  health  in  the  University  of  British  Columbia 
will  be  endowed  by  the  Provincial  Red  Cross  of 
Canada,  the  Red  Cross  paying  the  salary  of  the  pro- 
fessor for  three  years. 

Abandoned  Base  Hospital  Burned. — Twent} 
buildings  of  the  former  United  .States  Base  Hos- 
pital No.  1,  now  abandoned,  in  the  Bronx.  Xew 
York  City,  were  destroyed  by  fire  on  the  night  of 
September  2iid.  The  damage  is  estimated  at 
S20.000. 

Cholera  in  Corea. — A  press  dispatch  from 
Corea  .states  that  there  are  9.000  cases  of  cholera 
in  Corea  and  that  3.000  deaths  are  reported  there. 
Corean  superstition  has  added  to  the  difficulties  in 
fighting  the  epidemic,  as  the  natives  conceal  tlie 
bodies  of  victims  in  their  homes  to  prevent  cre- 
mation. 

Increased  Birth  Rate. — The  birth  rate  for  the 
first  seven  months  of  this  year  is  22.34,  as  com- 
pared with  a  rate  of  21.90  for  the  corresponding- 
period  in  1919,  according  to  statistics  of  the  New 
York  City  health  department.  In  addition  to  this 
the  infant  mortality  rate  for  the  periods  referred  to 
has  declined  from  92  in  1919  to  83  for  the  present 
year. 

Army  Commissions. — Commissions  in  the 
Medical  Corps  of  the  regular  army  have  been  ,  is- 
sued recently.  Dr.  Attilo  M.  Caccini,  who  for  the 
last  eighteen  months  has  been  engaged  in  sanitary 
work  at  the  U.  S.  aviation  camp  at  Garden  City, 
L.  I.,  was  commissioned  a  major.  Dr.  William 
Frank  McLaughlin,  of  Fox  Hills  General  Hospital. 
Staten  Island,  received  the  commission  of  captain. 

Tuberculosis  Workshop. — A  workshop  and 
training  school  for  the  industrial  rehabilitation  of 
exservice  men,  convalescent  from  tuberculosis  in 
the  arrested  stage,  is  being  maintained  in  Long  Is- 
land City  by  the  Federal  Vocational  Board,  the 
National  Tuberculosis  Association,  and  the  New 
York  Tuberculosis  Association.  As  soon  as  the 
shop  has  become  selfsustaining  others  than  ex- 
service  men  will  be  received. 

The  shop  is  incorporated  under  the  name  of  the 
Reco  Manufacturing  Company.  Inc..  and  is  located 
at  458  Pierce  avenue.  I>ong  Island  City,  in  a  large, 
airy,  well  lighted  loft  with  lunch  room  and  other 
conveniences.  Medical  care  and  treatment  are  at 
hand  in  any  emergency.  The  object  is  to  teach 
gradually  and  safely  a  trade  tfiat  will  not  be  in- 
jurious and  in  which,  after  the  men  have  learned  to 
make  marketable  goods,  they  will  be  paid  the  same 
wages  as  others  doing  the  same  work.  An 
opportunity  is  thus  offered  to  learn  one  of  the 
following  skilled  trades  under  instruction  of  ex- 
perts: Watch  repairing,  jewelry  manufacturing 
(gold  and  platinum),  or  high  class  cabinet  making. 
As  soon  as  a  man  learns  to  make  goods  that  can  l)e 
sold  or  repairs  that  are  paid  for,  he  will  receive  the 
regular  union  wage  for  that  particular  kind  of 
work.  This  training  does  not  in  itself  affect  any  com- 
pensation he  may  now  be  receiving  from  the  Gov- 
ernment. To  apply  for  admission,  men  must  come 
in  per.son  to  the  New  York  Tuberculosis  Associa- 
tion, 10  Ea.st  Thirty-ninth  street.  New  York  City 
(third  floor). 


Memorial   at   Jefferson   Medical   College. — A 

bronze  tablet  engraved  with  the  names  of  twenty- 
five  graduates  of  Jefferson  ^Medical  College.  Phila- 
delphia, who  lost  their  lives  in  the  war,  will  be  dedi- 
cated on  October  7th.  The  tablet  is  the  gift  of  the 
Alumni  Association. 

New  York  State  Health  Conference. — The 
nineteenth  annual  conference  of  sanitary  officers 
and  the  second  annual  conference  of  public  health 
nurses  of  the  state  of  New  York  were  held  Septem- 
ber 7th  to  9th  at  Saratoga  Springs,  N.  Y.,  under  the 
auspices  of  the  State  Department  of  Health. 

Railway  Surgeons  Meet. — The  thirtieth  annual 
session  of  the  New  York  and  New  England  Asso- 
ciation of  Railway  Surgeons  will  be  held  Tuesday. 
October  19th,  at  the  Hotel  McAlpin,  New  York, 
under  the  presidency  of  Dr.  William  B.  Coley,  of 
New  York.  Among  those  who  will  deliver  ad- 
dresses are  Dr.  Joseph  A.  Blake,  of  New  York ; 
Dr.  George  W.  Crile,  of  Cleveland,  and  Dr.  Fred 
H.  Albee,  of  New  York.  Clinics  will  be  held  at 
local  hospitals  on  Wednesday  and  Thursday,  Oc- 
tober 20th  and  21st. 

Viennese  Physicians  in  Need  of  Aid. — An  ap- 
peal has  been  received  from  the  American  Relief 
Committee  for  Sufferers  in  Austria,  of  which  Fred- 
eric Courtland  Penfield.  late  American  ambassador 
to  Austria-Hungary,  is  honorary  chairman,  for  the 
relief  of  destitute  Viennese  physicians  and  sur- 
geons. The  committee  has  created  a  special  fund 
to  aid  medical  men,  who  must  combat  an  increas- 
ing mortality  on  pitifully  inadequate  incomes.  Con- 
tributions may  be  made  to  Alvin  W.  Krech,  presi- 
dent. Equitable  Trust  Company,  37  W^all  street. 
New  York,  treasurer  of  the  committee. 


Died. 

Beukers. — In  Berkeley,  Cal  .  on  Monday.  .August  16th. 
Dr.  Joseph  M.  Beukers.  aged  .sixty-five  years. 

Booker. — In  Selma.  Cal..  on  Saturday.  August  21st,  Dr. 
Thomas  .A.lvin  Booker,  aged  forty-eight  years. 

Br.\dner. — In  New  York,  on  Tuesday,  August  31st,  Dr. 
Frederick  Clark  Bradner,  aged  forty-seven  years. 

C.XLDERON. — In  San  Francisco,  Cal.,  on  Wednesday, 
.\ugust  25th,  Dr.  Eustorjio  Calderon.  aged  fifty-nine  years. 

FoLLETT. — In  Machias.  N.  Y.,  on  Sunday.  August  29th, 
Dr.  William  Follett.  aged  forty-nine  years. 

H.WES. — In  Lock  Haven,  Pa.,  on  Wednesday.  August 
25th.  Dr.  Joseph  Henry  Hayes,  aged  seventy-nine  years. 

LowRiGHT. — In  .Allentown  Pa.,  on  Saturday,  July  24th, 
Dr.  James  Harvey  Lowright.  of  Center  \'aney.  aged  sixty- 
two  years. 

XiLES. — In  Marshall.  Mich.,  Dr.  \\'illiam  Holyoke  Xiles, 
aged  thirty-five  years. 

Pheuvn. — In  San  Jose.  Cal..  on  Monday,  .\ugust  9th, 
Dr.  Daniel  J.  Phelan.  of  Xew  York. 

Shimer. — In  Easton.  Pa.,  on  Monday.  August  23rd.  Dr. 
Sterling  Shimer.  aged  fifty  years. 

Stuckmever. — In  Indianapolis,  Ind..  on  Sunday.  August 
22nd,  Dr.  William  E.  Stuckmeyer,  aged  thirty-eight  years. 

Terry. — In  Providence,  R.  I.,  on  Tuesday,  August  24th, 
Dr.  Herbert  Terry,  aged  sixty-six  years. 

YoDER.^ — In  Catasauqua,  Pa.,  on  Tuesday,  .A.ugust  24th, 
Dr.  Daniel  Yoder,  aged  eighty-seven  years. 


Book  Reviews 


PSYCHOANALYSIS. 

An  Outline  of  Psychoanalysis.  By  Barbara  Low,  B.  A., 
Member  of  the  British  Psjxhoanalytical  Society,  For- 
merly Training  College  Lecturer.  Introduction  by  Er- 
nest Jones,  M.  D.,  M.  R.  C.  P.  (London),  President  of 
the  British  Psychoanaly-tical  Society,  etc.  New  York: 
Harcourt,  Brace  and  Howe,  1920.    Pp.  v-199. 

From  a  critical  point  of  view  it  would  not  be 
difficult  to  find  minor  faults  in  this  exposition  of 
psychoanalysis,  but  in  spite  of  the  annoyance  of 
frequent  italics  and  more  frequent  capitalization, 
which  are,  no  doubt,  intended  to  emphasize  more 
important  words  and  passages,  the  book  is  well 
worth  reading.  Its  purpose  is  to  present  to  the 
reader  a  resume  of  a  comparatively  new  science — • 
a  science  more  farreaching  in  its  scope  than  any 
which  man  has  heretofore  attempted  to  study,  and 
the  work  is  given  in  a  spirit  of  profound  sincerity. 
Man}-  new  discoveries  have  been  made.  The  en- 
tire old  line  psychology  has  been  relegated  to  limbo, 
though  they  still  teach  the  old  psychology  in  schools 
and  colleges.  Many  old  pedagogues,  fearful  of  be- 
ing disturbed,  do  not  venture  into  new  fields.  The 
unconscious  mind  is  a  vast  newly  discovered  ter- 
ritory for  which  psychoanalysis  presents  a  method 
of  exploring.  No  more  and  no  less.  New  valua- 
tions are  frequently  evolved  from  facing  the  con- 
ditions discovered.  In  a  none  too  startling  fashion 
Barbara  Low  has  presented  this  fairly. 

With  the  science  in  its  early  growth  it  is  a  bit 
early  to  set  down  concretely  all  its  salient  points. 
There  is  so  much  to  say,  so  many  new  words  to  ex- 
plain, and  it  is  necessary  to  understand  them  all. 
Many  surprising  discoveries  have  been  unearthed  by 
the  application  of  analysis.  These  are  so  diverse 
from  what  we  have  been  in  the  habit  of  regard- 
ing as  the  behavior  of  the  human  mental  mechanism 
that  we  are  prone  at  first  glance  to  reject  them  as 
absurd.  The  underlying  motives  of  many  of  our 
everyday  actions  are  explained  and  so  frequently 
are  our  protective  coverings  torn  away  that  we 
instinctively  seek  for  shelter,  resulting  in  the  de- 
velopment of  resistances.  The  very  mainsprings 
of  existence  are  tapped,  matters  of  sex  are  brought 
to  light,  and  an  explanation  is  given  for  the  re- 
pressions which  surround  us  at  every  turn. 

Barbara  Low  tells  us  that  Freud  in  making  use 
of  various  clinical  material  discovered  the  work- 
ings of  the  unconscious.  He  showed  how  certain 
emotional  contents  were  rejected  by  the  conscious 
mind  and  suppressed  into  the  unconscious,  which 
were  then  only  revealed  to  the  conscious  mind  in  an 
acceptable  form.  One  of  the  most  common  forms 
of  disguising  the  unresolved  complexes  which  had 
accumulated  in  the  unconscious  was  by  the  use  of 
the  symbol.  During  sleep  when  the  censor  was 
relaxed  these  suppressed  wishes  were  woven  into 
dreams  in  which  the  symbol  and  other  protective 
mechanisms  were  employed.  Sex  was  one  of  the 
earliest  things  pushed  back  into  the  unconscious 
and  therefore  one  of  the  most  commonly  dis- 
guised by  the  symbol.  Sex  also  played  the  most 
prominent  part  in  the  unraveling  of  the  uncon- 
scious, for  there  was  so  little  place  allowed  for  it 


in  the  conscious  existence  in  an  undisguised  form. 

Much  credit  is  given  Dr.  Ernest  Jones  for  the 
work  he  has  done  in  analysis  in  England.  If  it  is 
made  to  appear  that  he  has  discovered  some  of  the 
points  to  which  reference  is  made  in  connection 
with  his  work,  we  must  take  into  consideration  the 
enthusiasm  of  the  worker  who  has  found  so  much 
inspiration  in  working  with  him.  After  all  it  matters 
little  to  whom  credit  is  given.  The  source  is  not  of 
primary  importance.  The  vital  thing  is  to  understand 
the  great  forces  which  are  constantly  at  work  with- 
in ourselves  and  to  apply  the  knowledge  gained. 
To  get  full  benefit  from  analysis,  as  Barbara  Low 
points  out,  it  does  not  suffice  to  get  a  cursory  in- 
tellectual grasp  of  the  underlying  principles ;  it  is 
necessary  to  plumb  to  the  depths  and  reach  the 
ultimate  emotional  level.  Then  we  shall  get  down 
to  true  values. 

She  also  shows  how  analysis  can  be  applied  to 
numberless  fields  of  human  endeavor;  to  the  under- 
standing of  self,  to  the  understanding  of  the  urges 
which  drive  us  on.  She  shows  how  farreaching  it 
can  be  made  when  applied  socially,  in  teaching,  and 
in  an  understanding  of  the  new  interpretation  of 
the  things  that  are  studied.  She  shows  how  im- 
portant a  place  in  the  social  group  the  teacher  has, 
how  he  may  by  his  rigorous  behavior  in  the  class 
room  create  a  twisted  father  complex  or  how  by 
punishment  create  a  sex  sadistic  complex.  These 
are  only  a  few  points  that  have  been  brought  out 
in  this  small  book  and  many  of  the  more  vital  ones 
in  analysis  have  hardly  been  touched.  On  the 
whole,  considering  the  condensation  that  was  re- 
quired, a  great  deal  of  territory  has  been  covered 
and  an  understanding  portrayal  of  the  elements  of 
psychoanalysis  presented. 

THE  PROBLEM  OF  TUBERCULOSIS. 

Tuberculosis  and  Public  Health.  Bv  H.  Hyslop  Thomson, 
M.  D.,  D.  P.  H.;  County  Medical  Officer  of  Health, 
County  Tuberculosis  Officer,  and  School  Medical  Officer 
for  Hertfordshire;  Formerly  Tuberculosis  Officer  for 
Newport  and  East  Alonmouthshire,  etc.  New  York  and 
London :  Longmans,  Green  &  Co.,  1920.   Pp.  xi-104. 

With  laboring  breath  and  halting  steps,  the  thou- 
sands of  tuberculous  in  England  had  faced  the  road 
which  leads  to  cure,  and  the  great  wave  of  health 
they  met  was  encouraging  others  to  set  out.  The 
death  rate  was  diminishing  when  war  and  progress 
met.  In  1914  the  number  of  deaths  had  gone 
down  from  53,120  to  50,298;  in  1918  it 
had  risen  to  58,073.  The  war  emphasized  the 
relationship  between  a  deficient  food  supply  and 
tuberculosis  and  showed  that  a  diet  rich  in  fats  and 
vitamines  is  essential  to  protect  the  human  body. 
Today  the  fight  is  renewed,  heavily  handicapped  by 
the  scarcity  of  food  and  housing,  though  often  it 
is  the  nonhygienic  habits  of  the  householders  which 
do  the  mischief.  The  mid- Victorian  ideas  of  the 
viciousness  of  fresh  air,  especially  at  night,  still 
prevail.  Moreover,  the  construction  of  cities  from 
a  health  point  of  view  has  never  been  considered, 
still  less  has  any  attention  been  paid  to  the  question 
of  housing  for  the  tuberculous.    But  nothing  will 


September  11,  1920.] 


BOOK  REVIEWS. 


379 


I 

be  done  effectually  without  the  intelligent  co- 
operation of  the  people.  There  must  be  amplification 
of  the  present  system  of  notification ;  fats  and  sugars 
must  be  sold  at  reasonable  prices;  there  must  be 
abolition  pf  insanitar\-  areas,  segregation  of  ad- 
vanced cases,  and  the  provision  of  a  clean  milk 
supply.  All  these  seem  simple  weapons  to  fight 
so  powerful  an  enemy,  but  none  more  effectual 
have  yet  been  discovered.  The  modern  tendency 
to  provide  hospital,  sanatorium,  and  colony  in 
one  has  proved  the  best.  A  large  and  suitable 
site  and  much  expenditure  are  necessary,  but  the 
preventive  treatment  of  advanced  cases,  the  con- 
ser\-ative  treatment  of  quiescent  ones,  and  the 
improvement  of  the  economic  standard  of  the 
patient  are  now  maintained.  As  the  type  of  com- 
mon adult  pulmonar}-  consumption  is  rarely  met 
with  in  children  under  fifteen,  the  usual  form 
being  latent  tuberculosis  of  bovine  origin,  a 
special  block  or  place  should  be  provided  for  these. 

Considered  economically,  tuberculosis  is  a  great 
cause  of  poverty,  and  to  complete  the  vicious  circle, 
poverty  is  a  great  cause  of  tuberculosis,  therefore 
all  schemes  for  relief  should  have  governmental 
and  official  support.  The  disease  is  a  cause  of  death 
when  life  should  be  at  its  strongest,  and  the  annual 
loss  is  estimated  at  many  million  pounds. 

Even  after  apparent  return  to  normal  working 
health,  the  questions  come  swarming  as  to  how  that 
health  shall  be  kept.  \'arious  other  points  are  con- 
sidered and  ably  treated  by  one  who  has  wrestled 
with  the  problems  in  many  responsible  positions. 

THE  COLLOIDS. 

The  Use  of  Colloids  in  Health  and  Disease.   By  Alfred  B. 

Searle.     With   Foreword   by    Sir   Malcolm  Morris, 

E.  C.  V.  O.  Illustrated.  London  :  Constable  &  Co..  Ltd.. 
'1920;  New  York:  E.  P.  Button  &  Company.    Pp.  vii-120. 

Thomas  Graham  in  1861  added  another  perplexity 
to  the  medical  sciences.  His  discovery  that  certain 
solutions  would  pass  through  a  membrane  and 
others  not,  threw  light  upon  a  state  of  matter  of 
which  little  or  nothing  was  known  at  the  time, 
though  so  much  in  life  and  the  commercial  world 
depended  on  it.  He  gave  the  name  colloidal  (Kolla- 
glue)  to  that  state  in  which  substances  may  show 
characteristics  in  solution  quite  different  from  those 
of  a  true  solution.  These  solutions  he  named  sols. 
There  are  no  groups  of  substances  invari- 
ably colloid.  Soaps  dissolving  in  alcohol  are 
correctly  termed  crystalloids.  In  water  they  behave 
equally  characteristically  as  colloids.  There  are  or- 
ganic substances  between  the  two  which  are  called 
semicolloids.  Each  true  colloidal  particle  carries  a 
definite  charge  of  electricity,  some  being  electro- 
positive, other  electronegative. 

The  difficulties  of  research  seem  endless,  but  the 
part  to  be  played  by  colloidal  sols  and  gels  in  hy- 
giene is  realized.  Chadwick  firmly  believed  that  the 
entire  removal  of  all  conditions  of  •  dirt,  including 
foul  air  and  bad  drainage,  was  an  effectual  preven- 
tive of  all  forms  of  epidemic,  and  here  Mr.  §earle 
goes  aside  to  describe  the  peculiar  behavior  of  soap, 
due  to  its  colloidal  character.  He  also  frankly  points 
out  where  the  colloids  hitherto  have  failed  as  germi- 
cides and  disinfectants,  but  gives  the  hopeful  views 
born  of  recent  studies.    The  chapters  on  the  uses 


of  colloidal  remedies,  with  authentic  cases  of  cure 
given  by  men  like  Sir  James  Cantlie  and  Sir  Mal- 
colm ]\Iorris,  who  found  that  colloidal  silver  had  a 
distinctly  soothing  effect  while  curing  perineal  ec- 
zema, hemorrhoids,  and  enlarged  prostate  with  irri- 
tation of  the  bladder,  also  contain  much  about  col- 
loidal mercury,  iron,  antimony,  and  manganese. 

In  conclusion  it  is  urged  that  the  colloids  used  by 
physicians  should  be  prepared  with  the  greatest 
care,  for  preparations  good  enough  for  the  chemical 
lectures  are  usually  too  unstable  for  medical  pur- 
poses. Also  a  small  number  of  recent  writers  have 
confused  colloidal  elements  and  complex  organic 
compounds  which  may  be  used  either  in  a  colloidal 
state  or  as  a  true  solution.  The  condemnatorv- 
statements  have  usually  been  made  by  those  with  an 
imperfect  knowledge  of  colloids,  or  relate  to  those 
nonisotonic  with  serum  and  other  body  fluids. 

The  author  is  surely  justified  in  his  plea  that  the 
discovery-  of  artificially  prepared  colloids  which  are 
stable  when  in  the  human  organism  is  so  recent,  yet 
the  results  after  administration  so  interesting  that 
they  merit  a  clear  setting  forth,  for  the  learned  to 
become  more  learned  and  the  unconverted  more 
confounded  and  unable  to  answer. 

wo:viAN. 

Woman.  By  Magdeleixe  ^L\RX.  Introduction  by  Henri 
Barbusse.  Translated  bv  Adele  Szold  Seltzer.  New 
York:  Thomas  Seltzer,  1920.    Pp.  vii-228. 

It  is  not  possible  to  subscribe  unqualifiedly  to  the 
extravagant  praise  which  the  introduction  bestows 
upon  this  book.  It  is  true  that  it  has  various 
poetic  qualities  which  give  the  author  a  certain 
literar}-  rank.  It  has  truth,  the  fearless  expression 
of  the  new  attitudes,  the  untrammeled  convictions 
of  a  young  soul  who  must  find  life  for  herself. 
She  must  do  more  than  this ;  she  must  live  that  life 
apart  from  the  conventional  molds  to  which  it  may 
attach  itself  even  by  its  own  choice.  So  in  ac- 
cepting the  various  experiences  of  womanhood,  in- 
dependence of  parents,  earning  of  livelihood, 
marriage,  motherhood,  even  a  second  love,  she 
strives  for  an  independence  which  is  the  finding 
and  the  assertion  of  the  need  to  live  out  her  own 
inner  self.  There  are  other  poetic  marks,  charm 
of  style,  the  grace  of  enticing  the  moods  of  wind 
and  weather  to  express  the  play  and  the  cry  of 
human  feeling. 

Yet  when  these  things  are  appreciated  there  is 
a  bitter  flavor  underneath,  a  slightly  sour  morbidity, 
one  might  say,  which  demands  deeper  probing.  The 
woman,  fictitious  character  though  she  may  be, 
spends  too  much  force  upon  self  inspection.  She 
might  say  she  escaped  morbidness  because  of  her 
appraisal  of  all  this  self  in  terms  of  living  and  of 
loving  widely.  Yet  there  is  an  insistent  note  of 
narcissism,  too  much  reference  of  it  all  to  herself 
and  in  terms  of  herself.  Her  love,  toward  her  male 
objects,  her  child,  the  friend  of  her  own  sex,  turns 
upon  itself  for  measurement  and  for  definition,  not 
toward  the  loss  of  itself  in  an  extraneous  out- 
pouring. Superficially  the  book  seems  to  reveal  a 
high  unselfishness  which  reaches  out  more  truly 
than  narrow  conventions  would  allow.  The  rule 
of  measurement,  however,  remains  behind  even  in 
the  beautiful  body  which  fills  the  horizon  rather 


380  BOOK  H 

tlian  forms  only  a  stimulus  to  wider  things.  This 
is  the  reason  why,  when  a  new  love  intruded  upon 
the  old  and  took  possession  both  of  soul  and  bodv, 
it  was  coimted  justified.  The  more  ancient  ex- 
perience of  woman  in  giving  herself  to  the  free 
enjoyment  of  any  claims  upon  her  presented  itself 
as  this  woman's  right  and  her  extravagant  ai)Sorp- 
tion  in  self  obscured  the  reversionary  character  of 
this  promiscuity.  Her  need  to  take  as  freely  of 
love  as  of  sim  and  air  seemed  to  efface  another 
need  that  belongs, to  progress,  that  of  bending  the 
rights  of  the  individual  to  a  restriction  which  has 
for  its  end  a  different  broadening  out  beyond  self. 

The  book  does  not  speak  entirely  of  such  blind 
absorption  in  one's  own  need.  It  does  represent 
the  awakening  of  woman  to  greater  sincerity  with 
herself  in  her  relation  to  life  and  love.  It  reveals 
the  effort  to  obtain  greater  imderstanding  and  freer 
exercise  of  one's  powers.  It  reveals,  however,  those 
inner  psychic  factors  which  emotionally  forge 
chains  about  the  self.  For  this  reason  the  poetry 
is  too  self  indulgent  and  it  becomes  self  deceptive. 
It  is  true  that  the  way  out  has  to  be  learned  first 
through  a  genuine  valuation  of  soul  and  body  which 
has  been  in  danger  of  being  forgotten,  but  one  is 
tempted  to  remain  only  at  this  valuation.  The 
franker  literature  of  the  present  day,  in  which  this 
more  fearless  evaluation  of  self  is  found,  must 
nevertheless  fix  its  eye  upon  a  higher  end.  It  must 
not  begin  and  end  with  I  and  my. 

THE  SUPERSTITION  OF  CHESTERTON 

The  Superstition  of  Divorce.  By  G.  K.  Chesterton,  Au- 
thor of  Heretics,  Orthodoxy,  etc.  New  York :  John  Lane 
Company.  1920.    Pp.  11-150. 

The  controversy  over  the  proposed  changes  in  the 
divorce  law  in  England  has  1)rought  Mr.  Chester- 
ton rushing  to  the  defense  of  the  status  quo.  He 
comes,  like  the  White  Knight,  equipped  with  all 
manner  of  fantastic  and  useless  apparatus — puns, 
prejudices,  paradoxes,  anecdotes,  epigrams,  incon- 
sistencies, and  with  a  professed  determination  not 
to  employ  the  "religious  argument."  Literally,  he 
does  not,  but  actually  he  speaks  from  the  ecclesias- 
tical viewpoint. 

.IMr.  Chesterton  does  not  believe  in  divorce  because 
he  does  not  believe  in  remarriage.  Marriage,  he 
says,  is  a  vow,  like  poverty  or  chastity ;  it  is  "the 
idea  of  loyalty":  it  is  "a  tryst  with  oneself."  The 
tragedy  of  imsuited  people  he  admits  with  a  certain 
sadistic  satisfaction :  it  is  a  "noble  and  fruitful  trag- 
edy, like  that  of  a  man  who  falls  fighting  for  his 
country,  or  dies  testifying  to  the  truth."  These 
arguments  reveal  Mr.  Chesterton's  mind — a  mind 
occupied  with  the  tenuous  concepts  of  theological 
ethics  and  preferring  noble  attitudes  to  reality. 
For  the  whole  conception  of  vows  is  a  superstition, 
the  superstition  of  an  ancient  theology  which  opposed 
the  facts  of  himian  nature  with  an  implacable  idea. 
Man  was  ill  at  ease  in  the  days  of  the  church  fathers, 
he  was  only  in  inconsiderable  degree  the  master  of 
his  environment,  and  because  he  felt  little  and  un- 
comfortable he  bolstered  up  his  courage  with  grand- 
iose conceptions.  Mr.  Chesterton,  of  course,  is  only 
one  of  the  many  who  still  hold  these  conceptions,  but 
in  his  case  is  found  the  rcductio  ad  absurduni.  No 
doubt  he  views  the  "tryst  with  oneself"  and  the  gall- 


FIEll'S.  [New  York 

Medic.vl  Journal. 

t 

ery  of  unsuited  martyrs  as  an  indication  of  the  tri- 
um])h  of  spirit  o^er  flesh.  Perhaps,  but  too  often 
that  is  a  negation  of  joy  and  healthful  love  of  living. 
And  martyrdom  is  not  a  thing  to  be  encouraged. 

^Ir.  Chesterton  was  born  some  centuries,  too  late. 
He  should  have  been  a  fat.  jolly  friar  of  medieval 
times,  penning  polemics  on  the  doctrine  of  original 
sin  of  debating  how  many  angels  could  stand  on  the 
point  of  a  needle.  Such  a  contribution  from  him 
would  be  exceedingly  interesting.  But  in  the  twen- 
tieth century  he  is  ill  at  ease^  Our  "worthless, 
poisonous  plutocratic  modern  society"  does  not 
please  him  and  so  he  tilts  at  it  like  Don  Quixote  at 
the  windmill — his  weapon  a  paradox. 



New  Publications  Received. 


[IVe  publish  full  lists  of  books  received,  but  we  acknoTJi'l- 
eage  no  obligation  to  revieiv  them  all.  Nevertheless,  so 
far  as  space  permits,  we  rezneiv  those  in  zvhich  zve  think 
our  readers  are  likely  to  be  interested.] 


THREE  VE.\RS  OF  WORK  FOR   H.\XDIC.\PPED  ,MEX.     A  Report 

of  the  -Activities  of  the  Institute  for  Crippled  and  Disabled 
Men.  By  John  Cui.bekt  Faries.  Ph.D.  New  York: 
1920.    Pp.  3-95. 

KXOPHTH.ALMIC   (;OITRE  ITS   XO.XSURCilCAL  TREATMENT. 

By  Israel  Bram.  M.  D..  Instructor  in  Clinical  Medicine, 
Jefferson  Medical  College,  Philadelphia,  etc.  St.  Louis ' 
C.  v.  Mosby  Company.  1920.    Pp.  i.x-438. 

THE  Fuxi)AMEXT.\LS  OF  HCMAX  AXATOMv.  Including 
Its  Borderland  Districts.  From  the  Viewpoint  of  a  Prac- 
titioner. By  M.\RSH  PiTZMAx,  A.B.,  M.  D.,  Professor  of 
.\natomy  in  the  Dental  Department  of  Washington  Uni- 
versity, St.  Louis.  Illustrated.  St.  Louis :  C.  \'.  Moshv 
Company,  1920.    Pp.  iii-356. 

THE  INDUSTRIAL  CLINIC.  A  Handbook  Dealing  with 
Health  in  Work.  Bv  Several  Writers.  Edited  bv  Edgar  L 
CoLLis,  M.  D.  (O.xon.),  M.  R.  C.  P.,  Talbot  Professor  of 
Preventive  Medicine  in  the  University  of  Wales  :  Late  Di- 
rector of  Welfare  and  Health.  Ministry  of  Munitions,  and 
H.  M.  Medical  Inspector  of  Factories.  Modern  Clinic 
Manuals.  New  York :  William  \\'ood  &  Co.,  1920.  Pp.  xii- 
239. 

Di.\GN0STic  METHODS.  Chemical.  Bacteriological,  and 
^Miscroscopical.  A  Textbook  for  Students  and  Practitioners. 
By  Ralph  W.  Webster,  M.  D..  Ph.  D..  .Assistant  Professor  * 
of  Pharmacological  Therapeutics  and  Instructor  in  Medi- 
cine in  Rush  Medical  College,  University  of  Chicago :  Direc- 
tor of  Chicago  LaboratorA'.  etc.  Sixth  Edition.  Revised  and 
Enlarged.  Illustrated.  Philadelphia  :  P.  Blakiston's  Son  & 
Co.    Pp.  xxxix-844. 

mental  deficiency.  (.Amentia.  ^  By  .\.  F.  Tredgold. 
M.  D.,  F.  R.  S.  (Edin.).  Fellow  of  the  Royal  Society  of 
Medicine ;  Consulting  Physician  to  the  National  .Associa- 
tion for  the  Feeble  Minded:  Consulting  Mental  Specialist 
to  the  Willesden  Education  .Authority ;  Vice-President. 
Central  Association  for  the  Mentally  Defective,  etc.  Third 
Edition,  Revised  and  Enlarged.  Illustrated.  New  York: 
William  Wood  &  Co.,  1920.    Pp.  xx-531. 

.\X  ATLAS  OF  THE  PRIMARY  AND  CUTANEOUS  LESIONS  OF  AC- 
QUIRED  SYPHILIS   IN   THE   MALE.      By   ChaRLES   F.  WhITE, 

O.  B.  E.,  M.  C.  Major,  Royal  Army  Medical  Corps:  Lec- 
turer on  A'enereal  Disease  and  Officer  in  Charge,  Rochester 
Row  Military  Hospital ;  and  W.  Herbert  Brown,  M.  D., 
Physician  for  Diseases  of  the  Skin.  \'ictoria  Infirmary, 
Glasgow:  Late  Captain.  Royal  Army  Medical  Corps  (T.  C). 
With  a  Foreword  bv  Lieutenant  General  Sir  T.  H.  J.  C. 
Goodwin,  K.  C.  B.,  C.  M.  G.,  D.  S.  P.,  K.  H.  P..  Director 
General,  Army  Medical  Service.  New  York :  William 
Wood  &  Co.,  1920.    Pp.  vii-32. 


Miscellany  from  Home  and  Foreign  Journals 


Causes  and  Definition  of  Cancer. — Leo  Loeb 
(American  Journal  of  the  Medical  Sciences,  June. 
1920)  discusses  the  following  factors  that  may 
enter  as  causes  of  cancer :  External  stimulation  of  a 
mechanical  or  chemical  nature ;  internal  chemical 
stimulation,  especially  through  the  action  of  inter- 
nal secretion;  heredity,  which  includes  various  not 
yet  well  defined  factors,  some  of  them  probably 
identical  with  other  causes ;  embryonal  character  of 
tissue  or  disturbances  of  embryonal  development, 
including  parthenogenetic  development  of  the 
ovum ;  in  an  indirect  way  age ;  contact  between 
normal  and  cancerous  tissue ;  a  possible  effect  of 
microorganisms.  Cancer  is  abnormality  of  growth. 
Primarily  it  is  a  disturbance  in  the  equilibrium  of 
the  individual,  not  through  toxins  but  through  an 
increased  proliferative  activity  of  the  cells  which  is 
usually  associated  with  an  increased  motility.  This 
increase  is  long  continued  and  often  permanent. 
It  is  in  all  probability  in  the  large  majority  of  cases 
due  to  changes  in  cell  metabolism  which  are  of  such 
a  character  that  they  propagate  themselves.  In 
some  cases  the  same  efifect  may  perhaps  be  pro- 
duced through  extraneous  causes,  such  as  micro- 
organisms. 

Malignancy  in  Diseases  of  the  Gallbladder. — 

J.  F.  Erdmann  (American  Journal  of  Obstetrics, 
December,  1919),  among  224  cases  subjected  to 
operation  for  cholecystitis,  found  the  gallbladder 
malignant  in  fifteen,  or  6.7  per  cent.  All  these 
ca.ses  were  in  females.  In  the  report  of  the  New 
York  City  Board  of  Health  for  1918,  nearly  ten  per 
cent,  of  the  2.170  deaths  from  cancer  were  instances 
of  cancer  of  the  liver  or  gallbladder.  The  frequency 
of  cancer  of  the  biliary  system  shows  the  follow- 
ing order :  Gallbladder,  cystic  duct,  and  liver ;  pan- 
creas, with  common  duct  contiguity ;  common  he- 
patic ducts ;  papilla  of  Vater.  In  all  the  author's 
victims  of  gallbladder  carcinoma  stones  were  found 
in  the  organ.  Gallstones  or  biliary  .sand  evidently 
act  as  a  provocative  factor  in  the  production  of 
malignancy.  The  statistical  aspect  of  malignancy, 
as  compared  with  the  operative  mortality,  should  be 
clearly  placed  before  all  i)atients  with  gallbladder 
disease.  The  mortality  of  cholecystostomy  and  cho- 
lecystectomy is  well  under  four  per  cent. ;  in  fact, 
below  three  and  even  two  per  cent,  in  the  hands  of 
experienced  clinicians;  and  if  it  is  recognized  that 
the  malignant  incidence  is  between  four  and  six 
per  cent.,  the  patient  selecting  the  operative  risk 
plainly  has  the  advantage  of  avoiding  a  malignant 
death  by  two  to  three  per  cent.  No  definite  symp- 
toms of  malignancy  can  be  described  in  the  early 
onset  of  the  disease.  When  the  gallbladder  or  mass 
in  the  right  hypochondriac  region  becomes  palpable 
in  nonacute  cases,  with  or  without  an  ever  deep- 
ening jaundice,  malignancy  must  be  given  weighty 
consideration.  Increasing  jaundice,  .slow  or  insidi- 
ous, is  pathognomonic.  Loss  of  weight  is  evident 
only  when  the  tumor  extends  to  the  common  duct, 
pancreas,  or  adjacent  viscera.  Many  patients  with 
gallbladder  malignancy  mention  pain  as  the  first 


symptom.  Removal  of  stones  in  these  ca.ses,  with- 
out complete  cholecystectomy,  is  prone  to  be  fol- 
lowed by  a  rapidly  fatal  issue.  A  satisfactory 
cholecystectomy  can  be  done  in  certain  cases  of  in- 
volvement of  the  fundus  and  body  of  the  gallblad- 
der. These  are  the  cases  detected,  as  a  rule  inci- 
dentally to  an  operation  for  cholecystitis.  Excision 
of  sections  of  the  common  and  hepatic  ducts  may 
be  attempted  but  resection  of  the  head  of  the  pan- 
creas is  attended  with  imdue  risk.  Involvement  of 
the  papilla  and  ampulla  is  l)est  overcome  by  a  cysto- 
gastrostomy. 

Intussusception  from  Benign  Tumor  of  the  In- 
testines.— A.  Murat  Willis  (Surgery,  Gynecology, 
and  Obstetrics,  Jime.  1920)  emphasizes  the  follow- 
ing points  in  intussusception  resulting  from  benign 
tumor  of  the  intestine  : 

1.  The  possibility,  or  indeed,  the  probability  exists 
that  benign  tumors  of  the  small  intestine  are  of 
more  frequent  occurrence  than  the  number  of  cases 
reported  from  surgical  clinics  would  lead  one  to  sus- 
pect. 

2.  There  is  no  reason  to  l^elieve  that  the  material 
from  the  Boston  institutions  is  unique  and  that 
Bostonians  suffer  from  lienign  intestinal  tumor  more 
than  persons  in  other  localities.  Accepting  this,  we 
face  the  striking  fa<ft  that  appro .ximately  one  subject 
in  every  1,500  coming  to  autopsy  .shows  the 
presence  of  adenoma  of  the  small  intestine.  Even 
more  striking  is  the  fact  that  in  the  7,492  autopsies, 
benign  tumors  of  the  small  intestine  were  encoun- 
tered nineteen  times,  so  that  we  have  an  incidence 
of  nearly  one  to  every  400  autopsies. 

'3.  In  considering  the  few  cases  of  adenoma  that 
have  been  reported  by  surgeons,  it  must  be  remem- 
bered that  many  of  the  socalled  polyps  are  adeno- 
matous in  structure,  but  cannot  be  included  because 
of  the  failure  to  make  a  histological  examination  of 
the  tumor. 

Acquired  Immunity  in  Recent  Grippe  Epi- 
demics.— Chauff^ard  {Bulletin  de  rAcadtrniic  dc 
medecine,  April  27,  1920)  refers  to  a  theory  re- 
cently advanced  by  P.  Jacquet  to  the  eiTect  that 
whereas  true  epidemic  influenza,  such  as  that  of 
1918.  confers  acttial  immunity,  the  more  connnon 
seasonal  disorder  generally  labelled  grippe  is  a 
nonimmunizing  affection.  Chauffard  presents  sta- 
tistics on  forty  cases,  comprising  twenty-two  men 
and  eighteen  women  who  developed  grippe  between 
October  13,  1919,  and  March  29.  1920.  The  eight- 
een cases  in  women  were  of  a  more  or  less  severe 
thoracic  type,  ranging  from  diffuse  bronchitis  to 
instances  of  congestive  or  bronchopneumonic  areas 
in  the  lungs.  Of  the  twenty-two  cases  in  men,  fif- 
teen were  likewise  instances  of  thoracic  grippe, 
while  seven  were  cases  of  milder,  uncomplicated 
grippe.  Out  of  the  entire  series  of  forty,  eleven, 
or  27.5  per  cent.,  had  had  an  attack  of  influenza 
during  the  epidemic  of  1918-1919.  These  eleven 
comprised  eight  men,  or  thirty-six  per  cent.,  with 
a  history  of  influenza,  and  three  women,  or  16.6 
per  cent.    Five  of  the  eleven  original  attacks  had 


382 


MISCELLANY  FROM  HOME 


AND  FOREIGN  JOURNALS. 


[New  York 
Medical  Journal. 


consisted  of  more  or  less  severe  thoracic  grippe 
and  six  of  mild,  uncomplicated  grippe.  In  no  case, 
apparently,  had  the  attack  been  one  of  typical  febrile 
influenza  with  nervous  manifestations.  In  view  of 
the  enormous  number  of  persons  afflicted  in  the 
great  epidemic  of  1918-1919  it  seems  remarkable 
that  nearly  three  fourths  of  the  more  recent  cases 
should  have  occurred  in  persons  unaffected  in  the 
former  epidemic.  This  ratio  is  of  some  significance 
as  indirect  proof  of  an  immunizing  action  of  epi- 
demic influenza.  The  fact  that  none  of  the  forty 
recent  cases  gave  a  history  of  nervous  febrile  in- 
fluenza tends  to  show  that,  among  the  complex 
forms  in  which  epidemic  influenza  occurs,  the  most 
specific  and  probably  the  most  immunizing  form 
is  the  nervous  febrile  variety  which  marks  the  be- 
ginning of  great  pandernics  and  runs  its  course 
without  secondary  infectious  complications.  Rec- 
ognition of  the  immunizing  property  of  influenza 
introduces  the  possibility  of  preventive  vaccination 
against  the  disease. 

Complement  Fixation  in  Influenza.— H.  J.  B. 
Fry  and  C.  Lundie  (Lancet,  February  14,  1920) 
carried  out  a  rather  small  but  carefully  controlled 
series  of  experiments  on  complement  fixation  in  in- 
fluenza, using  the  sera  of  patients  in  a  venereal  hos- 
pital for  investigation.  The  antigen  used  was  pre- 
pared from  an  organism  isolated  from  a  blood  cul- 
ture made  during  the  third  wave  of  the  epidemic. 
Control  sera  from  normal  individuals,  syphilitics, 
patients  with  typhoid,  malaria,  and  tuberculosis,  and 
from  patients  with  pyrexia  of  unknown  origin  were 
utilized.    The  results  are  summarized  as  follows: 

1.  The  antigen  shows  greater  or  less  fixation  of 
complement  with  sera  derived  from  cases  of  influ- 
enza, both  recent  and  those  occurring  in  previous 
waves  of  the  epidemic. 

2.  This  complement  fixation  is  absent  from  the 
sera  of  normal  individuals  who  have  never  had 
influenza. 

3.  It  is  absent  in  the  case  of  sera  from  individ- 
uals who  are  suffering  from  other  specific  diseases 
and  are  free  from  any  recent  history  of  influenza. 

4.  An  antigen  prepared  from  a  coliform  organ- 
ism, isolated  as  a  contamination  from  the  spinal 
fluid  of  an  influenza  patient,  shows  no  fixation  of 
complement  with  sera  from  cases  of  influenza. 

Chest  Measurements.  —  Robert  M.  Culler 
(Military  Surgeon,  June,  1920)  writes  of  the  futility 
of  recording  chest  measurements  at  the  nipple  line, 
giving  the  following  reasons  for  his  deductions: 

1.  Lung  capacity  and  competency  cannot  be  esti- 
mated by  a  tape  line  nor  actual  lung  disease  excluded. 

2.  The  degree  of  chest  expansion  or  mobility, 
expressed  in  inches  on  reports  of  physical  examina- 
tions, are  of  no  value  except  to  suggest  develop- 
mental possibilities  in  the  immature. 

3.  The  form  of  the  chest  in  young  men  is  imma- 
terial, since  all  forms  can  be  increased  in  size  by 
rib  elevation  through  muscular  development.  None 
of  the  classical  chest  forms  are  incompatible  with 
great  lung  power  and  physical  vigor. 

4.  If  chest  mobility  is  to  be  recorded  by  inches, 
the  measurements  should  be  made  at  the  level  of 
the  ensiform  cartilage. 


The  Prevention  of  Respiratory  Diseases  in 
Infancy  and  Early  Childhood. — John,  Sobel 
(Medical  Record,  May  15,  1920)  remarks  that 
acute  bronchitis  and  bronchopneumonia  are  the  two 
diseases  which  cause  most  deaths  in  children  under 
five  years.  In  prophylactic  measures  two  main 
considerations  present  themselves:  1,  The  need  of 
placing  the  throat,  nose,  mouth  and  teeth  in  such 
condition,  through  nasal  and  oral  hygiene,  that  the 
various  bacteria  ever  present  in  these  localities  will 
find  the  throat  and  nose  less  favorable  for  either 
development ;  2,  that  by  the  avoidance  of  overeat- 
ing, overexercise,fatigue,  irritability  and  a  lack  of 
the  necessary  amount  of  sleep,  the  general  health 
may  be  kept  at  such  a  standard  as  to  maintain  suf- 
ficient resistance  to  ward  off  diseases  of  the 
respiratory  tract  or  to  minimize  their  effects. 

Plea  for  Systemic  Research  Work  in  Endo- 
crinology.— J.  Aug.  Hammar  (Endocrinology, 
January-March,  1920)  states  that  direct  lesions  of 
endocrine  organs  occur  and  frequently  a  certain 
clinical  syndrome  has  more  or  less  unanimously 
been  considered  to  be  connected  with  such  lesions 
of  one  organ  or  another.  To  discern  such  direct 
lesions,  at  least  when  they  are  somewhat  pro- 
nounced, our  present  knowledge  has  often  proved 
sufficient.  But  in  connection  with  exophthalmic 
goitre,  Addison's  disease,  acromegaly  and  diabetes 
occur,  formes  frustes,  in  which  the  want  of  preci- 
sion in  our  present  anatomical  knowledge  is  per- 
ceptible. 

The  endocrine  organs  are  closely  connected  with 
each  other  functionally,  so  that  a  disturbance  in  the 
function  of  one  of  these  organs  involves  a  disturb- 
ance in  the  function  of  a  larger  or  smaller  number 
of  the  others.  Whether  this  state  of  things  is 
characteristic  only  of  the  endocrine  system  or 
whether  after  more  careful  research  anything  of 
this  sort  will  also  be  proved  for  other  organs  of  the 
body  is  another  question.  It  is  sufficient  to  estab- 
lish that  in  such  cases  we  must  reckon  not  only 
with  direct  but  also  with  indirect  disturbances  of 
the  endocrine  organs. 

Mental  and  Nervous  States  and  Military  Effi- 
ciency.— Karl  M.  Bowman  (Military  Surgeon, 
June,  1920)  discusses  the  relation  of  defective  mental 
and  nervous  states  to  military  efficiency,  and  states 
that  there  are  in  the  United  States  a  large  number 
of  cases  of  mental  or  nervous  disease  or  defect. 
This  is  shown  by  the  fact  that,  out  of  every  twenty 
men  rejected  in  the  draft,  one  man  was  rejected 
for  mental  defect  and  one  man  for  mental  or  nerv- 
ous disease.  During  the  war  every  army  had  large 
numbers  of  cases  of  mental  or  nervous  disease  which 
markedly  impaired  the  efficiency  of  the  fighting 
forces.  To  secure  the  most  efficient  army  possible, 
it  is  necessary  to  eliminate  the  mentally  unfit  as 
soon  as  possible,  but  to  use  available  cases  of  mental 
or  nervous  disease  or  defect  whenever  possible  and 
where  best  fitted.  To  eliminate  the  mental  defec- 
tives, the  best  way  is  to  use  the  group  examina- 
tions given  by  the  psychologists  to  recruits.  Such 
an  estimate  was  perfected  and  used  in  our  own  army 
and  is  satisfactory.  Borderline  cases,  depending  on 
their  mental  age,  their  physique,  and  disposition, 
may  be  fitted  for  service.    The  majority  of  cases 


September  11,  1920.]  MISCELLANY  FROM  HOME   AND  FOREIGN  JOURNALS.  383 


with  a  history  of  a  psychosis  are  unfit  for  military 
service.  Those  offering  the  best  prognoses  are: 
manic  depressive,  and  infective  exhaustive  psy- 
choses ;  acute  alcohoHc  conditions,  per  se,  are  not  a 
bar  to  service;  chronic  alcoholic  conditions,  if  pro- 
nounced or  with  paranoidal  tendencies.  Espe- 
cially should  it  be  guarded  against  allowing  arrested 
cases  of  dementia  praecox  and  paranoia  from  enter- 
ing the  service.  Every  case  must  be  judged  on  its 
individual  merits  and  by  a  trained  board  of  psychi- 
atrists. 

Of  the  psychoneuroses,  all  extreme  cases  are  unfit 
for  service.  Psychasthenia  and  anxiety  neuroses 
are  the  worst  types ;  hysteria  and  neurasthenia  are 
the  best.  Because  of  the  high  intelligence  of  many 
psychoneurotics,  they  are  valuable  individuals,  and 
should  be  used,  preferably  in  noncombatant  service. 
The  conscientious  objector  and  the  malingerer  are 
frequently  cases  of  mental  disease,  and,  if  so,  should 
be  treated  as  such;  if  not,  they  should  be  rigidly 
dealt  with.  To  prevent  nervous  and  mental  dis- 
eases from  occurring,  the  method  used  by  our  army 
in  France  is  to  be  commended — and  the  method  of 
treatment  used  is  as  good  as  has  been  devised.  The 
public  should  be  educated  toward  a  truer  under- 
standing of  the  war  neuroses  in  an  endeavor  to  pre- 
vent their  occurrence.  In  the  future  our  army  will 
be  benefited  in  mental  health  and  efficiency  if  the 
general  education  in  the  country  is  raised  and  Eng- 
lish is  universally  known ;  if  a  program  of  general 
mental  hygiene  for  the  country  is  adopted  ;  if  syphilis 
is  prevented  and  properly  treated,  and  if  a  system 
of  universal  military  service  is  adopted. 

Sigma  Test. — Herman  Goodman  (American 
Journal  of  Syphilis,  July  1920)  states  that  he  has 
been  attracted  to  the  term  sigma  test  or  sigma  re- 
action, which  is  coming  into  use  in  France  and  else- 
where as  standing  for  the  term  complement  fixation 
test  for  syphilis.  The  use  of  the  Greek  letter  sigma 
^  has  had  some  popularity  instead  of  the  word 
syphilis,  lues,  or  specific.  For  exactness  in  report- 
ing the  sigma  test,  the  qualifying  words  Wasser- 
mann,  Noguchi,  alcoholic  antigen,  cholesterinized 
antigen,  or  others,  may  be  added.  As  the  doctor 
who  receives  and  studies  his  serological  reports 
becomes  better  acquainted  with  the  technical  side 
of  the  reaction,  he  insists  that  the  laboratory  inform 
him  of  the  method  in  use.  It  certainly  would  be 
confusing  if  some  test  were  reported  Wassermann 
which  was  based  upon  principles  and  technic  remote 
from  the  original. 

The  criticism  that  substituting  the  sigma  for 
Wassermann  would  tend  to  accredit  the  test  with 
specificity  for  syphilis  can  easily  be  disregarded, 
as  those  diseases  which  react  positively  and  are  not 
syphilitic  in  nature  are  infrequent,  and  those  likely 
to  meet  with  them  can  keep  in  mind  that  frambesia 
tropica  (yaws),  leprosy  (nodular  form),  and  pos- 
sible sleeping  sickness  giVe  the  paradoxical  positive. 
Another  criticism  that  has  more  weight  is  that  it 
adds  another  term  to  our  nomenclature  and 
that  the  older  and  now  well  known  phrase  Wasser- 
mann test  will  endure,  even  as  the  word  salvarsan 
has  been  deeply  rooted  as  standing  for  the  chemo- 
therapentic  arsenic  compound  which  has  been  given 
the  new  American  name  arsphenamine. 


Practical  Considerations  in  the  Diagnosis  of 
Peripheral  Nerve  Injuries,  with  Special  Refer- 
ence to  Compensatory  Movements. — Samuel  D. 
Ingham  and  John  H.  Arnett  (Journal  of  Neurol- 
ogy and  Psychiatry,  February,  1920)  state  that  in 
examining  the  results  of  a  large  number  of  peri- 
pheral nerve  lesions,  the  characteristic  and  classic 
symptoms  will  commonly  be  found;  however,  a 
certain  number  of  cases  will  exhibit  unusual  phe- 
nomena. These  atypical  cases  are  the  ones  that 
offer  the  greatest  difficulties  in  neurosurgical  diag- 
nosis. It  is  inadequate  simply  to  learn  a  list  of  the 
classic  symptoms  as  signs  of  nerve  injuries.  The 
fundamental  requisites  for  accurate  diagnosis  in 
such  cases  include  a  thorough  anatomical  knowledge, 
a  mastery  of  the  mechanics  of  joint  action  and  dis- 
criminating observation.  With  the  application  of 
these  broad  principles  to  neurosurgical  diagnosis, 
the  difficulties  are  minimized  and  the  proper  treat- 
ment can  be  confidently  instituted. 

Toxicity  of  Phenylacetic  Acid. — Carl  P.  Sher- 
win  and  K.  Sellars  Kennard  (Journal  of  Biological 
Chemistry,-  December,  1919)  find  that  phenylacetic 
acid,  which  is  one  of  the  most  important  putrefac- 
tion products  of  the  normal  human  body,  is  not 
nearly  as  nontoxic  as  it  was  believed  to  be.  Experi- 
ments on  a  hen,  a  dog.  a  monkey,  and  twelve  adult 
males  showed  that  where  this  acid  was  ingested 
thirst,  nausea,  and  in  the  case  of  the  humans, 
symptoms  of  poisoning,  not  unlike  those  of  alco- 
holic poisoning,  were  produced.  To  determine  the 
toxicity  of  the  acid  a  dog  was  fed  increasing  doses 
until  the  seventh  day,  when  death  occurred.  Micros- 
copic examination  of  the  kidney  showed  that  the 
secreting  epithelium  of  the  proximal  convoluted 
tubule  was  affected  and  the  epithelium  of  the 
arched  collecting  tubule  also  showed  evidence  of  a 
destructive  action,  while  the  secreting  epithelium 
of  the  limbs  of  Henle's  loop  showed  the  most  in- 
volvement. The  interstitial  tissue  of  the  kidney, 
the  straight  collecting  tubules,  and  the  endothelium 
of  the  blood  vessels  did  not  appear  to  share  in  the 
destructive  process. 

Congenital  Absence  of  the  Vagina  and  Uterus. 

— W.  R.  Robinson  (Surgery,  Gynecology  and  Ob- 
stetrics, July,  1920)  states  that : 

1.  The  diagnosis  of  absent  vagina  and  uterus,  or 
of  vagina  alone,  can  in  most  cases  be  made  from 
the  clinical  history,  supplanting  at  times  the  physical 
examination,  when  the  latter  is  not  readily  obtain- 
able. 

2.  Operative  measures  tending  to  create  a  vaginal 
tract  should  be  undertaken  only  in  individuals  who 
are  physically  and  psychically  women,  in  the  full 
sense,  which  this  definition  implies. 

3.  In  order  that  the  newly  constructed  vagina 
should  approach  the  normal  as  closely  as  possible 
it  should  be  lined  with  a  soft,  lubricated  mucosa, 
and  the  employment  of  an  intestinal  loop  for  that 
purpose,  as  advocated  and  executed  by  Baldwin,  is 
the  choice  operation. 

4.  It  is  my  personal  belief  that  it  is  much  safer 
to  start  the  separation  of  the  tissues  interposed  be- 
tween the  rectum  and  the  bladder,  in  order  to  es- 
tablish the  copulating  channel,  from  above,  instead 
of  from  below. 


Proceedings  of  National  and  Local  Societies 


BRITISH  MEDICAL  ASSOCIATION. 

Eighty-eighth  Annual  Meeting.  Held  June  25,  1920. 
at  Cambridge,  England. 

The  President,  Sir  Cofford  Allbutt.  in  the  Chair. 

President's  Address. — The  title  of  Sir  Clif- 
ford Allbutt's  presidential  address  was  The  Uni- 
versities in  Medical  Research  and  Practice.  He  said 
that  the  better  class  of  general  practitioner  of  fiftA- 
years  ago  was  rather  after  the  kind  of  Hippocrates 
or  Pare  than  of  the  modern  graduate.  His  uni- 
versity, in  the  days  before  great  cities,  was  nature : 
in  his  clinical  experience  he  enriched  the  instruc- 
tion, half  empirical,  half  dogmatic,  of  his  medical 
school  by  the  shrewd,  observant,  selfreliant.  re- 
sourceful qualities  of  the  naturalist.  His  science 
and  practice  were  of  the  naturalist,  not  of  the  biolo- 
gist. In  Sir  Clifford's  early  days  a  coimtry  drive 
with  such  a  doctor  in  Yorkshire  used  to  be  one  of 
the  rewards  of  the  consultant  and  a  bedside  talk 
with  him  a  lesson  in  quickness  of  hand  and  wit. 
and  of  instructive  inference  and  prognosis.  He 
was  as  clever  as  the  modern  cardiologist  in  knowing 
when  to  give  digitalis  and  when  to  withhold  it. 
even  if  he  were  content  to  diagnose  a  case  as  "some 
bedevilment  of  the  liver."  His  rules  of  thumb  were 
not  without  their  efficacy  and  his  flair  for  the  issues 
of  disease  marvelous.  He  did  not  come  across 
much  science,  and  what  he  did  see  of  it,  chiefly  in 
casual  locums.  did  not  attract  him  much:  for  in 
truth  half  science  was  less  useful  to  him  than  whole 
craftmanship.  He  was  a  woodland  guide,  not  a 
geographer :  but  as  Aristotle  and  Darwin  well 
knew,  the  woodlander  gathers  much  curious  lore. 

However,  in  the  march  of  intellect  this  comrade, 
kindly  and  loyal  as  he  had  been,  was  gone,  and  his 
sort  of  wisdom  died  with  the  individual.  W  ho  was 
to  come  next?  The  of?icial  doctor,  or  a  family 
physician  more  intellectual  but  no  less  independent? 
An  official  doctor  would  be  as  alert  and  as  pro- 
gressive as  a  country  parson  whose  service  was  not 
much  kindled  by  the  changes  of  promotion  to  an 
archdeaconry  or  a  bishopric :  while  to  shift  an 
ofticial  doctor  from  place  to  place  would  be  to  cut 
the  inner  threads  of  those  intimacies  which  we  were 
now  declaring  to  be  the  clews  to  the  detection  of 
diseases  at  their  sources.  Yet  as  things  were,  the 
independent  practitioner  was  isolated ;  even  in  a 
town  he  was  apt  to  make  a  little  orbit  for  himself, 
to  drift  otit  of  intimacy,  perhaps  into  some  jealous- 
ies Avith  his  brethren ;  he  lacked  mental  incentive, 
and  gradually  let  slip  occasions  of  scientific  retmion 
and  renewal.  Indeed  he  could  not  readily  leave 
home  to  attend  scientific  meetings,  so  that  too  often, 
as  Morsant  complained,  medical  men  did  not  think 
nor  express  themselves  in  a  statesmanlike  way.  His 
time  even  at  home  was  so  broken  up  that  he  lost 
the  habit  of  study.  He  might  leave  his  hospital 
school  full  of  ardor  and  in  rapid  growth,  but  in 
practice  his  ardor  cooled  and  he  dropped  into  rou- 
tine :  or  at  any  rate  such  was  his  peril.  And  so  less 
and  less  might  the  doctor  feel  himself  a  member  of 


a  great  profession ;  he  might  drift  out  of  public 
affairs,  his  outlook  and  his  sympathizers  might 
diminish,  his  work  become  a  trade,  and  his  medical 
neighbor  his  opponent. 

Again  for  some  years  past  a  few  of  its  had  been 
protesting  against  the  clipping  of  family  practice 
by  official  shears  to  see  the  subjects  of  infectious 
fevers  carried  into  isolation,  and  the  tuberculous 
and  syphilitic  disappearing  with  them.  The  chil- 
dren were  turned  over  to  the  school  doctor,  the 
parturient  women  to  the  new  midwife,  and  so  on. 
\\'hat  was  to  be  the  end  of  this  pollarding  of  family 
practice?  Were  its  branches  to  be  scattered  about 
in  a  wilderness  of  specialties  and  the  family  physi- 
cian be  a  mere  sweeper  up  of  unconsidered  trifles? 
Panel  practice,  for  some  time  discredited  by  its 
hereditary  taint  of  the  club  of  infamous  memor\' 
and  by  the  continual  dearth  of  the  means  of  its 
development,  should,  if  duly  provided,  expand  into 
a  large,  honorable,  and  even  universal  department 
of  medical  work.  The  terms  of  engagement  were 
to  be  more  liberal,  the  clockwork  was  complete. 

But  how  was  the  practitioner  to  rise  to  higher 
standards  of  modem  science  and  skill  when  no 
means  of  investigating  disease  or  making  an  inti- 
mate diagnosis  were  provided  for  him?  He  was 
well  aware  that  modern  methods  of  medicine  de- 
pend on  such  means  as  x  rays,  a  battery  of  stains 
and  other  cultural  and  biochemical  apparatus :  and 
not  only  an  education  in  the  use  of  these,  but  also 
the  time  to  give  to  them.  What  should  we  think 
of  a  regiment  of  recruits  called  out  to  fight  the 
enemy  but  unprovided  with  weapons  or  munitions? 
If  the  doctor  was  near  a  universitv',  he  could  get 
blood  tested  for  morphological  elements  or  for 
sugar  or  nitrogen  content,  excretions  analyzed,  bac- 
terial examinations  and  vaccines  made,  and  so  forth, 
but  it  was  imperative  that  these  opportunities,  now 
confined  to  the  few.  should  be  universal.  More- 
over, if  they  were  to  be  fruitful,  the  practitioner 
must  consult  personally  with  the  scientist.  These 
plants  with  their  staff  must  be  established  in  all 
districts,  together  with  a  much  larger  provision  of 
cottage  hospitals.  In  the  United  States  medical 
men  were  banding  together  in  districts  for  such  a 
development  of  their  private  practices.  Five  or 
six  of  them  combined  to  rent  a  house  with  consult- 
ing rooms  for  each,  a  common  apartment  for  minor 
surgery,  and  so  on.  Each  member  of  the  alliance 
— they  were  not  exactly  partners — was  expected,  in 
addition  to  his  general  practice,  to  take  up  special 
work  supplementary  to  the  others  so  that  a  fair 
variety  of  special  skill  might  be  available  in  the 
house,  skill  which,  if  not  of  high  expert  value,  was 
yet  quite  sufficient  for  ordinary  diagnosis  and 
treatment.  For  this  purpose  visits  of  members  of 
special  clinics  and  ordinary  holidays  were  naturally 
arranged.  Patients  liked  the  system :  they  saw  that 
it  was  more  thorough.  Domiciliary  visits  became 
fewer,  ytt  there  was  always  one  of  the  group  on 
the  spot.  The  fees  were  received  by  a  secretary 
attendant  on  the  separate  accoimt  of  each  member. 


September  11,  1920.] 


PROCEEDINGS  OF  NATIONAL   AND  LOCAL  SOCIETIES. 


385 


and  after  all  upkeep  expenses  were  met  the  surplus 
was  divided  according  to  the  credit  of  each.  The 
individual  earnings  were  higher  than  on  the  separ- 
ate practices.  Such  were  some  of  the  material  ad- 
vantages, the  spiritual  were  the  disappearance  of 
petty  jealousies  in  a  spirit  of  comradeship  and  a 
larger  freedom  for  scientific  and  social  life  and  for 
public  service.  The  patients  learned  that  a  due 
remuneration  of  medical  service  was  no  longer 
gained  by  a  multiplication  of  visits  nor  by  profits 
of  dispensing.  These  ends  could  no  doubt  be  at- 
tained by  different  methods,  but  the  essential  need 
was  the  generally  accessible  laboratory  and  stafif, 
to  be  a  little  academy  and  place  of  reunion,  possibly 
a  centre  for  the  meeting  of  the  divisions  of  this 
association.  But  one  word  of  caution ;  this  centre 
must  not  be  municipal,  it  must  be  free  from  all 
kinds  of  officialism  and  kept  alive  by  a  small  com- 
mittee of  local  practitioners  in  alliance  with  the 
Insurance  Committee. 

Surgial    Treatment    of    Gastric    Ulcer. — Sir 

Berkeley  Moyxihax  said  that  the  necessity  for 
the  surgical  treatment  of  gastric  ulcer  was  a  con- 
fession that  medical  treatment  had  failed.  As  com- 
monly employed  it  was  doomed  to  failure.  The 
surgical  treatment  of  a  chronic  gastric  ulcer  called 
for  the  performance  of  one  of  the  following  opera- 
tions :  gastroenterostomy,  excision,  ga.stroenterosto- 
my  combined  with  excision  by  knife  or  cautery 
(Balfour's  operation),  gastroenterostomy  combined 
with  jejunostomy;  resection  of  a  part  of  the  body 
of  the  stomach  (sleeve  resection),  partial  gastrecto- 
my. Moynihan  first  reviewed  and  criticized  gastro- 
enterostomy and  stated  that  in  consequence  of  his 
experience  he  had  abandoned  gastroenterostomy 
alone  in  the  treatment  of  chronic  gastric  ulcer,  be- 
cause: 1,  The  results,  even  when  the  operation  was 
successful,  were  not  so  satisfactory  as  those  which 
now  followed  gastrectomy.  The  morbidity  was 
greater,  the  return  to  health  slower,  a  more  watch- 
ful aftercare  was  neces.sary.  2.  .Some  patients  re- 
turned with  the  ulcer  still  open,  and  a  further 
operation  was  required.  In  such  cases  the  ulcer 
had  almost  always  perforated  all  the  walls  of  the 
stomach,  and  adhesions  had  occurred  to  the  liver, 
pancreas  or  abdominal  wall.  3.  Some  few  patients 
returned  with  carcinoma  of  the  stomach  after  so 
long  an  interval  as  to  make  it  prol^able  that  the 
cancerous  change  had  occurred  after  the  operation 
had  been  performed.  Estimates  of  this  sort  were 
fallacious,  for  the  chronicity  of  some  forms  of 
malignant  disease  of  the  stomach  was  remarkable. 
He  had  recently  been  consulted  on  account  of  a 
return  of  her  symptoms  by  a  patient  upon  whom 
four  years  and  seven  months  ago  he  performed 
gastroenterostomy  for  carcinoma  of  the  lesser  curv- 
ature of  the  stomach,  causing  obstruction :  second- 
an,'  deposits  were  present  in  many  glands,  in  the 
falciform  ligament  (one  of  these  nodules  was  re- 
moved for  microscopical  examination  and  con- 
firmed the  diagnosis),  and  the  liver.  4.  There  was 
evidence  to  show  that  gastric  ulcer  might  develop 
even  after  gastroenterostomy  had  been  performed, 
when  the  stomach  itself  was  normal.  Excision  of 
the  ulcer  was  given  a  fair  trial  but  for  various 
sound  reasons  had  been  abandoned  by  Moynihan. 


Excision  with  gastroenterostomy  had  been  found 
to  be  superior  to  gastroenterostomy  alone.  Con- 
cerning excision  by  cautery,  Moynihan  .said  Bal- 
four, of  Rochester,  with  that  fertility  of  resource 
which  was  one  of  the  characteristics  of  his  fine 
work,  replaced  the  method  of  excision  of  the  ulcer 
by  that  of  its  complete  destruction  by  the  actual 
cautery.  Balfour's  operation  had  among  its  many 
merits  that  of  simplicity.  If  an  ulcer  lay  upon  the 
lesser  curvature  or  near  it,  a  little  nearer  the  cardia 
than  the  pylorus,  or  down  upon  the  po.sterior  wall, 
the  operation  of  excision  was  likely  to  be  difiicult. 
The  method  of  Balfour  made  the  treatment  much 
easier,  quicker,  and  safer  and  gave  far  more  satis- 
factory results.  Gastroenterostomy  combined  with 
jejunostomy  was  a  method  which  Moynihan  had 
advocated  and  practised  in  cases  of  grave  difficulty 
and  the  results  had  been  excellent.  There  were 
ulcers  of  the  stomach  so  large,  so  awkwardly  placed 
and  so  deeply  penetrating  the  liver  or  the  pancreas, 
in  patients  whose  general  condition  was  poor, 
that  any  operation  became  serious.  Such  cases 
might  be  unsuitable  for  Balfour's  operation  by 
reason  of  the  size  or  remoteness  of  the  ulcer,  and 
for  the  operation  of  gastrectomy  by  reason  of  the 
extremely  feeble  condition  of  the  patient,  who  had 
perhaps  recently  suffered  from  a  copious  hemor- 
rhage. In  all  such  cases  Moynihan  performed  gas- 
troenterostomy in  Y,  generally  by  the  anterior  route. 
The  operation  of  resection  of  a  part  of  the  body  of 
the  stomach — sleeve  resection — was,  of  course,  re- 
served for  those  cases  in  which  the  ulcer  occupied 
approximately  the  middle  part  of  the  .stomach. 
After  resection  of  a  cylindrical  portion  of  the  organ 
the  cut  ends  were  united.  Advocacy  of  this  opera- 
tion appeared  to  be  restricted  to  a  few  surgeons, 
and  consequently  the  number  of  cases  performed 
was  relatively  small  He  practised  it  on  two  occa- 
sions only,  long  ago.  In  both  the  operation  prom- 
ised well,  but  one  of  the  patients  returned  after 
four  years  with  an  hourglass  stomach,  for  which  a 
second  operation  was  necessary.  The  role  of  the 
operation  was  necessarily  A-ery  limited. 

Moynihan  contended  that  the  diagnosis  of  gastric 
ulcer  was  often  inaccurate  and  that  a  host  of  dis- 
eases, organic  and  functional  alike,  were  called  gas- 
tric ulcer.  Consequently  much  literature  and  most 
of  the  statistics  dealing  with  the  subject  of  gastric 
ulcer  lacked  that  foundation  of  truth  which  only 
an  accurate  diagnosis  could  afford.  In  the  cases 
of  indisputable  gastric  ulcer,  when  the  ulcer  was 
demonstrated  beyond  cavil  by  a  radiological  exami- 
nation or  by  inspection  upon  the  operation  table,  a 
far  greater  seriousness  attached  to  the  disease  than 
to  the  condition  of  duodenal  ulcer.  Operations  upon 
it  were  more  serious,  partly  by  reason  of  the  extent 
of  the  operations  themselves,  but  chiefly  in  conse- 
quence of  the  less  robust  state  of  the  patients.  This 
on  reflection  w^as  not  so  startling  as  might  at  first 
appear,  for  many  of  the  patients  suffering  from 
duodenal  ulcer  were  otherwise  of  robust  strength 
and  splendid  health.  Moynihan  had  operated  upon 
international  football  players,  golfers,  lacrosse  play- 
ers, and  many  distinguished  athletes,  for  duodenal 
ulcer.  Such  people  were  not  often  found  among 
those   who   suffered   from  gastric  ulcer ;  though 


386 


PROCEEDINGS  OF  NATIONAL  AND  LOCAL  SOCIETIES. 


[New  York 
Medical  Journal. 


there  were  exceptions,  the  types  of  stomach  found 
in  the  two  diseases  were  distinct  from  one  another, 
as  Hurst  had  shown. 

Moynihan  leaned  to  the  belief  that  many  of  the 
cases  of  carcinoma  of  the  stomach  with  which  a 
surgeon  could  deal  successfully  had  their  origin  in 
a  chronic  ulcer.  That  was  not  the  universal  view, 
but  the  opinion  of  those  that  hold  it  was  weighty 
and  well  founded.  Prompted  by  all  these  consid- 
erations, he  was  gradually  brought  to  the  view  that 
gastric  ulcer  was  a  disease  requiring  direct  and 
radical  treatment  and  that  it  was  not  safe  to  trust 
to  the  direct  method  of  gastroenterostomy,  which 
whether  its  action  was  physiological  or  mechanical, 
merely  produced  a  condition  of  things  in  which 
healing  could  more  easily  take  place.  As  for  partial 
gastrectomy,  the  operation  of  his  choice,  the  risk 
was  not  great ;  over  a  period  of  ten  years  it  has 
not  been  more  than  2.5  per  cent.  -\11  things  consid- 
ered and  account  being  taken  of  the  five  years  suc- 
ceeding operation,  it  was  probably  a  safer  and  cer- 
tainly a  more  immediately  satisfactory  operation  than 
gastroenterostomy  alone.  It  could  not  always  be 
practised.  The  ulcer  might  be  so  large  and  so  placed 
as  to  make  removal  a  matter  of  such  great  technical 
difficulty  that  the  immediate  hazards  were  unfair  to 
the  patient.  But  as  experience  grew  the  number  of 
such  cases  diminished. 

Moynihan  said  that  nowadays  he  very  rarely 
practised  any  other  operation  than  partial  gas- 
trectomy or  gastroenterostomy  in  Y  combined  with 
jejunostomy.  He  gave  the  technic  of  his  partial 
gastrectomy  operation  for  gastric  ulcer,  and  statis- 
tics of  results  as  follows :  There  were  in  all  835 
operations  since  the  year  1909.  with  twelve  deaths, 
a  total  mortality  of  1.43  per  cent.  Excluding  the 
cases  of  jejunal  ulcer  there  were  808  operations  or 
cases  of  gastric  and  duodenal  ulcers  with  ten  deaths, 
a  mortality  of  1.23  per  cent.  This  included  all  kind 
of  operations ;  as  stated  before,  his  operative  mor- 
tality with  partial  gastrectomy  was  2.5  per  cent. 

Dr.  Charles  ]\Iavo,  of  Rochester,  Minn.,  dis- 
cussed factors  in  the  etiology,  symptomatology, 
treatment,  complications  and  results  of  gastric  ulcer. 
He  pointed  out  that  gastric  ulcer  was  more  common 
in  males  than  females  and  that  according  to  statis- 
tics of  the  Rochester  Clinic  duodenal  ulcer  was  four 
times  more  frequent  than  gastric  ulcer.  Medical 
treatment  was  chiefly  dietetic,  and  duodenal  ulcer 
rarely  became  malignant.  Gastric  ulcer  was  not 
caused  by  traumatism,  neither  was  perforation  as 
serious  as  believed.  The  best  means  of  diagnosis 
was  by  the  x  ray ;  by  this  agency  an  accurate  diag- 
nosis could  be  made  in  ninety-five  per  cent,  of  cases, 
dif¥erentiating  between  gastric  and  duodenal  ulcer. 
Cancer  of  the  stomach  rarely  occurred  with  high 
acidity.  Gastric  ulcer  was  potentialh-  malignant. 
Copious  statistics  were  given  and  the  various  forms 
of  operation  practised  at  Rochester  were  described 
in  detail.  Both  Moynihan  and  Mayo  emphasized 
the  wisdom  of  using  absorbable  sutures  for  this 
operation.  Mayo,  quoting  from  Hunter  of  the  New 
York  Life  Assurance  Company,  stated  that  the  op- 
erative mortality  of  gastric  ulcer  was  three  per 
cent,  over  normal  while  that  of  duodenal  ulcer 
was  less  than  normal. 


Mr.  Herbert  Patersox,  of  London,  referring 
to  the  question  of  whether  gastrojejunostomy  ex- 
erted a  physiological  action  or  was  solely  mechan- 
ical, said  that  as  scepticism  was  the  sure  precursor 
of  belief  the  scepticism  displayed  by  some  as  to  the 
physiological  effects  of  gastrojejunostomy  was  a 
sign  that  they  would  soon  be  converted  to  his  way 
of  thinking.  Mr.  Paterson  showed  on  the  screen 
the  physiological  effects  of  this  operation.  These 
effects  enabled  Nature  to  relieve  or  cure  hyperchlor- 
hydria  by  her  own  methods,  which  were  better  by 
far  than  artificial  means.  He  did  not  believe  that 
malignancy  was  grafted  upon  chronic  gastric  ulcer, 
but  was  of  the  opinion  that  when  a  gastric  ulcer 
developed  malignancy,  the  ulcer  was  inherently  ma- 
lignant. He  said  that  either  malignant  disease  did 
not  develop  on  gastric  ulcer  or  gastrojejunostomy 
was  a  cure  for  cancer. 

Mr.  Burgess,  of  Manchester,  said  the  object  was 
to  get  rid  of  gastric  ulcer  by  abolishing  the  patho- 
logical basis,  namely,  the  hyperacidity.  The  effect 
of  the  cautery  was  superficial,  but  hyperacidity  was 
best  cured  by  gastroenterostomy.  However,  gas- 
troenterostomy alone  was  insufficient;  the  logical 
combination  was  excision  and  gastroenterostomy 
of  which  gastroenterostomy  was  the  essential  part. 
The  physiological  effect  of  gastroenterostomy  had, 
in  his  opinion,  been  proved  beyond  doubt.  He  em- 
phasized the  importance  of  aftertreatment. 

Mr.  Charles  Ryall  said  that  gastric  ulcer  was 
a  simple  inflammatory  process.  He  was  in  favor 
of  gastroenterostomy  from  the  physiological  point 
of  view.  The  kind  of  operation  must  be  in  accord- 
ance with  the  conditions  found,  but  he  did  not  be- 
lieve in  laying  down  the  rule  that  partial  gastrec- 
tomy must  be  done  in  all  cases  of  gastric  ulcer.  The 
cautery  was  dangerous  and  too  much  importance 
was  attached  to  the  connection  between  chronic 
ulcer  and  cancer. 

Dr.  FixxEY  said  that  he  had  been  through  the 
whole  gamut  of  operations  and  failed  in  a  sufficient 
number  of  cases  to  produce  scepticism.  Therefore  he 
was  never  too  sure  and  he  thought  it  is  unwise  to 
lay  down  hard  and  fast  rules  for  operation.  All 
cases  must  be  judged  by  the  conditions  found.  Fin- 
ney also  disbelieved  in  any  sure  method  of  diagno- 
sis. He  had  opened  the  abdomen  and  even  the 
stomach  and  then  he  did  not  know  whether  there 
was  an  ulcer. 

Mr.  BiLLixGTON  said  that  Sir  Berkeley  Moyni- 
han had  taught  much  concerning  the  surgery  of 
gastric  ulcer.  In  his  opinion  the  site  of  the  ulcer 
should  determine  the  kind  of  operation.  The  depth 
and  penetration  of  the  ulcer  were  also  factors  that 
must  be  considered.  As  a  rule  partial  gastrectomy 
was  not  worth  the  risk.  He  inclined  to  gastro- 
enterostomy. 

Mr.  Rowlaxds,  of  London,  did  not  believe  that 
the  X  ray  could  be  depended  upon  for  the  purpose 
of  diagnosis,  and  he  put  down  the  failures  of  gas- 
troenterostomy to  bad  selection  of  cases  and  de- 
fective operative  technic.  Gastroenterostomy  should 
not  be  entered  into  lightly.  Gastroenterostomy  ex- 
erted physiological  effects.  Partial  gastrectomy  was 
indicated  in  some  cases  but  in  the  hands  of  the  ordi- 
nary surgeon  was  a  perilous  undertaking. 


September  11,  1920.]  PROCEEDINGS  OF  NATIONAL  AND  LOCAL  SOCIETIES. 


387 


Sir  George  Makins  thought  there  was  Httle  doubt 
that  malignant  ulcer  did  follow  simple  ulcer  of 
the  stomach.  Sir  Berkeley  Moynihan  doubted 
whether  any  physiological  rjssults  ensued  upon  gas- 
troenterostomy. He  thought  the  alleged  physio- 
logical effects  of  the  operation  were  nonexistent. 
Partial  gastrectomy  cured  in  the  right  cases. 

Professional  Secrecy. — Dr.  Langdon-Down, 
of  Hampton  Wick,  moved  that  having  considered 
the  question  of  professional  secrecy,  more  particu- 
larly with  regard  to  venereal  disease,  the  represen- 
tative body  reiterate  the  opinion  that  the  medical 
practitioner  should  not  in  any  circumstances  disclose 
voluntarily  without  the  patient's  consent  informa- 
tion which  he  had  obtained  from  that  patient  in 
the  exercise  of  his  professional  duties.  Dr.  Lang- 
don-Down held  strongly  that  the  medical  profes- 
sion should  not  deviate  from  the  position  it  had 
always  taken  in  the  matter,  that  secrecy  should  be 
maintained.  There  were  cases,  he  said,  in  which 
one  received  from  a  court  of  law  an  order  to  di- 
vulge one's  professional  confidence.  That  was  a 
recognized  thing.  There  were  also  cases  in  which 
the  professional  man  would  defy  the  order  of  the 
court  and  take  the  consequences.  If  that  was  done 
in  a  sound  case  the  punishment  should  not,  and 
would  not,  be  unduly  severe.  There  were  also 
cases  when  the  medical  man  might  feel  it  his  duty 
to  divulge  a  secret  received  in  a  professional  way 
in  order  to  prevent  the  committing  of  crime.  The 
question  was  whether  we  should  weaken  our  rule 
by  satisfying  these  exceptions.  If  there  was  a 
breach  of  confidence  between  the  doctor  and  the 
public,  untold  damage  would  result.  We  would  do 
well  to  adhere  to  our  old  rule  of  secrecy,  leaving 
the  doctor,  in  those  cases  in  which  there  was  doubt, 
to  decide  whether  there  was  a  sufficiently  com- 
pelling reason  for  him  to  break  his  confidence 

Dr.  T.  R.  Bradshaw,  of  Liverpool,  proposed  that 
the  question  be  referred  back  to  the  medical  council. 
He  said  that  they  had  clear  ideas  as  to  what  secrecy 
meant,  but  it  was  a  different  matter  to  write  those 
ideas  down  and  formulate  them.  The  council, 
he  hoped,  would  find  words  upon  which  the  profes- 
sion could  agree.  Mr.  E.  H.  Snell,  of  Coventry  said 
there  certainly  was  a  difference  of  opinion  as  to 
what  a  medical  man  should  do  in  the  case  of  syphi- 
lis. Some  believed  that  nothing  should  be  disclosed 
unless  the  patient  consented,  while  others  thought 
the  man  who  declined  to  disclose  ought  to  be  shot. 

Dr.  Christine  Morell,  of  London,  expressed 
herself  as  strongly  opposed  to  referring  back.  She 
said  that  if  we  did  not  know  what  we  wanted,  we 
could  hardly  expect  the  public  or  state  to  support  us. 
We  were  at  the  parting  of  the  ways  on  this  ques- 
tion. If  we  had  no  definite  opinions  we  should 
be  bound  by  the  State  and  society  to  divulge  prac- 
tically all  we  knew  about  patients.  Dr.  Bishop 
Harman,  of  London,  said  the  question  of  venereal 
disease  made  it  necessary  that  there  should  be  a 
rule  and  a  clear  view  as  to  what  medical  men  should 
do.  The  solicitor  of  the  association  stated  the  legal 
position.  He  said  that  so. far  as  the  legal  profes- 
sion was  concerned,  secrecy  was  not  recognized  by 
the  law.  So  far  as  secrecy  in  the  church  was 
concerned,  it  was  based  on  sentimental  and  not  on 


legal  grounds.  In  America  there  was  an  enactment 
that  no  doctor  should  be  compelled  to  disclose  any 
information  he  might  have  received  in  his  profes- 
sional capacity,  and  in  Scotland  a  court  decision 
was  recorded  that  secrecy  was  an  essential  part  of 
the  contract  between  the  doctor  and  the  patient. 
Secrecy  had  grown  up  by  custom  and  strong  com- 
mon sense,  as  regarded  solicitors.  It  appeared  to 
him  that  they  would  be  aiming  at  almost  the  impos- 
sible in  endeavoring  to  get  an  Act  of  Parliament  to 
establish  that  if  a  medical  man  knew  that  secrecy 
was  going  to  cause  crime  he  would  be  justified  in 
telling.  He  submitted  the  following  substitute  for 
the  resolution :  That  having  further  considered  the 
question  of  professional  secrecy  from  the  view- 
point of  the  medical  profession  and  with  spe- 
cial regard  to  venereal  diseases,  the  representative 
body  reiterated  the  opinion  that  the  medical  prac- 
titioner should  not  without  his  patient's  consent 
voluntarily  disclose  information  which  he  had  ob- 
tained from  such  patient  in  the  exercise  of  his  pro- 
fessional duties. 

Dr.  C.  Sanders,  of  Stratford,  asked  whether  the 
resolution  meant  that  as  a  profession  we  were  to  al- 
low a  bounder  to  live  and  his  wife  and  child  to  die. 
Dr.  Langdon-Down  pointed  out  that  from  the  nature 
of  the  case  we  had  a  fluid,  elastic  and  difficult  set 
of  circumstances  which  it  was  impossible  to  define 
in  a  brief  resolution.  We  wanted  to  make  our 
position  such  that  in  time  of  difficulty  a  man  should 
be  guided  by  judgment  and  common  sense.  Dr. 
Bishop  Harmon  said  that  if  a  man  was  affected 
with  venereal  disease  and  the  doctor  held  his  peace, 
he  would  be  affecting  somebody  else.  In  that  case, 
if  he  could  save  persons  from  death  or  a  life  of 
misery  and  did  not  do  so  and  that  circumstance 
became  known,  would  he  not  be  liable  to  have  an 
action  brought  against  him  by  the  person  inj'ured? 
If  anybody  took  that  course  he  would  win  hands 
down.  They  could  not  say  that  in  no  circum- 
stances would  they  disclose  information.  He 
asked  them  not  to  be  afraid  of  being  illogical  if 
there  were  instances  which  needed  it.  The  resolu- 
tion as  drafted  by  the  solicitor  was  carried  with 
only  two  dissenters.  Dr.  Sheahan,  of  Portmouth, 
moved  that  the  medical  profesison  be  placed  on  the 
same  footing,  as  to  professional  secrecy,  as  clergy, 
barristers,  and  solicitors.  He  remarked  that  the 
most  advanced  and  civilized  peoples  in  the  world 
were  the  Americans  and  Scotch,  and  the  latter,  the 
most  careful  people  in  the  British  Isles,  adhered 
to  secrecy,  it  was  only  England  of  the  present  day 
that  did  not.  Dr.  Sheahan's  motion  was  defeated. 
Dr.  Dain,  of  Birmingham,  moved  that  the  council 
be  instructed  to  consider  the  extent  to  which  and 
the  ways  in  which  the  association  was  prepared  to 
support  its  members  in  maintaining  professional 
secrecy.    The  resolution  was  carried. 

Report  on  Medical  Services. — At  the  resumed 
meeting,  June  29th,  the  main  discussion  was  on  the 
interim  report  on  the  future  provision  of  medical 
and  allied  services,  issued  by  the  Medical  Con- 
sultation Council  of  the  Ministry  of  Health  and 
containing  proposals  for  the  coordination  of  all  medi- 
cal services,  infirmaries,  hospitals,  dispensaries  and 
the  like,  thus  insuring  that  the  health  resources  of 


.388 


PROCEEDINGS  OF  NATIONAL     AND  LOCAL  SOCIETIES. 


[New  Vork 
Medic.\l  Journal. 


the  country  should  be  fully  exploited  by  the  com- 
munity without  actually  being  taken  over  by  the 
State.  Dr.  Turner  moved  that  the  representative 
bod}^  should  express  a  general  approval  of  the  re- 
port and  stated  that  such  a  drastic  change  in  the 
handling  of  public  health  could  not  be  forced  down 
in  a  lump  but  would  come  by  degrees.  On  this 
motion  Dr.  C.  Buttar,  of  London,  moved  that  the 
meeting  define  the  general  principles  contained  in  the 
report  and  that  these  principles  be  submitted  to  the 
divisions  for  an  expression  of  opinion.  He  con- 
tended that  they  were  asked  for  premature  ap- 
proval. Sir  James  Barr.  of  Liverpool,  made  a 
slashing  attack  on  the  scheme.  He  said  we  ought 
to  consider  what  the  scheme  was  going  to  cost.  His 
estimate  was  that  if  it  was  carried  out  as  it  should 
be  the  cost  in  the  first  five  years  would  be  one  hun- 
dred million  pounds  a  year  and  in  the  next  ten  years 
one  hundred  and  fifty  million  a  year.  He  had 
heard  it  said  that  this  was  an  ideal  scheme,  but  an 
ideal  scheme  must  be  practical.  If  a  man  wanted 
to  change  his  residence  to  the  moon  he  did  not  con- 
sider whether  it  was  ideal  or  not,  he  turned  it  down 
because  it  was  not  practical.  This  whole  business 
started  with  Sir  Auckland  Geddes.  who  had  told 
Mr.  Lloyd  George  that  if  he  only  had  a  proper 
scheme  there  would  be  no  C3  men  but  all  AL  Mr. 
Lloyd  George  was  credulous  enough  to  believe  him. 
The  result  was  that  Mr.  Lloyd  George  began  to 
think  how  the  population  could  be  fnade  Al  and  he 
established  the  Ministry  of  Health,  which  had  no 
more  to  do  with  health  than  the  man  in  the  moon. 
The  Local  Government  Board  had  done  remarkably 
well.  No  one  could  convert  C3  men  into  Al  men 
by  act  of  Parliament.  In  his  view  the  State  should 
be  engaged  not  in  the  treatment  but  with  the  pre- 
Aention  of  disease.  Adenoids  was  a  perfectly  pre- 
ventable disease,  pneumonia  was  also  preventable. 
<and  chronic  disease  of  the  heart  was  altogether 
preventable.  Dr.  Fothergill,  of  Brighton,  warned 
the  medical  profession  to  be  careful,  as  otherwise 
they  would  be  jockeyed  into  a  scheme  as  they  had 
l)een  jockeyed  into  the  insurance  business. 

Lord  Dawsox.  chairman  of  the  English  Consulta- 
tive Council  and  a  member  of  the  council  of  the 
British  Medical  Association,  who  is  largely  respon- 
sible for  the  drafting  of  the  interim  report,  said 
the  report  only  pretended  to  give  the  broad  outlines 
of  the  direction  in  which  the  medical  profession 
should  move.  It  was  time  we  asked  ourselves 
whether  we  were  going  in  for  individualism  or  for 
something  of  the  nature  of  State  action.  This 
scheme  might  take  twenty  years  to  materialize.  The 
medical  profession  stood  higher  today  than  ever 
before  in  the  estimation  of  'the  public,  who  looked 
to  the  profession  for  guidance  as  to  the  form  med- 
ical practice  should  take  in  the  future.  Many  points 
were  raised  by  delegates,  and  ultimately  it  was 
resolved  that  the  gathering  should  consider  the 
general  principles  contained  in  the  report  and  sub- 
mit the  whole  question  to  the  divisions,  and  that 
it  be  considered  at  a  special  representative  meeting. 
The  report  recommended  the  establishment  of  pri- 
mary health  centres  equipped  for  services  of  cura- 
tive and  preventive  medicine,  to  be  conducted  by 
the  general  practitioners  of  the  various  districts  in 


conjunction  with  an  ethcient  ntirsing  service.  A 
resolution  was  proposed  affirming  that  the^  estab- 
lishment of  these  centres  was  the  pivotal  idea  of 
the  changes  recommended.  Lord  Dawson  supported 
the  motion.  The  idea,  he  said,  was  that  the  State 
would  provide  the  equipment,  but  this  would  not 
alter  the  relations  existing  between  doctor  and 
patient.  It  was  intended  that  the  centres  should 
be  on  a  j^art  time  basis.  There  had  also  been  favor- 
ably considered  the  attaching  to  the  centres  of  pro- 
vision for  what  might  be  called  the  intermediate 
section  of  the  community  as  paying  patients.  A 
resolution  was  passed  declaring  that  in  order  to 
attain  the  objects  of  an  ideal  system  of  medical  and 
allied  service,  it  was  necessary  that  the  prevention 
of  disease  as  well  as  the  provision  for  its  treatment 
should  be  based  on  domiciliary  medical  service,  and 
that  general  active  practitioners  should  be  actively 
encouraged  in  the  practice  of  both.  Reference  was 
made  to  the  wisdom  which  had  been  displayed  in 
the  .setting  up  of  the  Medical  Consultative  Cotmcil 
to  the  Ministr}'  of  Health,  and  the  conference  car- 
ried a  resolution  regarding  the  cotmcil  as  an  im- 
portant step  in  an  es.sential  organized  means 
whereby  the  medical  profession  could  exercise  its 
influence  on  the  health  policy  of  the  nation. 

Unqualified  Medical  Practitioners. — The  ques- 
tion of  uiKiualified  medical  practitioners  was  raised 
by  Dr.  R.  Hopkins,  of  Southwest  Wales,  who 
moved  that  steps  should  be  taken  in  the  public  in- 
terest to  bring  to  the  notice  of  Parliament  the  in- 
jurious efTects  of  imqualified  practice  in  medicine 
and  surgery.  During  a  brief  disctission  of  the  sub- 
ject it  was  stated  that  at  present  in  Glasgow  fifty 
unqualified  persons  were  going  about  vaccinating 
people.  The  resolution  was  agreed  to  and  a  promise 
made  that  the  committee  of  the  association  should 
bring  the  matter  to  the  notice  of  the  government. 

Hospital  Service. — Dr.  Bolam,  chairman  of  the 
Hospitals  Committee,  stibmitted  the  following  mo- 
tion on  behalf  of  the  council  of  the  British  Medical 
Association:  That  for  all  work  for  soldiers  and 
.sailors,  whether  discharged  or  not,  for  any  disease 
or  injuries  connected  with  the  war,  the  medical  staff 
of  voluntary  hospitals  should  be  adequately  remu- 
nerated. For  the  present  the  remtmeration  should 
represent  an  addition  of  not  less  than  twenty-five 
per  cent,  to  the  cost  of  maintenance  for  inpatients, 
and  not  less  than  twenty-five  per  cent,  of  the  ascer- 
tained cost  "for  outpatients,  the  additional  sum  to 
ha  placed  at  the  disposal  of  the  medical 
staff ;  that  in  the  case  of  special  clinics,  the  fee 
payable  to  the  medical  practitioner  should  not  be 
less  than  the  fee  payable  l)y  the  Ministry  of  Pen- 
sions for  identical  or  similar  services,  viz.,  £2.2 
a  session  The  Representative  Body  adopted 
the  following  motion :  That  the  Representa- 
tive Body  is  of  opinion  that  the  suggested  remedy 
for  existing  financial  straits  of  hospitals,  namely, 
to  demand  contributions  in  aid  of  their  maintenance 
from  the  jiatients,  fimdamentally  alters  the  basis 
of  the  relationship  hitherto  existing  between 
honorary  medical  staffs  and  subscribers,  and 
refers  the  ([uestion  to  the  coimcil  for  consideration 
and  report. 

(To  he  continued) 


New  York  Medical  Journal 


INCORPORATING  THE 


Philadelphia  Medical  Journal     Medical  News 

A  Weekly  Revieiu  of  Medicine,  Established  184S. 


Vol.  CXII,  No.  12. 


NEW  YORK.  SATURDAY.  SEPTEMBER  18,  1920. 


Whole  No.  2181. 


Original  Communications 


HOW  MAY  THE  TUBERCULOUS  PATIENT 
SECURE  AN  ARRESTMENT  AND  AVOID 
BECOMING  AN  INVALID?* 


By  F.  M.  Pottenger,  A.  M. 

F.  A.  C.  P., 

Monrovia,  Cal. 


M.  D.,  LL.D., 


The  systematic  campaign  against  tuberculosis  in 
America  is  now  in  the  second  half  of  its  second 
decade.  It  is  now  time  for  us  to  take  stock  and 
see  if  we  are  accomplishing  what  we  should ;  for 
it  is  only  by  analyzing  facts  that  we  have  a  basis 
for  future  progress.  While  it  would  be  profitable 
to  discuss  the  successes  and  failures  of  the  move- 
ment as  a  whole  and  to  show  the  great  good  that 
has  come  to  mankind  in  general,  as  a  result  of  the 
gospel  of  fresh  air  and  better  living  that  has  been 
incessantly  preached  by  those  interested  in  the  anti- 
tuberculosis crusade,  I  shall  limit  my  discussion 
to  one  important  clinical  problem  which  confronts 
all  who  are  trying  to  help  those  who  are  afflicted 
with  tuberculosis  to  regain  their  health,  viz.,  how 
can  they  regain  their  health  and  again  be  useful 
members  of  society. 

This  theme  forces  the  discussion  of  two  ques- 
tions ;  first,  how  to  regain  health ;  second,  how 
to  remain  healthy ;  and  carries  with  it  an  imputa- 
tion that  the  ultimate  results  gained  from  the  treat- 
ment of  tuberculosis  are  not  all  they  should  be. 

The  case  may  be  stated  as  follows:  1,  Observa- 
tion of  those  who  are  treated  for  tuberculosis, 
whether  in  the  home,  the  dispensary,  or  the  sanato- 
rium, reveals  the  sad  fact  that  the  total  percentage 
of  those  who  secure  an  arrestment  or  healing  of 
their  processes  is  disappointingly  small ;  2,  of 
those  who  are  pronounced  arrested  or  healed  the 
number  who  relapse  is  disappointingly  large ;  3,  of 
those  who  remain  well  as  far  as  their  tuberculous 
infection  is  concerned  a  disappointingly  large  num- 
ber are  in  a  state  of  invalidism  or  semiinvalidism 
which  incapacitates  them  for  taking  their  place  in 
the  social  and  industrial  world.  Each  of  these 
statements  deserves  full  and  free  discussion,  which 
should  be  preceded,  however,  by  certain  statements 
regarding  tuberculosis,  its  general  characteristics 
and  its  curability.  Many  of  the  shortcomings  in 
the  diagnosis  and  treatment  of  tuberculosis  depend 
upon  a  failure  to  understand  the  essential  nature 
of  the  disease,  and  the  manner  in  which  it  affects 

*  Read  before  the  sixteenth  annual  meeting  of  the  National  Tuber- 
culosis Association,  St.  Louis,  April  22,  23  and  24,  1920. 


the  patient ;  or  if  understood,  a  failure  to  act  in  the 
interest  of  the  patient  at  the  proper  time. 

Tuberculosis  is  a  chronic  infectious  inflammatory 
process  in  which  there  is  a  long  interval  between 
the  time  of  infection  and  the  clinical  manifestation 
of  the  disease.  While  tubercles  undergo  much  the 
same  type  of  evolution  that  is  noted  in  a  boil  on 
the  body  surface — implantation  followed  by  indura- 
tion, necrosis,  rupture,  and  healing — these  changes 
take  place  extremely  slowly,  taking  weeks,  months 
or  years  for  the  cycle  instead  of  a  few  hours  or  a 
few  days.  Often  the  stage  of  necrosis  and  rupture 
fails  to  appear,  the  process  remaining  as  an  indura- 
tion for  a  long  period  and  then  changing  into  scar. 
During  this  long  period  there  may  be  a  gradual 
progressive  extension  of  the  infection  or  there  may 
be  intermittent  extensions.  The  infection,  how- 
ever, does  not  become  a  clinical  disease  until  suffi- 
cient toxins  have  passed  out  into  the  blood  stream, 
and,  acting  through  the  nerves  and  endocrine  sys- 
tem, interfere  with  the  normal  physiological  equili- 
brium of  the  various  organs  and  structures ;  or, 
until  the  process  acting  locally  on  the  nerve  endings 
in  the  areas  of  inflammation,  causes  reflex  disturb- 
ances in  physiological  equilibrium ;  or,  until  it  pro- 
duces some  local  change  which  makes  its  presence 
known,  such  as  pleurisy,  sputum  or  blood  spitting. 

It  is  evident  that  a  disease  process  which  shows 
such  resistance  to  the  healing  forces  of  the  body 
as  tuberculosis,  offers  chances  of  healing  somewhat 
in  proportion  to  the  extent  of  the  infection  and  the 
pathological  condition  of  the  tubercles ;  and  further, 
that  the  chances  of  the  disease  spreading  are  largely 
in  proportion  to  the  degree  of  pathological  activity 
in  the  individual  tubercles,  the  danger  being  much 
greater  in  necrotic  ruptured  tubercles  than  in  those 
which  have  reached  only  the  stage  of  induration. 
Whereas,  limited  infiltration  prior  to  the  time  that 
the  tubercles  undergo  necrosis  oflfers  a  fair  oppor- 
tunity for  the  process  to  become  quiescent,  quies- 
cence occurs  much  less  readily  when  necrosis  has 
occurred  and  especially  when  the  process  is  at  the 
same  time  extensive.  Infection  is  usually  present 
in  the  individual  in  a  quiescent  or  semiquiescent, 
condition  long  before  it  is  recognized.  Unfortu- 
nately, it  may  not  produce  symptoms ;  or,  if 
present,  they  may  not  be  recognized ;  so  the  disease 
as  met  today  is  often  an  advanced  destructive  pro- 
cess. 

From  the  very  nature  of  the  case  it  must  be  evi- 
dent that  disappointments  in  results  of  treatment 


Copyright,  1920,  by  A.  R.  Elliott  Publishing  Company. 


390 


POTTENGER:  THE  TUBERCULOUS  PATIENT. 


[New  York 
Medical  Journal. 


are  unavoidable.  'But  if  these  disappointments  are 
greater  than  they  should  be  it  is  our  duty  to  find 
out  why.  A  study  of  reports  in  the  literature,  par- 
ticularly those  from  institutions,  shows  a  wide 
variation  in  the  number  of  cases  which  are  dis- 
charged as  arrested.  It  also  shows  wide  variation 
in  the  character  of  the  patients  as  to  the  stage  of 
the  disease,  and  the  length  and  character  of  treat- 
ment carried  out. 

The  fact  that  practically  all  patients  who  mani- 
fest their  clinical  symptoms  in  adult  life  have  been 
in  stages  alternating  between  activity  and  arrest- 
ment prior  to  the  time  that  it  was  recognized  clini- 
cally, should  suggest  the  possibility  of  healing  in  a 
very  large  proportion  of  early  clinical  cases  when 
the  patient's  resistance  has  been  first  overcome ; 
and,  if  such  a  desirable  result  is  not  being  pro- 
duced it  must  be  because  the  methods  of  treatment 
available  are  not  sufficient,  or  because  patients  are 
not  given  or  do  not  take  advantage  of  a  treatment 
which  is  capable  of  producing  results. 

That  tuberculosis  is  not  being  treated  during  this 
early  favorable  stage  is  apparent  to  all  who  will 
observe.  Sanatoria  and  dispensaries  are  filled  with 
advanced  cases.  Specialists  who  should  be  best  able 
of  all  members  of  our  profession  to  cope  with  this 
disease  successfully  are  spending  most  of  their 
energy  fighting  a  losing  fight  with  patients  far  ad- 
vanced in  the  disease.  While  they  are  often  suc- 
cessful yet  they  might  nearly  always  be  successful 
if  only  they  guided  the  patient  in  the  early  stages  of 
his  disease.  This  has  been  the  tuberculosis  special- 
ist's lament  for  the  past  quarter  of  a  century.  How 
much  longer  it  shall  continue  to  be,  will  depend 
upon  the  impression  which  the  truths  about  tuber- 
culosis make  upon  the  profession  and  upon  those 
who  are  afflicted. 

The  tuberculous  patient  must  not  be  permitted  to 
become  a  consumptive.  It  is  only  a  step  from  the 
early,  limited,  apparently  innocent  process  to  the 
advanced,  extensive,  dangerous  one.  The  early 
lesion  carries  with  it  all  of  the  possibilities  of  the 
advanced  one ;  and  unless  checked,  may  at  any  time 
assume  dangerous  proportions.  That  a  small  infil- 
tration which  has  scarcely  yet  made  sufficient  dis- 
turbance in  the  normal  physiological  working  of  the 
human  machine  to  make  its  presence  known  carries 
with  it  a  threat  or  a  present  danger  to  life,  is  not 
easily  appreciated  by  those  who  are  not  more  than 
casually  interested  in  this  disease.  Unfortunately, 
this  confuses  most  laymen  and  an  all  too  large  num- 
ber of  medical  men.  What  specialist  has  not  had 
the  experience  of  making  an  early  diagnosis  of 
tuberculosis  at  a  time  when  a  life  could  be  saved, 
and  having  it  contradicted  by  some  good  doctor,  and 
then  seeing  the  same  patient  after  a  few  months, 
or  sometimes  after  a  few  years,  go  down  to  death 
with  advanced  tuberculosis.  The  specialist  knows 
that  months,  and  at  times,  years  intervene  between 
different  periods  of  activity  in  tuberculosis.  The 
patient  and  the  good  doctor  too  often  do  not  know 
this,  but  expect  active  disease  to  follow  at  once 
when  the  process  is  sufficiently  advanced  for  a 
diagnosis  to  be  made ;  and  when  it  does  not,  they 
too  often  foolishly  assume  that  the  diagnosis  was 
in  error.   I  do  not  desire  to  be  understood  as  assert- 


ing that  specialists  never  err  in  diagnosis,  but  they 
should  not  err  as  often  as  other  members  of  the 
profession.  Infallibility,  however,  must  not  be 
expected. 

Unfortunately  there  is,  as  yet,  no  specific  cure 
for  tuberculosis,  and  our  success  in  therapy  must 
depend  upon  measures  which  imitate  or  aid  the  pa- 
tient in  his  own  natural  defensive  methods.  We 
are  forced,  too,  to  apply  them  at  a  time,  as  is  evi- 
denced by  the  activity  of  the  process,  when,  at  least 
temporarily,  the  body,  unaided,  has  failed  to  win  its 
fight.  The  earlier  we  come  to  the  aid  of  the  patient 
the  more  surely  can  we  help  him.  While  it  is 
possibly  true  that  the  patient  with  an  advanced  le- 
sion has  a  higher  degree  of  immunity  than  the  one 
with  a  smaller  one,  yet  the  advanced  lesion  pro- 
duces a  more  serious  local  injury  which  cannot  be 
so  readily  repaired ;  and  a  more  serious  general  im- 
pairment of  function  which  weakens  the  general 
resistance  of  the  patient ;  and  these  together  make 
healing  difficult  or  impossible. 

It  is  a  selfevident  fact  that  a  satisfactory  result 
can  be  obtained  in  a  large  proportion  of  those  af- 
flicted with  tuberculosis  only  in  case  they  receive 
treatment  when  the  disease  is  limited  in  extent,  and 
before  severe  pathologic  changes  have  taken  place. 
The  fact  that  our  agencies  for  the  treatment  of  tu- 
berculosis are  so  generally  engaged  with  advancd 
cases  largely  defeats  the  efficacy  of  the  effort  and 
at  the  same  time  furnishes  a  basis  for  the  persis- 
tence of  the  harmful  pessimistic  psychology  which 
unfortunately  has  surrounded  tuberculosis  since 
the  dawn  of  therapeutic  endeavor.  While  early 
diagnosis  and  early  intelligent  treatment  will  re- 
store most  tuberculous  patients  to  health,  the  opin- 
ion of  the  success  of  therapeutic  results  today  is 
based  too  largely  upon  the  treatment,  often  poorly 
carried  out,  of  advanced  cases  in  which  defeat  is 
conceded  as  sure  and  positive  in  a  large  proportion 
before  it  is  undertaken.  This  fact  has  done  much 
to  discredit  the  treatment  of  tuberculosis. 

While  the  imputation  that  the  number  of  tuber- 
culous patients  who  attain  an  arrestment  of  their 
disease  process  is  disappointingly  small  is  based  on 
fact,  it  should  in  no  way  discourage  therapeutic  ef- 
fort. It  should,  however,  spur  on  all  who  are  in- 
terested in  the  treatment  of  this  disease  to  increased 
effort  to  secure  early  diagnosis  and  immediate  in- 
telligent treatment.  Then  and  then  only  can  ac- 
ceptable results  be  obtained. 

The  large  proportion  of  relapses  among  those  wha 
have  secured  an  apparently  satisfactory  result  is 
another  disappointment  to  clinicians  as  well  as  to 
patients.  This  danger  must  always  be  recognized 
and  guarded  against  in  all  ways  possible.  All  other 
factors  being  equal  the  danger  of  relapse  is  in  pro- 
portion to  the  severity  of  the  pathological  pro- 
cess ;  which  again  emphasizes  the  importance  of 
early  diagnosis  and  early  treatment.  Probably  the 
next  most  important  factor  which  contributes  to  re- 
lapses is  inadequate  and  insufficient  treatment.  The 
chronic  nature  of  tuberculosis  must  always  be  borne 
in  mind  ;  so  must  its  resistance  to  the  defensive  forces 
of  the  body.  It  must  further  be  borne  in  mind,  if 
the  disease  has  existed  for  any  length  of  time,  that 
it  so  injures  its  host  as  to  reduce  his  fighting  power. 


September  18,  1920.] 


POTTENGER:  THE  TUBERCULOUS  PATIENT. 


391 


Whether  or  not  an  arrestment  shall  be  attained  and 
maintained  depends  greatly  upon  the  patient's  own 
powers  of  resistance  ;  a  vague  expression,  to  be  sure, 
but  one  that  has  come  to  be  understood  as  meaning 
the  ability  of  the  body  cells  to  functionate  in  such 
a  manner  as  to  be  able  to  check  attempts  at  multipli- 
cation on  the  part  of  the  bacilli  and  extensions  of 
the  process  to  new  tissues,  and  to  promote  tissue  gen- 
eration in  the  form  of  scar  in  the  areas  of  disease. 
The  greater  the  extent  and  the  more  active  the  proc- 
ess the  greater  the  disturbance  in  the  physiological 
processes  of  the  body  of  the  host  and  the  longer  the 
time  required  for  the  establishment  of  equilibrium. 

While  an  individual  tubercle  might  pass  through 
all  the  changes  from  implantation  of  bacilli  to  tu- 
bercle formation  and  conversion  into  scar  in  a  few 
weeks'  time  under  circumstances  favorable  to  heal- 
ing, in  a  process  so  extensive  as  to  produce  symp- 
toms and  cause  clinical  tuberculosis,  even  in  an  early 
stage,  tubercles  are  massed  together  in  such  a  man- 
ner as  to  preclude  this  rapid  healing.  Instead  of 
weeks,  under  most  favorable  circumstances,  months 
are  required  for  a  favorable  pathological  transfor- 
mation ;  and,  during  all  this  time  it  is  necessary  that 
the  patient's  fighting  power  be  adequate  not  only  to 
prevent  further  growth  of  bacilli  and  extension  to 
new  tissues  but  so  to  encapsulate  the  bacilli  pre- 
sent that  fui^ther  activity  is  impossible.  To  this 
end  hygienic  working  colonies  should  be  provided 
for  those  who  are  financially  dependent  where  pa- 
tients with  arrested  disease  can  work  according  to 
their  strength  after  their  discharge  from  sanatoria. 

Patients  are  often  unable,  for  financial  or  other 
legitimate  reasons,  to  carry  out  the  necessary  regime 
long  enough  to  secure  an  arrestment;  at  other 
times,  they  feel  so  sure  of  winning  that  they  can- 
not see  the  necessity ;  or  they  yield  to  some  desire 
which  at  the  time  seems  paramount.  The  physi- 
cian will  be  successful  in  treating  tuberculosis  just 
to  the  extent  that,  knowing  the  character  of  the 
process  and  nature's  way  of  overcoming  it,  he  is 
able  to  keep  up  his  own  interest  in  the  patient  and 
to  secure  the  patient's  cooperation  for  the  time 
necessary  for  the  pathological  process  to  be  trans- 
formed into  scar  and  the  patient's  physical,  psychi- 
cal and  nervous  equilibrium  to  be  restored  to  nor- 
mal or  as  nearly  to  normal  as  possible.  The  length 
of  time  required  for  this  is  far  longer  than  is 
usually  believed.  'In  early  cases  this  may  take  two 
years  or  more,  and  in  advanced  cases  the  time  is 
proportionately  longer.  The  time  also  differs  in 
difYerent  individuals,  and  they  must  be  made  to  un- 
derstand this.  It  is  natural  and  usual  for  each  one 
to  feel  that  his  case  is  one  of  the  most  favorable 
ones  and  that  he  will  get  well  in  the  minimum 
time ;  but  usually  such  is  not  the  case. 

We  must  regard  the  psychology  of  the  patient. 
With  this  in  mind  it  is  necessary  to  impress  upon 
him  first  that  tuberculosis  heals  slowly  and  second 
that  is  it  an  individual  matter,  healing  faster  in  one 
person  than  in  another,  both  because  the  disease 
process  differs  in  diflferent  individuals  and  because 
the  fighting  power  of  patients,  including  both 
natural  resistance  and  willingness  to  cooperate, 
differs.  It  should  be  further  impressed  upon  him 
that  it  will  be  a  matter  of  two  or  three  years  or 


more  before  healing  will  be  completed,  and  that 
he  will' have  to  take  extra  good  care  of  himself  dur- 
ing that  time.  We  have  found  psychologically  as 
well  as  from  the  viewpoint  of  results,  that  it  is 
best  not  to  keep  the  average  patient  too  long  under 
treatment  at  one  time,  but  to  have  him  at  two  or 
more  periods.  In  our  early  work  we  noted  that 
relapses  which  took  place  usually  occurred  from 
three  to  nine  months  after  the  patient  left  off 
treatment.  We  noticed  too  that  there  was  a  re- 
lationship between  the  tendency  to  relapse  and  the 
degree  of  healing  which  took  place  prior  to  dis- 
charge, the  stage  of  the  disease,  and  the  faithful- 
ness with  which  the  patient  followed  the  necessary 
regime.  It  was  then  that  we  saw  that  it  was  a 
duty  as  well  as  as  an  absolute  necessity  that  the 
physician  gain  the  confidence  of  his  patients  to 
such  a  degree  that  they  would  be  willing  to  co- 
operate long  enough  to  get  well.  It  is  now  our 
rule  to  treat  our  patients  until  physical  exercise, 
such  as  walking  from  one  to  ten  miles,  according  to 
the  condition  of  the  patient,  produces  no  toxic 
symptoms,  and  until  we  feel  that  the  chest  signs 
are  no  longer  those  of  a  nature  which  are  likely 
to  reactivate  and  spread.  The  patient  is  then  al- 
lowed to  interrupt  treatment,  following  out  a  re- 
stricted regime  with  only  occasional  supervision 
for  a  period  varying  from  three  to  nine  months, 
when  he  returns  for  another  period  of  strict  guid- 
ance. In  far  advanced  cases  a  second  period  of 
rest  followed  by  a  third  period  of  strict  guidance  is 
adopted.  The  results  of  this  method,  which  is  fash- 
ioned somewhat  after  the  Etappen  methodc  of  tu- 
berculin treatment  followed  by  Petruscliky,  has  been 
most  satisfactory  to  both  patient  and  physician.  It 
furnishes  an  opportunity  for  applying  the  healing 
measures  under  favorable  psychological  conditions 
long  enough  for  arrestment  to  occur ;  and  in  this 
way  reduces  relapses  to  an  unavoidable  minimum. 

The  third  criticism  of  the  results  of  treatment 
that  I  desire  to  discuss  is  that  of  those  who  secure 
and  maintain  an  arrestment  of  their  tuberculous 
process,  a  disappointingly  large  number  remain  in 
a  state  of  invalidism  or  semiinvalidism  which  makes 
it  impossible  for  them  to  take  their  places  in  the 
social  and  industrial  world.  Again  we  must  admit 
the  truth  of  the  criticism ;  and  it  is  our  duty  to  en- 
deavor to  find  some  method  of  overcoming  it. 

Several  causes  for  such  a  state  of  invalidism  are 
apparent. 

1.  Many  are  so  seriously  injured  by  the  disease 
that  they  are  invalids  before  the  treatment  is  insti- 
tuted ;  or  become  so  later.  This  can  be  overcome  to 
a  large  extent  by  earlier  diagnosis  and  earlier  treat- 
ment. 

2.  The  struggle  to  regain  health,  with  its  attendant 
sacrifices  and  disappointments,  makes  such  a  psy- 
chological impression  on  the  patient  that  he  fears 
that  any  exertion  physical  or  mental  may  lower  his 
resistance  and  allow  the  disease  to  again  become 
active.  The  length  of  the  struggle,  with  its  conse- 
quent deleterious  psychic  impressions,  can  be  re- 
lieved partly  by  treating  the  disease  early  instead 
of  when  advanced.  Another  factor  of  importance 
is  that  of  inculcating  a  positive,  philosophy  into  these 
patients,  telling  them  what  they  can  do  instead  of 


392 


VANDER  VEER:  ASTHMA. 


[New  York 
Medical  Journal. 


what  they  cannot  do.  There  are  too  many  don'ts 
for  consumptives  and  not  enough  do's ;  the  result  of 
which  teaches  them  to  fear  all  acts  which  call  for 
more  than  a  minimum  of  energy. 

A  very  important  factor  in  preventing  invalid- 
ism is  to  restore  the  patient's  nervous  and  psychi- 
cal equilibrium  and  his  physical  vigor  and  resistance 
to  a  high  degree  before  discharging  him.  This 
latter  must  be  done  after  all  activity  is  over  when 
exercise  will  not  be  attended  by  toxemia  or  other 
annoying  symptoms.  I  have  no  patience  with  the 
idea  of  making  patients  work  or  allowing  them  to 
be  up  and  around,  when  their  disease  is  active.  It 
is  contrary  to  sense  and  proves  to  be  the  factor 
which  prevents  healing  in  a  great  number.  Tox- 
emia should  be  eliminated  as  soon  as  possible  be- 
cause of  its  deleterious  influence  upon  the  body 
functions  and  because  of  its  harmful  psychic  ef- 
fect. Strength  must  be  conserved  to  fight  the  in- 
fection in  every  way  possible.  If  the  patient  ex- 
ercises when  the  disease  is  active  both  of  these 
principles  are  disregarded.  With  rest  during  the 
period  of  activity,  the  time  of  treatment  is  short- 
ened ;  and  with  graduated  exercise,  always  within 
the  patient's  strength  and  always  short  of  tiring, 
pursued  until  the  patient  has  built  up  a  strong 
physical  resistance,  the  danger  of  invalidism  will 
be  largely  overcome,  because  the  resistance  is  built 
up  under  the  direct  guidance  of  the  physician. 

Many  do  not  seem  to  recognize  the  value  of  rest 
as  a  therapeutic  measure  and  blame  it  for  making 
the  patient  overcautious  and  producing  invalid- 
ism. This  is  unfair.  If  it  produces  this  result  it 
is  because  it  is  incorrectly  applied  and  because 
other  measures  such  as  exercise  at  the  right  time 
and  the  psychology  of  the  patient  are  neglected. 

As  clinicians  we  must  admit  the  truth  of  these 
criticisms ;  but,  on  the  other  hand,  we  must 
insist  that  they  are  largely  remediable.  As  Dett- 
weiler  so  aptly  suggested  many  years  ago,  the  cure 
of  tuberculosis  is  a  matter  of  character  and  the 
pocketbook.  It  is  only  a  comparatively  small 
number  of  people  who,  unaided,  are  able  to  finance 
the  long  treatment  necessary  for  early  tuberculosis, 
let  alone  that  of  advanced.  It  may  be  further  said 
with  equal  truth  that  few  people,  unaided,  possess 
sufficient  strength  of  character  to  persist  in  a  regime 
of  selfdenial  and  selfcontrol  long  enough  to  get 
well  of  their  tuberculosis,  either  early  or  late. 

Fortunately  financial  aid  is  being  secured  for 
large  numbers  through  private  philanthropy  and 
public  recognition  of  the  tuberculous  patient's 
rights.  At  the  same  time  it  will  be  a  long  time  be- 
fore such  aid  will  be  adequate.  It  must  be  re- 
membered, however,  that  one's  resources  will  go 
two  or  three  times  further  in  financing  the  treat- 
ment of  early  tuberculosis  than  they  will  in  financ- 
ing advanced  tuberculosis ;  and  the  chances  of  mak- 
ing a  useful  citizen  who  can  take  up  his  or  her 
burden  in  the  home  or  state  are  infinitely  greater. 

Unfortunately  character  is  something  which  can- 
not be  bought.  Fortunately,  however,  it  may 
exist  as  well  in  those  not  possessed  of  means  as 
those  who  are.  Whether  it  shall  stand  the  test  and 
be  able  to  carry  the  patient  through  the  long  course 
of  treatment  imtil  an  arrestment  has  been  secured 


and  the  patient  restored  to  usefulness  will  always 
depend  largely  on  the  physician"  who  guides  the 
case;  but  to  a  certain  degree  upon  all  those  who 
come  in  contact  with  the  patient.  Not  only  must 
the  physician  furnish  the  proper  psychology  for  the 
patient,  but  also  for  the  attendants  as  well.  This 
is  a  considerable  burden,  but  one  necessary  to  be 
assumed. 

As  the  financial  burden  increases  with  the  time 
of  treatment  extended,  so  do  the  psychological 
problems  in  the  handling  of  the  patient.  The 
remedy  for  both  of  these  difficulties  as  far  as  they 
can  be  remedied  is  early  diagnosis  and  immediate 
intelligent  treatment. 

The  just  but  unfortunate  criticisms  herein  dis- 
cussed may  all  be  largely  corrected  in  the  following 
manner : 

1.  In  order  to  increase  the  proportion  of  arrest- 
ments and  prevent  relapse  early  diagnosis  and  im- 
mediate application  of  an  adequate  treatment  are 
essential ;  and  further,  such  treatment  must  be  con- 
tinued long  enough  to  afford  the  patient's  defen- 
sive forces  the  opportunity  of  not  only  checking 
the  power  of  the  bacilli  to  grow  and  multiply  but 
also  to  repair  the  damage  done  to  the  patient. 

2.  The  patient,  if  treated  early,  will  not  be  so 
prone  to  become  an  invalid,  because :  a.  The  dis- 
ease itself  has  not  yet  proven  so  injurious  to  his 
anatomical  and  physiological  processes,  b.  It  will 
not  have  made  so  great  and  so  harmful  an  impres- 
sion upon  him  psychologically,  c.  His  struggle  for 
regaining  health  has  been  shorter  and  it  has  not 
taxed  his  finances  so  heavily  nor  has  it  created  in 
him  such  fear  of  relapse. 

3.  If  the  patient  is  to  go  back  and  become  a  use- 
ful member  of  society  the  physician  must  prepare 
him  for  so  doing.  To  this  end  it  is  not  sufficient 
to  arrest  the  tuberculous  process,  but  it  is  equally 
important  to  restore  his  nervous  equilibrium  and  to 
build  up  his  physical  strength  so  that  he  can  endure 
work  and  to  arm  him  with  a  positive  optimistic 
psychology  which  will  help  him  to  readjust  him- 
self to  the  hostile  forces  about  him. 


THE  ASTHMA  PROBLEM* 

By  Albert  Vander  Veer,  Jr.,  M.  D., 
New  York,  " 

(From  the  Department  of  Medicine  and  Bacteriology  of  Cornell 
University  and  the  Clinic  of  Applied  Immunology,  New  York 
Hospital.) 

For  man}^  years  the  problem  of  asthma  has  been 
one  of  the  most  difficult  in  medicine.  In  fact, 
it  is  only  within  the  last  decade  that  any  marked 
advance  in  its  solution  has  taken  place.  Until  this 
late  date  the  usual  attitude  toward  the  asthmatic 
patient  was  summed  up  in  the  oft  quoted  remark, 
"Of  course  it's  a  very  distressing  disease  but  no- 
one  ever  dies  from  asthma."  Cold  comfort  this  for 
the  poor  suffering  patient  who  might  go  from  doc- 
tor to  doctor,  from  allopathy  to  homeopathy,  to 
osteopath  and  chiropractor,  always  in  pursuit  of 
that  mythical  "friend  of  a  friend  of  mine  who  was 

cured  by  ,"  to  be  met  in  the  end  by  the  remark 

quoted  above.    No  wonder  he  finally  gave  up  try- 

*  Read  before  the  Albany  County  Medical  Society,  March  10,  1920. 


September  18,  192r.] 


J-.-iXDER  ]'EER:  ASTHMA. 


393 


ing  and  accepted  his  fate  with  what  resignation  he 
could,  branded  as  a  neuropath  by  those  of  us  who 
could  do  nothing  for  him,  and  bearing  with  his 
physical  ills  the  half  contemptuous  pity  of  ■  those 
splendid,  healthy,  normal  individuals  who  were  not 
neurasthenic  and  had  no  asthma.  And  yet  at 
times  a  ray  of  hope  broke  through  his  cloud  of 
despair.  An  occasional  authenticated  case  of  cure 
or  relief  came  to  his  attention.  Some  asthmatic 
moves  from  Maine  to  Arizona  and  is  free — or  else 
moves  from  Arizona  to  Maine.  He  gives  up  farm- 
ing to  become  a  banker,  or  carries  a  lucky  penny 
in  his  pocket,  and  our  patient  tries  the  same  scheme 
with  renewed  hope,  but  it  doesn't  work  for  him 
and  another  fond  hope  is  blasted. 

I  well  remember,  in  m\-  medical  school  days  at 
the  College  of  Physicians  and  Surgeons,  Dr.  James, 
professor  of  medicine,  telling  us  of  a  colony  of 
asthmatics  who  could  live  only  around  Sec- 
ond Avenue  and  Thirteenth  Street,  New  York. 
As  soon  as  they  came  above  Fort)--second  Street 
they  had  an  attack.  ]Many  tales  as  strange  as  this 
are  current  and  they  explain  our  readiness  to  dub 
the  asthmatic  as  a  neuropath  and  our  insistency 
that  if  he  would  only  get  hold  of  his  nerves  and 
make  a  man  of  himself  he  would  cease  to  suflfer. 
With  our  more  recent  knowledge  how  easy  it  is  to 
explain  some  of  these  apparent  inconsistencies. 

It  is  time  something  was  done  to  help  these  suf- 
ferers. There  is  probably  not  one  of  us  who  has 
not,  at  some. time,  sat  near  a  patient  suffering  from  an 
acute  attack  of  asthma,  suffering  with  him  in  his  dis- 
tress and  feeling  powerless  to  help,  or,  worse  yet, 
able  to  help  and  not  daring  to.  We  all  know  that 
the  injection  of  a  small  dose  of  morphine  will  ease 
the  labored  breathing  and  bring  comfort  to  the 
patient — for  a  time.  We  also  know  that  these  at- 
tacks will  come  again  and  again  and  that  the  mor- 
phine injection  will  bring  less  and  less  relief  with 
a  larger  and  larger  dose  imtil  finally  we  have  two 
evils  to  fight  where  before  there  was  but  one. 

The  first  real  step  of  progress  was  made  when 
Meltzer  ( 1 )  brought  forth  the  hypothesis  that 
asthma  was  an  anaphylactic  phenomenon.  This  was 
in  1910  and  succeeding  steps  have  come  rapidly 
imtil  now  it  is  rare  to  read  a  medical  magazine 
which  does  not  contain  at  least  one  article  on 
asthma  or  hypersensitiveness. 

In  1911  Freeman  and  Noon  (2),  in  England, 
published  a  short  article  on  the  treatment  of  hay 
fever  by  injections  of  pollen  extract,  which  was 
apparently  the  first  step  in  the  scientific  treatment 
of  hypersensitiveness.  Their  work  was  soon  fol- 
lowed by  similar  experiments  in  the  United  States. 
Much  of  the  pioneer  work  in  this  line  in  America 
has  been  done  by  Dr.  R.  A.  Cooke,  of  New  York, 
with  whom  I  have  been  associated  for  ten  years, 
and  most  of  the  statistics  on  which  this  paper  is 
based  have  been  drawn  from  his  case  records. 

Starting  with  the  asthma  associated  with  hay 
fever  the  work  has  been  a  steady  assault  on  the 
asthmas  due  to  hypersensitiveness  to  other 
substances  until  now  I  think  it  is  fair  to  estimate 
that  about  seventy  per  cent,  of  all  asthmas  (of 
course  in  this  paper  I  exclude  the  socalled  cardiac 
and  renal  asthmas)  may  be  diagnosed  by  careful 


work,  and  in  this  disease  the  diagnosis,  as  a  rule, 
is  more  than  half  the  battle. 

•  DEFIXITIOX  AXD  CL.\S.SIFICATIOX. 

The  following  definition  and  classification  of 
asthma,  with  postulates  which  must  be  fulfilled 
before  one  may  assume  the  allergic  condition  of  an 
individual  to  any  substance,  are  taken  from  the 
article  on  bronchial  asthma  h\  Cooke  in  Tyson's 
System  of  Medicine. 

Definition.— Bronchial  asthma  is  a  condition 
characterized  by  dyspnea,  both  inspiratory  and  ex- 
piratory, especially  the  latter,  due  to  bronchial  spasm 
and  edema  of  the  bronchial  mucous  membrane.  It 
may  be  acute,  subacute  or  chronic.  The  term  bron- 
chial asthma  should  be  restricted  to  that  condition 
which  is  the  result  of  an  allergic  reaction. 

Classification. 

^  Animal  dander. 

1.  Allergic,    a,  by  inhalation          ■  Pollens. 

'  Sachets  and  perfumes. 

u  u    •  I  Drugs. 

b,  by  ingestion   |  p^^|^ 

c,  by  absorption  from  f  gacterial  proteins. 

focus    ( 

d,  by     subcutaneous  i 

or  intravenous  -J  Therapeutic  sera, 
injection  ....  ( 

f  Acute  bronchitis 

Chronic  bronchitis  and  emphysema. 
J  Pulmonarj-  tuberculosis. 

2.  Xonallergic  .1  Cardiorenal  disease. 

Thymic  enlargement. 
Enlarged  bronchial  glands. 
1  Reflex  bronchial  spasm. 

The  relative  size  of  the  groups  under  this  classifi- 
cation may  be  judged  from  the  following  figures. 
I  had  hoped  to  have  a  large  group  of  cases  cover- 
ing the  work  done  in  1917,  1918  and  1919  but 
owing  to  the  short  notice  on  which  this  paper  was 
written  I  am  only  able  to  give  the  figures  for  1917, 
a  total  of  143  cases.  Of  these,  eight  were  seen 
but  once  or  twice  and  are  rejected  as  giving  insuffi- 
cient data  for  a  diagnosis.  The  135  remaining 
cases  were  divided  as  follows:  Pollen  52,  or  38.5 
per  cent. ;  mixed  19.  or  14  per  cent. ;  animal  12.  or 
9  per  cent.;  bacterial  11,  or  8  per  cent.;  food  2,  or 
1.5  per  cent.;  undiagnosed  39.  or  29  per  cent. 

A  word  in  regard  to  this  classification.  A  large 
number  of  patients  will  .give  skin  reactions  to  two 
or  more  substances  in  different  groups,  for  instance 
to  a  pollen,  several  foods  and  possibly  some  animal 
dander,  and  yet  the  only  complaint  may  be  asthma 
occurring  with  hay  fever  in  September.  This  is 
therefore  classed  as  a  pollen  asthma  and  not  mixed, 
although  giving  skin  reactions  for  other  sub- 
stances. The  patient  is  said  to  be  potentially  al- 
lergic to  the  other  substances  but  for  some  reason 
they  do  not  come  in  sufficiently  close  contact  with 
the  bronchial  mucous  membrane  to  set  up  a  re- 
action. At  an}-  time,  however,  clinical  symptoms 
may  result  from  such  substances  and  the  patient 
should  be  warned  of  that  fact  when  the  diagnosis 
is  made. 

The  two  postulates,  formulated  by  Cooke,  that 
must  be  fulfilled  before  we  may  assume  that  any  sub- 
stance is  etiologically  important  in  a  case  of  hyper- 
sensitiveness, are  as  follows : 


394 


VAXDER  J'EER:  ASTHMA. 


[New  York 
Medical  Journal. 


1.  Hypersensitiveness  must  be  demonstrated 
either  by,  a,  a  positive  local  reaction,  cutaneous  or 
ophthalmic,  or  b.  the  original  allergic  manifestation 
must  be  artificially  reproduced  at  will  on  introduc- 
tion of  the  substance,  either  inhaled,  ingested  or 
subcutaneously  injected. 

2.  It  must  be  shown  that  the  individual  comes 
in  contact  in  some  way  with  the  suspected  sub- 
stance in  order  to  permit  it  to  act  as  an  etiological 
factor. 

DIAGNOSIS,  TREATMEXT  AND  PROGXOSIS. 

I  shall  now  take  up  in  detail  the  diagnosis,  treat- 
ment and  prognosis.  First  and  foremost  a  care- 
ful history  is  essential.  This  should  include  the 
place  and  time  of  year  of  the  first  attack,  if  known, 
and  the  general  course  of  subsequent  attacks.  If 
the  asthma  is  confined  to  one  season  of  the  year, 
summer  or  fall  or  summer  and  fall,  particularly  if 
it 'occurs  with  hay  fever,  it  is  almost  surely  a  pollen 
asthma.  This  premise  is  strengthened  if  it  occurs 
in  localities  where  pollen  is  abundant,  as  in  the 
country,  and  is  absent  or  minimized  at  the  sea- 
shore, on  shipboard,  or  in  localities  where  pollen  is 
at  a  minimum.  It  is  well  to  remember  that  there 
is  no  rag  weed  in  Europe  and  ver\-  little  in  Can- 
ada and  northern  United  States:  Hence  the 
asthmatic  victim  of  rag  weed  pollen  will  state  that  he 
is  free  in  those  localities.  Grass  pollen,  which  causes 
hay  fever  and  asthma  in  ^lay,  June  and  July  (in  this 
zone)  is  present  in  Europe,  Canada  and  most  of 
the  United  States.  Therefore  the  patients  sensitive 
to  grass  pollen  will  have  their  hay  fever  and  asthma 
no  matter  where  they  go  for  relief.  In  patients 
with  hay  fever  asthma  is  likely  to  develop  during 
a  particularly  severe  attack  but  they  usually  suffer 
only  at  the  height  of  the  season  and  recover  rapidly 
after  the  disappearance  of  the  pollen  unless  a  sec- 
ondary bacterial  infection  is  acquired,  of  which  more 
will  be  said  later. 

The  histor}-  should  also  take  into  consideration 
animal  hypersensitiveness.  ^lany  people  know  that 
they  have  such  a  hypersensitiveness  to  horses  and 
that  proximity  brings  on  an  attack  of  asthma  or 
hay  fever,  but  few  realize  that  cats.  dogs,  and 
other  domestic  animals  may  be  the  cause  of  their 
trouble.  The  mere  presence  of  such  an  animal  in 
the  house,,  continually  shedding  its  epithelium,  may 
cause  much  discomfort  to  a  hypersensitive  patient 
even  if  he  shuns  intimate  contact  with  the  animal. 
An  illustration  of  this  is  furnished  by  a  lady  who 
knew  that  she  was  hypersensitive  to  cats  but  had 
several  in  the  house,  avoiding  close  contact  with 
them.  She  suffered  from  asthma  but  was  free  at 
Atlantic  City,  attributing  the  freedom  to  the  change 
in  climate.  Removal  of  the  cats  plus  a  thorough 
house  cleaning  for  a  week  entirely  removed  the 
trouble. 

It  is  well  to  get  a  careful  history  of  the  location 
of  the  attacks.  A  case  in  point  is  that  of  a  boy 
who  had  lived  in  Coney  Island  for  nine  years  with- 
out any  trouble.  He  then  moved  to  a  new  house 
where  he  and  his  parents  lived  in  two  rooms. 
Within  a  few  days  he  started  to  have  asthma  which 
continued  intermittently  for  two  years.  He  came 
to  New  York  and  spent  ten  days  in  a  hospital  where 
he  was  free.    The  next  month  at  home  he  had  it 


continually.  A  week  at  a  relative's  house  in  the 
Bronx  and  he  was  free.  The  asthma  returned 
when  he  went  home.  The  father  of  the  boy  wanted 
to  move  from  Coney  Island  as  "the  climate  did  not 
agree  with  him  there,"  but  from  the  history  it  was 
apparent  that  the  causative  factor  in  the  asthma 
was  inside  those  two  rooms.  Careful  investigation 
and  testing  revealed  two  pillows  stuffed  with  rabbit 
hair  to  which  the  boy  gave  marked  skin  reactions, 
and  removal  of  those  two  pillows  removed  his 
asthma  completely  with  no  further  treatment.  This 
of  course  is  an  extreme  case  but  it  illustrates  how 
valuable  a  careful  history  is  in  tracking  down  the 
offending  substance. 

Practically  all  asthmatics  are  bothered  by  cold, 
windy  days  or  damp,  muggy  weather  but  these 
factors  should  be  recognized  as  nonspecific  and  not 
as  the  specific  exciting  agents.  Like  epilepsy,  the 
more  asthma  a  patient  has,  the  easier  it  is  to  set 
up  an  attack,  and  conversely,  if  we  can  remove 
the  main  exciting  cause  and  give  the  patient  free- 
dom for  some  time,  mechanical  causes  will  not,  of 
themselves,  excite  an  attack. 

It  is  often  possible  to  get  a  history  of  gastrointes- 
tinal disturbances  preceding  or  accompanying  the 
asthma  and  here  it  is  necessary  to  find  out  if  the 
patient  has  noticed  any  particular  articles  of  diet 
which  may  cause  trouble.  Such  a  history  must, 
however,  be  accepted  with  caution  and  subject  to 
future  confirmation  by  tests  as  we  have  often  found 
patients'  own  deductions  in  this  matter  most  er- 
roneous. It  is  not  unusual  to  be  told  that  certain 
articles  of  diet  at  times  give  rise  to  symptoms  and 
at  other  times  can  be  eaten  with  impunity.  We  know 
that  the  skin  tests  with  many  foods  occasionally 
give  us  positive  results  at  one  time  and  negative  at 
another,  so  it  is  probable  that  there  is  some  other 
element  which  enters  into  the  situation  here,  con- 
stipation, rapid  absorption,  certain  combinations  of 
food,  we  know  not  what  it  is,  and  thus  gives  rise 
to  such  differences  in  the  action  of  foods. 

The  family  history  should  be  carefully  elicited. 
It  has  been  shown  (3)  that  hypersensitiveness  is 
probably  transmitted  as  a  dominant  characteristic 
according  to  the  Mendelian  law.  In  a  series  of  621 
cases  of  human  allergy  it  was  shown  that  if  both 
parents  were  hypersensitive,  67.5  per  cent,  of  the 
children  would  exhibit  some  clinical  form  of  hyper- 
sensitiveness (not  necessarily  the  same  as  either 
parent)  and  that  this  would  appear  before  the  fifth 
year  as  a  rule.  If  one  parent  is  hypersensitive 
sixty  per  cent,  of  the  children  will  show  hyper- 
sensitiveness and  the  height  of  the  curve  of  inci- 
dence will  be  before  the  fifteenth  year.  In  those 
cases  with  a  negative  family  history  the  height  of 
the  curve  was  between  the  twentieth  and  twenty- 
fifth  year.  In  504  cases  with  satisfactory  history 
there  was  a  positive  antecedent,  direct  or  collateral 
family  history  in  48.5-  per  cent.,  which  contrasted 
strikingly  with  a  positive  history  of  hypersensitive- 
ness of  14.5  per  cent,  in  the  antecedents  of  seventy- 
six  normal  controls.  It  is  estimated  that  hyper- 
sensitiveness occurs  in  about  ten  per  cent,  of  all 
people. 

After  a  careful  history  has  been  obtained  the 
patient  should  be  tested  against  substances  to  which 


September  18,  1920.] 


VANDER  VEER:  ASTHMA. 


395 


he  may  react.  The  basis  of  this  test  is  the  fact 
tliat  where  an}'  part  of  the  body  is  hypersensitive 
to  a  foreign  substance,  as  the  bronchial  mucous 
membrane  in  asthma,  the  nose  and  eyes  in  hay  fever, 
the  skin  in  urticaria  and  angioneurotic  edema,  there 
is  usually  a  corresponding  hypersensitiveness  of 
the  skin  to  such  substance.  This  is  not  an  invari- 
able rule  but  occurs  in  the  vast  majority  of  cases. 
The  usual  way  to  make  such  test  solutions  is  to 
grind  up  the  substance  to  be  tested  in  salt  solution 
(with  a  little  carbolic  acid  added  as  a  preservative), 
alternately  freeze  and  thaw  several  times  and  then 
filter.  Such  solutions  will  keep  for  a  long  time  if 
placed  in  a  cool  atmosphere  when  not  in  use  and  are 
not  easily  contaminated,  if  ordinary  precautions  are 
used.  Such  test  solutions  are  now  put  out  by 
many  commercial  drug  houses. 

The  testing  is  conveniently  done  in  groups — thus 
the  inhalation  group  consisting  of  the  pollens,  ani- 
mal emanations,  sachets  and  dusts — the  foods — the 
drugs,  etc.    Of  these  the  inhalation  group  is  the 
most  important.    The  solution  is  injected  intra- 
dermally  (not  subcutaneously )  into  the  skin  on  the 
outer  surface  of  the  upper  arm,  using  a  one  c.  c. 
tuberculin  syringe  and  a  fine  needle.    A  separate 
syringe  is.  of  course,  used  for  each  solution.  A 
minute  quantity  is  sufficient,  about  one  fiftieth  c.  c. 
Avhich  raises  the  skin  in  a  wheal  about  one  quarter 
inch  in  diameter.    From  eight  to  thirty  of  these 
tests  may  be  done  at  one  sitting  providing  the  pa- 
tient is  not  too  sensitive.    Here  I  wish  to  empha- 
size a  word  of  warning.    Where  you  have  reason 
to  believe  the  patient  is  very  sensitive  do  only  a 
few  tests  at  a  time.    If  a  patient  is  hypersensitive 
to  three  or  four  different  substances,  particularly  if 
these  are  pollens  or  animal  emanations,  it  is  quite 
possible  to  excite  an  attack  of  asthma  or  urticaria 
from  these  skin  tests  alone.    Therefore  a  second 
word  of  warning — do  not  perform  any  of  these 
tests  or  give  any  injections  without  a  bottle  of 
epinephrine  at  hand.    If  a  reaction  develops  it  is 
easily  and  safely  controlled  by  a  subcutaneous  in- 
jection of  one  half  to  one  c.  c.  of  epinephrine  re- 
peated every  ten  or  fifteen  minutes  if  necessary. 
Reactions  will  occur.    After  ten  years  of  this  work 
we  are  still  getting  reactions  at  unexpected  times 
due  to  the  unknown  hypersusceptibility  of  some 
people  but  with  the  prompt  administration  of  epine- 
i:)hrine  I  have  yet  to  see  any  reaction  which  was 
more  than  a  passing  discomfort.    I  have  seen  many 
however,  which  would  have  been  most  uncomfor- 
table, if  not  even  dangerous,  but  for  the  prompt 
and  sufficient  administration  of  epinephrine.    As  to 
the  latter,  I  have  never  seen  any  bad  effects  from 
an  overdose  except  a  nervous,  shaky,  chilly  feeling 
which  passes  off  in  a  longer  or  shorter  time.    I  do 
not  want  to  overemphasize  the  dangers  of  this 
method  of  diagnosis  and  treatment  but  if  you  will 
bear  in  mind  this  precaution  you  will  save  your 
patients  and  yourself  a  most  uncomfortable  hour 
which  may  come  when  least  expected. 

The  skin  reaction,  if  positive,  will  show  in  from 
five  to  fifteen  minutes  and  in  an  urticarial  wheal 
varying  in  size  from  a  dime  to  a  silver  dollar  or 
larger.  The  readings  commonly  employed  are, 
negative  (  no  enlargement  of  the  original  wheal)  ; 


slight  (about  the  area  of  a  dime)  :  moderate  (be- 
tween slight  and  marked)  ;  and  marked  (varying  in 
size  from  a  nickel  up,  with  pseudopod  formation). 
There  is  usually  an  area  of  redness  about  the  wheal 
and,  with  the  marked  reactions,  almost  invariably  a 
sense  of  itching.  The  reactions  usually  begin  to 
fade  away  after  fifteen  or  twenty  minutes  but  if 
many  tests  are  done  and  several  are  positive  the 
arm  may  remain  red  and  swollen  for  twenty-four 
hours.  This  is  in  no  sense  an  infection  and  the 
patient  should  be  reassured  and  told  to  apply  cold 
cloths  to  take  away  the  itchy  feeling  if  it  is  un- 
comfortable. Where  many  tests  are  to  be  done  it 
is  well  to  alternate  the  arms  and  possibly  allow  a 
day  or  two  to  elapse  between  tests.  Adults  rarely 
mind  the  discomfort  when  they  are  anxious  to  dis- 
cover the  cause  of  their  trouble  but  it  is  difficult  to 
perform  many  tests  on  children  and  it  is  therefore 
necessary  to  eliminate  by  the  history  as  much  as 
possible  and  only  test  for  what  is  felt  to  be  abso- 
lutely essential.  Fortunately  their  diet  is  much 
simpler  than  adults  and  as  milk,  eggs  and 
wheat  are  the  chief  offenders  in  their  cases  it  is 
often  possible  to  get  a  good  result  with  the  mini- 
mum of  testing. 

As  to  the  extracts  used,  where  the  case  is  a 
pollen  asthma  it  is  rarely  necessary  to  use  more 
than  the  grass  pollen  (for  June  and  July  cases)  or 
the  rag  weed  pollen  (August  and  September).  Very 
few  people  are  hypersensitive  to  other  pollens  to  a 
degree  to  cause  them  trouble,  although  they  are 
convinced  that  roses,  goldenrod  and  other  flowers 
are  at  fault.  After  many  years  of  testing  and  treat- 
ing we  have  discarded  the  use  of  these  other 
pollens  except  in  a  very  few  instances. 

From  the  skin  tests  it  is  possible,  in  a  rough  way, 
to  judge  somewhat  of  the  degree  of  hypersensitive- 
ness of  the  patient — the  more  marked  the  reaction 
the  more  susceptible  the  patient,  and  the  smaller 
the  dose  needed  to  immunize.  I  do  not  believe,  how- 
ever, that  it  is  possible  to  determine  absolutely  the 
size  of  the  dose  by  measuring  the  size  of  the  wheal. 

Eye  tests  should  also  be  done.  A  drop  of  the 
same  solution  placed  in  the  eye  will  often  give  a 
reddening  of  the  caruncle  and  conjunctiva  with  a 
sensation  of  itching  and  may  cause  sneezing  and 
l^locking  of  the  nose  on  the  same  side  by  running 
down  the  nasal  duct.  It  is  easier  to  judge  of  the 
hypersensitiveness  of  the  patient  by  his  reaction  to 
solutions  of  different  strengths  in  the  eye  than  by 
the  skin  reactions. 

Horse  epithelium  is  the  most  important  of  the 
animal  emanations  (which  are,  of  course,  quite  dif- 
ferent in  their  action  from  the  animal  sera),  next 
in  importance  being  cat  and  dog.  Other  animal 
dander  for  which  tests  should  be  made  are  rabbit 
(used  in  stuffing  pillows  and  as  a  fur),  cow,  sheep 
and  the  feathers  of  chicken,  duck  and  goose  (used 
in  pillows).  Animal  sera  are  of  less  importance 
but  a  test  should  always  be  made  with  horse  serum 
and,  if  positive,  the  patient  should  be  M^arned  of 
the  danger,  to  him,  of  diphtheria  or  other  anti- 
toxin injection. 

The  number  of  skin  tests  to  be  done  varies  with 
the  history  obtained.  In  a  clear  cut  pollen  asthma 
it  is  unnecessary  to  subject  the  patient  to  tests  with 


396 


VANDER  VEER:  ASTHMA. 


[New  York 
Medical  Journal. 


all  the  foods  and  other  substances.  Here  you  are 
only  interested  in  confirming  the  rag  weed  or  grass 
pollen  hypersensitiveness  and  its  degree.  Where 
the  history  is  irregular  it  is  necessary  to  test  with 
animal  emanations,  sachets  (as  well  as  the  pollens), 
food,  and  in  fact  all  the  preparations  at  your  com- 
mand. 

Beside  the  skin  tests  it  is  essential  to  make  a 
complete  physical  examination  in  all  cases.  This 
will  enable  you  to  rule  out  cardiac  and  renal 
asthmas,  mediastinal  growths,  and  possible  foci  of 
chronic  infection  located  in  sinuses,  teeth,  or  the 
gastrointestinal  tract.  Of  these  the  sinus  infec- 
tions are  the  most  frequent  and  important  and  a 
diagnosis  of  such  trouble  should  be  followed  im- 
mediately by  proper  remedial  measures. 

The  blood  count  in  asthma  shows  little  that  is 
characteristic  except  an  increase  of  the  eosinophile 
cells  in  the  differential  count.  They  are  usually 
between  four  and  ten  per  cent,  but  may  go  as  high 
as  sixty  or  seventy  per  cent.  As  yet  we  do  not 
know  the  significance  of  this  increase  but  its  occur- 
rence points  to  an  asthma  due  to  hypersensitiveness 
rather  than  to  one  of  renal  or  cardiac  origin. 

TREATMENT. 

The  first  thing  is  treatment  of  the  immediate  at- 
tack. Here  our  chief  reliance  must  be  placed  on 
epinephrine  used  hypodermically.  From  five  to  fif- 
teen minims  of  this  drug  repeated  every  half  hour 
or  so  will  control  the  great  majority  of  asthmatic 
attacks,  the  relief  lasting  from  a  few  hours  to  a 
day  or  more.  I  think  this  drug  is  too  sparingly 
used,  because  of  the  impression  that  it  raises  blood 
pressure  and  eventually  causes  chronic  hyperten- 
sion. This  is  not  true  and  you  may  easily  prove  to 
your  satisfaction  that  epinephrine,  administered  dur- 
ing an  attack  of  asthma,  actually  lowers  the  blood 
pressure  from  ten  to  thirty  or  more  points  by  re- 
lieving the  bronchial  spasm.  I  have  seen  patients 
who  have  taken  epinephrine  for  many  years  in  con- 
siderable doses  and  who  do  not  exhibit  hypertension 
or  any  ill  effects  from  it ;  nor,  as  a  rule,  do  they 
have  to  increase  the  dose.  Incidentally  I  may  men- 
tion that  it  is  of  equally  great  value  in  other  mani- 
festations of  hypersensitiveness  such  as  urticaria, 
angioneurotic  edema  and  those  rare  cases  of  shock 
following  the  ingestion  of  food  or  drugs  to  which 
a  patient  may  be  allergic.  It  is  one  of  the  few 
drugs  which  can  be  depended  on  to  work  and 
should  be  in  every  practitioner's  armamentarium. 

Morphine  has  been  used  for  the  acute  attacks. 
Personally  I  have  a  great  dread  of  it  in  such  a 
chronic  condition  as  asthma.  It  will,  of  course, 
relieve  the  immediate  condition  as  well  as  epine- 
phrine but  the  danger  of  forming  a  habit  is  too 
great  and  it  should  be  used  only  in  cases  of  the 
most  urgent  need.  For  milder  attacks  there  are 
a  number  of  pastilles,  powders  and  cigarettes  on 
the  market,  most  of  them  with  a  base  of  stra- 
monium leaves,  which  are  very  valuable  and  should 
be  used  to  give  the  patient  relief.  Atropine  may 
be  given  in  doses  of  1/200  to  1/75  of  a  grain  as 
indicated.  It  can  be  given  by  mouth  or  hypoder- 
mically and  is  a  valuable  aid.  Benzyl  benzoate  in 
doses  of  twenty  to  thirty  minims  four  times  a  day 
has  lately  been  highly  recommended.    What  little 


experience  I  have  had  with  it  has  been  most  dis- 
appointing, but  in  view  of  the  good  reports  from 
other  observers  I  think  it  is  worthy  of  a  thorough 
trial. 

The  treatment  of  the  underlying  condition,  of 
course,  depends  on  the  history  and  results  of  the 
examination  and  tests.  Where  the  exciting  cause 
can  be  eliminated  from  intimate  contact  with  the 
patient,  this  should  be  done.  Where  this  cannot  be 
done  the  patient  should  be  immunized  against  the 
exciting  cause.  To  illustrate :  Where  the  patient  is 
hypersensitive  to  one  or  more  articles  of  food,  these 
should  be  eliminated  from  his  diet.  It  often  hap- 
pens that  after  abstaining  for  a  time  he  is  again  able 
to  eat  such  foods  in  moderation  without  trouble. 
This  is  particularly  true  with  children  who  are 
hypersensitive  to  egg  or  milk  proteins.  We  have 
records  of  a  number  of  such  cases,  hypersensitive 
in  early  childhood  but  now  able  to  eat  milk  and 
eggs  in  adult  life,  without  any  trouble.  This  is  in 
marked  contrast  to  hypersensitiveness  to  animals 
and  pollens  which  is  very  likely  to  continue  during 
the  life  of  the  patient. 

In  the  case  of  the  boy  hypersensitive  to  rabbit 
hair  the  treatment  was  simply  to  remove  the  pillows 
stu fifed  with  such  hair  and  to  warn  him  of  his 
enemy  for  the  future.  In  cases  of  cat  and  dog 
hypersensitiveness,  it  is  easy  to  immunize  against  the 
dander  but  as  the  treatment  must  be  continued  in- 
definitely it  is  wiser  to  remove  the  offending  animal. 
It  is  not  sufficient  to  stay  away  from  the  cat  or 
dog — it  must  be  entirel}'  removed  from  the  house 
and  then  all  the  rooms  must  be  carefully  cleansed 
several  times  to  get  rid  of  the  dander  scattered 
about. 

In  pollen  hypersensitiveness  it  is  ordinarily  im- 
possible for  the  average  person  to  avoid  exposure 
during  certain  times  of  the  year.  For  the  leisure 
class  there  is  always  the  opportunity  and  excuse  of 
a  trip  to  Europe  where  they  may  escape  the  late 
hay  fever  and  asthma  but  the  grass  pollen  cases  are 
as  much  exposed  in  Europe  as  they  are  in  this  coun- 
try. We  must  here  make  use  of  active  immuniza- 
tion and  fortunately  the  results  are  excellent,  better 
in  fact  than  the  results  of  the  treatment  of  the 
hay  fever  with  which  the  asthma  is  associated. 
Cooke  reports  a  series  of  135  cases  of  hay  fever 
and  asthma  treated  by  pollen  injections  with  the 


following  results: 

Asthma  not  improved   5  per  cent. 

Asthma  slightly  improved   6  per  cent. 

Asthma  improved    36  per  cent. 

Asthma  absent    53  per  cent. 

Hay  fever  not  improved   4  per  cent. 

Hay  fever  slightly  improved   5  per  cent. 

Hay  fever  improved   85  per  cent. 

Hay  fever  absent   6  per  cent 


In  other  words  the  asthma  was  entirely  con- 
trolled in  over  half  the  cases  while  in  thirty-six 
per  cent,  more  a  fairly  satisfactory  result  was  ob- 
tained. 

The  principle  of  the  treatment  is  the  injection  of 
gradually  increasing  doses  of  pollen  extract  at  in- 
tervals of  from  five  to  seven  days.  Such  extracts 
are  now  obtainable  from  many  commercial  drug 
houses.  The  only  disadvantage  in  their  use  is  that 
the  dose  is  graduated  to  the  more  sensitive  cases  in 


Septemb:r  18,  1920.] 


VAXDER  VEER:  ASTHMA. 


397 


order  to  avoid  constitutional  reactions  and  hence 
the  doses  are  too  small  to  immunize  completely  the 
less  sensitive  persons.  The  results,  however,  are 
surprisingly  good.  In  the  series  quoted  above  the 
extract  was  standardized  according  to  the  amount 
of  nitrogen  contained  and  this  enables  one  to  gradu- 
ate the  doses  very  exactly.  All  patients  were  tested 
out  by  eye  and  skin  tests  and  their  degree  of  sen- 
sitiveness thus  determined.  It  takes  about  fifteen 
to  twenty  injections  all  told  and  the  treatment 
should  be  begun,  if  possible,  six  weeks  before  the 
season.  If  the  patient  is  not  seen  until  the  hay 
fever  and  asthma  have  actually  started  then  he  is 
treated  phylactically  instead  of  prophylactically. 
Several  small  doses  are  given  on  succeeding  days, 
then  at  intervals  of  two,  three  and  four  days  until 
the  end  of  the  season.  The  results  in  cases  so 
treated  are  almost  as  good  as  those  treated  before 
the  season  begins.  By  these  pollen  injections  the 
asthma  is  not  only  relieved,  but  the  patients  are, 
as  a  rule,  protected  against  secondary  infections  at 
the  end  of  the  season  which  very  often  prolong 
the  asthma  and  cough  until  long  after  the  pollen 
factor  has  disappeared  and  also  renders  them  much 
less  susceptible  to  attacks  of  asthma  and  bron- 
chitis during  the  winter  months. 

I  wish  to  emphasize  again  the  importance  of 
bearing  in  mind  the  value  of  epinephrine  in  this 
treatment.  We  endeavor  to  give  as  large  doses 
as  possible  of  the  pollen  extract  without  causing  a 
general  or  very  marked  local  reaction.  Occasion- 
ally the  patient  receives  a  larger  dose  than  he  can 
stand  and  within  a  few  minutes  general  urticaria, 
asthma,  or  hay  fever  develops.  These  reactions 
can  be  readily  controlled  by  one  or  more  doses 
of  the  epinephrine  and  are  no  more  than  a  passing 
inconvenience.  The  patient  should  be  warned  of 
this  and  reassured.  If  such  reaction  occurs  un- 
expectedly and  is  not  treated  the  patient  is  need- 
lessly alarmed  and  often  refuses  to  continue  a 
treatment  which  seems  to  him  dangerous. 

In  patients  hypersensitive  to  animals  it  is  usu- 
ally possible  to  avoid  exposure  and  thus  there  is 
no  necessity  for  active  immunization.  In  the  few 
cases  where  it  seems  best  to  immunize  it  is  for- 
tunately easy  to  do  so.  These  are  usually  horse 
epithelium  victims.  The  first  doses  sliould  be  ex- 
tremely small  but  after  about  ten  injections  the 
patient  is  almost  always  able  to  come  in  the  closest 
contact  with  horses  without  experiencing  discom- 
fort. Injections  may  now  be  given  at  monthly  in- 
tervals or  may  be  discontinued  entirely  if  the 
patient  is  constantly  exposed  to  horses  and  thus 
keeps  up  his  own  immunity. 

Hypersensitiveness  to  sachets  is  best  treated  by 
avoidance  of  such  sachets  if  the  patient  is  only 
moderately  hypersensitive.  This  will  give  freedom 
except  on  rare  occasions  when  brought  into  con- 
tact with  unusually  severe  exposure.  In  some 
cases  it  may  be  necessary  to  immunize  with  doses 
of  sachet  extract  and  the  results  are,  as  a  rule, 
very  good. 

Patients  exhibiting  an  allergic  reaction  to  drugs 
are  extremely  interesting.  Quinine  and  aspirin  are 
the  two  most  frequently  met  with.  The  reaction 
is  not  like  an  overdose  of  the  drug  in  a  normal 


person  but  a  typical  allergic  one — asthma,  urti- 
caria or  even  extreme  shock  and  may  occur  after 
a  very  small  dose.  It  is  well  to  bear  in  mind  there 
are  such  persons,  who  usually  say  they  have  an 
idiosyncrasy  to  such  and  such  a  drug,  for  we  have 
records  of  at  least  two  dozen  aspirin  cases,  in  one 
of  which  there  developed  an  attack  of  asthma  lasting 
three  weeks  following  the  ingestion  of  five  grains, 
and  another  patient  who  immediately  went  into 
shock  and  died  in  five  minutes  from  the  same 
amount.  It  is  probable  that  some  cases  of  un- 
explained sudden  death  are  due  to  a  hitherto  un- 
known allergy  to  one  of  these  commonly  used 
drugs.  The  treatment  is  avoidance  of  the  offend- 
ing drug  and  great  care  on  the  part  of  the  patient 
that  he  never  receives  a  dose  of  it  by  mistake. 

Many  cases  of  chronic  asthma  are  complicated 
by  an  accompanying  chronic  bronchitis.  Some  of 
these  will  clear  up  when  the  tinderlying  cause  of 
the  asthma  is  removed  but  many  of  them  will  re- 
quire treatment  for  the  bronchitis  as  well  as  the 
asthma.  Here  it  is  well  to  have  an  autogenous 
vaccine  made  from  organisms  recovered  from 
the  washed  sputum  (this  must  be  done  by  a  com- 
petent bacteriologist  to  get  any  satisfactory  re- 
sults) and  these  must  be  properly  interpreted  and 
the  injections  of  this  vaccine  should  be  given  over 
a  long  period  of  time.  The  maximum  dose  should 
be  at  least  three  to  six  billion  and  the  injections 
should  be  continued  for  some  time  after  the  or- 
ganism has  disappeared  from  the  sputum. 

Local  treatment  for  all  foci  of  infection  is,  of 
course,  essential.  Polypi  should  be  removed,  sin- 
uses drained,  diseased  tonsils  thoroughly  removed 
and  teeth  radiographed  and  treated.  Every  ef- 
fort should  be  made  to  place  the  patient  in  as  nor- 
mal physical  condition  as  possible. 

You  will  frequently  be  asked  whether  a  change- 
in  climate  is  advisable,  and  if  you  are  honest  witln 
your  patient  and  yourself  the  answer  is  usually  no. 
I  admit  that  the  temptation  is  strong,  when  you 
have  been  dealing  with  a  particularly  obstinate  case, 
to  shift  the  responsibility  to  some  other  doctor  liv- 
ing in  California,  or  Texas,  or  Colorado,  but  the 
chances  are  that  the  patient  will  there  encounter 
the  same  pollen,  pillows,  food,  sachet,  or  animals 
which  he  encounters  at  home  and  if  a  change  is 
made  it  is  often  just  as  efficacious  to  move  next 
door  or  across  the  street  and  much  cheaper.  Be- 
conscientious  and  persevere  until  you  have  solved 
the  problem  yourself.  An  exception  to  this  rule- 
can  be  made  in  a  few  cases,  complicated  by  tuber- 
culosis or  run  down  by  long  suffering  or  a  chronic 
bronchitis,  who  occasionally  need  a  change  in  cli- 
mate to  build  up  their  general  health. 

PROGNOSIS. 

This  has  been  touched  on  under  treatment.  The 
prognosis  depends  on  the  diagnosis.  At  the 
present  time  about  seventy  per  cent,  of  all  cases  can 
l3e  diagnosed.  Over  one  third  of  these  are  pollen 
asthmas  and  the  figures  already  quoted  show  that 
ninety  per  cent,  of  these  patients  can  be  made  quite 
comfortable.  Of  the  animal  and  food  asthmas  the 
great  majority  can  be  entirely  relieved.  The  really 
difficult  cases  are  those  with  a  complicating  infec- 
tion,  sinus,   bronchial   or   intestinal.    The  larger- 


398 


VANDER  VEER:  ASTHMA. 


[New  York 
Medical  Joirxal. 


proportion  can  be  relieved  by  appropriate  treatment 
but  they  require  long  and  careful  investigation  with 
a  maximum  of  patience  and  perseverance  on  the 
part  of  both  doctor  and  patient.  As  to  the  un- 
diagnosed thirty  per  cent. — this  class  is  steadily  be- 
coming smaller  and  I  am  sure  will  continue  to  de- 
crease. Each  difficult  case  solved  is  an  advance. 
It  took  two  months  of  hard  work  to  solve  the  prob- 
lem of  the  lad  who  was  sensitive  to  rabbit  hair 
but  when  that  was  achieved  three  more  difficult 
cases  were  found  to  be  similar  and  all  were  re- 
lieved immediately. 

The  word  relieved  is  here  used  intentionally  for 
it  cannot  be  said  that  these  patient  are  cured  any 
more  than  a  diabetic  is  cured  who  keeps  within  his 
sugar  tolerance  and  is  symptomless  and  sugar  free. 
They  are  still  sensitive  to  their  particular  sub- 
stance and  as  far  as  we  know  they  will  continue 
to  be  so  indefinitely.  A  few  rare  cases  show  com- 
plete cure,  some  spontaneous  and  some  as  the  re- 
sult of  treatment  but  they  are  the  exception  and 
we  do  not  know  the  reason  for  their  recovery. 
However  you  will  find  that  patients  care  very  little 
whether  you  use  the  word  cure  or  relieve.  If  they 
do  not  have  asthma  they  are.  as  a  rule,  satisfied. 

I  wish  to  introduce  here  the  case  records  of  two 
ratlier  typical  and  dissimilar  asthmatics  which  will 
serve  to  illustrate  somewhat  the  method  of  treatment. 

Case  I. — Male,  aged  twenty-five,  single,  packer 
by  occupation.  Family  history  negative  as  far  as 
any  hypersensitiveness  is  concerned.  Past  his- 
tor}',  pneumonia  three  times,  in  infancy,  at  seven, 
at  eighteen ;  typhoid  fever  at  seven  ;  no  malaria,  ton- 
sillitis nor  rheumatism.  No  ha}-  fever  nor  hives.  Xo 
food  hypersensitiveness  as  far  as  known. 

Present  illness. — Asthma  began  when  he  was 
seven,  following  typhoid  fever  and  a  cold.  He  has 
had  it  more  or  less  ever  since,  all  the  year  round.  He 
knows  that  horses  bother  him  but  does  not  think 
he  is  afTected  by  cats  or  dogs.  Diet  is  general, 
including  milk  and  eggs. 

Physical  examination. — Thin,  rather  pale.  Weight 
one  hundred  pounds.  Heart  normal,  blood  pres- 
sure 120-80.  Lungs  hyperresonant  and  inany 
coarse  squeaking  rales.  Tonsils  large  and  boggy. 
Nosg  and  sinuses  negative.  Ears,  right  drum  per- 
forated, left  retracted.  Urine  negative.  X  ray  of 
lungs  shows  bronchitis  of  long  standing,  no  tuber- 
culosis. Sputum  negative  for  tubercle  bacilli. 
Culture  shows  streptococcus  and  Micrococcus  catar- 
rhalis.  Vaccine  made.  Differential  blood  count — 
polynuclears  43  per  cent.,  l}-mphoc\tes  41  per  cent., 
eosinophiles  8.5  per  cent.,  transitionals  4  per  cent., 
basophiles  3.5  per  cent. 

Skin  tests  extended  over  several  days  showed 
positive  for  rag  weed,  negative  for  grass  pollen, 
positive  for  horse  and  chicken  epithelium,  negative 
for  other  animals,  and  for  all  foods  and  sachets. 
Later  he  gave  positive  reactions  for  rabbit  epithel- 
ium, and  some  pillow  feathers  and  the  stuffing  from 
his  mattress.  His  treatment  has  been  as  follows, 
first  he  secured  a  new  position  as  his  packing  job 
was  very  dusty  and  would  tend  to  increase  his 
asthma  by  mere  mechanical  irritation.  He  was  told 
to  get  rid  of  his  feather  pillows  and  use  pillows 
stuffed  with  silk  floss  instead.    His  mattress  was 


wrapped  in  several  sheets  to  minimize  the  dust  com- 
ing from  it.  Of  course  a  silk  floss  mattress  would 
be  better  but  they  are  expensive.  His  rooms  were 
carefully  scrubbed  and  cleaned  to  remove  all  traces 
of  the  chicken  feather  dust.  He  was  given  injec- 
tions of  his  autogenous  vaccine  and  horse  epithelium 
at  weekly  intervals. 

Course. — The  patient  was  first  seen  on  October 
13,  1919,  and  his  asthma  continued  until  the 
first  week  in  X'ovember.  when  the  injections  had 
reached  a  sufficient  strength  to  begin  to  give  him 
immunity.  Xovember  14th  he  had  some  asthma 
following  his  injection.  December  18th-19th  slight 
asthma.  Januarj-  4th  and  10th  slight  asthma.  None 
after  this  to  date  (March  10,  1920).  January  17, 
1920.  weight  103  pounds,  differential  count  eosino- 
philes 12.5  per  cent. ;  February  14,  1920.  differen- 
tial count  eosinophiles  8.5  per  cent.  March  6, 
1920.  weight  104^:^.  some  cough,  no  asthma  since 
January  10th.    Is  working  right  along. 

Of  course  this  man  is  not  cured  of  asthma 
and  if  he  is  again  exposed  to  the  substances  to 
which  he  is  hypersensitive  he  will  react  as  be- 
fore but  he  knows  his  enemy  and  can  avoid  it.  He 
still  has  bronchitis  and  it  may  take  a  long  time 
to  cure  that,  but  I  am  sure  he  will  get  rid  of  it 
eventually.  He  will  need  rag  weed  injections  in 
the  summer  and  fall.  If  he  can  avoid  the  asth- 
matic attacks,  which  have  been  almost  constant  for 
many  years,  I  think  he  will  be  able  to  stand  slight 
exposures  without  treatment  and  without  getting 
intro  trouble. 

C.\SE  II. — Male,  aged  forty-nine,  single,  iron 
manufacturer.  Family  history,  negative  for  hyper- 
sensitiveness. Past  history  negative  except  for  scar- 
let fever,  without  nephritis,  and  rheumatism, 
without  heart  complication.  Uses  alcohol  mod- 
erately ;  heart}-  eater :  six  to  eight  cigars  a  day ;  no 
headaches ;  no  change  in  weight. 

Present  history. — The  patient  had  his  first 
attack  of  bronchitis  twenty  years  ago,  during 
X'ovember  and  December.  Xo  asthma  w-ith  it. 
Had  a  similar  bronchial  cold  each  October  to  De- 
cember for  five  years.  All  right  the  next  year  but 
the  following  year  he  had  severe  bronchitis  and 
asthma  w-ith  it.  Following  this  he  took  great  pre- 
cautions against  catching  cold  and  was  well  until 
1919.  In  January.  1919,  during  a  few.  cold  days 
he  had  constriction  of  the  throat,  pain  in  the  pre- 
cordium  and  dyspnea.  In  June,  1919,  he  had 
asthma  for  two  nights,  went  to  Canada  for  two 
weeks  and  was  better  there,  but  since  his  return 
he  has  had  asthma  more  or  less  all  the  time  up  to 
the  present  (January  6.  1920).  The  present  at- 
tack has  lasted  since  December  25th.  He  often 
has  heart  oppression.  The  cough  is  worse  in  the 
morning.  The  asthma  seems  to  be  the  result  of 
the  bronchitis.  There  is  no  real  hay  fever,  has  oc- 
casionally had  pain  after  eating  clams  but  no  trouble 
lately.  One  attack  from  eating  scallops.  Knows  of 
no  animal  hypersensitiveness.  He  keeps  a  dog,  and 
his  iron  foundry  is  very  dusty. 

Physical  examination. — Weight  183  pounds. 
Blood  pressure  1 18/90.  Few  capped  teeth ;  the  x 
rays  of  the  teeth  were  negative.  Heart,  systolic 
murmur  at  apex,  slightly  enlarged  to  left,  regular. 


September  18,  1920.] 


MASON:  BRONCHIAL  ASTHMA  IN  CHILDHOOD. 


399 


Electrocardiogram  of  heart  normal.  Lungs,  signs 
of  a  chronic  bronchitis  and  emphysema.  The  ab- 
domen was  negative.  The  Wassermann  was  nega- 
tive. Urine  1,024.  no  albumin,  no  sugar,  no  indi- 
can,  few  hyaline  and  granular  casts.  Blood  differ- 
ential polynuclears  74  per  cent.,  lymphocytes  23  per 
cent. ;  eosinophiles  j4  per  cent.,  transitionals  2  per 
cent.,  basophiles  per  cent.  Sputum  negative  for 
tubercle  bacilli.  Vaccine  made  containing  staphy- 
lococci, streptococci,  and  ]Micrococcus  catarrhalis, 
three  billion  to  the  c.  c.  Skin  tests  negative  for 
pollens,  animal  emanations,  sachets  and  dusts, 
marked  for  beef,  lamb,  clam,  halibut,  lima  bean. 

Treatment. — Told  to  omit  beef,  etc..  from  his 
diet  and  given  injections  of  vaccine.  These  were 
started  January  15,  1920,  and  given  every  five  days 
at  first.  He  had  distressing  attacks  of  asthma 
January  16th,  19th,  23rd,  28th,  29th.  By  this  time 
he  was  getting  one  c.  c.  of  the  vaccine  and  had 
been  on  a  diet  three  weeks.  He  was  last  seen 
March  10th  and  had  had  no  asthma  since  January 
29th.  He  still  gave  marked  skin  reactions  to  beef, 
lamb  and  clam. 

An  interesting  fact  in  his  history  was  obtained 
only  after  his  test  had  been  made.  He  said  that 
he  was  very  fond  of  beef  and  accustomed  to  eat 
it  SIX  or  eight  times  a  week.  He  also  said  that  he 
was  very  fond  of  clams  and  that  when  the  asthma 
commenced  in  June  he  was  eating  them  frequently. 
At  times  they  gave  him  gastric  distress  but  at 
other  times  he  ate  them  without  trouble.  His  skin 
test  was  negative  for  them  at  first  but  markedly 
positive  on  two  later  occasions.  It  is  probable 
that  he  has  a  cardiorenal  condition  as  well  as 
asthma,  as  but  with  a  normal  electrocardiogram  and 
blood  pressure  I  do  not  think  it  is  A^ery  serious 
and  restricting  his  meat  intake  will  do  him  no  harm 
at  least.  His  bronchitis  apparently  cleared  up 
under  vaccine  injections  and  if  he  experiences  a 
second  infection  I  think  it  will  be  wise  to  have 
another  vaccine  made.  His  is  apparently  a  case 
of  food  hypersensitiveness  with  a  complicating 
bronchitis. 

COXCLUSIOX. 

If  this  paper  leaves  you  with  the  impression  that 
the  diagnosis  and  treatment  of  asthma  are  now 
simple  matters  I  have  failed  in  my  purpose. 
It  is  only  the  rare  and  exceptional  case  where 
you  can  make  a  few  tests,  tell  the  patient  to  banish 
the  family  cat  or  remove  such  and  such  a  pillow  and 
be  well  forever  after.  Both  you  and  your  pa- 
tient will  become  discouraged  time  and  again  and  it 
will  try  your  resourcefulness  to  the  limit.  \\'hat 
I  do  wish  to  make  clear  is  that  asthma  is  no  longer 
the  hopeless  problem  that  it  has  been  in  years  gone 
by.  Inspire  your  patient  with  the  same  enthusia.sm 
and  confidence  that  you  have  in  the  search  and  keep 
everlastingly  at  it.  The  result  in  suffering  relieved 
will  more  than  repay  your  effort  and  the  unsolved 
cases  will  become  fewer  as  our  knowledge  increases. 

REFERENCES. 

1.  Meltzer:  Journal  A.  M.  A.,  1910,  55,  1021. 

2.  Freeman  and  Noox :  Lancet,  June  10,  1911,  p.  1572. 
nal  of  Immunology,  vol,  i.  No.  3. 

3.  Cooke  and  Vander  Veer  :  Human  Sensitization,  ./  our- 
116  E.\ST  Fifty-eighth  Street. 


BRONCHIAL  ASTHMA  IN  CHILDHOOD. 
By  Frederick  R,\oul  Mason,  M.  D., 

New  York, 

Instructor  in  Pediatrics,  New  York  Postgraduate  Medical  School 
and  Hospital. 

It  is  fairly  well  established  that  nearly  all  cases 
of  bronchial  asthma  in  children  are  anaphylactic  in 
origin,  although  influenced  by  such  factors  as  the 
mental  state  and  climatic  conditions.  It  is  only 
by  keeping  this  in  mind  that  we  can  hope  to  obtain 
permanent  results  with  any  treatment.  Bron- 
chial asthma  is  only,  one  of  the  many  forms  in  w^hich 
anaphylaxis  manifests  itself.  We  shall  gain  much 
valuable  information  by  considering  the  phenome- 
non of  anaphylaxis  as  a  whole,  before  going  into 
this  one  particular  manifestation. 

The  following  is  a  list  of  diseases  which  have 
been  found  to  be  forms  of  anaphylaxis  and  as  time 
goes  on  we  may  have  many  others  to  add  to  it : 
Ha}"  fever,  bronchial  asthma,  urticaria,  angioneur- 
otic edema,  certain  skin  diseases  (or  rather  certain 
types  of  these  diseases,  such  as  eczema),  cyclic 
vomiting,  other  gastrointestinal  upsets,  possibly  ivy 
poisoning,  migraines.  serun>  disease  and  certain 
reaction  to  drugs  (1). 

\\'hat  do  we  mean  by  anaphjlaxis?  It  can  be 
defined  as  an  abnormal  reaction  of  the  organism 
to  certain'  substances.  Experimentally,  it  has  been 
produced  in  the  following  manner.  When  a  for- 
eign protein  is  introduced  into  the  organism,  no  re- 
action occurs  after  the  first  injection.  If,  however, 
we  wait  a  suitable  period  of  time,  a  second  injection 
will  produce  definite  changes  varying  with  the  ani- 
mal used  for  the  experiment.  The  first  injection 
has  sensitized  the  animal  and  the  changes  following 
the  second  injection  are  called  anaphylaxis. 

The  following  are  the  reactions  observed  in 
various  animals :  spasm  of  the  bronchioles,  urti- 
caria, increased  peristalsis,  and  fall  in  blood  pres- 
sure. There  is  also  an  eosinophilia.  These 
reactions  also  occur  in  man,  although  we  rarely 
see  marked  falling  of  blood  pressure,  except 
possibly  in  some  of  the  cases  of  death  from  anti- 
toxin in  highly  susceptible  subjects.  Animal 
experimentation,  moreover,  has  brought  out  valu- 
able data  having  a  practical  application.  Sensitiza- 
tion has  been  found  to  be  a  result  of  heredity, 
inoculation  with  a  protein,  inhalation,  inunctions, 
intravenous  injection,  introduction  by  mouth  or 
instillation  into  the  conjunctival  sac.  From  this 
we  may  see  that  it  is  quite  possible  to  produce 
anaphylaxis  by  the  improper  introduction  of  certain 
foods  into  the  diet.  We  know,  for  instance,  that 
a  number  of  people  suffer  from  urticaria  after 
eating  shell  fish,  or  strawberries,  articles  of  food 
obtainable  at  certain  seasons,  and  therefore  there 
is  a  sufficient  interval  between  the  introductions 
to  bring  about  sensitization  in  the  individual.  It 
is  quite  possible  that  anaphylaxis  to  white  of  egg 
is  due  to  the  custom  of  giving  albumen  water  to 
infants  suffering  from  gastroenteritis.  For  this 
reason,  when  a  new  article  of  food  is  introduced 
into  the  diet,  it  is  best  given  in  small  quantities  and 
in  frequent  increasing  doses  so  as  to  prevent  a 
possil)le  change  of  sensitization.    Of  course  there 


400 


MASON:  BRONCHIAL  ASTHMA  IN  CHILDHOOD. 


[New  York 
Medical  Journal. 


is  no  doubt  that  a  large  number  of  patients  inherit 
their  anaphylactic  tendencies.  We  have  sufficient 
proof  of  this  among  our  patients,  a  large  number  of 
whom  have  at  least  one  parent  suffering  from 
asthma  or  one  of  the  allied  conditions.  Recently 
there  was  in  the  wards  of  the  Postgraduate  Hos- 
pital a  breast  fed  baby  suffering  from  eczema.  In 
spite  of  the  fact  that  he  was  breast  fed,  and  never 
had  partaken  of  anything  but  mother's  milk,  he  was 
found  to  be  sensitized  to  several  other  foods. 

Experimentally,  it  has  been  possible  to  transmit 
anaphylaxis  by  what  has  been  termed  passive  ana- 
phylaxis. This  is  accomplished  by  injecting  the 
blood  of  a  sensitized  guineapig  into  a  normal  one, 
after  which  it  is  found  that  the  second  animal  has 
become  anaphylactic  to  the  same  proteins  as  the 
first.  There  are  several  cases  on  record  in  which, 
after  a  transfusion  from  the  blood  of  an  asthmatic, 
typical  asthma  has  developed  in  a  subject  previously 
free  from  respiratory  embarrassment.  Experi- 
mentally, depending  on  the  initial  dose  used  to 
sensitize,  it  takes  a  small  or  a  large  quantity  of  the 
protein  to  produce  an  attack.  The  same  applies  in 
the  various  anaphylactic  manifestations  in  man. 

Sensitizing  substances  cause  sensitizations  which 
are  specific  to  that  protein  or  to  closely  related  ones. 
It  is  quite  common  to  find  a  child  sensitized  to  a 
certain  food  who  will  also  react  to  species  very 
closely  related.  Apparently  it  is  necessary,  in  order 
to  establish  anaphylactic  phenomena,  to  have  a 
proteid  which  is  not  reduced  lower  than  the  poly- 
peptides ;  recently,  however,  anaphylaxis  has  been 
reported  from  quinine  and  aspirin.  I,  personally, 
know  a  doctor  who  will  sneeze  when  a  box  of 
ipecac  is  opened  at  the  other  end  of  the  room  and 
will  sufifer  a  typical  attack  of  bronchial  asthma 
should  he  get  near  enough  to  this  substance. 

Why  anaphylaxis  takes  on  one  form  more  than 
another  is  hard  to  determine,  except  in  certain  cases 
of  hay  fever  or  asthma  of  the  inspiratorv  type. 
Here  we  have  direct  contact  between  the  sensitizing 
substance  and  the  affected  part  of  the  organism. 
All  cases-  have  in  common  a  disturbance  of  the 
sympatnetic  or  autonomic  fibres  supplying  the 
affected  organs.  It  is  possible,  moreover,  to  get 
a  combination  of  these  phenomena,  and  it  is  not 
uncommon  to  find  in  a  child,  given  egg  for  the  first 
time,  a  severe  swelling  of  the  lips,  an  urticarial  rash 
all  over  the  body,  and  a  marked  attack  of  asthma 
will  develop. 

Asthma  has  been  described  as  a  spasmodic  con- 
traction of  the  bronchioles,  accompanied  by  hyper- 
emia of  the  mucous  membrane,  and  characterized 
by  wheezing  low  rales  on  expiration,  with  numer- 
ous moist,  musical  or  crackling  rales  heard  all  over 
the  chest.  Textbooks  have  laid  considerable 
emphasis  on  the  presence  of  Charcot-Leyden 
crystals  in  the  sputum  and  an  eosinophilia  of  about 
ten  per  cent,  in  the  blood.  In  children,  we  do  not 
necessarily  get  all  these  symptoms  and  we  can 
divide  asthma  into  four  clinical  groups,  which  of 
course  merge  into  each  other  and  are  really  only 
degrees  of  severity : 

1.  Frequent  coughing  spells,  which  vary  in  dura- 
tion and  frequency.  This  type  is  very  common  in 
infants. 


2.  Frequent  attacks  of  bronchitis,  not  associated 
with  any  rise  in  temperature.  These  two  types  are 
rarely  recognized  as  asthma. 

3.  True  bronchial  asthma  attacks.  These  are 
fairly  easy  to  diagnose.  During  the  interval  the 
patient  feels  perfectly  well,  but  on  auscultation  a 
few  musical  rales  can  sometimes  be  heard  in  the 
chest.  Immediately  preceding  the  attack  there  is 
often  irritability  and  headache.  When  the  attack 
is  severe,  the  patient  sits  up  and  grasps  some  firm 
object,  the  face  is  pale,  and  the  lips,  fingers  and 
eyelids  become  livid.  The  expression  is  anxious, 
there  is  difficulty  in  breathing  and  limited  expan- 
sion of  the  chest  and  the  chief  difficulty  appears  to 
be  in  expiring  air.  The  respirations,  for  this  reason, 
are  slowed  down  in  number  to  ten  or  twelve.  In- 
spiratory sounds  are  short  and  soft,  expiration  is 
long  and  accompanied  by  a  low  wheeze.  The  ac- 
cessory muscles  of  respiration  are  brought  into  play 
and  to  help  this,  the  shoulders  are  raised.  On 
percussion  hyperresonance  is  heard  over  the  chest. 
In  older  children,  the  area  of  cardiac  dullness  is 
diminished,  although  there  is  often  dilatation  of  the 
right  side  of  the  heart.  On  auscultation,  the 
expiratory  sound  is  prolonged  and  wheezing  and 
sonorous  rales  are  heard  all  over  the  chest. 

4.  Constant  asthma. 

In  all  cases  the  essential  feature  is  a  recurrence 
at  intervals  of  difficulty  of  respiration  or  cough, 
independent  of  any  infection  of  the  air  passages. 

There  are,  therefore,  many  diseases  which  may 
simulate  bronchial  asthma  and  it  is  well  to  eliminate 
these  before  making  a  positive  diagnosis.  The 
more  common  are :  chronic  bronchitis,  whooping 
cough  in  infants,  and  reflex  causes.  The  reflex 
causes  can  be  divided  into  mediastinal  enlargement, 
foreign  body  in  the  larynx,  bronchi,  lung,  ear  and 
esophagus,  and  possibly  worms  in  the  gastro- 
intestinal tract.  All  these  can  be  determined  by 
either  the  direct  examination  or  the  x  ray. 

Mediastinal  enlargements  are  rather  frequent, 
enlarged  thymus  being  perhaps  the  most  common. 
This  is,  as  a  rule,  characterized  by  coughing  spells, 
appearing  shortly  after  birth  and  made  worse  by 
flexion  of  the  chest ;  there  may  or  may  not  be  a 
harsh  inspiratory  sound  and  rales  in  the  chest. 
Percussion  of  the  thymus  is  of  little  value  and  apart 
from  the  history,  the  x  ray  is  the  only  reliable  aid 
to  diagnosis,  beside  being  the  easiest  and  best  mode 
of  treatment.  Enlarged  mediastinal  glands,  usually 
tuberculous,  often  cause  coughing  spells.  These  are 
demonstrated  by  the  d'Espine  sign,  and  the  x  ray. 
The  Von  Pirquet  test  will  help  to  decide  in  a 
tuberculous  case.  We  must  not  forget  that  oc- 
casionally Hodgkin's  disease,  or  leucemia,  may 
affect  these  glands  early,  but  this  is  a  remote 
possibility.  Occasionally  congenital  laryngeal 
stridor,  laryngismus  stridulous,  and  retropharyn- 
geal abscess  may  be  mistaken  for  bronchial  asthma, 
and  it  is  well  to  keep  this  in  mind.  Once  we  have  • 
decided  that  we  are  dealing  with  a  true  case  of 
bronchial  asthma,  certain  phases  in  the  history 
should  be  looked  into,  as  likely  to  give  valuable 
information  as  to  the  etiology. 

1.  When  did  the  first  anaphylactic  phenomenon 
develop?  This  may  immediately  put  us  on  the  trail. 


September  18,  1920.] 


M.4S0X:  BRONCHIAL  ASTHMA  LV  CHILDHOOD. 


401 


To  illustrate :  The  child  who  had  asthma  following 
bronchopneumonia  would  make  one  think  at  once 
of  a  bacterial  origin  of  the  disease ;  or  a  child 
in  whom  asthma  develops  at  the  time  of  weaning, 
or  when  put  on  cow's  milk,  probably  has  a  dietary 
cause  for  his  affliction. 

2.  Time  of  the  year  the  attack  occurred.  Asthma 
in  winter  usually  suggests  a  bacterial  cause ;  asthma 
at  a  definite  season  of  the  year  is  suggestive  of  the 
pollen  of  plants  blooming  at  that  particular  time ; 
or  foods  in  season  (certain  fruits,  for  instance). 

3.  Location.  We  may  find  that  a  certain  room, 
a  certain  house,  or  certain  country  localities  will 
bring  about  an  attack.  When  traced  to  the  country 
or  to  a  garden,  pollens  from  plants  come  under 
suspicion.  A  certain  room  leads  to  a  careful  exam- 
ination of  the  premises  and  perhaps  the  finding  of 
the  of?ending  factor.  When  a  whole  house,  the 
problem  is  less  easy.  It  may  be  the  particular  food 
served  in  that  house,  a  pet  cat  or  dog,  or  the 
proximity  of  neighboring  stables. 

4.  Time  of  the  day.  Cases  of  asthma  in  which 
the  attacks  occur  only  at  night  suggest  something 
connected  with  the  patient's  bed,  such  as  the 
feathers  in  the  pillows,  the  hair  in  the  mattress,  or 
the  blankets. 

5.  Finally,  patients  will  often  have  noticed  them- 
selves, or  when  placed  on  their  guard  will 
frequently  discover  some  factor  in  the  occurrence 
of  an  attack.  In  this  way  we  have  been  able  to 
find  the  following  variety  of  things  to  be  causative 
factors  (at  least  one  of  them)  :  dog,  cat,  rabbit, 
horse,  smell  of  herring,  a  cold,  ipecac,  hay,  linseed, 
various  foods,  certain  types  of  canned  foods 
(depending  on  the  brand),  plants,  pillows,  stuffed 
animals,  and  skins. 

In  order  to  get  a  clear  idea  of  the  subject,  it  is 
advisable  to  group  the  causes  of  bronchial  asthma 
luider  the  following  classification : 

Inspiratory  cause. — a.  Pollens  from  plants ; 
b,  animal  emanations,  and  animal  hair  or  dander, 
bird  feathers ;  c,  dust  from  certain  drugs. 

Injected  cause. — Serums   (antitoxins,  etc.). 

Ingested  cause. — a.  Egg;  b.  milk;  c.  grains;  d, 
vegetables  :  e,  meats ;  f ,  fruits ;  g,  nuts ;  h,  fish  and 
shell  fish;  i,  spices;  j,  drugs. 

Bacterial  cause. — a,  Focal  infection  (tonsils,  teeth, 
gallbladder,  appendix,  etc.)  ;  b,  bacterial  infection, 
from  the  respiratory  or  the  gastrointestinal  tract. 

In  the  children's  clinic  we  have  found  that  in- 
spiratory and  ingestion  causes  were  the  most  fre- 
quent and  that  usually  there  were  several  causes 
not  necessarily  all  belonging  to  the  same  group. 
Among  the  foods  the  most  common  have  been  egg 
white,  milk,  and  wheat.  Focal  infection  does  not 
appear  to  play  a  very  important  part,  although  no 
doubt  it  does  occur.  As  a  rule  bacteria  from  the 
nasopharynx  are  the  source  of  the  sensitizing 
bacterial  protein. 

In  determining  the  etiology  of  the  asthmatic  at- 
tacks, we  are  greatly  helped  by  the  skin  reac- 
tions. Briefly,  these  are  performed  as  follows :  The 
proteins  from  various  foods,  bacteria,  and  emana- 
tions are  isolated,  in  order  to  be  sufficiently  con- 
centrated to  produce  a  reaction,  or  they  can  be  ob- 
tained ready  prepared  by  certain  commercial  labora- 


tories. They  are  then  either  injected  intradermally, 
in  solution,  or,  which  is  easier,  with  the  commercial 
preparations.  The  skin  is  gently  scarified  with  a 
scalpel,  a  drop  of  decinormal  solution  of  sodium  hy- 
droxide placed  on  it  (to  make  a  solution  of  the 
protein),  and  a  small  quantity  of  the  protein  dis- 
solved in  this.  A  positive  reaction  is  indicated  by 
the  appearance  of  a  white  wheal  surrounded  by  an 
area  of  erythema,  at  the  site  of  the  application  of 
the  offending  protein.  It  often  happens  that  asth- 
matics have  a  certain  degree  of  dennographia  and 
for  this  reason  it  is  wise  to  compare  with  the  con- 
trol. The  anaphylactic  wheals  are  usually  irregu- 
lar in  outline  and  their  size  does  not  necessarily  bear 
much  relationship  to  the  degree  of  severity  of  the 
disease.  treatment. 

As  it  takes  considerable  time  to  determine  the 
provocative  agent,  it  is  necessary  to  do  something 
to  relieve  the  discomfort  of  the  patient.  The  fol- 
lowing are  some  of  the  drugs  which  may  be  used 
to  give  relief : 

Adrenalin. — This,  as  a  rule,  clears  up  a  case,  or 
at  least  gives  marked  relief,  within  a  few  minutes, 
but,  because  of  its  potentiality  and  the  fact  that  it 
loses  its  effect  if  repeated  often,  it  should  be  given 
only  during  severe  attacks  or  in  cases  where  there 
is  only  an  occasional  attack,  say  once  a  j^ear.  Adren- 
alin can  be  given  in  doses  from  three  to  ten  minims, 
of  the  one  to  a  thousand  solution,  by  hypodermic 
injection. 

Benzyl  benzoate. — This  is  a  harmless  antispas- 
modic and  in  many  cases  gives  very  satisfactory  re- 
sults. Unfortunately,  it  does  not  relieve  in  all  cases 
and  has  the  disadvantage  of  having  an  unpleasant 
and  lasting  taste.  In  children  who  are  old  enough  I 
give  the  drug  in  capsules  containing  two  minims 
each,  four  times  a  day.  In  the  ten  per  cent,  solu- 
tion, the  dose  is  half  a  teaspoonful  four  times  a  day 
for  a  child  six  years  old.  Increased  doses  do  not 
appear  to  be  more  effective,  although  I  know  of 
one  case  in  which  benzyl  benzoate  afforded  absolute- 
ly no  relief  when  given  in  one  half  teaspoonful 
doses  but  which  responded  to  one  teaspoonful 
doses,  when  two  weeks  later  the  patient  had  his 
next  attack.  Benzyl  benzoate  is  best  given  con- 
tinously  to  patients  having  frequent  attacks,  but 
this  is  not  necessary  in  those  having  only  occa- 
sional asthmatic  attacks. 

Atropine. — When  given  up  to  the  physiological 
limit  it  will  sometimes  be  of  benefit,  but  I  have 
never  found  it  quite  satisfactory. 

Iodides. — These  drugs  may  sometimes  improve 
the  patient's  condition,  and  can  be  given  in  the  form 
of  syrup  of  iodide  of  iron  as  a  general  tonic  in 
all  cases. 

Drugs,  such  as  aspirin,  and  the  bromides,  are  of 
doubtful  value ;  nitrite  of  amyl  or  nitrite  fumes  are 
beneficial  in  relieving  spasmodic  breathing  during 
the  paroxysm. 

Recently  the  French  and  British  have  found  that 
peptone  by  mouth  or  by  hypodermic  injection  pre- 
vents anaphylaxis,  and  they  have  been  giving  it  in 
doses  of  five  grams,  three  times  a  day,  by  mouth. 

Auld  has  reported  good  results  in  a  certain  num- 
ber of  asthma  cases  by  this  means.  We  have  tried 
peptone  for  a  few  weeks  only  in  our  clinic,  so  that 


402 


MASON:  BRONCHIAL  ASTHMA  IN  CHILDHOOD. 


[New  York 
Medical  Journal. 


we  are  unable  yet  to  report  any  definite  results  (2). 

My  own  experience  has  been  that  no  drug  will 
help  in  all  cases,  but  usually  some  one  particular 
drug  will  help  in  each  case.  Of  course,  all  these 
measures  are  merely  palliative.  We  can  only  expect 
results  by  investigating  the  causes  of  the  anaphy- 
laxis and  eliminating  such  causes  as  are  fovuid. 
This  is  done  as  follows ; 

The  patient  is  placed  on  a  diet  of  milk  (including 
milk  products),  yoke  of  egg,  wheat,  potatoes,  and 
one  vegetable.  He  is  then  tested  out  for  each  of 
these  proteins,  and  should  one  of  them  be  found  to 
be  anaphylactic,  it  is  removed  from  the  diet  list.  It 
is  also  advisable  to  test  with  various  feathers  if  their 
proteins  are  available.  The  patient  is  kept  on  this 
restricted  diet  for  a  week.  Should  the  asthma  be 
entirely  due  to  food  proteins,  there  will  at  once 
be  marked  improvement.  The  course  to  follow  then 
is  to  test  out  for  more  foods  and  add  them  to  the 
diet  one  at  a  time,  eliminating,  of  course,  all  those 
giving  positive  skin  reactions  or  symptoms.  The 
skin  reactions  are  not  infallible  and  for  this  reason 
we  should  supplement  each  by  a  clinical  test.  It  is 
also  important  to  give  these  foods  in  a  simple  form, 
otherwise  there  may  be  a  trace  of  some  other  sub- 
stance which  might  precipitate  an  asthmatic  attack. 

To  illustrate :  We  have  in  our  clinic  a  child  who 
is  not  sensitized  to  either  pork,  beans,  or  toma- 
toes, yet  we  have  found,  as  a  result  of  several 
experiments,  that  he  will  get  an  asthmatic  attack 
if  he  eats  a  particular  brand  of  pork  and  beans.  jBy 
proceeding  in  this  way,  we  are  able  to  determine 
^he  majority  of  foocFs  to  which  the  patient  is  sen- 
sitized. We  will  take  up  later  the  treatment  of 
these  cases  of  a  purely  alimentary  type. 

Should  we  get  no  result  after  a  diet  limited  to 
the  few  foods  mentioned  previously,  we  must  next 
try  to  find  some  other  causative  factor.  Inspiratory 
causes  should  be  looked  for.  Pollens  in  the  city 
can  fairly  well  be  eliminated  but  emanations  may 
come  from  so  many  sources  that  we  may  fail  to  find 
their  origin.  It  is  best  to  give  the  patient  a  cotton 
pillow  and  mattress,  to  remove  all  skins  from  floors, 
such  as  bear  or  tiger,  and  eliminate  pets,  like  canar- 
ies, dogs  and  cats.  The  proteins  from  dog  hair,  cat 
hair,  horse  dander  and  feathers  from  chickens  and 
geese  should  be  tested.  Obviously  we  cannot  obtain 
the  proteins  for  all  the  various  animals,  therefore, 
should  these  measures  fail,  the  best  thing  to  do  is 
to  have  the  child  brought  to  a  hospital  and  removed 
from  the  environment  of  all  sources  of  animal  or 
flower  emanations.  This  will  very  often  clear  up 
the  case  and  confirm  the  diagnosis. 

The  next  step  is  to  find  the  cause  by  a  process 
of  elimination.  It  is  well  to  remember  that  con- 
tact with  the  offending  material,  even  for  a  few- 
minutes,  will  bring  about  an  attack  several  hours 
afterward.  Dr.  Pisek  reported  a  case  in  which  the 
patient  was  sensitized  to  chicken  feathers  and  when 
placed  upon  a  cotton  pillow  was  asthma  free.  The 
child  had  another  mild  attack  afterward,  traced 
to  a  pillow  fight  the  previous  evening.  Should 
all  these  precautions  fail  to  discover  the 
real  cause,  we  can  reasonably  assume  that  we  are 
dealing  with  a  bacterial  type.  All  obvious  foci  of 
infection,  such  as  caries  and  infected  tonsils,  should 


be  removed.  Results  are  obtained  occasionally  by 
this  alone.  By  skin  tests  it  is  sometimes  possible 
to  isolate  the  offending  organism,  in  which  case  a 
stock  vaccine  given  in  gradually  increasing  doses 
is  .administered.  Of  more  value  is  a  culture  from 
the  nasopharynx,  grown  on  both  agar  and  bouillon, 
and  a  mixture  from  these  used  As  a  vaccine.  Some 
authors  advise  growing  the  predominant  organism 
only,  btit  unless  this  happens  to  be  the  one  giving 
the  positive  skin  reaction,  I  do  not  believe  it  is  neces- 
sary. In  case  of  failure,  and  as  a  last  resort,  either 
a  second  vaccine  from  the  nasopharynx  or  a  vac- 
cine grown  from  the  feces  may  be  tried.  In  the 
case  of  pollens,  according  to  the  season  of  the  year, 
and  by  means  of  the  skin  tests,  we  are  also  able  to 
isolate  the  plant  for  susceptible  individuals.  These 
are  the  only  patients  who  are  benefited  by  changes 
of  climate,  sea  trips,  or  seaside  resorts  with  pre- 
dominating sea  breezes. 

In  the  case  of  food  anaphylaxis,  it  often  happens 
that  the  patient  is  sensitized  to  some  widely  dis- 
tributed article  of  diet,  milk  for  instance,  lactalbu- 
men  being  the  most  common  offender.  This  can 
be  eliminated  by  boiling  the  milk  and  allowing  it  to 
cool,  the  lactalbumen  rising  to  the  surface  as  thick 
skin  which  can  be  removed.  Unfortunately  a  great 
many  children  object  to  the  taste  of  boiled  milk, 
but  it  can  at  least  be  used  for  the  cooking  of  their 
food.  Occasionally  we  have  found  that  dry  milk 
was'  tolerated  in  these  cases.  Yolk  of  egg  rarely 
brings  about  any  anaphylactic  disturbance,  while 
the  white  is  a  frequent  cause  of  asthma.  Clinical 
experience  has  shown  that  the  cereals,  when  toasted, 
are  less  likely  to  cause  anaphylactic  changes  and 
can  be  taken  with  less  harm  in  this  \\ay. 

From  the  most  common  foods,  we  can  desensi- 
tize the  patients  with  small  increasing  doses  of  the 
protein  hypodermically.  Such  preparations  are  put 
up  in  commercial  laboratories,  as  are  also  a  few  of 
the  animal  emanations  and  pollens.  With  such 
simple  food  as  white  of  egg  we  can  desensitize  the 
individual  by  giving  a  very  dilute  solution  by 
mouth  three  times  a  day  and  increasing  the  dose  by 
a  minim  each  time  until  tolerance  is  obtained. 

During  acute  attacks,  dietary  in  origin,  removing 
the  offending  substance  by  stomach  lavage  will 
sometimes  afford  relief.  As  time  goes  on  the  treat- 
ment will  probably  be  considerably  simplified,  but  at 
present  it  is  chiefly  a  question  of  making  the  pa- 
tient understand  what  mar  cause  an  attack  and 
when  possible,  desensitize. 

REFEREXCKS. 

1.  Prcssc  mcdicalc,  February  4,  1920,  No.  10;  Archive- 
of  Inlcrnal  Medicine,  24,  378. 

2.  Auld:  British  Medical  Journal,  April,  1920;  Paris 
Medical,  Alarch,  1920. 


Puncture  of  the  Superior  Longitudinal  Sinus. 

— M.  Gonzalez- Alvarez  and  T.  Gonzalez  Edo  (La 
Mcdicina  Ibera,  April  10,  1920)  find  that  this 
route  is  one  of  great  advantage  in  taking  Wasser- 
mann  specimens,  in  giving  quinine  solutions  in  ma- 
laria, neosalvarsan  in  lues,  serum  in  diphtheria,  and 
tetanus;  in  administering  alkalies  in  acidcsis.  and 
for  the  transfusion  of  blood.  There  is  only  one 
contraindication,  namely,  hemophilic  diathesis. 


September  IS.  1920.]  WOLOSHIN:  ASTH M A.— KEARN EY :  EYE  EXAMINATIONS. 


403 


THE    TREATMENT    OF    ASTHMA  WITH 
BENZYL  BENZOATE  BY  INJECTION. 
By  Benjamin  Woloshin,  M.  D., 
New  York, 

Instructor  in  Medicine,  New  York  Post-Graduate  School  and  Hospital. 

Among  the  un.satisfactory  and  at  times  trouble- 
some patients  are  the  asthmatics.  In  the  cHnic,  as 
well  as  in  private  practice,  one  is  often  confronted 
by  the  obstinate  asthmatic  who,  in  spite  of  every 
mode  of  treatment,  obtains  little  or  no  relief. 
As  is  the  case  with  all  diseases,  the  etiology  of 
which  is  not  known  or  definitely  established,  one 
frequently  comes  across  reports  by  different  ob- 
servers, who  assert  that  successful  results  have  been 
obtained  with  various  methods  of  treatment. 
Strange  as  it  may  seem,  those  same  methods  applied 
to  our  patients  often  result  in  failure. 

While  a  good  deal  has  been  written  lately  about 
the  use  of  benzyl  benzoate  in  cases  of  true  asthma, 
very  little  is  said  about  its  use  b}'  injection  in  that 
condition.  This  point  is  of  particular  importance 
when  one  finds,  as  we  have,  that  this  drug  will  give 
gratifying  results  by  the  hypodermic  route,  where 
oral  administration  fails.  The  following  case  will 
serve  as  an  illu.stration. 

Case. — Mrs.  L.,  fifty-four  years  of  age,  came 
under  my  observation  about  one  year  ago,  with  a 
history  of  l^ronchial  asthma  of  fourteen  years' 
standing,  during  which  time  she  was  under  fairly 
constant  medical  treatment.  Her  attacks,  which 
varied  in  severity  and  frecjuency,  were  as  a  rule 
promptly  relieved  by  injections  of  morphine  and 
atropine  or  adrenalin.  About  eight  months  ago 
her  asthmatic  attacks  increased  in  both  frequency 
and  severity.  Adrenalin  would  no  longer  give  her 
relief,  while  the  dose  of  morphine  had  to  be  in- 
creased. She  was  put  on  benzyl  benzoate  in  twenty 
drop  doses  every  four  hours  by  mouth.  She  was 
completely  relieved  in  several  days  and  remained  so 
for  two  months.  Without  any  apparent  cause  she 
suddenly  began  to  suffer  severely,  being  in  an  al- 
most constant  state  of  dyspnea.  Neither  adrenalin 
by  injection  nor  benzyl  benzoate  by  mouth  gave 
her  the  slightest  relief.  The  hypodermic  adminis- 
tration of  morphine,  one  third  to  one  half  a  grain 
every  four  to  six  hours,  was  necessary  to  give  her 
temporary  alleviation.  This  condition  continued  for 
about  two  weeks.  She  became  obstinately  consti- 
pated, took  scarcely  any  nourishment,  her  skin  was 
dry,  tongue  parched,  heart  action  poor,  pulse  rapid 
and  weak,  thus  presenting  a  picture  of  misery.  I 
I)ut  her  on  benzyl  benzoate,  twenty  drops  every 
three  hours  by  hypodermic  injections,  and  digalen, 
ten  drops  every  four  hours  by  the  same  method,  at 
the  same  time  cleansing  her  alimentary  tract  with 
salines  and  colonic  irrigations.  In  three  days  she  was 
completely  relieved,  was  out  of  bed  at  the  end  of 
a  week,  and  has  been  free  from  attacks  since. 

I  believe  we  are  justified  in  emphasizing  here  the 
value  of  digitalis  in  asthma,  particularly  in  cases 
of  long  standing,  where  the  resulting  dilated  right 
heart,  with  the  consequent  impaired  pulmonary  cir- 
culation, adds  greatly  to  the  sufferer's  embarrass- 
ment. 

1331  Prospect  Avenue. 


EXAMINATION  OF  THE  EYE  ESSENTIAL 
IN  PHYSICAL  EXAMINATION. 

By  J.  A.  Kearney,  M.  D., 

New  York, 

Profcs.sor  of  Ophthalomology   New   York   Polyclinic   Medical  School 
and  Hospital.    Ophthalmic  Surgeon  Out  Patient  Depart- 
ment Gouverneur  Hospital,  Ophthalmologist  Out 
Patient  Department,  French  Hospital. 

Today  the  fashion  of  endeavoring  to  trace  gen- 
eral constitutional  disturbances  to  foci  of  infection 
and  to  toxemias  of  various  origins  is  prevalent  and 
records  show  strikingly  important  results  from  this 
wave.  The  imbalance  of  interaction  of  the  endo- 
crines  also  occupies  a  prominent  place  at  present. 
Enthusiasts  in  these  important  studies  sometimes 
neglect  other  time  honored  determinations,  the 
treatment  of  which,  when  found,  has  given  relief 
repeatedly. 

The  necessity  of  examining  the  eyes  is 
seldom  disregarded  nowadays,  when  headaches  and 
eye  discomfort  and  pain  exist,  but  symptoms  that 
occur  remotely  from  the  eyes  are  often  overlooked 
as  being  the  probable  result  of  existing  eye  af- 
fection or  undue  ocular  strain.  Indigestion, 
flatulent  and  other  dyspepsias,  malaise,  insomnia, 
as  well  as  headaches  of  various  characters,  not  in- 
frequently disappear  when  a  dry  and  roughened 
conjunctiva  is  cleared  up  by  treatment  or  when 
correcting  glasses  for  existing  errors  of  refraction 
and  imbalance  of  extrinsic  ocular  muscles  are  worn 
for  a  time. 

Valuable  information  may  be  elicited  from  a 
complete  ophthalmoscopic  examination  of  the  fun- 
dus of  the  eye  that  cannot  be  obtained  in  any  other 
way.  When  certain  changes  from  the  normal  are 
observed,  they  are  often  leading  indicators  of  some 
general  or  special  malady  that  is  now  present  or  has 
existed  heretofore. 

Retinal  hyperemia,  hemorrhages,  fatty  degenera- 
tion and  atrophy  or  combinations  of  two  or  more 
of  these,  which  may  be  observed  in  the  eyes  of  pa- 
tients with  nephritis  at  times,  aid  in  determining 
an  existing  kidney  affection.  Indeed  the  socalled 
typical  albuminuric  retinitis  in  which  fatty  degen- 
eration and  atrophic  changes  occur  about  the  macula 
(macular  star)  is  not  as  frequently  observed  as  the 
less  elaborately  produced  lesions  of  this  affection. 
The  recorded  proportion  of  retinitis  in  nephritics  va- 
ries from  nine  to  thirty-three  per  cent,  and  it  would 
be  considerably  higher  if  there  were  included  the 
minor  blurrings  of  the  disc  and  retinal  details,  the 
result  of  slight  alterations  in  the  walls  of  the  blood 
vessels  and  the  reaction  in  the  retinal  tissue  to 
cytotoxic  substances  in  the  circulating  blood.  In 
diabetes,  similar  changes  are  noted  in  the  fundus 
that  occur  in  nephritics,  but  retinal  fatty  degenera- 
tions and  atrophies  occur  in  the  equatorial  regions 
more  frequently  than  about  the  macula  as  in  albu- 
minuric retinitis.  When  retinal  degenerative 
changes  are  noted  in  diabetes  the  disease  is  usually 
advanced  and  prognosis  as  to  life  is  grave,  just  as 
similar  changes  in  the  retina  of  patients  with 
nephritis  denote  a  bad  prognosis.  Cataracts  are  not 
uncommon  concomitants  of  diabetes. 


404 


TAYLOR:   REPARATIVE  MEASURES. 


[New  York 
Medical  Journal. 


In  a  recent  attack  of  syphilis  an  eye  ground 
examination  is  expressly  required  by  leading  syphi- 
lographers,  particularly  when  intravenous  medi- 
cation with  arsenical  preparations  is  to  be  employed, 
as  certain  diseased  conditions  when  found  in  the 
eye  fundi  may  contraindicate  its  administration  or 
compel  modification  of  its  use.  Later  in  life  when 
other  untoward  general  conditions  develop  you  will 
discover,  on  taking  a  previous  history,  that  a  luetic 
infection  is  frequently  denied  or  forgotten  or  it 
may  have  been  innocently  contracted,  and  the  early 
evidences  may  have  disappeared  without  any  medi- 
cation. If  scars,  atrophies  or  old  exudates  are  seen 
in  the  fundus  oculi  as  the  result  of  the  early  stages 
of  this  disease,  a  doubtful  tertiary  aspect  may  be 
cleared  up  years  after  the  occuirence  of  the  initial 
infection. 

Arteriosclerosis  may  be  observed  as  a  kinking 
and  tortuosity  of  the  smaller  retinal  blood  vessels 
in  the  earliest  stages,  and  in  the  later  stages  by  an 
indent  noted  in  a  vein  where  an  artery  crosses  it. 
When  these  changes  are  noted,  similar  vascular 
conditions  may  well  be  suspected  in  the  cerebral 
blood  vessels.  If  twenty-four  hour  interval  obser- 
vations of  the  fundi  of  the  eyes  are  made  in  all 
cases  of  apparent  or  suspected  recent  fracture  of 
the  skull,  sufficient  edematous  changes  may  fre- 
quently be  noted  which  will  s^iggest  a  possible  in- 
tracranial pressure.  This  is  often  verified  by  lum- 
bar puncture.  A  cranial  decompression  operation 
in  these  cases  removing  a  cerebral  blood  clot  or  just 
relieving  the  pressure,  is  reported  to  have  saved 
many  lives. 

The  location  of  basal  brain  injuries,  softenings 
and  hemorrhages,  occurring  in  the  pathways  of  the 
visual  fibres  from  the  back  part  of  the  eyeball  to 
the  perceptive  centres  of  vision  in  the  occipital  lobes 
of  the  brain,  may  be  traced  when  existing  hemian- 
opsias or  even  less  marked  amaurotic  areas  occur  in 
the  retinae,  together  with  a  notation  of  pupillary 
activities,  when  light  is  thrown  upon  the  retina  of 
one  or  both  eyes.  A  fundus  examination  has  at 
times  revealed  a  choked  disc,  the  result  of  a  brain 
tumor,  in  patients  admitted  to  our  hospitals  suf- 
fering from  persistent  uncontrollable  headaches  and 
said  to  have  an  obscure  neurological  condition. 

A  neurological  examination  that  includes  the  fol- 
lowing data  derived  from  an  eye  examination  is 
always  more  valuable  than  one  that  does  not :  The 
diameters  of  each  pupil,  their  shape,  the  difference 
in  their  size,  their  reactions  to  stated  stimuli,  the 
state  of  health  of  the  extrinsic  ocular  muscles,  the 
refraction  error,  if  one  exists,  the  degenerative  ede- 
matous, inflammatory  and  other  untoward  changes 
in  the  optic  nerve  head  and  retina,  if  any  are  present, 
the  variations  in  the  structure  of  the  retinal  blood 
vessels,  amaurotic  areas  in  the  retina,  visual  acuity 
and  visual  fields  for  form  and  colors. 

A  doubt  as  to  the  diagnosis  of  meningitis  is  often 
cleared  up  by  characteristic  changes  that  may  be 
seen  at  the  time  in  the  fundi  of  the  eyes  as  the 
result  of  this  disease.  Migraine  symptoms  are 
sometimes  relieved  by  wearing  accurate  correcting 
lenses  when  a  refraction  error  or  extrinsic  ocular 
muscle  imbalance  is  found  to  exist  and  occasionally 
a  cupping  of  the  optic  discs  is  discovered  in  a  fundi 


examination  denoting  a  glaucomatous  process  that 
may  be  the  source  of  the  symptoms.  Tonometric 
and  other  examinations  usually  verify  the  diagnosis 
by  recording  an  increase  in  the  intraocular  tension. 

Monocular  papilledema  suggests  pressure  extend- 
ing to  the  optic  nerve  from  diseased  adjoining  nasal 
accessory  sinuses,  particularly  the  frontal  ethmoidal 
and  sphenoidal.  Toxemias  lasting  for  a  time  tend 
to  disturb  the  subretinal  pigment  layer  and  cause 
particles  of  its  pigment  to  migrate  into  the  retinal 
tissues  proper,  changing  the  color  of  the  retina,  from 
that  corresponding  to  the  complexion  of  the  pa- 
tient and  in  some  instances  giving  the  eye  ground 
throughout  a  pepper  shaken  appearance. 

The  general  conditions  cited  in  this  paper  are 
ones  most  commonly  met  and  for  this  reason  they 
are  reviewed  with  some  of  the  accompanying  eve 
changes  to  show  the  importance  of  an  eye  examina- 
tion in  all  thoroughly  studied  cases. 

127  West  Fifty-eighth  Street. 


SUPPLEMENTAL  ACTION  IN  REPAIL\TIVE 
MEASURES. 

With  Special  Reference   to   Scrogenic  Remedies 
Reinforced  Through  Kinetogenic  Agencies. 

By  J.  Madison  Taylor,  A.  B..  M.  D., 

Philadelphia, 

Professor   of  Physical   Therapeutics  and   Dietetics,   Medical  Depart- 
ment, Temple  University. 

Evidence  is  accumulating  to  the  eflfect  that  groups 
of  efficient  therapeutic  procedures  mutually  supple- 
ment each  other,  hence  results  can  be  obtained  in 
proportion  to  the  resources  of  each  being  under- 
stood and  judiciously  applied.  Of  the  four  major 
groups,  a,  medicines,  b,  serums  and  vaccines,  c, 
mental  readjustments  and,  d,  socalled  physical 
remedies,  the  last  have  not  yet  come  to  be  accredited 
the  importance  they  deserve,  nor  are  the  established 
principles  adequately  understood  or  appreciated.  All 
clinical  problems,  except  the  simplest,  need  to  be 
approached  from  most,  if  not  all,  of  the  directions 
indicated. 

Let  me  here  oi¥er  further  evidence  of  interaction 
between  the  two  groups,  the  serogenic  and  the  kine- 
togenic or  the  physical,  or  mechanical.  Also  permit 
me  to  suggest  a  descriptive  name  for  this  last  group 
of  agencies  which  seems  best  calculated  to  convey 
an  exact  meaning,  and  that  is  kinetogenic  instru- 
mentalities, since  they  all  involve  motivation  in  some 
of  their  diverse  modalities.  Among  these  are  elec- 
tricity (electrogenics) ,  heat  and  cold  (thermogenics), 
light  (photogenics),  the  adjustments  of  the  mind 
or  emotions  (psychogenics),  and  orthogenics,  physi- 
cal or  morphological  adjustments  of  the  body,  the 
muscles,  joints,  reflexes,  etc.,  through  movements 
on  or  by  these  structures,  i.  e.,  passive  or  active. 

Another  point  offers,  namely :  Any  remedial  agency 
induces  effects  in  a  twofold  manner,  yet  in  varying 
degrees,  by  a,  influencing  the  organism  as  a  whole, 
and  b,  upon  areas  or  localities  or  groups  of  struc- 
tures. It  seems  to  be  assumed  by  many  that  the  ef- 
fects of  most  medicaments  or  serums  or  vaccines  are 
so  widely  diffused  that  their  influence  is  exerted 


September  18,  1920.] 


TAYLOR:  REPARATIVE  MEASURES. 


405 


uniformly  upon  the  organism  as  a  whole.  The  fact 
is,  or  many  facts  are  becoming  adduced  to  prove, 
that  we  have  much  to  learn  of  these  varying  local 
states  wherein  energies  in  their  transmission  are 
often  delayed,  retarded  or  accelerated  or  otherwise 
unequally  distributed.  In  respect  to  the  sera  and 
the  problems  of  immunity,  Sir  Almroth  E.  Wright 
has  told  us  much,  especially  in  his  recent  communi- 
cations. 

The  central  aim  of  all  therapeutics  may  be  de- 
scribed as  the  achievement  of  cellular  poise,  the 
equalization  of  blood  and  lymph  propulsion  leading 
to  wider  distribution  of  vital  fluids,  principles, 
hormones,  antibodies,  adrenoxidioxidase  and  other 
essentials  to  life  processes,  also  the  reduction  of 
end  products  to  conditions  favorable  for  elimina- 
tion. The  instrumentalities  include  hydrostatic, 
hematogenic,  thermogenic,  and  the  profoundly  com- 
plex reflexogenic  mechanisms.  Likewise  there  are 
now  coming  to  our  attention  electrotonic  factors 
which  may  prove  to  be  of  yet  deeper  significance. 
The  great  regvilative  agencies,  the  ductless  glands, 
exert  influences  throughout  which  must  at  all  stages 
be  reckoned  with. 

During  the  processes  of  functional  fulfillment, 
many  associated  or  collateral  factors  combine  to 
hr'mg  about  and  maintain  a  stabilization.  The  prob- 
lems thus  stretch  out  beyond  our  present  ken.  How- 
ever, much  improvement  in  therapeutic  efficiency 
will  result  from  achieving  a  practical  familiarity 
with  those  forces  of  which  enough  is  already  known. 

Among  the  chief  enterprises  is  the  equalization 
of  the  reflexes.  In  particular  there  may  be  men- 
tioned the  graphic  phenomena  of,  1,  tonicity  in 
the  cardiovascular  renal  mechanisms ;  2,  resistance 
in  the  blood  stream  and  the  defence  of  the  organism 
against  interferences  with  blood  flow ;  3,  tonicity 
in  the  various  tul^ular  and  hollow  viscera, 
the  digestive,  the  respiratory,  the  reproductive,  the 
genitourinary  and  other  cycles  and  groups  of  struc- 
tures ;  4,  the  extreme  significance  of  balanced  ton- 
icity (isotonicity)  in  the  muscles,  not  alone  the 
large  muscles  but  the  small  ones  as  well,  as  form- 
ing parts  of,  and  distributed  among  these  viscera, 
which  is  of  equal  importance,  as  I  have  tried  to  show 
elsewhere.  In  short,  health  consists  of  maintain- 
ing poise  in  the  neuromuscular  cycle,  especially  the 
release  of  tonic  spasm,  cramp,  or  in  the  correction 
of  undue  relaxation.  This  attribute  of  quantival- 
ance  it  is  the  prerogative  of  the  mechanisms  of 
movement  or  rest  (kinetogenic  instrumentalities) 
to  bring  about  most  promptly  and  permanently. 

An  organism  would  obviously  be  in  a  position 
of  far  greater  advantage  to  profit  by  any  remedy 
introduced  into  the  circulation,  if  measures  were 
available  whereby  these  varied  processes  could  be 
made  to  cooperate  harmoniously. 

Only  when  the  reflexogenic,  the  neuromuscular 
and  the  thermogenic  mechanisms,  in  short  equalized 
tonicity,  temperature  and  propulsion  are,  and  re- 
main at  their  norm,  or  so  near  their  norm  as  to 
functionate  economically,  is  it  possible  for  the  sub- 
sidiary, collateral  or  finer  mechanisms  to  perform 
their  functions  to  advantage.  Only  when  the 
structures  of  an  organism  exhibit  fair  tone,  uni- 


formity of  pressure,  hydrostatic  and  osmotic  com- 
petency, temperature,  automatic  selfregulation  of 
those  forces  essential  to  distribution  of  nerve  im- 
pulse, also  static  or  kinetic  support,  can  balanced  in- 
teraction be  attained  and  maintained.  Only  while  an 
organism  is,  and  continues  to  be,  in  such  a  state 
of  harmonious  integration  can  it  be  expected  that 
nutrient  fluids  and  cells  can  be  sent  where  or  when 
they  are  most  needed,  or  can  any  curative  substances, 
principles,  enzymes,  sera,  and  the  like,  be  distributed 
promptly  and  do  perfect  work. 

Such  helpful  agencies  are  available  and  efficient. 
At  least  it  is  necessary  to  concede  the  efficacy  of 
these  accessory  or  supplemental,  indeed  these  es- 
sential instrumentalities,  and  to  give  to  them  the 
same  critical  study,  also  to  grant  them  the  same  con- 
fidence when  demonstrated  or  proven,  as  is  now  so 
freely  accorded  to  pharmacodynamic  agencies.  Con- 
sider, in  this  connection,  the  significance  of  the  bi- 
ological law  that  protoplasm  tends  persistently  and 
unerringly  (unless  thwarted  by  excess  stimulation) 
to  come  back  to  the  original  state  as  soon  as  the 
stimulus  ceases. 

This  reaction  to  stimulation  can  be  secured  al- 
most indefinitely,  short  of  exhausting  the  governing 
reflex  or  reflexes,  or  the  controlling  centres.  Also 
it  obtains  that  no  destruction  of  cells  follows  upon 
a  mechanical  stimulus,  whereas,  on  the  contrary, 
after  stimulation  by  a  chemical  agency  there  in- 
variably follows  more  or  less  change  in  the  cells  or 
fluids  or  structures.  Whether  sera,  vaccines  or 
other  bacteriogenic  agencies  produce  chemical  or 
mechanical  changes  I  do  not  know.  These  sub- 
stances come  close  to  being  foods.  Thus  the  sup- 
plemental power,  perhaps  superiority  of  kineto- 
genic agencies,  modalities  of  motion,  or  mechanical 
stimuli  to  function  are  made  clear.  At  least  they 
are  wholly  safe. 

The  point  to  be  determined  by  research  in  this 
domain  is :  How  far  can  present  biokinetic  meas- 
ures be  relied  on  and  how  far  can  they  yet  come 
to  be  developed?  Meanwhile  the  pertinent  query  is: 
How  far  can  the  ef¥ects  of  serogenic  remedies  be 
influenced,  expedited  or  enhanced  through  biokinetic 
instrumentalities  ? 

Obviously  their  distribution  can  be  materially  ex- 
pedited and  hence  their  effects  amplified,  at  least 
through  enhanced  solution,  absorption  and  distribu- 
tion, thus  inviting  antibodies  to  remote  parts  when 
materials  are  introduced  into  the  blood  currents. 

Let  lue  cite  here  and  later  from  Sir  Almroth  E. 
Wright's  address  (2)  ;  "Therapeutic  inoculation 
can  be  approached  also  from  a  point  of  view  dif- 
ferent from  that  taken  up  by  Pasteur.  With  re- 
spect to  immunizing  response,  the  body  has  been 
visualized  as  a  single  and  undivided  unit.  That  is 
clearly  erroneous.  One  region  of  the  body  may 
be  making  immunizing  response  while  the  other  is 
inactive.  For  instance,  in  the  stage  of  incubation 
it  is  presumably  only  the  region  which  is  actually 
harboring  the  microbe  and  in  the  stage  of  general- 
ized infection  it  is  presumably  the  entire  body  which 
is  incited  to  respond.  And  again,  in  localized  in- 
fections we  may — making  here  some  reserves — as- 
sume that  we  have  only  localized  response. 


406 


TAYLOR:  REPARATIVE  MEASURES. 


[New  York 
Medical  Journal. 


THE  DEFENSIVE  MECHANISM  OF  THE  BODY. 

"To  combat  bacterial  infection  the  organism  must 
have  defensive  powers.  That  power  of  guarding 
itself  against  infection  we  may  call  phylactic 
power.  The  leucocytes  and  the  bacteriotropic  sub- 
stances in  the  blood  fluids  we  may  call  phylactic 
agents.  There  is  required  also  efificient  staflf  work 
to  bring  your  defensive  force  to  the  point  attacked. 
The  self  same  thing  applies  to  the  body.  You  must 
have  not  only  phylactic  power  in  the  blood,  but  also 
provision  for  the  transport  of  your  leucocytes  and 
bacteriotropic  blood  fluids  to  the  site  of  infection. 
Let  me  call  this  transport  of  phylactic  agents  to 
the  site  of  infection,  kataphylaxis.  Let  me  term  any 
condition  which  interferes  with  tliat  transport  an 
antikataphylactic  influence. 

"When  in  sound  physiological  condition,  we  have 
efficient  kataphylactic  arrangements — blood  fluid 
and  leucocytes  have  unrestricted  access  to  every  por- 
tion of  the  body.  But  when  antikataphylactic  in- 
fluences are  brought  to  bear ;  when  the  arterial  sup- 
ply is  uninterrupted  or  is  closed  down  by  collapse, 
or  the  body  is  petrified  l)y  cold,  and  the  alkalinity 
of  the  lymph  is  blunted  off  by  acid  metabolites  de- 
rived from  the  muscles :  then  the  emigration  of  leu- 
cocytes is  arrested,  and  the  transport  of  blood  fluids 
into  the  tissues  comes  to  a  standstill. 

ECPHYL.\XIS. 

'T  drew  attention  twenty  years  ago  to  the  terms 
'regions  of  diminished  bacteriotropic  pressure,'  'non- 
bacteriolropic  niduses/  and  nonbacteriotropic  en- 
velopes.' These  terms  have  not  proved  effective 
missionaries  of  the  idea,  and  I  would  propose  now 
to  try  to  put  into  currency  instead  the  terms  ec- 
phylaxis,  ecphylactic  region  and  ecphylactic  en- 
A^elope.  When  I  speak  of  an  ecphylactic  region  you 
will  understand  me  to  mean  a  region  in  which  the 
guardian  elements  of  the  blood  have  been  rendered 
impotent  or,  as  the  case  may  he,  have  been  ex- 
cluded. In  describing  the  effects  produced  by  the 
abolition  or  suspension  of  the  circulation  by  injury 
to  the  blood  vessels  or  exposure  to  cold,  I  was  pic- 
turing to  you  an  ecphylactic  region.  ^Vluch  more 
commonly  the  ecphylactic  region  has  been  fabricated 
by  a  bacterial  colony.  You  will  appreciate  that 
every  living  bacterial  colony  must  become  the  centre 
of  an  ecphylactic  sphere.  It  will  liecome  so,  a,  by 
radiating  out  toxins  which  will  (when  of  sufficient 
strength)  repel  leucocytes;  b,  by  absorbing  bacterio- 
tropic substances  from  the  blood  fluids ;  and  prob- 
ably, c,  by  abstracting  antitryptic  power  from  the 
blood  fluids  and  so  converting  these  into  a  congenial 
culture  medium." 

HOW  CAN  WE  PROFITABLY  CONTROL  BLOOD  PRESSURE 
AND  LYMPH  PROPULSION? 

As  supplemental  measures  for  enhancing  the  ef- 
fects of  bacteriotropic  or  serotropic  or  pharmaco- 
tropic  remedies,  we  may  mention :  Thermogenic, 
various  modalities  of  heat  and  cold,  the  balancing 
of  temperature  conditions  whereby  various  expedi- 
tive  or  retardative  effects  are  wrought  on  cellular 
activities,  on  phylaxis,  kataphylaxis,  antiphylaxis, 
also  epiphylaxis,  apophylaxis  and  ecphylaxis. 

As  Wright  says  the  kataphylactic  measures  in- 
clude evacuation  of  an  ecphylactic  focus;  also  nor- 


mal conditions  may  be  restored  by  augmentation  of 
the  transudation  of  lymph  into  the  focus  of  infec- 
tion and  displacing  and  expelling  by  this  agency 
the  ecyphlactic  lymph ;  also  by  restoring  physiologi- 
cal conditions  by  processes  of  diffusion.  Let  me 
quot»  Wright's  recommendations : 

KATAPHYLACTIC  MEASURES. 

"Normal  conditions  may  be  restored  by  augment- 
ing the  transudation  of  lymph  into  the  focus  of 
infection,  and  displacing  and  expelling  by  this 
agency  the  ecphylactic  lymph.  Physiological  con- 
ditions may  be  restored  by  processes  of  single  dif- 
fusion. 

"1.  Procedures  for  evacnating  the  ecphylactic 
fluid  into  the  exterior. 

a.  Incision  into  the  focus  of  infection. 

b.  Incision  and  cupping.  In  actual  practice  the 
method  fails,  when,  as  in  carbuncle,  we  have  to 
deal  with  lymph  spaces  blocked  with  leucoc>tes  and 
coagulated  exudate. 

c.  Application  of  hpertonic  salt  solution  to 
naked  tissue  surfaces. 

d.  -A.pplication  of  irritant  solutions  to  naked 
tissue  surfaces.    An  outpouring  of  lymph. 

"2.  Procedures  for  restoring  normal  conditions  by 
anguicntitig  transudation  from  the  blood  and  dis- 
placing and  driving  out  the  ecphylactic  fluid  from 
the  focus  of  infection. 

"Under  this  heading  may  be  enumerated  three 
procedures :  the  application  of  hot  fomentations,  the 
a])])lication  of  a  Bier's  liandage,  and  massage.  In  the 
first  two  we  make  use  of  increased  transudation — 
obtaining  that  increased  transudation  in  the  one 
case  by  active  and  in  the  other  by  passive  conges- 
tion. In  massage  we  use  mechanical  propulsion. 
It  will  generally  be  inapplicable  to  an  active  focus 
of  infection. 

"3.  Procedures  for  restoring  physiological  con- 
ditions in  the  focus  of  infection  by  spontaneous 
diffusion  of  protective  substances  from  the  blood. 

"If  we  had  under  Socratic  cross  examination  the 
man  who  expects  benefit  indiscriminately  from 
ever}-  therapeutic  inoculation  it  would  be  elicted 
that  he  had  a  confused  expectation  that  the  protec- 
tive substance  obtained  by  inoculation  would  dif- 
fuse into,  and  do  effective  work  in,  every  focus  of 
infection.  In  the  case  of  a  focus  which  has  at- 
tained a  certain  magnitude  that  cannot  by  any  pos- 
sibility happen,  for  the  infecting  microbes  are  in- 
cessantly obstructing  the  work  of  immunization. 
The\'  are  continuously  paralyzing  and  repelling  the 
leucocytes  and  depraving  the  blood  fluid  to  their 
advantage,  and  thus  they  neutralize  and  more  than 
neutralize  the  instreaming  protective  substances. 
\\'e  get  as  good  as  no  success  from  therapeutic  in- 
oculations when  dealing  with  large  and  unopened 
foci  of  infection :  and  our  ver}^  best  when  as  in 
]irophylactic  inoculation,  we  are  dealing  with  in- 
fecting microbes  before  they  have  had  time  to  fab- 
ricate round  themselves  an  ecphylactic  focus. 

"Of  such  dominating  importance  is  efficient  kata- 
phylaxis in  the  conflict  with  bacterial  disease  that  I 
do  not  hesitate  to  assert — and  these  are  views  with 
which  ever}-  surgeon  will  fall  in — that  if  we  were  to 
jnU  our  election,  on  the  one  hand,  between  efficient 


September  18,  1920.] 


WILE:  HEALTH  OP  SCHOOL  CHILDREN. 


407 


epiphylaxis  without  kataphylaxis ;  and,  on  the  other 
hand,  efficient  kataphylaxis  without  epiphylaxis,  we 
ought  every  time  to  choose  the  latter." 

In  a  paper  read  before  the  American  Clinical  and 
Climatological  Association  (3)  I  reviewed  the  sub- 
ject carefully. 

Let  me  here  remark  upon  the  topic  of  massage 
or  better  manipulative  procedures  in  this  connection. 
The  profession  has  by  no  means  directed  its  at- 
tention adequately  to  the  resources  of  manipulation. 
Ancient  error,  prejudices  and  queer  preferential 
limitations  still  prevail.  What  are  the  contraindi- 
cations to  massage  which  are  still  believed  to 
obtain  ? 

Among  the  more  unfortunate  dicta  which 
demand  revision  are :  1 ,  Not  to  apply  massage  to 
a  patient  in  whom  fever  is  present.  On  the  con- 
trary this  is  often  most  necessary,  since  by  gentle 
strokes,  light  touches,  as  Menell  has  shown,  extra- 
ordinary results  can  often  be  obtained  in  relaxing 
local  or  general  vasomotor  overtension. 

2,  To  avoid  massage  in  the  vicinity  of  wounds, 
devitalized,  injured  or  infected  areas,  structures, 
etc.,  also  where  diseases  of  the  skin  exist,  such  as 
eczema.  The  fact  is  that  the  application  of  mas- 
sage to  contiguous  areas  is  often  followed  by 
prompt  repair,  cure  or  pronounced  advantage. 

3.  To  avoid  massage  where  the  heat  making 
(thermogenic)  mechanisms  are  overborne.  Here  it 
is  demonstrated  that  massage  afifords  one  of  the 
most  efficacious  means  of  restoration.  This  efifect 
of  restoring  equipoise  in  the  heat  generating  mech- 
anisms is  peculiarly  valuable,  notably  in  condi- 
tions of  lymph  stasis,  when  subderinal  adhesions 
are  present,  and  the  like. 

REPUTABLE  INFERENCES. 

The  evidence  in  behalf  of  the  efficacy  of  kinelo- 
genic  instrumentalities  as  contrasted  with  pharma- 
cogenic  and  to  meet  diversified  emergencies  is 
steadily  growing.  It  demands  openminded  atten- 
tion and  confidence.  Heretofore  serogenic  reme- 
dies when  applied  have  been  relied  on  to  suffice 
alone.  Now  evidence  is  accumulating  to  the  effect 
that  these  can  also  be  enhanced  by — may  indeed 
often  demand  supplementing  by — the  kineto- 
genic.  By  common  consent  of  surgeons  who  have 
actually  worked  under  Willems  in  Belgium,  he  has 
made  the  largest  contribution  to  surgery  of  the  war 
in  his  method  of  treating  acute  septic  arthritis  and 
traumatic  arthritis  by  compelling  volitional  effort 
from  the  start. 

I  may  cite  a  personal  communication  to  Dr. 
S.  Fosdick  Jones,  of  Denver,  Col.,  who  worked 
under  Willems  to  this  efifect.  So  also  of  the  work 
of  Dr.  La  Panne  at  the  Ambulance  dc  L'Occan,  in 
preserving  function  in  amputations.  Further  clin- 
ical evidence  is  needed  but  here  we  have  indicated 
most  promising  accessory  measures. 

REFERENCES. 

1.  Todd:  Clinical  Lectures  on  Paralysis;  Koundjy, 
P. :  Jour,  de  Physiotherapy,  1905 ;  Kouxdjy  and  Strag- 
xell:  Physiotherapy,  C.  V.  Mosby  &  Co. 

2.  Wright:  Proceedings  of  the  Royal  Society  of  Medi- 
cine, February  25,  1919. 

3.  Taylor,  J.  Madison  :  Cardiovascular  Renal  Regula- 
tion by  Other  Means  Than  Drugs,  Boston  Medical  and 
Surgical  Journal,  October  9,  1919. 


HOW^    TO    PROTECT   THE    HEALTH  OF 
SCHOOL  CHILDREN* 

By  Ira  S.  Wile,  M.  D., 
New  York. 

While  foreign  nations  are  grappling  with  the 
problem  of  repopulation,  the  United  States  is  busily 
concerned  with  the  questions  involved  in  conserving 
the  existing  generation  and  in  improving  the  chances 
of  survival  of  those  still  unborn.  Public  health 
measures  of  the  past  decade  have  shown  a  material 
advance  in  the  direction  of  efiforts  to  protect  the 
health  of  school  children.  In  the  evolution  of  this 
work,  more  attention  has  been  bestowed  upon  child- 
ren during  the  school  age  than  at  any  other  period 
of  child  life,  save  infancy. 

As  a  matter  of  logic,  devoting  attention  to  child- 
ren during  the  school  age  represents  merely  an  en- 
tering wedge  into  work  with  children.  Because 
of  the  glaring  handicaps  and  defects  noted  in  the 
school  population,  rationally,  the  protection  of 
health  during  the  school  period  should  be  begun 
before  entrance  upon  school  work.  In  other  words, 
the  potential  school  child  presents  a  more  important 
problem  for  public  health  work  and,  in  consequence, 
every  effort  should  be  made  to  supervise,  control 
and  impart  the  necessary  hygienic  information  con- 
cerning childhood  during  the  first  six  years  of  life. 
Any  system  of  public  health  may  be  said  to  be 
caring  for  children  inadequately,  unless  its  efforts 
are  directed  along  lines  of  prenatal  work,  the  organ- 
ization of  infant  welfare  stations  and  the  continu- 
ous care  of  children  during  the  preschool  age. 

For  this  reason  I  emphasize  the  necessity  of 
guiding  childlife  from  conception  to  the  age  of  six 
years,  as  a  prerequisite  or  rather  a  fundamental 
part  of  hygienic  protection  of  the  school  child. 

The  purpose  of  education  is  thwarted  or  handi- 
capped when  the  pupil  is  physically  or  mentally  in- 
capacitated to  receive  an  education  or  indeed  to 
develop  its  latent  potentialities.  The  reports  of 
medical  inspectors,  indicating  the  numerous  defects 
and  handicaps  of  school  children,  bear  witness  to 
our  failure  properly  to  prepare  children  for  the 
educational  system.  The  recognition  of  defective 
nutrition,  carious  teeth,  impaired  vision  and  hear- 
ing, spinal  curvatures,  pathologically  enlarged  ton- 
sils and  adenoids  certainly  merits  attention  during 
the  preschool  period.  The  postponement  of  atten- 
tion to  handicaps  of  this  type  until  school  work 
lias  been  begun  is  indicative  of  a  failure  to  appreci- 
ate the  necessity  for  entering  children  into  school 
work,  capable  of  functioning  in  as  nearly  a  normal  ' 
manner  as  is  humanly  possible  in  the  present  state 
of  our  knowledge. 

Economically  and  socially  it  is  distinctly  advan- 
tageous to  spread  some  of  the  attention  now  be- 
stowed upon  the  school  epoch  over  the  period  of 
life  antedating  the  school  age.  It  is  simpler  and 
cheaper  to  undertake  protective  measures  at  the 
time  suggested  than  to  wait  vmtil  there  are  addi- 
tional charges  to  the  community  through  wastage 
due  to  the  loss  of  time,  because  of  preventable  dis- 
eases or  corrective  measures. 

*  Read  before  the  Child  Health  Conference  at  Asbury  Park,  N.  J., 
June  12,  1920. 


408 


jriLE:  HEALTH  OF  SCHOOL  CHILDREX. 


[Xew  Vork 
Medical  Jolrxal. 


The  protection  of  the  health  of  school  children 
must  take  cognizance  of  more  factors  than  are 
ordinarily  considered.  The  physical  bases  of  health 
have  received  considerable  attention  but  insufficient 
thought  has  been  devoted  to  the  matter  of  educa- 
tional, social  and  moral  factors  involved  in  the 
health  of  school  children.  Our  sphere  of  influence 
must  be  enlarged  in  conformity  with  the  concept 
of  the  unity  of  childhood  and  the  interrelations  and 
interdependence  of  all  factors  affecting  health.  Xo 
longer  is  public  health  work  restricted  to  the  con- 
sideration of  contagious  diseases  and  personal  han- 
dicaps. It  now  contemplates  the  broader  horizon 
of  health,  as  covering  mental  and  moral  wellbeing, 
and  thus  influences  methods  of  administrative  pro- 
cedure. 

From  the  more  traditional  point  of  view,  con- 
serving the  health  of  school  children  involves  the 
recognition  and  correction  of  the  existent  defects 
and  handicaps  and  the  establishment  of  methods 
tending  to  prevent  the  development  of  such  ob- 
stacles to  normal  development  during  the  school 
period.  Obviously,  if  a  large  part  of  this  work 
is  performed  before  entrance  into  school,  there  will 
be  less  of  the  corrective  work  to  be  done  during  the 
school  period.  The  need  would  still  exist  for  the 
complete  examination  of  new  pupils  along  present 
lines  with  a  view  to  determining  their  physical 
status  and  improving  upon  it. 

The  regular  procedure  involved  in  medical  in- 
spection for  the  prevention  of  contagion  and  the 
control  of  children  during  the  existence  of  epidem- 
ics is  of  inestimable  importance.  The  mere  tabula- 
tion of  statistics,  however,  is  without  service  to  the 
state,  save  in  so  far  as  it  indicates  the  problems  to 
be  attacked.  Correction  of  defects  is  the  only  ex- 
cuse for  efforts  at  detection. 

Every  system  of  medical  inspection  requires  for 
complete  usefulness  a  followup  system  which  will 
insure  a  full  measure  of  attention  for  every  child 
found  to  be  physically  handicapped.  In  this  con- 
nection, of  course,  the  school  nurse  is  a  necessity, 
while  a  great  deal  could  also  be  accomplished 
throtigh  the  home  and  school  visitor,  discussions 
before  mothers'  clubs  with  vokmtary  committees, 
willing  and  able  to  assist  the  medical  inspectors  in 
carr\-ing  out  their  program. 

The  importance  of  dental  disorders  has  now  been 
recognized  so  that  an  inclusive  health  program 
merits  the  assistance  of  dental  hygienists  and  dent- 
ists. This  phase  of  dental  hygiene,  though  fully 
appreciated  for  several  years,  has  not  received  the 
attention  it  deserves.  The  haphazard  service  given 
the  mouths  of  children  during  the  preschool  age 
has  deluged  the  schools  with  children  whose  dental 
state  is  lamentable. 

I  am  firmly  convinced  that  in  the  expansion  of 
state  oversight  of  school  children,  more  use  will  be 
made  of  school  clinics,  which  will  serve  as  the  rally- 
ing point  for  health  centres,  now  growing  in  favor. 
These  school  clinics  may  merely  serve  as  clearing 
houses  or  under  careful  management  triay  offer 
adequate  instruction  to  care  for  a  large  proportion 
of  the  conditions  requiring  continuous  direction 
and  control.  This  is  particularly  true  of  health 
classes  which  are  established  for  the  purpose  of 


alleviating  malnutrition,  postural  defects,  unclean 
mouths,  etc.  I  believe  also  that  more  attention  is 
reqtiired  to  the  physical  welfare  of  teachers.  The 
means  to  be  employed  must  necessarily  vary  ac- 
cording to  the  regulations  for  admission  to  the  edu- 
cational system,  and  in  consequence  I  hesitate  to 
suggest  a  definite  program,  though  the  reason  for 
one  is  apparent. 

The  problems  of  physical  sanitation,  involving 
light,  heat,  ventilation,  adjustable  furniture,  the  use 
of  water,  towels  and  toilets,  are  sufficiently  impor- 
tant to  be  given  consideration  in  any  large  plan 
involving  the  complete  protection  of  the  health  of 
school  children.  In  addition  to  these  questions, 
largely  taken  care  of  by  departments  of  education, 
there  offers  a  broader  educational  field  which  is  of 
interest  from  the  viewpoint  of  public  health.  I 
refer  specifically  to  the  need  for  special  classes  for 
cripples,  the  blind  and  the  deaf,  as  well  as  provision 
for  open  air  classes  for  children,  anemic,  or  con- 
valescing from  intermittent  diseases  and  children 
in  the  pretuberculous  or  incipient  tuberculotts  stage. 
Furthermore,  there  is  a  necessity,'  for  classes  aiming 
to  conserve  vision,  particularly  for  myopics,  and 
likewise  the  institution  of  methods  for  the  preven- 
tion and  the  correction  of  speech  defects.  All  of  these 
classes  while  ordinarily  regarded  as  parts  in  an 
educational  system,  in  the  same  way  as  are  the  un- 
graded classes,  by  reason  of  the  conditions  calling 
for  their  existence,  are  also  classes  possessing  a 
value  protective  to  the  health  of  school  children. 

They  are  designed  not  merely  to  give  special 
attention  to  the  education  of  handicapped  children, 
but  to  do  so  without  sacrifice  of  greater  vitality  and 
indeed  with  a  desire  to  supplement  and  increase 
their  latent  physical  powers  and  development. 
From  the  health  viewpoint,  as  well  as  the  social 
point  of  view,  the  serving  of  school  lunches 
must  not  be  forgotten,  though  the  underlying  basis 
of  this  need  is  fotmd  in  the  ignorance  of  dietetic 
requirements,  slightly  complicated  by  inadequate 
family  incomes. 

It  is  unnecessary  to  dwell  upon  the  interrelation 
of  physical  and  mental  causes  in  the  health  of  school 
children.  The  aim  of  public  health  work  with 
children  is  not  merely  in  the  value  of  physical 
health  to  the  individual,  but  lies  in  the  worth  of 
efficient  citizenship.  Patently,  this  involves  mental 
health  as  well  as  physical  wellbeing.  For  this 
reason  the  mental  health  of  the  school  child  merits 
protection.  The  amount  of  interest  which  has  been 
manifested  in  children  of  low  mentality  shotild  be 
given  the  entire  school  population.  Those  children 
whose  social  and  economic  returns  to  the  state  will 
be  of  greatest  value  deserve  as  high  a  degree  of 
mental  protection  as  those  whose  greatest  return 
will  be  a  low  limit  of  self  support  or  those  who 
possibly  will  require  institutional  segregation.  Un- 
der a  rational  system,  every  child  in  school  would 
receive  a  psychological  test  with  the  determination 
of  its  intelligence  quotient  as  one  of  the  factors  in 
determining  its  school  adjustment.  The  child 
capable  of  doing  work  of  the  third  year  should  not 
be  obliged  to  mark  time  in  the  first  year  class,  be- 
cause it  is  chronologically  six  years  of  age.  and 
thus  begin  the  formation  of  habits  and  conduct 


September  18,  1920.] 


BEHREND:  BACKACHE. 


409 


harmful  to  its  mental  development.  The  growth 
of  the  mental  hygiene  movement  bears  witness  to 
the  importance  of  undertaking  some  new  program 
in  connection  with  children  of  the  school  age.  There 
is  a  great  need  for  proper  school  adjustments,  the 
development  of  rapid  advancement  classes,  and  the 
giving  of  thought  to  the  bright  children  just  as  is 
now  given  to  morons  and  imbeciles.  Pedagogical 
discrimination  forms  an  important  part  of  mental 
hygiene,  but  the  urging  of  health  authorities  would 
be  useful  in  hastening  the  advance  of  the  educa- 
tional aids  in  promoting  mental  health. 

Nature  has  been  kind  to  children  in  that  it  has 
provided  certain  natural  barriers  preventing  over 
study  and  overwork  in  school.  Nevertheless,  there 
is  a  growing  demand  for  greater  elasticity  in  school 
curricula,  a  longer  school  year,  promotion  by  sub- 
iect,  and  a  more  careful  distribution  of  work,  study 
and  play  in  school  life.  I  mention  these  phases  of 
educational  work,  because  health  departments  and 
bureaus  of  child  hygiene  can  find  a  greater  field 
for  the  expression  of  opinions  concerning  the  im- 
provement of  health  and  for  giving  wise  counsel 
to  school  children  through  a  higher  degree  of  co- 
operation with  educational  systems.  It  seems  irra- 
tional to  establish  clinics  of  mental  hygiene,  without 
at  the  same  time  entering  upon  a  campaign  to  safe- 
guard growing  generations  against  mental  disabili- 
ties due  to  faulty  school  methods. 

From  the  same  point  of  view,  the  protection  of 
school  children  involves  more  knowledge  concern- 
ing the  hvgiene  of  teaching,  the  proper  adjustment 
of  school  hours,  particularly  during  the  first  few 
years,  the  balance  of  recreation,  the  advantages, 
methods  and  dangers  of  physical  education.  Many 
groups  of  children  suffering  from  such  handicaps 
as  cardiac  diseases,  tuberculosis,  cripplings,  flat 
feet,  deformities  of  the  spine  and  similar  conditions 
demand  the  adjustment  of  school  program,  and 
this  should  be  a  concern  of  health  authorities. 

It  must  be  obvious  that  no  scheme  of  protecting 
the  health  of  school  children  would  be  complete 
without  at  least  mentioning  the  importance  of  teach- 
ing hygiene  in  its  widest  implications,  not  merely 
as  an  isolated  subject,  but  as  part  of  every  subject 
with  which  it  has  correlation.  The  institution  of 
events  in  educational  circles  under  the  stimulus  of 
health  departments,  such  as  Babies'  Week.  Clean 
Up  Week.  No  Accident  Week,  Health  Day,  etc., 
possesses  a  value  from  the  topical  viewpoint  but 
does  not  suffice  to  fix  the  facts  of  hygiene  as  firmly 
as  does  the  proper  daily  instruction  of  hygiene  in 
connection  with  history,  civics,  geography,  nature 
study,  physical  education,  and  indeed  English  and 
art.  domestic  science  and  manual  training.  The 
educational  machinery  which  has  revolutionized 
public  health  work  for  childhood,  should  possess  an 
adequate  place  in  the  schools  that  there  may  be 
understanding  of  the  human  body  in  its  relations 
to  individual,  family  and  civic  health. 

One  more  phase  of  our  general  scheme  must  be 
considered.  The  moral  factors  of  health  require 
more  attention  than  the  past  has  offered.  The 
great  truths  and  the  underlying  purpose  of  sex 
education  must  be  imparted  to  children  natural- 
ly and  rationally,  utilizing  the  home,  the  school, 


the  Sunday  school,  the  clinic  and  the  class  room 
as  occasion  arisas.  The  vast  importance  of  mal- 
adjustments of  conduct  and  behavior,  and  the  com- 
plexes that  distort  personalities  are  not  to  be  over- 
looked, in  a  complete  organization  of  activities  to 
protect  the  health  of  school  children.  This  is  merely 
a  suggestion,  because  it  would  involve  too  long  a 
period  of  time  to  give  it  adequate  discussion. 

I  have  endeavored  to  present  briefly,  though  it 
may  not  appear  so,  my  conception  of  the  field  of 
work  that  must  be  entered  in  order  to  give  due 
consideration  to  the  important  elements  entering 
into  the  health  of  school  children.  Laying  greatest 
emphasis  upon  the  organization  of  health  work 
during  the  prenatal  period,  infancy  and  the  pre- 
school age,  I  should  continue  every  line  of  endeavor 
thus  begun,  permitting  them  to  expand  in  the  di- 
rections that  child  nature  develops.  The  physical, 
mental  and  moral  phases  of  child  health  require 
guidance,  support,  constructive  suggestion  and 
remedial  efforts.  These  indicate  a  large  variety 
of  functions  to  be  consolidated  and  coordinated. 
On  this  broad  principle  I  believe  it  will  be  possible 
to  build  up  a  type  of  work  that  will  lead  to  a 
complete  system  of  health  protection  for  school 
children.  With  such  a  plan  and  an  adequate  or- 
ganization the  future  will  find  the  nation  richer 
in  man  power  and  woman  power  and  with  a  greater 
confidence  in  the  healthful  development  of  the 
future  generations. 

264  West  Sevexty-third  Street. 


BACKACHE  FROM  THE  MEWPOINT  OF 
THE  GENERAL  SURGEON.* 

By  Moses  Behrexd.  ^l.  D.. 

Philadelphia.  f 

In  a  symposium  of  this  character  the  general 
surgeon  has  to  some  extent  an  advantage  over  the 
gynecologist,  the  orthopedist,  and  the  urologist, 
provided  he  received  his  training  before  the  various 
branches  of  surgery  were  specialized  as  they  are 
now.  Theoretically,  we  can  divide  the  back  into 
the  gynecological,  the  orthopedic,  the  neurological, 
the  medical,  and  the  surgical  back.  The  surgical 
back  refers  especially  to  injuries  which  may  result 
in  a  fracture  of  one  or  more  spinal  vertebrae  and 
to  injuries  in  the  loin  space,  especially  the  kidneys. 
Injuries  to  the  body  of  the  vertebrae  are  the  most 
difficult  to  treat  and  at  the  same  time  often  the 
most  benign.  Fractures  of  the  spine  as  a  result 
of  a  crushing  injury  may  disintegrate  the  cord  to 
such  an  extent  as  to  cause  permanent  paralysis  or 
death  in  a  comparatively  short  time.  Backache  re- 
sulting from  these  injuries  varies  to  a  great  degree. 
It  persists  in  some  cases  for  a  lifetime,  especially 
when  the  injury  has  not  been  severe.  There  is  an- 
other type  of  case  in  which  the  patient  recovers 
after  a  favorable  settlement  has  been  made,  either 
in  court  or  out. 

Injuries  to  the  back  may  also  occasionally  cause 
traumatic  inguinal  hernia.  I  have  seen  two  such 
cases  resulting  from  severe  blows  on  the  back,  the 

*Read  at  a  meeting  of  the  Northern  Medical  Association  of  Phila- 
delphia. May  14,  1920,  as  part  of  i  .symposium  on  backache. 


410 


DUNCAN:  MEDICAL  MEN  IN  THE  AMERICAN  REVOLUTION. 


[New  York 
Medical  Journal. 


hernia  being  of  a  direct  inguinal  variety.  The  pa- 
tient operated  upon  most  recently  gave  a  history  of 
having  received  a  blow  on  the  back  while  lifting  a 
case  of  glass  from  a  wagon.  There  was  no  history 
of  a  previous  hernia  and  at  operation  there  was  no 
preformed  sac.  The  patient  was  brought  into  the 
hospital  with  the  hernia  irreducible  immediately  af- 
ter the  accident.  It  is  well  known  that  a  large 
hernia  often  causes  backache  on  account  of  the  at- 
tachment of  the  mesentery  to  the  spinal  column. 
The  dragging  of  a  large  scrotal  or  vulvar  hernia 
would  necessarily  give  rise  to  some  discomfort  in 
the  back,  especially  if  adhesions  were  present,  and 
very  often  this  was  the  case  in  old  irreducible 
hernias. 

The  appendix  must  not  be  forgotten  in  consider- 
ing a  subject  so  important  as  backache.  We  all 
know  that  an  acutely  inflamed  appendix  often  gives 
rise  to  pain  in  the  loin  space,  especially  where  the 
appendix  is  posterior  to  the  cecum  and  pointing  in 
the  direction  of  the  gallbladder.  The  character  of 
incision  will  often  depend  on  the  diagnosis  of  an 
appendix  in  this  position.  In  chronic  cases,  where 
the  appendix  is  tightly  bound  down  to  the  cecum 
and  the  peritoneum,  backache  is  often  a  symptom  of 
this  condition.  Only  recently  a  patient  was  admit- 
ted to  the  hospital  in  whom  we  diagnosed  right 
tuboovarian  disease  and  retroversion.  On  opening 
the  abdomen  the  pelvic  organs  were  found  to  be 
practically  normal  but  a  chronic  appendicitis  existed 
in  which  the  tip  of  the  appendix  pointed  in  the  direc- 
tion of  the  gallbladder. 

At  times  grave  disease  in  the  loin  space,  such  as 
retroperitoneal  sarcoma  may  be  retroactive,  namely, 
in  the  early  stages  of  its  growth  pain  may  be  re- 
ferred to  the  anterior  portion  of  the  abdomen  instead 
of  to  the  back.  This  I  believe  is  found  only  in  the 
early  stages  of  the  disease.  As  an  illustration  of  this 
point  I  should  like  to  cite  the  case  of  a  young  boy 
who  had  all  the  symptoms  of  chronic  appendicitis, 
this  diagnosis  having  been  made  by  a  reputable  in- 
ternist and  myself.  The  appendix  was  removed  and 
the  youth  left  the  hospital  in  a  short  time.  About 
eight  weeks  after  the  operation  he  complained  of 
backache,  for  which  no  assignable  cause  could  be 
found.  A  late  infection  of  the  wound  was  thought 
of  but  this  idea  had  to  be  discarded  when  shortly 
afterward  a  swelling  was  found  in  the  loin  space 
rather  high  up  under  the  border  of  the  ribs.  We 
operated  again  on  account  of  the  swelling  and  in- 
tense backache  and  notwithstanding  all  the  well 
recognized  treatments,  such  as  Colej^'s  fluid,  radium 
and  the  x  ray,  the  boy  died  complaining  persistently 
of  the  most  intense  backache. 

Dr.  Hirsch  has  alluded  to  stones  in  the  kidney  as  a 
cause  of  backache.  It  is  difficult  to  separate  the  con- 
sideration of  gallstone  from  that  of  kidney  stone. 
When  these  symptoms  occur  on  the  right  side  there 
may  exist  some  doubt  as  to  the  proper  organ  involved 
but  one  must  bear  in  mind  that  colic  from  stone  in 
the  kidney  starts  in  the  back  and  then  radiates  down 
the  front  of  the  abdomen,  while  in  gallstone  disease 
the  pain  usually  starts  in  front  and  then  may  radiate 
to  the  back,  even  to  the  shoulders.  The  character  of 
the  pain  from  these  sources  may  be  quite  alike,  bor- 


ing or  knifelike  in  character,  or,  as  one  patient  de- 
scribed it,  as  though  some  one  was  taking  his  live 
fingers  and  trying  to  dig  a  hole  through  to  the  back. 
There  may  be  silent  stones  in  the  gallbladder  similar 
to  those  in  the  kidney,  but  when  old  gallbladder  dis- 
ease is  present,  with  obstruction  of  the  cystic  duct, 
there  is  often  a  continuous  backache,  especially  after 
meals.  This  symptom  accompanies  the  socalled 
symptoms  of  indigestion. 

Ulcer  of  the  duodenum  and  ulcer  of  the  stomach 
on  the  anterior  wall,  the  lesser  curvature,  or  at  the 
pylorus,  rarely  give  rise  to  backache,  but  ulcers  on 
the  posterior  wall  of  the  stomach,  especially  those 
adherent  to  the  pancreas  and  even  to  the  parietal 
peritoneum,  may  cause  backache  burning  in  char- 
acter. Recently  I  have  operated  in  several  of  these 
the  cases  of  ulcer  on  the  posterior  wall  of  the  stom- 
ach. The  same  may  be  true  of  cancer  of  the  stomach 
in  its  early  stages,  backache  not  being  a  prominent 
symi)tom  until  adhesions  occur  between  the  pan- 
creas, the  stomach,  and  other  organs. 

Syphilis  when  it  affects  the  liver  may  give  rise  to 
a  continual  dragging  sensation  in  the  back.  This 
refers  especially  to  the  massive  liver  that  accom- 
panies some  cases  of  syphilis.  To  illustrate  this 
point  I  will  cite  the  case  of  a  patient  with  a  large, 
soft  swelling  in  the  abdomen,  who  was  admitted  to 
the  hospital.  Many  diagnoses  were  made  because 
the  Wassermann  reaction  was  negative.  At  opera- 
tion the  liver  was  found  to  extend  from  the  dia- 
]:)hragm  to  the  os  pubis,  hiding  entirely  from  view 
the  coils  of  the  intestine.  A  section  of  liver  was 
taken  for  histological  study  and  another  Wasser- 
mann was  obtained  because  we  were  not  satisfied 
with  the  result  of  the  first  Wassermann,  which  was 
not  made  in  the  hospital.  The  second  Wassermann 
was  positive  and  the  histological  study  confirmed 
the  diagnosis. 

1427  XoRTH  Broad  Street. 


MEDICAL   MEN    IN   THE  AMERICAN 
REVOLUTION. 
The  A^cw  York  Campaign  of  1776. 
Bv  Louis  C.  Duncan,  M.  D.. 
Washington,  D.  C, 

Lieutenant  Colonel,  Medical  Corps,  U.  S.  Army. 

(Coiitiiiued  from  page  349) 

THE  MEMORIAL  OF  THE  REGIMENTAL   SURGEONS  TO 
CONGRESS. 

This  sets  forth  that  when  troops  were  assembled 
in  haste,  at  the  first  breaking  otit  of  war,  regimental 
surgeons  were  appointed  to  accompany  them,  pro- 
vided with  medicine  chests,  from  the  different  parts 
of  the  cotintry,  where  they  were  raised,  at  Colonial 
expense.  That  when  it  became  a  common  cause  of 
the  whole  continent,  and  provision  was  made,  by 
Congress,  for  the  care  of  the  sick  and  wounded  of 
the  Army,  by  the  establishment  of  a  general  hos- 
pital, with  a  Director  General,  four  surgeons  and 
twenty  mates,  there  was  no  mention  of  the  regular 
surgeons  and  mates,  nor  any  provision  made  for 
them,  either  of  medicines,  instruments,  or  other 


September  18,  1920.]       DUXCAX:  MEDICAL  MEN  IN    THE  AMERICAN  REVOLUTION. 


411 


necessaries ;  yet  they  were  kept  in  pay.  That,  in 
this  situation,  it  might  be  presumed  the  hospital  sur- 
geons and  mates,  appointed  to  take  care  of  the  sick 
and  wounded,  were  scarcely  sufficient  to  attend  so 
great  a  number  of  patients  as  an  unhealthy  season, 
or  an  active  campaign  might  produce;  yet  the  regi- 
mental surgeons  and  mates,  for  want  of  a  suitable 
provision,  must  in  their  present  situation,  be  very 
useless ;  although  they  were  so  much  more  numer- 
ous than  the  hospital  surgeons  and  mates,  and  al- 
ways professed  an  ardent  desire  of  being  properly 
employed,  and  of  answering  the  design  of  their 
appointment.  That  not  knowing  where  else  to  look 
for  relief,  they  had  applied  to  the  director  general, 
who  assured  them  of  his  inclination  to  serve  them ; 
but  having  no  orders  to  issue  out  supplies  to  them, 
and  it  being  unusual  for  regimental  surgeons  to 
depend  upon  the  General  Hospital  for  all  they 
wanted,  he  had  advised  them  to  make  application 
of  the  Commander  in  Chief,  or  Congress,  for  estab- 
lishing a  proper  method  to  obtain  supplies,  prom- 
ising to  second  their  applications,  with  the  warmest 
representations  from  himself.  That  it  was  with  his 
advice,  the  present  memorial  was  drawn  up,  to  lay 
before  Congress.  That  he  had  given  them  several 
meetings,  and  a  set  of  proposals  were  agreed  upon, 
as  regulations,  provided  they  met  with  the  appro- 
bation of  Congress,  which  were  enclosed  for  con- 
sideration ;  praying  for  such  relief  on  the  premises, 
as  to  the  wisdom  of  Congress  should  seem  meet. 

The  proposed  plans  will  be  found  in  the  appendix 
to  this  chapter  (4). 

In  July  he  also  sent  Dr.  Binney  to  Philadelphia 
to  procure  medicines  and  instruments.  Binney  wrote 
him  that  no  instruments  were  to  be  had ;  that  the 
only  instrument  makers  in  the  city  were  employed 
by  Mr.  Marshall  for  the  Congre'ss.  Dr.  Binney  at 
length  (August  15th)  sent  forward  such  a  supply  of 
medicine  as  he  could  procure,  and  they  arrived  at 
Newark  a  short  time  before  the  retreat  from  New 
York.  This  was  a  fortunate  accident,  for  they  served 
the  hospital  established  in  Newark  about  that  time. 

The  Director  General  forwarded  the  various  docu- 
ments to  Congress,  together  with  a  long  letter  of 
explanation  addressed  to  Samuel  Adams,  Es- 
quire, and  the  rest  of  the  medical  committee.  He 
stated  their  troubles,  dwelt  on  the  great  shortage  of 
supplies  with  the  regimental  surgeons,  and  implored 
that  he  be  clothed  with  authority  and  definite  orders. 
He  also  referred  to  the  great  distress  of  the  army 
in  Canada  and  enclosed  a  plan  observed  by  the 
British  in  conducting  their  general  and  regimental 
hospitals.    He  closed  with  this  request : 

(6)  I  beg  instruments  may  be  sent  us,  particularly  am- 
putating; crooked  needles  and  sponges.  The  enemy  are 
at  hand;  the  campaign  is  opening;  I  have  done  all  my 
limited  power  will  allow.  I  hope,  though  late,  almost  too 
late,  that  it  is  not  altogether  so,  either  to  receive  power, 
instructions,  or  means  to  regulate  the  affairs  of  my  Dept. 
I  have  done  my  duty  in  giving  the  necessary  information 
for  what  is  connected  with  it,  and  preparing  for  the  faith- 
ful discharge  of  my  trust.  I  now  rest  the  matter  on  your 
determinations,  being,  with  all  possible  regard. 
Gentlemen, 

Your  most  dutiful  and  obedient  servant, 

JOHX  MORG.^X. 

Congress  was  busy  with  many  things  then,  but 
Morgan's  regulations  were  mainly  approved.  The 


only  letter  received  from  Adams  was  one  of  August 
5th,  in  which  he  said: 

I  have  received  several  letters  from  you,  which  1  should 
sooner  have  acknowledged,  if  I  could  have  found  leisure. 
I  took  however,  the  necessary  steps  to  have  what  you 
requested  effected  in  Congress. 

Congress  had  acted  on  July  17th  (5)  and  com- 
plied with  most  of  Morgan's  recommendations  :  jirac- 
tically  all,  in  fact. 

This  resolution,  or  law,  was  on  the  whole  in  ac- 
•  cordance  with  the  ideas  of  Morgan,  and  very  near- 
ly abolished  regimental  hospitals — in  law,  but  not  in 
fact.  They  continued  as  before.  It  put  all  sur- 
geons, hospital  and  regimental,  on  the  same  level  in 
so  far  as  rank  was  concerned.  It  established  a 
system  of  property  returns,  and  reports  of  the  sick, 
as  well  as  of  personnel.  It  displays  the  usual 
thoughtlessness  with  which  those  in  authority  direct 
the  preparing  of  endless  papers  by  those  under 
them.  It  was  the  answer  to  ^Morgan's  proposals, 
and  should  have  been  reasonably  satisfactory  to 
him.  It  was  not  at  all  satisfactory  to  the  regimental 
surgeons,  who  were  required  to  abandon  any  real 
hospitals,  and  apply  elsewhere  for  all  supplies  ex- 
cept medicines  and  instruments.  They  then  re- 
newed, with  increased  vigor,  their  efforts  to  under- 
mine Morgan's  standing  with  the  Congress.  In  this 
work  they  were  soon  joined  by  the  Medical  Direc- 
tor of  the  Flying  Camp,  Dr.  William  Shippen.  Dr. 
^lorgan  then  obtained  permission  to  go  to  Phila- 
delphia and  lay  the  case  before  Congress.  ~He 
learned  that  Congress  had  purchased  a  valuable 
stock  of  medicines  that  were  in  the  hands  of  drug- 
gists there.  As  sales  had  been  made  from  this 
stock,  and  considerable  quantities  sent  southward, 
he  feared  it  might  be  dissipated,  though  it  was  the 
best  collection  of  medicines  that  he  had  ever  seen 
in  the  American  Army. 

While  on  principle  opposed  to  supplying  the  regi- 
ments, he  offered  to  take  a  portion  and  supply  chests 
to  the  regiments  at  New  York,  for  one  year,  as  an 
experiment.  He  says,  "I  did  not  conceive  that 
there  would  be  more  than  forty  or  fifty  regiments 
assembled  at  New  York ;  nor  did  I  suppose  that  half 
of  them  would  come  destitute  of  medicines  and 
chirttrgical  apparatus,  when  I  heard  that  the  South- 
ward (Southern)  regiments  were  supplied  by  the 
Continental  Druggists.  I  supplied  from  forty  to 
fifty  regiments  with  medicine  chests  by  the  end  of 
Atigust ;  besides  all  the  branches  of  the  General 
Hospital  at  New  York,  in  the  Bowery  and  neighbor- 
hood and  on  Long  Island :  which  reduced  many  of 
our  capital  articles  to  an  insufficiency  for  the  gen- 
eral hospital  for  the  remaining  part  of  the  cam- 
paign." 

For  the  purpose  of  supplying  the  hospitals  and 
regiments,  Congress  authorized  a  continental  drttg- 
gist  at  Philadelphia,  on  August  20,  and  elected  to 
that  position  Dr.  William  Smith  (6).  This  conti- 
nental druggist  acted  as  a  medical  supply  officer. 

The  ^Medical  Department  of  the  Continental  Army 
at  this  time  was  modeled  after  that  of  the  British 
Army.  It  consisted  of  the  general  hospital,  under 
the  personal  direction  of  the  medical  director,  and 
regimental  hospitals,  maintained  by  the  regimental 
surgeons.    The  general  hospital,  at  first  a  single  in- 


412  DUXCAX:  MEDICAL  MEX  IX   THE  AMERICAX  REVOLUTIOX.  [New  York  , 

Medical  Toirxal. 


stitution,  had  necessarily  been  divided  and  branches 
of  it  instituted,  at  Fort  George,  Boston  and  other 
places.  It  was  served  by  hospital  surgeons,  mates, 
and  hired  cooks,  nurses,  etc.  These  latter  were 
paid  from  fifty  cents  to  one  dollar — not  per  day 
but  per  month.  The  general  hospital  was  located  in 
large  public  buildings  when  possible ;  otherwise  in 
churches,  warehouses,  private  homes  and  barns.  The 
value  of  the  ration  due  the  sick  was  drawn  in 
money.  A  principal  article  of  the  hospital  stores 
then  purchased  was  rum.  Some  sort  of  beds  and 
bedding  were  furnished,  but  it  was  customary  to 
put  two  men  (or  more)  in  one  bed.  It  is  not 
strange  that  hospital  fever  (typhus)  prevailed. 

The  entity  termed  a  regimental  hospital  was  no 
hospital  in  any  definite  sense  of  the  word.  It  was 
merely  a  collection  of  the  sick  of  a  regiment,  in 
some  house,  barn  or  other  building.  There  were  no 
beds  or  other  facilities.  Each  man  brought  his 
own  blanket,  which  was  spread  on  straw.  Each 
drew  the  ordinary  rations ;  hard  bread,  salt  beef  or 
pork,  and  a  tot  of  rum.  The  British  regimental 
hospitals  were  little  better.  Dr.  Robert  Jackson, 
acting  surgeon's  mate  of  the  71st  Regiment  (Eraser's 
Highlanders)  says  that  his  regimental  hospital  at 
King's  Bridge  was  a  turf  hut.  Jackson  was  after- 
ward captured  at  the  Cowpens  on  account  of  hav- 
ing generously  given  his  horse  to  Tarleton.  Hav- 
ing no  dressings  for  the  wounded  he  took  ofT  his 
own  shirt  and  tore  it  in  strips  for  that  purpose. 
Whatever  may  have  been  the  effect  of  this  action  on 
the  wounded,  it  so  impressed  General  IMorgan  that 
Jackson  was  soon  sent  back  to  the  British  Army, 
without  exchange.  He  was  captured  a  second  time 
at  Yorktown.  He  was  one  of  the  first  surgeons 
of  the  British  Army  to  secure  commutation  of  ra- 
tions for  the  sick  in  regimental  hospitals. 

This  system  of  regimental  and  general  hospitals 
obtained  in  both  armies  for  a  hundred  years.  The 
functionary  known  as  a  surgeon's  mate  was,  in  both 
armies,  a  warrant  officer,  not  commissioned.  Later, 
in  the  Continental  Army  the  mates  received  a  status 
somewhat  approximating  commissioned  rank.  Dr. 
Jackson,  while  performing  the  duties  of  a  regi- 
mental surgeon's  mate,  was  carried  on  the  muster 
and  payrolls  as  an  ensign,  which  gave  him  more 
nearly  the  rank  of  an  officer. 

The  controversy  between  the  Director  and  the 
regimental  surgeons  never  ceased.  They  not  only 
refused  to  report  to  him  but  even  had  the  audacity 
to  seize  for  regimental  hospitals  the  very  hotises 
assigned  to  him  for  a  general  hospital  by  the  State 
of  New  York.  A  sample  of  ^Morgan's  troubles 
throws  light  on  the  various  socalled  army  hospitals 
of  that  time.  General  Fellows'  IVIassachusetts 
Brigade  was  stationed  along  the  Xorth  River  from 
Greenwich  to  Chelsea,  to  defend  that  line.  ^lorgan 
rode  out  with  Quartermaster  General  Moylan  to 
view  the  sick  and  the  houses  where  they  were  qtiar- 
tered.  They  found  one  house  so  crowded  with  sick 
that  he  remonstrated  with  the  responsible  regimental 
surgeon.    He  says : 

On  looking  into  the  rooms,  they  were  found  to  be  filled 
with  sick,  and  the  surgeons  who  had  their  care,  panting 
for  breath,  in  the  midst  of  them.  It  was  amidst  the  sul- 
try heat  of  summer.  In  vain  I  represented  to  him  the 
danger  of  engendering  a  putrid,  malignant  fever,  from 


crowding  so  many  sick  in  confined  rooms,  in  that  hot 
season.  He  had  near  a  hundred  sick  in  the  house.  I 
forbade  him  then,  as  I  had  uniformly  prohibited  everj- 
regimental  surgeon,  from  taking  charge  of  more  than 
thirty  or  forty  sick.  I  recommended  to  him  to  send  at 
least  one  half  of  his  sick  to  the  general  hospital,  and 
remove  the  greater  part  of  his  men  into  the  barn.  He 
disregarded  my  advice,  a  putrid  fever  prevailed,  he  caught 
the  infection  and  paid  the  forfeit  of  his  rashness  with  his 
Hfe. 

The  general  orders  at  this  time  allowed  regimental 
hospitals,  under  certain  restrictions  which  were 
seldom  observed.  In  this  case  Morgan  applied  to 
General  Heath,  but  got  no  satisfaction.  He  remon- 
strated with  the  colonels  commanding,  but  they  re- 
fused to  compel  the  regimental  surgeons  either  to 
report  to  the  Director,  or  send  their  sick  to  the 
general  hospital.  The  colonel  of  this  particular 
regiment  said  that  if  in  his  power  to  prevent  it, 
none  of  his  men  should  ever  be  carrried  to  a  general 
hospital.  When  the  Director  ordered  bed  frames 
made,  as  fast  as  forty  or  fifty  were  made  the  regi- 
mental surgeons  carried  them  off,  some  two  thou- 
sand in  all.  Such  were  the  difficulties  of  the  hos- 
pital surgeons  that  both  Dr.  John  Warren  and  Dr. 
Isaac  Foster  asked  to  resign  and  were  only  pre- 
vented from  doing  so  by  Morgan.  The  particularly 
aggravating  thing  in  the  whole  affair  was  that  the 
regimental  surgeons  were  continually  writing  fo 
members  of  Congress :  an  old  complaint,  not  yet  en- 
tirely cured. 

Lord  Howe  arrived  in  the  Bay  on  June  29th 
with  a  fleet  and  eight  thousand  soldiers.  The  pros- 
pects of  the  colonists  were  dismal.  The  Northern 
Army,  defeated  and  discouraged,  was  making  its 
way  back  to  Crown  Point  by  slow  and  painful  de- 
grees, sickness  and  starvation  vying  with  each  other 
in  the  work  of  destruction.  In  every  tent  there 
was  a  sick  or  dying  man.  From  thirty  to  forty 
were  buried  each  day. 

Adjutant  General  Reed  wrote,  "Had  I  known 
the  true  picture  of  affairs,  no  consideration  would 
have  tempted  me  to  have  taken  an  active  part  in  this 
scene :  and  this  sentiment  is  universal." 

Early  in  June  General  Clinton  arrived  from  the 
South  with  some  eight  thousand  more  men ;  and  on 
the  12th  of  August  still  another  fleet  arrived,  with 
the  first  of  the  Hessians,  seven  thousand  eight  hun- 
dred ;  men  from  Bunswick  and  Hesse  Cassell.  for 
whom  King  George  had  bargained  to  pay  thirty-four 
dollars  and  fifty  cents  for  every  one  killed,  and  to 
cotmt  three  wounded  as  one  dead.  General  De 
Heister  commanded  this  contingent.  The  calcu- 
lation as  to  wounded  may  well  have  been  based  on 
the  experience  of  the  time. 

The  combined  fleet  now  consisted  of  thirty-seven 
men  of  war  and  four  hundred  transports ;  with  an 
army  of  twenty-seven  thousand  men.  This  was 
the  largest  British  force  ever  concentrated  in 
America.  The  troops  were  landed  on  Staten  Is- 
land. All  were  well  organized,  splendidly  equipped, 
and  in  every  way  fit  and  sufficient  to  have  effected 
their  purpose,  had  they  been  ably  led. 

Washington  had  on  August  8th  about  seventeen 
thousand  men.  of  whom  part  were  militia,  and  three 
thousand  seven  hundred  were  unfit  for  duty,  sick. 
The  urgency  of  the  situation  brought  in  more  militia, 
more  new  men.    Of  the  whole  army  not  six  thou- 


September  18,  1920.]       DUNCAN:  MEDICAL  MEN  IN   THE  AMERICAN  REVOLUTION. 


413 


sand  had  been  in  the  army  a  year.  The  constant 
coming  and  going  made  discipHne  impossible.  Not  a 
single  regiment  was  properly  equipped.  There  were 
not  enough  muskets  to  go  around,  and  many  of 
them  were  useless.  The  cannon  were  small  and 
poor,  and  without  skilled  gunners.  Knox,  the  ar- 
tillery commander,  was  but  recently  from  his  Bos- 
ton bookshop.  General  Sullivan  had  been  a  lawyer. 
Lord  Stirling's  experience  had  been  limited.  Put- 
nam's only  tactics  were  to  fight.  Greene  was  the 
most  cautious  and  skillful  of  the  subordinate  com- 
manders, but  unfortunately  he  fell  sick  of  a  raging 
fever  a  few  days  before  the  battle  (7).  The  com- 
mand fell  to  Putnam,  who  had  little  or  no  knowl- 
edge of  the  ground,  and,  it  must  be  confessed,  was 
no  general. 

On  August  22nd  the  British  troops  on  Staten  Island 
began  to  cross  to  Long  Island  in  boats,  and  by  noon 
fifteen  thousand  men  had  landed  near  where  Fort 
Hamilton  now  stands,  with  forty  pieces  of  artillery. 
The  force  moved  to  Flatbush  and  Flatland.  Wash- 
ington hurried  over  reinforcements  and  did  his  best 
to  inspire  them  with  courage,  but  it  was  clear  that 
the  morale  of  the  troops  was  low.  A  shadow  seemed 
brooding  over  this  new  army,  now  about  to  undergo 
its  first  great  pitched  battle :  for  it  was  outnumbered 
nearly  three  to  one,  by  a  better  army;  destined  to 
be  completely  outgeneraled;  and  to  be  sacrificed 
to  no  good  purpose. 

The  battle,  now  more  certainly  anticipated,  in- 
duced Dr.  Morgan  to  provide  more  complete  hospital 
facilities.  He  went  before  the  New  York  Conven- 
tion to  appeal  for  buildings  to  be  used  as  hospitals 
for  the  wounded  (8).  A  certain  number  of  houses 
were  ordered  turned  over  to  him.  and  now,  with  his 
surgeons  instructed,  supplies  prepared,  and  hospitals 
waiting,  he  may  have  felt  in  some  measure  prepared 
for  the  coming  battle. 

General  Greene  had  intrenched  a  strong  camp, 
protected  by  Wallabout  Bay  on  the  left  and  by 
Gowanus  Bay  and  a  creek  running  into  it,  on  the 
right.  This  line  was  less  than  a  mile  and  a  half 
long  and  was  strongly  fortified — so  much  so  that 
the  British  hesitated  to  attack  it  after  the  battle. 
It  was.  however,  resolved  first  to  defend  the  line 
of  wooded  hills,  some  two  miles  in  front  of  the 
camp,  extending  from  the  narrows  eastward  toward 
Tamaica.  There  were  four  passes  through  these 
iiills.  Greene  planned  that  all  should  be  guarded, 
and  Washington  ordered  it ;  but  on  the  day  of  bat- 
tle Bedford  Pass  was  left  almost  unguarded,  and 
Jamaica  Pass,  farthest  east,  was  without  defense. 
It  has  been  well  said  that  through  the  latter  Pass 
"marched  the  Nemesis  which  dogs  the  feet  of 
carelessness." 

Lord  Stirling  with  five  small  regiments  held  the 
right  of  the  line,  next  the  water.  Sullivan  with 
five  regiments  held  the  centre,  now  Prospect  Park, 
Brooklyn  (9).  A  few  regiments  remained  in  the 
fortified  lines.  At  most  five  thousand  were  along 
the  line  of  hills,  facing  at  least  four  times  as  many 
British  and  Hessians  (10). 

In  front  of  these  passes,  two  defended,  were 
twenty  thousand  of  the  best  soldiers  that  England 
could  produce,  which  were  as  good  as  any  in  the 
world.    In   front  of  Lord  Stirling  was  General 


Grant  with  two  brigades,  one  Highland  regiment 
and  two  companies  of  New  York  Royalists.  Stir- 
ling met  them  in  what  is  now  Greenwood  Ceme- 
tery, and  imagined  that  he  held  them  in  check ;  but 
they  were  only  biding  their  time.  In  the  Flatbush 
Pass  Sullivan  was  likewise  confronted  with  the 
eight  thousand  Hessians  under  De  Heister.  De 
Heister  fired  some  shots,  but,  like  Grant,  did  not 
engage  heavily — the  time  had  not  come. 

During  the  night  Clinton  and  Cornwallis  with 
seventeen  regiments  and  eighteen  guns  had  made  a 
flanking  march  to  the  east,  crossed  the  unguarded 
Jamaica  Pass,  and  then  turned  westward.  By  half- 
past  eight  the  vanguard  was  at  Bedford  Four  Cor- 
ners. Here  the  spell  of  silence  was  broken ;  the 
bands  struck  up,  the  troops  burst  into  cheers ;  and, 
pushing  on,  by  nine  o'clock  the  advance  columns 
rested  on  the  junction  of  the  old  Flatbush  and  Ja- 
maica Roads,  now  the  junction  of  Flatbush  and 
Atlantic  Avenues ;  only  a  few  rods  in  front  of  the 
inner  line  of  the  American  fortifications.  Then  it 
was  that  the  two  heavy  guns  sounded  the  precon- 
certed signal  for  De  Heister  to  press  the  attack. 

De  Heister  heard  it  and  ordered  Donop  to  carry 
the  Flatbush  Pass.  The  Hessians  swept  through  the 
woods,  followed  by  the  Grenadiers,  driving  before 
them  the  feeble  forces  of  Henshaw's  and  John- 
ston's Massachusetts  and  New  Jersey  men,  with 
Hand's  Pennsylvania  Riflemen.  Sullivan  heard  the 
signal  guns,  divined  their  meaning,  and  started  for 
the  fortified  lines.  A  detachment  of  the  British 
had  marched  through  the  Clove  Road  and  reached 
the  rear  of  Miles's  Pennsylvanians ;  they  were  soon 
in  full  retreat.  These  various  regiments,  driven 
backward  to  the  northern  slopes  of  Prospect  Hill, 
were  suddenly  confronted  by  the  bayonets  of  Clin- 
ton and  Cornwallis.  They  were  thrown  backward 
and  forward  between  fire  and  bayonet.  The  greater 
part  found  themselves  shut  between  closing  jaws  of 
fire.  The  retreat  l^ecame  a  rout,  and  a  massacre.  The 
Hessians  gave  no  quarter.  Men  who  had  thrown 
away  their  arms  were  shot  down  or  bayoneted-  For 
two  hours  the  area  now  enclosed  by  Atlantic,  Flat- 
bush and  Clinton  Avenues  saw  this  unequal  strug- 
gle. More  than  five  hundred  perished,  a  few  were 
made  prisoners  (Sullivan  among  them)  ;  a  few 
escaped. 

It  was  nearly  eleven  o'clock  when  Grant  heard 
the  second  signal,  which  was  his  order  to  attack.  He 
had  just  been  reinforced  by  two  fresh  regiments 
from  the  fleet.  Pushing  rapidly  forward.  Colonel 
Atlee  and  his  235  skirmishers  were  soon  killed  or 
made  prisoners.  Huntington's  Connecticut  men 
fared  little  better.  And  now,  with  the  frontal  at- 
tack, the  Hessians  came  streaming  in  on  Stirling's 
left  and  Cornwallis  came  hurrying  down  from  the 
rear  to  seize  the  old  Cortelyou  house  on  his  only 
road  of  escape.  The  situation  was  now  frightful, 
but  Stirling  kept  his  head.  He  saw  that  if  he  could 
not  hold  back  Cornwallis  his  whole  command  must 
suffer  death  or  capture.  He  resolved  on  a  costly 
sacrifice.  Taking  three  hundred  of  Colonel  Small- 
wood's  Maryland  Line,  he  ordered  all  the  remainder 
of  his  troops  to  retreat  across  the  marsh  and  creeks 
of  Gowanus  Bay  to  the  intrenched  lines.  The  ris- 
ing tide  made  this  more  difificult  each  minute. 


414 


Di'XCAX:  MEDICAL  MEX  IX  THE  AMERICAX  REVOLUTIOX. 


I  New  York 
Medical  Jovrnal. 


Taking  his  place  at  the  head  of  the  three  hun- 
dred, all  of  them  boys,  he  led  them  straight  at  the 
British,  posted  in  the  Cortelyou  house  with  two 
gims;  while  the  Hessians  held  the  adjoining  hills. 
The  terrible  fire  drove  them  back.  But  his  men 
were  not  yet  safe.  Again  he  rallied  them  and  led 
them  on  this  forlorn  hope ;  this  time  to  the  house, 
where  for  a  moment  they  held  the  guns.  Again 
and  again  this  little  band  was  led  forward.  After 
the  fifth  rally  there  were  too  few  for  another 
charge,  'but  it  was  not  needed.  The  sacrifice  had 
accomplished  its  end.  Stirling's  force  had  escaped. 
Two  hundred  and  fifty-six  of  Small  wood's  regiment 
were  killed,  wounded  or  missing.  A  feeble  rem- 
nant of  tlie  regiment  struggled  across  the  creek 
bearing  their  tattered  colors  with  them.  Stirling, 
an  Englishman,  rode  away  across  the  hills  and  sur- 
rendered to  De  Heister.  Taken  on  board  the  fleet, 
he  found  Sullivan  already  there. 

The  battle  was  ended  before  noon.  Five  thousand 
men  had  been  surrounded  by  four  times  their  num- 
ber. A  thousand  were  captured.  Several  hundred 
were  killed.  General  Howe  estimated  the  American 
loss  at  three  thousand  five  hundred.  It  was  not 
that  much,  but  the  army  was  broken  up.  His  own 
loss  he  reported  as  367  killed,  wounded  and  miss- 
ing. This  was  the  most  discreditable  defeat  the 
Continental  Army  ever  experienced,  though  the  men 
never  fought  more  bravely.  Yet  it  might  have  been 
worse.  Had  General  Howe  but  given  the  word, 
his  generals,  who  were  eager,  would  have  rushed  on 
the  intrenched  lines,  almost  certainly  have  carried 
them,  and  captured  the  whole  American  force  on 
Long  Island.  The  loss,  some  eight  thousand  men 
in  all,  would  have  ruined  the  army. 

At  the  close  of  the  day  the  intrenched  camp  was 
filled  with  the  weary,  beaten,  and  dispirited  soldiers. 
Some  were  wounded,  many  without  arms :  all  dis- 
couraged. Hundreds  of  the  patriotic  farmers  of  the 
neighborhood  had  fled  to  this  place  of  refuge,  driv- 
ing their  flocks  and  herds  with  them  to  prevent  their 
capture.  Drenching  rains  filled  the  trenches  with 
water  and  added  to  the  general  discomfort.  A  thou- 
sand cattle  roamed  about  the  camp.  But  the  vague 
terrors  of  the  night  at  length  gave  place  to  the  more 
definite  apprehensions  of  another  day.  A  thick  mist 
clung  to  the  landscape,  concealing  the  enemy. 

During  the  afternoon  two  brigades  had  been 
brought  over.  At  four  in  the  morning  Washington 
came  to  cheer  and  reinforce  his  shattered  forces. 
He  brought  Shea's  and  Hands's  Pennsylvania  Regi- 
ments, and  a  little  later  came  Glover's  Regiment  of 
!Marblehead  fishermen.  There  were  now  nine  thou- 
sand men  in  the  intrenchments.  and  \\'ashington  at 
first  re.solved  to  hold  them.  But  when  the  mists 
cleared  awa}'.  revealing  twenty  thousand  men  in  his 
front,  he  resolved  to  retreat.  On  the  night  of  the 
29th  the  whole  force  was  withdra\ra  to  ^Manhat- 
tan  Island.  The  Pennsylvania  regiments  of  Hand 
and  Shea  were  crossed  first :  the  Delaware  and  !Mary- 
land  regiments  formed  the  rear  guard.  Glover's 
regiment  handled  the  boats,  and  a  hea^y  fog  aided 
the  undertaking. 

The  regimental  surgeons  had  little  opportunity 
to  follow  Morgan's  teaching  in  this  battle.  Several 
were  captured.    They  may  have  collected  the  early 


wounded  behind  the  hills  ;  but  suddenly  this  line 
also  was  attacked,  there  was  no  longer  anv  rear. 
The  army  broke  up  and  fled.  Those  wounded  able 
to  walk  had  some  chance  to  escape :  the.  severely 
wounded  were  captured  and  the  majority  killed. 
Brigadier  General  WoodhuU  of  the  militia  was  killed 
while  a  prisoner,  by  De  Lancey  or  some  of  his 
Royal  Americans.  Some  of  the  wounded,  however, 
escaped.  All  were  removed  to  Xew  York,  by  order 
of  General  Washington,  (11)  on  August  29th.  be- 
fore the  evacuation. 

XOTES. 

1. — John  Warren,  jounger  brother  of  Joseph 
Warren,  was  born  in  Roxbury  in  1753.  He  gradu- 
ated at  Harvard  in  1770,  studied  medicine  with  his 
brotlier.  and  began  the  practice  of  medicine  in  Salem 
in  1772.  being  but  nineteen  years  of  age.  He  at- 
tended the  wounded  at  Bunker  Hill,  and  wliile  try- 
ing to  reach  his  brotlier  received  a  ])ay()net  wound. 
After  the  battle  he  was  appointed  a  hospital  sur- 
geon, and  served  in  the  hospitals  about  Boston.  He 
accompanied  the  army  to  New  York,  and  was,  as 
we  have  seen,  in  charge  of  the  hospital  on  Long 
Island.  Later,  he  was  at  Newark  and  Philadelphia. 
At  Trenton  the  army  marched  in  the  night  for 
Princeton,  leaving  the  surgeons  behind.  Tliey  gal- 
loped olT.  barely  escaping  capture.  In  1777  War- 
ren was  made  superintendent  of  hospitals  at  Bos- 
ton, and  served  there  until  the  end  of  the  war.  For 
forty  years  Dr.  ^^'arren  occupied  a  foremost  place 
among  the  surgeons  of  Xew  England.  In  1785  he 
was  made  professor  of  anatomy  and  surgery  in  the 
newly  established  medical  school  of  Harvard.  He 
was  first  president  of  the  Massachusetts  Medical 
Society,  and  held  that  position  continuously  from 
1804  until  his  death  in  1815.  His  son.  John  Col- 
lins Warren.  1778-1856.  was  a  distinguished  medical 
practitioner,  teacher  and  writer. 

IXSTRUCTIOXS  TO  TOHX  WARREX.  ESQ..  SURGEOX  OF 
THE  GEXERAL  HOSPITAL.  WASHIXGTOX.  D.  C. 

Xew  York.  Jmie  is.  1776. 

Sir : 

You  are  desired  to  go  over  to  Long  Island  and 
to  consult  with  General  Greene,  about  the  proper 
houses  for  the  forming  of  a  hospital  (to  be  part  of 
the  general  hospital)  for  the  reception  of  the  sick 
in  his  brigade.  For  your  assistants  you  will  be 
pleased  to  take  over  three  of  the  hospital  mates,  of 
which  Mr.  Glover  is  to  be  one,  the  other  two  as 
}'ou  agree  with  the  other  surgeons. 

^lake  out  a  proper  assortment  of  medicines,  such 
a  list  as  you  think  needful,  after  constilting  with  Dr. 
Foster,  Dr.  Adams  and  Dr.  ^McKnight,  and  order 
it  to  be  put  up  from  the  hospital  stores.  If  you 
have  occasion  for  further  assistants,  make  requisi- 
tion from  General  Greene's  brigade,  of  as  many 
surgeons  and  mates  as  you  shall  stand  in  need  of. 

Keep  a  register  of  the  sick,  in  which  you  are  to 
make  an  entry  of  the  times  of  their  admission  and 
discharge,  as  well  as  of  the  diseases  they  labor  under  ; 
and  require  of  the  respective  surgeons  of  the  difler- 
ent  regiments,  weekly  returns  of  the  sick  in  the 
hospital  belonging  to  their  regiments;  in  order  to 
compare  with  yours:  From  which  a  roll  is  to  be 
made  out  once  a  month,  for  receiving  the  ration 
money  from  the  commissary  general. 


September  18,  1920.]       DUXCAX:  MEDICAL  MEX  IX  THE  AMERICAX  REVOLUTIOX. 


415 


What  nurses  you  require  for  the  sick,  you  will 
eng-age  at  the  price  of  half  a  dollar  per  week :  the 
number  not  to  exceed  one  for  every  ten  persons 
sick  or  wounded ;  the  necessary  laborers  to  be  em- 
ployed by  the  day,  as  usual,  in  which  avoid  engaging 
a  greater  number  than  is  absolutely  necessary. 

Deliver  out  no  stores  of  any  kind  to  the  regimental 
surgeons.  When  the  sick  require  further  aids  than 
they  can  give,  let  them  be  reported  to  you,  and  if 
their  cases  require  it.  receive  them  into  the  general 
hospital.  Take  with  you  at  least  1,500  bandages, 
and  a  quantity  of  tow,  with  a  set  of  capital  instru- 
ments, and  all  suitable  dressings  in  case  of  action. 

Use  your  best  endeavors  to  make  the  surgeons 
and  mates  of  the  regiments  attentive  to  their  duty. 

For  any  debts  contracted  for  the  «se  of  the 
general  hospital,  agreeable  to  the  above  rules,  draw 
on  me.  You  will  employ  the  same  person  to  supply 
fresh  meat  and  at  the  same  prices,  as  in  the  hospital 
at  New  York. 

Weekly  returns  of  the  sick  to  be  sent  over  early 
every  Monday  morning  as  usual. 

Be  pleased  to  call  on  ^Ir.  Delameter  for  one  hun- 
dred additional  blankets  ....  and  as  many 
beds :  applying  to  the  quartermaster  for  straw,  from 
time  to  time,  and  order  the  nurses,  washerwomen, 
etc..  to  clean  them  from  time  to  time. 

An  orderly  mate  is  to  take  charge  of  the  blankets 
and  bedding,  etc.,  and  of  the  hospital  furniture  every 
week :  to  enter  into  a  book  for  the  purpose,  w'hat 
stores  of  this  kind  are  given  out,  to  examine  what 
each  sick  (person)  brings  with  them,  and  to  see 
that  nothing  is  carried  out  on  their  dismission  not 
belonging  to  them. 

An  orderh"  sergeant,  or  corporal,  or  careful  soldier 
(if  the  general  will  allow)  ought  to  be  stationed  at 
the  hospital,  to  take  charge  of  the  arms,  etc.,  of  the 
sick,  whilst  in  hospital,  and  to  give  them  up  on  his 
death  or  dismission. 

A  carpenter  ought  to  attend  constantly  to  make 
coffins,  or  to  perform  other  work,  for  which  you 
will  apply  to  the  quartermaster  general. 

No  blankets,  or  other  effects  of  the  hospital,  to 
be  expended  at  the  funeral  of  those  soldiers  who  die 
in  the  hospital. 

I  remain,  sir,  your  most  humble  servant, 

JOHX  MORGAX. 

3. — Regul.\tioxs  proposed  by  the  Director-Gen- 
eral of  the  Hospital;  and  agreed  upon  with  the 
Regimental  Surgeons,  to  be  laid  before  congress 

FOR  THEIR  DETERMIXATIOX  UpOn  them. 

First. — That  regimental  surgeons  apply  to  the 
quartermaster  general  and  obtain  from  him.  or  the 
barrack  master,  by  an  order  from  him,  some  proper 
quarters  convenient  for  the  situation  of  each  regi- 
mental or  brigade  hospital. 

Second. — That  said  hospitals  be  furnished  from 
the  quartermaster  general's  department  with  neces- 
sary utensils  and  hospital  furniture,  according  to  a 
list  of  enumerated  particulars. 

Third. — That  regimental  surgeon  be  supplied  in 
future  by  continental  druggists,  with  medicines,  in- 
struments and  old  linen  for  bandages,  and  neces- 
sary dressings. 

Fourth. — That  they  shall  report  to  director  general 
or  surgeons  of  the  general  hospital,  all  such  sick  pa- 


tients of  their  regiments,  who  are  proper  objects ; 
making  use  of  every  possible  precaution,  to  guard 
against  crowding  in  the  hospital  with  putrid  cases, 
that  require  fresh  air  for  recovery  of  the  sick ;  lest 
hospital,  malignant,  or  pestilential  diseases  be  ex- 
cited, to  the  great  devastation  and  ruin  of  the  army. 

Fifth. — That  they  make  proper  reports  from  said 
register,  to  accompany  every  person  they  recom- 
mend to  the  general  hospital,  with  an  account  of  the 
patient's  care,  and  previous  treatment,  and  what 
clothing  is  sent  with  each  patient,  certified  by  the 
surgeon  or  mate,  and  signed  also  by  a  commissioned 
officer. 

Si.i'th. — That  they  make  daily  returns  to  quarter- 
master or  adjutant  of  the  regiment;  of  the  sick 
belonging  to  that  regiment,  who  are  unfit  for  duty, 
whether  remaining  under  their  own  care,  or  sent 
to  the  general  hospital,  that  no  soldiers  may  be  ex- 
empt from  duty,  as  sick  men,  that  are  not  borne  on 
the  doctor's  list ;  and  that  no  rations  be  drawn  for 
them,  amongst  the  effective  men,  whilst  they  are 
drawn  for  with  the  sick,  whether  in  the  general  or 
regimental  hospitals. 

Sczriifh. — That  they  make  weekly  returns  of  the 
sick  from  their  registers,  both  in  the  general  hospital, 
and  regimental  or  brigade  hospitals,  as  well  to  the 
director  general  as  to  the  commandant  or  brigade, 
that  a  true  state  of  the  sick  of  the  whole  army  may 
be  made  out,  to  lay  before  the  Commander  in  Chief, 
and  to  be  transmitted  to  Congress,  weekly. 

Eighth. — That  agreeable  to  the  sick  list  returned 
to  the  director  general,  the  regimental  surgeons  be 
entitled  to  draw  from  the  general  hospital,  for  the 
sick  remaining  under  their  care,  any  articles  they 
may  choose,  agreeable  to  the  various  diet  tables  made 
use  of  for  the  patients  of  the  general  hospital :  and 
whatever  other  refreshments  they  choose,  with  which 
the  general  hospital  is  supplied,  to  the  full  amount 
of  their  rations.  If  they  require  more  from  the  gen- 
eral hospital,  the  sick  are  to  be  sent  to  the  general 
hospital. 

A'inth. — That  Colonels  of  regiments  be  allowed  to 
draw  monies  for  defraying  any  extraordinary  or 
incidental  charges  of  regimental  hospitals,  and  for 
such  articles  as  are  not  to  be  got  in  the  stores  of 
the  general  hospital,  nor  in  the  commissariat  or 
quartermaster's  department,  and  on  account  of  the 
disbursement  to  be  settled,  with  the  weekly  or 
monthly  abstract  of  the  regiment. 

Tenth. — That  the  state  of  the  several  regimental 
or  brigade  hospitals,  of  the  sick,  and  of  the  medi- 
cine chests,  be  subjected  from  time  to  time  to  the 
director  general,  or  such  hospital  surgeons  as  he 
shall  appoint  to  that  duty. 

Eleventh. — That  in  all  things,  not  particularly  as- 
certained in  these  regulations,  the  usage  of  the 
British  and  other  armies  be  followed,  till  otherwise 
directed  as  far  as  is  consistent  with  the  good  of  the 
service. 

One  is  astonished  at  the  completeness  of  these 
regulations,  the  number  of  details  covered.  It  is 
evident  that  they  were  not  evolved  at  once,  but  were 
taken  from  the  regulations  and  customs  of  the  Brit- 
ish Army.  Paper  work  must  have  existed  long 
before  that  time,  ^^'hen  the  term  brigade  is  used 
here  probably  it  does  not  refer  to  a  brigade  of  several 


416 


LONDON  LETTER. 


[New  York 
Medical  Journal. 


regiments,  but  to  a  small  force  of  a  few  hundred 
men,  termed  a  brigade  rather  than  a  regiment. 

4.  ADDRESS  TO  THE  SURGEONS. 

I  have,  with  all  care  and  attention  in  my  power, 
taken  into  consideration  the  state  of  the  regimental 
surgeons,  with  a  view  to  getting  them  provided  with 
regimental  hospitals,  and  pointing  out  the  means  for 
their  being  in  future,  supplied  with  the  usual  requis- 
ites, for  the  more  easy,  more  regular,  and  more 
extensive  discharge  of  their  duties  annexed  to  their 
stations.  To  answer  this  end,  I  have  considered 
that  it  is  within  our  power,  as  matters  now  stand, 
and  what  we  are  to  aim  at,  for  further  improvement ; 
and  have,  by  a  train  of  reflexions  on  the  subject, 
been  led,  in  the  first  place,  to  propose  certain  regu- 
lations, which  appear  to  me  to  be  both  salutary  and 
practicable,  if  they  meet  with  your  concurrence,  for 
which  I  shall  submit  them  to  your  hearing  and 
strictures,  for  correction  and  amendment.  If  we 
can  agree  in  them,  it  will  be  one  step  gained,  and 
may  serve  as  a  foundation,  on  which  to  proceed, 
in  smoothing  every  difficulty  that  may  still  remain, 
toward  forming  a  more  perfect  plan,  or  model  of 
economy,  in  the  conducting  of  the  military  hos- 
pital, and  providing  for  the  sick  and  wounded. 

The  next  step  I  apprehend  we  have  to  take,  is  to 
apply  to  Congress  for  an  immediate  supply  of  chir- 
urgical  instruments  and  bandages,  for  the  regimental 
surgeons,  and  for  its  approbation  of  the  proposed 
regulations,  as  well  that  that  of  the  Commander  in 
Chief  ;  that  those  regulations  may  have  a  proper  au- 
thority to  rest  upon,  for  their  sanction  and  sup- 
port ;  and  3dly  to  suggest  such  others,  as  may  be  still 
more  useful,  in  future,  though  the  continuance  of 
the  war  may  make  further  regulations  necessary. 

5.  — "On  July  17,  1776,  Congress  took  into  con- 
sideration the  report  of  the  Committee  on  the  me- 
morial of  the  director  general  of  the  American 
hospital,  whereupon.  Resolved 

First. — That  the  number  of  hospital  surgeons  and 
mates  be  increased,  in  proportion  to  the  augmen- 
tation of  the  army,  not  exceeding  one  surgeon  and 
five  mates  to  every  five  thousand  men,  to  be  reduced 
when  the  army  is  reduced,  or  when  there  is  no  fur- 
ther occasion  for  such  a  number. 

Second. — That  as  many  persons  be  employed  in 
the  several  hospitals,  in  the  quality  of  storekeepers, 
stewards,  managers,  and  nurses,  as  are  necessary 
for  the  service,  for  the  time  being,  to  be  appointed 
by  the  director  of  the  respective  hospitals. 

Third. — That  the  regimental  chests  of  medicine 
and  chirurgical  instruments,  which  are  now,  or 
hereafter  shall  be  in  the  possession  of  the  regimental 
surgeons,  be  subject  to  the  inspection  and  inquiry  of 
the  respective  directors  of  hospitals,  and  the  direc- 
tor general,  and  that  the  said  regimental  surgeons 
shall,  from  time  to  time,  when  thereto  required,  ren- 
der account  of  the  said  medicines  and  instruments 
to  the  said  director,  or,  if  there  be  no  director  in 
any  particular  department,  to  the  director  general ; 
the  said  accounts  to  be  transmitted  to  the  director 
general,  and  by  him  to  the  Congress ;  and  the  medi- 
cines and  instruments  not  needed  by  any  regimen- 
tal surgeon  to  be  returned,  when  the  regiment  is 
reduced,  to  the  respective  directors,  and  an  account 


thereof  rendered  to  the  director  general  and  by  him 
to  Congress. 

Fourth. — That  the  directors  of  hospitals  in  the 
several  departments,  and  the  regimental  surgeons, 
where  there  is  no  director,  shall  transmit  to  the 
director  general  regular  returns  of  the  number  of 
surgeons  and  mates  and  other  officers  employed  un- 
der them,  their  name  and  pay ;  also  on  account  of 
the  expenses  and  furniture  of  the  hospital  under 
their  direction ;  and  that  the  director  general  make 
a  report  of  the  same  from  time  to  time,  to  the 
Commander  in  Chief,  and  this  Congress. 

Fifth. — That  tlie  regimental  and  hospital  sur- 
geons in  the  several  departments  make  weekly  re- 
turns of  the  sick  to  the  respective  directors  in  their 
departments. 

Sixth. — That  no  regimental  surgeon  be  allowed  to 
draw  upon  the  hospital  of  his  department  for  any 
stores  except  medicines  and  instruments ;  and  that 
when  any  sick  person  shall  require  other  stores, 
they  shall  be  received  into  said  hospital  and  the  ra- 
tions of  the  said  sick  persons  be  stopped,  so  long 
as  they  are  in  said  hospital,  and  that  the  direc- 
tors of  the  several  hospitals  report  to  the  commis- 
sary the  names  of  the  sick,  when  received  into  and 
when  discharged  from  the  hospitals,  and  made  a  like 
return  to  the  board  of  treasury. 

Seventh. — That  all  extra  expense  for  bandages, 
old  linen,  and  other  articles  necessary  for  the  serv- 
ice, incurred  by  any  regimental  surgeon,  be  paid  by 
the  director  of  that  department,  with  the  approbation 
of  the  commander  thereof. 

Eighth. — That  no  more  medicines  belonging  to 
the  contingent  be  disposed  of  till  further  order  of 
Congress. 

Ninth. — That  the  pay  of  the  hospital  surgeons  be 
increased  to  one  dollar  and  two  thirds  of  a  dollar  by 
the  day ;  the  pay  of  the  hospital  mates  to  one  dollar 
by  the  day,  and  the  pay  of  hospital  apothecary  to 
one  and  two  thirds  of  a  dollar  by  the  day,  and 
that  the  hospital  surgeons  and  mates  take  rank  of 
regimental  surgeons  and  mates. 

Tenth. — That  the  director  general  and  the  several 
directors  of  hospitals  be  empowered  to  purchase, 
with  the  approbation  of  the  commanders  of  the  re- 
spective departments,  medicines  and  instruments  for 
the  use  of  their  respective  hospital,  and  draw  upon 
the  paymaster  for  the  same,  and  make  the  report 
of  such  purchases  to  Congress." 

Journal  of  Congress,  July  17,  1776. 
(To  he  continued) 


LONDON  LETTER. 
{From  Our  Own  Correspondent) 
Red  Cross  Societies  Meeting. — Conference  of  the  Imperial 
Bureau  of  Entomology. — Society  for  the  Prevention  of 
Venereal  Disease. — Sir  John  Bland  Sutton  Retires. 

London,  July  Jg,  igzo. 
The  first  meeting  of  the  Medical  Advisory 
Board  of  the  League  of  Red  Cross  Societies  took 
place  on  July  5th,  when  it  discussed  with  the  direc- 
tor general,  the  general  medical  director,  and  the 
chiefs  of  the  medical  department  of  the  league  the 
health  work  to  be  undertaken  by  the  league.  The 
board  is  composed  of  the  following  experts:  Bel- 


September  18.  1920.] 


LONDON  LETTER. 


417 


giuni,  Professor  Bordet,  director  of  the  Brussels 
Pasteur  Institute ;  Denmark,  Professor  ^Madsen,  di- 
rector of  the  Copenhagen  State  Serum  Institute ; 
France,  Professor  Ronx,  director,  and  Professor 
Albert  Calmette,  subdirector  of  the  Paris  Pasteur 
Institute,  and  Dr.  Leon  Bernard,  professor  of  hy- 
giene in  Paris  University ;  Great  Britain,  General 
Lyle  Cummins,  professor  of  pathology,  London, 
Sir  Walter  Fletcher,  secretary  of  the  medical  re- 
search committee,  London.  Sir  George  Newman, 
chief  medical  officer  of  the  Ministry  of  Health; 
Italy,  Professor  Bastianelli,  pathologist  to  the  Rome 
Polyclinic,  and  Dr.  Castellani,  professor  of  tropi- 
cal diseases  at  the  London  School  of  Tropical  Medi- 
cine ;  Japan,  Dr.  Kinnosuke  ^liura,  professor  at 
Tokyo  University ;  South  America,  Dr.  Chagas, 
director  of  the  Oswald  Cruz  Institute  of  Rio  de 
Janeiro ;  United  States,  Dr.  William  Welch,  direc- 
tor of  the  School  of  Hygiene  at  Johns  Hopkins 
University.  Dr.  Herman  Biggs,  Health  Commis- 
sioner of  New  York  State  and  Dr.  Simon  Flexner, 
director  of  the  Rockefeller  Institute. 

^        ^  ^ 

Representative  entomologists  from  all  parts  of  the 
British  Empire  assembled  on  Tuesday,  June  1st,  at 
a  conference  arranged  by  the  Imperial  Bureau  of 
En-tomology,  South  Kensington.  Dr.  Guy  A.  K. 
^Marshall,  director  of  the  Imperial  Bureau,  remarked 
that  the  department  was  inaugurated  in  1909  under 
the  name  of  the  Entomological  Research  Commit- 
tee, Tropical  Africa,  by  the  then  Secretarj-  of  State 
for  the  Colonies,  for  the  purpose  of  stimulating  the 
study  of  the  numerous  insect  pests  that  were  re- 
tarding the  development  of  tropical  Africa,  and 
especially  the  blood  sucking  and  disease  carrying 
insects.  In  1913  its  activities  were  extended  to  cover 
the  whole  of  the  Empire,  its  principal  functions  be- 
ing to  collect  and  disseminate  all  the  published  in- 
formation relating  to  injurious  insects,  to  identify 
insects  sent  by  entomological,  medical,  and  veterin- 
ary officers  from  all  parts  of  the  Empire,  to  distribute 
entomological  specimens  required  for  research  or 
teaching  purposes,  and  geneally  to  render  all  pos- 
sible assistance  to  economic  entomologists  in  the 

carrying  out  of  their  work  against  injurious  insects. 

*    *  * 

The  first  annual  meeting  of  the  Society  for  the 
Prevention  of  Venereal  Disease  was  held  at  the 
house  of  the  Royal  Society  of  Medicine,  1  \\'impole 
Street,  London,  W.,  on  the  evening  of  Thursday 
June  3d.  The  president  of  the  Society  Lord  Wil- 
loughby  de  Broke  was  in  the  chair.  In  the  course 
of  an  able  speech  in  which  the  objects  and  aims  of 
the  society  were  recapitulated  he  strongly  con- 
demned the  "policy  of  suppression"  adopted  by  the 
Government  in  all  matters  relating  to  venereal  dis- 
ease and  moved  a  resolution  asking  that  the  Min- 
istry of  Health  should  authorize  druggists  to  sup- 
ply means  of  self  disinfection  which  they  are  now 
prevented  from  doing  by  act  of  Parliament.  Dr. 
Saleeby,  who  seconded  the  resolution,  said  he  be- 
lieved that  venereal  diseases  were  on  the  increase 
despite  official  statements  and  explanations.  Sir 
James  Crichton  Browne  supported  the  resolution  in 
an  eloquent  speech.  Sir  William  Arbuthnot  Lane 
observed  that  the  society  should  be  called  the  sui- 


cide club,  because  it  was  mainly  composed  of  medi- 
cal men  who  by  preventing  the  spread  of  venereal 
diseases  were  taking  away  their  own  living.  Most 
of  the  diseases  from  which  the  world  suffered  could 
be  traced  to  venereal  disease.  The  resolution  was 
carried.  *    *  * 

Sir  John  Bland  Sutton,  the  well  known  London 
surgeon  has  retired  from  the  active  staff  of  the 
^Middlesex  Hospital  with  which  he  has  been  con- 
nected for  forty-two  years.  He  has  been  a  gen- 
erous giver  to  the  hospital.  He  founded  and  en- 
dowed the  Bland-Sutton  Institute  of  Pathology.  Sir 
John  was  recently  made  the  president  of  the  newly 
formed  association  of  British  surgeons.  The  Board 
of  Governors  of  the  American  Hospital  in  Lon- 
don gave  a  dinner  on  July  6th,  at  which  the  guest 
of  the  evening  was  Dr.  Charles  H.  Mayo,  of 
Rochester,  Minn.  Lord  Bryce  and  Lord  Read- 
ing were  the  hosts  at  the  dinner. 

^        ^  ^ 

It  has  just  been  anounced  that  the  scheme  for 
providing  a  memorial  to  Sir  Mctor  Horsley  has 
now  been  given  a  definite  start.  The  nucleus  of  a 
committee  has  been  formed,  with  Sir  Charles  Bal- 
lance  as  chairman.  Sir  Frederick  Mott  and  Dr. 
H.  H.  Tooth  will  act  as  honorary  treasurers  pro 
few,  and  Sir  W.  Arbuthnot  Lane  and  Edward  J. 
Donville  will  act  as  joint  secretaries.  In  a  letter 
contributed  to  the  British  Medical  Journal,  June 
5,  1920,  Mr.  Donville  says  that  Lady  Horsley  has 
withdrawn  any  objection  she  had  previously  ex- 
pressed, and  it  is  hoped  to  found  a  lectureship  bear- 
ing Sir  Mctor  Horsley's  name,  probably  under  the 
auspices  of  the  University  of  London,  but  all  details 
have  yet  to  be  formtilated  by  the  much  larger  com- 
mittee which  is  in  course  of  formation.  Sir  Mctor 
Horsley  was  probably  the  greatest  English  speak- 
ing medical  scientist  of  this  generation.  His  in- 
vestigations into  the  surgery  of  the  brain  were  epoch 
making  and  paved  the  way  for  the  marvellous  oper- 
ations now  done  in  that  region.  He  was  essentially 
a  pioneer  in  medical  science  and  no  Englishman 
who  died  in  the  war  fighting  for  country  and  civil- 
ization is  more  worthy  to  be  remembered. 

With  regard  to  the  need  for  more  dentists  in 
Great  Britain  and  the  prevalence  of  dental  disease 
in  various  forms,  the  speakers  at  the  Congress  of 
the  Food  Education  Society  held  in  Manchester,  on 
May  13,  1920.  emphasized  the  gravity  of  the  situa- 
tion. Among  these  speakers  none  was  more  in- 
teresting, original,  and  scientific  than  Dr.  Harry 
Campbell.  In  the  course  of  his  speech  he  stated 
that  the  public  stood  in  need  of  four  great  health 
reforms,  namely,  food,  dwellings,  including  satis- 
factory working  conditions,  alcohol,  and  lues.  All 
the  political  questions  of  the  day  are  as  nothing 
compared  to  the  urgent  need  for  reform  in  these 
four  directions.  Dr.  Campbell  said  further  that 
perhaps  the  greatest  reform  needed  in  Great  Britain 
was  the  reform  of  the  faulty  dietetic  customs  of 
its  inhabitants  and  one  of  the  consequences  of  these 
bad  dietetic  habits,  namely,  the  shocking  state  of  the 
nation's  teeth,  which  in  his  opinion  were  the  worst 
of  any  nation.  The  number  of  dentists  in  Great 
Britain  was  wholly  inadequate. 


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NEW  YORK,  SATURDAY,  SEPTEMBER  IS,  1920. 


THE  FUTURE  OF  HOSPITALS. 
It  seems  as  if  the  mode  of  medical  practice  is 
about  to  undergo  a  change.  If  the  situation  in 
Great  Britain  be  taken  as  any  criterion  of  other  na- 
tions a  change  is  coming.  It  is  likely  that  the  prac- 
tice of  medicine  in  the  future  will  have  more  of  a 
preventive  character  than  now.  This  is  not  to  say 
that  curative  and  remedial  treatment  will  not  be 
employed,  but  the  object  will  be  to  diagnose  early 
and  to  prevent  ailments  from  attaining  serious  di- 
mensions. Sir  James  Mackenzie,  the  British  heart 
specialist,  is  the  pioneer  in  this  departure  from  tra- 
ditional methods,  and  his  idea  is  that  the  student 
and  the  general  practitioner  should  be  trained  to 
detect  early  symptoms.  At  St.  Andrews,  in  Scot- 
land, he  is  endeavoring  to  put  his  views  to  practical 
use.  If  this  method  of  preventing  disease  is  shown 
to  be  successful,  it  follows  that  the  function  of  the 
hospital  will  change.  At  the  present  time  the  func- 
tion of  the  hospital  is  to  take  charge  of  cases  which 
the  general  practitioner  does  not  think  fit  to  treat. 
Hospitals  afford  opportunities  for  research  which 
are  not  available  under  such  favorable  conditions 
elsewhere  and  lastly  they  provide  the  means  for 
teaching  students.  It  is  obvious  that  the  most  im- 
portant function  of  the  physician  is  to  diagnose 
correctly. 

Comparatively  little  disease  is  detected  in  the  hos- 
pital. Only  serious  cases  are  sent  in,  for  if  slight 
cases  are  admitted  they  are  not  or  should  not  be 
kept  long.  The  great  proportion  of  early  disease  is 
seen  in  general  practice ;  only  when  disease  is  estab- 


lished is  the  patient  deemed  a  fitting  inmate  of  a 
hospital.  Therefore  hospitals  should  be  employed 
mainly  as  centres  for  diagnosis  and  when  diseases 
have  been  recognized  the  sufferers  therefrom 
should  be  sent  to  the  country  to  be  treated  and 
cared  for.  This  would  be  an  economical  proce- 
dure. Rents  in  the  country  are  considerably  lower 
than  in  the  city,  fresh  air  abounds  and  a  pleasant  en- 
vironment is  accessible.  By  these  methods  medical 
education  might  be  directed  into  more  productive 
channels  and  more  in  keeping  with  the  latest  views. 

There  would  be  no  need  of  the  palatial  buildings 
which  are  now  considered  necessary  for  these  in- 
stitutions. The  money  that  has  been  thus  expended 
in  bricks  and  mortar,  and  especially  in  this  covmtry 
during  recent  years,  might  in  many  instances  have 
been  put  to  better  purpose.  Tlie  war  has  taught 
the  value  of  the  hutted  hospital,  which  in  the  coun- 
try is  more  suitable  and  comfortable  than  the  mag- 
nificent buildings  which  are  erected  in  the  big 
centres  of  population.  The  conception  of  the  func- 
tions of  the  hospital  held  by  many  who  have  made 
a  life  long  study  of  the  subject  is  not  as  a  place  in 
which  treatment  for  an  indefinite  time  may  be  given 
or  in  which  those  suft'ering  from  organic  diseases 
may  linger  until  death  releases  them,  but  as  an  insti- 
tution in  which  certain  medical  and  surgical  cases 
may  be  treated,  and  above  all  as  medical  clear- 
ing houses.  The  scheme  is  as  yet  only  in  embryonic 
form  and  doubtless  is  surrounded  with  many  diffi- 
culties. It  may  never  develop  and  certainly  will  be 
subjected  to  much  destructive  criticism.  On  the 
other  hand,  none  of  the  difticulties  appears  to  be 
insuperable  and  even  if  discussion  is  aroused  as  to 
the  true  functions  of  the  hospital,  the  question  will 
not  have  been  in  vain.  The  hospitals  as  they  are 
now  are  by  no  means  perfect  and  the  hospital  of 
the  future  must  be  a  revised  edition  of  the  existing 
institution. 


GENERAL  EFFECTS  OF  SUPRARENIN. 

The  general  effects  of  left  suprarenin  are  similar 
to  those  of  other  bodies  of  the  same  group.  All 
these  substances  exhibited  in  toxic  doses  produce 
death  from  pulmonary  edema,  which  occurs  within 
a  few  minutes  or  several  hours  later.  The  cause 
of  this  edema  is  not  clear.  Some  writers  attribute 
it  to  excessive  pressure;  Gerhardt  maintains  that  it 
exercises  a  nefarious  action  on  the  heart,  especially 
the  left  heart,  while  Hallion  admits  that  adrenalin 
attacks  the  endothelium  of  the  pulmonary  vessels. 
It  is  clear  in  all  experimental  work  that  it  is  pul- 
monary edema  which  kills  the  animal,  and  in  his 


September  18,  1920.] 


EDITORIAL  ARTICLES. 


419 


many  experiments  Loup,  of  Geneva,  is  particular  to 
state  that  he  never  met  with  cardiac  fibrillation.  It 
seems  certain,  however,  that  the  mechanism  of  the 
edema  is  dififerent  in  the  case  of  rapid  and  of  tardy 
death.  In  the  former  the  serious  cardiac  dis- 
turbances which  accompany  excessive  pressure  are 
sufficient  to  explain  the  accident;  in  the  latter  the 
edema  occurs  at  the  time  when  the  pressure  has 
fallen  to  normal  for  some  time  and  the  heart  beats 
are  regular.  It  would  therefore  seem  as  if  the  pul- 
monary edema  was  simply  the  last  phase  of  more 
complex  phenomena.  It  may  be  that  its  cause  should 
be  looked  for  in  a  change  of  the  pulmonary  endo- 
thelium, since  at  the  time  the  edema  arises  there 
is  present  a  cardiac  disturbance  which  explains 
its  occurrence. 

Death  is  preceded  by  manifestations  of  muscular 
paralysis  of  central  origin,  all  this  group  of  sub- 
stances producing  them,  although  they  are  more  in- 
tense from  left  suprarenin.  Naturally  it  is  in  tardy 
death  that  they  are  more  easily  observed.  The  animal 
often  languishes  for  hours  without  being  able  to 
move  and  responds  hardly  at  all  when  excited.  Never- 
theless, it  is  rare  that  he  is  incapable  of  any  move- 
ment, as  the  paralyses  are  generally  incomplete, 
while  their  intensity  varies  during  the  progress  of 
the  intoxication.  They  usually  increase  up  to  the 
time  of  death  and  when  this  takes  place  the  animal 
will  have  been  an  instant  in  complete  inertia.  Tardy 
death  appears  to  be  at  least  partially  due  to  grad- 
ual weakening  of  the  central  nervous  system;  and 
this  opinion  is  confirmed  by  the  fact  that  at  the 
time  of  death  the  asphyxia  resulting  from  the  pul- 
monary edema  produces  only  very  weak  convul- 
sions, sometimes  none,  and  that  strychnine  no  long- 
er has  any  action  on  the  profoundly  depressed 
animal.  The  sensibility  appears  to  be  almost  wholly 
preserved  excepting  in  the  last  stages  of  the  intoxi- 
cation. Finally,  there  is  an  inconstant  glycosuria, 
with  salivation  and  occasionally  dilatation  of  the 
pupils.  The  respiration,  which  is  suspended  for  an 
instant  following  the  infection,  begins  again  super- 
ficially and  rapidly.  Occasionally  the  dyspnea  is  in- 
terrupted by  a  series  of  deep,  slow  respirations 
which  last  only  for  a  few  minutes.  Surely  lethal 
doses  cause  death  quickly,  while  weaker  doses — 
which  some  animals  resist— kill  more  slowly. 

Briefly,  it  would  seem  as  if  this  group  of  sub- 
stances kills  rabbits  either  rapidly  from  cardiac  dis- 
turbances set  up  or  tardily  by  progressively  increas- 
ing paralysis  of  the  central  nervous  system,  although 
in  each  case  pulmonary  edema  is  the  immediate 
cause  of  death.  All  the  substances  belonging  to 
this  group  produce  the  same  clinical  picture.  The 
lethal  dose  varies. 


Aberhalden  and  Glava  have  studied  the  toxicity 
of  right  and  left  suprarenins  in  mice  by  subcutane- 
ous injection.  Left  suprarenin  kills  the  animal  at 
a  dose  of  one  tenth  milligram,  while  one  centi- 
gram of  right  suprarenin  is  necessary  to  kill.  The 
latter  should  consequently  be  one  hundred  times 
less  active  than  the  levogyric  form.  This  difiference 
with  the  results  arrived  at  by  Loup  may  be  due  to 
the  matter  of  introducing  the  drug  as  well  as  the 
species  of  animal  used  for  the  experiments.  Mice, 
like  rabbits,  die  either  a  few  minutes  following  the 
injection  or  after  some  hours.  They  present  com- 
plete muscular  paralysis  and  a  considerable  drop  in 
temperature.  At  the  time  of  death  the  temperature 
falls  to  20°  C.  Loup,  experimenting  with  rabbits, 
never  met  with  a  temperature  lower  than  34°  C. 


PHYSICIAN  AUTHORS— DR.  JOHN  McCR.A.E 

The  World  War  seems  to  have  reawakened  a 
universal  interest  in  the  Muse  and  apparently  the 
interest  has  not  yet  reached  its  uttermost  heights. 
This  interest  is  manifested  in  two  directions.  First, 
the  output  of  new  poetry  is  so  great  and  of  such 
quality  that  an  impression  is  arising  that  another 
golden  age  of  j^oetry  is  at  hand.  Second,  books  of 
poetry  are  selling  as  they  never  sold  before — single 
limited  editions  no  longer  are  the  rule ;  nor  do  the 
volumes  grow  dusty  and  worn  on  the  shelves  of  the 
shops.  Psychologists  can  give  you  elaborate  rea- 
sons for  all  this,  but  those  reasons  need  not  be  set 
down  here. 

Scarcely  had  war's  first  tocsin  sounded  when  this 
remarkable  reanimation  of  the  Muse  began.  There- 
after throughout  the  course  of  the  conflict  there 
was  a  steady  flow  of  poetry,  good,  bad  and  indiflfer- 
ent.  Most  of  it  is  doomed  to  oblivion — is  already 
forgotten — but  there  is  one  poem  that  was  born  of 
the  terror  and  suffering  at  the  front  that  the  world 
will  never  forget — Dr  John  McCrae's  In  Flanders 
Fields.  Unquestionably  this  is  the  great  outstand- 
ing poem  of  the  war  period,  the  most  widely  read, 
the  most  widely  quoted  of  all.  Who  has  not  heard 
it  recited  from  platform,  pulpit  or  stage  during 
bond  drives  and  war  gatherings  of  all  descriptions? 
The  souls  of  mankind  often  have  been  stirred  to 
great  emotional  heights  by  the  versifier's  fervor  and 
skill,  but  it  is  doubtful  if  in  the  whole  realm  of 
literature  any  other  bit  of  verse  ever  was  so  suc- 
cessful in  firing  the  hearts  of  humanity. 

If  ye  break  faith  with  us  who  die 
We  shall  not  sleep,  though  poppies  grow, 
In  Flanders  fields. 
Whatever   its    merits    as   poetry,   In  Flanders 
Fields  is  assured  of  immortality.      Its  historical 


420 


EDITORIAL  ARTICLES. 


[New  York 
Medical  Journal. 


association  has  given  it  a  permanent  place  in  litera- 
ture. It  gave  expression  to  a  mood  that  was  well 
nigh  universal  and  will  remain  as  a  permanent  rec- 
ord of  that  mood,  now  that  it  has  passed  away. 
Dr.  McCrae's  fame  will  rest  on  this  single  poem,  just 
as  surely  as  the  fame  of  Charles  Wolfe  rests  solely 
on  The  Burial  of  Sir  John  Moore.  McCrae's  other 
poetry  is  meagre — one  slender  volume  holds  all  of 
it — and,  although  it  reveals  here  and  there  the 
touch  of  the  true  poet,  it  is  not  remarkable  as  po- 
etry. The  volume  also  contains  some  of  Dr.  Mc- 
Crae's prose  writings,  mostly  extracts  from  diaries 
and  letters.  He  wrote  many  essays  on  miscellane- 
ous subjects  and  many  contributions  to  medical 
publications,  but  these  have  not  been  collected. 
Other  than  the  volume  of  poetry,  the  only  book  that 
bears  his  name  is  a  Textbook  on  Pathology,  of 
which  he  and  Professor  Adami  of  McGill  Univer- 
sity were  coeditors. 

Writing  was  distinctly  a  pastime  with  Dr.  John 
McCrae,  his  biographer  tells  us,  adding  that  medi- 
cine was  his  main  concern  in  life,  in  the  profession 
of  which  he  spent  twenty  years  in  study,  practise 
and  teaching.  He  was  said  to  be  a  born  teacher. 
When  he  was  graduated  from  the  medical  school 
of  the  University  of  Toronto  in  1898  he  was  the 
gold  medallist  of  his  class.  He  began  his  career  in 
medicine  as  an  intern  in  Toronto  and  Baltimore 
hospitals,  but  interrupted  this  work  to  get  his  first 
taste  of  war.  This  was  in  South  Africa  in  1899 
and  1900,  where  he  was  a  lieutenant  colonel  of  ar- 
tillery during  the  Boer  War  and  won  the  Queen's 
Medal  with  three  stripes.  A  number  of  his  poems 
were  inspired  by  his  experience  on  the  veldt.  After 
his  return  from  South  Africa  he  resumed  intern 
work,  but  soon  accepted  a  professorship  in  path- 
ology at  McGill  University.  For  several  years  he 
also  was  professor  of  pathology  at  the  University 
of  Vermont. 

McCrae  was  one  of  the  martyrs  of  the  war.  He 
was  aboard  ship  on  his  way  to  London  when  the 
war  broke  out.  Immediately  upon  disembarking- 
he  cabled  home,  offering  his  services,  and  was  ap- 
pointed by  his  old  friend.  Major  General  Morrison, 
to  be  surgeon  of  the  First  Brigade,  Canadian  Artil- 
lery, in  which  capacity  he  served  throughout  the 
fighting  along  the  Ypres  sector,  where  the  Canadi- 
ans covered  themselves  with  glory.  He  was  under 
intense  shell  fire  often,  for  periods  of  many  days, 
and  his  brigade  was  behind  the  area  where  the  first 
gas  attack  was  launched.  In  his  diary  he  gives  a 
graphic  description  of  their  moving  up  to  hold  the 
front  line  trenches.  It  was  during  his  fourteen 
months  with  the  Ypres  guns  that  he  wrote  In  Flan- 
ders Fields,  which  was  first  published  in  Punch. 


Overwork  and  the  conditions  under  which  that 
work  had  to  be  performed,  undermined  his  health 
and  he  was  finally  persuaded  to  leave  the  front  and 
accept  a  transfer  to  a  base  hospital,  where  he  served 
two  years.  In  the  performance  of  his  duties  he 
was  stricken  with  pneumonia,  complicated  by  men- 
ingitis, and  died  after  five  days'  illness.  McCrae 
came  of  old  Scotch  stock  that  emigrated  to  Canada 
about  the  middle  of  the  last  century,  settling  in 
Guelph,  Ontario,  where  he  was  born  in  1872. 


A  PROBLEM. 

A  recent  perusal  of  Charles  Reade's  Hard  Cash 
created  a  lively  feeling  of  gratitude  to  all  legis- 
lators, philanthropists,  and  authors  who  had 
brought  into  glaring,  uncompromising  daylight 
the  inmates  of  our  lunatic  asylums.  There  were 
those  competent,  but"  debarred  from  speaking  for 
themselves ;  those  bullied  into  greater  debase- 
ment, whose  every  word  was  disbelieved  by  men 
in  authority,  and  usually  ended  in  becoming  what 
their  keepers  said  they  were.  Now  the  doctors, 
in  danger  of  being  driven  mad  themselves  by 
overwork,  answer  the  legislators  and  philan- 
thropists by  demanding  more  trained  help,  more 
buildings,  more  prophylaxis.  A  man  is  found 
incapable  on  the  street  by  a  policeman.  His 
behavior  is  eccentric.  Is  he  mad,  drugged,  or 
drunk?  The  doctors  say  that  policemen  should 
be  trained  to  discriminate.  A  man  is  certified 
as  mad  and  committed  to  an  asylum  where  he  as- 
sociates with  many  far  worse  than  himself.  The 
medical  committee  demands  trained  keepers,  bud- 
ding alienists  with  the  patience  of  Job,  to  observe 
the  men.  You  say  the  insane  are  capable  of  being- 
taught  habit  formation.  Send  us  proper  teachers 
who  will  adapt  their  teachings  to  each  man's  ability. 
This  is  not  doctor's  work. 

There  are  thousands  of  delinquent  boys  and 
girls  who  for  their  own  protection  and  that  of 
society  must  be  confined.  The  old  plan  was  to 
term  all  of  them  idiots  or  wanting^.  Now  there 
are  a  dozen  fine  distinctions.  Train  teachers, 
train  nurses,  send  them  to  help  the  doctors. 
Thousands  of  mentally  deficient  girls  add  to  the 
population  every  month,  and  the  doctor,  a  demo- 
crat when  an  obstetrician,  opens  the  gates  of  life 
as  politely  to  a  weary  faced  little  idiot  as  to  a 
plump  young  Hercules.  But  his  cry  is,  send  set- 
tlement workers,  send  lecturers,  send  reformers  of 
homes  to  spread  the  knowledge  of  evitable  evils ; 
not  ours  the  tremendous  task  of  grappling  with 
the  evils  an  educated  public  should  provide  funds 
to  prevent.  Whether  insane  or  criminal,  a  test, 
an  analysis,  is  now  demanded.    There  are  many 


September  18.  1920.] 


NEWS  ITEMS. 


421 


who  should  be  transferred  to  the  asylum  from  the 
prison,  many  who  should  go  to  prison.  But  who 
is  to  decide  wisely  unless  a  mighty  band  of  com- 
petent people  are  trained  to  go  on  the  institutional 
staff,  and  who  is  to  find  the  money?  Are  the  help- 
ers to  be  paid  as  generously,  as  adequately,  as  the 
overworked  doctors  who  try  to  do  all  the  social 
reformers  imagine  it  is  the  doctor's  work  to  carry 
out? 

The  lunatics,  idiots,  feebleminded  form  only  one 
section  of  those  demanding  medical  care.  Open 
war  is  declared  against  the  venomous,  devastating 
trio,  cancer,  tuberculosis,  syphilis,  while  influenza 
gathers  fresh  forces  every  year.  The  doctor  is  also 
required  to  cooperate  with  the  engineer  in  rendering 
new  lands  habitable,  in  determining  healthy  condi- 
tions for  those  who  submarine,  for  those  who  super- 
terrate,  and  as  yet  their  number  of  skilled  assistants 
is  pitiably  small.  The  doctors'  protest  against  more 
work  is  no  mere  petty,  selfish  consideration  for 
themselves  or  righteous  demand  for  more  money, 
but  the  protest  of  those  who  realize  what  ought  to 
be  done  yet  cannot  do  it. 


EXPECTANT  INDIA. 
With  the  courtesy  and  patience  characteristic  of 
the  Indian,  statements  of  the  urgent  need  for  medi- 
cal reform  have  been  put  before  the  British  authori- 
ties during  long  years.  The  latter  urge  that  no 
real  help  would  be  given  to  the  millions  committed 
to  their  care  by  giving  them  half  trained  medical  men 
and  that  funds  are  lacking  for  furnishing  any 
appreciable  increase  in  the  supply  of  qualified  ones. 
Even  if  more  medical  schools  and  colleges  are 
to  be  opened,  the  pay,  position  and  prospects  are 
so  poor  that  they  militate  against  the  popularity 
of  the  service.  There  is  no  inducement  for  a  young 
doctor  to  take  up  rural  practice  in  the  government 
dispensaries.  He  gets  no  practice,  all  minor  ail- 
ments being  sent  to  bigger  medical  institutions,  and 
no  surgical  equipment — not  even  a  stove  or  steri- 
lizer being  provided,  whereas  hydrocele,  anal  fistula, 
piles,  buboes,  amputations,  could  be  treated  if  proper 
equipment  were  provided.  Knowledge  rusts  for 
want  of  use,  and  a  listless  laziness  assails  the  young 
doctor.  There  are  two  species  of  medical  men,  one 
possessing  university  qualifications,  the  others 
diploma  holders  from  a  governmental  or  competent 
examining  body.  The  present  anomalous  position 
of  medical  graduates  and  diploma  holders  should 
be  at  once  done  away  with.  The  standards  of 
minimum  qualifications  for  admission  in  the  dif- 
ferent provinces  vary  and  this  is  greatly  due  to  the 
absence  of  a  General  Medical  Council  for  India  to 
control  the  medical  education  of  the  whole  country. 
The  minimum  qualification  for  admission  into  any 
institution  should  be  laid  down  by  the  Council, 
and  recruitment  to  the  Civil  Medical  Service  be  by 
open  competition.  The  postponement  of  some  of 
the  most  pressing  health  reforms  is  due  to  the 
paucity  of  medical  men.    There  are  hundreds  who 


eagerly  look  to  medicine  for  an  honorable  career, 
but  the  institutions  for  learning  are  so  few,  the  ac- 
commodation in  these  so  limited  that  numbers  have 
to  be  turned  away. 


WEALTH  AND  HEALTH. 

The  Industrial  Fatigue  Research  Board  of  Eng- 
land has  put  forth  one  excellent  report  after  an- 
other shedding  light  on  the  human  machine  in 
industry.  Some  of  its  studies  are  general,  others 
deal  with  particular  industries.  The  latest  report, 
by  Dr.  H.  M.  Vernon,  is  on  The  Speed  of  Adapta- 
tion of  Output  to  Altered  Hours  of  Work.  Com- 
menting editorially  on  Dr.  Vernon's  findings,  the 
Lancet  says : 

"These  facts  suggest  that  there  is  a  certain  amount 
of  energy  at  the  daily  disposal  of  the  human  ma- 
chine :  that  there  is  a  definite  urge  forward  to 
expend  this  energy,  an  urge  due  to  the  anabolic 
activity  of  rest  stimulating  the  katabolic  activity  of 
work ;  and  that  when  the  two  balance  one  another 
a  level  of  productive  activity  is  maintained.  Prac- 
tice may  increase  productivity  still  further,  but  prac- 
tice only  consists  in  using  energy  economically,  so 
that  more  things  are  made  with  the  same  exertion 
previously  required  for  making  fewer.  Interest 
also  centres  on  the  fact  that  quicker  work  during 
shorter  hours  is  associated  with  less  lost  time 
(represented  by  sickness),  from  which  health  ap- 
pears to  be  a  function  of  activity ;  and,  from  the 
viewpoint  of  health,  there  appears  to  be  an  opti- 
mum rate  of  activity  for  the  human  organism  which 
seems  to  coincide  with  the  optimum  rate  of  produc- 
tion. The  Industrial  Fatigue  Board  will  indeed 
justify  its  existence  if  it  is  able  to  convince  those 
who  control  the  destinies  of  the  industrial  world 
that  material  wealth  and  individual  health  depend, 
so  far  as  labor  is  concerned,  on  the  same  factors." 

 «^  

News  Items. 

Cannot  Prescribe  Whiskey  for  Yourself. — Un- 
der a  new  ruling  of  the  Bureau  of  Internal  Revenue, 
medical  men  cannot  make  out  prescriptions  for 
whiskey  for  themselves,  even  though  they  are  sick. 

Loyola  University  Appointments. — Dr.  Charles 
Louis  Max  has  been  appointed  professor  and  head 
of  the  department  of  medicine  and  Dr.  Edward  L. 
Moorehead  has  been  appointed  professor  and  head 
of  the  department  of  surgery  in  Loyola  University 
School  of  Medicine. 

Surgeon  Lavinder  Named  Assistant  Surgeon 
General. — Senior  Surgeon  C.  H.  Lavinder,  for- 
merly in  charge  of  the  hospital  division  of  the 
U.  S.  Public  Health  Service,  has  been  named  as- 
sistant surgeon  general  and  is  now  in  charge  of  the 
division  of  hospitals  and  relief. 

Poliomyelitis  Increasing  in  Boston. — An  in- 
crease in  the  number  of  cases  of  acute  anterior  poli- 
omyelitis is  reported  in  Boston.  There  were  seven- 
teen cases  in  that  city  between  January  1st  and  July 
1st,  sixteen  cases  during  July,  ninety-four  in 
August,  and  sixty-three  for  the  first  nine  days  of 
Septeml)er. 


422 


XEJVS  ITEMS. 


[New  York 
Medical  Journal. 


Hospital  Bequests. — The  will  of  the  late  Con- 
gressman Colonel  Thomas  W.  Bradley,  of  W'alden, 
New  York,  leaves  $5,000  to  St.  Luke's  Hospital 
in  Newburgh,  and  $5,000  to  the  Thrall  Hospital  in 
Middletown. 

Death  of  Indian  Medical  Editor. — Lieutenant 
Colonel  William  Dunbar  Sutherland,  imperial 
serologist  to  the  Govemment  of  Lidia  and  for- 
merly editor  of  the  Indian  Medical  Gazette,  died 
June  27th  in  Calcutta,  at  the  age  of  fifty-three. 

Hospital  Association  Meeting. — The  American 
Hospital  Association  will  hold  its  twenty-second 
annual  conference  October  4th  to  8th  at  Montreal. 
In  connection  with  the  meeting  there  will  be  re- 
ports from  the  American  Conference  on  Hospital 
Service. 

Hospital  Bequests. — The  will  of  the  late  Ber- 
thold  Bendheim,  of  Xew  York  provides  the  fol- 
lowing bequests  to  hospitals :  $2,000  each  to  the 
Mount  Sinai  Hospital  and  the  Montefiore  Home ; 
$500  each  to  Beth  Israel  Hospital  and  St.  Mark's 
Hospital. 

New  York  State  Health  Conference. — ^Dr.  Guy 
H.  Turrell,  of  Xew  York,  was  elected  president  of 
the  conference  of  Xew  York  state  health  officers 
and  public  health  nurses,  held  recently  at  Sara- 
toga Springs.  It  was  decided  that  the  1921  con- 
ference will  be  held  at  Ithaca. 

End  Latvian  Relief. — The  child  feeding  work 
of  the  American  Relief  Administration  in  Latvia 
has  been  terminated.  That  country  now  has  suffi- 
cient food  to  meet  its  needs,  and  in  addition  the 
government  has  built  up  an  eflective  child  welfare 
S)-stem  'that  will  continue  whatever  relief  is  neces- 
sary. 

United  States  Civil  Service. — The  United 
States  Civil  Service  Commission  announces  an  ex- 
amination for  microscopist  in  the  office  of  the  sur- 
geon general,  Armv  Medical  Museum.  \\'ashing- 
ton.  D.  C,  at  $1,800  a  year  plus  a  bonus  of  S20 
a  month.  Receipt  of  applications  will  close  Oc- 
tober 19th. 

Public  Health  School  at  Georgia  University. — 

A  School  of  Public  Health  and  Hygiene  is  to  be 
added  to  the  medical  department  of  the  University 
of  Georgia,  at  Augusta.  Dr.  C.  C.  Applewhite.  P. 
A.  Surgeon.  U.  S.  Public  Health  Service,  has  been 
detailed  to  Augusta  for  the  purpose  of  starting  the 
school. 

For  Ratproof  Buildings. — At  a  recent  confer- 
ence of  public  health  officers  at  Beaumont,  Texas, 
to  discuss  bubonic  plague,  recommendations  were 
made  to  Surgeon  General  Hugh  S.  Gumming  that 
the  Public  Health  Service  draw  up-  standard  speci- 
fications for  ratproof  buildings  and  furnish  these 
to  the  different  states  and  cities  for  incorporation 
in  building  codes  throughout  the  country. 

Delegates  to  Antialcoholism  Meeting. — Gov- 
ernor Smith,  has  appointed  delegates  to  represent 
Xew  York  state  at  the  Fifteenth  International  Con- 
gress Against  Alcoholism,  to  be  held  in  Washing- 
ton, September  21st  to  27th.  The  following  medical 
men  are  among  those  named :  Dr.  Charles  W.  Pil- 
grim, chairman  of  the  State  Hospital  Commission, 
of  Albany;  Dr.  Mathias  Xicoll,  Jr.,  deputy  com- 
missioner of  health,  Albany,  and  Dr.  Pearce  Bailey, 
of  Katonah. 


Pellagra  Hospital  to  Be  Discontinued. — The 

Pellagra  Hospital  at  Spartanburg,  S.  C,  maintained 
by  the  U.  S.  Public  Health  Service  has  been  dis- 
continued because  the  disease  has  been  practically 
wiped  out  in  that  locality.  The  equipment  will  be 
distributed  among  other  hospitals  of  the  Public 
Health  Service. 

Railway  Surgeons  Elect  Officers. — Officers 
have  been  elected  as  follows  by  the  Baltimore  and 
Ohio  Association  of  Railway  Surgeons,  recently  in 
convention  in  Baltimore :  President,  Dr.  E.  B.  Fit- 
tro.  of  Salem,  W.  Va. :  vice-presidents.  Dr.  J.  G. 
Shirer,  of  Xewark,  Ohio ;  Dr.  D.  Lespinasse, 
of  Chicago ;  secretary -treasurer,  C.  E.  Johnson,  of 
Baltimore. 

Death  of  Sir  William  Babtie. — Lieutenant 
General  Sir  William  Babtie.  A'.  C,  of  the  British 
Medical  Service,  died  the  early  part  of  September 
while  spending  a  holiday  in  Belgium.  He  was 
sixty-one  years  old.  Sir  William  Babtie  served  as 
principal  director  of  medical  services  in  1915-16  in 
Gallipoli,  Egypt  and  Salonika  and  later  as  director 
and  inspector  of  medical  services  at  the  War  Office. 

Navy  Drops  Whiskey  as  Medicine. — Spiritu- 
ous liquors  are  to  be  dropped  from  the  supply  table 
of  the  medical  department  of  the  Navy,  according 
to  an  order  recently  promulgated  by  the  Bureau  of 
Medicine  and  Surgery  prohibiting  their  issuance 
to  naval  vessels  for  medicinal  purposes.  Medical 
supply  depots  may  issue  whiskey  only  to  hospitals, 
and  when  the  present  supplies  have  become  ex- 
hausted, whiskey  will  be  banned  entirely.  The  or- 
der states  that  when  whiskey  is  no  longer  available 
and  a  medical  officer  deems  alcoholic  stimulation  ab- 
solutely essential  for  the  preservation  of  hujinan 
life,  the  ethyl  alcohol  obtainable  from  supply  officers 
may  be  prescribed.  This  alcohol  conforms  in  all 
respects  with  the  requirements  of  the  United  States 
Pharmacopoeia.  The  order  directs  that  no  further 
purchase  from  any  source  be  made  of  distilled 
spirits,  wine  or  alcohol  preparations.  It  is  esti- 
mated that  the  supply  on  hand  will  last  only  two  or 
weeks. 

Personal. — Dr.  James  M.  [NfcTiernan  has  re- 
moved his  office  to  Euclid  Hall.  Broadway  and 
Eighty-sixth  street,  Xew  York. 

Dr.  George  Chaffee,  formerly  of  New  York  City, 
announces  the  opening  of  his  office  at  100  Hawley 
street,  Binghamton,  X.  Y.,  practice  limited  to  oper- 
ative bone  surgery,  maternity  cases,  and  to  con- 
sultation. 

Dr.  John  W.  Moore  has  been  elected  full  time 
professor  of  research  medicine  in  the  medical  de- 
partment of  the  University  of  Louisville.  Kentucky. 

Dr.  Leonard  G.  Rowntree.  professor  of  medicine 
in  the  medical  school  of  the  L'niversity  of  Minne- 
sota, and  Dr.  Reginald  Fitz,  associate  in  medicine 
of  the  ^lassachusetts  General  Hospital,  have  joined 
the  staff  of  the  Mayo  Foundation  and  the  Mayo 
Clinic  at  Rochester.  Minn. 

Dr.  J.  G.  Adami,  F.  R.  S..  ViceChancellor  of 
the  University  of  Liverpool  and  lately  Strathcona 
professor  of  pathology  and  bacteriology  in  McGill 
University,  ^lontreal.  has  been  elected  to  an  honor- 
ary fellowship  at  Christ's  College,  Cambridge,  of 
which  he  was  formerly  a  scholar. 


September  18,  1920.]  XEJl'S   ITEMS.  423 


Proposed   International   Health   Office. — The 

Council  of  the  League  of  Nations  has  recommended 
for  formal  adoption  at  the  General  Assembly  of  the 
League  in  November  the  proposal  for  an  interna- 
tional health  office  prepared  at  the  recent  London 
conference.  The  London  conference  of  public 
health  experts  made  a  series  of  detailed  recommen- 
dations regarding  the  functions  and  duties  of  the 
proposed  organization,  the  incorporation  within  it 
of  the  existing  Office  International  d'Hygicne  Pub- 
liquc  established  under  the  Rome  Convention  of 
1907,  and  the  nature  of  the  pennanent  machinery 
which  the  new  international  health  office  would 
require. 

Death  of  Professor  Gautier. — Dr.  Armand 
Gautier,  professor  of  chemistry  in  the  Faculty  of 
Medicine  of  Paris  and  director  of  the  laboratory 
of  biological  chemistry,  died  July  27th  at  Cannes, 
France,  at  the  age  of  eighty-two  years.  He  was 
the  discoverer  of  leucomaines,  and  he  studied  with 
equal  success  many  other  problems  relating  to  cell 
tissue  and  general  hygiene.  He  made  the  discovery 
of  arsenic  as  a  normal  element  of  animal  tissues, 
of  free  hydrogen  in  the  air,  of  iodine  in  the  land 
alga;,  of  the  genesis  of  mineral  waters,  of  the  role 
of  fluorine,  and  of  a  new  method  of  preparation  and 
therapeutic  application  of  certain  organic  com- 
pounds of  arsenic. 

Acid  Test  for  Chauffeurs. — Due  to  the  frequency 
of  automobile  accidents  in  Xew  York  city.  Health 
Commissioner  Royal  S.  Copeland  has  written  a 
letter  to  Secretar}-  of  State  Francis  M.  Hugo  sug- 
gesting amendments  to  the  Sanitary  Code  which 
will  make  it  impossible  for  persons  with  defective 
sight  or  hearing  or  those  addicted  to  narcotic  drugs 
to  become  chaufTeurs.  Dr.  Copeland  pointed  out 
that  398  people  had  been  killed  by  automobiles  in 
the  first  seven  months  of  this  year  and  that  767 
lost  their  lives  in  1919.  Out  of  7,464  self  confessed 
drug  addicts  registered  with  the  health  department, 
534  were  listed  as  drivers  or  chauffeurs.  Dr.  Cope- 
land also  stated  that  many  chauffeurs  had  defective 
sight  or  hearing. 

Health  Department  Plans  More  Consultation 
Clinics. — The  Group  Consultation  Clinic  held 
during  the  week  of  August  22nd  at  Goshen,  X.  Y., 
proved  so  successful  that  the  State  Department  of 
Health  is  planning  similar  clinics  for  other  locali- 
ties. Dr.  E.  C.  Body  is  quoted  as  follows  in  the 
daily  press  regarding  the  conduct  of  the  clinic : 

"Patients  are  referred  to  the  clinic  by  their  at- 
tending physician.  After  a  careful  history  of  the 
case  the  patient  is  referred  to  the  proper  consul- 
tant for  examination.  If  the  consultant  thinks  that 
additional  information  is  necessary  before  a  diag- 
nosis is  made,  such  as  laboratory  examination  or 
an  X  ray  examination  or  examination  by  another 
consultant,  the  case  is  referred  to  that  department. 

'"When  the  examinations  are  completed  the  con- 
sultant reviews  all  the  evidence,  makes  his  diag- 
nosis and  any  recommendations  concerning  the  fu- 
ture course  of  procedure  for  the  patient.  All  this 
information  is  then  forwarded  to  the  patient's  at- 
tending physician.  It  is  obvious  that  under  this 
arrangement  the  relation  between  the  patient  and 
family  doctor  is  not  altered  in  any  degree,  and  that 
the  clinic  is  conducted  along  ethical  lines." 


Insanitary  Dairy  Conditions  Found. — Investi- 
gations conducted  by  the  Bureau  of  Foods  and 
Drugs  of  the  Department  of  Health  of  Xew  York 
city  have  disclosed  insanitary  dairy  conditions  which 
are  considered  contributory  to  the  high  bacterial 
content  of  Grade  B  milk.  According  to  a  letter 
from  Mr.  Ole  Salthe,  acting  director  of  the  bureau, 
to  the  Xew  York  Alilk  Conference  Board,  milking 
machines  were  improperly  cleaned  between  milk- 
ings,  clean  milk  cans  were  not  allowed  to  air,  milk 
was  insufficiently  cooled,  milking  utensils  were  not 
properly  washed,  and  in  several  dairies  dirty  stables 
and  cows  were  found. 

Proposed  Hospital  for  Insane  Soldiers. — Plans 
are  under  consideration  by  state  officials  for  the 
erection  by  Xew  York  state  of  a  hospital  for  insane 
soldiers,  the  hospital  to  be  operated  and  maintained 
under  the  supervision  of  the  War  Risk  Insurance 
Bureau.  An  appropriation  of  $1,000,000  will  be 
asked  of  the  Legislature  for  this  purpose.  At  the 
present  time  there  are  in  the  state  about  900  former 
service  men  who  have  become  insane.  Of  this 
number  474  are  in  state  hospitals  and  the  rest  in 
other  institutions.  The  need  of  such  a  hospital  is 
evidenced  by  the  overcrowded  condition  of  the 
state  hospitals  for  the  insane. 

Civil  Service  Examinations. — The  Xew  York 
State  Civil  Service  Commission  announces  exami- 
nations, written  or  unwritten,  for  the  following  po- 
sitions: medical  examiner  and  assistant  medical  ex- 
aminer. State  Industrial  Commission.  $2,000  to  $2,- 
800;  physiological  chemist  State  Department  of 
Health,  $1,650;  sanitary  supervisior.  State  Depart- 
ment of  Health,  $3,500;  laboratory  assistant  in 
bacteriology.  State  Department  of  Health,  $1,500; 
assistant  in  pathology,  State  Institute  for  the  Study 
of  ]\Ialignant  Disease,  $2,500:  dentist,  State  Hos- 
pital Service,  $1,200  to  $1,500:  first  assistant  physi- 
cian, Letchworth  Village,  $2,500  and  maintenance; 
psychologist,  New  York  State  Reformatory  for 
Women,  Bedford  Hills,  $1,000  and  maintenance; 
.supervisor  of  child  hygiene  centres.  State  Depart- 
ment of  Health,  $3,000 :  supervisor  of  tuberculosis 
hospitals,  dispensaries,  and  clinics.  State  Depart- 
ment of  Health,  $3,000. 



Died. 

Comfort.— In  Port  Dalhousie.  Out.,  on  Monday,  Sep- 
tember 6th,  Dr.  John  Harris  Comfort,  aged  ninety -three 
years. 

Cox.— In  Stanford,  \'a.,  on  Friday,  July  30th,  Dr.  J.  Ed- 
ward Cox,  aged  fifty-two  years. 

Gerrish. — In  Portland,  Me.,  on  Wednesday.  September 
8th,  Dr.  Frederick  Henry  Gerrish,  aged  seventy-five  years. 

McGciRE. — In  Dobbs  Ferry,  N.  Y..  on  Sunday,  September 
12th,  Dr.  George  Harrington  McGuire,  of  New  York,  aged 
fiftj'-eight  years. 

MoRG.\x. — In  Hadlyme,  Conn.,  on  ^londay,  August  30th, 
Dr.  John  Morgan,  of  New  York,  aged  seventy-five  years. 

O'Dav. — In  Dover,  Del.,  on  Tuesday,  September  7th,  Dr. 
Edward  Francis  O'Day,  aged  fifty- four  j-ears. 

RvAX. — In  Glendale,  Cab,  on  Thursday,  August  19th,  Dr. 
Lee  ^lathew  Ryan,  aged  thirty-seven  years. 

Stout. — In  New  York,  N.  Y.,  on  Tuesday,  September 
7th,  Dr.  Stephen  V.  W.  Stout,  of  Jersey  Cit>',  N.  J.,  aged 
seventy-four  years. 

Thom.\s. — In  Cambridge,  Mass..  on  Saturday,  September 
4th,  Dr.  Charles  Holt  Thomas,  aged  seventy  years. 


Book  Reviews 


THE  PSYCHOLOGICAL  INTERPRETATION 
OF  RELIGION. 

Religion  and  the  New  Psychology.  A  Psychoanalytical  Study 
of  Religion.  By  Walter  Samuel  Swisher,  B.  D.  Bos- 
ton :  Marshall  Jones  Company,  1920.    Pp.  xv-261. 

The  time  is  ripe  for  a  book  such  as  this.  There 
are  signs  of  the  awakening  of  interest  in  psycho- 
analysis in  every  department  of  life;  there  is  active 
inquiry  into  its  practical  value.  In  this  case  the 
new  psychology  has  as  much  relation  to  religion  as 
to  any  socalled  secular  province.  Swisher's  con- 
ception of  religion  is  that  of  a  certain  department  or 
phase  of  human  interest  which  cannot  be  detached 
from  the  whole.  Religion  to  him  is  one  of  the 
means  by  which  life  may  attain  that  freedom  of  ex- 
pansion in  which  alone  lies  the  realization  of  well 
being  and  of  satisfying  activity. 

In  his  broad  study  of  religion  he  shows  it  as  a 
means  by  which  this  end  may  be  attained, 
but  at  the  same  time  it  may  be  used  only  to  fix 
more  firmly  the  factors  which  obstruct  freedom. 
Religion  has  worn  different  aspects  throughout  his- 
tory. That  its  more  conspicuous  later  day  function 
is  an  ethical  one  does  not  blind  the  writer  to  the 
element  of  wish  fulfillment  in  selfprotection  and  in 
sexual  need  which  forms  its  source.  Long  before 
ethics  played  a  part  man  created  his  religion  to  sup- 
port and  satisfy  him  in  a  world  of  undesirable  or 
difficult  reality.  Swisher,  examining  the  content 
of  the  unconscious,  gives  groimd  for  his  assertion 
that  "religion  is  primarily  emotional  and  is  thus,  in 
the  broadest  sense,  of  sex  origin." 

He  discovers  in  early  man  the  need  to  be  freed 
from  a  sense  of  helplessness  and  of  the  bondage 
of  his  own  powers.  This  is  the  content  of  the  later 
sense  of  sin.  The  writer  confesses  that  he  differs 
somewhat  from  Freud  in  not  accepting  the  early 
fear  of  one's  own  impulses  as  the  origin  of  the  sense 
of  sin.  Freud  would  see  an  ethical  sense  arising  in 
man's  earliest  experience.  Here  it  is  that  religion  and 
psychoanalysis  manifest  sameness  of  aim  and  that 
psychoanalysis  enters  to  interpret  the  function  of  re- 
ligion and  to  guide  its  ftmction  in  accordance  with 
the  more  scientific  needs  of  the  present  time.  Both 
seek  to  free  the  repressions  and  permit  the  individual 
a  realization  of  his  elements  of  power  and  freedom 
in  their  use.  It  is  psychoanalysis  which  has  discov- 
ered the  existence  of  repressions  and  the  hemming 
of  pow'cr  through  them  and  which  adds  to  the  older 
methods  of  religion  its  principles  of  investigation 
and  readjustment. 

Swisher  presents  in  interesting  comparison  the 
forms  and  methods  with  which  religion  has  helped 
man  toward  this  end.  Examples .  of  the  misinter- 
pretations of  religion  which  have  tended  toward 
fixations  and  repressions  are  prominent  in  the 
Christian  religion  in  some  of  its  phases  and  expo- 
nents. Often  religion  has  been  only  the  opportunity 
for  the  play  of  certain  neurotic  traits.  The  writer 
makes  his  position  plain :  these  are  not  necessary 
results  of  religion.  Religion  may,  however,  be 
joined  to  a  neurotic  character  and  furnish  fruitful 
opportunity  for  the  development  of  neurotic  fea- 
tures.   Here  the  province  of  religion  is  enlightened 


by  psychoanalysis.  Originally  religion  sought 
chiefly  the  setting  right  of  the  individual  with  un- 
known powers ;  now  the  emphasis  is  laid  upon  his 
social  relations.  , 

The  author  has  discussed  in  brief  but  sprightly 
fashion  a  number  of  problems  which  have  always 
perplexed  men.  He  turns  the  broad  light  of 
the  unconscious  upon  the  mystic  experience  in  re- 
ligion, upon  the  occult  and  its  prominence  in 
belief.  He  treats  with  special  clearness  the  psy- 
chology of  the  various  forms  of  healing  associated 
with  religion  as  he  does  that  of  conversion.  Free 
will  and  determination  in  religion  are  presented  in 
the  light  of  the  new  psychology ;  so  also  is  man's  re- 
lation to  the  problem  of  evil.  The  author  makes  a 
rightful  distinction  between  evil  without  or  cosmic 
evil  and  that  within  and  shows  the  relation  of  each 
to  man's  individual  psychic  freedom  or  repression. 
In  brief  the  book  is  a  lively  presentation  of  old 
mooted  points  in  religion,  giving  them  new  life  and 
an  illimiination  as  to  their  origin  and  significance 
in  man's  psychic  life.  At  the  same  time  it  presents 
the  facts  of  psychoanalysis  in  a  simple  fashion 
which  should  make  an  authoritative  and  stimulating 
appeal  to  the  general  reader.  Sometimes  these  psy- 
choanalytical facts  might  be  more  deeply  pressed  into 
or  the  implication  in  regard  to  religion  might  be 
pressed  further.  Nevertheless  the  author  has 
spoken  fearlessly.  Such  a  book,  in  the  style  in 
which  it  is  written,  must  do  much  to  fasten  atten- 
tion upon  psychoanalytical  advance  and  at  the  same 
time  render  service  in  the  explanation  and  main- 
tenance of  the  essential  in  religion. 

FROM  THE  RUSSIAN. 

An  Honest  Thief  and  Other  Stories.  By  Fvodor  Dostoev- 
SKY.  From  the  Russian  by  Constance  Garnett.  New 
York:  The  Macmillan  Company,  1919.    Pp.  i-325. 

The  Chorus  Girl  and  Other  Stories.  By  Anton  Chekhov. 
From  the  Russian  by  Constance  Garnett.  New  York: 
The  Macmillan  Company,  1920.    Pp.  iii-301. 

Letters  of  Anton  Chekhov.  With  Biographical  Sketch. 
Translated  by  Constance  Garnett.  New  York :  The 
Macmillan  Company,  1920.    Pp.  i-416. 

Until  recent  years  there  has  been  a  paucity  of 
translations  into  English  of  representative  Russian 
literature.  Tolstoi,  Turgenev  and  Gorky  were 
among  the  most  frequently  read  of  the  writers, 
while  Gogol,  the  father  of  modern  Russian 
literature,  Dostoevsky,  the  master  of  all  writers, 
and  the  incomparable  Chekhov,  who  is  without  a 
peer  in  the  realm  of  short  story  writers,  received 
little  consideration  among  English  readers  in 
America.  In  England  translations  from  the  works 
of  these  writers  were  more  frequently  encountered. 

The  influence  of  Chekhov  is  being  felt  today  more 
than  ever  before  among  English  writers.  It  may 
be  said  without  exaggeration  that  his  works  today 
exert  an  influence  similar  to  that  of  Henry  James  in 
the  same  field  a  decade  ago.  All  this  before  he 
has  been  widely  read  by  the  public  at  large.  His 
plays,  with  their  rich  symbolism,  are  more  infltt- 
ential  in  their  eflfect  upon  English  writers 
than  his  short  stories.  Didactic  professors  and  the 
no  less  didactic  critics  have  given  Maupassant  a 
clear  field  in  the  realm  of  short  story  telling;  Chek- 


September  18,  1920.] 


BOOK  REVIEWS. 


425 


hov  received  scant  consideration.  There  is  little  to 
compare.  The  French  writer  is  decadent,  while  the 
Russian  presents  life  and  people  meeting  life.  Pro- 
gress on  the  one  hand,  smug  mouthings  on  the 
other.  In  our  Anglo  Saxon  prudery  ]\Iaupassant 
has  spiced  many  dull  hours  for  us  but  he  has  done 
little  else.  Chekhov  has  given  us  warmth  and 
movement,  ever  forward,  ever  in  close  contact  with 
human,  very  human  beings.  On  the  one  hand  an 
incipient  disease,  on  the  other,  a  solid  heahhy 
growth. 

Reading  the  letters  of  Chekhov  we  get  nearer  to 
the  man,  and  such  a  man !  His  was  a  constant 
struggle — poverty,  the  difficulties  of  his  profession, 
and  tuberculosis.  Through  all  this  we  find  him  op- 
timistic, rarely  introverted,  always  productive,  and 
eivins:  of  himself  and  his  abilities  to  the  world. 
Through  his  constant  activities  he  acquired  an  un- 
derstanding of  men  and  their  problems.  \Mienever 
difficulties  were  to  be  faced  he  did  not  shirk  his 
responsibilities.  During  epidemic  and  famine  we 
find  him  working  far  into  the  night  alleviating  the 
sufferings  of  his  neighbors  and  he  always  found 
time  to  do  the  thing  he  most  wanted  to  do — to 
write.  This  active  life  of  his  should  be  a  splendid 
lesson  to  those  whose  chronic  complaint  of  not 
being  able  to  do  the  thing  they  most  want  to  do 
becomes  a  melancholy  whine,  and  to  those  who  shift 
the  responsibility  of  their  own  shortcomings,  in 
surroundings  that  are  excellent  in  comparison  with 
those  under  which  Chekhov,  the  sick  man,  labored. 
Tolstoi  is  credited  with  saying  that  Chekhov's 
medicine  cluttered  up  his  writing;'.  This  'niay  be 
true,  but  it  is  difficult  to  contemplate  what  it  would 
have  been  if  he  had  not  had  his  medicine.  Per- 
haps it  would  be  more  fitting  to  say  that  Tolstoi 
would  have  had  a  more  tolerant  understanding  of 
life  and  men  if  he  had  had  the  medical  experiences 
of  Chekhov. 

The  Chorus  Girl  and  Other  Stories  contains  an 
excellent  collection  of  Chekhov's  tales.  His  let- 
ters are  a  mirror  of  this  splendid  man.  They  are 
candid,  full  of  enthusiasm  and  show  a  healthy  out- 
look toward  life.  They  are  not  imbued  with  sickly 
sentimentality,  nor  are  they  filled  with  self  pity. 
They  should  not  remain  unread  by  anyone  who  is 
interested  in  literature  or  its  makers. 

Fyodor  Dostoevsky !  For  many  this  is  enough. 
When  the  rubbish  of  accumulated  writing  has  been 
swept  aside,  in  generations  to  come  he  will  stand 
out  boldly  and  clearly  in  sharp  relief.  In  his  works 
we  find  a  giant  struggling  to  express  his  own  diffi- 
culties and  through  his  constant  battles  finding  in- 
sight into  the  problems  of  those  around  him.  Pov- 
erty, epilepsy,  gambling,  and  other  supposedly  non- 
social  traits  were  his  to  overcome.  From  a  timid 
boy  be  became  a  swaggering  hero  flattered  by  the 
success  of  his  first  works.  He  imagined  himself 
a  radical  and  was  sentenced  to  death  for  what  would 
today  be  considered  less  than  a  misdemeanor.  At 
the  last  moment  a  courier  brought  the  news  that 
changed  his  sentence  to  imprisonment  in  Siberia. 
Xew  sufYerings  and  new  insights  followed.  He  be- 
came a  broken  man  and  his  sensitive  soul  was 
beaten  arid  bruised.  He  begged  for  mercy,  and 
through  influential  friends  came  release,  with  new 


adventures  ever  filled  with  despair  and  sadness. 
Then  out  of  the  press  came  his  golden  works. 

In  A)i  Honest  Thief  and  other  stories  we  find  a 
rather  versatile  collection  of  tales,  some  in  the 
lighter  vein,  all  with  a  fundamental  psychological 
insight.  The  second  of  the  series,  Uncle's  Dream, 
is  wonderful  in  construction  and  very  Russian  in 
its  concept.  Some  of  the  other  stories  have  a  more 
universal  concept.  The  last  story  in  the  volume. 
The  Dream  of  a  Ridiculous  Man,  shows  a  splendid 
phantasy  in  which  he  portrays  an  ideal  world — his 
ideal  world.  Here  he  goes  back  to  childhood  for 
his  material,  back  to  the  past,  and  portrays  a  world 
as  he  would  have  it  in  the  future. 

Those  of  us  who  desire  more  than  a  flippant 
story,  who  desire  a  tale  beautifully  told,  cannot  do 
without  Dostoevsky  and  Chekhov.  If  it  is  only  a 
narcotic  we  are  seeking,  something  we  can  easily 
read  and  quickly  forget,  we  do  not  want  to  trouble 
ourselves  with  men  of  this  calibre.  For  those  of 
us  who  need  this  and  nothing  more  these  men  have 
labored  in  vain  and  it  may  be  said  in  truth  that 
their  works  are  much  too  good  for  us. 

PERSONAL  AND  COMMUNITY  HYGIENE. 

Healthy  Living.  How  Children  Can  Grow  Strong  for 
Their  Country's  Service.  Bv  Ch.\rles  Edward  Amory 
WijxsLOW,  D.  P.  H.,  Professor  of  Public  Health,  Yale 
Medical  School,  and  Curator  of  Public  Health,  American 
Museum  of  Natural  History.  Enlarged  Edition.  In  Two 
Volumes.  With  Chapters  on  Physical  Exercises  and 
Sport  and  Health,  hy  Walter  Camp.  New  York  and 
Chicago :  Charles  E.  Merrill  Company,  1920.    Pp.  iii-405. 

There  were  one  or  two  volumes  which  used  to 
figure  in  our  childhood's  reading,  chiefly  about  de- 
portment, manners,  and  morals.  There  were  good 
little  children  who  kept  themselves  clean  and  gave 
pennies  to  the  poor,  and  poor  contented  children, 
who  knew  their  "station  in  life,"  and  were  duly 
grateful  to  the  rich  donors  of  pennies.  The  vol- 
umes before  us  would  have  been  as  much  treasured 
as  story  books.  They  would  have  told  us  so  much 
we  did  not  know  about  our  mysterious  insides,  the 
top  part  which  had  to  have  poultices  on,  and  the 
lower,  all  stomach,  which  had  griping  pains  and 
required  shuddery  remedies.  We  do  not  know 
whether  the  volumes  are  to  be  used  as  class  books; 
we  recommend  them  for  private  perusal  with  an 
ofTer  of  explaining  the  unfamiliar  words  afterward. 
There  are  questions  at  the  end  of  each  chapter 
which  the  thoughtful  child  will  use ;  the  physical 
exercises  are  easily  learned.  The  chapters  on  Our 
Unseen  Enemies,  Some  Undesirable  Neighbors, 
Bad  Habits,  Fuel  for  the  Body  are  easily  under- 
stood and  the  meaning  of  such  words  as  pasteurize 
gratefully  explained.  Some  of  the  don'ts  will  irri- 
tate socialist  fathers.  "Stealing  rides,  coasting  and 
roller  skating  in  the  streets  are  dangerous  amuse- 
ments." "Why  do  we  have  to  play  in  the  streets, 
Daddy?"  asks  the  young  reader.  Clean  clothes, 
daily  washing  of  the  body,  ventilated  rooms,  are 
not  always  possible,  even  in  apartment  houses, 
where  the  bleaching  green  is  often  a  network  of 
strings  across  the  back  windows  and  the  bathroom 
shared  with  the  numerous  ofifspring  by  one  or  two 
lodgers. 

But  it  is  the  duty  of  an  author  to  say  what  should 


42b 


BOOK  REVIEWS. 


[New  York 
Medical  Journai. 


be  done  even  though  he  sees  no  chance  of  his  ad- 
vice being-  followed.  The  ideas  of  cleanliness  and 
good  health  may  fall  on  good  soil  and  breed  distaste 
for  a  condition  of  things  that  tired  mothers  and 
fathers  regard  as  inevitable. 

The  second  volume  seems  destined  for  senior 
scholars  and  young  teachers,  though  they  may  pro- 
fess to  have  done  the  subject  already.  The  chap- 
ters on  the  digestive  system,  hygiene  of  foods,  care 
of  the  skin,  genns,  tuberculosis,  municipal  sani- 
tation, the  health  board  and  its  work,  contain 
much  they  have  forgotten.  The  idea  is  good,  too,  of 
not  preaching  health  that  one  may  lead  a  healthier 
life  for  the  immediate  benefits  to  self,  but  by  show- 
ing forth  its  benefit  to  provoke  and  foster  emula- 
tion and  bring  about  municipal  reform.  To  those 
of  all  ages  looking  back  is  encouraging.  We  can  all 
recall  conditions  which  today  would  not  be  toler- 
ated, and  there  will  always  exist  those  who  daily 
lament  things  as  they  are  or  disparage  the  bold 
adventures  into  the  wild  lands  of  ignorance,  yet  do 
absolutely  nothing  themselves  except  find  fault. 

SKIN  DISEASES 

Handbook  of  Skin  Disease's.  Bv  Frederick  Gardixer. 
M.p.,  B.  Sc.  (Public  Health).  F.  R.  C.  S.  E..  LecUirer  on 
Skin  Diseases,  University  of  Edinburgh.  New  York: 
William  Wood  &  Co.,  1919.    Pp.  1-160. 

The  usefulness  of  these  little  manuals  is  more 
evident  today,  when  the  learned  laity  are  more  and 
more  inclined  to  self  treatment.  This  book  will  be 
a  help  to  the  young  doctor  who  has  not  had  time  to 
keep  his  dermatology  well  brushed  up.  Yet  he 
should  ever  bear  in  mind  the  interrelation  of  disease 
and  not  be  content  with  treating  effects.  The  chap- 
ter on  tuberculosis  brings  in  the  wide  question  of 
radiotherapy.  Some  wonderfully  clean  healings 
of  tuberculous  sores  have  been  effected  with  the 
ultraviolet  rays,  sores  that  had  existed  for  over  a 
year.  Warts  on  the  chin  disappeared  after  three 
ray  treatments.  Syphilis  is  another  big  question 
which  the  author  could  not  omit  even  from  an  ele- 
mentary volume,  but  he  wisely  admits  the  inadequacy 
of  a  lecture  and  refers  the  reader  to  the  result  of  a 
thorough  examination  by  the  best  men  procurable. 

 ?  

New  Publications  Received. 


[IVe  publish  full  lists  of  books  received,  but  we  acknowl- 
eage  no  obligation  to  revieiv  them  all.  Nevertheless,  so 
far  as  space  permits,  zve  reviezv  those  in  which  ive  think 
our  readers  are  likely  to  be  interested.] 


REPUT.\Tioxs.  Essays  in  Criticism.  B}-  Douglas  Gold- 
RiXG.   New  York :  Thomas  Seltzer,  1920.   Pp.  vii-232. 

WOMAN    AXD    THE    NEW    RACE.      Bv    MaRG.\RET  SaXGER. 

With  a  Preface  bv  Havelock  Ellis.  New  York :  Bren- 
tano's,  1920.    Pp.  xi-234. 

TEN  MINUTE  T.-VLKS  WITH  WORKERS.  From  Thc  Timcs 
(London)  Trade  Supplement.  Garden  Citv  and  New  York: 
Doubleday.  Page  &:  Co.,  1920.    Pp.  viii-203. 

OCCUPATIONAL  DISEASES  AND  THEIR  COMPENSATION.  With 

Special  Reference  to  Anthrax  and  ^liners'  Lung  Diseases. 
By  Frederick  L.  Hoffman,  LL.  D.,  Third  Vice-President 
and  Statistician.  The  Prudential  Insurance  Company  of 
America:  ^^lemlier  National  Conference  of  Social  Work, 
etc.    Newark.  N.  J. :  Prudential  Press,  1920.    Pp.  iii-45. 


krebsbuchleix  fur  axgehexde  pr.vktische  .\erzte. 
Ziirich:  Hans  Rhaue,  1920.    Pp.  i-69. 

dwellers  IX  THE  VALE  OF  siDDEM.  By  A.  C.  RoGERS  and 
^L\ud  a.  2ilEREiLL.    Boston :  Richard  C.  Badger,  1920. 

aglohallucixosis.  Yon  S.  G.vlaxt.  Mit  8  Abbildungen 
un  Text.    Berlin:  Verlag  von  August  Hirschwald,  1920. 

ALTITUDE  and  HEALTH.  By  F.  F.  RocET,  a  Privat  Doccnt 
Professor  in  the  University  of  Geneva.  New  York :  E.  P. 
Dutton  &  Co.   Pp.  xii-186. " 

THE  SURPRISES  OF  LIFE.  By  Georges  Clemenceau.  Trans- 
lated by  Grace  Hall.  Garden  City  and  New  York : 
Doubleday,  Page  &  Co.,  1920.    Pp.  vi-326. 

THIRD    INDUSTRIAL    DIRECTORY    OF    PEXNSYLVANIA.  1919. 

Department  of  Lalwr  and  Industry.  Clifford  B.  Connel- 
LEV,  Commissioner.    Harrisburg,  Pa.,  1920.    Pp.  ii-1212. 

THE  AMERICAN  RED  CROSS  IX  THE  GRE.\T  WAR.    By  HenRV 

P.  Davison,  Chairman  of  the  War  Council  of  the  American 
Red  Cross.  Illustrated.  New  York :  The  Macmillan  Com- 
pany, 1920.   Pp.  i-302. 

PHYSIOLOGY  AND  N.ATIOXAL  XEEDS.  Edited  bv  W.  D.  HAL- 
LIBURTON, M.  D.,  LL.  D.,  F.  R.  C.  P.,  F.  R.  S.,'  Professor  of 
Physiology,  King's  College,  London.  New  York :  E.  P. 
Dutton  &  Co.    Pp.  vii-162. 

MILITARY  PSYCHI.\TRY  IX  PEACE  AND  WAR.  By  C.  STAN- 
FORD Read,  ^I.  D.  (Lond.),  Physician  Fisherton  House 
Mental  Hospital,  Salisbury.  With  Two  Charts.  London : 
H.  K.  Lewis    Co.,  Ltd.,  1920. 

LEHMANX'S    MEDIZINISCHE    LEHRBUCHER.       Band    I.  Er- 

kennung  der  Geistesstorungen.  (Psychiatrische  Diagnos- 
tik.)  Von  WiLHELM  Wfyg.\ndt.  Miinchen :  J.  F.  Leh- 
mann's  \"erlag,  1920. 

PROCEEDINGS     OF     THE    AMERICAX  MEDICO-PSYCHOLOGICAL 

ASSOCIATION.  At  the  Seventv-fifth  Annual  Meeting  held  at 
Philadelphia,  Pa.,  June  18-20,  1919.  Illustrated.  Published 
by  the  Association.  1919.   Pp.  vii-600. 

SCIENCE  AND  LIFE.  Aberdeen  Addresses.  By  Frederick 
SoDDV,  M.  A.,  F.  R.  S.,  Dr.  Lee's  Professor  of  Inorganic 
and  Physical  Chemistn,-,  Universitj-  of  Oxford ;  Lately  Pro- 
fessor of  Chemistry.  University  of  Aberdeen.  Illustrated. 
New  York :  E.  P.  Dutton  &  Co.',  1920.   Pp.  xii-229. 

LECTURES  ox  INDUSTRIAL  PSYCHOLOGY.  By  Bernard 
Muscio,  M.  A.  (Sydney),  M.  A.  (Conville  and  Caius  Col- 
lege, Cambridge)  :  Late  University  Demonstrator  in  Ex- 
perimental Psychology,  Cambridge,  etc.  Second  Edition, 
Revised.  New  York:  E.  P.  Dutton  &  Co.,  1920.  (London: 
George  Routledge  &  Sons,  Ltd.)    Pp.  iy-300. 

THE  MEASLTREMEXT  OF  ixTELLiGExcE.  An  Explanation  of 
and  a  Complete  Guide  for  the  Use  of  the  Stanford  Reyision 
and  Extension  of  the  Binet-Simon  Intelligence  Scale.  By 
Lewis  M.  Termax,  Professor  of  Education,  Leland  Stan- 
ford Junior  LTniversity.  Illustrated.  New  York  and  Chi- 
cago :  Houghton  Mifflin  Company.    Pp.  xviii-362. 

public  health  and  insurance.  American  .\ddresses. 
By  Sir  Arthur  Newsholme,  K.  C.  B.,  M.  D..  F.  R.  C.  P., 
Lecturer  on  Public  Health  Administration  at  the  School  of 
Hygiene  and  Public  Health,  Johns  Hopkins  Uniyersity,  Bal- 
timore, Maryland;  Late  Principal  Medical  Officer  of  the 
Local  Government  Board,  England,  etc.  Baltimore :  The 
Jolins  Hopkins  Press,  1920.    Pp.  xiy-269. 

atlas  und  grundriss  der  bakteriologie  uxd  lehrbuch 
per  speziellen  bakteriologischen  di.\gnostik.  Von  Pro- 
fessor Dr.  K.  B.  Lehmann,  Direktor  des  Hygienischen  Insti- 
tutes in  ^^■i^rzbu^g,  und  Professor  Dr.  ]Med.  et  Phil,  R.  O. 
Neum.\nn.  Direktor  des  Hygienischen  Institutes  in  Bonn.  6. 
Auflage.  Durch  Einen  Nachtrag  Erganzter  Neudruck  der 
5.  Auflage.  Teil  1.  Atlas.  Teil  11.  Te.xt.  Miinchen: 
J.  F.  Lehmanns  A'erlag,  1919. 

hygiene,  dental  and  general.  By  Clair  Els  mere  Tur- 
ner, Assistant  Professor  of  Biologj-  and  Public  Health  in 
the  Ivlassachusetts  Institute  of  Technologv- :  Assistant  Pro- 
fessor of  Hygiene  in  the  Tufts  College  Medical  and  Dental 
Schools.  \Vith  Chapters  on  Dental  Hygiene  and  Oral 
Prophylaxis,  by  William  Rice.  Dean,  Tufts  College  Dental 
School.  Illustrated.  St.  Louis:  C.  V.  Mosby  Company, 
1920.    Pp.  v-400. 


Practical  Therapeutics  and  Preventive  Medicine 

A  Compendium  of  Treatment  and  Prophylaxis,  Original  and  Adapted 


Diets  for  the  Ambulant  Treatment  of  Diabetes 
Mellitus. — Herman  O.  Mosenthal  and  Herbert 
J.  Wiener  (American  Journal  of  the  Medical  Sci- 
ences, July,  1920)  says  that  the  measured  diets  in  the 
modern  treatment  of  diabetes  must  meet  two  require- 
ments, the  control  of  the  glycosuria  and  the  control 
of  the  acidosis.  The  first  is  accomplished  by  regu- 
lating the  consumption  of  carbohydrates,  the  second 
by  adjusting  the  fat  intake.  Two  sets  of  diets 
therefore  are  necessary,  one  in  which  the  fats  are 
reduced  to  a  minimum,  another  in  which  fats  are 
allowed  more  liberally,  but  in  limited  amounts.  The 
latter  is  the  preferable  diet  to  use  when  possible,  as 
it  is  more  palatable  when  continued  for  a  long  time. 
The  authors  furnish  seven  tables  illustrating  the 
minimal  fat  diet  and  the  low  fat  diet.  Table  I  gives 
the  minimal  fat,  starch  free  diet;  Table  H  the  meat 
and  fish  portions  for  use  with  the  minimal  fat  diet; 
Table  HI  a  list  of  vegetables  that  may  be  used  in 
both  forms  of  diet :  Table  IV  the  low  fat,  starch 
free  diet ;  Table  \'  the  meat  and  fish  portions  for 
use  with  this  diet ;  Table  VI  the  approximate  quan- 
tities of  protein,  fat  and  carbohydrate  in  the  mini- 
mal fat,  starch  free  diet  when  round  steak  or  blue- 
fish  are  used  as  meat  or  fish ;  and  Table  VII  the 
approximate  quantities  of  protein,  fat  and  carbohy- 
drate in  the  low  fat,  starch  free  diet  when  roast 
beef,  steak,  or  flounder  are  used  as  meat  or  fish. 

Modern  Individualized  Dietary  Treatment  in 
Diabetes. — Marius  Lauritzen  (American  Journal 
of  the  Medical  Sciences,  July,  1920 )  maintains  that 
no  single  dietary  scheme  suits  the  diflferent  forms 
and  stages  of  this  disease,  and  that  each  patient  has 
to  be  examined  carefully  and  treated  with  the  diet 
that  qualitatively  and  cjuantitatively  suits  him  at 
the  time.  In  a  mild  case  he  gives  the  patient  mixed 
food,  or  the  diet  prescribed  by  the  practitioner  who 
sent  him,  and  makes  quantitative  examinations  for 
blood  sugar,  urinar\-  sugar,  nitrogen  and  ammonia 
in  the  urine,  acetone,  diacetic  acid,  albumin,  etc. 
The  patient  is  then  given  a  test  diet  for  two  or 
three  days  consisting  of  150  grams  of  roast  meat, 
four  eggs,  eighty  grams  of  butter,  fifty  grams  of 
cheese,  three  hundred  grams  of  vegetables  with  two 
to  five  per  cent,  of  carbohydrates,  one  hundred 
grams  of  compote  of  rhubarb,  two  hundred  grams 
of  broth,  one  hundred  grams  of  cream,  one  hundred 
grams  of  bread,  one  third  bottle  of  claret,  five  hun- 
dred grams  of  tea,  five  hundred  grams  of  coffee, 
and  five  hundred  grams  of  soda  water.  This  diet 
contains  one  hundred  and  four  grams  of  protein, 
one  hvmdred  and  forty  grams  of  fat,  seventy-two 
grams  of  carbohydrate,  eighteen  grams  of  alcohol, 
total  2,151  calories.  In  some  mild  cases  the  urine 
will  be  sugar  free  in  two  or  three  days.  If  this  is 
not  the  case,  or  if  the  percentage  of  blood  sugar 
remains  above  normal,  a  vegetable  diet  is  prescribed 
for  one  day,  and  then  an  animal  diet,  which  is  like 
the  test  diet  but  without  cream,  bread,  according  to 
the  nature  of  the  case,  being  replaced  by  sixty  to 
one  hundred  and  twenty  grams  of  gluten  bread  or 


left  out  altogether,  or  changed  for  vegetables  very 
poor  in  carbohydrates.  The  diet  fixed  in  this  way 
is  kept  up  for  months. 

In  uncomplicated  cases  of  moderate  severity 
one  of  the  following  methods  of  treatment  may  be 
employed. 

1.  The  treatment  described  above,  with  strict  vege- 
table diet  for  several  days,  may  be  applied  until  the 
attainment  of  the  desired  result,  when  a  slow  pas- 
sage to  mixed  diet  poorer  in  proteins  than  the  first 
diet  may  be  made.  2.  Instead  of  a  strict  vegetable 
diet,  fasting  may  be  used  as  advised  by  Allen  or 
Cantani,  followed  by  a  slow  passage  to  a  diet  poor 
in  protein.  3.  One  may  rest  content  with  inter- 
calating one  vegetable  day  at  a  time  and  then  pass 
to  a  diet  poorer  in  protein  intercalating,  if  needed, 
another  vegetable  day,  after  which  the  ration  of 
protein  is  further  restricted,  until  blood  sugar  and 
urine  are  normal.  4.  If  the  case  is  one  in  which 
ketonuria  is  likely  to  develop,  as  in  children  and  in 
very  young  people,  Lauritzen  generally  has  re- 
course to  Von  Noorden's  oat  cure,  with  the  rations 
of  oatmeal  and  butter,  kneaded  in  water  to  remove 
fatty  acids,  that  are  suited  to  each  individual  case ; 
after  the  concluding  vegetable  days  he  slowly  passes 
to  strict  animal  diet  with  vegetables.  If  diaceturia 
is  troublesome,  small  doses  of  alkalies  may  be  used. 
In  severe  cases  with  acidosis  of  moderate  severity, 
as  a  rule  treatment  according  to  method  Xo.  3  is 
applied,  with  reduction  of  the  protein,  especially 
meat  and  food  containing  casein.  Both  protein  and 
carbohydrate  are  gradually  restricted  and  replaced 
by  green  vegetables  until  the  attainment  of  agly- 
cosuria  and  the  lowest  percentage  of  blood  sugar 
possible. 

If  the  immediate  attainment  of  sugar  freedom  is 
wanted,  vegetable  treatment  or  fasting  with  con- 
finement to  bed  is  used.  When  aglycosuria  and 
hypoglycemia  are  not  attained  by  method  Xo.  3, 
he  tries  Von  X'oorden's  oatmeal  treatment.  If  one 
of  these  methods  succeeds  in  rendering  urine  and 
blood  normal  and  removing  ketonuria,  diet  poor  in 
protein,  plus  vegetables  poor  in  carbohydrate  with 
washed  out  butter,  or  with  olive  oil,,  vinegar  and 
other  spices,  and  for  drinks  soda  water,  tea,  coffee, 
and  brandy  should  be  continued  as  long  as  possible. 
In  the  severest  cases  with  heavy  acidosis  treatment 
is  more  difficult  and,  as  a  rule,  we  have  obstipation 
and  dyspepsia  to  contend  with.  Confinement  to  bed 
for  a  considerable  period  is  necessary.  The  acido- 
sis will  diminish  through  vegetable  treatment  or 
fasting  with  or  without  subsequent  oatmeal  treat- 
ment. Alkalies  should  be  used.  The  diet  in  the 
aftertreatment  must  contain  very  small  quantities 
of  protein,  vegetable  protein  and  protein  of  hen's 
eggs  are  tolerated  here  better  than  any  other.  Car- 
bohydrate must  be  derived  from  vegetables  and 
fruits  containing  little.  Avoid  milk  and  cream. 
Alcohol  is  almost  indispensable  in  large  doses  of 
claret,  hock,  sugar  free  champagne,  brandy  or  whis- 
ky according  to  the  patient's  liking. 


428 


PRACTICAL  THERAPEUTICS  AND  PREVENTIVE  MEDICINE. 


[New  York 

Medical  Journal. 


The   Treatment   of   Chronic    Fatigue. — John 

Bryant  (Boston  Medical  and  Surgical  Journal, 
June  17,  1920)  says  that  the  world  is  full  of  per- 
sons, mostly  chronic  invalids,  who  react  excessively 
to  sensory  stimuli  of  both  mental  and  physical  ori- 
gin. One  obvious  ultimate  result  of  this  continued 
overreaction  to  sensory  stimuli  is  chronic  fatigue, 
and  the  patient  will  not  recover  until  this  is  re- 
lieved. In  order  to  relieve  the  chronic  fatigue,  its 
cause  must  be  attacked.  Diet  and  exercise,  prop- 
erly used,  are  valuable  factors  in  decreasing  over- 
*reaction  to  sensory  stimuli  and  promoting  a  return 
to  health  of  the  chronic  invalid  The  foremost  es- 
sential in  the  regulation  of  the  diet  is  the  temporary 
elimination  of  meat  and  fish,  and  the  thorough  cook- 
ing and  careful  serving  of  all  foods  allowed.  A 
direct  method  of  raising  the  action  of  the  control 
mechanism  toward  normal  is  the  employment  of  a 
special  type  of  physical  exercise  which  has  for  its 
immediate  object  the  sharpening  of  muscle  sense 
perception  in  relation  to  balance  and  physical  poise. 

The  Treatment  of  Thyroid  and  Other  Endo- 
crine Disturbances  as  Viewed  by  the  Internist. — 
John  A.  Lichty  (American  Journal  of  the  Medical 
Sciences,  June,  1920)  thus  summarizes  his  paper : 
1.  Exophthalmic  goitre  or  hyperthyroidism  from 
other  causes  should  be  recognized  early  and  treated 
promptly.  2.  The  earlier  it  is  recognized,  the  more 
likely  is  medical  treatment  to  be  sufficient  and  to 
give  permanent  results.  3.  The  neglected  cases  or 
cases  having  definite  pathology  besides  are  likely  to 
require  surgery  or  rontgen  ray,  or  both.  In  this  is 
included  radium.  4.  The  rontgen  ray  treatment 
of  the  enlarged  thyroid  presents  most  attractive 
advantages,  but  the  indications  for  its  use  do  not 
seem  definite  yet,  and  the  results  are  not  so  certain. 
5.  In  hyperthyroidism  the  rontgenologist  and  the 
surgeon  at  best  can  only  break  through  a  vicious 
circle  for  which  the  internist  may  or  may  not  have 
been  responsible. 

Tissue  Sparing  Amputations  of  the  Foot. — 

Savariaud  (Prcsse  medicale,  February  7,  1920) 
notes  that,  in  practice,  it  is  seldom  possible  to  per- 
form a  classical  Lisfranc  or  Chopart  amputation 
owing  to  lack  of  a  plantar  flap.  Better  than  to  re- 
sort to  a  Syme  operation  or  some  osteoplastic  pro- 
cedure involving  the  heel,  is,  if  the  disease  is  con- 
fined to  the  border  of  the  foot  and  the  tissues 
immediately  adjacent,  to  bring  over  the  integument 
from  the  opposite  side.  According  to  existing  con- 
ditions, then,  a  flap  is  made  on  the  inner  or  outer 
side  of  the  foot  with  all  the  normal  portion — usu- 
ally a  half — of  the  dorsoplantar  integument.  By 
slight  twisting  the  flap  is  brought  opposite  to  the 
cut  bone  surface  and  sutured.  A  good  bearing  sur- 
face is  thus  obtained  upon  the  plantar  aspect,  and 
at  the  same  time  enough  bone  can  be  saved  to  re- 
produce a  Lisfranc  operation,  though  a  flap  only 
one  half  as  large  is  required.  The  author  em- 
ployed this  procedure  in  four  cases,  with  excellent 
results.  One  patient  had  been  subjected  to  trauma, 
another  had  a  sarcoma  of  the  muscles  of  the  great 
toe,  and  two  had  tuberculosis  of  the  inner  tarsome- 
tatarsal bone  tissues  with  sinus  formation.  The  lat- 
ter condition  constitutes  the  largest  field  for  the 
operation  described. 


The  Cure  of  Chancroids  with  the  High  Fre- 
quency Current. — W.  C.  Kessler  (Urologic  and 
Cutaneous  Review,  May,  1920)  emphasizes  certain 
points  in  the  technic :  There  is  more  danger  of  too 
little  cauterization  than  too  much ;  thorough  cleans- 
ing at  the  time  the  sore  is  fulgurated  must  not  be 
neglected ;  especial  care  must  be  exercised  in  carry- 
ing the  spark  well  down  into  every  fissure  and  un- 
dermined edge  of  the  sore ;  the  application  should 
extend  over  the  edge  of  the  sore  about  one  sixteenth 
inch  into  the  apparently  healthy  area ;  the  current  is 
not  turned  off  until  every  crack  and  crevice  has 
been  thoroughly  treated  and  the  surface  of  the  sore 
has  been  turned  to  a  dark  greenish  gray;  the  sur- 
face of  the  sore  is  then  covered  with  a  thick  moist 
dressing  of  a  two  per  cent,  solution  of  boric  acid ; 
tap  water  often  answers  just  as  well.  This  method 
has  produced  excellent  results.  Treatment  is  given 
every  two  days. 

Injection  of  Turpentine  Oil  in  the  Treatment 
of  Lethargic  Encephalitis. — A.  Netter  (Bulletin 
de  V Academic  de  medecine,  April  6,  1920)  recom- 
mends injection  of  oil  of  turpentine  to  induce  a  fixa- 
tion abscess  in  all  cases  of  lethargic  encephalitis,  as 
soon  as  the  diagnosis  has  been  made.  Out  of  nine- 
teen cases  in  which  this  measure  was  carried  out 
and  in  which  an  abscess  formed  so  that  it  could  be 
incised,  all  but  two  patients  recovered,  and  these  two 
deaths  were  both  in  pregnant  women,  in  whom 
lethargic  encephalitis  is  known  to  be  particularly 
dangerous.  Recovery  was  especially  rapid  among  the 
patients 'in  whom  the  oil  injection  and  the  opening 
of  the  abscess  were  carried  out  early.  This  indi- 
cates that  the  treatment  should  be  applied  not  only 
in  the  more  severe  cases  but  in  all  patients  with  this 
disease.  The  diagnosis  of  the  latter  may  now  be 
made  quite  early,  thanks  to  the  procedure  of  investi- 
gating the  "electric"  muscular  contractions  recently 
described  by  Sicard.  Testing  for  the  amount  of 
glucose  in  the  cerebrospinal  fluid  is  likewise  of  serv- 
ice in  early  diagnosis. 

Differentiation  of  Structures  by  the  X  Ray. — 

Gustav  Kolischer  and  R.  A.  Arens  ( Urologic  and 
Cutaneous  Review,  May,  1920)  consider  two  prob- 
lems:  1,  How  to  accomplish  the  elimination  of  the 
secondary  rays  in  order  to  avoid  blurring  of  the 
picture,  and  2,  how  to  establish  a  graded  relation 
between  the  pictorial  density  of  the  organs  and  cer- 
tain pathologic  changes. 

The  authors  use  an  aluminum  filter  of  two  milli- 
metre thickness,  in  order  to  prevent  the  interfer- 
ence of  the  secondary  radiation  with  the  clearness 
of  the  picture  taken  of  an  organ.  This  as  a  rule  is 
sufficient  to  bring  out  the  contours  of  the  organ  in 
question  very  clearly. 

In  order  to  illustrate  the  possibilities  of  this 
proposition,  three  observ^ations  are  noted.  In  the 
first,  in  a  case  of  sarcoma  of  the  epididymis,  the 
outlines  of  the  tumor  in  contrast  with  the  shadow 
of  the  testis  were  not  to  be  seen  distinctly  on  the 
rontgenogram  until  a  picture  with  interpolation  of 
a  three  millimetre  filter  was  taken.  In  a  case  of 
unilateral  proliferating  tuberculosis  of  a  kidney 
and  in  cases  of  kidney  stone,  the  interpolation  of 
the  filter  gave  a  much  better  and  more  distinct 
picture. 


Proceedings  of  National  and  Local  Societies 


BRITISH  MEDICAL  ASSOCIATION. 

Eighty-eighth  Annual  Meeting,  Held  June  25,  1920, 
at  Cambridge,  England. 

SECTION    IX  MEDICINE. 

The   President,   Sir   Humphry   D.   Rollestox,   K..C.  B., 
M.  D.,  F.  R.  C.  P.,  in  the  Chair. 

{Continued  from  page  432) 
Diagnosis  of  Nervous  Disorders  of  ^he  Stom- 
ach and  Intestines. — Dr.  Arthur  F.  HuftST, 
physician  and  neurologist  to  Guy's  Hospital, 
pointed  out  that  an  attempt  must  be  made  to 
gain  a  clear  conception  of  what  was  meant  by 
certain  terms,  such  as  functional  neurosis,  psy- 
choneurosis,  neurasthenia,  and  hysteria.  A 
functional  disorder  was  one  which  did  not  de- 
pend upon  organic  change ;  it  might  be  either 
biochemical  or  nervous  in  origin.  Functional 
disorders  of  nervous  origin  were  of  two  kinds : 
the  neuroses,  which  were  independent  of  mental 
processes,  whether  conscious  or  subconscious,  and 
the  psychoneuroses,  which  had  a  psychical  cause. 
This  distinction  was  of  fundamental  import- 
ance, as  the  psychoneuroses  alone  were  amenable 
to  psychotherapy.  Neurasthenia  had  generally 
been  classified  as  a  neurosis,  but  it  really  de- 
pended upon  definite  though  evanescent  organic 
changes  in  the  central  nervous  system  and  in  the 
suprarenal  and  possibly  endocrine  glands,  re- 
sulting from  mental  and  physical  exhaustion  and 
chronic  intoxications.  It  was,  therefore,  an  or- 
ganic and  not  a  functional  disorder.  However, 
the  relation  of  neurasthenia  to  the  nervous  disor- 
ders of  digestion  required  discussion. 

The  psychoneuroses  could  be  classified  under  the 
headings  of  hysteria  and  psychasthenia.  Before 
the  war  Hurst  would  have  classed  the  tics  separ- 
ately, but  he  was  not  convinced  that  they  were 
really  hysterical.  By  hysteria  was  meant  a  con- 
dition in  which  symptoms  were  present  which 
had  been  produced  by  suggestion  and  were  cur- 
able by  psychotherapy.  During  the  war  his 
fellow  workers  and  he  gathered  together  a  great 
deal  of  evidence  to  show  that  in  the  absence  of 
gross  hysterical  manifestations  there  was  no 
underlying  condition  to  which  the  name  of  hys- 
teria could  be  given.  They  had  confirmed  Bab- 
inski's  observations  that  Charcot's  physical  stig- 
mata were  invariably  a  result  of  suggestion  on 
the  part  of  the  observer,  and,  what  was  more  im- 
portant, they  Avere  firmly  convinced  that  although 
an  abnormal  degree  of  suggestibility  predisposed 
to  hysteria,  it  was  not  essential  and  that  hys- 
teria might  occur  in  individuals  with  a  perfectly 
normal  mental  makeup.  When  this  was  once 
realized,  it  became  clear  that  absence  of  thelrien- 
tal  characteristics  which  lead'  to  an  individtial  be- 
ing labelled  as  neurotic  did  not  in  any  way  ex- 
clude the  possibility  of  the  digestive  or  other 
disorder  from  which  he  was  suffering  being  hys- 
terical, any  more  than  it  could  be  assumed  that 
symptoms  in  a  neurotic  girl  were  not  due  to 


organic  disease.  It  followed  that  a  diagnosis 
could  only  be  made  from  the  nature  of  the  symp- 
toms and  the  results  of  physical  and  laboratory 
methods  of  examination. 

Hurst  pointed  out  that  the  traditional  descrip- 
tion of  the  nervous  disorders  of  digestion  de- 
pended upon  false  ideas  of  physiology-  and  anat- 
omy. It  was,  for  example,  assumed  that  a  cer- 
tain degree  of  tone  and  a  certain  activity  of  peris- 
talsis were  normal  and  that  a  normal  stomach 
secreted  juice  of  a  certain  strength.  Any  di- 
vergence from  these  standards,  which  were  as  a 
matter  of  fact  often  vague,  was  regarded  as  evi- 
dence of  disordered  function.  Such  a  condition 
as  atonic  dyspepsia,  dtie  to  atonic  dilatation  of  the 
stomach  caused  by  deficient  tone,  associated  with 
deficient  peristalsis  and  secretion,  and  acid  dys- 
pepsia due  to  hypersecretion  were  described, 
while  the  more  scientific  writer  spoke  of  hypo- 
chlorhydria  and  hyperchlorhydria  as  clinical  en- 
tities. In  addition  to  the  motor  and  secretory  neu- 
roses a  sensor}'  neurosis  was  recognized  in  which 
indigestion  was  supposed  to  result  from  hyper- 
esthesia of  the  gastric  mucous  membrane. 

Hurst's    own    itivestigations,    which    had  '  been 
confirmed     by     niuuerous     radiographers  both 
in   England   and   abroad,   and  the   recent  chem- 
ical    investigations     by     fractional     test  meals 
carried     out     by      Rehfuss     and      Crohn  in 
America     and     Ryle     and    Bennett     at  Gtiy's 
Hospital,  had  shown  that  such  great  variations 
occur  in  the  muscular  tone,  peristalsis,  and  secre- 
tory activity  of  the  stomach  in  normal  individuals 
that  it  might  well  be  doubted  whether  what  was 
generally    regarded    as    atonic    dilatation,  hyper- 
chlorhydria and  hypochlorhydria  did  not  really 
fall  within  the  normal  limits.    This  remained 
true  even  when  the  diagnosis  was  supported  by 
an  X  ray  examination  and  gastric  analysis.  Hurst 
had  seen  so  many  doctors  who  believed  patients 
had  atonic  dilatation  of  the  stomach,  but  found  with 
the   X   ray  that   they  had   hypertonic  stomachs, 
and  he  had  seen  so  many  many  in  which  the  symp-* 
toms  pointed  to  hyperchlorhydria  but  actually 
acliA-lia  was  present,  that  he  was  quite  certain 
that  it  was  utterly  impossible  to  form  a  reliable 
estimate  of  the  muscular  or  secretory  activity  of 
the  stomach  from  a  consideration  of  the  symp- 
toms alone.    The  investigations  he  carried  out 
with  several  of  the  students  of  Guy's  Hospital 
some  years  ago  proved,  moreover,  that  the  theory 
of  gastric  hyperesthesia  had  no  basis  in  fact,  as 
the  mucous  membrane  of  the  stomach  both  in 
health  and  disease  was  entirely  insensitive  to 
tactile,  thermal,  and  painful  stimuli  and  to  hydro- 
chloric acid  up  to  the  maximum   strength  in 
which  it  could  conceivably  be  present  in  the  gas- 
tric jtiice.    The  discovery  of  variations  from  the 
average  normal  tone  peristalsis  and  secretion  in 
individuals  with  digestive  symptoms  was,  there- 
fore, no  evidence  that  these  variations  were  in 
any  way  responsible  for  the  symptoms. 


430 


PROCEEDINGS  OF  NATIONAL   AND  LOCAL  SOCIETIES. 


[New  York 
Medical  Journal. 


The  atonic  dilatation  and  hyposecretion  which 
were  supposed  to  be  the  cause  of  dyspepsia  of  the 
exhausted  neurasthenia  as  a  rule  existed  only  in 
the  imagination,  as  there  was  not  the  smallest  evi- 
dence to  show  that  true  neurasthenia  in  any 
way  affected  the  motor  or  secretory  functions  of 
the  stomach.  He  could  well  believe  that  an  ex- 
hausted individual 'who  happened  to  have  a  stomach 
the  tone,  peristalsis  and  secretion  of  which  were 
below  the  average,  would  be  more  likely  to  suffer 
from  indigestion  than  a  man  with  a  normal  stom- 
ach. His  condition  fnight  be  correctly  described  as 
neurasthenic  dyspepsia  and  he  might  benefit  from 
treatment  directed  to  increase  the  motor  and  secre- 
tory activity  of  his  stomach,  but  it  must  be  re- 
membered that  the  neurasthenia  was  not  the  cause 
of  the  deficient  tone  and  secretion,  and  that  in  the 
absence  of  the  neurasthenia  there  would  be  no 
digestive  symptoms  although  the  deficient  tone  and 
secretion  would  still  be  present.  Exhaustion  might 
be  the  exciting  cause  of  a  different  group  of  gastric 
symptoms  in  a  man  whose  stomach  was  of  the 
hypertonic  hypersecretory  type,  and  these  symptoms 
might  be  the  herald  of  an  attack  of  duodenal  ulcer. 
But  the  hypertonus  and  hyperchlorhydria  were  con- 
genital and  not  caused  by  the  exhaustion  or  the 
duodenal  ulcer;  they  simply  predispose  to  a  certain 
forn)  of  indigestion — the  acid  dyspepsia  or  hyper- 
chlorhydria of  the  textbooks  which  occurred  as  a 
result  of  various  conditions,  one  of  which  was 
exhaustion.  Hurst  believed  there  was  little  justi- 
fication for  retaining  such  terms  as  atonic  dilata- 
tion of  the  stomach,  hyperchlorhydria,  hypochlor- 
hydria,  atonic  and  acid  dyspepsia,  as  descriptions  of 
clinical  conditions.  We  could  separate  two  varie- 
ties of  neurasthenic  dyspepsia,  which,  however, 
could  be  recognized  with  certainty  only  by  the  aid 
of  the  X  rays  and  gastric  analysis ;  the  atonic,  oc- 
curring in  an  individual  with  a  stomach  with  less 
than  the  average  tone  and  secretion,  and  the  hyper- 
tonic, occurring  in  one  with  a  stomach  with  more 
than  the  average  tone  and  secretion. 

It  was  comparatively  rare  for  a  patient  to  consult 
a  doctor  on  account  of  constipation  without  having 
already  attempted  to  cure  himself  with  aperients. 
But  no  accurate  diagnosis  could  be  made  until  it 
"  had  been  ascertained  whether  the  patient  was  really 
constipated.  In  Dr.  Hurst's  experience  the  symp- 
toms generally  ascribed  to  autointoxication  caused 
by  intestinal  stasis  were  really  produced  by  purga- 
tives. They  led  to  the  absorption  of  an  excess  of 
toxic  material,  partly  by  hastening  the  half  digested 
contents  of  the  small  intestine  into  the  cecum  where 
fermentation  and  putrefaction  were  consequently 
increased,  and  partly  by  causing  the  contents  of  the 
transverse,  descending  and  pelvic  colon  to  be  fiuid 
instead  of  solid,  so  that  absorption  of  toxins  took 
place  in  the  cecum  and  ascending  colon  alone.  The 
patient  should  be  instructed  to  see  what  happened  if 
no  drugs  were  taken  for  a  week,  an  effort  being 
made  to  open  the  bowels  each  morning.  In  most 
cases  he  quickly  lost  his  abdominal  pain  and  his 
socalled  toxic  symptoms.  The  bowels  were  often 
opened  daily,  in  which  case  a  diagnosis  of  hysterical 
pseudoconstipation  could  be  made — hysterical  be- 
cause the  patient  had  suggested  to  himself  as  a 


result  of  faulty  education  combined  with  the  read- 
ing of  pernicious  advertisements  that  he  was  con- 
stipated and  required  aperients  to  keep  him  well, 
whereas  a  little  psychotherapy  in  the  form  of  ex- 
planation of  the  physiology  of  his  bowels  and  the 
origin  of  his  symptoms,  and  persuasion  to  try  to 
open  his  bowels  each  morning  without  artificial 
help,  resulted  in  a  cure.  In  many  cases,  however, 
the  patient  did  not  succeed  in  opening  his  bowels, 
although  he  might  feel  more  comfortable  than  when 
he  was  taking  drugs.  A  further  abdominal  and 
rectal  examination  should  then  be  made.  If  no 
sign  of  organic  disease  was  present  and  if,  as  was 
generally'  the  case,  no  accumulation  was  felt  in  the 
abdomen,  the  rectum  would  be  found  filled  with 
feces  which  were  in  some  cases  stony  hard  but  in 
others  quite  soft,  proving  that  there  was  no  delay 
in  the  passage  through  the  intestines.  In  spite  of 
this  the  patient  had  no  desire  to  open  his  bowels, 
although  a  normal  individual  would  feel  an  urgent 
call  to  defecation  under  the  conditions.  In  1908 
he  called  this  condition  of  inefficient  defecation 
dyschezia  to  distinguish  it  from  true,  intestinal 
stasis,  in  which  there  was  a  delay  in  the  colon.  The 
majority  of  cases  of  dyschezia,  which  was  the  com- 
monest form  of  severe  constipation,  were  of  nerv- 
ous origin.  They  were  caused  by  neglect  to  re- 
spond to  the  call  to  defecate  owing  to  laziness,  in- 
sanitary conditions  of  toilets,  or   false,  modesty. 

The  rectum  gradually  dilated,  so  that  an  increasing- 
quantity  of  feces  was  needed  to  produce  the  inter- 
nal pressure  required  to  give  the  sensation  of  full- 
ness which  was  the  natural  call  to  defecation  and 
finally  the  sensation  was  lost  completely.  But  the 
patient  was  still  capable  of  emptying  his  rectum  if 
he  tried.  He  had,  however,  convinced  himself  that 
he  could  not  get  his  bowels  open  unless  he  took 
enemata  or  such  enormous  doses  of  aperient  that 
the  fluid  feces  practically  acted  as  enemata.  He 
thus  suggested  to  himself  that  his  rectum  was  pow- 
erless to  act  by  itself,  true  hysterical  dyschezia  be- 
ing thus  produced.  In  many  cases  no  treatment 
was  required  beyond  explaining  to  the  patient  the 
nature  and  cause  of  his  condition  and  persuading 
him  to  make  an  effort  to  empty  his  rectum,  which 
he  must  realize  was  quite  capable  of  doing  its  work, 
but  occasionally  it  was  also  necessary  to  reeducate 
his  rectum  with  graduated  enemata.  In  severe  cases 
it  was  advisable  to  examine  the  intestinal  functions 
with  the  X  rays,  a  barium  meal  being  given  after 
the  patient  had  discontinued  taking  his  aperients. 

Dr.  Hurst  said  that  the  time  table  he  gave  ten 
years  ago  for  the  passage  of  food  along  the  ali- 
mentary canal  was  nothing  more  than  the  average 
taken  from  numerous  records  obtained  with  the 
X  rays,  but  it  had  unfortunately  often  been  re- 
garded as  representing  the  normal  standard,  the 
slightest  variations  from  which  indicated  the  pres- 
ence of  intestinal  stasis.  The  fallacy  of  this  had 
been  pointed  out  frequently,  as  the  normal  limits 
were  very  wide,  but  he  still  often  saw  patients  who 
had  been  advised  to  submit  themselves  to  colectomy 
or  other  drastic  treatment  as  a  result  of  an  x  ray 
examination  which  showed  a  somewhat  slow  pas- 
sage, which  was,  however,  well  within  the  normal. 
He  therefore  thought  it  necessary  once  again  to 


September  18,  1920.1  PROCEEDINGS  OF  NATIONAL   AND  LOCAL  SOCIETIES. 


431! 


describe  briefly  the  evidence  required  in  order  to 
diagnose  stasis  in  different  parts  of  the  intestinal 
tract.  Ileac  stasis  should  only  be  diagnosed  if  no 
trace  of  barium  had  reached  the  cecum  six  hours 
after  the  opaque  meal,  or  if  a  considerable  quantity 
of  barium  containing  chyme  was  still  in  the  end 
of  the  ileum  nine  hours  after  the  meal,  if  the  stom- 
ach was  known  to  have  emptied  itself  in  three 
hours.  If  most  of  the  barium  was  still  in  the 
cecum  and  ascending  colon  at  the  end  of  twenty- 
four  hours,  they  were  the  seat  of  stasis,  even  if  a 
little  had  passed  to  the  more  distant  parts  of  the 
colon,  but  a  faint  shadow  of  the  cecum  was  often 
visible  in  normal  individuals  even  three  days  after 
the  meal.  If  the  splenic  flexure  was  reached  in 
twenty-four  hours  and  the  greater  part  of  the 
barium  was  in  the  transverse  colon  at  the  end  of 
forty-eight  hours,  there  must  be  stasis  in  the  trans- 
verse colon.  Lastly,  if  at  the  end- of  twenty-four 
hours  the  greater  part  of  the  barium  had  collected 
in  the  pelvic  colon  or  rectum  or  both,  and  in  spite 
of  this  no  desire  to  open  the  bowels  was  felt, 
dyschezia  could  be  diagnosed.  Apart  from  dys- 
chezia  the  only  common  form  of  constipation  of 
nervous  origin  was  that  resulting  from  anorexia. 
Anorexia  was  a  common  symptom  of  both  neu- 
rasthenia and  psychasthenia,  and  the  deficient  stimu- 
lation of  the  intestine  which  it  caused  generally 
led  to  a  slow  passage  through  the  entire  colon.  In- 
testinal activity  was  also  likely  to  be  inhibited  by 
depressing  emotions  in  psychasthenia.  There  was, 
however,  no  evidence  to  show  that  the  nerve  ex- 
haustion of  neurasthenia  had  any  influence  on  the 
bowels.  Hurst  was  convinced  that  no  such  thing 
as  atonic  constipation  existed,  for  tone  and  peristal- 
sis were  independent  functions ;  and  whereas  de- 
ficient peristalsis  was  a  common  cause  of  constipa- 
tion, the  x  rays  had  proved  that  atony  of  the  colon 
was  a  rare  condition,  generally  organic  in  origin 
and  not  necessarily  associated  with  any  disturbance 
in  peristalsis. 

SECTION   IN  TROPICAL  MEDICINE. 

The  President,  Professor  Q.  H.  F.  Nuttall,  M.  D.,  F.  R.  S., 
in  the  Chair. 

Dietetic  Deficiency  and  Endocrine  Activity. — 

Lieut.-Colonel  Robert  McCarrison,  M.  D.,  D.  Sc., 
LL.D.,  F.  R.  C.  P.,  of  the  Indian  Medical  Service, 
pointed  out  that  the  endocrine  organs,  regulators 
of  metabolism,  were  profoundly  influenced  by  diete- 
tic defects.  This  fact  had  been  demonstrated  by 
experimentation  on  pigeons,  guineapigs,  and  mon- 
keys. Animals  of  these  species  were  fed  on  six 
classes  of  deficient  dietaries.  The  first  was  deficient 
in  all  three  classes  of  vitamines  and  in  suitable 
protein,  and  was  disproportionately  rich  in  carbo- 
hydrates ;  the  second  was  deficient  in  B  and  C  vita- 
mines  and  disproportionately  rich  in  carbohydrates 
and  fats ;  the  third  was  deficient  in  B  vitamine  and 
disproportionately  rich  in  carbohydrates  and  fats ; 
the  fourth  was  deficient  in  A  and  B  vitamines ;  the 
fifth  in  B  vitamine  only ;  the  sixth  in  C  vitamine 
only.  The  effects  of  these  dietaries  on  the  en- 
docrine organs  was  attributable  to  three  factors 
operating  in  varying  combinations:  1,  Deficiency  of 
vitamines ;  2,  imperfect  balance  of  the  food  with 
respect  to  proximate  principles ;  3,  the  fortuitous 


occurrence  of  pathogenic  agents  in  the  body.  The 
first  two  factors  came  into  operation  when  the  first 
three  dietaries  were  used ;  they  were  aided  in  a 
proportion  of  cases  by  the  third  factor.  The  first 
factor  was  chiefly  concerned  in  producing  the  re- 
sults when  the  last  three  dietaries  were  used.  It 
also  was  aided  in  a  proportion  of  cases  by  the  third 
factor.    McCarrison  summed  up  as  follows : 

1,  Dietetic  deficiency  had  a  profound  influence  on 
endocrine  activity.  2.  All  endocrine  organs,  with 
the  adrenal  glands  and  the  pituitary  body,  under- 
went a  greater  or  less  degree  of  atrophy  and  de- 
preciation of  functional  capacity  as  a  result  of  diet- 
etic deficiencies.  3.  The  adrenal  glands  and  in 
males  the  pituitary  body  enlarged  in  consequence  of 
dietetic  defects ;  the  former  greatly,  the  latter  slight- 
ly. 4.  The  adrenals  were  the  most  susceptible  of  all 
endocrine  structures  to  dietetic  defects.  5.  The 
character  of  the  adrenal  enlargement  varied  with 
the  character  of  the  dietetic  deficiency.  6.  The 
adrenalin  content  of  the  enlarged  adrenals  varied 
with  the  character  of  the  dietetic  defect.  It  was 
in  excess  of  normal  when  the  food  was  deficient 
in  vitamines,  in  proteins,  and  disproportionately 
rich  in  starch ;  it  was  below  normal  when  the  diet 
was  scorbutic  and  also  when  concurrent  infec- 
tions were  associated  with  dietetic  defects. 
7.  Edema  was  invariably  associated  with  massive 
enlargement  of  the  adrenal  glands  in  pigeons  fed 
on  autoclaved  rice,  but  massive  enlargement  of 
the  adrenals  was  not  invariably  associated  with 
edema.  This  association  bore  an  intimate  rela- 
tionship to  the  adrenalin  content  of  the  enlarged 
organs ;  when  the  content  was  high  edema  oc- 
curred in  eighty-six  per  cent,  of  cases ;  when  the 
content  was  low  edema  did  not  occur.  8.  Fresh 
butter  contained  some  substance  which  tended 
to  protect  against  edema.  This  substance  was. 
not  present  in  a  cocoanut  oil.  9.  The  hypo- 
thetical "antiedema  substance  in  butter  had  a 
pronounced  influence  over  the  adrenal  glands. 
It  appeared  to  exert  its  protective  action  against 
edema  by  maintaining  their  adrenalin  content  at 
a  low  level.  10.  Butter  varied  in  its  capacity  to 
protect  against  edema.  This  variation  was  de- 
pendent on  the  quality  of  the  cow's  food ;  butter 
was  richer  in  antiedema  substance  when  the 
cows  were  fed  on  green  fodder  than  when  the>^ 
were  fed  on  dry  fodder. 

In  a  paper  on  the  pathogenesis  of  deficiency 
disease  published  some  time  ago  McCarrison 
suggested  that  edema  was  initiated  by  increased 
intracapillary  pressure  consequent  on  hyper- 
adrenalinemia.  More  extended  experience  had 
caused  him  to  alter  his  opinion.  Recent  work 
on  the  effects  of  adrenalin  did  not  support  this, 
suggestion.  It  seemed  more  probable  that  an 
excess  of  adrenalin  might  reach  the  kidneys  di- 
rect and  interfere  with  the  normal  excretion  of 
urine,  thus  favoring  the  retention  of  fluid  in  the 
tissues.  A  number  of  closely  correlated  facts 
pointed  in  this  direction.  Thus  the  adrenals 
were  enlarged  in  human  beri  beri  and  their  ad- 
renalin content  was  high,  the  urinary  out- 
put in  human  beri  beri  is  small,  although  in  gen- 
eral no  disease  of  the  kidneys  was  present;  excess 


432  LETTERS  TO 

of  adrenalin  introduced  into  the  venous  circulation 
inhibited  the  flow  of  urine  (Gunning)  and  caused 
retention  of  sodium  chloride  in  the  tissues 
(Bulche  and  Weiss)  ;  a  channel  of  communication 
existed  between  the  adrenal  glands  and  the  kid- 
neys, whereby  the  products  of  the  glands  might 
reach  the  kidneys  without  either  dilution  or 
oxidation  in  the  general  circulation,  (Gow). 
finally  a  diminution  of  the  flow  of  urine  could  be 
produced  by  the  direct  action  of  adrenalin  reach- 
ing the  kidneys  by  this  route  (Gow^).  Adrena- 
lin thus  appeared  to  control  the  excretion  of 
urine ;  this  being  so.  it  was  of  great  importance 
to  be  aware  of  the  fact  that  adrenalin  was  in  its 
turn  controlled  by  the  quality  of  the  food.  Other 
factors  in  addition  to  impaired  excretion  no  doubt 
played  their  part  in  the  causation  of  edema — im- 
pairment of  endothelial  function  Avith  associated 
alterations  in  vascular  permeability,  impaired 
metabolism  of  proteins  and  lipoids,  and  chemical 
changes  in  the  tissues  themselves,  all  of  which 
were  consequences  of  the  disturbed  endocrine 
function  and  of  the  disturbed  metabolism  which 
was  the  outcome  of  vitamine  deprivation  and 
malnutrition. 

SECTIOX    IX    PATHOLOGY   AND  BACTERIOLOGY 

The  President,  Professor  J.  Lorraix  Smith,  M.  D.,  F.  R.  S., 
in  the  Chair. 

Present  Position  of  Cancer  Research. — Dr.  J. 

A.  jNIurr-ay,  Director  of  the  Imperial  Cancer  Re- 
search Fund,  said  that  attention  should  be  drawn  to 
the  bearing  of  the  results  of  experimental  work  on 
the  important  statistical  character  of  cancer,  and  its 
increasing  frequency  with  advancing  age  in  man  and 
animals.  It  was  not  easy  to  say  to  what  extent  this 
peculiar  age  incidence  was  a  consequence  of  the 
chronicity  of  the  forms  of  irritation  which  most 
constantly  led  to  the  development  of  cancer  and  how 
far  senile  cellular  changes  were  a  necessar}'  ante- 
cedent. The  results  of  the  culture  of  normal  tis- 
sues in  vitro  showing  practically  unlimited  powers 
of  growth  under  suitable  conditions  would  appear 
to  relegate  the  senile  failure  of  growth  to  a  posi- 
tion of  secondary  consequence  of  accidental  cell 
damage  inseparable  from  the  chances  of  life.  If 
this  were  so,  then  the  age  incidence  of  cancer  could 
be  regarded  as  a  consequence  of  the  relative  in- 
efficiency of  most  of  the  forms  of  irritation  asso- 
ciated with  the  origin  of  cancer  in  producing  the 
disease. 

In  support  of  this  view  it  could  be  noted  that 
Dr.  L.  J.  Dublin  recorded  a  higher  evidence  of 
cancer  in  the  experience  of  a  Xew  York  insurance 
company  among  industrial  policyholders  than  among 
those  in  easier  social  circumstances.  The  former 
were  of  necessity  more  exposed  to  various  forms  of 
chronic  irritation  than  the  latter.  Fibiger  had  de- 
veloped the  same  argument  in  reply  to  the  obj  ections 
raised  to  the  cancerous  nature  of  the  growths  in 
rats'  stomachs,  namely  that  they  were  not  neces- 
sarily associated  with  old  age.  He  claimed  that  the 
spiroptera  infection  was  so  potent  a  cause  of  the 
disease  that  the  long  duration  necessary  in  other 
forms  of  irritation  was  not  required. 

(To  he  concluded) 


THE   EDITORS.  ,    [New  York 

Medical  Journal. 

Letters  to  the  Editors. 


INTERNATIONAL       ASSOCIATION  OF 
PNEUMOTHORAX  ARTIFICIALIS. 

New  York,  August  j/,  1920. 

To  the  Editor: 

I  have  been  requested  by  Professor  Carpi,  of  Lugano, 
Switzerland,  the  General  Secretary  of  the  International  As- 
sociation of  Pneumothorax  Artificialis,  to  translate  the  fol- 
lowing circular  letter  from  the  French  which  he  had  recently 
sent  me,  and  to  cause  it  to  be  published  in  as  many  of  the 
American  medical  journals  as  will  be  willing  to  give  it 
space.  May  I  ask  you  to  extend  to  it  the,  hospitality  of 
your  esteemed  paper,  and  believe  me 

\'ery  truly  yours, 

S.  Adolphus  Knopf. 

The  International  Association  of  Pneuinothorax 
Artificialis,  the  work  of  which  was  paralyzed  dur- 
ing the  long  war,  desires  to  resume  its  activity  by 
inviting  all  former  members  of  the  association  to 
•  renew  their  subscription  and  all  other  physicians 
interested  in  artificial  pneumothorax  to  send  their 
names  and  addresses  to  Professor  Umberto  Carpi, 
Lugano,  Switzerland,  and  to  become  members. 

The  purpose  of  the  association  is  to  spread  all 
practical  and  scientific  information  concerning  arti- 
ficial pneumothorax.  Although  induced  pneumo- 
thorax for  therapeutic  purposes  has  become  remark- 
ably prevalent  it  has  remained  a  procedure  applied 
only  by  physicians  specially  trained  and  experienced 
in  this  operation.  For  the  convenience  of  the  patients 
who  may  be  obliged  to  change  their  residences,  to 
know  the  names  and  addresses  of  physicians  who 
practice  artificial  pneumothorax  is  of  great  value,  in 
order  that  the  patient  may  continue  the  treatment  by 
periodic  refilling.  A  complete  list  of  physicians 
practicing  artificial  pneumothorax  will  be  published 
with  the  scientific  journal  known  as  Pneumothorax 
Tlicrapcutiquc  for  1920-1921,  edited  by  Carlo  For- 
lanini.  This  list  will  be  sent  to  all  the  members  and 
to  the  most  important  medical  societies,  medical 
academies,  and  similar  institutions  of  the  different 
countries.  In  the  journal  will  be  enumerated  and 
discussed  all  the  world's  literature  on  pneumo- 
thorax. The  association  will  continue  its  labors 
under  the  policy  indicated  by  the  illustrious  master 
and  creator  of  artificial  pneumothorax  therapy.  As 
soon  as  the  finances  of  the  society  will  permit  the 
renewal  of  the  publication,  the  editor  will  put  hiin- 
self  in  communication  with  the  editors  of  such 
medical  journals  of  other  countries  as  are  publish- 
ing articles  on  artificial  pneumothorax.  For  the 
present  these  are  die  Sondcrhefte  des  Tuberkulose 
Ccntralhlattes  iiehcr  LungcnkoUapsthcrapie  and  the 
monographs  in  the  journal  La  Tuherculosi,  Rome. 

The  subscription  price  of  five  francs  should  be 
addressed  to  the  General  Secretary,  Prof.  U.  Carpi, 
Lugano.  The  subscriber  is  entitled  to  receive  the 
journal  with  the  list  of  names.  Those  who  desire 
to  receive  the  monographs  of  the  journals  indicated 
should  make  a  request  for  them  to  the  General  Sec- 
retary, who  also  has  an  international  exchange  office 
for  all  publications  appertaining  to  artificial  pneu- 
mothorax. Summaries  in  English,  French  and 
German  on  any  topic  relating  to  artificial  pneu- 
mothorax will  be  gratefully  received  and  published. 

Prof.  U.  Carpi,  General  Secretary. 
LuGAXo,  August  10,  1920. 


New  York  Medical  Journal 

INCORPORATING  THE 

Philadelphia  Medical  Journal     Medical  News 

A  Weekly  Review  of  Medicine,  Established  18^3. 

Vol.  CXII.  No.  13.  NEW  YORK.  SATURDAY.  SEPTEMBER  25.  1920.  •         Whole  No.  2182. 

Original  Communications 


PERSISTENT  VOLUXTARY  MUTISM.* 
By  Alfred  Gordo x,  M.  D., 

Philadelphia. 

Mutism  is  a  form  of  speech  disturbance  which 
may  be  encountered  in  a  large  variety  of  conditions. 
Hysteria  is  the  affection  in  which  mutism  is  most 
frequently  found.  In  the  works  of  older  writers 
facts  are  recorded  showing  sudden  recovery  from 
mutism;  they  all  have  reference  to  cases  of  hysteria. 
In  this  affection  the  condition  may  develop  suddenly 
after  an  emotional  disturbance  or  gradually  after  a 
period  of  aphonia,  when  the  patient  is  still  able  to 
converse  but  in  a  low  voice.  Occasionally  trau- 
matism or  an  infectious  disease  is  likely  to  be  the 
cause  of  mutism. 

Among  other  causative  factors  of  mutism  may 
be  mentioned  abulic  inhibition  in  psychasthenia  and 
the  psychoses.  Mutism  is  frequently  observed  in 
the  insane.  It  is  common  to  see  in  them  an  obstin- 
ate silence  extending  over  months  and  years.  The 
depressive  cases  usually  present  a  mutism  of  long 
duration  together  with  absolute  immobility.  In  the 
cases  of  negativism,  such  as  is  observed  in  dementia 
praecox,  mutism  may  be  one  of  the  negativistic  man- 
ifestations. In  a  patient  under  the  writer's  obser- 
vation, after  the  birth  of  her  first  child  and  after  a 
period  of  slight  confusion  accompanied  by  mild 
delirium,  a  state  of  resistiveness  developed  which 
soon  invaded  the  faculty  of  speech  and  mutism  fol- 
lowed. Not  only  words  but  £ven  sounds  are  never 
emitted  by  the  patient.  She  is  absolutely  silent  but 
at  times  movements  of  the  lips  are  observable  as  if 
she  was  making  an  effort  to  reply  to  questions 
asked.  The  mutism  has  been  in  existence  for  nine 
weeks  and  there  is  no  indication  of  a  prompt  return 
of  her  voice. 

That  organic  cerebral  lesions  are  likely  to  produce 
aphasic  manifestations  and  complete  mutism  is  too 
obvious  to  dwell  upon.  In  the  recent  war  traumatic 
cases  have  been  observed  in  which  the  individuals 
lost  consciousness.  After  the  return  of  conscious- 
ness amnesia  or  deafness  was  noticed  and  when  the 
injured  attempted  to  speak  they  failed.  As  there  was 
no  intervallary  period  and  the  loss  of  speech  was  im- 
mediate, there  can  be  no  hesitation  as  to  the  hysteri- 
cal character  of  their  mutism.  Emotion  probably 
played  a  preponderant  role. 

Mutism  in  children,  apart  from  the  psychoses,  is 
rare.    The  following  case  presents  an  example  of 

*  Read  before  the  Philadelphia  Psychiatric  Society,  May  14,  1920. 


mutism  occurring  in  a  child  of  thirteen  previously 
free  from  morbid  phenomena.  It  also  presents  a 
group  of  phenomena  in  which  the  mutism  developed 
concurrently  with  profound  changes  of  personality. 
The  mutism  is  persistent  in  spite  of  the  fact  that 
the  patient  is  fully  conscious  of  it. 

Case. — Boy,  A.  S.,  thirteen  years  of  age,  hereto- 
fore with  a  school  record  of  average  intelligence, 
happened  to  read  a  book  containing  a  story  of  a  man 
who  gradually  lost  his  speech.  Soon  his  parents 
noticed  that  the  boy  talked  very  little,  only  what  he 
was  obliged  to  say.  Rapidly  he  ceased  to  speak 
altogether.  Not  only  his  speech  but  his  voice  could 
not  be  heard  in  the  house.  During  a  period  of  six 
months  the  condition  remained  unaltered. 

Presently  he  was  totally  mute.  No  word  or 
sound  was  ever  uttered  by  him.  Occasionally  he 
could  be  heard  laughing  in  his  room ;  he  did  it  only 
when  nobody  was  around  him  and  the  sounds  re- 
minded one  of  those  uttered  by  a  wild  animal — - 
they  did  not  resemble  those  coming  from  a  human 
larynx.  They  were  brief,  unusually  loud  and 
rough — not  continuous  but  sharply  interrupted.  He 
indulged  in  such  laughing  without  the  least  provo- 
cation and,  as  mentioned  before,  exceptionally. 

All  attempts  to  make  him  speak  utterly  failed.. 
He  fully  understood  when  he  was  spoken  to  and 
was  always  willing  to  give  replies  to  questions  in 
writing.  Asked  why  he  did  not  speak,  he  shrugged 
his  shoulders  and  wrote  down,  "I  don't  know." 
Asked  whether  he  would  like  to  speak,  he  replied, 
"Xo."  Asked  whether  he  would  ever  speak  again 
he  replied  in  writing,  "Yes,"  but  when  asked  to  name 
the  date  he  shrugged  his  shoulders  and  wrote  down, 
"I  don't  know."  Asked  again  whether  it  would  be 
more  than  a  year,  he  wrote,  "Yes,"  but  when  asked, 
"Will  it  be  less  than  two  years?"  he  replied.  "I 
don't  know."  To  all  efforts  to  make  him  admit 
the  necessity  of  communicating  with  fellow  beings 
by  speech  he  invariably  persisted  in  shrugging  his 
shoulders  and  in  writing,  "I  don't  know."  He  spent 
his  time  in  his  room  in  reading  or  writing.  He 
read  anything  that  he  could  lay  his  hands  on  but 
he  was  especially  fond  of  serious  subjects  concern- 
ing industry  and  development  of  the  cities  in  the 
United  States.  At  my  request,  for  the  purpose  of 
testing  his  ability  of  fully  grasping  the  essential 
features  of  a  serious  article,  the  patient  wrote  down 
a  resume  of  two  papers  published  in  the  Saturday 
Evening  Post.  It  was  presented  by  him  in  a  fairly 
logical  manner  and  in  fairly  correct  English. 


Copyright,  1920,  by  A.  R.  Elliott  Publishing  Company. 


434 


GORDON: 


MUTISM. 


[New  York 
Medical  Journal. 


He  was  so  eager  to  spend  his  time  reading  that 
all  the  money  he  succeeded  in  getting  from  his 
parents  he  used  for  purchasing  magazines  and  news- 
papers. In  buying  the  latter  he  did  not  speak  but 
rushed  to  the  stand,  handed  over  the  money,  picked 
up  the  article  purchased,  and  left  at  once.  AH  his 
acts,  including  walking  and  eating,  were  done  in  an 
abrupt  and  jerky  way.  When  he  was  through  eat- 
ing he  rushed  upstairs  with  great  speed  and  locked 
himself  in  his  room,  went  to  bed  and  abandoned 
himself  to  his  favorite  occupation,  reading.  Hasti- 
ness and  rapidity  were  seen  even  in  reading;  he 
devoured  the  books,  according  to  his  parents,  and 
would  read  two  or  three  books  in  a  day.  Unusual 
rapidity  was  noticed  in  eating.  He  never  allowed 
anyone  to  wait  on  him.  Should  his  mother  put 
some  food  on  his  plate,  he  would  not  eat  it ;  he  must 
help  himself  and  before  doing  so  he  wiped  the 
plate  two  or  three  times  to  make  sure  of  its  thor- 
ough cleanliness  though  he  would  pile  on  it  indis- 
criminately anything  he  could  get  hold  of  to  eat. 
Occasionally  he  would  sit  at  the  table  with  his 
parents  and  the  other  children,  and  then  no  one 
could  wait  on  him :  he  reached  for  the  food  before 
anyone  else  had  time  to  sit  down,  and  as  soon  as 
he  had  finished  he  rushed  upstairs  to  his  room. 
Xot  only  did  he  eat  rapidly  but  he  ate  abundantly 
and  ravenously,  more  than  anyone  else,  and  more 
than  he  ever  did  at  the  time  before  the  mutism  had 
developed.  As  the  parents  said,  he  did  not  eat 
like  a  human  being  but  like  a  wild  animal. 

In  his  room  he  kept  the  windows  and  door  her- 
metically closed,  placing  paper  and  rags  in  each 
crevice  and  opening  that  he  could  find.  He  smoked 
cigarettes  only  in  his  room.  The  air  was  suffo- 
cating when  one  entered  and  the  only  time  that 
ventilation  was  possible  was  when  he  was  out  on 
his  errands  of  buying  a  paper.  \\'hen  he  was  in 
the  room  he  would  never  permit  a  window  or  door 
to  be  opened  and  when  he  observed  that  the  paper 
or  rags  were  removed  from  under  the  door  he  be- 
came excited  and  immediatel)'  replaced  them ;  with 
violent  gestures  and  movements  of  his  hands  he 
expressed  his  dissatisfaction  and  threatened  bodily 
in  inn.-.  While  in  the  room  he  seldom  sat  on  a 
chair,  but  was  always  found  in  bed. 

He  was  not  particular  about  his  personal  ap- 
pearance, although  he  was  always  careful  in  having 
his  collar  and  necktie  on  when  he  expected  me  to 
visit  him.  He  slept  in  his  drawers  but  would  not 
have  underwear  on  during  the  day  and  in  the  coldest 
days  of  winter  he  would  go  out  without  under- 
garments. From  a  former  careful  and  neat  boy 
he  became  slovenly,  as  he  did  not  care  how  he  ap- 
peared before  strangers  on  the  street  and  before 
the  magazine  dealers  whom  he  saw  daily  when  buy- 
ing his  papers.  Questioned  on  this  subject  he  wrote 
that  he  did  not  know  why  he  changed  at  all.  When 
asked  why  he  did  not  appear  well  dressed  he  gave 
the  reason,  "Since  I  will  not  speak  to  people,"  as 
his  written  reply. 

Beside  the  newspaper  stand,  the  only  other  place 
he  liked  to  go  to  was  the  cinema.  Among  the 
pictures  he  preferred  those  which  dealt  with  strong 
scenes,  stories  of  the  woods,  shooting,  and  attacking. 
He  did  not  care  for  sentimental  stories. 


In  his  relations  with  members  of  the  family  it 
was  interesting  to  notice  a  pronounced  want  of  af- 
fection. In  him  there  developed  a  particular  dis- 
like and  even  an  open  antagonism  toward  his  twin 
sister ;  at  times  he  showed  hatred  and  not  infre- 
quently he  attacked  her.  Interrogated  on  the  sub- 
ject he  wrote  that  he  did  not  believe  she  was  his 
sister  and  that  he  did  not  wish  to  have  anything 
to  do  with  her ;  she  could  not  possibly  be  his  twin, 
he  said. 

He  did  not  show  any  trace  of  affection  toward  the 
other  brothers  and  sisters ;  he  never  went  near 
them,  refused^to  spend  any  time  with  them  and  al- 
ways declined  their  invitation  to  go  to  the  cinema 
or  to  play  together.  He  never  looked  at  them.  If 
they  happened  to  be  in  the  room  when  he  en- 
tered, he  immediately  left.  Toward  his  parents  he 
was  totally  indifferent.  He  would  never  carry  out 
an  order  given  by  them.  He  was  afraid  of  his 
father  because  the  latter  threatened  bodily  punish- 
ment. The  supplications  of  his  mother  were  totally 
ignored  by  him  and  were  of  no  avail  as  to  the 
correction  of  his  changed  habits  or  with  regard  to 
his  mutism.  It  is  well  to  remember  tliat  prior  to 
this  period  he  was  fond  of  his  relatives  and  showed 
toward  them  the  affection  of  the  average  normal 
child.  Presently  he  avoided  them,  and  was  not  con- 
cerned at  all  if  an  illness  occurred  in  the  house  or  if 
an  accident  occurred  to  anyone  in  the  family.  The 
open  enmity  and  antagonism  to  his  twin  sister,  the 
indifference  to  his  other  sisters  and  brothers,  total 
lack  of  consideration  for  his  mother,  and  absolute 
want  of  affection  for  his  father  have  been  the 
most  striking  features  since  the  condition  developed. 

His  innermost  desire  to  be  detached  from  his 
family  was  shown  in  a  letter  which  he  wrote  to 
some  distant  relatives  at  the  pressing  and  repeated 
insistence  of  his  mother.  After  expressing  his 
pleasure  at  their  safe  arrival  and  wishing  them  a 
happy  life  in  the  future,  he  terminated  the  epistle 
by  saying,  "Regards  to  all."  signing,  "Anna,  David, 
and  the  whole  family  except  niyself." 

The  boy's  previous  medical  history  presented  no 
striking  peculiarity  as  far  as  could  be  ascertained 
from  his  parents.  However,  enuresis  had  been 
present  since  infancy ;'  he  still  continued  wetting  his 
bed  every  night.  He  was  born  at  term,  commenced 
to  speak  and  walk  at  a  normal  age,  never  met  with 
an  accident  and  never  sustained  an  injury.  He  was 
considered  a  strong  and  healthy  boy,  and  he  went  to 
school  and  made  progress  as  the  average  boy.  Never- 
theless he  was  not  fond  of  play,  preferred  to  stay 
home  and  was  selfconscious  and  timid.  He  was 
very  sensitive  to  remarks  about  his  personality  or 
to  any  offense.  He  was  shy  in  the  presence  of 
strangers.  He  did  not  show  a  penchant  for  any 
special  play  or  study  or  other  activit}*.  He  exhibited 
no  peculiarities  in  his  general  behavior  or  special 
tendencies.  There  were  no  vicious  or  defective 
habits. 

The  physical  examination  of  the  boy  gave  nega- 
tive results.  Station,  gait,  motor  and  sensory  ap- 
paratus, and  pupillary  reactions  were  all  normal. 
Hysterical  stigmata  were  absent.  The  cardiorespira- 
tory apparatus  was  normal.  Larynx,  pharjTix,  vocal 
cords,  showed  no  lesions.    The  family  history  was 


September  25,  1920.] 


SOLOMON:  STAMMERING. 


435 


negative  as  far  as  constitutional  diseases  were  con- 
cerned. The  parents  were  of  average  intelligence 
and  the  other  children  presented  the  average  type 
of  apparently  normal  children.  Although  serologi- 
cal tests  were  not  made,  nevertheless  there  were 
no  clinical  indications  whatsoever  to  suspect  an  un- 
derlying luetic  basis  in  the  parents  or  in  the  physical 
characteristics  of  the  children. 

To  sum  up,  we  were  dealing  with  a  young 
individual  who,  along  with  normal  features  m  the 
intellectual  sphere,  presented  certain  abnormalities 
in  the  field  of  judgment  and  in  the  domain  of  his 
affective  faculties.  The  abnormal  manifestation 
of  absolute  mutism  developed  rapidly  after  reading 
a  story  on  mutism.  No  power  of  persuasion  or 
argumentation  succeeded  in  breaking  the  disorder. 
One  witnesses  here  not  only  the  development  of  a 
speech  and  voice  disorder,  but  a  decided  change  in 
the  entire  personality.  On  one  hand  the  boy's  at- 
titude toward  his  parents  and  nearest  relatives  be- 
came distinctly  altered ;  not  only  did  he  disregard 
their  advice  or  orders,  but  he  lost  all  sense  of  obli- 
gation, of  obedience,  of  respect,  of  affection,  and 
there  even  developed  a  sense  of  enmity  and  hatred 
toward  one  of  them.  Moreover  his  behavior,  his 
manner,  his  failure  of  comprehending  the  discus- 
sion of  his  mutism,  his  contradictions  in  replying 
to  questions  concerning  the  disorder,  all  denote  a 
profound  change  in  a  boy  who  previously  presented 
a  type  of  individual  of  average  intelligence. 

Although  the  mutism  was  the  most  conspicuous 
morbid  phenomenon  in  this  case,  nevertheless  it 
was  not  an  isolated  manifestation.  It  was  asso- 
ciated with  a  number  of  other  abnormal 
symptoms.  The  latter  were  not  the  result 
of  and  are  not  focused  around  the  former. 
They  were  manifestations  of  a  different  order.  The 
mutism  was  evidently  due  to  an  inhibitory  func- 
tional paralysis  of  cerebral  nervous  centres  which 
controlled  speech  and  emission  of  sounds,  affecting 
not  only  the  highest  cortical  levels  but  also  the  un- 
conscious mechanisms  depending  upon  the  middle 
levels  (Grasset)  as  well  as  the  muscles  themselves 
connected  with  speech  and  sound.  May  we  not  be 
dealing  here  with  a  paralysis  due  to  an  inhibition  or 
to  exhaustion  produced  by  excessive  stimulation  of 
the  nervous  system,  and  in  this  particular  case 
through  intensive  reading  of  a  story  concerning  a 
man  who  ceased  to  speak?  Further  analysis  shows 
that  only  the  motor  element  of  speech  was  involved. 
Since  the  sensory  speech  was  intact  (he  understood 
spoken  or  written  words),  the  motor  centre  of 
speech  was  evidently  separated  from  the  ideative 
centres  and  consequently  from  the  remaining  cor- 
tex. The  function  of  the  associative  fibres  going 
from  the  entire  cortex  to  the  motor  speech  centre 
was  disturbed  or  interrupted. 

The  mechanism  of  the  interruption  of  function 
in  this  case  is  apparently  intimately  associated  with 
the  deep  impression  caused  by  the  reading  about 
the  loss  of  speech.  A  question  arises  :  Are  we  deal- 
ing here  with  a  case  similar  to  those  observed  after 
deep  emotions?  A  multitude  of  cases  of  mutism 
have  been  reported  in  the  last  war  following  explo- 
sions in  the  vicinity  but  without  material  injury  to 
the  individuals.    That  in  civil  life  strong  emotions 


may  be  followed  by  aphonia  has  been  known  from 
time  immemorial.  Hysterical  aphonia  and  hysterical 
mutism  are  well  known  conditions.  In  the  present 
case  the  patient  was  totally  free  from  mental  stig- 
mata of  the  great  neuroses.  The  emotional  element 
was  equally  not  of  the  character  usually  observed  in 
hysterical  aphonia  or  mutism  as  far  as  the  sudden- 
ness of  their  appearance  was  concerned.  On  the 
other  hand  other  symptoms  suggest  the  possibility  of 
hysterical  mutism  in  that  there  was  no  trace  of  word 
deafness  or  word  blindness ;  it  was  a  motor  aphasia 
in  the  extreme  degree.  Malingering  is  also  not  to 
be  considered  by  virtue  of  the  fact  that  fraud  and 
deceit  have  no  conscious  or  unconscious  motive  in 
this  case;  there  was  no  purpose  of  gaining  a  certain 
end.  Besides,  the  change  of  personality  described 
above  is  a  sufficient  guarantee  against  the  assump- 
tion of  an  intentional  or  conscious  focusing  of  a 
malingering  attempt  upon  one  feature  of  speech — 
mutism. 

The  peculiarities  of  behavior,  of  conduct,  of  re- 
lationship to  his  parents  and  brothers  and  sisters, 
of  judgment  concerning  his  faculty  of  speech — all 
of  which  developed  simultaneously  and  parallel  with 
the  mutism — designate  a  disability  indicative  of  a 
profound  mental  disorder  notwithstanding  the  fact 
that  the  boy  was  able  to  understand  printed  matter, 
that  he  was  able  to  become  interested  in  certain 
subjects,  that  he  was  able  to  answer  questions  in 
writing.  The  character  of  his  acts  and  the  total  in- 
ability to  criticise  his  own  abnormal  acts,  his  fail- 
ure to  observe  the  striking  contrast  between  his 
present  mode  of  acting  or  feeling  and  that  of  the 
former  normal  condition,  the  impossibility  of  ap- 
preciating the  radical  changes  which  have  taken 
place  in  every  detail  of  his  life,  are  all  evident 
proofs  of  the  boy's  perverted  adjustment  as  a  result 
of  a  change  in  his  personality. 

1812  Spruce  Street. 


THE  NATURE  AND  CAUSE  OF  STAMMER- 
ING. 

By  Meyer  Solomon,  M.  D., 

Chicago. 

■  The  terms  stammering  and  stuttering  are  used 
synonymously  in  this  paper.  The  speech  apparatus 
proper  consists  of  two  portions:  1,  the  articulative 
organs,  used  in  articulation  or  the  pronunciation  of 
consonants  (the  lips  for  labial,  the  point  of  the 
tongue  for  dental,  and  the  back  of  the  tongue  for 
guttural  sounds)  :  and,  2,  the  vocalizing  organs, 
consisting  of  the  laryngeal  apparatus,  used  in  pho- 
nation,  vocalization,  or  more  plainly  in  pronuncia- 
tion of  vowels.  Furthermore,  changes  in  respira- 
tion are  constant  accompaniments  of  the  act  of 
speaking.  Both  articulation  and  phonation  are  un- 
der voluntary  (motor)  control,  as  is  also,  to  a  certain 
degree,  the  respiratory  apparatus  (chest  move- 
ments). 

Briefly  summarized,  the  nature  and  cause  of 
stammering  can  be  presented  as  follows :  The  stam- 
merer suffers  from  nervous  excitability  and  emo- 
tionality;  this  expresses  itself,  in  the  stammerer, 


436 


WILLIAMS:  NATIONAL  MORALE. 


[New  York 
Medical  Journal. 


in  a  speech  disorder ;  the  speech  disorder  in  the 
stammerer  is  produced  as  the  result  of  a  definite 
series  of  phenomena,  all  of  which  are  under  the 
stammerer's  control.  First,  there  is  the  tendency  on 
the  stammerer's  part  to  hurry,  virtually  to  rush 
headlong  and  precipitately  into  speech  expression 
of  his  thought.  So  great,  so  intense,  so  acute  is 
this  haste,  that  the  stammerer  really  thinks  faster 
than  he  can  speak,  and  he  endeavors  to  say  imme- 
diately that  which  he  has  in  mind.  As  a  result  of 
this,  he  throws  his  speech  apparatus — either  the  ar- 
ticulative  (for  consonants)  or  vocal  (for  vowels) 
portion — into  sudden,  more  or  less,  violent  spasm. 
Respiratory  spasm  is  commonly  present  in  either 
case.  In  his  blind  rush  the  stammerer  tries  to  pro- 
nounce a  vowel  (laryngeal  sound)  with  his  articu- 
lative  organs— that  is,  while  his  speech  apparatus  is 
in  the  position  for  articulative  (consonant)  expres- 
sion ;  or,  he  makes  efforts  to  produce  articulative 
sounds  with  his  vocal  (laryngeal)  organs — that  is, 
while  his  phonation  apparatus  is  in  action. 

As  a  consequence  the  stammerer  either  maintains 
a  fixed  articulative  (consonant  producing)  position 
and  endeavors,  while  in  this  position,  to  pronounce 
a  vowel;  or,  he  keeps  his  vocal  (laryngeal)  appara- 
tus in  continued  action  while  battling  to  proceed 
hurriedly  and  stubbornly  to  the  pronunciation  of  a 
consonant.  Both  of  these  feats  are  impossibilities 
for  any  human  being.  One  must  cease  articulative 
(consonant  producing)  efforts  to  pronounce  a  vow- 
el, just  as  one  must  stop  vocal  (vowel  producing 
or  laryngeal)  efforts  to  pronounce  a  consonant.  The 
stammerer  unthinkingly  persists  in  his  misdirected 
efforts  to  do  the  impossible — that  is,  to  pronounce 
a  vowel  with  his  articulative  organs  (lips,  tongue) 
or  a  consonant  with  his  vocal  organs  (larynx). 

In  his  insistence  in  this  direction  the  stammerer 
may  bring  into  play  much  of  his  voluntary  motor 
system  and  assume,  during  the  act  of  speaking,  va- 
rious accessory  or  supporting  attitudes  and  pos- 
tures, spasmodic  in  nature,  just  as  one  would  in 
hard  work  or  fighting  or  running.  The  stammerer 
may  become  exhausted  from  his  efforts.  Finally, 
in  despair  or  by  compulsion,  the  stammerer  gives 
up  the  useless  struggle,  relaxes  the  portion  (articu- 
lative or  vocal,  as  the  case  happens  to  be)  of  his 
speech  apparatus  which  up  to  that  nioment  has  been 
in  spasm,  and  only  then,  often  to  his  great  surprise, 
is  he  able  to  proceed  to  the  pronunciation  of  the 
next  sound. 

The  stammerer  wishes  to  say  the  word  but.  He 
begins,  as  he  should,  with  the  labial  b,  shaping  the 
articulative  organs  to  this  end.  l^ow,  to  pronounce 
the  second  sound,  u,  which  is  a  vowel,  the  vocal 
(laryngeal)  apparatus  must  be  brought  into  play. 
The  stammerer,  however,  is  in  so  much  of  a  hurry  to 
pronounce  the  vowel  u,  that,  not  knowing  just  what 
he  is  doing,  he  does  not  take  the  time  to  relax  his 
articulative  organs  (in  this  case  the  lips)  before 
proceeding  to  the  pronunciation  of  the  succeeding 
vowel.  Instead  of  this,  the  stammerer  insists  in 
pronouncing  the  vowel  u  with  his  mouth  fixed  in 
the  position  for  the  pronunciation  of  the  labial  b. 
He  repeats  the  effort  over  and  over  again.  The 
stammerer,  in  this  case,  is  thus  unable  to  proceed 
to  the  pronunciation  of  the  vowel  u  until,  for  one 


reason  or  another,  he  ceases  efforts  at  articulation 
(in  other  words,  opens  his  mouth)  and  permits  vo- 
calization (from  the  larynx).  The  inability  of  the 
stammerer  to  proceed  from  the  vowel  o  (laryngeal 
apparatus)  to  the  consonant  v  (articulative  organs 
— tongue  and  lips)  in  attempts  to  say  over,  can  be 
explained  in  an  analogous  manner. 

The  mental  state  of  confusion  and  fear,  with 
timidity,  shame,  embarrassment,  feeling  of  inferior- 
ity, and  the  rest  are  but  aftereffects.  However, 
fear  of  stuttering  in  a  stutterer  leads  to  increased 
nervous  excitability  and  hence  to  increased  efforts 
to  do  the  impossible,  as  explained  above.  Anything 
- — fear,  shame,  embarrassment,  malnutrition,  over- 
work, or  insufficient  sleep— which  enhances  the 
stutterer's  nervous  excitability  makes  his  stuttering 
or  tendency  to  it  worse.  The  therapeutic  indica- 
tions are  simple,  are  clearly  indicated,  and  will  be 
discussed  in  a  separate  communication. 

5501  Prairie  Avenue. 


NATIONAL      MOILALE      IN  RELATION 
TO  HYSTERIA,  MILITARY  AND 
INDUSTRIAL.* 

By  Tom  A.  Willi.\ms,  M.  D., 
Washington,  D.  C. 

The  high  morale  which  was  preserved  in  the 
French  Army,  in  spite  of  the  discouragement  of  the 
rest  of  the  world,  must  be  largely  credited  to  the 
work  of  the  French  neurologists.  It  prevented  the 
defection  of  men  on  account  of  psychological  inade- 
quacies ;  other  men  learning  thus  that  the  functional 
nervous  disorders  would  not  get  them  out  of  the 
army,  stiffened  themselves  against  this  temptation. 
In  the  British  Army  the  problem  had  become  un- 
manageable ;  100,000  men  were  let  go  on  account 
of  functional  nervous  disorders,  uncured  because 
of  the  antiquated  concepts  by  neurologists  in  that 
country.  Later  the  British  rather  crudely  imitated 
the  French  methods. 

An  uncured  neurotic  is  a  trouble  maker,  while  a 
man  who  is  cured  is  not  only  grateful  but  becomes 
an  educational  force  against  similar  troubles  in 
others.  Much  of  the  dissatisfaction  among  the 
laboring  people  in  England  can  be  attributed  to  the 
unskillful  management  of  the  neurologists,  permit- 
ting these  thousands  of  men  to  leave  the  Army  and 
pervade  those  around  them  with  discontent. 

Insurance  against  what  had  happened  in  England 
was  early  instituted  in  the  American  expeditionary 
force,  and  a  competent  and  adequate  staff  was  pro- 
vided to  deal  with  functional  nervous  diseases. 
They  had  begun  to  do  valuable  work  when  hostili- 
ties ceased  but  the  real  demonstration  of  the  value 
of  good  neurologists  to  a  nation  was  given  only  by 
the  French. 

The  great  frequency  of  hysteria  among  soldiers 
has  been  thoroughly  established  during  the  recent 
war.  About  ten  per  cent,  of  the  casualties  bear 
the  stamp  of  functional  nervous  disorders  and  the 
vast  majority  of  these  were  hysterical  cases.  This 
is  true  not  only  of  battle  periods,  but  also  during 
times  of  relative  quiet,  although  the  rate  rises  in 

*Read  before  the  American   Medico-Psychological  Association. 


Septeraoer  25,  1920.] 


WILLIAMS:  NATIONAL  MORALE. 


437 


anticipation  of  important  attacks.  The  depletion 
of  the  ranks  is  serious  enough  in  itself,  but  when  it 
leads  to  extensive  discharge  of  trained  soldiers  from 
the  army  it  becomes  a  great  danger  to  man  power. 

The  loss  of  man  power  is,  however,  the  least  im- 
portant disadvantage  of  hysteria  improperly  dealt 
with.  The  effect  upon  other  workers  of  thousands 
of  incapacitated  men  without  lesions  is  most  per- 
nicious, for  the  contagiousness  of  their  example  is 
pervasive  beyond  expression.  This,  too,  was  dis- 
covered by  the  British,  but  only  after  it  had  given 
rise  to  serious  disaffection  among  the  workers.  The 
sight  of  what  they  called  shell  shocked  men,  pro- 
viding apparently  horrible  examples  of  what  might 
happen  to  themselves  were  they  drafted  to  France, 
was  not  calculated  to  encourage  the  spirit  of  bellig- 
erency. Furthermore,  100,000  chronic  invalids  were 
a  drag  upon  the  national  resources.  When  this 
was  found,  herculean  efforts  were  made  to 
recuperate  these  men  at  enormous  expense,  but  with 
only  limited  success  in  spite  of  the  exercise  of  very 
high  skill.  Had  a  modicum  of  this  skill  been  per- 
mitted in  the  Army  itself,  no  such  problem  would 
have  occurred  among  the  British. 

The  French  entirely  obviated  these  disadvan- 
tages by  applying  the  neurological  skill  where  its 
efficiency  was  at  a  maximum,  namely,  in  the  fighting 
zone  itself,  so  that  soldiers  with  functional  nervous 
disorders  were  immediately  differentiated,  and 
treated  where  possible.  Even  where  this  could  not 
be  done,  no  discharge  was  obtainable,  but  the  sol- 
diers were  sent  to  neurological  hospitals  in  the  in- 
terior until  such  time  as  organizations  for  their 
intensive  treatment  came  into  operation.  In  this 
way  the  French  nation  was  spared  the  lamentable 
spectacle  of  complaining  men  with  grievances 
against  the  Army  and  the  countr)?  which  had  dis- 
charged them  uncured  and  only  too  ready  to  dissemi- 
nate alarm  by  emphasizing  the  awful  horror  of 
war  to  timorous  lay  people  already  exhausted  by  the 
privations  through  which  they  had  to  go  to  maintain 
the  Army. 

MANAGEMENT  OF  WAR  HYSTERIA. 

The  treatment  of  hysterical  manifestations  de- 
pends upon  one  principle,  namely,  the  replacement 
of  the  patient's  morbid  mental  attitude  by  a  normal 
one.  It  is  a  reconditioning,  a  substitution,  a  re- 
education to  which  the  patient  has  to  be  persuaded. 

The  means  of  persuasion  are  innumerable.  The 
most  successful  in  the  hands  of  one  therapeutist  are 
not  necessarilv  those  which  should  be  employed 
by  another.  The  choice  depends  far  less  upon  the 
nature  of  the  hysterical  symptom,  or  even  upon  the 
nature  of  the  patient's  makeup,  than  upon  the  tem- 
perament of  the  therapeutist  himself.  Some  men 
are  most  successful  when  they  employ  methods 
which  in  reality  are  pure  suggestion ;  others  are 
more  successful  if  they  use  methods  which  make  the 
patients  suffer.  Others  again  cure  more  cases  when 
they  are  permitted  to  elaborate  a  systematized  re 
education  of  the  patient. 

Suggestion. — The  methods  which  are  scarcely 
more  than  direct  affirmation  and  suggestion,  are 
only  of  utility  during  the  whirl  of  the  dressing  sta- 
tion at  the  front,  at  a  time  when  the  man's  belief 
that  he  is  justified  in  reporting  sick  is  not  at  all 


firm.  The  diagnosis  can  be  made  swiftly  and  eas- 
ily. To  restore  the  patient's  military  capacity  it 
suffices  to  assure  him  confidently  that  his  trouble 
has  disappeared  and  that  there  is  no  reason  for  its 
return. 

Torpillage. — The  removal  of  hysterical  symp- 
toms by  the  infliction  of  suffering  is  applicable  to 
perseverators  and  simulators  rather  than  to  the 
general  hysterical  patients.  It  is  a  method  most  read- 
ily employed  by  those  physicians  who  have  not  the 
patience  and  the  spirit  of  organization  required  for 
more  systematic  treatment.  It  is,  of  course,  a  very 
rapid  method,  saving  a  great  deal  of  time  for  the 
doctor,  and  providing  a  great  economy  of  man 
power,  in  that  a  patient  treated  in  this  way  can  be 
restored  to  the  service  in  less  than  a  month,  whereas 
a  patient  in  whom  the  more  moderate  method  of 
influence  and  reeducation  are  employed  required 
several  months  to  become  fit  for  service. 

The  severe  and  painful  methods  of  treatment, 
however,  are  greatly  restricted  in  utility  unless  they 
are  completed  throughout  the  army,  unless  the  as- 
surance that  they  will  be  employed  is  known  to  the 
soldiers,  and  unless  their  use  is  sustained  by  public 
opinion.  When  the  chance  of  evading  this  treat- 
ment exists  either  because  the  patients  knew  that 
the  doctor  dare  not  push  it  or  on  account  of  fear  of 
interference  by  political  appeal,  the  treatment  loses 
its  authority  and  becomes  a  very  painfvil  ordeal 
for  the  doctor  who  uses  it.  Besides  not  every  man 
has  the  tenacity,  the  courage  and  the  skill  required 
for  its  utilization.  Mere  relentlessness  does  not 
suffice.  The  doctor  must  know  when  to  cease  the 
painful  stimulation  and  invoke  the  patient's  own 
will  in  the  removal  of  his  disability,  for  intem- 
perate zeal  and  bungling  brutality  inevitably  produce 
a  spirit  of  vindictiveness  in  those  subjected  to  the 
treatment  which  has  a  detrimental  effect  upon  the 
neurological  services  in  general. 

Reeducation. — Torpillage  should  never  be  at- 
tempted except  in  thoroughly  successful  hands.  Ac- 
cordingly, it  is  necessary  to  have  recourse  to  the 
method  of  gradual  reeducation.  The  principle  util- 
ized to  effect  the  metamorphosis  of  the  patient's 
mental  attitude  by  this  procedure  is  that  of  the 
building  up  of  hopeful  expectancy  by  the  giving  of 
examples  of  cure,  and  by  other  means  calculated  to 
create  an  atmosphere  of  confidence.  The  subject 
is  more  fully  gone  into  in  my  forthcoming  book 
on  the  disorders  of  the  nervous  system  in  war- 
fare and  also  in  a  recent  article  (1). 

PROPHYLAXIS   OF   WAR  HYSTERIA 

The  best  preventive  of  hysteria  is  that  the  soldiers 
realize  that  most  of  the  functional  nervous  dis- 
orders are  quickly  cured,  and  give  rise  to  no  future 
diminution  of  military  value ;  that  shell  shock  rarely 
occurs  even  in  men  stunned  by  explosions  ;  and  that 
every  man  will  immediately  meet  with  skilful  diag- 
nosis and  sympathetic  treatment  if  he  has  to  be 
taken  from  the  line,  but  that  any  attempt  to  evade 
duty  by  the  assumption  or  exaggeration  of  symp- 
toms will  be  quickly  detected  and  firmly  dealt  with. 

I  consider  that  the  excellent  morale  of  the  French 
Army,  under  the  most  appalling  conditions,  was 
made  possible  only  by  the  skill,  fidelity  and  deter- 
mination of  the  French  neurologists,  who  persist- 


438 


WILLIAMS:  NATIONAL  MORALE. 


[New  York 
Medical  Journal. 


ently  kept  before  the  soldiers  the  fact  that  func- 
tional nervous  disorders  should  all  be  recovered 
from,  and  that  no  one  could  be  absolved  from  army 
service  because  of  them.  However,  so  incom- 
plete was  the  understanding  of  the  nature  of  hys- 
teria by  the  laity,  even  in  France,  that  repeated 
attempts  were  made  to  interfere  with  the  labors  of 
the  neurologists  charged  with  the  restoration  of 
obstinate  hysterics  to  active  service.  Emphasis 
was  laid  upon  the  severity  of  the  treatment,  by 
agitators,  who  would  not  or  could  not  see  that  a 
temporary  suffering  necessary  for  permanent  wel- 
fare was  not  only  legitimate  but  essential.  Those 
who  never  thought  of  objecting  to  the  suffering  con- 
tingent upon  a  surgical  procedure,  held  up  their 
hands  in  horror  at  the  much  less  painful  procedure 
necessary  to  overcome  hysterics  with  contractures, 
persistent  paralysis,  deafmutism,  stammering, 
tremor,  convulsion,  incontinence  of  urine,  pseudo- 
gastropathy,  or  what  not. 

Subsequent  to  a  court  martial  implicating  Dr. 
Clovis  Vincent,  the  newspapers  so  violently  at- 
tacked his  work  at  Tours  that  the  intensive  treat- 
ment had  to  be  given  up.  This  in  spite  of  the  fact 
that  nine  hundred  men  who  had  previously  en- 
cumbered hospitals  for  months  were  returned  by 
Vincent  to  the  army  in  less  than  a  year. 

The  newspaper  La  Victoire  then  attacked  the 
establishment  at  Maison  Blanche  and  destroyed  its 
usefulness,  in  spite  of  the  complete  exoneration  and 
high  praise  expressed  by  Gustave  Herve,  the  edi- 
tor, subsequent  to  a  visit  incognito  to  the  hospital. 
He  then  wrote  as  follows : 

"Our  readers  have  certainly  not  forgotten  un- 
tavorable  criticism  of  our  neurologists.  Because 
of  what  I  had  heard  from  different  sources,  I  went 
to  the  Under  Secretary  of  State  of  the  Service  de 
Sante  and  asked  him  to  put  an  end  to  the  cruelties 
that  certain  doctors  were  guilty  of  toward  our 
wounded  soldiers.  In  reply  Mr.  Justin  Godart  said : 
'Let  us  arrange  a  day  and  without  announcing  our 
arrival  we  will  go  to  the  Maison  Blanche  where 
these  horrors  you  have  told  me  of  take  place.'  We 
paid  our  visit  together,  and  I  will  give  a  short  ac- 
count of  what  we  saw. 

"About  sixteen  kilometres  from  Paris  is  situated 
a  hospital  which  before  the  war  was  used  for  the 
treatment  of  the  insane  of  the  Department  of  the 
Seine.    It  is  called  the  Maison  Blanche. 

"The  hospital  was  disinfected.  It  is  a  beautiful 
place  with  large  courtyards  and  garden,  large  win- 
dows giving  plenty  of  light  and  sunshine  can  pene- 
trate. It  is  here  that  the  wounded  are  cared  for 
while  waiting  for  their  artificial  limbs  with  which 
everyone  is  provided.  In  three  separate  pavilions 
the  soldiers  suffering  from  nervous  diseases  are 
treated  by  nerve  specialists. 

THE  WOUNDED. 

"We  were  taken  first  of  all  into  a  large  room 
where  under  the  direction  of  Professeur  Amar  the 
artificial  limbs  are  suited  and  reeducation  exercises 
are  given  according  to  the  methods  of  Dr.  Amar, 
which  greatly  diminish  the  incapacity  of  the  wound- 
ed. The  artificial  limbs  are  as  perfect  as  possible ; 
the  doctor  himself  fits  them  with  the  great- 
est care.    After  many  experiments  the  manufacture 


of  artificial  limbs  has  been  standardized  and  soon 
the  wounded  will  not  have  to  wait  for  them  as  they 
have  done  in  the  past. 

THE   NERVOUS  CASES 

"The  effects  of  the  war  upon  the  nerves  are 
sometimes  very  unexpected.  Sometimes  they  are 
the  direct  results  of  the  wounds,  and  sometimes 
there  appears  to  be  no  direct  reason  for  them. 

"The  patients  are  cared  for  in  two  large  pavil- 
ions furnished  with  beautiful  white  beds,  and  with 
large  windows.  Some  have  lost  the  use  of  their 
legs,  and  others  walk  bent  double ;  this  one  was 
deaf,  dumb  and  blind,  but  already  he  sees,  hears 
and  is  beginning  to  speak.  A  Zouave  trembles 
so  that  he  cannot  stand  up.  The  toes  of  a  soldier 
were  entirely  turned  back  (rctournes) .  This  would 
all  be  very  terrifying  if  the  doctors  did  not  assure 
me  that  all  these  unfortunates  are  curable,  and  if  I 
had  not  seen  those  who  were  nearly  cured. 

"The  mechanical  treatment  is  unfortunately 
rather  rough ;  it  is  necessary  to  reeducate  the  limbs 
which  do  not  obey  the  will  and  the  necessary  mus- 
cular tractions  and  those  that  do  not  understand. 
They  are  in  fact  very  painful  for  the  patient  who 
does  not  always  understand  how  necessary  they  are. 

"I  questioned  all  the  patients  one  after  the  other 
quite  openly ;  some  know,  some  do  not  understand, 
and  it  is  certain  that  when  these  patients  told  their 
families  of  the  treatment  they  had  received  and 
which  they  were  made  to  undergo,  these  misinformed 
relatives  became  agitated  and  judged  with  severity 
the  tortures  the  soldiers  had  undergone. 

"In  order  to  prevent  the  natural  but  very  un- 
fortunate judgment  which  the  best  intentioned 
patients  can  give  about  the  procedures  which  they 
cannot  explain,  it  is  necessary  to  limit  the  visits  of 
the  relatives.  It  is  necessary  for  them  to  know 
that  if  their  children  suffer,  this  suffering  is  nec- 
essary and  that  the  results  legitimate  it. 

"The  patients  I  have  met  have  talked  with  great 
freedom,  with  one  or  two  exceptions,  accept  willing- 
ly the  care  given  them. 

"I  have  even  seen  the  cells  in  which  the  patients 
are  placed  who  are  in  need  of  complete  isolation. 
They  do  not  at  all  resemble  the  cells  of  civil  or 
military  prisons.  There  is  absolute  solitude  and  it 
is  not  at  all  gay  but  it  is  clean  and  light,  the  doors 
have  glass  in  them,  there  is  good  fresh  air  and  a 
comfortable  bed.  No  essential  is  missing  and  I 
am  only  too  happy  to  say  that  my  apprehensions 
were  unjustified. 

"As  for  the  patients  they  should  wish  to  be 
cured  as  much  as  -  we  wish  it  for  them  and  so 
the  only  possible  means  of  cure  must  be  accepted. 
The  parents  should  have  no  fear,  they  should  un- 
derstand that  one  wishes  to  return  to  them  and  to 
the  nation  their  children  sane  and  healthy  and  that 
there  is  nothing  to  do  but  to  leave  the  matter  in 
the  hands  of  the  doctors  specially  trained  for  the 
diseases.  Every  one  must  be  patient  and  have  confi- 
dence and  it  is  not  at  all  necessary  to  say  to  these 
doctors  who  undertake  the  treatment  of  the  nervous 
patients  that  gentleness  would  accomplish  more  than 
violence ;  it  seems  to  me  that  they  do  their  work  with 
science  and  kindness. 


September  25,  1920.J 


WILLIAMS:  NATIONAL  MORALE. 


439 


"The  above  is  the  account  of  what  I  saw.  I 
hope  that  the  relatives  of  these  patients  who  know 
our  desire  to  discover  the  truth  will  now  be  con- 
soled and  reassured." 

On  account  of  the  likelihood  of  misunderstanding 
by  families  and  friends  causing  friction  and  perhaps 
public  agitation  which  would  interfere  with  the  task 
of  physicians  and  the  efficiency  of  the  service, 
patients  needing  treatment  by  isolation  and  reedu- 
cation should  be  sent  to  regions  inaccessible  to 
families  or  other  sympathizers. 

In  addition  it  is  important  that  such  a  centre 
should  be  away  from  drinking  shops,  cafes,  or  any 
amusement,  and  that  it  should  be  protected  from 
all  kinds  of  smuggling.  The  less  distraction  the 
patients  can  find  outside,  the  greater  the  impression 
made  upon  them  by  the  atmosphere  of  the  service 
itself,  and  the  desire  to  enjoy  again  the  pleasures 
of  which  they  have  been  deprived  is  an  additional 
stimulus  to  their  own  efforts  to  recover.  There  is 
every  reason  to  found  such  establishments  near  the 
front  lines,  and  on  no  account  should  patients  of 
this  description  be  returned  to  the  United  States. 
On  the  contrary,  there  should  be  a  widespread  un- 
derstanding that  .such  patients  will  remain  in  the 
military  hospitals  near  the  front. 

On  the  other  hand,  the  impression  must  not  be  al- 
lowed to  originate  that  these  hospitals  are  centres  of 
coercion.  For,  although  strong  persuasion  is  needed 
to  arouse  the  patients'  efforts  at  cooperation,  and 
severe  discipline  is  often  imposed,  yet  the  object 
is  primarily  therapeutic,  and  for  the  patients'  own 
good,  as  well  as  having  the  object  of  restoring  a 
soldier  already  trained  to  his  dut}',  and  of  prevent- 
ing the  demoralization  which  would  occur  if  psycho- 
neuroses  were  found  to  be  an  easy  way  for  the 
perverse  willed  or  cowardly  to  evade  service  or 
responsibility.  A  mutiny  might  be  organized  by 
a  spiteful  patient  with  ability.  To  prevent  this, 
such  hospitals  should  be  under  military  law.  When 
sent  back  to  the  regimental  depot,  patients  who  have 
been  cured  of  hysterical  attacks  or  the  simulation  of 
them  are  likely  to  manufacture  a  relapse,  hoping 
that  it  will  catch  unawares  the  medical  personnel 
without  neurological  knowledge. 

The  nature  of  industrial  hysteria  and  its  manage- 
ment has  been  considered  b}-  us  in  many  publica- 
tions, generally  under  the  rubric  traumatic  neu- 
rosis. Latterly  the  method  I  have  advocated  of 
using  the  netirologist  as  a  referee  has  been  employed 
in  Washington,  much  to  the  facilitation  of  adjust- 
ments and  the  avoidance  of  litigation. 

Even  as  late  as  1918  further  attacks  were  launch- 
ed against  the  very  gentle  methods  •  employed  in 
the  centre  of  the  seventh  region,  to  which  then  near- 
ly all  the  recalcitrant  neurotics  were  being  sent  to 
undergo  a  cure  by  the  progressive  persuasion  which 
was  the  method  adopted  by  Roussy  and  Boisseau 
there. 

SOLDIERS  AND  CI\T:LIANS 

Campaigns  of  this  kind  are  to  be  feared  in  any 
country.  They  have  occurred  in  the  past  against 
surgical  hospitals ;  even  now  they  continue  against 
many  kinds  of  scientific  research,  especially  that 
occupying  itself  with  experiments  upon  animals. 


Xo  more  need  be  said  about  this  sociological  ques- 
tion, as  its  merjts  are  fully  set  forth  in  various 
pamphlets  issued  both  in  England  and  America 
by  research  defense  societies  and  medical  organiza- 
tions. 

The  agitation  against  the  French  neurological 
centres  has  perhaps  been  in  part  aroused  by  the 
zeal  with  which  some  French  neurologists  have  pur- 
sued their  ideal  of  duty  to  the  country  and  the 
cause  of  the  Allies,  for  some  of  these  men  have 
thought  less  of  their  personal  relation  to  possible 
blame  than  they  have  thought  of  the  welfare  of 
the  patients,  and  hence  they  have  failed  to  safe- 
guard themselves  against  unjust  aspersions.  The 
best  weapon  against  unjust  agitation,  is,  of  course, 
instructed  public  opinion.  It  is  this  which  has 
sustained  the  practice  of  surgery  in  hospitals  so 
that  it  is  no  longer  a  question  of  debate,  and  it  is 
this  which  has  sustained  in  the  main  the  physio- 
logical experiments  on  animals. 

In  the  United  States,  public  opinion  is  already 
in  a  better  position  to  comprehend  the  complex  and 
difficult  problem  of  the  care  of  the  psychoneuroses 
than  it  is  in  England,  for  instance.  For  in  Amer- 
ica the  public  mind  has  been  saturated  for  twenty 
years  by  the  facts  of  the  influence  of  mental  states 
upon  bodily  conditions,  and  by  the  knowledge  that 
there  are  such  things  as  psychogenetic  disorders. 
This  is  already  a  step  in  advance,  even  though  it 
has  been  taken  in  the  main  at  the  instigation  of 
protagonists  who  inculcate  also  erroneous  doctrines, 
and  carry  the  psychogenetic  factor  to  absurd 
lengths.  This,  however,  is  because  of  their  ignor- 
ance of  the  facts  of  psychology  and  medicine  when 
it  is  not  from  motives  which  are  far  from  dis- 
interested. We  are  referring,  here,  of  course,  to  the 
teachings  of  the  numerous  mental  healing  cults,  whose 
influence  has  been  far  more  pervasive  than  most 
doctors  realize.  In  order  to  amplify  the  infor- 
mation spread  by  them,  it  is  only  necessary  to 
rectify  that  portion  of  it  which  is  erroneous,  by 
giving  to  the  public  clear  and  well  illustrated  ex- 
amples of  the  limits  of  psychogenetic  possibilities. 
This,  of  course,  cannot  be  done  in  a  day,  but  frorp 
each  judicious  presentation  there  should  emanate 
a  few  individuals  who  will  form  an  enlightening 
focus  which  would  gradually  spread  its  influence  in 
the  community  where  they  live. 

The  present  reporter  has,  for  the  past  ten  years 
been  endeavoring  persistently  to  spread,  not  only 
in  the  medical  profession  but  among  the  laity  and 
especially  the  women,  the  principles  and  the  limita- 
tions of  psychotherapy,  and  in  some  of  the  com- 
munities in  which  this  has  been  done,  the  results 
are  already  apparent.  One  of  the  practical  corol- 
laries of  this  teaching  has  been  the  necessity  of 
treating  psychoneurotics,  not  by  means  of  laymen 
or  even  psychologists,  but  by  physicians  only,  for 
it  is  only  they  who  are  sufficiently  trained  to  appre- 
ciate the  physical  factors  which  are  constantly 
changing  in  every  case,  and  without  an  apprecia- 
tion of  which  psychotherapy  often  proves  hurtful 
rather  than  beneficial. 

The  mental  hygiene  movement,  too,  has  done 
something  in  this  direction,  but  as  it  has  been  occupied 


440 


WILLIAMS:  NATIONAL  MORALE. 


[New  York 
Medical  Journal. 


in  the  main  by  the  grosser  practical  problem  of  the 
prevention  of  the  physical  states  which  produce 
alienation,  it  has  not  yet  attained  the  influence 
which  it  will  have  with  reference  to  psychogenetic 
disturbances.  However,  through  mental  hygiene 
organizations  it  will  be  possible  rapidly  to  reach 
the  public  now,  and  to  instruct  them  in  advance 
concerning  the  role  of  the  military  doctor  in  deal- 
ing with  the  numerous  psychic  affections  engen- 
dered by  the  continuance  of  the  war.  It  will  be 
much  better  to  do  this  in  an  organized,  sane  and 
temperate  fashion  through  a  well  balanced  committee 
of  mental  hygienists  than  to  allow  it  to  be  done  by 
medical  journalists  who  are  prone  to  forget  their 
educative  function  in  pandering  to  sensationalism 
and  mysterymongering  in  order  to  obtain  higher 
prices  and  a  wider  circulation  for  their  effusions. 
The  facts,  on  the  contrary,  should  be  presented 
in  the  most  simple,  clear  and  demonstrative  fashion ; 
and  the  theme,  which  is  full  enough  of  sensational- 
ism, should  be  shorn  as  much  as  possible  of  that 
element.  The  mode  of  presentation  adopted  by 
Dr.  Addington  Bruce,  of  Cambridge,  and  Dr.  Evans, 
of  Chicago,  in  these  explanations  cannot  be  taken 
exception  to,  as  both  of  these  writers  present  their 
subject  as  truthfully  and  sanely  as  is  in  their  power. 

I  am  aware  that  it  is  a  dangerous  field  to  permit 
public  discussion  to  enter  into,  and  that  the  task  is 
difficult ;  but  in  view  of  what  has  happened  in 
England,  and  to  a  far  lesser  degree  in  France,  it 
seems  imperative  that  we  should  not  adopt  a 
laissez-faire  attitude  towards  the  possibility  of  a 
situation  which  foresight  may  be  able  to  pre- 
vent, and  which  threatens  to  such  a  degree  that 
we  can  be  certain  of  its  occurrence  unless  something 
happens  to  prevent  it.  We  cannot  afford  to  leave 
to  chance  the  occurrence  of  more  favorable  cir- 
cumstances. By  intelligent  prevision,  we  may  be 
able  to  prevent  what  we  fear.  A  good  deal  will 
depend  upon  the  ability  with  which  the  preven- 
tive measures  are  undertaken. 

The  public  already  recognize  the  need  of  a  cer- 
tain amount  of  suffering  in  the  cure  of  disease  by 
surgery,  and  especially  in  orthopedic  work.  The 
(lifficulty  of  explaining  to  them  that  the  cure  of 
psychoneuroses  cannot  be  accomplished  upon  a  bed 
of  roses  should  not  be  insuperable.  Furthermore, 
as  the  public  has  already  accepted  the  principle  of 
compulsory  vaccination  which  entails  temporary  suf- 
fering for  the  prevention  of  disease,  there  is  no 
logical  bar  to  its  accepting  the  principle  of  some  de- 
gree of  temporary  discomfort  or  unpleasantness 
for  the  prevention  of  nervous  disease.  Further,  as 
the  public  has  long  ago  accepted  the  principle  of 
compulsory  education,  which  is,  for  the  child,  an  ex- 
ceedingly unpleasant  experience  as  compared  with 
the  free  life  it  might  otherwise  lead  among  the  alleys 
of  the  city  of  the  hedgerows  and  streams  of  the 
country,  there  should  be  no  logical  bar  to  a  general 
acceptance  of  the  principle  of  compulsory  reeduca- 
tion for  the  men  who  have  fallen  into  a  condition 
which  imperatively  requires  it. 

To  the  objection  that  medical  science  is  not  per- 
fect, and  that  medical  men  are  very  far  from  it, 
and  that  some  doctors  are  negligent,  some  incom- 


petent and.  some  harsh,  we  can  reply  that  no  one 
proposes  to  abolish  the  school  system  because  some 
teachers  are  incompetent,  negligent  or  harsh,  and 
nobody  advocates  the  abolition  of  surgery  because 
some  surgeons  blunder  and  others  operate  merely 
for  profit.  In  every  art  we  have  to  set  against  the 
human  imperfections  the  many  excellencies  and 
accomplishments ;  and  so  in  the  art  of  reeducation- 
al  psychotherapy. 

The  war  has  furnished  us  with  statistics  which 
show  that  in  the  best  hands  with  early  treatment 
under  good  conditions,  the  recovery  rate  approaches 
one  hundred  per  cent.,  and  that  even  old,  obstinate 
and  resistant  cases  are  cured  in  a  proportion  from 
eighty-five  per  cent,  to  ninety-four  per  cent,  when 
the  conditions  for  doing  so  are  properly  organized. 
Even  men  not  of  the  highest  skill,  practising  under 
conditions  far  from  ideal,  are  able  to  restore  to 
health  about  seventy  per  cent,  of  the  psycho- 
neurotic soldiers  who  pass  through  their  hands.  It 
is  quite  true  that  there  are  certain  areas  which  are 
regarded  as  dumping  grounds  where  the  patient  has 
little  hope  of  improvement;  but  that  simply  affords 
an  illustration  of  the  wrong  man  for  the  job,  and 
it  is  a  situation  which  should  be  easily  avoided  in 
the  American  service,  which  has  at  its  disposal  a 
very  large  number  of  men,  so  that  a  man  who  does 
not  succeed  with  the  psychoneuroses  can  very  easily 
be  transferred  to  other  work. 

Some  of  the  facts  regarding  the  question  in 
which  it  might  be  desirable  to  instruct  the  public 
are  as  follows : 

As  the  motive  of  many  men  with  psychoneuroses 
is,  at  root,  a  desire  to  avoid  their  duty,  some  of  them 
will  resort  to  any  expedient  to  prevent  themselves 
from  being  cured,  provided  that  the  said  expedient 
does  not  give  them  the  air  of  dodging  an  obligation. 
In  France  some  of  the  men,  after  realizing  that  the 
treatment  will  be  painless  and  that  once  in  the  hos- 
pital for  treatment  they  have  every  chance  of  being 
cured  in  spite  of  themselves,  have  adopted  the  dodge 
of  refusing  to  enter  the  hospital,  basing  this  refusal 
upon  the  principle  of  the  liberty  of  the  individual 
to  choose  what  treatment  he  shall  give  to  his  own 
body.  This  implies  a  refusal  to  submit  to  a  medical 
or  surgical  prescription.  This  is  regarded  as  a  civil 
right,  and  even  in  the  military  service,  the  right 
has  not  been  abrogated.  This  civil  right  is,  how- 
ever, abrogated  in  cases  where  the  question  of  men- 
tal soundness  enters,  provided  that  there  is  danger  to 
the  patient  himself  or  others.  In  the  case  of  a  psycho- 
neurotic there  is  nowadays  no  dispute  that  the  men- 
tal factor  is  the  primary  and  all  important  one ;  so 
that  fundamentally  we  are  dealing  with  what  in  re- 
ality is  an  instance  of  mental  unsoundness — if  we  are 
entitled  to  give  that  term  to  social  inadaptability. 

Where  the  defense  of  the  country  is  concerned 
such  behaviour  as  a  fatuous  refusal  to  take  steps 
which  will  end  in  making  oneself  fit  for  service 
can  be  stigmatized  justly  as  a  danger  to  the  nation. 
Furthermore,  there  is  no  doubt  that  the  life  of 
these  men  imcured  is,  if  not  a  danger,  at  least  a 
serious  detriment  to  themselves  and  their  relatives. 
They  become  a  veritable  nuisance  to  their  com- 
munity, absorbing  an  untold  amount  of  wasted 


September  25,  1920.]  MASSEY :  RHYTHMIC  CURRENTS  IN  GYNECOLOGY. 


441 


sympathy,  besides  using  up  material  resources  which 
might  be  better  applied  in  the  upbuilding  of  the 
country.  Such  men,  too,  live  under  a  sense  of 
grievance  against  a  community  which  has  permitted 
them  to  lapse  into  a  state  of  desuetude,  and,  worst 
of  all,  they  form  a  bad  example  as  to  the  possibility 
of  such  serious  consequences  happening  to  any  one. 
Thereby  they  propagate  a  false  impression  as  to 
the  sequences  of  warfare  which  are  bad  enough 
without  adding  unnecessary  contingencies. 

These  very  men,  on  the  contrary,  after  they 
have  been  cured  are  full  of  gratitude  and  recogni- 
tion for  the  transformation  which  they  have  under- 
gone. The  letters  written  to  the  doctor  who  has 
cured  them  are  only  a  few  of  scores  expressing  the 
intense  personal  satisfaction  derived  from  their  re- 
storation to  active  participation  in  the  affairs  of 
life.  No  longer  a  cowering  neurotic,  the  patient  be- 
comes happy  to  take  his  place  beside  his  comrades, 
even  in  the  danger  zone,  proud  of  the  conscious- 
ness than  he  is  a  man  once  more  and  able  to  take 
part  in  the  defence  of  his  country.  He  learns  how 
false  has  been  his  view  of  the  beneficent  physician 
who  has  cured  him  in  spite  of  himself.  He  has 
found  that  the  school  which  he  dreaded  was  nothing 
like  so  hard  as  he  had  anticipated,  and  he  is  grateful 
for  the  privilege  of  having  been  chosen  to  pursue 
the  salutary  discipline  which  has  retrained  him  once 
more  into  a  man. 

All  these  benefits  will  be  abrogated  if,  by  the 
fatuous  pushing  to  an  extreme  the  principle  of  in- 
dividual liberty,  there  is  dangled  before  the  eyes  of 
recalcitrants,  sophists  or  weaklings,  the  opportunity 
of  easily  evading  the  duty  of  taking  advantage  of 
the  means  to  make  oneself  fit.  And  yet,  the  argu- 
ment is  so  specious  that  it  has  led  away  a  great 
many  into  this  dangerous  counsel.  They  neglect  the 
fact  that  we  are  at  war,  and  while  they  do  not 
grumble  at  the  far  greater  hardships  involved  in 
the  restriction  of  food  and  in  the  liberty  of  travel,  in 
the  shortage  of  wheat  and  transportation,  yet  they 
swallow  this  camel  and  strain  at  the  gnat  of  per- 
sonal privilege  where  the  restoration  of  health  to 
the  sick  is  concerned.  Let  such  objectors  look  for 
a  moment  at  the  disastrous  example  furnished  by 
the  ineptitude  with  which  psychoneurotic  patients 
have  been  managed  in  the  British  service,  where 
over  one  hundred  thousand  men  have  been  dis- 
charged unfit  from  this  cause.  Let  them  reflect  upon 
the  loss  of  fighting  efficiency  of  this  number.  Let 
them  reflect  upon  the  pernicious  example  furnished 
by  these  cases  to  the  rest  of  the  Army,  and  the 
softhearted  persons  who  attend  to  them  at  home. 
Let  them  think  of  the  wastage  of  personnel  and 
materials  used  up  in  their  cure,  and  the  enormous  ex- 
pense to  which  the  country  is  now  being  put  in  be- 
lated efforts  to  do  now  with  great  difficulty  what 
could  have  been  done  with  comparative  ease  in 
the  early  stages  of  these  men's  trouble,  namely,  to 
reeducate  them  into  useful  citizens.  A  further  ex- 
pense to  the  nation  is  the  enormous  pensions  which 
these  men  are  receiving,  and  which  the  country  can 
ill  afford  to  pay.  This  would  have  been  entirely 
unnecessary  had  the  correct  treatment  been  given 
them  in  the  first  place.  It  is  this  eventuality  with 
which  we  are  faced  if  the  etalkinghorse  of  personal 


liberty  is  permitted  to  be  used  to  interfere  with  the 
essentials  which  neurologists  know  are  required  for 
the  restoration  to  health  of  patients  of  this  kind. 

The  fundamental  need  in  organizing  the  treat- 
ment is  the  fabrication  of  a  moral  atmosphere  of 
the  most  delicate  construction ;  and  ill  advised  in- 
terference on  the  part  of  those  ignorant  of  the  com- 
plexity of  the  problem  inevitably  destroys  the  atmos- 
phere which  is  the  chief  requisite  for  success  in  the 
treatment  of  these  unfortunate  patients. 

Before  rushing  into  public  discussion,  either  in 
Parliament,  in  public  meetings  or  in  the  press,  it 
would  be  a  wise  move  for  those  who  honestly  be- 
lieve that  they  have  a  grievance  to  bring  it  before 
some  of  the  neurologists  who  have  dealt  with  these 
patients.  The  information  gained  in  this  way 
would  rectify  the  misapprehension  of  many.  There 
will  be  some,  however,  who  from  lack  of  imagination 
are  incapable  of  the  insight  required  to  understand 
the  question.  These  people,  however,  being  less 
clever,  are  less  dangerous.  The  most  dangerous 
of  all  are  those  who  are  disingenuous,  and,  at  the 
same  time,  clever.  Their  testimony  is,  however, 
often  discredited  in  advance  when  their  character 
is  known. 

REFERENCES. 

1.  Williams,  Tom  :  Military  Surgeon,  November,  1919. 

2.  Idem:  Journal  of  Abnormal  Psychology,  1910;  Medi- 
cal Record,  1909;  New  York  Medical  Journal,  1911; 
Journal  of  Criminal  Lazv,  1916. 


RHYTHMIC  ELECTRIC  CURRENTS  IN  THE 
TREATMENT  OF  ABDOMINAL  AND 
PELVIC  RELAXATION. 
By  G.  Betton  Massey,  M.  D., 

Philadelphia. 

I  have  sent  many  messages  to  those  of  the  medi- 
cal profession  interested  in  the  possibilities  of 
electric  power  in  gynecology,  but  none  of  more  uni- 
versal application  and  usefulness  than  the  few 
words  I  shall  now  have  to  say  of  rhythmic  currents. 

A  well  known  colleague,  who  had  never  placed 
reliance  even  in  the  past  on  a  single  remedy, 
though  it  be  the  knife,  accosted  me  recently  with 
the  question :  "I  have  a  lot  of  women  coming  here 
in  the  afternoon  office  hours.  What  kind  of  elec- 
tricity can  I  use  for  them?"  Having  a  vivid  recol- 
lection of  another  surgical  gynecologist  asking  me 
if  putty  wouldn't  do  as  well  as  potter's  clay  for  a 
dispersing  electrode  on  the  abdomen  I  was  puzzled 
for  a  moment.  The  answer  then  came  at  once : 
rhythmic  currents.  The  chances  were  that  nine  out 
of  ten  of  the  patients  would  be  benefited  by  this 
modality,  even  administered  by  the  nurse,  and  that 
the  tenth  might  possibly  be  made  more  comfortable, 
and  surely  no  worse. 

A  rhythmic  current  differs  from  the  older 
methods  of  electric  neuromuscular  stimulation  in 
that  waves  of  stimulation  are  produced  by  me- 
chanical means  that  have  a  rhythm  adapted  to  the 
normal  muscular  impulses  of  the  part  treated.  Their 
administration  may  be  continued  for  a  half  hour  at 
a  time  without  fatigue  (either  to  the  patient  or 
the  operator),  and  present  the  best  solution  of  the 
problem  of  how  best  to  restore  muscular  tone  to 


442 


SO  BEL:  INFANT  FEEDING. 


[New  York 
Medical  Journal. 


the  muscular  organs  of  the  pelvis  and  abdomen.  Be- 
ing rhythmic,  and  therefore  painless,  we  can  use 
enough  current  amperage  in  waves  slow  enough  to 
stimulate  the  smooth  muscular  fibres  of  the  uterus, 
tubes,  and  intestinal  muscular  coats,  while  at  the 
same  time  contracting  the  striated  muscles  of  the 
pelvis  and  abdominal  wall. 

These  currents,  produced  by  more  or  less  perfect 
machines,  have  been  called  sinusoidal  from  the  shape 
of  the  basal  wave  of  the  current,  but  only  what 
was  known  as  the  slow  sinusoidal  was  rhythmic 
with  normal  muscle  contractions.  The  curve  of  the 
galvanic  sinusoidal  current  is  rhythmic,  when  the 
waves  are  slow  enough,  but  unless  what  has  been 
called  the  rapid  sinusoidal  current  surges  in  cre- 
scendo and  diminuendo  waves  not  faster  than  fifty 
a  minute,  with  selection  of  slower  surges  down  to 
about  twelve  a  minute,  it  is  not  rhythmic.  These 
rapid  waves  are  themselves  from  forty  to  seventy- 
two  thousand  a  minute. 

Our  handicap  in  the  past,  and  even  now  when 
rhythmic  surges  are  not  used,  was  that  a  current 
had  to  be  turned  on  smoothly,  turned  off,  reversed, 
and  turned  on  and  off  again  smoothly  by  hand  re- 
peatedly, for  half  an  hour,  to  be  of  equal  value. 
This  was  tiresome,  even  when  a  nongalvanic  cur- 
rent did  not  need  to  be  reversed  but  only  surged. 
The  result  was  that  a  continuous,  unwavering  stim- 
ulus was  applied  to  a  part  that  normally  contracted 
and  relaxed  in  slow  waves. 

I  leave  the  practical  indications  of  this  remedy 
to  the  good  sense  of  both  trained  and  untrained 
gynecologists.  It  is  selfevident  that  a  wave  of 
power  that  can  reach  and  contract  intestinal  mus- 
cles, for  instance,  in  a  manner  tending  to  restore 
their  normal  tone,  is  better  than  merely  taking  tucks 
in  these  tubes  or  structures ;  and  that  when  a  torn 
muscle  has  been  repaired,  as  in  the  perineum,  fur- 
ther effort  to  restore  the  power  of  the  muscle  should 
be  made. 

1823  Wallace  Street. 


FIRST  AID  IN  INFANT  FEEDING. 
By  Jacob  Sobel,  M.  D., 

New  York, 

Assistant  Director  Bureau  of  Child  Hygiene,  Department  of  Health; 
Professor  of  Hygiene,  Fordham  University  School  of  Medicine. 

Infant  feeding  may  be  a  complex  problem,  a  song 
of  many  stanzas,  as  it  has  been  called,  but  the  re- 
frain— yesterday,  today  and  tomorrow — must  al- 
ways be  breast  feeding,  if  we  hope  to  conserve  the 
health,  growth,  development  and  life  of  infants  to 
the  greatest  degree.  In  fact,  we  may  say  that  there 
are  three  first  aids  in  infant  feeding — -1,  breast  milk, 
2,  breast  milk,  and  3,  more  breast  milk,  and  of  the 
three,  the  last  is  by  far  the  most  important. 

I  have  no  quarrel  with  the  cow.  In  her  place  she 
fulfills  an  important  part  in  our  socioeconomic 
sphere.  However,  I  do  not  know  but  that  I  may 
appear  somewhat  unorthodox  in  an  exposition  of 
this  kind,  in  which  the  slogan  is  "milk  is  Nature's 
most  valuable  food,"  if  I  preach  the  gospel  of 
"mother's  milk  is  the  infant's  most  valuable  food." 

'Presented  at  the  first  session  of  the  New  York  Child  Health  Con- 
ference, held  at  the  Academy  of  Medicine,  May  19,  1920. 


But  I  would  not  be  true  to  myself  and  to  the  large 
number  of  infants  whom  it  has  been  my  privilege  to 
supervise,  in  private  practice  and  in  public  health 
work,  for  over  twenty  years,  if  I  did  not  tell  you 
frankly  that  I  will  boost  the  mother  and  not  the 
cow.  If  then,  during  the  course  of  my  remarks,  I 
should  emphasize  mother's  milk  for  mother's  baby 
rather  than  cow's  milk  for  mother's  baby,  you  will 
realize.  I  hope,  that  while  this  attitude  may  be  bad 
for  the  milk  business,  it  is  best  for  the  infant. 

Let  me  say  at  the  outset  that  I  am  entirely  in 
accord  with  the  statement  of  Dr.  McMurchy  that 
a  mother  should  not  sublet  her  duty  to  a  cow.  The 
problem  of  infant  feeding  is  not  merely  a  tempor- 
ary one,  a  problem  of  preventing  the  immediate  ills 
of  gastrointestinal  disturbances,  malnutrition  or 
marasmus.  It  aims  further,  in  that  it  endeavors  to 
secure  the  maximum  growth,  development  and  re- 
sisting power  of  the  infant,  with  a  minimum  by- 
derangement.  Feeding  in  early  life  determines  in 
a  great  measure  whether  the  child  or  man  of  the 
future  will  be  a  weakling,  or  strong,  robust  and 
vigorous,  physically  and  mentally.  With  Riha,  "I 
hold  a  dietetic  creed  that  no  amount  of  proselyting 
can  take  away  from  me,  namely,  that  the  majority 
of  gastritides  among  adults  have  their  origin  in  the 
gastroenteric  insults  of  infancv  and  earlv  child- 
hood." 

It  is  entirely  unnecesary  to  present  in  detail 
the  reasons  for  the  superiority  of  breast  milk  over 
cow's  milk  in  infant  feeding — however  pure,  safe, 
clean  and  properly  cared  for  and  prepared  the  latter 
may  be.  It  is  sufficient  to  remind  you  of  the  lower 
morbidity  and  lower  mortality  among  breast  fed  in- 
fants, especially  from  diseases  of  the  gastrointes- 
tinal tract ;  of  the  greater  and  more  rapid  growth, 
development,  resistance  and  recuperative  powers  of 
breast  fed  babies,  and  perhaps,  their  greater  mental 
development ;  of  the  presence  in  the  breast  milk,  and 
particularly  in  the  colostrum,  of  immunizing  and 
protective  substances ;  of  the  greater  assimilability, 
adjustment  and  adaptability  of  breast  milk  in  and 
to  the  infant's  stomach  and  digestive  powers,  and 
its  greater  ability  to  strengthen  the  stomach ;  the 
automatic  adaptation  of  mother's  milk  and  the  se- 
cretion of  the  infant's  gastrointestinal  tract ;  of  the 
ideal  composition  of  human  milk,  in  that  it  con- 
tains the  necessary  health  and  growth  giving  food 
constituents  in  proper  proportions  and  in  compara- 
tively uniform  amounts;  of  its  proper  temperature 
at  all  times ;  of  its  freedom  from  harmful  bacteria ; 
and  its  ever  readiness  under  proper  healthful  and 
physiological  conditions  and  environment  of  the 
mother.  Moreover,  it  is  a  common  observation  that 
even  under  unfavorable  hygienic  surroundings,  the 
mortality  among  breast  fed  infants  in  the  tene- 
ments is  comparatively  low. 

There  is,  in  other  words,  something  about  breast 
milk  which  enables  the  baby  to  put  up  a  better 
fight  against  the  many  dangers  with  which  it  is  sur- 
rounded daily.  Truly,  breast  milk  is  the  infant's 
elixir  of  life,  and  an  ounce  in  the  breast  is 
worth  two  in  the  bottle.  Surely,  a  food  of  this 
kind  is  one  devoutly  to  be  wished  for  by  every  in- 
fant. Indeed,  if  the  infant  could  talk,  or  if,  to  ap- 
ply an  expression  used  by  one  of  our  famous  car- 


September  25,  1920.] 


SOBEL:  INFANT  FEEDING. 


.  443 


toonists,  we  were  to  ask  ourselves,  "I  wonder  what 
a  baby  is  thinking  about,"  we  would  find  it  saying  or 
thinking,  "I  wish  my  mother  would  feed  me  on, what 
Nature  intended  I  should  have."  But  infants  can- 
not talk  and  therefore  it  remains  for  others  to  file 
a  brief  in  their  behalf  and  to  leave  no  stone  un- 
turned in  teaching  and  urging  every  mother  to  breast 
feed  her  baby. 

An  infant  that  is  deprived,  of  mother's  milk 
is  essentially  and  physiologically  a  premature 
child.  It  is  said  that  the  baby  kangaroo  at- 
taches itself  to  the  mother's  nipples,  clings  fast, 
and  only  lets  go  when  it  is  fully  matured.  Chapin 
sa3-s,  "5?b where  in  Nature  do  we  see  that  parents 
leave  their  young  until  the  young  are  able  to  secure 
food  for  themselves ;  if  the  necessary  food  is  not 
all  derived  from  the  parent's  body,  suitable  food  is 
provided  until  the  young  is  able  to  look  out  for  it- 
self." Most  of  the  newborn  of  the  lower  animals 
are  able  to  look  after  themselves  within  a  compara- 
tively short  time  and  guard  themselves  against  at- 
tack and  injury  of  all  kinds.  Unlike  the  lower  ani- 
mals, it  was  never  intended  that  an  infant  should 
shift  for  itself,  but  rather,  that  it  should  depend 
for  its  food,  its  shelter,  its  clothing,  its  comfort  and 
care,  for  its  very  existence,  upon  the  aid  of  its  par- 
ents, especially  the  mother,  and,  in  proportion  as 
this  aid  is  good,  bad  or  indifferent,  will  the  future 
man  or  woman  become  a  credit  or  liability  to  so- 
ciety. 

Breast  milk  is  in  a  sense  quite  as  essential  for  the 
nourishment  of  the  child  after  birth,  as  the  placental 
circulation  is  during  the  prenatal  period,  and  it 
would  be  better  if  we  were  to  consider  that  an  infant 
should  be  nourished  by  the  mother  approximately 
eighteen  months,  nine  months  through  the  placental 
circulation,  and  nine  months  by  the  breast. 

Granted,  then,  that  breast  feeding  is  Nature's 
way,  it  is  plain  that  we  should  strive  to  have  one 
hundred  per  cent,  nursing,  if  it  is  possible.  In  fact, 
the  vast  majority  of  mothers  can  nurse  their  babies 
if  they  will  it  or  desire  it.  There  are  legitimate  ex- 
ceptions, it  is  true,  but  they  are  few  and  far  between. 
Unfortunately  there  is  a  feeling  abroad  in  certain 
quarters  that  the  capacity  for  lactation  among  moth- 
ers is  less  these  days  than  in'  former  years.  This  is 
not  true  in  my  opinion.  The  capacity  is.  as  great 
today  as  ever  it  was ;  and  if  there  is  a  tendency  in 
some  places  toward  diminished  maternal  nursing, 
it  is  due  rather  to  unfortunate  economic  conditions, 
which  force  mothers  to  engage  in  gainful  occupa- 
tion ;  to  poor  food  and  housing,  which  undermine 
their  health ;  to  unwillingness  or  indifference ;  in 
some  quarters  to  pressure  of  social  duties ;  to  the 
entrance  of  women  into  political  and  social  spheres ; 
or.  to  the  only  too  frequent  custom  among  many 
physicians  and  institutions,  to  tie  back  the  breasts, 
a  few  days  or  weeks  after  the  birth  of  the  child,  be- 
cause the  flow  of  milk  has  not  been  as  rapid  or 
sufficient  as  was  anticipated,  or  because  of  the  dis- 
couragement of  the  mother  as  to  the  establishment 
of  a  promptly  functionating  breast.  The  latter  in  my 
opinion  is  a  fatal  mistake  and  frequently  means 
the  loss  of  the  breast  milk  to  the  infant.  Even  in 
cases  where  there  has  been  apparent  loss  of  breast 
milk,  placing  the  infant  to  the  breast  every  three  or 


four  hours,  combined  with  diet,  exercise,  a  ready 
assurance  to  the  mother  of  success  and  a  healthful 
frame  of  mind,  it  is  possible  to  restore  the  secretion 
of  an  apparently  nonfunctionating  breast  and  have 
it  continue  for  many  months.  It  may  be  taken  as 
axiomatic,  that  the  further  the  mother  is  removed 
from  the  home  the  less  the  likelihood  or  possibility 
of  successful  breast  feeding.  Motherhood  should 
not  be  sacrificed  to  society.  There  are  few  breasts 
that  cannot  be  made  to  functionate  properly,  if  the 
infant  is  applied  frequently  enough — not  too  fre- 
quently— every  three  or  four  hours,  let  us  say,  and 
if  the  mother  has  the  necessarj'  hygienic  and  dietetic 
care,  proper,  liberal,  wholesome  well  balanced,  pal- 
atable, enjoyable  and  sufficient  diet,  food  to  which 
she  is  accustomed,  good  teeth,  skin  and  bowels 
properly  cared  for,  rest,  sleep,  exercise,  recreation, 
encouragement  and  particularly,  mental  poise. 

Aside  from  those  cases  of  congenital  malfor- 
mation of  the  breast  and  nipples  or  insufficient 
mammary  development  which  make  nursing  imper- 
fect or  impossible,  I  might  say  that  from  the 
viewpoint  of  infant  feeding,  there  are  no  malfunc- 
tionating  breasts ;  they  are  all  good,  but  some  are 
better  than  others. 

There  are  some  lessons  to  be  learned  from  the 
cow.  She  continues  to  calf  year  after  year  for 
several  years,  and  to  be  milked  day  in  and  day  out 
for  the  greater  part  of  each  year  and  continues  to 
give  milk  of  sufficient  quantity  and  good  quality, 
provided,  of  course,  that  her  food  and  environ- 
ment are  sufficient  and  proper.  IMany  mothers,  on 
the  other  hand,  and  unfortunately  many  physicians, 
consider  the  mother's  milk  improper  or  insufficient 
after  several  months,  or,  indeed  after  several  weeks 
of  nursing.  The  cow  seems  to  feel  that  she  has 
been  placed  here  for  a  purpose,  to  be  milked,  and 
she  appears  happy  and  contented  with  her  task.  She 
never  seems  to  tire  giving  milk.  She  seems  to  see 
her  duty  and  she  does  it.  Can  we  say  the  same 
of  all  mothers?  I  recognize  the  shortcomings  of 
this  comparison,  but  the  point  which  I  wish  to 
bring  out  is  the  fact  that  we  seem  to  spend  more 
money  and  care  on  the  health  and  efficiency  of  the 
cow  and  her  milk  than  on  the  care,  health  and  life 
of  the  mother.  Shall  we  confess  that  commercial- 
ism is  considered  of  greater  moment  than  human- 
itarianism?  The  truth  of  the  matter  is  that  a  large 
part  of  what  applies  to  the  cow  applies  to  the  nurs- 
ing woman.  It  has  been  found,  time  and  again, 
that  wet  nurses  in  foundling  and  infant  institu- 
tions can  nurse  one  or  more  infants  for  a  consid- 
erable length  of  time,  for  one  or  two  years,  and 
give  them  proper  nutriment  if  their  breasts  are 
stimulated  by  periodical  suckling,  if  they  are  well 
emptied,  and,  if  their  food  and  surroundings  are  in 
keeping  with  the  maintenance  of  good  health. 

While  it  may  not  be  possible  or  desirable  that  an 
individual  mother  should  continue  lactation  longer 
than  nine  to  ten  months,  or  perhaps,  during  the  first 
year  of  the  child's  life,  it  is  a  fact  that  the  great 
majority  of  mothers  can  nurse  their  infants  if  they 
so  desire,  or,  if  the  physician  persists  and  insists 
in  surrounding  them  with  all  the  essential  factors 
for  establishing  and  maintaining  a  proper  supply. 
In    fact,    such    noted    clinicians    as  Finkelstein, 


444 


SOBEL:  INFANT  FEEDING. 


[New  York 
Medical  Journal. 


Schlossman  and  Engel,  have  said  "there  is  prac- 
tically no  limit  to  the  period  of  lactation  of  a  good 
wet  nurse,  and  that  the  breast  will  continue  to 
secrete  a  good  quantity  of  milk  so  long  as  the  stimu- 
lus of  suckling  is  supplied."  That  these  are  true  state- 
ments I  have  reason  to  believe  from  the  many  years 
of  observation  and  from  my  own  personal  experi- 
ences in  which  I  was  able  to  reestablish  a  satis- 
factory supply  of  milk  in  the  breasts  of  women  who 
for  one  reason  or  another  had  discontinued  such 
feeding  at  the  time  the  infants  came  under  my 
personal  care.  Most  breasts  can  be  educated  into 
giving  a  liberal  supply  of  good  milk,  by  persistence 
on  the  part  of  the  physician  and  the  mother. 

If  but  a  small  fraction  of  the  time,  energy,  and 
thought  that  have  been  given  by  physicians  to  the 
elaboration  of  the  different  methods  of  artificial 
feeding,  to  say  nothing  of  the  vast  amount  of 
money  spent  by  commercial  concerns  in  propa- 
ganda directed  to  convincing  physicians  and  the 
public  at  large  that  their  proprietary  foods  are 
God  given  substitutes  for  milk,  were  devoted  to  the 
study  and  encouragement  of  breast  feeding,  the 
bottle  fed  baby  would  be  the  great  exception.  There 
is  no  perfect  substitute  for  mother's  milk.  Science 
at  best  can  only  approximate  it. 

Truby  King  says,  "The  mere  changing  of  the  per- 
centage of  the  food  elements  in  cow's  milk,  to  corre- 
spond with  those  in  breast  milk,  does  not  by  any 
means  change  cow's  milk  into  mother's  milk.  The 
differences  are  far  more  subtle  than  mere  per- 
centages." No  mother  should  be  permitted  to  feed 
her  baby  artificially  unless  some  direct  and  definite 
contraindication  to  breast  feeding  exists — tuber- 
culosis, epilepsy,  insanity,  chronic  wasting  disease, 
extensive  infection  of  the  breasts — or,  until  the 
physician  is  convinced  beyond  any  doubt  that  all 
known  accessory  measures  have  failed  to  arouse  the 
breast  to  activity.  Even  if  there  is  only  sufficient 
breast  milk  at  hand  for  one  or  more  feedings  these 
should  be  given  and  supplemented  by  cow's  milk 
for  "every  drop  of  mother's  milk  is  precious  to  the 
baby,  especially  during  the  first  months  of  life." 

The  activity  of  the  breasts  depends  largely  upon 
the  stimulation  which  they  receive,  and  the  best 
stimulus  is  the  suckling  of  a  vigorous  infant.  Here 
too,  we  can  learn  much  from  the  cow.  The  farm- 
ers soon  found  that  unless  the  udder  was  emptied  at 
each  milking  and  unless  the  milkings  took  place  at 
sufficiently  frequent  intervals,  the  cows  did  not  give 
a  full  amount  and  in  time  ceased  to  give  milk  at  all. 
The  failure  of  milking  machines  was  due  to  the 
fact  that  they  did  not  empty  the  udders  and  the 
cows  gave  less  milk  than  in  hand  milking.  So  it 
is  in  the  human  breasts.  Unless  the  child  is  placed  at 
the  breast  at  frequent  intervals  and  the  breasts  are 
emptied,  they  soon  functionate  imperfectly  or  cease 
to  functionate  altogether.  For  an  efficient  empty- 
ing of  the  breasts  it  is  necessary  that  the  infant  be 
hungry  and  too  frequent  feeding,  that  is,  every 
two  or  two  and  a  half  hours,  makes  the  infant  less 
hungry,  less  desirous  of  suckling  and  therefore  less 
likely  to  empty  the  breasts.  Besides,  the  end  milk 
of  the  breasts,  as  well  as  of  the  udder,  contains 
the  bulk  of  fat  and  therefore  if  the  breast  is  not 
emptied  the  child  does  not  get  sufficient  nourish- 


ment. Too  frequent  feeding"  and  improper  suckling, 
therefore,  have  a  deleterious  effect  upon  the  nour- 
ishment of  the  infant  as  well  as  upon  the  milk  sup- 
ply of  the  breasts.  While  mechanical  or  artificial 
emptying  of  the  breasts — sometimes  necessary  in 
the  case  of  frail  and  delicate  infants  and  in  acute 
illness  of  the  mother,  by  the  use  of  breast  pumps, 
affords  a  certain  amount  of  stimulation,  like  the 
milking  machine,  it  is  at  best,  a  poor  substitute  for 
the  natural  method  of  suckling  by  the  infant. 

One  word  of  caution  in  regard  to  breast  feeding. 
Despite  its  great  value  and  its  advantages  over  ar- 
tificial feeding,  there  is  sometimes  a  tendency  on 
the  part  of  mothers  and  physicians  who  "desire  to 
persevere  in  this  method  of  feeding  to  continue  its 
administration  too  long  even  though  the  infant  is 
not  thriving;  that  is  to  say,  either  remaining  sta- 
tionary in  weight,  losing  in  weight  or  otherwise 
suffering  from  indigestion.  Breast  feeding  must 
be  conducted  in  a  practical  and  commonsense  way. 
Therefore,  it  has  been  well  said  by  Reuben,  "good 
breast  milk  is  better  than  good  artificial  feeding  but 
good  artificial  feeding  is  better  than  poor  breast 
milk."  On  the  other  hand  there  are  mothers  who  are 
reluctant,  because  of  fancied  or  imaginary  reasons, 
to  suckle  their  young  and  who  have  been  led  to  be- 
lieve by  friends  and  neighbors  and  often  by  some 
physicians  to  regard  feeding  with  cow's  milk  as  just 
as  good  as  breast  milk.  The  best  answer  to  give 
these  mothers  is  to  tell  them  the  story  quoted  by 
Jacobi :  Old  Dr.  Heim  was  told  by  a  socalled  noble 
mother:  "I  keep  an  ass  for  my  baby.  Ass's  milk 
is  as  good  for  my  baby  as  my  own  milk  would  be,  is 
it  not?"  "Yes,  yes,"  said  the  old  man,  "just  as 
good  for  young  asses." 

Dr.  Chapin  has  started  the  call  "back  to  the  home" 
for  the  supervision  of  children  deprived  of  a 
mother's  care.  It  is  high  time  that  we  take  up  a 
similar  call  with  reference  to  the  feeding  of  infants 
and  proclaim  "back  to  the  breast." 

But,  after  all,  I  must  confess  that  an  unneces- 
sarily large  number  of  infants  are  deprived  of 
what  is  theirs  by  right,  mother's  milk,  never  through 
any  fault  of  their  own,  frequently  through  no  fault 
of  the  mother  but  often  because  of  the  failure  of 
municipalities  to  surround  the  expectant  mother 
with  those  safeguards  which  make  for  the  protec- 
tion of  her  life  and  the  maintenance  of  her  health. 
Too  frequently  we  forget  that  "the  baby's  life  and 
pathology  begin  nine  months  before  its  birth." 
There  is  something  so  interesting,  so  human,  so 
tangible,  so  dramatic  about  the  newborn  baby,  that 
we  fail  to  realize  that  the  condition  of  the  baby 
at  birth  and  for  the  greater  part  of  the  first  year, 
depends  largely  upon  the  care  of  the  mother  before 
its  birth.  The  question  of  breast  feeding  there- 
fore arises  or  should  arise,  long  before  the  birth  of 
the  baby.  Since  it  is  admitted  tliat  breast  feeding 
is  the  method  of  feeding  par  excellence,  and  since 
the  ability  to  nourish  the  infant  depends  upon  the 
health  and  vitality  of  the  mother,  it  follows  that 
all  efforts  should  be  directed  toward  preparing  the 
breasts  to  functionate  properly  at  the  time  of  the 
birth  of  the  baby.  To  me,  therefore,  the  very  first 
aid  in  infant  feeding  consists  in  a  proper  super- 
vision of  the  expectant  mother. 


September  25,  1920.] 


SO  BEL:  INFANT  FEEDING. 


445 


Aside  from  the  many  advantages  which  accrue  to 
mothers  and  infants,  as  the  result  of  proper  prenatal 
care,  let  us  concentrate  upon  the  relation  of  this  care 
to  the  infant's  procurement  of  what  is  its  birthright 
— mother's  milk.  It  is  safe  to  say  that  the  better  the 
prenatal  care  received  by  the  mother,  the  greater 
the  likelihood  of  her  desire  and  ability  to  nurse  the 
baby.  It  is  a  sad  commentary  upon  the  progres- 
siveness  of  our  country  to  find  that  the  United 
States  is  fourteenth  in  the  list  of  countries  of  the 
world  as  regards  maternal  mortality  rates  relative 
to  pregnancy  and  seventh  in  the  list  as  regards  the 
infant  mortality  rate.  In  other  words,  in  thirteen 
other  countries  the  life  of  the  mother  during  preg- 
nancy is  safer  than  in  our  own  country. 

I  wonder  whether  many  people  stop  to  consider 
the  relation  between  prenatal  care  and  breast  feed- 
ing ?  Whether  they  stop  to  consider  that  the  first  aid 
is  placing  the  mother  in  such  a  condition  during 
pregnancy  that  she  will  not  only  desire  to  nurse  her 
baby  but  that  she  will  be  alive  and  healthy  enough 
to  do  so.  But  even  that  is  not  enough.  We  must  also 
surround  her  with  all  necessary  precautions  which 
will  enable  her  to  bring  into  the  world  a  vigorous 
and  healthy  baby,  one  who  will  suckle  well  and  by 
such  stimulation  maintain  a  proper  and  sufficient 
flow  of  breast  milk.  Why  then,  is  prenatal  care  so 
important  in  relation  to  breast  feeding?  The  an- 
swer is  to  be  found  in  the  maternal  and  infant 
mortality  and  morbidity  statistics  incident  to  preg- 
nancy. Here  is  the  indictment  with  its  many  counts 
— and  to  which  future  civilization  must  answer 
"guilty"  or  "not  guilty." 

1.  The  Federal  Children's  Bureau  makes  the 
statement  that  more  women  of  the  child 
bearing  age,  fifteen  to  forty-five  years,  die 
from  conditions  incident  to  pregnancy  than  from 
any  other  single  cause  except  tuberculosis.  Dr. 
Henry  C.  Davis  says,  that  "the  records  of  life  in- 
surance companies  show  that  for  all  women  who 
are  insured  under  forty-five  years  of  age  the  dis- 
eases of  pregnancy  and  the  puerperal  state  are  the 
second  greatest  causes  of  death."  The  Metropoli- 
tan Life  Insurance  Company  makes  the  statement, 
"that  it  is  a  national  blemish  that  the  death  hazard 
involved  in  bearing  children,  is  greater  than  that  in 
mining  coal  or  in  railway  services."  Death  robs 
the  infant  of  mother's  milk — of  mother's  care. 
While  in  recent  years,  the  deaths  from  many  com- 
municable and  other  diseases  have  been  reduced  ma- 
terially, the  mortality  incident  to  childbirth  has 
shown  comparatively  little   appreciable  reduction. 

2.  A  large  number  of  maternal  accidents  and  in- 
juries incident  to  childbirth  and  of  other  conditions 
occurring  during  pregnancy  undermine  the  health 
and  vitality  of  mothers,  result  in  infections  of  the 
breasts  and  nipples  and  other  conditions  which 
make  the  mother  a  chronic  invalid  and  pre- 
vent her  from  nursing  the  baby,  however  anxious 
and  willing  she  may  be  to  do  so.  The  saddest  feature 
of  all  this  is  that  very  many  of  these  conditions  are 
preventable.  As  Dr.  George  Newman  puts  it,  "A 
vast  number  of  women  are  made  invalids  for  life 
or  lose  a  large  part  of  their  economic  value  or 
become  sterile  or  die  ultimately  from  injuries  re- 
ceived   or    disease    acquired    while    fulfilling  or 


attempting  to  fulfil  the  functions  of  mother- 
hood." 

3.  Over  forty  per  cent,  of  all  deaths  during  the 
first  year  of  life  are  due  to  congenital  diseases  which 
are  dependent  in  a  large  measure  upon  improper 
care  received  by  the  mother  during  pregnancy ;  and 
here  too,  a  large  proportion  of  these  deaths  are  pre- 
ventable. In  fact,  during  the  years  1918  and  1919, 
the  infant  mortality  statistics  for  the  city  of  New 
York  showed  that  more  deaths  were  ascribed  to 
congenital  diseases  alone  than  to  diarrheal  and  res- 
piratory diseases  combined. 

4.  About  forty-two  per  cent,  of  the  deaths 
of  infants  under  one  year  of  age  take  place 
during  the  first  month  of  life  and  the  majority 
of  these  deaths  are  due  to  congenital  diseases,  pre- 
maturity, debility,  marasmus,  convulsions,  accidents, 
injuries,  etc. — conditions  which  often  call  for 
mother's  milk  as  a  life  saving  measure.  With  a 
mother  dead  or  invalided  because  of  improper,  in- 
sufficient, or  no  prenatal  care,  what  chance  has  the 
majority  of  these  infants? 

5.  While  statistics  show  that  the  infant  mor- 
tality rate  as  a  whole  and  the  rate  from  the 
second  to  the  twelfth  month  of  life  have  shown  a 
steady  decline  in  recent  years  the  infant  mortality 
rate  under  one  month  of  age  has  remained  prac- 
tically stationary.  Since  the  vast  majority  of 
deaths  during  the  first  month  of  life  are  due  to  con- 
genital causes,  largely  dependent  upon  the  health 
and  environment  of  the  mother  during  pregnancy, 
and  to  conditions  in  which  breast  milk  would  prove 
a  life  saving  measure,  the  importance  of  pre- 
natal supervision  is  selfevident. 

Wherever  and  whenever  intensive  prenatal  work 
has  been  conducted  by  municipalities,  by  private  or- 
ganizations or  by  large  insurance  companies,  the 
maternal  and  infant  mortality  and  morbidity  among 
these  selected  groups  of  expectant  mothers  and 
their  infants  have  been  considerably  lower  than 
among  similar  unsupervised  groups  of  the  commun- 
ity. In  witness  whereof  we  point  to  the  results 
of  the  Bureau  of  Child  Hygiene  of  New  York  city, 
the  maternity  centre  associations,  the  Metropolitan 
Life  Insurance  Company,  and  to  similar  results  in 
Boston,  Pittsburgh,  Cleveland  and  other  cities. 

There  are  many  other  statistics  recorded  in 
previous  publications  which  I  could  quote  in  justifi- 
cation of  the  urgent  need  of  systematic  prenatal 
care,  but  I  have  purposely  limited  myself  to 
those  which  bear  directly  upon  the  question  of 
breast  feeding.  In  the  face  of  such  a  presentation 
can  there  be  any  doubt  of  the  verdict  of  the  jury — 
the  public — as  to  the  immediate  and  direct  need 
of  placing  at  the  disposal  of  every  expectant  mother 
all  necessary  information  and  material  assistance 
for  her  own  safety  and  that  of  the  newborn  infant. 
Society  owes  a  debt  to  the  expectant  mother  which  it 
must  discharge.  It  is  not  enough  to  await  the  arrival 
of  the  baby  and  then  proceed  to  look  after  the 
breasts.  The  way  must  be  paved  by  prenatal  care. 
Instruction  and  supervision  of  expectant  mothers 
will,  as  numerous  studies  and  experiments  have 
demonstrated,  give  in  most  cases  a  healthy  mother 
and  a  healthy  infant ;  and  if  as  a  result  of  the  intrica- 
cies of  Nature  and  despite  all  prenatal  care,  there 


446 


SOBEL:  INFANT  FEEDING. 


[New  York 
Medical  Journal. 


is  born  into  the  world  a  puny,  delicate  infant,  the 
existence  of  a  healthy  mother  with  an  abundance  of 
good  breast  milk  is  the  best  health  and  life  insur- 
ance policy  that  the  baby  could  have.  \\'ith  all 
these  facts  before  us,  with  a  knowledge  that  breast 
feeding  is  God's  way,  that  prenatal  care  is  the  most 
pressing,  urgent  and  direct  need  of  the  present  for 
the  protection  and  conservation  of  mothers  and 
babies,  with  the  indifference  shown  on  the  part  of 
most  cities  in  the  organization  of  a  corps  of  prenatal 
nurses,  it  is  not  too  much  to  predict,  that  soon  the 
citizenry  of  our  country  will  cry  aloud,  "How  long, 
oh  municipalities,  will  you  abuse  our  patience?" 

In  spite  of  all  the  known  and  frequently  repeated 
argumentative  data  in  favor  of  prenatal  care,  a 
thoroughly  organized  municipal  service  for  such 
care  exists  in  comparatively  few  cities.  It  seems 
as  if  private  and  semiprivate  philanthropic  and  so- 
cial organizations  have  seen  the  light  of  this  great 
need  to  a  degree  far  in  excess  of  that  evinced  by 
municipal  authorities,  by  the  organization  of  mater- 
nity centres  which  seek  to  coordinate  in  localized 
sections  all  existing  facilities  for  the  examination, 
home  or  institutional  supervision,  care  and  treatment 
of  expectant  mothers.  Why  this  is  so  is  difficult 
to  understand,  unless  it  is  that  the  results  and  pos- 
sibilities of  prenatal  care  are  not  so  immediately  or 
directly  demonstrable  as  those  of  infant  mortality 
control  and  for  this  reason  those  in  charge  of  city 
funds  hesitate  to  make  the  necessary  appropriation. 

Prenatal  care  has  a  double  purpose  to  perform 
— the  giving  of  a  healthy  mother  to  the  newborn  in- 
fant, and  the  giving  of  a  strong  and  vigorous  infant 
to  the  mother.  Without  a  healthy  mother  there  is 
a  possibility  and  likelihood  of  insufficient  breast 
milk  in  quality  and  quantity;  without  a  healthy  in- 
fant there  is  a  likelihood  of  inability  to  suckle  well 
and  the  danger  of  improperly  functionating  breasts. 
The  interdependence  of  mother  and  child  in  rela- 
tion to  breast  feeding  becomes  apparent. 

Happily,  there  is  an  awakening,  slow  though  it  is, 
as  to  the  dire  need  of  prenatal  care.  There  is  no 
earthly  reason  why  more  women  of  child  bearing 
age  should  die  from  causes  incident  to  pregnancy 
than  from  any  other  cause  except  tuberculosis,  no 
other  reason  than  an  indifference  or  neglect  on  the 
part  of  municipalities.  ]\Iaternal  and  infant  mor- 
bidity and  mortality'  dependent  upon  pregnancy, 
labor  and  puerperium  are  amenable  to  a  decided  re- 
duction through  a  properly  organized  prenatal  pro- 
gram, and  not  the  least  advantage  of  such  procedure 
will  be  the  saving  of  the  lives  and  health  of  a  larger 
number  of  mothers. 

That  the  supervision  of  expectant  mothers  has 
a  distinct  bearing  upon  the  possibility  of  increasing 
the  number  of  babies  who  are  breast  fed  has  been 
shown  in  several  studies  conducted  by  the  Bureau 
of  Child  Hygiene,  Department  of  Health,  City  of 
New  York,  in  which  as  a  result  of  surveys  made 
It  has  been  found  that  while  approximately  eighty 
per  cent,  of  mothers  among  the  tenement  population 
nurse  their  babies  exclusively  and  while  approxi- 
mately sixty-eight  per  cent  of  the  babies  enrolled 
at  the  baby  health  stations  are  breast  fed  exclusively 
and  some  thirteen  per  cent,  partially,  the  number  of 
infants  who  are  entirely  breast  fed  during  the  first 


month  of  life,  while  under  the  care  of  a  special  corps 
of  prenatal  nurses,  maintained  by  the  Bureau  of 
Child  Hygiene,  is  approximately  ninety-three  per 
cent. 

I  desire  to  emphasize  the  importance  of  prenatal 
care,  because  in  my  opinion  it  forms  the  basis  of 
every  program  for  securing  a  larger  number  of 
nursing  mothers.  Every  child  has  a  right  to  be  well 
bom.  A  child's  greatest  asset  is  a  healthy  father 
and  a  healthy  mother.  Prenatal  supervision  car- 
ried out  during  many  months  of  pregnancy,  pre- 
pares the  way  for  the  good  health  of  the  mother, 
a  healthy  mental  attitude  towards  nursing,  good 
breasts  and  nipples,  in  other  words,  a  comfortable 
pregnancy,  a  safe  labor,  and  an  uneventful  puer- 
perium. Sir  Arthur  Newsholme  has  said,  "the 
mother  is  the  main  element  in  the  environment  of 
the  infant."  Since  many  of  the  conditions  which 
surround  the  expectant  mother  and  which  maim  or 
kill  her  are  preventable,  it  behooves  us  for  the  sake 
of  the  infant,  i-f  not  for  the  mother's  sake,  so  to 
safeguard  her  health  and  wellbeing  that  she  will 
be  in  a  position  to  nurse  her  infant. 

This  is  how  the  venerable  Jacobi  sums  up  the 
question.  "What  I  want  is  that  a  pregnant  woman 
should  be  in  a  condition  to  carry  her  fetus  to  its 
legitimate  end  in  health  and  vigor  and  be  able  to 
nurse  her  infant.  Every  textbook  talks  to  us  of 
the  inability  of  the  woman  to  do  so  and  indicates 
formulae  and  trade  shops  and  factories  from  which 
to  graduate  toothless  young  Americans.  One  hun- 
dred per  cent,  of  our  women,  however,  can  be  made 
to  nurse,  even  the  flower  and  fashion  of  the  land. 
By  breast  feeding  you  will  save  a  hundred  thousand 
babies  that  now  die  or  become  invalids,  from  no  other 
cause  than  unnatural  feeding." 

The  care  of  the  expectant  mother  has  passed  be- 
yond the  borders  of  municipalities  or  states.  It  has 
assumed  national  importance  and  has  engaged  the 
attention  of  the  Government,  to  the  end  that  ways 
and  means  are  now  being  formulated  to  give  federal 
aid  to  various  states  for  the  public  protection  of 
maternity  and  infancy  and  to  establish  minimum 
standards  for  such  protection.  An  infant  is  always 
fighting  with  its  back  to  the  wall ;  but  it  is  a  brave 
little  fighter  holding  on  tenaciously  until  the  re- 
serves of  care,  attention  and  diet  are  brought  to  its 
aid.  Yes,  the  most  dangerous  occupation  in  the 
world  is  that  of  being  a  baby.  Less  chance  to  live 
a  week  than  a  man  of  ninety,  and  to  live  a  year  than 
a  man  of  eighty;  less  likely  to  survive  its  first  year 
than  an  aviator  who  makes  ascensions  daily  has  of 
being  alive  at  the  end  of  the  first  year.  Six  times  more 
dangerous  than  life  in  the  trenches,  do  you  wonder 
that  it  is  necessary  to  surround  it  with  safeguards 
against  the  many  pitfalls  which  endanger  it  daily? 
And  of  these  safeguards,  the  two  most  important 
are:  1,  proper  instruction  and  supervision  of  the 
mother  who  bore  it ;  2,  every  effort  to  provide  it 
with  what  God  and  Nature  intended  it  should  have — 
breast  milk.  To  nurse  a  baby  is  a  mother's  privi- 
lege and  duty,  to  be  nursed  by  its  mother  is  a  baby's 
birthright.  Let  there  be  no  slackers  in  the  great  cam- 
paign of  first  aid  in  infant  feeding,  in  the  great  cause 
for  more  and  better  babies — the  instruction  and 
supervision  of  expectant  mothers. 


September  25,  1920.] 


JO.VES:  ASTIGMATISM. 


447 


DISTURBANCES    OF   THE   HEART  AND 
LIVER  CAUSED  BY  LOW  GRADES  OF 
ASTIGMATISM  * 
By  E.  L.  Jones,  M.  D., 

Cumberland,  Md. 

From  the  army  which  was  recently  drafted  in  the 
United  States,  a  number  of  men  who  had  been  de- 
clared perfect  on  examination  had  to  be  dropped 
because  of  the  fact  that  when  they  were  put  to  the 
actual  task  of  drilling  and  other  physical  exercises 
their  hearts  failed,  and  they  became  winded  and 
exhausted,  and  yet  showed  nothing  demonstrable 
on  physical  examination  to  explain  why  they  were 
not  as  good  as  the  others  who  stood  up  under  similar 
conditions.  In  an  article  by  George  E.  Pf abler  (1), 
this  class  is  characterized  as  the  constitutionally  in- 
ferior or  third  raters.  While  explaining  nothing, 
cardiologists  have  termed  this  condition  neurocircu- 
latory asthenia,  and  as  far  as  I  am  able  to  gather 
from  my  reading,  they  have  nothing  of  value  to  offer 
for  its  relief. 

For  more  than  a  decade  I  have  observed  cases 
of  this  type  in  civil  life,  whose  number  would  run 
into  hundreds,  if  limited  to  circulatory  symptoms, 
and  into  thousands  if  many  of  the  associated  symp- 
toms were  the  objects  of  consideration,  which  were 
largely  or  totally  relieved  by  a  thorough  correction 
of  errors  of  refraction.  The  title  of  this  paper  is 
intended  to  emphasize  that  any  or  all  astigmatism 
must  be  corrected  to  the  finest  degree  possible  as  to 
strength  and  axis  of  cylinder,  else  the  small  error 
remaining  for  the  eye  to  overcome  will  still  permit 
the  continuance  of  symptoms.  This  does  not  mean 
that  the  other  source  of  refractive  eyestrain,  hyper- 
opia, does  not  play  its  part  and  need  correction, 
which  should  be  done ;  neither  does  it  mean  that  my- 
opia, which  is  not  a  source  of  refractive  eyestrain,  is 
not  to  be  reckoned  with.  But  associated  with  myopia 
and  hyperopia  of  all  degrees,  and  in  cases  of  sup- 
posedly noncorrectible  irregular  refraction,  there  is 
usually  more  or  less  astigmatism,  at  times  very  diffi- 
cult to  establish  as  to  exact  amount  and  axis,  unless 
the  examiner  is  dominated  by  a  fixed  conviction  that 
the  symptoms  point  to  astigmatism,  and  he  will  not 
stop  until  it  has  been  worked  out  correctly. 

I  have  found  it  best  to  presume  that  astig- 
matism is  always  present  until  its  absence  is 
indisputably  proved,  and  in  few  cases  pre- 
senting sufficient  symptoms  to  call  for  examination 
can  its  absence  be  proved.  It  is  said  that  in 
the  early  days  of  modern  refraction,  when  visual 
acuteness  was  the  only  desideratum,  that  astigmatism 
under  1  D.  did  not  amount  to  much ;  and  without 
wishing  to  disturb  the  shade  of  the  great  Donders,  it 
is  stated  he  considered  half  a  dioptre  as  the  mini- 
mum of  value.  This  is  still  largely  true  in  non- 
presbyopes,  from  the  viewpoint  of  attaining  the 
sharpest  vision  possible ;  but  where  that  search  ends, 
the  search  for  socalled  eyestrain  properly  begins. 

It  would  be  desirable  if  a  better  term  could  be  sub- 
stituted for  eyestrain,  say  eyestress,  as  the  former 
term  to  the  laity  conveys  the  meaning  of  conscious 
efTort  on  the  part  of  the  eyes,  whereas  it  is  most 

*Read  before  the  American  Academy  of  Ophthalmology  and  Oto- 
laryngology, Cleveland,  October  16,  1919. 


often  totally  unconscious.  Another  error  to  be  com- 
batted  in  the  minds  of  the  laity  and  general  medical 
professon  is  that  all  cases  of  eyestress  must  produce 
either  pain,  discomfort  or  weakness  of  eyes,  or  some 
of  the  old  classical  symptoms  of  headache,  nausea  or 
nervousness.  I  wish  to  state  with  all  emphasis  pos- 
sible that  more  people  in  my  belief  suffer  from  the 
eyes,  than  with  the  eyes,  and  my  hope  that  the  day 
will  come  when  every  patient  affected  with  a  persist- 
ent vertigo,  pain  or  drawing  in  the  neck  or  shoul- 
ders, unexplainable  general  fatigue,  nervous  de- 
pression, gas  in  stomach,  cardiac  asthenia,  or  cold, 
clammy  feet,  will  be  referred  to  the  most  painstaking 
oculist  available,  for  that  careful  search  for  astig- 
matism, either  alone  or  buried  under  a  smaller  or 
larger  amount  of  far  or  near  sightedness,  the  cor- 
rection of  which  usually  brings  relief  after  enough 
time  elapses  to  permit  the  dying  out  of  these  vicious 
symptoms  after  removal  of  their  cause.  Not  to  in- 
form patients  of  this  necessary  lapse  of  time  is  like- 
ly to  cause  them  to  discard  our  efforts  as  futile, 
bringing  loss  to  themselves  and  disrepute  to  their 
oculist. 

During  the  earlier  years  of  my  career,  fol- 
lowing the  lead  of  such  authors  as  I  had 
been  able  to  study,  I  held  the  belief  that  astig- 
matism not  reducing  vision  in  pr^sbyopes,  especially 
advanced  presbyopes,  was  of  little  or  no  consequence, 
and  that  presbyopia  when  fairly  complete  had  so 
set  the  accommodative  mechanism  that  eyestress 
could  not  result.  To  me  the  doctrine  is  now  an- 
athema maranatha ;  one  that  should  be  utterly  stamp- 
ed out,  regardless  of  any  theoretical  bolstering  up, 
when  cold  facts  prove  how  much  somatic  disturbance 
may  come  from  astigmatism,  especially  of  low  de- 
gree, at  advanced  ages. 

As  some  of  the  tenets  set  forth  in  this  article,  to- 
gether with  their  attempted  explanation,  will  no 
doubt  challenge  the  credulity  of  some  and  the  antag- 
onism of  others,  it  is  desirable  to  go  into  certain 
details  that  would  otherwise  seem  unwarrantable. 
Lieut.  Col.  R.  H.  Elliott,  in  a  paper  on  errors  of  re- 
fraction says  (2)  :  "Let  each  one  tell  what  they 
actually  do  in  their  practice  and  not  what  they  would 
like  to  do,  or  what  they  would  like  others  to  think 
they  do" ;  and  further  on  quotes  Kipling's  lines : 

"But  each  for  the  joy  of  the  working, 

And  each  on  his  separate  star, 
Shall  draw  the  Thing  as  he  sees  It, 
For  the  God  of  Things  as  They  are." 

In  the  first  place,  the  fitting  of  glasses,  aside  from 
simple  presbyopia,  should  be  considered  as  much  a 
part  of  the  practice  of  medicine,  as  diagnosing  dis- 
eases, prescribing  drugs,  or  doing  minor  surgery.  In 
many  patients  the  issues  of  being  able  to  enjoy  good 
health  and  successfully  pursue  happiness,  are  as 
much  dependent  on  a  proper  refraction  as  the  out- 
'come  of  some  of  the  most  ambitious  operations  of 
major  surgery,  where  the  issue  of  life  itself  is  not 
involved.  But  in  the  estimation  of  the  laity,  and 
sometimes  of  the  medical  profession,  getting  glasses 
is  merely  a  matter  of  purchase  with  the  purchaser 
as  the  chief  arbiter  of  what  is  to  be  done. 

In  late  years  much  stress  has  been  laid  on  dis- 
turbances of  the  ductless  glands,  in  the  practical  in- 
vestigation and  application  of  which  Dr.  Crile  has 


448 


JONES:  ASTIGMATISM. 


[New  York 
Medical  Journal. 


played  a  prominent  part.  In  his  masterful  contribu- 
tion on  the  kinetic  drive  he  has  shown  the  effect  of 
infections,  of  loss  of  sleep,  and  great  fear  or  long 
continued  anxiety  or  depressing  emotions,  and  as 
the  ductless  glands  and  sympathetic  nervous  system 
are  the  drivers  of  the  heart,  vi^hatever  stimulates  or 
inhibits  these  must  bear  out  its  effects  on  the  heart. 
To  his  list  of  disturbers  should  be  added  another, 
as  potent  as  any,  and  probably  more  common  than 
all  of  the  others,  viz.,  eyestrain.  Since  the  pro- 
mulgation of  our  present  day  beliefs  as  to  hyper- 
thyroidism and  hypothyroidism,  the  similarity  of 
these  in  many  respects  to  long  continued  eyestrain 
has  forcibly  struck  me,  and  caused  a  belief  that  the 
thyroid  was  being  held  responsible  for  a  number  of 
sins  chargeable  to  the  prime  cause  of  eyes  under 
stress,  although  they  work  their  harm  by  causing 
secondary  derangement  of  the  ductless  glands, 
chiefly  the  thyroid,  and  probably  the  adrenals  and 
pituitary.  These  cases  early  in  their  evolution 
probably  first  pass  through  a  short  phase  of  hyper- 
thyroid  symptoms,  as  in  the  case  of  a  girl  of  twelve 
who  came  in  while  this  paper  was  being  written. 
She  came  on  account  of  mild  discomfort  in  her 
eyes  with  nervous  excitability.  Her  pulse  on  admis- 
sion, after  a  short  conversation  on  commonplace 
things,  was  136;  after  sitting  an  hour  waiting  on 
cycloplegic  drops,  it  was  120,  and  pounding  like  a 
triphammer.  Her  mother  had  noticed  this  in  her 
sleep.  The  more  common  cases  have  passed  from 
hyperthyroid  to  hypothyroid  symptoms  of  ner- 
vous depression.  In  a  recent  case  in  a  young  married 
woman  apparently  in  the  best  of  health  the  pulse 
was  64.  She  had  been  sent  by  her  physician  to  seek 
relief  for  headaches,  and  inquiry  showed  that  she 
also  had  dizziness,  pain  in  the  neck  and  shoulder, 
was  nervous,  depressed,  tired,  easily  winded,  and  had 
a  palpitating  heart,  the  first  sounds  of  which  were 
rather  faint,  but  no  discomfort  or  weakness  about 
the  eyes.  She  had  undergone  a  thyroidectomy  sev- 
enteen months  previously.  When  she  came  back 
five  weeks  after  having  her  astigmatism  corrected, 
she  was  already  beginning  to  feel  better,  her  pulse 
was  76,  and  the  heart  sounds  were  distinct. 

A  misconception  universal  among  the  laity,  and 
general  among  physicians,  is  that  eyestress  only 
comes  from  the  near  use  of  the  eyes,  and  is  de- 
pendent on  long  hours  of  close  work,  and  should 
therefore  find  its  chief  sufferers  among  bookkeepers, 
students,  stenographers,  and  seamstresses,  and  should 
be  relieved  by  giving  up  these  various  callings  for 
a  life  in  the  open.  A  more  pernicious  and  mislead- 
ing doctrine  was  never  promulgated.  The  majority 
of  the  patients  observed  were  the  wives  or  daughters 
of  farmers,  miners,  carpenters,  railroaders,  and  mill 
workers,  who  gave  relatively  more  time  to  domestic 
duties  and  less  to  reading  or  needle  work  than  did 
those  who  call  themselves  the  intellectuals. 

Women  are  more  frequently  subject  to  symptoms 
of  eyestrain  than  men,  notably  in  regard  to  nervous- 
ness, the  neck  and  shoulder  pain  or  drawing,  and 
cold  feet.  The  man  more  often  controls  his  nerves. 
But  when  a  man  does  have  the  neck  and  shoulder 
pain,  which  is  a  liver  symptom,  or  cold  feet,  a  heart 
symptom,  he  usually  has  them  badly.    It  is  a  com- 


mon occurrence  to  have  a  well  developed'  husky 
farmer  or  mechanic  come  for  some  minor  discom- 
fort of  the  eyes,  and  reveal,  upon  inciuiry,  that  he 
is  easily  tired  and  winded  by  a  short  amount  of 
physical  effort,  and  has  been  puzzled  as  to  why  it 
should  be ;  or  has  been  taking  general  or  heart 
tonics  without  avail.  These  are  often  presbyopes 
with  reading  glasses  or  bifocals  giving  perfect 
vision,  but  poor  satisfaction.  A  recent  illustrative 
case  occurred  in  a  man  of  forty-eight,  healthy  and 
robust  in  looks,  leading  an  active  outdoor  life,  who 
complained  for  many  years  that  his  eyes  burned, 
itched,  reddened,  and  pained  from  bright  light,  that 
things  would  blur  after  a  short  time,  and  the  eyes 
would  water  too  readily.  He  had  frequent  headaches, 
occasional  sick  headaches,  was  very  dizzy,  had  severe 
neck  and  shoulder  pain,  was  easily  tired  and  winded, 
with  palpitation  of  heart,  and  his  feet  and  legs  were 
cold.  He  stated  that  he  frequently  bandaged 
his  knees  to  keep  them  warm.  The  glasses  he  had 
been  wearing  were  lost  when  an  attack  of  dizziness 
struck  him  while  he  was  driving,  and  the  car  with 
himself  and  wife  rolled  down  a  bank.  This  pa- 
tient had  a  common  condition  that  may  never  ap- 
preciably blur  vision,  but  is  prolific  of  eyestrain — 
mixed  astigmatism  of  low  degree.  Roby  and  Boas 
(3)  gave  the  results  of  studying  a  series  of  cases 
of  neurocirculatory  asthenia  at  Camp  McClellan,  in 
which  they  concluded  that  exercises  accomplish 
little  or  nothing  toward  overcoming  the  weakness, 
but  are  of  great  value  in  establishing  the  diagnosis. 
They  refer  to  accompanying  dizziness,  and  emo- 
tional stress.  In  discussing  this  paper.  Sir  James 
Mackenzie,  of  London,  spoke  of  some  of  these  pa- 
tients having  cold  extremities,  at  times  being  flushed. 
It  is  common  to  have  some  patients  with  eye  symp- 
toms complain  of  hot  burning  feet,  when  under  sim- 
ilar conditions  others  complain  of  cold. 

Friedlander  and  Freyhof  (4)  and  Barringer  (5) 
emphasize  the  associated  symptoms  of  dizziness, 
nervousness  and  cold,  clammy  extremities,  and  the 
fact  that  many  of  the  patients  were  below  par  since 
childhood.  Other  observers  (6)  started  out  with  a 
belief  that  statistics  would  show  the  condition  more 
often  associated  with  enlarged  thyroid,  but  the  re- 
sult, as  far  as  any  differences  went,  was  in  favor 
of  a  greater  prevalence  where  there  was  no  thyroid 
enlargement.  To  show  that  their  clinical  descrip- 
tion conforms  to  the  types  of  cases  which  have  been 
relieved  by  correcting  astigmatism  carefully,  several 
quotations  will  be  made.  "The  symptoms  were  pre- 
cordial pain  with  dyspnea  and  palpitation  on  mod- 
erate exertion,  such  indications  of  vasomotor  insta- 
bility as  dizziness,  flushing  and  fainting,  and  a 
variety  of  other  complaints,  all  pointing  to  a  state 
of  excessive  reaction  of  the  nervous  system  to 
psychic  or  physical  strain. 

"Dyspnea,  palpitation,  and  precordial  pain  are 
taken  as  cardiac  symptoms.  Dizziness,  flushing  and 
fainting  are  taken  as  indications  of  vasomotor  in- 
stability. Mental  irritability,  emotionalism,  appre- 
hensions, depression,  excitability  and  exhaustion-, 
and  shakiness  after  exertion  or  excitement,  were  all 
grouped  under  the  heading  of  nervous  instability." 

One  of  the  outstanding  clinical  features  in  both 


September  25,  1920.] 


JOXES:  ASTIGMATISM. 


449 


conditions,  though  this  is  more  especially  true  in 
neurocirculatory  asthenia,  is  the  multiplicity  of  sub- 
jective complaints,  and  the  paucity  or  absence  of 
objective  evidence.  So  it  is  mainly  on  symptoms 
and  not  on  signs,  that  the  diagnosis  rests.  And 
the  special  characteristic  of  the  symptoms  is  the 
wide  field  they  cover.  It  is  not  only  the  cardiac 
or  the  vasomotor  or  the  nervous  system  which  is 
at  fault,  but  all  three  together.  "What  has  been 
termed  the  symptom  complex,  that  is,  an  associa- 
tion in  the  same  individual  of  symptoms  of  cardiac, 
vasomotor  and  nervous  instability,  is  as  often  seen 
in  nonthyroid  as  in  thyroid  cases." 

These  cases  are  not  rare  in  civil  life,  but  when 
looked  for,  will  be  found  rather  commonly.  When 
it  is  considered  to  what  extent  the  patients  may  be 
relieved  by  a  correction  of  all  the  errors  of  refrac- 
tion, and  proper  glasses  worn  all  the  time  for  a 
long  enough  period,  it  makes  the  remark  of  one  of 
America's  foremost  surgical  ophthalmootorhinolog- 
ists  publicly  expressed  some  years  ago  that  the 
refractionists  claim  to  cure  everything  from  head- 
aches to  hemorrhoids  with  glasses,  seem  as  full  of 
truth  as  of  sarcasm,  for  it  can  safely  be  said  that 
by  this  means  many  ills  from  vertigo  to  cold  feet  are 
permanently  eradicated. 

In  addition  to  the  hyperthyroid  and  emotional 
stress  hypotheses,  i\Iajor  Carroll  (7)  seeks  to 
establish,  as  have  also  some  of  the  other  authors 
quoted,  chronic  infections  as  a  cause  of  neurocir- 
culatory asthenia.  There  is  no  doubt  that  all 
of  these  play  a  contributing  part  in  a  lowered 
resistance  caused  by  some  previously  acting  cause. 
Few  things  of  slow  development  come  from  a 
single  condition,  but  a  combination  of  conditions 
and  circumstances,  and  sudden  collapse  of  a  heart 
or  a  mind  is  more  often  due  to  long  and  slowly 
acting,  unrecognized  undermining,  than  the  im- 
mediate precipitating  cause.  If  the  matter  could 
be  tested  out,  it  would  probably  be  found  that  a 
large  proportion  of  shell  shock  cases,  as  well  as  the 
neurocirculatory  cases,  had  been  undermined  by  a 
long  acting  eye  strain.  As  corroborative  of  my  asser- 
tion that  eye  strain  symptoms  affecting  the  heart  are 
not  more  common  among  close  workers  with  the 
eyes,  the  following  quotations  from  F.  G.  Hein  (8) 
are  based  on  studies  of  neurocirculatory  asthenia  at 
Camp  Sherman :  "Three  hundred  men  returned  to 
the  development  battalion  from  the  various  line 
organizations  because  of  complaint  of  heart  trouble 
throw  some  light  on  this  problem.  The  men  passed 
apparently  normal,  were  placed  in  organizations, 
found  unable  to  drill,  rejected  as  unfit  for  military 
service,  and  referred  to  the  development  battalion. 
It  is  interesting  to  note  that  154  have  had  symptoms 
for  five  years  or  more,  some  insisting  that  they  have 
always  had  distress.  As  shown  in  Chart  I,  the 
largest  number  of  cases  occurred  among  farmers, 
with  laborers  next,  the  two  classes  forming  fifty- 
six  per  cent,  of  the  total.  The  clerical  positions 
came  next,  with  seventeen  per  cent.  Giddiness, 
present  in  242  cases,  was  the  most  common 
symptom ;  on  prolonged  or  sudden  severe  effort, 
dyspnea  occurred  in  239  instances.  A  hike,  or 
double  quick  time,  sent  these  men  out  of  formation 
in  short  order." 


An  impressive  illustration  of  the  effect  of  cor- 
recting astigmatism  in  these  heart  cases,  and  the 
permanency  of  the  relief,  occurred  some  years  ago 
in  Mr.  H..  a  man  of  athletic  build  and  exemplary 
habits.  He  was  raised  on  a  farm  and  worked  at 
milling  when  the  farm  work  did  not  demand  his 
attention.  After  manhood  he  qualified  for,  and 
entered  the  legal  profession.  After  getting  into 
his  early  forties  his  heart  began  to  functionate 
poorly,  and  anemia  and  morbid  fears  developed  to 
the  extent  that  for  several  years  he  never  began  a 
day  with  any  feeling  of  assurance  he  would  live 
through  it ;  did  not  dare  to  lock  a  door  for  fear  he 
would  drop  dead  and  some  one  would  have  to  break 
in  the  door  ;  dreaded  to  undertake  the  simplest  duties 
of  his  profession,  for  fear  he  might  not  live  to 
finish  them ;  if  he  started  across  the  street  to  the  bar- 
ber shop,  he  wondered  if  he  would  live  to  get  there, 
and  seated  in  the  chair  he  would  think  "this  barber 
will  look  up,  and  when  he  looks  down  again,  he  will 
be  looking  at  a  dead  man."  His  home  physician 
could  make  out  no  organic  heart  trouble,  and  finally 
referred  him  to  Dr.  Thayer,  in  Baltimore,  who  also 
pronounced  him  free  of  any  organic  heart  trouble 
on  three  separate  occasions,  and  advised  him  to 
return  for  a  season  to  the  simple  rural  life,  living  in 
the  open,  attending  as  hostler  to  his  pony  and  other 
tasks.  He  also  went  to  Florida  for  a  few  months 
as  a  relaxation  and  diversion.  His  eyes  had  never 
given  him  the  slightest  trouble  in  feeling  or  func- 
tion until  at  the  age  of  forty-five  he  began  to  have 
considerable  trouble  skirmishing  for  lights  and 
focus ;  in  other  words,  he  had  normal  presbyopia. 

On  ]\Iay  13,  1910,  at  the  age  of  forty-six,  he  ap- 
plied to  me  for  optical  aid.  There  were  no  symptoms 
of  eye  discomforts  or  headaches,  he  simply  had  to 
hold  the  print  off,  and  then  could  not  see  the  two 
smaller  blocks  of  Jaeger  types.  An  examination 
showed  a  considerable  amount  of  mixed  astigma- 
tism ;  the  cycloplegic  drops  were  used,  and  as  is 
generally  the  case',  eliminated  a  considerable  part  of 
the  minus  element.  I  had  for  some  years  been 
convinced  of  the  disturbing  action  of  astigmatism 
on  the  heart,  especially  as  exemplified  in  chronic 
cold  feet  in  women  of  a  most  robust  type,  as  well 
as  delicate  looking  persons.  I  told  him:  "Mr.  H., 
I  think  we  have  the  nigger  in  the  woodpile  that  has 
been  causing  all  your  heart  trouble."  Such  proved 
to  be  the  case,  for  with  the  constant  wearing  of 
glasses,  to  which  presbyopic  addition  was  subse- 
quently made,  he  soon  threw  off  his  disabilities,  and 
he  has  remained  well  to  the  present  time.  Last 
year  he  applied  for  life  insurance,  and  the  company 
held  up  his  application  because  of  a  loss  of  weight 
of  twenty  pounds  from  his  erstwhile  average,  and 
asked  for  an  explanation.  His  answer  was  that 
the  country  was  at  war  and  long  on  lawyers  and 
short  on  farmers,  so  he  went  back  to  the  farm  and 
worked  off  that  twenty  pounds.  They  gave  him 
the  insurance.  The  anemia  referred  to  has  often 
been  noted,  and  it  is  no  rare  thing  to  see  it  vanish 
as  rapidly  after  eye  correction,  as  it  does  in  other 
cases  when  the  cause,  such  as  malaria,  sepsis,  or 
hookworm  is  removed.  Likewise,  patients  under 
their  normal  health  weight,  often  gain  flesh  with 
the  same  rapidity.    Where  the  anemia  and  loss  of 


450 


JOXES:  ASTIGMATISM. 


[New  York 
Medical  Journal. 


weight  have  been  marked,  it  is  sometimes  hard  to 
recognize  the  patient  as  the  same  person  after  a  few 
months.  This  is  because  the  nutritional  system  is 
upset  by  the  disturbances  of  the  liver. 

Dr.  Lyster  says  (9)  :  "After  studying  the  subject 
in  the  military  camp  at  Camp  Custer,  Mich.,  I  am 
convinced  that  this  syndrome,  which  was  first 
described  by  Da  Costa,  during  the  Civil  War,  and 
by  the  French,  English  and  American  physicians 
during  the  recent  war,  is  not  a  cardiovascular  dis- 
turbance primarily,  but  the  disturbance  of  the  auto- 
nomic and  sympathetic  nervous  systems."  Dr.  Bliss 
says,  "An  internist  in  France  insisted  that  all  these 
cases  were  caused  by  a  hyperthyroid  condition, 
while  I  insisted  that  relatively  few  were  due  to  a 
hyperthyroid  condition.  There  are  constitutional 
cases.  You  cannot  make  soldiers  out  of  these  men. 
No  form  of  treatment  changed  these  individuals, 
either  physically  or  mentally,  so  as  to  enable  them 
to  be  good  soldiers.  The  important  point  to 
recognize  is  that  they  were  constitutionally  inferior, 
and  not  capable  of  such  restoration  as  would  make 
them  efficient  men."  Dr.  Neilson  says,  "When  the 
first  soldiers  were  being  examined  in  St.  Louis,  I 
went  so  far  as  to  accuse  some  one  of  giving  these 
young  men  thyroid  extract.  We  put  many  of  them 
into  the  army.  Some  came  back  with  neuritis,  some 
with  hyperthyroidism,  and  some  with  constitutional 
disorders.  Later  I  decided  to  put  these  individuals 
into  limited  service,  but  I  found  that  the  limited 
service  men  worked  just  as  hard  as  the  regular 
soldiers,  so  we  decided  to  send  them  back  to  their 
own  work.  We  do  not  know  what  is  wrong  with 
these  people,  or  that  there  is  anything  wrong  with 
them,  but  I  believe  there  is  something  behind  it. 
I  am  not  so  enthusiastic  as  to  attribute  all  these 
disturbances  to  the  ductless  glands." 

Time  and  again  I  have  observed  patients  of  this 
type  who  applied  either  for  minor  discomforts 
about  their  eyes,  or  in  their  opinion,  things  which 
might  be  due  to  eyes,  when  inquiry  revealed  that 
they  were  either  tired,  or  became  easily  ex- 
hausted, and  became  dyspneic  from  the  slightest 
exertion,  when  their  appearance  indicated  they 
should  measure  up  to  full  standards  of  strength. 
Not  a  few  have  come  for  aural  troubles,  and  in  a 
purely  accidental  way,  have  spoken  of  how  tired  they 
always  were,  and  how  quickly  they  became  ex- 
hausted, and  had  no  complaint  whatever  as  to  com- 
fort or  endurance  of  vision,  and  yet  a  painstaking 
correction  of  refractive  errors,  often  exceedingly 
small  and  hard  to  find,  w^ould  relieve  them  of  the 
asthenia.  In  many  of  these  cases  vision  was  ab- 
solutely normal,  and  the  eyes  rejected  all  glasses 
indicative  of  ametropia;  but  the  use  of  a  cyclop- 
legic  would  often  reveal  a  surprising  amount  of 
concealed  error,  even  up  to  the  age  of  fifty  or 
beyond.  On  the  other  hand,  the  error  may  be  so 
slight  that  vision  under  a  cycloplegic  is  normal,  and 
apparently  no  error  to  tests  made  with  no  more 
than  ordinary  care,  but  by  taking  sufficient  pains, 
a  low  cylinder  can  be  definitely  proved  to  be  called 
for  and  in  this  class  of  cases  some  of  the  inost  phe- 
nomenal results  have  been  achieved. 

A  few  years  ago  a  civil  engineer,  aged  thirty, 
complained  of  great  fatigue  in  the  presence  of  a 


railroad  official,  who  had,  by  accident,  fallen 
under  eye  treatment  which  relieved  him  of 
these  mysterious  fatigue  symptoms,  and  was 
told  to  have  his  eyes  investigated.  He  had  in  addi- 
tion to  a  general  fatigue  beyond  reason,  several  other 
symptoms  of  eye  strain,  and  as  usual  no  importance 
was  attached  to  the  fact  that  the  vision  was  super- 
normal and  tests  for  error  repudiated,  but  when 
under  a  cycloplegic  vision  was  20/16,  and  all  glasses 
for  a  time  rejected,  things  began  to  get  interesting. 
By  much  persistence,  the  presence  in  one  eye  of 
one  quarter  of  a  diopter  of  astigmatism  with  axis 
at  off  angle,  and  the  other  a  like  astigmatism  with 
equal  spherical  error,  was  finally  established.  It 
was  explained  to  him  he  must  wear  glasses  all  the 
time.  Some  months  later,  he  was  observed  to  be 
much  improved  in  appearance  and  weight. 

Detractors  of  the  value  of  exact  correction  of 
errors  say  that  much  of  the  good  observed  is 
due  to  suggestion  on  the  part  of  an  enthusiastic 
refractionist,  and  expectancy  on  the  part  of  the 
patient.  This  criticism  is  readily  answered  by  the 
havoc  played  with  many  patients  who  have  been 
relieved,  when  one  cylinder  gets  thrown  a  few 
degrees  off  axis,  and  the  patient  still  thinks  his  glasses 
the  same.  Such  patients  will  sometimes  say,  "I 
cannot  wear  my  glasses,  and  I  cannot  go  without 
them."  In  older  days  with  flat  lenses,  this  often 
came  about  by  a  glass  falling  out  and  being  put  in 
backward,  or  having  the  frame  bent;  in  latter  days, 
by  accidental  rotation  of  a  round  lens.  Another 
source  of  trouble  is  replacing  lenses  from  the 
broken  pieces,  when  either  the  axis  of  a  recognized 
cylinder  is  slightly  misplaced,  or  a  weak  cylinder, 
in  combination  with  a  strong  spherical,  is  altogether 
overlooked.  An  illustrative  case  is  a  man  of  forty, 
of  athletic  proportions,  who  came  six  years  ago  for 
sundry  vague  complaints  about  his  eyes  of  several 
years'  duration.  Inquiry  revealed  that  he  was 
always  tired,  got  no  relief  from  vacations,  and  had  to 
force  an  interest  in  his  .  business.  Eyes  tested 
normal,  but  under  a  cycloplegic,  right  showed  one 
and  a  half  spherical  with  one  quarter  cylinder  axis 
135,  and  left  one  spherical  with  -{-0.62  cylinder 
axis  forty-five,  which  were  given  for  constant  wear. 
After  the  usual  difficulty  of  getting  used  to  them  for 
distance,  he  was  relieved  in  body  and  mind,  and 
got  on  well  for  two  years.  His  old  symptoms  then 
returned,  and  he  came  for  reexamination.  It  was 
observed  he  had  other  glasses,  which  he  said  were 
made  on  the  formula  of  those  first  worn.  Inspec- 
tion showed  the  cylinders  had  been  omitted,  and 
when  glasses  were  supplied  by  correct  formula,  he 
became  well  again.  At  the  expiration  of  another 
year,  he  indulged  in  the  new  style  round  lenses,  and 
symptoms  again  drove  him  to  report  for  relief, 
when  lenses  were  found  correct,  but  axis  of  cylin- 
ders reversed.  They  were  set  right  and  marked, 
and  no  trouble  has  been  reported  since.  The 
majority  of  these  patients  with  muscular  asthenia, 
neurasthenia,  and  psychasthenia,  if  questioned,  will 
also  be  found  to  present  evidences  of  neurocircu- 
latory asthenia,  as  exemplified  by  their  being  easily 
winded,  with  palpitation  of  the  heart  from  slight 
effort,  clammy  hands  and  feet,  and  the  other 
symptoms    detailed    in    the    previous  quotations. 


Stpteraber  25,  1920.] 


JONES:  ASTIGMATISM. 


451 


These  conditions  are  much  more  common  among 
women  than  among  men,  and  in  a  regiment  of 
Amazons  a  large  proportion  would  drop  out  when 
put  to  drilling.  To  see  these  Amazon  women  who 
are  always  dead  tired,  with  pain  or  drawing  in  the 
neck  and  shoulders,  easily  winded,  with  fluttering 
hearts,  gas  in  stomachs,  and  cold,  clammy  extremities, 
measure  up  to  their  looks  after  having  an  astig- 
matism corrected,  is  more  suggestive  of  a  play 
that  is  staged,  than  the  realities  of  life.  They 
will  often  say  on  presentation,  that  the  worst  of 
it  is,  they  look  so  healthy  and  strong,  that  no  one 
will  believe  how  tired  they  are,  and  how  miser- 
able they  feel.  On  the  other  hand,  some  of  the 
opposite  type  look  as  miserable  as  they  feel,  and 
in  such  the  improvement  in  looks,  color  and  weight 
may  be  observed  pari  passu,  with  their  feelings. 
One  not  infrequent  afterresult  is  that  those  who  had 
settled  down  into  a  condition  of  confirmed  celibacy 
feel  so  buoyed  up  in  health  and  spirits,  that  they 
view  life  from  a  different  angle,  and  embark  on 
the  sea  of  matrimony.  Nearly  two  decades  ago 
I  began  to  note,  more  frequently  in  women,  in  cases 
of  eyestrain,  the  presence  of  a  pain  or  pulling 
in  the  neck,  or  shoulders,  or  between  the  shoulders, 
not  rarely  running  out  into  the  arm,  or  even  to  the 
finger  tips,  accompanied  by  a  tingling  or  numbness 
in  the  arm  which  has  been  pronounced  by  some 
as  neuritis.  This  pain  also  in  some  instances  runs 
from  neck  to  ear,  or  continues  on  from  ear  to  eye. 
However  old,  or  well  known  this  symptom  may  be 
to  others  it  is  only  in  very  recent  years  I  can  recall 
having  seen  any  reference  to  it  in  such  promiscuous 
articles  as  I  am  able  to  peruse,  as  for  instance  in 
the  report  of  Major  Newcomb  (10),  of  the  Army 
Service,  where  it  is  referred  to  as  the  checkrein 
symptom. 

It  is  not  mentioned  by  Stephenson  (10),  who 
covered  the  literature  of  the  subject  up  to  date 
of  its  publication  four  or  five  years  ago.  In  seeking 
its  explanation,  I  came  to  the  conclusion  it  was  a 
distress  signal  of  the  liver ;  the  older  works  on 
medicine  abounded  in  references  to  pain  in  the 
shoulder  as  a  symptom  of  liver  disease.  Anatomists 
tell  us  the  parenchyma  of  the  liver  has  no  sensory 
nerves,  but  only  sympathetic  fibres,  but  that  these 
sympathetic  fibres  anastomose  with  the  spinal 
sensory  nerves,  and  it  is  most  likely  by  this  means 
the  protest  of  the  liver  is  registered  against  a  factor 
disturbing  its  normal  functioning.  By  this  same 
inhibition  of  hepatic  functioning  is  also  plausibly 
explained  the  flatulence  so  commonly  due  to  eye- 
strain in  elderly  people  of  both  sexes,  but  probably 
more  common  in  females.  In  presbyopes,  who  have 
obtained  age  glasses  and  found  them  unsatisfactory, 
it  is  one  of  the  very  commonest  of  symptoms,  and 
usually  diminishes  or  goes  away  when  the  causative 
astigmatism  is  properly  corrected  by  glasses  worn 
absolutely  all  the  time  except  when  patients  go  to 
bed  to  sleep.  It  is  likewise  my  belief  that 
the  headaches  and  sick  headaches  recognized  for 
two  generations  as  coming  from  the  eyes,  and  the 
vertigo  equally  common,  but  not  so  generally  ad- 
mitted as  an  eyestrain  reflex,  are  directly  due  to 
the  inhibition  of  hepatic  function  by  eyestrain,  and 
are  consequently  exactly  the  same  in  nature  as  the 


acute  bilious  attacks  due  to  other  transient  causes, 
putting  the  liver  out  of  commission  for  the  time 
being,  such  as  getting  overheated  on  a  full  stomach. 
Inasmuch  as  Dame  Nature  finds  relief  from  empty- 
ing the  stomach  under  these  conditions  by  vomiting, 
she  tries  the  same  tactics  in  the  headaches  due  to 
eyestrain,  thus  explaining  the  nausea  or  vomiting 
of  sick  headaches. 

On  February  15,  1910,  a  woman  aged  thirty- 
nine,  came  to  me  because  of  sundry  discom- 
forts in  the  use  of  her  eyes,  and  inquiry  re- 
vealed she  had  for  several  years  suffered  from  a 
severe  pain  under  her  right  shoulder  blade,  which 
remained,  much  to  the  perplexity  of  her  surgeon, 
after  he  had  removed  a  large  number  of  gallstones 
by  operation,  other  symptoms  due  to  gallstones  hav- 
ing vanished.  I  remarked  that  I  had  for  some 
years  been  interested  in  the  similarity  of  certain 
symptoms  arising  from  gallstones  and  eyestrain 
and  hjers  would  be  a  good  case  to  try  them  out 
separately.  She  showed  some  manifest  error  but 
much  more  under  a  cycloplegic,  and  surprised  and 
pleased  her  oculist  by  w.earing  the  full  correction 
without  the  usual  protests  about  the  annoyances  of 
breaking  the  eyes  to  the  glasses.  When  com- 
mended for  this,  she  said  the  glasses  were  doing 
too  much  good  to  complain  about.  That  before, 
life  did  not  seem  worth  living;  the  pain  was  gone, 
and  even  her  children  noticed  a  change. 

In  discussing  the  origin  of  vertigo,  the  older  med- 
ical works  had  much  to  say  of  plethora,  and  disor- 
ders of  the  stomach  and  liver,  while  the  latter  day 
works  speak  of  high  blood  pressure,  arteriosclero- 
sis, and  aural  troubles.  It  seems  to  me  that  in  late 
years  the  current  literature  on  vertigo  from  aural 
origin  to  that  from  ocular  origin  is  about  in  the 
proportion  of  an  unabridged  dictionary  to  a  pocket 
edition,  while  from  my  observations  the  reverse  is 
really  the  case.  Patients  with  hardening  of  the 
arteries  and  vertigo  to  the  point  of  complete  in- 
capacity for  the  ordinary  tasks  or  pleasures  of 
life,  have  been  relieved  of  the  vertigo  by  correcting 
astigmatism,  often  buried  under  a  farsighted- 
ness for  which  they  had  for  many  years  worn  bi- 
focals, or  in  those  having  in  the  glasses  they  had 
been  wearing  an  astigmatic  recognition  which  was 
not  correct  as  to  strength  and  angle.  By  reason  of 
the  abundant  literature  on  aural  vertigo,  a  number 
of  these  cases  have  been  referred  for  ear  treatment, 
but  cured  by  attention  to  eyes.  One  old  lady  of 
sixty-seven  had  suffered  severely  from  vertigo  for 
thirty  years,  so  much  so  that  her  physician  considered 
it  IMeniere's  disease ;  she  was  wearing  spherical  bi- 
focals. On  correcting  a  moderate  amount  of  com- 
plicating astigmatism,  she  soon  became  entirely  free 
of  her  dizziness,  and  wrote,  a  few  years  back,  that 
she  had  had  only  one  bad  spell  in  three  years,  which 
she  attributed  to  overloading  her  stomach  during  a 
hot  spell  of  weather. 

In  numerous  instances  patients  have  refused  to 
believe  the  constant  wearing  of  glasses  necessary, 
usually  stating  they  could  not  wear  the  glasses,  en- 
during their  symptoms  months  or  years  before  set- 
tling down  to  make  themselves  carry  out  instruc- 
tions which  brought  the  desired  relief. 

When  we  consider  what  a  transformation  in  one's 


452 


DUXNINGTON:  SQ UINT. 


[New  York 
Medical  Journal. 


life  the  uprooting  of  a  small  astigmatism  can  make, 
we  may  well  conclude  that  one  in  the  search  for  it 
should  have  the  convictions  of  Columhus  that  there 
is  something  worth  searching  for,  and  in  finding  it, 
if  need  be,  the  patience  of  Job. 

REFERENXES. 

1.  Pfahlee,  George  E.  ;  Cardiovascular  Examinations  of 
Fiftj'-five  Thousand  Recruits  at  Camp  Travis,  Journal  A. 
M.  A.,  January  18.  1919. 

2.  Elliott,  R.  H.  :  British  Journal  of  Ophthalmology, 
June,  1918. 

3.  RoLV  and  Boas  :  Journal  A.  M.  A.,  August  17,  1918. 

4.  Friedlaxder  and  pRfiiiOi-:  An  Intenbive  Study  of 
Fifty  Cases  of  Neurocirculatory  Asthenia,  Archives  of 
Internal  Medicine,  December,  1918. 

5.  Barrixger  :  Tachycardia  of  Unknown  Origin, 
Archives  of  Internal  Medicine,  December,  1918. 

6.  Archives  of  Internal  Medicine,  March,  1919. 

7.  Carroll:  Neurocirculatory  Asthenia,  American  Jour- 
nal of  the  Medical  Sciences,  July,  1919. 

8.  Hein,  G.  E.  :  Studies  in  Neurocirculatory  Asthenia 
at  Camp  Sherman,  Journal  A.  M.  A.,  January  25,  1919. 

9.  Lyster  :  Socalled  Irritable  Heart  of  Soldiers,  Journal 
A.  M.  A.,  June  28,  1919. 

10.  Newcomb:  American  Journal  of  Ophthalmology, 
May,  1919. 

11.  Stephexsox  :  £3'('  Strain  in  Eirryday  Practice. 


SOME  PRACTICAL  CONSIDEIL^TIOXS  OF 
SQUINT.* 

By  John  H.  Dunnixgton,  M.  D., 
New  York. 

Looking  at  an  object  with  the  two  eyes  open  a 
normal  person  fixes  the  same  object  with  both  eyes. 
A  squint  is  present  when  it  is  possible  for  him 
to  fix  on  an  object  with  only  one  eye  at  a  time. 
Divergent  squint  is  the  condition  when,  with  both 
eyes  open,  one  eye  is  looking  at  an  object  and  the 
other  one  is  turned  outward,  i.  e.,  there  is  an  actual 
divergence  of  the  visual  axes  of  the  two  eyes.  The 
deviation  is  called  convergent  squint  when  the 
squinting  eye  is  turned  inward.  Also  the  condition 
of  upward  squint  and  downward  squint  designates 
the  position  of  the  squinting  eye.  Therefore  it 
can  be  said  that  the  character  of  the  squint  depends 
upon  the  position  of  the  nonfixing  eye. 

Normally  the  two  eyes  are  capable  of  being  sim- 
ultaneously moved  in  any  direction,  i.  e.,  up,  down, 
right  or  left,  but  in  addition  to  these  excursion  move- 
ments, the  eyes  perform  two  very  important  move- 
ments, that  of  divergence  and  that  of  convergence. 
Divergence  of  the  eyes  is  produced  by  simultaneous 
outward  rotation  of  both  eyes.  This  act  of  diverg- 
ing the  visual  axes  is  probably  produced  by  simul- 
taneous equal  relaxation  of  both  internal  recti  mus- 
cles accompanied  by  equal  simultaneous  contraction 
of  both  external  recti.  There  is  a  definite  cerebral 
centre  to  govern  divergence.  Neurologists  are 
loath  to  admit  the  existence  of  such  a  centre,  but 
clinical  evidence  strongly  supports  the  contention 
of  ophthalmologists  that  one  exists.  Dr.  Alexander 
Duane,  who  has  made  a  very  thorough  stucj^'  of  the 
ocular  movements,  is  of  the  opinion  that  this  centre 
is  in  close  proximity  to  the  nuclei  of  the  sixth 
nerves  which  are  situated  on  the  floor  of  the  fourth 
ventricle  near  the  median  line.    Errors  of  diverg- 

*Presented  before  the  Richmond  County  Medical  Society,  March 
10,  1920. 


ence  result  from  an  overaction  or  an  underaction 
of  this  centre. 

A  divergence  excess  is  therefore  present  when 
the  eyes  possess  an  abnormally  great  power  of 
simultaneous  outward  rotation.  This  is  a  common 
condition  and  is  the  starting  point  for  many  di- 
vergent squints.  It  is  impossible  to  inhibit  the  over- 
exacting  centre,  so  we  have  to  adopt  the  measure 
of  weakening"  the  acting  muscles.  This  is  done  by 
tenotomies  of  the  external  recti  muscles.  The  use 
of  glasses  to  correct  a  squint  due  to  divergence  ex- 
cess always  results  in  failure.  Operative  treatment 
is  the  only  cure  for  such  cases. 

The  opposite  condition,  that  of  paralysis  of  the 
power  of  divergence,  affords  a  more  interesting  pic- 
ture. In  this  condition  there  is  usually  a  sudden 
onset  of  a  distressing  double  vision  (diplopia)  for 
distance,  but  no  diplopia  for  close  range.  That  the 
patient  has  usually  detected  this  is  evidenced  by  his 
statement  that  he  has  diplopia  when  he  looks  at  a 
distance,  but  can  see  to  read  without  difficulty. 
There  is  a  marked  convergent  squint  as  the  patient 
looks  at  a  distant  object,  but  none  as  he  fixes  on  a 
near  point.  Both  eyes  can  move  outward  in  a 
perfectly  normal  manner  and  there  is  no  limitation 
of  motion  of  either  eye  in  any  field.  This  normal 
outward  rotation  of  each  eye  would  differentiate  it 
from  an  external  rectus  paralysis,  with  which  it  is 
commonly  confused. 

Dr.  Wheeler,  with  whom  I  am  associated,  re- 
ported the  following  typical  case  : 

Case. — In  February,  1918,  a  man,  W.  J.,  twenty- 
five  years  of  age,  called  at  the  New  York  Eye 
and  Ear  Infirmary  saying  that  on  August  1,  1917, 
while  digging  a  ditch  his  vision  became  suddenly 
confused  and  since  that  time  he  had  seen  double  at 
a  distance.  He  was  in  the  hospital  three  months 
but  left  unimproved.  \'ision  was  normal  in  each 
eye ;  nothing  pathological  could  be  found  in  the 
interior  of  either  eye.  There  was  no  limitation  of 
motion  of  either  eye  in  any  field.  There  was  dip- 
lopia at  a  distance  but  none  for  near  range.  Pupils 
reacted  to  light  and  accommodation  in  a  normal 
manner.  The  urine,  blood  and  spinal  fluid  Wasser- 
mann  were  all  negative.  In  this  case  paralysis  of 
divergence  probably  restilted  from  hemorrhage  into 
the  divergence  centre  while  the  patient  was  under 
physical  exertion. 

The  pathology  of  such  a  paralysis  is  doubtless  a 
lesion  in  the  centre.  The  most  likely  causes  of 
such  a  localized  disturbance  are  lues,  cerebral  tumor, 
multiple  sclerosis  and  tabes,  but  often  it  is  impos- 
sible to  find  any  etiological  factor.  The  prognosis 
for  recovery  from  the  paralysis  is  bad,  but  usually 
relief  from  double  vision  is  achieved  by  suppres- 
sion of  one  of  the  images.  A  constant  convergent 
squint  is  the  final  result.  The  knowledge  of  the 
existence  of  such  a  condition  is  of  importance  in 
that  its  presence  means  a  definite  cerebral  lesion 
and  warrants  a  most  thorough  examination.  It 
may  be  the  precursor  of  a  much  more  serious  cere- 
bral disturbance. 

Convergence  is  the  otlier  unparallel  movement 
which  the  eyes  are  capable  of  performing.  Both 
internal  recti  muscles  contract  at  the  same  time  and 
to  an  equal  extent,  thereby  causing  both  eyes  to  be 


September  2S,  1920.] 


DUXXINGTOX:  SQUINT. 


453 


turned  inward.  The  act  of  convergence  is  also 
controlled  by  a  cerebral  centre.  This  centre  may 
be  overactive  or  underactive. 

Convergence  excess  is  therefore  produced  by  an 
overacting  centre.  This  frequent  anomaly  of  con- 
vergence is  responsible  for  many  convergent  squints. 
It  is  often  associated  with  hyperopia  (farsighted- 
ness). It  is  in  these  cases  that  glasses  do  the  most 
good  toward  correcting  the  squint. 

With  an  underacting  centre  we  get  an  insufficient 
power  of  convergence.  This  inability  to  converge 
may  vary  in  degree  from  a  slight  underaction  to  a 
complete  paralysis.  ^Many  divergent  squints  result 
from  untreated  convergence  insufficiencies.  There 
are  many  causes  of  convergent  anomalies  besides  re- 
fractive errors,  but  we  cannot  consider  them  at  this 
time.  However,  it  is  important  for  us  to  remem- 
ber that  disorders  of  convergence  produce  squints. 
A  convergent  squint  may  be  the  result  of  an  excess 
of  convergence,  or  a  divergent  squint  may  come 
from  an  inability  to  converge  the  eyes.  This  con- 
verging power  must  not  be  confused  with  the  power 
of  internal  rotation.  A  patient  may  have  normal 
power  of  turning  each  eye  in  separately,  i.  e.,  the 
power  of  internal  rotation  be  good  in  each  eye  and 
still  be  unable  to  converge.  This  fact  clearly  dem- 
onstrates that  the  convergence  movement  is  a  sep- 
arate and  distinct  function  from  that  of  simple 
inward  rotation. 

A  squint  can  also  be  caused  by  a  paralysis  of  one 
or  more  of  the  ocular  muscles.  The  character  of 
the  squint  depends  upon  what  muscle  is  affected. 
For  example,  if  the  right  external  rectus  is  para- 
lyzed the  right  eye  will  turn  inward.  There  will 
be  limitation  of  movement  of  the  right  eye  out- 
ward because  the  muscle  which  moves  that  eye  out 
is  paralyzed.  In  paralytic  cases,  unless  they  are  of 
congenital  origin,  the  onset  is  usually  sudden.  The 
patient  complains  of  diplopia  with  its  attendant 
nausea  and  confusion.  There  may  or  may  not  be 
an  evident  squint.  A  history  of  the  sudden  onset 
of  double  vision  is  most  suggestive  of  an  ocular 
muscle  paralysis. 

Consideration  of  the  etiology  of  ocular  palsies  is 
of  interest  to  the  general  physician.  Syphilis  is  the 
most  common  cause.  It  is  not  an  tincommon  thing 
in  fracture  of  the  base  of  the  skull  for  a  patient 
to  get  an  ocular  muscle  palsy  from  injury  to  one  of 
the  nerves  as  it  emerges  from  the  base  of  the  skull. 
It  occurs  as  an  occasional  complication  in  influenza, 
diphtheria,  whooping  cough  and  in  the  acute  exan- 
thematous  diseases.  Congenital  paralyses  occur  not 
infrequently,  and  often  a  case  of  supposed  torti- 
collis is  due  to  congenital  ocular  muscle  paralysis. 

The  treatment  of  these  acquired  parah-tic  squints 
is  largely  that  of  the  underlying  cause.  If  syphi- 
litic in  origin  give  energetic  antisyphilitic  treatment. 
In  the  traumatic  cases  it  is  often  wisest  to  do 
nothing  until  nature  has  had  time  to  repair  the 
damage  by  regeneration.  Operative  intervention  is 
indicated  in  the  congenital  types,  but  in  the  acquired 
parahtic  squints  give  the  patients  the  benefit  of 
thorough  treatment  before  considering  operation. 

PSEUDOSQUIXT  OR  APPARENT  SQUINT. 

Having  considered  the  etiological  factors  in  ac- 
tual squint,  we  pass  now  to  a  most  interesting  con- 


dition, pseudosquint  or  apparent  squint.  It  is  com- 
mon among  cWldren  and  I  believe  fully  one  third 
of  the  cases  of  supposed  convergent  squint  in  chil- 
dren belong  to  this  category.  The  child  appears  to 
have  crossed  eyes  but  the  examination  shows  no 
evidence  of  squint.  What  then  is  present?  The 
child's  nose  has  a  broad  and  flat  appearance,  the 
bridge  of  it  is"  underdeveloped.  The  skin  of  the 
nose,  instead  of  being  tightly  adherent  to  it,  is  loose- 
ly attached ;  except  at  the  inner  canthal  ligament. 
This  laxity  of  attachment  may  permit  the  skin  to 
hang  in  a  vertical,  fold  producing  a  condition  known 
as  epicanthus.  The  inner  canthi  are  farther  apart 
than  normal.  This  increased  distance  between  the 
inner  canthi  is  caused  by  two  factors.  First,  the 
looseness  of  the  attacliment  of  the  skin  to  the 
underlying  bones  and  second,  the  underdevelopment 
of  the  bridge  of  the  nose.  The  position  of  the  eye- 
ball in  the  orbit  is  normal  and  the  distance  between 
the  nasal  orbital  walls  is  no  greater  than  normal. 
This  loosely  attached  skin  therefore  covers  a  part 
of  the  nasal  portion  of  the  sclera  on  either  side, 
giving  the  patient  the  appearance  of  having  a  con- 
vergent squint.  Such  a  facial  appearance  is  a  char- 
acteristic of  the  Mongolian  race.  We  are  all  fa- 
miliar with  the  peculiar  appearance  of  a  Chinaman's 
eyes.  He  has  this  underdevelopment  of  the  nasal 
bridge  which  gives  him  an  apparent  convergent 
squint.  His  nasal  bridge  never  develops  so  he 
keeps  this  condition  throughout  life.  The  ordin- 
ary child,  however,  does  develop  a  bridge  to 
his  nose  and  as  this  development  proceeds  the  skin 
is  drawn  inward  and  forward.  In  this  way  the 
deformity  is  corrected.  A  cure  then  is  simply  de- 
pendent upon  full  facial  development.  I  cannot 
stress  too  strongly  the  importance  of  recognition 
of  this  condition.  The  failure  of  physicians  to 
appreciate  this  facial  change  has  led  to  the  very 
widespread  belief  that  a  squint  will  correct  itself. 
I  have  known  of  several  cases  where  glasses  have 
been  prescribed  to  correct  the  squint  when  only  this 
apparent  condition  existed.  It  is  not  always  easy 
to  differentiate  these  two  conditions  especially  in 
very  young  children  but  a  careful  examination  will 
definitely  establish  the  diagnosis.  The  importance 
of  differentiating  the  actual  from  the  apparent 
squint  is  evident,  as  actual  squints  demand  early 
treatment  and  apparent  squints  need  none.  Do  not 
tell  the  parents  the  child  will  be  all  right  when  he 
grows  up  unless  you  are  positive  it  has  only  an 
apparent  squint. 

The  reverse  condition  of  apparent  divergent 
squint  is  occasionally  seen  in  persons  who  have  a 
particularly  high,  narrow  nasal  bridge.  In  these 
cases  the  skin  is  stretched  tightly  over  the  bony 
structures  and  more  than  a  normal  amount  of  scleral 
tissue  is  exposed  on  the  nasal  side  of  the  limbus. 
This  demands  no  treatment  and  is  rarely  marked 
enough  to  be  disfiguring. 

GENERAL  C0NSrDER.\TI0NS. 

There  ^re  certain  features  of  squint  cases  which 
are  of  particular  interest  to  the  general  physician. 
He  is  the  man  who  usually  is  first  consulted  about 
this  deformity.  What  should  he  do?  It  is  his  duty 
to  advocate  early  treatment  in  all  his  squint  cases. 
Do  not  accept  the  responsibility  of  postponing  treat- 


454 


DUNNINGTON:  SQUINT. 


[New  York 
Medical  Journal. 


ment.  Put  that  up  to  the  oculist.  The  chief  rea- 
sons for  advocating  very  early  correction  of  the 
squint  are  three  in  number.  The  first  is  the  loss 
of  vision  in  the  squinting  eye.  Amblyopia  exanopsia 
as  this  deterioration  in  sight  from  disuse  is  called, 
ensues  very  rapidly  in  young  children.  Some  ocu- 
lists contend  no  such  loss  in  sight  can  occur  yet  the 
clinical  evidence  strongly  indicates'  its  existence. 
Worth,  an  eminent  English  ophthalmologist  who  has 
devoted  a  great  part  of  his  time  to  the  study  of  this 
problem,  says  "a  child  with  good  vision  in  each  eye 
who  develops  a  constant  unilateral  squint  at  the  age 
of  six  or  eight  months  will  in  the  absence  of  proper 
treatment  become  rapidly  blind  in  the  squinting  eye. 
This  loss  of  vision  in  the  infant's  deviating  eye  is 
so  rapid  that  the  power  of  central  fixation  is  often 
lost  within  eight  to  ten  weeks."  The  older  the  child 
the  less  rapid  is  the  loss  of  vision.  After  six  years 
of  age  amblyopia  exanopsia  rarely  takes  place  to 
any  marked  extent.  Acquired  amblyopia  is  a  true 
loss  of  vision,  not  a  failure  of  function  to  develop. 
Not  every  case  of  squint  develops  this  amblyopia, 
for  in  some  we  see  first  one  eye  fixing  and  then 
the  other.  It  is  in  the  unilateral  squint  that 
this  gradual  loss  of  vision  does  its  greatest  harm. 

There  is  another  or  second  important  reason  for 
the  early  correction  of  the  squint.  A  permanent 
loss  in  the  ability  to  use  the  two  eyes  together  oc- 
curs in  practically  every  squint  of  long  standing. 
Binocular  single  vision  is  affected  by  a  psychical 
blending  of  the  two  sets  of  visual  impressions  into 
one  composite  picture.  According  to  Worth,  the 
power  of  fusion  of  the  images  of  the  two  eyes  be- 
gins development  very  early  (by  the  end  of  the  first 
year)  and  is  considered  complete  by  him  at  the  end 
of  the  sixth  year.  It  is  impossible  for  the  mind's 
eye  to  fuse  the  images  of  the  two  eyes  into  one  when 
a  squint  is  present,  therefore  to  him  everything 
appears  double.  Children  readily  overcome  this 
double  vision  by  ignoring  the  image  of  one  eye.  This 
necessitates  the  using  of  only  one  eye  at  a  time. 
Therefore,  unless  the  squint  is  corrected  early,  the 
ability  to  use  the  two  eyes  together  is  lost  and  never 
regained.  With  only  monocular  vision  it  is  impos- 
sible to  judge  distances  accurately  or  to  appreciate 
fully  the  sense  of  depth.  The  possession  of  this 
faculty  of  binocular  vision  was  considered  im- 
portant in  the  army  air  service.  Without  it  no  one 
could  qualify  as  a  flier,  for  in  aviation  accurate 
estimation  of  distances  is  often  essential. 

The  third  or  cosmetic  reason  for  the  early  cor- 
rection of  squint  is  the  one  which  usually  brings  the 
patient  to  consult  an  oculist.  The  unfortunate  cross- 
eyed child  is  greatly  handicapped.  Children  poke  fun 
at  him ;  call  him  "Mamma's  crosseyed  baby."  He  is 
very  sensitive  about  it.  He  become  shy  and  backward 
in  school.. He  avoids  his  playmates,  and  becomes  of 
a  sullen,  disagreeable  nature.  Early  correction  of  the 
squint  removes  the  possibility  of  such  a  change  oc- 
curing  in  the  child. 

To  summarize,  then  we  should  advise  early  cor- 
rection of  squint,  1.  To  prevent  amblyopia  exanopsia 
(loss  of  sight  from  disuse.  2.  To  preserve  the  ability 
to  use  the  two  eyes  together.  2.  To  remove  the  de- 
formity which  is  a  genuine  handicap  to  the  develop- 
ment of  the  child's  mind  and  body. 


TREATMENT. 

How  should  a  squint  be  treated?  Every  case  of 
squint  should  receive  a  most  careful  eye  examina- 
tion. The  first  duty  of  the  oculist  is  to  find  out 
what  is  causing  the  squint.  If  the  refraction  of  the 
eye  be  a  factor,  correct  that,  but  most  ophthalmolo- 
gists make  the  mistake  of  considering  every  case  of 
squint  one  of  only  refraction.  Do  not  tell  your  pa- 
tients with  squint  that  it  is  simply  a  matter  of 
glasses.  Too  many  other  factors  have  to  be  con- 
sidered to  warrant  such  a  broad  statement.  Many 
squints  do  not  require  glasses  and  some  are  even 
made  worse  by  the  use  of  them. 

If  the  squint  is  due  to  a  syphilitic  muscle  paralysis 
glasses  will  not  help  but  antisyphilitic  treatment  will. 
In  every  case  of  squint  a  most  careful  search  for 
the  cause  of  the  actual  condition  should  be  made 
and  your  treatment  be  directed  toward  the  correc- 
tion of  the  productive  factor.  The  nonoperative 
treatment  should  therefore  be  strictly  causal  in 
nature. 

Many  cases  require  operative  interference.  The 
age  at  which  operation  should  be  advised  is  an  im- 
portant consideration.  There  is  a  widespread  belief 
among  practitioners  and  oculists  that  it  is  unwise 
to  operate  on  any  patient  with  squint  under  ten 
years  old.  Parents  are  therefore  continually  be- 
ing told  to  wait  until  the  child  is  older  before  think- 
ing of  operation.  We  have  already  considered  the 
great  harm  resulting  from  such  neglect.  Operative 
measures  are  indicated  as  soon  as  you  have  satisfied 
yourself  that  nonoperative  treatment  will  not  cure 
the  patient.  It  does  not  matter  whether  the  patient 
is  two  or  twenty,  if  operation  is  indicated,  operate. 
Good  results  follow  early  correction.  Operate 
when  necessary  to  correct  the  squint  regardless  of 
the  age.  The  youngest  patient  I  have  heard  of 
was  two  years  old  at  the  time  of  operation,  but  I 
see  no  reason  why  if  the  case  required  operation  it 
could  not  be  done  at  an  earlier  age  than  this. 

We  have  in  general  two  operative  procedures :  1. 
A  weakening  of  an  overacting  muscle ;  2,  a  strength- 
ening of  an  underacting  muscle.  The  tendon  of  the 
muscle  at  its  insertion  into  the  globe  is  severed 
either  partially  or  completely  to  effect  this  weak- 
ening in  the  tenotomy  operation.  There  are  two 
ways  of  increasing  the  action  of  a  weakened  muscle; 
first,  the  tendon  can  be  shortened  or  resected,  sec- 
ond, the  insertion  of  the  muscle  can  be  carried  fur- 
ther forward  (near  the  limbus),  in  other  words,  ad- 
vance the  insertion.  It  is  quite  often  necessary  in 
squints  of  long  standing  to  combine  a  resection  of 
one  muscle  with  a  tenotomy  of  its  antagonist.  Co- 
caine anesthesia  for  these  operations  can  be  effec- 
tiveh-  used  on  young  children.  Local  anesthesia 
has  to  my  knowledge  been  used  with  perfect  success 
in  a  patient  six  years  old. 

In  conclusion  let  me  again  call  to  your  attention 
these  considerations : 

1.  That  the  existence  of  divergence  as  a  separate 
and  distinct  function  from  that  of  external  rotation 
is  an  established  fact.  Also  that  convergence  is  not 
simply  an  act  of  internal  rotation  but  that  it  is  a 
distinct  entity.  The  performance  of  these  move- 
ments are  controlled  by  cerebral  centres. 

2.  Pseudosquint  is  a  common  condition,  the  ex- 


September  25.  1920.]       DUNCAN:  MEDICAL  MEN  IN  THE  AMERICAN  REVOLUTION. 


455 


istence  of  which  is  responsible  for  the  very  strong 
belief  that  a  squint  corrects  itself  in  time. 

3.  An  actual  squint  demands  early  correction  to 
save  the  vision  in  the  squinting  eye,  to  preserve  the 
ability  to  fuse  the  images  of  the  two  eyes,  and  to 
remove  the  deformity  which  is  a  great  handicap  to 
the  child's  progress. 

4.  Operate  when  indicated  regardless  of  age.  No 
bad  effects  result  from  early  operation.  ]Much  is 
lost  by  waiting. 

80  West  Fortieth  Street. 


MEDICAL  MEX  IX  THE  AMERICAN 
RE\'OLUTIOX. 
The  New  York  Campaign  of  1776. 

By  Louis  C.  Duncan,  M.  D., 
Washington,  D.  C, 

Lieutenant  Colonel,   Medical  Corps,  U.  S.  Army. 

(Continued  from  page  416) 

6.  — Resolved  : 

That  every  director  of  a  hospital  possesses  the  ex- 
clusive right  of  appointing  surgeons  and  hospital 
officers  of  all  kinds,  agreeable  to  the  resolution  of 
Congress  of  the  17  July,  in  his  own  department  un- 
less otherwise  directed  by  Congress.  That  Dr. 
Stringer  be  authorized  to  appoint  a  surgeon  for  the 
fleet  now  fitting  out  on  the  lakes. 

That  a  druggist  be  appointed  at  Philadelphia 
whose  business  it  shall  be  to  receive  and  deliver  all 
medicines,  instruments,  and  shop  furniture  for  the 
benefit  of  the  United  States.  That  a  salary  of 
thirty  dollars  a  month  be  paid  to  said  druggist  for 
his  labor. 

"Congress  proceeded  to  the  election  of  a  druggist 
and  the  ballot  being  taken.  Dr.  Wm.  Smith  was 
elected." 

This  druggist  appears  to  have  been  a  storekeeper, 
Or  medical  supply  officer.  The  medical  committee 
of  Congress  seems  to  have  done  the  purchasing. 

GENERAL  GREENE'S  LETTER  TO  WASHINGTON. 

Camp  at  Long  Island,  August  11,  1776. 

7.  — Dear  General : 

There  is  no  proper  establishment  for  supplying 
the  regimental  hospitals  with  proper  utensils  for  the 
sick;  they  suffer  for  want  of  proper  accommoda- 
tions. There  is  repeated  complaint  on  that  head. 
The  regimental  hospitals  are  and  ever  will  be  ren- 
dered useless,  nay  grievous,  unless  there  is  some 
proper  fund,  to  provide  the  necessary  conveniences. 
The  general  hospital  cannot  receive  all  the  sick :  and 
those  that  are  in  the  regimental  hospitals  are  in  a 
suflFering  condition.  If  this  evil  continues,  it  must 
injure  the  service,  as  it  will  dispirit  the  well,  to  see 
the  sick  suffer,  and  prevent  their  engaging  (enlist- 
ing) again,  upon  any  conditions  whatever.  Great 
humanit)'  should  be  exercised  toward  those  indis- 
posed. Kindness  on  one  hand,  leaves  a  favorable 
and  lasting  impression ;  neglect  and  suffering  on  the 
other,  are  never  forgotten. 

I  am  sensible  there  has  formerly  been  great  abuses 
in  the  regimental  hospitals,  but  I  am  in  hopes  men 


of  better  principles  are  elected  to  those  places,  and 
that  the  same  evils  will  not  happen  again.  But  the 
Continent  had  better  suffer  a  little  extraordinary 
expense,  than  the  sick  should  be  left  to  suffer,  for 
want  of  those  conveniences  so  easily  provided. 

I  would  beg  leave  to  propose  that  Colonels  of  regi- 
ments be  allowed  to  draw  monies,  to  provide  the 
regimental  hospitals  with  proper  utensils ;  an  ac- 
count of  the  disbursements,  weekly  or  monthly,  to 
be  rendered :  This  will  prevent  abuse  and  remedy 
the  evil. 

Something  is  necessary  to  be  done,  speedily,  as 
many  sick  are  in  a  suffering  condition. 

The  general  hospital  is  well  provided  with  every- 
thing and  the  sick  are  very  comfortable.  I  wish  it 
was  extensive  enough  to  receive  the  whole,  but  it  is 
not. 

I  am,  your  Excellency's  most  obedient  servant, 

Nath.  Greene. 
August  13,  1776. 

8. — "Doctor  John  Morgan,  Director  General  of 
the  Hospital,  attending,  was  admitted.  He  in- 
formed the  convention  that  General  Washington  had 
directed  him  to  have  all  the  sick  removed  to  proper 
places  out  of  such  parts  of  said  city  as  are  closely 
built  and  inhabited;  that  a  list  of  houses  had  been 
handed  to  him  for  that  purpose,  by  private  persons, 
but  that  as  he  is  a  stranger,  and  does  not  know 
what  particular  persons  might  be  proper  to  be  ex- 
empted, and,  therefore  requests  the  direction  of  the 
convention  in  the  premises. 

Resolved  that  his  Excellency  General  Washington 
be  and  is  hereby  empowered  to  apply  the  following 
houses,  to  wit: 

Mr.  Aplethorpe's, 

Oliver  Delancej^'s  and 

Robert  Bayard's  at  Bloomingdale. 

William  Bayard's,  at  Greenwich. 

Mr.  \\'atts',  near  Kipp's  Bay,  [East  34th  St.  now]. 

Robert  Murray's,  on  Jacklam  Bergh. 

Mr.  Wm.  McAdam's,  and  the  houses  and  buildings 
occupied  by  Mr.  Watson  near  the  old  glass  house.  , 

Nicholas  Stuyvesant's,  Peter  Stuvvesant's,  Mr. 
Elliott's. 

Mr.  Horsemanden's  commonly  called  Frog  Hall. 

Widow  Leake's,  near  Kipp's  Bay;  for  the  use  of 
the  general  hospital  of  the  Americans. 

Ordered,  That  the  General  Committee  of  the  City 
of  New  York  do,  on  application  of  Dr.  John  Mor- 
gan, Director  of  Hospitals  of  the  Continental  Army, 
appoint  a  proper  committee  of  their  body,  to  ascer- 
tain and  designate  to  him  such  houses  on  Nassau 
Island,  to  be  by  him  used  as  a  general  hospital,  as 
he  may  from  time  to  time  have  occasion  for  that 
purpose." 

9.    American  Army  on  Long  Island: 

Major  General  Israel  Putnam,  Commander; 
Right  Wing,  General  Lord  Stirling — Kich- 
line's  Pennsylvania  Rifle  Battalion,  Atlee's 
Penn.  Regt.,  Smalhvood's  Maryland  Regt., 
Haylet's  Delaware  Regt.,  Huntington's  Con- 
necticut Regt. 
Left  Wing,  General  Sullivan — Miles'  Pennsyl- 
vania Rifle  Battalion,  Bedford  Pass :  Hen- 
shaw's  Massachusetts  Regt.,  Johnston's  Xew 
Jersey  Regt.,  Hand's   Pennsylvania  Regt., 


456 


DUNCAN:  MEDICAL  MEN  IN  THE  AMERICAN  REVOLUTION. 


[New  York 
Medical  Journal. 


Prospect  Hill,  \\'vlley's  Connecticut  Regt., 

Bedford  Pass. 
Reserve — Little,  Hitchcock,  Chester. 
Two  brigades  came  over  after  the  battle. 
■  Total  about  8,000. 

Total  strength  of  the  American  Army  August 
3rd — Total  present  and  absent,  17.225 ;  sick, 
3,678;  total  effective  for  dut}-,  10,514. 

10.  — British  Forces  at  Battle  of  Loxg  Island. 

Advance  Guard — 4  Battalions  Light  Infantry 

and  Light  Dragoons. 
Reserve — 4  Battalions  Grenadiers.  33  and  42 

Foot. 

1st  Brigade — 15.  27.  4.  45  Foot. 
2nd  Brigade— 5.  28,  49,  35  Foot. 
3rd  Brigade— 10.  37,  38.  52  Foot. 
4th  Brigade — ^^17,  40,  46,  55  Foot. 
5th  Brigade — 22.  43  .  54.  63  Foot. 
6th  Brigade— 23.  57.  64,  44  Foot. 
7th  Brigade — 71st,  Xew  York  Companies,  Ar- 
tillery. 

De  Heister,  Hessians — Three  brigades  of  three 
regiments  each ;  one  brigade  of  two  regi- 
ments. 

Total,  forty-three  regiments,  besides  artillery 
and  small  detachments.  The  total  was  at 
least  twenty  thousand  officers  and  men — 
probably  somewhat  more  than  that  number. 
Some  of  the  regiments  were  large ;  the  42nd 
numbered  1,168  and  the  71st  1,298. 

The  returns  of  the  British  Army  on  August 
27th  showed  present  26,247  (excluding  Roy- 
al Americans)  and  24,464  effectives. 

HoRS.  LoxG  Island,  Aug.  29th. 

11.  - — Parole  Sullivan.     Countersign  Green. 

As  the  sick  are  an  incumbrance  to  the  Army, 
and  troops  are  expected  this  afternoon  from  the 
Flying  Camp  in  Jersey,  under  General  Mercer, 
who  is  himself  arrived,  and  cover  is  wanted  for  the 
troops,  the  commanding  officers  of  regts.  are  im- 
mediately to  have  such  sick  removed.  They  are  to 
take  their  arms  and  accoutrements  and  be  con- 
ducted by  an  officer  to  the  General  Hospital,  as  a 
rendezvous,  and  there  to  cross  together,  under  the 
directions  of  the  person  appointed  there,  taking 
general  directions  from  Dr.  !NIorgan.  As  the  above 
forces,  under  General  Mercer,  are  expected  this 
afternoon,  the  General  proposes  to  relieve  a  pro- 
portionate number  of  regiments,  and  make  a  change 
in  the  situation  of  them. 

Morgan  says  that  in  part  of  a  day  and  night 
several  hundred  sick  and  wounded  were  transported 
from  Long  Island,  in  a  heavy  rain  which  fell  dur- 
ing the  retreat.  They  were  landed  at  different 
wharves  and  carried  to  different  houses,  while  he 
and  his  officers  had  great  difficulty  in  collecting 
them  in  the  barracks  and  hospitals  that  he  had 
provided.  All  possible  care  was  taken,  yet  some 
unavoidably  suffered.  He  gave  his  personal  assist- 
ance in  dressing  the  patients,  and  states  that  there 
was  not  a  single  wounded  man  brought  to  the 
General  Hospital  in  Xew  York  (Kings  College) 
that  he  did  not  himself  dress.  He  also  assisted  in 
the  operations  and  visited  officers  and  men  outside 
the  hospital,  either  alone  or  in  consultation.  These 


statements  give  us  a  better  idea  of  the  activities  of 
a  medical  director  at  that  time,  and  more  especially 
of  the  energy  of  Dr.  ^Morgan,  who  did  the  work 
of  superior  and  subordinate  so  well  that  there  was 
never  a  complaint  of  the  hospitals  where  he  was 
present.  The  wounded  in  this  case  were  not  in 
great  numbers,  the  best  estimate  being  that  few 
more  than  fifty  seriously  wounded  escaped  from  the 
affair  on  Long  Island. 

The  army  had  scarcely  arrived  in  Xew  York 
when  the  necessity  for  abandoning  tlie  place  ap- 
peared. On  September  5,  General  Greene  urged 
that  the  city  be  abandoned  and  burned.  On  the 
seventh  a  council  of  war  decided  on  the  half  meas- 
ure that  nine  thousand  men  should  retire  to  Harlem 
Heights,  leaving  Putnam  with  five  thousand  in 
the  city.  Heath  commanded  a  reserve  of  two 
brigades,  and  ]^Iercer  was  in  the  vicinity  of  Fort 
Lee  with  the  Flying  Camp.  It  was  determined  to 
send  the  sick  to  Orangetown,  Xew  Jersey,  and  to 
the  barracks  at  Kingsbridge. 

Conditions  in  the  city  soon  became  unhealthful. 
The  letters  of  Dr.  Solomon  Drowne,  a  hospital 
mate,  to  his  father  picture  the  rapid  change.  He 
wrote : 

June  4th.  We  arrived  jesterday.  We  waited  on  Dr. 
Morgan  today  and  were  kindly  received.  He  mapped 
out  a  course  of  duty  for  us  at  the  Hospital,  which  will 
keep  us  verj-  busj".  The  College  is  occupied  for  the  gen- 
eral hospital.  It  is  a  very  elegant  building  and  its  situa- 
tion is  pleasant  and  salubrious.  ...  I  have  a  list  of 
medicines,  purchased  here  for  ye  Continental  Hospital, 
to  copy  for  Dr.  Morgan,  which  obliges  me  to  conclude. 

June  i/th.  As  there  happened  to  be  some  vacancies  in 
the  hospital  I  have  as  good  a  berth  as  I  could  have  wished 
for  (the  same  as  Dr.  Binney's).  We  draw  twenty  dol- 
lars a  month  and  two  rations  per  day.  .  .  .  We  have 
been  closely  employed  a  good  part  of  ye  time,  assorting 
and  putting  up  medicines  for  thirty  chests. 

August  9th.  Our  wages  were  raised  some  time  ago  (in 
consequence  of  a  petition  to  Congress)  to  thirty  dollars 
per  month.  The  pay  would  be  no  inducement  to  stay  a 
minute  in  this  stinking  place,  at  the  expense  of  health,  that 
best  of  blessings.  The  air  of  the  whole  city  seems  in- 
fected.   In  almost  ever>-  street  there  is  a  horrid  smell. 

Dr.  Morgan  had  a  reserve  of  stores  collected 
which,  before  the  evacuation,  were  sent  to  Stam- 
ford. Connecticut.  Had  this  not  been  done  tliey 
would  have  been  captured.    He  says  : 

It  being  in  the  most  violent  heat  of  summer,  and  so  the 
less  wanted,  I  ordered  the  greater  part  of  the  rugs  and 
blankets,  the  newest  and  best  beddings,  of  which  I  had 
collected  a  very  large  stock,  and  a  thousand  sheets,  of 
which  I  had  lately  got  to  the  amount  of  nearly  two  thou- 
sand, many  of  them  new.'  and  a  number  of  shirts,  at  Xew 
York,  to  be  set  apart  for  the  purpose,  and  a  large  quantity 
of  hea\T  hospital  furniture,  some  of  the  largest  bell  metal 
and  iron  mortars,  a  number  of  crates  of  vials  and  jelly 
pots,  the  largest  bottles,  with  the  most  bulla"  articles,  and 
those  in  the  least  demand,  as  some  hogsheads  and  casks 
of  cascarilla.  and  other  such  particulars  as  we  could  best 
spare,  to  accompany  them.  To  these  I  ordered,  a  share  of 
whatever  we  had  in  so  great  a  plenty,  as  to  not  fear  being 
soon  destitute  of  them :  to  be  added  with  a  small  assort- 
ment of  chosen  medicines,  to  be  made  up  and  kept  together 
in  one  or  two  suitable  boxes  as  a  reserve. 

A  vessel  was  found  and  these  stores  set  off',  tinder 
charge  of  Dr.  Ledyard.  They  were  landed  at 
Stamford  and  taken  charge  of  by  John  Lloyd.  Esq.. 
in  his  own  house.  Later,  in  fear  of  a  landing  by 
the  enemy,  the  general  ordered  them  moved  some 
fifty  miles  into  the  country. 

A  branch  of  the  General  Hospital  was  later 


September  25,  1920.]       DUXCAX:  MEDICAL  MEN  IN  THE  AMERICAN  REVOLUTION. 


457 


established  by  Dr.  Philip  Turner  at  Norwich,  where 
their  stores  were  doubtless  used  to  advantage.  Had 
they  been  held  in  Xew  York  the)'  would  have  been 
lost,  yet  ^Morgan  was  blamed  at  the  time  for  sending 
them  away. 

The  morale  of  the  army  at  this  time  was  not 
high.  It  was  composed  of  a  heterogeneous  mass  of 
men  of  all  ages,  from  all  the  colonies,  with  a  large 
proportion  of  militia.  The  defeat  on  Long  Island 
was  depressing,  and  on  top  of  that  came  the  news 
of  failure,  suffering  and  death  in  Canada.  The  first 
"  enthusiasm  had  waned,  and  the  formidable  army 
assembled  by  Britain,  together  with  a  powerful 
navy,  were  things  to  give  pause.  Above  all,  there 
was  now  much  sickness.  During  the  siege  of 
Boston  there  had  been  comparatively  little  serious 
disease;  now  there  was  a  great  deal.  Dr.  Rush 
says :  "It  was  not  until  the  troops  of  the  eastern, 
middle,  and  southern  states  met  at  Xew  York  and 
Ticonderoga  in  1776,  that  the  typhus  became  uni- 
versal and  spread  with  such  mortality  in  the  armies 
of  the  United  States."  Rush  also  says  that  "the 
southern  troops  were  more  sickly  than  the  northern 
or  eastern  troops."  This  was  due  to  the  fact  that 
there  was  in  the  south  a  class  of  poor  whites,  not 
known  in  New  England  and  the  middle  colonies. 
To  these  may  have  been  due  the  typhus  which 
ravaged  the  army.  Dysentery  was  now  common  in 
the  camps  of  the  Americans  and  also  of  their  op- 
ponents ;  but  usually  not  of  a  fatal  type.  Early  in 
September  three  additional  battalions  were  ordered 
up  from  \'irginia,  and  two  from  North  Carolina. 
Of  those  from  \'irginia  (the  4th,  5th  and  6th 
Regts.)  nearly  one  half  of  the  men  were  sick.  A 
return  of  the  army  at  the  middle  of  September 
showed  that  of  the  rank  and  file  there  were  present, 
fit  for  duty,  15,243;  present  sick,  6,098;  absent 
sick,  1.215.  The  total  number  of  sick  was  8,528, 
more  than  a  third  of  the  army. 

Washington  was  holding  on  to  New  York  and 
the  sick  not  yet  evacuated.  On  the  8th  of  Septem- 
ber he  asked  the  New  York  Convention  for  four 
large  sloops  for  this  purpose,  having  no  wagons 
to  spare;  and  on  the  12th  he  wrote  again,  saying 
that  the  vessels  had  not  yet  arrived.  Dr.  Mor- 
gan made  a  considerable  tour  through  western  New 
Jersey  in  search  of  a  site  for  the  general  hospital. 
On  his  return  he  wrote  to  Washington  (September 
12th)  (12)  stating  that  no  suitable  place  could  be 
found  in  Orange  County,  but  that  Newark  was 
satisfactory,  and  that  the  patients  could  be  trans- 
ported there  almost  entirely  by  water  carriage; 
only  four  miles  would  be  by  land  transport.  Mean- 
while, events  were  compelling  action. 

On  September  9th  the  British  had  landed  on 
Blackwell's  Island.  General  Greene  again  called  for 
a  council  of  war,  and  this  time  it  was  decided  that 
the  city  must  be  given  up.  There  was  still  a  large 
number  of  sick,  more  than  could  be  moved  in  a 
regular  manner.  As  a  necessary  measure,  ^Morgan 
agreed  to  a  plan  of  Greene's,  that  the  regimental 
sick  of  each  brigade  be  collected  in  a  body,  placed 
in  charge  of  a  medical  officer,  and  sent  off  into  the 
country  (New  Jersey).  All  not  able  to  move  them- 
selves were  ordered  sent  to  the  general  hospital. 
This    measure    of    necessity    produced  endless 


irregularities  and  confusion.  The  sick  escaped  from 
all  control.  Some  surgeons  also  remained  away 
and  did  not  rejoin  the  army.  At  the  next  battle, 
the  White  Plains,  few  regimental  surgeons  were 
present,  and  Morgan  was  obliged  to  care  for  the 
wounded  on  the  field,  as  well  as  at  the  general 
hospital  at  North  Castle.  The  removal  of  the 
slightly  sick,  convalescents,  and  malingerers  left 
several  hundred  seriously  sick  still  in  the  city, 
^lorgan  said  of  the  brigade  plan :  "I  am  still  of  the 
opinion  it  was  the  best  step  that  could  have  been 
taken  to  prevent  the  sick  falling  into  the  hands  of 
the  enemy,  unless,  what  I  mentioned  to  your  Ex- 
cellency as  my  wish  could  have  been  accomplished, 
viz. :  That  protection  might  be  granted  to  the  hos- 
pitals on  both  sides,  and  the  sick  not  become 
prisoners  of  war,  but  their  person  and  attendants 
might  be  privileged  and  safe,  as  was  the  case  be- 
tween the  French  and  English  in  the  wars  of 
Europe."  This  letter  to  Washington  shows  that 
^lorgan  understood  the  principles  now  embodied 
in  the  Geneva  Convention.  He  had  served  in  the 
last  Colonial  War  and  must  have  been  familiar 
with  the  practices  of  the  French  and  English  in 
that  war. 

On  September  15th  matters  came  to  a  crisis  in 
New  York.  The  British  sent  war  vessels  up  the 
Hudson,  and  at  the  same  time  landed  at  Kipps  Bay 
on  the  east  side  of  the  Island.  A  brigade  of  militia 
ran  away,  leaving  Washington  alone  and  exposed 
to  capture  within  a  hundred  yards  of  the  enemy. 
This  is  one  of  the  occasions  on  which  he  is  -said 
to  have  lost  control  of  his  temper.  Putnam  made 
his  escape  to  Harlem  Heights,  in  some  confusion, 
with  the  loss  of  275  prisoners,  the  heavy  guns  and 
much  supplies.  Washington  said,  "]\Iost  of  the 
heavy  guns  and  part  of  the  stores  were  lost."  The 
loss  of  stores  was  due  to  lack  of  wagons.  He  says 
that  the  removal  of  the  sick  was  "completely 
effected."  In  a  letter  to  John  Augustine  Washing- 
ton he  say  that  they  "held  on  till  the  sick  and  wound- 
ed were  sent  away."  A  more  exact  statement  would 
be  that  they  got  the  sick  away  before  they  were 
obliged  to  leave. 

The  state  of  the  army  after  the  battle  on  Long 
Island  was  such  as  to  occasion  alarm  in  the  mind 
of  John  Adams,  Chairman  of  the  Board  of  War 
and  virtual  head  of  such  war  department  as  then 
existed.  On  September  19th  he  secured  the  passage 
of  a  resolution  requiring  daily  drills.  He  said : 
This  resolution  was  the  effect  of  my  late  journey 
through  the  Jerseys  to  Staten  Island.  I  had  observed  such 
dissipation  and  idleness,  such  confusion  and  distraction 
among  officers  and  soldiers,  in  various  parts  of  the  coun- 
try, as  disturbed,  grieved  and  alarmed  me.  Discipline,  disci- 
pline, had  become  my  constant  topic  of  discussion.  .  .  . 
I  saw  ver\-  clearly  that  the  ruin  of  our  cause  and  coun- 
try must  be  the  consequence  if  a  thorough  reformation 
and  strict  discipline  could  not  be  secured. 

On  September  20th  he  secured  the  adoption  of  a 
set  of  articles  of  war,  which  was  practically  the 
same  as  the  articles  of  the  British  Army.  The 
British  articles  were,  as  he  says,  a  literal  transla- 
tion of  the  Articles  of  War  of  the  Roman  Army. 

As  before  mentioned,  Morgan  had  inspected 
buildings  for  a  general  hospital  in  Newark.  Dr. 
Foster  and  Dr.  Burnet  (13)  were  placed  in 
charge  of  this  hospital,  with  seven  or  eight  mates. 


458 


DUNCAN:  MEDICAL  MEN  IN  THE  AMERICAN  REVOLUTION. 


[New  York 
Medical  Journal. 


and  it  was  pfepared  for  a  thousand  patients.  Part 
of  the  medicines  and  stores  at  New  York  were 
ordered  over  by  the  Adjutant  General  (Reed),  and 
to  his  personal  activity  it  was  due  that  they  were 
saved.  But  the  valuable  part  still  remained  in  New 
York  after  the  British  had  landed  and  were  sup- 
posed to  be  entering  the  city.  Morgan  himself 
then  went  back  in  a  boat  with  some  assistants  and 
saved  these  stores,  "like  a  brand  from  the  burning," 
as  he  says.  He  had  previously  sent  two  chests  to 
Kingsbridge  for  hospital  use.  His  own  words  give 
the  best  description  of  the  evacuation  of  the  sick 
and  wounded  from  New  York. 

The  sick  and  wounded  above  mentioned  were  landed  at 
Hoebuck  and  \\'ehock,  &c.  Some  of  our  mates  fell  into 
the  hands  of  the  enemy,  and  many  of  the  nurses  and  wait- 
ers fled,  and  the  militia  ran  off  and  impressed  every 
wagon  they  could  find  in  the  neighborhood. 

In  another  place  he  describes  the  actions  of  the 
militia : 

I  have  been  an  eye  witness  myself  to  whole  battalions 
running  off  from  Powle's  Hook  and  the  Heights  of  Ber- 
gen, upon  the  firing  of  a  broadside  from  a  man  of  war 
.  .  .  although  not  a  man  was  hurt  by  that  fire.  These 
doughtj'  champions  never  stopped  till  thej'  came  to  Second 
River,  but  forced  away  the  very  wagons  impressed  to 
transport  the  sick  and  those  wounded  at  Long  Island,  to 
Newark ;  to  carry  off  themselves  and  baggage,  for  many 
of  them  chose  to  ride,  to  save  their  legs,  in  case  of  being 
more  nearly  pursued. 

It  therefore  required  some  days  to  get  on  all  the  sick 
and  wounded,  through  many  difficulties,  from  the  fright 
of  the  inhabitants,  and  their  reluctance  to  admit  of  the 
hospitals  being  stationed  at  that  place  (Newark).  I  had 
provisions  to  collect,  a  commissary  and  wardmaster  to 
seek,  and  nurses  and  waiters  to  procure,  with  everything 
necessary  for  the  comfortable  accommodation  of  the  sick 
and  wounded.  I  had  little  enough  assistance  to  per- 
form this  task:  Your  Excellency  having  enjoined  me  to 
leave  the  most  considerable  number  of  surgeons  and  mates 
at  York  Island,  in  case  of  need.  I  made  all  possible  haste, 
however,  to  put  the  hospital  at  Newark  on  a  safe  footing, 
which  I  accomplished  in  about  ten  days,  and  then  returned 
to  headquarters. 

Morgan  was  even  blamed  in  this  aflfair  and 
feelingly  wrote: 

All  the  consequences  of  the  sick  suffering  for  want  of 
necessities — sad  spectacles  of  human  woe,  presenting 
themselves  in  towns,  villages  and  on  the  roads,  and  strag- 
gling through  the  countr}%  thereby  exciting  the  terror  as 
well  as  the  compassion  of  the  inhabitants — have  been 
ascribed  to  my  department  and  the  officers  under  me,  at  a 
time  when  we  ourselves  suffered  and  called  in  vain  for 
assistance  from  other  departments,  and,  so  far  as  we  were 
able,  became  fatigue  men  and  laborers  to  the  sick  and 
wounded,  as  we  could  procure  none  from  the  Army,  and, 
as  I  mentioned  before,  manv  of  our  attendants  and  nurses 
had  fled. 

This  hospital  remained  at  Newark  until  the  ad- 
vance of  the  British  in  November  compelled  the 
removal  of  the  sick  to  Morristown  and  then  to 
points  in  Pennsylvania. 

On  September  19th,  Dr.  Shippen  wrote  a 
rather  boastful  letter  to  Congress  (from  Perth 
Amboy),  informing  them  that  "all  the  wounded 
from  Long  Island  were  now  recovered."  These 
wounded  men  were  never  in  his  charge  at  any  time. 
He  also  stated  that  he  had  lost  but  ten  or  twelve 
men  of  twenty  or  thirty  thousand  passing  through 
camp.  Not  half  that  number  could  possibly  have 
passed  through  the  Flying  Camp.  It  will  be  remem- 
bered that  Dr.  Shippen  was  made  medical 
director  of  the  Flying  Camp  on  July  15th.  Al- 


though without  previous  military  experience,  he 
soon  aspired  to  a  much  loftier  position  and  took 
advantage  of  his  station  at  or  near  Philadelphia  to 
ingratiate  himself  with  the  members  of  Congress. 
He  was  a  born  courtier,  of  good  professional  ability 
and  high  social  standing  and  without  fine  scruples. 
While  Morgan  was  in  the  field,  riding  on  horse- 
back hundreds  of  miles,  gathering  supplies  from 
Boston  to  Baltimore,  providing  hospitals,  instruc- 
ting incapable  surgeons,  wrestling  with  insubordin- 
ate officers,  and  doing  surgery  with  his  own  hands, 
Shippen  was  working  on  the  members  of  Congress, 
whose  fears  were  excited  by  the  numerous 
complaints  of  conditions  which  neither  Morgan, 
Shippen,  nor  anyone  else  could  then  have  remedied. 
The  bulk  of  the  real  complaints  came  from  the 
Northern  Army,  where  ^Medical  Director  Stringer 
had  from  the  beginning  denied  and  resisted  Morgan's 
authority.  Even  then  iMorgan  had  sent  what  supplies 
he  could  collect  and  had  given  what  aid  was  possible. 
Washington  was  not  approached  or  consulted  in 
a  scheme  which  was  now  under  way  to  supplant 
Morgan.  On  October  9th  Congress  passed  a  reso- 
lution (14)  dividing  the  jurisdiction;  giving  Morgan 
control  of  the  hospitals  east  of  the  Hudson,  and 
Shippen  control  of  those  west  of  that  river.  This 
was  an  indefensible  plan,  which  left  no  head  to  the 
jNIedical  Department,  and  was  sure  to  bring  about 
confusion  and  failure.  It  was  most  probably  a 
step  toward  the  elimination  of  Morgan  and  the 
placing  of  Shippen  in  the  supreme  position.  Mean- 
while, Morgan  was  everywhere,  doing  everything — 
except  playirig  politics. 

During  the  absence  of  Morgan  there  seems  to 
have  been  no  general  hospital  with  the  army  at 
Harlem  Heights.  On  September  18th  an  order  was 
issued  to  this  effect : 

The  Regimental  Surgeons  are  to  take  care  of  their  own 
sick  for  the  present,  until  the  general  hospital  can  be  es- 
tablished on  a  proper  footing.  They  are  to  keep  as  near 
the  regiments  as  possible,  and  in  case  of  action,  to  leave 
the  sick  under  the  care  of  their  mates,  and  be  at  hand  to 
assist  the  wounded. 

The  headquarters  were  then  at  ]\Iorfisania. 
General  Greene  had  command  on  the  Jersey  side. 
Sickness  continued  and  even  increased.  The  sick 
filled  houses,  barns,  outbuildings ;  they  even  lay 
under  trees  and  in  fence  corners.  Washington  was 
not  unmindful  of  them,  and  on  September  16th — 
an  eventful  day — a  letter  was  written  asking  that 
the  pay  of  nurses  be  increased  (15).  He  also 
asked  Congress  for  camp  kettles,  tents,  blankets, 
and  other  necessities,  to  replace  those  lost  during 
the  retreat  from  New  York.  Several  hundred  carts 
and  wagons  had  been  sent  to  Long  Island  in  July; 
when  the  retreat  took  place  they  were  lost.  So 
when  the  army  retired  from  the  city  there  were 
few  wagons  for  baggage,  and  the  camp  equipage  of 
tents  and  other  essentials  of  Putnam's  regiments 
were  left  behind. 

Washington  wrote  Congress  again,  on  September 
24th,  concerning  the  surgeons  as  follows: 

No  less  attention  should  be  paid  to  the  choice  of  sur- 
geons than  to  other  officers  of  the  army.  They  should 
undergo  a  regular  examination,  and  if  not  appointed  by 
the  director  general  and  surgeons  of  the  hospital,  they 
ought  to  be  subordinate  to  and  governed  by  his  directions. 

The  regimental  surgeons  I  am  speaking  of,  many  of 


September  25,  1920.]       DUNCAN:  MEDICAL  MEN  IN  THE  AMERICAN  REVOLUTION. 


459 


whom  are  very  great  rascals,  countenancing  the  men  in 
sham  complaints  to  exempt  them  from  duty,  and  often  re- 
ceiving bribes  to  certify  indispositions  with  a  view  to  secure 
discharges  or  furloughs. 

But  independent  of  these  practices,  while  they  (the 
regimental  surgeons)  are  considered  as  unconnected  with 
the  general  hospital,  there  will  be  nothing  but  continual 
complaints  of  each  other — the  director  of  the  hospital 
charging  them  with  enormity  in  their  drafts  for  the  sick; 
and  they  him  for  denying  such  things  as  are  necessary. 
In  short,  there  is  a  constant  bickering  among  them,  which 
tends  greatly  to  the  injury  of  the  sick,  and  will  always 
subsist  till  the  regimental  surgeons  are  made  to  look  up  to 
the  director  general  of  the  hospital  as  a  superior.  Whether 
this  is  the  case  in  regular  armies  or  not,  I  cannot  under- 
take to  say;  but  certain  I  am,  there  is  a  necessity  for  it  in 
this,  or  the  sick  will  suffer.  The  regimental  surgeons  are 
aiming,  I  am  persuaded,  to  break  up  the  general  hospital, 
and  have  in  numberless  instances  drawn  for  medicines, 
stores,  etc.,  in  the  most  profuse  and  extravagant  manner 
for  private  purposes. 

Washington  was  not  deceived  in  any  of  these 
things;  his  observations  were  remarkably  accurate. 

A  considerable  number  of  barracks  and  huts 
were  built  at  Harlem  Heights  and  Kingsbridge. 
The  men  were  crowded  in  these,  and  the  sick  in- 
creased. Dysentery  and  typhus  were  the  principal 
affections.  Little  mention  is  made  of  smallpox. 
As  a  rule,  the  men  in  the  army  about  New  York 
had  by  this  time  had  smallpox,  either  in  the  natural 
way  or  by  inoculation.  Surgeon  James  Tilton  of 
the  Delaware  regiment  afterwards  wrote  of  the 
sickness  which  he  saw  at  this  time : 

In  the  year  1776,  when  the  Army  was  encamped  at 
King's  Bridge  in  the  State  of  New  York,  our  raw  and  un- 
disciplined condition  at  that  time,  subjected  the  soldiers 
to  great  irregularity.  Besides  a  great  loss  and  want  of 
clothing,  the  camp  became  excessively  filthy.  All  manner 
of  excrementitious  matter  was  scattered  indiscriminately 
throughout  the  camp,  insomuch  that  you  were  offended 
by  a  disagreeable  smell,  almost  everywhere  without  the  lines. 
A  putrid  diarrhea  was  the  consequence.  The  camp  dis- 
ease, as  it  was  called,  became  proverbial.  Many  died, 
melting  as  it  were,  and  running  off  at  the  bowels.  Medi- 
cine answered  little  or  no  purpose.  A  billet  in  the  coun- 
try was  only  to  be  relied  on.  When  the  enemy  moved  to 
the  East  River,  our  army  moved  to  White  Plains  and  left 
their  infectious  camp  and  the  attendant  diseases  behind 
them.  It  was  remarkable,  during  this  disorderly  cam- 
paign, before  our  officers  and  men  could  be  reduced  to 
strict  discipline  and  order,  the  army  was  always  more 
healthy  when  in  motion,  than  in  fixed  camps. 

I  recollect  in  the  campaign  of  '76,  while  our  army  was 
on  the  peninsula  of  New  York,  we  were  so  deranged  as  to 
be  deprived  of  ovens,  and  flour  was  served  to  the  troops 
instead  of  bread.  We  could  only  make  sodden  bread  and 
dumplings.  Some  baked  their  bread  on  hot  stones,  and 
others  in  the  ashes.  The  consequence  was  that  many 
were  afflicted  with  the  jaundice.  Being  a  regimental  sur- 
geon at  that  time,  I  shared  the  fate  of  the  rest,  and  shall 
never  forget  my  fatiguing  march  from  the  North  River  to 
Brunswick,  with  the  jaundice  on  me. 

A  return  of  the  army  under  Washington  on  the 
east  side  of  the  river,  of  September  30th,  shows 
that  of  the  rank  and  file  there  were :  Present,  fit 
for  duty  15,104;  present  sick,  4,211;  absent  sick, 
3,399;  total  sick,  7,610. 

General  Greene  had  at  Fort  Washington  and  on 
the  west  side  of  the  river  3,531  present  fit  for  duty; 
964  present  sick ;  and  259  absent  sick.  A  consider- 
able part  of  both  forces  was  made  up  of  the  militia, 
which  was  poorly  equipped  and  had  little  or  no 
tentage  .  An  order  of  September  30th  directed 
the  militia  to  "build  huts  with  straw,  rails,  and  sod, 
on  the  Morrisania  side  of  the  Harlem."  An  order 
of  the  28th  directed  that  the  boards  sent  up  for 


tent  floors  be  not  used  for  building  up  walls.  On 
October  4th  an  order  was  issued  bearing  on  the 
situation  of  the  cainp. 

Orders: — The  shameful  inattention,  in  some  camps,  to 
decency  and  cleanliness,  in  providing  necessaries,  and  pick- 
ing up  the  offal  and  filth  of  the  camp,  have  been  taken 
notice  of  before  in  general :  after  this  time  particular 
regiments  will  be  pointed  out  by  name  when  such  practice 
prevails. 

At  this  time  an  engagement  was  generally  ex- 
pected. General  Heath  issued  an  order  of  battle 
for  his  division  on  October  3rd,  in  which  provision 
was  made  for  attention  to  the  wounded.  "A  stout, 
ablebodied  man  of  a  (each)  company  is  to  be 
appointed,  who,  with  the  camp  colourmen  and  mu- 
sick,  are  to  assist  the  wounded." 

The  British  having  landed  at  Throg's  Neck,  the 
Continental  Army  was  drawn  back  to  the  line  of 
White  Plains,  early  in  October.  It  was  now  organ- 
ized in  four  divisions  under  Lee,  Heath,  Sullivan 
and  Lincoln.  Greene  was  allowed  to  leave  twenty- 
seven  hundred  men  in  Fort  Washington.  This  was 
contrary  to  the  judgment  of  Washington.  For  once, 
as  Reed  intimates;  the  decision  of  the  great  man 
faltered,  and  the  foundation  was  laid  for  adding 
another  to  the  growing  list  of  disasters. 

When  Morgan  returned  from  Newark  to  head- 
quarters he  received  a  letter  from  one  of  the  aides- 
de-camp  "setting  forth  the  miserable  situation  to 
which  the  sick  were  reduced,  and  the  clamor  for 
want  of  medicines,  absolutely  insisting  on  im- 
mediate and  sufficient  supply,"  and  saying  that, 
"whilst  he  was  reserving  the  medicines  for  cases 
of  emergency,  the  sick  were  dying  in  numbers,  for 
want  of  a  necessary  supply."  Morgan  had  just  sent 
to  Mr.  William  Smith,  the  continental  druggist  at 
Philadelphia,  with  what  success  may  be  judged. 
"Instead  of  ten  pounds  of  tartar  emetic  I  sent  for, 
four  ounces  were  all  I  could  obtain."  He  then 
induced  a  regimental  surgeon  to  go  at  once  to 
Hartford,  Norwich,  Providence  and  Boston,  to  pro- 
cure medicines ;  but  these  places  were  so  very  bare 
of  them  that  he  was  greatly  disappointed  in  the 
outcome.  He  next  applied  to  Governor  Trumbull 
of  Connecticut,  and  in  person  to  the  Assembly  of 
New  York  at  Fishkill.  He  found  that  the  stock 
owned  by  this  state  had  been  sent  to  the  Northern 
Army.  Governor  Trumbull  collected  a  supply  for 
him,  but  it  did  not  reach  the  army  until  November. 

This  was  an  incident  in  his  labors.  As  has  been 
stated,  the  general  hospital  with  the  army  suffered 
while  he  was  away;  rather,  it  ceased  to  exist.  It 
was  necessary  to  establish  it  again.  As  the  army 
was  then  looking  toward  New  Jersey,  he  decided 
to  establish  a  hospital  at  Hackensack.   He  says: 

I  recommended  Hackensack.  Every  general  officer,  to 
whom  it  was  mentioned,  approved  of  it,  as  the  most  suit- 
able place  of  all  others  for  the  sick  of  the  army  on  York 
Island,  there  being  no  such  convenient  place  on  the  Island 
itself,  and  the  enemy  had  just  made  a  descent  about 
Kingsbridge.  I  was  ordered  over  the  river  to  view  Hack- 
ensack (probably  about  October  ist)  and  to  report  what 
number  of  sick  could  be  provided  for  at  that  place.  On 
my  return  I  did  accordingly  report  that  if  a  sufficient 
number  of  carpenters  and  masons  were  set  to  work  im- 
mediately, to  fit  up  the  church,  manufactory,  and  a  store- 
house or  two,  &c.,  six  or  seven  hundred  men,  and  perhaps 
more,  might  be  accommodated  in  the  town  and  neighbor- 
hood ;  but  it  would  require  many  workmen  and  some  time 
to  prepare  places  for  their  convenient  reception.    I  was 


460 


LONDON  LETTER. 


[New  York 
Medical  Journal. 


then  ordered  back  to  carry  the  plan  into  execution  with  all 
possible  diligence.  I  went  accordingly,  and  next  day  no 
less  than  three  hundred  men  (sick)  were  brought  into  the 
neighborhood  for  me  to  look  after,  though  I  was  quite 
alone  in  respect  to  help.  They  daily  increased  in  num- 
bers, so  that  within  a  few  days  they  amounted  to  upwards 
of  a  thousand  (i6).  I  had  left  instructions  for  Dr. 
Warren,  and  a  number  of  mates  and  other  hospital  officers 
to  follow  and  attend  the  sick.  At  first  we  had  neither 
bread,  flour,  nor  fresh  provisions  in  readiness,  nor  were 
Commissaries  at  hand,  from  whom  I  could  obtain  any 
help.  General  Greene,  to  whom  I  sent  to  Fort  Lee  for  as- 
sistance, was  gone  over  to  York  Island.  So  soon  as  my 
hands  were  strengthened  with  Dr.  Warren's  and  Mr. 
Zabrisky's  help,  and  the  appointment  of  a  commissary  and 
quartermaster,  difficulties  abated  by  degrees,  and  our  af- 
fairs got  into  a  more  promising  train.  In  the  meantime, 
the  armies  having  reached  toward  the  White  Plains,  a 
battle  was  expected.  I  therefore  hastened  to  join  your 
Excellency.  (This  seems  to  have  been  about  October  25th.) 

The  British  had  slowly  moved  forward,  and 
toward  the  end  of  October  were  ready  to  attack. 
Morgan  found  that  the  surgeons  with  the  army 
had  fixed  upon  the  church  at  North  Castle  as  a  con- 
venient .place  for  the  wounded  and  at  a  suitable 
distance  from  the  expected  conflict  at  the  White 
Plains.  He  set  about  preparing'  the  place,  but  be- 
fore it  could  be  done  the  battle  began.  As  mentioned 
before,  many  of  the  regimental  surgeons  were 
absent,  having  gone  off  with  their  sick  and  not 
returned.  Morgan  learned  of  this  and  went  at  once 
to  the  field  to  supply  this  deficiency.    He  says : 

While  we  were  getting  in  readiness,  a  firing  of  cannon 
was  heard  anew,  for  there  had  been  a  firing  heard  the  day 
before  at  Fort  Washington.  On  learning  it  was  at  the 
White  Plains,  every  surgeon  of  the  hospital  then  present 
set  out  with  me,  immediately  for  the  Plains,  several  mates 
following  with  a  waggon,  to  bring  the  instruments  and 
dressings.  We  fixed  (located)  near  the  lines,  and  I  never 
stirred  from  thence  till  the  enemy  retreated,  which  was 
about  a  week  later ;  nor  till  Your  Excellency  crossed  the 
river  to  hasten  to  the  support  of  Fort  Washington  (about 
Nov.  I2th).  In  the  meantime  the  situation  of  affairs 
would  not  permit  Your  Excellency  to  give  me  leave  to 
return  to  North  Castle,  but  for  a  few  hours,  to  give  direc- 
tions, and  to  assist  in  providing  for  the  sick  and  wounded ; 
one  hospital  surgeon,  and  sometimes  two  or  more,  with 
three  or  four  mates,  attending  the  whole  time  at  the  Plains, 
in  expectation  of  a  second  attack. 

{To  he  concluded) 


LONDON  LETTER. 
{From  our  ozvn  correspondent) 
Medical  Education  in  Great  Britain. 

London,  August  2/,  1920. 
The  question  of  medical  education  is  of  intense 
interest  to  medical  men  in  all  parts  of  the  world. 
It  is  in  a  state  of  flux  in  Great  Britain,  or,  more 
correctly,  it  is  in  a  state  of  transition.  It  is  be- 
lived  that  too  much  attention  is  paid  nowadays  to 
bacteriology  to  the  neglect  of  clinical  medicine.  The 
argument  is  made  that  it  is  the  clinical  experience 
which  counts,  for  if  one  cannot  make  a  correct  diag- 
nosis without  always  resorting  to  the  services  of  the 
laboratory  man,  then  the  practice  of  medicine  is 
in  a  parlous  condition.  It  must  be  remembered  that 
the  largest  proportion  of  medical  practice  is  in  the 
hands  of  the  general  practitioner,  who  has  to  rely 
on  his  own  trained  powers  of  diagnosis  and  in  the 
vast  majority  of  cases  must  dispense  with  the  aid 
of  the  laboratory.    The  time  may  come,  and  it  will 


come  if  the  Consultative  Council  of  the  Ministry  of 
Health  has  its  way  in  England,  when  the"  general 
practitioner  will  have  at  hand  facilities  for  labora- 
tory aid.  This  does  not  mean,  of  course,  that  the 
student  should  not  be  thoroughly  trained  in  clinical 
methods  of  diagnosis.  The  laboratory  should  be  the 
coadjutor  to  clinical  methods  and  must  not  be  al- 
lowed to  dominate  the  situation. 

It  is  painfully  evident  that  in  this  country,  and 
probably  also  in  all  civilized  countries,  the  medical 
curriculum  is  far  too  comprehensive.  Sir  George 
Newman,  chief  medical  adviser  to  the  British  Min- 
istry of  Health,  in  an  excellent  review  of  the  state 
of  medical  education  in  England,  which  he  pre- 
sented at  the  recent  meeting  of  the  British  Medical 
Association,  emphasized  these  points.  He  declared 
that  the  medical  curriculum  required  lightening  at 
both  ends  and  that  the  question  of  lightening 
without  lengthening  the  curriculum  was  one  of  car- 
dinal importance.  He  suggested  several  ways  to 
accomplish  this  object  and  ended  by  stating  that  in 
his  opinion  there  was  need  of  further  state  aid,  but 
with  a  minimtim  of  state  control.  He  pointed  out 
that  the  cost  of  proper  medical  training  has  now 
risen  beyond  the  means  of  the  average  man,  and  yet 
it  was  in  the  interest  of  the  state  to  secure  well 
equipped  doctors.  To  provide  a  satisfactory  medical 
education  more  teachers  were  needed,  better  teach- 
ers and  better  paid  teachers.  Clinical  units  were 
needed.  Improved  laboratory  accommodation  and 
better  equipment  were  needed.  An  extension  of 
hospital  and  clinical  facilities  were  needed.  All  these 
called  for  money  and  organization  which  had  been 
lacking  in  the  past.  As  Sir  George  Newman  truly 
said,  the  edtication  of  the  medical  man  was  no  longer 
a  matter  of  proprietary  or  professional  interest,  it 
was  of  national  concern,  for  the  health  of  the 
people  was  the  principal  asset  of  the  state.  Other 
well  known  authorities  on  medical  education 'aired 
their  views  and  it  is  obvious  that  while  on  some 
points  they  did  not  agree,  they  were  unanimous  in 
believing  that  there  should  be  changes  introduced 
into  the  methods  of  British  medical  education. 

In  the  Student's  Number  of  the  Lancet  an  ex- 
haustive account  is  given  of  medical  education  in 
Great  Britain  and  it  will  not  be  out  of  place  to 
quote  some  of  the  statements  with  regard  to  the 
powers,  duties,  and  constitution  of  the  General 
Council  of  Medical  Edtication  and  Registration  of 
the  United  Kingdom.  It  is  first  a  registering  body ; 
no  person,  even  though  he  has  the  proper  qualifi- 
cations, is  a  legally  quahfied  inedical  practitioner 
unless  his  name  appears  on  the  medical  register. 
Secondly,  it  is  a  standardizing  body,  insuring  the 
keeping  of  medical  education  up  to  efficient  standard 
by  scientific  examinations.  Thirdly,  it  is  a  plenary 
and  disciplinary  body,  having  power  to  remove  from 
the  register  any  practitioner  adjudged  guilty  of  con- 
duct "infamous  in  a  professional  respect."  Fourth- 
ly, to  the  council  is  committed  the  codification  of 
pharmaceutical  remedies.  The  council  at  present 
consists  of  thirty-eight  members,  of  whom  all  but 
eleven  are  official  representatives  of  some  corporate 
body.  Five  members  are  chosen  by  the  Crown  on 
the  advice  of  the  Privy  Council  and  six  others  are 
elected  by  the  members  of  the  medical  profession 
as  direct  representatives. 


September  25,  1920.] 


LOXDOX  LETTER. 


461 


The  educational  curriculum  is  as  follows :  The 
course  of  professional  study  after  registration  oc- 
cupies at  least  five  years.  The  final  examination  in 
medicine,  surgery  and  midwifery  must  not  be  passed 
before  the  close  of  the  fifth  academic  year  of 
medical  study.  The  following  are  the  General  ]Med- 
ical  Council's  regulations  in  reference  to  the  regis- 
tration of  students  in  medicine.  Every  medical 
student  should  be  registered  in  the  manner  pre- 
scribed by  the  council,  and  the  registration  of  medi- 
cal students  is  placed  under  the  charge  of  branch 
registrars.  Every  person  desirous  of  being  regis- 
tered as  a  medical  student  should  apply  to  the  branch 
registrar  of  the  division  of  the  United  Kingdom  in 
which  he  is  residing  and  should  produce  or  for- 
ward to  the  branch  registrar  a  certificate  of  his 
having  passed  a  preliminary  examination  as  re- 
quired by  the  General  Medical  Council  and  evidence 
that  he  has  attained  the  age  of  sixteen  years,  and 
has  commenced  medical  study  at  an  institution  ap- 
proved by  the  council.  The  branch  registrar  shall 
enter  the  applicant's  name  and  other  particulars  in 
the  students'  register  and  shall  give  him  a  certifi- 
cate of  such  registration.  The  commencement  of 
the  course  of  professional  study  recognized  by  any 
of  the  qualifying  bodies  should  not  be  reckoned  as 
dating  earlier  than  fifteen  days  before  the  date  of 
registration.  In  addition  to  the  universities  and 
schools  of  medicine,  there  are  many  institutions 
where  medical  study  may  be  commenced. 

The  one  change  in  the  development  of  medical 
education  which  has  taken  place  recently  in  some  of 
the  British  medical  schools  is  the  establishment  of 
clinical  units.  Sir  George  Xewman  referred  to  this 
matter  in  the  address  quoted  previously  and, 
while  protesting  that  there  was  nothing  celestial 
about  the  clinical  unit,  said  that  it  was  merely  a 
matter  of  convenient  arrangement  by  which  three 
general  advantages  were  secured.  1.  The  clinical 
teacher  devotes  a  regular  and  substantial  proportion 
of  his  time  to  his  teaching  work  and  instead  of  be- 
ing casual,  secondary,  incidental  or  spasmodic,  it 
becomes  his  chief  task,  and  for  the  student  instruc- 
tion in  clinical  medicine  and  surgery  is  thus  sys- 
tematized, thorough  and  always  available.  2.  The 
unit  consists  of  a  staff  of  competent  men  working 
as  a  group  or  team  who  pool  their  experience — the 
physician,  the  assistant  physician,  the  resident 
physician,  the  house  physician,  wards,  outpatient 
department,  laboratory,  auxiliary  departments  for 
special  forms  of  treatment,  all  in  a  composite  unit. 
3.  There  is  full  integration  of  the  science  and  art 
of  medicine  and  surgery,  the  teaching  of  which  may 
thus  be  raised  to  university  standards.  There  is  the 
association  of  research  with  study,  and  the  study 
itself  is  intimate  and  intensive.  It  should  compre- 
hend Sir  James  Mackenzie's  subjective  and  asso- 
ciated phenomena,  it  should  investigate  the  mech- 
anism of  symptoms,  and  it  should  follow  end  re- 
sults back  to  their  origin.  The  example  on  the 
largest  scale  in  Great  Britain  is  at  Edinburgh,  where 
there  are  seven  surgeons  in  the  unit;  Sir  Harold 
Stiles  is  regius  professor  of  clinical  surgery,  with 
an  assistant  surgeon,  a  clinical  tutor,  and  a  house 
surgeon.  The  unit  contains  forty-four  beds,  out- 
patients and  laboratory  accommodations  adjoining. 


The  work  of  the  week  comprises  ward  clinics,  sys- 
tematic clinical  lectures,  tutorial  classes  and  opera- 
tions. There  is  intensive  study  of  the  cases  and 
exceptionally  full  integration  of  anatomy  and  path- 
ology with  surgery. 

In  the  Student's  Number  of  the  Lancet  a  leading 
article  is  devoted  to  medical  training  and  the  clinical 
units  and  a  lucid  explanation  is  given  as  to  why  such 
a  development  was  called  for.  It  is  pointed  out  that 
the  time  was  when  the  whole  of  medical  education 
was  in  the  hands  of  the  working  leaders  of  the  pro- 
fession and  progress  was  great  in  those  simpler 
days.  But  as  learning  became  more  intense,  as  well 
as  of  a  greater  range,  the  preliminary  and  inter- 
mediate subjects  passed  into  the  hands  of  teachers 
with  special  equipment,  the  instruction  in  the  prin- 
ciples of  medicine  and  surgery  being  left  to  the 
honorary  staffs  of  the  voluntary  hospitals.  These 
men  earned  their  living  by  private  practice,  carried 
on  during  time  that  was  already  heavily  pledged  to 
gratuitous  labor  in  the  wards.  Scientific  research 
and  systematic  teaching  of  the  students  were  prose- 
cuted in  addition  to  their  duties  to  private  and  hos- 
pital patients  and  with  results  of  which  all  may  be 
proud.  But  the  strain  was  obviously  too  great,  while 
in  election  to  the  honorary  staff  capacity  or  inclina- 
tion for  teaching  carried  but  little  weight.  Nor  was 
the  appointment  of  the  clinical  teachers  under  the 
control  of  the  medical  school  attached  to  the  hospital, 
so  that  every  teacher  was  a  law  unto  himself,  and 
the  whole  organization  was  at  the  mercy  of  the 
less  conscientious  members  of  the  staff.  That  these 
were  few  proves  the  rectitude  and  enthusiasm  of  a 
large  number  of  men,  but  for  some  time  it  has 
been  known  that  a  more  efficacious  and  orderly 
scheme,  one  less  dependent  upon  personal  sacrifice, 
must  be  found  to  supplement  the  clinical  education 
of  the  student.  The  scheme  is  designed  to  correct 
defects  that  have  arisen  in  the  system  as  science  has 
progressed. 

It  may  be  mentioned  that  the  idea  of  clinical 
units  was  suggested  by  the  late  Sir  William  Osier 
and  !Mr.  Abraham  Flexner.  It  is  likewise  worthy 
of  notice  that  in  each  of  the  five  schools  which  have 
established  clinical  units  special  room  and  labora- 
tories have  been  allocated  or  are  to  be  constructed 
for  research,  and  the  assistant  directors,  as  well  as 
the  directors,  will  have  opportunities  for  investi- 
gating patients  under  their  own  charge  as  inpatients. 
In  every  case  it  is  proposed  eventually  to  institute 
research  studentships,  so  that  promising  juniors  may 
be  trained  after  qualification  in  the  methods  of  re- 
search. The  arrangements  for  research  will  vary 
with  the  individual  bias  of  the  investigators  and 
moreover,  will  have  no  direct  connection  with  the 
undergraduate,  except  in  so  far  as  he  is  being 
taught  by  men  who  are  keenly  alive  to  the  impor- 
tance of  discovering  a  scientific  basis  for  medical 
practice.  It  would  appear  that  for  all  concerned 
the  institution  of  clinical  units  signifies  the 
simplification  of  medical  training,  as  well  as  tend- 
ing to  great  thoroughness  and  general  efficiency. 
It  is  well  to  know  that  medical  education  here  is 
not  at  a  standstill  or  marking  time,  but  is  striding 
forward  in  keeping  with  the  trend  of  modern  medi- 
cine and  surgery. 


Editorial  Notes  and  Comments 


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NEW  YORK,  SATURDAY,  SEPTEMBER  25,  1920. 


THE  THEIL-\PEUTIC  IMPORTANCE  OF 
PSYCHOLOGY. 

The  importance  of  psychology  as  a  science  and  its 
value  in  medicine  is  more  and  more  in  evidence  as 
time  goes  on.  It  is  not  so  long  ago  that  the  views 
of  Freud,  who  taught  that  the  unconscious  mind  is 
released  into  activity  from  the  shackles  that  the  con- 
scious mind  puts  into  it  only  during  sleep,  were 
condemned  and  despised.  Although  the  teachings  of 
the  Viennese  professor  are  not  accepted  by  all,  the 
basic  principles  of  his  theory  are  now  generally 
agreed  to.  This  was  shown  at  the  meeting  of  the 
British  Association  for  the  Advancement  of  Sci- 
ence held  recently  in  Cardit?,  \\'ales,  where 
in  the  section  devoted  to  psychology  five  papers  out 
of  every  six  read  revealed  the  influence  of  Freud. 

Another  branch  of  psychology  which  is  rapidly  com- 
ing to  the  fore  is  that  of  industrial  psychology.  How- 
ever, to  return  to  the  matter  of  investigating  the  un- 
conscious, it  may  be  said  that  an  excellent  paper  was 
read  at  Cardiff  by  Dr.  C.  W.  Kimmins  dealing  with 
the  dreams  of  children  who  are  physically  abnormal. 
The  speaker  pointed  out  that  the  great  value  of  the 
dream  of  the  neurotic  in  the  diagnosis  of  cases  of 
mental  disturbances  had  been  proved  beyond  all  dis- 
pute in  the  treatment  of  war  neurosis  and  a  great 
variety  of  nervous  ailments.  On  the  other  hand,  the 
dream  of  the  normal  healthy  child  also  appeared  to 
him  to  open  up  a  very  useful  field  for  research  as 
being  the  best  method  of  investigating  the  uncon- 
scious which  played  such  an  important  part  in  human 
behavior. 


At  the  title  denoted,  the  paper  by  Kimmins  was 
taken  up  with  the  investigation  of  the  dreams  of 
physically  abnormal  children.  Dealing  with  an  in- 
vestigation of  the  dreams  of  five  hundred  physically 
defective  children,  blind  and  deaf  but  not  suffering 
from  mental  defects,  he  said  that  the  dreams  of  the 
physically  defective  differed  from  those  of  the  nor- 
mal in  the  following  way:  L  First,  they  dream  far 
less  about  food,  from  which  it  would  appear  that  the 
crippled  child  is  better  fed  than  the  normal  child.  2. 
Among  the  fears,  a  larger  proportion  dream  of  acci- 
dents, and  the  fear  of  animals  is  clearly  greater  than 
among  normal  children.  3.  The  kinesthetic  or  fall- 
ing dreams  are  more  common,  especially  at  the  ages 
of  thirteen  and  fourteen  years.  4.  Among  the  ful- 
filled wishes,  visits  to  the  coimtry  bulk  very  largely. 
5.  The  death  element  in  the  dream  occurs  more  fre- 
quently than  is  the  case  in  normal  children,  and  more 
even  then  in  the  dreams  of  the  deaf  and  blind. 

Kimmins  analyzed  and  discussed  the  subject  at 
length  and  concluded  that  from  an  educational  point 
of  view  there  was  in  the  dream  a  valuable  and  fasci- 
nating field  for  research  and  that  a  further  study  of 
the  dreams  of  children  who  were  physically  abnor- 
mal might  clear  the  way  to  a  fuller  understanding  of 
the  significance  of  the  dreams  of  normal  children.  A 
careful  study  of  children's  dreams  might  throw  much 
light  on  the  study  interests  and  desires  of  the  child 
at  different  ages  and  especially  where  persistent 
dreams  were  recorded  of  unfulfilled  wishes  or  those 
elements  which  were  conspicuously  lacking  in  the 
life  of  the  child,  and  which  might  seriously  interfere 
with  his  natural  development.  From  various  sources 
there  comes  a  mass  of  evidence  as  to  the  great 
influence  the  unconscious  exerts  in  every  depart- 
ment of  mental  activity,  and  a  fuller  knowledge  of 
the  unconscious  might  be  as  essential  in  dealing  with 
the  normal  development  of  children  as  in  the  ab- 
normal cases  in  which  it  has  proved  to  be  of  such 
extraordinary  value. 

The  veteran  anthropologist,  Karl  Pearson,  at  the 
same  meeting  also  paid  his  respects  to  psychology, 
saying  that  a  good  knowledge  and  practice  of  the 
science  were  of  the  utmost  use  in  all  phases  of  human 
endeavor  and  especially  so  to  the  State  and  to  in- 
dustry. He  even  went  so  far  as  to  affirm  his  belief 
that  the  war  might  possibly  have  been  prevented  and 
certainly  many  of  its  horrors  assuaged  if  properly 
directed  psychology  had  been  allowed  free  sway. 
That  psychology  is  of  great  therapeutic  value  in  the 
diagnosis  and  treatment  of  certain  complaints  is  now 
a  matter  of  common  knowledge. 


September  25,  1920.] 


EDITORIAL  ARTICLES. 


463 


PHYSICIAX-AUTHORS— GEORGES  B.  E. 
CLEMENCEAU. 

Everybody,  of  course,  knows  Georges  Benjamin 
Eugene  Clemenceau,  France's  Grand  Old  Man,  for 
his  fame  was  so  recently  at  its  high  tide.  Destiny  cast 
him  for  an  heroic  role  on  the  grand  stage  of  life, 
the  role  of  statesman  at  an  hour  when  his  country 
needed  all  the  genius  of  statecraft  he  could  bring 
to  bear  on  the  situation.  It  is  in  that  role  that  we 
know  him,  but  he  has  played  other  roles  in  his  time 
and  played  them  well.  The  chief  of  these  minor 
activities  were  as  a  physician  and  as  a  writer.  He 
became  a  physician  through  the  influences  of  her- 
edity and  parental  suggestion ;  for  three  hundred 
years  without  a  break  his  forbears  had  been  physi- 
cians ;  and  he  became  an  author  through  a  temporary 
eclipse  of  his  political  fortunes. 

Clemenceau's  career  as  a  physician  was  brief,  but 
notable  and  unique.  Doubtless  the  troubled  political 
conditions  in  France  at  the  time  served  to  cut  it 
short.  He  was  a  republican,  and  the  Second  Em- 
pire was  at  the  height  of  its  fame  and  influence 
when  he  studied  medicine  in  Paris.  His  father  had 
been  a  leader  of  radical  republicans  in  the  pictur- 
esque Biscayan  village  of  Mouilleron-en-Pareds, 
where  Clemenceau  was  born  (in  1841),  and  im- 
parted to  the  son  those  strong  democratic  tenden- 
cies which  have  been  the  outstanding  characteristic 
of  his  political  career.  Naturally,  then,  he  was  a 
bitter  foe  of  the  Empire.  Before  he  was  twenty- 
five  years  old  he  was  imprisoned  for  shouting  Vive 
la  Rcpublique !  at  an  Imperial  celebration.  He 
served  his  term  and  then,  practically  in  exile,  came 
to  New  York.  This  was  in  1866,  within  a  year 
after  he  had  received  his  medical  degree.  As  a 
student  he  had  shown  marked  medical  aptitude  and 
his  thesis,  The  Generation  of  Anatomical  Elements, 
written  at  his  graduation,  was  acclaimed  the  ablest 
paper  published  by  the  Faculty  of  Medicine  that 
year.  This  gave  him  great  advantages,  but  he  ig- 
nored them  and  established  himself  in  the  Mont- 
martre  section,  where  he  began  treating  patients 
gratuitously  and  expounding  republican  doctrines  to 
them.  It  was  from  this  practice  that  he  was  driven 
by  the  semivoluntary  exile. 

In  New  York  Clemenceau  tried  to  build  up  a 
practice  but  failed,  and  so  went  to  Stamford,  Conn., 
where  he  taught  French  in  a  girls'  school.  It  was 
in  America  he  did  his  first  writing,  letters  to  Le 
Temps  of  Paris  on  social  and  political  conditions 
here,  and  at  Stamford  he  translated  John  Stuart 
Mill  into  French.  Early  in  1870  he  returned  to 
Paris  and  resumed  his  Montmartre  practice.  Then 
came  the  disastrous  Franco-Prussian  war  and  the 
collapse  of  the  Second  Empire.    His  dream  had 


been  realized  and  destiny  had  launched  him  fairly 
on  his  political  career.  In  a  short  time  he  was 
weaned  wholly  away  from  medicine,  coupling  jour- 
nalism with  politics  to  increase  his  power.  He  had 
a  ready  pen  and  a  bitter  one,  and  it  was  at  this  period 
that  his  ability  to  upset  cabinets  earned  him  the  name 
of  the  Tiger.  In  1880  he  founded  and  edited  La 
Justice,  a  daily,  and  wrote  about  anything  and  every- 
thing, but  mainly  about  politics.  This  periodical  was 
suspended  three  years  later  when  Clemenceau  fell 
from  political  eminence  with  astonishing  sudden- 
ness, due  to  charges  in  connection  with  the  Panama 
Canal  scandal.  Although  he  met  every  charge,  his 
constituency  turned  solidly  against  him  and  for  nine 
years  he  had  no  connection  with  the  government  of 
France.  Immediately  he  became  a  man  of  letters  and 
during  the  nine  years  wrote  one  novel,  two  volumes 
of  tales  and  sketches,  a  volume  of  sociology,  a  play 
with  scenes  laid  at  the  court  of  China,  a  quantity  of 
ordinary  journalism  including  articles  on  the  Drey- 
fus case  which  make  four  fat  volumes,  and  several 
other  books.  His  best  known  work  is  the  volume  of 
essays.  Great  Pan,  which  critics  assure  us  is  replete 
with  ironic  grace  and  humor  and  a  delicate  classical 
spirit.  Episodes  that  grew  out  of  his  experience  as 
a  physician  are  contained  in  the  two  volumes  of 
tales,  and  these  are  said  to  be  his  best  fiction,  grimly 
picturesque,  clear  cut  and  full  of  realism.  His 
novel,  The  Strongest,  a  severe  criticism  of  social 
life,  was  a  dull  and  tedious  failure.  Recently  it  was 
published  in  translation  in  America,  not  because  of 
its  merit  but  because  of  widespread  interest  in  the 
author. 

When  the  Dreyfus  case  developed  Clemenceau 
founded  L'Aiirore,  devoted  to  proving  Dreyfus  in- 
nocent. It  was  in  L'Aurore  that  Zola  published  his 
famous  J'Accuse.  No  less  a  critic  than  Sidney 
Brooks  has  said  that  Clemenceau's  Dreyfus  articles 
are  "the  most  brilliant  masterpieces  of  polemics  that 
French  literature  has  produced  since  Pascal's  fa- 
miliar Provincial  Letters."  It  was  these  articles  that 
restored  him  to  that  political  power  which  culmi- 
nated in  the  premiership. 

What  may  perhaps  be  Clemenceau's  last  volume 
is  a  book  entitled  France  Facing  Germany,  a  collec- 
tion of  speeches  and  articles  on  the  origin  of  the 
World  War  and  the  progress  of  hostilities — a  vol- 
imie  that  doubtless  will  be  of  great  historical  value 
in  future  years.  In  style  Clemenceau's  writings  are 
fluent  and  vivid  always,  an  admirable  byproduct 
that  serve  to  show  the  almost  limitless  capacities  of 
a  very  remarkable  man. 

At  present,  Clemenceau  is  again  somewhat  in 
eclipse  because  of  dissatisfaction  with  the  peace- 
making and  nearly  all  French  newspapers  are  re- 


464 


EDITORIAL 


ARTICLES. 


[New  York 
Medical  Journal. 


viling  him  and  accusing  him  either  of  incompetence 
or  treachery.  Only  a  few  months  ago  he  came  near 
being  President  of  France.  Several  journals  have 
urged  him  to  take  up  the  pen  again  in  his  defense, 
but  the  old  statesman  has  declined  and  his  decision 
appears  irrevocable.  He  is  seventy-nine  and  his 
fame  is  secure.  He  can  af¥ord  to  regard  it  all  as  a 
sardonic  joke. 


ERYSIPELAS  IN  ELDERLY  SUBJECTS. 

Of  all  the  local  complications  of  erysipelas  in 
elderly  people  suppuration  is  the  most  frequent, 
arising  in  the  phlyctense — rare  in  old  subjects — or 
in  the  cellular  tissue  underlying  the  dermatitis,  pre- 
ferably where  it  is  loose.  They  are  due  to  the 
streptococcus  alone  and  not  to  an  association  with 
the  staphylococcus.  Suppurating  erysipelas  is 
also  observed,  while  gangrene  of  the  limbs  and 
scrotum  has  been  met  with,  especially  in  cachectic, 
diabetic,  and  renal  subjects.  An  acute  angina  at 
the  onset  of  erysipelas,  suppurating  otitis  media,  and 
lesions  of  the  ocular  and  nasal  mucosa  are  very 
common.  In  thirty  cases  of  erysipelas  in  old  peo- 
ple, Lamy  met  with  a  mild  catarrhal  conjunctivitis 
and  once  a  conjunctivitis  with  dacryocystitis ;.  both 
were  bilateral.  The  streptococcus  was  found  in 
pure  culture,  but  the  conjunctiva  and  ocular  globe 
did  not  become  involved. 

The  most  frequent  local  complication,  according 
to  Lamy,  is  sclerosis  of  the  derma  of  the  face,  a 
sequela  of  the  streptococcal  dermatitis.  The  thick- 
ening of  the  derma  is  accompanied  by  redness  over 
the  site  of  the  erysipelas  that  has  disappeared  and 
may  lead  one  to  suspect  a  return  of  the  process,  but 
the  absence  of  local  hyperthermia  is  the  best  sign 
that  such  is  not  the  case.  This  hard  edema  is  more 
frequent  in  the  lower  limbs  and  face  and  is  more 
prone  to  occur  in  relapsing  erysipelas.  Bendix,  Du- 
pouy,  and  others  have  shown  that  in  the  face  the 
lesion  is  a  pachydermic  change  without  any  inflam- 
matory process,  and  in  the  area  of  the  sclerous  der- 
matitis the  lymph  does  not  contain  the  streptococcus. 
In  Lamy's  cases  this  special  type  of  scleroderma 
was  accompanied  by  a  cutaneous  vasodilatation 
which  gave  rise  to  the  redness  of  the  skin.  The  fre- 
quency of  infectious  erythemata  during  and  follow- 
ing the  various  infectious  processes  are  well  known, 
this  frequency  being  due  to  the  very  marked  action 
of  the  microbic  toxins  on  the  vasomotor  centres. 
.  The  toxins  stimulate  the  vasodilators  so  that  they 
react  with  the  greatest  facility  and  the  redness  re- 
maining after  erysipelas  is  a  manifestation  of  this 
action.  These  vasomotor  disturbances  may  awaken 
a  latent  eczema  or  cause  an  outburst  of  syphilides 
in  old  syphilitics. 


The  general  complications  during  erysipelas  in  the 
aged  are  regarded  as  common  by  most  observers,  and 
death  is  frequent,  although  it  is  due  not  to  a  strepto- 
coccal infection  but  rather  to  the  insufficiency  of 
some  viscus.  The  early  or  initial  pulmonary  con- 
gestion often  observed  should  be  looked  upon  as  a 
symptom  of  erysipelas  and  not  as  a  complication. 
Enriquez  and  others  believe  that  renal  complications 
are  frequent  in  erysipelas  in  old  people  but  Lamy 
never  met  with  any. 

Besides  the  true  visceral  complications,  visceral 
distvirbances  with  a  favorable  prognosis  are  also  met 
with,  according  to  Lucien  and  Parisot.  According 
to  these  observers  renal,  hepatic  and  cardiac  com- 
plications arise  in  organs  previously  the  seat  of 
lesions.  Streptococcal  endocarditis,  pericarditis 
and  pleural  empyema  have  been  observed  as  compli- 
cations of  ei'ysipelas  in  the  aged.  Pneumonia  and 
pulmonary  congestion  have  also  been  described. 
The  pneumonia  of  erysipelas  has  a  rapid  evolution, 
a  vague  symptomatology,  and  a  fatal  issue,  and  to 
detect  it  at  its  onset  the  thorax  should  be  given  a 
daily  auscultation,  otherwise  the  lung  process  may 
not  be  recognized. 

Delirium  is  a  common  complication  of  all  infec- 
tious processes  in  elderly  people  and  often  after- 
ward the  first  symptoms  of  senile  dementia  arise. 

Of  the  abnormal  types  of  erysipelas  in  the  aged 
may  be  mentioned  the  bilious  and  adynamic  forms, 
although  they  are  uncommon.  Recurring  erysipelas 
is  far  more  fatal  in  elderly  subjects  than  in  adults 
because  their  systems  are  less  resistant.  A  progres- 
sive attenuation  of  the  specific  dermatitis  may  be  ob- 
served in  them  and  each  recurrence  reveals  a  grow- 
ing opposition  between  general  immunity  and  the 
local  predisposition,  both  increasing  after  the  pre- 
vious attack. 


SPIRITS  AND  SCIENCE. 
Suppose  a  violent  shaking  of  the  earth  amid  an 
accustomed  peaceful  scene.  In  its  train  will  be 
found  cast  up  fossils,  relics  of  a  time  so  long  for- 
gotten that  these  objects  appear  to  the  inhabitants 
of  the  green  earth  utterly  strange  and  new.  They 
do  not  belong  to  the  familiar  soil.  Their  origin 
must  have  been  some-  unknown  land  from  which 
they  have  intruded  upon  the  view.  Such  an  earth- 
quake, in  greater  or  smaller  proportions,  occurs  at 
every  crisis  in  individual  life  or  in  that  of  nations. 
At  such  time  intruders  seem  to  make  themselves 
felt,  apparently  unfamiliar  and  so  attributable  to 
almost  any  external  agency.  Is  is  strange  that  in 
the  psychic  upheavals  of  the  past  six  years  there  has 
been  a  strong  revival  of  belief  in  such  presences, 


September  25,  1920.] 


EDITORIAL  ARTICLES. 


465 


intruding  in  daily  affairs  or  more  softly  coming  to 
visit  their  own  living  ones? 

One  of  the  world's  keenest  modern  psychologists 
explains  on  the  basis  of  such  cataclysmic  disturb- 
ances this  present  day  revival  of  the  really  never  ex- 
tinct belief  in  spirits.  In  a  timely  address  before 
the  Society  for  Psychical  Research  in  England,  Jung^ 
presents  scientific  facts  to  explain  that  inner  psychic 
experiences  give  origin  to  such  belief  in  spirits. 
He  does  not  deny  "that  mystic  and  supernatural 
something  which  alone  makes  a  man  a  man."  He 
shows  how  man  could  create  this,  however,  out  of 
his  own  buried  psychic  life.  Thus  man  preserves 
something  about  himself  which  has  ever  recurred 
in  one  form  or  another  to  preserve  him  from  a 
demoralizing  materialism.  ]\Ian's  perception  of  the 
natural  world  around  him,  as  well  as  of  his  inner 
psychic  activity,  has  always  remained  the  same.  His 
interpretation  of  it  has  varied  with  time  and  with 
change  in  intellectual  viewpoint.  Particularly  in 
more  primitive  times  man  has  been  more  prone  to 
interpret  the  things  he  perceived  arising  from  his 
inner  psychic  realm  as  ghosts  coming  to  him  from 
without.  Later  he  has  weakened  this  conception 
by  calling  them  merely  dreams  or  morbid  symptoms, 
without  even  consideration  enough  for  them  to  stop 
to  inquire  their  significance.  They  were  still  for- 
eign to  his  external  thought,'  which  he  was  inclined 
to  think  was  all  there  was  of  his  mental  activity. 
Yet  under  special  stress  they  might  take  on  for  him 
the  appearance  of  objective  reality. 

Now,  however,  science  has  laid  its  hand  on  the 
dream,  the  apparition,  the  neurotic  imagining.  Each 
one  yields  itself  as  a  product  of  the  mental  life  but 
lying  so  deep,  sometimes  so  separated  from  the 
ego's  realization  of  itself  that  when  it  appears  it 
has  the  force  of  a  foreign  intruder.  Jung  likes  to 
describe  the  unconscious  as  separated  into  two  parts. 
He  names  first  an  individual  unconscious  made  up 
of  experiences  which  have  been  repressed  below  con- 
sciousness within  the  individual's  own  life.  These 
are  not  felt  as  foreign  to  the  ego  when  they  are 
again  brought  into  its  ken,  as  through  the  process  of 
analysis.  But  there  is  also  a  larger  unconscious, 
which  he  calls  a  superpersonal  or  collective  uncon- 
scious, meaning  thereby  the  "congenital  instincts  and 
primordial  forms  of  apprehension"  which  belong 
not  to  individual  experience  but  which  appertain  to 
the  whole  of  mankind.  These  appear  to  conscious- 
ness as  foreign,  adverse.  Traces  of  such  archaic 
images  appear  in  dreams  and  in  more  disturbing 
form  in  certain  cases  of  mental  derangement,  chiefly 
in  dementia  praecox.  ' 

•  C.  C.  Jung,  The  Psychological  Foundation  of  Belief  in  Spirits, 
Proceedings  of  the  Society  for  Psychical  Research.  Part  LXXIX 
Vol.  XXXI.  ' 


There  are,  and  always  have  been,  people  of  more 
than  the  usual  range  of  intuitive  perception.  They 
have  been  able  to  grasp  more  than  others  of  this 
larger  unconscious  and  translate  it  over  into  new 
ideas.  These  may  be  acceptable,  answering  per- 
haps to  an  unconscious  preparation  which  has  tend- 
ed toward  their  acceptance.  They  may  prove 
unacceptable  and  conflict  too  violently  with  what 
has  long  been  held  true.  In  either  case  there  oc- 
curs a  change  in  conscious  thought  and  in  conse- 
quent activity,  which  on  such  grounds  needs  no 
explanation  of  extrahuman  intervention  but  has 
its  origin  only  in  the  larger  human  life  of  the 
past  as  well  as  of  the  present.  The  appearance 
of  departed  spirits  rests  upon  the  same  psychic 
mechanism.  Furthermore,  the  amount  of  psychic 
energy  attached  to  a  loved  one  is  applied,  when 
the  object  is  removed  by  death,  to  the  mere 
image  or  idea  of  that  object.  This  attachment  of 
energy  to  an  image  may  so  separate  this  portion  of 
psychic  energy  from  the  personal  ego  that  the  image 
attains  the  force  of  a  separate  existence.  The  loss 
of  this  energy  may  even  be  felt  to  such  an  extent 
that  the  spirit  itself  is  accounted  an  injurious 
presence. 

Jung  makes  no  arrogant  assertions  which  deny 
the  possible  independent  existence  of  actual  spirits. 
His  familiarity,  however,  with  the  content  and  the 
mechanisms  of  the  unconscious  gives  weight  to  this 
scientific  basis  for  the  spiritual  phenomena  which 
have  always  been  present  in  man's  speculation.  It 
should  help  to  steady  intellectual  thought  in  these 
days  when  spirits  of  many  sorts  have  been  roused 
from  their  psychic  hiding  places. 


NEEDLESSLY  BLIND. 
The  days  when  workmen  were  seriously  injured 
and  incapacitated  for  work  through  no"  fault  of 
their  own  are  rapidly  coming  to  an  end.  Formerly 
a  small  compensation  or  tiny  pension  calmed  the 
employer's  conscience ;  now  the  law  is  standing  out- 
side the  door  and  none  may  keep  her  from  the  dis- 
cussion of  how  much  shall  be  paid.  The  employer's 
one  loophole  is  contributory  negligence,  and  this 
happens  very  frequently,  for,  to  the  employee,  it 
seems  waste  of  time  to  take  precautions  against 
an  evil  he  has  never  had  to  face  and  which,  to  his 
knowledge,  has  never  happened  where  he  works. 
So  the  National  Committee  for  the  Prevention  of 
Blindness  has  to  state  that  out  of  the  one  hundred 
thousand  blind  in  the  United  States  more  than  fifty 
per  cent,  are  needlessly  so.  The  national  council 
estimates  there  are  two  hundred  thousand  eye  in- 
juries in  our  land  and  the  International  Association 
of  Labor  Legislation  has  issued  a  list  of  fifty-six 
industrial  poisons  of  which  thirty-six  affect  the 
eyes.  Men  repeatedly  disobey  the  foreman  and  ne- 
glect to  wear  the  goggles  provided.  They  complain 
they  are  heavy,  disagreeable  to  wear,  and  some- 


466 


NEWS  ITEMS. 


[New  York 
Medical  Journal. 


times  become  cloudy.  The  providing  of  indi- 
vidual goggles,  insistence  on  their  being  worn,  re- 
moval of  dangerous  vapors  and  gases  and  properly 
ventilated  and  lighted  rooms,  ought  to  remove  all 
objections,  but  many  times  when  the  employer 
is  honestly  doing  his  best,  the  employees  behave 
like  children.  Practically  all  California's  eye  in- 
juries are  caused  by  flying  objects,  small  pieces  of 
steel  or  emery  dust.  The  injured  one's  plea  was 
that  he  only  had  to  do  one  minute's  grinding  at  the 
emery  wheel  and  did  not  wear  goggles  as  he  thought 
nothing  could  happen  in  that  time.  Stodgy  ignor- 
ance, willful  or  pardonable,  is  one  of  the  slowest  but 
most  vicious  devils  the  medical  profession  has  to 
encounter. 



News  Items. 


Smallpox  in  Scotland. — To  date  474  cases  of 
smallpox  have  been  reported  in  the  Glasgow  district. 
Vaccination  is  stated  to  be  falling  off. 

New  Philadelphia  Hospital. — A  new  hospital 
to  be  known  as  the  Robert  H.  Crozer  Hospital  will 
be  erected  on  the  grounds  of  the  Chester  Hospital, 
Philadelphia,  and  deeded  to  that  institution  for 
ninety-nine  years. 

State  Institution  Leased  by  Government. — 
The  United  States  Government  has  leased  the  for- 
mer state  home  for  inebriates  at  Knoxville,  Iowa, 
and  will  remodel  it  as  a  hospital  for  former  service 
men  in  the  Aliddle  West. 

Course  in  Sex  Education. — Announcement  has 
been  made  by  the  University  of  Cincinnati  of  a 
new  course  dealing  with  sex  education.  The  sub- 
ject will  be  presented  from  the  sociological  and  psy- 
chological as  well  as  the  biological  viewpoint. 

Walter  Reed  Hospital  Work  Filmed. — A  film 
showing  the  work  at  the  Walter  Reed  Hospital, 
Washington,  for  wounded  soldiers,  from  a  physical, 
educational  and  recreational  viewpoint,  will  soon  be 
exhibited  through  the  efforts  of  the  Potomac  divi- 
sion of  the  American  Red  Cross  Society. 

Neurological  Society  Meets. — A  stated  meet- 
ing of  the  New  York  Neurological  Society  will  be 
held  on  October  5th.  Papers  will  be  presented  by 
Dr.  Junius  W.  Stephenson  on  Clinical  Studies  of 
Syphilis  of  the  Central  Nervous  System  and  by 
Hannah  M.  Creasey  on  Stuttering :  Etiology  and 
Therapy. 

Proposed  Memorial  to  Major  General  Gorgas. 

— An  international  institute  for  the  study  of  trop- 
ical diseases,  to  be  established  in  Panama,  has  been 
proposed  as  a  memorial  to  the  late  Major  General 
William  C.  Gorgas.  It  has  been  stated  that  the 
government  of  Panama  is  willing  to  donate  the  St. 
Thomas  hospital  for  the  use  of  the  institute. 

Akron's  Twins. — Akron,  Ohio,  is  having  an 
epidemic  of  twins,  according  to  a  press  dispatch 
quoting  figures  at  the  Bureau  of  Vital  Statistics. 
Akron  lays  claim  to  the  largest  proportion  of  twins 
to  other  births  of  any  city  in  the  union.  In  1919 
forty-six  pairs  of  twins  were  born,  and  forty-one 
pairs  have  already  been  born  up  to  August  31st 
of  this  year.  Of  the  1920  twins,  sixteen  pairs 
are  male,  twelve  female,  and  thirteen  mixed. 


Safety  Congress.— The  ninth  annual  safety- 
congress  of  the  National  Safety  Council  will  be  held 
September  27th  to  October  1st  in  Milwaukee. 

Red  Cross  Magazine  Discontinued. — The  Red 
Cross  Magazine  will  suspend  publication  with  the 
October  issue,  on  account  of  the  increased  cost  of 
paper  and  publication. 

University  of  Sydney. — Dr.  J.  T.  Wilson  has 
been  elected  dean  of  the  medical  faculty  of  the  Uni- 
versity of  Sydney,  Australia,  succeeding  the  late 
Sir  Thomas  Anderson  Stuart. 

Battleship  Laboratories. — The  British  Minis- 
try of  Agriculture  is  arranging  to  employ  obsolete 
battleships  as  floating  laboratories  for  the  investiga- 
tion of  foot  and  mouth  disease. 

Chair  of  Pharmacology. — The  University  of 
Sheffield,  England,  has  established  a  whole  time 
chair  of  pharmacology  to  which  Dr.  Edward  Mel- 
lanby,  at  present  professor  of  physiology  in  the  Uni- 
versity of  London,  has  been  appointed. 

Increase  in  German  Women  Students. — Re- 
ports from  Germany  state  that  there  are  at  present 
approximately  8,000  women  studying  in  German 
universities,  twice  the  number  registered  five  years 
ago.  Of  these,  more  than  2,000  are  medical  students. 

Queen's  Medical  College. — Dr.  Lorimer  J. 
Austin,  of  London,  has  been  appointed  professor 
of  clinical  surgery  and  Dr.  James  Miller,  of  the 
University  of  Edinburgh,  has  been  appointed  pro- 
fessor of  pathology  in  Queen's  Medical  College, 
Kingston,  Ont. 

French  Orthopedic  Congress. — The  second 
French  Orthopedic  Congress,  will  be  held  October 
8th  and  9th  in  Paris.  The  questions  to  be  con- 
sidered are :  Treatment  of  scoliosis  by  Abbott's 
method ;  ischemic  retraction  of  Volkmann ;  treat- 
ment of  paralysis  by  tendinous  anastomosis. 

Redard  Prize. — A  fund  yielding  an  income 
which  is  to  be  awarded  as  a  5,000  franc  prize  every 
fifth  year  for  the  best  work  on  orthopedic  surgery, 
has  been  bequeathed  to  the  Academic  de  medicine, 
by  Dr.  P.  Redard,  a  prominent  French  orthopedic 
surgeon.  Physicians  of  all  countries  and  interns  in 
Paris  hospitals  may  compete. 

Meeting  of  Colored  Physicians. — The  National 
Medical  Association  of  Negro  Physicians,  Sur- 
geons, Dentists  and  Pharmacists  held  its  annual 
meeting  August  25th  to  27th  in  Atlanta.  Ga.,  under 
the  presidency  of  John  P.  Turner,  of  Atlanta.  Dr. 
Henry  M.  Green,  of  Knoxville,  Tenn.,  was  elected 
president  and  Louisville,  Ky.,  was  selected  as  the 
next  place  of  meeting. 

Classification  of  Paris  Professors. — Professors 
in  the  Paris  Faculty  of  Medicine  are  said  to  have 
been  placed  in  two  categories  according  to  their 
seniority,  receiving,  respectively,  twenty-five  and 
and  twenty-three  thousand  francs  yearly.  Profes- 
sors Richet,  Pouchet,  Hutinel,  De  Lapersonne,  Gil- 
bert, Roger,  Nicolas  Ribemont-Dessaignes,  Quenu, 
Prenant.  Widal,  Chauffard.  and  Weiss  have  been 
put  in  the  first  class,  and  Professors  Delbet,  Mar- 
fan, Hartmann,  Bar,  Marie,  Broca,  Teissier, 
Desgres,  Lejars,  Achard,  Robin  Legueu,  Letulle. 
Couvelaire,  Carnot,  Besangon,  Vaquez,  Dupre  and 
Jeanselme  in  the  second  class. 


September  25,  1920.] 


NEWS  ITEMS. 


467 


Sixth  International  Surgical  Congress. — It  has 

been  decided  by  the  recent  Paris  conference  that  the 
sixth  congress  of  the  International  Surgical  Asso- 
ciation will  be  held  in  London  in  1923,  under  the 
presidency  of  Professor  MacEwen,  of  Glasgow. 

Funds  for  Broad  Street  Hospital. — In  view  of 
the  splendid  work  done  by  the  Broad  Street  Hos- 
pital, New  York,  during  the  Wall  Street  explosion 
of  September  16th,  a  movement  is  under  way  in 
the  financial  district  to  solicit  funds  for  this  insti- 
tution. It  was  revealed  that  the  quarters  and  staff 
of  the  hospital  are  too  small  for  such  emergencies. 

Immigrants  to  Be  Vaccinated. — Orders  for  the 
vaccination  of  all  third  class  passengers  leaving 
European  ports  for  this  country  have  been  issued 
to  United  States  Public  Health  Service  surgeons 
in  Europe  by  Dr.  Rupert  Blue,  formerly  surgeon 
general  of  the  Service.  The  precaution  has  been 
taken  to  prevent  the  spread  of  smallpox  from 
Central  Europe.  Dr.  Blue  has  also  announced  that 
more  health  officers  are  soon  to  be  sent  abroad ;  at 
present  there  are  ten  in  Europe. 

State  Drug  Clinics  Close. — All  clinics  estab- 
lished by  the  New  York  State  Narcotic  Drug  Con- 
trol Commission  in  sixteen  cities  have  been  ordered 
closed,  following  the  refusal  of  hospitals  to  receive 
drug  addicts  to  complete  their  cures.  Commis- 
sioner Walter  R.  Herrick  plans  to  ask  the  next  legis- 
ature  to  appropriate  funds  for  the  construction  of 
at  least  three  state  hospitals  for  drug  users,  one  in 
New  York,  one  in  the  northern  part  of  the  state, 
and  the  third  in  the  western  part. 

Personal. — Assistant  Surgeon  W.  C.  Rucker, 
of  the  United  States  Public  Health  Service,  has 
been  appointed  chief  quarantine  officer  at  Balboa, 
Canal  Zone,  relieving  Surgeon  S.  B.  Grubbs. 

Dr.  Oscar  Davis,  of  Anderson,  has  been  ap- 
pointed state  health  officer  of  Texas,  succeeding  Dr. 
Charles  W.  Goddard.  Dr.  Goddard  has  resigned  to 
become  chief  of  the  medical  staff  of  the  University 
of  Texas,  Galveston. 

Professor  Frank  G.  Haughwout,  head  of  the  de- 
partment of  parasitology  in  the  University  of  the 
Philippines,  has  been  appointed  protozoologist  in 
the  Bureau  of  Science,  Manila. 

Canadian  Medical  Association. — The  fifty-first 
annual  meeting  of  the  Canadian  Medical  Associa- 
tion was  held  June  22nd  to  25th  at  Vancouver, 
with  over  one  hundred  medical  men  from  the  United 
States  in  attendance.  Dr.  Murdoch  Chisholm,  of 
Halifax,  was  elected  president.  It  was  decided  to 
hold  the  next  meeting  in  Halifax.  Among  the 
important  items  of  business  considered  were  the 
general  reorganization  of  the  association  on  a  more 
businesslike  basis,  the  proposal  to  form  a  Canadian 
College  of  Physicians  and  Surgeons,  the  organiza- 
tion of  the  profession  in  its  relation  to  the  Work- 
men's Compensation  Act,  and  the  making  of  cer- 
tain changes  in  the  size  and  appearance  of  the 
Canadian  Medical  Association  Journal.  The  follow- 
ing committee  was  appointed  to  consider  the  for- 
mation of  a  Canadian  College  of  Physicians  and 
Surgeons :  Dr.  H.  A.  MacCullum,  of  London ;  Dr. 
S.  E.  Moore,  of  Regina ;  Dr.  F.  W.  Marlow,  of 
Toronto ;  Dr.  A.  E.  Garrow,  of  Montreal ;  Dr. 
James  McKenty,  of  Winnipeg. 


New  Hospitals  in  China. — The  China  Medical 
Journal  records  the  opening  of  several  new  hospitals 
in  China.  The  Chinese  Infectious  Diseases  Hospital 
in  Shanghai  and  a  new  quarantine  hospital  at  New- 
chwang  were  both  opened  in  July.  The  Summer 
Diseases  Hospital  in  Shanghai  was  opened  in  June. 

University  of  Toronto  Senate. — Dr.  Augusta 
Stowe-Gullen,  Dr.  Charles  J.  C.  O.  Hastings,  Dr. 
Arthur  C.  Hendrick,  and  Dr.  Andrew  S.  Moor- 
head,  all  of  Toronto,  have  been  elected  medical  rep- 
resentatives to  the  senate  of  the  University  of 
Toronto. 

Michigan   Takes   Tuberculosis    Clinics. — The 

tuberculous  clinics  formerly  supervised  by  the 
state  antituberculous  association  have  been  taken 
over  by  the  Michigan  Department  of  Health,  which 
will  conduct  clinics  throughout  the  state.  Dr. 
George  H.  Ramsey,  formerly  director  of  the  tuber- 
culosis pavilion  in  the  Herman  Kiefer  Hospital,  De- 
troit, will  have  charge  of  the  examination  of  pa- 
tients for  tuberculosis,  while  under  the  direction  of 
Dr.  Frank  L.  Rose,  of  Jackson,  children  will  be  ex- 
amined for  pretuberculosis  defects.  The  work  will 
be  under  the  supervision  of  the  division  of  com- 
municable diseases  of  the  State  Health  Department. 

Infant  Mortality  Report. — A  statistical  report 
of  infant  mortality  in  269  cities  of  the  United 
States  has  been  published  by  the  American  Child 
Hygiene  Association.  The  report  lists  the  follow- 
ing cities  with  low  infant  mortality  rates  under  the 
caption — Where  Babies  Have  the  Best  Chance: 
Brookline,  Mass.,  40;  Berkeley,  Cal.,  44;  Marinette, 
Wis.,  45;  Aberdeen,  Wash.,  45;  Everett,  Mass.,  47; 
Madison,  Wis.,  47;  Piqua,  Ohio,  48;  Alameda, 
Cal.,  49.  The  infant  mortality  rate  for  New  York 
City  is  given  at  82.  Cities  with  particularly  high 
infant  mortality  rates  are:  Pittsburgh,  115;  Bufifalo, 
107;  Kansas  City,  Mo.,  103;  New  Bedford,  Mass., 
124;  Camden,  N.  J.,  121;  Nashville,  Tenn.,  116; 
EI  Paso,  245 ;  Knoxville,  Tenn.,  135 ;  Racine,  Wis., 
123;  Burlington,  Vt.,  150;  Paducah,  Ky.,  146;  Han- 
nibal, Mo.,  145. 

 <$>  

Died. 

Baer. — In  Philadelphia,  Pa.,  on  Saturday,  September  11th, 
Dr.  Benjamin  F.  Baer,  aged  seventy-four  years. 

Booker. — In  Selma,  Cal.,  on  Friday,  August  20th,  Dr. 
Thomas  A.  Booker,  aged  forty-eight  years. 

BuLLWiNKLE. — In  Brooklyn,  N.  Y.,  on  Tuesday,  Septem- 
ber 14th,  Dr.  Henry  Bullwinkle,  aged  fifty- four  years. 

Cotter. — In  Brooklyn,  N.  Y.,  on  Wednesday,  September 
15th,  Dr.  John  Henry  Cotter,  aged  fifty-two  years. 

Gibson. — In  Ramsey,  N.  J.,  on  Thursday,  Septamber  16th, 
Dr.  James  T.  Gibson,  aged  sixty-four  years. 

Drum.— In  Syracuse,  N.  Y.,  on  Saturday,  August  28th, 
Dr.  James  Henry  Drum,  aged  fifty-one  years. 

Gregory. — In  Stroudsburg,  Pa.,  on  Thursday,  September 
9th,  Dr.  William  Edwin  Gregory,  aged  sixty-seven  years. 

Holland. — In  Winnipeg,  Can.,  Dr.  Robert  A.  Holland,  of 
Calais,  Me.,  aged  fifty  years. 

Judge. — In  Philadelphia,  Pa.,  on  Thursday,  September 
9th,  Dr.  Robert  B.  Judge,  aged  sixty-three  years. 

LuxFORD. — In  Princess  Anne,  Va.,  on  Thursday,  Septem- 
ber 9th,  Dr.  Thomas  B.  Luxford,  aged  forty-nine  years. 

Miller. — In  Omaha,  Neb.,  Dr.  George  F.  Miller,  aged 
eighty-nine  years. 

Stearns. — In  Port  Alleghany,  Pa.,  on  Tuesday,  Septem- 
ber 7th,  Dr.  John  S.  Stearns,  aged  seventy-two  years. 


Book  Reviews 


TREATMENT  OF  NEUROSES. 

Treatment  of  the  Neuroses.  Bv  Erxest  Joxes,  M.  D. 
(Lond.),  M.  R.  C.  P.  (Lond.),  President  of  the  British 
Psychoanalytical  Society;  Member  (for  England  and 
Arnerica)  of  the  Council  of  the  International  Congress 
for  Medical  Psychology  and  Psychotherapy;  Honorarj- 
^Member  of  the  American  Psychopathological  Association. 
New  York :  William  Wood  &  Co.,  1920.    Pp.  viii-233. 

More  progress  has  been  made  in  the  treatment  of 
the  neuroses  than  in  any  other  branch  of  medicine, 
and  among  the  most  progressive  of  the  workers  in 
this  branch  of  medicine  is  Dr.  Ernest  Jones.  The  book 
which  he  presents  on  the  treatment  of  the  neuroses 
is  an  elaboration  of  the  section  devoted  to  this 
subject  in  JelHffe  and  White's  Modern  Treatment 
of  Nervous  and  Mental  Diseases. 

One  of  the  interesting  features  of  Jones's  book  is 
his  tolerance  toward  other  more  obsolete  methods 
of  treatment.  He  traces  step  by  step  the  important 
measures  that  have  replaced  other  methods  in  the 
evolutionary  progress  that  has  been  made  in  this 
branch  of  medicine.  He  first  considers,  in  a  broad 
way,  the  handling  of  hysterical  subjects,  analyzing 
the  various  physiological  means  that  have  been  used. 
The  ^^'eir  ^litchell  treatment  is  described  in  detail. 
The  author  then  takes  up  the  various  psychological 
methods  and  divides  them  into  three  principal  di- 
visions, viz.,  suggestion,  reeducation,  and  psycho- 
analysis. Under  suggestion  he  places  various  types 
of  hypnotisin.  In  an  exceedingly  simple  manner 
he  shows  the  mechanism  underlying  these  processes 
and  how  they  fall  short  of  the  ukimate  aim. 

The  chapter  on  reeducation  is  more  complete.  This 
method  of  treatment,  while  it  shows  much  progress 
over  the  methods  previously  used,  still  does  not 
suffice.  A  deeper  search  is  made  for  the  patho- 
genic factors  in  place  of  being  content  with  dealing 
with  the  results  of  the  pathological  condition.  There- 
fore from  the  point  of  view  of  stability  this  sys- 
tem is  superior  to  that  of  suggestion.  In  searching 
for  causative  factors  it  was  found  necessary  to  go 
beneath  the  surface.  The  reactions  of  the  patients 
are  not  due  to  the  stimuli  which  are  seen  on  the 
surface  but  to  traumatic  shocks  received  at  other 
periods  of  the  patient's  life  and  the  emotional  re- 
actions are  caused  by  the  present  stimulus  bringing 
back  the  former  effects,  which  may  be  forgotten 
by  the  patient,  but  which  continue  to  exist  in  his 
unconscious  and  retain  their  vitality  in  an  amazing 
manner. 

Finally  psychoanalysis,  the  method  devised  by 
Freud,  is"  discussed.  The  method  which  was  first 
intended  for  the  treatment  of  hysteria  has  been  put 
to  wider  application  and  at  present  is  successfully 
used  in  many  other  forms  of  psychoneuroses. 
Fundamental  problems  of  psychologv'  have  under- 
gone revision  and  the  fields  of  m}-thology,  folklore, 
philology,  and  anthropology  have  been  examined  by 
this  new  science. 

Nevertheless  it  has  remained  the  treatment  of 
choice  among  progressive  neurologists  for  hysteria 
and  similar  neuroses.  The  findings  of  reeducational 
methods  are  in  the  main  confirmed  by  Freud.  It  is 
granted  that  every  hysterical  symptom  has  for  its 
basis  an  amnesia.    It  is  acknowledged  that  the  un- 


conscious functioning  of  unconscious  inaterial  is  an 
important  factor  in  the  theory,  but  Freud  does  not 
emphasize  the  factor  of  a  vague  constitutional  in- 
feriority as  being  a  secondary  factor.  The  inability 
of  the  patient  to  make  adjustments  to  his  surround- 
ings due  to  his  inability  to  orient  himself  to  the 
situation  as  it  exists  in  his  own  unconscious  is 
largely  responsible  for  the  disordered  state. 

Jones  shows  how  psychoanalysis  is  the  method 
of  choice  as  it  is  the  most  thorough  method  of  all. 
He  carefully  explains  the  technic  of  transference, 
the  analysis  of  the  dream,  and  other  unconscious 
material,  how  use  is  made  of  free  association  in 
tracing  back  complexes,  and  how  the  patient  gradu- 
ally becomes  acquainted  with  himself  by  the  un- 
raveling of  his  unconscious  which  has  been  hidden 
from  him  and  yet  "has  created  the  havoc  which  led 
to  the  neuroses. 

Some  space  is  also  devoted  to  the  anxiety  neu- 
roses, anxiety  hysteria,  neurasthenia,  obsessions, 
hypochondria,  and  the  traumatic  neuroses.  Other 
topics  of  a  forensic  nature  are  also  discussed. 

The  book  is  extremely  well  written  and  unlike 
many  books  on  neurological  subjects  it  does  not 
run  away  from  the  practitioner  by  the  use  of  highly 
technical  phrases.  Dr.  Jones  has  been  careful  to  keep 
it  within  the  reach  of  everyone  who  would  be  likely 
to  read  the  book  and  at  the  same  time  he  has  not 
in  any  way  lost  the  import  of  any  of  the  material 
presented.  It  is  seldom  that  one  can  say  in  speak- 
ing of  a  medical  text  book  that  it  may  be  read  and 
enjoyed. 

GOTTFRIED  KELLER. 

Gottfried  Keller.  Psychoanalyse  des  Dichters  Seiner  Ge- 
stalten  und  Motive.  Yon  Dr.  Eduard  Hitschmann. 
Wien,  Austria :  Internationaler  Psychoanalytischer  Ver- 
lag,  G.  M.  B.  H.,  1919.    Pp.  vii-125. 

Poets  afford  a  peculiarly  instructive  study  of  what 
man  is  and  why  he  is  hindered  in  being  more  than 
he  is.  Poets  are  poets  in  that  they  are  compelled 
from  within  to  reveal  what  constitutes  a  human  life, 
with  its  limitations.  Psychoanalysis  turns  fearless 
eyes  upon  these  itmer  things  and  a  sympathetic  ear 
to  these  self  revealing  voices.  Through  a  psycho- 
analytical study  of  the  poets,  therefore,  knowledge 
is  gained  which  has  a  manifold  value,  the  poet  him- 
self is  better  understood  and  comes  closer  into  the 
common  brotherhood  of  striving  and  divided  suc- 
cess. His  message  is  fraught  with  more  universal- 
ly pointed  meaning.  The  limitations  which  mark 
his  work,  which  often  are  but  the  warring  of  ele- 
ments of  greatness  and  power,  are  the  wholesome 
lessons  directed  upon  all  lives.  Especially  in  the 
spirit  of  today  they  call  for  an  invigorating  search 
into  our  own  lives  to  understand  our  failures,  to 
find  only  in  some  other  form  the  same  inner  psychic 
causes  for  limitation  and  imperfection  everywhere. 
In  this  way  they  act  as  reproachful  stimuli  to  a 
better  guidance  of  child  nature  than  the  race  has 
yet  deemed  worth  while. 

It  is  this  last  consideration  which  is  urgently 
forced  upon  one  from  the  psychoanahtical  study 
of  Gottfried  Keller,  poet  and  artist,  and  a  striking 
figure  in  German  literature.    For  he  had  greatness 


September  25,  1920.] 


BOOK  REVIEWS. 


469 


and  the  limitation  which  his  fundamental  childish 
fixations  put  upon  him  were  in  themselves  largely 
the -starting  point,  after  a  good  deal  of  delay,  of  the 
forms  his  creative  activity  made  its  own.  Yet  his 
work  was  so  much  less  freely  expressive  than  it 
might  have  been,  the  imprint  of  his  personal  con- 
flicts was  so  great,  his  personal  life  fell  so  far  short 
of  that  of  the  healthy  man.  that  one  is  almost  op- 
pressed with  the  sense  of  burdening  waste  which  a 
bad  early  adjustment  can  work  in  any  life.  On  the 
other  hand,  one  i5  heartened  by  the  innate  resolute- 
ness of  the  human  psyche  which  turns  to  an  expres- 
sion which,  more  or  less  successfully,  frees  the 
burden  in  the  poet  and  in  those  to  whom  he  speaks. 

It  is  not  an  idle  surmise,  this  dis.covery  of  the 
source  of  incompleteness  in  artistic  power  and  of 
failure  in  life  in  Keller's  early  years.  He  has  given 
testimony  in  his  own  reminiscences,  though  he  was 
a  silent,  reserved  man,  as  well  as  in  his  manner  of 
life.  His  works,  particularly  his  Griiner  Hcin- 
rich,  are  autobiographical,  not  so  much  of  external 
events  as  of  the  attitudes  and  inner  experiences 
which  they  contain.  So  also  are  the  years  of  groping 
after  his  work  and  the  final  slow  development  of 
it.  Something  prevented  him  from  devoting  his  life 
to  painting  the  human  figure,  and  landscape  painting 
passed  over  into  word  painting  and  the  deeper 
development  of  epic  writing. 

This  history,  with  its  close  reference  to  the  psy- 
chic life  of  Gottfried  Keller,  is  sketched  in  this  at- 
tractive volume  of  Hitschmann.  One  by  one  the 
various  infantile  elements  are  revealed  as  playing  a 
conspicuous  part  in  his  life  and  his  work.  It  would 
seem  that  Hitschmann  might  have  entered  some- 
what more  enthusiastically  into  his  subject  and  car- 
ried his  readers  more  completely  into  the  poet's 
psychic  experience.  Perhaps  this  is  due  in  part 
to  a  lack  of  familiarity  with  his  works  on  the  part  of 
the  English  reader  such  as  Hitschmann  may  pre- 
suppose with  his  readers  nearer  home.  The  book, 
in  spite  of  its  slightly  sketchy  character,  forms  a 
welcome  addition  to  the  growing  number  of 
psychoanah-tical  studies  of  our  creative  writers.  It 
reveals  as  such  that  knowledge  of  human  life  which 
is  needed  more  and  yet  more  and  it  stimulates  to  a 
use  of  such  knowledge.  Thus  failure  may  be  pre- 
vented and  success  increased. 

A  MODERN  DON  QUIXOTE. 

Youth  and  Egolatry.'  By  Pio  Baroja.  Translated  from 
the  Spanish  by  Jacob  S.  Fassett,  Jr.,  and  Frances  L. 
Philups.  Edited  with  Introduction  bv  H.  L.  Mexckex. 
New  York:  Alfred  A.  Knopf,  1920.    Pp.  v-265. 

A  most  refreshing  book.  It  is  rather  difficult  to 
agree  with  a  man  like  Baroja  who  disagrees  with 
almost  everybody  and  everything  but  at  least  he  is 
to  be  admired  for  his  candor.  He  deals,  in  this 
small  volume,  with  all  manner  of  things  and  most 
fearlessly.  Politics,  literature,  art,  religion,  and 
men  are  all  inspected  by  the  gaze  of  this  vigorous 
Basque.  Basque  he  is  and  physician  and  baker  he 
was,  but  through  it  all  he  has  remained  a  rebel. 
In  his  analysis,  if  such  it  may  be  called,  he  uses 
an  acid  that  bites  deeply,  but  no  matter  how  far- 
reaching  his  deductions  one  feels  that  he  is  sincere- 
ly searching  for  the  truth.  He  loathes  the  com- 
placent bourgeois,  with  their  selfsatisfaction  and 


their  tolerance  of  orders  and  things  they  know 
nothing  about.  He  hates  bitterly  all  of  the  instru- 
mentalities that  help  keep  people  in  darkness.  He 
feels  that  they  are  his  enemies,  for  they  are  the 
enemies  of  progress. 

He  has  a  few  literary  favorites,  including  our  own 
Poe.  With  Dostocvsky  and  Nietzsche  he  finds  no 
fault,  but  few  others  are  immune  from  his  wither- 
ing criticism.  Shakespeare,  Moliere,  Cervantes,  are 
all  flayed.  Then  he  attacks  Goethe,  Hugo,  Chateau- 
briand, Stendhal  and  Balzac  and  in  truth  it  must  be 
.told  he  finds  their  weaknesses  with  precision.  He 
is  daring  in  his  attacks  and  with  a  few  acrid  words 
closes  the  incident.  For  the  critic  he  finds  little 
praise  and  so  he  burns  his  way  through,  respecting 
little  but  striving  to  maintain  his  own  selfrespect. 
It  is  a  small  book  but  it  would  be  difficult  to  fall 
asleep  reading  it.  Of  great  interest  to  us  is  the 
fact  that  at  one  time  he  was  a  physician,  ^his, 
however,  should  not  account  for  his  bitterness,  for 
they  do  not  all  get  that  way. 

BREAKERS  AHEAD. 

Feminism  and  Sex  Extinction.  By  Arabella  Rexe.\ly, 
L.  R.  C.  P.  (Dublin).  New  York:  E.  P.  Button  &  Co.. 
1920.    Pp.  vii-313. 

Arabella  Kenealy  draws  three  vivid  pictures : 
What  woman  was,  what  woman  is,  and  what  she 
^\■^ll  become.  Two  fates  await  her,  feminism  and 
femininisticism,  unless  she  rids  herself  of  a  contempt 
for  functions  and  duties  purely  hers.  ^Moreover, 
she  is  handicapped  every  month  for  two  or  three 
days  by  a  certain  amount  of  weakness  and  pain, 
and  every  man  knows  her  temper  is  affected  at  such 
times.  Many  months  are  consumed  in  childbear- 
ing,  and  still  more  months  in  childrearing. 
It  is  no  use  quoting  the  rude  health  of  savages. 
Mrs.  Savage  has  not  to  clothe  her  offspring; 
nor  have  a  washing  day,  nor  go  shopping.  The 
modem  woman  can  get  all  sorts  of  appliances  for 
lessening  the  care  of  children,  but  no  one  has  yet 
borne  an  automatic  baby  whose  crying  could  be 
turned  off  and  sleep  turned  on.  "The  hand  that 
rocks  the  cradle  rules  the  world."  Well,  she  may 
have  an  ^automatic  hand  to  do  the  rocking,  but  the 
psychologists  have  already  condemned  rocking  as 
an  evil  practice.  Girls  can  refuse  to  have  babies. 
The  law  can  exert  no  compulsion,  but  that  would 
result  in  extinction  of  the  civilized  stock  and  domi- 
nation by  savage  tribes.  This  craze  to  do  man's 
work  will  end  in  the  emasculation  of  men.  This 
desire  to  figure  in  the  senate  "far  from  stiffening 
the  manly  calibre  of  weak  men  in  it  will  still  fur- 
ther enervate  them.  Women  should  have  a  house 
of  their  own,  wherein  to  foster  the  interests  of 
women  and  children  mainly."  [Members  of  either 
sex  are  not  capable  of  doing  their  best  work  while 
in  association  with  the  other.  Sex  rivalries  are 
.stirred,  sex  ascendancy  engendered.  Besides,  man 
inherits  from  his  mother  the  quotum  of  "woman 
apprehension,  foresight  and  altruism  required  to 
present  the  woman's  bent  and  viewpoint.  More  of  it 
would  be  superfluous."  The  author  thinks  the  huge 
numerical  preponderance  of  women  must  presently 
swamp  masculine  initiative  in  state  affairs,  unless 
the  political  functions  of  the  sexes  are  separated. 


470 


BOOK  REVIEWS. 


[New  York 
Medical  Journal. 


Also  that  women  are  swiftly  coming  up  abreast  of 
men  and  threaten  to  outdistance  them,  but  the  emo- 
tions and  devotions,  purity,  sweetness,  patience,  for- 
bearance, loveableness,  courtesies  and  graces  have 
fallen  out  of  culture.  The  yielding  by  man  to  the 
other  sex  of  masculine  essential  rights  and  obliga- 
tions is  a  symptom  of  declining  virility,  physical  and 
mental.  So  far  the  author  does  not  draw  flattering 
pictures.  Here  is  one  which  may  arouse  whole- 
some alarm : 

One  serious  aspect  of  feminism  is  that  woman  in 
gaining  mannishness  is  losing  beauty.  The  faces 
even  of  our  handsomest  women  are  preeminently 
bold,  sophisticated,  clever  without  sweetness. 
The  eyes  are  cold  and  critical  and  challenging.  The 
naturally  delicate  contours  of  chin  and  cheek  have 
deteriorated  to  the  crude  and  heavy  lower  jaws  of 
those  desexed  by  masculinity.  Our  schoolgirls  and 
workgirls  are.  biologically  speaking,  spoiled  copies 
of  men.  The  neuter  state  shows  in  the  faces  of 
many  women.  In  the  eyes  of  young  women  of 
strenuous  pursuits  the  characteristic  sterile  glint, 
part  boldness,  part  antagonism,  is  common. 

But  how  about  the  ultra  feminine  who  plunge 
in  violent  recoil  into  social  frivolities,  vani- 
ties, dissipations,  pranks,  intrigues,  excesses? 
.Two  extreme  camps  are  being  formed,  the  mannish 
and  strenuous  and  the  overfeminized  and  purpose- 
less, more  or  less  idle  and  frivolous,  selfishly  ab- 
sorbed in  clothes,  in  luxury  and  pleasure ;  exacting 
masculine  tribtite  in  mind  and  kind,  and  since  ever\' 
privilege  is  shared  by  both  sides — liberty,  latchkeys 
and  general  latitude.  Between  the  two  extremes 
stand  the  natural,  noble  and  invaluable  moderates, 
normal  women  content  to  be  normal  women  and  to 
fulfil  the  destined  role  of  such.  Man,  however, 
seems  to  prefer  the  feminist. 

There  are  other  evils  growing.  Our  school  and 
college  girls  make  heroes  of  their  own  sex  who  ex- 
cel in  manly  sports,  they  worship  the  man  in  them ; 
also  strong  attachments  between  the  sexes,  man  for 
man,  w^oman  for  woman,  are  intensifying.  Women 
are  attracted  by  mannish  traits  in  their  sex.  men  by 
efTeminate  men  who  possess  feminine  traits  of  sym- 
pathy and  sentiment.  Both  sexes  are  lapsing  to- 
wards a  neuterdom,  evidence  of  sex  decline.  The 
present  day  decline  in  parental  impulse  and  affec- 
tion shows  it.  To  quote  Havelock  Ellis:  "These 
weak  chinned,  neurotic  young  men  are  no  match  at 
all  for  the  heavy  jawed  resolute  young  women  fem- 
inist methods  are  creating.  The  yielding  to  women 
of  masculine  rights  is  a  symptom  of  declining  vir- 
ility. Equality  in  all  things  yielded,  pride  in  him- 
self, in  his  work,  gone,  he  will  descend  to  the  state 
of  the  decadent  savage  who  keeps  as  many  wives  to 
work  for  him  as  their  work  for  him  enables  him  to 
keep." 

^loreover.  overworked  woman  may  impair  the 
constitutional  vigor  of  man.  while  she  works  with 
him.  She  is  kept  up  by  nervous  excitement,  by 
strong  tea  or  drugs.  In  short,  woman  is  fussy.  In 
a  stress  of  work  she  will  work  on  with  crimson 
cheeks  and  growing  irritation,  while  man  will  put 
on  his  hat  and  calmly  resort  to  the  nearest  lunch 
room.  Women  by  their  eternal  high  pressure  as 
heads  of  departments  are  making  nervous  wrecks 


of  the  men.  "Nervous  depletion  caused  by  work- 
ing wives  has  doubtless  much  to  do  with  the  inani- 
tion and  depression  now  crippling  our  industrial 
output." 

Can  the  man  keep  his  chivalry  and  meet  the  wo- 
man on  equal  terms  ?  He  will  still  see  her  as  mother, 
wife  or  love  (mistress).  He  cannot  disregard  her 
involuntary  looking  to  him  for  aid.  How  it  will  be 
when  men  realize  what  feminism  means  we  cannot 
tell.  Women's  abnormal  mentality  added  to  their  im- 
pulsiveness impels  them  to  break  loose  from  those 
bonds  of  affection,  tradition  and  aspiration  which 
are  their  safeguards.  Power,  which  steadies  all  but 
weak  men,  too  often  drives  women  to  destruction. 

So  far  we  have  quoted  the  author  in  giving  her 
fears  for  the  future.  What  does  she  w^ant?  She 
would  have  the  sexes  work  in  unison  but  in  differ- 
ent areas,  apart  from  and  independent  of  the  other. 
Women  are  to  bear  children,  suckle  them,  rear 
them,  and  those  who  have  none  are  to  aid  them  in 
securing  what  every  child  should  have.  The  w^ork 
a  mother  has  to  do  in  pregnancy  should  not  tend  to 
damage  the  child.  The  question  of  abolishing  the 
legal  contract  in  marriage  deals  slashing  blows  at 
modern  ideas.  If  love  is  the  sole  bond  then  the 
waning  of  love  must  release  from  the  bondage.  But 
we  doubt  if  any  man  will  want  to  marry  the  terrible 
mannish  woman.  "More  and  more  the  hidden  male 
emerges  from  the  female  wreckage."  Woman  has 
been  striving  after  masculinity  all  these  years.  She 
has  gained  the  gift,  but  at  a  tremendous  price. 

It  would  take  many  pages  to  give  an  idea  of  IMiss 
Kenealy's  book.  She  deals  with  the  evolution  of 
sex,  the  female  brain,  sex  instincts ;  how  feminist 
doctrines  and  practice  destroy  womanly  attributes, 
morale  and  progress.  There  is  much  that  is  true 
and  the  present  attitude  of  young  men  confirms  it, 
but  we  cannot  see  the  terrible  results  foretold ; 
rather,  woman  should  be  considered  drunk  with  her 
new  power,  of  which  she  will  tire  when  she  is  re- 
quired to  face  man's  obligations  as  well  as  his  priv- 
ileges. 

 ^  

New  Publications  Received. 


\lVe  publish  full  lists  of  books  received,  but  we  acknowl- 
eage  no  obligation  to  rez-iezv  them  all.  Nevertheless,  so 
far  as  space  permits,  we  reviezv  those  in  which  we  think 
our  readers  are  likely  to  be  interested.] 


ANNUAL  REPORT  OF  THE  DEPARTMENT  OF  HE.\LTH.     City  of 

Newark,  N.  J.  (Department  of  Public  Affairs).  Illustrated. 
Newark :  The  Essex  Press.    Pp.  ix-240. 

THE   FOUR   JUST   MEN.      B3'   EdGAR  WaLLACE.   Author  of 

The  Clue  of  the  Twisted  Candle,  The  Secret  House.  Green 
Rust,  etc.    Boston :  Small,  Maj-nard  &  Co.    Pp.  i-310. 

VACCINATION  IN  THE  TROPICS.     By  W.  G.  KiND,  C.  I.  E., 

Colonel.  I.  M.  S.  (Retired)  :  Late  Sanitary  Commissioner 
with  the  Government  of  Madras,  and  Superintendent  Gen- 
eral of  Vaccination  and  Inspector  General  of  Civil  Hos- 
pitals in  Burma.  Illustrated.  London :  Tropical  Diseases 
Bureau,  1920.   Pp.  vi-64. 

THE  de\'elopment  OF  THE  HUMAN  BODY.  A  Manual  of 
Human  Embryolog>'.  By  J.  Playfair  McMurrich,  A.  M., 
Ph.  D.,  LL.  D.,  Professor  of  Anatomy  in  the  University 
of  Toronto;  Formerly  Professor  of  Anatomy  in  the  Uni- 
versity of  Michigan.  Sixth  Edition,  Revised  and  Enlarged. 
Illustrated.  Philadelphia:  P.  Blakiston's  Son  &  Co.,  1920. 
Pp.  X-50L 


Practical  Therapeutics  and  Preventive  Medicine 

A  Compendium  of  Treatment  and  Prophylaxis,  Original  and  Adapted 


Intravenous  Mercuric  Iodide  in  Syphilis. — R. 
L.  Spittel  (Lancet,  February  14,  1920),  working 
on  the  assumption  that  intravenous  mercurj'  and 
iodide  would  give  even  more  favorable  results  in 
conjunction  with  arsenic  preparations  than  does 
the  intramuscular  medication,  has  given  over  four 
thousand  injections  of  the  following  preparation 
into  the  vein  during  the  last  four  years : 


Mercuric  iodide  50  grains 

Sodium — or  potassium — iodide,  8  dr. 

Phenolphthalein,  0.5  per  cent,  sol  20  minims 

Sodium  hydrate,  25  per  cent,  sol  about  2  dr. 

Distilled  water  to  40  oz. 


The  sodium  hydrate  is  added  last  and  slowly. 
When  the  neutral  point  is  reached  it  is  put  in  drop 
by  drop  until  a  clear  pink  color  is  reached.  The 
solution  keeps  indefinitely  but  tends  to  become  de- 
colorized. It  may  always  be  restored  to  normal  by 
the  addition  of  more  sodium  hydrate. 

Eight  to  twelve  c.c.  of  this  solution,  diluted  to 
twice  the  amount  and  filtered,  is  the  dose  to  be 
given  into  the  vein.  The  reaction  to  small  doses 
is  little  or  none,  but  if  larger  doses  are  given  chills, 
fever,  and  abdominal  pains  with  diarrhea  may  re- 
sult. The  symptoms  of  mercurialism  must  of 
course  be  watched  for.  The  results  of  such  injec- 
tions are  much  quicker  than  when  the  ordinary 
methods  are  used,  both  from  the  standpoint  of  the 
\\  assermann  reaction  and  from  the  effects  on  syphi- 
litic lesions.  The  course  of  treatment  consists  of 
five  or  six  injections  of  salvarsan  and  a  similar 
number  of  mercuric  iodide  injections  given  every 
seven  to  ten  days,  alternately  or  in  whatever  se- 
quence seems  best.  Prolonged  treatment  with  mer- 
cury by  mouth  or  inunction  should  be  continued  for 
a  year  or  so  even  if  the  serological  test  is  negative, 
as  a  matter  of  precaution. 

Frontal  Sinus  Drainage. — Max  Unger  (Ameri- 
can Journal  of  Surgery,  ]May,  1920)  employed  the 
following  technic  in  frontal  sinus  drainage:  The 
nasal  mucosa  is  anesthetized  and  the  frontal  sinus 
is  probed.  The  probe  is  first  used  by  itself  to  de- 
termine the  size  and  the  direction  of  the  fronto- 
nasal opening.  If  the  opening  is  obstructed  by  the 
middle  turbinate  this  must  be  removed.  The  size 
and  direction  of  the  opening  having  been  ascer- 
tained, the  probe  is  then  pushed  through  the  lumen 
of  the  proper  sized  catheter  to  its  end.  The  probe, 
encased  in  the  catheter,  is  then  reinserted  in  the 
frontal  sinus.  The  catlieter  is  held  looselv  bv 
the  fingers  of  one  hand  and  the  probe  is  gently 
withdrawn  by  the  other,  leaving  the  catheter  in  situ. 
The  catheter  is  then  grasped  near  its  entrance  into 
the  opening  with  a  nasal  forceps  and  pushed  further 
into  the  frontal  sinus  as  far  at  it  will  easily  go.  Be- 
ing flexible  it  will  pass  over  projections  that  will 
block  a  metal  catheter.  The  lower  end  of  the  cathe- 
ter is  then  cut  off  intranasally,  so  that  the  remaining 
portion  rests  on  the  floor  of  the  nose.  At  the  end 
of  this  procedure  there  is  then  left  a  tube  about  two 
and  a  half  inches  in  length,  extending  from  the  floor 


of  the  nose  up  into  the  frontal  sinus.  This  tube  is 
left  in  place  for  one  to  two  days,  when  it  is  removed 
and  replaced  by  another.  Before  the  tube  is  re- 
placed the  sinus  can  be  irrigated.  The  catheter  is 
cut  three  and  a  half  inches  long  to  begin  with  be- 
cause its  lower  end  will  then  project  from  the  nose 
after  its  tip  is  in  the  sinus  and  furnish  a  place  for 
holding  it  when  the  carrying  probe  is  withdrawn.  If 
linen  or  silk  catheters  are  used,  they  should  be 
dipped  into  hot  water  before  being  inserted  into  the 
nose,  in  order  to  make  them  softer. 

Intravenous  Injection  of  Hypertonic  Glucose 
Solution  in  Chronic  Nephritis  with  Azotemia. — 
F.  Rathery  and  H.  Boucheron  (Bulletins  et  me- 
moircs  de  la  Societe  medicate  des  hopitaux  de 
Paris,  January  22,  1920)  calls  attention  to  the  fact 
that  in  chronic  nephritis  with  nitrogen  accumulation 
in  the  blood  intravenous  injection  of  thirty  per 
cent,  glucose  solution  fails  to  exert  its  usual  diur- 
etic effect.  Careful  clinical  tests  showed  that  such 
injections  caused,  in  these  cases,  a  diminution  of 
urinar\-  output,  including  that  of  total  nitrogen, 
urea,  sodium  chloride,  and  ammonia.  In  two  pa- 
tients with  pronounced  azotemia  the  latter  was 
made  considerably  worse  by  the  measure,  and  in 
one  case  with  moderate  azotemia  the  blood  urea 
was  temporarily  increased.  These  changes  were 
often  more  marked  two  or  three  days  after  the  glu- 
cose injection  than  on  the  next  day. 

Surgical  Treatment  of  Acute  Empyema  by 
Valve  Drainage. — \\  illiam  Reid  Morrison  (Bos- 
ton Medical  and  Surgical  Journal,  April  8,  1920) 
sums  up  as  follows  the  advantages  of  valve  drain- 
age :  An  indirect  valve  opening  is  made  in  the  chest. 
A  valve  made  of  the  living  tissues  is  the  most  effi- 
cient type  because  it  does  not  get  out  of  order; 
mechanical  valves  in  aspirating  trocars,  and  devices, 
such  as  a  rubber  dam  pasted  on  three  sides  of  a 
wound,  are  less  desirable.  In  cases  of  pneumococ- 
cus  and  mixed  infection,  masses  of  fibrin,  detritus 
and  pus  are  readily  removed.  The  gloved  finger  is 
able  to  break  up  any  recently  formed  adhesions 
which  may  anchor  the  lung  and  prevent  its  expan- 
sion. Foreign  bodies,  if  any,  may  be  extracted. 
Collapse  of  the  lung,  mediastinal  flapping  and 
pneumothorax  may  be  avoided,  with  more  rapid 
convalescence,  avoiding  chronic  empyema.  He  fur- 
ther says  that  no  empyema  should  be  operated  on  be- 
fore a  careful  consultation  with  the  medical  man 
in  charge  of  the  case.  Too  early  or  too  late  opera- 
tion is  to  be  avoided ;  the  duration,  extent  and  vir- 
ulence of  the  process  in  the  lung,  embarrassment 
of  respiration  from  large  amounts  of  fluid,  and 
progress  of  the  case  are  the  factors  that  influence 
the  surgeon's  judgment.  Local,  combined  with 
paravertebral  injection,  is  the  anesthetic  of  choice. 
In  pneumococcus  cases,  valve  drainage  with  pleu- 
rotomy  or  rib  resection  with  indirect  drainage  of 
the  chest  may  be  used  to  advantage.  In  strepto- 
coccus cases,  partictilarly  in  hemolj-tic  streptococcus 


472 


PRACTICAL   THERAPEUTICS  AND  PREVENTIVE  MEDICINE.  [New  York 

Medical  Journai. 


infection,  Kenyon's  tube,  with  or  without  suction, 
or  repeated  aspirations,  may  be  of  value,  allowing 
no  air  to  enter  the  chest.  The  surgical  treatment 
should  be  supplemented  by  careful  attention  to  a 
high  caloric  diet,  principally  milk  and  raw  eggs  for 
the  first  few  days.  Medication  in  the  form  of  digi- 
talis leaves  or  other  cardiac  stimulants  to  tide  over 
the  lung  infection,  morphine  for  pain,  tincture  of 
nux  vomica  as  an  appetizer,  and  later  iron  are 
given  as  indicated.  Good  nursing,  warmth,  and 
fresh  air  are  essential.  Early  bottle  blowing  and 
later  proper  gymnastic  exercises  are  desirable  to 
stimulate  lung  and  chest  expansion  and  prevent  de- 
formity. A  half  sitting  position  aids  respiration 
and  drainage  after  operation.  A  direct  opening 
into  the  pleural  cavity  should  not  be  made  in  acute 
empyemata.  The  writer  has  not  been  favorably 
impressed  by  the  use  of  serological  treatment. 

General  Anesthesia. — A.  R.  Egafia  (Scniana 
Mcdica,  April  29,  1920)  sums  a  lengthy  article  by 
stating  that  for  short  operations,  where  absolute 
muscular  relaxation  is  not  necessary,  nitrous  oxide 
and  oxygen  is  the  anesthetic  of  choice.  He  prefers 
Gwathmey's  apparatus  as  it  conforms  to  the  condi- 
tions required,  namely,  easy  graduation  of  the  pro- 
portion of  the  gases,  valves  of  easy  access,  easy  and 
rapid  utilization  of  ether  when  required,  and  warm- 
ing of  the  anesthetic  vapor. 

Where  muscular  relaxation  is  imperative  and  es- 
pecially in  abdominal  surgery,  the  nitrous  oxide- 
ether  sequence  is  the  best.  Chloroform  owing  to 
its  dangers  is  inferior  to  ether,  with  which,  how- 
ever, it  may  be  readily  combined. 

The  open  or  semiopen  method  of  administering 
ether  is  advisable  except  when  the  intrapharyngeal 
route  is  necessitated,  as  in  operations  on  the  neck, 
the  face,  the  skull  or  in  the  ventral  position.  The 
intratracheal  route  is  useful  in  operations  on  the 
thorax,  while  rectal  administration  of  ether  in  a 
five  per  cent,  solution  in  oil  is  quite  feasible. 

Severe  Cerebral  Toxemia  After  Intravenous 
Novarsenobillon. — R.  J.  G.  Parnell  and  S.  F. 
Dudley  {Lancet,  January  24,  1920)  report  a  case 
of  secondary  syphilis  which  was  being  treated  with 
this  arsenic  compound.  The  first  dose  was  0.45 
gm.  producing  no  reaction  and  the  second,  0.9  gm. 
given  four  days  later  produced  no  reaction  until 
fifty-six  hours  after  injection  into  the  vein.  The 
patient  began  to  vomit  and  during  the  next  three 
days  he  had  a  series  of  seven  epileptiform  convul- 
sions with  unconsciousness,  biting  of  the  tongue, 
incontinence  of  urine  and  feces,  together  with  a 
macular  eruption  on  the  skin,  marked  cyanosis  and 
failing  pulse.  Adrenalin  injections,  calomel  in 
hourly  doses,  and  lumbar  puncture  failed  to  re- 
lieve the  symptoms,  so  oxygen  inhalations  were 
given  to  corribat  the  evident  anoxemia  and  caflfein 
0.2  gm.  with  urotropin  1.5  gm.  in  15  c.c.  of  sterile 
distilled  water  was  given,  in  accordance  with  the 
work  of  H.  Michel,  to  relieve  the  maniacal  state, 
probably  through  the  great  diuresis  resulting.  Five 
hours  after  the  injection  was  begun  and  the  oxygen 
inhalations  were  started  the  patient  had  become 
entirely  rational  and  thereafter  made  an  uneventful 
recovery,  though  he  suffered  from  a  partial  amnesia 
for  fourteen  days. 


Treatment  of  Tuberculous  Glands  of  the  Neck. 

—A.  W  iese  Hammer  {Medical  Council.  June, 
1920)  thinks  that  not  every  case  demands  surgical 
interference.  In  cases  where  the  aflfection  seems 
to  recede  at  times  the  patients  recover  under  proper 
hygienic  treatment  supplemented  by  medical  meas- 
ures. X  ray  treatments  tend  to  produce  fibrous  tis- 
sue which  is  a  serious  obstacle  to  operation  at  a 
later  date.  In  obstinate  cases  operative  measures 
offer  two  great  advantages,  viz.,  the  prevention  of 
sinus  formation  and  of  unsightly  cicatricial  forma- 
tion and  the  elimination  of  tuberculous  infection 
from  the  body.  Operation  to  be  successful  must 
be  radical ;  partial  removal  is  useless.  The  usual 
incision  is  along  the  whole  posterior  length  of  the 
sterno  mastoid  muscle  from  the  mastoid  process  to 
the  clavicle.  Hammer  prefers  incisions  which  fol- 
low the  circular  furrows  on  the  neck,  thus  leaving 
far  less  unsightly  scars  than  by  the  linear  methods 
of  incision.  In  any  incision  the  skin  and  platysma 
are  reflected,  bringing  the  sterno  mastoid  into  view, 
which  is  then  divided.  Great  care  must  be  exer- 
cised against  injuring  the  internal  jugular  vein,  and 
the  occurrence  of  air  embolism.  The  glands  are 
stripped  by  blunt  dissection  from  the  subclavian 
and  internal  jugular  veins,  and  from  the  space  pos- 
terior toward  the  trapezius  muscle,  care  being 
taken  not  to  wound  the  thoracic  duct. 

Chlorine  Antiseptic.  —  Walter  Estell  Lee 
{Annals  of  Surgery,  June,  1920)  gives  the  clinical 
uses  of  sodium  hypochlorite,  chloramine-T,  and 
dichloramine-T  as  follows : 

1.  The  direct  germicidal  effect  of  all  the  chlorine 
antiseptics  is  dependent  upon  the  liberation  of  their 
chlorine  and  the  combination  of  this  chlorine  with 
bacterial  protein. 

2.  The  rapidity  with  which  the  hypochlorite  solu- 
tions liberate  their  chlorine  necessitates,  in  order 
to  avoid  the  destruction  of  living  tissues,  the  pres- 
ence of  large  masses  of  available  protein  (devital- 
ized tissues  and  profuse  wound  exudate)  or  the 
use  of  such  dilute  solutions  that  a  safe  margin  in 
the  relative  masses  of  the  active  chlorine  and  avail- 
able protein  is  insured.  Thus  the  usable  strengths 
of  hypochlorite  solutions,  which  should  be  less  than 
0.5  per  cent.,  liberate  such  a  small  mass  of  chlorine 
that  their  direct  germicidal  effect  is  almost  negligi- 
ble. But,  unlike  the  other  chlorine  antiseptics,  they 
exert  a  very  definite  indirect  germicidal  effect  by 
the  formation  of  hydroxides  which  act  as  solvents 
of  the  culture  material  provided  by  devitalized 
tissues  and  wound  exudate. 

3.  The  synthetic  chloramines  are  more  stable 
compounds  of  chlorine  than  the  hyprochlorites  and 
therefore  can  be  used  in  greater  concentrations  or 
larger  germicidal  masses.  They  act  practically  as 
reservoirs  from  which  chlorine  is  slowly  and  auto- 
matically given  off  as  the  tissues  present  the  neces- 
sary reacting  substances. 

4.  The  hypochlorite  solutions  are  indicated  where 
there  are  large  masses  of  dead  and  devitalized 
tissues  or  profuse  tissue  exudate  which  cannot  be 
removed  by  mechanical  means.  They  should  not 
be  used  where  such  as  are  not  present  or  applied 
to  tissues  poorly  supplied  with  blood,  tendons  or 
cartilage. 


September  25,  1920.]         PRACTICAL  THERAPEUTICS   AXD  PREVENTIVE  MEDICINE. 


473 


5.  The  chloramines  are  indicated  where  there  is 
but  Httle,  if  any,  dead  tissue,  and  where  the  wound 
exudate  is  moderate  in  amount.  Their  only  value 
is  as  a  germicide.  When  in  the  human  tissues,  they 
slowly  liberate  their  chlorine  over  a  period  of  from 
three  to  twenty-four  hours  and  in  sufificient  quanti- 
ties to  automatically  unite  with  the  bacterial  and 
other  proteins  presented  by  the  wounds. 

Operation  for  Urethral  Strictures. — Stern 
{International  Journal  of  Surgery,  April,  1920) 
states  that  as  all,  or  nearly  all,  strictures  occur  an- 
terior to  the  superficial  layer  of  the  triangular  liga- 
ment, this  operation  can  easily  reach  them.  Extra- 
vasation of  urine  or  infiltrating  abscesses  are  not  to 
be  feared  in  a  surgical  procedure  which  does  not  dis- 
turb the  membranous  or  i^rostatic  urethra  lying 
posterior  to  the  triangular  ligament.  An  operation 
which  is  directed  precisely  to  the  diseased  area,  and 
which  does  not  inflict  injury  to  any  other  part  of 
the  urethra,  must  be  conceived  as  a  logical  step  to 
a  cure,  and  as  superior  to  procedures  heretofore 
in  vogue. 

High  Forceps  Operation ;  Version  and  Caesarean 
Section.  —  William  B.  Doherty  {International 
Journal  of  Surgery,  April,  1920)  believes  that 
Caesarean  section  is  rapidly  gaining  favor  in  the 
management  of  labor  in  the  presence  of  pelvic  dis- 
tortion among  the  most  conservative  obstetricians 
and  surgeons,  yet  in  these  borderline  cases,  unless 
there  is  a  marked  neurotic  and  debilitated  condition 
of  the  woman,  it  is  better  that  she  go  into  labor 
and  the  measures  advocated  be  attempted  before 
resorting  to  the  Caesarean  operation.  With  capable 
surgeons  and  m^ernity  hospitals  which  can  now 
be  reached  in  a  few  minutes  and  the  improved 
technic  which  obtains,  the  chances  for  the  safety  of 
the  woman  and  her  child  in  a  case  of  pelvic  con 
traction  are  far  better  than  they  were  a  few  years 
ago. 

The  Clinical  Importance  of  Anatomical  Anoma- 
lies in  Biliary  Surgery. — Daniel  X.  Eisendrath 
(Boston  Medical  and  Surgical  Journal,  June  3, 
1920)  says  that  recent  anatomical  studies  have 
shown  that  the  normal  angular  mode  of  union  of 
the  cystic  and  hepatic  ducts  is  present  in  only 
seventy-five  per  cent,  of  the  cases ;  that  the  cystic 
artery  is  a  single  structure  and  has  its  generally 
accepted  origin  in  only  about  eighty-eight  per  cent. ; 
and  that  there  are  two  cystic  arteries  in  twelve  per 
cent,  of  individuals.  He  describes  with  illustra- 
tions the  variations  in  the  relation  of  the  right  he- 
patic artery  to  the  main  hepatic  duct ;  variations  of 
the  gastroduodenal  artery ;  anomalies  in  origin  of 
a  single  cystic  artery;  relation  of  a  single  cystic 
artery  to  the  main  hepatic  duct ;  two  cystic  arteries 
which  may  both  arise  from  the  right  hepatic,  one 
from  the  right  hepatic  and  one  from  the  gastroduo- 
denal artery,  one  from  the  right  hepatic  and  the 
other  from  the  main  hepatic,  or  both  from  the  left 
hepatic ;  variations  in  the  course  and  mode  of  union 
of  the  cystic  and  hepatic  ducts,  and  variations  in 
the  hepatic  ducts.  Some  of  these  variations  in  an- 
atomical structure  are  of  much  importance,  for  their 
presence  may  give  rise  to  accidents  during  opera- 
tion. 


Treatment  of  Fracture  of  the  Ulna  with  Dis- 
location of  the  Head  of  the  Radius. — C.  Dujarier 
and  P.  Mathieu  (Paris  medical,  April  10,  1920), 
from  experience  with  a  personal  case  and  study  of 
the  literature,  have  reached  the  conclusion  that  re- 
duction of  the  radial  head  alone  in  recent  cases,  is 
not  always  followed  by  a  sufficient  degree  of  reduc- 
tion of  the  ulnar  fracture,  so  that  actual  osteosyn- 
thesis is  advisable ;  indeed,  persistent  shortening  of 
the  ulna  would  in  itself  predispose  to  recurrence  of 
the  radial  dislocation.  Reduction  of  the  ulnar  frac- 
ture alone  does  not  generally  result  in  reduction  of 
the  radial  dislocation.  The  capsule  often  becomes 
interposed  beneath  the  radial  head,  requiring  opera- 
tion upon  the  humeroradial  joint.  Evidently  two 
operations,  one  upon  the  radial  dislocation  and  the 
other  upon  the  ulnar  fracture,  are  required  in  these 
cases.  Abadie  thinks  that  the  reduction  of  the  ul- 
nar fracture  should  precede  the  rduction  of  the  lux- 
ation, the  latter  being  facilitated  by  the  former  pro- 
cedure. The  authors  believe,  however,  that  in  re- 
cent fractures,  i.  e.,  fractures  in  which  the  ulna  is 
not  yet  in  process  of  consolidation  in  a  faulty  posi- 
tion, it  is  well  first  to  reduce  the  radial  head  by 
arthrotomy,  remove  any  interposed  portion  of  cap- 
sule, and  restore  the  joint  by  capsulorrhaphy.  Re- 
duction and  fixation  of  the  ulnar  fracture  are  there- 
by greatly  simplified.  In  long  standing  cases,  in 
which  the  ulna  has  healed  in  a  faulty  position,  with 
angular  deformity  and  overriding,  it  would  per- 
haps be  better  to  begin  by  liberating  the  ulnar  frag- 
ments, next  reduce  the  radial  luxation,  and  finally 
proceed  to  operative  fixation  of  the  ulna.  Resec- 
tion of  the  head  of  the  radius  should  not  be  re- 
sorted to  until  after  an  open  restoration  of  the  joint 
has  been  attempted. 

Application  of  War  Methods  to  Civil  Practice. 
— A.  Bowlby  (Lancet,  January  17,  1920)  discusses 
the  significance  of  the  surgical  discoveries  of  the 
war  as  regards  treatment  in  civil  practice.  Shock, 
being  due  in  part  to  privations  suffered  by  the  sol- 
dier before  injury,  is  not  so  frequently  found  in 
civil  life  but  when  it  is  present  it  must  be  treated 
with  warmth,  fluids,  rest,  and  morphine.  It  must 
be  guarded  against  by  the  proper  care  of  the  patient 
during  the  peribd  of  temporary  treatment  as  with 
splints,  to  prevent  further  damage  of  tissue  or  un- 
necessary pain  during  transportation.  It  is  pos- 
sible to  train  orderlies  to  prepare  a  fractured  femur 
for  transportation  with  the  Thomas  outfit  more 
suitably  than  the  trained  surgeon  could  have  done 
it  before  the  war.  If  the  patient  be  in  shock  and 
vmable  to  retain  fluids  by  mouth,  rectal  adminis- 
tration is  indicated,  as  fluids  absorbed  by  the  gastro- 
intestinal mucosa  are  of  more  lasting  benefit  than 
those  put  into  the  vein.  In  extremis,  however,  in- 
travenous fluids  are  necessary  and  in  the  opinion 
of  the  writer,  six  per  cent,  gum  arable  solution  in 
saline  is  the  most  useful  of  all  except  blood  itself. 

Where  anesthesia  must  be  used  shortly  after  re- 
covery from  the  more  urgent  symptoms  of  shock, 
it  was  found  that  ether,  though  unlikely  to  cause 
pulmonary  conditions  or  vomiting  when  warmed, 
did  produce  a  dangerous  and  prolonged  lowering 
of  blood  pressure.  The  most  satisfactory  results 
were  obtained  with  nitrous  oxide  and  oxygen  com- 


474 


PRACTICAL  THERAPEUTICS  AND  PREVENTIVE  MEDICINE. 


[New  York 
Medical  Journal. 


bined  with  local  infiltration  of  the  incision  region, 
particularly  in  abdominal  operations. 

The  advance  in  treatment  of  fractures  is  summed 
up  in  the  statement  that  during  the  last  half  of  the 
war,  fractures  were  treated  by  suspension  and  ex- 
tension so  that  the  circulation,  nourishment,  and 
mobility  of  the  extremity  were  maintained  as  far 
as  possible.  Regarding  wound  infections,  the  points 
emphasized  are,  1,  the  uselessness  of  antiseptics  in 
grossly  infected  wounds ;  2,  the  importance  of  ex- 
cision of  damaged  tissues  around  the  wound  with 
either  primary  or  delayed  primary  suture;  3,  the 
great  danger  of  secondary  infection  of  the  wound 
if  not  quickly  sutured ;  4,  the  value  of  irrigation,  as 
by  the  Carrel  method  if  properly  carried  out,  in 
the  cure  of  suppurating  wounds. 

Electrical  Osmosis  of  the  Eye. — Roux,  P. 
Girard,  and  Morax  (Paris  medical,  April  10,  1920) 
report  experimental  work  in  which  a  cup  containing 
solution  of  salt  was  placed  as  positive  electrode 
over  the  cornea  of  a  rabbit  and  a  negative  electrode 
placed  over  the  back  of  the  neck.  Upon  passing  a 
current,  increased  intraocular  tension  results  if  the 
solution  in  the  cup  contains  magnesium  sulphate. 
If,  on  the  other  hand,  the  solution  is  one  of  barium 
chloride,  reduction  of  intraocular  tension  occurs 
and  the  eye  shrivels.  The  opposite  eye  and  the  eyes 
of  another  animal  were  used  as  controls.  The  au- 
thors hope  by  application  of  this  principle  to  obtain 
useful  therapeutic  efifects  in  certain  eye  afifections. 

Splints  Used  for  Peripheral  Nerve  Cases  at  the 
U.  S.  Army  General  Hospital  No.  ii. — Robin  C. 
Bureki  (Archives  of  Neurology  and  Psychiatry, 
February,  1920)  reports  that  at  Army  Gen- 
eral Hospital  No.  11  it  was  decided  that  the 
splints  which  had  been  applied  in  the  nerve  cases 
had  numerous  disadvantages.  They  were  heavy 
and  cumbersome  and  in  a  large  number  of  cases 
were  retarding  rather  than  aiding  recovery.  With 
these  faults  in  mind,  each  lesion  was  studied  from 
the  standpoint  of  splints,  and  a  special  group  of 
splints  was  designed  for  each  type  of  case.  These 
were  then  tried  out  and  the  one  found  by  actual 
practice  to  be  the  more  satisfactory  was  adopted  as 
a  standard  splint  for  a  given  lesion. 

Transplantation  of  Kidney  'and  Ovary. — 
Carleton  Dederer  (Surgery,  Gynecology  and  Ob- 
stetrics. July,  1920)  presents  the  following  conclu- 
sions from  experimental  transplant. 

1.  A  homotransplanted  kidney  during  twenty-six 
days  has  passed  the  same  functional  tests  as  are 
required  of  normal  kidneys. 

2.  In  dogs  of  the  same  litter  a  homotransplanted 
kidney  and  ovary  lived  for  twenty-six  days.  Path- 
ological examination  showed  that  the  organs  reacted 
to  the  severe  constitutional  infection,  distemper,  in 
a  manner  similar  to  that  in  which  the  animal's  own 
organs  reacted. 

3.  Phenolsulphonephthalein  after  being  injected 
into  the  external  saphenous  vein  began  to  be  ex- 
creted from  a  homotransplanted  kidney  in  two  min- 
utes and  forty  seconds. 

4.  It  is  possible  in  making  a  homotransplantation 
of  the  kidney  to  get  a  satisfactory  arterial  anasto- 
mosis by  suture  when  the  renal  artery  is  less  than 
a  millimetre  in  diameter. 


Submucous  Resection  of  Nasal  Septum. — W. 

D.  Dunning  (American  Journal  of  Surgery,  May 
1920)  states  that  the  advantage  of  the  submucous 
operation  over  other  operations  for  deflection  are : 

1.  That  no  mucous  membrane  has  been  destroyed. 

2.  That  spurs  and  deflections  have  been  entirely 
removed  with  the  thickening  of  the  septum. 

3.  That  the  ridge  of  cartilage  which  is  wedged 
in  between  the  lateral  cartilage  has  not  been  inter- 
fered with,  and  there  is  absolutely  no  danger  of  a 
falling  or  saddleback  nose. 

Mercury  in  the  Treatment  of  Syphilis. — Louis 
D.  Smith  (Illinois  Medical  Journal,  May,  1920) 
has  used  mercurosal  (or  disodium  mercuri  salicyl- 
acetate)  with  satisfactory  results.  This  salt  is  de- 
rived from  mercuric  acetate  and  salicylacetic  acid 
and  contains  forty-four  per  cent,  metallic  mercury 
by  weight.  He  has  demonstrated  that  this  prepa- 
ration, in  a  dosage  of  five  c.c.  containing  over  one- 
half  grain  of  mercury,  answers  the  question  of 
mercury  medication  very  well,  as  by  its  use  it  is 
possible  to  employ  a  larger  dosage  of  mercury  more 
safely  and  more  painlessly  than  by  any  other 
method. 

The  Use  of  Radium  in  Gynecology. — William 
C.  Gewin  (Southern  Medical  Journal,  July,  1920) 
says  that  radium  is  the  treatment  of  choice,  a,  in 
cases  of  menorrhagia  of  menopause  not  associated 
with  large  fibroid  tumors  and  in  which  the  possi- 
bility of  carcinoma  has  been  eliminated ;  b,  in  cases 
of  menorrhagia  in  patients  between  thirty-five  and 
forty  years  of  age  who  have  small  mucous  fibroid 
tumors  without  malignacy ;  c,  in  cases  of  myoma  in 
which  operation  is  contraindicated ;  d,  in  cases  of 
menorrhagia  in  young  persons  resistant  to  all  medi- 
cal treatment,  and  in  all  cases  with  a  malignant  ten- 
dency ;  after  operations  for  cancer ;  in  all  inoperable 
cancers  to  relieve  pain,  eradicate  odor  and  stop 
hemorrhage.  Radium  will  render  operable  many 
inoperable  cases,  and  is  practically  the  only  means 
of  relief  in  cases  of  recurrent  carcinoma  of  the 
uterus. 

Value  of  Radium  in  the  Treatment  of  Bladder 
Tumors. — J.  T.  Gerachty  (Southern  Medical  Jour- 
nal, July,  1920)  says  that  while  benign  and  malig- 
nant papilloma  and  the  early  papillary  carcinoma 
disappear  under  the  influence  of  radium,  the  infil- 
trating types  have  proved  very  resistant  to  this 
agent.  Therefore,  when  the  infiltrating  character 
of  the  growth  has  been  determined,  and  when  the 
tumor  is  sufificiently  localized  to  permit  of  complete 
removal,  he  performs  a  radical  resection.  Follow- 
ing the  removal  of  an  infiltrating  papillary  carci- 
noma, cystoscopy  should  be  done  at  an  early  date, 
as  the  not  infrequent  recurrences  will  yield  prompt- 
ly in  many  instances  to  radium,  notwithstanding 
the  resistance  of  the  primary  tumor.  The  use  of 
radium  has  not  diminished  the  tendency  of  bladder 
tumors  to  recur,  but  the  recurrence  responds  to  ra- 
dium in  most  cases.  Radium  has  proved  to  be  a 
valuable  aid  in  the  treatment  of  bladder  tumors, 
and,  while  the  results  obtained  in  the  infiltrating 
types  are  far  from  satisfactory,  improved  technic 
whereby  more  intensive  radiation  may  be  safely 
accomplished  offers  a  more  encouraging  outlook 
in  the  future  handling  of  these  cases. 


Proceedings  of  National  and  Local  Societies 


BRITISH  MEDICAL  ASSOCIATION. 

Eighty-eighth  Annual  Meeting,  Held  June  25,  1920, 
at  Cambridge,  England. 

{Concluded  from  page  432.) 

SECTION   IN    MEDICAL  EDUCATION 
The  President,  Sir  George  Newman,  in  the  Chair. 

President's  Address. — Sir  George  Newman, 
chief  adviser  to  the  Ministry  of  Health,  said  that 
the  establishment  of  clinical  teaching  units  was 
but  an  expression  of  the  growth  of  integration.  The 
clinical  unit  was  merely  a  matter  of  convenient  ar- 
rangement by  which  three  general  advantages  were 
secured.  1.  The  clinical  teacher  devoted  a  regular 
and  substantial  portion  of  his  time  to  his  teaching 
work  and  instead  of  being  casual,  secondary,  or 
spasmodic,  it  became  his  chief  task ;  for  the  student 
instruction  in  clinical  medicine  and  surgery  was 
thus  systematized,  thorough,  and  always  available. 
2.  The  unit  consisted  of  a  staff  of  competent  men 
working  as  a  team  who  pooled  their  experience — 
the  physician,  the  assistant  physician,  the  resident 
physician  and  the  house  physician,  wards,  outpa- 
tient department,  laboratory,  auxiliary  departments 
for  special  forms  of  treatment,  all  in  a  composite 
unit.  3.  There  was  full  integration  of  the  science 
and  art  of  medicine  and  surgery,  the  teaching  of 
which  could  thus  be  raised  to  university  standard. 
There  was  the  association  of  research  with  study, 
and  the  study  itself  was  intimate  and  intensive;  it 
should  comprehend  Sir  James  Mackenzie's  sub- 
jective and  associated  phenomena,  it  should  investi- 
gate the  mechanism  of  symptoms,  and  it  should  fol- 
low end  results  back  to  their  origins.  At  Edin- 
burgh there  were  seven  surgeons,  with  Sir  Harold 
Stiles  as  Regius  professor  of  clinical  surgery,  he 
himself  an  assistant  surgeon,  a  clinical  tutor,  and 
a  house  surgeon.  The  unit  contained  forty-four 
beds,  outpatients,  and  laboratory  accommodation. 
The  work  of  the  week  comprised  ward  clinics,  sys- 
tematic clinical  lectures,  tutorial  classes,  and  opera- 
tions. 

Sir  George  said  that,  speaking  generally,  the  main 
reforms  needed  in  the  medical  curriculum  were  four  : 
1.  A  lightening  of  the  curriculum  at  both  ends;  in 
other  words,  fuller  preparation  in  science  before  en- 
trance to  the  medical  school,  and  a  postponement  of 
instruction  in  certain  specialties  and  in  general  prac- 
tice to  the  postgraduate  period  in  order  to  provide 
continued  education  of  the  qualified  man,  teaching 
which  required  organization  on  the  basis  of  pro- 
fessoriate, hospital,  laboratory  and  clinical  experi- 
ence, which  may  well  be  organized  in  such  coopera- 
tive practitioner  clinics  as  those  devised  by  Sir 
James  Mackenzie  at  St.  Andrews.  This  question 
of  lightening  without  lengthening  the  curriculum 
was  of  cardinal  importance.  Much  of  our  trouble 
arose  from  the  overloaded  condition  of  the  five 
years.  There  was  insufficient  time  allowed  for  true 
study,  for  digestion  and  assimilation.  He  sug- 
gested several  remedial  steps  and  remarked  that  the 
true  criterion  of  training  in  medicine  was  equipment 
for  life,  not  preparation  for  an  examination.  2.  A 


fuller  study  of  the  sciences  preliminary  to  medicine 
dnd  a  nearer  application  of  these  subjects  to  clinical 
work.  Above  all,  there  was  great  need  for  biology, 
anatomy  and  physiology.  3.  Development  of  clin- 
ical teaching  of  university  standard,  particularly  in 
relation  to  the  beginnings  of  disease,  the  child  and 
the  outpatient ;  the  science  of  prevention ;  the  closer 
integration  of  various  forms  of  clinical  practice  and 
of  clinical  with  intermediate  study ;  concentration  on 
the  protean  diseases  of  tuberculosis,  malaria,  vene- 
real and  malignant  diseases ;  an  understanding  of 
the  social  side  of  therapeutics,  environment,  diet, 
occupation  and  the  use  of  physical  agents,  as  well  as 
the  social  aspects  of  disease.  Some  of  this  should 
clearly  come  after  graduation.  4.  There  was  need 
of  further  state  aid,  though  with  a  minimum  of 
state  control.  The  cost  of  proper  medical  train- 
ing had  now  risen  beyond  the  means  of  the  aver- 
age man  and  yet  it  was  in  the  interest  of  the  state 
to  secure  well  equipped  doctors.  To  provide  a 
satisfactory  medical  education  there  were  needed : 
a,  better  teachers  and  better  paid  teachers ;  b,  clinical 
units ;  c,  improved  laboratory  accomtnodation  and 
better  equipment ;  d,  an  extension  of  hospital  and 
clinic  facilities  for  teaching.  All  this  meant  money 
and  organization,  both  of  which  had  been  lacking  in 
the  past.  The  education  of  the  medical  man  was 
no  -  longer  merely  a  professional  interest.  It  was 
of  national  concern,  for  the  health  of  the  people 
was  the  principal  asset  of  the  state.  Sir  George  said 
that  while  some  advocate  removal  of  preliminary  sci- 
ence from  the  curriculum,  he  was  convinced  that  it 
was  more  essential  than  ever.  Physics,  chemistry  and 
biology  were  key  subjects,  absolutely  fundamental. 
Newman  was  particularly  insistent  upon  the  claims 
of  biology.  The  two  chief  needs  of  English  medi- 
cine were  a,  the  full  integration  of  its  several 
branches  and  constituent  parts,  and  b,  its  new  re- 
lationship to  sociology.  Man  was  a  social  animal 
and  all  disease  had  its  social  aspect.  The  student 
must  be  taught  this,  he  must  learn  to  use  his  stock 
of  knowledge  socially  as  well  as  logically.  The 
great  problems '  which  would  face  him  in  practice 
had  a  social  setting — tuberculosis,  infant  mortality, 
rickets,  physical  impairment,  venereal  diseases,  heart 
disease,  mental  abnormality,  all  bore  a  highly  com- 
plex relation  to  society,  industry  and  government. 

Mr.  Sydney  J.  Hickson,  F.  R.  S.,  professor  of 
zoology  in  the  University  of  Manchester,  made 
some  caustic  remarks  with  regard  to  the  standard 
of  general  education  of  medical  students.  He  de- 
clared that  the  real  difficulty  with  all  English  sci- 
ence classes  in  the  first  year  of  medical  study  is 
caused  by  a  minority,  but  often  a  substantial 
minority,  of  students  with  a  lower  standard  of 
school  education.  Too  many  students  were  en- 
tered by  the  medical  schools  whose  vocabulary  and 
facility  in  composition  were  not  sufficient  to  en- 
able them  to  .profit  by  the  lecture  system,  or  to 
express  what  little  they  had  learned  in  a  written 
examination.  Further,  and  still  more  important, 
many  students  did  not  possess  a  mind  trained  to  re- 
member or  to  think.  It  was  these  students  who  acted 


476 


PROCEEDINGS  OF  NATIONAL   AND  LOCAL  SOCIETIES. 


[New  York 
Medical  Journal. 


as  a  drag  upon  the  machine  and  so  hindered  the 
development  of  medical  courses  in  science  on  the 
lines  which  would  be  most  useful  for  medical  men. 
The  first  step  in  this  direction  was  to  insist  that  the 
lowest  standard  accepted  for  registration  should  Ije 
that  of  the  matriculation  examination  of  the  British 
universities.  The  five  years'  study  of  a  medical 
student  was  not  enough  to  enable  him  to  grasp  all 
the  knowledge  that  it  was  desirable  or  even  neces- 
sary for  him  to  have  as  a  qualified  man. 

Mr.  Arthur  Keith,  F.  R.  S.,  Hunterian  pro- 
fessor, Royal  College  of  Surgeons  of  England, 
thought  it  was  not  the  student  who  was  at  fault  but 
the  teachers  and  that  the  problem  to  be  faced  was 
not  how  to  improve  the  education  of  the  medical 
student  but  how  to  educate  and  reform  his  teachers. 
In  fact  the  real  problem  to  be  solved  was  how  a 
staff  of  specialist  teachers  was  to  produce  an  army 
of  effective  medical  practitioners.  Mr.  Keith 
thought  the  specialist  teacher  should  keep  up  his 
knowledge  of  general  medicine  and  that  at  the  great 
medical  schools  every  teaching  anatomist  and  phys- 
iologist should  have  to  hold  occasional  clinical  ap- 
pointments up  to  their  thirty-fifth  year.  In  seven 
cases  out  of  ten  the  practitioner  could  not  make  a 
diagnosis  unless  he  knew  the  exact  situation  and 
action  of  the  multitude  of  parts  which  made  up  the 
human  body.  But  when  we  turned  to  our  text- 
books of  anatomy  we  found  that  less  than  half  of 
their  pages  were  devoted  to  a  study  of  the 
action  and  uses  of  parts.  It  was  not  ,  so 
in  the  early  textbooks,  they  were  keys  to  the  liv- 
ing body.  Textbooks  now  were  masses  of  descrip- 
tion. Our  examination  papers  were  a  weari- 
some repetition  of  "describe"  this  and  "describe" 
that,  as  if  a  student  could  apply  pure  description  in 
practice,  or  obtain  any  assistance  from  it  in  the  di- 
agnosis, treatment,  or  prevention  of  disease.  Here 
again  the  reform  must  lie  with  the  teachers. 

Professor  Sir  E.  Rutherford,  F.  R.  C,  was  of 
the  opinion  that  as  large  a  proportion  as  possible  of 
medical  students  should  receive  a  sound  training 
of  honors  standard  in  pure  science  before  or  during 
their  more  professional  studies.  The  best  method 
of  dealing  with  the  present  unsatisfactory  situation 
seemed  to  require  a  preliminary  knowledge  of  sci- 
ence, and  particularly  of  physics  and  chemistry,  be- 
fore admission  as  a  medical  student.  This  prelimi- 
nary training  could  best  be  given  in  the  schools, 
where  instead  of  being  concentrated  in  a  brief 
course  two  years  or  so  might  be  devoted  to  gaining 
a  sound  knowledge  of  some  branches  of  physics 
and  chemistry.  The  element  of  time  was  of  great 
importance  in  gaining  a  grasp  of  scientific  princi- 
ples, and  for  this  the  present  university  training 
was  much  too  concentrated. 

Dr  J.  Lorrain  Smith,  professor  of  pathology 
at  the  University  of  Edinburgh,  stated  that  in  gen- 
eral the  present  curriculum  was  wasteful  of  the 
students'  time  because  it  gave  a  general  introduc- 
tion to  the  sciences  but  left  it  to  the  later  teachers 
or  the  students  themselves  to  apply,  the  principles 
and  methods  of  these  sciences  in  the  various 
branches  of  medicine.  A  continuity  of  teaching 
would  concentrate  the  intellectual  effort  and  would 
attain  with  much  more  certainty  the  standard  of 


work  which  the  curriculum  was  designed  to  reach. 

Mr.  Arthur  Smithells,  F.  R.  S.,  professor  of 
chemistry  at  the  University  of  Leeds,  criticized 
severely  the  cram  system  of  preparing  medical  stu- 
dents for  the  work  of  medicine.  He  pointed  out 
that  a  conventional  syllabus  had  been  created  and 
the  subject  had  been  scheduled,  with  the  inevitable 
results.  The  teacher  was  put  in  bonds  and  in  one 
way  or  another,  irrespective  of  his  own  views  and 
methods,  must  prepare  the  student  for  the  pre- 
scribed test  as  applied  by  any  appointed  outside 
person.  The  examination  became  the  goal,  the  syl- 
labus the  beaten  track,  and  the  spirit  of  true  study 
took  flight.  Medical  students  should  be  taught  some 
chemistry  at  school,  but  the  teachers  of  chemistry 
should  be  men  of  experience,  possessing  a  wide 
outlook. 

SECTION    IN    pathology   AND  BACTERIOLOGY 
The  President,  Professor  J.  Lorrain  Smith,  M.  D.,  F.  R.  S. 
in  the  Chair. 

Present  Position  of  Cancer  Research. — Dr.  J. 

A.  MURR.A.Y.  in  a  further  discussion  of  the  >;uhiert 
observed  that  for  some  investigators  the  conviction 
was  gradually  gaining  ground  that  knowledge  of 
the  fundamental  processes  of  cell  life  was  not  yet 
sufficiently  advanced  for  the  special  purpose  of 
cancer  research.  The  cancer  cell  was  in  some  way 
different  from  the  cells  of  the  same  kind  among 
which  it  originated.  The  nature  of  the  change  was 
still  unknown.  It  was  probably  thoroughgoing 
and  in  most  instances  of  a  surprising  degree  of 
permanence.  All  the  differences  which  had  been 
foimd  thus  far  between  cancer  cells  and  those  of 
adult  tissues  could  be  paralleled  in  rapidly  grow- 
ing tissues  of  the  embryo.  Cancerous  tissue,  for 
example,  contained  more  water  of  imbibition  than 
adult  tissue,  and  the  most  rapidly  growing  tumors 
had  the  highest  proportion  of  water  to  solids.  In 
consequence  some  slowly  growing  tumors  were 
found  to  be  less  watery  than  testis  and  embryonic 
tissues.  The  differences  in  this  respect  were  not 
absolute,  so  that  no  one  could  say  that  no  cancer 
had  less  than  a  certain  percentage  of  water  and 
below  this  level  were  ranged  all  normal  tissues, 
embryonic  and  adult. 

The  line  of  investigation  which  was  being  pur- 
sued at  present  was  the  study  of  normal  and  tumor 
cells  by  culture  outside  the  body.  Murray  was  of 
the  opinion  that  when  technical  improvements  had 
increased  the  flexibility  of  this  method  it  should 
provide  a  powerful  means  of  attack  on  the  funda- 
mental problems  of  the  disease.  At  present  the 
technical  difficulties  made  the  mere  achievement  of 
maintaining  tissue  cultures  something  of  a  tour  de 
force.  The  one  positive  character  of  new  growths 
was  their  progressive  proliferation  uninfluenced  by 
the  forces  limiting  the  increase  of  the  elements  of 
healthy  or  diseased  tissues.  The  transplantable 
tumors  of  laboratory  animals  presented  this  prob- 
lem. The  subtlety  of  the  cellular  derangement  and 
its  close  contact  with  the  fundamental  problems 
of  biology  gave  an  atmosphere  of  adventure  to 
every  attempt,  however  indirect  it  might  seem, 
which  human  ingenuity  devised  to  elucidate  the  har- 
monies and  contradictions  which  lay  on  every  side 
of  the  problem  of  cancer. 


New  York  Medical  Journal 

INCORPORATING  THE 

Philadelphia  Medical  Journal  "'e  Medical  News 

A  Weekly  Review  of  Medicine,  Established  18^3. 

Vol.  CXII.  No.  14.  NEW  YORK.  SATURDAY.  OCTOBER  2.  1920.  Whole  No.  ■21>^i. 

Original  Communications 


THE    IXFLUEXXE   OF    THE    COLOR  OF 
URINE  OX  READINGS  OF  THE  PHEXOL- 
SULPHONEPHTHALEIN  TEST.* 

By  Victor  Cox  Pedersex,  A.  M..  M.  D..  F.  A.  C.  S., 

Xfw  York. 

The  aim  of  this  paper  is  to  accoimt  for  the  fif- 
teen per  cent,  apparent  loss  of  dye,  indicated  by 
the  readings  of  the  scale,  between  the  usual  maxi- 
mum of  eighty-five  per  cent,  of  the  material  excret- 
ed by  the  patient  in  two  hours  and  the  one  hundred 
per  cent,  of  the  phenolsulphonephthalein  that  has 
been  injected.  So  far  as  a  research  of  literature 
reveals,  this  question  has  never  been  fully  studied, 
perhaps  because  the  practical  results  have  been  re- 
garded as  good  enough  without  settlement  of  this 
doubt. 

I  thought  that  much  of  this  fifteen  per  cent, 
would  be  found  absorbed  by  the  color  of  the  urine 
in  such  a  way  that  a  reliable  percentage  table  could 
be  evolved  for  the  various  colors  of  urine  as  given 
by  Vogel's  scale.  Such  tables  would  permit  the 
readings  to  be  brought  to  nearly  an  absolute  total 
instead  of  as  at  present  an  indicated  total  with  an 
error  of  about  fifteen  per  cent.  It  was  a  great  sur- 
prise, however,  as  shown  hereinafter,,  to  find  that 
the  darker  the  color  of  the  fluid  tested  the  higher 
the  percentage  of  error  in  the  reading. 

The-  factor  responsible  is  that  of  color  alteration 
or  combination,  so  that  one  cannot  really  match 
the  beautiful  reddish  purple  of  the  alkalized  phenol- 
sulphonephthalein test  solution  with  the  same  qual- 
ity of  reddish  purple  in  the  urine,  because  the 
latter  is  materially  altered  by  the  urinary 
pigments.  In  fact,  therefore,  the  test  is  in 
very  large  degree  one  of  judging  the  intensitj'  of 
two  colors  nearly  alike  but  never  absolutely  alike 
in  tone  or  quality. 

The  possible  sources  of  destruction  of  a  portion 
of  the  dye  are  metabolism,  excretion,  technic  and 
vision.    Each  of  these  factors  requires  discussion. 

The  metabolic  or  physiological  factors  presup- 
pose destruction  of  this  fifteen  per  cent,  of  the  dye 
in  the  liver  or  elsewhere  in  the  body.  Several 
authors  suggest  this  explanation  but  literature 
records  no  experiments  in  support  or  denial  of  it. 
It  is,  of  course,  quite  certain  that  at  least  some 
loss  of  this  kind  occurs,  but  the  amount  is  probably 
amazingly  small. 

'Read  before  the  annual  meeting  of  the  American  Urological 
Association.  March  23-25,  1920. 


The  excretory  factors  establish  that  after  the 
second  hour  of  the  ordinary  test  very  little  of  the 
dye  is  recovered.  Of  course  if  only  fifteen  per 
cent,  would  remain  it  could  not  be  accurately  read 
except  by  the  author's  (1)  method  of  subdilution 
and  computation.  Several  years  ago  I  carried  on 
a  number  of  experiments  which  were  never  pub- 
lished. They  tended  to  show  that  during  the  twenty- 
four  hours  following  the  test  the  percentage  of 
dye  was  very  hard  to  measure  unless  the  total  ex- 
cretion during  the  first  two  hours  was  relatively 
low.  As  an  average  very  little  dye  was  recovered 
after  the  fourth  hour  of  the  test.  If  these  obser- 
vations were  correct  one  may  say  that  the  entire 
excretion  is  over  on  an  average  of  four  hours. 

The  technical  factors  to  account  for  the  loss  of 
the  fifteen  per  cent,  of  dye  are  important  and 
comprise  chiefly  losses  during  injection  and  devia- 
tions between  measures.  Elsewhere  (2)  I  have 
stated :  "It  must  be  remembered  that  a  cubic 
centimetre  is  about  sixteen  minims  and  that  the 
loss  of  one  drop  is  an  error  of  nearly  seven  per 
cent,  and  two  drops  one  of  nearly  fourteen  per 
cent."  Carelessness  will,  therefore,  easily  account 
for  nearly  fifteen  per  cent.  Deviations  between 
measures  include  those  between  the  graduations  of 
the  cubic  centimetre  making  the  standard  solution 
and  those  of  the  cubic  centimetre  syringe  making 
the  injection.  These  variations  might  again  account 
for  ten  or  fifteen  per  cent.  As  pointed  out  in  the 
same  paragraphs  of  the  paper  just  referred  to  the 
following  is  important:  "In  order  to  avoid  error  in 
reading,  exactly  the  same  quantity  must  be  used  in 
making  up  the  control  or  comparison  solution,  which 
.should  be  accomplished  by  using  the  same  syringe 
for  measuring  the  fluid  for  the  container  as  for  the 
vein." 

\'isual  factors  comprise  the  variations  in  eyes 
from  individual  to  individual  and  sometimes  be- 
tween the  two  eyes  of  one  individual,  in  the  per- 
ception of  grades  of  color,  absorption  of  color,  hue 
of  color,  intensity  of  color  and  the  like.  As  just 
stated  the  whole  matter  of  reading  the  scale  is  the 
estimate  of  comparative  intensity  of  slightly  or 
greatly  different  colors  rather  than  of  depth  of 
identity  colors.  Of  course,  the  error  in  the  eyes  of 
a  given  observer  is  a  constant  factor  of  error  for 
himself.  Such  error  could  not  greatly  aff^ect  clin- 
ical judgment  of  his  cases  unless  more  or  less  defi- 
nite color  blindness  was  present.  For  example, 
eyes  which  are  five  or  ten  per  cent,  above  or  below 


Copyright.  1920.  by  A.  R.  Elliott  Publishing  Company. 


478 


PEDERSEN:    PHENOLSULPHONEPHTHALEIN  TEST. 


[New  York 
Medical  Journal. 


the  Standard  of  color  vision  will  hardly  affect  the 
interests  of  the  patients,  because  all  such  a  surgeon's 
reading  for  all  his  patients  will  contain  the  same 
five  or  ten  per  cent,  of  error,  which  thus  practically 
eliminates  itself. 

It  may  be  said  that  absorption  error  is  different 
because  all  eyes,  normal  or  otherwise,  will  have  no 
escape  from  this  error.  In  illustration,  if  that  er- 
ror in  dark  urines  is  an  addition  of  ten,  fifteen  or 
twenty  per  cent,  then  a  patient  excreting  absolutely 
only  twenty  per  cent.,  during  the  first  hour  will  be 
credited  with  readings  of  thirty,  thirty-five  or 
forty  per  cent,  which  are  close  to  the  normal  mini- 
mum for  the  first  hour.  Again  if  his  absolute 
excretion  is  forty  per  cent.,  then  his  readings  will 
be  advanced  to  fifty,  fifty-five  or  sixty  per  cent, 
which  again  are  practicalh-  the  normal  maximum 
for  the  first  hour.  Again  a  urine  with  a  positive 
yellow  like  No.  3  of  the  Vogel  scale  will  give  much 
the  same,  although  perhaps  slightly  lower  errors. 
The  tables  of  this  paper,  however,  show  that  there 
is  very  little  difference. 

In  brief,  this  question  of  color  absorption  in  this 
article  is  somewhat  analogous  to  the  difficulties  of 
reading  small  percentages  except  by  the  author's 
method  of  subdilution  and  computation  described  in 
the  paper  (2)  already  quoted,  in  these  words: 
"Those  who  have  done  much  of  this  work  are  fa- 
miliar with  the  fact  that  the  most  convenient  read- 
ings on  the  colorimeter  are  from  about  thirty  per 
cent,  upward,  and  with  the  fact  that  below  thirty 
per  cent,  the  colors  are  so  pale  as  to  make  it  almost 
impossible  to  read  percentages  within  five  per  cent, 
of  error,  which  has  been  accepted  as  the  standard 
of  accuracy.  By  my  method  of  subdilution  I  feel 
that  far  more  accurate  readings  may  be  obtained. 
The  steps  are  as  follows:  When  the  quantity  of  dye 
in  a  specimen  is  obviously  little,  instead  of  raising 
this  excretion  to  the  dilution  of  1,000  c.  c,  it  is 
raised  only  to  a  prime  factor  of  1,000 — for  example, 
50,  100,  200  or  250  c.  c.  The  reading  is  then  taken 
and  must  obviously  be  divided  by  the  number  of 
times  which  the  prime  factor  of  subdilution  is  con- 
tained in  1,000  which,  following  the  foregoing 
prime  factors  in  the  order  given,  would  make  the 
divisors  20,  10,  5  or  4,  and  then  if  the  method  of 
subdivision  had  been  followed  this  reading  must  be 
again  multiplied  by  two  to  reach  the  correct  result.  A 
good  eye  for  color  with  the  aid  of  these  procedures 
will  make  the  reading  almost  absolutely  accurate." 

The  question  of  error  through  color  absorption 
or  combination  is  in  a  degree  academic  when  one 
considers  the  large  amount  of  excellent  work  done 
with  the  phenolsulphonephthalein  test  as  it  stands. 
The  matter  has  a  practical  value  of  even  greater  de- 
gree when  one  considers  the  borderline  or  doubtful 
cases  in  which  a  patient's  urine  may  give  a  readmg 
showing  an  indicated  excretion  of  fifty  per  cent,  but 
through  its  having  a  dark  color  may  have  an  abso- 
lute excretion  of  only  thirty  per  cent.  Such  a  pa- 
tient might  be  subjected  to  operation  and  perish 
because  of  this  variation  between  his  indicated  and 
absolute  excretion.  Every  urologist  has  had  pa- 
tients who  died  notwithstanding  a  seemingly  fa- 
vorable phenolsulphonephthalein  reading.  One 
cause  may  be  this  color  absorption  error  in  the  test 
and  subsequent  judgment  therefrom.    The  average 


report  does  not  note  or  respect  the  color  of  the 
urine.  Highly  pathological  urine  is  usually  largely 
altered  in  color. 

It  may  be  urged  that  chemical  hematology  of  the 
blood  for  its  content  of  urea,  uric  acid,  creatinin, 
sugar,  chlorides  and  the  like  is  an  almost  infallible 
check  on  all  this  work.  I  always  employ  it  with 
great  satisfaction.  It  should  never  be  omitted  even 
in  apparently  favorable  cases  and  is  essential  in  all 
borderline  cases.  Unfortunately,  however,  much 
modern  kidney  surgery  must  be  done  away  from 
laboratories  equipped  for  this  work.  If,  therefore, 
the  detection  and  correction  of  a  color  absorption 
error  will  aid  the  surgeon  who  cannot  reach  such  a 
laboratory  quickly,  much  practical  value  should  be 
the  result.  This  fact  again  emphasizes  the  great 
practical  value  of  this  entire  matter. 

Irr  the  following  observation  caution  was  taken 
to  eliminate  even  small  errors  in  measuring,  mixing, 
readings,  the  Heliger  colorimeter  and  my  own  eyes. 
Each  of  these  five  matters  deserves  separate  notice. 

The  measuring  contained  the  following  checks. 
The  same  litre  measure  was  used  throughout  and 
accurately  levelled.  The  alkali  was  dumped  in  first 
to  avoid  addition  to  the  1,000  c.  c.  of  the  stock  or 
the  test  solution  or  urine.  The  same  syringe  (one 
c.  c.  capacity)  graduated  in  tenths  was  used  to  make 
all  stock  solutions  and  all  additions  from  small  to 
high  percentages.  The  drop  was  washed  off  the 
needle  into  the  stock  or  test  solutions,  thus  avoiding 
the  approximate  seven  per  cent,  of  error  by  its 
loss,  previously  discussed.  The  test  cup  was  always 
dumped  back  into  the  litre  graduate  to  avoid  de- 
crease below  the  1,000  c.  c.  Subdilution  by  the 
author's  method  was  not  employed  except  in  the 
tables  where  so  stated,  because  it  was  thought  that 
the  average  reader  would  prefer  to  have  every  test 
brought  up  to  1,000  c.  c.  These  tables,  as  given, 
were  really  control  tests.  Mixing  was  felt  to  require 
pouring  the  stock  and  test  fluid  from  the  litre  gradu- 
ate into  a  pitcher  and  back  three  or  four  times.  The 
majority  of  the  fluids  were  so  alkaline  as  to  be  slip- 
pery to  the  finger  and  the  color  unquestionably  uni- 
form. 

Readings  were  felt  to  demand  the  following 
checks :  A  white  light  such  as  is  used  in  microscopy 
was  very  serviceable  because  it  did  not  add  to  the 
reddish  or  yellow  color  of  the  test  fluid.  The  test 
wedge  was  not  changed  on  the  scale  until  the  read- 
ing of  one  test  was  compared  with  the  next  pre- 
ceding test.  Thus,  for  example,  the  reading  for 
twenty  per  cent,  was  compared  with  forty  per  cent., 
and  forty  with  sixty  and  sixty  with  eighty  before 
the  wedge  was  changed  in  position  to  make  an  inde- 
pendent reading  for  the  newer  and  higher  percentage. 
Binocular  vision  was  less  tiresome  than  monocular. 
Very  often  the  scale  was  set  at  the  point  of  known 
strength  of  the  test  fluid,  say  sixty  per  cent.,  on 
the  chance  that  the  reading  would  be  correct.  In 
not  one  instance,  however,  was  the  reading  cor- 
rect, but  always  too  low,  showing  that  the  indicated 
percentage  was  much  higher  than  the  absolute  con- 
tent in  the  fluid.  Where  double  readings  occur  in 
the  tables  it  means  that  the  eyes  were  shut,  quickly 
opened  and  a  slightly  different  reading  obtained. 

As  a  test  of  my  own  vision  the  wedge  of  the 
Heliger  colorimeter  was  filled  with  properly  pre- 


October  2,  1920.] 


PEDERSEN:   PHEXOLSULPHOXEPHTHALEIN  TEST. 


479 


pared  stock  solution,  well  alkalinized  and  containing 
a  cubic  centimetre  of  phenolsulphonephthalein.  Then 
a  thousand  c.  c.  of  well  alkalinized  distilled  water 
were  taken.  To  these  were  added  (from  the  same 
syringe  as  was  used  in  making  up  the  foregoing 
stock  solution)  phenolsulphonephthalein  ascending 
from  one  tenth  c.  c.  to  one  c.  c.  A  reading  of  the 
scale  was  taken  at  each,  one  tenth  c.  c.  added  and  all 
readings  were  found  to  be  without  error  in  the  scale 
for  each  known  quantity  of  dye.  This  test  not  only 
proved  my  own  perception  of  color  to  be  very  good 
but  established  the  accuracy  of  my  colorimeter. 

In  the  following  tables  of  readings  in  the  ordei 
given  distilled  water  was  used  artificially  colored  to 
imitate  closely  numbers  4,  3,  2  and  1  of  the  Vogel 
scale.  The  work  was  begun  with  the  dark  fluids  on 
the  ground  that  error  would  be  greatest  in  them. 

Tables  numbered  1  and  2  were  the  first  made. 
Ordinary  electric  light  was  used,  which,  although 
not  white,  did  not  seem  to  change  the  readings 
greatly  from  those  of  all  other  tables  which  were 
made  with  artificial  or  solar  white  light. 

The  stock  solution  for  comparison  is  1,000  c.  c. 
of  distilled  water,  alkalinized  with  fifteen  per  cent, 
sodium  hydroxide,  with  the  phenolsulphonephtha- 
lein added,  usually  one  c.  c.  or  in  larger  propor- 
tional amounts  such  as  one  and  one  tenth  or  one 
and  one  fifth  c.  c. 

TABLE  1". 

VOGEL'S  SCALE  4  REDDISH  YELLOW 


Stock  Solution 

1000  c.c.  of 
distilled  water 
alkalized  with 
15%  sodium 
hydroxide  with 
dye  as  stated 
below 


B 

Test  Fluid 

Fraction  of 

1  c.c.  of  dye 
in  1000  c.c. 
of  distilled 
water  alkal- 
ized with 
15%  sodium 
hydroxide 


CD  E 
Absolute         Indicated  Indicated 
per  cent.  per  cent.  Error 

Injected  into  By  readings  of 
test  fluid        the  Heliger 
colorimeter 


1  c.c. 

0.1 

10 

25-30 

15-20 

1  c.c. 

0.2 

20 

35-40 

15-20 

1  c.c. 

0.3 

30 

45-50 

15-20 

1  c.c. 

0.4 

40 

60 

20 

1  c.c. 

0.5 

50 

70 

20 

1  c.c. 

0.6 

60 

80 

20 

1  c.c. 

0.7 

70 

90 

20 

1  c.c. 

0.8 

80 

100 

20 

1.10  c.c. 

0.9 

90 

110 

20 

1.20  c.c. 

1.0 

100 

120 

20 

The  error 

runs 

between 

fifteen  and 

twenty  per 

cent,  and  is  most  significant  in  doubtful  cases  in  the 
readings  between  thirty  and  fifty  per  cent. 

TABLE  2. 


VOGEL  S  SCALE  3 
A  B 

Test  Fluid 


C 


Stock  Solution 

1000  c.c.  of 
distilled  water 
alkalised  with 

15%  sodium 
hydroxide  with 

dye  as  stated 
below 


Fraction  of 
1  c.c.  of  dye 
in  1000  c.c. 
of  distilled 
water  alkal- 
ized with 
15%  sodium 
hydroxide 


Absolute 
per  cent. 
Injected  into 
test  fluid 


DARK  YELLOW 
D 

Indicated 
per  cent. 
By  readings  of 
the  Heliger 
colorimeter 


E 

Indicated 
Error 


1  c.c. 

0.1 

10 

20 

10 

1  c.c. 

0.2 

20 

30 

10 

1  c.c. 

0.3 

30 

40 

10 

1  c.c. 

0.4 

40 

50 

10 

1  c.c. 

0.5 

50 

60-62  ■ 

10-12 

1  c.c. 

0.6 

60 

70 

10 

1  c.c. 

0.7 

70 

78-80 

8-10 

1  c.c. 

0.8 

80 

90 

10 

1  c.c. 

0.9 

90 

97-100 

7-10 

1  c.c. 

1.0 

100 

110 

10 

»  My  chemist,.  M.  F.  Schlesinger,  A.  B.,  M.  Ph.,  informs  me 
that  he  used  for  Vogel's  scale  4  and  dark  colors  a  saturated 
solution  of  Bismarck  brown  and  for  Vogel's  scale  3  and  lighter 
colors  a  saturated  solution  of  potassium  bichromate.  It  may  be  well 
for  any  other  observer  desirous  of  repeating  these  tests  to  use  the 
same  dyes. 


The  error  averages  about  ten  per  cent.  Like  that 
in  Table  1  it  is  important  in  the  middle  of  the  scale 
for  borderline  cases. 

The  tables  from  3  forward  were  made  with 
white  light.  This  fact  tends  to  account  for  many 
double  readings.  Likewise  when  many  tests  are 
made  consecutively  the  eyes  weary  and  lose  decision. 


T.\BLE 
VOGEL'S  SCALE  4 


REDDISH  YELLOW 


A 

B 

C 

D 

E 

Stock  Solution 

Test  Fluid 

Absolu  te 

Indicated 

Indicated 

per  cent. 

per  cent. 

Error 

1000  c.c.  of 

Fraction  of 

Injected  in 

'o  By  readings  of 

distilled  water 

1  c.c.  of  dye 

test  fluid 

the  Heliger 

alkalised  with 

in  1000  c.c. 

colorimeter 

15%  sodium 
hydroxide  with 

of  distilled 

water  alkal- 

dye as  stated 

ized  with 

below 

15%  sodium 

.  hydroxide 

5-10 

1  c.c. 

0.1 

10 

15-20 

1  c.c. 

0.2 

20 

35-40 

15-20 

1  c.c. 

0.4 

40 

55-60 

15-20 

1  c.c. 

0.6 

60 

78-80 

18-20 

1  c.c. 

0.8 

80 
TABLE 

95-100 

4. 

15-20 

CONTROL  OF  TABLE 

3            METHOD  OF  SUBDILUTION 

A 

B 

C 

D 

E 

Stock  Solution 

Test  Fluid 

Absolu  te 

Indicated 

Indicated 

per  cent. 

per  cent. 

Error 

1000  c.c.  of 

Fraction  of 

Injected  in 

to  By  readings  of 

distilled  water 

1  c.c.  of  dye 

test  fluid 

the  Heliger 

alkalized  with 

in  250  c.c. 

colorimeter 

15%  sodium 

of  distilled 

hydroxide  with 

water  alkal- 

4 c.c.  of  dye 

ized  with 

15%  sodium 
hydroxide 

4  c.c. 

0.1 

10 

15-20+ 

S-10 

4  c.c. 

0.2 

20 

30-40 

10-20 

4  c.c. 

0.4 

40 

60  -f 

20 

4  c.c. 

0.6 

60 

70-80 

10-20 

4  c.c. 

0.8 

80 

90-100 

10-20 

To  demonstrate  the  question  of  this  paper  with- 
out multiplying  detail,  rom  Table  3  forward  only 
alternate  percentages  up  to  eighty  will  "be  used.  In 
Tables  3  and  4  it  is  noticed  that  the  error  is  again 
close  to  twenty  per  cent,  in  the  midscale  readings. 
The  deep  color  of  subdilution  was  a  disadvantage 
and  control  tables  with  it  were  not  tried  further. 


Stock  Solution 

1000  c.c.  of 
distilled  water 
alkalised  with 
15%  sodium 
hydroxide  with 
dye  as  stated 
below 

1  c.c. 
1  c.c. 
1  c.c. 
1  c.c. 
1  c.c. 


TABLE 
VOGEL'S  SCALE  3 
B 

Test  Fluid 


DARK  YELLOW 


C  D 
Absolute  Indicated 
per  cent.  per  cent. 

Fraction  of   Injected  into  By  readings  of 


E- 

Indicated 
Error 


1  c.c.  of  dye 
in  1000  c.c. 
of  distilled 
water  alkal- 
ized with 
15%  sodium 
hydroxide 

0.1 

0.2 

0.4 

0.6 

0.8 


test  fluid 


10 

20 
40 
60 
80 


the  Heliger 
colorimeter 


20  ± 
30  ± 
50  ± 
70  ± 
90  ± 


10  ± 
10  ± 
10  ± 
10  it 
10  ± 


As  in  the  preceding  Table  2 
close  to  ten  per  cent. 

TABLE  6. 
VOGEL  S  SCALE  2 


the  error  is  very 


Stock  Solution 


B 

Test  Fluid 


1000  c.c.  of 
distilled  water 

alkalized  with  in  1000  c.c. 

15%  sodium  of  distilled 

hydroxide  with  water  alkal- 

dyc  as  stated  ised  with 

below  15%  sodium 
hydroxide 

1  c.c.  0.1 

1  c.c.  0.2 

1  c.c.  0.4 

1  c.c.  0.6 

1  c.c.  0.8 


C 

Absolute 
per  cent. 


YELLOW 
D 

Indicated 
per  cent. 


E 

Indicated 
Error 


Fraction  of   Injected  into  By  readings  of 
1  c.c.  of  dye     test  fluid        the  Heliger 
colorimeter 


10 
20 
40 
60 
80 


20 
30 
50 
65 
85 


10 
10 
10 
5 
S 


480 


PEDERSEN 


PHENOLSULPHONEPHTHALEIN  TEST. 


[New  York 
Medical  Journal. 


In  tables  4,  7  and  9,  instead  of  dividing  the  read- 
ings by  four  to  compensate  for  the  subdilution  250, 
the  stock  sohition  was  made  up  witli  four  c.  c.  of 
dye  and  thus  the  scale  readings  were  direct  and  not 
computed; 


CONTROL  OF  TABLE 

A  B 
Stock  Solution     Test  Fluid 


1000  c.c.  of 
distilled  water   1  c.c.  of  dye 
alkalized  with     iit  250  c.c. 
15'7<  sodium     of  distilled 
hydroxide  with  water  alkal- 
4  c.c.  of  dye      i~ed  with 

Ib^/r  sodium 
hydroxide 
4  c.c.  0.1 
4  c.c.  0.2 
4  c.c.  0.4 
4  c.c.  0.6 
4  c.c.  0.8 


TARLE  ;. 

METHOD  OF  SUBDILUTION 
CD  E 
Absolute         Indicated  Indicated 
per  cent.  per  cent.  Error 

Fraction  of   Injected  into  By  readings  of 


test  fluid 


10 
20 
40 
60 
80 


the  Heliger 
colorimeter 


25 

30/35 
45/50 
65  -f- 
85/87 


Stock  Solution 

1000  c.c.  of 
distilled  water 
alkalized  with 
15%  sodium 
hydroxide  with 
dye  as  stated 
below 

1  c.c. 
1  c.c. 
1  c.c. 
1  c.c. 
1  c.c. 


TABLE  8. 

VOGEL  S  SCALE  1  LIGHT  YELLOW 

B 

Test  Fluid 


C  D 
Absolute  Indicated 
per  cent.  per  cent. 

Fraction  of  Injected  into  By  readings  of 
1  c.c.  of  dye     test  fluid        the  Heliger 


15 
15 
10 

5+ 

7 


£ 

Indicated 
Error 


in  1000  c.c. 
of  distilled 
water  alkal- 
ized with 
15%  sodium 
hydroxide 

0.1 

0.2 

0.4 

0.6 

0.8 


10 
20 
40 
60 
.80 


colorimeter 


30 
30 
45 
65 


20 
10 
S 
5 
5 


CONTROL  OF  TABLE  8 
A  B 

Test  Fluid 


TABLE  9. 

METHOD  OF  SUBDILUTION 


Stock  Solution 

1000  c.c.  of  Fraction  of 

distilled  water  1  c.c.  of  dye 

alkalized  with  in  250  c.c. 

15%  sodium  of  distilled 

hydroxide  with  water  alkal- 

4  c.c.  of  dye  ized  with 

15%  sodium 
hydroxide 

4  c.c.  0.1 

4  c.c.  0.2 

4  c.c.  0.4 

4  c.c.  0.6 

4  c.c.  0.8 


C  D 
Absolute  Indicated 
per  cent.  per  cent. 

Injected  into  By  readings  of 


E 

Indicated 
Error 


test  fluid 


10 
20 
40 
60 
80 


the  Heliger 
colorimeter 


30 

35/40 
45/50 
65— 
85 


20 
15 
10 

5 
5 


Although  the  foregoing  results  seem  to  show  that 
the  apparent  error  in  readings  in  dark  fluids  is  be- 
tween fifteen  and  twenty  per  cent,  and  that  in  light 
fluids  between  ten  and  fifteen  per  cent,  the  follow- 
ing two  systems  of  controls  were  adopted :  The  full 
strength  method  and  the  dilute  method.  On  the  full 
strength  principle  1,000  c.  c.  of  plain  distilled  water 
solutions  were  taken,  injected  with  the  phenolsul- 
phonephthalein  from  one  tenth  c.  c.  to  eight  tenths 
c.  c.  and  readings  at  each  step  taken.  Necessarily 
these  were  all  normal.  As  each  step  was  taken  from 
one  fraction  to  the  next,  dye  was  injected  to  bring 
the  water  up  to  the  desired  Yogel's  scale  color  as 
.stated  in  the  tables  10,  11,  12  and  13.  A  fresh 
supply  of  water  was  used  each  time  and  the  read- 
ings taken  as  stated  with  the  resulting  indicated 
errors. 

By  the  dilution  plan  the  eighty  per  cent,  strength 
solution  was  made  at  once  just  as  in  the  foregoing 
procedure,  and  then  diluted  to  forty,  twenty  and 
ten  per  cent.  With  each  dilution  sufficient  dye  was 
added  to  maintain  the  proper  Vogel's  scale  color. 
As  in  the  fir.st  tables  all  these  measures  were  iden- 
tical and  thus  variations  avoided.  Tables  14,  15, 
16  and  17  show  these  tests. 


TABLE  10. 

VOGEL'S  SCALE  4  CONTROL  BY  FULL  STRENGTH  METHOD 

A                 B                 C                    D  E 

Distilled  water    Phenol-     Reading  before  Reading  after  Indicated  error 

c.c.            sulphone-       injecting          injecting  due  to  coloring 

phthalein         coloring           coloring  matter 
injected  c.c.  matter  V.S.  4    matter  V.S.  4 

1000              0.1                  10                20-25+  10-15 

1000              0.2                  20                30-35+  10-15 

1000              0.4                  40                50-55+  10-15 

1000             0.6                 60               70-75+  10-15 

1000              0.8                  80                90-95+  10-15 

TABLE  11. 

VOGEL'S  SCALE  3  CONTROL  BY  FULL  STRENGTH  METHOD 


A 

B 

C 

D 

E 

illed  water 

Phenol- 

Reading  before 

Reading  after  Indicated  error 

c.c. 

sulphone- 

in  jccting 

injecting 

due  to  coloring 

phthalcin 

coloring 

coloring 

matter 

injected  c.c. 

matter  V.S.  3 

matter  V.S.  3 

1000 

0.1 

10 

30-35 

15-20 

1000 

0.2 

20 

35-40 

10-15 

1000 

0.4. 

40 

50-58 

10-15 

1000 

0.6 

60 

75-80 

10-15 

1000 

0.8 

80 

95  + 

10-15 

TABLE  12. 

VOGEL'S  SCALE  2  CONTROL  BY  FULL  STRENGTH  METHOD 

A  B 
Distilled  water  Phenol- 
c.c.  sulphone 


C  D  E 

Reading  before  Reading  after  Indicated  error 


1000 
1000 
1000 
1000 
1000 


phthalein 
injected  c.c. 
0.1 
0.2 
0.4 
0.6 
0.8 


injecting 
coloring 
matter  V.S. 
10 
20 
40 
60 
80 


injecting 
coloring 
matter  V.S. 
25-30 
30-35 
50-55 
70-75 
90-95 


due  to  coloring 
matter 

15-20 
10-15 
10-15 
10-15 
10-15 


TABLE  13. 

VOGEL'S  SCALE  1  CONTROL  BY'  FULL  STRENGTH  METHOD 

ABC                    D  E 

Distilled  water    Phenol-     Reading  before  Reading  after  Indicated  error 

c.c.            sulphone-       injecting          injecting  due  to  coloring 

phthalein         coloring           coloring  matter 
injected  c.c.  matter  V.S.  1    matter  V.S.  1 

1000             0.1                 10               20-25  10-15 

1000              0.2                  20                30-35  10-15 

1000              0.4                  40                50-52  10-12 

1000              0.6                 60               70-75  10-15 

1000              0.8                  80                85-90  5-10 


In  the  foregoing  four  control  tables  the  second 
readings  in  Column  D  are  minimums.  They  might 
be  from  two  to  five  per  cent,  higher. 

TABLE  14. 

VOGEL'S  SCALE  4  CONTROL  BY  DILUTION 
ABC  D  E 

Distilled  water    Phenol-     Reading  before  Reading  after  Indicated  error 


1000 
1000 
1000 


sulphone- 
phthalein 
injected  c.c. 

0.8 

0.4 

0.2 


injecting 
coloring 
matter  V.S.  4 
80 
40 
20 


injecting 
coloring 
matter  V.S.  4 
90-95+ 
50-55  + 
30-35 


10-15  + 
10-15+ 
10-15  + 


TABLE  15. 

VOGEL'S  SCALE  3  CONTROL  BY  DILUTION. 
ABC  D  E 

Distilled  water    Phenol-     Reading  before  Reading  after  Indicated  error 
c.c.  sulphone-       injecting  injecting 

phthalein         coloring  coloring 
injected  c.c.  matter  V.S.  3    matter  V.S.  3 
1000  0.8  80  95±  15± 

1000  0.4  40  •     50-55+  10-15  + 

1000  0.2  20  35-40  15-20 

TABLE  16. 

VOGEL  S  SCALE  2  CONTROL  BY  DILUTION 
ABC  D  E 

Distilled  water    Phenol-     Reading  before  Reading  after  Indicated  error 


1000 
1000 
1000 


sulphone-  injecting 

phthalein  coloring 

injected  c.c.  matter  V.S.  2 

0.8  80 

0.4  40 

0.2  20 


injecting 
coloring 
matter  V.S.  2 
90-92+ 
50-53 
28-30+ 


10-12  + 
10-13 
8-10  + 


T.\BLE  17. 

VOGEL'S  SCALE  1  CONTROL  BY  DILUTION 

ABC  D  E 

Distilled  water    Phenol-     Reading  before  Reading  after  Indicated  error 

-   7i./.  t*i  I  ti/'ft  n  /I  )»lt/'/'^?ii/l 


1000 
1000 
1000 


sulphone-  injecting 
phthalein  coloring 

injected  c.c.  matter  V.S.  1 
0.8  80 
0.4  40 
0.2  20 


in  jccting 
coloring  ' 
natter  V.S.  1 
85-88 
47-50+ 
30+ 


5-8 
7-10  + 
10+ 


October  2,  1920.] 


PEDERSEN:   PHENOLSULPHONEPHTHALEIN  TEST. 


481 


In  order  to  produce  the  colors  Vogel's  scale  4-3-2-1 
in  tables  14  to  17.  inclusive,  it  was  found  that  the  hy- 
podermic syringe  had  to  be  filled  four  times  for  Vo- 
gel's scale  4;  three  times  for  Vogel's  scale  3;  twice 
for  Vogel's  scale  2  and  once  for  Vogel's  scale  one  in 
one  thousand  c.  c.  of  water.  In  the  dilutions 
for  eighty  per  cent,  to  forty  per  cent,  and  from 
forty  per  cent,  to  twenty  per  cent,  of  the  phenol- 
sulphonephthalein.  when  the  stock  solution  was 
again  brought  up  to  the  one  thousand  c.  c.  standard, 
sufiicient  coloring  matter  was  introduced  to  secure 
a  return  to  the  proper  Vogel  scale  color  used  for  the 
next  previous  strength.  In  this  way  errors  in  this 
particular  were  eliminated  because  when  forty  per 
cent,  was  read  off  the  coloring  matter  had  been  re- 
stored to  the  standard  of  the  eighty  per  cent,  solu- 
tion. And  so  with  the  twenty  per  cent,  to  forty  per 
cent,  solution. 

The  preceding  tables  1  to  17.  both  inclusive,  com- 
plete the  various  observations  with  distilled 
water.  The  following  tables  18  to  23  inclusive 
comprise  the  studies  applied  to  mixed  urines 
and  developed  by  exactly  the  same  precaution  and 
technic.  All  these  urines  were  unavoidably  decom- 
posed and  turbid,  but  in  a  generous  sense  such 


changes 
well 


made  them   simulate  pathological  urines 


A 
Urine 


c.c. 
1000 
1000 
1000 
1000 
1000 


A 
Urine 


c.e. 
1000 
1000 
1000 


A 
Urine 


c.c. 
1000 
1000 
1000 
1000 
1000 


The  turbidity  made  the  readings  difficult. 

T.ABLF.  IS. 
VOGEL  SCALE  4  TURBID  URIXE 

BCD  E 

Phen<l.fiilphonc-      Absolute       Reading  due  to  Indicated  error 

phthalein         reading  in     urinary  coloring  due  to  coloring 

injected       distilled  water     matter  equal  matter 
c.c.                                      to  V.S.  4 

0.1                  10                  25-28  15-18 

0.2                  20                  36-40  16-20 

0.4                   40                        SO  10 

0.6                   60                        70  10 

0.8                  80                  85-90  5-10 

TABLE  19. 

VOGEL  SCALE  4  CONTROL  BY  DILUTION 

PCD  E 

Phenclsulphone-      Absolute       Reading  due  to  Indicated  error 

phthalein         reading  in    urinary  coloring  due  to  coloring 

injected       distilled  water     matter  equal  matter 
c.c.                                    to  V.S.  4 

4                      80                       90±  10 

6                      60                       70±  10 

8                      40                       50±  10 

TABLE  20. 
VOGEL  SCALE  3  TURBID  URINE 

PCD  E 

Phcnolsulphone-      Absolute       Reading  due  to  Indicated  error 

phthalein         reading  in    urinary  coloring  due  to  coloring 

injected        distilled  water     matter  equal  matter 
c.c.                                      to  V.S.  S 

0.1                    10                        2S±  15 

0.2                   20                        36±  16 

0.4                   40                        50  10 

0.6                   60                        70±  10 

0.8                  80                  88-90  8-10 


TABLE  21. 

VOGEL  SCALE  3  TURBID  URINE  CONTROL  BY  DILUTION 


A 
Urine 


c.c. 
1000 
1000 
1000 


A 
Urine 


c.c. 
1000 
1000 
1000 


BCD  E 

Phcnolsulphone-      Absolute  Reading  due  to  Indicated  error 

phthalein         reading  in  urinary  coloring  due  to  coloring 

injected       distilled  water  matter  equal  matter 

c.c.  to  V.S.  3 

0.8                   80  90-95  10-15 

0.4                   40  50-1-  10 

0.2                   20  30-f  10 


VOGEL  SCALE 
B 


TABLE  22. 

2  CONTROL  BY  DILUTION. 


CD  E 

Phcnolsulphone-      Absolute       Reading  due  to  Indicated  error 
phthalein         reading  in    urinary  coloring   due  to  coloring 

injected       distilled  water     matter  equal  matter 
c.c.                                      to  V.S.  2 

0.4  80  48-f(50?)  88-1- (?)  8-1- (?) 

0.6                   60                   68-|-(70?)  8-|-(10?) 

0.8                   40                   48-1- (50)  8-t-(10) 


In  Tables  19  and  21  the  urine  was  diluted 
with  equal  parts  of  water  Vogel  scale  No.  4  then 
became  practically  No.  3  and  Vogel  scale  became 
practically  No.  2. 


Thus  new  controls  were  gained. 


A 
Urine 


c.c. 
1000 
1000 
1000 


TABLE  23. 

BY 

D 

Reading  due  to 


VOGEL  SCALE  2  CONTROL 
B 

Phcnolsulphone 
phthalein 
injected 
c.c. 

0.8  80 
0.4  40 
0.2  20 


DILUTION. 


C 

Absolute 
reading  in 
distilled  water 


urinary  coloring 
matter  equal 
to  V.S.  2 
88-92 
48-50 
25-30 


Indicated  error 
due  to  coloring 
matter 

8-12 
8-10 
5-10 


RESUME 

In  order  to  correlate  all  the  tests  and  to  determine 
the  average  of  errors  from  which  to  draw  conclu- 
sions the  following  tables  were  prepared  for  each 
of  the  four  colors  used.  It  will  be  noted  that  these 
tables  of  averages  confirm  almost  exactly  the  con- 
clusions finally  drawn  by  me. 

AVERAGES  OF  ERRORS 
Primary  and  control  tests  combined  in  the  averages 


Per  cent,  of 
phcnolsul- 
phone- 
phthalein 


TABLE  24. 
VOGEL'S  SCALE  4 


Tables  of  distilled  water  and  urine 


1 

3 

4 

10 

14 

18 

19 

Averages 

10 

18 

18 

8 

13 

17 

13 

20 

18 

18 

15 

13 

13 

18 

10 

15 

40 

20 

18 

20 

13 

13 

10 

10 

15-1- 

60 

20 

19 

15 

13 

10 

154- 

80 

20 

18 

15 

13 

13 

8 

10 

14 

TABLE  25 

VOGELS 

SCALE  3 

Per  cent,  of 

phenolsul- 

phone- 

phthalein 

Tables  of  distille 

d  water  and 

urine 

3 

5 

1 1 

15 

20 

22 

Averages 

10 

10 

10 

18 

15 

13 

20 

10 

10 

13 

18 

16 

10 

13 

40 

10 

10 

13 

13 

10 

10 

11-1- 

60 

10 

10 

13 

10 

IH- 

80 

10 

10 

13 

15 

9 

8 

n± 

In  Table 

24,  Column 

1, 

the 

dye 

was 

darker 

than  in  any  other.  Unfortunately  two  lots  of  dye 
had  to  be  employed  but  the  differences  were  not 


Per  cent,  of 
phenolsul- 
phonc- 


TABLE  26. 
VOGEL'S   SCALE  2 


phthalein 

Tables  of  distilled  water 

and  urine 

6 

7 

12 

16 

23 

Averages 

10 

10 

15 

18 

14-f- 

20 

10 

15 

13 

9 

10 

11-h 

40 

10 

10 

13 

11 

9 

11 — 

60 

5 

5 

13 

8— 

80 

5 

7 

13 

11 

8 

9 

TABLE  27. 

VOGEL'S    SCALE  1 

Per  cent,  of 

phcnolsul- 

phone- 

1 ..  .._»tni 

Tables  of  distilled 

water  a 

nd  urine 

8 

9 

13 

17 

Averages 

10 

20 

20 

13 

17 

20 

10 

15 

13 

10  + 

12 

40 

5 

10 

11 

8 

11 

60 

5 

5 

13 

8— 

80 

5 

5 

8 

7 

6  + 

CONCLUSIONS 


It  is  reasonable  to  draw  conclusions  from  the 
foregoing  studies  because  of  the  variety  of  tests 
employee!,  with  careful  checks  and  controls. 

The  first  was  the  direct  method  wherebv  the 


482 


PEDERSEN:   PHENOLSULPHONEPHTHALEIN  TEST. 


[New  York 
Medicai,  Journal. 


phenolsulphonephthalein  was  in  exact  tenths  of  a 
c.  c.  added  to  a  litre  of  distilled  water  previously 
colored  with  Vogel's  scale,  4,  3,  2  and  1  dye.  This 
work  is  embraced  in  tables  1,  2,  3,  5,  6  and  8.  These 
tests,  shown  in  tables  4,  7  and  9,  were  controlled  by 
the  method  of  subdilution.  / 

It  again  was  desirable  to  check  up  the  work  by 
the  direct  method  which  consisted  in  injecting  the 
phenolsulphonephthalein  into  distilled  water  and 
then  adding  the  dyes  to  produce  Vogel's  Scales  4, 
3,  2  and  1.  These  steps  are  shown  in  tables  10,  11, 
12  and  13. 

A  still  further  control  was  introduced  by  the 
same  method  but  starting  with  eighty  per  cent,  of 
phenolsulphonephthalein,  then  diluting  it  with 
equal  parts  of  water  for  forty  per  cent,  and  twenty 
per  cent.,  correcting  the  dilution  of  the  dye  stuff  by 
the  appropriate  quantity  of  Vogel's  scale  4,  3,  2,  1. 
These  tests  are  shown  in  tables  14,  15,  16  and  17. 
The  urines  were  tested  by  exactly  the  same  steps 
of  direct  methods  and  control  methods.  The  de- 
tails are  shown  in  tables  18,  19,  20,  21,  22  and  23. 

Allowing  for  differences  due  to  variations  in  the 
dyes  used  and  for  weariness  of  the  eyes  after  mak- 
ing many  tests  the  resume  shown  in  tables  24,  25, 
26  and  27  are  very  interesting.  From  these  tables 
it  is  quite  evident  that  in  urines  equivalent  to  Vo- 
gel's Scale  4  the  average  error  is  at  least  fifteen  per 
cent.,  probably  twenty  per  cent.,  with  the  darker 
urines. 

With  the  Vogel's  scale  3  the  error  is  at  least 
ten  per  cent,  and  in  some  circumstances  may  be 
nearly  fifteen  per  cent.  With  Vogel's  scales  2  and  1 
the  indicated  error  is  about  ten  j^er  cent.  As  pre- 
viously stated  the  practical  importance  of  these  in- 
dicated errors  is  in  the  middle  of  the  scale,  by  which 
are  often  decided  doubtful  cases. 

I  believe  that  in  all  the  ordinary  scale  readings 
ten  per  cent,  should  be  deducted  for  pale  yellow, 
fifteen  per  cent,  for  positive  yellow  and  twenty  per 
cent,  for  urines  with  a  reddish  or  orange  tinge,  in 
order  to  arrive  at  the  absolute  excretion,  and  there- 
after decide  in  favor  of  or  against  operation. 

ADDENDUM 

Since  the  completion  and  reading  of  this  paper 
the  thought  has  occurred  that  a  series  of  tables 
should  be  made  using  Cabot's  method  or  its  equiva- 
lent, namely  bottles  having  the  same  quality  of  glass, 
diameter  and  capacity  to  contain  both  the  control 
fluid  and  the  artificially  colored  distilled  water.  The 
purpose  of  this  last  step  was  to  eliminate  any 
influence  which  the  wedge  shape  of  the  test  fluid 
in  the  colorimeters  might  have  on  the  readings. 

The  details  were  the  same  as  those  adopted  in  the 
original  paper.  For  the  stock  solution  four  c.  c.  of 
strong  potassium  hydrate  solution  were  poured  into 
a  1,000  c.  c.  beaker  and  brought  up  to  full  measure. 
Then  with  all  preliminary  precautions  phenolsul- 
phonephthalein was  injected  one  tenth  c.  c.  at  a  time 
ascending  to  one  c.  c.  and  thus  creating  a  set  of 
bottles  for  comparison  beginning  with  ten  per  cent, 
and  ending  with  one  hundred  per  cent. 

The  test  fluids  Vogel's  scale  4.  3,  2  and  1  were 
brought  in  the  same  way  up  to  1,000  c.  c.  and  then 
one  tenth,  two  tenths,  four  tenths,  six  tenths  and 
eight  tenths  c.  c.  were  injected,  thus  producing  ten. 


twenty,  forty,  sixty  and  eighty  solutions.  Bot- 
tles of  the  same  size,  thickness  and  quality  of  glass 
were  then  filled  with  these  fluids  and  compared  with 
the  test  bottles  just  described. 

Absence  of  a  sliding  scale  as  provided  in  a  color- 
imeter made  it  very  difficult  to  estimate  the  exact 
color  error.  It  may  be  said  in  general  that  this 
method  supported  and  corroborated  the  other 
method.    The  tables  speak  for  themselves. 


VOGEL'S  SCALE  4 


TABLE  28. 

REDDISH  YELLOW 

C 

Absolute 
per  cent. 


A  B  C  D  E 

Stock  solution        Test  fluid       Absolute        Indicated  Indicated 

per  cent.  error 
1000  c.c.  of  distilled  Fraction  of   Injected  into  By  readings 
water,  alkalized  with  1  c.c.  of         test  fluid    of  the  Heliger 

IS  per  cent.  dye  in  \000  colorimeter. 

■  sodium  hydroxide  of  distilled 
ivith  dye  as  stated     water  alkal- 

below.  ised  with  15% 

sodium  hydrox- 
ide V.  S.  4. 


0.1 

0.1 

10 

20 

10 

0.2 

0.2 

20 

30-35 

10-15 

0.4 

0.4 

40 

50-55 

10-15 

0.6 

0.6 

60 

70-75 

10-15 

0.8 

0.8 

80 

90-95 

10-15 

There  may  have  been  a  little  doubt  in  reading  due 
to  the  fact  that  the  dyes  for  producing  the  Vogel 
scale  colors  4-3-2-1  were  in  these  tests  different 
from  the  dyes  of  the  other  series.  The  ten  per  cent, 
ascents  in  the  scale  of  bottles  also  made  gradua- 
tion readins:  difficult. 


TABLE  29 


VOGEL'S  SCALE  3 


DEEP  YELLOW 


A  B  C  D  E 

Stock  solution        Test  fluid       Absolute        Indicated  Indicated 
per  cent.         per  cent.  error 
1000  c.c.  of  distilled  Fraction  of   Injected  into  By  readings 
water,  alkalized  with  1  c.c.  of         test  fluid    of  the  Heliger 
15  per  cent.  dye  in  1000  colorimeter, 

sodium  hydroxide     of  distilled 
with  dye  as  stated     water  alkal- 
below.  iaedwith15% 
sodium  hydrox- 
ide V.  S.  3. 


0.1 

0.1 

10 

20+  10+ 

0.2 

0.2 

20 

30+  10+ 

0.4 

0.4 

40 

50+  10+ 

0.6 

0.6 

60 

70+  10+ 

0.8 

0.8 

80 

90+  10+ 

TABLE  30. 

VOGEL'S 

SCALE  2 

YELLOW 

A 

B 

C 

D  E 

Stock  solution        Test  fluid 


Absolute 
per  cent. 

WOO  c.c.  of  distilled  Fraction  of  Injected  into  By  readings 
zvater,  alkalized  with  1  c.c.  of  test  fluid  of  the  Heliger 
dye  as  stated         dye  in  1000  colorimeter. 


Indicated  Indicated 
per  cent.  error 


below. 

of  distilled 
water  alkal- 
ized with  1 5  % 
sodium  hydrox- 
ide V.  S.  2. 

0.1 

0.1 

10 

20  + 

10-t- 

0.2 

0.2 

20 

30-t- 

10-H 

0.4 

0.4 

40 

50-H 

10-t- 

0.6 

0.6 

60 

70-t- 

lO-H 

0.8 

0.8 

80 

90  + 

lO-h 

TABLE  31. 

VOGEL'S  SCALE  1  LIGHT  YELLOW 

A  B  C  D  E 

Stock  solution        Test  fluid       Absolute        Indicated  Indicated 
per  cent.         per  cent.  error 
1000  c.c.  of  distilled  Fraction  of  Injected  into  By  readings 
water,  alkalized  with  \  c.c.  of         test  fluid    of  the  Heliger 
15  per  cent.  dye  in  1000  colorimeter, 

sodium  hydroxide     of  distilled 
-with  dye  as  stated     water  alkal- 
below.  ized  with  15% 

sodium  hydrox- 
ide y.s.i. 

0.1  0.1  10  20—  10— 

0.2  0.2  20  30—  10— 

0.4  0.4  40  50 —  10 — 

0.6  0.6  60  70—  10— 

0.8  0.8  80  90 —  10— 


October  2,  1920.] 


BLODGETT:  KIDNEY  TEST. 


483 


There  is  much  more  thought  and  labor  repie- 
sented  in  this  preHminary  contribution  than  might 
appear  to  the  average  reader  through  the  approved 
tables.  If  the  result  is  the  correction  of  doubt  in 
those  patients  who  perish  even  after  a  favorable 
phenolsulphonephthalein  test  the  thought  and  the 
labor  will  have  been  immeasurably  worth  while. 

REFERENCES. 

1.  Pedersex  :  Limitations  of  Functional  Tests  of  the 
Kidneys,  Transactions  American  i'rological  Association, 
1915,  ix,  374  to  388  inc. 

2.  Ibid,  p.  378. 

45  West  Xixth  Street. 

THE  UREA   OUTPUT    AS   A  PRACTICAL 
KIDNEY  FUNXTIOX  TEST. 
By  Stephen  H.  Blodgett,  M.  D.. 
Boston. 

In  the  present  rather  imperfect  state  of  our 
knowledge  regarding  diseased  conditions  of  the  kid- 
ney, the  information  most  necessary  to  secure,  when 
a  patient  with  chronic  nephritis  comes  under  our 
care,  is:  How  much  is  the  kidney  damaged  as  re- 
gards its  ability  to  get  rid  of  the  waste  products  of 
metabolism,  and  is  the  condition  present  essentially 
a  progressive  one  or  not  ?  Or  perhaps  I  would  bet- 
ter explain  my  meaning  by  saying  that  we  wish  to 
know  how  much  the  damage  to  the  kidney  interferes 
with  the  permeability  as  regards  the  waste  products 
or  toxins  of  body  metabolism  which,  if  not  passed 
out  through  the  kidney,  cause  poisoning  and  ulti- 
mately death. 

If  in  a  coal-burning  furnace  where  we  use  the 
greatest  care  to  keep  the  grate  free  from  clinkers, 
and  with  frequent  shakings  we  can  only  get  through 
a  hodful  of  ashes  in  twenty-four  hours,  it  i*  per- 
fectly obvious  that  we  must  not  put  more  coal  on  the 
fire  than  will  produce  a  hodful  of  ashes  in  twenty- 
four  hours;  for  if  we  do,  the  surplus  ash  accumu- 
lating day  by  day  will  ultimately  choke  the  fire  and 
put  it  out.  ^ 

It  seems  to  me  that  the  knowledge  that  is  vital, 
in  order  that  we  may  prescribe  a  suitable  diet  and 
give  a  fairly  accurate  prognosis  is  what  part  of 
the  waste  products  that  should  pass  throtigh,  or  be 
eliminated  by.  the  healthy  kidney  cannot  be  fully 
eliminated  by  the  kidney  under  consideration.  This 
will  give  tis  an  indication  as  to  the  amount  of  cer- 
tain foods  it  is  safe  or  advisable  to  allow  our  pa- 
tient. Having  procured  an  answer  to  this  question, 
we  must  then  limit  the  amotint  of  exercise  or  activity 
to  correspond  to  the  amotint  of  food  that  we  find 
we  can  safely  allow.  To  illustrate  again  by  the 
furnace  fire :  If  we  find  the  grate  is  damaged,  first 
find  out  how  much  ash  we  can  get  through  the  grate 
daily ;  secondly,  put  in  only  that  amount  of  coal 
which,  when  burned,  will  produce  that  amount  of 
ash;  and,  thirdly,  try  to  heat  only  as  much  of  the 
house  as  that  amount  of  coal  will  heat  and  do  not 
expect  the  furnace  with  a  damaged  grate  (therefore 
a  restriction  as  to  the  amoimt  of  ashes  that  can 
pass  through )  and  consequently  a  restricted  capacity, 
to  burn  coal  to  heat  the  same  number  of  rooms 
that  the  furnace,  when  new,  with  a  perfect  grate 
would  formerly  heat. 


First  and  foremost,  I  wotild  say  that  if  some 
foreign,  innoctious  substance,  when  injected  into 
the  body,  will  be  eliminated  by  the  kidney  at  a 
certain  rate,  it  does  not  follow  that  the  poisons 
from  the  waste  of  the  body  will  be  eliminated  at 
the  same  rate.  It  must  be  understood  that  it  de- 
pends on  what  part  of  the  kidney  is  affected  as 
to  which  of  the  various  waste  products  may  or  may 
not  be  adequately  eliminated.  For  instance,  we 
are  all  familiar  with  conditions  of  the  kidney, 
where  the  nitrogenous  waste  (urea)  is  freely  passed 
through  while,  on  the  other  hand,  only  very  small 
amounts  of  sodium  chloride  are  eliminated.  In 
other  cases  of  kidney  damage,  relatively  small 
amounts  of  urea  can  pass  through  the  kidney,  while 
sodium  chloride  will  pass  freely;  and  there  are 
other  conditions  where  only  relatively  small 
amounts  of  either  urea  or  sodium  chloride  will  pass 
throttgh. 

What  particular  portions  of  the  kidney  are  at  fault 
when  these  various  imperfect  eliminations  occtir,  I 
shall  not  discuss  here,  for  this  knowledge  will  not 
help  us  to  formulate  a  better  diet  for  our  patient 
or  to  give  a  more  correct  prognosis ;  and  besides 
this,  I  do  not  feel  that  the  question  is  definitely  set- 
tled as  yet,  but  should  be  considered  as  theoretical 
rather  than  proved. 

We  knov.'  that  the  inability  to  properly  eliminate 
salt  by  the  kidney  is  tistially  an  accompaniment  of 
an  actite  disease,  and  the  retention  does  not  cause 
poisoning  and  death.  On  the  other  hand,  we  know 
that  the  retention  of  toxins  which  the  kidney  is  un- 
able to  eliminate  to  the  same  degree  as  urea,  causes 
a  poisoning  and  ultimately  death,  if  continued  long 
enough. 

It  has  been  frequently  stated  by  many  medical 
writers  that  the  amount  of  tirea  eliminated  by  the 
kidney  has  an  absolute  relation  to  the  amount  of 
nitrogenous  food  ingested.  This  is  true,  to  a  large 
extent,  in  health  but  in  some  conditions  of  preg- 
nancy and  in  many  conditions  of  a  damaged  kidney 
it  is  not  true.  Under  these  latter  conditions  the  urea 
excreted  may  be  much  less  than  would  be  repre- 
sented by  the  amount  of  nitrogenous  food  taken  in, 
with  a  consequent  retention  of  certain  poisons  in  the 
system,  and  when  tliis  retention  is  continued  long 
enough  or  in  large  amounts,  death  will  ensue. 

Therefore,  it  seems  clear  that  in  order  to  secure 
information  as  to  the  ability  of  the  kidney  to  do  the 
work  which  is  vitally  important,  it  is  in  many  cases 
absolutely  necessary  to  know  just  how  much  urea 
wa.ste  the  kidney  under  discussion  will  eliminate  in 
twenty-four  hours,  and  not  how  much  sodium 
chloride  or  phenolsulphonephthalein  or  any  other 
substance  can  be  eliminated  unless  the  ability  of  the 
kidney  to  eliminate  any  of  these  substances  is  shown 
to  be  parallel  to  the  elimination  of  the  urea  poison. 

So  far  as  we  know  at  present,  the  ability  of  the 
kidney  to  filter  out,  or  eliminate  from  the  blood  any 
known  substance  is  not  in  many  kidney  conditions 
an  exact  measure  of  the  kidney's  ability  to  filter 
otit  or  eliminate  the  urea  poison.  Therefore,  be- 
cause in  most  chronic  kidney  conditions  the  knowl- 
edge regarding  the  urea  poison  is  the  most  vitally 
important  thing  for  us  to  discover,  it  stands  to 
reason  that  in  these  conditions,  the  ability  to  filter 


484 


BLODGETT:  KIDNEY  TEST. 


[New  York 
Medical  Journal. 


out  or  eliminate  some  foreign  substance  is  of  little 
benefit  to  us  as  far  as  increasing  our  knowledge 
as  to  what  is  the  best  and  safest  food,  also  the 
proper  amount,  for  our  patient,  and  in  aiding  us  to 
give  a  fairly  accurate  prognosis. 

As  far  as  my  experience  goes,  there  is  at  present 
no  one  of  the  socalled  function  tests  that  will  give 
us  the  needed  information  in  all  cases  of  damaged 
kidney,  and  the  particular  cases  in  which  tests 
fail  are  the  very  ones  in  which  the  information 
we  seek  through  the  test  is  vitally  necessary  in 
order  that  we  may  successfully  advise  our  patient  as 
to  the  cjuality  and  amount  of  diet,  and  as  to  exer- 
cise. 

In  order  to  illustrate  my  meaning  more  fully, 
I  .will  quote  briefly  from  several  cases : 

Case  I. — The  patient  had  been  a  semiinvalid  for 
several  years,  and  had  consulted  several  physicians. 
Two  weeks  before  I  saw  her,  her  urine  had  been 
examined  and  something  had  been  injected  into  her 
arm  and  her  urine  collected  through  a  catheter  for 
two  hours.  After  this  her  husband  had  been  as- 
sured that  there  was  no  serious  kidney  condition 
present,  and  she  was  allowed  an  unrestricted  diet. 
One  year  ago  she  had  weighed  132  pounds ;  now 
she  weighs  120  pounds;  was  sleeping  well;  in  fact, 
was  rather  dopey  and  drowsed  a  lot.  The  blood 
pressure  was  170  systolic,  110  diastolic,  pulse  pres- 
sure 60.  Her  heart  was  regular,  not  enlarged  but 
somewhat  weak,  and  the  patient  was  slightly  listless. 
She  did  not  have  a  good  appetite,  l)ut  had  been  eat- 
ing meat  or  eggs  at  least  twice  a  day,  with  two 
glasses  of  milk.  She  was  placed  on  the  following 
diet: 

Breakfast. — Melon,    cereal    and    cream,    tea,    half    slice    toast,  little 
butter. 

Dinner. — Soup    (thin),   string  beans,   baked   potato,   pear,   and  some 
grapes. 

Supper. — Melon,    puffed    rice    with    cream,    soup    (thin),    roll  and 
butter,  half  an  apple. 

Of  course  the  diet  was  varied  from  day  to  day 
by  such  substitutes  as  a  peach  for  the  pear,  and  we 
will  call  it  her  basic  diet.  She  had  previously  been 
on  a  diet  containing  meat,  eggs,  and  milk  daily. 


Day 

Output 
Urine 

Total 

Urea 

Diet 

Solids 

1st 

1597  c.c. 

24. 

15. 

basic 

2nd 

1863  c.c. 

23.6 

13.6 

basic 

3rd 

1800  c.c. 

26. 

11.6 

basic 

4th  ♦ 

1810  c.c. 

30. 

13. 

basic+1  egg-|-steak-|-fish 

5th 

1600  c.c. 

22. 

14.9 

basic 

6th 

1744  c.c. 

23. 

14. 

basic 

7th 

1774  c.c. 

21. 

11. 

basic 

8th 

1600  c.c. 

22. 

11.2 

basic  +  fish 

9th 

2012  c.c. 

23. 

14. 

basic 

10th  ** 

1900  c.c. 

22. 

11.3 

basic 

nth 

2050  c.c. 

27. 

14. 

basic-|-2  eggs,  steak,  lamb 

12th 

2000  c.c. 

28. 

16. 

basic 

13th 

2010  c.c. 

27. 

14. 

basic 

14th 

2000  c.c. 

26. 

11. 

basic 

15th 

1900  c.c. 

25. 

11.2 

basic 

*On  this  day,  said  she  did  not  sleep  as  well  as  formerly,  and  when 
questioned,  said  she  slept  all  right  at  night,  but  did  not  care  to 
have  her  usual  nap  in  her  chair  during  the  forenoon.  She  did  not 
take  another  nap  during  the  day  until  the  twelfth  day,  when  she 
slept  an  hour  in  her  chair  during  the  morning. 

**On  this  day,  was  given  injection  in  the  thigh  of  phenothaline 
and  the  catheter  was  placed  in  her  bladder;  reaction  in  nine  minutes. 

It  will  be  noticed  that  when  the  patient  was  placed 
on  the  low  nitrogenous  diet  called  her  basic  diet 
following  a  diet  high  in  nitrogen,  the  urea  output 
fell  daily  for  three  days.  A  significant  symptom 
was  the  fact  that  after  four  days  of  this  low  nitro- 
gen diet,  the  patient  complained  of  not  sleeping  as 
well  as  usual,  but  on  inquiry  it  developed  that  she 
slept  as  well  as  usual  at  night,  but  did  not  feel 
sleepy  enough  to  have  a  nap  in  her  chair  during 


the  morning  as  she  had  done  for  months.  On  the 
fourth  day  there  was  added  to  her  basic  diet  an  egg 
for  breakfast,  a  piece  of  steak  for  dinner,  and  some 
fish  for  supper.  During  this  twenty-four  hours  she 
eliminated  thirteen  grams  of  urea,  but  during  the 
following  twenty-four  hours,  when  she  had  returned 
to  her  basic  diet,  she  eliminated  fourteen  and  nine 
tenths  grams  of  urea,  and  during  the  following 
twenty- four  hours,  while  still  on  a  basic  diet,  four- 
teen grams.  It  was  not  until  the  fourth  twenty-four 
hour  period  after  she  had  received  the  extra  amounts 
of  nitrogenous  food  that  her  urea  output  returned  to 
normal,  about  eleven  grams. 

On  the  eighth  day,  in  addition  to  her  basic  diet, 
she  had  fish  at  two  meals  (at  supper,  however,  she 
only  took  a  very  small  amount),  returning  the  next 
day  to  her  basic  diet.  During  that  twenty-four 
hours  she  only  passed  eleven  and  two  tenths  grams 
of  urea,  the  second  day  fourteen  grams,  and  the 
third  day  she  had  eleven  and  three  tenths  grams  of 
urea,  the  normal  output.  On  the  next  day,  the 
eleventh  day,  she  was  given  (in  addition  to  her  regu- 
lar diet)  two  eggs  for  breakfast,  a  piece  of  steak 
for  lunch,  and  a  piece  of  roast  lamb  at  supper.  Dur- 
ing that  twenty-four  hours  she  passed  fourteen 
grams  of  urea.  The  twelfth  day  on  basic  diet  she 
passed  sixteen  grams  of  urea,  the  thirteenth  day 
fourteen  grams,  and  the  fourteenth  day  eleven 
grams,  a  normal  amount,  thus  showing  that  it  took 
three  days  for  the  system  to  get  rid  of  the  great 
excess  of  waste  material,  and  that  the  system  could 
not  pass  much  over  fifteen  grams  a  day. 

Following  this,  she  was  .sent  home  and  placed 
on  the  following  diet : 

Breakfast. — Fruit,  half  an  egg,  small  amount  of  cereal  and  cream, 

(mostly  top  of  bottle)    weak  coffee. 
Lunch. — Four  ounces  soup    (any  kind),   two  vegetables,   bread  and 

butter  as  wanted,  a  glass  of  milk. 
Supper. — Two  vegetables,  bread  or  cracker,   cheese,   baked  apple  or 

a  sweet  dessert. 
Bedtime. — Fruit. 

The  analysis  at  various  intervals  follows : 

Output  Urine  Total  Solids  Urea 

After  3  days                  2050                  24  12 

After  6  days                  1750                  28  12.2 

Arfter  1  week                 2000                  28  12 

After  1  month                1500                  25  14 

The  patient  had  gained  four  pounds.  Weight 
119^/2  pounds.  Blood  pressure  unchanged.  Said 
she  felt  better  than  she  had  for  years.  It  was 
deemed  advisable  to  send  this  patient  to  a  warm 
climate  where  she  could  be  outdoors  more  than 
it  seemed  best  for  her  to  do  in  a  New  England 
winter,  and  where  the  added  excretory  action  of 
the  skin  would  help  relieve  the  kidney. 

While  in  the  South,  a  local  physician  was  con- 
sulted in  relation  to  a  slight  diarrhea.  Later  he 
decided  she  did  not  have  a  damaged  kidney,  and 
advised  her  to  go  to  a  large  hospital  for  observa- 
tion. The  patient  followed  the  advice,  and  was 
admitted  as  a  patient  for  observation.  Three  days 
later,  following  various  tests,  one  of  which  was  an 
injection  in  the  arm  and  collecting  the  urine  for 
four  hours  by  catheter,  her  husband  was  told  thai 
her  kidneys  were  working  properly,  and  that  she 
needed  a  much  more  nourishing  diet  in  order  to 
build  her  up.  She  was  then  given  three  eggs  a 
day,  one  quarter  pound  of  meat,  and  a  pint  of  milk, 
besides  vegetables.  After  six  days  on  the  new 
diet,  she  was  found  by  the  nurse  one  morning  to 


October  2,  1920.] 


BLODGETT:  KIDNEY  TEST. 


485 


be  nearly  unconscious;  within  six  hours  she  be- 
came comatose,  and  twelve  hours  later,  died  in 
coma  (uremia?). 

Case  II. — This  patient,  briefly  gave  a  history 
that  for  several  years  he  had  had  slight  dyspnea 
on  exertion.  One  year  ago,  there  was  sudden  loss 
of  sight  in  one  eye,  which  gradually  improved.  No 
other  symptoms  except  that  he  had  lost  about  fifteen 
pounds  in  three  months.  One  month  ago,  he  had 
suddenly  lost  consciousness ;  no  convulsions ;  con- 
sciousness slowly  returned  in  about  ten  hours.  This 
attack  occurred  following  two  days  when  the  ther- 
mometer was  below  zero. 

He  came  under  my  care  with  the  following  an- 
alysis:  2,130  c.  c,  slightly  pale  color;  specific  grav- 
ity, 1,009.  Total  solids  forty-three  grams.  Urea 
twenty-one  grams ;  very  slight  trace  albumin ; 
many  hyaline  and  granular  casts,  numerous  renal 
cells.  Heart  strong,  regular ;  apex  beat  two  inches 
outside  nipple  line.  He  was  placed  on  a  diet  as 
follows : 

Breakfast. — One  half  grapefruit  or  an  orange,  toast  or  biscuit  and 

butter,  cereal  and  cream  with  sugar. 
Dinner. — Bread,  any  cereal,  any  dessert. 

Supper. — Any  vegetable,  any  vegetable  or   fruit   salad,   baked  apple 
and  cream  and  sugar. 

Two  glasses  milk  during  twenty-four  hours. 

This  continued  for  five  days ;  on  the  sixth  was 
added  a  dropped  egg  at  breakfast,  one  glass  of  milk 
at  10  a.  m.  Dinner,  a  large  portion  of  turkey.  Sup- 
per, custard  containing  two  eggs.  Bedtime,  a  glass 
of  milk ;  seventh  day,  return  to  previous  diet ;  ninth 
day,  discontinue  the  milk ;  eleventh  day,  diet  to  con- 
sist only  of  cereals,  fruits  and  vegetables. 


Day 

Output 

Total 

Urea 

Diet 

Urine  c.c. 

Solids 

1 

830 

25. 

12.4 

basic  (part  of  this  urine  was  lost) 

2 

1180 

43.8 

18.8 

basic 

3 

1240 

55. 

16. 

basic 

4 

1120 

44. 

15.6 

basic 

5 

1660 

61. 

19.9 

basic 

6 

1360 

76. 

23. 

extra  nitrogen 

7 

1720 

64. 

20.6 

basic 

8 

1S70 

54.7 

18.8 

basic 

9 

1660 

61.7 

21.5 

basic   minus  milk 

10 

1480 

72. 

19.2 

n 

14. 

only  cereals,  fruits  and  vegetables 

12 

1840 

63. 

16. 

13 

950 

55. 

17.1 

Creatinin  content  of  blood=.3  per  100  c.c. 

On  the  tenth  day,  phenolsulphonephthalein  was 
injected,  and  the  catheter  showed  reaction  in  fifteen 
minutes.  This  patient  apparently  could  pass  a  mod- 
erate amount  of  urea  through  the  kidney,  and  was 
given  a  home  diet  as  follows : 

Breakfast. — Fruit,  egg,  bread,  coffee  and  cream. 

Dinner. — Soup    (milk,   corn   or   potato),    any   vegetable,   bread,  and 

a  dessert  containing  one  egg. 
Supper. — Any  vegetable,  bread  and  butter,   cheese,   olives   or  baked 

apple. 

Two  weeks  after  leaving  the  hospital,  analysis 
showed  1,892  c.  c,  slightly  pale,  acid,  specific  gravity 
1,011,  total  solids  49,  urea  17,  albumin  trace  +.  A 
few  fine  granular  casts  small  amount  of  free  fat. 

About  one  week  after  this  he  became  uncon- 
scious, with  the  following  history.  The  weather 
had  been  extremely  cold  for  several  days ;  the 
patient  got  up  as  usual  at  6  a.  m.  He  ate  breakfast 
at  7  :30  and  put  on  his  overcoat  and  hat  and  went 
to  his  office  at  9  (five  minutes'  walk).  He  went 
to  his  desk,  and  began  work.  Soon  the  janitor 
came  in,  and  failing  to  get  intelligent  replies  to 
questions,  began  to  observe  him  carefully.  In  about 
ten  minutes  the  patient  arose  from  his  chair  and 
fell  to  the  floor.  He  was  taken  in  an  ambulance  to 
the  hospital,  and  about  four  hours  later  would  put 


out  his  tongue  when  sharply  ordered  to  do  so,  and 
in  twelve  hours  would  answer  questions ;  in  twenty- 
four  hours  he  was  apparently  normal  mentally,  ex- 
cept that  he  could  not  remember  any  of  the  happen- 
ings. The  next  day,  by  careful  questioning,  he  could 
remember  having  eaten  breakfast  before  the  attack, 
but  could  not  recall  what  he  had  eaten,  and  had 
no  recollection  of  anything  after  breakfast  until 
he  realized  he  was  in  a  hospital  about  eight  hours 
later.  He  remained  in  a  hospital  until  he  went 
to  Florida,  where  he  was  getting  on  nicely  until 
he  had  a  cerebral  hemorrhage,  and  died  in  twelve 
hours. 

In  this  case,  while  the  food  test  showed  that  the 
excretion  of  urea  was  only  slightly  delayed  after  the 
ingestion  of  nitrogenous  food  the  phenolsulphone- 
phthalein test  showed  a  marked  delay.  It  was  there- 
fore considered  advisable  to  give  the  patient  a  suffi- 
cient amount  of  nitrogenous  food  and  to  allow  a 
fair  amount  of  exercise. 

Case  III. — This  patient  was  a  woman,  aged  forty- 
six  years,  the  menopause  passed.  Five  years 
ago,  felt  tired  most  of  the  time,  and  was  examined 
by  a  physician,  who  said  she  had  nephritis.  She 
has  been  on  a  restricted  diet  as  regards  meat  since 
that  time.  She  has  slight  dyspnea  on  exertion,  and 
tires  easily ;  digestion  good ;  headaches  very  rare. 
No  excess  of  urine  at  night ;  specific  gravity  low 
for  several  years.  Sleeps  well,  but  dreams  a  great 
deal.  Feels  tired  when  she  awakes,  but  by  nine 
o'clock  feels  better.  Blood  pressure  systolic  120, 
diastolic  85,  pulse  pressure  35.  Heart  in  good  con- 
dition.   Weight,  160  pounds. 

Analysis  of  five  years  previously  showed  1,300 
c.  c.  pale,  specific  gravity  1011,  urea  thirteen 
grams,  very  slight  trace  of  albumin;  rare  hyaline 
casts.  Four  years  previously,  1,655  c.  c.  pale,  1006 
specific  gravity,  urea  eleven  grams,  very  slight  trace 
albumin.  First,  previous  to  examination,  urine 
showed  1,400  c.  c.  yellow,  acid,  1010  specific  grav- 
ity thirty-three  grams  solids,  nine  grams  urea; 
slightest  possible  trace  of  albumin ;  occasional  hya- 
line cast.    She  was  placed  on  the  following  diet : 

Breakfast. — Toast  and  butter,  weak  coffee  and  cream. 

Dinner. — Potatoes,  string  beans,  or  peas,  or  asparagus,  berries  and 
cream  for  dessert,  water. 

Supper. — Bread,  any  vegetable  salad,  any  of  the  following  vege- 
tables: beans,  peas,  asparagus,  beets,  or  squash,  and 
any  fruit. 

This  will  be  called  her  basic  diet. 


Day 


6 

7 
8 
9 
10 
1 1 
12 
13 
14 


Output 
Urine  c.c. 
1450 
1537 
1242 

1537 

1714 
1361 
1301 
1420 

780 

769 

lost 
1124 
1242 
1200 


Total  Urea  Diet 
Solids 

20. 

28.7 

29. 


43. 

41. 
26. 
27. 
33. 
23. 
53. 

26. 
38. 
29. 


11.5  basic 

12.3  basic 

16.    basic  +2   eggs  -f  3   glasses  milk,  steak 
and    2  chops. 

24.6  basic  +  2  eggs  +  3   glasses  milk,  steak 

19.5  basic  "^'^    '  '^'^^ 

12.  basic 

12.    basic   (took  excessive  exercise) 
1 1.1  basic 

11.  basic  (very  hot  day,  100-mile  auto  ride) 
20.    basic  +  5  eggs 

basic 
10.  basic 

16.1  basic  -f-1  glass  milk,  3  eggs,      lb.  cheese 

11.4  basic 


Phenolsulphonephthalein  injected  showed  reaction 
in  sixteen  minutes ;  first  hour,  twenty-two  per  cent. ; 
second  hour,  fifteen  per  cent. 

In  this  case  I  wished  to  find  out  if  excessive  ex- 
ercise or  long  auto  rides  had  any  deleterious  effects 
on  the  kidney  output.  As  will  be  seen,  no  such 
effects  were  apparent.  From  the  rapidity  with 
which  the  urea  was  eliminated  after  the  ingestion 


486 


BLODGETT:  KIDNEY  TEST. 


[New  York 
Medical  Journal. 


of  an  extra  amount,  it  was  felt  that  the  patient 
had  been  on  a  too  restricted  diet,  and  had  taken  too 
much  exercise,  considering  the  restricted  diet.  She 
was,  therefore,  sent  home  and  placed  on  the  fol- 
lowing diet :  Basic  plus  an  egg  for  breakfast ;  a 
glass  of  milk  at  10  a.  m. ;  an  egg  in  dessert  at  din- 
ner; considerable  cheese  at  supper. 

Two  weeks  later  she  reported ;  weight,  165 
pounds.  Was  feeling  better  than  for  several  years. 
Urine  analysis,  1,892  c.  c,  color  slightly  pale,  spe- 
cific gravity  1009,  solids  40  grams,  urea  17  grams, 
very  slight  trace  albumin,  rare  hyaline  casts.  Blood 
pressure,  diastolic  120,  systolic  75 ;  pulse  pressure 
45.  Two  months  later  she  was  feeling  very  well, 
and  her  family  reported  that  she  had  more  energy 
than  for  years.  The  urine  showed  2,012  c.  c.  color 
pale  specific  gravity  1009,  42  grams  solids,  20 
grams  urea,  slightest  possible  trace  albumin,  rare 
hyaline  casts.  Weight  1663^  pounds.  Ten  months 
later  she  was  compelled  to  undergo  a  considerable 
physical  strain  for  two  weeks,  but  without  undue 
fatigue,  and  showed  946  c.  c,  color  normal,  specific 
gravity  1018,  solids  40  grams,  urea  21  grams, 
slightest  possible  trace  of  albumin.  No  casts. 

I  shall  not  quote  from  any  more  cases,  as  I 
feel  that  these  typical  cases  are  sufficient  to  illus- 
trate my  points.  In  the  first,  the  patient 
showed  an  inability  to  pass  more  than  about  six- 
teen grams  of  urea  daily  through  the  kidney.  The 
phenolsulphonephthalein  test  (catheter  in  bladder) 
showed  a  reaction  in  nine  minutes.  When  placed  on 
a  diet  not  making  more  than  twelve  to  fourteen 
grams  of  urea  daily,  and  very  limited  exercise,  she 
gained  in  weight  and  strength ;  but  when  placed  by 
another  physician  on  a  highly  nitrogenous  diet  for 
a  week  in  order  to  build  her  up,  coma  developed  and 
death  followed  (uremia?). 

The  second  patient  had  a  contracted  kidney,  but 
was  able  to  pass  ordinary  amounts  of  urea.  The 
phenolsulphonephthalein  test  showed  reaction  in  fif- 
teen minutes.  He  was  allowed  in  his  diet  enough 
milk  and  eggs  to  have  an  output  of  fifteen  to  twenty 
grams  of  urea  daily,  and  was  doing  well  until  a 
cerebral  hemorrhage  caused  death. 

The  third  patient  had  been  on  a  very  nitrogenous 
restricted  diet  for  several  years,  and  was  very  ac- 
tive, but  easily  tired.  The  food  test  showed  she 
could  pass  much  more  nitrogenous  waste  (urea)  ■ 
than  her  diSt  contained.  The  phenolsulphonephtha- 
lein showed  a  reaction  in  sixteen  minutes.  She  was 
given  more  nitrogenous  food,  and  has  been  better 
and  has  felt  better  than  for  several  years. 

CONCLUSIONS. 

The  ability  of  the  kidney  to  pass  ofT  the  waste 
products  of  metabolism  is  not.  in  many  cases,  shown 
by  any  of  the  socalled  kidney  function  tests. 

The  ability  of  the  kidney  to  pass  of¥  the  dan- 
gerous waste  products  of  metabolism  is  easily  dis- 
covered by  means  of  feeding  definite  amounts  of 
nitrogenous  food  to  a  person  previously  put  on  a 
socalled  basic  diet  and  watching  the  output  of  urea. 

Having  this  knowledge,  the  diet  can  then  be  built 
up  so  that  the  person  takes  the  maximum  amount 
of  nitrogenous  food,  the  waste  from  which  his  kid- 
neys can  get  rid  of,  and  then  his  exercise  must  be 
limited  to  correspond  to  his  prescribed  diet. 


SURGERY  OF  THE  PROSTATE.* 

By  John  F.  X.  Jones,  B.  Sc.,  M.  D., 
A.  M.,  F.  A.  C.  S., 
Philadelphia, 

Instructor  in  Surgery  in  the  Jefferson  Medical  College;  Surgeon  to 
St.   Joseph's  Hospital,   Misericordia   Hospital   and   St.  Agnes' 
Hospital;  Lieutenant,  Medical  Corps,  U.  S.  N.  R.  F. 

Glancing  at  the  historical  chapters  of  Deaver  ( 1 ) 
and  of  F.  S.  Watson  (2)  one  is  amazed  at 
the  vicissitudes  of  fortune  undergone  by  the  of- 
fending prostate.  It  has  been  tunnelled,  compressed, 
crushed,  twisted,  cooked,  excised,  enucleated,  elec- 
trified and  punched  either  per  urctJiram,  perineally, 
or  suprapubically.  Since  it  first  assumed  surgical 
importance  it  has  created  difiference  of  opinion  as  to 
the  etiology  of  its  enlargement,  the  anatomy  of  its 
component  parts  its  physiology,  pathology,  and  the 
proper  method  of  removing  it. 

Varied  as  well  as  numerous  have  been  the  the- 
ories regarding  the  pathogenesis  of  the  enlarged 
prostate,  hence  a  multiplicity  of  statements  some- 
what confusing,  for  instance :  "All  are  agreed 
that  the  true  hyperplasia  of  the  gland  elements  is 
not  the  result  of  inflammation.  On  the  other  hand, 
it  is  the  writer's  belief  that  many  of  the  deformities 
of  the  prostate  where  there  is  no  true  cytoplasia  are 
the  results  of  inflammation"  (Pilcher)  (3).  "The 
evidence  derived  from  the  more  recent  pathological 
studies  of  the  prostate  gland  points  somewhat  to  the 
dependence  of  this  condition  upon  chronic  inflam- 
mation, etc."  (White  and  Martin)  (4).  ...  And 
then  these  authors  exhibit  the  arguments  against  the 
inflammation  theory.  Ciechanowski  (5)  alleges  that 
])rostatism,  whether  adenomatous  or  sclerotic,  is  es- 
setitially  the  same :  that  it  is  due  to  obscure,  inflam- 
matory processes  originating  in  the  stroma  of  the 
gland,  etc.  .  .  .  And  Keyes  (5),  not  being  in  sympa- 
thy with  this  view,  thinks  that  we  should  accept  the 
theory  that  the  adenomatous  changes  are  due  to  k 
neoplastic  process  and  that  the  sclerotic  changes  are 
the  results  of  inflammation.  Ramon  Guiteras  (6) 
accepted  the  theory  of  the  French  school  that  "So- 
called  hypertrophy  of  the  prostate  is  benign  neo- 
plasm." 

Then  there  is  the  arteriosclerosis  theory  (Guyon 
and  Launois)  (7),  which  was  apparently  ousted  by 
the  theory  of  Casper  and  Motz  (8).  Velpeau's  (9) 
fibromyoma  and  White's  (10)  sexual  senility 
theories  have  also  had  their  advocates  Hawley 
(11)  believes  that  altered  prostatic  secretion  is  the 
cause  of  the  enlargement.  Even  the  view  that 
prostatic  hypertrophy  is  essentially  a  senile  change 
has  been  opposed.  (Bangs)  (12).  Perverted 
action  of  the  testes,  pelvic  congestion  and  sexual  ex- 
cesses have  been  cited  as  causes,  but  little  is  known 
about  the  etiology  of  simple  prostatic  hypertrophy. 

Lowsley  (13)  has  clarified  the  question  of  the 
lobes  of  the  prostate,  having  shown  that  this  gland 
develops  from  five  separate  buds.  Physiologists  as 
yet  have  not  agreed  upon  the  mechanism  of  mictu- 
rition and  hence  some  writers  maintain  that  the  pros- 
tate is  concerned  in  this  act  and  others  (notably 
Keyes)  (14)  assert  that  the  prostate  has  nothing 
to  do  with  urination. 

*Read  before  the  St.  Joseph's  Hospital  Clinical  Conference 
February  10,  1920. 


October  2,  1920.] 


J  OSES:   SURGERY  OF  PROSTATE. 


487 


Of  the  many  classifications  of  benign  enlarge- 
ments of  the  prostate  that  of  Pilcher  (15)  seems  the 
least  involved.  I  quote  it  in  full :  "Excluding 
syphilis,  tuberculosis  and  cancerous  lesions  of  the 
prostate,  the  noninflammatory  enlargements  of  the 
prostate  are  either  cytological  or  mechanical,  viz : 
1.  Cytological  hyperplasia,  a,  of  the  parenchyma, 
b,  of  the  stroma,  c.  of  both ;  2,  mechanical — due  to 
retention  of  gland  contents  with  cystic  dilatation. 
In  addition  to  this  we  have  deformities  in  and  about 
the  prostate  due  to  inflammation  and  irregularities 
of  development  of  accessory  glands  which  cause 
symptoms  similar  to  hypertrophy  of  the  prostate." 

As  to  the  manner  of  removing  the  prostate,  it  is 
becoming  more  and  more  apparent  that  the  surgeon 
must  use  a  method  to  fit  the  case  and  not  try  to 
make  the  case  fit  the  method.  While  the  suprapubic 
operation  has  given  wonderful  results  in  the  hands 
of  its  masterful  exponent,  Freyer  (16),  and  while 
the  perineal  method,  when  performed  by  its  most 
able  advocate.  Young  (17),  has  shown  a  surprisingly 
low  mortality,  yet  the  surgeon  who  limits  himself  to 
either  method  exclusively  cannot  help,  sooner  or 
later,  doing  an  injustice  to  his  patient.  If  the  opera- 
tion has  not  been  selected  with  due  regard  to  the 
position  and  size  of  the  enlarged  gland,  incontinence 
of  urine  or  rectourethral  fistula  may  follow  either 
method.  The  small  fibrous  gland  should  not  be 
removed  suprapubically ;  the  large,  soft  gland  which 
projects  into  the  bladder  ought  to  be  removed  supra- 
pubically. If  the  abdomen  is  thick  and  the  bladder 
small  the  perineal  is  the  safer  method.  When  the 
gland  is  not  palpable  per  rectum,  but  presents  symp- 
toms and  is  demonstrably  enlarged  when  seen 
through  the  cystoscope,  the  suprapubic  is  the  better 
method.  John  H.  Cunningham  (18)  believes  that 
"Those  professing  to  be  expert  in  prostatic  surgery 
should  possess  a  skill  in  performing  the  diflferent 
proved  operations  and  should  have  the  ability  to 
select  the  most  appropriate  operation  for  the  indi- 
vidual, not  employing  a  single  operative  technic  for 
all  patients."  J.  Chalmers  DaCosta  (19)  says,  "No 
one  routine  plan  is  suitable  in  all  cases.  The  patient 
should  be  studied,  and  the  operation  chosen  which 
is  safest  and  best  for  that  individual  patient.  The 
surgeon  who  uses  one  method  only  must  wrong 
many  patients,  and  he  retains  consistency  at  the  ex- 
pense of  humanity." 

Young's  (20)  punch  operation,  originally  recom- 
mended for  obstruction  of  the  vesical  neck  by 
medium  bar  (Randall)  (21),  sclerosis  of  the  vesical 
neck  and  intravesical  or  intraurethral  isolated  pro- 
static lobules,  should  be  limited,  according  to 
Braasch  (22),  "to  cases  in  which  the  superficial 
medium  tissues  obstruct  the  vesical  orifice,  and  to 
occasional  cases  of  involvement  of  the  bilateral  lobes 
in  which  enucleation  is  otherwise  inadvisable."  Ac- 
cording to  Judd  (23),  it  is  an  operation  which  re- 
quires considerable  skill.  It  may  be  followed  by 
bleeding  and  may  necessitate  subsequent  operations. 

Prostatotomy  by  means  of  the  Bottini  (24)  or 
Chetwood  (25)  method  should  be  employed  in  such 
aged  and  enfeebled  subjects  as  can  neither  endure 
catheter  life  nor  submit  to  a  prostatectomy.  There 
is  an  element  of  uncertainty  about  the  Bottini 
operation,  which  will  always  retard  its  popularity 
among  general  surgeons  who,  as  a  class,  prefer  to 


see  what  they  are  doing.  Binnie  (26)  tells  us  that 
he  saw  one  patient  who  had  been  operated  upon  by 
the  Bottini  method  by  a  surgeon  of  great  experience 
in  this  class  of  work,  and  that  the  patient's  urethra 
had  been  burned  and  partly  obliterated  while  the 
prostate  had  escaped  cauterization.  Bouffleur  (27) 
performs  a  galvanocautery  operation  through  a 
suprapubic  cystotomy  incision,  the  actual  cautery 
having  been  heated  to  a  white  heat ;  and  small 
median  lobe  enlargements  of  the  prostate  have  been 
treated  successfully  through  the  cystoscope  by 
means  of  the  Oudin  current. 

The  most  important  phase  of  the  question  of 
prostatic  surgery  is  the  proper  selection  of  cases  for 
operation.  With  the  exception  of  the  case  of  abso- 
lute retention  which  cannot  be  catheterized — and 
which  may  be  treated  by  making  a  very  small  supra- 
pubic opening  into  the  bladder  in  order  to  allow 
gradual  drainage  through  a  female,  selfretaining 
catheter  (28) — there  is  always  ample  time  for  the 
careful  study  of  cases  of  prostatism. 

It  is  important,  first  of  all,  to  make  a  diagnosis. 
When  a  patient  of  middle  age  or  over  complains  of 
nocturnal  irregularities  of  urination,  one  should 
think  of  hypertrophy  of  the  prostate,  urethral  stric- 
ture and  cancer  of  the  prostate.  While  the  presence 
or  absence  of  stricture  usually  can  be  determined  by 
careful  investigation,  it  is  often  most  difficult  to 
separate  prostatism  plain  from  prostatism  associated 
with  carcinoma.  Of  course,  if  the  carcinoma  has 
extended  beyond  the  limits  of  the  gland — a  hopeless 
state  in  which  diagnosis  is  too  late  to  be  of  much 
service— a  rectal  examination  will  reveal  the  growth. 
Small  nodes  in  the  prostate  may  mean  tuberculosis, 
cancer  or  chronic  prostatitis — or,  if  in  the  lateral 
lobes,  perhaps  stone.  In  such  cases  x  ray  examina- 
tions should  be  made,  or  it  may  be  helpful  to  intro- 
duce a  sound  into  the  urethra  during  rectal  palpa- 
tion. It  may  be  impossible  to  use  either  sound  or 
cystoscope,  and  the  latter  may  give  no  information, 
even  when  employed  in  such  cases.  If,  with  symp- 
toms of  prostatism,  there  are  sciatica,  pelvic  pain  or 
tumor  of  bone  or  in  the  abdomen,  cancer  of  the 
prostate  may  be  suspected  (29).  Bleeding  is  more 
frequent  in  simple  hypertrophy  than  in  carcinoma. 
Growths  within  the  bladder  may  be  differentiated 
by  cystoscopic  examination.  Besides  rectal  touch, 
the  abdomen  should  be  palpated,  the  urine  examined, 
the  residual  urine  estimated  and  the  length  of  the 
urethra  measured.  The  passage  of  a  catheter  should 
be  extremely  gentle  and  guarded  by  rigid  local  anti- 
sepsis and  the  administration  of  hexamethylenamine 
— and  in  spite  of  all  of  these  precautions,  if  infec- 
tion does  not  already  exist,  it  will  usually  follow  the 
regular  employment  of  the  catheter.  The  cysto- 
scope. if  the  urethra  will  tolerate  its  passage,  will 
reveal  stone  and  often  afiford  information  as  to  the 
shape  and  size  of  the  prostate. 

In  these  cases  it  is  essential  to  posses  in- 
formation about  the  functional  capacity  of  the  kid- 
neys, and,  of  the  various  tests  devised  for  this  pur- 
pose, the  indigo  carmin  and  the  phenolsulpho- 
nephthalein  methods  are  perhaps  the  most  practical. 
The  indigo  carmin  method  was  introduced  by 
Voelcker  (30)  and  Joseph  and  is  used  in  this  coun- 
try extensively  by  B.  A.  Thomas  (31).  Ira  Remsen 
(32)  was  the  first  to  make  phenolsulphonephthalein 


488 


JOXES:   SURGERY  OF  PROSTATE. 


[Xew  York 
Medical  Journal. 


and  Rowntree  and  Geraghty  (33)  introduced  this 
method  of  testing  for  the  functional  capacity  of  the 
kidneys.  Of  the  experimental  polyuria  test  of 
Albarran  (34),  Keyes  (35)  states  that  "its  accuracy 
by  no  means  compensates  for  the  length  of  time 
consumed." 

A  twenty-four  hours'  specimen  of  urine  should  be 
collected.  If  the  total  quantity  is  between  1000  c.c. 
and  2000  c.c,  it  may  be  considered  for  all  practical 
purposes  a  normal  output.  Oliguria  and  polyuria 
are  significant  of  so  many  conditions,  surgical  or 
otherwise,  that  either  symptom  is  only  important 
when  accompanied  by  other  pathognomonic  signs. 

Oliguria  may  occur  when  there  has  been  a  lessen- 
ing of  intake  of  water,  the  intake  in  a  water  balance 
being  water  taken  in  as  such,  the  watery  contents 
of  foods  (vegetables,  milk,  etc.)  and  oxidation  wa- 
ter from  the  oxidation  of  the  hydrogen  of  fats,  car- 
bohydrates and  proteins  during  metabolism  (Bar- 
ker) (36).  Oliguria  may  be  due  to  excessive  per- 
spiration, constant  vomiting,  or  severe  diarrhea 
(cholera,  exophthalmic  goitre).  It  may  be  the  result 
of  passive  congestion  of  the  kidney,  the  result  of 
myocardial  insufficiency.  It  may  follow  pressure  on 
the  renal  veins  by  timiors  or  collections  of  fluid  in 
the  abdomen.  Oliguria  may  be  observed  during  the 
formation  of  edema  and  transudates.  It  may  be 
caused  by  spasm  of  the  renal  arteries  or  arterioles 
as  a  result  of  acute  strychnine  poisoning.  It  occurs 
in  gout,  fevers,  acute  nephritis  and  in  chronic  paren- 
chymatous nephritis.  If  oliguria  occurs  in  chronic 
interstitial  nephritis  it  is  a  danger  signal  of  oncom- 
ing uremia.  If  it  is  accompanied  by  cylindruria. 
albumin  and  blood,  it  is  a  sign  of  organic  renal  dis- 
ease— usually  glomerulonephritis.  Oliguria  mav 
mean  serious  impairment  of  kidney  function,  acute 
Bright's  disease  or  obstruction  to  the  outflow  of  the 
urine. 

Poh-uria  may  be  due  to  increased  circulation 
through  the  kidneys,  to  a  watery  composition  of  the 
blood  or  to  an  increase  in  the  secretory  activity  of 
.the  kidney  following  the  consumption  of  large 
'quantities  of  liquid.  Polyuria  may  follow  tlie  resto- 
ration of  compensation  in  cardiac  failure  or  in  renal 
incompetency.  It  may  appear  during  convalescence 
from  typhoid  and  other  fevers  and  while  edemas 
and  exudates  are  disappearing.  It  may  be  due  to 
certain  salts  or  drugs  (sodium  chloride,  the  caffeine 
group,  digitalis,  etc.).  Poh-uria  may  exist  when 
there  are  lesions  of  the  central  nervous  system, 
when  there  is  injury  to  the  floor  of  the  fourth  ven- 
tricle, in  puncture  of  the  medulla  and  when  there  is 
tumor  anywhere  in  the  brain.  Pohniria  is  present 
in  hypopituitarism  and  follows  section  of  the 
splanchnic  nerves.  Gushing  (37)  has  shown  that 
subcortical  transplantation  of  the  posterior  lobe  of 
the  hypophysis  may  cause  polyuria.  A  polyuria 
which  persists  with  urine  of  low  specific  gravity 
usually  means  contracted  kidney  or  diabetes  insipi- 
dus ;  if  associated  with  high  specific  gravity  we 
should  think  of  diabetes  mellitus.  Polyuria  occurs 
in  amyloid  disease  of  the  kidney  and  in  pyelitis. 
There  may  be  a  transitory  (vasomotor)  polyuria  in 
migraine,  epilepsy  or  hysteria.  Polyuria  occurs 
when  there  is  chronic  renal  congestion,  as  in  stone, 
prostatism,  tuberculosis  and  retention.    From  all  of 


which  it  might  be  concluded  that  either  oliguria  or 
polyuria  means  nothing  as  an  isolated  symptom. 

The  specific  gravity  of  the  urine  should  be  care- 
fully noted  in  these  cases  of  enlarged  prostate. 
Deaver  (38)  states  that  he  will  not  operate  if  the 
specific  gravity  of  the  urine  continues  below  1005. 

The  urea  of  the  twenty  four  hours'  specimen 
should  be  investigated  because  while  absence  of  urea 
concentration  in  the  urine  does  not  of  itself  prove 
that  there  is  a  diseased  kidney,  the  presence  of  such 
concentration  is  a  sign  of  a  healthy  kidney. 

A  determination  of  the  amount  of  nonprotein 
nitrogen  in  the  blood  should  be  made  but  it  is  of 
little  value,  as  Frank  (39)  states,  unless  one  is 
aware  of  the  nitrogen  intake.  In  his  most  interest- 
ing paper.  Frank  calls  attention  to  the  advent  of  an 
era  of  physiological  surgeons  the  advance  gviard  of 
whom  have  been  the  investigators  of  such  vital  ques- 
tions as  shock,  acidosis  and  renal  function.  He 
feels,  as  do  many  others,  that  some  of  the  physiolog- 
ical studies,  which  in  the  past  have  been  applied  to 
urology  almost  exclusively,  should  now  take  a  prom- 
inent place  in  general  operative  surgery.  AH  of 
Frank's  conclusions  are  not  established  or  beyond 
debate  but  they  constitute  a  step  in  the  right  direc- 
tion— the  reduction  of  operative  mortality — and 
they  should  be  accepted  or  rejected  after  careful 
trial.  The  prostatic  patient's  genitourinary  tract 
should  be  submitted  to  careful  x  ray  examination  in 
which  it  may  or  may  not  be  necessary  to  catheterize 
the  ureters. 

In  the  differential  diagnosis  of  prostatic  condi- 
tions perhaps  nothing  is  more  puzzling  than  when 
the  surgeon  examines  a  sufferer  from  retention  of 
urine  with  no  palpable  enlargement  of  his  gland  and 
with  no  stricture.  In  such  a  case  the  patient  may 
have  carcinoma  and  perhaps  have  nodules  or  an 
indurated  posterior  lobe :  he  may  have  a  peduncu- 
lated middle  lobe  or  bar  which  will  show  through  the 
cystoscope :  or  the  bladder  may  be  paralyzed.  If  the 
bladder  is  paralyzed  cystoscopic  and  urethroscopic 
Examination  may  show  typical  trabeculation  and 
perhaps  some  relaxation  of  the  sphincters :  rectal 
examination  will  be  either  negative  or  reveal  a 
prostate  which  seems  smaller  than  normal  and  is 
surrounded  by  flabby  tissues  (40)  :  the  cerebro- 
spinal fluid  will  probably  be  positive  to  the  Wasser- 
mann  test :  and  perhaps  there  will  be  lessening  or 
absence  of  deep  muscular  sensation.  Judd  and 
Braasch  (40)  state  that  in  these  tabetics  "when  it  is 
evident  that  the  sphincter  itself  is  not  relaxed,  [and 
this  may  be  noted  through  the  cystoscope,  J-  F.  X.  J.] 
that  there  is  sufficient  hypertrophy  of  the  prostate 
to  account  for  the  urinary  obstruction,  and  that  the 
general  condition  is  favorable,  then  prostatectomy 
may  be  attempted."  Young  (41)  has  also  operated 
under  similar  circumstances.  Keyes  (42)  is  not 
hopeful  about  operative  cures  in  these  conditions. 

Rarely,  formnately,  there  is  a  condition,  encoun- 
tered in  younger  men.  which  is  negative  to  rectal 
and  cystoscopic  examination  and  yet  in  which  there 
is  prostatic  sclerosis.  Tabes  must  be  carefully  ex- 
cluded before  making  such  a  diagnosis  ('43).  Judd 
(44)  "believes  that  many  of  the  patients  with  pros- 
tatic trouble,  who  continue  to  have  the  socalled  cys- 
titis and  residual  urine  after  the  obstruction  has 


October  2,  1920.] 


JONES:   SURGERY  OF  PROSTATE. 


489 


been  removed,  are  in  reality  suffering  from  diverti- 
cula, and  that  if  a  careful  examination  is  made  for 
a  diverticulum  at  the  time  of  the  prostatectomy  in 
such  cases  this  error  will  be  avoided." 

It  is  somewhat  trite,  perhaps,  to  say  that  a  gen- 
eral and  thorough  physical  examination  should  be 
made  in  addition  to  the  urological  investigations.  If 
the  surgeon  ca:n  no  longer  trust  his  ear  as  far  as 
hearts  and  lungs  are  concerned — which  is  often  the 
case — his  colleague,  the  internist,  should  be  called 
in  to  permit  the  patient  to  benefit  by  such  consulta- 
tion. Xo  prostatic  (nor  any  other  surgical  case,  ex- 
cept an  emergency)  should  be  given  a  general  anes- 
thesia while  he  has  bronchitis.  It  is  seldom,  if  ever, 
necessary  to  submit  a  case  of  prostatism  to  opera- 
tion during  an  epidemic  of  influenza  or  of  any  other 
infectious  disease.  Low  kidney  function,  heart  dis- 
ease with  failing  or  absent  compensation,  high  blood 
pressure,  arteriosclerosis,  infection  anywhere  in  the 
genitourinary  system,  are  some  of  the  conditions 
which  may  absolutely  contraindicate  operation  and 
they  all  will  require  the  most  careful  preoperative 
treatment — even  should  operation  be  decided  upon. 
We  ought  to  be  on  the  watch  or  acidosis  always. 

Acting  on  the  acknowledged  fact  that  prostatic 
patients,  who  have  cystitis  and  other  evidence  of 
chronic  infection  at  the  time  of  operation,  usually 
fare  better  than  those  who  have  no  symptoms  of 
infection.  Judd  (45)  tried  the  use  of  a  colon  bacil- 
lus in  order  to  modify  infection  in  prostatectomies. 
His  results  were  suggestive  only  but  the  idea  should 
be  acted  upon  and  worked  out  on  a  large  scale  be- 
fore drawing  any  conclusions.  Cultures  of  the 
urine  should  be  made  in  all  cases  of  prostatism. 

Preoperative  drainage  of  the  bladder  ought  to  be 
effected — ^through  the  urethra,  if  this  is  possible, 
otherwise  suprapubically — until  the  patient's  local 
and  general  conditions  warrant  prostatectomy. 
Preliminary  suprapubic  drainage  adds  to  the  diffi- 
culty of  the  subsequent  prostatectomy  and,  if  the 
urethra  permits  of  it,  preoperative  drainage  should 
be  conducted  through  the  urethra.  Freyer  (46)  was 
obliged  to  perform  the  two  stage  operation  seventy- 
two  times  only  in  a  total  of  1,550  suprapubic  prosta- 
tectomies. He  believes  that  preliminary  suprapubic 
drainage  should  be  effected  in  those  cases  where  the 
bladder  is  badly  infected,  perhaps  containing  phos- 
phatic  stones  and  especially  if  the  kidneys  are  in- 
volved as  manifested  by  chills  and  fever,  emaciation 
and  debility  and  when  the  patient  has  very  frequent, 
painless  urination  due  to  an  overdistended  bladder 
— no  catheter  having  previously  been  used — and 
with  this  condition,  incipient  signs  of  uremia.  In 
the  latter  case  Freyer  drains  the  bladder  slowly  by 
means  of  a  retained  catheter  and  a  few  days  later 
does  a  suprapubic  cystostomy.  Then,  in  about  two 
weeks,  when  the  kidneys  have  regained  normal 
function,  he  enucleates  the  prostate.  Freyer  says 
that  it  is  much  more  difficult  to  remove  the  prostate 
ten  days  or  longer  after  preliminary  cystostomy  be- 
cause of  increased  rigidity  of  the  tissues  about  the 
incision.  Judd  (23)  believes  that  it  is  difficult  to 
do  an  accurate  operation  after  the  bladder  has  been 
opened  and  drained,  and  a  sinus  has  persisted  for 
some  time  and  that  if  this  preliminary  opening  be 
enlarged  the  adjoining  tissues  are  immediately  ex- 
posed to  infection.    Deaver  (47)  thinks  that  it  is 


dangerous  to  enlarge  the  incision  of  a  preliminary 
suprapubic  cystostomy  because  of  the  risk  of  open- 
ing into  the  peritoneal  cavity,  the  peritoneum  having 
become  attached  to  the  bladder  wall  in  the  line  of 
the  original  incision. 

If  the  retained  catheter  is  employed  during  the 
preoperative  treatment  of  prostatism,  it  must  be 
remembered  that  there  is  a  well  established  nervous 
relation  between  the  deep  urethra  and  the  secretory 
apparatus  of  the  kidney  (Pilcher)  (48),  and  that 
anuria  may  result  directly  from  the  irritation  of  the 
deep  urethra  by  the  catheter.  Here,  obviously,  the 
preoperative  drainage  must  be  suprapubic. 

In  addition  to  the  drainage  tube  in  the  bladder, 
after  suprapubic  prostatectomy,  a  cigarette  drain 
should  be  placed  in  the  prevesical  space — indeed, 
Judd's  (23)  suggestion  to  use  Dakin's  solution  and 
Carrel  technic  in  the  space  of  Retzius  seems  a  sound 
one.  The  same  surgeon  (23)  does  not  believe  in 
irrigation  until  after  the  first  day  following  opera- 
tion. Irrigation  immediately  after  suprapubic  pros- 
tatectomy prolongs  oozing.  Rockey  (49)  thinks 
that  irrigation  after  prostatectomy  is  a  surgical 
error.  "It  promotes  the  continuance  of  bleeding, 
devitalizes  the  freshly  exposed  tissues,  and  favors 
the  formation  of  sloughs  by  removing  the  blood 
which  is  the  natural  hemostatic  and  protective  of 
the  wound." 

The  mortality  of  prostatectomy  in  the  hands  of 
the  average  general  surgeon  has  been  in  the  neigh- 
borhood of  fifty  per  cent.  The  reduction  of  this 
mortality  will  depend  upon : 

1.  Intimate  association  of  the  internist,  physiol- 
ogist and  the  laboratorj-  man  with  the  surgeon  in  the 
study  of  the  case. 

2.  Thorough  examination  of  the  patient  by  one 
skilled  in  physical  diagnosis — particular  stress 
being  laid  upon  t^he  lungs,  heart,  arteries,  kidneys 
and  nervous  system. 

3.  Complete  investigation  of  the  blood  and  urine 
by  a  competent  laboratory  man.  If  it  gives  the 
slightest  promise  of  reducing  the  death  rate,  no  test, 
functional  or  otherwise,  should  be  considered  by  tlie 
surgeon  too  fantastic  to  merit  trial. 

4.  Willingness  and  ability  on  the  part  of  the 
surgeon  to  adapt  his  methods  to  the  special  require- 
ments of  each  case — irrespective  of  the  fact  that  he 
has  rejoiced  in  the  performance  of  a  certain  technic 
heretofore. 

REFERENCES. 

1.  Deaver.  J.  B. :  Enlargement  of  the  Prostate,  1911. 

2.  Watsox,  F.  S.  :  Cabot  Modern  Urology,  vol.  i,  1918. 

3.  Pilcher,  P.  M. :  Cabot  Modern  Urology,  vol.  i,  1918. 

4.  M.\RTix,  E.,  Thomas,  B.  A.,  Moorhead,  S.  W.  : 
White  and  Martin's  Genitourinary  Surgery  and  Venereal 
Diseases,  1917,  p.  402. 

5.  CiECHAXOWSKi :  Quoted  by  Keyes,  E.  L.,  Urology, 
1919,  p.  284. 

6.  Guiteras,  R.  :  Urology,  vol.  ii,  p.  226. 

7.  GuYOX  :  Annates,  1885,  iii,  148,  and  Lauxois' :  De  I'Ap- 
pareil  urinaires  des  vielliards,  Paris,  1885.  (Both  quoted 
in  Keyes's  Urology,  1919,  p.  283.) 

8.  Casper:  Virchozv's  Archiv.,  1891.  cxxvi.  139:  Motz  : 
Structure  histologiquc  de  I'hypertrophie  de  la  prostate,  Paris, 
1896. 

9.  Velpeau:  Le  consoralcs,  Paris,  1841,  iii,  478. 

10.  White,  J.  W. :  Annals  of  Surgery,  1893,  xviii.  152. 

11.  Hawlev  :  Annals  of  Surgery,  November,  1903. 

12.  Baxgs,  L.  Boltox  :  Journal  of  Dermatology  and 


490 


McXAIR:   TREATMEXT  OF  URETHRITIS. 


[Xew  York 
Medical  Jourxal. 


Gcititoiirinary  Diseases,  March,  1901,  quoted  in  DaCosta. 
Modern  Surgery,  eighth  edition,  1919,  p.  1525. 

13.  LowsLEY :  Gross  Anatomy  of  the  Human  Prostate 
Gland  and  Contiguous  Structures,  Surgery,  Gynecology,  and 
Obstetrics.  1915.  xx,  183.  The  Development  of  the  Human 
Prostate  Gland  with  Reference  to  the  Development  of  Other 
Structures  at  the  Neck  of  the  Urinary  Bladder,  American 
Journal  of  Auatovix.  1912.  xiii,  299. 

14.  Keves,  E.  L':  Urology,  1919.  p.  281. 

15.  Pilcher:  Cabot's  Modern  Urology,  1918,  vol.  i,  p. 
555. 

16.  American  Journal  of  Dermatology  and  Genitourinary 
Diseases,  1912,  and  British  Medical  Journal,  February  1, 
1919. 

17.  YouxG,  H.  H. :  International  Urological  Congress, 
London,  1911,  and  Keen's  Surgery,  vol.  vi,  p.  687. 

18.  CuxNixGH.\M.  J.  H. :  New  York  Medic.\l  Journal, 
January  24,  1920,  p.  139. 

19.  DaCosta,  J.  Chalmers:  Modern  Surger\%  eighth 
edition.  1919,  p.  1529. 

20.  YouxG,  H.  H. :  Keen's  Surgery,  vol.  vi,  p.  678. 

21.  Raxdall,  a.:  Annals  of  Surgerx,  A{)ril,  1917,  p. 
471. 

22.  Braasch,  \V.  F.  :  Journal  American  Medical  Asso- 
ciation, 1918,  Ixx.  758,  759. 

23.  JcDD,  E.  J. :  Pennsylvania  Medical  Journal,  1917, 
xxi,  72-75. 

24.  BoTTixi :  //  Gak  ani,  1874.  (This  has  not  been  located 
by  the  writer,  but  is  quoted  from  the  bibliography,  on  page 
244,  of  John  B.  Deaver's  Enlargement  of  the  Prostate,  Its 
Diagnosis  and  Treatment,  1905.) 

25.  Watsox  and  Cuxxixgham  :  Diseases  and  Surgery 
of  the  Genitourinary  System,  vol.  i,  p.  405-410. 

26.  Bixxie  :  Operative  Surgery,  seventh  edition,  1916, 
p.  702. 

27.  White  and  Martix  :  Genitourinary  Surgery  and 
Venereal  Diseases,  by  Martin,  Thomas,  and  Moorhead,  1917, 
p.  415  and  56. 

28.  Dea\-er,  J.  B. :  The  American  Journal  of  the  Medical 
Sciences,  Tanuarv,  1920,  p.  6. 

29.  Keyes  :  Urology,  1919,  p.  315. 

30.  \'oelcker  and  Joseph  :  Dfsch.  Med.  Wchnschr., 
1904,  XXX,  536.  Voelcker,  Diagnose  der  chirurgisclien 
Niarenerkrankungen  unter  Vcrivertung  der  Chromocysto- 
skopie,  Wiesbaden,  1906  (quoted  in  Kelly  and  Burnham, 
Diseases  of  the  Kidneys,  Ureters,  and  Bladder,  vol.  i.  p. 
315). 

31.  Thomas.  B.  A.:  Journal  American  Medical  Associa- 
tion, No.  28.  1914. 

32.  Remsex,  Ira:  American  Chemical  Journal,  1884,  vi, 
208. 

33.  Rowxtree  and  Geraghty  :  Journal  of  Pharmacology 
and  E.vperimental  Therapy,  1910,  i.  579. 

34.  Albarrax  :  Exploration  des  Fonctions  Renales,  1905. 

35.  Keyes  :  Keyes's  Urology,  1919.  p.  84. 

36.  Barker,  L.  F.  :  Monographic  Medicine,  1916,  vol. 
iv,  pp.  733  and  763. 

37.  CusHixG.  H. :  Boston  Medical  and  Surgical  Journal, 
1913,  clxviii,  901. 

38.  Deaver,  J.  B. :  The  American  Journal  of  the  Medi- 
cal Sciences,  January,  1920,  p.  5. 

39.  Fraxk,  Louis  :  Surgerv,  Gynecology,  and  Obstetrics, 
February.  1920.  p.  186. 

40.  JuDD  and  Braasch  :  The  American  Journal  of  Syph- 
ilis. 1917,  i,  752-59. 

41.  YouxG,  H.  H. :  Journal  American  Medical  Associa- 
tion, 1913,  Ix,  253-257. 

42.  Keyes  :  Urology,  1919,  p.  47 

43.  Keyes:  Urology,  1919,  p.  301. 

.  44.   JuDD,  E.  J. :  Annals  of  Surgery,  1918,  Ixviii,  295-305. 

45.  JuDD,  E.  J.:  Annals  of  Surgery,  1917,  Ixvi,  362-730. 

46.  Freyer:  British  Medical  Journal,  February  1,  1919, 
p.  121. 

47.  Dea%'er,  J.  B. :  The  American  Journal  of  the  Medi- 
cal Sciences,  January,  1920,  p.  8. 

48.  Pilcher,  P.  M. :  Cabot's  Modern  Urology,  1918,  vol. 
i,  p.  594.  - 

49.  Rockey,  a.  E.  :  Surgery,  Gynecology,  and  Obstetrics, 
February-,  1920.  p.  206.  Prostatectomy  Without  Irrigation, 
Boston  Sicdical  and  Surgical  Journal,  March  12,  1914. 

103  South  Tvvext\'-first  Street. 


THE  TREATMEXT  OF  SPECIFIC 
URETHRITIS. 
A  Simple  Technic. 

By  Robert  H.  McXair,  M.  D., 
Springfield,  Mass. 

Almost  every  practitioner,  whether  specialist  in 
urology  or  not,  is  doubtless  aware  of  the  fact  that 
nitrate  of  silver  comes  nearest  to  being  a  specific 
against  the  gonococci  than  any  other  agent  employed. 
Yet  after  much  experimentation  with  various 
strengths  of  silver  solution,  I  have  come  to  the 
conclusion  that  the  secret  of  a  successful  treatment 
of  gonorrheal  infection,  especiall}-  during  the  first 
few  weeks  of  its  course,  is  to  be  found  in  de- 
termining the  right  strength  of  solution  to  apply  in 
individual  cases.  In  other  words,  it  is  very  es- 
sential to  find  out  definitely  the  strength  of  solution 
which  may  be  safely  used  without  inducing  harm- 
ful reactionary  irritation  to  the  delicate  mucous 
membrane  already  injured,  and  causing  a  greater 
degree  of  epithelial  exfoliation,  hence  rendering  the 
inflammatory  area  more  favorable  for  the  micro- 
organism to  flourish  and  continue  active  destruc- 
tion. 

It  is  impossible  to  inundate  completely  and 
destroy  the  active  germs  with  one  free  ir- 
rigation, therefore  the  application  of  the  remedy 
must  be  repeated  often  and  carefully. 

I  think  the  simple  technic  that  has  been  repeatedly 
and  quite  success ftilly  employed  may  be  best  de- 
scribed by  citing  a  few  typical  cases  of  gonorrheal 
urethritis.  Several  of  the  patients  complained  of 
having  sufiFered  from  painful  nocturnal  erection  and 
troublesome  chordee. 

Case  I. — T.  P.  C.  aged  twenty-eight,  a  railroad 
employee,  was  first  seen  early  in  March  of  the 
present  year,  with  a  history  of  nearly  five  weeks' 
duration  of  free  discharge  and  much  discomfort.  The 
patient  had  consulted  several  physicians  and  as  many 
druggists.  This  case  was  one  of  troublesome 
chordee.  The  treatment  was  instituted  with  one 
half  of  one  per  cent,  silver  nitrate  solution,  after 
the  urethra  had  been  carefully  flushed  with  a  ster- 
ilized irrigating  fluid.  Thus  the  silver  solution  was 
gently  and  carefully  instilled  into  the  urethra — 
rather  than  injected  by  means  of  a  properly  shaped 
pipette. 

The  rubber  bulb  at  the  base  of  the  glass  instil- 
lator  was  quite  strong  enough  to  deliver  the  solu- 
tion. The  long,  tapering  neck,  or  nozzle,  of  the 
instillator  was  almost  as  long  as  an  average  index 
finger,  with  a  smoothly  turned  end,  so  that  there 
could  be  no  possible  danger  of  injury  to  the  in- 
flamed mucous  membrane.  "  The  solution  is  simply 
sucked  up  into  the  pipette,  gently  inserted  to  the 
full  length  of  the  nozzle  into  the  urethra,  and  the 
contents  delivered.  Several  syringefuls,  are  used 
at  each  sitting. 

This  patient  received  just  fourteen  treatments,  in 
as  many  consecutive  days,  during  which  period  the 
strength  of  solution  was  gradually  increased  up  to 
one  and  a  half  per  cent.  At  the  expiration  of  the 
period  of  daily  application,  the  discharge  had  dis- 
appeared, and  within  a  few  days  more  there  were 
no  clap  strings  in  the  urine.    After  repeated  tests 


October  2,  1920.]     BROWN  AXD  CADWALLADER:    CLINICAL  STATUS  OF  GONORRHEA. 


491 


the  patient  was  discharged  and  has  remained  so. 
Several  more  railroad  employees  subsequently  came 
to  me  and  were  good  patients. 

Case  II.— On  April  10,  1920,  J.  G.,  twenty-two 
years  of  age,  employed  by  a  furniture  company,  was 
referred  to  me  for  treatment.  There  was  a  free 
gonorrheal  discharge  with  accompanying  symptoms 
of  the  infection,  subacute  in  character.  Painful  erec- 
tions and  chordee  were  complained  of.  This  pa- 
tient had  also  received  treatment  with  astringent 
injections  and  capsules  internally.  Practically  the 
same  course  of  treatment  was  pursued,  only  the 
silver  strength  was  increased  to  two  per  cent,  solu- 
tion. The  discharge  subsided  in  two  weeks.  Clap 
strings  disappeared  from  the  urine  within  the  fol- 
lowing week  and  the  patient  was  discharged  cured 
in  just  three  weeks  from  the  date  of  first  treatment. 

C.ASE  III. — J.  G.  B.,  twenty-five  years  of  age,  a 
grocery  clerk.  History  given  was  of  a  free  dis- 
charge, considerable  pain  and  swelling,  that  had 
lasted  a  little  less  than  three  weeks.  Treatment  at 
drug  stores  had  been  by  capsules  only.  The  patient 
was  treated  each  evening,  beginning  with  half  of 
one  per  cent,  silver  solution,  and  gradually  increas- 
ing the  strength  to  two  per  cent. 

It  may  be  appropriate  to  remark  here  that  the 
increase  of  the  strength  of  the  solution  was  deter- 
mined by  the  degree  of  after  irritation  caused  by 
the  application.  It  has  been  found  that  in  most  cases 
the  urethra  will  rapidly  become  quite  tolerant  to 
the  irritating  effect  of  silver  if  it  is  applied  in  grad- 
ually increasing  strength  and  in  a  small  quantity 
at  a  time. 

The  discharge  had  completely  disappeared  in  this 
latter  case  after  two  and  a  half  weeks  of  daily 
treatment.  The  two  glass  urine  test  was  made  for 
clap  strings  during  one  more  week  and  the  patient 
was  discharged  cured ;  there  has  been  no  further 
trouble.  Other  similar  cases  might  be  cited,  but 
would  only  repeat  what  has  been  said,  hence  con- 
sume time  and  space  unnecessarily.  Silver  prop- 
erly applied  is  the  remedy  par  excellence  for  specific 
urethritis. 


THE  CLINICAL  STATUS  OF  GONORRHEA. 
By  Joseph  M.  C.a.dw.vllader,  A.  'M.,  ^I.  D., 

AND 

Alexander  A.  Brown,  ]M.  D., 

Formerly  Chief  of  Genitourinary  Service,  Fort  Sara  Houstpn 
Base  Hospital, 

San  Antonio.  Tex. 
Having  reflected  upon  the  respectable  antiquity 
of  gonorrhea,  and  the  voluminous  mass  of  litera- 
ture extant  thereupon,  one  might  wonder  what 
could  remain  to  be  said  upon  this  commonplace 
subject.  Nevertheless,  gonorrheal  infection  still 
remains  a  glaring  social  evil ;  not  because  the  treat- 
ment is  unsatisfactory,  but  because  many  cases  are 
unsatisfactorily  treated.  In  attestation  of  this,  wit- 
ness the  ever  large  number  of  cases  of  lingering, 
but  nevertheless  curable,  infection ;  the  serious  com- 
plications, usually  preventable,  genital,  extragenital, 
and  metastatic ;  the  countless  sufferers  from  pyosal- 
pinx  who  flock  to  the  gynecologist.  What,  then,  is 
the  reason  for  these  grave  and  distressing  conse- 


quences? In  answer  to  this  query,  we  repeat  our 
assertion :  It  is  not  because  the  treatment  is  unsatis- 
factory but  because  many  cases  are  unsatisfactorily 
treated.    And  there  are  various  reasons  for  this. 

First  and  foremost,  there  still  exist  a  not  inconsid- 
erable number  of  practitioners  who,  through  super- 
ficiality or  prejudice,  adhere  to  the  absurd  dictum 
of  Noeggerath :  "Once  a  gonorrheic,  always  a 
gonorrheic ;  once  infected,  always  infectious." 
Again  there  are  others,  and  their  number  is  not 
small,  who,  from  inherent  aversion,  will  not  them- 
selves treat  such  cases  conscientiously,  possibly  not 
at  all,  and  do  not  encourage  the  patients  to  seek 
proper  treatment  at  the  hands  of  those  who  are 
willing  and  competent ;  and  still  others  who  fail  to 
estimate  the  extent  and  gravity  of  the  infection, 
and  consequently  apply  inadequate  and  improper 
treatment.  What,  therefore,  is  to  be  said  and 
done  ? 

Gonorrhea  is  a  perfectly  and  permanently  curable 
disease.  What  are  the  essentials  to  the  at- 
tainment of  this  end  ?  We  believe  that  the  answer 
may  be  tersely  stated  in  three  words,  spirit,  ability, 
equipment.  Without  an  adequate  armamentarium 
and  the  ability  to  employ  it,  and  without  conscienti- 
ous effort  and  painstaking  care  in  diagnosis,  prog- 
nosis, and  treatment,  the  prospect  of  failure  is  al- 
most certain  to  supplant  that  of  cure. 

The  prime  essential  is  a  correct  and  complete 
diagnosis :  the  mere  fact  that  the  patient  has  ure- 
thritis of  gonorrheal  origin  is  not  sufficient.  While 
always  beginning  in  the  anterior  urethra,  in  only 
twenty  per  cent,  of  the  cases  does  the  infection  re- 
main limited  to  this  part ;  in  other  words,  eight  out 
of  ten  patients  eventually  suffer  from  involvement 
of  the  deep  urethra  and  the  structures  appertaining 
thereto.  The  extent  of  this  involvement  must  al- 
ways be  determined ;  systematic  examination  must 
be  made  to  disclose  the  existence  of  posterior  ure- 
thritis, alone  or  in  conjunction  with  trigonitis,  pros- 
tatitis, and  seminal  vesiculitis.  Only  by  this  means 
is  the  practitioner  able  to  institute  intelligent  treat- 
ment. 

The  next  essential  is  the  armamentarium :  de- 
spite the  triviality  with  which  some  physicians  re- 
gard gonorrheal  infection,  we  reiterate  that  this  dis- 
ease should  be  treated  only  by  competent  practi- 
tioners adequately  equipped.  Besides  the  common- 
place instruments,  the  armamentarium  must  com- 
prise the  deep  urethral  instillator.  endoscopes, 
straight  and  curved,  with  a  range  in  calibre  from 
twenty-two  to  twenty-six ;  cystourethroscopes  and 
urethroscopic  syringes ;  and  finally,  as  the  third  es- 
sential, a  thorough  knowledge  of  how  to  use  them, 
and  a  conscientious  spirit  in  their  application. 

\\'hen  shall  the  patient  with  gonorrhea  be  pro- 
nounced cured?  When  may  he  be  assured  of  con- 
jugal safety?  L^pon  the  answer  of  this  weighty 
question  may  depend  the  future  of  a  home ;  like- 
wise the  reputation  of  the  urologist.  We  daily  meet 
with  extreme  views :  one  asserting  the  patient  to  be 
innocuous  as  soon  as  the  discharge  is  reduced  to  the 
socalled  morning  drop;  the  other  (which  is,  to  say 
the  least,  a  blatant  anachronism)  that  infection  is 
never  cured ;  that  it  may,  phoenixlike,  apparently 
die,  and  slumber  in  its  own  ashes,  only  to  begin 


492 


MELTZER:   CURE  OF  GONORRHEA. 


[New  York 
Medical  Journal. 


life  afresh  five,  ten  or  twenty  years  after.  Both 
these  views  are  illogical ;  both  must  be  avoided.  The 
patient  is  either  infective  or  innocuous ;  which,  can 
and  must  be  determined.  If  infective  he  can  be 
cured  and  must  be  treated;  if  free  from  infection 
he  must  not  be  denied  connubial  privilege.  Before 
being  pronounced  clean,  his  condition  must  qualify 
according  to  a  criterion  embracing  the  following 
principles : 

All  specimens  of  urine  obtained  in  the  three  glass 
test  must  be  clear ;  three  smears  made  from  the 
affluent  of  the  entire  urethra  and  its  appendages, 
and  taken  on  alternate  days  must  be  negative ;  endo- 
scopic examination  must  be  negative  as  to  granu- 
lations and  verumontanitis ;  prostate  and  seminal 
vesicles  must  be  normal  to  the  touch  and  the  ure- 
thra practically  normal  in  calibre.  Patients  who 
successfully  pass  the  foregoing  tests  are  cured,  and 
it  is  our  practice  to  place  them  on  probation  for  a 
period  of  six  weeks,  at  the  end 'of  which  time,  if  the 
urine  has  remained  clear  and  sparkling,  no  further 
test  examinations  are  required,  and  the  patients  are 
formally  pronounced  cured  and  permitted  to  marry. 

If  the  method  delineated  in  the  foregoing  is  ad- 
hered to  with  conscientious  and  painstaking  at- 
tention to  details  the  practitioner  need  never  fear 
for  the  propriety  of  his  prognosis  or  the  safety  of 
his  reputation.  It  has  been  our  pleasurable  experi- 
ence to  follow  many  of  these  patients  to  the  point 
of  begetting  ofYspring  and  in  not  even  a  single  in- 
stance has  there  been  an  ill  consequence,  which, 
needless  to  say,  would  have  been  quickly  brought 
home  had  it  occurred. 

219  MooRE  Building. 


"WHEN  IS  GONORRHEA  CURED?" 

By  Maurice  Meltzer,  M.  D., 
New  York, 

The  question.  "When  is  gonorrhea  cured?"  is 
always  timely,  interesting  and  exceedingly  impor- 
tant. For  as  long  as  human  nature  remains  as  it  is, 
with  all  the  teaching  of  sex  hygiene,  prophylactic  in- 
struction and  an  attempt  to  divert  the  minds  of  men 
by  athletics  and  various  other  healthy  means  of 
recreation,  gonorrhea  will  probably  always  be  with 
us.  That  gonorrhea  is  a  serious  and  obstinate  dis- 
ease to  treat  will  not  be  denied  by  anyone  who 
sees  many  cases  and  attempts  to  cure  them.  \\'hile 
the  number  of  freshly  infected  patients  in  the  clinic 
or  at  the  office  of  the  specialist  is  always  numerous, 
how  much  more  numerous  are  the  chronic  or  so- 
called  gleet  cases.  The  complaints  of  patients  in  the 
latter  instances  date  back  from  a  few  months  to 
several  years,  in  many  instances  despite  more  or  less 
faithful  adherence  to  treatment  and  the  usual  gon- 
orrheal precautions.  Either  through  neglect  or  ill- 
directed  treatment,  patients  go  about  for 
months  or  years  wnth  symptoms  of  chronic  gonor- 
rhea or  recurrences,  and  if  ignorant  or  depraved 
they  are  a  distinct  menace  in  the  spread  of  the  in- 
fection. 

Authorities  differ  as  to  statistics,  because  even  in 
the  best  regulated  city  health  departments,  where 
physicians  are  required  to  report  venereal  diseases. 


many  cases,  for  various  reasons,  are  not  reported. 
At  best  a  statistical  study  can  only  be  a  relative  esti- 
mate. It  is  safe  to  assume  that  there  are  more  cases 
of  venereal  disease  than  is  apparent  from  a  glance 
at  tables  of  statistics  compiled  by  dif¥erent  men. 

Admitting  the  importance  of  the  medical  side  of 
the  question,  we  also  have  to  deal  with  the 
economic,  sociological  and  moral  issues ;  a  discus- 
sion of  the  subject  would  never  be  complete  without 
them.  The  decent,  self  respecting  man.  who 
unfortunately  had  an  attack  of  gonorrhea  is  ob- 
sessed, and  properly  so,  with  the  fear  of  marrying 
and  infecting  a  virtuous  girl.  This  point  is  em- 
phasized by  Abraham  Flexner  in  his  report  on 
prostitution  in  Evirope — "It  is  shocking  to  learn 
that  almost  one  third  of  the  reported  cases  of  gon- 
orrhea occurred  in  married  women  to  whom  infec- 
tion had  been  carried  by  their  husbands."  It  is  too 
well  known  that  so  many  gynecological  operations 
are  necessary  through  the  ignorance  or  wantonness 
of  an  uncured  husband  who  infects  his  wife. 

An  uncured  or  chronic  patient  with  gonorrhea  has 
dormant  foci  of  infection  in  various  parts  of  the 
urethral  canal,  prostate  or  seminal  vesicles,  which 
account  for  much  ill  health  and  invalidism.  A  per- 
sistent discharge,  inconveniencing  and  distressing 
urinary  symptoms  due  to  strictures,  or  inflammation 
of  the  posterior  urethra,  prostate  or  seminal  ves- 
icles, arthritic  or  muscular  pains  due  to  toxins  given 
off  by  the  gonococci — all  contribute  to  undermine 
health  and  morale.  It  is  difficult  to  calculate  the  num- 
ber of  working  days  lost,  as  a  direct  result  of 
severe  acute  symptoms,  gonorrheal  rheumatism,  or 
operations  for  the  relief  of  various  complications. 
Gonorrhea  is  considered  a  serious  disease ;  in  fact 
some  regard  it  on  a  par  with  syphilis.  Simple  acute 
anterior  urethritis,  even  under  the  best  circum- 
stances, frequently  extends  and  complications  set  in 
due  to  the  anatomical  arrangement  of  the  genito- 
urinary tract.  It  hardly  needs  further  elaboration 
to  convince  one  of  the  importance  of  follow^ing  out 
a  systematic  plan  to  determine  whether  a  patient  i- 
cured  of  his  infection.  The  following  examinations 
are  essential  in  determining  a  cure. 

MICROSCOPIC  EXAMINATION. 

In  making  a  microscopic  examination  of  any  dis- 
charge presenting  at  the  meatus  or  of  that  which 
can  be  expressed  along  the  course  of  the  urethra 
the  discharge  is  gathered  on  a  glass  slide,  and  is 
fixed  and  stained  '.vith  methylene  blue  solution  in 
the  usual  way.  The  slide  is  then  examined  for  the 
presence  of  pus  cells,  epithelia  and  bacteria.  Spe- 
cial search  is  made  for  the  intracellular  diplo- 
cocci.  In  chronic  or  subacute  cases,  gonococci  are 
seldom  found.  One  can  usually  distinguish  a 
chronic  discharge  by  the  scattered  fields  of  pus 
cells,  epithelia,  thin  strands  of  desquamating  tissue 
and  the  presence  of  specific  or  nonspecific  cocci.  A 
similar  examination  is  made  of  morning  drop  se- 
cretions. When  in  doubt  about  the  type  of  bacteria, 
a  gram  negative  stain  is  made.  Normally  there 
should  be  no  secretion  and  if  any  material  is  stained, 
it  should  not  show  any  pus.  Cases  wnth  redundant 
prepuce  often  show  a'  variety  of  bacteria,  due  to 
balanoposthitis. 

The  morning  drop  complaint  should  not  l^e  dis- 


October  2,  1920.] 


MELTZER:  CURE  OF  GONORRHEA. 


493 


missed  lightly ;  patients  are  at  times  told  to  disre- 
gard it,  as  it  is  only  "an  escape  of  spermatozoa  or 
spermatic  fluid."  It  should  always  be  examined  mi- 
croscopically and  as  long  as  pus  cells  are  seen,  there 
is  a  focus  somewhere  and  it  must  be  eradicated.  The 
presence  of  intracellular  diplococci  in  such  smears 
is  the  exception,  rather  than  the  rule. 

THE  TWO  GLASS  TEST. 

The  patient  is  asked  to  void  separately  into  two 
glasses,  and  the  urine  is  held  up  before  a  light  to 
note  whether  it  is  clear,  cloudy,  hazy  or  cloudy  and 
sanguineous.  The  terms  cloudy  and  hazy  are  arbi- 
trarily used  to  denote  the  degree  of  pus  in  the  urine, 
the  former  indicating  a  large  amount  of  pus.  If 
cloudy  or  hazy  a  small  amount  of  thirty-three  per 
cent,  acetic  acid,  is  added;  if  the  urine  remains 
cloudy  or  hazy  then  it  is  usually  due  to  pus ;  if  it 
clears  on  the  addition  of  acetic  acid,  phosphates  are 
the  cause  of  the  turbidity.  In  exceptional  cases 
when  the  urine  does  not  Ijecome  clear,  it  may  be 
due  to  marked  desquamation  of  epithelia ;  this  can 
be  differentiated  by  microscopic  examination.  For 
practical  purposes  the  urine  in  the  first  glass  is  taken 
to  represent  the  washings  of  the  anterior  urethra 
and  the  second  glass  that  of  the  posterior  urethra. 
Theoretically  this  is  incorrect.  For  the  sake  of  an- 
alogy, the  bladder  is  a  tank  which  empties  through 
a  pipe,  the  urethra,  which  is  divided  into  the  prox- 
imal or  posterior  and  distal  or  anterior  urethra. 
The  urine  in  the  first  glass  really  is  that  from  both 
the  posterior  and  anterior  urethrse,  for  coming  from 
the  bladder  it  washes  away  the  secretions  of  the 
entire  urethra.  Therefore  some  urologists  have 
adopted  a  five  or  seven  glass  test,  which  aims  to 
examine  separately  the  urine  or  washings  with  the 
secretions  from  the  anterior  and  posterior  urethrse 
and  from  the  prostate  and  seminal  vesicles. 
Practically,  the  two  glass  test  serves  its  purpose  well, 
when  it  is  carried  out  in  conjunction  with  a  system- 
atic routine  examination. 

The  number,  size  and  general  appearance  of  the 
shreds  in  a  clear  or  cloudy  urine,  are  noted ;  if  the 
urine  is  perfectly  clear  these  shreds  are  often  ex- 
amined microscopically  for  the  presence  of  gon- 
ococci.  The  urine  from  a  cured  patient  should 
show  clear  and  contain  few  shreds;,  such  shreds 
merely  represent  shedding  from  an  old  noninfective 
desquamating  surface. 

EXAMINATION  OF  THE  URETHRA  FOR  STRICTURE. 

Silk  rubber  bougie-a-houlcs  and  sounds  are  used 
for  this  purpose.  The  largest  size  bougic-a-boule  or 
sound  to  pass  the  meatus  is  tried  first.  It  is  in- 
teresting to  note  that  many  individuals  present  meati 
that  do  not  admit  anything  much  larger  than  French 
number  20;  this  in  itself  in  some  cases  may  in- 
terfere with  the  proper  drainage  of  urethral  secre- 
tions. In  such  cases  a  meatotomy  up  to  number 
30  French  is  indicated.  The  bougie  is  gently  passed 
down  to  the  bulbomembranous  junction  (the  site 
of  the  external  urinary  sphincter  and  the  anterior 
layer  of  the  triangular  ligament.)  It  is  then  gently 
withdrawn.  If  there  is  any  narrowing  of  the  ure- 
thral calibre,  or  if  there  are  any  chronic  inflamma- 
tory bands  or  ridges  along  the  course  of  the  urethra, 
these  are  felt  to  catch  on  the  neck  of  the  olivary  tip 
of  the  bougie.    Often  several  such  tugs  are  felt 


over  indurated  ridges,  giving  the  sensation  of  a  cob- 
ble stone  surface.  In  soft  or  freshly  forming  stric- 
tures, the  passage  of  such  a  soft  elastic  instrument 
often  produces  some  bleeding.  The  size  of  a  stric- 
ture, if  present,  is  noted  by  the  size  of  the  bougie 
which  it  will  allow  to  pass.  The  largest  sized  sound 
to  pass  the  meatus  is  then  gently  passed  through 
the  entire  urethra  and  into  the  bladder ;  the  sound 
is  now  withdrawn.  Normally,  a  sound  passes  in 
and  out  of  the  urethra  by  its  own  weight.  A  stric- 
ture, or  one  that  is  forming,  grasps  the  sound  as  if 
between  the  jaws  of  a  vise.  This  grasping  sensa- 
tion is  quite  characteristic  of  stricture  formation. 
If,  in  spite  of  gentle  technic,  bleeding  occurs,  it  is 
usually  pathognomonic  of  a  soft  or  freshly  form- 
ing stricture. 

EXAMINATION     OF    THE    PROSTATE    AND  SEMINAL 
VESICLES. 

It  is  advisable  to  first  fill  the  bladder  with  a 
solution  of  boric  acid  or  weak  silver  nitrate  solu- 
tion, for  a  distended  -bladder  allows  for  a  better 
examination  of  the  prostate  and  seminal  vesicles, 
which  are  brought  down  closer  to  the  examining 
finger  in  the  rectum.  By  a  gentle  sweeping  of  the 
finger,  the  siz^e,  consistency,  tenderness  and  the 
presence  of  fibrous  adhesions  are  noted ;  often  one 
lobe  is  larger  than  the  other  and  firm  nodules  may 
be  present  in  one  or  both  lobes.  The  vesicles  in 
some  cases  are  sausage  shaped.  The  prostate  and 
vesicles  are  gently,  yet  firmly  rubbed  from  above 
downward,  not  laterally.  The  secretion  expressed 
is  caught  on  a  glass  slide  and  is  either  examined  in 
the  wet  state  or  dried,  fixed  and  stained  with 
methylene  blue.  A  search  is  made  for  pus  and 
bacteria.  The  importance  of  this  examination  is  to 
note  the  presence  and  the  amount  of  pus  cells. 
This  examination  should  be  repeated  several  times 
in  the  course  of  a  few  weeks.  The  number  of  pus 
cells,  as  a  matter  of  convenience  and  routine,  can 
be  indicated  by  the  use  of  plus  signs.  Four  plus 
would  indicate  that  practically  every  field  examined 
shows  an  abundance  of  pus  cells  such  as  is  seen  in 
an  ordinary  urethral  smear.  Fewer  pus  cells  are  in- 
dicated by  two  or  one  plus ;  or,  the  examiner  can 
use  the  terms  small,  moderate  or  large  amount  of 
pus.  It  is  the  exception  rather  than  the  rule  to  find 
intracellular  diplococci  in  such  smears.  As  other 
organisms  can  induce  prostatitis,  such  secretion  ob- 
tained by  massage  is  often  cultured  for  the  identi- 
fication of  the  organisms.  Repeated  smears  should 
.show  no  pus  or  but  few  very  scattered  fields  in  a 
cured  case. 

CYSTOURETHROSCOPIC  EXAMINATION. 

This  examination  is  a  visualization  of  the  entire 
urethra  from  the  bladder  neck  down  to  the  meatus. 
The  irrigating  instruments  of  the  McCarthy,  Buer- 
ger or  Greenberg  types  are  ideal  for  this  exami- 
nation. They  give  splendid  illumination  and 
magnification ;  perfect  detail  of  the  mucosa  is  ob- 
tained. The  irrigating  fluid  washes  away  bleeding 
surfaces  or  sheds.  In  the  fluid  medium,  pus  appears 
as  rice  flakes.  One  doing  such  examinations  can- 
not but  be  impressed  with  the  variety  of  lesions  met 
in  the  urethra.  In  spite  of  clear  urine  and  in  some 
cases  without  any  symptoms  such  lesions  can  re- 
main undetected  and  can  keep  up  the  infection  for 


494 


GOODMAN:  ADMINISTRATION    OF  ARSPHEN AMINE. 


[New  York 
Medical  Journal. 


years  and  act  as  foci.  The  lesions  encountered  in 
the  posterior  urethra  are :  Uniform  turgescence,  so 
that  the  mucosa  bleeds  easily  (soft  infiltrations)  ; 
erosions,  granulations,  or  desquamations ;  congestion 
or  enlargement  of  the  verumontanum  or  polyps  or 
vegetations  or  cystic  conditions  on  or  about  the 
verumontanum.  In  the  anterior  urethra ;  Soft  in- 
filtrations, hard  infiltrations  (characterized  by  spe- 
cial paleness  of  the  mucosa  which  later  on  becomes 
a  yellowish  white,  or  the  urethra  appears  in- 
elastic and  is  actually  the  seat  of  true  stricture  for- 
mation) ;  on  the  roof  and  lateral  walls  the  glands 
of  Littre  and  the  crypts  of  Morgagni  are  bright 
red  in  appearance  and  are  the  seat  of  subacute  or 
chronic  inflammation ;  erosions  and  desquamating 
surfaces  are  often  seen  on  the  floor.  Cystoure- 
throscopy  is  therefore  a  very  important  examina- 
tion in  that  it  calls  attention  to  lesions  that  may 
never  be  suspected,  and  in  that  appropriate  treat- 
ment can  be  instituted  to  cure  them.  It  is  most 
gratifying  to  the  examiner  to  note  by  subsequent 
examinations  the  improvement  or  cure  of  such  le- 
sions after  a  rational  method  of  treatment. 

COMPLEMEXT  FIXATION  TEST  OF  THE  BLOOD. 

This  is  a  serological  test  similar  to  and  based  on 
the  same  principle  as  the  Wassermann  test  for  syph- 
ilis, and  like  the  W'assermann  test  it  is  only  of  value 
in  conjunction  with  clinical  findings.  A  positive 
complement  fixation  test  without  symptoms  should 
institute  a  quest  for  foci.  On  the  other  hand,  numer- 
ous patients  are  seen  with  symptoms  and  objective 
evidence  of  chronic  gonorrhea  who  give  a  negative 
test.  Obviously  a  negative  test  in  such  cases  is  of 
no  value.  In  acute  cases,  in  discharging  patients  as 
cured  it  should  be  remembered  that  the  comple- 
ment fixation  test  should  be  done  about  two  to  three 
months  after  the  infection  has  presumably  been 
cured.  On  the  other  hand,  if  the  blood  is  positive 
and  all  the  other  examinations  show  no  evidence  of 
infection,  then  this  positive  test  should  carry  no 
more  weight  than  a  positive  Wassermann  test  witli- 
out  any  cHnical  or  laboratory  manifestations  of 
syphilis.  A  positive  test  helps  in  the  diagnosis  of 
rheumatic  joints. 

CULTUR.\L    METHODS    FOR    THE    ISOLATION    OF  THE 
GONOCOCCI. 

Usually  the  methylene  blue  and  gram  negati\e 
stains  are  sufficient  for  the  identification  of  the  gon- 
ococcus.  In  chronic  cases  where  the  bacteriological 
examinations  shoW  a  variety  of  bacteria  in 
smears,  to  establish  definitely  a  diagnosis  of  gon- 
orrhea, the  secretions  from  the  genitourinary 
tract  should  be  cultured.  The  secretions  must 
be  grown  on  suitable  culture  media.  In  a  paper  of 
this  kind  the  technical  laboratory  details  are  omit- 
ted ;  these  are  lucidly  explained  in  standard  bacteri- 
ological works.  In  the  male  the  secretions  from  the 
urethra,  bladder,  prostate  and  seminal  vesicles  and  in 
the  female  those  of  the  urethra,  bladder,  cervix  and 
vagina  are  utilized.  This  method  is  of  great  im- 
portance in  differential  diagnosis  of  inflammation 
in  the  female  and  often  oflfers  the  only  absolute  way 
of  deciding  whether  the  gonococcus  is  the  etiological 
factor.  This  method  should  be  utilized  when  re- 
peated smear  examinations  show  pus  but  no  bac- 
teria. 


COMMENT. 

Gonorrhea  can  be  cured.  In  acute  cases  a  cure 
may  even  require  three  months  or  longer.  In  chronic 
cases  a  much  longer  time  is  required,  depending  on 
the  objective  findings  in  the  individual  case.  The 
old  antiquated  method  of  suggesting  a  sexual  or 
alcoholic  spree,  to  see  whether  a  urethral  discharge 
is  noted  thereafter,  should  be  condemned  because 
it  is  unreliable  and  unscientific.  Likewise  the  ex- 
amination of  a  condom  specimen  for  the  presence 
of  gonococci  is  not  enough.  Too  often  laboratory 
reports  of  centrifuged  urines  or  prostatic  and  semi- 
nal vesicle  smears  simply  state  that  no  gonococci 
are  found,  but  with  no  mention  of  the  presence  or 
the  amount  of  pus,  which  is  an  indicator  of  a  focus. 
It  is  only  by  a  systematic  routine  examination  that 
one  can  tell  whether  a  patient  is  free  from  infec- 
tion. What  is  still  more  important  foci  or  lesions 
are  so  often  discovered  that  would  have  gone  on 
unnoticed. 

1.  A  cured  patient  should  present  no  morning 
drop  or  urethral  secretion  at  any  time  of  the  day. 
2.  Microscopical  examination  should  show  no  pus 
or  gonococci  in  the  urine,  prostatic,  or  seminal  ves- 
icle smears.  3.  The  urine  should  be  clear,  though 
in  some  cases  small  noninfective  desquamating 
shreds  may  persist.  4.  The  urethral  lumen  should 
be  free  from  any  narrowing  or  stricture  formation. 
5.  The  complement  fixation  test  should  be  negative 
in  conjunction  with  the  other  findings.  6.  In 
doubtful  cases  the  secretions  from  the  genitouri- 
nary organs  should  l^e  cultured  to  prove  the  ab- 
sence of  gonococci  on  suitable  culture  media.  7. 
Cystourethroscopic  examination  should  show  the 
urethra  free  of  lesions. 

115  West  Sixteenth  Street. 


THE   INTENSIVE   ADMINISTR^^TION  OF 
ARSPHENAMINE. 

By  Herman  Goodman,  B.  S.,  M.  D., 
New  York. 

Since  the  publication  of  the  reports  (1)  of  the 
treatment  of  women  with  arsenobenzol  and  neodiar- 
senol  requests  for  the  result  of  this  form  of  therapy 
in  men  have  been  received. 

The  following  serves  as  a  report  of  the  intensive 
specific  therapy  in  eighty  hospitalized  syphilitic 
negro  patients.  The  cases  were  divided  among  the 
syphilitic  periods  as  follows : 

Primary  syphilis,  twenty-eight  cases ;  silent 
generalization,  twenty-three  cases ;  secondary 
syphilis,  sixteen  cases ;  latent  tertiary,  four  cases ; 
active  tertiary,  nine  cases.  Diagnosis  in  primary 
cases  was  made  by  the  demonstration  of  the  spiro- 
chaeta  pallida  in  cases  where  the  diagnosis  was  at 
all  doubtful  clinically  (2). 

We  regarded  the  history  as  of  little  value.  The 
stated  incubation  time  cannot  be  reliable  with  men 
who  are  repeatedly  exposing  themselves  to  infection. 
Even  the  duration  given  by  the  patient  was  more 
often  than  not  at  variance  with  the  known  course 
of  the  disease.  Men  told  us,  with  no  intent  to 
deceive,  that  the  lesion  on  the  penis  had  been  there 


OctAei  2,  1920.] 


GOODMAN:  ADMINISTRATION   OF  'ARSPHEN AMINE. 


495 


onlv  two  or  three  days,  yet  the  inguinal  nodes  were 
enlarged  and  the  ^\'assern-lann  test  was  reported 
four  plus  positive- 

As  often  demonstrated  before,  the  frenum  is  a 
point  of  lowered  resistance  to  the  entry  of  the 
spirochxta  pallida,  and  at  least  half  of  our  patients 
presented  the  initial  lesion  in  this  location.  In  not  a 
few  of  these  cases,  neglect  and  secondary  infection 
leading  to  ulceration  had  proceeded  to  such  an  extent 
that  the  corpora  cavernosa  and  corpus  spongiosum 
were  exposed  for  over  an  inch.  In  our  opinion 
practically  every  lesion  at  the  frenum  harbors  the 
spirochseta  pallida. 

We  rarely  saw  the  indurated,  ulcerated  papular 
chancre  which  bears  Hunter's  name.  The  ulcerated 
lesions  we  did  see  were  usually  larger  and  the 
tumor  character  was  absent.  One  type  of  initial 
lesion  was  presented  by  multiple  lesions  of  the  free 
edge  of  the  prepuce,  a  sort  of  rosette,  which,  because 
of  the  accompanying  edema,  resulted  in  an  artificial 
phimosis.  Another  fairly  common  type  of  initial 
lesion  was  one  of  the  meatus  urinaris.  The  sclerosis 
was  situated  either  on  the  mucous  surface  or  on  the 
skin  border. 

Patients  were  admitted  with  the  clinical  diagnosis 
of  primary  syphilis  who  had  passed  the  primary 
serological  stage  and  were  in  the  stage  of  silent 
generalization.  These  patients  presented  chancres, 
no  secondary  lesions  of  the  skin  or  mucous  mem- 
branes but  the  Wassermann  tests  were  reported 
positive  four  plus  (3).  Twenty-three  patients  were 
in  this  group.  This  emphasizes  the  conclusion  that 
a  genital  lesion  is  often  lightly  considered  and  no 
medical  advice  or  treatment  is  sought  until  the 
organ  is  so  distorted  as  to  be  useless.  I  have 
seen  instances  of  destruction  of  the  entire  glans 
penis,  for  example,  for  which  the  patient  had  had 
no  prior  treatment. 

I  had  surprisingly  few  recent  secondary  cases  to 
deal  with.  Of  the  eighty  patients  under  treatment 
sixteen  were  in  the  generalized  secondary  period. 
Among  the  skin  lesions  I  saw  one  corymbiform 
s\-philide.  one  circinate  secondary  lesion,  examples 
of  macular  and  papular  syphilides,  a  number  of 
recurrent  secondary  syphilides,  and  five  men  with 
condylomata  lata.  Mucous  patches  were  also  seen. 
In  the  majority  of  cases  the  patients 'had  had  no 
modern  treatment  and  in  all  too  many  cases  self- 
treatment  alone  had  constituted  the  previous  therapy. 
Three  cases  were  diagnosed  by  the  serological  re- 
action. These  cases  were  in  the  latent  tertiary- 
period  and  presented  no  lesions. 

One  patient  was  admitted  for  bed  wetting. 
Clinically  he  presented  no  syphilitic  lesions  but  the 
routine  '\\'assermann  reaction  was  four  plus  positive. 
Incidentally,  arsphenamine  therapy  did  not  improve 
his  sad  condition. 

Nine  patients  were  admitted  with  active  tertiary 
manifestations  of  syphilis.  The  age  of  the  infection 
varied  from  two  to  eight  years.  This  group  of  men 
presented  gummatous  infiltration  of  circumcision 
wounds,  ulcerating  groin  adenitis,  in  one  case 
gimima  of  the  tongue,  and  in  a  second  case,  gumma 
of  the  shaft  of  the  penis  at  the  site  of  his  primary- 
lesion  five  years  before  (chancre  redux). 

The  plan  of  treatment  was  on  lines  laid  down 


by  Dr.  S.  PoUitzer  (4).  This  plan  I  have  termed 
the  intensive  method  in  distinction  to  the  intermit- 
tent method.  The  intensive  method  consists  of  the 
daily  administration  intravenously  of  arsphenamine 
for  three  doses.  Each  dose  consists  of  four  deci- 
grams dissolved  in  fifty  c.c.  of  freshly  distilled  and 
boiled  water,  and  then  alkalinized  to  comparative 
neutrality  with  fifteen  per  cent,  sodium  hydroxide 
I  5  ) .  This  mode  of  treatment  is  a  desirable  variant 
of  the  therapia  stcrilisans  magna  of  Ehrlich. 

The  theoretical  reason  for  the  failure  of  this 
method  was  that  the  single  dose  killed  a  large 
number  of  spirochetes  but  that  some  few  escaped  and 
later  by  multiplication  were  nearly  as  numerous  as 
before,  sensitized  to  arsenic  and  more  dangerous. 
Another  reason  was  that  the  excretion  of  the  ar- 
sphenamine was  begim  almost  as  soon  as  injected 
and  that  in  the  first  few  hours  most  of  the  drug 
was  out  of  the  body. 

The  only  figures  we  had  access  to  were  those  in 
Wolbarst's  (6)  translation. 

Parahtics  given  0.3  gm.  intravenously. 

First    day    0.0072  gm.  arsenic  found. 

Second  day  0.0792  gm.  arsenic  found. 

Third  day   0.0053  gm.  arsenic  found. 

Fourth  day  negative. 

Investigations  in  other  patients  showed  the  same 
results,  the  excretion  of  arsenic  having  been  com- 
pleted within  two  or  three  days. 

Since  arsphenamine  is  essentially  thirty  per  cent, 
arsenic,  it  appears  that  injected  intravenously, 
ninety  per  cent,  is  excreted  by  the  kidneys  in  the 
first  three  days.  The  intensive  method  counter- 
acts both  of  these  undesirable  features  because  the 
concentration  of  the  arsenic  product  in  the  blood 
is  kept  at  an  efficient  high  level.  Following  the 
intravenous  medication,  mercury  salicylate  in  grain 
doses  was  given  once  each  week. 

It  has  been  our  experience  that  the  negro  is  a  bad 
subject  for  mercurial  therapy  because  of  the  ease 
with  which  even  small  doses  cause  stomatitis.  This 
occurs  despite  the  care  that  the  patients  take  of 
their  teeth  and  gums.  They  used  tooth  brushes  twice 
daily  and  the  mouth  wash  after  each  meal.  We 
painted  the  gtmis  also  with  a  mixture  of  equal  pai'ts 
of  tincture  of  iodine  and  myrrh  but  the  results  were 
not  gratifying  subjectively.  In  bad  cases  we  had 
the  buccal  cavity  put  into  good  condition  lefore  we 
administered  mercury. 

Although  it  is  too  early  to  speak  of  the  end  re- 
sults of  the  intensive  method  for  using  arsphena- 
mine, it  is  possible  to  note  that  the  manifestations 
were  speedily  cleaned  up.  Uncomplicated  syphilitic  le- 
sions disappeared  within  a  very  short  time.  Early 
chancres  and  condylomata  lata  were  readily  amen- 
able. In  other  words  the  infectious  lesions  w-ere 
soon  destro\-ed.  The  patients  that  remained  in  bed 
for  a  long  period  were  those  with  secondarily  in- 
fected lesions,  and  syphilitics  with  other  than  syph- 
ilitic manifestations.  In  several  instances  of  sec- 
ondarily infected  incised  inguinal  glands  the  intra- 
venous therapy  alone  did  not  heal  the  lesion,  but  in 
several  cases  which  gave  fluctuation  of  a  gland  that 
was  not  incised,  the  intravenous  medication  relieved 
the  swelling.  In  addition  the  general  effect  of  this 
intensive  therapy  on  the  patient  has  been  exceedingly 
gratifying. 


496 


HVMAN:  POST ARSPHEN AMINE  JAUNDICE. 


[New  York 
Medical  Journal. 


We  have  seen  no  important  ill  effects.  In  one 
case,  the  second  dose  of  the  preparation  we  were 
using  gave  symptoms  of  intolerance  and  we  inter- 
rupted the  course.  The  drug  which  gave  this  was 
salvarsan,  but  on  the  same  day  eleven  other  patients 
received  the  same  preparation  without  any  ill  effect. 
On  odd  occasions,  a  patient  would  vomit  after  par- 
taking of  the  light  repast  provided  six  hours  after 
receiving  the  injection.  This  did  not  contraindicate 
further  use  of  the  drug,  but  the  patient  went  with- 
out his  luncheon  thereafter.  The  greater  number 
of  the  patients  received  arsenobenzol  (Schamberg) 
which  gives  remarkably  few  reactions  of  any  kind. 
We  find  that  this  preparation  dissolves  more  readily 
now  than  formerly. 

SUMMARY. 

Eighty  hospitalized  syphilitic  negro  men  were 
given  the  intensive  arsphenamine  treatment  as  sug- 
gested by  Pollitzer.  The  clinical  results  were  im- 
mediate in  all  uncomplicated  syphilitic  manifesta- 
tions. The  infectiousness  of  the  patient  was  re- 
duced thereby  much  quicker  than  with  the  same 
amount  of  the  arsphenamine  introduced  intraven- 
ously by  the  socalled  intermittent  method.  The 
changes  in  serology  were  most  encouraging,  but  no 
attempt  is  made  to  base  conclusions  on  them.  Ref- 
erence to  the  former  publications  on  this  method 
will  give  information  on  this  phase  of  the  subject. 

W'ith  no  further  precaution  than  that  taken  for  the 
administration  of  arsphenamine  intermittently,  the 
eighty  men  were  given  this  intensive  form  of  treat- 
ment with  excellent  results,  and  we  do  not  hesitate 
to  recommend  the  procedure  for  more  general  use 
by  those  especially  skilled  in  the  application  of  ar- 
sphenamine as  generally  administered. 

The  public  health  value  of  this  method  of  therapy 
should  be  emphasized  since  the  period  of  hospitaliza- 
tion of  infectious  syphilitic  persons  is  much  re- 
duced. This  is  an  important  consideration  in  the 
prophylaxis  of  syphilis  by  treatment. 

REFERENCES. 

1.  Goodman:  The  Intensive  Treatment  of  Women  with 
Arsenobenzol,  American  Journal  of  SyphUis,  3,  449,  1919: 
The  Intensive  Treatment  of  Women  with  Neodiarsenol. 
American  Journal  of  Syphilis,  3,  661,  1919. 

2.  Idem:  Diagnostic  Demonstration  of  Spirochseta 
pallida,  Interstate  Medical  Journal,  January,  1919. 

3.  Idem:  Diagnosis  and  Treatment  of  Syphilis  in  Men, 
American  Journal  of  Syphilis,  2,  344,  1918. 

4.  Pollitzer,  S.  :  Journal  of  Cutaneous  Diseases,  Sep- 
tember, 1916. 

5.  Goodman  :  Preparation  of  Salvarsan  and  Arseno- 
benzol for  Intravenous  Use,  New  York  Medical  Journal, 
April  15,  1918. 

6.  Wolbarst,  a.  L.  :  The  Treatment  of  Syphilis  ivith 
Salivrsan,  by  Wechselmann,  Rebman  Company,  1911,  p.  85. 

15  Central  Park  West. 


Injections  of  Milk  in  the  Treatment  of  Gonor- 
rhea and  Venereal  Adenitis. — M.  Trossarello 
(La  Rifonna  Medico,  April  3,  1920)  has  had  ex- 
cellent results  in  these  conditions  with  the  injection 
into  the  gluteal  muscles  of  sterilized  milk  in  doses 
of  from  five  to  ten  c.c.  Five  injections  were  given 
at  intervals  of  two  or  three  days.  There  was  in 
each  case  a  marked  reaction  with  elevation  of  tem- 
perature and  local  reaction  which  soon  disappeared 
and  was  less  marked  after  each  injection. 


FATAL  POSTARSPHEXAMINE  JAUNDICE.* 

By  Albert  S.  Hyman,  M.  D., 
Boston, 

Assistant  Resident  Physician,  Long  Island  Hospital. 

Toxic  jaundice  following  the  intravenous  ad- 
ministration or  arsphenamine,  while  not  uncommon 
in  large  syphilitic  clinics,  is  always  of  sufficient 
prognostic  significance  to  command  attention.  A  re- 
cent paper  by  Lynch  and  Hoge  ( 1 )  has  pointed  out 
the  paucity  of  medical  literature  upon  this  subject, 
especially  in  regard  to  the  fatal  cases  which  occur 
but  rarely.  These  authors  have  collected  a  total  of 
four  fatal  cases  from  an  intensive  survey  of  the 
literature ;  two  reported  by  Fenwick,  Sweet  and 
Lowe  (2),  one  by  Veale  and  Wedd  (3),  and  one 
from  their  own  series. 

In  a  review  of  several  thousand  doses  of  arsphen- 
amine given  at  the  Venereal  Clinic  of  the  Long 
Island  Hospital  we  have  been  able  to  demonstrate 
seven  cases  of  toxic  jaundice  which  were  undoubt- 
edly due  to  this  specific  drug.  All  but  one  of  the 
patients  recovered,  and  since  this  is  apparently  ttie 
fifth  case  to  have  occurred,  we  believe  it  to  be  of 
sufficient  interest  to  be  recorded. 

This  case  is  made  the  more  interesting  in  that 
the  condition  was  produced  by  a  single  dose  of 
arsphenamine,  while  the  cases  previously  reported 
followed  a  series  of  intensive  treatments.  The  pa- 
tient remained  in  the  hospital  throughout  her  illness 
and  this  made  possible  an  exceptionally  complete 
study  of  her  condition  from  every  possible  angle. 
Moreover,  she  appeared  at  a  time  when  I  was  in- 
vestigating the  causes  of  the  postadministrative  re 
actions  ot  arsphenamine  (4)  and  for  this  reason 
the  laboratory  reports  of  her  case  are  of  consider- 
able value. 

Case. — The  patient  (Hospital  Number  40014) 
was  a  very  well  developed  and  nourished  woman, 
thirty  years  old,  weighing  about  170  pounds,  who 
entered  the  venereal  service  of  the  hospital  for  the 
treatment  of  gonorrhea  contracted  maritally.  Her 
previous  history  was  unimportant  save  that  there 
was  a  suggestion  of  luetic  infection  from  her  story 
of  frequent  miscarriages. 

Her  physical  examination  was  entirely  negative 
except  for  a  slight  leucorrhea,  a  smear  from  which 
showed  Neisser's  organism  in  large  numbers.  A 
blood  Wassermann  was  found  to  be  positive  and  she 
was  accordingly  transferred  to  the  syphilitic  division 
for  treatment. 

On  January  24,  1919,  she  received  four  tenths 
gram  of  arsphenamine  intravenously.  She  suffered 
a  slight  immediate  reaction  with  nausea  and  some 
vertigo,  but  on  the  following  day  she  had  entirely 
recovered.  About  five  days  later  she  began  to  com- 
plain of  a  general  weakness  and  lassitude,  the  like 
of  which  she  had  never  experienced  before.  With 
the  exception  of  a  slightly  reddened  throat  her 
physical  findings  were  negative.  Laboratory  exami- 
nation of  a  twenty-four  hour  specimen  of  urine 
showed  nothing  of  importance.  i\ll  antisyphilitic 
treatment — mercury  and  potassium  iodide — was 
stopped. 

For  the  next  two  weeks  the  patient  continued  to 

•From  the  Venereal  Service  of  the  Long  Island  Hospital. 


October  2,  1920.] 


HYMAN:  POSTARSPHEN AMINE  JAUNDICE. 


497 


grow  weaker  without  any  other  signs  developing ;  on 
February  21st,  about  one  month  after  receiving  the 
arsphenamine,  she  showed  a  shght  icteroid  tint  in 
tlie  sclerse.  No  bile  was  found  in  the  urine.  A 
well  marked  jaundice  was  seen  the.  following  day 
and  bile  was  easily  demonstrated  in  the  urine ;  fecal 
bile  was  found  in  normal  amounts.  As  the  jaun- 
dice increased  the  prostration  became  more  marked 
so  that  the  patient  was  obliged  to  remain  in  bed. 

At  this  time  she  began  to  complain  of  a  terrific 
burning  pain  in  the  right  thigh  which  was  not  well 
localized.  Small  areas  of  hyperesthesia  the  size  of 
a  silver  quarter  could  occasionally  be  marked  out 
upon  the  anterior  surface  of  the  thigh.  On  the 
following  day,  small  purpuric  spots  were  seen 
developing  over  the  areas  just  described.  The  pain 
accompanying  the  development  of  these  ecchymotic 
areas  was  so  great  that  sedatives  were  required  to 
comfort  the  patient. 

From  this  time  on  purpuric  areas  continued  to 
develop  over  all  parts  of  the  body.  The  jaundice 
was  increasing  in  severity ;  the  stools  still  contained 
bile,  while  the  urine,  of  course,  showed  it  in  large 
amounts.  There  was  apparently  no  change  in  the 
size'  of  the  liver  or  spleen.  On  February  26th  the 
patient  began  to  vomit  bile  stained  fluid  which 
microscopically  showed  little  of  interest.  Purpuric 
spots  then  developed  upon  the  mucous  membranes 
of  the  mouth  and  pharynx  and  the  vomitus  gradually 
became  coffee  ground  in  appearance  and  was  found 
to  contain  much  blood.  Occult  blood  was  founa 
in  the  stools. 

Previous  weekly  examinations  showed  the  blood 
to  be  normal.  Examination  at  this  time  showed; 
erythrocytes  5,600,000;  leucocytes  13,000;  hemo- 
globin (Sahli)  100  per  cent.;  no  erythroblasts,  no 
anisocytosis  or  poikilocytosis.  A  dififerential  leu- 
cocyte count  showed :  Seventy-four  per  cent,  poly- 
morphonuclears, twenty-five  per  cent,  mononuclears, 
and  one  per  cent,  eosinophiles.  Clotting  time  of  the 
blood  was  found  to  be  slightly  increased.  Blood 
pressure  .as  at  entrance  was  systolic  110,  diastol- 
ic 75. 

Urine  examination :  twenty-four  hour  volume 
960  c.c. ;  dark  brown  in  color ;  slightly  alkaline, 
albumin  found  in  small  traces ;  no  sugar ;  bile  pig- 
ments in  large  amounts ;  no  blood ;  Marsh  tests 
for  arsenic  negative.  Centrifuged  sediment  showed 
granular  bile  stained  casts,  a  few  epithelial  cells 
and  leucocytes. 

Stool  examination :  formed,  soft,  dark  brown, 
normal  odor,  no  gross  mucus  or  blood.  Chemical 
examination :  alkaline,  bile  present,  occult  blood 
found  in  large  amounts.  Marsh  test  for  arsenic 
negative.  Microscopic  examination :  many  un- 
digested meat  fibres,  unchanged  fat  globules  in 
excess,  many  erythrocytes  ;  no  pus  cells. 

For  a  brief  period  the  patient  seemed  to  be  getting 
better ;  the  vomiting  ceased,  the  patient  looked  and 
felt  better.  The  jaundice  continued  to  increase 
however,  and  on  March  20th,  she  was  forced  to 
return  to  bed  again.  The  weakness  and  apathy  re- 
turned and  the  purpuric  spots  became  more  tender. 
A  painful  molar  having  developed,  the  dentist  was 
consulted  and  he  extracted  four  loosened  teeth 
without  great  difficulty. 


Due  apparently  to  the  great  increase  in  the 
coagulation  time  of  her  blood,  which  upon  test  was 
found  to  be  delayed  forty  minutes  in  comparison 
with  a  previous  test  which  showed  a  delay  of  six 
minutes,  the  patient  continued  to  *bleed  profusely 
from  the  gums.  Application  of  local  hemostatic 
solutions  were  of  slight  avail.  During  the  night, 
the  patient  swallowed  much  of  the  blood  and  on  the 
following  morning  vomited  a  considerable  quantity 
of  partially  digested  blood  with  some  mucus. 

The  patient's  condition  became  so  poor  that  an 
immediate  transfusion  of  whole  blood  was  decided 
upon.  Accordingly,  Dr.  L.  H.  Rockwell  and  my- 
self, using  the  Kimpton  tube  method  and  securing" 
about  450  c.c.  of  blood  from  a  satisfactory  donor, 
transfused  the  patient. 

For  a  short  interval  following  the  transfusion, 
the  patient's  pulse  and  general  condition  seemed 
to  be  considerably  improved,  although  the  oozing 
from  the  gums  still  persisted.  Subpectoral  salt 
solution  was  given  and  a  rectal  tap  apparatus 
started.  The  patient  continued  to  go  down  hill, 
however,  and  after  sinking  into  a  semidelirious 
state  died  soon  afterwards. 

The  postmortem  findings  so  approximate  those 
previously  described  by  Lynch  and  Hoge  as  to  be 
almost  identical.  They  reported  that  "the  post- 
mortem examination  revealed  hemorrhagic  phen- 
omena in  one  or  more  of  the  viscera  of  all  the 
bodies.  In  one  of  the  cases  the  petechial  hem- 
orrhages were  present  in  almost  all  of  the  viscera, 
but  especially  in  the  walls  of  the  stomach  and  small 
intestines.  There  were  a  few  points  of  hemorrhage 
in  the  kidney  and  visceral  pleura.  The  other  cases 
showed  the  walls  of  the  stomach  and  intestine 
deeply  injected.  The  pancreas  seemed  free  from 
gross  pathological  lesions.  Microscopically  the 
kidneys  showed  a  type  of  tubular  nephritis  much 
like  that  seen  in  cases  of  mercurial  poisoning.  The 
liver  was  small  and  mottled.  It  did  not  favor 
identically  any  of  the  more  common  types  of  cir- 
rhosis. There  was  little  or  no  fatty  degeneration 
in  any  of  the  specimens  examined. 

The  stomach  in  our  case  showed  a  large  area  of 
submucosal  hemorrhage  upon  its  lesser  curvature. 
There  seemed  to  be  many  small  bleeding  points  near 
the  pyloric  end  of  this  area  which  also  showed 
numerous  tiny  varices.  This  would  tend  to  indicate 
that  the  blood  which  was  found  in  the  vomitus  was 
not  due  entirely  to  that  which  was  swallowed. 

The  liver  differed  in  some  degree  from  previous 
findings  in  these  cases.  It  was  slightly  larger  than 
normal,  and  purplish  red  in  color.  The  surface  was 
smooth  and  resistant.  The  cut  surface  was  essen- 
tially normal  in  appearance ;  there  was  no  evidence 
of  fatty  degenerative  changes.  The  gallbladder  was 
large  and  filled  with  many  stones ;  the  ducts  were 
patent  and  no  obstruction  of  any  kind  was  found. 
All  of  the  tissues  of  the  body  were  deeply  stained 
with  bile  pigments.  The  spleen  showed  nothing  of 
interest. 

COMMENT. 

The  interest  in  these  cases  is  focused  upon  the 
etiological  factors  responsible  for  the  condition. 
To  a  great  extent  the  symptomatology  and  patho- 
logical findings   point  incriminatingly  toward  the 


498      STRICKLER:  REACTIONS  FOLLOWING  ARSPHENAMINE  ADMINISTRATION.        [New  York 

Medical  Journal. 


employment  of  arsphenamine  and  the  unusual 
response  of  the  body  toward  the  arsenic  containing 
drugs.  The  story,  however,  is  not  a  clear  cut  one 
either  of  acute  or  chronic  arsenic  poisoning.  In 
the  case  just  reviewed,  the  symptoms  were  late  in 
developing  and  insidious  in  origin.  It  is  somewhat 
difficult  to  believe  that  the  small  quantity  of  arsenic 
— about  122  mg. — which  was  contained  in  the  first 
and  only  dose  of  arsphenamine  that  was  adminis- 
tered, was  capable  of  producing  all  of  the  subse- 
quent symptoms  and  finally  the  death  of  a  patient 
who  apparently  was  in  excellent  physical  condition 
prior  to  the  beginning  of  her  antisyphilitic  treatment. 

Previous  writers  have  commented  upon  the  un- 
expected histological  picture  found  in  the  kidneys 
in  these  cases,  and  invariably  they  have  described 
the  renal  findings  as  being  comparable  to  those  seen 
in  mercuric  poisoning.  This  suggests  that  there  may 
be  other  factors  concerned  in  the  production  of  the 
condition.  In  all  of  the  cases  described  the  patients 
received  both  arsenic  and  mercurial  medication  and 
while  it  cannot  be  said  that  the  picture  presented 
in  these  cases  is  one  of  combined  poisoning  both 
by  arsenic  and  mercury,  yet  it  is  not  unbelievable 
that  under  certain  rare  conditions  these  two  sub- 
stances enter  upon  a  synergistic  relationship  within 
the  body. 

The  need  of  accurate  experimental  work  along 
these  lines  is  only  too  evident.  Using  such  data  as 
we  have,  however,  it  does  not  seem  rational  to 
classify  these  cases  of  toxic  and  fatal  jaundice  under 
the  socalled  idiosyncratic  group — a  group  of  un- 
explainable  reactions  which  occasionally  follow  the 
use  of  arsenic.  The  importance  of  simultaneous 
mercury  medication  should  not  be  forgotten,  and  it 
is  not  at  all  unlikely  that  the  untoward  symptoms 
and  occasionally  death  itself  which  follow  the  ad- 
ministration of  small  doses  of  arsenic  and  mercury 
may  be  due  to  a  mutual  interaction  of  these  two 
powerful  agents  upon  the  important  organs  of  the 
body. 

REFEREXCES. 

1.  Lynch,  T.  J.,  and  Hoge,  S.  F.  :  Toxic  Jaundice  Fol- 
lowing Intensive  Antisyphilitic  Treatment,  Journal  A.M.  A., 
vol.  Ixxiii,  No.  22,  p.  1687. 

2.  Fexwick,  p.  C,  Sweet,  G.  B.,  and  Lowe,  E.  C.  : 
Icterus  Gravis  After  Novarsenobillon,  British  Medical 
Journal.  1  :448,  1918. 

3.  Veale,  R.  a.,  and  Wedd,  B.  H.  :  A  Case  of  Fatal 
Jaundice,  British  Medical  Journal.  2:341,  1918. 

4.  Hyman,  a.  S.  :  The  Administration  of  Arsphenamine, 
Boston  Medical  and  Surgical  Journal,  vol.  clxxxi,  No.  12, 
p.  353. 


Different  Spirochetes  in  General  Paralysis  and 
Common  Syphilis.  —  A.  Marie  and  Levaditi 
(Prcsse  medicale,  December  24,  1919)  have  made 
a  comparative  study  of  the  local  effects  in  rabbits 
of  inoculation  with  virus  from  a  syphilitic  chancre 
and  inoculation  with  virus  from  the  blood  of 
paretics.  The  viruses  in  the  two  instances  were 
found  to  be  different  as  regards  period  of  incuba- 
tion, duration  of  the  lesions  produced,  appearance 
and  pathogenic  properties  of  rhe  lesions,  and 
crossed  immunity.  The  conclusion  reached  was 
that  there  was  probably  a  neurotrophic  form  of 
syphilis  distinct  from  the  ordinary,  dermatrophic 
syphilis. 


REACTIONS  FOLLOWING  INTRAVENOUS 
ADMINISTR^ATION  OF  ARSPHENAMINE. 

The  Influence  of  Atropine  Sulphate  and  Adrenalin 
Chloride  Upon  These  Reactions. 

By  Albert  A.  Strickler,  M.  D., 
Philadelphia, 

Associate    in    Dermatology,    Jefferson    Medical    College;  Assistant 
Dermatologist  and  Chief  of  the  Dermatological  Clinic,  Jefferson 
Hospital;    Assistant    Dermatologist   to   the  Philadelphia 
General   Hospital,  etc. 

{From  the  Department  of  Dermatology  and  Syphilology  of  the  Jef- 
ferson Medical  College,  Philadelphia,  and  in  collaboration  with 
Henry  G.  Munson.  M.  D..  David  M.  Sidlick.  M.  D..  and  A. 
Strauss,  M.  D.) 

While  the  symptomatology  of  the  reactive  pheno- 
mena at  times  attending  the  intravenous  administra- 
tion of  arsphenamine  has  been  carefully  and  system- 
atically studied,  the  imderlying  causes  of  these  reac- 
tions remain  shrouded  in  obscurity,  and  the  suggested 
preventive  remedies  have  proved  of  but  little  value. 
Out  of  the  great  mass  of  theoretical  considerations 
advanced  relative  to  the  reaction  following  the  in- 
travenous administration  of  arsphenamine  only  two 
factors  stand  out  prominently  and  they  are,  first, 
those  that  relate  to  the  patient  and,  second,  those  that 
relate  to  the  medicament,  i.  e.,  arsphenaiuine.  In 
another  paper,  we  indicated  that  in  our  belief,  ar- 
sphenamine might  produce  reactive  phenomena, 
either  as  a  result  of  some  impurities  in  its  compo- 
sition, or  due  to  some  chemical  interaction  between 
the  medicament  (arsphenamine)  and  the  elements 
of  the  blood,  or  both  factors  may  be  operative  at 
the  same  time.  Let  us  briefly  review  some  of  the 
more  authoritative  theories  which  have  been  sug- 
gested relative  to  arsphenamine  reactions. 

Soon  after  the  employment  of  arsphenamine  be- 
gan, and  reactive  symptoms  were  being  reported, 
Wechselmann  announced  his  Wasscr-fehler  or  water 
error  theory  as  explanatory  of  the  untoward  symp- 
toms. It  was  his  belief  that  the  decomposition  of 
protein  material  in  the  water  was  the  responsible 
factor.  An  extended  experience  has  sh,own  that 
while  in  a  measure  his  contention  has  proved  cor- 
rect, it  explains  only  a  small  number  of  the  reactions 
encoimtered.  In  1910  Neisser  brought  forth  the 
hypothesis  that  the  rapid  killing  off  of  spirochetes 
following  arsphenamine  injection,  and  the  liberation 
of  endotoxins  which  circulate  in  the  blood  stream, 
would  account  for  the  untoward  phenomena  en- 
countered. In  a  recent  paper  we  have  proved  that 
this  theory  is  probably  incorrect,  as  normal  patients 
receiving  arsphenamine  intravenously  report  reac- 
tive symptoms  in  the  same  ratio  as  syphilitic  pa- 
tients receiving  the  identical  serial  number  of  the 
same  make  of  arsphenamine,  adiuinistered  under 
exactly  similar  conditions.  Among  others  McKee 
in  1912  observed  that  the  injection  of  acid  and 
partially  alkalinized  arsphenamine  solutions  pro- 
duced a  precipitate  and  reactions.  This  observation 
has  been  abundantly  confirmed  by  others. 

Syphilographers  have  for  a  long  time  noted  that 
the  mental  attitude  of  the  patient  treated  exercises 
an  important  influence  on  the  reactive  symptoms. 
This  psychic  state  we  have  observed,  not  only  when 
administering  arsphenamine,  but  also  when  inject- 
ing the  mercurial  preparations  intravenously. 


October  2,  1920.]      STRICKLER:   REACTIONS  FOLLOWING  ARSPHENAMINE  ADMINISTRATION.  499 


In  1917  Danyzs  published  his  precipitation  hy- 
pothesis as  an  explanation  of  the  reactions  fol- 
lowing arsphenamine  medication.  In  this  hypothe- 
sis, Danyzs  states  that  the  carbon  dioxide  and  sodium 
bicarbonate  of  the  blood  changes  arsphenamine  into 
an  insoluble  base  which  is  carried  in  the  circulation 
till  dissolved  by  the  leucocytes  and  the  organic  bases 
of  the  plasma.  The  biphosphates  of  calcium,  so- 
dium and  magnesium,  as  well  as  the  chloride  and 
iron  salts,  are  alleged  to  behave  similarly.  Scham- 
berg  and  his  associates,  after  an  extensive  study  of 
Danyzs's  theory,  conclude  that  many  of  the  hy- 
potheses which  Danyzs  advanced  are  probably  in- 
correct, stating  as  their  belief  that  many  of  the 
reactions  following  arsphenamine  treatments  are  due 
to  some  impurity"  in  the  arsphenamine,  which  they 
have  not  isolated  as  yet  and  which  they  have 
termed  substance  X.  We  must  not  lose  sight  of 
the  fact  that  the  reactions  in  some  of  our  patients 
may  be  explained  on  the  basis  of  a  hypersuscepti- 
bility  to  arsphenamine  (arsenic),  and  that  this  idio- 
syncrasy may  act  as  either  the  sole  cause  or  as  the 
predisposing  one. 

A  survey  of  the  views  herein  expressed  points  to 
errors  of  technic,  the  syphilitic  state  of  the  patient, 
his  mental  attitude,  the  hypersusceptibility  of  the 
individual  subjected  to  the  treatment,  impurities  in 
the  drug,  and  the  interaction  between  the  medica- 
ment and  the  elements  of  the  blood,  all  or  some  of 
these  offering  an  explanation  of  the  reactions  fol- 
lowing the  administration  of  arsphenamine.  In  this 
study  two  drugs  were  administered  intramuscularly 
and  their  ability  to  prevent  the  early  reactions  at- 
tending arsphenamine  treatments  noted.  The  medica- 
ments employed  were  atropine  sulphate  and  adrena- 
lin chloride  in  a  one  in  one  thousand  solution.  Atro- 
pine sulphate  was  selected  because  of  its  well  known 
inhibitory  effect. 

In  our  series  atropine  sulphate,  one  seventy-fifth 
of  a  grain,  was  administered  intramuscularly  about 
ten  to  fifteen  minutes  before  the  arsphenamine  in- 
jections. A  total  of  one  hundred  and  one  patients  re- 
ceived the  intramuscular  injections  of  atropine  sul- 
phate and  ninety-five  patients  were  used  as  controls. 
Both  groups  of  patients  received  the  arsphenamine 
of  the  Dermatological  Research  Laboratories  of  the 
same  serial  number  and  administered  under  similar 
conditions.  A  statistical  study  of  the  reactive  symp- 
toms shows  the  following  results:  In  the  atropine 
series  of  one  hundred  and  one  patients  thirty-four, 
or  thirty-four  per  cent.,  reported  absence  of  any 
reactions,  while  sixty-seven,  or  sixty-six  per  cent., 
complained  of  various  reactive  phenomena.  In  de- 
tail, twenty-two,  or  thirty-three  per  cent.,  complained 
of  fever;  twenty-nine,  or  forty-three  per  cent.,  of 
chills  or  chilliness ;  forty-five,  or  seventy  per  cent., 
of  headache;  thirty-nine,  or  fifty-nine  per  cent,  of 
nausea ;  nineteen,  or  twenty-eight  per  cent.,  of  vom- 
iting, and  sixteen,  or  twenty-three  per  cent.,  of 
diarrhea.  In  the  control  series  of  ninety-five  pa- 
tients thirty-one,  or  thirty-three  per  cent.,  were  free 
from  reactions,  while  sixty-four,  or  sixty-seven  per 
cent.,  experienced  untoward  reactive  symptoms. 
Out  of  this  number  sixteen,  or  twenty-five  per 
cent.,  complained  of  fever,  twenty-three,  or  thirty- 
six  per  cent.,  of  chills  or  chilliness,  thirty-seven,  or 


fifty-eight  per  cent.,  of  headache,  twenty-nine,  or 
forty-five  per  cent.,  of  nausea,  twelve,  or  twenty 
per  cent.,  of  vomiting ;  and  twenty-three,  or  thirty- 
six  per  cent.,  of  diarrhea. 

From  these  tables  it  is  apparent  that  in  so  far  as 
our  series  is  concerned,  the  intramuscular  injec- 
tion of  atropine  sulphate  had  no  appreciable  in- 
fluence for  the  prevention  of  the  early  reactive 
symptoms  which  may  follow  arsphenamine  treat- 
ment. The  percentage  of  patients  reporting  total 
absence  of  reactive  symptoms  was  equal  in  both  the 
atropine  and  control  series,  and  although  some  dif- 
ferences were  recorded  in  the  percentage  of  the 
individual  symptoms,  such  can  readily  be  accounted 
for  on  the  basis  of  individual  peculiarity. 

In  another  group  of  patients  adrenalin  chloride 
(1  in  1,000  solution)  was  injected  intramuscularly 
in  the  dose  of  0.5  c.  c,  a  few  minutes  before  the 
arsphenamine  was  administered.  At  first  we  at- 
tempted giving  the  adrenalin  intravenously,  bift  the 
symptoms  which  developed  as  a  result  of  the  injec- 
tion were  so  alarming  that  this  method  of  admin- 
istration was  discontinued.  The  total  of  ninety- 
seven  patients  received  the  adrenalin  preceding  their 
arsphenamine  treatment,  while  forty-two  patients 
received  the  arsphenamine  alone.  Both  groups  of 
cases  received  the  arsphenamine  of  the  Dermatalogi- 
cal  Research  Laboratories  of  the  same  serial  num- 
bers administered  under  identical  conditions.  In  the 
adrenalin  series,  twenty-four  patients,  or  twenty- 
five  per  cent.,  were  free  of  reactions^  while  seventy- 
three,  or  seventy-five  per  cent.,  reported  some  un- 
toward symptoms.  The  following  is  the  statistical 
study  of  the  reactive  symptoms  reported :  Fever 
occurred  in  twenty-six  patients,  or  thirty-six  per 
cent. ;  chills  or  chilliness  in  twenty-two,  or  thirty 
per  cent. ;  headache  in  forty-nine,  or  sixty-seven  per 
cent.;  nausea  in  forty,  or  fifty-five  per  cent.;  vomit- 
ing in  sixteen,  or  twenty-two  per  cent. ;  and  diar- 
rhea in  twenty-two  or  thirty  per  cent. 

In  our  control  series,  there  were  forty-two  pa- 
tients, and  of  this  number  eleven,  or  twenty-six  per 
cent,  reported  a  total  absence  of  reaction ;  thirty- 
one,  or  seventy- four  per  cent.,  reported  untoward 
symptoms,  which  were  as  follows ;  fever  in  nine 
instances,  or  thirty-five  per  cent. ;  chills  or  chilliness 
in  ten,  or  thirty-eight  per  cent. ;  headache  in  seven- 
teen instances,  or  sixty-five  per  cent. ;  nausea  in 
thirteen,  or  fifty  per  cent.;  vomiting  in  seven,  or 
twenty-seven  per  cent.,  and  diarrhea  in  nine,  or 
thirty-five  per  cent.  Although  Millian  reported  fa- 
vorable prophylactic  influence  from  the  use  of 
adrenalin  in  arsphenamine  injections,  our  series 
seems  to  show  the  same  percentage  of  reactions 
whether  adrenalin  was  employed  or  not. 

RESUME 

As  a  result  of  our  investigation,  we  can  conclude 
that  the  injections  of  either  atropine  sulphate  in  the 
dose  of  one  seventy-fifth  of  a  grain  or  adrenalin  in 
chloride  in  the  dose  of  0.5  c.  c.  previous  to  arsphena- 
mine injections,  in  no  wise  influences  the  occurrence 
of  early  reactive  phenomena. 

I  wish  to  express  my  thanks  to  my  assistants 
Henry  G.  Munson,  M.  D. ;  David  M.  Sidlick,  M. 
D..  and  A.  Strauss,  M.  D.,  for  their  cooperation 
during  the  course  of  this  investigaiton. 


500 


RID  DELL:    VENEREAL  DISEASE  PROBLEM. 


[New  York 
Medical  Journal. 


THE    VENEREAL    DISEASE  PROBLEM* 

By  the  Honorable  William  Rexwick  Riddell, 
LL.  D.,  F.  R.  H.  S., 
Toronto,  Canada. 

President  of  the  Canadian  National  Council  for  Combating 
Venereal  Disease. 

It  cannot  be  said  that  the  subject  to  be  discussed 
is  one  which  is  palatable  or  delightful,  yet  the 
situation  must  be  faced  and  faced  honestly  and 
without  flinching.  We  may  not  find  it  as  pleasant 
to  speak  of  the  cesspool  and  the  scavenger  as  of  the 
rose  garden  and  the  gardener — and  yet  the  one  may 
be  as  important  as  the  other,  or  vastly  more  so. 
There  are  diseases  which  are  eating  the  heart  out  of 
our  people,  sapping  their  very  life — unless  well 
grounded  estimates  are  gravely  wrong  half  a  million 
of  Canadians  are  infected  with  the  most  serious 
form  of  venereal  disease ;  in  Toronto  at  least  forty 
thousand,  many,  very  many  without  knowing  it. 
For  one  reason  or  another,  the  terrible  extent  of 
these  diseases  is  not  generally  known — delicacy  has 
been  considered  to  forbid  the  discussion  of  them  in 
public  and  those  who  suffer  from  them  do  not  dis- 
close their  disease  willingly.  In  insanity  we  know 
that  until  the  other  day  it  was  considered  not  only  a 
calamity  but  also  a  disgrace  that  any  one  of  the 
family  should  be  considered  insane ;  a  little  of  the 
same  feeling  lingers  in  respect  of  cancer  and  per- 
haps other  diseases. 

In  venereal  diseases  there  has  been  a  widespread 
•  view  that  those  who  suffer  from  them  are  being 
punished  for  sin.  That  thought  has  prevented  the 
members  of  the  family  of  the  afifected  from  making 
known  the  state  of  their  kinsfolk ;  and  the  stricken 
one  himself  has  concealed  from  all  eyes  that  he  is 
stricken.  But  medical  men  have  long  known  the  ex- 
tent of  these  diseases ;  and  at  length  it  has  become 
absolutely  necessary  for  the  Government  to  take 
notice  of  them.  It  has  long  been  cast  up  to  govern- 
ments as  a  reproach  that  in  case  of  a  disease  attack- 
ing animals  the  utmost  care  and  attention  was  at 
once  paid  to  them  but  that  when  human  beings  were 
attacked  little  if  any  attention  was  paid  to  them. 
Whether  that  is  true  or  not  I  do  not  enquire — the 
Governments,  Dominion  and  local,  are  now  awake 
to  the  terrible  importance  of  venereal  diseases.  The 
Dominion  Government  has  set  aside  two  hundred 
thousand  dollars  to  fight  this  powerful  enemy  of  the 
human  race  and  the  Provincial  Governments  are  also 
doing  their  share. 

It  was  full  time.  In  Britain  the  country  was  wide 
awake ;  in  the  United  States  the  efforts  of  many 
agencies  were  bent  to  the  extirpation  or  at  least  dim- 
inishment  of  the  evil.  In  both  these  countries  it  was 
considered  that  the  end  could  be  best  attained  with 
the  assistance  of  a  national  council,  a  semipnvate 
body  acting  in  harmony  with  the  central  and  local 
authorities,  and  our  organization  was  called  into  ex- 
istence for  that  purpose.  I  was  honored  by  being 
made  president  of  the  council,  an  honor  unexpected 
as  it  was  unsought;  and  in  view  of  the  tremendous 
importance  of  the  movement  I  could  not  refuse  to 
give  what  assistance  I  could. 

'Presented  before  the  organization  meeting  of  the  Toronto  Com- 
mittee of  the  Canadian  National  Council  for  Combating  Venereal 
Di9?ase?,  Toronto,  March  24,  1920. 


It  is  not  the  sinner  alone  who  suf¥ers — even  if  that 
were  so  the  case  would  be  hard  enough — but  the 
danger  of  infection  is  never  absent  from  millions  of 
the  innocent ;  not  a  man,  not  a  woman,  scarcely  even 
a  child  but  runs  the  risk  of  infection  every  day. 
These  we  must  in  some  way  protect.  Tuberculosis, 
smallpox,  measles,  scarlatina,  all  call  for  prevention 
and  curative  measures  and  such  measures  are 
promptly  taken.  Syphilis,  which  is  more  to  be 
dreaded  than  any  or  all  of  these  diseases,  and  is  more 
common  than  any  (except  possibly  measles),  calls 
for  more  careful  measures. 

Think  of  the  eflfect  of  syphilis :  it  afYects  about 
eight  per  cent,  of  the  total  population ;  is  transmiss- 
ible to  the  offspring  and  causes  death  in  eighty  per 
cent,  of  those  infected ;  is  the  cause  of  ten  to  thirty- 
five  per  cent,  of  all  insanity;  of  most  mentally  defec- 
tive children ;  of  locomotor  ataxia ;  of  paresis ;  of 
apoplectic  and  paralytic  strokes  in  early  life ;  of 
nearly  half  the  abortions  and  miscarriages  ;  of  a  large 
proportion  of  diseases  of  the  heart,  blood  vessels  and 
other  vital  organs.  Syphilis  decreases  the  length  of 
life  about  a  third  and  greatly  decreases  one's  earning 
capacity  during  the  remainder. 

And  what  is  very  generally  considered  of  trifling 
importance,  "not  much  worse  than  a  cold,"  gon- 
orrhea, while  not  so  virulent,  is  still  a  deadly  foe  to 
the  Canadian  people,  and  is  more  common  than 
syphilis.  Gonorrhea  is  the  cause  of  more  than  ten 
per  cent,  of  all  blindness ;  of  eighty  per  cent,  of  con- 
genital blindness ;  of  many  surgical  operations  on  the 
female  generative  organs ;  of  many  chronic  diseases 
of  the  joints,  bladder  and  generative  organs,  and 
this  disease  greatly  decreases  one's  earning  capacity. 

These  surely  are  enemies  worth  fighting — not  in 
my  time  or  in  yours,  not  for  generations  to  come 
will  they  be  extirpated ;  but  something,  much,  can 
be  done  by  us  in  our  generation. 

We  are  not  perhaps  to  expect  that  those  who 
know  themselves  to  be  infected  will  do  much  for 
others — God  knows  they  have  a  heavy  enough  bur- 
den of  their  own  to  bear — but  I  feel  that  I  may  call 
upon  those  who  know  themselves  to  be  clean  to  help 
those  less  fortunate,  and  to  assist  those  who  are 
clean  to  remain  clean. 

The  appalling  versatility,  the  unearthly  cunning  of 
these  diseases  are  such  that  thousands  and  tens  of 
thousands  have  their  seed  within  their  bodies  with- 
out knowing  it,  and  I  am  well  justified  in  saying 
that  no  man  can  be  sure  that  today  he  is  so  clean  and 
so  immune  from  infection  that  he  will  be  safe  tomor- 
row. We  intend  to  educate  people,  to  make  such  in- 
vestigation as  will  enable  us  best  to  educate  the 
people  while  we  are  ourselves  learning.  We  shall 
try  to  do  all  possible  to  prevent  infection  and  to  cure 
it  where  unhappily  incurred. 


Some  Notes  on  Asexualization,  with  a  Report 
of  Eighteen  Cases. — Martin  W.  Barr,  (Journal  of 
Nervous  and  Mental  Disease,  March,  1920)  pre- 
sents a  study  of  ancient  literature  upon  asexualiza- 
tion and  notes  the  various  stages  in  the  develop- 
ment of  the  practice  for  the  mentally  deficient  and 
moral  degenerates  in  state  institutions  of  this  coun- 
try. A  series  of  eighteen  case  reports  sets  forth 
in  detail  the  actual  results  attained. 


October  2,  1920.] 


DUNCAN:  MEDICAL  MEN  IN  THE  AMERICAN  REVOLUTION. 


501 


MEDICAL   MEN   IN   THE  AMERICAN 
REVOLUTION. 
The  New  York  Campaign  of  1776. 
By  Louis  C.  Duncan,  M.  D., 

Washington,  D.  C, 

Lieutenant  Colonel,  Medical  Corps,  U.   S.  Army. 

(Concluded  from  page  460) 
The  encounter  at  White  Plains  took  place  on 
October  28th.  The  British  attacked  McDougall's 
New  York  Brigade,  a  part  of  which  did  not  stand 
well,  obliging  the  whole  to  fall  back.  Washington 
then  retired  to  a  stronger  position  near  North  Castle. 
The  losses  were  not  serious :  less  than  a  hundred 
in  killed  and  wounded.  As  IMorgan  says,  he  cared 
for  these  wounded,  both  on  the  field,  and  in  a  sort 
of  general  hospital  at  North  Castle.  This  double 
duty,  instead  of  bringing  about  praise,  seems  only 
to  have  caused  increased  complaint :  as  he  indicates : 
Here  I  cannot  but  feel  for  the  hospital  surgeons,  who 
before  they  could  obtain  any  quarters,  except  such  as  a 
few  hours'  industry  enabled  them  to  do,  in  a  country 
which  was  not  well  calculated  to  afford  any  good,  were 
suddenly  overwhelmed  with  numbers  of  sick  sent  them, 
as  well  as  the  wounded  in  time  of  an  engagement,  and 
whilst  many  of  the  regimental  surgeons  were  absent  in  the 
country,  having  left  their  corps  in  the  field  without  as- 
sistance, contrary  to  the  orders  of  July  3rd;  at  a  time 
when  an  engagement  was  considered  inevitable  there  were 
few  at  hand  to  give  any  aid.  Hence,  while  the  hospital 
surgeons  were  preparing  matters  at  their  proper  stations 
in  the  hospital,  clamors  were  excited  against  them  for  not 
being  with  the  troops ;  and  when  they  were  detained  at 
the  lines,  to  supply  the  place  of  regimental  surgeons  who 
ought  to  have  been  there,  the  wounded,  who  were  con- 
veyed to  the  hospital,  naturally  demanded  the  attention  of 
the  whole  body  of  surgeons,  to  administer  to  them. 

On  November  5th  he  issued  a  circular  requiring 
the  surgeons  to  return  to  and  remain  at  their  proper 
places  (17). 

The  action  of  Morgan  at  this  time  cannot  be  too 
highly  commended.  We  shall  see  later  how  Shippen 
managed  aiYairs  at  Trenton  and  Princeton. 

When  Morgan  finally  returned  to  North  Castle 
he  attempted  to  put  the  hospital  in  order  there  by 
constructing  berths,  building  chimneys,  etc.,  but 
could  get  little  done.  He  states  that  some  died 
from  effects  of  cold,  which  was  severely  felt  at  that 
time — the  latter  part  of  November.  Leaving  what 
sick  could  be  cared  for  at  North  Castle,  in  charge 
of  Drs.  Adams  and  Charles  McKnight,  he  had 
the  remainder  (about  a  thousand)  sent  to  Stamford 
and  Norwich  in  Connecticut.  That  colony  had 
established  hospitals  in  all  the  principal  towns  be- 
tween Hartford  and  New  York.  These  too  seem 
to  have  been  taken  over  by  the  Congress.  Morgan 
says  that  he  visited  both  places  in  person,  and  that 
they  handled  nearly  two  thousand  patients,  refusing 
not  a  single  one. 

The  hospital  at  Stamford  was  in  charge  of  Dr. 
Philip  Turner  (18)  and  received  in  all  about  twelve 
hundred  patients.  Morgan  says  that  it  was  well 
supplied,  that  the  patients  were  comfortably  pro- 
vided for,  and  that  most  of  them  recovered.  There 
is  a  letter  from  Dr.  Turner,  in  November,  recom- 
mending the  discharge  of  191  tnen  at  Stamford, 
as  no  longer  fit  for  duty.  On  November  30th  he 
again  asked  to  have  seventy-three  discharged.  He 
then  said  there  were  six  or  seven  hundred  in  the 


town,  largely  convalescents,  but  of  whom  not  a 
fourth  would  be  of  any  service.  As  the  regiments 
to  which  they  belonged  were  soon  to  be  disbanded, 
he  recommended  that  these  men  be  discharged. 
Apparently  this  was  done,  for  Morgan  says  that  in 
February  but  twenty-five  of  the  men  remained  in 
hospital.  There  is  no  account  of  any  serious  amount 
of  sickness  or  many  deaths  at  this  hospital. 

The  hospital  •  at  Norwich  was  in  charge  of  Dr. 
William  Eustis.  He  reported  that  upwards  of  seven 
hundred  sick  and  wounded  were  well  provided  for 
and  attended  with  satisfaction.  When  he  left  Nor- 
wich, in  March,  1777,  but  eight  or  ten  remained. 
On  December  10th,  Eustis  wrote  to  Heath,  saying 
that  he  had  four  hundred  sick,  mostly  convalescents. 
He  was  discharging  the  militia  men  and  asked 
authority  to  discharge  those  belonging  to  Conti- 
nental regiments  also,  as  their  terms  of  enlistment 
would  soon  expire.    The  authority  was  granted. 

On  November  13th  all  the  troops  of  New  York 
and  the  colonies  south  were  on  the  Jersey  side,  at 
Hackensack,  Amboy,  Newark,  Brunswick,  and 
Elizabethtown.  Morgan  left  New  Castle  and 
crossed  the  Hudson  about  November  12th.  He 
found  the  army  in  rather  a  bad  state  and  entirely 
destitute  of  hospital  surgeons  to  take  charge  of  the 
wounded  in  case  of  an  attack.  The  resolution  of 
October  9th,  dividing  the  hospitals,  was  at  first 
believed  by  him  not  to  take  away  his  general  super- 
vision. With  Washington's  permission  he  went  to 
Philadelphia  for  the  purpose  of  laying  the  matter 
before  Congress  and  getting  an  explanation  of  the 
meaning  of  that  resolution.  He  was  unable  to  ob- 
tain an  audience,  and  in  a  few  days  the  Congress 
adjourned  to  Baltimore.  He  then  returned  to  head- 
quarters and  there  received  a  letter  from  a  inember 
informing  him  that  it  was  the  design  of  Congress 
that  he  should  be  restricted  to  the  east  side  of  the 
Hudson.  He  immediately  started  for  his  station, 
where  General  Lee  now  commanded. 

On  November  20th  the  British  had  landed  six 
thousand  men  above  Fort  Lee.  The  garrison  was 
withdrawn,  losing  two  or  three  hundred  tents,  a 
thousand  barrels  of  flour,  and  a  few  guns.  On  the 
21st,  Washington  wrote  from  Hackensack  saying 
that  he  had  not  above  three  thousand  men,  much 
broken  and  dispirited,  with  no  intrenching  tools, 
or  other  implements.  He  recommended  that  Lee 
come  to  his  aid  with  his  Continental  troops,  but 
did  not  order  it.  He  then  crossed  the  Hackensack, 
beginning  his  retreat.  A  return  on  November  23rd 
.showed  5,410  men  present  for  duty,  but  1,360  were 
to  be  discharged  on  December  1st,  and  950  more 
on  January  1st.  The  Flying  Camp  was  going  to 
pieces.  The  condition  of  this  army  was  desperate. 
On  the  24th  Congress  authorized  Washington  to 
call  the  Pennsylvania  and  New  Jersey  regiments 
from  the  Northern  Army ;  the  Light  Horse  of 
Virginia,  and  the  inilitia  of  Pennsylvania,  known 
as  the  Associators.  On  this  day  Washington  crossed 
the  Passaic  to  Newark.  The  troops  were  without 
tents,  poorly  clad,  marching  wrapped  in  blankets, 
and  presented  a  miserable  appearance.  The  sick 
at  Newark  appear  to  have  been  sent  to  Morristown, 
and  then  to  Bethlehem  and  other  places. 

During  the  latter  part  of  October  and  five  days 


502 


DUNCAN:  MEDICAL  MEN  IN   THE  AMERICAN  REVOLUTION. 


[New  York 
Medical  Journal. 


of  November  the  movements  of  the  British  were  a 
puzzle  to  the  Americans.  By  threatening  first  one 
side  and  then  the  other,  they  had  finally  brought 
about  a  division  of  the  Continental  Army.  On 
November  4th  they  retired  toward  the  Harlem.  On 
November  10th  the  division  took  place.  General 
Lee  was  assigned  to  the  troops  east  of  the  Hudson. 
He  had  seven  brigades,  thirty  regiments,  of  New 
England  troops.  On  November  .24th  his  return 
showed  5,589  present  fit  for  duty;  1,290  present 
sick;  and  1,599  absent  sick.  General  Heath  was 
given  three  small  brigades ;  also  New  England 
troops,  for  the  defense  of  the  Highlands.  His 
headquarters  was  about  Peekskill.  He  had  on 
November  9th,  2,135  present  fit  for  duty;  403 
present  sick ;  and  885  absent  sick.  Washington, 
with  Greene,  took  all  the  troops  from  New  York 
and  the  states  to  the  south,  for  the  defense  of  the 
Jerseys.  At  this  time  his  force  may  have  amounted 
to  eight  thousand  men,  but  it  decreased  very 
rapidly,  and  on  November  23rd  he  had  but  5,410 
present  for  duty.  Of  these,  a  third  would  claim 
their  discharge  on  December  3rd,  and  a  second  third 
on  January  1st.  while  the  troops  of  Lee  and  Heath 
remained  longer  and  were  more  promptly  replaced. 

On  November  16th  the  blow  fell  at  Fort  Wash- 
ington. After  a  doubtful  defense,  the  post  was 
surrendered  with  great  stores  and  twenty-seven 
hundred  prisoners.  The  force  included  Magaw's 
and  Shea's  Pennsylvania  regiments,  Rawlin's  Mary- 
land riflemen,  and  some  militia  from  the  Flying 
Camp.  Dr.  Hugh  Hodge  and  Dr.  James  McHenry 
were  among  the  prisoners  (19)  also  Dr.  John 
Beatty  (20).  The  captures  of  the  British  at  Long 
Island,  Fort  Washington  and  in  various  lesser  con- 
flicts now  amounted  to  more  than  three  hundred 
officers  and  4,430  men.  In  this  campaign  they  had 
captured  almost  as  many  men  as  Burgoyne  sur- 
rendered at  Saratoga.  Fortunately  for  the 
Americans,  then  as  since,  men  were  their  most 
plentiful  war  commodity.  They  were  replaced, 
though  the  recruiting  of  men  took  time. 

When  the  British  (under  Cornwallis)  advanced 
on  Hackensack,  General  Greene  ordered  the  sick 
sent  to  the  country.  They  went  in  various  direc- 
tions; about  a  hundred  of  Colonel  Bradley's  regi- 
ment went  to  Fishkill,  where  the  New  York  Coun- 
cil of  Safety  authorized  Dr.  Chauncey  Graham  to 
care  for  them  in  the  unfinished  academy.  When 
the  army  was  divided  General  Heath,  with  the 
smaller  division,  was  left  without  a  general  hos- 
pital. On  November  19th  he  wrote  a  letter  making 
a  proper  complaint  (21).  Morgan,  then  at  North 
Castle,  rode  up  to  Peekskill,  and  interviewed  Heath 
on  the  subject  of  a  hospital  and  surgeons.  He  of- 
fered to  furnish  the  surgeons  and  fit  up  a  hospital 
for  three  hundred  sick,  as  soon  as  the  building  should 
be  ready  (22).  When  he  called  on  the  quarter- 
master for  workmen  and  material  to  put  the  build- 
ings in  order,  build  chimneys,  construct  berths  and 
other  necessary  equipment,  the  quartermaster  replied 
that  every  man  was  on  some  necessary  work,  and 
recommended  that  he  apply  to  General  Heath.  Mor- 
gan did  so,  and  the  reply  received  was,  "That  the 
General  did  not  choose  to  meddle  with  anything  to 
be  done  in  the  quartermaster  general's  department." 


This  is  a  sample  of  Morgan's  difficulties,  here,  at 
Hackensack,  and  other  places.  Dr.  Adams  and  Dr. 
McKnight  were  sent  to  Peekskill,  but  as  no 
buildings  were  available  the  sick  had  to  be  taken 
twenty  miles  across  the  Highlands  to  Fishkill.  On 
December  5th  the  New  York  Convention  informed 
Heath  that  barracks  for  two  thousand  men  were 
being  constructed  between  Peekskill  and  Fishkill; 
that  the  sick  could  be  cared  for  in  some  of  these, 
and  that  more  would  be  built  if  necessary. 

The  year  was  drawing  to  an  end  and  with  it  ]\Ior- 
gan's  service  as  medical  director.  On  January  9th, 
1777,  Congress,  without  consulting  Washington  and 
without  giving  any  hearings,  passed  a  most  unjust 
resolution  dismissing  both  Morgan  and  Stringer 
from  the  army.  (23.)  A  later  committee  found 
that  there  was  no  charge  against  Morgan's  character 
or  ability,  but  his  reputation  was  irretrievably  in- 
jured, and  he  was  left  a  disappointed  and  broken 
man ;  sacrificed  as  a  sort  of  scapegoat,  on  account  of 
public  clamor,  for  faults  more  chargeable  to  Con- 
gress than  to  himself. 

The  political  game  was  played  and  Morgan  was 
thrown  to  the  wolves.  His  tireless  energy  under 
every  discouragement ;  his  faithfulness  and  econo- 
mies; his  integrity  of  character  which  made  work 
for  the  sick  and  wounded,  not  personal  favor,  the 
goal — all  were  forgotten.  It  is  true  that  the  hospi- 
tals had  sometimes  failed.  So  had  every  depart- 
ment of  the  army,  and  the  army  itself,  failed.  Treat 
every  man  according  to  his  deserts,  as  measured  by 
success,  and  they  had  all  been  hanged.  The  com- 
missary failed,  the  quartermaster  failed,  the  whole 
army  was  beaten  in  every  battle,  outmaneuvred  and 
outwitted;  at  the  last  of  ihe  year  it  was  a  -wreck 
which  Washington  himself  said  woidd  come  to  an 
end  within  ten  days. 

Little  credit  can  be  claimed  for  the  General  him- 
self in  the  actual  management  of  this,  his  first  cam- 
paign. All  were  amateurs  pitted  against  profes- 
sionals. All  had  to  learn  the  difficult  art  of  war 
through  the  costh'  lessons  of  failure.  The  real 
encomium  of  all  is.  not  that  they  had  any  success,  but 
that  they  stood  steadfast  in  the  face  of  continual 
defeat.  Any  fair  comparison  will  prove  that  the 
Medical  Department  of  the  Continental  Army  was 
handled  as  well  as  any  other  department.  But, 
following  the  custom  of  politicians,  .public  clamor 
had  to  be  appeased  by  a  sacrifice.  Morgan  was 
even  informed  that  he  was  not  dismissed  on  ac- 
count of  any  particular  act  or  omission,  but  be- 
cause of  general  complaint.  That  he  was  given  no 
hearing,  no  chance  to  defend  himself,  only  accentu- 
ated the  meanness  of  this  act  of  injustice. 

The  New  York  campaign  actually  came  to  an  end 
when  Washington  and  then  Cornwallis  crossed  the 
river  into  New  Jersey.  The  contest  was  thence- 
forth for  the  Jerseys,  possibly  Philadelphia.  The 
Continental  Army  was  fatally  divided.  Gates  had 
above  five  thousand  troops  for  duty  at  Ticonderoga ; 
Lee  had  as  many  east  of  the  Hudson ;  Heath  had 
three  thousand  in  the  Highlands.  Washington 
probably  had  the  weakest  force  of  all,  about  five 
thousand,  of  whom  only  half  were  Continentals. 

This  campaign  had  been  very  near  a  total  failure. 
Every  battle  had  been  lost ;  New  York  sttrrendered ; 


October  2,  1920.]  DUNCAX:  MEDICAL  MEN  IN    THE  AMERICAN  REVOLUTION. 


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nearly  five  thousand  of  the  army  had  been  taken 
prisoners ;  and  toward  the  end  the  men  had  not  stood 
well  in  battle.  Yet  in  the  whole  series  of  battles  less 
than  a  thousand  men  had  been  killed  and  wounded. 
Probably  not  more  than  two  hundred  had  been  killed 
or  had  died  of  wounds,  and  six  or  seven  hundred 
wounded  who  recovered.  Of  the  five  thousand 
prisoners  at  least  half  died  of  disease  and 
neglect.  It  is  impossible  to  make  even  a  reliable 
estimate  of  the  losses  from  disease  from  the  time 
the  army  reached  New  York  until  the  end  of  the 
year.  I  do  not  believed  that  five  thousand  would 
be  at  all  high.  At  least  as  many  more  were  lost  in 
the  Northern  Army.  The  battle  losses  (killed  and 
wounded )  of  that  army  were  also  very  small,  little 
if  any  more  than  five  hundred.  The  British  had 
taken  a  thousand  prisoners,  most  of  whom  were  rea- 
sonably well  treated  and  returned  by  exchange. 
Those  officers  captured  at  Quebec  in  December,  and 
at  Three  Rivers  in  June,  reached  Elizabethtown, 
New  Jersey,  in  September. 

The  sufferings  of  American  prisoners  of  war  in 
New  York  were  long  the  subject  of  bitter  com- 
plaint. The  prisoners  taken  on  Long  Island,  at 
Fort  Washington,  and  elsewhere  were  crowded  into 
buildings  in  the  city  and  into  old  hulks  in  the  har- 
bor, where  under  the  worst  sanitary  conditions  they 
died  by  hundreds.  Both  smallpox  and  typhus 
contributed  to  the  death  roll  of  these  wretched  vic- 
tims of  the  war.  In  the  city  the  principal  prisons 
were :  the  Middle  Dutch  Church  on  Nassau  Street, 
afterward  the  Post  Office ;  the  Lutheran  Church,  at 
the  northeast  corner  of  Frankfort  and  William 
Streets ;  the  old  Provost  Prison,  converted  into  the 
Hall  of  Records  in  1831  ;  the  Huguenot,  the  Brick 
Church,  and  the  Friends'  Meeting  House ;  the  Van 
Cortlandt  Sugar  House :  another  near  the  Dutch 
Church ;  and  the  Rhinelander  Sugar  House,  at  the 
corner  of  William  and  Duane  Streets.  In  all  these 
places  the  sufferings  were  intense.  "I  have  gone 
into  a  church,"  writes  Colonel  Ethan  Allen,  "and 
seen  sundry  of  the  prisoners  in  the  agonies  of 
death  in  consequence  of  very  hunger,  and 
others  speechless  and  near  death,  biting  pieces  of 
chip.  .  .  .  The  filth  of  these  churches  was  al- 
most beyond  description.  I  have  seen  in  one  of 
them  seven  dead  at  the  same  time."  Three  thousand 
were  crowded  into  the  Dutch  Church,  but  an  out- 
break of  smallpox  Compelled  their  removal.  Colonel 
Ethan  Allen,  !Major  Travis  of  Virginia,  Judge  Field 
of  Bergen,  Major  Van  Zandt  and  others  of  rank 
were  subjected  to  the  brutality  of  one  Captain  Cun- 
ningham, who  boasted  that  he  had  starved  two 
thousand  rebels  by  selling  their  rations. 

The  treatment  of  military  prisoners  at  that  time 
was  generally  inhuman.  It  was  the  more  so  in  the 
case  of  the  colonists  who  were  considered  as  rebels, 
to  be  punished  as  well  as  imprisoned. 

Clothed  in  rags  and  scarcely  covered  from  the 
wintry  air,  crowded  in  narrow  rooms  and  weak- 
ened by  disease,  the  prisoners  died  by  the  hun- 
dreds. The  feeble  shivered  in  the  wintry  blast,  the 
sick  lay  down  on  beds  of  snow  to  perish.  Food 
was  of  the  coarsest  kind  and  was  served  out  in 
scanty  measure.  Smallpox  and  the  deadly  jail  fever 
raged    unopposed.    Every    night    ten    or  twenty 


died ;  every  day  the  meagre  bodies  were  thrown  into 
pits,  with  no  burial  rites.  Even  when  led  out  for 
exchange  there  was  little  hope,  for  many  died  on 
the  way  home,  or  lingered  on  for  but  a  few  mis- 
erable weeks.  So  wretched  was  the  condition  of 
these  exchanged  prisoners  that  Washington  refused 
to  consider  them  fit  subjects  for  exchange.  "You 
give  us  only  the  dead  or  dying,"  he  wrote  to  Howe, 
"for  our  well  fed  and  healthy  prisoners,"  and 
pointed  to  the  condition  in  which  they  reached  him, 
diseased,  famished,  emaciated  and  dying,  as  they 
were  conducted  to  their  quarters. 

The  A'czi'  Hampshire  Gazette  of  April  26,  1777, 
said : 

The  enemy  in  New  York  continues  to  treat  the  Ameri- 
can prisoners  with  great  barbarity.  Their  allowance  to 
each  man  for  three  days  is  one  pound  of  beef,  three 
wormeaten  biscuits,  and  a  quart  of  salt  water.  The  meat 
they  are  obliged  to  eat  raw  as  they  have  not  the  smallest 
allowance  of  fuel.  Owing  to  this  more  than  savage  cruel- 
ty, the  prisoners  die  fast,  and  in  the  small  space  of  three 
weeks  (during  the  winter)  no  less  than  1,700  brave  men 
perished.  Lieutenant  Collin  narrates  that  he  with  225  men 
were  put  on  board  the  Glasgozv  on  the  25th  of  December, 
1777.  to  be  carried  to  Connecticut  for  exchanges.  They 
were  on  shipboard  eleven  days,  crowded  between  decks, 
and  twenty-eight  of  their  number  died  through  illness  in 
that  brief  space  of  time. 

The  contagion  of  the  prisons  did  not  fail  to  spread 
to  the  city.  During  the  winter  the  smallpox  made 
fearful  ravages.  Hundreds  of  the  citizens  died,  and 
the  wealthy  fled  in  fright  to  their  country  homes,  to 
undergo  inoculation.  The  violent  putrid  fevers  of 
the  prisons  spread  to  the  inhabitants.  New  York 
w-as  full  of  mourning.  Of  thirty  persons  in  one 
family  only  ten  escaped.  The  graveyards  teemed 
with  burials.  The  summer  air  brought  no  relief, 
but  seemed  malarious  and  deadly. 

Terrible  as  were  the  conditions  in  these  prisons, 
they  were  even  worse  on  the  prison  ships :  old  hulks 
moored  near  Wallabout  Bay.  The  most  notorious 
of  these  was -the  Jersey,  whose  evil  repute  is  scarce- 
ly less  than  that  of  the  Black  Hole  of  Calcutta. 
Her  guard  was  composed  of  Hessians.  Frequently  a 
thousand  Continental  soldiers  were  confined  on 
board,  and  there  they  sickened  and  died  by  hun- 
dreds. At  night  the  hatches  were  battened  down, 
in  the  morning  the  jailers  shouted,  "Rebels,  turn 
out  your  dead."  No  aid  could  be  extended  to  them, 
not  even  medical  service. 

These  facts  are  recorded  merely  to  show  the  price 
paid  by  the  colonists  for  liberty ;  that  the  people  of 
today  may  not  forget  the  sufferings  of  those  who, 
going  forth  to  battle  for  freedom,  died  in  misery 
and  filth  in  these  horrible  prisons ;  aiding,  however, 
in  securing  that  freedom  for  us. 

During  the  year  1776  there  were  in  service  forty- 
seven  thousand  Continentals,  one  year  troops ;  and 
twenty-seven  thousand  militia,  who  served  from  a 
few  days  to  a  few  months,  some  near  a  year ;  so 
many  never  enlisted  in  one  year  again.  Their  cas- 
ualties may  be  estimated  roughly  at  one  thousand 
killed  or  died  of  wounds,  twelve  hundred  other 
wounded,  six  thousand  taken  prisoners,  ten  thou- 
sand died  of  disease,  and  several  thousand  who  de- 
serted or  disappeared.  At  the  end  of  the  year  the 
term  of  enlistment  of  nearly  all  expired.  Some  few 
regiments  had  been  organized  later  than  others ; 


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[New  York 
Medical  Journal. 


some  were  persuaded  to  remain  a  few  weeks  beyond 
their  terms  of  service ;  but  the  main  Continental 
Army  disappeared,  the  new  one  was  not  yet  formed, 
and  the  often  reviled  militia  had  to  fill  the  gap,  as 
at  Boston  the  year  before.  Fortunately  for  the 
country,  the  British  Army  followed  its  time  hon- 
ored custom  of  going  into  winter  quarters.  No 
of¥ensive  movements  were  made  after  December. 
Time  was  thus  given  to  organize  a  new  army  and 
to  prepare  for  the  next  year's  campaign.  Congress 
had  already  provided  the  necessary  legislation,  and 
recruiting  was  in  progress.  That  the  work  could 
be  done  in  the  face  of  general  defeat  and  failure 
throughout  the  year  is  an  enduring  memorial  to  the 
faith  and  steadfastness  of  the  struggling  colonists. 

NOTES. 

12.  DR.    MORG.\X   TO   GENERAL  WASHINGTON. 

New  York,  September  i2,  1776. 

Agreeable  to  orders  I  have  been  in  the  County 
of  Orange  and  collected  seven  members  of  the 
Committee  and  spent  the  whole  of  yesterday  and 
part  of  this  day  in  viewing  the  country,  and  looking 
out  for  proper  covering  for  the  reception  of  the 
sick  and  wounded. 

I  am  sorry  to  report  that  in  a  circuit  of  fourteen 
miles  in  that  County,  I  cannot  find  or  hear  of  any 
suitable  accommodations  for  more  than  about  one 
hundred  sick.  No  country  can  be  worse  provided 
in  all  respects ;  and  the  places  proposed  are  remote 
from  any  landing.  From  the  knowledge  I  have  of 
New  Ark  I  am  persuaded  it  is  a  place  infinitely 
superior  in  all  respects  for  the  establishment  of  a 
general  hospital.  There  are  but  four  miles  of  land 
carriage  required ;  all  the  rest  is  water  carriage. 
The  houses  are  numerous,  large  and  convenient.  If 
it  be  objected  that  they  are  full  of  inhabitants  from 
New  York,  so  is  every  hovel  through  Orange 
County :  and  as  to  the  town  of  Orange,  I  cannot 
find  that  there  is  room  for  one  sick  person  without 
incommoding  some  one  or  other. 

After  this  report,  which  is  grounded  on  the  most 
careful  inquiry  and  inspection,  I  await  your  Excel- 
lency's further  orders;  but  if  I  may  be  permitted 
to  ofifer  my  sentiments  it  is  that  no  time  be  lost  in 
applying  to  the  Committee  at  New  Ark  by  requis- 
ition for  room  for  the  sick ;  and  if  your  Excellency 
thinks  proper,  I  will  immediately  repair  with  all 
despatch  to  urge  the  matter  without  delay,  or  pro- 
ceed in  any  other  way  your  Excellency  may  see  fit. 

I  am  your  Excellency's  most  obedient  and  very 
humble  servant, 

John  Morgan. 

13. — Dr.  William  Burnet,  of  Newark,  New  Jer- 
sey, was  a  member  of  the  Committee  of  Public 
Safety  of  that  Colony,  and  was  made  Surgeon  Gen- 
eral of  the  militia,  February  17,  1776.  His  son, 
Tchabod  Burnet,  was  an  aide  of  General  Greene. 
When  Mrs.  Washington  journeyed  to  Cambridge  in 
1775  she  stayed  at  the  house  of  Dr.  Burnet  in  Broad 
Street.  He  was  Physician  and  Surgeon  General  of 
the  Eastern  Department,  April  11,  1777,  and  Hos- 
pital Physician  and  Surgeon,  Oct.  6,  1780;  and 
Chief  Hospital  Physician  and  Surgeon,  March  5, 
1781  to  the  end  of  the  war.  He  was  stationed  at 
West  Point  at  the  time  of  Arnold's  treason ;  after 
the  war,  was  president  of  the  State  Medical  So- 


ciety, and  Judge  of  the  Court  of  Common  Pleas. 
A  son,  David  Burnet,  became  President  of  Texas. 
Dr.  Burnet  died  October  7,  1791. 

14.  RESOLUTION   OF  CONGRESS. 

Resolved.  That  no  regimental  hospitals  be  in 
future  allowed  in  the  neighborhood  of  the  general 
hospital.  "  t 

That  John  Morgan,  Esq.,  provide  and  superin- 
tend a  hospital  at  a  proper  distance  from  the  camp, 
for  the  Army  posted  on  the  east  side  of  Hudson's 
River. 

That  William  Shippen,  Esq.,  provide  and  super- 
intend a  hospital  for  the  Army  in  the  State  of  New 
Jersey. 

That  each  of  the  hospitals  be  supplied  by  the  re- 
spective directors,  with  such  a  number  of  surgeons, 
apothecaries,  surgeons'  mates  and  other  assistants ; 
and  also  with  such  quantities  of  medicines  and  bed- 
ding, and  other  necessaries,  as  they  shall  judge  ex- 
pedient. 

That  they  make  weekly  returns  to  congress,  and 
to  the  Commander  in  Chief,  of  the  officers  and  as- 
sistants of  each  denomination ;  and  also  the  num- 
ber of  sick  and  deceased,  in  their  respective  hos- 
pitals. 

That  the  regimental  surgeons  be  directed  to  send 
to  the  general  hospital  such  officers  and  soldiers  of 
their  res])ective  regiments,  as  confined  by  wounds, 
or  other  disorders,  shall  require  nurses  or  other  at- 
tendance, and  from  time  to  time  apply  to  the  Quar- 
termaster General,  or  his  deputy,  for  convenient 
wagons,  for  their  purpose ;  also,  that  they  apply  to 
the  directors  in  their  respective  departments  for 
medicines  and  other  necessaries. 

That  the  wages  of  the  nurses  be  augmented  to 
one  dollar  a  week. 

That  a  commanding  officer  of  each  regiment,  be 
directed  once  a  week  to  send  a  commissioned  officer, 
to  visit  the  sick  of  his  respective  regiment,  in  the 
general  hospital,  and  report  their  state  to  him. 

Charles  Thompson,  Secretary. 

15.  — LETTER  OF  WASHINGTON  TO  CONGRESS. 

Before  I  conclude  I  would  beg  leave  to  mention 
to  Congress,  that  the  pay  now  allowed  to  nurses 
for  their  attendance  on  the  sick  is  by  no  means 
adequate  to  their  services — the  consequence  of  which 
is  that  they  are  extremely  difficult  to  procure;  in- 
deed they  are  not  to  be  got,  and  we  are  under  the 
necessity  of  substituting  in  their  place  a  number  of 
men  from  the  respective  regiments,  whose  services 
by  that  means  is  entirely  lost  to  the  proper  line  of 
their  duty,  and  but  little  benefit  indeed  to  the  sick. 
The  officers  I  have  talked  with  upon  the  subject  all 
agree  that  they  should  be  allowed  a  dollar  a  week, 
and  that  for  less  they  cannot  be  had.  Our  sick  are 
extremely  numerous,  and  we  find  their  removal 
attended  with  the  greatest  difficulty.  It  is  a  matter 
that  employs  much  of  our  time  and  care,  and  what 
makes  it  more  distressing,  is  the  want  of  proper 
and  convenient  places  for  their  reception.  I  fear 
their  sufferings  will  be  great  and  many;  however 
nothing  on  my  part  that  humanity  or  policy  can 
require  shall  be  wanting  to  make  them  comfortable, 
so  far  as  the  state  of  things  will  permit  it. 

I  have  the  honor  to  be  &c. 

Geo.  Washington. 


October  2,  1920.]  DUNCAN:  MEDICAL  MEN  IN  THE  AMERICAN  REVOLUTION. 


505 


16.  — TO  DOCTOR  BENJAMIN  RUSH  MEMBER  OF  THE 

MEDICAL  COMMITTEE  OF  CONGRESS. 

Sir :  By  command  of  General  Washington,  all  the 
sick  and  wounded,  both  in  the  general  hospital  and 
those  remaining  under  the  care  of  regimental  sur- 
geons, are  removed  within  two  days,  to  this  side  of 
the  river^  and  chiefly  in  this  neighborhood.  They 
amount  to  several  hundreds,  in  addition  to  about 
300  who  were  before  removed  to  Newark,  and  4 
or  500  in  Orange  County. 

The  general's  commands  were  to  leave  a  respec- 
table body  of  surgeons  and  mates  above  Kingsbridge, 
a  general  action  being  daily  expected,  as  the  whole 
force  of  the  enemy  is  drawn  to  that  quarter. 

So  soon  as  I  get  this  part  of  the  general  hospital 
into  order  I  am  to  return  and  provide  accommoda- 
tions at  the  White  Plains,  for  which  indeed  I  gave 
the  necessary  orders  before  I  came  over. 

John  Morgan. 

17.  circular  letter. 

To  the  regimental  surgeons  and  mates,  belonging 
to  the  Army  of  His  Excellency,  General  Washington, 
now  absent  with,  or  without  the  sick  of  their 
respective  regiments  and  brigades,  on  either  side  of 
Hudson  River.    Gentlemen : 

Few  of  the  surgeons  or  sick,  allowed  to  remove 
from  camp  some  time  ago,  being  yet  returned,  and 
no  report  being  made  of  them  to  me.  His  Excellency 
the  Commander  in  Chief,  conceives  that  his  former 
indulgence  to  the  sick,  in  permitting  them  to  retire 
from  the  camp  for  the  recovery  of  their  health,  has 
been  much  abused  both  by  the  sick  and  the  generality 
of  the  surgeons  and  mates,  under  whose  care  they 
were  allowed  that  indulgence;  it  is  His  Excellency's 
orders,  therefore,  that  each  of  you  do  forthwith 
wait  upon  Isaac  Foster,  Esq.,  at  Hackensack ;  John 
Warren,  Esq.,  at  Newark,  or  Philip  Turner,  Esq.,  at 
Norwalk ;  Surgeons  in  the  general  hospital,  who- 
ever of  them  is  nearest  at  hand,  and  make  a  faithful 
and  accurate  report  of  the  sick  and  wounded  under 
your  care,  and  remove  those  who  are  fit  subjects, 
immediately,  to  the  general  hospital,  under  their 
care;  for  which  you  are  to  apply  to  the  quarter- 
master general's  dept.  for  wagons,  and  accompanying 
them  yourselves  

Such  of  you  as  those  gentlemen  require  to  assist 
them  for  the  present  in  the  general  hospital,  and 
who  are  willing  to  attend  to  their  sick  there,  under 
their  direction,  are  allowed  to  do  so  till  further 
orders ;  all  others  are  to  repair  immediately  to  head- 
quarters, and  join  their  respective  regiments :  first 
furnishing  me  with  an  accurate  register,  duly  certi- 
fied, of  the  state  of  the  sick  that  went  out  with  them, 
or  have  been. since  under  their  care,  specifying  the 
time  of  their  being  taken  ill,  their  diseases,  and 
events  as  to  death,  recovery,  or  continuance ;  and 
whether  any  of  the  sick  have  been  allowed  to  with- 
draw from  under  their  care,  and  when. 

As  all  who  are  absent  without  leave  must  naturally 
be  looked  upon  as  deserters.  And  the  surgeons,  or 
mates,  who  cannot  give  a  regular  and  satisfactory 
account  of  the  faithful  discharge  of  their  duty, 
necessarily  subject  themselves  to  an  inquiry  into 
their  conduct. 

John  Morgan. 


18.  — Philip  Turner  was  born  at  Norwich,  Connec- 
ticut in  1740.  Being  left  an  orphan  at  twelve,  he  was 
taken  into  the  family  of  Dr.  Elisha  Tracy  and  in 
time  studied  medicine.  In  1759  he  was  an  assistant 
surgeon  with  a  provincial  regiment  at  Ticonderoga: 
continuing  with  the  army  vmtil  1763.  At  the  begin- 
ning of  the  war  he  stood  at  the  head  of  his  pro- 
fession, but  left  his  practice  to  become  surgeon  of 
Huntington's  Regiment  (8th  Connecticut,  later  the 
17th  Continental).  He  was  at  Boston,  accompanied 
the  army  to  New  York,  and  was  at  Long  Island  and 
White  Plains.  In  1777  he  narrowly  missed  being 
made  Director  General  instead  of  Dr.  Shippen.  He 
was  a  little  later  made  Surgeon  General  of  the 
Eastern  Department ;  and  served  as  such  vmtil  near 
the  end  of  the  war.  He  then  returned  to  Norwich 
and  resumed  practice.  In  1800  he  removed  to  New 
York  City,  and  later  was  appointed  a  staff  major 
in  the  army,  with  station  at  Governor's  Island.  He 
held  this  position  until  his  death  in  1815. 

19.  — Dr.  James  McHenry  was  born  in  Ireland  in 
1753,  came  to  America  in  1771,  studied  medicine  in 
Philadelphia  under  Dr.  Benjamin  Rush,  but  does  not 
appear  to  have  graduated  from  the  Medical  College. 
He  was  made  surgeon  of  the  5th  Pennsylvania  Regi- 
ment on  August  10,  1776,  and  was  taken  prisoner 
at  the  capture  of  Fort  Washington,  November  16, 
1776.  He  was  on  parole  until  exchanged,  March  5, 
1778.  In  May  he  was  appointed  secretary  to  Gen- 
eral Washington,  and  this  ended  his  medical  career. 
On  May  25th  he  was  commissioned  a  major  in  the 
Continental  Army.  In  1780-81  he  was  an  aide-de- 
camp to  LaFayette.  After  the  war  he  was  a  mem- 
ber of  the  Maryland  Legislature.  He  was  Secre- 
tary of  War  from  January  29th,  1796,  to  May  13, 
1800.  Fort  McHenry,  Baltimore,  the  scene  of  the 
incident  giving  rise  to  the  writing  of  The  Star 
Spangled  Banner,  was  named  in  his  honor.  He 
died  May  8,  1816. 

20.  — John  Beatty  was  a  native  of  Bucks  County, 
Pennsylvania,  where  he  was  born  in  1748,  but  re- 
ceived his  education  in  New  Jersey  and  lived  in  that 
State  for  forty  years.  He  graduated  from  Princeton 
College  in  1769,  and  afterward  studied  medicine 
under  Dr.  Rush.  Like  many  other  medical  men,  at 
the  beginning  of  the  war  he  exchanged  the  civilian 
dress  of  the  surgeon  for  the  regimentals  of  a  line 
officer.  By  September  of  1776  he  had  reached  the 
rank  of  lieutenant  colonel.  Fickle  fortune  placed  him 
in  one  of  those  Pennsylvania  regiments  selected  to 
defend  Fort  Washington.  As  they  were  unable  to 
defend  it,  he  became  a  prisoner  of  war,  and  as  such 
endured  great  hardship  and  suffering.  He  was  not 
released  until  his  health  had  entirely  failed,  requir- 
ing several  years  for  restoration.  Not  until  1779 
was  he  able  to  resume  active  duty.  He  was  then 
appointed  Commissary  General  of  prisoners,  which 
position  he  is  believed  to  have  held  until  the  close 
of  the  war. 

[Notes  21,  22  and  23  have  been  omitted,  owing 
to  lack  of  space ;  they  will  appear  in  the  author's 
reprints.  Notes  21  and  22  comprise  a  letter  from 
General  Heath  to  Dr.  Morgan  and  Dr.  Morgan's 
reply;  Note  23  embodies  the  resolution  dismissing 
Dr.  Morgan  from  the  service.  Editors.] 


Editorial  Notes  and  Comments 


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NEW  YORK,  SATURDAY,  OCTOBER  2,  1920. 

OCULAR  ACCIDENTS  ATTRIBUTED  TO 
ARSENICAL  PRODUCTS. 

The  arsenical  compovmds,  both  mineral  and  or- 
ganic, have  been  the  cause  of  various  accidents,  but 
ocular  disturbances  attributed  to  these  products  are 
the  most  serious  of  all.  The  arsenical  prodticts  that 
have  produced  slight  ocular  accidents  having  a  good 
prognosis  are  the  cacodylates  and  sodium  and  potas- 
sium arsenate ;  those  producing  serious  disturbances 
are  atoxyl,  arsacetine,  hectine  and  hectargyre,  as  well 
as  salvarsan  and  neosalvarsan. 

Regardless  of  the  very,  extensive  use  made  in  re- 
cent years  of  the  cacodylates  lesions  of  the  optic 
nerve  have  never  been  recorded.  The  few^  cases  re- 
ported of  optic  neuritis  following  the  internal  exhi- 
bition of  sodium  or  potassitim  arsenate  have  been 
neuritides  presenting  the  type  of  toxic  neuritis  or 
infectious  neuritis  with  a  central  scotoma,  without 
any  change  in  the  peripheral  visual  field  but  offering 
a  slight  irregularity  in  the  outline  of  the  papilla. 
The  prognosis  is  favorable  in  these  cases. 

Atoxyl  produces  complete  and  incurable  atrophy 
of  the  optic  nerve  following  a  retrobulbar  neuritis, 
the  symptoms  being  a  narrowed  visual  field,  decrease 
of  the  pupil  reflex,  white  papillae  and  a  narrowing 
of  the  vessels  of  the  retina.  Arsacetine  acts  in  the 
same  way  only  its  toxicity  is  somewhat  less.  Hec- 
tine and  hectargyre  produce  identical  lesions  of  the 
optic  nerve  but  nevertheless  not  so  serious  as  those 
resulting  from  atoxyl. 

However,  all  things  considered,  ocular  complica- 
tions have  been  reported  too  frequently  from  these 


products  so  that  preference  should  be  given  to  sal- 
varsan, arsenobenzol  or  neosalvarsan.  The  ocular 
accidents  attributed  to  salvarsan  may  be  placed  in 
three  categories,  namely,  accidents  in  the  uveal  tract, 
those  of  the  optic  nerve,  and  accidents  arising  in  the 
motor  nerves,  the  globe  of  the  eye,  and  the  eyelids. 

The  accidents  arising  in  the  uveal  tract — iritis  and 
choroiditis — attributed  to  salvarsan  are,  in  reality, 
merely  syphilitic  manifestations  and  are  not  the  re- 
sult of  the  drug.  Their  early  appearance  is  proof 
of  this.  Likewise,  the  optic  neuritis  attributed  to 
salvarsan  wotild  seem  also  to  be  of  a  syphilitic  na- 
ture ;  it  is  neither  more  frequent  in  occurrence  nor 
earlier  in  appearance  than  before  salvarsan  came  into 
use. 

As  to  the  disturbances  of  the  motor  nerves  of  the 
eye  they  are  simply  manifestations  of  the  syphilitic 
virus  and  cannot  be  attributed  to  salvarsan.  The 
cases  recorded  by  Bizard,  Sicard,  Guttmann,  and 
others  were  due  to  meningeal  phenomena  which  re- 
acted upon  the  cranial  nerves  as  might  be  expected; 
these  meningeal  phenomena  were  noted  at  the  very 
onset  of,  the  syphilis  and  before  treatment  with  sal- 
varsan had  been  given. 

It  is  also  safe  to  assume  that  what  has  been  said 
of  salvarsan  applies  as  well  to  neosalvarsan,  arseno- 
benzol and  other  recent  products  of  arsenic,  and 
that  with  very  small  doses  repeated  daily  or  every 
second  day,  either  subcutaneously  or  intravenously, 
no  accidents  of  any  description  need  be  feared. 


SLEEPING  SICKNESS. 
Sleeping  sickness  has  been  confounded  to  some 
extent  with  encephalitis  lethargica.  When  the  latter 
condition  was  somewhat  prevalent  in  this  country, 
the  daily  journals  usually  referred  to  it  as  sleeping 
sickness.  According  to  H.  L.  Duke  the  date  of 
commencement  of  the  great  epidemic  of  sleeping 
sickness  on  the  shores  of  Lake  Victoria  is  difficult 
to  determine.  The  attention  of  Europeans  was  first 
drawn  to  the  disease  in  1901,  but  inquiry  among  the 
Buganda  chiefs  revealed  the  fact  that  mongota,  the 
native  name  for  the  disease,  existed  previous  to  this 
date  in  endemic  form.  In  1906  Sir  H.  Hesketh 
Bell  proposed  a  scheme  for  dealing  with  the  malady 
which  was  put  into  execution.  Segregation  of  the 
infected  was  the  principle  of  this  scheme  and  was 
commenced  in  1906,  and  by  the  end  of  1907  the 
mainland  population  had  been  removed  inland  for 
a  depth  of  two  miles  from  the  coast.  These  mea- 
sures were  enforced  only  within  the  limits  of  the 
Uganda  protectorate. 


October  2,  1920.] 


EDITORIAL  ARTICLES. 


507 


Different  means  of  endeavoring  to  extirpate  the 
disease  prevailed  in  the  adjoining  fly  areas  of  Ger- 
man East  Africa  and  British  East  Africa.  The 
Germans  combined  deforestation  measures  with  a 
Hmited  depopulation  scheme  applied  to  certain  dan- 
gerous localities.  In  British  East  Africa  the  natives 
were  left  in  contact  with  the  flies,  an  attempt  to 
encourage  voluntary  segregation  and  isolation  prov- 
ing abortive.  Along  the  shores  of  the  Kavirondo 
Gulf,  the  epidemic  apparently  worked  itself  out 
after  causing  a  very  heavy  mortality.  The  disease 
in  this  area  now  appears  to  be  endemic  and  the 
population  is  reported  to  be  increasing.  As  for 
German  East  Africa,  the  authorities  there  described 
the  measures  taken  as  completely  successful  yet 
admitted  that  isolated  cases  of  fresh  infection  oc- 
curred from  time  to  time. 

Concerning  the  part  played  by  the  tsetse  flies 
in  the  transmission  of  the  infection,  as  a  result 
of  most  careful  and  critical  examination  of  all  avail- 
able information  with  regard  to  the  Uganda  epidemic 
Duke  brings  forward  the  hypothesis  that  mechanical 
transmission  from  man  to  man  of  a  virulent  strain 
of  Trypanosoma  gambiense  played  a  most  important 
part.  He  points  out  that  the  conditions  necessary 
for  direct  transmission,  viz.,  the  presence  of  many 
large  biting  flies  and  of  many  potential  hosts  of  the 
parasite  in  close  juxtaposition,  were  fulfilled  in  the 
closely  packed  canoes  of  Victoria  Nyanza.  How- 
ever, the  chief  point  raised  by  Duke  is  as  follows : 

While  it  appears  that  segregation  had  its  effect 
in  Uganda,  in  preventing  the  spread  of  the  disease, 
nipping  it  in  the  bud  in  fact,  does  it  follow  that 
those  responsible  for  the  direction  of  affairs  in  that 
district  of  Africa  are  justified  in  accepting  the  most 
obvious  interpretation  and  proceeding  to  reconstruc- 
tive effort  on  the  assumption  that  an  epidemic  of 
sleeping  sickness  is  impossible  unless  there  is  suf- 
ficient contact  between  the  flies  and  the  population 
to  render  possible  the  development  of  a  virulent 
mechanical  transmission  strain,  or  must  the  possi- 
bility also  be  taken  into  account  that  the  patho- 
genicity of  the  trypanosome  may  be  subject  per  se 
to  variations,  irrespective  of  the  method  by  which 
it  is  transmitted  ?  On  the  latter  explanation  the 
disappearance  of  acute  trypanosomiasis  in  Uganda 
is  not  altogether  due  to  the  preventive  measures  but 
also  in  greater  or  less  degree  to  diminution  in  patho- 
genicity of  the  parasite,  and  the  trypanosome  is 
likely  to  resume  a  virulent  state,  even  in  Uganda, 
under  existing  conditions.  Duke,  therefore,  considers 
that  further  specific  inquiry  is  needed  to  elucidate 
the  question.  Reading  the  results  of  such  inquiry 
the  following  hypothesis  affords  the  best  answer 
that  can  be  given  to  what  may  be  regarded  as  the 


main  question.  It  recognizes  the  possibility  that  the 
trypanosome  may  vary  greatly  in  pathogenicity  to 
man ;  it  takes  into  account  the  manner  in  which 
peculiarly  virulent  strains  of  normally  less  virulent 
species  of  insect  borne  trypanosomes  are  developed; 
it  recognizes  also  the  real  probability  that  such 
strains  may  develop  in  nature  as  well  as  in  the  lab- 
oratory ;  it  recognizes  a  clear  possibility  that  a  pe- 
culiarly virulent  strain  of  trypanosome  may  have 
been  developed  in  this  manner ;  and  finally,  if  it 
could  be  proved  well  founded,  it  would  indicate  that 
very  broad  contact  between  the  flies  and  the  popu- 
lation is  a  prime  essential  to  the  occurrence  of  sleep- 
ing sickness  in  the  form  of  a  widespread  epidemic. 
The  inquiry  recommended  by  Duke  should  be  valu- 
able not  only  with  regard  to  sleeping  sickness  but 
with  respect  to  other  insect  borne  diseases  and  per- 
haps disease  generally  of  an  infective  character. 


PHYSICIAN  AUTHORS— JOHN  LOCKE. 

The  most  important  figure  in  English  philosophy 
is  Dr.  John  Locke,  a  physician  whose  Essay  on 
Human  Understanding  has  been,  ever  since  its  pub- 
lication in  1690,  one  of  the  two  fountain  heads  of 
modern  philosophy.  The  other  is  Kant's  Kritik  of 
Pure  Reason.  What  Kant  is  to  German  philosophy 
Locke  is  to  English.  These  are  the  two  giants  of 
modern  philosophy.  Locke's  Essay — that  is  all  the 
title  it  generally  gets  in  discussion — gave  a  new  di- 
rection to  European  philosophy  and  provided  a  new 
basis  for  the  science  of  psychology.  It  opened  a 
better  and  clearer  way  to  reasoning.  John  Stuart 
Mill,  Locke's  spiritual  descendant,  called  Locke  the 
"unquestionable  founder  of  analytical  philosophy  of 
the  mind,"  and  D'Alembert  says :  "It  may  be  said 
that  he  created  the  science  of  metaphysics,  for  he 
reduced  metaphysics  to  that  which  it  ought  to  be, 
viz.,  the  experimental  physics  of  the  mind."  Henry 
Hallam  is  equally  enthusiastic.  He  describes  the 
essay  as  "the  first  and  most  complete  chart  of  the 
human  mind  laid  down ;  the  most  ample  repertory 
of  truths  relating  to  our  intellectual  being  and  the 
one  book  which  we  are  still  compelled  to  name  as 
the  most  important  in  metaphysical  science." 

But  the  essay  has  its  inconsistencies  and  these 
have  been  assailed  as  hotly  as  its  truths  have  been 
defended.  It  is  not  the  individual  doctrines,  how- 
ever, that  give  it  its  superiority.  Many  of  these 
have  succumbed  to  hostile  criticism.  The  excellence 
lies  rather  in  the  general  drift  and  the  direction  it 
gave  to  the  philosophical  studies  of  others.  "There 
is  hardly  a  single  French  or  English  writer  (and 
we  may  add  Kant)  .  .  .  who  does  not  profess 
either  to  develop  Locke's  system,  or  to  supplement. 


508 


EDITORIAL  ARTICLES. 


[New  York 
Medical  Journal. 


or  to  criticise  it,"  says  Thomas  Fowler.  In  short, 
around  this  essay  a  whole  literature  of  attack  and 
defence  has  arisen.  "He  suggests  as  much  as  he 
teaches,"  says  George  Henry  Lewes,  and  it  is  not  to 
be  denied  that  the  essay  opened  up  vast  tracts  of 
thought  and  has  had  an  enormous  influence,  despite 
its  weaknesses. 

It  took  Locke  twenty  years  to  write  this  splendid 
textbook  of  what  has  been  called  "the  noblest  branch 
of  human  learning."  Twenty  years  of  concentra- 
tion and  toil  whenever  he  had  the  time,  and  he  got 
only  thirty  pounds  for  the  copyright.  Purchase  of 
the  most  renowned  treatise  of  its  time,  the  greatest 
book  of  its  generation,  for  a  miserable  pittance  of 
thirty  pounds !  Many  an  author  today  would  spurn 
this  amount  if  it  were  ofifered  for  a  trifling  short 
story  sketched  during  one  weekend  and  completed 
before  another. 

George  Henry  Lewes  says  Locke's  education  as 
a  physician  fitted  him  for  the  meditation  necessary 
to  write  the  essay,  and  other  writers  have  assured 
us  that  his  medical  observations  had  a  powerful  in- 
fluence on  his  speculative  studies.  Locke  was  one 
of  the  most  renowned  physicians  of  his  day,  al- 
though he  was  one  of  the  late  blooming  variety.  It 
was  not  until  he  was  forty-two  years  old  that  he 
took  his  degree  of  Bachelor  of  Medicine,  in  1674. 
This  was  because  when  he  first  went  to  Oxford  he 
studied  theology,  and  it  was  only  after  several  years 
of  classical  and  theological  study  that  he  determined 
to  be  a  physician.  His  chronic  ill  health  also  delayed 
his  medical  studies.  He  was  afflicted  with  lung 
trouble  and  on  two  occasions  had  to  take  extensive 
rests  in  southern  France.  It  was  his  good  fortune 
to  have  a  lord  as  his  first  patient.  Lord  Ashley,  after- 
wards Lord  Shaftesbury,  whose  life  he  saved.  The 
two  were  fast  friends  forever  after  and  their  names 
are  linked  in  politics,  in  which  Locke  took  such  an 
active  interest  that  he  had  to  flee  to  Holland,  where 
he  spent  five  years  in  exile  under  the  assumed  name 
of  Dr.  Van  der  Linden.  It  was  while  he  was  in 
Holland  that  he  completed  the  essay.  His  exile 
weighed  heavily  upon  him,  we  are  told,  but  at  the 
end  of  it  fortune  smiled  upon  him  and  through  the 
influence  of  friends  he  held  several  highly  paid  gov- 
ernment positions. 

The  Essay  on  Human  Understanding  was  but 
one  of  many  writings  on  which  Locke's  fame  rests. 
He  wrote  four  other  philosophical  treatises  of  lesser 
consequence,  five  on  Christianity,  eight  on  social 
economy,  five  on  education  and  several  on  miscel- 
laneous subjects.  Perhaps  second  in  importance 
was  his  Essay  on  Tolerance,  in  which  he  is  credited 
with  having  uttered  more  good  sense  on  the  subject 
of  religious  tolerance  than  is  found  in  the  works  of 


any  preceding  writer.  It  came  at  a  time  when  the 
spirit  of  toleration  and  charity  in  religious  differ- 
ences was  badly  needed  and  it  wrought  much 
improvement.  Carlyle  said  of  it  that  "it  paved  the 
way  for  banishing  religion  from  the  world,"  but 
that,  perhaps,  may  be  an  overappreciation  of  its  in- 
fluence. By  means  of  his  Essay  on  Education 
Locke  became  a  great  educational  reformer,  chang- 
ing the  whole  attitude  of  English  and  continental 
society  toward  the  subject.  His  Essay  on  Govern- 
ment diffused  throughout  the  world  the  love  of  civil 
liberty.  This  essay  was  the  first  on  which  his  name 
appeared.  The  Essay  on  Tolerance  and  many  of 
the  others  appeared  anonymously. 

John  Locke  was  born  in  Somersetshire,  England, 
on  August  29,  1632,  six  years  after  the  death  of 
Bacon,  and  died  in  1704  at  the  age  of  seventy-two. 
In  the  inscription  on  his  tomb,  prepared  by  himself, 
he  refers  to  his  books  as  a  true  representation  of 
what  he  was.  "If  we  consider  his  genius  and  pene- 
trating and  exact  judgment,  or  the  strictness  of  his 
morals,  he  has  scarce  any  superior  and  few  equals," 
said  Dr.  Thomas  Sydenham,  the  famous  physician 
after  whom  the  Sydenham  society  was  r;iamed,  in  his 
Medical  Observations. 


THE    BRITISH    NATIONAL  INSURANCE 
ACT. 

It  was  shown  at  the  recent  meeting  of  the  British 
Medical  Association  that  much  discontent  prevails 
among  the  members  of  the  British  medical  profes- 
sion generally  with  regard  to  the  National  Insur- 
ance Act.  Perhaps  it  is  not  so  much  a  question  of 
remuneration,  although  the  pay  of  panel  practi- 
tioners is  by  no  means  too  liberal,  as  the  compara- 
tive loss  of  independence  and  the  fear  that  they 
may  be  under  the  thumb  of  the  societies.  The 
British  medical  profession  is  almost  a  negligible 
quantity  politically,  whereas  the  societies  are  im- 
mensely powerful.  The  societies  are  antagonistic 
to  the  medical  profession,  regarding  its  members  as 
belonging  to  the  privileged  classes.  In  the  Medical 
Press,  August  25th  last,  is  an  article  entitled  Some 
Thoughts  on  the  National  Health  Insurance  Act 
and  the  Panel,  by  Dr.  James  Hamilton,  who  gives  an 
opinion  of  the  matter  which  probably  is  also  the 
opinion  of  many  a  practitioner.  The  main  objec- 
tion that  the  writer  brings  against  the  panel  system 
is  the  loss  of  liberty  and  individuality  that  the  doc- 
tor suffers.  He  points  out  that  new  rules  and  regu- 
lations and  new  rulers  and  a  new  agreement  came 
along  on  April  Fool's  day,  and  since  then  a  new  act, 
which  is  like  its  predecessor  in  being  only  a  skele- 
ton to  be  completed  by  orders  in  council  and  regu- 


October  2,  1920.] 


EDITORIAL  ARTICLES. 


509 


lations.  The  panel  practitioners  are  therefore  ig- 
norant of  what  is  in  store  for  them  in  the  future. 
The  writer  goes  on  to  point  out  that  if  there  was 
anything  Hke  accurate  bookkeeping  between  the 
societies  and  the  insurance  committees  it  ought  to 
be  possible,  seeing  that  the  act  has  been  in  force  for 
about  seven  years,  for  an  insurance  committee  to 
be  able  to  tell  the  doctor  that  there  are  so  many  on 
his  list  at  the  end  of  each  quarter  and  so  much  a 
quarter  will  be  paid  for  each  one. 

The  act  simply  bristles  with  absurd  and  irritating 
regulations,  but  the  great  objection  to  it  from  the 
medical  man's  point  of  view  is  that  he  is,  to  some 
extent,  now  under  the  domination  of  the  approved 
societies,  and  it  looks  as  if  this  domination  would  not 
grow  less  but  greater.  Many  medical  men  fear  that 
it  is  the  insertion  of  the  thin  edge  of  the  wedge 
leading  to  nationalization  of  the  medical  profession, 
and  when  the  labor  representative  who  attended  the 
meeting  of  the  Sociological  Section  of  the  British 
Medical  Association,  held  recently  in  Cambridge, 
stated  outright  that  he  was  in  favor  of  nationalizing 
the  profession,  this  fear  appeared  to  be  justified. 
There  has  been  much  talk  in  the  United  States  of  late 
of  having  an  insurance  act  and  placing  a  goodly  pro- 
portion of  the  medical  men  on  a  similar  status  to 
that  held  by  the  panel  practitioners  of  Great  Britain. 
It  will  be  as  well  if  doctors  here  move  cautiously, 
and  make  sure  that  they  are  not  sacrificing  liberty 
before  pledging  themselves  to  any  such  course.  It 
is  better  to  endure  the  ills  we  know,  than  to  fly  to 
those  we  wot  not  of. 


OSLER  MEMORIAL  NUMBER. 

What  will  prove  a  valuable  historical  publication 
in  the  medical  world  is  the  Sir  William  Osier  Mem- 
orial Number  of  the  Canadian  Medical  Assocmtion 
Journal  of  July,  1920.  There  are  several  portraits 
of  Sir  William,  notably  one  at  the  time  he  was  pre- 
fect in  Trinity  College  School ;  Osier  as  a  student 
of  medicine  at  McGill  University  in  1871 ;  the  hand- 
some, debonair  Osier  in  1881  ;  Osier  at  Oxford  in 
1908.  Relatives,  personal  friends,  classmates,  stu- 
dents, distinguished  men  of  science,  confreres  in 
practice,  faculty  associates  have  contributed  to  this 
volume  which  should  have  been  presented  to  the 
profession  in  other  than  regular  journal  covers. 

There  is  a  foreword  by  Dr.  Francis  J.  Shepherd, 
classmate  and  lifelong  friend;  the  memorial  ser- 
mon by  the  Reverend  H.  Symonds,  Christ  Church 
Cathedral,  Montreal ;  biographical  sketch  by 
Francis  J.  Shepherd ;  Osier's  boyhood  by  a  nephew, 
Dr.  Norman  Gwyn,  Toronto ;  Montreal  days  by 
Dr.  A.  D.  Blackader,  Montreal ;  Osier  and  the  Mon- 
treal Veterinary  College ;  a  tribute  to  Sir  William 
Osier  by  Dr.  W.  W.  Keen ;  early  days  at  Johns 
Hopkins  Hospital  by  H.  A.  Lafleur,  Montreal ;  A 


Student's  Impression  of  Osier  by  W.  G.  MacCal- 
lum :  Sir  William  at  Oxford  by  Archibald  Malloch ; 
Sir  William  and  Oxford  by  two  friends ;  Last  Days 
of  Sir  William  Osier  by  J.  George  Adami ;  The 
Influence  of  Sir  William  Osier  on  Medicine  in 
America  by  Thomas  McCrae ;  Osier  as  Clinician 
and  Teacher  by  Charles  F.  IMartin ;  Sir  William 
Osier  and  the  McGill  Medical  Library  by  Jean 
Cameron ;  Osier's  Influence  on  the  Research  Stu- 
dent by  A.  B.  MacCallum ;  The  Pathological  Collec- 
tions of  the  late  Sir  William  Osier  and  His  Rela- 
tion With  the  Medical  Museum  of  McGill  Uni- 
versity by  Maude  E.  Abbott ;  a  Classified  Bibliogra- 
phy of  Sir  William  Osier's  Canadian  Period  (1868- 
1885)  by  Maude  E.  Abbott. 


REFINED  GENEROSITY; 

In  these  days  of  frequent  moving  from  street 
to  street,  from  earthly  mansions  to  heavenly  man- 
sions, there  are  always  stacks  of  medical  books 
awaiting  a  fixed  destination  by  the  ignorant  women 
of  the  household  left  mourning  the  doctor,  or  the 
hurried  decision  of  a  tired  man.  If  worldly  wise 
he  will  not  give  first  editions,  nor  the  latest.  He 
will  not  give  reprints  sent  from  great  men.  These 
are  marketable,  and  besides  the  medical  students  of 
some  small  town  would  not  appreciate  them.  So  the 
doctor  who  is  glad  to  get  the  credit  of  being  gen- 
erous and  at  the  same  time  placate  his  wife  by 
clearing  out  those  "horrid  old  books,"  gathers  his 
second  and  third  editions,  his  loosely  tied  up  piles 
of  reprints,  his  volumes  by  faddists,  his  piles  of 
journals  whose  numbers  containing  valuable  articles 
are  missing,  and  dumps  them  down  in  the  small 
library  addressed  to  the  resigned,  sorrowful  libra- 
rian who  knows  their  worth  before  she  unpacks 
them  and  contemplates  a  larger  laundry  bill  because 
of  their  dustiness.    Is  this  generous? 

The  same  thing  is  done  to  medical  missionaries. 
These  men  often  go  out  from  big  centres  where 
they  had  the  most  recent  in  medical  literature.  A 
generous  doctor  is  asked  for  books,  and,  he,  re- 
garding missionaries  as  long  bearded  old  gentlemen 
raised  on  the  literature  of  1850,  sends  a  box  which 
only  provokes  Christian  substitutes  for  curses.  They 
do  not  even  get  any  amusement,  as  the  soldiers  did 
when  a  lady  sent  in  a  gift  box  to  the  Red  Cross 
with  the  Dolly  Dimple  Series  and  some  books  on 
baby  treatment  for  young  mothers. 

Now  how  much  better  if  the  overbooked  doctor 
would  send  one  or  two  new  editions  of  well  known 
works,  or  a  goodly  pile  of  reprints  with  cases, 
or  a  year's  subscription  to  a  medical  society's 
journal  or  transactions  not  usually  seen  in  small 
libraries.  Personally  I  have  always  found  most  gen- 
erous response  to  a  direct  appeal  to  our  leaders  in 
science  for  their  own  works,  but  a  circular  note  'is 
usually  handed  over  to  a  secretary,  only  too  glad 
to  clear  out  the  shelves.  It  will  require  some  little 
thought,  some  selfdenial  to  send  the  book  hungry 
doctor  what  he  needs,  but  those  who  have  known 
the  pleasant  feel  of  a  new  book,  the  certainty  of 
finding  what  is  wanted  in  it,  surely  will  not  again 
send  those  bulky,  unprofitable  selections  to  their 
poorer  brothers. 


510 


XEJI  S  ITEMS. 


[New  York 
Medical  Jocrxal. 


News  Items. 


Cholera  in  Corea. — Cholera  is  said  to  be 
spreading  rapidly  in  Corea.  According  to  a  press 
dispatch  from  Seoul,  on  September  22nd  there  were 
20,000  cases  of  cholera  and  more  than  9,000  deaths 
from  the  disease. 

New  Medical  Publication. — Dr.  Pietri,  director 
of  the  French  hospital  in  Athens,  is  the  editor  of  a 
new  Greek  medical  journal.  latrikos  Typos,  the 
monthly  publication  of  the  French  hospital  and  of 
the  Pasteur  Institute  of  Athens. 

German  Universities. — A  note  in  the  Paris 
medical  states  that  a  new  university  has  been  estab- 
lished at  Cologne,  that  the  University  of  Bonn  has 
been  enlarged,  and  that  new  departments  have  been 
added  in  several  other  German  universities. 

Pacific  Coast  Oto-Ophthalmological  Society. — 
The  annual  meeting  of  this  society  was  held  July 
29th  and  30th  at  Portland,  Ore.  The  following  "offi- 
cers were  elected :  President,  Dr.  George  W.  Swift, 
of  Seattle ;  vice-presidents.  Dr.  E.  E.  Maxey.  Boise, 
Ida. ;  Dr.  J.  O.  Chapelle,  of  Chico.  Cal. ;  secretary- 
treasurer.  Dr.  E.  E.  Wheeler,  of  Tacoma. 

Infantile  Paralysis  Here. — Following  the  epi- 
demic of  anterior  poliomyelitis  in  Boston  and  its 
appearance  at  other  points  in  the  state,  the  disease 
has  now  made  its  appearance  in  New  York  City. 
Three  cases  and  one  death  were  reported  in  one 
day,  September  24th.  Massachusetts  had  ninety- 
four  cases  in  August  and  134  during  the  first  twenty- 
four  days  of  September. 

Shanghai  Medical  School  Project  Abandoned. 
— The  China  Medical  Board  of  the  Rockefeller 
Foundation  recently  decided  to  abandon  its  project 
for  the  establishment  of  a  medical  school  at  Shang- 
hai. A  reason  for  this  change  is  the  unexpectedly 
high  cost  of  all  the  Board's  enterprises  in  China,  the 
Peking  Union  ^Medical  College  having  cost  larger 
sums  than  it  had  been  thought  in  1914  would  be 
necessary  for  both  schools.  In  addition,  the  capacity 
of  the  Peking  school  has  not  yet  been  reached. 

Traumatic  Neurosis  Committee. — A  committee 
has  been  appointed  in  England  to  "consider  the  dif- 
ferent types  of  hysteria  and  traumatic  neurosis, 
commonly  called  'shell  shock'  to  collate  the  expert 
knowledge  derived  from  the  service  medical  authori- 
ties and  the  medical  profession  from  the  experience 
of  the  war,  with  a  view  to  recording  for  future  use 
the  ascertained  facts  as  to  its  origin,  nature,  and 
remedial  treatment  and  to  advise  whether,  by  mili- 
tary training  or  education,  some  scientific  method  of 
guarding  against  its  occurrence  cannot  be  devised." 
Lord  Southborough.  G.  C.  B.,  is  chairman. 

Institute  of  Psychology  of  Paris. — A  psycho- 
logical institute  is  to  be  established  at  the  University 
of  Paris  associated  with  the  Facultcs  Jcs  Lcttrcs  ct 
dcs  Sciences.  Professors  H.  Delacrois.  G.  Dumas, 
P.  Janet,  H.  Pieron  and  E.  Rabaud  will  form  the 
council  of  directors.  The  institute  will  undertake 
the  practical  and  theoretical  teaching  of  all  branches 
of  psychology — physiological,  experimental,  patho- 
logical, comparative,  and  general,  and  reserach  can 
be  carried  out  in  the  laboratories  in  preparation  for 
university  degrees.  The  diploma  course  will  consist 
of  two  terms. 


International  Institute  of  Anthropology. — At  a 

meeting  held  September  9th  to  14th  in  Paris,  there 
was  held  a  conference  looking  toward  the  estab- 
lishment of  an  international  institute  of  anthro- 
pology. A  permanent  office  was  created  to  organize 
periodical  meetings.  Subjects  taken  up  at  the  pre- 
liminary meeting  were  means  of  organizing  inquiries 
and  unification  of  means  of  investigation  and  meas- 
urement. 

Proposed  Coordination  of  British  Hospitals. — 

The  British  Red  Cross  has  proposed  a  plan  for 
coordinating  all  the  hospitals  in  England  and  Wales, 
so  that  the  working  population  throughout  the 
country  may  have  the  benefit  of  the  best  possible 
medical  care.  It  is  the  object  of  this  projected  or- 
ganization to  reduce  the  expenses  and  increase  the 
revenue  of  hospitals.  The  Red  Cross  offers  to  assist 
volimtary  hospitals  by  affording  them  the  ad- 
vantages of  a  big  organization,  as  in  some  cases 
their  finances  do  not  permit  of  their  making  all  the 
necessary  modern  improvements. 

Hoover  Seeks  Aid  for  European  Children. — 
The  feeding  of  destitute  European  children  has  again 
become  urgent  because  of  inadequate  harvests  in 
many  countries,  and  Mr.  Herbert  Hoover  has  taken 
up  with  various  welfare  organizations  the  problem 
of  caring  for  them.  Reports  from  agents  of  the 
American  Relief  Administration  indicate  that  about 
two  million  children  in  Austria,  Czecho-Slovakia, 
Poland,  and  Baltic  States,  and  other  regions  are  in 
need  of  food  and  clothing.  The  American  Relief 
Administration  formerly  fed  six  million  children, 
but  its  funds  will  be  exhausted  by  January  1st  and 
its  chief  activities  have  been  turned  over  to  other 
agencies. 

Pathological  Congress. — The  second  interna- 
tional congress  of  comparative  pathology,  which 
was  to  have  taken  place  in  1914,  will  be  held  in 
Rome  in  April,  1921.  under  the  presidency  of  Pro- 
fessor E.  Perroncito.  The  preliminary  program 
annoimces  the  subjects  for  discussion  as  influenza  of 
man  and  animals,  cancer  and  sarcoma,  rabies  and 
the  results  of  Pasteurian  vaccination,  plague  among 
ruminants,  chicken  pest  and  bee  pest,  evolutionary 
cycles  of  Dibothriocephalus  latus  and  Ascarides, 
scabies  of  man  and  animals,  nerve  regeneration, 
vegetable  symbiosis,  and  parasitism.  Pathologists 
or  others  wishing  to  attend  should  communicate 
with  the  general  secretary.  Professor  Mario  Levi 
della  Vida,  at  58.  \'ia  Palermo.  Rome. 

Spanish  Antimalaria  Campaign. — -The  League 
of  Red  Cross  Societies,  in  agreement  with  the 
Spanish  Government  and  the  Spanish  Red  Cross, 
has  decided  to  undertake  an  antimalaria  campaign 
in  Spain. 

The  mission  which  was  sent  to  investigate  malftria 
had  as  its  chief  Dr.  Massimo  Sella,  chief  of  the 
Department  of  Malaria  of  the  League.  Major 
Stuart,  assistant  chief  of  the  Department  of  Sani- 
tation ;  Dr.  Huntington  Williams,  of  the  League 
staff,  and  Mr.  Juan  Larrosa  chief  of  the  Spanish 
section  of  the  Department  of  Publicity  and  Publica- 
tion. At  Madrid  the  mission  was  joined  by  Pro- 
fessor Pittaluga,  an  authority  on  the  subject  of 
malaria.  The  mission  began  its  work  during  the 
first  two  weeks  of  August. 


October  2,  1920.] 


NEWS  ITEMS. 


511 


American  Electrotherapeutic  Association. — At 

the  twentieth  annual  meeting  of  the  American  Elec- 
trotherapeutic Association,  held  September  14th  to 
17th  at  Atlantic  City,  the  following  ofificers  were 
elected:  President,  Dr.  Byron  Sprague  Price,  of 
New  York;  vice-presidents,  Dr.  V.  C.  Kinney,  of 
Wellsville,  N.  Y. ;  Dr.  C.  M.  Sampson,  of  St.  Joseph, 
Mo. ;  Dr.  Charles  Collins,  of  Washington,  D.  C. ; 
Dr.  D.  A.  Cater,  of  East  Orange,  N.  J. ;  Dr.  W.  T. 
Johnson,  of  Philadelphia;  trustees.  Dr.  F.  B.  Gran- 
ger and  Dr.  F.  H.  Morse,  of  Boston;  Dr.  W.  M. 
Clark  of  Philadelphia;  Dr.  William  Martin,  of  At- 
lantic City;  Dr.  Frederic  deKraft,  Dr.  E.  C.  Titus 
and  Dr.  J.  W.  Travell,  of  New  York;  secretary 
and  registrar.  Dr.  A.  Bern  Hirsh,  of  New  York. 

Local  Society  Meetings. — The  following  local 
Mercy,  St.  Joseph's,  Morrow  and  University, 
medical  societies  will  meet  during  the  coming  week : 

Monday,  October  4th. — New  York  German  Medical  So- 
ciety. 

Tuesday,  October  5th. — New  York  Academy  of  Medicine 
(Section  in  Dermatology  and  Syphilis),  Clinical  Society  of 
Harlem  Hospital,  New  York  Neurological  Society,  Society 
of  Alumni  of  Lebanon  Hospital. 

Wednesday,  October  6th. — New  York  Academy  of  Medi- 
cine (Section  in  Historical  Medicine),  Bronx  Medical  As- 
sociation, Harlem  Medical  Association,  Psychiatrical  Society 
of  New  York,  New  York  Urological  Society,  Society  of 
Alumni  of  IBellevue  Hospital,  Brooklyn  Society  for 
Neurology. 

Thursday,  October  7th. — New  York  Academy  of  Medi- 
cine (stated  meeting),  Brooklyn  Surgical  Society. 

Friday,  October  8th. — New  York  Academy  of  Medicine 
(Section  in  Otology),  Eastern  Medical  Society  of  the  City 
of  New  York,  Flatbush  Medical  Society. 

Saturday,  October  9th. — Medical  Officers'  Reserve  Corps 
Association  of  the  United  States  Army,  New  York  Division. 

Medical  Corps  Examinations, — Another  exam- 
ination will  be  held  October  25th  to  31st,  to  de- 
termine the  eligibility  for  appointment  of  applicants 
for  the  Medical  and  Dental  Corps  of  the  Regular 
Army.  Persons  of  the  following  classes  who  served 
as  officers  of  the  United  States  Army  at  some  time 
between  April  6,  1917,  and  June  4,  1920,  are  eligible 
to  take  this  second  examination : 

1.  Those  who  for  any  good  reason  did  not  apply  and 
were  not  authorized  to  take  the  July  examinations. 

2.  Those  who  were  authorized  to  take  the  July  examina- 
tions but  who  for  some  good  reason  were  unable  to  appear 
before  the  examining  boards. 

3.  Those  who  were  authorized  to  take  the  July  examina- 
tions and  who  appeared  before  examining  boards  hui  who 
for  some  good  reason  of  their  own  volition  or  through  ill- 
ness or  accident  failed  to  complete  the  examination. 

4.  Those  examined  during  the  July  examination  who 
were  found  disqualified  on  account  of  physical  defects 
which  have  been  removed  by  operation  or  which  do  not  exist 
at  the  time  of  the  October  25th  examination. 

The  examination  will  not  be  competitive.  The 
number  of  vacancies  in  the  Medical  Corps  is  suf- 
ficient to  provide  for  any  reasonable  number  of 
applicants  who  may  qualify  for  appointment.  The 
reference  in  War  Department  announcement  limiting 
appointments  to  be  made  to  200  does  not  apply  to 
the  Medical  Department.  As  in  the  past,  the  mili- 
tary record  and  general  efficiency  of  the  officer  will 
be  determining  factors  for  appointment.  Candidates 
must  be  fifty-eight  years  of  age  or  under  and  meet 
the  physical  requirements  fixed  by  the  War  Depart- 
ment. Blank  application  forms  may  be  obtained 
from  the  Adjutant  General  of  the  Army  or  at  any 
-.military  post  or  station. 


Anesthesia  Record. — The  National  Anesthesia 
Research  Society  has  adopted  a  uniform  chart, 
which  it  recommends  for  use  in  all  hospitals.  The 
committee,  consisting  of  Dr.  A.  H.  Miller,  of  Provi- 
dence;  Dr.  E.  I.  McKesson,  of  Toledo,  and  Dr.  A. 
F.  Erdmann,  of  Brooklyn,  stitdied  and  compared 
charts  from  all  leading  hospitals  and  clinics  of  the 
United  States  and  the  resulting  chart  is  designated 
to  embrace  all  the  essential  points  in  the  administra- 
tion of  an  anesthetic.  The  society  will  print  and 
distribute  the  chart  at  cost  to  all  hospitals  using  it. 

Venereal  Diseases  Conference.  —  The  All- 
America  Conference  on  Venereal  Diseases,  to  be 
held  December  6th  to  11th  in  Washington,  D.  C, 
under  the  presidency  of  Dr.  William  H.  Welch,  of 
•Johns  Hopkins  University,  is  the  first  of  a  series 
of  regional  conferences  suggested  by  the  Interna- 
tional Health  Conference  held  at  Cannes  under  the 
auspices  of  the  League  of  Red  Cross  Societies.  The 
administrative  committee  consists  of  Dr.  Thomas  A. 
Storey,  United  States  Interdepartmental  Social  Hy- 
giene Board ;  Dr.  C.  C.  Pierce,  United  States  Pub- 
lic Health  Service ;  Dr.  Livingston  Farrand,  Ameri- 
can Red  Cross,  and  Dr.  William  F.  Snow,  American 
Social  Hygiene  Association.  Subjects  to  be  dis- 
cussed are :  Present  status  and  recent  progress  in 
medical  investigations ;  education  as  a  means  of 
controlling  venereal  diseases;  law  enforcement  and 
protective  social  measures  with  individuals ;  social 
influence  in  the  control  of  venereal  diseases ;  ad- 
ministrative measures  in  the  United  States,  Canada, 
Latin-America,  and  other  countries.  The  conference 
will  endeavor  to  adopt  recommendations  relating  to 
a  practicable  three  year  program  for  each  of  the 
North  and  South  American  countries  participating 
and  to  suggest  plans  for  putting  such  programs  into 
efifect. 

 <»>  

Died. 

Andrews. — In  Philadelphia.  Pa.,  on  Friday,'  September 
17th,  Dr.  Reuben  H.  Andrews,  aged  seventy  years. 

Boies. — In  East  Aurora,  N.  Y.,  on  Friday,  September  17th, 
Dr.  Loren  F.  Boies,  aged  eighty-four  years. 

Brodnax. — In  Brooklyn,  N.  Y.,  on  Tuesday,  September 
21st,  Dr.  Robert  Brodnax. 

Dillon. — In  Holyoke,  Mass.,  on  Sunday,  September  12th, 
Dr.  John  Aloysius  Dillon,  aged  forty-two  years. 

Jenkins. — In  Saranac  Lake,  N.  Y.,  on  Saturday,  Sep- 
tember 18th,  Dr.  Elisha  Averett  Jenkins,  aged  forty-six 
years. 

Lefferts. — In  Katonah,  N.  Y.,  on  Tuesday,  September 
21st,  Dr.  George  Morewood  Leflferts,  aged  seventy-four 
years. 

Marshall. — In  Philadelphia,  Pa.,  on  Monday,  Septem- 
ber 20th,  Dr.  Anna  M.  Marshall,  aged  eighty  years. 

Paist. — In  Philadelphia,  Pa.,  on  Tuesday,  September 
21st,  Dr.  Henry  Carver  Paist,  aged  eighty-seven  years. 

Stuart. — In  Minneapolis,  Dr.  John  Harlan  Stuart,  aged 
eighty- four  years. 

Thomson. — In  Glens  Falls,  N.  Y.,  on  Wednesday,  Sep- 
tember ISth,  Dr.  Lemon  Thomson,  aged  sixty-three  years. 

Urquhart. — In  Los  Gatos,  Cal.,  on  Saturday,  September 
4th,  Dr.  Richard  Alexander  Urquhart,  aged  seventy  years. 

Van  Derzee. — In  Dannemora,  N.  Y.,  on  Thursday,  Sep- 
tember 16th,  Dr.  Douw  Lansing  Van  Derzee,  aged  forty- 
eight  years. 

Van  Patten. — In  Los  Angeles,  Cal.,  on  Wednesday, 
September  15th,  Dr.  Philip  S.  Van  Patten,  aged  forty- 
eight  years. 


Book  Reviews 


FORESTRY  AND  HEALTH. 

Forests,  Woods,  and  Trees  in  Relation  to  Hygiene.  By 
AuGUSTixE  Henry,  M.  A.,  F.  L.  S.,  M.  R.  I.  A.,  Professor 
of  Forestry.  Royal  College  of  Science,  Dublin.  Illus- 
trated.   New  York:  E.  P.  Button  &  Co.    Pp.  xii-314. 

Trees  for  beauty  and  tree  shade  for  lovers'  meet- 
ings, trees  for  healing,  trees  to  build  rough  huts 
and  to  beautify  the  inside  of  palaces ;  trees  to  build 
wave  conquering  ships  and  frolicsome  canoes;  trees 
to  bear  men  far  above  the  highest  mountains  in  air 
planes ;  trees  to  fashion  man's  last  resting  place,  his 
narrow  wooden  home.  Hack  at  them,  make  long 
planks,  squeeze  out  their  life  blood,  take  even 
their  dust,  and  from  first  to  last  all  in  them  and 
of  them  feeds  the  ever  turning  wheel  of  production 
and  usefulness.  The  traveler  sees  the  forest 
crowned  hills,  the  miles  of  forests,  the  tiny  steamers 
dragging  thousands  of  tree  trunks  to  the  saw  mills 
and  thinks,  if  he  thin"ks  at  all,  that  there  is  plenty 
of  wood  in  the  world. 

But  war  and  forest  fires,  tiny  insects  and  ravag- 
ing storms,  the  greed  of  man  who  despoils  for  the 
present  and  plants  not  for  posterity,  are  making  a 
change  in  woodlands  appreciable  even  to  the 
thoughtless,  and,  like  the  unwise  virgins,  nation  is 
saying  to  nation,  "Give  us  of  your  trees,  for  ours 
are  few ;  few,  because  we  recklessly,  greedily,  con- 
suiried  our  store." 

What  has  Augustine  Henry  to  say?  He  pleads 
for  the  trees,  not  on  the  grounds  of  pure  utility, 
but  as  hygienists  in  parks  and  streets,  for  water 
catchment  areas,  as  living  green  to  clothe  the  hide- 
ous pit  mounds,  as  hosts  to  revivify  the  tired  guest 
who  comes  to  the  sanatorium  from  hot  pave- 
ments and  miles  of  houses,  as  gentle  creatures  who  in 
new  surroundings  will  find  a  foothold  and  do  their 
best  to  conquer,  who  will  use  their  old  summer 
clothes  to  make  winter  counterpanes  for  their  feet 
and  guard  the  seedlings  of  spring  beauties  from 
harsh  frosts.  All  this  he  says  of  trees  in  general ; 
he  then  tells  of  the  various  kinds  used  as  healers, 
where  they  abound,  what  they  like,  where  they  will 
thrive  and  what  wonderful  guards  they  will  form 
against  sun  and  wind  and  raging  storm.  In  study- 
ing the  influence  of  forests  on  temperature  it  was 
found  that  a  richly  afforested  country  has  a  lower 
temperature  in  summer,  and  that  the  effect  of  local 
afiforestation  is  to  increase  the  rainfall.  Forests  also 
have  a  restraining  influence  on  the  melting  of  snow 
and  so  retard  streamflow  at  a  time  when  floods 
are  most  frequent. 

As  to  the  sanitary  influence  of  forests,  their 
advantage  in  windswept  districts  is  incalcu- 
lable. The  chilly  effect  of  the  peat  bogs  in  Ireland 
and  Scotland  giving  rise  to  severe  spring  frosts  is 
well  known.  Plantations  of  spruce,  maritime  pine, 
Scotch  pine  and  larch  would  obviate  all  this.  Forests 
depress  the  level  of  the  underground  water  and 
effectual  draining  can  be  done  by  planting  trees, 
eliminating  those  marshy  places  which  breed  mos- 
quitoes. Napoleon  was  always  ready  for  sugges- 
tion and  stayed  the  malaria  in  north  Africa  by 
those  groves  of  rapidly  growing  eucalyptus  which 
delight  the  present  residents.  But  the  most  impor- 
tant asset  is  that  smoke,  dust,  injurious  gases  and 


bacteria  are  rare  or  absent  in  the  air  of  forests. 
Indian  villages  surrounded  by  forests  are  never 
visited  by  cholera.  The  greatest  example  is  that 
of  the  Landes  in  Gascony,  once  a  bare,  marshy  dis- 
trict subject  to  malaria  and  pellagra.  Since  1850 
some  1,800,000  acres  have  been  planted  with  mari- 
time pine,  and  these  diseases  have  practically  dis- 
appeared. 

Good  pictures,  in  print  and  photos,  are  given  of 
some  of  the  famous  sanatoria,  such  as  Nordrach, 
Brompton  Hospital,  Frimlay,  etc.,  dwelling  on  the 
effect  of  trees  as  wind  guards  and  as  forming  winter 
walks  but  cautioning  avoidance  of  too  great  crowd- 
ing near  the  house  itself.  He  admits  the  curative  ef- 
fect of  the  volatile  pine  oil  but  says  that  no  scien- 
tific studies  from  a  therapeutic  point  of  view,  have 
ever  been  attempted,  Professor  Hamburger,  of 
Groningen  University,  having  gone  the  furthest. 

There  is  much  wise  counsel  as  to  town  planting, 
and  here  he  has  something  to  say  about  desirable 
aliens.  In  England,  the  black  walnut  and  the  tulip 
tree  and  the  Robinia  pseudacacia  are  successful,  and 
the  London  plane  (Platanus  aceri folia)  is  the  street 
tree  which  grows  best,  not  only  in  England,  but  in 
Europe  and  the  United  States.  Birch  and  poplar 
grow  well  in  heavy  clay  soils.  Scarcely  any  coni- 
fers succeed  in  smoky  towns,  the  best  being  the 
Austrian  and  the  Corsican  pines.  He  points  out 
that  priming  is  a  surgical  operation  and  a  necessity 
with  town  trees,  therefore  advises  expert  pruners 
as  being  more  economical  in  the  end. 

The  afforestation  of  hideous  pitmounds  has  been 
triumphantly  proved  a  success.  The  Black  Country 
in  England  has  some  30,000  acres  of  pit  banks.  The 
psychic  effect  of  so  much  ugliness  is  big,  but  the 
Midland  Reafforesting  Association  is  bigger  and 
much  has  been  done.  Best  of  all,  the  children  have 
been  enlisted  and  supported  by  the  Forestry  Board, 
so  two  good  ends  have  been  attained.  The  trees 
which  grow  best  are  the  alder,  birch  and  Italian 
poplar.  Lessons  are  given  at  the  school  on  rainfall, 
wind  force,  frost,  drought,  geology,  fungi,  insects, 
and  the  parents  begin  to  see  there  "is  something  in 
it."  In  some  parts  of  France  little  forestry  socie- 
ties have  been  founded  and  flourish  finely. 

Now  comes  the  biggest  part  of  the  subject — the 
water  we  drink.  The  afforestation  of  water  catch- 
ment areas  is  not  only  a  hygienic  measure  but  one 
to  increase  the  timber  reserves.  This  plan  of  im- 
pounding the  water  falling  on  upland  and  sparsely 
inhabited  tracts  is  in  the  category  with  artificial 
reservoirs,  deriving  its  supply  from  drainage  of 
surrounding  watersheds.  In  some  cases  the  land  is 
rented,  at  others  purchased  outright.  The  expedi- 
ency of  keeping  it  uninhabited  is  contested  by  Mr. 
Hazen,  especially  with  regard  to  the  gathering 
grounds  which  supply  New  York  and  Boston  but 
Dr.  A.  C.  Houston  says  this  can  only  be  done  by 
storage  and  filtration  if  habitation  is  per- 
mitted. Afforestation,  not  necessarily  of  the  whole 
area,  is  the  best  remedy.  Questions  of  aspect,  depth, 
nature  of  soil,  where  and  what  to  plant  must  be 
considered.  On  most  catchment  areas  over  1,000 
feet  elevation,  a  combination  of  grazing  and  fores- 


October  2,  1920.] 

N 


BOOK  REVIEWS. 


513 


try  must  be  resorted  to.  When  heavy  rain  comes, 
the  run  off  water  is  much  lessened ;  the  quahty  of 
the  water  will  be  better  as  the  soil  on  the  hill 
slopes  will  be  held  together  by  the  roots  of  the 
trees,  flood  waters  will  be  diminished  and  the  reser- 
voirs not  silted  up.  The  careful  description  of  the 
various  suitable  trees  is  a  most  interesting  chapter, 
the  pictures  excellent.  The  records  from  the  catch- 
ment areas  in  the  British  Isles,  though  local,  contain 
some  valuable  points  applicable  to  any  towns  on  any 
continent.  We  are  grateful  to  Augustine  Henry 
for  introducing  us  to  trees  as  doctors  and  rural 
policemen  and  are  sure  that  when  the  book  was 
completed,  the  trees,  as  in  David's  time,  "clapped 
their  hands  for  joy." 

HISTORY  OF  NURSING.  . 

A  Short  History  of  Nursing.  From  the  Earliest  Times  to 
the  Present  Day.  By  Lavinia  L.  Dock,  R.  N.,  Secretary, 
International  Council  of  Nurses,  in  Collaboration  with 
Isabel  Maitland  Stewart,  A.  M.,  R.  N.,  Assistant  Pro- 
fessor, Department  of  Nursing  and  Health,  Teachers' 
College,  Columbia  University,  New  York.  New  York : 
G.  P.  Putnam's  Sons,  1920.    Pp.  vi-392. 

Nurse,  nourish,  to  look  after  the  sick  and  the 
well ;  hospital  or  zenodochium  included  inns  for 
the  well  to  do,  a  hospital  for  the  sick,  insane  and 
lepers,  asylums  for  foundlings  and  orphans,  alms 
houses,  houses  for  doctors  and  nurses,  so  here  we 
are  traveling  round  to  original  meanings.  A  nurse, 
no  longer  one  who  only  attends  the  sick,  but  a  co-, 
operator  in  public  works  to  ward  off  disease,  a 
teacher  in  health,  a  hygienist,  a  panacea,  a  niedi- 
trina  all  in  one.  The  hospital  finds  its  counter- 
part in  the  new  Central  Health  Stations,  and  the 
reason  they  endured,  at  least  the  ideal  was  that 
they  were  doing  their  best  to  fight  disease  and 
misery.  Their  methods  were  crude,  even  smile  pro- 
voking, bixt  their  fight  was  for  the  truth  and  every 
century  sees  disease  and  dirt  and  miserable  hous- 
ing retreating  further  and  further.  It  was  an  in- 
ternational fight,  Greeks,  Hindus,  Egyptians,  Ro- 
mans, the  enemy  never  has  been  tolerated  by  them 
and  is  now  far  spent.  To  open  the  door  to  Lavinia 
Dock  and  Isabel  Stewart  is  to  admit  an  immense 
throng  of  workers  of  all  nationalities,  of  all  creeds, 
giving  up  everything  to  clear  the  road  to  health  for 
others.  It  will  be  'a  revelation  to  the  budding  nurse 
who  thinks  that  Eve  had  a  trained  nurse  when  Cain 
was  born  and  that  a  Red  Cross  Unit  was  attendant 
at  the  first  battle,  to  learn  how  very  ignorant,  how 
very  narrow  minded  yet  how  very  advanced  were 
ideas  far  away  back  and  to  find  there  was  always 
a  Nightingale  in  every  age  to  carol  a  victory  strain 
and  always  a  body  of  muddle  headed,  obstinate  men 
who  kick  against  change  as  an  evil  thing. 

There  is  one  term  which  might  aptly  be  applied 
to  the  book:,  that  is,  thorough.  We  cannot  find 
any  lazy  scurrying  over  important  periods  because 
information  was  difficult  to  find.  It  furnishes  the 
nurse  with  correct  information,  brightly  written, 
and  one  volume  may  tempt  readers  who,  tired  with 
the  daily  routine  of  nursing,  might  shrink  from  the 
four  vols,  of  the  larger  History  of  Nursing,  yet  it 
may  induce  others,  hungry  for  details,  to  embark  on 
the  reading  of  the  four. 

The  fight  is  not  over :  in  fact,  ammunition  is  be- 
ing hurried  up  by  the  scientists  at  such  a  rate  that 


the  nurse's  life  will  be  burdened  trying  to  undcr- 
and  its  use. 

Our  hospital  system  often  needs  remodeling,  our 
nurses  need  more  humane  treatment.  No  stern  ab- 
bess or  sister  of  ancient  times  could  draw  more 
tears  or  make  toil  more  unhappy  than  many  sisters 
of  today.  Their  glance  freezes,  their  nagging  is 
nerve  rasping,  their  sarcasm  is  bkmt,  and  their  daily 
visit  leaves  flushed  cheeks  and  uncornplimentary  re- 
marks from  the  dominated. 

TEXTBOOK  ON   INFECTIOUS  DISEASES. 

Infectious  Diseases.  A  Practical  Textbook.  (Oxford 
Medical  Publiaations.)  By  Claude  Buchanan  Ker, 
M.  D.  (Ed.),  F.  R.  C.  P.  (Ed.),  Medical  Superintendent, 
City  Hospital,  Edinburgh,  and  Lecturer  on  Infectious 
Diseases  to  the  University  of  Edinburgh;  Major, 
R.  A.  M.  C,  T.  F.  Second  Edition.  Illustrated.  London  : 
Henry  Frowde,  Hodder  &  Stoughton  (Oxford  University 
Press),  1920.    Pp.  xii-627. 

Writers  of  medical  textbooks  seldom  succeed  in 
taking  their  readers  to  the  hospitals,  to  the  beds  of 
patients,  and  presenting  the  patients,  thus  giving 
practical  information  concerning  the  proper  classi- 
fication and  treatment  of  disease.  Ker,  in  the  sec- 
ond edition  of  his  book  on  infectious  diseases,  has 
accomplished  these  things. 

He  has  taken  his  subject  material  from  the  City 
Hospital  in  Edinburgh  and  confined  himself  to  the 
diseases  they  handle  in  that  institution,  which  are  in 
reality  the  bulk  of  the  infectious  diseases  encoun- 
tered in  general  practice.  The  diseases  he  has  con- 
sidered are  measles,  rubella,  scarlet  fever,  smallpox, 
vaccinia,  chickenpox,  typhus  fever,  enteric  fever 
(known  in  America  as  typhoid  fever),  diphtheria, 
erysipelas,  whooping  cough,  mumps,  and  cerebro- 
spinal meningitis.  Throughout  the  book  Ker  has 
dwelt  at  great  length  on  the  important  subjects  of 
diagnosis,  prognosis,  and  treatment.  Vairious  theo- 
retical phases  of  the  various  diseases  are  carefully 
avoided.  The  aim  throughout  the  book  has  been 
to  make  it  useful  to  the  practitioner;  useful  in  an 
immediate  practical  way  and  not  in  an  abstract 
fashion.  The  portion  of  the  book  dealing  with  ty- 
phoid fever  is  a  most  excellent  monograph  when 
taken  separately.  The  general  tone  of  the  book  is 
not  one  of  tmcertainty ;  the  subjects  are  presented 
with  clarity  and  directness.  The  arrangement  of 
the  hook  makes  the  various  sections  easily  available 
for  quick  reference. 

BEAUTY. 

The  Substance  of  a  Dream.  Translated  from  the  Original 
Manuscript  by  F.  W.  Bain.  Illustrated.  New  York :  G. 
P.  Putnam's  Sons,  1920.    Pp.  iii-216. 

From  India,  the  mystic  land  of  legends  and  cults 
founded  on  phantasy,  we  have  had  much  that  is 
beautiful.  Centuries  of  grappling  with  the  un- 
known ;  an  endeavor  to  create  beauty  to  compensate 
for  crushing  circiunstances  and  a  soaring  in  worlds 
of  wonder;  coimtless  centuries  of  silent  suffefing 
have  led  to  an  acceptance  of  things  as  they  are.  Yet 
the  stoic  exterior  covered  a  nimble  brain  that  was 
creating  spirals  in  an  effort  to  make  up  for.  the 
things  that  had  been  deprived.  They  decorated  their 
temples  with  the  spirals  and  wove  them  intf)  the 
tracery  of  their  stories.  They  spent  little  time  in 
portraying  reality,  for  they  were  surrounded  by 
too  much  reality  and  a  reality  that  was  too  sordid ; 


514 


BOOK  REJ'/EIVS. 


[New  York 
Medical  Journal. 


they  did  not  have  the  physical  nor  the  psychic  cour- 
age to  combat  the  forces  which  they  f eh  were 
stronger  than  any  powers  they  could  create  from 
their  own  ego.  Some  say  there  is  an  awakening 
today — who  can  tell.  We  shall  not  go  into  that ;  we 
shall  only  consider  some  of  the  products  of  the  day 
before,  when  they  found  their  outlet  not  in  trying 
CO  better  their  condition  materially  but  created  one 
in  their  mind  and  retreated  to  the  beauties  of  their 
own  making. 

The  Substance  of  a  Dreaui  is  the  latest  of  a  se- 
ries of  translations  from  the  original  Sanscrit  by 
Bain.  These  stories  sing  with  a  melodious  beauty, 
for  they  have  been  retold  by  a  man  who  felt  joy  in 
the  telling.  The  tale  is  one  of  love  and  the  pitfalls 
encountered.  Here,  as  in  affairs  less  emotional,  pit- 
falls and  difficulties  are  encountered  along  the  road 
and  at  the  turnings.  Frequently  we  recognize  our 
own  excursions,  though  they  would  require  an  elas- 
tic transformation  to  the  realm  of  phantasy  to  cope 
with  the  heroic  outlines  cast  by  the  shadow  of  the 
Hindoo  participants.  But  why  dwell  upon  this, 
for  in  every  story  obstacles  of  one  kind  or  another 
are  encountered.  This  is  as  it  should  be — for  the 
convenience  of  the  taleteller.  It  is  not  here  that 
he  quarrels  with  reality  but  only  in  the  solution  of 
the  difficulties. 

One  of  the  dominant  notes  of  the  Bain  transla- 
tions, and  we  may  infer  that  they  reflect  much  Hin- 
doo •  philosophy,  is  the  rebirth  phantasy.  Here  the 
great  retreat  is  found.  Back  to  the  day  of  infantile 
pleasure  unmarred  by  unbending  reality.  Another 
chance  is  called  for  and  the  easiest  way  to  realize  it, 
in  imagination,  is  the  phantasy  of  a  rebirth.  These 
stories  reveal  the  psychological  reaction  of  a  people 
long  held  in  a  bondage  of  soul  and  body.  And  we 
find  the  reactions  not  unlike  those  of  other  peoples 
under  similar  circumstances.  The  difficulties  found 
in  their  love  life  will  be  reduplicated  and  met  in  the 
same  way  in  all  of  the  less  beautiful  phases  of  life, 
The  stories  are  of  the  beautiful  and  are  beautifully 
told. 


New  Publications  Received, 


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


THE  THEORY  AND  PRACTICE  OF  MASSAGE.     By  BEATRICE  M. 

GooDALL-CoPEST.\KE,  Examiner  to  the  Incorporated  Society 
of  Trained  Masseuses  ;  Teacher  of  Massage  and  Swedish 
Remedial  Exercises  to  the  Nursing  Staff  of  the  London 
Hospital.  Second  Edition.  Illustrated.  New  York :  Paul 
B.  Hoeber,  1919.    Pp.  xxi-265. 

THE  DI.\GX0SIS  AND  TREATMENT  OF  HEART  DISEASE.  Prac- 
tical Points  for  Students  and  Practitioners.  By  E.  M. 
Brockbank,  M.  D.  (Vict.),  F.  R.  C.  P.,  Hon.  Physician, 
Royal  Infirmary,  Manchester ;  Lecturer  in  Clinical  Medi- 
cine, Dean  of  Clinical  Instruction,  University  of  Manches- 
ter. Fourth  Edition.  Illustrated.  New  York :  Paul  B. 
Hoeber.    Pp.  viii-158. 

THE'X  ray  atlas  OF  THE  SYSTEMIC  ARTERIES  OF  THE  BODY. 

By  H.  C.  Orrin,  O.  B.  E.,  F.  R.  C.  S.,  Ed.,  Fellow  of  Royal 
Society  of  Medicine,  London;  Civil  Surgeon  Attached  3rd 
London  General  Hospital,  R.  A.  M.  C.  (T.).  Illustrated. 
New  York :  William  Wood  &  Co.,  1920.    Pp.  i-91. 


FEMINIS.M    AND    SEX    EXTINCTION.      Bv    ARABELLA  KeaN- 

EALV,  L.R.C.P.  (Dublin).  New  York;  E.  P.  Dutton  & 
Co.    Pp.  x-313. 

TRANSACTIONS  OF  THE  AMERICAN  CLIMATOLOGICAL  ASSOCIA- 
TION. For  the  Year  1918.  Volume  xxxiv.  Lancaster,  Pa. 
The  New  Era  Printing  Co.,  1918.   Pp.  v-294. 

THE  NEW  PSYCHOLOGY  AND  ITS  RELATION  TO  LIFE.        By  A. 

G.  Tansley.  Illustrated.  New  York :  Dodd,  Mead  &'  Co. 
(London:  George  Allen  &  Unwin,  Ltd.).    Pp.  v-283. 

FORTY-SEVENTH  ANNUAL  REPORT  OF  THE  COMMISSIONER  OF 
THE    MICHIGAN    DEPARTMENT    OF    HEALTH    FOR    THE  FISCAL 

YEAR  ENDING  JUNE  30,  1919.  Fort  Wayne,  Indiana,  1920. 
Pp.  5-196. 

LA  CURE  DE  DiURESE.  Par  le  Docteur  Charles  Ric.\rd 
PoMAREDE,  Laureate  de  Faculte  de  Medicin,  Ex-Interne 
P.  des  Hopitaux  de  Montpelier,  etc.  Paris  :  J.  B.  Balliere 
et  Fils,  1920.    Pp.  vii-88. 

studies  in  NEUROLOGY..  By  Henry  Head,  M.D.,  F.R.S.. 
in  conjunction  with  W.  H.  R.  Rivers,  M.D.,  F.R.S.,  Gordon 
Holmes,  M.D.,  C.M.G.,  and  several  others.  In  Two 
Volumes.  London:  Henry  Frowde  (Oxford  Universitv 
Press),  and  Hodder  &  Stoughton,  Ltd.,  1920.    Pp.  ix-862.  ' 

HANDBOOK   OF   DISEASES   OF   THE   NOSE,  THROAT,   AND  EAR. 

For  Students  and  Practitioners.  By  W.  S.  Syme,  M.  D., 
F.  R.  F.  P.  and  S.  G.,  F.  R.  S.  E.,  Surgeon  to  the  Ear,  Nose 
and  Throat  Hospital,  Glasgow ;  Extra-Academical  Lecturer 
on  Disease  of  the  Throat  and  Nose,  Glasgow  Universitv, 
etc.  Illustrated.  New  York:  William  Wood  &  Sons,  1920. 
(Edinburgh:  E.  &  S.  Livingstone.)    Pp.  viii-329. 

A  SHORT  HISTORY  OF  NURSING.     FROM  THE  EARLIEST  TIMES 

TO  THE  PRESENT  DAY.  By  Lavinia  L.  Dock,  R.  N.,  Secre- 
tary, International  Council  of  Nurses.  In  Collaboration 
.with  Isabel  Maitland  Stewart,  A.  M.,  R.  N.,  Assistant 
Professor,  Department  of  Nursing  and  Health,  Teachers 
College,  Columbia  University,  N.  Y.  New  York :  G.  P.  Put- 
nam's Sons,  1920.    Pp.  vi-392. 

INFECTIOUS  diseases.  A  Practical  Textbook.  (Oxford 
Medical  Publications).  By  Claude  Buchanan  Ker,  M.D., 
Ed.,  F.R.C.P.,  Edin.,  Medical  Superintendent,  City  Hospital, 
Edinburgh,  and  Lecturer  on  Infectious  Diseases  to  the 
University  of  Edinburgh,  Major,  R.A.M.C.,  T.F.  Second 
Edition.  Illustrated.  London:  Henry  Frowde  (Oxford 
University  Press),  and  Hodder  &  Stoughton,  1920.  Pp. 
xii-627. 

THE  OXFORD  MEDICINE.  By  Various  Authors.  Edited  by 
Henry  A.  Christian,  A.M.,  M.D.,  Hersey  Professor  of 
the  Theory  and  Practice  of  Physic,  Harvard  University, 
Physician  in  Chief  to  the  Peter  Bent  Brigham  Hospital. 
Boston,  Mass.,  and  Sir  James  M.\ckenzie,  M.D.,  F.R.C.P., 
LL.  D.,  F.  R.  S.,  Consulting  Physician  to  the  London  Hos- 
pital, and  Director  of  the  Clinical  Institute,  St.  Andrews, 
Scotland.  In  Five  Volumes.  Illustrated.  New  York  and 
London :  Oxford  University  Press.    Pp.  xxiii-923. 

massage  and  exercises  combined,  a  Permanent  Physi- 
cal Culture  Course  for  Men,  Women,  and  Children.  Health 
Giving,  Vitalizing,  Prophylatic,  Beautifying.  A  New  Sys- 
tem of  the  Characteristic  Essentials  of  Gymnastic  and 
Indian  Yogis  Concentration  Exercises  Combined  with  Scien- 
tific Massage  Movements.  With  eighty-six  Illustrations  and 
Deep  Breathing  Exercises.  By  Albrecht  Jensen,  For- 
merly in  Charge  of  Medical  Massage  Clinics  at  Polyclinic 
Hospital  and  Other  Hospitals,  New  York.  New  York :  Pub- 
lished by  the  Author,  1920.    Pp.  13-93. 

plastic  surgery  of  the  face.  Based  on  selected  cases 
of  War  Injuries  of  the  Face  Including  Burns.  With  Orig- 
inal Illustrations.  By  H.  D.  Gilues,  C.B.E.,  F.R.C.S., 
Major,  R.  A.  M.  C,  Surgical  Specialist  to  the  Queen's 
Hospital,  Sidcup  Surgeon  in  Charge  of  the  Department  for 
Plastic  Surgery,  and  Late  Surgeon  in  Charge  of  the  Ear, 
Nose  and  Throat  Department,  Prince  of  Wales  Hospital. 
Tottenham,  etc.  With  Chapter  on  The  Prosthetic  Prob- 
lems of  Plastic  Surgery,  by  Captain  W.  Kelsey  Fry,  M.C, 
R.A.M.C.,  Senior  Dental  Surgeon,  Queen's  Hospital,  etc. 
Remarks  on  Anesthesia,  by  Captain  R.  Wade,  R.A.M.C, 
Late  Senior  Anesthetist,  Queen's  Hospital,  etc.  London : 
Henry  Frowde,  (Oxford  University  Press)  and  Hodder 
and  Stoughton,  1920.    Pp.  xiii-408. 


Practical  Therapeutics  and  Preventive  Medicine 

A  Compendium  of  Treatment  and  Prophylaxis,  Original  and  Adapted 


Secondary  Syphilis  of  the  Heart. — C.  Oddo  and 
C.  Mattei  {Bulletin  de  1' Academic  de  medecinc, 
March  30,  1920)  believe  the  heart  to  be  mucli  more 
frequently  involved  in  the  secondary  stage  of  syph- 
ilis than  is  generally  thought.  They  report  a  case 
of  syphilitic  pericarditis  and  rapid  heart  failure  in 
a  patient  aged  fifty-four  years  with  mucous  patches 
of  the  labial  commissures  and  scrotum.  The  heart 
improved  slightly  under  mercury  cyanide  and  nov- 
arsenobenzol  injections — though  refractory  to  digi- 
talis—  but  on  the  day  of  the  last  injection  pulmon- 
ary edema  developed  and  death  followed.  The 
autopsy  showed  marked  pericardial  disease  but  no 
involvement  of  the  myocardium  nor  endocardium. 
Cases  already  recorded  show  that  mild  secondary 
syphilitic  involvement  of  the  heart  may  be  mani- 
fested merely  in  arrhythmia,  and  more  severe  in- 
volvement, in  more  or  less  pronounced  heart  weak- 
ness or  failure.  The  diagnosis  is  based  on  the  his- 
tory and  clinical  course  of  the  case,  the  Wasser- 
mann  reaction,  and  especially,  the  therapeutic  test. 
Cardiac  disturbance  should  be  carefully  watched  for 
in  secondary  syphilis,  and  syphilis  should  be  thought 
of  in  all  cases  of  rapid  heart  enfeeblement  without 
known  cause.  The  prognosis  should  be  as  guarded 
as  that  of  definite  syphilitic  meningitis  in  the  sec- 
ondary stage.  Antisyphilitic  treatment,  after  pre- 
paratory measures  similar  to  those  preceding  digi- 
talis administration,  is  of  greater  service  than  the 
usual  heart  tonics.  ^Mercury  seems  to  be  the  remedy 
of  choice.  Arsphenaniine  should  be  used  with  cau- 
tion as  it  may  favor  dangerous  heart  collapse  and 
pulmonary  edema. 

Influence  of  Insufficient  Treatment  upon  the 
Appearance  of  Meningeal  Syphilis. — Marcel  Pi- 

nard  (Paris  medical.  ^Nlarch  6.  1920)  asserts  that 
either  insufficient  or  active  antisyphilitic  treatment 
may  favor  syphilitic  involvement  of  the  nervous 
system.  In  such  cases  an  active  drug  has  been  given 
in  insufficient  doses,  in  unduly  brief  courses,  or  with 
undue  intervals  between  successive  courses.  The 
treatment  has  been  active  enough  to  prevent  the  ap- 
pearance of  skin  lesions,  but  the  spirochetes  have 
migrated  to  the  nervous  system,  where  they  are  less 
vulnerable.  This  accounts  for  the  numerous  nerv- 
ous disturbances,  deafness,  ocular  paralyses,  etc., 
noted  during  the  earlier  trials  of  arsphenaniine,  es- 
pecially during  the  period  in  which,  owing  to  fear 
of  untoward  happenings,  the  doses  were  reduced. 
Nicolau,  among  fifty-one  patients  with  chancres, 
found  a  spinal  lymphocytosis  in  eighteen.  \\"hen 
these  cases  were  given  twenty  injections  of  0.02 
gram  of  mercury  biniodide,  the  lymphocytosis,  in- 
stead of  diminishing,  nearly  always  increased.  The 
author  observed  similar  efl:'ects  in  the  treatment  of 
nervous  syphilis  with  arsenicals.  Often  there  is 
aggravation  of  the  clinical  manifestations  and  in- 
crease of  spinal  lymphoc}'tosis  after  the  first  series 
of  arsphenaniine  injections.  One  of  the  cases  men- 
tioned showed  that  even  an  intensive  treatment 
might  be  insufficient,  in  spite  of  the  administration 


of  5.25  grams  of  neoarsphenamine ;  the  difficulty 
in  this  case  was  that  the  maximum  doses  of  0.9  or 
1.05  grams  were  not  reached  and  that  the  first  se- 
ries of  injections  was  not  followed  up  by  further 
series.  Therapeutic  neurotropism  may  occur  alike 
after  mercurial  or  arsenical  treatment.  The  essen- 
tial point  is  that  the  compounds  that  are  only  mod- 
erately active,  such  as  the  benzoate  or  biniodide  of 
mercury  and  mercurial  pills  are  dangerous ;  likewise, 
small  doses  of  highly  active  preparations  are  dan- 
gerous, and  single  series  of  treatments  or  treatments 
at  excessive  inter\-als  with  the  highly  active  prepa- 
rations are  dangerous.  At  the  onset  of  syphilis  the 
treatment  given  should  be  intensive  and  the  drugs 
used  administered  in  actually  spirocheticide  doses. 
After  the  initial  treatment,  the  period  of  rest  should 
be  short.  Treatment  should  be  kept  up  to  the  point 
of  disappearance  of  the  clinical,  serological,  and 
cerebrospinal  signs.  The  least  nervous  reaction  in- 
dicates intensive  treatment.  Intense  and  continuous 
treatment  of  syphilis  during  the  first  few  weeks  of 
the  infection  affords  some  chances  of  complete  cure. 
On  the  other  hand,  faulty  management  at  the  out- 
set may,  as  in  one  of  the  cases  reported,  result  in 
the  development  of  lesions  removable  only  with  dif- 
ficulty, even  by  prolonged  treatment. 

A  Comparative  Study  of  the  Trypanocidal 
Activity  of  Arsphenamine  and  Neoarsphena- 
mine.— Jay  F.  Schamberg,  John  A.  Kolmer.  and 
George  W.  Raiziss  (American  Journal  of  the 
Medical  Sciences,  July,  1920).  say  that  trypanocidal 
tests  employing  rats  infected  with  Trypanosoma 
equiperdvmi  provide  a  means  for  determining  the 
curative  properties  of  arsphenaniine  and  neoarsphe- 
namine. ^ledicinals  which  prove  trypanocidal  in 
vivo  are  probably  curative  in  syphilis ;  other  com- 
pounds, such  as  the  mercurials,  which  are  unable  to 
influence  experimental  trypanosomiasis,  may  still 
influence  infections  with  Trypanosoma  pallida;  such 
tests  possess,  therefore,  a  greater  positive  than  neg- 
ative value  in  chemotherapeutic  studies  in  syphilis. 
In  conducting  such  tests  the  virulence  of  the  strain, 
the  method  of  infection,  the  interval  between  in- 
fection and  treatment,  and  the  weight  of  the  test 
animals  are  modifying  factors  and  must  be  ren- 
dered uniform  to  secure  satisfactory  results.  With 
the  strain  of  Trypanosoma  equiperdum  employed 
in  the  experiments  described,  the  smallest  amounts 
of  arsphenamine  sterilizing  rats  infected  twenty- 
four  hours  previously  varied  from  0.010  to  0.030 
gram  to  the  kilo  of  body  weight,  the  average  being 
0.023  gram  to  the  kilo  of  rat.  The  smallest  steriliz- 
ing doses  of  neoarsphenamine '  under  identical  con- 
ditions varies  from  0.020  to  more  than  0.040  gram 
to  the  kilo  of  rat;  average  about  0.040  gram  to 
the  kilo.  The  trypanocidal  activity  of  different 
lots  of  arsphenamine  and  neoarsphenamine  prepared 
l)y  the  same  laboratory  and  by  different  laborator- 
ies varied  in  a  manner  analogous  to  variations  in 
lethal  toxicity  for  rats.  The  trypanocidal  activity 
of  arsphenamine  is  1.74  times  greater  than  that  of 


516 


PRACTICAL   THERAPEUT/fS   AND  iREJ-EXTlFE  MEDICINE. 


[New  York 
Medical  Jcujrkai,. 


neoarsphenamine.  and  0.6  gram  arsphenamine 
equals  1.05  rather  than  0.9  grams  of  neoarsphena- 
mine in  therapeutic  activity.  The  trypanocidal  dose 
of  arsphenamine  is  4.56  times  less  the  highest  tol- 
erated dose  for  the  rat;  that  of  neoarsphenamine  is 
6.35  times  less  the  highest  tolerated  dose.  These 
results  indicate  that  neoarsphenamine  is  a  somewhat 
safer  compound  than  arsphenamine ;  even  when  one 
gram  of  the  former  is  administered  as  equivalent  in 
therapeutic  activity  to  0.6  gram  arsphenamine,  the 
margin  of  safety  is  greater. 

Comparative  Studies  of  the  Toxicity  of  Ars- 
phenamine and  Neoarsphenamine.  —  Jay  F. 
Schamberg,  John  A.  Kolmer,  and  George  W.  Rai- 
ziss  {American  Journal  of  the  Medical  Sciences. 
August,  1920)  say  that  in  so  far  as  the  toxicity  of 
arsphenamine  and  neoarsphenamine  may  be  deter- 
mined by  intravenous  injection  of  solutions  in  rats, 
the  single  dose  of  arsphenamine  commonly  admin- 
istered (0.6  gram)  may  be  said  to  be  about  one 
twelfth  the  highest  tolerated  dose,  and  the  highest 
single  dose  of  neoarsphenamine  commonly  injected 
(0.9)  gram)  is  about  one  nineteenth  that  of  the  tol- 
erated dose.  From  the  viewpoint  of  the  margin  of 
safety  larger  amounts  of  neoarsphenamine  may  be 
given  and  maintain  the  same  ratio  between  the 
therapeutic  and  the  tolerated  dose  as  apparently  ex- 
ists with  arsphenamine. 

Relapses  After  Prostatectomy. — Victor  Blum 
( Urologic  and  Cutaneous  Rez'iezc.  May,  1920) 
mentions  the  following  possibilities  in  recurrence 
after  prostatectomy:  1,  Carcinomatous  relapse, 
either  as  a  local  recurrence  after  extirpation  of  a 
carcinomatous  prostate,  or  as  a  carcinomatous  de- 
generation of  the  site  of  operation  or  of  the  scar 
after  removal  of  an  apparently  benign  tumor,  but 
in  reality  one  undergoing  malignant  change :  2,  re- 
currence due  to  an  incompletely  performed  pros- 
tatectomy, that  is,  in  place  of  a  total  or  subtotal 
prostatectomy,  an  incomplete  operation ;  3,  rectir- 
rence  in  consequence  of  cvst  formation  in  the  loge 
prostatique^an  observation  made  by  Papin,  cited 
by  Nogues :  4,  recurrence  due  to  new  formation  of 
glandular  tissues. 

Treatment  of  Syphilis. — F.  W.  Cregor  (Journal 
of  the  Indiana  Stale  Medical  Association) ,  in  dis- 
cussing the  method  of  treating  syphilis  practised  in 
United  States  Public  Health  Service  Clinics  of  In- 
diana, emphasizes  the  following  points:  1.  The 
medical  profession  should  take  an  uncompromising 
stand  for  the  full  and  complete  treatment  of  syph- 
ilis. 2.  This  can  best  be  done  by  full  cooperation 
with  the  lawfully  constituted  health  organizations  of 
the  country.  3.  Syphilis  may  be  aborted  if  encoun- 
tered before  five  weeks  have  elapsed  from  the  con- 
traction of  the  disease.  4.  Syphilis  may  be  cured 
by  one  year  of  treatment,  providing  it  is  encoun- 
tered before  it  has  found  lodgment  in  the  tissues  of 
the  host.  5.  Syphilitics  may  be  assured  that  they 
will  remain  free  of  symptoms,  providing  they  fully 
cooperate  in  the  treatment.  6.  The  Wassermann 
test  should  be  employed  as  an  aid  and  a  comfort, 
and  not  as  a  guide  and  a  control  for  action.  7.  As 
full  cooperation  is  impossible  in  the  face  of  igno- 
rance of  the  disease  and  its  potentialities,  it  is  nec- 
essary that  the  patient  be  apprised  fully  and  honest- 


ly of  these  things.  8.  Steps  should  be  taken  to  re- 
claim the  neurosyphilitic,  possibly  throtigh  the  in- 
sane institutions,  until  such  time  as  public  enlight- 
enment will  relieve  the  present  demand.  9.  A  spi- 
nal Wassermann  test  should  be  made  in  all  cases 
before  the  patient  is  discharged. 

Hereditary  Syphilis  and  Dystrophies. — P.  Hu- 

tinel  {ArcJiives  de  medccinc  dcs  enfants,  January, 
February,  March,  and  April,  1920)  divides  the  le- 
sions dependent  upon  hereditary  syphilis  into  two 
groups,  those  containing  specific,  localized  altera- 
tions, such  as  treponema.  and  those  involving  nutri- 
tional difificulties  producing  dystrophies.  Most  of 
the  stigmata  of  the  disease  are  found  among  the 
dystrophies.  Stigmata  are  usually  multiple,  such 
as  deformities  of  the  skull,  the  nose,  the  teeth,  alter- 
ation of  the  cornea,  the  ear,  the  testicles,  etc.  There 
may  also  be  visceral  scleroses.  These  are  the  local 
dystrophies.  The  general  dystrophies  interfere 
with  the  development  of  all  parts  of  the  same  appa- 
ratus. They  are  usually  indicated  by  nutritional 
difficulties,  often  involving  the  nutritive  agency  of 
the  endocrine  glands.  When  the  nutritional  diffi- 
culties, 'imputable  to  glandular  or  organic  lesions, 
have  been  caused  by  hereditary  syphilis  or  by  some 
other  morbid  processes,  they  may  be  transmitted 
from  parents  to  children.  Specific  medication  be- 
comes less  important  as  the  dystrophies  caused  by 
hereditary  syphilis  draw  away  from  their  infectious 
origin.  Opotherapeutic  medication  is.  however,  in- 
creasingly indicated  as  the  infection  recedes. 

Significance  of  Syphilis  in  Prenatal  Care  and 
in  the  Causation  of  Fetal  Death. — J.  Whitridge 
Williams  (Bulletin  of  the  J  alms  Hopkins  Hospital, 
May,  1920)  bases  the  present  study  on  302  fetal 
deaths  occurring  in  4,000  consecutive  deliveries  be- 
tween April,  1916.  and  December.  1919.  In  each 
case  a  Wassermann  test  was  made  and  if  the  result 
was  positive  the  patient  was  given  treatment  pro- 
vided sufficient  time  was  available  before  delivery ; 
1,839  of  the  patients  were  white,  and  2,161  were 
colored  women.  The  Wassermann  reaction  was 
positive  in  2.48  per  cent,  of  the  white  patients  and 
in  16.29  per  cent,  of  the  blacks.  Autopsies  were 
performed  on  212  of  the  302  dead  babies.  In  these 
figures  are  included  not  only  those  dying  at  the 
time  of  labor  or  during  the  two  weeks  immediately 
following  it,  but  also  those  dying  during  pregnancy 
from  the  time  of  viability  onward.  Ninety-nine  of 
the  302  deaths  occurred  in  white  and  203  in  black 
infants,  while  157  occurred  at  the  time  of  labor  or 
during  the  first  two  weeks  of  the  puerperium,  and 
145  were  in  premature  children.  Syphilis  was 
noted  in  104  cases,  in  89  of  which  the  diagnosis  was 
confirmed  at  autopsy  by  the  demonstration  of  spiro- 
chetes ;  in  the  rest  it  was  made  on  the  presence  of 
syphilitic  lesions  in  the  placenta,  associated  with  a 
positive  Wassermann  in  the  mother.  Syphilis  was 
responsible  for  34.44  per  cent,  of  the  total  number 
of  deaths  in  this  group  of  cases.  In  the  patients 
where  syphilis  was  recognized  early  in  pregnancy 
and  appropriate  and  efficient  treatment  was  given, 
hopeful  results  were  obtained,  so  that  if  women  reg- 
ister prior  to  the  middle  of  pregnancy  in  properly 
conducted  clinics  syphilis  may  be  practically  eradi- 
cated as  the  cause  of  fetal  death. 


Octob:r  2,  1920.] 


PRACTICAL   THERAI'EUTICS   AND  rKEl-ENTJJ-E  MEDIC  J  NE. 


517 


Sodium  Taurocholate  in  the  Prophylaxis  of 
Gonorrhea. — L.  Cheinisse  {^Prcssc  medicalc,  Feb- 
ruary, 14,  1920)  notes  that  Aldo  Castellani  has 
found  that  bile  and  bile  salts  prevent  the  develop- 
ment of  the  gonococcus  in  vitro  and  has  recom- 
mended the  local  use  of  a  solution  of  two  to  four 
grams  of  sodium  taurocholate  in  thirty  grams  of 
pure  glycerine  as  a  gonorrhea  prophylactic.  A  few 
drops  of  this  solution  are  dropped  in  the  meatus, 
held  open  for  the  purpose,  and  over  the  glans  and 
the  balanopreputial  sulcus,  before  coitus.  Later 
the  organ  is  washed  and  the  prophylactic  local  medi- 
cation repeated.  Some  of  the  solution  may  be  in- 
stilled with  a  small  syringe.  In  one  clinical  experi- 
ment, fresh  gonorrheal  pus  containing  many  gono- 
cocci  was  mixed  for  three  minutes  with  the  sodium 
taurocholate  solution  and  introduced  into  the  healthy 
meatus.  In  another,  a  few  drops  of  the  remedy 
were  introduced  into  the  meatu's,  followed,  three 
minutes  later,  by  gonorrheal  pus;  after  five  min- 
utes, the  subject  urinated,  washed  the  organ  with 
soap  and  water,  and  introduced  a  few  more  drops 
of  the  taurocholate  solution.  Neither  of  these  sub- 
jects contracted  gonorrhea.  The  preparation  is  con- 
sidered advantageous  in  being  easily  prepared,  in- 
expensive, requiring  no  apparatus  for  its  employ- 
ment, and  in  causing  no  local  burning  or  pain. 

Removing  Ureteral  Calculi  Without  Operation. 
— A.  J.  Crowell  and  Raymond  Thompson  {South- 
ern Medical  Journal,  June,  1920)  reported  in  Au- 
gust, 1918,  the  successful  application  of  the 
method  given  below  in  twenty-nine  out  of  thirty- 
one  cases  of  urethral  stone,  and  since  then  have 
been  .successful  in  twenty-five  other  cases.  A  bis- 
muth catheter  is  inserted  into  the  ureter  until  it 
meets  with  obstruction.  An  x  ray  picture  is  taken 
to  demonstrate  that  the  obstruction  is  stone,  as  well 
as  to  ascertain  its  size  and  location.  No  obstruc- 
tion should  be  diagnosed  as  stone  unless  it  is  shown 
in  the  picture  or  is  recovered,  as  the  symptoms  of 
.••tone  may  be  simulated  by  ureteritis,  ureteral  stric- 
ture, kink,  or  pressure  on  the  ureter.  Two  c.  c.  of 
a  two  per  cent,  solution  of  cocaine  or  procaine  is 
slowly  injected  into  the  ureter  at  the  site  of  impac- 
tion. The  ureteral  .spasm  is  so  relaxed  in  a  few 
moments  that  the  catheter  will  usually  pass  beyond 
the  stone,  where  another  c.  c.  or  two  of  the  anes- 
thetic is  injected  further  to  deaden  the  sensation. 
At  this  point  it  is  well  to  distend  the  kidney 
pelvis  with  a  physiological  salt  solution  and  in- 
ject sterile  olive  oil  as  the  catheter  is  being  re- 
moved. In  this  way  the  pressure  above  the  stone 
is  increased  and  assists  in  expelling  it,  while  the 
muscular  fibres  of  the  ureter  are  relaxed  and  the 
sensation  is  deadened.  If  we  fail  to  get  the  eye  of 
the  catheter  above  the  stone,  sterile  oil  is  injected 
against  it  with  considerable  force  in  an  endeavor  to 
dislodge  it  as  well  as  to  lubricate  the  parts  and  di- 
late the  ureter  below  the  obstruction.  The  patient 
is  given  morphine  and  instructed  to  drink  water 
freely.  This  technic  is  repeated  every  second  or 
third  day,  increasing  the  size  of  the  ureteral  cathe- 
ter each'  treatment.  Quite  frequently  a  No.  11 
stoppered  catheter  is  inserted  and  left  in  situ  for 
hours.  This  is  especially  beneficial  where  it  is  im- 
possible to  get  past  the  stone  and  the  obstruction  to 
the  secretion  is  incomplete. 


Precocious  Malignant  Syphilis. — Oueyrat  and 
Mouquin  {Prcssc  medicate,  January  31,  1920)  re- 
port the  case  of  a  woman  sutYering  from  primary 
malignant  syphilis,  with  fever  and  poor  general  con- 
dition. The  Bordet-Wassermann  reaction  was  par- 
tially positive.  No  spirochetes  could  be  found,  but 
under  injections  of  novarsenobenzol  the  lesions  un- 
derwent prompt  retrogression,  the  temperature  re- 
ceded and  the  general  condition  improved.  The 
writers  make  a  distinction  between  severe  syphilis 
and  precocious  malignant  syphilis ;  in  the  former 
the  spirochete  is  generally  found,  but  in  the  latter 
it  is  wanting.  The  condition  is  a  special  morbid 
entity  beginning  with  a  chancre,  often  of  ulcerative 
type.  There  was  no  mucous  patches  and  no  roseola. 
Lesions  of  different  age  are  found  on  the  patient  at 
the  same  time,  viz.,  papules,  vesicopustules,  and 
crusted  and  ulcerous  lesions.  The  Wassermann  re- 
mains negative  at  first,  becoming  positive  two  or 
three  months  after  the  start  of  the  infection.  The 
various  mercurials  and  potassium  iodide  are  gener- 
ally insufficient  to  remove  the  manifestations  of  the 
disease.  Arsenobenzol,  on  the  other  hand,  is  very 
efficacious.  The  etiology  of  this  precociously  ma- 
lignant form  of  syphilis  remains  obscure.  It  does 
not  seem  possible  to  ascribe  it  to  the  general  condi- 
tion of  the  patient,  for  the  disease  occurs  in  robust 
individuals.  Possibly  a  special  strain  of  spirochete 
is  responsible  for  it. 

Diagnosis  and  Treatment  of  Luetic  Involve- 
ment of  the  Optic  Pathways. — Mark  J.  Schoen- 
berg  (Archives  of  Ophthalmology,  March.  1920) 
says  that  although  our  present  means  of  establish- 
ing a  diagnosis  constitute  a  pretty  good  armamen- 
tarium to  furnish  more  or  less  satisfactorv  infor- 
mation, early  diagnosis  of  syphilis  of  the  optic 
pathways  is  not  made  except  in  an  infinitesimal 
percentage  of  cases.  He  asserts  that  examinations 
should  be  begun  as  soon  as  the  primary  lesion 
makes  its  appearance  and  repeated  at  regular  in- 
tervals during  the  entire  time  the  patient  is  under 
the  observation  of  the  physician.  Diagnosis  must 
be  accurate,  and  one  of  the  most  difficult  problems 
is  the  diagnosis  of  a  nonsyphilitic  condition  in  a 
patient  with  syphilis.  There  are  many  pitfalls, 
of  which  he  considers  the  first  and  most  dangerous 
to  be  the  Wasseroiann  blood  test.  It  has  almost 
become  an  established  tradition  that  a  patient  with 
an  optic  neuritis  or  an  optic  atrophy,  and  a  three 
or  four  plus  Wassermann  blood  reaction,  must 
have  a  syphilitic  optic  nerve  lesion,  yet  nothing 
ma}'  be  further  from  the  truth.  A  single  blood 
test  can  never  be  depended  on  for  a  final  decision. 
The  condition  may  be  due  to  a  cause  other  than 
syphilis,  though  the  patient  be  syphilitic,  or  it  may 
be  due  to  syphilis  plus  one  or  several  other  causes. 
Conditions  to  be  borne  in  mind  while  investigating 
such  cases  include,  first,  acute  or  chronic  sepsis 
from  foci  of  infection  in  nasal  sinuses,  tonsils, 
teeth,  gallbladder,  appendix,  genitals,  and  intes- 
tines ;  second,  acute  or  chronic  toxemias,  lead,  ar- 
senic, alcohol  and  disturbances  of  digestion,  nutri- 
tion, elimination,  and  the  endocrine  system ;  third, 
acute  or  chi-onic  trauma,  emotional,  physical,  oc- 
cupational, such  as  aneurysms,  empyema  of  the 
nasal  sinuses,  periostitis  of  the  optic  foramen  ;  and 
fourth,   heredity  and  congenital   conditions.  One 


518 


PRACTICAL   THERAPEUTICS   AXD  PREVENTIVE  MEDICINE.  [New  York 

Medical  Journal. 


of  the  most  valuable  additions  to  our  diagnostic 
armamentarium  of  late  years  is  the  examination  of 
the  spinal  fluid.  The  information  we  obtain  shows 
us  whether  we  have  to  deal  with  a  luetic  involve- 
ment of  the  central  nervous  sj'stem ;  gives  a  clue  as 
to  about  what  pathological  type  of  lesion  of  the 
optic  path  we  are  dealing  with,  and  furnishes 
us  a  good  deal  of  information  about  the  prognosis. 
Concerning  the  disagreement  of  opinion  regarding 
the  indications  and  efficacy  of  intraspinal  and  in- 
tracranial medication,  he  thinks  that  the  good  re- 
sults obtained  are  due  not  so  much  to  the  medica- 
tion as  to  the  meningeal  reaction,  the  active  hyper- 
emia. 

After  a  diagnosis  has  been  made  we  must  ascer- 
tain whether  there  is  yet  present  an  active  process. 
End  results  of  a  condition  which  has  come  to  a 
standstill  need  no  treatment.  A  partial  optic  atro- 
phy with  no  tendency  to  progress,  with  negative 
findings  in  the  blood  and  spinal  fluid,  and  no  clin- 
ical evidence  of  an  active  neurological  disease, 
should  be  watched  but  not  treated.  For  patients 
with  vision  reduced  to  counting  fingers  at  a  few 
feet,  poor  fields  and  atrophic  discs,  there  is  not 
much  hope.  There  remains  the  group  of  cases 
with  20/200  vision  or  more,  with  fairly  good 
fields,  and  in  good  general  condition,  to  be  treated 
according  to  the  type  of  neurolues  and  type  of 
optic  nerve  lesion  present.  Therapeutically  it  is 
of  the  greatest  importance  to  have  a  clear  idea  of 
whether  we  have  to  deal  with  taboparesis,  cerebro- 
spinal lues,  or  a  vascular  case ;  what  type  of  optic 
pathway  lesion  the  patient  has,  and  in  what  stage 
of  lues  the  optic  pathway  became  involved.  The 
indications,  the  dose,  the  freqtiency  of  treatments, 
and  the  method  of  administration  are  quite  differ- 
ent, not  only  in  each  type  of  neurolues,  but  also 
in  each  type  of  optic  path  syphilis.  It  is  thera- 
peutically meaningless  to  say  optic  atrophy,  with- 
out mentioning  the  kind  of  atrophy  we  are  dealing 
with. 

Treatment  of  Varicose  Ulcers,  Chronic  Metri- 
tis, and  Chancroid  vidth  the  Salts  of  Rare  Earth 
Metals. — Albert  Frouin  {Bulletin  de  I' Academic 
de  medecinc,  April  6,  1920)  asserts  that  salts  of  the 
rare  earth  metals,  and  in  particular  the  sulphates  of 
the  cerium  group,  which  are  less  irritating  than  the 
nitrates  and  chlorides,  possess  antiseptic  properties. 
Two  to  four  per  cent,  solutions  of  these  salts  pro- 
mote the  healing  of  wounds,  and  favor  the  forma- 
tion of  the  dermis  and  of  the  epithelial  layers.  In 
war  practice  good  results  were  obtained  in  atonic 
wounds  that  had  already  been  suppurating  for  pro- 
longed periods.  One  patient  had  been  in  a  hospital 
eighteen  months  with  a  large  burn  of  the  scalp  in 
the  occipital  region.  Suppuration  was  very  marked 
and  showed  both  the  staphylococcus,  streptococcus, 
and  pyocyaneus;  grafting  had  already  been  tried 
without  success.  Later  another  graft  was  applied 
and  covered  with  dressings  of  two  per  cent,  lanth- 
anum sulphate  solution.  Six  weeks  later  the  wound 
had  almost  completely  closed.  In  four  cases  of 
long  standing  varicose  ulcer,  moist  (pressings  of 
rare  earth  salts  twice  daily  brought  about  healing  in 
twenty  to  thirty-three  days.  In  thirty-four  patients 
with  ulcers  of  the  cervix  or  chronic  metritis  tamp- 


ons impregnated  with  solutions  of  rare  earth  salts 
were  used  twice  weekly.  In  some  instances  an 
iodine  compound  wsa  applied  for  a  short  time  be- 
fore introduction  of  the  tampons.  As  a  result,  pain 
and  dragging  sensations  were  relieved,  discharge 
ceased,  and  healing  took  place  in  four  to  twelve 
weeks  or,  in  five  patients  in  whom  daily  treatment 
could  be  given,  in  fifteen  to  twenty-two  days.  In 
a  case  of  chancroid  of  the  fourchette,  insertion  two 
or  three  times  a  day  of  a  tampon  impregnated  with 
lanthanum  sulphate  solution,  together  with  special 
treatments  twice  a  week,  was  followed  by  recovery 
in  seven  days.  Guenot,  in  a  number  of  cases  of 
chancroid  in  men,  treated  with  two  to  four  per  cent, 
solutions  of  lanthanum  sulphate,  obtained  recovery 
in  from  seven  to  twenty  days. 

Effects  of  Mercury  Salicylate  on  the  Wasser- 
mann  Reaction.— Herman  Goodman  (Archives 
of  Dermatology  and  Syphilology,  August,  1920), 
presents  his  observations  on  the  results  of  serologi- 
cal treatnient  in  previously  untreated  syphilitic 
men.  He  states  that  eighty-seven  of  these  men, 
with  four  plus  Wassermann  reactions,  were  given 
one  grain  of  mercury  salicylate  intramuscularly  at 
weekly  intervals  for  courses  of  from  six  to  eight 
injections.  The  Wassermann  reaction,  immediately 
after  treatment,  remained  strongly  positive  in  sixty- 
six  per  cent,  of  the  cases.  In  only  nine  per  cent, 
was  there  a  reversal  to  negative ;  and  in  some  of  the 
patients,  who  were  given  a  third  Wassermann  test 
after  an  interval  without  treatment,  the  reaction 
was  positive.  It  seems  fair  to  conclude,  with  An- 
derson and  Xelson  who  carried  on  a  similar  study 
in  1915,  that  mercury  salicylate  alone  and  for  the 
period  given  does  not  qualify  as  a  curative  agent  in 
syphilis.  The  plans  for  a  longer  study  were  cur- 
tailed by  the  demobilization.  In  the  future  mercury 
salicylate  will  be  used  in  increasing  doses  up  to  two 
and  two  and  a  half  grains  weekly. 

Tests  of  Renal  Function. — C.  W.  Dowden 
(Soiitlicr)t  Medical  Journal,  May,  1920),  in  pre- 
senting a  comparison  of  a  few  of  the  simpler  tests 
with  the  more  elaborate  ones,  states  that  in  his  opin- 
ion practically  as  many  facts  can  be  obtained  by  a 
careful  examination  of  the  urine  at  each  voiding, 
regardless  of  time  and  covering  a  period  of  three 
days  or  longer,  during  which  only  capacity  diet  is 
insisted  upon,  especially  in  the  quantity  of  the  night 
urine  and  the  fixation  of  specific  gravity  at  a  high 
or  low  level,  as  can  be  obtained  by  the  more  elabo- 
rate methods.  Comparing  the  daily  output  with 
the  intake  offers  not  only  valuable  diagnostic  evi- 
dence, but  is  a  most  helpful  index  for  proper  treat- 
ment. He  has  seen  marked  improvement  in 
chronic  nephritis  by  limiting  the  intake  of  fluids  to 
not  more  than  400  c.  c.  in  excess  of  the  previous 
day's  output.  Blood  pressure  (except  in  the  arterio- 
sclerotic) usually  declines  promptly,  and  when  there 
is  close  agreement  in  intake  and  output  there  is  al- 
ways noticeable  a  marked  improvement  in  the  pa- 
tient's general  condition.  He  is  firmly  convinced 
that  the  indiscriminate  advice  to  nephritics  to  drink 
an  abundance  of  water  is  wrong  and  probably  as 
dangerous  as  to  advise  them  to  eat  plenty  of  meat 
and  salt.  In  chronic  nephritis  the  salt  output  is  dis- 
turbed little  or  not  at  all. 


Proceedings  of  National  and  Local  Societies 


SOCIETY  FOR  THE  PREVENTION  OF 
VENEREAL  DISEASE. 

First  Annual  General  Meeting  held  in  London  on 
Thursday,  June  3,  1920. 

Lord  WiLLOUGHBY  DE  Broke,  President  of  the  Society,  in 
the  Chair. 

President's  Address. — Lord  Willoughby  de 
Broke  said  that  the  origin  of  this  society  was  a 
certain  White  Paper  which  w^as  pubHshed  by  the 
Government  some  months  ago  setting  forth  the 
official  view  w^ith  regard  to  what  was  then  called 
prophylaxis  in  relation  to  the  treatment  of  venereal 
disease.  That  White  Paper  was  issued  as  an  ac- 
count of  the  deliberations  of  an  Interdepartmental 
Committee  appointed  for  the  purpose  of  inquiring 
into  the  stibject.  The  whole  purport  of  the  report 
and  the  whole  complexion  of  the  official  point  of 
view  was  against  the  policy  of  immediate  self- 
disinfection  as  a  prophylaxis  against  venereal  dis- 
ease, which  had  undoubtedly  been  proved  to  have 
been  a  success.  No  disease  had  ever  been  stamped 
out  merely  by  trying  to  heal  the  symptoms,  unless 
the  healing  had  been  accompanied  by  the  most 
scientific  methods  of  prevention.  The  prevention 
of  venereal  disease  was  of  two  kinds :  moral  pre- 
vention, and  second,  abstinence  from  promiscuous 
intercourse.  All  that  was  very  good  and  should 
be  advocated  on  every  possible  occasion,  but  the 
common  sense  of  the  thing  was  that  if  you  wished 
to  avoid  contagion  you  should  avoid  contact.  It 
was  equally  true  that  in  spite  of  all  the  exhortation 
and  in  spite  of  the  fact  that  the  nation — and  in  par- 
ticular the  army — had  been  lectured  over  and  over 
again  with  regard  to  the  dangers  of  promiscuous 
intercourse,  venereal  infection  was  still  proceeding 
at  an  alarming  rate ;  moral  prevention,  although  an 
excellent  thing  so  far  as  it  went,  had  hitherto  failed 
to  achieve  the  object  of  stamping  out  or  even  of 
lessening  the  incidence  of  the  disease. 

There  remained  medical  prevention  of  two  kinds, 
delayed  or  immediate.  The  official  policy  was  that 
of  delayed  disinfection  which  it  was  proposed  to 
carry  out  at  ablution  centres  where  those  who  had 
been  incontinent  shotild  be  treated  by  a  skilled  at- 
tendant. If  people  w^ere  to  know  where  they  were, 
these  ablution  centres  must  be  made  conspicuous. 
But  if  they  were  made  sufficiently  conspicuous  to 
attract  attention  they  wotild  be  so  conspictious  that 
no  person  would  care  to  be  seen  entering  an  estab- 
lishment of  that  kind.  Nothing  was  more  gro- 
tesqtie  or  more  liable  to  incite  the  blackmailer  and 
the  spy  than  an  abltition  centre  in  a  rural  village. 
So  much  for  delayed  disinfection.  Therefore,  it 
remained  to  consider  the  other  policy,  which  was 
the  primary  policy  of  this  society,  that  was  the 
policy  of  immediate  selfdisinfection  applied  by  the 
man  or  the  w'oman  within  a  few  seconds  after 
coition  had  taken  place.  The  Government  thought 
this  would  make  promiscuous  intercourse  between 
the  sexes  too  easy  and  would  deliberately  invite 
people  to  indulge  in  it.    That  was  a  low  estimate  to 


form  of  the  morality  of  one's  fellow  countrymen, 
and  if  venereal  disease  was  only  kept  in  check  by 
fear  of  the  consequences,  he  was  afraid  fear  had 
not  been  a  very  successful  agent  in  stamping  out 
promisctious  intercourse  between  the  sexes.  The 
only  safe,  the  only  wise,  the  only  human,  the  only 
statesmanlike  course  was  to  recognize  the  fact  that 
in  spite  of  all  this  preaching  and  lecturing  and  in- 
citement to  lead  a  healthy  life,  we  had  at  present 
failed  to  suppress  the  sexual  instinct  to  such  a 
degree  as  to  have  any  efifect  upon  the  incidence  of 
venereal  disease.  Therefore,  if  you  were  to  attack 
venereal  disease,  you  must  attack  it  at  the  weakest 
link,  and  the  weakest  link  in  the  chain  of  infection 
was  immediately  after  the  connection  had  taken 
place.  Hence  the  whole  aim  and  object  of  this  so- 
ciety was  to  tirge  the  Government  to  bring  pressure 
on  all  public  bodies  to  issue  such  instructions  to  our 
fellow  countrymen  and  countrywomen  as  would 
enable  them  to  take  advantage  of  the  latest  teachings 
of  science,  in  order  that  they  might  themselves  use 
immediately  after  connection,  if  connection  there 
must  be,  such  ample  disinfectants  as  were  known  to 
be  efficacious  in  destroying  immediately  the  spiro- 
chete and  the  gonococcus. 

The  highest  moral  attittide  that  the  State 
cottld  adopt  was  the  health  of  the  citizens,  and  we 
would  not  be  responsible  to  future  generations  for 
our  having  suppressed  knowledge  which,  if  intelli- 
gently applied,  might  well  prevent  thousands  of 
them  from  hideous  sufferings  in  the  ftiture.  Only 
one  obstacle  which  stood  in  the  way  of  the  adoption 
of  that  policy  and  that  obstacle  was  contained  in  a 
certain  clatise  in  the  Venereal  Disease  Act  of  1917, 
the  gist  of  which  was  that  no  person  should  hold 
out  or  recommend  to  the  public  any  notice  or  ad- 
vertisement of  anything  for  the  prevention,  cure  or 
relief  of  any  venereal  disease.  In  order  to  test  this 
the  speaker  went  to  a  well  known  chemist  in  the 
W^est  End  of  London  and  asked  him  whether  he 
could  supply  some  calomel  cream  ointment,  thirty- 
three  per  cent.,  and  a  solution  of  one  in  a  thousand 
of  potassium  permanganate,  and  he  said  yes.  If  he 
had  come  into  the  shop  and  asked  for  these  things 
with  a  view  to  averting  venereal  disease  the  chemist 
said  he  could  not  legally  supply  them.  Inasmuch 
as  a  little  unscientific  knowledge  was  dangerous  in 
the  highest  degree,  it  was  important  that  knowledge 
should  be  made  available  to  the  public  under  the 
control  and  with  the  supervision  of  qualified  medical 
authorities,  such  as  the  Ministry  of  Health,  medical 
officers  of  health  all  over  the  cotmtry,  or  the  local 
government  board.  It  was  to  that  policy  that  he 
invited  cooperation,  he  therefore  asked  votes  for 
this  resolution : 

Resolved,  That  inasmuch  as  the  Ministry  of  Health  had 
failed,  and  public  bodies,  including  the  London  County  Coun- 
cil, have  declined  to  provide  the  means  of  delayed  disinfec- 
tion against  venereal  disease  at  ablution  centres,  this  meet- 
ing calls  upon  the  Ministry  of  Health  and  upon  local 
authorities  to  instruct  all  qualified  chemists  to  sell  such 
means  of  immediate  selfdisinfection  against  venereal  disease 
as  may  be  approved  from  time  to  time  by  the  Alinistry  of 
Health  or  by  medical  officers  of  health. 


520 


PROCEEDINGS  OF  NATIONAL   AND  LOCAL  SOCIETIES. 


[New  York 
Medical  Journal. 


Dr.  C.  W.  Saleeby,  F.  R.  S.  E.,  said  that  it  was 
astonishing  that  those  who  were  now  opposed  to 
us  had  themselves  connived  at  the  confusion  be- 
tween prevention  and  treatment  which  we  desired 
put  an  end  to.  When  attempts  were  made  in  the 
army  to  deal  with  the  disease  by  means  of  disin- 
fection, those  attempts  were  labeled  early  treatment, 
and  by  those  who  labeled  disinfection  early  treat- 
ment we  are  now  told  that  a  policy  of  disinfec- 
tion would  lead  to  the  belief  that  disinfectants 
could  be  used  for  treatment.  That  was  not  our 
fault ;  it  was  the  fault  of  those  who  did  not  have 
the  common  honesty  to  label  disinfectants  as  such, 
but  called  them  early  treatment,  which  they  were 
not,  and  could  not  be.  The  resolution  which  Lord 
\\'illoughby  de  Broke  had  proposed  drew  attention 
to  the  fact  that  at  this  moment  there  was  no  ef- 
fective work  being  done  against  the  spread  of  vene- 
real disease  in  this  country.  The  great  obstacle  in 
the  way  of  making  progress  was  the  Ministry  which 
had  been  largely  created  for  the  purpose  of  dealing 
with  venereal  disease.  He  drew  attention  to  the 
fact  that  there  had  just  been  publishd  the  report  of 
the  National  Birthrate  Commission,  a  body  which 
devoted  a  great  deal  of  attention  to  this  subject.  In 
the  last  two  years  they  heard  evidence  from  Sir 
William  Osier.  Sir  Bryan  Donkin,  and  Mr.  E.  B. 
Turner,  a  body  which  comprised  a  number  of 
women,  a  minority  of  whom  were  .scientific,  and 
which  was  presided  over  by  the  Bishop  of  Birming- 
ham. The  National  Birthrate  Commission  recog- 
nized that  no  difficulty  of  an  official  kind  should  be 
placed  in  the  way  of  obtaining  disinfectants  by  in- 
dividuals for  use  after  exposure. 

Sir  James  Crichton-Browne,  F.  R.  S.,  said 
the  society  had  every  reason  to  be  grateful  to  the 
people  of  the  country  for  the  support  and  the  en- 
couragement it  had  received,  but  it  had  a  great 
task,  and  if  it  was  to  perform  that  task  properly  it 
must  appeal  for  help  and  support,  and  he  would 
particularly  bring  this  home  to  the  employers  of 
labor.  In  the  Times  this  morning  there  was  a  let- 
ter from  Mr.  Hyndman  pointing  out  that  the  rats 
were  at  this  moment  consimiing  grain  to  the  value 
of  £45,000,000  annually.  There  was  another  kind 
of  vermin,  a  much  smaller  kind,  the  spirochete, 
which  was  responsible  for  sjphilis  that  was  cost- 
ing the  country  hundreds  of  millions  per  annum, 
and  it  would  be  a  great  economy  on  the  part  of 
the  government  if  it  would  place  in  our  hands 
£100,000  at  this  moment  to  carry  out  a  complete 
and  efficient  propaganda  throughout  the  whole 
country.  It  would  result  immediately  in  the  saving 
of  millions.  They  should  remember  that  20,000  in- 
fants were  destroyed  by  syphilis  before  birth ;  all 
through  childhood  it  was  carrying  off  promising 
children ;  it  was  rendering  fruitful  women  barren, 
and  if  we  could  only  obtain  an  accurate  account  of 
its  effect  on  labor,  and  the  number  of  day's  labor 
that  were  lost  by  men  sufifering  from  syphilis  and 
whose  productivity  afterward  was  reduced  by  poor 
health,  we  should  have  a  most  startling  return.  That 
was  what  this  disease  was  costing  the  country. 

He  would  urge  the  employers  of  labor  to  come  to 
us,  to  invite  us  to  provide  lectures  for  their  work- 
ing men  so  that  there  could  be  further  propaganda. 


Sir  Frederick  Mott,  K.  B.  E.,  M-  D.,  F.  R.  S., 
said  it  was  true  that  the  disabilities  produced  by 
syphilis  were  colossal,  and  from  an  economic  point 
of  view  it  would  be  of  the  greatest  value  to  the 
government  to  do  everything  they  could  to  support 
this  propaganda  both  from  a  health  point  of  view 
and  from  an  economic  point  of  view. 

Mr.  H.  Wansey  Bayly,  M.  C,  said  the  progress 
during  the  seven  months  of  the  society's  existence 
had  ])een  most  encouraging.  When  he  first  con- 
ceived the  idea  of  forming  this  society  he  gathered 
that  the  majority  of  the  medical  opinion  would  favor 
such  a  scheme,  and  after  consultation  with  Lord 
Willoughby  de  Broke  and  Dr.  Saleeby  the  first  small 
meeting  of  the  Venereal  Prevention  Committee 
took  place  on  September  22nd ;  a  month  later  this 
committee  formed  itself  into  the  Society  for  the 
Prevention  of  Venereal  Disease  and  a  provisional 
constitution  was  accepted.  On  December  10th  our 
president  raised  the  cjuestion  in  the  House  of  Lords 
of  immediate  selfdisinfection  as  a  preventive  of 
venereal  disease  and  asked  for  papers  relative  to 
incidence  of  venereal  disease  in  Portsmouth  Mili- 
tary Area.  The  Ministry  of  Health  replied  in  a 
White  Paper  in  February  in  which  inaccuracy  in 
former  statements  was  admitted.  Our  membership 
now  ran  into  hundreds  and  our  grand  committee, 
which  was  limited  to  100,  was  full.  During  the  first 
seven  months  of  the  society's  existence  we  held 
two  public  meetings  in  London.  The  edi- 
torials of  The  Lancet,  Public  Health,  Medical  Press, 
Medical  Officer,  Medical  Times  and  National 
Health,  made  it  evident  that  these  journals  recog- 
nized the  supreme  importance  of  immediate  self- 
disinfection  as  a  method  of  preventing  venereal  dis- 
ease. 

American  medical  papers  were  mostly  sympathetic. 
The  New  York  Medical  Journal,  in  re- 
viewing his  book  on  venereal  disease,  which  ex- 
pressed the  views  of  the  society,  stated :  "The  chap- 
ter on  prophylaxis  is  extremely  sane  and  wholesome 
and  in  marked  contrast  with  the  sentimental  exhorta- 
tion of  elderly  men  influenced  by  their  moral 
views."  The  nonmedical  press  was  still  rather  shy, 
with  the  exception  of  the  Times,  which  had  pub- 
lished three  leading  articles  in  support  of  our  move- 
ment and  four  letters  from  the  E.xecutive  Committee. 
Branches  of  trade  unions  were  showing  a  keen  de- 
sire to  hear  lectures  on  the  subject  of  the  prevention 
of  venereal  disease,  and  he  was  now  giving  two  or 
three  lectures  a  week  to  most  appreciative  and  in- 
telligent audiences. 

To  stamp  out  venereal  disease  was  a  noble  goal, 
and  if  this  goal  were  achieved  it  would  be  cheaply 
bought  at  the  expenditure  of  all  our  lives  and  all 
our  money.  In  this  small  society  centred  the  prin- 
ciple that  it  was  immoral  to  withhold  a  scientific 
truth  from  the  people,  the  knowledge  of  which 
would  diminish  disease,  pain  and  sorrow.  We  were 
but  an  obscure  few,  a  voice  in  the  darkness,  but  it 
was  possible  that  we  might  achieve  a  niche  in  history 
as  a  society  which  dared  range  itself  in  opposition 
to  clericalism  and  the  government  and  which  added 
to  the  sum  of  human  happiness  in  spite  of  this 
opposition  by  appealing  directly  to  the  innate  san- 
ity of  the  people. 


New  York  Medical  Journal 

INCORPORATING  THE 

Philadelphia  Medical  Journal  thl  Medical  News 

A  Weekly  Review  of  Medicine,  Established  ISJfS. 

Vol.  CXII,  Xo.  13.  NEW  YORK,  SATURDAY.  OCTOBER  9,  1920.  Whole  No.  21S4. 

Original  Communications 


THE  DIAGNOSIS  OF  INFLAMMATIONS  OF 
THE  MALE  URETHRA. 
By  Abr.  L.  Wolbarst,  M.  D., 

Cystoscopist  and  Chief  of  the  Urologic  Clinic,  Beth  Israel  Hospital; 
Consulting  Urologist  to  the  Central  Islip  and  Manhattan 
State  Hospitals. 

At  first  glance  it  may  seem  almost  superfluous 
to  discuss  the  diagnosis  of  urethritis,  the  sub- 
ject is  apparently  so  simple  and  elementary.  In 
fact,  however,  the  subject  is  neither  simple  nor 
elementary,  to  which  statement  any  patient  who  has 
been  a  victim  of  an  erroneous  diagnosis  readily 
can  testify  from  his  bitter  experience. 

It  is  essential  to  remember  primarily  that  ure- 
thral infections  vary  considerably  as  to  their  etiology 
and  the  clinical  manifestations  will  reflect  in  great 
measure  these  variations  in  the  causative  factors.  We 
recognize  two  kinds  of  urethritis:  specific  urethri- 
tis, in  which  the  gonococcus  is  the  predominating 
etiological  factor,  and  nonspecific  urethritis,  which 
includes  all  the  other  kinds  of  urethral  infections. 

When  a  patient  presents  himself  with  a  urethral 
discharge  and  other  symptoms  indicating  an  inflam- 
mation of  the  urethral  canal,  we  are  brought  face 
to  face  with  the  task  of  determining  the  nature  of 
the  infection  in  order  that  appropriate  treatment 
may  be  instituted ;  and  the  first  step  that  must  be 
taken  is  to  determine  whether  we  are  dealing  with 
a  specific  or  a  nonspecific  infection,  and  if  the 
latter,  what  is  the  underlying  factor  in  the  case. 

Unfortunately,  it  is  probably  within  the  truth  to 
say  that  this  is  not  the  usual  procedure.  The  task 
of  determining  the  precise  nature  of  the  urethral 
infection  is  n'ot  an  easy  one,  and  the  busy  practi- 
tioner does  not  readily  find  the  time  that  must  be 
devoted  to  it  if  it  is  to  be  attempted  conscientiously. 
Usually  the  presence  of  a  discharge,  purulent  urine, 
and  urinary  discomfort  are  considered  sufficient  to 
make  the  diagnosis  of  gonococcic  infection,  but  the 
experienced  practitioner  sooner  or  later  learns  to  his 
regret  and  mortification  that  this  procedure  is  not 
always  fair  either  to  his  patient  or  to  his  own  repu- 
tation. 

Let  us  first  consider  the  nonspecific  urethrites. 
Luys  (1),  referring  to  the  organisms  which  have 
been  found  in  nonspecific  urethral  discharges,  men- 
tions a  formidable  array,  the  following  being  among 
the  most  important:  streptococcus,  bacillus  coli, 
pneumococcus,  staphylococcus,  various  Sarcinae, 
diphtheria  bacillus,  tubercle  bacillus.  Micrococcus 


fallax,  and  Micrococcus  cereus  albus.  In  addition, 
we  may  include  perhaps  the  most  important  and  the 
most  frequently  encountered — the  Micrococcus  ca- 
tarrhalis.  Then  there  are  the  socalled  aseptic  in- 
flammations, in  which  neither  the  gonococcus  nor 
other  organisms  can  be  found.  '  The  microscope 
shows  nothing  but  pus  cells,  a  few  epithehal  cells, 
and  occasionally  strings  of  mucus. 

It  is  of  supreme  importance  to  know  whether 
we  are  dealing  with  an  undoubted  gonococcus  in- 
fection or  one  of  the  nonspecific  types — not  alone 
because  our  treatment  must  depend  on  this  differ- 
entiation but  because  extremely  vital  social  and  eco- 
nomic questions  may  be  involved.  Still  more  im- 
portant is  the  fact  that  these  nonspecific  inflamma- 
tions do  not  respond  kindly  to  the  measures  which 
are  often  inflicted  on  the  patients  in  the  belief  that 
the  gonococcus  is  the  offending  organism. 

The  expert  urologist,  accustomed  to  seeing  pa- 
tients who  have  refused  to  get  well  under  the  persist- 
ent administration  of  silver  salts  and  astringents,  will 
frequently  score  a  decided  hit  if  he  will  recognize 
the  nonspecific  character  of  the  disease  and  adjust 
his  therapeutic  measures  in  accord  with  these  find- 
ings. 

THE  TYPE  OF  IXFECTION. 

It  is  therefore  evident  that  if  our  therapy  is  to 
succeed  we  first  of  all  must  know  what  sort  of  in- 
fection we  are  dealing  with.  Familiarity  with  the 
use  of  the  microscope  is  a  sine  qua  non,  but  that  is 
not  enough.  One  should  be  able  to  correlate  the  mi- 
croscopic findings  with  a  thorough  knowledge  of  the 
clinical  symptoms  presented  by  the  patient.  In  a 
great  measure  this  knowledge  can  be  obtained 
only  through  extensive  clinical  experience.  This 
is  true  of  all  knowledge,  but  with  this  knowledge 
must  come  wisdom — the  ability  to  differentiate  the 
clinical  manifestations  of  specific  and  nonspecific  in- 
fections. 

This  is  particularly  true  in  the  urethral  inflamma- 
tions produced  by  the  ^Micrococcus  catarrhalis.  For 
all  practical  purposes  there  seems  to  be  no  dif- 
ference between  the  symptoms  of  acute  catarrhal 
inflammation  and  the  typical  gonococcus  infection, 
yet  there  is  a  decided  difference  if  one  has  ac- 
quired the  ability  to  observe  and  detect  it.  The 
symptoms  generally  are  less  severe ;  the  discharge 
is  less  profuse,  it  is  likely  to  be  more  watery  or 
mucoid  in  its  character  from  its  incipiency;  the 
urinary  discomfort  may  be  slight  or  absent;  the- 


Copyright,  1920.  by  A.  R.  Elliott  Publishing  Company. 


522 


WOLBARST:  INFLAMMATION   OF  THE  MALE  URETHRA. 


[New  York 
Medical  Journal. 


meatus  is  but  slightly  or  not  at  'all  inflamed.  As 
the  case  proceeds,  we  are  impressed  with  this  un- 
usual mildness  throughout  its  course,  and  if  the 
urethral  mucosa  is  not  irritated  by  strong  local  ap- 
plications recovery  almost  certainly  follows  with- 
out complications  or  other  distressing  symptoms. 
Associated  with  these  phenomena  there  may  exist 
a  general  condition  of  diminished  vitality,  evidences 
of  a  catarrhal  diathesis  in  other  parts  of  the  body, 
and  evidences  or  history  of  alcoholism  or  sexual 
excesses. 

THE'  MICROCOCCUS  CATARRHALIS 

In  dealing  with  the  Micrococcus  catarrhalis  we 
are  confronted  by  the  extreme  difficulty  of  dis- 
tinguishing it  from  the  gonococcus,  since  it  bears 
so  close  a  resemblance  to  the  gonococcus  in  almost 
all  respects  that  it  can  be  differentiated  only  by 
culture.  This  organism  grows  profusely  on  agar, 
and  in  tliis  respect  it  differs  materially  from  the 
gonococcus  and  the  meningococcus  which  it  closely 
resembles  in  other  characteristics.  It  does  not  neces- 
sarily follow,  however,  that  a  urethral  inflamma- 
tion is  to  be  considered  as  an  acute  catarrhal  con- 
dition because  it  happens  to  be  mild  in  character. 
Every  urethral  discharge  must  be  regarded  with  sus- 
picion and  considered  potentially  gonorrheal  unless- 
it  is  proved  otherwise ;  but  it  is  the  part  of  wisdom 
to  keep  one's  eyes  alert  to  all  the  possibilities  and 
to  use  every  means  at  one's  disposal  whereby  doubt 
and  suspicion  may  be  replaced  by  certainty  and  con- 
viction. Whatever  treatment  is  instituted  should  be 
administered  with  caution  and  the  developments 
should  be  watched  closely.  If  it  is  found  that  medi- 
cation is  increasing  the  inflammation  instead  of 
diminishing  it,  we  must  recognize  that  nature  is 
presenting  us  with  substantial  evidence  (if  we 
could  but  understand  her  warnings)  that  our  treat- 
ment is  unsuitable  to  this  particular  case  of  specific 
infection  or  that  the  infection  is  not  gonococcal  at 
all.  In  either  event  it  is  well  to  have  a  culture  made 
and  determine  definitely  whether  we  are  dealing 
with  the  gonococcus,  the  Micrococcus  catarrhalis, 
or  some  other  organism. 

On  the  other  hand,  occasions  may  and  often  do 
arise  which  require  an  immediate  answer  to  the 
question  whether  or  not  a  certain  urethral  inflam- 
mation is  actually  gonococcal  in  character,  without 
waiting  for  '  clinical  corroboration.  In  such 
cases  if  the  microscope  cannot  decide  the  question, 
we  are  of  necessity  reduced  to  the  single  expedient 
of  making  a  culture  of  the  urethral  discharge,  and 
abiding  by  its  results. 

THE  COLON  BACILLUS 

The  colon  bacillus  is  not  an  infrequent  factor  in 
the  production  of  urethral  inflammation,  especially 
in  persons  suffering  from  rectal  and  intestinal  dis- 
turbances. Clinically  the  cases  resemble  the  catarrhal 
infections.  The  microscope  shows  an  utter  absence 
of  diplococci  but  a  culture  reveals  the  colon 
bacillus.  In  a  case  which  I  saw  recently  through 
the  courtesy  of  Dr.  Herman  Roth  of  this  city,  the 
inflammation  began  as  a  distinctly  Neisserian  infec- 
tion— typical  both  clinically  and  microscopically. 
Several  months  after  all  evidences  of  the  inflamma- 
tion had  disappeared  under  appropriate  treatment. 


in  the  patient,  while  traveling,  there  suddenly  de- 
veloped a  severe  acute  prostatitis  followed  by  a  ure- 
thral discharge  which  contained  no  organism  but 
Bacillus  coli.  Under  treatment,  the  prostatic  in- 
flammation diminished  perceptibly  and  was  suc- 
ceeded shortly  after  by  an  orchiepididymitis  with 
suppuration.  At  operation,  the  entire  epididymitis 
was  found  to  be  involved  and  the  testis  proper  pre- 
sented a  number  of  suppurating  foci.  Numerous 
microscopic  examinations  and  cultures  of  the  dis- 
charge and  the  urine  have  been  made  repeatedly, 
and  nothing  has  ever  been  found  but  the  Bacillus 
coli. 

OTHER  XONSrECIFIC  TYPES 

The  remaining  nonspecific  types  of  urethritis  are 
so  rarely  encountered  that  they  need  only  be  referred 
to,  with  the  warning  that  they  should  be  kept  in 
mind  in  every  case  which  departs  in  any  appreciable 
degree  from  the  classical  specific  urethritis.  Principal 
among  these  are  the  pyogenic  or  purulent  urethritis 
following  the  introduction  of  vuiclean  catheters  or 
sounds  into  the  urethra.  Instead  of  the  gonococcus, 
pyogenic  bacteria  are  found  in  the  discharge.  Not 
infrequently  there  may  be  an  appreciable  elevation 
of  temperature,  due  to  toxic  absorption.  The  same 
conditions  sometimes  develop  as  the  result  of  coitus 
in  oram ;  in  these  cases,  the  normal  flora  of  the 
mouth  may  be  recovered  in  the  urethral  discharge. 

The  urethritis  which  accompanies  the  develop- 
ment of  a  syphilitic  chancre  at  or  within  the  urethral 
meatus  is  less  frequent.  This  type  is  most  deceiving, 
even  to  the  conscientious  and  skillful  observer,  for 
the  meatus  looks  red  and  swollen,  the  discharge  is 
rather  profuse,  and  the  urine  is  purulent.  Gono- 
cocci  are  absent.  One's  attention  is  attracted,  how- 
ever, to  the  character  of  the  meatus.  The  lips  are 
rather  whitish  and  shiny ;  they  stand  apart  instead 
of  approximating,  and  when  felt  between  the  fingers 
the  typical  induration  of  the  initial  lesion  can  be 
perceived.  It  goes  without  saying  that  the  intra- 
urethral  chancre  cannot  be  felt  at  the  meatus,  but 
it  is  not  rare  for  the  keen  observer  to  locate  a 
chancre  in  the  urethra  by  the  sense  of  touch.  The 
induration  at  the  site  of  the  lesion  is  distinct  and 
unmistakable. 

Chancroidal  infection  of  the  urethral  meatus  re- 
sembles the  type  just  mentioned  except  that  there 
is  the  chancroidal  wormeaten  ulceration,  without 
induration,  at  the  site  of  the  infection.  A  painful 
inguinal  bubo  tending  to  suppuration  is  a  frequent 
early  accompaniment,  and  immediately  should  at- 
tract particular  attention  to  the  unusual  character 
of  the  urethritis. 

If  the  lesion  is  phagedenic  in  character,  destruc- 
tion of  the  meatal  lips  and  urethral  walls  proceeds 
ruthlessly  and  without  abatement  until  the  process 
is  halted.  Treatment  seems  to  be  of  no  avail.  In 
a  case  under  my  care  some  years  ago,  fully  an  inch 
of  the  urethra  was  destroyed  in  this  way  in  spite 
of  (possibly  because  of)  the  most  conscientious  and 
vigorous  efforts.  The  destruction  ceased  only  after 
the  patient  had  been  saturated  with  mercury  and 
iodide — a  combination  which  has  been  found  very 
useful  in  these  cases.  For  several  weeks  this  man 
had  been  treated  for  gonorrhea  by  his  attending 
physician  before  the  chancroidal  lesion  was  noted. 


October  9,  1920.] 


WOLBARST:  INFLAMMATION  OF  THE  MALE  URETHRA. 


523 


THE  GONOCOCCAL  TYPE. 

Having  considered  the  most  important  nonspecific 
types  of  urethritis,  the  acute  specific  gonococcal  type 
presents  itself  for  our  attention.  With  the  unusual 
types  in  mind,  the  diagnosis  of  acute  gonorrheal 
urethritis  is  a  fairly  simple  matter.  I  was  taught 
many  years  ago  by  a  former  preceptor,  Dr.  M.  W. 
Ware,  to  look  for  the  typical  acute  gonococcal  triad, 
angry  meatus,  profuse  discharge  and  purulent  urine. 
Experience  has  borne  out  the  correctness  of  this 
teaching.  When  corroborated  by  the  microscopic 
finding  of  the  gonococcus,  whether  the  gram  stain 
or  the  simple  methylene  blue,  or  the  Unna-Pappen- 
heim  differential  stain,  there  can  be  very  little  pos- 
sibility of  error  in  the  diagnosis.  It  is  well  to  re- 
peat this  acute  specific  triad  :  angry  meatus,  profuse 
discharge,  and  purulent  urine.  If  one  or  more  of 
these  symptoms  is  wanting,  the  case  should  be  re- 
garded with  suspicion  until  all  doubts  have  been- 
removed,  but  the  absolute  diagnosis  never  should 
be  made  without  the  positive  bacterial  finding. 

Frequently  a  recurrent  chronic  urethritis  will  pre- 
sent the  discharge  and  the  purulent  urine ;  in  such 
cases  the  angry  meatus  will  be  lacking,  and  the 
gonococcus  may  not  be  found  in  the  secretion.  It  is 
rarely  that  a  chronic  urethritis  will  present  the  red, 
angry,  and  swollen  meatus  that  characterizes  the 
acute  infection.  When  it  is  present,  one  may  safely 
act  on  the  theory  that  an  acute  process  has  been 
superimposed  on  a  chronic  infection,  either  from 
without  or  from  within. 

It  is  well  to  remember  an  important  diagnostic 
feature  in  this  connection.  If  the  practitioner  will 
take  the  trouble  to  examine  a  large  number  of  ure- 
thral discharges  microscopically  and  study  them 
carefully,  he  will  observe  that  leucocjtes  predomi- 
nate in  the  acute  infection  with  few  or  no  epithelial 
cells :  whereas  in  chronic  infections  epithelial  cells 
appear  in  much  greater  number  and  the  leucocytes 
are  diminished  in  quantity.  A  knowledge  of  this 
fact  will  often  assist  materially  in  determining 
whether  the  infection  is  a  new  one  or  merelv  an 
acute  exacerbation  of  an  old  inflammation. 

In  the  diagnosis  of  urethritis  this  fact  is  important 
to  know  and  remember,  in  so  far  as  it  helps  to 
determine  whether  we  are  dealing  with  a  new  in- 
fection, or  an  exacerbation  of  an  old  one.  It  is  of 
great  importance  to  determine  this  distinction  be- 
cause the  therapy  of  the  two  conditions  is  decidedly 
diflFerent. 

The  next  step  in  order  but  not  less  important,  is 
the  determination  of  the  extent  of  the  inflammation, 
that  is.  whether  it  has  been  confined  to  the  anterior 
urethra  or  has  passed  beyond  the  cut  off  muscle  into 
the  posterior  urethra.  Generally,  when  the  patient 
voids  urine  into  two  cylinders,  if  the  first  is  puru- 
lent and  the  second  clear,  it  is  safe  to  assume  an- 
terior involvement.  Both  glasses  purulent,  usuallv 
indicates  anteroposterior  involvement.  To  make  cer- 
tain, it  is  advisable  to  do  the  simple  two  glass  irri- 
gation test  (Smith)  from  time  to  time  during  the 
course  of  the  disease.  This  test,  as  well  as  others 
devised  for  the  purpose  of  determining  the  source 
of  the  pus  in  the  urine,  has  been  fully  described  by 
me  in  previous  publications  (2). 

Additional  evidence  of  extension  to  the  posterior 


urethra  is  the  development  of  urinary  symptoms, 
frequency,  dysuria,  perineal  discomfort,  chordee, 
and  a  feeling  of  fullness  in  the  rectum  usu- 
ally proportionate  to  the  degree  of  swelling  and 
inflammation  of  the  prostate  and  seminal  vesicles. 
The  irrigation  tests,  however,  will  reveal  the  ex- 
istence of  posterior  involvement  long  before  the 
patient  may  present  any  symptoms  pointing  thereto. 

When  we  approach  the  subject  of  chronic  ure- 
thral infections,  we  are  treading  on  treacherous  and 
difficult  ground.  Here  the  problem  is  much  more 
complicated  and  a  correct  solution  can  be  arrived 
at  only  through  most  careful  clinical  observation 
and  study. 

CHROXIC  URETHRITIS 

The  S)Tnptoms  of  chronic  urethritis  vary  consid- 
erably. The  most  frequent  symptom  is  a  urethral 
discharge,  usually  designated  as  the  morning  drop ; 
less  frequently,  there  is  an  elusive  discharge  which 
haunts  the  patient  at  odd  times ;  he  cannot  say 
what  particular  time  of  the  day  it  is  likely  to  ap- 
pear. Both  of  these  types  may  be  most  provokingly 
elusive  in  character.  The  patient  may  swear  by  all 
that  he  deems  holy  that  he  sees  a  definite  drop 
every  morning  or  every  afternoon ;  he  describes  it 
as  to  quantity,  consistency,  and  color ;  but  when  he 
is  asked  to  come  to  the  consulting  room  in  the 
morning,  retaining  his  urine  all  night,  he  is  usually 
compelled  to  admit  (much  to  his  regret)  that  there 
is  no  discharge  present  and  the  virine  is  absolutely 
clear  and  sparkling.  "But,"  he  insists,  "yesterday 
there  was  a  discharge,"  and  he  is  sure  there  will  be 
a  discharge  "tomorrow."  I  have  been  unable  to 
explain  the  elusiveness  of  this  particular  kind  of 
morning  drop  except  on  the  theory  that  it  is  pro- 
duced only  as  the  result  of  milking  the  urethra  for 
a  sufficiently  long  period  to  squeeze  out  all  the 
accumulated  urethral  matter.  It  is  a  good  policy, 
however,  to  minimize  the  importance  of  any  dis- 
charge that  has  to  be  "milked"  before  the  first 
morning  urine  is  passed.  The  adoption  of  such  a 
policy  will  do  more  to  reassure  and  satisfy  a  wor- 
ried neurasthenic  patient  than  anything  else  known 
to  me.  One  must  be  discreet,  however,  in  the  man- 
ner in  which  this  favorite  possession  of  the  neu- 
rasthenic is  eliminated  from  his  accumulation  of 
complaints. 

In  any  given  case  involving  a  chronic  urethral 
discharge,  morning  or  otherwise,  the  first  question 
to  be  decided  is :  Where  does  it  originate  ?  This 
cannot  be  determined  by  the  urethroscope  nor  by 
the  patient  urinating  in  three,  five,  seven,  or  twenty 
glasses.  A  careful  study  and  application  of  the 
tests  above  referred  to  must  be  made  before  any 
diagnosis  or  therapy  can  be  determined  upon.  If, 
however,  there  is  the  slightest  ground  for  suspicion 
that  the  pus  in  the  urine  is  derived  from  the  bladder 
or  higher  up  in  the  urinary  tract,  the  five  glass 
catheter  test  (Wolbarst)  will  provide  definite  infor- 
mation that  will  eliminate  any  existing  doubt  (2). 

Now,  having  determined  the  origin  of  the  pus  or 
shreds,  the  next  step  is  to  locate  the  lesion  and  de- 
termine its  character.  When  the  physician  has 
solved  these  two  problems  correctly,  his  patient  mav 
consider  himself  a  lucky  man;  he  is  half  cured. 
Every  case  must  be  studied  on  its  own  merits. 


524 


WOLBARST:  INFLAMMATION    OF  THE  MALE  URETHRA. 


[New  York 
Medical  Journal. 


The  most  frequent  cause  is  stricture ;  less  fre- 
quently, are  folliculitis,  prostatitis,  vesiculitis,  and 
all  their  respective  variations.  Occasionally  a  case 
will  be  encountered  in  which  one  cannot  discover 
the  existence  of  any  of  the  conditions  just  men- 
tioned ;  but  a  careful  examination  made  with  the 
posterior  urethroscope  will  reveal  a  well  defined  in- 
flammation of  the  verumontanum  and  the  adjacent 
urethral  roof,  floor  and  walls.  The  moral  to  be 
learned  from  this  observation  is  that  no  examina- 
tion of  a  case  of  chronic  urethritis  is  to  be  con- 
sidered complete  without  a  urethroscopic  examina- 
tion covering  both  portions  of  the  urethra.  If  the 
physician  is  not  in  a  position  to  make  this  examina- 
tion understandingly,  it  is  unfair  for  him  to  under- 
take the  diagnosis  and  treatment  of  sucli  a  case. 
Stricture  in  the  anterior  urethra  cannot  be  diag- 
nosed by  the  passage  of  a  sound,  as  is  so  frequently 
attempted.  If  the  urinary  meatus  is  a  large  one, 
the  bougies  d  houle  are  satisfactory  but  time  con- 
suming and  wearing  on  the  patient's  patience  and 
good  nature.  The  Otis  urethrometer  is  a  decidedly 
useful  and  practical  instrument,  and  if  it  is  in  good 
working  order  may  be  considered  reasonably  exact 
in  the  information  it  conveys.  Unfortunately,  it 
cannot  be  employed  in  the  posterior  urethra,  in 
which  the  steel  sound  and  the  urethroscope  must  be 
brought  into  requisition.  If  the  urethrometer,  di- 
lated up  to  29-30  F.,  passes  through  the  anterior 
urethra  without  impinging  on  an  obstruction,  there 
is  no  appreciable  stricture  of  any  account  in  that 
canal.  It  is  wise,  however,  to  increase  the  dilatation 
as  high  as  33-35  F.,  because  distinctly  appreciable 
obstructions  are  sometimes  encountered  at  that 
figure.  These  may  consist  of  fine  bands  of  tissue 
or  swollen  follicles  projecting  slightly  into  the  lumen 
of  the  urethra.  These  fine  projections  may  and  of- 
ten do  produce  the  continuing  discharge.  The  ure- 
throscope must  be  brought  into  requisition  for  the 
exact  determination  of  their  number  and  character, 
and  the  treatment  required  to  relieve  the  patient  of 
them.  The  diagnosis  of  chronic  urethral  folliculitis 
is  made  by  the  urethroscope  unless  the  infected  fol- 
licles are  situated  so  far  forward  as  to  be  visible  to 
the  naked  eye. 

Prostatitis  is  found  in  practically  every  case  of 
chronic  urethritis,  possibly  because  nearly  every 
prostate  examined  is  more  or  less  congested,  and  it 
is  not  an  easy  matter  to  draw  a  sharp  line  between 
the  normal  congestion  and  the  pathological  inflam- 
mation. A  prostate  that  is  larger  than  the  average 
normal  organ,  tender  on  pressure,  and  exuding  ab- 
normal material  after  massage,  must  be  considered 
pathological.  Considerable  enlightenment  as  to  the 
diagnosis  is  afforded  by  a  study  of  the  urine  voided 
after  a  fairly  vigorous  massage  of  the  prostate.  It 
is  well  to  have  the  patient  retain  his  urine  as  long 
as  possible,  from  six  to  ten  hours  preferably.  He 
then  voids  half  an  ounce  in  one  glass.  This  urine 
may  be  absolutely  clear,  or  it  may  contain  a  small 
number  of  fine  shreds.  The  prostate  is  massaged 
while  the  patient  holds  a  clean  glass  slide  under  the 
urinary  meatus.  The  massage  is  continued  until 
some  of  the  secretion  has  fallen  upon  the  slide.  The 
patient  then  voids  all  his  urine,  and  this  urine  is 
studied  carefully.    If  it  is  still  clear  or  but  slightly 


hazy,  the  prostate  may  be  considered  normal ;  in  a 
typical  case  of  chronic  prostatitis  this  urine  voided 
after  massage  will  be  found  purulent  to  a  greater 
or  less  degree  and  may  present  large  masses  of 
broken  down  detritus  which  are  nothing  else  than 
purulent  casts  of  the  prostatic  follicles.  The  im- 
portant thing  to  remember  is  that  clear  urine  voided 
by  the  patient  does  not  necessarily  mean  a  normal 
genital  tract.  Prostatic  inflammation  first  must  be 
eliminated,  and  this  can  be  done  only  by  massage 
and  study  of  the  massaged  secretion.  It  need  not 
be  emphasized  that  the  massaged  secretion  should 
be  examined  microscopically  at  frequent  intervals, 
with  particular  reference  to  the  presence  of  gono- 
cocci  and  pyogenic  bacteria.  The  disappearance  of 
gonococci  and  the  decrease  and  ultimate  total  ab- 
sence of  other  organisms  from  this  secretion  is  the 
most  convincing  evidence  possible  of  the  restoration 
of  the  prostate  to  the  normal. 

What  has  just  been  said  in  connection  with  pros- 
tatitis applies  in  all  respects  to  the  subject  of  chronic 
vesicuHtis,  In  point  of  fact,  these  organs  are  so 
closely  interwoven,  both  anatomically  and  pathologi- 
cally, that  it  is  well  to  consider  them  practically 
one.  Some  writers  maintain  that  they  can  obtain 
the  vesicular  secretion  without  contamination  with 
the  secretion  from  the  prostate ;  but  the  common 
experience  of  most  clinicians  is  that  such  claims 
cannot  be  substantiated  except  in  rare  cases.  The 
anatomical  conformation  and  position  of  the  vesicles 
is  such  that  it  is  practically  impossible  for  the  in- 
dex finger  in  the  rectum  to  strip  them  of  their  re- 
tained secretion,  as  can  be  done  with  the  prostate. 
There  are  exceptional  cases,  of  course,  in  which 
they  hang  low  and  are  very  large,  and  thus  can  be 
manipulated,  but  these  exceptions  are  rare  indeed. 
However,  if  perchance  the  vesicular  secretion  can 
be  obtained  uncontaminated  with  that  from  the  pros- 
tate, it  is  highly  desirable  to  take  advantage  of  the 
fortunate  circumstance  and  the  secretion  thus  ob- 
tained should  be  studied  both  macroscopically  and 
microscopically. 

A  clear  understandmg  of  the  points  made  in  this 
discussion  of  the  differential  diagnosis  of  urethritis 
will  often  produce  results  that  will  be  most  aston- 
ishing and  surprising  to  both  the  physician  and  his 
grateful  patient. 

SUMMARY. 

1.  A  correct  diagnosis  in  urethritis  means  half  a 
cure. 

2.  In  acute  urethritis  the  etiological  factors  must 
be  determined  to  a  certainty  before  treatment  can 
be  begun.  The  principal  factors  to  remember  are 
the.  gonococcus,  Micrococcus  catarrhalis,  and  the 
Bacillus  coli.  Next  in  importance,  the  extent  of  the 
inflammation  must  be  determined.  Extension  to 
deeper  structures  must  be  recognized  immediately. 

3.  In  chronic  inflammation,  stricture,  folliculitis, 
prostatitis,  vesiculitis,  and  collicuHtis  are  predomi- 
nating causative  factors.  The  diagnosis  must  be 
arrived  at  through  precise  scientific  measures,  not 
through  guesswork, 

REFERENCES. 

1.  LuYS :  Traite  de  la  bletuiorragie,  1912,  p.  59. 

2.  Wolbarst:  hiternational  Clinics,  vol.  i,  Twenty-second 
Series,  p.  1 ;  New  York  Medical  Journal,  May  13,  1916. 

792  Lexington  Avenue. 


October  9,  1920.]  TUCKER:   GEN ITOU RI X ARY  ORGANS  OF  LOWER  ANIMALS. 


525 


COMPARATIVE      AXATOIMY      OF  THE 
GENITOURINARY   ORGANS    OF  THE 
LOWER  ANIMALS* 
By  Henry  Tucker,  M.  D., 

Philadelphia, 

Curator,  The  Academy  of  Natural  Sciences  of  Philadelphia,  Fellow 
of    the   College   of    Physicians,    Member  Philadelphia 
Genitourinary  Society,  etc. 

The  character  of  this  paper  makes  it  necessary 
.for  me  to  review,  in  a  superficial  way,  the  em- 
bryology of  the  organs  of  generation,  as-  in  many 
of  the  lower  vertebrates  the  adult  condition  is  a 
counterpart  of  that  found  in  some  period  of  de- 
velopment of  the  human  embryo.  All  of  the  genito- 
urinary organs  are  intimately  associated  in  their 
development.  The  essential  kidney  consists  of  a 
tube  open  at  the  distal  end  from  which  are  given 
off  diverticulae  terminating  in  blind  sacs.  Such  a 
kidney  is  present  in  adult  life  in  some  of  the  lowest 
types  of  fishes  and  as  a  transitory  condition  in  the 
human  fetus. 

In  the  human  embryo  the  common  duct  running 
from  end  to  end  of  the  body  on  either  side  of  the 
notochord  is  known  as  the  Wolffian  body.  It  is  de- 
veloped from  the  skin  sensory  layer  and  acts  as 
the  primitive  kidney,  to  terminate  in  the  cloaca. 
With  the  further  development  of  the  Wolffian  body 
there  is  formed  at  the  same  time  the  socalled  indif- 
ferent body  to  become  the  future  ovary  or  testicle. 
Such  a  condition  is  of  short  duration,  there  being 
developed  out  of  the  posterior  part  of  the  Wolffian 
duct  near  its  entrance  into  the  cloaca  a  secondary- 
duct,  the  primitive  ureter;  this  gradu^ly  elongates 
giving  off  diverticulae,  as  noted,  which  become  the 
renal  tubules  and  are  disposed  in  reference  to  the 
blood  vessels  exactly  as  were  the  diverticulse  of  the 
Wolffian  body. 

The  urine  excreted  passes  into  the  posterior  part 
of  the  stalk  of  the  allantois,  which,  dilating,  is  re- 
tained in  the  body  as  the  primitive  bladder,  later 
to  separate  from  the  cloaca  and  that  part  of  the  all- 
antois that  comes  away  with  the  umbilical  cord.  Thus 
are  the  permanent  kidneys  developed  and  replace 
the  primitive,  formed  out  of  the  Wolftian  body,  the 
duct  of  which  does  not  disappear  but  separates  into 
two  distinct  tubes  the  outer  one  still  known  as  the 
Wolffian  the  inner  as  the  duct  of  ^liiller.  For  a 
while  the  Wolffian  duct  still  carries  urine  secreted 
by  its  tubules,  but  as  the  function  is  taken  up  by 
the  ureter  and  the  true  kidney  it  is  gradually  trans- 
formed. If  the  individual  is  to  become  a  male  the 
body  changes  into  an  epididymis  and  vas  deferens 
and  carries  the  spermatozoa  formed  in  the  former 
indifferent  body  which  is  now  a  testicle ;  the  duct 
of  Miiller  persisting  as  the  sinus  pocularis,  the 
homologue  of  the  vagina.  If  the  individual  is  to 
become  a  female  the  indifferent  body  produces  eggs 
and  becomes  an  ovary,  the  ^liillerian  ducts  fuse  to- 
gether from  below  upward  and  become  the  vagina, 
uterus  and  Fallopian  tubes — the  Wolffian  ducts 
atrophy  but  persist  as  the  parovarian,  which  in 
certain  animals,  such  as  the  pig,  is  patulous  and 
opens  into  the  vagina. 

Early  in  intrauterine  life  the  conjoined  Wolffian 

*Read  before  the  Philadelphia  Genitourinary  Society,  May  24,  1920. 


and  ^liillerian  ducts  pass  into  the  expanded  stalk 
of  the  allantois.  the  latter  emptying  with  the  ali- 
mentary canal  into  the  cloaca.  As  the  fetus  de- 
velops the  rectum  separates  and  if  the  fetus  is  a 
female  the  united  ^Miillerian  ducts  have  a  distinct 
opening  lying  between  the  urethra  and  the  rectum. 
The  urethra,  if  the  fetus  is  a  female,  passes  be- 
neath the  clitoris  or  female  penis — the  two  adjacent 
folds  of  skin  become  the  labia  minora,  the  external 
the  labia  majora.  the  ovaries  remaining  in  the  body 
cavity.  If  the  fetus  is  to  be  a  male  the  urethra 
passes  through  the  penis,  the  underskin  of  which 
is  formed  by  the  coalescence  in  the  midline  of  what 
in  the  female  is  the  labia  minora,  the  scrotum  being 
formed  by  the  fusion  at  the  ra'phse  of  the  labia  -ma- 
jora, the  testicles  descending  through  the  inguinal 
canal  to  the  scrotum  pushing  in  front  of  them  their 
peritoneal  investment  to  form  the  tunica  vaginalis 
testis. 

Bearing  these  points  in  mind  hermaphroditism  is 
possible  by  a  diverse  development  of  the*  sexual 
units,  i.  e.,  the  indifferent  body,  the  Wolffian  and 
^Miillerian  ducts,  but  is  hardly  possible  in  the  higher 
animals,  though  it  does  obtain  in  some  lower  forms, 
as  the  mollusca,  worms,  and  in  many  plants,  the 
stamens  and  pistil  of  the  flowers  forming  the  male 
and  female  organs  respectively.  In  all  vertebrates 
the  sexes  are  distinct  and  the  individual  is  developed 
from  an  impregnated  ovum  of  a  similar  specie. 

Starting  with  the  lowest  type,  the  fishes,  the  pri- 
mordial kidney  (Wolffian  body)  is  persistent  and 
excretes  the  urine  from  the  venous  blood.  I  shall 
not  dwell  in  detail  on  other  anatomical  peculiarities 
that  separate  the  four  great  divisions  of  vertebrates 
— fish,  reptiles,  birds  and  mammals.  Fish  exist  and 
breathe  in  water.  Some  retain  the  primitive  vermJ- 
f orm  shape  and  develop  no  limbs ;  in  others  the  fins 
are  simple,  mov  oen  one  joint  and  are  only  adapted 
for  propulsion  or  guidance.  The  body  surface  is 
either  smooth  or  covered  by  scales.  The  brain  is 
small,  consisting  merely  of  a  succession  of  gan- 
glionic nerve  masses  connected  with  the  organs 
of  special  sense.  Touch  is  feebly  developed.  The 
tongue  as  an  organ  of  taste  is  hardly  apparent  and 
functions  chiefly  in  the  act  of  swallowing  or  breath- 
ing. There  is  no  external  ear.  The  internal  ear 
or  labyrinth  is  present  with  largely  developed  semi- 
circular- canals,  the  cochlea  rarely  has  a  separate 
chamber  but  is  lodged  in  the  cranial  cavity  with  the 
brain.  The  eyes  are  large,  not  protected  by  eye- 
lids and  have  no  lacrymal  apparatus.  The  alimen- 
try  tract  is  short  and  simple.  The  esophagus  is 
hardly  to  be  distinguished  from  the  stomach.  The 
heart  consists  of  one  auricle  receiving  the  venous 
blood,  and  one  ventricle,  to  propel  the  blood  to  the 
gills  for  aeration,  by  the  minute  bubbles  of  air  sus- 
pended in  the  water,  taken  into  the  fishes'  mouth ; 
from  the  gills  the  blood  is  circulated  through  the 
entire  body  being  largely  aided  by  local  muscular 
contraction.  The  blood  rarely  has  a  temperature 
above  the  surrounding  water. 

Many  fish  have  a  hydrostatic  air  bladder  between 
the  alimentary  canal  and  the  kidneys  which  may 
communicate  by  a  duct  with  the  gullet.  In  reptiles 
as  this  structure  becomes  more  highly  specialized 
with  increased  vascularity  and  pharyngeal  relations. 


526 


TUCKER:   GENITOURINARY   ORGANS  OF  LOWER  ANIMALS. 


[New  York 
Medical  Journal. 


the  form  changes  to  the  cellular  structure  of  a  lung. 
The  limbs  acquire  the  character  of  feet,  first  two 
mere  many  jointed  filaments  as  in  Lepidosiren,  then 
two  fingers  with  elbow  and  wrist  joints,  as  in  land 
animals  (amphiuma),  next  three  fingered  as  in  pro- 
teus,  or  four  fingered  but  reduced  to  a  pectoral  pair 
as  in  Lepidosiren.  From  these  gill  retaining  forms 
up  to  and  including  the  crocodilia  all  cold  blooded 
vertebrates  with  lungs  are  called  reptiles.  The  heart 
has  two  auricles,  the  ventricle  is  imperfectly  divided, 
so  the  venous  and  arterial  blood  are  more  or  less 
mixed.  The  lungs  are  baglike,  either  single  or  in  a 
pair  of  unequal  size,  with  cellulovascular  walls  and 
are  contained  in  a  common  thoracicoabdominal 
cavity. 

In  the  bird  there  are  certain  modifications. 
The  air  bag  becomes  obliterated  by  the  multiplica- 
tion of  the  air  cells,  so  forming  a  spongy  lung.  A 
four  chambered  heart  prevents  mixture  of  the  ar- 
terial and  venous  blood,  so  furnishing  pure  arterial 
blood  to  the  body ;  the  temperature  is  maintained  at 
from  90°  to  105°  F.,  irrespective  of  the  surround- 
ing conditions.  The  lungs  are  fixed  and  communi- 
cate by  air  cells  extending  into  the  abdomen  or  other 
parts  of  the  body.  They  are  oviparous,  have 
feathers,  and  the  fore  limbs  are  modified  as  wings. 

In  mammals  the  lungs  are  suspended  in  the  thor-- 
acic  cavity,  separated  from  the  abdomen  by  the  dia- 
phragm. They  are  hairy,  give  birth  to  living  young 
with  exception  of  the  monotremes.  All  suckle  their 
young.  Although  for  convenience  we  can  divide 
all  vertebrates  into  hot  and  cold  blooded,  based  on 
the  character  of  the  cardiac  and  respiratory  sys- 
tem, this  but  tends  to  mask  their  many  affinities.  For 
example,  the  hot  blooded  birds  with  their  complex 
lungs  and  heart  by  their  genetic  and  developmental 
characters  and  their  anatomical  structure  are  more 
closely  allied  to  the  Saurians  than  to  the  \Varm 
blooded  mammals,  while  the  modem  Batrachians 
(frogs,  etc.)  differ  from  other  cold  blooded  air 
breathers  by  their  developmental  and  genetic  char- 
acters and  closely  agree  with  the  fishes.  The  ex- 
tinct Pterosauria,  a  flying  reptile,  with  wings  and  air 
sac,  links  the  birds  with  this  class  of  reptiles.  Other 
extinct  orders,  as  Ganocephala  and  Labyrinthodon- 
tia  show  the  artificial  nature  of  distinctions  between 
fish  and  reptiles  and  the  close  transitions  that  con- 
nect all  cold  blooded  vertebrates. 

Vertebrates  might  be  divided  into  oviparous,  in- 
cluding fish,  reptiles  and  birds,  and  viviparous,  con- 
taining mammals  ;  second,  into  anallantoic  or  branch- 
iates  or  allantoic  or  abranchiate ;  into  Haeniato- 
thermal,  having  spongy  lungs  and  a  four  chambered 
heart  and  hot  blood  and  Hsematocryal,  having  a 
simple  heart,  less  perfect  lungs  and  cold  blood.  The 
first  two  classifications  will  not  hold,  as  some  reptiles 
and  fish  are  viviparous,  and  the  lower  types  of 
mammals  as  the  platypus  and  echidna  lay  eggs.  In 
the  group  of  Marsupialia  the  young  are  not  nour- 
ished by  placental  attachment  but  early  placed  in  a 
maternal  marsupium  or  pouch  and  nourished  by^milk 
forced  into  their  mouths  by  contraction  of  a  mus- 
cle surrounding  the  efferent  milk  ducts.  The  third 
classification  will  not  hold,  for  certainly  warm  blood- 
ed birds  are  more  closely  allied  to  reptiles  than  they 
are  to  placental  warm  blooded  mammals.    So  all 


divisions  are  artificial  and  not  founded  on  fact 
either  in  their  present  form  or  the  forms  of  their 
fossil  ancestors. 

Taking  these  orders  up  in  sequence  I  shall  try  to 
explain  some  of  the  peculiarities  of  the  renal  organs 
and  the  organs'  of  generation.  In  all  vertebrates 
there  is  developed  at  an  early  period  an  excretory 
organ  consisting  of  a  tube  extending  from  each  side 
of  the  cloaca  forward  along  the  dorsal  region  close- 
to  the  spine,  where  numerous  small  blind  tubes  en- 
ter at  a  right  angle.  The  long  tube  is  the  excretory 
duct ;  the  blind  tube  entering  into  the  dis- 
tal end  of  the  duct  is  the  Wolffian  body  or  rudi- 
mentary kidney.  This  condition  persists  in  the  fishes 
and  acts  as  a  true  kidney  by  excreting  urine.  In  the 
bony  fishes  the  kidneys  are  long  and  extend  through 
the  whole  of  the  greater  part  of  the  dorsal  region 
of  the  abdomen.  The  ureters  may  open  directly  by  a 
short  canal  into  the  cloaca  as  in  the  lampreys  or 
into  a  urinary  bladder  in  the  higher  types,  either 
as  a  conjoined  tube  or  two  distinct  canals.  In  the 
sturgeon  the  ureters  receive  the  vas  deferentia  or 
oviducts  in  their  course  toward  the  cloaca,  where 
they  unite  as  a  short  duct  to  form  the  common  outlet 
for  the  urine  as  well  as  the  generative  products.  In 
the  sharks  this  single  canal  terminates  in  a  common 
penis  or  clitoris  at  the  back  of  the  anus  within  the 
cloaca. 

In  reptiles  the  kidneys  are  always  distinct,  two 
in  number  and  more  compact  in  form,  otherwise  re- 
sembling the  fishes.  In  the  higher  types  the  mal- 
pighian  bodies  are  demonstrable.  In  snakes  the  kid- 
neys take  the  elongated  form  of  the  reptile  and  are 
flattened,  divided  into  numerous  overlapping  lobes 
to  accommodate  themselves  to  the  flexuosities  of 
the  body  in  which  they  are  located.  In  most 
species  they  are  unsymmetrically  situated.  The  kid- 
neys in  the  Lacertilia  are  shorter  and  broader  than 
in  serpents — this  condition  is  even  more  marked  in 
the  chelonia  or  turtles.  In  the  crocodiles  the  ureters 
terminate  in  a  low  papilla  in  the  urogenital  com- 
partment of  the  cloaca  behind  the  genital  orifices. 
The  forepart  of  the  cloaca  is  dilated  and  the  rectum 
opens  therein  by  a  valvular  protrusion.  The  adren- 
als may  or  may  not  be  present  in  different  species 
of  reptiles.  The  kidneys  in  Batrachians  resemble  the 
higher  types  of  fishes. 

The  organs  .of  generation  in  fishes  present  a  pro- 
gressive gradation  from  an  essential  gland,  whether 
ovary  or  testicle  being  determined  only  by  a 
microscopic  examination  of  its  contents,  to  a 
concentrated  form  of  testicle,  through  to  the  de- 
velopment of  a  true  vas,  a  seminal  vesicle,  and  an  in- 
tromittent  organ  with  finally  added  claspers  for 
holding  the  female  during  coitus.  The  female  organs 
correspond  closely  to  the  male  in  their  gradation.  In 
all  fish  where  the  vas  is  absent  in  the  male  the 
oviducts  are  absent  in  the  female.  The  male  organs 
in  Batrachians  are  the  testes  with  their  ducts  and  ap- 
pendages, the  seminal  reservoir,  a  common  excretory 
canal,  and  a  terminal  papillae,  but  no  true  penis. 

In  the  lizards  and  snakes  the  ducts  from  the 
kidneys  and  testes  are  distinct  to  the  cloaca  and 
terminate  on  separate  papillas,  the  testicles 
small  and  compact,  abdominally  placed  and  covered 
fully  by  peritoneum,   frequently  brightly  colored. 


October  9,  1920.] 


TUCKER:   GENITOURIXARV   ORGAXS  OF  LOWER  ANIMALS. 


h23 


They  are  much  more  complex  and  convoluted  than 
in  the  Batrachian.  The  tunica  albuginea  is  dense 
and  firmly  attached  to  the  secreting  portion  of  the 
gland.  As  is  to  be  expected  the  testicles  of  the 
snakes  are  more  elongated  than  in  the  lizards.  The 
vas  deferens  goes  along  the  kidney  in  short  undula- 
tions to  the  cloaca  terminating  in  papillae  near  the 
beginning  of  the  seminal  groove.  The  penis  con- 
sists of  two  invertible  sheaths  with  a  highly  vascular 
lining  membrane,  bifurcating  at  the  blind  end,  to 
which  are  attached  the  muscles  of  inversion  and 
retraction  for  keeping  them  hidden  in  the  base  of 
the  tail.  The  mechanism  of  eversion  and  erection 
is  by  tumefaction  of  the  vascular  lining,  plus  con- 
traction of  the  constrictor  basis  caudae  and  sphinc- 
ter cloacae.  The  surface  of  the  everted  and  erect 
organ  in  many  species  is  covered  with  either  large 
papillae  or  even  in  some  retroverted  scales  like 
horny  processes.  As  corresponding  depressions  are 
found  in  the  bifurcated  vagina  of  the  female,  it  is 
evidently  a  provision  of  nature  to  prevent  slipping 
during  intercourse. 

Lizards,  due  to  their  short  and  outwardly  ex- 
tended legs,  and  snakes,  in  whom  external  legs  are 
totally  absent,  are  obliged  to  use  absolute  ver- 
tical progression,  so  it  is  necessary  that  for  the 
testes  to  be  abdominally  placed  and  the  intromittent 
organs  capable  of  retraction  and  lodgement  in  the 
base  of  the  tail,  to  prevent  injury  when  not  in  use. 
In  turtles  the  testicle  is  elongated,  the  vas  is  large 
and  compacted  b}-  many  convolutions.  Each  vas 
terminates  with  the  ureter  in  common  papillae,  the 
spermatic  orifice  being  near  the  bladder.  The  penis 
is  short  and  is  indicated  when  not  erect  by  the  sem- 
inal groove.  Only  the  glans  and  the  pointed  end  of 
the  fibrocartilaginous  part  above  it  project  from  the 
surface  of  the  cloaca.  This  is  enclosed  in  a  redu- 
plication of  the  cloacal  membrane  which  acts  as  a 
pseudoprepuce.  On  erection  this  fold  is  obliterated 
by  eversion.  The  penis  in  fresh  water  and  land 
turtles  is  longer  and  larger  than  in  marine  species, 
on  account,  probably,  of  the  more  domeshaped  car- 
apace. The  urethral  groove  extends  along  the  mid- 
dorsum  becoming  more  deeply  situated  as  it  ap- 
proaches the  glans.  On  erection  the  swelling  of  its 
borders  converts  the  groove  into  a  temporarv-  canal ; 
it  then  appears  to  end  in  an  orifice.  The  penis  is 
composed  of  two  corpora  cavernosa  cohering  in  the 
middle  line  and  attached  to  the  ventral  surface  of 
the  cloaca  and  two  median  tracts  of  highly  vascular 
erectile  tissue,  forming  the  walls  of  the  median 
groove.  This  is  lined  with  a  mucouslike  mem- 
brane. They  arise  by  an  enlargement  analogous  to 
the  bulb  and  are  continued  forward  to  the  glans. 
On  each  side  of  the  penis  is  a  canal,  the  proximal 
end  communicating  with  the  peritoneal  cavity,  the 
distal  end  ending  chiefly  in  a  reticulate  sinus.  The 
penis  has  two  retractors  arising  from  the  ischium 
and  extending  along  the  ventral  surface  to  the  glans. 
This  muscle  folds  up  the  penis  on  retraction  at  the 
same  time  closing  the  rectal  orifice  and  that  of  the 
allantoic  bladder.  Erection  is  followed  by  eversion 
of  the  cloaca  effected  by  the  cloacal  sphincter.  In 
the  Crocodilia  the  testicles  are  longer,  the  penis  is 
single  with  a  dorsal  groove  and  resembles  the  fore- 
e:oing  genera  with  the  exception  that  the  peritoneal 


canals  do  not  penetrate  the  cavernous  structure  but 
open  outwardly  on  papillae  situated  on  each  side  of 
the  base  within  the  cloaca. 

From  the  foregoing  it  can  be  seen  that  lizards 
are  allied  to  snakes  by  their  double  extra  cloacal 
penis  ;  tortoises  are  allied  to  crocodiles  by  their  single 
intracloacal  organ.  The  structure  of  the  organ  con- 
firms the  two  types.  In  the  females  of  the  Ba- 
trachia  the  cloaca  presents  the  following  outlets,  in 
front,  the  opening  of  allantois  bladder,  next  the  rec- 
tum, then  the  outlets  of  the  oviducts,  and  finally  the 
ureters.  In  scaled  reptiles  there  is  a  rudimentary 
clitoris  or  some  trace  of  the  intromittent  organ  of 
the  other  sex.  In  snakes  the  termination  of  the 
oviducts  are  in  semilunar  fissures  within  the  cloaca. 

The  accessory  parts  of  some  of  the  female  rep- 
tiles are  remarkable.  As  the  temporary  skin 
pouches  on  the  back  of  some  of  the  frogs — i.  e., 
pipa,  in  Xotatrema  and  Opisthodelphys  there  is  a 
single  large  sac  with  its  entrance  above  the  vent. 
When  functionally  active  it  covers  the  entire  back; 
when  not  it  shrinks  so  as  to  be  hardly  visible.  In 
the  pipe  fish  and  sea  horse  the  male  develops  a 
marsupium  or  pouch  in  which  the  eggs  are  placed, 
hatched,  and  the  young  carried  until  they  are  able 
to  shift  for  themselves. 

ACQUIRED  SEXUAL  CHARACTERS. 

I  shall  mention  only  a  few  of  the  acquired  sexual 
characters.  The  newts  acquire  a  dorsal  crest  and 
a  broader  tail  fin,  with  swelling  of  the  cloacal  labia 
in  both  sexes.  The  Japanese  salamander  develops 
a  claw  on  each  digit  of  the  forelimbs,  the  male  frog 
acquires  a  dark  swelling  of  the  thumb  so  as  to 
better  hold  his  slippery  mate.  A  number  of  the  fish 
have  claspers  near  the  anal  orifice  for  the  same  rea- 
son. The  larynx  of  the  toads  and  frogs  hypertro- 
phy in  the  spring,  all  reptiles  develop  a  brighter 
color,  as  do  the  birds  in  their  nuptial  plumage.  The 
buttocks  and  genitalia  of  some  of  the  doglike  apes, 
especially  the  mandrill,  are  wonderfully  and  gor- 
geously colored.  In  lizards  and  snakes  the  anal 
scent  glands  and  in  the  crocodiles  the  submaxillary 
glands  are  active  and  give  out  a  strong  musky  odor. 
In  the  mammalian,  hoofed  animals,  especially,  the 
scent  glands  increase  in  size  and  activitv  during  the 
rut. 

In  birds,  the  few  peculiarities  met  with  occur  in 
the  male  sex.  The  organs  exhibit  the  essential  char- 
acters of  the  oviparous  type.  The  testicles  are  situ- 
ated high  in  the  abdominal  cavity  and  never  descend 
into  a  scrotum.  The  penis  is  either  double  as  in  ser- 
pents, when  it  is  extremely  small,  or  it  is  single,  but 
no  matter  to  what  extent  it  may  be  developed  it  is 
simply  grooved  along  the  dorsal  surface  for  the  pas- 
sage of  semen.  As  there  is  no  true  urethra,  Cow- 
per's  glands  and  the  prostate  are  absent.  The  testicles 
are  two  in  number  and  vary  greatly  in  size  and  color 
in  different  birds.  They  are  white  in  the  falcon 
and  the  dove,  pale  yellow  in  the  homed  owl  and 
the  gallinule,  bright  yellow  in  the  magpie,  ruff  ibis 
and  oyster  catcher,  black  in  the  partridge,  heron 
and  some  seagulls.  They  have  a  strong  tunic  and 
are  suspended  in  a  peritoneal  fold.  There  is  a 
marked  periodical  variation  in  size,  due  to  the  short 
period  of  sexual  activity,  but  this  limited  period  is 
compensated  by  the  frequency  and  energy  of  the 


528 


TUCKER:  GENITOURINARY  ORGANS  OF  LOWER  ANIMALS. 


[New  York 
Medical  Journal. 


sexual  act.  For  example,  in  the  sparrow  in  Janu- 
ary they  are  the  size  of  a  pinhead,  while  in  April 
at  the  height  of  the  breeding  season  the  glands  are 
the  size  of  a  large  marrowfat  pea ;  the  left  is  usu- 
ally larger  than  the  right.  The  only  suggestion  of 
an  epididymis  is  the  remnant  of  Wolffian  body. 
This  part  is  frequently  a  different  color  from  the 
testicle  proper.  The  vas  passes  down  to  the  cloaca 
beside  the  ureter ;  it  may  be  dilated  at  its  lower  end 
into  a  false  seminal  vesicle.  It  ends  in  birds  with 
a  double  penis  in  small  papillae  in  the  urogenital 
division  of  the  ureter.  The  base  of  each  papilla  is 
surrounded  by  a  plexus  of  veins  and  arteries  which 
serve  as  an  erectile  organ  during  the  orgasm,  when 
the  fossa  is  everted  and  brought  in  contact  with'  the 
likewise  congested  everted  fossa  of  the  female.  In 
many  of  the  birds  that  copulate  in  water  a  long 
single  penis  is  developed  to  permit  of  a  more  effi- 
cient coitus.  I  shall  take  the  drake  as  my  example. 
The  penis  is  a  highly  vascular  part  of  the  lining 
membrane  of  the  cloaca  continued  from  the  front 
part  of  that  cavity ;  in  the  passive  state  it  is  coiled 
up  like  a  screw  by  the  elasticity  of  its  associated 
ligament.  The  vascular  membrane  gives  off  many 
small  pointed  processes  arranged  in  transverse  rows 
on  either  side  of  the  urethral  groove;  these  incline, 
backward  near  the  point  of  the  penis.  The  elastic 
ligament  is  surrounded  by  cavernous  tissue  and  ter- 
minates in  the  blind  end  of  the  evertible  sac.  A 
groove  commencing  widely  at  the  base  follows  the 
spiral  turns  of  the  sac  to  its  termination.  The 
spermatic  ducts  open  upon  papillae  at  the  base  of 
the  groove.  Therefore,  this  form  of  penis  has  a 
muscle  by  which  it  can  be  everted,  protruded  and 
erected. 

In  the  ostrich  the  penis  is  attached  to  the  front 
wall  of  the  cloaca,  the  body  is  bent  in  a  recess  out  of 
which  it  can  be  drawn  and  returned  by  muscles.  It 
consists  of  two  firm  fibrous  bodies,  the  fissure  be- 
tween which  is  covered  by  the  cavernous  erectile 
tissue  bounding  the  seminal  groove.  It  has  no 
evertible  sac  formation.  There  is  a  third  elastic 
cord  internal  to  the  cavernous  substance  which 
produces  the  twisted  form.  The  organs  of  most 
birds  resemble  the  fishes  and  frogs,  while  those  of 
ducks  are  like  the  hemipenis  of  serpents  and  lizards, 
and  the  ostrich  that  of  the  tortoise  and  crocodile.  In 
the  female  bird  in  early  life  both  ovaries  are  the 
same  size,  but  only  the  left  develops,  the  right  re- 
maining stationary  or  finally  completely  disappear- 
ing. In  the  embryo  the  basis  of  the  ovary  appears 
in  the  same  relation  to  the  primitive  kidney  as  the 
testis  in  the  male.  The  clitoris  of  the  ostrich  arises 
from  the  anterior  margin  of  preputial  cavity  of 
the  cloaca  and  is  grooved  like  the  penis  of  the  male 
and  has  similar  muscles.  A  smaller  clitoris  exists 
in  those  birds  in  which  the  male  has  a  well  devel- 
oped penis.  Most  birds  in  adult  age  show  external 
sexual  characters.  In  the  eagles  and  hawks  the 
female  is  larger  than  the  male.  In  the  gallinacae  and 
similar  polygamous  birds  she  is  smaller.  In  most 
birds  the  males  have  the  more  brilliant  plumage, 
while  the  hen  has  a  more  or  less  protective  coloring. 
An  exception  is  the  phalarope,  but  in  this  instance 
the  male  does  the  incubating,  the  female  on  the 
completion  of  ovideposition  deserting  the  nest.  The 


comb  and  wattles  of  the  cock  demonstrate  sexual 
cutaneous  appendages.  In  swifts,  swallows,  crows, 
doves,  and  a  majority  of  the  waders  the  sexes  are 
alike. 

MAMMALS. 

In  mammals  the  external  manifestations  of  sex 
are  extremely  indefinite  in  the  moles,  shrews  and 
rats,  and  often  require  careful  dissection  to  be  de- 
termined. The  male  monotrema  has  the  heel  spur, 
the  female  marsupial  has  the  pouch  and  is  of 
smaller  size.  The  male  narwhal  has  a  tusk;  the 
cachalot  the  large  head.  In  seals  the  canines  are 
usually  larger.    This  holds  good  in  most  carnivora. 

External  genital  characters  are  marked  in  most 
orders  as  well  as  in  many  grass  eaters.  The  male  has 
the  larger  horns,  when  these  characteristics  are 
present.  The  lion  has  the  mane.  The  elephant  has  the 
large  tusks.  In  quadrumana  up  to  and  including  the 
gorilla  the  male  is  larger  and  has  bigger  canines. 
In  the  orang  and  chimpanzee,  as  well  as  in  man,  the 
male  exceeds  the  female  in  size  and  has  a  more 
abundant  hairy  covering. 

The  testicles  in  mammals  are  more  complex  and 
compact,  the  peritoneum  adds  a  serous  layer  to  the 
proper  sclerous  covering  of  the  glands.  In  the  ma- 
jority they  are  extraabdominal  all  or  part  of  the 
time  and  are  contained  in  a  skin  pouch  or  scrotum. 
The  epididymis  varies  in  size  and  position  in  many 
species.  In  all  the  semen  is  conducted  in  coitus  by 
a  penis  traversed  by  a  canal  or  urethra  which  may 
bifurcate  in  the  lowest  orders.  Additional  secre- 
tions are  added  by  the  vesicular,  prostatic  and  Cow- 
perian  glands,  when  these  exist. 

In  monotremata  each  testicle  is  situated  below 
the  kidney,  to  which  it  is  suspended  by  a  fold  of 
peritoneum.  The  vas  arises  from  the  upper  pole 
of  the  testicle  and  is  so  transversely  folded  as  to 
appear  to  prolong  the  epididymis  to  the  neck  of  the 
bladder.  The  duct  dilates  at  its  distal  end  and  ter- 
minates in  a  papilla  in  the  beginning  of  the  urogeni- 
tal canal.  Its  proximal  urethral  opening  is  not  in 
contact  with  the  vas  in  the  quiescent  state.  It  is 
divided  by  a  median  septum  into  two  lateral  parts 
enclosed  in  a  dense  fibrous  sheath.  The  whole  penis, 
when  collapsed  and  retracted,  is  concealed  in  a  large 
preputial  fold.  The  terminal  half  forms  the  glans, 
which  in  the  ornithorhynchus  has  a  quadrilateral 
form,  the  upper  and  lower  surface  of  which  is  tra- 
versed by  a  marked  groove.  The  exterior  surface  is 
covered  with  numerous  hard  epidermal  spines.  Its 
extremity  is  bifurcated,  each  lobe  terminating  in 
three  or  four  large  but  softer  spines.  A  levator 
muscle  runs  along  the  upper  surface  of  the  penis. 
This  muscle  arises  by  two  lateral  slips  from  the  pro- 
trusive sphincter.  The  retractor  penis  arises  from 
the  base  of  the  coccyx  and  is  inserted  into  the  origin 
of  the  penis  near  the  beginning  of  the  urogenital 
canal.  The  urethra  begins  by  a  small  orifice  at  its 
root  communicating  with  the  termination  of  the 
urogenital  passage.  So  with  the  action  of  the  re- 
tractor penis  and  the  sphincter  cloaca  it  can  be 
brought  in  contact  with  the  terminal  papillae  of  the 
sperm  ducts.  Such  temporary  continuation  of  the 
urethra  and  seminal  passages  takes  place  only  dur- 
ing the  vigorous  muscular  and  vascular  engorge- 
ment of  the  parts  during  coitus,  the  semen  being 


October  9,  1920.] 


TUCKER:  GENITOURIXARY   ORGAXS  OF  LOWER  ANIMALS. 


529 


isj^  expelled  from  one  to  the  other  without  escaping 
into  the  cloaca.  Under  ordinary  circumstances  the 
urine  is  transmitted  along  the  urogenital  passages, 
escaping  into  the  cloacal  vestibule,  there  blending 
with  the  feces,  as  in  birds.  The  seminal  urethra 
continues  single  to  the  middle  of  the  glans  where  it 
divides  into  two  canals.  Each  branch  runs  along 
the  middle  of  the  bifurcation  of  the  glans  to  the 
base  of  the  terminal  papillae,  where  it  subdivides 
into  smaller  channels  opening  on  their  apices.  If 
you  would  slit  the  canal  along  its  under  surface, 
thus  converting  it  into  a  groove,  the  male  organ 
would  be  like  that  of  the  tortoise ;  and  although  the 
mammalian  type  of  penis  is  manifest  by  a  complete 
urethra,  it  resembles  the  lizards  by  the  bifurcation 
of  the  glans.  That  the  penis  is  essentially  a  sexual 
and  not  a  renal  organ  is  demonstrated  by  this  com- 
plete separation  of  the  urourethral  from  the  semi- 
nourethral  passage  in  the  monotremata.  Cowper's 
glands  are  of  large  size  and  their  psysiological  re- 
lation to  a  true  urethra  is  demonstrated  by  their 
presence  in  these  egg  laying  mammals,  while  they 
are  absent  in  egg  layers  with  merely  a  seminal 
groove.  The  prostate  and  vesicular  glands  are  ab- 
sent. The  function  of  the  spur  is  unknown,  but  it 
may  be  used  as  a  clasper  during  the  sexual  act. 

In  the  marsupials  the  testicles  are  contained  in  a 
pedunculated  scrotum  in  advance  of  the  preputial 
orifice,  the  epididymis  is  large  and  loosely  attached 
to  the  testicle.  The  vas  passes  along  the  muscle 
sheath  formed  by  the  cremaster  as  far  as  the  ab- 
dominal ring,  there  binding  down  and  back  to  termi- 
nate at  the  comrriencement  of  the  urethra.  There 
are  no  vesicular  glands.  As  a  homotype  of  the 
female  vagina  the  prostatic  urethra  is  longer  and 
wider  in  the  marsupials  than  any  other  mammals. 
There  are  three  pairs  of  Cowper's  glands.  The 
penis  consists  of  a  cavernous  and  spongy  portion. 
The  separate  origin  of  each  lateral  half  of  the 
spong>'  body  constitutes  a  double  bulb  with  a  cor- 
responding double  accelerator  urinae  muscle  for 
compressing  its  particular  bulb.  The  two  processes 
soon  unite  to  surround  the  urethra  but  again  divide 
to  form  a  double  glans  in  the  multiparous  marsupi- 
als, in  which  most  of  the  ova  are  impregnated  in 
both  ovaries,  i.  e.,  phalangers,  opossums,  etc.  In 
the  uniparous  marsupials,  as  the  kangaroo,  the 
penis  is  single. 

Between  the  two  extremes  are  the  dasyure,  koala 
and  wombat.  In  the  koala  the  glans  terminates  in 
two  lobes,  the  urethra  being  continued  as  a  bifur- 
cated groove  along  the  mesial  surface ;  in  the  wom- 
bat the  urethra  terminates  in  similar  grooves  but 
the  glans  is  larger  and  partially  divided  into  four 
lobes.  In  the  phalangers  the  glans  is  bifurcated  and 
the  papillae  homy.  In  Perameles  lagotis  each 
bifurcated  division  is  perforated  by  the  urethra, 
while  in  the  phalangers  and  ogossums  a  simpler 
groove  is  present.  The  retractor  penis  arises  in  the 
kangaroos  from  the  middle  of  the  sacrum,  divides 
into  two  muscles  behind  the  rectum  to  be  inserted 
with  its  fellow  at  the  base  of  the  glans.  In  the 
marsupials,  like  the  opossum  which,  having  a  bifid 
glans,  enjoy  a  double  coitus,  there  is  a  levator  penis. 
This  muscle  is  absent  in  the  uniparous  kangaroo. 
Another  powerful  muscle  of  erection  is  the  sphinc- 


ter cloaca  which  surrounds  the  base  of  the  organ 
and  by  contraction  compresses  the  venous  blood 
supply.  In  all  marsupials  the  penis  when  not  in  use 
is  bent  upon  itself,  retracted  and  hidden  just 
within  the  cloacal  orifice,  from  which  it  emerges  as 
in  egg  laying  vertebrates  when  erect. 

In  rodentia,  such  as  squirrels,  beavers,  rats  and 
mice,  the  passive  penis  is  retracted  and  bent,  with 
the  glans  directed  backward  within  a  prepuce  which 
opens  into  and  forms  part  of  a  common  passage  in 
which  the  rectum  terminates.  The  testicles  undergo 
a  periodical  increase  in  size  with  change  of  position, 
passing  from  the  abdomen  into  a  scrotum  and  being 
again  retracted  after  the  rut.  Cowper's  gland,  the 
vesicular  glands  and  prostate  are  present  in  all  ex- 
cepting the  hares.  In  the  porcupine  the  levator  is  in- 
serted into  an  ossicle  in  the  glans.  The  penial  bone  is 
large  in  the  capybara.  In  the  agouti  the  testicles 
during  the  rut  are  perineal  in  position.  In  the  cavia 
(guineapig)  the  os  penis  is  a  large  flat  curved  bone 
situated  above  the  urethra  extending  to  the  tip  of 
the  glans ;  below  the  termination  of  the  urethra  is 
a  wide  eversible  pouch  armed  with  two  large  horny 
styles.  The  surface  of  the  glans  is  covered  with 
homy  scales.  In  marmots  the  preputial  sac  is  more 
distinct  from  the  rectal  orifice  than  in  other  rodents. 

In  insectivorse  (males)  the  descent  of  the  testicles 
is  better  marked  than  in  the  rat  family.  In  bats  the 
prepuce  is  long  and  the  penis  pendulous.  The  glans 
offers  strange  modifications  in  some  species.  The 
OS  penis  is  well  developed  in  the  fruit  eating  bats. 

In  the  armadillo  the  testicles  lie  above  the  rim 
of  the  pelvis  and  do  not  descend  at  the  time  of  the 
rut.  A  similar  condition  prevails,  in  anteaters  and 
sloths.  In  the  armadillos  the  penis  is  proportion- 
ately large,  a  condition  to  be  expected  because  of 
the  mechanical  obstruction  of  the  body  armor.  In 
Bradypodidse  the  testicles  He  between  the  bladder 
and  rectum ;  the  penis  is  mdimentary  without  a  cor- 
pus spongiosum,  as  in  birds.  In  females  the  vagina 
is  divided  by  a  fibrous  septum.  In  Cetacea  (whales, 
dolphins,  porpoises)  the  testicles  are  always  abdom- 
inal, the  vas  is  short  and  convoluted.  The  penis 
commences  by  two  cavernous  crurae  enclosed  in 
strong  erectors  arising  from  the  loosely  suspended 
ossicle  of  the  same  side.  These  crura  coalesce  into 
a  single  cavernous  body.'  The  glans  is  long  and 
tapering.  The  corpus  spongiosum  commences  by  a 
bulbous  expansion  but  degenerates  as  it  penetrates 
the  corpora  cavemosa.  When  not  erect  the  penis 
is  hidden  in  the  long  preputial  cavity,  the  orifice  of 
which  is  well  in  advance  of  the  vent;  vesicular 
glands  are  absent.  The  Sirenia  (sea  cows  and 
dugongs)  have  vesicular  glands.  The  glans  con- 
sists of  semilunar  side  lobes  including  a  conical 
process,  on  the  point  of  which  the  urethra  opens. 

The  testicles  of  the  elephant  (Probocidia)  remain 
below  and  beyond  the  kidney.  Vesicular  glands  and 
a  tme  seminal  vesicle  are  present.  There  are  four 
prostates,  two  on  each  side  of  the  urethra.  The 
corpora  cavernosa  of  the  penis  is  divided  by  a  thick 
fibrous  partition  beneath  which  lies  the  corpora 
spongiosum  containing  the  urethra,  besides  the  ordi- 
nary' muscles  there  are  a  large  pair  of  levators. 

In  Perissodactyla  (rhinoceros,  etc.)  the  testicles 
are  inguinal.  The  prostate  resembles  that  of  the  rat. 


530 


TUCKER:   GEXITOURIXARY    ORGAXS  OF  LOWER  AXIMALS. 


[New  York 
Medical  Journal. 


.  being  composed  of  long,  slender  blind  tubes  with 
glandular  walls.  There  is  no  os.  Retractors  are 
present,  as  are  levators  and  two  suspensory  liga- 
ments. The  total  length  of  the  flaccid  organ  is 
three  feet  nine  inches ;  the  circumference  of  the  pre- 
puce is  one  foot  five  inches.  The  glans  is  a  long,  slen- 
der, compressed  cone  with  a  truncate  apex,  and  in 
the  undisturbed  state,  measures  one  foot  in  length. 
The  apex  of  the  glans  resembles  a  mushroom  on  a 
thick  peduncle  projecting  from  an  excavation  at  the 
end  of  the  glans,  with  a  thin  wall,  like  a  second  pre- 
puce. On  either  side  of  the  base  of  the  glans  tliere 
is  a  longitudinal  thick  oblong  ridge  with  a  heavy 
rounded  border.  The  base  of  the  glans  penis  of  the 
tapir  has  an  upper  lobe  as  well  as  one  on  each  side, 
beyond  which  it  is  continued  forward,  contracting 
and  terminating  in  a  truncate  surface.  The  tes- 
ticles are  inguinal,  lying  in  a  sessile  scrotum. 

In  the  horse  the  scrotum  is  suspended  nine  inches 
beneath  the  anus,  whence  it  is  prolonged  forward, 
to  terminate  in  the  prepuce.  The  corpora  cavernosa 
is  forftied  by  the  confluence  of  the  crura  without  a 
vertical  septum,  the  glans  has  two  lateral  semilu- 
nar lobes  and  at  the  apex  a  central  p\  ramidal  proc- 
ess. In  the  castrated  horse  the  retractors  of  the 
penis  atrophy.  In  Artiodactyla  the  chief  distinctive 
character  is  the  enormous  development  of  Cowper's 
glands.  The  testes  are  perineal.  The  scrotum  pro- 
jects but  is  not  pendulous.  The  penis  shows  a  sig- 
moid flexure.  The  glans  is  long  and  pointed.  The 
preputial  opening  is  near  the  umbilicus. 

The  ruminants  have  no  vesicular  glands ;  the 
testicles  are  carried  in  a  pedunculated  scrotum. 
The  glans  is  long  and  pointed  and  in  the  camel  the 
apex  is  continued  beyond  the  urethral  opening  and 
bent  back.  Preputial  follicles  are  usually  abundant, 
most  marked  in  the  antelopes,  reaching  enormous 
size  in  the  musk  deer. 

CARXIVOR.\. 

The  sexes  are  hardly  distinguishable  in  the  seals. 
The  testicles  are  imbedded  in  fat  between  the  pubis 
and  the  thighs,  and  the  penis  makes  no  outward  pro- 
jection. The  preputial  orifice  is  inconspicuous. 
The  glans  is  pointed  and  supported  by  a  small  os. 
The  OS  penis  of  the  walrus  is  massive,  about 
eighteen  inches  in  length.  The  scrotum  when  de- 
veloped in  carnivora  is  hairy  and  less  pendulous 
than  in  ruminants.  The  os  penis  in  bears  may  be 
six  inches  long.  The  prostate  is  well  developed  in 
the  raccoon  and  other  members  of  the  genus  IMeles. 

Canis. — In  dogs,  wolves,  foxes,  the  scrotum  is 
more  prominent  than  in  the  IMustellenes  and  planti- 
grades. The  prostate  is  protuberant.  The  spongy 
tissue  of  the  urethra  expands  suddenly  and  consid- 
erably at  the  base  of  the  glans,  which  presents  an 
ossicle.  The  blood  is  returned  from  the  penis  by 
two  dorsal  veins.  These  are  compressed  by  action 
of  the  levators  arising  from  the  first  caudal  verte- 
bra, then  passing  one  on  each  side  of  sphincter  ani 
to  converge  to  the  dorsum  of  the  penis,  crossing  the 
veins  and  terminating  at  the  base  of  the  bulbous 
portion  of  the  glans.  So  long  as  the  levators  are 
stimulated  to  contract,  after  coition  the  distended 
glans  forms  a  mechanical  impediment  to  withdraw- 
ing the  penis  from  the  vagina. 

In  the  hyena  the  prostate  is  large,  there  is  no  os 


penis,  the  prepuce  is  large,  covers  the  organ  fully 
and  is  much  the  same  color,  so  diflFering  from  the 
dogs.  In  the  cat  the  glans  is  covered  with  retro- 
verted  callous  papillae,  less  numerous  in  the  lion  and 
tiger.  The  prostate  is  small,  Cowper's  glands  large. 
In  the  nonerect  condition  the  penis  is  bent  backward. 

Quadmmana. — In  the  aye  aye  (chiromys)  the 
testicles  occupy  a  sessile  scrotum,  the  penis  projects 
and  is  covered  by  a  thin  hairless  prepuce.  In  the 
lemurs  the  penis  has  an  ossicle  and  hangs  conspicu- 
ously as  in  chiromys.  In  the  higher  quadrumana 
and  platyine  apes  the  scrotum  is  more  pendulous 
with  a  prominent  penis.  In  the  spider  monkeys 
(ateles)  the  glans  is  largely  expanded.  In  Macacus 
the  vesicular  gland  is  large  and  lobate,  the  prostate 
large,  the  os  penis  small.  The  testicles  are  larger 
than  in  man  and  project  on  either  side  of  the  base 
of  the  penis.  In  apes  and  monkeys  the  preputial 
fold  is  absent. 

The  chief  modification  of  the  mammalian  kidney 
is  its  composition  of  a  seeming  multiplication  of 
simple  kidney,  with  or  without  a  common  cortical 
envelope  and  an  absence  of  the  mammillae.  This  last 
condition  is  present  in  the  ornithorhynchus,  in  which 
the  uriniferous  tubules  terminate  on  the  concave 
surface  of  a  small  and  simple  pelvis.  The  ureter 
takes  its  course  to  the  contracted  neck  of  the  blad- 
der but  terminates  in  the  male  in  the  urogenital  ca- 
nal below  the  vas,  in  the  female  beyond  the  uterine 
orifice,  which  thus  intervenes  between  the  ureters 
and  the  orifice  of  the  urinary  bladder.  In  other  re- 
spects, save  the  termination  of  the  ureters  in 
relation  to  the  bladder,  the  urinary  system  of  mono- 
tremes  adheres  to  the  mammalian  type.  This  cir- 
cumstance of  deviation  places  them  near  the  reptiles. 
The  urine  in  these  animals  may  dribble  out  with  the 
feces  or  flow  back  into  the  bladder.  In  either  case 
it  is  expelled  through  the  cloaca  and  not  through 
the  urethra.  The  penis  in  the  male  is  used  only  for 
the  transmission  of  semen.  In  all  other  mammals 
the  urethra  transmits  both  urine  and  semen.  In 
some  shrews  and  moles  and  in  the  slow  lemur  the 
clitoris  in  the  female  is  perforated  by  a  canal  which 
is  here  used  exclusively  for  the  urine,  the  vaginal 
orifice  intervening  between  the  anus  and  clitoris. 

The  scope  of  this  review  does  not  permit  me  to 
take  up  the  question  of  deviation  of  the  female  or- 
gans of  generation,  or  the  secondary  sexual  charac- 
ters found  in  animals. 

In  closing,  we  must  remember  that  we,  as  the 
highest  order  of  mammalia,  are  not  in  fact  so  far 
removed  from  the  lower  types  and  that  at  one  time 
in  the  past  our  first  ancestor,  a  reptile,  prompted 
b)-  a  warmer  blood  and  a  more  efficient  circulation, 
dragged  its  sinuous  length  from  the  alluvial  slime  to 
seek  surroundings  more  congenial.  By  this  first 
eflFort,  be  it  accidental  or  otherwise,  the  chain  of  ad- 
vance was  started,  so  during  the  millions  of  years 
that  have  since  elapsed  we  have  developed  link  by 
link  till  now  the  human  race  stands  at  the  top. 

Xo  claim  of  originality  is  made  in  this  communi- 
cation. It  is,  as  stated,  simply  a  review.  I  have 
quoted  freely  from  many  authors,  among  them  Sir 
Richard  Owen's  comprehensive  works  on  Compara- 
tive Anatomy,  Flower  and  Lydekker's  Manunalian 
Zoology,  Dr.  H.  C.  Chapman  and  other  writers. 


October  9,  1920.] 


LEVIN: 


TREATMENT  OF  SYPHILIS. 


531 


MODERN    TREATMENT    OF  SYPHILIS. 

By  Oscar  L.  Levin,  M.  D., 
New  York, 

Attending   Physician,   Department   of   Dermatology  and  Syphilology, 
Beth  Israel   Hospital  and   Cornell   University   Medical  College; 
Chief  of  Clinic,  Department  of  Dermatology  and  Syphilology, 
Mount  Sinai  Hospital,  O.  P.  D. 

In  this  article  I  shall  epitomize  the  rationale  of 
my  methods  of  procedure  in  the  usual  case 
of  syphilis.  No  attempt  is  made  to  describe  special 
plans  of  attack  employed  for  those  special  types  of 
cases,  like  congenital  syphilis,  nor,  for  those  cases 
where  specialized  tissues,  like  the  nervous  system, 
are  involved.  Of  course,  it  must  be  understood  that 
all  measures  conducive  to  the  promotion  of  good 
health  should  be  employed  and  that  much  depends 
upon  the  cooperation  of  the  patient. 

Syphilis  is  an  infectious  constitutional  disease 
caused  by  the  Spirochaeta  pallida.  From  a  local 
point  of  inoculation,  where  the  chancre  develops, 
the  organisms  migrate  with  the  blood  stream  and 
the  lymph  current  to  all  parts  of  the  body,  causing 
anatomical  and  physiological  changes  in  the  organs. 
Thus,  after  a  primary  incubation  period,  and  a  lo- 
calized initial  lesion  with  enlarged  adjacent  lymph 
nodes,  the  infection,  at  the  end  of  a  second  incuba- 
tion period,  usually  of  four  to  six  weeks,  manifests 
itself  as  a  generalized  condition.  The  infection  is 
slowly  diluted  and  appears  usually  at  the  end  of  a 
year  or  more  by  localized  evidence  of  the  disease. 
The  course  of  the  disease  is,  therefore,  conveniently 
described  in  three  stages ;  the  primary,  the  second- 
ary and  the  tertiary.  The  pathological  changes  of 
.syphilis  in  all  its  phases  are  essentially  the  same  and 
are  characterized  by  the  presence  of  a  granuloma 
which  is  made  up  of  a  perivascular  infiltration  of 
small  round  and  plasma  cells.  The  various  lesions 
are  merely  expressions  of  different  degrees  of  in- 
tensity in  the  reaction  of  the  tissues  to  the  excitant. 
The  older  lesions  are  afifected  by  a  more  marked 
endarteritis  and  periarteritis  and  a  greater  subsri- 
tution  of  the  cellular  tissue  by  fibrous  tissue. 

It  is  evident  that  the  cure  of  the  disease  depends 
upon  the  destruction  of  the  spirochetes  and  the 
restoration  of  the  normal  anatomy  and  physiology 
of  the  affected  tissues.  The  destruction  of  the  or- 
ganisms is  effected  by  the  administration  of  spe- 
cific spirocheticidal  remedies  and  the  employment 
of  measures  to  stimulate  the  resisting  forces  of  the 
body.  By  the  internal  administration  of  iodides  the, 
spirochetes  are  destroyed,  the  pathological  tissues 
are  removed  and  the  normal  structure  regained. 
With  the  destruction  of  the  spirochetes  and  the  de- 
velopment of  normal  tissue  the  normal  functions 
return,  which  at  times  are  aided  by  methods  of 
reeducation.  Where  special  tissues  have  been  de- 
stroyed and  replaced  by  scar  tissue  there  may  be  no 
return  of  function  or  only  a  partial  return. 

THE  SPIROCHETICIDES. 

Arsphenamine  and  its  congeners,  and  mercury 
are  spirocheticides.  While  less  bactericidal  than 
mercury  arsphenamine  is  a  more  powerful  spiro- 
cheticide,  exerts  a  more  rapid  and  destructive  ac- 
tion on  the  organisms  and  is  a  tonic  to  the  system. 
Mercury  is  only  slightly  spirocheticidal  but  possesses 


the  power  to  stimulate  the  body  to  resist  the  syph- 
ilitic invasion,  and  favors  the  absorption  of  newly 
formed  connective  tissue.  Therefore,  arsphenamine 
is  indicated  in  all  phases  of  the  disease,  esf)ecially 
for  the  destruction  of  the  spirochetes  while  they  are 
still  localized  in  the  chancre  and  after  they  have 
invaded  the  system  prior  to  their  entrenchment  be- 
hind obliterated  blood  vessels  and  masses  of  fibrous 
tissue.  The  drug  will  not  cure  syphilis  in  a  single 
dose,  nor,  with  rare  exceptions,  in  a  single  course 
of  several  doses,  but  it  will  eradicate  the  disease 
when  given  in  a  systematic,  scientific  manner  for 
several  years.  The  combined  administration  of  both 
specifics,  arsphenamine  and  mercury,  gives  the  best 
results.  They  destroy  the  spirochetes  and  stimulate 
the  production  of  antibodies. 

REMOVAL  OF  PATHOLOGICAL  TISSUE. 

Arsphenamine  and  mercury,  by  destroying  the 
spirochetes,  remove  the  factors  which  incite  the 
formation  of  the  pathological  tissue  and  thus  favor 
involution.  Mercury  also  shows  a  tendency  to  stim- 
ulate the  absorption  of  the  poorly  formed  connec- 
tive tissue.  Iodides,  once  considered  specific  in  their 
action,  are  now  known  to  be  without  effect  upon 
the  organisms,  but  they  are  of  immense  value  in 
removing  abnormal  tissue  and  opening  the  way  for 
arsphenamine  and  mercury.  The  removal  of  the 
pathological  tissue  is  possibly  favored  by  the  in- 
hibitory action  of  iodine  on  the  antiferments  and 
thus  permitting  the  normal  proteolytic  ferments  to 
digest  the  infiltrations.  By  producing  prolonged 
vasodilatation  the  iodides  improve  the  circulation 
through  the  tissues.  It  is  also  possible  that  the 
action  of  iodides  upon  the  thyroid  gland  may  aid  by 
stimulating  the  antiseptic  action  of  the  secretion  and 
by  promoting  absorption  of  infiltrations.  It  has 
been  said  that  the  main  signs  of  hypothyroidism  de- 
pend upon  the  development  of  infiltrations  and  it 
has  been  shown  that  stimulation  of  the  thyroid  or 
the  administration  of  the  gland  extract  will  cause 
the  disappearance  of  these  infiltrations. 

VARIOUS  PHASES   OF  SYPHILIS. 

For  purpose  of  treatment  it  is  advisable  to  con- 
sider the  three  stages  of  syphilis  as  follows : 

Primary  stage. — This  includes  the  primary 
incubation  period  as  well  as  the  phase  in  which  the 
chancre  and  the  adjacent  adenitis  are  present ;  the 
spirochetes  are  localized  and  there  is  a  negative 
Wassermann  reaction  of  the  blood. 

Secondary  stage. — a.  A  preflorid  phase  in 
which  there  is  evidence  of  primary  lesions  usually 
still  present,  there  is  no  clinical  evidence  of  general 
syphilis,  but  the  blood  shows  a  positive  Wasser- 
mann reaction,  b,  In  the  florid  phase  there  are 
clinical  signs  and  symptoms  of  active  secondary 
syphilis  and  there  is  a  strong  positive  Wassermann 
reaction  of  the  blood,  c,  A  declining  or  latent  sec- 
ondary phase  which  shows  fading  or  no  clinical 
evidence  of  secondary  syphilis.  The  blood  shows  a 
strong  positive  Wassermann  reaction. 

Tertiary  stage.— a,  In  the  latent  tertiary  phase 
there  is  no  clinical  evidence  of  syphilis  but  there 
are  positive  biological  findings  in  the  blood  or  spinal 
fluid,  or  a  positive  luetin  reaction  is  found,    b,  This 


532 


LEVIN:   TREATMENT  OF  SYPHILIS. 


[New  York 
Medical  Journal. 


is  followed  by  an  active  tertiary  phase  in  which  there 
is  evidence  of  tertiary  syphilis  of  the  skin  or  viscera 
with  or  without  positive  biological  findings  in  the 
blood  or  spinal  fluid  and  a  positive  or  negative  luetin 
test. 

SPECIFIC  TREATMENT. 

In  view  of  the  fact  that  in  primary  syphilis  the 
spirochetes  are  still  localized  and  the  prognosis  for 
a  cure  is  most  promising  during  this  phase  of  the 
disease,  the  attempt  is  made  to  destroy  the  organisms 
in  situ  by  vigorous,  intensive  treatment.  Wide  di- 
vergence of  opinion  exists  as  to  the  best  manner 
in  which  the  abortive  treatment  should  be  applied. 
There  are  some  who  advocate  the  administration  of 
several  doses  of  arsphenamine  daily,  while  others 
assert  that  weekly  injections  of  several  moderate 
doses  of  the  drug  are  sufficient.  I  have  tried  a  medium 
course  and  have  employed  the  following  method  of 
abortive  treatment  with  success. 

It  is  urged  that  the  initial  lesion  or  its  scar  if 
indurated  should  be  completely  extirpated  when- 
ever the  site  allows  of  such  an  operative  pro- 
cedure. By  excising  the  lesion  it  is  not  proposed 
to  cure  or  abort  syphilis  but  merely  to  remove  a 
possible  focus  from  which  spirochetes  may  invade 
the  blood  and  lymph  channels.  In  those  cases  where 
it  is  not  feasible  to  excise  the  chancre,  local  cleanli- 
ness and  the  continuous  application  of  a  thirty  per 
cent,  calomel  ointment  are  prescribed. 

Combined  administration  of  arsphenamine  and 
mercury  consists  in  the  administration  of  four  in- 
travenous injections  of  arsphenamine  in  doses  of 
three  tenths  gram  at  intervals  of  three  days  fol- 
lowed by  a  course  of  six  intravenous  injections  of 
arsphenamine  in  doses  of  four  tenths  gram  at  five 
day  intervals.  Two  days  after  the  fourth  injection 
of  arsphenamine  an  intramuscular  injection  of  a 
grain  of  mercury  salicylate  is  given. 

The  mercury  is  then  administered  in  the  same 
dose  two  days  after  each  of  the  last  six  arsphena- 
mine injections.  It  is  then  continued  in  doses  of 
one  to  three  grains  at  intervals  of  five  days  until 
a  course  of  twelve  has  been  completed.  As  the 
chancre  shows  endarteritis  and  new  connective  tis- 
sue potassium  iodide  is  prescribed  in  daily  doses  of 
thirty  grains  after  the  completion  of  the  course  of 
arsphenamine. 

The  patient  is  now  given  a  rest  from  treatment 
for  a  month  after  which  the  Wassermann  reaction 
of  the  blood  is  determined.  If  the  reaction  proves 
positive  the  patient  is  advised  to  undergo  the  plan 
of  treatment  which  will  be  described  for  the  de- 
clining phase  of  the  secondary  stage.  A  negative 
Wassermann  reaction  is  followed  by  a  course  of 
four  weekly  injections  of  arsphenamine  in  doses  of 
four  tenths  gram  and  twelve  weekly  injections  of 
mercury  in  doses  of  a  grain.  A  final  Wassermann 
reaction  of  the  blood  justifies  a  lumbar  puncture  for 
examination  of  the  spinal  fluid.  If  the  spinal  fluid 
does  not  show  any  biological  evidence  of  svphilis  the 
patient  is  told  that  he  is  apparently  cured  but  ad- 
vised to  undergo  a  general  physical  examination 
every  six  months  and  an  examination  of  the  blood 
every  two  months  for  a  year  and  then  annually  for 
the  rest  of  his  life. 

During  the  preflorid  phase  of  the  disease  there 


are  no  clinical  signs  of  general  infection  although 
the  Wassermann  reaction  of  the  blood  is  positive. 
It  seems  possible  that  such  a  positive  reaction  may 
occur  early  in  the  disease  on  account  of  the  reagent 
which  escapes  into  the  blood  from  the  initial  lesion. 
In  view  of  this  and  also  because  there  are  few 
spirochetes  in  the  blood  and  they  are  not  firmly  es- 
tablished in  the  tissues  the  abortive  treatment  should 
be  attempted.  As  a  precaution  against  violent  focal 
or  general  reaction  five  minims  of  a  one  to  one 
thousand  solution  of  adrenalin  is  injected  subcutane- 
ously  prior  to  the  first  four  injections  of  arsphena- 
mine. The  development  of  a  reaction  should  be 
followed  by  the  plan  of  treatment  employed  for  the 
florid  phase ;  the  absence  of  a  reaction  warrants  the 
further  application  of  the  intensive  treatment. 

During  the  florid  phase  the  spirochetes  are  widely 
disseminated  they  swarm  in  the  blood,  invade  all 
the  tissues  and  overwhelm  the  general  system  before 
the  natural  resisting  forces  of  the  body  are  fully 
mobilized.  The  blood  shows  a  four  plus  Wasser- 
mann reaction  and  the  various  clinical  signs  and 
symptoms  of  active  secondary  syphilis  are  present. 

As  there  is  no  hope  of  completely  eradicating  the 
spirochetes  by  a  course  of  intensive  treatment  dur- 
ing this  phase  and  because  violent  reactions  may 
result,  a  more  conservative  plan  of  attack  is  strong- 
ly recommended.  The  employment  of  arsphenamine 
at  this  time  results  in  the  destruction  of  large  num- 
bers of  the  organisms,  the  consequent  liberation  of 
an  enormous  amount  of  endotoxins  which  may  in- 
tensify the  local  and  the  general  phenomena  of  the 
disease  and  overwhelm  the  patient.  This  phenomenon 
is  known  as  the  Herxheimer  reaction.  The  produc- 
tion of  such  a  reaction  in  the  nervous  system  gives 
rise  to  symptoms  of  temporary  embarrassment  or 
permanent  destruction  of  tissue,  as  in  the  case 
of  the  third,  seventh  and  eighth  cranial  nerves 
which  traverse  compact  bony  apertures  and  canals. 
It  is  therefore  desirable  to  employ  a  method  of 
treatment  which  diminishes  the  tendency  to  these  re- 
actions, destroys  a  certain  number  of  organisms  and 
favors  the  development  of  the  resistance  of  the  body 
to  the  invasion. 

The  procedures  followed  in  florid  syphilis  may  be 
described  in  three  steps. 

1.  A  series  of  soluble  mercury  injections.  Mer- 
cury is  spirocheticidal  in  action  but  to  a  far  less 
extent  than  arsphenamine.  Its  employment  liberates 
a  much  smaller  an'ount  of  endotoxins  and  the  pos- 
sibility of  reactior  s  is  much  diminished.  The  use 
of  the  drug  also  tends  to  favor  the  development 
of  the  natural  resisting  forces  of  the  body.  Soluble 
mercury  should  be  injected  for  this  purpose  because 
it  is  painless,  absorbed  quickly  and  the  desired  effect 
obtained  rapidly.  A  two  per  cent,  solution  of  mer- 
cury cyanide  is  injected  daily  for  six  days^;  the  first 
dose  of  eight  minims  being  increased  one  minim 
with  each  injection. 

2.  Combined  arsphenamine  and  insoluble  mer- 
cury injections.  At  the  termination  of  the  series 
of  soluble  mercury  injections  the  patient  is  given 
six  weekly  injections  of  arsphenamine  in  doses  of 
three  tenths  to  five  tenths  gram.  Two  days  after 
each  injection  of  arsphenamine  a  grain  of  mercury 
salicylate  is  injected  intramuscularly. 


October  9,  1920.] 


ROUT:   VENEREAL  INFECTION. 


533 


3.  A  course  of  insoluble  mercury  injections. 
Twelve  weekly  injections  in  doses  of  one  to  three 
grains  are  then  administered. 

This  is  followed  by  a  period  of  rest  during  which 
potassium  iodide  is  given.  The  Wassermann  reac- 
tion of  the  blood  is  now  determined.  A  positive 
reaction  should  be  followed  by  a  repetition  of  the 
combined  administration  of  arsphenamine  and  mer- 
cury salicylate.  A  negative  reaction  after  the  first 
or  second  course  of  treatment  should  be  followed 
by  courses  of  four  weekly  injections  of  arsphena- 
mine in  doses  of  four  tenths  gram  and  twelve  weekly 
injections  of  mercury  salicylate  with  rest  periods 
of  two  months  for  at  least  three  years.  The  Was- 
sermann reaction  of  the  blood  is  determined  at  the 
end  of  each  rest  period.  Iodides  should  be  taken  on 
and  off  during  the  entire  course  of  treatment. 

If  the  patient  comes  under  treatment  six  months 
to  one  year  after  the  appearance  of  the  chancre,  or 
the  declining  phase,  we  find  reminders  of  lesions 
characteristic  of  the  secondary  stage  and  a  strong 
positive  Wassermann  reaction.  On  the  other  hand, 
there  may  be  no  evident  signs  but  subjective  symp- 
toms of  the  general  infection  and  a  strong  positive 
Wassermann  reaction. 

In  such  patients  Nature  has  been  given  the  oppor- 
tunity to  resist  the  invasion  of  the  disease.  The 
antibodies  in  the  blood  and  tissues  are  mobilized  in 
sufficient  force  to  repel  the  onslaughts  of  the  spiro- 
chetes and  gradually  dilute  the  infection.  The  plan 
of  therapeutic  attack  employed  in  this  phase  is  sim- 
ilar to  that  in  the  florid  phase  but  the  preliminary 
course  of  soluble  mercury  is  omitted.  This  omis- 
sion is  warranted  because  there  is  little  or  no  danger 
from  a  Jarisch-Herxheimer  reaction. 

In  the  latent  tertiary  phase  many  syphilitic  pa- 
tients show  no  visible  signs  or  subjective  symptoms 
of  the  disease,  yet  upon  testing  the  blood  for  the 
Wassermann  reaction,  a  weak  and  at  times  a  strong 
positive  result  is  obtained.  This  latent  phase  de- 
velops a  year  or  more  after  the  onset  of  the  infec- 
tion and  is  occasioned  by  the  attenuation  of  the  in- 
fection by  insufficient  therapy  in  the  past  or  by 
nature. 

In  those  instances  the  spirochetes  are  not  present 
in  the  blood  but  are  entrenched  in  various  localities 
behind  fibrous  tissue  and  vessels  with  partially  or 
completely  obliterated  lumina.  After  a  preliminary 
course  of  eight  weekly  injections  of  arsphenamine 
in  doses  of  four  tenths  gram  there  follows  a  course 
of  twelve  weekly  injections  of  mercury  salicylate 
and  iodides  by  mouth.  At  the  completion  of  this 
course  a  period  of  rest  from  treatment  follows  and 
the  Wassermann  reaction  of  the  blood  determined. 
Subsequent  to  this  courses  of  four  weekly  arsphena- 
mine injections  in  doses  of  four  tenths  gram  and 
twelve  weekly  injections  of  mercury  salicylate  are 
given  twice  a  year  for  three  years. 

Iodides  are  given  while  the  patient  is  receiving 
mercury  and  during  the  rest  periods.  I  prefer  giv- 
ing the  saturated  solution  of  potassium  iodide  in 
essence  of  pepsin.  The  mixture  is  employed  by 
pouring  the  required  amount  into  a  glass  of  milk 
and  the  curds  which  form  are  ingested  after  meals. 

Evidence  of  active  tertiary  syphilis  may  develop 
at  any  time.    The  gummatous  tumor  which  is  the 


characteristic  lesion  of  this  phase  is  made  up  of  a 
dense  mass  of  connective  tissue,  plasma  and  round 
cells  and  blood  vessels  with  marked  endarteritis. 
I  have  pursued  the  following  scheme  in  the  treat- 
ment of  syphilitic  patients  with  signs  of  visceral  or 
cutaneous  gummata. 

1.  The  administration  of  potassium  iodide  in  daily 
doses  of  one  to  two  drams. 

2.  Weekly  injections  of  arsphenamine  until  the 
disappearance  of  the  lesions. 

3.  An  injection  of  mercury  salicylate  two  days 
after  each  injection  of  the  arsphenamine. 

4.  With  the  disappearance  of  symptoms  referable 
to  the  lesions,  or  of  the  lesions  themselves,  mer- 
cury is  continued  in  weekly  injections  for  three 
months. 

5.  Subsequent  treatment  is  similar  to  that  sug- 
gested for  latent  syphilis.  In  the  presence  of  ter- 
tiary syphilis  of  the  viscera  this  plan  is  generally 
employed  but  precautions  must  be  taken  against 
increasing  the  damage  to  the  organs. 

I  recommend  the  routine  method  of  treatment  out- 
lined above  in  those  cases  which  run  the  usual  course. 
The  local  treatment  of  syphilis  may  be  obtained  from 
the  various  textbooks  and  monographs.  Criteria  for 
an  apparent  cure  are  :  repeated  negative  Wassermann 
reactions  of  the  blood  and  negative  clinical  findings 
for  at  least  one  year  after  stopping  treatment,  a 
normal  spinal  fluid  and  a  negative  luetin  skin  test. 
Even  in  the  presence  of  all  these  the  patient  who  has 
once  had  syphilis  is  told  to  receive  annual  physical 
examintaions  and  occasional  Wassermann  tests  of 
the  blood. 

161  East  Sevexty-xixth  Street. 


THE  CONQUEST  OF  VENEREAL 
INFECTION. 
By  Ettie  a.  Rout, 

London, 

Xew    Zealand    Government    Authorized    Reporter    and  Honorable 
Secretary  New  Zealand  Volunteer  Sisters. 

Some  fifteen  years'  experience  as  an  official  re- 
porter in  Australia  and  New  Zealand,  and  some 
five  years'  work  at  home  and  in  Egj-pt,  France, 
Belgium  and  England  gave  me  a  general  knowl- 
edge of  the  nature  and  extent  of  the  venereal  dis- 
ease problem.  The  set  purpose  to  send  home  as 
many  clean  men  as  possible  was  kindled  by  the  vivid 
realization  of  what  it  meant  to  the  women  at  home 
that  in  a  few  months  some  ten  thousand  Anzacs 
had  become  infected  with  venereal  disease  in  Egypt. 
Moral  measures  having  proved  insufficient,  obvious- 
ly they  must  be  supplemented  by  medical  effort. 
Would  this  succeed?  Then  I  did  not  know.  Now 
my  general  knowledge,  combined  with  several 
years'  experience  with  the  practical  application  of 
prophylaxis — mainly  among  overseas  Britishers  and 
Americans — makes  me  feel  that  victory  is  now  at- 
tainable by  all  who  are  willing  to  think  clearly  and 
act  courageously.  Our  worst  failures  in  the  army 
were  due  to  the  fact  that  we  were  caught  napping. 
Our  successes,  and  they  are  completely  convincing, 
were  due  to  the  fact  that  we  combined  means  of  les- 
sening contacts  with  methods  of  eliminating  dis- 


534 


ROUT:   VENEREAL  INFECTION. 


[New  York 
Medical  Journ.vl. 


ease.  Not  merely  must  we  try  to  prevent  sin,  but 
we  must  try  to  prevent  the  poisoning  of  the  sinner; 
for  if  not,  we  shall  have  blind  babies,  invalid  wives, 
and  ruined  husbands ;  broken  hearted,  broken  bodied 
mothers  each  adding  one  more  fragment  to  the 
Nation's  pile  of  damaged  goods. 

Early  in  the  war  because  of  an  outbreak  of 
venereal  disease  in  Egypt,  one  of  our  brigadier- 
generals  visited  a  number  of  young,  educated  men 
in  one  of  the  camps,  and  asked  for  their  viewpoint. 
They  said  that  many  of  the  men  were  influenced  by 
the  moral  appeals  made  to  them,  but  that  a  propor- 
tion of  the  men  had  indulged  in  this  way  throughout 
their  adult  life,  and  intend  to  continue  to  do  so 
irrespective  of  anything  medical  officers,  chaplains, 
or  generals  might  say  to  them.  That  is  the  funda- 
mental position  which  every  reformer  must  face. 
So  long  as  a  number  of  men  determine  to  adopt  this 
policy,  and  so  long  as  there  is  a  sufficient  number 
of  women  prepared  to  cater  to  them,  the  problem 
of  venereal  disease  will  continue  to  be  acute  in 
every  country. 

How  then  was  venereal  disease  conquered  in  the 
Army?  First,  Was  it  conquered?  It  certainly 
was.  Wherever  prophylaxis  was  properly  applied, 
at  least  two  thirds  of  the  cases  of  venereal  disease 
were  eliminated.  That  is  the  official  statement  of 
the  American  Army,  and  it  coincides  with  that  of 
the  Canadian  and  Australian  armies,  on  broad  lines. 
In  particular  cases  enormously  better  results  than 
this  were  attained.  For  example,  in  August-Sep- 
tember, 1917,  over  five  thousand  British  troops 
came  to  Paris  on  leave  without  prophylactic  meas- 
ures being  provided,  and  1,038  became  infected, 
over  twenty  per  cent.  Leave  was  then  closed  down  ; 
three  prophylactic  stations  were  established,  and 
prophylactic  tubes  were  issued,  with  the  result  that 
although  during  the  next  six  months  some  twenty- 
five  thousand  to  thirty  thousand  troops  came  on 
leave  to  Paris,  the  amount  of  venereal  infection 
among  them  was  reduced  to  less  than  three  per  cent. 

By  a  special  additional  effort  in  Paris,  backed  up 
officially  and  unofficially  by  the  Australian  Army 
authorities,  I  succeeded  in  making  the  Anzacs  the 
cleanest  troops  that  ever  came  on  leave  to  Paris.  In 
five  months  we  had  only  twenty  venereal  infections 
recorded  against  us  at  the  Medical  Report  Centre, 
whereas  many  hundreds  of  infections  were  recorded 
against  other  troops.  It  is  noteworthy  that  in  No- 
vember-December, a  period  of  five  weeks,  when  our 
supplies  of  prophylactic  outfits  ran  out,  we  had 
twenty-four  infections  to  our  discredit,  four  more 
than  during  the  previous  five  months.  The  most 
striking  return  was  one  furnished  for  the  twenty- 
two  days  ending  October  17,  1918,  because  a  special 
medical  effort  was  made  to  protect  the  Anzac  troops 
during  September-October,  the  result  being  as  fol- 
lows :  Venereal  infections  recorded  at  Medical  Re- 
port Centre,  Paris,  for  twenty-two  days  ending  Oc- 
tober 17,  1918,  no  New  Zealanders,  no  Australians, 
thirty-three  Canadians,  and  twenty-four  English, 
and  a  further  return  for  the  six  weeks  ending 
October  31,  1918,  gave  us  only  three  infections 
among  the  Anzac  troops  and  forty-two  among  the 
English.  As  the  New  Zealanders  and  Australians 
were  the  only  troops  given  an  unlimited  supply  of 


prophylactic  outfits,  the  conclusion  is  obvious.  I 
am  sure  that  when  men  and  women  are  properly 
instructed  in  the  mode  of  preventing  infection,  and 
are  supplied  with  the  necessary  medicaments,  vene- 
real disease  can  be  practically  extirpated  except 
among  the  drunken,  and  experience  shows  quite 
clearly  that  the  vast  majority  of  those  who  risk  in- 
fection are  not  in  a  state  of  alcoholism  when  they 
do  so ;  on  the  contrary  they  are  able  to  take  care 
of  their  health  if  they  know  how  and  the  means  are 
available.  Further,  the  providing  of  these  means 
does  not  act  as  an  incentive  to  immorality :  rather 
it  is  a  continual  reminder  of  the  dangers  likely  to 
be  incurred  by  loose  and  irregular  relationship — 
hence  a  deterrent  rather  than  an  incentive  to  im- 
morality. 

Similarly  the  establishment  of  prophylactic  sta- 
tions was  never  misunderstood  by  the  soldiers  as 
an  encouragement  of  vice,  rather  they  argued  that 
the  menace  to  their  health  and  efficiency  must  be 
extraordinarily  great,  or  the  Government  would  not 
incur  the  expense  and  deep  odium  of  setting  them 
up.  Some  differences  of  opinion  existed  among 
medical  officers  as  to  whether  the  issue  of  disin- 
fectants, in  a  portable  form,  was  advisable  or  not. 
Experience  proved  that  disease  could  certainly  be 
reduced  by  this  method,  and  the  danger  to  morality 
was  merely  a  surmise,  neither  provable  nor  dis- 
provable.  Certainly  experience  proved  that  large 
numbers  of  men  and  women  were  able  and  willing 
to  take  suitable  precautions  to  insure  hygienic 
safety,  and  those  who  take  the  responsibility  of  sup- 
pressing a  knowledge  of  prophylaxis  from  them 
must  also  be  held  responsible  for  the  resulting 
spread  of  disease  among  the  innocent — bom  and 
unborn.  The  hardiest  fanatic  shudders  from  such 
a  responsibility,  and  in  the  end  is  driven  to  admit 
that  the  world  will  not  be  rendered  less  moral  by 
the  abolition  of  venereal  disease — only  cleaner  and 
happier  for  all  of  us. 

Thus  one  hails  with  relief  the  news  that  the 
Portsmouth  area,  which  has  long  been  notable  for 
the  extraordinarily  efficient  control  of  venereal  in- 
fection, secured  by  Sir  Archdall  Reid,  by  means  of 
a  potassium  permanganate  lotion,  has  now  decided 
on  the  advice  of  its  medical  officer  of  health  to  ap- 
ply the  same  system  to  the  male  civilian  community. 
The  following  figures  are  interesting  in  this  con- 
nection : 

In  1917  the  Army  venereal  disease  rate  for  the 
whole  of  the  United  Kingdom  was  thirty-eight  to 
the  one  thousand,  and  for  Portsmouth  town  ninety- 
two  to  the  one  thousand ;  in  1919  the  United  King- 
dom rate  had  risen  to  sixty-four,  whereas  Ports- 
mouth town  had  fallen  to  fifty-four  and  four  tenths, 
and  Portsmouth  area  (Dorsetshire  and  Hamp- 
shire) to  forty-seven  and  seven  tenths,  the  Ports- 
mouth area  rate  in  1919  minus  disease  imported 
from  overseas  being  only  thirteen  to  the  one 
thousand  soldiers.  In  France  the  increase  was  even 
greater  among  British  soldiers  than  in  the  United 
Kingdom.  In  1917  the  British  Army  rate  was 
twenty-seven  to  the  thousand  for  1917;  in  1919  it 
had  risen  to  over  eightj^  to  the  thousand,  and  in 
1920  it  is  still  higher ;  whereas  among  the  American 
troops,  I  am  authoritatively  informed,  there  has  been 


October  9,  1920.] 


ROUT:   VENEREAL  INFECTION. 


535 


a  steady  decline.  This  would  appear  to  be  partly 
due  to  the  simple  and  serious  instruction  in  prophyl- 
axis given  to  all  enlisted  men,  and  partly  to  the  more 
adequate  and  efficient  establishment  and  maintenance 
of  prophylactic  stations,  and  the  much  greater  prom- 
inence given  in  American  areas  to  the  notice  boards. 
Prophylaxis  had  been  adopted  officially;  then  it  had 
to  be  put  into  proper  practice ;  and  the  Americans 
were  able  to  build  up  their  system  more  surely  and 
quickly  because  of  their  careful  study  of  the  past 
mistakes  of  other  armies.  Hence  one  is  not  alto- 
gether surprised  to  learn  that  under  the  supervision 
of  the  commissioner  of  health.  Dr.  Edward  Martin, 
sixteen  prophylactic  stations  have  been  established 
in  different  cities  and  towns  throughout  the  State  of 
Pennsylvania ;  and  that,  as  part  of  the  campaign 
against  venereal  disease,  suitable  packets  of  dis- 
infectants have  been  put  on  sale  in  the  drug  stores. 
This  is  an  extraordinarily  valuable  effort  not  merely 
to  the  United  States  of  America,  but  to  all  English- 
speaking  nations,  for  the  social  and  sexual  habits  of 
all  these  nations  are  much  the  same.  The  American 
solution  of  the  question  of  the  distribution  of  pack- 
ets strikes  one  as  eminently  practical.  Most  Anglo- 
Saxon  communities  are  sufficiently  advanced  to  ac- 
cept the  prophylactic  station  as  a  necessary  institu- 
tion, but  they  feel  really  anxious  and  unhappy  about 
accepting  the  responsibility  of  distributing  disinfect- 
ants, or  on  the  other  hand  of  forbidding  such  dis- 
tribution. If  private  enterprises  put  suitable  dis- 
infectants on  sale,  the  general  public  would  prefer 
to  accept  this  as  evidence  of  the  demand.  It  seems 
a  pity  they  should  be  necessary,  of  course,  but  while 
they  are  necessary,  it  is  a  question  of  individual 
responsibility.  All  this  proves  there  has  been  some- 
thing wrong  with  the  sexiral  education  of  men  and 
women,  let  us  try  and  do  better  with  the  next  genera- 
tion. 

"The  crux  of  the  position  lies  with  the  woman,  as 
regards  the  man  we  know  pretty  well  what  to  do 
and  how  to  do  it.  But  as  regards  the  woman,  we 
neither  know  what  to  do,  nor  how  to  do  it."  These 
words  were  said  to  me  some  three  years  ago  by  a 
thoughtful  Scotch  doctor,  in  urging  the  necessity  for 
establishing  toilet  rooms  for  women,  a  scheme  he 
thought  within  the  bounds  of  possibility,  and  more 
in  accordance  with  Anglo-Saxon  sentiment  than 
licensed  houses.  One  or  two  tentative  experiments 
were  made  on  the  continent  during  the  war,  and  we 
found  that  French  and  Belgian  public  women  were 
quite  ready  to  attend  a  Red  Cross  dispensary  for 
prophylactic  treatment,  and  quite  ready  to  accept 
prophylactic  outfits  from  the  soldiers  (we  had  the 
directions  for  women  printed  in  French  and  Eng- 
lish). In  the  licensed  houses,  of  course,  the  women 
and  the  men  always  practised  prophylaxis,  and  from 
properly  conducted  houses,  such  as  those  in  Paris, 
we  got  practically  no  disease  at  all.  But  the  mere 
existence  of  licensed  houses  in  any  area  certainly 
offers  no  solution  of  the  problem  of  venereal  con- 
trol, though  personally  I  believe  it  helps  to  limit 
both  disease  and  immorality  to  the  classes  of  women 
to  which  it  naturally  belongs :  that  is,  to  the  women 
who  either  cannot  or  will  not  refrain  from  the  anti- 
social act  of  offering  promiscuous  and  loveless  re- 
lationship to  men.    Probably  the  majority  of  such 


women  are  not  bad  at  all  but  merely  temporarily 
oversexed  and  perhaps  going  through  a  phase  in 
the  life  history  of  the  race  which  other  women  are 
born  fortunate  enough  to  avoid — and  certainly 
most  of  the  socalled  bad  women  are  willing  for 
their  own  sake  to  take  precautions  against  disease. 
Why  then  debar  them  from  obtaining  that  knowl- 
edge in  a  clean  and  efficient  manner?  Doesn't  one 
diseased  woman  spread  disease  much  more  than 
one  diseased  man?  Why  then  confine  ourselves  to 
protecting  men  only? 

As  a  fact,  the  advice  we  give  to  men  is  often 
quite  useless,  because  it  is  given  too  late.  If  the 
man  is  already  infected,  and  knows  it,  he  will  not 
trouble  to  apply  prophylaxis.  In  a  mercenary  rela- 
tionship, both  parties  are  quite  conscienceless.  In 
marriage  we  have  many  cases  of  wives  being  in- 
fected by  their  husbands,  and  reinfected,  and  they 
will  not  let  the  doctors  deal  effectively  with  their 
husbands.  The  production  of  a  health  certificate 
by  the  man  and  the  woman  before  marriage  would 
lessen  the  number  of  such  cases ;  but  the  spread  of 
a  knowledge  of  sexual  hygiene  among  women 
would  do  far  more. 

Opposition  to  the  spread  of  such  knowledge  can 
be  removed  by  insisting  on  the  fact  that  the  venereal 
diseases  are  not  immorality  diseases.  By  typewritten 
circular  letters  and  short  lectures  I  have  found  no 
difficulty  in  putting  this  view  clearly  before  thou- 
sands of  soldiers  during  the  war,  and  the  induce- 
ments of  self  interest  and  reputation  are  enormously 
stronger  among  civilians  than  among  soldiers ;  hence 
similar  advice  given  quietly  and  straightforwardly 
to  adult  men  and  women  would  be  even  more  effec- 
tive in  civilian  life.  Briefly,  this  is  the  advice  I 
gave : 

The  microbes  of  venereal  disease  grow  al- 
most exclusively  in  the  genital  passages  of  men  and 
women.  If  these  pasages  are  kept  clean  and  dis- 
infected, the  microbes  will  not  grow.  Venereal  dis- 
ease does  not  always  spring  from  immorality,  or 
even  from  sex  relationship,  but  from  contact  with 
infective  matter.  You  had  far  better  not  risk  such 
contact,  but  if  you  do,  cleanse  and  disinfect 
yourself  at  once.  Using  some  sort  of  grease  be- 
forehand prevents  direct  contact,  the  microbes  will 
not  pass  through  a  film  of  oil,  for  they  are  gummy. 
They  will  not  adhere  to  a  greasy  surface,  hence 
they  are  easily  washed  off  with  soap  and  water  af- 
ter contact,  and  soap  is  destructive  of  the  microbes- 
both  of  syphilis  and  gonorrhea.  It  is  seldom  that 
a  person  who  has  used  vaseline  beforehand  and  soap 
and  water  afterwards  becomes  infected;  if  so,  that 
merely  proves  that  the  precautions  were  carelessly 
carried  out.  Urinating  immediately  after  contact 
is  also  a  protection.  Bathing  with  cold  water  is  also 
protective.  There  is  no  excuse  for  doing  nothing, 
and  little  excuse  for  delay;  but  if  there  has  been  de- 
lay, you  should  seek  skilled  treatment  as  soon  as 
possible.  The  kind  of  precautions  necessary  to  en- 
sure protection  is  dependent  on  the  kind  of  risk  run. 
Only  the  persons  themselves  know  the  nature  of  the 
contact,  the  length  of  time  occupied,  the  number  of 
repetitions,  and  so  forth.  Contact  with  infective 
matter  for  a  few  moments  is  one  thing;  contact 
with  infective  matter  for  a  whole  night,  quite  an- 


536 


GOLDFADER:   TREATMENT   OF  NEUROSYPHILIS. 


[New  York 
Medical  Journal. 


other.  But  every  irregular  contact  is  a  risk ;  avoid 
risks,  or  if  you  disregard  this  advice,  disinfect  im- 
mediately. Do  not  let  anybody  persuade  you  that 
promiscuous  relationship  is  safe.  It  never  is,  and 
do  not  let  anybody  mislead  you  into  believing  that 
disinfectants  do  not  disinfect;  they  certainly  do.  If 
you  become  infected,  the  fault  is  really  your  own. 
You  should  not  have  risked  infection ;  or,  risking 
infection,  you  should  have  taken  proper  precau- 
tions. If  you  insist  on  making  these  your  habits, 
then  you  had  far  better  carry  a  town  dressing  with 
you,  in  the  same  way  as  a  soldier  carries  a  field 
dressing.  You  will  give  yourself  a  double  chance 
of  safety  by  taking  your  own  emergency  precau- 
tions, and  reporting  for  prophylaxis  at  the  prophy- 
lactic station  as  well. 

From  the  Australian  depots,  prophylactic  outfits 
were  available  without  cost  and  small  syringes  and 
rubber  protectors  were  on  sale  at  nominal  prices. 
In  Paris  we  had  twelve  prophylactic  stations,  one 
English,  two  Canadian,  one  Australian,  and  eight 
American.  We  prevented  as  much  disease  as  pos- 
sible ;  when  we  failed,  we  cured  as  early  as  possible ; 
and  we  did  our  best  to  reduce  concealment  to  a 
minimum.  Nevertheless,  as  a  result  of  war  and  af- 
ter war  conditions,  venereal  disease  has  greatly 
increased  in  all  the  Allied  and  enemy  countries ; 
probably  no  European  country  has  less  than  three 
or  four  times  the  amount  of  disease  it  had  in  1913- 
14.  Once  in  the  life  time  of  evefy  generation,  all 
mankind  must  pass  through  the  bodies  of  its  wo- 
men. Shall  we  make  and  keep  those  bodies  clean? 
Knowledge  has  given  us  power,  and  with  this  new 
power  we  shall  be  able  to  rid  our  nation  of  the 
most  dreadful  of  all  human  scourges.  Victory  is 
within  sight.  When  it  comes  sex  will  regain  its 
loveHness. 


RESULTS  IN  THE  TREATMENT  OF 
NEUROSYPHILIS 

By  Philip  Goldfader,  M.  D., 
Brooklyn,  N.  Y. 

Associate  in  Urology  and  Venereal  Diseases,   St.   Mark's  Hospital, 
New  York,  and  Clinical  Assistant  in  Urology  and  Venereal 
Diseases,  Brooklyn  Hospital. 

A  review  of  the  results  of  treatment  of  neuro- 
syphilis, as  conducted  by  the  urologioal  service 
of  the  Brooklyn  Hospital  during  the  calendar  years 
of  1918  and  1919,  has  proved  of  great  interest  to 
me  and  a  brief  survey  of  that  review  is  presented 
here,  with  the  hope  that  it  may  be  of  interest  to  those 
who  are  sceptical  as  to  the  value  of  intraspinal 
therapy.  It  is  not  my  intention  to  disclose 
any  new  or  startling  discoveries  in  the  treat- 
ment of  neurosyphilis,  but  to  state  the  results  of 
treatment  by  a  method  which  in  our  hands  has  given 
better  results  than  the  older  methods. 

In  order  to  treat  neurosyphilis,  with  a  hope  of  ob- 
taining results,  treatment  must  be  instituted  as  early 
as  possible.  Since  the  spinal  fluid  is  involved  in  from 
sixty  to  seventy-five  per  cent,  of  cases  during  the 
secondary  stage  and  in  twelve  to  twenty-five  per 
cent,  of  the  cases  the  pathological  changes  of  the 
fluid  persists,  it  behooves  us  to  be  on  the  watch  for 
early  involvement  of  the  central  nervous  system.  A 


lumbar  puncture  is  therefore  indicated  in  the  fol- 
lowing cases : 

1.  All  cases  coming  under  observation  after  the 
primary  stage  has  passed,  as  a  diagnostic  procedure. 
This  includes  patients  who  have  been  treated  and 
latent  or  tertiary  cases  where  treatment  has  been 
neglected.  2.  Patients  who  have  been  under  active 
treatment  for  eight  to  twelve  months,  with  no  im- 
provement in  the  blood  Wassermann.  3.  To  dif- 
ferentiate between  involvement  of  the  nervous  sys- 
tem of  syphilitic  and  nonsyphilitic  origin.  4.  As  a 
diagnostic  measure  before  discharging  a  patient  as 
cured. 

During  the  two  years  covered  by  this  report  we 
performed  diagnostic  punctures  in  sixty-one  cases, 
which  included  syphilitic  patients  who  had  symp- 
toms referable  to  the  nervous  system  and  those  who 
were  ready  to  be  discharged.  Out  of  that  number 
eleven,  or  eighteen  per  cent.,  gave  positive  fluid  find- 
ings showing  involvement  of  the  central  nervous 
system.  Out  of  the  eleven  cases,  two  or  three  per 
cent.,  were  in  women.  The  smaller  proportion  of 
positive  findings  in  women  is  due  to  the  fact  that 
we  find  it  more  difficult  to  convince  women  of  the 
advisability  of  having  a  lumbar  puncture  per- 
formed. 

During  the  same  period  we  gave  210  intraspinal 
treatments  to  forty-two  patients.  The  number  of 
treatments  given  to  any  patient  varied  between  one 
and  thirty.  The  ages  of  the  patients  varied  between 
twenty-one  and  fifty-eight.  Between  the  ages  of 
twenty  and  thirty,  four  patients,  or  ten  per  cent.; 
between  the  ages  of  thirty  and  forty,  nine  patients, 
or  twenty-two  per  cent. ;  between  the  ages  of  forty 
and  fifty,  twenty-two  patients,  or  fifty-two  per 
cent.;  between  the  ages  of  fifty  and  sixty,  seven 
patients,  or  sixteen  per  cent.  Of  the  forty-two  pa- 
tients ten  were  single  and  thirty-two  were  married, 
which  also  includes  one  single  and  one  married  fe- 
male patient.  Our  series  of  forty-two  cases  were 
divided  clinically  as  follows :  Twenty-nine  cases  of 
tabes,  or  sixty-eight  per  cent. ;  twelve  cases  of 
cerebrospinal  syphilis,  or  twenty-nine  per  cent. ;  one 
case  of  paresis,  or  three  per  cent.  Our  diagnosis  in 
each  case  was  determined  by  history,  physical  exam- 
ination, blood  Wassermann  and  spinal  fluid 
examination. 

The  opinion  held  today  by  such  syphilographers 
as  Fournier,  Kaposi  and  Newman,  and  by  such 
neurologists  as  Heubner,  Gilbert  and  Kuh,  is  that  in 
those  individuals  who  have  had  no  antispecific 
treatment  or  insufficient  treatment,  syphilitic  in- 
volvement of  the  nervous  system  is  likely  to  develop. 
On  the  other  hand,  Collins  in  a  study  of  ninety-six 
cases  of  tabes  concludes  that  a  thorough  treatment 
of  syphilis  neither  prevents  nor  postpones  the  de- 
velopment of  syphilitic  nervous  disease  which  oc- 
curs later  rather  than  earlier  in  cases  not  thoroughly 
treated. 

In  going  over  the  histories  of  our  series  of  cases, 
I  was  able  to  find  references  to  early  treatment  in 
thirty-four  cases  only.  In  nineteen  cases,  or  fifty- 
five  per  cent.,  the  patients  had  had  no  treatment  at 
all ;  in  four  cases,  or  eleven  per  cent.,  they  had  had 
only  local  treatment;  in  four  cases,  or  eleven  per 
cent.,  they  had  had  mercury  pills  by  mouth  for  vary- 


October  9,  1920.] 


GOLDFADER:   TREATMENT   OF  NEUROSYPHILIS. 


537 


ing  periods ;  in  six  cases,  or  seventen  per  cent.,  they 
had  had  one  course  of  treatment,  and  in  two  cases, 
or  six  per  cent.,  they  had  had  two  courses  of  treat- 
ment. In  other  words,  in  sixty-six  per  cent,  of  the 
cases  the  patients  had  had  no  constitutional  treat- 
ment whatsoever  before  the  onset  of  symptoms. 

We  have  had  a  few  patients  in  whom  neurosyphiHs 
developed  a  few  months  after  the  appearance  of  the 
initial  lesion,  even  though  they  were  energetically 
treated  from  the  outset.  There  are  no  doubt  sev- 
eral strains  of  Spirochseta  pallida,  some  more  potent 
than  the  others  and  some  that  have  a  predilection 
for  nerve  tissue.  In  a  patient  with  lowered  resistance 
and  infected  with  a  strain  of  a  malignant  type 
of  spirochete  involvement  of  the  nervous  system  is 
more  likely  to  occur  with  astounding  rapidity  in 
spite  of  early  and  well  directed  treatment.  In  the 
face  of  our  results,  we  are  convinced  that  the  cases 
treated  vigorously  from  the  start  are  less  likely  to 
be  complicated  by  neurosyphilis.  Even  though 
authorities  disagree  on  the  value  of  antispecific 
treatment  in  preventing  involvement  of  the 
nervous  system,  we  should  not  conclude  from  these 
observations  that  syphilis  in  whatever  stage  it  is  seen 
should  not  be  thoroughly  and  energetically  treated. 

In  our  series  the  earliest  involvement  appeared 
seven  months  after  the  initial  lesion  in  the  form 
of  optic  atrophy.  Our  records  also  show  some 
cases  in  which  manifestations  of  involvement  of 
the  nervous  system  did  not  appear  for  thirty-eight 
years  after  the  appearance  of  the  chancre.  The 
average  duration  of  time  for  the  appearance  of 
symptoms  referable  to  the  nervous  system  was 
twelve  years  and  eleven  months. 

The  treatment  employed  in  our  series  was  the 
Swift-Ellis  method,  which  in  detail  is  as  follows: 

One  hour  after  the  intravenous  administration 
of  salvarsan  (.4  to  .6  gm.)  forty  mils  of  blood  is 
withdrawn  and  allowed  to  clot,  after  which  it  may 
be  centrifugalized.  The  following  day  twelve  mils 
of  the  serum  is  pipetted  off  and  diluted  with 
eighteen  mils  of  sterile  normal  saline  solution,  mak- 
ing a  forty  per  cent,  solution.  The  serum  is  heated 
at  56°  C.  for  half  an  hour,  after  which  it  is  ready 
for  intraspinal  injection.  A  lumbar  puncture  is 
then  performed  in  the  usual  manner  and  the  sal- 
varsanized  serum  is  allowed  to  run  slowly  into  the 
spinal  canal  by  gravity.  The  intraspinal  treatments 
were  given  at  intervals  of  one  to  three  weeks  de- 
pending upon  the  condition  of  the  patient  and  the 
reaction  following  the  injection.  Treatments  were 
given  in  courses  of  six  to  eight  injections  and  in- 
tervals of  four  to  six  weeks  allowed  between 
courses. 

Fordyce  sums  up  the  rationale  of  intraspinal 
therapy  in  these  words :  "It  does  not  require 
the  experience  of  a  trained  neurologist  to 
convince  these  patients  that  their  condition  has 
been  changed  from  hopeless  invalidism  to 
comparatively  good  health.  The  advocates  of 
intraspinal  therapy  have  never  claimed  for  the 
method  that  it  should  be  used  to  the  exclusion 
of  the  intravenous,  nor  have  they  claimed  that 
the  choroid  plexus  is  impermeable  in  all  cases  and 
that  remedies  introduced  intravenously  could  not 
reach  the  cerebral  or  spinal  tissue."  The  intravenous 


administration  of  salvarsan  can  be  employed  in 
early  cases  of  cerebrospinal  syphilis  (meningitis, 
meningomyelitis,  meningoencephalitis),  early  cases 
of  tabes,  and  syphilitic  epilepsy.  In  these  classes  of 
cases,  the  improvement  both  clinically  and  serologi- 
cally is  fairly  rapid  under  intensive  treatment,  but 
at  times  we  see  patients,  who  have  not  responded 
to  intensive  intravenous  treatment,  show  marked 
and  rapid  improvement  by  combined  intravenous 
and  intraspinal  treatments. 

The  following  histories  and  laboratory  findings 
are  submitted  as  illustrations  of  our  results  with 
the  Swift-Ellis  method : 

.  Case  I. — Diagnosis,  tabes.  F.  H.,  a  man,  fifty- 
eight  years  old,  reporting  for  treatment  in  No- 
vember, 1917,  with  a  history  of  chancre  twenty 
years  previously.  Had  had  local  treatment  and  the 
sore  disappeared  in  a  short  time.  For  the  last  ten 
years  had  had  shooting  pains  in  lower  extremities 
and  occasional  pains  in  joints.  Walked  with  dififi- 
culty.  Had  incontinence  of  urine  for  several  years 
which  necessitated  the  wearing  of  a  urinal.  Physical 
examination  revealed  the  following  condition :  An 
anemic  male  of  slight  build;  fundi,  negative;  pupils, 
unequal  and  irregular,  both  light  stiff;  knee  jerks  ab- 
sent ;  Romberg,  plus  two ;  sphincters,  vesical  incon- 
tinence complete ;  rectal  incontinence  at  times ;  gait 
ataxic,  facial  and  lingual  tremors  absent ;  toe-heel 
impossible  without  support ;  speech,  slight  defect  on 
test  phrases ;  mental  condition  negative ;  sensory, 
lancinating  pains  in  legs ;  blood  and  spinal  Wasser- 
manns,  four  plus. 

On  Novemljer  15,  1917,  the  patient  had  albumin 
in  urine;  administration  of  salvarsan  postponed.  He 
received  three  injections  of  mercury  salicylate  at 
weekly  intervals  and  increasing  doses  of  potassium 
iodide.  On  December  6,  1917,  there  was  no  albumin 
in  the  urine,  and  he  was  given  six  Swift-Ellis  treat- 
ments at  weekly  intervals.  On  January  17,  1918, 
the  patient  could  hold  his'  urine  for  three  hours 
and  the  urinal  was  discarded.  His  gait  was  im- 
proved. For  the  next  year  he  received  weekly 
injections  of  mercury  salicylate  and  moderate  doses 
of  potassium  iodide. 

In  this  case  both  clinical  and  serological  improve- 
ment was  satisfactory.  The  patient  works  all  night 
and  is  able  to  hold  his  urine  without  any  difficulty. 


Spinal  Fluid 

Blood  Wassermann 

Date 

Cells 

Globulin 

Wass. 

Date 

Result 

1-20-17 

50 

positive 

4  plus 

11-20-17 

4  plus 

7-18-18 

22 

positive 

2  plus 

7-18-18 

negative 

1-19-19 

7 

negative 

negative 

11-8-18 

negative 

8-8-19 

7 

negative 

negative 

1-19-19 

negative 

4-15-20 

6 

negative 

negative 

8-8-19 

negative 

4-15-20 

negative 

Case  II.- — Diagnosis,  tabes.  S.  Z.,  a  man  of  thirty- 
three,  reported  for  treatment  in  April,  1918,  with  a 
history  of  chancre  nineteen  years  ago,  followed  by 
a  maculopapular  rash  and  sore  throat.  Did  not 
receive  any  treatment  until  four  years  ago  when 
he  began  to  complain  of  a  sore  throat  and  stomach 
trouble.  Was  treated  by  his  family  doctor  and  at 
several  hospital  clinics  where  he  received  twelve 
salvarsan  and  about  two  hundred  mercurial  in- 
jections. At  present  complains  of  shooting  pains 
in  legs  and  back,  dyspepsia,  slight  congestion  of 
throat,  spots  appearing  before  right  eye  and  dif- 
ficulty in  seeing  with  right  eye. 

Physical  examination  revealed  the  following:  A 


538 


GOLDFADER:   TREATMENT   OF  NEUROSYPHILIS. 


INew  York 
Medical  Journai,. 


thin  male  with  bony  frame,  fair  musculature;  fundi 
clear ;  pupils  moderately  dilated  and  fixed  to  light ; 
Romberg  absent ;  knees,  right  plus  two,  left  plus 
minus ;  sphincters,  O.  K. ;  gait  normal ;  Babinski 
absent ;  no  facial  or  lingual  tremors ;  no  ataxia  of 
upper  or  lower  extremities ;  speech  O.  K. ;  mental 
negative ;  blood  and  spinal  Wassermanns  four  plus. 

Beginning  April  4,  1918,  he  received  six  Swift- 
Ellis  treatments  at  weekly  intervals,  followed  by 
twelve  mercury  injections  at  intervals  of  four  days 
with  increasing  doses  of  potassium  iodide.  Be- 
ginning July  11,  1918,  he  received  six  more  Swift- 
Ellis  treatments  at  weekly  intervals,  followed  by 
weekly  injections  of  mercury  salicylate.  The. 
patient  now  feels  much  better  and  the  pains  in 
legs  and  back  have  disappeared. 


Spinal  Fluid 

Blood  W.\ssermann 

Date 

Cells 

Globulin 

IVass. 

Date  Result 

3-12-18 

46 

positive 

4  plus 

3-12-18     4  plus 

4-14-18 

46 

positive 

4  plus 

8-2-18  negative 

4-12-18 

38 

positive 

3  plus 

2-26-20  negative 

4-19-18 

negative 

2  plus 

4-26-18 

negative 

2  plus 

5-3-19 

14 

negative 

1  plus 

5-10-18 

16 

negative 

negative 

7-12-18 

12 

negative 

negative 

7-19-18 

10 

negative 

negative 

8-2-18 

18 

negative 

negative 

9-20-19 

10 

negative 

negative 

Case  III. — Diagnosis,  tabes.  J.  W.,  a  man  of 
thirty-seven,  reported  for  treatment  in  September, 
1916,  with  a  history  of  chancre  fourteen  years  ago. 
Had  trouble  in  walking  for  past  two  years,  and  for 
past  four  months  had  had  lancinating  pains  in 
legs.    He  also  suffered  from  headaches. 

Physical  examination  revealed  a  thin  male  weigh- 
ing 125  pounds.  Pupils  unequal  and  irregular, 
both  light  stiff';  knee  jerks  absent;  gait  ataxic: 
speech,  slight  defect  on  test  phrases :  mental, 
memory  for  business  affairs  O.  K. ;  distinct  memory 
defects  for  articles  used  and  acts  performed  in 
daily  life :  sensory,  lancinating  pains  in  legs ;  blood 
and  spinal  Wassermanns,  four  plus. 

Between  September,  1916,  and  July,  1920,  he  re- 
ceived ten  intraspinal  treatments,  twenty-one  treat- 
ments with  salvarsan,  about  one  hundred  injections 
of  mercury  and  potassium  iodide  administered  in- 
ternally. /\bout  March,  1917,  he  complained  of 
severe  headaches  and  tremors,  the  latter  occurring 
when  he  was  in  bed,  from  no  apparent  cause,  and 
referred  especially  to  the  left  foot.  After  a  few 
injections  of  mercury  and  potassium  iodide  inter- 
nally, the  headaches  were  relieved. 

Abovit  October,  1918,  our  notes  showed  that  he 
did  not  walk  as  well  as  formerly,  his  steps  were 
heavier  than  usual  and  when  he  bent  over  he 
trembled.  He  was  then  energetically  treated  with 
ten  intravenous  injections  of  salvarsan  when  he 
improved  somewhat.  In  February,  1920,  he  began 
to  have  difficulty  in  walking,  with  renewal  of  head- 
aches. He  was  given  four  Swift-Ellis  treatments 
and  improved  somewhat. 


SPINAL 

FLUID 

BLOOD  WASSERMAXN 

Date 

IVass. 

Date 

Result 

9-7-16 

4  plus 

9-7-16 

4  plus 

1-25-18 

1  plus 

3-16-17 

negative 

2-3-18 

1  plus 

3-6-19 

negative 

3-15-lS 

negative 

7-2-20 

negative 

3-22-18 

negative 

4-5-18 

negative 

4-12-18 

negative 

7-2-20 

negative 

The  records  for  the  reports  of  the  spinal  fluid 
in  this  case  were  lost  up  to  the  spinal  fluid  taken 


on  January25,  1918.  The  patient  had  received  up 
to  that  time  four  intraspinal  treatments^  eight  sal- 
varsan treatments  and  thirty  injectiens  of  mercury. 
In  this  case  there  was  marked  serological  im- 
provement, with  but  slight  improvement  in  the 
symptoms. 

Case  IV. — Patient  I.  P.  Diagnosis,  cerebral 
type  central  paralysis,  involving  right  arm,  right 
side  of  face,  and  right  leg;  date  of  infection  Sep- 
tember, 1917.  Onset  of  symptoms,  November, 
1918.  The  patient  had  received  six  doses  of  sal- 
varsan and  twenty  injections  of  mercury  salicylate 
between  infection  and  paralysis.  Symptoms  de- 
veloped three  months  after  cessation  of  treatment. 
He  received  three  intraspinal  treatments  of 
salvarsanized  serum  and  three  treatments  of  mer- 
curialized serum.  In  the  course  of  treatment,  edema 
of  lower  extremities  and  marked  albuminuria  de- 
veloped which  could  not  be  accounted  for  by  cardiac 
or  renal  deficiency  under  careful  medical  study. 
This  edema  was  always  less  following  lumbar  punc- 
ture. The  paralysis  had  completely  disappeared, 
and  on  account  of  the  edema  and  albuminuria  we 
discontinued  the  Swift-Ellis  treatments. 


SPINAL 

FLUID 

BLOOD  \ 

Date 

IVass. 

« 

Date 

11-15-18 

4  plus 

11-15-18 

11-22-18 

4  plus 

7-7-20 

12-3-18 

4  plus 

12-6-18 

4  plus 

12-11-18 

4  plus 

12-18-18 

4  plus 

7-7-20 

3  plus 

The  patient  could  not  take  further  spinal  treat- 
ment at  this  time,  but  seemed  to  be  in  excel- 
lent condition.  Even  though  there  was  improve- 
ment in  the  blood  Wasserniann  and  but  slight 
improvement  in  spinal  fluid,  clinically  he  made  an 
excellent  recovery. 

Case  V. — Patient,  C.  R.  Diagnosis,  tabes  with 
optic  atrophy.  Date  of  infection  unknown.  The 
patient  had  had  two  courses  of  treatment,  but  had 
been  two  years  without  treatment.  Had  had  four 
salvarsanized  intraspinal  treatments  and  three  mer- 
curialized serum  treatments  at  weekly  intervals.  At 
time  of  beginning  treatment  the  blood  Wassermann 
was  three  plus ;  spinal  Wassermann  ten  plus.  At 
completion  of  this  course  of  treatment,  patient  felt 
well,  resumed  work,  and  was  absohxtely  steady  on 
his  feet,  though  totally  blind. 

SFI.NAL    FLUID  BLOOD  WASSERMANN 

Date  Wass.  Date  Result 

6-10-18        10  plus  6-10-18        3  plus 

2-8-19        5  plus  2-14-19  negative 

2-14-19        5  plus 

7-8-19        5  plus 

This  patient  was  improved  clinically,  with  no 
improvement  in  his  sight.  He  was  seen  too  late 
for  treatment  to  be  of  any  benefit  to  his  eye  condi- 
tion. Serologically  he  improved  to  some  extent. 
We  used  mercurialized  serum  in  this  case  because 
the  patient  had  marked  reaction  after  salvarsan. 

^^'ith  two  exceptions,  we  have  had  no  disagree- 
able complications  in  the  treatment.  In  one  case, 
the  patient  became  delirious  a  few  hours  after  the 
treatment  and  there  was  a  transient  paralysis  of 
both  lower  extremities  which  cleared  up  entirely  in 
one  week.  In  another  case  of  tic  douloureux  with 
symptoms  for  only  six  months  jaundice  developed 
after  three  treatments.    With  jaundice  still  present 


October  9,  1920.] 


DARN  ALL:  SYPHILIS  AND   DELAYED  HEALING. 


539 


he  received  another  intraspinal  treatment  and  died 
three  days  later,  probably  due  to  the  overwhelming 
toxemia. 

While  Ave  had  a  few  cases  in  which  we  could 
see  no  improvement  either  clinically  or  serologically, 
we  have  had  a  few  cases  with  brilliant  results  and 
definite  results  in  a  considerable  number.  We 
therefore  feel  that  our  results  are  better  with  the 
combined  method  of  treatment,  than  we  have  been 
able  to  obtain  with  the  intravenous  method  alone. 
Tabulated  our  results  are  as  follows:  Improved, 
twenty-seven,  or  sixty-four  per  cent. ;  unimproved, 
fourteen,  or  thirty-three  per  cent. ;  died,  one,  or 
three  per  cent. 

I  believe  when  properly  performed  intraspinal 
treatment  is  indicated  as  a  routine  in  all  cases  of 
syphilis  where  clinical  symptoms  and  examination 
of  the  spinal  fluid  indicate  involvement  of  the  cen- 
tral nervous  system. 

In  conclusion,  I  wish  to  express  my  thanks  to 
Dr.  Nathaniel  P.  Rathbun  and  Dr.  William  F. 
McKenna  for  having  permitted  me  to  use  the  re- 
sults of  their  private  cases  in  compiling  this  report. 

123  Reid  Ave. 


SYPHILIS    AS    A    CAUSE    OF  DELAYED 
HEALING  IN  THE  NONINFECTED 
ABDOMINAL  INCISION.* 

Bv  William  Edgar  Darxall,  A.  M.,   ]\I.  D., 
F.  A.  C.  S., 
Atlantic  City,  N.  J. 

In  1914,  Miles  F.  Porter  discussed  the  question 
of  delayed  healing  in  the  noninfected  incision.  He, 
however,  confined  his  discussion  exclusively  to  the 
epigastric  region  and  sought  to  show  the  cause  as 
due  to  the  increased  tension  of  the  upper  abdomen, 
or  to  the  scantiness  of  the  circulation  in  these  tis- 
sues, or  to  nutritional  disturbances  of  the  nerve 
supply.  There  seems  to  be  little  or  no  literature 
on  this  subject,  although  nearly  every  surgeon  of 
considerable  experience  has  had  one  or  more  cases. 
Morris's  article  (1)  is  about  the  only  reference  to 
the  subject.  Morris  thinks  that  the  occurrence  of 
delayed  healing  in  the  upper  abdomen  is  due  to  tro- 
phic or  neurovascular  disturbance  in  the  zone  of 
Head. 

Porter  collected  personal  expressions  from  a 
number  of  surgeons.  Some  of  these  attributed  the 
separation  of  the  tissues  to  soiling  of  the  incision 
with  the  contents  of  the  upper  bowel  or  stomach,  in- 
asmuch as  most  of  the  operations  in  the  upper 
abdomen  are  performed  on  these  organs.  Others 
thought  blood  dyscrasia,  malnutrition,  and  toxemic 
conditions,  such  as  advanced  carcinoma,  might  be 
the  cause ;  but  Gerster  significantly  remarks  that 
"back  of  all  these  there  must  lie  biochemical  causes 
as  yet  unknown  to  science."  Madelung  asks  why 
the  discussion  of  delayed  healing  should  be  confined 
to  the  upper  abdomen,  when  eighty-two  out  of  one 
hundred  and  fifty-six  cases  occurred  in  incisions 
below  the  umbilicus.    Deaver  sees  no  reason  why 

*Read  at  the  Thirty-second  Annual  Meeting  of  the  American 
.■Association  of  Obstetricians  and  Gynecologists,  Cincinnati,  Ohio. 
September  15-19,  1919. 


wounds  anywhere  in  the  abdomen  should  not  heal, 
in  the  absence  of  infection. 

None  of  these  reasons  seems  to  me  to  answer  the 
question  adequately.  If  it  is  due  in  the  last  analysis, 
as  Bloodgood  thinks,  to  catgut,  why  does  not  the 
same  catgut  used  by  the  same  surgeon  in  the  same 
\Vay  not  more  often  result  in  failure?  As  a  matter 
of  fact,  these  cases  occur  so  infrequently  that  this 
can  hardly  be  the  reason.  The  same  question  may 
be  asked  if  it  is  due  to  faulty  technic  or  to  infection, 
and  yet  busy  surgeons  of  wide  experience  in  each 
instance  seem  to  be  able  to  rcall  only  a  few  cases. 

Some  have  thought  that  the  lack  of  union  is  most 
marked  in,  or  wholly  confined  to,  the  deeper  struc- 
tures. The  question  may  well  be  put :  Why  should 
a  surgeon  who  has  been  constantly  operating  over 
a  period  of  fifteen  or  twenty  years  in  hundreds  of 
■cases,  with  a  well  developed  and  highly  refined 
technic  and  employing  methods  of  suturing  which 
succeed  and  are  expected  to  succeed  in  perfect 
incisions  in  practically  all  clean  cases,  suddenly 
be  confronted  with  an  incision  w'hich,  when  the 
sutures  are  removed  at  the  usual  time,  opens  to  the 
bottom  with  no  attempt  at  union  of  anything,  not 
even  the  peritoneum,  which  ought  to  be  sealed  to- 
gether in  twenty-four  hours,  and  with  no  evidence 
whatever  of  any  infection?  Why  should  it  occur  so 
rarely,  if  it  is  due  to  faulty  technic,  or  catgut,  or 
neurovascular  disturbance,  or  lack  of  blood  supply, 
or  tension  ?  Certainly  these  conditions  occur  so 
constantly  that,  if  delayed  healing  is  due  to  them, 
it  ought  to  be  as  commonplace  as  the  usual  occur- 
rences in  abdominal  incisions,  such  as  stitch  ab- 
scess, incisional  hernia,  and  other  conditions. 

In  my  own  experience,  which  covers  an  active 
service  of  nearly  twenty  years.  I  can  find  but  three 
cases  among  hundreds  of  abdominal  incisions.  This 
comparative  infrequenc\-  accords  with  the  experi- 
ence of  most  of  those  discussing  the  question,  and 
also  of  those  quoted  by  Porter.  No  surgeon  seems 
to  have  had  many  cases,  and  yet  almost  all  can  point 
to  a  few.  But  if  the  few  cases  occurring  in  the 
practice  of  each  of  us  could  be  collected  and  studied, 
the  number  in  the  aggregate  would  be  sufficient 
from  which  to  draw  valuable  conclusions. 

Two  of  my  cases  occurred  in  patients  with  in- 
cisions below  the  umbilicus  and  one  above.  The  first, 
a  ward  case,  was  that  of  a  negress  on  whom  I  did  a 
subtotal  hysterectomy  for  large  fibroids.  The  case 
was  a  perfectly  clean  one.  There  was  no  indication 
after  the  operation  of  any  infection  of  the  incision, 
either  locally  or  constitutionally.  We  thought  she 
was  making  a  satisfactory  recovery  until  the  remov- 
al on  the  tenth  day  of  the  silkworm  sutures  from 
the  skin.  Then  the  whole  Avound  fell  wide  open,  peri- 
toneum and  all,  so  that  one  could  look  with  unob- 
structed view  to  the  bottom  of  Douglas's  cul-de-sac 
She  became  infected  and  died.  This  case  occurred 
before  the  discovery  of  the  Wassermann  reaction, 
but  the  almost  universal  prevalence  of  syphilis 
among  the  Southern  negroes  at  least  places  her 
under  suspicion. 

The  second  case  occurred  in  1913  in  a  husky 
Italian,  on  whom  I  did  a  cholecystostomy.  The  in- 
cision was  made  through  the  right  rectus  muscle. 
Five  days  after  the  operation  the  incision  showed 


540 


RIDDELL:  EARLY  VIEW   OF  VENEREAL  DISEASE. 


[New  York 
Medical  Journal. 


no  healing  and  no  infection,  and  the  intestines  were 
protruding.  He  was  taken  to  the  operating  room, 
sewed  up  again,  and  fed  actively  on  iodides,  with 
the  result  that  his  incision  healed  perfectly.  In  his 
case  the  Wassermann  reaction  was  positive. 

The  third  instance  occurred  in  a  patient  on  whom 
I  did  a  Wertheim  operation  for  carcinoma  of  the 
cervix.  The  other  two  patients  were  strong  and  ro- 
bust. This  one  was  of  lowered  vitality,  although 
the  cancer  had  not  progressed  extensively.  When 
the  skin  stitches  were  removed  on  the  tenth  day, 
the  incision  presented  a  straight  line  of  apparently 
perfect  union.  There  had  been  absolutely  no  evi- 
dence whatever  of  infection.  A  few  hours  after- 
ward, however,  it  had  all  fallen  apart,  even  the 
peritoneum.  The  Wassermann  test  was  reported 
negative,  but  it  was  learned  that  she  had  conducted 
for  years  a  number  of  houses  of  ill  fame,  in  a  series 
of  cities.  Her  general  facies  and  appearance  with 
sunken  nasal  bridge  and  husky  voice  would  have 
suggested  specific  disease  if  there  were  no  such 
thing  as  a  Wassermann,  and  there  is  no  doubt  in 
my  mind  of  the  presence  of  an  old  specific  infection, 
in  spite  of  the  negative  Wassermann. 

These  three  cases  are  not  enough  for  definite  con- 
clusions, but  two  were  undoubtedly  syphilitic  and 
the  other  was  probably  so.  This  evidence  is  enough 
to  suggest  syphilis  as  one  of  the  causes  at  least,  of 
delayed  healing  in  the  abdominal  incision.  H  by 
this  report  I  may  be  able  to  stimulate  the  discus- 
sion of  your  individual  experiences  and  to  urge 
each  surgeon  who  may  have  a  few  cases,  to  study 
them  from  the  viewpoint  of  specific  syphilitic  in- 
fection and  report  the  results,  in  a  year  or  two 
enough  data  may  be  collated  to  enable  us  to  con- 
clude what  part  old  syphilitic  infection  plays  in  the 
absolute  lack  of  healing  in  incisions  in  which  we 
had  every  reason  to  expect  perfect  results,  primary 
union  and  better  things. 

REFEREXCES. 

1.    Morris  :  Jmrnal  A.  M.  A.,  June,  1911. 
1704  Pacific  Avenue. 


AN  EARLY  VIEW  OF  VENEREAL  DISEASE 

By  The  Hon.  William  Renwick  Riddell, 
LL.D.,  F.R.H.S.. 

Toronto, 

President   of  the   Canadian   National   Council   for  Combating 
Venereal  Diseases. 

The  terrible  prevalence  of  venereal  diseases  has 
been  forced  upon  the  attention  of  the  Canadian 
government  and  a  national  council  has  been  formed 
to  assist  the  central  and  local  governments  in  com- 
bating the  evil.  As  president  of  this  council  I  was 
led  to  examine  again  what  some  of  the  older  au- 
thorities had  to  say  about  these  diseases. 

From  a  somewhat  extensive  collection  of  ancient 
medical  literature  in  my  library,  I  select  as  one  of 
the  most  instructive  and  interesting  a  volume  of  516 
pages,  licensed  September  2,  1664,  and  published  in 
London  in  the  following  year.  The  title  of  the  work 
is  Mcdcla  Mcdichue,  a  Plea  for  the  Free  Profession 
and  a  Renovation  of  the  Art  of  Physick.  The 
author  is  given  as  M.  N.,  Med.  Londinensis,  the 


motto  Medic e  cura  teipsum.  It  is  known,  however, 
that  the  author  was  Marchmont  Nedham  (or  Need- 
ham),  a  versatile  journalist  (1). 

Mcdela  Mcdicincc,  healing  of  medicine,  is  an 
attack  on  the  formal  practice  of  the  physicians  of 
the  time.  It  attacks  the  jMethodists  who  strictly 
followed  rule,  Galenists  who  care  not  if  a  patient 
die  so  long  as  he  has  been  treated  secundum  artetn 
("Let  him  die,  if  he  will,  so  he  die  secundum  ar- 
tem.")  (2),  Hke  Balzac's  physician  of  Mantua,  who 
"did  not  only  not  particularly  inquire  into  the  cure 
of  diseases  but  boasted  that  he  had  killed  a  man  by 
the  fairest  method  in  the  world."  The  writer  urges 
experiment,  the  use  of  the  microscope,  inquiry  of 
smiths,  grooms,  farriers,  cattle  breeders,  barbers, 
midwives,  nurses,  old  women,  as  to  their  remedies. 
Spurning  as  mere  chimeras  the  old  doctrine  of  four 
elements  attributed  to  Hippocrates,  of  four  quali- 
ties and  four  complexions  fathered  by  Galen,  and 
also  Galen's  real  "allopathic"  principle  that  "con- 
traries are  to  be  cured  by  contraries,"  he  himself 
accepts  Dr.  Willis's  five  elements :  water,  earth,  salt, 
sulphur  and  spirit  (3). 

Nedham  does  not  so  much  find  fault  with  the 
practice  of  Hippocrates — he  savagely  artacks  Galen 
— as  try  to  show  that  however  useful  the  practice  was 
in  Hippocrates's  country  and  time,  it  was  not  useful 
in  England  in  the  seventeenth  century,  and  "in 
plain  English  a  Doctor  bred  in  the  Contemplative 
Philosophy  of  the  Schools  may  be  a  Scholar  and  a 
very  fine  Gentleman,  but  what  is  that  to  the  Curing 
of  a  Disease  or  the  rousing  of  a  Heartsick  Man 
from  his  bed  of  Languishment."  As  an  example 
of  a  drug  with  medicinal  qualities  elsewhere,  but 
not  in  England,  he  speaks  of  "Coffee  which  Prosper 
Alpinus  (the  last  of  the  Methodists)  in  his  book 
De  Medicina  JEgyptorum  relates  to  have  abundance 
of  vertues  in  that  Country  of  Egypt,  of  which  we 
find  no  effect  in  England  save  that  it  sen-es  to  make 
a  Liquor  harmless  enough  in  Rheumatick  Bodies, 
for  ordinary  conversation  like  other  Drink  but  not 
for  any  considerable  peculiar  uses  of  Medicine  as  in 
Egypt." 

His  main  thesis  is  that  diseases  have  been  much 
changed  and  that  they  "are  of  another  nature  than 
they  were  in  former  times."  The  main  causes  of 
this  alteration  he  states  as  being  the  French  pox  (4) 
and  the  scurvy.  It  is  his  account  of  the  former  dis- 
ease which  is  of  interest  to  us  in  this  connection. 

At  its  first  appearance  in  the  world,  the  French 
pox  was  very  different  from  what  it  had  become. 
Fracastorius  (5)  and  Benivenius  (6)  tell  us  that 
"it  in  the  beginning  broke  (7)  forth  in  odious  pus- 
tules of  several  kinds  upon  the  privates,  the  head, 
the  face,  the  neck,  the  breast,  the  arms  and  gener- 
ally the  whole  body.  Some  also  it  disfigured  after 
the  rate  of  a  leprosy;  others  had  a  kind  of  scurf, 
which  scaling  of?  discovered  the  skin  underneath  to 
be  black  or  blue.  Upon  some,  foul  ichorous  sores 
were  continually  running.  And  besides  all  these 
they  had  in  the  inward  parts  great  tormenting  ex- 
ulcerations,  as  in  the  mouth,  the  throat,  the  nostrils, 
the  urinary  and  spermatic  passages  which  did  eat 
off  the  penis,  the  palate,  the  lips,  the  nose  in  despite 
of  all  medicines,  so  that  men  being  affected  with 
the  disease,  their  friends  were  frightened  from  look- 


October  9,  1920.] 


RID  DELL:   EARLY  VIEIV 


OF  VENEREAL  DISEASE. 


541 


ing  upon  them  and  spurned  them  as  if  they  had  been 
visited  with  the  pestilence.  These  things  being  con- 
sidered with  the  terrible  pains  that  racked  them  it 
was  rightly  termed  by  a  certain  author  Miserabile 
scortatorum  flagelliim." 

But  Fracastorius,  who  he  observes  was  born  be- 
fore the  introduction  of  syphilis  into  Europe,  says 
that  in  twenty  years  it  altered  much  and  that  there 
was  after  this  another  imitation  within  six  years' 
time,  the  disease  not  raging  as  before  in  the  exter- 
nal parts.  This  agrees  with  the  account  of  Fernel- 
ius  "who  was  born  almost  twenty  years  before  it 
was  discovered  in  Europe  and  lived  to  seventy-two 
years  of  age,  saw  it  much  changed  in  the  space  of 
thirty  or  forty  years,  in  so  much  as  he  tells  us  in 
his  time  it  was  much  altered,  not  defacing  the  bod- 
ies of  men  with  pustules,  scurfs,  and  virulent  ulcers 
but  tormenting  them  more  with  intolerable  pains 
which  though  they  might  be  increased  by  the  igno- 
rant and  preposterous  ways  of  curing  them  used, 
yet  the  disease  itself  also  changed  continually  and 
seemed  to  decline  and  grow  old — adeo  ut  lues  quce 
nunc  grassatur,  vix  illius  generis  esse  putetur"  (8). 

Two  or  three  generations  later  Sennertus  (9) 
observed  that,  whereas  in  earlier  times  nearly  all  if 
not  all  infections  took  place  in  coition,  now  "where 
one  person  gets  this  disease  by  the  beastliness  of 
venery,  many  hundreds  have  it  by  traduction,"  for 
he  says,  "The  French  disease  is  now  become  hered- 
itary, being  derived  from  parents  to  their  posterity 
by  generation  and  communicated  from  infected 
persons  to  others  by  kissing,  by  sucking,  by  clothes 
and  the  like." 

Nedham  points  out  that  the  venereal  distempers 
contracted  in  either  of  these  ways  differ  externally 
from  that  gotten  by  unlawful  contact,  for  they 
(i.  e.,  those  contacts  in  any  of  the  ways  mentioned) 
"usually  appear  in  the  form  of  other  maladies,"  for 
which  he  vouches  not  only  eminent  authors  but 
also  his  own  daily  practice  "as  abundance  of  people 
grow  sickly  and  languish  under  the  appearance,  it 
may  be,  of  a  consumption  (10),  a  gout,  a  dropsy, 
an  ague,  a  slow  fever  and  sometimes  an  acute  one, 
sore  eyes,  green  sickness  and  indeed  all  manner  of 
diseases,  which  when  the  other  ordinary  means 
have  long  been  used  in  same,  have  at  length  been 
relieved  by  an  orderly,  i.  e.,  systematic,  use  of  anti- 
venerous  remedies."  He  says  further:  "This  dis- 
ease falls  sometimes  but  gently  on  the  hair, 
sometimes  on  the  nerves  and  causes  all  manner  of 
palsies,  cramps,  convulsions,  toothache,  pains  in  the 
limbs,  gout  of  all  sorts,  lameness,  general  debility, 
etc. ;  sometimes  on  the  bones,  sometimes  on  the 
fleshy  parts  whence  come  leprosies,  scurfs,  ulcers, 
knotty  swellings,  and  the  like;  sometimes  on  the 
brain,  whence  come  sore  eyes,  rheums,  catarrhs, 
epilepsies,  etc. ;  sometimes  on  the  lungs,  whence 
come  asthmas,  coughs,  phthisical  consumptions, 
etc.,  and  so  many  other  diseases  too  long  to  enu- 
merate." He  warns  "strikers"  (11)  of  their  great 
danger  and  says  of  "women  strikers"  that  there  is 
scarcely  any  possibility  of  escaping  infection  be- 
cause they  are  the  receivers  of  impurity.  The  very 
carefully  prescribed  precautions  for  the  "male 
strikers"  are  given  in  the  "decent  obscurity  of  a 
learned  language" — Latin.    They  consist  of  imme- 


diate and  thorough  ablution  preferably  with  hot  wa- 
ter post  coitum,  for  while  "an  internal  taint  (more 
or  less)  be  scarce  ever  avoided  by  any,  yet  cleanli- 
ness ex  post  facto  is  a  great  means  to  prevent  the 
virulent  eruptions  of  a  gonorrheal  exulceration 
and  other  sad  effects  in  and  about  the  genitals." 
Such  measures  may  be  quite  ineffective  quo  flagraii- 
tius  libidine  exardescunt  et,  equorum  instar,  igneo 
spermate  stimulati  rem  ferocius  affectant  (12). 

One  cause  of  the  impossibility  of  preventing  con- 
tagion is  the  supposed  fact  of  contagion  at  a  dis- 
tance. This  our  author  firmly  believes,  and  quotes 
learned  authors  in  support.  Zacutus  Lusitanius 
(13)  says:  "I  have  proved  the  French  pox  is  con- 
tagious at  a  distance."  Minadous  (14)  considered 
that  he  had  also  proved  the  same  and  thought  that 
natural  spirits  might  carry  contagions  from  one  to 
another.  Avicenna  (15)  is  authority  for  contagion 
at  a  distance  in  leprosy,  Zacutus  in  leprosy,  scabs, 
scurfs,  itches,  sore  eyes,  catarrhs,  etc. ;  and  our  au- 
thor submits  that  there  is  no  reason  why  it  should 
not  be  the  case  in  French  pox.  He  does  not  indeed 
accept  the  theory  of  Minadous  that  "natural  spirits 
carry  contagion" ;  he  has  two  other  media  which  he 
advances  explaining  them  on  scientific  lines,  as  sci- 
ence was  then  understood.  True  "the  ordinary 
gross  conceit  (conception)  of  the  world  concerning 
corporeity  renders  doctrines  of  this  kind  very  diffi- 
cult to  comprehend ;  but  he  who  reads  the  finer  phil- 
osophy of  this  wiser  age  and  does  not  take  measure 
of  it  by  the  beards  of  our  ancestors  but  has  digested 
the  principles  of  the  magnetic  or  sympathetic  doc- 
trine of  our  noble  Digby  (16)  and  others  treating 
of  the  subject  ...  of  the  truth  of  which  daily 
experiments  are  a  sufficient  testimony,  will  soon 
agree  upon  the  probability,  the  certainty  indeed, 
of  persons  being  seizable  at  a  distance  by  virtue  of 
the  continual  efifluxes  of  atomical  corpuscles  which 
one  may  call  bodikins  instead  of  bodies,  whereby 
the  grosser  substances,  usually  termed  bodies,  are 
touchable  by  each  other  and  hold  communication 
with  each  other  at  remote  distances  and  so  operate 
upon  each  other  by  infection  or  qualification."  The 
principles  are  plain  and  quite  in  accord  with  the  sci- 
ence of  the  time.  Every  body  struck  by  light  has 
small  atoms  separated  from  its  mass  and  then  the 
light  .carries  off  these  atoms,  minute  corpuscles, 
"bodikins,"  these  flow  with  the  light  or  without  it, 
through  the  air  at  all  times  and  in  all  directions  and 
may  be  attracted  by  their  like  or  may  strike  at  ran- 
dom. Consequently,  as  "Fracastorius  and  Nicolaus 
Leonicenus"  (17)  two  learned  Italians  do  both 
contend  that  the  French  pox  rambles  .  .  .  seizing 
folk  that  never  had  any  carnal  mixture  with  un- 
clean persons."  Fortunately  perhaps  the  disease 
thus  communicated  is  different  in  its  effect  from 
that  caught  by  carnal  intercourse — the  latter  is  usu- 
ally more  visible  in  its  dire  effects  upon  the  body  by 
gonorrheas,  buboes,  ulcers,  etc.,  while  the  former 
"is  of  a  finer  nature  and  dives  not  so  deep  at  once 
into  the  blood  and  humors  (fluids)  as  it  insinuates 
into  the  spirits  and  ferments  of  the  body  and  acts 
by  time  and  stratagem,  lying  still  till  it  has  an  op- 
portunity, not  but  that  the  other  many  times  lurks 
some  years  also,  but  this  more  curious  (18)  way  of 
contagion  for  the  most  part  after  it  has  made  entry 


542 


RIDDELL:  EARLY  VIEW   Of   VENEREAL  DISEASE. 


[New  York 
Medical  Jouenai,. 


proceeds  leisurely  and  gradually  to  debauch  (19) 
the  whole  habit  of  the  body  and  seldom  plays  the 
tyrant  till  it  has  made  a  full  and  final  usurpation 
which  it  seldom  accomplishes  without  a  revolution 
of  many  years.  And  then  perhaps  it  appears  not 
like  itself  but  in  the  shape  of  some  one  or  more 
diseases  .  .  .  So  in  this  disease,  the  pox,  may 
lurk,  but  the  manner  how  with  the  reason  why,  we 
can  only  guess  at."  Sennertus  is  quoted  with  ap- 
proval as  saying  that  the  lues  passes  under  the  name 
of  many  diseases,  for  the  venom  lurking  in  the  body 
though  it  seems  extinct  will  show  itself  after  thirty 
years'  time.  "It  will  act  all  the  diseases  of  the 
stomach,  liver  and  spleen ;  it  will  appear  in  a  head- 
ache, vertigo,  falling  sickness,  catarrhs  and  distilla- 
tions (20)  of  all  sorts,  strange  arthritical  pains,  dis- 
eases of  the  lungs  and  of  the  womb,  etc." 

So  much  for  mechanical  effluvia.  The  author  is 
more  interesting  when  he  speaks  of  another  source 
of  infection  not  unlike  the  former.  It  is  the  con- 
ception of  the  famous  Jesuit  Athanasius  Kircher 
(21)  of  Fulda,  then  living  at  Rome,  which  Nedham 
approves.  The  "new  paradox"  (22)  of  Kircher 
was  that  contagion  was  conveyed  "not  only  by  the 
volatility  of  such  effluvia,  atoms  and  corpuscles  as 
were  inanimate  but  by  such  also  as  were  animate, 
living  creatures,  and  were  a  sort  of  invisible  worms 
or  vermicles  which  were  visible  only  under  the  mi- 
croscope. (Had  he  said  bacilli,  spirochetse,  or  the 
like,  he  would  have  been  modern.)  Our  author 
says  that  by  the  use  of  his  microscope  he  discov- 
ered why  sage  unwashed  is  hurtful  to  those  who 
eat  it:  for  Nedham  examined  sage  with  his  micro- 
scope and  found  what  appeared  to  be  animals  ex- 
ceedingly small  on  it — he  gives  a  number  of  other 
experiments  showing  the  marvel  of  the  microscope 
and  is  perfectly  satisfied  that  measles,  smallpox, 
spotted  fevers  and  purples  (23)  (purpura,  petechial 
fever  socalled)  come  from  small  worms  or  vermicles, 
and  does  not  hesitate  to  say  that  much  of  the  infec- 
tion of  the  lues  is  due  to  these  small  animals,  animal- 
culae.  But  more  than  the  terminology  is  wanting  to 
bring  him  up  to  our  modern  way  of  thought.  He 
believed  these  small  animals  were  flying  all  the  time 
through  the  air  retaining  their  vitality  indefinitely, 
a  conception  contrary  to  our  modern  science. 

As  to  the  treatment  and  cure  of  venereal  disease, 
he  seems  to  give  full  credence  to  a  superstition  still 
prevalent,  namely,  that  one  recently  infected  may 
get  rid  of  the  disease  by  passing  it  along  without 
delay  to  another  of  the  opposite  sex.  He  reprobates 
the  practice  indeed,  but  does  not  doubt  its  efficacy. 
"For  at  first  taking  the  disease  lodges  in  the  out 
parts,  viz.,  the  urinary  and  spermatic  vessels,  and 
doubtless  ought  to  be  sent  back  the  same  way  that 
it  came  in,  as  is  evident  by  the  immediate  cure  that 
some  as  soon  as  they  have  been  clap't  have  pro- 
cured to  themselves  by  repeated  coitions  with  sound 
women :  and  some  I  have  known  to  glory  in  this 
villainy  of  debauching  that  sex  in  order  to  bring 
about  a  cure." 

He  has  no  patience  with  the  do  nothing  physician 
and  he  rightly  deprecates  the  neglect  of  an  infected 
person  "to  look  out  for  a  cure"  and  has  nothing  but 
condemnation  for  the  custom  "to  run  to  any  pre- 
tender for  a  cure  for  pox    .   .   .   for  the  pretend- 


ed cure  very  often  proves  worse  than  the  disease 
destroying  the  constitution."  Some  physicians  are 
no  better  "because  they  inake  use  of  the  common 
scope  and  remedies  in  curing."  He  condemns  the 
cheap-poor-whore-cure  by  fontanels  or  issues  de- 
rived from  the  practice  of  the  poorer  Spaniards. 
Mercurial  unguent  may  serve  for  "carriers  and  por- 
ters and  other  robustious  bodies"  but  "setting  upon 
every  venereous  patient  with  this  dreadful  remedy" 
is  unpardonable.  The  resulting  salivation  with  other 
dreadful  symptoms  following  its  use  show  that 
Nedham  was  speaking  of  the  unguent  treatment 
carried  to  excess.  The  mercurial  cinnabar  fume 
was  yet  worse  and  to  those  with  pectoral  troubles  it 
was  pernicious  for  "use  what  care  you  can,  the  mer- 
curial air  will  get  into  the  chest."  Salivation  by 
internal  medicine  was  quite  as  bad  as  managed  by 
most  surgeons,  although  it  was  the  best  of  all 
ordinary  ways — but  care  should  be  used  to  "do  the. 
work  of  salivation  without  those  tedious  and  intol- 
erable afflictions  of  swollen  head,  loose  teeth,  sore- 
and  swollen  mouth,  tongue  and  throat,  etc." 

Keep  away  from  receipt  mongers,  for  the  "com- 
mon sort  .  .  .  err  not  only  in  their  pretended- 
way  of  curing  the  pox  when  it  is  inveterate  and  con- 
firmed but  they  stumble  and  do  as  much  mischief  in- 
the  very  beginning  when  it  is  but  a  clap  (as  they 
call  it)  a  virulent  running  of  the  reins,  etc."  There 
must  be  due  temperance  and  rule  of  eating,  drink- 
ing, exercise  and  recreation ;  but  when  all  is  said  and 
done  mercurial  salivation  is  the  only  cure. 

I  do  not  here  follow  the  author  in  his  remarks  as 
to  the  treatment  of  scurvy  and  other  diseases,  or 
into  his  animadversions  on  physicians  and  their  prac- 
tice in  general;  these  matters  are  not  germane  to- 
the  object  of  the  present  inquiry. 

NOTES. 

1. — Marchmont    Nedham    (or    Needham)  born' 
1620,  educated  at  Oxford  where  he  took  his  B.A. 
at  the  age  of  seventeen.     He  was  afterwards  an> 
usher  in  Merchant  Taylors'  school,  then  an  undei 
clerk  in  Gray's  Inn,  of  which  he  became  a  member- 
in  1652.    He  also  studied  medicine,  when,  where 
and  under  whom  does  not  appear.    He  found  his 
true  vocation  in  journalism.   He  was  a  supporter  of 
Cromwell   and   his    .scurrility,  vigor  and  boldness 
were  not  surpassed  in  any  of  the  writings  of  the 
period.    On  the  restoration  of  the  Stuarts  in  1660' 
he  took  refuge  in  Holland  but  soon  obtained  a  par- 
don and  returned  to  England.    For  the  rest  of  his  - 
life  (he  died  in  1678)  he  practised  medicine  with 
an  occasional  excursion  into  journalism. 

My  copy  of  the  Medela  Medicin(S  is  bound  in 
contemporary  calf,  not  tooled  or  gilded.  It  seems  . 
to  have  at  one  time  belonged  to  a  Dr.  Mudd  (not 
the  Dr.  Mudd  who  looked  after  Wilkes  Booth's 
fractured  fibula  and  paid  so  dear  for  his  humanity). 
Some  previous  owner  had  made  a  memorandum  on 
the  page  opposite  the  title  page,  "There  is  an  an- 
swer made  to  this  book  by  Dr.  Spraddin,"  referring 
to  Dr.  Robert  Spracklin's  Medela  Ignorantiee,  1666. 
There  were  two  other  answers,  one  by  Dr.  John 
Twysden,  Medicina  Vetcrum  vindicata,  1666,  and ' 
the  other  by  Dr.  George  Castle  in  Reflections  on  a 
Book   called  Medela  Medicince,  printed   with   The  • 


Octobei  9,  1920  J 


RIDDELL:  EARLY  VIEW   OF  VENEREAL  DISEASE. 


543 


Chyniical  Galcnist  in  1667.  Nedham  himself  says, 
"Four  champions  were  employed  by  the  College  of 
Physicians  to  write  against  the  book,"  and  adds 
that  two  died  shortly  afterward,  the  third  took  to 
drink  and  the  fourth  asked  his  pardon  publicly.  See 
D.  N.  B.,  Vol.  XL,  Pp.  159-164:  Athen^e  Oxon. 
Vol.  iii,  1187. 

2.  — This  reminds  one  of  the  skit  on  the  well 
known  Dr.  Lettsom,  who  flourished  in  London  to- 
ward the  end  of  the  eighteenth  and  the  beginning 
of  the  nineteenth  century.  One  very  usual  form 
runs : 

"When  patients  sick  to  me  apply 
I  physics,  bleeds,  and  sweats  'em ; 

If  after  that  they  please  to  die, 
What's  that  to  me?  I.  Lettsom. 

3.  _Dr.  Thomas  WilHs  (1621-1676),  M.A.,  Ox- 
ford 1642:  M.B.  1646:  M.D.  1660:  F.R.S., 
F.R.C.P.  1664.  He  was  the  first  to  distinguish  dia- 
betes melHtus  and  was  physician  in  ordinary  to 
King  Charles  II. 

4.  — Nedham  calls  this  disease  by  many  names — 
pox,  French  pest,  French  disease,  French  ferment, 
French  pox,  pocky  disease,  pocky  lues,  pocky  fer- 
ment, pocky  infection,  lues  venerea,  lues,  French 
lues,  French  infection,  venereal  disease,  venereal  dis- 
temper, never  syphilis.  Gonorrhea  is  mentioned  but, 
of  course,  it  was  then  supposed  that  gonorrhea  was 
a  form  of  pox,  mi  error  which  was  later  confirmed 
by  Dr.  John  Hunter's  classic  experiment  on  him- 
self and  which  gave  way  only  after  the  investiga- 
tions of  Ricord  and  his  school.  Neisser,  of  Breslau, 
placed  the  specific  identity  of  gonorrhea  beyond 
question  in  1879  by  his  discovery  of  the  gonococcus : 
but  it  was  not  till  1905  that  Schaudinn  and  Hoffman 
identified  the  Spirochseta  pallida  of  syphilis. 

5.  — Girolamo  Fracastoro  (latinized  Fracastorius) 
1483-1553  of  Verona,  physician  to  Pope  Paul  III: 
he  revised  the  old  theory  of  "critical  days"  and  rather 
gave  it  a  new  lease  of  life.  It  was  in  full  vigor  in 
England  in  Nedham's  time  and  is  attacked  by  him. 
Fracastorius,  among  many  other  works,  medical 
and  poetical,  wrote  a  book  on  Contagious  Diseases 
but  is  best  known  by  his  famous  poem  Sypliilidis 
sine  Morbi  Gallici  libri  trcs,  Verona,  1530,  often 
reprinted  and  translated  into  French  and  Italian. 
(The  Latin  form  is  very  rare,  I  have  seen  only 
one  copy.)  The  hero  of  the  poem  was  a  swineherd, 
Syphilus,  i.  e.,  the  swine  lover  (without  apparently 
any  implication  of  unnatural  vice,  although  that 
form  of  crime  has  been  not  infrequently  suggested 
as  the  original  of  syphilis)  and  his  sufferings  from 
the  Morbus  Gallicus  were  the  theme  of  the  poem. 
The  Italians  charged  the  French  with  being  the  orig- 
inators of  the  infection,  whence  Morbus  Gallicus, 
while  the  French  not  to  be  behind  in  international 
courtesy  gave  the  honor  to  the  Italians,  whence  Mai 
de  Naples.  The  almost  universal  use  of  the  term 
syphilis  seems  to  be  largely  due  to  Sauvages — 
Francois  Boissier  de  la  Croix  de  Sauvages  (1706- 
1767)  the  animistic  mechanician  who  made  a  sys- 
tem of  diseases  on  the  lines  of  Linnaeus'  System 
of  Botany  in  his  Nosologia  Methodica.  Sauvages 
makes  ten  classes  of  diseases,  295  genera,  and  2,400 
species.    (Linnaeus  had  325  genera  of  plants). 

6.  — Antonio  Benivieni  (ob.  circ.  1502),  of  Flor- 


ence, a  Hippocratic  of  a  somewhat  rigid  school.  He 
is  of  some  note  as  an  obstetrician  and  pathologist. 

7.  — I  modernize  the  spelling,  capitalization,  punc- 
tuation, etc. — archaisms  in  these  are  apt  to  draw 
the  attention  away  from  the  substance.  There 
could  not  be  said  to  be  a  standard  English  orthog- 
raphy until  Dr.  Samuel  Johnson's  time,  every  one 
following  his  own  judgment,  taste  or  caprice  and  not 
infrequen^tly  two  or  more  spellings  of  the  same- 
word  would  be  found  by  the  same  author  in  the 
same  book,  the  same  paragraph,  sometimes  in  the 
same  sentence.  Capitalization  did  not  become  thor- 
oughly standardized  until  well  into  the  nineteenth 
century — often  the  nouns  were  written  with  a  cap- 
ital as  is  the  custom  still  in  German ;  other  impor- 
tant words  were  often  capitalized  while  adjectives 
generally  received  a  small  letter  as  in  French. 

8.  — Jean  Francois  Fernel  (Fernelius)  was  born 
in  1497  by  which  time  syphilis  had  been  recognized 
in  parts  of  Europe.  The  celebrated  siege  of  Naples 
by  Charles  VIII  of  France  which  was  the  cause  or  at 
least  the  occasion  of  spreading  the  infection  took 
place  in  1495.  But  Nedham  gives  his  age  at  death 
as  seventy-two;  Fernel  died  in  1558,  therefore  Ned- 
ham must  have  thought  that  he  was  born  circ.  1486, 
and  indeed  1485  is  given  as  his  birth  year  by  some 
authorities,  e.  g.,  Bass  in  his  History  of  Medicine. 
Fernel  was  a  great  mathematician  but  turned  his 
full  attention  to  medicine  at  the  age  of  thirty-five ; 
he  was  the  most  distinguished  physiologist  of  his 
age  but  thought  the  blood  originated  in  the  liver  and 
the  "elements"  were  actual  bodies.  Nedham  quotes 
from  Fernel's  De  Lue  Venerea  and  part  of  his  work 
De  abditis  rertim  causis.  The  Latin  with  which  the 
quotation  ends  means :  "So  much  so  that  the  lues 
which  now  prevails*  can  hardly  be  considered  of  the 
same  kind." 

9.  — Daniel  Sennert  (Sennertus)  1572-1637,  the 
son  of  a  shoemaker  in  Breslau,  studied  at  Wittem- 
berg  where  he  received  his  degree  in  medicine,  Leip- 
sic,  Jena,  Frankfort  and  Berlin.  He  became  a  pro- 
fessor in  Wittemberg  and  introduced  the  study  of 
chemistry  in  that  university.  He  died  there  of  the 
plague  in  1637.  He  was  one  of  the  first  to  describe 
scarlet  fever  (1619)  ;  he  was  an  "atomist"  and  held 
that  each  element  had  primary  particles,  corpuscles 
or  atoms  peculiar  to  itself.  His  works  are  in  six  large 
folio  volumes,  the  last  edition  published  at  Lyons 
in  1696;  the  quotation  is  from  Book  VI,  part  IV, 
chapter  5. 

10.  — It  must  be  borne  in  mind  that  consumption 
until  very  recently  had  a  wide  connotation.  See 
Note  7  to  my  article  in  the  New  York  Medical 
Journal  of  September  27,  1919,  on  Medical  Theory 
and  Practice  of  an  18th  Century  Doctor  of  Divinity. 
Nedham  himself  speaks  of  three  species,  hectick,. 
phthisic,  atrophic. 

11.  — This  word  is  no  doubt  akin  to  the  German 
Streicher;  while  it  was  not  in  very  common  literary 
use  before  and  at  Nedham's  time  it  had  been  used 
by  Nash  and  some  others.  The  New  English  Dic- 
tionary, p.  1136  sub  voc.  Striker  2  d  quotes  this  very 
book  Medcla  Mcdicincc  for  its  use.  The  word  is 
synonymous  with  scortator  or  what  Nedham  blunt- 
ly calls  whoremonger.  A  woman  striker  is  the  fe- 
male of  the  species. 


544 


MARTIN:   URINARY  BLADDER. 


[New  York 
Medical  Journal. 


12.  — "Where  they  are  too  passionately  inflamed 
with  desire  and,  like  horses,  urged  on  by  burning 
semen  attempt  their  aim  too  fiercely."  The  precau- 
tions to  be  taken  are  given  in  Latin  "locked  up  from 
the  eyes  of  common  readers  partly  for  modesty's 
sake  and  partly  because  such  cautions  may  prove  an 
encouragement  to  wickedness."  The  reasons  for 
avoiding  all  reference  to  such  diseases  and  prophy- 
lactics against  them  are  only  now  beginning  to  yield 
to  terrible  necessity.  Zacutus  Lusitanius  (Abraham 
Zacuto),  1575-1672,  a  learned  Portuguese  Jew  born 
in  Lisbon,  an  ardent  follower  of  Galen  and  the 
Arabians  and  a  pathologist  of  some  merit,  is  quoted 
for  preventive  rules  but  even  Zacutus  admits  their 
failure  in  some  cases. 

13.  — See  Note  12.  The  works  of  Zacutus  cited 
are  his  Praxis  admiranda,  Book  II,  obs.  134;  and 
De  MedicincE  Principalium  Historice  72>. 

14.  — Thomas  or  Aurelius  Minadous,  1554-1604, 
a  celebrated  practitioner  and  professor  at  Padua, 
one  of  Harvey's  preceptors — the  work  of  Minadous 
citied  is  De  Lue  Venerea,  Chap.  V. 

15.  — Avicenna  (Ebu  Sina,  Abu  Aliebu  Abdallah 
ebu  Sina)  980-1037,  "the  Prince  of  Physicians,"  too 
well  known  to  require  further  notice  here. 

16.  — As  to  Sir  Kenelm  Digby  and  his  powder  of 
sympathy  see  my  article  in  the  New  York  Medi- 
cal Journal  for  February  19,  1916. 

17.  — Nicholas  Leonicenus  (1478-1524)  was  the 
first  to  write  on  anything  like  modern  lines  on 
syphilis  (1497)  ;  he  was  well  acquainted  with  the 
symptoms  and  many  of  the  effects  of  the  disease 
which  he  considered  infectious  and  epidemic :  he  did 
not  believe  in  the  American  origin  of  the  disease 
but  thought  it  had  existed  in  antiquity.  He  was  a 
fine  classical  scholar  and  occupied  with  lustre  the 
chair  of  medicine  at  Ferrara.  He  was  largely  re- 
sponsible for  the  reinstatement  of  Hippocrates  and 
the  loss  of  influence  of  Pliny. 

18.  — "Curious"  in  the  seventeenth  century  had 
certain  meanings  now  rare  or  obsolete ;  it  means 
here  ingenious,  clever. 

19.  — "Debauched  the  whole  habit  of  body" — "de- 
bauched" was  a  new  word  in  English  at  that  time, 
having  been  imported  from  France  about  1600 — 
the  French  debaucher — it  meant  corrupt  or  pervert: 
"habit  of  the  body"  was  the  same  as  our  late 
"diathesis,"  valdc  deflendus. 

20.  — "Distillations"  are  fluids  forming  in  minute 
drops  from  any  tissue — not  distinguishable  from 
catarrhs  except  that  the  catarrh  is  rather  flowing 
and  en  masse,  the  distillation  stationary  and  minute. 

21.  — Athanasius  Kircher,  (latinized  Kircheus), 
1601-1680,  entered  the  Jesuit  order  at  the  age  of 
seventeen ;  he  became  almost  an  Admirable  Crichton. 
He  lectured  at  the  University  of  Wurzburg  on  phil- 
osophy, mathematics,  Hebrew  and  Syriac,  afterward 
he  taught  mathematics  and  Hebrew  at  Rome,  where 
he  died.  He  was  one  of  the  first  to  study  the  hiero- 
glyphics of  Egypt.  It  is  his  work  De  Peste  which 
Nedham  makes  use  of ;  it  was  written  in  1658  and 
afterward  printed  at  Leipsic  with  a  preface  by  John 
Christian  Lange. 

22.  — "Paradox"  in  the  proper  and  etymological 
sense  of  an  opinion  opposed  to  that  commonly  held, 
of.  De  Morgan's  Budget  of  Paradoxes. 


23.  — Nedham  says  that  Drs.  Lange  and  August 
Hauptman  even  before  Kircher's  investigations 
were  troubled  over  "that  terrible  disease,  the  pur- 
ples, which  so  frequently  befalls  women  within  the 
month  after  childbearing"  and  laid  their  heads  to- 
gether to  determine  the  cause.  They  found  under 
the  microscope  petty  vermicles  spread  upon  the 
whole  superficies  of  the  characteristically  rough 
skin  and  concluded  them  to  be  the  cause.  It  is  per- 
haps better  not  to  know  things  than  to  know 
things  that  are  not  so. 

24.  — We  know  that  Lange  ascribed  syphilis  to 
microscopic  worms  and  Hauptman  to  small  insects 
— a  mere  difference  in  terminology. 

OsGooDE  Hall, 


DISORDERS  OF  FUNCTION   OF  THE 
URINARY  BLADDER.* 

By  Sergeant  Price  Martin,  M.  D., 
Buffalo,  N.  Y. 

The  function  of  the  urinary  bladder  is  to  act 
as  a  reservoir  for  the  urine  received  from  the 
renal  ducts  and  to  retain  it  until  discharged 
through  the  urethra.  After  the  completed  act  of 
urination  the  bladder  under  normal  conditions  is 
empty,  its  walls  being  retracted  to  their  full  ex- 
tent. As  urine  flows  in  from  the  kidneys  the  walls 
gradually  relax  to  accommodate  the  fluid,  so  that 
the  internal  pressure  remains  at  a  constant  level. 
The  extent  to  which  the  walls  can  relax  depends 
on  the  individual  bladder  and  whether  its  walls  are 
healthy  or  in  a  state  of  disease.  At  any  time,  how- 
ever, if  the  attention  of  the  brain  is  called  to  the 
bladder  a  feeling  or  desire  to  evacuate  the  bladder 
may  be  induced,  which  desire  also  can  be  set  aside 
by  will  if  the  attention  is  diverted  from  the  blad- 
der, but  at  last  a  condition  is  reached  when  the 
bladder  walls  have  relaxed  to  their  fullest  extent 
and  then  they  begin  'to  undergo  slight  tonic  con- 
tractions. If  the  call  is  neglected  long  hypogastric 
pain  is  felt,  continuous  and  spasmodic,  and  finally 
the  desire  to  micturate  becomes  uncontrollable. 

The  call  to  micturate  under  normal  conditions  is 
largely  a  matter  of  habit.  The  normal  bladder  can 
be  trained  to  retain  urine  for  many  hours  or  it  can 
be  made  to  fall  into  bad  habits  through  nervousness 
and  ability  to  gratify  the  desire  readily  and  often. 
Various  foods  and  drinks  have  a  profound  in- 
fluence. Urine  of  a  high  density  containing  much 
pigment  and  uric  acid  in  suspension  can  often  be 
held  for  hours,  whereas  urine  of  low  density  may 
have  to  be  passed  every  hour  or  oftener. 

The  muscles  of  the  bladder  consist  of  two  sets : 
The  detrusor  set,  consisting  of  longitudinally  and 
circularly  disposed  smooth  muscle  fibres,  and  a 
sphincter  set,  consisting  of  the  muscles  of  the  trigone 
and  circularly  disposed  smooth  muscles  at  the  entry 
of  the  prostatic  urethra.  The  muscles  are  under 
voluntary  control  to  a  certain  extent,  that  is  to 
say,  the  whole  complex  act  of  micturition  can  be 
started  or  stopped  by  means  of  voluntary  impulses 
descending  from  the  brain  but  beyond  a  certain 
limit  the  brain  ceases  to  be  able  to  control  them 

*Read  before  the  Buffalo  Academy  of  Medicine,  April  7,  1920. 


October  9,  1920.] 


MARTIX:   URINARY  BLADDER. 


545 


and  micturition  becomes  involuntary  and  forced. 
The  compressor  uretlira  is  a  voluntary  muscle 
which  can  be  used  as  a  sphincter  of  the  bladder 
and  in  addition  there  is  a  set  of  voluntary  musdes 
which  can  be  made  to  empty  the  bladder  by  in- 
creasing the  general  abdominal  pressure,  namely, 
the  muscles  of  the  belly  wall  and  the  diaphragm. 

The  involuntar}-  muscles  of  the  bladder  are  sup- 
plied by  two  sets  of  nerves :  sympathetic  fibres  from 
the  hypogastric  plexus  which  run  out  from  the  cord 
along  the  lumbar  nerves ;  sympathetic  fibres  from 
the  sacral  plexus  which  run  out  along  the  second 
and  third  sacral  nerves  forming  the  nerve  erigentes. 
Stimulation  of  the  hypogastric  ner\-e  endings  pro- 
duces inhibition  and  relaxation  of  the  detrusor 
fibres  and  contraction  of  the  sphincter  fibres.  Stim- 
ulation of  the  nerve  erigentes  produces  inhibition 
and  relaxation  of  the  sphincter  and  contraction  of 
the  detrusor. 

During  the  act  of  micturition  the  sphincter  is 
relaxed  and  the  detrusor  contracts.  The  act  can  be 
stopped,  however,  voluntarily  by  contraction  of  the 
compressor  urethra  till  the  inhibitory  impulses  to 
the  involuntary  muscles  have  time  to  act,  or  urina- 
tion may  be  stopped  by  disease  of  the  coordinating 
nervous  mechanism. 

The  following  disorders  of  the  bladder  will  be 
briefly  discussed :  Inflammations,  tumors,  vesical 
calculi,  atony,  hypertrophy,  and  nervous  disorders. 

IXFLAMMATIOX  OF  THE  BLADDER. 

The  inflammations  of  the  bladder  may  be  reduced 
to  a  small  number  of  clinical  types,  though  each  of 
these  types  has  many  variations.  Authorities  difTer 
so  widely  in  their  classifications  of  cystitis  that  an 
accepted  classification  can  hardly  be  said  to  exist. 
The  following  simple  classification,  however,  will 
suffice  to  illustrate:  1,  Nonbacterial  cystitis,  a, 
traumatic,  b,  chemical ;  2,  simple  bacterial  cystitis 
which  may  be  acute  or  chronic,  acid  or  alkaline ; 
3,  tuberculous  cystitis. 

Traumatic  cystitis. — A  mild  cystitis  or  irritability 
of  the  bladder  as  it  is  often  called  may  be  caused 
by  the  passage  of  a  highly  concentrated  urine  con- 
taining phosphates,  urates  and  oxalates.  This  is 
characterized  by  more  or  less  frequency  of  urina- 
tion and  distress.  The  socalled  gouty  or  rheumatic 
cystitis  is  of  this  type. 

Chemical  cystitis. — Any  strong  irritant  entering 
the  healthy  bladder  whether  from  the  kidneys  or 
through  the  urethra  may  cause  a  cystitis.  Rehm  and 
Lichtenstein  (4)  have  called  attention  to  marked 
vesical  tenesmus  occurring  in  coal  tar  workers,  ap- 
parently due  to  inhalation  of  irritating  vapors. 
While  hyperacid  urine  is  irritating  to  the  bladder, 
ammoniacal  urine  is  far  more  so,  and  the  reason 
why  an  alkaline  cystitis  is  likely  to  be  so  much 
more  intense  may  be  due  to  the  fact  that  the 
ammonia  adds  fuel  to  the  fire  of  bacterial  attack. 
Cystitis  may  equally  be  caused  by  irritants  intro- 
duced through  the  urethra.  Nitrate  of  silver  is  so 
often  used  in  a  concentrated  solution  that  it  bears 
an  unenviable  notoriety  in  this  regard. 

Simple  bacterial  cystitis. — -This  is  the  disease 
that  is  generally  spoken  of  as  cystitis. 

Acute  bacterial  cystitis. — This  is  characterized  by 
a  sharp  congestion  most  marked  around  the  trigone 


and  the  neck,  or  it  may  be  entirely  confined  to  that 
region.  The  mucous  membrane  is  swollen  and 
bright  red  in  color.  The  capillaries  are  dilated, 
the  epithelial  cells  swollen.  Later  the  epithelial 
cells  begin  to  desquamate.  Then  the  angry  crimson 
of  the  mucous  membrane  is  blotched  by  petechiae, 
its  gloss  is  lost  and  here  and  there  minute  vesicles 
or  abscesses  may  appear.  After  these  break,  small 
ulcers  remain.  If  the  acute  condition  persists  the 
muscular  and  peritoneal  coat  become  inflamed. 

Chronic  bacterial  cystitis. — The  mucous  mem- 
brane is  irregularly  thickened  and  dense.  Its  sur- 
face may  be  red  or  gray  in  color,  while  here  and 
there  may  be  seen  areas  of  ulceration  or  granula- 
tion. 

Frequency  of  urination  is  the  constant  symptom 
of  cystitis  except  in  mild  cases  or  where  there  is 
retention  or  suppression  of  urine.  It  is  a  fair  index 
of  the  severity  of  the  inflammation.  In  mild  cases 
the  patient  may  urinate  every  three  hours  or  so 
during  the  day  and  empty  his  bladder  only  once 
or  twice  during  the  night.  On  the  other  hand,  a 
patient  suffering  from  acute  cystitis  may  urinate 
with  great  frequency  during  the  day  and  night,  the 
calls  to  urinate  occurring  ever>-  ten  to  fifteen  min- 
utes and  if  they  are  not  obeyed  they  result  in  the 
expulsion  of  the  contents  of  the  bladder  no  matter 
how  much  the  patient  may  strain  to  retain  the  blad- 
der contents.  Frequency  of  urination,  however,  is 
by  no  means  pathognomonic  of  cystitis,  it  may  be 
purely  neurotic  or  may  be  due  to  prostatitis,  hyper- 
trophy of  the  prostate,  vesical  calculi  or  other 
causes. 

Vesical  pain  in  cystitis  is  due  as  a  rule  to  the 
presence  of  urine  in  the  bladder.  If  there  is  no 
retention  the  pain  is  intermittent.  If  there  is  reten- 
tion the  pain  is  constant.  It  is  most  severe  at  the 
time  of  urination.  In  mild  cases  it  may  only  be  felt  at 
that  time.  It  is  felt  chiefly  in  the  glans  penis  and  the 
perineum  though  it  may  radiate  along  the  under 
surface  of  the  penis  up  the  rectum  to  the  hypogas- 
trium,  groin,  hip,  testicle  or  loin.  When  the  inflam- 
mation is  marked  there  is  often  a  continuous  ache 
in  the  perineum,  the  hypogastrium  or  the  hip,  while 
in  dysuria  there  may  also  be  an  irritating  spasm  of 
the  bladder  and  its  sphincter  as  the  last  drops  of 
urine  are  passed.  The  patient  straining  after  the 
bladder  is  empty  markedly  adds  to  the  irritation 
already  present. 

Although  patients  suffering  from  cystitis  often 
exhibit  such  symptoms  as  chills,  fever,  sleepless- 
ness, anorexia  and  loss  of  weight  and  strength, 
these  symptoms  are  not  necessarily  directly  refer- 
able to  inflammation  of  the  bladder,  but  may  be 
due  to  inflammation  of  the  prostate  gland  or  to 
involvement  of  the  kidneys,  or  may  be  the  result 
of  the  distressing  symptoms  of  pain,  dysuria  and 
tenesmus. 

Chronic  cystitis  is  so  common  that  there  are 
few  diseases  of  the  lower  urinary  passages  of 
which  it  does  not  form  a  part  of  the  picture. 
Chronic  cystitis  rarely  commences  as  an  acute 
disease  but  is  chronic  from  the  start.  Once  started 
it  does  not  tend  to  get  well  spontaneously  but  slowly 
and  steadily  becomes  worse.  Fortunately  its  causes 
are  well  known  and  most  of  them  easy  of  demon- 


546 


MARTIX 


URINARY  BLADDER. 


(New  York 
Medical  Journal. 


stration.  Many  of  them  can  be  removed  and  with 
them  the  chronic  inflammation  which  they  keep  up. 
Some  cases  are  incurable  on  account  of  permanent 
structural  alterations  that  have  taken  place  in  the 
bladder  walls  or  because  the  cause  cannot  be  reached. 
All,  however,  may  be  benefited  by  careful  study  and 
judicious  management  in  the  hands  of  a  skilled 
urologist. 

Tuberculosis  of  the  bladder. — The  characteristic 
irritability  of  the  bladder,  the  frequency  of  urina- 
tion and  the  pain  accompanying  the  act  is  often  the 
earliest  and  always  the  most  distressing  symptoms 
of  tuberculosis.  At  first  the  irequency  of  urination 
is  not  so  great  although  there  may  be  marked  dis- 
comfort, as  soon  as  a  few  ounces  of  urine  have 
collected  in  the  bladder,  and  the  pain  is  chiefly  con- 
fined to  the  end  of  urination.  As  the  bladder  con- 
tracts down  on  the  last  drops  of  urine  a  terminal 
hematuria  may  appear  and  a  sharp  pain  may  be 
felt  in  the  perineum  and  often  on  the  vinder  surface 
of  the  penis  at  the  penoscrotal  angle.  The  effect 
of  this  pain  is  to  excite  a  tighter  spasm  of  the 
bladder  and  the  result  of  this  spasm  is  an  increase 
in  the  pain  so  that  a  good  deal  of  pain  and  spasm 
persist  after  the  last  drops  of  urine  have  been 
voided.  This  will  leave  a  soreness  which  may  not 
pass  off  before  another  urinary  act  renews  the 
distressing  cycle.  At  first  this  pain  is  only  fairly 
constant  but  later  accompanies  every  act  of  urina- 
tion. 

As  the  disease  progresses  vilcers  are  formed  or 
mixed  infection  occurs,  then  another  pain  may  be 
felt,  a  pain  before  urinating,  characterized  by  an 
irresistible  urgency,  which  if  not  immediately 
gratified  may  result  in  a  spurt  of  a  few  drops  of 
urine  down  the  sufferer's  thigh  in  spite  of  all  his 
efforts  to  prevent  it.  The  urine  of  tuberculous 
cystitis  is  acid.  At  first  it  may  be  clear  or  bloody. 
Later  it  is  bloody  and  often  foul  with  products 
of  suppurative  cystitis.  But  however  foul  and  am- 
moniacal  it  may  be,  its  one  striking  characteristic 
is  its  continued  acidity.  However,  it  is  not  impos- 
sible for  the  urine  of  a  mixed  infection  to  be  alka- 
line when  passed  as  a  result  of  the  predominance 
of  pyogenic  cocci.  The  most  important  part  of  the 
urinary  examination  in  this  type  of  cystitis  is  the 
search  for  and  finding  of  the  tubercle  bacillus. 

TUMORS. 

The  majority  of  the  tumors  of  the  bladder  are 
of  epithelial  origin.  The  tumors  generally  begin  as 
benign  papillomatous  growths  but  soon  undergo 
carcinomatous  degeneration.  Next  in  frequency 
come  the  connective  tissue  gro\\i:hs  fibroma,  myx- 
oma, sarcoma  and  the  mixed  tumors.  No  more  is 
known  about  the  pathogenesis  of  tumors  of  the 
bladder  than  about  tumors  occurring  elsewhere. 
In  the  report  of  ninety-nine  cases  of  bladder  cancer 
collected  by  Nason,  seventy-eight  occurred  in  men. 
From  this  we  are  led  to  believe  that  the  condition 
is  met  with  at  least  twice  and  perhaps  three  times 
as  often  in  men  as  women.  Tumors  may  occur  at 
any  age,  but  the  majority  of  carcinomata  occur  in 
the  decades  between  thirty  and  sixty. 

The  first,  the  last  and  often  the  only  symptom 
of  a  tumor  of  the  bladder  is  hematuria.  As  a  rule 
the  more  villous  the  tumor  the  more  profuse  the 


bleeding.  The  characteristic  hemorrhage  of  a  neo- 
plasm begins  without  apparent  cause  or  warning,  may 
last  for  several  days,  be  copious  and  painless,  unaf- 
fected by  rest,  diet  or  medication,  and  cease  as  sud- 
denly as  it  began  without  any  apparent  reason.  Its 
cessation  may  leave  the  urine  entirely  normal  and  the 
patient  is  lulled  into  a  false  sense  of  security  by 
what  he  considers  his  narrow  escape  from  a  peril- 
ous condition.  A  profuse  hemorrhage  of  this  type 
is  almost  pathognomonic  of  neoplasm.  Though  it 
may  assume  any  form  the  hemori-hage  usually 
grows  more  severe  and  recurs  more  frequently  as 
the  disease  progresses. 

Of  all  the  instrumental  manipulations  employed 
in  the  diagnosis  of  tumors  of  the  bladder,  cystoscopy 
stands  first,  for  it  alone  indicates  the  presence,  the 
nature,  as  far  as  can  be  determined,  the  location 
and  the  number  of  tumors. 

VESICAL  CALCULI. 

Single  calculi  are  generally  rounded  or  ovoidal 
in  shape.  Multiple  calculi  are  usually  phosphatic, 
less  frequently  uratic.  In  general  their  number 
bears  an  inverse  relation  to  their  size.  There  are 
no  symptoms  absolutely  and  invariably  pathogno- 
monic of  stone  in  the  bladder,  yet  there  is  a  cer- 
tain group  of  symptoms  which  are  very  suggestive 
of  stone.  Chief  among  these  are  frequency  of 
urination,  pain  and  hematuria,  occurring  by  day 
and  increased  by  exercise.  The  pollakiuria  and 
dysuria  of  stone  are  usually  intensely  marked  and 
appear  earh-  in  the  disease.  The  pains  are  situated 
chiefly  in  the  glans  penis  along  the  pendulous  ure- 
thra and  in  the  perineum.  The  characteristic  dis- 
tress is  absent  during  the  night  or  when  the  patient 
lies  quietly  on  his  back.  Many  different  ways  have 
been  suggested  to  prove  the  existence  of  stone  in 
the  bladder.  Among  these  the  cystoscope  and  x  ray 
are  the  most  popular  today. 

ATOXY  OF  THE  BLADDER. 

Loss  of  bladder  power  may  be  due  to  disease 
of  the  muscle  fibres  themselves  rather  than  the 
nerve  supply.  A  state  of  atonic  relaxation  may  be 
produced  which  is  so  complete  that  there  is  passive 
distention  of  the  bladder  with  continual  passive 
overflow  or  it  may  be  incomplete,  the  muscle  fibres 
being  unable  to  retract  to  their  full  extent. 

Atony  of  the  muscle  fibres  is  produced  by  the 
following  causes:  1.  Mechanical  overdistention,  a, 
after  a  single  acute  unrelieved  retention,  b,  insid- 
ious onset  from  chronic  back  pressure.  2.  Poisons 
acting  on  the  muscle  itself,  a,  acute  specific  fevers, 
especially  typhoid  and  influenza,  b,  chronic  cystitis 
(diffuse  fibroses  of  the  wall).  3.  Poisons  acting 
on  the  nerve  supply  and  the  muscle,  belladonna  and 
morphine. 

It  used  to  be  held  that  if  the  muscle  of  the  blad- 
der became  atonic  no  recovery  of  tone  would  take 
place.  From  observations  of  the  end  results  of 
prostatectomy  it  is  becoming  increasingly  clear 
that  recovery  of  tone  can  be  expected  and  may  even 
be  complete  if  the  cause  is  removed,  especially  if 
caused  by  urethral  obstruction.  Drugs  such  as  nux 
vomica  are  useful  adjuvants,  and  the  muscle  can 
also  be  exercised  by  applications  of  the  triphase 
electric  current  to  the  hypogastrium. 

Hypertrophy  of  the  bladder  is  the  result  of  an 


October  9,  1920.] 


CUMSTON:  THE  IVASSERMANX  REACTION. 


547 


obstacle  to  the  free  flow  of  urine  through  the  ure- 
thra. The  commonest  causes  of  obstruction  are 
enlargement  of  the  prostate  gland  and  stricture  of 
the  urethra.  It  may  however  be  caused  by  severe 
prolonged  inflammation  with  but  little  obstruction 
(vesical  stone  or  vesical  tuberculosis).  There  are 
no  special  symptoms  of  vesical  hypertrophy  except 
frequency  of  urination.  The  treatment  of  hyper- 
trophy of  the  bladder  is  the  removal  of  obstructive 
and  inflammatory  /:auses. 

NERVOUS  DISORDERS. 

One  of  the  first  and  often  the  first  sign  of  tabes 
is  a  bladder  that  functions  badly.  A  tabetic  blad- 
der crisis  generally  begins  suddenly  towards  the  end 
of  micturition.  As  the  last  drops  of  urine  are 
squeezed  out  an  intense  cramping  pain  is  felt  in 
the  urethra  and  at  the  end  of  the  penis.  The  pain 
passes  off  in  a  few  minutes  but  in  a  short  time  the 
desire  to  urinate  returns  and  the  attack  is  then 
repeated.  The  intervals  between  attacks  may  vary 
from  a  few  minutes  to  hours  or  days.  The  pain 
usually  is  so  intense  as  to  cause  the  patient  to  double 
up  and  cry  out.  These  pains  presumably  take  ori- 
gin in  the  degenerating  neurons  and  as  degeneration 
becomes  complete  the  pains  pass  away  and  do  not 
return.  The  patient  then  passes  into  the  stage  of 
painless  paralysis.  These  crises,  however,  are  rather 
the  exception  than  the  rule  in  tabetic  cases  and  the 
patient  may  have  little  or  no  pain  from  the  onset. 

In  the  early  stages  the  coordination  of  the  act  of 
urination  is  interfered  with,  the  sphincter  hesitates 
to  relax  as  the  detrusor  contracts  so  that  sudden 
interruption  of  the  stream  occurs  or  the  urine  drips 
away  slowly.  In  a  later  stage  there  is  a  partial 
retention  of  urine  with  increased  frequency  of 
micturition.  The  detrusor  becoming  relatively  insuffi- 
cient, the  bladder  is  neither  full  nor  ever  completely 
empty,  a  residual  urine  varying  from  six  to  twelve 
ounces  may  be  removed  by  a  catheter.  This  stage 
gradually  passes  into  one  of  complete  retention  with 
overflow  and  incontinence  but  as  the  sphincter  is 
relaxed  the  mere  act  of  coughing  or  any  slight 
straining  movement  may  produce  a  dribble  of  urine. 
In  considering  diagnosis  the  nature  of  the  nerve 
lesion  must  be  determined  and  suitable  treatment 
applied,  especially  if  there  is  a  syphilitic  taint  and 
the  exact  condition  of  the  bladder  should  be  investi- 
gated by  means  of  the  cystoscope. 

This  paper  is  presented  in  the  hope  that  a  better 
cooperation  may  be  arrived  at  between  the  general 
practitioner  and  the  urologist  in  diagnosing  and 
treating  lesions  of  the  genitourinary  tract. 

REFEREXCES. 

1.  Nasox:  British  Medical  Journal,  1,  1199. 

2.  Keyes  :  Genitourinary  Diseases. 

3.  KiDD  :  Urinary  Surgery. 

4.  LicHTEXSTEix  :  Deutsche  Wochenschr..  1898,  xxiv,  709. 

Acute  Endaortitis  with  Formation  of  Two 
Aneurysms  and  Rupture  of  the  Aorta. — F.  Merke 
{Sclra.rizcrischc  mcdizinischc  U'ochcnschrift,  Feb- 
ruary 12,  1920)  reports  the  case  of  a  man  fift\--one 
years  old,  suffering  from  chronic  cystitis,  in  whom 
an  aortitis  developed.  This  was  followed  by  the 
formation  of  two  aneurysms  of  the  aorta  and  final 
rupture.  The  aortitis  was  ascribed  to  a  bacteriemia 
arising  from  the  urinary  passages. 


THE  WASSERMANN  REACTIOX. 
By  Charles  Greexe  Cumston,  M.  D., 

Geneva,  Switzerland. 
The  subject  of  \\'assermann's  reaction  is  still  un- 
der discussion  and  in  the  remarks  which  are  to  fol- 
low I  shall  borrow  freely  from  the  work  done  by 
Golay  and  others  at  the  syphilographic  clinic  of  the 
University  of  Geneva,  based  on  some  four  thousand 
five  hundred  reactions.  Negative  in  all  subjects  free 
from  syphilis,  Wassermann's  reaction  must  neces- 
sarily become  positive  after  infection  since,  without 
exception,  every  person  with  florid  specific  second- 
ary lesions  as  yet  untreated  will  give  a  positive  re- 
action. 

The  date  of  the  appearance  of  the  reaction,  after 
the  onset  of  the  initial  sclerosis,  varies  with  dif- 
ferent observers  and  with  the  subjects,  as  Golay  has 
been  able  to  show,  since  he  has  had  cases  of  chancre 
positive  on  the  fifth  day  after  its  appearance  and 
others  negative  as  late  as  the  thirty-second  day,  but 
after  this  time  the  results  have  been  invariably  posi- 
tive. Consequently  it  sometimes  happens  that  in 
some  cases  recent  syphilitic  chancres  give  a  positive 
reaction  while  in  others  the  chancre  may  have  un- 
dergone cicatrization  and  the  Wassermann  still  re- 
main negative,  which  explains  the  varying  percent- 
age of  positive  results  obtained  by  different  ob- 
servers during  the  primary  phase  of  the  infection : 

Levaditi,  Laroche,  Yamanouchi   46  per  cent. 

Wassermann,  Citron,  Blaschko,  Brulius .  .  .88  to  91  per  cent. 

Gaston  and  Mauriac  79  to  81  per  cent. 

Ejowsk>-  . .  )  (      69  per  cent. 

Pribilsk'v.   >  Clinic  of  Geneva  \      70  per  cent. 

Golay  . . . .  )  (      76  per  cent. 

Statistics,  to  be  sure,  are  of  only  relative  impor- 
tance because  they  comprise  reactions  made  at 
periods  more  or  less  distant  from  the  date  of  the  in- 
fection. The  same  statistics  made  thre  days  after  the 
first  appearance  of  the  chancre  should  give  one  hun- 
dred per  cent,  negative  results,  according  to  Golay's 
researches,  and  if  done  on  the  thirteenth  day  in  all 
untreated  cases  of  syphilis,  they  should  give  one 
hundred  per  cent,  positive  results.  What  is  still 
inore  interesting  and  useful  from  the  viewpoint  of 
practice  is  to  establish  the  average  date  of  the  ap- 
pearance of  Wassermann's  reaction.  Evidently  it 
must  be  positive  when,  the  infection  having  become 
generalized,  it  can  be  detected  in  the.blood.  The  septf- 
cemia,  as  Gaucher  has  shown,  always  precedes  the 
secondary  lesions,  so  that  if  we  take  the  appearance 
of  the  chancre  as  a  starting  point,  by  combining  the 
figures  given  by  different  observers,  we  can  place  it 
at  about  the  fifteenth  to  the  twentieth  day.  By  fol- 
lowing his  patients  in  series  and  making  a  daily  ex- 
amination— ^the  only  proper  method,  to  follow — 
Gaucher  noted  that  the  reaction  became  positive  in 
the  average  case  on  the  fifteenth  to  the  twentieth 
day.   Here  are  some  figures  : 

Jadassohn  (Berne)  fifteenth  to  twenty-fifth  day. 

Oltramare   (Geneva)  fifteenth  to  twentieth  day. 

Audry  (Paris)  twenty -fifth  day. 

Finger  (Vienna)  ) 

Wassermann    (Berlin)  . .  ]  twent>--first  day. 

Troisfontaines   twenty-fifth  to  thirty-fifth  day. 

It  would  appear  the  more  sensitive  the  antigen, 
the  earlier  will  the  reaction  be  positive,  and  in  point 
of  fact,  Desmoulieres,  using  his  reinforced  antigen. 


548 


CUMSTON:  THE  WASSERMANN  REACTION. 


[New  York 
Medical  Journal. 


found  that  the  mean  date  of  appearance  of  the  re- 
action was  between  the  eleventh  and  the  thirteenth 
day.  Contrary  to  what  has  been  maintained  by 
others,  it  would  seem  to  result  from  this  fact  that 
the  antibodies  do  not  appear  suddenly  in  the  blood, 
but  are  produced  little  by  little,  and  can  be  detected 
only  at  the  moment  that  their  quantity  corresponds 
to  the  sensitiveness  of  the  antigen.  As  Joltrain  and 
others  have  pointed  out,  the  septicemia  develops 
earlier  following  chancres  of  the  lips  than  of  the 
genital  organs. 

From  these  figures  it  results  clinically  that  so 
long  as  a  chancre  has  not  fifteen,  or  even  in  some 
rare  cases  thirty-two  days'  existence,  the  serore- 
action  may  not  agree  with  the  diagnosis ;  hence  the 
conclusion  that  the  clinical  signs  of  chancre,  the  in- 
cubation period,  the  local  lesion,  adenopathy  and 
above  all  the  presence  of  the  spirochetes,  have  a 
far  more  considerable  importance  than  Wasser- 
mann's  reaction.  On  the  other  hand,  the  latter 
may  render  real  help  in  cases  where  cicatrization  of 
the  chancre  has  already  taken  place  or  is  under- 
going repair,  in  which  it  is  no  longer  possible  to 
find  the  spirochete  nor  decide  upon  its  nature  until 
the  secondary  lesions  develop.  A  distinctly  positive 
reaction  will  settle  the  question  and  intensive  treat- 
ment be  instituted  at  once. 

The  seroreaction  during  the  period  of  chancre, 
however,  will  be  of  interest  if  it  can  be  proved,  as 
some  observers  maintain,  that  abortion  of  the  in- 
fection is  easier  to  obtain  with  the  arsenical  products 
while  the  seroreaction  is  still  negative.  Yet  in  spite 
of  a  large  number  of  cases  Golay  and  others  of  the 
Geneva  school  are  not  prepared  to  oflfer  a  positive 
opinion  in  thife  respect. 

All  untreated  cases  of  secondary  syphilis  will 
give  a  positive  reaction.  Nevertheless,  from  the 
viewpoint  of  the  diagnosis,  the  reaction  has  not  at 
this  time  a  primordial  value,  since  the  nature  of 
the  lesions,  the  still  visible  cicatrix  of  the  initial 
sore,  the  inguinal  adenopathy,  etc.,  will,  in  the  vast 
majority  of  cases,  make  the  diagnosis  only  too  evi- 
dent. A  Wassermann  reaction  will  then  only  con- 
firm the  nature  of  the  disease,  but  from  the  view- 
point of  the  clinical  value  of  the  Wassermann  re- 
action a  positive  result  will,  on  the  contrary,  be  of 
great  importance,  since  it  proves  that  all  syphilitics, 
unless  they  have  received  energetic  treatment  during 
the  primary  phase,  have  had  at  a  given  time  a  posi- 
tive Wassermann.  At  this  time  also,  the  reaction 
has  another  scientific  and  clinical  point  of  interest. 
I  refer  to  those  cases  where  the  differential  diag- 
nosis between  chancriform  syphilides  and  reinfec- 
tion is  doubtful.  A  positive  reaction  before  the 
fifth  day  following  the  appearance  of  the  chancre 
is  positive  proof  that  the  lesion  is  merely  a  recur- 
rence and  not  a  new  infection. 

The  percentage  of  one  hundred  afterward 
decreases  as  time  goes  on,  with  the  disap- 
pearance of  the  lesions  and  especially  with  treat- 
ment, which,  perhaps,  explains  the  sixty,  seventy, 
eighty  per  cent,  positive  results  in  secondary  syph- 
ilis obtained  by  some  observers,  and  frequently  com- 
prising all  categories  of  patients,  treated  or  un- 
treated, with  or  without  lesions.  In  this  respect 
Mauriac  has  given  statistics  of  the  results  obtained  by 


the  Wassermann  in  untreated  cases  of  syphilis  as 
eighty-eight  per  cent,  and  fifty-four  and  one  half  per 
cent,  in  treated  cases,  but  he  does  not  state  if  in  these 
cases  the  patients  had  or  did  not  have  lesions  present. 
On  the  contrary,  Ledermann,  in  his  statistics,  clas- 
sified the  ■  results  in  positive  Wassermann  reactions 
in  secondary  syphilis  with  symptoms  as  ninety- 
eight  and  one  tenth  per  cent,  and  sixty  two  and  one 
half  per  cent,  in  latent  cases,  but  he  does  not  refer 
to  the  question  of  treatment. 

By  classifying  the  cases  of  secondary  syphilis  into 
syphilis  with  lesions  and  syphilis  without  lesions 
(latent),  Golay  presents  the  following  results: 

Secondar>'  syphilis  with  lesions,  untreated  100  per  cent. 

Secondary   syphilis  with  lesions,  treated  or 

untreated    89  per  cent. 

Secondary  syphilis  with  lesions  treated   79  per  ecnt. 

Secondary  syphilis  without  lesions,  treated....  47  per  cent. 

It  will  be  noted  that  in  the  table  given  above 
untreated  secondary  syphilis  without  lesions  does  not 
appear,  which  would  have  been  highly  interesting, 
inasmuch  as  it  would  fix  our  opinion  of  the  state  of 
the  reaction  in  patients  left  to  their  own  devices. 
But  these  cases  which  unquestionably  exist  can  only 
be  detected  indirectly,  when  lesions  develop  a  long 
time  after  infection,,  for  the  simple  reason  that  a 
subject,  who  believes  himself  to  be  in  perfect  health 
and  without  any  specific  lesions,  will  naturally  not 
consult  a  syphilologist.  However,  Golay  has  found 
that  syphilitics  who  have  had  little  or  bad  treatment 
usually  present  a  positive  reaction  for  a  long  time 
and  he  has  found  that  syphilitics  of  thirty  or  thirty- 
five  years'  standing,  subjected  to  more  or  less  treat- 
ment, but  who  nevertheless  had  never  presented 
manifest  lesions  and  enjoyed  excellent  health,  pre- 
sented very  positive  Wassermann  reactions. 

These  data  would  seem  to  confirm  the  opinion  of 
a  large  number  of  syphilographers  that  clinically, 
syphilis  left  to  itself  will  never  be  recovered  from 
and  that  although  it  leaves  the  patient  with  remissions 
of  thirty,  forty  or  more  years,  the  presence  of  a 
positive  seroreaction  proves  the  existence  of  latent 
foci  at  any  time  ready  to  become  active.  Cases  of 
general  paresis  with  a  negative  Wassermann,  far 
from  invalidating  this  fact,  prove  that  the  foci  may 
undergo  their  evolution  in  a  closed  area,  so  to  speak, 
without  influencing  the  composition  of  the  blood. 

During  tertiary  syphilis,  the  Wassermann  would 
at  first  sight  seem  to  offer  no  rules  whatever.  For 
example,  it  may  happen  that  a  subject  with  a  tertiary 
lesion,  whose  clinical  diagnosis  leaves  no  doubt,  may 
nevertheless  give  a  negative  reaction,  even  when  little 
or  no  treatment  has  been  followed  in  the  past.  But 
it  is  probable  that  such  instances  are  rare,  since 
several  conditions  may  explain  this  situation,  namely, 
the  effect  of  former  treatment  or  the  localization  of 
the  process  in  the  central  nervous  system.  In  the 
latter  case  the  reaction  is  often  negative,  while 
Gaucher,  Paris  and  Sabareanu,  studying  the  sero- 
reaction in  twenty  cases  of  incompletely  treated 
tertiary  syphilis,  obtained  four  negative  results ;  in 
three,  the  central  nervous  system  was  involved,  while 
the  fourth  presented  no  lesion. 

On  the  other  hand  it  may  happen  and  this  is  by 
far  more  frequent,  that  a  very  positive  Wassermann 
coincides  with  a  syphilis  which  has  been  latent  for 


October  9,  1920.] 


CUMSTON:  THE  WASSERMANN  REACTION. 


549 


many  years  and  all  these  data  which  surprise  us  and 
are  most  confusing  may  nevertheless  find  their 
explanation.  If  one  is  dealing  with  the  paradoxical 
case  of  an  active  syphilis  with  a  negative  Wasser- 
mann  and  the  syphilis  is  mild,  it  may  be  admitted  that 
the  treponemae  being  localized  in  one  or  several 
foci  have  lost  their  activity  and  do  not  secrete  suf- 
ficient toxin  for  the  tissues  to  react  by  the  manu- 
facture of  antibodies,  or  perhaps  that  these  anti- 
bodies, for  unknown  reasons,  are  destroyed  as  fast 
as  they  are  produced.  If  the  syphilis  is  severe,  it  must 
then  be  admitted  that  the  organism  is  too  weakened 
to  react  by  producing  antibodies.  The  same 
phenomenon  is  met  with  in  tuberculosis,  because, 
generally  speaking,  a  mild  tuberculosis  reacts  much 
better  to  tuberculin  than  a  rapidly  progressing 
caseous  tuberculosis. 

If,  on  the  other  hand,  one  is  dealing  with  yet 
another  paradoxical  condition  but  of  an  inverse 
order,  that  of  syphilis  without  lesions  but  with  a 
positive  Wassermann,  two  contingencies  may  take 
place  theoretically :  either  the  lesions  exist  but  are 
unnoticed  by  both  patient  and  physician,  or  they  do 
not  exist  and  it  may  be  admitted  that  the  spirochetes 
secrete  toxins  and  produce  antibodies  by  contrecoup, 
without  producing  any  lesion.  But  now  if  factors, 
often  badly  understood,  come  into  play  lesions 
develop  consequent  upon  the  awakening  and  the 
pullulation  of  the  treponema  which  had  been  until 
then  well  tolerated  by  the  subject. 

The  transformation  of  a  positive  into  a  negative 
reaction  by  treatment  is  explained  by  the  complete 
or  partial  destruction  of  the  parasite.  The  secretion 
of  toxins  is  then  arrested  or  greatly  eliminated,  the 
tissues  no  longer  react  or  react  insufficiently  for  the 
antibodies  produced  to  be  detected  by  the  serore- 
action.  An  interesting  fact  has  been  demonstrated 
by  Iversen  and  brought  to  light  by  Milian,  who 
has  even  derived  from  it  a  very  interesting  diagnostic 
and  therapeutic  proof,  namely,  that  before  disap- 
pearing the  reaction  passes  through  a  maximum 
which  coincides  with  the  bacterial  lysis.  At  this 
moment  destruction  of  the  parasites  is  massive  and 
the  toxins  they  contain  are  then  liberated  in  the 
blood  in  great  quantity.  This  fact  can  also  be  com- 
pared with -what  takes  place  in  tuberculosis  where, 
according  to  Gougerot  and  Troisier,  the  microbe 
dies  in  a  state  of  solubility  and  may  be  more  toxic 
than  the  living  bacillus. 

A  statistical  study  of  Wassermann's  reaction  in 
the  tertiary  phase  of  syphilis  undertaken  by  several 
syphilographers  has  given  quite  constant  results. 
Joltrain  found  from  eighty  per  cent,  to  ninety  per 
cent,  positive  reaction ;  Bruch  and  Stern,  in  a  total 
of  378  cases,  found  it  positive  in  57.4  per  cent. ; 
Bering,  in  a  total  of  391  cases,  found  it  positive  in 
82.2  per  cent,  and  Bayet  seventy  per  cent.  These 
slight  variations  from  one  observer  to  another  are 
to  be  explained  by  the  fact  that  they  did  not  take 
into  consideration  when  making  their  statistics,  either 
the  treatment  or  the  activity,  or  on  the  other  hand, 
the  latency  of  the  syphilis  presented  by  their  patients. 
In  order  to  obtain  a  distinct  idea  of  the  question 
the  cases  should  be  divided  into  four  classes:  1, 
patients  with  tertiary  syphilis  in  activity  and  not 
treated;  2,  patients  with  tertiary  syphilis  in  activity 


and  treated;  3,  patients  with  tertiary  syphilis  in 
latency  and  not  treated ;  4,  patients  with  tertiary 
syphilis  in  latency  and  treated. 

In  practice  such  a  classification  is  impossible,  as 
classes  one  and  three  would  be  wanting.  Today, 
patients  coming  without  having  been  treated  during 
the  secondary  period  are  becoming  more  and  more 
rare,  so  that  in  the  present  circumstances  we  must 
be  content  with  two  categories,  first,  tertiary  syphilis 
with  lesions,  and  secondly,  tertiary  syphilis  without 
lesions.  In  parasyphilitic  affections,  the  Wasser- 
mann reaction  gives  quite  as  high  a  percentage,  if 
not  higher,  of  positive  results  of  tertiary  syphilis. 
But  in  these  cases,  as  in  those  of  cerebral  and  medul- 
lary lesions  of  luetic  origin,  the  examination  of  the 
cerebrospinal  fluid  should  always  be  done  at  the  same 
time.  Their  combined  study  will  be  of  immense 
help  and  when  the  Wassermann  is  negative  the 
cerebrospinal  fluid  will  be  positive,  especially  when 
gross  meningeal  lesions  exist. 

All  observers  have  noted  the  fact  that  the  reaction 
of  the  cerebrospinal  fluid  may  be  positive  while  that 
of  the  blood  is  negative.  Jacobsthal  says  that  is 
especially  true  of  recently  developed  parasyphilitic 
processes,  but  that  later  on  in  the  evolution  of  the 
process  the  blood  will  also  give  a  positive  reaction. 
Therefore,  in  order  to  detect  general  paresis  or 
locomotor  ataxia  at  their  very  onset  a  Wassermann 
and  a  cerebrospinal  test  are  of  utmost  importance. 
Here  are  some  of  the  results  obtained  with  the  cere- 


brospinal fluid ; 

Levediti  and  Marie,  positive  results   80    per  cent. 

Beaussart.  positive  results  in  tabes  and  general 

paresis    90     per  cent. 

Cesar,  positive  results  in  tabes  and  general 

paresis    78    per  cent. 

Lesser,  positive  results  in  general  paresis. ..  .100    per  cent. 

Lesser,  positive  results  in  tabes  ;  96    per  cent. 

Mauriac,  positive  results  in  general  paresis...  80  per  cent. 
Ledermann,  positive  results  in  general  paresis  96.9  per  cent. 
Ledermann,  positive  results  in  tabes   76.4  per  cent. 

For  such  striking  results  comment  is  unnecessary. 


In  hereditary  syphilis  Wassermann's  reaction  is  no 
less  important  and  its  results  are  no  less  encouraging 
than  in  other  luetic  manifestations  and  may  be  com- 
pared to  those  obtained  in  the  acquired  form  of  the 
infection.  Demanche  and  Detre  state  that  in  early 
hereditary  syphilis  and  during  its  evolution  positive 
results  are  obtained  in  87.5  per  cent,  of  the  cases ; 
Mulzer  and  Michaelis,  in  ninety-five  per  cent. ;  Bauer 
in  100  per  cent,  and  Bertin  and  Gayet  in  ninety- 
eight  per  cent.,  but  in  late  hereditary  syphilis  the 
percentage  of  positive  reaction  is  very  much  less. 
Knoepfelmacher  and  Lehndorff  are  likewise  of  this 
opinion.  The  two  last  named  observers  state  that  the 
Wassermann  is  invariably  positive  when  the  heredi- 
tary syphilitis  infant  presents  cutaneous  lesions, 
otherwise  the  reaction  is  often  negative,  becoming 
positive  only  when  lesions  appear.  It  then  remains  af- 
ter treatment  for  many  years,  regardless  of  the  ab- 
sence of  any  lesion.  On  the  other  hand,  Paris  and 
Desmouliere  have  shown  that  in  hereditary  syphilis 
the  reaction  at  first  positive,  later  on  becomes  nega- 
tive, even  when  the  patient  is  untreated,  an  opinion 
based  on  a  very  large  number  of  cases,  and  what 
goes  to  show  that  the  hereditary  form  has  a  tendency 
to  cure,  even  without  treatment,  is  that  these  subjects 
may  contract  syphilis  late  in  life. 


Editorial  Notes  and  Comments 


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NEW  YORK,  SATURDAY,  OCTOBER  9,  1920. 


THE  SCARLET  FEVER  MYSTERY. 

The  war  has  assisted  in  unravelHng  some  of  the 
tangled  skeins  of  disease,  although  perhaps  none  of 
these  has  been  completely  unravelled.  Some  light 
has  been  thrown  on  cerebrospinal  fever  and  possibly 
■on  that  form  of  pneumonia  generally  known  as  septic 
pneumonia.  Instructive  light  is  thrown  on  infectious 
diseases  in  England  and  Wales  by  the  second  report 
of  the  Ministry  of  Health  on  the  Incidence  of  Noti- 
fiable Infectious  Diseases  in  each  Sanitary  District 
of  England  and  Wales  During  the  Year  1919.  Espe- 
cially is  this  the  case  so  far  as  scarlet  fever  is  con- 
cerned. The  figures  show  that  as  soon  as  the  war 
began  the  rate  of  incidence  of  this  disease  went  down 
until  in  1917  it  reached  1.44  to  the  thousand  popula- 
tion. The  same  rate  stood  in  1918,  but  in  1919  it 
went  up  to  2.23  a  thousand.  In  1914  it  stood  at  4.38 
a  thousand.  Moreover,  the  death  rate  from  the  dis- 
ease in  1917  and  1918  was  described  in  the  Registrar 
General's  return  as  the  lowest  recorded  in  England 
and  Wales ;  the  mortality  being  trifling  compared 
with  that  prevalent  a  generation  earlier. 

While  the  scarlet  fever  rate  dwindled  during  the 
war,  the  rate  for  cerebrospinal  fever  increased  by 
•  leaps  and  bounds.  The  figures  for  cerebrospinal  dis- 
ease rushed  up  from  0.01  to  0.08  a  thousand  in  1915 
and  remained  high  up  until  1918,  when  there  was  a 
sharp  fall.  Why  then  when  scarlet  fever  was  going- 
down,  was  cerebrospinal  fever  rushing  up  ?  Dr.  Ha- 
mer,  the  Medical  Officer  of  Health  for  London,  be- 
lieves that  there  is  a  connection  between  scarlet  fever 
and  fleas.    The  war,  by  moving  the  population  from 


place  to  place  and  cleaning  a  portion  of  it  not  usu- 
ally cleaned,  may  have  cut  down  the  flea  population. 
Dr.  Hamer  reports  fewer  beds  flea  marked  in  com- 
mon lodging  houses  during  the  war  period.  This 
view  has  not  been  substantiated,  but,  at  any  rate,  the 
hypothesis  is  a  plausible  one  and  it  is  more  than 
likely  that  increased  cleanliness  may  have  reduced 
the  number  of  fleas  throughout  England  and  Wales. 
Moreover,  this  suggestion  is  in  accord  with  the  opin- 
ions of  some  observers  who  hold  that  a  considerable 
number  of  the  infectious  diseases  are  to  a  certain 
extent  insect  borne.  Typhus  has  been  definitely 
proved  to  be  spread  in  this  manner. 

Another  remarkable  feature  of  the  report  with  re- 
spect to  scarlet  fever  is  that  while  the  scarlet  fever 
rate  to  the  thousand  persons  was  2.23  for  Eng- 
land during  1919,  it  was  60.98  for  the  coimtry  dis- 
trict of  King's  Lynn  in  Norfolk  and  20.36  for  the 
town  of  King's  Lynn.  It  is  true  that  these  districts 
have  a  small  population,  which  detracts  greatly  from 
their  statistical  value,  yet  the  disproportion  of  the 
figures,  to  the  rest  of  England,  is  so  large  that  it 
would  seem  that  Dr.  Hamer's  suggestion  might  be 
put  to  a  practical  test  either  in  King's  Lynn  or  in 
any  other  place  where  an  unusual  rate  is  found.  It 
would  seem  after  all  that  John  Wesley's  saying  that 
"Cleanliness  is  next  to  godliness"  is  very  near  the 
truth  and  one  to  be  highly  coinmended  as  a  health 
axiom.  It  has  been  denied  that  there  is  any  inherent 
sanitary  virtue  in  cleanliness  and  that  after  all  it  is 
l)Ut  more  or  less  an  esthetic  luxury.  However,  where 
dirt  is  there  vermin  flourish,  and  if  vermin  are  car- 
riers of  disease,  as  they  have  been  proved  to  be  in 
the  case  of  plague  and  typhus,  and  as  they  may  be 
and  probably  are  in  scarlet  fever  and  other  infectious 
diseases,  then  the  sanitary  motto  should  be,  let  clean- 
liness and  especially  personal  cleanliness  prevail. 


HEREDITARY  TRANSMISSION  OF 
SYPHILIS. 

George  Vella  was  the  first  to  conceive  the  idea  of 
the  hereditary  transmission  of  syphilis  in  1508. 
After  him  came  Jacob  de  Bethencourt  in  1526,  then 
Frascator,  Massa,  Feruel  and  Fallopius  in  the  six- 
teenth century  and  Sylvaticus,  in  1601.  All  these 
observers  mention  the  hereditary  transmission  of 
the  mal  francais,  but  they  only  seem  to  have  encoun- 
tered cases  in  which  the  manifestations  of  the  in- 
fection appeared  shortly  after  birth.  Ucay,  in 
1699,  first  suspected  that  c;ongenital  syphilis  might 
occur  for  the  first  time  in  late  childhood  or  even  in 
adolescence  and  he  does  not  hesitate  to  say  that  "it 


October  9,  1920.] 


EDITORIAL  ARTICLES. 


551 


is  from  syphilis  that  so  many  hereditary  diseases  are 
derived,  such  as  scrofulous  tumors,  old  (chronic) 
ulcers,  gouts  and  rheumatisms  as  well  as  the  whites 
in  women."  Later  writers  on  syphilis  soon  went 
astray  in  the  matter  of  congenital  syphilis,  so  that 
in  1736,  the  learned  Astruc,  although  not  admitting 
the  transmission  of  syphilis  by  heredity  in  the 
strict  sense  of  the  meaning,  believed  that  several 
very  different  affections,  such  as  rickets  or  tubercu- 
losis, were  derived  from  what  he  termed  degen- 
erated syphilis. 

Sanchez,  Fabre,  I.  L.  Petit,  Rosen  von  Rosen- 
stein  and  other  writers  of  the  eighteenth  century 
went  still  further  and  attributed  all  sorts  of  disease 
— even  alopecia  areata — to  hereditary  syphilis.  To- 
ward the  end  of  this  century  congenital  lues  domi- 
nated both  in  surgical  and  medical  pathology  with 
the  exception  of  traumatic  surgical  affections.  In 
these  circumstances  a  reaction  was  bound  to  occur, 
so  that  Hunter  refused  to  admit  the  transformations 
of  hereditary  syphilis,  but  he  was  wrong  when  he 
denied  the  possibility  of  the  transmission  of  the  in- 
fection from  parent  to  offspring.  Bell,  in  1793, 
maintained  that  this  transmission  did  exist  and  he 
even  added  that  it  might  remain  latent  for  some 
years.  Then  in  1828,  Lagneau  gave  an  excellent 
description  of  congenital  syphilis,  while  Cullevier 
and  Ratien,  in  1836,  regarded  the  late  manifestations 
as  due  to  scrofula.  Baumes,  of  Lyons,  maintained 
in  1840  that  congenital  syphilis  manifested  itself, 
"sometimes  while  the  child  is  in  the  uterus  of  the 
mother,  at  others  at  the  time  of  birth,  of  a  few 
months,  a  year,  or  several  years  after." 

Thirteen  years  later,  Ricord  upheld  his  doctrine 
of  tardy  heredity  before  the  Academy  of  Medicine 
of  Paris,  and  in  1862  illustrious  syphilologists  de- 
clared that  "late  hereditary  manifestations,  not  pre- 
ceded by  early  accidents,  must  be  regarded  as  an  ac- 
quired fact,"  and  since  that  time  all  writers  on  the 
subject  have  described  two  forms  of  hereditary 
syphilis ;  an  early  form  with  manifestations  at  birth 
or  in  early  childhood  and  a  late  form  arising  in  late 
childhood,  at  puberty  or  even  later.  Little  attention 
has  been  given  to  the  nervous  manifestations  of  her- 
editary syphilis,  although  in  1712,  Hoffmann  said 
that  he  had  cured  a  nervous  affection  by  mercury  in 
a  young  girl  nine  years  old  "of  illustrious  birth  and 
whose  father  had  been  infected  with  a  pox  as  thor- 
oughly as  one  could  be."  At  about  the  same  epoch 
Beckers,  Joseph  Pleuck  (1779)  and  Rosen  von 
Rosenstein  mention  similar  cases,  while  in  1783 
Carrere  attributed  certain  types  of  paralysis,  epilepsy 
and  apoplexy  to  hereditary  syphilis.  It  was,  how- 
ever, only  in  the  second  half  of  the  last  century  that 
hereditary  cerebral  syphilis  commenced  to  be  seri- 


ously studied  and  although  some  well  observed  cases 
were  reported  before  1868,  this  year  is  memorable 
from  the  fact  that  Hughlings  Jackson's  paper  ap- 
peared. Cases  of  Diseases  of  the  Nervous  System  in 
Patients  Subjects  of  Inherited  Syphilis,  which 
marked  the  beginning  of  our  present  knowledge  of 
syphilis  of  the  nervous  system  in  subjects  with  her- 
editary syphilis. 

PHYSICIAN-AUTHORS— DR.  JOHN 
ARBUTHNOT. 

There  are  many  authoritative  students  of  letters- 
who  contend  that  the  clearest  and  most  virile  mind 
of  all  the  wits  of  Queen  Anne's  reign  was  that  of 
Dr.  John  Arbuthnot.  To  attribute  to  a  man  a  bril- 
liancy and  depth  of  learning  beyond  that  of  Swift, 
Pope,  Addison,  Congreve,  Gay,  Atterbury  and  Par- 
nell  is  indeed  a  tribute.  Thackeray  admired  Arbuth- 
not above  all  his  contemporaries  and  Samuel  John- 
son said:  "I  think  Arbuthnot  the  first  man  among 
them."  For  that  matter,  the  contemporaries  them- 
selves conceded  his  intellectual  superiority  and  grace- 
fully acknowledged  many  a  debt  to  him.  Why, 
then,  is  he  not  better  known  at  present?  Why  is  he 
now  almost  totally  unknown  and  his  writings  prac- 
tically unread?  There  are  two  main  reasons.  First, 
he  has  not  survived  in  general  literature  because  of 
the  ephemeral  nature  of  the  topics  he  chose  to  write 
about.  To  appreciate  his  writings  it  is  necessary  to 
have  a  fairly  complete  knowledge  of  the  period  in 
which  he  dwelt.  Second,  Arbuthnot  preferred  to  be 
a  man  of  medicine.  He  had  a  complete  lack  of  lit- 
erary ambition  and  was  contented  to  assist  his  con- 
temporaries toward  literary  fame  rather  than  to 
compete  with  them.  He  was  lavish  in  his  assistance 
of  Pope,  Swift  and  Gay.  They  were  his  intimate 
friends  and  got  ideas  and  inspiration'  directly  from 
him.  Others  got  ideas  and  inspiration  from  him 
through  his  writings.  Thus  Dr.  Arbuthnot  may  be 
said  to  owe  his  fame  today  to  what  he  did  not  write 
rather  than  to  what  he  wrote. 

There  are  two  satires  by  which  Dr.  Arbuthnot  is 
chiefly  remembered  today.  These  are  his  famous 
History  of  John  B'ull  and  TJie  Memoirs  of  the  Ex- 
traordinary Life,  Works,  and  Discourses  of  Mar- 
tinus  Scriblerus.  The  first  of  these,  written  in  1712. 
follows  the  structure  of  Swift's  Tale  of  a  Tub  and 
is  fully  its  equal  in  merit.  It  was  an  ingenuous  and 
lively  attack  on  the  war  policy  of  the  Whigs  and  it 
achieved  results.  As  an  allegory  of  statecraft  it  re- 
mains without  a  rival  and  was  the  model  of  all  politi- 
cal satires  in  England  for  a  century  or  more  after  its 
appearance.  But  it  was  a  satire  of  passing  men  and 
events  and  not  built  for  lasting  popularity.    The  most 


552 


EDITORIAL  ARTICLES. 


[New  York 
Medical  Journal. 


enduring  part  of  it  has  been  its  title.  The  appellation 
Jolin  Bull  was  originated  by  Dr.  Arbuthnot  and  it 
has  clung  to  the  British  nation  ever  since.  So,  too, 
has  his  description  of  John  Bull.  The  John  Bull  of 
the  cartoonists  today  is  John  Bull  as  Dr.  Arbuthnot 
described  him. 

The  Scriblerus  Memoirs  ranks  as  one  of  the  finest 
pieces  of  sarcastic  humor  in  the  language.  It  was 
from  this  work  that  Sterne  appropriated  the  bulk 
of  his  material  for  the  earlier  chapters  of  Tristram 
Shandy  and  the  same  source  gave  Swift  his  inspira- 
tion for  Gulliver's  Travels  and  Pope  the  inspiration 
for  his  Dunciad.  "If  the  world  had  but  a  dozen 
Arbuthnots  in  it,"  said  Swift,  "I  would  burn  my 
Travels."  Pope  in  his  Epistle  to  Dr.  Arbuthnot, 
which  forms  the  prologue  to  his  satires,  pays  further 
generous  tribute  to  his  learned  friend.  The  Scriblerus 
Memoirs  were  first  printed  in  some  of  Pope's  works. 
They  were  the  outgrowth  of  the  Scriblerus  club 
which  Arbuthnot,  Swift,  Pope  and  others  of  the 
Queen  Anne  galaxy  organized  in  London.  The 
socalled  memoirs  were  to  have  consisted  of  several 
books  satirizing  the  abuses  of  learning,  and  several 
members  of  the  club  were  to  have  collaborated  in 
the  writing  of  them.  Only  the  first  book,  by  Arbuth- 
not, was  completed. 

Other  writings  of  Arbuthnot  included  Virgilius 
Rcstauratus,  in  which  he  gave  us  Virgil  corrected  and 
improved  in  a  playful  vein ;  The  Art  of  Political  Ly- 
ing, which  would  seem  not  to  have  permanently  cor- 
rected this  evil ;  a  monograph  entitled  An  Argument 
for  Divine  Providence,  essays  On  the  Usefulness  of 
Matltcniatical  Learning,  and  a  considerable  number 
of  other  essays  on  subjects  of  current  interest. 

Dr.  Arbuthnot  was  born  at  Arbuthnot,  Kincardine- 
shire, Scotland,  in  1667.  He  attended  the  University 
College  at  Oxford  from  1694  to  1696  and  took  his 
medical  degree  later  at  St.  Andrew's  University, 
Aberdeen.  He  established  himself  in  medical  prac- 
tice in  London,  but  patients  were  few  and  far  be- 
tween and  he  supplemented  his  income  by  teaching 
mathematics'.  He  found  time,  also,  to  compile  a 
comparative  table  of  Greek,  Roman  and  Jewish 
measures,  to  translate  from  the  Dutch  The  Laws  of 
Chance,  or  a  Method  of  Calculating  the  Hazards  of 
the  Game,  and  to  do  a  little  writing.  His  fame  as 
a  wit  and  man  of  learning  was  growing  but  his 
medical  practice  was  not.  Then  came  a  stroke  of 
good  fortune.  Prince  George  of  Denmark,  husband 
of  Queen  Anne,  fell  ill  at  Epsom  and  Dr.  Arbuthnot 
happened  to  be  there  at  the  time.  No  other  physi- 
cian being  immediately  accessible,  he  was  called  in, 
and  became  the  prince's  physician  during  the  rest  of 
his  life.  Shortly  thereafter,  in  1705,  he  also  be- 
came physician  extraordinary  to  the  queen.  His 


medical  reputation  was  established  and  distinguished 
patients  flocked  to  him  by  the  dozens.  In  1723  he 
became  one  of  the  censors  of  the  Royal  College  of 
Physicians  and  in  1727  he  delivered  the  Harveian 
oration,  the  supreme  medical  honor  of  the  day. 

Pope  said  of  Dr.  Arbuthnot  that  "He  was  as  good 
a  doctor  as  any  man  for  one  that  is  ill  and  a  better 
doctor  for  one  that  is  well."  His  principal  medical 
writings  were  An  Essay  Concerning  the  Nature  of 
Ailments,  in  which  he  argued,  among  other  things, 
that  all  that  is  done  by  medicine  might  be  equally 
well  done  by  diet,  and  An  Essay  Concerning  the 
Effect  of  Air  on  Human  Bodies.  Sir  Benjamin 
Richardson  called  this  second  work  "one  of  the  most 
remarkable  books  in  the  literature  of  medicine"  and 
pointed  out  that  Arbuthnot  was  far  in  advance  of 
his  age  in  medical  science  and  made  some  remark- 
able discoveries.  Dr.  Arbuthnot  died  in  1735  at  the 
age  of  sixty-eight. 


PROGRESS  IN  PSYCHIATRY. 

An  unusually  fascinating  records  of  events  is  pre- 
sented in  Professor  Kraepelin's  [Prof.  Emil  Krae- 
pelin :  Hundert  Jahre  Psychiatric,  Ein  Beitrag  zur 
Geschichte  menschlicher  Gesitung,  Arbeiten  aus  der 
Deutschen  F orschungsanstalt  fiir  Psychiatrie  in 
Miinchcn,  Vol.  I,  Berlin,  Julius  Springer,  1920.]  pa- 
per, which  introduces  the  recently  published  first  re- 
port of  the  new  German  institute  for  research  in 
psychiatry.  The  slow  development  of  scientific 
interest  in  this  important  field  is  told  in  such 
manner  that  one  is  compelled  to  acknowledge 
the  magic  of  evolutionary  growth  which  not  even 
the  thick  prejudices  of  selfdefending  ignorance  are 
able  to  stem.  Progress  forces  its  way,  however  it  is 
temporarily  halted  by  such  barriers,  however  its 
force  is  partially  dissipated  in  half  fruitless  experi- 
ments at  understanding  mental  disease.  It  lies  in 
the  essence  of  human  nature  that  it  casts  strong  de- 
fenses about  itself  in  its  timidity  toward  what  is  still 
unknown,  that  it  hinders  just  that  work  into  which 
it  is  drawn  by  its  own  instincts. 

So  it  has  come  about  that  in  the  realm  which  be- 
longs to  psychiatry,  that  of  mental  disease,  timidity 
and  ignorance  supporting  one  another  have  made 
the  road  into  intelligently  humane  treatment  of  the 
insane  a  long,  hard  one.  For  understanding  is  in  its 
very  nature  fellow  feeling,  and  therefore  to  admit 
that  one  understands  mental  disease  implies  partici- 
pation in  experience  with  the  sick.  The  mind  is 
afraid  of  such  acknowledgment  and  strongly  on  its 
guard  against  it.  Thus,  feeling  at  least  maintains 
an  ignorance  of  mental  disease  as  long  as  is  possible 
and,  as  must  be  admitted,  long  after  science  has  prof- 
fered enlightenment  of  these  darksome  matters. 


October  9,  1920.] 


EDITORIAL  ARTICLES. 


553 


It  is  not  strange  that  even  a  few  decades  ago  the 
mentally  diseased  were  shoved  aside  from  a  calm 
businesslike  approach  to  their  problems  and  were 
relegated  to  the  forcible  confinement  of  cells  and 
chains;  or  their  agonies  of  mind  and  absurdities 
of  behavior  were  the  work  of  the  devil  or  of  evil 
propensities  on  their  own  part  which  must  be  ejected 
by  the  severest  discipline.  It  is  difficult  even  today 
to  acknowledge  that  a  neighbor's  differing  conduct 
or  his  opinion  that  varies  from  an  establishsed  code 
can  deserve  a  considerate  approach  which  might  at 
least  lead  to  understanding  and  perhaps  acceptance. 
One  can  still  preserve  one's  own  accustomed  attitude 
so  much  more  comfortably  by  putting  him  in 
chains  or  submitting  him  to  exorcising  tortures. 
For  these  in  themselves  set  the  stamp  of  disapproval 
and  therefore  release  from  further  responsible 
effort. 

All  these  considerations,  not  intellectually  but 
rather  intuitively  adhered  to,  hindered  but  could  not 
permanently  retard  the  gradual  introduction  into 
psychiatry  of  real  investigation  into  the  state 
of  the  mentally  sick  and  the  possibility  of  elements 
of  humanity  still  residing  beneath  the  sufferers'  ap- 
parent strangeness.  So  with  experiment  in  many 
directions,  with  an  attitude  of  sympathetic  approach 
of  one  sort  and  another  a  way  was  gradually  made 
into  the  darkness. 

The  granting  of  freedom  of  body  to  those  once 
shackled  was  at  the  same  time  justified  by  the  slow 
discovery  that  there  was  a  certain  freedom  and  elas- 
ticity of  the  mind  in  which  access  to  the  sick  person 
could  be  attained.  Possibility  of  healing  still  remained. 
The  varied  attempts  made  under  such  awakening  hu- 
man interest  foreshadowed  the  varieties  of  approach 
which  today  maintain  an  even  surer  hold  upon  medi- 
cal thought.  They  arose  then  out  of  the  principle  of 
unity  which  lay  in  the  nature  of  mind  and  body  with 
their  close  interrelationship,  they  ground  themselves 
today  even  more  deeply  in  such  foundation.  They 
tend  in  it  to  a  simpler  basis  of  understanding.  Yet 
from  this  they  again  branch  into  ever  widening  ter- 
ritories in  which  mental  disease  must  be  variously 
studied. 

To  such  broadening  end  Kraepelin's  review 
of  psychiatry  leads.  To  fruitful  attack  upon 
the  problems  of  mental  disease  in  these  various 
spheres  he  points  with  hopeful  inspiration.  Looking 
backward  or  looking  forward,  his  words  are  such  as 
to  enlist  the  reader's  interest.  It  is  to  be  regretted 
that  he  has  not  disclosed  more  deeply  the  fruitful 
psychical  field  which  can  lay  claim  to  no  less  impor- 
tance than  the  anatomical  and  in  which  he  might 
have  said  much  more  of  the  profounder  implication 
of  psychic  factors  in  mental  disturbances. 


THE  TORONTO  CANCER  CURE. 

When  the  medical  profession  has  before  it  many 
well  authenticated  cases  of  epitheliomatous  cancers 
(of  two  or  three  months'  rapid  growth),  cured  by 
radium  in  six  weeks  or  two  months,  then  they  begin 
to  wonder  why  Dr.  T.  J.  Glover,  Toronto,  withholds 
even  a  progress  report  on  his  serum  treatment  of 
cancer,  which,  during  the  past  two  or  three  months, 
has  received  such  wide  publicity  in  the  lay  press 
of  both  Canada  and  the  United  States.  Many  hun- 
dred cases  have  been  treated  in  St.  Michael's  Hos- 
pital, Toronto,  but  within  the  past  month,  a  million- 
aire's mansion  has  been  purchased  for  Dr.  Glover, 
and  his  patients  are  said  to  run  at  the  present  time 
into  the  hundreds.  The  newspaper  press  has  been 
supplying  the  profession  of  some  details  of  the  work 
but  so  far  not  a  single  case  of  cure  has  been  reported. 

The  medical  press  in  Toronto  are  now  calling  the 
attention  of  Dr.  Glover  to  this  very  unusual,  if  not 
unethical,  way  of  bringing  a  cure  for  cancer  before 
the  medical  profession ;  and  some  nasty  remarks 
have  been  made  even  in  the  newspaper  press  about 
the  intention  of  Dr.  Glover  keeping  his  cure  secret 
for  the  benefit  of  his  own  personal  gain.  So  far  as 
the  profession  in  Toronto  is  concerned,  they  would 
like  to  have  some  pronouncement  from  Dr.  Glover 
either  in  the  scientific  press  of  Canada,  England, 
or  the  United  States ;  or  perhaps  better  before  the 
local  medical  body — the  Academy  of  Medicine. 
Cancer  is  such  a  terrible  disease,  so  hopeless  of  cure, 
that  the  profession  would  be  very  glad  and  proud 
of  the  facts  if  a  real  cure  emanated  from  Toronto ; 
but  in  the  plainest  English  they  hope  that  there  is 
now  sufficient  data  available  to  warrant  Dr.  Glover 
giving  it  to  the  profession  in  the  regular  way  for 
benefit  of  mankind  at  large. 


OVERWORK  A  STIMULANT. 
The  up  to  date  factory  physician  and  inspector 
are  wide  awake  in  their  researches  into  sleep  and 
fatigue.  If  employees  could  be  massed  together  as 
to  needful  rest  all  would  be  easy,  but  the  constitu- 
tion and  endurance  of  every  man  vary.  It  is  noted 
by  Spaeth  (Industrial  Management.  1920)  that 
with  most,  normal  fatigue  is  usually  relieved 
by  sleep  and  food ;  in  some,  it  quickly  goes 
on  to  cumulative  fatigue,  the  precursor  of  nervous 
breakdown.  Curiously,  recent  observations  have 
shown  that  production  actually  increases  with  fa- 
tigue within  certain  limits ;  feverish  haste  and  a 
dislike  of  not  finishing  up  are  not  infrequent  even 
when  the  work  is  not  congenial. 


OR.\NGEADE. 
"Made  from  fresh  oranges,"  so  the  vendor  at 
the  stall  says ;  but  the  Bureau  of  Chemistry  at 
Washington,  D.  C,  otherwise  labels  it.  The  drink 
is  usually  made  from  sweetened,  artificially,  car- 
bonated water  colored  with  a  dye  to  imitate  orange 
juice  and  flavored  with  a  little  oil  from  orange  peel. 
Wliile  not  containing  ingredients  injurious  to  the 
health  of  adults,  they  are  imitations  and  the  young 
do  not  get  the  medicinal  or  food  value  of  fruit 
juice.  Such  drinks  do  not  come  under  the  Food  and 
Drugs  Act. 


554 


NEWS  ITEMS. 


[New  York 
Medical  Journal. 


News  Items. 


French  Speaking  Physicians  Meet. — French 
speaking  physicians  of  North  America  held  their 
sixth  congress  September  9th  to  11th  at  Quebec, 
under  the  presidency  of  Dr.  Arthur  Rousseau. 

Southern  Medical  Association. — The  Southern 
Medical  Association  will  meet  November  15th  to 
18th  in  Louisville,  Ky.,  under  the  presidency  of 
Dr.  E.  H.  Gary,  of  Dallas,  Tex. 

Louisiana  Lepers'  Home  Sold. — The  Louisiana 
leprosarium  at  Carrville,  La.,  has  been  sold  to  the 
Federal  Government  for  use  as  a  national  lepro- 
sarium. The  institution  and  the  lepers  who  are  in- 
mates will  be  taken  over  by  the  U.  S.  Public  Health 
Service. 

Infantile  Paralysis. — Figures  given  out  by  the 
Health  Department  indicate  that  there  have  been 
sixty-five  cases  in  this  city  since  January  1st  and 
thirty-eight  in  the  last  month.  Sixteen  cases  were 
reported  in  one  week  in  the  latter  part  of  September. 
There  have  been  six  deaths  in  two  weeks. 

Southwestern  Medical  Association.  —  The 
Southwestern  Medical  Association,  which  comprises 
the  states  of  Missouri,  Kansas,  Oklahoma,  Arkansas 
and  Texas,  will  hold  its  fifteenth  annual  meeting 
November  22nd  to  24th  at  Wichita,  Kan.,  under 
the  presidency  of  Dr.  E.  E.  Day,  of  Arkansas  Gity, 
Kans. 

Consultation  Clinics  in  Massachusetts. — ^The 
Massachusetts  State  Department  of  Public  Health 
has  announced  its  plan  of  holding  a  series  of  con- 
sultation clinics  in  early  pulmonary  tuberculosis,  to 
be  conducted  by  the  medical  staf¥  of  the  state 
sanatoria.  Patients  will  be  referred  to  the  clinics 
by  the  family  physician. 

Hospital  Fund  Drive. — The  United  Hospital 
Fund,  comprising  forty-six  Manhattan  and  eight 
Brooklyn  nonmunicipal  hospitals,  will  endeavor  to 
raise  a  fund  of  $1,500,000  beginning  November 
15th.  This  sum  will  represent  approximately  half 
the  expense  incurred  in  giving  free  treatment  to 
those  who  are  unable  to  pay. 

Chair  in  Bronchoscopy  and  Esophagoscopy. — 
The  Graduate  School  of  Medicine  of  the  University 
of  Pennsylvania  has  established  the  first  medical 
chair  in  bronchoscopy  and  esophagoscopy,  the  in- 
cumbent being  Dr.  Ghevalier  Jackson,  of  Philadel- 
phia. Dr.  Jackson  will  also  continue  his  work  at 
Jefiferson  Medical  Gollege,  where  he  is  professor  of 
laryngology. 

Attend  Medical  Congress. — A  number  of  med- 
ical men  sailed  on  September  30th  on  the  Maure- 
tania  to  attend  the  International  Gongress  on  the 
Glassification  of  the  Gauses  of  Death,  in  Paris.  The 
congress  has  been  called  by  the  French  Government 
and  will  last  ten  days.  Dr.  Haven  Emerson,  former 
health  commissioner,  representing  the  Public  Health 
Association ;  Dr.  F.  J.  Monaghan,  assistant  health 
commissioner,  and  Dr.  W.  H.  Guilfoy,  director  of 
the  Bureau  of  Vital  Statistics  of  the  Health  De- 
partment, who  represent  the  Gity  of  the  New  York ; 
Dr.  Otto  Eichel  of  the  Bureau  of  Vital  Statistics 
of  the  State  Department  of  Health,  Dr.  W.  H. 
Davis  of  the  United  States  Bureau  of  Gensus  in 
in  Washington  were  passengers. 


Miners'  Hospital. — A  $200,000  hospital  for  the 
exclusive  use  of  coal  miners  is  to  be  erected  in 
Gharleston,  W.  Va.,  by  District  No.  17,  United 
Mine  Workers  of  America. 

Quarantine  Mexican  Tourists. — Because  of  the 
prevalence  of  yellow  fever  in  the  seacoast  cities  of 
Mexico,  the  U.  S.  Public  Health  Service  has  placed 
quarantine  restrictions  against  all  travelers  from 
those  ports. 

Sir  Arthur  Newsholme  Returns. — Sir  Arthur 
Newsholme,  resident  lecturer  on  Public  Health  Ad- 
ministration at  the  School  of  Hygiene  and  Public 
Health,  Johns  Hopkins  University,  has  returned  to 
Baltimore  after  having  spent  the  summer  at  his 
home  in  England. 

The  Harvey  Lectures. — Dr.  Jacques  Loeb,  of 
the  Rockefeller  Institute  for  Medical  Research,  will 
deliver  the  first  of  the  Harvey  Society  Lectures  at 
the  New  York  Academy  of  Medicine,  Saturday  eve- 
ning, October  16,  1920.  His  subject  will  be  The 
Proteins  and  Golloidal  Ghemistry. 

Tuberculous  Soldiers  Ordered  from  Saranac 
Lake. — Tuberculous  ex-service  men  who  are  be- 
ing cared  for  by  the  government  at  the  Home  Sana- 
torium, Saranac  Lake,  N.  Y.,  have  been  ordered 
transferred  to  New  Haven  and  other  government 
hospitals  by  October  15th. 

Women  in  Virginia  Medical  Faculty. — The 
Medical  Gollege  of  Virginia,  in  Richmond,  which 
last  year  opened  its  doors  for  the  first  time  to 
women  students,  now  has  its  first  woman  professor. 
Dr.  Margaret  Morris  Hoskins,  associate  professor 
of  anatomy.  Dr.  Hoskins  was  formerly  at  the  Uni- 
versity of  Minnesota. 

Vienna  Doctors  Strike. — A  press  dispatch  from 
Vienna  states  that  about  four  thousand  doctors  who 
have  been  treating  patients  under  the  auspices  of 
sick  benefit  associations  have  gone  on  strike,  and 
have  refused  to  make  visits  except  for  the  regular 
fees  of  their  private  practice. 

Intoxication  Increasing. — The  number  of  ar- 
rests for  intoxication  in  New  York  city  is  increas- 
ing, according  to  a  statement  issued  by  Ghief  Gity 
Magistrate  William  McAdoo.  The  figures  for  the 
first  six  months  of  1920,  from  January  to  April, 
give  the  total  number  for  the  Greater  City  as  571, 
During  April,  May  and  June  these  figures  rose  to 
1,396,  approximating  those  of  the  first  part  of  1919. 
Violence  which  follows  intoxication  shows  that  the 
liquor  in  many  instances  must  be  of  high  alcoholic 
strength. 

Change  of  Address. — Dr.  Wolflf  Freudenthal 
announces  the  removal  of  his  office  from  59  East 
Seventy-fifth  Street  to  24  West  Eighty-eighth 
Street,  New  York. 

Dr.  Maurice  Packard  announces  his  removal  to 
17  West  Seventieth  Street,  New  York. 

Dr.  Byron  G.  Glark  announces  the  removal  of 
his  office  to  163  West  Ninety-second  Street,  New 
York. 

Dr.  Robert  Abrahams  has  removed  his  office  to 
260  West  Seventy-second  Street,  New  York. 

Dr.  Abr.  L.  Wolbarst  announces  his  removal 
from  113  East  Nineteenth  Street,  to  792  Lexington 
Avenue,  New  York. 

Dr.  Jacob  Rosenbloom  announces  his  removal  to 
120  West  Seventieth  Street,  New  York. 


October  9,  1 920. J 


NEWS  ITEMS. 


555 


Baltimore  Charity  Hospitals  Raise  Rates. — 

Baltimore  hospitals  which  contract  for  the  care  of 
city  patients  have  notified  the  municipality  that  they 
will  not  renew  the  contracts  at  the  old  rate  of  one 
dollar  a  day.  They  ask  three  dollars  a  day  for  each 
patient  cared  for  in  the  future.  The  hospitals  in- 
clude the  Maryland  General,  Franklin  Square  and 
St.  Agnes. 

State  Hospital  for  Ex-Service  Men — An  ap- 
propriation of  $3,000,000  has  been  made  by  the 
New  York  State  Legislature  for  the  establishment 
of  a  state  hospital  for  discharged  soldiers,  sailors, 
and  marines  suffering  from  mental  diseases.  The 
hospital  will  be  built  in  the  Borough  of  Queens, 
on  land  acquired  for  the  Long  Island  State  Hospital, 
and  will  have  a  capacity  of  1,000  beds. 

Ambulance  Drivers  Lacking. — Bellcvue  Hos- 
pital is  experiencing  a  shortage  of  ambulance  drivers, 
and  for  the  first  time  since  the  establishment  of 
Bellevue  Hospital  in  1736  the  working  hours  of 
ambulance  drivers  have  had  to  be  changed.  It  was 
announced  that  the  drivers  will  wofk  twenty- four 
hours  on  and  twenty-four  hours  ofif,  instead  of  a 
six  day  week  with  the  seventh  day  off  as  heretofore. 

Hospital  Bequests. — Under  the  will  of  Max  J. 
Breitenbach,  of  New  York,  the  following  bequests 
are  made  to  charitable  and  educational  institutions : 
New  York  College  of  Pharmacy,  $25,000;  Sani- 
tarium for  Hebrew  Children  of  the  City  of  New 
York,  $5,000;  Montefiore  Home,  $5,000;  Beth 
Israel  Hospital,  $5,000;  Lebanon.  Hospital,  $5,000; 
Jewish  Maternity  Hospital,  $5,000;  Crippled  Chil- 
dren's East  Side  Free  School,  $5,000;  Mount  Sinai 
Hospital,  $3,000;  Hospital  at  Albany,  Ga.,  $1,000. 

The  will  of  Jacob  H.  Schiff,  which  has  recently 
been  made  public,  contains  many  bequests  to  char- 
itable institutions.  The  Montefiore  Home  and  Hos- 
pital for  Chronic  Diseases,  of  which  the  testator  was 
for  many  years  president,  receives  $300,000.  Other 
bequests  were :  Solomon  and  Betty  Loeb  Memorial 
Home  for  Convalescents,  $25,000;  New  York  Asso- 
ciation for  the  Blind,  $10,000;  Babies  Hospital  in 
the  City  of  New  York,  $5,000 ;  Tuberculosis  Preven- 
torium for  Children  at  Farmingdale,  N.  J.,  $5,000. 

A  gift  of  $50,000  has  been  made  to  the  Ware 
Visiting  Nurse  and  Hospital  Association,  Ware, 
Mass.,  by  the  late  Lewis  N.  H.  Gilbert,  of  that  place. 

Local  Medical  Societies. — The  following  local 
medical  societies  will  meet  during  the  coming  week : 

Monday,  October  nth. — Society  of  Medical  Jurisprudence, 
New  York  Ophthalmological  Society,  Yorkville  Medical 
Society,  Association  of  Alumni  of  St.  Mary's  Hospital 
(Brooklyn),  Williamsburg  Medical  Society. 

Tuesday,  October  I2th. — New  York  Academy  of  Medi- 
cine (Section  in  Neurology  and  Psychiatry),  Manhattan 
Dermatological  Society,  New  York  Obstetrical  Society, 
Clinical  Society  of  the  Hospital  and  Dispensary  for  De- 
formities and  Joint  Diseases. 

WEDNESD.A.Y,  October  13th. — Medical  Society  of  the  Bor- 
ough of  the  Bronx,  New  York  Pathological  Society,  New 
York  Surgical  Society,  Alumni  Association  of  Norwegian 
Hospital,  Brooklyn  Medical  Association. 

Thursday,  October  14th. — New  York  Academy  of  Medi- 
cine (Section  in  Pediatrics),  West  End  Clinical  Society, 
Brooklyn  Pathological  Society. 

Friday,  October  15th. — New  York  Academy  of  Medicine 
(Section  in  Orthopedic  Surgery),  Clinical  Society  of  the 
New  York  Postgraduate  Medical  School  and  Hospital,  New 
York  Microscopical  Society,  Brooklyn  Medical  Society. 


Health  Department  Budget. — Dr.  Royal  S. 
Copeland,  health  commissioner,  has  asked  for  an  ap- 
propriation of  $8,821,027.23  to  run  the  New  York 
City  Department  of  Health  for  1921,  against  $4,- 
758,951  for  1920.  Of  this  amount  $7,551,978  is  to 
run  the  department  and  the  difference  is  for  new 
buildings.  One  of  the  new  activities  for  which  the 
Commissioner  is  asking  an  annual  salary  list  of  $11,- 
600  is  the  establishment  of  a  Bureau  of  Public  Health 
Intelligence.  Dr.  Copeland  said  that  for  two  years  the 
department  had  been  asking  for  a  new  official  to 
watch  the  trend  of  disease  in  this  city  and  through- 
out the  world,  in  order  to  apply  advance  informa- 
tion for  the  safeguarding  of  New  York  against 
invasion  by  disease.  The  director  of  this  bureau  is 
to  receive  $5,000  a  year 

Dr.  Copeland  has  asked  for  an  allowance  that 
would  enable  him  to  engage  thirty  inspectors  of  food 
at  $1,769  each,  sixty-eight  nurses  for  maternity  work, 
nine  dentists  at  $1,244  each,  nine  nurses  at  $1,800 
each,  and  18  dental  hygienists  at  $960  each. 

It  is  the  Commissioner's  desire  to  increase  facili- 
ties for  making  the  Schick  test  for  diphtheria.  He 
estimated  the  needs  of  the  department  for  this  work 
as  six  medical  inspectors  at  $1,464  each  a  year,  six 
nurses  at  $1,800  each,  and  five  laboratory  helpers  at 
$840  each.  He  asked  also  for  $2,550  for  a  bacterio- 
logical diagnostician  and  a  sum  to  allow  for  increas- 
ing the  force  of  laboratory  assistants  and  helpers. 
The  department  is  asking  that  supervising  nurses  re- 
ceive a  salary  of  $1,980  a  year  and  field  nurses  $1,800 
a  year.    To  do  this  $46,217  will  be  required. 

 <i>  

Died, 

BosHER. — In  Richmond,  Va.,  on  Sunday,  September  12th, 
Dr.  Lewis  Crenshaw  Bosher,  aged  sixty  years. 

BuRCH. — In  Long  Lake,  N.  Y.,  on  Wednesday,  September 
22nd,  Dr.  Elmer  D.  Burch,  aged  fifty-three  years. 

Cole.— In  New  York,  N.  Y.,  on  Saturday,  September  25th, 
Dr.  John  D.  Cole,  aged  sixty-three  years. 

Harrison. — In  Roanoke,  Va.,  on  Wednesday,  September 
1st,  Dr.  Henry  William  Harrison,  aged  seventy-one  years. 

Hill. — In  Nanticoke,  Pa.,  on  Sunday,  September  26th, 
Dr.  Jacob  Franklin  Hill,  aged  sixty-four  years. 

James. — In  New  York,  N.  Y.,  on  Wednesday,  September 
29th,  Dr.  Howard  James,  aged  fifty-five  years. 

Johnson. — In  Los  Angeles,  Cal.,  on  Friday,  September 
17th,  Dr.  Walter  Sydney  Johnson,  aged  forty-nine  years. 

Kean. — In  Manchester,  N.  H.,  on  Thursday,  September 
23rd,  Dr.  M.  E.  Kean. 

KooNS. — In  Waynesboro,  Pa.,  on  Wednesday,  September 
29th,  Dr.  John  H.  Koons,  aged  sixty-six  years. 

Morgan. — In  Rolling  Bay,  Wash.,  on  Monday,  September 
20th,  Dr.  William  P.  Morgan,  aged  seventy-four  years. 

Roberts. — In  New  York,  N.  Y.,  on  Monday,  September 
27th,  Dr.  Charles  Forrester  Roberts,  aged  seventy-eight 
years. 

Sterling. — In  Philadelphia,  Pa.,  on  Friday,  September 
24th,  Dr.  Joseph  Marshall  Sterling,  aged  thirty-one  years. 

Thomas. — In  Wilmington,  N.  C,  on  Sunday,  September 
5th,  Dr.  George  Gillette  Thomas,  aged  seventy-seven  years. 

Upson. — In  Bristol,  Conn.,  on  Tuesday,  September  21st, 
Dr.  Charles  Ransom  Upson,  aged  sixty-eight  years. 

WooLF. — In  New  York,  N.  Y.,  on  Sunday,  September 
26th,  Dr.  Edgaj-  Morton  Woolf,  aged  thirty-two  years. 


Book  Reviews 


NEW  VIEWS  ON  GOITRE. 

Exophtliahnic  Goitre  and  Its  Nonsurgical  Treatment.  By 
Israel  Bram,  M.  D.,  Instructor  in  Clinical  Medicine, 
Jefferson  Medical  College,  Philadelphia,  etc.  St.  Louis  : 
C.  V.  Mosby  Company,  1920.    Pp.  ix-438. 

Readers  of  the  New  York  Medical  Journal 
will  welcome  Dr.  Bram's  book  on  the  nonsurgical 
treatment  of  exophthalmic  goitre.  Much  that  is  in 
the  book  has  appeared  in  the  Journal.  As  the 
book  stands  today  it  is  the  most  thorough  exposi- 
tion of  Graves's  disease  to  be  found.  When  the 
risk  attending  surgical  removal  of  the  thyroid  is 
considered  and  when  we  realize  the  splendid  results 
that  have  been  obtained  by  nonsurgical  treatment, 
it  is  absolutely  necessary  to  study  the  disease  from 
the  nonsurgical  viewpoint.  It  is  not  to  be  thought 
that  nonsurgical  means  only  medicinal.  The  non- 
surgical treatment  embraces  many  methods  of  treat- 
ment, local,  general  and  psychotherapeutic,  and 
Bram  has  gone  into  the  subject  thoroughly,  attack- 
ing it  from  every  angle.  He  first  studied  the  patient 
and  the  patient's  life  in  an  endeavor  to  trace  the 
real  etiology  of  the  disease;  he  is  not  misled  by  the 
surface  findings  nor  does  he  accept  the  apparent 
causative  factors  of  the  disease. 

Following  this,  he  endeavors  to  ascertain  the  value 
of  every  form  of  treatment,  giving  due  credit  to 
each  one.  He  shows  that  the  manifestations  of 
goitre  may  be  symptoms  having  many  underlying 
causes.  They  may  be  the  defense  reaction  of  one 
leading  a  lonely  home  life ;  they  may  be  fear  reac- 
tions caused  by  the  outcropping  of  the  latent  un- 
known content  of  the  patient's  unconscious. 
He  shows  the  importance  of  the  endocrine  chain 
and  how  easily  the  equilibrium  of  the  chain  is  up- 
set. This  knowledge  is  made  use  of  in  a  diagnostic 
way  when  endocrine  diagnostic  tests,  like  the  pitui- 
tary test,  are  utilized.  It  is  also  of  primary  impor- 
tance in  the  treatment  of  the  disease.  While  the 
study  of  practical  endocrinolgy  is  in  its  infancy,  we 
are  now  beginning  to  use  much  of  the  knowledge 
that  has  been  acquired  in  the  laboratory,  linking  it 
up  with  our  clinical  finding,  and  applying  these  find- 
ings in  a  therapeutic  way.  The  results  have  been 
most  encouraging  and  in  many  cases  startling. 

The  use  of  the  x  ray  has  also  found  favor  among 
many  and  in  the  hands  of  skilled  operators  has 
proved  far  more  efficacious  than  the  ordinary  sur- 
gical procedures.  Radium  also  has  frequently  given 
excellent  results.  Bram  has  given  us  a  host  of  reme- 
dial measures  and  in  many  cases  one  remedy  may 
prove  to  be  excellent  where  another  may  fail.  Some 
observers  maintain  that  they  have  had  a  number  of 
positive  cures  with  every  one  of  the  therapeutic 
methods  they  have  employed  as  their  favorite  one. 
Yet  it  cannot  be  said  in  looking  over  the  entire  list 
that  any  one  of  these  can  be  called  a  specific  for  the 
cure  of  thyroid  disease.  There  must  be  something 
more  behind  all  this.  The  answer  is  given  when 
we  search  for  the  etiology  of  the  disease.  Bram 
helps  us  materially  when  he  stresses  the  underlying 
psychic  factors  and  shows  how  they  are  universally 
responsible  for  setting  the  responsive  mechanism  of 
a  susceptible  patient  into  operation  and  thereby 


causing  the  chain  of  symptoms,  either  separately  or 
to  the  completion  of  the  entire  clinical  picture  known 
as  Graves's  disease  or  true  exophthalmic  goitre. 
Therefore,  it  is  safe  to  assume  that  much  of  the 
good  that  has  come  from  the  many  measures  men- 
tioned by  Bram  has  come  through  the  rapport  estab- 
lished between  the  patient  and  the  physician ;  a  con- 
dition technically  known  as  transference. 

The  patient,  feeling  inadequate  within  himself,  a 
martyr,  unburdens  himself  to  the  physician.  In 
many  instances  this  alone  will  tend  to  improve  the 
patient's  condition.  The  more  thoroughly  this  rap- 
port is  established,  the  more  interest  the  physician 
takes  in  the  intimate  life  of  the  patient,  the  more 
will  the  benefit  of  this  procedure  be  found.  Nat- 
urally the  patient  must  reveal,  as  far  as  he  is  able, 
the  things  that  trouble  him.  Frequently  it  is  impos- 
sible for  the  patient  to  know  what  the  underlying 
difficulty  is,  for  it  will  be  buried  deeply  in  his  un- 
conscious. Bram  shows  that  it  is  most  impor- 
tant '  to  ascertain  the  patient's  habits,  tendencies, 
petty  obsessions,  and  vices.  In  speaking  of  this 
Bram  quotes  Weir  Mitchell,  who  said  that  "The 
cases  of  breakdown  and  nervous  disaster,  and  the 
consequent  emotional  disturbances  and  their  bitter 
fruit  are  oftener  to  be  sought  in  the  remote  past. 
He  may  dislike  the  quest  but  he  cannot  avoid  it. 
*  *  *  Tht  moral  world  of  the  sick  bed  explains 
in  a  measure  some  of  the  things  that  are  strange  in 
daily  life,  and  the  man  who  does  not  know  sick 
women  does  not  know  women."  Confidence  must 
be  secured.  Once  this  is  done  rapid  strides  will  be 
made.  Sympathy  must  be  extended  and  the  patient 
must  know  that  the  physician  is  interested  in  the 
welfare  of  the  patient.  Then  the  patient  must  be 
reeducate  and  be  taught  to  stand  on  his  own  feet, 
take  an  independent  place  in  the  world,  and  be  made 
selfreliant. 

Frequently  the  patient's  friends  and  relatives, 
those  of  a  talkative  trend,  have  a  bad  influence  upon 
him.  They  may  in  some  cases  be  the  cause 
of  the  patient's  condition.  All  that  must  be  ascer- 
tained and  the  objectionable  surroundings  removed, 
e.  g.,  the  talkative  friends.  The  patient's  general 
hygiene  must  not  be  neglected.  There  must  be  regu- 
larity of  bathing,  sleep,  rest,  exercise,  feeding;  in 
fact,  the  general  condition  of  the  patient  must  re- 
ceive careful  attention.  One  of  the  important  issues 
emphasized  by  Bram  is  the  sexual  life  of  the  patient. 
He  shows  how  powerful  a  factor  this  may  become 
under  certain  conditions.  Sexual  instruction  must 
be  given,  after  the  sexual  cravings  and  sex  life  of 
the  patient  have  been  determined. 

This  leads  us  to  the  social  environment  of  the 
patient.  In  treating  a  patient  we  seldom  inquire 
into  this  part  of  their  lives.  We  know,  and  Bram 
realizes  it,  that  the  patient's  household  may  be  an 
inferno  seething  with  suppressed  antagonisms  and 
hatreds.  A  patient's  condition  cannot  readily  im- 
prove under  these  circumstances  and  all  the  medi- 
cation and  surgical  intervention  known  to  medical 
science  will  not  get  at  the  bottom  of  the  difficulty. 
The  only  advantage  of  a  radical  surgical  operation 
is  secured  by  the  removal  of  the  patient,  for  the 


October  9,  1920.] 


BOOK  REVIEWS. 


557 


time  being,  from  the  unfavorable  surroundings  to 
the  hospital. 

Bram's  book  is  replete  with  just  such  useful  in- 
formation. We  realize  that  a  busy  surgeon,  or  gen- 
eral practitioner,  for  that  matter,  will  not,  as  a 
rule,  go  into  all  of.  the  details  of  the  patient's  life 
as  he  should  in  handling  a  delicate  situation.  He 
will  be  more  likely  to  attempt  a  more  perfect  technic 
for  the  operation.  However,  we  are  coming  more 
and  more  to  realize  that  the  high  psychic  levels  of 
the  patient  are  important — most  important.  Never- 
theless, it  is  essential  that  some  basis  of  therapy, 
similar  to  that  mapped  out  by  Bram,  should  be  at- 
tempted before  surgical  measures  are  used.  In  most 
instances  surgery  will  not  be  required.  Even  the 
surgeon  would  do  wisely  to  ascertain  what  can  be 
done  outside  his  own  field  in  the  treatment  of 
Graves's  disease.  In  consideration  of  the  impor- 
tance of  the  subject  and  the  careful  handling  it  has 
received  in  this  book  it  may  be  considered  as  one  of 
the  most  important  additions  to  medical  literature  of 
the  present  day. 

ALTITUDE  AND  HEALTH. 

Altitude  and  Health.  (The  Chadwick  Lectures.)  By  F.  F. 
RoGET,  a  Privat-Docent  Professor  in  the  University  of 
Geneva.    New  York :  E.  P.  Button  &  Co.    Pp.  xii-186. 

The  heights  by  great  men  reached  and  kept 
Were  not  attained  by  sudden  flight, 

But  they,  while  their  companions  slept. 
Were  toiling  upwards  in  the  night. 

And  while  we  were  ignorantly  huddled  in  the  plains, 
and  maligning  cold  air,  Professor  Roget  and  dozens 
like  him,  were  frantically  waving  to  us  from  the 
heights  to  follow  on.  But  we  shut  our  windows 
tighter  and  feebly  shouted  that  we  had  a  cold  on 
our  chest.  "Nonsense,"  called  out  the  mountain- 
eers, "it's  on  your  mind."  But  we  created  and  filled 
a  few  more  cemeteries  before  learning  that  they 
were  right.  We  have  learned  that  the  immune 
countries  are  the  coldest.  That  phthisis  is  accele- 
rated where  the  average  shade  temperature  is  very 
high,  and  reaches  its  maximum  of  frequency  in 
those  regions  of  the  temperate  European  zone  which 
are  only  moderately  cold,  whether  low  lying  or  not. 
A  few  ventured  up  and  were  improved,  but  there 
is  probably  a  precise  altitude  which  is  the  best  indi- 
vidually, and  to  that  side  deep  attention  is  being 
given.  Men  go  up  there  worn  with  toil  or  illness. 
"They  have  spent  their  reserve  of  nutrition  and 
have  not  had  time  to  replenish  their  store  of  warmth, 
so  they  must  be  reconstituted  by  a  larger  and  wiser 
choice  of  food.  Another  evil  arose  from  mountain 
stations  being  advertised  as  winter  playgrounds.  It 
would  have  been  well  but  the  visitors  brought  civil- 
ization with  them.  Out  of  doors  all  day — splendid 
— but  the  evenings  were  spent  in  crowded  hotels 
and  closed  bedrooms.  All  the  wicked  germs  who 
had  to  come  with  them  expecting  speedy  death, 
gambolled  about  boldly  and  thrived.  Overcrowd- 
ing is  as  unsanitary  in  the  Swiss  Alps  as  in  cities. 
»  But  those  invalids  who  live  there,  who  have 
learned  to  avoid  overexertion  with  consequent  reac- 
tion and  have  got  the  body  to  fulfill  of  its  own  accord 
the  conditions  which  will  procure  a  regular  output  of 
warmth,  cannot  now  return  to  the  lowlands  without 
a  return  of  their  illness. 


Prefaced  by  a  kindly  and  patient  explanation  of 
all  that  a  change  to  high  altitude  means  (and  the 
author  speaks  after  thirty-five  years'  experience) 
he  goes  more  fully  into  tlie  thermic,  electric,  baro- 
metric and  hygrometric  conditions,  also  pointing  out 
that  it  is  necessary  to  distinguish  enrichment  of 
blood  at  altitudes  (say,  not  exceeding  10,000  feet) 
and  impoverishment,  which  certainly  begins  for 
most  at  8,000,  particularly  within  the  tropics.  To 
distinguish  between  these  two  stages  is  the  oftice 
of  the  new  science,  hematology,  in  which  Dr.  H.  C. 
Lombard  and  Dr.  William  Marcet  have  done  splen- 
did work. 

The  chapter  on  Air  at  Altitudes  is  easy  and 
pleasant  reading  and  gives  the  balloon  experiments 
of  Professor  J.  Quale  of  Zurich  with  mountain 
sickness  and  blood  and  the  latest  British  experi- 
ments by  Barcroft,  Roberts,  Mathison  and  Ryffel. 
The  monks  in  the  Great  St.  Bernard  Pass  and  the 
community  at  Avers  are  well  described.  The  mor- 
tality statistics  concerning  them  enlist  the  attention 
in  an  unusual  way.  The  claims  of  the  seacoast  are 
admitted,  but  highest  honor  is  given  to  the  sun  as 
doctor  and  friend.  Some  of  the  stodgy  volumes  on 
the  question  of  altitude  and  health  show  how  difficult 
it  is  to  fit  pretty  garments  of  speech  on  angular 
facts,  or  to  write  persuasively  so  that  those  dam- 
aged in  health  may  joyfully  pack  their  suitcases  and 
climb  to  health,  but  we  can  imagine  many  wheez- 
ing, coughing,  holloweyed,  one-foot-in-the-grave 
persons  taking  that  foot  out  again  and,  limping  but 
rejoicing,  seeking  the  pure  air  of  the  mountains. 

A  LABOR  VERSUS  CAPITAL  PLAY. 

Touch  and  Go.  A  Play  in  Three  Acts.  Plays  for  a  Peo- 
ple's Theatre.  By  David  H.  Lawrence.  New  York : 
Thomas  Seltzer,  1920.   pp.  v-103. 

Mr.  D.  H.  Lawrence,  whose  field  has  heretofore 
been  the  analysis  of  more  personal  passions,  has 
turned  his  eye  upon  the  industrial  situation  and 
produced  a  labor  capital  play,  a  play  with  a  preface. 
As  is  usual  in  such  instances,  the  preface  is  more 
illuminating  than  the  play.  In  the  preface  Mr. 
Lawrence  tells  what  he  thinks  about  a  great  many 
subjects,  including  a  People's  Theatre.  A  People's 
Theatre  he  conceives  as  a  place  where  will  be  pro- 
duced plays  about  people — "not  noses  on  two  legs, 
not  burly  pairs  of  gaiters,  stufifed  and  voluble,  not 
white  meringues  of  chastity,  not  incarnations  of 
co-respondence" — in  contradistinction  to  the  Chu 
Chin  Chow  sort  of  thing. 

Unfortunately  Touch  and  Go  is  not  a  play  about 
people.  It  is  a  tedious  and  wordy  affair,  utterly 
lacking  in  direction  or  in  high  moments.  The  theme 
is  a  strike  in  the  colliery  of  Barlow  and  Walsall  and 
young  Gerald  Barlow's  refusal  to  have  anything  to 
do  with  what  he  regards  as  a  mess.  In  the  mob 
scene  at  the  end  Gerald  tells  the  men  that  he  wants 
a  new  way  of  life,  that  he  doesn't  care  about 
money,  but  that  he  is  not  going  to  be  bullied.  And 
a  ribald  voice  from  the  mob,  with  one  of  the  few 
touches  of  conviction  in  the  play,  answers,  "No, 
because  you've  got  everything." 

If  the  characters  are  to  be  taken  as  at  all  repre- 
sentative of  their  respective  classes,  Mr.  Lawrence 
regards  labor  as  inexpressibly  stupid  and  capital  as 
jaded  but  stubborn.   He  also  regards  them  as  natu- 


558 


BOOK  REVIEWS. 


[New  York 
Medical  Journal. 


ral  enemies.  "The  two  dogs  are  making  the  bone 
a  pretext  for  a  fight  with  each  other.  .  .  .  Labor 
not  only  wants  his  debt.  He  wants  his  pound  of 
flesh.  .  .  .  What's  the  solution?  There  is  no  solu- 
tion. But  still  there  is  a  choice.  There's  a  choice 
between  a  mess  and  a  tragedy."  Possibly  the  work- 
ers will  not  be  as  concerned  as  Mr.  Lawrence  in 
seeing  that  they  are  tragical  instead  of  messy  and 
in  going  through  the  conflict  beautifully.  There 
are  afTairs  of  more  importance.  Mr.  Lawrence  in 
this  play  writes  like  a  minor  poet  who  has  strayed 
from  his  daisy  field. 

A  PSYCHOANALYTICAL  SHERLOCK 
HOLMES. 

The  Ivory  Disc.    Bv  Percy  James  Brebner.    New  York  : 
Duffield  &  Co.,  1920.    Pp.  254. 

An  uncanny  kind  of  doctor  is  taking  the  place  of 
the  ones  created  by  Barrie,  Wendell  Holmes  and 
earlier  writers.  He  is  a  psychoanalytical  Sherlock 
Holmes  with  a  touch  of  the  Eastern  mystic,  yet  suf- 
ficiently human  to  yield  to  the  modern  idea  that  to 
love  is  to  take,  no  matter  how  many  husbands  or 
children  the  lady  already  possesses.  He  has  a  la- 
boratory, always  locked,  and  is  experimenting  with 
some  new  poison  which  will  kill  the  toughest  villain 
in  five  minutes.  Or  a  sudden  death  has  occurred. 
"Heart  disease,"  says  the  jury,  but  the  doctor's 
steely  blue  eye  has  a  peculiar  glint  of  suspicion  in 
it.  He  has  the  body  exhumed  and  triumphantly 
■exposes  the  villainy  of  a  murder. 

Dr.  Bruce  Oliver  manages  to  carry  on  his  detec- 
tive work  and  woo  the  wife  of  a  polished  Indian 
professor  at  the  same  time.  Now  this  professor 
sends  his  pretty  young  English  wife  around  with 
a  ring  containing  subtle  poison  which  she  uncon- 
sciously injects  during  a  handshake,  and  it  naturally 
makes  him  angry  to  see. his  wife  growing  to  lose 
"her  fear  of  him  and  his  hypnotic  powers  lessening. 
Meanwhile  Dr.  Oliver  "felt  that  she  was  his,  not 
through  overmastering  passion,  but  by  right  of  love. 
He  had  said  no  word  of  love  to  her  until  love  was 
with  them  suddenly,  not  to  be  denied,  not  to  be 
considered  a  crime."  His  only  hope  lies  in  expos- 
ing the  professor,  but  this  man  is  very  wily  and 
glosses  evil  intentions  with  a  suave  manner.  His 
evil  intention  of  adding  the  doctor  to  his  poisoned 
victims  is  frxistrated  by  the  ivory  disc,  a  talisman 
given  him  by  Estelle,  the  bad  professor's  wife, 
whom  he  finally  persuades  to  leave  her  husband  and 
live  in  a  lonely  cottage  with  a  trained  nurse  until  a 
divorce  or  annulment  of  Indian  marriage  is  ob- 
tained. While  there  she  greatly  desires  her  dog, 
and  Dr.  Oliver  will  fetch  it  for  her.  Then  we  have 
a  mysterious  house  right  in  the  heart  of  London, 
dim  lights,  soft  footed  servants,  a  sudden  surprise 
in  the  professor's  study  and  Oliver  is  swiftly 
strapped  to  a  chair  until  his  enemy  shall  choose  to 
touch  him  with  the  fatal  ring.  But  the  Indian  serv- 
ants discover  the  talisman  on  his  neck  and  super- 
stition induces  them,  when  bidden  to  leave  the 
room,  to  loose  the  big  dog,  who  hates  the  profes- 
sor, for  his  protection.  Brutal  thrashings,  since 
Estelle's  departure,  have  made  the  animal  vindic- 
tive. He  scents  out  his  master  just  as  the  hour  has 
struck  for  the  poisoning,  then  a  deadly,  horrible 


fight  takes  place  with  Oliver  utterly  powerless  to 
help.  Finally  the  professor  is  killed,  the  dog  also, 
because  it  rubs  against  the  ring,  and  the  doctor  is 
free  to  wed  Estelle. 

The  story  will  be  enjoyed  by  those  who  revel  in 
improbabilities.  We  do  not  meqt  any  of  these  mys- 
terious practitioners  in  New  York ;  they  have 
enough  to  do  getting  toxins  out  of  their  patients 
without  putting  any  in.  Of  course,  the  women 
patients  can  invest  the  most  plump,  jovial  and  ordi- 
nary doctor  with  occult  powers.  Many  owe  their 
large  practice  to  this  blessed  blindness  of  woman- 
kind, but  if  such  stories  as  these  flood  in  we  shall 
have  even  women  a  little  inclined  to  avoid  friendly 
handshakes,  hypnotizing  glances,  dimly  lighted  re- 
ception rooms  and  anything  supposed  to  be  oriental. 

~ — -^^^  •  .    :  , 

New  Publications  Received. 


[We  publish  full  lists  of  books  received,  but  we  acknoivl- 
eage  no  obligation  to  revieiv  them  all.  Nevertheless,  so 
far  as  space  permits,  we  reviezv  those  in  which  we  think 
our  readers  are  likely  to  be  interested.^ 


TRUE  LOVE.  By  Allan  Monkhouse.  New  York :  Henry 
Holt  &  Co.,  1920.   Pp.  vi-373. 

THE  BROKEN  LAUGH.  By  Meg  Villars.  New  York : 
Robert  M.  McBride  &  Co.,  1920.   Pp.  vii-343. 

THE  elfin  artist  AND  OTHER  POEMS.     By  AlFRED  NoYES. 

New  York :  Frederick  A.  Stokes  Company,  1920.  Pp.  ix- 
187. 

TOUCH  AND  GO.  A  Play  in  Three  Acts.  Plays  for  a  Peo- 
ple's Theater.  By  D.  H.  Lawrence.  .  New  York :  Thomas 
Seltzer,  1920.    Pp.  v-103. 

HEALTH  AND  SOCIAL  PROGRESS.     By  RuDOLPH  M.  BiNDER, 

Ph.  D.,  Professor  of  Sociology,  New  York  University.  New 
York:  Prentice-Hall^  Inc.,  1920.    Pp.  i-295. 

ALL  THINGS  ARE  POSSIBLE.  By  Leo  Shestov.  Authorized 
Translation  by  S.  S.  Koteliansky.  With  a  Foreword  by 
D.  H.  Lawrence.  New  York:  Robert  M.  McBride  &  Co., 
1920.    Pp.  vii-244. 

PROBLEMS   OF    POPULATION    AND    PARENTHOOD.      Being  the 

Second  Report  of  and  the  chief  evidence  taken  by  the  Na- 
tional Birthrate  Commission.  1918-1920.  New  York:  E.  P. 
Button  &  Co.,  1920.    Pp.  v-423. 

mind  energy.  Lectures  and  Essays.  By  Henri  Bergson. 
Member  of  the  French  Academy,  Professor  in  the  College 
de  France.  Translated  by  H.  Wildon  Carr,  Hon.  D.  Litt.. 
Professor  in  the  University  of  London.  New  York :  Henrv 
Holt  &  Co.,  1920.   Pp.  x-262. 

letters  from  the  kaiser  TO  THE  CZAR.  Copies  From 
Government  Archives  in  Petrograd  Unpublished  Before 
1920.  Private  Letters  From  the  Kaiser  to  the  Czar  Found 
in  a  Chest  After  the  Czar's  Execution  and  Now  in  Posses- 
sion of  the  Soviet  Government.  Copied  and  Brought  From 
Russia  by  Isaac  Don  Levine.  Illustrated.  New  York: 
Frederick  A.  Stokes  Company.    Pp.  xxxv-264. 

THE  shibboleths  OF  TUBERCULOSIS.     By  MaRCUS  PaTER- 

son,  M.  D.,  Medical  Superintendent,  Metropolitan  Asylums 
Board,  Colindale  Hospital ;  Late  Medical  Superintendent, 
Brompton  Hospital  Sanatorium,  Frimley ;  Medical  Director, 
King  Edward  VII  Welsh  National  Memorial  Association; 
Resident  Medical  Officer,  Brompton  Hospital,  London.  New 
York :  E.  P.  Dutton  &  Co.,  1920.   Pp.  xi-239. 

OPERATIVE  gynecology.  By  Harry  Sturgeon  Crossen,  * 
M.  D.,  F.  A.  C.  S.,  Associate  in  Gynecology,  Washington 
University  Medical  School,  and  Associate  Gynecologist  to 
the  Barnes  Hospital ;  Gynecologist  to  St.  Luke's  Hospital, 
St.  Louis  Alaternity  Hospital,  and  Bethesda  Hospital.  Sec- 
ond Edition.  Illustrated.  St.  Louis:  C.  V.  Mosby,  1920. 
Pp.  v-717. 


Miscellany  from  Home  and  Foreign  Journals 


Delayed  Arsenical  Poisoning  Following  the 
Administration    of    Salvarsan    Preparations. — 

George  S.  Strathy,  C.  H.  V.  Smith,  and  Beverley 
Hannah  {Canadian  Medical  Association  Journal, 
April,  1920)  report  their  observations  in  fifty-eight 
cases  of  delayed  poisoning  following  administration 
of  salvarsan  and  mercury.  Forty-seven  of  these 
showed  symptoms  referable  to  the  liver,  jaundice, 
decreased  digestive  power,  and  liver  atrophy.  Eight 
were  fatal  and  showed  at  autopsy  marked  atrophy, 
of  the  liver.  Atrophy  of  the  liver  may  be  marked 
in  patients  who  ultimately  recover.  This  condition 
can  be  diagnosed  by  the  x  rays.  Dermatitis  oc- 
curred in  eight  cases ;  five  were  severe  with  marked 
exfoliation.  Peripheral  neuritis  was  observed  in 
two  cases.  Albuminuria  was  present  in  over  fifty 
per  cent,  of  the  cases ;  edema  was  found  in  two. 
The  onset  of  the  symptoms  seldom  occurred  until 
five  weeks  after  the  administration  of  salvarsan  had 
ceased.  The  earliest  symptoms  of  poisoning  of  the 
liver  were  bile  in  the  urine,  albuminuria,  loss  of 
appetite  and  jaundice.  These  symptoms  should  be 
looked  for  in  all  patients  receiving  salvarsan  treat- 
ment, and  on  their  appearance  the  administration 
of  the  remedy  should  cease.  By  x  ray  examination 
atrophy  of  the  liver  may  be  diagnosed  at  an  early 
stage.  Where  evidence  of  liver  damage  is  present, 
the  diet  should  be  reduced  to  a  minimum.  Dermat- 
itis with  atrophy  of  the  liver  occurred  in  one  patient 
who  received  arsenic  in  the  form  of  Fowler's  solu- 
tion, five  minims  three  times  a  day  for  five  months. 

Specific  Aortitis. — William  D.  Reed  {Boston 
Medical  end  Surgical  Journal,  July  15  and  22, 
1920)  says  that  syphilitic  disease  of  the  aorta  is 
one  of  the  most  common  and  most  serious  find- 
ings in  all  cases  of  acquired  syphilis.  The  lesion 
is  essentially  mesoaortitis,  and  a  manifestation 
of  active  syphilis ;  its  conception  as  a  para- 
syphilide  being  made  untenable  by  the  discovery  in 
1906  of  the  spirochete  directly  in  the  aortic  lesion. 
The  aortic  process  frequently  extends  to  the  aortic 
cusps,  and  \\'arthin  has  shown  that  relatively  often 
there  is  an  accompanying  myocarditis  of  spirochetal 
origin.  Aortic  roughening,  aortic  regurgitation, 
dilatation  or  aneurysm  of  the  aortic  arch,  and  angina 
j)ectoris  are  common  in  syphilitic  aortitis.  Aortic 
or  mitral  stenosis  is  of  exceptional  occurrence  in 
connection  with  specific  aortitis.  Xonsyphilitic 
forms  of  aortitis  are  rare.  Many  cases  may  be 
called  latent,  in  that  symptoms  are  absent :  such 
cases  are  commonly  undiagnosed  until  disclosed, 
perhaps,  in  a  routine  rontgen  examination.  There 
is  no  one  point  on  which  a  diagnosis  should  be 
based,  but  only  after  a  study  of  all  the  facts  in  a 
given  case  should  a  decision  be  rendered.  Every 
case  of  cardiac  disturbance  of  obscure  origin,  espe- 
cially if  the  patient  is  a  young  adult,  and  if  there 
are  signs  of  involvement  of  the  aortic  valve,  should 
promptly  suggest  the  probability  of  syphilitic  cau.sa- 
tion.  A  positive  Wassermann  reaction  is  of  con- 
firmatory value,  but  is  frequently  absent.  Rontgen 
examination,  though  unreliable  in  early  cases,  gives 


perhaps  the  most  reliable  findings.  Specific  aortitis 
evidences  a  tendency  to  progressive  impairment  of 
the  heart  and  aorta  and  is  of  serious  import.  Treat- 
ment should  be  directed  primarily  toward  killing  the 
spirochetes  in  the  aortic  lesions.  Decompensation  of 
the  heart  is  to  be  treated  as  in  that  of  nonsyphilitic 
origin.  Early  diagnosis  is  imperative.  There  should 
be  a  greater  willingness  on  the  part  of  clinicians  to 
make  a  tentative  diagnosis  of  specific  aortitis  and 
a  resort  to  a  therapeutic  test. 

Sporotrichosis    of    the    Genital    Organs. — A. 

Brainos  {Paris  medical,  March  20,  1920)  reports 
two  cases,  both  in  young  men,  illustrating  the  fact 
that  sporotrichosis  may  be  localized  upon  the  genitals 
and  cause  a  septicemic  reaction.  In  one  of  these 
cases  the  omission  of  potassium  iodide  in  the  anti- 
syphilitic  treatment  at  first  administered— without 
result — led  to  the  thought  that  sporotrichosis  might 
be  present,  for  had  the  iodide  been  used  from  the 
first,  prompt  recovery  would  have  occurred  and  a 
wrong  diagnosis  of  syphilitic  gumma  probably  have 
been  made.  Cultures  showed  the  sporotrichum  in 
this  case,  which  recovered  rapidly  under  potassium 
iodide  by  mouth  and  iodine-iodide  solution  locally. 
Whenever  the  physician  administers  the  antisyph- 
ilitic  therapeutic  test  in  a  case  with  a  local  lesion 
the  syphilitic  nature  of  which  is  confirmed  neither 
by  laboratory  tests  nor  clinical  study,  potassium 
iodide  should  be  omitted,  in  order  to  pemiit  of  dif- 
ferentiation between  syphilis  and  sporotrichosis. 

Comparative  Study  of  the  Wassermann  Test 
and  the  Hecht-Weinberg-Gradwohl  Modification. 

- — A.  J.  Blaivas  (Journal  of  Laboratory  and  Clin- 
ical Medicine,  January,  1920)  states  that  seventeen 
per  cent,  of  the  100  sera  examined  had  no  hemo- 
lytic index,  so  that  the  Hecht-Weinberg-Gradwohl 
test  could  not  be  done.  Nineteen  cases  showed  a 
positive  or  borderline  Hecht-Weinberg-Gradwohl 
test  and  a  negative  or  borderline  Wassermann. 
Of  the  fourteen  of  these  cases  in  which  the  history 
was  obtainable  there  was  generally  direct  evidence 
of  an  early  infection  or  of  a  mild  easily  overlooked 
case  of  syphilis  or  of  a  syphilitic  association  or 
consanguinity.  In  sixty-five  per  cent,  of  the  cases 
the  reactions  were  the  same.  Five  per  cent,  showed 
a  strong  positive  in  the  modified  test,  and  a  nega- 
tive Wassermann  reaction.  An  additional  five  per 
cent,  were  positive  in  tubes  twelve  and  thirteen  in 
the  Hecht-Weinberg-Gradwohl  test,  and  negative  in 
the  Wassermann,  and  four  per  cent,  were  positive 
in  tube  thirteen  in  the  Hecht-Weinberg-Gradwohl 
test,  and  negative  in  the  Wassermann.  Blaivas  be- 
lieves that  the  Hecht-Weinberg-Gradwohl  test 
should  never  be  used  alone  to  diagnose  syphilis,  but 
always  in  conjunction  with  the  Wassermann  test, 
and  that  a  physician  should  be  very  wary  in  pro- 
nouncing a  case  syphilis  when  the  modified  test 
is  positive  and  the  \Vassermann  is  negative.  Blaivas's 
results  are  not  in  conformity  with  Gradwohl's  claim 
that  a  complete  inhibition  of  hemolysis  is  obtained 
in  the  Hecht-Weinberg-Gradwohl  test,  as  he  ob- 
tained several  borderline  reactions. 


560 


MISCELLANY  FROM  HOME   AXD  FOREIGN  JOURNALS. 


[New  York 
Medical  Journal. 


The  Colloidal  Gold  Reaction  with  Cerebrospinal 
Fluid. — Ellis  Kellert  (American  Journal  of  the 
Medical  Sciences,  February,  1920)  considers  the 
colloidal  gold  reaction  to  be  useful  as  an  additional 
or  confirmatory  test.  It  is  of  greatest  value  in  the 
syphilitic  diseases  of  the  central  nervous  system, 
especially  tabes  and  paresis,  and  it  may  serve  to 
differentiate  between  tuberculous  and  other  forms 
of  meningitis.  The  reaction  is  correct  in  approxi- 
mately eighty  per  cent,  of  cases.  Cerebrospinal 
fluid  contaminated  with  blood  in  small  quantity  fre- 
quently gives  reactions  in  the  luetic  zone.  Positive 
results  unconfirmed  by  other  tests  are  of  only  slight 
value.  The  Wassermann  reaction  and  the  cytolog- 
ical  examination  of  the  cerebrospinal  fluid  are  of 
greater  value  than  the  colloidal  gold  test. 

Contraction  Waves  in  the  Normal  and  Hydro- 
nephrotic  Ureter. — Wilder  G.  Penfield  {American 
Journal  of  tlie  Medical  Sciences,  July,  1920)  says 
that  the  ureter  is  a  muscular  tube  which,  when 
subjected  to  partial  obstruction,  always  dilates, 
usually  hypertrophies,  and  whose  peristaltic  rate  is 
increased.  Contraction  waves  pass  in  either  direc- 
tion with  equal  facility,  depending  on  the  location 
of  the  area  whose  rate  of  spontaneous  contraction 
is  most  rapid.  This  area  is  normally  in  the  renal 
pelvis,  but  abnormally  a  more  rapid  pacemaker  may 
be  established  elsewhere.  It  is  suggested  that  un- 
derlying the  more  rapid  rhythm  of  the  pacemaking 
area  is  the  fact  that  its  metabolic  rate  is  more  rapid 
than  in  any  other  level  of  the  ureter.  Production 
of  a  constriction  ring  which  becomes  pacemaker  for 
the  ureter  above  and  below  it  depends  on  three 
things :  the  metabolic  gradient,  ureteral  distention 
and  refractoriness  during  contraction  and  the  first 
part  of  relaxation.  It  is  suggested  that  in  the  pas- 
sage of  a  ureteral  stone,  trauma  and  inflammation 
increase  the  rate  of  metabolism  in  the  ureter  wall 
about  the  stone,  a  constriction  ring  results,  followed 
by  distention  of  the  ureter  and  retroperistalsis. 
This  would  cause  great  distention  of  the  renal  pelvis 
and  give  to  renal  colic  its  peculiar  rhythmical 
character. 

Renal  Manifestations  in  Heart  Weakness. — 

O.  Josue  and  Parturier  {Pat'is  medical,  IMarch 
13,  1920)  note  that  in  heart  cases  with  manifest 
signs  of  renal  insufficiency  there  has  been  a  natural 
tendency  to  ascribe  these  signs  to  actual  renal  disease 
coexisting  with  the  cardiac  disturbance.  As  a  mat- 
ter of  fact,  however,  simple  oliguria  from  heart 
weakness  is  sufficient  to  bring  about  a  renal  5301- 
drome  with  azotemia  or  anasarca,  and  many  cases 
classed  as  cardiorenal  on  the  basis  of  both  blood  and 
urine  examinations  are  not  actually  cardiorenal 
cases.  Recognition  of  actual  participation  of  the 
kidneys  in  the  syndrome  is  not  possible  during  the 
period  of  heart  weakness  and  oliguria,  but  after 
digitalis  has  acted  and  diuresis  become  reestablished, 
the  desired  information  may  be  secured,  in  particular 
with  the  aid  of  Ambard's  ureosecretory  coefficient. 
Often  the  kidneys  are  thus  shown  to  be  quite  nor- 
mal ;  or  the  kidneys  may  be  slightly  diseased,  yet 
sufficient  to  eliminate  urea  so  long  as  cardiac  com- 
pensation persists.  A  high  Ambard  coefficient  gives 
warning  that  in  the  event  of  loss  of  compensation. 


prolonged  oliguria  will  prove  a  more  serious  matter 
than  usual.  In  all  heart  cases  exihibiting  a  renal 
syndrome  with  oliguria,  even  though  heart  weakness 
is  not  pronounced,  impaired  renal  function  due  to 
heart  weakness  should  be  thought  of  and  heart  tonics 
prescribed.  Edema  and  oliguria  are  alike  among  the 
earliest  and  most  reliable  signs  of  cardiac  insuffi- 
ciency. Before  the  myocardium  is  toned  up  with 
digitalis,  aqueous  plethora  must  first  be  reduced  by 
venesection  and  drastic  purgation,  which  often  re- 
lieve dyspnea  at  once  and  enable  the  patient  to  sleep. 
A  milk  diet  should  be  ordered,  and  in  cases 
with  extreme  oliguria,  water  alone  allowed.  Not 
more  than  1,500  mils  of  fluid,  with  100  to  150  grams 
of  lactose,  should  be  permitted  in  the  twenty-four 
hours.  Xativelle's  digitaline  in  single  daily  doses  of 
thirty  to  thirty-five  drops  is  the  best  heart  remedy 
for  these  cases.  In  grave  cases,  with  persistent 
oliguria  and  increasing  azotemia,  such  doses  should 
be  kept  up  for  three,  four,  or  even  five  days,  in  or- 
der finally  to  induce  diuresis.  When  the  latter  does 
set  in,  the  digitaline  should  be  continued  but  gradu- 
ally tapered  down.  Wliere  oliguria  is  continuously 
threatening,  digitaline  may  be  advantageously  kept 
up  for  some  time  in  daily  amounts  of  five  to  ten 
drops.  Neither  the  albuminuria,  azotemia,  nor  high 
blood  pressure  contraindicate  the  drug  in  these  pa- 
tients, but  are  instead  benefited  by  it.  Theobromine, 
1.5  to  two  grams  a  day,  may  be  combined  with  the 
digitalis  or  follow  it.  The  salt  free  diet  will  assist 
in  the  removal  of  edema,  but  once  the  usual  cardiac 
energy  has  been  restored,  salt  may  be  resumed  with- 
out causing  edema  to  reappear. 

Coxofemoral  Arthritis  FoUow^ing  Ingestion  of 
Hexamethylenamine  in  Large  Amounts. — Pierre 
Marie  and  Pierre  Behague  (Bulletin  de 
I' Academic  de  medecine  May  11,  1920) 
report  the  cases  of  two  men  aged  about 
forty  years  who,  in  order  to  escape  from  German 
prison  camps,  ingested  massive  doses  of  urotropin. 
Nearly  100  grams  of  the  drug  were  taken  irt 
twenty-four  hours,  and  in  one  case  the  total  amount 
taken  is  estimated  to  have  been  one  kilogram.  In 
both  instances  marked  and  painful  hematuria  set  in 
a  day  or  two  later,  passing  off  two  or  three  days 
after  the  drug  was  discontinued.  Upon  their  re- 
turn to  France  the  men  seemed  to  have  completely 
regained  their  health,  but  in  one  instance  ten 
months  and  the  other  eighteen  months  after  the 
use  of  the  drug  there  developed  a  progressive  ar- 
thritis sicca  of  both  hip  joints,  which  became  so 
marked  that  the  patients  could  walk  only  with 
great  difficulty  and  have  remained  thus  incapaci- 
tated ever  since.  In  one  case  x  ray  examination 
showed  considerable  changes  in  the  head  of  the 
femur,  which  was  irregular  and  presented  cauli- 
flowerlike masses  projecting  beyond  the  joint  sur- 
faces. In  the  other  case  the  changes  were  less 
marked,  but  there  were  visible  some  .ridges  and  ir- 
regularities completely  surrounding  the  joint  and 
the  femoral  head  likewise  showed  deformity.  The 
precisely  similar  effects  in  the  two  cases  suggest 
that  the  drug  was  responsible  for  these  joint 
changes.  Experiments  are  being  conducted  to  eluci- 
date the  matter  and  have  already  been  attended 
with  somewhat  suggestive  results. 


October  9,  1920.]  MISCELLANY  FROM  HOME   AND  FOREIGN  JOURNALS.  561 


Anomalies  of  the  Bile  Ducts. — Daniel  N. 
Eisendrath  (Surgery,  Gynecology  and  Obste- 
trics, July,  1920)  in  discussing  the  possibility  of 
injury  to  the  bile  ducts  gives  the  anomalies  which 
may  occur  as  follows : 

1.  The  gallbladder  may  be  absent,  rudimentary 
or  hour  glass;  it  may  lie  more  or  less  completely 
enveloped  by  the  liver  (intrahepatic  form)  ;  the 
pelvis  may  be  on  the  upper  instead  of  the  lower  side 
(reversed  ampulla  or  pelvis)  ;  right  hepatic  duct 
may  empty  into  the  gallbladder ;  there  may  be 
transposition  of  viscera. 

2.  The  cystic  duct  may  be  double,  i.  e.,  there 
may  be  two  cystic  ducts;  the  hepatic  (right)  duct 
may  empty  into  the  cystic  duct ;  an  accessory  he- 
patic duct  may  empty  into  either  the  cystic  or  the 
angle  of  junction  of  the  cystic  and  main  hepatic 
ducts ;  the  cystic  duct  may  be  so  greatly 
dilated  as  to  be  almost  indistinguishable  from  the 
main  hepatic  duct ;  the  cystic  duct  may  be  ver\' 
small  and  extremely  short;  parallelism  (short  or 
long)  is  present  in  seventeen  per  cent.,  and  a 
spiral  course  of  the  cystic  in  eighty  per  cent,  of 
individuals. 

3.  The  hepatic  ducts.  There  may  be  four  or  five 
instead  of  one  main  duct,  which  is  formed  just  out- 
side of  the  liver,  and  accessory  hepatic  ducts. 

4.  The  common  duct  may  be  extremely  short  or 
very  long ;  a  double  common  duct  may  be  present ; 
in  nearly  ninety-five  per  cent,  of  individuals  the 
common  duct  lies  within  the  pancreas. 

5.  The  blood  vessels.  There  may  be  anomalies 
of  the  right  hepatic  artery ;  of  the  single  cystic  ar- 
tery ;  of  the  double  cystic  arteries ;  and  of  the 
gastroduodenal  artery. 

Sliding  Hernia. — Louis  Frank  (American  Jour- 
nal of  Surgery,  March,  1919)  discusses  sliding 
hernia  and  presents  the  following  conclusions : 

1.  Sliding  hernia  (Iiernie  par  glissement)  involv- 
ing any  of  the  abdominopelvic  viscera  is  infre- 
quently encountered,  and  sliding  vesical  hernia  is  the 
rarest  type  known. 

2.  Sliding  hernia  is  noted  with  greater  frequency 
in  males  than  females  in  the  proportion  of  about 
four  to  one ;  it  usually  accompanies  inguinal  hernia 
in  the  former  and  femoral  hernia  in  the  latter. 

3.  Sliding  hernia  seldom  occurs  in  young  subjects 
of  either  sex,  those  of  middle  and  advanced  age 
being  most  susceptible ;  but  there  are  strange  excep- 
tions to  this  rule. 

4.  No  viscus  completely  invested  by  peritoneum 
can  become  the  sliding  part  of  a  hernia,  in  the 
absence  of  anatomic  abnormality. 

5.  The  anteoperative  diagnosis  of  sliding  hernia, 
irrespective  of  what  may  be  the  sliding  viscus,  is  a 
physical  impossibility. 

6.  The  sliding  portion  of  a  sliding  hernia  cannot 
become  strangulated,  although  strangulation  of  the 
true  contents  of  the  hernial  sac  is  commonly  ob- 
served. 

7.  The  treatment  of  hernia,  including  the  sliding 
type,  is  essentially  surgical ;  and  unless  the  nature 
of  the  pathological  condition  is  promptly  recognized 
and  extreme  care  exercised  in  executing  the  opera- 
tive steps,  irreparable  damage  may  be  inflicted  upon 
the  sliding  viscus. 


Diabetes  Due  to  Syphilitic  Disease  of  the  Pan- 
creas.— P.  Carnot  and  P.  Harvier  (Paris  medical 
May  15,  1920)  report  the  case  of  a  woman  aged 
fifty-three  years,  exhibiting  both  syphilitic  nervous 
disease — beginning  tabes  and  sacral  anterior  polio- 
myelitis— and  diabetes  with  loss  of  weight  and 
marked  glycosuria.  At  the  autopsy  a  syphilitic  cir- 
rhosis of  the  liver  and  fibrogummatous  syphilitic 
pancreatitis  were  found,  the  latter  process  having 
resulted  in  almost  complete  disappearance  of  all 
pancreatic  tissue.  The  clinical  and  pathological 
features  were  so  clear  cut  as  to  establish  beyond  a 
doubt  the  occurrence  of  a  form  of  diabetes  due  to 
syphilitic  disease  of  the  pancreas. 

Urogenital  Tuberculosis. — ^I.  J.  Latimer  Uro- 
logic  and  Cutaneous  Review,  May,  1920)  says  that 
urogenital  tuberculosis  is  the  most  curable  of  the 
various  forms  of  surgical  tuberculosis ;  routine 
general  and  local  examinations  are  essential  to  a 
correct  understanding  of  all  the  associated  factors 
and  the  definite  localization  of  foci ;  the  treatment 
of  election  is  radical  surgical  procedure ;  accessible 
foci  should  be  eradicated,  even  where  radical  elimi- 
nation of  all  foci  is  impracticable ;  palliative  sur- 
gery is  especially  indicated  in  advanced  eases 
because  it  often  is  thereby  possible  to  eliminate  the 
almost  constantly  present  factor  of  mixed  infection 
and  secondary  toxemia. 

Traumatism  of  the  Spleen. — E.  L.  Connor 
(Canadian  Medical  Association  Journal,  June, 
1920)  says  that  ruptured  spleen  can  only  be  treated 
as  a  siugical  condition  of  the  abdomen.  Although 
the  severe  symptoms  may  be  delayed,  we  should 
more  often  think  of  this  condition  in  examining 
patients  with  histories  of  slight  injury  to  the  lower 
left  thoracic  region.  Pain  in  the  left  shoulder, 
when  no  injury  can  be  found  about  the  joint, 
should  at  least  be  considered  as  being  referred  from 
the  spleen.  Splenectomy  is  not  a  difficult  opera- 
tion and  should  be  undertaken  by  any  man  who  has 
reasonable  operating  facilities.  Ruptured  spleen 
should  always  be  considered  as  a  condition  demand- 
ing early  treatment  rather  than  postponed  treat- 
ment at  some  large  centre. 

Fishscale  Gallbladder. — John  Ripley  Corkery 
(Annals  of  Surg.ery,  June,  1920)  from  a  study  of 
museum  and  fresh  studies  of  socalled  multiple 
small  cysts  of  the  mucosa  of  the  gallbladder  pre- 
sents his  conclusions  as  follows : 

1.  Multiple  small  cysts  of  the  mucosa  is  a  mis- 
nomer for  this  condition. 

2.  Fishscale  appearance  is  due  to  chronic  inflam-  - 
mation. 

3.  Lipoid  substance  leaves  an  apparent  trail  from 
the  lumen  of  the  blood  vessel  to  the  lumen  of  the 
gallbladder  and  is  a  constant  feature  in  active 
cholecystitis  in  this  condition. 

4.  Lipoid  substance  occurs  in  leucocytes  in  fish- 
scale gallbladder. 

5.  The  large  polygonal  cells  in  the  submucosa  may 
be  transitional  leucocytes. 

6.  The  process  of  inflammation  of  the  gallbladder 
is  practically  identical  with  inflammation  of  the 
appendix  and  barring  mechanical  difficulties  the 
end  result  is  the  same,  i.  e.,  obliteration. 


Proceedings  of  National  and  Local  Societies 


AMERICAN    GYXECOLOGICAL  SOCIETY. 

Forty-fifth  Anmual  Meeting.  Held  in  Chicago,  May 
24,  23  and  26, 1920. 

The  Pre^dent,  Dr.  RfHExr  L-  Dickixsox,  of  Xew  York, 
m  tibe  CfaajT. 

Ar.i.^esia  and  Anestbeaa  in  Labcr  — _  •  rlr- 
w.ABD  P.  Davts,  of  Philaddp  ; 
best  qnafity  of  eSther,  ^iillfiil 
successful  in  the  majority  of  :  -  t  ^  : 
labor  dorii^  the  second  stage.  I  ^ 
of  the  pain,  qnickfy  remoTcd 
subsided,  it  stimulated  and  did  : 
the  moment  when  esqmlsions     :  " 
inhalatioras  without  air  wonlc  ~ 
insensible  to  pain  although  car r.  ^- 
ing  sensations  of  feeling,  heari:  _     -  -^ght. 
The  mother  roused  easfly  after  -  i 

no  anesdiesia  while  the  placeni;:.  r 
the  insQtion  of  stitdbes  imr.  r 
ether  properly  administered  wi  ^ 
paratively  safe  and  efficient.    He  had  ~tt 
dence  that  such  use  during  the  stage  ::  ;  _  .  .  . 
injured  the  fetus.    It  was  true  that  ether  was  in- 
flammable, that  some  patients  were  excited  by  it. 
that  it  was  irritable  to  the  bronchial  tubes  and  kid- 
neys, and  that  it  was  difficult  to  anesthetize  sooit 
patients  with  ether,  but  if  skillfully  administered  :: 
was  usnalhr  successful'  and  its  combinaticHi  witl 
oxygen  rendered  it  in  his  experience  the  safest  c: 
obstetrical  anesthetics. 

The  modem  anesthetizer  should  be  prepared  to 
use  nitrons  oxide  and  oxjrgen,  ether  and  oxygen, 
diloroform  with  or  without  ox  v  gen,  drangins".  :f 
necessary,  from  one  to  the  other  of  these  durirr  z. 
proknged  operation.    In  special  fields  of  siir 
the  inventicm  of  special  apparatus  had  made  ane  - 
sia  \^astly  more  accurate  and  successfuL  For 
obstetrician  analgesia  or  anesthesia.  skillfuUy  ^ 
made  for  more  accurate  diagnosis  during  lalmr 
for  the  successful  management  not  only  of  ~ 
taneous  and  normal  parturiticm,  but  of  compli:  .  . 
conditions.    It  was  a  familiar  fact  that  recovery 
from  parturition  was  greatly  ddayed  by  exhaustion 
during  labor.    In  this  r^ard  modem  analgesia  and 
anesthesia  were  among  the  greatest  advances  made 
by  modem  obstetrical  science.    One  must  not  for- 
get the  considerable  f^al  mortalitj  and  morbidity 
produced  by  prolonged  birth  pressure  and  by  nn- 
~  r^iilated  and  violent  expulsive  efforts.   The  danger 
of  aqihyxia  to  the  fetus  during  labor  by  analgesia 
and  anesthesia  was  vastly  less  than  the  dai^er  of 
hemonbage  from  birth  pressure  and  the  avoidance 
of  this  latter  cmiq>lication  was  greatly  enhanced  by 
obstetrical  analgesia  and  anesthesi£. 

Indoction  of  Labor;  Indications  ar.d  MetJicds 
with  Special  Reference  to  the  Use  of  Pituitary 
fixtract. — Dr.  Bext.\mix  P.  Watsox,  of  Toronto, 
Ontario,  said  diat  Blair  Bell  in  1909  was  die  first 
to  employ  in  practice  the  results  of  experimental 
investigaticms  carried  out  on  the  extract  of  the  pitui- 
tary gland  up  to  that  time.  Since  then  a  great  mass 
of  literature  had  accumulated  on  the  subject.  It 


was  universally  recognized  that  it  was  a  most  vahi- 
able  agent  for  acceloating  the  seomd  stage  of  labor 
when  delay  was  due  to  feeble  uterine  contraction. 
In  most  of  the  articles  whidli  had  appeared  tiie 
reader  was  warned  against  using  it  for  Ae  indudtion 
of  labor  cm-  before  the  cervix  was  fully  dilated.  He 
had  used  it  extensively  for  the  induction  of  labor 
and  during  all  stages  of  labor,  and  had  never  had 
'  r  y  bad  results.    In  1913  he  recorded  three  cases 
.hich  he  had  successfully  induced  labor  by  its 
3ne  of  these  was  at  the  eighth  month,  one 
---m.  and  one  at  three  weeks  post  term.  He 
e  method  was  worth  an  extended  trial 
. that  his  fnrtiber  results  bore  ttas  out. 
i  was  to  begin  with  a  dose  of  one 
1-  administered  intramnscnlarly  with 
a  kmg  needle.    In  most  cases  uterine  contractions 
commenced  in  about  ten  minutes  and  increased  in 
seventy  during  the  next  twenty  minutes.    At  the 
end  of  this  time  die  second  injection  of  (me  half  c  c 
•^ri=.  ~--eri.   If,  after  a  time,  the  contractions  tended 
or  to  come  at  longer  intervals,  the  dose 
As  nony  as  six  or  eight  doses  m^ht 
.    thi  at  intervals  of  about  half  an  hour. 
T  -  'oint  was  to  admiiiister  a  further 

effects  of  the  previous  one  had 
The  effects  from  a  single  dose 
for  about  half  an  hour  and 
e  effect.    Sufficient  doses 
—  '  -  keep  up  uterine  con- 
;  -  e  a  certain  amount  of 

opcr.:,rg  '""en  the  cervix  had 

besrm  t*:-  es  to  bulge  into  it 

— ^^  -je  without  the 
:    :    -  The  failures 

■      -  ;  *  r  result  of 
_  —  :_r  H       .'  'pundit 

give  eight  or  :  c.  c. 

-  — tervals. 

Z9rx  the  av-  ,  jf 


the  bag  ' 
labor  be^-::  :  :  ::       ;   :  ^        -  r 

duration  of  labor  was  :  .  r 

of  course,  was  ve-;  -  -  —  iraw 

conclusions  froc: 

five  cases  the  av^-  .;t  :    ,    '  " 

dose  to  the  defit  :  T  - 
wlnle  the  averagr      -  :        :   i  :r  . 
seven  for  muhif  a  t  - 

pituitrin  alone  ir.  .  the  aver- 

age time  elapsrr ,  "  :       -7  ind  the 

definite  onset  of  r  aver- 

age durati(m  of  .:rs 
for  five  piimipar 
tiparse.    With  quinir  t  1:  _  :  : 
,t(Mal  of  sixty-two  C2^ci  r.::y-^.rr-  t 
and  nine  were  totally  unsuccessful.   Six  of  the  suc- 
cessful cases  required  re?-*::":-  of  the  r    -  — r  be- 
fwe  labcH"  began.   In  the    :  v     -ee  succt  -es 
the  average  time  dapsinc 

jntuitrin  and  the  onset  o:        :  .  — 


October  9,  1920.J 


PROCEEDINGS  OF  NATIONAL   AND  LOCAL  SOCIETIES. 


563 


the  average  duration  of  labor  was  ten  hours ;  four- 
teen hours  for  twenty-three  primiparae  and  seven 
hours  for  thirty  multiparae.  In  the  quinine  and  pit- 
uitrin  cases  labor  was  spontaneous  except  in  fouf 
cases  in  which  forceps  were  used  when  the  head 
was  on  the  perineum.  In  the  total  of  fifty-three 
cases  there  were  four  stillborn  babies. 

Dr.  Watson  said  that  recently  two  of  his  col- 
leagues, members  of  his  staff,  J.  G.  Gallic  and  W. 
A.  Scott,  had  recorded  a  series  of  sixty-five  cases 
in  which  they  had  used  pituitary  extract  alone  for 
the  induction  of  labor.  Out  of  this  total  number 
fifty-five  were  entirely  successful.  The  average 
number  of  doses  given  was  three  and  the  average 
duration  of  labor  was  seven  hours.  There  was  one 
fetal  death  twenty-eight  hours  after  delivery  from 
atelectasis.  The  delivery  was  normal  in  forty-five, 
by  forceps  in  nine  and  by  version  in  one. 

Taking  these  results  with  those  which  he  had 
recorded,  he  thought  we  must  recognize  that  the 
method  had  a  definite  place  in  obstetrical  practice 
and  should  be  considered  before  other  methods 
were  adopted.  It  had  very  special  advantages  in 
cases  of  slight  disparity  between  the  head  and  pel- 
vis, as  it  did  not  in  any  way  prejudice  the 
Cassarean  operation  should  it  prove  to  be  neces- 
sary— an  argument  which  could  not  apply  to  the 
bougie  or  bag  method. 

The  Induction  of  Labor  at  Term.  —  Dr. 
Charles  B.  Reed,  of  Chicago,  said  that  labor  could 
be  inaugurated  by  quinine  and  pituitrin,  by  castor 
oil  and  quinine,  by  the  modified  de  Ribes  bag  or 
by  both.  The  castor  oil  acted  in  about  two  cases 
out  of  five  and  most  reliably  when  the  patient  was 
a  little  bit  past  the  calculated  date.  The  Voorhees 
bag,  in  his  experience,  was  the  most  dependable 
and  was,  therefore,  the  favorite  agent  at  his  hos- 
pital. The  patient's  bowels  should  receive  attention 
the  night  before  and  in  the  morning  the  external 
genitalia  given  a  careful  obstetrical  preparation. 

Assemble  and  sterilize  by  boiling  twenty  min- 
utes a  modified  de  Ribes  bag  No.  4  (Voorhees),  a 
Simon  speculum  or  vaginal  retractor,  a  pair  of 
long  Pean  forceps  (dressing  forceps  would  serve), 
two  pairs  of  volsellum  forceps,  two  pairs  of  com- 
pression forceps,  a  Goodell  dilator,  a  tenaculum 
forceps,  a  hand  bulb  syringe  with  glass  tubes  and 
rubber  connections  for  the  bag  or  a  large  piston 
syringe.  The  bag  and  accessory  apparatus  must 
be  tested  for  defects  before  using.  The  patient 
prepared  as  for  delivery  was  placed  upon  the  table 
in  exaggerated  lithotomy  position  with  legs  held 
by  assistants  or  by  stirrups.  The  vagina  was  re- 
tracted, a  smear  made  from  the  cervix  and  the 
mucous  membrane  wiped  clean  with  pledgets.  An- 
esthesia was  only  occasionally  necessary  even  in 
primiparse.  One  lip  of  the  cervix  was  seized  by 
the  volsellum  and  brought  down.  If  the  bag  had 
been  properly  prepared  the  os  would  admit  it  origi- 
nally without  dilatation.  The  bag  must  be  emptied 
of  residual  air  and  the  flat  end  pulled  out.  It  was 
next  rolled  into  a  compact  mass  like  a  cigarette  and 
seized  by  the  Pean  forceps  so  that  the  tips  extended 
just  to  the  largest  diameter  of  the  rolled  bag.  Af- 
ter annointing  the  bag  with  sterile  glycerin  it  was 
passed  into  the  cervix  with  the  concavity  of  the 


forceps  turned  toward  the  patient's  left  leg  and  as 
it  entered  the  os  the  concavity  was  turned  upward 
one  quarter  of  a  circle  so  that  when  the  maneuver 
was  completed  the  curve  of  the  instrument  con- 
formed to  the  flexure  of  the  uterus.  Release  the 
lock  of  the  introducing  forceps.  Connect  the  tube 
of  the  bag  with  the  filling  apparatus  and  force  the 
sterile  solution  (lysol,  boric  acid  or  plain  water) 
slowly  into  the  bag.  Do  not  overfill  by  force  or  the 
bag  will  break.  Tension  in  the  tube  of  the  bag  or 
the  feeling  of  resistance  to  the  injection  are  signs 
of  fullness  to  the  experienced  operator.  If  uncer- 
tain of  the  technic,  a  measured  amount  of  fluid 
might  be  used.  A  piston  syringe  of  tested  size 
would  also  serve  to  inform  the  operator  when  the 
capacity  of  the  bag  (six  ounces)  had  been  reached. 
The  Pean  forceps  were  removed  as  soon  as  the  bag 
was  sufficiently  filled  to  keep  it  from  slipping  out. 
Snap  the  compression  forceps  on  the  tube ;  remove 
the  volsellum  from  the  cervix  and  disconnect  the 
syringe.  Tie  the  tube  of  the  bag  strongly  with 
tape.  Remove  the  compression  forceps.  Place  two 
sterile  pads  on  the  vulva,  one  on  either  side  of  the 
tube.  Remove  the  stirrups  and  pull  the  patient  up 
in  the  bed.  The  bag  might  break  from  overfilling 
or  being  insufficiently  filled  might  slip  out  of  the 
cervix  before  the  uterine  contractions  began.  If 
so,  another  bag  should  be  inserted.  If  the  pains  did 
not  start  within  an  hour  a  weight  of  one  or  two 
pounds  was  attached  by  a  tape  to  the  protruding 
tube  and  passed  over  the  foot  of  the  bed.  Usually 
in  from  five  minutes  to  half  an  hour  the  contrac- 
tions began  and  labor  was  under  way. 

In  a  variable  period,  rarely  more  than  four  hours 
(three  hours  and  twenty  minutes  in  his  series)  the 
bag  was  expelled  by  strong  pains,  the  dilatation 
was  practically  complete  and  the  head  followed  the 
bag  down  into  the  pelvis,  the  membranes  ruptured 
and  the  second  stage  began.  From  then  on  the 
case  was  managed  according  to  general  obstetrical 
principles.  The  tedious,  exhausting,  and  painful 
first  stage  had  been  definitely  shortened.  The  bag 
acted  as  a  mechanical  aid  to  cervical  dilatation,  a 
dynamic  stimulant  to  the  contractions  and  it  pre- 
served the  membranes  from  injurious  pressure  un- 
til physiological  rupture  occurred.  When  the  mem- 
branes had  been  accidentally  ruptured  by  the  in- 
sertion of  the  bag  no  attempt  should  be  made  to  pull 
on  it  to  mark  advancement  lest  it  come  out  and  by 
suction  bring  down  the  cord.  When  the  i^ag  came 
out  after  accidental  rupture  of  the  membranes  at 
the  time  of  insertion  it  was  good  practice  to  make 
an  internal  examination  to  discover  the  presence  or 
absence  of  a  prolapsed  cord. 

In  the  series  of  two  hundred  cases  hitherto  re- 
ported he  had  114  multiparae  and  eighty-six  primi- 
parae.  The  average  duration  of  labor  was  seven 
hours  and  fifty-six  minutes ;  the  longest  labor  was 
thirty  hours,  due  to  a  tough,  inelastic  cervix.  Two 
other  patients  were  in  labor  twenty-eight  hours 
from  cervical  conditions.  In  one  the  cervix  was 
a  mass  of  cicatricial  tissue.  The  shortest  labor  in  a 
multipara  was  fifty-five  minutes  and  in  a  primi- 
para  sixty  minutes.  The  bag  broke  while  being 
filled  or  shortly  after  insertion  nine  times.  An- 
other bag  was  introduced  four  times.    The  mem- 


564 


J-'ROCEEDINGS  OF  NATIONAL   AND  LOCAL  SOCIETIES. 


[New  York 
Medical  Journal. 


branes  were  ruptured  by  the  insertion  of  the  bag 
seven  times ;  in  one  case  intentionally  for  hydram- 
nios.  The  bag  was  expelled  in  an  average  period 
of  three  hours  and  twenty  minutes.  The  longest 
detention  was  nine  hours ;  the  shortest  was  ten 
minutes.  Two  mothers  died.  One  had  myocardi- 
tis associated  with  a  marginal  insertion  of  the  pla- 
centa. Her  labor  lasted  only  an  hour  and  a  half 
and  was  accompanied  by  a  normal  amount  of 
hemorrhage  only.  Death  came  two  hours  after  the 
delivery.  The  other  had  pneumonia  and  died  eight 
days  after  labor.  In  no  case  did  the  bag  fail  to 
inaugurate  contractions  nor  the  woman  to  deliver. 

The  Prophylactic  Forceps  Operation. — Dr. 
Joseph  B.  De  Lee,  of  Chicago,  stated  that  the 
prophylactic  forceps  operation  was  the  routine  de- 
livery of  the  child  in  head  presentation  when  the 
head  had  come  to  rest  on  the  pelvic  floor  and  the 
early  removal  of  the  placenta.  Primiparous  labors 
and  those  where  the  conditions  of  the  soft  parts 
approximated  a  first  labor,  were  treated  by  this 
method,  which  really  comprised  more  than  the 
actual  delivery  of  the  child.  It  was  a  rounded 
technic  for  the  conduct  of  the  whole  labor,  with 
the  defined  purpose  of  relieving  pain,  supplement- 
ing and  anticipating  the  efforts  of  Nature,  reducing 
the  hemorrhage,  preventing  and  repairing  damage. 

Sir  J.  Y.  Simpson  said  that  labor,  according  to 
Nature's  plans,  should  be  normal,  but  that  in  a  large 
proportion  of  cases  it  was  not  so.  So  frequent 
were  these  bad  effects,  that  he  had  often  wondered 
if  Nature  did  not  deliberately  intend  women  should 
be  used  up  in  the  process  of  reproduction,  in  a 
manner  analogous  to  that  of  the  salmon,  which 
died  after  spawning.  The  radical  interference  with 
the  mechanism  of  the  third  stage  was  intended  to 
reduce  the  amount  of  blood  lost,  shorten  the  an- 
esthetic period  and  reduce  the  danger  of  infection 
from  retained  blood  clots,  membranes  and  insuffi- 
cient uterine  contraction.  He  freely  admitted  that 
this  method  of  treating  labor  was  a  revolutionary 
departure  from  time  honored  customs  and  must 
have  really  sound  scientific  basis  for  recommenda- 
tion. This  it  had.  First,  it  saved  the  woman  the 
debilitating  effects  of  the  suffering  in  the  first  stage 
and  the  physical  labor  of  a  prolonged  second  stage, 
and  in  the  modern  nervous  inefficient  product  of 
civilization,  this  was  becoming  more  frequently 
necessary.  The  saving  of  blood  had  much  to  do 
with  the  quick  and  smooth  recoveries  he  had  ob- 
served in  his  cases.  In  the  combination  with  mor- 
phine and  scopolamine  in  the  first  stage,  gas  or 
ether  in  the  second  stage  and  operative  delivery, 
one  had  robbed  labor  of  most  of  its  horrors  and 
terrors,  and  the  increase  of  the  population  ought 
to  be  thus  favored.  Second,  it  undoubtedly  pre- 
served the  integrity  of  the  pelvic  floor  and  introitus 
vulvae  and  forestalled  uterine  prolapse,  rupture  of 
the  vesicovaginal  septum  and  the  long  train  of 
sequelae.  Virginal  conditions  were  often  restored. 
Third,  it  saved  the  babies'  brains  from  injury  and 
from  the  immediate  and  remote  effects  of  prolonged 
compression.  Incision  in  the  soft  parts  not  alone 
allowed  shortening  of  the  second  stage,  but  it  also 
relieved  the  pressure  on  the  brain  and  would  re- 
duce the  amount  of  idiocy,  epilepsy,  etc.    The  easy 


and  speedy  delivery  also  prevented  asphyxia,  both 
its  immediate  effects  and  its  remote  influence  on 
the  early  life  of  the  infant. 

The  Value  of  the  Wassermann  Reaction  in  Ob- 
stetrics Based  upon  the  Study  of  4,547  Consecu- 
tive Observations. — Dr.  J.  Whitridge  Williams, 
of  Baltimore,  said  that  four  thousand  of  the  wo- 
men were  delivered  between  the  twenty-eighth 
week  of  pregnancy  and  full  term — 1,839  whites  and 
2,161  blacks.  In  the  series  a  positive  Wassermann 
was  noted  in  421  cases,  an  incidence  of  4.2  per 
cent. ;  2.4  per  cent,  in  whites  and  16.29  per  cent, 
in  blacks ;  302  children  were  born  dead  or  died 
during  the  two  weeks  following  delivery,  and  in  102, 
or  34.4  per  cent,  death  was  proved  to  be  due  to 
syphilis.  Study  of  the  421  positive  cases  showed, 
1,  that  the  presence  of  a  positive  Wassermann  did 
not  necessarily  meant  the  birth  of  a  syphilitic  child ; 
and,  2,  that  efficient  treatment  instituted  by  the 
middle  of  pregnancy  gave  almost  ideal  results  as  far 
as  the  child  was  concerned.  Observations  proved 
that  a  negative  maternal  Wassermann  did  not  nec- 
essarily imply  the  absence  of  syphilis,  as  shown  by 
positive  autopsy  findings  in  twenty-two  children. 
Study  of  the  significance  of  the  fetal  Wassermann 
at  birth  and  a  comparative  study  of  the  diagnostic 
value  of  the  Wassermann  reaction  and  placental 
findings,  also  a  brief  discussion  of  the  applicability 
of  Colles's  law  was  undertaken. 

Extraperitoneal  Cassarean  Section. — Dr  John 
A.  McGlinn,  of  Philadelphia,  stated  that  extraperi- 
toneal Caesarean  section  operations  could  be  divided 
into  two  general  types :  a.  The  true  extraperitoneal 
in  which  the  peritoneal  cavity  was  not  invaded  at 
any  stage  of'  the  operation ;  this  operation  would  be 
referred  to  as  the  extraperitoneal,  b.  The  trans- 
peritoneal in  which  the  peritoneal  cavity  was 
opened  and  subsequently  isolated  by  attaching  the 
parietal  and  visceral  peritoneum  and  the  uterus 
opened  into  this  artificial  extraperitoneal  space;  this 
operation  would  be  referred  to  as  the  transperi- 
toneal. 

The  advantages  of  the  two  types  of  extraperi- 
toneal operation  might  be  summed  up  as  follows : 
1.  The  peritoneal  cavity,  not  being  opened,  was 
isolated  from  the  field  of  operation,  the  danger  from 
infection  was  less  and  therefore  a  better  operation 
in  the  infected  or  supposedly  infected  case.  2.  If 
the  uterus  ruptured  at  the  site  of  the  incision  in 
subsequent  pregnancies  or  labors  it  was  an  acci- 
dent of  no  material  consequence.  3.  There  was 
no  danger  from  the  formation  of  peritoneal  adhes- 
sions.  4.  The  scar  was  not  unsightly  and  the  pos- 
sibility of  incisional  hernia  nil.  5.  There  were  no 
postoperative  intestinal  complications.  6.  Hemor- 
rhage during  the  operation  was  slight. 

His  own  feeling  was  that  the  Beck  operation  with 
thorough  protection  of  the  peritoneal  cavity  and 
perfect  peritonealization  of  the  uterine  incision  was 
superior  to  the  transperitoneal  operation  as  a  rou- 
tine procedure.  While  theoretically  it  was  not  as 
efficient  as  the  extraperitoneal  method,  practically 
on  account  of  the  many  disadvantages  of  the  latter, 
it  was  the  better  operation. 

(To  be  continued) 


New  York  Medical  Journal 


INCORPORATING  THE 


Philadelphia  Medical  Journal     Medical  News 

A  Weekly  Review  of  Medicine,  Established  184,3. 


Vol.  CXII.  No.  16. 


NEW  YORK.  SATURDAY,  OCTOBER  16,  1920. 


Whole  No.  2185. 


Original  Communications 


THE  RELATION  OF  THE  MEDICAL  PRO- 
FESSION   TO   THE   CAMPAIGN  FOR 
THE  CONTROL  OF  CANCER.* 

By  Robert  B.  Greenough,  M.  D., 
Boston. 

The  developments  of  the  last  ten  years  have 
brought  many  new  duties  and  responsibilities  upon 
the  medical  profession  in  the  way  of  public  service. 
One  of  these  responsibilities,  the  control  of  can- 
cer, I  shall  consider  in  this  paper,  and  while  I  re- 
fer to  it  as  a  responsibility  I  shall  hope  to  show  you 
that  it  is  also  an  opportunity  to  accomplish  an  im- 
measurable amount  of  good,  not  only  to  your  own 
patients  but  to  the  community  as  well. 

We  know  from  the  figures  of  the  statisticians  that 
cancer  causes  the  death  of  a  very  large  number  of 
our  population — estimated  at  present  at  from  eighty 
to  a  hundred  thousand  persons  a  year.  We  know 
that  cancer  is  one  of  the  most  common  causes  of 
death  of  persons  over  forty  years  of  age,  and  we 
know  that  in  spite  of  the  best  efforts  of  the  re- 
search institutions  a  sovereign  cure  for  cancer  has 
not  yet  been  found,  and  that  a  radical  surgical 
operation  is  at  present  our  best  and  surest  method 
for  the  complete  extirpation  of  the  disease.  We 
know,  too,  that  a  relatively  large  proportion  of 
cases  of  cancer  are  presented  for  operation  too 
late  to  make  it  reasonable  to  attempt  a  radical  cure 
of  the  disease.  A  recent  study  by  Simmons  and 
Daland  of  the  statistics  of  the  Massachusetts  Gen- 
eral Hospital  show  that  of  519  patients  with  cancer 
of  all  varieties  entering  the  surgical  wards  of  the 
hospital  for  treatment  only  forty-four  per  cent, 
were  suited  even  for  the  attempt  to  be  made  to 
accomplish  a  radical  cure  by  operation.  When  we 
consider  that  the  operative  mortality  diminishes  this 
number  further,  we  find  that  only  thirty-eight  per 
cent,  of  these  519  patients  stood  any  chance  what- 
ever, of  a  radical  cure.  We  must  remember,  also, 
that  the  results  of  any  attempt  at  radical  cure  are 
problematical,  according  to  the  location  of  the  dis- 
ease, and  the  expectation  of  failure  is  in  many  re- 
gions greater  than  the  expectation  of  success.  It 
behooves  us,  therefore,  as  the  health  officers  of  the 
community,  to  consider  this  situation  and  do  all 
that  lies  within  our  power  to  obtain  a  control  of 
the  situation  which  we  do  not  now  possess.  Four 

*Presented  before  the  Medical  Society  of  the  County  of  New  York, 
May  24,  1920,  and  at  a  meeting  of  the  Queens-Nassau  Medical 
Society,  Jamaica,  Long  Island,  May  25,  1920. 


lines  of  attack  present  themselves  at  once  for  our 
consideration : 

1.  The  education  of  the  public  to  the  early  symp- 
toms of  the  disease. 

2.  The  instruction  of  the  medical  profession  as 
to  the  actual  facts  of  this  serious  situation  to  bring 
about  earlier  diagnosis. 

3.  The  promotion  of  investigations  on  the  part 
of  surgeons  in  regard  to  more  effective  means  of 
operative  treatment. 

4.  The  promotion  of  investigations  in  the  labora- 
tory in  regard  to  the  causes  of  cancer,  and  of 
methods  of  treatment  other  than  by  operation. 

It  is  with  the  second  line  of  attack  that  we  are 
especially  concerned,  but  a  brief  reference  to  what 
has  been  done  in  other  fields  may  make  our  problem 
easier  and  better  defined.  The  last  ten  years  have 
seen  a  very  marked  difference  in  the  attitude  of  the 
public  toward  matters  of  public  health.  A  knowl- 
edge of  disease  has  been  obtained  by  the  layman,  far 
more  accurate  and  intelligent  than  he  ever  had  be- 
fore. This  is  the  result  of  the  many  agencies  which 
have  taken  up  the  problem  of  educating  the  public 
for  its  own  protection.  Starting  with  tuberculosis 
and  extending  over  such  diverse  subjects  as  baby 
hygiene  and  venereal  disease,  health  matters  have 
been  given  wide  publicity,  and  topics  never  for- 
merly mentioned  in  the  lay  press  are  now  subjects 
of  frequent  notice  and  discussion.  In  this  campaign 
of  publicity  the  American  Society  for  the  Control 
of  Cancer  has  had  an  important  share,  and  it  has 
been  ably  seconded  by  progressive  health  commis- 
sioners and  public  health  officers  who  have  seen  the 
value  of  an  educated  public  in  relation  to  public 
health. 

By_  the  use  of  the  lay  press,  the  magazines— 
especially  the  women's*  and  household  magazines — 
by  posters,  by  health  department  publications, 
through  churches  and  women's  clubs,  and  by  the 
normal  agencies  for  the  spread  of  medical  infor- 
mation, nurses  and  physicians,  this  education  of  the 
public  can  be  brought  about. 

The  facts  which  have  to  be  impressed  upon  the 
public  are  relatively  few  and  simple.  The  layman 
must  be  taught  that  delay  is  dangerous,  that  it  is  in 
the  early  and  not  the  late  case  that  the  patient  with 
cancer  can  be  cured  by  operation,  and  that  in  early 
cases  operation  can,  and  does,  cure  many  patients 
with  this  disease.  It  is  an  unfortunate  fact  that  it 
is  the  failures  and  not  the  successes  of  the  opera- 
tive treatment  of  cancer  that  are  known  to  the  public. 


Copyright,  1920,  by  A.  R.  Elliott  Publishing  Company 


566 


GREEN OUGH:  COXTROL  OF  CANCER. 


[New  York 
Medical  Joirnal. 


Women  who  have  been  cured  of  cancer  by  an  ampu- 
tation of  the  breast  or  by  a  hysterectomy,  do  not 
allow  even  their  intimate  friends  to  know  of  the 
fact,  but  the  death  certificate  rarely  fails  to  in- 
dicate the  cause  of  death  correctly  in  unsuccessful 
cases.  The  public  must  be  made  to  understand  that 
unlike  most  other  diseases  pain  does  not  occur  as 
a  symptom  of  early  cancer,  and  they  must  learn 
that  a  lump  or  sore,  or  any  abnormal  discharge, 
especially  if  it  contains  blood,  is  a  symptom  in  a 
person  of  cancer  age  which  demands  immediate  and 
competent  medical  examination.  It  is  asserted  that 
a  distinct  improvement  is  already  evident  in  those 
districts  in  which  the  education  of  the  public  has 
been  carried  on  systematically,  but  there  is  a  great 
deal  more  to  do  before  the  work  is  finished. 

In  this  education  of  the  public  the  physician 
must  take  his  part,  and  it  is  an  important  part. 
The  community  of  his  own  patients  look  to  him  for 
information  on  subjects  of  this  character.  Articles 
in  the  newspapers  and  magazines  may  arouse  the 
layman's  interest  but  it  is  his  own  physician  to 
whom  he  appeals  for  corroboration.  In  the  edu- 
cation of  the  public,  therefore,  the  physician  has  a 
definite  duty  to  perform.  In  the  519  cancer  cases 
referred  to,  an  average  delay  of  five  and  four- 
tenths  months  occurred  after  symptoms  were  first 
noticed  by  the  patient  before  he  consulted  a  physi- 
cian. Although  the  lapse  of  this  amount  of  time 
is  more  serious  in  some  cases  than  in  others,  it  is 
far  too  long  in  any  case  for  the  best  interests  of 
the  patient,  and  it  must  be  shortened  very  materially 
and  patients  must  be  induced  to  consult  their  medical 
advisers  much  more  promptly  if  we  are  to  make 
progress  in  combating  the  disease. 

By  means  of  the  instruction  of  the  public  we 
may  confidently  hope  to  bring  the  patient  to  his 
physician  at  an  earlier  stage  of  his  disease.  In  do- 
ing this,  however,  we  add  enormously  to  the  diffi- 
culties and  responsibilities  of  the  physician.  It  is 
a  well  established  fact  that  the  typical  textbook 
symptoms  of  cancer  of  any  organ  are,  as  a  rule, 
the  symptoms  of  cancer  that  has  extended  beyond 
the  possibilities  of  radical  cure.  If  we  wish  to 
secure  for  every  person  afflicted  with  cancer  the 
opportunity  for  cure  to  which  he  should  be  entitled 
we  must  abandon  the  textbook  symptoms  of  ad- 
vanced cancer  and  deal  with  the  earliest  symptoms 
of  the  disease.  Under  these  conditions  a  positive 
diagnosis  will  often  be  impossible,  and  a  method  of 
dealing  with  these  suspicious  but  doubtful  cases 
must  be  made  available.  The  first  step,  however, 
in  this  direction  depends  upon  the  examination  of 
the  patient.  No  sense  of  false  modesty  on  the  part 
of  the  patient  or  of  indifTerence  on  the  part  of  the 
physician  should  be  allowed  to  interfere  with  the 
investigation  by  direct  digital  or  visual  examina- 
ton,  or  with  instruments  if  necessary,  to  obtain 
positive  data  for  the  establishment  of  a  diagnosis: 
A  Fabian  policy  of  delay  deprives  a  patient  of  an 
opportunity  for  cure,  and  thus  signs  the  death 
warrant  of  many  a  patient  who  could  otherwise 
be  saved. 

In  the  519  cancer  cases  at  the  Massachusetts 
General  Hospital  to  which  I  have  referred,  an 
average  delay  of  three  months  occurred  after  the 


patient  first  consulted  his  physician  before  opera- 
tive treatment  was  advised.  It  is  interesting  to 
note  the  confidence  of  the  patient  in  his  physician's 
advice,  for  the  average  delay  on  the  part  of  the 
patient  after  he  had  once  been  advised  to  undergo 
operation  was  only  three  weeks.  It  is  clearly  the 
duty  of  the  physician  to  see  that  the  patient's  confi- 
dence in  him  is  not  misplaced,  but  we  must  admit 
that  an  average  delay  of  three  months  at  arriving  at 
a  diagnosis  is  far  too  long  if  we  are  dealing  with  a 
disease  which  progresses  so  rapidly  as  cancer  does 
at  this  critical  period  of  development. 

In  dealing  with  the  group  of  early  and  doubt- 
ful cases  of  cancer  the  question  of  the  exploratory 
incisfon  and  removal  of  tissue  for  microscopic  ex- 
amination becomes  a  serious  one.  The  trend  of 
the  best  surgical  opinion  is  strongly  opposed  to  any 
incision  into  cancer  tissue  when  a  positive  diag- 
nosis is  otherwise  available,  on  the  ground  that  in- 
cision gives  opportunity  for  an  immediate  spread 
of  the  disease.  While  this  risk  undoubtedly  varies 
considerably  with  the  location  of  the  primary  tumor 
there  are  some  tumors  in  which  the  exploratory  in- 
cision is  successfully  practised  when  a  positive 
diagnosis  cannot  be  made  in  any  other  way.  There 
are  other  tumors,  however,  such  as  cancer  of  the 
breast  or  bone  sarcoma,  where  a  preliminary  in- 
cision for  the  removal  of  tissue  for  examination, 
to  be  followed  after  a  week  or  ten  days  delay  by 
radical  operation,  is  almost  universally  condemned. 
Such  cases  are  best  treated  by  incision  and  frozen 
section  diagnosis  when  necessary,  and  the  radical 
operation  completed  immediately,  under  one  anes- 
thesia. In  fact,  the  use  of  the  frozen  section  with 
immediate  microscopic  examination  is  probably  the 
safest  measure  in  any  case  where  a  biopsy  is  nec- 
essary to  obtain  a  diagnosis  sufficiently  certain  to 
justify  the  radical  operation. 

The  term  precancerous  lesion  is  one  which  has 
been  employed  of  recent  years  to  indicate  those  es- 
sentially benign  lesions  which  experience  has  shown 
appear  too  often  as  precursors  of  actual  malignant 
disease.  WHiile  the  term  is  perhaps  unfortunate  in 
the  sense  that  all  lesions  of  this  nature  do  not  neces- 
sarily result  in  cancer,  the  frequent  incidence  of  ma- 
lignant disease  in  cases  of  this  kind  demands  that 
treatment  of  these  characteristic  lesions  be  carried 
out  with  this  principle  in  mind. 

The  lesions  which  commonly  fall  into  this  socalled 
precancerous  group  are  as  follows :  Keratoses  and 
papillomata  of  older  persons,  leucoplakia,  fissures 
and  sores  of  the  lips,  tongue  and  marginal  mucous 
membranes,  lacerations  of  the  cervix,  and  benign  tu- 
mors of  the  breast,  thyroid  and  other  organs.  In 
this  group,  also,  should  be  placed  the  pigmented 
moles  which  are  so  commonly  distributed 
over  the  body,  and  which  under  any  form 
of  continued  irritation  are  likely  to  give  rise  to  the 
frightfully  malignant  tumor  known  as  melanosar- 
coma.  A  very  appreciable  number  of  cases  of  can- 
cer develop  at  the  site  of  precancerous  lesions  "of 
the  type  described.  It  is  not  open  to  doubt  that  the 
removal  or  destruction  of  the  precancerous  lesion 
would  have  saved  the  patient  from  the  more  serious 
disease.  In  this  respect  removal  by  surgical  meas- 
ures— generally  an  operation  of  the  most  minor 


October  16,  1920.] 


GKEENOUGH :  CONTROL  OF  CANCER. 


567 


character — is  the  best  method  of  treatment  in  that 
the  total  removal  is  accomplished  and  the  tissue  is 
made  available  for  pathological  examination.  In  this 
connection  the  establishment  of  a  free  diagnosis 
.service  for  cancer  tissue,  by  the  public  health  de- 
partments of  the  states,  or  by  the  state  universities, 
gives  opportunity  for  the  examination  of  such  sus- 
pected tissue  free  of  charge.  Under  these  conditions 
the  failure  of  a  surgeon  to  submit  the  tissue  re- 
moved for  examination  deprives  his  patient  of  the 
advantage  of  an  accurate  pathological  report,  to 
which,  as  a  citizen  of  the  state,  he  is  entitled. 

Where  for  any  reason  removal  by  surgical  meas- 
ures is  not  expedient,  destruction  of  the  lesion,  if  it 
is  a  small  one,  can  be  accomplished  by  the  use  of 
radium  or  x  rays.  This  destruction,  however, 
should  be  secured  if  possible  by  one  vigorous  and 
adequate"  exposure,  for  repeated  irritation,  either  by 
radiation,  by  chemicals,  or  by  any  other  agent,  is  to 
be  strenuously  avoided.  It  is  by  chronic  irritation 
that  we  believe  most  of  the  socalled  precancerous 
lesions  are  converted  into  cancer. 

The  operative  treatment  of  cancer  in  its  various 
locations  has  been  so  standardized  in  the  operative 
clinics  of  the  world  that  little  opportunity  exists  for 
individual  variation.  This  standardization  has  been 
brought  about  by  the  study  of  operating  room  and 
autopsy  material  which  has  shown  the  typical  lines 
of  extension  from  the  original  focus  of  the  disease, 
which  are  characteristic  and  different  for  each  of 
the  common  sites  of  cancer.  Although  the  ex- 
ternal incision  may  vary  the  anatomical  structures 
removed  are  the  same  in  practically  every  operating- 
clinic  for  cancer  in  each  of  its  common  situations, 
and  the  general  principle  of  avoiding  by  a  wide  mar- 
gin the  possibility  of  incision  into  cancer  tissue  at  the 
time  of  operation  is  universal. 

In  a  recent  pamphlet  issued  by  a  committee  of 
the  American  Society  for  the  Control  of  Cancer 
these  matters  are  discussed,  and  the  standard  opera- 
tive procedure  and  the  differential  diagnosis  of  can- 
cer in  its  many  situations  have  been  summarized. 
This  pamphlet  has  been  reprinted  by  the  health  com- 
missioners of  a  number  of  states,  and  issued  to 
every  practising  physician  in  the  state. 

While  the  operative  treatment  has  thus  been 
standardized  it  must  be  admitted  that  the  prospects 
of  success  vary  greatly  with  the  different  situations 
in  which  cancer  most  commonly  occurs.  While  this 
variation  is  due,  in  part,  to  the  rapidit}"  of  growth 
and  extension  of  the  individual  tumor,  it  is  deter- 
mmed  even  more  by  the  anatomical  situation  in 
which  the  tumor  lies,  for  this  is  the  factor  which 
limits  the  extent  of  local  removal  of  tissue  which 
can  be  sustained.  We  must  hope,  therefore,  that 
further  improvements  in  surgical  technic  mav  give 
us  methods  of  attacking  and  removing  the  disease 
successfully  in  situations  which  arc  at  present  be- 
yond operative  attack. 

Recent  developments  have  shown  that  the  com- 
bination of  radium  and  x  ray  treatment  with  oper- 
ation adds  materially  to  our  resources  and  gives 
promise  of  success  in  the  treatment  of  certain  cases 
of  cancer  in  and  about  the  mouth,  and  in  other  re- 
gions which  with  operation  alone  would  of  neces- 
sity be  considered  beyond  hope  of  relief.  In  certain 
cases,  also,  the  destruction  of  a  local  lesion  may  be 


accomplished  by  the  use  of  radium  and  the  cautery 
accompanied  by  the  subsequent  dissection  and  oper- 
ative removal  of  the  regional  lymphatics.  In  this 
way  the  attempt  may  be  made  to  cure  a  certain  num- 
ber of  cases  which  would  otherwise  be  inoperable 
and  beyond  relief.  In  the  line  of  development  of 
these  combined  operative  measures  advances  in  the 
surgical  treatment  of  the  disease  may  confidently  be 
expected. 

In  the  many  cancer  research  institutes  of  this 
country  and  abroad  studies  have  been  carried  on 
looking  to  the  discovery  of  the  cause  of  cancer,  its 
manner  of  growth,  and  the  methods  other  than  oper- 
ation by  which  it  may  be  expected  to  be  cured.  While 
none  of  these  problems  have  been  brought  to  a  final 
solution  many  facts  have  been  established  of  the 
greatest  value  in  the  treatment  of  disease.  From  the 
transplantable  tumors  of  mice  facts  have  been  ob- 
tained which  have  determined  both  the  advantages 
and  dangers  of  the  treatment  of  cancer  by  radium 
and  the  x  rays.  The  fact  that  there  is  a  degree  of 
natural  resistance  to  the  growth  of  cancer  tissue  has 
been  established.  Experimental  confirmation  has 
been  obtained  to  support  the  dictum  that  rough 
handling  and  massage  of  cancer  tissue  increases 
the  rapidity  of  the  spread  of  the  disease,  and  it  has 
been  determined  by  the  same  means  that  the  clean 
incision  into  cancer  tissue  for  the  removal  of  a  speci- 
men for  micro.scopic  examination  is  the  safest  meas- 
ure to  obtain  a  certain  diagnosis  when  circumstances 
make  a  positive  diagnosis  necessary  that  is  other- 
wise unobtainable.  From  the  laboratories,  also,  evi- 
dence has  been  produced  to  show  that  the  supposed 
relation  of  chronic  irritation  of  one  kind  and  an- 
other to  the  production  of  cancer  is  of  great  sig- 
nificance. 

In  the  cancer  research  institutes  many  of  the 
methods  advertised  from  time  to  time  as  effective 
methods  of  treatment  of  cancer  have  been  investi- 
gated. Many  socalled  cancer  cures  have  been  put 
before  the  public  and  new  ones  develop  from  day  to 
day.  Some  of  these  measures  are  assumed  to  de- 
stroy the  disease  by  biological  methods,  and  others 
are  of  bacterial  or  chemical  nature,  but  none  has  yet 
been  found  to  be  of  sufficient  value  to  justify  its 
acceptance  by  the  medical  profession  as  a  whole.  It 
is  the  duty  of  the  cancer  research  institutes,  how- 
ever, to  continue  the  investigation  of  these  suggested 
remedies,  and  to  prosecute  the  search  for  any  rem- 
edy which  may  be  applied  to  advantage  in  the  treat- 
ment of  this  disease. 

There  is  no  room  to  doubt  that  in  radium  and  the 
X  rays  agents  of  the  greatest  value  in  combating 
cancer  have  been  made  available.  While  it  is  per- 
haps true  that  the  first  claims  as  to  the  successes  of 
these  methods  of  treatment  were  somewhat  exag- 
gerated a  place  has  now  been  found  for  each  of 
them,  and  in  that  situation  they  are  productive  of 
the  greatest  good.  There  is  reason  to  hope,  also, 
that  further  investigation  of  these  two  agents  may 
make  their  value  in  the  trtotment  of  cancer  greater 
even  than  it  is  at  present. 

In  this  brief  communication  I  have  tried  to  show 
that  the  situation  in  regard  to  cancer  is  at  present  a 
very  serious  one,  and  that  it  demands  the  best  efforts 
of  the  whole  medical  profession  toward  its  relief. 
While  the  first  step  must  be  taken  by  the  education 


568 


FORBES:  RADIUM  IN  CANCER. 


[New  York 
Medical  Jol'rnai,. 


of  the  public  to  the  dangers  of  delay  and  the  recog- 
nition of  the  early  symptoms  of  cancer,  more  must 
yet  be  done  to  help  the  physician  to  recognize  the 
disease  in  its  earliest  and  curable  stages,  in  order 
that  his  patient  may  have  the  benefit  of  such  re- 
sources in  the  way  of  operation  and  other  methods 
of  treatment  as  the  community  affords.  We  must 
teach  that  the  socalled  precancerous  diseases  justify 
and  demand  treatment  in  prophylaxis  of  cancer,  and, 
finally,  we  must  support  in  every  way  we  can  the 
investigations  which  are  being  carried  on  in  hospi- 
tals and  in  laboratories  all  over  the  world  to  improve 
the  ef¥ectiveness  of  our  methods  of  treatment  of  this 
insidious  and  frightful  disease. 
8  Marlborough  Street. 


THE  USE  OF  RADIUM  IN  ESOPHAGEAL 
CANCER. 

By  Hexry  Hall  Forbes,  M.  D., 
New  York. 

The  gloomy  outlook  for  the  patient  suflfering 
from  esophageal  cancer,  and  the  gravity  of  the  trans- 
thoracic operation  with  one  cure  to  the  credit  of 
the  procedure,  the  famous  case  of  Dr.  Torek  (1  and 
2),  gave  me  a  stimulus  to  use  our  available  supply 
of  radium  in  a  series  of  cases  in  the  nose  and  throat 
department  of  the  New  York  Post-Graduate  Hos- 
pital, where  the  director,  Dr.  Duncan  Macpherson, 
has  referred  all  cases  to  me.  This  has  been  done 
with  my  associate  Dr.  George  Stuart  Willis,  who  is 
in  charge  of  the  radium  department  of  our  institu- 
tion and  who  has  been  in  charge  of  the  radium  ther- 
apy, the  aftercare,  and  the  compilation  of  the  results 
in  our  cases.  Dr.  W.  H.  Meyer,  in  charge  of  the 
department  of  rontgenology,  has  had  control  of  this 
phase  of  our  work.  Both  Dr.  Willis  and  Dr.  Meyer 
have  been  most  conscientious  coworkers  and  have 
made  it  possible  to  do  this  team  work.  Our  thought 
was  the  possibility  of  giving  to  the  patient  and  to 
radium  a  scientific  standing,  and  now  that  nearly  a 
year  has  passed  I  feel  that  the  results  warrant  my 
bringing  the  facts  to  the  attention  of  the  profession 
for  discussion  and  to  stimulate  other  endoscopists 
to  carry  on  and  suggest  modifications. 

I  cannot  pass  to  the  use  of  radium  without  a  ref- 
erence to  the  transthoracic  operation  for  the  cure  of 
cancer  of  the  esophagus,  which  is  to  my  mind  one  of 
the  most  remarkable  in  the  field  of  surgery.  It  was 
my  good  fortune  to  witness  this  operation  as  per- 
formed by  Dr.  Howard  Lilienthal  on  a  patient  in 
Bellevue  Hospital  about  a  year  ago,  the  surgery  and 
skill  of  the  operator  being  most  brilliant.  The  re- 
sult in  this  case  was  death.  As  far  as  I  am 
able  to  learn  the  only  cure  credited  to  this 
operation  is  the  case  of  Dr.  Torek,  who  only  a 
few  weeks  ago  told  me  that  the  patient  was  living 
and  enjoying  good  health,  seven  years  having 
elapsed  since  the  operation.  It  is  well  to  remember 
that  no  transthoracic  operation  should  be  attempted 
until  a  specimen  has  been  removed  by  esophago- 
scopy  for  pathological  examination. 

The  results  of  the  use  of  radium,  with  a  rather 
indefinite  technic  was  reported  by  Abbe  (3)  in  1914. 

*Read  at  the  third  annual  meeting  of  the  Association  of  American 
Peroral  Endoscopists,  at  Boston,  Mass.,  on  June  1.  1920. 


This  covered  work  beginning  in  1905,  750  cases  in 
all  being  treated,  which  included  150  carcinomata 
of  the  tongue,  larynx,  and  esophagus ;  the  results 
were  reported  as  excellent.  Many  patients  had  re- 
mained free  from  recurrences  over  several  years 
and  others  showed  remarkable  improvement.  Jack- 
son (12)  devotes  considerable  space  in  his  book  to 
cancerous  growths  of  the  esophagus.  Note  is  made 
of  his  experience  that  the  growths  are  usually  single 
(which  has  also  been  my  experience),  and  the  im- 
portance of  exercising  care  in  passing  the  esophago- 
scope  in  these  cases  is  emphasized.  He  has  used 
radium,  but  does  not  appear  to  favor  its  use  in 
operative  cases.  Relief  has  been  given  in  the  in- 
operable cases.  Special  reference  is  made  to  the 
necessity  for  direct  application  of  the  radium  to  the 
growth  and  to  note  the  position  of  the  radium  tube 
by  the  fluoroscopic  screen  but  evidently  not  carried 
out  in  his  cases.  The  schematic  representation  of 
a  radium  capsule  in  the  centre  of  an  annular  esoph- 
ageal cancer  is  imdoubtedly  the  ideal  method  and 
one  we  have  attempted  in  our  work. 

We  note  other  references  to  the  use  of  radium 
and  especially  the  technic  followed  by  various  au- 
thors. In  1914,  Lewin  (4)  reports  twenty-five  cases 
with  successful  results,  subjective  symptoms,  such 
as  stenosis,  improving  in  a  short  time.  The  radium 
or  mesothorium  was  placed  in  a  platinum  or  gold 
filter  and  covered  with  hard  rubber;  dose  fifty  to 
eighty  mg. ;  exposure  two  to  four  hours,  two  or 
three  times  weekly  for  about  five  weeks.  The  radium 
tube  was  introduced  by  means  of  a  hollow  tube.  No 
reference  is  made  to  an  exact  method  of  locating  the 
radium  other  than  the  fact  that  it  was  held  in  place 
by  a  slender  bougie.  Further  encouragement  is  given 
by  the  report  of  a  case  by  Portis  (5)  in  1919  in 
which  great  improvement  was  noted  in  a  case  of 
squamous  celled  carcinoma  where  sixty  mg.  of 
radium  were  introduced  into  the  stricture  for  two 
and  a  half  hours.  No  details  were  given.  Most  in- 
teresting also  were  the  cases  of  Pinch  (7)  from  the 
Radium  Institute  of  London,  who  considered  that 
symptomatic  treatment  was  better  than  gastrostomy, 
a  patient  taking  food  nearly  to  the  end  and  being 
comfortable.  Pinch  (7)  tabulates  his  cases  in  the 
years  1914,  1915,  1917,  and  1918.  In  all  he  treated 
twenty-five  cases  of  cancer  of  the  esophagus,  with 
tlie  following  results : 

Improved,  three ;  unimproved,  five ;  dead,  nine ; 
abandoned  treatment,  three;  results  not  noted,  five. 

The  work  in  France  has  been  taken  up  by  Tuf- 
fier  (8)  who  notes  a  case  examined  by  the  esoph- 
agoscope  in  which  a  diagnosis  of  malignancy  was 
made.  Direct  application  of  the  radium  was  im- 
possible through  the  esophagoscope  owing  to  exten- 
sive edematous  inflammation.  Gastrostomy  was 
performed  and  when  the  patient  had  improved, ~tKe 
neoplasm  was  attacked  by  the  transpleural  route. 
The  details  are  most  interesting.  It  was  possible 
to  place  a  tube  of  radium  emanation  equalling  one 
mc.  in  twelve  hours  against  the  growth  for  twelve 
hours.  In  this  case  Tufiier  hopes,  from  the  im- 
provement noted  in  the  growth,  to  Qontinue  treat- 
ments by  the  natural  routes.  This  case  is  mentioned 
to  show  the  resourcefulness  of  the  worker  and  the 
improvement  in  what  seemed  to  be  a  hopeless  case. 


October  16,  1920  ] 


FORBES:  RADIUM  IN  CANCER. 


569 


I  cannot  take  up  my  personal  work  without  refer- 
ring to  Dr.  Janeway's  hook  on  Radium  Therapy 
in  Cancer  (11).  In  addition  to  his  work  in  radium 
Dr.  Janeway  is  active  in  the  work  of  direct  exami- 
nation of  the  esophagus  and  stomach.  The  cases 
reported  in  1917  inckided  twenty-two  of  esophageal 
growths ;  only  one  complete  retrogression  can  be 
assumed.  This  patient,  I  am  advised,  was  alive  on 
May  6,  1920.  The  first  treatment  was  given  in 
June,  1916.  Five  other  patients,  now  dead,  were 
definitely  improved ;  fifteen  others  were  imim- 
proved.  His  failures  he  considered  due  to  the  large 
size  of  the  growth  and  the  too  frequent  repetition 
of  treatment.  I  am  advised  that  Dr.  Zwick,  Dr. 
Janeway's  assistant,  states  that  the  last  year's 
work  is  much  more  encouraging,  but  that  cases 
are  too  recent  for  one  to  give  a  positive  report. 
Reports  have  been  made  recently  by  Japanese  (9) 
and  Spanish  investigators  (10),  but  it  was  impossi- 
ble for  me  to  obtain  translations  in  time  for  this 
report.  In  February,  1920,  Dufourmental  (13), 
Paris,  reported  most  encouragingly,  noting  cases  in 
whidi  the  patients  had  been  relieved  from  pain, 
swallowing  had  improved,  and  there  had  been  a 
gain  in  weight.  Patients  had  survived  for  more 
than  eighteen  months  to  three  years. 

As  we  read  the  various  reports  and  note  the 
therapy  outlined  it  may  seem  that  we  are  not  pre- 
senting any  new  facts,  yet  I  feel  the  corollary  of 
our"  method  of  procedure  has  been  an  advance  in 
the  technic  of  the  treatment  of  esophageal  cancer 
by  radium  and  that  these  very  points  may  have 
been  the  cause  of  failures.  Surely  no  one  will  doubt 
the  results  in  the  use  of  radium  in  cancerous 
growths  involving  the  mucous  membrane  in  acces- 
sible parts  of  the  body.  It  must  also  be  noted  that 
unfortunately  the  esophageal  groA\i:hs  are  not  pro- 
ductive of  symptoms  in  the  early  stage  of  the  dis- 
ease and  hence  not  discovered  by  the  patient  until 
the  really  grave  symptoms  become  apparent  and  the 
disease  has  progressed  to  an  almost  inoperable  stage. 
The  operation  by  the  transthoracic  route  in  addi- 
tion to  its  gravity,  has  as  noted  previously,  only 
one  living  patient  to  testify  to  its  merit.  It  does 
seem  to  me  that  it  is  our  duty,  in  which  we  should 
be  encouraged,  to  add  to  the  details  in  the  technic 
of  radium  treatment  of  this  disease  and  not  be  dis- 
couraged in  our  work  if  we  do  not  accomplish  bril- 
liant results  at  first. 

In  detail,  our  work  has  consisted  of  a  full  his- 
tory with  complete  physical  examination  as  well  as 
blood  tests.  This  is  followed  by  a  fluoroscopic  ex- 
amination of  the  esophagus  using  the  barium  salts 
as  well  as  an  x  ray  plate.  With  these  data  before 
us  an  examination  of  the  esophagus  is  made  in  the 
operating  room,  usually  under  local  anesthesia,  us- 
ing the  Jackson  esophageal  speculum  for  the  upper 
portion  of  the  tube  and  the  seven  mm.  or  ten  mm. 
esophagoscope  to  continue  the  examination  down- 
ward. An  attempt  is  made  to  "note  the  local  condi- 
tions. The  placing  of  the  radium  tube  in  position 
has  been  the  next  problem ;  this  has  not  always  been 
easy.  The  radium  tube  to  which  a  silk  thread  is  at- 
tached is  passed  down  through  and  out  the  lower 
end  of  the  esophagoscope  and  held  there  by  forceps 
while  the  esophagoscope  is  gently  withdrawn  a 


short  distance.  Our  idea  has  been  to  place  the 
radium  tube  in  the  centre  of  the  growth.  The 
esophagoscope  is  then  withdrawn  completely. 
The  silk  thread  prevents  the  radium  tube  advanc- 
ing further  downward  by  its  attachment  to  a  strip 
of  adhesive  plaster,  which  is  in  turn  attached  to 
the  cheek.  The  patient  is  immediately  taken  to 
the  X  ray  room  where  a  fluoroscopic  examination  is 
made  and  usually  a  plate  is  developed  at  once. 
Should  the  placing  of  the  radium  tube  have  been 
faulty  it  is  immediately  removed  and  the  opera- 
tion repeated  in  forty-eight  hours.  The  amount  of 
radium  is  25.5  mg.  of  a  bromide  salt.  The  tube  is 
screened  with  .1  mm.  gold  and  to  absorb  the  irri- 
tating secondary  rays  about  two  mm.  of  pure  Para 
rubber  is  used  as  a  cover  to  the  tube,  which  is  usu- 
ally left  in  place  for  twenty-four  hours.  The  re- 
applications  are  made  not  oftener  than  once  in  three 
weeks.  The  blood  picture  is  noted  in  this  period. 
We  are  not  in  a  position  to  claim  cures,  for  our 
working  time  has  been  short,  but  we  do  feel  that 
we  have  obtained  symptomatic  relief  in  all  our  cases 
and  have  added  to  the  comfort  and  morale  of  our 
patients.  The  following  is  a  brief  summary  of  our 
cases :  We  have  treated  six  cases  of  malignant  dis- 
ease of  the  esophagus,  and  the  death  of  one  patient 
is  noted,  hemorrhage  being  the  cause  of  death. 

[Since  this  paper  was  written  the  use  of  the  ra- 
dium tube  has  been  abandoned  and  the  radium 
needles  substituted. — Author.] 

REFEREXCES. 

1.  Torek,  F.  :  The  First  Successful  Resection  of  tlie 
Thoracic  Portion  of  the  Esophagus  for  Carcinoma,  Jour- 
nal A.  M.  A.,  1918,  p.  1533. 

2.  Idem:  The  Operative  Treatment  of  Carcinoma  of 
the  Esophagus,  Amcr.  Jour,  of  Surg.,  1915,  pp.  385-405. 

3.  Abbe,  R.  :  L'Emploi  du  radium  dans  le  traitment  des 
affections  malignes,  Archiv.  d'clect.  med.,  1914,  xxii. 

4.  Lewix,  C.  :  Radium  therapie  des  oesophagus,  Therapie 
dcr  Gegenwart,  1914,  Iv,  103. 

5.  PoRTis,  M.  M. :  Carcinoma  of  the  Esophagus  Treated 
with  Radium,  Medical  Clinics  of  North  America,  July,  1919, 
No.  1,  p.  63. 

6.  PoRTis,  AI.  M. :  Report  of  the  Work  of  Radium  In- 
stitute, London,  January  1,  1917,  to  December  31,  1917. 

7.  Pinch,  A.  E.  H. :  Report  of  the  Radium  Institute, 
London,  Jan.  1  to  Dec.  31,  l9l8,  Tabular  Classification. 

8.  TuFFiER,  M. :  Cancer  de  I'cesophage  traite  par  I'appli- 
cation  directe  par  voie  transpleurale  d'un  tube  I'emanation 
de  radium  sur  Ila  paroi  oesophagienne.  Bull.  et.  Mem.  Soc. 
Chir.,  Paris,  1919,  xlv,  979. 

9.  Shinshi  :  Radium  Treatment  of  Cancer  of  the 
Esophagus,  Bull.  Naval  Med.  Assn.,  Japan,  Tok>-o,  1915, 
No.  12,  1. 

10.  EscALADA,  M.  C. :  Cancer  del  esofago  y  su  trata- 
miento  por  el  radium,  Buenos  Aires.  1915. 

11.  Janeway,  H.  H.  :  Radium  Therapy  in  Cancer,  1917. 

12.  Jackson,  C.  :  Peroral  Endoscopy,  p.  444. 

13.  Dufourmental:  Radium  Treatment  of  Cancer  of 
the  Esophagus,  Paris  medicate,  Februar>-  7,  1920,  No.  6. 


Retroperitoneal  Liposarcoma. — Edwin  F.  Hirsch 
and  H.  Gideon  Wells  {American  Journal  of  the 
Medical  Sciences,  March,  1920)  report  the  micro- 
scopical and  chemical  examination  of  a  retroperi- 
toneal liposarcoma  without  myxomatous  elements, 
weighing  sixty-nine  pounds.  It  illustrated  the 
capacity  of  malignant  tumors  to  store  up  protein 
and  fat,  despite  extreme  emaciation  of  the  patient. 


570 


MUSSER:  ARTERIAL  HYPERTENSION. 


[New  York 
Medical  Journal, 


TREATMENT     OF     ARTERIAL  HYPER- 
TENSION. 

By  John  H.  Musser,  M.  D., 
Philadelphia. 

Arterial  hypertension  is  a  subject  about  which 
much  has  been  written  in  past  years,  as  to  the  eti- 
ology, pathogenesis,  and  treatment.  In  spite  of  all 
that  has  been  written  and  despite  the  facility  with' 
which  medical  men  are  accustomed  to  manage  cases 
of  hypertension,  several  new  methods  of  treating 
this  condition  have  appeared  in  the  past  two  years 
and  it  is  these  newer  methods  that  I  wish  to  ac- 
centuate. First,  however,  it  might  be  well  to  de- 
scribe briefly  just  what  we  understand  by  hyper- 
tension, to  present  a  general  outline  of  the  treat- 
ment for  such  high  pressure,  and  then  to  discuss 
the  more  recent  therapeutic  innovations  in  the  man- 
agement of  these  cases,  namely,  benzyl  benzoate  and 
the  restriction  of  salt  and  water  intake. 

Hypertension  for  which  there  is  no  obvious  cause 
is  a  symptom,  not  a  disease,  and  yet  it  is  a  symptom 
which  is  so  closely  related  to  disease  that  it  is  not 
ahiiss  to  treat  the  symptom,  though  as  a  general  rule 
it  is  wise  to  observe  the  well  known  dictum  "treat 
the  disease  and  not  the  symptoms."  A  high  pres- 
sure, though  merely  a  manifestation  of  some  under- 
lying pathological  process,  is  so  frequently  the  main 
symptom  and  the  cause  of  so  many  closely  related 
symptoms  that  it  has  come  to  be  regarded  as  a  defi- 
nite entity,  no  matter  whether  the  increased  blood 
pressure  is  the  result  of  a  nephropathy,  an  endo- 
crine dystrophy,  or  a  narrowing  of  the  smaller 
elements  of  the  blood  vascular  tree.  Furthermore, 
by  the  ordinary  clinical  and  laboratory  tests,  with 
which  we  are  acquainted,  in  many  cases  of  high 
pressure  we  are  unable  to  demonstrate  renal  changes, 
internal  secretory  disorders,  or  other  causes  to  ex- 
plain the  pathogenesis  of  the  condition  of  high  pres- 
sure. We  are  accustomed  to  assume  in  such  cases 
that  there  is  present  a  glomerular  nephritis  or  a  renal 
sclerosis,  yet  we  are  unable  to  show  any  distinct 
evidence  of  kidney  pathology.  This  absence  of 
symptoms  and  signs,  except  these  referable  to  the 
high  pressure,  has  led  to  a  variety  of  names  being 
applied  to  the  syndrome.  Janeway,  because  of  the 
frequency  with  which  such  patients  died  a  cardiac 
death,  has  labelled  the  disorder  cardiovascular  hyper- 
tensive disease.  Allbutt  has  applied  the  term  hyper- 
piesis  to  a  group  of  cases  in  which  elevation  of  the 
blood  pressvu"e  is  rather  sudden  and  associated  with 
many  symptoms.  Essential  hypertension  is  the 
name  most  frequently  applied  to  the  disorder. 

From  this  brief  preliminary  discussion  of  high 
blood  pressure  we  may  say  that  by  essential  hyper- 
tension we  understand  a  condition  of  continuous 
high  blood  pressure,  systolic  pressure  over  175 
mm.  of  mercury,  of  unexplained  cause.  The 
patient  may  have  many  symptoms  referable  to 
the  high  pressure,  yet  on  the  other  hand  a  high 
pressure  may  exist  without  symptoms  and  only  be 
discovered  accidentally  when  making  a  routine 
sphygmomanometer  examination.  Individuals  of 
this  latter  type  are  not  truly  patients,  yet  the  in- 
creasing incidence  of  disability  and  death  from  the 
results  of  high  pressure  and  the  likelihood  of  such 


events  taking  placing  within  a  comparatively  short 
time  in  the  life  cycle  make  such  a  person  a  patient, 
one  who  requires  treatment.  He  is  objectively 
though  not  subjectively  sick. 

General  treatment. — In  the  management  of  cases 
of  hypertension  it  must  not  be  forgotten  that  the 
hypertension  is  a  compensatory  process  and  that 
any  efforts  to  reduce  suddenly  the  pressure  by 
drugs,  bleeding,  and  so  on  should  be  avoided,  un- 
less there  is  a  threatened  apoplexy  or  some  such 
catastrophe  imminent.  Active  measures  are  to  be 
avoided  unless  absolutely  necessary,  and  the  pres- 
sure should  be  reduced  slowly.  Fortunately,  Na- 
ture in  her  kindness  has  so  ordained  things  that  it 
is  extremely  difficult  to  reduce  pressure  at  any 
time  and  more  than  difficult  to  reduce  it  suddenly. 
This  is  indeed  a  blessing  for  many  are  the  attempts 
to  lower  suddenly  a  high  pressure  where  success 
would  lead  to  cardiac  failure  or  to  uremia.  But  in 
most  cases  the  gradual  reduction  of  the  pressure  is 
distinctly  indicated,  if  for  no  other  reason  than 
to  relieve  the  heart  of  a  tremendous  amount  of  un- 
necessary and  harmful  work. 

Diet. — The  first  step,  and  probably  the  most  im- 
portant in  the  handling  of  these  cases,  is  the  correc- 
tion of  faulty  habits  of  life  and  notably  the  cor- 
rection of  the  more  than  probable  abuse  of  food. 
Overeating  is  to  be  avoided.  Probably  overeating 
has  induced  high  pressure  more  frequently  than 
any  other  single  cause.  Food  should  be  taken  at 
regular  hours,  eaten  slowly,  and  should  be  followed 
by  a  short  rest  of  fifteen  or  twenty  minutes,  as  the 
pressure  rises  during  and  immediately  after  eating. 
Alcohol  should  be  avoided  and  tobacco  should  be 
used  moderately.  The  protein  foods  should  be  elimi- 
nated from  the  diet  to  a  great  extent.  Animal  foods 
form  the  great  bulk  of  the  proteins  and  it  is  these 
foods  that  should  be  restricted.  Fish,  white  meats, 
and  eggs  are  as  culpable  as  the  long  condemned  red 
meats  in  the  production  of  harmful  nitrogenous 
waste  products,  so  it  is  of  little  value  to  tell  the 
patient  to  reduce  one  type  of  protein  while  he  is 
given  tacit  permission  to  go  as  far  as  he  likes  with 
other  types.  One  small  slice  of  meat  a  day  should 
suffice  the  patient  suffering  from  hypertension.  Milk 
also  should  be  taken  moderately  in  chronic  cases, 
whereas  using  it  as  a  food  alone,  one  thousand  c.c.  a 
day  for  several  days,  will  reduce  a  pressure  which 
has  been  found  resistant  to  all  other  means. 

Physical  effort. — Excessive  physical  effort  is 
to  be  avoided,  by  all  means.  Work  should  be  much 
restricted  and  outdoor  recreations  should  not  be  too 
strenuous.  A  certain  amount  of  physical  effort  and 
exercise  is  advisable,  however,  as  it  aids  the  proper 
elimination  of  toxic  waste  products  and  brings 
about  a  healthy  metabolic  increase.  Sudden  severe 
violent  physical  effort  is  especially  to  be  warned 
against. 

Hurry,  worry,  and  mental  strain. — The  patient 
with  high  tension  should  avoid  mental  stress  and 
strain.  The  hurry  of  present  day  Hfe,  the  worry 
incidental  to  so  many  diverse  factors  in  business, 
and  the  mental  strain  accompanying  such  hurry  and 
worry  are  distinctly  to  be  avoided.  The  hyperten- 
sive patient  should  cultivate  a  calm,  lethargic  mien, 
if  possible. 


October  16,  1920.] 


MUSSER:  ARTERIAL  HYPERTENSION. 


571 


Sleep  and  rest. — During  sleep  the  pressure  falls 
most  decidedly  and  the  same  applies  to  absolute 
rest  in  the  recumbent  position.  The  patient,  there- 
fore, should  be  instructed  by  the  physician  to  ob- 
tain a  good  night's  rest  and  when  insomnia  prevents 
this,  some  of  the  mild  sedatives  should  be  prescribed. 

Eliminafion. — In  these  cases  the  bowels  should 
be  kept  well  open.  One  or  two  good  loose  move- 
ments a  day  should  be  secured  by  a  morning  saline 
purge  and  once  or  twice  a  week  calomel  or  blue 
mass  should  be  taken,  or  the  mercurial  may  be  taken 
when  the  symptoms  of  hypertension  are  particularly 
annoying. 

Hydrotherapy. — It  is  my  custom  to  order  for  my 
patients  electric  cabinet  baths  twice  a  week.  In  my 
dispensary  patients  this  is  obtained  in  the  hydro- 
therapeutic  department  of  the  University  Hospital. 
Elimination  through  the  skin  may  be  aided  further 
when  it  is  impossible  to  get  the  cabinet  baths  by 
having  the  patient  take  Turkish  baths  once  or  twice 
a  week  and  follow  this  with  mild  exercise.  When 
hydrotherapy  of  this  type  is  unobtainable  I  recom- 
mend a  prolonged  warm  bath  for  fifteen  minutes  at 
a  temperature  of  103°  F. 

Drugs. — It  has  been  shown  conclusively  that  drugs 
are  of  little  value  in  combating  high  pressure  over 
any  length  of  time.  The  iodides  are  of  value  only 
in  syphilitic  cases.  The  nitrites  produce  a  temporary 
fall  in  pressure  only  and  a  tolerance  to  them  cjuickly 
follows  their  prolonged  use.  They  should  be 
reserved  for  emergencies.  Radium  charged  water 
has  not  been  followed  by  any  particular  action,  as 
far  as  I  could  determine  in  the  few  cases  in  which 
I  have  employed  it.  Of  the  newer  drugs  benzyl 
benzoate  has  received  particular  attention  as  a 
reducer  of  blood  pressure. 

This  drug  was  introduced  by  Macht  in  1918  and 
came  into  general  use  in  the  fall  of  1919.  Benzyl 
benzoate  is  one  of  the  socalled  minor  alkaloids  of 
opium  and  was  isolated  by  Macht  during  the  course 
of  his  study  of  these  alkaloids.  He  discovered  that 
these  preparations  have  a  marked  relaxing  action 
on  the  unstriped  muscles  of  the  body  and  are  capable 
of  relieving  spasm  of  such  muscle.  On  account  of 
this  antispasmodic  and  tonus  lowering  efifect  Macht 
had  the  drug  tried  out  in  a  variety  of  conditions 
which  are  associated  with  muscular  spasm.  He 
asserts  that  he  received  good  results  in  relieving  the 
following  spasmodic  conditions :  Diarrhea  and 
dysentery,  intestinal  colic  and  enterospasm,  pyloro- 
spasm,  spastic  constipation,  biliary  colic,  ureteral 
colic,  vesical  spasm,  spasmodic  pains  in  seminal 
vesicles,  uterine  colic,  bronchial  asthma,  and  arterial 
spasm  hypertension. 

It  is  with  this  last  condition  that  we  are  particular- 
ly interested  today  and  I  will  recount  to  you  my 
rather  brief  experience.  In  a  small  series  of  six 
cases  I  religiously  gave  the  drug  for  some  weeks. 
In  order  to  test  it  out  I  used  but  few  auxiliary 
methods  but  rather  made  an  effort  to  see  if  the 
benzyl  benzoate,  plus  a  few  simple  general  hygienic 
directions,  would  lower  the  pressure.  In  no  case 
did  I  see  any  efifect  from  it  whatsoever.  Likewise 
I  have  talked  with  some  of  my  colleagues  and  they 
have  been   almost   unanimous   in   expressing  the 


opinion  that  it  has  but  little  effect  on  the  blood 
pressure. 

While  I  have  seen  little  if  any  result  from  the 
administration  of  benzyl  benzoate  in  the  treatment 
of  increased  blood  pressure  I  have  had  the  oppor- 
tunity of  testing  it  in  two  cases  of  angina  pectoris 
and  can  testify  as  to  its  value  in  this  condition. 
Likewise  in  several  other  painful  or  disagreeable 
spastic  conditions  its  action  has  been  truly  remark- 
able. 

Reduction  of  salt  and  water  intake. — Some  months 
ago  Dr.  F.  M.  Allen  published  an  article  (1)  on 
arterial  hypertension  in  which  he  advocated  the 
reduction  of  water  intake  and  the  elimination  of 
salt  in  the  treatment  of  hypertensive  cases.  Allen's 
thesis  is  that  in  many  cases  high  pressure  is  a  com- 
pensating process  in  which  the  elevated  pressure 
is  necessary  "to  force  a  filtrate  of  water  and  dis- 
solved substances  through  a  damaged  and  partially 
blocked  glomerular  filter."  His  theory,  while  not 
a  new  one,  has  never  received  much  attention  in  this 
country  or  Germany,  though  to  a  certain  extent  the 
French  school  has  recognized  the  coexistence  of  high 
pressure  and  salt  retention.  Allen  shows  by  his 
results  that  there  is  a  very  definite  relation  between 
salt  retention,  large  water  intake,  and  high  pressure. 
To  determine  the  value  of  this  procedure  we  have 
observed,  in  the  medical  dispensary  of  the  University 
Hospital,  the  efifect  of  the  lowering  of  salt  and  water 
intake  upon  patients  with  arterial  hypertension,  not 
caused  by  obvious  renal  disease.  Likewise  in  three 
private  cases  I  have  had  the  opportunity  of  watching 
the  efifect  of  this  treatment  upon  the  blood  pressure. 
Though  there  are  only  seven  cases  to  report  upon 
and  it  is  unwise  to  draw  deductions  from  this  small 
series,  nevertheless  as  the  results  were  so  uniform, 
it  does  not  seem  unfair  to  present  them. 

BLOOD  PRESSURE. 

Before  Treatment  After  Treatment 

Systolic      Diastolic  Systolic  Diastolic 


Case  1  185  85  125  75 

Case  II  215  105  170  85 

Case  III  157  79  130  80 

Case  IV  204  115  1^0  105 

Case  V  205  120  160  100 

Case  VI  174  80  14S  75 

Case  VII  230  110  210  100 


In  the  dispensary  cases  studied  by  Dr.  Robert 
McMillan  repeated  examinations  were  made  of  the 
blood  urea,  plasma  chlorides,  and  phenolphthalein 
elimination.  He  found  that  the  plasma  chlorides 
were  raised  before  reducing  the  salt  intake  and  that 
the  reduction  in  chlorides  was  commensurate  with 
the  lowering  of  the  salt  intake.  Likewise  the  height 
of  the  pressure  had  a  fairly  definite  relation  to  the 
plasma  chloride  fall.  In  order  to  illustrate  more 
satisfactorily  the  result  of-  this  treatment  I  will 
recount  briefly  the  history  of  a  patient  I  have  treated 
with  potassium  iodide  and  sajodin,  and  subsequently 
placed  upon  a  modified  restricted  salt  free  diet. 

Case. — Mrs.  M.,  aged  fifty-three,  widow.  Patient 
referred  on  account  of  gastric  symptoms.  Except 
for  the  gastric  symptoms,  ringing  in  the  ears,  nyc- 
turia once  a  night,  and  an  intermittent  heart,  she  had 
no  other  complaints.  There  was  no  edema  nor 
dyspnea.  In  her  past  history  there  was  noted 
eclampsia  sixteen  years  ago  and  hysterectomy  nine 
years  ago.     The  family  history  showed  that  her 


572 


REDFIELD:   WHAT  IS  DISEASE? 


[New  York 
Medical  Journal. 


mother  had  died  of  apoplexy  at  the  age  of  seventy- 
one,  and  one  brother  of  nephritis  and  apoplexy  at 
fifty-six. 

Examination  showed  a  rather  well  nourished  fe- 
male ;  eyes,  teeth,  tonsils,  and  thyroid  negative ;  lungs 
clear ;  heart  enlarged  down  and  left.  There  was 
heard  a  presystolic  mitral  murmur,  a  much  accentu- 
ated aortic  second  sound,  and  an  occasional  extra- 
systole.  Abdominal  examination  showed  nothing  but 
a  slight  ptosis  of  the  stomach.  The  gastric  examin- 
ation showed  a  marked  subacidity.  The  urine  in 
repeated  tests  showed  a  specific  gravity  varying  from 
1008  to  1024.  Occasionally  a  trace  of  albumin  was 
found.  The  preliminary  blood  presstire  was  205- 
120,  the  hemoglobin  ninety  per  cent.  The  eye 
grounds  were  negative. 

The  patient  was  ordered  sodium  phosphate  daily, 
prolonged  warm  baths  twice  a  week,  a  low  protein 
diet,  and  was  given  general  directions  as  to  daily 
hygiene.  In  a  short  time  iodide  of  potassium  was 
ordered  and  subsequently  sajodin.  For  a  month  the 
pressure  ranged  between  205-190  systolic,  120-110 
diastolic.  At  the  end  of  this  time,  when  the  pressure 
was  205-115,  the  patient  was  suffering  very  much 
from  dizziness  and  tinnitus.  She  was  ordered  to 
cut  out  salt  from  her  dietary  and  restrict  water  to 
800  c.c.  a  day.  Eight  days  later  the  pressure  was 
185-105 ;  in  nine  subsequent  examinations  it  had 
fallen  steadily  until  at  the  present  time  it  is  160-100. 
The  patient  is  now  practically  free  from  symptoms 
and  is  apparently  in  good  general  condition. 

There  are  several  minor  observations  I  would  like 
to  make  upon  this  phase  of  the  treatment  of  hyper- 
tension. If  a  reduction  in  salt  intake  is  ordered, 
the  need  of  the  organism  for  water  for  the  purpose 
of  diluting  the  increased  chlorides  retained  in  the 
body  is  not  pronounced.  Therefore,  with  the  re- 
duction in  the  salt  the  desire  for  water  is  decreased 
and  the  water  intake  is  almost  automatically  dimin- 
ished. The  estimation  of  the  plasma  chlorides  gives 
positive  evidence  of  the  reduction  of  these  salts 
which  is  confirmed  by  the  blood  pressure  observa- 
tions. While  the  plasma  chloride  estimation  is  of 
great  value  and  should  be  used  whenever  possible 
in  treating  the  hypertension  patients,  nevertheless 
the  parallelism  of  the  reduction  of  the  pressure  and 
the  chlorides  is  so  close  that  by  simply  following  the 
blood  presstire  a  fairly  accurate  idea  may  be  attained 
as  to  the  actual  reduction  of  the  plasma  chlorides 
when  laboratory  facilities  are  lacking.  Lastly,  it 
must  not  be  supposed  that  all  cases  respond  to  this 
form  of  treatment,  as,  for  example,  Case  \'II  in  the 
table. 

CONCLUSION. 

The  management  of  a  case  of  hypertension  re- 
quires a  careful  study  of  the  patient.  Unless  some 
threatened  vascular  cardiac  or  renal  catastrophe 
seems  imminent  physical  and  hygienic  measures 
should  be  relied  upon  more  than  drugs.  The  reduc- 
tion of  salt  and  water  intake  forms  a  valuable 
adjuvant  to  these  measures. 

REFERENCES. 

1.  .\llen,  F.  M.:  Arterial  Hypertension,  Journal  A.  M. 
A..  1920,  Ixxiv,  652. 

262  South  Twextv-first  street. 


WHAT  IS  DISEASE? 
By  Casper  L.  Redfield, 

Chicago. 

In  a  work  on  pathology,  health  is  defined  as  "that 
condition  of  function  and  structure  which  we  find 
to  be  normal,"  and  disease  is  defined  as  "any  de- 
parture from  the  normal  standard  of  structure  or 
function  of  tissue  or  organ."  At  the  same  time  the 
"normal"  is  defined  as  that  which  "we  find  to  be 
the  commonest."  In  other  words,  the  average  of 
function  and  structure  is  taken  as  the  normal,  and 
any  departure  from  that  average  is  designated  as 
disease.  Under  that  definition,  the  champion  pugil- 
ist, the  champion  wrestler,  and  the  champion  oars- 
man would  be  diseased  men.  The  champion  trotter 
would  be  a  diseased  horse,  and  the  dairyman  who 
kept  specially  good  milkers  should  be  prosecuted 
for  selling  milk  from  diseased  cows.  And  men  with 
such  robust  intellects  as  Newton,  Franklin  and 
Edison  must  have  diseased  brains.  At  some  time 
in  the  past,  man's  ancestor  was  mtich  more  apelike 
than  manlike,  and  to  get  human  beings  from  such 
ancestors  there  must  have  been  departures  "from 
the  normal  standard  of  structtire  and  function." 
Under  the  definitions  qtioted,  the  entire  human  race 
must  be  a  diseased  product.  And  what  is  more, 
evolution  must  be  a  disease. 

The  object  here  is  to  present  a  new  definition  for 
disease,  and  to  indicate  some  of  the  reasons  why  it 
is  thottght  that  this  new  definition  is  superior  to  the 
old.  This  new  definition  will  incltide  among  dis- 
eases some  things  not  now  considered  as  disease  at 
all,  and  perhaps  will  exclude  as  not  being  disease 
some  things  now  considered  as  disease.  The  real 
object  of  presenting  the  new  definition  is  to  cause 
disease  to  be  looked  at  from  a  new  angle,  and  such 
new  view  will  be  instructive  even  if  the  reader  does 
not  agree  that  the  definition  is  of  the  proper  scope. 
As  a  convenient  procedure,  the  definition  will  be 
given  first  and  the  argument  later. 

Disease  is  the  effect  produced  upon  certain  cells 
or  organs  by  a  continued  overload,  which,  if  not 
interrupted,  results  in  the  death  of  the  cells  or  or- 
gans. The  term  disease  might,  with  propriety,  be 
used  to  represent  both  the  overload  and  the  result 
produced  by  the  overload.  It  might  also  be  used  to 
represent  the  process  by  which  an  overload  destroys 
life.  In  this  last  meaning,  the  definition  wotild  be 
reduced  to  the  epigrammatic  form 

disease  is  the  road  to  de.\th 
Under  these  definitions,  nothing  could  be  called 
disease  unless  it  led  toward  death,  either  of  the 
individual,  or  of  certain  cells  or  organs  in  the-indi- 
vidual.  A  mere  stress  or  strain  which  catised  pain 
and  abnormal  action  within  an  organ  would  not  be 
disease  unless  the  magnitude  of  the  stress  or  strain 
were  sufficient,  if  continued,  to  cause  the  death  of 
some  of  the  cells  within  the  v  ^gan.  A  deformity, 
while  it  might  be  the  product  a  disease,  would 
not  be  a  disease  itself  tmless  it  weic  of  a  kind  which 
would  necessarily  cause  death.  In  such  a  case,  the 
deformity  wotild  be  the  overload.  Or  a  deformiiy 
pltis  something  else  might  amotmt  to  an  overloai\ 
in  which  case  the  deformit\-  would  be  a  part  of  it. 


October  16,  1920.] 


REDFIELD:  WHAT  IS  DISEASE? 


573 


Let  us  suppose  that  I  should  stab  a  man  in  the 
arm,  or  leg,  or  back,  and  he  should  lose  consider- 
able blood  before  the  flow  could  be  stopped.  He 
would  be  weakened  by  the  loss  of  blood.  Suppose 
that  the  next  day,  before  he  had  been  able  to  re- 
cover from  the  loss  he  stififered,  I  should  stab  him 
again,  and  he  should  lose  still  more  blood.  Sup- 
pose further  that  day  after  day  I  should  stab  him 
in  the  same  way  and  that  day  after  day  he  became 
weaker  and  weaker  tintil  he  finally  died.  Xo  one 
would  say  that  the  man  died  as  the  result  of  dis- 
ease. 

Suppose  that  a  man  traveling  in  a  tropical  jungle 
should  find  leeches  so  numerous  that  he  was  unable 
to  protect  himself,  and  that  day  after  day  they 
drew  so  much  blood  from  him  that  he  finally  died. 
This  is  not  disease  under  the  ordinary  meaning  of 
that  term.  But  let  us  suppose  that  unknown  micro- 
organisms cause  increased  destrtiction  of  blood  cor- 
puscles day  after  day  until  the  man  dies  of  anemia. 
That  is  disease. 

\\'herein  do  these  things  differ  in  their  essence? 
In  each  case  the  man  dies  from  blood  losses  day 
after  day.  Are  we  to  use  the  term  disease  to  repre- 
sent only  the  mysterious  and  the  unknown  ?  Small 
leeches  taken  in  drinking  water  sometimes  attach 
themselves  to  the  fauces,  and  the  effects  produced 
have  been  mistaken  for  disease.  Does  a  disease 
cease  to  be  a  disease  as  soon  as  we  understand  it  ? 

Suppose  that  a  man  is  bitten  by  scorpions  or  by 
tarantulas,  or  is  stung  by  bees,  wasps  or  hornets  un- 
til he  becomes  seriotisly  ill  as  the  result  of  the  poi- 
son injected  into  him.  Xo  one  says  that  such  illness 
is  due  to  disease.  If  a  man  is  similarly  poisoned  by 
typhoid  or  pneumonia  or  other  germs,  that  surely  is 
disease,  but  wherein  is  the  difference?  Is  the  first 
not  a  di.sease  because  it  is  by  some  familiar  insect, 
and  the  latter  a  disease  because  it  is  by  some  un- 
familiar bacterium?  Is  the  qtiestion  of  disea.se  and 
not  disease  to  be  determined  by  the  factory  in  which 
the  poison  is  manufactured  rather  than  by  the  na- 
ture of  the  poison  and  the  effect  it  produces? 

In  several  cases  it  has  been  discovered  that  stags, 
in  fighting,  have  got  their  antlers  locked  together 
and  have  died  in  this  condition.  W  e  can  picture 
the  combat  with  the  horns  locked.  The  deer  can 
struggle  only  by  pushing  and  pulling  and  twisting. 
They  cannot  produce  any  wounds  upon  each  other. 
But  in  that  pushing  and  pulling  and  twisting  they 
wear  themselves  out  and  finally  fall  down  and  die 
from  sheer  exhaustion.  Did  those  animals  die  as 
the  restilt  of  disease? 

When  a  person  is  worn  down  or  exhatisted  from 
long  contintied  physical  exertions  he  is  mtich  more 
susceptible  to  bacterial  infection  than  when  not  so 
exhausted.  Also,  after  a  man  has  been  throtigh  a 
long  illness  due  to  some  bacterial  infection,  he  is 
worn  out  and  weak.  These  are  facts  which  show 
that  the  same  energy  used  in  a  physical  struggle  is 
the  energy  used  in  fighting  bacterial  infection. 
The  burden  thrown  upon  a  man's  powers  by  bac- 
terial infection  is  called  disease,  btit  the  similar  bur- 
den thrown  on  the  same  powers  by  an  opponent  or 
by  some  physically  observed  and  fully  understood 
circumstances  is  not  disease.  But  wherein  is  the  dif- 
ference?   In  both  cases  the  physical  powers  are  ex- 


hausted by  efforts  which  expend  energy  of  the  same 
kind.  Does  a  disease  cease  to  be  a  disease  when 
the  millions  of  cells  which  a  man  fights  are  or- 
ganized into  large  bodies  instead  of  being  separate 
entities  ? 

We  can  convert  work  fully  and  completely  into 
heat,  but  we  can  make  the  reverse  transformation 
only  in  part.  .A.s  a  consequence,  heat  is  called  the 
degraded  form  of  energy,  and  is  always  a  product 
of  work  performed.  \\'hen  a  person  takes  violent 
exercise,  as  in  a  foot  race  or  a  wrestling  match,  his 
temperature  increases  and  may  rise  to  105"  F.,  or 
more,  and  such  appearance  of  extra  heat  is  evidence 
of  the  exertion  he  makes.  A  fever  represents  an 
increase  in  the  heat  form  of  energy  and  is  evidence 
of  a  physical  struggle  of  some  kind  which  is  in- 
visible because  it  is  within  the  body.  The  invisible 
struggle  which  produces  a  fever  is  said  to  be  disease, 
and  the  visible  struggle  of  a  foot  race  which  corre- 
spondingly raises  temperature  is  not  disease.  Is  a 
question  of  disease  to  turn  upon  the  degrees  of  visi- 
bility? Is  a  bacterium  to  be  considered  as  the  cause 
of  disease  because  he  can  be  seen  only  with  a  micro- 
scope, and  an  opponent  in  a  wrestling  match  not 
the  cause  of  disease  because  he  can  be  seen  with 
the  naked  eye? 

When  a  man  swings  Indian  clubs  or  dumbbells  he 
exercises  certain  mtiscles  and  expends  certain  foot 
pounds  of  energy.  As  the  swinging  continues,  he 
gradually  becomes  tired  and  has  to  stop  for  a  rest. 
After  resting  for  a  few  minutes  he  can  resume  his 
exercise,  but  soon  becomes  tired  and  must  rest  a 
.second  time.  After  another  short  rest  he  can  begin 
the  exercise  a  third  time,  and  so  on  time  after  time 
for  perhaps  several  hours.  Each  period  in  which 
the  man  was  taking  this  exercise  consumed  the 
available  energy  in  the  muscles  being  exercised,  and 
during  each  period  of  rest  the  supply  in  the  exer- 
cised muscles  was  partially  replenished  by  drawing 
tipon  the  store  existing  at  the  time  in  other  organs. 

The  fact  that  severely  exercised  muscles  in  the 
arms  may  draw  upon  the  reserves  in  unexercised 
parts  of  the  body  is  evident  from  the  fact  that  a 
person  who  has  become  tired  by  swinging  dumb- 
bells is  in  no  condition  to  compete  in  a  foot  race  or 
in  a  debating  contest.  Each  organ  has  in  it  a 
store  of  energy  normally  appropriated  for  the  use 
of  that  organ,  but  in  emergency,  a  severely  taxed 
organ  may  draw  upon  the  supplies  in  other  organs. 
An  organ  so  taxed  is  suffering  from  an  overload 
dtiring  the  time  when  the  efforts  are  continued.  But 
if  the  man  rests  until  the  next  day,  or  for  a  period 
long  enough  for  his  system  to  get  back  into  the 
organs  from  the  food  supply  the  amount  equal  to 
that  expended,  then  there  is  no  overload  when  the 
efforts  are  measured  in  the  longer  period.  The 
overload  was  interrupted  by  the  rest.  If  not  in- 
terrupted, then  the  man  would  ultimately  die  from 
exhaustion  as  in  the  case  of  the  deer  with  locked 
horns. 

When  a  man  goes  into  a  gymnasium  or  out  onto 
a  golf  course  and  takes  more  exercise  than  has  been 
customar}-  or  habitual  with  him,  but  an  amount 
which  is  less  than  an  overload  when  the  resting  time 
is  counted  with  the  exercising  time,  he  builds  up  the 
energy  supply  in  the  exercised  organs  to  something 


574 


RED  PI  ELD: 


WHAT  IS  DISEASE? 


[New  York 
Medical  Journal. 


greater  than  it  was  before.  If  he  begins  such  ex- 
ercise comparatively  early  in  life  and  keeps  it  up 
regularly,  he  may  develop  his  powers  to  some- 
thing much  in  excess  of  an3-thing  he  inherited.  Ex- 
amples of  such  development  may  be  seen  in  the 
trotting  horse.  In  the  evolution  of  the  two  minute 
trotter  from  stock  not  capable  of  trotting  a  mile  in 
three  minutes,  many  thousands  of  the  horses  trained 
and  raced  have  developed  trotting  powers  much  in 
excess  of  anything  which  ever  existed  in  any  an- 
cestor. In  this  connection  the  reader  should  re- 
member that  the  run  is  the  natural  high  speed  gait 
for  the  horse,  and  that  high  speed  at  the  trot  is  an 
artificial  product  of  the  nineteenth  century. 

The  reverse  of  the  development  of  powers  by  ex- 
ercise is  the  degeneration  of  powers  by  idleness — 
the  term  idleness  meaning  an  amount  of  exercise 
to  the  unit  of  time  which  is  somewhat  less  than  has 
been  habitual.  In  previous  articles  (1)  I  have  given 
many  examples  of  the  development  of  powers  by 
exercise  and  the  degeneracy  of  powers  by  idleness 
in  animals,  plants,  bacteria  and  protozoa.  A  few 
more  examples  will  be  given  here. 

Pasteur  found  that  the  anthrax  bacillus  could  be 
raised  on  an  artificial  medium,  as  bouillon  at  blood 
temperature.  When  so  raised  the  bacilli  do  not 
have  to  fight  for  life  in  a  hostile  blood  reaction, 
and  because  they  do  not  have  to  fight  they  gradu- 
ally lose  their  power  of  fighting,  which  is  their 
virulence.  He  used  two  cultures,  a  very  weak  one 
produced  by  a  long  period  of  idleness  in  life  on 
artificial  food,  and  one  not  so  weak  produced  by  a 
shorter  period  of  idleness.  He  then  inoculated  an 
ox  with  the  weaker  culture,  and  twelve  days  later 
with  the  stronger  culture.  An  animal  so  inoculated 
was  immune  to  fully  virulent  virus.  Here  we  have 
the  progressive  decay  of  powers  in  the  bacilli  by 
idleness,  and  the  progressive  development  of  pow- 
ers in  the  ox  by  exercise. 

But  Pasteur's  experiments  went  still  further  in 
this  matter.  By  long  cultivation  on  artificial  food 
he  got  anthrax  germs  so  weak  from  the  lack  of 
exercise  in  fighting  for  food  that  they  were  unable 
to  survive  even  in  a  mouse.  But  by  taking  such 
weak  virus  and  inoculating  a  very  feel)le  animal,  as 
a  guineapig  a  day  old,  and  then  passing  it  along  by 
inoculation  to  stronger  and  stronger  animals,  he 
found  that  the  strength  of  the  virus  was  built  up 
step  by  step  with  each  inoculation  until  it  was  pow- 
erful enough  to  attack  the  strongest  animals.  Here 
we  have  a  case  of  absolute  control  over  the  gain  and 
loss  of  powers  in  the  same  organism  by  controlling 
the  amount  of  its  exercise. 

Haffkine  made  similar  experiments  with  the  chol- 
era vibrio.  This  is  a  motile  organism,  the  viru- 
lence of  which  seems  to  be  directly  proportional 
to  its  power  of  movement.  He  found  that,  for  the 
two  inoculations  he  wanted  to  make  to  produce 
immunity,  the  germs  obtained  from  the  intestinal 
canal  were  too  powerful  for  the  preliminary  inocu- 
lation, but  not  sufficiently  active  for  the  second,  if 
marked  protection  was  to  be  obtained.  He  also 
found  that  by  growing  this  germ  on  agar,  or  other 
nutrient  media,  it  gradually  lost  its  activity'  and 
virulence,  and  he  could  thus  get  a  weak  form  suit- 
able for  the  first  inoculation.    Also,  he  found  that 


b\-  passing  germs  from  the  original  stock  through 
a  series  of  about  thirty  guineapigs"  he  got  a  virus 
of  "great  acti^'ity." 

Here  we  have  a  case  of  producing  two  strains 
of  microorganisms  from  the  same  stock — one  a 
weak  strain  which  gradually  lost  its  powers  be- 
cause it  did  not  have  to  exert  itself  by  a  struggle 
for  existence  in  a  hostile  environment,  and  the  other 
a  superpowerful  strain  which  became  such  by  be- 
ing compelled  continually  to  exert  itself  by  pass- 
ing from  hostile  environment  to  hostile  environment 
for  about  thirty  times.  These  two  strains  formed 
the  weak  and  strong  vaccines  which  he  used  suc- 
cessfully to  make  guineapigs  immune  against  doses 
of  cholera  poison  from  eight  to  ten  times  the  normal 
lethal  dose.  But  he  found  one  thing  more.  He 
found  that  after  he  had  got  the  powerful  culture  he 
must  maintain  it  by  the  process  by  which  he  ob- 
tained it.  On  agar,  the  powerful  germs  soon 
lost  their  activity,  and  it  was  necessary,  from  time 
to  time,  to  pass  them  again  through  a  series  of 
guineapigs. 

Without  multiplying  examples  of  cases  in  whicli 
the  powers  of  living  organisms  have  been  increased 
or  decreased  at  will  by  causing  those  organisms  to 
either  exercise  or  fail  to  exercise  the  powers  they 
have  at  the  time,  we  may  consider  what  overload 
is  in  bacteria.  When  Pasteur  got  anthrax  virus  so 
weak  that  it  could  not  survive  in  the  blood  of  a 
guineapig  a  month  old,  the  powers  of  the  guineapig 
were  an  overload  for  those  germs.  But  when  he 
came  down  to  something  as  feeble  as  a  guineapig 
a  day  old,  ihen  those  weak  germs  were  an  overload 
for  that  young  guineapig. 

Now  the  difference  between  a  guineapig  a  clay 
old  and  a  guineapig  a  month  old  is  a  difference  in 
physical  powers  developed  by  normal  activity  in 
the  interval  between  a  day  and  a  month,  and  not 
a  difference  in  inheritance.  Guineapigs  do  not  do 
any  inheriting  after  they  are  born.  A  load  is  meas- 
ured by  the  powers  necessary  to  carry  it,  and  as 
powers  increase  or  decrease  in  accordance  with  the 
extent  to  which  they  are  exercised,  it  is  evident  that 
what  may  be  an  overload  at  one  time  may  not  be 
an  overload  at  another.  Also,  powers  may  be  de- 
creased by  simply  shutting  off  the  power  supply, 
in  which  case  a  load  which  was  less  than  an  over- 
load might  become  an  overload.  For  example,  a 
load  which  a  person  could  carry  with  ease  and  not 
even  be  aware  of  its  presence  might  become  an 
overload  by  reason  of  an  insufficient  supply  of 
food,  or  of  some  ingredient  of  food.  An  animal 
weakened  by  starvation  is  more  than  normally  likely 
to  fall  a  victim  of  some  disease. 

If  a  man  exercises  the  muscles  of  his  arms  and 
not  the  muscles  of  his  legs,  his  powers  are  de- 
veloped in  his  arms  and  not  in  his  legs.  If  his  work 
is  mental  exercise  and  not  ph3'sical  exercise,  then 
powers  are  built  up  in  the  brain  and  not  in  the 
muscles.  If  a  man  begins  by  taking  small  doses  of 
arsenic  and  later  becomes  an  arsenic  eater,  he  de- 
velops his  powers  of  resisting  arsenic  and  not  those 
of  resisting  opium  or  some  other  drugs.  When  a 
person  is  vaccinated  his  powers  of  resisting  small- 
pox are  developed  and  not  those  of  resisting  pneu- 
monia or  some  other  disease.   And  so  on. 


October  16,  1920.] 


BALL:  DOCTOR  AXD  XEUROPATH. 


575 


While  these  things  are  relatively  true,  they  are 
not  absolutely  true.  When  any  kind  of  powers 
develop  in  a  person  by  exercise  without  at  the  same 
time  permitting  some  other  powers  to  decline  by 
idleness,  the  total  powers  in  his  organism  are  in- 
creased, and  the  total  supply  may  be  called  on  for 
assistance  when  some  particular  organ  is  over- 
loaded. This  is  illustrated  in  the  case  of  the  dumb- 
bell exercise  previously  given.  It  is  further  illustrat- 
ed in  the  case  of  snake  venom,  for  which  no  animal 
has  normally  developed  a  specific  resistance.  But  bv 
beginning  with  small  doses  insufficient  to  cause 
death,  and  then  gradually  increasing  them,  a  few- 
doses  have  been  sufficient  to  enable  an  animal  to 
withstand,  without  harm,  a  dose  fifty  times  as  great 
as  would  have  been  fatal  in  the  first  instance.  Such 
great  development  of  some  specific  power  in  a 
short  time  can  be  obtained  only  by  the  conversion 
of  some  powers  already  within  the  system. 

If  a  man  is  attacked  by  smallpox  or  pneumonia 
or  other  equally  dangerous  ailment,  and  then  re- 
covers, is  the  attack  a  disease  within  the  definition 
here  given? 

Yes.  It  is  a  case  of  an  overload  which  was  con- 
tinued for  a  time  but  failed  to  produce  death  be- 
cause it  was  interrupted.  The  fact  that  there  was 
an  attack  whfch  caused  distress  is  evidence  of  an 
overload.  A  load  which  is  carried  easily  is  not  an 
overload.  For  example,  the  heart  carries  a  load 
from  birth  to  old  age  without  difficulty  or  distress, 
but  let  there  be  a  considerable  increase  of  blood 
pressure,  and  the  load  becomes  an  overload.  An 
attack  of  smallpox  is  possible  only  because  the 
system  does  not  have  in  it  enough  of  that  specific 
form  of  power  which  resists  this  kind  of  germ.  In 
attempting  to  meet  this  form  of  attack  the  system 
builds  up  its  resisting  powers  by  exercising  them 
and  by  calling  on  other  powers  for  help.  When 
these  resisting  powers  become  greater  than  the 
powers  of  attack,  the  overload  passes  from  the  man 
to  the  germ,  and  the  germ  not  having  outside  powers 
it  can  call  upon  for  help  is  quickly  destroyed,  and 
the  man  becomes  convalescent.  In  this  proceeding 
the  man's  resisting  powers  have  become  very  great 
at  the  expense  of  other  powers,  as  is  evident  from 
the  fact  that  a  convalescing  man  is  physically  weak. 

REFERENCES. 

1.  Redfield,  Casper  L.  :  Resistance  to  Disease.  New 
York  Medical  Journal,  March  29,  1919;  Origin  of  Im- 
munity, New  York  Medrwl  Journal,  July  12,  1919. 

526  MoNADXocK  Building. 


Study  of  Wound  Healing  in  the  Rat. — Hachiro 
Akaiwa  {Journal  of  Medical  RescarcJi,  September, 
1919)  studied  wounds  of  various  kinds  in  the  skin 
of  the  ears  of  rats,  produced  with  trocars  or  razors. 
A  detailed  description  of  the  results  obtained  is 
given.  Among  the  conclusions  arrived  at  by 
Akaiwa  are  the  following:  The  shallower  the 
wounds,  the  more  rapidly  the  new  epidermis  en- 
larges, which  is  due  to  the  smooth  wound  surface, 
over  which  the  epithelium  moves  with  little  resist- 
ance. The  larger  the  wound  the  more  rapidly  the 
new  epidermis  enlarges,  so  that  larger  wounds  close 
relatively  more  rapidly  than  smaller  ones,  and  shal- 
low wounds  more  quickly  than  deep  ones. 


THE  DOCTOR  AXD  THE  XEUROPATH. 

By  Charles  R.  Ball,  M.  D., 
St.  Paul,  Minn. 

Various  comments  which  my  colleagues  have 
made  with  reference  to  hysterical  and  neurasthenic 
patients,  as  well  as  an  experience  with  a  multitude 
of  such  patients  who  have  gone  the  rounds,  are 
some  of  the  reasons  why  I  have  chosen  this  subject. 
A  remark  not  infrequently  heard  is  something  like 
this :  'T  do  not  know  a  thing  about  nervous  dis- 
eases," and  then  there  is  often  added,  as  if  in  self- 
defense — "And  I  am  rather  glad  of  it." 

If  I  were  a  Freudian,  I  would  be  inclined  to 
consider  such  expressions  on  the  part  of  my  con- 
freres as  svmptomatic  of  past  embarrassing  and  un- 
satisfactory experiences  with  these  patients  which 
they  have  endeavored  to  bury  in  their  unconscious- 
ness but  which  from  time  to  time  tend  to  symbolize 
themselves  in  this  manner. 

This  reaction  of  the  doctor  to  the  type  of  patient 
described  is  not  without  its  justification  from  his 
viewpoint.  In  his  examination  of  them  they  had 
passed  the  acid  test.  Their  temperature,  pulse, 
blood  pressure  and  urine  examinations  were  nor- 
mal. The  bismuth  meal  and  fluoroscope  examina- 
tion showed  that  their  gastrointestinal  tract  was 
performing  normally.  The  absence  of  anything 
definite  or  positive  in  either  their  physical  or  labora- 
tory findings  forced  the  doctor  to  the  conclusion 
that  these  patients,  for  whose  numerous  and  di- 
verse symptoms  he  could  find  no  adequate  or 
tangible  explanation,  which  often  increased  rather 
than  decreased  under  his  ministrations,  were  simply 
victims  of  their  own  imagination  and  that  nothing 
really  ailed  them  anyway.  In  the  end  he  usually 
dismissed  them  with  the  parting  injunction  to  "go 
home  and  forget  it." 

During  my  early  days  of  practice,  the  term  neu- 
ropath was  neither  as  much  in  vogue  or  as  well 
understood  as  it  is  now.  Neurasthenic  and  neuras- 
thenia were  the  expressions  used  in  referring  to  the 
functional  nervous  type  of  patient.  The  rest  cure 
of  Weir  Mitchell  was  then  at  the  height  of  its  popu- 
larity with  the  nerve  specialists  as  a  successful 
means  of  treating  these  cases.  The  neurologist  in 
making  use  of  the  rest  cure  was  carrying  out  a 
logical  method  of  therapy  according  to  the  under- 
standing which  he  had  at  that  time  of  his  patient's 
malady.  The  best  conception  of  neurasthenia  was 
that  of  a  nervous  exhaustion — pure  and  simple.  The 
state  of  mind,  the  attitude  of  the  patient  himself, 
as  an  important  contributing  factor  in  the  causa- 
tion of  his  symptomatology  received  little  or  no  con- 
sideration. 

When  we  reflect  on  this  conception  of  neuras- 
thenia and  the  manner  of  treating  it  by  the  neurolo- 
gist, we  must  admit  that  at  this  time  he  had  little 
to  boast  of  in  his  methods  over  those  of  his  med- 
ical colleagues — the  surgeon  and  the  internist.  The 
improvement  observed  in  so  many  cases  by  patients 
who  had  taken  the  rest  cure  was  also  noted  by  the 
surgeon  after  many  of  his  operations,  testified  to  by 
thousands  who  had  drank  of  the  waters  of  Lourdes, 
gazed  reverently  on  one  of  the  bones  of  St.  Anne, 
experienced  the  laying  on  of  hands  of  magnetic 
healers,  worn  electric  belts  and  undergone  numerous 


576 


BALL:  DOCTOR  AXD  XEUROPATH. 


[New  York 
Medical  Journal. 


Other  both  mystic  and  mysterious  procedures.  Their 
faith,  if  it  had  not  made  them  entirely  whole,  had 
worked  wonders  for  them.  Autosuggestion  and 
heterosuggestion  were  chiefly  responsible  for  their 
improvement. 

The  neurasthenic  has  always  been  a  hete  noir  to 
the  medical  man.  He  can  point  with  pride  to  his 
progress  and  accomplishment  in  almost  all  other 
directions  but  at  the  feet  of  the  neurasthenic  he 
is  compelled  to  acknowledge  his  Waterloo. 

What  may  be  considered  as  a  rational  explana- 
tion of  this  thus  far  baffling  patient?  In  regard  to 
his  etiology,  we  realize  more  clearly  than  former- 
ly that  the  neuropath,  like  the  poet,  is  more  often 
born  than  made.  W^e  see  in  him  an  individual 
with  a  nervous  diathesis,  which  is  inherited  and 
inherent,  just  as  truly  as  the  diathesis  of  the  patient 
of  whom  we  speak  as  being  rheumatic,  hemor- 
rhagic, gouty  or  strumous.  We  also  recognize  that 
the  neuropath  is  closely  akin  in  the  genesis  of  his 
condition  to  a  large  number  of  other  mental  and 
nervous  diseases  also  called  functional  in  origin — 
as  for  example,  migraine,  epilepsy,  dipsomania,  an- 
gioneurotic   edema    and    the    various  psychoses. 

Often  one  of  these  other  conditions,  such  as 
migraine,  is  found  in  the  neuropathic  individual  as  a 
further  proof  of  his  nervous  dyscrasia  and  compli- 
cates his  neurasthenic  symptoms.  The  affections 
which  I  have  just  mentioned  are  regarded  as  both 
physiological  and  psychic  stigmata  of  this  nervous 
diathesis  and  may  be  considered  as  interchangeable 
with  one  another  either  in  the  same  individual  or 
more  especially  some  member  of  his  family.  As  il- 
lustrative of  this,  the  father  of  a  neuropath,  instead 
of  being,  strictly  speaking,  a  neuropath  himself, 
may  have  exhibited  this  predisposition  as  a  dipso- 
maniac. A  neuropathic  mother  may  have  passed  on 
her  nervous  dyscrasia  to  some  one  of  her  offspring 
in  the  form  of  an  epilepsy  and  so  on.  All  these 
types  of  functional  nervous  affections  have  been 
classified  under  one  great  group,  called  the  psycho- 
neuroses.  The  important  thing  which  I  wish  to 
emphasize  in  the  consideration  of  the  neuropath  is 
that  fundamentally  and  physiologically  he  differs 
from  the  normal  individual  and  in  judging  him  in 
a  spirit  of  fairness  and  also  from  the  viewpoint  of 
his  welfare,  his  past  is  just  about  as  pertinent  as 
his  present.  He  has  an  inherited  tendency  to  neu- 
rasthenia and  so  called  neurasthenic  symptoms  which 
the  normal  person  does  not  have,  or  if  he  has,  not  to 
what  may  be  called  the  pathological  degree  of  the 
neuropath.  Such  stigmata  as  he  exhibits,  such  as 
migraine,  irritability  of  the  vasomotor  system,  as 
seen  in  the  rapidity  of  his  heart  beat,  the  coldness 
and  clamininess  of  his  extremities,  together  with 
the  tendency  to  redness  and  cyanosis  of  his  hands 
and  feet,  the  nervous  tremor  when  excited,  as  well 
as  his  attacks  of  angioneurotic  edema  and  other 
manifestations  of  this  nature,  must  be  considered, 
as  physiological.  They'  are  all  symptoms  which 
must  be  attributed  directly  to  the  sympathetic  nerv- 
ous system  which  not  only  furnishes  the  nervous 
mechanism  for  the  regulation  of  the  vasomotor 
system  but  also  supplies  all  of  the  smooth  muscle 
of  the  gastrointestinal  tract  and  the  glandular  struc- 
tures performing  the  secreting  and  excreting  func- 


tions of  the  body  of  which  the  endocrine  system  is 
a  part.  When  a  sympathetic  nervous  system  acts 
so  abnormally  in  its  visible  functions,  is  it  not  rea- 
sonable to  suppose  that  abnonnalities  in  function 
exist  also  in  its  other  activities,  such  as  the  main- 
taining of  normal  contraction  and  tone  in  the  gastro- 
intestinal tract,  as  well  as  the  normal  secretions  of 
the  stomach,  thyroid,  suprarenals,  ovaries  and 
testicles  ? 

In  the  clinical  manifestations  of  our  nervous  pa- 
tients we  are  continually  observing  disturbances  of 
function  of  this  sympathetic  neuroglandular  mech- 
anism, not  only  in  the  vasomotor  system  but  also  in 
all  of  its  other  activities.  Digestion  is  often  dis- 
turbed as  is  evidenced  by  the  furred  tongue,  the 
formation  of  gas  with  its  accompanying  distention 
and  atony,  alteration  in  the  menstrual  function 
in  the  form  of  dysmenorrhea  or  amenorrhea,  hy- 
peractivity of  the  thyroid,  with  persistently  increased 
pulse  rate  and  the  asthenic  state.  Definite  and  posi- 
tive disturbances  of  the  character  just  described  are 
an  integral  part  of  the  symptoms  in  nervous  cases. 

Recently  I  had  an  opportunity  of  observing  in  a 
case  of  vicious  vomiting  during  the  early  months 
of  pregnancy  not  only  the  important  role  which 
the  ovarian  function  plays  in  the  causation  of 
such  symptoms  but  also  the  influence  of  inheri- 
tance on  this  function  as  well.  In  this  case, 
in  addition  to  the  severe  vomiting,  there  was 
evidence  of  what  may  be  called  a  hyper  sub- 
jectivity, an  abnormal  selfconsciousness,  insomnia, 
hysterical  symptoms  as  manifested  by  alternate 
laughing  and  cr\-ing,  periods  of  slight  mental  confu- 
sion, with  incoherence  and  increased  irritability. 
The  patient's  sister  told  me  that  both  she  and  her 
mother  had  had  similar  symptoms  in  the  first  months 
of  their  pregnancies.  The  vomiting  in  this  case 
became  so  severe  that  an  interruption  of  the  preg- 
nancy was  found  necessary.  Inside  of  three  or  four 
days  after  this  had  been  done,  most  of  the  symp- 
toms had  passed  away. 

Another  case  in  point  was  that  of  a  chorea  of 
pregnancy,  chorea  gravidarum,  also  in  a  young 
woman,  at  about  the  seventh  month.  In  this 
patient,  vicious  vomiting  had  been  present  dur- 
ing the  early  months  and  when  the  vomiting 
began  to  subside  the  chorea  made  its  appearance. 
In  this  patient  the  jerking  movements  in  her  face 
and  body  were  something  frightful  to  witness.  At 
the  time  I  saw  her  she  was  unable  either  to  talk  or 
eat  because  of  them.  It  was  thought  best  to  resort 
to  operative  intervention  at  once,  and  so  a  Caesarean 
section  was  performed  by  the  surgeon.  In  spite  of 
this  severe  procedure  the  patient  showed  a  marked 
improvement  inside  of  three  days.  In  a  week's  time 
her  choreic  movements  had  disappeared  altogether. 

Ordinaril}'  we  do  not  have  as  good  an  opportunity 
of  observing  the  influence  of  the  sexual  glands  in 
men  as  we  do  in  women  but  occasionally  cases  are 
encountered  which  show  that  their  influence  here 
is  equally  as  great. 

Case  I. — A  young  man,  aged  twenty-one,  suffered 
a  severe  accident  to  his  testicles,  which  necessitated 
their  removal.  Ten  years  later,  besides  the  physical 
changes  which,  of  course,  were  distinctly  feminine  in 
nature,  he  exhibited  a  decided  love  for  personal 


October  !t.  1920.] 


BALL:  DOCTOR  AND  NEUROPATH. 


S77 


adornment — perfumes,  flowers  and  fruits.  He  had 
spells  of  easily  recognized  periodicity,  in  which  he 
felt  unwell,  complained  of  vertigo,  exhaustion, 
headache,  increased  irritability  and  mental  depres- 
sion. Outside  of  these  regularly  recurring  attacks, 
he  was  shy  and  obsessed  with  different  phobias. 

As  further  evidence  of  the  apparently  endogenous 
and  idiopathic  nature  ofttimes  of  mental  states,  I 
will  report  the  following  cases : 

Case  II. — A  patient  for  many  years  had  suf- 
fered from  severe  attacks  of  migraine  at  "her  men- 
strual periods  which  lasted  for  a  day,  beginning  in 
the  morning  and  terminating  at  night.  After  this 
patient  had  passed  the  menopause,  her  headaches 
stopped  but  seemingly  as  a  transformation  of  these 
headaches,  regularly,  each  month,  she  had  one  day  of 
severe  depression,  during  which  she  walked  the  floor, 
greatly  agitated,  sometimes  wringing  her  hands,  and 
was  possessed  with  distressing  suicidal  impulses. 

I  recall  two  cases,  both  in  women,  the  younger  one 
a  niece  of  the  older,  who  lived  in  distant  parts  of 
the  country  from  each  other.  Neither  one  had  any 
knowledge  of  the  nature  of  the  sickness  of  the 
other.  These  patients  were  both  subject  to  periodi- 
cal attacks  of  depression,  which  seemed  to  run  a  defi- 
nite course  and  in  their  attacks  were  obsessed 
with  the  same  identical  fears. 

I  relate  these  cases  to  show  that  in  any  full  appre- 
ciation of  the  neuropath  and  his  symptoms,  both 
physical  and  psychic,  his  inheritance  plays  a  role  by 
no  means  unimportant  and  is  responsible  for  both 
physiological  and  mental  symptoms  which  are  diffi- 
cult to  attribute  either  to  autosuggestion  or  hetero- 
suggestion  or  even  a  pathological  suggestibility. 

To  regard  this  complicated  neuroglandular  mech- 
anism as  the  endogenous  and  basic  factor  in  all 
those  states  grouped  under  the  heading  of  the  psy- 
choneuroses  off^ers,  to  my  mind,  the  best  working 
hypothesis  for  a  rational  explanation  of  the  multi- 
tudinous phenomena  which  such  cases  exhibit. 

We  must  reflect  that  the  etiological  factor  may 
be  and  usually  is  a  variable  one  in  every  case.  On 
the  one  hand  we  see  cases  where  the  endogenous  fac- 
tors play  the  chief  role,  not  only  as  in  epilepsy  and 
migraine,  but  also  in  the  neurasthenic  and  psychic 
conditions.  We  also  see  cases  where  the  physical 
state,  as  a  result  of  a  severe  infection  or  an  ex- 
hausting illness,  appears  to  be  the  chief  causative 
factor,  with  the  endogenous  and  psychic  influence 
standing  in  the  background.  On  the  other  hand,  we 
see  cases,  and  perhaps  the  majority  of  them,  where 
the  mental  element  occupies  the  centre  of  the  stage 
and  the  endogenous  factors  seem  relatively  unim- 
portant. 

In  tliese  days  when  the  trend  of  medical  opinion 
tends  to  attribute  a  psychogenetic  origin  to  all 
nervous  phenomena  of  a  functional  character,  we 
will  be  wise  if  we  do  not  permit  ourselves  to  lose 
sight  of  the  physical  and  physiological  factors. 

There  is  an  old  saying  which  admonishes  us  to 
pad  the  nerves  with  fat.  We  have  always  ob- 
served the  bad  effect  of  a  loss  in  weight  of  ten 
or  fifteen  pounds  in  the  individual  with  a  nervous 
diathesis.  As  he  loses  his  weight,  pound  by  pound, 
so  also  he  seems  to  lose  his  nervous  equilibrium 
and  vice  versa — as  he  increases  his  weight,  he  ac- 


quires nervous  stability.  Often  a  very  definite  re- 
lationship may  be  established  between  these  two 
things — weight  and  nervous  equilibrium.  As  a  con- 
crete example,  I  wish  to  cite  the  case  of  a  young 
woman,  who,  when  she  weighed  one  hundred  and 
twenty  pounds  had  a  severe  attack  of  migraine  once 
every  two  weeks  and  sometimes  oftener,  but  two 
years  later,  weighing  one  hundred  and  sixty  pounds, 
she  rarely  had  these  attacks,  sometimes  as  long  an 
interval  as  six  months  occurring  between  them. 

Recently  I  had  a  patient,  a  boy,  aged  ten,  ex- 
hibiting typical  neurasthenic  symptoms,  following  a 
slight  attack  of  chorea.  In  this  case,  what  may  be 
termed  the  strain,  the  exciting  cause,  was  insig- 
nificant. No  mental  element  was  discoverable.  The 
patient  had  alternating  bradycardia  and  tachycardia, 
flushing  and  blanching  of  the  skin  of  the  face  and 
nect:,  cold  extremities,  extreme  irritability  when 
tired,  was  easily  exhausted  and  slept  poorly.  Stories 
and  even  pictures  of  an  excitable  nature  agitated  him 
greatly.  The  boy  was  an  adopted  child  and  in  ad- 
dition to  a  bad  nervous  inheritance,  had  one  testicle 
which  was  undescended,  and  the  other  was  small 
and  atrophic.  In  this  case  the  endogenous  factor 
seemed  to  be  the  chief  one,  the  strain,  the  physical 
agent,  as  represented  by  the  chorea,  a  minor  one, 
while  the  influence  of  the  mental  state  was  not  per- 
ceptible. It  seems  to  me  we  are  justified  in  recog- 
nizing, in  such  cases  as  this,  what  may  be  termed  an 
endogenous  neurasthenia  which  no  doubt  is  similar 
in  character  to  those  cases  which  formerly  were 
grouped  under  the  older  term  of  essential  neuras- 
thenia. 

It  is  scarcely  necessary  to  call  attention  to  the 
close  relationship  existing  between  the  cerebrospinal 
and  the  sympathetic  nervous  systems.  We  have  all 
experienced  ourselves  and  also  been  witnesses  of 
this  fact  many  times.  In  some  this  relationship 
seems  more  delicate,  more  responsive,  more  sensi- 
tive than  in  others.  In  some  it  is  much  easier  for 
the  state  of  mind  to  disturb  the  normal  function 
of  the  sympathetic  than  it  is  in  others,  as  evidenced 
by  the  quickened  pulse  rate  to  the  least  excitement, 
the  dryness  of  the  tongue  and  mouth  when  in  a 
state  of  fear.  I  think  all  of  us  can  recall  cases 
of  sudden  cessation  of  the  menses  produced  by 
fright.  I  can  remember  three  cases  of  exophthalmic 
goitre  which  developed  suddenly  while  the  patients 
were  undergoing  intense  excitement.  We  have  re- 
peatedly seen  all  sorts  of  nervous  and  hysterical 
symptoms  developed  in  one  individual  as  the  result 
of  a  sudden  shock,  while  others,  in  the  immediate 
vicinity,  experiencing  the  same  shock,  were  entirely 
unaffected.  This  variation  in  influence  of  the  jctvt- 
brospinal  nervous  system  upon  the  function  of  the 
sympathetic  nervous  system  in  different  people  for 
the  sake  of  illustration,  at  least,  may  be  referred 
to  as  a  difference  in  contact — what  Cannon  has 
termed,  a  difference  in  threshold,  or,  as  it  were,  in 
the  degree  of  insulation  between  these  two  systems. 
This  difference  in  contact,  threshold,  insulation, 
pathological  suggestibility — or  whatever  you  may 
wish  to  call  it — may  be  regarded  as  an  explanation 
for  the  various  reactions  of  different  individuals 
to  their  own  environments.  Why,  for  example,  do 
some,  under  strain,  break  down  and  go  to  pieces 


578 


BALL:  DOCTOR  AND  NEUROPATH. 


[New  York 
Mkdical  Journal. 


easily  while  others  remain  perfectly  iinafifected  and 
indifferent  through  the  most  trying  ordeals. 

When  one  looks  over  the  case  records  of  his  nerv- 
ous patients  and  asks  himself  how  many  of  their 
symptoms  would  still  be  left  if  it  were  possible  to 
suddenly  and  completely  strip  them  of  all  of  their 
fears  and  change  their  mental  content  from  that  of 
worry  and  apprehension  to  that  of  hope  and  con- 
tentment, he  feels  inclined  to  answer — not  many. 
Granting  that  it  could  be  done,  there  is  still  good 
reason  for  thinking  that  it  might  be  compared  to  the 
delousing  process  of  the  soldiers  who  were  going 
back  to  the  trenches  the  next  day.  It  would  soon 
have  to  be  done  all  over  again.  We  hear  a  good 
deal  about  the  psychological  dugouts  to  which  our 
patients  flee  in  a  defensive  reaction  against  their 
environment  but  forget  to  suggest  that  perhaps  these 
dugouts  are  similar  in  nature  to  the  dugouts  some 
one  of  their  forbears  have  been  making  use  of  for 
generations.  While  the  mental  factor  in  most  cases 
is  a  very  important  one  and  often  seems  to  be  the 
chief  one,  it  is  never  entirely  uncomplicated.  The 
predisposing  cause,  the  inherited  and  endogenous 
agencies  always  have  to  be  reckoned  with. 

The  change  in  a  patient's  mental  attitude  may 
occur  as  suddenly  and  make  as  great  a  difference  in 
his  general  condition  as  a  change  in  the  wind  can 
make  in  th^  temperature  of  IMinnesota  when  it  blows 
from  the  north  or  south.  The  change  in  the  direc- 
tion of  the  wind  is,  of  course,  directly  responsible 
for  the  change  of  temperature — from  warm  to  cold 
and  vice  versa,  but  back  of  the  change  in  the  direc- 
tion of  the  wind  other  forces  in  atmospheric  condi- 
tions must  be  taken  into  consideration  which  are  in 
themselves  responsible  for  this  change  in  the  wind's 
direction.  So  also  in  the  nervous  patient,  we  note 
the  marvelous  effect  in  his  symptoms,  either  for 
better  or  worse,  apparently  depending  entirely  on 
the  change  in  his  state  of  mind  and  so  come  to  the 
conclusion  that  the  origin  of  his  trouble  is  wholly 
psychic,  overlooking  endogenous  disturbances  which 
are  in  themselves  responsible  largely  for  this  change, 
like  the  atmospheric  conditions  in  their  relation- 
ship to  the  wind. 

We  have  spoken  frequently  of  the  nervous  symp- 
toms of  this  class  of  patients.  Properly  speaking — 
what  are  some  of  these  symptoms?  I  think  some- 
times there  is  a  tendency  to  enroll  all  symptoms  for 
which  no  satisfactory  explanation  can  be  found  in 
this  category.  The  subjective  nature  of  so  many  of 
such  symptoms  is  probably  responsible  for  this.  It 
would  be  difficult  to  mention  all  of  them,  but  the 
following  are  the  symptoms  most  frequently  en- 
countered in  nervous  cases :  .Headache,  vertigo,  rest- 
lessness, inability  to  concentrate,  insomnia,  loss  of 
ambition,  lack  of  interest  in  environment,  fear  and 
apprehension,  hyperirritability,  feeling  of  exhaus- 
tion, irritable  vasomotor  system,  gas  eructations, 
abdominal  distention  and  atony,  paresthesias,  anes- 
thesias, and  tremors. 

If  we  carefully  investigate  the  nature  of  the  head- 
aches, for  example,  of  which  the  neurasthenic  com- 
plains, we  will  find  that  it  is  no  ordinary  headache, 
in  fact,  strictly  speaking,  it  is  not  a  headache  at  all  in 
the  customary  sense  in  which  this  term  is  used.  It  is  a 
feeling  of  pressure,  a  sensation  as  if  the  head  wqs  in 
a  vise  or  a  steel  band  was  applied  around  it.    If  a 


neurasthenic  patient  who  complains  of  his  head  is 
closely  questioned  concerning  the  nature  of  these 
head  sensations,  it  makes  no  difference  whether  he 
lives  in  St.  Paul  or  Berlin,  he  will  give  much  the 
same  description  of  them,  thus  indicating  that  the 
headache  of  a  nervous  patient  is  characteristic  in 
nature.  The  same  thing  may  be  said  in  regard  to 
all  of  his  other  symptoms.  They  are  remarkably 
similar  in  the  different  patients. 

To  regard  these  sensations,  these  socalled  sub- 
jective symptoms  of  our  nervous  patients,  as  wholly 
imaginative  in  character,  is  only  a  confession  on 
our  part  of  our  lack  of  a  suitable  explanation  for 
them.  In  my  opinion,  these  symptoms  are  to  be 
regarded  as  toxic  in  origin,  caused  by  disturbances 
in  the  metabolism  of  the  body  as  a  result  of  the 
disturbed  functioning  of  the  sympathetic  nervous 
system  and  the  glands  which  it  activates.  It  is  to 
be  remembered  that,  in  so  far  as  the  symptoms 
themselves  are  concerned,  it  makes  little  difference 
whether  this  disturbance  of  function  is  caused  by 
congenital  defects  in,  or  degenerations  produced 
by,  disease  of  the  glands  or  is  due  to  the  ab- 
normal stimulation  on  the  part  of  the  sympathetic 
mechanism,  caused  by  an  agitated  and  disturbed 
mental  state.  It  would  be  more  appropriate,  if  instead 
of  speaking  of  such  symptoms  as  nervous,  with  only 
a  vague  idea  of  what  we  mean  when  we  use  this 
term,  to  speak  of  them  as  toxic  symptoms  of  meta- 
bolic origin. 

In  the  mental  conflict  of  every  neurasthenic  and 
hysterical  patient,  fear  of  some  kind  plays  a  pre- 
dominating role.  It  makes  little  difference  so  far 
as  the  agitation  of  the  patient  is  concerned  whether 
this  fear  is  real  or  imaginary  in  character.  If  one 
is  awakened  in  the  night  by  some  sound  and  at  once 
jumps  to  the  conclusion  that  there  is  a  burglar  in 
his  bedroom  closet,  his  fear  is  going  to  be  just  as 
great  as  if  there  actually  were  one  there.  If  he  lies 
still,  afraid  to  move,  his  fear  increased  by  every 
sound  which  the  stillness  of  the  night  brings  to  his 
overstrained  nerves,  when  morning  comes  and 
the  daylight  shows  that  his  fears  were  groundless 
and  imaginative,  the  exhausting  effect  of  the  strain 
he  has  undergone  during  the  night  will  be  just  as 
real  and  positive  as  if  a  burglar  had  actually  been 
there.  This  illustration  explains  the  situation  of  so 
many  of  our  nervous  patients.  Their  fears  are 
imaginary  but  the  effect  of  these  fears,  because  of 
the  disturbances  which  these  fears  have  caused  in 
the  functioning  of  the  sympathetic  nervous  system, 
are  real  and  positive.  The  disturbance  in  function 
caused  by  the  cerebrospinal  nervous  system  acting 
upon  the  sympathetic  system  produces  changes  in 
the  metabolism  of  the  body  and  these  changes  in 
the  metabolism  create  a  toxemia  which  is  respon- 
sible for  the  nervous  symptoms  of  which  the  patient 
complains. 

We-  see  this  well  illustrated  in  patients  with  trau- 
matic neuroses  and  shell  shock.  In  the  cases  of 
traumatic  neuroses  oftentimes  the  symptoms  do  not 
begin  until  after  the  visit  of  the  claim  agent  or  the 
employment  of  a  lawyer.  They  are  always  worse 
as  the  date  of  the  trial  approaches  caused  by  the  in- 
creased mental  strain  and  when  their  cases  have 
finall}'  been  ended,  either  successfully  or  unsuccess- 
fully, and  the  thing  ceases  to  disturb  their  state  of 


October  16,  1920.] 


II  EHXER:  FAMILY  AND   PERSOXAL  HlSTORi 


579 


mind,  their  symptoms  disappear.  In  the  shell  shock 
cases  the  signing  of  the  armistice  had  the  same  effect 
as  the  termination  of  litigation  has  in  the  cases  of 
traumatic  neurosis — the  symptoms  vanished.  The 
removal  of  the  conditions  which  were  responsible 
for  their  disturbed  mental  state  caused  the  disap- 
pearance of  their  symptoms.  These  two  types  of 
cases  have  given  us  a  much  better  understanding  of 
all  cases  of  a  similar  nature. 

To  treat  such  cases  intelligently,  we  'should  make 
every  efifort  to  ferret  out  the  nature  of  the  strains 
in  the  environment  of  these  patients  and  remove  or 
at  least  adjust  them.  We  have  been  too  much  ac- 
customed to  seek  for  the  causes  of  our  patients' 
complaints  in  exogenous  factors,  such  as  physical 
defects  and  focal  infections.  The  idea  that  these 
symptoms  may  be  due  to  some  terrible  fear,  some 
secret  disappointment,  some  incompatibility  in  their 
environment,  plus  something  endogenous  and  inher- 
ited in  the  patient  himself,  has  not  been  sufficiently 
recognized.  If  we  wish  to  recover  lost  prestige  by 
our  failure  in  the  past  with  these  cases,  we  must 
think  more  broadly  concerning  them  than  in  terms 
of  infections  alone.  To  endeavor,  as  is  often  done, 
to  make  infected  teeth  or  tonsils  or  any  other  in- 
fection as  the  chief  etiological  agent  in  the  causa- 
tion of  a  neurosis,  a  psychosis,  a  migraine,  an 
epilepsy  or  tic  douloureux,  shows  a  woeful  miscon- 
ception of  a  large  and  important  group  of  cases. 
We  laugh  at  the  osteopath  because  he  claims  a  dis- 
located vertebra  pressing  on  a  nerve  as  the  chief 
cause  of  his  patient's  symptomatology.  \\"e  have 
equally  as  much  reason  for  laughter  at  the  medical 
man  who  removes  tonsils  or  does  a  circunision  for 
the  cure  of  epilepsy,  who  extracts  teeth  to  cure  a  tic 
douloureux,  who  removes  a  nasal  spur  for  the  relief 
of  migraine  or  performs  a  central  fixation  to  cure 
a  neurosis  or  psychosis. 

In  order  to  have  the  proper  conception  of  the 
etiology  of  these  cases  which  are  grouped  under 
the  general  term  of  psychoneuroses  and  to  which  the 
neuropath  belongs,  two  factors  must  be  carefully 
considered,  the  inherited  and  endogenous  on  the 
one  hand,  as  obtained  in  the  family  and  personal 
history  of  the  patient  and  the  exciting,  on  the  other, 
as  revealed  in  the  various  strains  which  it  is  possible 
to  discover  in  his  environment,  not  forgetting  that 
sometimes  the  predisposing,  sometimes  the  exciting 
cause  is  to  be  ascribed  the  predominating  role.  In 
the  light  of  this  conception  of  the  neuropath,  what 
can  be  done  to  benefit  him  ?  First,  we  must  estimate, 
as  carefully  as  possible,  the  weight  of  his  inherited 
burden,  then  do  our  best  to  seek  out  the  nature  of 
the  strains  not  only  physical  but  also  psychic,  pro- 
duced by  the  fears,  the  incompatibilities  and  obsta- 
cles which  exist  in  his  environment  and  which  are 
causing  his  two  nervous  systems  to  make  contact,  to 
short  circuit  as  it  were,  and  if  it  is  not  possible  to 
remove  these  strains,  entirely,  endeavor  to  adjust 
them  so  that  he  will  be  the  better  able  to  endure  them. 

If  we  strive  to  manage  our  nervous  cases  in  this 
manner,  we  will  very  soon  realize  as  a  result  of  our 
success  that  dope  and  electricity,  as  well  as  focal  in- 
fections, in  the  treatment  of  such  cases  are  not  the 
ultima  Thulc  and  be  led  to  exclaim  with  Hamlet : 
"There  are  more  things  in  heaven  and  earth,  Horatio, 
than  are  dreamt  of  in  your  philosophy." 


IMPAIRMENTS  REGARDING  FAMILY  AND 
PERSONAL  HISTORY.* 
TJicir  Expected  Mortality. 

By  William  H.  E.  Wehxer.  M.  D., 
Philadelphia. 

Medical  Director  of  the  Fidelity  Mutual  Life  Insurance  Company. 

Insurance  has  been  defined  as  "the  institution 
which  eliminates  risk  or  which  substitutes  cer- 
tainty for  uncertainty."  (1)  It  is  unquestionably 
true  that  "the  occurrence  of  events  insured  against 
cannot  wholly  be  prevented"  (1),  but  experience 
has  demonstrated  "that  the  uncertainty  of  financial 
loss  through  such  occurrences  can  be  eliminated  by 
distributing  the  loss  over  a  group"  ( 1 ) .  Therefore, 
"when  a  large  number  of  people  contribute  to  a 
common  fund  from  which  any  individual  con- 
tributor will  receive  a  certain  financial  return  at 
the  expiration  of  a  given  time"  (1),  or  his  estate 
or  beneficiary  be  recompensed  financially  in  case  of 
his  premature  decease,  "the  onl)-  certain  loss  sus- 
tained will  be  his  personal  contribution  or  the 
premium  charged,  and  the  sum  paid  to  his  estate  or 
to  his  beneficiary  is  apportioned  from  the  contri- 
butions of  each  member  in  the  group''  (1).  Hence, 
it  has  been  well  said.  ''Insurance  is  the  elimination 
of  uncertainty  or  the  replacement  of  uncertainty 
by  certainty."  With  morbidity  to  a  great  or  less 
degree  always  near,  prudence  demands  protection  to 
dependents,  and  aft'ection  for  those  we  love  insists 
that  such  protection  be  commensurate  with  present 
income,  in  case  of  accidental  or  premature  death. 
A  protecting  power  or  return  of  such  a  nature 
should  not  partake  of  a  gamble.  When  honestly 
and  conservatively  conducted  modern  assurance 
protection  is  the  safest  instittition  in  existence. 

Any  estimate  as  to  how  long  a  given  individual 
will  live  is  the  most  uncertain  problem  known,  but 
a  general  mortality  rate  based  upon  the  lives  of  a 
great  number  of  individuals  can  by  competent 
actuarial  means  be  quite  accurately  determined  and 
a  safe,  workable  forecast  of  future  terminations 
be  as  closeh"  ascertained.  Babbage  states,  "Few 
things  are  less  subject  to  fluctuation  than  the  dura- 
tion of  life  in  a  multitude  of  individuals."  (2) 

The  laws  of  probability  indicate  that  like  the  law 
of  chance,  there  must  be  a  law  governing  mortal- 
ity. \\'hat  cause  or  causes  operate  in  determining 
that  from  the  dates  of  birth  of  a  large  number  of 
people,  a  definite  number  will  die  each  year  until 
all  have  died,  no  one  knows.  Hence,  our  inability 
to  gauge  the  actual  force  of  mortality.  Nothwith- 
standing  this  lack  of  knowledge,  however,  human 
ingenuity  has,  "by  studying  the  records  and  death 
rates  or  rate  of  death  in  many  groups  of  individ- 
uals and  carefully  investigating  all  collateral  cir- 
cumstances" (3)  which  in  the  minds  of  numerous 
investigators  "have  probably  affected  that  rate, 
found  it  feasible  to  surround  any  future  group  of 
individuals  with  what  would  be  approximately  the 
same  condition  and  problems  and  so  anticipate 
closely  the  same  rate  of  mortality."  (3)  To  come 
thus  closely  to  a  sound,  workable  system  of  estimat- 
ing the  future  rate  of  death  of  a  large  group,  shows 

*  Read  before  the  Philadelphia  Medical  Examiners'  Association, 
February  11,  1920. 


IVEHNER:  FAMILY  AND   PERSONAL  HISTORY. 


[New  York 
Medical  Journal. 


the  value  of  accurate  mortality  statistics,  and  how, 
without  such  excellent  tables  at  hand,  certainty 
would  again  give  way  to  uncertainty,  and  a  prac- 
tical accuracy  degenerate  into  primitive  chaos. 

Accurate  and  original  data  in  all  mortality  statis- 
tics are  of  the  greatest  importance.  "The  two  sources 
from  which  the  best  known  mortality  tables  in  ex- 
istence today  have  been  obtained  are,  first :  Popu- 
lation statistics  from  census  enumerations  with 
mortality  records  from  registration  centres  and, 
second,  the  mortality  statistics  of  insured  lives.  (4) 
It  is  thought  to  be  questionable  whether  the  statis- 
tics of  a  general  population  can  be  used  in  deter- 
mining the  accurate  mortality  of  insured  lives. 
They  represent  the  average  death  rate  of  a  popula- 
tion group  and  so  approximate  the  "true  law  of 
general  mortality,"  but  an  insurance  company 
wants  to  know  more  particularly  as  to  the  mortal- 
ity occurring  among  selected  lives,  for  such  lives 
are  subject  to  factors  that  may  influence  the  death 
rate  considerably,  and  of  necessity  have  to  be  care- 
fully considered. 

It  is  true  "the  mortality  tables  based  on  popula- 
tion statistics  formed  the  first  scientific  basis  for 
insurance  rates,  but  as  their  approximation  to  true 
insurance  mortality  was  not  close,  they  were  sup- 
planted by  tables  based  on  insured  or  selected  lives 
as  soon  as  a  sufficiently  large  experience  on  selected 
lives  was  attained.  The  present  tables  used  by 
American  life  insurance  companies  and  required  by 
most  state  insurance  departments  as  a  basis  for 
the  valuation  of  policy  liabilities  have  been  built 
from  data  of  insured  lives.  Such  a  mortality  table 
has  been  described  as  'the  picture  of  a  generation 
of  individuals  passing  through  time.'  (5)  Taking 
a  group  of  persons  entering  at  a  certain  age,,  it 
traces  and  notes  the  history  of  the  entire  group, 
year  by  year,  until  all  have  died.  The  essential 
features  of  such  a  table  are  the  two  columns  of 
the  number  living  and  the  number  dying  at 
designated  ages.  Such  is  the  American  experience 
table  which  is  widely  used  by  the  old  line  com- 
panies in  the  United  States,  particularly  for  the 
computation  of  premium  rates.  It  is  assumed  that 
a  group  of  one  hundred  thousand  persons  come 
under  observation  at  exactly  the  same  moment  as 
they  enter  the  tenth  year  of  life.  Of  this  group 
749  die  during  the  year,  leaving  99,251  to  begin  the 
eleventh  year.  The  table  proceeds  in  this  manner 
to  record  the  number  of  the  original  one  hundred 
thousand  dying  during  each  year  of  life  and  the 
number  living  at  the  beginning  of  each  succeeding 
year  until  but  three  persons  of  the  original  group 
are  found  to  enter  upon  the  ninety-fifth  year  of 
life,  these  three  dying  during  that  year.  This  table 
represents  the  mortality  data  in  their  final  form  for 
use  in  expressing  the  probabilities  of  death  and  of 
survival.  It  is  manifestly  impossible  for  any  in- 
surance company  to  insure  a  group  of  one  hundred 
thousand  persons  at  exactly  the  same  age  and  at 
exactly  the  same  time,  and  it  is  equally  impossible 
to  keep  any  such  group  under  observation  until  all 
have  died.  Insurance  policies  are  written  at  all 
times  of  the  year  and  on  lives  at  various  ages.  It 
is  entirely  practicable  that  a  record  be  kept  of  all 
insured  lives,  showing  at  each  age  the  number  of 


persons  under  observation,  and  of  those  observed 
for  one  year  at  least,  the  number  who  have  died. 
If  data  are  collected,  therefore,  showing,  first,  the 
ages  at  which  persons  come  under  observation ; 
second,  the  duration  of  the  period  of  observation; 
and  third,  the  number  dying  during  one  year  for 
each  age,  the  material  will  be  furnished  out 
of  which  a  mortality  table  may  be  constructed. 
In  the  United  States  there  is  an  important 
classification 'of  tables  of  three  kinds  dependent  on 
the  data  used  in  their  calculation.  They  are  known 
as  select,  ultimate  and  aggregate  tables.  These 
terms  have  reference  to  the  question  whether  the 
data  used  have  been  afifected  by  medical  selection. 
The  tables  most  used  in  the  United  States  today  by 
insurance  companies  are  three,  i.  e.,  1,  the  Actu- 
aries' or  Seventeen  Offices  table  was  calculated  from 
the  experience  of  seventeen  British  life  insurance 
companies  and  was  introduced  into  the  United  States 
by  Elizar  Wright  as  the  standard  for  the  valuation 
of  policies  in  Massachusetts.  This  table  has  at  the 
present  time  been  largely  supplemented  by,  2,  the 
American  Experience  table,  which  was  published 
in  1868  by  Sheppard  Homans,  and  was  calculated 
from  the  mortality  experience  of  the  Mutual  Life 
Insurance  Company  of  New  York.  3.  The  Na- 
tional Fraternal  Congress  table  was  derived  from 
the  experience  of  two  American  fraternal  orders, 
and  was  first  published  in  1898."  (6)  Once  a 
satisfactory  mortality  table  has  been  built,  it  is  but 
logical  sequence  to  adopt  such  a  table,  until  a  bet- 
ter one  has  been  constructed ;  and  "by  applying  the 
laws  of  probability  to  it  the  risk  in  life  insurance  is 
measured  and  closely  approximated."  With  this 
rather  lengthy  resume  as  to  the  foundation  upon 
which  all  successful  life  assurance  institutions  must 
be  built,  let  us  now  consider  an  important  part  of 
both  the  ground  and  superstructure,  medical  se- 
lection. 

The  first  question  presenting  itself  to  the  medical 
director  as  he  scans  the  pen  picture  of  an  applicant 
seeking  insurance  protection,  is,  "Has  this  man  or 
woman,  an  average  chance  of  attaining  his  or  her 
expectancy?"  We  have  seen  that  the  "mean  dura- 
tion of  life,"  or  as  it  is  better  known  in  the  insur- 
ance world,  "the  expectancy  of  life,"  is  formulated 
by  the  use  of  an  approved  mortality  table  to  which 
is  applied  the  law  of  average  or  better,  of  proba- 
bility. The  expectancy  of  life,  therefore,  is  not  how 
long  an  individual  may  live,  but  it  is  or  means  the 
average  number  of  years,  members  of  a  large  group 
of  individuals  of  the  same  age  will  survive. 

Medical  decision  as  to  the  desirability  of  a  risk, 
must  also  be  influenced  by  a  number  of  other  im- 
portant factors,  the  probable  working  of- which  on 
each  individual  applicant  must  be  quickly  and  safe- 
ly determined.  Family  history,  personal  history, 
weight  and  measurements,  occupation,  environment, 
and  last,  but  not  least,  the  habits  and  character  of 
the  person,  and  the  reputation  and  ability  of  the 
medical  examiner  who  has  penned  the  sketch,  and 
the  care  he  has  exercised  in  making  the  report. 
These  would  cover  the  medical  aspects  of  the  case. 
The  issuing  of  a  policy,  however,  is  further  de- 
pendent upon  satisfactory  inspection  and  the  fa- 
vorable scrutinizing  views  of  the  authorities  who 


Octcber  16,  1920.] 


WEHNER:  FAMILY  AND  PERSONAL  HISTORY. 


581 


pass  upon  financial,  business  and  agency  questions. 

Lot  us  now  see  how  the  family  history  of  an 
applicant  influences  medical  selection : — An  ex- 
pressed marked  longevity  in  the  family  history  of  an 
applicant,  particuarly  in  the  parents  and  grand- 
parents, I  believe  to  be  the  strongest  single  factor 
in  estimating  the  desirability  of  any  risk.  The  off- 
spring from  such  a  stock,  have  usually  great  re- 
sisting power.  They  do  not  contract  infections 
readily,  and  if  disease  is  contracted,  they  resist  its 
ravages  longer,  respond  more  readily  to  treatment, 
and  unless  some  idiosyncrasy  is  present,  often  es- 
cape conditions  that  would  be  fatal  to  those  not  so 
blessed. 

Similarity  in  build  to  one's  ancestors  is  also  a  no- 
tably favorable  factor,  particularly  in  plus  weights. 
Where  an  applicant's  parents  live  to  the  age  of  sev- 
enty, or  over,  or  where  their  earlier  decease  resulted 
from  accidental  cause  or  acute  disease,  especially 
if  advanced  age  is  noted  in  the  grandparents,  and 
the  applicant's  brothers  and  sisters  appear  to  be 
healthy,  the  family  history  is  assumed  to  be  first 
class. 

The  Caucasian  race  shows  the  greatest  resisting 
powers  as  a  rule.  They  certainly  show  the  lowest 
mortality.  The  following  remarks  apply  to  the 
white  race  alone : 

Apoplexy  in  the  family  history,  even  two  or 
more  cases,  if  not  associated  with  other  impairments, 
or  trivial  ones  in  the  applicant,  is  ordinarily  not  of 
serious  import.  However,  with  this  history  a  more 
scrutinizing  selection  would  be  made.  These  appli- 
cants show  a  mortality  rate  actual  to  expected  of 
108  per  cent. 

Cancer  in  the  family  history,  two  or  more  cases, 
is  not  considered  serious.  A  recent  study  of  a 
great  number  of  cases  has  shown  that  the  disease 
is  probably  neither  hereditary,  infectious  nor  con- 
tagious. This  class  shows  a  mortality  rate  actual 
to  expected  of  79  per  cent. 

Epilepsy  in  the  family  history  is  of  no  moment. 
Too  few  could  be  found.  There  were  121  instances 
and  two  deaths. 

Heart  disease  in  the  family  history,  two  or  more 
cases,  shows  a  somewhat  higher  mortality  in  this 
class  of  applicants  and  would  cause  a  more  careful 
selection  to  be  made.  The  mortality  rate  actual  to 
expected  is  113  per  cent. 

Insanity  in  the  family  history,  two  or  more 
cases,  is  usually  of  little  moment,  as  affecting  the 
applicant.  Mortality  of  this  class  is  only  seventy- 
four  per  cent,  of  the  expected. 

Pneumonia  in  the  family  history,  two  or  more 
cases,  would  cause  a  tighter  selection.  This  is  usual- 
ly not  considered  an  important  impairment. 

Tuberculosis  in  the  family  history  profoundly 
and  unfavorably  influences  the  mortality  rate  of  an 
applicant,  particularly  if  he  is  a  light  weight  and 
under  thirty  five  years  of  age. 

An  applicant  under  thirty  should  be  of  average 
weight  and  even  then  a  history  of  associa- 
tion with  a  tuberculous  brother  or  sister  or 
parent,  or  the  fact  that  a  parent  died  of  or  has 
the  disease,  would  occasion  a  most  rigid  medical 
selection.  Changing  from  lower  to  higher  cost  plans, 
as  endowments,  will  not  meet  the  extra  mortality 


in  these  cases.  Only  a  lien  or  rating,  imposed  on 
selected  cases,  will  enable  the  successful  handling  of 
this  class.  Let  me  state  how  tuberculosis  in  an  appli- 
cant's family  history  affects  the  risk.  The  medico- 
actuarial  mortality  investigation  developed  that  the 
normal  death  rate  from  tuberculosis  of  the  lungs  for 
all  heights  and  weights  combined  is  twenty-two 
and  one-half  per  cent,  of  the  deaths  from  all  causes, 
at  ages  of  entry  under  twenty-nine  years,  and  at  ages 
of  entry  thirty  to  forty-four  years,  twelve  per 
cent.  With  this  in  mind  the  following  table  shows 
how  heavily  this  disease  falls  on  light  weights  with 
a  family  history  of  tuberculosis;  (7) 

VARIATION  FROM  AVERAGE  WEIGHT. 

Entry  Age  Entry  Age 

15-29  30-34 

Minus  25  lbs.  to  minus  45  lbs..  51  per  cent.  27  per  cent. 

Minus    5  lbs.  to  minus  20  lbs . .  48  per  cent.  26  per  cent. 

Average  weight  to  plus  20  lbs. .  34  per  cent.  12  per  cent. 

Plus  25  lbs.  to  plus  45  lbs   9  per  cent.  3  per  cent. 

In  judging  the  insurability  of  risks  of  this 
character,  we  would  find  a  fair  average  mortality 
is  obtained  in  subjects  having  a  family  history  of 
tuberculosis  if  we  eliminate  light  weights  under  thirtv 
years  of  age.  I  believe  infancy  and  childhood 
are  preeminently  periods  when  tuberculosis  in- 
fection is  likely  to  occur,  and  that  danger  of  infec- 
tion through  the  digestive  tract  is  nearly  as  great 
as  by  the  respiratory  passages. 

Clinically,  the  ages  from  fourteen  to  forty-five 
may  be  looked  upon  as  a  danger  zone.  At  the 
younger  ages  at  entry  with  an  associated  tubercu- 
lous family  history,  selection  more  particularly 
rests  upon  facts  as  to  past  and  present  development, 
home  and  occupational  environment  and  habits. 

PERSONAL  HISTORY 

Mortality  figures  mentioned  in  any  of  these  im- 
pairment classes  have  been  obtained  by  actual  ex- 
perience of  a  large  number  of  the  old  line  coin- 
panies  who  contributed  their  individual  experiences 
over  a  period  of  twenty- four  years  and  members 
of  the  committee  in  charge  thereof  were  among  the 
most  prominent  medical  directors  and  actuaries  in 
this  country.  The  material  embraced  many  hun- 
dreds of  thousands  of  cases  and  was  furnished  for 
their  study  by  institutions  that  controlled  ninety 
per  cent,  of  the  insurance  in  force  in  the  United 
States. 

The  presence  of  more  than  one  personal  impair- 
ment markedly  influences  any  action  taken  by  the 
luedical  director,  and  is  frequently  the  cause  of 
adverse  action  in  many  instances.  In  some  prospects, 
what  would  appear  as  an  apparently  slight  impair- 
ment would  be  of  marked  suggestive  import  when 
linked  v\^ith  a  defect  of  presumably  little  moment. 
This  should  always  be  borne  in  mind. 

Appendicitis — no  operation. — One  attack  within 
less  than  two  years  of  date  of  application  shows 
a  mortality  of  ninety  per  cent,  of  the  expected.  One 
attack  within  two  to  five  years  from  date  of  appli- 
cation shows  a  mortality  of  103  per  cent,  of  the 
expected.  One  attack  within  five  to  ten  years  of 
date  of  application  shows  a  mortality  of  sixty-eight 
per  cent,  of  -the  expected.  One  attack  without 
operation  would  postpone  the  case  for  a  full  year. 
Two  or  more  attacks  without  operation  would 
postpone  the  case  at  least  three  years,  but  each  case 


582 


U'EHKER:  FAMILY  AND  PERSONAL  HISTORY. 


[New  ^'oaK 
Medical  Journal. 


would  be  judged  on  its  individual  merits  before 
final  action. 

Appendicitis  with  operation. — If  wound  is  closed 
at  operation — no  drainage — we  would  consider  such 
a  case  three  months  after  recovery,  but  would  be 
careful  to  eliminate  any  subsequent  history  of  diges- 
tive disturbances  and  obtain  full  data  from  the 
operating  surgeon.  In  a  pus  case,  wound  not  closed, 
and  drainage  used,  we  would  not  consider  the  risk 
for  a  year  after  recovery.  Here  trouble  from  ad- 
hesions, etc.,  is  feared  as  it  is  vastly  more  likely  to 
occur  than  in  a  clean  case.  In  eighty  per  cent,  of 
drainage  cases,  however,  I  think  it  is  safe  to  assume 
that  if  any  trouble  from  adhesions,  etc.,  is  to  occur, 
it  will  occur  within  one  vear  of  operation  or  not  at 
all. 

Asthma. — Great  care  is  used  in  clearing  up  such 
histories  and  eliminating  emphysematous  conditions 
and  other  causes  or  effects  of  an  organic  nature. 
Mortality  in  these  cases  where  one  attack  has  oc- 
curred within  two  years  of  date  of  examination  is  120 
per  cent,  of  the  expected.  Between  two  and  five  years 
the  expected  mortality  is  less.  Only  the  most  favor- 
able cases  would  be  accepted  and  these  limited  to 
small  amounts  and  plans  going  ofif  the  books 
at  age  of  fifty-five  or  sixty  j'ears  at  the  latest. 
Exceptional  cases  might  be  accepted  for  longer 
plans  if  under  age  of  forty  provided  a  lien  or 
rating  were  imposed.  Statistics  show  that  more  than 
one  attack  within  two  years  of  date  of  application 
gives  a  mortality  experience  of  124  per  cent,  of  the 
expected,  and  after  two  years  mortality  increases  to 
129  per  cent,  of  the  expected. 

Blindness. — Total  blindness  or  eyesight  which  is 
poor  and  progressively  growing  worse  makes  a  case 
uninsurable  on  any  plan.  Only  in  exceptional  cases 
of  long  standing  where  a  constant  care  taker  is 
employed  and  unusually  favorable  environmental 
conditions  present  would  we  insure,  and  even  then 
only  a  small  amount  on  a  heavy  rated  endowment 
plan  would  be  rarely  considered.  Blindness  in  one 
eye,  from  traumatism  where  light  perception  exists 
and  is  not  growing  less,  the  other  eye  being  sound, 
would  not  be  a  bar  to  insurance  if  disability  bene- 
fits were  excluded. 

Bladder. — Cystitis  of  short  duration — in  young 
persons  is  usually  of  little  moment.  i\fter  forty, 
however,  it  may  be  a  manifestation  of  organic  dis- 
ease. All  cases  of  prostatitis,  stone,  papilloma,  etc., 
are  carefully  inquired  into,  family  physician's  blank 
obtained  and  careful  chemical  and  microscopical  ex- 
amination of  one  or  more  specimens  made  at  home 
office  before  deciding  as  to  insurability. 

Blood  spitting. — Is  alwa3s  an  impairment  of  the 
greatest  importance,  and  may  be  a  symptom  of 
tuberculosis,  ulcer  of  the  stomach,  or  cirrhosis  of 
the  liver.  Such  a  history  usually  postpones 
for  ten  years  or  declines  a  risk.  History  of  one 
attack  without  distinct  symptoms  of  tuberculosis 
of  the  lungs  occurring  less  than  five  years  prior  to 
date  of  application  gives  a  mortality  actual  to  ex- 
pected of  151  per  cent.  One  attaqk,  five  to  ten 
years  prior  to  date  of  application  131  per  cent,  and 
one  or  more  attacks,  more  than  ten  years  prior  to  date 
of  application  102  per  cent,  of  the  expected.  Other 
factors  being  favorable  such  cases  may  be  con- 


sidered on  selected  plans  only  after  that  period  of 
time  has  elapsed. 

Change  of  life. — Unless  first  class  in  all  other 
particulars,  women  at  the  climacteric  should  be 
postponed  until  the  change  has  been  successfully 
accomplished,  particularly  if  a  family  or  personal 
neurotic  history  exists. 

Deafness. — If  total  or  marked  and  increasing  the 
applicant  is  a  poor  risk  on  account  of  the  extra 
hazard  from  accident.  Deaf  mutes  if  of  matured 
age,  however,  might  be  considered,  all  else  being 
equal,  on  rated  endowment  without  disability.  Partial 
deafness  in  one  or  both  ears,  if  ordinary  conversation 
can  be  easily  heard  and  a  watch's  tick  recognized 
when  not  in  contact  with  the  skull,  would  not 
ordinarily  prevent  insurance  with  disability  bene- 
fits. 

Ear  disease. — A  history  of  otitis  media  or  dis- 
charge, if  recovered  from,  does  not  render  a  case 
uninsurable.  Recurrence  or  continuation  of  dis- 
charge, if  not  purulent,  ofifensive  and  gritty  with 
the  absence  of  evidence  of  mastoid  disease  or  bony 
involvement  and  a  sufficiently  large  perforation  in 
drum,  so  situated  that  drainage  could  take  place 
readily  if  discharge  recurred,  would  permit  of  insur- 
ance, perhaps  with  a  lien  or  rating,  rarely  without. 
If  repeated  attacks  occur  we  would  obtain  an  aurist's 
opinion.  Any  present  ear  trouble  with  persisting 
discharge  would  postpone  or  decline  such  a  case. 
After  a  mastoiditis  we  would  insure  upon  full  re- 
covery. 

Epilepsy. — Such  cases  cannot  be  safely  insured 
on  any  plan.  A  history  of  one  or  two  convulsions 
in  early  childhood  with  no  after  occurrence  is  usu- 
ally of  no  moment. 

Diabetes. — True  cases  of  diabetes  mellitus  are 
not  insurable  on  any  plan. 

Duodenal  ulcer. — If  diagnosis  is  unquestionably 
correct,  particularly  if  confirmed  by  operative  pro- 
cedure,' these  cases  are  insurable  two  years  after 
full  recovery,  for  moderate  amounts  on  endow- 
ment plans,  providing  no  digestive  disturbances 
have  occurred  since  recovery. 

Fever. — Typhoid  fever  cases  are  taken  six 
months  after  full  recovery.  Complete  restoration 
of  health  and  regaining  of  weight  might  enable 
favorable  consideration  two  or  three  months  earlier 
in  rare  instances.  Cases  with  history  of  malaria 
are  postponed  until  three  months  after  full  recov- 
ery. An  applicant  who  has  had  malarial  hematuria 
or  lives  in  a  locality  where  pernicious  malarial 
types  abound  is  ordinarily  uninsurable. 

Anal  fistula. — With  or  without  operation,  one  at- 
tack, less  than  two  years  of  date  of  application 
shows  a  mortality  of  120  per  cent,  of  the  expected. 
One  attack  within  two  to  five  years  of  application 
136  per  cent,  of  the  expected  and  one  attack  after 
five  years  of  the  date  of  application  100  per  cent,  of 
the  expected.  If  tuberculous  cause  can  be  elimi- 
nated and  successful  operation  has  been  done  we 
would  insure,  unless  applicant  was  a  light  weight 
with  doubtful  family  or  personal  history.  In  plus 
weights  the  history  of  anal  fistula  is  of  compara- 
tively little  moment. 

Gout. — Under  forty  it  is  an  exception  to  receive 
cases  where  such  a  history  is  confirmed.  We  would 


October  lb,  1920.] 


WERNER:   EAMILY  AND   PERSONAL  HISTORY. 


583 


always  investigate  carefully  and  call  for  all  avail- 
able data.  After  forty  or  in  any  case  if  we  believe 
true  gout  to  have  been  present,  we  would  decline  to 
consider.  One  attack  of  true  gout  within  five  years 
or  less,  of  date  of  examination,  shows  a  mortality 
of  190  per  cent,  of  the  expected.  One  attack 
of  true  gout  within  from  five  to  ten  years 
of  date  of  examination  shows  a  mortality  of  172 
per  cent,  of  the  expected. 

Gravel,  renal  colic,  stone  in  kidney,  renal  calcu- 
lus.— One  attack  with  stone  passed,  negative  chem- 
ical and  microscopical  home  office  specimen  and 
the  x  ray  negative  would  make  such  a  case  insur- 
able after  two  full  years  have  elapsed.  Repeated 
attacks  would  decline. 

Gonorrhea. — Postpones  a  case  until  full  recov- 
ery, then  we  would  consider  on  satisfactory  home 
office  specimen  and  no  evidence  of  sequelae. 

Goitre. — Simple  cystic  goitre  without  evidence  of 
pressure  and  nervous  symptoms  can  be  taken  on 
endowment  plans  for  limited  amounts.  Cases  are 
always  carefully  selected  and  full  history  developed. 
Any  suspicion  of  an  exophthalmic  nature  or  opera- 
tion for  suspected  Graves's  disease,  would  render 
the  case  uninsurable. 

Enlargement  of  glands. — If  not  due  to  tubercu- 
losis, syphilis  or  other  serious  disease,  glandular  en- 
largements are  of  little  moment.  Obtain  family 
physician's  blank  and  eliminate  all  tuberculosis  sus- 
picions before  considering.  Glandular  enlarge- 
ments of  the  neck  are  always  looked  upon  doubt- 
fully and  these  cases  rarely  taken. 

Disease  of  gallbladder. — One  attack  of  catarrhal 
jaundice  with  family  physician's  blank  .showing  same 
to  have  been  unaccompanied  with  colic  or  other  evi- 
dence of  cholecystitis  and  with  no  subsequent  his- 
tory of  digestive  disturbances  would  not  prevent 
insurance.  Ca.ses  of  cholelithiasis  (gallstones), 
however,  are  not  insurable  until  five  years  have 
elapsed  since  recovery  from  attack  with  no  diges- 
tive di.sturbances  in  the  interim.  Two  or  more  at- 
tacks would  decline. 

Gallstone  with  operation. — Gallbladder  removed 
or  not :  Selected  cases  are  insurable  for  .small 
amounts  on  endowment  plans  after  two  or  three 
years,  if  no  digestive  disturbances  have  been  in  evi- 
dence and  other  factors  are  first  class. 

Gastric  ulcer. — Cases  with  history  of  true  gastric 
ulcer,  whether  a  gastroenterostomy  has  been  per- 
formed or  not,  are  not  insurable  upon  any  plan. 

Hip  disease. — Renders  a  case  uninsurable. 

Heart  disease. — Valvular  disease,  myocarditis, 
cardiac  dilatation  or  hypertrophy  render  a  case  un- 
insurable. A  history  of  valvular  disease  due  to 
inflammatory  rheumatism  is  particularly  of  serious 
import.  An  irregular  or  intermittent  heart  usually 
postpones  or  rejects.  If  cause  can  be  deter- 
mined— i.  e.,  coffee,  tea  or  tobacco,  and  is  distinctly 
not  of  organic  nature,  we  might  in  a  young  prospect 
.issue  a  rated  or  liened  policy.  A  pulse  under  fifty- 
five  is  frequently  of  serious  import,  and  a  pulse  per- 
sistently over  ninety  would  be  postponed  or  de- 
clined. Only  where  of  long  standing  in  one  under 
forty  and  where  an  idiosyncrasy  can  be  satisfac- 
torily established,  would  the  issuing  of  a  modified 
policy  be  favorably  considered. 


Insanity. — In  an  applicant's  history  renders  a 
case  uninsurable. 

Laryngitis. — Cases  running  an  acute  course  and 
not  of  long  duration  are  not  of  much  moment.  Long 
continued  cases,  chronic  forms,  however,  are  fre- 
quently due  to  growths,  tuberculosis  of  chronic 
thickening  of  the  vocal  cords  of  uncertain  cause 
and  are  not  desirable  risks. 

Neurasthenia. — The  types  assumed  are  legion. 
Such  histories  are  always  carefully  investigated  and 
family  physician's  blanks  with  full  data  as  to  date, 
symptoms  present,  duration  and  treatment  ob- 
tained. Each  case  is  judged  individually  and  most 
careful  selection  made  in  every  instance. 

Ovarian  disease. — If  of  functional  nature  only 
at  menstrual  periods,  all  else  being  equal,  each  case 
is  carefully  considered  individually  after  obtain- 
ing complete  data  and  family  physician's  blank. 
Operative  procedure  in  such  cases  necessitates  care- 
ful study,  attending  physician's  and  surgeon's  opin- 
ions. Satisfactory  findings  do  not  prevent  the  issu- 
ance of  endowment  policy  for  small  amount  with 
or  without  a  lien  or  rating. 

Paralysis. — If  due  to  central  cerebral  lesions  de- 
clines a  case.  Peripheral  forms  such  as  Bell's  palsy, 
wrist  drop,  scrivener's  palsy  or  the  sequelae  of  ante- 
rior poliomyelitis,  if  not  extreme,  render  a  case  in- 
surable on  selected  plans.-  Mortality  rate  in  these 
latter  cases  is  105  per  cent,  of  the  expected. 

Pleurisy. — One  attack  of  dry  pleurisy  of  less 
than  ten  days'  duration  we  do  not  hesitate  to  ac- 
cept. Cases  with  effusion  are  studied  carefully  and 
full  details  with  physician's  blank  obtained.  We 
would  hesitate  to  take  a  case  of  serious  effusion  at 
any  time,  particularly  in  a  lightweight  or  where  it 
is  thought  a  family  or  probably  personal  tubercu- 
lous factor  is  present.  Cases  accompanying  pneu- 
monia where  good  laudable  pus  has  been  found  and 
evacuated  and  recovery  has  been  prompt,  would  be 
considered  favorably  after  six  months  from  date 
of  recovery,  all  else  being  equal. 

Pneumonia. — If  fully  recovered  from,  weight 
regained  and  no  sequehe  present,  are  insurable  after 
six  months. 

Prostate  gland. — With  such  a  history  the  risk  is 
declined  after  forty-five.  In  young  .subjects,  a 
physician's  statement  is  secured  with  complete  de- 
tails and  one  or  more  specimens  sent  to  the  home 
office,  before  decision  is  given. 

Articular  rheumatism. — One  attack  less  than  two 
years  of  date  of  examination  shows  a  mortality  of 
120  per  cent,  of  the  expected.  One  attack  more 
than  five  years  since  date  of  examination  shows 
mortality  ratio  of  109  per  cent,  of  the  expected. 
More  than  one  attack  less  than  two  years  of  date 
of  application,  123  per  cent,  of  the  expected.  One 
attack  two  to  five  years  from  date  of  application 
109  per  cent,  of  the  expected.  Careful  selection  is 
always  made  in  these  cases  and  heart  critically  ex- 
amined before  decision.  The  muscular  forms  of 
rheumatism  are  usually  of  no  great  moment.  True 
rheumatoid  arthritis  declines  such  an  applicant. 

Rupture. — A  complete  or  incomplete  hernia,  if 
easily  reduced  and  a  properly  fitting  truss  worn 
would  render  a  case  insurable.  If  no  truss  is  worn 
a  lien  or  rating  would  be  imposed. 


584 


EPSTEIN:  THERAPEUTIC  VALUE  OF  CUPPING. 


[New  York 
Medical  Journal. 


Urethral  stricture. — Each  case  is  individually 
considered  as  to  calibre  of  the  urethra,  complica- 
tions, whether  full  stream  can  be  easily  passed, 
duration,  etc.,  with  chemical  and  microscopical  ex- 
amination of  specimen  at  head  office.  IDoubtful 
cases  are  usually  declined.  History  of  esophageal 
stricture  declines. 

Syphilis. — Syphilis  has  the  distinction  of  being 
an  impairment  where  the  remoteness  of  the  original 
infection  adds  increasing  hazard  to  the  undesira- 
bility  of  the  prospect.  Under  the  most  favorable 
conditions  the  mortality  ratio  in  these  cases,  whether 
treated  or  untreated,  remote  or  recent,  is  138  per 
cent,  of  the  expected.  I  do  not  believe  any  com- 
pany can  afford  to  absorb  even  a  preferred  case  of 
syphilis,  even  where  medical  procedure  has  been 
followed,  no  matter  how  thoroughly,  on  any  life 
plan  at  ordinary  rates.  This  particularly  applies  to 
the  ages  of  thirty-five  and  over.  At  younger  ages, 
other  factors  being  desirable,  and  if  no  history  of 
secondary  or  tertiary  symptoms  has  been  discov- 
ered, we  might,  upon  satisfactory  negative  Wasser- 
mann  blood  tests,  issue  a  short  rated  endowment. 
These  plans  must  mature  not  later  than  fifty  or 
fifty-five  years  of  age,  and  no  disability  would  be 
granted. 

Tumors. — Such  histories  are  always  cjuestion- 
able.  Simple  cyst  or  fatty  tumors  if  favorably 
situated  and  not  extensive  do  not  afifect  insurability. 
Epithelioma  (notwithstanding  its  benign  nature  in 
many  instances),  cancer,  sarcomata  and  syphilitic 
gummata,  etc.,  always  decline  an  applicant. 

Vertigo. — Such  history  unless  unquestionably 
due  to  digestive  indiscretions,  refractive  troubles 
of  the  eye,  or  idiosyncrasy  such  as  sight  of  blood, 
etc.,  and  of  immaterial  nature,  we  would  not  con- 
sider insurable.  Vertigo  is  frequently  due  to  or- 
ganic disease  of  the  brain,  serious  ear  trouble  and 
epilepsy. 

Tuberculosis  of  the  lungs. — If  tubercle  bacilli 
have  ever  been  demonstrated  we  would  decline  no 
matter  how  remote  the  seizure  or  apparently  per- 
fect the  cure.  Tuberculosis  of  the  glands  including 
scrofulous  glands  of  the  neck,  one  attack  less  than 
ten  years  of  date  of  application  gives  a  mortality 
actual  to  expected  of  178  per  cent.  One  attack 
more  than  ten  years  of  date  of  application  113  per 
cent.  Tuberculosis  of  bones,  hip,  spine  and  joints, 
one  attack  less  than  ten  years  of  date  of  application 
gives  a  mortality  of  190  per  cent,  of  the  expected. 
One  attack  more  than  ten  years  of  date  of  applica- 
tion gives  a  mortality  of  120  per  cent,  of  the  ex- 
pected. Only  exceptional  cases  with  such  histories 
might  be  considered  after  ten  years  had  elapsed  on 
rated  endowment  plans. 

At  the  present  time  I  purposely  have  not  referred 
to  a  series  of  important  impairments  which  daily 
cause  anxiety  and  worry  to  the  medical  departments 
of  all  insuring  companies.  I  refer  to  the  chemical 
and  microscopical  findings  of  urine,  to  blood  pres- 
sure readings  and  to  specific  data  as  to  the  build  of 
an  applicant,  i.  e.,  a  decided  departure  from  aver- 
age weight.  These  impairments  would  necessitate 
time  and  space  not  contemplated  in  the  scope  of 
this  paper  and  have  been  reserved  for  a  more  op- 


portune time.  Suffice  it  to  say,  each  of  these  factors 
has  a  most  decided  bearing  on  conservative  selec- 
tion: each  must  be  considered  specifically  and  at 
the  same' time  weighed  as  a  part  of  the  whole;  each 
must  be  studied  individually  and  all  favorable  oflf- 
sets  considered ;  each  must  be  measured  by  the 
medical  director's  experience  tempered  by  the 
known  actuarial  and  statistical  findings  of  its  class. 

REFERENCES. 

1.  Bruce,  D.  M.  :  Science  of  Life  Insurance,  p.  119. 

2.  HuEBNER,  SoLOMox  S. :  Life  Insurance,  pp.  10.  12,  119, 
and  134. 

B.ABBAGE :  Quoted  by  A.  Newsholme,  J'ital  Statistics, 
Third  Edition,  p.  290. 

3.  Bruce,  D.  M.  :  Science  of  Life  Insurance,  p.  134. 

4.  Idem  :  Ibid,  p.  130. 

5.  Newsholme,  A. :  Vital  Statistics,  Third  Ed.,  p.  255. 

6.  Bruce,  D.  M.  :  Science  of  Life  Insurance,  p.  134. 

7.  Medicoactuarial  Mortality  Investigation,  vol.  v,  p.  11. 

329  WiSTER  Street. 


THE  THERAPEUTIC  VALUE  OF  CUPPING. 
Its  Use  and  Abuse. 
By  J.  Epstein,  M.  D., 

New  York. 

In  the  healing  art  advantage  is  taken  of  every 
therapeutic  means.  To  cure  or  alleviate  the  ills  of 
mankind  pharmacotherapy  is  most  frequently  used, 
and  when  prescribed  in  the  right  case  and  in  the 
right  way  will  always  do  much  good.  A  lack  of 
knowledge  of  the  science  of  pharmacology  and  the 
art  of  therapy  has  created  therapeutic  pessimists, 
who  timidly  use  one  or  two  drugs  in  the  treatment 
of  disease,  and  therapeutic  polypharmacists,  whose 
prescriptions  are  a  conglomeration  of  too  many 
drugs. 

In  addition  to  drug  therapy,  mechanical,  thermal, 
chemical,  electrical,  psychic  and  hydrotherapy  are 
occasionally  used  yith  good  results.  The  improper 
or  indiscriminate  use  of  any  of  them  does  harm  to 
the  patient,  to  the  value  of  the  remedy  itself  and  to 
the  physician.  One  of  the  most  popular  mechanical 
therapeutic  agents  is  dry  cupping.  This  is  a  remedy 
of  great  antiquity  and  it  is  used  by  many  people  in 
many  lands.  It  belongs  to  that  groujj  of  therapeu- 
tic substances  known  as  counterirritants,  which, 
when  applied  to  the  surface  of  the  body,  will,  by 
their  own  irritating  action,  relieve  irriLation  of  the 
underlying  deeper  structures  or  organs. 

The  entire  theory  on  which  the  physiological  ac- 
tion of  counterirritation  is  based  is  indefinite  and 
uncertain.  In  the  earlier  days  of  medicine,  when 
humoral  pathology  dominated  medical  thought, 
counterirritants  were  supposed  to  draw  the  diseased 
humors  from  the  deeper  organs  to  the  suiface  of 
the  body.  With  the  advance  of  medical  knowledge 
the  therapeutics  of  counterirritation  and  cupping 
were  based  on  the  theory  that  irritation  or  suction 
of  the  skin  produced  a  local  hyperemia,  bringing 
more  blood  to  the  surface  and  thereby  relieving 
congestion  of  diseased  internal  organs.  It  was  also 
thought  that  surface  irritation  caused  reflex  action 
resulting  in  favorable  circulatory  or  trophic  changes 
in  the  underlying  organs.    The  work  of  Head  and 


October  16.  1920.] 


HOROVITZ:   BIOCHEMISTRY   Of  DRUG  ADDICTION. 


585 


Mackenzie  on  surface  localization  in  visceral  dis- 
eases has  thrown  much  light  on  the  subject  of  coun- 
terirritation.  According  to  these  observers,  every 
diseased  internal  organ,  through  its  nerve  supply 
causes  an  area  of  hypersensitiveness  in  a  certain 
segment  of  the  spinal  cord.  Within  this  hyper- 
sensitive spinal  area  there  are  nerves  which  pro- 
ject to  the  periphery  to  supply  definite  areas  or 
zones  of  muscle  and  skin.  Through  the  proximity 
of  certain  sensory,  visceral  and  skeletal  nerves  in  the 
spinal  cord,  disease  or  irritation  of  an  internal  organ 
causes  an  area  of  pain,  tenderness  or  hypersensitive- 
ness in  a  corresponding  definite  area  or  zone  on 
the  surface  of  the  body.  It  is  therefore  evident 
that  since  visceral  irritation  affects  a  definite  area  on 
the  skin,  a  counterirritant  applied  to  that  surface 
area  will  afifect  the  corresponding  internal  organ. 

The  humoral  theory  is  mentioned  here  for  his- 
torical reasons  only.  To  assume  that  the 
therapeutic  value  of  cupping  is  due  to  the 
removal  of  blood  from  the  internal  organs 
to  the  surface  of  the  body  is  erroneous.  The  entire 
quantity  of  blood  held  in  the  hyperemic  circular 
spots  produced  by  the  cups  on  any  area  of  the  body 
is  insignificant  when  compared  with  the  quantity  of 
blood  which  is  circulating  within  the  body.  To 
produce  sufficient  peripheral  vasodilatation  as  to 
bring  more  blood  to  the  surface  and  less  to  the 
internal  organs  quite  other  therapeutic  means  are 
necessary.  A  warm  bath  or  a  mustard  bath  will 
cause  dilatation  of  the  surface  blood  vessels  and 
will  do  more  good  than  any  amount  of  cupping.  It 
is  doubtful  whether  the  application  of  cups,  like  so 
many  dots,  all  over  the  chest  will  produce  reflexly 
changes  in  the  lungs.  To  cause  reflex  action  in  the 
lungs  nothing  will  serve  the  purpose  better  than 
the  proper  application  of  cold  water.  A  mustard 
paste,  applied  all  over  the  chest,  especially  when 
the  mustard  is  mixed  with  warm  ground  flaxseed, 
will  produce  peripheral  vasodilatation,  and  reflexly 
aflfect  the  internal  organs. 

Whatever  the  theory  on  which  this  popular 
remedy  of  cupping  is  based,  its  true  value  as  a  thera- 
peutic agent  can  only  be  determined  by  practical 
clinical  investigation.  During  the  last  two  influenza 
epidemics,  when  it  was  hard  to  find  a  living  human 
being  whose  chest  had  not  been  cupped  either  as  a 
prevention  or  as  a  cure  for  influenza  or  pneu- 
monia, I  carefully  investigated  the  therapeutic  worth 
of  this  old  traditional  remedy.  I  have  asked  quite 
a  number  of  patients  how  they  felt  after  being 
cupped,  the  cupping  usually  having  been  done  either 
on  the  advice  of  the  family  physician  or  because  of 
their  own  faith  in  this  inherited  household  remedy. 
The  majority  of  patients  thought  that  they  were 
not  at  all  benefited  by  the  cupping.  Some  said 
that  they  felt  somewhat  better  for  a  while  after 
being  cupped  but  soon  felt  no  change  for  the 
better.  A  few  stated  that  they  felt  much  better 
after  the  cupping  process  and  were  sure  it  had 
saved  them  from  a  serious  illness.  In  the  cases 
where  the  cupping  was  said  to  have  done  much 
good,  it  was  difficult  to  tell  how  much  of  the  benefit 
was  due  to  the  actual  cupping  and  how  much  to  the 
hypnotic  suggestion  produced  by  so  old  and  re- 
spected a  household  remedy.    The  patients,  how- 


ever, all  complained  that  the  cupping  had  made  them 
weak  and  that  the  skin  felt  sore  and  painful. 

In  addition  to  their  own  statements  as  to  their 
subjective  feelings  after  being  cupped,  the  efifect  of 
cupping  on  the  physical  signs,  the  pathological 
symptoms,  and  the  temperature  curve  were  studied 
in  a  number  of  cases.  Observations  were  made  on 
the  possible  influence  of  cupping  on  the  onset, 
course,  and  termination  of  various  respiratory  dis- 
eases. 

From  this  clinical  investigation  on  the  subjective 
and  objective  effects  of  cupping  it  may  be  definitely 
stated  that  it  does  not  prevent  or  cure  influenza  or 
pneumonia  or  any  other  disease  of  the  lungs  for 
which  it  is  most  commonly  used.  Cupping  may  do 
some  good  in  edema  or  congestion  of  the  bases  of 
the  lungs,  in  renal  congestion,  in  subacute  pleuritis, 
in  lumbago  or  other  muscle  aches,  in  neuritis  and 
neuralgia.  Cupping  does  actual  harm  to  infants, 
young  children,  asthenic  adults,  and  the  aged.  It 
makes  them  weak,  and  their  skin  sore,  painful,  and 
black  and  blue.  The  entire  process  of  cupping, 
with  its  imposing  paraphernalia,  is  so  terrifying 
to  young  children  that  it  should  never  be  used  in 
any  disease  of  childhood. 

Whatever  good  there  may  be  in  the  counterirri- 
tation  of  cupping  has  been  grossly  abused.  It  is 
being  advised  in  almost  any  real  or  imaginary  dis- 
ease of  the  chest  without  any  diagnostic  thought  or 
therapeutic  reason.  It  has  become  almost  the  ex- 
clusive trade  of  barbers,  discarded  nurses,  and 
crafty  old  women.  When  cupping  is  used  in  the 
right  case  with  proper  care  and  discretion  it 
may  be  of  some  assistance  in  the  care  of  the  sick. 
That  it  renders  some  useful  service  in  the  ills  of 
mankind  has  been  attested  to  by  its  extensive  use 
as  a  household  remedy  for  many  generations.  But 
its  careless,  thoughtless,  and  offhand  use  for  any 
disease  or  no  disease  has  done  much  harm  to  many 
patients  and  brought  down  this  popular  remedy  to 
the  ranks  of  a  quack  medicine  and  a  therapeutic 
humbug. 

222  East  Broadway. 


THE  BIOCHEMISTRY  OF  DRUG 
ADDICTION. 

By  A.  S.  HoROViTZ,  M.  D., 
Cincinnati,  Ohio. 

The  medical  profession  has  always  regarded 
drug  addiction  as  something  unethical,  to  be  treated 
with  contempt,  probably  because  it  was  looked  upon 
as  a  vice,  which  they  were  unable  to  combat.  The 
contempt  for  the  drug  addict  became  so  general  that 
almost  every  ethical  practitioner  refused  to  treat 
these  unfortunate  sufferers.  National  prohibition 
brought  the  subject  to  the  foreground  and  made  it 
a  widely  discussed  topic.  Now  the  public  justly 
looks  to  the  profession  for  relief  and ,  cure. 

The  helplessness  of  the  profession  was  not  due  to 
the  incurability  of  the  drug  habit,  but  rather  to  a 
lack  of  knowledge  of  the  subject.  Physiological 
chemistry  and  biochemistry  had  not  developed  suffi- 
ciently to  accord  investigators  a  clear  picture  of  the 
biochemical  composition  of  the  protoplasmic  struc- 


586 


OUTPATIENT  MEDICAL  WORK. 


[New  York 
Medical  Journal. 


ture  of  various  tissue  building  cells,  either  in  the 
normal  or  in  the  pathological  state. 

The  wonderful  progress  made  in  biochemistry 
during  the  last  decade  has  made  possible  accurate 
investigations  and  determination  of  the  qualitative 
and  quantitative  makeup  of  certain  chemical  com- 
plexes, hitherto  unknown  to  science.  One  type  of 
these  chemical  complexes  is  the  lipoids.  Careful 
parallel  investigations  of  normal  and  pathological 
tissues  led  to  discoveries  and  conclusions  of  great 
value  in  almost  all  diseases,  including  the  ailment 
wrongly  designated  as  drug  habit.  The  name  drug 
habit  covers  only  the  inordinate  desire  for  opiates, 
but  does  not  include  the  pathological  changes  which 
take  place  in  various  tissues  of  the  body,  especially 
in  the  protoplasmic  structure  of  the  nervous  system. 
Biochemical  investigations  prove  that  the  tissues 
of  drug  addicts  are  decidedly  poorer  in  lipoids  than 
those  of  normal  individuals  and  that  the  difference 
in  Hpoidal  content  is  especially  marked  in  the  tissues 
of  the  nervous  system.  The  lack  of  sufficient  lipoids 
in  the  nervous  system  is  responsible  for  the  longing 
for  drugs,  as  will  be  explained  later. 

Overton  and  Meyer  were  among  the  first  to  re- 
port on  the  influence  of  certain  Hpoids  upon  poisons 
and  toxins.  Their  early  investigations  show  that 
lipoids  have  a  solvent  action  upon  narcotics.  Nerk- 
king  and  Reichert  state  that  the  introduction  of 
certain  lipoids  into  the  blood  stream  diminishes,  or 
entirely  eliminates,  the  effect  of  narcotics.  Fur- 
thermore, it  is  a  well  established  fact  that  the  lipoids 
of  various  organs,  as  well  as  of  the  nervous  sys- 
tem, may  be  extracted  and  consumed  by  the  ad- 
ministration of  narcotic  alkaloids.  An  excess  of 
toxins  has  a  similar  effect.  The  detoxicating  action 
of  the  lipoids  is  of  considerable  significance  in  cell- 
ular physiology.  The  fact  that  the  detoxicating 
capacity  of  lipoids  remains  after  extraction  from 
the  mother  cell  aggregate,  gives  us  another  means 
of  controlling  certain  conditions  which  previously 
resisted  every  effort  of  the  medical  profession.  One 
of  these  is  drug  addiction. 

All  narcotic  alkaloids  have  either  a  stimulating 
or  a  paralyzing  power,  and  all  have  the  common 
characteristic  of  a  solvent  action  upon  the  lipoids 
of  the  tissues.  Through  this  biochemical  activity  of 
the  narcotic  alkaloids  the  detoxicating  influence  is 
diminished.  An  abundant  quantity  of  toxins  of 
low  nitrogen  content  in  the  tissues  exert  their  ir- 
ritating influence,  which  requires  a  certain  amount 
of  neutralizing  chemicals,  in  this  instance  narcotics, 
usually  alkaloids,  to  overcome  the  craving  produced 
by  the  toxins.  In  this  way  a  gradual  progressive 
destruction  takes  place  in  the  nerve  tissues,  requir- 
ing more  and  more  opiates  for  stabilization. 

The  belief  that  certain  addicts  through  experience 
and  selfanalysis  can  properly  regulate  the  amount 
of  opiates  required  daily  to  keep  them  balanced,  is 
erroneous  and  contrary  to  the  pathological  findings. 
It  is  probable  that  addicts  will  regulate  the  amount 
of  one  kind  of  opiate,  but  use  another.  Generally 
addicts  are  multinarcotics,  using  all  available  drugs. 

The  rational  treatment  for  restoring  the  lipoidal 
equilibrium  of  the  tissues  of  addicts  would  be  to 
replace  the  amount  of  lipoids  lost.  The  ver>^  im- 
portant fact  that  the  detoxicating  power  is  retained 


in  their  chemical  complex  when  this  has  been  ex- 
tracted to  the  same  degree  as  in  the  mother  cell 
sgg^egate,  supplies  us  with  a  reliable  foundation  on 
which  to  base  proper  therapeutic  treatment  to  over- 
come the  pathological  changes  caused  by  narcotics 
in  the  tissues,  and  the  craving  which  is  the  result  of 
these  changes. 

Lipoids  are  found  in  practically  all  the  various 
cells  of  the  body  of  both  animals  and  plants.  Their 
peculiar  chemical  character  makes  their  use  pos- 
sible. We  are  in  position  to  determine  the  syn- 
ergy of  various  lipoids,  which  fact  enables  us  to 
replace  the  lost  lipoids  of  the  body  up  to  a  normal 
point,  bringing  the  patient  into  normal  condition, 
both  physically  and  mentally.  The  clinical  and  ex- 
perimental data  at  hand  indicate  that  the  introduc- 
tion of  lipoids  into  therapeutics  will  prove  a  means 
of  enlightening  us  regarding  various  aspects  of 
metabolism. 


ANALYSIS    OF    OUTPATIENT  MEDICAL 
WORK.* 

A  Study  of  8,863  Dispensary  Records  by  the  Puhlic 
Health  Committee  of  the  New  York  Academy 
of  Medicine 

INTRODUCTION. 

In  an  analysis  of  the  medical  work  of  dispensaries 
an  objective  gauge  had  to  be  taken  as  a  measure  of 
the  efficiency  of  the  different  institutions.  The  only 
extant  and  easily  analyzable  measuring  standard  is 
the  medical  history.  L'nder  the  prevailing  conditions 
it  is  admittedly  an  imperfect  standard,  but  the  only 
one  available.  This  method  of  study  is  predicated 
on  the  fact  that  certain  basic  information  concerning 
the  patient's  physical  condition,  past  history  and  en- 
vironment, as  well  as  results  of  laboratory  and  other 
procedures,  must  be  recorded  as  an  intelligent  guide 
in  diagnosis  and  treatment.  It  is  obviously  impos- 
sible for  anyone  to  hold  in  mind  the  necessary  de- 
tails for  a  group  of  persons,  particularly  in  dis- 
pensaries where  large  numbers  come  to  each  physi- 
cian's attention  daily  and  where  the  medical  service 
is  frequently  changing  and  several  different  physi- 
cians may  handle  the  same  case.  If  the  records  do 
not  contain  a  minimum  of  information  that  is  gen- 
erally recognized  as  indispensable,  it  is  justifiable  to 
assume  that  the  medical  service  is  of  an  inadequate 
character. 

The  study  presented  herewith  is  based  on  this 
premise,  and  is  open  to  the  objection  that  the  hur- 
riedly made  out  records  in  the  dispensaries  do  not 
properly  represent  the  work  done,  and  that  it  is  fre- 
quently superior  to  what  the  records  would  indicate. 
Yet,  the  records  constitute  the  only  means  by  which 
an  objective  presentation  of  medical  work 
can  be  accomplished,  and  when  a  considerable  num- 

*This  constitutes  a  part  of  the  report  on  the  Dispensary  Situation 
in  New  York  City  by  the  Public  Health  Committee  of  the  New 
York  Academy  of  Medicine,  of  which  Dr.  Charles  L.  Dana  is  chair- 
man, Dr.  James  Alexander  Miller  is  secretary,  and  E.  H.  Lewin- 
ski-Corwin,  Ph.  D.,  is  executive  secretary.  The  membership  of  the 
committee  is  as  follows:  Dr.  John  S.  Billings,  Dr.  Nathan  E.  Brill, 
Dr.  Robert  J.  Carlisle,  Dr.  James  B.  demons.  Dr.  Haven  Emerson, 
Dr.  Lewis  F.  Frissell.  Dr.  Arpad  G.  Gerster,  Dr.  S.  S.  Goldwater,. 
Dr.  John  A.  Hartwell,  Dr.  Ward  A.  Holden,  Dr.  L.  Eramett  Holt, 
Dr.  Otto  V.  Huffman,  Dr.  Walter  B.  James,  Dr.  Walter  L.  Niles,. 
Dr.  Bernard  Sachs,  Dr.  Thomas  W.  Salmon,  Dr.  Frederic  E. 
Sondern,  Dr.  M.  Allen  Starr,  Dr.  Howard  C.  Taylor,  Dr.  W.  Gil- 
man  Thompson.  Dr.  Philip  Van  Ingen,  Dr.  Karl  M.  Vogel,  Dr. 
George  B.  Wallace,  Dr.  Cassius  H.  Watson,  Dr.  Herbert  B.  Wilcox. 


October  16,  1920.] 


OUTPATIEXT  MEDICAL  li  ORK. 


587 


ber  of  records  is  used  a  fairly  accurate  picture  of 
the  clinical  procedures  can  be  obtained.  It  is  to  be 
hoped  that  this  study  will  stimulate  the  institutions 
toward  making  better  provision  for  the  satisfactory 
recording  of  medical  work  in  dispensaries. 

Three  different  sets  of  records  have  been  used  in 
the  preparation  of  this  study :  First,  a  large  number 
of  sequence  cases,  or  cases  filed  in  the  order  in  which 
the  patients  applied  to  the  dispensary,  were  taken ; 
secondly,  an  analysis  was  made  of  selected  diagnosed 
conditions  from  the  different  departments,  and  third- 
ly, an  analysis  was  made  of  records  from  special 
institutions.  The  sequence  records  were  taken  from 
the  various  departments  of  the  following  dispen- 
saries :  Bellevue,  Beth  Israel,  Cornell  ^Medical  Col- 
lege, Fordham,  Gouverneur,  Harlem.  Lebanon, 
Lenox  Hill,  Lincoln.  Long  Island  College,  Mount 
Sinai,  New  York  Hospital,  Northeastern,  Post- 
Graduate,  Roosevelt,  Staten  Island,  St.  Bartholo- 
mew's, St.  Luke's,  St.  Mark's,  St.  Vincent's,  Belle- 
vue Medical  College,  Vanderbilt,  West  Side. 

The  reason  that  selected  diagnoses  were  taken  in 
addition  to  "sequence"  cases,  was  that  cases  taken  in 
order  of  sequence  from  the  general  files  of  the  dis- 
pensaries and  relating  to  a  wide  variety  of  patho- 
logical conditions,  many  of  trifling  significance, 
might  not  adequately  reflect  the  kind  and  quality 
of  medical  service  in  outpatient  departments,  and 
an  additional  study  of  selected  diagnosed  conditions 
treated  for  a  considerable  length  of  time  might  in 
fairness  to  the  institutions  well  supplement  the  other 
study.  The  conditions  chosen  were  those  which 
readily  lend  themselves  to  ambulatory  treatment, 
which  run  a  more  or  less  protracted  course,  pre- 
sent some  medical  interest  to  the  physician  and 
which  in  many  instances  are  the  cause  of  eco- 
nomic and  social  difficulties  to  the  patients.  Ac- 
cordingly 2,718  such  diagnosed  records  from  the 
several  departments  were  collected  and  tabulated. 

They  were  taken  from  twenty-one  of  the  twenty- 
four  dispensaries  from  which  the  sequence  cases 
were  selected,  and  from  the  Presb}terian  Hospital, 
where  a  filing  system  arranged  by  diagnosis  had 
made  the  collecting  of  sequence  records  impossible. 
At  the  Staten  Island  Hospital,  the  Northeastern 
Dispensary  and  St.  Bartholomew's  Clinic  it  was  not 
possible  to  find  a  sufficient  number  of  diagnosed 
cases  in  any  of  the  departments  of  the  institution 
to  make  such  a  study  of  value  for  these  institutions. 
At  five  other  institutions — Fordham.  Long  Island 
College.  Roosevelt,  \'anderbilt  and  Gouverneur^ — 
no  diagnosed  records  could  be  found  for  the  gener- 
al medical  clinic,  although  they  were  available  in 
other  departments.  At  Cornell  ^ledical  College  in 
the  general  medical  clinic  only  a  few  records  could 
be  found  diagnosed  for  the  selected  chronic  dis- 
eases. At  Bellevue  and  at  the  Post-Graduate  it  was 
necessary  to  go  through  the  records  for  eight 
months  to  find  a  sufficient  number  of  cases  for  pur- 
poses of  comparison.  In  departments  other  than 
general  medical  it  was  not  always  possible  to  ob- 
tain a  sufficient  number  of  records  for  each  group, 
which  accounts  for  the  variety  in  the  numbers 
taken  from  different  institutions. 

A  third  series  of  records  was  taken  from  the  fol- 
lowing institutions  treating  special  conditions : 


Eye,  ear.  iwse  and  throat. — Manhattan  Eye, 
Ear,  Nose  and  Throat  Hospital ;  New  York  Eye 
and  Ear  Infirmary :  Herman  Knapp  Memorial  Hos- 
pital. 

Orthopedic. — Hospital  for  Ruptured  and  Crip- 
pled ;  Hospital  for  Deformities  and  Joint  Diseases ; 
New  York  Orthopedic  Hospital. 

Neurological. — Neurological  Institute. 

Dcrniatological.  —  New  York  Skin  and  Cancer 
Hospital. 

Gynecological. — \\'oman's  Hospital ;  New  York 
Nursery  and  Child's  Hospital ;  Lying-in  Hospital. 

Pediatric. — Babies'  Hospital ;  New  York  Nurs- 
ery and  Child's  Hospital. 

In  these  institutions  both  sequence  and  diagnosed 
records  were  studied ;  first,  a  group  of  sequence 
cases  was  taken,  and  if  this  group  did  not  contain 
a  sufficient  number  of  cases  of  a  selected  disease  to 
make  possible  a  comparison  with  the  corresponding 
departments  of  the  general  dispensaries,  another 
group  was  added,  but  the  selection  was  then  limited 
to  diagnosed  records  of  the  selected  condition. 
With,  minor  exceptions,  all  the  records  were  for 
patients  treated  from  January  to  April,  1917,  and 
from  January  to  April,  1918,  thus  providing  a  basis 
upon  which  to  judge  the  effect  of  the  war  upon  dis- 
pensar>-  service  and  to  make  the  survey  represent, 
the  average  work  in  two  different  years. 

The  number  of  records  of  each  group  of  records, 
sequence,  diagnosed,  and  special  institution,  is  ap- 


pended herewith. 

SFQUEXCF  RECORDS. 

General  medical  departments   1.774 

Pediatric  departments    398 

Xeurological  departments    247 

Surgical  departments    946 

Dermatological  departments    333 

Orthopedic  departments    140 

Gynecological  departments    437 

Eye.  ear.  nose,  and  throat  departments   695 


Total    4,970 

RECORDS  OF  SELECTED  DI.\GNOSED  CASES. 

Bronchitis    283 

Chronic  nephritis    102 

Chronic  rheumatism    150 

Chronic  valvular  heart  lesion   219 

Rachitis    57 

^lalnutrition    105 

Fracture    268 

Cellulitis    223 

Lacerated  pelvic  floor  and  cervix   211 

Epilepsy    41 

Gastric  ulcer    117 

Eczema    241 

Syphilis    192 

Cerebrospinal  syphilis    69 

Gonorrhea    156 

Conjunctivitis    87 

Trachoma    25 

Otitis  media   .'   170 


Total    2715 

RECORDS  FROM   SPECIAL  IXSTITUTIOXS. 

Pediatric  dispensaries    100 

Xeurological  institute  dispensary    140 

Skin  and  cancer  hospital  dispensary   67 

Orthopedic  dispensaries    322 

Gynecological  dispensaries    154 

Eye,  ear,  nose,  and  throat  dispensaries   394 


Total    1,177 


Total  numlxr  of  records   8.863 


388 


OUTPATIENT  MEDICAL  WORK. 


[New  York 
Medical  Journal. 


The  following  is  a  general  summary  of  the  find- 
ings upon  the  examinations  of  the  records  subdi- 
vided under  f  ovir  heads :  a,  the  effect  of  the  war  on 
the  quality  of  dispensary  work ;  b,  comparison  of 
special  institutions  with  the  corresponding  depart- 
ments of  general  dispensaries ;  c,  comparison  of  di- 
agnostic, therapeutic  and  supervisory  procedures  for 
sequence  cases  by  departments  and  d,  comparison 
of  diagnostic  procedures  for  selected  diagnosed 
conditions. 

THE  EFFECT  OF  THE  WAR  OX  THE  QUALITY  OF  DIS- 
PENSARY WORK. 

As  noted  in  the  introductory  statement,  the  rec- 
ords studied  were  taken  partly  from  the  files  of  the 
first  three  months  of  the  year  1917  and  partly  for 
the  same  period  of  the  year  1918,  in  order  to  make 
possible  a  comparison  of  the  dispensary  service  be- 
tween these  years  and  to  judge  to  what  extent  the 
war  had  afifected  ordinary  dispensary  procedure. 
The  analysis  of  the  records  in  the  general  medical, 
pediatric  and  neurological  departments  did  not 
show  any  definite  tendency  towards  either  improve- 
ment or  deterioration  in  1918,  compared  with  the 
year  before.  As  the  results  of  the  comparison  for 
these  three  departments  did  not  indicate  any 
appreciable  change,  the  comparative  study  between 
the  work  in  the  prewar  and  the  war  periods  was  not 
extended  to  the  other  departments. 

The  comparative  study  in  the  general  medical 
department  showed  (Table  I)  that  local  examina- 
tion, laboratory  tests,  treatment,  and  revisits  were 
recorded  in  a  slightly  higher  proportion  of  cases  in 
1917  than  in  1918.  The  pediatric  departments  re- 
corded diagnosis  and  local  examinations  to  a  slightlv 
higher  extent  in  1917,  and  in  the  neurological  clin- 
ics, the  diagnosis,  general  physical  examination, 
laboratory  tests,  treatment,  and  revisits  were  more 
often  recorded  in  1917  than  in  1918.  The  only  marked 
decrease  in  1918  was  observed  in  general  physical 
examinations  in  the  neurological  departments  (52.5 
per  cent,  in  1917;  42.4  per  cent,  in  1918),  and  in  the 


and  the  pediatric  division  showed  in  1918  an  im- 
provement over  1917. 

COMPARISON   OF   SPECIAL   INSTITUTIONS    WITH  THE 
CORRESPONDING  DEPARTMENTS  OF  GENERAL 
DISPENSARIES 

A  comparison  of  all  the  cases  selected  from  the 
special  institutions  with  those  from  the  correspond- 
ing departments  of  the  general  dispensaries  shows 
that,  as  a  rule,  the  special  institutions  are  superior 
in  their  procedures  (Table  II).  By  a  juxtaposition 
of  the  date  as  to  phys.ical  examination,  laboratory 


TABLE  II. 

SPECIAL  CLINICS  COMPARED  WITH  THE  CORRESPOND- 
ING DEPARTMENTS  OF  THE  GENERAL  DISPENSARIES. 


CASES    IN  SEQUENCE. 


Patien  ts 

Physical 

Making 

No.  of  Examination 

Laboratory 

Treatment 

More  Than 

Cases 

Recorded 

Tests 

Recorded 

One 

Visit 

Departments 

No. 

cr 

No. 

% 

No. 

% 

No. 

% 

Pediatric — 

Spec...  100 

66 

66. 

21 

21. 

88 

88. 

66 

66. 

Gen....  398 

234 

58.7 

38 

9.5 

275 

69.1 

168 

42.2 

Neurological — 

Spec...  102 

101 

99. 

27 

26.5 

66 

64.7 

39 

38.2 

Gen...  247 

133 

53.8 

27 

10.9 

185 

74.9 

94 

38. 

Dermatological — 

Spec. .  .  67 

12 

17.9 

1 

1.5 

64 

95.5 

41 

61.3 

Gen.  . .  333 

151 

45.4 

19 

5.7 

281 

84.5 

118 

35.4 

Orthopedic- 

Spec...  322 

153 

47.7 

71 

22.2 

252 

78.6 

113 

35.3 

Gen...  140 

77 

55. 

27 

19.3 

90 

64.3 

33 

23.6 

Gynecological — 

Spec. .  .  154 

123 

79.8 

24 

15.6 

119 

77.2 

87 

56.5 

Gen...  437 

231 

52.8 

41 

9.3 

183 

41.8 

89 

20.3 

Eye,  Ear,  Nose 

and  Throat — 

Spec...  394 

143 

35.7 

24 

6.1 

229 

58.2 

130 

33. 

Gen...  695 

241 

34.6 

11 

1.6 

341 

49.1 

134 

19.3 

tests,  treatment  and  revisits,  it  is  found  that  the 
special  pediatric,  gynecological,  and  eye,  ear,  nose 
and  throat  institutions  are  better  in  all  respects 
than  the  corresponding  departments  of  general  dis- 
pensaries ;  the  special  orthopedic  institutions  are  bet- 
ter in  all  respects  but  physical  examination,  and  the 
special  neurological  clinics  in  all  but  the  recording 
of  treatment.  The  special  dermatological  institu- 
tion studied  was  an  exception  to  the  rule,  the  cor- 


TABLE  I. 

<:OMPARISON  OF  WORK  DONE  IN   1917   AND    1918  IN   THE    GENERAL    MEDICAL,   PEDIATRIC   AND  NEUROLOGICAL 

DEPARTMENTS   OF   GENERAL  DISPENSARIES 

Patients  Making 

No.  of         Diagnosis  c  Physical  Examination  ,  Laboratory  Treatment  More  Than  One 

Cases  Recorded  General  Local  Tests  Recorded  Visit 


No. 

% 

No. 

% 

No. 

% 

No. 

% 

No. 

% 

No. 

% 

General  Medical — 

1917  

:  ,  848 

372 

43.8 

365 

43. 

192 

22.6 

187 

22. 

672 

79.3 

354 

41.7 

1918  

926 

414 

44.7 

407 

43.9 

197 

21.3 

153 

16.5 

712 

76.9 

903 

33.3 

Pediatric — 

1917  

159 

117 

73.6 

54 

34. 

28 

17.6 

11 

6.9 

101- 

63.5 

61 

38.3 

1918  

189 

138 

73. 

65 

34.4 

33 

17.4. 

15 

7.9 

128 

67.7 

75 

39.6 

Neurological  Department 

Including 

Neurological  Institute — 

1917  

232 

178 

76.7 

122 

52.5 

44 

14.6 

45 

19.4 

181 

78. 

98 

42.2 

1918  

217 

161 

74.2 

92 

42.4 

42 

19.3 

39 

18. 

166 

76.5 

80 

36.4 

■  frequency  of  revisits :  in  42.4  per  cent,  of  the  neu- 
rological cases  more  than  one  visit  was  made  in 
1917  and  in  only  36.4  per  cent,  in  1918.  For  the  fol- 
lowing items  the  records  were  better  in  1918 :  gen- 
eral physical  examinations  and  the  noting  of  diag- 
noses in  the  general  medical  departments ;  general 
physical  examinations,  laboratory  tests,  treatment 
and  revisits,  in  the  pediatric  departments,  and  local 
examinations  in  the  neurological  clinics.  On  the 
W'hole,  the  departments  of  general  medicine  and  of 
neurology  were  slightly  better  in  1917  than  in  1918, 


responding  departments  of  the  general  dispensaries 
excelling  the  special  institution  in  the  record  of  phy- 
sical examinations  and  laboratory  tests,  but  were 
inferior  as  to  the  noting  of  treatment  and  revisits. 
One  reason  for  this  is  the  fact  that  the  special 
institution  under  consideration  does  not  treat  syphilis 
in  the  skin  department,  and  this  condition  usually 
calls  for  more  laboratory  tests  and  physical  exam- 
inations than  the  other  conditions  cared  for  in  the 
dermatological  departments.  Syphilis,  however, 
was  treated  in  many  of  the  dermatological  depart- 


October  16,  1920.] 


OUTPATIENT  MEDICAL  WORK. 


589 


merits  of  the  general  dispensaries  which  were 
compared  with  the  special  institution. 

When  groups  of  selected  cases  of  a  certain  dis- 
ease, obtained  from  the  special  departments  of  the 
general  dispensaries,  such  as  otitis  media,  conj'unc- 
tivitis,  eczema,  malnutrition  and  lacerated  perineum, 
were  compared  with  similar  selected  cases  from 
special  institutions,  the  special  institutions  excelled 
only  in  some  points  and  fell  below  in  others 
Table  III).  Laboratory  tests  were  noted  more 
often  in  the  general  dispensaries  for  con- 
junctivitis, eczema,  and  lacerated  perineum  and 
cervix,  and  in  the  special  institutions   for  otitis 

TABLE  III. 

COMPARISON    OF    LABORATORY    TEST,    PHYSICAL  EX- 
AMINATION,   TREATMENT,    AND    REVISITS  FOR 
SELECTED  DIAGNOSED  CONDITIONS. 


Patients 

Making 

Physical 

Treat- 

More 

No.  of 

Examination 

Laboratory 

ment 

Than  One 

Cases 

General 

Local 

Tests 

Record 

Visit 

No. 

% 

No. 

% 

No. 

% 

No.  % 

No. 

% 

Conjunctivitis — 

Spec...  84 

7 

8.3 

1 

1.2 

25  29.7 

24 

28.5 

Gen...  170 

53 

31. 

6 

3.5 

58  34. 

30 

17.6 

Otitis  Media — 

Spec. .  .  65 

23 

35.3 

3 

4.4 

55  84.4 

21 

32.3 

Gen...  87 

57 

65. 

1 

1.1 

72  82.5 

14 

16. 

Eczema — 

Spec...  29 

3 

10  3 

29  100. 

20 

69. 

Gen...  241 

9 

i.7 

128 

53.1 

11 

4.5 

208  86.3 

85 

35. 

Lacerated  Pelvic 

Floor  and  Cervi.x — 

Spec. .  .  52 

3 

5.8 

47 

90.5 

3 

5.8 

48  92.5 

37 

71.1 

Gen...  211 

2 

.9 

180 

85.3 

24 

11.4 

143  67.7 

79 

37.4 

Malnutrition — 

Spec.  .  17 

11 

64.6 

11 

64.6 

3 

17.3 

16  94.1 

Gen...  162 

69 

42.6 

54 

33.4 

27 

16.7 

138  85.1 

media  and  malnutrition.  The  recording  of  revisits 
was  the  only  feature  in  which  the  special  institu- 
tions excelled  for  all  the  selected  conditions  com- 
pared. In  this  item,  the  advantage  was  very  much 
on  the  side  of  the  special  institutions,  which  showed 
revisits  for  nearly  twice  as  many  cases  as  did  the 
general  dispensaries.  On  the  whole,  the  special  in- 
stitutions were  somewhat  superior  to  the  corre- 
sponding branches  of  general  outpatient  clinics. 

COMPARISON     OF     DIAGNOSTIC,     THERAPEUTIC  AND 
SUPERVISORY  PROCEDURES  FOR  SEQUENCE  CASES 
BY  DEPARTMENTS. 

In  the  analysis  of  medical  work,  the  most  im- 
portant comparison,  of  course,  is  that  relating  to 


found  to  vary  greatly  in  their  procedure,  the  three 
departments,  general  medicine,  pediatrics  and  neuro- 
logy, treating  a  large  proportion  of  systemic  condi- 
tions, constituting  one  group,  and  the  surgery, 
gynecology,  orthopedics,  dermatology,  and  eye,  ear, 
nose  and  throat  departments,  treating  more  local 
conditions,  falling  into  another.  The  former  group 
recorded  general  physical  examination,  laboratory 
tests  and  revisits  in  a  higher  proportion  of  cases, 
and  the  latter  local  physical  examination  and  diag- 
nosis. As  to  the  recording  of  treatment  no  definite 
classification  can  be  established. 

DIAGNOSIS. 

Diagnosis  was  found  recorded  for  a  relatively 
high  proportion  of  cases  in  all  departments,  but 
in  a  much  higher  percentage  of  instances  in  other 
departments  than  in  general  medicine,  where  the 
diagnoses  were  stated  on  only  43.9  per  cent,  of 
histories.  The  skin  clinics  led  in  this  respect,  diag- 
nosing 95.5  per  cent,  of  cases;  the  orthopedic  de- 
partments were  next  in  order  of  excellence,  with 
94.5  per  cent.,  and  the  ear,  nose  and  throat,  with 
93.4  per  cent,  of  records  diagnosed.  From  seventy 
to  eighty  per  cent,  of  the  cases  studied  were  diag- 
nosed in  the  surgical,  neurological,  eye  and  pediatric 
departments,  and  63.4  per  cent,  of  those  in  the 
gynecological  clinics. 

One  reason  for  the  low  proportion  of  cases  diag- 
nosed in  the  general  medical  departments  is  no  doubt 
the  fact  that  often  the  conditions  referred  to  this 
department  are  obscure  and  having  no  definite 
pathology  are  difficult  to  classify.  The  converse  of 
this  explains  why  the  orthopedic  and  ear,  nose  and 
throat  departments  have  diagnoses  recorded  in  such 
a  high  percentage  of  cases.  In  order  to  be  referred 
to  a  special  department,  a  condition  must  be  more 
or  less  localized,  and  consequently  of  a  more  def- 
inite nature  than  one  treated  in  the  general  medical 
department. 

Furthermore,  it  must  be  noted  that  in  giving 
credit  for  the  recording  of  diagnosis  in  this  survey, 
anything  written  on  the  history  form  in  the  space 
for  diagnosis  was  accepted,  irrespective  of  other 
considerations.  This  meant  giving  no  credit  in  cases 
where  a  physical  examination  recorded  on  the  his- 
tory macle  the  diagnosis  apparent,  and  accepting 


TABLE  IV. 

COMPARISON   OF  CONTENT   OF   RECORDS   REGARDING   DIAGNOSIS,    EXAMINATION,  LABORATORY    TESTS,  TREAT- 
MENT AND  REVISITS,  TABULATED  BY  DEPARTMENTS 


No.  of 

Departments  Cases 

General  Medical    1774 

Pediatric    498 

Neurological    349 

Surgical    946 

Skin    400 

Orthopedic   ;   462 

Gynecological    591 

E.ve    548 

Ear,  Nose  and  Throat   541 

General  Total  for  all  Departments  6309 


Diagnosis 
Recorded 


-Physical  Eamination- 


Gencral 


Local 


Laboratory 
Tests 


Patients  Making 
Treatment  More  Than  One 


Recorded 


Visit 


No. 

% 

No. 

% 

No. 

% 

No. 

% 

No. 

% 

No. 

% 

786 

43.9 

772 

43.5 

389 

22. 

340 

19.3 

1384 

78. 

663 

37.5 

365 

73.3 

199 

40. 

141 

28.3 

59 

11.7 

363 

72.9 

234 

47. 

267 

76.5 

164 

47. 

79 

22.6 

54 

15.5 

251 

71.99 

133 

38.1 

755 

79.9 

15 

1.6 

266 

28.1 

78 

8.3 

431 

45.6 

253 

26.7 

382 

95.5 

15 

3.7 

148 

37. 

20 

5. 

345 

86.2 

159 

39.7 

436 

94.5 

51 

11. 

183 

39.6 

98 

21.2 

342 

74. 

146 

31.6 

375 

63.4 

17 

2.9 

342 

57.8 

65 

11. 

302 

51. 

176 

29.8 

420 

76.7 

12 

2.2 

269 

49. 

17 

3.1 

410 

74.8 

153 

27.9 

505 

93.4 

3 

.5 

115 

21.2 

18 

3.3 

160 

29.6 

111 

20.5 

4291 

68. 

1248 

19.7 

1932 

30.6 

749 

11.8 

3988 

63.1 

2028 

32.2 

the  general  diagnostic  and  therapeutic  procedures 
(Table  IV).  This  comparison  has  been  made  on 
the  basis  of  the  sequence  cases  studied  in  the  various 
(lepartments  of  the  general  dispensaries  and  of  spe- 
cial institutions.   The  several  departments  have  been 


comparatively  blank  record  forms  containing  a  single 
word  in  the  diagnosis  space,  even  when  this  word 
was  merely  a  symptom,  such  as  constipation  or 
nervousness.  This  is  one  reason  why  the  proportion 
of  cases  diagnosed  in  some  of  the  departments  of 


590 


OUTPATIENT  MEDICAL  WORK. 


[New  York 
Medicai,  Journal. 


the  several  dispensaries  does  not  always  correspond 
with  the  proportion  of  diagnostic  procedure  indi- 
cated. 

PHYSICAL  EXAMINATION. 

The  three  departments  treating  the  larger  pro- 
portion of  systemic  conditions,  the  general  medical, 
pediatric,  and  neurological,  all  recorded  a  very  much 
higher  percentage  of  general  physical  examinations 
than  the  departments  treating  conditions  which  are 
more  local  in  their  nature,  but  even  the  former  de- 
partments indicated  general  physical  examination 
for  less  than  half  of  their  cases.  The  proportions 
of  general  physical  examinations  recorded  in  the 
difYerent  departments  are  as  follows :  neurological, 
47  per  cent. ;  general  medical,  43.5  per  cent. ; 
pediatric,  40  per  cent. ;  orthopedic,  11  per  cent. ;  der- 
matological,  3.7  per  cent. ;  gynecological,  2.9  per 
cent.;  eye,  2.2  per  cent.;  surgical,  1.6  per  cent.; 
ear,  nose  and  throat,  .5  per  cent. 

When  the  fact  is  considered  that  patients  are  re- 
ferred to  special  departments,  as  a  rule,  without  any 
])revious  physical  examination  to  ascertain  wheljier 
or  not  there  are  present  deficiencies  other  than  the 
one  for  which  special  attention  is  being  sought  at 
the  time,  the  very  small  proportion  of  general  physi- 
cal examinations  noted  for  the  patients  in  the  special 
departments  demonstrates  one  of  the  weak  points 
of  the  present  dispensary  system. 

Local  physical  examination,  as  would  be  expected, 
was  found  recorded  much  more  often  in  the  depart- 
ments treating  local  conditions  than  in  the  other 
divisions,  although  the  ear,  nose  and  throat  and 
surgical  departments  exhibited  histories  less  satis- 
factory in  this  respect  than  those  from  the  other  spe- 
cial departments.  The  proportions  of  local  exam- 
inations stated  in  the  different  departments  were  as 
follows :  Gynecological,  57.8  per  cent. ;  eye,  49  per 
cent.;  orthopedic,  39.6  per  cent.;  dermatological, 
37  per  cent.;  pediatric,  28.3  per  cent.;  surgical,  28.1 
per  cent.;  neurological,  22.6  per  cent.;  general  medi- 
cal, 22  per  cent.;  ear,  nose  and  throat,  21.2  per  cent. 

LABORATORY  TESTS. 

The  three  departments  treating  mainly  systemic 
conditions  recorded  laboratory  tests,  including  skia- 
graphs, for  a  larger  proportion  of  cases  than  did  any 
other  special  department  except  the  orthopedic,  al- 
thought  histories  from  all  the  departments  showed 
the  laboratory  to.  have  been  used  for  only  a  small 
proportion  of  cases.  The  percentage  of  cases  re- 
corded as  having  received  laboratory,  including 
rontgenographic,  diagnosis  from  each  department 
was  as  follows:  Orthopedic,  21.2  per  cent.;  general 
medical,  19.3  per  cent.;  neurological,  15.5  per  cent.; 
pediatric,  11.7  per  cent.;  gynecological,  11  per  cent.; 
surgical,  8.3  per  cent. ;  dermatological,  5  per  cent. ; 
ear,  nose  and  throat,  3.3  per  cent.,  and  eye,  3.1  per 
cent.  The  high  score  in  this  procedure  in  the  ortho- 
pedic departments  was  due  chiefly  to  the  large  pro- 
portion of  radiographic  examinations  recorded  in 
these  departments. 

TREATMENT. 

Treatment  was  recorded  for  less  than  three 
fourths  of  the  patients  from  every  department  ex- 
cept general  medicine  and  dermatology,  and  the 
line  of  cleavage  between  departments  caring  for 
systemic  disease  and  those  treating  local  conditions 


is  not  visible  here  as  it  is  in  certain  other  respects. 
The  treatment  accorded  the  patient  was  recorded  in 
the  following  proportions  of  cases  in  the  different 
departments :  Dermatological,  86.2  per  cent. ;  gen- 
eral medical,  78  per  cent. ;  eye,  74.8  per  cent. ;  ortho- 
pedic, 74  per  cent. ;  pediatric,  72.9  per  cent. ;  neuro- 
logical, 71.9  per  cent.;  gynecological,  51  per  cent.; 
surgical,  45.6  per  cent. ;  ear,  nose  and  throat,  29.6 
per  cent. 

REVISITS. 

As  indicated  by  the  recording  of  revisits,  the  fol- 
lowing departments,  all  treating  a  large  proportion 
of  chronic  cases,  excelled  in  supervision  of  patients : 
the  pediatric,  with  this  information  in  47  per  cent, 
of  instances ;  the  dermatological,  giving  it  in  39.7 
per  cent.;  the  neurological  in  38.1  per  cent.;  the 
general  medical  in  37.5  per  cent.,  and  the  orthopedic 
in  31.6  per  cent,  of  cases.  The  other  departments 
recorded  revisits  for  less  than  30  per  cent,  of  cases, 
in  the  following  proportions :  gynecological,  29.8 
per  cent. ;  eye,  27.9  per  cent. ;  surgical,  26.7  per 
cent. ;  ear,  nose  and  throat,  20.5  per  cent.  The  rela- 
tive excellence  of  the  pediatric  departments  in  this 
respect  reflects,  no  doubt,  the  influence  of  the  class 
plan  of  organization  as  applied  to  cardiac  and  mal- 
nutrition cases. 

GENERAL  CONTENT  OF  RECORDS. 

The  general  content  of  records,  as  shown  by  the 
average  for  all  departments,  is  most  inadequate. 
Diagnosis  and  treatment  were  recorded  for  only 
about  two  thirds  of  all  patients  (68  per  cent,  and 

63.1  per  cent.,  respectively)  ;  local  examinations  and 
revisits  for  less  than  one  third  (30.6  per  cent,  and 

32.2  per  cent.)  ;  general  physical  examination  for 
less  than  one  fifth  (19.7  per  cent.),  and  laboratory 
tests  for  only  about  one  tenth,  or  11.8  per  cent,  of 
all  patients. 

COMPARISON   OF  DIAGNOSTIC   PROCEDURE  FOR 
SELECTED   DIAGNOSED  CONDITIONS. 

Altogether,  2,716  selected  diagnosed  records  were 
studied,  and  those  refer  to  bronchitis,  chronic  ne- 
phritis, rheumatism,  chronic  valvular  heart  lesions, 
and  gastric  ulcer,  from  the  general  medical  depart- 
ments; rickets  and  malnutrition,  from  the  pediatric 
departments;  syphilis  of  the  nervous  system  and 
epilepsy,  from  the  neurological  departments;  frac- 
ture and  cellulitis,  from  the  surgical  departments; 
eczema,  from  the  dermatological  departments;  la- 
cerated perineum  and  gonorrhea,  from  the  gyneco- 
logical departments;  conjunctivitis,  trachoma,  and 
otitis  media  from  the  eye,  ear,  nose  and  throat  de- 
partments, and  syphilis  and  gonorrhea  from  the 
genitourinary  departments.  The  tuberculosis  cases 
were  omitted  from  this  study  because  of  certain 
data  missing,  but  a  special  comparison  with  the 
other  clinics  is  given  in  the  special  tuberculosis 
study  published  in  the  March,  1920,  issue  of  the 
American  Review  of  Tuberculosis. 

Lungs. — Examination  of  lungs  was  recorded 
much  more  often  for  the  conditions  treated  in  the 
general  medical  departments  than  in  any  other.  It 
was  found  recorded  for  55.4  per  cent,  of  all  cases 
of  bronchitis ;  48  per  cent,  of  cases  of  chronic  valvu- 
lar heart  lesions ;  46  per  cent,  of  cases  of  chronic 
nephritis ;  37.3  per  cent,  of  cases  of  chronic  rheu- 


October  16,  1920.] 


OUTPATIENT  MEDICAL  WORK. 


591 


matisni,  and  26.4  per  cent,  of  those  of  gastric  ulcer. 
The  only  other  disease  with  a  high  proportion  of 
lung  examinations  was  rachitis,  for  which  this  pro- 
cedure was  noted  in  36.8  per  cent,  of  instances. 

Heart. — The  examination  of  the  heart  was  re- 
corded for  a  relatively  large  proportion  of  cases 
for  all  conditions,  and  especially  for  the  following 
diseases  treated  in  the  medical  departments ;  chronic 
heart  lesions,  84.9  per  cent. :  chronic  nephritis,  60.7 
per  cent. ;  chronic  rheumatism,  45.3  per  cent. ;  bron- 
chitis, 38.2  per  cent.,  and  gastric  ulcer.  25.6  per  cent. 
The  only  other  diseases  where  examination  of  the 
heart  was  noted  in  a  large  proportion  of  cases  were : 
rachitis,  with  this  item  on  38.5  per  cent,  of  the  his- 
tories studied :  syphilis,  with  it  recorded  in  12.5 
per  cent.,  and  syphilis  of  the  nervous  system,  hav- 
ing it  stated  in  10.1  per  cent,  of  instances. 

Abdomen. — Examination  of  the  abdomen  was 
recorded  most  often  for  the  diseases  treated  in  the 
general  medical  and  pediatric  departments.  This  in- 
formation was  given  on  the  following  proportions 
of  histories  of  the  conditions  stated :  gastric  ulcer, 
58.1  per  cent. ;  heart  lesions,  38.8  per  cent. ;  rachitis, 
38.5  per  cent. ;  nephritis,  33  per  cent. ;  malnutrition, 
34  per  cent.;  bronchitis.  17.6  per  cent.;  rheumatism, 
16  per  cent. 

Genitourinary  examination. — Genitourinary  ex- 
amination was  noted  for  only  six  of  the  diseases 
studied :  85  per  cent,  of  cases  of  lacerated  perineum ; 
21.1  per  cent,  of  gonorrhea  patients:  4.1  per  cent, 
of  syphilis ;  2.4  per  cent,  of  epilepsy ;  .9  per  cent, 
each  of  rheumatism  and  heart  lesions. 

Muscles  and  bones. — Examination  of  muscles 
and  bones  was  recorded  more  often  for  rachitis  (in 
73.7  per  cent,  of  instances)  than- for  any  other  con- 
dition. This  information  was  noted  on  the  histories 
of  50.7  per  cent,  of  the  fracture  cases;  18.6  per 
cent,  of  cases  of  chronic  nepliritis ;  17.3  per  cent, 
of  cases  of  chronic  rheumatism,  and  eleven  per  cent, 
of  cases  of  malnutrition. 

Skin. — Examination  of  the  skin  was  recorded  for 
53.1  per  cent,  of  patients  treated  for  eczema.  Case 
histories  of  cellulitis  and  syphilis  also  had  examina- 
tion of  the  skin  recorded  for  a  large  number  of 
cases — in  30.9  per  cent,  and  23.4  per  cent,  of  in- 
stances, respectively. 

Nervous  system. — The  cases  of  syphilis  of  the 
nervous  system  studied  were  gi\en  an  examination 
of  the  nervous  system  in  79.7  per  cent,  of  instances. 
The  other  diseases  for  which  such  examinations 
were  recorded  were :  epilepsy,  with  this  procedure 
stated  for  24.3  per  cent,  of  cases :  chronic  nephritis, 
with  it  recorded  in  13.7  per  cent. ;  chronic  rheuma- 
tism, in  12.9  per  cent. ;  syphilis,  in  12.5  per  cent. : 
malnutrition  in  8.2  per  cent.,  and  heart  lesions,  in 
7.7  per  cent,  of  instances. 

Special  senses. — An  examination  of  the  special 
senses  was  also  recorded  for  a  very  high  proportion 
(79.7  per  cent.)  of  cases  of  syphilis  of  the  nervous 
system.  Such  examination  was  also  noted  for  a 
large  number  of  cases  of  conjunctivitis  (65.5  per 
cent.)  ;  trachoma  (60  per  cent.)  :  otitis  media  (31.1 
per  cent.)  and  primary  and  secondary  lues  (21.8  per 
cent.). 

G/aHc?^.— Examination  of  glands  was  recorded 
for    only    eight    of    the    diseases    studied,  and 


for  a  very  small  proportion  of  cases  of  each  of 
these  conditions  except  malnutrition,  for  which  this 
item  was  noted  on  sixteen  per  cent,  of  histories. 

Teeth. — Teeth  were  examined  for  a  relatively 
high  proportion  of  patients  treated  in  the  general 
medical  departments  and  for  malnutrition.  The 
cases  diagnosed  as  rheumatism  received  the  most 
attention  in  this  respect,  such  examination  being  re- 
corded in  26  per  cent,  of  instances.  It  was 
also  reported  for  22.5  per  cent,  of  cases  of  nephritis ; 
for  20  per  cent,  of  cases  of  malnutrition ;  for  16 
per  cent,  of  heart  lesions ;  10.6  per  cent,  of  bron- 
chitis, and  6.8  per  cent,  of  cases  of  gastric  ulcer 
studied. 

Throat. — Examination  of  the  throat  was  record- 
ed about  as  often  as  was  examination  of  the  teeth, 
but  for  twice  as  many  cases  of  malnutrition  as  of 
chronic  rheumatism.  The  conditions  receiving  the 
largest  proportions  of  throat  examinations  were : 
malnutrition.  20  per  cent. ;  nephritis,  18.6  per  cent. ; 
chronic  heart  lesions,  16.6  per  cent. ;  bronchitis,  14.4 
per  cent. :  rheiunatism,  10  per  cent. ;  otitis  media. 
8.2  per  cent. ;  rachitis,  7  per  cent.,  and  syphilis,  6.7 
per  cent. 

Tongue. — The  condition  of  the  tongue  was  noted 
most  often  for  the  disease  treated  in  the  general 
medical  and  neurological  departments.  This  infor- 
mation was  noted  for  chronic  nephritis  in  7.8  per 
cent,  of  instances ;  for  syphilis  of  the  nervous  sys- 
tem in  7.2  per  cent. ;  for  heart  lesions  in  5.5  per 
cent.:  for  bronchitis  in  5.3  per  cent.:  for  epilepsy 
in  4.8  per  cent.,  and  for  malnutrition  in  4.7  per 
cent,  of  cases. 

Temperature. — Temperature  was  recorded  for  a 
larger  number  of  cases  of  malnutrition  (27.6  per 
cent. )  than  of  any  other  condition.  This  item  was 
also  recorded  on  the  histories  of  heart  lesions  in 

26.4  per  cent,  of  instances ;  for  chronic  nephritis  in 

20.5  per  cent. ;  for  bronchitis  in  16.6  per  cent. ;  for 
rachitis  in  15.8  per  cent,  and  for  rhetimatism  in 
14  per  cent,  of  instances. 

Pulse. — Pulse  was  noted  for  cases  of  heart  le- 
sion in  a  larger  proportion  of  instances  (35.6  per 
cent.)  than  for  any  other  disease.  This  item  was 
recorded,  however,  for  19.7  per  cent,  of  cases  of 
nephritis ;  for  14  per  cent,  of  cases  of  rheumatism ; 
for  8.6  per  cent,  of  cases  of  malnutrition,  and  for 

7.7  per  cent,  of  those  of  bronchitis. 
Respiration. — Respiration  was  noted  for  only  six 

of  the  various  conditions  studied ;  23.5  per  cent,  of 
cases  of  chronic  nephritis ;  22  per  cent,  of  chronic 
valvular  heart  lesion ;  4.9  per  cent,  of  bronchitis : 

3.8  per  cent,  of  malnutrition ;  2.6  per  cent,  of 
chronic  rheumatism,  and  .4  per  cent,  of  eczema. 

Weight. — Weight  was  recorded  for  only  seven  of 
the  different  conditions  studied,  as  follows:  16  per 
cent,  of  cases  of  malnutrition:  12.7  per  cent,  of 
nephritis  :  8.9  per  cent,  of  rheumatism  ;  7.7  per  cent, 
of  heart  lesions;  5.1  per  cent,  of  gastric  ulcer;  3.8 
per  cent,  of  bronchitis,  and  .5  per  cent,  of  syphilis. 
The  instance  last  noted  was  the  only  case  where 
weight  has  found  recorded  outside  of  the  general 
medical  and  pediatric  departments. 

Blood  pressure. — Blood  pressure  was  never  found 
recorded,  except  in  the  general  medical  and  pediatric 
departments,  and  for  only  a  small  percentage  of 


592 


ori  r.iriiiNT  mepicai.  /coa'A' 


[New  York 
Medicm.  I(u  rnai  . 


llu"  ilisoascs  Irt'atcil  in  llu'sc  ilrparlnu'iils,  with  tho 
except  ion  of  nephritis,  for  which  this  jirctcedure 
was  nolcd  in  17.8  per  cent,  of  instances:  rheuma- 
tism, for  whicli  it  was  stated  for  7.vi  per  cent,  ami 
heart  lesions,  for  5  j^er  cent.  o\  instances. 

(iciicral  {physical  c.vaiiiiiiatioii. — By  far  the  more 
adeciuate  general  physical  examinations  were  re- 
corded in  the  general  medical,  pediatric,  and  neu- 
rological departments,  which,  as  has  heen  empha- 
sized heretofore,  treat  contlitions  systemic  in  na- 
ture. \'ery  little  jihysical  examination  was  noted 
on  the  histories  from  the  siu-gical  departments,  or 
for  gonorrhea,  wliether  treated  in  gynecological  or 
genitourinary  departments.  The  eye,  ear,  nose  and 
throat  departments  also  had  little  record  of  physical 
examination,  except  of  the  .special  senses.  Of  all 
the  items  of  physical  examination  stated  for  the 
various  diseases  studied,  examination  of  the  heart 
was  recorded  for  the  largest  proportion,  20.8  per 
cent,  of  all  the  cases.  The  hmgs,  also,  were  ex- 
amineil  in  a  relatively  high  projiortion  of  all  cases, 
18.3  per  cent. ;  the  ahdomen  in  12.6  per  cent.,  the 
.skin  in  10.7  jier  cent.,  and  the  special  senses  in  10.4 
per  cent,  of  instances.  All  other  divisions  of  physical 
examination  were  recorded  for  less  than  10  per 
cent,  of  ca.ses :  temperature;  pulse;  examination  of 
teeth,  throat,  genitourinary  tract,  muscles  and  hones, 
nervous  system,  all  for  hetween  tive  and  ten  per 
cent,  of  paticTits  whose  histories  were  analyzed ; 
while  examinations  of  tongue,  glands,  weight,  hlood 
l>ressure  and  resjiiration  were  recorded  for  less  than 
four  per  cent,  of  cases. 

Of  all  the  contlitions  studied  gonorrhea,  as  indi- 
cated hy  the  records,  would  .seem  to  have  been 
given  the  least  of  general  physical  examination,  as 
on  77.5  per  cent,  of  case  histories  of  this  condition, 
examination  was  not  noted.  Likewise,  (i8.8  per 
cent,  oi  ca.ses  of  otitis  media,  (i8.1  per  cent,  of  cellu- 
litis, 58.5  per  cent,  of  ejiilepsy ;  4^.2  per  cettt.  of 
fractmv.  48.4  per  cent,  of  syj^hilis,  M^  per  cent,  of 
eczema  ami  40  per  cent,  of  trachoma  hail  no  ])hysical 
examination  recorded.  The  diseases  accorded  the 
highest  proportions  of  physical  examinations  were : 
syphilis  of  the  nervous  system,  for  which  some  ex- 
amination was  recoriled  for  all  hut  10.1  per  cent, 
of  cases;  heart  lesions,  for  which  this  item  was 
noted  for  all  hut  11.4  per  cent.,  anil  lacerated  per- 
ineum, all  but  14.(1  per  cent,  of  which  were  examined. 

l..\HOR.\TORV  TliSTS. 

I'ranalysis. — In  accordance  with  natural  expecta- 
tion, the  analysis  of  urine  for  sugar  and  alhumin 
was  recorded  for  a  higher  projiortion  of  cases  of 
chronic  nephritis  than  of  any  other  conditioii  and 
that  was  in  only  39.2  per  cent,  of  the  cases.  This 
]irocedure  was  noted  for  12.8  per  cent,  of  cases  of 
lieart  lesions;  for  g-astric  ulcer  in  11.1  ptr  cent.; 
for  rheumati.sm  in  9.7  per  cent,  and  for  epilepsy  in 
4.*^)  per  cent,  of  instances.  Microscopic  uranalysis 
was  reconleil  more  often  for  gonorrhea  than  for 
chronic  nejihritis,  this  item  being  noted  in  44.9  per 
cent,  of  cases  for  the  former  and  37.2  per  cent,  for 
the  latter  condition.  The  other  diseases  having  this 
procedure  noted  in  a  relatively  high  proportion  of 
ca.ses  were,  heart  lesions.  10.5  per  cent. ;  rheuma- 
tisni.  10.4  per  cent.;  gastric  ulcer.  (•>  per  cent.,  and 
epilepsy.  4.9  per  cent. 


Sk'iayraf'liir  I'.vaiiiiiu.lion. —  .\n  x  ray  examination 
was  recorded  on  some  proportion  of  the  histories  of 
all  di.sea.ses  studied  except  eczema,  conjunctivitis  and 
trachoiua:  and  for  a  relatively  higher  proportion  in 
cases  of  fracture  (56.7  per  cent.)  and  of  gastric 
ulcer  (45.3  per  cent.)  than  in  others.  The  patients 
with  chronic  nephritis  had  rontgenographic  exami- 
nation recorded  in  7.8  per  cent,  of  instances ;  those 
with  rheumatism  in  6  per  cent. ;  those  with  rachitis 
in  5.3  per  cent.;  and  those  with  other  conditions  all 
in  proiwrtions  less  than  5  per  cent. 

WasscniuDui  test. — Although  the  Wassermann 
test  was  noted  for  a  slightly  higher  proportion  of 
cases  than  was  the  x  ray  examination,  the  applica- 
tion of  the  former  was  more  restricted,  as  four  con- 
ditions (  fracture,  cellulitis,  conjunctivitis,  and  tra- 
choma) had  no  record  of  this  ]>rocediu-e.  .\s  would 
he  expected,  syphilis  and  syphilis  of  the  nervous 
system  received  this  examination  most  often — in 
(V.2  per  cent,  and  78.2  per  cent,  of  cases  respect ive- 
Iv.  The  only  other  conditiiMi  having  this  itetri  noted 
for  more  than  the  average  number  of  cases  was 
epilepsy,  with  the  Wassermaim  test  recorded  for 
12.2  per  cent,  of  cases. 

lilood  cxaiiiiiiatioii. — A  blood  count  or  hemoglo- 
bin test  was  noted  much  more  often  for  cases  of 
g"astric  ulcer,  being  recorded  in  11.1  per  cent,  ot 
instances,  than  for  any  other  condition.  Blooil  ex- 
amination was  entered  on  the  histories  of  3.6  per 
cent,  of  cases  of  malnutrition,  and  iJi  nephritis  for 
2.9  per  cent.,  in  heart  lesions  for  1.8  per  cent.,  in 
syphilis  of  the  nervous  system  for  1.4  per  cent.; 
and  in  syphilis,  rheumatism  and  bronchitis,  each  for 
less  than  one  per  cent,  of  the  cases  studied. 

.liialysis  of  -  sf^utunt. — Analysis  of  sputum  was 
recorded  for  only  5;ix  of  the  conditions  studied,  as 
follows:  for  bronchitis  in  7.8  per  cent,  of  cases;  for 
gastric  ulcer  in  3.4  per  cent. ;  for  nephritis  in  2  j^er 
cent. ;  for  heart  lesions  and  malnutrition,  each  in 
1.8  per  cent.,  and  for  rheumatism  in  .7  per  cent. 

()//((•/•  laboratory  tests. — A  Von  Pirquet  test  was 
recorded  for  8.6  per  cent,  of  cases  of  malnutrition, 
1.8  per  cent,  of  heart  lesions.  .8  per  cent,  of  eczema 
and  .3  per  cent,  of  bronchitis.  Siuear  was  noted 
for  34  jier  cent,  of  the  jiatients  with  gonorrhea ;  2.3 
per  cent,  of  those  with  heart  lesions;  1.9  per  cent, 
of  those  with  lacerated  perineum;  1.1  per  cent,  with 
conjunctivitis,  and  .5  per  cent,  with  syphilis.  A  com- 
plement fixation  test  was  recorded  for  4.8  per  cent, 
of  cases  of  epilepsy,  .7  per  cent,  of  rheumatism  and 
.5  per  cent,  of  eczema.  Spinal  puncture  was  noted 
on  the  case  histories  of  only  three  conditions — 21.7 
per  cent,  of  the  cases  of  syphilis  of  the  nervous 
svstem ;  5.1  per  cent,  of  cases  of  gonorrhea,  and  1.6 
per  cent,  of  s}-philis.  Stools  were  examineil  for 
blood  in  only  one  case  of  gastric  ulcer.  A  test  meal 
was  noted  on  the  records  of  but  two  conditions :  for 
37.6  per  cent,  of  the  cases  of  gastric  ulcer  and  for 
.9  per  cent,  of  patients  with  heart  lesions. 

GEXERAl.  COMP-XRISOX 

Laboratory  tests  were  recorded  as  having  been 
employed  much  more  often  for  the  diseases  treated 
in  the  general  medical  departments  than  for  those 
from  the  other  clinics.  Of  all  the  laboratory  tests 
for  the  conditions  di.scus.sed,  x  ray  exatnination  and 
the  Wassermann  test  were  .stated  to  have  been  used 


October  16,  V-120.1 


LONDON  LETTER. 


59J 


for  the  highest  proportion  of  cases,  9.5  per  cent,  and 
9.6  per  cent,  respectively.  Microscopic  uranalysis 
was  noted  for  6.6  per  cent,  of  cases ;  analysis  of 
urine  for  sugar  and  albumin  for  5  per  cent. ;  smear 
for  2.3  per  cent. ;  and  test  meal,  examination  of 
stools,  hemoglobin  and  blood  count,  sputum.  Von 
Pirquet,  complement  fixation  tests  and  spinal  punc- 
ture investigations  for  only  small  proportions  of 
cases  (less  than  two  per  cent.). 

The  diseases  for  which  the  highest  proportions  of 
laboratory  tests  were  recorded  were :  syphilis  of 
the  nervous  system,  which  had  this  procedure 
noted  in  some  form  for  84  per  cent,  of  cases ; 
syphilis,  with  tests  recorded  in  67.2  per  cent,  of 
instances ;  nephritis  and  gonorrhea,  with  this  in- 
formation on  66.7  per  cent,  of  case  histories  for 
each ;  gastric  ulcer  in  59  per  cent.,  and  fracture  in 
56.7  per  cent,  of  instances.  No  laboratory  tests 
whatever  were  recorded  for  the  cases  of  trachoma 
studied  ;  98.8  per  cent,  of  the  cases  of  conjunctivitis ; 

96.5  per  cent,  of  cases  of  otitis  media ;  98.2  per 
cent,  of  cases  of  cellulitis ;  95.4  per  cent,  of  cases 
of  eczema,  and  93.2  per  cent,  of  rachitis,  received 
no  laboratory  tests. 

The  highest  proportion  of  any  laboratory  test  for 
a  given  condition  was  78.2  per  cent,  of  Wassermann 
reaction  for  syphilis  of  the  nervous  system.  The 
following  conditions  all  received  laboratory  tests  in 
a  high  proportion  of  cases :  syphilis,  67.2  per  cent, 
of  Wassermann;  fracture,  56.7  per  cent.,  and  gastric 
ulcer,  45.3  per  cent,  of  x  ray;  gonorrhea,  44.9  per 
cent,  of  microscopic  uranalysis ;  nephritis,  39.2  per 
cent,  of  uranalysis  for  sugar  and  albumin  and  37.2 
per  cent,  of  microscopic  uranalysis ;  gastric  ulcer, 

37.6  per  cent,  of  test  meals  and  gonorrhea,  thirty- 
four  per  cent,  of  smears. 

CONCLUSION. 

The  foregoing  analysis  speaks  for  itself.  The 
dispensaries  and  out  patient  departments  of  hospi- 
tals evidently  do  not  utilize  sufficiently  their  op- 
portunities for  the  application  of  accurate  methods 
in  diagnosis  and  treatment.  An  improvement  in 
these  respects  and  in  the  general  adaptation  of  the 
dispensaries  to  the  functions  they  are  intended  to 
fulfill  is  much  to  be  desired  in  the  interests  of  both 
medical  advancement  and  public  health. 


LONDON  LETTER. 
{From  our  own  correspondent) 

British  Association  for  the  Advancement  of  Science. 

London,  September  4,  ig20. 

On  August  24,  1920,  the  eighty-eighth  annual 
meeting  of  the  British  Association  for  the  Ad- 
vancement of  Science  opened  at  Cardiff,  Wales,  and 
was  well  attended  by  British  men  of  science  and 
oversea  visitors.  The  president  for  the  year  is  Pro- 
fessor W.  A.  Herdman,  professor  of  oceanography 
in  the  University  of  Liverpool.  The  association 
was  founded  at  York  in  1831  as  a  result  of  the 
efiforts  of  Sir  David  Brewster  and  can  point  to  a 
great  past,  when  men  like  Humphrey  Davy,  Her- 
schel,  Playfair,  Hurley,  Lyndall,  Kelvin,  Clark 
Maxwell,  Abel,  \'ernon  Harcourt,  Murchison,  and 
a  host  of  others  were  the  shining  lights  in  the  sci- 


entific firmament.  The  association  generally  deals 
with  questions  of  medical  interest,  and  the  meeting 
this  year  is  no  exception  to  the  rule. 

Professor  Karl  Pearson,  in  his  presidential  ad- 
dress before  the  Section  of  Anthropology,  impressed 
upon  his  audience  that  anthropology  must  be  pur- 
sued on  broader  lines  if  it  were  to  yield  more  use- 
ful results  to  mankind.  He  confessed  that  per- 
haps he  was  a  scientific  heretic  in  that  he  did  not 
believe  in  science  for  its  own  sake  but  for  man's 
sake.  What,  he  asked  were  anthropologists  doing 
during  the  war  with  their  own  science  ?  The  whole 
period  of  the  war  produced  the  most  difficult  prob- 
lems in  folk  psychology.  There  were  occasions  in- 
numerable when  thousands  of  lives  and  heavy  ex- 
penditure of  money  might  have  been  saved  by  a 
greater  knowledge  of  what'creates  and  what  discour- 
ages folk  movements  in  the  various  races  of  the 
world.  India,  Egypt,  Ireland,  even  our  present  re- 
lations with  Italy  and  America,  showed  only  too 
painfully  how  difficult  we  found  it  to  appreciate 
the  psychology  of  other  nations.  We  would  not  sur- 
mount these  difficulties  until  anthropologists  took  a 
wider  view  of  the  material  they  had  to  record.  It 
was  not  the  physical  measurement  of  native  races 
which  was  a  fundamental  feature  of  anthropometr}- 
today;  it  was  the  pyschometry  and  vigorimetry  of 
white  as  well  as  of  darked  skinned  men  that  must  be- 
come the  main  subject  of  study.  Anthropology  should 
be  made  a  wise  counsellor  of  the  state,  a  counsellor 
in  political,  commercial,  and  social  matters.  "I  will 
not,"  said  Professor  Pearson,  "go  so  far  as  to  say 
that  if  the  science  of  man  had  been  developed  to  the 
extent  of  physical  science  in  all  European  countries, 
and  had  then  had  its  due  authority  recognized,  there 
would  have  been  no  war,  but  I  will  venture  to  say 
that  the  war  would  have  been  of  a  diflferent  char- 
acter and  we  should  not  have  felt  that  the  fate  of 
European  society  and  European  culture  hung  in  the 
balance,  as  at  this  moment  they  certainly  do." 

The  man  of  today  is  precisely  what  his  past  history 
and  his  prehistory  have  made  him.  It  is  impossible 
to  build  your  man  for  the  future  until  you  have 
studied  the  origin  of  his  physical  and  mental  con- 
stitution. Whence  did  he  draw  his  good  and  evil 
characteristics?  Are  they  the  product  of  his  nature 
or  his  nurture?  Man  has  not  a  plastic  mind  and 
body  which  the  enthusiastic  reformer  can  at  will 
mold  to  the  model  of  his  golden  age  ideals.  He 
has  taken  thousands  of  years  to  grow  into  what  he 
is,  and  only  by  like  processes  of  evolution,  intensified 
and  speeded  up,  if  we  work  consciously  and  with 
full  knowledge  of  the  past,  can  we  build  his  future. 
It  does  matter  in  regard  to  the  gravest  problems 
before  mankind  today  whether  our  ancestry  was 
hylobatic  or  troglodyte.  If  the  spirit  of  violence  lie 
innate  in  man,  if  there  be  times  when  he  not  only 
sees  red  but  rejoices  in  it,  and  that  was  the  stronger 
impression  I  formed  when  I  crossed  Germany  on 
August  1,  1914,  then  outbreaks  of  violence  will  not 
cease  till  troglodyte  mentality  is  bred  out  of  man. 
That  is  why  the  question  of  troglodyte  or  hylobatic 
ancestry  is  not  a  pursuit  of  dead  bones.  It  is  a  vital 
jiroblem  on  which  turns  much  of  folk  psychology. 
It  is  a  problem  utile  to  the  state." 


Editorial  Notes  and  Comments 


NEW  YORK  MEDICAL  JOURNAL 

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NEW  YORK,  SATURDAY,  OCTOBER  16,  1920. 


DISORDERLY  ACTION  OF  THE  HEART. 

During  the  war  disorderly  action  of  the  heart  was 
greatly  in  evidence  and  the  condition  was  closely 
studied.  Much  useful  knowledge  on  the  subject  has 
been  accumulated  which  should  be  and  no  doubt  will 
be  of  much  service  in  medical  practice,  as  it  must  be 
borne  in  mirid  that  this  symptom  complex  is  by  no 
means  confined  to  those  who  have  served  in  the 
army.  Dr.  W.  I.  Ritchie  read  a  paper  on  prognosis 
in  certain  affections  of  the  heart  before  the  Medico- 
Chirurgical  Society  of  Edinburgh  on  July  7,  1920. 
published  in  the  Lancet  on  September  25th,  in  which 
he  refers  at  some  length  to  disorderly  action  of  the 
heart.  He  pointed  out  that  when  the  man  who  was 
always  a  weakling,  unfit  to  play  games  at  school,  and 
who  found  the  true  level  in  a  quiet,  sedentary,  un- 
ambitious walk  of  life,  attempts  to  undertake  larger 
responsibilities,  he  becomes  incapacitated  by  the 
giddiness,  fatigue,  palpitation,  precordial  pain,  and 
other  symptoms  characterizing  this  disorder.  This 
type  of  person  will  never  become  robust,  but  those 
in  whom  the  disorder  has  arisen  as  a  sequel  to  shell 
concussion,  or  in  civil  life  to  some  other  form  of 
trauma,  may  be  expected  to  improve  slowly  under 
judicious  treatment. 

After  excluding  this  group  of  cases,  and  those 
in  whom  is  found  visceroptosis,  obesity,  arterio- 
sclerosis, early  pulinonary  tuberculosis  and  hyper- 
thyroidism, Ritchie  states  that  in  over  .forty  per 
cent,  of  these  patients  there  is  evidence  of  some 


recent  infection,  and  in  an  additional  ten  per  cent, 
there  is  anemia,  presumably  of  toxic  origin.  In  all 
these  cases,  fifty  per  cent,  of  the  total,  the  prognosis, 
in  Ritchie's  opinion,  is  good.  In  fact  it  is  not  the 
heart  that  is  primarily  at  fault.  Therefore  do  not 
give  a  guarded  prognosis  and  coddle  the  patient. 
A  good  prognosis  is  the  first  essential  in  restoring 
the  patient's  confidence.  He  should  be  told  that 
there  is  little  the  matter  with  him.  not  be  allowed 
to  remain  in  bed,  nor  waited  upon  more  than  is 
absolutely  necessary. 

At  first  massage  and  passive  exercise  are  of 
value  and  when  he  has  begun  to  walk  he  should 
be  encouraged  to  undertake  an  increasing  amount 
of  physical  exercise  daily.  He  should  soon  be  taking 
active  e.xercise  out  of  doors.  Drugs  are  seldom  in- 
dicated and  digitalis  is  wholly  useless.  In  the  army 
this  mode  of  treatment  was  remarkably  successful. 
However,  in  civil  life  the  prospects  of  good  recoverv 
are  not  so  uniformly  good.  The  patient  does  not 
lead  such  a  healthy  life  as  does  a  soldier;  he  is  less 
amenable  to  control.  Physical  training  under  skilled 
supervision  is  costly,  and  not  so  efficient  as  in  the 
army ;  there  are  devoted  relatives  whose  influence  is 
the  reverse  of  helpful,  and  in  certain  grades  of  the 
community  there  is  the  sure  expectation  that  inca- 
pacity for  work  will  be  compensated  by  grants  from 
public  funds.  Yet,  with  all  these  drawbacks,  Ritchie 
assures  us  that  brilliant  results  may  be  obtained,  and 
a  man  or  woman  who  has  been  practically  bedridden 
for  months  may,  within  a  few  weeks,  be  leading  an 
active  and  useful  life.  It  is  also  instructive  to  learn 
that  the  cases  in  which  the  dominant  manifesta- 
tions are  those  of  neurasthenia  are  the  most  intract- 
able and  the  most  prone  to  relapse. 

The  diagnosis  of  heart  disease,  or  rather  the  dif- 
ferential diagnosis  of  organic  and  functional  heart 
disease,  is  a  matter  concerning  which  the  general 
practitioner  often  knows  little.  Gross  lesions  he  is 
able  to  detect,  but  the  more  subtle  forms  of  heart 
disorder  he  is  likely  to  pass  by  or  to  magnify  greatly. 
This  inability  to  diagnose  correctly  was  shown  over 
and  over  again  during  the  war  when  men  were 
labelled  as  having  heart  disease,  who  on  examination 
by  really  experienced  physicians  were  found  to  be 
practically  sound  in  this  respect. 

To  Sir  Tames  Mackenzie  is  chiefly  due  the 
honor  of  demonstrating  how  to  diagnose  affec- 
tions of  the  heart  and  how  to  treat  them.  There 
is  no  doubt  that  Ritchie  is  right  in  recommend- 
ing that  a  good  prognosis  should  be  given  in 
these    cases    and    that    the    patient    should  take 


October  16,  1920.] 


EDITORIAL  ARTICLES 


595 


regulated  physical  exercise.  Sane  and  rational  ways 
of  treating  heart  disorders  have  happily  come  into 
>  vogue  based,  of  course,  on  correct  diagnosis.  It  is 
obvious  that  in  order  that  correct  diagnosis  may  be 
arrived  at  the  medical  student  and  practitioner  must 
be  well  trained  in  modern  methods  of  diagnosis  and 
treatment. 

PHYSICIAN-AUTHORS:  JOSIAH  GILBERT 
HOLLAND 
The  medical  profession  is  not  always  a  royal  road 
to  wealth.  This  is  not  an  exciting  bit  of  news.  A 
number  of  physicians  have,  from  time  to  time,  had 
more  than  a  suspicion  of  the  fact.  In  sooth,  there 
have  been  authentic  instances  where  physicians  have 
considered  it  necessary  to  abandon  the  profession 
to  keep  body  and  soul  together — an  extreme  measure 
that  reflects  only  on  the  resourcefulness  of  the 
physician.  There  is  the  case  of  Dr.  Josiah  Gilbert 
Holland.  Whether  it  was  youthful  impatience,  or 
injudicious  location,  or  some  other  reason,  is  not 
known,  but  Dr.  Holland  became  discouraged  after 
about  two  years'  practice  and  returned  to  other  pur- 
suits. He  had  studied  four  years  at  the  Berkshire 
Medical  College,  at  Pittsfield,  Mass.,  receiving  his 
degree  in  1844,  and  entered  practice  at  Springfield, 
Mass. 

Holland  did  not  immediately  return  to  editorial 
work  and  literature,  in  which  field  he  became  a  best 
seller.  He  spent  a  few  months  as  a  country  school 
teacher  and  traveling  daguerreotypist  and  got  his 
first  taste  of  journalism  as  publisher  of  the  Bay  State 
Weekly  Courier.  The  Courier  failed  in  a  few 
months  and  he  went  to  Richmond,  Va.,  to  teach 
school.  He  seemed  to  have  been  fairly  well  launched 
on  a  career  as  an  educator,  for  his  next  position  was 
as  superintendent  of  the  public  schools  of  Vicks- 
burg.  Miss.,  but  in  1849  he  got  an  opportunity  to 
join  the  staff  of  the  Springfield,  Mass.,  Republican, 
and  accepted  it.  His  writings,  mostly  under  the 
pseudonym  of  Timothy  Titcomb,  were  largely 
responsible  for  putting  the  Republican  in  the  front 
rank  of  American  newspapers.  In  time  he  became 
part  owner  of  the  Republican  and  in  1866  sold  his 
interest  for  fourteen  times  as  much  as  he  had  paid 
for  it.  He  then  took  a  long  vacation  in  Europe  and 
it  was  there  he  planned  a  new  monthly  magazine, 
originally  known  as  Scribucr's  MontJily  from  which 
has  grown  the  Century  Magazine  of  today.  Holland 
was  the  editor  of  the  magazine  from  its  establish- 
ment until  his  death. 

As  a  writer  Holland  was  preeminently  a  moralist. 
With  him  literary  work  never  was  a  matter  of 
art  for  art's  sake.  His  was  the  role  of  uplifter. 
Because  of  this  lack  of  literary  finish  his  work 


was  freely  criticized.  Reviewers  fell  upon  him 
mercilessly,  but  that  fact  did  not  deter  the  less 
fastidious  public  from  buying  his  books  by  the 
hundreds  of  thousands.  Perhaps  the  most  popular 
of  his  prose  was  the  novel  Seven  Oaks  and  his  most 
popular  verse  the  long  narrative  poem,  Bitter  Sweet, 
which  James  Russell  Lowell  called  "an  obstinately 
charming  little  book."  "We  mean  it  as  very  high 
praise,"  said  Lowell,  "when  we  say  that  Bitter  Sweet 
is  one  of  the  few  books  that  have  found  the  secret 
of  drawing  up  and  assimilating  the  juices  of  this 
New  World  of  ours."  Katlirina,  another  of  Hol- 
land's long  poems,  was  a  close  rival  of  Longfellow's 
Hiawatha  in  its  day.   Today  it  is  almost  unknown. 

It  was  Holland's  poetry  that  drew  most  of  the 
fire  of  the  critics.  The  New  York  Sun  had  dubbed 
him  "the  American  Tupper,"  for  like  Tupper  (Mar- 
tin Farquahar  Tupper,  an  English  writer  who  was 
at  the  time  an  object  of  great  derision)  he  did  much 
commonplace  moralizing.  The  Tupper  designation 
clung  to  him  the  rest  of  his  life  and  hurt  him  deeply. 
Edward  Eggleston,  author  of  The  Hoosier  School- 
master, described  Dr.  Holland  as  a  man  of  dignified 
and  impressive  presence,  "a  man  of  rare  simplicity 
who  loved  approbation  and  craved  affection."  To 
such  a  man  the  undisguised  sneers  of  the  reviewers 
were  gall  in  his  cup  of  happiness  over  large  sales. 
But  though  the  judgment  of  the  critics  was  against 
his  writings,  there  was  none  that  failed  to  recognize 
the  charm  of  his  personality  and  Richard  Watson 
Gilder  and  Edmund  Clarence  Stedman,  among 
others,  felt  the  loss  of  him  so  keenly  that  they  in- 
scribed poems  to  his  memory. 

Besides  Bitter  Sweet  and  Kathrina,  Dr.  Holland's 
poetry  also  included  Garnered  Sheaves,  a  collection 
of  shorter  poems ;  and  The  Puritan's  Guest  and  The 
Mistress  of  the  Manse,  lengthy  poems  of  early  New 
England  life.  His  novels,  in  addition  to  Seven  Oaks, 
included  Miss  Gilbert's  Career,  NicJwlas  Minturn, 
Arthur  Bonnicastle  and  The  Bay  Patli  all  of  which 
had  New  England  settings  and  all  of  which  were 
greatly  popular.  His  novels  were  undoubtedly  his 
best  work,  artistically  considered.  He  also  pub- 
lished several  books  of  shorter  prose  writings,  the 
inspirational  nature  of  which  may  be  judged  from 
their  titles — Letters  to  the  Young,  Gold  Foil,  Plain 
Talks  on  Faviily  Subjects  and  others.  He  also  wrote 
The  Life  of  Abraham  Lincoln,  of  which  nearly 
200,000  copies  were  sold.  Holland  also  was  a  pop- 
ular lecturer  on  social  topics  and  took  an  active  part 
in  the  civic  life  of  New  York.  In  1872  he  was 
ai:)pointed  a  member  of  the  city  board  of  educa- 
tion and  later  became  president  of  the  board.  He 
also  was  chairman  of  the  board  of  trustees  of  New 
York  University.    He  died  suddenly  in  New  York 


596 


EDITORIAL  ARTICLES 


[New  York 
Medical  Journal. 


on  October  12,  1881,  at  the  age  of  sixty-two,  having 
been  born  on  July  24,  1819.  at  Belchertown,  Mass. 
Death  came  as  he  was  busy  writing  an  editorial  on 
poverty  as  a  means  of  developing  character.  The 
editorial,  half  finished,  was  based  on  the  lives  of 
Presidents  Lincoln  and  Garfield.  The  latter,  a  per- 
sonal friend  of  Holland,  had  just  died  as  the  result 
of  wounds  inflicted  by  the  assassin  Guiteau. 


TORSION  OF  THE  SPERMATIC  CORD. 

Among  the  clinical  lesions  of  the  testicle  resulting 
from  morbid  changes  in  its  vasculonervous  pedicle 
torsion  of  the  cord  is  paramount.  In  order  that  the 
testicle  can  twist  on  the  cord  the  gland  must  plunge 
in  the  vaginalis  as  the  heart  does  in  the  pericardium, 
that  is  to  say,  an  embryonal  defect  exists  having  as  a 
consequence  the  absence  of  the  mesorchium,  the  tes- 
ticle being  suspended  like  a  cherry  on  its  stem.  In 
these  circumstances  a  strain  or  violent  movement  will 
cause  torsion  of  the  pedicle  with  the  resulting  clinical 
phenomena.  \'anverts  was  able  to  collect  only  fortv- 
four  reported  cases  to  which  he  added  one  of  his 
own  and  after  clinical  and  experimental  researches 
on  the  subject  he  came  to  two  conclusions  different 
from  those  of  his  predecessors  which  relate  to  the 
evolution  and  surgical  treatment  of  the  lesions.  Ac- 
cording to  the  opinion  of  most  observers,  torsion  of 
the  cord  almost  invariably  results  in  suppuration  and 
septic  gangrene  of  the  structures  involved.  Now 
A'an\  erts  maintains  that  these  phenomena  only  occur 
when  there  is  a  superadded  infection  and  the  aseptic 
focus  that  the  testicle  represents  after  its  own  cir- 
culation has  been  cut  off  should  not  be  any  more  ex- 
posed to  infection  than  would  be  a  subcutaneous 
hematoma.  For  this  reason  \'anverts  believed  that 
recovery  with  simple  atrophy  of  the  testicle  without 
suppuration  is  the  rule  both  in  man  and  animals. 

The  experiments  undertaken  to  demonstrate  this 
special  viewpoint  were  positive  and  conclusive  in  this 
respect,  so  that  Vanverts  has  been  led  to  regard  the 
testicle  as  being  much  less  compromised  in  its  vitality 
after  torsion  of  the  cord  than  is  generally  admitted 
imless  an  infection  becomes  superadded.  Too  much 
importance  must  not  be  attributed  to  the  vascular 
lesions.  Some  observers — \'olkmann,  Miflet,  Neu- 
mann, and  English — have  recorded  curious  instances 
of  hemorrhagic  gangrene  of  the  testicle  without  tor- 
sion of  the  cord  including  them  either  among  cases 
of  torsion  of  the  testicle  or  among  those  of  primary 
phlebitis  or  arteritis  of  the  vessels  of  the  cord.  In 
fact  torsion  and  phlebitis  often  coexist  as  in  Bevan's 
case  of  gangrene  of  the  testicle  in  which  the  phlebitis 
of  the  spermatic  veins  of  an  ectopic  testicle  was  most 
manifest.    The  venous  coagulum  being  filled  with 


bacteria,  while  torsion  of  the  cord  was  distinctly 
made  out.  In  Nicoladom's  case  the  veins  were  com- 
pletely occluded  and  the  artery  partially  so.  This 
was  likewise  the  condition  found  by  Keers  and  Lang- 
let  in  their  cases. 

Unquestionably,  the  effects  of  torsion  vary  ac- 
cording to  the  presence  or  absence  of  blood  infection 
and  comparatively  with  Chauveau's  researches,  it 
may  be  admitted  that  in  many  if  blood  infection  does 
not  preexist  or  follow,  torsion  ends  in  simple  atrophy 
of  the  testicle.  Although  not  denying  the  frequency 
of  phlebitis  and  venous  and  arterial  thromboses  fol- 
lowing torsion  there  is  reason  to  ask  whether  or  not 
among  these  cases  some  were  not  in  reality  simple 
primary  phlebitis  and  venous  and  arterial  thromboses 
with  a  torsion  more  apparent  than  real  and  Scheeds 
has  remarked  that  torsion  of  the  testicle  may  merely 
be  a  secondary  symptom  and  not  the  cause  of  necro- 
biosis of  the  testicle  which  often  takes  place  spon- 
taneously. But  if  we  consider  only  simple  cases  it 
appears  evident  that  when  no  infection  exists  the 
morbid  changes  arising  in  the  testicle  can  only  be 
attributed  to  some  mechanical  factor.  If  torsion 
causes  a  complete  occlusion  of  the  elements  of  the 
cord  the  surgeon  in  some  cases  provokes  the  same 
condition  of  affairs  with  no  imtoward  results  to  the 
testicle. 

Lucas-Championniere  excised  the  cord  in  eight 
cases  of  operation  for  large  inguinal  hernia  and 
eight  cases  of  operation  for  large  inguinal  hernia  and 
the  operation  in  no  way  aflfected  the  testicle  although 
the  gland  was  deprived  of  its  excretory  duct  and  ar- 
terial supply.  The  gland  at  first  swelled  and  was 
painful  but  the  tumefaction  soon  retrogressed  and 
never  completely  atrophied.  Carlier  is  also  of  the 
opinion  that  an  aseptic  total  excision  of  the  cord  does 
not  necessarily  result  in  necrosis  of  the  testicle  and 
absence  of  atrophy  may,  in  some  cases,  be  attributed 
to  anastomoses  of  the  arteries  of  the  cord  with  the 
arterial  circulation  of  the  bursae. 

These  results  conflict  with  the  findings  in  atrophy 
of  the  testicle  sometimes  occurring  rapidly  after  op- 
erations for  varicocele  in  young  adults  or  in  cases 
of  hernia  where  the  spermatic  artery  has  been  di- 
vided unintentionally.  This  may  be  due  to  absence 
or  insufficiency  of  the  collateral  circulation  in  youth 
— as  in  the  case  of  dogs — hence  the  necessity  of 
maintaining  a  more  complete  arterial  irrigation  of 
the  testicle  in  young  people  than  those  of  advanced 
years.  The  age  of  the  patient,  the  individual  differ- 
ences in  the  blood  supply  and  the  length  of  time  the 
patient  is  followed  after  operation  must  all  be  taken 
into  consideration.  When  this  is  done  sufficiently 
numerous  and  careful  histological  examinations  will 
then  have  some  real  value. 


Octolier  16,  1920.] 


NEWS  ITEMS. 


597 


BASAL  PNEUMONIC  RESIDUES  IN 
CHILDREN. 

It  is  a  well  known  fact  that  after  children  have 
been  suffering  from  pneumococcal  infections  of  the 
lungs  they  fail  to  recover  completely,  and  also 
measles,  whooping  cough,  influenza,  especially  in 
mouth  breathers,  and  in  rickety,  badly  nourished 
children,  frequently  leave  a  bronchopneumonic  con- 
dition which  may  be  overlooked.  In  Tubercle,  Sep- 
tember last.  Dr.  Walker  Overend  urges  a  more  fre- 
quent radiological  examination  of  the  chest  in  chil- 
dren who  have  undergone  attacks  of  any  of  these 
infections.  He  points  out  that  many  of  the  physical 
signs  simulate  those  of  tuberculosis,  and  that  if  there 
should  be  a  clear  family  history  of  tuberculosis,  the 
diagnosis  of  phthisis  may  be  hastily  made  by  the 
medical  attendant  or  by  the  school  medical  officer, 
and  the  child  sent  to  the  tuberculosis  dispensary  for 
further  observation  or  for  sanatorium  treatment. 

It#is  shown  that  Sutherland  and  Jubb  examined 
the  sputum  of  230  children  under  suspicion  of  tuber- 
culosis during  the  period  April,  1911,  to  October, 
1912;  they  found  only  nine  per  cent,  were  positive. 
In  tlie  sputum  of  these  children  the  pneumococcus 
constituted  the  most  abundant  organism.  According 
to  Overend  the  following  statements  seem  justifiable : 
1.  Many  cases  of  illhealth  after  pneumonia  and  in- 
fectious disease  among  children  are  due  to  unre- 
solved pneumonia  produced  by  a  chronic  pneumo- 
coccal infection,  and  are  not  tuberculous.  2.  Bron- 
chiectasis of  the  internal  moiety  of  the  lower  lobe, 
or  of  the  whole  lobe,  is  more  likely  to  follow  at- 
tacks of  chronic  or  indurative  basal  pneumonia ; 
disseminated  patches  of  bronchopneumonia  are  more 
likely  to  produce  areas  of  diffuse  bronchial  dilatation. 
3.  After  removal  of  enlarged  tonsils  and  adenoids, 
the  expediency  of  surgical  intervention  should  again 
be  discussed  if  the  lower  lobe  alone  is  solid,  honey- 
combed with  bronchiectasis  abscesses  and  dilated 
bronchi,  and  also  accompanied  by  symptoms  of 
septic  absorption. 

JACOB'S  LADDER. 
The  harassed  municipal  surgeon  must  sometimes 
wish  an  exact  account  of  Jacob's  ladder  had  been 
given,  for  he  has  to  contend  with  accidents  brought 
about  by  faultily  constructed  ones  which,  breaking, 
twisting,  slipping,  falling,  hurl  a  workman  to  de- 
struction. Then  follow  the  loss  of  time  or  life  to 
the  worker,  surgical  assistance,  sick  allowance  or 
pension,  witnessing  in  the  courts,  and  all  this  proce- 
dure lirought  about  by  faulty  ladders  or,  very  often, 
by  thoughtless  or  daring  men.  People  who  view 
lofty  buildings  under  construction  little  know  that 
so  great  is  the  risk  run  by  workers  that  Rule  1222 
of  the  Industrial  Commission  says  that  none  but 
skilled   workmen  who  thoroughly  understand  the 


dangers  shall  build  the  scafifolding  whose  faulty  con- 
struction may  lead  to  accidents  on  ladders,  etc. 
Another  worry  coming  to  the  municipal  surgeon 
is  the  "contributory  negligence"  one.  The  men  will 
slide  down  levels,  jump  from  higher  levels,  even 
consider  the  ladders  installed  as  a  reflection  on 
their  agility,  or  say  they  breed  habits  of  carelessness. 
Distinct  specifications  are  made  for  the  making  of 
ladders,  but,  we  fear,  faults  creep  in  even  as  in  air- 
plane building.  To  reduce  the  1,000  accidents 
which  occur  almost  yearly  would  be  encouraging  be- 
cause they  do  not  include  many  scaffolding  accidents. 


DISCARNATE  SPIRITS. 
In  these  days,  when  every  morning  there  are 
paragraphs  concerning  those  who  have  slipped  out 
of  the  back  door  of  Life  by  means  of  knife  and 
rope,  gas  fumes,  poison,  it  may  be  consoling  to 
relatives  who  are  burdened  not  only  with  grief  but 
shame,  to  learn  from  the  spiritists  that  there  are 
not  only  good  spirits,  but  weak  ones,  hovering 
around,  working  us  evil,  though  well  meaning. 
These  discarnate  spirits  believe  it  is  sad  sometimes 
that  human  souls  must  tarry  in  this  world  when 
everything  is  against  them.  They  long  to  have  them 
enjoy  the  larger,  freer  life.  If  one  of  these  spirits 
becomes  attuned  to  a  weak  or  diseased  mind,  it 
may  suggest  suicide,  but  purely  from  a  desire  to 
help.  Suicides  are  generally  deemed  irresponsible. 
This  theory  confirms  it ;  but  one  reluctantly  admits 
the  invading  of  our  borderland  by  weak  minded 
spirits.  Devils  and  angels  we  know,  but  how  are 
we  to  discern  these  others? 

 <$>  

News  Items. 


International  Congress  Against  Alcoholism. — 

The  fifteenth  Internal  Congress  against  Alcoholism 
was  held  in  Washington,  D.  C,  September  21st  to 
26th. 

Anniversary  of  Ether  Day. — The  seventy- 
fourth  anniversary  of  Ether  Day  will  be  observed 
with  suitable  exercises  at  the  Massachusetts  General 
Hospital,  on  Monday,  October  18th.  The  address 
will  be  delivered  by  Dr.  Alonzo  E.  Taylor,  of  the 
University  of  Pennsylvania. 

Insanitary  Jails. — The  New  York  City  Police 
Department  plans  to  abandon  many  of  the  jails  in 
the  police  stations  as  the  conditions  have  been  shown 
to  be  insanitary  and  inadequate.  Many  improve- 
ments are  contemplated  and  it  is  thought  that  $500,- 
000  will  be  required  to  make  the  necessary  changes. 

Aged  Count  a  Ship's  Surgeon. — Count  Eugene 
Geraud  Fraysses  is  the  surgeon  on  the  Fabre  liner 
Asia.  He  is  seventy  years  old  and  a  veteran  of 
the  Franco-Prussian  war  of  1870.  He  also  served 
in  the  recent  war  and  has  received  many  decorations, 
including  that  of  commander  of  the  Legion  of 
Honor. 

A  Tuberculosis  Preventorium  in  Grand  Rap- 
ids, Mich. — The  tuberculosis  preventorium  estab- 
lished by  the  Antituberculosis  Society  of  Grand 
Rapids,  Mich.,  was  thrown  open  for  inspection  on 
September  19th.  It  has  accommodation  for  twenty- 
five  patients. 


598 


XEirS  I  TEMS. 


[New  York 
Medical  Journal. 


Yellow  Fever  in  Mexico. — Yellow  fever  is  re- 
ported to  be  spreading  in  ^Mexico.  A  press  dis- 
patch quotes  official  statements  to  the  effect  that 
there  are  100  cases  in  \'era  Cruz  and  between  thirty- 
five  and  fifty  in  Tampico  and  that  the  epidemic  has 
spread  to  other  cities. 

Vacancies  in  the  Social  Hygiene  Board. — The 
United  States  Civil  Service  Commission  announces 
examinations  for  several  vacancies  in  the  United 
States  Interdepartmental  Social  Hygiene  Board,  for 
duty  in  Washington,  D.  C,  and  in  the  field.  For 
full  particulars  regarding  these  examinations  address 
the  Commission.  Washington,  D.  C. 

Poliomyelitis  Commission  in  Massachusetts. — 
A  commission  has  been  appointed  at  Harvard  Uni- 
versity to  investigate  the  outbreak  of  poliomyelitis 
in  Massachusetts,  consisting  of  Dr.  Milton  J.  Ros- 
enau,  professor  of  preventive  medicine,  Dr.  Robert 
W.  Lovett,  professor  of  orthopedic  surgery,  and 
Dr.  Francis  W.  Peabody.  professor  of  medicine. 

Mental  Clinic  for  Children. — A  free  mental 
clinic  for  children  was  opened  at  St.  Joseph's  Hos- 
pital, New  York,  on  Wednesday  afternoon,  October 
13th.  This  clinic  is  equipped  to  examine  and  advise 
both  in  cases  of  mental  disease  and  mental  defect, 
and  is  under  the  direction  of  a  psychiatrist  from  the 
Hudson  River  State  Hospital,  assisted  by  a  psycho- 
metric examiner  from  the  State  Commission  for 
^Mental  Defectives. 

China  Medical  Missionaries  Meet. — The  fol- 
lowing officers  were  elected  by  the  China  Aledical 
Missionary  Association  at  its  annual  meeting  in  Pe- 
king in  February,  1920 :  President.  Dr.  C.  F.  John- 
son, of  Tsinan ;  vice-president,  Dr.  Thomas  Gilli- 
son,  of  Tsinan ;  executive  secretary.  Dr.  R.  C.  Beebe, 
of  Shanghai;  recording  secretary.  Dr.  H.  H.  ^^lorris, 
of  Shanghai;  editor  of  China  Medical  Journal.  Dr. 
E.  M.  Merrins,  of  Shanghai. 

Antinoise  Campaign. — Dr.  Royal  S.  Copeland, 
Health  Commissioner  of  the  City  of  Xew  York, 
from  a  study  of  the  existing  conditions  has  been 
convinced  that  certain  classes  of  industry  should  be 
prevented  from  encroaching  upon  residential  sec- 
tions in  order  that  the  residents  be  protected  from 
the  noise  which  they  produce.  Hucksters,  rattling 
automobiles  and  the  clatter  of  dishes  in  restaurants 
tend  to  increase  the  din.  In  this  way  the  health  of 
the  community  is  affected. 

Personal. — Dr.  Fred  H.  Albee.  of  Xew  York, 
was  the  guest  of  the  Chicago  Medical  Society  at  a 
banquet  given  at  the  University  Club  on  Wednesday. 
October  6th.  Later  Dr.  Albee  delivered  a  lecture 
on  Osteoplastic  Surgery,  which  was  illustrated  with 
lantern  slides. 

Dr.  J.  Lewis  Amster^  has  been  appointed  con- 
sulting surgeon  of  the  penitentiary  and  correctional 
hospitals  of  Xew  York  City. 

Smallpox  on  Ocean  Liner. — The  Holland- 
American  liner  Xicuzi'  Atnstcrdam,  which  arrived  in 
Xew  York  on  October  12th,  from  Rotterdam,  with 
621  cabin  and  1.673  steerage  passengers,  was  de- 
tained in  quarantine  by  the  Health  Officer  of  the 
Port  on  account  of  a  case  of  smallpox  in  the  steerage. 
The  Nicuw  Amsterdam  will  be  detained  at  quaran- 
tine indefinitely  with  the  1.673  steerage  passengers 
on  board. 


Gives  American  Hospital  to  Italy. — A  chil- 
dren's hospital  has  been  offered  to  Italy  by  the  Com- 
mittee on  the  American  Tribute  to  Italy.  It  will 
be  called  the  International  Child  Welfare  at  Rome. 

British  Surgeon  Brings  Gift. — Sir  Berkeley 
Moynihan,  who  recently  left  England  to  attend  the 
convention  of  the  American  College  of  Surgeons  in 
Montreal,  brings  with  him  the  silver  mace  which  is 
the  gift  of  the  consulting  surgeons  of  the  British 
army  and  is  a  memento  of  the  assistance  they  re- 
reived  from  American  colleagues  during  the  war. 

Red  Cross  Medical  Personnel  in  Europe. — The 
Red  Cross  medical  report  for  July,  1920.  shows 
ninety-six  physicians,  nine  dentists,  ten  pharmacists 
and  one  laboratory  man,  making  a  total  of  116 
medical  personnel  in  Europe.  This  number,  how- 
ever, has  been  cut  rapidly  by  the  expiration  of  con- 
tracts so  that  there  are  now  only  about  fifty  medical 
men  still  in  Red  Cross  service  in  Europe. 

Serum  Treatment  of  Appendicitis. — According 
to  press  dispatches.  Professor  Pierre  Delbet.  of  the 
University  of  Paris,  announces  the  successful  treat- 
ment of  appendicitis  by  an  antigangrenous  serum, 
instead  of  by  operation.  Profesor  Delbet  is  re- 
ported to  have  said  that  the  tests  have  extended 
over  a  period  of  thirteen  years  and  the  results  have 
been  satisfactory. 

University  of  Paris. — A  diploma  of  radiology 
and  radiotherapy  has  been  instituted  by  the  medical 
faculty  of  the  University  of  Paris.  M.  Cosset, 
jirofessor  of  external  pathology,  has  been  named 
for  the  chair  of  the  surgical  clinic  to  replace  M. 
Quenu,  retired.  M.  \'aquez,  professor  of  internal 
pathology,  has  been  named  for  the  chair  of  the 
therapeutic  clinic  in  place  of  M.  Robin,  retired. 

A  Typhus  Hospital  in  Poland. — At  the  request 
of  the  League  of  Red  Cross  Societies  a  large  hos- 
pital for  research  work  in  typhus  fever  will  be 
operated  in  connection  with  the  American  Red  Cross 
Hospital  at  ^Vilno.  For  the  last  two  years  hospitals 
in  northern  and  eastern  Poland  have  been  over- 
crowded with  typhus  fever  patients,  and  in  local- 
ities where  the  hospital  service  was  inadequate 
whole  communities  have  been  wiped  out. 

Red  Cross  Society  Establishes  a  Health  Serv- 
ice.— The  American  Red  Cross  Society  annoimces 
the  establishment  of  a  department  of  health  serv- 
ice and  an  extension  of  its  nursing  service.  The 
organization  has  36,000  nurses  on  its  rolls  working" 
in  more  than  15,000  communities.  In  order  to  in- 
crease the  number  of  qualified  public  health  nurses 
288  scholarships  have  been  established  and  67  loans 
have  been  made  from  the  national  fund,  and  in 
addition  approximately  250  scholarships  have  been 
awarded  by  the  various  chapters. 

Public  Lectures  on  the  League  of  Red  Cross 
Societies  and  the  League  of  Nations. — Professor 
F.  F.  Roget,  of  the  University  of  Geneva,  will  de- 
liver three  public  lectures  in  London  on  October 
18th,  25th,  and  29th.  The  first  lecture  will  be  on 
the  League  of  Xations  and  the  League  of  Red 
Cross  Societies,  the  second  the  declaration  of  the 
five  national  delegations  sitting  in  conference  at 
Cannes  will  be  considered,  and  the  third  will  deal 
with  the  program  of  work  laid  down  for  the  medical 
department  of  the  League  of  Red  Cross  Societies. 


October  16,  1920.] 


NEWS  ITEMS. 


599 


Leprosy  Committee  in  Philippines. — Dr.  Vi- 
cente de  Jesus,  acting  director  of  health  of  the  Phil- 
ippines, has  appointed  a  Leprosy  Investigation  Com- 
mittee to  meet  at  Manila  from  time  to  time  for  the 
purpose  of  undertaking  investigations  in  connection 
with  the  treatment  of  leprosy.  The  committee  con- 
sists of  Dr.  Jose  P.  Bantug,  Philippine  Health  Serv- 
ice, chairman ;  Dr.  H.  W.  Wade,  University  of  the 
Philippines,  pathologist  and  Bureau  of  Science ;  Dr. 
Liborio  Gomez,  Bureau  of  Science,  bacteriologist; 
Dr.  Daniel  de  la  Paz,  University  of  the  Philippine, 
pharmacologist ;  Dr.  Granville  A.  Perkins,  Bureau 
of  Science,  chemist ;  Dr.  Proceso  Gabriel,  Philippine 
Health  Service,  and  Dr.  Luis  Guerrero,  University 
of  the  Philippines,  clinicians. 

American  Scientists  to  Explore  Amazon  Basin. 
— A  party  of  American  scientists,  headed  by  Dr. 
H.  H.  Rusby,  dean  of  the  College  of  Pharmacy, 
Columbia  University,  are  planning  an  expedition 
to  South  America  early  next  year  for  the  purpose 
of  studying  medicinal  plants,  insects  and  animals, 
with  the  hope  that  discoveries  of  economic  value 
may  be  made.  Search  will  be  made  for  supplies  of 
certain  drugs  now  in  use  and  for  others  not  now 
Icnown  to  science,  and  several  new  drugs  will  be 
investigated.  About  one  thousand  miles  of  the 
Amazon  Basin  in  Eastern  Ecuador  and  Peru  will 
be  explored.  The  expedition  is  to  be  financed  by 
the  H.  K.  Mulford  Company,  of  Philadelphia,  and 
is  called  the  Mulford  Biological  Exploration  of  the 
Amazon. 

Tuberculosis  Conferences. — The  North  Atlan- 
tic Tuberculosis  Conference  held  its  seventh  annual 
meeting  in  Richmond,  Va.,  last  week,  with  delegates 
in  attendance  from  eight  states.  Dr.  Thomas  T- 
Riley,  general  secretary  of  the  Bureau  of  Charities. 
Brooklyn,  presided  at  one  of  the  sessions  and  pre- 
sented a  paper  dealing  with  the  service  in  Brooklvn 
on  behalf  not  only  of  tuberculosis  victims  but  also 
of  crippled  children  and  the  blind.  Dr.  Louis  L 
Harris,  of  the  New  York  health  department,  was 
also  present  and  presented  a  paper  on  Tuberculosis 
as  an  Industrial  Problem. 

The  Southern  Tuberculosis  Conference  met  in 
Jacksonville,  Fla.,  October  11th  to  13th,  with  state 
health  officers  from  Mississippi,  Georgia,  Kentucky, 
and  Florida  in  attendance. 

Meetings  of  Local  Medical  Societies. — The 
following  local  medical  societies  will  meet  during 
the  coming  week: 

Monday,  October  18th. — New  York  Academy  of  Medi- 
cine (Section  in  Ophthalmology)  ;  Medical  Association  of 
the  Greater  City  of  New  York;  Psychiatric  Society  of 
Ward's  Island ;  Yorkville  Medical  Society. 

Tuesday,  October  19th. — New  York  Academy  of  Medi- 
cine (Section  in  Medicine)  :  Federation  of  Medical  Eco- 
nomic Leagues  of  New  York. 

Wednesday,  October  20th. — New  York  Academy  of  Medi- 
cine (Section  in  Genitourinary  Diseases);  Geriatric  Soci- 
ety ;  Medicolegal  Societj- ;  Northwestern  Medical  and  Sur- 
gical Society ;  Alumni  Association  of  the  City  Hospital. 

Thursday,  October  21st. — New  York  Academy  of  Medi- 
cine (stated  meeting)  ;  New  York  Celtic  Medical  Society. 

Friday,  October  22d. — Academy  of  Pathological  Science ; 
Audubon  Medical  Society ;  New  York  Clinical  Society ;  So- 
ciety of  Alumni  of  Sloane  Hospital  for  Women ;  Brooklyn 
Society  of  Internal  Medicine. 

Saturday,  October  23d. — Lenox  Medical  and  Surgical  So- 
ciety ;  New  York  Medical  and  Surgical  Society ;  West  End 
Medical  Society. 


First  Aid  on  Pullmans. — The  Pullman  car 
service  is  giving  the  American  Red  Cross  first  aid 
training  to  the  entire  force  of  colored  maids  em- 
ployed on  the  transcontinental  trains.  Several  of 
the  women  have  already  finished  the  cotirse  and 
now  carry  as  part  of  their  equipment  the  regulation 
first  aid  kit.  The  Pullman  Company  has  arranged 
with  the  New  York  County  chapter  of  the  Red 
Cross  to  give  the  course  of  training  in  first  aid  and 
home  hygiene  to  some  hundreds  of  maids  reporting 
to  its  New  York  terminal. 

Indiana  State  Medical  Association. — The  an- 
nual meeting  of  this  society  was  held  in  South  Bend, 
September  23d  to  25th,  under  the  presidency  of  Dr. 
Charles  H.  McCully,  of  Logansport.  The  follow- 
ing officers  were  elected :  President,  Dr.  David 
Ross,  of  Indianapolis ;  first  vice-president,  Dr.  Hugh 
J.  W  hite,  of  Hammond ;  second  vice-president,  Dr. 
Ira  M.  Washburn,  of  Rensselaer :  third  vice-presi- 
dent, Dr.  Otto  R.  Spigler,  of  Terre  Haute  :  secretary- 
treasurer.  Dr.  Charles  N.  Combs,  of  Terre  Haute 
(reelected).  The  next  annual  meeting  will  be  held 
in  Indianapolis,  September  27  to  29,  1921. 

 <»  

Died. 

Bkifxow. — In  Island  Falls,  Me.,  on  Sunday,  September 
26th,  Dr.  Frederick  F.  Bigelow,  aged  sixty-two  years. 

Carroll. — In  Brooklyn,  N.  Y.,  on  Saturday,  October  2nd, 
Dr.  Edward  J.  Carroll. 

Clark. — In  Staten  Island,  N.  Y.,  on  Tuesday,  October 
5th,  Dr.  Frederick  E.  Clark,  aged  seVenty-three  years. 

Cl.w. — In  Malta,  Mont.,  on  Sunday,  September  5th,  Dr. 
George  W.  Clay,  aged  forty-seven  years. 

Connors. — In  Boston,  Mass.,  on  Tuesday,  October  5th. 
Dr.  Willett  Spurgeon  Connors,  aged  fifty-one  years. 

D'.^QUix.— In  New  Orleans,  La.,  on  Wednesday,  Septem- 
ber 8th,  Dr.  John  Joseph  d'Aquin,  aged  forty-eight  years. 

DuPEE. — In  Bridgeport,  Conn.,  on  Wednesday,  September 
29th,  Dr.  Edward  Wilson  Dupee,  aged  forty-eight  years. 

Ellin  WOOD. — In  Rome,  N.  Y.,  on  Friday,  October  1st,  Dr. 
Eliza  Maria  Ellinwood,  aged  seventy-one  j'ears. 

Gibbons. — In  Stockton.  Cal.,  on  Tuesda\%  September  21st, 
Dr.  William  Edward  Gibbons,  aged  seventy-five  years. 

Graham. — In  Little  Falls,  N.  Y.,  on  Saturday,  September 
25th,  aged  thirty-six  years. 

Harris. — In  Atlantic  City,  N.  J.,  on  Wednesday,  October 
6th,  Dr.  Robert  Edward  Harris,  aged  thirtj'-nine  years. 

Hicks. — In  Menominee,  Mich.,  on  Sunday,  September 
26th,  Dr.  W'alter  Raleigh  Hicks,  aged  fifty-five  years. 

Howell. — In  Cogan  Station,  Pa.,  on  Tuesday,  October 
Sth,  Dr.  William  M.  Howell,  aged  seventy-three  years. 

HuHNER. — In  New  Orleans,  La.,  on  Friday,  Septeml^er 
10th,  Dr.  George  Huhner,  aged  seventy-one  years. 

Larkev. — In  Oakland,  Cal.,  on  Sunday,  September  26th, 
Dr.  Alonzo  S.  Larkey. 

Maxson. — In  Berkeley,  Cal.,  on  Sunday,  September  26th. 
Dr.  Harriet  S.  Maxson,  aged  fifty -one  years. 

McDonald. — In  Coblenz,  Germany,  on  Wednesday.  Oc- 
tober 6th,  Dr.  James  Wilson  McDonald,  of  Fairmount, 
W.  \'a.,  aged  fifty-nine  years. 

Rothwell. — In  Denver,  Col.,  on  Tuesday,  September  7th, 
Dr.  Edwin  J.  Rothwell,  aged  seventy-eight  years. 

Rowe. — In  Boston,  Mas.,  on  Saturday,  September  18th, 
Dr.  Anna  Forrest  Rowe,  of  Brooklyn,  aged  sixty-three 
years. 


Book  Reviews 


NEW  BOOKS  ON  THE  TUBERCULOSIS 
PROBLEM. 

The  Shibboleths  of  Tuberculosis.  By  Marcus  Paterson, 
M.  D. ;  Medical  Superintendent,  Aletropolitan  Asylums 
Board,  Colindale  Hospital ;  Late  Medical  Superintendent, 
Brompton  Hospital  Sanatorium,  Frimley;  Medical  Direc- 
tor, King  Edward  VH  Welsh  National  Memorial  Asso- 
ciation ;  Resident  Medical  Officer,  Brompton  Hospital, 
London.  New  York:  E.  P.  Button  and  Company,  1920. 
Pp.  ii-239. 

A  Study  on  the  Epidemiology  of  Tuberculosis.  With  Special 
Reference  to  Tuberculosis  of  the  Tropics  and  of  the  Ne- 
gro Race.  By  George  E.  Bushnell,  Ph.D.,  M.  D.,  Colo- 
nel, United  States  Army,  Medical  Corps,  retired,  Honor- 
ary Vice-President  and  Director  of  the  National 
Tuberculosis  Association  of  the  United  States.  Illus- 
trated. New  York :  William  Wood  and  Company,  1920. 
Pp.  v-221. 

The  reviewer  remembers  an  English  doctor 
bringing  charts  and  views  of  Frimley  Sanatorium 
to  Johns  Hopkins  Medical  Society  and  giving  an 
address  on  that  which  was  novel  and  giving  good 
results  in  the  treatment.  He  was  very  convincing 
and  many  were  convinced. 

Only  the  enthusiastic,  the  really  dutiful,  will  be 
grateful  to  Dr.  Marcus  Paterson  of  Frimley  for 
airing  and  making  a  clean  sweep  of  erroneous 
statements,  false  doctrines  of  which  his  work  there 
and  elsewhere  has  taught  him  the  pervasion  and 
evil.  He  finds  about  fifty-nine,  so  imagine  the 
nuisance  and  mess  he  creates  pulling  them  down, 
but  he  does  not  believe  in  patching  up  or  compro- 
mising" because  these  statements  were  once  believed 
in  by  great  men  in  medicine  and  are  still  believed 
by  the  laity. 

To  give  the  first  shibboleth  will  .show  that  the 
others  are  clear  and  well  put.  It  is,  Why  sterilize 
milk  and  neglect  butter  and  cheese?  These  also 
could  be  purchasable.  The  English  and  American 
Public  Health  service  have  both  deinonstrated 
tubercle  bacilli  in  cheese  two  months  old  and  in 
butter  ninety-nine  days  old. 

Then,  having  reviewed  the  fifty-nine,  he  says 
what  he  has  found : 

That  open  air  treatment  and  homes  for  tubercu- 
losis are  not  sanatoria.  A  "little  gardening"  is 
neither  graduated  labor  nor  autoinoculation,  which 
latter  is  a  natural  method  of  treatment,  and  inocu- 
lation tests  of  sputum  and  blood  should  always  be 
made  when  microscopic  examinations  yield  negative 
results.  Practically  all  cases  of  pleurisy  or  hemop- 
tysis are  due  to  tuberculosis.  That  it  is  better 
to  test  by  exercise.  That  climate,  if  not  actually 
unsuitable,  has  little  to  do  with  treatment.  That 
our  treatment  of  those  carrj'ing  sputum  flasks  is 
unreasonable :  a  man  with  one  is  a  safer  neighbor 
than  one  who  uses  his  handkerchief.  Also  that 
patients  may  have  bacilli  free  sputum. 

Finally,  Nageli  has  shown  that  large  numbers 
have  recovered  from  tuberculosis  without  their 
being  aware  they  had  it.  This  is  an  indication  of 
an  increasing  high  natural  resistance  to  the  disease, 
and  a  proper  apprecation  of  autoinoculation  would 
be  of  infinite  value  to  the  state.  Too  much  atten- 
tion is  given  to  the  value  of  physical  signs  at  rest, 
disregarding  tests  by  graded  exercise. 

He   draws,  a  good  picture  of   the  (English) 


apathy.  Confronted  with  an  imdeniable  fact  that 
tuberculosis  is  preventable,  he  supposes  a  Great 
Britain  practically  free,  then  allowing  a  weekly 
shipload  of  one  thousand,  or,  practically,  fifty-two 
thousand,  which  is  about  the  annual  mortalit}',  to 
land  there.  Every  step  necessary  to  see  that  it  did 
not  take  root  would  be  made  as  rapidly  as  if  fight- 
ing an  Asiatic  plague. 

He  makes  some  remarks  on  the  qualifications  of 
a  medical  superintendent  of  a  sanatorium.  '"The 
patience  of  Job  and  a  capacity  for  working  twelve 
hours  a  day,  seven  days  a  week."  Walther,  of 
Nordrach,  touched  the  bedrock  of  successful  treat- 
ment when  he  said  it  was  not  the  buildings  of  the 
sanatorium,  but  the  man  in  charge.  The  idea  of 
any  open  air  place  where  patients  do  as  they  like 
and  are  overfed  being  called  a  sanatorium  is  absurd. 
The  patients  generally  become  fat,  neurotic  and 
selfish. 

The  book  is  so  lucid  and  instructive  that  it  de- 
serves more  space  than  can  be  given.  It  gives 
much  food  for  reflection — reflection  that  must  lead 
to  determined  action  against  the  enemy. 

The  reviewer  came  across  an  epitaph  on  the 
grave  of  a  Dr.  Moses  Little  (1766-1811).  The 
whole  family  died  of  tuberculosis,  but  Dr.  Marcus 
Paterson  would  most  probably  say  ignorance. 
"Phthisis  insatiabilis 
Patrem,  matremque  devorasti 
Parce  !    O  parce  liberis." 
but  the  children  died  shortly  after  their  i)arents. 

There  is  a  certain  amount  of  usefulness  in  care- 
fully retelling  and  explaining  what  everyone  knows, 
because  there  never  was  a  greater  fallacy  than  that 
everyone  does  know.  But  when  to  common  infor- 
mation is  added  some  carefully  trimmed  ideas  which 
tell  of  great  consideration  of  the  subject,  the  small 
audience  who  took  back  seats  that  they  might  more 
easily  escape,  will  be  reinforced  and  give  good  at- 
tention. The  man  on  the  platform  says  that  to 
understand  tuberculosis  of  the  temperate  zone  and  of 
our  race,  we  mtist  know  also  how  it  affects  other 
races,  but  the  epidemiological  data  are  little  known 
and  are  often  in  inaccessible  periodicals.  He  imder- 
takes  to  tell  us  all  about  them  and  therein  lies  the 
attraction  of  his  book.  He  has  on  his  mind  the 
great  prevailing  ignorance  of  the  disease  as  it  af- 
fects races  as  yet  not  fully  tuberculized,  and  wants 
to  help  doctors  who  meet  the  disease  in  far  away 
countries,  though  he  admits  the  difficulty  of  getting 
facts  and  will  not  condescend  to  use  airy  statements 
liowever  impressive.  He  thinks  the  von  Pirquet  test 
will  become  increasingly  important,  not  only  in  the 
tropics  but  also  at  home,  and  recommends  the  wider 
study  of  tuberculosis,  not  only  in  large  cities  but  in 
such  places  as  Samoa  and  Porto  Rico,  where  the  date 
of  introduction  is  comparatively  recent. 

Dr.  Bushnell  pursues  the  enemy  all  over  the  world 
asking.  When  did  it  come  ?  How  did  it  come  ?  He 
divides  the  countries  into  two  classes  and  finds  the 
law  of  Romer  holds  good:  That  where  it  is  a  rare 
disease  the  cases  are  acute  and  fatal:  Where  com- 
mon, it  is  chronic  and,  relatively,  benigfn.    That  is. 


October  16,  1920. J 


BOOK  REVIEWS. 


601 


contact  affords  a  certain  protection.  This  was  proved 
by  the  fine  work  of  von  Pirquet  and  others  working 
with  the  tubercuHn  reaction,  who  proved  that,  in 
European  cities  at  least,  the  adult  population  was 
thoroughly  tuberculized.  We  comprehend  this  in 
reading  of  such  races  as  the  Marquesas  (South 
Seas)  about  whom  Buisson  says  that  the  population 
will  soon  disappear.  The  tribe  of  Hapaa  is  said  to 
have  numbered  400 ;  first  smallpox  reduced  them  by 
one  fourth,  then  tuberculosis  exterminated  them  save 
two.  The  natives  of  Tierra  del  Fuego  once  num- 
bered 5,000;  of  these,  barely  300  remained  in  1910. 
The  natives  say  that,  before  the  whites  came,  people 
only  died  of  old  age. 

As  a  note  of  cheerfulness  in  this  mortuarial  in- 
formation, we  are  told  that  tuberculization  sets  in — 
that  is,  unless  all  are  exterminated,  when  it  would  be 
superfluous  !  Instances  of  this  are  American  Samoa, 
Tahiti  and  Hawaii.  One  class  in  all  communities, 
the  children,  are  always  exposed  to  primary  tubercu- 
losis, and  the  urgency  of  a  determined  fight  by  un- 
dermining ignorance  and  securing  sanitation  is  ines- 
timable. 

The  chapter  on  the  American  negro  and  the 
American  Indian  is  full  of  interest,  also  the  one  on 
Epidemics  of  Tuberculosis  and  Prophylaxis  of  the 
Noninimunized.  It  would  be  difficult  to  comment 
fully  on  the  book.  For  to  do  so  would  mean  a 
larger  quotationing  than  space  allows.  The  author 
does  not  claim  original  investigation,  but  he  may 
rightly  claim  originality  in  putting  old  facts  in  a 
new  light. 

DIAGNOSIS  OF  CANCER 

The  Exact  Diagnosis  of  Latent  Cancer.  An  Inquiry  Into 
the  True  Significance  of  the  Morphological  Changes  in  the 
Blood.  By  O.  C.  Gruner,  M.  D.  Philadelphia :  P.  Blakis- 
ton's  Son  &  Co.,  1919.    Pp.  v-79. 

In  this  small  monograph  Dr.  Gruner  is  careful 
to  state  that  from  a  study  of  the  blood  alone  it  is 
not  possible  to  secure  an  accurate  diagnosis.  How- 
ever, he  considers  it  possible  to  attain  a  fairly 
accurate  diagnosis  of  latent  cancer  when  the  various 
data  possible  to  secure  are  correlated  and  the  proper 
deductions  made.  The  essential  thing  to  do,  as  he 
points  out,  is  to  establish  the  relationship  between 
the  various  hemic  phenomena  and  the  underlying 
biological  processes.  He  seeks  primarily  to  estab- 
lish a  new  concept  of  the  interpretation  of  the  vari- 
ous clinical  findings.  From  the  blood  picture  he 
shows  us  many  deductions  can  be  made.  The  drop 
of  blood  is  a  true  sample  of  all  the  blood  in  the 
body  and  we  are  told  it  should  serve  as  an  index 
of  great  value. _  It  is  of  interest  to  note  that  while 
Gruner  attaches  much  importance  to  the  hematology 
of  a  patient  he  tells  us  to  investigate  carefully  the 
background  of  the  patient,  his  home  life,  his  busi- 
ness surroundings,  so  that  we  may  be  able  to  elim- 
inate, or  give  full  value  to  the  functional  disorders 
or  the  malfunctioning  of  any  of  the.  ductless  glands 
which  may  have  their  origin  in  some  psychic  dis- 
order. 

This  warning  is  a  very  healthy  note  in  a  mono- 
graph which  dwells  upon  minuteness  in  diagnosis. 
If  we  can  study  the  little  things  without  allowing 
them  to  master  us,  we  will  be  taking  a  long  step 
forward  in  diagnostic  medicine.    To  be  sure,  can- 


cer is  one  of  the  most  baffling  diseases  known  to 
medicine  and  the  method  of  approach  adopted  by 
Gruner  should  go  far  toward  helping  us  grasp  the 
fundamental  underlying  causes  of  this  dread  disease, 

X  RAY  ATLAS 

The  X  Ray  Atlas  of  the  Systemic  Arteries  of  the  Body.  By 
H.  C.  Orrin,  O.  B.  E.,  F.  R.  C.  S.,  Ed.  Fellow  of  Royal 
Society  of  Medicine,  London ;  Civil  Surgeon  Attached 
Third  London  General  Hospital,  R.  A.  M.  C.  (T.).  Illus- 
trated.  New  York :  William  Wood  &  Co.,  1920.    Pp.  i-9J. 

This  series  of  remarkable  x  ray  plates  illustrat- 
ing the  anatomy  of  the  vascular  system  has  appeared 
in  The  Archives  of  Radiology.  Work  of  this  char- 
acter should  lead  to  a  revision  of  our  study  of  the 
blood  vessels,  for  the  subject  presented  in  this 
fashion  gives  a  new  concept  of  the  arteriovenous 
system  of  the  human  body.  A  visual  projection  of 
the  vascular  system  is  made  possible,  especially  by 
the  use  of  the  stereoscopic  plates.  New  values  are 
gained.  The  anastomotic  and  distributory  elements 
of  this  vast  network  which  reaches  every  cell  in 
the  body  attains  a  new  significance.  We  should 
not  be  led  into  the  fallacy  of  allowing  these  x  ray 
studies  to  supplant  careful  anatomical  studies  by 
dissection  and  cross  section ;  they  should  rather  be 
used  as  supplemental  to  the  other  studies. 

The  arrangement  followed  by  Orrin  is  the  head 
and  neck,  including  the  arch  of  the  aorta,  the  upper 
extremity,  the  thorax,  the  abdomen,  the  pelvis  and 
lower  extremity.  The  work  has  been  done  with 
painstaking  care  and  the  resttlt  is  a  series  of  beauti- 
ful photographs.  The  book  should  be  received  with 
favor  by  anatomists,  and  surgeons  in  every  branch 
of  the  profession. 

SURGEON  GENERAL  STERNBERG. 

A  Biography  of  George  Miller  Sternberg.  By  His  Wife, 
Martha  L.  Sternberg.  Illustrated.  Chicago :  American 
Medical  Association,  1920.    Pp.  ix-331. 

The  best  biography  is  one  which  retains  its  in- 
terest after  many  years  and  beguiles  into  reading  it 
those  who  never  knew  the  man,  for  none  can  write 
comprehendingly  without  giving  the  life  of  the  times 
his  hero  lived  in,  and  so  the  book  becomes  an  in- 
teresting reference  voluine. 

The  task  which  lay  before  the  author  was  to  depict 
fairly  a  triple  personality — her  husband  as  doctor, 
scientist  and  soldier — and  this  has  been  successfully 
done.  The  fourth  page  finds  him  assistant  surgeon 
in  the  U.  S.  Army,  dodging  bullets  at  Bull  Run 
then  follow  his  work  as  army  surgeon  at  many  out 
of  the  way  places,  disease  fighting  being  varied  with 
natural  history  studies  and  exciting  discoveries  in 
shell  mounds  and  ancient  burial  places.  He  could  not 
choose  his  dwelling  place,  and  it  was  often  in  an 
unsanitary  place  or  where  disease  flourished  because 
tolerated  by  ignorance  or  indifiference.  The  chapter 
on  the  Nez  Perces  Campaign  delightfully  savors  of 
Fenimore  Cooper,  and  the  reader  half  regrets 
Sternberg's  transportation  from  Walla- Walla  to  the 
Ha  vana  \ellow  Fever  Commission.  We  who  en- 
joy the  fruits  of  such  work  can  hardly  imagine  the 
hopes  defeated,  the  toil  in  the  laboratory,  the  dis- 
tasteful task  of  refuting  theories  advanced  by  con- 
freres, which  Sternberg  went  through.  He  was  cer- 
tainly the  pioneer  bacteriologist  in  America.  His 


602 


BOOK  RE]'IEIVS. 


[New  York 
Medical  Journal. 


discovery  of  the  pneumococcus  before  Pasteur  is 
well  known,  and  he  most  assuredly  cleared  the 
ground  for  Walter  Reed's  discovery.  But  where  he 
cleared  he  also  encouraged  valiant  scientists  to  walk. 
In  his  ten  years  as  surgeon  general  he  realized  his 
ideal  of  establishing  a  laboratory  at  every  military 
post  in  the  country  and  created  the  Army  Medical 
School.  The  Army  Nurse  Corps  was  also  of  his 
making ;  also  the  Dental  Corps.  Best  of  all,  he 
fought  that  arch  enemy,  tuberculosis,  and  established 
a  hospital  at  Fort  Bayard  and  many  general  hos- 
pitals during  the  Spanish- American  war,  which  war 
was  begun  with  the  usual  skirmishing  for  obviously 
needed  men  and  supplies  with  reactionaries  at  Wash- 
ington, officials  who  could  not  see  the  economy  of 
having  medical  officers  fully  trained  in  hospital  war 
work. 

One  rather  regrets  that  neat,  cold  tombstone  at  the 
end  of  the  life.  It  has  an  air  of  finality;  its  very 
weight  seems  to  press  out  any  vital  spark  of  heavenly 
flame ;  whereas  George  Sternberg  is  still  living, 
working,  in  the  men  who  desire,  as  he  did,  a  happy 
victory  over  all  disease. 

SELFHEALTH  AS  A  HABIT. 

Self  health  as  a  Habit.  By  Eustace  Miles,  M.  A..  Formerly 
Scholar  of  King's  College,  and  Honors  Coach  and  Lec- 
turer at  Cambridge  University :  Assistant  Master  at 
Rugby  School :  Amateur  Champion  at  Racquets  and 
Tennis ;  Author  of  Hozc  to  Prepare  Essays,  Hoiv  to  Re- 
member, etc.  Illustrated.  New  York  :  E.  P.  Button  & 
Co.,  1919;  London  and  Toronto:  T.  M.  Dent  &  Sons, 
Ltd.    Pp.  V-34L 

Some  twenty  years  ago,  right  in  the  heart  of 
London  a  new  restaurant  appeared.  No  chops  or 
steaks  or  meat  foods  of  any  kind,  just  vegetables, 
cereals,  fruits.  The  young,  the  faddy,  the  dys- 
peptic cautiously  ventured  in  and  looked  suspicious- 
ly at  the  dishes  offered.  It  was  generally  expected 
that  the  usual  notice  "This  Shop  to  Let"  would 
soon  appear.  Eustace  Miles  and  his  wife  walked 
around  among  the  tables  with  explanations  vocal 
and  printed  and  gently  enticed  people  to  learn  a 
little  of  the  insides  into  which  they  were  putting 
the  food.  Last  year,  when  on  a  visit  to  London, 
I  found  the  shop  still  open  and  no  new  undertak- 
ing business  opened  nearby.  Certainly  the  advice 
in  this,  Eustace  Miles's  last  book,  on  how  to  eat 
less  ought  to  be  feverishly  read  in  these  H.  C.  L. 
•days. 

What  is  this  selfhealth?  A  state  of  satisfactory 
well  being,  independent  of  particular  surroundings. 
It  radiates  health  to  others.  It  means  selfmastery, 
increasing  intelligence.  Frequently  repeated  deep 
and  full  breathing,  simple  exercises,  water  sipping, 
the  avoidance  of  worry,  the  ctiltivation  of  happi- 
ness will  all  help.  Read  the  chapters  on  Economy 
and  Rest,  Position  and  Expression,  Better  Breath- 
ing, Balanced  Diets,  Exercise,  Hobbies,  ]\Iainly 
About  Helping  Others.  Every  suggestion  is  good 
and  will  not  make  one  faddy  or  abnonnally  self- 
conscious.  No  expense  is  involved,  rather  less  for 
the  ordinary  person,  but  Mr.  Miles  imagines  a  co- 
operation from  restaurateurs,  landlords,  and  employ- 
ers which  does  not  exist.  His  dietary  plan,  when 
well  carried  out  and  unstinted,  is  capital.  But  send 
the  homeless  man  to  a  pure  food  restaurant  and 
"he  comes  away  not  half  satisfied.    With  a  meat 


order,  however  small,  he  gets  five  cents  knocked 
oflf  soup,  roll  and  butter  for  nothing,  and  at  least 
one  vegetable.  Possibly  tea  or  coffe  is  five  cents 
cheaper  also.  Now  at  the  pure  food  place,  soup  is 
fifteen  cents,  bread  and  butter  are  charged  for,  salad 
— one  wilted  lettuce  leaf  and  two  slices  of  tomato — 
is  ten  or  fifteen  cents,  one  tablespoonful  of  any 
vegetable  or  fruit  is  priced  the  same,  and  a  dish — 
eggs,  macaroni,  curry — from  the  menu  is  twenty- 
five  to  forty  cents,  and  they  are  so  digestible  that 
he  is  hungry  again  three  hours  later,  not  being 
able  to  afford  enough. 

Then  life  in  a  rooming  hotise — the  stuft'y  bed- 
room, his  sitting  room  the  streets  or  parks,  no  in- 
clination to  exercise  after  a  ride  on  crowded  car 
or  a  long  day's  work,  the  daily  bath  with  a  queue 
at  the  rooming  house  waiting  to  get  in,  the  sip- 
ping of  water  with  none  save  that  down  three  flights 
of  stairs,  and  a  smudgy  jam  glass  to  drink  from.  I 
am  not  depreciating  the  author's  advice,  but  simply 
putting  in  a  plea  for  those  seemingly  obstinate 
people  who  do  not  follow  his  advice.  The  book  is 
very  reasonable  and  holds  nothing  to  make  a  man  a 
fidgety  nuisance  or  to  behave  as  though  he  was  the 
only  one  to  possess  a  stomach. 

OSCAR  WILDE. 

A  Critic  ill  Pall  Mall.  By  Oscar  Wilde.  Reviews  and 
Miscellanies.  New  York :  G.  P.  Putnam's  Sons.  Pp. 
vi-290. 

To  judge  fairly  of  an  author's  book  it  should  first 
be  judged  as  a  book  and  the  impression  it  creates 
without  also  judging  the  author.  Then,  in  ex- 
tenuation of  faults,  his  life,  education,  pectiliar  cir- 
cumstances should  be  weighed  and  his  condemna- 
tion pronounced  only  when  he  has  wilfully  and 
plainly,  not  given  his  best,  or  when  he  has  treated  his 
readers  discotirteously  by  giving  them  illdressed 
untruths  in  an  attempt  to  be  witty. 

Taking  then  this  little  book  without  regard  to  its 
author :  "The  reviewer  unconsciously  gave  not  only 
the  hour  he  could  have  spared,  but  another  two, 
which  proved  pleasant  reading.  Among  the  best  of 
the  reviews  is  Aristotle  at  Afternoon  Tea  and  Some 
Literary  Ladies.  Yates,  Swinburne  and  Henley  come 
in  for  some  rather  severe  criticism.  Of  Swin- 
burne it  has  been  said  he  was  a  master  of  language, 
rather,  language  was  his  master.  Words  dominated 
him,  alliteration  tyrannizes  over  him."  There  are 
some  amusing  accounts  of  !Mr.  Rawnsley  trying  to 
get  intimate  details  of  Wordsworth  from  the  farm 
folk  in  Westmoreland.  "He  wrote  potry  because 
he  couldn't  help  it.  He  was  not  a  man  as  folks 
could  crack  wi',  nor  not  a  man  as  -could  crack  wi' 
folks." 

Wilde  has  high  praise  for  William  Morris's  trans- 
lation of  the  Odyssey  and  for  Walter  Pater's  Ap- 
prcciatio)is.  which  he  says  is  "an  exquisite  collection 
of  exquisite  essays,  of  delicately  wrought  works  of 
art."  The  Sc}itcnfi(r  at  the  end  of  the  book  are 
v.-holesome  without  hurting,  as  good  scarcasm  should 
be. 

Satire  should,  like  polished  razor  keen, 
\\'ound  with  a  touch  that's  neither  felt  nor  seen. 

And  the  book  is  worth  being  accorded  a  companion- 
ship in  our  life  because  the  author  has  given  of  his 
best  and  it  is  good. 


Miscellany  from  Home  and  Foreign  Journals 


Nondiphtheritic  Pseudomembranous  Laryngi- 
tis.— R.  Rendue  {Lyon  medical,  March  25,  1920) 
reports  the  case  of  a  man  aged  thirty-two  years 
admitted  to  a  hospital  for  what  appeared  to  be  an 
ordinary  laryngotracheal  bronchitis,  with  slight 
fever,  some  hoarseness,  cough,  and  a  few  rhonchi 
and  sibilant  sounds.  Two  weeks  later  the  patient 
had  improved,  but  was  still  hoarse.  Laryngoscopy 
showed  a  creamy,  white  false  membrane  on  the  an- 
terior valves  of  the  vocal  cords,  contrasting  by  its 
color  with  the  swollen  posterior  valves.  There  was 
slight  enlargement  of  the  glands  below  the  angle  of 
the  jaw.  Swabbing  of  the  cords  showed  that  the 
material  was  actually  pseudomembrane  and  not 
merely  white  adherent  mucus.  Xo  Klebs-Loeffler 
bacilli  could  be  found,  but  staphylococci  were  pres- 
ent. This  patient  never  exhibited  dyspnea  nor 
signs  of  pseudomembranous  bronchitis.  He  seemed 
but  little  inconvenienced  and  insisted  upon  leaving 
the  hospital  before  the  pseudomembrane  had  disap- 
peared. Rendu  notes  that  acute  nondiphtheritic 
pseudomembranous  laryngitis  has  been  recognized 
since  1890  but  occurs  characteristically  in  children, 
with  practically  the  same  clinical  signs  as  laryngeal 
diphtheria,  and  is  even  more  serious  than  the  latter 
owing  to  its  tendency  to  extend  downward  to  the 
entire  bronchial  tree.  ^ 

Prophylaxis  Against  Infectious  Diseases  in  the 
Macedonian  Campaign. — Armand-Delille,  Le- 
maire,  and  Paisseau  (Bulletin  de  I' Academic  dc 
mcdccine,  April  6,  1920)  describe  the  results  of  the 
activities  of  the  International  Commission  on  Hy- 
giene, originally  created  in  1915  by  Major  General 
^lacpherson  in  Salonica.  Although  in  the  case  of 
dysentery  and  malaria  the  efiforts  put  forth  came 
too  late  to  do  much  good,  the  severe  epidemic  affec- 
tions, such  as  plague,  cholera,  and  typhus,  were  so 
controlled  that  the  damage  done  was  far  less  than 
in  other  armies  on  the  Eastern  front  during  the 
same  campaign.  As  regards  cholera,  all  the  troops 
were  systematically  vaccinated,  either  with  vaccine 
from  the  Institut  Pasteur  as  in  the  French, 
Serbian  and  Greek  armies  or  with  Castellani's 
vaccine,  as  in  the  British  army.  No  case 
of  cholera  developed  among  these  armies,  although 
a  large  focus  of  infection  occurred  at  Kor- 
itza  in  the  zone  of  occupation.  Systematic  vacci- 
nation of  10.000  natives  was  likewise  carried  out, 
rapidly  arresting  the  epidemic.  In  the  case  of 
plague,  a  service  for  rat  destruction  and  bacterio- 
logical study  was  set  up  at  the  French  base,  and 
succeeded  in  localizing  the  foci  of  infection,  both  at 
Salonica  and  Mytilene.  Relapsing  fever  appeared 
in  a  rather  extensive  epidemic  form  in  the  native 
])opulation  and  Greek  army.  Strict  debusing  meas- 
ures prevented  the  spread  of  the  disease  to  the  Al- 
lied armies,  among  which  only  a  few  isolated  cases 
developed.  The  measures  against  typhus  fever  in- 
cluded systematic  delousing  of  the  entire  Serbian 
army  brought  over  from  Corfu.  A  similar  service 
was  established  in  the  Russian  brigade,  in  which  a 
few  fatal  cases  had  occurred. 


A  Case  of  Meningoencephalitis  Lethargica. — 

William  \V.  Hala  and  Cyril  !M.  Smith  {Archives 
of  Neurology  and  Psychiatry,  February-,  1920) 
report  a  case,  clinically  diagnosed  as  encephalitis 
lethargica,  verified  by  observations  antemortem 
and  postmortem.  From  the  clinical  viewpoint  the 
author's  case  was  one  of  meningoencephalitis,  with 
lethargy  and  involvement  of  the  motor  fibres  of 
the  third,  sixth,  seventh,  tenth  and  twelfth  cranial 
nerves.  The  etiological  cause  was  a  gram  negative 
motile  bacillus,  unidentified,  but  probably  belonging 
to  some  intermediate  class  of  colon-typhoid-enter- 
itidis  group.  Pathologically,  the  lesion  demon- 
strated septic  meningoencephalitis  and  ependymitis, 
with  punctate  hemorrhages  and  perivascular  cell  in- 
filtration of  the  centrum  ovalve,  corpus  striatum 
and  optic  thalamus. 

Disseminated  Sclerosis  due  to  Shell  Concussion. 

— Ducamp  and  ^Nlilhaud  {Prcsse  medicalc,  May  5, 
1920)  report  the  case  of  a  man  who  was  tempor- 
arily buried  by  the  explosion  of  a  mincnzvcrfcr, 
remained  deaf  for  two  days,  and  then  resumed  his 
military  service.  One  year  later  he  felt  pain  in  the 
left  lower  extremity,  sometimes  of  lightninglike 
character,  which  came  on  with  fatigue  and  passed 
oft  with  rest.  Later  paralysis  of  the  right  arm  and 
leg  appeared,  together  with  sphincter  disturbances. 
A'ision  was  impaired  for  a  time.  The  paralysis  w'as 
later  partly  recovered  from,  but  the  patient,  on 
detailed  examination,  showed  the  various  disorders 
of  locomotion,  motility  of  the  i;pper  limbs,  reflex 
action,  vision,  sensation.  A-oice  and  sphincters  char- 
acteristic of  disseminated  sclerosis.  A  number  of 
more  or  less  similar  cases  have  been  recorded  by 
other  observers.  The  long  delay  between  the  trauma 
and  the  appearance  of  symptoms  is  ascribed  to 
the  gradual  development  of  the  central  nervous 
lesions  from  the  original  capillary^  hemorrhages  pro- 
duced by  the  former  in  the  nerve  tissues. 

The  Tenue  Phase  of  Plasmodium  Vivax. — 

A.  J.  Chalmers  and  R.  G.  Archibald  {Journal  of 
Tropical  Medicine  and  Hygiene,  February  2,  1920) 
report  a  case  of  malaria  in  a  British  soldier,  caused 
by  two  generations  of  plasmodium  vivax,  the  para- 
site of  simple  tertian  malaria.  The  patient's  blood 
showed  parasites  in  the  peculiar  tenue  phase,  which 
the  authors  believe  to  represent  an  attempt  at  asex- 
ual reproduction  by  fission,  both  simple  and  multiple 
In  one  of  the  illustrations  two  parasitic  rings  are 
shown,  joined  by  a  narrow  loop  of  protoplasm,  but 
with  only  one  ring  provided  with  chromatin.  Fur- 
ther steps  are  also  shown,  the  last  development 
depicted  being  one  in  which  a  single  erythrocyte  con- 
tains five  connected  rings  with  chromatin  and  one 
ring  without  chromatin.  The  whole  process  appears 
to  be  a  throw  back  to  a  method  of  reproduction 
w^hich  may  have  been  useful  to  some  ancestor  of 
the  malarial  parasites,  but  which  is  now  devoid  of 
practical  importance  and  rarely  seen.  No  trace  of 
migration  of  the  parasites  could  be  found.  The 
same  patient  aftorded  a  good  example  of  dermatitis 
scarlatiniformis  due  to  quinine. 


604 


'MISCELLANY  FROM  HOME   AND  FOREIGN  JOURNALS. 


[New- 
Medical 


YOKK 

Journal. 


Mental  Disorders  Associated  with  Old  Age. — ■ 

Sir  George  Savage  {Journal  of  Xcrvous  and  Men- 
tal Disease,  March,  1920)  discusses  the  medico- 
legal aspects  of  old  age.  Loss  of  memory,  espe- 
cially for  recent  occurrences,  loss  of  self  control 
and  concentration,  disturbed  sleep,  hysterical  or 
emotional  condition  during  which  the  individual  is 
particularly  prone  to  the  influence  of  younger  per- 
sons in  his  immediate  environment,  are  some  of  the 
outstanding  features  of  senile  dementia.  Senile 
melancholia  is  also  frequent  and  hallucinations  of 
smell  and  sight  complete  the  list  of  manifestations. 

A  Case  Presenting  an  Epidermoid  Papillary 
Cystoma  Involving  the  Third  Ventricle. — Donald 
J.  MacPherson  (Archives  of  Neurology  and  Psy- 
chiatry, April,  1920)  shows  a  case  presenting  an 
epidermoid  papillary  cystoma  involving  the  third 
ventricle,  the  tumor  probably  originating  either 
from  a  hypophyseal  rest,  or  as  a  result  of  a  de- 
velopmental abnormality  of  the  infundibulum.  The 
clinical  signs  and  symptoms  of  sixteen  months'  dur- 
ation did  not  lead  to  a  localization  before  death. 
Correlation  of  clinical  and  pathological  findings  has 
been  complicated  by  the  difficulty  of  separating 
local  from  remote  and  general  effects  and  the  pau- 
citv  of  data  as  to  the  normal  physiological  function 
of  the  structures  involved. 

Preparation  of  a  Stable  Vitamine  Product  and 
Its  Value  in  Nutrition. — H.  E.  Dubin  and  J. 
Lewi  {American  Journal  of  the  Medical  Sciences, 
February,  1920)  assert  that  they  have  prepared  a 
stable  vitamine  product,  an  analysis  of  which  shows 
its  chief  components  to  be  calcium,  expressed  as 
calcium  oxide,  10  per  cent. ;  phosphorus,  15  per 
cent. ;  nitrogen,  3.5  per  cent. ;  fat,  2.5  per  cent. ; 
iron,  0.3  per  cent. ;  silicates,  5.6  per  cent. ;  moisture, 
10  per  cent.  The  remainder  goes  to  make  up  the 
rest  of  the  phutin  molecule — the  main  constituent 
of  the  product — which  is.  a  double  calcium  and  mag- 
nesium compound  of  inosite  phosphoric  acid.  It  is 
not  intended  as  a  substitute  for  any  method  of 
treatment,  nor  is  it  meant  to  be  used  in  infant  feed- 
ing only,  but  is  rather  intended  to  be  a  valuable 
aid  whenever  its  use  is  indicated. 

Renal  Calculus  with  Negative  X  Ray  Find- 
ings.— A.  Hyman  (Boston  Medical  and  Surgical 
Journal,  July  15,  1920)  tells  us  that  negative  ra- 
diographic findings  in  renal  lithiasis  are  not  infre- 
quent, four  such  cases  being  observed  within  the 
period  of  a  few  months.  Latent  kidney  stones  are 
also  not  uncommon ;  in  two  cases  there  were  no 
symptoms  referable  to  the  side  on  which  calculi 
were  found.  The  chemical  analysis  showed  urates 
to  be  the  predominating  constituent  in  all  four 
cases.  The  passage  of  a  ureteral  catheter  unob- 
structed into  the  pelvis  of  the  kidney  does  not 
prove  the  absence  of  a  ureteral  calculus.  The 
wax  tipped  bougie  is  of  value ;  it  will  every  now  and 
then  demonstrate  the  presence  of  a  stone  when 
other  means  fail.  Conservation  should  be  the 
watchword  in  all  operations  upon  the  kidney.  Neph- 
rectomy should  be  practiced  as  a  last  resort,  for 
despite  negative  radiograms  and  absence  of  symp- 
toms, the  opposite  kidney  may  be  the  seat  of  cal- 
careous disease. 


Anthrax  from  the  Shaving  Brush  and  Primary 
Anthrax  Meningitis. — H.  W.  Carey  (American 
Journal  of  the  Medical  Sciences,  May,  1920)  tells 
us  that  a  new  method  of  anthrax  transmission  from 
the  use  of  the  shaving  brush  has  been  discovered 
during  the  war.  The  hair  used  in  the  manufac- 
ture of  the  infected  brushes  came  chiefly  from 
China  and  Siberia,  to  a  lesser'  extent  from  the  Ar- 
gentine and  Chicago.  The  hair  was  either  not 
disinfected  at  all,  or  inadequately  disinfected.  The 
isolation  of  the  Bacillus  anthracis  from  the  shaving- 
brush  is  accomplished  better  by  the  inoculation  of 
susceptible  animals  than  by  cultural  methods, 
^leningitis  due  to  anthrax  may  occur  without  any 
apparent  point  of  entry.  The  spinal  fluid  is  always 
bloody  and  contains  the  anthrax  bacilli  in  large 
numbers. 

The  Capsule  in  Cataract  Extraction. — Edward 
Jackson  (Archives  of  Ophthalmology,  May,  1920) 
says  that  the  capsule  of  the  crystalline  lens  can 
rarely  cause  any  serious  impairment  of  vision  when 
left  in  situ  after  the  extraction  of  senile  cataract. 
Even  the  epithelium  lining  the  anterior  capsule  is 
not  a  source  of  danger  in  this  connection  in  senile 
eyes,  Aftercataract  is  in  most  cases  essentially 
composed  of  tissue  developed  from  fibroblasts 
which  reach  the  capsule  during  a  period  of  inflam- 
mation following  cataract  extraction ;  such  inflam- 
mation being  especially  favored  by  the  presence  of 
lens  substance  within  the  eye  and  outside  the  lens 
capsule.  '  Peripheral  linear  capsulotomy  guards 
against  the  danger  of  such  damage  from  the  pres- 
ence of  lens  substance  in  the  anterior  chamber  quite 
as  well  as  the  more  difficult  and  formidable  opera- 
tion of  intracapsular  extraction. 

Foreign  Body  of  Dental  Origin  in  a  Bronchus. 
— Carl  Arthur  Hedblom  (Annals  of  Surgery,  May, 
1920)  presents  the  following  conclusions:  1,  As- 
piration infection  of  the  lungs  is  most  common  in 
operations  about  the  mouth  following  general  an- 
esthesia. 2,  Symptoms  may  be  immediate  and  con- 
tinuous or  there  may  be  an  intervening  symptom- 
less period  of  months  or  years.  There  may  be  no 
iiTunediate  symptoms.  3,  The  most  constant  and 
characteristic  immediate  symptoms  are  cough,  dys- 
pnea, wheezy  respiration,  and  pain  in  the  chest. 
The  late  symptoms  in  varying  number  and  degree 
are  those  of  pulmonary  suppuration.  4,  Late  symp- 
toms of  foreign  body  infection  often  simulate  phthi- 
sis, and  that  is  the  diagnosis  often  made.  5.  Posi- 
tive diagnosis  rests  essentially  on  history  taking,  x 
ray,  and  bronchoscopy.  The  history  may  be  that 
of  having  swallowed  the  foreign  body.  6,  Bron- 
choscopy for  diagnosis  is  indicated  in  any  early 
doubtful  case.  7,  Spontaneous  expulsion  of  small, 
irregular  foreign  bodies  of  high  specific  gravity,  es- 
specially  teeth,  is  always  doubtful.  Spontaneous 
expulsion  often  occurs  only  after  an  abscess  lias 
formed.  8,  Bronchoscopy  is  the  only  treatment  to 
be  considered  in  early  uncomplicated  cases.  In  cases 
in  which  there  is  suppuration,  thoracotomy  for 
drainage  gives  the  best  results.  9,  In  fatal  cases 
death  is  usually  due  to  abscess,  bronchiectasis,  or 
gangrene  of  the  lung,  ^ny  of  which  may  be  compli- 
cated by  empyema.  10,  Tuberculosis  may  coexist 
with  a  suppurative  process. 


October  16,  1920.]  MISCELLANY  FROM  HOME    AND  FOREIGN  JOURNALS.  605 


Torsion  of  the  Left  Testicle  Followed  by  Gan- 
grene of  the  Testicle  and  Epididymis. — R.  E. 

Powell  (Canadian  Medical  Association  Journal, 
June,  1920)  reports  the  case  of  a  young  man  in 
whom,  after  violent  gymnastic  exercise,  acute  pain 
and  swelling  appeared  within  the  scrotum  and 
simulated  acute  epididymitis.  At  operation  there 
was  found  torsion  of  the  left  testicle  with  strangu- 
lation of  the  vessels  of  the  spermatic  cord,  which 
had  led  to  gangrene  of  the  testicle  and  epididymis. 
Castration  was  done  and  the  patient  recovered. 

Effect  of  Therapeutic  Doses  of  Mercury  on  the 
Kidneys  and  the  Duration  of  Its  Excretion. — L. 

G.  Beinhauer  (American  Journal  of  the  Medical 
Sciences,  June,  1920)  says  that  the  excretion  of 
calornel  in  ordinary  therapeutic  doses  begins 
within  six  to  twelve  hours  and  is  continued  until 
the  sixth  day,  depending  on  the  size  of  the  dose. 
A  small  dose  is  excreted  as  rapidly  as  a  larger  one, 
but  over  a  shorter  period  of  time.  In  so  far  as 
could  be  determined  by  the  urine  analysis  the  drug 
is  excreted  without  bad  effects  upon  the  kidney. 

Method  of  Performing  External  Urethrotomy 
Without  a  Guide. — G.  R.  Livermore  (Urological 
and  Cutaneous  Review,  May,  1920)  describes  his 
method  in  great  detail,  and  then  concludes  that  for 
those  who  do  not  thoroughly  understand  the  steps 
of  an  external  urethrotomy  without  a  guide,  or  in 
cases  in  which  there  is  so  much  scar  tissue  that  a 
sound  cannot  be  introduced  to  the  face  of  the  stric- 
ture, it  is  safer  for  the  patient  and  much  easier  for 
the  operator  to  do  a  preliminary  suprapubic  cysto- 
tomy and  retrograde  catheterization,  thus  locating 
the  urethra  behind  the  stricture  and  converting  an 
intricate  operation  into  a  very  simple  one. 

An  Unusually  Large  Cyst  of  the  Epididymis. 

— Abr.  L.  Wolbarst  (Urological  and  Cutaneous  Re- 
view, May,  1920)  reports  a  case  with  these  inter- 
esting features :  The  cyst  was  evidently  purely  re- 
tention in  character,  arising  in  all  probability  from 
a  dilatation  of  a  seminal  tubule  due  to  some  obstruc- 
tion in  the  vas  deferens  or  some  other  portion  of 
the  excretory  passages ;  it  was  unusually  large  in 
size — almost  as  large  as  a  hen's  egg ;  the  blood 
vessels  were  clearly  outlined  on.  its  external  walls ; 
spermatozoa  were  completely  absent ;  the  walls 
wei;p  very  thin ;  there  was  no  assignable  cause  for 
its  development  and  no  testicular  involvement  or 
malignant  potentialities. 

The  Tuberculosis  Problem  and  the  General 
Hospital. — ]\Iax  Taschman  and  B.  Stivelman 
(American  Journal  of  the  Medical  Sciences,  May, 
1920)  say  that  ninety  per  cent,  of  the  most  compe- 
tent observers  in  the  field  of  tuberculosis  consider  it 
helpful  and  advisable  to  have  beds  set  aside  in  the 
general  hospitals  for  the  purpose  of  study  and  di- 
agnosis of  cases  of  pulmonary  tuberculosis  before 
patients  are  sent  away  for  treatment.  These  ob- 
servers apparently  mean  sanatoria,  for  only  about 
fifty  per  cent,  of  the  large  general  hospitals  which 
replied  to  a  questionnaire  have  a  tuberculosis  serv- 
ice, and  none  of  the  others  contemplate  its  estab- 
lishment. The  writers  maintain  that  a  tuberculosis 
service  comprising  ward  and  clinic  in  the  general 
hospital  is  not  only  advisable  but  necessary. 


On  Deep  Localization  in  the  Cerebral  Cortex. 

■ — E.  G.  Van't  Hoog  (Journal  of  Nervous  and 
Mental  Disease,  April  1920)  found  from  his  re- 
searches that  the  supragranular  layers  of  the 
larger  animals  consistently  appeared  higher  than 
the  corresponding  zones  in  related  small  animals. 
There  was,  moreover,  a  corresponding  decrease  of 
the  granular  layer.  The  granular  cells,  he  feels, 
should  be  considered  matrix  cells,  not  only  in  the 
fascia  dentata  but  also  in  the  neocortex.  The 
supragranular  cortex  layers  are  receptor  associative 
in  accordance  with  Ariens  Kappers  functional  divi- 
sion, and  the  functional  nature  of  the  granules  is 
also  receptive  and  associative  in  the  post  central 
region. 

Multiple  Brain  Abscesses. — Clarence  C.  Sael- 
hof  (Journal  of  Nervous  and  Mental  Disease, 
April,  1920)  describes  a  case  of  multiple  bilateral 
brain  abscesses,  secondary  to  bronchiectasis,  caused 
by  the  wedging  of  the  lower  lobe  of  the  right  lung 
into  a  pocket  formed  by  kyphoscoliosis.  As  causa- 
tive agents  the  B.  fusiformis  and  anaerobic  strepto- 
cocci were  isolated  and  cultivated  from  both  the 
abscesses  and  the  suppurating  lung.  The  blood 
stream  was  considered  the  most  probable  route  by 
which  the  infection  travelled  from  its  primary 
focus. 

Determination  of  Magnesium  in  Blood. — A\'. 

Denis  (Journal  of  Biological  Chemistry,  ^larch, 
1920)  describes  a  method  for  determining  magne- 
sium in  small  amounts  of  plasma  which  has  been 
adapted  for  use  with  the  filtrate  obtained  after  the 
precipitation  of  calcium  in  plasma  or  whole  blood 
by  Lyman's  method.  The  procedure  briefly  con- 
sists in  the  removal  of  organic  material  contained 
in  the  filtrate  from  the  calcium  determination,  the 
precipitation  of  magnesium  as  magnesium  ammo- 
nium phosphate,  and  the  nephelometric  determina- 
tion of  the  phosphate  in  this  compound  by  the 
reagent  of  Pouget  and  Chouchak. 

Human  Arteriosclerosis :  Some  Remarks  Con- 
cerning Its  Etiology  and  Symptomatology. — 
George  William  Norris  (American  Journal  of  tlie 
Medical  Sciences,  June,  1920)  leaves  unsettled  the 
question  whether  clinical  arteriosclerosis  may  sim- 
ply be  an  involutional  process,  a  part  and  parcel  of 
aging ;  or  of  a  mechanical  or  toxic  origin.  It 
seems  to  him  more  than  likely  that  it  will  ultimately 
be  shown  to  be  the  result  of  chemical  changes  asso- 
ciated with  the  bodily  metabolism,  which  exert 
their  effects  upon  the  individual  visceral,  vascular 
and  somatic  cells,  either  directly  or  through  the 
mediation  of  the  ductless  glands. 

Two  Cases  of  Fibrinous  Bronchitis.— I.  Chand- 
ler Walker  (American  Journal  of  the  Medical  Sci- 
ences, June,  1920)  thinks  that  cases  of  fibrinous 
bronchitis  would  probably  not  be  as  rare  as  the  lit- 
erature would  indicate  if  the  sputa  of  patients  were 
more  carefully  examined.  The  diagnosis  is  made 
only  by  the  finding  of  long,  branching  bronchial 
casts  in  the  sputum  of  patients  who  do  not  have 
tuberculosis,  diphtheria,  pneumonia,  or  any  other 
primary  bronchial  disease.  Fibrinous  bronchitis 
is  an  idiopathic  disease,  the  cause  of  which  is  un- 
known. 


Proceedings  of  National  and  Local  Societies 


AMERICAN  .GYNECOLOGICAL  SOCIETY. 

Forfv-fifth  Annual  Meeting,  Held  in  Chicago',  May 
24,  25  and  26,  1920. 

The  President,  Dr.  Robert  L.  Dickinson,  of  New  York, 
in  the  Chair. 

{Continued  from  page  564.) 
Sterility  in  the  Female. — Dr.  Charles  G. 
Child,  Jr.,  of  New  York,  said  that  in  his  series  of 
cases  the  average  period  of  sterility  was  three  and 
one  half  years.  In  one  case  of  seven  years'  duration 
the  patient  was  cured  in  ten  months.  The  average 
time  from  operation  to  the  birth  of  the  first  child 
was  15.3  months,  while  seven  patients  gave  birth 
within  one  year  after  operation.  Seven  of  these 
patients  were  unconditionally  sterile,  due  to  tubal 
occlusion,  and  these  subsequently  bore  eight  chil- 
dren, who  owed  their  appearance  in  the  world  abso- 
lutely to  conservative  surgery.  These  eleven 
women  operated  upon  had,  to  date,  borne  sixteen 
living  children,  and  eight  were  still  in  the  child- 
bearing  period.  Such  results  as  had  been  obtained 
in  these  cases  should  go  far  towards  creating  in  the 
surgeon  added  respect  for  the  art  he  practised,  and 
a  firmer  belief  in  the  value  of  conservative 
gynecology. 

Errors  in  Gynecological  Diagnosis  Due  to 
Misplaced  Organs. — Dr.  Reuben  Peterson,  of 
Ann  Arbor,  Mich.,  drew  the  following  conclusions : 
1.  Mistakes  in  gynecological  diagnosis  arising  from 
misplaced  organs  are  not  uncommon,  as  shown  by 
the  literature  in  which  only  a  small  proportion  of 
such  mistakes  is  probably  recorded.  2.  Such  errors 
in  diagnosis  arise  from  either  carelessness,  or  pre- 
conceived ideas  of  diagnosis  whereby  important 
facts  in  the  history  and  equally  important  physical 
findings  are  either  overlooked  or  ignored.  3.  Such 
diagnostic  errors  can  be  averted  by  greater  care  in 
systematically  considering  with  a  free  mind  the 
facts  in  the  case  relating  to  the  history  and  physical 
findings  provided  the  latter  are  obtained  through  the 
employment  of  the  most  modern  methods  of  exami- 
nation. 4.  In  every  case  a  preoperative  diagnosis 
should  be  made  and  recorded  in  order  to  profit  by 
mistakes  revealed  at  the  operation  or  autopsy. 

The  Gynecological  Problem  in  Industrial 
Medicine. — Dr.  Harry  E.  Mock,  of  Chicago,  said 
that  the  scope  of  industrial  medicine  involved  the 
supervision  of  the  health  of  employees  in  industry 
and  other  problems  connected  with  the  factor  of 
human  maintenance.  It  included  the  prevention  of 
diseases  and  accidents ;  the  constant  supervision  of 
the  physical  conditions  of  the  employees  by  medical 
examinations  and  frequent  conferences ;  adequate 
medical  and  surgical  care ;  industrial  sanitation,  and 
nursing  service.  Comprehensive  medical  systems 
had  been  installed  in  a  great  many  of  the  large  in- 
dustrial plants  of  the  country.  Where  women  were 
.employed,  this  health  supervision  had  given  a  great 
opportunity  to  study  many  gynecological  problems, 
and  their  efifect  upon  the  efficiency  and  desirability 
of  women  employees  in  industry.  A  common  cause 
for  absenteeism  among  women  workers  was  dysmen- 


orrhea. Personal  observations  of  this  condition 
among  several  thousand  women  employees  in  a  large 
industry  were  given  extending  over  a  period  of  sev- 
eral years.  Other  gynecological  problems  met  in 
industry  included  the  frequency  of  venereal  diseases 
among  women  employees  where  complete  medical 
examinations  of  women  were  made ;  the  frequency 
of  pregnancy  among  girl  workers  and  how  this 
problem  should  be  met;  the  effect  of  dress,  diet,  and 
habits  upon  the  health  and  efficiency  of  women 
workers;  the  need  of  convalescent  homes  in  large 
cities  for  the  women  workers.  Industrial  medicine 
presented  a  wonderful  opportunity  for  studying 
certain  medicosociological  problems  as  related  to 
the  large  group  of  employees. 

The  Treatment  of  Suppurating  Wounds  Fol- 
lowing Abdominal  Section. — Dr.  Thomas  J. 
Watkins,  of  Chicago,  said  that  no  sutures  were 
removed  on  account  of  suppuration  except  when 
they  cut  deeply  into  the  tissues,  and  no  drains  were 
inserted.  No  probing  was  permitted.  Moist  boric 
acid  dressings  were  placed  over  the  wound  as  soon 
as  signs  of  suppuration  appeared  and  were  contin- 
uously applied  until  excessive  redness  disappeared. 
The  moist  dressings  were  used  to  keep  the  wound 
secretions  from  desiccating,  thus  promoting  drain- 
age. Experience  had  shown  that  a  large  amount  of 
drainage  would  take  place  through  very  small  open- 
ings when  thus  treated,  that  the  drainage  would  be 
efficient,  and  that  the  suppurating  surfaces,  by  vir- 
tue of  atmospheric  and  intraabdominal  pressure, 
would  keep  in  relative  apposition. 

The  author  had  used  this  treatment  for  about 
fifteen  years  and  had  found  that  the  wounds  healed 
quickly,  that  the  treatment  was  painless,  that  the 
patient  was  not  unnecessarily  disturbed  mentally, 
and  that  the  ultimate  strength  of  the  abdominal 
wall  was  seldom  injured  by  the  suppuration.  When 
the  discharge  ceased  no  open  wound  remained  to 
heal  by  granulation.  Antiseptic  solutions  were  not 
employed  as  they  injured  the  tissues  more  than 
they  harmed  the  bacteria.  Irrigations,  drains  and 
the  like  did  much  damage  to  the  delicate  tissue  re- 
pair which  was  present  in  the  healing  wounds. 
Photographs  were  presented  of  wounds  which  had 
suppurated  and  showed  no  evidence  that  there  had 
been  any  suppuration.  It  was  not  uncommon  for 
patients  who  had  had  suppurating  wounds  to  re- 
cover entirely,  and  leave  the  hospital  at  the  end  of 
the  third  week  after  operation. 

A  Neglected  Form  of  Cervical  Endometritis. 

— Dr.  Henry  T.  Byford,  of  Chicago,  stated  that 
as  a  result  of  acute  cervical  endometritis  a  perma- 
nent exudate  was  sometimes  left  about  the  internal 
OS  uteri,  which  for  descriptive  purposes  he  called  a 
constriction  ring,  although  in  reality  it  was  merely 
a  greater  thickness  of  the  mucosa  at  that  point.  This 
constriction  ring  not  only  produced  the  characteris- 
tics of  stenosis  in  many  cases,  but  gave  rise  to  the 
ordinary  symptotns  that  were  usually  attributed  to 
endometritis,  such  as  backache,  reflex  stomach  dis- 
turbances,  malaise,   dysmenorrhea,  intermenstrual 


October  16,  1920.] 


PROCEEDINGS  OF  NATIONAL  AND  LOCAL  SOCIETIES. 


607 


pain,  menorrhagia  and  sterility.  The  number  and 
severity  of  the  symptoms  varied  greatly  in  different 
patients,  depending  in  part  upon  the  interference 
with  the  patency  of  the  lumen,  the  chronicity  and 
the  associated  pelvic  conditions,  and  partly  upon 
the  patient's  general  resisting  powers  and  nervous 
habits.  The  diagnosis  was  made  by  means  of  the 
sound  which  detected  a  tender  area  at  the  internal 
OS  and  which  caused  more  or  less  bleeding.  In  the 
more  chronic  cases  firm  pressure  exerted  by  a 
dilating  wound  produced  a  slight  discharge  of  in- 
spissated mucus  which  adhered  to  the  sound.  The 
treatment  called  for  gradual  progressive  dilatation 
with  round  dilators  under  the  strictest  aseptic  and 
antiseptic  precautions,  and  later  stimulating  applica- 
tions of  iodized  phenol.  The  occasional  failure  of 
an  Emmet  trachelorrhaphy  to  cure  the  symptoms 
was  laid  to  a  persistence  of  such  an  exudate  at  the 
internal  os. 

Hemorrhages  Into  the  Pelvic  Cavity  Other 
Than  Those  of  Ectopic  Pregnancy. — Dr.  Rich- 
ard R.  Smith,  of  Grand  Rapids,  Mich,  stated  that 
although  ectopic  pregnancy  was  by  all  odds  the  most 
frequent  cause  of  hemorrhage  within  the  pelvic 
cavity,  it  occurred  occasionally  from  other  causes. 
The  most  frequent  source  of  such  hemorrhage  was 
the  ovary.  For  clinical  purposes  they  might  be 
conveniently  divided  into  three  groups. 

1.  Caused  by  a  ruptured  Graafian  follicle  or  cor- 
pus luteum  which  occurred  most  frequently  in  young 
women,  and  in  which  the  symptoms  rather  closely 
resembled  an  ectopic  pregnancy.  Many  patients  had 
been  operated  upon  also  for  supposed  appendicitis. 
Blood  might  be  found  in  lesser  amounts  or  in 
amounts  large  enough  to  cause  grave  symptoms. 
A  microscopical  examination  ordinarily  showed  a 
normal  Graafian  follicle  or  corpus  luteum. 

2.  The  second  group  was  not  uncommonly  desig- 
nated as  hematoma  ovarii.  Here  one  was  dealing 
with  a  distinctly  pathological  condition,  which  might 
be  evidenced  with  hematomata  into  the  Graafian 
follicles,  with  secondary  changes  following  in  the 
ovarian  structure.  This  condition  was  rather  fre- 
quently associated  with  fibroids  or  with  some  inflam- 
matory trouble  with  the  appendages.  In  other 
cases  no  such  association  apparently  existed  nor  was 
the  cause  clear.  In  young  women  it  was  sometimes 
the  cause  of  severe  dysmenorrhea. 

3.  A  group  of  hemorrhages  associated  with  ova- 
rian tumors  (cystic  or  solid)  of  considerable  size,  in 
which  the  bleeding  occurred  into  the  tumor  or  from 
it  into  the  peritoneal  cavity.  Such  bleeding  tumors 
were  commonly  the  seat  of  a  twisted  pedicle  or  of 
inflammatory  adhesions ;  also  a  ruptured  pedicle  had 
been  the  cause. 

Although  the  tube  might  on  rare  occasions  give 
rise  to  hemorrhage  without  the  cause  being  evident, 
in  most  cases  the  reason  for  such  hemorrhage  was 
apparent.  A  tube  involved  in  the  twisted  pedicle 
of  an  appendage  was  a  good  illustration  of  such 
hemorrages ;  occasionally  it  was  found  associated 
with  the  thickened  tubes  of  an  old  infection.  Such 
hemorrhages  were  small  in  quantity  in  the  reported 
cases  and  the  condition  should  be  easily  differentiated 
from  ectopic  pregnancy.  Intraperitoneal  hemor- 
rhages from  fibroid  tumors  formed  a  very  interest- 


ing group.  Wallace  reported  seventeen  collected 
cases  and  Gerstenberg  one.  The  hemorrhage  was 
often  severe  and  the  mortality  had  been  very  high 
(thirty-five  per  cent.).  They  occurred  from  dilated 
veins  or  from  a  rupture  of  the  tumor  itself. 

Presidential  Address. — Dr.  Robert  L.  Dickin- 
son, of  New  York,  stated  that  in  all  other  depart- 
ments of  medicine  and  surgery  the  war  made  an  in- 
ventory of  men  and  methods.  Gynecology  should 
now  conduct  a  complete  self  survey.  The  special- 
ty was  limited  but  large,  the  procedures  being  few, 
yet  gynecological  operations,  as  studied  in  clinical 
congresses  or  in  daily  operation  notices  of  large 
cities,  omitting  lesser  operations,  were  shown  to  com- 
prise one  fourth  of  surgery.  Operation  was  re- 
quired in  less  than  one  tenth  of  patients  with  dis- 
abilities peculiar  to  women,  obstetrics  being  ex- 
cluded. The  future  problems  that  gynecology  was 
alone  qualified  to  solve  were  considered.  The  first 
was  its  own  portion  of  a  standard  nomenclature, 
whereupon  the  new  census  volume  was  presented. 
The  'operation  nomenclature  was  under  way. 
Standards  were  defined  as  the  best  present  prac- 
tice, widely  studied,  fairly  epitomized,  succinctly 
written  down,  warily  applied,  both  flexible  and  pro- 
gressive. There  was  need  of  taking  stock  of  ob- 
stetrical and  gynecological  clinics.  The  lack  of  lead- 
ers was  deplored,  one  cause  shown  by  the  war  cen- 
sus being  a  want  of  hospital  connection,  only  one 
medical  man  in  twenty-eight,  and  one  surgeon  in 
four  having  such  connection.  Therefore,  deliberate 
selection,  training,  full  knowledge  concerning  spe- 
cialists, teaching  centres  for  the  future  were  urged, 
and  the  carrying  of  obstetrical  education  directly 
to  the  practitioner  in  his  own  locality.  Women 
should  be  given  hospital  opportunity,  so  that  Amer- 
ican women  might  prove  themselves  as  good  as 
British. 

What  were  some  of  the  sociological  problems? 
Sterilization  of  women  by  simple  means,  with  tests 
of  tube  patency ;  artificial  impregnation ;  contracep- 
tives ;  the  definition  of  normal  sex  life;  the  doctor's 
section  of  sex  instruction ;  and  the  extension  of 
routine  pelvic  examination  before  marriage  and  the 
harder  forms  of  industry.  He  advocated  the  estab- 
lishment of  a  journal  under  the  auspices  of  the 
society ;  also  gynecological  centres  in  libraries  and 
museums,  including  a  slide  library,  loan  charts,  and 
a  studio.  Finally,  action  was  considered  looking  to- 
,ward  certification  of  specialists,  such  certification  to 
hold  good  some  ten  years  at  a  time. 

The  Development  of  Prenatal  Care  and  Ma- 
ternal Welfare  Work  in  Paris  Under  the  Chil- 
dren's Bureau  of  the  American  Red  Cross. — Dr. 
Fred  L.  Adair,  of  Minneapolis,  said  that  prenatal 
or  antenatal  care  was  that  part  of  a  public  health 
program  which  had  as  an  ultimate  object  the  bene- 
ficial influencing  of  the  health  of  the  offspring  by 
surrounding  the  mother  with  proper  conditions  dur- 
ing the  period  of  pregnancy.  Any  complete  health 
and  social  welfare  program  should  include  two  pub- 
lic welfare  activities,  i.  e.,  maternal  and  infant  wel- 
fare, which  were  closely  related  and  should  be  very 
carefully  coordinated.  These  activities  were  inti- 
mately bound  up  with  the  family  and  concerned  par- 
ticularly the  mother  and  child.    While  these  two 


60S 


FROCEEDIXGS  OF  NATIONAL   AND  LOCAL  SOCIETIES. 


[New  York 
Medical  Journal. 


subprograms  were  more  or  less  closely  related  to  all 
the  other  public  welfare  work,  they  had  more  points 
of  contact  with  each  other  than  with  the  rest  of 
such  activities.  From  an  administrative  viewpoint 
these  two  activities  should  be  comprised  in  a  ma- 
ternal and  child  welfare  program,  but  from  a  med- 
icosocial  viewpoint  the  work  should  be  handled  by 
experts  in  the  different  lines  of  work. 

The  objects  of  the  maternal  welfare  program 
were :  1 .  To  develop  healthy  parents,  especially 
mothers  who  were  intelligently  trained ;  2,  to  bring 
them  through  life  to  maturity  capable  of  bearing  and 
rearing  normal  children :  3,  to  reduce  the  maternal, 
fetal  and  newborn  morbidity  and  mortality  to  the 
lowest  possible  level ;  4,  to  leave  the  mother  with  a 
desire  and  capacity  to  bear  and  rear  children  proper- 
ly in  a  sufficient  number  and  of  such  a  quality  as  not 
only  to  maintain  the  integrity  of  the  human  race, 
but  constantly  to  improve  its  character.  The 
family  should  be  protected  from  various  detrimental 
influences  by  education,  legislation,  and  proper  help 
and  advice.  This  meant  that  each  family  should 
have  a  normal  economic  status,  proper  housing,  good 
sanitarjr  surroundings,  proper  advice,  and  care  in 
case  of  physical  or  other  needs  resulting  from  dis- 
ease, economic  reverses,  or  distress  of  any  kind. 
Some  of  the  medical  problems  which  vitally  affected 
the  individuals  and  the  family  were  those  dealing 
with  tuberculosis  and  venereal  diseases.  These  ac- 
tivities were  very  closely  allied  to  maternal  welfare 
work. 

The  legislative  program  included  those  laws  which 
were  designed  to  protect  the  family  unit  in  health, 
economic  independence  and  happiness,  or  to  prevent 
any  invasion  by  medical  or  social  disease.  The  re- 
lief of  social  distress  and  disease  was  not  less  im- 
portant than  the  cure  of  physical  ailments  and  dis- 
eases. For  the  happiness  and  wellbeing  which  could 
be  brought  to  the  individual  mother  and  those  asso- 
ciated with  her  by  intelligent  guidance,  sympathy 
and  help  were  unmeasurable. 

The  Importance  of  a  FoUowup  System. — Dr. 
George  W.  Kosmak,  of  New  York,  asked  whether 
a  recently  delivered  mother  in  either  private  or  hos- 
pital practice  was  accorded  as  much  attention  in  a 
followup  sense  as  a  patient  recovering  from  medical 
or  surgical  illness.  During  the  past  decade  the  de- 
velopment of  prenatal  care  might  be  regarded  as  one 
of  the  most  important  advances  in  obstetrics.  In 
view  of  the  tendency  to  injuries  resulting  in  invalid- 
ism remaining  unrecognized  in  the  usual  postpartum 
examination,  a  discharge  of  the  patient  should  not  be 
made  for  at  least  three  months  after  the  birth  of  the 
child.  During  this  interval  at  least  two  or  three  ex- 
aminations of  the  patient  should  be  made.  It  was 
possible  to  treat  minor  traumatic  and  other  lesions 
during  this  period  and  avoid  later  complicating  con- 
ditions resulting  in  invalidism. 

A  survey  of  forty-eight  American  maternity  hos- 
pitals showed  that  thirty-six  of  this  number  main- 
tained some  sort  of  followup  system  but  in  the 
majority  of  the  latter  the  patients  returned  only  if 
abnormalities  developed.  The  admission  was  made 
by  practically  all  observers  that  a  followup  system 
for  obstetrical  patients  was  not  only  desirable  but 
necessary.   Certain  difficulties  must  be  acknowledged 


in  instituting  such  a  system  but  with  the  better  edu- 
cation of  the  patient  the  realization  of  the  need  would 
become  apparent  to  her  and  her  family.  A  regularly 
organized  postpartum  clinic  should  be  part  of  tire 
equipment  of  every  maternity  hospital  and  in  con- 
nection with  the  same  an  organization  of  social  serv- 
ice workers  or  followup  nurses  to  visit  the  patients 
in  their  homes  was  essential.  The  necessity  of  more 
prolonged  postpartum  observation  should  be  includ- 
ed in  every  scheme  of  hospital  standardization  and 
the  shortcomings  of  institutional  work  in  this  field 
applied  with  equal  force  to  private  patients.  The 
advisability  of  some  form  of  maternity  insurance 
might  do  a  great  deal  to  obviate  some  of  the  diffi- 
culties connected  with  the  scheme  of  more  prolonged 
postpartum  care  of  obstertical  patients. 

An  Analysis  of  the  Failures  in  Radium  Treat- 
ment of  Cervical  Cancer. — Dr.  Frederick  J. 
Taussig,  of  St.  Louis,  stated  that  radium  treat- 
ment of  uterine  cancer  should  be  kept  in  the  hands 
of  the  gynecologist  rather  than  the  rontgenologist, 
but  such  a  gynecologist  should  seek  preliminary 
training  in  the  use  of  radium  and  must  have  con- 
tinued opportunity  for  observation  and  treatment  of 
cancer  cases  in  order  to  reduce  mistakes  to  a  mini- 
mum. Good  permanent  results  could  be  obtained 
in  a  certain  proportion  of  cervical  cancers  with 
amounts  of  radium  not  exceeding  one  hundred  to 
one  hundred  and  fifty  mgs.  of  the  element,  though 
the  use  of  large  amounts  in  the  form  of  emanation 
would  doubtless  decrease  complications  and  increase 
the  number  of  cures  to  some  degree.  If  possible,  all 
necessary  treatment  should  be  given  within  the  first 
six  or  eight  week  period  before  sclerosis  had  set  in 
and  rendered  the  cancer  less  accessible  and  the  nor- 
mal tissues  more  susceptible  to  injury. 

Tumor  filtration  or  light  metal  filtration  together 
with  intracer\-ical  application  did  most  good  and 
least  damage ;  twenty-five  hundred  to  thirty-five 
hundred  mgs.  were  usually  enough  to  give  results  in 
the  favorable  cases.  In  the  absence  of  the  Bailey 
bomb  and  large  amounts  of  emanation,  well  directed 
and  prolonged  x  ray  from  six  to  eight  portals  would 
usually  affect  the  parametrial  and  glandular  involve- 
ments. Prolonged  necrosis,  and  fistulas  were  due  to 
repeated  treatments,  to  vaginal  applications  and  to 
heavy  gamma  radiation  or  to  a  combination  of  the 
three.  Rectovaginal  fistulas  were  more  frequent 
and  vesicovaginal  fistulas  less  frequent  after  radium 
treatment.  Operation  was  to  be  preferred  in  all 
operable  cases  where  the  patient  was  under  thirty- 
five  A'ears  and  in  the  early  operable  cases  where  the 
patient  was  beyond  this  age.  Radium  was  to  be  rec- 
ommended wherever  obesity,  lung,  heart  or  kidney 
lesions  made  operation  difficult  or  dangerous,  and  in 
advanced  operable,  borderline  and  inoperable  cases, 
but  not  in  the  advanced  inoperable  group  with  cach- 
exia. The  advanced  inoperable  cases  had  better  be 
treated  with  acetone,  since  radium  increased  the  ten- 
dency to  fistulas  and  pain  in  most  instances.  These 
views  were  based  on  an  experience  extending  over 
two  and  a  half  years  in  the  treatment  of  eighty-six 
cases  of  cer\-ical  and  vaginal  cancer  and  six  cases  of 
vulvar  cancer,  in  which  radium  or  a  combination  of 
radium  with  operation  was  employed. 

{To  be  concluded.) 


New  York  Medical  Journal 

INCORPORATING  THE 

Philadelphia  Medical  Journal  "'e  Medical  News 

A  Weekly  Revieiv  of  Medicine,  Established  184S. 

Vol.  CXII,  No.  17.  NEW  YORK.  SATURDAY,  OCTOBER  23,  1920.  Whole  No.  21S6. 

Original  Communications 


XATIOXAL  HEALTH  PROBLEMS.* 

By  Hugh  S.  Cummixg,  ^L  D., 
Washington.  D.  C. 
Surgeon  General,  United  States  Public  Health  Service. 

In  the  last  analysis  most  health  problems  are  in 
a  certain  sense  local  problems,  and  the  Federal  Con- 
stitution, which  as  handed  down  by  our  forefathers 
T  am  old  fashioned  enough  to  believe  is  the  wisest 
instrument  of  government  ever  devised  by  man. 
sets  distinct  limitations  upon  federal  activities  in 
public  health ;  limitations  which  are  apparently  over- 
looked by  many  enthusiastic  workers — and  others. 
For  such  problems.  I  look  upon  the  United  States 
Public  Health  Service  as  a  reserve  to  be  called  upon 
by  state  and  local  authorities  when  the  forces  of 
disease  or  diminished  economic  efficiency  consequent 
therefrom  are  for  any  reason  more  than  local  or 
state  authority  can  subdue,  or  in  which  they  request 
federal  aid  and  cooperation. 

There  are.  however,  problems  concerning  the  na- 
tion's servants,  be  they  military  or  civil,  and  prob- 
lems involving  foreign  and  interstate  commerce  in 
its  broad  sense  which  clearly  require  national  ac- 
tion. There  are  also  other  problems  in  preventive 
medicine  which  are  naturally  federal  in  scope.  In 
nearly  every  great  campaign  there  arise  crises  and 
battle  is  forced  at  some  points  not  of  our  choosing, 
but  which  require  for  the  success  of  our  war  a  tem- 
porary withdrawal  or  weakening  of  forces  at  points 
which  we  know  are  our  ultimate  goal.  Two  such  cri- 
ses are  now  before  the  Federal  health  service,  both 
consequent  upon  the  World  War.  One  of  these  is  the 
prevention  of  the  introduction  into  America  of  three 
great  epidemic  diseases,  typhus  fever,  cholera  and 
bubonic  plague. 

Detailed  in  1918  in  charge  of  Service  activities  in 
Europe,  with  especial  reference  to  sanitation  of  re- 
turning troops  and  the  inspection  of  ports  of  Europe 
with  reference  to  resumption  of  trade  and  immigra- 
tion, president  of  the  Interallied  Medical  Mission 
to  Poland,  the  American  delegate  to  the  Interna- 
tional Convention  of  Public  Health,  and  with 
twenty-five  years  of  experience  at  home  and  abroad, 
I  may  be  considered  a  fairly  competent  authority, 
and,  in  my  opinion,  there  never  before  has  been  so 
grave  a  danger  of  the  introduction  of  these  diseases. 
For  six  years,  plague,  pestilence,  famine  and  death, 
the  four  offspring  of  war,  have  ravaged  Europe.  So 

*Read  b'fore  the  Philadelphia  County  Medical  Societv,  May  12, 
1920. 


far  as  Western  Europe  is  concerned,  there  was  com- 
paratively little  danger  to  us,  so  long  as  the  war 
conditions  continued,  becatise  of  the  absence  of 
trade  and  the  constant  supervision  of  troops,  though 
even  in  Holland  there  was  a  sharp  epidemic  of  ty- 
phus in  the  winter  of  1918-19,  and  occasionally  rat 
plague  at  a  British  port.  These  conditions  have 
changed,  commerce  and  emigration  have  been  re- 
sumed. In  central  and  eastern  Europe,  the  near 
Orient  and  Mediterranean  littoral  conditions  are 
more  menacing.  It  should  not  be  forgotten  that 
while  commerce  has  been  resumed,  war,  famine 
and  disease  are  still  raging. 

There  have  been  for  several  years  thousands  of 
cases  of  typhus  fever  in  Poland  and  elsewhere  in 
central  and  eastern  Europe,  including  ports.  Much 
to  our  surprise,  we  found  last  year  no  true  Asiatic 
cholera  in  Poland,  even  among  the  Bolshevist  pris- 
oners, among  whom  were  Chinese,  Tartars,  and 
others  from  cholera  areas.  This  year  reliable  in- 
formation leads  us  to  fear  an  epidemic  in  Southern 
Europe  and  the  near  East.  The  third  disease, 
plague,  is  much  more  insidious  and  difficult  to  con- 
trol. Fifteen  years  ago  Sir  Patrick  Manson  in  my 
quarters  at  the  San  Francisco  quarantine  station 
predicted  that  within  twenty  years  plague  would  be 
pandemic  unless  it  could  be  stopped  by  our  quar- 
antines. We  now  know  that  plague  infection  may 
persist  among  rats  on  a  vessel  for  months  before 
personnel  are  infected.  Once  it  obtains  a  foothold 
in  a  port,  it  may  persist  for  years  until  the  rat  popu- 
lation is  starved  and  built  out.  and  it  takes  millions 
of  dollars  to  accomplish  this. 

In  every  Mediterranean  port  visited  by  me  from 
Barcelona.  Spain,  to  Constantinople  human  or  rat 
plague  or  both  were  or  had  recently  been  present ; 
in  many  it  was  endemic.  Plague,  human  or  rat.  has 
been  occurring  with  disturbing  frequency  at  British 
ports,  as  well  as  elsewhere,  and  there  have  recently 
been  sharp  human  outbreaks  in  several  European 
ports.  Generally  speaking,  the  permanent  stone  struc- 
ture of  the  quays,  docks,  and  warehouses  of  Europe 
are  not  conducive  to  a  long  continued  epizootic 
among  rats,  but  in  most  of  our  American  ports  wood 
frame  wharves  and  warehouses  are  ideal  harbors. 
The  great  difficulty  and  cost  of  eradicating  plague 
from  such  ports  has  been  shown  in  Xew  Orleans  and 
San  Francisco.  The  danger  from  cholera  carriers 
was  shown  a  few  years  ago  when  the  Public  Health 
Service  found  carrier  after  carrier  in  emigrants 
arriving  from  Naples  despite  the  long  voyage. 


Copyright,  1920,  by  A.  R.  tlliott  Publishing  Company. 


610 


GUMMING:  NATIONAL  HEALTH  PROBLEMS. 


[New  York 
Medical  Journal. 


To  lessen  the  danger  from  plague  the  Public 
Health  Service  is  requiring  periodical  fumigation 
of  all  vessels  and  the  fumigation  of  vessels  from 
Mediterranean  and  certain  other  ports,  while  trained 
medical  officers  are  now  in  Europe.  I  am  glad  to 
say  that  the  pending  Sundry  Civil  Bill  provides  for 
the  purchase  and  taking  over  of  the  New  York, 
Baltimore  and  Texas  maritime  quarantine  stations. 
It  is  quite  conceivable  that  if  the  present  conditions 
abroad  continue  or  become  worse  that  the  Federal 
government  may  deem  it  wise  to  take  additional 
measures  of  safety  by  restricting  emigration  from 
certain  dangerous  areas. 

I  hope  that  our  respective  state  and  local  authori- 
ties will  cooperate  by  vigorous  deratization  of  cities, 
especially  ports,  looking  into  water  supplies,  and 
the  improvement  of  housing  and  public  baths.  It 
may  be  added  that  the  Federal  government  is  urg- 
ing such  a  revision  of  the  International  Sanitary 
Convention  of  Paris  of  1912,  to  which  over  thirty 
nations  are  signatory,  as  will  insure  the  recognition 
of  cholera  carriers,  of  rat  plague,  and  of  typhus, 
and  a  reliable  reporting  of  disease. 

The  second  great  problem  consequent  upon  the 
war,  thrust  upon  the  Public  Health  Service,  is  the 
hospitalization  and  care  of  the  sick,  wounded  and 
disabled,  discharged  soldiers  and  sailors.  These 
men  to  whom  the  country  and  indeed  civilization 
itself  owe  so  much  are  primarily  the  wards  of  the 
Bureau  of  War  Risk  Insurance,  and,  after  conval- 
escence, of  the  Federal  Board  of  Vocational  Train- 
ing, the  medical  staff  of  both  organizations  being 
furnished  by  the  Public  Health  Service  to  whom  has 
been  assigned  by  Congress  the  care  of  the  sick  and 
wounded. 

The  duty  has  been  a  difficult  one  in  some  locali- 
ties, at  times  almost  insuperable.  Generally,  there 
were  insufficient  hospital  facilities,  especially  for 
neuropsychiatric  and  tuberculous  patients  when  the 
war  began ;  there  has  been  little  construction  for 
six  years,  and  the  normal  increase  of  population  in- 
creased the  deficiency.  The  army  took  over  for  its 
emergency  many  civil  hospitals,  and  such  of  the 
temporary  camp  and  evacuation  hospitals  as  it  has 
not  needed  have  been  transferred  to  the  Service, 
but  many  of  them,  because  of  location  or  deteriora- 
tion of  frame  buildings,  are  unfit  for  our  needs. 
At  present,  the  Service  has  about  16,000  men  in 
fifty-two  hospitals  either  owned  or  leased  by  it  and 
in  about  1,800  civil  hospitals  under  contract.  The 
number  needing  hospitalization  is  increasing  at  the 
approximate  rate  of  1,200  a  month.  Many  of  the 
institutions  now  in  use  are  unsuitable  and  we  are 
constantly  being  pressed  by  civil  authorities  to  re- 
lease institutions.  I  sincerely  hope  that  Con- 
gress will  appreciate  the  necessity  of  appropriating 
sufficient  money  to  carry  out  the  building  program 
presented  by  the  Public  Health  Service  to  provide 
for  the  number  of  patients,  approximately  35,000, 
which  we  expect  to  reach  in  three  or  four  years. 

Some  public  health  agencies  may  have  misgivings 
that  this  duty  will  absorb  too  much  of  the  personnel 
of  the  Service.  I  think  this  view  a  narrow  and  er- 
roneous one.  The  work  in  a  very  direct  sense  is 
largely  preventive  medicine  and  toward  the  public 
health.    For  Example,  one  third  of  the  patients  are 


tuberculous,  one  third  neuropsychiatric,  and  taking 
care  of  the  tuberculous  and  psychiatric  among  nearly 
five  millions  of  our  population  will  meet  two  of  the 
nation's  important  health  problems.  Furthermore,  it 
is  hoped  that  many  of  the  hospitals  will  become 
centres  for  the  development  of  better  means  for 
the  cure  and  prevention  of  disease. 

That  group  of  communicable  diseases  known  as 
the  venereal  diseases  has  for  centuries  been  an  un- 
?olved  problem,  the  grave  importance  of  which  has 
been  brought  to  the  attention  of  the  general  public 
as  a  result  of  our  entrance  into  the  war.  He  is  in- 
deed an  optimist  who  imagines  that  this  very  serious 
problem  has  been  overcome  or  even  that  the  com- 
plete solution  of  it  has  been  found,  but  I  am  con- 
vinced that  it  is  to  be  best  found  in  teaching  the 
dangers  of  the  diseases  and  in  religious,  moral  and 
ethical  training,  rather  than  in  coercive  legislation 
alone,  though  proper  legislation  and  its  enforce- 
ment are  necessary  adjuncts. 

There  are  other  serious  questions  which  affect 
the  health,  efficiency  and  welfare  of  the  nation, 
such  as  malaria,  typhoid  fever,  and  general  rural 
sanitation,  child  hygiene,  and  industrial  diseases, 
which  can  be  met  efficiently  by  a  cooperation  of  the 
Federal,  state  and  local  authorities.  It  will  be  well 
to  consider  the  main  Federal  governmental  agency 
interested  in  and  responsible  for  disease  prevention 
in  the  United  States  and  its  relation  to  state  and 
local  agencies. 

The  United  States  Public  Health  Service  has  been 
built  up  on  the  old  Marine  Hospital  Service.  For 
over  a  hundred  years  it  has  been  growing.  Dur- 
ing that  time  Congress  has  imposed  one  duty  after 
another  until  now  it  practically  has  all  of  the  author- 
ity of  law  to  protect  the  health  of  the  nation  which 
under  the  Constitution  can  be  granted  to  any  Federal 
agency.  If  it  had  annual  appropriations  commen- 
surate with  the  authority  granted,  the  country  could 
expect  dividend  returns  in  the  way  of  disease  pre- 
vention that  would  be  astounding.  Even  now  it 
has  an  organization  and  funds  which  are  the  equal 
of  any  national  health  agency  in  the  world.  Begin- 
ning in  1798  with  a  fund  obtained  by  assessing  each 
sailor  of  our  merchant  marine  twenty  cents  a  month, 
it  will  spend  this  fiscal  year  for  health  work  over 
$2,400,000  in  addition  to  over  $17,000,000  on  its 
hospital  relief  work  for  the  War  Risk  Insurance 
patients  and  other  beneficiaries  of  the  Service. 

During  the  war  the  President  constituted  the 
Service  a  part  of  the  military  forces  and  its  war 
record  is  one  achievement  to  be  proud  of.  It  de- 
tailed officers  to  the  Army  and  Navy,  maintained 
sanitary  zones  about  the  camps  and  cantonments  of 
the  Army  and  had  supervision  over  the  health  of 
many  large  war  industries. 

Within  the  boundaries  of  the  camps  themselves 
the  Army  health  authorities  were  responsible  for 
proper  hygienic  conditions.  In  the  extracanton- 
ment  zones  the  Public  Health  Service,  in  cooperation 
with  State  and  local  health  authorities,  was  re- 
sponsible. Aided  by  funds  from  the  American  Red 
Cross  and  local  authorities,  the  Public  Health  Serv- 
ice established  complete  health  organizations  in 
fifty-one  extracantonment  zones.  In  all,  the  Public 
Health  Service  expended  $1,201,909,  the  American 


October  23,  1920.] 


CUMMIXG:   NATIONAL  HEALTH  PROBLEMS. 


611 


Red  Cross  $507,000,  and  the  States  and  local  au- 
thorities, $650,000.  The  civil  population  protected 
by  these  organizations  was  approximately  three  and 
three  quarter  million  persons,  in  addition  to  the 
military  population. 

It  is  not  possible  in  a  paper  of  this  kind  to  enu- 
merate all  of  the  work  done,  but  to  illustrate :  Two 
thousand  five  hundred  miles  of  ditches  were  dug 
and  1,200  square  miles  of  swamp  territory  drained, 
and  an  antimosquito  zone — one  mile  in  width — was 
established  around  each  camp.  It  is  a  well  known 
fact  that  malaria,  which  was  a  serious  potential 
disability  factor  about  many  of  these  camps,  was 
practically  eliminated  from  the  soldier  population, 
and  only  3,160  cases  were  reported  to  the  Public 
Health  Service  during  the  malaria  season  of  1918 
among  the  civil  population  of  three  and  three  quar- 
ter million,  a  rate  of  eighty-three  in  100,000.  From 
such  data  as  were  obtainable  for  previous  years 
this  was  a  tremendous  reduction  in  the  malarial 
rate  in  these  communities.  These  results  may  well 
be  compared  with  those  in  Panama,  especially  since 
they  were  obtained,  not  under  military  conditions, 
but  through  the  voluntarj-  work  of  a  civil  popula- 
tion. 

After  the  war  Congress,  in  providing  for  the 
medical  and  surgical  care  of  the  discharged  and 
disabled  soldiers  and  sailors,  appropriated  over  $10,- 
000.000  for  hospitals  for  the  Service  and  made  the 
discharged  and  disabled  soldiers  and  sailors  bene- 
ficiaries of  the  Service.  During  the  year  the  Service 
will  spend  over  $17,000,000  for  the  maintenance  of 
this  medical  care. 

The  Public  Health  Service  has  an  organization 
consisting  of  a  bureau  with  seven  divisions  and  450 
employees  in  Washington  and  a  field  force  of  593 
commissioned  officers,  consultants  and  local  medical 
men.  and  8,100  other  employees.  It  has  fifty-two 
hospitals  either  owned  or  leased,  and  contracts  with 
about  1,800  civil  hospitals;  ninety-one  immigration 
stations ;  ninety  quarantine  stations ;  thirty  stations 
for  investigation  and  prevention  of  disease;  thirty- 
four  states  are  organizing  with  the  Service  a  sys- 
tem of  morbidity  reports.  The  Venereal  Disease 
Division  has  organizations  working  with  the  health 
authorities  of  forty-seven  states.  Some  of  its  medi- 
cal officers  are  detailed  to  advise  and  cooperate  with 
other  federal  agencies  and  state  health  authorities. 
The  Federal  Government  is  responsible  for  the  con- 
trol of  international  and  interstate  spread  of  dis- 
ease ;  the  state  governments,  for  the  interstate  and 
intrastate  spread  of  disease ;  the  local  governments, 
for  the  intercommunity  and  intracommunity  spread 
of  disease. 

The  common  responsibility  is  the  control  of  dis- 
ease. One  case  of  any  preventable  disease  is  a 
matter  of  joint  concern  for  national,  state  and  local 
health  agencies.  Disease  carriers  do  not  recognize 
county  and  state  lines.  Once  introducecf  into  intra- 
state and  interstate  traffic  a  disease  may  cost  mil- 
lions of  dollars  and  many  human  lives.  The  rational 
and  businesslike  method  of  disease  prevention 
should  begin  at  the  bedside  of  the  first  patient  or 
before  and  not  wait  until  it  reaches  epidemic  pro- 
portions. Applying  such  a  business  principle  would 
make  it  imperative  that  the  national,  state  and 


local  health  agencies  work  together — form  a  joint 
partnership,  if  you  please — and  each  bear  its  proper 
share  in  the  work  and  expense.  If  Congress  should 
recognize  this  principle  and  authorize  such  a  part- 
nership, the  amounts  now  spent  in  the  cooperation 
with  the  states  would  have  to  be  greatly  increased 
and  a  plan  or  organization  would  have  to  be  care- 
fully worked  Qut  so  that  each  party  to  the  partner- 
ship would  meet  the  obligations  and  expenditures 
according  to  their  respective  responsibility. 

The  Public  Health  Service,  owing  to  its  size  and 
present  position  in  the  field  of  health  protection, 
would  constitute  the  foundation  upon  which  to 
build  the  federal  health  agency  in  such  a  partner- 
ship. The  other  federal  agencies  now  authorized 
by  Congress  to  perform  certain  health  functions 
would  necessarily  have  to  be  brought  into  the 
organization  and  their  work  correlated  with  that 
of  the  Public  Health  Service,  in  order  to  constitute 
a  smooth  working  machine.  In  state  and  local  organ- 
izations, where  there  are  several  legally  authorized 
agencies  performing  health  functions,  these  would 
have  to  be  brought  together  and  their  work  also 
correlated. 

In  the  formation  of  a  partnership  of  this  kind 
volunteer  health  agencies  now  organized  and  work- 
ing in  the  field  of  preventive  medicine  should  be 
recognized  and  made  a  part  of  the  machinery,  but 
it  should  be  distinctly  understood  that  such  agencies 
are  auxiliary  to  legally  constituted  health  agencies. 
However,  they  could  be  utilized  to  great  advantage 
in  this  partnership  owing  to  the  elasticity  of  organ- 
ization and  the  possibility  of  utilizing  funds  for  work 
not  authorized  by  law.  But  in  the  end  these  volunteer 
agencies  should  be  brought  under  either  federal, 
state  or  local  laws  and  form  a  legal  part  of  the 
health  machinery.  The  control  of  disease  is  a  gov- 
ernmental function  and  in  a  democratic  government 
all  agencies  should  finally  come  under  authorized 
legal  authorities,  otherwise  our  Government  would 
fail  to  be  a  democracy  and  would  be  subject  to 
control  by  volunteer  agencies  who  are  not  directly 
responsible  to  the  people. 

The  war  experience,  as  brought  out  by  the  re- 
sults of  the  physical  examination  of  the  draft  boards, 
has  so  impressed  the  Public  Health  Service  that  it 
has  already  presented  to  Congress  a  program  in- 
tended especially  to  meet  after  war  health  needs. 
The  fundamental  principle  in  this  program  is  fed- 
eral cooperation  with  state  and  local  health  agen- 
cies and  by  far  the  larger  part  of  the  two  million 
dollars  requested  of  Congress  would  be  spent  along 
the  Lever  plan  of  federal  aid  extension. 

When  the  organization  of  the  triple  partnership 
is  complete  it  must  be  recognized  that  the  Federal 
Government  would  have  to  bear  its  just  proportion 
of  the  expenses  in  the  state  and  local  health  ma- 
chinery of  forty-eight  states  and  over  four  thousand 
local  health  jurisdictions.  (There  are  about  3.000 
counties  and  about  1,300  cities  with  a  population  of 
5,000  and  over).  At  the  conference  of  state  and 
territorial  health  authorities  with  the  Public  Health 
Service,  I  intend  to  discuss  the  subject  of  federal 
health  organization  and  present  for  discussion  by 
that  conference  a  definite  plan  which  would  lead  to 
concerted  action  of  a  constructive  character. 


612 


GRANET:  REJUVENATION.. 


[New  York 
Medical  Journal. 


EUGEN  STEIN ACH'S  WORK  ON 
REJUVENATION. 

By  a.  Granet,  M.  D., 
New  York, 

Instructor  in  Medicine,   Columbia  University. 

While  the  lay  press  is  heralding  in  its  usually 
sensational  manner  the  demonstration  of  the  methods 
of  transplantation  of  sex  glands,  I  thought  it  would 
be  interesting  for  the  medical  profession  to  get 
acquainted  with  the  fascinating  and  farreaching 
results  of  the  elaborate  experimental  work  in  this 
field  by  Professor  Eugen  Steinach  of  Vienna.  His 
researches  date  back  many  years.  In  1912  he  sub- 
mitted for  safekeeping  to  the  Scientific  Academy  of 
Vienna  the  manuscript  and  protocols  of  his  prelim- 
inary work  on  the  subject  in  order  to  establish  pri- 
ority and  to  continue  further  research  work. 

In  1913,  at  the  International  Congress  of  Biology 
in  Vienna  he  demonstrated  experimentally  artificial 
sex  mutation  in  young  female  or  male  animals  by 
transplantation  of  the  opposite  secretory  gland 
(Pubcrtiitsdriise) .  His  last  and  complete  publica- 
tion bears  the  title :  Verjiingung  durch  experimen- 
telle  Neubclcbung  dcr  altcnide  Pubertdtsdriise  (re- 
juvenation through  experimental  regeneration  of  the 
aging  interstitial  gonadal  gland),  and  was  recently 
dedicated  to  Professor  Wilhelm  Roux  of  Halle  on 
the  latter's  seventieth  anniversary,  and  first  pub- 
lished in  Roux's  Archiv  fiir  Entwicklungsmcchanic, 
Vol.  46,  1920,  and  later  edited  in  book  form  by 
Julius  Springer,  Berlin,  1920. 

The  outstanding  features  of  his  work  are : 

1.  The  conception  and  anatomicophysiological  defi- 
nition of  the  puberty  gland  {Pubertdtsdriise)  as  the 
internal  secretory  portion  of  the  gonads.  This  con- 
sists of  the  interstitial  cells  in  the  male  and  of  the 
lutein  cells  in  the  female. 

2.  He  observed  in  animals  with  protracted  rutting 
periods  alternating  stages  of  overdevelopment  of 
the  interstitial  gland  and  the  generative  gland  proper ; 
this  periodical  and  alternating  overdevelopment  oc- 
curs in  the  evolution  of  every  individual,  the  inter- 
stitial gland  predominating  in  infancy,  attaining  its 
maximum  development  at  puberty  and  adolescence 
when  the  general  growth  and  vital  energy  of  the 
organism  is  also  at  its  maximum.  At  this  time  the 
generative  gland  increases  in  power  and  both  the 
interstitial  and  generative  portions  continue  to  be 
equally  active  or  nearly  so  until  climacterium  sets 
in,  after  which  the  recession  of  the  interstitial  gland 
progresses  rapidly  and  brings  about  all  characteristics 
of  senility.  He  contends  that  senility  is  not  due  to 
an  ultimate  using  up  of  all  organs,  but  to  the  lack 
of  potential  stimulus  due  to  the  degeneration  of  the 
interstitial  gland. 

3.  The  possibility  of  inducing  experimentally  the 
regeneration  of  the  interstitial  gland  even  after  senile 
degeneration  has  taken  place  and  all  the  characteristic 
marks  of  senility  have  appeared,  in  animals  as  well 
as  in  man.  This  he  obtains  by  making  use  of  the 
oscillating  balance  of  nature  in  the  mixed  gland,  by 
artificially  inhibiting  the  generative  portion  and 
thereby  causing  a  com])ensatory  regeneration  and 
revival  of  the  interstitial  portion,  with  all  its  rejuv- 
enating elYects,  and  the  recession  and  disappearance 
of  the  characteristics  of  senility. 


4.  The  means  to  accomplish  this  are :  a.  The 
simple  ligation  under  local  anesthesia  of  the  vas 
deferens.  This  causes  a  regression  of  the  gen- 
erative gland  and  a  compensatory  regenera- 
tion of  the  interstitial  portion  {Pubertdtsdriise). 
A  one  sided  operation  is  sufficient  in  all  cases  and 
has  the  advantage-  of  preserving  in  addition  the 
power  of  procr-eation.  For  obvious  reasons  the 
ligation  of  the  fallopian  tube  in  the  female  does  not 
produce  this  result,  b.  Repeated  mild  exposures  of 
the  gonads  to  the  x  ray  is  a  slower  but  just  as  effec- 
tive means  of  obtaining  the  same  results  for  both 
the  ovary  and  testes,  c.  Finally  the  eflfects  of  re- 
juvenation may  be  experimentally  produced — as  we 
know — by  transplantation  in  the  old  of  the  respec- 
tive gonad  of  a  young  animal  of  the  same  species. 

For  the  male  the  method  of  choice  is  the  ligation 
of  the  vas  deferens,  for  the  female  the  x  ray  expo- 
sure. These  are  in  short  the  fundamentals  of  the 
laborious  experimental  studies  of  Steinach  and,  as 
W'C  see,  they  represent  a  great  advance  over  the 
efiforts  of  Brown-Sequard,  Hufeland,  Metchnikoff 
and  others  to  fight  senility. 

The  preliminary  work  leading  to  this  subject 
which  was  done  by  Steinach  and  his  coworkers  on 
birds,  insects,  amphibia  and  mammalia  has  also  been 
of  late  related  by  Paul  Kammerer  (1).  For  years 
Steinach  has  bred  and  raised  healthy  generations  of 
laboratory  animals,  has  studied  and  observed  their 
dispositions,  habits,  physical  characteristics  in  all 
the  stages  of  their  development  with  particular 
emphasis  on  sex  development  and  characters  of 
senility.  His  conclusive  experiments  he  made  on 
rats.  He  shows  with  an  abundance  of  illustrations 
and  photographs  the  influence  of  the  interstitial 
gland  on  those  animals.  The  animals  which  have- 
acquired  the  characteristics  of  old  age  have,  a  strik- 
ing appearance :  Their  hair  becomes  bristly  and 
sparse,  they  are  timid  and  uninterested  in  the  sur- 
roundings, the  head  is  drooping,  the  spine  is  arched, 
the  eyes  have  lost  their  tonus  and  their  brightness, 
they  do  not  seem  to  relish  their  food,  they  show  loss 
of  weight,  muscular  weakness,  inability  to  climb ; 
they  don't  fight  other  males  nor  pursue  the  females ; 
they  harbor  parasites. 

The  same  animals  two  weeks  after  the  ligation 
of  the  vas  deferens  begin  to  change.  They  begin 
to  pick  up  their  heads,  the  eyes  brighten  and  regain 
their  tonus,  they  become  livfely,  watchful  and  play- 
ful ;  their  appetite  returns ;  the  hair  begins  to  grow, 
becomes  thick,  soft  and  glossy;  they  gain  weight, 
they  move  about  with  new  vigor  and  agility,  they 
fight  other  males  let  into  their  cage,  they  pursue  and 
possess  the  female  and  bring  forth  new  generations 
which  grow  up  into  normal  adults. 

This  true  rejuvenation  is  accomplished  by  the 
simple  experimental  procedure  of  ligating  the  vas 
deferens.  The  increased  resistance  to  disease  and 
actual  proldiigation  of  life  of  the  operated  animals 
he  estimates  at  twenty-five  per  cent.  After  a  time 
senescence  sets  in  again. 

The  records  of  two  men  who  underwent  ligation 
of  the  vas  are  also  given.  One  at  the  age  of  forty- 
four  showed  symptoms  of  premature  senility,  loss 
of  weight,  flabby  muscles,  myasthenia,  senile  depres- 
sion, tremor  and  other  senile  characteristics.  In 
this  case  complete  return  of  vigor,  alertness  and 


October  23,  1920.] 


CLEMONS:  HEMORRHOIDECTOMY. 


613 


capacity  for  hard  labor  followed  unilateral  ligation 
of  the  vas.  Another  man,  a  merchant  seventy 
years  of  age,  was  operated  on  with  complete  suc- 
cess. Two  years  after  ligation  he  still  enjoys  the 
return  of  general  muscular  tonus,  steady  gait,  good 
appetite,  a  good  memory  and  interest  in  life. 

In  women  of  climacteric  and  postclimacteric  age 
the  beneficial  effects  of  x  ray  applications  for 
myomata  and  metorrhagias  have  been  noticed  by 
many  observers.  This  improvement  consists  of 
general  wellbeing,  alertness,  increased  capacity  for 
work,  and  was  first  attributed  to  the  removal  of 
the  diseased  condition.  But  Steinach  contends  that 
its  real  meaning  is  the  warding  off  of  senility  caused 
by  regeneration  of  interstitial  ovarian  structures. 

Professor  Bordier,  of  Lyon,  also  emphasizes  the 
rejuvenating  effects  of  the  x  ray  applied  in  series. 
(For  metrorrhagias  of  the  climacterium  and  for  the 
treatment  of  interstitial  fibroids.)  After  the  second 
or  third  series  anemic,  withered  complexions  assume 
a  fresh,  rosy,  youthful  appearance.  General  de- 
bility and  mental  depression  are  replaced  by  a  flour- 
ishing state  of  health.  This  is  due  to  the  fact  that 
the  interstitial  portion  of  the  ovary  is  not  affected 
by  the  x  ray ;  whereas  colloidal-albuminoid  precipi- 
tation occurs  in  the  cells  of  the  graafian  follicles 
which  arc  radio  sensitive,  the  same  as  neoplastic  cells. 
The  affected  cells  disappear  later  by  autolysis,  meno- 
pause sets  in,  and  the  interstitial  portion  alone  whose 
hormones  produce  the  rejuvenating  effect  remains 
functioning.  He  has  perfected  a  technic  of  applica- 
tion of  massive  doses  in  series  which  give  positive 
results  and  secure  protection  from  burns  (2). 

The  effects  of  implantation  are  the  same  and 
according  to  Steinach's  work  the  shrinking  of  the 
transplanted  gland  which  occurs  after  varying 
periods  is  probably  due  to  the  atrophy  of  the  sperm 
gland  and  should  not  prevent  rejuvenating  effects. 

As  we  see,  the  experiments  on  men  are  but  few. 
However  his  extensive  and  thorough  work  on 
animals,  which  is  apparently  beyond  criticism,  war- 
rants further  attempts  and  opens  a  very  promising 
field.  When  the  original  publications  of  Professor 
Steinach's  work  reach  this  country  American  re- 
search workers  will  start  control  experiments. 

Steinach's  work  aside  from  its  applicability  to 
senility  could  be  made  use  of  in  the  sexual  neuroses. 
Functional  impotence  in  man  should  be  amenable 
to  cure.  The  study  of  the  behavior  of  cancerous 
growths  in  animals  which  have  undergone  ligation 
of  the  vas  deferens  would  show  how  much  our 
conception  of  cancerous  age  is  worth.  Arterio- 
sclerosis may  perhaps  also  be  influenced.  The 
much  debated  question  of  the  harmfulness  of  mas- 
turbation may  perhaps  be  settled  in  the  light  of 
Steinach's  conception.  The  reason  for  the  failure 
of  the  Brown-Se(|uard  injections  and  of  organo- 
therapy with  testicular  glands  becomes  somewhat 
clearer.  The  manufacturers  of  glandular  tablets 
may  use  testes  of  animals  which  have  undergone 
ligation  of  the  vasa  deferentia  with  greater  effec- 
tiveness ;  these  could  be  used  for  patients  unwilling 
to  undergo  ligation  or  x  ray  application. 

I  have  based  this  paper  on  an  article  by  Pro- 
fessor Wilhelm  Roux,  director  of  the  Anatomical 
Institute  of  Halle,  and  one  by  Professor  Dr.  G. 
Holzknecht.  chief  of  the  Central  Rontgen  Labora- 


tory of  the  Wiener  Algemeines  Krankenhaus.  These 
articles  have  appeared  in  the  Neue  Freie  Pressc, 
July  11th  and  18th,  and  aroused  the  interest  of  the 
world  in  Professor  Steinach's  work.  They  were 
published  as  an  appeal  for  the  endowment  of  the 
Biological  Laboratory  of  the  University  of  Vienna. 

REFERENCES. 

1.  Kammerer,  Paul:  Ergcbnisse  der  inneren  Mcdicin 
und  Kinderkrankheiten,  vol.  xvii,  1919. 

2.  Bordier,  H.  :  Considerations  generales  sur  la  radio- 
therapie  des  fibromyomes  uterins.  Le  Monde  Medical 
No.  573,  July  1920.   

HEMORRHOIDECTOMY. 
By  E.  Jay  Clemons,  M.D., 
Los  Angeles,  Cal. 

Before  proceeding  with  an  anorectal  surgical  op- 
eration it  is  necessary  to  make  a  proctoscopical  ex- 
amination. Instruct  the  patient  to  take  no  laxatives, 
to  eat  as  usual,  to  take  a  tub  bath  the  night  before, 
and  to  have  dry  toast  and  black  coffee  for  the  previ- 
ous meal.  Prepare  the  patient  for  operation  by 
administering  a  two  quart  cold  water  enema.  With 
hemorrhoids  prolapsed  place  the  patient  upon  the 
left  side,  with  knees  flexed  on  abdomen  and  two  pil- 
lows between  the  knees.  Cleanse  the  parts  and  see 
that  all  instruments  and  solutions  are  cold,  before 
proceeding  with  the  operation,  as  heat  applied  to  a 
visceral  area  gives  pain. 

The  hemorrhoidal  areas  are  three  in  number,  one 
on  the  left  and  two  on  the  right  side.  The  median 
raphe  lies  to  the  left  of  the  median  line,  in  this 
region,  both  above  and  below,  establishing  the  left 
hemorrhoidal  area  in  the  centre  on  the  left  side. 

First  stage. — Select  a  ])oint  upon  the  skin,  a 
half  inch  to  the  left  of  the  anus,  and  apply  the 
cotton  tipped  end  of  an  applicator  which  has  been 
dipped  in  phenol,  to  anesthetize  the  skin,  and  to 
mark  the  spot  for  the  insertion  of  the  needle.  When 
the  place  has  turned  white  insert  into  the  loose  sub- 
cutaneous tissue  a  fine  hypodermic  needle  attached 
to  a  half  ounce  metal  syringe  loaded  with  an 
eighth  of  one  per  cent,  quinine  urea  hydrochloride 
solution.  Inject  this  solution  very  slowly.  At  the 
first  indication  of  pain  stop  and  wait  till  the  pain 
cea.ses,  then  inject  a  little  more  solution,  being  sure 
to  inject  so  slowly  that  you  do  not  hurt  the  patient 
or  blanch  the  parts.  While  distending  the  tissues  and 
producing  pressure  anesthesia  use  the  one  needle 
puncture,  which  is  indicated  by  the  opening  on  the 
white  carbolized  area ;  by  so  doing  you  prevent  the 
solution  running  out  of  a  former  opening  while 
injecting  at  another.  After  thoroughly  distending 
the  parts  from  this  one  puncture  you  find  that  just 
the  tissues  you  wish  have  become  distended  and  at 
the  same  time  the  solution  has  not  passed  the  median 
raphe  but  you  have  prolapsed  the  hemorrhoid  and 
brought  out  the  anorectal  line.  Now  pass  a  sharp 
ligature  carrier  threaded  with  number  two  ten  day 
chromic  catgut,  beginning  at  the  junction  of  the 
hemorrhoid  and  the  raphe  below  at  the  anorectal 
line,  pass  deeply,  penetrating  the  deep  fascia  com- 
ing out  at  the  junction  of  the  raphe  above  and  the 
hemorrhoid  at  the  level  of  the  anorectal  line. 

Second  stage. — Remove  the  ligature  carrier,  leav- 
ing double  ligatures.  Place  forceps  on  each  end  of 
these  ligatures.  Grasp  the  skin  with  a  vulsellum  and 
draw  on  the  .stretch.   While  thus  making  traction  on 


614 


MULLER:   GUNSHOT  INJURIES  OF  CHEST. 


[New  York 
Medical  Journal. 


the  skin,  place  another  vulsellum  at  the  level  of  the 
anorectal  line,  one  blade  at  each  exit  of  the  ligatures. 
This  vulsellum  is  placed  for  two  reasons ;  first,  in 
case  the  ligatures  are  accidentally  cut  during  the  re- 
moval of  the  hemorrhoid  you  will  have  landmarks 
for  placing  other  ligatures,  and,  second,  a  branch  of 
the  inferior  hemorrhoidal  artery  enters  the  parts 
through  these  tissues.  After  placing  the  two  vul- 
sellum forceps,  try  the  ligatures  to  make  sure  that 
they  have  not  been  caught  within  the  grasp  of  the 
forceps.    If  free,  cut  the  skin  up  to  the  ligatures. 

Third  stage. — Grasp  the  hemorrhoid  with  sponge 
holders  and  make  traction  slowly  and  steadily  out- 
ward and  downward  until  normal  mucosa  is  exposed. 
Now  tie  each  ligature  separately  around  the  base 
of  the  tracted  hemorrhoid.  In  making  the  first  knot, 
do  so  very  slowly  so  as  not  to  hurt  the  patient,  as  the 
parts  have  not  been  anesthetized.  After  making  the 
first  tie,  the  others  can  be  made  more  rapidly  as  the 
first  knot  produces  pressure  anesthesia. 

Fourth  stage. — Cut  away  the  hemorrhoid  just  ex- 
ternal to  the  ligatures.  Remove  the  vulsellum.  If 
there  is  spurting  from  the  inferior  hemorrhoidal  ar- 
tery clamp  and  ligate  it.  Leave  the  stump  of  the 
hemorrhoid  free.  This  stump  is  anchored  by  the 
ligatures  to  the  deep  fascia  and  cannot  retract,  but 
remains  within  the  grasp  of  the  anal  sphincters. 
There  is  just  enough  stretch  on  the  skin  to  bring  the 
two  edges  together ;  at  the  same  time  do  not  inter- 
fere with  postoperative  oozing,  which  is  very  essen- 
tial, as  any  interference  with  oozing  produces  edema. 

Repeat  the  procedure  by  passing  through  the  four 
stages  with  each  hemorrhoid  on  the  right  side,  ex- 
cept when  dealing  with  hemorrhoids  of  the  first  and 
second  degrees,  in  which  cases  the  two  right  hemor- 
rhoidal areas  should  be  removed  at  one  time,  taking 
away  twice  the  amount  of  tissue  on  the  right  as  you 
did  on  the  left  side.  It  i'j  always  advisable  to  oper- 
ate on  both  sides  in  each  and  every  case  of  hemor- 
rhoids to  avoid  future  trouble. 

The  operative  advantages  of  quinine  urea  hydro- 
chloride anesthesia  are  as  follows :  While  following 
the  operative  technic  it  is  necessary  to  proceed  so 
slowly  that  you  do  not  hurt  the  patient,  and  by  so 
doing  you  ascertain  definitely  the  exact  amount  of 
pressure  you  are  using.  The  quinine  urea  hydro- 
chloride being  nontoxic,  the  operator  is  enabled  to 
prolapse  the  hemorrhoids  and  bring  out  the  well 
defined  median  raphe,  at  the  same  time  leave  the 
intervening  mucosa  to  cover  the  surfaces.  In  being 
able  to  regulate  the  amount  of  pressure,  which  is 
necessary  to  prolapse  the  hemorrhoids,  it  is  possible 
to  limit  the  distention  and  anesthetization  of  the 
skin  to  that  portion  which  should  be  removed. 

The  postoperative  advantages  of  the  use  of  qui- 
nine urea  hydrochloride  anesthesia  are  as  follows : 
First,  being  nontoxic  there  is  no  reaction,  as  occurs 
after  the  use  of  certain  toxic  drugs.  Second,  it  is 
not  necessary  to  use  drugs  of  the  nature  of  epi- 
nephrine hydrochloride  to  block  ot¥  absorption,  so 
there  is  no  interference  with  blood  pressure.  Third, 
this  drug  being  a  mechanical  irritant  to  the  tissues, 
it  causes  the  production  of  a  plastic  fibrinous  ex- 
udate, which  is  a  decided  advantage  when  operating 
on  hemorrhoids,  as  it  brings  the  elements  of  repair 
to  the  parts,  and  after  the  first  sanguineous  exuda- 
tion, minimizes  postoperative  oozing.    Fourth,  this 


plastic  fibrinous  exudate  having  been  thrown  out 
and  absorbed,  a  barrier  is  produced  which  enables 
the  operator  to  get  his  patient  safely  on  his  feet  and 
back  to  his  work  during  the  period  the  process 
of  repair  is  taking  place.  Fifth,  there  is  produced 
what  is  to  the  patient,  at  least,  the  main  advantage, 
namely,  that  the  anesthesia  being  postoperative  it 
lasts  during  the  period  the  fibrinous  exudate  is  being 
absorbed,  which  is  generally  a  week  to  ten  days. 

In  conclusion,  I  will  say  that  a  patient  proceeds 
to  recovery  with  practically  no  discomfort,  provided 
the  operative  technic  is  handled  in  such  a  manner 
as  not  to  hurt  the  patient,  that  we  receive  his  co- 
operation, and  that  he  goes  about  his  business ;  by 
so  doing  our  patient  is  relieved  pleasantly.  If,  while 
following  the  operative  technic,  we  attack  and  re- 
move only  those  tissues  necessary  to  give  relief,  and 
by  the  use  of  the  mechanical  irritation  of  quinine 
urea  hydrochloride  we  bring  the  products  of  repair 
to  the  parts,  the  healing  will  proceed  quickly.  Not 
having  interfered  with  the  higher  centres,  and  by 
the  use  of  quinine  urea  hydrochloride  we  produce  a 
natural  barrier,  we  can  say  that  we  relieved  our 
patient  safely.  This  makes  me  believe  that  we  come 
near  fulfilling  the  golden  rule  of  surgery  by  "re- 
lieving our  patient,  pleasantly,  quickly  and  safely" 
in  a  class  of  cases,  composed  to  a  large  extent 
of  patients  who  would  generally  be  considered  be- 
yond the  age  for  safe  surgical  intervention.  The 
average  age  for  the  development  of  first  degree 
hemorrhoids  is  forty  years,  and  the  time  necessary 
for  the  evolution  from  first  degree  to  third  degree 
hemorrhoids  is  generally  ten  years,  which  brings 
the  average  age  for  the  beginning  of  the  third  de- 
gree hemorrhoidal  period  at  fifty.  As  this  unre- 
lieved pathological  condition  persists  during  life,  it 
necessitates  our  dealing  with  a  class  of  patients  the 
majority  of  whom  arc  in  the  fifth  to  the  eighth 
decade  of  life. 

605  HOLLINGSWORTH  BuiLDING. 


GUNSHOT  INJURIES  OF  THE  CHEST  IN 
CIVIL  PRACTICE. 

By  George  P.  Muller,  M.  D. 
Philadelphia. 

The  treatment  of  gunshot  injuries  of  the  chest 
constituted  one  of  the  most  interesting  and  important 
chapters  in  the  medical  history  of  the  war  and  in 
the  volume  of  literature  was  hardly  exceeded  by 
any  subject  except,  of  course,  that  of  wounds  per  se 
and  their  treatment  by  revision,  suture,  and  anti- 
septics. To  the  French  we  are  indebted  for  much 
that  is  new,  particularly  to  Duval  for  the  develop- 
ment of  the  method  of  wide  open  thoracotomy  and 
to  Petit  de  la  Villeon  for  his  method  of  extraction 
of  late  projectiles.  Those  of  us  who  were  unable 
to  participate  in  the  active  surgical  work  of  the  war 
must  get  our  ideas  from  those  who  did  the  work, 
must  assimilate  the  literature,  and  be  prepared  to 
adopt  the  plan  of  procedure  in  the  hospitals  with 
which  we  are  connected,  when  a  gunshot  wound  is 
brought  under  our  observation.  Let  us  first  glance, 
superficially  of  course,  over  the  record  of  accom- 
plishment, and  the  plans  of  procedure,  during  the 


October  23,  1920.] 


MILLER:   GUNSHOT  INJURIES  OF  CHEST. 


615 


forty  years  preceding  the  war.  The  oldest  book  on 
surgery  which  I  own  is  that  of  Agnew  who  was 
professor  of  surgery  in  the  University  of  Penn- 
sylvania from  1871  to  1888.  Writing  in  1878  he 
devotes  considerable  space  to  chest  wounds  but  his 
opinions  are  entirely  colored  by  the  work  of  Otis 
who  wrote  the  chapters  on  thoracic  surgery  (1). 
His  descriptions,  however,  of  wounds,  of  hemo- 
thorax, and  other  matters,  are  minute  and  really 
worth  reading  at  this  day,  but  he  suggests  nothing 
that  is  radical.  In  speaking  of  hemothorax  he  ad- 
vises enlargement  of  the  wound,  if  by  so  doing  the 
outlet  for  the  blood  to  escape  will  be  increased. 

Agnew  was  succeeded  by  John  Ashhurst  and  at 
the  time  I  graduated,.  (1899)  we  were  told  by  him 
to  practice  rest,  apply  cold  and  give  opium.  If 
bleeding  from  the  lung  continued  he  advised  re- 
opening the  original  wound  to  allow  the  blood  to 
escape  or  the  performance  of  paracentesis  to  relieve 
the  dyspnea.  Gross,  professor  of  surgery  in  the 
Jefferson  Medical  College,  writing  in  1882,  had  a 
fair  idea  of  the  pathological  consequences  of  chest 
wounds.  He  classifies  them  as :  Primary — shock, 
collapse  of  the  lung,  hemorrhage  and  pneumothorax^; 
and,  secondary — inflammation  and  accumulation  of 
serum,  lymph,  and  pus  in  the  pleural  cavity.  He 
states  that  in  the  Russian  Army  at  the  siege  of 
Sebastopol  the  mortality  from  chest  wounds  was 
ninety-eight  and  five  tenths  per  cent. ;  in  the  British 
Army  it  was  eighty-one  and  five  tenths  per  cent. 
He  states  that  the  Russian  surgeons  relied  chiefly 
upon  the  use  of  digitalis ;  the  British  upon  copious 
venesection.  In  the  Civil  War,  of  1272  cases, 
seventy-three  per  cent,  were  fatal.  Gross  makes  no 
mention  of  thoracotomy  and  he  recounts  a  fatal  case 
where  the  ball  was  loose  in  the  pleural  cavity  and 
was  followed  by  violent  inflammation  and  death  in 
four  weeks.  Such  cases  he  says  "must  necessarily 
be  fatal."  Venesection  and  purgation  were  his 
sheet  anchors,  and  the  patient  was  always  placed 
with  the  wound  dependent  to  allow  the  blood  to 
drain  out. 

In  an  address  before  the  American  Medical 
Association  in  1903  Rodman  stated  that  the  treat- 
ment for  gtmshot  wounds  of  the  chest  should,  as  a 
rule,  be  a  "masterly  inactivity;  absolute  rest,  cooling 
drinks,  a  little  opium,  and  a  sterile  immobilizing 
dressing  constituting  the  only  treatment  necessary 
in  the  majority  of  cases.  Pressure  may  be  relieved 
by  aspiration  and  hemorrhage  controlled  by 
strapping.  Any  attempt  to  recover  the  ball  would 
be  fraught  with  danger  and  is  rarely  justifiable,  as 
the  bullet  will  continue  to  be  harmless  unless  it  has 
carried  in  septic  material." 

But  Koenig  in  the  same  year  stated  that  the  treat- 
ment of  these  cases  depends  upon  individual  circum- 
stances. In  general,  he  says,  it  may  be  stated  that 
only  rarely  is  one  justified  in  operating  within  a 
short  time  after  the  accident  for  the  purpose  of 
arresting  hemorrhage.  If  two  or  three  days  after 
the  injury  the  phenomena  (respiratory  distress,  fre- 
quency of  pulse,  and  elevation  of  temperature) 
increase,  one  should  not  hesitate  to  perform  a  thorac- 
otomy. A  rise  of  temperature  and  difficult  breath- 
ing appearing  at  a  later  stage  suggest  infection,  and 
constitute  another  indication  for  operation.  Notice 


that  Koenig  refers  to  the  elevation  of  temperature 
accompanying  the  hemothorax  per  se.  This  has 
often  led  to  the  mistaken  diagnosis  of  infection  and 
precipitated  a  thoracotomy  plus  drainage,  thus  almost 
inevitably  producing  infection.  In  order  to  avoid  the 
possibility  of  infection  in  a  hemothorax,  operation 
should  be  performed  only  under  the  strictest  aseptic 
precautions;  otherwise  a  hemothorax  may  be  con- 
verted into  an  empyema.  When  the  resorption  is 
slow,  one  may  remove  the  blood  by  puncture,  and 
only  when  this  proves  unavailing  is  a  thoracotomy 
justifiable.  This  advice  relative  to  the  treatment 
of  hemothorax  is  practically  that  of  Elliot  (1919) 
one  of  the  best  of  the  English  authorities  on  the  sub- 
ject. Elliot  says  "early  aspiration  must  be  the 
routine  and  if  this  is  found  to  fail  by  reason  of 
clot,  then  the  chest  must  be  evacuated  at  the  earliest 
possible  date  by  thoracotomy,  without  drainage." 

In  the  following  year  Grunert  advocated  a  more 
radical  plan  of  treatment,  and  advised  delayed 
thoracotomy  for  the  removal  of  the  blood  clot  in 
slowly  developing  hemorrhage  and  immediate 
operation  in  severe  cases  with  an  attempt  to  arrest 
the  hemorrhage  by  ligature,  suture  or  tampon.  In 
1905  the  epoch  making  paper  of  Garre  appeared  in 
which  he  presented  a  statistical  study  of  700  wounds 
of  the  lung  treated  conservatively,  dwelt  upon  the 
high  mortality  under  such  methods  of  treat- 
ment, and  exposed  some  of  the  fallacies  which 
had  long  influenced  the  treatment  of  these 
lesions.  He  pointed  out  that  the  general  mor- 
tality was  forty  per  cent. ;  in  ruptures  of  the 
lung,  uncomplicated  by  other  injury  it  exceeded 
fifty  per  cent. ;  while  stab  wounds  and  gunshot 
wounds  in  the  antiseptic  era  exhibited  a  death  rate 
of  thirty-eight  per  cent.,  and  thirty  per  cent,  respec- 
tively. He  also  clearly  demonstrated  that  antisepsis 
as  ordinarily  applied  could  not  favorably  influence 
the  internal  wound  which  opened  the  lung  itself  ; 
that  the  small  calibre  jacketed  bullet  was  as  danger- 
ous as  the  old  fashioned  projectile;  he  also  asserted 
that  the  often  repeated  view  that  bleeding  spon- 
taneously ceased  in  the  collapsed  lung  had  neither 
clinical  nor  experimental  confirmation.  The  prime 
indications  for  operation,  according  to  Garre,  were 
hemorrhage,  (abundant,  persisting,  or  recurring,) 
and  pressure  pneumothorax  not  yielding  to  aspira- 
tion. While  these  were  only  present  in  five  or  six  per 
cent,  of  cases  of  lung  injury,  they  demanded  prompt 
interference.  He  collected  nine  cases  of  suture  of 
the  lung,  including  one  case  of  ruptured  lung  (his 
own)  with  six  recoveries.  The  principles  of  treat- 
ment, as  he  laid  them  down,  are  not  very  different 
from  those  found  useful  by  his  followers ;  nor  has 
his  technic  been  greatly  modified  except  as  in- 
fluenced by  the  facilities  afiEorded  by  the  develop- 
ment of  differential  pressure  and  a  better  under- 
standing of  the  influences  of  pneumothorax  and  its 
relationship  to  drainage. 

This  paper  of  Carre's,  and  the  invention  of  the 
negative  pressure  chamber  of  Sauerbruch  and  the 
positive  pressure  helmet  of  Brauer  gave  an  impetus 
to  thoracic  surgery  which  has  continued  to  this  day. 
A  number  of  valuable  contributions  appeared  in 
the  German  literature  particularly  those  of  Kiittner, 
Lawrow,  Stockey,  Moller,  Wolf,  and  Grassman, 


616 


MILLER:   GUXSHOT  LXJURIES  OF  CHEST. 


[New  York 
Medical  Jovrsal. 


and  the  question  was  discussed  in  detail  in  the  Paris 
Surgical  Society  in  1907  and  1909.  In  1911  a  lively 
discussion  between  the  abstentionists  and  the  inter- 
ventionists took  place  at  the  International  Surgical 
Congress.  Lenormant  drew  up  the  report  for  this 
congress  and.  according  to  his  statistics,  out  of  1056 
cases  the  rate  of  mortality  was  only  ten  per  cent. 
In  order  to  appreciate  these  figures  correctly,  it 
must  be  mentioned  that  they  deal  only  with  patients 
in  civil  practice,  and  that  cases  complicated  by  injury 
of  the  vessels  of  the  hilum  were  excluded.  The 
rate  of  mortality  would  be  considerably  higher  if 
all  cases  of  injuries  to  the  lungs  were  included.  A 
third  of  the  mortality  in  Lenormant's  cases  was  the 
result  of  infection  and  two  thirds  from  hemorrhage. 
He  favored  expectant  treatment.  At  that  time  the 
abstentionists  seemed  to  have  the  better  of  the 
argument  because,  while  the  reasoning  of  the  inter- 
ventionists was  perfectly  sound  and  their  operative 
indications  the  result  of  logical  deduction,  the 
statistical  evidence  was  not  always  as  convincing. 
Thus  LavroflF  quotes  the  results  of  a  series  of  257 
cases  occurring  in  Zeidler's  clinic  during  a  period 
of  five  years.  Of  these,  155  cases  operated  upon 
gave  a  mortality  of  thirty-six  and  seven-tenths  per 
cent.,  while  in  102  cases  treated  conservatively  the 
mortalitv  was  only  fourteen  and  seven  tenths  per 
cent.  The  author  explains  the  figures  by  stating 
that  the  nonoperative  cases  were  far  less  severe  in 
character. 

Holmberg  reported  a  series  of  324  cases,  of  which 
266  were  stabwounds,  thirty-nine  gimshot  wounds, 
and  nineteen  closed  or  subparietal  injuries.  All 
but  four  of  these  patients  were  treated  conserva- 
tively, that  is,  the  stab  wounds  were  carefully  dis- 
infected and  sutured;  the  gunshot  wounds  were 
cleaned  and  an  aseptic  dressing  applied,  and  the 
closed  injuries  were  treated  expectantly.  The  total 
mortality  in  this  series  in  injuries  involving  the  lung 
or  pleura  was  fifteen  and  eight  tenths  per  cent.,  of 
which  the  largest  series,  that  is,  the  stab  wounds, 
showed  eight  and  one  tenth  per  cent.,  the  gunshot 
injuries  thirty-seven  per  cent.,  and  the  closed  rup- 
tures, forty-seven  per  cent.  In  spite,  however,  of 
the  statistics  of  Lenormant,  Holmberg  and  others, 
the  tendency  of  the  times  was  towards  active  inter- 
ference, especially  in  those  cases  when  hemorrhage 
and  pneumothorax  threatened  life. 

Thus,  in  an  article  by  Brewer  (2),  written  in 
1907,  he  advised  the  following:  Treatment  of  exist- 
ing shock:  control  of  cough  and  restlessness  by 
morphine:  disinfection  of  the  wound  area,  rest, 
strapping  of  the  chest;  aspiration  of  air  in  pneu- 
mothorax. If  there  is  a  progressively  increasing 
hemothorax  threatening  life,  the  surgeon  should 
freely  open  the  pleural  sac  by  resection  of  one  or 
more  ribs  and  attempt  to  arrest  the  hemorrhage  by 
suture,  ligature,  or  by  packing. 

But,  five  years  later  Brewer  wrote  that  he  would 
advise  immediate  exploratory  thoracotomy  in  all 
cases  of  penetrating  wounds  of  the  chest  which  pre- 
sented signs  of  hemorrhage  threatening  the  life  of 
the  individual  or  seriously  embarrassing  respiration ; 
in  all  cases  where  there  was  reason  to  suspect  in- 
jury of  the  diaphragm,  heart,  or  other  important 
structures ;  and  in  all  cases  of  large  pleural  wounds 


where  there  is  evident  septic  contamination  and  an 
open  pneumothorax.  He  advised  careful  disin- 
fection and  aseptic  dressings  in  penetrating  gunshot 
wounds  without  symptoms  or  signs  of  a  more  grave 
injury,  and  in  simple  stab  wounds  without  evidence 
of  grave  hemorrhage,  pneumothorax,  or  injury  to 
diaphragm  or  heart.  In  all  cases  of  doubt,  in 
wounds  of  the  heart  zone,  or  in  the  region  of 
possible  diaphragmatic  injury,  he  favored  explora- 
tory operation  as  the  safest  method  of  treatment. 

In  1911  Jopson  read  an  illuminating  paper  before 
the  Philadelphia  Academy  of  Surgery.  He  pointed 
out  that  the  binding  indications  for  operation  in 
penetrating  wounds  were  as  follows : 

1.  A  wound  which  from  its  situation  and  direc- 
tion would  render  likely  a  penetration  of  the  heart, 
pericardium,  or  diaphragm. 

2.  Severe  primary  or  recurring  hemorrhage,  as 
shown  by  the  physical  signs  of  hemothorax  or  ex- 
ternal bleeding,  or  by  severe  hemoptysis  with 
threatened  aspiration  of  blood  into  the  other  lung. 

3.  Secondary'  hemorrhage,  especially  to  be  looked 
for  in  gunshot  wounds. 

4.  Severe  pneumothorax,  especially  when  accom- 
panied by  symptoms  of  mediastinal  and  cardiac  dis- 
placement, dyspnea,  cyanosis,  and  threatened  suffo- 
cation, and  which  is  not  relieved  by  aspiration;  also 
when  extensive  and  increasing  external  emphysema 
is  present. 

5.  Secondary  pneumothorax,  which  is  always 
due,  according  to  V.  Moller,  to  suppuration  or 
sloughing  of  lung  tissue. 

6.  Empyema. 

At  about  the  same  time  Dorrance,  also  of  Phila- 
delphia, reported  the  results  of  some  experimental 
work  on  animals  and  advised  the  following:  "If 
hemothorax  develops  the  chest  wall  should  be 
opened  as  soon  as  the  diagnosis  is  made ;  all  clots 
and  serum  removed ;  the  woimds  in  the  lung  sutured  : 
the  pleural  cavity  inspected  and  its  toilet  completed ; 
and  the  chest  wall  immediately  closed,  the  lung 
being  expanded  by  either  negative  or  positive  pres- 
sure. The  suturing  of  the  chest  wall  is  effected  by 
means  of  the  layer  method.  With  absolute  asepsis 
and  a  faultless  technic,  especially  in  the  matter  of 
Sfentle  handling,  recoverv  without  the  formation  of 
adhesions  ought  to  take  place  in  a  large  proportion 
of  cases.  The  worst  that  can  happen  when  this 
method  is  used  is  the  formation  of  an  empyema." 

There  is  no  essential  difference  between  this  pro- 
cedure and  the  method  of  Duval  now  so  widely 
known,  from  his  writings,  from  the  paper  of 
Movnihan  and  the  personal  observations  of  those 
at  the  front. 

This  brings  us  to  the  period  covered  by  the  war, 
and  while  the  experience  in  chest  surgery  during 
this  time  has  been  enormous  in  material  and  in  the 
lessons  learned,  I  will  attempt  no  extensive  review 
partlv  because  of  the  limitations  of  space,  but 
mosti}-  because  it  is  so  fresh  in  our  minds  and  so 
familiar  to  everyone  who  has  read.  Also  it  seems 
to  me  that  many  of  the  problems  that  engrossed 
the  minds  of  Duval,  Piery,  Gregoire,  Gask,  Elliot, 
and  others,  were  bound  up  with  the  militar}'  aspects, 
with  transportation,  the  lack  of  equipment  at  the 
front,  the  sucking  open  wounds,  the  shell  fragments 


October  23,  1920.] 


MULLER:  GUNSHOT  INJURIES  OF  CHEST. 


617 


and  so  on,  with  which  there  is  nothing  comparable 
in  civil  life.  The  real  problems  seemed  to  be  these, 
and  not  the  management  of  the  infected  pneumo- 
thorax at  the  base  hospitals,  over  which  so  much 
was  made  in  the  early  years  probably  from  the 
shortage  of  experienced  surgeons.  I  would  espe- 
cially commend  the  books  by  Duval  and  by  Gre- 
goire,  and  the  articles  of  Piery,  LeFort,  Gask,  Lock- 
wood,  Elliot,  Bradford,  Nixon,  and  Moynihan.  On 
our  own  side  the  list  is  already  a  long  one,  and  is 
headed  by  the  contributions  of  Yates  and  Graham. 

The  conclusions  of  Nixon  were  published  !in 
April,  1919,  and  therefore  represent  the  latest 
opinion  of  those  experienced  in  war  chest  surgery, 
especially  as  he  was  associated  at  various  times  with 
Duval,  Gask,  Anderson,  Roberts,  and  Lockwood. 
The  indications  for  immediate  operation  indicated 
by  Nixon  are:  1,  Hemorrhage,  2,  injuries  of  the 
diaphragm,  3,  open  pneumothorax  (traumatopnea), 
4,  stove  in  chest,  5,  retained  missiles,  bone,  and 
clothing,  and  6,  early  acute  infection. 

The  patient  may  be  unfit,  for  operation  owing  to : 
1,  Intrathoracic  injuries,  2,  severity  of  the  external 
or  complicating  wounds,  3,  loss  of  blood,  and  4, 
collapse  or  shock  due  to  cold  and  transportation. 
Nixon  then  states  that  it  is  the  physician's  province 
to  decide  as  to  the  nature  of  the  intrathoracic  in- 
juries, and  he  must  form  a  definite  opinion  on  the 
following  points: 

Is  there  a  sufficient  degree  of  the  following  to 
account  for  the  severity  of  the  symptoms?  1,  Pneu- 
mothorax, 2,  hemothorax,  3,  collapse  of  lung,  4, 
laceration  or  hematoma  of  lung,  5,  injury  of  heart, 
pericardium,  or  great  vessels,  6,  injury  of  diaphragm, 
or  7,  injury  of  vertebrae  or  spinal  cord.. 

Radioscopy  and  radiography  are  almost  indis- 
pensable in  order  to  reach  a  correct  conclusion  on 
these  points,  but  it  will  sometimes  happen  that  a 
patient's  condition  will  not  permit  of  immediate 
X  ray  examination.  When  this  is  so,  the  question 
is  rendered  easier  rather  than  harder.  The  patient 
is  thus  unfit  for  any  immediate  operation  save  one 
of  the  following: 

1.  Immediate  and  rapid  operation  for  the  arrest 
of  visible  hemorrhage  from  the  chest  wall  or  thorax. 

2.  Arrest  of  hemorrhage  from  coexisting  wounds. 

3.  Aspiration  for  relief  of  pneumothorax  (usually 
valve  pneumothorax). 

4.  Aspiration  for  relief  of  hemothorax. 

5.  Temporary  closure  of  open  pneumothorax. 
Apart  from  one  of  these  procedures,  there  remains 

nothing  else  to  be  done  than  to  resort  to  measures 
for  resuscitation  of  the  patient.  Now,  it  is  obvious 
that  in  civil  practice  many  of  these  indications  will 
not  be  met.  The  wide  open  pneumothorax  and  the 
stove  in  chest  from  shell  wounds  are  practically 
never  seen.  I  say  practically  because  Waters  (3) 
recorded  a  remarkable  case  of  shotgim  injury  in  a 
boy  in  whom  a  great  hole  was  torn  in  the  antero- 
lateral aspect  of  the  left  side  of  the  thorax.  The 
great  majority  of  the  wounds  encountered  will  be 
stab  wounds,  or  gunshot  injuries  with  or  without 
retained  missile,  and  sometimes  with  complicating 
injuries  of  the  heart,  mediastinum,  diaphragm,  or 
the  abdominal  organs,  particularly  the  stomach, 
colon,  spleen,  or  liver. 


Duval  states  "that  bullet  wounds  of  the  lung  are 
either  fatal  at  once  by  reason  of  injury  to  a  large 
vessel,  or  comparatively  benign ;  the  wound  is  either 
aseptic  or  seldom  followed  by  grave  infection.  To 
this  single  factor  their  slight  severity  is  due." — 
Further,  he  states  "from  a  surgical  point  of  view 
bullet  wounds  are  of  little  interest,  as  they  do  not 
demand  operative  interference."  But  bullet  wounds 
and  stab  wounds  will  be  the  injury  in  civil  practice, 
and  they  will  be  of  interest  to  the  civil  surgeon. 

The  problem  before  us  is — shall  we  operate  in 
all  cases  of  stab  or  gunshot  wounds  of  the  chest,  or 
shall  we  wait  for  the  complications  of  hemor- 
rhage, pneumothorax,  or  infection  to  ensue?  If  it 
were  not  for  the  occurrence  of  infection  we  might 
formulate :  Early  operation  is  indicated,  a,  when 
there  is  a  rapidly  increasing  pneumothorax  (from 
a  valvelike  opening)  ;  b,  when  the  rib  has  been 
splintered  by  the  bullet,  and  the  fragments  press 
on  the  pleura,  or  have  been  driven  inwards ;  c, 
when  hemothorax  is  large  and  seems  to  be  increas- 
ing. Late  operation  is  indicated :  a,  at  any  time 
when  the  pleural  cavity  appears  to  be  infected ;  b, 
after  six  or  seven  days,  when  the  patient's  condi- 
tion is  excellent  and  he  has  been  well  studied,  to 
remove  clot  or  missile. 

The  crux  of  the  situation,  however,  hinges  on 
the  matter  of  infection.  If  we  wait  until  the 
patient  is  in  excellent  shape  to  stand  the  operation 
we  may  lose  the  opportunity  to  so  cleanse  the 
pleural  cavity  that  aseptic  conditions  can  be  estab- 
lished. If  we  operate  in  all  patients  immediately, 
we  will  lose  many  from  shock,  and  the  mortality 
of  the  total  will  rise. 

Shock  must  be  met  first.  The  patient  should  not 
be  handled  roughly  or  rushed  to  the  x  ray  room. 
The  chest  should  be  immobilized  immediately  on 
arrival,  however  slight  the  injury  may  appear  to  be. 
The  patient  should  be  placed  in  bed,  kept  warm, 
and  the  wound  dressed,  and  quiet  assured  by  the 
aid  of  morphine.  He  should  remain  in  the  ward, 
propped  up  in  bed  and  only  examined  immediately 
if  serious  signs,  such  as  those  of  persistent  hemor- 
rhage or  asphyxiation  pneumothorax  suggest  the 
necessity  of  an  immediate  operation.  Elliot  in  his 
interesting  paper  published  in  1919  states  that  the 
reflex  reaction  to  the  chest  wound  causes  a  strong 
muscular  contraction  of  the  walls  of  the  bronchioles 
producing  the  early  cyanosis  and  dyspnea.  Rest 
and  morphine  soon  allav  this  spasm  in  most  cases. 
If  prolonged  reflex  constriction  of  the  bronchial 
musculature  occurs  with  cyanosis,  dyspnea,  and 
inspiratory  retraction,  operation  is  not  well  borne. 

The  diagnosis  of  hemorrhage  and  pneumothorax 
depends  on  the  usual  well  known  signs  with  the 
variations  so  well  described  by  Bradford  and  others, 
viz.,  the  elevation  of  the  diaphragm,  the  small  size 
of  the  chest,  the  tendency  to  complete  or  partial 
collapse  of  the  lung  in  any  area,  the  compensatory 
emphysema  above  and  other  known  physical  signs. 
The  important  point  for  the  surgeon  to  determine 
is  whether  the  hemorrhage  is  continuing  or  is  pro- 
gressive. If  from  the  location  of  the  wound  of 
entry  injury  of  the  abdominal  viscera  is  suspected 
immediate  operation  should  be  done.  In  those  cases 
where  all  goes  well  and  the  proper  surroundings 


618 


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[New  York 
Medical  Journal. 


and  skill  are  available  there  seems  no  reason  why 
we  should  not  routinely  open  the  thorax  in  from 
five  to  eight  hours  after  the  injury  in  cases  even 
where  there  is  moderate  hemothorax  or  where  there 
is  a  retained  missile.  I  admit  that  the  mere  reten- 
tion of  a  missile  is  a  debatable  indication  for  opera- 
tion but  the  dangers  of  fibrosis,  abscess,  or  bronclii- 
ectasis  are  too  real  to  be  disregarded.  It  has  been 
noted  by  all  of  us  that  hemorrhage  and  infection 
are  the  causes  of  nearly  all  the  fatalities  and  many 
of  the  fatal  hemorrhage  cases  are  probably  beyond 
help  by  reason  of  large  vessel  injury  and  death 
before  operation  can  be  attempted.  But  I  am  cer- 
tain that  some  patients  die  who  could  have  been 
saved  by  prompt  thoracotomy.  Early  operation 
should  avoid  most  of  the  fatalities  from  infection. 

W  here  there  has  been  delay  and  infection  of  the 
clot  supervenes,  immediate  thoracotomy,  removal  of 
the  clot  and  institution  of  proper  drainage  should  be 
the  rule.  Finally,  the  missile  should  be  removed 
from  the  lung  at  the  earliest  practicable  time,  usually 
within  two  weeks,  if  primary  thoracotomy  h  as  no. 
been  performed. 

It  is  not  necessary  to  review  the  technic  of  opera- 
tion. The  socalled  method  of  Duval  may  be  taken 
as  the  standard  procedure.  The  methods  practised 
by  LeFort  should  be  studied,  particularly  when  we 
undertake  the  removal  of  a  bullet  from  the  medias- 
tinum. I  do  not  know  whether  Petit  de  la  Villeon's 
method  will  become  the  universal  practice ;  the  recent 
papers  by  LeConte  and  !Moynihan  highly  praise 
its  efficacy,  but  it  demands  a  special  apparatus  and 
a  technic  made  perfect  by  practice  and  gunshot  in- 
juries of  the  chest  are  not  so  common  in  civil  sur- 
gery. In  stab  wounds  involving  the  diaphragm  the 
consensus  of  opinion  favors  the  thoracic  route  but 
I  have  successfully  operated  in  such  a  case  by  the 
abdominal  route.  The  physiological  principles  in- 
volved in  opening  the  chest  and  producing  a  pneumo- 
thorax must  be  well  understood,  and  the  brilliant 
paper  by  Evarts  Graham  should  be  memorized. 

The  use  of  inhalation  anesthesia  and  particularly 
ether  or  chloroform  is  a  factor  adding  considerably 
to  the  risk.  Duval  advises  local  or  regional  anes- 
thesia, stating  that  the  patches  of  pulmonary  con- 
gestion which  so  frequently  occur  after  operation, 
may  be  in  some  measure  attributed  to  the  effects 
of  inhalation  anesthesia  as  well  as  to  the  after- 
effects of  the  wound  of  the  lung. 

Lockwood  and  Xixon  also  use  local  anesthesia 
reinforced  by  gas-oxygen  while  the  hand  is  inside 
the  chest  or  if  the  patient  is  restless.  On  the  other 
hand,  Gask  prefers  chloroform,  either  by  itself  or 
combined  with  oxygen.  Yates  found  that  a  safe 
sequence  in  practice  was  found  to  be  as  follows : 
after  the  effect  of  the  preoperative  hypodermic  of 
morphine  was  apparent,  the  administrations  of  pure 
oxygen  under  no  tension  were  started.  Then  very 
gradually  the  pressure  was  increased,  and  the  ad- 
ministration of  nitrous  oxide  started.  Rapidity  of 
induction  of  the  anesthesia  was  undesirable.  Avoid- 
ance of  excitation  and  the  production  of  gradually 
increasing  inflation  were  essential.  During  the 
operation  the  proportions  of  the  gas-oxygen  mixture 
and  the  pressure  transmitted  to  the  trachea  were 
varied  to  meet  varying  conditions.    After  the  pari- 


etal pleura  was  closed  the  amotnit  of  nitrous  oxide 
was  gradually  reduced ;  oxygen  under  pressure  was 
continued  until  the  patient  was  conscious. 

The  tendency  of  most  writers  has  been  to  mini- 
mize the  importance  of  pressure  apparatus  or  endo- 
tracheal methods  in  traumatic  chest  surgery,  but 
IMeyers  considers  it  wrong  to  draw  sweeping  con- 
clusions from  the  experience  gained  in  the  war.  I 
have  recently  operated  on  patients  with  gunshot  and 
stab  wounds  and  performed  exploratory  thoracoto- 
mies for  malignant  disease  under  ether  anesthesia 
on  open  gauze  but  believe  that  the  method  of  Yates 
just  described  is  the  best.  This  method  gives  all 
practical  requirements  for  intrathoracic  surgery 
without  necessitating  deep  anesthesia  for  the  intro- 
duction of  intratracheal  or  endopharyngeal  tubes. 
Moreover,  its  safety  and  ease  of  control  has  re- 
moved the  chief  obstacle  to  a  wider  appHcation  of 
surgical  therapy. 

One  of  the  problems  of  chest  surgery  is  the  diffi- 
culty of  suturing  the  pleura,  so  as  to  hermetically 
seal  the  opening.  Duval  sutures  the  intercostal 
muscles  and  pleura  together ;  Moynihan  in  his  well- 
known  paper  advises  wide  separation  of  the  pleura 
from  the  ribs  in  all  directions  (thus  mobilizing  it) 
before  opening  the  cavity.  I  have  not  found  this 
to  be  a  very  satisfactory  procedure,  however,  in 
several  cases.  The  reason  lies  in  the  persistence  of 
the  rib  separation  at  the  conclusion  of  operation. 
A  number  of  surgeons  overcome  this  separation  by 
passing  silver  or  bronze  sutures  around  the  ribs 
above  and  below  the  incision  and  tying  with  suffi- 
cient tension.  Duval  mentions  particularly  the  im- 
portance of  covering  the  resected  ends  of  the  rib 
with  a  staunch  muscle  suture  because  of  the  diffi- 
culty in  bringing  the  pleurae  together  here. 

Time  does  not  permit  further  discussion.  Bastia- 
nelli's  use  of  artificial  pneumothorax  in  the  treat- 
ment of  chest  wounds  is  quite  interesting.  He  be- 
lieves that  the  air  keeps  the  lung  from  contact  with 
the  pleural  membrane  until  complete  expansion  has 
resulted,  thus  minimizing  adhesions  at  abnormal 
positions.  Duval  on  the  other  hand  considers  a 
pneumothorax  as  an  injurious  process  and  urges  its 
removal.  Yates  brings  out  the  interesting  point 
that  in  his  dog  experiments  in  which  the  phrenic 
nerve  was  sectioned,  the  dogs  showed  a  remarkable 
freedom  from  distress  and  a  reduction  in  the  amount 
of  postoperative  effusion.  This  method  has  been 
used  for  the  treatment  of  tuberculous  cavity  but 
taken  in  conjunction  with  Bastianelli's  observations 
would  repay  further  study  of  lung  wounds. 

The  surgery  of  the  chest  is  now  well  on  its  way 
to  further  development  and  improvement,  but  the 
tyro  must  keep  his  hands  off  until  he  has  studied 
the  work  of  the  masters  of  the  past  and  has  digested 
the  lessons  of  the  war.  While  Duval's  famous  dic- 
tum, "that  the  surgery  of  gimshot  wounds  of  the 
lungs  must  be  governed  by  the  principles  of  surgery 
as  applied  to  any  other  gunshot  wounds,"  requires 
a  number  of  exceptions,  it  is  in  the  main  true,  and 
should  lead  us  to  the  point  where  we  can  open  the 
chest  as  safely  as  we  now  open  the  abdominal  cavity. 

REFERENCES. 

1.  Otis:  Medical  History  of  the  War  of  the  Rebellion. 

2.  Brewer  :  Keen's  Surgery. 

3.  Waters  :  Journal  A.  M.  A.,  November,  1919. 


October  23,  1920.] 


RUTZ:  OCCULT  BLOOD  IX  GASTRIC  CONTEXTS. 


619 


THE   FUTILITY   OF   EXA:MIXIXG  THE 
FILTRATE   FOR   THE  PRESENCE 
OF  OCCULT  BLOOD  IX  THE 
GASTRIC  CONTEXTS. 
By  Anthony  A.  Ruxz,  M.  D., 

Brooklyn,  X.  Y. 

Certain  clinical  and  laboratory  observations  have 
recently  impressed  upon  me  the  futility  of  examin- 
ing the  filtrate  for  the  presence  of  occult  blood 
in  the  gastric  contents.  Xot  infrequently  it  has 
been  observed  that  gastric  contents  which  on  macro- 
scopic examination  contained  blood  when  filtered 
become  negative  to  occult  blood  tests.  Furthermore, 
negative  results  from  examination  of  the  filtrate 
were  too  often  at  variance  with  the  history  and  other 
findings. 

In  view  of  these  facts  it  was  determined  whenever 
possible  to  make  separate  tests  upon  filtered  and  un- 
filtered  gastric  contents,  and  the  results  showed  that 
in  the  majority  of  cases,  in  which  the  unfiltered  con- 
tents were  positive  the  filtrate  was  negative  to  occult 
blood  tests.  In  a  series  of  twenty-four  cases  in 
which  the  unfiltered  contents  were  positive  the  filtrate 
was  faintly  positive  in  two  and  negative  in  the  re- 
maining twenty-two  cases.  •  In  these  twenty-two 
cases  the  unfiltered  contents  were  strongly  positive 
in  thirteen,  and  faintly  so  in  the  remaining  nine 
cases.  Among  the  thirteen  former  were  two  cases 
of  inoperable  cancer  of  the  stomach.  In  one  of  these 
the  contents  were  light  cofifee  ground  in  character 
and  in  four  successive  examinations  the  filtrate  was 
negative. 

The  tests  employed  were  at  first  both  the  guaiac 
and  the  tablet  benzidin  test  of  Dudley  Roberts.  As 
the  results  were  similar,  and  as  the  latter  is  slightly 
more  sensitive  and  far  less  time  consuming,  the  ben- 
zidin test  alone  was  employed  in  the  later  examina- 
tions of  the  gastric  contents  and  in  the  subsequent 
experimental  tests.  The  objections  to  the  use  of 
pure  benzidin  in  the  examination  of  the  gastric  con- 
tents for  blood  do  not  apply  to  the  use  of  the 
prepared  tablets,  as  these,  though  slightly  more  sen- 
sitive than  the  guaiac,  are  far  less  so  than  the  pure 
benzidin.  The  test  meals  consisted  of  three  Uneeda 
biscuits  and  twelve  ounces  of  water,  the  contents  be- 
ing removed  one  hour  after  ingestion. 

It  is  evident  from  the  foregoing  that  a  distinct 
contrast  exists  between  the  filtered  and  the  unfiltered 
gastric  contents  in  their  action  toward  occult  blood 
tests.  To  determine  the  various-  factors  responsible 
for  this  difference  the  writer  conducted  a  series  of 
studies : 

1.  Filtrates  of  solutions  of  blood  (1  in  1000  )  in 
plain  water  or  in  sodium  citrate  solution  were  ex- 
amined for  blood.  These  were  invariably  as  stronglv 
positive  as  the  solutions  before  filtration,  showing 
that  mere  filtration  without  some  change  in  the 
blood  is  not  responsible  for  this  difference. 

2.  Soda  crackers  were  macerated  in  plain  water 
and  in  gastric  filtrates  which  were  negative  for  blood. 
These  gave  negative  tests  showing  that  the  pres- 
ence of  the  crackers  is  not  responsible  for  the  posi- 
tive reactions  in  the  unfiltered  contents.  This  is 
also  evident  from  the  fact  that  unfiltered  speci- 
mens containing  crackers  are  frequently  negative. 


3.  That  mucus  itself  is  not  responsible .  for  this 
contrast  is  evident  from  the  fact  that  often  unfiltered 
contents,  containing  large  quantities  of  mucus,  are 
negative  for  blood.  That  the  difference  is  not  es- 
sentially due  to  the  presence  of  blood  in  the  mucus 
is  shown  by  the  following  procedure :  Stomach  con- 
tents negative  for  blood  were  repeatedly  filtered  so 
as  to  remove  the  mucus.  To  these  filtrates  blood 
was  added  in  the  strength  of  1  in  1000.  They  were 
then  thoroughly  mixed  and  incubated  for  one  hour 
to  represent  more  or  less  the  physical  and  chemical 
changes  which  the  gastric  contents  undergo  in  the 
body.  At  the  end  of  one  hour,  these  mixtures  were 
examined  for  blood  and  were  always  found  positive.. 
These  were  then  filtered.  These  filtrates  were  in 
the  majority  of  cases  negative  and  only  at  times 
faintly  positive  for  blood,  showing  that  filtrates  of 
specimens  containing  blood  become  negative  even  in 
the  absence  of  mucus.  While  the  crackers  and  mucus 
are  not  the  essential  causes,  they  play  a  second- 
ary role,  as  will  subsequently  be  shown. 

4.  It  has  been  proved  that  mere  filtration  with- 
out previous  changes  in  the  blood  in  the  stomach 
contents  cannot  be  the  cause  of  the  negative  reaction 
in  the  filtrate.  The  blood  undergoes  definite  changes 
in  the  stomach  which  are  the  cause  of  its  total  or 
partial  disappearance  in  the  filtrate.  It  is  well  known 
that  in  the  presence  of  a  weak  acid,  hemoglobin  is 
decomposed  into  hematin  and  a  globulin.  The  he- 
matin  is  insoluble  in  weak  acids,  (occurring  as 
amorphous  granules,  which  by  reason  of  their  iron 
content  have  a  high  specific  gravity  and  are  strongly 
magnetic.  That  hydrochloric  acid  or,  when  this  is 
absent,  lactic  acid  is  the  essential  cause  of  the  con- 
trast which  exists  between  the  filtered  and  unfiltered 
gastric  contents,  and  that  this  is  due  to  the  fact 
that  the  granules  of  hematin  formed  by  the  action 
of  the  acid  upon  the  hemoglobin  are  too  large  read- 
ily to  find  their  way  through  ordinary  filter  paper, 
is  evident  from  the  following  tests : 

Three  solutions  are  placed  in  separate  beakers  and 
are  frequently  mixed  and  incubated  for  an  hour : 
a,  1  in  1000  solution  of  blood  and  water ;  b,  1  in 
1000  solution  of  blood  in  two  tenths  of  one  per  cent, 
hydrochloric  acid ;  c,  1  in  1000  solution  of  blood  in 
two  tenths  of  one  per  cent,  hydrochloric  acid,  with 
broken  crackers  added.  After  one  hour,  each  mix- 
ture is  tested  for  blood  before  and  after  filtration. 
In  a,  the  filtrate  and  vmfiltered  solution  are  equally 
positive  for  blood.  In  b,  the  unfiltered  solution  is 
distinctly  positive,  while  the  filtrate  is  most  often 
negative,  but  at  times  is  faintly  positive.  In  c,  the 
unfiltered  contents  will  be  found  positive,  while  the 
filtrate  will  be  invariably  negative. 

As  the  only  difference  between  a  and  b  is  the 
presence  of  hydrochloric  acid,  then  the  hydrochloric 
acid  must  be  the  cause  of  the  absence  of  blood  in 
the  filtrate.  It  will  be  noted  that  the  contrast  be- 
tween a  and  c  is  greater  than  that  between  a  and  b. 
It  is  evident  that  this  must  be  due  to  the  presence  of 
crackers  in  c.  The  granules  of  hematin  have  a 
marked  tendency  to  adhere  to  the  larger  particles 
of  crackers  in  suspension,  thus  rendering  filtration 
more  complete.  These  tests  were  repeated  with  two 
tenths  of  one  per  cent,  lactic  acid  solutions  and  the 
same  results  obtained  as  with  hydrochloric  acid.  As 


620 


TAYLOR:  FILING  CONVENIENCES. 


[New  York 
Medical  Journal 


gastric  contents  are  practically  always  acid,  contain- 
ing either  hydrochloric  or  lactic  acid,  what  has  been 
shown  applies  more  or  less  to  all  specimens. 

5.  That  the  hematin  granules  have  a  tendency 
to  adhere  to  other  particles  in  suspension  is 
evident  from  the  following  observation :  A 
weak  solution  of  blood  (1  in  5,000)  is  made 
in  two  tenths  of  one  per  cent,  hydrochloric 
acid  with  broken  crackers  in  suspension.  The 
unfiltered  mixture,  after  standing  for  an  hour 
in  an  incubator,  at  the  same  time  being  thoroughly 
mixed,  is  tested  for  blood.  It  will  be  found  that 
the  liquid  portion  presents  but  little  change  in  color, 
while  the  particles  of  cracker  will  be  stained  deep 
blue,  showing  that  the  hematin  granules  have  be- 
come attached  to  them. 

Frequently,  when  unfiltered  contents  are  exam- 
ined for  occult  blood,  it  will  be  found  that  the 
liquid  portion  is  negative  while  the  mucus  is  posi- 
tive. While  this,  at  times,  is  undoubtedly  due  to 
the  fact  that  the  mucus  has  been  detached  from  an 
eroded  or  congested  mucous  membrane,  yet  I  believe 
it  is  more  often  due  to  the  granules  of  hematin 
throughout  the  contents  having  become  adherent  to 
the  mucus.  The  mucus  and  food  particles  play  the 
same  role  in  the  filtration  of  the  gastric  contents, 
as  egg  albumen  in  the  preparation  and  filtration  of 
broth  cultures. 

6.  Specimens  of  gastric  contents  positive  for 
blood  were  examined  immediately  after  removal  and 
the  intensity  of  the  reaction  noted.  These  were 
then  allowed  to  stand  for  three  to  six  hours.  At  the 
end  of  this  time  the  upper,  clearer  portion  and  the 
sediment  were  examined  separately.  It  was  found 
that  the  former  was  either  negative  or  only  faintly 
positive  for  blood,  while  the  latter  gave  a  stronger 
reaction  than  the  freshly  mixed  contents.  This  is 
due  to  the  fact  that  the  blood  exists  in  the  form  of 
hematin  granules,  which  by  reason  of  their  high  spe- 
cific gravity  and  their  tendency  to  adhere  to  other 
particles,  rapidly  gravitate  to  the  bottom  of  the  glass. 
This  obviously  is  of  considerable  practical  import- 
ance ;  for  if  the  upper  portion  of  such  a  specimen  is 
poured  of¥  and  employed  for  the  blood  test,  almost 
the  same  negative  results  will  be  obtained  as  with 
the  filtrate. 

Certain  factors  influence  the  contrast  which  ex- 
ists between  the  filtrate  and  unfiltered  contents.  The 
sooner  the  filtration  after  removal  and  the  greater 
the  amount  of  blood  in  the  vuifiltered  contents,  the 
less  the  contrast.  The  greater  the  amount  of  par- 
ticles in  suspension,  and  the  more  thorough  the 
process  of  filtration,  the  greater  the  contrast  be- 
tween the  filtrate  and  unfiltered  contents  in  their 
behavior  to  occult  blood  tests. 

All  these  observations  have  been  made  sufficiently 
often  to  show  that  they  are  constant.  They  show 
clearly  that  examinations  of  the  filtrate  are  unreliable 
in  determining  the  presence  of  occult  blood  in  the 
gastric  contents.  The  mixed  unfiltered  contents  or,  if 
the  test  is  to  be  more  sensitive,  the  sediment  after 
standing  or  centrifuging  should  be  employed.  This 
fact  is  not  generally  recognized ;  for  in  the  leading 
textbooks  on  gastrointestinal  diseases  instructions 
are  given  to  employ  the  filtrate  for  the  test. 

16  Eighth  Avenue. 


FILING  CONVENIENCES  SUITABLE 
FOR  PHYSICIANS. 

By  J.  Madison  Taylor,  M.  D., 
Philadelphia. 

The  man  in  active  practice  has  need  for  con- 
venient and  systematic  means  for  filing  at  least  a 
dozen  varieties  of  data  of  written  or  printed  ma- 
terials. Among  them  are  the  following:  1.  Short 
notes  on  cases,  on  the  casual  client ;  to  jot  down 
the  name,  address,  complaint  and  primary  advice 
given.  2.  Fuller  notes  on  progressive  cases.  3. 
Associated  data,  correspondence  about  cases,  etc.  4. 
Business  correspondence.  5.  Reprints  of  medical 
and  scientific  papers.  6.  Useful  data  from  adver- 
tisers, objects,  instruments,  materials  and  drugs, 
especially  working  bulletins  of  new  products  and 
scientific  researches  of  the  manufacturing  houses, 
as  advocated  by  Dr.  Francis  E.  Stewart.  7.  Hos- 
pitals, sanatoria,  special  schools  for  mental  defec- 
tives, convalescent  homes,  summer  camps  for  boys 
and  girls  and  others.  8.  Climatic  data,  reports,  trans- 
portation, miscellaneous.  9.  Small  card  index  for 
books ;  a,  books  in  one's  own  library ;  b,  books  de- 
sirable to  read  at  some  time.  Differentiate  by  colors 
of  cards,  or  better  by  colors  and  separate  drawers. 
It  is  also  desirable  that  any  or  all  of  these  refer- 
ence data  should  be  readily  accessible,  in  reach  of 
his  office  chair. 

In  pursuance  of  an  earlier  enterprise  which  im- 
pressed me  with  its  importance,  I  wrote  a  series  of. 
letters  to  the  editor  of  Journal  of  the  American 
Medical  Association,  beginning  about  twenty-five 
years  ago,  offering  suggestions  to  the  great  manu- 
facturing houses,  the  purveyors  of  useful  objects, 
drugs  and  other  materials,  urging  that  they  adopt  a 
uniformity  in  the  size  and  shape  of  their  printed 
matter,  in  particular  that  they  use  the  standard 
three  by  five  inch  index  filing  card,  for  business 
summaries,  cards  or  small  booklets. 

These  recommendations  were  at  once  adopted  by 
certain  manufacturing  houses  and  now  most  of  the 
large  drug  firms  are  following  suit.  Later  I  urged 
that  the  leading  medical  journals  agree  upon  a  uni- 
fonn  size  and  shape  of  their  fuller  data.  So  far  no 
attention  has  been  given  to  the  hint.  They  must 
come  to  it ;  the  sooner  the  better.  A  recent  com- 
munication elicited  attention  from  some  of  the  drug 
houses  and  I  was  asked  to  offer  specific  recom- 
mendations. After  consulting  the  makers  of  filing 
cabinets  I  learn  that  it  is  entirely  practicable  to  use 
certain  standard  cases.  These  being  adjustable,  any 
one  being  able  to  adopt  some  one  or  more  parts,  I 
offer  the  following  idea. 

A  filing  cabinet  of  standard  qualities  can  be  as- 
sembled to  contain:  1,  one  section  of  five  filing 
cases  or  drawers,  each  five  by  eight  inches,  hori- 
zontally placed ;  2,  one  section,  three  drawers,  nine 
and  a  half  by  ten  and  five  eighths  inches  vertically 
placed ;  3,  one  section  of  five  drawers  each  three 
by  five  inches ;  4,  a  stand  sixteen  inches  in  height. 
The  whole  constitutes  a  cabinet  thirty  by  sixty  inches 
of  handsome  appearance. 

To  this  could  be  added  one  section  of  two 
drawers  each  eleven  by  fourteen  inches.  This 
would  be  admirably  complete  and  would  well  repay 


October  23,  1920.] 


GEYSER:  DIAGNOSIS  OF    CHRONIC  CONDITIONS. 


621 


the  cost,  in  time,  effort,  and  worry  now  expended. 
The  cost  of  this  cabinet  would  be  for  the  three 
sections  (as  first  described)  about  ninety  dollars  at 
present  prices.  Should  any  one  be  interested  I 
have  sent  a  manuscript  (accepted)  to  the  Scientific 
American  describing  my  own  method  of  arranging 
and  filing  scientific  data. 

The  serious  difficulty  which  remains  is  to  induce 
the  medical  journals  to  adopt  a  uniform  size 
and  shape  for  reprints.  And  yet  in  America  we 
boast  of  our  system ;  of  our  prompt  adoption  of  all 
labor  saving  devices ! 

These  suggestions  w'ould  meet  the  current  or 
urgent  needs  of  most  practitioners.  Should  any- 
one wish  to  go  into  the  enterprise  more  completely 
or  comprehensively,  the  methods  of  Melville  Dewey, 
of  the  New  York  State  Library  at  Albany,  might 
be  adopted,  wholly  or  in  part.  It  is  called  the  Deci- 
mal Classification  or  Relative  Index,  and  provides 
a  practically  perfect  system  for  classification  of  data. 

1504  Pine  Street. 


THE    DIAGNOSIS    OF   CHRONIC  CONDI- 
TIONS BY  THE  SPINAL  REFLEX 
SYSTEM. 

By  Albert  C.  Geyser,  M.D., 
New  York. 

Correct  diagnosis  must  forever  remain  the  key- 
stone to  proper  treatment.  Any  means  or  agents 
capable  of  furnishing  assistance  are  always  wel- 
comed by  the  physician  and  appreciated  by  the  pa- 
tient. Before  we  can  form  an  opinion  as  to  the  use 
of  electricity  in  determining  the  underlying  cause 
of  any  chronic  ailment,  it  will  be  necessary  to  re- 
view, at  least  lightly,  some  anatomical  as  well  as 
physiological  facts. 

Entirely  too  much  time  is  spent  and  too  much 
stress  is  laid  upon  considering  the  pathology  in  any 
given  case.  Pathology  is  that  branch  of  medical 
science  which  treats  of  the  modifications  of  function 
and  changes  in  structure  caused  by  disease.  It  is 
always  an  aftermath.  Let  us  suppose,  for  the  pur- 
pose of  illustration,  that  a  tornado  has  passed 
through  a  part  of  the  country.  Usually  an  area  of 
a  certain  width,  and  frequently  miles  in  length,  has 
been  devastated,  trees  have  been  uprooted,  houses 
blown  from  their  foundations,  fires  may  have  broken 
out,  and  perhaps  lives  lost.  After  the  storm  (the 
disease)  is  over,  those  who  were  lucky  enough  to 
escape  may  view  the  ruins  (the  pathology).  It  may 
be  granted  that  an  expert  in  such  matters  may  be 
able  to  tell  us  from  the  damage  (pathology)  done, 
just  what  kind  of  a  storm  it  was ;  he  may  be  able 
to  tell  us  the  extreme  velocity  of  the  wind  as  it 
passed  through,  as  well  as  the  direction  from  which 
it  came ;  he  may  even  know  just  how  many  such 
storms  have  previously  occurred  in  this  or  some 
other  region,  or  when  another  of  a  similar  nature 
might  be  anticipated.  While  all  of  this  is  very 
scientific  and  interesting,  the  stricken  population 
(the  patient)  are  more  interested  in  the  reconstruc- 
tion (the  physiology)  in  the  rebuilding  and  possibly 
in  the  prevention  (prophylaxis)  of  a  recurrence. 

So  far  as  the  actual  damage  is  concerned,  it  might 


have  been  worse  or  it  might  have  been  better  had  it 
been  caused  by  a  conflagration,  flood,  or  earthquake. 
This  does  not  mean  that  pathology  does  not  serve  a 
good  or  useful  purpose ;  but  it  does  mean  that,  so 
far  as  a  cure,  a  return  to  the  normal,  is  concerned, 
more  time  should  be  spent  in  the  study  of  physiol- 
ogy. This  at  least  applies  more  especially  to  the 
practising  physician.  Pathology  is  always  an  end 
result,  while  physiology  enlightens  us  in  the  actual 
reconstruction,  in  the  appreciation  of  the  deviation 
from  the  normal  and  a  return  to  it. 

Every  chronic  disease  depends  for  its  continu- 
ance upon  a  greater  or  lesser  deviation  from  the 
normal  anatomical  and  physiological  makeup  of 
the  individual.  It  is,  therefore,  apparent  that  we 
must  not  only  judge  the  individual  as  a  whole,  but 
must  ever  bear  in  mind  the  cellular  construction  of 
the  human  body.  Each  individual  is  but  a  conglom- 
eration of  cells ;  as  each  cell  is,  so  is  the  individual ; 
he  is  the  cells,  the  cells  are  he. 

THE  CELL  DOCTRINE. 

Nearly  a  half  century  has  passed  since  Vir- 
chow,  in  his  Cellular  Pathology,  expressed  the 
idea  that  each  animal  appeared  as  a  sum  of  vital 
units,  each  of  which  exhibited  all  the  characteristics 
belonging  to  life.  Not  only  that,  but  he  maintained 
the  thought  that  each  cell  sprang  from  a  preceding 
or  parent  cell  by  division,  budding  or  otherwise ; 
he  believed  that  the  character  and  unity  of  life  were 
referable  not  to  any  single  locality  of  a  higher  or- 
ganization— for  example,  the  brain  of  man — but 
rather  to  the  definite,  constantly  recurring  arrange- 
ment which  each  single  element  bears  to  itself. 

Taking  the  correctness  of  this  view  for  granted, 
the  composition  of  a  large  body  of  the  socalled  in- 
dividual must  always  depend  upon  a  social  arrange- 
ment :  in  fact,  it  represents  a  social  organism  in 
which  there  is  a  mass  of  single  existences  related  to 
one  another  in  such  a  way  that  every  element  has 
its  own  special  activity,  and  each,  when  excited  to 
activity  by  other  parts,  does  its  work  and  performs 
its  function  of  and  by  itself.  If  this  idea  is  correct 
it  must  apply  not  only  to  the  body  at  large,  but  also 
to  each  organ,  to  the  nervous  system,  even  to  each 
cell  entering  into  the  composition  of  any  tissue. 

During  the  last  few  years  it  has  been  possible  to 
approach  the  nervous  system  with  instruments  of 
great  precision,  with  better  recorded  observations  of 
disease  of  the  nervous  system  (testing  and  record- 
ing after  condensor  discharges  on  injured  nerves), 
aided  by  the  refutation  or  confirmation  of  pre- 
viously existing  data,  thereby  arriving  at  the  newer 
conception  of  the  neuron  as  a  unit.  In  fact,  the 
.study  of  the  functional  units  in  the  nervous  system 
could  be  approached  satisfactorily  only  after  it  had 
been  clearly  shown  that  the  nervous  system,  like 
all  other  tissues,  consisted  of  elements  more  or  less 
isolated  and  independent,  and  connected  directly 
with  one  another  apparently  only  by  contact,  con- 
crescence, or  protoplasmic  bridges,  and  after  we  had 
learned  to  recognize  the  different  structures  which 
belonged  to  the  single  elements. 

THE  NERVOUS  SYSTEM,  CENTRAL  AND  PERIPHERAL. 

In  describing  the  nervous  system,  for  convenience 
of  comprehension  we  separate  the  entire  system 


622 


GEYSER:  DIAGNOSIS  OF    CHRONIC  CONDITIONS. 


[New  York 
Medical  Journal. 


into  two  general  divisions,  yet  it  must  ever  be  borne 
in  mind  that  these  two  portions  are  anatomically, 
as  well  as  physiologically,  one  system.  The  central 
nervous  system  includes  the  cerebrum,  cerebellum, 
and  the  pons,  or  all  of  that  portion  enclosed  within 
the  cranium  proper,  while  the  peripheral  portion  in- 


,(ivt«niti>jlt!  luA  tiKS  mT 


<._Coltii.t<.rii.U, 


Fig.  1. — The  ganglion  cell  with  its  dendrons  and  axis  cylinder. 

eludes  the  spinal  cord,  the  nerves,  and  the  sympa- 
thetic system.  By  virtue  of  its  continuity,  the  ner- 
vous system  brings  into  connection  all  the  other 
systems  of  the  body.  Conforming,  as  it  does,  in 
shape  to  the  framework  of  the  body,  its  branches 
extend  to  all  parts.  These  branches  form  the  path- 
ways over  which  the  nerve  impulses  travel  toward 
the  central  system,  and,  in  consequence  of  the  im- 
pulses received,  there  pass  out  from  the  central 
system  other  impulses  to  the  muscles  and  glands. 
In  order  to  maintain  harmony  between  the  activities 
of  the  several  systems  composing  the  body,  it  is  at 
once  apparent  that  the  pathways  leading  to  the  cen- 
tral nervous  system,  as  well  as  the  paths  conducting 
impulses  from  the  centre  to  the  periphery,  must  be 
in  a  normal  state  to  perform  their  particular  func- 
tion. 

A  SHORT  REVIEW  OF  THE  ANATOMY  OF  A  NEURON. 

By  the  term  neuron  we  imderstand  the  entire 
mass  under  the  control  of  a  given  nucleus  forming 
both  the  cell  body  and  its  branches.  The  cell  body 
contains  the  usual  granular  material  with  a  nucleus 
and  a  nucleolus.  Nerve  cells  differ  in  the  number 
of  branches  arising  from  them  according  to  their 
physiological  function.  Motor  cells  possess  one 
principal  branch,  which,  when  spoken  of  alone,  is 
called  the  nerve  fibre,  but  when  considered  as  the 
ovttgrowth  of  the  cell  body  from  which  it  originated 
is  called  the  axone.  This  axone  usually  has 
branches,  which  are  designated  as  collaterals,  and  the 
distal  ends  of  the  axone  divide  into  finer  branches, 
forming  the  terminal  arborization. 

Contrasted  with  this  principal  outgrowth  are  the 
other  branches  of  the  cell,  which  are,  of  course,  in- 
dividually much  shorter  and  which  divide  dicho- 
tomously  at  frequent  intervals,  forming  a  treelike 
appearance ;    hence    their    designation  dendrites. 


An  axone  in  the  central  system  may  reach  from  the 
cerebral  cortex  to  the  lumbar  enlargement,  while 
the  longest  nerve  fibre  of  the  peripheral  system 
reaches  from  the  lumbar  enlargement  to  the  toe ; 
the  longest  fibres  are  found  in  the  spinal  ganglia  of 
the  lumbar  region,  where  one  axone  passes  to  the 
bulb  while  another  of  the  same  cell  passes  to  the 
skin  of  the  toes,  thus  spanning  the  entire  length  of 
the  body. 

Some  of  these  fibres  are  medullated,  while  others 
are  not ;  most  of  the  nonmedullated  fibres  are  found 
in  the  sympathetic  system,  although  a  few  are  pres- 
ent in  the  cerebrospinal  system.  The  function  of 
this  medullary  sheath  is  at  best  problematical ;  it 
has  been  suggested  that  this  coat  acts  as  an  insula- 
tion, but  there  is  hardly  any  warrant  for  such  con- 
clusion. That,  however,  it  may  act  to  the  nerve 
fibre  as  the  periosteum  does  to  the  bone  appears 
more  probable. 

The  ganglion  cell  with  its  dendrones  and  the  axis 
cylinder  with  its  terminal  fibrils  together  form  an 
anatomical  and  physiological  unit — a  neuron. 
(Fig.  1.).  Every  nervous  pathway  is  made  up  of 
a  series  of  such  neurons  communicating  with  one 
another.  There  does  not  seem  to  be  any  direct  ana- 
tomical continuity  in  these  neurons,  which  commu- 
nicate with  one  another  like  cog  wheels,  the  ter- 
minal fibrils  of  the  axis  cylinder  of  one  neuron  in- 
serting themselves  between  the  arborizations  of  the 
cells  of  another  neuron.  The  brain,  spinal  cord, 
peripheral  nerves,  and  sympathetic  system  are  com- 
posed exclusively  of  neurons  of  this  character  and 
their  articulations. 

It  is  thought  that  the  transmission  of  an  impulse 
is  effected  from  one  neuron  to  another  by  some 
protoplasmic  prolongation,  or  contraction  and  re- 


FiG.   2. — Communicating  dendrons  and  collaterals. 

laxation,  or  by  some  vibratory  movements  of  the 
terminal  filaments.  Such  impulses  are  carried  to 
the  cells  by  the  axis  cylinders.  Every  neuron  prob- 
ably acts  in  relation  with  several  others,  the  most 
extensive  communication  being  made  possible  by 
the  innumerable  dendrones  and  collaterals.  (Fig.  2.) 


October  23,  1920.] 


GEYSER:  DIAGXOSIS  OF    CHROXIC  CONDITIOXS. 

I 


623 


A  cortical  cell  may  receive  a  single  impression  or 
a  number  of  impressions  at  one  and  the  same  time. 
These  impressions  are  weighed  and  may  be  trans- 
mitted to  the  motor  cell  of  the  central  neuron.  The 
central  motor  neuron  transmits  the  desire  to  the  mul- 
tipolar cell  in  the  gray  matter  of  the  anterior  horn 
of  the  spinal  cord.  The  peripheral  motor  neuron 
is  then  actuated  and  causes  the  propagation  to  the 
end  organ ;  this  may  be  a  muscle,  gland,  or  other 
tissue,  which,  when  excited  into  activity,  performs 
its  physiological  function.  It  is  no  fault  of  a  nonnal 
tissue  that  it  performs  its  own  physiological  func- 
tion ;  it  cannot  do  otherwise. 

THE  PYRAMIDAL  TR.\CT. 

Situated  in  the  central  convolution  of  the  brain 
is  the  motor  cortical  zone.  The  cells  located  in  this 
area  form,  first,  the  corona  radiata,  then,  b}'  con- 
verging, enter  the  internal  capsule  where  they  are 
found  in  the  knee  and  the  anterior  third  of  the  pos- 
terior limb.  This  portion  of  the  ventral  peduncular 
fibres  emerges  at  the  posterior  border  of  the  pons 
in  a  compact  bundle,  known  as  the  pyramid,  and 


Fig.  3. — The  pyramidal  tract. 


continues  its  way  down  the  spinal  cord  as  the  pyra- 
midal tract.    (Fig.  3.) 

Most  of  the  fibres  undergo  decussation  and  occu- 
py the  lateral  column,  while  the  smaller,  uncrossed 
portion  remains  in  the  anterior  column.  This  tract 
contains  the  longest  fibres  of  the  corona  radiata  and 
can  be  followed  in  the  lateral  column  of  either  side 
as  far  down  as  the  conus  medullaris.  This  tract 
forms  the  central  motor  pathway.  The  axis  cylin- 
der, or  nerve  fibre,  of  this  central  tract  splits  up 
along  various  levels  of  the  brain  and  spinal  cord 
into  its  terminal  fibrils,  which  surround  the  den- 
drones  of  the  ganglion  cells  of  the  peripheral  motor 
neuron,  located  in  the  various  ganglionic  enlarge- 
ments of  the  spinal  cord.  The  nerve  processes  of 
the  peripheral  cells  emerge  as  nerve  roots  from  the 
brain  and  anterior  horn  of  the  spinal  cord  of  the 
same  side,  and  are  continued  as  motor  fibres  to  the 
muscle,  where  they  finally  break  up  into  their  ter- 


minal fibrils  among  the  individual  muscle  fibres 
(end  organs).  The  central  motor  neuron,  there- 
fore, undergoes  decussation,  while  the  peripheral 
does  not. 

The  impulses  A\hich  originate  in  the  cells  of  the 
cortex  are  transmitted  to  the  muscle  through  the 
pathway  formed  by  these  two  neurons,  and  from 
the  decussation  of  the  central  neurons  it  follows 
that  the  cortex  of  each  hemisphere  controls  the  mus- 
cles of  the  opposite  side  of  the  body.  In  apoplexy 
the  lesion  occurs  upon  one  side  of  the  cerebral 
hemisphere,  while  the  muscular  paralysis,  owing  to 
the  decussation  of  the  central  motor  fibres,  presents 
itself  upon  the  opposite  side  of  the  body.  On  the 
other  hand,  in  poliomyelitis,  the  multipolar  cell  in 
the  anterior  horn  of  the  spinal  cord  is  involved.  It 
is  at  this  point  that  the  central  neuron  ends,  while 
the  peripheral  begins.  Since  the  peripheral  motor 
neuron  does  not  decussate,  it  follows  that  the  mus- 
cle paralysis  must  occur  upon  the  same  side  as  the 
lesion  in  the  spinal  cord.  In  cerebral  apoplexy  the 
blood  clot  presses  upon  some  portion  of  the  motor 
cortical  zone  or  upon  some  of  the  axis  cylinders  in 
the  capsule,  hence  the  will  or  the  desire  for  muscular 
contraction  cannot  be  transmitted  to  the  multipolar 
cells  in  the  cord.  This  lack  of  impulse  transmission 
causes  the  paralysis.  Since  the  affected  muscles 
are  in  anatomical  and  physicHogical  contact  with 
their  trophic  centre  there  is  not  only  no  wasting  nor 
atrophy,  but  there  may  be  a  spastic  paralysis  in  ad- 
dition, instead  of  a  flaccid  paralysis.  In  poliomyeli- 
tis the  axis  cylinder,  the  end  plates,  and  the  muscles 
are  separated  from  their  trophic  centre ;  hence  there 
is  complete  flaccid  paralysis,  as  well  as  early  atro- 
phy. The  atrophy  in  cerebral  hemorrhage  is  grad- 
ual, the  result  of  nonuse ;  the  atrophy  in  poliomye- 
litis is  due  to  the  loss  of  the  nerve  or  centre  of  nutri- 
tional control — secondarily  to  the  nonuse. 

Every  neuron  cell  exercises  a  trophic  influence  on 
its  processes,  including  the  long  axis  cylinder  proc- 
ess, the  end  organs,  and  the  tissues,  which  it  sup- 
plies. If  this  influence  is  destroyed,  the  correspond- 
ing nerve  fibre  undergoes  degeneration,  and  the 
ganglion  cell  itself  suffers  degenerative  changes  if 
the  continuity  of  the  neuron  is  for  a  long  time  in- 
terrupted. 

THE  SENSORY  PATHWAY. 

The  function  of  the  sensory  pathway  is  to  con- 
duct sensory  impressions  from  the  periphery  to  the 
centre.  The  peripheral  sensory  neuron  complex  of 
the  extremities  and  trunk  is  contained  in  the  sensory 
fibres  of  the  peripheral  nerves.  From  its  various 
distributions  to  the  skin  and  other  parts,  it  continues 
its  course  to  the  spine  through  the  fibres  of  the  vari- 
ous plexuses,  and  ends  in  the  cells  of  the  spinal 
ganglia,  without  directlv  entering  the  spinal  cord. 
(  Fig.  4.) 

The  cells  in  the  spinal  ganglia  differ  from  other 
cells  in  that  they  possess  two  axones,  giving  the  ap- 
pearance of  the  fibre  entering  at  one  end  of  the  cell 
and  leaving  at  the  other ;  these  fibres,  by  which  the 
nerve  leaves  the  cell  in  the  spinal  ganglia,  collective- 
ly form  the  posterior  root,  and,  as  such,  the  sensor\' 
peripheral  neuron  finally  reaches  the  spinal  marrow, 
the  posterior  roots  entering  in  two  separate  parts 


624 


GEYSER:  DIAGXOSIS  OF    CHRONIC  COXDITIOXS. 


[New  York 
Medical  Journal. 


into  the  posterior  columns  that  lie  between  the  pos- 
terior horns.  After  its  entrance  into  the  spinal  cord, 
each  root  fibre  divides  into  an  ascending  and  a  de- 
scending branch,  and  these  branches  soon  divide  to 
communicate  with  the  cells  in  the  gray  matter  of 
the  spinal  cord,  as  well  as  sending  collateral  branches 


/5« 


Fig.    4. — The   sensory  pathway 


upward  into  the  posterior  columns,  where  are  lo- 
cated fibres  controlling  tactile  sense  and  muscular 
coordination.  These  fibres  pass  upward  through  the 
entire  length  of  the  spinal  cord,  and  finally  break  up 
surrounding  cells  in  the  nucleus  of  Burdach  and 
Goll,  located  in  the  medulla  oblongata.  The  terminal 
divisions  of  the  peripheral  sensory  neurons  take 
place  about  the  nerve  cells  lying  in  the  following 
regions  (Fig.  5)  :  First,  in  Goll's  and  Burdach's 
nuclei  in  the  medulla ;  second,  in  the  various  por- 
tions of  the  posterior  horns ;  third,  in  the  middle 
zone  between  the  anterior  and  the  posterior  horns ; 
fourth,  in  the  columns  of  Clark;  fifth,  in  the  ante- 
rior horn. 

The  central  sensory  neuron  complex  begins  at  the 
ending  of  the  peripheral  neuron  in  the  regions  men- 
tioned in  the  first  four  above  noted  distributions. 
These  fibres,  which  enter  the  posterior  root  zone 
and  communicate  with  cells  situated  in  the  anterior 
horns  (noted  fifth  above)  are  especially  concerned 


•...1P,...W,V  J 


Fig.   5. — The  terminal  divisions  of  the  peripheral  sensory  neurons. 

in  reflex  action.  Up  to  this  point  the  distribution  is 
fairly  well  settled,  but  the  further  coarse  of  the 
central  sensory  tract  is  still  a  matter  of  dispute.  By 
some  authorities  it  is  maintained  that,  after  the  cen- 
tral sensory  neurons  reach  the  medulla  oblongata, 
one,  two,  and  even  more  neurons,  are  required  be- 


fore the  cortex  of  the  cerebrum  is  .put  into  commu- 
nication with  the  periphery. 

THE  REFLEXES. 

By  a  reflex  action,  we  mean  a  motor  act  per- 
formed automatically  in  response  to  a  sensory  im- 
pression. The  entire  act  is  confined  to  the  peri- 
pheral neurons,  which,  therefore,  form  the  reflex 
arc  (Fig.  6).  This  reflex  arc  is  composed  of  a 
sensory  portion  contributed  by  the  peripheral  sen- 
sory neuron,  a  motor  portion  contributed  by  the 
motor  .peripheral  neuron,  and  a  connecting  link 
formed  by  a  branch  of  the  sensory  neuron  after  its 
entrance  into  the  spinal  cord;  the  last  is  known  as 
the  reflex  collateral.  The  course  of  the  cutaneous 
and  tendon  reflex  arc  is  better  known  than  that  of 
any  of  the  others.  W'e  distinguish  a  short  and  a 
long  reflex  arc.  The  short  reflex  arc  consists  of  a 
collateral  which  passes  directly  from  the  posterior 
column  through  the  posterior  horn  to  the  cell  in  the 
anterior  horn ;  under  this  head  are  included  the 
plantar  and  spinal  reflexes.  The  long  reflex  arc  is 
formed  by  the  reflex  collateral  splitting  up  about  a 
cell  in  the  anterior  horn ;  from  this  cell  an  ascend- 

i 


Fig.  6. — The  reflex  arc. 

ing  and  a  descending  branch,  with  several  collaterals, 
pass  to  one  or  more  motor  ganglion  cells,  which  may 
be  situated  at  various  levels  of  the  anterior  horn. 
This  gives  the  possibility  of  reflex  movements  being 
transmitted  to  more  remote  muscle  groups. 

Of  the  more  complicated  reflex  arcs  we  have  little 
definite  knowledge,  as  the  pharyngeal,  nasal,  bron- 
chial, conjunctival,  pupillary,  and  others.  There  are, 
however,  a  few  of  the  more  important  reflexes  that 
should  not  go  unnoticed.  Locomotor  ataxia,  for  in- 
stance, even  in  the  beginning,  may  be  diagnosed  by 
the  absence  of  the  patellar  reflex,  the  absence  of  the 
pupillary  reflex,  and  the  swaying  of  the  body  with 
the  eyes  closed  ;  here,  then,  we  have  three  reflex  arcs, 
any  one  of  which  should  cause  a  further  investiga- 
tion, while  the  presence  of  any  two  of  these  would 
strongly  point  to  an  assured  diagnosis  of  tabes  dor- 
ealis. 

In  order  to  elicit  the  presence  or  absence  of  the 
knee  jerk,  the  patient  should  be  placed  in  a  sitting 
posture,  on  a  high  stool,  so  that  both  legs  are  free 


October  23,  1920.] 


GEYSER:  DIAGXOSIS  OF    CHRONIC  CONDITIOXS. 


625 


and  not  resting  upon  anything ;  the  patient  should 
then  be  instructed  to  Hnk  his  hands  together,  close 
his  eyes,  and  to  exert  a  strong  pulling  force  with 
both  hands  the  moment  that  he  feels  the  blow  struck 
upon  his  patellar  tendon ;  this,  of  course,  simply 
assists  in  diverting  the  patient's  attention  from  him- 
self, and  all  tmdue  strain  or  tension  is  thereby  re- 
moved from  his  lower  extremities ;  it  is  also  well  to 
bear  in  mind  that,  with  some  normal  individuals, 
the  knee  jerk  is  absent.  This  absence  of  the  knee 
jerk  was  first  described  by  Westphal,  hence  its  name, 
the  Westphal  sign. 

The  Arg}-ll-Robertson  pupil  is  a  loss  to  accommo- 
dation to  light,  but  not  to  distance.  It  may  be  ob- 
tained best  in  a  dark  room  by  suddenly  flashing  a 
small  electric  light,  when  a  contraction  of  the  pupil 
should  occur ;  the  absence  of  this  contraction  fur- 
nishes a  valuable  reflex  diagnostic  sign. 

The  Romberg  symptom  is  usually  present  early 
in  locomotor  ataxia  and  is  due  to  loss  of  muscular 
coordination.  Place  the  patient  in  a  standing  posi- 
tion with  his  heels  and  toes  together,  body  erect, 
order  him  to  close  his  eyes,  and  ver}-  shortly  a 
marked  swaying  of  his  body  will  be  observed.  This 
swaying  may  become  so  intense  that  the  patient 
must  be  guarded  lest  he  fall.  The  Achilles  reflex  in 
some  cases  of  locomotor  ataxia,  as  well  as  in  pare- 
sis, is  sometimes  absent  even  earlier  than  either  of 
the  previous  ones. 

In  lesions  of  the  peripheral  nervous  system  we 
have,  then,  generally  speaking,  a  loss  of  reflex  ac- 
tion, while  in  disease  of  central  origin  we  expect  to 
be  assisted  by  an  undue  increase  of  these  reflex 
phenomena. 

IXCRE.\SED  REFLEXES 

The  patellar  reflex  may  be  markedly  increased : 
the  increased  reflex  act,  however,  is  best  shown  by 
the  ankle  clonus,  especially  if  clonus  is  present. 
Take  the  heel  of  the  patient  in  the  palm  of  the  hand 
and  with  the  other  hand  make  sudden  pressure  upon 
the  ball  of  the  patient's  foot  so  as  to  cause  a  strong 
flexion  of  the  foot ;  as  long  as  this  flexion  is  main- 
tained the  ankle  clonus,  if  present,  will  be  mani- 
fested. Such  an  increased  action,  then,  would  indi- 
cate a  lesion  of  central  origin,  with  possible  second- 
ary changes  in  the  pyramidal  tract,  as  in  lateral  mul- 
tiple sclerosis,  or  as  the  result  of  apoplexy. 

The  cutaneous,  or  superficial,  reflexes  are  not  so 
well  understood :  attention  should,  however,  be  di- 
rected to  the  Babinski  phenomenon.  Under  normal 
conditions,  if  the  sole  of  the  foot  be  irritated,  ex- 
cepting in  very  young  infants,  there  is  a  flexion  of 
all  the  toes,  but  in  diseases  of  the  pyramidal  tract 
or  apoplexy,  when  the  sole  of  the  foot  is  gently 
irritated,  there  is  a  gradual  extension  of  the  big  toe, 
sometimes  of  all  the  toes ;  tjiis  becomes,  therefore, 
a  valuable  reflex  sign  in  cases  of  coma,  for  if  pres- 
ent it  will  be  pathognomonic  of  cerebral  apoplexy. 

SPIXAL  REFLEX  DIAGXOSIS. 

Last,  but  by  no  means  least,  is  a  condition  of  the 
sympathetic  system  along  the  entire  length  of  the 
spinal  column.  During  the  past  ten  years  I  have 
examined  over  a  thousand  spines  for  this  sign,  for 
I  know  of  no  other  means  or  symptoms  capable  of 
furnishing  such  unerring  evidence  of  disease  as  the 


spinal  sympathetic  system.  No  matter  how  recently 
an  injury  has  taken  place,  no  matter  how  long  ago 
or  how  obscure  the  symptom  of  a  chronic  ailment 
may  be,  as  long  as  some  portion  or  organ  of  the 
economy  suffers,  a  reflex  centre  corresponding  to 
that  portion  or  organ  will  surely  be  found  some- 
where in  the  spinal  cord.  Some  of  these  spinal  cen- 
tres are  well  known ;  others  are  more  or  less  ob- 
scure. The  sense  of  sympathetic  painful  areas, 
however,  comes  to  our  aid,  though  in  eliciting  pain 
we  are  obliged  to  rely  upon  the  statements  of  a 
patient  who  may  be  nervous  and  whose  sense  of  pain 
may  be  perverted  and,  therefore,  misleading.  For- 
tunately, I  am  able  to  call  your  attention  to  a  system 
that  will  at  once  commend  itself  to  you  for  its  sim- 
plicity as  well  as  for  its  accuracy. 

A  correct  diagnosis  usually  narrows  the  treat- 
ment down  to  a  very  few  agents,  and  it  is  merely  a 
matter  of  expedience  which  particular  method  of 
therapeutics  we  employ  in  any  given  case.  Admit- 
ting for  the  sake  of  argument  that  it  was  difficult, 
nay,  even  impossible,  to  arrive  at  a  correct  diag- 
nosis during  the  acute  stage  of  the  disease :  what, 
then,  are  our  chances  during  the  chronic  stage? 
Again,  we  must  bear  in  mind  that  the  patient  dur- 
ing the  chronic  stage  is  no  longer  suffering  from 
the  acute  disease :  but  rather  from  some  changes 
that  have  taken  place  in  the  economy,  as  the  result 
of  the  acute  condition.  In  other  words,  the  symp- 
toms have  entirely  changed.  Hence  we  speak  of 
symptomatic  treatment,  meaning  thereby  the  ameli- 
oration of  the  various  symptoms  as  they  may  be 
complained  of  by  the  patient.  If  we  give  this  so- 
called  symptomatic  treatment  a  passing  notice,  we 
must  admit  the  absurdity  of  it  and  our  inability  to 
do  better.  Here  we  have  a  patient  whose  whole 
system  has  been  more  or  less  changed  by  the  proc- 
esses of  disease  and  repair,  whose  manifestations 
and  interpretations  are  anything  but  normal.  Let 
us  take,  for  instance,  the  neurasthenic,  the  hysteric, 
and  the  hypochondriac.  If  we  were  to  administer 
treatment  according  to  the  interpretations  of  their 
feelings,  our  already  overcrowded  therapeutic  ar- 
mamentarium would  certainly  be  inadequate  and 
our  restilts  even  more  chaotic  than  they  are  now.  In 
refutation  it  might  be  said  that  these  three  condi- 
tions are  not  truly  disease  conditions,  but  rather 
psychic  conditions ;  let  us  bear  in  mind  that  the 
man  or  women  who  thinks  he  or  she  is  sick,  and  is 
not,  is  sick  indeed. 

I  venture  to  say  there  is  not  a  single  symptom  or 
manifestation  of  disease  without  some  underlying 
cause.  The  first  step  in  therapeutics  is  to  remove  the 
cause,  for  no  matter  how  often  or  how  much  we 
may  treat  the  symptoms,  unles  the  underlying  cause 
is  removed,  the  same  symptoms  must  again  appear, 
though  changed  through  the  administration  of  our 
sjTnptomatic  treatment.  It  is  the  cause  of  the  symp- 
toms, and  not  the  symptoms  themselves,  that  require 
our  attention.  To  make  it  more  clear,  let  us  suppose 
a  patient  complaining  of  nothing  more  than  a  head- 
ache, which  may  be  due  to  toxemia  from  intestinal 
origin,  derangement  of  the  gastric  functions,  changes 
in  the  circulatory  system,  changes  in  the  kidneys, 
defects  of  the  visual  apparatus,  frontal  sinus  disease, 
nasal  or  middle  ear  lesions,  uterine  lesions,  intra- 


626  GEYSER:  DIAGXOSIS  OF 

cranial  tumors,  congestion  or  anemia  of  the  brain 
or  its  coverings,  syphilitic  changes,  constipation, 
and  a  host  of  psychical  impressions.  Certainly, 
with  even  a  slight  thought  upon  the  subject,  we 
must  become  convinced  that  a  cause  must  be  dis- 
covered and  removed  before  any  real  benefit  can 
be  expected  from  our  therapeutic  applications. 

As  has  been  stated,  in  chronic  diseases  we  are 
more  often  suffering  from  some  obscure  cause  and 
the  symptom  complex  is  frequently  referable  to 
some  undiscovered  lesion  bringing  forth  rather  re- 
flex manifestations  than  directly  associated  condi- 
tions. Pain  is  an  expression  of  some  interference 
with  a  sensory  nerve,  central  or  peripheral.  With- 
ovit  the  intervention  of  a  nerve  of  sensation  there 
could  be  no  sensory  impression.  Paralysis,  or  motor 
inabilit}-,  necessitates  the  interference  with  the  func- 
tion of  a  motor  nerve,  either  the  nerve  itself  cen- 
trally or  peripherally,  or  joint  and  muscle  changes 
preventing  the  motor  nerve  from  carrying  out  its 
physiological  function. 

Changes  in  tissues  or  organs  in  general  are  pre- 
sided over,  not  by  the  sensory  or  the  motor  nerves, 
but  by  that  third  system  of  nerves,  the  sympathetic. 
All  growth  and  repair  of  tissue  is  under  the  direct 
control  of  the  sympathetic  system.  All  injuries, 
traumatic,  chemical,  or  biological,  aside  from  the 
pain,  loss  or  increase  of  motion,  are  under  the  direct 
influence  of  the  sympathetic  nervous  system.  It  is 
this  system  that  takes  cognizance  of  the  changes 
which  have  taken  place  and,  under  its  control 
through  the  vasoconstrictors  and  dilators,  the  proc- 
ess of  repair  is  more  or  less  perfectly  carried  out. 

THE  AUTONOMIC  OR  SYMPATHETIC  SYSTEM. 

For  our  purpose  and  for  the  sake  of  brevity  we 
will  make  no  special  distinction  between  the  sympa- 
thetic proper,  the  bulbar,  and  the  sacral  subdivi- 
sions. Neither  is  it  advisable  to  consider  in  too 
much  detail  the  anatomy  of  this  system,  but  only 
so  much  of  it  as  is  really  necessary  for  the  elucida- 
tion of  the  problem  of  spinal  reflex  diagnosis.  The 
sympathetic  nervous  system  is  intimately  connected 
with  the  cerebrospinal'  system,  though  it  differs 
from  it  in  many  ways,  especially  in  its  peripheral 
distribution. 

The  sympathetic  system  consists  of  a  highlv 
complex  arrangement  of  ganglia,  nerve  fibres  and 
nerve  plexuses,  which  are  distributed  to  the  different 
regions  of  the  body.  Especially  does  this  peripheral 
distribution  hold  good  for  the  blood  vessels,  ^^'her- 
ever  blood  flows,  there  is  found  a  sympathetic  nerve 
to  control  the  same.  The  largest  blood  vessel,  as 
well  as  the  smallest  capillary  tube,  has  its  own  sym- 
pathetic fibre.  In  its  minute  structure  the  sympa- 
thetic system  presents  the  same  general  constituent 
elements  as  the  rest  of  the  nervous  sj-stem,  viz., 
nerve  fibres,  ganglion  cells,  and  a  complicated  fibril- 
lary network  around  the  ganglion  cells  which  prob- 
ably originates  in  the  processes  of  the  nerve  fibres. 
The  single  nerve  fibres  unite  into  nerve  trunks,  while 
the  ganglion  cells  and  the  network  of  fibrils  accu- 
mulate at  certain  points  along  their  course. 

THE  SYMPATHETIC  AXD  VASOMOTOR  SYSTEM. 

Beginning  with  the  Gasserian  and  otic  ganglia 
within  the  craniaum  we  have  placed  upon  the  ante- 


CHROXIC   COXDITIOXS.  [New  York 

Medical  Journal. 

rior  and  lateral  aspects  of  the  spinal  column  a  chain 
of  similar  glands.  In  the  cervical  region  we  find 
three  ganglia,  the  superior,  the  middle,  and  the  in- 
ferior cervical,  while  below  this  region  there  is 
placed  one  ganglion  corresponding  to  each  of  the 
vertebrae.  These  two  chains  of  ganglia  are  connect- 
ed so  as  to  unite  in  the  lowest  ganglion,  the  ganglion 
impar.  From  each  one  of  these  ganglia  fibres  are 
given  off  to  pass  into  the  cerebrospinal  column 
through  the  nervi  rami  communicants.  Other  fibres 
are  given  oft'  at  various  levels  of  the  spinal  cord  to 
follow  the  course  of  the  blood  vessels,  and  in  this 
way  the  sympathetic  nervous  system  is  brought  into 
close  contact  with  every  single  part  of  the  body.  In 
fact,  each  individual  cell  is  under  the  direct  influence 
and  control  of  this  system. 

If,  then,  a  single  cell  within  the  body  were  to  re- 
ceive even  the  slightest  injury,  it  would  become  the 
duty  of  this  system  at  once  to  recognize  such  injury 
and,  by  sending  some  sort  of  stimulus  to  the  corre- 
sponding ganglion  of  the  cord,  start  the  process  of 
repair  either  by  limiting,  or,  as  is  more  likely  to  be 
the  case,  to  increase  the  local  blood  supply  to  this 
part. 

Each  organ  within  the  body  has  located  some- 
where along  the  spinal  column  one  or  more  of  these 
sympathetic  ganglia  which  neither  rest  nor  sleep, 
but  continualy,  like  faithful  sentinels,  attend  to  the 
least  beck  and  call  of  the  particular  region  or  organ 
with  which  they  are  connected.  Let  us  suppose  for 
a  moment  that  something  has  gone  wrong  with  the 
stomach ;  then  the  ganglia  located  at  the  third, 
fourth,  fifth,  sixth,  and  seventh  dorsal  vertebras 
would  at  once  be  made  aware  of  such  an  injury  and 
within  these  ganglia  all  would  be  excitement ;  much 
as  though  some  fire  station  should  receive  a  hurry 
call  or  to  hold  itself  in  readiness  to  give  assistance 
at  the  next  tap  of  the  bell.  Let  us  carry  our  imag- 
inary excitement  a  little  further  by  assuming  that 
the  call  bell  has  struck,  again  and  again,  yet  with  all 
the  available  force  working,  the  apparatus  can  not 
be  moved  an  inch ;  the  call  bell  keeps  on  ringing ; 
the  men,  frantic,  at  their  work,  now  gradually  cease 
and  drop  from  sheer  exhaustion ;  no  help  has  been 
sent  and  the  destruction  by  fire  goes  on.  So  in  our 
sympathetic  ganglia ;  if  the  injury  is  great  enough 
or  repeated  sufficiently  often,  these  ganglia,  after  a 
valiant  effort,  are  obliged  to  refuse,  in  order  to  save 
themselves  from  utter  destruction.  Such  stations 
along  the  spine  are  known  as  sympathetic  spinal 
centres.  Many  of  these  centres  are  well  known,  as 
the  centre  for  respiration,  the  centre  for  cardiac  ac- 
tivity, the  centre  for  the  liver,  large  and  small  intes- 
tines, the  centre  for  parturition,  micturition  and 
defecation. 

During  the  last  few  years,  laboratory  and  clinical 
data  have  enabled  us  to  locate  more  or  less  definitely 
nearly  all  the  various  centres  along  the  spine.  In 
the  first  part  of  this  paper  we  saw  that  this  sympa- 
thetic nervous  system  sent  its  branches  wherever 
blood  flows ;  it  so  happens  that  a  branch  of  these 
ganglia  controls  the  blood  supply  to  the  skin  imme- 
diately overlying  the  region  of  the  particular  gang- 
lion in  question.  That  is  to  say,  if  we  are  dealing 
with  a  lesion  of  the  stomach,  for  instance,  the  py- 
loric end  of  the  stomach,  then  the  area  over  the 


October  23,  1920.] 


GEYSER:  DIAGNOSIS  OF    CHROXIC  COXDITIOXS. 


627 


fourth  and  fifth  dorsal  vertebrie  would  be  supplied 
by  a  branch  of  the  sympathetic  from  the  ganglion, 
because  the  ganglion  located  here  controls  the  py- 
loric end  of  the  stomach.  Would  it  seem  very  far- 
fetched if,  in  carcinoma  of  the  pyloric  end,  or  any 
other  chronic  lesion  at  this  region,  we  should  also 
find  some  small  involvement  of  the  region  surround- 
ing the  centre  along  the  spine?  We  know  that  this 
does  happen.  I  can  do  no  better  than  refer  to  any 
one  of  the  modern  textbooks  on  diagnosis,  where 
complete  charts  will  be  found  giving  locations  of 
painful  areas  along  the  spine  associated  with  various 
internal  disorders. 

In  Its  distribution  along  the  spine,  the  entire  sym- 
pathetic system  may  be  divided  into  three  main  divi- 
sions, viz.,  the  cervical  brain,  extending  from  the 
atlas  to  the  fifth  cervical  vertebra ;  the  abdominal 
brain,  extending  from  the  first  dorsal  to  the  second 
lumbar ;  the  pelvic  brain,  extending  from  the  ninth 
dorsal  to  the  fifth  lumbar.  While  these  divisions 
are  only  arbitrary,  they  nevertheless  serve  as  a  guide 
to  the  distribution  of  the  main  plexi  and  the  par- 
ticular area  they  control.  In  order  to  appreciate 
more  thoroughly  the  diagnosis  of  chronic  ailments, 
it  will  be  necessary  to  keep  in  mind  the  fact  that  we 
may,  and  usually  do,  have  symptoms  in  some  organ, 
yet  that  organ  is  perfectly  healthy  and  so  requires 
no  therapeutics ;  it  is  simply  a  reflex  symptom.  A 
gravid  uterus  may  cause  uncontrollable  emesis ;  the 
gastric  organ  is  not  at  fault,  yet  the  vomiting  is  the 
only  symptom  of  which  the  patient  complains.  In- 
testinal parasites  may  cause  convulsions,  yet  no 
physical  signs  of  the  worms  may  be  present ;  in  fact, 
nothing  seems  to  point  to  the  intestines  at  all  as  the 
possible  site  of  the  trouble.  Ocular  defects  have 
been  known  to  be  the  only  cause  for  epilepsy,  yet 
have  never  been  suspected.  Lumbago,  a  frequent 
condition  during  stone  in  the  kidney  or  bladder; 
yet  there  may  be  nothing  wrong  with  the  lumbar 
region  itself.  Headache,  due  to  some  gastric  dis- 
turbance, hemorrhoids  and  constipation  furnish  re- 
flex symptoms  too  varied  and  too  numerous  to  men- 
tion. This  array  ser\es  once  more  to  impress  the 
necessity  of  locating  and  treating  the  cause  and  not 
the  apparent  symptoms. 

HOW   TO  LOCATE   THE  CAUSE. 

We  thoroughly  appreciate  the  fact  that  every 
organ  in  the  body  is  controlled  by  the  sympathetic 
nervous  system,  and  that  this  system  has  located 
near  the  spinal  vertebrae  certain  ganglia ;  that  these 
ganglia  act  as  substations  or  centres  from  which 
impulses  are  sent  out.  We  also  appreciate  the  fact 
that  the  overlying  skin  area  surrounding  these  cen- 
tres shares  in  the  immediate  condition  of  the  centres 
themselves.  If,  then,  any  one  organ  in  the  body  is 
abnormal,  the  corresponding  centre  must  also  be 
abnormal.  Now  it  is  simpler  to  find  the  abnormal 
spinal  centre  per  sc  than  to  find  the  abnormal  organ 
per  se.  Knowing  the  centre  we  can  easily  locate  the 
organ  supplied  by  that  centre  and  so  find  the  under- 
lying cause  for  the  particular  ailment. 

APPARATUS  NECESSARY. 

Procure  a  high  tension  faradic  coil  with  not  less 
than  five  thousand  feet  in  the  secondary  winding ; 
personally,  I  never  use  less  than  seven  thousand  feet. 


and  lately  I  had  built  for  me  a  coil  with  eight  thou- 
sand feet  of  especially  fine  wire,  and  two  interrupt- 
ers in  the  primary.  '\\'hy  do  I  use  such  a  length  of 
fine  wire,  and  why  two,  instead  of  the  usual  one 
interrupter,  in  the  primary?  The  greater  the  num- 
ber of  secondary  turns  surrounding  the  primary  of 
a  faradic  coil,  the  oftener  are  the  fines  of  force  cut 
and,  therefore,  the  greater  the  tension,  or  the  pene- 
trative power,  of  the  secondary  current.  The  fine 
wire  is  used  instead  of  tlie  coarse  so  as  to  make  the 
distance  between  the  centre  of  the  coil  and  the  peri- 
pher}',  or  the  last  layer  of  winding,  as  short  as  pos- 
sible. The  more  rapidly  the  current  is  interrupted 
the  less  the  sensation  to  the  sensory  nerves,  and  so 
this  kind  of  current  may  be  used  to  its  fullest  extent 
without  practically  any  sensation  or  muscular  con- 
traction to  the  patient.  For  these  reasons  the  error 
should  not  be  made  of  using  a  short  coil,  for  it  can- 
not produce  the  desired  penetrative  power  nor  the 
necessary  interruptions,  but  instead  it  may  cause 
severe  muscular  contractions  of  a  decidedly  painful 
quality. 

A  muscle  will  respond  to  individual  stimuli  up  to 
about  thirty  a  second.  As  musclar  contractions  and 
relaxations  require  time  for  their  performance, 
wlien  the  rate  of  interruption  is  higher  than  thirty 
a  second,  there  is  not  enough  time  for  complete 
relaxation  and  the  muscle  assumes  a  condition  of 
tetanus.  This  tetanic  condition  becomes  more  and 
more  manifest  as  the  oscillations  increase  in  fre- 
quency, until  they  reach  about  three  thousand  a  sec- 
ond, and  is  stationary  or  at  its  maximum  up  to 
five  thousand  a  second.  If  the  rate  of  vibrations  is 
still  further  increased,  the  muscle  gradually  returns 
to  a  flaccid  condition  because  it  can  no  longer  re- 
spond ;  it  no  longer  appreciates  the  stimulus ;  conse- 
quently, there  is  no  muscular  reaction. 

TECHNIC. 

The  patient  is  placed  in  the  horizontal  posture 
upon  the  examination  chair  or  couch ;  the  spine  is 
uppermost  and  bared.  A  large  felt  electrode,  not 
less  than  six  by  eight  inches  square,  properly  moist- 
ened, is  placed  just  above  the  umbilicus  so  as  to 
cover  the  abdominal  brain  or  solar  plexus.  This 
pad  is  attached  to  the  positive  end  of  the  coil,  while 
the  negative  end  is  attached  to  an  ordinary  sponge 
hand  electrode,  not  over  two  inches  square.  This 
examining  electrode  should  be  fitted  with  an  inter- 
rupting device. 

The  current  is  now  turned  on  from  the  full  length 
of  the  winding  to  about  one  half  of  its  possible 
strength  and  the  sponge  brought  in  contact  with 
the  cervical  region  of  the  patient.  The  interrupting 
device  is  released  and  the  current  flows.  The  patient 
is  now  consulted  as  to  the  feeling  of  the  current, 
which  must  be  in  no  wise  disagreeable.  If  every- 
thing is  working  satisfactorily,  the  electrode  is  gently 
moved  up  and  down  the  entire  length  of  the  spine 
six  to  eight  times,  with  moderate  pressure  only.  The 
patient  should  now  tell  the  examiner  if  the  current  is 
felt  more  in  one  spot  than  in  another.  If  it  is  not 
felt  anywhere  in  particular  or  everywhere  alike,  in- 
crease the  current  and  proceed  as  before.  If  the 
patient  shows  by  wincing  that  there  are  some  tender 
spots,  mark  these  spots  with  an  indelible  pencil. 


628  \~~     'X       McEVOY:  HEREDITY. 


The  current  may  now  be  stopped  and,  to  our  sur- 
prise, just  where  the  patient  complained  of  feeling 
the  current,  there  appeared  bright  red  areas  from 
the  size  of  a  twenty-five  cent  piece  to  the  size  of  the 
palm  of  the  hand. 

These  spots  stand  out  in  bold  relief  upon  an  other- 
wise white  background.  This  phenomenon  must 
liave  a  cause  and  we  must  account  for  its  occur- 
rence. Immediately  underneath  this  red  area  are 
located  spinal  centres  which,  perhaps,  have  been  for 
a  long  time  laboring  under  great  stress  from  the 
impulses  sent  there  from  some  abnormal  organ. 
Now,  when  this  hypersensitive  area  is  irritated  with 
the  proper  kind  of  current,  it  will  respond  by  an 
increase  in  the  local  blood  supply  long  before  the 
rest  of  the  skin  along  the  spine  is  even  aware  of  the 
presence  of  the  irritant.  By  looking  at  our  chart 
we  find  which  particular  part  of  the  body  or  which 
organ  is  associated  with  the  responsive  centre,  and 
so  locate  the  abnormal  or  diseased  organ  which  is 
responsible  for  the  hypersensitiveness  of  the  sym- 
pathetic area  just  tested. 

Once  having  located  the  organ  or  region  it  is  not 
very  difficult  by  a  process  of  exclusion  to  arrive  at 
the  correct  diagnosis. 

j  ANEMIC  AREAS. 

Besides  the  red  spots  just  mentioned,  every  once 
in  a  while  it  happens  that  a  certain  sharply  circum- 
scribed area  will  suddenly  become  blanched.  Such 
areas  are  of  the  same  general  contour  as  the  red 
spots.  There  is  no  doubt  that,  in  my  earlier  tests, 
many  of  these  anemic  spots  escaped  my  observa- 
tion, yet  when  once  seen,  thereafter,  when  one  is 
on  the  lookout  for  them,  they  appear  almost  as  plain 
as  the  hyperemic  areas.  At  this  writing  I  am  not 
able  to  give  a  very  satisfactory  explanation  as  to 
their  true  significance. 

Since  the  red  spots  apparently  reflect  a  condition 
of  hyperexcitability  in  the  ganglion  from  some  irri- 
tation from  a  distant  organ,  is  it  not  also  possible 
that  these  anemic  spots  portray  the  true  condition 
when  the  opposite  state  exists  ?  Let  us  suppose  that 
an  organ  like  the  kidney  is  in  an  anemic  state,  the 
small  fibrous  contracted  kidney;  then,  if  the  gang- 
lion has  long  since  given  up  the  attempt  to  produce 
any  change  or  repair,  the  ganglion  itself  would  be 
in  a  more  or  less  anemic  state ;  it  would  then  reflect 
its  own  condition  through  the  blood  supply  in  the 
overlying  skin  area,  hence  the  anemic  or  blanched 
spots.  It  is,  however,  purely  speculative  on  my 
part  at  this  time  to  venture  these  suggestions. 

Just  a  word  about  such  diseases  as  hysteria  and 
neurasthenia.  It  seems  as  though  two  such  diseases 
ought  to  be  dififerentiated  easily,  but  as  a  matter  of 
fact  they  are  not,  especially  when  the  main  symp- 
toms of  either  are  more  or  less  present  or  absent  in 
the  same  individual.  How  will  a  spinal  diagnosis 
help  us,  then  ?  Simple  enough,  if  one  stops  to  think 
before  proceeding  with  the  mechanical  part  of  the 
work.  Neurasthenia  is,  as  the  name  implies,  an 
asthenic  condition  of  the  nervous  system  due  to 
debility  or  weakness  of  the  nerve  centres,  not  in 
any  one  particular  spot,  but  a  general  exhaustion. 
When  the  sympathetic  nervous  system  has  for  a 
long  time  taken  notice  of  such  a  condition,  it  is  ready 
to  respond  to  almost  any  kind  of  stimulation  or  irri- 


[New  York 
Medical  Journal. 

tation,  and  thus,  in  neurasthenia,  the  entire  length 
of  the  spine  will  present  one  long  red  streak.  In 
this  instance  the  neurasthenic  patient  and  his  spine 
are  in  absolute  harmony.  Such  patients  respond 
to  every  new  kind  of  a  therapeutic  procedure  for  a 
time;  they  are  the  ones  who  constantly  supply  the 
sinews  of  war  to  the  ever  new,  and  more  or  less  fan- 
tastic, therapeutic  measures  brought  to  their  atten- 
tion. 

If  the  examination  is  made  with  extreme  caution 
we  will  frequently  be  able  to  locate  the  underlying 
causes  by  watching  the  manner  or  order  in  which 
the.  various  portions  of  the  spine  turn  red.  In  every- 
case  of  neurasthenia  there  is  an  underlying  cause; 
it  is  not  always  easy  to  detect  it,  but  it  is  there. 

In  hysteria  we  have  the  opposite  condition;  a 
more  or  less  perverted  state  of  the  mind  due  in 
most  instances  to  some  slight  underlying  physical 
cause.  When  a  spinal  examination  is  made,  hardly 
a  single  spot  or  reaction  is  seen,  even  after  pro- 
longed irritation,  because  the  psychical  element  pre- 
dominates over  the  physical.  Neither  does  such  a 
patient  complain  of  the  strength  of  the  current;  in 
fact,  as  a  rule,  the  stronger  the  current  the  better 
he  seems  to  like  it.  But  even  here,  if  a  reaction 
does  appear  it  is  very  insignificant,  out  of  all  pro- 
portion to  the  gravity  of  the  symptoms  as  complained 
of  by  the  patient.  Nevertheless,  we  again  are  fre- 
quently led  to  the  source  of  this  disease. 

I  do  not  wish  to  convey  the  impression  that  this 
method  of  diagnosing  disease  is  in  any  \yay  a  sub- 
stitute for  other  methods ;  on  the  contrary,  in  locat- 
ing the  organ  at  fault  all  the  other  methods  must 
be  brought  to  bear,  until,  by  a  process  of  elimination, 
the  final  and  true  pathological  status  becomes 
known.  Perfect  and  valuable  as  this  system  of  re- 
flex diagnosis  may  be,  it  merely  locates  the  seat  of 
the  trouble,  leaving  us  to  find  out  the  rest;  it  does 
not  tell  us  what  the  trouble  is. 

301  West  Ninety-first  Street. 


HEREDITY. 

By  L.  Donald  McEvoy,  M.  D., 
New  York. 
THE  NEURAL  CONTROL. 

It  has  been  indicated  how  the  fixed  principles  of 
natural  law  necessitate  the  perpetuation  of  a  cell 
type  indefinitely,  irrespective  of  the  effects  of  en- 
vironment or  natural  selection :  how  the  prolifer- 
ation of  a  cell  into  a  mass  (or  zone)  carries  within 
the  zone  evidences  of  a  limiting  power  analogous 
to  that  giving  form  and  shape  to  a  crystal :  how 
groups  of  heterogeneous  proliferating  cells  held  to- 
gether by  chemical  affinity,  will  upon  proliferation 
form  bodies,  and  how  the  necessity  of  coordina- 
tion and  function  between  the  zones  of  a  body,  re- 
quire the  establishment  of  a  mechanism  of  balance 
and  what  was  termed  a  neural  control. 

The  combination  of  elements  forming  a  cell  whose 
functions  are  limited  to  intake,  output,  and  prolifer- 
ation, would  obviously  require  little  control  other 
than  that  furnished  by  the  chemical  valencies  of  its 
elements.  When,  however,  a  group  of  heterogeneous 


October  23,  1920.] 


AUEVOV:  HEREDITY. 


629 


cells,  each  bearing  the  potential  of  a  zone,  prolifer- 
ates to  form  a  body,  then  the  complexity  of  a  body 
is  in  direct  ratio  with  its  number  of  zones.  Its 
neural  control  will  be  correspondingly  complex,  ap- 
proaching infinity  in  the  number  of  its  possible 
variations.  The  addition  of  special  senses,  mechan- 
isms to  accommodate  environment,  and  its  motility 
— one  and  all  add  their  quota  to  the  bewildering 
labyrinth  of  neural  activities  as  impalpable,  intan- 
gible and  undefinable  as  electricity,  yet  obviously 
as  quantitively  and  qualitively  dependent  upon  chem- 
ical reactions. 

THE   INSTINCT  OF  POSSESSION. 

The  zone  is  the  unit  of  structure.  It  as  a  unit 
develops,  matures  and  reproduces  its  kind.  It  may 
mature  earlier  or  later,  may  be  weaker  or  stronger, 
yet  as  one  of  a  communal  group  it  is  dependent  upon 
the  action  of  the  neural  control.  A  zone  therefore 
has  no  method  of  escaping  the  responsibilities  of  its 
position.  Its  desires  must  be  transmitted  to  the 
neural  control,  compliance  with  which  would  mean 
the  activation  of  all  the  mechanisms  of  the  body. 
Thus  a  deficit  of  chemical  elements  transmitted  by 
a  zone  would  produce  hunger  in  the  neural  con- 
trol. To  appease  it  the  huge  complex  of  the  body 
mechanism  must  be  set  in  motion.  To  satisfy  the 
zone  the  muscles  of  volition  move  the  legs,  the 
arms,  the  jaws.  The  mechanism  of  digestion  pre- 
pares to  disintegrate  the  food  into  the  elements 
suitable  for  all  its  zones,  and  the  distributing 
channels  dispose  of  it  impartially — to  the  zone  com- 
plaining— but  also  to  the  others.  If  the  environ- 
ment is  unfavorable  and  the  food  difficult  to  se- 
cure, the  action  becomes  more  complex.  The  special 
senses  are  called  upon.  They  register  impressions 
which  are  referred  to  memory  cells.  If  memory 
fails  to  recall  experience,  a  process  of  reasoning 
must  ensue,  and  the  experiment  of  edibility  tried, 
controlled  in  a  measure  by  the  chemical  repulsions 
indicated  by  odor  and  taste.  If  an  object  known  to 
be  edible  is  in  possession  of  another,  offensive 
measures  may  be  tried,  or,  if  this  fails,  methods  of 
deception  used. 

In  either  case,  the  origin  of  a  habit  can  be  ob- 
served, forming  within  the  neural  control  of  con- 
sidering the  desirability  of  objects — a  sense  of 
ownership  regarding  them.  It  should  be  clear  that 
an  environment  whose  aspect  was  harsh  and  for- 
bidding would  more  readily  produce  such  an  effect 
than  one  offering  a  profusion  of  edible  substances. 

It  is  of  importance  that  the  relation  between  the 
chemical  wants  of  the  zones  and  the  resulting  effect 
upon  the  neural  control  be  clearly  understood,  as, 
though  applicable  to  all  forms  of  life,  it  will  be  es- 
pecially significant  when  the  gestational  phenomena 
of  woman  is  considered.  The  sense  of  ownership 
is  the  natural  corollary  of  the  struggle  to  live,  fol- 
lowing as  it  does  the  ordinary  process  of  growth  en- 
tailing the  constant  supply  of  elements.  It  is,  there- 
fore, a  primal  impulse  or  instinct,  and  for  want  of  a 
better  designation  it  can  be  termed  "The  instinct  of 
possession." 

When  the  quantitive  nature  of  this  instinct  is 
shown  to  follow  the  influence  of  environment,  its 
great  potential  in  the  economic  life  of  man  and  con- 


sequent bearing  on  the  subject  of  heredity  will  be 
apparent.  It  is  undeniable  that  the  constant  use  of 
offensive  mechanisms  to  obtain  food  might  develop 
a  ferocity  of  great  and  unreasoning  power,  might 
even  produce  an  unbalance  in  the  neural  control 
changing  an  appetite  omnivorous  in  nature,  into  one 
purely  carnivorous,  but  the  ferocity  which  resented 
the  presence  of  another,  to  say  nothing  of  question- 
ing its  claims,  would  produce  nothing  more  than  a 
consciousness  of  self — an  ego — with  but  rudimen- 
tary impulses  of  possession. 

If,  however,  an  ovum  is  fecundated  and  its  zones 
proliferate  within  the  uterus  of  a  woman,  it  is  ob- 
vious that  its  growth  will  depend  upon  the  mechan- 
isms of  her  body.  Moreover,  every  zone  in  her 
body  being  a  chemical  analogue  or  replica  of  those 
in  process  of  proliferation  within  her  uterus,  will 
have  added  to  its  normal  demands  for  food  the  re- 
quirements of  the  fetus.  The  result  will  be  that 
every  energy  of  her  neural  control  is  constantly  di- 
rected in  its  dual  capacity  of  sustaining  two  or  more 
groups  of  zones.  To  this  responsibility  for  the 
proliferating  zones  is  added  the  necessity  of  secur- 
ing protection  for  them.  Thus  the  female  becomes 
peculiarly  susceptible  to  environment  and  anything 
remotely  suggesting  protection  received  through  her 
special  senses  will  exert  enormous  influence. 

The  driving  impulses  of  hunger  transmitted  from 
her  zones  and  of  the  body  of  the  fetus  will,  after  the 
delivery  of  her  progeny,  culminate  in  the  de- 
velopment of  the  great  primal  instinct  of  possession, 
modified  by  the  attending  protective  impulse,  pro- 
ducing that  most  wonderful  of  emotions — the 
mother  love.  In  the  transmission  of  this  instinct, 
the  factors  of  its  production  are  active,  carrying  its 
potential  from  generation  to  generation  through  the 
zonal  nucleii.  Thus  habits  will  be  formed,  as  each 
body,  depending  as  the  case  may  be  upon  one  or 
more  of  its  special  senses,  will  perpetuate  the  cus- 
tom of  selecting  certain  foods,  raising  its  progeny 
or  adopting  a  mode  of  life,  thereby  increasing  the 
scope  of  judgment  of  the  neural  control. 

It  will  be  observed  that  the  possessive  instinct 
differs  in  its  manifestation.  In  the  female  it  is  pro- 
tective and  selfsacrificing,  while  in  the  male  it  is 
essentially  selfish.  This  selfishness  produces  end 
results  of  remarkable  significance.  Thus  a  perfectly 
coordinating  body,  having  by  its  ruthless  power  se- 
cured the  food  or  necessities  of  others  in  a  group, 
becomes  a  menace,  driving  them  to  the  use  of  cun- 
ning. Complex  judgments  have  to  be  formed  re- 
sulting in  group  action  to  enforce  the  right  of  the 
individual.  Here  then  would  be  established  a 
precedent,  the  glimmering  of  the  recognition  of 
the  law  of  ownership  as  applied  to  the  entire 
group. 

Custom  will  establish  the  precedent  by  which  the 
group  profited,  which  in  turn  will  react  upon  the 
neural  control  of  the  strongest  in  an  effort  to  estab- 
lish his  precedence.  In  all  the  complex,  the  neural 
control  is  activated  and  driven  by  the  same  impulse 
unmodified,  brutal  and  ruthless.  It  is  the  personi- 
fication of  the  law  of  survival  whether  exemplified 
by  strength  or  cunning,  in  the  group  or  in  the  indi- 
vidual— the  possessive  instinct  of  the  male. 


630 


McEVOY:  HEREDITY. 


[New  York 
Medical  Journal. 


THE  INSTIXCT  OF  SEX. 

\\'hen  a  zone  matures  it  extrudes  nucleii,  which 
are. carried  to  the  ovary  or  testicle,  there  to  await 
the  action  of  the  body.  One  zone  may  mature  be- 
fore another.  In  this  event  the  zone  may  seek  to 
readjust  the  relative  importance  of  its  position  in 
its  communal  group  and  as  a  consequence  cause  an 
unbalance  in  the  neural  control.  Thus  vague  and 
unformed  sexual  manifestations  often  appear  be- 
fore puberty,  due  to  the  maturity  of  one  or  more 
zones,  the  degree  being  in  direct  ratio  to  the  num- 
ber of  zones  maturing  and  the  unbalance  differing 
as  the  control  is  more  or  less  influenced  by  their 
chemical  activation.  When  the  body  matures  (all 
the  zones)  the  tremendous  power  exerted  by  the 
combined  forces  demanding  the  extrusion  of  their 
nucleii,  may  even  counterbalance  the  influence  of 
the  instinct  of  possession,  depriving  the  neural  con- 
trol of  its  power  to  reason  and  producing  as  a  con- 
sequence varying  degrees  of  incoordination. 

However,  the  result  of  one  zone  maturing  or  the 
whole  group  is  alwaj'S  conducive  to  unbalance  of  a 
greater  or  less  degree,  but  fortunately,  as  in  the  ad- 
justment of  the  special  senses  to  coordination,  the 
regularity  of  zonal  impulses  produced  habits,  so  in 
the  adjustment  of  sexual  elements,  the  habit  of 
functioning  at  regular  intervals  is  caused  by  quan- 
titive  changes.  The  extrusion  of  nucleii  by  a  zone 
depending  as  it  does  upon  the  zone's  virility,  and 
the  latter  in  turn  depending  upon  the  amount  of 
food  furnished,  would  inhibit  excessive  prolifera- 
tion under  normal  conditions. 

(As  an  interpellation  and  with  apologies  it  is 
thought  advisable  to  mention  the  possible  role 
played  by  the  zonal  nucleii  in  the  production  of 
malignant  growths.  The  fact  that  Cohnheim  made 
a  suggestion  connecting  embiyonic  elements  >was 
the  result  of  the  observation  of  their  behavior. 
The  fact  that  such  growths  are  influenced  by  the 
same  destructive  agency  inimical  to  ovii  and  sper- 
matozoon as  to  cancer,  is  striking,  especially  so 
when  it  is  recalled  that  no  known  agenc)'  capable 
of  destroying  the  fecundated  ovum  in  utero  with- 
out injuring  the  mother,  exists.  It  can  be  expelled 
but  not  destroyed — except  by  radium.) 

Resuming  the  consideration  of  the  impulses  es- 
sential to  the  perpetuation  of  life  forms,  we  find 
that  in  the  manner  detailed  is  thus  thrust  upon  the 
body,  the  second  great  quantitive  instinct  as  a  factor 
in  the  phenomena  of  the  life  of  a  mature  body — 
the  instinct  of  sex. 

Like  the  instinct  of  possession  it  is  quantitive, 
varying  in  direct  ratio  with  the  activity  of  zonal  re- 
production. It  is  unlike,  however,  in  the  period  of 
its  activity.  The  instinct  of  possession  persists  in 
varying  degrees  throughout  the  life  of  the  body, 
while  the  instinct  of  sex,  as  the  zones  one  by  one 
cease  to  proliferate,  become  inefTective  and  nuga- 
tory. Thus  a  period  of  greater  or  lesser  length 
may  transpire  between  the  end  of  sexual  activity 
and  the  dissolution  of  the  body,  in  which  the  neural 
control  ceases  to  be  influenced  by  the  impulse  of 
sex.  Here,  then,  is  a  period  of  varying  length  of 
time  wherein  the  neural  control  retaining  memory, 
capable  of  observing  and  registering  impressions, 
is  not  under  the  driving  zonal  impulse.    The  calls 


for  food  are  perfunctory,  the  zones  are  quiescent, 
the  neural  control  is  left  to  dream  on  its  memory 
pictures. 

W  e  have,  then,  two  governing  factors,  the  one 
resulting  from  the  chemical  needs  of  the  body  struc- 
ture, the  other  from  the  requirements  of  the  law 
of  proliferation,  the  one  arising  from  deficit  and 
the  other  from  a  surplus.  And  yet  a  third  appears,  a 
factor  which  intrudes  itself  with  intangible  persist- 
ence and  unknown  potential.  It  is  the  neural  con- 
trol itself  with  the  suggestive  power  of  its  dreams 
formed  when  bereft  of  its  impulses,  an  ego  with- 
out responsibility,  capable  of  forming  thought. 

SPECIAL  SEXSES. 

Reference  has  been  made  to  the  special  senses 
acting  as  aids  to  the  neural  control  and  the  mech- 
anisms of  the  body.  The  recognition  of  but  five 
may  be  due  to  our  exceedingly  limited  powers  of 
observation,  or  to  the  fact  that  the  present  environ- 
ment of  man  has  not  called  into  use  the  full  po- 
tential of  his  structure.  We  know  of  curious 
phenomena  regarding  thought  transference  in  what 
has  been  termed  telepathy,  of  strange  gifts  re- 
garding the  multiplication  of  numbers,  of  complex 
vague  phenomena  relating  to  unknown  conditions 
and  suggesting  the  bewildering  possibility  of  pro- 
jecting without  the  body,  an  unknown  entity,  but 
whether  this,  if  possible,  would  be  a  special  sense, 
an  aid  to  the  control,  or  the  neural  control  itself  is 
a  question.  Fantastic  as  the  notion  may  be,  it  must 
be  met  with  an  open  mind.  It  is  probable  that  as 
the  neural  control  accommodates  itself  to  new 
environment  it  seeks  to  make  use  of  a  poten- 
tial of  which  nothing  is  known,  and  that  such  phe- 
nomena are  nothing  more  than  manifestations  of 
a  special  sense,  as  yet  unde\-eloped  because  of  lack 
of  use. 

The  donated  elements  forming  the  neural  control 
are  received  from  the  zones,  leaving  them  connect- 
ing filaments  to  transmit  their  desires.  Individu- 
ally, the  zones  have  no  use  for  special  senses  other 
than  the  tactile,  and  in  this  the  economy  of  Nature 
may  limit  an  allotment,  or  distribute  it  over  many 
zones  through  the  medium  of  their  covering.  If 
the  connecting  filament  is  broken,  the  zone  is  cut 
oS  from  its  neural  control.  It  wastes  away,  not 
being  able  to  transmit  its  wants,  and  it  is  doubtful 
that  it  proliferates,  as  a  starving  body  ceases  to 
proliferate,  becoming  sterile  if  the  degree  of  starva- 
tion is  extreme.  If  the  connecting  filaments  have 
been  incompletely  severed,  the  attention  of  the  con- 
trol can  be  called  to  the  trouble  and  the  body 
mechanisms  of  repair  activated. 

The  ability  of  a  zone  to  transmit  its  desires 
gives  it  protection,  as  it  then  comes  under  the  super- 
vision of  the  control.  This  may  explain  the  so- 
called  faith  or  miraculous  cures  wherein  the  con- 
centration of  the  neural  control  has  been  centred 
upon  one  or  more  zones,  with  the  result  that  the 
complaining  zones  secure  relief,  if  within  the  power 
of  the  body  mechanism  to  give  it. 

Thus  tactile  sensibility  might  be  considered  the 
essential  of  the  group  of  special  senses.  To  what 
degree  of  acuteness  it  might  be  trained  would  be 
difficult  to  determine,  but  that  it  has  a  profound 
connection  with  the  neural  control  should  be  obvi- 


October  23,  1920.] 


McEVOY:  HEREDITY. 


631 


ous.  It  serves  the  body  in  many  capacities  and  it 
would  reasonably  hold  a  place  of  great  importance. 

The  hand  as  the  prinicpal  factor  using  the  tac- 
tile sense  would  therefore  be  worth  observing. 
When  the  palm  of  an  infant  is  touched,  it  closes 
its  fingers.  When  the  palm  of  an  infant  ape  is 
touched  it  does  not  grip  except  perfunctorily.  The 
grip  of  an  imbecile  corresponds  to  that  of  the  ape. 
The  idiot  does  not  close  its  fingers.  Beginning  then 
with  the  idiot  we  can  ascend  the  scale  of  mental 
development  and  it  would  seem  to  correspond  to 
the  reflex  of  the  sensory  nerves  of  the  hand.  When 
therefore  the  palmar  reflex  of  an  infant  at  birth  is 
weak  and  ineffectual,  the  existence  of  an  unbal- 
ance in  its  neural  control  can  be  suspected,  in  the 
same  manner  that  the  reflex  of  Babinski  is  elicited 
in  certain  lesions  of  the  brain. 

Every  zone  in  the  body  has  an  interest  in  the 
ability  of  the  hand  to  function,  its  potential  there- 
fore should  be  correspondingly  great,  and  that 
superstition  and  ignorance  may  have  deduced  great 
numbers  of  foolish  inferences,  should  not  rob  us  of 
the  real  significance  of  its  indices.  The  infinite 
variation  of  the  whorls  and  deltas  observed  in 
finger  prints  must  have  their  significance,  as  well 
as  the  shape,  motility  and  ability  to  coordinate. 

Thus  a  perfect  hand  would  suggest  a  normal 
zonal  alignment  if  coupled  with  normal  sensibility 
and  power  of  coordination ;  the  inference  could 
be  drawn  that  no  unbalance  existed  in  the  control. 
If  variation  from  normal  was  found,  and  the  hand 
could  be  identified  as  ancestral,  the  unbalance,  if 
any,  might  be  traced.  However,  the  tactile  sen- 
sibilities are  rarely  acute.  Many  errors  of  judgment 
follow  their  transmission  to  the  neural  control,  yet 
the  errors  made  are  relatively  few  when  compared 
to  the  number  following  the  transmission  of  visual 
impressions.  The  complexity  of  the  latter  mechan- 
ism involves  so  many  -adjustments  that  this  is  to 
be  expected,  nevertheless,  such  judgments  (faulty 
or  accurate)  as  are  made,  are  more  lasting  than 
those  attributable  to  other  special  senses.  They 
may  be  modified  by  the  discovery  of  the  error,  but 
the  unreliability  of  visual  transmissions  will  have 
impressed  the  neural  control.  A  state  of  indecision 
is  produced.  Judgment  is  held  in  abeyance,  and 
the  inability  or  refusal  to  decide  forms  a  habit, 
thereby  increasing  the  amenability  to  suggestion. 

Thus  a  mass  of  individuals  may  be  swayed  "by 
suggestion  and  accept  the  preformed  judgment 
suggested.  It  is  the  dominating  factor  of  the  group, 
and  may  influence  habits  in  the  matter  of  food  and 
testation  to  such  a  degree  that  an  imbalance  mav 
ensue.  However,  the  same  factors  working  for 
unbalance  could  be  directed  to  constructive  and 
beneficial  ends,  as  the  receptive  potential  is  the  same. 
Plasticity  of  group  consciousness  is  an  essential  to 
the  coordination  of  the  group. 

That  interpretations  of  visual  impressions  may 
be  used  as  suggestions,  and  are  transmitted  as 
received  through  the  auditory  apparatus,  would 
indicate  that  the  auditory,  like  the  sensory,  is 
reliable  in  its  transmissions.  Its  faults  are  more 
prone  to  be  those  of  omission  than  distortion.  It 
must  not  be  inferred  from  this  that  the  auditon,' 
transmissions  have  little  influence  except  as  they 


may  be  used  for  tlie  purpose  of  suggestion.  The 
fact  that  the  position  of  the  tympanum  may  alter 
its  functional  ability  to  transmit,  indicates  that  as 
in  the  visual  mechanism,  the  necessity  of  perfect 
coordination  is  required  before  maximum  results 
are  obtained.  Thus  the  tilting  of  a  lens  may  cause 
an  astigmatism,  or  the  inclination  of  the  tympanum 
to  a  greater  or  less  degree  from  the  vertical,  may 
interfere  with  the  perfect  transmission  of  sound. 
The  result  of  perfect  coordination  is  observed  in 
the  one  by  the  production  of  marvelous  artistic 
creations,  in  the  other  by  equally  wonderful  com- 
binations of  sound  meeting  in  harmony.  The 
olfactorj-  in  man,  like  the  sense  of  taste  is  hardly 
worth  consideration,  as  its  capacity  for  either  trans- 
mission or  reception  is  perfunctory. 

THE  COXTROL.  ' 

Emerging  from  this  jumble  of  complexities  sur- 
rounding- the  neural  control,  we  enter  the  domain 
of  the  control  itself.  So  far  the  reactions  of  trans- 
mitted impulses  have  been  considered,  its  depen- 
dence upon  various  mechanisms  of  special  sense, 
and  its  duty  to  secure  coordination,  have  been 
roughly  outlined.  The  possibility  and  degree  of 
variation,  due  to  the  inefiicient  serA-ice  of  its  aids 
has  been  mentioned,  also  its  amenability  to  sugges- 
tion. There  yet  remains  the  neural  control  when 
deprived  of  its  special  senses  and  its  driving  im- 
pulses. Difficult  indeed  is  the  conception  of  this 
thing  as  an  entity,  imless  we  accept  the  vague  fan- 
cies of  the  ancients  and  call  it  a  soul. 

However,  assuming  the  structure  of  the  body 
to  be  zonal  in  nature,  the  neural  control  would  of 
necessity  have  to  be  formed  from  elements  donated 
by  each  zone,  thereby  supplying  the  essentials  of 
coordination  and  function.    A  study  of  the  neural 
control,  would  however,  eliminate  all  the  factors 
with  which  it  is  surrounded,  even  the  zones  from 
which  it  derived  its  elements.    We  would  then  have 
a  group  of  elements  whose  potential  would  be  in 
direct  ratio  with  their  number  and  ability  to  func- 
tion.   In  this  case  the  consideration  of  an  indi- 
vidual element  might  lead  to  an  estimate  of  the 
potential  of  the  group.    Here  there  intrudes  the 
elusive,  intangible  factor,  attributable  to  the  innate 
inabilit)-  of  the  mind  to  reason  except  from  simple 
analogies.    To  speak  of  energy,  either  electronic  or 
atomic,  or  the  principles  of  chemical  attraction  or 
gravitation,  would  lead  to  nothing.  We  accept  these 
principles  as  axiomatic  in  their  application  without 
understanding.    It  is  useless,  therefore,  to  attempt 
an  analysis  of  what  we  term  nerve  energy,  yet  we 
can  accept  as  a  fact  that  such  energy  depends  upon 
the  presence  of  neural  elements.     Moreover,  the 
quantitive  nature  of  its  energy  must  follow  varia- 
tion in  the  quantitive  amount  of  elements.  In  the 
matter  of  qualitive  factors  we  can  only  surmise. 
Every  neural  element  may  be  protean  in  its  potential, 
.  or  contrarily  may  differ  in  functionable  adaptability. 
The  fact  that  special  senses  are  formed,  suggest 
special  adaptabilit3%  though  no  reason  exists  for  as- 
suming such  an  hypothesis  to  be  correct.   The  optic 
ner\e.  if  supplied  with  the  mechanism  of  conduc- 
tion, may  be  as  well  able  to  transmit  auditory  im- 
pressions, as  the  aural,  or  vice  versa.    The  inability 
of  the  afferent  nerves  to  transmit  efferent  impulses 


632 


CUMSTON:  INTESTINAL    SYMPTOMS  IN  MALARIA. 


[New  York 
Medical  Journal. 


may  be  only  apparent,  or  it  may  be  that  nerves  of 
special  sense  are  formed  from  elements  dififering 
in  potential  from  those  of  the  neural  control.  How- 
ever, the  phenomena  of  life,  as  we  observe  its 
manifestations  would  indicate  that  neural  elements 
had  special  adaptability.  In  either  case  the  pheno- 
mena that  is  of  interest  is  presented  by  a  group  of 
elements  capable  of  forming  judgments,  and  even 
if  a  reasonable  solution  of  this  problem  were  avail- 
able, there  would  yet  remain  an  unknown  potential. 

The  bewildering  possibilities  suggested  by  the 
appearance  of  strange  and  unknown  forms  of  en- 
ergy such  as  are  manifested  in  telepathy,  mind  read- 
ing, and  thought  transference  excites  the  imagina- 
tion. The  existence  of  an  astral  body  and  its  pos- 
sible projection  follows  as  a  natural  inference. 
However,  if  the  neural  control  is  a  complex,  it 
must  receive  the  factors  of  its  complexity  from  its 
elements,  in  a  similar  manner  to  that  in  which  it 
receives  the  quantitive  factors  of  its  elements  from 
its  zones. 

The  quantitive  factors  together  with  the  quali- 
tive  make  up  the  neural  control  and  while  an 
estimate  could  possibly  be  made  as  to  the  former, 
it  would  be  impossible  to  even  approximate  the  lat- 
ter, formed,  as  it  is  assumed  to  be,  by  donations 
of  elements  from  the  body  zones,  the  quantitive 
factor  would  resolve  itself  into  a  question  of  the 
absence  or  presence  of  the  donations.  This  would 
have  significance  wherein  relative  variations  in  size 
could  be  observed. 

We  know  that  teratomata  are  produced  having 
headless  bodies,  and  from  this  fact,  could  infer  that 
zones  can  and  do  proliferate  without  donating 
neural  elements,  but  the  presence  of  a  head  of  its 
size  or  shape  could  not  be  used  as  a  positive  index 
of  the  quantitive  aspect  of  the  neural  control.  It 
must  not  be  assumed  that  the  contents  of  the  cra- 
nium constitute  the  neural  control.  Far  from  it. 
The  control  does  not  proliferate.  It  is  doubtful  that 
it  has  growth,  as  growth  would  entail  the  need  of 
supply  and  waste.  Therefore  from  birth  to  dis- 
solution it  remains  as  first  formed  by  the  group- 
ing of  its  elements.  Exceedingly  minute  as  this 
entity  must  be,  it  should  be  obvious  that  its  posi- 
tion as  control  requires  a  huge  complex  as  an 
aid,  and  it  is  this  complex  that  fills  the  skull. 

It  is,  of  course,  probable  that  a  body  having  do- 
nated the  required  elements  to  form  a  perfect  neural 
control,  might  fail  to  furnish  the  normal  amount  of 
material  to  equip  the  mechanisms  of  special  sense. 
We  would  then  have  a  small  skull  enclosing  a  very 
acute  intelligence,  capable,  no  doubt,  of  making  up 
its  deficiencies  in  special  aids. 

If,  however,  the  control  has  been  formed  with 
a  deficiency  of  elemental  donations,  it  would  be 
improbable  that  such  a  control  would  require  the 
same  number  of  aids  as  a  normal  group.  If  present 
they  would  only  add  to  its  inability,  and  if  absent 
would  present  an  index  of  the  deficit  in  the  size 
of  the  head. 

Therefore  a  small  head  attached  to  a  body  in- 
capable of  coordination,  or  having  obvious  mental 
deficiencies  of  greater  or  less  degree,  would  be  the 
index  of  an  imperfect  neural  control,  one  which 
lacked  in  zonal  donations,  and  which  as  a  conse- 


quence, would  be  unable  to  function  normally,  even 
if  equipped  with  perfect  mechanisms  of  special 
sense. 

As  space  forbids  a  lengthy  consideration  of  the 
subject,  it  can  only  be  remarked  in  closing,  that  the 
neural  control  seems  to  represent  a  plastic  entity 
whose  susceptibility  to  suggestion  is  its  most  aston- 
ishing attribute.  Its  impulses  (instincts),  its  spe- 
cial senses,  its  environment — one  and  all  sway  it 
from  one  extreme  to  another.  It  gives  the  impres- 
sion of  seeking  an  outlet  by  accepting  anything 
ofifered,  then  finding  the  means  or  the  information 
to  be  unavailable  or  untruthful,  it  turns  to  some- 
thing new.  Most  of  its  abnormalities  are  the  re- 
sult of  accepted  suggestions  leading  it  to  the  brink 
of  destruction,  hence  it  doubts  everything  that  is 
new,  or  apparently  new,  yet  blunders  time  after 
time  because  of  its  limited  experience. 

620  West  190th  Street. 


INTESTINAL    SYMPTOMS    IN  MALARIA. 

By  Ch.\rles  Greene  Cumston,  M.  D., 
Geneva,  Switzerland. 

Intestinal  morbid  phenomena  are  to  be  counted 
among  the  reactions  of  malaria,  and  to  these  I  de- 
sire to  call  attention.  Some  arise  during  a  malarial 
paroxysm  and  have  only  an  ephemeral  existence ; 
others  are  quite  independent  of  any  attack  and  repre- 
sent individualized  stubborn  accidents  of  some  dura- 
tion. To  the  chronic  intestinal  accidents  of  palu- 
dism  I  shall  not  refer.  No  matter  how  frequent  or 
serious  they  may  be,  their  origin  is  quite  variable 
and  is  due  either  to  intestinal  or  hepatic  lesions. 
The  clinical  picture  is  more  likely  to  be  that  of  dys- 
peptic states  rather  than  true  enteritis,  although  a 
number  of  observers,  impressed  by  their  diarrheal 
or  mucorrheic  character,  are  inclined  to  classify 
them  among  the  enteritides. 

On  the  other  hand,  the  acute  infections  are  easier 
to  study  and  present  a  considerable  clinical  interest. 
Their  origin  is  more  univocal  and  their  nature  quite 
similar.  The  acute,  temporary  and  occasionally  al- 
most cyclical  character  makes  of  them  a  class  by 
themselves ;  their  early  occurrence  in  malaria  de- 
fines them  distinctly  from  chronic  lesions  or  from 
functional  or  glandular  disturbances  of  long  stand- 
ing which  might  disfigure  their  clinical  aspect.  Fi- 
nally, their  fleeting  character  facilitates  a  comparison 
eminently  useful  from  the  physiological  viewpoint 
between  the  reactions  of  the  paroxysms  and  those 
entirely  dififerent  arising  in  the  premonitory  or  inter- 
calary state.  On  the  other  hand,  as  they  are  simply 
the  stepping  stone  to  chronic  accidents,  they  fore- 
tell the  progressive  development  by  throwing  light 
on  the  true  causes,  and  permit  of  a  better  under- 
standing of  the  biological  processes  which  govern 
them. 

The  intestinal  accidents  of  acute  paludism  consist 
essentially  of  watery  diarrheal  intestinal  discharges. 
They  are  for  the  intestine  what  bilious  vomiting  is 
to  the  stomach  during  a  paroxysm.  They  are  accom- 
panied by  epigastric  pain  and  hepatic  tenderness.  The 
liver  is  increased  in  size.  The  intestinal  reaction  con- 
sists of  frequently  repeated  intestinal  discharges  of  a 


October  2:-.  1920.] 


CUMSTOX:  IXTESTIXAL   SYMPTOMS  IX  MALARIA. 


633 


serous,  bilious  or  mucorrheic  liquid,  which  causes  a 
burning  sensation  in  the  anus.  They  sometimes  last  as 
long  as  the  attack  of  malaria,  but  generally  subside 
on  the  second  or  third  day.  They  cease  with  the 
sudoral  crisis. 

Abrami  and  Foix  divide  these  intestinal  accidents 
into  two  categories,  namely  diarrheic  and  dysen- 
teric, and  maintain  that  the  former  are  more  fleet- 
ing, while  the  latter  are  more  stubborn,  but  in  reality, 
the  first  indic^e  an  almost  physiological  excitation  of 
the  liver,  the  latter  a  true  lesion  of  the  intestine, 
whose  progressive  development  may  end  in 
chronic  colitis  and  cachexia.  In  some  cases  the 
diarrhea  appears  as  much  as  two  hours  before  the 
onset  of  the  malarial  paroxysm,  in  others  only  a 
half  hour  or  fifteen  minutes  before,  announcing 
the  imminence  of  the  attack.  Out  of  a  total  of  seven 
cases  observed  by  Loeper.  of  Paris,  three  times 
the  diarrhea  disappeared  with  the  chill,  three  times 
it  continued  up  to  the  sudoral  phase,  and  in  one 
only  did  it  continue  until  the  following  day.  One  of 
these- patients  later  on  presented  an  atypical  form 
even  after  treatment  with  quinine  and  arsenic,  exclu- 
sively characterized  by  attacks  of  diarrhea  with 
hardly  any  elevation  of  the  temperature,  and  accom- 
/  panied  by  enlargement  of  the  liver. 

These  intestinal  accidents  may,  consequently,  be 
very  early  in  their  occurrence  and,  in  a  way,  are  a 
sort  of  prelude  to  the  paroxysm  of  malaria.  Out  of 
a  total  of  eighty-two  patients,  Loeper  found  it  thus 
in  nine  per  cent,  and  always  with  the  same  char- 
acter. The  diarrhea  is  never  painful,  there  is  no 
intense  colic  reaction  and  palpation  of  the  abdomen 
is  painless.  Alone,  the  enlargement  of  the  liver  is 
constant,  contemporary  with  the  diarrhea  and  occur- 
ring quite  as  early  in  the  process,  indicating  the  re- 
lationship between  the  hepatic  and  intestinal  reac- 
tions. Loeper  never  found  any  glairs  or  blood  in 
the  intestinal  discharge,  and  only  occasionally  a 
slight  mucorrhea.  The  stools  were  invariably  very 
liquid,  somewhat  frothy,  brown,  yellow  or  green 
in  color,  but  always  becoming  green  when 
exposed  to  the  air.  Therefore,  these  are  bilious 
stools,  similar  to  polycholic  stools  accompanying 
certain  hepatic  morbid  processes  or  such  as  occur 
during  certain  thermal  cures,  for  example  Chatel- 
Guyon,  Grande-Grille  or  Vihel.  For  that  matter,  it 
is  not  uncommon  to  observe  a  mild  icterus  and  a  bil- 
ious tint  of  the  urine  on  the  next  day.  Besides,  the 
blood  often  contains  a  rather  high  content  of  urea 
which  may  reach  forty  to  fifty  centigrams  to  the 
litre  of  serum.  The  serum  is  distinctly  yellower 
than  normal,  while  the  cholemia  is  higher  than  ordi- 
nary cholemia,  and  these  data  suffice  to  prove,  as 
the  clinical  examination  predicted,  the  part  played 
by  the  liver  in  the  various  morbid  manifestations. 

Desirous  of  more  precisely  establishing  the  he- 
patic origin  of  certain  forms  of  malarial  diarrhea. 
Loeper  carried  out  a  more  complete  and  close  ex- 
amination of  the  stools  and  hepatic  functions.  The 
examination  first  of  all  dealt  with  the  chemical  com- 
position of  the  stools,  their  tenor  in  bile  and  pig- 
ment. After  this  attention  was  given  to  the  liver  in 
relation  to  its  functions.  Research  for  biliary  pig- 
ment in  the  stools  was  positive,  Schmidt's  technic 
with  a  three  per  cent,  to  five  per  cent,  mercurous 


chloride  solution  caused  the  characteristic  green  hue. 
Cholesterin  was  also  detected  and  occasionally  even 
the  biliary  salts.  Carbohydrate  and  muscular  debris 
were  noted  and  merely  indicate  a  rapid  transit 
through  the  intestine.  There  was  no  albumin  un- 
doubtedly because  no  blood  or  serosity  of  inflam- 
matory origin  was  present  in  the  stools.  On  the 
other  hand,  search  for  amylolytic  ferments,  accord- 
ing to  the  technic  of  -\mbard,  Binet  and  Stodel, 
often  placed  a  large  proportion  of  amylolysis  in  evi- 
dence, a  fact  which  would  tend  to  prove  that  the 
pancreas,  like  the  liver,  is  the  seat  of  an  abnormal 
functional  excitation  and  of  an  exaggerated  secre- 
tion. 

Exploration  of  the  liver  may  be  carried  out  by 
several  methods,  the  one  most  frequently  employed 
being  alimentary  glycosuria  and  the  study  of  the 
nitrogen  coefficient.  In  respect  to  the  disturbances 
so  far  considered  and  whose  principal  character  is 
their  extreme  suddenness  and  fleeting  nature,  it  is 
evident  that  the  test  of  alimentary  glycosuria  can 
only  be  utilized  with  difficulty.  The  same  may  be 
said  of  alimentary  glycemia,  which  Beaudoin  has 
tried  to  substitute  for  glycosuria  in  many  cases.  On 
the  contrary,  the  nitrogen  coefficient  can  be  quickly 
established  by  an  examination  of  the  urine  at  the 
onset  of  the  attack  and  during  the  phase  of  full 
development.  It  unquestionably  gives  interesting 
results,  since  it  permits  one  to  note  from  the  pre- 
monitory phase  a  very  high  content — from  ninety- 
three  to  ninety-six  centigrams,  and  in  the  later 
phase,  especially  the  terminal,  the  rather  low  read- 
ings of  eighty  and  seventy-six,  which  in  the  first 
instance  show  an  excitation  of  the  organ,  in  the  lat- 
ter an  inhibition.  Another  still  more  certain  proof 
of  this  hepatic  excitation  can  be  found  by  the  study 
of  adrenalinic  glycemia.  It  is  a  well  known  fact 
that  an  increase  of  sugar  in  the  blood  is  a  result  of 
an  injection  of  adrenalin.  This  increase,  according  to 
Loeper 's  researches,  is  constant  and  invariably  about 
equal  in  a  healthy  individual,  submitted  to  a  similar 
diet.  As  an  echo,  there  is  glycosuria,  but  glycosuria 
is  less  constant  than  glycemia.  The  rise  of  the  glyce- 
mia is  due  to  exaggeration  of  the  amylolytic  power 
of  the  liver  and  as  both  \'erpy  and  Loeper  have  sur- 
mised, many  data  can  be  obtained  from  its  patho- 
logical variations  relating  to  this  very  important 
function  of  the  gland.  Loeper  employs  the  follow- 
ing technic : 

The  patient  should  be  fasting  and  in  identical 
+ormer  alimentary  condition  (one  litre  of  milk, 
mashed  potatoes  and  macaroni).  An  injection  of 
one  milligram  of  adrenalin  is  given  in  the  thigh  and 
both  before  and  after  the  injection  a  sample  of  blood 
is  taken  and  by  Bertrand's  invariable  procedure,  the 
sugar  is  estimated  in  the  state  of  glucose.  In  nor- 
mal conditions  the  glycemia  increases  very  quickly 
and  the  ascending  curve  returns  to  the  normal 
after  the  lapse  of  about  three  hours.  The  most 
constant  figure  is  that  of  the  first  hour  and  it  is 
for  this  reason  that  Loeper  has  taken  the  sample  of 
blood  at  the  end  of  the  hour.  In  a  normal  subject 
the  increase  of  the  glycemia  attains  from  forty  to 
fifty  centigrams  with  a  most  curious  regularity.  In 
affections  of  the  liver  it  is  quite  variable,  much  lower 
than  forty  centigrams  in  some,  much  over  forty  in 


634 


CUMSTON:  INTESTINAL 


SYMPTOMS  IN  MALARIA. 


[New  York 
Medical  Journal. 


Others,  even  reaching  one  gram  in  some  cases.  Low 
increases  occur  in  atrophic  cirrhosis,  in  serious  mor- 
bid processes  of  the  hver  and  in  exhausted  hepatic 
glands  and  hepatic  insufficiency.  The  high  rates 
occur  in  hvers  stimulated  by  the  violent  initial  re- 
actions of  acute  diseases  and  the  more  durable  ones 
of  hypertrophic  and  hyperplastic  hepatitis. 

In  acute  malarial  paroxysms  these  same  phenom- 
ena of  excitation  and  of  deficit  are  most  manifest. 
At  the  onset  of  the  attack,  at  the  very  time  that 
the  diarrhea  takes  place  and  the  liver  prepares  its 
defensive  action,  the  reaction  increases  and  may  at- 
tain from  seventy-five  centigrams  to  one  gram  eight 
centigrams.  At  the  height  of  the  attack  it  constantly 
diminishes  and  hardly  ever  exceeds  seven  to  ten 
centigrams.  Then  the  sugar  content  progressively 
returns  to  normal.  A  rather  curious  thing  is  that  the 
preceding  glycemia  is  usually  more  intense  at  the 
onset  of  the  attack  and  less  during  the  phase  of 
full  development,  but  the  adrenalin  reaction  is  not 
greatly  disturbed  by  these  initial  variations.  These 
variations  are  often,  but  not  always,  absolutely  pro- 
portional with  those  of  the  Jiitrogen  coefficient  or 
that  of  the  alimentary  glycemia,  because  they 
are  related  to  the  different  functional  processes ;  in 
some  the  ureogenic,  in  others  amylopexic,  in  still 
others  amylolytic. 

It  is  curious  to  observe  with  what  rapidity,  the 
attack  having  ended,  the  hepatic  reactions  return  to 
their  previous  state.  These  change  later  on  as  suc- 
cessive attacks  occur,  following  the  same  plan  and 
order,  then  they  lose  their  importance,  their  regu- 
larity and  distinctiveness.  This  is  because  in  the  ad- 
vanced phase  of  paludism  the  test  is  no  longer  made 
on  new  soil  but  on  one  that  has  been  overturned. 
The  hepatic  gland  gradually  becomes  accustomed  to 
these  multiple  irritations  and  becomes  immune  to 
them.  The  charts  are  no  longer  those  of  frank 
paludism.  The  progressive  changes  of  the  liver  suc- 
ceed these  successive  assaults  so  that  the  various 
tests  do  not  give  their  former  distinct  results. 

The  liver  is  unquestionably,  of  all  the  abdominal 
viscera,  the  one  which  gives  rise  to  the  most  inter- 
esting reactions  during  the  evolution  of  chronic  ma- 
laria, namely,  hypertrophic  and  nodular  hepatitis,  re- 
sulting from  repeated  functional  excitations,  each 
one  of  which  adds  its  quota  and  leaves  its  imprint 
on  the  glandular  parenchyma.  Or  there  may  be  an 
atrophic  hepatitis,  the  hepatic  activity  becomes  ex- 
tinct and  the  secretions  progressively  dry  up.  There- 
fore, to  these  two  orders  of  lesions  correspond  two 
very  different  functional  states  which  are  distinctly 
revealed  by  a  chemical  analysis  of  the  blood  and 
urine.  In  the  first  are  met  the  high  nitrogen  coef- 
ficients, marked  glycemic  reactions  and  high  per- 
centages of  urea;  in  the  second,  a  lowering  of  the 
nitrogen  content,  a  diminution  of  the  glycemia  and 
blood  amylolasis,  and  the  adrenalin  test  increases  the 
glycemia  to  eighty  centigrams  to  one  gram  in  the 
first,  while  in  the  second  it  is  hardly  twenty-five  to 
thirty  centigrams. 

From  these  functional  hepatic  disturbances  a  se- 
ries of  general  and  abdominal  symptoms  result,  one 
of  the  most  frequent  being  diarrhea.  The  diarrhea 
of  chronic  malaria  becomes  progressively  installed,  it 
then  becomes  permanent  and  leads  to  cachexia.  Al- 


though its  origin  may  be  a  superadded  dysentery, 
awakened  and  kept  up  by  the  malaria,  or  even  a 
true  malarial  inflammatory  mucorrheic  enteritis,  in 
the  stools  of  which  some  observers  have  found  red 
blood  cells  containing  the  plasmodium,  it  is  quite  as 
often  due  to  some  morbid  change  in  the  liver.  It 
is  no  longer  an  enteritic  diarrhea  but  a  dyspeptic  one, 
in  which  an  excess  of  bile  or  hepatic  insufficiency 
are  to  be  held  responsible,  and  should  the  enteritic 
process  develop  later,  it  has  none  the  less  been  set 
up  by  the  dyspeptic  state.  Thus  the  variations  in 
the  hepatic  functions  during  an  acute  paroxysm  of 
malaria,  in  their  almost  cyclical  and  rapid  succes- 
sion, sum  up  the  changes  of  these  same  functions 
in  the  evolution  of  the  malarial  liver.  They  are, 
to  a  certain  extent,  the  imprint  that  the  malarial 
process  makes  on  the  entire  existence  of  the  pa- 
tient. In  what  has  been  said  I  have  endeavored  to 
make  clear  the  understanding  of  the  intestinal  acci- 
dents of  paludism  in  general,  and  this  now  brings 
up  the  subject  of  hepatic  dyspepsia. 

Some  of  these  intestinal  reactions  might  well  be 
given  the  name  of  premonitory  diarrheas.  Exact 
from  the  clinical  viewpoint,  iji  the  sense  that  the 
diarrhea  announces  the  near  advent  of  a  paroxysm, 
the  term  premonitory  is  inexact  from  the  standpoint 
of  physiology,  because  the  diarrheic  reaction  is  not, 
in  the  strict  sense,  a  humoral  reaction.  It  is,  in  some 
cases,  the  indicative  reaction,  while  other  symptoms, 
such  as  lassitude,  chilliness  and  discomfort,  pass  by 
unnoticed.  It  marks  the  entrance  upon  the  scene 
of  the  parasite  that  an  examination  of  the  blood 
from  the  liver,  spleen  or  even  of  the  general  circu- 
lation will  reveal.  This  has  been  done  hy  obtaining 
blood  simultaneously  from  the  liver  by  puncture 
and  from  the  pulp  of  the  finger.  In  two  cases  the 
Plasmodium  was  the  falciparum  type,  in  the  third 
case  it  was  the  vivax.  On  the  slides  the  crescent 
shaped  extraglobular  bodies  were  seen  adherent  on 
the  red  cells,  young  schizonts  with  their  annular 
shape  and  fine  nutritive  vesicle  and  even  some  rose 
shaped  ones.  Staining  showed  these  details  dis- 
tinctly. They  were  the  parasites  of  the  tertian,  usu- 
ally simple,  rarely  those  of  pernicious  paroxysms. 
Unquestionably,  the  fact  that  they  were  found  does 
not  necessarily  imply  that  the  diarrhea  would  not 
have  occurred  without  them. 

This  early  appearance  of  the  diarrhea  testifies  to 
an  invasion  of  the  liver  by  the  parasite  and  likewise 
indicates  the  exciting  action  of  the  latter  on  the  he- 
patic gland  and  the  effort  of  the  liver  to  rid  itself 
of  them  by  the  bile.  It  is  quite  natural  that  it  may 
precede  the  initial  chill  since,  on  its  way,  it  is  the 
liver  that  the  parasite  encounters  before  becoming 
scattered  in  the  general  circulation. 

It  is  difficult  to  say  why  in  some  patients  the 
hepatic  reaction  is  more  prone  to  occur  than  in 
others  and  there  is  no  evidence  that  there  is  an 
abnormal  susceptibility  of  the  organ.  It  appears 
probable  that,  although  not  yet  verified,  the  intimate 
mechanism  of  the  excitation  is  the  outcome  of  a 
direct  action  or  the  secretion  of  toxic  substances, 
perhaps  even  the  production  of  new  proteic  bodies, 
as  has  been  advanced  by  Abrami  who  has  attempted 
to  explain  the  production  of  the  paroxysms  by  this 
theory. 


October  23,  1920.] 


LONDON  LETTER. 


635 


LONDON  LETTER. 
{From  our  own  Correspondent.) 

First  Annual  Report  of  the  Ministry  of  Health — St.  An- 
drew's Institute  for  Clinical  Research — Report  of  the 
Interdepartmental  Committee  on  Insurance  Records — 
The  Municipal  Hospital  at  Bradford. 

London,  September  17,  ig20. 
Two  reports  notable  from  the  viewpoint  of  pub- 
lic health  and  preventive  medicine  have  recently 
been  issued,  the  most  important  of  which  is  the 
first  annual  report  of  the  Ministry  of  Health.  This 
document  begins  by  discussing  the  work  done  by 
the  Ministry  in  fighting  tuberculosis.  The  main 
conclusions  of  a  report  of  an  Interdepartmental 
committee  appointed  in  1919  to  investigate  the  mat- 
ter were  that  the  existing  accommodation  in  sana- 
toria and  hospitals  for  the  treatment  of  tuberculosis 
in  the  United  Kingdom  was,  as  a  result  of  the 
financial  and  other  restrictions  of  building  during 
the  war,  most  seriously  inadequate  in  quantity ;  and 
that  in  the  development  of  schemes  for  the  institu- 
tional treatment  of  tuberculosis  it  was  necessary 
not  merely  to  increase  the  available  sanatorium  and 
hospital  accommodation  but  in  addition  to  secure 
the  provision  of  facilities  for  the  occupational  and 
vocational  training  of  sanatorium  patients  and  also 
for  their  permanent  settlement,  a'fter  training,  in 
village  communities  where  they  could  earn  a  liveli- 
hood under  sheltered  conditions.  The  sanatorium 
patient  would  thus  pass  through  three  stages,  first 
of  treatment  in  the  sanatorium,  second  of  training 
under  medical  supervision  in  the  training  colony, 
and  third  of  permanent  employment  or  occupation 
in  the  village  settlement.  The  training  colony, 
though  it  might  be  physically  separate  from  the 
sanatorium,  should  always  form  part  or  be  a  di- 
rect extension  of  the  sanatorium.  The  committee 
also  expressed  the  view  that  the  tentative  standard 
of  one  sanatorium  bed  and  one  hospital  bed  for 
each  5,000  of  the  population,  which  was  suggested 
in  1912  by  the  Departmental  Committee  on  Tuber- 
culosis, had  now  proved  to  be  insufficient. 

It  was  also  recommended  by  the  Interdepart- 
mental Committee,  with  regard  to  sanatoria  for  sol- 
diers, that  the  national  scheme  for  the  treatment  of 
tuberculosis  should  be  supplemented  by  a  scheme 
for  training  and  employment  in  training  colleges 
and  village  settlements,  which  would  in  the  first  in- 
stance be  available  for  tuberculous  ex-service  men. 
The  Treasury  has  approved  the  scheme  and  the 
funds  will  be  supplied.  It  is  pointed  out  that  the 
selection  of  suitable  occupations  in  which  tubercu- 
lous men  should  be  trained  while  under  treatment 
at  sanatoria  has  been  receiving  consideration  for 
some  time  past.  The  difficulties  which  will  arise  in 
the  absorption  of  these  men  into  industries  are  con- 
siderable, and  probably  the  only  method  by  which 
many  of  the  men  will  be  able,  after  training,  to  earn 
a  livelihood  for  any  prolonged  period  without  fre- 
quent relapse  and  ultimate  permanent  breakdown 
is  by  being  placed  in  such  special  conditions  and 
surroundings  as  will  afford  them  shelter  from  the 
full  stress  of  competitive  industry  by  enabling 
them  to  live  in  a  village  settlement  or  an  industrial 
colony  established  on  lines  specially  designed  for 
these  purposes.    It  is  essential  to  remember  in  this 


connection  that  the  working  capacity  of  the  tuber- 
culous person  in  whom  the  disease  has  developed  to 
any  appreciable  extent  is  seriously  impaired,  per- 
haps permanently.  The  Ministry  is  accordingly  in 
communication  with  the  Treasury  on  the  whole 
question  of  village  settlements  and  other  kindred 
arrangements  under  which  the  tuberculous  patient 
would,  after  training,  be  able  to  be  employed  under 
specially  sheltered  and  favorable  conditions. 

A  considerable  part  of  the  report  of  the  Minis- 
try of  Health  is  taken  up  with  a  consideration  and 
discussion  of  the  venereal  problem  and  in  giving 
an  account  of  the  means  taken  by  the  Ministry  for 
preventing  and  treating  the  disease.  During  the 
year  1919  the  total  number  of  patients  dealt  with 
for  venereal  disease  for  the  first  time  amounted  to 
over  98,000:  of  this  total  15,500  had  been  proved 
on  examination  not  to  be  suffering  from  venereal 
disease,  a  figure  which  seems  to  indicate  that  per- 
sons who  are  apprehensive  that  they  may  have  con- 
tracted venereal  disease  are  willing  to  avail 
themselves  of  the  facilities  provided  for  diagnosis 
and  treatment.  The  attendance  at  the  treatment 
centres  during  1919  amounted  to  1,003,000,  as  com- 
pared with  485,000  in  1918.  The  number  of  treat- 
ment centres  open  on  December  31,  1918,  was  134 
as  compared  with  160  on  December  31,  1919,  but 
the  increase  in  the  facilities  available  was  much 
greater  than  is  indicated  by  these  figures  owing  to 
a  considerable  increase  in  the  number  of  clinics 
held  each  week.  The  work  of  the  National  Council 
for  Combating  Venereal  Disease  is  favorably  com- 
mented upon  and  it  was  agreed  that  a  publicity  cam- 
paign should  be  conducted  by  the  agency  of  this 
body.  The  National  Council  submitted  a  program 
of  special  propaganda  and  publicity  work  estimated 
to  cost  £30,000  ($150,000).  The  estimate  was 
carefully  scrutinized  by  the  Ministry,  and  the  sanc- 
tion of  the  Treasury  was  obtained  to  a  grant  of  not 
exceeding  £20,000  '($100,000)  in  respect  of  press 
advertisements,  propaganda  by  cinema  films,  slides, 
and  exhibits,  by  pamphlets,  posters,  and  other  lit- 
erature and  in  respect  of  special  propaganda  in 
backward  areas.  During  the  year  ended  March 
31,  1920,  the  Ministry  paid  grants  in  aid  of  vene- 
real disease  schemes  amounting  to  £224,716  ($1,- 
123.580). 

With  regard  to  maternity  homes  and  hospitals, 
the  report  states .  that  institutional  accommodation 
for  confinements  has  in  the  past  been  provided  in 
general  maternity  hospitals  supported  by  voluntary 
subscriptions  and  in  lying-in  wards  in  infirmaries 
and  workhouses  provided  by  Boards  of  Guardians. 
The  number  of  beds  for  maternity  cases  in  general 
hospitals  is  difficult  to  estimate  approximately,  since 
in  many  instances  no  special  accommodation  is  re- 
served for  such  cases.  They  are  chiefly  for  com- 
plications of  confinement,  but  a  certain  number  of 
normal  cases  are  also  taken  in  hospitals  which  train 
medical  students  and  pupil  midwives.  The  number 
of  maternity  hospitals,  according  to  the  hospital 
return  of  1915  issued  by  the  Local  Government 
Board,  was  eighteen,  with  about  560  beds.  Near- 
ly all  Boards  of  Guardians  have  some  institutional 
provision  for  maternity,  either  in  the  wards  of  the 
workhouse  or  in  a  separate  infirmary.    The  Town 


636  '  LONDON  LETTER. 


Council  of  Bradford  was  the  first  local  authority 
to  establish  a  municipal  maternity  hospital.  This 
was  in  1915,  and  since  that  date  forty-five  matern- 
ity houses  and  hospitals  have  been  started,  the  ma- 
jority by  local  authorities  and  the  remainder  by 
voluntary  bodies  working  in  cooperation  with  local 
authorities  carrying  out  maternity  and  child  wel- 
fare schemes.  The  accommodation  which  is  pro- 
vided in  adapted  houses  comprises  altogether  about 
500  beds.  Apart  from  this,  300  beds  for  confine- 
ments exist  in  homes  for  unmarried  mothers  and 
their  babies,  although  the  general  rule  in  these  in- 
stitutions is  for  the  women  to  go  to  a  lying-in 
hospital  for  her  confinement,  returning  to  the  home 
afterwards.  The  policy  of  the  Ministry  has  been 
to  encourage  local  authorities  as  much  as  possible 
to  provide  accommodation  for  maternity  cases. 
The  shortage  of  houses  and  consequent  overcrowd- 
ing have  emphasized  the  need  for  homes  for  nor- 
mal confinements  as  well  as  for  hospitals  for  com- 
plicated cases.  The  difficulty  of  building  has  ren- 
dered it  necessary  in  most  cases  for  an  existing  house 
to  be  adapted  for  the  purpose,  and  suitable 
houses  have  been  hard  to  obtain.  Nevertheless 
proposals  for  about  thirty-five  additional  maternity 
homes  have  been  sanctioned  or  are  now  under  the 
consideration  of  local  authorities  and  of  the  IMin- 
istry. 

As  for  children's  hospitals,  the  report  points  out 
that  the  accommodation  for  the  treatment  of  chil- 
dren under  five  in  general  and  special  hospitals 
supported  by  voluntary  contributions  has  been 
supplemented  in  the  course  of  the  development  of 
maternity  and  child  welfare  schemes  in  various 
ways.  In  maternity  and  child  welfare  centres 
which  receive  a  large  number  of  children  the  med- 
ical officer  examines  those  who  for  some  cause  which 
is  not  immediately  apparent  are  not  making  satis- 
factory progress.  About  twelve  centres  have  pro- 
vided observation  beds  in  which  these  children  can 
be  kept  until  the  reason  why  they  are  not  thriving 
is  ascertained,  and  a  remedy  for  their  condition 
can  be  applied.  Such  observation  beds  tend  to  de- 
velop into  wards  or  small  hospitals  for  ailing  ba- 
bies, and  in  sixteen  other  instances  new  infants' 
and  children's  hospitals  have  been  established,  fre- 
quently in  connection  with  centres  for  children  un- 
der five  sufifering  from  marasmus,  rickets,  and  sim- 
ilar conditions  not  ordinarily  admitted  to  general  or 
children's  hospitals.  Hospitals  for  general  diseases 
and  illnesses  for  children  under  five  have  been  estab- 
lished in  five  districts  in  which  the  hospital  accom- 
modation for  children  was  inadequate,  and  more  in- 
stitutes for  all  of  these  classes  are  now  being  planned 
or  considered.  A  hospital  for  cases  of  ophthalmia 
neonatorum  has  been  provided  by  the  Metropoli- 
tan Asylums  Board.  Altogether  about  220  beds 
have  been  added  to  the  hospital  accommodation  for 
children  in  connection  with  maternity  and  child 
welfare  schemes. 

Attention  is  drawn  in  the  report  to  the  fact  that 
the  passing  of  the  Nurses  Registration  Act,  in  De- 
cember, 1919,  ended  a  controversy  which  had  lasted 
some  twenty  years.  The  Act  provides  for  the  es- 
tablishment of  a  General  Nursing  Council,  two 
thirds  of  whose   members   should   be   nurses,  the 


[New  York 
Medical  Journal. 

remaining  one-third  being  representatives  of  the 
departments  concerned,  of  the  medical  profession 
and  of  the  nurses'  training  schools.  The  first 
council  is  wholly  nominated,  but  the  act  provides 
that  in  from  two  to  three  years'  time  when  a  suf- 
ficient number  of  nurses  have  been  registered  to 
form  an  adequate  electorate,  the  nurse  members  of 
the  second  and  all  subsequent  councils  shall  be 
elected  by  the  nurses  on  the  register.  In  accord- 
ance with  the  invaluable  practice  in  establishing 
registers  of  this  kind,  the  interests  of  existing  nurses 
are  fully  safeguarded,  and  those  engaged  in  bona 
fide  practice  as  nurses  for  at  least  three  years  be- 
fore November  1,  1919,  may  be  admitted  to  the 
register  without  examination,  provided  that  they 
apply  for  registration  within  two  years  after  the 
date  when  the  rules  to  be  made  by  the  General 
Nursing  Council  come  into  operation.  Subsequent 
admissions  to  the  register  will  be  made  only  by 
examination  after  the  prescribed  training  in  an  in- 
stitute approved  by  the  Council.  Similar  measures 
were  passed  establishing  nursing  councils  in  Scot- 
land and  Ireland,  and  provision  is  made  in  all  three 
acts  for  reciprocal  recognition  by  the  various  coun- 
cil's of  nurses  registered  in  other  parts  of  the 
United  Kingdom. 

^    ^  ^ 

The  other  document  which  has  just  been  issued 
is  a  report  of  the  interdepartmental  committee  in 
relation  to  certain  phases  of  national  health  insur- 
ance and  is  chiefly  valuable  by  reason  of  its  appen- 
dix, which  is  a  memorandum  on  some  of  the 
medical  aspects  of  the  National  Health  Insurance 
Act  by  Sir  James  Mackenzie  and  the  staflE  of  the 
St.  Andrew's  Institute  for  Clinical  Research.  As 
mentioned  in  a  previous  letter  Sir  James  Macken- 
zie, the  great  heart  specialist  who  is  known  well  by 
the  medical  profession  of  America,  became  con- 
vinced that  much  disease  could  be  prevented  from 
attaining  serious  proportions  if  the  general  medi- 
cal practitioner  was  cognizant  of  some  of  the  early 
symptoms  of  disease  and  was  able  by  proper  treat- 
ment to  prevent  these  early  manifestations  from 
going  further.  As  the  general  practitioner  is  the 
only  medical  man  who  has  an  opportunity  to  ob- 
serve and  study  these  early  symptoms  Sir  James 
suggested  that  these,  and  especially  the  panel  prac- 
titioners, should  be  taught  how  to  detect  such 
symptoms  and  treat  them  properly.  Sir  James  not 
only  suggested  such  a  scheme  but  gave  up  his  prac- 
tice in  London  and  founded  the  St.  Andrew's  In- 
stitute of  Clinical  Research  in  St.  Andrew's, 
Scotland,  for  the  purpose  of  carrying  his  views 
into  effect.  It  is  pointed  out  in  the  memorandum 
that  though  the  vast  majority  of  medical  students 
become  general  practitioners  no  attempt  is  made 
to  teach  them  how  to  make  use  of  their  opportuni- 
ties in  general  practice  and  no  hint  is  ever  given 
them  that  the  phases  of  disease  which  they  will 
meet  will  be  different  than  those  they  have  seen  in 
the  hospitals.  Consequently  there  is  an  urgent 
need  for  a  definite  course  of  training  students  in 
their  last  year  as  to  how  they  should  conduct  their 
practices  as  panel  doctors.  If  there  was  a  scheme 
by  which  they  could  learn  how  to  question  a  pa- 
tient intelligently,  how  to  make  short  but  accurate 


October  23,  1920.] 


LONDON  LETTER. 


637 


notes,  how  to  watch  the  patient  as  he  passes  from 
one  phase  of  disease  to  another,  the  working  of  the 
Insurance  Act  would  year  by  year  be  greatly 
facilitated,  while  a  great  impetus  would  be  given  to 
the  investigation  of  those  dark  fields  of  medicine 
which  only  the  general  practitioner  can  explore. 

The  memorandum  goes  on  to  point  out  that  the 
system  of  specialization  at  present  prevalent  enables 
the  specialist  only  to  see  disease  at  a  late  stage. 
Moreover,  as  in  ill  health  there  are  reactions  af- 
fecting several  organs  or  systems,  a  man  who 
restricts  himself  to  the  study  of  but  one  organ  or 
system  cannot  acquire  the  power  of  detecting  the 
primary  cause  of  the  patient's  ill  health.  It  is  rec- 
ognized that  a  general  practitioner  who  makes  a 
special  study  of  the  diseases  of  one  organ  or  sys- 
tem is  better  qualified  in  that  he  has  a  wider  experi- 
ence and  can  therefore  take  a  broader  outlook  of 
his  patient's  complaint,  besides  having  an  oppor- 
tunity for  seeing  disease  at  an  early  stage.  The 
following  are  the  methods  pursued  at  St.  Andrew's 
Institute.  1.  Each  clinician  has  a  private  room  in 
the  institute.  This  is  reserved  from  eleven  to  one  on 
Mondays,  Wednesdays,  and  Thursdays  for  re- 
search cases.  During  the  rest  of  the  day  each 
practitioner  may  use  his  private  room  as  a  private 
consulting  room.  An  index  file  and  cards  are  pro- 
\  ided  in  each  room  upon  which  brief  notes  are  kept 
of  each  private  or  panel  patient.  These  cards  will, 
in  time,  form  records  of  the  life  history  of  each  pa- 
tient. In  the  event  of  a  patient  removing  to 
another  district  these  notes  can  be  sent  to  his  new 
attendant.  2.  Cases  for  research  are  selected  from 
his  own  practice  by  each  member  of  the  clinical 
staff.  These  are  first  seen  by  him  and  he  is  at  lib- 
erty to  consult  Sir  James  Mackenzie  or  any  col- 
league at  any  stage  of  the  case.  If  any  special 
investigations  are  required,  these  are  carried  out 
by  the  staff  of  the  special  departments.  3.  On 
Tuesday  afternoons  some  special  subject,  arranged 
beforehand,  is  discussed  by  a  general  meeting  of 
all  members  of  the  staff.  4.  On  Friday  afternoons 
the  whole  staff  discuss  the  cases  seen  during  the 
week  and  any  suggestions  for  investigation  of  any 
case  made  at  that  meeting  are  proceeded  with  and 
added  to  the  record. 

*  * 

In  an  article  on  the  Municipalization  of  Hospitals, 
published  recently  in  the  British  Medical  Journal, 
Dr.  Charles  Buttar  describes  the  Municipal  hospital 
in  Bradford,  emphasizing  the  importance  of  a  study 
by  the  medical  profession  of  the  methods  by  which 
this  institution  was  brought  into  existence  and  the 
proposals  for  its  management. 

Dr.  Buttar  goes  on  to  say  that  for  a  long  time 
there  were  no  medical  men  in  the  city  who  confined 
themselves  to  purely  consulting  and  specialist  work 
and  that,  more  than  ten  years  ago,  it  was  recognized 
that  the  buildings  of  the  Royal  Infirmary,  where 
much  of  the  institutional  work  was  done,  were  out 
of  date  and  insufficient,  and  a  site  for  a  new  infir- 
mary was  acquired.  But  the  £200,000  then  thought 
necessary  was  never  collected  and  the  war  interfered 
with  the  proposals  for  building.  It  appears  prob- 
,able  that  the  project  of  the  Bradford  Municipal 
Hospital  is  to  be  legitimized  by  a  clause  in  the 


Ministry  of  Health  bill.  A  site  has  been  leased 
where  there  will  be  as  little  overcrowding  of  build- 
ings, and  as  much  open  space  as  possible.  This  new 
hospital  is  expected  to  have  1,148  beds  in  ten  pa- 
vilions; the  medical  ward  to  accommodate  502,  and 
the  surgical,  324  patients.  To  maternity  cases  90 
beds  will  be  allotted,  to  children  84  and  to  infants  40. 
The  remaining  108  are  for  venereal  cases. 

In  order  to  build  up  the  hospital  on  modern  lines, 
it  is  proposed  that  the  institution  should  consist  of 
a  number  of  small  units,  each  composed  of  senior 
part  time  officer,  physician  or  surgeon,  an  assistant 
(part  time)  and  a  resident  officer.  The  City  Coun- 
cil, which  is  responsible  for  the  management,  will 
delegate  the  care  of  the  hospital  to  the  Public  Health 
Committee.  The  medical  staff  will  consist  of  part 
time  senior  and  assistant  medical,  surgical,  and 
gynecological  officers,  and  of  the  residents  attached 
to  the  units.  It  is  proposed  that  the  senior  officers 
shall  be  consultants  or  specialists  employed  for  two 
hours  each  on  four  days  a  week.  The  remunera- 
tion suggested  for  this  service  is  £500  a  year.  The 
assistant  medical  officers  may  be  general  practi- 
tioners, who  would  be  employed  for  six  hours  a 
week,  and  be  paid  £300  a  year.  The  residents  will 
be  whole  time  officers,  and  no  suggestion  seems  to 
have  been  made  as  to  the  rate  of  remuneration  to 
be  paid  them.  Patients  will  be  admitted  through 
the  outpatient  department,  which  is  to  be  open, 
apparently,  to  any  inhabitant  of  Bradford,  but  which 
it  is  hoped  will  be  fed  from  the  various  clinics,  the 
outdoor  Poor  Law  medical  officers,  and  by  general 
practitioners.  No  mention  is  made  of  emergency 
operations,  which  often  occur  in  the  night. 

One  interesting  proposal  in  connection  with 
carrying  out  the  plan  of  the  hospital  is  the  matter 
of  the  senior  medical  officer.  He  is  supposed  to 
have  a  university  degree  or  to  be  a  Fellow  of  one 
of  the  Royal  Colleges,  and  not  to  be  in  general 
practice,  nor  hold  any  other  hospital  appointment 
save  with  the  consent  of  the  committee.  Now  the 
committee  proposes  to  purchase  eight  hours  a  week 
of  a  consultant's  time,  and  it  is  a  little  difficult  to  see 
why  they  should  be  anxious  to  know  what  he  does 
with  the  remainder  of  his  time.  May  it  not  be  that 
this  provision  may  deprive  them  of  the  services  of 
some  of  the  more  distinguished  consultants  ? 

The  attitude  "of  the  population  of  Bradford  to- 
ward municipal  health  enterprise  is  interesting. 
Some  doctors  assert  that  their  practice  among 
children  has  almost  ceased.  One  doctor  regarded 
Bradford  as  so  municipalized  that  the  City  Council 
takes  charge  of  the  whole  population  "from  con- 
ception to  cremation." 

It  is  proposed  that  charges"  shall  be  made  to 
patients,  according  to  the  means  of  each,  but  no 
special  amenities  will  be  provided  for  those  who 
pay  the  larger  sums.  All  will  be  treated  and  fed 
in  the  same  way. 

Though  the  plan  outlined  above  is  interesting,  the 
question  is  asked,  why  should  attempts  be  made  to 
fetter  part  time  medical  officers?  Would  it  not 
be  well  for  the  Minister  of  Health  to  withhold 
approval  of  a  scheme  embodying  such  principles  as 
these  in  Bradford  until  some  measure  of  consulta- 
tion with  the  medical  profession  has  been  achieved? 


Editorial  Notes  and  Comments 


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NEW  YORK.  SATURDAY.  OCTOBER  23,  1920. 


ACUTE  ADENOIDITIS  IN  CHILDREN. 

This  aflection  is  of  great  practical  importance.  In 
infants  and  children  up  to  the  age  of  five  years  it 
occurs  as  frequently  as  it  is  overlooked.  Usually 
these  small  patients  are  treated  for  almost  every 
disease  excepting  the  right  one  and  in  most  instances 
the  specialist  is  finally  consulted  for  the  complica- 
tions. In  practice,  all  that  is  necessary  is  to  recall 
that  there  is  such  a  disease  as  acute  adenoiditis  for 
the  purpose  of  recognizing  it,  because  its  symptom- 
atology is  very  special  and  really  characteristic.  The 
affection  is  especially  freauent  in  winter  and  at  the 
beginning  of  spring  and  autumn.  In  an  infant  or 
young  child  after  coryza,  a  temperature  develops ; 
the  baby  Ijecomes  restless,  sleeps  poorly,  snores  and 
breathes  with  the  mouth  open.  At  the  same  time  a 
paroxysmal  and  almost  incessant  cough  develops  of 
a  type  much  like  that  of  pertussis,  allowing  the 
patient  little  rest.  The  cough,  usually  dry  unless  there 
is  a  concomitant  tracheitis,  occasionally  precedes  in 
somewhat  long  paroxysms  during  the  day  but  is 
much  more  accentuated  at  night  when  the  child-  is 
lying  down.  It  is  not  uncommon  to  find  a  tempera- 
ture of  102°  to  104°  F.  lasting  for  several  days. 
Generally  it  lasts  for  five  or  six  days,  sometimes  a 
fortnight  or  even  a  month.  Even  when  long  con- 
tinued the  child  is  likely  to  retain  its  appetite  and 
eat  as  usual. 

An  examination  of  the  throat  will  enlighten  the 
diagnosis.  The  pharynx  and  tonsils  are  bright  red 
and  if  the  velum  is  pushed  up  a  transverse  line  of 
accumulated  mucus  will  be  perceived  at  the  upper 


part  of  the  cavum.  This  band  of  mucus  varies  in 
thickness  and  has  a  mucopurulent  look.  If  the  finger 
explores  the  parts  adenoid  growths  will  be  de- 
tected immediately.  The  long  duration  of  the  process 
in  some  cases,  the  temperature  and  the  difficulty 
in  feeding  may  result  in  a  certain  degree  of  emacia- 
tion and  change  in  the  general  health.  On  the  other 
hand,  complications  of  various  kinds  may  arise  such 
as  bronchitis,  bronchopneumonia,  otitis,  asthma, 
and  laryngitis  stridulosa. 

Two  types  of  the  process  deserve  mention ;  a  dry 
form  with  paroxysmal  coughing,  without  secretion, 
and  a  catarrhal  form  with  secretions  and  rise  in  tem- 
perature but  without  cough.  The  diagnosis  is  easy 
if  the  physician  will  only  recall  that  acute  adenoiditis 
is  relatively  common  in  young  subjects,  especially 
when  the  patient  offers  the  characteristic  facies  of 
adenoid  growths,  and  in  infants  when  they  sleep 
with  open  mouth  and  snore. 

Auscultation  will  immediately  eliminate  bron- 
chitis or  bronchopneumonia.  In  simple  acute  trache- 
itis there  are  no  nasopharyngeal  symptoms,  while 
tracheobronchial  adenopathy  can  be  also  eliminated 
by  the  absence  of  presternal  or  interscapular  dull- 
ness or  subdullness.  In  whooping  cough  the  par- 
oxysms of  cough  are  not  so  frequent,  the  affection  is 
apyretic  unless  complications  arise,  and  viscous  mu- 
cus will  be  discharged  with  the  coughing.  Adenoid- 
itis is  prone  to  frequent  recurrences  and  removal  of 
the  growths  should  be  undertaken  as  soon  as  the 
inflammatory  phenomena  have  subsided.  In  the  in- 
fant, the  treatment  consists  in  disinfection  of  the 
cavum  by  mornino-  and  evening  instillation  of  thirty 
centigrams  of  resorcin  in  twelve  cubic  centigrams  of 
sterilized  oil.  In  older  children  gomenol  oil  or  solu- 
tions of  protargol  or  collargol  may  be  used,  as  well 
as  irrigations  with  tepid  water  for  removal  of  the 
secretions.  The  bromide  salts  are  useless  for  con- 
trolling the  cough  and  urethane  is  used  in  the  daily 
dose  of  from  twenty-five  to  fifty  centigrams  after 
the  age  of  one  year. 

FRENCH  RESEARCH  ON  GAS  GANGRENE. 

When  gas  gangrene  appeared  among  the  troops 
on  the  Western  Front  little  was  known  of  this  seri- 
ous complication  of  wounds.  The  condition  had 
almost  disappeared  from  peace  time  practice  and 
the  present  medical  generation  had  practically  for- 
gotten it.  French  medical  men  determined  to  learn 
all  that  was  possible  concerning  it,  so  as  to  be  able 
to  treat  it  effectively.  According  to  Dr.  E.  Sacquepee. 
professor  at  the  Val-de-Grace,  Paris,  writing  in  the 


October  23,  1920.] 


EDITORIAL  ARTICLES. 


639 


French  Supplement  of  the  Lancet,  September  18, 
1920,  these  efforts  have  been  directed  above  all  to 
elucidate  the  pathogeny  of  the  accidents.  The  com- 
plication was  of  an  infectious  nature  and  it  was 
necessary  to  find  out  the  species  of  microbe  respon- 
sible for  it. 

Before  the  war  knowledge  of  the  pathogeny  was 
as  follows :  Pasteur  following  Davaine  in  his  study 
of  experimental  septicemia  showed  that  the  infec- 
tion was  due  to  the  Vibrion  septique.  Chauveau  and 
Arloing  then  demonstrated  that  this  same  germ  also 
existed  in  gas  gangrene  in  hiunan  beings.  Clinical 
researches  into  the  question  then  became  difficult 
in  France,  since  the  first  effect  of  the  application  of 
Pasteur's  principles  to  surgery  was  to  render  gas 
gangrene  extremely  rare.  On  the  other  hand  in 
foreign  countries,  especially  in  Germany  and 
America,  the  study  of  certain  new  facts  was  pos- 
sible. Welch  and  Fraenkel,  and  following  them  a 
number  of  other  observers,  charge  \\^elch's  bacillus, 
the  Bacillus  perfringens  of  French  writers,  with  be- 
ing the  main  cause  of  the  condition.  According  to 
these  authorities  the  \^ibrion  septique  seems  entirely 
eliminated  as  far  as  its  influence  goes. 

The  war  gave  opportunities  for  further  investi- 
gations under  favorable  circumstances  of  which  full 
advantage  was  taken.  Welch's  bacillus  was  found 
to  be  the  predominant  microbe  implicated.  The 
first  work  of  the  French  investigation  began  in  ^lay 
and  Jime,  1915,  and  was  based  on  the  following 
principle,  i.  e.,  that  the  best  criterion  of  a  patho- 
genic species  is  constituted  by  its  ability  to  repro- 
duce the  malady  experimentally.  It  was  found 
that  Welch's  bacillus  could  reproduce  the  local  le- 
sions of  the  gangrene,  but  it  could  not  be  made  to 
produce  a  potent  toxin. 

The  investigators  therefore  thought  that  an  ex- 
amination should  be  made  to  determine  whether 
there  were  not  in  the  gangrenous  tissues  other  path- 
ogenic germs  which  comply  better  with  the  experi- 
mental criterion.  In  the  majority  of  cases  investiga- 
tions in  this  direction  gave  an  affirmative  answer. 
They  found  either  the  Vibrion  septique  or  a  new 
bacillus  which  was  later  to  receive  the  name  of 
Bacillus  bellonensis.  In  short,  it  was  made  clear 
that  gas  gangrene  was  associated  with  three  species 
of  organisms,  Welch's  bacillus,  Vibrion  septique  and 
Bacillus  bellonensis  and  the  Inter-Allied  Surgical 
Conference,  which  met  at  Paris,  came  to  the  same 
conclusion. 

The  results  of  the  analysis  of  121  cases  under  the 
French  investigators'  personal  supervision  were : 
Welch's  bacillus,  eighty-two  per  cent. ;  typical  Vi- 
brion septique,  twenty-eight  per  cent. ;  nontypical 
Vibrion  septique,  eleven  per  cent.;  Bacillus  bellon- 


ensis, thirty-five  per  cent.  The  germs  were  often 
associated  in  pairs.  An  analytical  study  of  the  Bacil- 
lus bellonensis  showed  that  it  is  a  highly  pathogenic, 
xtry  toxic  species,  capable  of  reproducing  perfect 
gas  gangrene  experimentally.  As  for  specific  treat- 
ment, a  knowledge  of  the  causative  germs,  suggested 
the  application  of  a  specific  serotherapy  either 
against  all  three  germs  or  against  the  germ  involved 
in  each  particular  case.  The  carrying  out  of  this 
conception  resulted  in  the  preparation  of  three 
serums.  The  really  great  difficulty  was  to  know 
which  serum  was  to  be  used  in  each  case.  In  most 
of  the  cases  it  was  decided  to  inject  all  three  simul- 
taneously, although  this  was  evidently  only  a  make- 
shift procedure.  Even  so  this  method  has  given  de- 
cided results.  However,  in  the  last  months  of  the 
war  a  means  of  rapid  pathogenic  diagnosis  was  dis- 
covered, so  that  treatment  can  now  be  applied 
promptly  on  the  right  lines.  Of  course,  from  the 
preventive  viewpoint  this  method  of  treatment  is  still 
more  powerful,  as  Sacquepee  points  out,  as  it  reduces 
the  cases  of  gas  gangrene  to  a  small  number  of  those 
wounds  which  are  most  exposed  to  it.  French  in- 
vestigators clearly  defined  the  pathogeny  of  gas  gan- 
grene and  have  employed  serotherapy,  curative,  re- 
medial, and  preventive,  with  the  happiest  results,  a 
really  notable  achievement. 


PHYSICIAX-AUTHORS:    DR.  FRANCIS 
BRETT  YOUNG. 

Dr.  Francis  Brett  Young,  the  English  poet  and 
novelist,  admits  that  when  his  father  sent  him  to 
the  University  of  Birmingham  to  study  medicine 
he  rebelled,  for  he  was  already  afflicted  with  that 
seemingly  incurable  disease,  cacoethes  scribcndi. 
"But  I  know  now,"  he  declares,  "that  there  is 
nothing  in  the  world  that  so  fits  a  man  of  letters  to 
wrestle  with  the  mind  of  a  man  as  an  intimate  c.c- 
quaintance  with  his  body.  Literally  and  figuratively 
the  doctor  sees  thousands  of  men  and  women  naked ; 
he  sees  the  spring  of  curious  motives,  he  shares 
strange  secrets.  A  man  or  a  woman  will  tell  lies 
or  feign  emotions  to  the  pastor  or  the  lawyer ;  with 
the  physicians  they  know  that  only  the  truth  will 
help  them.  There  is  no  education  in  humanity  that 
compares  with  the  doctor's  life ;  and  indeed,  the 
names  of  great  literary  artists  confirm  this." 

Unless  he  has  given  it  up  quite  recently.  Dr. 
Young  is  still  practising  medicine  while  at  the  same 
time  writing  novels.  He  took  his  degree  in  1906 
and  immediately  set  out  to  see  the  world  as  a  ship's 
surgeon,  an  easy  berth  which  gave  him  plenty  of 
leisure  to  gather  impressions  and  put  them  on  paper. 
In  this  capacity  he  saw  the  whole  of  the  East,  from 
Egypt  to  Korea  and  Japan  and  and  then  settled 


640 


EDITORIAL  ARTICLES. 


[New  York 
Medical  Journal. 


down  in  medical  practice  at  Brixham,  a  fishing  vil- 
lage in  the  south  of  Devon.  "My  patients  at  Brix- 
ham," he  says,  "were  nearly  all  fishing  people,  speak- 
ing a  racy  dialect.  Their  life  is  the  subject  of  the 
novel.  Deep  Sea,  which  distantly  resembles  Pierre 
Loti's  Pcchenrs  d'Islande  and  is  dedicated  to  him." 
Deep  Sea  was  not  Dr.  Young's  first  novel.  The 
first,  called  Undergrowth,  was  written  in  collabora- 
tion with  his  brother,  Eric  Brett  Young,  and  pub- 
lished in  1913.  This  was  followed  by  a  long  critical 
study  of  the  poetry  of  Robert  Bridges,  poet  laureate, 
and  in  1914  came  The  Dark  Tow.er,  which  the  author 
describes  as  "an  exalted  love  story  following  the 
lines  of  the  old  tale  of  Pelleas  and  Melisande,  with 
the  mountain  country  of  the  Welsh  border  for  its 
setting."  He  was  writing  The  Iron  Age,  a  story  of 
the  Black  Country  near  Birmingham,  when  the 
World  War  broke  out,  and  he  finished  it  abruptly  by 
packing  his  hero  ofiF  to  the  war  and  then  following 
suit  himself.  Young,  having  offered  his  services  to 
the  War  Office  as  soon  as  they  could  find  a  substi- 
tute for  him  in  civil  practice,  joined  the  Royal  Artil- 
lery Medical  Corps  early  in  1915  and  spent  the  first 
two  years  of  his  service  in  East  Africa.  At  the  end 
of  that  period  he  had  to  return  because  of  ill  health, 
but  continued  to  serve  the  colors  until  after  the 
armistice,  ending  with  the  rank  of  major. 

As  a  result  of  his  experiences  in  East  Africa  he 
has  given  us  two  novels,  the  first,  Marching  on 
Tanga,  and  later.  The  Crescent  Moon,  perhaps  the 
author's  best  known  work.  It  was  Marching  on 
Tanga  which  brought  his  name  into  real  prominence 
for  the  first  time.  "Written  under  a  stress  of  emo- 
tion and  exaltation  in  a  rhythmical  prose  that  too 
frequently  breaks  into  blank  verse,"  says  Compton 
Mackenzie,  "it  is  a  remarkable  record  of  a  remark- 
able experience,  and  it  already  beautifully  fills  in  the 
immense  library  of  war  books  a  space  which  is  as- 
suredly a  permanent  one." 

There  are  two  other  novels  and  two  volumes  of 
poetry  from  his  pen.  The  novels  are  The  Tragic 
Bride  and  The  Young  Physician,  the  latter  being  ad- 
mittedly autobiographical ;  the  record  of  a  youth's 
development,  during  the  last  half  of  which  period 
the  hero  is  seen  at  a  medical  school.  Both  volumes 
of  poetry  are  largely  expressions  of  the  author's 
emotions  in  East  Africa.  They  are  Poems  1916- 
1918  and  Five  Degrees  South.  The  author  describes 
Five  Degrees  South  as  "a  sort  of  lyrical  commen- 
tary on  Marching  on  Tanga.  The  poems  were  slen- 
der, intimate  things,  written  to  my  wife  and  one  or 
two  of  them  published  in  the  London  Times  and  the 
New  Statesman,  but  since  they  have  been  published 
I  am  always  coming  upon  people  who  i)refer  them 
to  all  my  other  work." 

If  we  are  to  accept  the  verdict  of  the  critics,  the 


fiction  of  Dr.  Francis  Brett  Young  is  extraordinary 
fiction  and  the  poems  are  extraordinary  poems.  Al- 
ready his  work  has  given  him  an  international  repu- 
tation that  is  growing  rapidly.  His  poetry  has  met 
with  universal  acclaim.  Reviewers  have  said  that 
as  a  poet  his  work  has  a  distinction  and  merit  that 
is  rare  among  the  unending  flood  of  jingling  rhymes, 
blatant  nonsense,  and  mediocre  workmanship  that  is 
constantly  being  poured  out.  His  novels,  the  critics 
say,  show  steady  progress  toward  a  high  place  in 
the  literature  of  the  next  decade.  No  less  a  critic 
than  Hugh  Walpole  says  of  him  that  "among  the 
more  romantic  younger  English  novelists  he  is  eas- 
ily the  first."  A  fine  eye  for  landscape,  plenty  of 
exciting  action,  unhackneyed  scenes  and  situations 
and  a  finely  polished  style,  these  are  characteristics  of 
Dr.  Young's  fiction.  His  output  has  been  heavy, 
considering  his  medical  practice,  his  war  service  and 
his  age — he  is  only  thirty-six,  having  been  born  in 
1884,  the  son  of  a  country  doctor,  near  Birmingham. 
Mor«  than  mere  byproduct  is  this  heavy  output  of 
literature,  and  it  would  seem  to  indicate  that  before 
long,  if  not  already.  Dr.  Francis  Brett  Young  and 
the  practice  of  medicine  will  part  company. 


THE  ETIOLOGY  OF  CUTANEOUS 
PIGMENTATION. 
The  pathogenesis  and  etiology  of  cutaneous  pig- 
mentation ar^  unquestionably  interesting  but  little 
known,  and  the  divers  notions  we  possess  are,  to  say 
the  least,  hypothetical.  The  appearance  of  dyschro- 
mias appears  to  be  related  to  external  and  internal 
causes,  the  former  being  the  best  understood.  It  is 
known  that  any  irritation  when  somewhat  intense 
and  prolonged  can  give  rise  to  pigmentation  of  the 
skin,  but  as  Darier  has  pointed  out,  these  fragmen- 
tary disturbances  have  for  the  most  part  the  charac- 
ter of  vital  reactions  against  an  irritant,  and  conse- 
quently their  manifestations  and  intensity  depend 
less  frequently  on  the  nature  of  the  causal  agent  than 
on  the  reactionary  tendency  of  the  subject.  Among 
the  irritating  causes,  physical  agents  play  an  impor- 
tant part.  For  example,  the  production  of  sunburn  is 
principally  due  to  light  and  in  particular  to  the  chem- 
ical rays  of  the  spectrum.  Heat  may  be  a  factor  in 
some  cases  and  Neisser  incriminates  the  caloric  action 
of  furnaces  in  cases  of  syphilitic  dyschromia  occur- 
ring in  blacksmiths  and  bakers.  In  the  same  way  non- 
chemical  agents  can  give  rise  to  pigmentation  or  at 
least  can  play  a  secondary  part  as  localizing  agents. 
Vitiligo  and  the  socalled  primary  pigmentary  syph- 
ilide  are  frequently  localized  in  areas  chronically  irri- 
tated, as  has  been  .shown  by  Thibierge  and  Finger. 
Finally,  to  conclude  with  the  external  causes,  beside 
the  parasitic  dyschromias  whose  etiology  seems  to 


October  23,  1920.] 


NEWS  ITEMS. 


641 


be  complex,  it  may  seem  logical  to  include  those 
which  are  secondary  to  the  dermatoses,  such  as  the 
bullae  of  pemphigus,  herpes  zoster,  boils,  papulone- 
crotic tuberculides,  etc.,  as  well  as  syphilitic  lesions. 
The  macula  of  roseola,  secondary  papules,  and  ulcer- 
ating lesions  are  the  starting  points  of  pigmentary 
change  in  which  either  a  melanodermia  or  a  more  or 
less  atrophic  leucodermia  are  observed. 

Still  other  causes  of  dyschromia  have  been  in- 
voked, both  general  and  internal,  whose  mechanism 
has  been  diversely  interpreted.  Among  them  hyper- 
emia should  first  be  mentioned  :  it  unquestionably  in- 
tervenes in  pigmentations  having  a  local  or  external 
cause,  for  example,  the  melanodermia  occurring  on 
varicose  limbs.  Lesions  of  the  suprarenal  capsules 
have  for  some  time  been  recognized  as  a  cause  of 
the  melanodermia  of  Addison's  disease,  but  space 
forbids  a  discussion  as  to  what  extent  renal  insufifi- 
ciency  or  lesions  of  the  pericapsular  nervous  plexus 
act  as  factors.  If  suprarenal  insufficiency  is  incrim- 
inated, it  should  be  pointed  out  that  normally  the 
suprarenals  destroy  pigment  or  a  pigmentogenous 
substance  and  that  when  diseased  they  cannot  do  so. 
Or  if  a  sympathetic  theory  is  maintained,  it  will  be 
said  that  w^hen  irritated  a  hyperactivity  of  the  cells 
secreting  pigment  occurs.  The  sympathetic  and 
cerebrospinal  systems  undoubtedly  play  a  part  in 
many  dyschromias,  as  in  leprosy,  vitiligo,  and  the  so- 
called  primary  pigmentation  of  syphilis.  The  latter 
does  not  belong  exclusively  to  lues  because  it  has  been 
observed  in  tuberculosis  and  chlorosis.  On  the  other 
hand,  in  many  ways  it  is  similar  to  the  chloasma  of 
pregnancy  and  Addison's  disease,  and  it  may  well  be 
asked  if  the  syphilitic  dyschromia  is  not  also  conse- 
quent upon  some  disturbance  of  the  pericapsular 
nerves  resulting  from  the  Spirochseta  pallida. 

Other  dyschromias  have  been  regarded  as  due  to 
hematic  changes  such  as  malarial  melanodermia  and 
perhaps  bronze  diabetes.  According  to  Diday  the 
blood  of  syphilitics  undergoes  a  peculiar  change  in 
its  coloring  matter  which  allows  it  to  become  de- 
posited in  the  tissues.  If  for  any  reason  congestion 
arises,  with  a  consequent  increase  of  the  blood  in  the 
skin,  it  will  progressively  infiltrate  the  integuments 
and  finally  the  coloring  matter  will  come  near  enough 
to  the  surface  to  produce  a  perceptible  change  in  hue. 
Petresco  likens  the  mechanism  of  the  pigmentary 
syphilide  to  that  observed  in  paludism ;  there  is  an 
exaggerated  deposit  of  hemoglobin  coming  from  the 
destroyed  red  blood  corpuscles,  hence  melanin  and 
its  deposit  in  the  tissues.  Other  observers  have 
thought  that  the  presence  of  bile  pigments  in  the 
blood  might  be  the  origin  of  a  good  number  of  dys- 
chromias, and  perhaps  syphilis,  which  does  not  spare 
the  liver,  produces  pigments  in  this  way.  Finally 
certain  disturbances  of  pigmentation  have  a  toxic 


origin,  such  as  arsenical  melanodermia  and  argyria. 
Although  the  etiology  of  dyschromia  is  poorly  under- 
stood, this  process  can  be  divided  into  primary  and 
secondary  types.  The  first  or  spontaneous  type  is 
not  preceded  by  an  eruptive  element.  Secondary 
pigmentations  are  those  succeeding  an  eruptive  ele- 
ment, which  was  seated  at  the  spot  where  the  dys- 
chromia, melanodermia,  or  achromia,  according  to 
the  case,  ultimately  arises.  In  the  first  group  can 
be  placed  the  melanodermia  of  Addison's  disease, 
lentigo  and  chloasma  of  pregnancy.  In  the  second 
group  of  secondary  dyschromias  are  the  melanoder- 
mias  or  achromias  following  some  local  dermatosis, 
such  as  pemphigus,  lichen  planus  and  varicose  ulcer. 


]MUSIC  WITH  WORK. 
Transplanting  rice  in  the  Philippines  costs  about 
forty  centavos  a  day,  with  two  meals,  cigarettes 
and  betel  nut,  but  when  music  is  provided  the  out- 
put of  work  is  increased  thirty  per  cent.  It  is  often 
a  blind  man  who  plays.  He  sits  on  the  low  rice 
dyke  and  sings  the  old  folk  songs  to  his  guitar,  and 
frequently  the  workers  join  in  the  chorus.  Some 
of  the  large  stores  in  the  States  also  tried  the  effect 
of  music,  with  good  results.  We  have  not  heard 
much  lately  concerning  music  in  hospitals  and  oper- 
ating rooms ;  perhaps  the  patients  were  of  the  same 
opinion  as  the  Socialist  press,  which  says  that  all 
this  welfare  work  is  enlightened  selfinterest.  It 
proceeds  without  taking  the  trouble  to  find  out 
whether  such  patronizing  efforts  are  desired  or 
appreciated. 

 ^  • 

News  Items. 


American  Dietetic  Association. — This  organi- 
zation will  meet  in  annual  session  in  New  York 
October  25th  to  27th,  with  headquarters  at  the  Hotel 
IMcAlpin. 

Mississippi  Valley  Medical  Association. — This 
organization  will  meet  in  annual  session  in  Chicago, 
October  26th,  27th  and  28th,  under  the  presidency 
of  Dr.  Frank  B.  Wynn,  of  Indianapolis,  Ind. 

Harvey  Lecture. — The  second  Harvey  Society 
Lecture  will  be  given  at  the  New  York  Academy 
of  ^Medicine,  Saturday  evening,  October  30th,  by 
Professor  Jules  Bordet,  director  of  the  Pasteur  In- 
stitute of  Brussels.  His  subject  will  be  Coagulation 
of  the  Blood. 

Coroner's  Physician  for  Monroe  County. — The 
Civil  Service  Commission  announces  an  examination 
for  the  position  of  coroner's  physician  for  Monroe 
County,  X.  Y.  Candidates  must  be  licensed  physi- 
cians and  a  residence  of  three  months  in  the  county 
is  required :  salary  $200  a  year. 

Cutter  Lectures  on  Preventive  Medicine. — Dr. 
Theobald  Smith,  of  the  Rockefeller  Institute  for 
^Medical  Research,  delivered  the  Cutter  Lectures  on 
Preventive  Medicine  at  the  Harvard  Medical  School 
on  October  19th  and  20th,  his  subject  being  Medical 
Research  and  the  Conservation  of  Food  Producing 
Animals. 


642 


NEWS  ITEMS. 


[New 
Medical 


York 
Journal. 


Yellow  Fever  in  Mexico. — Quarantine  meas- 
ures against  Tampico,  Mexico,  on  account  of  yellow 
fever,  were  ordered  on  September  27th,  to  be  en- 
forced at  Gulf  and  South  Atlantic  ports  of  the 
United  States.  During  the  four  weeks  from  July 
19th  to  September  18th,  fifty-two  cases  were  re- 
ported in  Vera  Cruz,  with  twenty-eight  deaths,  and 
on  September  26th  Dr;  Hedrick,  of  the  United 
States  Public  Health  Service,  died  from  the  disease. 
In  Tuxpan,  during  the  month  of  September,  there 
were  twenty-one  deaths. 

American  Association  of  Railway  Surgeqns. — 
At  the  seventeenth  annual  meeting  of  this  society, 
held  in  Chicago,  October  6th  to  8th,  Dr.  Clarence 
W.  Hopkins,  of  Chicago,  was  elected  president  and 
other  of¥icers  were  elected  as  follows :  First  vice 
president,  Dr.  Edwin  B.  Shaw,  of  Las  Vegas,  N. 
M. ;  second  vice  president.  Dr.  Joseph  B.  Wharton, 
of  Eldorado,  Ark. ;  third  vice  president.  Dr.  George 
W.  Pirtle,  of  Carlisle,  Ind. ;  treasurer,  Dr.  Henry 
B.  Jennings,  of  Council  Bluffs,  la.  (reelected)  ;  sec- 
retary, De  Louis  J.  Mitchell,  of  Chicago  (reelected). 

Assistant  Medical  Officer  Wanted  at  the  Port 
of  New  York. — The  Civil  Service  Commission  of 
the  State  of  New  York  announces  an  examination 
on  October  30th  for  the  position  of  assistant  medical 
officer,  office  of  Health  Officer,  Port  of  New  York ; 
salary  $1800.  Candidates  must  be  licensed  phy- 
sicians. The  appointee  must  reside  at  City  Island 
and  give  part  of  his  time  to  the  inspection  of  vessels 
from  foreign  ports  and  the  examination  of  pas- 
sengers and  crews  for  the  detection  of  quarantinable 
diseases,  such  as  cholera,  plague,  typhus  fever,  yel- 
low fever,  smallpox,  and  leprosy. 

Pharmacologist  in  the  Bureau  of  Internal  Rev- 
enue.— The  LInited  States  Civil  Service  Commis- 
sion announces  an  examination  for  pharmacologist 
to  fill  a  vacancy  in  the  Bureau  of  Internal  Revenue, 
Treasury  Department;  salary  $2,500  to  $3,000  a 
year.  Applicants  must  have  an  M.  D.  degree  from 
an  institution  of  recognized  standing,  and  at  least 
an  A.  B.  or  a  B.  S.  degree  from  a  college  or  uni- 
versity of  recognized  standing,  and  have  had  at  least 
two  years'  postgraduate  experience  in  experimental 
pharmacology  or  physiology,  such  experience  to  have 
included  study  of  the  physiological  action  of  drugs. 
Additional  credit  will  be  given  to  applicants  who 
show  that  they  have  a  reading  knowledge  of  French 
and  German. 

Lectures  on  Industrial  Health  and  Preventive 
Medicine. — The  Long  Island  College  Hospital 
College  of  Medicine  announces  a  series  of  lectures 
and  ])ractical  demonstrations  on  industrial  health  and 
preventive  medicine  to  be  held  during  the  collegiate 
year  of  1920-21.  The  course  on  industrial  health 
will  be  given  in  the  form  of  twelve  lectures  and 
four  demonstrations  by  Dr.  Alfred  Edward  Shipley, 
director  of  the  New  York  Industrial  Health  Bureau, 
who  has  recently  been  added  to  the  staff  of  the  col- 
lege. Preventive  medicine  will  be  discussed  in  a 
course  of  fifteen  lectures  by  Dr.  Edward  H.  Marsh, 
assistant  professor  of  preventive  medicine  and  hy- 
giene. These  lectures  will  be  free  to  licensed  physi- 
cians. For  full  particulars  write  the  head  of  the 
department.  Dr.  H.  Sheridan  Baketel,  350  Henry 
Street,  Brooklyn. 


Flower  Hospital  Asks  Aid. — Flower  Hospital 
has  asked  for  subscriptions  in  order  that  the  insti- 
tution may  be  properly  maintained  and  its  ambu- 
lance service  continued.  It  also  desires  to  add  sixty- 
five  beds  to  the  200  now  in  use  and  to  provide  better 
quarters  for  the  nurses.  An  expansion  of  the  free 
work  of  the  hospital  is  also  contemplated.  The 
ambulance  service  of  Flower  Hospital  covers  a 
territory  of  275  city  blocks  in  the  heart  of  Man- 
hattan. 

Far  Eastern  Association  of  Tropical  Medicine. 

— The  fourth  congress  of  this  association  will  be 
held  in  Batavia,  Java,  in  August,  1921,  under  the 
presidency  of  Dr.  W.  T.  de  Vogel,  of  the  Civil 
Medical  Service.  Dr.  Neeb,  of  Batavia.  is  secre- 
tary of  the  society.  Among  the  countries  which 
will  be  represented  at  the  congress  are  the  Philip- 
pine Islands,  Australia,  New  Zealand,  British  India, 
Straits  Settlements,  Ceylon,  the  French  and  Portu- 
guese colonies,  China,  Japan,  and  Siam. 

Meetings  of  Local  Medical  Societies. — The  fol- 
lowing local  medical  societies  will  meet  in  New  York 
during  the  coming  week : 

Tuesday,  October  26th. — New  York  Academy  of  Aledicine 
(Section  in  Obstetrics  and  Gynecology)  ;  New  York  Der- 
matological  Society ;  New  York  Medical  Union ;  Metropoli- 
tan Medical  Society ;  New  York  Psychoanalytical  Society ; 
Riverside  Physicians'  Association;  Therapeutic  Club;  Val- 
entine Mott  Society  ;  Washington  Heights  Medical  Society  ; 
Woman's  Hospital  Society;  Clinical  Society  of  the  Hospi- 
tal and  Dispensary  for  Deformities  and  Joint  Diseases. 

Wednesday.  October  27th. — New  York  Academy  of  Medi- 
cine (Section  in  Laryngology  and  Rhinology)  ;  New  York 
Society  of  Internal  Medicine ;  New  York  Surgical  Society ; 
Brooklyn  Pediatric  Society. 

Thursday,  October  28th. — Hospital  Graduates'  Club,  New 
York ;  New  York  Physicians'  Association  ;  Ex-Intern  Soci- 
ety of  the  Methodist  Episcopal  Hospital,  Brooklyn. 

Friday,  October  2gth. — Hospital  Graduates'  Club,  Brook- 
lyn. 

Personal. — Sir  Berkeley  Moynihan,  C.B.,  M.S., 
F.  R.  C.  S.,  of  Leeds,  England,  read  a  paper  on 
Gastric  Ulcer  and  Its  Treatment  at  a  stated  meet- 
ing of  the  New  York  Academy  of  Medicine,  Thurs- 
day evening,  October  21st. 

Dr.  James  Francis  Brady,  of  Boston,  has  been 
placed  in  charge  of  the  Dermatological  Department 
of  Carney  Hospital. 

Dr.  Byron  G.  Clark  announces  the  removal  of  his 
office  to  163  West  Ninety-second  Street,  New  York. 

Mr.  Ralph  Mosteller,  formerly  assistant  bacteri- 
ologist to  the  Board  of  Health  of  Atlanta,  Ga., 
returned  recently  from  Siberia,  where  for  two  years 
he  had  been  in  charge  of  the  clinical  laboratory  of 
the  Red  Cross  Russian  Island  Hospital  at  Vladi- 
vostok. 

Dr.  William  W.  Keen,  of  Philadelphia,  was  deco- 
rated recently  with  the  Belgian  order  by  the  King 
of  Belgium. 

Dr.  A.  B.  MacCallum,  of  Toronto,  administrative 
chairman  of  the  Research  Council  of  Canada,  has 
been  appointed  to  the  new  chair  of  biochemistfy  in 
McGill  University,  Montreal. 

Dr.  W.  D.  Witherbee  has  resigned  from  the  staff 
of  the  Rockefeller  Instittite  for  Medical  Research 
and  has  opened  an  office  at  116  East  53d  Street, 
where  his  practice  will  be  limited  to  x  ray  therapy. 
He  will  also  have  charge  of  the  x  ray  work  at  the 
Presbyterian  Hospital. 


October  23,  1920.] 


NEWS  ITEMS. 


643 


Conference  on  Venereal  Diseases. — The  All- 
America  Conference  on  \'enereal  Diseases  will  be 
held  in  Washington,  D.  C,  December  6th  to  11th, 
under  the  auspices  of  the  United  States  Inter- 
departmental Social  Hygiene  Board  of  the  United 
States  PubHc  Health  Service,  the  American  Red 
Cross  Society,  and  the  American  Social  Hygiene 
Association.  The  administrative  committee  con- 
sists of  Dr.  Thomas  A.  Storey,  Dr.  C.  C.  Pierce, 
Dr.  Livingston  Farrand,  and  Dr.  WilHam  F.  Snow. 
The  aim  of  tlie  conference  is  to  bring  together 
recognized  authorities  and  to  make  possible  a  com- 
parison and  evaluation  of  the  methods  now  employed 
in  various  parts  of  the  world  for  the  control  of 
venereal  diseases.  All  correspondence  should  be 
addressed  to  the  Executive  Secretary,  411  Eighteenth 
Street,  X.  W.,  Washington,  D.  C. 

Public  Health  Service  Institute  on  Venereal 
Disease  Control. — The  United  States  Public  Health 
Service  has  organized  an  institute  on  venereal  dis- 
ease control  and  social  hygiene  to  be  held  in  Wash- 
ington, November  22d  to  December  4th.  The 
faculty  of  the  institute  will  consist  of  Dr.  J.  H. 
Stokes,  of  the  Mayo  Clinic,  Rochester,  Minn. ;  Dr. 
Hugh  Young,  of  Baltimore ;  Dr.  John  A.  Fordyce, 
of  New  York ;  Dr.  E.  L.  Keyes,  Jr.,  of  New  York ; 
Dr.  Thomas  M.  Balliet,  Dr.  William  A.  White,  Prof. 
M.  A.  Bigelow,  Dr.  Katherine  B  Davis,  Airs.  Martha 
P.  Falconer,  and  some  thirty  or  forty  other  leading- 
specialists. 

During  the  ten  days  of  the  Institute  four  full 
courses  and  eleven  half  courses  will  be  given.  The 
first  three  full  courses  will  consist  of  lectures  on 
the  diagnosis  and  treatment  of  the  venereal  dis- 
eases, and  the  fourth  will  be  on  delinquent  women 
and  their  relation  to  the  law.  The  half  courses  will 
be  on  the  diagnosis  of  the  mental  condition  of  delin- 
quent women  ;  on  protective  work  for  girls  ;  the  work 
of  the  venereal  disease  nurse ;  heredity  and  eugenics  ; 
sociology  and  social  hygiene ;  public  education  in 
venereal  diseases ;  law  enforcement ;  sex  psychology  ; 
clinic  management ;  and  clinic  social  work. 

Officers  of  State  and  city  boards  of  health,  clin- 
icians, nurses,  social  workers,  judges,  and  probation 
officers  of  courts  of  domestic  relations  and 
juvenile  courts,  police  matrons,  police  wo.nen, 
superintendents  of  eleemosynary  institutions, 
chiefs  of  police,  medical  officers  of  commercial  in- 
stitutions, urologists,  dermatologists,  gynecologists, 
neurologists,  psychologists,  and  officers  of  medical 
and  sociological  organizations  are  all  eligible  for  ad- 
mission to  the  Institute.  Others  who  wish  to  attend 
will  be  expected  to  present  credentials  from  State 
or  city  health  officers. 

Application  for  admission  should  be  made  as  soon 
as  possible  in  order  to  enable  those  in  charge  of  the 
institute  to  make  arrangements  for  the  educational 
facilities,  comfort,  and  pleasure  of  the  guests.  No 
applications  will  be  accepted  after  November  15th 
except  by  special  direction  of  the  Surgeon  General. 
Applications  that  have  been  sent  in  may,  however, 
be  withdrawn,  if  circumstances  make  attendance  im- 
possible. No  tuition  is  charged  the  generous  co- 
operation of  the  faculty  making  this  unnecessary. 
Hotel  accommodations  will  be  reserved  if  instruc- 
tions therefor  are  sent  to  the  U.  S.  Public  Health 
Service,  Washington,  D.  C. 


Medical  Society  of  the  County  of  New  York. — 

A  stated  meeting  of  this  society  will  'be  held  in 
Hosack  Hall,  New  York  Academy  of  Medicine, 
Monday  evening,  October  25th.  The  scientific  pro- 
gram will  consist  of  a  symposium  on  blood  trans- 
fusion, as  follows:  A  General  Introduction,  by  Dr. 
R.  Ottenberg ;  Indications  for  Blood  Transfusion, 
by  Dr.  R.  E.  Stetson ;  Selection  of  Donor,  by  Dr. 
L.  J.  Unger ;  Technic,  by  Dr.  R.  E.  Brennan  and 
Dr.  Richard  Lewisohn.  Among  those  who  will  take 
part  in  the  discussion  are :  Dr.  Harold  Hays,  Dr. 
C.  C.  Heyd,  Dr.  E.  Libman,  and  Dr.  E.  W.  Peterson. 

Medical  Society  of  Pennsylvania. — At  the 
twentieth  annual  meeting  of  this  society,  held  in 
Pittsburgh,  October  4th  to  7th,  under  the  presidency 
of  Dr.  Cyrus  L.  Stevens,  of  Athens,  the  following- 
officers  were  elected :  President,  Dr.  Henry  R. 
Jump,  of  Philadelphia ;  president  elect.  Dr.  Frank 
G.  Hartman.  of  Lancaster ;  first  vice  president.  Dr. 
Harold  A.  Miller,  of  Pittsburgh ;  second  vice  presi- 
dent. Dr.  Spencer  M.  Free,  of  Duboise;  third  vice 
president,  Dr.  David  Funk,  of  Harrisburg ;  fourth 
vice  president,  Dr.  Anthony  F.  Myers,  of  Blooming 
Glen;  secretary,  Dr.  Walter  F.  Donaldson,  of  Pitts- 
burgh (reelected)  ;  assistant  secretary,  Dr.  Christian 
B.  Longenecker,  of  Philadelphia ;  treasurer.  Dr.  John 
B.  Lowman,  of  Johnstown. 



Died. 

CoMEAu. — In  Norwich,  Conn.,  on  Fridaj-,  October  1st, 
Dr.  George  .A..  Comeaii. 

Dyer. — In  New  Orleans,  La.,  on  Tuesday,  October  12th, 
Dr.  Isadore  Dyer,  aged  fifty-four  years. 

GiLsoN. — In  Boston,  Mass.,  on  Wednesday,  October,  13th, 
Dr.  Alfred  H.  Gilson,  aged  sixty-seven  years. 

Kraft. — In  Weehawken,  N.  J.,  on  Thursdaj',  October 
14th,  Dr.  Charles  Kraft. 

McClane. — In  Clarksburg,  W.  Va.,  on  Saturday,  October 
9th,  Dr.  William  McClane,  aged  seventy-five  years. 

Morse. — In  New  York  City,  on  Sunday,  October  10th, 
Dr.  C.  F.  Morse,  aged  fifty-nine  years. 

Noble.— In  Brooklyn,  N.  Y.,  on  October  10th,  Dr.  Har- 
Viet  I.  Noble,  aged  sixty-one  years. 

RuppEL. — In  Lynn,  Mass.,  on  Sunday,  October  10th,  Dr. 
Emil  F.  Ruppel,  aged  sixty-one  years. 

ScHLEMM. — In  Union  Hill,  N.  J.,  on  Sunday,  October 
3rd,  Dr.  Richard  Schlcmm,  aged  fifty-five  years. 

Simmons. — In  Bangor,  Me.,  on  Monday,  October  4th, 
Dr.  William  Hammatt  Simmons,  aged  seventy-two  years. 

Stewart. — In  Canandaigua,  N.  Y.,  on  Tuesday,  October 
5th,  Dr.  Henry  Stewart,  aged  seventy-three  years. 

Stires. — In  Columbus,  Neb.,  on  Thursday,  September 
30th,  Dr.  Ferd  Taylor  Stires,  aged  thirty-eight  years. 

Spaulding. — In  Clifton  Springs,  N.  Y.,  on  Thursday, 
October  7th,  Dr.  Frank  W.  Spaulding,  aged  seventy-six 
years. 

Stutsman. — In  Seattle,  Wash.,  on  Wednesday,  September 
22nd,  t)r.  William  Harold  Stutsman,  of  Chicago,  aged 
thirty-four  years. 

Thomson. — In  Summit  Point,  W.  Va.,  on  Monday,  Octo- 
ber 4th,  Dr.  Augustus  Pembroke  Thomson,  aged  seventy- 
three  years. 


Book  Reviews 


PSYCHIATRY  IX  GERMANY 

Arbeiten  axis  der  Dcutschen  Forschungsanstalt  filr  Psychia- 
trie  in  Muncfvcn.  Edited  in  December,  1919.  Julius 
Springer,  Berlin,  1920. 

This  first  report  of  the  new  German  Institute  for 
Psychiatric  Research  is  richly  suggestive  of  the 
literary  and  scientific  character  to  be  expected  of 
the  contributions  which  will  be  made  through  its 
work.  Kraepelin's  review  of  the  history  of  psy- 
chiatry through  the  hundred  years  preceding,  with 
which  the  report  opens,  gives  an  instructive  outline 
of  the  facts  of  such  history  presented  with  a  stimu- 
lating appreciation  of  the  evolutionary  relation  of 
such  facts  to  one  another.  This  becomes  evident 
in  a  progressive  field  like  that  of  psychiatry,  which 
contains  the  promise  for  wider  developments  for 
the  future  as  they  gleam  through  the  slow  growth 
of  the  past.  The  somewhat  familiar  story  of  the 
abuses  which  arose  through  ignorance  and  super- 
stition, and,  we  might  add,  through  the  fear  of 
mental  facts  which  these  nourish,  receives  new  light 
from  Kraepelin's  treatment.  The  story  is  set  forth 
in  clearly  related  detail,  and  thus,  illustrated  as  it 
is  also  by  pictures,  it  gathers  together  in  striking 
summary  the  delays  and  yet  the  progress  in 
theoretical  and  experimental  approach  to  problems 
of  the  insane  made  simultaneously  in  the  several 
lands  of  Christendom.  It  reveals  the  similarity  and 
the  cooperation  w'hich  are  in  line  with  the  definite 
progress  of  enlightenment  and  with  the  growing 
conception  of  a  mental  reality  even  in  the  insane 
which  must  be  accepted  and  dealt  with  in  a  scienti- 
fically reasonable  manner. 

The  promise  for  wider  understanding  of  mental 
diseases  in  all  phases  of  approach  to  them  as  well 
as  for  the  possibilities  of  active  development  of  the 
science  of  psychiatry  is  more  than  intimated  in  the 
writer's  words.  This  prospective  work  is  still  more 
definitely  outlined  in  his  following  article  on  the 
goals  and  the  paths  of  psychiatric  research.  Fur- 
ther stimulus  is  given  in  his  presentation  of  the 
needs  of  research  into  the  various  forms  of  mental 
disease.  His  article  on  epilepsy  gives  a  brief 
glance  also  in  one  of  these  special  directions.  It 
does  not  lessen  the  force  of  his  appeal  for  the 
various  types  of  research,  of  which  this  report  gives 
encouraging  examples,  if  it  is  objected  that  too 
little  attention  is  given  to  the  general  background 
of  all  mental  disease  and  too  little  definite  emphasis 
laid  upon  the  weight  of  psychic  factors  which  work 
much  more  deeply  in  the  causation  and  development 
of  mental  disturbances  than  even  this  experienced 
obser\'er  makes  clear.  It  is  true  as  he  says  that  there 
is  not  one  mental  disease  but  that  research  should 
proceed  upon  the  admission  of  most  devious  paths 
for  research.  This  is  unquestionably  true  in  the 
field  of  anatomical  investigation ;  it  cannot  be  dis- 
puted from  the  viewpoint  of  many  psychic  factors 
and  countless  deviations  in  the  psychic  expression 
of  mental  disease.  Yet  there  is  danger  of  too  much 
distinction  which  tends  to  separate  too  sTiarply  any 
disease  manifestation  from  the  whole  background 
of  personal  character  and  of  energy  striving.  The 
fuller  acceptance  of  such  unified  background  does 


not  confusedly  merge  dit?erent  pathways  of  research 
but  would  obliterate  falsely  distinctive  boundaries 
which  too  often  shut  out  the  more  vital  interpreta- 
tion. 

Such  criticism  would  in  no  way  detract  from  the 
high  character  of  the  special  research  reports  which 
are  published  here.  These  fully  indicate  the  scienti- 
fic thoroughness  and  exactitude  of  the  work  that 
may  be  expected  from  the  investigators  working 
under  this  institute.  .  The  various  subjects  are 
treated  with  a  completeness  of  detail,  a  fulness  of 
description,  and  a  wealth  of  illustration  worthy  of 
note. 

A  last  word  from  Nissl  appears  in  regard  to  the 
histological  implications  of  the  spirochete.  He  has 
also  confributed  an  extended  notice  of  Brodmann's 
work,  whose  death  preceded  Nissl's  own.  Spielmeyer 
has  contributed  a  paper  on  the  histopathology 
of  the  cortex  in  typhus,  as  well  as  a  study  of  the 
relations  between  ganglion  cell  changes  and  gliosal 
phenomena.  Plaut  reports  upon  the  Sachs-Georgi 
reaction  in  syphilis  and  together  with  Steiner  upon 
recurrent  infection  in  general  paresis.  Spatz  has 
a  study  of  a  special  manner  of  reaction  of  the 
immature  central  nervous  tissue.  There  are  also 
briefer  reports  of  papers  presented  at  meetings  of 
the  institute.  Most  of  the  articles  of  the  collection 
have  appeared  in  the  Zcitschrift  filr  die  gesammcltc 
Neurologic  unci  Psychiatric  but  all  are  here  pre- 
sented in  convenient  book  form. 

THE  PROBLEMS  OF  PARENTHOOD 

Problems  of  Population  and  Parenthood.  Being  the  Sec- 
ond Report  of  and  the  chief  evidence  taken  by  the  Na- 
TioxAL  Birth  Rate  Commission,  1918-1920.  New  York: 
E.  P.  Button  &  Co..  1920.    Pp.  v-423. 

It  was  like  a  nightmare  of  immigration  with  no 
officers  to  control,  no  Ellis  Island.  All  day,  every 
day,  there  was  a  swift  incoming  of  white  babies,, 
brown  babies,  black  babies,  crjdng,  smiling,  with 
well  rounded  limbs,  with  limbs  distorted,  splendidly 
healthy,  woefully  diseased,  babies  eagerly  welcomed, 
babies  unloved,  unwanted.  Some  so  spent  with  the 
journey  that  they  soon  flittered  back  into  the  great 
silence,  with  no  power  of  speech  to  tell  their 
amazement  at  so  blank  a  world.  Those  who  stayed 
on  grew  to  earn  the  name  of  "a  problem"  for  though 
pocketless  the  rogues  had  brought  in  large  stores 
of  original  sin  and  imoriginal  disease,  so  that 
flurried  philanthropists  had  to  enlarge  the  reforma- 
tories and  idiot  asylums  and  devise  means  for  only 
better  babies  to  land  in  the  world. 

It  was  sad  to  learn  at  their  last  big  meeting  in 
London  that  men  like  Professor  Leonard  Hill  and 
Dr.  Saleeby  had  each  a  family  of  six  and  no  means 
of  bringing  them  up  healthily ;  that  Sir  Rider  Hag- 
gard and  Professor  Arthur  Keith  had  only  a  two 
roomed  lodging  and  no  playground  near  for  their 
children.  That  Miss  Maude  Royden  and  Dr.  Marie 
Stopes,  though  warned  of  the  social  disabilities  and 
the  immorality,  had  children  called  children  of 
shame,  and  the  Bishop  of  Birmingham  and  Dr. 
Sims  Woodhead  had  married  at  the  early  age  of 
sixteen  and  preferred  to  live  in  a  slum  with  their 
children  rather  than  accept  a  fifty  acre  tract  of  land 


October  23,  1920.] 


BOOK  REVIEWS. 


645 


the  other  end  of  nowhere  with  free  air  and  water. 
Principal  Garvie  and  Major  Leonard  Dawson  were 
found  incorrigible  in  preferring  a  glass  of  beer  at 
the  saloon  every  night  to  staying  at  home  in  their 
kitchen-parlor-bedroom  while  their  wives  washed 
up  the  supper  things  and  the  baby.  Lady  Selborne 
and  Mrs.  Bramwell  Booth,  though  repeatedly 
warned,  had  trusted  their  three  weeks'  old  babies 
to  minders  only  ten  years  old,  while  they  themselves 
went  out  to  work  when  debts  were  many  and 
pennies  few.  Mr.  Sidney  Webb  and  Sir  Conan 
Doyle  spent  their  evenings  going  to  vaudeville  and 
movies,  though  they  both  had  a  luxurious  un- 
warmed,  unventilated  attic  at  two  dollars  a  week 
and  could  have  had  pleasant  evenings  with  books 
on  racial  degeneration  and  social  hygiene  from  the 
free  libraries.  The  accumulation  of  records  during 
six  years'  work  showed  sixty  thousand  aristocratic 
lunatics  to  have  married  with  an  income  of  only 
nine  thousand  dollars  a  year.  The  daughters  of  the 
rich,  though  aware  of  the  kind,  winning  treatment 
w^hich  the  w^orld  would  give,  persisted  in  going 
wrong  and  wickedly  refused  to  be  restrained  in  a 
beautiful,  cheerful  home  and  do  washing  in  order 
to  go  right.  It  was  also  found  that  Judge  Henry 
Xeil  and  Dr.  Eric  Pritchard,  subway  laborers,  re- 
fused to  take  a  bath  each  night  at  the  public  baths 
when  work  wearied,  but  unwholesomely  ate  un- 
wholesome food  unwashed. 

But  the  reviewer  had  evidently  become  a  little 
distracted  with  the  appalling  contents  of  the  national 
cesspool.  It  was  the  people  who  were  weak  and 
foolish.  The  big  people  mentioned  were  met  to 
discuss  their  reformation.  But  what  had  kept  them 
decent  citizens  ?  Xot  leisure ;  they  often  worked 
harder  than  the  workmen.  Not  education ;  that  was 
free  to  all. 

Well,  the  commission  of  rich  and  learned  men 
and  women  discussed  the  prenatal,  the  postnatal 
baby :  the  care  of  the  pregnant  mother,  the  un- 
married mother,  the  illegitimate  father ;  whether 
help  in  avoiding  venereal  disease  and  care  for  love 
babies  would  increase  vice.  (Many  thought  it 
would).  Who  should  emigrate  and  to  what  land? 
Is  it  wrong  to  arrest  pregnancy?  Decided — No 
nation  can  acquiesce  in  the  destruction  of  children. 
It  was  found  that  the  defensive  and  industrial 
powers  of  the  empire  are  in  danger  if  the  increasing 
diminution  of  the  birth  rate  continues,  especially  as 
the  decrease  is  chiefly  among  those  most  capable 
of  having  healthy  children.  The  questions  of 
alcoholism,  gonorrhea,  syphilis,  tuberculosis,  re- 
striction of  children  earning  wages,  good  housing, 
recreation  centres,  food,  endowment  of  mother- 
hood, were  fully  gone  into,  in  fact,  there  was  a 
mass  of  evidence  from  well  known  men  and  women 
which  showed  thorough  and  exhaustive,  even 
sympathetic  study.  A  special  warning  was  given 
by  Sir  Rider  Haggard  to  train  the  tide  of  emigration 
frgm  England  to  her  own  colonies,  and  to  combat 
the  growing  socialism  which  would  like  to  keep 
emigrants  out  in  case  of  having  to  share. 

The  choice  of  the  commission  was  wonderfully 
wide :  the  evidence  was  fully  reported  and  six 
years  of  it  should  bear  weight,  but  it  would  be  help- 
ful to  know  why  the  commissioners  were  not  being 


judged  as  well  as  the  people,  or,  if  you  prefer — 
masses,  lower  classes,  submerged  tenth.  What  has 
the  rich  man  that  the  working  man  lacks,  that  he 
requires  no  investigation  ?  The  latter  has  free  parks, 
education,  medical  care,  libraries,  museums,  baths, 
assisted  emigration,  disablement  pensions,  clubs, 
music,  everything  save  the  certainty  of  wages,  a 
suitable  home  and  that  home  his  own.  He  would 
rather  have  a  small,  healthy  house,  a  little  garden 
all  his  own,  than  live  in  a  workman's  model  dwell- 
ing and  have  all  Central  Park  free  for  his  children 
to  play  in.  Work  as  he  will,  a  few  weeks  of  in- 
voluntary idleness  will  exhaust  his  savings  and 
risk  his  being  turned  out  of  his  home.  He  has 
nothing  he  can  call  his  own,  and  is  humiliatingly 
forced  to  take  anything  a  generous  or  a  depraved 
municipality  will  offer.  This  is  the  greatest  obstacle 
to  reform :  Uncertainty  of  labor  and  no  sure 
dwelling  place.  Meanwhile  it  would  advance 
progress  if  a  commission  were  chosen  to  inquire 
why  the  rich  needed  no  such  agency. 

BEYOND  LAW. 

The  Rescue.    By  Joseph  Coxr.^d.    Garden  City  :  Double- 
day,  Page  &  Co..  1920.   Pp.  iii-404. 

Mr.  Conrad's  latest  book  is  not  entirely  his  latest 
conception.  It  embodies  a  theme  which  he  bore 
around  with  him  for  many  years,  returning  to  it 
again  and  again  until  it  took  the  form  of  the  present 
novel.  The  Rescue  is  one  of  those  marvelous  Con- 
rad works,  all  shimmering  with  color,  filled  with 
the  mystery  of  strange  seas  and  the  high  handed 
deeds  of  adventurers  who  were  beyond  law.  In  it 
the  author  tells  of  the  attempt  to  rescue  a  kingdom 
of  the  South  Seas,  of  a  ^lalay  princess  and  a  British 
yacht,  of  a  woman  who  was  too  civilized,  and  of  a 
man  who  was  "undone  by  a  glimpse  of  paradise" — 
Captain  Lingard  or  King  Tom. 

It  would  be  futile  to  outline  the  story,  for  no  mere 
indication  of  theme  could  give  an  idea  of  its 
penetrating  analysis  of  human  motives,  of  the  rich- 
ness of  its  setfmg,  and  of  the  exquisite  prose.  Mr. 
Conrad  has  chosen  as  his  main  character  a  figure 
of  extraordinary  interest.  "Whatever  he  (Lingard) 
might  have  been  he  was  not  medicore.  The  glamour 
of  a  lawless  life  stretched  over  him  like  the  sky 
over  the  sea  down  on  all  sides  to  an  unbroken 
horizon.  Within,  he  moved  very  lonely,  dangerous 
and  romantic.  There  was  in  him  crime,  sacrifice, 
tenderness,  devotion,  and  the  madness  of  a  fixed 
idea." 

Lingard,  the  owner  of  a  brig,  has  pledged  him- 
self to  help  Hassim  and  his  sister,  Immada,  regain 
their  kingdom  of  Wajo.  Something  of  "the  mad- 
ness of  a  fi.xed  idea"  is  in  his  determination.  And 
then  into  his  horizon  comes  the  yacht  of  Mr. 
Travers,  bearing  with  it  all  the  decorum  and  dulness 
of  British  officialdom — and  Mr.  Travers'  wife.  "It 
seemed  to  him  that  till  iMrs.  Travers  came  to  stand 
by  his  side  he  had  never  known  what  truth  and 
courage  and  wisdom  were." 

The  story  does  not  seem  to  be  told  as  much  as 
to  unfold  -itself,  so  absorbing  are  the  persons  con- 
cerned and  so  inevitable  the  denouement.  .  Mr. 
Conrad  is  a  master  at  this  sort  of  thing.  His 
characters  seem  to  reveal  themselves  almost  with- 


646 


BOOK  REVIEWS. 


[New  York 
Medical  Journal. 


out  external  aid,  so  deftly  does  the  author  encourage 
them.  There  are  no  undigested  lumps  of  psy- 
chologj- ;  instead  there  is  illumination  in  almost  every 
gesture.  W^ith  Mrs.  Travers,  ]\Ir.  Conrad  is  slightly 
less  successful  than  in  the  depiction  of  King  Tom. 
She  remains  something  of  a  mystery,  a  woman 
whose  disenchantment  with  life  is  hinted  at  but  not 
fully  revealed.  We  never  really  catch  her  off  her 
guard.  In  the  case  of  many  writers  who  care  as 
much  about  the  setting  as  Mr.  Conrad,  the  internal 
struggle  of  the  characters  might  as  well  take  place 
somewhere  el^e.  This  is  not  so  with  The  Rescue. 
One  cannot  imagine  the  drama  of  King  Tom 
and  Hassim  and  Edith  Travers  having  been  played 
out  in  another  environment.  King  Tom  himself  is 
too  representative  of  that  life  beyond  law. 

And  yet  real  as  this  book  is,  compelling  and 
beautiful  as  it  is,  it  may  easily  leave  the  reader 
unsatisfied.  ]\1t.  Conrad  is  far  too  sympathetic 
with  his  characters  to  regard  them  as  puppets,  and 
yet  in  effect  they  are  just  that,  in  the  sense  that 
human  beings  everywhere  are  puppets.  These 
people  move  in  a  setting  that  dwarfs  them  by  its 
gorgeousness,  small  and  helpless  and  terribly  alone 
amid  a  sea  and  sky  that  have  no  concern  with  them, 
in  a  terrible,  impersonal  beauty  that  only  emphasizes 
their  isolation.  One  feels  in  the  author's  attitude 
that  same  detachment,  the  absence  of  a  word  of 
hope. 

■    A  NEW  DISSECTOR. 

The  Anatomy  of  Socictv.     Bv  Gilbert  Caxxax.  New 
York :  E.  P.  Button  &  Co.,  1919.    Pp.  v-216. 

Gilbert  Cannan,  who  wields  one  of  the  most 
trenchant  pens  among  the  younger  English  novel- 
ists, has  written  a  book  which  is  part  treatise,  part 
sermon  and  part  prophecy,  which  is  vehement  and 
incoherent  and  at  times  splendid.  It  is  a  rather 
young  book.  Dissecting  society  is  a  large  order. 
Mr.  Cannan  keeps  up  a  verbal  barrage  against  cap- 
ital, restrictions  on  divorce,  tyranny,  institutional- 
ism,  and  every  sort  of  exploitation.  He  believes  in 
freeing  parents  from  their  children  and  from  each 
other  when  desirable,  in  reclaiming  the  school,  in 
socializing  industry — in  freeing  the  human  spirit. 
Interesting,  but  difficult.  Dissection  is  an  opera- 
tion which  should  be  attended  with  calmness,  and 
Mr.  Cannan  is  not  calm.  He  hits  society  on  the 
head  with  an  axe  and  considers  the  job  done. 

INTERRUPTED  LAUGHTER. 

The  Broken  Laugh.   By  Meg  Villars.   New  York :  Robert 
McBride  &  Co..  1920.   Pp.  vii-343. 

If  one  were  given  two  guesses  as  to  Miss  Villars's 
favorite  reading  matter,  the  first  would  be  the 
novels  of,  Compton  McKenzie  and  the  second  the 
Ladies'  Home  Journal.  .She  has  not  achieved  the 
blend  of  farce  comedy  and  metaphysics  of  the  Sylvia 
Scarlett  novels ;  in  place  of  the  metaphysics  are  bits 
calling  for  an  emotional  tear  or  two  if  one  is  that 
sort  of  person.  But  the  foundation  is  McKenzie — 
snappy  narrative  built  around  an  obscure  little  per- 
son who  is  no  better  than  she  should  be,  complica- 
tions interwoven  with  what  the  newspapers  call 
human  interest,  a  dash  of  sentiment — the  whole 
designed  to  keep  the  reader  up  all  night  if  he  is 
unfortunate  enough  to  start  it  in  the  evening. 


The  heroine  is  named  Kissy,  and  as  a  result  of 
gullibility  and  ignorance  she  has  a  baby  the  father 
of  which  she  does  not  even  know.  Her  journey 
to  Paris  after  she  has  identified  the  man  by  a  news- 
paper clipping  and  the  subsequent  adventures  that 
befall  her  when  she  learns  her  mistake  form  the 
theme  of  the  story.  Miss  Villars  is  not  quite  as 
snappy  as  IMr.  McKenzie  and  the  narrative  drags 
in  spots,  particularly  toward  the  end.  The  con- 
clusion is  a  nicely  tempered  bit  of  justice.  Miss 
\'illars  does  not  want  to  be  too  hard  on  Kissy, 
neither  can  she  exonerate  her  after  the  baby  and 
her  ending  is  nicely  calculated  to  obviate  both  of 
these  courses. 

TALKS. 

Ten  Minute  Talks  JVith  Workers,  from  Tlie  Times  (Lon- 
don) Trade  Supplement.  Pp.  208.  New  York:  Double- 
day,  Page  &  Co.,  1920. 

There  are  many  shoutful,  aggressive  arguers  who 
delight  to  get  an  audience  and  choke  them  with 
phrases.  Many  such  use  terms  of  which  they  know 
not  the  exact  meaning  themselves  or  as  little  as 
those  they  talk  to.  Now  if  the  bullied  will  carefully 
study  these  Ten  Minute  Talks  they  will  understand 
the  terms  used  in  labor  and  capital,  profits  and 
wages,  banks  and  markets,  and  be  able  to  use 
staggering  arguments  to  discomfit  the  windbag  of 
words  next  time  he  comes  along,  for  the  book  is 
clearly  written. 

 . 

New  Publications  Received. 


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


PEARLS  ASTRAY.  A  Romantic  Episode  of  the  Last  Democ- 
racy. By  CoxsTAxcE  M.  Warren.  Illustrated.  Boston: 
Small,  Maynard  &  Co.,  1920.    Pp.  158. 

PATHOLOGiscHE  BiOLOGiE.  (Immunitatswisscnschaft.) 
Dritte  Auflage.  Von  Prof.  Dr.  Haxs  Much.  Leipzig: 
Verlag  von  Curt  Kabitzsch,  1920.    Seiten  323. 

AMERICAX  MEDICAL  BIOGRAPHIES.     Bv  HoWARD  A.  KeLLY 

M.  D.,  LL.  D.,  F.  A.  C.  S.,  Hon.  F.  R.  C.  S.  (Edin.),  and 
Walter  L.  Burrage,  A.  M.,  M.  D.  Baltimore :  The  Nor- 
man Remington  Company,  1920.    Pp.  xix-1320. 

DIE    THER.A.PIE    AX    DEN    BONNER  UNIVTRSIT-XTSKLINIKEN. 

Herausgegeben  von  Prof.  Dr.  Rudolf  Finkelnburg,  in 
Bonn,  Dritte,  vermehrte  Auflage.  Bonn :  A.  Marcus  &  E. 
Webers  Verlag  (Dr.  Jur.  Albert  Ahn),  1920.  Seiten  xii-74S. 

THE  VICTORY  AT  SEA.  By  Rear  Admiral  Willi.\m  Sowdex 
Sims,  U.  S.  Navy,  Commander  of  the  American  Naval 
Forces  Operating  in  European  Waters  During  the  Great 
War,  in  Collaboration  with  Burton  J.  Hendrick.  Garden 
City-New  York :  Doubleday,  Page  &  Co.,  1920.    Pp.  xi-410. 

DIAGNOSTIK  UNO  THERAPIE  DER  KINDERKRAXKHEITEX.  Mit 

speziellen  Arzneiverordnungen  fiir  das  Kindesalter.  Ein 
Taschenbuch  fiir  den  praktischen  Arzt.  \'on  Prof.  Dr.  F. 
Lust,  Oberarzt  der  Universitats-Kinderklinik  in  Heidelberg. 
Zweite  neubearbeite  Auflage,  Berlin  N-Wien  I :  Urban  & 
Schwarzenberg,  1920.    Seiten  vi-471. 

PATHOGENIC  MiCROORGAXiSMS.  A  Textbook  of  Microbiol- 
ogy for  Physicians  and  Students  of  Medicine.  By  Ward  J. 
M.\cNeal,  Ph.  D.,  M.  D.,  Professor  of  Pathology  and  Bac- 
teriolog>-  and  Director  of  the  Laboratories  in  the  New  York 
Post-Graduate  Medical  School  and  Hospital,  New  York. 
Second  Edition,  Revised  and  Enlarged.  Illustrated.  Phila- 
delphia :  P.  Blakiston's  Son  &  Co.    Pp.  xx-488. 


Practical  Therapeutics  and  Preventive  Medicine 

A  Compendium  of  Treatment  and  Prophylaxis,  Origmal  and  Adapted 


Radium  Puncture  in  the  Treatment  of  Cancer. 

— C.  Regaud  (Paris  medical,  February  7,  1920) 
notes  that  radium  puncture  consists  in  introducing, 
into  a  tumor  for  example,  needles  charged  with 
radium.  By  suitable  implantation  of  the  needles  a 
high  degree  of  evenness  in  the  exposure  of  the 
tumor  tissues  to  the  radium  can  be  obtained.  The 
treatment  is  very  economical  in  the  sense  that,  for 
equal  effects,  it  requires  much  less  radioactive  en- 
ergy than  does  the  external  application  of  radium. 
In  a  thick  tumor  mass,  a  few  millicuries  introduced 
with  the  needles  yield  greater  effects  than  would 
several  hundreds  of  millicuries  used  externally.  In 
the  last  eight  months  the  author  and  his  coworkers 
have  used  radium  puncture  in  about  fifty  miscel- 
laneous malignant  tumors.  Too  little  time  has  as  yet 
elapsed  to  speak  of  cures,  but  there  have  occurred 
at  least  temporary  remissions  in  the  cases,  all  in- 
operable, so  far  treated.  The  method  undoubtedly 
marks  a  great  step  forward  in  the  treatment  of  mal- 
ignant growths,  both  because  it  affords  new  possi- 
bilities in  the  treatment  of  certain  rather  inacces- 
sible forms  of  cancer  and  because  it  procures  an 
increase  of  therapeutic  efficiency  in  the  treatment  of 
relatively  insensitive  and  bulky  tumors.  While 
highly  efficacious,  radium  puncture  is  harmless  only 
when  radiation  of  healthy  tissues  is  avoided.  An 
illustrated  description  of  the  armamentarium  and 
technique  is  presented. 

Treatment  of  Congenital  Dislocation  of  the 
Hip.— Calot  (Bttlletin  de  I' Academic  de  mcdccine_ 
April  20,  1920),  from  extensive  anatomical  and 
pathological  studies,  as  well  as  from  x  ray,  clinical, 
and  therapeutic  observation  in  several  thousand  chil- 
dren treated  for  congenital  dislocation,  found  that 
hitherto  x  ray  specialists  and  surgeons  have  nearly 
always  misjudged  the  location  of  the  upper  margin 
of  the  primitive  cotyloid  fossa,  into  which  the  head 
of  the  femur  must  be  finally  adjusted  if  true  ana- 
tomical cure  is  to  be  obtained.  This  upper  limit  is 
not  situated  at  the  uppermost  and  outermost  point 
of  the  diagrammatic  V  representing  the  cotyloid 
region  in  x  ray  textbooks,  but  at  the  apex  of  the 
V,  i.  e.,  at  the  upper  part  of  the  Y  cartilage.  Be- 
cause of  this  anatomical  error,  incomplete  and  false 
reductions,  rather  than  true  reductions,  have  been 
obtained.  The  primitive  cotyloid  fossa  corresponds 
in  small  children  to  the  ischial  and  not  the  ilial  por- 
tion of  the  coxal  bone.  A  mistake  has  also  been 
made  in  placing  the  axis  of  the  head  and  neck  of 
the  femur  in  an  oblique  direction.  Instead,  this 
axis  should,  on  x  ray  observation,  be  found  hori- 
zontal. The  head  should  be  opposite  the  ischial 
portion ;  the  fteck  should  appear  in  its  greatest 
length,  and  contact,  or  better,  insertion  of  the  head 
and  cotyloid  fossa  should  be  obtained.  If  this  is  not 
possible  at  first,  it  may  be  gradually  secured  by 
pressure  with  cotton  upon  the  great  trochanter 
through  an  opening  for  it  in  the  plaster  apparatus 
opposite  the  trochanter.  A  broad,  horizontal  vault 
for  the  head  must  be  created  at  the  proper  point. 


This  is  accomplished  both  by  keeping  the  axis 
of  the  head  and  neck  transverse  througliout  the 
period  of  immobilization  and  by  flexing  the  thigh 
to  an  angle  of  135°  in  the  first  apparatus  used. 
This  overflexion  also  serves  to  correct  the  frequent- 
ly existing  anteversion  and  antetorsion  of  the  head 
and  neck.  Autopsies  and  radiographs  showed  that  a 
roof  for  the  cotyloid  fossa  as  horizontal,  strong, 
and  extensive  as  on  the  normal  side  can  thus  be 
created  in  from  eight  to  twelve  months.  The  newly 
formed  roof  or  vault  appears  in  the  x  ray  picture 
as  stalactites  and  islets  of  bone  which  later  become 
confluent.  Equivalent  changes  take  place  even  in  the 
very  small  children,  in  whom  ossification  is  normally 
less  advanced.  To  avoid  undue  encroachment  upon 
the  femoral  head  by  the  bony  proliferations  above 
it,  the  head  is  not  left  in  a  fixed  position  through- 
out the  eight  to  twelve  months,  but  is  moved 
through  the  use  of  three  successive  plaster  dressings, 
the  first  holding  the  thigh  flexed  at  135°,  the  second 
at  90°,  and  the  third  at  45°. 

Chemotherapy  of  Chronic  Tuberculous  Infec- 
tions.— H.  Grenet  and  H.  Drouin  (Bulletin  dc 
I' Academic  de  medecine,  March  9,  1920)  refer  to 
the  experiments  of  A.  Frouin  which  showed  that 
intravenous  injections  of  the  sulphates  of  samarium, 
lanthanum,  neodymium,  and  praseodymium  induce 
an  intense,  progressive,  and  lasting  mononuclear 
leucocytosis,  and  that  in  vitro  the  same  salts  cause 
definite  alterations  in  the  vitality,  morphology,  and 
chemical  constitution  of  the  tubercle  bacillus,  the  fat 
content  of  which  is  reduced  from  thirty-five  or  forty 
per  cent,  to  twenty-two  or  even  sixteen  per  cent. 
Clinically,  intravenous  injections  of  a  two  per  cent, 
solution  of  one  of  the  above  mentioned  compounds — 
usually  neodymium  sulphate— were  given  in  series 
of  twenty  or  twenty-five,  daily  or  on  alternate  days, 
repeated  after  intervals  of  fifteen  or  twenty  days. 
The  dose  was  gradually  increased  from  two  to  five 
mils  of  the  two  per  cent,  solution.  The  injections 
were  well  borne  in  cases  of  local  tuberculosis  or 
with  small  pulmonary  lesions  and  in  fair  general 
health.  In  more  severe  pulmonary  cases  the  treat- 
ment caused  temporarily  slight  lassitude  and  loss  of 
weight.  In  hectic  cases  and  those  with  extensive 
cavities  the  treatment  was  not  tried.  In  eight  cases 
of  tuberculous  lymphadenitis  marked  improvement 
followed  one  or  two  series  of  injections,  the  glands 
becoming  smaller,  movable,  hard,  and  fibrotic,  and 
long  standing  sinuses  closing  in  fifteen  to  twenty 
days.  In  eleven  cases  of  lupus  erythematosus  and 
two  cases  of  indurated  erythema  rapid  improve- 
ment usually  occurred,  the  lupus  cases  sometimes 
being  cured  in  a  few  days,  or,  where  of  longer 
standing,  after  one  or  two  series  of  injections. 
Among  twenty-four  cases  of  true  skin  tuberculosis, 
weeping  and  suppurating  lesions  were  soon  dried  up, 
and  later  healing  took  place,  in  some  instances  with 
scarifications  or  the  cautery-  as  auxiliary  measures. 
Lupoid  tubercles  of  the  nasal  mucosa  were  cured 
without   local   treatment.     The   pulmonary  cases 


648 


PRACTICAL   THERAPEUTICS   AND  PREVENTIVE  MEDICINE. 


[New  York 
Medical  Journal. 


treated  included  three  in  which,  in  spite  of  manifest 
physical  signs,  no  tubercle  bacilli  had  been  found 
before  the  beginning  of  treatment,  and  twenty-one 
with  tubercle  bacilli,  subcrepitant  or  crackling  rales 
at  the  apexes,  rough  breathing,  prolonged  expira- 
tion, etc.  In  the  first  group,  'all  physical  signs  dis- 
appeared and  apparent  recovery  was  secured  in  from 
two  to  six  months.  In  the  second  group,  expectora- 
tion ceased  in  four  after  two  to  seven  months  of 
treatment ;  the  bacilli  apparently  disappeared  in 
eight;  rales  disappeared  in  all  but  one  of  these 
twelve  cases.  In  the  remaining  nine  cases  of  the 
second  group  tubercle  bacilli  were  still  present  after 
treatment,  but  always  showed  morphological  changes, 
becoming  narrow,  branched,  and  agglutinated,  or 
stout,  short,  and  irregular  in  outline,  invariably  with 
poor  staining  properties.  X  ray  examinations 
showed  improvement  corresponding  to  that  noted 
in  the  physical  signs.  In  brief,  all  patients  were 
benefited   by   the  treatment 

Colloidal  Arsenic  and  Silver  in  the  Treatment 
of  Influenza. — Capitan  {Bulletin  de  I' Academic 
dc  mcdccinc,  March  9,  1920)  reports  recent  cases 
illustrating  the  value  of  intravenous  or  intramus- 
cular injections  of  colloid  arsenic  and  silver  in  grave 
influenza  cases.  In  a  case  seen  with  Tertois,  the 
patient  was  a  man  aged  ninety  years  with  double 
basal  bronchopneumonia,  subnormal  temperature, 
and  delirium.  In  addition  to  the  ordinary  measures, 
such  as  cupping,  camphor  in  oil,  strychnine,  and 
sparteine,  intramuscular  injections  of  two  mils  of 
colloidal  arsenic  into  the  buttocks,  morning  and  even- 
ing, were  administered.  Progressive  improvement 
followed,  and  after  four  days  the  dose  was  reduced. 
Complete  recovery  took  place.  In  the  same  patient's 
wife,  aged  seventy-seven,  and  likewise  gravely  ill,  in- 
jection of  two  one  mil  doses  of  colloidal  arsenic  and 
two  three  mil  doses  of  colloidal  silver  was  followed 
by  defervescence  in  twenty-four  hours  and  eventual 
recovery.  Similar  results  were  obtained  in  other 
cases.  The  colloidal  preparations  employed  are  ad-, 
vantageous  in  being  nontoxic  and  in  acting  rapidly. 

Iodine  Absorption  from  the  Human  Skin. — 
Norman  C.  Wetzel  and  Torald  Sollmann  {Journal 
of  Pharmacology  and  Experimental  Therapeutics, 
April,  1920)  report  experiments  in  which  iodine 
tincture  was  painted  on  the  palmar  surface  of  the 
forearm  and  other  iodine  preparations  rubbed  thor- 
oughly into  the  skin  of  the  chest  and  abdomen.  Con- 
trary to  the  widely  prevalent  impression  that  free 
iodine  is  absorbed  (juite  readily  through  the  skin, 
the  urine  did  not  contain  demonstrable  quantities  of 
iodine  compounds.  Failure  to  excrete  iodine  does 
not  necessarily  mean  that  none  is  absorbed,  for  if 
only  very  small  amounts  have  been  absorbed  it  is 
conceivable  that  they  may  be  retained  completely 
in  the  body.  Yet  the  experiments  are  held  to  have 
shown  that  the  absorption  of  iodine  through  the  skin 
is  not  nearly  as  extensive  as  is  commonly  supposed. 
The  results  obtained  referred  only  to  single  appli- 
cations to  normal  skin.  Probably  if  the  skin  is 
injured,  as  by  repeated  applications  of  strong  io- 
dine solution,  its  ])ermeability  may  be  increased.  This 
would  doubtless  occur  if  there  were  actual  vesica- 
tion, f)r  probably  even  if  the  epidermis  had  been 
desf|uamated. 


Treatment  of  Enterocolitis  in  Infancy. — W. 

W.  Harper  {Southern  Medical  Journal,  June, 
1920)  says  that  to  treat  enterocolitis  successfully, 
one  must  make  a  distinction  between  the  cases  due 
to  the  gas  bacillus  and  those  due  to  the  dysentery 
bacillus.  The  former  thrives  best  on  a  carbohy- 
drate diet,  so  this  infection  is  best  combated  by 
withholding  carbohydrates  and  giving  proteins, 
while  carbohydrates  furnish  media  not  favorable 
to  the  growth  of  the  dysenteric  group  of  organisms 
and  is  the  food  of  preference  in  the  early  stages  of 
such  infection,  although  there  are  subjects  who  do 
better  on  a  protein  diet.  Again,  the  infection  may 
be  principally  in  the  lower  ileum,  or  in  the  lower 
colon ;  in  the  former  case  there  is  early  and  pro- 
found toxemia,  rapid  desiccation  of  the  tissues,  a 
marked  tendency  to  acidosis,  and  often  a  severe 
nephritis.  Absence  of  lactic  acid  bacilli  indicates 
that  the  intestinal  canal  has  surrendered  to  the  in- 
vading bacteria.  The  treatment  is  as  follows:  1. 
Prompt  cleaning  of  the  intestinal  canal  by  cathar- 
sis and  enema ;  2,  withdrawal  of  all  food  for  twen- 
ty-four to  forty-eight  hours;  3,  sowing  the 
intestinal  canal  with  virile  strains  of  lactic  acid 
bacilli ;  4,  an  abundance  of  water  by  mouth,  rec- 
tum, and  hypodermoclysis ;  5,  free  administration  of 
alkalies  and,  if  acidosis  threatens,  the  use  of  car- 
bohydrates ;  6,  adopting  measures  to  prevent 
urinary  suppression ;  7,  early  return  to  breast  or 
bottle. 

As  an  initial  purge  the  writer  prefers  castor  oil. 
If  the  first  dose  is  vomited,  a  second  is  given  at 
once,  and  if  this  is  vomited  a  third.  From  the 
three  doses  enough  will  be  retained  to  act.  An 
enema  of  two  teaspoonfuls  of  sodium  bicarbonate  to 
a  quart  of  warm  water  is  given  every  six  hours  for 
the  first  day  or  two.  All  food  is  withdrawn  and 
water  forced.  To  encourage,  the  drinking  of  wa- 
ter, it  may  be  given  as  iced  tea,  lemonade  or 
orangeade,  sweetened  with  saccharine.  If  the 
baby  refuses  to  take  the  fluids,  or  if  there  is  marked 
nausea  or  emesis,  sterile  tap  water  should  be  sup- 
plied by  hypodermoclysis,  six  to  eight  ounces  every 
six  to  eight  hours  to  an  infant  six  months  old. 
Should  acetone  appear  in  the  urine,  the  solution 
should  contain  one  per  cent,  citrate  and  two  per 
cent,  glucose.  A  less  preferable  method  of  intro- 
ducing fluid  is  through  the  stomach  or  duodenal 
tube.  The  least  satisfactory  method  is  by  procto- 
clysis. As  soon  as  the  castor  oil  is  out  of  the  stom- 
ach, give  a  lactic  acid  bacillus  tablet  in  sweetened 
water  every  two  hours;  these  to  be  continued  until 
the  stools  are  normal.  As  acidosis  is  the  great  dan- 
ger, the  urine  should  be  kept  alkaline  with  bicarbo- 
nate of  soda,  or  sodium  citrate,  five  to  ten  grains 
every  two  hours  to  a  child  six  months  old;  it  is 
rarely  necessary  to  continue  this  longer  than  forty- 
eight  hours.  If  the  baby  is  breast  fed  nursing  is 
resumed  at  the  end  of  twenty-four-  to  forty-eight 
hours,  the  baby  to  nurse  one  minute  from  each 
breast  every  four  hours,  to  be  preceded  with  lime 
and  plain  water.  If  the  infection  is  due  to  the  gas 
bacillus,  the  baby  is  given  lactic  acid  milk,  or  pro- 
tein milk,  before  each  nursing;  this  replaces  the 
lime  and  plain  water.  If  the  infection  is  due  to  the 
dysentery  bacillus,  the  nursing  is  preceded  by  a 


October  23,  1920.]  PRACTICAL  THERAPEUTICS   AND  PREJ'ENTIVE  MEDICINE. 


649 


lactose  barley  solution,  varying  in  strength  from 
two  teaspoonfuls  each  to  two  tablespoonfuls  each 
to  the  pint  of  water.  If  the  baby  is  bottle  fed,  the 
same  treatment  is  carried  out  except  as  to  the  nurs- 
ing. Although  carbohydrates  are  contraindicated 
in  gas  bacillus  infections,  they  must  be  given  in 
threatened  acidosis.  Toxic  nephritis  with  impend- 
ing anuria  is  best  combated  with  hot  baths,  hot 
packs,  and  warm  soda  flushes  of  the  colon.  For 
restlessness  give  chloral  by  enema,  or  morphine  by 
injection.  As  a  stimulant,  atropine  in  fairly  large 
doses  gives  good  results.  Now  and  then  one  will 
meet  with  a  case  of  vasomotor  paralysis  which  can 
be  benefited  by  an  intravenous  injection  of  adrena- 
lin. When  the  stools  are  large,  frequent  and  wa- 
tery, opium  is  often  a  life  saver ;  paregoric  by 
mouth  or  morphine  by  hypodermic  injection.  For 
tenesmus  the  writer  likes  an  enema  of  silver  nitrate 
solution,  One  half  to  one  per  cent.,  in  distilled  water. 
Intestinal  antiseptics  and  astringents  are  mentioned 
only  to  be  condemned. 

The  Therapeutic  Use  of  Oxygen. — R.  D.  Ru- 
dolf {American  Journal  of  the  Medical  Sciences, 
July,  1920)  says  that  oxygen  is  of  value  whenever 
a  state  of  anoxemia  exists,  as  in  cases  of  mountain 
sickness,  sickness  from  high  flying,  in  poisoning  by 
carbon  monoxide,  nitrites,  and  arseniuretted  hydro- 
gen, and  in  the  effects  of  enemy  gas.  It  should  be 
tried  in  all  cases  of  cyanosis,  and  in  such  acute 
respiratory  conditions  as  pneumonia  when  anoxemia 
threatens.  The  ordinary  method  of  giving  oxygen 
by  holding  a  funnel  connected  with  the  oxygen 
cylinder  near  the  face  of  the  patient  is  practically 
useless ;  a  better  method  is  to  give  the  gas  through 
a  rubber  tube  inserted  into  one  nostril,  and  this  may 
be  made  more  efifectual  if  the  opposite  nostril  is 
rhythmically  compressed  during  inspiration,  the 
mouth  being  kept  closed.  The  oxygen  chamber  is  a 
very  ef¥ectual  way  of  giving  oxygen,  but  it  involves 
much  expense  and  care.  A  very  useful  and  ef- 
fectual appliance  for  the  administration  of  oxygen 
is  Meltzer's  apparatus  for  oral  insufflation. 

Vaccine  Therapy  in  the  Acute  Osteomyelitis 
of  Adolescents. — Raymond  Gregoire  {Journal  de 
mcdecine  de  Paris,  April  5,  1920)  states  that  in 
certain  selected  cases  of  this  disorder  vacciiie  treat- 
ment gives  excellent  results.  In  the  septic  form 
of  osteomyelitis  prompt  surgical  treatment  is,  of 
course,  indicated,  though  vaccine  treatment  might 
prove  of  some  value  as  an  auxiliary  measure.  In 
the  acute  or  subacute  cases,  in  which  the  general 
condition  is  less  seriously  impaired,  the  advisability 
of  vaccine  treatment  depends  entirely  upon  the  state 
of  the  involved  bone.  Where  a  more  or  less  exten- 
sive portion  of  bone  has  become  transformed  into 
a  sequestrum,  vaccine  treatment  is  inappropriate 
and  the  foreign  substance  must  be  surgically  re- 
moved. Such  a  condition  is  detected  by  x  ray 
examination.  In  all  other  cases,  however,  irrespec- 
tive of  the  duration  of  the  case,  extent  of  local 
inflammatory  reaction,  and  condition  of  neighboring 
joints,  vaccine  therapy  may  yield  surprising  results. 
Cases  were  thus  cured  after  several  weeks  of  sup- 
puration and  fever.  Where  purulent  accumulation 
about  the  bone  is  excessive  and  threatens  to  open 


into  a  joint  or  cause  marked  separation  of  tissues, 
it  is  well  to  puncture  the  abscesses,  repeatedly  if 
necessary,  until  the  pus  becomes  clear  and  finally 
ceases  to  form.  Joint  involvement  would  at  first 
sight  seem  to  demand  incision.  Yet  in  several  cases 
distended  joints  went  on  to  recovery  without  it  and 
even  recovered  their  mobility,  wholly  or  in  part. 
To  avoid  persisting  with  vaccine  treatment  for  more 
than  a  reasonable  and  safe  period,  reliance  should 
be  placed  on  the  temperature  curve.  The  vaccine 
tends  to  subdue  the  temperature  very  rapidly.  In 
some  cases  it  drops  quickly  from  39°  or  40°  C.  to 
about  37°,  though  frequently  several  days  are  re- 
quired for  it  to  reach  normal.  Whenever  the  vac- 
cine acts,  there  is  noted  a  distinct  depression  in  the 
temperature.  If  by  the  third  day  no  remission  has 
occurred,  the  vaccine  may  be  considered  insufficient 
in  the  case  under  treatment,  and  open  surgery  should 
be  resorted  to  at  once. 

Pituitary  Syndrome  Coexisting  with  Spinal 
Deformities. — Apert  and  Cambessedes  {Presse 
medicale,  January  31,  1920)  report  the  case  of  a 
boy  of  twelve  who  for  some  years  had  been  exhibit- 
ing general  torpor,  somnolence,  headache,  and  in- 
creasing obesity.  The  hips  and  breasts  enlarged  so 
as  to  resemble  the  feminine  type  and  the  pubes  be- 
gan to  show  a  premature  growth  of  hair.  The  ex- 
tremities were  cold  and  cyanotic.  The  sella  turcica 
was  found  broadened.  In  addition,  the  child  had 
presented  at  birth  an  upper  dorsal  meningocele, 
which  had  been  subjected  to  operative  treatment. 
X  ray  study  of  the  back  showed  multiple  malfor- 
mations of  the  vertebrae.  It  is  supposed  that  the 
same  condition  of  dysembryoplasia  involved  simul- 
taneously the  spinal  and  pituitary  regions,  the  lat- 
ter constituting,  as  a  matter  of  fact,  the  upper  ex- 
tremity of  the  spinal  tissues. 

X  Ray  Treatment  in  Primary  Neuralgia. — A. 

Zimmern  {Paris  medical,  February  7,  1920)  re- 
ports marked  benefit  in  cases  of  occipital,  trigeminal, 
and  lumbar  neuralgia  and  in  meralgia  paresthetica 
from  radicular  x  ray  treatment.  With  the  exception 
of  the  cases  of  facial  neuralgia,  particularly  those  of 
the  tic  douloureux  type,  the  results  obtained  were 
remarkably  constant.  They  were  especially  rapid 
and  complete  in  neuralgia  of  the  brachial  plexus. 
Only  rather  small  doses  of  the  rays  need  be  used. 
One  or  two  applications  averaging  three  H  units, 
with  filtration  through  two  or  three  millimetres  of 
aluminium,  proved  sufficient  to  bring  about  com- 
plete cure  or  at  least  to  allay  the  pain  very  greatly. 
In  the  brachial  cases  the  irradiation  should  be  prac- 
tised over  an  area  extending  from  the  fourth  cervical 
to  the  first  dorsal,  and  be  directed  obliquely  from 
behind  forward  and  from  \yithout  inward.  The 
patient  should  be  warned  that  a  few  hours  after 
the  first  treatment  there  may  occur  a  painful,  though 
never  severe,  reaction  preceding  the  ultimate  seda- 
tive effect.  This  reaction  seemed,  however,  to  occur 
less  frequently  in  the  brachial  cases  than  in  cases 
of  sciatica  similarly  treated.  With  the  doses  men- 
tioned, one  remains  below  that  required  to  produce 
erythema  even  if  it  becomes  necessary  to  repeat  the 
treatment  every  week.  Furthermore,  with  a  suffi- 
cient degree  of  filtration  no  trace  of  pigmentation 
can  occur. 


Proceedings  of  National  and  Local  Societies 


AMERICAN    GYNECOLOGICAL  SOCIETY. 

Forty-fifth  Annual  Me-eting,  Held  in  Chicago,  Mav 
24,  25,  26, 1920. 

Dr.  Robert  L.  Dickinson,  of  New  York,  in  the  Chair. 
{Concluded  from  page  608.) 

Operation  or  Radium  for  Operable  Cancer  of 
the  Cervix. — Dr.  William  P.  Gilwes,  of  Boston, 
stated  that  his  paper  was  an  inquiry,  based  on  per- 
sonal experience,  into  the  question  of  the  treatment 
of  choice  in  operable  cases  of  cancer  of  the  cervix. 
The  subject  was  opportune  because  of  the  recent 
severe  criticisms  that  some  of  the  radium  enthusiasts 
had  cast  on  the  modern  operative  methods  of  treating 
cervical  cancer,  and  because  a  few  excellent  surgeons 
had  of  late  practically  discarded  surgery  for  radi- 
ation in  this  field. 

Dr.  Graves  reviewed  the  cases  of  cervical  cancer 
which  had  come  under  his  observation  and  that  of 
his  associate  Dr.  F.  A.  Pemberton.  During  a  period 
of  eleven  years  181  cases  were  seen,  of  which  114, 
or  sixty-four  per  cent.,  received  radical  operation 
(deducting  three  cases  in  which  operation  was  re- 
fused.) Of  the  114  operations  ninety-nine  were 
performer  by  the  Wertheim  technic.  In  fifteen  the 
Wertheim  method  was  considered  too  dangerous, 
and  a  complete  hysterectomy  was  performed  in  the 
usual  manner.  There  were  six  operative  deaths  in 
the  series,  making  an  immediate  mortality  of  5.2 
per  cent.  Of  postoperative  disabilities  due  to  the 
operation  there  was  one  vesical  fistula  and  one  rec- 
tal fistula.  The  five  year  curability  percentage  at 
the  time  of  writing  was  27.6  per  cent. — 34.2  pel 
cent,  according  to  the  particular  method  used  in 
computation.  These  figures  seemed  to  refute  in 
some  degree,  at  least,  the  criticisms  of  operative 
treatment  on  the  ground  of  "low  percentage  of  op- 
erability,  shockingly  high  immediate  mortality,  and  a 
large  majority  of  distressing  and  desperate  sequela." 

Dr.  Graves  then  reviewed  his  personal  experience 
with  radium  in  the  treatment  of  cervical  cancer.  Ra- 
dium in  his  hands  had  proved  to  be  an  invaluable 
agent  in  the  palliation  of  inoperable  cases.  Many 
brilliant  primary  results  had  been  achieved  but,  as  a 
rule,  the  ultimate  results  had  been  disappointing, 
there  being  only  one  case  which  he  could  at  present 
confidently  pronounce  cured. 

On  account  of  the  danger  of  fistula  formation 
from  burns,  radium  had  been  discarded  in  frankly 
operable  cases,  either  before  or  after  the  operation. 
If  the  operation  had  been  unsatisfactory  so  far  as  a 
complete  extirpation  of  the  disease  was  concerned, 
radium  was  used  as  a  prophylactic  against  recur- 
rence. In  numerous  borderline  cases,  difficult  of 
operation,  the  patients  were  treated  first  with  radium 
and  then  operated  upon.  In  most  of  these  cases 
there  were  recurrences  ultimately. 

Dr.  Graves  concluded  that  there  was  as  yet  noth- 
ing in  his  personal  experience  with  radium  to  justify 
giving  up  the  radical  operation  in  operable  cases. 
He,  however,  called  attention  to  the  fact  that  the 
results  of  radium  treatment  observed  at  the  Memo- 
rial Hospital,  New  York,  were  superior  to  his  own 


and  ascribed  this  superiority  to  a  greater  knowledge 
and  experience  in  radium,  to  the  possession  of  larger 
quantities  of  the  radium  element,  and  to  a  more  ela- 
borate and  efficient  technic  of  application.  He  stater' 
therefore,  that  the  conclusions  from  his  own  per- 
sonal results  should  not  be  generalized  at  present. 

A  New  Method  of  Covering  Raw  Surfaces 
Upon  the  Uterus. — Dr.  George  Gellhorn,  of  St. 
Louis,  stated  that  the  practitioner  started  to  do  a 
Gilliam  operation  or  one  of  its  numerous  modifica- 
tions or  substitutes  in  a  case  of  fixed  retroflexion. 
The  adhesions  that  held  the  uterus  glued  to  depth 
of  the  cul  de  sac  or  the  rectum  were  broken  up,  the 
round  ligaments  were  shortened  and  the  uterus  was 
now  lying  in  a  more  normal  position,  but  with  a 
more  or  less  extensive  area  of  denudation  on  its 
fundus  which  invited  the  speedy  formation  of  new 
adhesions.  The  difficulty  was  easily  solved  by  a 
procedure  the  various  steps  of  which  were  given  by 
the  author  in  the  following  words :  "The  fundus  is 
grasped  by  a  volsellum  and  pulled  backward  and 
upward  in  the  direction  of  the  promontory.  The 
reflection  of  the  bladder  peritoneum  upon  the  cervix 
which  now  becomes  plainly  visible  is  incised  trans- 
versely as  in  a  hysterectomy  and  pushed  off  from 
the  uterus.  If  this  blunt  dissection  with  the  finger 
is  gentle  enough  and  does  not  extend  into  the  broad 
ligaments,  the  bleeding  is  usually  insignificant  and 
is  quickly  checked  by  the  pressure  of  a  sponge.  The 
uterus  is  then  tilted  forward,  the  bladder  peri- 
toneum is  pulled  over  the  uterus  and  stitched  to  the 
posterior  aspect  of  the  fundus,  where  an  intact  peri- 
toneal surface  presents  itself.  In  small  uteri,  the 
bladder  peritoneum  may  be  fastened  as  far  back  as 
the  insertion  of  the  sacrouterine  ligaments,  if  neces- 
sary. After  the  first  or  second  turn  of  this  con- 
tinuous catgut  stitch  the  volsellum  is  removed  and 
the  stitching  is  continued  until  the  entire  fundus 
with  its  denuded  area  has  disappeared  beneath  its 
new  peritoneal  covering.  By  using  an  inverting 
stitch,  even  the  catgut  knots  become  visible.  The 
newly  formed  covering  consists  only  of  the  bladder 
peritoneum  which,  in  many  cases,  is  so  thin  and 
transparent  that  the  raw  uterine  surface  and  even 
the  volsellum  holes  may  be  distinguished." 

The  method  just  outlined  not  only  supplied  the 
raw  fundus  with  a  new  serous  coat,  but  it  also 
safeguarded  a  normal  position  and  mobility  of  the 
uterus,  and  the  late  results  had  remained  most  satis- 
factory. It  was,  however,  not  to  be  relied  upon 
exclusively  in  a  case  of  fixed  retroflexion.  In  such 
a  case  the  order  of  the  operative  steps  were  these, 
viz.,  first,  loosening  of  the  bladder  peritoneum  as 
described  above ;  second,  shortening  of  the  round 
ligaments  ;  third,  fastening  of  the  bladder  peritoneum 
to  the  back  of  the  uterus  beyond  the  area  of  denu- 
dation. He  anticipated  two  pertinent  questions. 
Was  the  function  of  the  bladder  disturbed  after 
this  procedure,  and  what  happened  to  the  bladder 
in  a  subsequent  pregnancy?  In  the  six  or  seven 
years  that  he  employed  the  method,  he  had  never 
observed  an  instance  of  vesical  disturbance  other 
than  those  that  might  follow  any  laparotomy. 


October  23,  1920.]  PROCEEDINGS  OF  NATIONAL  AND  LOCAL  SOCIETIES. 


651 


Lutein  Cysts  Accompanying  Hydatiform  Mole. 

— Dr.  W.  A.  Coventry,  of  Duluth,  Minn.,  said 
that  the  cases  which  he  reported  presented  several 
very  interesting  features:  1.  The  appearance  of  the 
ovarian  tumors  in  one  case  appeared  with  the  mole 
(in  fact,  clouding  somewhat  the  history  of  mole), 
and  in  the  other  case  seemed  to  arise  and  start  to 
grow  rapidly  after  the  mole  had  been  removed.  2. 
The  gross  and  microscopical  appearances  of  these 
cysts  were  in  marked  contrast  to  those  of  the  ordi- 
nary type  of  ovarian  cyst.  3.  These  multiple  lutein 
cysts  Were  beyond  a  doubt  different  from  those  nor- 
mally appearing  during  pregnancy.  4.  These  lutein 
cysts  undoubtedly  accompanied  only  the  formation 
of  chorioepithelioma  and  mole  and  were  probably 
not  to  be  found  in  any  associated  condition.  There 
were  many  references  in  the  literature  to  the  oc- 
currence of  cysts  of  the  ovaries  accompanying  preg- 
nancy, mole  or  chorioma,  but  he  was  sure  that  many 
of  these  references  were  only  to  small  cysts,  which 
disappeared  spontaneously  after  expulsion  of  the 
mole  or  the  fetus. 

As  regards  prognosis  and  treatment,  Eden  and 
Lockyear  asserted  that  some  of  these  cysts  receded 
following  the  expulsion  of  the  mole,  and  some 
such  cases  had  been  recorded  by  Russell,  Andrews 
and  Albert,  but  this  literature  was  not  available. 
Findley  stated  that  occasionally  cystic  ovaries 
became  greatly  reduced  in  size  following  delivery  of 
the  mole,  and  reported  in  the  fifty-eight  cases  col- 
lected by  him  that  in  only  four  was  there  any  retro- 
gressive change  following  the  expulsion  of  the  mole. 
Still,  he  did  not  specifically  state  that  these  were 
large  lutein  cysts  such  as  described  in  this  condition. 
In  view  of  the  fact  that  the  literature  in  the  large 
majority  of  cases  connected  this  condition  with  the 
presence  of  chorioepithelioma,  and  also  in  view  of 
the  fact  that  the  condition  was  undoubtedly  a  retro- 
grade metamorphosis  from  the  normal  cystic  con- 
ditions found  in  the  ovary,  he  believed  that  we  were 
perfectly  justified  in  not  waiting  for  the  recession 
of  these  tumors  but  that  we  should  operate  and  re- 
move them  when  found. 


MEDICAL  SOCIETY  OF  THE  STATE  OF 
NEW  YORK. 

On.e  Hundred  and  Fourteenth  Annual  Meeting, 
Held  in  New  York,  M.arch  23  to  25,  1920 

The  President,  Dr.  Claude  C.  Lytle,  of  Geneva,  in  the 
Chair. 

{Continued  from  page  344.) 
The  Abduction  Treatment  of  Fracture  of  the 
Neck  of  the  Femur. — Dr.  Royal  Whitman,  of 
New  York,  stated  that  he  had  presented  this 
method  before  but  that  the  results  obtained  by  it 
had  been  so  highly  satisfactory  that  there  was  no 
reason  for  abandoning  it.  For  the  restoration  of 
function  it  was  essential  that  deformity  be  reduced 
and  that  the  fractured  surfaces  be  fixed  in  contact. 
Contact  could  be  assured  only  by  adapting  the  out- 
ward fracture  to  the  inward.  To  accomplish  this 
the  patient  must  be  anesthetized,  and  the  shorten- 
ing was  then  reduced  by  direct  traction.  The  thigh, 
having  been  lifted  to  the  proper  plane,  was  abducted 
to  the  normal  limit,  and  abduction  was  ef¥ected 


with  the  perineum  against  a  perineal  support.  Ab- 
duction turned  the  fractured  surface  down  to  meet 
the  head  of  the  femur;  it  made  the  capsule  tense 
and  aligned  fragments ;  it  relaxed  muscles  whose 
contraction  tended  to  displace  the  fragments ;  it 
apposed  the  trochanter  to  the  side  of  the  pelvis,  or, 
if  the  fracture  was  near  the  head,  engaged  the  neck 
beneath  the  rim  of  the  acetabulum  and  provided  a 
mechanical  check  to  displacement.  What  was 
known  as  impacted  fracture  was  usually  a  complete 
fracture.  After  reduction  the  body  and  limb  were 
covered  with  sheet  wadding  and  cotton  flannel 
bandages,  all  bony  points  being  carefully  protected, 
and  a  long  plaster  spica  support  was  applied.  With 
the  fracture  thus  dressed  the  patient  could  be 
turned  completely  over  on  the  abdomen,  avoiding 
bed  sores  and  also  the  danger  of  hypostatic  pneu- 
monia. The  head  of  the  bed  was  elevated  at  an 
angle  of  twenty-five  degrees,  providing  a  semi- 
reclining  position  which  favored  the  nutrition  of 
the  injured  parts.  The  neck  of  the  femur  in  young, 
vigorous  persons  might  be  broken  by  slight  violence 
and  the  fracture  might  not  cause  complete  disabil- 
ity. The  bad  prognosis  usually  given  for  fractures 
of  the  femur  was  not  warranted,  and  was  largely 
due  to  incorrect  technic.  He  had  treated  many 
elderly  persons  by  the  abduction  method  with  grati- 
fying results.  His  oldest  patient  was  a  woman 
eighty-nine  years  of  age  who  lived  to  be  ninety- 
three. 

Urological  Diagnosis  in  the  Practice  of  the  Gen- 
eral Surgeon. — Dr.  Leo  Buerger  stated  that  mod- 
ern urological  investigation  with  highly  developed 
urological  instruments  and  practice  in  their  use 
made  available  to  the  urologist  many  special  proce- 
dures not  ordinarily  employed  by  the  general  sur- 
geon. The  general  surgeon  could  cooperate  with 
the  urologist  to  his  own  advantage  and  to  that 
of  his  patient.  There  was  great  need  for  educating 
young  men  in  the  field  of  urological  diagnosis,  for 
here  many  mistakes  were  made.  For  instance,  cal- 
culus of  the  ureter  might  give  symptoms  simulat- 
ing intestinal  obstruction  and  even  peritonitis,  and 
operation  might  be  performed  when  it  would  have 
been  possible  to  remove  the  calculus  through  the 
urinary  tract.  Urinary  calculus  in  the  lumbar  re- 
gion might  be  taken  for  retrocecal  appendicitis. 
When  there  were  signs  of  urinary  retention,  calcu- 
lus should  be  suspected.  In  some  cases  of  supposed 
subacute  or  chronic  appendicitis  vaginal  examina- 
tion revealed  the  presence  of  ureteral  calculus  low 
down.  Tuberculous  nodules  in  the  ureter  might  be 
mistaken  for  calculi.  Ovarian  disorders  had  been 
diagnosed  in  cases  in  which  a  cystoscopic  examina- 
tion woulfl  have  revealed  intraureteral  debris.  The 
indications  for  and  method  of  employing  the  reten- 
tion catheter  were  discussed  and  lantern  slide  dem- 
onstration showed  what  the  urologist  could  discover 
by  means  of  the  shadow  graf  catheter,  the  pyelo- 
graph,  which  though  its  use  was  restricted,  was  im- 
portant in  certain  cases ;  the  baby  cystoscope,  which 
had  aided  in  the  diagnosis  and  treatment  of  pyelitis 
in  children ;  the  Buerger  opera  cystoscope,  which 
carried  a  scissors-like  instrument  which  made  pos- 
sible certain  operative  procedures  on  the  bladder, 
and  the  direct,  indirect  and  retrograde  cystoscopes. 


652 


PROCEEDIXGS  OF  NATIONAL  AND  LOCAL  SOCIETIES. 


[New  York 
Medical  Journal. 


Surgical  and  Nonsurgical  Treatment  of  the 
Prostate  and  Seminal  Vesicles  in  Arthritis. — Dr. 

Oswald  S.  Lowsley.  of  Xe\v  York,  stated  that 
the  teeth,  tonsils,  sinuses,  and  various  other  focal 
infections  had  received  attention  in  their  relation 
to  arthritis  and  he  wished  to  call  attention  to  the 
part  played  by  tlie  prostate  gland  and  the  seminal 
vesicles  in  the  production  of  this  condition.  His 
observations  were  based  on  a  stud}'  of  100  cases  of 
arthritis  in  the  urological  department  of  Bellevue 
Hospital.  The  ages  of  these  patients  ranged  from 
seventeen  to  fifty-one  years,  the  average  being 
twenty-nine  and  one  third.  The  season  of  the  year 
did  not  seem  to  make  any  difTerence  except  that 
there  were  not  quite  so  many  cases  during  the  sum- 
mer months.  The  joints  affected,  in  the  order  of 
frequency,  were  the  knee  in  fifty-three,  the  ankle  in 
forty-four,  the  wrist  in  thirty,  and  the  foot  in 
twenty-six.  The  infection  was  traced  to  the  teeth 
in  thirty-one  cases  and  to  the  tonsils  in  ten.  Twenty- 
three  per  cent,  of  the  patients  denied  having  had 
gonorrhea.  The  impression  that  infection  arising 
from  the  prostate  and  seminal  vesicles  was  usually 
gonorrheal  was  incorrect.  An  analysis  of  these 
cases  showed  other  organisms  predominating  in 
this  locality  such  as  the  Staphylococcus  aureus, 
Streptococcus  viridans,  and  other  forms  of  strepto- 
cocci. In  three  of  the  cases  brilliant  results  were 
obtained  with  vaccines.  In  a  nimiber  of  cases  treat- 
ment by  steaming  was  very  satisfactory.  Ten 
cases  were  treated  surgically  with  good  result. 
Where  there  was  chronic  seminal  vesiculitis,  sem- 
inal vesiculectomy  was  preferable  to  vesiculotomy. 
Of  fifty  cases  of  polyarthritis  in  which  infection 
from  other  sources  was  eliminated,  examination  of 
the  prostate  and  seminal  vesicles  showed  these  to  be 
the  source  of  the  infetion.  In  searching  for  the 
source  of  infection  in  any  case  of  arthritis  the  pros- 
tate and  seminal  vesicles  should  not  be  overlooked. 
Autonomous  vaccines  were  extremely  valuable  in 
same  cases  used  in  conjunction  with  other  methods 
of  treatment. 

The  Role  of  the  Colon  Bacillus  in  Infections  of 
the  Kidney. — Dr.  Hugh  Cabot,  of  Ann  Arbor, 
Mich.,  said  that,  excluding  tuberculosis,  the  colon 
bacillus  was  foimd  to  be  the  infecting  organism  in 
a  large  proportion  of  kidney  infections.  The  num- 
ber of  these  infections  did  not  seem  to  be  decreas- 
ing. The  most  common  and  perhaps  the  most  im- 
portant kidney  lesion  was  pyelitis.  Of  this  condi- 
tion there  were  two  groups  of  cases :  In  the  first 
there  was  no  demonstrable  reason  for  the  infection 
in  the  urinary  tract,  while  the  second  group  was 
dependent  upon  urinary  outflow.  The  second  class 
presented  the  least  difficulty.  These  cas*  were  de- 
pendent upon  stricture,  stone  in  the  bladder,  or  other 
obstruction  to  the  urinary  outflow  in  the  urinary 
tract  itself.  Such  obstruction,  however,  was  not 
the  only  factor,  but  was  merely  instrumental  in  pre- 
paring for  infection.  He  did  not  believe  instru- 
mentation of  the  urinary  tract  was  frequently  the 
cause  of  infection.  Where  there  was  residual  urine 
associated  with  lowered  resistance  the  soil  was  pre- 
pared for  infection.  The  socalled  catheter  system 
following  operation  was  open  to  criticism.  It  was  too 
much  the  custom  to  delay  catheterization  and  trust 


that  retention  would  not  occur,  and  it  was  too  fre- 
quently assumed  that  catheterization  was  responsible 
for  infection.  So  long  as  patients  were  catheterized 
by  the  clock,  just  so  long  would  infections  continue 
to  be  a  reproach  to  the  physician.  All  these  patients 
should  be  regarded  as  likely  to  have  retention.  The 
bladder  should  never  be  allowed  to  become  distended 
above  twelve  ounces.  If  early  catheterization  was 
carried  out,  postoperative  cystitis  would  become  a 
rarity.  The  first  group  of  cases  was  that  in  which 
kidney  function  might  be  below  normal  and  the 
cause  lay  outside  the  urinary  tract.  In  this  group 
pressure  from  the  outside  produced  interference 
with  the  urinarv  outflow,  leading^  to  congestion, 
which  prepared  the  soil  for  the  infecting  organism. 
In  this  group  came  the  pyelitis  of  pregnancy  as  well 
as  the  socalled  spontaneous  cases  associated  with 
disease  of  the  large  intestine,  such  as  mucous  colitis 
and  ulcerative  colitis.  There  was  also  a  group  of 
cases  occurring  in  adult  life,  particularly  in  women 
suffering  from  constipation  and  visceroptosis,  and 
another  group,  in  female  children  in  which  we  had 
been  accustomed  to  blame  the  condition  on  the  ana- 
tomical conformation.  If  these  infections  in  female 
children  were  due  to  the  introduction  of  the  colon 
bacillus  by  way  of  the  urethra,  it  was  strange  that 
they  were  not  more  common.  Experiment  had  shown 
that  introduction  of  the  colon  bacillus  into  the  blad- 
der did  not  produce  pyelitis,  and  clinical  experience 
was  against  this  view.  It  might  well  be  that  the  colon 
bacilli  affected  the  kidneys  of  those  who  had  little  re- 
sistance. The  use  of  formaldehyde  in  local  irrigation 
of  the  kidneys  had  been  much  in  vogue,  but  it  had 
failed  to  live  up  to  its  temporary  reputation.  It 
was  quite  strange  that  patients  with  a  stormy  onset 
and  severe  symptoms  were  most  likely  to  go  on  to 
complete  recovery,  while  chronic  cases  often  resisted 
treatment.  Attempts  with  autogenous  vaccines 
might  at  times  relieve  the  symptoms  but  failed  to 
remove  the  infection.  '  He  was  not  sure  they  had 
pushed  the  use  of  autogenous  vaccines  to  their  logi- 
cal conclusion.  There  was  need  of  further  study 
of  bacilluria,  and  perhaps  conditions  in  the  large 
intestine  might  give  a  clue  to  the  treatment  of  pve- 
litis. 

Dr.  Edward  L.  Keyes,  Jr.,  of  New  York,  asked 
Dr.  Cabot  concerning  the  relation  of  the  passage  of 
instruments  into  the  ureter  to  pyeHtis.  Attempts  to 
wash  out  the  pelvis  of  the  kidney  had  not  proved 
satisfactory.  It  was  possible  that  a  certain  amount 
of  benefit  might  be  due  to  the  straightening  out  of 
the  ureter  by  the  passage  of  the  instrument  em- 
ployed in  giving  the  irrigation. 

Dr.  A.  W.  Brasch,  of  North  Germantown,  ques- 
tioned whether  the  large  intestine  was  the  etiologi- 
cal factor  in  pyelitis.  It  was  his  impression  that  the 
connection  between  the  colon  and  the  kidney  was 
limited.  In  treating  pyelitis  he  removed  the  foci  of 
infection  in  the  teeth  or  tonsils  if  any  were  present 
and  then  employed  lavage  of  the  kidney  pelvis  with 
silver  nitrate,  placing  the  patient  in  the  Trendelen- 
berg  position.  He  passed  good  sized  bulbs  that 
straightened  out  any  stricture  which  might  be  pres- 
ent, and  he  believed  this  cured  pyelitis  in  a  large 
proportion  of  cases. 

(To  be  continued) 


New  York  Medical  Journal 

INCORPORATING   THE  ' 

Philadelphia  Medical  Journal  thl  Medical  News 

A  Weekly  Review  of  Medicine,  Established  18^3. 

Vol.  CXII,  No.  18.  NEW  YORK,  SATURDAY,  OCTOBER  30,  1920.  Whole  No.  2187. 

Original  Communications 


A  SERIES  OF  FOREIGN  BODIES  IN  THE 
BRONCHI  AND  ESOPHAGUS.* 

By  Henry  Lowndes  Lynah,  M.  D. 
New  York 

In  the  presentation  of  this  series  of  foreign 
bodies  in  the  food  and  air  passages,  I  wish  to  call 
attention  to  the  difficulties  often  encountered  in 
the  removal  of  some  of  the  intruders,  the  mechan- 
ical method  of  removal,  and  also  the  comparative 
ease  in  which  many  of  the  uncomplicated  foreign 
bodies  may  be  removed. 

In  the  removal  of  all  sharply  pointed  objects., 
such  as  pins  and  tacks,  great  care  should  be  taken 
to  see  that  the  point  is  disengaged  from  the  bronchial 
wall  before  removal  is  attempted.  Faulty  manipu- 
lation of  a  sharply  pointed  foreign  body  may  place 
it  in  such  a  position  in  the  bronchial  wall  as  to 
render  its  removal  extremely  difficult,  if  not  impos- 
sible. The  prolonged  sojourn  of  a  foreign  body 
in  the  bronchus  makes  the  removal  much  more 
difficult  than  one  that  has  been  recently  aspirated. 
Long  standing  foreign  bodies  in  the  bronchus  are 
usually  surrounded  by  granulation  tissue.  There  is 
also  a  stricture  of  the  bronchial  wall,  with  a  result- 
ant bronchiectasis  or  pulmonary  abscess  below  the 
foreign  body  or  stricture,  due  to  the  retention  of 
pulmonary  secretion  of  long  duration.  Patients  with 
bronchiectasis  and  pulmonary  abscess  usually  im- 
prove, and  even  get  entirely  well,  after  the  removal 
of  the  obstructing  foreign  body  and  pumping  out  of 
the  sponge  soaked  lung  and  establishment  of  proper 
lung  drainage.  Bronchoscopic  dilatation  of  the  re- 
maining stricture  and  evacuation  of  the  bronchiec- 
tactic  cavity  may  be  necessary  several  times  before 
the  cavity  is  finally  obliterated.  These  are  only  a 
few  of  the  complications  which  may  arise  in  bron- 
choscopic foreign  body  extraction ;  the  difficulties 
and  dangers  however  are  numerous,  and  perfora- 
tion of  the  bronchial  wall  and  sudden  death  of  the 
patient  from  pneumothorax  has  been  known  to  occur 
in  the  attempted  removal  of  sharply  pointed  foreign 
bodies,  and  one  case  is  recorded  where  the  bronchus 
was  ruptured  accidentally  on  the  introduction  of 
the  bronchoscope.  Therefore,  extreme  care  on 
the  introduction  of  the  bronchoscopic  tube,  and 
gentle  manipulation  of  the  foreign  body  should 
be  constantly  before  the  operator  who  yvishes  to 
successfully  remove  foreign  bodies  from  the  bron- 

*Read  before  the  Southern  Section  of  the  American  Laryngological, 
Rhinological  and  Otological  Society,  Richmond,  Va.,  March  1,  1919. 


chi  and  esophagus  with  a  minimum  amount  of 
damage  being  caused. 

The  difficult  removals  encountered  in  this  series 
were  the  sharply  pointed  objects,  one  of  which  was 
transfixed,  and  the  impacted  foreign  bodies,  at  times 
completely  covered  with  edema.  As  a  rule  smooth 
objects  are  extremely  difficult  to  grasp  with  forceps, 
and  are  therefore  difficult  to  extract.  The  esoph- 
ageally  lodged  foreign  bodies,  such  as  coins,  are  as  a 
rule  easy  of  removal,  especially  when  the  operator 
sees  the  patient  before  several  unsuccessful  attempts 
and  much  traumatism  have  been  made. 

At  times  the  foreign  body  is  buried  in  a  dense 
ring  of  edema,  which  renders  its  exact  localization 
problematical,  and  its  removal  in  these  instances  is 
extremely  difficult.  The  irritation  and  inflamma- 
tion produced  by  the  lodgement  of  metallic  foreign 
bodies  in  the  bronchi  are  not  nearly  as  pronounced 
as  the  result  of  inspired  nuts  and  food  of  any  sort. 
The  longer  the  lodgement  of  a  bronchial  or  esoph- 
ageal foreign  body  the  greater  the  danger  to  the 
patient  and  the  more  difficult  the  removal.  At  times 
the  very  innocently  lodged  penny  in  the  esophagus 
may  slough  through  into  the  trachea  and  the  patient 
succumb  to  pneumonia. 

The  most  extremely  irritating  substances  bron- 
chially  lodged  in  this  series  were  found  to  be  raw 
carrot,  parched  peanut  kernel,  masticated  toilet  paper 
pulp,  cheesy  infectious  material  from  the  tonsil, 
meat  and  casts  of  diphtheritic  membrane.  All  of 
them  were  looked  upon  with  extreme  suspicion  as 
diphtheria,  for  the  symptomatology  and  physical 
signs  are  much  the  same.  In  bronchial  diphtheria 
asthmatic  respiration  is  usually  present  and  this  is 
also  an  accompaniment  of  all  irritating  substances 
inhaled  into  the  lung.  The  onset  in  the  fulminating 
types  of  bronchopulmonary  or  asthmatic  types  of 
influenza  simulate  these  types  of  foreign  body, 
closely,  both  in  characteristic  symptoms  and  phys- 
ical signs,  where  there  is  no  history  of  foreign  body 
inspiration.  Given  a  case  with  such  symptoms, 
negative  radiographic  findings  mean  nothing,  and 
the  only  means  of  one  being  able  to  arrive  at  a 
definite  diagnosis  is  by  a  bronchoscopic  examina- 
tion. When  such  substances  are  inhaled  by  young 
children,  which  is  frequently  the  case,  they  wheeze 
and  rasp  and  are  profoundly  prostrated.  There  is 
often  a  marked  pulmonary  emphysema  on  the  side- 
of  the  obstruction,  for  air  is  much  more  easily 
inspired  by  the  foreign  body  than  expired.  There- 
fore, the  lung  necessarily  compensates  in  turn  by 


Copyright,  1920,  by  A.  R.  Elliott  Publishing  Company. 


654 


LYNAH:  FOREIGN  BODIES. 


[New  York 
Medical  Journal. 


a  marked  ballooning.  The  x  ray  may  show  a  de- 
pressed diaphragm  in  such  cases,  on  the  affected 
side.  If  the  effort  at  inspiration  by  a  tight  obstruc- 
tion is  kept  up  for  many  hours  the  child  soon  be- 
comes exhausted  and  death  may  rapidly  follow.  In 
one  of  these  cases  there  was  such  an  enormotis 


1 


Fig.  1. 


Fig.  2. 


Fig.  1. —  (Case  I.)  Shawl  pin  removed  from  right  superior  lobe 
bronchus. 

Fig.  2. — (Case  II.)  Shawl  pin  removed  from  left  upper  lobe 
bronchus. 

amount  of  pulmonary  emphysema  that  the  lung 
ruptured,  and  there  was  a  generalized  tissue  emphy- 
sema just  prior  to  death.  There  is  always  extreme 
cyanosis  when  pulmonary  or  tissue  emphysema 
appears.  ^^^^^^  reports 

Case  I.  Shawl  pin  in  right  superior  lobe  bron- 
chus of  a  woman  thirty  years  of  age,  referred  by 
Dr.  Ard,  of  Plainfield,  N.  J.  In  bronchus  twenty- 
five  hours.  By  radiographic  and  bronchoscopic 
examination  the  point  was  deeply  imbedded  in  the 
opposite  bronchial  wall.  The  head  of  the  pin  had 
entered  the  upper  lobe  orifice  as  far  as  it  could  go, 
while  the  point  was  transfixed  in  the  opposite  bron- 
chial wall.  The  shaft  of  the  pin  presented  across 
the  mouth  of  the  bronchoscopic  tube  and  neither 
head  nor  point  was  visible.  The  head  of  the  pin 
could  not  be  pushed  farther  into  the  upper  lobe 
orifice  to  release  the  point  and  a  very  difficult 
mechanical  problem  presented.  The  point  of  the 
pin  by  lateral  radiographic  measurement  had  pene- 
trated deeply  into  the  opposite  bronchial  wall.  To 
attempt  to  remove  the  pin  in  the  position  presenting 
would  only  court  failure  and  attempting  to  pull  it 
out  would  prove  disastrous  by  causing  a  rupture  of 
the  bronchial  wall. 

With  a  nine  mm.  bronchoscope  in  situ,  the  head 
and  neck  of  the  patient  were  rotated  well  to  the 
right,  for  the  transfixed  and  buried  point  had  to  be 
attacked  in  the  bronchial  wall  on  the  opposite  side. 
The  long  slanting  tip  of  the  bronchoscopic  tube  was 
used  to  press  out  the  bronchial  wall  just  above  the 
imbedded  point  while  the  side  curved  forceps  partly 
open  covered  the  shaft  of  the  pin  and  gradually 
followed  it  up  towards  the  point  while  pressure 
was  made  with  the  bronchoscopic  tube  lip.  By  keep- 
ing the  blades  of  the  forceps  in  such  position  they 
acted  by  gentle  counter  pressure  on  the  bronchial 
wall  and  at  the  same  time  were  in  a  position  to  grasp 
the  pin  point  as  soon  as  it  was  released.  After 
seventeen  minutes  the  point  was  released  and  as  the 
forceps  were  in  position  it  was  grasped.  Now  the 
head  of  the  patient  was  moved  to  the  left  and  the 


pin  easily  extracted  in  the  normal  manner.  Had 
the  head  not  been  rotated  well  to  the  right  it  would 
have  been  next  to  impossible  to  disengage  the  point. 

The  patient  had  been  a  sufferer  for  a  long  time 
from  a  substernal  goitre  and  the  x  ray  revealed  an 
enormous  thymus  gland.  While  the  patient  had 
received  a  dose  of  morphine  and  cocaine,  the  cough 
reflex  was  not  affected  locally,  and  an  extremely 
irritating  cough  from  which  she  had  suffered  for  a 
long  time  persisted  during  the  entire  operation. 

Case  II.  A  girl  aged  sixteen  referred  by  Dr. 
William  Dougherty  of  Xew  York.  The  girl  gave 
a  history  of  having  swallowed  a  shawl  pin  some 
five  days  before  and  had  no  cough  or  discomfort 
after  it  had  disappeared.  A  radiographic  picture 
taken  by  Dr.  George  S.  Dixon  showed  the  pin  to 
be  located  in  the  upper  cervical  region.  There  was 
considerable  swelling  of  the  neck  of  the  patient  and 
she  complained  of  pain  in  her  throat  from  an 
attempted  removal  before  admission.  The  patient 
had  some  difficulty  in  swallowing.  The  patient  was 
prepared  for  an  esophagoscopic  examination  and 
the  spatula  esophagoscope  was  introduced  without 
anesthesia.  There  was  no  pin  in  the  larynx.  There 
was  a  long  rip  in  the  cricopharyngeous  constrictor 
and  esophageal  wall  and  the  swelling  we  had  noted 
in  the  neck  was  due  to  subcutaneous  emphysema, 
no  foreign  body  was  visible.  As  the  pin  had  dis- 
appeared the  patient  was  sent  again  to  the  radio- 
graphic room  and  another  picture  taken  of  the  entire 
chest  and  abdomen. 

The  chest  plate  showed  the  pin  to  be  lodged  in 
the  left  bronchus  with  the  point  in  the  upper  lobe 
orifice.  As  the  patient  was  in  a  very  poor  condi- 
tion from  the  esophageal  rupture  no  anesthetic  was 


 J0 


Fig.  3. — (Case  I.)  X  ray  picture  showing  shadow  of  shawl  pin. 

used.  A  dose  of  morphine  was  administered  and  the 
pin  was  rapidly  removed  through  a  seven  mm.  tube. 
The  point  of  the  pin  was  in  the  left  upper  lobe 
bronchus,  but  it  was  easily  pushed  downward  after 
grasping  the  shaft  with  forceps  and  disengaged.  The 
removal  of  the  pin  from  the  bronchus  taking  three 
minutes.  After  the  removal  of  the  pin  the  esoph- 
agus was  inspected. 


October  30,  1920.] 


LYNAH:  FOREIGN  BODIES. 


655 


There  was  a  long  slit  in  the  esophagus,  the  edges 
of  the  wound  were  covered  with  a  thick  slough.  A 
suction  tube  was  introduced  into  the  wound  and 
with  a  twenty  inch  vacuum  some  foul  smelling 
material  was  removed.  The  wound  was  then 
swabbed  with  tincture  of  iodine.    As  the  patient 


Fig.  4. — Shawl  pin  in  the  larynx  supposed  to  be  in  the  upper 
esophagus.  Radiographic  plate  taken  before  attempted  removal  from 
the  esophagus.     (Case  II.) 

had  been  unable  to  swallow  for  the  past  twenty- 
four  hours  and  was  suffering  from  water  hunger, 
milk  and  water  were  injected  by  syringe  into  the 
stomach  through  the  esophagoscope.  A  soft  rubber 
stomach  tube  was  then  introduced  and  the  patient 
fed  by  the  syringe  method  through  the  proximal 
end  of  the  tube  which  extended  out  of  her  mouth. 
The  tube  was  attached  to  the  neck  by  tape  to  prevent 
its  becoming  dislodged  and  swallowed.  By  this  time 
there  was  marked  emphysema  of  the  neck  and  face 
and  the  temperature  had  risen  to  103.2°  F.  The 
pulse  was  weak  and  rapid.  The  patient  was  at  all 
times  conscious,  and  her  chief  complaint  was  a  severe 
stabbing  pain  in  the  region  of  the  sternum  on  inspi- 
ration. There  was  a  booming  systolic  heart  sound 
over  the  entire  precordial  region.  The  second  sound 
could  not  be  elicited.  Scattered  rales  were  elicited 
over  the  anterior  aspect  of  the  chest,  but  these  were 
probably  due  to  the  crackles  of  the  subcutaneous 
emphysema  in  this  area.  The  following  day  after 
a  thorough  dose  of  the  water  cure  treatment,  the 
patient  requested  that  the  tube  be  removed.  This 
was  done  and  the  wound  in  the  esophagus  was  again 
swabbed  with  iodine  after  thorough  evacuation  of 
the  pocket.  The  feeding  tube  was  then  replaced. 
This  treatment  was  continued  from  day  to  day  and 
by  the  end  of  the  first  w-eek  the  patient  showed 
signs  of  improvement.  The  temperature  was  101.4°, 
pulse  110  and  regular  and  respirations  32.  There 
was  a  pleuritic  rub  over  the  region  of  the  sternum 
but  the  heart  sounds  could  be  distinctly  heard.  By 
the  tenth  day  the  patient  continued  to  show  improve- 
ment but  strenuously  objected  to  the  method  of 
feeding.  The  esophagoscope  was  passed  and  the 
wound  inspected.  The  wound  had  almost  com- 
pletely healed  but  there  was  still  an  inflammatory 


exudate  about  it.  This  was  probably  protective  for 
there  was  no  foul  odor.  The  patient  w-as  given  a 
swallowing  trial  with  a  glass  of  milk  and  did  fairly 
well.  The  reintroduction  of  the  feeding  tube  was 
discontinued.  By  the  end  of  the  second  week  the 
girl  was  able  to  be  up  and  about  and  by  the  end  of 
the  fourth  week  she  was  able  to  leave  the  hospital. 
She  could  sw-allow  without  difficulty  at  this  time 
and  the  esophageal  wound  had  completely  healed. 
The  patient  w^as  seen  a  year  later  and  there  was  no 
stricture  of  the  esophagus  and  no  difficulty  in  swal- 
lowing. A  radiographic  plate  taken  at  this  time 
showed  the  lungs  and  precordial  region  to  be  normal. 
It  is  extremely  interesting  to  note  the  difference  in 
the  two  radiographic  plates.  The  one  taken  just 
after  the  accident  before  an  attempt  was  made  to 
remove  the  pin  from  the  cervical  esophagus  and  the 
other  after  the  attempted  esophageal  removal  and 
rupture  of  the  esophagus.  Air  entered  the  medias- 
tinum and  it  can  be  definitely  made  out  in  the  radio- 
graphic plate  taken  after  the  esophageal  rupture. 

Case  III.  A  boy  aged  seven  was  admitted  to  the 
Kingston  Avenue  Hospital  suffering  from  measles 
and  croup.  There  was  a  large  perilaryngeal  abscess 
present  which  Dr.  Cannon,  the  resident  physician, 
recognized  as  the  probable  cause  of  the  croupy 
symptoms.  As  the  abscess  was  opened  there  was 
a  blast  of  air  through  the  wound  and  much  pus 
was  sucked  in  with  inspiration.  The  child  was 
immediately  inverted  and  a  quantity  of  foul  smelling 
pus  was  drained  from  the  abscess  cavity.  Then  the 
wound  was  examined  and  found  to  communicate 
with  the  trachea.  On  examination  of  the  tracheal 
fistula  Dr.  Cannon  saw  an  object  in  the  wound  and 
as  he  opened  the  tracheal  fistula  the  object  dropped 
into  the  lung.    The  following  day  a  radiographic 


Fig.  5. — Radiographic  plate  taken  on  admission  after  an  at- 
t"mpted  removal  of  pin  from  the  esophagus.  Note  that  the  pin  was 
dislodged  from  the  larynx  and  was  found  in  the  left  bronchus. 
The  white  area  over  the  base  of  the  heart  is  due  to  mediastinal 
pneumothora.x.  Compare  this  plate  with  the  one  taken  before  the 
esophagus  was  ruptured.     (Case  II.) 


plate  was  made  which  showed  a  closed  safety  pin 
in  the  right  main  bronchus.  By  peroral  broncho- 
scopy through  a  five  mm.  tube  the  pin  was 
located  and  easilv  extracted  in  four  minutes.  The 


656 


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[New  York 
Medical  Journau 


larynx  looked  not  unlike  a  larynx  following  pro- 
longed intubational  tubage,  but  it  readily  returned 
to  normal.  The  tracheal  fistula  healed  in  the  usual 
manner.  The  child  had  been  treated  for  diphtheria 
and  croup  for  six  weeks,  and  it  was  only  after  he 
was  admitted  to  the  hospital  for  measles  that  the 


Fig.  6.  Fig.  7. 

Fig.  6. — Safety  pin  removed  from  right  main  bronchus  (Case  III). 
Fig.    7. — Dental    root    brooch    removed   from   left   superior  lobe 
bronchus  (Case  IV). 

true  nature  of  the  cause  of  the  croup  was  recog- 
nized. The  boy  made  a  complete  recovery  and 
there  was  no  stenosis  after  a  year. 

Case  IV.  Dental  root  brooch  in  left  superior  lobe 
bronchus.  The  patient  was  a  young  lady  aged 
seventeen  who  inhaled  the  tooth  canal  reamer  which 
slipped  from  the  fingers  of  the  dentist.  Dr.  Fidler 
saw  the  patient  and  after  having  taken  some  excel- 
lent radiographic  plates  referred  the  patient  to  me 
for  removal  of  the  foreign  body.  The  brooch  was 
in  the  left  superior  lobe  bronchus  for  thirty  hours. 
Under  local  anesthesia  the  brooch  was  readily 
extracted  through  a  seven  mm.  bronchoscope  in  two 
minutes.  No  sign  of  the  presenting  hair  like  point 
could  be  seen  in  the  mouth  of  the  left  upper  lobe 
bronchus  until  the  patient's  body  was  rotated  well 
to  the  right.    In  this  position  a  small  hair  like  point 


Fig.  10.  Fig.  11. 

Fig.   10. — O'Dwyer  tube  removed  from  bronchus   (Case  VII). 
Fig.    11. — Intubation   tube  removed   from   right   bronchus  (Case 
VIII). 

was  visible  lying  on  the  floor  of  the  bronchus.  It 
was  gently  grasped  by  straight  forceps  and  removed. 
The  patient  recovered. 

Case  V.  Carpenter  screw  in  the  lung  of  a  boy 
of  two  years.  I  had  the  good  fortune  to  see  this 
case  with  Dr.  Arrowsmith  whom  I  assisted  at  the 


first  trial.  Neither  of  us  was  able  to  grasp  the 
head  of  the  screw  at  the  first  trial  with  the  forceps 
at  hand,  for  there  was  a  firm  ring  of  edema  above 
the  head  of  the  screw  which  almost  completely  hid 
it  from  view.  It  was  evident  from  the  radiographic 
plate  that  the  screw  was  a  large  one  and  the  head 


Fig.  S.  Fig.  9. 

Fig.  8. — Carpenter  screw  removed  from  lung  (Case  IV). 
Fig.  9. — Metal  intubation  tube  from  right  main  bronchus  (Case 
VI). 


mu^t  have  been  considerably  larger  than  the  diameter 
of  the  bronchus  into  which  it  had  entered ;  never- 
theless it  had  worked  its  way  downward  by  its 
ratchet  movement  as  far  as  it  was  possible  to  go. 

After  fifteen  minutes'  trial  further  attempts  at  re- 
moval were  discontinued  and  a  second  trial  was  to 
be  made  a  week  later.  In  the  interval  I  had  a  spe- 
cial pair  of  alligator  forceps  made  which  would  dilate 
the  stricture  above  the  head  of  the  screw  and  at  the 
same  time  grasp  it  firmly.  A  week  later  a  second 
attempt  was  made  to  extract  the  screw  by  upper 
bronchoscopy,  and  after  Dr.  Arrowsmith  had  worked 
for  a  few  minutes  he  decided  that  it  would  be  advis- 
able to  remove  the  screw  by  tracheotomic  broncho- 
scopy owing  to  the  massive  head  of  the  screw  which 
was  bound  to  cause  much  traumatism  if  removed 
through  the  glottis,  and  the  resultant  secondary  sub- 


FiG,  12.  Fig.  13. 

Fig.  12. — Intubation  tube  removed  from  right  bronchus  (Case  IX). 
Fig.    13. — Noncoughup  tube  removed  from  right  bronchus  (Case 
X). 

glottic  edema  would  necessitate  tracheotomy  later. 
Dr.  Arrowsmith  performed  a  low  tracheotomy  with 
the  five  mm.  bronchoscope  in  situ.  After  working 
for  a  short  time  Dr.  Arrowsmith's  eyes  became  very 
tired  and  he  gave  me  a  second  trial  at  removal.  I 
had  the  good  fortune  to  have  the  blades  of  the  for- 


October  30,  1920.] 


LYNAH:  FOREIGN  BODIES 


657 


ceps  dilate  the  edematous  stricture  above  the  foreign 
body  and  engage  it  and  the  screw,  forceps  and 
bronchoscope  were  removed  through  the  tracheal 
fistula.  Had  not  Dr.  Arrowsmith's  eyes  become 
tired  I  would  never  have  had  a  chance  to  remove 
the  foreign  body  as  he  would  have  worked  a  few 


Fig.  14. — X  ray  shadow  of  dental  brooch  removed  (Case  IV). 

minutes  longer  and  removed  it  himself.  The  can- 
nula was  successfully  removed  and  the  child  made 
a  complete  recovery. 

Case  VI.  Metal  intubation  tube  removed  from 
the  right  main  bronchus  of  a  child  of  two  years. 
The  child  was  admitted  to  the  Kingston  Avenue 
Hospital  suffering  from  laryngeal  diphtheria  for 
which  she  was  intubated.  A  large  dose  of  antitoxin 
was  administered  and  as  the  general  condition  of  the 
child  was  good  on  the  fourth  day  an  attempt  was 
made  to  remove  the  tube.  The  tube  was  lost  during 
the  attempt  and  was  thought  at  first  to  have  been 
coughed  up  and  swallowed,  for  the  child  had  little 
discomfort  and  breathed  well  through  the  larynx. 
During  the  afternoon  the  child  had  some  difiicultv" 
in  breathing  but  intubation  was  not  considered 
necessary.  The  case  was  referred  to  me  for  bron- 
choscopic  examination,  and  on  the  introduction  of  a 
five  mm.  tube  the  head  of  the  tube  was  seen  to  be  in 
the  right  bronchus.  The  lumen  in  the  head  of  the 
tube  was  entered  with  the  extracting  forceps  and 
it  was  removed  through  the  mouth.  As  the  head 
of  the  tube  was  much  larger  than  the  glottis  there 
was  some  traumatic  subglottic  edema  which  followed 
and  the  child  again  became  croupy,  but  reintubation 
was  not  necessary.  The  child  made  a  complete 
recovery. 

Case  Yll.  A  special  O'Dwyer  tube  with  large 
retaining  swell  and  head  was  accidentally  shoved 
down  during  the  act  of  digital  extubation.  The 
tube,  a  three  year  size,  was  introduced  into  one  of 
the  coughup  cases  owing  to  the  great  diameter  of 
the  retention  swell.    The  tube  gravitated  downward 


owing  to  the  absence  of  the  cricoid  cartilage  which 
would  have  ordinarily  held  it  in  place,  had  not  the 
cartilage  sloughed  out  as  a  result  of  perichondritis 
which  is  the  chief  factor  in  all  cases  of  coughing 
up  of  the  tube.  As  the  head  of  tube  had  gravitated 
downward,  there  being  no  cricoid  cartilage  to  hold 
it  in  position,  the  added  attempt  to  remove  it  shoved 
it  down  into  the  bronchus  below.  The  child  imme- 
diately became  cyanotic  and  an  emergency  trache- 
otomy was  performed.  The  tube  was  removed 
through  the  tracheotomic  fistula.  The  child  re- 
covered but  became  one  of  the  postdiphtheritic 
retained  tracheal  canula  cases.  He  was  eventually 
decannulated  and  made  c.  complete  recovery. 

Case  A  III.  A  two  year  intubation  tube  removed 
from  the  right  brofichus  in  a  child  aged  two  and  a 
half  at  Riverside  Hospital.  The  usual  thing  oc- 
curred at  attempted  extubation  by  the  digital  method 
that  the  tube  head  was  pushed  through  the  glottic 
opening  and  fell  into  the  bronchus.  A  second  tube 
was  introduced  after  the  first  tube  fell  into  the 
bronchus  but  as  this  gave  no  relief  tracheotomy  was 
performed  and  the  tube  was  extracted  by  trache- 
otomic bronchoscopy,  a  five  mm.  tube  being  used. 
The  child  was  greatly  improved  following  the  re- 
moval of  the  tube  but  as  she  had  a  bronchopneu- 
monia before  the  accident  which  continued  to  spread 
she  succumbed  two  weeks  later. 

Case  IX.  A  two  year  intubation  tube  removed 
from  the  left  bronchus  in  a  boy  of  two  years  and 
nine  months.  The  boy  was  admitted  to  the  Willard 
Parker  Hospital  and  intubated  for  laryngeal  diph- 
theria. A  large  dose  of  antitoxin  was  administered 
and  as  the  general  condition  was  good  on  the  fifth 
day  a  digital  detubatory  trial  was  made.    The  at- 


FlG.  15. — X  ray  showing  location  of  carpenter  screw  removed 
from  the  lung  (Case  V). 

tempt  to  remove  the  tube  was  unsuccessful  at  the 
first  trial  and  several  attempts  were  made.  Finally 
the  operator  said  that  he  could  not  feel  the  tube. 
An  attempt  was  made  by  the  resident  physician  to 
locate  the  tube  but  this  was  unsuccessful.  The 
writer  was  notified  of  the  condition  and  removed 
the  tube  the  same  afternoon  with  some  difficulty 


658 


LYNAH:  FOREIGX  BODIES. 


[New  York 
Medical  Journal. 


through  the  mouth.  The  child  became  stenotic  a 
few  hours  after  the  removal  of  the  tube  and  rein- 
tubation  was  necessarj'  to  relieve  subglottic  edema. 
The  tube  was  worn  for  one  week  and  removed  by 
the  direct  method.  The  child  remained  without  the 
tube  and  made  a  complete  recovery. 

Case  X.    A  one  year  noncoughup  tube  removed 


Fic.  16. — Intubation  tube  shown  by  x  ray  removed  from  right 
bronchus  (Case  VIII). 

from  the  right  bronchus  of  a  child  aged  a  year  and 
half.  The  child  was  admitted  to  the  Kingston 
Avenue  Hospital  and  intubated  with  a  one  year 
O'Dwyer  tube.  After  a  large  dose  of  antitoxin  the 
child  improved  but  was  unable  to  remain  without 
the  tube  at  the  first  trial.  During  the  second  week 
the  child  started  to  cough  up  the  tube,  and  one  of 
my  noncoughup  tubes  was  introduced.  This  tube 
was  retained  and  put  a  stop  to  further  trouble.  One 
week  later  one  of  the  staff  while  attempting  to 
remove  the  tube  shoved  it  down  into  the  bronchus. 
At  first  the  tube  was  thought  to  have  been  extracted 
and  swallowed,  for  there  was  little  discomfort  fol- 
lowing the  lodgement  in  the  bronchus.  A  radio- 
graph showed  the  tube  to  be  in  the  right  bronchus. 
The  child  had  so  little  discomfort  from  the  tube  in 
the  bronchus  that  at  first  it  was  thought  impossible, 
until  the  child  became  stenotic  five  days  after  the 
accident,  the  afternoon  of  the  same  day  that  the  x  ray 
was  taken.  I  attempted  to  remove  the  tube  after- 
the  introduction  of  a  five  mm.  bronchoscope  and 
while  the  tube  could  be  brought  up  to  the  glottis  it 
could  not  be  extracted.  A  tracheotomy  was  per- 
formed with  the  bronchoscope  as  a  guide  and  the 
tube  removed  by  the  straight  extractor  through  the 
tracheotomic  fistula.  The  child  wore  the  tracheal 
cannula  for  a  long  period  after  the  removal  of  the 
tube  but  was  eventually  decannulated  and  made  a 
complete  recovery'. 

Case  XL  A  small  piece  of  toilet  paper  in  the 
right  lower  lobe  bronchus  in  an  infant  of  eight 
months.  The  case  was  referred  by  Dr.  Angelo 
.  Smith,  of  Yonkers,  N.  Y.  The  infant  was  in  the 
habit  of  putting  paper  in  her  mouth  and  the  nurse 
who  had  been  left  in  charge  of  the  baby  probably 


paid  little  attention  to  her  during  the  absence  of  the 
parents.  When  the  nurse  returned  to  the  room  she 
found  the  child  choking.  She  immediately  put  her 
finger  in  the  mouth  of  the  infant  and  removed  sev- 
eral pieces  of  toilet  paper.  The  child  was  in 
extremis  and  Dr.  Smith  was  notified.  When  I  saw 
the  child  a  few  hours  later  she  was  in  poor  condi- 
tion. The  lungs  were  ballooned,  and  there  was  a 
marked  asthmatic  wheeze  on  expiration.  Little  air 
entered  the  right  lower  lobe  of  the  lung.  The  radio- 
graphic plate  was  negative.  The  infant  was  bron- 
choscoped,  a  four  mm.  tube  being  used.  In  the  right 
bronchus,  as  far  downward  as  it  could  go,  was  seen 
a  whitish  mass  which  looked  like  a  plaque  of  diph- 
theritic membrane.  This  was  removed  by  suction, 
for  fear  of  maceration  with  forceps.  Both  bronchi 
were  then  explored  but  no  further  pulpy  masses 
found.  The  baby  improved  after  the  removal  of 
the  piece  of  paper  and  much  secretion  by  suction 
but  within  a  short  time  the  lungs  began  to  fill  and 
there  was  difficulty  in  breathing.  The  four  mm.  tube 
was  again  introduced  and  much  secretion  evacuated. 
Alarked  subglottic  stenosis  was  seen  on  the  second 
introduction  of  the  bronchoscope  even  though  we 
had  only  worked  fifteen  minutes.  We  decided  to 
perform  tracheotomy  for  the  subglottic  stenosis  and 
drainage  of  the  lung.  Tracheotomy  was  performed 
with  the  bronchoscope  as  a  guide. 

The  tracheotomy  temporarily  relieved  the  condi- 
tion, but  pulmonary  edema  became  very  bothersome 
and  repeated  aspirations  were  made  to  remove  secre- 
tion. This  was  easily  accomplished  by  the  intro- 
duction of  a  small  catheter  into  the  tracheotomy 
tube.  Repeated  aspirations  continued  each  time 
that  there  was  difficulty  with  respiration,  but  this 
was  all  to  no  purpose,  for  thirty-four  hours  after 
bronchoscopy  the  unfortunate  infant  succumbed  to 
pulmonary  edema. 

Case  XIL  This  is  a  bronchoscopic  gauze  sponge 
which  became  detached  from  a  sponge  holder  which 
was  not  fixed  properly  and  became  lodged  in  the 
right  upper  lobe  bronchus.  This  accident  occurred 
in  an  adult  suffering  from  tracheobronchial  diph- 


FiG.   17.  Fig.   18.  Fig.  19. 

Fig  17. — Toilet  paper  removed  from  right  lower  lobe  bronchus 
(Case  XI). 

Fig.  18. — Gauze  sponge  removed  from  right  upper  lobe  bronchus 
(Case  XII). 

Fig  19. — Upholsterer's  tack  removed  from  right  stem  bronchus 
(Case  XIII). 

theria  after  the  removal  of  a  diphtheritic  cast.  It 
was  during  the  process  of  swabbing  the  tracheo- 
bronchi  with  antitoxin  that  the  sponge  was  lost. 
The  nurse,  in  applying  the  sponge,  did  not  tighten 
the  collar  over  the  grasping  blades  of  the  sponge 


October  30,  1920.] 


LVNAH:  FOREIGN  BODIES. 


659 


holder  and  it  was  easily  detached  and  lost.  The 
sponge,  readily  absorbing  the  bloody  secretion  in  the 
bronchus  after  the  removal  of  the  membrane,  was 
difficult  to  locate.  However,  after  a  few  minutes' 
search,  it  was  located  in  the  upper  lobe  orifice  and 
was  easily  removed.    The  pa  ient  made  a  complete 


Fig.  20. — Upholsterer's  tack  seen  in  right  stem  bronchus  opposite 
the  middle  lobe  orifice  (Case  XIII). 

recovery  from  the  diphtheritic  foreign  body  and 
sponge. 

Case  XIII.  An  upholsterei;'s  tack  removed  from 
the  right  stem  bronchus  opposite  the  middle  lobe 
orifice  after  a  sojourn  of  two  and  a  half  years.  I 
had  the  pleasure  of  seeing  this  patient,  a  boy  of  eight 
years,  with  Dr.  Forbes.  The  tack  was  in  a  diffi- 
cult location  in  the  right  stem  bronchus,  and  the 
head  was  anchored  at  the  middle  lobe  bronchus, 
imbedded  in  a  firm  stricture  of  long  duration.  The 
point  of  the  tack  could  be  easilj-  seen  through  the 
seven  mm.  tube  pointing  well  to  the  left.  The  head 
of  the  tack  was  not  visible.  Dr.  Forbes  had  dilated 
the  stricture  several  times  but  the  tack  could  not  be 
budged.  I  had  the  good  fortune  to  be  of  assistance 
at  two  sittings  and  it  was  at  the  last  trial  that  I 
was  given  the  opportimity  to  remove  the  tack.  The 
difficult  problem  presenting  was,  that  the  shaft  and 
point  of  the  tack  were  pointing  well  to  the  left,  and 
that  the  head  of  the  tack  would  be  reanchored  in 
the  lip  of  the  middle  lobe  bronchus  each  time  an 
attempt  was  made  to  remove  it  against  the  axis  of 
the  presenting  point.  Therefore,  the  boy's  body 
was  rotated  well  to  the  left  and  the  bronchoscope 
and  forceps  were  brought  into  a  line  with  the  pre- 
senting shaft  and  point  of  the  tack.  Now  axis  trac- 
tion was  applied  with  considerable  pull,  and  in  one 
minute  the  bronchoscope,  forceps  and  tack  were  all 
removed  together.  .  There  was  a  lung  abscess  which 
ruptured  into  the  pleura,  and  a  rib  was  resected  to 
drain  the  cavity.  It  was  a  long  time  after  the  re- 
moval of  the  foreign  body  before  the  drainage  tube 
could  be  removed  from  the  pleura.  The  boy  re- 
covered. 

C.\SE  XIV.  Four  pieces  of  raw  carrot  inhaled  into 
the  right  and  left  bronchi  in  a  child  aged  three.  The 


child  l:ad  a  croupy  cough  and  violent  asthmatic 
wheezing  for  five  days,  and  had  been  treated  as  a 
case  of  diphtheria.  As  the  asthmatic  dyspnea  did 
not  improve  after  antitoxin,  and  as  Dr.  Raymond 
Laub  had  obtained  a  history  from  the  mother  that 
the  child  had  a  choking  spell  five  days  prior  while 
eating  raw  carrot,  the  child  was  referred  to  me  for 
bronchoscopic  examination.  On  admission,  the  child 
was  ill  extremis  and  made  no  eft'ort  to  cough.  There 
was  a  marked  asthmatic  wheezing  expiration  aud- 
ible at  some  distance.  Dr.  Laub  had  made  a  phys- 
ical examination  of  the  chest,  and  stated  that  little 
air  was  entering  either  lung,  and  that  the  percussion 
note  was  tympanitic.  There  was  a  general  subcu- 
taneous emphysema  present  which  involved  the  face, 
chest  and  trunk.  The  larynx  was  emphysematous 
and  shiny.  The  trachea  and  bronchi  were  not  in- 
volved. AX'ith  a  five  mm.  tube  a  piece  of  carrot  was 
removed  from  the  right  main  bronchus.  The  child 
was  njoribund  and  died  shortly  after  the  removal  of 
the  large  piece,  of  carrot.  An  autopsy  was  per- 
mitted by  the  parents  and  three  smaller  pieces  of 
carrot  were  removed  from  the  lung.  One  piece 
was  found  in  the  right  superior  lobe  bronchus;  the 
third  piece  in  the  left  main  bronchus,  and  the  fourtli 
piece  in  the  dorsal  branch  of  the  left  lower  lobe 
bronchus,  at  which  location  there  was  a  well  defined 
abscess  containing  foul  smelling  pus.  The  lungs 
were  beefily  congested  and  ballooned  with  air.  The 
visceral  pleura  was  covered  with  air  blebs  from  the 
size  of  a  pea  to  a  half  dollar.  The  rupture  of  the 
blebs  probably  caused  a  leaking  of  air  into  the 
media.stinum,  which   follov.-ed  the  cervical  fascicC 


Fig.  21. — Lateral  view  of  upholsterer's  tack  in  right  stem  bronchus 
(Case  XIII).  — 

and  produced  tissue  emphysema.  The  heart  was 
increased  in  size.  This  case  illustrates  the  valve- 
like  action  of  loosely  placed  foreign  bodies  in  the 
air  passages.  It  also  illustrates  that  the  irritating 
effect  of  raw  carrot  in  the  air  passages  is  equally  as 
irritating  and  fatal  as  the  inhalation  of  peanut  ker- 
nels, and  was  rapidly  productive  of  food  inhalation 
bronchitis  and  king  abscess  within  five  days  of  the 
accident. 


660 


UN  AH:  FOREIGX  BODIES. 


[New  York 
Medical  Journal. 


Case  XV.  Peanut  pulp  of  a  parched  nut  removed 
from  the  right  bronchus  of  a  child  two  and  a  half 
years  of  age.  The  child  had  been  given  several 
pieces  of  peanut  which  had  been  partly  broken  up 
by  the  mother.  The  child  aspirated  it  into  her  lung 
shortly  after  taking  it  into  her  mouth  and  had  a 


been  a  fatal  peanut  bronchitis  and  pulmonary  ab- 
scess. 

Case  XVL  Peanut  kernel  and  several  small  pieces 
removed  from  the  right  bronchus  of  a  child  of  three 
years  and  eight  months.  The  child  was  admitted 
to  the  hospital  five  days  after  the  accident.  A 


Fig.  22.  Fig.  23. 

Fig.  22. — Four  pieces  of  raw  carrot  removed  from  the  bronchi 
of  a  child  (Case  XIV). 

Fig.  2.^. — Peanut  pulp  removed  from  right  bronchus  (Case  XV). 

violent  choking  spell.  The  child  was  brought  to 
the  hospital  six  hours  after  the  accident.  The  phys- 
ical examination  showed  that  little  air  was  entering 
the  right  lung.  There  was  an  asthmatic  expiratory 
wheeze.  An  x  ray  plate  revealed  a  shadow  over 
the  right  upper  and  middle  lobes,  but  the  radi- 
ographer thought  there  was  also  a  shadow  in  the 
right  lower  bronchus.  Bronchoscopy  was  performed 
without  anesthesia  and  a  small  piece  of  peanut  was 
removed  from  the  right  stem  bronchus  opposite 
the  middle  lobe  orifice,  a  five  mm.  tube  being  used. 
As  the  piece  removed  by  forceps  seemed  to  be  the 
largest  piece,  the  remaining  fragments  were  removed 
by  suction  through  a  two  millimetre  tube.  The 
small  pieces  of  pulp  were  readily  removed  by  this 
method,  care  being  taken  not  to  wad  the  pulp  in 
the  lower  lobe  bronchus. 

All  of  the  peanut  pulp  was  apparently  removed 
for  air  entered  the  whole  of  the  right  lung.  There 
was  a  high  rise  in  temperature  to  105.2°,  following 
the  removal,  but  gradually  fell  to  normal  within 
two  days.  The  child  was  kept  under  observation 
for  two  weeks  and  then  discharged  after  repeated 
stethoscopic  examinations  of  the  chest.  The  child 
made  a  complete  recovery  and  was  in  perfect  health 
six  months  after  the  extraction.    This  case  illus- 


FiG.  24. 

Fig.  24. — Peanut  kernel  removed  from  right  bronchus  (Case  XVI). 

splendid  radiograph  taken  showed  a  dense  shadow 
over  the  right  lobe.  Bronchoscopic  examination 
was  made  and  a  fragment  removed  from  the  right 
stem  bronchus.  By  suction  several  small  frag- 
ments were  removed  and  about  a  dram  of  foul 
smelling  pus  evacuated  from  the  lower  lobe  bron- 
chus. After  having  worked  for  fifteen  minutes  the 
procedure  was  discontinued.  There  was  consider- 
able reaction  following  the  bronchoscopic  examina- 
tion and  the  temperature  rose  to  104.2°.  The  pulse 
and  respiration  were  rapid.  A  physical  examina- 
tion made  at  this  time  showed  that  there  was  a 
dififuse  bronchitis  and  pneumonia  over  the  lower  lobe 
of  the  right  lung.  Posteriorly  there  was  no  air 
entering.  Three  days  later  a  second  bronchoscopic 
examination  was  made  with  a  four  mm.  tube  and  the 
dor.sal  branch  of  the  lower  lobe  bronchus  explored. 
No  fragments  of  peanut  were  removed,  but  some 
pus  was  evacuated.  From  this  time  on  the  child 
began  to  run  a  septic  temperature.  The  left  lower 
lobe  was  aspirated  with  a  long  needle  and  the  abscess 
cavity  located.  Unfortunately  a  pulmonary  abscess 
developed,  owing  to  the  failure  to  remove  a  small 
fragment  which  had  entered  a  small  dorsal  branch 
bronchus.  Later  the  abscess  increased  in  size  and 
a  rib  was  resected.  This  drained  the  abscess  but 
the  child  did  not  improve.    She  continued  to  linger 


Fig.  25. — Fragments  of  meat  removed  from  right  bronchus  (Case  Fu;.  26. — Piec  s  of  infectious  material  removed  from  right  upper 

XVII).  lobe  bronchus  (Case  X\'I1I). 

trates  the  value  of  suction  in  removing  small  pieces  in  this  septic  condition  and  succumbed  six  weeks 

of  peanut  from  the  lung.    Had  an  attempt  been  later. 

made  to  remove  all  of  the  small  fragments  with  Case  XVIL    Some  fragments  of  meat  removed 

forceps  there  would  have  been  great  danger  of  from  the  right  bronchus  of  a  boy  aged  four.  The 

macerating  them,  and  some  of  the  tiny  fragments  boy  was  admitted  to  the  Kingston  Avenue  Hospital 

would  have  been  lost,  and  the  result  would  have  for  laryngeal  diphtheria,  for  a  dose  of  antitoxin 


Octob.r  M).  1920.] 


UN  AH:  FOREIGN  BODIES. 


661 


given  by  tlie  family  pliysician  did  not  relieve  the 
dyspnea.  On  admission,  Dr.  Adam  Eberle,  by  a 
very  careful  physical  examination,  ruled  out  tracheo- 
bronchial diphtheria,  and  notified  me  of  the  possi- 
bility of  a  foreign  body  on  account  of  the  mother's 
statement  that  the  child  choked  while  at  the  table 


Ku;.  17. — X  ray  of  peanut  pulp  in  right  bronchus   (Case  XV). 

and  developed  croup  the  same  night.  The  onset  of 
the  croupy  attack  was  too  sudden  for  dijjhtheria, 
and  Dr.  Eberle  suspected  that  a  foreign  body  in  tlie 
right  lung  was  the  cause  of  the  trouble.  A  broncho- 
.scopic  examination  was  made  with  a  five  mm.  tube 
and  a  small  mass  of  chewed  meat  was  removed 
from  the  right  bronchus.  The  physical  signs  did 
not  clear  up  while  the  bronchoscope  was  in  situ, 
and  on  a  second  inspection  a  small  piece  was  re- 
moved from  the  lower  lobe  bronchus.  The  physical 
signs  as  elicited  by  the  stethoscope  immediately 
improved  after  the  removal  of  the  fragment,  and 
air  readily  entered  the  lung.  The  boy  was  kept  in 
the  hospital  for  two  weeks  and  discharged  as  cured. 
The  interesting  points  of  this  case  are  the  diagnosis 
of  a  foreign  body  by  Dr.  Eberle  on  a  vague  history 
and  the  stethoscopic  signs  in  the  chest.  And  second, 
that  a  stethoscope  physical  examination  with  the 
bronchoscope  in  situ  is  of  the  greatest  aid  in  deter- 
mining whether  all  of  the  foreign  body  has  been 
removed. 

C.\SE  XVm.  Some  small  pieces  of  cheesy  infec- 
tious material  removed  from  the  right  upper  lobe 
bronchus  of  a  child  of  one  year.  The  child  was 
admitted  to  Riverside  Hospital  for  supposed  diph- 
theria. After  the  acute  diphtheritic  process  had 
subsided  there  was  a  severe  hacking  cough  and  a 
peculiar  wheeze  on  expiration.  Dr.  John  Crawford 
suspected  the  presence  of  a  foreign  body  and  had 
an  X  ray  picture  made.  The  x  ray  showed  a  very 
dense  shadow  over  the  upper  lobe  of  the  right  lung. 
Two  days  later  we  bronchoscoped  the  child  and 
located  a  foreign  body  in  the  orifice  of  the  right 
upper  lobe  bronchus.  A  whitish  mass  was  seen  in 
the  orifice  of  the  upper  lobe  bronchus  through  a 
four  mm.  tube.  It  was  grasped  with  forceps  and  re- 


moved. On  its  removal  a  small  piece  was  seen  to 
fall  into  the  stem  bronchus.  The  child  was  placed 
in  an  exaggerated  Trendelenburg  position  and  with 
a  small  suction  tube  this  piece  was  removed.  With 
the  first  piece  removed  there  was  a  small  sac  which 
seemed  to  contain  the  particles.  A  few  hours  later 
subglottic  edema  developed,  even  though  we  had 
only  worked  ten  minutes.  The  stenosis  required 
intubation,  a  oneyear  tube  being  worn  for  two 
days.  One  month  later  the  child  was  discharged 
from  the  hospital  cured.  The  specimen  was  sent  to 
Dr.-  Jeffries  of  the  Polyclinic  ]\Iedical  School  Lab- 
oratory and  he  reported  that  the  material  was  en- 
closed in  an  epithelial  sac.  "The  material  removed 
from  the  right  bronchus  of  K.  Z.  was  a  mass  of  pus 
cells  and  mixed  organisms,  no  tubercle  bacilli  were 
found.  The  mass  is  similar  to  the  cheesy  infectious 
material  removed  from  the  crypts  of  tonsils,  and 
no  doubt  it  fell  from  the  tonsil  into  the  lung."  The 
child  had  hypertrophied  tonsils  with  cheesy  material 
in  them  when  examined  after  the  report  from  Dr. 
Jefferies.  The  small  mass  in  its  epithelial  covering 
produced  a  complete  blocking  of  the  right  upper 
lobe  of  the  lung.  Later  x  ray  plates  showed  the 
lung  to  be  clearing. 

Case  XIX.  A  tracheobronchial  diphtheritic  cast 
removed  from  the  right  bronchus  of  a  boy  eight 
years  of  age.  The  boy  had  been  ill  with  a  mild 
bronchitis  for  six  days  and  diphtheria  was  suspected 
by  Dr.  Brendler,  who  asked  me  to  see  the  patient 
with  him.  A  large  dose  of  antitoxin  had  failed  to 
relieve  the  croupy  attack,  which  had  become  gradu- 
ally worse  twenty-four  hours  later.  The  child  was 
in  extremis,  and  expiration  was  difficult  and  accom- 
panied by  an  asthmatic  wheeze.  A  rapid  stetho- 
scopic examination  showed  that  little  air  was  enter- 
ing the  right  lung.  There  were  many  noisy  rales 
over  both  lungs.  We  bronchoscoped  the  boy  and 
found  the  larynx  congested.  The  lower  tracheal 
and  right  bronchus  were  filled  with  membrane,  which 


Fig.  28. — X  ray  of  peanut  kernel  in  right  bronchus  (Case  XVI). 

was  easily  removed  by  suction.  The  trachea  and 
bronchi  were  swabbed  with  antitoxin  and  a  long 
intubation  tube  introduced.  There  was  a  very 
severe  reaction  following  the  removal  of  the  mem- 
brane and  the  temperature  gradually  rose  until  it 
was  107°  an  hour  later.    It  was  evident  at  this  time 


662 


LYNAH:  FOREIGX  BODIES. 


[New  York 
Medical  Journal. 


that  the  boy  was  in  extremis  and  would  probably 
succumb.  He  was  irritable  and  craved  for  water, 
which  he  could  not  swallow  on  account  of  the 
trickling  into  the  tube.  A  small  rubber  catheter 
was  introduced  through  his  nose  into  the  esophagus 


Fig.  29. — X  rav  showing  dense  shadow  over  upper  lobe  of  right 
lung  (Case  .Will). 

and  a  half  pint  of  milk  with  two  drams  of  whiskey 
introduced.  His  thirst  having  been  relieved  the  boy 
fell  asleep.  Within  two  hours  liis  temperature  had 
fallen  to  105°  and  it  continued  to  range  between 
105°  and  103.2°  for  the  ne.xt  two  days.  Feeding 
was  continued  by  gavage  and  as  he  was  getting  a 
good  amount  of  nourishment  he  continued  to  im- 
prove. By  the  end  of  the  fourth  day  the  general 
condition  of  the  boy  had  improved  to  such  a  degree 
that  I  decided  to  r.emove  the  long  bronchial  tube. 
This  was  done  and  there  was  no  discomfort  after 
its  removal.  Reintubation  was  not  necessary.  The 
boy  had  a  protracted  convalescence  owing  to  a  patchy 
pneumonia  following,  but  he  made  a  complete 
recovery  after  two  months. 

Case  XX.  Membranous  diphtheritic  plaques  re- 
moved from  the  trachea  and  bronchi.    This  case 


Fig.  30.  Fig.  31. 

Fig.  30. — Diphtheritic  cast  removed  from  risht  bronchus  (Case 
XIX). 

Fig.  31. — Diphtheritic  plaques  removed  frot»i  trachea  and  bronchi 
(Case  XX). 

was  seen  with  Dr.  Ginsberg,  of  Yonkers.,  ^S^.  Y.  The 
child  had  been  intubated  by  Dr.  Pisek  who  had  given 
a  large  dose  of  antitoxin.  The  child  was  greatly 
improved  after  intubation  of  the  larynx,  but  the 
same  evening  he  became  dyspneic  in  spite  of  the 


tube,  and  I  was  called  to  bronchoscope  the  patient. 
In  the  meantime  the  tube  had  been  coughed  up  and 
when  I  arrived  the  boy  was  in  much  distress.  The 
bronchoscopic  examination  revealed  a  loose  cast  of 
membrane  in  the  trachea.  This  was  removed  and  a 
thin  piece  was  visible  in  the  right  bronchus.  After 
this  was  removed  there  was  no  further  membrane 
visible.  An  intubation  tube  was  introduced.  The 
condition  of  the  boy  was  much  improved  the  fol- 
lowing day  and  he  was  in  sufficiently  good  condition 
to  remove  the  tube  on  the  third  day.  There  was  no 
further  trouble  after  the  removal  of  the  tube  and 
the  patient  made  an  uneventful  recovery.  The  tube 
used  was  a  five  mm.  and  the  time  of  operation  six 
minutes. 

ESOPH.\t;E.\L  FOREIGN  BODIES. 

Case  I.  Codfish  bone  imbedded  in  the  plicacrico- 
pharyngeus  with  only  the  small  beaded  head  of  the 
articulating  end  presenting.    Referred  by  Dr.  H.  T. 


Fig.  39.  Fig.  40.  Fig.  41. 

F'iG.  33. — Codfish  bone  (Case  I). 

Fig.  34. — Chicken  bone  removed  from  esophagus  (Case  II). 

Fig.  35. — Chicken  bone  from  esophagus  (Case  III). 

Figs.  37  to  41. — Diameters  of  coins  removed  (Cases  IV  to  IX). 


Galpin.  Radiographic  plate  negative.  Great  pain 
from  spasmodic  contraction  of  cricopharyngeus,  and 
much  gagging  and  discomfort.  Beaded  end  pre- 
senting in  area  of  inflammation.  Easily  removed 
through  spatula  esophagoscope  in  one  minute ;  no 
anesthesia :  recovery". 

Case  II.  Clinical  case  in  child  of  four  years. 
Small  piece  of  the  breast  bone  of  a  chicken, 
presenting  crosswise  and  transfixed  in  upper  thor- 
acic esophagus  for  five  days  ;  marked  edema.  Radio- 
graphic plate  did  not  show  bone.  Easily  removed 
through  seven  m.m.  esophagoscope  in  a  few  seconds 
after  turning  to  avoid  cutting  esophageal  wall. 


October  30,  1920.] 


LVXAH:   FOREIGN  BODIES. 


663 


Case  III.  Piece  of  breast  bone  of  chicken  in 
esophagus  of  a  child  of  ten  years;  in  esophagus 
three  days ;  below  cricopharyngeus.  Easily  removed 
through  esophagoscope  in  two  minutes ;  no  anes- 
thesia. 

Case  IV.  American  penny  in  esophagus  of  a  child 
of  one  year.    It  was  lodged  in  the  esophagtis  below 


Fig.  32. — Penny  in  esophagus   (Case  IV). 

cricopharyngeus  for  a  week.  The  esophagus  was 
lacerated  and  swollen  from  two  attempts  to  remove 
before  admission.  A  spatula  esophagoscope  and 
alligator  forceps  was  used ;  extraction  in  eight 
minutes.  It  was  difficult  to  locate  on  account  of 
marked  edema  and  sloughs  in  esophagus ;  extraction 
followed  by  cure.  There  was  no  stricture  of  esoph- 
agus six  months  later. 

C.\SE  \*.  Coin,  penny,  in  esophagus  of  child  two 
years;  in  esophagus  fourteen  hours;  easily  extracted 
in  one  minute :  cure. 

Case  \T.  Referred  by  Dr.  Angelo  Smith.  Coin, 
nickel,  in  esophagus  of  child  two  and  a  half  years, 
upper  thoracic  region  for  eight  days ;  much  edema 
covering  coin;  extraction,  cure.  Removed  in  four 
minutes.    Tube,  seven  mm.  bronchoscope. 

Case  \TI.  Coin,  nickel,  in  esophagus  of  a  child  of 
three  years  and  eight  months ;  in  esophagus  four 
weeks ;  opposite  bronchial  crossing  after  having 
Deen  thought  to  have  been  shoved  down  with  a 
stomach  tube ;  extraction,  cure.  Esophagoscope. 
Time,  ten  minutes. 

Case  VIII.  Coin,  nickel,  in  esophagus  of  a  child 
two  and  a  half  years;  in  esophagus  twelve  days; 
edema  covering  whole  of  presenting  edge ;  extrac- 
tion through  tube  spatula  with  alligator  in  six 
minutes. 

C.\se  IX.  Coin,  nickel,  in  esophagus  of  an  infant 
of  one  and  a  half  years;  in  upper  esophagus  two 
days ;  difficulty  in  breathing  and  swallowing ;  extrac- 
tion through  laryngeal  spatula  with  alligator  forceps 
in  one  minute. 

Case  X.  Coin,  quarter  of  a  dollar,  in  esophagus 
of  a  child  of  three  years  for  fourteen  days.  There 
was  a  marked  edema ;  esophagtts  covered  with  thick 


exudate;  no  history  of  any  attempted  re;no^al  be- 
fore admission ;  pharyngeal  wall  much  inflamed ; 
membrane  removed  was  diphtheritic  by  culture. 
The  foreign  body  was  completely  hidden  from  view 
in  membrane  and  edema.  The  extraction  was  diffi- 
cult owing  to  edema,  which  was  difficult  to  push 
aside  to  see  coin.  The  esophago.scope  and  long  alli- 
gator forceps  were  tised  after  the  edema  over  the 
coin  was  separated  with  blades  of  forceps.  Time  of 
operation,  seven  minutes.  Recovery. 

Case  XI.  Triangular  piece  of  sterninu  of  chicken 
in  esophagus  below  plicacricopharyngeus  of  a  yoimg 
lady  of  sixteen  years  for  twenty  hours.  The  patient 
was  referred  to  me  by  Dr.  Ard  of  Plainfield.  X^.  J. 
Easy  removal  in  three  minutes  with  spatula  esopha- 
goscope and  alligator  forceps. 

Case  XII.  Large  triangular  piece  of  the  sterntmi 
of  a  chicken  in  esophagus  below  cricopharyngeus  of 
a  woman  of  thirty  years  for  two  days.  Good  x-ray 
l)late  of  triangular  piece  of  bone.  Referred  by  Dr. 
Angelo  Smith,  of  Yonkers,  X.  Y.  Points  deeply 
imbedded  in  esophagtts  with  some  bleeding  at  fixa- 
tion of  points ;  spattila  esophagoscope :  rotated  to 
disengage  points  to  prevent  laceration;  extraction, 
cure.    Time  of  operation,  four  minutes. 

Case  XIII.  Mother  of  pearl  button  in  upper 
thoracic  esophagus  in  a  girl  of  ^ix  years  for  forty- 
six  hours.  Eas)-  extraction  through  seven  mm.  eso- 
phagoscope in  two  minutes.  Xo  anesthesia.  Re- 
covery. 

C.\SE  XI\'.  Large  mother  of  pearl  btitton  in  eso- 
phagus of  a  girl  of  ten  years  for  five  days.  Referred 
bv  Dr.  Angelo  Smith.    Radiographic  plate  tfiowed 


Fig.  42. — Quarter  dollar  in  csoj.liagus  (Case  X). 

button  below  bronchial  crossing.  Patient  had  been 
fed  by  force  and  efTorts  had  been  made  to  push  the 
button  down.  There  had  also  been  several  emetics 
administered  by  the  j^arents  with  the  hope  of  bring- 
ing it  up  or  sending  it  down.  Xo  new  x  ray  ])ic- 
ture  taken  just  before  esophagoscopy.  A  seven 
millimetre  esophagoscope  showed  a  curdled  mass  be- 
low the  bronchial  crossing,  but  no  button  was  seen. 
X  ravs  were  then  taken  of  the  stomach  and  intes- 


664 


LYNAH:  FOREIGN  BODIES. 


[New  York 
Medical  Journal. 


tines,  but  no  button  was  located.  The  curdled  mass 
seen  in  the  esophagus  was  the  remains  of  the  dis- 
solved button,  the  button  having  been  dissolved  by 
the  frequent  emesis  of  hydrochloric  acid.  At  the 
suggestion  of  Dr.  Goldhorn,  a  similar  button  was 


Fig.  43. — Cli  cke  i  bore  in  efi-.phagus  (Cas?  XIIV 

removed  from  her  coat  and  immer.ied  in  a  very  di- 
lute solution  of  hydrochloric  acid.  The  button 
became  a  cheesy  mass  within  twenty-four  hours. 
It  is  interesting  to  note  that  these  buttons,  .so  often 
called  mother  of  pearl,  are  made  of  compressed 
casein  and  are  readily  dissolved  in  dilute  hydro- 
chloric acid.  Had  an  x  ray  plate  been  made  just 
prior  to  the  csophagoscopic  examination  the  opera- 


Fio.  44. — Pearl  button  in  esophagus  (Case  XIII). 

tion  would  never  have  been  attempted,  for  no  for- 
eign body  shadow  would  have  been  seen.  However, 
on  the  other  hand,  failure  to  find  nothing  but  the 
cheesy  mass  of  the  button  taught  us  what  these  but- 
tons were  made  of. 


Fig.  45.  Fig.  46. 

Fig.  45. — Diameter  of  quarter  removed  from  esophagus  (Case  X). 
Fig.  46. — Chicken  bone  removed  from  esophagus  (Case  XI). 


Fig.  47.  Fig.  48. 

Fig.  47. — Chicken  bone  removed  from  esophagus  (Case  XII). 
Fig.  48.  —  Pearl  button  removed  from  esophagus  (Case  Xlllj. 


Fig.  49.  Fig.  50. 

Fig.  49. — Lead  skirt  weight  removed  from  esophagus  (Case  XV). 
Fig.    50. — Apricot   seed   removed   from   esophagus    (Case  XVI). 

Case  XV.  A  lead  skirt  weight  in  esophagus  of  a 
boy  of  six  years.  In  e.sophagus,  below  cricopharyn- 
geus.  for  four  days.  Extraction  by  .spatula 
esophagoscope  in  two  minutes. 

Case  X\  I.    Apricot  seed  held  firmly  in  crico- 


FiG.    51. — Olive    bougie    in    gastru|>tiitic    !-trimacb    (Case  -W'll). 


October  30.  1920.]         COUGH  LIS:  SURGICAL    TREATMENT  OF  HAND  INFECTIONS. 


665 


pharyngeus  ill  a  man  of  sixty-two  years.  In 
esophagus  five  hours.  Much  pain  and  gagging  and 
difiiculty  in  breathing.  Extraction  through  spatula 
esophagoscope  with  Jackson's,  safety  pin  closer  in 
five  minutes.  The  head  was  held  well  over  end  of 
table  for  fear  that  the  relaxation  of  the  spasm  of 
the  cricopharyngeus  would  release  the  foreign  body. 

Case  XVIl.  Olive  pointed  bougie  and  staff  acci- 
dentally broken  ofif  while  a  gastroenterologist  was 
attempting  to  dilate  a  stricture  blindly.  Case  re- 
ferred by  Dr.  Wolfif  Freudentlial.  The  patient  was 
an  extremely  emaciated 
woman  of  forty-three  years. 
Bougie  in  esophagus  forty- 
six  hours.  Much  laceration 
of  upper  esophagus  from  at- 
tempted extraction  before 
admission.  Olive  by  x  rays 
in  gastrostotic  stomach  in 
pelvis.  Metal  of  staflf  oppo- 
site and  below  bronchial 
crossing.  A  ten  mm.  esoph- 
agoscope was  used  and  the 
presenting  metal  part  of  staff 
grasped  by  long  alligator 
force[)S.  Extraction  in  three 
minutes.  The  bulbous  end 
was  not  held  in  a  stricture  on 
removal. 

FAILURES    AND  DEATHS 

Out  of  this  series  of  for- 
eign body  extractions  there 
has  been  one  failure  to  re- 
move the  foreign  body  at  the 
first  trial,  and  three  deaths. 
The  failure  was  an  attempt- 
ed extraction  of  a  deeply- 
located  shawl  pin  in  the  dor- 
sal branch  of  the  right  lower 
lobe  bronchus,  the  point  hav- 
ing penetrated  through  the 
bronchial  wall  of  the  oppo- 
site side.  The  point  was  dis- 
engaged and  an  attempt  was 
made  to  remove  the  intruder, 
which  now  seemed  to  be 
extremely  easy.  The  point 
and  shaft  of  the  pin  were 
brought  outward  through  the  bifurcation,  while  the 
head  of  the  i)in,  which  caught  on  the  opposite  bron- 
chial wall,  held  it  firmly,  and  this  caused  the  forcep> 
to  slip  its  hold.  The  writer  had  worked  only  a  short 
time,  but  as  the  pin  was  now  placed  in  an  extremely 
difficult  position,  further  attempts  were  not  made, 
as  it  was  decided  then  that  new  x  ray  plates  were 
advisable  to  determine  the  changed  position  before 
another  attempt  was  made.  The  second  trial  for 
me,  however,  was  not  forthcoming,  as  Dr.  Jackson 
was  consulted  in  the  meantime,  and  the  pin  success- 
fully extracted  by  him  one  week  later.  The  patient 
suffered  no  discomfort  other  than  the  mental  anxiety 
of  knowing  that  the  pin  was  still  in  the  lung.  The 
temperature  and  pulse  remained  normal  throughout 
the  week  before  the  successful  removal. 

Of  the  three  deaths,  two  occurred  shortly  after 
bronchoscopy.     One  was  moribund  on  admission 


Fig.  52. — Olive  pointed 
bougie  from  esophagus 
(Case  X\  II). 


and  would  have  died  shortly  with  or  without  exam- 
ination, and  the  other,  an  infant,  had  pulmonary 
edema  at  the  time  of  the  bronchoscopic  examina- 
tion, which  continued  up  to  the  time  of  her  death. 
The  third  death  was  due  to  the  retention  of  a  piece 
of  peanut  kernel,  which  caused  septic  bronchitis  and 
pulmonary  abscess,  and  death  ensued  six  weeks 
later.  General  anesthesia  was  not  used  for  any  of 
the  extractions.  Cocaine,  ten  per  cent.,  was  used 
for  the  bronchoscopic  examinations  in  adults,  and 
no  anesthesia  for  the  esophagoscopic  in  children. 

The  patients  with  the  two  diphtheritic  foreign 
bodies  included  in  this  series  recovered,  but  one  of 
them  had  a  stormy  time.  In  a  former  series  of 
diphtheritic  foreign  bodies  reported,  all  of  the  cases 
without  complications  recovered.  Pneumothorax 
occurred  in  one  very  difficult  extraction  after  the 
report  of  this  series  and  is  therefore  not  included, 
but  will  be  reported  later  in  another  series. 


ACUTE  INFECTIONS  OF  THE  HAND  AND 
THEIR  SURGICAL  TREATMENT. 

Bv  William  T.  Coughlin,  M.  D.,  F.  A.  C.  S., 
St.  Louis,  Mo., 

Professor    of    Surgery,    St.    Louis  University. 

The  general  practitioner  is  seldom  called  upon  to 
treat  a  condition  which  can  give  him  more  annoyance 
than  an  infected  hand,  nor  one  whose  treatment  is 
fraught  with  greater  difficulty ;  and  perhaps  no  sub- 
ject in  the  whole  field  of  surgery  has  been  more 
neglected  by  the  surgeon.  Even  though  the  results 
may  be  the  best  obtainable,  they  are  never  satis- 
factory from  the  viewpoint  of  the  patient,  who  ex- 
pects restitutio  ad  integrum,  and  that  in  much  less 
time  than  is  always  required ;  while  the  compen- 
sation to  the  .surgeon,  for  his  efforts  and  skill  in 
preserving  through  a  tedious  course  of  treatment 
a  useful  though  often  a  somewhat  disabled  hand 
or  finger,  is  always  more  grudgingly  allowed  than 
would  be  that  for  the  total  removal  of  the  same 
part  followed  by  a  quick  recovery. 

The  neglect  of  this  subject  by  the  general  surgeon 
probably  arises  from  the  fact  that  few  of  these  cases 
are  referred  to  him,  and,  like  other  people,  surgeons 
prefer  to  talk,  teach,  or  write  about  that  which 
comes  most  often  under  their  .special  care.  In  our 
schools  the  teaching  of  the  surgery  of  the  hand  con- 
sists in  telling  the  student  how  to  perform  amputa- 
tions, or  reduce  fractures  or  dislocations,  while  the 
topic  of  how  to  deal  with  hand  infections,  which, 
by  the  way,  are  more  frequent  than  all  three  former 
conditions  put  together,  is  hurriedly  passed  over,  or, 
if  dealt  with  at  all,  is  wrongly  taught.  If  you 
doubt  it,  just  ask  yourself  if  you  were  not  taught 
that  through  and  through  drainage  was  the  best 
way  to  deal  with  palmar  phelgmon? 

A  knowledge  of  the  gross  anatomy  of  the  hand 
is  a  sine  qua  non  to  the  intelligently  successful  treat- 
ment of  any  infection  in  finger,  hand  or  forearm, 
and  I  would  like  to  call  attention  to  it  briefly  by 
means  of  the  diagrams  herewith  shown. 

The  most  common  site  for  the  entry  of  infection 
is  the  distal  phalanx,  and  Fig.  1  shows  a  diagram 
sketched  from  a,  section  through  any  distal  phalanx 


( 


666 


COUGH  LIN:  SURGICAL    TREATMEXT  OF  HAND  INFECTIONS.  [New  Yofk 

Medical  Journal. 


close  to  the  proximal  end  of  the  nail.  In  the  centre 
note  the  bone  covered  tightly  everywhere  (except 
under  the  nail  and  over  its  articular  surface),  \vitb 
periosteum.  Under  the  nail,  filling  up  the  interval 
between  it  and  the  bone  and  strongly  adherent  to 
both,  is  a  fibrous  layer — the  matrix  of  the  nail. 


Fig.  1. — Diagram  of  cross  section  through  distal  phalanx;  a,  fold 
of  nail;  b,  nail;  c,  matrix  of  nail;  d,  bone  covered  with  periosteum; 
e.  fibrous  trabeculae  of  pulp  reaching  from  periosteum  to  skin. 

This  layer  has  very  slight  resistance  to  infection 
and.  once  infected,  there  is  no  room  for  the  inflam- 
matory exudate  to  be  thrown  out.  Even  ver\-  slight 
inflammatory  reaction  produces  such  pressure  be- 
t^veen  bone  and  nail  that  the  blood  supply  at  the 
point  is  cut  off  or  diminished  and  spread  of  the 
infection  ensues.  This  is  why  infections  of  the 
matrix  of  the  nail  are  so  slow  in  getting  well. 

I  remember  a  strong,  healthy  young  man,  whose 
thumb  nail,  partly  undermined  with  pus.  had  been 
treated  for  a  period  of  nine  weeks,  and  then,  as  he 
expressed  it,  ''was  worse  than  ever."  He  had  been 
accused  of  syphilis  but  his  W'assermann  reaction 
was  negative,  and  his  thumb  got  well  without  any 
antiluetic  treatment  in  about  eight  or  ten  days  when 
he  was  treated  surgically.  The  quickest  and  best 
way  to  deal  with  an  infected  matrix  is  to  remove 
that  portion  of  the  nail  overlying  the  infected  area 
— wide  removal  so  that  there  will  be  no  overhang- 
ing edges — and  apply  a  moist,  mild  antiseptic  or 
normal  saline  dressing.  Keep  the  part  at  rest  and 
change  the  dressings  often.  Never  allow  a  dress- 
ing to  become  dr\-  before  healing  begins,  and  there- 
after it  is  better  to  use  an  ointment. 

In  Fig.  1  notice  how  the  soft  parts  roll  up  over 
the  sides  of  the  nail :  Fig.  2  shows  a  longitudinal 
section  through  the  same  phalanx.  In  this  figure 
note  the  fold  of  soft  parts — skin  and  subcutaneous 
tissue  carried  forward  over  the  back  of  the  nail. 
This  fold  over  the  back  and  along  the  sides  of  the 
nail  is  perhaps  the  most  commonly  infected  part 
of  the  finger,  this  tissue  being  much  exposed  to 
injury.  The  bacteria  get  into  the  injured  tissue  and 
suppuration  on  the  deep  aspect  of  the  fold  ensues, 
for  here  they  find  moisture,  warmth  and  darkness, 
while  injured  tissue  makes  for  them  a  good  culture 
medium.  It  is  but  a  short  distance  around  the  root 
or  side  of  the  nail  to  the  matrix,  and  if  this  becomes 
infected  the  overlying  part  of  the  nail  must  come  off. 

For  the  ordinary  slight  infections  hardly  more 
than  a  splint  and  alcohol  pack  are  needed.  If,  how- 
ever, the  condition  does  not  yield  to  such  measures 
the  fold  should  be  cut  through  at  once.    It  is  worth 


doing  under  anesthesia.  It  can  be  properly  done 
only  when  the  patient  feels  no  pain.  Cut  through 
the  fold  backward  from  its  free  edge  on  each  side 
until  the  incision  reaches  back  as  far  as  the  root  of 
the  nail  extends.  That  is  nearly  half  way  from 
the  edge  of  the  fold  to  the  joint.  One  must  be 
careful  not  to  open  the  joint,  Fig.  3.  The  fold 
thus  incised  can  now  be  turned  back  as  a  flap.  The 
underlying  nail  root  is  examined  to  make  sure  that 
the  matrix  under  it  is  not  infected.  Pus  under  the 
nail  looks  yellowish  white.  If  there  is  pus  under  it 
remove  the  nail  widely ;  then  lay  a  thin  bit  of  rubber 
or  lint  in  the  wound  and  replace  the  flap.  Apply  a 
mild  antiseptic  wet  dressing  and  put  the  part  on  a 
splint  and  the  arm  in  a  sling.  Change  the  dressing 
frequently  and  keep  immobilized  until  well. 

In  Figs.  1  and  2,  notice  the  socalled  pulp  of  the 
finger.  Observe  the  lines  stretching  from  perios- 
teum to  skin.  They  represent  dense,  tough  fibrous 
bands  or  partitions.  These  divide  the  space  between 
skin  and  bone  into  innumerable  chambers  and  each 
chamber  is,  filled  with  fat.  Were  it  not  for  these 
partitions,  at  every  grasp  sensitive  nerve  endings 
would  be  painfully  pressed  betwen  skin  and  bone, 
for  the  fat.  being  fluid  at  body  temperature,  would 
flow  to  one  side  of  the  point  pressed  upon.  But 
these  same  fibres  prevent  the  skin  from  being  pushed 
away  from  the  bone  when  exudation  occurs  between 
the  two.  When  for  any  reason,  therefore,  an  in- 
flammation occurs  here,  it  is  not  long  until  the  pres- 
sure against  the  skin  on  the  one  hand  and  against 
the  periosteum  oit  the  other,  becomes  sufiicient  to 
imperil  the  vitality  of  one  or  both,  and  also  that  of 
the  parts  intervening.  In  such  a  circumstance  the 
fat  and  the  fascia  are  always  the  first  to  suflfer. 
Always  oflFering  poor  resistance  to  infection,  when 
thus  injured  they  now  favor  the  growth  of  bacteria 
and  a  bad  condition  becomes  worse. 

For  infection  in  the  pulp  the  alert  physician  never 
waits  for  the  pointing  of  suppuration.  An  early 
and  free  incision,  not  only  through  the  skin  but 
down  through  the  pulp,  with  proper  dressing  and 
fixation,  will  check  the  spread  of  the  trouble.  Inci- 
sion relieves  the  tension,  and  it  is  the  tension  which 
causes  death  of  the  periosteimi.  the  .skin,  the  bone, 
and  of  all  the  intervening  tissues,  for  the  tension 
soon  shuts  oflf  the  blood  supply. 


Fig.  2. — Diagram  of  longitudinal  section  through  middle  of  distal 
phalanx;  lettering  is  the  same  as  in  Fig.  1. 

I  have  called  attention  to  the  periosteum.  sa}*ing 
that  it  was  firmly  adherent  to  the  bone  except  over 
its  articular  surface.  Exposed  to  trauma  as  the 
distal  phalanx  is,  and  separated  only  such  a  short 
distance  from  the  surface  as  its  periosteum  is,  it  is 
not  surprising  that  the  periosteum  is  itself  often 


October  30,  1920.]  COUGH  LIN:  SURGICAL    TREATMENT  Of  HAND  INFECTIONS. 


667 


injured.  When  injured,  blood  or  serum  collects 
under  it,  as  all  have  seen  it  collect  under  the  nail  at 
the  site  of  trauma,  and  such  small  extravasation  is 
often  a  focus  for  the  development  of  bacteria 
lodged  here  by  the  blood  stream. 

When  liacteria  reach  such  a  site  the  result  will 


.  a  j 

Fig.  3. — a  and  b,  incision  tbrough  the  inflamed  fold  of  nail;  c,  flap 
to  be  turned  back  to  expose  root  of  nail. 

most  probably  be  an  abscess  under  the  periosteum. 
The  signs  are  unmistakable.  The  patient  com- 
plains of  severe  pain  in  the  finger,  which  is  con- 
stant, throbbing  and  almost  unbearable ;  pus  is 
about  to  form,  or  has  already  done  so,  under  the 
periosteum.  The  periosteum  does  not  readily  stretch 
in  any  direction,  but  it  yields  a  little  in  all  direc- 
tions aroimd  the  pus  and  soon  the  pus  has  lifted 
it  up  from  the  bone  over  a  considerable  area.  The 
pus  may  pass  completely  around  the  bone,  and 
spreading  backward  when  it  reaches  the  end  of  the 
periosteum  at  the  edge  of  the  articular  cartilage,  it 
may  break  into  the  joint.  But  before  it  has  done 
this,  or  afterward,  it  may  break  through  the  peri- 
osteum into  the  subcutaneous  space — into  the  pulp. 
Whenever  the  pus  escapes  from  the  periosteal 
covering,  then  the  throbbing  pain  is  instantly  re- 
lieved. The  patient  will  have  pain  later  on  but  for 
a  while  there  is  relief,  and  when  the  pain  recurs, 
which  it  does  when  the  subcutaneous  tension  in- 
creases, it  is  not  so  severe  as  it  was  at  first.  A 
strange  thing  is,  that  at  the  onset  of  any  subperi- 
osteal suppuration,  while  the  patient  is  complaining 
so  bitterly  of  the  pain,  there  is  very  little  swelling 
of  the  part  or  perhaps  none  whatever.  In  fact, 
there  is  little  swelling  before  the  periosteum  bursts. 

Careful  examination  will  always  reveal  a  point 
of  maximum  tenderness,  which  is  to  be  found  by 
pressing  gently  on  the  skin  with  a  toothpick  or  some 
such  pointed  object.  The  patient  can  often  locate 
this  spot  very  accurately.  This  tender  point  exists 
very  early  in  the  disease  before  the  infection  has 
spread  far  or  broken  through  the  periosteum.  Under 
the  tenderest  point  between  the  periosteum  and  the 
bone  is  the  seat  of  the  trouble.  Over  this  point  is 
the  place  to  open,  and  the  knife  point  should  reach 
the  bone  here  only.  A  large  incision  is  never  needed 
if  one  can  get  the  patient  early.  Often  only  a  very 
small  drop  of  pus  is  found.  The  process  usually 
lasts  two  or  three  days  before  the  periosteum  gives 
way. 

Knowing  the  pathology,  course,  and  prognosis  of 
infections,  no  sane  man  would  counsel  any  other 
than  surgical  treatment ;  yet,  those  who  do  not  know 


advocate  poulticing  until  the  felon — for  this  is  a 
real  felon — is  "ripe." 

The  ofifending  organisms  in  hand  infections  are 
usually  the  staphylococcus  and  the  streptococcus, 
and  the  pus  is  very  thick  and  does  not  run  out 
easily.  Saline  in  which  citrate  of  soda  has  been 
dissolved,  two  drams  to  a  pint,  helps  to  thin  the 
pus.  So  does  Dakin's  solution.  Dress  with  gauze 
moistened  in  such  a  solution,  change  often,  and 
keep  the  part  at  rest.  Instead  of  the  moist  dressing, 
constant  immersion  in  a  hot  bath  of  saline  and  citrate 
is  often  better.  We  use  the  latter  during  the  day 
and  the  warm,  wet  pack  at  night. 

When  infection  following  wounds  in  the  skin  or 
subcutaneous  tissue  spreads,  it  does  so  most  often 
by  way  of  the  lymphatics.  There  are  lymphatic 
vessels  passing  along  the  sides  of  the  fingers.  Their 
radicles  are  in  the  deeper  layers  of  the  skin,  the  sub- 
cutaneous tissue,  and  in  the  periosteum  and  bone. 
But  in  addition  there  are  what  are  known  as  lymph 
spaces ;  for  example,  what  are  called  perifascial 
lymph  spaces  exist  between  the  subcutaneous  fat 
and  the  deep  fascia  or  tendon  sheaths,  and  there  are 
perivascular  lymph  spaces  around  the  vessels  on 
each  side  of  the  finger.  If  now,  for  any  reason,  a 
lymph  space  becomes  infected,  the  pus  can  easily 
spread  in  any  direction  until  the  whole  space  is 
involved.  This  explains  how  it  happens  that  pus 
may  extend  completely  around  a  finger  and  not  affect 
the  tendon  sheaths  or  periosteum  at  all.  It  is  a 
point  to  remember  in  opening  phlegmons  of  the 
fingers ;  for  if  one  cut  deeper  than  the  plane  where 
he  encounters  the  pus,  and  if  the  incision  is  over 
a  tendon  sheath,  he  may  cut  through  the  fibrous 
tendon  sheath  and  unnecessarily  open  its  synovial 
lining.  This,  too,  may  follow  the  insertion  of  a 
drain  or  pack,  the  pressure  of  the  same  causing 
necrosis  of  the  tendon  sheath.  The  ordinary  lym- 
phatic vessels  passing  down  the  sides  of  the  fingers 
converge  in  the  web,  unite,  and  crossing  the  web, 
enter  the  palm  or  pass  to  the  back  of  the  hand. 
Great  numbers  of  them  eventually  reach  the  back 
of  the  hand.  This,  as  well  as  the  loose  nature  of 
the  subcutaneous  tissue  there,  explains  why  it  is 


Fig.  4. — Shows  the  web  in  first  space  cut  across  to  open  a  web 
abscess. 

that  the  back  of  a  hand  undergoes  such  great  swell- 
ing in  all  these  infections.  It  is  simple,  lymphatic 
edema.  Very  seldom  does  pus  so  spread,  but  the 
web  between  the  fingers  is  the  place  to  look  for  the 
first  metastatic  abscess  in  finger  infections.  Bac- 
teria— not  pus — get  into  the  lymph  channels  and 


668 


COUGHUN:  SURGICAL    TREATMENT  OF  HAND  INFECTIONS. 


[New  York 
Medical  Journal. 


flowing  back  reach  the  web.  The  web  is  filled  with 
fat.  Fat  is  poorly  supplied  with  blood,  its  resist- 
ance being  low.  This  fat  is  no  exception  to  the  rule 
and  the  bacteria  find  a  good  place  to  grow,  just  as 
they  do  when  crossing  the  ischiorectal  fossa  through 
the  lymphatics  there.    An  abscess  develops  in  the 


Fig.  5. — Diagram  of  cross  section  of  hand  through  weh  of  finger; 
a,  tendons  of  lumbricals  and  interossei. 

web.  Treated  in  time,  nothing  serious  will  happen  ; 
but  delay  is  dangerous,  for  this  little  abscess  in  the 
web  can,  in  a  few  days,  extend  directly  into  the 
palm,  and  while  recovery  is  to  be  expected,  the  hand 
will  never  be  as  good  as  it  formerly  was,  once  it  has 
sufifered  from  a  deep  palmar  abscess. 

At  the  beginning,  metastatic  abscess  in  the  web 
is  not  very  painful.  There  is  plenty  of  room  for 
the  exudate ;  therefore  the  pres.sure  is  not  great  at 
first.  At  the  same  time,  the  pain  at  the  original 
site  of  infection  is  great  and  distracts  the  patient's 
attention.  If  the  diagnosis  of  metastatic  abscess  is 
not  made  before  the  patient  directs  attention  to  it, 
it  is  too  late  to  prevent  him  from  having  a  deep  pal- 
mar abscess.  How  then  shall  we  make  the  diag- 
nosis? First,  by  being  aware  of  the  fact  that  here 
is  the  first  site  for  the  development  of  a  metastatic 
ab.scess,  and  that  metastatic  abscesses  may  develop 
here  in  any  kind  of  finger  infection,  but  most  often 
in  those  of  the  .skin  and  subcutaneous  tissues ;  and 
secondly,  by  looking  for  the  abscess  in  the  weh. 
Pain  on  pressure  over  the  web  is  a  sign  that  infec- 
tion is  present.  One  may  elicit  tenderness  deep  in 
the  web  within  a  few  hours  after  the  infection  begins 
there,  and  when  first  the  diagnosis  is  made  is  the 
time  to  treat  the  condition.  Never  wait  for  that 
sign  which  even  fools  may  read — fluctuation.  Re- 
member that  to  delay,  means  to  provoke  a  palmar 
abscess. 

Fig.  4  illustrates  the  proper  way  to  open  a  web. 
Cut  .straight  through  it  for  at  least  half  an  inch 
from  its  free  edge,  and  if  pus  is  not  found,  open 
bluntly  through  the  fat  in  the  middle  of  the  incision 
still  further  toward  the  palm.  If  one  cuts  back 
farther  than  the  point  where  the  pus  is,  he  will  carry 
the  infection  into  the  palm.  Insert  a  thin  bit  of 
rubber  to  keep  the  wound  edges  from  agglutinating 
and  dress  the  fingers  wide  apart.  Immobilize  the 
whole  hand  and  forearm  and  immerse  all  in  a  hot 
bath  as  before.  Do  not  practise  changing  the  drains 
daily  and  never  pack  a  wound  in  which  there  is 
virulent  or  viscid  pus.  The  web  abscess  in  any  of 
the  three  inner  spaces  spreads  by  direct  continuity 
into  the  fat  of  the  palmar  pad  and  thus  an  infection 


of  any  one  web  may  lead  to  infection  of  all  the 
others.    I  have  often  seen  this  happen. 

Now  how  does  the  web  abscess  become  a  palmar 
abscess?  The  lumbrical  muscles  are  found  deep  in 
the  palm.  Springing  from  the  tendons  of  the  deep 
finger  flexors,  they  run  downward  and  pass  to  the 
radial  side  of  the  base  of  the  corre.sponding  finger ; 
going  through  the  base  of  the  web,  they  insert  into 
the  tendon  found  lying  on  the  back  of  the  first 
plialanx — the  common  extensor  of  the  fingers.  The 
tendons  of  the  interossei  do  almost  the  same.  Thus 
the  fat  of  the  web  comes  into  actual  contact  with 
these  tendons.  Each  tendon  is  surrounded  with 
loose  areolar  tissue — a  lymph  space — and  so  it  is 
easy  for  pus,  having  once  come  into  direct  contact 
with  a  tendon  to  dissect  its  way  along  it. 

Infection  (metastatic)  of  the  web  of  the  first 
space  is  in  a  class  by  itself,  inasmucli  as  it  is  nearly 
always  intermuscular  from  the  beginning.  It  fol- 
lows infection  of  either  thumb  or  index  finger  and 
can  occur  by  direct  extension  of  pus  along  peri- 
fascial  lymph  s])aces,  or  by  the  ordinary  lymphatic 
route  to  the  base  of  thumb  or  index,  and  then  along 
muscle  tendons  into  the  intermu.scular  space  between 
the  first  dorsal  intcrosseus  muscle  and  the  adductors 
of  the  thumb.  As  before,  tenderness  on  deep  pres- 
sure is  the  sign  to  watch  for,  and  the  space  should 
be  opened  as  soon  as  that  sign  api)ears.  Fig.  4  shows 
the  incision  directly  across  the  web.  It  continues 
through  the  superficial  and  deep  fasciae  until  the 
edges  of  the  mu.^cles  are  seen.  The  lines  of  their 
fibres  cross  each  other  x  wise.  The  space  between 
the  two  is  found  and  opened  by  blunt  dissection. 
The  pus  is  there.  A  drain  is  inserted  to  the  bottom 
of  the  ab.scess  cavity  and  fastened  there.  The  whole 
hand  and  forearm  arc  immobilized  with  thumb  and 
index  slightly  separated. 

An  abscess  in  this  web  can  readily  become  a 
palmar  abscess  by  dissecting  its  way  around  the 
edge  of  the  adductors  of  the  thumb,  or  along  the 
palmar  arch,  or  it  can  spread  easily  to  the  wrist 
along  the  synovial  sheath  of  the  flexor  longus  pol- 
licis.    In  dealing  with  abscess  in  this  web,  no  muscle 


Fig.  6. — Diagram  of  cross  section  of  hand  through  proximal  half 
of  palm  to  show  compartments. 

is  cut.  Through  and  through  drainage  is  never 
used. 

We  shall  briefly  consider  abscess  in  the  palm. 
You  are  told  of  three  compartments.  The  parti- 
tions between  the  compartments  are  none  of  them 
strong,  and  pus  may  pass  from  any  one  compart- 


October  Ju,  1920.]          COUGH  UN:  SURGICAL    TREATMENT  Of  HAND  INFECTIONS. 


669 


ment  to  any  other,  for  the  partitions  fail  as  the 
bases  of  the  phalanges  are  approached.  The  parti- 
tions are  of  fascia  and  are  backward  extensions  of 
the  deep  palmar  fascia.  The  outer  compartment 
lodges  the  thumb  muscles,  the  inner  one  the  flexor 
tendons  and  short  muscles  of  the  little  finger,  while 
"in  the  middle  we  have  the  flexor  tendons  and  lum- 
bricals  of  the  middle  fingers,  together  with  vessels 
and  nerves.  Tendons  and  muscles  must  be  sur- 
rounded with  loose  areolar  tissue,  or  they  will  work 
but  stiffly,  and  infective  material  spreads  readily 
through  loose  areolar  tissue.  The  deep  palmar 
fascia  is  strongest  over  the  middle  compartment, 
and  over  all  compartments  the  deep  palmar  fascia 
thins  out,  becomes  cribriform,  and  finally  fails  en- 
tirely as  we  proceed  distally.  It  disappears  first  in 
the  interdigital  spaces,  leaving  the  digital  vessels 


Fig.   7. — Palniiir   lascia.     iCray'i  .liiatomy.  \t.  488.) 


and  nerves  uncovered  by  it  as  they  enter  the  webs 
of  the  fingers. 

Here  the  superficial  fat  of  palm  and  web  becomes 
continuous  with  fat  and  areolar  tissue  under  the 
deep  palmar  fascia.  One  can  thus  see  how  readily 
a  primary  superficial  abscess  can  become  a  deej) 
palmar  abscess  by  direct  extension,  because  the 
fascia  forming  the  roofs  of  the  palmar  compart- 
ments is  so  strong  and  unyielding,  and  abscess  in  any 
of  the  compartments  may  spread  well  up  into  the 
wrist  or  forearm  along  the  tendons  or  into  its 
neighboring  compartment  long  before  it  points  on 
the  surface  of  the  palm.  The  swelling  in  the  i)alm 
is  for  the  same  reason  never  marked  until  the  ab- 
scess is  well  advanced. 

Swelling  on  the  back  of  the  hand  is  always 
marked,  but  this  swelling  alone  should  not  induce 
one  to  incise  the  dorsum.  It  is  nearly  always 
lymphedema,  because  as  before  mentioned  the  lym- 
phatics drain  toward  the  dorsum,  but  pus  does  some- 
times collect  here  in  the  peri  fascial  lymph  space,  and 
here  as  elsewhere  localized  deep  tenderness  is  an 
early  and  never  failing  sign.  The  tender  .spot  should 
be  opened  as  soon  as  found.  To  "squeeze  out"  the 
pus  is  the  most  primitive  surgery. 

How  to  open  a  palmar  abscess  is  a  real  problem 


and  whether  to  incise  vertically  or  transversely  is 
a  moot  question.  A  transverse  incision  will  remain 
open  better  while  the  fingers  are  extended,  and  the 
fingers  should  always  be  dressed  in  extension,  but 
a  transverse  incision  in  the  lower  part  of  the  palm 
exposes  the  digital  vessels  and  nerves  to  danger, 
while  a  vertical  one  higher  up  imperils  the  palmar 
arch.  The  patient  should  be  anesthetized  and  an 
Esmarch  bandage  applied.  One  cannot  use  an  Es- 
march  bandage  to  advantage  unless  the  patient  is 
anesthetized ;  hence  the  need  for  a  general  anes- 
thetic and,  besides,  a  local  anesthetic  in  an  inflamed 
area  is  not  often  successful.  We  use  the  ether 
rausch  or  ethyl  chloride  for  such  operations.*  Use 
whichever  incision  you  prefer,  but  identify  the 
structures  before  you  cut  them.  Cut  down  to  the 
deep  fascia  and  proceed  with  caution.  Divide  the 
deep  fascia  and  then  lay  down  the  knife.  If  you 
have  opened  over  the  spot  most  tender  on  deep 
pressure,  go  straight  on  with  blunt  dissection  until 
the  pus  appears.  Do  not  pack,  but  insert  soft  rub- 
ber and  tasten  it  in  the  wound.  Any  drainage 
material  that  presses  on  a  tendon  with  any  force 
for  even  a  few  hours,  may  cause  local  death  of  the 
latter.  If  a  tendon  or  part  of  one  dies,  it  takes 
four  to  six  weeks  to  separate  and  come  away. 
lmmol)ilize  fingers,  hand  and  wrist,  keep  fingers  in 
extension,  and  use  the  hot  bath  or  moist  dressing. 

Every  student  remembers  the  synovial  sheaths 
of  the  flexor  tendons.  He  knows  that  there  is 
around  each  set  of  flexor  tendons,  as  they  lie  on 
the  phalanges,  a  strong  fibrous  tunnel  through 
which  they  run  and  which  holds  them  to  the  bones. 
But  inside  this  fibrous  tunnel  is  a  synovial  bursa, 
as  it  were,  which  .surrounds  each  set  of  tendons. 
These  .synovial  investments  extend  farther  up  into 
the  palm  than  do  the  fibrous  sheaths :  those  for  the 
index,  medius,  and  anjiularis  extending  up  to  the 
middle  of  the  palm,  while  tho.se  for  the  thumb  and 
little  finger  reach  right  up  to  join  the  bursa  imder 
the  anterior  annular  ligament.  When  pus  is  found 
in  any  of  these  synovial  sheaths,  that  sheath  is  to 
be  laid  wide  open  over  the  ])lace  where  the  pus  is, 
and  for  at  least  one  to  two  centimetres  above  and 
below  this.  When  the  tendon  sheath  is  involved, 
any  attempt  to  move  the  tendon  causes  pain,  and 
there  is  local  tenderness  over  it. 

When  pus  has  invaded  the  great  bursa  at  the 
wrist,  the  anterior  annular  ligament  is  cut  through 
and  the  hand  and  fingers  dressed  in  hyperextension 
and  left  so  until  healing  is  well  advanced. 

When  the  hot  bath  is  used,  the  part  must  be  kept 
on  the  splint  while  in  the  bath,  and  the  solution 
should  be  as  hot  as  can  be  borne  without  blistering. 
On  no  account  should  the  temperature  of  the  bath 
fall  below  110°  F.  In  weak  ])atients  it  is  not  well 
to  continue  the  bath  day  and  night,  because  of 
fatiguing  the  patient;  therefore  during  sleeping 
hours  the  part,  still  on  the  splint,  is  placed  in  large, 
hot  packs  wrung  out  of  the  solution  and  wrapped 
in  waterproof  cover,  and  the  whole  surrounded 
with  hot  water  bags  which  are  frequently  renewed. 

If  an  infection  of  the  palm  is  properly  opened 
and  treated  as  outlined  above,  the  progress  of  the 

'  In  my  servic?  ethyl  chlorid-  has  been  much  used  as  a  general 
anesthetic  for  short  operations  since  1915. 


670 


KRUPP:  X  RAY  A    GUIDE  IN  PNEUMOTHORAX. 


[New  York 
Medical  Journal. 


disease  is  quickly  checked.  The  drains  are  removed 
in  from  three  to  ten  days  and  the  wound  kept  open 
so  that  pus  cannot  be  retained  and  burrow.  Active 
motion  is  encouraged  for  a  few  minutes  at  a  time 
two  or  three  times  daily  as  soon  as  the  drains  are 
removed  and  gradually  these  periods  of  activity  are 
increased  and  lengthened.  Only  those  too  long 
immobilized  or  improperly  handled  fail  to  regain 
useful  function. 

405-413  University  Club  Building. 


THE  X  RAY  AS  AN  ESSENTIAL  GUIDE 
FOR    PRODUCING   ARTIFICIAL  PNEU- 
MOTHORAX IN  ADVANCED  CASES  OF 
PULMONARY  TUBERCULOSIS  * 

By  David  Dudley  Krupp,  M.  D., 
Brooklyn,  N.  Y., 

First  Lieutenant,   Medical  Corps,  U.   S.  A.;   Rontgenologist  to  the 
U.   S.  Army  General  Hospital,  Fort  Bayard,  New  Mexico. 

The  purpose  of  this  article  is  to  show  the  advan- 
tages of  the  use  of  the  x  ray  in  the  control  of  the 
production  of  an  artificial  pneumothorax  in  ad- 
vanced cases  of  pulmonary  tuberculosis ;  and  to 
demonstrate  the  necessity  of  a  careful  study  of  such 
cases  before  attempt  is  made  to  produce  this  con- 
dition. 

In  advanced  cases  of  pulmonary  tuberculosis,  the 
almost  constant  harassing  cough  and  frequent  hem- 
orrhages are  the  most  difficult  symptoms  to  treat. 


Fig.  1. — Condition  of  lungs  prior  to  injections  of  air  (Case  I). 


Narcotics  and  other  methods  are  used  to  give  relief, 
which  is  only  temporary.  With  the  production  of 
an  artificial  pneumothorax,  the  afifected  lung  is  col- 
lap.■^ed  and  the  annoying  symptoms  are  more  or  less 
permanently  relieved ;  certainly  to  a  more  marked 

'Published  by  permission  of  the  Surgeon  General  of  the  U.  S. 
Armv.  Now  on  duty  at  U.  S.  A.  Gen  ral  Hospital  No.  19,  Oteen, 
N.  C,  June,  1920. 


extent  than  by  the  use  of  narcotics,  and  without 
their  undesirable  depressing  effects.  The  purpose 
of  the  pneumothorax  in  these  cases  is  not  to  produce 
a  cure,  primarily,  but  to  render  the  patient's  life 
more  comfortable  and  possibly  increase  his  chances 
for  recovery.    This  relief  from  the  harassing  cough 


Fig.   2. — Condition   of   lung  after   injections   of   air    (Case  I). 

and  pain  will  also  have  a  favorable  effect  upon  the 
morale  of  the  patient,  which  is  a  matter  of  great 
importance  in  the  treatment  of  pulmonary  tuber- 
culosis. The  relief  of  his  sufferings  is  what  we 
strive  for.  In  certain  seemingly  hopeless  cases,  this 
treatment  has  caused  an  apparent  arrestment  of  the 
disease  in  three  selected  cases  cited  in  this  article. 
Two  of  the  advanced  cases  became  ambulatory,  after 
the  patients  had  been  bedridden  for  almost  a  year. 
They  have  shown  a  great  amount  of  improvement. 

There  are  several  important  factors  to  be  con- 
sidered before  a  pneumothorax  is  tried,  and  the  x 
ray  stands  out  as  the  essential  guide  to  the  clinician. 
I  must  not  omit  the  aid  of  the  fluoroscope,  which  is 
also  part  of  the  guide.  With  the  bedside  unit,  the 
hand  fluoroscope  is  used  to  great  advantage.  The 
X  ray  plates  give  the  pathological  findings  as  a  per- 
manent record,  while  the  fluoroscope  gives  a  clue  as 
to  the  mobility  of  the  chest  and  the  excursion  of 
the  diaphragm  of  the  affected  side.  The  following 
points  were  studied  before  pneumothorax  was  pro- 
duced:  1.  The  extent  of  the  pathology,  especially  as 
to  cavities.  2.  Will  the  opposite  lung  be  able  to 
furnish  sufficient  pulmonary  tissue  after  the  affected 
lung  has  been  collapsed  without  throwing  additional 
risk  to  the  patient?    3.  Pleurisy  and  adhesions. 

1.  In  the  extent  of  the  pathological  involvement 
of  the  lungs,  the  x  ray  stands  out  as  the  positive 
guide.  Cavities  will  always  show  on  the  x  ray 
plate,  whereas  they  may  be  missed  by  the  most 
thorough  physical  examination  (without  entering 
into  a  discussion  of  the  relative  merits  of  the  phys- 
ical examination )  ;  and  in  deciding  the  extent  of  the 


• 


October  30,  1920.] 


KRUPP:  X  RAY  A    GUIDE  IN  PNEUMOTHORAX. 


671 


involvement,  I  think  it  has  been  found  that  the  ront- 
genological  studies  are  the  final  and  deciding  factor. 

2.  The  question  of  the  opposite  lung  being  able 
to  furnish  sufiicient  pulmonary  tissue  to  functionate 
after  the  affected  lung  has  been  collapsed,  is  a  seri- 
ous problem  to  determine.    In  a  case  where  one 


Fig.  .V  —  X  ray  of  lung  prior  to  injection  of  air  (Case  II). 

lung  is  involved  and  the  other  lung  normal,  there 
is  no  question,  of  course,  that  this  is  the  ideal  treat- 
ment. But  it  is  in  those  cases  where  both  lungs  are 
heavily  involved,  and  perhaps  one  somewhat  less 
than  the  other,  that  the  difficulty  arises.  A  careful 
study  of  such  cases  is  necessary,  before  any  attempt 
is  made  to  collapse  the  lung.  Now,  what  is  the 
course  to  follow  when  such  is  the  case  and  the 
patient  needs  relief  from  his  sufferings?  In  all 
probability  this  patient  is  going  to  die.  Therefore 
we  must  be  governed  by  the  following  factors, 
namely:  the  cessation  of  the  cough,  with  a  less 
copious  expectoration ;  control  of  the  hemorrhages 
and  lessening  the  toxemia,  which  outweighs  the 
risk  we  take  in  throwing  additional  burden  on  the 
small  amount  of  uninvolved  lung  tissue  remaining. 

3.  Adhesions  and  fibrinous  pleurisy  associated 
with  a  pulmonary  tuberculosis,  as  seen  by  the  x  ray 
plate,  is  another  factor  to  be  thoroughly  considered, 
for  one  cannot  attempt  to  collapse  a  lung  that  is 
firmly  plastered  to  the  parietal  pleura. 

Of  the  453  x  ray  examinations  made  in  the  last 
three  months,  forty-six  were  bedside  examinations. 
I  also  made  use  of  the  hand  fluoroscope.  The  re- 
maining cases  were  examined  stereoscopically.  With 
this  large  number  of  cases  to  choose  from  for  the 
production  of  an  artificial  pneumothorax,  the  prob- 
lem was  less  difficult.  Of  the  three  selected  cases, 
which  I  have  followed  by  a  series  study  of  x  ray 
plates,  the  results  obtained  are  here  noted  and  illus- 
trations given.  The  cases  were  given  vip  as  hopeless. 
Two  of  the  patients  were  bedridden  for  almost  a 
year  and  now  they  are  walking  about  the  hospital 


grounds  to  a  limited  extent.  Tlie  third  patient  was 
the  worst  of  the  three,  because  both  lungs  were 
heavily  involved  in  addition  to  the  cavities  in  both 
upper  lobes.  By  a  study  of  these  cases,  with  the 
X  ray  plates  and  the  fluoroscope,  an  excellent  guide 
is  given  to  the  clinician  for  the  procedure  of  an 
artificial  pneumothorax. 

Case  I.  Cadet  H.,  admitted  to  the  hospital  on 
December  18,  1918,  with  a  diagnosis  of  pulmonary 
tuberculosis,  chronic,  active,  of  the  entire  right 
lung:  sputum  positive;  the  left  lung  was  apparentlv 
healthy.  On  October  20,  1919,  the  first  introduc- 
tion of  air  was  begun.  Fig.  1  shows  the  lung  con- 
dition prior,  and  Fig.  2  shows  the  lung  after  numer- 
ous injections  of  air.  This  lung  shows  a  few  bands 
of  fibrous  tissue  holding  the  upper  part  of  the  lung 
from  complete  collapse.  On  January  8,  1920,  this 
patient  had  200  C.  C.  of  fluid  removed  from  the 
Ijase  of  the  affected  chest.  He  is  now  able  to  w^alk 
around  after  being  in  bed  for  about  a  year.  The 
number  of  hemorrhages  have  been  markedly  re- 
duced ;  the  cough  and  expectoration  have  moderated 
greatly.  In  this  case  a  tuberculous  laryngitis  seems 
to  be  developing,  which  may  account  for  the  patient 
in  Case  II  being  in  a  better  physical  condition 
although  the  lung  is  collapsed  to  a  lesser  extent. 

Case  II.  Colonel  M.  ,  admitted  to  the  hos- 
pital on  Jmie  18,  1918,  with  a  diagnosis  of  pul- 
monary tuberculosis,  chronic,  active,  of  the  entire 
left  lung.  He  had  been  in  bed  for  over  a  year  and 
had  numerous  hemorrhages.  In  September,  1919, 
the  first  injection  was  given.    Since  that  time  the 


Fig.  4. — Condition  of  lung  after  injection  of  air  (Case  II). 


injections  of  air  have  been  very  frequent.  Fig.  3 
shows  the  lung  prior  to,  and  Fig.  4  shows  the  lung- 
after  the  production  of  pneumothorax.  For  the 
last  set  of  X  ray  plates,  this  patient  was  able  to  walk 
to  the  laboratory  unaided,  a  distance  of  600  feet, 
and  also  able  to  walk  up  and  down  a  flight  of  stairs. 


672 


KRUPP:   X  RAY  A    GUIDE  IX  PXEUMOTHORAX. 


[New  York 
Medical  Journal. 


He  has  shown  remarkable  physical  improvement, 
and  has  not  had  a  hemorrhage  in  the  last  three 
months.    Sputum  is  still  positive. 

Case  III.  Private  B.  ,  admitted  to  the  hos- 
pital on  September  22,  1919,  with  a  diagnosis  of 
pulmonary  tuberculosis,  chronic,  active,  all  lobes, 
both  lungs ;  sputum  positive.    On   December  22. 


Fig.  5. — Lung  prior  to  injection  of  air  (Case  III). 

1919.  he  went  on  a  furlough  and  had  several  severe 
hemorrhages.  He  returned  to  the  hospital  in  a 
serious  condition.  On  IMarch  15,  1920.  the  follow- 
ing general  report  was  made  of  his  condition : 
Patient  in  bed  with  a  temperature  of  100.6°  ;  general 
condition,  unfavorable;  cough,  severe;  expectora- 
tion, copious.  He  had  several  hemorrhages  in  the 
week  prior  to  this  report  and  it  was  then  that  the 
first  injection  of  air  was  made  to  stop  the  hemor- 
rhages. The  right  chest  received  400  c.c.  of  air 
when  a  positive  pressure  was  reached.  It  was  seen 
by  the  first  injection  of  air  that  the  hemorrhages 
were  stopped  and  he  received  further  injections  of 
air  about  once  a  week  to  keep  the  pressure  on  the 
inside  of  the  right  chest  positive.  The  amount 
necessary  would  vary  from  two  to  four  hundred  c.c. 
The  result  of  the  pneumothorax  was  successful,  as 
the  hemorrhage  ceased  and  the  expectoration  was 
less  copious  and  coughing  controlled  to  a  great  ex- 
tent. The  X  ray  findings  were  as  follows :  All  lobes, 
both  lungs,  show  a  heavy  flocculent  infiltration  with 
multilocular  cavities  in  both  upper  lobes.  Fig.  5 
shows  the  lung  prior  to  the  injection  of  air  and 
Fig.  6  shows  the  lung  at  the  last  examination.  This 
patient,  although  bedridden,  has  been  made  more 
comfortable,  and  weakness  is  the  only  bad  symptom 
he  complains  of. 

As  to  the  future  of  these  patients,  there  is  a 
possibility  of  the  complication  of  a  hydropneumo- 
thorax,  as  illustrated  in  Fig.  7,  in  the  following  case. 
This  patient  (a  beneficiary  of  the  Soldiers'  Home) 
was  di.scharged  from  the  hospital  in  1914,  with  an 
artificial  pneumothorax  on  one  side  and  an  inactive 
tuberculosis  in  the  other  lung.    He  returned  to  this 


hospital  a  month  ago  with  a  hydropneumothorax 
containing  about  two  thousand  c.c.  of  fluid.  Under 
the  fluoroscope,  the  first  examination  was  made  and 
the  waves  of  the  fluid  were  clearly  demonstrated 
on  slightly  shaking  the  patient.  During  his  stay 
away  from  the  hosjjital  he  had  been  working  con- 
stantly and  without  any  other  bad  result  than  the 
collection  of  fluid  in  the  chest.  The  fluid  is  gradu- 
ally being  removed  and  air  injected  to  replace  it. 

DISCUSSION. 

Since  it  is  in  the  hemorrhage  cases  that  the  most 
satisfactory  results  are  obtained,  it  should  never- 
theless be  borne  in  mind  that  it  is  in  this  class  of 
cases  that  the  greatest  risk  is  also  taken ;  for,  while 
it  is  usually  possible  to  presume  that  the  hemor- 
rhage is  from  the  side  showing  the  greatest  involve- 
ment, .still  it  is  possible  to  collapse  a  lung  showing 
considerable  involvement  when  the  hemorrhage 
might  occasionally  be  from  the  lung  showing  the 
minor  lesion.  In  these  cases,  the  x  ray  plates  have 
been  showing  small  cavities  in  the  region  of  the 
hilum  of  the  lung  that  appears  to  be  least  involved. 
A  few  patients  have  come  to  the  autopsy  table  and  on 
sectioning  the  lung,  the  apex  of  the  lower  lobes  and 
the  middle  lobe  on  the  right  side  revealed  very  small 
cavities. 

The  condition  of  the  chests  of  the  tuberculous 
patients,  found  at  the  autojxsy  table,  brings  out  the 
statements  made  in  the  i)aragraph  on  adhesions  and 
pleurisy.  The  pathologist  found  great  difficulty  in 
trying  to  remove  the  lungs  in  .such  cases  without 
tearing  part  of  the  lung  tissue.  If  these  conditions 
are  present,  it  would  then  be  useless  to  try  to  force 
air  into  such  a  chest.  In  a  few  cases,  fibrous  bands 
of  adhesions  can  be  released  by  persistent  frequent 
injections  of  air.  If  these  bands  are  not  too  strong, 
the  chances  for  collapsing  the  lungs  are  very  good. 
The  gradual  tearing  loose  of  these  bandlike  adhe- 
sions can  be  beautifully  studied  by  the  radiographic 


Fig.  6. — Final  examination  of  patient  (Case  III). 

examinations,  as  the  treatments  are  continued.  In 
the  lieginning,  one  sees  air  pockets  formed  about 
the  adhesions  with  gradual  thinning  out ;  finally  the 
desired  result,  the  complete  separation  and  the  col- 


Octob.r  30.  1920.] 


VAN  PAIXG:  SURGERY  01-   THE  THORAX. 


673 


lapse  of  the  lung.  We  always  find  these  bands 
attached  to  the  upper  lobes,  where  the  greater  per- 
centage of  cavities  occur,  and  which  may  communi- 
cate with  the  periphery  of  the  lung. 

CO.N'CLUSIOX. 

In  compressing  the  affected  lung,  the  walls  of 
the  cavities  are  put  in  opposition  and  become  fixed 


Fig.  7. — H>dropn.umothorax  as  a  complication. 

together  and  the  desired  results  are  obtained,  namely, 
giving  the  patient  the  feeling  of  wellbeing  and  com- 
fort. Since  the  symptoms  are  lessened  and  comfort 
increased,  there  is  no  doubt  in  my  mind  that  an 
artificial  pneumothorax  is  an  excellent  adjunct  to 
the  other  treatments  of  pulmonary  tuberculosis  in 
the  advanced  cases,  in  association  with  the  rontgen- 
ologist, who  gives  the  clinician  the  guide  to  the  suc- 
cessive steps  taken  for  collapsing  the  lungs.  We 
must  not  forgret  the  possibility  of  acceleration  of 
the  tuberculous  process  of  the  opposite  lung,  when 
one  lung  is  collapsed  and  a  burden  put  upon  that 
lung  to  functionate  and  take  care  of  the  toxemia 
from  the  affected  lung. 
485  Stone  Avenue.  ^ 


THE  KXIFE  CAUTERY  IX  SURGERY  OF 
THE  THOR.AX  * 

By  John  F.  V.\n  P.ung.  M.  D., 
Chicago. 

In  a  recent  article  ( 1 )  I  called  attention  to  the 
importance  of  the  knife  cautery  procedure  as  an 
operative  technic  in  decreasing  postoperative  shock, 
hemorrhage,  and  the  morbidity  incidental  to  con- 
valescence. It  can  be  used  in  incising  the  visceral 
pleura  and  the  lung  proper,  in  removing  foreign 
bodies,  such  as  bullets,  fragments  of  high  explosive 
shells,  and  particles  of  bone  or  bits  of  clothing, 
carried  into  the  lung  tissue  by  the  missile,  and  in 
operating  for  hemorrhage,  lung  abscess,  or  tumor. 
Before  the  advent  of  the  knife  cautery,  pulmonary 
operations  were  the  least  developed  and  the  least 
understood  from  the  viewpoint  of  technic  and  post- 


operative complications  of  all  forms  of  surgery. 
The  mortality  rate  was  exceedingly  high,  shock 
and  hemorrhage  being  the  chief  contributors,  and 
the  postoperative  morbidity  continued  over  a  period 
of  weeks  or  months. 

HcDiorrhage. — Heretofore  hemorrhage  has  been 
very  difiicult  to  control  and  postoperative  oozing 
has  caused  a  large  number  of  deaths,  owing  to  the 
facts  that  suture  of  lung  tissue  is  unsatisfactory  in 
the  control  of  bleeding  and  the  needle  punctures 
themselves  continue  to  bleed  after  the  wound  is 
closed.  Lung  tissue  in  particular  must  be  free  . 
from  oozing  when  the  wound  is  closed,  or  the  bleed- 
ing may  continue  for  an  indefinite  period,  exsan- 
guinating the  patient  and  being  almost  impossible 
to  control  without  a  large  firm  packing.  The  re- 
moval of  this  packing  produces  a  return  of  bleeding, 
and,  while  it  is  in  position,  it  causes  incessant  cough- 
ing, which  so  greatly  weakens  an  already  over- 
burdened heart  that  cardiac  dilatation  is  likely  to 
occur.  Furthermore,  iodoform  or  cyanide  gauze 
will  in  almost  every  case  cause  some  symptoms  of 
toxemia,  the  absorption  being  so  rapid  that  often 
within  twenty-four  hours  toxic  symptoms  manifest 
themselves  by  rigor,  vomiting,  high  temperature,  and 
delirium. 

Shock. — Profound  shock  followed  by  delirium 
accompanies  a  large  percentage  of  pulmonary 
operations  by  the  older  methods,  induced,  I  believe, 
by  the  combined  factors  of  hemorrhage,  anesthesia, 
and  packing.  Then,  too,  the  class  of  patients  in 
whom  these  operations  are  indicated  suffer  from 
low  vitality,  .secondary  anemia,  and  usually  present 
profound  toxic  phenomena.  Blood  transfusion  is, 
in  my  opinion,  the  ideal  treatment  in  this  condition. 

Lung  abscess,  tumors  and  foreign  bodies  are  in- 
dications for  surgical  intervention,  and  with  all  of 
these  dyspnea  and  cardiac  weakness  or  irregularity 
are  prominently  associated.  Obviously,  therefore, 
any  procedure  which  decreases  the  danger  of  post- 
operative shock  or  cardiac  dilatation  is  to  be  pre- 
ferred. 

Dysf^uca. — All  cases  of  pulmonary  disease  re- 
quiring surgical  operation  are  accompanied  by  dysp- 
nea, its  severity  depending  upon  the  location  of  the 
diseased  area,  the  toxic  element,  and  cardiac  com- 
pensation. Pleural  effusions  and  hemothorax  greatly 
embarrass  respiration,  and  I  believe  it  is  good  prac- 
tice to  aspirate  or  drain  these  accumulations  forty- 
eight  hours  before  pneumotomy  is  to  be  performed. 
Atropin  and  digitalis  in  full  doses  sometimes  will 
temporarily  control  dyspnea  to  a  great  extent.  When 
it  is  dependent  upon  increased  intrathoracic  pres- 
sure it  is  impossible  to  control  until  this  pressure  is 
relieved.  Postoperatively,  strychnine,  administered 
in  large  doses  hypodermically,  diminishes  respira- 
tion and  may  sustain  the  circulation  through  the 
shock  period.  Morphine  of  cotirse  is  preeminent 
in  decreasing  respiration  and  quieting  delirium,  as 
well  as  controlling  cough. 

TECHNIC 

Location  of  incision — external  marking. — The 
location  of  the  primary  incision  on  the  chest  wall 
should  conform  to  the  pulmonary  area  to  be  incised 
as  nearly  as  possible.    Preliminary  outlining  with 

•Read  before  the  Chicago  Academy  of  Medicine.  May  27,  1920. 


674 


J'AN  PAING:  SURGERY  OF  THE  THORAX. 


[New  York 
Medical  Journal. 


iodine  or  silver  nitrate  stick  is  useful  in  that  it 
remains  as  a  guide  after  sterilization  of  the  chest 
wall  is  complete.  The  incision  may  be  U  shaped 
or  longitudinal,  conforming  to  the  contour  of  the 
ribs,  the  primary  flap  consisting  of  skin,  superficial 
and  deep  fascia  down  to  the  muscle.  The  muscles 
may  be  separated  or  incised.  The  number  of  ribs 
chosen  is  important,  three  being  the  usual  number. 
All  of  them  may  be  fractured,  and  reflected;  or  one 
may  be  fractured  and  removed  aiid  the  one  above 
and  below  displaced  widely  with  a  rib  spreader  or 
a  Balfour  abdominal  retractor,  which  answers  the 
same  purpose.  At  this  point  I  make  a  practice  of 
tying  all  bleeding  points  and  removing  all  forceps. 

The  parietal  pleura  is  grasped  with  stomach  for- 
ceps and  the  knife  cautery  at  red  heat  is  applied 
in  a  line  about  three  inches  in  length  and  enlarged 
if  necessary  to  admit  of  free  access  to  the  under- 
lying structures.  This  incision  in  most  instances 
should  conform  to  the  direction  of  the  ribs.  Four 
stomach  forceps  are  applied  to  this  parietal  incision, 
and  it  is  retracted  well  above  and  below,  and  stitched 
to  the  visceral  pleura  with  single  O  continuous  cat- 
gut on  a  full  curved  fine  needle. 

The  knife  cautery  at  red  heat  is  applied  to  the 
visceral  layer,  the  length  corresponding  to  the 
parietal  incision.  The  anesthetic  is  removed  as  the 
lung  is  approached  and  the  cautery  is  used  as  one 
would  use  a  scalpel  in  penetrating  the  lung  tissue. 
With  this  method  hemorrhage  is  practically  absent 
except  in  the  division  of  the  larger  blood  vessels, 
and  for  the  sake  of  safety  these  should  be  tied. 

The  foreign  body  having  been  removed,  or  the 
abscess  drained,  as  the  case  may  be,  the  line  of 
incision  is  permitted  to  collapse  after  the  insertion 
of  a  fanshaped  drain  of  rubber  tissue  or  a  small 
cigarette  drain,  loosely  covered  and  without  gauze 
projecting  from  the  end.  If  the  wound  edges  are 
not  apposed  at  the  completion  of  the  operation,  one 
kidney  suture  of  fine  catgut  may  be  used  on  a 
heated  needle.  The  wound  in  the  pleura  may  be 
partially  closed  over  the  drainage  and  a  buttonhole 
incision  made  through  the  skin.  The  rib  retractor 
is  removed  and  the  fractured  rib  replaced,  or  re- 
moved entirely,  in  the  pus  cases.  The  skin  is  closed 
with  interrupted  silk  or  silkworm  gut  and  adhesive 
tape  tightly  applied,  the  wound  is  dressed  and  a 
pneumonia  jacket  applied. 

LUNG  COLLAPSE 

When  gas-oxygen  is  used  wnth  a  rebreathing  ap- 
paratus the  lung  does  not  collapse  in  a  large  per- 
centage of  cases,  and  in  others  only  partially  so,  the 
entire  operation  being  performed  with  only  a  slight 
change  in  respiration.  The  postoperative  morbidity 
is  decreased  materially  if  we  can  circumvent  lung 
collapse  and  the  tedious  convalescence  of  delayed 
reexpansion  is  obviated  to  a  great  extent. 

Postoperative  posture. — Posture  is  important  in 
that  it  favors  drainage  and  prevents  in  a  great 
measure  the  respiratory  embarrassment  so  common 
in  chest  surgery.  The  patient  usually  rests  better 
in  the  .semiFowler  position,  lying  on  the  afifected 
side.  If  the  incision  inclines  posteriorly  air  bags 
or  pillows  should  be  placed  to  insure  rest. 

Postoperative  attention  is  of  great  importance 
and  the  smoothness  of  convalescence  will  be  in 


direct  proportion  to  the  care  the  patient  receives. 
Morphine  and  atropine  hypodermically  in  full  doses 
repeated  until  respirations  are  decreased  to  eight 
or  ten  a  minute  the  first  twenty-four  hours,  is,  in 
my  opinion,  good  treatment.  A  wool  pneumonia 
jacket  should  be  applied  in  every  case  and  I  believe 
it  decreases  the  incidence  of  bronchitis  or  lobular 
pneumonia,  so  frequent  in  these  cases  and  so  serious 
when  they  occur. 

Postoperative  delirium. — This  may  be  very  vio- 
lent in  character  and  necessitate  constant  watching, 
or  it  may  manifest  itself  as  a  low  muttering  speech 
and  restlessness.  I  am  of  the  opinion  that  the  toxic 
element  with  its  attendant  fever  is  first  in  the  pro- 
duction of  delirium  and  secondly  cardiac  decom- 
pensation manifesting  itself  as  a  tachycardia,  ar- 
rh}1:hmia,  or  cyanosis,  and  due  possibly  to  dilatation 
of  the  right  heart.  Cool  sponging,  the  hot  wet  pack, 
normal  salt  solution  with  sodium  bicarbonate  intra- 
venously, or  blood  transfusion  may  be  required. 

Cyanosis. — Slight  cyanosis  always  is  present  to 
some  extent,  owing  to  the  sudden  changes  in  the 
pulmonary  circulation  and  the  attempt  on  the  part 
of  the  heart  to  maintain  circulatory  equilibrium. 
Cyanosis  in  favorable  cases  usually  disappears  in 
forty-eight  to  seventy-two  hours,  but  I  have  seen 
instances  of  its  persisting  for  days,  and  this  with 
a  healed  wound,  regular  heart,  and  low  temperature. 
Strychnine  and  belladonna  are  useful  in  this  con- 
dition, in  that  they  sustain  the  patient  and  tend  to 
equalize  circulation. 

Temperature.- — Postoperative  temperature  is  some- 
times quite  high  for  the  first  twenty-four  to  seventy- 
two  hours,  and  may  require  a  warm  pack,  glucose 
solution  intravenously,  or  blood  transfusion  the 
second  or  third  day  following,  if  the  temperature 
rises  again,  usually  will  control  temperature  in  the 
favorable  cases. 

Delayed  rce.vpaiision. — This  condition  should  be 
treated  by  breathing  exercises,  the  two  bottle  siphon 
method,  and  an  abundance  of  fresh  air. 

Sinus  formation. — This  sometimes  persists  for 
an  indefinite  period  and  does  not  seem  to  materially 
affect  the  "general  health.  Phenol,  bismuth,  and 
methyl  violet  in  a  petrolatum  base  usually  is  suffi- 
cient when  combined  with  general  measures,  such  as 
rigid  hygiene,  nutritious  diet,  and  hematopoietic 
drugs  such  as  iron  and  arsenic.  It  will  be  interest- 
ing to  observe  the  effect  of  mercurochrome-220  in 
an  ointment  base  in  these  cases  of  chronic  sinus 
formation. 

SUMMARY 

I  would  emphasize  the  following  points : 

1.  As  rapid  an  operation  as  is  consistent  with 
careful  technic. 

2.  Accurate  diagnosis  relying  upon  the  physical 
signs,  the  history,  and  the  x  ray. 

3.  Avoidance  of  delay  in  operation. 

4.  The  knife  cautery  at  red  heat,  to  the  exclusion 
of  all  other  methods  when  the  lung  tissue  is  to  be 
incised. 

5.  Avoidance  of  sutures  whenever  and  wherever 
possible. 

6.  Rubber  tissue  in  the  drainage  cases. 

7.  Strict  postoperative  attention  with  a  pneumonia 
jacket  and  nutritious  diet. 


October  30,  1920.] 


GUTTMAN 


CARCINOMA   OF  MIDDLE  EAR. 


67S 


8.  Morphine  to  the  point  of  narcosis  the  first 
twenty-four  to  seventy-two  hours. 

9.  Blood  transfusion  early  and  repeated  if  neces- 
sary in  shock,  hemorrhage,  delirium  and  anemia. 

10.  The  importance  of  breathing  exercises  and 
fresh  air  in  delayed  reexpansion. 

REFERENCES. 

1.  \^AK  Paing  :  Gunshot  Wounds  of  the  Chest,  Illinois 
Medical  Journal,  January,  1920. 

25  East  Washington  Street. 


CARCINOMA  OF  THE  MIDDLE  EAR.* 
Report  of  a  Case. 
By  John  Guttman,  M.  D., 
New  York. 

Malignant  new  growth  of  the  middle  ear  are  of 
comparatively  rare  occurrence,  therefore  the  report 
of  such  a  case  should  prove  of  interest. 

Case. — Ph.  L.,  aged  sixty  years,  consulted  me  for 
the  first  time  in  July,  1919.  Five  years  ago  he 
suffered  from  an  attack  of  otitis  media  purulenta 
acuta  of  the  left  ear.  The  purulent  discharge 
ceased  after  a  time  and  the  ear  remained  well  until 
six  months  ago,  when  the  purulent  secretion  ap- 
peared again  and  he  began  to  complain  of  dizziness. 
Three  months  ago,  some  granulations  were  removed 
from  the  same  ear.  Subsequently  a  facial  paralysis 
set  in,  and  four  weeks  later  a  swelling  of  the  zygoma 
region  appeared,  whereupon  a  mastoidectomy  was 
performed  by  an  attending  aurist. 

Present  state :  In  the  zygoma  region  in  front  and 
above  the  ear  lobule,  extending  backward  to  the 
mastoid  bone,  there  existed  a  swelling  the  size  of  a 
walnut  slightly  fluctuating.  Back  of  the  ear  the  mas- 
toid bone  showed  a  groove  about  half  an  inch  deep. 


Fig.  1. — Circumscribed  swelling  in  the  zygoma  region  as  shown 
by  the  x  ray. 


caused  by  a  previous  mastoidectomy.  The  wound 
was  fairly  clean  and  its  base  was  covered  with 
healthy  granulations.  In  the  tympanic  cavity  there 
exists  a  slight  purulent  discharge.    The  left  facial 

*Read  before  the  Section  in  Otology  of  the  New  York  Academy 
of  Medicine.  May  14,  1920. 


nerve  in  all  its  branches  and  the  left  abduceus  nerve 
•were  paralyzed.  There  was  total  deafness  in  the 
left  ear.  The  labyrinth  of  the  left  ear  did  not  react 
to  cold  water  irrigation.  The  reaction  of  the  right 
labyrinth  was  sluggish.  The  examination  of  the 
fundi  of  the  eye,  and  of  the  urine  and  blood,  did  not 


Fig.  2. — Narrowing  of  the  lumen  of  the  esophagus  as  shown  by 
the  X  ray. 

show  any  pathological  changes.  The  Wassermann 
reaction  was  negative  and  the  x  ray  showed  a  cir- 
cumscribed swelling  in  the  zygoma  region,  and  a 
considerable  narrowing  of  the  lumen  of  the  esoph- 
agus. There  was  dysphagia.  The  laryngeal  exam- 
ination did  not  show  any  pathological  change.  It 
was  doubtful  whether  the  swelling  of  the  zygoma 
region  was  an  extension  of  the  preceding  mastoid- 
itis into  the  zygomatic  cells,  or  whether  this  swell- 
ing was  a  neoplasm.  I  therefore  decided  to  explore 
it. 

An  incision  in  the  skin  was  made  connecting  this 
swelling  in  the  zygoma  region  with  the  mastoid 
wound.  A  large  amount  of  pus  and  granulation 
tissue  was  evacuated.  Thereupon  the  mastoid  bone 
was  attacked  with  chisel  and  rongeur.  The  cortex 
was  found  to  be  sclerosed,  and  did  not  show  any 
softening.  In  entering  the  antrum  large  masses 
of  neoplasm  were  encoimtered  and  these  were 
evacuated.  The  wound  was  then  packed  and  the 
patient  returned  to  his  bed.  The  diagnosis  of  the 
removed  tissue  made  by  the  pathologist  was  squam- 
ous cell  carcinoma.  Six  weeks  later  the  patient 
died  showing  the  symptoms  of  a  purulent  meningitis. 

In  all  cases  of  this  kind  it  is  very  difficult  to 
ascertain  the  time  and  place  of  the  onset.  It  is 
difficult  to  state  where  the  primary  seat  of  the  dis- 
ease was,  whether  in  the  tympanic  cavity,  the  antrum 


676 


ITTELSOX:  TYPES   OF   NASAL  OBSTRUCTIOX. 


[New  York 
Medical  Journal. 


of  the  mastoid,  the  petrous  bone,  or  in  the  inner 
ear.  Most  cases  of  carcinoma  of  the  ear  show  an 
early  affection  of  the  facial  nerve.  In  this  case 
the  paralysis  of  the  facial  nerve  was  accompanied 
by  a  paralysis  of  the  abducens  nerve  on  the  same 
side.  The  x  ray  picture  seems  to  indicate  that  the 
dysphagia  was  probably  caused  by  a  metastasis  in 
the  esophagus,  as  the  larynx  did  not  show  any  patho- 
logical condition. 

1261  Madisox  Avenue. 


FREQUENT  TYPES  OF  XASAL  OBSTRUC- 
TIOX AND  THEIR  TREATMENT. 

By  M.  S.  Ittelsox,  M.  D.. 
Brooklyn,  N.  Y.. 

Assistant  Surgeon.  Manhattan  Eye,  Ear,  and  Throat  Hospital. 

The  impression  is  frequent  that  defective  nasal 
breathing  in  the  adult  is  due  to  a  mechanical  obstruc- 
tion within  the  nasal  passages  and  that  this  symp- 
tom requires  operation  or  local  treatment.  This  is 
true  only  in  .some  cases.  The  causes  that  are  respon- 
sible for  this  condition  are  many.  The  treatment 
too  is  often  puzzling,  as  is  evidenced  by  the  variety 
of  opinion  that  is  .sometimes  expressed  in  a  given 
case.  Difference  of  opinion  is  to  be  expected  here 
as  in  most  other  conditions,  but  to  some  extent  this 
could  be  avoided.  From  the  numerous  patients 
who  seek  relief  from  this  condition  certain  types 
can  be  recognized  as  occurring  very  frequently.  It 
is  well  to  consider  the  pathological  conditions,  both 
local  and  general,  that  are  often  found  to  be  present 
in  these  types. 

Those  patients  who  complain  of  obstruction  when 
none  exists  are  interesting.  Those  with  atrophy  of 
the  nasal  mucous  membrane,  not  associated  with  scab 
formation  or  other  complications  and  where  an 
intranasal  examination  reveals  a  wide  breathing 
space,  will  often  complain  of  blocked  up  noses.  This 
symptom  is  also  noticed  in  those  on  whom  extensive 
nasal  $urgery  has  been  performed.  It  is  difficult 
to  give  a  satisfactory  explanation  of  this  condition 
and  probably  several  factors  are  involved.  This  is 
most  often  due  to  some  sensory  disturbance,  where 
the  patient  does  not  feel  the  air  either  because  of 
the  involvement  of  the  sensory  nerve  filaments  or 
because  of  the  wide  passage  the  current  of  air  does 
not  exert  sufficient  pressure  on  the  mucous  mem- 
brane. This  is  well  illustrated  in  those  cases  where 
the  lumen  in  one  side  of  the  nostril  is  wider  than 
in  the  other,  in  which  case  the  trouble  is  more  often 
referred  to  the  open  side.  It  is  doubtful  whether 
a  sinus  affection  by  preventing  ventilation  and  an 
interchange  of  air  within  the  sinuses,  an  interchange 
which  normally  occurs,  should  by  itself  be  respon- 
sible for  this  symptom.  In  rarer  cases  the  trouble 
will  be  found  to  be  general  rather  than  local.  Due 
to  a  diminished  alkalinity  of  the  blood  or  to  some 
other  error  in  metabolisni,  there  is  an  increased 
demand  for  oxygen,  the  lack  of  which  may  be 
referred  to  the  nose.  Occasionally,  too,  local  and 
general  conditions  are  both  apparently  normal  and 
we  are  obliged  to  use  such  terms  as  nasal  neurosis 
or  na.sal  neurasthenia.  Whatever  opinion  one  may 
have  as  to  the  causes  of  this  symptom  it  is  important 


to  remember  that  in  this  type  the  obstruction  com- 
plained of  is  apparent  and  not  real. 

A  more  frequent  condition  is  an  obstruction  due 
to  the  abnormal  action  of  the  nasal  mucous  mem- 
brane.' To  perform  its  function  of  warming, 
moistening,  filtering,  and  perhaps  regulating  the 
amount  of  the  inspired  air,  this  membrane  expands 
and  contracts,  thus  varying  constantly  the  lumen 
of  the  nose.  The  causes  responsible  for  this  varia- 
tion in  dimension  of  the  mucous  membrane  are 
often  obscure,  and  to  some  extent  depend  on  the 
function  that  is  to  be  performed.  Changes  in  the 
atmosphere,  chemical  and  mechanical  irritants,  and 
mental  emotions — all  affect  this  highly  susceptible 
membrane  and  cause  it  to  expand  and  contracc. 
This  expansion  is  due  to  an  increase  in  the  blood 
supply,  which  distends  the  venous  sinuses  not  unlike 
the  erectile  tissue  elsewhere  in  the  body  and  with 
little  or  no  inflammatory  reaction.  The  term  fvmc- 
tional  obstruction  is  suggested  for  this  type  of  cases. 
There  are  few  individuals  who  have  not  occasionally 
experienced  a  sudden  change  from  opening  to 
closure  and  reversely  occurring  in  both  nostrils  or 
more  often  alternating  from  one  nostril  to  the  other 
without  any  apparent  cause. 

Inflammation  of  the  nasal  mucous  membrane  is 
another  condition  that  is  frequently  responsible  for 
obstruction.  Functional  disturbance  may  occur  in  a 
normal  mucous  membrane :  more  often  it  occurs  in 
one  that  has  undergone  inflammatory  changes. 
Clinically,  a  chronically  inflamed  mucous  membrane 
is  either  hyperthrophied  or  atrophied  or  without 
change  in  size  and  it  loses  its  moist  pearl  pink  color 
which  is  characteristic  of  a  normal  mucous  mem- 
brane. The  hypertrophy  or  hyperplasia  may  be  a 
conservative  process,  one  of  Nature's  efforts  to 
compensate  for  some  loss  of  function  or  for  some 
local  anatomical  irregularity.  Thus,  large  turbinates 
are  found  in  roomy  noses  and  on  the  concave  side 
of  a  deviated  septum.  No  such  utilitarian  purpose 
is  evident  in  an  atrophic  or  ptherwise  chronically 
inflamed  membrane.  One  cannot  but  feel  that  here 
the  underlying  cause  is  some  general  systemic  dis- 
turbance, such  as  syphilis,  gout,  rheumatism  or 
intestinal  intoxication.  It  may  be,  too,  that  a  dis- 
turbed secretion  of  the  ductless  glands  has  some 
influence.  The  relation  of  the  erectile  tissue  of  the 
nose  to  the  gonadal  glands  has  long-  been  noticed. 
The  facies  of  those  with  atrophic  rhinitis  is  not 
unlike  those  with  a  deficiency  of  the  thyroid  gland. 
The  broad  nose,  dry  skin,  and  its  frequent  occur- 
rence in  women  all  suggest  this,  as  well  as  the  fact 
that  the  condition  is  less  often  seen  in  patients  with 
hyperthyroidism.  In  the  acute  cases  of  inflamma- 
tion the  individual  immunity  is  an  important  element. 
A  virulent  Klebs-Loefffer  may  be  innocuous  to 
some,  while  a  bit  of  innocent  dust  will  in  a  suscept- 
ible person  excite  the  most  violent  inflammatory 
paroxysm. 

In  the  treatment  of  these  forms  of  obstruction 
much  can  be  accomplished  by  the  correction  of  any 
general  disturbance,  which  even  a  superficial  exam- 
ination will  in  most  cases  disclose.  Changes  in  the 
diet,  the  prevention  of  autointoxication,  the  correc- 
tion of  hygienic  errors,  and  the  treatment  of  any 
indefinite  gouty,  rheumatic,  glandular  or  syphilitic 


/ 


October  30,  1920.] 


RACHFORD:  CONGENITAL  UNDERDEVELOPMENT. 


677 


conditions  do  more  good  as  a  rule  than  local  appli- 
cations. In  this  connection  may  be  mentioned  the 
favorable  action  of  laxatives,  potassium  iodide,  and 
small  doses  of  thyroid  extract  carefully  admin- 
istered. If  the  obstruction  is  suspected  to  be  of 
an  anaphylactic  origin  vaccine  therapy  and  protein 
desensitization  might  be  tried.  As  for  local  treat- 
ment irrigation  is  the  one  most  frequently  employed. 
Nichol's  nasal  syphon  is  well  suited  for  this  purpose, 
acting  as  it  does  more  by  suction  than  by  pressure. 
A  solution  of  soda  bicarbonate,  a  teaspoonful  to  a 
quart  of  water,  is  less  irritating  than  normal  saline. 
There  are  some  nasal  membranes  on  which  water  in 
any  form  acts  unfavorably.  In  these  cases  an  oily 
preparation  may  be  substituted.  Menthol,  three 
grains :  ichthyol.  thirty  grains,  and  petrolatum,  one 
ounce,  is  a  prescription  that  can  be  freely  used  and 
often  repeated  by  patients.  Intranasal  operations 
are  now  undertaken  reluctantly.  Removal  of  a  dis- 
eased tonsil  by  improving  the  general  health  relieves 
local  symptoms.  Turbinectomy  or  turbinotomy  has 
largely  proved  a  failure.  There  are,  of  course, 
exceptions  to  this  as  to  other  rules,  but  the  essential 
validity  of  this  statement  is  apparent  to  all  who 
have  seen  the  passing  of  what  was  once  a  popular 
operation.  Among  the  exceptions  may  be  men- 
tioned the  removal  of  the  hypertrophied  portion  of 
the  inferior  turbinate,  or  of  an  enlarged  posterior 
tip,  which  is  still  done  occasionally. 

Considerable  attention  is  now  paid  to  the  appear- 
ance of  the  septum.  Deviation  of  the  septum,  par- 
ticularly if  it  is  of  traumatic  origin  and  limited  to 
the  anterior  portion,  does  prevent  the  air  from 
passing  through,  and  there  are  few  operations  where 
the  good  results  are  more  striking.  On  the  other 
hand,  it  must  be  noticed  that  some  form  of  septal 
irregularity  is  almost  a  universal  condition,  and  a 
perfectly  straight  septum  is  an  anatomical  excep- 
tion. The  curves  and  angles  that  one  sees  so 
frequently  on  the  septum  are  usually  normal  and 
innocent  variations  occurring  coincidently  with  some 
other  pathological  condition.  Patients  have  a  way 
of  disappearing  and  it  is  difficult  to  get  accurate 
data  regarding  many  submucous  operations.  Many 
of  these  subsequently  show  up  again  at  a  different 
clinic  or  office  with  the  same  complaint.  The  sur- 
geon thus  sees  less  of  his  own  unsuccessful  cases 
and  more  of  those  of  his  colleagues,  unsuccessful 
as  far  as  the  functional  result  is  concerned,  although 
the  appearance  of  the  septum  following  such  opera- 
tion is  all  that  could  be  desired  and  shows  evidence 
of  surgical  skill.  Many  feel  that  a  submucous 
resection  is  always  a  conservative  operation  because 
the  original  incision  is  small  and  the  mucous  mem- 
brane is  not  sacrificed.  In  the  separation  of  the 
periosteum  and  in  the  removal  of  the  bone  and  car- 
tilage considerable  trauma  is  done  which  with  the 
subsequent  fibrosis  often  affects  the  mucous  mem- 
brane unfavorably.  Following  the  removal  of  the 
bone  and  cartilage  there  remains  considerable  re- 
dundant tissue  which  assumes  somewhat  its  former 
position,  and  a  deviation  may  persist  after  opera- 
tion. Diagnosis  of  a  deviated  septum  is  easily  made, 
but  to  determine  its  relative  importance  in  the 
causation  of  the  obstruction  requires  careful  watch- 
ing and  good  judgment. 


COXGEXITAL  UXDERDEVELOPMEXT  OF 
THE  RIGHT  SIDE  IX  AX  IXFAXT 
THREE  MOXTHS  OLD.* 

Bv  B.  K.  Rachi-ord,  M.  D., 
Cincinnati,  Ohio, 

Professor  of   Pediatrics,   University  of  Cincinnati. 

C.\SE — J.  S.,  infant  three  months  old,  brought  to 
my  office  on  December  11,  1919,  by  his  mother  be- 
cause she  had  noticed  a  few  days  before  that  his 
left  leg  was  much  larger  than  his  right. 

Previous  historx. — Labor  was  instrumental. 
Baby  was  apparently  normal  at  birth.  He  had  been 


Fig.   1. — Underdeveloped  fibula  and  tibia. 


fed  exclusively  upon  breast  milk  and  had  never  been 
ill,  and  until  a  few  days  before  his  mother  had  not 
noticed  that  the  left  side  of  his  body,  especially  the 
left  leg,  was  larger  than  the  right. 

*Read  by  title  before  the  American  Pediatric  Society. 


678 


SATTEKTHirAITE:  INCREASES   IN  VENEREAL  DISEASES. 


[New  York 
Medical  Journal. 


Physical  examination. — This  showed  an  apparent- 
ly perfectly  nourished  male  child.  He  had  been  all 
of  his  life  and  was  at  that  time  perfectly  well.  His 
only  abnormality  was  the  underdevelopment  of  the 
right  side  of  the  body,  especially  the  right  leg.  The 
right  leg  was  ten  inches  long,  the  left  leg  eleven 
inches  long,  measured  from  the  anterior  superior 
spine  to  the  internal  malleolus.  The  right  thigh, 
one  inch  above  the  knee,  was  eight  and  one  quarter 
inches  in  circumference,  the  left  thigh  was  ten  inches 
in  circumference.  The  right  foot,  plantar  surface, 
measured  by  placing  the  foot  on  a  sheet  of  paper, 
was  three  and  three  quarter  inches,  the  left  foot, 
measured  in  the  same  way,  was  four  inches.  The 
right  chest,  measured  from  the  xyphoid  process  to 
the  corresponding  spinous  process  of  vertebrae,  was 
eight  and  one  quarter  inches.    The  left  side  of  the 


Fig.  2. — Underdeveloped  epiphyseal  ossification  centre;  underde- 
veloped greater  and  lesser  trochanter,  as  compared  with  left  side; 
lesser  transverse  diameter  of  right  femur,  as  compared  with  left. 

chest,  measured  in  the  same  way,  was  eight  and 
three  quarter  inches.  The  right  femur  was  one  and 
four  fifths  inches  shorter  than  the  left.  The  right 
tibia  was  one  and  one  fifth  inches  shorter  than  the 
left. 

On  March  23,  1920,  the  baby  being  then  about 
seven  months  old,  had  remained  perfectly  well  and 
had  continued  to  be  nourished  exclusively  upon 
breast  milk.  He  weighed  twenty  pounds.  The  left 
side  of  his  body  was  as  well  developed  as  that  of 
any  normal  breast  fed  baby  of  his  age,  but  the 
whole  right  side  of  his  body,  although  there  had  been 
a  marked  increase  in  development,  still  remained 
underdeveloped  as  compared  with  the  left. 

The  left  side  of  the  baby's  face  was  larger  than 


the  right  and  the  left  arm  and  hand  were  larger  than 
the  right.  The  most  marked  difference  was  in  the 
size  of  the  legs.  The  whole  left  leg  was  much  larger 
than  the  right.  This  was  especially  noticeable  in 
the  thighs.  The  left  foot  was  several  sizes  larger 
than  the  right.  It  was  also  apparent  that  the  left 
side  of  his  chest  was  larger  than  the  right.  The 
baby  was  normally  developed  mentally.  In  stand- 
ing the  baby  on  his  feet  it  was  evident  that  he  had 
more  strength  in  the  left  leg  than  he  had  in  the  right. 
He  apparently  also  had  more  strength  in  his 
left  arm  and  hand  than  he  had  in  his  right,  but  this  _ 
dil¥erence  between  the  left  and  the  right  side  was 
only  comparative,  as  the  baby  used  his  right  arm  and 
his  right  leg  in  an  apparently  normal  way,  and 
there  was  not  the  slightest  evidence  of  paralysis  of 
any  kind.  In  fact,  the  mother  believed  that  he  had 
quite  as  good  use  of  his  right  arm  and  leg  as  he  had 
of  his  left. 

Measurements  on  March  23,  1920,  were  as  fol- 
lows :  Right  leg,  twelve  inches ;  left  leg,  thirteen  and 
a  quarter  inches ;  circumference  of  right  thigh,  nine 
inches ;  circumference  of  left  thigh,  ten  and  one 
half  inches.  Left  foot  four  and  three  quarters 
inches  long,  right  foot,  four  and  one  quarter  inches 
long. 

The  accompanying  radiograms  show  the  under- 
development of  the  bones  of  the  right  leg  and 
the  progress  of  development  that  has  occurred  in 
five  months. 

Seventh  and  Race  Streets. 


THE  RECENT  INCREASES  IN  VENEREAL 
DISEASES. 

An  International  Peril. 

By  Thomas  E.  Satterthwaite,  M.  D., 
New  York. 

Dr.  Joseph  E.  Moore,  an  American  officer,  con- 
sulting urologist  to  the  district  of  Paris  in  France, 
has  told  us  that  following  the  late  armistice  seventy 
thousand  prostitutes  were  for  a  time  thronging  the 
streets  of  that  city,  of  whom  only  five  thousand 
were  registered  as  under  police  surveillance,  while 
two  thousand  five  hundred  hotels  were  used  for 
assignation  purposes.  He  has  also  stated  that  at 
one  time  he  found  the  incidence  of  infection  in  the 
American  Expeditionary  forces  from  some  kind  of 
venereal  disease  about  330  in  a  thouand,  i.  e.,  about 
one  in  three ;  and  that  there  was  no  special  effort 
made  to  lower  this  rate.  Eventually,  however,  it 
was  reduced  to  ninety-four  in  a  thousand.  In 
August  and  September,  1917,  the  incidence  among 
five  thousand  British  troops  in  Pairs  was  two  hun- 
dred in  a  thousand.  The  ratio  alluded  to  above  by 
Moore  was  said  to  be  four  times  greater  than  else- 
where among  our  men  in  zones  occupied  by  them, 
the  inference  being  that  special  efforts  were  capable 
of  reducing  the  disease,  if  proper  measures  were 
adopted.  (1) 

Someone  was  responsible  for  this  wholesale  infec- 
tion. Was  there  collusion  or  laxity  on  the  part  of 
the  French  officials,  or  our  own  ?    In  either  case 


Octob;r  30,  1920.] 


SATTERTHWAITE:  INCREASES   IX  T'EXEREAL  DISEASES. 


679 


should  not  the  guilty  be  held  morally,  if  not  other- 
wise, responsible  for.  failure  to  "prevent  infections, 
which  must  necessarily  lead,  if  they  have  not  already 
done  so.  to  widespread  disease  throughout  the 
United  States  and  France.  Humanity  demands  an 
investigation.  Of  this  there  can  be  no  doubt,  for 
public  prostitution  is  capable  of  being  controlled  in 
time  of  war  by  military  or  civil  authorities,  the  first 
naturally  being  the  more  effective.  I  know  this 
from  personal  experience  in  one  of  the  provincial 
towns  of  France,  where  at  one  time  it  had  assumed 
the  proportions  of  an  epidemic.  Civil  control  by 
local  police,  with  legal  punishment,  such  as  prevails 
in  Denmark,  is  also  a  powerful  agency  in  this  re- 
gard, provided  the  laws  are  properly  administered. 
It  may  not  be  generally  known,  but  I  believe  it  to 
be  true,  from  my  experience,  that  French  prosti- 
tutes are  likely  to  be  contaminated  with  aggravated 
forms  of  venereal  diseases.  We  have  the  authority 
of  the  New  York  Medical  Journal  (2j  that  vene- 
real diseases  increased  greatly  during  the  war.  and 
on  the  authority  of  Riddell,  (3 )  there  are  probably 
more  than  half  a  million  syphilitics  now  in  Canada, 
forty  thousand  of  them  being  in  Toronto.  But  it  is 
generally  agreed  that  the  increase  in  Europe  has 
been  more  marked  than  on  this  side  of  the  water, 
pointing  to  the  probability  that  Europe  has  been 
largely  responsible  for  the  increase  over  here. 
This  statement  is  also  borne  out  by  Miss  Ettie  A. 
Rout  (4).  According  to  Miss  Rout  the  British 
military  rate  in  1917  was  twenty-seven  in  a  thou- 
sand. In  1919  it  had  risen  to  eighty  in  a  thousand, 
while  in  the  present  year  it  is  still  higher.  She  also 
sayS  "probably  no  European  country  has  less  than 
three  or  four  times  the  amount  of  venereal  diseases 
if  had  in  1913-1914." 

We  come  now  to  one  of  the  special  causes  of  in- 
fection. Writing  in  the  Daily  Herald,  of  London, 
E.  D.  Morel  (5)  has  stated  that  he  was  informed  by 
letters,  personal  statements,  and  other  data,  which 
he  regarded  as  trustworthy,  that  eighteen  months 
after  the  armistice,  when  the  French  had  from  thirty 
to  forty  thousand  of  their  colored  African  troops 
in  the  Bavarian  Palatinate,  these  men  were  raping 
women  and  girls,  so  that  in  this  zone  their  victims 
filled  the  hospitals  to  overflowing,  naturally  spread- 
ing syphilis,  with  which  they  were  to  a  large  extent 
affected,  right  and  left.  As  is  known  to  many  of 
the  medical  profession,  the  colored  race  is  contam- 
inated with  syphilis  to  a  much  larger  degree  than 
the  white  race.  Recently  at  Fort  Riley,  Kansas,  the 
incidence  of  syphilis  among  the  colored  troops  was 
set  at  about  twenty-three  per  cent,  against  about 
thirteen  per  cent,  among  the  white  (6) .  Though  sta- 
tistics on  this  point  are  not  very  numerous,  the  con- 
sensus of  medical  opinion  is  that  the  general  inci- 
dence among  colored  people  is  much  greater  than 
among  the  whites. 

In  this  connection  the  report  of  Moron  (7)  throws 
some  light  on  the  matter.  He  states  that  syphilis  is 
not  taken  seriously  by  the  colored  people  of  Mada- 
gascar, a  French  protectorate.  Indeed,  with  them 
syphilis  in  young  girls  is  regarded  as  an  asset,  be- 
cause brides  are  then  immune  against  subsequent  at- 
tacks, and  their  value  in  the  matrimonial  market  is 
thereby  enhanced.    Notwithstanding,  if  Dr.  E.  T- 


Dillon,  the  famous  war  correspondent  and  author 
of  The  Inside  Story  of  the  Peace  Conference^  is  to 
be  credited,  the  French  military  authorities  not  only 
compelled  local  authorities  to  open  public  brothels 
within  the  occupied  zone,  for  their  colored  soldiers, 
but  supervised  and  received  the  money  for  the  traf- 
fic. In  one  page  of  his  book  he  publishes  a  copy, 
in  French,  of  the  military  orders  in  the  case  of  a 
brothel  at  Muenchen-Gladbach,  under  the  title : 
Exploitations  et  police  de  la  maison  piiblique  de 
Muenchen-Gladbacli.  The  notice  gives  in  detail  the 
rules  and  regulations  of  the  house,  both  as  to  the 
men  and  women.  Dillon  publishes  it  in  French 
without  translation,  as  he  infers  his  readers  would 
prefer  to  read  it  in  the  original ! 

As  no  exception  has  been  made,  apparently,  to 
such  statements,  it  seems  probable  that  the  method 
is  still  practised  in  Muenchen-Gladbach.  Indeed,  it 
has  come  to  the  writer's  notice  recently  that  a  sim- 
ilar brothel  is  being  operated  at  Wiesbaden.  The 
plea  in  defense  of  these  practices  would  be  that  they 
are  military  necessities.  In  Denmark  today,  under 
its  present  laws,  if  a  civilian  should  undertake  to 
keep  a  public  brothel  or  rent  rooms  for  immoral  pur- 
poses, he  would  be  liable  to  a  prison  sentence.  We 
are  led,  therefore,  to  believe  not  only  that  there  is 
a  veritable  plague  emanating  from  Europe,  but  that 
the  fons  uiali  is  still  pouring  out  its  deadly  poison, 
to  be  carried  to  the  four  corners  of  the  itniverse. 

I  hold  that  this  infamous  traffic,  as  it  is  regarded 
by  most  Americans,  can  be  stopped  at  any  time  by 
a  note  from  Washington,  for  if  only  well  known 
sanitary  measures,  such  as  come  within  the  scope  of 
police,  military  or  civil  authorities,  are  put  in  prac- 
tice, as  the  laws  of  Denmark  provide,  the  danger  of 
infection  can,  I  believe,  be  reduced  to  a  minimum, 
even  without  the  prophylactic  measures  that  are  used 
in  our  military  and  naval  services.  We  cannot,  of 
course,  abolish  venereal  diseases  now,  for  present 
sources  of  contagion  must  necessarily  continue  for 
an  indefinite  time  to  be  a  danger  to  the  public,  even  if 
no  new  instances  of  the  disease  should  occur.  More- 
over, we  can  never  prevent  clandestine  relations. 

I  was  present  at  a  meeting  at  the  New  York  Acad- 
emy of  Medicine  on  October  7  when  a  paper  on 
present  measures  for  limiting  venereal  infection 
was  read  by  a  prominent  government  official.  The 
paper  and  the  discussion  that  followed  bore  on  the 
efforts  that  have  been  made  by  the  United  States 
Public  Health  Service,  various  boards  of  health  and 
private  or  semiprivate  associations  to  combat  vene- 
real diseases  by  public  lectures,  posters  and  public- 
ity measures  in  general.  These  methods  probably 
have  some  value.  I  admit  it.  They  emphasize,  how- 
ever, a  popular  fallacy  that  prophylaxis  can  effec- 
tively prevent,  by  bureau  work,  backed  by  a  liberal 
use  of  money.  There  is  always  stress  'laid  on  the 
latter  word.  No  mention  was  made  in  the  paper 
as  to  military  or  civil  repression  of  this  traffic.  We 
should  not  be  led  astray  by  visionary  views.  On 
the  contrary,  our  opinions  should  be  based  on  those 
of  practical  men  who  have  dealt  successfully  with 
such  problems.  The  strong  arm  of  the  law  is,  and 
always  will  be,  the  most  deterrent  force. 

As  Moore  has  said,  probably  one  third  of  the 
cases  of  infection  he  has  described  would  have  oc- 


680 


SATTERTHll  AITE:   IXCREASES  IN   VENEREAL  DISEASES. 


[New  York 
Medical  Journal. 


curred  in  his  Paris  experience  any  way,  under  the 
license  then  prevailing.  Given  the  cupidity  of  the 
prostitute,  the  money  of  the  American  soldier,  the 
opportunity  easily  afforded,  the  recklessness  of 
men  and  women,  and  conditions  were  present  for 
infection,  notwithstanding  the  warnings  of  humane 
associations,  public  service  organizations,  or  the  like. 
In  fact,  while  these  various  agencies  have  some- 
thing of  a  deterring  force,  venereal  diseases  have 
also  increased  rather  than  diminished,  as  I  have 
shown.  We  should  also  remember  that  in  the  case 
of  sanitary  prophylactic  measures,  the  belief  that 
they  will  prevent  contagion  may  widen  the  doorway 
to  immoral  relations. 

Miss  Ettie  A.  Rout,  a  Xew  Zealand  Government 
authorized  reporter  and  honorable  secretary  of  the 
New  Zealand  Volunteer  Sisters,  who  has  already 
been  referred  to,  says  on  this  point  (8)  :  "We  found 
that  French  and  Belgian  public  women  were  quite 
ready  to  attend  a  Red  Cross  dispensary  for  prophy- 
lactic treatment  and  quite  ready  to  accept  prophy- 
lactic outfits  from  the  soldiers.  (We  had  the  direc- 
tions printed  in  French  and  English.)"  In  other 
words,  "Employ  regulation  safeguards  and  you  run 
little  risk."  What  a  satisfactory  statement  for  the 
inmates  and  patrons  of  brothels.  Miss  Rout's  paper 
is  called  the  Conquest  of  \'enereal  Disease.  Might 
it  not  quite  as  appropriately  have  been  called.  Pro- 
miscuous intercourse  made  comparatively  safe  by 
scientific  methods  ? 

Now  assuming  from  Miss  Rout's  given  title  in 
her  article  that  she  is  a  New  Zealander,  and  that 
the  New  Zealand  troops  in  the  war  as  a  class  were 
clean  and  healthy  men,  as  they  are  reputed  to  have 
been,  would  not  some  of  them  nevertheless,  under 
the  tutelage  of  Miss  Rout's  associates  who  appear  to 
have  opened  the  door  fo'-  them  to  comparatively  safe 
promiscuous  intercourse,  have  eventually  become  in- 
^fected,  provided  their  experiences  were  sufficiently 
large  ? 

Certainly  the  prophylaxis  as  practised  in  military 
and  naval  life  does  not  prevent  infection  so  surely 
as  vaccination  against  smallpox.  In  fact.  Miss  Rout 
asserts  that  prophylaxis  is  successful  when  properly 
applied  in  only  two  thirds  of  the  cases,  as  .shown  by 
the.  returns  of  the  American,  Canadian,  and  Aus- 
tralian armies,  as  against  the  almost  complete  pro- 
tection claimed  by  Moore  in  his  personal  experi- 
ences. 

Why  lay  so  much  stress  on  prophylaxis  when  all 
authorities  agree  that,  except  in  accidental  cases, 
ab.stinence  is  the  only  practice  that  really  prevents ; 
and  medical  men,  in  general,  say  it  does  no  harm 
to  men  or  women.  I  do  not  propose,  however,  to 
discuss  the  moral  side  of  the.se  prophylactic  meas- 
ures ;  but  will  say  that  notwithstanding  their  use,  it 
is  shown  that  infection  will  occur  sufficiently  often 
to  make  immoral  relations  dangerous  to  one's  life 
and  health,  and  the  individuals  infected  a  menace  to 
society. 

This  .statement  cannot  be  confuted  successfully. 
Even  from  the  viewpoint  of  protection,  such  meas- 
ures will  not  stand  the  crucial  tests  of  actual  condi- 
tions. Take  life  in  Europe  today,  among  civilians 
in  the  many  localities  where  they  are  .still  bearing  the 
burdens  and  sorrows  of  the  war.    Poverty  and  hun- 


ger, produced  by  embargoes  on  food  for  which 
Americans  are  to  a  large  extent  responsible,  lack  of 
work,  and  the  high  cost  of  living,  with  a  currency 
depreciated  by  the  results  of  the  war,  while  thou- 
sands are  kept  alive  simply  by  the  generosity  of  a 
comparatively  few  philanthropic  Americans  make 
women  and  girls  the  easy  prey  of  licentious  soldiers, 
especially  if  they  are  Africans,  armed  with  brief  au- 
thority and  backed  by  military  officers  who  have 
neither  fear  of  God  nor  man  before  their  eyes.  How 
can  such  a  depraved  condition  of  things  be  reme- 
died by  lectures,  posters,  or  any  other  form  of  pub- 
licity? Intelligent  people  know  it  cannot.  Or  is 
it  to  be  supposed  that  where  brothels  were  opened 
on  the  outskirts  of  our  camps,  during  the  late  war, 
lectures  or  literature  effectually  restrained  our 
youth.  We  know  they  did  not.  I  am  certain  from 
personal  experience  at  home  and  abroad  that  public 
])rostitution,  our  greatest  danger,  in  this  regard  can 
be  controlled  by  the  law.  Public  women,  of  course, 
have  the  greatest  opportunities  for  producing  infec- 
tion and  are  almost  certain  to  be  infected  sooner  or 
later.  To  regulate  by  military  or  civil  forces  this 
feature  of  the  case,  therefore,  would  be  the  method 
most  effective  in  results  of  any  in  the  prophylaxis 
of  venereal  diseases. 

Therefore,  let  us  fir.st  of  all  bend  our  efforts  to 
suppressing  the  public  traffic  by  the  well  known 
methods,  which  are  simple,  efficient  and  economical, 
and  let  other  methods,  such  as  those  I  have  described 
which  are  largely  theoretical,  expensive  and  ineffi- 
cient, if  not  in  some  cases  immoral,  have  a  secondary 
consideration.  These  facts  can,  however,  be  brought 
into  a  clearer  light,  if  .some  of  these  scandalous 
practices  that  I  have  mentioned,  whether  interna- 
tional or  national,  are  made  themes  of  a  Congres- 
sional inquiry.  Fortunately  we  have  at  hand  many 
high  in  Government  circles  who  have  had  an  op- 
])ortunity  of  witnessing  some  of  the  orgies  I  have 
described,  in  foreign  lands.  Their  testimony  might 
be  most  valuable;  indeed,  we  .should  recognize  that 
Europe  is  the  source  of  the  venereal  diseases  that 
just  now  are  threatening  civilization. 

There  are  various  reasons  why  an  inquiry  into 
this  topic  should  emanate  from  the  Government. 
The  profession  of  medicine  is,  as  a  rule,  fearful  that 
under  the  pressure  of  outside  influence  laws  will 
be  introduced  compelling  them,  on  the  witness  stand, 
to  violate  the  tenets  of  professional  secrecy.  Fear 
of  it  would  prevent  many  of  the  laity  from  telling 
the  truth  about  themselves.  Moreover,  inasmuch  as 
venereal  diseases  prevail  more  or  less  extensively  in 
the  practice  of  every  physician  and  surgeon,  com- 
jiulsory  notification  would  remove  a  source  of  con- 
siderable revenue.  Indeed  the  patient  might  prefer 
to  use  nostrums  to  having  his  disease  exposed  on 
the  public  records.  To  be  sure,  if  notification  were 
made  compulsory  we  may  be  quite  certain  physi- 
cians would  not  be  likely  to  carry  it  out  and  public 
opinion  would  sustain  them.  In  fact,  compulsory 
notification  could  not  be  carried  out  successfully 
in  American  circles  at  the  present  time.  But  as  a 
result  of  compulsory  notification  laws  the  disease, 
though  perhaps  making  alarming  strides  forward, 
would  apparently  be  dimini.shing,  according  to  the 
reports  of  our  public  health  authorities.    Again  by 


October  30.  1920.]      SHAPIRO:  NEW  IXSTRL  MENT  FOR   SIMPLIFYING  TONSILLECTOM) 


681 


a  government  inquiry  the  public  should  be  officially 
informed  of  the  real  dangers  of  these  diseases  and 
the  comparative  values  of  prophylactic  measures. 
For  example,  if  the  following  queries  were  taken 
up  at  such  an  inquiry,  imder  the  subjoined  heads, 
as  bearing  on  the  Parisian  scandal,  they  would  be 
prodtictive  of  the  most  valuable  results  to  our  peo- 
ple at  large.   The  topics  to  be  taken  up  might  be : 

1.  Could  public  women  in  France  have  been  suc- 
cessfully quarantined  ? 

2.  Could  not  the  danger  of  contagion  have  been 
prevented  by  the  withholding  of  passes,  by  the  mili- 
tary or  naval  authorities  ? 

3.  Is  abstinence  harmful  to  men  or  women? 

4.  Is  not  the  public  woman  the  source  of  the 
greatest  danger? 

5.  Is  the  furnishing  of  public  women  by  socio- 
logical associations  with  prophylactic  packets  a  safe 
procedtire.  or  a  moral  one? 

6.  What  is  really  the  ratio  of  effectiveness  by  the 
prophylactic  measures  pursued  in  military  and  navy 
circles  ? 

Certainly  if  we  joined  the  League  of  Nations  as 
at  present  constituted,  would  we  not  be  expected, 
to  at  least  give  tacit  consent  to  the  maintenance  and 
regulations  of  military  brothels,  such  as  have  been 
•in  operation  recently,  and  probably  are  now.  under 
the  guise  of  military  necessities. 

Now  while  the  statements  I  have  made  in  this 
paper,  based  on  the  reports  of  government  officials, 
will  probably  be  accepted  as  true  by  the  medical 
profession  at  large,  we  need  not  expect  they  will 
be  accepted  by  all  of  the  sociological  workers  who 
have  visited  the  areas  referred  to.  This  attitude  on 
their  part,  which  has  already  been  observed  by  the 
writer,  was  to  have  been  expected,  and  for  various 
reasons.  In  many  instances  the  men  and  women 
sent  over  to  supervise  the  work  of  their  associations 
or  gather  material  for  home  consimiption.  were 
either  ignorant  of  foreign  languages  or  of  the  nature 
of  the  diseases,  or  otherwise  tmqualified ;  or  they 
thought  it  unjiatriotic  to  tell  of  unpleasant  conditions 
noted  in  their  work.  This  remark  applies  to  the 
clergy  as  well  as  to  the  laity  employed  in  such  mis- 
sions. 

We  may,  therefore,  expect  no  help  from  any  of 
them  imless  it  can  he  shown  that  now  we  require  the 
truth,  and  it  is  pseudopatriotic  for  them  to  withhold 
it.  But.  after  all,  prophylaxis  in  venereal  diseases  is 
essentially  a  medical  problem  and  it  is,  therefore, 
most  fitting  that  efforts  to  solve  it  should  emanate 
from  the  medical  profession. 

REFERENCES. 

1.  Journal  A.  M.  A..  April  24  and  October  2,  1920; 
New  York  Medic.\l  Journal,  October  9,  1920. 

2.  New  York  Medical  Journal,  June  12,  1920. 

3.  Riddell:  Ibid,  October  2.  1920. 

4.  Rout  :  Ibid,  October  9.  1920. 

5.  Morel,  E.  D.  :  Daily  Herald,  London,  .\pril  10,  1920. 

6.  Journal  of  Svphilolocix  and  Clinical  Medicine,  vol..  v. 
1919. 

7.  Moron  :    Journal  de  Bordeaux,  August  27,  1919. 

8.  Rout:  New  York  Medical  Journal.  Oct.  9.  1920. 

7  East  Eightieth  Street. 


INSTRUMENT  FOR  SIMPLIFYING  TONSIL- 
LECTOMY BY  SNARE. 

By  IsiDOR  F.  Sh.apiro.  M.D., 
New  York. 

The  saving  of  time  at  a  critical  jiuicture  in  the 
course  of  the  snare  operation  has  been  effected  by 
the  use  of  the  instrument  shown  in  Fig.  1,  which  I 
have  devised.  It  consists  simply  of  a  Hurd  dissec- 
tor onto  which  has  been  brazed  part  of  a  Weder 
tongue  depressor.  This  saves  the  operator  the  trou- 
ble and  extra  motions  that  go  with  two  separate  in- 
strimients  and  permits  a  considerable  saving  in  the 
time  of  the  operation,  which  is  important  for  a  pa- 
tient under  a  general  anesthetic.    It  also  reduces  the 


Fig.  1. — Combination  tonsil  dissector  and  tongue  depressor. 


amount  of  hemorrhage  and  sponging  which,  after 
all,  is  traimiatic  and  is  to  be  avoided  as  far  as  possi- 
ble. All  these  advantages  are  especially  apparent 
when  the  operation  is  done  without  many  assistants 
or  at  the  patient's  home,  where  there  are  no  suction 
facilities.  The  loss  of  blood  is  reduced  when  the 
suction  method  is  used,  on  accoimt  of  the  saving  of 
time  of  operation. 

355  E.\ST  149th  Street. 


Influenza  in  the  Tuberculous. —  Maurice  Fish- 
berg  and  Ernst  P.  Boas  {.-hncrican  Journal  of 
the  Medical  Sciences.  August,  1920 )  state  that  in 
an  outbreak  of  influenza  in  the  tuberctilosis  pavilion 
of  the  Montefiore  Hospital  during  January  and  Feb- 
ruary, 1920.  twenty-eight  out  of  127  patients  were 
affected.  The  proportion  seems  to  be  about  the 
same  as  might  be  expected  among  nontubert;ulous 
individuals.  The  clinical  form  of  tuberculosis  and 
the  stage  of  the  disease  had  no  influence  on  the 
tendency  of  the  patients  to  contract  influenza.  Of 
the  twenty-eight  patients  who  contracted  influenza 
nine  died,  which  is  a  higher  rate  of  mortality  than 
is  generally  observed.  Of  the  twenty-eight  patients 
with  influenza,  twenty-two  developed  bronchopneu- 
monia, again  a  rate  much  higher  than  is  usually 
seen.  It  seems  that  the  tendency  to  complicating 
bronchopneumonia  varies  with  the  epidemic.  Dur- 
ing the  ej)idemic  of  1918  this  complication  developed 
in  a  smaller  proportion  of  patients  and  the  mortality 
was  lower.  The  clinical  course  of  the  influenza 
resembled  that  seen  in  the  nontuberculous.  The 
tendency  to  develop  complicating  bronchopneiunonia 
bears  no  relation  to  the  stage,  clinical  form,  or 
acuteness  of  the  ttiberctilous  process  in  the  lung  and 
pleura.  In  nearly  all  of  the  patients  who  recovered 
the  complicating  disease  had  no  appreciable  influence 
on  the  tuberculotis  lung  lesion,  so  far  as  could  be 
ascertained  by  physical  exploration  of  the  chest  or 
on  the  subseqtient  course  of  the  disease.  They 
cannot  say  that  the  anergic  state  brottght  about  by 
influenza  had  an  influence  on  the  incidence,  course 
and  termination  of  this  disease  in  the  tuberculous. 


Editorial  Notes  and  Comments 


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NEW  YORK.  SATURDAY.  OCTOBER  30,  1920. 


VENEREAL  PROPHYLAXIS 
The  venereal  problem  i.^  one  tliat  has  confronted 
the  world  for  many  centuries.  Slowly,  very  slowly, 
have  we  gained  accurate  knowledge  regarding  the 
transmission  of  venereal  diseases.  First  of  all  our 
•efforts  were  directed  to  cure.  Then  diagnostic  meth- 
ods were  perfected  and  we  found  that  our  hospitals 
and  homes  were  filled  with  victims  of  syphilis  and 
gonorrhea.  These  victims  ranged  from  the  fetus 
killed  in  the  uterus  by  a  s\philitic  virus  to  the  latent 
inanifestations  in  general  paresis.  Between  these  two 
we  found  a  formidable  host  of  lesions  attacking 
every  portion  of  the  bod}- — the  eyes,  the  bones,  the 
nervous  system,  the  skin  and  viscera — no  structure 
escaped.  Blind  babies  were  born.  This  is  not  a  sen- 
timental plea,  but  a  statement  of  reality.  Textbooks 
were  written  and  various  ways  and  means  devised  to 
combat  the  results  of  the  twin  evils,  gonorrhea  and 
syphilis. 

Finally,  the  more  sane  realized  that  this  ghastly 
.army  of  the  sick  and  disabled  did  not  need  to  exist. 
Ibsen  and  Brieux  portrayed  from  the  stage  the  re- 
sults of  venereal  infection.  The  less  timid  gave  sup- 
port :  the  reactionaries  attempted  to  stippress.  Pro- 
fessional uplifters  crusaded  and  attemped  to  clean  up 
•communities.  But  the  practice  of  the  genitourinary 
specialists  did  not  decrease.  The  enforcement  of 
prophylactic  care  of  the  eyes  of  newborn  babies, 
Itowever,  decreased  the  number  of  blind  babies.  Then 
came  the  great  war  where  the  youth  of  our  socalled 
■civiliza'ion  pitted  themselves  one  against  the  other 
in  the  held  of  battle.    Some  say  that  man  in  his  in- 


genuity could  have  prevented  that  catastrophe.  How- 
ever, we  shall  not  discuss  the  point.  Others  may 
take  up  their  cudgels  in  protecting  man  from  his 
own  folly  in  war ;  we  as  physicians  will  deal  with 
his  follies  of  health. 

This  week  we  are  presenting  the  paper  of  a 
most  earnest  physician,  Dr.  Thomas  E.  Satter- 
thwaite,  who  has  seen  many  of  the  venereal  prob- 
lems that  were  brought  to  a  focus  during  the  war. 
While  we  do  not  agree  with  all  he  has  to  say,  there 
is  so  much  truth  in  what  he  says,  that  we  feel  it 
should  be  published,  even  though  we  do  not  believe 
in  the  efificacy  of  the  tactics  by  which  he  thinks  the 
venereal  problem  can  be  solved.  He  takes  issue  with 
]\Iiss  Rout,  of  New  Zealand,  Riddell,  of  Toronto, 
and  a  host  of  others  on  the  question  of  the  advisabil- 
ity of  the  use  of  prophylaxis.  His  two  objections 
are :  It  will  increase  illicit  intercourse,  and  the  pro- 
phylaxis is  not  effective  in  every  case.  In  regard  to 
the  first  point,  it  is  difiicult  to  conceive  how  this 
would  l)e  possible  on  the  face  of  things.  Civilization 
plunging"  along  at  a  mad  pace,  with  its  countless 
sexual  stinuilants,  the  press,  the  theatre,  the  cinema, 
clothes  designed  to  lure  and  captivate,  and  the  mon- 
etary incentive  to  prostitutes  and  their  accessories, 
all  these  tend  to  sexual  excitation.  The  gonadal 
powers  of  youth  are  awakened  prematurely.  It  is 
difficult  to  conceive  how  venereal  prophylaxis  is  go- 
ing to  increase  ^•enereal  diseases  under  these  con- 
ditions. It  is  well  to  consider  the  entire  background 
and  not  focus  too  sharply  on  one  particular  spot.  Dr. 
Satterthwaite  carefully  quotes  only  part  of  Miss 
Rout's  paper,  which  appeared  in  the  New  York 
Medical  Journal,  October  9,  1920 ;  he  does  not  go 
into  the  statistics  of  her  experience  with  the  soldiers 
on  leave  in  Paris.  We  all  know  that  prostitution 
flourished  there,  especially  during  the  war.  It  would 
be  interesting  to  go  into  the  economic  reason  for 
this;  much  food  for  thought  would  come  out  of  this 
study.  However,  she  proved  that  venereal  infection 
was  decreased  to  a  minimum.  She  showed  that  con- 
tinence could  not  be  enforced.  ]\Ian  is  a  complex 
animal  and  the  sexual  urge  is  great.  The  intellectual 
level  is  not  equal  and  it  is  not  possible  to  prevent 
illicit  intercourse. 

How  are  prophylactic  measures  going  to  increase 
the  number  of  illicit  relationships?  The  feeble  an- 
swer is  that  it  will  make  intercourse  safe.  On  the 
other  hand,  with  the  prophylactic  measures  a  certain 
amount  of  edtication  is  necessary  and  is  stire  to 
follow.  The  prophylaxis  calls  to  mind  not  the 
safety  of  the  sex  relationship  but  the  danger.  With 
the  reminder  and  the  realization  that  follows  men 


October  30,  1920.] 


EDITORIAL  ARTICLES. 


683 


and  women  will  seek  early  treatment  when  infected. 
The  entire  question  will  come  to  light  and  not  be 
suppressed.  We  shall  be  able  to  discuss  the  subject 
without  the  age  long  inhibitions  that  have  sur- 
rounded us.  We  shall  be  able  to  fight  the  foe  where 
it  can  be  seen.  The  method  of  suppression  urged  by 
Satterthwaite  has  never  proved  successful  in  any 
field  of  human  afiFairs ;  we  have  nothing  to  show  that 
it  will  be  more  effective  for  the  venereal  problem. 
Wft  cannot,  by  force  or  any  other  means,  push  the 
problem  into  the  dark  where  it  will  fester  and  break 
out  anew.    We  need  more  light,  more  light. 


ELECTROTHER.\PEUTICS  IN  THE  TREAT- 
MENT OF  PARALYSIS. 

Electrotherapy  has  not  been  accorded  the  po- 
sition which  is  its  due  in  the  treatment  of  certain 
conditions.  Perhaps,  by  some  its  therapeutic  efiicacy 
has  been  exaggerated,  but  in  certain  forms  of  mus- 
cular paralysis  electricity  plays  a  role  of  no  mean 
importance.  Mr.  H.  S.  Souttar,  F.  R.  C.  S.,  as- 
sistant surgeon  and  director  of  surgical  unit,  Lon- 
don Hospital,  in  a  paper  read  before  the  British 
Medical  Association,  laid  emphasis  on  the  fact  that 
in  the  care  of  a  limb  in  which  a  nerve  has  been  sev- 
ered there  were  many  considerations  other  than 
those  that  appear  on  the  surface.  The  inevitable 
paralysis  of  a  certain  group  of  muscles  carries  with 
it  a  whole  train  of  consequences,  many  of  which 
are  hy  no  means  inevitable.  Leaving  on  one  side 
the  muscles  directly  affected,  the  loss  of  the  normal 
range  of  movement  will  lead  to  the  formation  of 
adhesions  between  Qther  muscles,  around  tendons, 
and  within  joints.  The  limb  may  readily  fall  into 
positions  of  deformity  which  give  rise  to  the  stretch- 
ing of  muscles  and  ligaments,  the  skin  itself  will 
suffer  from  disuse,  and  the  limb  will  suffer  from 
its  corresponding  loss  of  excretory  power.  It  is 
therefore  evident  that  in  estimating  the  value  of  any 
one  method  of  treatment  the  limb  as  a  whole  must 
be  considered  and  the  vision  must  not  be  bounded 
by  the  narrower  field  of  the  small  group  of  muscles 
which  may  be  paralyzed. 

In  the  application  of  electricity  the  primary  object 
is  to  evoke  contractions  in  the  paralyzed  muscle. 
By  doing  so  it  is  compelled  to  fulfill  its  normal  func- 
tions, in  however  diminished  a  degree,  and  the  imi- 
versal  experience  is  that  this  is  essential  for  the  pre- 
vention of  atrophy  in  any  tissue.  The  tissues  re- 
quire for  their  nutrition  something  more  than  the 
supply  of  food,  even  something  more  than  perfect 
innervation.  They  must  work,  and  according  to 
Souttar  electrical  stimulation  can  do  for  the  muscle 
something  quite  out  of  the  reach  of  any  other 
method.    Indeed,  the  prima  facie  evidence  of  the 


value  of  contractions  of  paralyzed  muscle  is  so  over- 
whelming, that  it  would  require  the  strongest  prac- 
tical evidence  of  their  uselessness  to  justify  their 
being  ignored.  Yet,  if  electrical  treatment  is  to  be 
really  effective  one  condition  must  not  be  overlooked  : 
if  the  muscle  as  a  whole  is  to  receive  the  same  bene- 
fit as  the  fibres  which  contract,  it  must  be  made  to 
contract  as  a  whole,  and  this  result  is  often  exceed- 
ingly difficult  to  obtain.  As  Souttar  pointed  out, 
the  ideal  means  of  stimulation  would  be  the  passage 
through  the  whole  limb  of  a  current  which  would 
stimulate  the  paralyzed  muscles,  leaving  the  intact 
muscles  undisturbed.  This  is  not  as  yet  solved,  al- 
though the  researches  of  Lapicque  and  of  Tur- 
rell  have  brought  this  ideal  within  measurable  dis- 
tance. For  the  contraction  of  paralyzed  muscle  spe- 
cial forms  of  current  should  be  developed.  The 
discovery  of  some  simple  means  by  which  the  con- 
traction of  every  fibre  of  a  paralyzed  muscle  could 
with  certainty  be  obtained  would  give  a  powerful 
impetus  to  treatment.  - 

Souttar  holds  the  viev.-  that  there  is  little  fear  of 
overfatiguing  paralyzed  muscles  by  continued  stimu- 
lation. Major  Cooper  has  put  the  matter  to  a  direct 
test  and  has  found  that  after  six  hundred  contrac- 
tions in  fifteen  minutes  a  paralyzed  muscle  showed  no 
evidence  of  fatigue.  Consequently,  it  seems  to  be 
indicated  that  each  muscle  might  be  exercised  for  a 
longer  period  than  is  usual  with  great  advantage.  As 
for  the  faradic  current  which  does  not  produce  con- 
tractions Souttar  is  of  the  opinion  that  apart  from 
its  indirect  action  through  the  muscles,  it  is  prob- 
able that  a  faradic  current  has  a  direct  stimulating 
action  upon  the  circulation,  either  upon  the  vessels 
themselves  or  through  the  sympathetic  system,  and 
in  this  way  it  may  ha^-e  a  direct  action  upon  the 
vitality  of  the  limb  as  a  whole. 

But  further  it  has  recently  occurred  to  him  that 
a  faradic  current  stimulating  the  muscles  antago- 
nistic to  those  which  are  paralyzed,  might  probably 
have  a  good  effect.  \Miile  no  evidence  exists  to  show 
that  the  mere  passage  of  a  current  through  a  limb 
has  any  effect  on  the  growth  of  a  divided*  nerve, 
there  is  every  reason  to  suppose  that  the  growth  of  a 
divided  nerve  is  influenced  by  the  activity  of  the 
cell  from  which  it  arises,  and  Souttar  asks  what 
better  means  could  be  found  of  stimulating  the  an- 
terior horn  cell  than  the  production  of  the  physiolog- 
ical reflex  arising  from  the  contraction  of  the  an- 
tagonistic muscle  group? 

There  is  little  doubt  that  there  is  a  great  future  for 
the  electrical  treatment  of  paralysis  caused  by  nerve 
injury.  It  also  appears  certain  that  the  modes  of 
applying  such  treatment  are  developing  in  a  satis- 
factory manner.     However,  those  who  apply  the 


684 


EDITORIAL 


ARTICLES. 


[New  York 
Medical  Journal. 


treatment  should  I)e  experts  and  thoroughly  under- 
stand the  end  they  have  in  view.  Much  has  heen 
learned  in  this  direction  during  the  war,  and  it  is  to 
be  hoped  that  this  knowledge  will  be  developed  so 
successfully  that  it  will  be  put  to  the  best  use  in  in- 
dustrial medical  practice.  There  is  a  wide  scope  for 
electrotherapeutics  in  this  field. 


PHYSICIAN-AUTHORS:  DR.  WILLIAM 
HENRY  DRUMMOND. 
There  are  two  predominating  grou])s  of  people 
in  the  eastern  provinces  of  Canada,  the  English  and 
the  French,  and  there  are  remote  hi.storical  reasons, 
taking  us  back  to  the  days  of  New  France,  why  these 
two  groups  have  not  been  wholly  in  political  and 
siocial  harmony,  despite  the  fact  that  for  so  many 
decades  they  have  been  fellow  countrymen  sharing 
the  advantages  and  the  burdens  of  a  great  and 
growing  dominion.  Today,  however,  these  two  great 
groups  are  more  nearly  in  sympathetic  touch  with 
one  another  than  ever  before.  A  number  of  con- 
tributing factors  have  brought  about  this  spirit  of 
concord,  and  Canadians  of  both  groups  agree  that 
not  the  least  of  these  factors  was  a  big,  warm  heart- 
ed, whole  souled  Iri.sh  physician  who,  in  odd  mo- 
ments of  leisure  when  his  practice  was  not  too 
pressing,  found  time  and  inspiration  to  wield  his 
pen  for  the  entertainment  of  his  family  and  friends. 
This  man  was  Dr.  William  Henry  Drummond,  of 
Toronto.  Ontario. 

Poetry  was  Dr.  Drummond's  medium,  and  by 
means  of  it  he  interpreted  w-ith  a  kindly  sympathy, 
a  tender  pathos  and  an  inimitable  humor  the  simple 
life  and  characteristics  of  the  habitants  of  On- 
tario and  Quebec.  It  was  the  first  time  the  French- 
Canadian  farmer  had  been  utilized  as  a  literary  fig- 
ure, except  when  some  ribald  scribbler  poked  fun  at 
him  and  his  patois.  French-Canadians  were  in- 
clined to  resent  Drummond's  poetical  effusions  at 
first.  They  glanced  at  them  without  reading  and  as- 
sumed that  they  were  merely  another  attempt  to 
make  a  laughing  stock  of  the  simple  minded  liabi- 
tant.  But  after  they  had  been  induced  to  read  them, 
and  realized  that  here  was  a  sincere  attempt  to  pre- 
sent the  habitant  in  a  clean  and  pleasing  way,  their 
praise  knew  no  bounds,  and  today  there  are  no  great- 
er admirers  of  Dr.  Drummond's  poetry  than  the 
French-Canadian  element. 

In  the  preface  to  his  first  volume,  The  Habitant, 
he  says :  "Having  lived  practically  all  my  life  side 
by  side  with  the  French-Canadian  people,  I  have 
frown  to  love  and  admire  them,  and  I  have  felt 
that  while  many  of  the  English  speaking  people 
know,  perhaps  as  well  as  myself,  the  French-Can- 


adians of  the  cities,  yet  they  have  had  little  oppor- 
tunity to  become  acquainted  with  the  habitant, 
therefore  I  have  endeavored  to  paint  a  few  types, 
and  in  doing  this  it  has  seemed  to  me  that  I  could 
best  attain  the  object  in  view  by  having  my  friends 
tell  their  own  tales  in  their  ow-n  way,  as  they  would 
relate  them  to  English  speaking  auditors  not  con- 
\ersant  with  the  French  tongue."  This  was  tlie 
spirit,  then,  which  served  to  bring  the  two  racial 
divisions  of  The  Lady  of  the  Snows  a  step  or  two 
nearer  a  friendly  fellow  feeling.  The  good  spirit 
and  tempered  delicacy  Dr.  Drummond  displayed  in 
the  treatment  of  the  habitants  created  an  equally 
pleasing  impression  in  the  English  speaking  world. 
The  Habitant  was  followed  by  three  other  volumes 
of  French-Canadian  poems — The  J'ovageur,  Johnnv 
Conrtcau  and  The  Great  Fight.  These  four  vol- 
umes had  a  vogue  in  their  day  that  was  almost 
unparalleled  in  the  history  of  modern  verse,  not 
only  in  Canada  ])ut  in  England  and  the  United  States 
as  well.    They  still  have  a  steady  sale  in  Canada. 

If  Canadian  literature  were  of  maturer  develop- 
ment perhaps  Drummond's  poetry  would  in  time 
pass  into  oblivion,  for  it  is  not  great  poetry.  But 
Canadian  literature  is  still  in  its  infancy  and  this 
man's  work  seems  assured  of  perpetuity  because,  as 
Dr.  Louis  Frechette,  the  Poet  Laureate  of  Canada, 
has  said,  "he  was  a  new  pathfinder  in  the  land  of 
song." 

Dr.  Drummond  was  born  on  April  13,  1854,  in 
County  Leitrim,  Ireland,  and  passed  his  boyhood  in 
the  village  of  Tawley,  near  the  Bay  of  Donegal. 
When  he  was  ten  years  old  the  family  removed  to 
Canada,  and  shortly  thereafter  the  father  died.  Being 
the  eldest  son.  young  Drummond  had  to  set  about 
finding  ways  to  help  his  widowed  mother,  and  so 
he  learned  telegraphy.  He  became  a  full  fledged 
telegrapher  in  the  lumber  camp  village  of  Bord-a- 
Plouffe,  on  the  River  des  Prairies,  and  there  came 
into  contact  with  those  voyagetirs  and  habitants 
whom  he  later  wove  into  his  poems.  The  songs 
they  sang  gave  to  his  style  its  mould  and  spirit. 
His  poems  are,  for  the  most  part,  merely  metrical 
renditions  of  their  quaint  tales  of  backwood  life.  Af- 
ter a  few  years  of  work  he  w^as  able  to  attend  McGill 
University,  and  later  Bishop's  Medical  College,  where 
he  got  his  medical  degree  in  1884.  His  first  medical 
work  was  as  house  surgeon  at  the  Western  Hospital 
in  Montreal,  and  subsequently  he  took  up  the  prac- 
tice of  medicine  in  the  little  village  of  Stornoway, 
near  Lake  Megantic.  After  two  years  there  and  two 
more  at  the  village  of  Knowlton  he  returned  to 
Montreal,  w  here  he  practised  until  his  death  on  April 
6,  1907,  in  the  Cobalt  mining  district,  where  he  had 
■gone  to  fight  an  epidemic  of  smallpox. 


Octcb  r  30,  1920.1 


EDITORIAL 


ARTICLES. 


685 


In  Stornoway  and  Knowlton  he  gathered  impres- 
sions and  material  for  his  pictures  of  The  Can- 
adian Country  Doctor  and  Ole  Doctor  Fiset.  In 
Montreal  Dr.  Drummond  lived  in  on  old  house  on 
Mountain  Street  which  had  been  the  home  of  Jef- 
ferson Davis,  the  exiled  President  of  the  Confed- 
eracy, and  it  was  there  he  wrote  practically  all  of 
his  poems.  In  addition  to  his  practice  he  for 
several  years  occupied  the  chair  of  medical  juris- 
prudence in  his  alma  mater.  In  recognition  of  his 
literary  achievements  the  University  of  Toronto  in 
1902  conferred  upon  him  the  degree  of  LL.  D.  and 
subsequently  he  was  elected  a  fellow  of  the  Royal 
Society  of  Literature  in  England  and  of  the  Royal 
Society  of  Canada.  These,  with  the  degree  of  D.  C. 
L.  from  Bishop's  College,  made  up  the  sum  of  his 
literarv  honors. 


.A.  HUGE  JOKE 

To  ordain  by  legislative  enactment  that  alcoholic 
liquors  shall  be  medicine  and  then  watch  and  spy 
upon,  haul  into  court  and  fine  any  doctor  who  over- 
steps the  bounds  set  by  a  license  commission,  is  one 
of  the  greatest  jokes  ever  perpetrated  on  a  com- 
munity. This  is  what  the  Ontario  Temperance 
Law  does  for  the  physicians  of  that  province.  The 
farce  goes  further.  Seven  dispensaries  are  dis 
tributed  throughout  the  land,  two  being  located  in 
Toronto  where  there  is  only  one  fifth  of  the  pop- 
ulation. Xo  wonder  there  is  a  lot  of  socalled  sick- 
ness in  Toronto,  markedly  intensified  every  week- 
end. Nearly  all  the  illustrious  legislators,  many  of 
them  great  legal  liuninaries,  who  were  instrumental 
in  framing  and  passing  this  wonderful  piece  of 
legislation,  have  by  the  will  of  the  people  been  left 
to  the  comfort  of  their  own  firesides,  and  cellars, 
but  new  ones  are  in  the  saddle  riding  the  govern- 
mental steed.  They  ride,  but  so  far  as  controlling 
the  beast,  they  lack  control,  for  have  they  not  a 
sp>ecial  commission  inquiring  into  the  administration 
of  the  Ontario  Temperance  Act  which,  from  one 
end  of  the  province  to  the  other  and  from  Lake  On- 
tario and  Lake  Erie  to  the  confines  of  Hudson  Bay 
is  of  questionable  repute.  When  the  inquiry  is 
completed  the  medical  profession  may  have  some 
measure  of  relief.    At  all  events  that  is  their  prayer. 

Few  e.xpress  any  desire  for  a  return  to  the  open 
bar.  Some  may  wish  to  get  their  socalled  medicine 
now  and  again  without  recourse  to  the  doctor  and 
the  added  cost.  The  act  is  iniquitous  in  that  it 
discriminates  in  the  rich  man's  favor.  To  the  pro- 
fession it  is  burdensome  in  that  they  have  to  carry 
the  stigma  of  harboring  in  their  ranks  three  or  four 
hundred  imscrupulous  physicians  who  fatten  their 
averages  by  the  medicinal  prescription. 


OCULISTS  AND  PEOPLES. 
The  beauty  of  a  pretty  workgirl  is  not  enhanced 
by  huge  goggles,  nor  is  a  young  man  made  more 
prepossessing  by  their  use.  yet,  in  the  long  proces- 
sions lunchwards,  homewards,  which  trips  and 
stumbles  and  strides  through  our  streets,  there  are 
hundreds  wearing  glasses.  If  asked  by  the  oculist 
as  to  the  lighting  of  store  or  factory  or  oflSce  the 
ready  answer  will  be  that  there  is  "plenty  of  electric 
light :  quite  a  glare  of  it."  But  the  oculists  on  the 
Board  of  the  Industrial  Accident  Commission  de- 
fine light  as  "that  quantity  and  quality  which  en- 
ables normal  eyes  to  work  without  discomfort." 
and  they  are  trying  to  make  employers  see  the  eco- 
nomic advantages  of  supplying  this.  When  the 
light  is  insufficient  the  eye  keeps  changing  its  focus 
in  a  vain  eflFort  to  detect  details.  This  constant 
drawing  up  and  releasing  action  of  the  fine  mus- 
cular construction  results  in  strain  and  definite  fa- 
tigue. Also,  a  bright  light  suspended  in  the  line  of 
vision,  or  a  sharp  contrast  and  flickering  on  the 
eye  gives  the  extra  work  of  constant  adjustment. 
This  is  not  only  a  serious  strain,  but  introduces  a 
neutral  stage  of  the  pupil  action  by  the  lagging  of 
tired  nniscles.  which  results  in  a  momentary,  par- 
tial blindness,  making  it  almost  impossible  for  a 
worker  to  observe  the  graduations  of  a  precision 
instrument  or  lay  out  fine  work  in  detail. 


THE  XER\'OUS  COW. 
It  is  little  realized  by  the  laity  how  much  the 
health  of  animals  affects  our  own,  nor  how  much 
is  being  done  in  the  veterinary  world  on  this  ac- 
count. There  is  the  question  of  abortion  in  cows 
and  its  relation  to  hunvm  mothers,  of  tuberculosis 
as  aflfecting  everyone,  and.  greatest  of  all.  the  dis- 
tribution of  pasteurized  milk  un freed  by  protection 
against  subsequent  cont.',mination.  There  is  even 
published  a  large  veteimary  dentistn.-,  but  it  is 
not  difticult  to  imagine  that  a  bull  or  a  horse  would 
require  some  p>atient  handling  when  toothache  set 
in.  One  veterinary  has  had  a  cow  suffering  from 
nervous  shock.  She  could  not  bear  anyone  near 
her,  and  walked  with  a  stiff,  irregular  gait,  making 
the  motions  of  stejiping  over  an  obstacle  before  she 
came  to  it.  Sodium  cacodylate  arid  restful  solitude 
in  a  darkened  stall  led  to  a  complete  cure.  It  is 
rather  difficult  to  believe,  but  pigs  also  are  delicate, 
nervous  animals,  and  require  more  care  than  cows. 


PREMATURE  BURIAL. 
Every  year  gloomy  little  articles  are  issued  con- 
cerning the  burying  of  the  living  and  advising  the 
dead  to  have  their  veins  opened  and  various  other 
devices  are  suggested  to  ascertain  their  real  condi- 
tion. Out  in  Akron,  Ohio,  one  William  Wirt  found 
himself  on  a  memorial  tablet  erected  to  those  who 
had  died  in  France.  He  says  there  are  nearly  two 
thousand  so  commemorated  in  different  States  who 
have  since  been  traced  as  living.  He  suggests  start- 
ing a  Club  of  Dead  Men.  Perhaps  he  means  a 
hermitage  where  they  could  forget  the  world  and  be 
forgotten  by  it.  These  soldiers  have  been  officially 
declared  dead.    How  does  the  law  stand? 


686 


NEJVS  ITEMS. 


[New  York 
Medical  Journal. 


News  Items. 


A  Vaccination  Campaign  in  New  York. — Dur- 
ing the  month  of  September  25,453  vaccinations 
were  performed  in  Greater  New  York  by  medical 
inspectors  of  the  health  department,  compared  with 
12,029  during  August. 

Tuberculosis  Clinics  in  Ontario  County. — Un- 
der the  joint  auspices  of  the  Ontario  County  Tu- 
berculosis Committee  and  the  Geneva  Health  Bureau 
a  monthly  tuberculosis  clinic  has  been  established  in 
Geneva.  Up  to  the  middle  of  August  a  total  of  117 
patients  had  been  examined. 

Hospital  at  St.  Mihiel  to  Be  War  Memorial.— 
Cooperating  with  the  French  Government,  the  jun- 
ior section  of  the  American  Red  Cross  Society  will 
finance  the  erection  and  operation  of  a  hospital  for 
children  at  St.  Mihiel,  France,  in  memory  of  the 
first  great  American  battle  eflfort  of  the  war. 

The  Length  of  Human  Life. — The  average  du- 
ration of  life  in  India  is  less  than  25  years.  In 
Sweden  it  is  over  50  years ;  in  Massachusetts,  45 
years;  in  Denmark  it  is  51.17;  in  France,  47.4;  in 
England  and  Wales,  45.9 ;  in  Italy,  42.9,  and  in 
Prussia,  42.8.  In  Geneva,  where  records  are  avail- 
able for  the  past  three  centuries,  the  sixteenth  cen- 
tury showed  a  life  span  of  21.2  years,  the  seven- 
teenth century  showed  25.7  years,  the  eighteenth, 
33.6  years,  and  the  nineteenth,  39.7  years. 

New  Quarters  for  Health  Department  Venereal 
Disease  Clinic. — ^The  Department  of  Health  of 
the  City  of  Xew  York  announces  the  removal  of  its 
Manhattan  \'enereal  Disease  Clinic  to  the  depart- 
ment headquarters  at  505  Pearl  street.  This  clinic 
was  established  in  compliance  with  the  State  vene- 
real disease  law  and  is  intended  for  those  who  can- 
not afford  to  pay  the  charges  made  by  dispensaries. 
The  medical  profession  is  invited  to  refer  to  this 
clinic  such  patients  as  are  believed  to  be  suitable  for 
free  treatment. 

Civil  Service  Examination  for  Anatomist. — 
— The  United  States  Civil  Service  Commission  an- 
nounces an  examination  for  the  position  of  anato- 
mist in  the  office  of  the  Surgeon  General,  Army 
Medical  Museum,  Washington,  D.  C,  at  $1,600  a 
year,  plus  increase  granted  by  Congress  of  $20  a 
month.  The  duties  of  the  appointee  will  consist 
of  the  preparation  of  gross  and  histological  material, 
their  reproduction  in  drawings,  photographs,  or 
paintings  for  illustrative  purposes.  Those  interested 
should  apply  for  Form  1312.  No  applications  will 
be  received  after  December  7th. 

New  York  Neurological  Society. — A  joint 
meeting  of  the  New  York  Neurological  Society  and 
the  Section  in  Neurology  of  the  New  York  Acad- 
emy of  Medicine  will  be  held  on  Tuesday  evening, 
November  9th.  Dr.  Hyman  Climenko  will  present  a 
case  of  Nanism  and  Dr.  A.  L.  Soresi  a  case  of  Psy- 
chosis following  Surgical  Operation.  Dr.  Joseph 
Byrne  will  read  a  paper  on  Pupil  Dilatation  and  the 
Sensory  Pathways,  illustrated  with  lantern  slides. 
Dr.  Samuel  Brock  will  present  a  study  in  motor 
aphasia  of  the  Cortical  or  Mixed  Type,  with  report 
of  a  case,  and  Dr.  Karl  Winfield  Ney  will  describe 
the  operation  and  findings  in  the  case. 


Improvements  at  Glen  Ridge  Sanatorium. — 

The  Board  of  Supervisors  of  Schenectady,  N.  Y., 
has  voted  $50,000  for  repairs  and  improvements 
to  be  made  at  Glen  Ridge  Tuberculosis  Sanatori- 
um. In  addition  to  extensive  repairs,  a  new  pa- 
vilion is  to  be  created,  a  cooling  system  installed, 
and  the  present  administration  building  enlarged. 

Christmas  Seal  Campaign. — Active  prepara- 
tions are  being  made  for  this  season's  Christmas 
seal  campaign  to  raise  funds  for  antituberculosis 
work,  which  will  open  on  December  1st.  New  York 
State's  quota  this  year  will  be  $582,000.  Last  year 
a  total  of  $375,000  was  raised  in  New  York  State, 
outside  of  New  York  city,  for  the  work  of  national, 
State  and  local  tuberculosis  organizations. 

Wisconsin  Cancer  Committee.  —  The  State 
Medical  Society  of  Wisconsin  recently  appointed  a 
committee  for  the  study  of  cancer,  with  the  follow- 
ing membership :  Dr.  J.  P.  McMahon,  of  iMilwau- 
kee,  chairman ;  Dr.  Edward  Evans,  of  La  Crosse ; 
Dr.  W.  A.  Ground,  of  Superior;  Dr.  C.  H.  Bunt- 
ing, of  Madison,  and  Dr.  W.  K.  Grey,  of  Milwau- 
kee. 

Menorah  Hospital. — Nearly  $25,000  was  con- 
tributed at  a  dinner  held  at  the  Hotel  Bossert  on 
October  17  to  the  building  fund  of  the  new  IVIenorah 
Hospital  at  Coney  Island.  The  new  institution 
will  be  nonsectarian,  and  will  receive  both  acute 
and  chronic  cases.  For  the  purchase  and  equip- 
ment of  the  hospital  $400,000  is  required. 

Sanitary  Survey  of  Interstate  Park. — At  the 
request  of  the  Public  Health  Council  a  sanitary 
survey  is  being  made  of  the  Palisades  Interstate 
Park.  This  park  consists  of  about  36,000  acres 
and  is  situated  between  the  palisades  along  the 
Hudson  River  and  the  Ramapo  Mountains,  partly 
in  New  Jersey  and  partly  in  New  York.  About 
sixty  camps  are  maintained  throughout  the  park 
and  this  survey  includes  detailed  studies  and  inspec- 
tions of  the  water  supply  and  sewage  disposal. 

American  Academy  of  Ophthalmology  and 
Otolaryngology.  —  At  the  twenty-fifth  artnual 
meeting  of  this  organization,  held  in  Kansas  City, 
Mo.,  on  October  15th,  the  following  officers  were 
elected :  President,  Dr.  Emil  Mayer,  of  New 
York ;  first  vice-president,  Dr.  John  R.  Newcomb, 
of  Indianapolis ;  second  vice-president,  Dr.  Robert 
Ridpath,  of  Philadelphia ;  third  vice-president,  Dr.. 
W.  C.  Finnoff,  of  Denver ;  treasurer.  Dr.  Secord 
H.  Lodge,  of  Cleveland ;  secretary,  Dr.  Luther  C. 
Peter,  of  Philadelphia :  editor  of  Transactions, 
Dr.  Clarence  Loeb,  of  Chicago.  Next  year's  meet- 
ing will  be  held  in  Philadelphia. 

Philadelphia  Medical  Club  Nominations. — At 
a  recent  meeting  of  the  ^Medical  Club  of  Phila- 
delphia the  following  officers  were  nominated  for 
the  coming  year :  President,  Dr.  Barton  Cooke 
Hirst ;  first  vice-president.  Dr.  Hobart  A.  Hare ; 
second  vice-president.  Dr.  Alexander  MacAlister ; 
secretary,  Dr.  WilHam  S.  Wray;  treasurer.  Dr.. 
George  A.  Knowles  and  Dr.  Lewis  H.  Adler,  Jr. ; 
governor.  Dr.  G.  Orm  Ring  and  Dr.  Walter  L. 
Pyle;  additional  directors,  Dr.  John  A.  Sherger^ 
Dr.  B.  Frank  Wentz,  Dr.  Wilmer  Krusen,  Dr. 
Howard  A.  Sutton,  Dr.  S.  ^NlacCuen  Smith,  Dr. 
Thomas  R.  Neilson. 


■Octrb  r  30,  1920.] 


NEWS  ITEMS. 


687 


Dentists  Cooperate  in  Campaign  Against  Ve- 
nereal Diseases. — Of  the  forty  thousand  licensed 
and  registered  dentists  in  the  United  States,  15,252 
have  signified  their  intention  of  cooperating  fully 
with  the  United  States  Public  Heath  Service  in  its 
national  campaign  for  venereal  disease  control, 
agreeing  to  report  all  venereal  disease  cases  which 
come  under  their  observation  in  their  practice  in 
accordance  with  the  laws  and  board  of  health  regu- 
lations, and  to  advise  treatment  in  all  such  venereal 
disease  cases  which  come  under  their  observation, 
referring  them  to  a  clinic  or  to  a  physician  known 
to  be  competent  in  the  treatment  of  such  cases. 

The  Alvarenga  Prize. — The  College  of  Physi- 
cians of  Philadelphia  announces  that  the  next  award 
of  the  Alvarenga  Prize,  amounting  to  about  $250, 
will  be  made  on  July  14,  1921,  provided  that  an 
essay  deemed  by  the  Committee  of  Award  to  be 
worthy  of  the  prize  shall  have  been  ofifered.  Essays 
intended  for  competition  may  be  upon  any  subject 
in  medicine,  but  cannot  have  been  published.  They 
must  be  typewritten,  and  if  written  in  a  language 
other  than  English  should  be  accompanied  by  an 
English  translation,  and  must  be  received  by  the 
secretary  of  the  college,  Dr.  John  H.  Girven,  19 
South  Twenty-Second  Street,  Philadelphia,  on  or 
before  May  1,  1921.  No  prize  was  awarded  for  1920. 

Meetings  of  Local  Medical  Societies. — The  fol- 
lowing medical  societies  will  meet  in  New  York 
during  the  coming  week : 

MOXD.A.V,  Noveftiber  ist. — Medical  Society  of  the  New 
York  Polyclinic  Medical  School  and  Hospital. 

Tuesday,  November  ^d. — New  York  Academy  of  Medi- 
cine (Section  in  Dermatology  and  Syphilis)  ;  Medical  So- 
ciety of  Harlem  Hospital :  New  York  Neurological  Society ; 
Society  of  Alumni  of  Lebanon  Hospital. 

Wednesday,  November  ^d. — New  York  Academy  of 
Medicine  (Section  in  Historical  Medicine)  ;  Bronx  Medical 
Association  ;  Harlem  Medical  .Association  ;  Psychiatric  So- 
ciety of  New  York ;  Society  of  Alumni  of  Bellevue  Hos- 
pital :  Brooklyn  Society  for  Neurology. 

Thursday,  November  4th. — New  York  Academy  of  Medi- 
cine (stated  meeting)  ;  Brooklyn  Surgical  Society. 

Friday,  November  5th. — New  York  Academy  of  Medi- 
cine (Section  in  Surgery)  ;  New  York  Microscopical  So- 
ciety ;  Practitioners'  Society  of  New  York ;  Alumni  Associa- 
tion of  Roosevelt  Hospital ;  Gynecological  Society  of 
Brooklyn  (annual). 

Saturday,  November  6th. — Benjamin  Rush  Medical  So- 
ciety. 

Gifts  to  Columbia  University. — ^Among  the 
twenty-one  gifts  aggregating  $27,9(32.80,  in  addition 
to  a  valuable  collection  of  books  forming  the  nucleus 
of  a  memorial  library,  announced  by  Columbia 
University,  are  the  following: 

From  the  Borden  Company,  of  New  York,  $10,000  to  be 
added  to  their  previous  gift  for  research  in  food  chemistry 
and  nutrition,  carried  on  under  the  direction  of  Professor 
Henry  C.  Sherman. 

From  William  S.  Grosvenor,  of  Providence,  R.  I.,  $2,500 
to  establish  the  Grosvenor  Memorial  Fund  in  memory  of 
Robert  Grosvenor,  a  former  member  of  the  1918  class  in 
medicine.  The  income  of  the  fund  is  to  be  used  to  purchase 
books  for  the  library  of  the  medical  school. 

From  Mrs.  Elizabeth  S.  Coolidge  $2,400  for  the  mainte- 
nance of  the  Coolidge  Research  Fellowships  in  Medicine. 

From  the  classmates  of  the  late  Alexander  Weinstein,  a 
member  of  the  class  of  1920,  $800  to  establish  the  Alexander 
Weinstein  Memorial  Fund,  the  interest  of  which  is  to  be 
used  for  the  purchase  of  books  for  the  library  of  the  medi- 
cal school. 

From  an  anonymous  donor  $237.80  to  be  applied  toward 
ti\e  completion  of  the  equipment  of  the  surgical  laboratory. 


War  Department  Sells  Hospital  Supplies. — 

The  Surplus  Property  Branch  of  the  Office  of  the 
Quartermaster  General  of  the  Army  has  sold  to 
the  Thomas  &  Kelly  Co.,  of  Boston,  the  remaining 
surplus  of  bandages  and  absorbent  cotton,  pur- 
chased for  the  use  of  the  Army  during  the  war, 
the  sale  netting  the  Government  more  than  $1,000,- 
000.  The  bandages  alone  represent  a  quantity  suf- 
ficient, to  supply  the  hospitals  aod  surgeons  of  the 
United  States  with  all  their  needs  for  at  least 
eighteen  months.  Included  in  the  sale  were  a  mil- 
lion dozen  roller  and  between  two  and  two  and  one 
half  million  compressed  bandages,  and  approxi- 
mately two  and  one  quarter  million  one  ounce 
packages  of  absorbent  cotton. 

Psychiatric  Institute  to  Be  Expanded  Into  a 
Psychopathic  Hospital. — ^A  bill  has  been  signed 
by  Governor  Smith  which  provides  for  the  transfer 
of  the  Psychiatric  Institute  from  Ward's  Island  to 
a  site  to  be  obtained  in  New  York,  where  it  will  be 
expanded  into  a  psychopathic  hospital  and  out- 
patient department  for  the  reception,  study  and 
treatment  of  patients.  The  bill  authorized  the  ap- 
propriation of  $700,000  toward  the  construction  of 
such  an  institution  when  a  site  was  available.  A 
hospital  of  this  kind,  by  preventing  and  curing  cases 
of  mental  disease  in  incipient  and  early  stages, 
would  save  the  State  the  expense  of  the  continuous 
care  of  chronic  cases  for  long  terins  of  years  in  the 
State  hospitals. 

 ^  • 

Died. 

Bullock. — In  Upland,  Pa.,  on  Monday,  October  18th, 
Dr.  Edwin  G.  Bullock,  aged  thirty-seven  years. 

Cronemiller. — In  Los  Angeles,  Cal.,  on  Monday,  October 
11th,  Dr.  Mary  M.  Cronemiller,  of  Sacramento,  aged  fifty- 
nine  years. 

Ealer. — In  Philadelphia,  Pa.,  on  Sunday,  October  17th, 
Dr.  Percy  H.  Ealer,  aged  sixty-two  years. 

Ebersole.— In  Cleveland,  Ohio,  on  Tuesday,  October  5th, 
Dr.  W.  G.  Ebersole,  aged  fifty-six  years. 

Fleischmer. — In  Manila,  Philippine  Islands,  on  Monday, 
September  20th,  Dr.  H.  J.  Fleischmer,  of  Chicago,  aged 
fifty-five  years. 

I\-ES. — In  Pecatonica,  111.,  on  Sunday,  October  10th,  Dr. 
Charles  G.  Ives. 

Lyons. — In  New  Rochelle,  N.  Y.,  on  Tuesday,  October 
12th,  Dr.  George  A.  Lyons. 

MacDougall. — In  Haverhill,  Mass.,  on  Saturday,  October 
16th,  Dr.  Duncan  MacDougall,  aged  fifty-four  years. 

Mackenzie. — In  Trenton,  N.  J.,  on  Tuesday,  October 
19th,  Dr.  Thomas  H.  MacKenzie,  aged  seventy -three  years. 

Moody. — In  Sunbury,  Pa.,  on  Saturday,  October  16th, 
Dr.  William  M.  Moody,  aged  eighty-six  years. 

O'Reilly. — In  Middletown,  N.  Y.,  on  Wednesday,  Octo- 
ber 13th,  Dr.  James  A.  O'Reilly,  of  Brooklyn,  aged  thirty- 
three  years. 

Sears. — In  Beverly,  Mass.,  on  Wednesday,  October  20th, 
Dr.  Harry  E.  Sears,  aged  fifty  years. 

Simpson. — In  Banning,  Cal.,  on  Wednesday,  October 
13th,  Dr.  Jessie  Harriet  Simpson,  of  Patton,  Cal.,  aged 
forty-seven  years. 

Spaulding. — In  Clifton  Springs,  N.  Y.,  on  Thursday,  Oc- 
tober 14th,  Dr.  Francis  Wood  Spaulding,  agen  seventy-six 
years. 

Sullivan. — At  Providence,  R.  L,  on  Friday,  October  8th, 
Dr.  James  E.  Sullivan. 


Book  Reviews 


PLASTIC  SURGERY 

Plastic  Siirycry  of  the  Face.  Based  on  Selected  Cases  of 
War  Injuries  of  the  Face  Including  Burns.  With  Origi- 
nal Illustrations.  By  H.  D.  Gillies,  C.  B.  E.,  F.  R.  C.  S., 
Major  R.  A.  M.  C,  Surgical  Specialist  to  the  Queen's  Hos- 
pital, Sidcup  Surgeon  in  Charge  of  the  Department  for 
Plastic  Surgery,  and  Late  Surgeon  in  Charge  of  the  Ear, 
Nose  and  Throat  Department,  Prince  of  Wales  Hospital, 
Tottenham,  etc.  With  a  Chapter  on  the  Prosthetic  Prob- 
lems of  Plastic  Surgery,  by  Captain  W.  Kelsey  Fry, 
M.  C,  R.  A.  M.  C,  Senior  Dental  Surgeon,  Queen's  Hos- 
pital, etc.  Remarks  on  Anesthesia,  by  Captain  R.  Wade, 
R.  A.  M.  C,  Late  Senior  Anesthetist,  Queen's  Hospital, 
etc.  London:  Henry  Frowde  (Oxford  University  Press), 
Hodder  &  Stdughton,  1920.    Pp.  xiii-408. 

Much  credit  is  due  Gillies  for  the  splendid  work 
he  has  done  in  plastic  surgery.  His  are  the  greatest 
of  all  contributions  to  the  advance  of  this  interest- 
ing reparative  work  which,  we  are  told,  dates  back 
to  antiquity.  In  America  his  work  was  first  made 
known  to  the  medical  profession  through  the  columns 
of  the  New  York  Medic.m.  Journal.  Since  that 
time  many  surgeons  recognizing  the  superiority  of 
this  master  workman  have  profited  by  his  methods 
and  given  them  wide  application  with  excellent  re- 
sults. Now  we  have  his  work  presented  in  an 
admirable  form  in  his  new  book.  Arbuthnot  Lane, 
of  intestinal  stasis  fame,  calls  our  attention  to  the 
many  fields  of  usefulness  to  which  Gillies's  technic 
may  be  applied.  He  lists  ugly  scars  from  burns 
and  accidents,  deformities  of  the  nose  and  lips, 
harelip  and  cleft  palate,  abnormal  protrusion  or  ill 
development  of  the  mandible,  moles,  port  wine 
stains.  Surgeons  know  how  the  lives  of  many 
useful  people  are  made  ugly  by  the  difYerences  they 
present  on  account  of  various  deformities  and  ab- 
normalities ;  how  they  come  with  their  appeals, 
vainly  striving  for  some  help  to  eradicate  the  blight 
which  has  caused  them  endless  suffering  and  unhap- 
piness. 

Again,  burns  and  accidents  require  surgical 
intervention  of  a  plastic  nature  in  order  to  allow 
for  proper  functioning.  Cases  have  been  recorded 
where  patients  have  been  fed  for  years  throtigh  a 
tube  because  of  inability  to  move  their  jaws.  This 
immobility  was  caused  by  adhesions  from  old  scars 
due  to  burns  or  other  accidents.  Frequently,  too, 
we  are  called  upon  to  repair  a  deficiency  due  to  the 
removal  of  malignant  growths.  But  why  enumer- 
ate the  many  fields  of  usefulness  of  this  method? 
They  are  well  known  to  most  of  us.  Many  methods 
have  been  tried,  but  it  may  safely  be  said  that  none 
compare  with  the  tubed  pedicle  method  of  Gillies. 
The  reviewer  recalls  the  crude  attempts  at  facial 
repair  which  were  attempted  in  the  French  army 
hospitals  in  the  early  months  of  the  war.  The  best 
of  these  were  poor,  very  poor,  compared  with  the 
results  obtained  by  Gillies.  Parts  of  the  face  were 
used  to  repair  the  face  and  the  process  was  fre- 
quently repeated  over  the  same  area  in  order  to 
secure  a  satisfactory  result.  At  times  the  results 
were  fairly  good,  but  the  procedure  was  painfully 
slow  and  at  best  far  short  of  what  might  be  called 
good.  The  method  of  Gillies  is  so  simple  and  so 
satisfactory  by  comparison  that  it  seems  strange  that 
it  was  not  thought  of  earlier. 


An  interesting  historical  outline  is  offered  in 
which  we  are  told  of  the  very  early  operations  in 
India  for  the  repair  of  the  punitive  mutilation  of 
the  nose.  The  forehead  flap  is  the  operation  which 
has  survived  until  the  present  day.  Cheek  flaps 
were  also  used  and  these  survived  until  fairly  re- 
cently, but  they  were  finally  relegated  to  limbo. 
Keegan  is  praised  for  his  realization  of  the  necessity 
of  a  lining  membrane  for  the  repair  of  mucous 
lined  cavities.  The  method  of  Tagliacozzi  of  the 
two  stage  operation  from  the  patient's  arm  to  nose 
goes  back  to  1415.  But  the  tubed  pedicle,  the  best 
method  known  to  surgery,  was  devised  by  Gillies 
and  he  should  be  given  due  credit  for  this  excellent 
idea. 

He  tells  us  of  the  preparatory  steps  in  the  con- 
servation of  the  remaining  tissue  and  various  use- 
ful little  hints  for  the  hastening  of  recovery ;  warn- 
ings of  what  should  not  be  done  and  the  harm  that 
may  result  from  the  neglect  of  his  injunctions;  of 
the  dangers  of  secondary  hemorrhage  and  how  it 
can  be  avoided. 

The  dentist  is  called  in  to  attend  to  the  toilet  of 
the  buccal  cavity  and  to  rearrange  the  bony  frag- 
ments. Stispensory  wiring  of  fragments  is  disap- 
proved of  on  account  of  having  a  foreign  body  in 
contact  with  inflammatory  bone  lesions.  Bone  graft- 
ing, which  has  been  perfected  by  our  own  Dr. 
Albee,  is  highly  recommended.  Then  come  the 
late  repair,  the  careful  planning  of  the  operation ; 
the  consideration  of  the  many  difficulties  which  ex- 
perience has  shown  we  may  encoimter.  A  careful 
selection  of  the  lining  membrane  is  a  inost  important 
part  of  the  procedure.  A  modification  of  the  Amer- 
ican Esser  epithelial  inlay,  as  revised  by  Waldron, 
of  Canada,  and  Pickerill,  of  New  Zealand,  was 
used  with  great  success.  Then  we  are  shown  how 
every  stage  of  the  operation  is  imjwrtant,  the  anes- 
thesia, the  prevention  of  edema,  the  preservation 
of  the  viability  of  the  flaps,  the  cartilage  that  must 
be  replaced,  and  the  care  of  the  bone  grafts.  Every 
detail  is  cared  for  and  in  every  instance  simplicity 
and  common  sense  prevail.  The  various  regions  are 
taken  up,  every  conceivable  form  of  repair  being 
discussed,  and  every  problem  that  may  be  encoun- 
tered is  carefully  considered.  In  order  to  remove 
the  w^ork  from  the  abstract  and  bring  it  into  the 
realm  of  complete  reality,  many  actual  cases  are 
given.  The  photographs  and  diagrams  are  all  that 
can  be  wished  for.  Finally  several  civil  cases  are 
shown  in  order  that  the  usefulness  of  the  work 
may  be  appreciated  in  this  field.  Lane  did  not 
mention  in  his  list,  the  prenatal  diseases  where  the 
technic  could  be  applied.  These  include,  ectopia 
vesicie,  hypcspadias,  meningocele,  imperforate  anus, 
and  also  the  various  fistulas  so  commonly  en- 
coimtered. 

Many  surgeons  the  world  over  will  appreciate 
this  monumental  work,  but  the  greatest  praise  will 
come  from  those  unhappy  creatures  who,  as  a  result 
of  this  new  procedure,  can  again  take  their  place 
among  the  tmmarked.  These  unfortunate  beings 
will  forever  be  grateful  to  their  benefactor,  H.  D. 
Gillies  of  London. 


Octcb  r  30,  1920.] 


BOOK  REVIEWS. 


689 


:\I1XD  ENERGY. 

Mind  Eiicryy.  Lectures  and  Essays.  By  Henri  Beroson, 
Member  of  the  French  Academy.  Professor  in  the  Col- 
lege de  France.  Translated  by  H.  Wildon  Carr,  Hon. 
D.  Litt.,  Professor  in  the  University  of  London.  New 
York:  Henry  Holt  &  Co.,  1920.  Pp.  x-262. 
"I  have  sometimes  asked  myself  what  would 
have  happened  if  modern  science  .  .  .  instead 
of  bringing  all  its  forces  to  converge  on  the  study 
of  matter,  had  begun  by  the  consideration  of  mind 
— if  Kepler,  Galileo  and  Xewton,  for  example,  had 
been  psychologists.  .  .  .  The  most  general  laws 
of  mental  activity  once  discovered  '.  .  .  science 
would  have  passed  from  pure  mind  to  life."  Berg- 
son  confesses  to  losing  himself  occasionally  for  a 
moment  in  such  a  dream  to  return  nevertheless  to 
the  practical  admission  that  it  could  not  be  other- 
wise than  it  is.  Even  if  as  much  talent  and  genius 
had  been  expended  upon  mental  phenomena  as 
have  been  "consecrated  to  sciences  of  matter."  Yet 
some  things  would  have  been  found  wanting. 
These  are  the  very  intellectual  qualities  which  have 
been  developed  through  occupation  with  physical 
matters  and  which  are  quite  indispensable  as  meth- 
ods of  investigation  in  the  mental  realm.  Bergson 
is  too  clear  a  thinker  to  proceed,  even  where  the 
force  of  his  genius  directs  him,  without  the  preci- 
sion, exactness,  certitude,  to  adopt  his  words,  which 
have  become  the  habit  of  material  science.  Berg- 
son is  a  guide  whose  vision  may  seem  to  alight  upon 
mountain  peaks  which  appear  unsubstantially  above 
the  clouds,  but  the  confidence  of  the  most  cautious 
is  assured  by  his  truly  scientific  attitude.  Stimu- 
lated by  his  daring  penetration  into  certain  discover- 
able facts  of  mind,  we  can  with  him  "adventure 
without  fear  into  the  scarcely  explored  domain  of 
psychical  realities." 

His  book  Mind  Energy  is  a  .series  of  lectures 
and  articles  given  to  the  world  from  time  to  time. 
They  represent  the  exercise  of  his  thought  upon 
certain  often  discussed  questions  regarding  the 
mind,  with  that  deeper  entering  into  such  questions 
which  makes  Bergson  a  stimulating  leader  in  the 
.science  of  mind  study.  He  considers  first  the  defi- 
nition, rather  the  nature  of  mind  in  its  distinguish- 
ing manifestation,  consciousness.  This  word  does 
not  mean  here  the  mere  point  of  ordinarily  recog- 
nized awareness.  It  stands  for  the  entire  effort  of 
the  mind  toward  the  future  through  the  present, 
with  the  entire  storing  of  the  past  in  memory.  He 
describes  it  as  thus  conserving  all  necessary  mate- 
rial, and  moving  on  creatively  to  the  new  in  its 
relation  to  life  and  as  opposed  to  matter.  With  the 
latter,  however,  it  has  its  reaction.  The  discussion 
of  Soul  and  Body,  in  another  chapter,  that  of  Brain 
and  Thought,  are  extensions  of  such  consideration. 
The  study  of  the  experiencing  of  phantasms  and  the 
relation  of  such  a  phenomenon  to  psychic  matter  yet 
unestabli.shed  naturally  follows  the  line  of  thought 
which  the  first  essay  introduces.  So  also  does  the 
examination  of  the  phenomenon  of  false  recogni- 
tion as  contrasted  with  the  ordinary  process  of 
memory,  the  sense  of  having  certainly  before  ex- 
perienced the  matter  in  question.  The  discussion 
of  the  phenomenon  of  memory  brings  forward 
those  illuminating  views  upon  memory  and  its  serv- 
ice in  the  mental  life  in  which  Bergson  has  already 


shown  himself  an  authoritative  leader.  His  care- 
fully expressed  reasoning  gives  therefore  peculiar 
interest  to  the  chapter  on  Intellectual  Efifort,  where 
he  gives  a  detailed  exposition  of  the  thought  pro- 
cess and  the  sense  of  effort  accompanying  it.  For 
in  this  he  shows  the  method  by  which  thought  pro- 
ceeds not  only  by  darting  forward  under  the  in- 
spiration of  memory  images,  but  also  by  working 
backward  among  these  images  for  substantiation 
and  adjitstment  in  the  mental  life  already  there. 

The  chapter  on  Dreams  is  not  a  recent  enough 
one  to  add  mitch  that  is  new.  It  represents  an  en- 
trance into  the  conception  of  dreams  which  is  grow- 
ing ill  acceptance,  and  forms  part  of  the  frame- 
work on  which  Freud's  theory  rests.  A  reference 
to  dreams  in  the  chapter  on  False  Recognition  re- 
veals even  better  than  the  special  chapter  Bergson's 
vital  appreciation  of  dream  phenomenon. 

Bergson  is  a  writer  of  rare  power.  His  force- 
fulness  is  expressed  in  pregnant  words  which  an- 
swer to  his  intuitive  grasp  of  facts.  At  the  same 
time  he  subinits  these  visions  of  his  to  careful 
logical  as  well  as  observational  testing.  There  is 
therefore  no  page  of  this  small  book  that  is  not 
stimulating  to  thought.  One  need  not  follow  him 
implicitly,  not  even  to  await  the  verification  of  some 
things  which  he  claims  as  "probabilities,"  but  one 
cannot  fail  to  be  roused  at  least  to  active  question- 
ing and  quickened  toward  the  mental  processes  of 
Hfe. 

HIGH  SCHOOL  BIOLOGY. 

Biology  for  High  Schools.  By  W.  M.  Smallwood,  Ida  L. 
Reveley,  and  Guv  A.  Bailey.  Illustrated.  New  York: 
Allyn  &  Bacon,  1920.    Pp.  xxi-590. 

Men  under  thirty  can  hardly  realize  how  dull  and 
dusty  were  the  scientific  paths  made  in  the  last  cen- 
tury. True,  it  was  a  century  of  magnificent  works, 
high  priced,  finely  illustrated,  but  the  average  stu- 
dent could  not  get  these,  and  the  writings  were 
above  the  comprehension  of  beginners.  There  were 
a  few  dull  volumes  in  schools  sparsely  illustrated, 
but  none  on  biology,  so  it  can  be  imagined  that  the 
book  before  us  would  have  been  eagerly  welcomed 
not  only  by  teachers  but  by  pupils.  One  great 
merit  is  that  nothing  is  left  unexplained  on  the 
asstimption  that  everyone  knows  it,  and  there  are 
excellent  references  for  those  who  care  to  know 
more,  as  well  as  Practical  Applications,  Laboratory 
Work,  Summaries,  Questions  and  Home  ^^'ork. 
The  first  and  second  sections  are  on  animal  and 
plant  biology,  followed  by  one  on  human  biology 
and  a  stimmary  and  review  of  general  biology. 
Four  hundred  and  thirty-nine  illustrations  enliven 
the  way  and  the  derivation  of  names  makes  the 
pupil  feel  more  at  home  when  using  long  words 
he  comprehends.  Nine  portraits  of  men  who  have 
helped  to  stnooth  the  biological  path  and  coax  the 
world  to  consider  its  marvels  are  inserted.  It  will 
makes  youth  more  jtist,  in  judgmetit,  for  many  in- 
sects, animals  and  plants  hitherto  deemed  evil  are 
shown  to  be  useful  and  harmless.  Naughty  Jane, 
who  used  to  kill  flies  in  our  reading  primers,  is  no 
longer  called  cruel :  the  fear  of  every  snake  is 
proved  to  be  senseless.  The  chapter  on  forestry 
and  preservation  of  woods  is  specially  useful  to- 
day.   Community  life  as  seen  in  nature  and  among 


690 


BOOK  REVIEWS. 


[New  York 
Medical  Journal. 


men,  environment,  heredity,  and  variation  are  also 
considered  and  put  into  simple  language.  It  is  only 
a  guess,  but  the  author  may  be  imagined  to  have 
wanted  to  know  things  in  his  boyhood  and  to  have 
had  no  answers  from  his  elders;  hence  his  anxious 
effort  to  make  all  things  clear,  in  which  he  certainly 
has  succeeded. 

AN  ASSORTMENT  OF  HEALTH. 

Health  and  Social  Progress.  By  Rudolph  M.  Binder, 
Ph.  D,,  Professor  of  Sociology,  New  York  University. 
New  York:  Prentice-Hall,  Inc.,  1920.    Pp.  i-295. 

Take  the  obverse  of  the  title,  111  Health  as  an 
Obstacle  to  Social  Progress,  and  you  would  come 
nearer  the  correct  one  for  Doctor  Binder's  book. 
It  is  easy  to  imagine  that  in  his  researches  the 
-question  of  disease  was  a  more  fertile  field  than  that 
of  health.  But  the  author  is  an  optimist.  He  will 
drench  you  with  horrible  statistics,  then  cheer  you 
11])  with  I'asteur  and  Lister,  Reed  and  (iorgas.  His 
health  researches  leave  no  corner  of  the  earth  un- 
touched, no  peoples,  ancient  or  modern,  uncriticized. 
Ill  Health  and  the  Classical  World;  Health  and 
the  Tropics;  Health  and  World  Progress,  these 
cha])ters  give  some  idea  of  the  ground  he  has  trod- 
den. PTis  book  has  a  wonderful  amount  of  informa- 
tion, the  result,  evidently,  of  much  .study,  yet  it  is 
suggestive  of  a  big  exhibition,  not  quite  ready. 
There  is  an  accumulation  of  interesting  facts  which 
leisure,  or  lack  of  power,  has  failed  to  arrange  in 
coniprehensive  order,  and  the  author  resembles  an 
eager  host,  newly  returned  from  a  voyage,  who 
urges  fresh  treasures  upon  his  guest  before  he  has 
given  due  attention  to  those  he  is  admiring.  'I.Te 
portion  on  health  and  other  conditions  in  cities 
merits  great  consideration,  and  he  winds  up  op- 
timistically with  reference  to  the  splendid  work  done 
by  bureaus  of  research,  amalgamation  of  effort,  and 
private  benevolence  to  prepare  a  fit  highway  for  the 
goddess  of  health. 

AN  UNACADEMIC  CRITIC. 

Reputations.    Essays  in  Criticism.    By  Douglas  Goldrinc;. 

New  York  :  Thomas  Seltzer,  1920.    Pp.  vn-232. 

Reputations  are  more  easily  made  than  demolished 
—unfortunately.  The  aroma  of  success  lingers; 
"lo.st  leaders"  'are  not  really  lost  as  soon  as  they 
should  be.  For  this  reason  Douglas  Goldring's 
book  should  be  welccjmed  by  those  who  wish  to 
do  away  with  false  gods.  Mr.  Goldring  has  set 
his  face  against  all  forms  of  tawdriness  in  art. — 
not  only  commercialism  but  the  more  insidious  sins 
-of  respectability  and  middleagedness.  H.  G.  Wells 
suffers  as  well  as  Compton  Mackenzie.  It  is  a 
glorious  slaughter— and  there  is  not  an  epigram  in 

it!  .  .  ., 

Rcj->utations  opens  in  a  noncommittal  vcm  with 
an  ap])reciation  of  James  Elroy  Flecker.  Then  the 
author  proceeds  to  evaluate  three  Georgian  novelists 
—Compton  Mackenzie,  Hugh  Walpole,  and  Gilbert 
Cannan,  and  to  appraise  Gilbert  Cannan  as  a  writer 
who  has  not  yet  found  himself  but  whose  work 
shows  the  most  promise  of  the  three.  He  praises 
D.  H.  Lawrence,  though  admitting  that  "frequently 
his  poems  are  battlefields  on  which  he  has  been 
defeated."  Arnold  Bennet  he  terms  "the  Gordon 
,Scl fridge  of  English  letters"  and  "one  of  the  most 


brilliant  second  rate  minds  which  England  has  pro- 
duced in  the  present  century."  Wells  is  in  danger 
of  becoming  a  "lost  leader" ;  Wyndham  Lewis  is 
irrelevant. 

But  Mr.  Goldring  does  much  more  than  attack 
reputations  in  these  papers.  He  voices  the  ideals 
of  that  keen,  ruthless  youth  which  came  out  of  the 
war  determined  that  the  agencies  which  had 
wreaked  such  tragic  waste  should  not  have  power  to 
do  the  same  thing  again.  He  is  for  courage  and  a 
clean  sweep  of  that  which  should  be  swept  away. 
He  is  quiet  about  it,  but  firm.  And  yet  this  book 
is  in  no  sense  propaganda.  It  is  the  work  of  a  man 
who  does  not  strive  to  be  literary,  who  is  close  to 
life  as  well  as  to  books,  an  unacademic  critic.  His 
philosophy  can  perhaps  best  be  summed  up  in  the 
goal  he  sets  up  for  the  new  criticism — and  which  he 
himself  so  nearly  approaches: 

"And  if  we  are  to  have  a  renaissance  of  poetry 
in  England  we  must  have  a  new  criticism  to  meet 
it — a  savage,  rasping  criticism,  speaking  with  the 
bitter  notes  of  an  idealism  which  longs  passionately 
for  the  best,  and  will  no  longer  tolerate  shams. 
Criticism  must  once  again  become  the  task  of  those 
who  have  an  uncompromising  standard  of  values, 
of  those  whose  love  for  what  is  real  and  sincere 
will  not  permit  them  to  deal  gently  with  what  is 
false,  pretentious,  empty  and  ephemeral." 

 <t>  

New  Publications  Received. 


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


MAC  OF  PLACID.  By  T.  MoRRis  LoNGSTRETH.  New  York: 
The  Century  Company,  1920.    Pp.  xi-339. 

DIE  IMPOTENZ  DES   MANNES.     Von  Dr.  WlLHELM  SxEKEL. 

Berlin-Wicn :  Urban  &  Schwarzenberg,  1920. 

DiTTE :  GIRL  ALIVE.  By  Martin  Anderson  Nexo.  Trans- 
lated from  the  Danish.  New  York :  Henry  Holt  &  Co., 
1920.    Pp.  iii-333. 

A  BIOGRAPHY  OE  GEORGE  MILLER  STERNBERG.     By  His  Wife, 

Martha  L.  Sternberg.  Illustrated.  Chicago :  American 
Medical  Association,  1920.    Pp.  ix-331. 

thirty-first    annual    report    of    the    state  HOSPITAL 

COMMISSION,  state  OF  NEW  YORK.  By  Commissioners 
Charles  W.  Pilrgim,  M.  D.,  Andrew  D.  Morgan,  and 
Frederick  A.  Higgins.   Albany,  1920.    Pp.  vi-442. 

life,  a  Study  of  the  Means  of  Restoring  Vital  Energy 
and  Prplonging  Life.  By  Dr.  Serge  Voronoff,  Director 
of  Experimental  Surgery  at  the  Laboratory  of  Physiology 
of  the  College  de  France.  Translated  by  Evelyn  Bostwick 
Voronoff.  New  York :  E.  P.  Dutton  &  Co.,  1920.  Pp.  xx- 
160.  I 

TEXTBOOK  ON  INDIGESTION.  By  Dr.  G.  Herschell.  Revised 
and  Rewritten  by  Adolphe  Abrahams,  O.  B.  E.,  M.  D. 
(Camb.),  M.  R.  C.  P.  (Lond.),  Assistant  Physician  to 
Westminster  Hospital,  to  the  Hampstead  and  North-West- 
ern  General  Hospital,  etc.  New  York :  Longmans,  Green  & 
Co. ;  London  :  Edward  Arnold,  1920.    Pp.  228. 

HANDBOOK  OF  PULMONARY  TUBERCULOSIS,  ITS  DIAGNOSIS, 
PROGNOSIS,    PREVENTION,    AND    TREATMENT.      By  JeFFERSON 

Demetrius  Gibson,  M.  D.,  Denver,  Col.,  Member  of  Denver 
City  and  County  Medical  Society;  Denver  State  Medical 
Association ;  American  Medical  Association,  etc.,  etc.  Den- 
ver •  The  Denver  Scientific  Publishing  Company,  1920. 
Pi).  130. 


Practical  Therapeutics  and  Preventive  Medicine 

A  Compendium  of  Treatment  and  Prophylaxis,  Original  and  Adapted 


Intravenous  Injection  of  Iodine  in  Oil. — Ra- 

thery  {Prcssc  mcdicale,  June  19,  1920),  after  ex- 
periments in  animals,  administered  intravenous  in- 
jections of  iodine  in  oil  in  human  subjects.  The 
amount  of  oil  thus  given  was  one  half  to  two  mils. 
Xo  discomfort  or  untoward  result  was  experienced 
by  the  patients.  After  such  treatment  iodine  was 
still  found  in  the  veins  twenty-one  days  after  the 
injection.  The  resulting  prolongation  of  the  thera- 
peutic action  accounted  for  the  clinical  effects 
obtained,  which  were  superior  to  those  secured 
upon  administering  potassium  iodide  by  the  mouth. 

Treatment  of  Syphilis  of  the  Stomach. — G.  Le- 

ven  {Prcssc  mcdicale,  June  19,  1920)  lays  stress 
on  the  frequency  of  incidence  of  gastric  syphilis, 
having  encotintered  many  cases  in  which  an  appar- 
ently justifiable  diagnosis  of  cancer  of  the  stomach 
proved  erroneous  upon  antisyphilitic  treatment. 
X  ray  examination  confirmed  the  cure  from  spe- 
cific treatment  in  these  cases.  In  syphilis  of  the 
stomach  mercury  should  be  given  not  only  in  in- 
jections, but  also  in  suppositories  and  by  inunction. 
Combined  administration  of  iodides  or  other  iodine 
compounds  is  likewise  indispensable. 

Treatment  of  Disorders  of  the  Spinal  System 
by  the  Intraspinal  Method. — F.  J.  Farnell  {Jour- 
nal of  Nervous  and  Mental  Disease,  May,  1920) 
says  that  the  extradural  space  containing  great 
amount  of  areolar  tissue,  which  is  well  vascularized 
and  contains  many  lymphatics,  was  utilized  for  treat- 
ment of  disorders  of  the  spinal  system  according  to 
this  method.  This  was  in  order  to  avoid  the  two 
usual  obstacles  in  the  way  of  those  seeking  treatment 
for  spinal  disease,  i.  e.,  puncture  headache  and  loss 
of  time  from  work  by  keeping  to  one's  bed.  Salvar- 
sanized  serum  was  injected  into  the  extradtiral  space, 
and  removal  of  spinal  fluid  thus  avoided.  Excellent 
results  were  obtained,  both  by  avoidance  of 
untoward  afterresults  and  for  the  improvement  of 
the  condition  for  which  the  patient  sought  treatment. 

Therapeutic  Pneumoconiosis  in  Pulmonary 
Tuberculosis. — E.  A.  Sevilla  (Plus-Ultra,  Madrid, 
April-I\Iay,  1920)  states  that  a  careful  investigation 
of  the  action  of  artificial  pneumoconiosis  in  the 
prevention  and  treatment  of  pulmonary  tubercu- 
losis justifies  the  following  conclusions:  1.  The 
inhalation  of  insoluble  powders  tends  to  promote 
healing  of  tuberculous  lesions  in  the  lung.  2.  This 
absorption  is  brought  about  by  an  increase  in  the 
defensive  cells.  3.  These  powders  when  combined 
with  an  antiseptic  constitute  a  measure  of  applying 
antisep.sis  to  the  lung  tissues.  4.  There  results  a 
sclerosis  of  varying  degree  in  the  lung,  which  acts 
as  a  protective  barrier.  5.  Insoluble  powders  are 
convenient  vehicles  for  the  application  to  the  lung 
lesions  of  antibacillary  products  of  varying  origin 
and  nature,  such  as  tuberculins,  antiseptic  sub- 
stances, and  desiccated  sera.  6.  This  measure  of 
therapy  is  capable  of  exerting  a  topical  action  in 
diverse  localized  pulmonary  alTections,  such  as 
gangrene  and  actinomycosis. 


Opium  in  Acute  Dilatation  of  the  Heart. — 

Diego.  T.  K.  Davison  {Sciiia)ia  Medica,  June  3, 
1920),  in  reporting  a  case  in  a  girl  of  twenty,  draws 
attention  to  the  fact  that  opium  has  no  depressant 
action  on  the  heart  and  that  it  acts  beneficially  in 
these  cases  of  acute  dilatation  by  quieting  the 
accelerator  nerves  which  by  their  overact  ion  are 
weakening  the  myocardium.  Rest  in  bed  is  essen- 
tial, of  course,  for  the  return  of  the  heart  cavities 
to  normal.  Digitalis  has  been  found  to  be  of  no 
avail  in  these  cases  either  during  the  acute  stage 
or  later  during  the  period  of  recuperation.  He 
prefers  to  build  up  the  heart  muscle  indirectly  with 
arsenic  and  the  hypophosphites. 

Treatment  of  Rheumatism  and  Gout  by  Hypo- 
dermic Injections  of  Salicylic  Acid. — ]\1.  J.  Se- 
journet  {Seniana  Medico,  June  3,  1920)  states  that 
for  the  ])ast  twelve  years  he  has  treated  articular 
rheiunatism  and  gout  by  the  subcutaneous  injection 
of  a  three  per  cent,  solution  of  salicylate  of  sodiiun. 
However,  he  found  that  this  procedure  was  quite 
painful  and  he  turned  to  the  solution  of  salicylic 
acid  in  a  strength  of  one  in  one  thousand,  which  he 
injected  under  the  skin  in  the  neighborhood  of  the 
affected  joints.  Even  here  he  found  it  necessary 
in  some  cases  to  precede  the  treatment  with  a  local 
anesthetic.  His  results  were  so  imiformly  good 
that  this  has  become  the  method  of  choice  with  him. 

Effect  upon  Blood  Pressure  of  Adrenalin  Injec- 
tions in  Dementia  Praecox. — Lawson  G.  Lowrey 
{Bosto)i  Medical  and  Surgical  Journal,  August  12, 
1920)  says  that  an  analysis  of  the  blood  pressure 
reactions  to  the  injection  of  adrenalin  in  seventy- 
eight  psychopathic  patients  makes  it  clear  that  such 
an  injection  does  not  have  the  value  in  differential 
diagnosis  which  has  been  claimed  for  it,  at  least 
in  early  cases,  since  some  cases  of  praecox  show  a 
rise  and  others  show  a  fall.  In  fifty-four  oiu  of 
sixty  cases  of  dementia  prjecox  there  was  an  in- 
crease in  blood  pressure,  forty  of  these  showing  a 
rise  of  more  than  five  mm.  Hg.  In  eighteen  cases 
of  other  types  taken  for  comparison  there  was  a 
depressor  reaction  in  four. 

Convulsive  Disturbances  Cured  by  Surgical 
Operations. — P.  Bazy  (Bulletin  dc  1' Academic  de 
mcdecinc,  June  1,  1920)  reports  a  case  in  which 
convulsive  seizures  simulating  epilepsy  disappeared 
after  an  operation  for  appendicitis  in  a  young  man 
eighteen  years  of  age.  The  manner  in  which  the 
convulsions  were  relieved  is  believed  to  have  been 
similar  to  that  in  which  convulsive  seizures  in  an- 
other young  man  wiio  had  been  taking  a  too  exclu- 
sive meat  diet  disappeared  when  a  more  vegetarian 
diet  was  prescribed.  Two  cases  of  convulsions 
accompanying  undescended  testicle  are  also  reported, 
in  which  relief  occurred  after  operation  for  the 
testicular  malposition.  Such  convulsions  are  not,  of 
course,  to  be  held  as  manifestations  of  actual  epi- 
lepsy, even  if  preceded  by  an  aura.  In  one  of  the 
cases  of  testicular  ectopy  referred  to,  pain  at  the 
site  of  the  misplaced  organ  was  a  distinct  feature. 


692 


PRACTICAL  THERAPEUTICS  AXD  PREVEXTIVE  MEDICIXE. 


[Xew  York 
Medical  Journal. 


Action  of  Gum  Acacia  on  the  Circulation. — 

W.  Bayliss    {Jounial   of  PJiannacology  and 

Experimental  Therapeutics,  ^Nlarch,  1920)  found,  in 
extensive  experimental  work,  that  a  sokition  of 
gum  acacia  of  six  to  seven  per  cent,  in  0.9  per  cent, 
sodium  chloride  solution  is  capable  of  effectively 
replacing  blood  lost,  unless  the  loss  exceeds  seventy- 
five  per  cent,  of  the  blood  volume.  Hence  its  use 
in  hemorrhage  due  to  various  causes.  Its  effect  is 
due  to  the  fact  that  the  blood  vessels  are  imper- 
meable to  colloids,  so  that  their  osmotic  pressure  is 
effective  in  retaining  within  the  circulation  the 
solution  injected.  It  has  no  chemical  or  drug  like 
action  and  can  be  used  m  large  quantities.  It  can 
also  be  used  with  benefit  when  the  blood  volume  is 
reduced  owing  to  removal  of  a  part  of  the  blood 
from  effective  circulation  by  stagnation  in  the  capil- 
laries, as  in  wound  shock  and  traumatic  toxemia. 
In  such  cases,  its  primary  object  is  to  maintain  a 
normal  circulation  until  the  toxic  products  are  elim- 
inated from  the  blood,  while  the  blood  out  of  circu- 
lation is  restored  to  use.  When  fluid  has  escaped 
from  the  blood  owing  to  the  capillaries  becoming 
permeable  to  colloids,  as  in  the  action  of  tissue 
toxins,  gum  saline  restores  the  normal  state  pro- 
vided the  morbid  condition  has  not  lasted  too  long ; 
if  it  has,  even  blood  transfusion  is  of  no  avail. 
When  the  blood  has  become  concentrated  by  loss 
of  fluid  from  the  body,  gum  saline  is  more  effective 
than  saline  solution  alone,  even  if  hypertonic,  since 
it  is  not  so  rapidly  lost  from  the  circulation.  Gum 
saline  has  also  proved  of  value  in  toxic  anemia, 
e.  g.,  in  blackwater  fever.  Neither  gum  nor  blood 
transfusion  has  any  permanent  effect  when  the 
blood  vessels  are  deprived  of  control  by  the  vaso- 
motor centres.  Gum  acacia  does  not  produce  ana- 
phylaxis nor  hemolysis.  It  does  not  agglutinate  the 
blood  corpuscles  in  man. 

The  Phenolsulphonephthalein  Test  and  the 
Nonprotein  Nitrogen  of  the  Blood  in  Chronic 
Nephritis. — Reginald  Fitz  {Boston  Medical  and 
Surgical  Journal,  Augitst  26,  1920)  presents  the 
following  conclusions :  The  phenolsulphonephtha- 
lein test  and  the  nonprotein  nitrogen  concentration 
of  the  blood  are  two  tests  for  kidney  function  which 
are  being  generally  used  for  the  diagnosis,  prog- 
nosis, and  treatment  of  chronic  nephritis.  These 
tests  are  not  of  obvious  value  in  the  diagnosis  of 
chronic  nephritis,  as  they  do  not  point  out  the 
presence  of  any  specific  pathological  type  of  lesion 
in  the  kidney  and  do  not  demonstrate  the  presence 
of  kidney  disease  in  the  absence  of  common  phys- 
ical signs.  From  a  pathological  point  of  view  there 
are  two  common  types  of  chronic  nephritis.  The 
essential  lesions  of  chronic  glomerulonephritis  are 
found  in  the  glomeruli  and  of  arteriosclerotic  ne- 
phritis in  the  smaller  renal  vessels.  Clinically  both 
types  of  chronic  nephritis  are  usually  associated 
with  cardiac  hypertrophy,  increased  blood  pressure 
and  eye  ground  changes,  and  with  a  urine  which 
contains  albumin,  blood,  casts,  or  leucocytes.  Both 
types  of  disease  are  chronic  and  slowly  progressive. 
Chronic  glomerulonephritis  is  a  disease  of  young 
people.  Arteriosclerotic  nephritis  may  appear  in 
young  people,  but  is  more  often  found  in  older 
people.    The  clinical  differentiation  of  these  types 


does  not  depend  upon  studies  in  renal  function,  but 
upon  careful  history  taking  and  routine  physical 
examination.  As  the  lesions  of  chronic  nephritis 
advance,  the  phenolsulphonephthalein  excretion 
diminishes  and  the  nonprotein  nitrogen  concentra- 
tion of  the  blood  increases.  At  present,  however, 
a  single  observation  with  these  tests  gives  less  prog- 
nostic information  than  does  careful  clinical  exam- 
ination. The  present  treatment  of  chronic  nephritis 
is  largely  empirical.  The  phenolsulphonephthalein 
test  and  the  nonprotein  nitrogen  concentration  of 
the  blood  offer  means  by  which  physiological  meth- 
ods may  be  applied  to  the  clinical  study  of  individual 
cases.  Unless  the  technic  of  these  tests  is  properly 
controlled,  the  interpretation  of  their  results  is  of 
little  value.  When  these  tests  are  properly  per- 
formed, they  can  be  used  to  assemble  facts  from  an 
individual  case  which  measure  the  progress  of  the 
disease  in  more  or  less  quantitative  fashion,  and 
which  make  possible  the  establishment  of  a  logical 
and  systematic  form  of  treatment. 

Treatment  of  Human  Anthrax  by  Normal  Bo- 
vine Serum. — J-  Penna.  J.  B.  Cuenca,  and  R. 
Kraus  {Monografias  del  Instituto  Bactcriologico  del 
Dept.  Nacional  de  Hygiene,  Buenos  Aires,  January, 
1920)  report  three  hundred  and  eighty  cases  of  an- 
thrax treated  with  normal  bovine  serum  with  a 
mortality  of  six  and  two  tenths  per  cent.  They 
found  that  the  normal  serum  was  quite  as  efficient 
as  the  serum  of  animals  immiuiized  against  anthrax 
by  inoculation ;  ftirthermore  they  verified  their 
former  findings  that  serum  sickness  does  not  result 
from  the  use  of  bovine  serum  heated  twice  to  56°  C. 
They  also  proved  that  the  mixture  of  bovine  serum 
with  horse  serum  prevented  the  serum  sickness 
which  so  often  occurs  when  the  latter  is  used  alone. 
They  used  in  severe  cases  intravenous  injections  of 
from  thirty  to  fifty  c.c.  of  the  normal  bovine 
serum  every  twenty  four  to  thirty  six  hours  up  to 
a  maximinn  of  two  hundred  and  fifty  c.c.  In  mild 
or  benign  cases  intramuscular  or  subcutaneous  in- 
jection sufficed. 

Autohemotherapy  in  Protracted  Infections. — 
G.  Mouriquand  (Lyon  uiediccl.  June  10,  1920) 
notes  that  some  acute  infections,  having  passed  into 
the  subfebrile  stage,  persist  for  weeks  or  months, 
as  though  vaccination  of  the  patient's  system  could 
not  be  brought  to  a  conclusion.  Such  dragging 
infections  seem  in  some  respects  comparable  to 
cases  of  pleurisy  with  delayed  absorption,  in  which 
Gilbert  has  recommended  autohemotherapy  to  initi- 
ate absorption  of  the  fluid.  A  case  of  peliosis 
rheumatica  is  reported  in  which  this  procedure  was 
applied,  apparently  with  complete  success.  The 
patient  was  a  wet  nurse  aged  thirty  years,  who  had 
been  suffering  for  six  weeks  from  joint  involve- 
ment and  erythema  multiforme,  which  resisted 
salicylates  and  aspirin,  and  recurred  every  two  or 
three  days.  The  temperature  had  hovered  about 
38°  C.  throughout  the  six  weeks.  Four  mils  of 
the  patient's  own  blood,  collected  in  citrate  solution, 
was  then  injected  into  the  subcutaneous  cellular 
tissues.  On  the  next  day  the  temperature  de- 
scended to  normal  and  joint  and  skin  manifestations 
completely  disappeared.  Three  weeks  later  they 
had  not  yet  returned. 


October  30,  1920.] 


PRACTICAL  THERAPEUTICS  AND  PREVENTIVE  MEDICINE. 


693 


General  Anesthesia. — Alberto  R.  Egana  (Se- 
mana  Mcdica,  April  29,  1920)  in  an  extensive  con- 
sideration of  the  subject  arrives  at  the  following 
conclusions:  1.  Minor  surgical  operations  or  those 
on  the  extremities  are  best  done  under  nitrous  oxide 
oxygen.  2.  For  all  operations  requiring  complete 
muscular  relaxation,  especially  in  abdominal  sur- 
gery, the  nitrous  oxide  ether  sequence  is  the  method 
of  choice.  3.  Chloroform  is  too  dangerous  for 
general  use,  but  it  may  more  safely  be  mixed  with 
ether.  4.  The  open  method  of  giving  ether  is  al- 
ways to  be  preferred.  5.  Intratracheal  insufflation 
is  of  value  for  thoracic  operations.  6.  Rectal  anes- 
thesia with  ether  in  five  per  cent,  oily  solution  is 
suited  to  operations  on  the  head  and  neck  com- 
bined with  local  anesthesia.  7.  Morphine  and  atro- 
pine injections  are  to  be  used  systematically. 

Local  Anesthetic  Action  of  Saligenin. — A.  D. 

Hirshf elder,  A.  Lundholm  and  H.  Norrgard  {Jour- 
nal of  Pliannacology  and  Experimental  Therapeu- 
tics, June,  1920)  report  experimental  and  clinical 
studies  on  saligenin — salicyl  alcohol — and  other 
phenyl  carbinols  as  local  anesthetics,  Saligenin 
proved  the  best  of  the  entire  series  of  phenolic  alco- 
hols investigated.  It  has  the  lowest  toxicity,  the 
least  tendency  to  form  wheals  or  edema,  and  the 
highest  selective  action  in  blocking  the  sensory 
nerves.  The  anesthesia  was  found  to  last  longer 
than  with  procaine  or  benzyl  alcohol.  In  tonsillec- 
tomy anesthesia  with  two  per  cent,  saligenin  solu- 
tion uniformly  proved  as  satisfactory  as  that  with 
0.2  per  cent,  procaine.  Two  sebaceous  cysts  were 
removed  by  Stratte  under  two  per  cent,  saligenin, 
ingrowing  toenail  operations  performed  under  it  by 
Stratte  and  Robitshek,  an  inguinal  hernia  dealt  with 
satisfactorily  by  Tinker  under  one  per  cent,  sali- 
genin, sensory  block  of  the  mandibular  nerve  for 
over  fifteen  minutes  obtained  in  two  cases  by  Schien 
w4th  a  four  per  cent,  solution,  and  a  like  solution 
used  with  success  for  cystoscopy  by  Wynne. 

Herpes  Iris. — A.  J.  Chalmers  and  Norman 
Macdonald  (Journal  of  Tropical  Medicine  and 
Hygiene,  June  15,  1920)  note  that  the  present  ten- 
dency is  to  look  upon  all  forms  of  erythema  multi- 
forme, including  herpes  iris,  as  being  due  to  ana- 
phylaxis caused  by  the  absorption  of  some  chemical 
product  from  the  intestine  or  other  passages,  or 
from  a  diseased  organ.  The  success  of  treatment  by 
intestinal  antiseptic  therapy  in  certain  cases  oflfers 
some  support  to  this  theory.  The  essential  features 
of  herpes  iris  are  the  central  vesicle  or  bulla,  the 
surrounding  ring  of  vesicles,  the  affection  of  the 
lips  and  mouth,  the  formation  of  several  rings  of 
vesicles  outside  the  first;  the  slight  constitutional 
disturbance,  and  the  tendencies  to  recur  if  not 
properly  treated.  It  is  differentiated  from  its  near- 
est ally,  erythema  iris,  by  the  fact  that  in  the  former 
there  is  a  vesicle  surrounded  by  an  erythematous 
blush.  The  first  aim  in  the  treatment  should  be  to 
find  the  site  from  which  some  form  of  chemical 
absorption  is  taking  place.  In  one  of  the  author's 
cases  the  intestinal  tract  appeared  to  be  the  only 
possible  source  of  trouble;  the  patient  was  placed  in 
bed  on  restricted  diet  and  given  purgatives  and 
salicin,  with  immediate  and  excellent  results. 


New  Method  of  Preventing  Anaphylactic 
Manifestations. — Kopaczewski  {Pressc  medicale, 
June  16,  1920)  has  shown  experimentally  that 
anaphylactic  manifestations  can  be  obviated  in  ani- 
mals by  injecting  chloroform  or  ether  in  amounts 
insufficient  to  produce  anesthesia.  The  widely  ac- 
cepted theory  of  the  important  role  played  by  the 
nervous  system  in  anaphylactic  shock  is  thought  to 
be  weakened  by  these  observations.  Since  general 
and  local  anesthetics  possess  to  a  marked  degree 
the  property  of  reducing  the  surface  tension  of  the 
blood,  and  since  this  property  is  also  known  to  be 
the  powerful  factor  preventing  precipitation  of  col- 
loids— and  therefore  precipitation  of  the  blood — 
the  author  is  led  to  consider  anaphylaxis  simply  as 
a  precipitation  of  the  colloids  of  the  blood.  The 
precipitate  formed  blocks  the  capillaries  and  thus 
causes  sudden  and  grave  asphyxia.  Widal's  labors 
have  shown  that  many  disorders  are  associated  with 
anaphylactic  manifestations,  e.  g.,  asthma,  hemo- 
globinuria, urticaria,  the  diathetic  and  dyscrasic 
affections,  eclampsia,  and  serum  disease. 

Diagnosis  and  Treatment  of  the  Hemorrhagic 
Diseases. — Ralph  C.  Larrabee  (Boston  Medical  and 
Surgical  Journal,  August  5,  19^0)  says,  concern- 
ing the  treatment  of  these  diseases,  that  local  appli- 
cations are  not  satisfactory.  The  older  astringents 
and  styptics,  such  as  ferric  chloride  and  alum,  do 
little  but  make  a  nasty  mess.  Epinephrine  solu- 
tions will  often  control  slight  bleeding  from  the 
mucous  membranes,  but  their  action  is  quite  fleet- 
ing. Cephaline,  coagulen,  coagulose  and  other  tis- 
sue extracts  are  of  somewhat  greater  value  locally, 
both  in  platelet  cases  and  in  hemophilia,  but  appear 
to  be  ineffectual  when  used  intramuscularly  or  in- 
travenously, while  the  possibility  of  producing  em- 
boli would  seem  to  make  the  intravenous  use  inad- 
visable. Calcium  salts  are  of  value  only  where  the 
hemorrhagic  tendency  is  the  result  of  calcium  de- 
ficiency. In  such  cases,  when  an  operation  is  con- 
templated, calcium  lactate  should  be  given  in  large 
doses  by  mouth  for  several  days,  and  operation 
should  be  deferred  until  coagulation  time  is  nor- 
mal. Fresh  animal  serum  contains  prothrombin, 
which  is  absent  in  hemophilia  and  hemorrhagic  dis- 
ease of  the  newborn,  but  this  disappears  in  a  few 
hours  and  old  serum  is  worse  than  useless.  Fresh, 
serum  does  not  contain  platelets,  so  can  be  of  no 
value  in  hemorrhagic  purpura  and  other  diseases 
where  the  bleeding  is  due  to  platelet  deficiency.  The 
value  of  diphtheria  antitoxin  rests  wholly  on  em- 
pirical grounds.  Theoretically  and  experimentally 
serum  is  of  little  value.  The  intravenous  adminis- 
tration of  whole  blood  comes  nearer  to  being  a 
universal  panacea  in  this  group  of  diseases  than 
any  other  procedure.  It  is  the  method  of  prefer- 
ence except  in  chronic  obstructive  jaundice,  where 
calcium  is  better.  Either  the  citrate  or  the  paraf- 
fined tube  method  may  be  vised.  He  prefers  the 
latter  because  the  citrate  method  causes  more  reac- 
tion and  introduces  fewer  platelets.  When  facili- 
ties for  intravenous  transfusion  are  lacking,  rapid 
intramuscular  injection  of  small  amounts  of  human 
blood  may  be  used,  preferably  in  tissues  near  the 
bleeding  area ;  especially  good  results  have  been 
reported  in  purpura  hemorrhagica. 


Proceedings  of  National  and  Local  Societies 


MEDICAL  SOCIETY  OF  THE  STATE  OF 
NEW  YORK 

One  Hundred  and  Fourteenth  Annual  Meeting, 
Held  in  New  York,  March  23  to  25,  1920 

The  President,  Dr.  Claude  C.  Lytle,  of  Geneva,  in  the 
Chair. 

{Continued  from  page  652) 
The  Role  of  the  Colon  Bacillus  in  Infections  of 
the  Kidney. — Dr.  Edwix  Beer,  of  New  York, 
in  a  further  discussion  of  the  subject,  asked  whether 
Dr.  Cabot  was  of  the  opinion  that  preliminary-  vac- 
cination prevented  complications  with  the  colon  ba- 
cillus following  prostatectomy  and  requested  liim 
to  discuss  the  question  of  ureteral  catheter  lavage 
of  the  pelvis  of  the  kidney.  Personally  he  had  seen 
absolutely  no  results  from  this  procedure.  In  cases 
of  acute  pyelitis  naturally  one  did  not  care  to  irri- 
gate the  pelvis  of  the  kidney,  but  there  might  be 
some  benefit  from  washing  out  the  ureter  and  thus 
cleaning  out  mucus  plugs  that  were  causing  some 
interference  with  the  outflow  of  urine.  The  reason 
they  did  not  get  results  by  this  procedure  was  that 
they  did  not  know  what  they  were  treating.  The 
only  diagnosis  made  was  made  after  pus  had  put  in 
its  appearance.  The  diagnosis  of  kidney  involve- 
ment was  not  made  until  after  the  fifth  day.  He 
did  not  believe  lavage  was  effective.  With  the 
patient  in  the  Trendelenburg  position  the  silver 
nitrate  might  go  to  the  pelvis  of  the  kidney,  but 
he  doubted  if  it  reached  the  foci  of  infection  in  the 
parenchyma. 

Dr.  Cabot  said  the  question  he  had  wanted  to 
hear  discussed  was  the  possibility  of  the  sensitiza- 
tion of  the  kidney  with  foreign  protein.  Dr.  Keyes 
had  asked  a  question  which  he  could  not  answer. 
It  was,  however,  beyond  doubt  that  occasionally 
there  was  a  case  in  which  the  use  of  the  ureteral 
catheter  with  or  without  lavage  of  the  kidney  had 
produced  spectacular  results.  He  could  not  sub- 
scribe to  the  theory  of  stricture  of  the  ureter. 
These  cases  did  not  occur  in  his  experience.  He 
had  been  asked  whether  he  had  retreated  from  his 
position  in  regard  to  certain  anatomical  relations 
which  might  account  for  the  frequency  of  pyelitis 
in  little  girls.  The  difficulty  here  was  that  there  had 
not  been  produced  a  sufficient  amount  of  good  work 
to  settle  the  question  one  way  or  the  other.  Dr. 
Grimes  and  he  had  studied  the  length  and  position 
of  the  large  intestine  in  females  as  compared  with 
males ;  it  was  possible  that  there  was  a  definite  ana- 
tomical difference  but  it  had  not  been  shown  thus 
far.  As  to  the  relation  of  the  intestines  to  the  kid- 
ney, he  did  not  agree  with  Dr.  Brasch.  The  rela- 
tion between  the  intestine  and  the  kidney  was  clear. 
He  had  a  series  of  twenty-five  men  between  the 
ages  of  twenty-five  and  thirty-five  years  whose 
urinary  tracts  were  sound,  men  in  good  circum- 
stances and  living  out  of  town,  who  had  had  acute 
illness  characterized  by  fever  and  diarrhea  and  evi- 
dence of  acute  colitis,  and  it  was  observ-ed  in  a  few 
days  that  colon  bacilli  were  passed  in  the  urine.  In 
many  cases  the  colon  bacilli  disappeared  from  the 
urine,  but  later  the  patients  would  have  another 


acute  attack,  with  symptoms  of  kidney  infection, 
fever  and  bacilluria.  The  relation  between  pyelitis 
and  ulcerative  colitis  was  often  striking.  Dr. 
Brasch  had  laid  a  good  deal  of  stress  on  the  impor- 
tance of  the  removal  of  focal  infections  elsewhere 
in  the  body.  Such  infections  were  occasionally  due 
to  the  colon  bacilli  but  they  were  oftener  due  to  the 
streptococcus  group ;  the  condition  he  was  talking 
about  had  nothing  to  do  with  that,  for  he  did  not 
believe  that  the  streptococcus  produced  pyelitis.  He 
believed  in  a  search  for  focal  infection,  but  he 
doubted  that  there  was  a  connection  between  colon 
bacillus  infection  of  the  kidney  and  infections  of  the 
mouth  and'  teeth.  Silver  nitrate  might  affect  the 
organisms  in  the  superficial  epithelium  and  even 
release  organisms  deeper  down,  but  he  doubted 
whether  silver  nitrate  did  more  than  ameliorate 
symptoms.  Unless  the  colon  bacilli  were  perma- 
nently eliminated  the  patient  did  not  stay  cured.  In 
the  group  of  little  girls  he  should  hesitate  to  use  the 
cystoscope  or  to  catheterize  the  kidney ;  he  did  not 
believe  local  treatment  would  be  of  much  help  in 
this  group.  He  was  inclined  to  believe  their  hope 
lay  in  vaccines,  but  here  the  difficulty  was  that  there 
was  no  measure  of  immunity  and  we  did  not  know 
whether  immunity  was  produced  hy  vaccines.  There 
were  many  strains  of  colon  bacilli  and  it  was  not 
known  whether  vaccination  against  the  strains  that 
were  producing  the  pyelitis  could  produce  an  im- 
munity against  those  organisms. 

SYMPOSIUM  ox  ENDOCRINE  DISEASES. 

Disturbance  of  Internal  Secretions  of  Sex 
Glands. — Dr.  William  C.  Quinby,  of  Boston,  dis- 
cussed the  clinical  and  experimental  evidence  of 
function  of  the  gonads,  that  is,  the  sex  glands,  and 
showed  instances  of  disturbed  function.  The  sper- 
matozoa and  ova  might  be  considered  analogous  to 
external  secretion  of  other  glands  of  the  endocrine 
system.  The  testicles  and  ovaries  had  a  definite  in- 
ternal secretory  function  the  products  of  which  so 
far  had  not  been  isolated  as  definite  chemical  prod- 
ucts. A  hypothetical  substance  called  spermin  had 
been  isolated  but  that  was  entirely  impure  and  had 
no  value.  In  the  male  the  endocrine  portion  of  the 
testis  was  situated  in  the  interstitial  tissue  or  the 
cells  of  Leidig.  These  cells  lay  between  the  tubules 
and  showed  different  degrees  of  development.  In 
the  female  the  endocrine  function  was  subserved 
also  by  interstitial  cells  and  probably  further  by 
corpora  lutea,  but  certainly  before  menstruation  oc- 
curred the  action  of  corpora  lutea  was  not  present. 
The  evidence  showed  definitely  that  the  internal 
secretion  of  the  gonads  caused  the  appearance  of 
the  secondary  sexual  characteristics.  The  term 
originated  with  John  Hunter.  Those  secondary 
changes  were  the  changes  occurring  at  puberty.  Cer- 
tain experiments,  especially  those  of  Steinach, 
showed  the  great  importance  of  the  internal  secre- 
tion of  the  testicles  and  ovaries.  Steinach  laid  so 
much  importance  on  this  interstitial  tissue  that  he 
named  it  the  puberty  gland,  indicating  that  puberty 
depended  entirely  upon  its  action.  By  experiments 
on  animals  he  showed  that  these  secondary  sexual 
characteristics  could  be  produced.    Thus  male  rats 


October  30,  1920.] 


PROCEEDINGS  OF  NATIONAL  AND  LOCAL  SOCIETIES. 


695 


which  had  been  castrated  before  puberty  and  in 
whom  an  ovary  had  been  transplanted  took  on  sec- 
ondary female  characteristics ;  the  same  was  true  of 
rats  of  the  opposite  sex.  We  did  not  know  the 
stimulus  that  called  into  activity  this  property  of 
the  gonads.  It  might  depend  on  the  interactivity  of 
other  endocrine  glands — for  instance,  the  hypo- 
physis. Gonadal  stimulating  properties  might  exist 
in  all  endocrine  glands.  We  should  find  clinical 
cases  in  man  showing  the  results  of  hyperfunction  or 
hypof  unction  of  these  organs ;  that  is,  we  should 
find  cases  of  precocious  or  delayed  puberty  in  botli 
sexes.  We  could  also  study  the  effects  of  double 
ovariotomy. 

Mild  Types  of  Thyroid  Toxic  Adenomata. — 

Dr.  Malcolm  S.  Woodbury,  of  Clifton  Springs, 
said  there  were  two  varieties  of  goitre  which  might 
be  toxic — the  exophthalmic  type  and  toxic  adeno- 
mata. The  opinion  was  that  adenomata  were  em- 
bryological  in  origin,  derived  from  fetal  rests. 
Work  was  being  done  on  this  and  would  be 
published  soon.  For  the  clinician  it  was  im- 
portant to  recognize  that  adenomata  might 
appear  as  distinct  nodules  or  there  might  be  a 
diffuse  process,  as  shown  by  the  microscope ;  the 
absence  of  nodules  did  not  rule  out  this  condition. 
The  recognition  of  thyroid  adenomata  as  an  entity 
marked  an  advance.  They  might  attain  a  large 
size,  but  usually  not  without  toxicity.  The  mild 
ones  might  produce  only  pressure  symptoms.  Small 
adenomata  might  be  toxic  just  as  small  exophthalmic 
goitres  might.  Plummer  stated  that  thirty-three 
per  cent,  of  all  hyperfunctioning  thyroids  were 
adenomata.  It  was  obviously  of  the  greatest  im- 
portance to  differentiate  toxic  states  associated  with 
goitre  from  psychoses.  The  term  thyrotoxicosis 
was  better  than  the  term  hyperthyroidism  when 
applied  to  adenomata.  In  our  recent  short  series 
there  was  a  family  history  in  eighty  per  cent,  of 
the  cases  and  infections  of  the  tonsils  or  teeth  in 
ninety  per  cent. ;  all  the  patients  came  from  districts 
in  which  goitre  was  rather  common.  Probably  the 
etiology  was  somewhat  as  follows :  It  appeared 
that  fetal  rests  might  be  transmitted  more  com- 
monly in  certain  families ;  be  due  to  the  water  con- 
tent in  localities  requiring  an  overactivity  of  the 
thyroid  in  metabolism  adjustment,  to  disturb- 
ance of  the  sympathetic  nervous  system,  or  to 
pregnancy.  The  cells  proliferated  and  took  on  the 
form  of  adenomata.  Whether  the  activity  was  due 
to  cells  in  the  adenoma  per  sc  or  the  surrounding 
cells  was  not  yet  established.  Nervous  symptoms 
in  the  cases  of  adenomata  were  no  different  from 
those  in  the  exophthalmic  cases.  In  adenomata 
fifty  per  cent,  of  the  patients  complained  of  depres- 
sion which  was  different  from  the  depression  of 
psychoses  in  the  absence  of  selfaccusatory  delu- 
sions. Definite  nodules  could  be  felt  in  half  the 
cases,  although  palpation  must  be  done  carefully  to 
detect  them.  Dr.  Woodbury  described  his  method 
of  palpating  the  thyroid  to  detect  adenomata.  With 
the  patient  sitting  with  the  head  on  a  head  rest 
turned  toward  the  side  on  which  the  examiner  stood, 
the  landmark  to  palpate  was  the  oblique  ridge  on 
the  alae  of  the  thyroid  cartilage  when  the  patient 
swallowed. 


The  metabolism  rate  had  received  a  great  deal 
of  attention  since  the  portable  apparatus  of  Bene- 
dict had  come  into  use,  but  too  much  reliance  must 
not  be  placed  on  it  and  it  was  necessary  to  allow  for 
differences  in  weight,  age  and  sex.  An  increase  of 
not  more  than  fifteen  per  cent,  was  to  be  considered 
normal.  Adenomatous  cases  might  show  only  a 
slight  increase  in  basal  metabolism  or  no  increase 
at  all,  and  the  question  arose  whether  these  were 
cases  in  which  a  toxic  element  was  playing  a  part. 
Dr.  Woodbury  thought  they  were.  The  Goetsch 
test  was  positive.  The  patients  were  operated  on 
by  Dr.  C.  W.  Webb,  with  good  results  where  the 
gland  was  available  for  operation.  The  Goetsch 
test  had  distinct  value  in  the  diagnosis.  One  point 
to  be  emphasized  was  that  solutions  of  adrenalin 
chloride  varied  a  great  deal  according  to  the  age  of 
the  solution.  This  ought  to  be  taken  into  consid- 
eration. Folin  had  described  a  test  for  determin- 
ing the  purity  of  adrenalin.  Dr.  Woodbury  did  not 
regard  the  Goetsch  test  as  positive  unless  there  was 
a  rise  of  over  ten  points  in  blood  pressure  together 
with  subjective  symptoms,  including  tremor.  One 
is  hardly  justified  in  ruling  out  all  thought  of  a 
thyrotoxic  state  because  the  basal  metabolism  ac- 
cording to  our  present  methods  ran  within  normal 
limits.  It  seemed  that  cases  occurred  in  which 
there  was  no  definite  rise.  The  Goetsch  test  was 
not  an  absolutely  reliable  criterion.  Certainly  for 
the  diagnosis  of  mildly  toxic  cases  of  adenomata 
study  of  the  individual  patient  must  be  made  and 
all  available  points  of  diagnosis  utilized. 

SYMPOSIUM  ON  GASTROINTESTINAL  DISEASES 

Practical  Clinical  Laboratory  Diagnosis  in 
Gastrointestinal  Disease. — Dr.  Howard  F.  Shat- 
TUCK  and  Dr.  John  Killian,  of  New  York,  pre- 
pared this  paper,  which  was  read  by  Dr.  Killian.  They 
stated  that  some  of  the  new  methods  of  examina- 
tion, particularly  the  x  ray,  had  lessened  the  use  of 
chemical  examinations  or  rendered  the  considera- 
tion of  them  less  important,  yet  they  often  yielded 
findings  in  clinical  problems  where  every  bit  of  evi- 
dence was  needed.  In  a  series  of  examinations 
made  at  the  Postgraduate  Hospital  the  authors  were 
impressed  by  the  great  amount  of  free  hydrochloric 
acid  in  cases  of  gastric  ulcer  as  compared  with  duo- 
denal ulcer.  The  average  per  cent,  of  free  hydro- 
chloric acid  was  under  0.50  in  cases  of  duodenal 
ulcer,  while  it  ranged  from  0.53  to  0.80  per  cent, 
in  cases  of  gastric  ulcer.  In  carcinoma  of  the  stom- 
ach the  average  percentage  of  the  free  hydrochloric 
acid  was  very  much  under  0.50,  reaching  that  figure 
in  only  one  instance.  A  large  group  of  miscellane- 
ous conditions  yielded  results  in  which  the  total 
percentage  of  free  hydrochloric  acid  was  under  0.50. 
A  second  interesting  point  was  the  association  of 
hydrochloric  acid  and  lactic  acid  in  cases  without 
retention.  It  was  common  to  find  lactic  acid  in  the 
gastric  contents  with  retention,  and  rarely  was  lac- 
tic acid  present  without  retention. 

In  regard  to  the  value  of  the  Wolff-Junghans 
test :  Smithies  reported  that  next  to  the  Boas- 
Oppler  bacillus  a  positive  Wolff  test  was  the  most 
frequent  finding  in  gastric  cancer.  This  test  was 
positive  in  eighty  per  cent,  of  the  cases ;  lactic  acid 


696 


PROCEEDINGS  OF  NATIONAL   AND  LOCAL  SOCIETIES. 


[New  York 
Medical  Journal. 


was  present  in  seventy-five  per  cent. ;  the 
Boas-Oppler  bacillus  was  present  in  ninety  per 
cent.  In  the  authors'  group  of  cancer  cases  eighty 
per  cent,  gave  a  positive  or  suspicious  Wolff  test. 
The  test  had  been  of  value  in  distinguishing  the 
malignant  from  the  benign  achylias.  The  records 
of  gastric  cases  had  brought  out  the  great  value  of 
gastric  analysis  in  the  differentiation  of  true  achy- 
lias  from  psychic  achylias.  In  none  of  the  cases  of 
true  achylia  gastrica  or  pernicious  anemia  were  they 
able  to  demonstrate  the  presence  of  free  hydro- 
chloric acid  at  any  time  in  the  digestive  cycle.  There 
were  cases  simulating  true  cases  which  proved  on 
examination  to  be  spuriovis  or  psychic  achylias.  In 
these  cases  improvement  was  obtained  by  the  use 
of  hydrochloric  acid. 

As  regards  enzyme  activity  of  the  duodenal  con- 
tents, Einhorn  had  shown  the  value  of  this  proce- 
dure in  pancreatitis.  It  gave  qualitative  rather  than 
quantitative  results.  The  duodenal  contents  were 
obtained  by  any  of  the  duodenal  tubes  after  test 
meals  and  removed  at  intervals.  In  thirty-one  cases, 
the  pancreatic  enzymes  were  present  except  in  the 
cases  of  pancreatitis,  in  which  the  protease  was 
absent  and  the  lipase  present  in  small  amount. 

What  the  authors  wished  to  emphasize  from  the 
data  obtained  was  the  proportion  of  the  total  acid- 
ity in  the  form  of  free  hydrochloric  acid.  In  a  series 
of  normal  cases  they  found  that  the  free  hydro- 
chloric acid  formed  about  forty  per  cent,  of  the  total 
acid  in  the  Ewald  meal  and  about  thirty  per  cent,  in 
the  retention  meal.  It  was  always  less  than  fifty  per 
cent.  In  a  series  of  cases  of  gastric  ulcer  they  were 
impressed  with  the  fact  that  the  total  acidity  was 
never  very  high.  In  only  two  cases  was  there  marked 
hyperacidity.  The  constant  feature  of  these  gastric 
ulcers  was  that  the  proportion  of  the  free  acid  to  the 
total  was  always  greater  than  fifty  per  cent,  and  in 
most  cases  it  approached  seventy-five  per  cents.  That 
was  true  of  the  Ewald  meal.  In  the  retention  meal 
the  percentage  of  free  hydrochloric  was  even  greater. 
The  secretion  of  hydrochloric  acid  seemed  to  be 
free  from  the  stimulus  of  food.  In  a  series  of  duo- 
denal ulcers  divided  into  two  groups,  postpyloric 
and  other  types,  in  the  postpyloric  the  total  acidity 
and  the  free  acid  were  relatively  high,  and  the  per- 
centage of  free  acid  was  greater  than  fifty  per  cent. ; 
it  was  similar  to  the  condition  in  gastric  ulcer,  but 
in  the  retention  meal  the  percentage  was  less  than 
in  the  Ewald  meal.  In  none  of  these  cases  of  post- 
pyloric ulcer  were  there  evidences  of  retention  and 
in  none  was  lactic  acid  found.  In  the  other  type  of 
duodenal  ulcer  the  percentage  of  free  acid  did  not 
exceed  fifty  per  cent,  and  in  the  retention  meal  it 
ranged  from  zero  up  to  thirty-two  per  cent.  In 
gastric  carcinoma  the  free  hydrochloric  acid  ranged 
from  zero  up  to  forty,  and  in  the  retention  meal  it 
ranged  from  zero  up  to  twenty.  In  these  cases 
there  was  free  hydrochloric  acid. 

In  normal  cases  the  average  percentage  of  free 
to  total  acid  was  forty  following  the  Ewald  test 
meal.  In  gastric  ulcer  the  proportion  of  free  to 
total  was  greater  in  the  retention  meal  than  in  the 
Ewald  meal.  In  postpyloric  ulcers  the  percentage 
of  free  hydrochloric  acid  was  not  as  high  as  in  gas- 
tric ulcers  after  the  retention  meal. 


So  far  as  examination  of  the  feces  was  con- 
cerned, there  were  two  factors;  one  was  the 
diastase  activity  of  the  stool  and  the  other  was  the 
presence  of  occult  blood.  In  the  diastase  the  normal 
activity  of  the  stool  varied  from  twenty-five  to 
thirty  per  cent.  When  stools  were  incubated  with 
starch  thirty  per  cent,  of  the  starch  was  converted 
into  sugar.  In  diseases  of  the  pancreas  the  diastase 
activity  of  the  blood  was  increased,  whereas  the 
diastase  activity  of  the  stool  was  either  absent  or 
greatly  decreased. 

Practical  Clinical  Examination  of  Upper  Gas- 
trointestinal Tract. — Dr.  Allen  A.  Jones,  of 
Buffalo,  presented  a  tabulation  of  diseases  most 
commonly  encountered.  In  gastric  and  duodenal 
ulcer,  pain  was  one  of  the  most  important  manifes- 
tations. Many  times  in  young  women  the  first 
symptom  was  hematemesis.  He  had  noticed  pain  to 
be  more  frequent  in  men  than  in  women.  Pain  was 
relieved  by  digestion,  and  it  supervened  sooner  after 
eating  in  gastric  than  in  duodenal  ulcer.  If  the 
ulcer  was  located  far  back  postprandial  pains  oc- 
cured ;  the  pain  was  intermittent  in  cases  with 
peristalsis.  Typical  hunger  pain  usually  felt  as  a 
gnawing,  was  strongly  indicative  of  duodenal  ulcer. 
The  pain  of  gastric  and  duodenal  ulcers  was  tempo- 
rarily relieved  by  alkalies.  Pain  simulating  hunger 
pain  might  arise  from  extragastric  conditions. 
Vomiting  or  lavage  relieved  the  pain  of  ulcer  but 
not  the  pain  from  extragastric  conditions.  In  perfora- 
tion the  pain  was  excruciating  and  prostrating  and 
was  accompanied  by  increased  frequency  of  the  pulse 
and  muscular  rigidity;  a  leucocytosis  was  found 
soon  after  perforation  occurred.  Pain  in  the  back 
at  or  near  the  tenth  dorsal  vertebra  was  an  import- 
ant symptom,  as  it  indicated  ulcer  on  the  posterior 
wall  of  the  stomach.  Tenderness  due  to  ulcer  was 
usually  present  in  some  part  of  the  epigastric  re- 
gion. A  full  stomach  gave  rise  to  tenderness. 
Vomiting  was  not  common  in  ulcer  unless  stenosis 
existed.  Hematemesis  was  one  of  the  classical  sym- 
toms  of  ulcer.  In  some  cases  of  ulcer  with  hyper- 
esthesia vomiting  was  present.  Fever  might  be 
present  if  there  was  suppurative  peritonitis. 
Anemia  was  common  in  gastric  ulcer. 

The  most  important  symptoms  of  cholecystitis 
and  cholelithiasis  were  the  irregular  temperature, 
pain,  and  tenderness  in  the  region  of  the  gallbladder. 
Suppurative  cholecystitis  might  be  suspected  if  there 
was  a  decided  leucocytosis.  If  cholangitis  accom- 
panied cholecystitis  there  was  evidence  of  some  de- 
gree of  jaundice.  In  rupture  there  were  tenderness 
over  the  liver,  rising  pulse,  and  shock.  The  symp- 
toms of  cholelithiasis  often  occasioned  confusion. 
This  affection  was  often  painless  and  the  symptoms 
might  be  gastric.  Some  sensory  gastric  disturbances 
might  be  present.  Tenderness  over  the  liver  was  a 
varying  factor,  which  might  be  elicited  only  on  pres- 
sure or  by  Murphy's  hammer  stroke  over  the  liver. 
Pyloric  spasm,  turbid  bile  withdrawn  through  Ein- 
horn's  tube,  and  traces  of  bile  in  the  urine  were  not 
infrequently  found  in  gallbladder  disease. 

Acute  gastritis  with  its  distress  after  eating  should 
be  remembered  as  a  cause  of  sudden  pain  in  the 
upper  abdomen. 

{To  he  continued.) 


New  York  Medical  Journal 


INCORPORATING  THE 


Philadelphia  Medical  Journal  the  Medical  News 

A  Weekly  Review  of  Mediciyie,  Established  18^3. 


Vol.  CXI  I.  Xo.  Ifl. 


XEW  YORK.  SATURDAY.  XOVEMBER  6,  1920. 


Whole  No.  2188. 


Original  Communications 


THE  ENDOCRINES  IN  GYNECOLOGY. 

By  William  P.  Graves,  M.  D., 
Boston, 

Professor  of  Gynecology,  Harvard  University. 

In  writing  a  paper  on  the  endocrines  in  gynec- 
ology I  am  confronted  with  two  alternatives,  one 
of  which  is  to  prepare  a  general  review  of  the  sub- 
jiect;  the  other  is  to  confine  myself  to  those  phases 
of  it  to  which  my  personal  interest  and  work  have 
been  especially  directed.  A  comprehensive  pres- 
entation of  the  entire  subject  in  a  brief  review  is  a 
difficult  task,  and  one  which  has  been  so  notably 
well  performed  in  a  recent  article  by  Dr.  Bandler, 
that  I  feel  that  any  attempt  at  repetition  on  my 
part  would  be  of  little  value.  I  shall,  therefore, 
restrict  myself  to  a  discussion  in  sohie  detail  of  two 
topics  which  have  seemed  to  me  to  be  of  especial 
importance  in  gynecological  endocrinology.  They 
are,  first,  the  relationship  of  the  endocrines  to  the 
specific  neuroses  of  patients  suffering  from  pelvic 
disease ;  and,  secondly,  the  histogenesis  and  func- 
tion of  the  internal  secreting  cells  of  the  ovary. 

THE  NEUROSES. 

No  one  can  practise  the  science  of  gynecology 
long  without  becoming  impressed  with  the  extreme 
importance  of  the  nervous  element  in  the  symp- 
tomatology of  his  patients.  In  order  to  give  some 
definite  figures  to  illustrate  this  point  I  have  re- 
viewed the  consecutive  histories  of  one  thousand 
private  patients  and  find  that  in  837  or  84  per  cent, 
nervousness  is  a  more  or  less  serious  part  of  their 
complaints.  In  a  considerable  number  of  cases  it 
appears  as  the  most  prominent  symptom,  for 
which  the  patient  seeks  relief. 

Although  in  employing  the  term  nervousness  one 
is  dealing  with  a  very  loose  expression,  neverthe- 
less popular  usage,  both  among  the  laity  and  the 
profession,  has  confined  its  meaning  to  rather  def- 
inite limits.  Thus  a  patient  who  states  that  she  is 
extremely  nervous  is  describing  a  symptom  that 
to  her  is  entirely  specific,  and  one  which  to  the 
physician  is  perfectly  intelligible.  To  the  term 
nervousness,  however,  it  is  almost  impossible  to 
give  a  strict  definition  on  account  of  its  well  nigh 
limitless  manifestations.  We  are,  in  the  present 
discussion,  not  so  much  concerned  with  the  various 
phases  of  nervousness  as  with  the  underlying  con- 
ditions that  cause  it.  We  shall  use  the  expression 
in  its  popular  sense  and  direct  our  attention 
only  to  those  cases  in  which  the  symptom  nervous- 
Copyright,  1920,  by  A.  R. 


ness  may  be  regarded  as  a  functional  disturbance. 
We  shall  leave  out  of  the  discussion  altogether  those 
cases  in  which  the  nervous  symptoms  indicate  some 
essential  mental  deviation. 

Functional  nervousness  may  be  constitutional  or 
acquired.  By  constitutional  we  mean  a  neurotic 
habit  which  is  either  the  result  of  an  unstable  nerv- 
ous inheritance,  or  one  which  has  been  fixed  dur- 
ing childhood,  or  one  in  which  both  factors  have 
played  a  part.  By  an  acquired  neurosis  we  mean 
one  which,  appearing  after  the  complete  formation 
of  character,  may  be  referred  to  some  intercurrent 
physical  disability,  such,  for  example,  as  a  pelvic 
lesion. 

The  excellent  work  of  the  psychoanalysts  has 
taught  us  much  concerning  the  constitutional 
neuroses.  From  Freud  we  have  become  acquainted 
with  the  great  field  of  unconscious  thought,  and 
learned  the  influence  of  childhood  fixations  on  fu- 
ture character.  Sidis,  though  not  a  psychoanalyst, 
has  demonstrated  the  importance  of  fear  in  the 
production  of  neuroses.  Adler  has  traced  the 
neurotic  constitution  to  the  sense  of  inferiority  in- 
duced by  congenitally  deficient  organs.  The 
psychoanalysts,  however,  have  paid  little  attention 
to  the  specifically  acquired  neuroses  that  are  of 
especial  interest  to  the  gynecologist,  nor  have  they 
given  due  consideration  to  the  important  role 
played  by  the  internal  secretions  in  all  emotional 
and  afifective  states.  The  gynecologist  is  therefore 
thrown  to  some  extent  on  his  own  resources  in 
estimating  the  cause,  character  and  therapeutics  of 
those  neurotic  conditions  which  he  as  a  specialist 
is  called  upon  to  treat. 

You  will  doubtless  agree  that  the  condition  popu- 
larly called  nervousness  is,  irrespective  of  its 
cause,  an  emotional  state,  and  that  this  emotional 
state  is  always  associated  with  certain  physiological 
body  changes  whether  the  inciting  cause  of  the 
emotion  be  some  acute  mental  excitement  or  a 
chronic  physical  disability,  or  a  subconscious 
mental  repression.  In  order  to  understand  this 
statement  fully  it  is  necessary  t6  have  in  mind  a 
clear  conception  of  the  term  emotion. 

Emotions  were  formerly  regarded  as  purely 
mental  states  which  gave  rise  to  specific  bodily  ex- 
pressions, as  for  example,  anger,  fear,  joy,  and 
many  others.  It  was  common  to  regard  them  as 
definite  psychic  attributes,  component  parts,  as  it 
were,  of  our  mental  equipment,  just  as  our  organs 
of  sense  or  limbs  are  parts  of  our  physical  ap- 

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paratus.  William  James  was  perhaps  the  first  to 
emphasize  the  idea  that  emotions  are  not  them- 
selves psychic  states  but  are  physical  sensations  re- 
sulting from  actual  bodily  changes.  Thus  he  says 
that  "our  feeling  of  the  bodily  changes  that  ensue 
after  the  perception  of  an  exciting  fact  is  the  emo- 
tion" and  invites  us  to  imagine  ourselves  as  being 
angry,  for  example,  from  a  purely  intellectual  view- 
point, eliminating  entirely  our  bodily  sensations. 
James,  unfortunately,  knew  little  of  the  glands  of 
internal  secretion,  and  therefore  was  unable  to 
describe  completely  the  physiology  of  those  bodily 
changes  to  which  he  referred  in  his  description  of 
the  emotions.  His  theor}^  of  the  emotions,  how- 
ever, has  received  remarkable  confirmation  from 
the  researches  of  scientific  physiology.  Animal  ex- 
perimentation has  shown  that  during  emotional  ex- 
citement such  as  that  induced  by  fear,  anger,  pain 
and  hunger,  there  is  a  markedly  increased  produc- 
tion and  absorption  in  the  blood  of  adrenalin. 
Cannon  has  demonstrated  the  reciprocating  action 
between  adrenalin  and  the  sympathetic  nervous 
system,  by  which  certain  bodily  changes  such  as  an 
increase  of  respiration  and  pulse  beat,  inhibition  of 
the  digestive  secretions  and  an  increase  in  the  pro- 
duction of  adrenalin  are  maintained  during  emotional 
states.  He  has  proved  that  the  action  of  adrenalin 
on  the  general  organism  when  artificially  intro- 
duced into  the  circulation  is  precisely  that  of  the 
sympathetic  nerves.  In  other  words,  the  sympa- 
thetic system  provides  the  organism  with  a  material 
which  by  its  presence  in  the  blood  automatically 
prolongs  the  effects  which  the  stimulated  nerves 
initiated. 

This  reciprocating  mechanism,  as  Cannon  states, 
is  undoubtedly  a  provision  of  nature  to  stimulate 
the  organism  to  a  higher  degree  of  motor  activity 
for  combat  and  defense.  It  may  readily  be  imag- 
ined, however,  that  these  bodily  changes  which  are 
of  immense  benefit  to  the  individual  in  a  temporary 
crisis,  may  under  the  influence  of  constant  stimula- 
tion become  a  serious  detriment  to  health.  And 
this  is  precisely  what  happens  in  the  case  of  the 
neurotic  in  whom  some  unremitting  physical  or 
mental  irritation  maintains  a  state  of  continuous 
emotional  excitement. 

The  scientific  discoveries  of  the  physiologists  in- 
troduces into  psychology  a  new  factor  of  great  in- 
terest since  they  prove  beyond  dispute  the  influence 
on  the  organism  during  emotion,  not  only  of  the 
sympathetic  system  of  nerves,  but  also  of  the  glands 
of  internal  secretion.  Accurate  experimentation 
has  been  carried  out  along  these  lines  chiefly  with 
the  secretion  of  the  adrenal  gland.  Nevertheless 
from  our  knowledge  of  the  intimate  interrelation- 
ship that  exists  between  all  the  endocrines  it  is 
entirely  probable  that  the  adrenal  gland  is  not  the 
only  one  that  takes  part  in  producing  the  sensa- 
tions of  the  emotional  states.  In  fact  this  is  suffi- 
ciently evident  from  the  observation  of  patients 
who  suffer  from  diseases  of  the  internal  secretory 
glands,  examples  of  which  are  the  emotional  ex- 
citability of  persons  with  organic  hyperthyroidism, 
and  the  mental  dulness  of  those  affected  by  the 
opposite  condition,  the  exaltation  of  the  bodily  and 
mental  functions  seen  in  those  with  early  pituitary 


disease,  and  the  premature  decay  of  the  same 
functions  as  the  disease  progresses,  and  finally  tlie 
marked  dispositional  changes  in  those  who  have 
undergone  early  castration. 

Just  what  part  the  individual  glands  take  in  the 
emotions  must  at  present  remain  a  matter  of  specu- 
lation. Next  to  the  adrenals,  one  would  expect  the 
thyroid  to  be  the  most  important.  The  nervous 
manifestations  of  pathological  hyperthyroidism 
are  so  well  defined  that  not  infrequently  in  the  re- 
actions of  functionally  nervous  patients  one  recog- 
nizes symptoms  of  an  unmistakably  hyperthyroidal 
character.  Furthermore  we  know  that  the  adrenals 
and  thyroid  are  rather  closely  and  harmoniously 
related  in  their  physiological ,  properties.  During 
sexual  emotion  it  seems  evident  that  all  the  glands 
of  internal  secretion  become  active.  Of  these  it 
is  probable  that  the  adrenals,  thyroid  and  pituitary 
play  the  most  important  role,  the  o-varies  apparently 
being  of  minor  significance. 

With  this  brief  survey  of  the  subject  we  are 
justified  in  describing  functional  nervousness  as  a 
continuous  state  of  emotional  excitement,  sensory 
in  character,  and  induced  by  the  reciprocal  action, 
under  stimulation,  of  the  autonomic  nervous  sys- 
tem and  certain  glands  of  internal  secretion.  This 
definition  is  incomplete  in  that  it  leaves  out  of  ac- 
count the  element  of  causation,  and  to  this  we  must 
now  direct  our  attention. 

We  have  already  referred  to  the  lessons  that 
we  have  learned  from  the  psychoanalysts.  To 
Freud  is  due  the  lasting  credit  of  proving  the  enor- 
mous influence  on  character  and  behavior  of  un- 
conscious repressions.  In  attempting,  however,  to 
apply  his  libidinistic  theory  of  causation  to  the 
specific  gynecological  neuroses  we  at  once  meet  with 
serious  obstacles.  It  is  indeed  true  that  the  gyneco- 
logist encounters  numerous  sexual  neurotics  who 
are  suffering  from  pelvic  disease  and  in  some  cases 
the  pelvic  lesion  bears  some  causal  relationship  to 
the  neurosis,  but  to  attribute  all  female  nervousness 
to  sexual  repression  is  an  absurd  fiction,  requiring 
as  it  does  an  acceptance  of  the  untenable  doctrine 
of  the  extreme  Freudians,  that  the  libido  in  its 
literal  sense  is  the  basis  of  all  human  motivation. 
I  have  in  other  articles  called  the  attention  of 
gynecologists  to  the  theories  of  Alfred  Adler  and 
shown  how  they  may  be  applied  to  the  subject  in 
hand.  Adler  in  brief  explains  the  neurotic  consti- 
tution on  the  ground  of  a  sense  of  inferiority  re- 
sulting from  organ  deficiency.  He  ably  and  con- 
vincingly deals  with  the  confirmed  neurotic  whose 
constitutional  habit  has  been  established  at  an  early 
age.  The  sense  of  inferiority  continues  as  an  un- 
conscious repression  in  the  Freudian  sense  and  may 
or  may  not  be  of  a  sexual  nature.  In  an  unpub- 
lished monograph,  in  which  an  attempt  is  made  to 
apply  Adler's  theory  to  motivation  in  general,  I 
have  endeavored  to  show  that  the  perception  of  in- 
feriority is  the  basic  cause  of  all  disquieting  emo- 
tions such  as  anger,  fear,  pain,  and  other  emotions. 
It  is  the  exciting  force  that  sets  in  action  the 
reciprocal  mechanism  of  the  autonomic  nervous 
system  and  the  glands  of  internal  secretion.  This 
theory  lends  itself  admirably  to  the  explanation  of 
the   acquired   gynecological    neuroses.     A  pelvic 


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699 


lesion,  such  for  example  as  one  due  to  the  injuries 
of  childbirth,  constitutes  a  definite  organ  inferiority, 
and  may  in  a  short  time  produce  in  the  most  normal 
individual  all  the  symptoms  exhibited  by  the  socalled 
constitutional  neurotic. 

It  is  of  the  utmost  importance  that  the  gyneco- 
logist be  able  to  classify  his  nervous  patients  with 
reference  to  causation  for  only  in  this  way  can  he 
avoid  making  mistakes  in  treatment  especially  in 
cases  that  involve  the  question  of  a  surgical  opera- 
tion. One  must  distinguish  the  neuroses  that  have 
definitely  been  acquired  as  a  result  of  pelvic  changes 
from  the  constitutional  fixations  of  childhood,  or 
from  those  of  a  purely  psychic  character.  One 
must  recognize  those  cases  in  which  there  is  a  super- 
activity of  the  glands  in  contradistinction  to  those 
in  which  there  is  a  glandular  deficiency.  And  above 
all  it  is  necessary  to  detect  the  cases  wherein  the 
nervous  manifestations  are  due  to  the  circulation  of 
abnormal  secretions  like  that  in  hyperthyroidism. 
The  ditJerential  therapy  to  be  employed  in  these 
various  types  of  cases  is  of  extreme  importance, 
but  does  not  come  within  the  scope  of  this  paper. 
The  wise  gynecologist  will  constantly  seek  the  aid 
of  the  neurologist  and  medical  internist,  and  in 
making  the  critical  decisions  as  to  treatment  will 
require  all  his  resources  of  education,  in  which 
psychology  and  philosophy  are  assets  of  unequivocal 
value. 

In  concluding  this  part  of  the  paper  it  may  be 
remarked  that  the  more  one  studies  the  socalled 
nervousness  of  women,  the  more  one  is  impressed 
with  the  possibility  that  the  purely  nervous 
mechanism  of  the  body  is  of  secondary  importance. 
It  is  quite  credible  that  the  nerves  are  only  the 
keys  or  instruments  which  are  played  upon  by 
more  dominant  agents  in  the  form  of  the  endocrine 
glands.  In  comparison  with  men,  women  are  said 
to  be  peculiarly  nervous.  Would  it  not  be  more 
accurate  to  say  that  on  account  of  the  undoubted 
instability  of  their  internal  glandular  equipment 
women  are  peculiarly  endocrinous?  Whether  this 
theory  be  true  or  not  there  is  no  doubt  whatever 
that  the  gynecologist  accomplishes  more  accurate 
results  if  he  estimates  his  nervous  patients  from  an 
endocrinological  rather  than  from  a  purely  neuro- 
logical viewpoint. 

THE  OVARIES. 

The  second  part  of  this  paper  deals  primarily 
with  the  histogenesis  of  the  secreting  cells  of  the 
ovary  and  is  presented  with  the  hope  of  pointing 
out  some  practical  lessons  that  may  be  gained 
thereby.  It  has  been  asserted  and  is  more  or  less 
generally  believed  that  the  ovary  is  a  compound 
secreting  gland  with  at  least  two  systems  of  secret- 
ing cells,  analogous  in  that  respect  to  the  hypophysis 
and  adrenals.  Thus  the  hypophysis  as  a  whole  is 
composed  of  two  very  distinct  parts  which  differ 
in  their  histogenesis,  their  effects  on  the  body  under 
the  influence  of  disease  and  in  the  specific  action 
of  their  respective  internal  secretions.  The  pos- 
terior lobe  is  nervous,  or  ectodermic  in  origin. 
Early  disease  of  the  lobe  produces  a  dwarfish  in- 
dividual. Extract  of  the  lobe,  commonly  called 
pituitrin,  exerts  an  influence  on  the  autonomic 
nervous  system  and  is  efficacious  in  the  treatment 


of  atonic  conditions  of  the  smooth  muscles  of  the 
bladder,  intestines,  and  uterus.  The  anterior  lobe 
on  the  other  hand,  is  glandular,  hence  mesodermal 
in  origin.  Early  disease  produces  giantism,  while 
extracts  of  the  lobe  affect  chiefly  the  sexual  system. 

In  like  manner  the  adrenals  are  made  up  of  two 
separate  tissue  structures,  which  are  so  distinct  in 
their  anatomical  and  physiological  characteristics 
that  they  may  properly  be  regarded  as  different 
organs,  that  happen  to  have  developed  in  juxtapo- 
sition. The  medulla  has  a  common  ectodermal 
origin  with  the  sympathetic  nervous  system,  from 
which  it  becomes  separated  during  the  process  of 
embryonic  evolution.  The  medullary  cells  are  not 
only  contained  within  the  cortex  of  the  adrenal 
body  but  are  scattered  along  the  sympathetic  nerves 
or  ganglia  in  isolated  bodies.  The  intimate  recipro- 
cal association  of  the  sympathetic  and  medullary 
systems  we  have  already  mentioned  in  our  discus- 
sion of  the  influence  on  the  emotions  of  adrenalin, 
the  specific  secretion  of  the  medullary  cells. 

The  cortical  cells  of  the  adrenals,  on  the  other 
hand,  are  mesodermal  in  origin  and  are  intimately 
related  to  the  cells  that  compose  the  ovary.  They 
spring  from  the  same  peritoneal  layer  from  which 
the  ovaries  take  their  origin.  The  cortical  cells 
resemble  the  cells  of  the  corpus  luteum  so  closely 
that  attempts  have  been  made  to  establish  some  sort 
of  identity  between  them.  As  in  the  case  with  the 
adrenal  medulla,  the  cortical  cells  are  not  confined 
to  the  adrenal  body,  but  are  found  scattered  along 
the  track  traveled  by  the  ovary  in  its  descent  into 
the  pelvis.  Physiologically  the  internal  secretory 
function  is  sexual,  though  comparatively  little  is 
known  of  its  action. 

Reasoning  by  analogy  to  the  hypophysis  and  ad- 
renals some  have  made  the  claim  that  the  ovary  is 
also  a  double  functionating  organ,  the  two  sources 
of  secretion  being  ascribed  to  the  corpus  luteum  or 
follicle  apparatus  on  the  one  hand  and  the  ovarian 
stroma  on  the  other.  A  study  of  the  histogenesis 
and  development  of  the  cells  that  compose  the 
ovarian  tissue  dispels  the  notion  of  a  close  analogy 
between  the  ovary  and  the  other  two  glands  men- 
tioned, for  it  can  be  shown  from  an  embryological 
viewpoint  that  the  ovar}-  is  a  single  homogeneous 
organ  and  that  the  differences  that  exist  between  the 
various  cell  elements  are  due  to  a  process  of  differ- 
entiation during  the  development  of  cells  that  have  a 
common  origin.  A  detailed  description  of  the  his- 
tological development  of  the  ovary  can  only  be  re- 
ferred to  in  briefest  outline. 

The  ovaries  are  developed  in  the  peritoneum  and 
from  the  peritoneum.  Their  primary  growth  is 
characterized  by  a  thickening  in  the  peritoneal  mem- 
brane due  to  a  localized  multiplication  and  change 
in  form  of  the  peritoneal  cells.  These  cells  con- 
stitute what  is  known  as  the  germinal  epithelium. 
The  ovaries,  at  first  simple  thickened  ridges  in  the 
peritoneum,  attain  their  fusiform  contour  by  a 
downgrowth  of  the  germinal  epithelium,  into  the 
subperitoneal  connective  tissue. 

The  germinal  epithelium  possesses  a  wonderful 
power  of  differentiation  and  growth.  Owing  to 
the  researches  of  Allen,  Alacllroy,  Goodall,  and 
others  it  is  now  known  that  all  the  inherent  cell 


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structures  of  the  ovaries  with  the  exception  of  the 
connective  tissue  supporting  framework  are  derived 
from  the  germinal  epithelium.  This  includes  the 
embr\-onic  rete  ovarii,  and  cords  of  Pfliiger,  the 
interstitial  cells  that  crowd  the  stroma  and  surround 
the  follicles,  the  granulosa  cells  that  line  the  fol- 
licles, and  finally  the  very  ova  themselves.  The 
early  investigators  of  the  ovary  as  a  gland  of  in- 
ternal secretion  believed  that  the  source  of  the 
secretion  resided  solely  in  the  corpus  luteal  cells, 
which  in  turn  were  thought  to  be  exclusively  mod- 
ified granulosa  cells.  Further  studies  revealed  that 
before  the  age  of  puberty  the  internal  secretory 
function  is  performed  by  the  interstitial  cells,  the 
existence  of  which  had  long  been  known.'  This  idea 
then  became  prevalent  that  there  are  two  secretions ; 
one  produced  by  the  interstitial  cells  and  one  by  the 
corpus  luteum,  and  that  these  two  secretions  possess 
selective  functional  powers. 

However,  it  has  been  shown  that  the  main  part 
of  the  corpus  luteum  cells,  the  theca  lutein  cells 
of  follicle  atresia  and  the  cells  of  the  interstitial 
gland  found  in  animals,  are  all  activating  inter- 
stitial cells.  Until  comparatively  recently  it  was 
generally  supposed,  as  stated  by  Tandler  and  Gross, 
that  the  interstitial  cells  are  derived  from  the  con- 
nective tissue  of  the  ovarian  stroma,  but  this  mystery 
has  been  solved  by  observations  that  the  stroma  of 
the  ovary  is  actually  composed  chiefly  of  interstitial 
cells  originally  derived  from  the  germinal  epithe- 
lium and  supported  by  a  connective  tissue  which 
acts  only  as  a  supporting  frame  work.  We  must 
conclude,  therefore,  that  all  the  cellular  elements  to 
which  the  source  of  an  internal  secretion  may  be 
ascribed  are  interstitial  in  character  and  origin. 

This  conclusion  disposes  of  the  theory  that  there 
exist  in  the  ovarv'  two  separate  and  independently 
functionating  endocrine  organs.  As  a  practical 
proof  of  the  truth  of  these  observations  one 
would  expect  to  find  little  or  no  qualitative  differ- 
ence in  the  clinical  results  from  the  administration 
of  such  extracts  as  those  respectively  from  the 
corpus  luteum,  the  whole  ovary  and  from  the 
stroma.  And  such  in  fact  is  the  case.  Early  in 
our  experience  we  gave  up  corpus  luteum  prepara- 
tions in  favor  of  those  compounded  from  the  whole 
ovary,  not  because  there  was  any  inherent  qualita- 
tive difference  in  their  action,  but  because  we  found 
that  for  the  various  gynecological  purposes  to 
which  we  applied  them  the  products  of  the  whole 
ovary  were  more  reliable  and  more  intensive  than 
those  from  the  corpus  luteum  alone.  In  order  to 
test  the  actual  value  of  the  corpus  luteum  we  ex- 
cluded it  altogether  and  treated  a  large  number  of 
patients  with  preparations  from  the  rest  of  the 
ovary.  It  was  not  difficult  to  obtain  the  material, 
for  up  to  this  time  it  had  been  discarded,  so  far  as 
medicinal  purposes  were  concerned,  during  the 
manufacture  of  corpus  luteum  preparations,  hence 
the  name  ovarian  residue.  It  was  no  surprise  to 
discover  that  the  residue  compared  favorably  with 
the  whole  ovary  products,  and  that  in  some  respects 
it  appeared  to  be  superior. 

Though  our  observations  and  deductions  lead  us 
to  deny  the  existence  of  two  independent  secretory 
organs  in  the  ovary,  we  must  admit  the  possibility 


of  a  minor  selective  action  on  the  part  of  different 
portions  of  the  ovarian  secreting  substance  but  even 
here  the  variation  is  probably  a  quantitative  one. 
Thus  in  our  cases  we  have  found  the  whole  extract 
and  the  residue  more  efficacious  than  the  corpus 
luteum  in  treating  hot  flushes,  but  the  superiority 
is  one  of  degree  rather  than  one  of  kind.  Other 
observers  have  found  corpus  luteum  preparations 
of  especial  value  in  the  nausea  and  vomiting  of 
pregnancy.  The  finer  distinctions  drawn  by  some 
in  the  treatment  of  certain  menstrual  irregularities 
do  not  seem  to  us  to  have  been  unequivocally  proved. 

In  the  light  of  theoietical,  experimental,  and 
anatomical  knowledge  combined  with  long  con- 
tinued observations,  our  general  estimate  of  the 
ovary  as  a  gland  of  internal  secretion  may  be 
briefly  summarized  as  follows. 

1.  For  complete  somatic  growth  and  sexual  de- 
velopment the  normal  secretion  of  the  ovary  is  es- 
sential. To  what  extent  the  action  of  the  secretion 
is  direct,  and  how  far  it  serves  as  a  balance  to  other 
more  powerful  secretory  influences  is  a  matter  of 
speculation. 

2.  During  menstrual  life  and  especially  during 
the  years  of  adolescence,  the  proper  functioning  of 
the  ovaries  has  a  very  important  bearing  on  the 
physical  and  mental  character  of  the  individual. 

3.  Dysfunctions  of  the  ovaries  are  usually  at- 
tended with  various  neuroses.  Some  of  these  may 
be  due  to  the  direct  disharmonious  action  of  other 
endocrines,  especially  those  that  have  an  affinity  for 
the  autonomic  nervous  system.  In  evaluating  these 
neuroses  one  must  also  take  into  account  those 
neurotic  habits  which  we  have  mentioned  in  the 
first  part  of  this  paper,  as  being  the  result  of  a 
sense  of  physical  inferiority,  and  characterized  as  a 
continued  endocrinous  emotional  state. 

4.  In  the  adult  the  ovarian  secretion  plays  a 
somewhat  minor  role  in  the  human  economy,  as  is 
indicated  by  the  comparatively  slight  physical 
changes  that  take  place  after  ablation  or  the  natural 
menopause.  This  has  an  important  bearing  on  the 
question  of  removing  the  ovaries  during  hyster- 
ectomy. 

5.  During  adult  life  the  most  definite  evidence 
of  the  existence  of  a  true  internal  secretion  from  the 
ovaries  is  the  occurrence  of  hot  flushes  and  genital 
atrophy  after  ablation.  These  symptoms  point  to 
a  balancing  rather  than  a  direct  action  of  the  ovar- 
ian secretion. 

6.  From  an  organotherapeutic  viewpoint,  the 
ovary  must  be  regarded  as  primarily  a  homogeneous 
gland,  the  essential  secreting  structure  being  the 
interstitial  cells.  \'ariations  in  secretions  of  differ- 
ent parts  of  the  gland  are  probably  differences  of 
degree  rather  than  of  kind.  A  selective  action  of 
the  secretion  from  different  parts  of  the  gland  is 
not  yet  proved  and  if  it  exists  is  probably  quanti- 
tative. 

7.  The  therapeutic  value  of  ovarian  prepara- 
tions in  our  experience,  may  be  stated  somewhat 
as  follows :  All  the  ovarian  preparations  exert  a 
specific  influence  on  hot  flushes.  In  this  respect 
the  residue  is  the  most  intensive,  but  the  difference 
in  efficacy  of  the  various  preparations  depends  to 
some  extent  on  the  idiosyncrasy  of  the  patient. 


November  6,  1920.] 


HIRST:  OBSTETRICAL  TRAINING. 


701 


In  the  treatment  of  menstrual  irregularities  ovar- 
ian extracts  exhibit  an  undoubted  specific  action 
but  this  action  is  inconstant.  In  temporary  func- 
tional amenorrhea,  delayed  menses,  dribbling  before 
and  after  catamenia,  and  small  clotting,  ovarian 
therapy  is  fairly  reliable,  and  is  at  least  the  best 
asset  that  the  gynecologist  at  present  possesses  for 
these  symptoms.  Theoretically  for  these  affections 
the  ovarian  action  may  be  enhanced  by  the  addition 
of  thyroid  and  pituitary  extracts,  but  of  this  our 
personal  clinical  experience  has  not  been  entirely 
convincing. 

For  the  permanent  amenorrheas,  especially  those 
associated  with  pluriglandular  disturbances,  ovar- 
ian therapy  has  little  or  no  effect  on  restoring  the 
menstrual  function,  but  is  of  undoubted  value  in 
improving  the  patient's  general  health.  It  is  best  in 
these  cases  to  administer  the  ovarian  treatment  in 
considerable  doses,  separately  from  the  other  gland 
extracts. 

In  certain  types  of  dysmenorrhea  ovarian  feed- 
ing is  efficacious,  occasionally  brilliantly  so,  but  it 
is  unreliable  and  often  disappointing  after  giving 
early  promise.  In  the  severe  types  of  dysmenorrhea 
it  is  of  comparatively  little  help.  For  menorrhagia 
and  metrorrhagia  ovarian  therapy  is  not  indicated. 


THE  OBSTETRICAL  DEPARTMENT  OF  A 
MODERN  MEDICAL  SCHOOL.* 

The  Equipment,  Organization,  and  Scope 
of  Teaching. 

By  Barton  Cooke  Hirst,  M.  D., 
Philadelphia. 

It  is  a  noteworthy  fact  that  the  revolutionary 
changes  in  the  teaching  and  practice  of  obstetrics 
in  the  United  States  during  the  past  twenty  years 
has  received  little  attention.  In  the  forty-four 
volumes  of  the  transactions  of  the  American  Gyne- 
cological Society,  among  the  many  papers  presented 
at  the  annual  meetings  I  remember  but  one  that 
dealt  with  the  improved  training  of  young  physi- 
cians who  will  be  our  successors.  Has  not  the 
American  Gynecological  Society  thus  lost  an  oppor- 
tunity for  leadership  which  would  have  added  to  its 
prestige  and  influence?  The  trustees  of  medical 
schools,  advisory  committees,  state  legislatures  and 
boards,  naturally  turning  to  the  leading  national 
society  for  advice  and  information,  must  have  been 
astounded  at  its  aridity  in  this  field.  My  endeavor 
in  this  communication  is  to  make  a  tardy  amend  for 
the  neglect  of  a  question  which,  it  would  seem, 
might  have  excited  interest  and  received  careful  con- 
sideration long  ago. 

There  are  medical  schools  still  undergoing  reor- 
ganization under  private  control.  Legislatures  must 
give  this  matter  thought  in  organizing  the  increas- 
ing number  of  schools  supported  by  the  State,  the 
expense  of  technical  education  often  making  private 
management  impracticable. 

It  is  in  the  hope  of  furnishing  information  for 
the  governing  bodies  of  such  institutions,  and  to  give 
aid  and  support  to  the  teachers  who  are  ambitious 

*Read  before  the  American  Gynecological  Society. 


to  have  their  departments  as  nearly  as  possible  on 
an  ideal  basis,  that  the  following  propositions  are 
advanced.  In  a  medical  school  designed  for  about 
four  hundred  students  in  a  four  years'  course,  the 
equipment  of  an  obstetrical  department  which  en- 
titles it  to  a  respectable  position  must  consist  of  : 

1.  \  hospital  of  at  least  one  hundred  beds, 
with  a  clinical  amphitheatre ;  a  separate  operating 
room  for  septic  patients  and  an  isolated  space  for 
infected  women.  The  apportionment  of  beds  should 
exceed  that  for  surgery  or  medicine,  for  the  aver- 
age instructive  capacity  of  each  case  in  obstetrics 
is  limited  in  the  majority  of  instances  to  one  or  two 
students. 

2.  An  ambulatory  dispensary  for  the  preliminary 
study  of  patients  and  for  the  followup  observation 
and  treatment  of  all  patients  after  discharge  from 
the  hospital.  Such  a  dispensary  accumulates  in 
time  a  large  service  illustrating  all  the  pathological 
sequellae  of  parturition,  including  practically  all  the 
diseases  of  women.  It  should  be  equipped  with 
every  appliance,  including  electrical,  for  treating 
women,  and  should  have  a  social  service  department 
attached  to  it. 

3.  An  outpatient  department,  with  the  necessary 
personnel  of  nurses,  physicians  and  social  service 
workers.  This  department  should  have  a  separate 
ambulatory  dispensary.  On  a  basis  of  about  two 
thousand  women  cared  for  in  their  homes  annually 
an  enormous  dispensary  attendance  can  be  secured 
of  women  awaiting  delivery  and,  by  a  followup 
system,  of  women  suffering  from  any  of  the  com- 
plications or  sequellae  of  the  process  of  generation 
at  any  stage.  This  service  is  a  valuable  feeder  to 
the  central  hospital,  to  which  all  patients  requiring 
operative  or  other  hospital  treatment  are  referred. 

It  is  evident  that  such  an  organization  gives  the 
obstetrical  department  an  amount  of  clinical  mate- 
rial in  all  the  conditions  peculiar  to  women  that  no 
other  department  can  rival  or  even  approach.  What 
is  more  important,  every  tlierapeutic  measure  re- 
quired by  women  can  be  shown  to  the  student ;  the 
preventive  treatment  of  gynecological  affections  by 
the  proper  management  of  labor ;  the  relationship 
of  diseases  of  the  pelvic  organs  to  the  reproductive 
function ;  the  effect  of  operative  measures  on  sub- 
sequent childbearing  and  vice  versa.  In  short,  to 
any  intelligent  student  the  necessity  is  made  obvious, 
of  a  closely  correlated  study  of  all  the  pathological 
and  physiological  phenomena  of  the  female  genera- 
tive organs ;  the  effect  of  the  former  on  fecundity 
and  reproduction,  and  the  causative  relationship  of 
parturition  to  the  vast  majority  of  women's  diseases. 

Such  is  the  broad  view  of  modern  education, 
contrasting  strikingly  with  the  provincial  American 
practice  of  the  past;  an  obstetrical  department  con- 
cerned only  with  the  delivery  of  women  without 
regard  to  their  future  and  a  misnamed  gynecological 
department  dealing  only  with  a  moiety  of  the  sub- 
ject; busily  engaged  for  the  most  part  in  patching 
up  the  results  of  other  physicians'  bad  obstetrics. 
Such  an  arrangement  was  evidently  doomed  to 
extinction  by  modern  progress  and  could  no  more 
be  revived  than  we  could  recall  to  life  the  elder 
Mr.  Weller. 

The  medical  pedagogues  of  America  must  agree 


702 


BLAND:  DISPLACEMENT  OF  UTERUS. 


[New  York 
Medical  Journal. 


with  their  confreres  in  the  rest  of  the  world  that 
the  scope  of  obstetrical  teaching  embraces  not  only 
the  physiology  and  pathology  of  reproduction  but 
necessarily  all  the  diseases  of  women.  The  chief 
of  an  obstetrical  department  must  be  a  thoroughly 
trained  abdominal  and  pelvic  surgeon  maintaining 
proficiency  in  his  art  by  constant  practice.  Other- 
wise he  is  not  fit  for  his  position  and  would  be 
incompetent  to  deal  with  the  cases  that  may  be 
admitted  to  his  clinic  at  any  moment ;  ruptured 
uterus  with  injury  of  intestines,  requiring  resection ; 
diaphragmatic  hernia  in  pregnancy ;  discovery  of 
disease  of  the  gallbladder  in  the  course  of  an  ab- 
dominal operation,  and  so  on  through  a  long  list. 
In  brief  he  must  be  prepared  to  deal  surgically  or 
otherwise  with  all  the  ills  of  women  whether  com- 
plicating pregnancy,  labor  and  the  puerperium  or 
often  their  indirect  consequence. 

We  have  in  the  University  of  Pennsylvania  a 
voluntary  and  a  compulsory  student's  internship 
in  the  maternity  hospital ;  the  amount  of  material 
he  sees,  the  notes  he  takes,  and  his  conduct  on  the 
service  are  collated  to  establish  his  rating  in  the 
final  examination.  I  find  this  record  of  a  student's 
clinical  opportunities  during  a  voluntary  intern- 
ship of  two  weeks :  Seven  normal  deliveries,  an 
extraperitoneal  Csesarean  section,  transverse  pre- 
sentation with  version,  Csesarean  section  for  pla- 
centa prsevia,  compound  presentation  with  two 
feet,  hand,  occiput  and  prolapsed  cord,  a  Caesarean 
section  for  a  monster,  dicephalus  tetrabrachius,  ten 
plastic  operations,  two  ovarian  cysts,  a  hydrosal- 
pinx, a  salpingitis,  an  exploratory  laparotomy,  a 
supravaginal  hysterectomy,  a  large  ovarian  cyst,  a 
cancer  of  the  sigmoid :  resection,  six  dilatations  and 
curettage,  three  appendectomies,  a  gas  anesthesia,  a 
radium  application,  two  intravenous  injections  of 
salt  solution,  a  blood  transfusion,  two  inevitable 
abortions,  a  uterine  irrigation,  and  a  ruptured  ecto- 
pic gestation. 

This  same  intern  had  another  compulsory  week's 
internship  in  the  hospital ;  a  two  weeks'  voluntary 
service  in  the  outpatient  department  and  another 
compulsory  ten  day  period ;  a  year  of  theoretical 
lectures ;  another  year  of  clinics,  conferences,  sec- 
tion work  and  ward  classes  in  which  he  saw,  heard 
described,  and  personally  assisted  in  the  treatment 
of  a  large  additional  number  of  cases,  such  as  have 
just  been  detailed.  The  following  question  natur- 
ally suggests  itself :  If  the  chief  of  an  obstetrical 
department  must  be  an  accomplished  pelvic  and 
abdominal  surgeon ;  if  his  department,  properly 
organized  and  conducted,  controls  an  amount  of 
clinical  material  that  no  other  can  rival ;  if  he  alone 
in  the  medical  faculty  can  teach  all  the  conditions 
which  the  physician  must  treat  in  women,  is  it 
pedagogically  or  economically  justifiable  to  main- 
tain in  a  medical  school  a  socalled  gynecological 
department,  which  can  only  duplicate  the  teaching 
of  the  surgical  and  obstetrical  departments  and  in 
a  manner  necessarily  inferior  to  both?  This  ques- 
tion has  already  been  answered  in  the  only  way 
it  could  be  answered  by  the  majority  of  our  best 
medical  schools ;  it  is  being  answered  as  opportunity 
occurs  by  vacancies  in  existing  chairs,  and  it  will 
presently  be  answered  conclusively  and  finally. 


As  an  interested  observer,  an  occasional  partici- 
pant in  the  transactions  and  an  old  member  of  the 
American  Gynecological  Society,  it  appears  to  me 
impolitic  to  allow  a  movement  which  vitally  con- 
cerns us  all  to  gain  irresistible  headway  and  to 
reach  its  ultimate  goal,  apparently  ignored  by  the 
very  organization  that  should  have  fostered  and 
directed  it. 

The  reason  for  our  attitude  is  obvious :  some  of 
the  members  might  fear  an  interference  with  their 
vested  interests.  Others,  disinterested,  might,  in 
the  spirit  of  a  laudator  temporis  acti,  be  honestly 
convinced  that  the  old  order  should  not  be  disturbed. 
But  the  issue  is  too  important  to  be  influenced  by 
selfinterest  or  unprogressive  minds.  This  is  the 
only  country  in  the  world  now  rich  enough  to  ad- 
equately equip  its  medical  schools ;  consequently  the 
hegemony  of  the  medical  education  of  the  world 
lies  within  our  grasp  if,  having  the  money,  we  have 
the  wit  to  seize  it. 

Apparently  the  world's  centre  of  wealth,  power 
and  civilization,  shifting  with  the  ages  from  Meso- 
potamia, Egypt,  Greece,  Rome,  and  Northern  Eu- 
rope, is  moving  to  this  continent.  It  is  an  inspir- 
ing thought  that  each  one  of  us  puny  mortals  in 
his  tiny  sphere  may  play  a  part  in  such  a  stupendous 
cosmic  drama.  Let  us  teachers  of  one  of  the  most 
important  medical  branches  put  our  house  in  order, 
that  we  may  merit  a  place  among  those  who  assist 
and  do  not  hinder  the  passage  to  America  of  the 
world's  leadership  in  medical  education. 


TREATMENT  OF  DISPLACEMENT 
OF  THE  UTERUS. 

By  P.  Brooke  Bland,  M.  D.,  F.  A.  C.  S., 
Philadelphia, 

Gynecologist    to    St.    Josephs    Hospital,    Assistant    Gynecologist  to 
Jefferson  Hospital,  Assistant  Professor  of  Gynecology,  Jefferson 
Medical  College. 

PROGRESS  IN  GYNECOLOGY. 

No  division  of  medical  science  has  made  more 
rational  and  definite  progress  than  that  of  gynecol- 
ogy. Nearly  all  the  lesions  affecting  the  pelvic 
organs  of  women  have  become  so  definitely  classi- 
fied tliat  there  is  practically  universal  unanimity  as 
to  the  methods  to  be  instituted  in  treatment.  To- 
day indiscriminate  sacrifice  of  reproductive  struc- 
tures has  given  place  to  judicious  conservatism. 
Acute  pelvic  infection  is  no  longer  considered  or 
treated  as  a  surgical  emergency  with  the  accom- 
panying high  degree  of  mortality,  morbidity  and 
the  useless  sacrifice  of  the  most  vital  organs  of  a 
woman's  body.  Postabortive  and  postpuerperal  in- 
fections are  now  largely  regarded  as  medical  and 
not  surgical  conditions  and,  therefore,  are  treated 
along  conservative  medical  lines.  Premalignant 
conditions  of  the  cervix  are  recognized  and  their 
serious  significance  is  becoming  more  and  more  ap- 
preciated. These  lesions,  fortunately,  are  being 
treated  less  and  less  by  expectant  medical  measures 
and  prophylactic  surgical  procedures  are  being 
promptly  applied.  There  is  no  longer  discussion 
as  to  the  proper  course  in  ruptured  extrauterine 
pregnancy,  a  topic  that  prominently  held  the  stage 
until  a  few  years  ago.   The  introduction  of  radium, 


November  6,  1920.] 


BLAND:  DISPLACEMENT  OF  UTERUS. 


703 


however,  has  somewhat  upset  the  estabHshed  views 
concerning  the  treatment  of  uterine  fibroids  and 
carcinoma,  but  the  majority  of  investigators  are 
unanimous  in  believing  that  early  surgical  inter- 
vention is  still  the  method  of  choice.  This  is  as  it 
should  be,  because  no  human  mind  can  fully  com- 
prehend the  true  cellular  nature  of  a  neoplasm  in- 
volving the  organs  concealed  within  the  pelvic 
cavity. 

GENERAL  CONSIDERATION  OF  MALP0SITI.0N. 

However,  in  the  treatment  of  malpositions  of  the 
uterus,  there  is  still  a  divergence  of  opinion,  but 
the  majority  of  authors  are  advocating  and  em- 
ploying surgical  methods.  This  is  due  to  the  fact 
that  no  attempt  has  been  made  to  draw  a  sharp 
dividing  line  between  what  constitutes  on  the  one 
hand  a  medical,  and  on  the  other  a  true  surgical 
displacement.  Hence  many  men  apply  operative 
measures  indiscriminately  to  all.  Before  institut- 
ing any  plan,  the  indications  for  treatment  should 
be  most  thoroughly  considered  and  surgical  methods 
only  should  be  utilized  in  those  cases  associated  with 
distinct  concrete  surgical  complications,  such  as 
lesions  involving  the  vaginal  walls,  the  cervix,  the 
uterine  body  or  the  structures  in  intimate  pelvic 
relation  with  this  organ.  Medical  and  mechanical 
means  are  definitely  indicated  in  the  simple,  uncom- 
plicated malpositions.  These  methods  should  be 
utilized  especially  in  virgin  women,  in  young  mar- 
ried women,  in  freely  movable  uteri  and  also  in 
the  prolapsus  of  elderly  women  of  poor  surgical 
resistance.  Indeed,  no  simple,  uncomplicated  mal- 
position of  the  uterus  should  be  regarded  as  a  sur- 
gical lesion  and,  therefore,  displacements  of  this 
nature  should  not  be  corrected  by  surgical  methods. 
A  simple  displacement  is  defined  as  one  not  asso- 
ciated with  pathological  change  in  the  organ  itself 
or  in  the  surrounding  structures.  This  definition 
seems  entirely  superfluous,  but  yet,  as  previously 
remarked,  the  distinction  between  this  form  and  the 
socalled  pathological  type  is  not  sharply  drawn  and 
surgical  measures  are  applied  to  all. 

Unquestionably,  today,  the  uterus  in  simple  mal- 
position is  more  sinned  against  than  sinning.  This 
is  especially  true  in  this  country,  and  have  we  not 
swung  the  surgical  pendulum  a  little  too  far?  Are 
not  too  many  patients  being  operated  upon  ?  Are 
we  not  building  up  a  major  surgical  condition  from 
a  minor/  medical  lesion  ?  Certainly  we  have  been 
more  assiduously  attentive  in  a  surgical  way  to  this 
condition  than  our  confreres  in  Europe.  Too  fre- 
quently, indeed,  we  utilize  surgical  intervention 
without  paying  due  regard  to  the  causative  factors, 
and  I  am  persuaded  that  before  deciding  on  any 
method  we  should  weigh  more  carefully,  investigate 
more  thoroughly,  not  only  the  pelvic,  but  the  sys- 
temic condition  of  our  patients  as  well.  Surely 
one  cannot  hope  to  afford  relief  by  operating  upon 
patients  who  are  nervously  and  muscularly  wracked. 
It  is  needless  to  state  that  a  stem  pessar}-  can- 
not possibly  accomplish  good  for  a  patient  with  a 
congenitally  antiflexed,  ill  developed  uterus,  yet  this 
socalled  simple,  but  really  dangerous  and  at  times 
harmful,  procedure  is  employed  all  too  commonly. 
A  uterus  of  this  type  is  not  the  disease,  but  only  a 
local  pelvic  manifestation  of  systemic  trouble.  A 


rudimentary  organ  of  this  character  usually  occurs 
in  large,  obese  women.  This  feature  tells  the  tale 
of  ductless  glands  or  endocrine  dysfunction  and 
should  be  ample  warning  to  any  observer  as  to  the 
futility  of  operation,  such  as  curettage,  the  use  of 
the  metranoikter,  stem  pessary,  or  any  of  the  other 
operative  procedures  commonly  in  vogue  today.  It 
is  inconceivable  that  the  Dudley  or  Pozzi  operations 
should  ever  be  performed  for  the  condition  described 
above  and  that  these  means  should  afford  relief  is 
likewise  beyond  comprehension.  In  these  patients 
a  general  survey  of  the  body  should  be  a  signal 
sufficient  to  tell  us  to  leave  the  uterus  alone.  The 
multiplicity  of  surgical  agencies  recommended  and 
employed  in  acute  anteflexion  should  also  be  sufifi- 
cient  evidence  to  show  that  we  are  still  distant  from 
an  infallible  remedy  and,  moreover,  that  surgical 
treatment  has  failed  to  afford  the  results  desired. 
Will  any  operation  prove  beneficent  to  poor  nerv- 
ously and  muscularly  incompetent  women  with  the 
intraabdominal  strucutres  in  a  state  of  general 
dependency  or  ptosis?  In  these  cases,  should  not 
the  malposed  uterus  be  regarded  as  a  concomitant 
of  the  condition  and  not  as  a  separate  entity?  The 
urologist  and  general  surgeon  have  recognized  the 
true  status  of  the  socalled  floating  kidney  and  the 
voluminous  reports  of  operation  for  this  condition 
which  formerly  appeared  in  our  literature  have 
practically  disappeared.  Will  we,  as  gynecologists, 
study  the  physiognomy  of  the  malposed  uterus  with 
the  same  degree  of  interest  and  intelligent  inter- 
pretation ? 

LAW  OF  MALPOSITION. 

It  is  absolutely  incumbent  upon  the  profession 
to  keep  in  mind  that  no  set  rule  applies  to  all  cases. 
Every  displacement  is  a  distinct  law  unto  itself, 
and  will  require,  therefore,  specific  methods  of 
treatment.  Undoubtedly  many  patients  will  never 
get  well  unless  operated  upon,  but  it  is  not  the 
function  of  this  paper  to  discuss  displacements  of 
a  surgical  nature.  It  is  my  purpose  to  limit  the 
consideration  of  the  subject  to  medical  and  me- 
chanical treatment  and  I  shall  consider  the  various 
malpositions  separately.  One  of  the  most  annoy- 
ing, discouraging  and  distressing  types  of  malposi- 
tion is  socalled  acute  anteflexion. 

ACUTE  ANTEFLEXION. 

The  condition  described  uijder  this  term  rarely, 
if  ever,  occurs  as  a  distinct  concrete  pathological 
lesion.  Indeed,  as  a  separate  entity  it  is  of  doubt- 
ful existence.  In  the  light  of  our  present  knowl- 
edge concerning  the  endocrine  system,  should  it  not 
be  regarded  as  a  physical  phenomenon  or  sign  of 
ductless  gland  disturbance  and  not  a  pathological 
condition  of  the  uterus?  Certainly  the  very  un- 
happy and  discouraging  results  obtained  by  local 
surgical  treatment  should  be  sufficient  to  force  us 
to  place  acute  anteflexion  in  the  category  of  disease 
in  which  it  rightfully  belongs.  While  associated  with 
local  symptoms,  such  as  scanty  or  absent  menstrual 
flow,  dysmenorrhea  and  sterility,  these  symptoms 
are  seldom  overcome  by  the  local  surgical  agencies 
in  common  employment  today.  Rarely  are  these 
patients  permanently  benefited  by  curettage,  the  use 
of  the  metranoikter,  the  stem  pessary,  Dudley  or 


704 


BLAND:  DISPLACEMENT  OF  UTERUS. 


[New  York 
Medical  Journal. 


Pozzi  operation,  or  any  other  surgical  measure  used 
at  the  present  time.  I  have  never  seen  the  stem 
drain  or  pessary  overcome  steriHty  nor  reUeve 
dysmenorrhea  for  more  than  a  period  of  three  or 
four  months,  and  most  assuredly  these  implements 
cannot  possibly  have  any  influence  in  establishing 
a  normal  menstrual  flow.  I  have  personally  seen 
serious  damage  result  from  the  use  of  these  instru- 
ments and  the  untold  harm  that  results  from  their 
general  employment  is  incalculable.  Infection  and 
permanent  functional  damage  frequently  result 
from  the  use  of  the  curette.  This  is  likewise  true 
of  the  stem  drain  and  the  latter  instrument  cannot, 
indeed,  be  used  without  danger. 

We  have  at  the  present  time  under  our  care  two 
young  women  suffering  from  extensive  pelvic  peri- 
tonitis resulting  from  the  use  of  the  latter  imple- 
ment.   Recently  we  operated  upon  a  girl  nineteen 
years  of  age  for  a  vesicovaginal  fistula.    The  open- 
ing in  the  bladder  wall  was  three  eighths  of  an  inch 
in  diameter  and  resulted  from  the  bar  or  the  arm 
of  the  pessary  rubbing  and  perforating  the  bladder 
cavity.    Therefore,  should  not  the  unhappy  results 
obtained  by  the  surgical  methods  as  practised  today 
be  sufficient  grounds  to  bar  their  continuance  or  at 
least  modify  their  use?    For  some  years  I  have 
entirely  abandoned  the  use  of  curettage  and  the 
stem  pessary  in  the  treatment  of  acute  anteflexion 
and  I  most  emphatically  disapprove  of  their  use  for 
this  condition.    A  uterus  in  the  majority  of  cases 
in  acute  anteflexion  should  be  looked  upon  as  a  local 
evidence  of  systemic  disease  and  any  effort  at  treat- 
ment, therefore,  must  be  directed  along  systemic 
medical  lines.    One  should  keep  in  mind  that  a 
certain  proportion  of  these  patients  will  not  be 
benefited  at  all  by  any  measure  and  in  so  far  as 
the  local  uterine  condition  is  concerned,  it  should 
be  placed  in  the  category  of  incurables.    No  known 
medical  or  operative  agency  will  cause  a  uterus  to 
grow.    An  infantile  uterus  in  an  adult  woman  will 
remain  infantile  forever,  regardless  of  any  plan  of 
treatment,  and  the  sterility  associated  with  the  con- 
dition will  likewise  persist  indefinitely.    The  obes- 
ity, amenorrhea  and  dysmenorrhea,  so  frequently 
an  accompaniment  of  the  trouble,  may  be  (to  a 
certain   degree)    modified,   but   not   cured.    In  a 
moderate  degree  of  infantilism,  however,  function 
in  a  small  proportion  of  cases  occasionally  is  re- 
stored, but  in  pronounced  cases  never.    Should  we 
not,  therefore,  cease  chasing  the  will  o'  the  wisp 
and  not  only  face  the  truth,  but  tell  the  truth  as 
well?    Too  frequently  these  patients  are  persuaded 
to  believe  their  symptoms  will  be  overcome  by 
surgery  and  all  too  soon  is  their  dream  of  promised 
happiness  shattered. 

TREATMENT    OF   ACUTE  ANTEFLEXION. 

In  the  condition  under  discussion,  four  condi- 
tions are  confronted,  each  demanding  specific  con- 
sideration and  attention.  First,  obesity ;  second, 
sterility ;  third,  partial  or  complete  amenorrhea,  and 
fourth,  painful  menstruation  or  dysmenorrhea. 
Perhaps  the  condition  can  well  be  described  by  out- 
lining a  typical  case. 

Case. — At  the  present  time,  I  have  under  my 
care  a  single  woman,  twenty-six  years  of  age.  She 
is  five  feet  two  inches  in  height,  and  weighs  236 


pounds.  Her  menstruation  was  established  at  four- 
teen and  always  has  been  more  or  less  irregular. 

At  present  it  recurs  every  three  or  four  months 
and  is  manifested  not  by  a  flow,  but  simple  spot- 
ting. The  duration  is  less  than  a  day  and  the  dis- 
charge is  accompanied  by  violent  pelvic  pain.  Her 
uterus  is  typical  of  the  infantile  type.  The  cervix 
is  long  and  its  diameter  does  not  exceed  the  tip  of 
my  little  finger.  The  dimensions  of  the  uterine 
body  are  all  contracted  and  the  organ  is  half  the 
size  of  the  normal  virgin  structure.  Systemically 
she  presents  the  train  of  nervous  phenomena  asso- 
ciated with  endocrine  dysfunction  and  rarely,  as 
personally  expressed,  "do  I  enjoy  a  well  day."  This 
patient  is  responding  well  to  treatment.  During 
the  first  four  weeks  she  lost  twenty-six  pounds  in 
weight.  Her  nervous  state  is  much  improved.  Her 
menstruation  recurs  regularly.  The  flow  is  mod- 
erate in  amount,  the  duration  is  from  two  to 
three  days,  and  the  pain  has  been  decidedly  relieved. 
There  is  no  palpable  change  in  the  uterine  cervix 
or  body,  but  the  general  improvement  and  the 
restoration  of  ovarian  function  have  been  remark- 
able indeed. 

The  marked  obesity  observed  in  these  patients 
must  be  overcome  by  a  strict  dietary  regime.  It 
should  be  the  custom  to  strike  and  strike  hard  at 
this  phase  of  the  trouble  and  endeavor  to  reduce 
the  patient  twenty  or  twenty-five  pounds  during 
the  first  four  weeks  of  treatment.  This  can  be 
readily  accomplished  by  feeding  the  patient  proteid 
broths,  green  vegetables,  raw  fruit  and  fruit  juices. 
We  generally  instruct  the  patient  to  begin  feeding 
at  seven  or  eight  a.  m.  and  eat  regularly  every  three 
hours  for  twelve  hours  or  from  seven  or  eight  a.  m. 
to  seven  or  eight  p.  m.,  taking  a  cup  of  hot  broth 
with  a  vegetable,  a  raw  fruit  or  fruit  juice.  Tea 
or  coffee  without  sugar  or  cream  may  also  be  taken. 
This  regime  is  rarely  a  hardship  and  we  have  never 
experienced  any  difficulty  in  having  the  plan  carried 
out.  After  the  initial  rapid  loss,  the  diet  is  still 
restricted  so  that  a  progressive  loss  of  from  five 
to  ten  pounds  a  month  is  maintained  until  the 
patient  returns  to  a  relatively  normal  weight.  We 
have  succeeded  by  this  plan  in  subtracting  from 
fifty  pounds,  in  mild  cases,  to  seventy-five  pounds 
or  more  in  marked  cases.  In  addition  to  a  strict 
dietary  regime,  scrupulous  attention  should  be  given 
to  the  bowels.  Two  evacuations  daily  should  be  in- 
sisted upon  and  these  should  be  accomplished,  if 
necessary,  by  the  use  of  a  saline  purge.  The  skin 
should  be  kept  active  by  systematic  exercise,  ob- 
tained either  in  employment  or  by  walking  and  also 
by  a  hot  tub  bath  on  retiring. 

The  obesity  and  other  systemic  phenomena  are 
also  favorably  influenced  by  the  administration  of 
the  organic  extracts  and  furthermore  these  sub- 
stances, in  many  instances,  exert  a  happy  effect 
on  the  menstrual  disturbance.  Frequently,  these 
agents  will  increase,  prolong,  regulate,  and  occa- 
sionally reestablish  the  flow.  Occasionally,  also, 
the  dysmenorrhea  is  relieved.  While  not  wishing 
to  go  on  record  as  asserting  that  these  agents  will 
cure  sterility,  yet  I  ha\'e  seen  apparently  hopeless 
cases  of  the  condition  overcome  and  patients  con- 
ceive.   Even  so  I  still  ask  myself :  "Was  the  result 


November  6,  1920.] 


BLAXD:  DISPLACEMENT  OF  UTERUS. 


705 


a  coincidence  or  due  to  the  drugs?"  For  several 
years  we  have  used  singly  and  in  combination  all 
of  the  organic  preparations,  but  for  the  past  three 
years  we  have  settled  down  to  a  combination  of 
three :  Thyroid  extract,  pituitary  extract,  and  ovarian 
extract.  \\'e  begin  with  a  small  dose,  starting  with 
one  grain  of  each  in  capsule  three  times  daily  and 
continue  for  three  weeks.  We  then  stop  for  a 
period  of  one  week,  at  the  end  of  which  time  we 
begin  with  two  grains  in  capsule  three  times  daily 
for  three  weeks,  again  discontinuing  'the  prepara- 
tion for  a  week.  We  then  give  three  grains  of  each 
drug  in  a  capsule  three  times  daily  for  another  three 
weeks,  stopping  a  week  and  then  continuing  with 
the  figure  three,  three  grains,  three  capsules,  three 
times  daily,  three  weeks,  for  a  period  of  six  months 
or  a  year.  By  thus  increasing  the  materials  gradu- 
ally and  with  a  rest  period  no  cumulative  action, 
toxic  or  untoward  efifects  have  occurred.  Despite 
the  plan  herewith  outlined,  dysmenorrhea  frequently 
persists  and  we  are  not  familiar  with  any  agent  that 
will  afford  complete  or  permanent  relief.  Benzyl 
benzoate,  a  substance  on  which  we  all  based  so 
much  confidence  and  hope,  has  been  generally 
disappointing.  The  coal  tar  preparations  are  not 
satisfying  and  opium  or  any  of  its  derivatives  we 
never  recommend  or  use.  Therapeutically,  dys- 
menorrhea has  no  specific  and  is  one  condition,  to 
use  a  homely  yet  descriptive  phrase,  in  which  we 
are  truly  "up  against  it.'" 

uteroVagixal  prolapse. 
This,  excepting  inversion,  is  the  most  infrequent 
type  of  malposition  and  is  more  of  an  obstetrical 
than  a  gynecological  problem.  It  constitutes  about 
five  per  cent,  of  all  displacements  and  usually  fol- 
lows a  recent  labor.  The  term  is  descriptive  and 
implies  that  the  displacement  involves  primarily  the 
uterine  body.  It  usually  follows  a  long,  hard,  tedi- 
ous labor  in  a  patient  unable  to  obtain  the  requisite 
rest  of  a  normal  lying-in  period.  It  is  seen  in 
women  who  are  unable  or  unwilling  to  take  advan- 
tage of  necessary  care  after  labor.  Therefore,  the 
trouble  can  largely  be  prevented  by  proper  prophy- 
lactic measures.  Indeed,  if  all  labor  cases  could 
be  cared  for  proper^-,  uterovaginal  prolapse  would 
exist  only  in  name.  On  the  part  of  the  obstetrician, 
three  conditions  may  be  mentioned  as  causative 
factors :  hastily  forced  deliver}',  neglect  in  failing 
to  carry  out  primary  repair  of  all  lacerations,  and 
failure  to  insist  on  requisite  rest  after  delivery; 
on  the  part  of  the  patient,  too  early  resumption  of 
the  care  of  the  baby  and  household  duties,  habitual 
overdistention  of  bladder,  and  violent  straining  in 
endeavoring  to  evacuate  the  bowels.  The  treatment 
then  is  summed  up  largely  in  the  word  prophy- 
lactic, on  the  part  of  both  doctor  and  patient.  If, 
however,  one  is  confronted  with  an  actual  condition, 
the  patient  should  be  forced  to  secure  absolute  rest. 
The  care  of  the  baby  so  far  as  possible  should  be 
placed  in  hands  other  than  those  of  the  mother. 
The  knee  chest  position  should  be  assumed  for 
fifteen  minutes  morning  and  evening,  the  bladder 
should  be  emptied  every  three  or  four  hours  and 
the  bowels  should  be  evacuated  daily  without 
straining,  assisted,  if  necessary,  with  one  of  the 
heavy  mineral  oils  or  a  low  cleansing  enema.  If 


the  uterus  is  enlarged,  subinvoluted  and  heavy, 
depletion  and  reduction  should  be  accomplished  by 
glycerinized  tampons  and  copious  hot  vaginal 
douches.  The  uterus  should  also  be  maintained  in 
position  by  the  introduction  of  a  properly  fitting 
pessary,  preferably  of  the  Thomas-^Iunde  type. 
Finally  the  sine  qua  non  is  rest,  and  no  treatment 
will  avail  unless  this  is  placed  first  in  importance. 

VAGIXOUTERIXE  PROLAPSE. 

This  is  the  most  common  type  of  surgical  dis- 
placement and  an  advanced  degree  of  this  condition 
cannot  possibly  be  corrected  permanently  and  com- 
pletely without  surgical  treatment.  Xo  medical  or 
mechanical  measure  can  overcome  the  second  or 
third  degree  of  the  lesion,  but  the  majority  of 
cases  of  the  first  stage,  as  expressed  in  the  term 
retroversion  or  retroflexion,  if  uncomplicated,  can 
be  treated  successfully  by  medical  and  mechanical 
means.  Included  then  under  this  heading  are 
mild  uncomplicated  cases  of  prolapsus,  retrover- 
sion and  retroflexion.  Before  considering  specifically 
the  treatment  of  these  conditions,  I  should  like  to 
refer  to  their  symptomatology.  Undoubtedly  the 
accusations  charged  against  these  lesions  have  no 
foundation  in  fact.  It  is,  indeed,  questionable 
whether  uncomplicated  retrodisplacements  ever  cause 
any  symptoms,  although  all  varieties  of  disturb- 
ances are  attributed  to  them.  All  forms  of  auto- 
nomic nerve  phenomena  are  frequently  assumed  to 
originate  in  displacements  of  this  character.  Locally, 
backache,  pelvic  discomfort  or  pain,  bladder  irrita- 
tion, rectal  irritability  and  gastrointestinal  disorders 
are  described  as  symptoms  resulting  from  malpo- 
sitions of  this  nature.  This  description  of  the 
symptomatology  is  far  from  the  truth,  as  abundantly 
proved  by  the  small  percentage  of  symptomatic 
recoveries  occurring  in  patients  operated  upon. 
Rarely,  indeed,  does  surgical  procedure  relieve 
either  the  local  or  general  disturbance  and  the  symp- 
toms persist  despite  operative  correction.  There- 
fore, to  attribute  such  a  vast  symptomatology  to 
this  condition  is  fallacious.  Rather  should  the 
uterine  condition  be  regarded  as  a  result,  not  a 
cause  of  the  autonomic  relaxation.  Xo  normal 
movable  appendage  ever  creaks  or  breaks  the  back 
of  the  parent  tree  and  the  same  may  be  said  of  the 
uterus.  It  cannot  possibly  cause  backache,  nervous 
phenomena  or  any  other  of  the  great  train  of  symp- 
toms of  which  it  is  accused,  regardless  of  positjon, 
so  long  as  the  organ  remains  natural  in  size  and 
normal  in  mobility.  Too  many  socalled  backaches 
are  attributed  to  the  "uterus  pressing  against  the 
spine."  and  the  sooner  we  sever  ourselves  from  this 
hereditary  belief  the  sooner  will  we  care  for  our 
patients  more  intelligently,  the  sooner  escape  the 
deserved  opprobrium  in  failing  to  give  our  patients 
relief. 

The  first  consideration  in  treatment  of  uncom- 
plicated retrodisplacements  should  be  directed  along 
systemic  lines.  Everv-  possible  efTort  should  be 
exerted  to  restore  the  patient  to  a  normal  physical 
and  psychical  status.  The  importance  of  muscular 
rehabilitation  must  also  be  kept  constantly  in  mind. 
Nerve  and  muscle  reconstruction  are  accomplished 
by  freeing  the  patient  from  all  nerv-ous  worry  and 
fatigue,  by  obtaining  for  her  an  abundance  of 


706 


HEINEBERG:  DISEASES  OF  THE  CERVIX. 


[New  York 
Medical  Journal. 


physical  and  mental  rest,  by  systematic  forced  feed- 
ing and  by  graduated  exercise  in  wholesome  fresh 
air.  Proper  and  well  fitting  clothing  should  be 
worn.  Overdistention  of  the  bladder  should  be 
prohibited  and  a  daily  easy  evacuation  of  the  bowels 
should  be  insisted  upon,  for  no  other  factors  are 
so  active  in  causation  as  these.  Constipation  must 
^  be  absolutely  overcome,  for  recovery  cannot  pos- 
sibly occur  with  the  patient  \nolently  increasing  the 
intraabdominal  pressure  with  every  attempt  at  fecal 
evacuation.  For  this  purpose  drugs  should  not  be 
employed,  unless  absolutely  necessary.  Mineral  oil 
may  be  utilized,  but  a  laxative  diet  with  massage 
and  exercise  of  the  abdominal  muscles  are  more 
desirable  and  more  lastingly  efficient.  Locally,  a 
copious  hot  vaginal  douche  of  one  or  two  gallons 
of  plain  hot  water  should  be  taken  morning  and 
evening.  If  the  uterus  is  large  and  heavy,  glycer- 
inized  tampons  should  be  introduced  twice  weekly. 
The  knee  chest  posture  should  be  assumed  for  a 
period  of  fifteen  minutes,  morning  and  evening. 
Manual  reposition  of  the  uterine  body  should  be 
performed  and  its  position  maintained  by  the  intro- 
duction of  a  properly  fitting  hard  rubber  pessary. 

PROLAPSUS   IX   ELDERLY  WOMEN. 

In  marked  prolapsus  of  elderly  women  of  low- 
surgical  resistance,  even  in  complete  prolapsus, 
medical  and  mechanical  methods,  while  not  curative, 
will  afiFord  the  patients  untold  relief.  Again  the 
importance  of  regular  bladder  and  bowel  action 
cannot  be  overemphasized.  Overcome  constipation 
and  uterine  displacements,  a  fertile  field  for  the 
gynecologist,  would  largely  disappear.  Accomplish 
reduction  or  replacement  manually  and  follow  this 
by  the  introduction  of  a  Menge  pessary.  The 
patient  should  be  instructed  to  keep  the  parts 
scrupulously  clean  by  using  a  plain  hot  water  douche 
morning  and  evening.  At  the  end  of  six  or  eight 
weeks  the  pessary  should  be  removed,  cleansed  and 
reintroduced.  If  the  parts  have  undergone  involu- 
tion or  contraction,  as  frequently  occurs,  a  smaller 
sized  instrument  should  be  used.  If  the  pessary 
is  worn  for  a  considerable  period  of  time  involution 
of  the  vaginal  walls  always  takes  place  and  pro- 
gressive reduction  in  the  size  of  the  implement, 
therefore,  becomes  absolutely  imperative.  After 
wearing  the  instrument  for  six  months  or  a  year, 
the  patient  may  be  allowed  to  discard  it  for  a 
period  of  two  or  three  months  at  a  time ;  indeed,  in 
some  instances  recovery  is  so  marked  that  one  could 
almost  term  it  complete. 

SUMMARY. 

1.  Therapeutically  there  is  a  distinct  need  for  a 
specific  line  of  division  between  medical  and  surg- 
ical malpositions. 

2.  The  symptomatology  of  uterine  displacements, 
in  general,  as  taught  today  is  erroneous.  This  is 
confirmed  by  the  small  percentage  of  socalled  cures 
following  operation. 

3.  Uncomplicated  malpositions  should  be  treated 
by  medical  and  mechanical  means.  Operative  meas- 
ures should  be  applied  to  those  associated  with  dis- 
tinct surgical  complications. 

4.  Operative  intervention  should  not  be  utilized 
in  the  simple  malpositions  of  virgins  or  young  mar- 
ried women. 


5.  The  infantile  uterus  never  requires,  nor  is  the 
condition  benefited  by  surgery.  Endocrine  dysfunc- 
tion as  an  etiological  factor  should  be  remembered. 
This  condition  should  be  treated  and  not  the  uterus. 

6.  Nerve  and  muscle  relaxation  (backache)  should 
be  regarded  as  a  causative  factor  and  not  the  result 
of  uterine  malposition. 

7.  Restoration  of  nerve  and  muscle  power  should 
be  restored  in  all  cases  and  is  best  accomplished  by 
rest  and  generous  feeding. 

8.  In  no  case  of  retroflexion  or  retroversion  will 
the  patient  recover  in  the  presence  of  obstinate  con- 
stipation or  bladder  overdistention.  Overcome  con- 
stipation and  malpositions  will  largely  disappear. 

9.  The  prolapsus  of  old  women  with  low  surgical 
resistance  is  best  treated  mechanically  by  the  Menge 
pessary. 

1621  Spruce  Street. 


DISEASES  OF  THE  CERVIX  UTERI.* 

By  Alfred  Heineberg,  P.  D.,  M.  D., 
Philadelphia, 

.Associate  in  Gynecology,  Jeflferson  Medical  College;  Obstetrician  to 
the  Jewish  Maternity;  Assistant  Gynecologist,  St.  Agnes  Hospital. 

The  ease  with  which  the  cervix  may  be  amputated 
has,  I  am  convinced,  frequently  led  to  its  removal 
without  due  consideration  of  other  possible  means 
of  restoring  it  to  a  healthy  condition.  A  careful 
study  of  the  afterefYects  of  amputation  of  the  cervix, 
as  ordinarily  performed,  must  reveal  that  frequently 
the  immediate  result  and  at  times  the  influence  upon 
subsequent  pregnancy  leave  much  to  be  desired.  In 
most  instances  the  amputation  is  done  to  remove  a 
cervix  which  has  undergone  hypertrophy  and  ero- 
sion. Such  conditions  result  from  laceration  and 
eversion  with  exposure  of  the  mucous  lining  of  the 
cervical  canal  to  infection,  trauma  and  irritation  of 
the  acid  vaginal  secretion.  To  insure  complete  re- 
moval of  the  diseased  cervical  mucosa  and  eroded 
area,  the  internal  incision  in  the  formation  of  the 
flaps  must  be  made  so  high  across  the  mucous  mem- 
brane of  the  cervical  canal  in  most  cases  that  the 
canal  or  internal  os  may  be  iippaired.  The  latter 
may  be  left  in  a  state  of  wide  dilatation ;  the  for- 
mer may  be  tightly  constricted  by  a  ring  of  cicatrix 
perpendicular  to  the  long  axis  of  the  cervix  formed 
at  the  edges  ©f  the  apposed  flaps.  A  permanently 
dilated  internal  os  favors  infection  of  the  uterine 
cavity,  with  the  production  of  a  leucorrheal  dis- 
charge which  is  much  more  difficult  to  cure  than 
that  which  resulted  from  the  preexisting  cervical 
disease.  More  important  than  the  annoyance  of  the 
discharge  is  the  influence  of  the  infected  uterine 
mucosa  and  widely  patulous  os  upon  subsequent 
pregnancy.  Both  produce  unfavorable  conditions 
for  the  retention  of  the  impregnated  ovum  in  the 
uterine  cavity.  Several  cases  of  inevitable  abortion 
have  come  under  my  observation  in  women  who, 
before  amputation  of  the  cervix,  had  had  no  diffi- 
culty whatsoever  in  carrying  a  fetus  to  full  term. 

I  recall  especially  one  patient  from  whom  I  had 
to  remove  retained  products  of  conception  as  a 

*Read  before  the  Northern  Medical  .\ssociation  of  Philadelphia, 
May  14,  1920. 


November  6,  1920.] 


HEINEBERG:  DISEASES  OF  THE  CERVIX. 


707 


result  of  spontaneous  abortion  in  the  twelfth  week 
of  gestation,  two  years  after  a  high  cervical  ampu- 
tation. She  had  undergone  three  normal  preg- 
nancies prior  to  the  operation.  About  a  year  fol- 
lowing the  abortion  I  was  asked  to  see  her  again 


KiG.  1. — Introduction  of  sutures  in  the  modified  Bonney  suture. 

by  her  physician,  and  found  her  in  the  tenth  week 
of  gestation  with  evidences  of  another  threatened 
abortion,  and  it  was  only  by  enforced  rest  in  bed 
for  a  number  of  weeks  that  we  were  able  to  insure 
the  continuation  of  the  p^-egnancy. 

Leonard  (1)  has  reported  abortion  or  premature 
labor  in  fifty-five  per  cent,  of  the  pregnancies  oc- 
curing  in  women  whose  records  could  be  traced 
after  amputation  of  the  cervix  in  Johns  Hopkins 
Hospital. 

Stenosis  of  the  cervical  canal  produced  by  a 
dense  ring  of  scar  tissue  formed  along  the  edges 
of  the  flaps  may  obstruct  the  flow  of  menstrual 
discharge  and  be  the  cause  of  dysmenorrhea.  Such 
a  cicatricial  ring  may  produce  a  prolonged  and  ex- 
hausting labor  and  uterine  dystocia  because  of  the 
inability  of  the  cervix  to  dilate  properly.  Indeed 
in  some  instances  the  cicatrix  may  refuse  to  dilate 
sufficiently  to  permit  the  passage  of  the  fetus.  Leon- 
ard found  that  in  nearly  seventy  per  cent,  of  the 
cases  of  amputation  of  the  cervix  the  patients  subse- 
quently had  difficult  labor.  In  two  patients  I  was 
forced  to  make  bilateral  incisions  in  such  a  cicatrix 
to  insure  complete  dilatation  of  the  cervix  and  per- 
mit the  progress  of  the  fetus  through  the  birth 
canal.  In  addition  to  the  unsatisfactory  results  thus 
far  considered,  failure  to  produce  pleasing  cosmetic 
effects  by  the  usual  method  of  suturing  the  flaps 
in  the  high  Schroeder  amputation  of  the  cervix  has 
induced  me  to  seek  and  finally  adopt  measures  which 


have  served  to  overcome  the  objectionable  features 
of  the  older  operations.  These  I  shall  describe 
later  on. 

No  method  of  operation,  however,  will  diminish 
the  necessity  for  high  amputation  of  the  cervix  in 
cases  of  extensive  hypertrophy  and  erosion,  because 
an  operation  which  does  not  remove  all  of  the  path- 
ological tissue,  especially  the  eroded  surface,  is  only 
partially  successful.  Any  part  of  the  erosion  which 
is  allowed  to  remain  will  continue  to  discharge  and 
in  time  spread  over  the  adjacent  surface  of  the  re- 
paired cervix  and  thus  lessen  the  benefit  which  the 
operation  should  have  afforded.  In  so  far  then  2/ 
amputation  of  the  cervix  is  concerned,  the  follow 
ing  possibilities  always  may  confront  us :  a,  stenosi\ 
of  the  canal ;  b,  permanent  dilatation  of  the  internal 
OS,  and,  c,  failure  resulting  from  insufficient  removal 
of  diseased  tissue. 

Since  the  amount  of  cervical  tissue  to  be  removed 
must  be  controlled  by  the  extent  of  the  erosion,  en- 
docervicitis  and  hypertrophy,  it  would  seem  advis- 
able to  reduce  these  pathological  changes,  if  possible, 
by  other  methods  of  treatment  in  order  to  limit  the 
extent  of  the  amputation  or  to  abolish  the  necessity 
for  its  performance.  Emmet  and  others  of  the 
older  operators  recognized  the  advisability  of  such 
procedure,  but  its  practice  has  been  neglected  in  re- 
cent years,  much  to  the  detriment  of  the  patient. 
It  has  been  my  practice  in  the  last  three  years  to 
subject  all  patients  suffering  from  a  combination 
of  erosion,  endocervicitis,  laceration  and  hypertrophy 
of  the  cervix  to  a  method  of  treatment  found  to  be 
uniformly  successful  in  restoring  the  cervix  to  a 
healthy  state  before  operation.  In  many  instances 
operations  have  been  avoided  on  cervices  which 
would  formerly  have  been  subjected  to  high  ampu- 
tation. It  is  the  method  employed  in  producing 
these  results  that  I  want  particularly  to  describe. 

The  secret  of  success  lies  in  the  preparation  of 


,! 


Fig.  2. — Sutures  in  the  cervical  wall  at  the  edge  of  the  internal' 
flap. 

the  cervical  mucous  membrane  for  the  reception  of 
the  active  medicating  agent.  We  know  that  the 
cervical  canal  in  health  contains  a  plug  of  clear, 
tenacious  mucus.  In  pathological  conditions  the 
cervical  secretion  is  increased  in  quantity  and  be- 


708 


HEIXEBERG:  DISEASES  OF  THE  CERVIX. 


[Xew  York 
Medical  Journal. 


comes  thick,  cloudy,  mucopurulent,  and  still  more 
tenacious.  Most  of  the  medicinal  agents,  such  as 
silver  nitrate,  phenol,  formalin  or  the  organic  silver 
compoimds,  which  are  useful  in  the  treatment  of 
diseased  mucous  membrane,  coagulate  mucus  as  soon 
as  they  come  in  contact  with  it.    The  resulting  dense 


Fig.   3. — Sutures  completed   showing  the  tension  distributed. 

wall  of  coagulum  acts  as  a  barrier  to  the  access  of 
the  medicinal  agent  to  the  mucous  membrane  and 
diminishes  whatever  effect  it  might  have.  Complete 
removal  of  the  secretion  cannot  be  eft'ected  by  swab- 
bing with  gauze  or  cotton,  or  by  the  use  of  a  suc- 
tion apparatus,  and  these  methods  when  persisted 
in  frequently  cause  bleeding,  which  still  further 
counteracts  the  action  of  the  medicament. 

After  experimenting  with  dift'erent  methods.  I 
have  found  that  the  cervical  discharge  can  be  easily 
and  thoroughly  dissolved  or  dislodged  by  irrigation 
of  the  cervical  canal  with  a  weak  alkaline  solution 
of  the  following  formula  : 

Sodii  bicarb.,  J  ' 

Sodii  chlorid,  >-  aa  gr.  xl 

Sodii  borat.  ) 

Aqua.  q.  s  01 

I  use  for  the  purpose  a  large  syringe,  the  tip  of 
which  is  introduced  well  into  the  cervical  canal  and 
the 'fluid  expelled  under  sufficient  pressure  to  dis- 
lodge the  mucus.  Several  injections  may  be  neces- 
sary.   There  is  not  much  likelihood  of  forcing  the 


Fig.  4. — Angulated  tenacula  for  hemostasis. 


solution  into  the  uterine  cavity,  unless  the  internal 
OS  is  dilated  or  too  much  force  is  employed.  Before 
beginning  the  treatment,  the  condition  of  the  in- 
ternal OS  should  be  determined  with  a  thin  sterile 
probe.   If  it  is  found  too  much  dilated,  as  it  rarely 


is,  the  alkaline  solution  should  be  applied  on  cotton 
wrapped  applicators  instead  of  by  irrigation.  After 
the  cervical  mucous  membrane  is  entirely  clean  it 
should  be  thoroughly  dried  with  absorbent  cotton, 
when  it  is  ready  for  the  application  of  the  medicat- 
ing agent.  I  find  no  drug  so  good  as  silver  nitrate 
for  the  purpose  of  curing  erosion  and  endocervi- 
citis.  In  the  aggravated  cases  of  long  standing,  in 
which  the  mucosa  is  greatly  thickened  and  the 
erosion  extensive,  I  begin  the  treatment  with  a 
fifty  per  cent,  solution,  applied  every  three  or  four 
days.  The  first  few  applications  are  likely  to  cause 
bleeding  from  the  eroded  surface.  As  the  discharge 
lessens  in  amount  and  becomes  thinner  and  less 
purulent,  the  strength  of  the  solution  is  gradually 
decreased  to  ten  per  cent. 

If  the  cervix  is  large  and  boggy,  the  applications 
of  the  silver  nitrate  are  supplemented  with  borogly- 
cerin  tampons  until  the  cervix  is  reduced  in  size. 
The  patient  is  given  a  prescription  for  the  alkaline 
powder,  with  directions  to  use  one  tablespoonful  in 


Fig.  5. — ^Angulated  forceps  applied  to  cervix  above  level  of  am- 
putation. 


two  quarts  of  water  as  a  vaginal  douche  once  or  twice 
a  day,  depending  upon  the  amount  of  discharge.  It 
is  most  gratifying  to  observe  the  changes  which  take 
place  in  the  cervix  under  this  treatment.  The  ero- 
sion gradually  decreases  in  area  through  substitution 
of  stratitied  squamous  for  the  thin  columnar  epithel- 
iinn.  The  change  can  be  well  seen  at  the  edges 
where  the  ingrowth  of  squamous  epithelium  radiates 
toward  the  internal  os.  In  addition,  islands  of 
squamous  epithelium  may  be  frequently  observed  in 
the  centre  of  the  erosion,  looking  very  much  like 
small  skin  grafts  on  a  granulating  surface. 

By  the  time  the  erosion  has  disappeared,  the  cer- 
vical mucosa  has  returned  to  its  normal  state,  the 
discharge  has  decreased  in  amount,  and  resumed 
its  clear,  mucoid  character.  Furthermore,  the  size 
of  the  cervix  will  have  perceptibly  diminished 
through  the  removal  of  the  underlying  cause  of  the 


November  6,  1920.] 


HEIXEBERG:   DISEASES   OF    THE  CERVIX. 


709 


6.— Seventh  stage 
of  bloodless  repair. 


hypertrophy,  except  in  those  cases  of  a  very  tough, 
fibrous  cervix.  In  many  cases  I  have  observed  a 
shrinkage  of  fifty  per  cent,  in  the  size  of  the  cervix. 
The  time  required  to  produce  the  desired  resuhs 
by  this  treatment  varies  between  three  and  six 
months.    Its  distinct  advantage  is  that  it  lessens  the 

necessity  for  extensive 
amputation.  The  cases 
of  bad  erosion  and 
ectropion  which  were 
formerly  subjected  to 
high  amputation  in 
order  to  get  rid  of  the 
diseased  tissue  require 
after  the  treatment  only 
trachelorrhaphy  or  a 
moderate  amputation, 
if  any  at  all. 

In  Leonard's  most 
instructive  and  impor- 
tant essay,  to  which 
reference  has  been 
made,  he  has  brought 
out  the  advantages  of 
trachelorrhaphy  over 
amputation.  He 
showed  that  after  tra- 
chelorrhaphy, as  com- 
pared with  amputation, 
there  was  an  increase 
in  fertility,  a  decrease 
in  the  frequency  of 
abortion  and  premature  labor,  and  a  more  favorable 
influence  upon  the  character  of  the  first  labor  after 
the  operation.  He  reports  fertility  in  thirty-eight 
per  cent,  of  the  cases  after  trachelorrhaphy  as 
against  nineteen  and  four  tenths  per  cent,  after  the 
amputation.  Abortion  and  premature  delivery  oc- 
curred in  twenty-eight  per  cent,  of  the  trachelor- 
rhaphy cases  and  in  fifty-five  per  cent,  of  the  ampu- 
tation cases.  The  character  of  the  first  labor  after 
each  operation  is  interesting.  "Following  amputa- 
tion of  the  cervix,  the  first  labor  was  difficult  in 
seven  of  the  eleven  cases.  In  striking  contrast  to 
this  result  is  the  fact  that  in  eight  of  the  ten  cases 
of  full  term  pregnancy  following  trachelorrhaphy 
labor  had  been  easy."  In  addition  to  these  figures 
of  Leonard,  other  authors  have  shown  that  dystocia 
after  amputation  of  the  cervix  (due  to  cicatricial 
stenosis)  is  not  only  of  frequent  occurrence  but  it 
may  reach  any  extreme,  even  causing  rupture  of  the 
uterus.  "After  trachelorrhaphy,  dystocia  has  evi- 
dently seldom  been  met  with,  for  references  to  its 
occurrence  are  very  scarce." 

If  after  the  treatment  of  the  cervix  described 
herein  an  amputation  of  moderate  extent  is  still  re- 
quired to  reduce  the  hypertrophy  and  relieve  the 
ectropion,  it  should  be  undertaken.  In  order  to  re- 
duce the  stenosis  following  the  amputation  and  to 
eliminate  the  uneven  surface  produced  by  the  older 
plan  of  tying  the  sutures  over  the  edges  of  the  flaps, 
I  resorted  to  the  Bonney  suture  to  invert  the  long, 
external  flap  of  the  amputated  cervix.  Unfortu- 
nately, the  traction  of  the  suture  not  infrequently 
caused  sloughing  of  the  central  area  of  the  inverted 
flap,  and  left  an  ulceration  which  occasionally  per- 


sisted for  a  long  time  and  in  cicatrization  caused  a 
depression  resembling  a  laceration,  which  detracted 
from  an  otherwise  satisfactory  result.  This  defect 
of  the  Bonney  suture  has  been  overcome  in  my  later 
cases  by  introducing  both  ends  of  the  suture  about 
one  quarter  of  an  inch  back  of  the  edge  of  the 
external  flap  and  then  carrying  them  through  the 
cervical  wall  at  the  edge  of  the  internal  flap  before 
they  are  tied  to  each  other.  (Figs.  1,  2  and  3.)  This 
modified  method  eliminates  the  pressure  caused  by 
tying  the  suture  over  the  edge  of  the  flap,  distributes 
the  tension  over  a  wider  area,  prevents  sloughing, 
and  gives  a  better  cosmetic  result. 

During  the  last  two  years  I  have  further  improved 
the  cosmetic  effect  of  amputation  by  exercising 
greater  precision  in  fashioning  the  flaps  and  more 
exact  coaptation  of  their  edges.  These  results  have 
been  rendered  easier  by  securing  a  bloodless  field 
of  operation. 

The  technic  of  bloodless  repair  which  I  have 
elsewhere  described  combines  simplicity,  ease  of  ap- 
plication, and  efficiency.  Hemostasis  is  secured 
through  the  use  of  two  angulated  tenaculum  for- 
ceps (Fig.  4)  and  a  rubber  band  about  one  quarter 
inch  wide.  The  chief  feature  of  the  forceps,  in 
addition  to  the  angulation,  is  a  pedunculated  ball 
which  is  attached  to  the  outer  aspect  of  each  blade 


Fig.  7. — Handles  of  forceps  separated  to  be  held  by  the  assistant. 

above  the  angle.  The  balls  serve  the  purpose  of 
retaining  the  rubber  band  in  a  position  to  compress 
the  cervix  above  the  grasp  of  the  forceps.  The 
technic  is  as  follows : 

I.  Introduce  a  self  retaining  speculum  into  the 
vasrina. 


710 


WEST:  AMPUTATION  OF  CERVIX. 


[Xew  York 
Medical  Journal. 


2.  Grasp  the  anterior  lip  of  the  cerv^ix  in  the  me- 
dian line  with  an  ordinary  double  tenaculum. 

3.  Dilate  the  cervix  moderately,  chiefly  to  deter- 
mine the  precise  location  and  direction  of  the  canal. 

4.  Draw  the  cervix  toward  one  side  and  apply 
the  angulated  forceps  to  the  cervix,  well  above  the 
level  of  the  proposed  amputation  or  denudation. 
(Fig.  5.) 

Draw  the  cervix  to  the  other  side  and  apply  the 
second  angulated  forceps  opposite  the  first  one. 

6.  Remove  the  ordinary  tenaculum. 

7.  Place  the  handles  of  the  forceps  together, 
stretch  the  rubber  ring  over  them  and  push  the  ring 
up  on  the  cervix  to  a  point  above  the  retaining  balls. 
(Fig.  6.) 

8.  Separate  the  handles  of  the  forceps  and  hand 
them  to  an  assistant.  (Fig.  7.) 

It  will  be  observed  that  the  forceps  thus  held  act 
also  as  lateral  retractors  of  the  vagina.  During  the 
progress  of  the  operation,  the  assistant  should  avoid 
undue  tension  on  the  forceps  or  unnecessary  separa- 
tion of  the  handles,  in  order  to  prevent  making  a 
ragged  tear  in  the  cervix  with  the  points  of  the 
forceps.  After  the  repair  has  been  completed,  cut 
the  rubber  ring  and  remove  the  forceps.  The  for- 
ceps and  ring  may  be  removed  before  the  sutures 
are  tied. 

The  application  of  these  methods  in  over  one 
hundred  cases  personally  treated  has  shown  that  in 
more  than  half  of  them  medical  treatment  alone  was 
sufficient  to  cure  the  existing  cervical  disease.  In  most 
of  the  others,  either  trachelorrhaphy  or  moderate 
amputation  restored  the  cervix  to  a  practically  nor- 
mal state. 

REFERENCES. 

1.  Leox.\rd,  V.  N. :  The  Postoperative  Results  of  Trach- 
elorrhaphy in  Comparison  with  Those  of  Amputation  of  the 
Cervix,  Surgery,  Gynecology,  and  Obstetrics,  Januan,\  1914, 
pp.  35-45. 

SiXTEEXTH  AXT)  SpRUCE  StREETS. 

AMPUTATIOX  OF  THE  CERVIX  UTERI. 
Bv  James  X.  West.  M.  D., 

Xew  York. 

Professor  of  Diseases  of  Women,  Post-Graduate  Medical 
School  and  Hospital. 

This  operation  I  believe  to  be  one  of  the  most 
important  that  the  surgeon  is  called  upon  to  per- 
form, on  account  of  the  frequency  with  which  the 
necessit}-  for  it  arises,  and  its  effectiveness  in  ac- 
complishing the  objects  desired.  The  fact  that  its 
performance  is  usually  required  upon  women  in 
the  most  active  and  responsible  period  of  their  lives, 
where  the  necessity  for  health  and  freedom  from 
symptoms  accompanying  laceration  of  the  cervix  is 
most  important  to  their  well  being  and  efficiency 
must  also  be  considered.  Perhaps  its  greatest  and 
most  important  use  is  in  prevention  of  cancer.  The 
writer  believes  that  he  has  demonstrated  with  many 
others,  that  the  incidence  of  cancer  of  the  lacerated 
cei-vices  is  about  six  times  as  frequent  as  in  the 
unlacerated  (1  to  9).  If  this  is  true,  the  surgeon 
has  no  better  field  of  endeavor  in  cancer  preven- 
tion than  here,  where  by  restoring  the  cervix  to  a 
healthy  condition,  he  could  prevent  five  out  of  six 


cases  of  cancer  of  this  part  of  the  body.  For  can- 
cer of  the  cervix  occurs  about  six  times  as  fre- 
quently in  lacerated  cervices  as  it  does  in  the  un- 
lacerated. The  writer  does  not  believe  in  doing 
everything  possible  to  increase  the  human  popula- 
tion of  the  world,  for  he  believes  that  many  evils 
and  infinite  distress  come  from  over  population, 
but  when  a  being  has  once  arrived  in  the  world, 
that  he  should  be  condemned  to  a  death  of  a  linger- 
ing, loathsome,  painful  character  is  one  of  the 
most  distressing  thoughts. 

It  seems  that  cancer  is  on  the  increase  among 
civilized  peoples,  and  its  prevention  by  any  possible 
means  therefore  assumes  proportionately  greater 
importance.  In  the  writer's  experience  the  most 
frequent  indications  for  amputation  of  the  cervix 
occur  in  the  following  order : 

1.  For  extensive  laceration  and  disease  of  the 
cervix  due  to  childbirth. 

2.  Elongation  and  hypertrophied  cervix  occur- 
ring in  prolapse  of  the  uterus. 

3.  Dysmenorrhea  and  sterility  due  to  acute  ante- 
flexion of  the  uterus. 

4.  Removal  of  the  cervix  for  chronic  gonorrheal 
endocervicitis  where  the  tubes  have  already  been 
removed. 

Amputation  of  the  cervix  for  malignant  disease 
is  not  included  here  because  today  if  we  find  ma- 
lignant disease  of  the  cervix  we  do  much  more 
extensive  operations,  although  two  decades  ago  the 
operation  done  with  a  cautery  was  advocated  by 
Byrnes  of  Brooklyn  and  had  a  considerable  vogue 
for  a  time.  But  since  this  time  the  clinic  of  Wert- 
heim  in  operative  cases  of  cancer  has  centered  the 
attention  of  the  profession  upon  the  most  radical 
procedures. 

The  technic  of  the  operation  is  practically  the 
same  in  each  of  these  conditions  except  the  second 
where  it  is  varied  to  meet  other  operative  pro- 
cedures which  are  resorted  to  for  the  cure  of 
procidentia.  The  importance  of  a  careful  technic 
here  cannot  be  exaggerated,  as  the  chief  use  of 
amputation  of  the  cervix  is  in  relief  of  chronic 
irritation  and  the  restoration  of  the  vaginal  vault 
to  a  healthy  state.  If  the  operation  is  done  hurried- 
ly and  carelessly,  leaving  little  points  of  tissue  to 
granulate  and  areas  to  cicatrize,  the  object  for 
which  it  is  performed  will  not  be  accomplished.  It 
must  be  borne  in  mind  that  it  is  a  small  organ,  not 
much  larger  than  the  eye,  and  that  therefore  proper 
instruments,  proper  suture  material,  and  a  careful 
technic  shotild  be  used. 

As  a  preliminary  step,  there  should  be  a  gentle 
but  careful  curettage  of  the  uterus,  for  in  nearly 
all  cases  of  laceration  of  the  cervix  there  is  endo- 
metrium hypertrophy  as  a  result  of  the  laceration. 
Following  the  curettage  it  is  wise  to  make  an  ap- 
plication to  the  endometrium  of  equal  parts  of  car- 
bolic acid  and  iodine,  wiping  away  the  excess  from 
the  vaginal  part  of  the  cervix,  but  not  from  the 
body  of  the  uterus.  I  advise  the  use  of  ten  day 
chromicized  catgut  sutures  as  they  have  given  satis- 
factory results.  If  plain  catgut  is  used  it  is  ab- 
sorbed too  soon  and  gaping  of  the  wound  may 
result.  For  some  reason  wounds  of  the  cervix 
do  not  heal  as  quickly  as  those  of  other  tissues  of 


November  6,  1920.] 


WEST:  AMPUTATION  OF  CERVIX. 


711 


the  body.  The  suture  material  used  should  last  at 
least  ten  days. 

OPERATION. 

A  point  is  selected  upon  the  left  side  of  the 
cervix  above  the  diseased  part  of  the  mucous  mem- 
brane and  the  mucous  membrane  is  cut  through 
to  the  solid  tissue  of  the  cervix.  The  scissors  are 
pushed  along  beneath  the  mucous  membrane  care- 


FiG.  1. — Cleveland's  needle  holder;  Emmet's  tenaculum;  Tuttle's 
cervix  scissors  (right  and  left) ;  double  volsella  forceps;  Dudley's 
cervix  needle. 

fully  preserving  the  proper  distance  from  the  os 
and  surrounding  the  cervix  with  a  circular  incision, 
which  usually  corresponds  to  the  line  surrounding 
the  cervix  at  its  greatest  periphery.  The  mucous 
membrane  of  the  vagina  is  then  wiped  back  with 
gauze  to  the  desired  height,  that  is,  to  a  point  above 
the  diseased  tissue.  The  cervix  is  then  amputated 
with  scissors  by  clean  cuts  at  right  angles  to  the 
long  axis  of  the  uterus.  Two  sutures  are  placed 
in  the  centre,  in  front,  and  two  behind  to  bind  the 
mucous  membrane  of  the  vagina  to  that  of  the 
cervix  to  insure  a  new  canal  which  will  not  con- 
tract. These  are'  passed  first,  then  the  sutures 
passing  from  before  backward,  picking  up  the  mu- 
cous membrane  of  the  vagina,  then  entering  the 
solid  tissue  of  the  cervix  beside  the  canal,  emerg- 
ing and  picking  up  the  vaginal  mucous  membrane 
of  the  posterior  wall.  From  three  to  five  sutures 
are  used  on  either  side  at  intervals  of  about  one 
quarter  of  an  inch,  picking  up  the  solid  tissue  of  the 
cervix  as  well  as  the  mucous  membrane  in  front  and 
behind.  After  all  sutures  have  been  passed,  they 
are  tied,  beginning  with  the  central  ones,  which 
pass  into  the  cervical  canal,  then  tying  those  on  the 
side.  For  better  understanding  of  the  technic,  see 
Figs.  1  and  2.  The  instruments  used  are  also 
shown  in  Fig.  1. 

HEIGHT   OF  AMPUTATIOX. 

In  cases  of  severe  dysmenorrhea  accompanying 
anteflexion  and  where  sterility  also  exists,  care 
must  be  used  not  to  amputate  the  cervix  too  high. 
If  the  amputation  extends  as  far  as  the  internal 
OS,  the  patient  will  be  unable  to  carry  a  fetus  to 
term  and  abortion  will  occur  almost  invariably  be- 
tween the  third  and  fourth  month,  the  circular 


fibres  in  the  cervix  which  keep  It  closed  having 
been  cut  away.  As  soon  as  its  tissues  become 
softened  as  a  result  of  pregnancy  and  the  fetus 
begins  to  attain  weight,  it  sags  down  into  the  lower 
segment  which  starts  dilatation  with  the  invariable 
result  of  being  expelled. 

If  the  amputation  is  made  to  extend  to  a  point 
within  one  third  of  an  inch  of  the  internal  os,  it 
will  easily  accomplish  the  purpose  attempted  and 
at  the  same  time  preserve  for  the  patient  the  abil>ty 
to  carry  a  fetus  to  term. 

A  modification  of  this  operation  which  has  a 
distinct  field  of  usefulness  constitutes  a  combina- 
tion amputation  trachelorraphy.  This  is  suitable 
for  cases  in  which  the  laceration  has  extended  to 
or  almost  to  the  internal  os.  The  amputation  if 
carried  beyond  the  point  of  the  laceration  would 
remove  so  much  of  the  cervix  that  childbearing 
would  not  be  possible.  By  amputation  of  the  an- 
terior and  posterior  lips,  and  then  by  cutting  out 
a  wedge  shaped  piece  from  the  site  of  the  laceration 
on  the  sides,  the  opertition  may  be  completed,  yet 
leaving  a  sufficient  amount  of  the  cervix  to  make 
childbearing  possible.  In  labors  following  ampu- 
tation of  the  cervix,  it  is  not  especially  prone  to 
tearing,  but  if  this  should  occur  it  should  be  re- 
paired again. 

Since  amputation  of  the  cervix  is  frequently  one 
of  several  operations  done  at  the  same  time,  the 
postoperative  care  is  embraced  '  in  that  which  is 
observed  for  the  sum  total  of  the  operations  done. 
But  where  it  is  the  primary  and  chief  operation, 


Fig.  2. — Amputation  of  the  cervix  (Emmet's  method). 

the  care  resolves  itself  to  that  of  amputation  of  the 
cervix  alone.  A  patient  should  remain  in  bed  for 
at  least  ten  days.  Douches  are  unnecessary,  ex- 
cept at  about  the  tenth  day,  when  a  bichloride 
douche  of  one  to  six  thousand  may  be  given  and 
repeated  every  other  day  for  eight  days.  Other 


712 


FOU  LER:  CERVICAL  LACERATION. 


[New  York 
Medical  Journal. 


aftertreatment  consists  in  the  usual  attention  to  the 
bowels,  the  diet  and  the  general  comfort  of  the 
patient.    It  is  unnecessary  and  bad  technic  to  place 
gauze  in  or  against  the  cervix  after  operation. 
References. 

1.  West,  J.  N. :  Laceration  of  the  Cervix  Uteri,  Its  Re- 
pair and  Relation  to  the  Development  of  Carcinoma.  The 
Post-Graditate,  April,  1911. 

2.  Bashford,  E.  M.  :  Irritation  in  General  in  Its  Rela- 
tion to  Causation  of  Cancer,  Report  of  the  Imperial  Cancer 
Research  Fund,  1908. 

3.  Idem:  Third  Report  of  the  Imperial  Cancer  Re- 
search Fund,  p.  9. 

4.  Tyzzer  :  Cancer  Commission,  Harvard  University. 
Lecture  on  Tumors,  1909. 

5.  RoBSON,  A.  W.  Mayo:  British  Medical  Journal,  De- 
cember 3,  1905. 

6.  Montgomery,  E.  E.  :  Journal  A.  M.  A.,  June  4,  1907. 

7.  CoE,  H.  C. :  American  Journal  of  Obstetrics,  1909, 
vol.  lix. 

8.  Weggemberg  :  Bulletin  de  la  Societe  Beige  de  Gyne- 
cologic ct  Obstetrique,  April  22,  1909. 

9.  Sampson  :  Cancer  of  the  Uterine  Cervix,  Its  Classi- 
fication and  Extension,  Albany  Medical  Journal,  May,  1903. 

71  West  Forty-ninth  Street. 


CERVICAL  LACERATION,  CYSTOCELE, 
PROLAPSUS  UTERI,  AND  MULTIPLE 
FIBROMATA. 

By  W.  Frank  Fowler,  M.  D., 
Rochester,  N.  Y. 

Justification  for  making  this  report  rests  upon 
several  remarkable  features  of  the  case  under  dis- 
cussion and  the  information  to  be  gained  by  a 
consideration  of  the  various  etiological,  patholog- 
ical, diagnostic  and  surgical  problems  incident  to  it. 

Case. — Mrs.  S.,  a  rather  obese  woman,  aged 
forty-one,  had  always  menstruated  regularly  every 
twenty-one  days  except  during  pregnancies.  Her 
first  pregnancy  occurred  in  1901  when  a  long  and 
painful  labor  was  terminated  by  instrumental  de- 
livery at  her  home  in  the  city.  Immediate  repair 
of  an  extensive  perineal  laceration  was  made.  On 
the  day  following  delivery  packing  was  inserted  and 
left  in  situ  for  several  days  with  the  object,  she 
surmised,  of  controlling  hemorrhage.  She  remained 
in  bed  three  weeks.  Her  strength  returned  rather 
promptly. 

In  1903  she  moved  to  a  farm  where  a  full  term 
pregnancy  was  terminated  spontaneously  after  a 
fairly  easy  labor  lasting  seven  hours.  Six  months 
later  she  was  annoyed  by  a  bearing  down  feeling 
and  pain  in  the  back  and  sides  and  she  noticed 
something  protruding  from  the  vulva. 

In  1905  her  third  full  term  pregnancy  ended  in 
spontaneous  delivery  after  an  easy  labor  lasting 
four  hours.  The  bulging  later  became  more  notice- 
able and  she  began  wearing  a  cup  pessary.  With- 
out this  support  she  was  greatly  troubled  with  fre- 
quent urination  if  she  was  on  her  feet. 

In  1907  she  again  became  pregnant.  She  was 
miserable  much  of  the  time,  the  protrusion  from 
the  vulva  became  very  marked  and  during  early 
pregnancy  there  was  profuse  yellow  leucorrhea 
which  became  bloody  occasionally.  She  flowed 
every  day  during  the  fifth,  sixth  and  seventh  months. 
This  pregnancy  ended  at  the  eighth  month  in  a 


spontaneous  delivery  after  a  labor  lasting  six  hours. 
The  child  lived  only  two  hours.  Again  she  ex- 
perienced, as  after  the  preceding  pregnancy,  an  in- 
creased protrusion  if  the  pessary  was  not  worn. 
The  three  spontaneous  deliveries  were  endured 
without  anesthesia.  During  the  past  ten  3'ears  she 
had  had  leucorrhea.  One  year  ago  she  began  to 
gain  in  weight.  Recently  the  pessary  had  failed 
to  function  and  disability  due  to  the  cystocele  had 
become  extreme.    Otherwise  she  felt  perfectly  well. 

Examination  under  anesthesia  revealed  a  very 
large  cystocele  and  a  second  degree  prolapsus  uteri. 
The  cervix,  apparently,  v.-as  the  seat  of  an  extensive 
bilateral  laceration  of  the  usual  type  with  widely 
separated  anterior  and  posterior  lips.  Further  ex- 
amination, however,  disclosed  a  slit  seetningly  in 
the  posterior  lip  and  extending  clear  through  it. 
Investigation  of  this  opening  showed  that  it  was, 
in  reality,  the  lower  cervical  canal  terminating 
below  in  the  external  os.  The  relatively  small  pos- 
terior lip  was  behind  it.  The  condition,  then,  proved 
to  be  a  transverse  tear  slightly  below  the  cervico- 
vaginal  junction  extending  entirely  through  the  an- 
terior lip  and  across  the  midcervical  canal.  The 
bulky  portion  of  the  anterior  lip  below  the  tear  had 
swung  down  and  concealed  the  posterior  lip  behind 
it.  The  walls  of  the  tear  were  amply  protected  by 
epithelial  covering,  but  the  floor  consisted  of  eroded 
mucosa. 

Operation  March  11,  1920:  The  Mayo  procedure 
for  the  relief  of  cystocele  and  uterine  prolapse  was 
done.  The  ovaries  and  fallopian  tubes  were  not 
removed.  The  operation  was  unduly  prolonged, 
first,  because  the  general  nodular  irregularity  of 
uterine  outline  due  to  unsuspected  multiple  fibro- 
mata contributed  to  the  difficulties  of  hysterectomy, 
(one  tumor,  in  particular,  the  size  of  a  walnut, 
bulged  into  the  septum  between  the  uterus  and  the 
bladder),  and  second,  because  approximation  and 
suture  of  the  broad  ligaments  behind  the  clamps 
was  difficult  due  to  tension.  It  was  decided,  on 
account  of  the  time  consumed,  to  repair  the  perineum 
ten  days  later.  Recovery  from  both  operations 
was  uncomplicated.  The  suggestion  of  Frank  (1) 
that  the  administration  of  ether  causes  a  constant 
lowering  of  the  carbon  dioxide  capacity  of  the  blood 
plasma  in  direct  proportion  to  the  duration  of  anes- 
thesia merits  serious  consideration. 

Pathological  report :  Multiple  leiomyofibromata, 
subperitoneal,  intramural  and  submucous ;  mild 
cystic  glandular  hyperplasia  of  cervix  with  active 
chronic  cervicitis ;  greatly  increased  vascularity  of 
cervix  with  hyperkeratosis. 

Mayo  (2)  mentions,  among  the  indications  for 
his  operation,  the  usual  age  limits  of  forty-five  to 
sixty-five  years  and  a  particular  applicability  to  the 
relief  of  uterine  prolapse  of  the  third  and  fourth 
degree.  He  also  reminds  us  that  when  difficulty 
in  approximation  of  the  broad  ligaments  is  antici- 
pated uterine  tissue  may  be  retained  on  both  sides. 
Although  my  patient  was  only  forty-one  years  old, 
the  prolapsus  was  merely  of  the  second  degree  and 
uterine  tissue  could  not  be  utilized  to  bridge  the 
gap,  nevertheless,  the  procedure  seemed  well  adapted 
to  relieve  the  pathological  entity. 

The  indications  for  cervical  repair  or  amputation, 


November  6,  1920.] 


FOWLER:  CERVICAL  LACERATION. 


713 


Goldspohn  (3)  observes,  are  to  be  found  in  the 
pathological  induration  resulting  from  previous  in- 
fection and  inflammation  following  laceration  rather 
than  the  laceration  per  se.  Goldspohn  believes  that 
the  pathological  condition  requiring  operation  is  so 
generalized  in  the  cervical  tissues  that  amputation 
of  the  gland  bearing  lower  half  of  the  cervix  is  the 
operation  of  choice.  Sturmdorf  (4)  also  states  that 
the  occurrence  of  infection  rather  than  the  mere 
incidence  or  degree  of  laceration  determines  the 
morbidity  of  a  cervical  lesion.  Sturmdorf  notes, 
too,  that  the  theory  of  reflex  neuroses  from  alleged 
"pinching  of  the  cervical  nerves  by  scar  tissue  in 
the  angles  of  laceration,"  is  almost,  but  not  quite, 
obsolete.  ^ 

Regarding  the  occurrence  of  carcinoma  following 
cervical  lacerations,  Ewing  (5)  writes,  "Cervical 
carcinoma  is  strongly  influenced  by  childbirths, 
which  average  over  five  in  such  patients.  While 
carcinoma  seldom  develops  in  scars,  yet  repeated 
cervical  lacerations  disturb  the  normal  structure 
and  functions  of  this  tissue,  interfere  with  its  nutri- 
tion and  expose  its  weakened  structure  to  chronic 
irritation  and  inflammation.  A  chronic  endocer- 
vicitis  precedes  cancer  in  a  majority  of  cases  and 
the  routine  examination  of  this  tissue  reveals  ab- 
normalities in  the  morphology  and  position  of  the 
epithelium  which  constitute  precancerous  conditions. 
The  most  prominent  of  these  conditions  is  the  cerv- 
ical erosion,  many  of  which  show  suspicious  hyper- 
trophy and  heterotopia  of  the  lining  epithelium." 

In  view  of  the  fact  that  the  patient  in  the  case 
under  discussion  had  three  deliveries  through  a 
shortened  cervical  canal,  a  consideration  of  the 
effect  of  amputation  of  the  cervix  upon  future 
pregnancies,  from  the  viewpoint  of  tissue  loss,  at 
least,  would  not  be  amiss.  Leonard  (6)  concludes, 
from  a  careful  investigation  of  the  literature,  that 
"a  pregnancy  occurring  after  amputation  of  the 
cervix  has  not  more  than  an  even  chance  of  pro- 
gressing to  term." 

Pavlik  (7)  reports  a  personal  case  with  the  fol- 
lowing history : 

Case. — Mrs.  S.,  aged  twenty-five,  married  six 
years,  had  a  difficult  forceps  delivery  eighteen  months 
after  marriage.  She  had  a  miscarriage  a  year  later 
at  three  months.  Shortly  afterward  an  amputation 
of  a  badly  lacerated  cervix  was  done.  Since  the 
operation  she  has  had  three  miscarriages  at  six  and 
a  half,  four  and  three  months  respectively.  I  saw 
her  in  the  third  month  of  her  sixth  pregnancy.  She 
complained  of  pain  and  bleeding.  Two  days  later 
she  miscarried.  At  present  she  is  again  about  two 
months  pregnant." 

Pavlik  emphasizes  the  importance  of  determining, 
if  possible,  the  role  pfayed  by  the  cervix  during 
pregnancy  and  labor,  and  states  his  belief  that  at 
all  events  "the  cervix  acts  as  does  a  puckering  string 
to  a  bag,  or  as  a  stopper  to  a  bottle,  so  far  as  it 
relates  to  the  gestating  uterus,  and  its  removal  sub- 
jects the  patient  to  the  danger  of  uterine  evacuation 
at  all  stages  of  pregnancy." 

Holmes  (8),  on  the  other  hand,  admits  the  pos- 
sibility of  premature  labor  following  amputation 
of  the  cervix  but  not  so  early  that  a  living  child 
might  not  be  delivered,  because  it  is  very  near  ter- 


mination of  labor  before  the  internal  os  gives  way. 
Holmes  concludes,  therefore,  that  the  cervix  plays 
an  unimportant  part  in  gestation.  Sturmdorf  concurs 
with  a  statement  that  pregnancy  and  labor  are  in- 
trinsically corporeal  functions.  Clinically,  Holmes 
found,  merely,  that  after  amputation  of  the  cervix 
the  earmarks  of  labor  were  lost  and  the  labor  was 
exceedingly  easy  and  uneventful.  Heaney  (9)  also 
has  observed  easy  labors  following  amputation  of 
the  cervix. 

The  question  of  the  advisability  of  conserving 
normal  ovaries  in  hysterectomy  invites  discussion. 
Culbertson  (10)  defines  the  menopause  as  a  func- 
ti6nal  derangement  on  the  part  of  various  glands 
of  the  endocrine  system  subsequent  to  the  cessation 
of  the  ovarian  secretion.  During  the  early  years 
following  puberty,  for  example,  before  glandular 
harmony  has  become  established,  castration  is  pro- 
ductive of  but  slight  disturbance.  Later,  with  some 
variations,  the  longer  the  gonad  has  been  function- 
ally associated  with  the  endocrine  group  the  greater 
disturbance  there  will  be  when  that  gonad  is  with- 
drawn, and  further,  the  syndromes  following  the 
cessation  of  ovarian  secretion  present  familiar  pic- 
tures of  underactivity  or  overactivity  of  the  vari- 
ous ductless  glands.  This  glandular  interrelation 
has  been  discussed,  also,  by  Frank  (11),  Goetsch 
(12),  Graves  (13),  Loeb  (14),  Marine  (15),  Rich- 
ardson (16),  Vincent  (17),  and  others.  Culbertson 
believes  that  ovarian  tissue  should  be  retained 
whenever  surgically  possible. 

Graves  states  that  during  maturity  until  the 
menopause  the  ovary  plays  a  subordinate  but  not  an 
insignificant  role  in  the  endocrine  group.  In  the 
reproductive  system,  on  the  other  hand,  it  is  a  pre- 
dominant but  not  independent  factor,  since  its 
proper  function  depends  upon  a  normal  relation 
with  the  uterus  and  its  endometrium.  The  break- 
ing of  this  relationship  and  the  consequent  upset  of 
the  physiological  balance  of  the  endocrine  group, 
whether  by  removal  of  the  ovaries  or  of  the  uterus, 
is  of  slight  difiference  symptomatically.  Retention 
of  the  ovaries  after  hysterectomy  or  of  the  uterus 
after  oophorectomy  are  both  potentially  trouble- 
some. 

The  investigation  of  Sampson  (18)  into  the  blood 
supply  of  the  ovary  convinces  him  that  the  actual 
supply  is  derived  from  the  ovarian  and  uterine 
arteries.  The  potential  supply  is  found  in  the  com- 
munications between  the  arteries  of  the  tube  and 
of  the  broad  ligament,  branches  of  uterine  and 
ovarian  origin.  The  blood  supply  is  considerably 
jeopardized  by  salpingectomy.  The  surgeon  should 
therefore  cut  close  to  the  tube  and  avoid  mass 
ligatures  of  the  broad  ligament.  Sampson  has  fol- 
lowed, with  satisfaction,  the  safer  plan  suggested 
by  Dickinson  (19)  of  retaining  the  tubes  in  hyster- 
ectomy when  the  ovaries  are  conserved.  Dickinson, 
in  1912,  strongly  advocated  retention  of  normal 
ovaries. 

Polak  (20)  believes  that  preservation  of  the 
menstrual  function  is  the  important  consideration. 
To  that  end,  when  infected  tubes  require  removal 
and  one  or  both  ovaries  can  be  conserved,  he  pro- 
tects the  ovarian  blood  supply  by  a  technic  similar 
to  that  suggested  by  Dickinson  with  the  addition 


714 


FOWLER:  CERVICAL  LACERATION. 


[New  York 
Medical  Journal. 


of  removal  of  the  fundus  uteri.  Polak  (21)  states, 
however,  that  in  hysterectomy,  with  ligation  of  the 
uterine  arteries,  the  ovarian  blood  supply  is  seri- 
ously reduced.  The  ovaries,  too,  when  hysterec- 
tomy is  indicated,  are  frequently  abnormal.  The 
life  history  of  the  retained  ovary  is  only  about  two 
years.  Polak  has  reoperated  upon  seventy-three 
women  for  painftil  and  cystic  ovaries  within  five 
years  of  the  primar}-  procedure. 

Mneberg  (22),  in  1915,  had  reoperated  upon  two 
patients  for  cystic  degeneration  of  the  ovaries  fol- 
lowing hysterectomy  for  fibroma.  \'ineberg  con- 
cludes that : 

1.  There  is  still  uncertainty  as  to  which  tissue  in 
tlie  ovary  produces  the  internal  secretion. 

2.  Although  the  follicles  continue  to  develop  in 
the  conserved  ovary  after  hysterectomy,  it  is  uncer- 
tain that  the  function  of  the  internal  secretion  con- 
tinues uninfluenced  by  the  great  changes  in  the 
blood  supply  and  by  the  traumatism  to  the  pelvic 
sympathetic  nerves  incident  to  the  operation. 

3.  The  relative  influence  upon  the  climacteric 
syndrome  of  oophorectomy  and  injury  to  the  pelvic 
nerves  during  operation  is  undetermined. 

4.  Clinically,  there  is  slight  symptomatic  dilfer- 


FiG  1. — Posterolateral  view  showing  the  relatively  small  posterior 
lip,  the  long  glass  rod  protruding  from  the  external  os  and  above, 
the  enormous  anterior  lip  with  an  angle  of  the  laceration. 


ence  between  hysterectomy  with  and  hysterectomy 
without  oophorectomy. 

5.  Logically,  the  ovaries  should  be  retained  at  all 
ages  and  not  limited  to  these  under  forty-five  years, 
as  is  done  by  most  of  the  advocates  of  conservation, 
since  it  has  been  shown  that  of  the  women  who 
suffered  most  severely  from  the  artificial  meno- 
pause twenty-three  per  cent,  were  over  forty-five 
years  of  age. 

6.  Subsequent  disease  of  the  conserved  ovary  oc- 
curs in  some  cases. 

7.  The  clinical  advantages  accruing  from  retain- 
ing the  ovaries  in  hysterectomy  are  doubtful  and 
the  likelihood  of  subsequent  disease  and  adhesions 
of  such  ovaries  is  great.  The  ovaries  should  not  be 
retained  in  hysterectomy  unless  enough  of  the  lower 
uterine  segment  with  its  endometrium  could  be  left 
to  insure  menstruation. 

Vineberg  cites  a  case  in  which  supravaginal 
hysterectomy  had  been  performed  elsewhere.  At 
reoperation  sixteen  months  later  \'ineberg  found  the 
ovaries  to  be  free  from  adhesions.  One  ovary  was 
removed  and  proved  to  be  normal  microscopically. 
Vineberg  notes  that  conditions  were  favorable  for 
conservation  of  the  ovaries  since  the  uterus  had 
been  about  normal  in  size  and  there  was  no  dislo- 


cation of  the  site  of  the  ovaries  as  occurs  frequently 
with  fibroid  growths  of  the  uterus. 

Richardson  concludes,  on  the  other  hand,  that 
our  knowledge  of  the  complex  ovarian  function  is 
incomplete ;  that  the  uterus  is  not  essential  to  a 
continuation  of  ovarian  function  except  as  regards 
menstruation  and  reproduction :  that  the  disturb- 
ances of  ovarian  function  attributed  to  hvsterec- 
tomy  are  partly  those  associated  with  normal  men- 
struation (the  clinical  syndromes  of  menstruation 
and  of  the  physiological  and  artificial  menopatise 
difTer  chiefly  in  degree  and  rate  of  development), 
and  paitly  those  arising  from  damage  to  the  ovary 
through  unnecessary  operative  trauma  or  disease  \ 
that  the  weight  of  evidence  furnished  by  anatom- 
ical, experimental  and  clinical  investigations  is 
overwhelmingly  in  favor  of  retention  of  sound 
ovaries  both  before  and  after  the  menopause  age. 

In  response  to  a  questionnaire  the  following 
replies  were  received : 

Dr.  J.  Wesley  Bovee  (23)  :  Normal  ovaries  should 
not  be  removed  with  the  utertis  in  women  under 
forty  years  of  age.  Since  interference  with  the 
ovarian  blood  supply  is  so  great  in  hysterectomy 
by  the  ordinary  technic  that  rapid  atrophy  of  the 
ovaries  ensues  we  can  only  expect  a  slower  and 
nearer  normal  type  of  menopause  from  thus  leaving 
in  the  ovaries. 

.  Dr.  John  G.  Clark  (24)  :  I  have  always  posi- 
tively taken  the  ground  that  whenever  it  is  possible 
to  conserve  the  ovaries,  particularly  in  yotmg 
women,  it  is  the  wise  plan  to  pursue.  ...  I 
have  worked  on  this  basis  for  fifteen  years  and 
personally  have  seen  no  reason  to  deviate  from 
that  rule. 

Dr.  Edward  P.  Davis  (25)  :  Up  to  the  age  of 
thirty-five  the  ovaries,  if  healthy,  should  remain. 
The  tubes  should  be  removed  in  hysterectomy.  In 
older  women  the  ovaries  should  be  removed  with 
the  body  of  the  uterus,  since,  at  this  time,  the  ovary 
is  most  prone  to  degenerative  changes.  Ovaries 
retained  after  hysterectomy  probably  undergo  rapid 
atrophy.  It  is  practically  impossible  to  remove  the 
body  of  the  uterus  and  the  fallopian  tubes  without 
so  interfering  with  the  ovarian  blood  supply  that 
atrophy  or  degeneration  soon  occur.  This  is  the 
only  reason  why  most  operators  invariably  remove 
ovaries  in  hysterectomy.  I  have  had  several  cases 
in  which  hysterectomy  was  done  and  the  ovaries 
left,  in  which  menstruation  occurred  from  the 
uterine  stump  for  an  indefinite  time.  There  seemed 
to  be  no  inconvenience  and  the  mental  effect  was 
good  as  the  patient  thought  she  was  having  no 
menopause. 

Dr.  E.  C-  Dudley  (26)  :  I  have  not  removed 
ovaries  in  hysterectomy  cases.  They  have  not,  in 
my  observation,  done  any  harm ;  on  the  contrary, 
there  is  apparently  a  more  normal  menopause  and 
a  more  normal  period  of  senility  when  the  ovaries 
are  left. 

Dr.  George  Gellhorn  (27)  :  Cystic  degeneration 
of  the  retained  ovaries  is  usual.  There  have  been 
adhesions  around  the  ovar\-,  or  where  the  tunica 
albuginea  shows  thickening  and  smoothing  out  of 
the  irregular  folds  of  the  surface,  the  saving  of  the 
ovary  is  a  mistake.    Without  the  uterus  even  a 


November  6,  1920.] 


FOWLER:  CERVICAL  LACERATION. 


715 


normal  ovary  soon  becomes  atrophic.  The  symp- 
toms of  artificial  menopause  are  greatly  amelior- 
ated by  the  administration  of  ovarian  substance  or 
corpus  luteum  extract.  A  radical  rather  than  a 
sentimental  attitude  now  influences  me. 

Dr.  B.  C.  Hirst  (28)  :    If  the  woman  is  ap- 


FiG.  2. — Anterolateral  view  showing  the  long  glass  rod  protrud- 
ing from  the  external  os,  traversing  the  laceration  and  entering  the 
internal  os,  and  the  tear  extending  through  the  anterior  lip  and 
across  the  cervical  canal,  with  margins  widely  separated  by  the 
short  rod.  (The  specimen  is  somewhat  distorted  by  the  fixing 
solution.) 

proaching  the  menopause  I  remove  the  ovaries.  If 
she  is  younger  I  prefer  leaving  them  on  condition 
that  I  do  not  remove  the  tubes  or  interfere  with 
the  circulation  of  the  broad  ligament;  otherwise  I 
would  prefer  removing  them  as  cystic  degeneration 
would  probably  occur. 

Dr.  C.  Jeff  Miller  (29)  :  I  retain  normal  ova- 
ries in  hysterectomy  if  the  patient  is  under  forty 
years  of  age.  The  ovarian  circulation  is  carefully 
guarded  because,  if  the  ovarian  vessels  are  tied 
cystic  changes  so  commonly  occur  that  it  is  best  to 
remove  the  ovary.  I  am  unable  to  determine,  how- 
ever, that  the  menopausal  symptoms  have  been 
greatly  reduced  by  retention  of  the  ovaries. 

Dr.  Reuben  Peterson  (30)  :  "I  always  retain 
one  or  both  normal  ovaries  after  a  hysterectomy, 
whether  it  is  supravaginal  or  panhysterectomy.  I 
am  firmly  convinced  that  the  patients  suffer  less 
from  the  effects  of  the  menopause  if  this  practice  is 
followed." 

Dr.  G.  W.  Roberts  (31):  I  have  been  remov- 
ing troublesome  tubes  and  ovaries  from  patients 
who  had  had  the  uterus  removed  at  previous  opera- 
tions for  the  past  twenty  years.  If  I  do  anything 
which  destroys  the  ability  of  the  pelvic  organs  of 
a  woman  to  function  I  make  a  clean  sweep  down 
to  the  internal  os  uteri,  unless  definitely  com- 
manded by  the  patient  not  to  do  so. 

Dr.  Arnold  Sturmdorf  (32)  :  I  always  remove 
ovaries  and  tubes  when  performing  a  hysterectomy. 
Some  of  my  reasons  are  that  the  ovaries  and  tubes 
present  links  in  the  reproductive  chain  of  organs. 
Removal  of  the  uterus  breaks  the  chain  by  destroy- 
ing an  essential  link.  We  find  the  surgical  climac- 
teric as  pronounced  in  the  cases  in  which  the  ova- 
ries are  preserved.  Preservation  of  the  ovaries 
after  hysterectomy  is  a  delusion,  inasmuch  as  their 
arterial  supply  is  cut  off  more  or  less  completely. 
Ovaries  left  behind  usually  undergo  various  forms 
of  degeneration,  some  of  which  are  productive  of 
symptoms  that  demand  secondary  removal.  All  ar- 
guments in  favor  of  preserving  the  ovaries  are 


based  upon  a  purely  theoretical  idealism  and  senti- 
ment. 

Dr.  Howard  C.  Taylor  (33  )  :  If  the  ovary  is 
not  removed  and  the  tube  is  normal  I  retain  the 
tube  also  as  by  doing  so  there  is  less  chance  of  in- 
terfering with  the  blood  supply  of  the  ovary.  Be- 
yond the  age  of  forty-five  I  make  little  or  no  ef- 
fort to  retain  the  ovary.  Under  the  age  of  thirty- 
five  I  make  every  effort  to  do  so.  Between  these 
ages,  if  the  patient  is  inclined  to  be  fat,  it  is  an  ad- 
ditional reason  for  saving  the  ovaries.  In  general 
I  am  sure  that  I  make  less  effort  to  retain  the  ova- 
ries than  many  men. 

A  comprehensive  survey  of  the  subject  of  ovarian 
conservation  is  beyond  the  scope  of  this  paper. 
However,  the  wide  divergence  of  opinion  elicited 
by  the  queries  of  Vineberg  in  1915  is  equally  ap- 
parent in  the  responses  to  my  questionnaire.  Dr. 
John  G.  Clark  informs  m.e  that  he  has  recently  been 
making  a  careful  study  of  the  question  with  the 
hope  that  definite  conclusions  may  be  reached.  The 
personal  opinion  of  Dr.  Clark  is  quoted  elsewhere 
in  this  paper. 

SUMMARY. 

The  subject  of  this  report  had  a  forceps  delivery 
in  1901.  At  intervals  of  two  years  she  had  three 
subsequent  pregnancies,  all  of  which  terminated 
spontaneously  after  short  labors,  two  at  full  term, 
the  third  at  the  eighth  month.  After  the  second 
delivery  she  noticed  a  protrusion  from  the  vulva, 
which  increased  after  each  of  two  later  pregnan- 
cies. In  1920  she  sought  surgical  relief  for  the 
disability  resulting  from  the  cystocele  which  a  pes- 
sary would  no  longer  support. 

Examination  prior  to  operation  revealed  an  ex- 
tensive laceration  through  the  anterior  lip  and 
across  the  cervical  canal,  due  presumably  to  instru- 


FiG.  3. — Showing,  at  the  right,  the  long  rod  in  the  external  os, 
in  the  centre  the  bulk  of  the  anterior  lip  and  to  the  left  the  gaping 
laceration  and  the  remainder  of  the  anterior  lip.  (Uterine  fibromata 
are  apparent  in  all  three  views.) 


mental  traumatism  during  the  first  delivery  nine- 
teen years  ago.  The  tear  had  apparently  remained 
undiagno.sed,  certainly  untreated,  during  this  long- 
period.     Examination  of  the  uterus  in  situ  and 


716 


PARKE:  RECTAL  EXAMINATION   IX  OBSTETRICS. 


[New  York 
Medical  Journal. 


after  removal  afiforded  convincing  evidence  that  the 
three  spontaneous  deliveries  had  taken  place 
through  the  rent  in  the  anterior  lip  rather  than 
through  the  external  os.  It  is  remarkable  that  this 
extensive  laceration  produced  such  a  slight  patho- 
logical change  in  the  cervix;  that  three  spontaneous 
deliveries  occurred  through  it,  and  finally  that  sur- 
gical relief  was  sought  after  nineteen  years  solely 
for  the  disability  due  to  the  cystocele. 

COXCLUSIOXS. 

1.  A  thorough  gynecological  examination  three 
months  after  delivery  should  be  routine  practice. 

2.  The  disability  following  cervical  lacerations 
is  dependent  upon  the  degree  of  subsequent  patho- 
logical condition  rather  than  the  tear,  per  se. 

3.  Premature  or  precipitate  labors  following  am- 
putations of  the  cervix  are  probably  due  to  some 
other  factor  than  the  mere  loss  of  tissue. 

4.  Operative  morbidity  and  mortality  will  be 
decreased  by  multiple  stage  operations  in  lieu  of 
one  prolonged  procedure. 

5.  The  advisability  of  conserving  normal  ova- 
ries in  hysterectomy  is  still  undetermined. 

REFERENCES. 

1.  Frank,  L.  :  Safet)'  Factors  in  Surgery  with  Especial 
Reference  to  the  Blood,  Surgery,  Gynecology,  and  Obstet- 
rics, 1920,  XXX,  182. 

2.  Mayo,  C.  H.  :  Uterine  Prolapse  with  Associated 
Pelvic  Relaxation,  Surgery,  Gynecology  and  Obstetrics, 
1915,  XX,  253. 

3.  GoLDSPOHN,  A. :    Discussion  of  Pavlik's  paper. 

4.  Sturmdorf,  a.  :  Tracheloplastic  Methods  and  Re- 
sults :  A  Clinical  Study  based  upon  the  Physiology  of  the 
Mesometrium,  Surgery,  Gynecology  and  Obstetrics,  1916, 
xxii,  93. 

5.  EwiNG,  James  :  Neoplastic  Diseases. 

6.  Leonard,  V.  N. :  Postoperative  Results  .of  Amputa- 
tion of  the  Cervix,  Surgery,  Gynecology  and  Obstetrics, 
1913,  xvi,  390. 

7.  Pavlik,  0.  S. :  Pregnancy  and  Labor  Following 
Amputation  of  Cervix  Uteri,  Surgery,  Gynecology  and 
Obstetrics,  1919,  xxix,  172. 

8.  Holmes,  R.  W.  :    Discussion  of  Pavlik's  paper. 

9.  Heaney,  N.  S.  :  Ibid. 

10.  Culbertson,  Cary:  A  Study  of  the  Menopause 
with  Special  Reference  to  Its  Vasomotor  Disturbances, 
Surgery,  Gynecology  and  Obstetrics.  1916,  xxiii,  667. 

11.  Fr.\nk,  Robert  T.  :  The  Clinical  Manifestations 
of  Disease  of  the  Glands  of  Internal  Secretion  in  Gyneco- 
logical and  Obstetrical  Patients,  Surgery,  Gynecology  and 
Obstetrics,  1914,  xix,  618. 

12.  GoETSCH,  Emil  :  The  Relation  of  the  Pituitary 
Gland  to  the  Female  Generative  Organs,  Surgery,  Gyne- 
cology and  Obstetrics,  1917,  xxv,  229. 

13.  Gra\-es,  William  P. :  Transplantation  and  Reten- 
tion of  Ovarian  Tissue  After  Hysterectomy,  Surgery, 
Gynecology,  and  Obstetrics,  1917,  xxv,  315. 

14.  LoEB,  Leo:  The  Relation  of  the  Ovary  to  the  Ute- 
rus and  Mammarj-  Gland  from  the  Experimental  Aspect, 
Surgery,  Gynecology  and  Obstetrics,  1917,  xxv,  300. 

15.  Marine,  David  :  The  Thyroid  Gland  in  Relation 
to  Gvnecologj'  and  Obstetrics,  Surgery,  Gynecology,  and 
Obstetrics,  1917,  272. 

16.  Richardson,  Edward  H.  :  The  Effect  of  Hys- 
terectomy Upon  Ovarian  Function,  Surgery,  Gynecology 
and  Obstetrics,  1919,  146. 

17.  Vincent,  Swale  :  The  Experimental  and  Clinical 
Evidence  as  to  the  Influence  Exerted  by  the  Adrenal  Bodies 
Upon  the  Genital  System,  Surgery,  Gynecology  and  Ob- 
stetrics, 1917,  xxv,  294. 

18.  Sampson.  John  A. :  The  Variations  in  the  Blood 
Supply  of  the  Ovary  and  Their  Possible  Operative  Impor- 
tance, Surgery,  Gynecology  and  Obstetrics  1917,  xxiv,  339. 

19.  Dickinson,  Robert  L,.  :  Conservation  of  Sound 
Ovaries  and  Tubes  in  Hysterectomies  Near  the  Meno- 


pause, Except  in  Malignant  Disease,  Surgery,  Gynecology 
and  Obstetrics,  1912,  xiv,  134. 

20.  PoLAK,  John  Osborn:  The  Preservation  of  the 
Menstrual  Function,  Journal  A.  M.  A.,  1917,  Ixix,  1938. 

21.  Idem:  A  Further  Study  of  the  End  Results  of  the 
Conserved  Ovary,  American  Journal  of  Obstetrics,  1918, 
Ixxviii,  No.  2. 

22.  Vineberg,  H.  N.  :  What  is  the  Fate  of  the  Ova- 
ries Left  in  Situ  After  Hysterectomy?  Surgery,  Gynecol- 
ogy and  Obstetrics,  1915,  xxi,  559. 

23.  BovEE,  J.  Wesley  :    Personal  Communication. 

24.  Clark,  John  G.  :  Personal  Communication. 

25.  Davis,  Edward  P. :  Personal  Communication 

26.  Dudley,  E.  C.  :    Personal  Communication. 

27.  Gellhorn,  George  :  Personal  Communication. 
(Courtesy  of  Dr.  H.  Taylor.) 

28.  Hirst,  B.  C.  :  Personal  Communication. 

29.  Miller,  C.  Jeff  :    Personal  Communication. 

30.  Peterson  Reuben  :    Personal  Communication. 

31.  Roberts,  G.  W.  :    Personal  Communication. 

32.  Sturmdorf,  Arnold  :  Personal  Communication. 

33.  Tavlor,  Howard  C.  :  Personal  Communication. 

The  writer  wishes  to  express  his  appreciation  of 
the  interest  and  cooperation  shown  by  the  person- 
nel of  the  Department  of  Pathology  of  Hahnemann 
Hospital  and  particularly  to  thank  Miss  Evelyn 
Mead,  of  the  Laboratory  Staff,  for  the  excellent 
photographs. 

183  Alexander  Street. 


THE  ROLE  OF  THE  RECTAL  EXAMINA- 
TION IN  OBSTETRICS.* 

By  William  E.  Parke,  M.  D.,  F.  A.  C.  S. 
Philadelphia. 

When  I  began  the  practice  of  obstetrics  I  felt 
that  it  was  my  duty  to  sit  at  the  bedside  of  my 
patient  with  my  examining  finger  tugging  at  the 
perineum  from  time  to  time  to  dilate  the  soft  parts 
and  stimulate  pains.  The  women  expected  it  and 
were  encouraged,  by  the  bystanders  at  least,  to 
think  that  the  doctor  was  helping  them.  Those  of 
you  who  attended  the  lectures  of  the  elder  Penrose 
will  remember  his  inimitable  monologue  and 
demonstration  on  the  manikin,  Mrs.  O'Flaherty, 
of  the  conduct  of  labor.  He  taught  that  it  was 
good  for  the  young  physician  to  familiarize  him- 
self with  the  process  of  parturition  by  keeping  his 
hand  in  contact  with  the  parts.  This  was  modestly 
done  under  cover  until  the  presenting  part  was 
about  to  be  born ;  and  this  I  think  was  typical  of 
obstetrical  practice  at  the  end  of  the  last  century. 
Now  the  fashion  has  changed ;  the  pendulum  has 
swung  to  the  other  extreme  and  even  vaginal  ex- 
aminations are  anathema  with  some  physicians. 

Let  us  consider  briefly — -1.  Wsat  can  we  learn 
from  a  rectal  examination?  2.  W^hat  advantage  do 
we  gain  by  this  method?  and  3.  Is  there  any  ob- 
jection to  a  vaginal  examination? 

Considering  the  last  question  first,  it  cannot  be 
denied  that  in  a  well  conducted  clinic  or  proper 
environment,  vaginal  examinations  with  the  gloved 
hand  or  the  carefully  cleansed  bare  hand  can  be 
practised  without  detriment  from  the  examiner's 
hand.  And  every  one  who  has  attended  women 
even  in  very  unsanitary  surroundings,  without 
clean  towels  or  bedding,  knows  that  they  commonly 
sticceed  in  avoiding  infection.    This  fact,  however, 

"Read  before  the  Philadelphia  Clinical  Association,  October  4,  1920. 


November  6,  1920.] 


PARKE:  RECTAL  EXAMIXATIOX    IX  OBSTETRICS. 


717 


does  not  warrant  one  in  disregarding  the  ordinary 
rules  of  sterility.  As  to  the  patients  themselves 
they  are  the  hosts  of  a  variety  of  organisms  which 
increase  in  virulence  from  the  cervix  to  the  vulva. 
The  folds  about  the  clitoris  and  the  glandular  dis- 
charges about  the  posterior  commissure  of  the 
vulva  are  especially  likely  to  harbor  infective 
germs.  The  Doderlein  bacillus  is  credited  with 
immunizing  the  upper  part  of  the  vaginal  tract 
against  infection.  Now  it  is  impossible  to  make  a 
vaginal  examination  without  carrying  germs  from 
the  lower  to  the  upper  part  of  the  vaginal  canal ; 
and  if  these  are  of  a  virulent  type  the  risk  to  the 
patient  is  not  avoided  by  any  preparation  of  the 
doctor's  hands,  no  matter  how  careful  he  is.  Routh, 
of  London,  has  shown,  with  respect  to  Csesarean 
section,  that  where  repeated  vaginal  examinations 
have  been  made  and  where  attempts  at  forceps  de- 
livery have  been  undertaken  the  mortality  follow- 
ing the  operation  was  vastly  greater  than  where 
the  same  operation  was  done  on  patients  in  labor 
with  unruptured  membranes  and  few  examinations. 
Dr.  Beck  in  reporting  a  series  of  Caesarean  sections 
done  at  the  Long  Island  College  Hospital  observed 
that  the  morbidity  following  the  operations  was 
thirty  per  cent,  in  cases  where  vaginal  examina- 
tions had  been  made,  whereas  it  was  only  twelve 
per  cent,  in  cases  where  no  vaginal  examinations 
had  been  made.  DeLee  (1)  records  the  occur- 
rence of  two  deaths  from  infection  in  the  serv- 
ice of  the  Chicago  Lying-in-Hospital  due  to  coitus 
shortly  before  parturition.  These  citations — and 
many  more  could  be  adduced — show  the  harmful 
effect  of  invading  the  birth  canal  shortly  before 
labor. 

Let  us  consider,  for  example,  the  patient  to  whom 
we  wish  to  give  the  test  of  labor.  Such  a  one  is 
a  potential  case  for  operation  and  examination 
from  time  to  time  over  a  period  of  twenty- four 
hours  or  more  would  be  the  usual  practice.  If  in 
the  end  section  is  resorted  to,  the  patient's  well- 
being  both  as  to  morbidity  and  mortality  will  be 
enhanced  if  no  vaginal  examinations  have  been 
made,  or  what  is  only  a  little  less  satisfactory  if 
only  one  vaginal  examination  is  made  immediately 
prior  to  delivery;  for  it  is  the  repeated  examina- 
tions over  a  long  period  that  are  most  likely  to  give 
rise  to  infection. 

In  the  normal  course  of  delivery  Nature  pro- 
vides a  flushing  of  the  birth  canal  when  the  bag 
of  waters  ruptures,  when  the  fetal  ellipse  advances, 
and  again  when  the  afterbirth  and  membranes  are 
discharged — the  current  being  always  from  above 
downward.  Such  patients  quite  uniformly  do 
well,  if  the  doctor  fails  to  arrive  on  time,  thus 
emphasizing  the  im.plied  suggestion  not  to  meddle 
with  Nature's  plan  by  introducing  something  from 
below  to  the  upper  part  of  the  canal. 

What  can  we  learn  from  a  rectal  examination? 
The  tyro  learns  nothing,  and  it  is  difficult  to  con- 
vince the  beginner  that  it  is  worth  while  to  practise 
the  method  often  enough  to  acquire  confidence  in 
his  findings,  for  a  large  experience  is  required  to 
learn  the  finer  points.  The  reason  for  making  any 
examination  is,  of  course,  to  learn  whether  the 
patient  is  in  labor;  how  far  advanced  the  labor  is; 


and  whether  there  is  any  malposition  or  dispropor- 
tion. 

It  is  not  difficult  to  determine  whether  the  head 
is  high  up  or  low  down.  Anyone  can  do  this.  If 
the  cerA-ix  is  not  effaced  it  is  readily  felt  through 
the  bowel.  However,  if  it  is  partially  dilated  and 
thinned  out  to  the  thickness  of  a  knife  blade  it 
becomes  a  difficult  matter  to  recognize  it ;  but 
patience  and  perseverance  even  in  these  circum- 
stances will  often  reveal  the  exact  amount  of  dila- 
tation. One  first  endeavors  to  recognize  the 
thinnest  area  over  the  presenting  part  and  then  by 
gently  thrusting  the  finger  tip  around  in  dift'erent 
directions  one  will  be  able  to  insinuate  it  beneath 
the  rim  of  the  cervix  at  some  point  in  its  circum- 
ference, and  having  done  so  to  follow  around  its 
whole  circumference.  When  the  head  is  well  in 
the  pelvis  it  is  not  difficult  to  recognize  the  direction 
in  which  the  sagittal  suture  lies.  This  information 
supplemented  by  the  external  findings,  namely,  the 
location  of  the  small  parts,  the  back  and  the  fetal 
heart  sounds  will  very  definitely  point  to  the  position 
of  the  occiput.  Thus  in  ninety  per  cent,  or  more 
of  the  cases  one  can  get  all  the  information  that  is 
needed  in  the  conduct  of  a  labor.  B)'  careful  ex- 
amination, when  the  head  is  low  down,  one  should 
recognize  the  cranium,  and  in  the  event  of  another 
part  of  the  fetus  presenting,  recognize  that  it  is 
not  the  cranium.  Thus  a  foot  or  hand  is  easy  to 
recognize.  It  is  more  difficult  to  recognize  a 
breech.  The  latter  has  been  mistaken  for  a  head 
both  by  vaginal  and  rectal  examination.  A  face 
presentation  by  its  irregularity  and  lack  of  rotund- 
ity should  excite  the  suspicion  of  the  examiner,  so 
that  if  need  be  a  vaginal  examination  can  be  re- 
sorted to.  And  in  all  cases,  for  whatever  reason, 
when  aid  is  to  be  invoked  a  thorough  vaginal  ex- 
amination should  be  made.  When  the  presenting 
part  is  high  in  the  birth  canal  or  movable  above  the 
brim,  this  fact  is  recognizable  by  rectal  and  external 
examination,  although  one  would  scarcely  rely  on 
such  an  examination  for  making  a  prognosis. 
\\'hen  no  advance  is  made,  after  a  prolonged  period 
of  severe  pain,  sufficient  to  make  an  impress  on  the 
mother's  or  baby's  pulse,  then  of  course  a  vaginal 
examination  would  be  in  order  before  deciding  on 
the  plan  of  giving  aid. 

\\'hat  advantage  do  we  gain  from  this  method? 
From  the  point  of  A'iew  of  the  patient,  we  avoid 
pushing  any  germs  from  the  lower  zone  of  the*  birth 
canal  to  the  upper.  An  examination  shortly  before 
the  completion  of  the  second  stage  is  less  delete- 
rious than  repeated  examinations  over  a  period  of 
twenty-four  hours  or  more.  From  the  doctor's 
viewpoint  there  is  this  to  be  said :  There  is  no  di- 
versity of  opinion  as  to  the  propriety  of  using 
sterile  gloves,  or  in  lieu  of  that,  preparing  the 
hands  as  if  for  an  operation,  or  indeed  of  doing 
both  when  making  vaginal  examinations.  This 
takes  time  and,  in  winter  especially,  is  hard  on  the 
hands,  and  soon  causes  chafing  or  worse.  Now  if 
one  adopts  the  rectal  method  of  examination  it  is 
necessary  only  to  put  on  a  clean  rubber  glove — it 
need  not  be  sterile — apply  a  lubricant  and  insert 
the  finger  into  the  rectum  and  thus  acquire  all 
needed  information  without  loss  of  time,  or  skin 


718 


LAKGROCK:  ECLAMPSIA.—  CUMMINGS :  INJURIES  TO  PELVIC  FLOOR   „  [Xew  York 

Medical  Journal. 


in  scrubbing.  By  all  needed  information  I  mean 
that  we  learn  that  the  labor  is  progressing  normally 
or,  on  the  other  hand,  that  it  is  not  progressing 
normally  and  some  aid  will  have  to  be  given.  In 
the  latter  event,  of  course,  we  make  a  vaginal  ex- 
amination since  we  are  going  to  work  through  the 
vagina. 

COXCLUSIOXS. 

There  is  a  distinct  risk,  in  making  vaginal  ex- 
aminations, of  carrying  up  into  the  birth  canal 
organisms  which  under  tavorable  conditions  may 
prove  deleterious. 

One  can  learn  from  a  rectal  examination  all  that 
is  necessary  to  know  in  order  properly  to  conduct  a 
delivery  in  ninety  per  cent,  of  the  cases. 

From  the  patient's  viewpoint  this  method  does 
not  go  contrary  to  Nature's  method  of  protecting 
the  puerperal  woman. 

From  the  doctor's  viewpoint  it  is  attended  with 
much  less  waste  of  time  and  trouble,  and  is  there- 
fore a  procedure  well  worth  the  effort  spent  in  ac- 
quiring confidence  in  it. 

REFERENCES. 

1.    De  Lee:  Principles  and  Practice  of  Obstetrics. 


C-ESAREAX  SECTION  FOR  ECLAMPSIA.* 

By  Edwix  G.  Langrock,  M.  D., 
New  York, 

Assistant  Visiting  Obstetrician  Harlem  Hospital. 

Case. — The  patient  was  admitted  to  the  obstet- 
rical service  of  Dr.  Brodhead  at  the  Harlem  Hos- 
pital on  November  23,  1919  at  six  p.  m.  Her  age 
was  twenty-one.  and  she  was  pregnant  for  the  first 
time.  She  was  in  a  state  of  coma  and  had  had 
three  general  convulsions  before  admission,  one 
convulsion  while  being  admitted,  and  one  twenty 
minutes  later.  From  then  until  she  was  operated 
upon  at  7 :30  p.  m.,  she  had  three  more  severe  gen- 
eralized convulsions,  making  eight  in  all.  Her 
urine  showed  about  two  per  cent,  albumin  and  all 
varieties  of  casts  and  blood.  Her  blood  pressure 
was  158  systolic.  She  was  eight  and  one  half 
months  along  in  her  first  pregnancy.  The  baby 
was  of  moderate  size  and  presenting  with  the 
vertex  in  the  right  occipitoanterior  position.  Her 
pelvis  was  ample  in  size.  The  patient  was  not  in 
labor  and  her  cervix  was  long;  conical  and  closed. 

Since  the  prognosis  in  eclampsia  depends  uj)on 
the  earliest  possible  delivery  of  the  baby,  after 
the  first  convulsion  a  Csesarean  section  was  decided 
upon.  At  7 :30  p.  ni.  the  classical  operation  was  per- 
formed. An  incision  six  inches  long  was  made  in 
the  midline  one  third  above  and  two  thirds  below 
the  navel.  In  making  the  incision  it  was  noted 
that  the  abdominal  wall  was  markedly  edematous, 
the  tissues  being  water  logged.  The  remainder  of 
the  operation  was  easily  performed  and  a  living 
baby,  weighing  seven  pounds,  was  extracted.  In 
placing  the  sutures,  twice  the  usual  number  of  silk- 
worm gut  retention  stitches  were  taken  on  account 
of  the  condition  of  the  abdominal  wall. 

*Case  reported  at  a  meeting  of  the  Harlem  Medical  Societv,  Feb- 
ruary, 1920. 


The  patient  was  given  the  usual  eclamptic  treat- 
ment of  hot  packs,  colon  irrigations,  etc.  She  had 
no  ccn-vulsions  after  her  operation  and  in  forty- 
eight  hours  was  conscious  and  rational.  Her  con- 
dition was  excellent  until  the  third  day  when  ex- 
amining the  dressing  it  was  found  to  be  saturated 
with  a  brownish  fluid,  her  temperature  being  normal, 
and  pulse  106  the  same  as  it  had  been  since  the 
operation. 

On  removing  the  dressing  a  mass  of  intestine  was 
found  on  the  abdominal  wall.  The  patient  was  im- 
mediately taken  to  the  operating  room  and  anes- 
thetized and  the  wound  resutured.  About  two  feet 
of  small  intestine  had  been  extruded  through  the 
abdominal  incision,  six  inches  of  which  was  ad- 
herent to  adhesive  plaster,  with  which  the  gauze 
dressing  had  been  fastened  to  the  abdominal  wall. 
This  was  gently  separated  from  the  intestine  by 
pouring  ether  over  it.  The  intestinal  mass  every- 
where covered  by  plastic  exudate  was  replaced  in 
the  abdominal  cavity  and  the  wound  resutured. 

The  patient  left  the  hospital  three  weeks  later 
with  complete  union  of  the  abdominal  wound, 
there  having  been  no  further  difficulty  except  a 
small  stitch  abscess. 

The  patient's  temperature  was  over  100°  F.  only 
once,  and  that  was  on  the  fifteenth  day  from  some 
extraneous  cause. 

IXTERESTIXG  FEATURES  OF  THE  CASE. 

1.  The  treatment  of  the  eclampsia  by  Caesarean 
section,  the  patient  having  no  convulsions  after  the 
delivery. 

2.  The  edematous  condition  of  the  tissues  in 
eclampsia  which  must  be  taken  into  consideration 
in  placing  the  sutures. 

3.  The  fortunate  outcome  of  the  case  in  spite  of 
the  possibility  of  peritonitis. 

REPAIR  OF  INJURIES  TO  THE  PELVIC 
FLOOR. 

By  W.  Clovis  Cummixgs,  M.  D., 
Oklahoma  City,  Okla., 
Surgeon  and  Gynecologist  to  St.  Luke's  Hospital. 

It  is  only  within  a  comparatively  recent  period 
that  the  female  perineum,  its  nature  and  functions, 
have  been  properly  understood.  In  the  study  of 
human  anatomy  the  female  perineum  has  not  re- 
ceived the  attention  that  its  surgical  importance  war- 
rants. Most  textbooks  make  its  description  sec- 
ondary to  that  of  the  male  perineum,  emphasizing 
only  the  important  structural  differences.  Probably 
this  custom  originated  at  a  time  when  gynecology 
was  little  studied  and  operations  were  relatively 
much  more  frequently  performed  on  the  male  per- 
ineum than  on  the  female. 

The  pelvis  floor  is  made  up  of  skin,  superficial  and 
deep  fasciae,  and  muscles  The  muscles  are  eight 
in  number — two  ischiocavernosi,  two  bulbocavernosi, 
two  transverse  perineal,  the  levator  ani  and  the 
sphincter  ani.  These  muscles  blend  with  each 
other  and  form  a  complete  muscular  diaphragm, 
which  fills  the  bony  outlet  of  the  pelvis.  These 
muscles   are    still    further    strengthened    by  lay- 


November  6,  1920.] 


CUMMINGS:  INJURIES  TO  PELVIC  FLOOR 


719 


ers  of  strong  pelvic  fascia  which  bind  them  together 
and  increase  their  power.  The  muscular  elements 
which  enter  into  the  construction  of  the  floor  are  its 
chief  source  of  strength,  and  the  levator  ani  is  the 
most  important  of  all  muscles,  as  the  support  which 
is  afforded  to  the  pelvic  viscera  depends  entirely 
upon  its  integrity. 

If  we  compare  the  perineal  region  of  a  woman 
who  has  not  borne  children  with  that  of  one  who  has, 
a  difference  is  at  once  noticed.  A  difference  exists 
even  though  there  has  been  no  visible  tear  in  the  sec- 
ond woman  or  only  a  tear  which  has  been  treated  by 
the  usual  primary  operation.  If  the  nullipara  is  young 
and  a  virgin  it  will  be  seen  that  the  anus  is  well 
forward  and  that  the  perineal  body  is  short  in  its 
ventrodorsal  diameter.  In  a  woman  who  has  given 
birth  to  a  child  the  anus  is  always  displaced  dorsally. 
If  the  perineal  body  is  superficially  intact  the  ventro- 
dorsal diameter  will  be  greatly  lengthened;  if  torn, 
the  perineal  body  will  be  shortened,  the  mucous 
membrane  everted,  and  the  vulva  will  gape.  If  torn 
and  repaired  primarily,  the  perineal  body  w'ill  be 
lengthened  ventrodorsally  and,  therefore,  shortened 
vertically.  The  dorsal  displacement  of  the  anus  is  a 
constant  deformity.  There  are  three  t\-pes  of  in- 
jury of  the  pelvic  floor:  superficial  median  tears, 
median  tears  involving  the  sphincter  ani,  and  lateral 
tears  involving  the  vaginal  sulci. 

SUPERFICIAL  MEDIAN'  TEARS 

A  superficial  median  tear  extends  in  the  median 
line  from  the  fourchette  either  backward  toward  the 
anus  or  upward  into  the  vagina  or  both.  It  splits 
the  tissues  between  the  posterior  border  of  the  vul- 
vovaginal orifice  and  the  anus,  and  occasionally  ex- 
tends internally  an  inch  or  more  up  the  posterior  wall 
of  the  vagina.  These  tears  are  of  no  practical  im- 
portance as  the  integrity  of  the  levator  ani  muscle 
is  not  damaged  nor  destroyed.  Occasionally,  how- 
ever, the  cicatrix  which  is  formed  may  become  irri- 
table and  cause  local  tenderness  and  reflex  disturb- 
ances. 

MEDIAN  TEARS 

Median  tears  involving  the  sphincter  ani  extend 
backward  in  the  median  line  from  the  fourchette 
through  the  sphincter  ani  muscle,  and  in  some  cases 
may  continue  up  the  rectovaginal  septum  for  a  dis- 
tance of  an  inch  or  more.  Sometimes  all  the  fibres 
of  the  sphincter  are  not  completely  divided  and  the 
appearance  of  the  tear  may  be  deceptive.  These 
tears  permanently  destroy  the  function  of  the 
sphincter  muscle.  The  levator  ani  muscle  is  not 
torn  and  consequently  the  supporting  power  of  the 
pelvic  floor  remains  unimpaired. 

LATER.\L  TEARS 

Lateral  tears  involving  the  vaginal  sulci  extend 
from  the  fourchette  up  into  one  or  both  of  the  va- 
ginal sulci  and  are  usually  accompanied  by  a  super- 
ficial median  tear  toward  the  anus.  This  laceration 
is,  as  a  rule,  bilateral,  though  in  rare  cases  the  in- 
jury may  occur  on  only  one  side  of  the  vagina.  In  this 
type  of  laceration  the  function  of  the  levator  ani 
muscle  is  destroyed  and  the  pelvic  organs,  as  well  as 
the  terminal  ends  of  the  urethra,  vagina  and  rectum, 
are  no  longer  supported  or  maintained  by  the  pelvic 
floor.    As  a  rule  involution  of  the  uterus  and  vagina 


is  arrested  and  in  time  the  uterine  ligaments  as  well 
as  the  pelvic  connective  tissue  become  elongated  and 
stretched,  resulting  in  prolapse  of  all  the  pelvic 
organs. 

The  treatment  of  lacerated  perineum  and  of  in- 
juries to  the  pelvic  floor  is  exclusively  surgical.  Un- 
less the  condition  of  the  patient  is  a  contraindication, 
immediate  repair  of  all  lacerations  should  be  made 
within  twenty-four  hours  of  delivery.  A  physician 
who  attends  a  case  of  labor  is  grossly  negligent  if 
he  fails  to  make  a  careful  inspection  of  the  pelvic 
floor  as  soon  after  delivery  of  the  child  as  is  con- 
sistent with  the  safety-  of  the  mother. 

It  is  with  unrepaired  tears  of  the  third  variety  that 
this  paper  is  concerned.  An  operation  which  has 
proved  satisfactory  is  performed  as  f oUow^s : 

A  U  or  V  shaped  or  transverse  incision  is 
made  along  the  mucocutaneous  line.  The  scar  tissue 
is  removed  by  denudation  with  the  scissors  to  allow 
access  to  the  deeper  and  more  important  struc- 
tures. In  inserting  the  scissors  care  must  be  exer- 
cised to  keep  the  points  pressed  against  the  vaginal 
wall.  By  delicate  manipulation  with  the  scissors, 
or  perhaps  better  with  the  gauze  covered  finger,  the 
plane  of  fascia  separating  the  vaginal  and  rectal  walls 
is  found  and  the  underlying  tissues  are  quickly  rolled 
off  the  vaginal  wall  so  as  to  expose  the  two  walls. 
The  tissues  are  easily  and  safely  separated  as  far  as 
desired  without  producing  any  bleeding.  The  flap 
should  now  be  elevated  and  care  should  be  used  to 
see  that  the  dissection  extends  sufficiently  high  on 
either  side  to  expose  the  upper  border  of  the  levator 
ani  muscle.  The  layer  of  veins  is  the  guide  to  safety 
and  one  should  keep  within  the  line  of  cleavage  so  as 
to  avoid  injuring  the  rectum. 

The  method  of  introducing  the  sutures  is  no  less 
important  than  that  of  denudation.  The  wound  is 
preferably  closed  in  two  layers.  The  first  row  of 
sutures  approximates  the  levator  ani  muscle  and 
fascia  in  the  median  line.  Each  suture  should  in- 
clude deep  bites  of  the  muscle  and  fascia  on  either 
side.  This  puts  the  muscle  and  fascia  on  either 
side  on  tension  and  brings  them  into  view,  thus  giv- 
ing a  broad  surface  for  approximation  by  figure 
of  eight  sutures.  The  second  row  of  sutures  unites 
the  mucous  membrane  and  skin  down  into  the 
muscle  and  fascia.  The  wound  is  closed  by  running 
sutures,  locked  at  intervals.  Twenty-day  chromi- 
cized  catgut  should  be  used  for  approximation. 
Where  this  is  not  available,  tension  sutures  of  silk- 
worm gut  should  be  employed.  Care  should  be 
taken  to  keep  sutures  and  scar  tissue  from  the  im- 
mediate vicinity  of  the  vulvovaginal  glands.  Other- 
wise a  hypersensitive  and  troublesome  scar^  or  cyst 
formation  may  result. 

235  American  National  Bank  Building. 


Role  of  the  Ovary  in  the  Female  Organism. — 

Alfred  Labhardt  (Schzvei:;erisclie  medizinsche 
Wochcnschrift,  ^lay  6,  1920)  uses  much  space  to 
say  that  the  influence  of  the  ovary  on  the  general 
condition  of  the  body  is  much  less  than  that  of  the 
other  endocrine  glands,  yet  this  influence  is  great, 
not  only  on  the  genital  system,  but  also  on  the 
entire  organism. 


720 


TOJ'EY 


FEMALE  PELVIC  URETERS. 


[New  York 
Medical  Journal. 


THE  FEMALE  PELVIC  URETERS  * 

By  David  W.  Tovey,  M.  Dj. 
New  York, 

Adjunct  Professor  of   Gj-necology,   Polyclinic   Medical   School  and 
Hospital,  Gynecologist  to  Harlem  Dispensary. 

Palpation  of  the  pelvic  ureters  should  be  a  part  of 
ever}-  vaginal  examination.  During  examination 
there  is  nothing  between  the  fingers  and  the  ureter 
but  the  vaginal  wall.  The  ureters  can  be  felt  from 
the  bladder  to  the  pelvic  brim.  At  the  New  York 
Polyclinic  Hospital  it  was  easy  to  teach  students  to 
palpate  the  ureters,  after  they  had  learned  their  po- 
sition, by  inserting  ureteral  catheters  into  them. 

The  ureters  are  an  inch  apart  in  the  trigone,  about 
an  inch  behind  the  internal  urethral  opening,  and 
two  inches  behind  the  external  meatus.  They  are 
about  two  inches  apart  at  their  entrance  into  the 
bladder,  where  they  run  through  the  bladder  wall  for 
three  quarters  of  an  inch.  These  points  are  about 
half  an  inch  in  front  of  the  cervix  on  the  anterior 
vaginal  wall,  and  about  an  inch  from  the  crossing 
of  the  ureter  by  the  uterine  artery.  After  leaving 
the  bladder  the  ureters  curve  over  the  anterior  va- 
ginal wall  and  lateral  fornix,  to  a  point  half  way 
between  the  lateral  border  of  the  cervix  and  the 
pelvic  wall,  where  they  are  crossed  by  the  uterine 
artery  on  a  level  with  the  internal  os.  about  an  inch 
from  the  lateral  border  of  the  cervix,  two  inches 
from  the  ureteral  openings.  From  the  point  of 
crossing,  the  uterine  artery  accompanies  the  ureter 
for  one  or  two  inches  through  the  base  of  the  broad 
ligament,  to  a  point  on  the  pelvic  wall  just  above 
the  spine  of  the  ischium,  where  they  turn  upward 
on  the  pelvic  wall  covered  by  peritoneum,  some- 
times in  front  and  sometimes  behind  the  internal 
iliac  to  the  pelvic  brim,  where  they  leave  the  pelvis 
through  the  infundibular  pelvic  ligament  behind  the 
ovarian  artery.  The  right  ureter  is  more  often  in 
front  of  the  division  of  the  common  iliac,  the  left 
one  behind  it.  The  ureters  are  often  outlined  on 
the  anterior  wall  by  the  ureteral  ridges.  In  1880 
Pawlick  catheterized  the  ureters  using  the  ridges 
as  landmarks. 

TECHNIC  OF  PALPATION" 

To  palpate  the  ureter  from  the  bladder  to  the 
base  of  the  broad  ligament  to  orient  the  position 
imagine  a  line  from  a  point,  about  half  an  inch  in 
front  of  the  cervix,  to  a  point  half  way  between  the 
lateral  border  of  the  cervix  and  the  lateral  pelvic 
wall.  The  point  half  an  inch  in  front  of  the  cervix 
where  the  ureter  enters  the  bladder,  varies  with 
the  position  of  the  cervix.  The  point  half  way  be- 
tween the  lateral  border  of  the  cervix  and  the  lateral 
pelvic  wall,  is  where  the  uterine  artery  crosses  the 
cervix  and  is  fixed. 

The  vaginal  fingers  are  introduced  into  the  an- 
terior lateral  vault  of  the  vagina.  Counterpressure 
is  made  downward  through  the  abdominal  wall. 
The  fingers  are  drawn  forward.  As  the  tissues 
slip  through  the  fingers,  the  ureter  is  palpated  as  a 
flattened  cordlike  body,  smaller  than  a  goose  quill, 
displaced  in  its  bed  of  loose  cellular  tissue,  as  it 
slips  through  the  fingers.  It  can  be  rolled  from 
side  to  side  under  the  palpating  fingers  by  moving 

*Read  before  the  American  Association  of  Obstetricians  and 
Gynecologists,  Atlantic  City,  N.  J.,  September  21,  1920. 


the  fingers  toward  the  bladder,  or  toward  the  broad 
ligament.  The  ureter  is  felt  from  the  bladder  to 
the  base  of  the  broad  ligament.  Posterior  to  the 
broad  ligament  it  is  felt  just  above  the  spine  of  the 
ischium,  covered  hy  the  peritoneum,  to  the  pelvic 
brim,  by  palpating  it  against  the  pelvic  wall.  It  may 
run  as  high  as  an  inch  above  the  ischial  spine. 
Judd  (1)  advises  sweeping  the  fingers  above  its  lo- 
cation, bending  the  fingers  as  in  picking  a  guitar. 
In  the  latter  part  of  pregnancy  the  ureters  do  not 
follow  the  pelvic  wall  to  the  spines  of  the  ischium, 
but  after  accompanying  the  internal  iliac  artery 
they  pass  beneath  the  broad  ligament  just  below  tlie 
pelvic  brim. 

EXAMIXATIOX   OF  THE  VRETER  BY  RECTUM 

The  finger  is  inserted  to  the  bifurcation  of  the 
iliac  artery,  which  is  located  and  traced  downward 
with  the  tip  of  the  finger.  The  palpation  is  done 
behind,  at  the  side,  and  in  front  of  the  artery.  The 
ureter  can  be  followed  in  its  course  until  it  passes 
under  the  broad  ligament.  The  normal  ureters  never 
cause  pain.  If  diseased,  they  are  enlarged  from  the 
size  of  a  goose  quill  to  that  of  a  lead  pencil,  or 
larger  ;  if  tender,  pressure  brings  an  intense  desire  to 
urinate.  The  tuberculous  ureter  feels  like  a  string 
of  beads.  Calculus,  pyelitis,  tuberculous  kidney, 
gonorrhea,  cervicitis,  lacerations,  and  infections  from 
the  cervix  cause  urethritis,  periureteritis  and  stric- 
ture, and  because  of  the  nerve  plexus  of  the  abdom- 
inal sympathetic,  pain  is  difiEuse  and  causes  symp- 
toms in  adjacent  abdominal  viscera,  bladder,  uterus, 
ovary,  appendix,  stomach,  gallbladder  and  other 
organs.  If  irritation  passes  over  the  intercostal 
nerves,  pain  in  the  abdominal  wall  results ;  if  over 
the  lumbar  plexus,  pain  in  the  inguinal  hypogastric 
and  external  genital  regions ;  over  the  sacral  plexus, 
pain  in  external  genitals,  rectum,  thigh,  legs ;  the 
uterine  plexus  where  artery  crosses  ureter,  pain  in 
uterus ;  ovarian  plexus  to  ovaries,  gastric  to  stomach, 
mesentery  to  intestines. 

Bladder  symptoms  following  hysterectomy,  in 
which  the  cystoscope  shows  a  normal  bladder,  are 
due  to  ureteritis  and  not  to  cystitis.  Sanger  in  1886 
reported  cases  of  ureteritis  treated  for  long  periods  as 
cystitis.  Judd  reported  a  case  of  early  pregnancy 
with  ureteritis  and  spotting,  which  was  mistaken  for 
ectopic  pregnancy.  Hunner  has  reported  a  large 
number  of  strictures  of  the  lower  ureter,  which  were 
mistaken  for  all  sorts  of  abdominal  conditions.  The 
IMayos  report  that  most  of  the  cases  of  kidney  and 
ureteral  stone  which  they  encountered  have  been 
mistaken  for  other  abdominal  conditions  and  the 
patients  operated  upon  for  disease  of  the  stomach, 
gallbladder,  ovary  or  appendix.  Kelly  (2)  states 
that  gonorrhea  is  a  common  cause  of  ureteritis  and 
stricture. 

Chronic  pyelitis  and  ureteritis  cause  stricture  of 
the  ureter  followed  by  hydronephrosis  if  the  con- 
dition is  not  treated.  Ureteritis  due  to  lacerations 
and  infections  of  the  cervix,  if  treated  early,  will 
not  result  in  strictures.  In  patients  treated  for  vari- 
ous abdominal  disorders  the  condition  is  made  clear 
by  palpation  of  the  pelvic  ureter. 

EXAMPLES  OF  CASES. 

Case  I. — R.  J.,  aged  thirty-five.  Since  the  birth 
of  her  child  five  years  ago,  the  patient  had  had  pain 


November  6,  1920.] 


TOVEY:  FEMALE  PELVIC  URETERS. 


723 


in  the  left  side  of  her  abdomen  and  back,  which  had 
been  very  severe  at  times,  and  had  also  complained 
of  frequent  urination,  which  was  painful.  She  was 
advised  to  have  her  ovaries  removed,  and  had  been 
treated  for  constipation,  cystitis,  ulcer  of  the 
stomach,  and  various  other  things.  The  examina- 
tion showed  the  pelvic  organs  to  be  normal,  the 
cervix  was  lacerated,  eroded,  and  infected.  The  left 
ureter  was  enlarged  and  very  tender ;  palpation 
brought  intense  desire  to  urinate.  The  injection  of 
collargol  showed  the  ureter  to  be  slightly  dilated 
just  over  the  bladder  and  the  kidney  pelvis  slightly 
dilated.  Pain  was  relieved  after  ureteral  cathe- 
terization. 

Case  II. — A.  G.,  aged  sixty  years,  a  patient  of 
Dr.  Wells ;  sent  to  New  York  Polyclinic  Hospital. 
Patient  complained  of  acute  pain  in  right  side  of 
abdomen  over  gallbladder  region,  which  was  tender 
and  rigid  over  right  abdomen ;  half  a  grain  of  mor- 
phine brought  only  partial  relief.  An  examination 
showed  that  the  right  ureter  was  enlarged,  tender, 
and  very  sensitive,  and  a  small  stone  was  felt  just 
above  the  bladder.  Cystoscopic  examination  showed 
the  right  ureteral  meatus  to  be  red  and  swollen,  and 
the  catheter  wa?  obstructed  at  two  cm.  above  the 


Fig.  1.— Sagittal  section  of  the  female  pelvis,  showing  bimanual 
palpation  of  lower  end  of  ureter. 


bladder.  An  injection  of  collargol  disclosed  a 
small  stone  in  the  pelvic  ureter  with  ureter  dilated 
above  it;  the  kidney  pelvis  was  moderately  dilated. 
The  patient  was  relieved  immediately  after  exami- 
nation and  four  days  later  a  gallstone  the  size  of  a 
shoe  button  was  passed. 

Case  III. — G.,  aged  thirty  years,  single.  The  pa- 
tient had  pain  in  the  right  abdomen,  suffered  from 
indigestion,  and  was  sent  to  the  hospital  to  have 
the  appendix  removed.  Examination  showed  the 
pelvic  organ  to  be  normal :  the  right  ureter  thickened 
and  tender,  and  pressure  brought  desire  to  urinate. 
Injection  of  collargol  showed  stricture  just  above 
the  bladder,  dilatation  of  the  ureter  above  it,  and 
small  hydronephrosis.  The  patient  was  cured  by 
dilatation  of  the  ureter. 

Case  IV. — R.  S.,  aged  twenty-two  years ;  mar- 
ried four  years,  has  one  child  three  years  old.  The 
patient  had  had  three  miscarriages  brought  on  by  a 
midwife ;  was  operated  on  two  years  ago  for  gall- 


stones, and  again  a  year  later  for  adhesions  of  g.  d, 
bladder.  She  complained  of  pain  in  the  right  abo'^ 
men,  backache,  which  was  worse  on  walking,  am. 
had  frequent  urination  and  profuse  leucorrhea.  Ex- 
amination showed  that  the  right  ureter  was  enlarged 
and  tender  and  palpation  brought  on  a  desire  to  pass 
urine.  The  cervix  was  found  to  be  eroded  and  in- 
fected. Collargol  injection  showed  that  the  ureter 
was  slightly  dilated  above  the  bladder.  Treatment 
of  the  cervix  and  vault  of  the  vagina  brought  reHef. 

Case  \'. — A  patient  of  Dr.  Wells,  aged  thirty- 
two  years;  married,  with  one  child  five  years  of 
age.  Last  menses  had  been  three  months  before, 
at  which  time  she  suffered  severe  pain  in  right 
ovarian  region,  which  was  accompanied  by  spotting. 
The  patient  was  sent  to  the  Polyclinic  Hospital  for 
operation  for  ectopy.  Examination  showed  the  uterus 
to  be  enlarged  and  that  she  had  been  pregnant  for 
three  months.  The  right  ureter  was  enlarged  and  very 
tender,  and  pressure  caused  the  desire  to  pass 
urine.  Treatment  of  the  vault  of  the  vagina,  uro- 
tropin,  and  lavage  of  the  kidney  pelvis  brought  relief. 

Case  Y1. — K.,  aged  forty  years.  Patient  had 
fever,  chills,  and  a  tumor  in  the  right  side  of  abdo- 
men, diagnosed  by  different  men  as  gallbladder  and 
ovarian  cyst.  Frequent  urination  was  also  present, 
and  at  times  there  were  blood  clots  in  the  urine. 
These  were  attributed  by  dift'erent  physicians  to  an 
inflamed  ureteral  meatus.  Examination  showed  that 
the  right  ureter  was  much  enlarged  and  tender,  and 
a  cystoscopic  examination  showed  that  the  blad- 
der was  normal  and  the  right  ureteral  meatus  red- 
dened and  contracted.  An  injection  of  collargol 
revealed  a  soft  stone  in  the  kidney  pelvis  about  the 
size  of  a  plum,  which  had  not  been  shown  by  the 
X  ray.  The  large  pus  kidney  with  a  very  soft  stone 
was  removed. 

Case  \^II. — I.  R..  aged  twenty-five  years ;  mar- 
ried three  years.  The  patient  complained  of  pain  in 
the  right  side  which  was  made  worse  by  walking,  of 
indigestion  and  of  constipation.  The  appendix  had 
l)een  removed  without  giving  relief,  and  the  pa- 
tient was  told  to  have  the  ovary  removed.  Exami- 
nation showed  that  the  right  ureter  was  enlarged  and 
very  tender  and  palpation  caused  an  intense  desire 
to  pass  urine.  A  small,  hard  mass,  believed  to  be 
a  stone,  was  felt  at  the  entrance  of  the  ureter  into 
the  bladder.  The  cystoscope  revealed  a  small  red- 
dish brown  stone  sticking  out  of  the  ureteral  meatus. 
An  X  ray  showed  that  there  was  a  stone  half  an  inch 
long  at  the  entrance  to  the  bladder.  A  few  days 
later,  the  x  ray  revealed  a  stone  two  inches  higher 
up  in  the  ureter.  At  the  first  examination  it  was 
impossible  to  dislodge  this  stone,  but  upon  dilating 
the  ureter  the  stone  passed. 

Case  \'III. — M.  K..  aged  thirty-seven  years.  An- 
other surgeon  operated  on  the  patient  two  years  ago 
for  tuboovarian  abscess.  For  the  past  year  there 
had  been  pain  in  the  left  kidney  and  abdomen,  fre- 
quent urination — every  half  hour  at  night — and  the 
pain  had  been  most  severe  lately.  Examination 
showed  that  the  uterus  was  slightly  fixed  and  the 
left  ureter  thickened  and  tender.  Palpation  brought 
on  intense  desire  to  urinate,  and  there  was  pain  in 
the  left  kidney  region.  Cystoscopy  showed  that  the 
left  meatus  was  contracted  and  retracted,  and  the 


12^ 


KOSTER:  ABDOMINAL  EXERCISES  IN  OBSTETRICS. 


[New  York 
Medical  Journal. 


athet^r  was  obstructed  at  six  cm.  from  the  bladder. 

The  ureteral  meatus  contracted,  but  no  urine  passed. 
An  operation  was  performed  and  a  small  hydrone- 
phrotic  kidney,  lined  by  thickened  membrane,  was 
removed. 

Case  IX. — J.  M.,  aged  thirty-five  years.  Since 
the  birth  of  her  last  child,  three  years  ago,  the  pa- 
tient had  suffered  from  indigestion,  pain  over  the 
right  kidney  and  right  abdomen.  Frequent  and 
sometimes  painful  urination  was  present  at  times. 
She  was  treated  for  cystitis  and  advised  to  have  the 
appendix  removed.  Pain  in  the  region  of  the  ovary 
was  present  during  the  menstrual  period.  Exam- 
ination showed  that  the  pelvis  was  normal,  and  the 
right  ureter  enlarged  and  tender.  Palpation  caused 
intense  desire  to  urinate.  The  cervix  was  lacerated, 
eroded  and  infected.  The  cystoscope  revealed  a 
normal  bladder  and  collar gol  injection  showed  the 
ureter  to  be  dilated  three  inches  above  the  bladder. 
Treatment  was  given  to  the  cervix  and  vault  of  the 
vagina. 

REFERENCES. 

1.  Judd:  American  Journal  of  Diseases  of  Jl'oiiien,  vol. 
xxii,  No.  6,  1916. 

2.  Kelly  :  Kelly  and  Burnham,  p.  352. 

240  Riverside  Drive. 


THE  VALUE  OF  ABDOMINAL  EXERCISES 
BEFORE  AND  AFTER  DELIVERY.* 

By  H.  KosTER,  M.  D., 

Brooklyn,  N.  Y., 

Assistant    Gynecologist   and   Obstetrician,    Kings    County  Hospital; 
Adjunct  Gynecologist.  Beth  Moses  Hospital;  Associate  Gyne- 
cologist and  Obstetrician,  Bikur  Cholim  Hospital. 

Considering  the  enormous  amount  of  attention 
paid  to  the  development  of  prophylactic  measures 
in  gynecology  and  obstetrics,  it  is  rather  surprising 
that  so  little  work  has  been  done  in  the  direction  of 
improving  the  tone  of  the  abdominal  muscles ;  par- 
ticularly so,  when  it  is  universally  conceded  that  the 
■element  of  muscular  activity,  as  a  fadtor  in  the 
mechanics  of  labor  and  in  the  maintenance  of  good 
health  at  all  other  times,  it  is  a  matter  of  utmost 
importance. 

Everyone  is  familiar  with  the  flabby,  flaccid,  pen- 
-dulous  abdominal  wall,  which  cannot  be  counted  on 
as  an  asset  during  parturition,  and  which  is  dis- 
tinctly a  liability  during  the  nonparturient  period, 
being  a  causative  factor  in  the  production  of  ptoses 
of  the  abdominal  viscera.  During  labor  such  an  ab- 
dominal wall  plays  a  negligible  part  in  assisting  the 
expulsive  activity  of  the  uterus ;  indeed,  in  many 
instances  the  relaxation  encountered  is  so  great  that 
it  allows  of  marked  deviation  of  the  uterus  from 
the  axis  of  expulsion.  At  all  other  times,  a  wall 
of  this  character  offers  no  support  to  the  abdominal 
viscera,  the  continued  absence  of  this  support  ulti- 
mately resulting  in  the  acquired  form  of  visceral 
ptosis. 

Remembering  that  the  abdominal  walls  of  the 
type  previously  described  belong  almost  always  to 
multiparse,  and  also  that  not  all  women  who  have 
born  children  have  visceral  ptoses  consequent  to  re- 

*Read  before  the  section  on  Gynecology  and  Obstetrics  of  the 
New  York  Academy  of  Medicine,  January  26,  1920. 


Fig.  1.  —  Record  of  contrac- 
tion of  frog's  gastrocnemius 
muscle;  myogram,  a,  muscle  not 
weighted;  myogram,  b,  muscle 
carrying  a  load  of  five  grams. 


laxed  abdominal  walls,  the  quest  for  the  causative 
factor  narrows  down  to  the  relation  of  the  amount 
of  strain  to  the  quantity  and  quality  of  muscle. 

In  the  normal  state  the  muscles  extending  from 
bone  to  bone  are  slightly  stretched.  This  state  of 
elastic  tension  insures  a  more  prompt  and  ef- 
fective contraction,  as 
shown  experimentally  by 
the  fact  that  the  amount 
of  rise  of  a  lever  to 
which  a  muscle  is  at- 
tached, when  excited  by 
an  electrical  stimulus  of 
definite  strength,  is 
greater  when  the  muscle 
is  placed  under  tension 
by  adding  a  slight  weight,  than  if  no  weight  is  added 
(Fig.  1).  Muscle  is  extensile  and  perfectly  elastic 
within  limits.  The  extensibility  of  muscle  for  suc- 
cessive equal  increments  of  weight  gradually  de- 
creases, approaching  zero  as  a  limit.  Before  that 
limit  is  reached,  removal  of  the  weights  results  in 
a  perfect  elastic  recoil.  If  the  weight  is  increased 
beyond  the  zero  limit,  which  is  also  the  elasticity 
limit,  the  amount  of  extension  then  increases  with 
increasing  increments  of  weight  up  to  the  rupture 
point,  and  elastic  recoil  from  beyond  the  elasticity 
limit  is  not  perfect  (Fig.  2). 

Frequently  an  abdomen  is  seen,  the  wall  of  which 
is  under  tension  only  while  the  woman  is  in  the  up- 
right position.  When  she  is  placed  in  the  dorsal 
recumbent  position,  the  loose  redundant  wall  spreads 
over  the  flanks  and  the  pubes.  It  is  evident  that  the 
tonus  in  these  muscles  is  low  and  also  that  they  have 
previously  been  stretched  beyond  their  elastic  re- 
coil limit.  That  wall  does  not  support  the  abdominal 
viscera,  and  is  one  of  the  most  frequent  causes  of 
the  acquired  form  of  visceral  ptosis.  A  saggital 
section  of  the  body  shows  the  outline  of  the  ab- 
dominal cavity  to  be  somewhat  pearshaped  with  the 
large  end  uppermost.  The  posterior  wall,  consist- 
ing of  the  psoas  muscle  and  a  'fat  pad,  is  in- 
clined backward  from  below  upward  at  an 
angle  of  about  fifty 
degrees,  and  it  forms 
a  padded  shelf  which 
helps  to  support  the 
organs  of  the  upper 
abdomen.  Its  value, 
however,  depends  upon 
a  firm  anterior  abdo- 
minal wall,  because  the 
inclination  is  so  steep 
that  unaided  by  any 
other  force  than  the 
mesenteric  attachments 
the  heavy  organs  would 
tend  to  slide  downward. 
The  force  of  the  an- 
terior abdominal  wall 
being  exerted  inward 
and  that  of  the  posterior  wall  diagonally  upward, 
the  resultant  of  the  two  forces  is  applied  in  a  direc- 
tion best  calculated  to  give  support  (Fig.  3). 

Recognition  of  these  facts  has  resulted  in  pallia- 
tive efforts  through  the  use  of  various  anterior  rein- 


FiG.  2. — (Above)  Gradient  of 
extensibility  and  elasticity  for 
ten  gram  weights,  before  elas- 
ticity limit  is  reached;  (below) 
gradient  of  extensibility  con- 
tinued beyond  elasticity  limit  a, 
rupture  point  at  b. 


November  6,  1920.] 


KOSTER:  ABDOMINAL   EXERCISES  IN  OBSTETRICS. 


723 


forcements,  pads,  and  bandages,  with  considerable 
success.  Such  relief,  however,  is  not  permanent. 
When  the  mechanical  support  is  removed,  the  symp- 
toms recur  because  nothing  has  been  done  to 
strengthen  the  muscles  which  have  lost  their  nat- 
ural elasticity  after  having  been  subjected  to  a  period 
of  increasingly  forcible  extension,  exceeding  the 


Fig.  3. — Support  of  the  organs  of  the  upper  abdomen  by  the 
abdominal  wall. 

limit  of  physiological  extensibility  with  perfect 
elastic  recoil. 

The  careful  analysis  of  obstetrical  case  records 
yields  as  one  of  the  conclusions  the  belief  that  many 
forceps  deliveries  might  have  been  avoided  by  the 
application  of  a  tight  abdominal  binder.  The  proper 
development  of  the  muscles  of  the  abdominal  wall 
before  pregnancy  will  obviate  the  use  of  an  ab- 
dominal binder.  If  the  tone  of  these  muscles  had 
been  raised  sufficiently  before  pregnancy,  the  wall 
would  yield  less  readily  and  less  completely  to  the 
gradually  increasing  pressure  of  the  enlarging 
uterus,  and  their  synergistic  rhythmic  contractions 
during  the  uterine  expulsive  efforts  would  furnish 
valuable  aid.  A  point  in  the  improvement  could 
also  be  reached  which  would  allow  a  margin  of 
extensibility  beyond  that  encountered  in  the  par- 
turient period  without  reaching  the  elastic  recoil 
limit,  and  thus  insure  perfect  elastic  recoil. 

Progressive  muscular  exercise  can  raise  the  qual- 
ity of  muscle  to  a  higher  standard  of  efficiency. 
That  the  elastic  tension  of  any  muscle  may  be  in- 
creased by  exercise,  has  been  demonstrated  beyond 
controversy.  This  is  well  exemplified  in  the  partial 
flexion  during  rest  of  the  forearm  of  the  blacksmith, 
and  the  great  degree  of  flexion  of  the  phalanges  of 
the  trained  weight  lifter  or  the  day  laborer.  Be- 
fore maternity,  therefore,  the  abdominal  muscles 
should  be  prepared  for  the  expected  strain  by  rais- 
ing their  power  through  progressive  exercise,  in- 
creasing the  limit  of  extensibility  with  complete 
elastic  recoil,  beyond  the  amount  of  extension  en- 
countered in  pregnancy.  In  the  case  of  muscles 
already  relaxed,  their  tone  must  be  increased  and  a 


corresponding  diminution  in  muscle  length  obtained, 
to  secure  a  wall  which  will  offer  resistance  to  the 
tendency  of  the  viscera  to  prolapse,  and  which  will 
also  be  a  valuable  aid  in  subsequent  pregnancy. 

An  exercise  is  here  suggested  which  is  ideal,  in- 
asmuch as  it  meets  with  all  requirements  regarding 
results,  is  capable  of  universal  application  because 
it  can  be  practised  at  home  without  apparatus,  and 
presents  a  wide  range  of  gradation  of  effort  neces- 
sary for  its  accomplishment,  thus  making  it  applic- 
able to  individuals  having  different  strengths  of  ab- 
dominal walls. 

With  the  patient  lying  flat  on  her  back,  the  entire 
lower  extremities  from  the  hips  down,  acting  like 
a  single  lever,  are  flexed  on  the  abdomen  to  a  line 
perpendicular  to  the  resting  surface,  and  then  low- 
ered (Fig.  4).  Throughout  the  exercise  there  should 
be  no  flexion  at  the  knee  joints.  This  movement 
should  be  repeated  as  many  times  as  possible  and 
the  number  noted,  at  each  succeeding  trial,  strenuous 
effort  being  made  to  increase  the  number  of  move- 
ments. This  exercise  should  be  practised  in  the 
morning,  before  dressing,  or  at  bedtime,  the  former, 
however,  being  preferable,  as  it  is  then  not  superim- 
posed on  the  arduous  labors  of  the  day. 

When  the  exercise  is  first  attempted,  the  average 
woman  will  find  difficulty  in  repeating  the  maneuvre 
twenty-five  times  without  pause,  but  it  is  aston- 
ishing to  note  the  rapidity  of  increase  possible,  and 
the  concomitant  improvement  in  muscular  tone.  For 
the  flabby,  muscularly  unfit  woman,  who  might  not 
be  able  to  perform  the  exercise  properly  even  once, 
the  simple  modification  of  allowing  slight  flexion 
at  the  knee  joints,  brings  it  within  the  range  of  her 
possibilities,  and  in  her  case,  the  first  aim  of  progres- 
sion should  be  the  development  of  enough  power  to 
perform  the  exercise  without  flexion.    An  expen- 


FiG.  4. — Flexion  of  lower  extremity  on  the  abdomen. 

diture  of  no  more  than  four  minutes  is  necessary 
for  the  performance  of  the  movement  one  hundred 
consecutive  times,  which  is  all  that  is  needed  ulti- 
mately to  develop  a  firm,  elastic,  supporting  wall. 
There  is  no  reason  why  the  abdominal  muscles  of 
woman  should  not  be  at  least  as  well  developed  as 
those  of  man,  and  the  faithful  performance  of  the 
movement  described  above,  daily  for  the  period  of 
a  year,  will  develop  in  woman  an  abdominal  wall 
similar  to  an  anatomical  cut. 


724 


ABBOTT:  OVARIAN  HEADACHES. 


[New  York 
Medical  Journai.. 


With  renewed  interest,  on  the  part  of  the  spe- 
ciaHst  in  diseases  of  women,  in  the  development  of 
the  abdominal  muscles,  the  indication  for  the  use  of 
forceps,  pituitrin,  and  the  abdominal  binder  will 
arise  less  frequently,  and  one  of  the  etiological  fac- 
tors in  the  acquired  form  of  visceral  ptosis  become 
negligible. 

721  Eastern  Parkway. 


PERIODIC  HEADACHES  OF  OVARIAN 
ORIGIN. 

By  George  Knapp  Abbott,  A.  B.,  M.  D., 
Sanatorium,  Cal. 

In  the  fall  of  1916  a  married  woman  aged  thirty- 
eight  years  came  to  me,  seeking'  relief  from  head- 
aches. This  patient  was  a  second  wife,  having  two 
children  of  her  own.  The  headaches  of  which  she 
complained  dated  back  over  many  years,  but  had 
become  very  troublesome  only  in  the  last  few- 
months.  They  were  comcident  with  the  menses, 
beginning  slightly  before  and  lasting  five  to  seven 
days.  Sometimes  a  less  severe  headache  would 
appear  half  way  between  her  periods.  The  head- 
aches were  always  exaggerated  by  social  respon- 
sibilities, and  by  art  work  in  which  the  patient 
engaged  considerably,  although  these  factors  never 
provoked  headaches  at  other  times.  On  further 
questioning  the  fact  was  elicited  that  these  head- 
aches were  entirely  absent  during  pregnancy.  Here 
is  a  patient  whose  headaches  are  definitely  associated 
with  the  menstrual  function,  who  has  no  headaches 
when  that  function  ceases  because  of  pregnancy  and 
who  ha^  recurrence  after  its  termination.  Some 
chemical  or  possibly  some  hormonic  change  is 
obviously  implicated  in,  and  is  possibly  the  cause 
of,  these  headaches. 

What  holds  them  in  abeyance  during  pregnancy? 
Is  there  in  this  patient  some  endocrine  deficiency 
periodic  in  recurrence,  during  the  nonpregnant  state 
which  is  fully  supplied  during  the  period  of  ges- 
tation? My  attention  was  at  once  centered  upon 
the  production  of  the  corpus  luteum  as  the  possible 
and  probable  explanation  of  this  phenomenon.  So 
definite  and  suggestive  was  the  history  that  I  imme- 
diately determined  to  administer  dried  corpora 
lutea.  Five  grains  of  a  standard  product  was  given 
in  capsule  form  three  times  a  day.  The  patient 
was  instructed  to  continue  this  until  a  perceptible 
result  was  obtained  and  after  that  to  reduce  the 
dose  for  the  next  two  weeks  after  each  period,  but 
return  to  the  full  dose  twelve  to  fourteen  days 
prior  to  the  period.  After  three  months  the  patient 
returned,  reporting  that  the  headache  occurring 
with  the  first  menses  after  beginning  treatment  was 
not  so  severe  as  usual.  The  second  one  was  but 
slight,  and  there  was  no  headache  at  all  with  the 
third  period.  The  patient  did  not  come  again  for 
five  or  six  months.  At  this  third  visit  she  reported 
that  she  had  stopped  the  medicine  entirely  after  the 
third  month  of  treatment  and  that  she  had  no  head- 
aches for  about  three  months  more,  when  a  recur- 
rence took  place  and  the  medicine  was  resumed. 

For  a  few  times  she  took  the  medicine  before 
each  period  and  has  had  no  headaches  since  the 
first  recurrence.    Over  two  years  from  the  begin- 


ning of  treatment  the  patient  reported  that  she  had 
taken  no  capsules  for  a  year  and  had  had  no  men- 
strual headaches. 

Since  treating  this  first  patient  I  have  treated 
about  twenty-five  women  with  headaches  of  this 
type.  The  results  have  been  highly  gratifying. 
With  the  majority  of  patients,  however,  it  seems 
to  be  necessary  to  repeat  monthly  a  brief  course 
of  corpora  lutea  prior  to  each  menstrual  period. 
Some  require  larger  doses  than  others  and  for  a 
longer  time  before  the  menses.  The  treatment  has 
ne\  er  provoked  an  increased  flow  or  any  other  un- 
toward symptoms.  One  patient  about  thirty-nine 
years  of  age,  who  had  had  menstrual  headaches  for 
many  years,  summed  up  the  result  of  three  months' 
treatment  by  saying,  "Life  is  now  worth  living. 
I  wish  I  could  have  had  this  j  ears  ago." 

A  trained  nurse  who  had  three  children  took  the 
corpus  luteum  negligently  for  two  months  and 
stopped  it,  feeling  she  received  little  benefit  com- 
mensurate with  the  expense.  Later  her  headaches 
returned  with  the  usual  severity  and  she  resumed 
the  medicine,  obtaining  by  more  continuous  dosage 
full  satisfactory  results,  although  when  last  heard 
from  she  had  to  take  the  capsules  every  month. 

Having  spent  about  twelve  years  in  institutional 
work,  where  I  came  in  contact  with  many  forms 
of  chronic  headache,  and  having  seen  these  cases 
treated  on  the  supposititious  etiology  of  autointoxi- 
cation and  Haig's  uric  acid  diathesis  by  most  thor- 
ough and  rigid  dieting,  eliminative  hydrotherapy 
and  everything  else  a  sanatorium  regime  could  bring 
to  bear  upon  such  cases,  all  with  very  slight  or  no 
results  at  all,  I  naturally  became  very  sceptical  of 
the  possibility  of  benefit  from  any  form  of  therapy. 
The  result  of  corpus  luteum  feeding  has  been  so 
uniformly  satisfactory  and  the  apparent  physiological 
basis  so  definite  clinically  that  the  results  seem  to  be 
well  worth  recording.  A  specialist  has  assured  me 
that  there  is,  up  to  this  time,  nothing  at  all  recorded 
in  the  literature  along  this  line  in  the  treatment  of 
periodic  headaches. 

In  order  to  obtain  definite  results  the  cases  must 
be  carefully  selected,  discarding  all  that  do  not  fall 
under  the  definite  symptomatology  and  course  out- 
lined below.  This  type  of  headache  always  occurs, 
in  the  first  place,  with  some  definite  time  relation 
to  the  menses.  It  may  be  during  the  period  only.  0 
It  may  begin  a  few  hours  or  even  a  week  before 
the  period.  In  some  cases  it  always  comes  after 
the  close  of  the  menstrual  flow.  However,  these 
latter  cases  are  less  common  and  in  my  experience 
give  somewhat  less  complete  results.  In  some 
patients  an  intermenstrual  headache  occurs  with 
quite  definite  regularity  and  in  others  it  is  both 
menstrual  and  intermenstrual  in  time. 

These  headaches,  which  for  want  of  a  better 
designation  I  have  called  periodic  headaches  of 
ovarian  origin,  never  occur  during  pregnancy.  This 
feature  has  been  absolutely  uniform  in  those  women 
who  have  borne  children  or  who  have  had  children 
since  the  inception  of  this  type  of  headache.  This 
was  especially  definite  in  the  case  of  one  patient 
who  had  had  four  children  and  in  whom  the  head- 
aches were  very  severe  and  of  many  years'  standing. 
During  pregnancy  she  was  free  from  headaches. 


November  6,  1920.] 


ABBOTT:  OVARIAN  HEADACHES. 


725 


A  third  feature  of  these  headaches  is  that  they 
become  worse  as  the  patient  approaches  the  meno- 
pause and  reach  their  maximum  with  the  usual 
height  of  the  nervous  symptoms  of  this  period  of 
life.  Some  patients  are  not  troubled  until  after 
their  thirty-fifth  year.  Others  give  a  history  of 
such  menstrual  headaches  from  puberty  or  within 
a  few  years  thereafter.  In  two  or  three  cases 
severe  headaches  antedated  puberty  by  five  years 
or  so,  and  after  puberty  seem  to  become  merged  in 
the  menstrual  headaches  and  appear  thereafter 
largely  to  be  of  this  type.  Such  patients  have  head- 
aches at  other  times  than  those  wliich  bear  a  defi- 
nite time  relation  to  the  menses.  These  latter, 
however,  are  never  missed.. 

Periodic  headaches  of  ovarian  origin  cease  after 
the  full  completion  of  the  ovarian  atrophy  of  the 
climacteric.  The  cessation  of  such  headaches  will 
therefore  occur  after  the  operative  removal  of  the 
ovaries  for  any  cause  whatsoever  and  will  be  very 
materially  hastened  by  proper  dosage  of  x  ray  or 
radium. 

When  very  seA'ere,  this  type  of  headache  is  usually 
accompanied  by  nausea  and  vomiting,  beginning 
several  hours  after  the  onset  of  the  headache.  For 
this  reason  women  often  speak  of  them  as  sick 
headaches.  Care  should  be  observed  that  this  does 
not  lead  to  confusion  with  other  forms  of  headache 
associated  with  nausea  or  vomiting,  or  both. 

In  connection  with  the  subject  of  periodic  nervous 
disturbances  of  apparent  ovarian  origin,  the  history 
of  the  follo"iving  case  now  under  treatment  may  be 
instructive  and  possibly  ofTer  a  suggestion  for  the 
endocrine  therapy  of  other  nerve  disturbances  asso- 
ciated in  certain  cases  with  the  periodic  function  of 
the  ovaries  or  uterus. 

Case. — A  single  woman,  thirty-two  years  of  age, 
with  negative  family  history  as  regards  nervous  or 
mental  disorders,  gives  the  following  personal  his- 
tory. She  was  well  up  to  nineteen  at  which  age 
the  catamenia  began.  These  were  regular  at  a 
twenty-eight  day  interval  and  of  three  day  type. 
With  each  period  she  suffered  from  severe  head- 
aches and  pelvic  pain,  both  of  two  weeks'  duration, 
beginning  one  week  before  and  lasting  one  week 
after  the  period.  For  twenty-four  hours  at  the 
beginning  of  the  mense;  the  pelvic  pain  was  ex- 
tremely severe.  There  was  a  free  interval  of  two 
weeks.  This  programme  continued  for  four  years, 
when  convulsions  began  to  occur  from  one  to  four 
times  during  the  week  of  headaches  preceding  each 
period.  The  convulsions  became  worse  during  the 
next  four  years.  The  left  ovary  was  found  to  be 
cj'stic  and  was  removed.  Its  size  was  almost  that  of 
an  orange.  The  patient  was  then  twenty-seven  years 
old.  For  nearly  three  years  following  this  opera- 
tion the  patient  was  free  from  headaches  and  pelvic 
pain  and  had  no  convulsions.  She  then  had  con- 
vulsions at  two  different  periods,  after  which  the 
right  ovary  was  removed.  It  was  reported  that  this 
ovary  was  not  cystic.  This  was  in  the  patient's 
thirtieth  year.  She  was  then  again  free  from  all 
symptoms  for  two  years  until  August.  1919,  when 
the  same  symptoms — headache,  pain  and  convul- 
sions— reappeared,  though  in  milder  form  than  be- 
fore. The  latest  symptoms  have  been  of  two  weeks' 


duration,  periodic  in  recurrence,  which  is  four  weeks 
from  the  beginning  of  one  to  the  beginning  of  the 
next.  She  has  had  no  menses  since  two  years 
ago,  when  her  second  ovary  was  removed.  When 
the  time  came  for  a  third  attack  of  this  series  she 
rested  in  bed  one  week  and  all  symptoms  were 
absent  except  pain  in  the  right  side  centering  about 
McBurney's  point.  Her  appendix  was  removed  at 
the  second  operation,  but  examination  shows  marked 
tenderness  in  this  region. 

Treatment  with  five  grains  of  corpus  luteum 
three  times  a  day  was  begun  and  the  patient  ordered 
to  rest  with  each  periodic  recurrence  of  the  former 
menstrual  dates.  August  31st,  one  month  from  the 
beginning  of  treatment,  the  patient  reported  that  she 
passed  an  entire  week  at  the  usual  period  without 
symptoms.  She  had  rested  as  much  as  possible, 
which,  however,  was  not  in  bed  nor  at  all  complete. 
The  side  was  still  sore.  In  September,  four  exam- 
inations revealed  tenderness  slightly  internal  to 
McBurney's  point  and  above  along  the  approximate 
course  of  the  right  ureter.  As  the  urine  showed 
pus  hexamethvlenamin  and  monobasic  sodium  phos- 
phate were  prescribed. 

In  October  the  patient  had  a  convulsive  attack 
not  observed  by  anyone.  She  has  not  followed  the 
prescribed  rest,  but  has  worked  fairly  steadily  as 
usual.  In  January,  1920,  an  attack  occurred  which 
lasted  a  few  minutes  only.  A  friend  reported  that 
the  attack  in  May,  before  treatment  was  begun, 
lasted  about  forty  minutes,  i.  e.,  that  the  twitching 
of  the  muscles  continued  during  that  time.  The 
July  attack,  also  before  treatment  was  begun,  lasted 
twenty  minutes.  In  addition  to  having  attacks  of 
lesser  severity  and  shorter  duration,  the  patient 
reports  that  these  last  attacks,  since  beginning  the 
corpus  luteum,  have  left  her  feeling  well  and  ready 
for  work  without  headache,  whereas  prior  to  this 
the  three  attacks  at  the  first  of  this  series  ended  in 
a  headache  and  several  days  of  indisposition.  It 
viill  also  be  noticed  that  while  a  monthly  periodic 
disturbance  with  headache  and  pain  still  occurs,  tlx 
convulsions  have  not  occurred  every  month,  but 
when  they  have  appeared  it  has  been  bimonthly 
both  before  and  since  treatment  was  begun. 

From  January  to  October,  1920,  the  patient  has 
had  but  one  con\'ulsion.  This  was  a  very  mild  one 
without  aftereffects.  It  occurred  at  the  beginning 
of  a  menstrual  date  which  had  been  preceded  by  a 
two  hours'  session  in  the  dentist's  chair.  With  this 
exception  there  have  been  none  of  the  usual  symp- 
toms for  nine  months.  The  patient  feels  better 
and  works  regularly,  usually  eight  hours  a  day.  She 
continues  to  use  the  corpus  luteum  three  times  a  day. 

There  are  several  interesting  questions  that  may 
be  propounded  regarding  this  particular  case :  1 . 
What  structure  in  her  body  maintains  her  period- 
icity of  symptoms  exactly  coinciding  in  time  with 
her  former  menses?  2.  To  use  endocrine  phrase- 
ology', did  she  not  have  an  ovarian  struma  with 
dysovarianism  or  hypoovarianism  ?  3.  Was  the 
epilepsy  direcdy  due  to  any  endocrine  disorder  or 
only  to  excessive  nerve  irritation  arising  from 
severe  headaches  and  pelvic  pain?  4.  Were  not  the 
headaches  of  the  same  type  as  those  under  discus- 
sion, viz.,  periodic  of  dyscvarian  etiology? 


Editorial  Notes  and  Comments 


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NEW  YORK,  SATURDAY,  NOVEMBER  6.  1920. 


A  NEW  ERA  IN  GYNECOLOGY. 

It  is  not  so  far  back  that  the  study  of  gynecology 
assumed  enough  importance  to  rank  as  a  specialty. 
With  the  coming  of  each  specialty  some  of  the 
more  farsighted  were  fearful  that  the  person  sur- 
rendered to  the  care  of  the  specialist  for  diagnosis 
and  treatment  would  cease  to  become  an  individual 
and  would  go  through  the  stages  of  being  a  patient, 
a  case,  and  finally  go  down  into  the  records  as  a 
history  number :  the  feature  of  the  malady  which 
we/e  of  especial  interest  to  the  specialist  would 
help  swell  the  statistics  and  these  would  be  added 
to  the  formidable  list  with  which  he  was  afmed. 
These  statistics,  when  brandished  before  the  less 
fortunate  practitioner  who  seldom  saw  more  than 
a  few  of  the  variants  of  certain  maladies,  did  much 
to  overawe  him.  The  specialists  increased.  The 
fields  Ijecame  ever  more  narrow  and  those  philoso- 
phers found  among  medical  men  from  time  to  time 
shook  their  heads  dolefully  as  they  saw  this  change 
and  witnessed  the  passing  of  the  individual,  while 
the  microscope  was  trained  upon  the  patient.  The 
patient  was  measured  and  weighed  in  the  laboratory 
and  with  the  focusing  of  the  picture  on  a  small 
detail  the  entire  background  of  the  patient's  person- 
ality, makeup  and  environment  was  blurred.  The 
operations  were  more  and  more  successful,  but  was 
the  patient  benefited?  .  .. 

With  the  growth  of  the  specialty  of  gynecology 
came  other  .specialties  in  other  fields.  Psychiatry 
grew  by  leaps  and  bounds  and  established  itself  on 
a  more  substantial  ])asis,  with  the  possibility  of  the 


exploration  of  the  unconscious  made  possible  by 
the  work  of  Freud.  Endocrinology,  entrusted  for 
a  time  to  the  laboratory,  more  recently  has  been 
invading  the  wider  field  of  practical  therapy.  Once 
the  results  of  its  application  were  seen,  the  new 
science  flourished  like  a  flower  allowed  to  see  the 
sun,  and  yet  these  studies  are  practically  in  their 
embryonal  form.  Then  Adler  \The  Study  of  Organ 
Inferiority,  Nervous  and  Mental  Disease  Mono- 
graph Series]  presented  his  most  valuable  hypo- 
thesis of  organ  inferiority  and  the  various  psychical 
and  physical  compensations  which  took  place. 

Now,  the  question  may  be  asked.  What  has  all 
this  to  do  with  the  new  era  in  gynecology?  The 
answer  will  be  found  in  the  splendid  paper  by  Graves 
in  this  week's  issue  of  the  New  York  Medical 
Journal,  in  another  paper  by  Bandler  which  will 
appear  in  next  week's  issue,  and  in  other  papers  by 
him  which  we  have  been  fortunate  enough  to  pub- 
lish. Other  papers  which  appear  in  these  special 
gynecological  numbers  show  signs  of  this  new 
movement.  These  men  have  begun  to  realize  how 
important  it  is  to  look  upon  the  patient  as  an  indi- 
vidual, to  consider  the  general  background  and  the 
endocrine  status  of  the  patient.  They  have  begun 
to  realize  that  many  factors  must  be  considered 
when  an  attempt  is  made  to  find  the  cause  of  a 
disordered  cycle  of  menstruation.  The  pituitary, 
that  tiny  gland  which  controls  the  rhythmicity  of 
bodily  functions  and  the  appreciation  of  rhythm, 
may  be  at  fault.  Psychic  disorders  originating  in 
unfulfilled  wishes,  which  seek  a  somatic  outlet  as 
a  manifestation,  may  be  causing  havoc.  Or  the 
body  may  •  be  marshalling  its  armies  of  defense 
against, an  anemia  which  in  turn  may  have  any  one 
of  many  causative  factors. 

This  is  only  given  as  an  example.  The  lesson 
may  be  carried  on  to  every  branch  of  the  complex 
specialty  of  gynecology.  A  few  of  the  more  pro- 
gressive men  have  realized  the  importance  of  con- 
sidering all  the  factors  which  may  enter  into  a  given 
case.  First  of  all,  the  entire  picture  must  be  in 
focus,  then  the  finer  details  may  be  explored  and 
elaborated.  If  necessary  a  part  of  a  patient  may 
be  sent  to  the  laboratory  as  an  aid  in  diagnosis, 
but  the  patient  as  an  individual  must  always  be 
before  our  eyes.  For  this  reason  the  philosophers 
who  prophesied  that  the  specialists  would  find  them- 
selves in  blind  alleys  may  be  reassured.  The  work 
of  synthesis  has  begun  before  analysis  became  too 
minute.  The  architect  must  know  the  strengtli  of 
each  beam  and  girder,  but  he  must  not  lose  sight 
of  the  structure  as  a  whole. 


November  6.  1920.] 


EDITORIAL  ARTICLES 


727 


RICKETS  AXD  THE  VITAMINES. 

Rickets  is  one  of  the  diseases  believed  by  many 
investigators  to  be  due  to  a  deficiency  of  the  vita- 
niine  element.  There  is.  however,  another  band  of 
observers  who  believe  in  the  prime  importance  of 
defective  hygiene  in  its  etiology  and  yet  others  who 
hold  the  theory  that  the  condition  is  brought  about, 
not  only  by  a  deficiency  or  lack  of  vitamines  but 
bv  a  deficiency  of  certain  articles  of  diet  which  pro- 
duces ill  balanced  metabolism.  Hess  and  Unger 
undertook  a  series  of  clinical  experiments,  the  re- 
sults of  which  were  published  in  the  Journal  of  the 
American  Medical  Association,  74,  1920,  which 
appear  to  show  that  deficiency  in  the  fat  soluble 
vitamine  has  little  to  do  with  the  causation  of  rickets. 

In  a  paper  read  before  the  British  Medical  Asso- 
ciation recently,  Dr.  F.  Gowland  Hopkins,  pro- 
fessor of  biochemistry  in  the  University  of  Cam- 
bridge, subjected  these  experiments  to  criticism. 
He  remarked  that  though  they  were  of  considerable 
importance,  they  failed  to  set  the  question  at  rest 
and  he  was  struck  with  the  exceptional  constitution 
of  the  diet  upon  which  infants  were  placed  whfen  it 
was  intended  to  create  a  vitamine  deficiency.  He 
pointed  out  that  in  respect  of  rickets  developing  in 
the  infants  when  they  were  placed  on  an  apparently 
noniial  fat  supply,  no  full  analysis  of  the  cases  was 
given.  Only  two  cases  were  mentioned  in  detail. 
The  most  striking  of  these,  one  in  which  rickets  de- 
veloped in  the  child  while  it  was  on  a  very  full  sup- 
ply of  whole  milk,  showed  at  the  same  time  some 
added  abnormality  because  the  generous  milk  diet, 
with  the  addition  of  spinach,  failed  to  produce 
growth. 

Hopkins  thought  it  was  noteworthy  that  the 
rickets  was  cured  and  growth  became  normal  when 
at  the  thirteenth  month  codliver  oil  was  added.  On 
the  other  hand  the  five  children  in  whom  ricKets  did 
not  develop,  although  their  food  was  prestimed  to 
be  highly  deficient  in  the  fat  soluble  vitamine,  were 
given  a  diet  of  an  extremely  high  total  caloric  value, 
containing,  together  with  a  vegetable  fat,  a  large 
daily  ration  of  a  skim  milk  powder.  Hopkins  was 
of  the  opinion  that  to  contrast  the  nutritive  effects 
of  skim  milk,  fortified  with  vegetable  fat,  with  those 
of  whole  milk,  was  doubtless  a  legitimate  method  of 
testing  the  influence  of  the  fat  soluble  vitamine,  so 
long  as  both  milks  were  administered  in  normal 
amounts.  But  he  drew  attention  to  the  fact  that 
skim  milk  was  by  no  means  free  from  the  socalled 
fat  soluble  substance.  He  had  experimental  evi- 
dence to  show  that  highly  separated  milk  contained 
an  amount  decidedly  in  excess  of  what  the  residual 
fat  would  seem  to  indicate.  ^\"hen.  then,  so  large 
an  amount  as  180  grams  of  a  milk  powder,  equal  to 


nearly  two  litres  of  the  original  milk,  was  daily  ad- 
ministered, as  in  Hess  and  Unger's  experiments,  in 
infants  aged  from  four  to  nine  months,  the  supply 
of  the  fat  soluble  -vitamine  was  far  from  being 
negligible.  Therefore,  Hopkins  deemed  that  valu- 
able as  this  tlinical  study  might  be,  he  did  not  think 
it  brought  evidence  that  was  final. 

It  does  seem  certain,  that  the  more  investigations 
undertaken  to  determine  the  causation  of  rickets, 
the  clearer  it  becomes  that  more  than  one  factor  is 
concerned  in  its  causation.  Too  great  stress  has 
been  laid  on  the  vitamine  element,  just  as  too  much 
emphasis  has  been  placed  on  defective  hygiene  in 
the  etiolog>-  of  rickets.  Each  plays  a  part,  and  the 
dietetic  factor  is  not  confined  to  the  vitamine  con- 
tent of  the  food.  The  point  that  requires  study  now 
is  the  relative  importance  of  each  factor. 


PHYSICIAX-AUTHORS :  DR.  OLIVER 
GOLDSMITH. 
It  requires  a  stretch  of  the  imagination,  perhaps, 
to  include  Oliver  Goldsmith  in  a  list  of  author- 
physicians,  for  the  truth  is  that  Goldsmith's  med- 
ical skill  was  of  a  low  grade,  and  as  for  patients, 
the  records  show  he  never  was  able  to  get  any  worth 
mentioning.  'T  do  not  practise,"  he  once  said;  "I 
make  it  a  rule  to  prescribe  only  for  my  friends." 
"Tray,  dear  doctor,"  said  Beauclerk,  "alter  your 
rule  and  prescribe  only  for  your  enemies."  Gold- 
smith took  up  medicine  only  after  he  had  failed  at 
several  other  professions — including  the  ministry, 
the  law  and  teaching.  He  spent  eighteen  months  at 
the  medical  school  of  Edinburgh  University  and 
about  the  same  length  of  time  at  Leyden  University. 
As  an  indication  of  how  much  of  that  time  he  de- 
voted to  study  it  need  only  be  mentioned  that  some 
time  later  when  he  presented  himself  at  Surgeons' 
Hall  for  examination  for  the  humble  position  of 
"mate  to  an  hospital"  he  was  unable  to  pass.  Gold- 
smith laid  claim  to  having  received  a  medical  de- 
gree somewhere  on  the  Continent — but  not  at  Ley- 
den. If  so.  no  one  has  ever  been  able  to  find  a 
record  of  it.  When  he  left  Leyden  he  rambled 
through  Flanders,  France,  Switzerland  and  Italy 
playing  a  flute  for  his  meals.  When  he  returned 
to  London  he  tried  to  build  up  a  practice  but  failed 
miserably.  Instead,  he  became  a  strolling  player, 
and  the  life  of  a  strolling  player  in  those  days  was 
a  dog's  life  indeed.  Later  he  pounded  drugs  and 
ran  errands  for  chemists.  A  friend  once  got  him  a 
medical  appointment  in  the  service  of  the  East  India 
Company,  but  this  was  speedily  revoked  when  it 
was  found  that  he  was  incompetent  and  wholly  un- 
fitted to  do  the  work. 


728 


EDITORIAL  ARTICLES 


[New  York 
Medical  Journal. 


And  yet,  in  spite  of  all  this,  Oliver  Goldsmith 
prided  himself  on  his  medical  knowledge  and,  even 
after  his  literary  successes,  preferred  to  be  known 
as  a  physician.  He  invariably  signed  himself  "Dr. 
Oliver  Goldsmith"  and  had  such  confidence  in  him- 
self that  for  several  weeks  at  the  beginning  of  his 
last  illness  he  prescribed  for  himself  and  refused  to 
let  a  real  physician  take  charge  of  his  case.  After 
his  first  failure  as  a  physician  in  London  Goldsmith 
had  worked  for  a  short  period  as  a  bookseller's 
hack,  and  when  he  failed  to  qualify  as  a  hospital 
mate  there  was  nothing  for  him  to  do  but  return 
to  this  lowest  form  of  literary  drudgery.  So,  at  the 
age  of  thirty,  Macaulay  tells  us,  he  sat  down  amid 
squalid  surroundings  to  toil  like  a  galley  slave.  And 
in  time  he  became  perhaps  the  most  beloved  of  Eng- 
lish writers,  a  position  he  held  for  many  decades, 
and  comes  mighty  near  holding  it  even  today. 

During  these  and  later  hack  days  Goldsmith  wrote 
a  little  of  almost  everything — several  volumes  of 
translations,  innumerable  essays,  many  poems,  a 
Life  of  Beau  Nash,  histories  of  England,  Rome  and 
Greece,  a  History  of  the  Earth  and  Animated  Na- 
ture in  eight  volumes,  and  other  writing  of  various 
sorts.  In  the  compilation  of  his  histories  he  was  a 
master  of  selection  and  condensation.  His  style  was 
pure  and  easy,  his  humor  rich  and  joyous,  and  his 
descriptions  picturesque.  Practically  all  this  work 
was  published  anonymously,  but  in  spite  of  this 
Goldsmith  was  becoming  a  popular  author.  A  series 
of  lively  sketches  of  London  life  and  narratives  of 
his  Continental  rambles,  in  particular,  aided  in  at- 
tracting attention  to  him.  Then,  too,  he  was  doing 
at  intervals  during  this  period  some  of  the  work 
which  made  him  famous  and  prosperous.  But  pro's - 
perity  didn't  help  Goldsmith  much ;  it  merely  served 
to  hasten  his  demise,  and  when  he  died  he  was  ten 
thousand  dollars  in  debt.  He  has  been  described 
as  vain,  sensual,  improvident  and  frivolous.  Horace 
Walpole  called  him  "the  inspired  idiot"  and  Samuel 
Johnson  said:  "No  man  was  more  foolish  when  he 
had  not  a  pen  in  his  hand  or  more  wise  when  he 
had.  But  let  not  his  frailties  be  remembered.  He 
was  a  very  great  man."  Goldsmith  was  one  of  those 
men  of  whom  we  say,  "He  was  his  own  worst 
enemy."  He  was  a  curious  compound  of  absurdity 
and  folly.  He  spent  lavishly,  gave  freely  and  was 
an  unlucky  gambler.  His  average  income  for  the 
last  seven  years  of  his  life  was  more  than  four 
hundred  pounds  a  year,  which  was  opulence  in  those 
days,  but  he  squandered  it  as  fast  as  he  got  it  and 
died  in  debt.  He  had  to  sell  The  Vicar  of  Wake- 
field to  pay  his  room  rent  and  got  only  three  hun- 
dred dollars  for  this  novel  which  charmed  all  Europe 
and  is  still  a  big  favorite. 


Goldsmith's  poem,  The  Traveler,  was  his  first 
signed  work.  It  is  one  of  the  finest  poems  in  Eng- 
lish literature.  While  the  fourth  edition  of  The 
Traveler  was  being  published  The  Vicar  of  Wake- 
field appeared  and  rapidly  attained  immense  popu- 
larity. Critics  says  it  is  one  of  the  worst  stories 
ever  constructed,  but  its  faults  are  offset  by  its 
vivacious  comedy.  After  its  appearance  Goldsmith 
turned  to  the  drama.  His  first  effort,  A  Good 
Natur'd  Man,  was  actually  too  funny  to  succeed, 
for  that  sort  of  comedy  was  unfashionable  at  the 
time.  His  second  great  poem,  Tlie  Deserted  Vil- 
lage, appeared  next,  and  this  was  followed  by  his 
second  play.  She  Stoops  to  Conquer,  an  incompar- 
able farce  which  marked  the  high  tide  of  his  pros- 
perity and  popularity.  Goldsmith's  other  notable 
work  includes  his  poems,  The  Hermit  and  Retalia- 
tion, both  replete  with  humor  and  charming  imagery. 

Goldsmith  was  born  in  Ireland,  of  English 
parents,  in  1728.  A  relative  taught  him  his  A  B  C's 
and  for  two  years  he  attended  a  school  kept  by  a 
retired  soldier.  Thereafter  he  attended  some  gram- 
mar schools  and  was  the  butt  of  ridicule  of  both 
pupils  and  teachers  because  he  was  so  homely  and 
such  an  incorrigible  dunce.  Later  he  went  to 
Trinity  College,  Dublin,  where  he  was  invariably  at 
the  foot  of  his  class  but  managed  to  get  a  bachelor's 
degree  in  1749.  His  father,  who  had  died  while 
he  was  at  Trinity,  was  a  minister ;  the  son  ap- 
plied in  a  scarlet  coat  for  a  ministerial  berth,  and 
was  turned  out.  He  next  tried  his  hand  at  tutoring 
and  failed,  and  his  despairing  relatives  tried  to  pack 
him  off  to  America.  They  gave  him  one  hundred 
and  fifty  dollars  and  a  good  horse  and  started  him 
off  to  Cork.  He  spent  the  one' hundred  and  fifty  in 
revelry  and  the  ship  sailed  without  him,  and  Gold- 
smith turned  up  again  like  a  bad  penny.  He  next 
tried  the  law,  in  Dublin.  An  uncle  gave  him  two 
hundred  and  fifty  dollars  to  start  with.  He  gambled 
the  money  away  in  a  few  days.  And  then  he  went 
to  Edinburgh.  Goldsmith  died  on  April  4,  1774, 
in  London,  of  a  nervous  ailment  brought  on  by 
those  habits  of  life  which  made  him  such  a  con- 
spicuous failure  in  everything  except  as  a  writer. 


MILK 

Milk  is  such  a  dangerous  food,  or  has  the  possi- 
bility of  being  such,  that  some  of  our  best  sanitarians 
hesitate,  in  their  own  households,  to  use  that  fur- 
nished by  the  finest  dairies  in  the  country  without 
its  previous  pasteurization.  In  the  light  of  some 
epidemics  that  have  been  traced  to  the  doors  of  these 
dairies,  they  are  justified  in  this  attitude  of  distrust 
of  the  raw  product.   Happy  is  the  consumer  of  milk 


November  6,  1920.] 


EDI  TO  RIAL  A  R  TICLES 


729 


who  knows  nothing  of  bacteriology,  but  the  one 
who  has  tasted  of  the  fruit  of  the  tree  of  the  knowl- 
edge of  such  forms  of  life,  must  have  a  damper  put 
on  his  appetite  for  the  lacteal  fluid.  At  best  it  is  a 
contaminated,  if  not  a  dangerous  food.  When  the 
high  proportion  of  tuberculous  cows  resident  in  some 
of  our  states  is  considered,  the  number  of  cases  of 
tuberculosis  in  children  which  may  have  been  derived 
from  milk  is  truly  alarming.  We  know  little  in- 
deed of  the  sources  of  tuberculous  infection  at  a  later 
age,  but  if,  as  has  been  suggested,  the  disease  -in  the 
adult  is  due  to  infection  in  early  childhood  the  food 
supply  of  that  period  comes  in  for  close  scrutiny. 

A  prominent  English  physician,  Campbell,  has 
proposed  that,  after  the  period  of  infancy,  milk 
should  be  dropped  from  the  diet  as  no  longer  needed 
and  because  of  the  high  element  of  danger  in  its  use. 
He  has  excellent  example  for  this  in  that  the  young 
of  animals  get  along  without,  or  can  get  along  with- 
out, milk  after  their  early  days.  Certainly  man, 
before  he  learned  to  take  advantage  of  the  cow, 
had  no  milk  after  his  first  year  or  so. 

On  the  other  hand  there  is  much  outcry,  on  the 
part  of  food  specialists,  about  the  need  for  vitamines 
which  are  contained  in  milk.  There  is  no  question 
about  the  presence  and  the  valfte  of  these  substances, 
but  is  it  so  essential  that  they  be  obtained  from  milk  ? 
If  so  it  would  seem  as  if  we  had  lost  the  ability  to 
utilize  these  substances  from  other  sources.  Con- 
sidering the  danger  of  infection  which  exists  iA  even 
the  best  of  milk  we  are  much  in  need  of  the  real 
facts  in  the  case  as  to  whether  it  is  essential  for  the 
human  being  in  other  than  the  earliest  months.  At 
least,  however,  we  can  feel  assured  that  milk  which 
has  been  carefully  pasteurized  or  has  been  boiled 
is  above  suspicion  of  danger,  and  all  efforts  to  im- 
prove the  milk  supply  of  a  community  should  receive 
the  heartiest  support  of  all  concerned  in  the  promo- 
tion of  health. 


FREE  USE  OF  MEMORY. 

Repression  is  manifest  in  a  timid  reluctance  to 
engage  in  health  stimulating  pursuits.  It  is  not  the 
distinct  positive  phobia  alone  which  shows  the  effect 
of  the  choking  back  of  psychic  energy.  The  acute 
distress,  the  vaguer  pain  that  realizes  itself  only  in 
restless  inaction,  these  are  familiar  marks  of  repres- 
sion. And  repression  builds  itself  upon  the  want 
of  courage  to  seize  knowingly  upon  one's  memory 
store.  Because  of  the  cutting  out  of  the  latter  there 
is  no  vigor  with  which  to  turn  to  action,  no  flaming 
energy  to  outleap  the  ashbed  of  despair. 

More  and  more  the  duty  of  discovering  the 
reasons  for  such  cutting  oflf  of  the  larger  part  of 
the  self  presses  itself  as  a  primary  one  of  medical 


practice.  This  is  psychoanalysis.  Bergson  in  Mind 
Energy  hints  at  the  hidden  material  which  "in 
reality"  lies  "concealed  in  the  depths  of  memory." 
He  is  not  interested,  however,  in  this  book  in  the 
inner  pathological  aspect  of  the  problem  of  un- 
available memory  material.  He  rather  pours  il- 
lumination upon  the  final  end  and  goal  of  psycho- 
analysis, the  gain  to  life  if  memory  is  free.  Access 
to  unconscious  material  is  power  and  quickening 
inspiration  where  once  was  listlessness  or  active 
despair. 

Bergson's  conception  of  the  brain  in  its  higher 
areas  is  that  of  an  organ  at  the  service  of  conscious 
choice  interposed  as  a  screen  against  a  flood  of  un- 
conscious intruders,  but  at  the  same  time  a  machine 
through  which  selective  admission  is  gained.  Thus 
memories  obtain  egress  to  enrich  the  situation  in 
hand.  This  selection  and  admission  must  not  be 
hindered  by  such  weighting  down  of  these  mem- 
ories that  they  cannot  emerge. 

The  man  of  action  is  the  opposite  of  the  timid 
soul  who  dares  not  act,  or  the  possessor  of  such 
positive  fear,  projected  result  of  the  unconscious 
weight,  that  there  is  no  room  for  endeavor.  Energy 
released  no  longer  drives  tortured  nerves  to  for- 
bidden and  therefore  impossible  action.  Such  action 
w/)uld  be  only  anyway  a  repetition  of  past  conceived 
desires  which  memory  stores.  Free  of  admission  to 
a  constructive  consciousness  these  memory  images 
become  reshaped  to  newly  created  uses.  With  such 
freedom  therefore  the  man  of  action  goes  out  to 
leave  "his  mark  on  the  events  in  which  chance  has 
called  on  him  to  take  part."  Free  behind  his  con- 
scious present  moment,  free  ahead  of  it,  he  is  able 
to  guide  his  action  through  a  "momentary  vision 
which  embraces  a  whole  course  of  events  within  one 
purview."  His  ability,  his  stimulus  toward  the 
future  owe  themselves  to  this  wholeness  of  his  men- 
tal life — and  wholeness  is  also  healthy  exuberance. 
"The  greater  his  hold  on  the  past  in  his  present 
vision,  the  heavier  is  the  mass  he  is  pushing  against 
the  eventualities  preparing.  His  action,  like  an 
arrow,  flies  forward  with  the  greater  force  the  more 
tensely  in  memory  his  idea  had  been  strung." 

SIMULATION  AKD  THE  CAMERA. 
Clever  simulation  requires  a  larger  amount  of 
selfcontrol  and  study  of  the  emotions  than  the 
average  faker  possesses.  A  little  faradic  psycho- 
therapy, restriction  of  food,  isolation,  generally 
bring  the  man  to  confession.  At  one  war  clinic 
where  simulations  of  mental  deficiency,  deafness, 
and  other  conditions  were  common  as  an  excuse 
to  avoid  military  service,  frequent  photographs 
were  made;  every  mood,  every  attitude  was  re- 
corded ;  the  pictures,  if  simulation  was  present,  bore 


730 


NEWS  ITEMS. 


[New  York 
Medical  Journal. 


no  consecutive  likeness  to  the  symptoms  asserted. 
In  the  first  the  man  would  be  worried,  confused ; 
in  another  indifferent,  melancholy ;  in  a  third  ex- 
pectancy would  be  betrayed  as  to  the  success  of  his 
simulation.  On  being  shown  the  many  photographs 
and  the  impossibility  of  so  many  mental  conditions 
being  coexistent,  the  expected  confession  was  nearly 
always  forthcoming. 

 ^ — ■ 

News  Items. 


Nobel  Prizes  Awarded. — The  Nobel  prizes  in 
medical  science  for  1919  and  1920  have  been  award- 
ed to  Dr,  Jules  Bordet,  of  Brussels,  and  Professor 
August  Krogh,  of  Copenhagen. 

California  Health  Officers  to  Meet. — ■  The  state, 
county,  and  municipal  health  officers  of  California 
will  hold  their  annual  conference  in  Chicago,  on 
November  8th  to  11th,  under  the  presidency  of  Dr. 
Ernest  H.  Pape,  of  Berkeley. 

'Gift  to  Red  Cross  Society. — By  the  will  of 
Emma  Chambers  Jones,  of  New  York,  who  died  in 
Grafton,  Mass.,  on  September  18th,  the  American 
Red  Cross  Society  will  receive  $10,000.  The  Char- 
ities Organization  Society  will  also  receive  $10,000. 

Gift  to  Presbyterian  Hospital. — By  the  will  of 
Adele  Emilie  Flint,  of  Larchmont,  the  Presbyterian 
Hospital  of  New  York  will  receive  $100,000. 
Another  beneficiary  is  the  Society  for  Improving 
the  Condition  of  the  Poor,  which  receives  $25,000. 

Bronx  Maternity  Hospital  Dedicated. — The 
new  $100,000  building  of  the  Bronx  MaternTty 
Hospital,  at  168th  street  and  the  Grand  Concourse, 
was  dedicated  with  suitable  ceremonies  on  Sunday, 
October  30th.  The  institution  is  now  open  for  the 
reception  of  patients.  The  building  will  accom- 
modate forty  beds. 

Public  Health  Lectures. — The  School  of  Hy- 
giene and  Public  Health  of  the  University  of  Penn- 
sylvania announces  a  course  of  ten  lectures  on  public 
health  problems,  at  the  University  of  Pennsylvania 
during  the  coming  term,  which  will  be  open  to  the 
public.  The  first  lecture  in  the  course  will  be  given 
Saturday  evening,  November  6th,  on  the  Objects, 
Aims,  and  Results  of  Medical  Inspection  of  Schools. 

Clinical  Congress  of  American  College  of  Sur- 
geons.— The  tenth  annual  session  of  the  Clinical 
Congress  of  the  American  College  of  Surgeons  was 
held  in  Montreal,  October  11th  to  15th.  Dr.  John 
B.  Deaver,  of  Philadelphia,  was  elected  president, 
to  succeed  Dr.  George  E.  Armstrong,  of  Montreal, 
and  Dr.  Harvey  G.  Mudd,  of  St.  Louis,  and  Dr. 
Charles  E.  Sawyer,  of  Marion,  Ohio,  were  elected 
vice-presidents.  The  secretary  and  treasurer  were 
reelected. 

American  Hospital  Association. — At  the  an- 
nual meeting  of  this  associationi,  held  in  Montreal, 
October  4th  to  8th,  the  following  officers  were 
elected:  Dr.  Louis  B.  Baldwin,  of  MinneapoHs, 
president;  Dr.  George  O'Hanlon,  of  New  York, 
president-elect ;  Dr.  Malcolm  T.  MacEachern,  of 
Vancouver,  B.  C,  Mr.  S.  G.  Davidson,  of  Memphis, 
and  Miss  Alice  M.  Gragg,  of  Louisville,  Ky.,  vice- 
pre.;i  'ents ;  Dr.  A.  R.  Warner,  of  Chicago,  secre- 
tary, rmd  Mr.  Ara  Bacon,  of  Chicago,  treasurer. 


Red  Cross  Establishes  Health  Centres  in  New 
York. — According  to  reports  issued  by  the  Red 
Cross  Society,  substantial  headway  has  been  made 
in  the  health  program  of  the  organization, 
eighteen  health  centres  having  been  established  in 
the  Metropolitan  District  of  New  York  and  in  New 
Jersey  and  Connecticut. 

Hahnemann  Hospital  Association. — A  meeting 
of  homeopathic  physicians  and  others  was  held  in 
New  York,  Thursday  evening,  November  4th,  for 
the  purpose  of  considering  how  best  to  carry  on  the 
work  of  the  hospital  as  was  originally  planned  when 
the  institution  was  established.  The  Hahnemann 
Hospital  Association  was  organized  with  this  ob- 
ject in  view. 

Civil  Service  Examination  for  Anesthetists. — 
The  United  States  Civil  Service  Commission  an- 
nounces an  open  competitive  examination  for  anes- 
thetist, to  fill  a  vacancy  in  Freedmen's  Hospital, 
Washington,  D.  C,  at  $1,200  a  year,  plus  increase 
granted  by  Congress  of  $20  a  month,  with  board. 
Freedmen's  Hospital  is  an  institution  for  the  treat- 
ment of  colored  patients.  Applications  will  not  be 
received  after  December  7th. 

$3,000,000  Police  Hospital  Planned. — It  is  an- 
nounced that  one  of  the  largest  and  best  equipped 
hospital  buildings  in  Greater  New  York  will  be 
erected  shortly  in  the  Eastern  Parkway  district  of 
Brooklyn  for  the  benefit  of  the  Police  Department 
of  New  York.  It  i^  estimated  that  $3,000,000  will 
be  required  to  erect  and  equip  the  necessary  build- 
ings and  a  drive  to  obtain  the  money  is  contem- 
plated- 

Faculty  Changes  at  Yale  Medical  School. — Dr. 

George  Blumer,  formerly  dean  of  the  faculty,  has 
accepted  •  a  temporary  appointment  as  clinical  pro- 
fessor of  medicine  at  Yale  Medical  School.  Dr. 
Wilder  Tilleston,  of  New  Haven,  has  been  named 
assistant  to  Dr.  Blumer,  and  Dr.  Edward  H.  Hume, 
dean  of  the  medical  school  of  Yale-in-China,  home 
on  leave  of  absence,  will  serve  as  visiting  professor 
of  medicine.  Dr.  John  E.  Lane  and  Dr.  Alfred  G. 
Nadler  have  been  appointed  clinical  professors  of 
dermatology. 

Coming  Meetings. — The  fourteenth  annual 
meeting  of  the  Southern  Medical  Association  will 
be  held  in  Louisville,  Ky.,  Nov.  15th  to  18th,  under 
the  presidency  of  Dr.  Edward  H.  Carey,  of  Dallas, 
Texas. 

The  eighth  annual  meeting  of  the  North  Pacific 
Surgical  Association  will  be  held  in  Spokane,  Wash., 
December  10th  and  11th,  under  the  presidency  of 
Dr.  John  H.  O'Shea,  of  Spokane. 

The  Western  Surgical  Association  will  meet  in 
annual  session  in  Los  Angeles,  December  3d  and 
4th,  under  the  presidency  of  Dr.  Arthur  T.  Mann, 
of  Minneapolis,  Minn. 

The  Southern  Surgical  Association  will  hold  its 
annual  meeting  at  Hot  Springs,  Va.,  December 
14th,  15th,  and  16th,  under  the  presidency  of  Dr. 
Willard  Bartlett,  of  St.  Louis,  Mo. 

The  Medical  Association  of  the  Southwest  will 
meet  in  annual  session  in  Wichita,  Kan.,  November 
22d,  23d,  and  24th,  under  the  presidency  of  Dr. 
E.  F.  Day,  of.  Arkansas  City,  Kansas. 


Novembe  -  6,  1920.] 


NEWS  ITEMS. 


731 


Personal. — Dr.  Casey  A.  Wood,  of  Chicago,  has 
gone  to  British  Guiana,  where  he  will  conduct  re- 
search work  in  comparative  anatomy  of  the  eye, 
with  special  reference  to  birds. 

Dr.  Thomas  R.  Brown,  of  Johns  Hopkins  Uni- 
versity, has  returned  from  Europe,  where  he  spent 
a  year  as  director  of  the  department  of  medical  in- 
formation for  the  League  of  Red  Cross  Societies. 

Dr.  William  B.  Cornell,  diagnostician  of  the  New 
York  State  Department  of  Education,  is  conducting 
a  survey  of  mental  deficiency  in  Maryland,  under 
the  direction  of  the  National  Committee  for  Mental 
Hygiene. 

Dr.  Ludwig  Hektoen  and  Dr.  Peter  Bassoe, 
of  Chicago ;  Dr.  Lewellys  F.  Barker,  of  Baltimore, 
and  Dr.  Warfield  T.  Longcope  and  Dr.  Rufus  I. 
Cole,  of  New  York,  have  been  elected  foreign  as- 
.  sociate  members  of  the  Swedish  Medical  Associa- 
tion . 

Dr.  Jules  Bordet,  director  of  the  Pasteur  Insti- 
tute of  Brussels,  delivered  the  Herter  lectures  at 
the  fohns  Hopkins  Hospital,  Baltimore,  on  October 
26tli",  27th,  and  28th. 

Hospital  for  Shell  Shocked  Soldiers. — The  new 
Government  hospital  at  Perryville,  Ind.,  where  the 
United  States  Public  Health  Service  will  provide 
special  care  and  treatment  for  shell  shocked  sol- 
diers, was  opened  on  September  24th,  and  over 
100  patients  were  transferred  from  the  temporary 
hospital  at  Cape  May,  N.  J.,  to  the  new  institution, 
where  Surgeon  E.  H.  Mullan  is  in  charge.  In  addi- 
tion to  the  main  hospital  building,  there  are  numer- 
ous individual  cottages  where  special  care  and  a 
homelike  environment  can  be  provided  where  neces- 
sary. At  the  present  time  the  Public  Health  Ser- 
vice has  under  treatment  over  twelve  thousand  dis- 
charged soldiers  suffering  from  shell  shock  and 
other  mental  disorders.  Of  these  5,578  are  in  hos- 
pitals operated  by  the  Service,  and  the  remainder 
in  other  hospitals  where  proper  care  and  treatment 
is  provided  under  contract. 

Public  Health  Service  Takes  Over  Army  Hos- 
pitals.— Two  army  hospitals,  one  in  North  Caro- 
lina and  the  other  in  New  York  Harbor,  were  taken 
over  by  the  United  States  Public  Health  Service 
during  the  past  week.  The  North  Carolina  hos- 
pital (O'Reilly  Hospital),  which  is  at  Oteen,  eight 
miles  from  Asheville,  will  be  continued  as  a  tuber- 
culosis hospital  with  about  one  thousand  beds ;  Dr. 
\V.  M.  Foster  will  be  in  temporary  charge. 

The  buildings  were  erected  by  the  army  for  that 
particular  purpose  and  are  superior  to  most  of  those 
in  base  camps.  Two  of  the  wards  will  be  remod- 
eled, and  some  additional  buildings  will  be  erected 
for  the  use  of  the  staff.  The  present  patients  will 
probably  remain,  if  the  hospital  equipment  can  be 
taken  over  with  them. 

The  hospital  in  New  York,  variously  known  as 
the  Hoff  General  Hospital  and  the  U.  S.  Debarka- 
tion Hospital,  is  at  Fox  Hills,  Staten  Island.  It 
will  be  continued  as  a  general  hospital  with  a  ca- 
pacity of  about  five  hundred  beds.  Dr.  J.  O.  Cobb, 
recently  in  charge  of  Public  Health  Service  activi- 
ties at  Chicago,  will  be  in  charge.  By  reason  of  its 
proximity  to  New  York  this  hospital  has  available 
the  best  consultation  facilities  in  the  country. 


Meetings  of  Local  Societies. — The  following 
medical  societies  will  meet  in  New  York  during  the 
coming  week : 

Monday,  November  8th. — Society  of  Medical  Jurispru- 
dence ;  New  York  Ophthalmological  Society ;  Yorkville 
Medical  Society  (annual)  ;  Williamsburg  Medical  Society, 
Brooklyn. 

Tuesday,  November  gth. — New  York  Academy  of  Medi- 
cine (Section  in  Neurology  and  Psychiatry)  ;  Manhattan 
Dermatological  Society ;  New  York  Obstetrical  Society ; 
Clinical  Society  of  the  Hospital  for  Deformities  and  Joint 
Diseases: 

Wednesday,  November  loth. — Medical  Society  of  the 
Borough  of  the  Bronx ;  New  York  Pathological  Society ; 
New  York  Surgical  Society;  Alumni  Association  of  the 
Norwegian  Hospital,  Brooklyn ;  Brooklyn  Medical  Asso- 
ciation. 

Thursday,  November  iith. — New  York  Academy  of 
Medicine  (Section  in  Pediatrics)  ;  West  End  Clinical  So- 
ciety ;  Brooklyn  Pathological  Society. 

Friday,  November  I2th. — New  York  Academy  of  Medi- 
cine (Section  in  Otology)  ;  Eastern  Medical  Society  of  the 
City  of  New  York;  Flatbush  Medical  Society,  Brooklyn; 
Society  of  Externs  of  the  German  Hospital  in  Brooklyn. 

 ^  

Died. 

Brooks. — In  Auburn,  Wash.,  on  Thursday,  October  21st, 
Dr.  Frank  Brooks,  of  Seattle,,  aged  seventy  years. 

Campbell. — In  Cohoes,  N.  Y.,  on  Wednesday,  October 
20th,  Dr.  William  M.  Campbell,  aged  fifty-nine  years. 

Drovvne. — In  Roxbury,  Mass.,  on  Sunday,  October  24th, 
Dr.  Edwin  Lewis  Drowne,  of  Boston,  aged  forty-three 
years. 

Gardner. — In  Philadelphia,  Pa.,  on  Tuesday,  October 
19th,  Dr.  Charles  H.  Gardner,  aged  eighty-two  years. 

Gerhard. — In  Philadelphia,  Pa.,  on  Wednesday,  October 
27th,  Dr.  George  S.  Gerhard,  aged  seventy-one  years. 

HoYT. — In  Concord,  N.  H.,  on  Thursday,  October  21st, 
Dr.  Adrian  H.  Hoyt,  aged  fifty -nine  years. 

Horning.— In  Collegeville,  Pa.,  on  Wednesday,  October 
20th,  Dr.  Samuel  B.  Horning,  aged  fifty-eight  years. 

Hudson. — In  Yonkers,  N.  Y.,  on  Saturday,  October  30th, 
Dr.  Walter  Guy  Hudson,  aged  fifty-one  years. 

Kinney. — In  Easton,  Pa.,  on  Tuesday,  October  26th,  Dr. 
Charles  S.  Kinney,  aged  sixty-six  j'ears. 

Lamont. — In  Hazleton,  Pa.,  on  Saturday,  October  23rd, 
Dr.  Robert  B.  Lamont,  aged  seventy-two  years. 

McGiNTY. — In  Olyphant,  Pa.,  on  Friday,  October  22nd, 
Dr.  James  McGinty,  aged  thirty-nine  years. 

Mann. — In  Brockport,  N.  Y.,  on  Saturday,  October  23rd, 
Dr.  William  B.  Mann,  aged  eighty-two  years. 

Newman. — In  New  York,  on  Monday,  October  26th,  Dr. 
Charles  F.  Newman,  of  Brooklyn,  N.  Y.,  aged  sixty-six 
years. 

O'Brien. — In  Orange,  N.  J.,  on  Monday,  October  18th, 
Dr.  Daniel  Jerome  O'Brien,  aged  forty-five  years. 

Radin. — In  New  York  City,  on  Thursday,  October  28th, 
Dr.  Maurice  L.  Radin,  aged  forty-eight  years. 

RoDGERS. — In  Mifflintown,  Pa.,  on  Sunday,  October  17th, 
Dr.  W.  H.  Rodgers,  aged  seventy-five  years. 

Stephens. — In  Mansfield,  Tex.,  on  Friday,  October  15th, 
Dr.  J.  P.  Stephens,  aged  seventy-one  years  . 

Thomas. — In  Rochester,  N.  Y.,  on  Thursday,  October 
21st,  Dr.  Cornelia  White  Thomas,  aged  fifty  years. 

Thompson. — In  Cambridge,  la.,  on  Friday,  October 
22nd,  Dr.  Frank  Thompson,  aged  sixty-two  years. 

Westbrook. — In  Rock  Island,  la.,  on  Wednesday,  Octo- 
ber 20th,  Dr.  Edwin  Westbrook,  aged  sixty-three  years. 

White. — In  Sandwich,  Mass.,  on  Wednesday,  October 
20th,  Dr.  George  E.  White,  aged  seventy-one  years. 


Book  Reviews 


TREATMENT  OF  WOUXDS  OF  LUXG 
AND  PLEURA. 

The  Treatment  of  Wounds  of  Lung  and  Pleura.  Based  on 
a  Study  of  the  ^Mechanics  and  Phj-siologj*  of  the  Thorax. 
Artificial  Pneumothorax  Thoracentesis  Treatment  of 
.  Empyema.  By  Professor  Eugenic  Morelli,  Assistant 
in  the  ^ledical  CHnic  of  the  Royal  University  of  Pavia, 
Maggiore  Medico,  Field  Hospital  Xo.  79.  Translated 
from  the  Italian  by  Lixcolx  Davis,  Formerlj-  Lieutenant 
Colonel,  AI.  C,  U.  S.  Army,  and  Frederick  C.  Irvixg, 
Formerlv  Major.  M.  C,  U.  S.  Armv.  Illustrated.  Bos- 
ton: W.  M.  Leonard,  1920.    Pp.  xvi-214. 

The  work  which  ^MorelH  did  in  connection  with 
the  treatment  of  wounds  of  the  lung  and  the  pleura 
places  him  among  the  men  who  devised  ingeniotis 
measures  for  the  treatment  of  the  wounded  in  war. 
He  takes  his  place  with  Gillies,  of  England,  who 
gave  us  the  pedicle  tube,  with  Carrel,  of  France,  who 
gave  us  a  new  method  for  the  treatment  of  infected 
wounds,  and  Willems,  of  Belgium,  who  gave  us  the 
most  radical  method — one  which  seemed  to  be  at 
variance  with  all  we  had  been  taught  in  regard  to 
injuries  involving  articulations. 

]\Iuch  opposition  was  developed  against  ]\Io- 
relli,  especially  in  regard  to  his  doctrine  of 
noninterference  as  far  as  foreign  bodies  were 
concerned.  This  was  contrary  to  the  teachings  of 
the  French  school.  In  France  great  skill  was 
shown  by  certain  surgeons  in  the  removal  of 
foreign  bodies  by  means  of  direct  fluoroscopic 
examination  and  through  a  minute  opening  in  the 
skin,  an  opening  just  large  enough  to  admit  a 
specially  constructed  forceps,  the  jaws  of  which 
were  skillfully  maneuvred  to  the  poiiit  of  contact 
with  the  foreign  body  and  then  opened  to  close 
again,  this  time  grasping  the  body  firmly  and  not 
releasing  it  until  it  was  well  outside  the  body  of 
the  patient.  Great  success  attended  the  use  of  this 
method  and  the  patients  would  be  sitting  up  within 
a  day  or  two  and  up  and  about  within  a  week. 
Infection  was  seldom  encountered.  The  only  un- 
toward results  occurred  when  the  region  of  the 
hilum  was  invaded.  But  let  us  get  back  to  a 
discussion  of  IMorelli's  book.  Of  course  he  was 
enthusiastic  about  his  methods  and  no  doubt  fre- 
quently used  them  when  others  would  have  served. 
For  this  reason  his  statistics  are  extremely  good. 
In  spite  of  all  this,  however,  it  seems  as  though 
the  methods  devised  by  Morelli,  the  perfection  of 
his  technic,  and  the  many  modifications  which  he 
so  skillfully  provided,  should  make  the  work  which 
he  did  so  enthvisiastically  during  the  war  of  far 
greater  importance  for  the  operation  of  pneumo- 
thorax in  civil  practice. 

There  will  be  many  opportunities  to  test  IMorelli's 
methods  under  conditions  identical  with  those  he 
encountered  during  the  war.  For  many  of  the 
injuries  of  peace  simulate  the  more  numerous  in- 
juries of  war.  And  it  would  be  well  for  the  sur- 
geons in  civil  practice  to  take  advantage  of  the 
findings  of  men  like  Willems  and  Morelli  and  take 
them  over  into  their  work ;  apply  them  fear- 
lessly and  energetically  to  the  cases  they  encounter. 
The  great  drawback  is  that  tliere  is  felt  a  lack  of 
familiarity  with  the  technic  and  the  older  methods ; 


the  methods  they  have  become  skillful  in  applying 
are  frequently  employed  rather  than  an  attempt 
made  to  adopt  the  newer  and  more  radical 
procedures  which  have  come  into  existence  through 
the  war.  For  just  this  reason  it  is  to  be  urged 
that  surgeons,  or  clinicians  for  that  matter,  in  the 
case  of  Morelli's  work,  attempt  to  familiarize  them- 
selves with  the  details  of  his  technic.  This  he  has 
outlined  with  great  care  and  elaboration  in  his  sec- 
tion on  treatment. 

He  gives  many  indications  for  the  use  of  his 
method.  Among  the  more  important  are :  acute 
pleural  eclampsia,  interference  with  healing  of  the 
wound  and  difficulty  of  encjstment  of  the  pro- 
jectile; acute  hem.orrhage;  continuovis  oozing.  By 
the  production  of  a  pneumothorax  immobilization 
is  obtained,  compression  of  the  lung  is  favored,  and 
thereby  both  the  healing  of  the  wound  and  encyst-  • 
ment  of  the  projectile  is  hastened;  through  the  pneu- 
mothorax the  movement  of  the  lung  and  suction 
ceases  and  hemorrhage  can  be  prevented  or  checked ; 
in  case  hemothorax  existed  it  should  be  evacuated^ 
and  the  danger  is  lessened  if  the  blood  is  substi- 
tuted by  the  air  as  it  is  removed  and  if  done  sa 
as  not  to  dilate  the  lung. 

The  principal  opposition  that  Morelli  has  found 
to  the  treatment  are  summed  up  in  the  following- 
assertions  ;  The  air  put  into  the  pleural  cavity  will 
escape  either  into  the  chest  wall  or  lung ;  the  air  may 
be  a  source  of  infection ;  the  establishment  of  a 
pneumothorax  and  the  evacuation  of  a  hemothorax 
with  the  substitution  of  air  may  cause  embolism ; 
and  finally  the  hemothorax  should  not  be  ev^acuated 
because  it  serves  for  the  compression  of  the  lung 
and  therefore  checks  the  hemorrhage.  These  as- 
sertions are  analyzed  and  each  one  carefully 
answered. 

In  this  country  where  pneumothorax  is  a 
common  procedure,  questions  of  this  kind  would 
not  be  likely  to  occur.  The  question  of  the  possi- 
bility of  an  embolus  would  seem  to  warrant  the 
most  serious  consideration,  but  IMorelli  states  that 
in  over  a  thousand  cases  he  has  not  caused  a  single 
embolus.  This  seems  satisfactory  enough  but  the 
question  comes  up  if  one  less  skillful  could  show 
a  similar  record.  The  last  point  of  allowing  the 
hemothorax  to  remain  so  that  it  may  serve  to  check 
hemorrhage  seems  rather  pointless  as  the  presence 
of  a  quantity  of  material  which  would  serve  as  an 
excellent  culture  medium  is  not  a  situation  that 
should  be  defended.  Morelli  admits  that  there  is 
danger  in  the  removal  of  clots  of  blood  when  this 
is  done  carelessly  or  too  rapidly,  for  hemorrhage 
may  again  be  started;  for  this  reason  firm  clotting 
should  be  allowed  to  take  place  and  then  the  clot 
removed  slowly  and  carefully.  Then  ^Morelli  goes 
into  the  physicodynamics  of  having  the  blood  used 
to  cause  compression  of  the  lung.  He  shows  that 
the  effusion  of  blood  is  little  fitted  for  this  task. 

Then  we  are  taken  into  the  details  of  the  technic 
and  this  is  worthy  of  most  careful  study.  Many 
case  histories  are  given,  with  numerous  x  ray 
photographs  portraying  the  character  of  the  work 
done. 


November  6,  1920.] 


BOOK  REVIEWS. 


733 


DIFFICULT  LABOR. 

Herman's  Difficult  Labor.  Sixth  Edition,  Revised  and  En- 
larged by  Carltox  Oldfield,  M.  D.  (Lond.),  F.  R.  C.  S. 
(Eng.),  Honorable  Obstetric  Surgeon  to  the  General  In- 
firmary, Leeds,  etc.  Illustrated.  New  York ;  William 
Wood  &  Co.,  1920.    Pp.  ix-573. 

Few  changes  have  been  made  in  Oldfield's  revi- 
sion of  Herman's  standard  textbook,  Difficult 
Labor.  The  principal  cliango  has  occurred  in 
regard  to  the  advisability  of  the  Csesarean  opera- 
tion. The  advice  is  given  that  the  operation  be  a 
more  frequent  one  in  cases  of  contracted  pelvis 
and  in  antepartum  hemorrhage.  The  reasons  for 
the  advisability  of  this  are  fully  explained.  For  a 
sinall  and  concise  book  of  this  character  the  illustra- 
tions are  exceptionally  good.  They  do  credit  to  a 
textbook  of  much  greater  size  and  .one  covering 
the  ground  more  extensively.  Many  revisions  in 
technic  are  also  noted.  These,  however,  are  not  of 
a  radical  nature  and  not  as  extensive  as  some  which 
have  appeared  recently  in  textbooks  devoted  to 
the  surgical  aspect  of  gynecology.  From  the  me- 
chanical point  of  view  there  is  little  to  critize,  but 
it  seems  as  though  more  attention  might  have  been 
given  to  the  chapters  on  infection  and  kidne}-  dis- 
eases. Nevertheless  the  subject  of  labor,  both  nor- 
mal and  abnormal,  is  presented  in  a  practical  fashion. 

ANALYSIS  OF  THE  UNCONSCIOUS 

Man's  Unconscious  Passion.  Bv  Wilfrid  L.\y,  Ph.D. 
N'ew  York  :  Dodd,  Mead  &  Co.,'  1920. 

An  ancient  preacher  sighed,  "Of  the  making  of 
books  there  is  no  end."  We  have  reason  to  suspect, 
however,  from  other  of  his  words  that  he  had  lost 
enthusiasm  for  the  active  phases  of  life.  There  are 
two  sufficient  reasons  for  reftising  to  heed  the  weary 
preacher's  complaint.  Any  new  book  can  be  ac- 
cepted if  it  fulfills  them.  Is  it  the  result  of  an  ef- 
fort to  rise  above  the  accepted  level  of  thought  and 
attainment?  Does  it  introduce  a  new  insight  into 
old  conditions  which  has  all  the  stimulus  of  newly 
created  thought?  Or  as  the  other  suital^le  condition 
does  the  book  fulfill  a  need  of  the  writer's  own,  a 
healthful  expression  of  his  energized  impulses.  The 
latter  can  be  really  known  only  by  the  author  hitn- 
self,  but  at  the  saine  time  such  true  ou^'let  is  possible 
only  if  the  first  condition  also  is  met,  if  the  work  is 
creative.  Then  the  elTect  upon  the  author  is  one 
shared  with  all  his  readers. 

It  is  only  fair  to  ask  the  author  of  this  book,  the 
third  in  a  series  of  which  he  promises  more  to  come, 
to  consider  whether  he  is  entering  deeply  enough 
into  the  contemplation  and  investigation  of  the  un- 
conscious to  give  the  public  in  each  new  Ijook  fresh 
stimtilus.  Lay  has  presented  some  of  the  cardinal 
facts  which  psychoanalysis  has  discovered  in  the 
unconscious  in  a  manner  to  win  the  general  reader's 
attention.  He  has  presented  these  with  special  ref- 
erence first  to  the  actual  existence  of  unconscious 
factors  and  the  mechanisms  by  which  these  work. 
Second  he  has  applied  these  facts  to  the  problems  of 
the  child  mind  and  its  education. 

In  this  present  volume  he  definitely  studies  them 
in  their  relation  to  the  mating  of  men  and  women,  the 
necessity  in  marriage  of  union  in  both  conscious  and 
unconscious  points  of  contact.  He  has  pointed  out 
the  infant  fixations  upon  the  parent  which  present 


such  complete  union.  This  brings  the  more  com- 
plete view  of  the  marriage  relation  to  the  attention 
of  men  and  women  who  have  thought  little  about 
the  real  reasons  why  inarriages  fail  or  who  know 
little  of  the  full  basis  of  lasting  union.  He  has  also 
again  included  simple  expression  of  fundainental 
psychological  truths  in  an  instrtictive  luanner  with 
the  force  of  everyday  language  and  frequent  apt 
illustration.  Yet  complaint  must  be  made  of  con- 
fusion of  thought  and  some  uncertainty  of  expres- 
sion. Most  glaring  is  the  introduction  and  attempt- 
ed explanation  of  the  division  of  the  emotional  life 
into  affection  and  passion.  We  thought  that  for 
professed  psychoanalysts  at  least  Freud  had  re- 
duced the  consideration  of  this  life  to  a  simpler  uni- 
fied basis.  To  find  Lay's  restatement  and  his  elabo- 
rated insistence  upon  it  gives  not  only  confusion  but 
a  sense  of  strained  uncertainty  of  position  on  the 
writer's  part. 

DENTAL  HYGIENE. 

Hygiene,  Dental  and  General.  By  Clair  Elsmere  Turner, 
Assistant  Professor  of  Biology  and  Public  Health  in  the 
Massachusetts  Institute  of  Technology;  Assistant  Pro- 
fessor of  Hygiene  in  the  Tufts  College  Medical  and 
Dental  Schools.  W'ith  Chapters  on  Dental  Hygiene  and 
Oral  Prophylaxis,  by  William  Rice,  Dean,  Tufts  College 
Dental  School.  Illustrated.  St.  Louis  :  C.  V.  Mosby  Com- 
pany, 1920.    Pp.  v-400. 

Again  we  hear  about  dental  hygiene  from  the 
New  England  States,  the  home  of  Fones  and  For- 
sjthe,  where  no  doubt  more  work  is  being  done  to 
stimulate  the  importance  of  hygiene  of  the  mouth 
than  anywhere  else  in  the  country.  Dr.  Turner, 
although  he  has  written  his  book  for  the  dentist, 
concerns  himself  most  with  a  consideration  of  the 
general  hygiene  of  both  the  functional  and  organic 
diseases  of  the  individual  and  his  relation  to  the 
community,  touching  carefully  enough  on  the  neces- 
sity for  proper  nutrition  and  the  expenditure  of 
sufficient  energy  through  exercise  or  work.  An 
itnportant  point  is  made  in  attributing  disease  or 
arrested  development  of  parts  of  the  body  to  a 
lack  of  proper  functioning  as  much  as  to  infective 
organisms.  Dr.  Rice,  who  has  written  the  chapters 
on  dental  hygiene,  gives  the  dentist  a  much  needed 
warning  when  he  says  that  "each  tooth  performs 
its  function  as  a  dependent  unit  in  a  perfect 
machine,"  for  in  truth  the  dentist  still  sees  the 
tooth  as  an  independent  structure  having  no  rela- 
tion to  what  is  really  a  most  delicately  constructed 
mechanism. 

GERSTER'S  AUTOBIOGRAPHY 

Recollections  of  a  N'ew  York  Surgeon.  By  Arpad  G. 
Gerster,  M.  D.  Illustrated.  New  York:  Paul  B.  Hoeber, 
1917.    Pp.  xi-347. 

It  is  often  a  matter  of  regret  to  a  fainily  that 
they  did  not  pay  more  heed  to  and  preserve  the 
stories  told  them  by  the  ancient  grandparents  who 
welcomed  a  listener  to  while  the  hours  which  were 
so  long.  Their  experiences,  touched  by  emotion, 
were  infinitely  more  interesting  than  bundles  of 
dusty  letters  often  undated,  or  files  of  papers. 
Doctor  Gerster 's  forbears  evidently  listened  to  and 
kept  all  records  faithfully,  so  he  greets  us  first  from 
his  own  cradle  in  Hungary  in  1848,  then  presents 
us  to  his  Swiss  ancestors  back  in  1378,  returning 


734 


BOOK  REVIEWS. 


[New  York 
Medical  Journal. 


to  Hungary  and  telling  of  the  family  circle  and 
the  political  and  social  conditions  which  prevailed 
during  his  childhood,  school  days,  and  his  being 
influenced  by  Robert  Ultzmann,  the  urologist,  to 
become  a  doctor.  The  scene  changes  to  Vienna 
in  1864,  and  the  youthful  Gerster  is  listening  to 
Hyrtyl  in  the  University.  Rakitansky,  Skoda, 
Billroth  figure  in  his  student  life,  then  followed 
army  service  and  after  that  a  determination  to  come 
to  New  York,  a  bold  step  for  a  youth.  On  the  ship 
there  was  a  certain  Anna  Wynne,  returning  to 
Cincinnati  from  musical  studies  in  Stuttgart,  who 
shortly  after  became  the  wife  of  this  adventurous 
physician. 

Owing  to  his  letters  of  introduction,  and,  pre- 
sumably, a  certain  amount  of  genius  he  is  too 
modest  to  mention,  he  is  well  received,  notably  by 
a  Doctor  Krachowitzer,  who,  better  than  his  jaw- 
cracking  name,  takes  much  pains  to  launch  young 
Gerster.  The  latter  noticed  at  once  something 
which  struck  English  doctors  and  soldiers  during 
the  late  war — the  informality  between  doctor  and 
patient,  the  absence  of  the  Harley  Street  manner, 
and  the  greater  cheeriness  in  the  hospitals.  He  is 
delighted  too  with  the  clean,  well  lighted  wards  and 
operating  rooms  and  the  cordiality  of  the  doctors, 
not  being  one  of  those  who  take  all  they  can  get 
in  a  foreign  land  and  slang  the  givers.  The  Ger- 
man Hospital;  Mount  Sinai,  the  Polyclinic  School 
knew  him  as  a  worker,  the  various  medical  societies 
and  the  Charaka  Club  know  him  as  a  member; 
some  hundred  medical  and  historical  papers  show 
him  as  a  writer.  Part  three  is  a  little  account  of 
his  ways  and  habits,  early  inclinations,  sports,  and 
his  joy  in  travels.  There  will  be  no  need  for  his 
biographer  to  hunt  for  material ;  he  himself  has  fur- 
nished enough,  though  in  selecting,  the  biographer 
may  unconsciously  wound  an  inarticulate  ghost  by 
ignoring  important  points,  but  the  man  who  really 
wants  to  know  can  always  consult  the  RecollecHons 
as  a  volume  which  gives  not  merely  one  man's  life 
but  things  of  international  interest  in  the  medical 
world. 

ROCKWELL'S  RECOLLECTIONS. 

Rambling  Recollections.  An  Autobiography.  By  A.  D. 
Rockwell,  M.  D.  Illustrated.  New  York :  Paul  B. 
Hoeber,  1920.    Pp.  ix-332. 

A  pleasant  book  of  men  and  things  is  this  which 
Doctor  Rockwell  has  prepared.  He  had  designed  it, 
he  states,  originally  only  for  his  family  but  has  now 
given  to  a  wider  circle  of  readers  these  pleasant 
reminiscences.  There  are  incidents  of  childhood  in 
abundance,  pleasant  tales  of  healthy  country  life.  The 
scenes  in  which  they  take  place  give  a  charming 
glimpse  back  into  the  simpler  aspect  of  localities 
since  greatly  changed.  There  are  reminiscences  of 
old  acquaintances  of  fellow  physicians  as  well  as  of 
patients  who  have  been  well  known  in  various  walks 
of  life.  References  also  to  inembers  of  other  pro- 
fessions with  whom  his  medical  life  has  been  as- 
sociated, all  these  give  many  human  points  of  in- 
terest. The  narrative  of  the  author's  experience  in 
the  Civil  War  presents  also  much  of  this  general 
anecdotal  personal  matter.  There  is  but  little  even 
here,  however,  of  his  real  surgical  experience,  as 


there  is  very  little  throughout  the  book  of  the  actual 
professional  activity  which  he  maintained. 

Those  of  every  age  still  in  active  service,  no  less 
than  those  at  the  very  entering  threshold  look  to  one 
who  has  passed  further  for  a  number  of  vital  things. 
They  expect  some  revelation  of  the  conflicts  through 
which  progress  has  been  achieved.  They  expect  a 
record  of  victories,  of  discoveries  and  achievements 
to  give  impetus  to  still  undeveloped  possibilities. 
They  look  for  the  stimulus  of  faithful  endeavor 
which  realizes  that  its  only  partial  fulfilment  is  the 
opportunity  to  those  following.  Thus  the  aged 
worker  flings  out  a  stirring  battlecry  to  those  fol- 
lowing. Pleasant  as  are  these  rambling  recollec- 
tions one  listens  in  vain  for  this  note.  One  cannot 
believe  the  author's  long  active  life  has  failed  to 
realize  such  an  inspirational  attitude  for  himself  or 
others.  He  forgot,  however,  in  writing  that  the 
younger  generations  are  listening  for  its  challenge. 
Or  if  they  are  not  listening  so  much  the  more  should 
they  be  startled  by  its  utterance. 

 ^>  

New  Publications  Received. 


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


PRACTICAL  VACCINE  TREATMENT.  For  the  General  Practi- 
tioner. By  R.  W.  Allen,  M.  A.,  M.  D.,  B.  S.,  Late  Captain, 
N.  Z.  M.  C.   New  York :  Paul  B.  Hoeber,  1920.   Pp.  xii-308. 

UNTERSUCHUNGEN  UBER  DIE  MYELOMKRANKHEIT.    Von  Dr. 

Arvid  Wallgren  Fruher  1  :  ster  Assistent  der  Med.  Klinik. 
Uppsala  and  Stockholm :  Almavist  &  Wiksellsboktryckeri- 

A.  -B.    1  Distribution.    Sid.  151. 

COMMISSIONE  PER  LO  STUDIO  DELLE  OPERE  DI  PICCOLA  BONI- 

FiCA.  Seconda  Relazione  della  Lotta  Antimalarica  A  Fiumi- 
cino  (Roma)  Diretta  dal  Prof.  B.  Grassi.  Roma  :  Tipo- 
grafia  del  Senato  di  Giovanni  Bardi,  1920.    Pp.  vii-314. 

RETRAINING  CANADA'S  DISABLED  SOLDIERS.     By  WaLTER  E. 

Segsworth,  M.  E.,  Formerly  Director  of  Vocational  Train- 
ing Department  of  Soldiers'  Civil  Reestablishment,  Canada. 
Illustrated.  Ottawa :  J.  de  Labroquerie  Tache,  1920.  Pp. 
193. 

DIE  partigengesetze  und  ihre  allgemeingultigkeit. 
Erkenntnisse,  Ergebnisse,  Erstrebnisse.  Allgemeinverstand- 
lich  dargestellt  von  Hand  Much,  Universitatsprofessor  in 
Hamburg.  Mit  2  Tafeln.  Leipzig:  Verlag  von  Curt 
Kabitzsch,  1921.    Seiten  70. 

taschenbuch  der  magen-  und  darmkrankheiten.  Von 
Dr.  Walter  Wolff,  dirig.  Arzt  der  inneren  Abetilung  am 
Konigin  -  Elisabeth  -  Hospital,  Berlin  -  Oberschoneweide. 
Zweite,  vermehrte  und  verbesserte  Auglage.  Mit  18  Text- 
abbildungen  und  einer  farbigen  Tafel.  Berlin-Wien :  Urban 
&■  Schwarzenberg,  1920.    Seiten  vii-199. 

maternitas.  a  Book  Concerning  the  Care  of  the  Pro- 
spective Mother  and  Her  Child.  By  Charles  E.  Paddock, 
M.  D.,  Professor  of  Obstetrics,  Chicago  Post-Graduate 
Medical  School ;  Assistant  Clinical  Professor  of  Obstetrics, 
Rush  Medical  College ;  Attending  Obstetrician,  St.  Luke's 
Hospital.   Chicago :  Cloyd  J.  Head  &  Co.,  1920.   Pp.  210. 

the  link  between  the  practitioner  and  the  labora- 
tory. A  Guide  to  the  Practitioner  in  His  Relations  with 
the  Pathological  Laboratory.  By  Cavendish  Fletcher. 
M.B.,  B.  S.  (Lond.),  M.  R.  C.  S.,  L.  R.  C.  P.,  Director, 
Laboratories  of  Pathology  and  Public  Health,  London,  and 
Hugh  McLean,  B.  A.,  B.C.  (Cantab.),  D.  P.  H.  (Camb.), 
M.  R.  C.  S.,  L.  R.  C.  P.,  Assistant  Pathologist,  Laboratories 
of  Pathology  and  Public  Health,  London.    New  York :  Paul 

B.  Hoeber,  1920.   Pp.  91. 


Practical  Therapeutics  and  Preventive  Medicine 

A  Compendium  of  Treatment  and  Prophylaxis,  Original  and  Adapted 


X  Ray  in  Fibromyomata  of  Uterus. — L.  Mar- 
tindale  (Archives  of  Radiology  and  Electrotherapy, 
September,  1920)  discusses  the  use  of  intensive 
X  ray  therapy  versus  hysterectomy  in  the  treatment 
of  fibromyomata  of  the  uterus  and  presents  the 
following  conclusions : 

As  long  as  one's  diagnosis  necessarily  remains 
faulty,  there  is  a  danger  in  using  intensive  x  ray- 
therapy  for  any  but  those  cases  in  which  we  are 
fairly  certain  we  are  dealing  with  a  straightforward 
uncomplicated  case,  e.  g.,  a  fibroid  uterus  well  under 
the  size  of  a  six  months  pregnancy,  interstitial 
rather  than  subperitoneal,  and  in  which  the  chief 
and  only  symptom  is  excessive  menorrhagia.  In 
such  a  case  it  seems  to  me  to  be  the  treatment  par 
excellence.  Also  in  cases  of  grave  heart  disease, 
where  no  surgeon  would  like  to  operate,  it  is  an 
ideal  treatment,  and  the  marked  improvement  in 
general  health  of  such  patients  is  wonderful.  In 
all  cases  where  diagnosis  is  doubtful,  an  explora- 
tory laparotomy,  followed  by  hysterectomy  where 
necessary,  is  the  only  right  treatment.  It  seems 
that  x  ray  treatment  may  be  looked  upon  as  the 
treatment  de  luxe  for  all  small  uterine  fibroid 
tumors  associated  with  hemorrhage.  It  improves 
the  health  of  the  patient  without  interfering  with 
her  usual  mode  of  life.  It  causes  a  great  reduc- 
tion in  the  size  of  the  tumor,  and  therefore  does 
away  with  pressure  symptoms.  It  eliminates  the 
nervous  shock  of  an  abdominal  operation  and  the 
inconveniences  of  an  anesthetic,  and,  as  I  said  be- 
fore, it  brings  about  a  climacteric  involving  less 
disturbances  even  than  a  natural  one.  Lastly,  and 
most  important  of  all,  it  is  a  treatment  eminently 
successful  in  suitable  cases — according  to  Gauss  in 
ninety-nine  per  cent,  of  cases,  and  even  according 
to  my  own  series  in  ninety-seven  and  four  tenths 
per  cent,  of  the  cases— and  it  is  a  treatment  free 
from  any  mortality. 

Maternal  and  Fetal  Blood. — Stander  and  Tyler 
(Surgery,  Gynecology  and  Obstetrics,  September, 
1920)  give  the  following  conclusions  from  their 
studies  of  the  ash  content  in  the  fetal  and  maternal 
blood:  1.  During  pregnancy  the  water  content  of 
the  blood  is  usually  found  to  be  between  seventy- 
seven  and  eighty-two  per  cent.,  the  accepted  normal 
limits.  The  tendency  is  toward  the  upper  extreme, 
and  in  one  third  of  our  cases  this  was  slightly  ex- 
ceeded. 2.  Examined  month  by  month  during  preg- 
nancy characteristic  fluctuations  in  the  blood  mois- 
ture become  apparent.  It  increases  gradually  until 
the  seventh  month  and  subsequently  remains  sta- 
tionary or  slowly  decreases.  At  the  onset  of  labor 
it  is  approximately  the  same  as  in  the  early  weeks 
of  gestation.  The  act  of  labor  has  no  constant  in- 
fluence upon  the  blood  moisture.  3.  The  water 
content  of  the  blood  and  the  corpuscular  count 
vary  inversely.  4.  The  plasma  moisture,  examined 
month  by  month,  presents  the  same  type  of  vari- 
ation as  that  characteristic  of  the  whole  blood.  5. 
Quantitatively  the  blood  ash  and  the  plasma  ash 


are  found  to  remain  normal  during  pregnancy.  6. 
Eclampsia  may  not  be  distinguished  from  nephritis 
on  the  basis  of  blood  moisture.  In  either  compli- 
cation, the  percentage  of  water  may  be  great  enough 
to  constitute  a  true  hydremia,  which  is  usually  pre- 
sented by  cases  with  marked  general  edema.  7. 
identical  values  for  the  ash  in  maternal  and  fetal 
plasma  indicate  that  a  free  exchange  of  their  in- 
organic constituents  takes  place  through  the  pla- 
centa in  accord  with  the  laws  of  osmosis.  8.  The 
moisture  of  whole  blood  is  appreciably  higher  in 
the  mother  than  in  the  fetus.  9.  The  plasma  mois- 
tures approach  each  other  closely,  though  by  the 
method  employed  a  difference  of  one  per  cent,  in 
favor  of  the  fetus  is  found  constantly.  Some  un- 
recognized factor,  physical  or  chemical,  maintains 
osmotic  equilibrium  between  the  two  circulations, 
and  water  passes  the  placental  partition  equally 
well  in  either  direction. 

Aspiration  and  Pressure  Treatment  of  Un- 
opened Mammary  Abscesses. — John  P.  Gardiner 
(American  Journal  of  Obstetrics,  November,  1919) 
states  that  the  aspiration  and  pressure  treatment 
is  superior  to  the  ordinary  radial  incision  and 
drainage  method  in  that  drainage  is  better  main- 
tained, practically  no  scar  remains,  and  the  breast 
heals  more  quickly.  In  none  of  the  eight  cases  he 
reports,  did  the  treatment  extend  over  nine  days, 
from  the  first  aspiration  until  no  more  pus  from 
the  cavity  was  obtained.  The  instruments  used 
consist  of  two  glass  syringes,  one  an  ordinary  hypo- 
dermic syringe  with  a  sharp  needle  of  twenty- four 
gauge  and  the  other  a  ten  mil  or  larger  syringe 
with  a  needle  of  seventeen  gauge  and  at  least  two- 
inches  in  length.  The  skin  is  first  washed  and 
painted  with  seven  per  cent,  tincture  of  iodine.  A 
0.5  per  cent,  solution  of  novocaine,  with  three  drops 
of  adrenalin  added  to  the  ounce  of  solution,  is 
then  injected  as  an  anesthetic  at  the  site  of  election, 
down  to  and  into  the  abscess  cavity.  The  left  hand 
now  steadies  the  breast,  and  with  the  syringe  in 
the  right  hand,  the  initial  puncture  is  made  with  a 
quick  stab  into  the  skin.  The  solution  is  distributed 
equally  along  the  proposed  track  for  the  aspirating 
needle.  After  a  few  minutes  the  latter  is  inserted, 
and  the  syringe  filled  and  emptied  repeatedly  until 
the  cavity  is  thoroughly  evacuated.  Upon  fre- 
quently repeated  aspirations  plus  constant  pressure 
on  the  breast  with  a  binder  depends  the  success  of 
the  method.  The  second  aspiration  is  performed 
four  to  six  hours  after  the  first,  and  the  amount 
of  fluid  then  obtained  determines  the  frequency  of 
the  subsequent  aspirations  Each  succeeding  needle 
puncture  is  made  through  the  original  one  and  is 
always  preceded  by  local  anesthesia.  Abscesses 
contiguous  to  the  original  abscess  are  not  difficult 
to  locate  because  the  pressure  exerted  by  the  band-  / 
age  prevents  any  excessive  edema,  so  that  any  in- 
duration between  the  skin  of  the  breast  and  the 
chest  wall  is  readily  recognized  by  palpation.  It 
is  usually  easy  to  drain  by  aspiration  these  con- 


736 


PRACTICAL  THERAPEUTICS  AND  PREVENTH'E  MEDICINE. 


[New  York 
Medical  Journal. 


tiguous  abscesses  through  the  original  cavity.  Dur- 
ing the  acute  stages,  before  the  abscess  has  local- 
ized, it  is  essential  that  the  pressure  bandage  should 
not  be  removed  from  the  breast  except  for  the 
briefest  possible  time ;  the  bandage  should  be  con- 
tinued for  several  days  after  a  dry  tap.  Cold 
should  be  continuously  applied  unless  pus  is  present, 
when  heat  is  substituted.  The  author  also  has  an 
autogenous  vaccine  made  and  administers  a  dose 
of  five  hundred  millions  on  the  fourth  or  fifth  day 
after  the  first  tap  as  a  preventive  against  recurrent 
abscesses.  Prenatal  care  of  the  nipples  does  not 
prevent  the  occurrence  of  sore  nipples  or  breast 
abscesses.  Care  of  the  lactating  breasts  and  nipples 
involves  the  following :  Cleanliness ;.  avoidance  of 
prolonged  and  frequent  nursings  during  the  first 
days  before  the  milk  comes  in ;  early  recognition 
of  a  failing  milk  supply  and  the  immediate  institu- 
tion of  supplemental  feedings,  and  temporary  ces- 
sation of  nursing  on  the  first  sign  of  local  trouble, 
the  lymphangitis  being  meanwhile  combated  by 
pressure  and  cold  to  the  breast. 

Generative  Organs  Treated  by  X  Ray. — I.  Seth 
Hirsch  {American  Journal  of  Electrotherapeutics 
and  Radiology,  August,  1920)  presents  the  follow- 
ing findings  from  his  use  of  the  x  ray  in  the  gyne- 
cological field : 

Advantages:  1.  The  treatment  is  painless.  2.  It 
takes  six  to  nine  weeks,  and  if  it  fails  the  operation 
may  be  carried  out  under  the  same  conditions  as 
before.  3.  If  successful  the  menopause  is  not 
usually  attended  by  any  severe  nervous  symptoms. 

4.  The  general  systemic  disturbances  present  after 
the  operation  are  not  present  with  this  treatment. 

5.  There  are  no  failures  in  the  properly  selected 
cases.  6.  There  is  practically  no  mortality  from 
this  treatment,  while  the  operative  mortality  varies 
from  one  to  four  per  cent. 

Disadvantages:  1.  There  is  a  definite  time  period 
before  the  cure  is  effected.  2.  The  fibroid  may 
only  partially  disappear  after  several  months,  and 
in  rare  cases  a  recurrence  may  occur.  3.  Malignant 
changes  in  fibroid  tumors  of  the  uterus  may  be 
present  and  overlooked,  or  malignant  changes  may 
take  place  in  the  fibroid  under  treatment.  The  last 
is  the  most  important  objection  to  the  use  of  radio- 
therapy. It  is  true  that  a  sarcoma  may,  except  in 
the  case  of  a  rapidly  growing  tumor,  be  overlooked 
in  determining  the  proper  treatment.  But  sarcoma 
is  very  rare  and  occurs  in  less  than  a  half  of  one 
per  cent,  of  cases.  Greater  stress  is  laid  on  the 
coincidence  of  carcinoma  or  epithelioma  with  fibro- 
myoma.  ,  It  may  occur  in  about  five  per  cent,  of  the 
fibroids.  Though  it  is  obvious  that  an  undiscovered 
cancer  of  the  uterus  will  lead  to  fatal  results,  in 
spite  of  radiotherapy,  it  is  also  obvious  that  the 
discovery  of  cancer  in  the  specimen  after  hyster- 
ectomy has  been  performed,  presents  the  problem 
of  surgical  treatment  in  a  new  aspect. 

Just  as  any  form  of  treatment  outlined  for  the 
fibroid  is  altered  when  the  cancer  is  discovered,  so 
the  rontgen  treatment  must  be  altered  if  after  the 
*  treatment  is  begun  carcinoma  is  discovered.  This 
phase  of  the  case  is  in  the  hands  of  the  gynecologist, 
whose  constant  scrutiny  will  minimize  the  possi- 
bility of  an  erroneous  diagnosis. 


Copper  Sulphate  in  the  Local  Treatment  of 
Inoperable  Uterine  Cancer  and  in  Vaginal  Re- 
currences.— D.  Pamboukis  and  G.  Berry  {Presse 
mcdicale,  May  22,  1920)  remove  any  extensive 
fungous  outgrowths  by  curettage,  apply  local  pres- 
sure for  a  few  moments  to  arrest  bleeding,  and  then 
cover  the  surface  with  a  powder  consisting  of  one 
part  of  copper  sulphate  in  twenty-five  parts  of 
powdered  talc.  To  maintain  contact  of  the  powder 
as  well  as  protect  the  surrounding  vaginal  mucosa 
a  tampon  or  sterile  compress  is  inserted.  At  sub- 
sequent dressings,  the  following  paste  is  generally 
used:  Copper  sulphate  (forty  per  cent.),  one  gram; 
magnesium  oxide,  ten  grams ;  adrenalin  solution,  ten 
drops ;  glycerin,  enough  to  make  a  pasty  fluid.  This 
preparation  is  painless  and  should  be  left  in  contact 
with  the  parts  for  one  or  two  days.  After  its  re- 
moval, an  injection  of  one  spoonful  of  sodium  bi- 
carbonate in  two  litres  of  warm  water  is  admin- 
istered. Internally,  the  following  combination  is 
simultaneously  prescribed :  Quinine  bihydrochloride, 
0.25  gram ;  magnesium  oxide,  0.50  gram.  Three 
such  doses  are  taken  in  cachets  each  day.  The  local 
dressings  are  renewed  at  least  three  times  a  week  at 
first,  later  less  frequently,  according  to  the  extent 
of  improvement  of  the  lesions.  Where  there  is  a 
tendency  to  exuberant  proliferation,  copper  sulphate 
crystals  are  applied  directly,  an  attempt  even  being 
made  to  force  them  into  the  depths  of  the  prominent 
vegetations  while  the  rest  of  the  vegetating  surface 
is  dusted  with  powdered  copper  sulphate  crystals. 
Plenty  of  sterile  petrolatum  should  be  used  on  the 
tampon  or  compress,  to  protect  the  remainder  of 
the  vaginal  mucosa.  The  pure  salt  should  never  be 
allowed  to  remain  in  contact  longer  than  twenty- 
four  hours,  and  should  be  alternated  with  the  diluted 
powder  or  the  paste. 

Treatment  of  Menorrhagia  with  Radium. — S. 

W.  Budd,  {Virginia  Medical  Monthly,  April,  1920), 
holds  that  in  radium  we  have  a  remedy  which  in 
a  large  measure  obviates  the  difficulties  associated 
with  successful  termination  of  an  intractable  case 
of  menorrhagia.  Among  the  fifty  cases  of  men- 
orrhagia  unassociated  with  cancer  or  fibroids, 
treated  by  the  author  with  radium,  some  of  the 
patients  had  to  return  for  two  or  more  radiations 
before  they  obtained  relief,  but  in  no  instance  did 
removal  of  the  uterus  become  necessary.  A  simple 
dilatation  and  curettage  is  first  done,  the  uterine 
cavity  swabbed  with  iodine,  and  the  radium  then 
applied  in  a  silver  capsule,  screened  with  one  mil- 
limetre of  brass.  In  short  radiations  the  author 
does  not  screen  with  rubber,  as  do  some  other 
operators.  The  amount  of  radium  to  be  used  de- 
pends largely  on  the  age  of  the  patient  and  the 
condition  under  treatment.  In  young  women  under 
thirty-five  years  of  age  more  than  three  hundred  to 
four  hundred  milligram  hours  is  seldom  given  in 
a  single  treatment.  Application  of  twice  this  dose 
might  bring  about  sudden  termination  of  the  menses. 
Three  months  are  allowed  to  elapse  and  if  the 
menstrual  flow  has  not  then  returned  to  normal  a 
second  application  is  advised.  The  first  period 
after  radiation  is  often  associated  with  menorrhagia, 
but  the  flow  during  the  third  period  is  usually  not 
excessive,  and  at  the  third  period  a  normal  state  is 


November  6,  1920.] 


PRACTICAL   THERAPEUTICS   AND  PREVENTIVE  MEDICIXE. 


7Z7 


reached.  In  women  over  thirty-five  years  of  age 
a  slightly  larger  dose  is  used,  and  more  than  one 
treatment  is  seldom  required.  Where  there  is  no 
fibroid  and  the  menorrhagia  results  from  a  hyper- 
trophic endometritis  or  chronic  metritis,  five  hun- 
dred to  seven  hundred  milligram  hours  are  usually 
given.  In  cases  of  menorrhagia  with  fibroids,  the 
latter  sometimes  entirely  disappear  as  a  result  of 
the  treatment.  After  a  radiation  symptoms  of  in- 
toxication such  as  nausea  and  slight  fever  may 
develop,  but  these  subside  within  twenty-four  hours. 
When  the  menorrhagia  ceases  the  patient  soon  re- 
gains her  hemoglobin  and  health. 

Late  Hereditary  Syphilis. — Custex  and  Del 
\'alle  {Surgery,  Gynecology  and  Obstetrics,  August, 
1920 J  state  that:  ' 

1.  Hereditary  syphilis  is  a  very  frequent  cause — 
perhaps  the  most  frequent — of  membranous  perien- 
teritis and  analogous  conditions. 

2.  Its  pathogenesis  is  complex  as  several  factors 
operate,  which  set  down  in  chronological  order  are : 
defects  of  conformation  in  the  intestinal  walls  be- 
cause of  the  faulty  endocrine  function  which  pre- 
sides over  and  governs  their  development.  These 
malformations  on  the  one  hand,  and  the  abnormal 
function  of  the  nervous  system  (sympathetic  and 
autonomous),  owing  to  the  endocrine  deficiencies, 
produce  defects  in  the  gastrointestinal  statics  and 
dynamics.  As  a  consequence  of  the  latter  we  have 
intestinal  stasis  which  brings  on  chronic  inflamma- 
tion of  the  colon.  From  the  wall  of  the  colon  the 
inflammation  spreads  to  the  surrounding  serous 
membrane,  aggravating  the  existing  congenital  le- 
sions. The  primary  cause  of  all  this  is  hereditary 
syphilitic  infection. 

3.  These  patients,  first  of  all,  should  be  given 
mixed  antisyphilitic  treatment  with  mercury  chiefly. 

4.  The  surgical  treatment  is  not  to  be  abandoned, 
but  is  to  be  restricted  to  cases  in  which  definite 
indications  confirmed  by  clinical  and  radiological 
diagnoses  point  to  mechanical  alterations  of  impor- 
tance (kinks,  adhesions,  etc.)  ;  or  to  coexisting  in- 
flammatory lesions  of  adjacent  organs :  ovaries, 
tubes,  appendix,  gallbladder,  duodenum,  and  stom- 
ach. Surgical  treatment  should  consist  in  separat- 
ing membranes  and  in  molding  and  mobilizing  the 
peritoneum,  together  with  careful  peritonization 
and  removal  of  the  adjacent  affected  organs. 

5.  There  is  the  group  in  which  the  patient  suffers 
from  the  chronic  abdoinen  and  yet  there  is  no 
anatomical  lesion  of  importance.  These  should  be 
considered  as  types  of  "sympathicopathy,"  owing 
to  the  particular  deficiencies,  more  or  less  marked, 
of  the  endocrine  glands  as  suprarenal  capsules  and 
thyroids,  principally.  It  is  itnportant  to  know  this 
type  of  chronic  abdomen,  for  it  involves  a  prognosis 
and  a  therapeutic  managetnent  very  different  from 
the  membranous  perienteritic  type. 

6.  The  prognosis  depends  on  the  anatomical  and 
clinical  type,  and  the  period  or  stage  of  the  affec- 
tion ;  good,  in  cases  of  early  diagnosis  and  rational 
treatment;  less  favorable,  in  those  of  late  diagnosis 
where  rational  treatment  is  impotent  in  modifying 
chronic  lesions  already  well  developed.  In  these  a 
more  or  less  pronounced  improvement  is  to  be  ob- 
tained by  carrying  out  suitable  surgical  treatment. 


Amniotic  Hernia. — Emanuel  Friend  {Surgery, 
Gynecology  and  Obstetrics,  September,  1920)  gives 
the  following  treatment  for  amniotic  hernia :  It 
is  obvious  that  operation  immediately  after  birth 
is  imperative  in  order  to  save  the  child's  life. 
Sanderson  states  that  the  time  to  operate  is  im- 
mediately after  birth,  before  there  is  any  drying 
out  of  the  thin  membrane  covering  the  abdominal 
wall  and  before  the  hernial  protrusion  has  been 
increased  in  size  by  accumulation  of  fluid  in  the 
stomach.  The  only  cases  which  are  amenable  to 
treatment  by  operation  are  those  which  are  small 
enough  so  that  their  contents  can  be  reduced  into 
the  abdomen  and  a  closure  of  the  abdomen  effected. 
When  resection  of  liver  or  other  abdominal  con- 
tents is  required  the  child  usually  dies.  The 
Olshausen  method  has  been  effective  in  small  pro- 
trusions of  this  type.  The  method  consists  in 
separation  of  the  skin  around  the  sac,  removal  of 
Wharton's  jelly,  and  reduction  of  the  hernia  en 
masse  without  opening  the  sac  and  suture  of  the 
skin.  Small  protrusions  can  be  treated  by  care- 
fully cleansing  the  parts,  keeping  them  as  nearly 
aseptic  as  possible  and  applying  pressure  to  the 
hernial  tumor  by  means  of  adhesive  plaster,  and 
encircling  the  entire  abdomen.  Amniotic  hernia 
is  a  rare  condition.  The  treatment,  when  resection 
of  abdominal  organs  is  not  indicated,  is  operative 
immediately  after  birth ;  for  small  protrusions  or  in 
case  of  failure  to  recognize  the  condition  until  late, 
the  treatment  is  palliative 

Empirical  Results  of  the  Treatment  of  Cancer- 
ous Tumors  with  Radium. — S.  A.  Heyderdahl 
{Acta  Cliirurgica  Scandinavica,  June  12,  1920) 
gives  a  statistical  summary  of  cases,  252  in  all, 
treated  by  him  during  a  period  of  five  years  in 
his  capacity  of  senior  physician  to  the  Rontgen 
Radium  Institute  of  the  Riks  Hospital,  Christiania. 
While  rodent  ulcer  and  skin,  mammary  and  uterine 
cancers  comprised  the  majority,  there  were  also 
cancers  of  the  lip,  cornea,  mouth,  maxillae,  neck, 
rectum,  thyroid  gland,  axillary  glands,  bladder, 
penis,  vagina,  vulva,  ovary,  prostate,  as  well  as 
leucoplasia  oris.  Of  these  eighty-eight  were  free 
from  symptoms  at  the  time  of  writing,  eighty-one 
were  improved,  eighty-three  not  cured.  Both  tube 
and  surface  preparations  were  emploA'ed.  In  the 
former  pure  radium  salts  (radium-barium  sul- 
phate) were  used,  enclosed  in  platinum  tubes  with 
walls  one-half  mm.  in  thickness,  this  tube  being 
enclosed  in  a  case  of  silver  one-tenth  mm.  thick. 
A  description  of  his  technic  follows,  including  the 
use  of  Kerr's  paste,  which  he  considers  an  indis- 
pensable aid  in  radium  therapeutics-  The  indi- 
vidual history  and  treatment  of  a  large  number  of 
cases  is  given.  The  author  points  out  the  neces- 
sity of  destroying  the  malignant  tumor  quickly  by 
the  aid  of  the  largest  possible  doses  of  radium,  as 
too  small  doses  only  irritate  the  more  deeply  situated 
parts  to  increased  growth.  Also  prolonged  treat- 
ment with  small  doses,  he  believes,  weakens  or 
renders  impossible  reaction  from  the  surrounding 
tissue  of  the  tumor,  by  causing  degenerative  changes 
in  the  blood  vessels  and  lymphatic  ducts,  while  the 
resorptive  processes  are  more  likely  to  be  stimulated 
by  acute  irritation  with  radium  rays. 


Miscellany  from  Home  and  Foreign  Journals 


Functional  Menstrual  Disturbances. — Florence 
L.  Meredith  (Surgery,  Gynecology  and  Obstetrics, 
October,  1920)  states  that  mental  hygiene  and 
general  hygiene,  including  general  and  special  ex- 
ercise, seem  to  be  the  treatment  of  choice  in  most 
cases  of  menstrual  disturbances  in  young  girls,  and 
in  many  cases  in  older  women.  These  disturbances 
are  largely  due  to"  faulty  muscular  development  and 
faulty  circulation  within  the  power  of  the  individual 
to  correct. 

Physiology  of  Ovulation. — ^S.  S.  Schochet 
(Surgery,  Gynecology  and  Obstetrics,  August, 
1920)  gives  the  following  as  the  results  of  his 
observations : 

1.  Ovulation  is  due  to  a  specific  enzyme,  its  nature 
being  similar  to  the  enzyme  erepsin.  Apparently 
there  are  other  proteolytic  enzymes  in  the  liquor 
folliculi ;  also  a  lipase.  2.  Atresia  of  the  follicles 
is  due  to  this  proteolytic  enzyme  or  enzymes. 
3.  That  the  experiments  which  were  made  offer  a 
rational  explanation  for  the  use  of  thyroid  extract 
and  corpus  luteum  in  sterility. 

Relation  of  Pregnancy  and  Reproduction  to 
Tumor  Growth. — ]^Iaud  Slye  (Journal  of  Cancer 
Researcli,  January,  1920)  reports  the  results  of  five 
years'  investigation  of  the  behavior  of  tumor  growth 
in  its  relation  to  pregnancy  and  reproduction.  The 
experimental  animals  were  mice  bearing  alveolar 
tubular  carcinoma  of  the  mammary  gland.  The 
conclusions  arrived  at  are  that  reproducing  females 
grow  much  less  tumor  than  nonreproducing  fe- 
males of  approximately  the  same  age  and  general 
state  of  nutrition ;  reproducing  females  also  grow 
much  less  tumor  during  the  period  of  reproduction 
than  when  they  are  not  pregnant.  The  various 
factors  entering  into  the  problem,  such  as  the  age  of 
the  mouse,  and  complicating  causes  of  death,  are 
given  consideration. 

Primary  Spontaneous  Tumors  of  the  Ovary  in 
Mice. — Maud  Slye,  Harriet  F.  Holmes,  and  H. 
Gideon  Wells  (Journal  of  Cancer  Research,  July, 
1920)  review  the  literature  of  ovarian  tumors  in 
animals,  and  state  that  among  22,000  mice  of  the 
Slye  stock,  dying  natural  deaths  at  all  ages,  forty- 
four  mice  had  primary  ovarian  tumors,  twenty-six 
having  tumors  in  other  parts  of  the  body.  Thirty- 
eight  of  the  tumors  were  simple  benign  solid  papil- 
lary adenomas,  only  occasionally  with  slight  cyst 
formation.  Nineteen,  or  fifty  per  cent,  of  these, 
were  bilateral,  so  that  there  were  fifty-seven  tumors 
of  this  class.  There  was  one  typical  papillary  cys- 
toma and  one  typical  solid  teratoma.  Four  un- 
questionably primary  malignant  tumors  of  the 
ovan,-,  all  showing  the  mesothelioma  type  of  growth 
characteristic  of  malignant  tumors  derived  from  the 
sex  glands  were  seen,  one  of  which  produced  peri- 
renal metastases.  One  other  tumor  of  the  same 
type  was  primary  either  in  the  ovary  or  the  ad- 
renal. Two  round  cell  sarcomas  arising  either 
from  the  ovarj-  or  some  other  organ  are  described, 
and  two  other  sarcomas  had  produced  secondary 
growths  in  the  ovary. 


Icterus  in  Ectopic  Gestation. — Edgar  H.  Norris 
(Surgery,  Gynecology  and  Obstetrics,  July,  1920) 
presents  the  following  conclusions  from  a  study  of 
icterus  in  ectopic  gestation:  1.  Jaundice  is  a  not 
uncommon  symptom  of  ectopic  gestation.  2.  The 
presence  of  jaundice  is  of  great  importance  and 
may  frequently  be  the  symptom  which  determines 
the  differential  diagnosis.  3.  The  jaundice  in  these 
cases  is  probably  due  entirely  to  the  absorption  of 
blood  derived  pigments  produced  by  the  hemolysis 
of  the  extravasated  blood.  4.  The  blood  serum 
often  contains  considerable  quantities  of  blood  pig- 
ment (hemoglobin,  hematin,  hemochromogen,  hema- 
toidin).  5.  In  the  progress  of  the  differential  diag- 
nosis the  blood  serum  should  be  studied  both  grossly 
and  with  the  aid  of  the  spectroscope. 

Leucoplasia  of  the  Bladder  and  Ureter. — Her- 
man L.  Kretschmer  (Surgery,  Gynecology  and  Ob- 
stetri<:s,  October,  1920)  presents  the  following  con- 
clusions from  his  extensive  study  of  leucoplasia. 
1.  As .  far  as  a  review  of  the  present  literature 
shows,  the  conclusion  seems  justified  that  leuco- 
plasia is  a  rare  condition.  2.  The  etiology  is  un- 
known. 3.  The  histopathological  findings  appear 
to  be  uniform  and  constant.  4.  There  is  no  symp- 
tom or  symptom-complex  by  means  of  which  the 
condition  can  be  diagnosed.  5.  The  presence  of 
large  quantities  of  squamous  epithelial  cells  in  the 
urine  from  the  bladder,  or  from  the  kidney  after 
ureteral  catheterization,  and  the  passage  of  pieces 
of  membrane  or  flakes  of  squamous  epithelial  cells, 
are  very  valuable  findings  in  making  the  diagnosis. 
6.  By  means  of  careful  cystoscopic  examination 
leucoplasia  of  the  bladder  can  definitely  be  recog- 
nized. 

Neonatal  Mortality. — A.  Xewsholme  (Lancet, 
J\lay  22,  1920)  discusses  this  subject,  giving  several 
charts  representing  the  conditions  in  England  and 
Wales.  He  states  that  a  high  infant  mortality  does 
not  indicate  that  there  is  a  selection  of  the  fittest 
to  survive,  for  it  is  shown  that  the  communities 
with  the  high  infant  death  rate  have  also  a  higher 
death  rate  in  the  later  periods  of  life  than  com- 
munities with  a  low  infant  mortality,  and  concludes 
that  the  high  early  mortality  rates  point  out  some 
fundamental  hygienic  weakness  of  the  locality. 
Moreover,  he  maintains  that  since  there  is  a  wide 
variation  between  the  neonatal  mortality  rates  of 
different  communities  there  must  be  some  remov- 
able cause  in  the  places  where  the  rate  is  high  and 
that  by  discovering  the  cause  we  may  appreciably 
reduce  the  deaths  of  newborn  babes  in  the  com- 
munities where  the  rate  is  now  high.  In  a  compre- 
hensive survey  of  the  possibility  of  improving 
the  conditions  he  considers  the  following  steps : 
1.  Continuous  medical  and  nursing  supervision  dur- 
ing pregnancy,  parturition,  and  infanc)-,  perhaps 
through  antenatal  and  postnat:al  clinics.  2.  Skilled 
care  during  parturition.  3.  Provision  of  maternity 
homes  and  hospitals.  4.  Raised  standards  of  the 
practice  of  midwifery.  S.  Further  research  in  ante- 
natal pathology. 


November  6,  1920.] 


MISCELLANY  FROM  HOME    AND  FOREIGN  JOURNALS. 


739 


Heat  and  Infant  Mortality. — Albert  Jobin 
{Canadian  Medical  Association  Journal,  July,  1920) 
asserts  that  poor  elimination  of  the  body  heat,  food 
in  excessive  amount,  and  the  depressing  influence 
of  a  prolonged  high  atmospheric  temperature,  are 
three  great  reasons  why  infant  mortality  is  so  high 
during  the  summer.  To  eliminate  these  causes  we 
must  watch  the  temperature  of  the  child's  room 
and  cut  down  the  food  to  about  two  thirds  of  the 
ordinary  allowance,  making  up  any  loss  in  fluids 
by  giving  water  in  sufficient  amount.  The  child 
should  also  be  lightly  clothed  and  kept  in  the  coolest 
and  best  ventilated  room.  During  the  heat  of  the 
day  windows  should  be  closed  and  opened  during 
the  night,  in  order  to  store  as  far  as  possible  the 
cooler  air  of  the  night. 

Toxicity  of  Mustard  Gas  to  the  Human  Eye. — 

C.  I.  Reed,  {Journal  of  Pharmacology  and  Experi- 
mental Therapeutics,  March,  1920),  reports  inves- 
tigations made  to  determine  the  minimum  concen- 
tration of  mustard  gas  that  will  produce  efifects  on 
the  unprotected  eye  of  man.    Thirteen  subjects 
were  exposed  for  periods  varying  according  to  the 
relative  degree  of  skin  sensitiveness  in  each  indi- 
vidual, previously  determined  by  a  special  method. 
Each  man  wore  a  respirator  and  nose  clip  to  pro- 
tect the  respiratory  tract,  and  one  eye  was  pro- 
tected as  a  control  with  one  half  of  a  close  fitting 
rubber  rimmed  goggle.    The  experiments  showed 
that  the  eyes  are  the  structures  of  the  body  most 
sensitive  to  mustard  gas.    Concentrations  of  0.0005 
milligram  of  mustard  gas  to  the  litre  of  air — one 
part  in  ten  millions — will  produce  visible  eye  re- 
actions from  less  than  one  hour  of  exposure  in 
individuals  whose  skin  resistance  is  relatively  high.* 
Acute   Encephalitis   in   Children. — J.  Comby 
{Bulletins  ct  memoircs  dc  la  Socicte  mcdicale  des 
hopitaux  de  Paris,  February  26,  1920)  directs  at- 
tention to  the  acute  nonsuppurative  variety  of  en- 
cephalitis in  children,  a  condition  already  described 
and  emphasized  by  him  in  1906.    The  onset  is 
sudden,  sometimes  with  fever,  vomiting,  convul- 
sions,  and   paralytic  or  comatose  manifestations. 
The  duration  of  the  affection  is  variable.    After  a 
stage  of  restlessness  or  somnolence — lethargy,  as 
it  would  now  be  termed — with  or  without  ocular 
disturbances,  secondary  disorders,  such  as  chorea, 
athetosis,   paralysis,   convulsions,   insanity,  idiocy, 
or  epilepsy  may  follow.    The  prognosis  is  likewise 
variable.    In  the  diagnosis,  lumbar  puncture,  show- 
ing absence  of  lymphocytosis  is  important.  The 
somnolence  of  lethargic  encephalitis  was  absent  in 
seventeen  out  of  the  twenty-five  cases  of  acute  en- 
cephalitis in  children  seen  by  the  author  since  1894. 
In  six  of  the  eight  cases  with  somnolence,  the  con- 
dition followed  influenza,  and  in  one  each,  whoop- 
ing cough  and  vaccination.    The  seventeen  non- 
lethargic  cases  showed  such  etiological  factors  as 
influenza,  one  case ;  whooping  cough,  two  cases ; 
vaccination,  one  case;  adenoiditis  with  otitis,  one 
case ;  enteritis,  six  cases ;  carbon  monoxide  poison- 
ing, one  case,  and  unknown  factors,  five  cases.  In 
all  these  cases  the  provisional  diagnosis  had  been 
tuberculous  meningitis;  from  this  they  were  soon 
distinguished  by  lumbar  puncture  and  the  course  of 
the  disease. 


Tetany  in  the  Adult,  Due  to  Thyroid  Apoplexy. 

- — Cordier,  {Prcsse  medicale,  April  3,  1920),  re- 
ports the  case  of  a  man  in  colonial  service  in  whom 
tetany  of  the  upper  extremities  developed,  with 
the  usual  clinical  and  electrical  signs  of  this 
condition.  Glandular  therapy  was  followed  by  al- 
most complete  recovery,  but  the  attacks  then  re- 
curred, cachexia  and  acidosis  set  in,  and  the  patient 
died  in  the  midst  of  intense  tetanoid  spasms  and 
violent  prelaryngeal  pain.  At  the  autopsy  a  hema- 
toma of  the  laryngopharyngeal  region  was  found. 
Serial  sections  revealed  destruction  of  one  external 
parathyroid  gland  by  the  hematoma  and  the  pres- 
ence of  large  areas  of  hemorrhage  in  the'  other. 
The  internal  parathyroids  could  not  be  located.  The 
tetany  must  undoubtedly  be  ascribed  to  the  para- 
thyroid injury.  The  case  would  seem  to  shed  light 
on  the  cause  of  many  cases  of  spontaneous  tetany 
in  adults.  The  acidosis  was  analogous  to  that  noted 
by  Morel  in  experimental  parathyroidectomy,  but 
whether  it  was  actually  the  result  of  a  parathyroid 
insufficiency  is  uncertain. 

Fibrous  Tumors  of  the  Palm. — R.  Ducastaing 
{Paris  medical,  March  20,  1920)  states  that  the 
cause  of  fibrous  tumors  of  the  palm  of  the  hand 
is  as  yet  unknown.  Care  should  be  taken  not  to 
confound  them  with  cysts,  the  result  of  traumatism 
and  epidermal  inclusion.  Small  fibromas,  independ- 
ent of  any  local  irritative  cause,  often  mark  the  first 
stage  in  retraction  of  the  palmar  fascia.  The  fibrous 
nodules  develop  insidiously.  There  is  no  manifest 
tuberculous  family  history,  but  a  familial  arthritic 
and  rheumatic  tendency  is  sometimes  elicited.  Path- 
ological study  of  such  a  nodule  revealed  many  new- 
formed  vessels  with  endovascular  inflammation ;  the 
centre  of  the  tumor  was  infiltrated  with  numerous 
hemoglobin  granulations.  Clinically,  the  nodules 
cause  little  discomfort.  There  occur  all  transition 
stages  between  camptodactylia,  palmar  nodosities, 
and  retraction  of  the  fascia.  In  one  of  the  author's 
cases  the  nodules  did  not  seem  to  have  any  tendency 
to  extend ;  in  another,  nodules  and  camptodactylia 
were  simultaneously  present,  and  in  the  third,  the 
patient  passed  gradually  through  the  various  stages 
of  fibrous  infiltration,  leading  eventually  to  Dupuy- 
tren's  contracture. 

Common  Origin  of  Chickenpox  and  of  Some 
Cases  of  Herpes  Zoster. — A.  Netter  {Bulletin  de 
I' Academic  de  medccine,  June  29,  1920)  reports 
two  instances  in  which  a  case  of  herpes  zoster  was 
manifestly  secondary  to  one  of  chickenpox  and 
itself  manifestly  gave  rise  to  another  case  of  the 
latter  disease.  In  the  first  instance  the  child  who 
had  herpes  zoster  had  been  in  a  hospital  for  forty- 
three  days,  but  had  been  transferred  to  a  ward  in 
which  chickenpox  had  prevailed  for  nearly  two 
months,  just  thirteen  days  before  the  herpes  zoster 
came  on.  In  the  second  instance  a  child  contracted 
herpes  zoster  ten  days  after  being  transferred  to  a 
hospital  from  a  boarding  school  in  which  chicken- 
pox  had  been  epidemic.  Fifteen  days  later  another 
child,  who  had  been  in  this  hospital  seventy-nine 
days  with  lethargic  encephalitis,  contracted  chicken- 
pox.  Feer  recently  reported  a  similar  instance 
from  a  hospital  in  Zurich.  Netter  reviews  other 
cases  in  the  literature,  illustrating  a  relationship  of 


740  MISCELLANY  FROM  HOME    AND  FOREIGN  JOURNALS.  [New  York 

Medical  Journal. 


chickenpox  to  some  cases  of  herpes  zoster,  and  con- 
cludes that  in  these  cases  of  zoster  the  eruption 
arose  through  the  localized  action  of  the  chicken- 
pox  virus  upon  the  corresponding  intervertebral 
ganglia.  Sixteen  cases  of  chickenpox  closely  fol- 
lowing herpes  zoster  in  the  same  person  have  been 
reported.  The  small  number  of  persons  contract- 
ing chickenpox  from  cases  of  herpes  zoster  is  to  be 
ascribed  to  the  fact  that  a  large  proportion  of  indi- 
viduals before  exposure  have  already  been  im- 
munised by  a  previous  attack  of  chickenpox.  The 
possibility  should  be  borne  in  mind  that  a  case  of 
herpes  zoster  may  be  followed  by  the  appearance 
of  chickenpox  in  the  same  ward  or  family. 

Action  of  Chloral  on  the  Pupil. — Hyatt,  Mc- 
Guigan,  and  Rettig  {Journal  of  Pharmacology  and 
Experimental  Therapeutics,  July,  1920)  point  out 
that  the  pin  point  pupil  in  many  cases  of  chloral 
poisoning  may  be  responsible  for  the  mistaking  of 
chloral  for  morphine  poisoning.  One  should  re- 
member that  toxic  doses  of  many  drugs  may  give 
a  pin  point  pupil,  and  that  in  the  diagnosis  other 
symptoms  must  be  observed,  the  great  difference 
between  morphine  and  chloral  poisoning  being  the 
condition  of  the  reflexes.  With  chloral  the  reflexes 
and  muscle  tone  are  lost,  while  with  morphine  most 
of  the  reflexes  are  either  normal  or  exaggerated. 
Small  doses  of  chloral,  such  as  one  gram,  produce 
in  man  a  slightly  contracted  pupil  resembling  that 
of  normal  sleep.  The  authors'  experiments  show 
that  large  doses  may  produce  a  pin  point  pupil. 
No  part  of  the  mechanism  of  the  eye  peripheral  to 
the  ciliary  ganglion  is  directly  acted  on  by  the 
chloral,  and  neither  the  ciliary  nor  the  sympathetic 
ganglia  are  involved.  The  action  is  therefore  cen- 
tral, and  due  to  removal  of  inhibitory  influences 
which  normally  are  active.  Strychnine,  caffeine, 
atropine,  and  other  centrally  acting  drugs  are  an- 
tagonistic to  the  action  of  chloral  on  the  pupil. 

Mechanism  of  Fever  Reduction  by  Drugs. — 

H.  G.  Barbour  and  J.  B.  Herrmann  {Proceedings 
of  the  National  Academy  of  Sciences,  March,  1920) 
note  that  dextrose  taken  by  mouth  has  been  found 
frequently  to  exert  a  mild  antipyretic  action.  The 
experimental  work  of  the  authors  showed  that 
various  antipyretic  drugs — sodium  salicylate,  qui- 
nine hydrochloride,  or  antipyrine  subcutaneousl  v, 
or  acetyl  salicylic  acid  by  mouth — increase  the 
blood  sugar  in  both  normal  and  fevered  dogs.  In 
the  latter  this  effect  is  accompanied  by  a  dilution 
of  the  blood — indicated  by  diminished  hemoglobin 
percentage — and  a  fall  in  temperature,  neither  of 
which  occur  in  healthy  animals.  The  authors' 
theory  of  the  action  of  antipyretics  is,  therefore, 
that  in  fevered  animals  these  drugs  produce  a 
dilution  of  the  blood  or  plethora,  hyperglycemia 
probably  contributing  largely  to  this  effect.  The 
plethora  promotes  dissipation  of  heat  both  by  ra- 
diation— peripheral  vasodilatation — and  by  water 
evaporation  from  the  surface  of  the  body.  The 
occurrence  of  the  plethora,  with  its  resulting  an- 
tipyretic effect,  is  apparently  limited  to  fevered 
animals.  This  fact  should  probably  be  attributed 
not  so  much  to  a  greater  degree  of  hyperglycemia 
as  to  the  relative  water  retention  by  the  tissues 
which  is  said  to  accompany  febrile  conditions. 


Major  Trigeminal  Neuralgias. — Harvey  Gush- 
ing {American  Journal  of  the  Medical  Sciences, 
August,  1920)  describes  five  types  of  facial  neu- 
ralgia capable  of  being  mistaken  for  trigeminal 
neuralgia;  those  ascribed  to  the  sphenopalatine 
ganglion,  those  secondary  to  zoster,  those  attributed 
to  the  geniculate  ganglion,  those  accompanying  cer- 
tain cases  of  convulsive  tic,  and  those  due  to  an 
involvement  of  the  trigeminus  by  tumors.  Finally, 
an  attempt  is  made  to  describe  what  are  considered 
minor  trigeminal  neuralgias  as  distinguished  from 
major  trigeminal  neuralgias,  for  which  the  Gasserian 
operation  is  the  proper  therapeutic  procedure. 
Though  the  difference  is  merely  one  of  degree,  it  is 
important  to  have  some  basis  for  separating  them. 
In  the  case  of  the  five  types  of  pseudotrigeminal 
neuralgia  which  may  be  mistaken  for  trigeminal 
neuralgia,  there  is  every  reason  to  refrain,  if  pos- 
sible, from  a  trigeminal  neurectomy. 

Functional  Insufficiency  of  the  Pulmonary  Ori- 
fice in  Association  with  Mitral  Stenosis. — Vaquez 
and  Magniel  {Bulletin  de  I'Academie  de  medecine, 
March  9,  1920)  report  three  cases  presenting  the 
usual  manifestations  of  mitral  stenosis  together  with 
a  diastolic  murmur  with  its  maximum  intensity  on 
the  left,  along  the  sternal  margin,  and  apparently 
originating  in  the  second  interspace.  This  murmur 
is  believed  to  have  been  that  already  described  by 
Graham  Steel  in  1886.  Such  a  murmur  may  arise 
in  one  of  two  different  ways.  In  one  instance  it  is 
due  to  mechanical  conditions  and  the  rise  of  pres- 
sure in  the  lesser  circulation,  which  results  in  dis- 
tention of  the  pulmonary  artery  and  its  orifice.  In 
other  instances  it  is  due  to  a  pulmonary  endarter- 
*itis,  rather  similar  to  the  superadded,  slowly  pro- 
gressive infectious  endocarditis  so  frequently  met 
with  in  valvular  disease.  Its  localization  in  the  pul- 
monary artery  may  be  accounted  for  on  the  ground 
that  this  artery  is  particularly  exposed  to  stress  in 
these  cases.  The  disturbance  of  the  pulmonary  ar- 
tery entails  additional  danger  chiefly  through  the 
infection  associated  with  it ;  often  it  disappears 
when  the  infection  is  recovered  from.  Where  it  is 
due  to  mechanical  distention  of  the  vessel,  the  prog- 
nosis is  much  less  serious,  and  it  may  even  constitute 
a  favorable  factor,  affording  some  degree  of  relief 
as  regards  the  primary  mitral  disturbance. 

Chemical  Disinfection  of  Tuberculosis  Sputum. 

— E.  Arnould,  {Presse  medicate,  April  3,  1920), 
recommends  highly  for  this  purpose  a  solution  al- 
ready used  with  success  by  Kiiss  for  several  years. 
It  consists  of  soft,  potash  soap,  eight  grams ; 
crystalline  sodium  carbonate,  ten  grams ;  thirty-five 
per  cent,  formaldehyde  solution,  forty  grams,  and 
water,  enough  to  make  one  litre.-  This  soapy,  alka- 
line solution,  containing  four  per  cent,  of  formalde- 
hyde, liquefies  the  sputum  thoroughly  and  certainly 
kills  the  tubercle  bacilli  in  from  fifteen  to  twenty 
hours.  The  solution  is,  moreover,  odorless,  gives 
off  no  irritating  fumes,  is  of  low  toxicity,  is  easily 
handled,  facilitates  cleansing  of  sputum  cups  by  its 
liquefying  property,  and  can  be  prepared  by  any 
one  at  slight  expense.  The  practitioner  is  urged 
to  use  this  solution  whenever  circumstances  do  not 
permit  of  disinfection  of  sputum  either  by  boiling 
water,  steam,  or  incineration. 


Proceedings  of  National  and  Local  Societies 


AMERICAN  ASSOCIATION  OF  OBSTETRI- 
CIANS,   GYNECOLOGISTS,  AND 
ABDOMINAL  SURGEONS. 

Thirty-third  Annual  Meeting,  Held  at  Atlantic  City, 
N.  J.,  September  20,  21,  and  22,  1920. 
The  President,  Dr.  George  W.  Crile,  in  the  Chair. 
Interesting  Surgical  Conditions  of  the  Liver 
and  Biliary  Tract. — Dr.  Joseph  H.  Br-\nham,  of 
Baltimore,  said  that  a  healthy  gallbladder  should 
never  be  removed,  nor  should  it  be  subjected  to 
operation.  When  symptoms  were  severe  enough 
to  warrant  operation,  in  most  cases  the  organ  was 
so  diseased  as  to  be  of  little  or  no  value  and  was 
a  menace  to  future  health.  For  several  years  he 
had  removed  the  gallbladder  by  a  method  that  was 
almost  subperitoneal.  After  the  abdomen  was 
opened  the  ducts  and  neighboring  organs  were 
carefully  examined.  This  could  usually  be  done 
by  palpation.  If  the  disease  was  confined  to  the 
gallbladder,  an  oval  incision  was  made  over  the 
lower  ainterior  surface  of  the  organ,  and  the  peri- 
toneal coat  was  dissected  from  the  deeper  tissues. 
When  the  duct  was  reached  it  could  always  be 
known  by  the  well  marked  sphincter.  A  consider- 
able margin  of  the  peritoneal  coat  was  left  at  the 
liver  attachment ;  the  duct  was  severed,  and  after 
being  explored  and  emptied  of  stones,  a  large 
catheter  was  fastened  to  it  by  a  twenty  day  catgut 
suture;  the  peritoneal  coat  from  each  side  was 
stitched  together,  and  then  to  the  ventral  peritoneum. 
This  left  the  catheter  outside  the  peritoneal  cavity 
and  gave  a  smooth  serous  surface  over  the  entire 
wound,  thus  preventing  adhesions.  By  confining 
the  incision  to  the  accessible  part  of  the  organ,  the 
suturing  was  made  easier.  A  small  cigarette  drain 
left  in  for  one  or  two  days  was  all  that  was  needed 
in  most  cases.  After  operations  were  done  in  this 
way,  there  were  few  adhesions,  and  the  patients 
were  left  usually  in  good  condition. 

Dr.  Oraxge  G.  Pfaff,  of  Indianapolis,  Ind.,  in 
discussing  the  subject,  said  that  all  aimed  to  be 
conser\^ative  in  the  treatment  of  gallbladder  dis- 
eases, but  in  t^e  last  few  years  the  statement  had 
been  made  tha  ^llbladder  once  diseased  always 
diseased.    This  ver,  was  not  always  the  case. 

If  the  abdomen  ^ned  and  no  stones  found,  a 

gallbladder  that  .wi  easily  emptied  by  pressure 

should  be  drain  ^,  but  in  most  instances,  instead  of 
draining  the  gallbladder  that  was  grossly  diseased, 
all  were  now  agreed  that  the  thing  to  do  was  to 
remove  it. 

Where  the  Rubber  Glove  Is  Behind  the  Times. 

— Dr.  Robert  T.  Morris,  of  New  Tork,  said  that 
discarding  the  rubber  glove  represented  one  of  the 
best  advances  of  surgery  in  general.  It  interfered 
with  the  sense  of  touch  in  some  kinds  of  work.  In 
abdominal  work  the  rubber  glove  was  not  necessary- 
if  the  hands  of  the  operator  were  other\vise  well 
prepared.  It  made  a  longer  incision  necessary,  and 
consequently  was  not  in  accordance  with  the  prin- 
ciples of  modern  surgery. 


Dr.  Herman  E.  Ha\d,  of  Buffalo,  N.  Y.,  said 
he  thought  that  Dr.  Morris  had  done  the  profession 
a  great  service  in  teaching  them  to  do  surgery 
through  small  incisions  and  to  develop  tactile  sense. 
He  was  rather  surprised  that  a  man  with  a  judicial 
mind  like  Dr.  Morris's  should  have  put  before  the 
association  so  strongly  the  results  of  the  work  of 
Kennedy  without  the  use  of  rubber  gloves.  It  was 
hard  for  him  to  believe  that  in  ninety-nine  per  cent, 
of  the  cases  in  which  other  surgeons  who  wore 
gloves  had  operated  there  were  adhesions,  while 
those  operators  who  did  not  wear  gloves  only  had 
seven  per  cent,  adhesions.  To  him  this  was  ridicu- 
lous. Out  of  one  hundred  cases,  probably  sixty 
to  seventy-five  per  cent,  were  the  simplest  kind  of 
operations  and  would  have  taken  but  a  short  time 
to  accomplish.  He  did  not  believe  it  was  possible 
that  such  results  could  take  place  in  the  hands  of 
ninetj'-nine  men  with  adhesions  and  Dr.  Kennedy 
had  only  seven  per  cent,  adhesions  from  operating 
without  gloves. 

Dr.  Charles  L.  Boxifield,  of  Cincinnati,  Ohio, 
could  not  believe  that  the  rubber  glove  in  and  of 
itself  caused  adhesions.  He  could  conceive  of  a 
man  with  rubber  gloves  being  rough,  and  a  man 
without  rubber  gloves  scratching  tissues  with  his 
finger  nails.  One  thing  that  induced  him  at  an 
early  age  to  wear  rubber  gloves  was  the  fact  that 
his  finger  nails  were  very  hard  to  keep  clean,  and 
he  seldom  knew  whether  he  had  them  clean  or  not, 
and  he  felt  it  was  better  to  cover  them  up  with 
something  that  he  could  boil.  While  rubber  gloves 
might  impair  tactile  sense  a  little,  still  they  should 
be  used  in  operating. 

Dr.  Gordon  K.  Dickixsox,  of  Jersey  City,  stated 
that  Dr.  Morris  wanted  to  standardize  surgery  by 
discarding  gloves.    Why  were  gloves  worn?  To 
prevent  infection.    Why  was  infection  likely?  I 
one  went  the  rounds  of  the  clinics  one  would  se 
the  most  incongruous  things  perpetrated,  such  a 
putting  on  soap  and  washing  it  off  again.    If  on 
wanted  to  get  his  hands  free  from  germs  he  mus 
not  wash  the  soap  off  and  must  not  scrape  it  off. 
It  did  not  do  any  good.    Put  soap  on,  rub  it  in, 
and  one  would  kill  the  germs,  and  there  was  no 
germicide  more  potent  than  potassium  soap. " 

Dr.  JoHX  W.  Keefe,  of  Providence,  R.  I.,  said 
that  a  surgeon's  tactile  sense  was  not  as  acute  with 
a  rubber  glove  on  as  it  was  without  it.  When 
rubber  gloves  first  came  into  use  he  used  them  in 
nearly  all  cases  in  which  he  operated.  Now  and 
then  he  slipped  the  rubber  gloves  off  because  he 
thought  he  could  feel  better  without  them.  At  one 
time  he  was  in  the  habit  of  going  to  see  Dr. 
McBumey,  who  was  one  of  the  greatest  surgeons 
America  had  ever  produced.  He  told  him  about 
his  difficulty,  and  he  said  that  was  exactly  where 
the  mistake  was  made.  The  rubber  gloves  should 
be  kept  on  in  a  difffcult  case  and  the  fingers  ought 
to  be  educated  as  to  how  differently  things  felt 
with  the  gloves  on.  He  went  home  and  had  prac- 
tised that  ever  since. 


742 


PROCEEDINGS  OF  NATIONAL  AND  LOCAL  SOCIETIES. 


[New  York 
Medical  Journal. 


Dr.  James  N.  West,  of  New  York,  said  that 
Dr.  Morris  had  spoken  of  the  great  tendency  to 
standardization,  with  the  result  that  it  stifled  orig- 
inality. There  were  times  when  the  surgeon  could 
operate  to  greater  advantage  without  the  use  of 
gloves  than  with  them,  particularly  if  he  was  very 
careful  in  the  preparation  of  his  hands. 

Dr.  Abraham  J.  Rongy,  of  New  York,  said  in 
a  large  city  like  New  York  it  was  not  only  unsafe 
to  operate  without  gloves,  but  unsafe  to  examine 
patients  in  the  office  without  gloves,  and  as  a 
measure  of  protection  the  use  of  gloves  was  one 
of  the  best  things  for  the  physician. 

Rupture  of  the  Bladder  during  Labor. — Dr. 
John  W.  Poucher,  of  Poughkeepsie,  N.  Y.,  re- 
ported a  case,  stating  that  rupture  of  the  bladder 
during  labor  was  very  rare.  It  might  be  caused  by 
instrumentation  or  spontaneously  by  an  overdis- 
tended  bladder.  The  immediate  symptoms  simu- 
lated those  of  rupture  of  the  uterus.  It  was  im- 
portant that  the  bladder  be  frequently  emptied  during 
severe  and  protracted  labor.  Recovery  of  the  patient 
depended  on  prompt  operative  treatment. 

My  Method  of  Performing  Version. — Dr. 
Irving  W.  Potter,  of  Buffalo,  N.  Y.,  stated  that 
for  the  year  ending  August  31,  1920,  he  had  per- 
sonally delivered  1,113  women,  920  of  whom  were 
delivered  by  version.  Of  the  920  versions,  400 
were  in  primiparse,  and  520  in  multiparse.  He 
showed  lantern  slides  demonstrating  his  method  of 
performing  podalic  version.  He  emphasized  the 
importance  of  proper  preparation  of  the  patient  for 
delivery,  the  condition  of  the  bladder,  cervix,  and 
vaginal  canal.  He  laid  stress  on  the  position  of  the 
patient  during  delivery,  and  the  degree  of  anesthesia 
necessary. 

Dermoid  Cysts  of  the  Ovary;  Etiology,  Diag- 
nosis, and  Treatment. — Dr.  Benjamin  R.  Mc- 
•  Clellan,  of  Zenia,  Ohio,  gave  a  brief  review  of 
'lermoid  cyst  of  the  ovary,  saying  that  recent  re- 
■'^^arch  into  the  etiology  of  these  strange  neoplasms, 
''ipecially  the  work  of  Goodall,  had  added  new  in- 
",rest  and  emphasis  to  the  parthenogenetic  theory. 
^tS  to  the  diagnosis,  the  question  of  possible  infec- 
tion and  malignant  potentiality  in  these  growths 
demanded  more  careful  study  of  all  tumors  arising 
from  the  pelvic  basin.  The  x  ray  should  be  more 
generally  utilized.  In  the  treatment  the  utmost  care 
should  be  exercised  in  removing  the  tumor  en 
masse,  without  the  use  of  trocar  or  aspirator.  The 
case  reported  by  the  author  only  added  another 
example  to  prove  the  fact  that  these  tumors  did  not 
prevent  pregnancy  nor  interfere  with  parturition  as 
long  as  the  pedicle  remained  untwisted. 

Certain  Procedures  in  Vaginal  Surgery. — Dr. 
Samuel  W.  Bandler,  of  New  York,  described  an 
operation  for  cystocele  and  prolapse  of  the  uterus, 
modified  by  partial  hysterectomy  and  complete  per- 
ineorrhaphy. He  exhibited  numerous  lantern  slides 
and  made  a  rvmning  comment  on  them. 

Case  of  Congenital  Absence  of  the  Vagina  with 
Other  Abnormalities. — Dr.  David  Hadden,  of 
Oakland,  Cal.,  reported  the  case  of  a  girl  of  eighteen 
with  absence  of  menstruation.  The  symptoms  were 
indefinite.    Examination  showed  external  parts  nor- 


mal with  unperforated  hymen.  A  body  felt  through 
the  rectum  occupied  the  position  of  the  uterus.  Op- 
eration revealed  the  absence  of  a  vaginal  canal,  the 
pelvic  mass  being  the  right  kidney  fixed  in  position 
The  cecum  and  appendix  were  undescended  and 
located  in  the  right  kidney  fossa.  A  general  con- 
sideration of  the  factors  involved  was  discussed. 

Luteum  Extract.— Dr.  Adam  P.  Leighton,  Jr., 
of  Portland,  Me.,  spoke  of  the  necessity  for  /com- 
bining thyroid  extract  with  luteum  in  many  cases. 
He  spoke  of  the  use  of  these  extracts  in  cases  of 
menorrhagia,  dysmenorrhea,  functional  amenorrhea 
and  obesity.  The  climacteric  symptoms  and  others 
were  due  to  ovarian  insufficiency.  He  pointed  out 
the  great  necessity  for  prolonged  administration  of 
luteum  extract  in  order  to  obtain  results. 

Submucous  Adenomyomata.— Dr.  Otto  H. 
Schwarz,  of  St.  Louis,  Mo.,  stated  that  submucous 
adenomyomata  were  comparatively  rare,  only  a  few 
cases  having  been  described  in  the  literature.  The 
condition  was  primarily  a  localized  adenomyoma  in 
the  uterine  wall.  These  tumors  were  usually  dif- 
fuse in  character  and  their  tendency  to  become  sub- 
mucous was  quite  unusual.  He  described  a  very 
large  submucous  adenomyoma,  unusual  in  struc- 
ture, with  marked  cystic  dilatation  and  intracanalicu- 
lar  projections.  A  subserous  tumor,  described  by 
Robert  Meyer,  arising  from  the  Wolffian  duct  or  the 
parovarian  tubules,  was  mentioned.  The  submucous 
tumor  in  the  author's  own  case,  although  identical 
in  structure  with  the  tumor  described  by  Meyer,  was 
definitely  of  Miillerian  origin. 

Endocrine  Influence,  Mental  and  Physical,  in 
Women.— Dr.  James  E.  King,  of  Buffalo,  N.  Y., 
pointed  out  that  the  endocrine  system  supplied  stim- 
uli for  the  fulfillment  of  the  two  fundamental  laws 
of  nature.  The  secretions  prompted  in  the  human 
being  many  mental  attributes.  In  women,  both  the 
physical  and  mental  phenomena  associated  with  re- 
production were  the  result  of  glandular  secretion. 
There  was  some  fact  and  much  theory  bearing  on 
this.  Woman  would  be  better  understood  when  we 
had  further  knowledge  of  the  complicated  opera- 
tion of  her  endocrine  system. 

Case  Reports.  —  Dr.  George  Van  Amber 
Brown,  of  Detroit,  Mich.,  reported,  1,  papilloma 
of  the  bladder  in  a  woman  forty-five  years  of  age; 
2,  a  case  of  advanced  carcinoma  of  the  uterus  in  a 
woman  of  thirty-eight;  3,  fibrosarcoma  mucocellu- 
lare  carcinomatodes  (Krukenburg  type  of  tumor)  in 
a  woman  fifty-seven  years  of  age;  4,  chorioepithel- 
ioma  malignum  with  multiple  fibroid  tumors  in  the 
uterine  tissue,  in  a  woman  thirty-five  years  of  age; 
5,  lymphoblastoma  primary  in  the  parovarium  of  a 
child  five  years  of  age. 

Accidental  Hemorrhage;  Caesarean  Section; 
Hematuria  in  Pregnancy.— Dr.  James  K.  Quig- 
LEY,  of  Rochester,  N.  Y.,  reported  two  cases,  one 
of  accidental  hemorrhage  in  which  a  CjEsarean  sec- 
tion was  done.  The  interesting  points  in  this  case 
were:  1.  Of  the  several  causes  advanced  as  factors 
in  the  etiology  of  accidental  hemorrhage,  this  pa- 
tient presented  three,  viz. ;  trauma,  a  marked  preg- 
nancy toxemia,  and  a  short  umbilical  cord  (seven- 
teen cm.)   2.  Extreme  intrauterine  pressure.  3. 


November  6,  1920.] 


PROCEEDINGS  OF  NATIONAL  AND  LOCAL  SOCIETIES. 


743 


Gross  appearance  of  the  uterus  in  situ,  correspond- 
ing to  that  described  by  Wing  and  by  the  author  in 
a  previous  pubhcation.  4.  Relatively  large  amount 
of  free  peritoneal  fluid.  5.  Leucocytosis  and  clinical 
improvement  following  the  two  transfusions.  The 
second  case  was  one  of  hematuria  in  pregnancy  in  a 
primipara  aged  thirty.  Of  the  various  causes  of- 
fered for  hematuria,  it  seemed  that  the  most  plausible 
etiological  factor  was  toxemia  of  pregnancy,  as  evi- 
denced by  increased  blood  pressure  and  edema. 

Hernia  of  the  Ileum  Through  a  Rent  in  the 
Mesentery. — Dr.  William  Edgar  Darnall,  of 
Atlantic  City,  N.  J.,  reported  the  case  of  Mrs.  D., 
aged  forty-six,  married,  one  child,  weight  two  hun- 
dred pounds.  She  had  never  been  seriously  sick, 
family  history  was  negative.  She  was  well  de- 
veloped, with  splendid  physique,  and  the  picture  of 
health.  She  had  had  no  symptoms  until  recently 
when  she  noticed  a  lump  in  the  abdomen  and  had 
suffered  from  menorrhagia.  Examination  revealed 
a  fibroid  tumor  of  some  size  freely  movable  and 
uncomplicated  and  there  was  a  very  slight  laceration 
of  the  cervix.  On  July  18,  1918,  he  performed  a 
supravaginal  hysterectomy,  from  which  she  made  a 
perfect  recovery  and  in  due  time  was  sent  home. 

On  August  12th,  a  month  afterward,  she  ate  a 
large  dinner,  and  the  next  morning,  about  six  o'clock, 
she  was  seized  with  an  agonizing  pain  in  the  epigas- 
trium and  vomited.  The  pain  was  so  severe  that 
morphine  was  administered.  Her  bowels  were  irri- 
gated, producing  a  copious  stool.  The  next  day 
her  pains  were  considerably  improved  but  distention 
appeared.  During  the  afternoon  there  was  an  ab- 
sence of  peristaltic  sounds  on  auscultation,  her 
pulse  was  increasing  in  rapidity  and  her  temperature 
had  risen  to  101°  F.  Dr.  Hobart  A.  Hare,  of  Phila- 
delphia, saw  her  with  Dr.  Darnall  in  consultation 
and  was  of  the  opinion  that  in  spite  of  the  tempera- 
ture there  was  some  form  of  obstruction,  although 
enemas  still  brought  away  some  feces  and  gas.  Op- 
eration w-as  decided  upon  and  performed  at  5  p.  m. 
The  findings  were  as  follows :  Through  an  opening 
in  the  mesentery  of  the  second  convolution  of  the 
ileum  there  had  slipped  a  loop  of  the  ileum  belong- 
ing to  the  first  convolution  high  up  on  the  left  side 
under  the  spleen.  There  was  a  volvulus  of  this 
loop  and  it  was  gangrenous  and  perforated.  There 
was  an  abscess  in  the  left  kidney  pouch  and  foci 
of  pus  at  various  locations  in  the  upper  abdomen. 
The  whole  abdominal  cavity  was  filled  with  fluid 
and  intestinal  contents. 

The  hernia  was  released  and  the  rent  in  the  mes- 
entery closed.  Twelve  inches  of  ileum  was  resected 
and  a  Murphy  button  used  for  anastomosis.  Drain- 
age and  counterdrainage  w^ere  used.  Proctoclysis 
with  Locke-Ringer  solution  was  instituted  and  the 
Fowler  position  ordered.  An  opportunit)^  was  af- 
forded of  inspecting  the  lower  abdomen  and  pelvis 
which  were  found  in  perfect  condition  with  no  ad- 
hesions or  constricting  bands.  He  was  unable  to 
account  for  the  rent  in  the  mesentery  so  far  away 
from  the  site  of  the  pelvic  operation,  which  made 
this  unusual  hernia  possible.  She  had  led  a  very 
quiet  and  well  ordered  life  since  her  first  operation 
and  seemed  in  perfect  health.  The  patient  suc- 
cumbed to  shock  in  about  five  hours. 


An  Unusual  Abdominal  Cyst. — Dr.  Orange  G. 
Pfaff,  of  Indianapolis,  Ind.,  on  INIarch  20,  1920, 
was  consulted  by  a  young  married  woman  on  ac- 
count of  a  large  abdominal  cyst  which  had  been 
tapped  ten  days  previously,  twelve  quarts  of  thin 
fluid  having  been  drawn  off  at  that  time,  according 
to  the  statements  of  the  patient  and  her  husband. 
Her  first  menstruation  occurred  at  the  age  of  four- 
teen and  this  function  had  always  been  normal.  She 
has  passed  through  three  normal  pregnancies,  the  last 
one  three  years  ago,  which  was  followed  by  phlebitis 
affecting  both  legs.  This  had,  however,  practically 
disappeared  when  he  first  saw  her.  She  had  no- 
ticed some  abdominal  swelling  about  four  months 
before  she  came  to  him.  This  had  not  given  her 
much  trouble  until  about  six  months  before  she  con- 
sulted him,  when  she  began  to  suft'er  severely  from 
pressure.  Her  appetite  was  also  impaired  and  she 
had  lost  a  few  pounds  in  weight  in  that  time.  The 
abdomen  was  greatly  distended  and  fluctuation  was 
readily  elicited  in  every  part.  Dullness  on  percus- 
sion was  general  with  the  exception  of  a  slight  indis- 
tinct resonance  at  the  epigastrium. 

The  case  was  considered  one  of  large  ovarian  cyst, 
and  on  ^larch  22d  she  came  into  the  hospital  and 
the  following  day  was  operated  upon.  Through 
the  usual  median  incision  Dr.  Pfaff  said  that  he 
came  directly  upon  the  sac,  which  was  so  densely 
adherent  to  the  parietal  peritoneum  that  it  required 
some  care  to  form  a  line  of  cleavage,  the  further 
separation,  however,  being  accomplished  with  only 
moderate  difficulty,  and  he  was  then  able  to  pass  his 
hand  freely  in  every  direction,  widely  on  either  side 
and  almost  from  the  diaphragm  to  the  pelvic  brim. 
Retracting  the  lower  angle  of  the  abdominal  incision 
the  bladder  came  into  view  and  appeared  to  be  nor- 
mal and  was  free  from  adhesions.  Its  healthy  color 
contrasted  strongly  with  the  dark,  purplish  red  of 
the  cyst  wall,  which  was  firmly  adherent  across  the 
brim  of  the  pelvis,  in  front  of  the  uterus  on  a  line 
corresponding  to  the  vesicouterine  fold.  Upon  sepa- 
rating the  sac  along  this  line  a  gush  of  several 
quarts  of  water  occurred.  He  continued  the  sepa- 
ration and  lifted  up  a  flap  of  the  material  consti- 
tuting the  anterior  wall  of  the  cyst,  which  was  now 
recognized  as  a  perverted  and  greatly  thickened 
omentum  being  in  places  more  than  half  an  inch 
thick.  With  the  lower  omental  flap  up  he  came 
upon  a  number  of  peritoneal  cysts  varying  in  size 
from  that  of  a  walnut  to  a  large  grapefruit  which 
filled  up  the  pelvis  on  both  sides.  The  intestines 
were  held  down  and  away  from  the  anterior  abdo- 
men wall  by  innumerable  strands  of  adhesions,  so 
that  even  when  distended  by  gas  there  would  be  no 
note  of  tympany  elicited  on  percussion.  This  was 
one  of  the  puzzling  elements  in  diagnosis.  The  la- 
boratory report  on  the  specimen  removed  for  ex- 
amination stated  that  the  condition  was  one  of  pro- 
liferating tuberculosis  with  much  newly  formed 
fibrous  tissues.  Dr.  Pfaff  said  that  the  case  was 
unique  in  his  experience.  The  great  thickening  of 
the  omentum,  the  extensive  fibrinous  formation,  and 
the  restrained  viscera  were  unusual  and  the  resultant 
absence  of  tympany  regardless  of  posture  consti- 
tuted a  complex  which  was  very  puzzling  indeed 
and  very  misleading  in  diagnosis. 


744 


PROCEEDINGS  OF  NATIONAL  AND  LOCAL  SOCIETIES. 


[New  York 
Medical  Journal. 


Obstruction  of  the  Superior  Mesenteric  Ves- 
sels from  Bands,  with  Threatened  Gangrene  of 
the  Greater  Part  of  the  Small  Intestine;  Recov- 
ery.— Dr.  James  N.  West,  of  New  York,  stated 
that  gangrene  of  the  small  intestine,  due  to  throm- 
bosis of  the  superior  mesenteric  vessels,  might  have 
been  cases  of  this  kind.  The  distribution  and  an- 
astomosis of  the  superior  mesenteric  vessels  was 
such  that,  if  they  were  destroyed,  death  must  neces- 
sarily ensue.  In  a  case  reported  by  Dr.  West,  the 
patient,  a  female,  aged  twenty,  had  general  abdom- 
inal pain  for  three  days,  when  suddenly  violent  and 
uncontrollable  pain  developed,  with  elevation  of 
temperature,  increase  of  pulse  rate,  and  moderate 
distention.  Abdominal  section  revealed  the  small 
intestinal  tract  in  a  state  approaching  gangrene, 
with  a  firm  band,  which  proved  to  be  a  cecal 
mesentery,  extending  across  the  superior  mesenteric 
vessels.  In  the  inflammatory  process  of  the  ap- 
pendix the  cecal  mesentery  undoubtedly  became 
tightly  constricted  across  the  superior  mesenteric 
vessels,  obstructing  them  completely,  and  resulting 
in  a  swelling,  edema,  and  bloody  effusion  in  the 
mesentery  of  the  small  intestines.  Appendectomy 
was  performed,  and  the  abdomen  closed  with- 
out drainage.  Protracted  recovery  ensued.  Union 
was  by  first  intention.  Collapse  on  the  second  and 
third  days  was  successfully  conibatted  by  intra- 
venous saline  infusions  with  adrenalin.  On  the 
fourth  day  there  was  a  mild  septic  temperature,  and 
on  the  sixth  day  there  was  diarrhea,  continuing 
violently  until  the  sixteenth  day.  Malpositions  of 
the  cecum  were  frequent,  and  might  be  hypodes- 
cent  and  hyperdescent.  In  hyperdescent  volvulus 
of  the  cecum  was  favored  and  at  times  necessitated 
operation.  The  collapse,  diarrhea,  and  septic  tem- 
perature were  probably  due  to  autolysis. 

The  Toxic  Thyroid;  Its  Treatment  by  Ether 
Oil  Colonic  Anesthesia. — Dr.  Gorbon  K.  Dickin- 
son, of  Jersey  City,  N.  J.,  said  that  mental  stress 
required  a  strong  thyroid,  adrenal  and  liver.  One 
or  more  might  fail  and  produce  symptoms.  To 
handle  such  a  case  skillfully  required  a  careful 
surgeon  and  an  adept  at  applied  psychology.  Ex- 
cessive action  of  thyroid  was  always  associated 
with  an  overactivity  of  adrenal  and  glycogenic 
function  of  liver,  and  a  mental  state  analogous  to 
fright.  Surgery  of  the  thyroid  under  these  con- 
ditions demanded  recognition  of  component  states. 
A  slight  affront  to  the  mind  overreacted  on  thyroid 
and  adrenal.  Proper  technic  demanded  elimination 
of  such  possibility.  An  anesthesia  cone  to  the  face 
and  a  surgeon  working  at  the  neck  were  mental 
traumatisms.  In  ether  oil  colonic  anesthesia  we 
had  the  ability  to  anesthetize  patients  safely  with- 
out their  knowledge. 

Gehrung  Pessary. — Dr.  Edward  J.  Ill,  of  New- 
ark, N.  J.,  drew  attention  to  the  value  of  the  Geh- 
rung pessary.  He  urged  its  use  in  those  who  were 
old  and  decrepit,  and  for  those  with  decompensated 
heart  disease,  diabetes,  oud  serious  renal  disease ; 
also  for  those  with  a  pulmonary  affection  that  con- 
traindicated  anesthesia  and  for  timid  patients.  The 
use  of  the  pessary,  however,  was  by  no  means  to 
take  the  place  of  the  Watkiiis  operation,  of  which 
Dr.  Ill  spoke  in  the  highest  term's. 


Enuresis. — Dr.  John  ^^^  Keefe,  of  Providence, 
R.  I.,  said  that,  viewing  the  subject  of  enuresis 
broadly,  he  had  arrived  at  the  following  conclu- 
sions:  1.  Considering  the  multiplicity  of  measures 
that  had  been  found  to  assist  in  the  cure  of  enuresis, 
it  seemed  that  underlying  them  all  there  must  be 
some  common  factor,  which  he  believed  to  be  a 
psychophysiological  impression  made  upon  the  brain. 

2.  Heredity  undoubtedly  played  an  important  role. 

3.  These  patients  had  a  neurotic,  unstable  nervous 
system  accompanied  many  times  by  mental  retarda- 
tion. 4.  Psychotherapy,  mental  suggestion  and  edu- 
cation of  the  subconscious  mind  should  supplement 
other  forms  of  treatment  to  the  end  that  involuntary 
or  voluntary  micturition  might  be  anticipated.  In  a 
word  his  contention  was  that  the  cure  was  the  result 
of  the  mental  awakening  and  stabilizing  of  the  brain 
cells  that  controlled  the  act  of  micturition. 

The  Female  Pelvic  Ureters. — Dr.  David  W. 
TovEY,  of  New  York,  said  that  palpation  of  the 
ureters  should  be  a  part  of  every  vaginal  examina- 
tion. Ureteritis,  because  of  the  nerves  irritated, 
might  simulate  disease  of  any  of  the  abdominal 
organs.  Palpation  would  make  the  diagnosis. 
There  was  nothing  between  the  palpating  fingers 
and  the  ureters  but  the  anterior  vaginal  wall.  They 
were  marked  on  the  anterior  wall  by  the  ureteral 
ridges  and  could  be  felt  from  their  entrance  into 
the  bladder  to  the  pelvic  brim.  They  were  felt  as 
flattened  cords  the  size  of  a  leather  shoe  string,  and 
could  be  displaced  in  the  loose  cellular  tissue.  In 
ureteritis,  periureteritis,  stone,  pyelitis,  and  tuber- 
culosis, the  ureter  was  thickened  and  tender.  Ure- 
teritis and  periureteritis  were  commonly  due  to 
infection  from  the  cervix,  and  it  might  follow 
hysterectomy.  It  was  a  condition  often  mistaken 
for  cystitis.  Palpation  showed  a  thickened  tender 
ureter  with  intense  desire  to  urinate.  Treatment 
should  be  applied  to  the  cervix  and  parametrium 
and  not  to  the  bladder,  as  cystoscopic  examination 
showed  the  bladder  to  be  normal. 

Pathological  Leucorrhea  and  Its  Treatment. — 
Dr.  Francis  Reder,  of  St.  Louis,  Mo.,  stated  that 
all  pathology  had  its  basis  in  physiology.  A  leucor- 
rhea which  was  physiological  must  be  differentiated 
from  one  which  was  pathological.  To  gain  an 
exact  knowledge  of  the  condition  of  the  genital 
tract  it  was  well  to  take  an  existing  leucorrhea  as 
a  starting  point.  The  character  of  the  discharge 
and  the  various  states  upon  which  the  discharge 
depended,  might  reveal  the  seat  of  the  disorder.^ 
The  term  leucorrhea  grouped  together  a  large  num- 
ber of  lesions,  and  although  it  was  the  most  com- 
mon and  prominent  symptom  in  the  majority  of 
uterovaginal  cases,  the  fact  that  certain  constitu- 
tional disorders  had  important  relations  with  the 
different  forms  of  leucorrhea  must  not  be  over- 
looked. Under  such  conditions  it  was  not  merely 
the  expression  of  a  symptom  but  of  the  disease 
itself.  Different  periods  of  female  life  presented 
different  kinds  of  leucorrhea.  Forms  of  leucor- 
rhea which  were  not  pathological  were  easy  to 
diagnosticate  and  readily  yielded  to  proper  treat- 
ment. A  pathological  leucorrhea  often  presented 
great  diagnostic  difficulties. 

{To  be  continued) 


New  York  Medical  Journal 

INCORPORATING  THE 

Philadelphia  Medical  Journal  the  Medical  News 

A  Weekly  Review  of  Medicine,  Established  18Ji.3. 

^'0L.  CXII,  No.  20.  NEW  YORK,  SATURDAY.  NOVEMBER  13,  1920.  Whole  No.  2189. 

Original  Communications 


THE  PLACENTAL  GLAND  AND  PLA- 
CENTAL EXTRACT. 

By  Samuel  W.  Bandler,  M.  D., 

New  York. 

Professor  of  Gynecology,  New  York  Post-Graduate  Medical  School 
and  Hospital. 

In  the  discussion  of  glandular  interrelations,  even 
though  we  leave  out  of  consideration  the  possible 
element  of  altered  character  of  the  secretions,  and 
concentrate  our  attention  only  on  the  thought  of 
oversecretion  or  undersecretion,  w^e  have  a  markedly 
complex  problem,  owing  to  the  numerous,  in  fact, 
almost  innumerable  variations  which  may  exist.  If 
to  this  already  complex  situation  are  added  the 
variations  in  balance  between  the  socalled  vagus 
system  on  the  one  hand,  and  the  sympathetic  on 
the  other,  with  their  intimate  and  purposed  associa- 
tion with  the  endocrine  structures  of  the  body, 
diagnosis  and  especially  the  reactions  to  endocrine 
therapy  become  still  more  uncertain.  If  we  add 
further,  what  must  not  be  omitted,  the  psychic  fac- 
tor in  each  individual  patient,  and  the  give  and  take 
dependence  on  physical  states,  on  the  autonomic 
nervous  system  and  on  the  endocrines,  we  are  led 
into  a  maze  of  problems  sufficient  to  prove  to  the 
most  unobserving  that  there  can  be  few  fixed  and 
definite  rules  except  such  as  serve  to  furnish  an 
outline  or  a  basis  from  which  to  proceed.  Whether 
purposed  or  no,  one  may  logically  state  that  the  out- 
standing sign  posts  of  endocrine  aberrations,  such 
as  acromegaly,  Graves's  disease,  myxedema,  Addi- 
son's disease,  tetany,  dystrophia,  adiposogenitalis, 
diabetes,  and  other  disturbances,  were  given  to  us 
to  form  or  to  help  develop  an  outline  or  basis  for 
the  understanding  of  some  of  the  vague  factors  in 
endocrinology.  And  even  after  years  of  observation 
and  study,  after  years  of  siirgery  and  clinical  ob- 
servation, after  the  close  study  of  the  changed 
metabolism,  we  are  beginning  to  recognize  more 
clearly  the  association  of  the  thymus,  the  adrenals, 
the  posterior  pituitary,  and  the  parathyroids  with 
the  numerous  symptom  complexes  of  the  states 
known  as  Graves's  disease  and  myxedema.  Myx- 
edema too  is  a  pluriglandular  disease,  cretinism  is 
a  lack  not  only  of  thyroid  but  of  other  endocrines 
essential  to  physical,  organic,  and  mental  growth. 
While  the  administration  of  thyroid  activates  the 
other  endocrines,  some  of  them  are  not  able  to 
respond  and  these  must  be  substituted  by  gland 
extracts  themselves.    And  we  also  must,  of  neces- 


sity, recognize  the  numerous  deviations  from  the 
cardinal  symptoms  as  expressed  by  what  has  been 
called  vagotonia  and  sympathicotonia.  And  with 
all  this,  we  have  not  yet  solved  the  questions  as 
they  relate  to  the  thyroid  itself,  for  it  is  probable 
that  the  thyroid  is  related  to  both  the  vagus  and 
the  sympathetic  systems  and  that  in  the  thyroid  we 
may  have  more  than  one  hormone. 

The  fact  that  the  thyroid  affections  tending  to- 
wards the  symptom  complex  myxedema  and  to  the 
symptom  complex  Graves's  disease,  with  their 
numerous  degrees  of  intensity,  are  more  frequent 
in  women  than  in  men,  points  to  the  sex  organs  and 
to  the  gonads  as  being  the  central  point  from  w^hich 
originate  those  differences  in  psyche,  in  the  auto- 
nomic system  and  in  the  endocrines,  which  render 
the  female  more  susceptible  to  the  psychic,  bac- 
terial, functional  or  environmental  causes  respon- 
sible for  these  diseases.  And  if  in  searching  more 
closely  for  the  finer  distinctions  implied  in  so  gen- 
eral-a  statement,  a  gynecologist  centres  his  attention 
on  the  ovary,  he  must  of  necessity  go  back  to  physi- 
ology and  the  physiological  processes  as  a  starting 
point.  The  very  fact  that  the  major  forms  of 
thyroid  abnormalities  come  into  the  sphere  of 
observation  after  menstruation  has  been  well  estab- 
lished, and  that  the  minor  forms  are  extremely 
frequent  at  puberty  and  adolescence  would  furnish 
a  suggestion  of  the  relation  of  the  menstrual  endo- 
crine interrelation  to  thyroid  aberrations.  That  the 
menstrual  life  of  women  of  itself  proves  endocrine 
interrelation  to  be  less  stable  and  settled  than  in  the 
male,  is  self  evident.  Therefore  endocrine  insta- 
bility or  imbalance  constitutes  a  predisposing  factor. 
But  this  lack  of  stability  involves  other  endocrines 
than  the  thyroid.  It  concerns  the  pituitary,  the 
parathyroids,  the  mamnic-e,  the  adrenals,  and  other 
glands. 

Pregnancy  makes  demands  on  vhese  endocrine 
structures  and  the  socalled  male  endocrine  glands 
are  brought  into  increased  activity  by  substances 
throw^n  off  by  the  ovum  designed,  of  course,  for  this 
special  purpose.  The  sequelje  of  abortion,  the  as- 
thenia postpartum,  the  psychic  disturbances  post- 
partum, are  only  factors  which  we  take  into  con- 
sideration. Lactation,  the  responsibilities  of  mother- 
hood, changed  or  altered  sexual  procedures  add 
hugely  to  the  accentuating  predispositions.  While 
all  these  numerous  and  diverse  sustaining  argu- 
ments may  be  brought  into  the  field  of  discussion 
we  must  in  the  first  instance  go  back  to  the  normal 


Copyright,  1920,  by  A    R.  Elliott  Publishing  Company. 


746 


BANDLER:  PLACENTAL  EXTRACT. 


[New  York 
Medical  Journal. 


physiological  process,  in  order  to  get  a  proper  start, 
and  therefore  the  relation  of  the  endocrines  to  nor- 
mal menstruation  is  brought  to  our  attention. 

The  instinct  of  curiosity  lies  at  the  root  of  science 
and  religion.  Suggestibility  is  the  quality  which 
implies  the  acceptance  of  opinions  without  question. 
Contrasuggestion  signifies  a  tendency  to  accept  the 
opposite  of  what  is  stated  or  implied.  A  judicious 
mixture  of  these  elements  in  any  individual  is 
responsible  for  ordinary  incredulity. 

As  I  recall  my  earliest  studies  in  medicine  two 
points  connected  with  gynecology  stand  out  quite 
plainly.  One  was  the  hesitation,  rather  decided,  to 
accept  the  then  current  theory  that  the  ovum  given 
out  from  the  ovary  entered  into  the  fallopian  tube 
when  the  outer  end  of  the  latter  partially  enveloped 
the  ovary  befdre  the  rupture  of  the  graafian  follicle. 
It  was  difficult  for  many  of  us  to  understand  how, 
in  a  case  in  which  the  ovary  of  one  side  had  been 
removed  and  the  tube  of  the  other  side  had  been 
removed,  the  fimbriated  end  of  the  fallopian  tube 
could  make  this  extensive  excursion  to  the  other 
ovary,  this  apart  from  the  marvellous  mechanism 
implied  in  the  timing  of  such  a  process.  It  was 
not  long  before  the  knowledge  of  the  action  of  the 
ciliated  epithelium  of  the  fallopian  tubes  made  clear 
the  manner  in  which  ova  enter  the  uterus.  The 
other  point  which  constituted  a  puzzle,  was  the 
amenorrhea  of  pregnancy;  in  other  words,  why 
does  menstruation  cease  when  fecundation  takes 
place?  Some  years  later  the  work  of  Von  Spee 
and  others  on  extremely  early  nested  fecundated 
ova  showed  that  the  ovum  buried  itself  in  the 
decidua  and  that  a  digestive  action  is  exerted  by 
the  trophoblast  upon  the  surrounding  decidual  cells 
and  capillaries  of  the  now  decidua  of  pregnancy. 
The  question  was,  then,  why  does  menstruation 
cease  when  embedding  takes  place?  Implantations 
of  thyroid  gland  furnished  not  only  the  physiolog- 
ical but  the  therapeutic  tests  of  the  existence  of  its 
internal  action.  Thyroid  extract,  in  myxedema, 
gave  the  final  touch  that  was  needed  in  the  demon- 
stration of  the  hormone  action  going  on  in  the  body. 

It  was  Knauer  who,  by  his  transplants  of  ovaries 
in  animals,  clearly  demonstrated  that  the  ovaries, 
too,  produced  their  eflfects  by  means  of  an  internal 
secretion,  and  not  by  any  mechanically  stimulated 
reflex  acting  through  the  autonomic  nervous  system. 
Then  came  the  wonderful  observations  of  the  path- 
ologists, who  showed  that  in  the  various  months  of 
pregnancy,  syncytial  cells  and  chorionic  epithelia 
were  being  continually  thrown  off  into  the  circu- 
lation, dissolved  and  absorbed.  This  made  easy 
the  interpretation  of  these  processes  as  a  secretory 
function ;  in  other  words,  it  showed  that  we  were 
dealing  with  what  was  truly  a  secretion  produced 
by  the  outer  shell  of  the  ovum — that  is,  the  pla- 
cental secretion,  for  the  placenta  is  only  an  exag- 
gerated development  of  the  chorion.  In  those  days, 
when  the  ovary  was  considered  the  sole  factor  in 
the  premenstrual  and  menstrual  functions,  a  step 
forward  was  taken  in  the  demonstration  by  these 
syncytial  processes  of  what  was  later  recognized 
as  the  antagonistic  or  inhibitory  action  of  one  secre- 
tory structure  upon  another  in  the  performance  of 
a  normal  physiological  process. 


While  later  the  ovary  and  thyroid  were  recog- 
nized as  of  almost  equal  significance  to  the  female 
sex  organs,  supporting  each  other  in  certain  phases 
and  probably  antagonistic  in  others,  yet  at  this  time 
no  direct  proof  of  any  relation  or  balance  between 
ovary  and  thyroid  was  clearly  disclosed.  It  did 
seem  clear,  however,  that  the  ovary  in  its  turn  pos- 
sessed the  power  of  influencing  thyroid  activity  and, 
therapeutically,  ovarian  extract  was  used  in  hyper- 
thyroidism. The  thyroid  develops  at  puberty  and 
adolescence,  it  swells  before  each  menstrual  flow,  it 
develops  noticeably  in  the  early  months  of  preg- 
nancy, and  numerous  experiments  on  the  thyroid 
and  the  results  of  its  failing  or  diminished  func- 
tions during  the  years  of  development,  prove  it  to 
be  intimately  related,  not  only  to  growth  and  to 
mental  development,  but  quite  specifically  related  to 
the  early  and  later  development  of  sex  organs.  In 
other  words,  the  thyroid  activates  the  other  endo- 
crines and  exerts  a  trophic  effect  on  tissues  and  cells. 
As  regards  the  ovaries  and  the  progressive  change 
of  the  corpus  luteum  of  menstruation  into  the  true 
yellow  body  of  pregnancy,  nothing  then  but  the 
external  envelope  of  the  nidated  ovum,  its  tropho- 
blast, syncytium,  and  chorionic  epithelium  could  be 
held  responsible.  The  reaction  and  stimulation  of 
the  corpus  luteum  by  the  tiny  ovum,  and  by  the 
off  throw  from  the  cells  invading  the  maternal 
capillaries,  is  an  evidence  of  unity  of  action  de- 
signed to  accomplish  a  definite  purpose. 

As  a  broader  understanding  of  endocrine  action 
on  menstrual  function  became  more  clear,  it  was 
apparent  that  while  the  ovaries  initiated  menstrua- 
tion, the  corpus  luteum  aided  in  changing  the  endo- 
metrium into  the  decidua  menstrualis  and,  by  limit- 
ing the  tendency  to  rhexis  and  diapedesis  was  con- 
cerned in  perpetuating  the  decidua  menstrualis  into 
the  decidua  of  pregnancy.  But  other  of  the  internal 
structures  are  also  concerned  in  this  function 
whereby  the  nesting  of  the  ovum  is  favored.  This 
relation  of  the  thyroid  was  not  recognized  early  but 
its  action  on  the  decidua,  trophic  in  character,  was 
later  readily  granted.  One  effect  is  to  prevent  any 
myxedematous  change  in  the  decidual  cells  and 
structure  and  to  limit  bleeding.  Thyroid  activity, 
we  believe,  first  exerts  a  trophic  effect  on  the 
decidua,  and  second,  aids  in  the  nidation  of  the 
ovum. 

Later  came  the  understanding  that  the  adrenals, 
and  particularly  the  pituitary  body,  were  involved 
in  the  cyclic  process,  called  menstruation.  If  this 
were  so,  then  activity  by  what  might  be  called 
placental  secretion  was  limited,  not  to  the  ovary 
alone,  but  concerned  other  glands.  Since  its  rela- 
tion to  the  corpus  luteum  is  of  a  stimulative  nature, 
the  corpus  luteum  and  placenta  have  then  a  some- 
what similar  function. 

The  study  of  the  action  of  the  pituitary  gland, 
and  its  relation  to  uterine  processes  during  men- 
struation, the  not  infrequent  occurrence  of  dys- 
menorrhea, the  realization  that  menstruation  was  a 
miniature  labor,  turned  our  thoughts  more  directly 
to  the  study  of  the  relations  of  the  posterior  pitui- 
tary to  menstruation  and  to  the  interrelation  be-'  ■ 
tween  the  various  endocrines  on  the  one  hand,  and  ' 
the  posterior  pituitary  on  the  other.    Since  the  i 


November  13,  1920.] 


BANDLER:  PLACENTAL  EXTRACT. 


7M 


thyroid  is  stimulated  before  and  during  menstrua- 
tion, the  natural  thought  is  that  corpus  luteum 
rouses  part  of  the  thyroid  and  stimulates  the  pos- 
terior pituitary.  Since  overactivity  of  the  posterior 
pituitary  is  a  stimulus  to  the  onset  of  menstruation, 
the  suggestion  becomes  more  relevant,  that  the  pla- 
cental secretion  inhibits  the  posterior  pituitary.  Such 
a  notion  would  make  the  placenta  and  another  part 
of  the  thyroid  and  corpus  luteum  partners,  so  to 
speak,  in  their  antagonism  to  one  and  the  same 
endocrine. 

The  production  of  menstruation  is  initiated  by 
the  ovary,  not  forgetting  the  interstitial  structure. 
Cooperation  is  evidenced  by  the  corpus  luteum  and 
thyroid  and  the  posterior  pituitary.  Unless  the  pos- 
terior pituitar}'  is  inhibited,  menstruation  takes 
place.  I  may  say  that  the  effect  of  the  posterior 
pituitary  in  aiding  the  onset  of  menstruation  is  evi- 
denced by  its  therapeutic  application.  It  would  seem 
as  if  all  these  endocrine  activities  suggested  and 
started  in  each  premenstrual  phase  are  then  accen- 
tuated and  made  into  a  definite  balance  for  nine 
months,  by  the  introduction  of  the  placenta.  The 
balance  in  the  autonomic  nervous  svstem  which 
takes  on  the  form  of  a  crisis  at  menstruation  is 
altered  by  placental  action  and  is  postponed  to  the 
day  of  labor.  In  pregnancy  the  entrance  of  the 
anterior  pituitary  and  particularly  of  the  adrenal 
cortex  is  assumed  as  produced  by  the  placenta. 

That  the  ovary  contains  elements  differing  in 
their  degree  of  influence  and  even  in  the  character 
of  their  influence  seems  to  be  fairly  well  estab- 
lished. While  extract  of  the  hilum  and  ovarin 
diminish  uterine  contraction  and  lengthen  the  coagu- 
lation time,  corpus  luteum  contracts  the  uterus  and 
shortens  coagulation  time.  While  all  the  elements 
further  uterine  hyperemia,  the  corpus  luteum  does 
so  less  markedly.  While  the  interstitial  tissue  and 
the  corpus  luteum  favor  dilatation  of  the  peripheral 
vessels,  the  follicle  tissue  and  the  liquor  folliculi  do 
not  dilate  the  peripheral  vessels  and  do  not  postpone 
the  coagulation  of  blood,  ovarin  and  lutein  and 
placenta  are  trophic  in  their  action  on  the  uterus 
and  favor  its  growth  and  hypertrophy.  But  they, 
too,  appear  dependent  on  an  associated  activity  of 
the  thyroid  so  that  their  normal  functions  may  be 
carried  out.  Even  though  the  contractile  function 
of  the  posterior  pituitary  is  normally  nullified  dur- 
ing pregnancy,  its  trophic  effect  is  still  exerted  and 
through  a  normal  relation  and  cooperation  of  these 
glands,  assisted  by  the  stimulated  activity  of  the 
anterior  pituitary,  and  the  suprarenal  cortex,  we 
have  a  growth  of  the  uterus,  especially  in  the  early 
months,  which  can  by  no  means  be  attributed  to 
any  mechanical  stretching  action  by  the  ovum. 
It  seems  as  if  the  placenta  which,  of  course,  is 
partly  m.ale  in  origin,  brings  into  the  sphere  of 
activity  what  might  be  called  the  male  glands,  mean- 
ing thereby,  the  anterior  pituitary  and  the  adrenal 
cortex  which  functionate  in  a  relative  degree,  more 
in  the  male  than  they  do  in  the  female.  Menstrua- 
tion is  not  a  process  which  Nature  wishes.  Instead 
of  thinking  of  menstruation  as  the  normal  picture 
and  pregnancy  as  a  new  process,  let  us  think  of  the 
matter  in  the  reverse  manner.  Let  us  view  men- 
struation as  a  process  to  which  Nature  yields  un- 


readily, hoping  each  month  to  see  use  made  of  the 
preparatory  steps  and  readjustments  taking  place 
in  the  uterus  and  in  the  endocrine  system.  If  a 
nest  for  the  awaited  impregnated  ovum  is  prepared, 
if  nidation  is  favored  by  certain  endocrines,  if  other 
endocrines  which  favor  menstruation  are  to  be 
checked,  then  the  fecundated  ovum  must  bring  its 
own  material  for  the  preservation  of  the  balance 
essential  to  continued  growth.  The  inability  to 
preserve  this  balance,  the  inability  to  hold  the  inter- 
stitial ovary,  the  posterior  pituitary,  and  probably 
the  adrenal  medulla  in  check,  accounts  very  readily 
then  for  many  cases  of  socalled  sterility  and  for 
many  cases  of  repeated  miscarriage. 

Before  going  further,  let  us  review  the  pre- 
menstrual constitutional  phenomena.  We  speak  of 
premenstrual  cyclic  changes,  but  they  are,  as  stated 
above,  changes  which  anticipate  nidation,  and  men- 
struation is  simply  to  be  viewed  as  an  evidence  that 
nidation  has  not  taken  place.  Stated  in  simple 
language,  ovary  and  thyroid,  pituitary  and  adrenals 
and  probably  other  endocrines  increase  their  func- 
tions. A  balance  exists  in  the  endocrines  and  in 
each  endocrine  awaiting  nidation.  Nidation  in- 
troduces a  new  secretion  and  one  end  of  the  balance 
becomes  stronger  and  the  crisis  known  as  men- 
struation is  postponed  for  ten  lunar  months,  when 
the  postponed  crisis  does  occur  in  a  magnified 
form,  known  as  labor.  Therefore  premenstrual 
phenomena  of  a  constitutional  nature  and  their 
variations  depend  greatly  on  the  interglandular 
relr'ttions  of  that  period  and  may  concern  interstitial, 
ovary,  corpus  luteum,  thyroid,  adrenal  cortex,  ad- 
renal medulla,  anterior  pituitary,  posterior  pituitary, 
and  other  glands. 

Of  the  various  endocrines,  little  is  generally 
known  or  established  concerning  the  pineal,  the 
adrenal  cortex,  and  concerning  posterior  pituitary 
overactivity.  It  was  the  study  of  this  latter  condi- 
tion, and  the  belief  in  its  frequent  occurrence  and 
its  probable  relation  to  many  premenstrual  annoy- 
ances, and  possibly  to  many  psychic  disturbances, 
that  attracted  me  to  the  study  of  the  effects  of 
placental  extract  administered  by  mouth  and  by 
hypodermic  injection.  My  belief  is  that  in  the 
premenstrual  rearrangement  of  the  endocrine  rela- 
tions, the  thyroid,  adrenal,  medulla,  and  the  posterior 
pituitary  are  responsible  for  the  largest  number  of 
annoying  symptoms.  Placental  extract  is  therefore 
used  with  judgment  in  selected  cases,  for  the  very 
fact  that  it  delays  menstruation  constitutes  a  bar 
to  its  use  in  cases  of  relative  amenorrhea  with  or 
without  dysmenorrhea  unless  given  in  combination 
with  ovarian  extract. 

When  pregnancy  takes  place,  the  placental  extract 
aids  by  throwing  its  weight  into  the  balance  against 
part  of  the  thyroid,  posterior  pituitary,  and  adrenal 
medulla.  For  months  the  constitutional  annoyances, 
which  so  often  occur  before  menstruation,  dis- 
appear and  even  though  the  nausea  and  vomiting 
of  pregnancy  may  be  severe,  these  are  of  a  different 
nature.  The  soothing  effect,  the  quieting  effect, 
the  stimulating  effect  in  the  vast  majority  of  cases 
of  pregnancy  should  of  itself  make  a  silent  plea 
for  the  powerful  influence  of  the  placental  secretion 
and  its  allies,  the  anterior  pituitary  and  the  adrenal 


I 


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[New 
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York 
Journal. 


cortex,  and  if  by  reason  of  an  unusual  power 
in  the  glands  to  be  inhibited,  this  soothing  effect  is 
not  in  evidence,  we  may  point  to  some  of  the 
annoyances,  especially  in  the  later  months,  as  an 
evidence  of  endocrine  rebellion  and  dysbalance  and 
to  other  annoyances,  as  probably  related  to  ana- 
phylaxis. 

If  cyclic  premenstrual  constitutional  phenomena 
are  an  index  to  the  endocrine  relations  of  the 
moment,  then  the  premenstrual  psychic  phenomena 
may  be  judged  by  the  same  token.  And  in  the 
study  of  the  premenstrual  psychic  upsets,  we  get 
a  glimpse  of  the  various  mental  aberrations  dignified, 
when  sufficiently  gross  by  the  term  psychosis.  And 
it  is  from  a  study  of  the  question  from  this  angle, 
as  it  were,  that  the  view  is  fixed  in  my  mind,  that, 
whatever  may  be  the  exciting  and  contributing 
causes,  abnormal  and  altered  endocrine  action 
should  be  given  an  important  place  in  discussing 
and  treating  the  socalled  mental  diseases.  The 
annoyances  of  pregnancy  are  physical  and  rarely 
psychic.  But  in  the  postpartum  period,  we  do 
observe  the  onset  of  melancholia,  mania,  or  other 
manifestations.  These  two  facts  are  mentioned 
again  as  proof  of  the  quieting  psychic  action  of 
the  placental  element  and  of  the  disturbed  relation- 
ship (which  sometimes  occurs)  in  the  attempt  at 
endocrine  rearrangement  after  the  termination  of 
pregnancy.  And  since  we  are  still  discussing  preg- 
nancy we  may  step  back  a  distance  and  call  atten- 
tion to  the  fact  that  while  sterility,,  in  some  cases, 
is  due  to  a  lack  of  proper  function  on  the  part  of 
the  ovary  or  the  thyroid,  or  the  pituitary,  yet,  exces- 
sive action  of  the  posterior  pituitary  is  a  very  fre- 
quent cause  of  sterility,  of  extremely  early  mis- 
carriage, often  not  recognized  as  such,  of  miscar- 
riage at  periods  when  it  is  readily  recognized,  and 
of  repeated  or  habitual  miscarriage. 

A  notable  action  of  placental  extract  is  the  pro- 
duction of  what  the  patient  calls  "a  sleepy,  dopey 
feeling,"  and  this  is  often  noted,  even  though  thy- 
roid extract  and  placenta  are  administered  together. 
Only  rarely  is  a  result  observed  in  regard  to  the 
pulse  rate.  A  few  patients  have  complained  of 
paroxysmal  tachycardia  even  though  thyroid  was 
not  given.  Therefore  there  "occasionally  take  place 
either  a  thyroid  or  an  adrenal  stimulation,  but  this 
influence  is  only  transitory,  for  I  have  given  pla- 
cental extract  in  h3'per!.hyroid  cases  without  pro- 
duction of  tachycardia,  or  an  increase  in  tachy- 
cardia, and  not  rarely  with  great  benefit. 

The  therapeutic  test  is  supplied  by  the  results 
obtained  on  the  administiation  of  placental  extract. 
What  is  its  effect  on  menstruation?  As  a  rule  the 
normal  rhythmical  menstruation  function  is  delayed 
thereby  several  days.  This  action  is  likewise  evi- 
denced in  many  individuals  whose  menstruation, 
while  regular,  comes  on  at  periods  three  to  five  days 
before  the  normal  interval  is  reached.  Going  fur- 
ther into  the  field  of  pathology  and  considering 
cases  of  menorrhagia  or  even  metrorrhagia,  it  is 
found  that  placental  extract  tends  to  diminish  bleed- 
ing. Therefore,  judging  by  my  own  experience, 
I  take  it  that  placental  extract  not  only  inhibits  those 
regular  processes  whereby  blood  is  lost  from  the 
uterus,    but    does    likewise    in    many  conditions 


simulating  menstruation,  even  though  the  flow  is 
profuse  or  the  interval  shorter  than  normal. 

Placental  extract  has  an  effect  second  only  to 
mammary  extract,  in  diminishing  excessive  men- 
.struation,  though  it  lacks  entirely  the  power  often 
evidenced  by  mammary  extract,  of  diminishing  the 
size  of  the  uterus  as  in  myomata,  and  it  does  not 
have  a  like  influence  in  aiding  involution.  Carrying 
the  therapeutic  effort  over  into  the  field  of  preg- 
nancy, I  find  that  threatened  early  miscarriage  or 
abortion  is  often  averted  by  the  administration  of 
placental  extract  and  thyroid  extract.  The  vari- 
ous processes  going  on  in  the  uterus,  which  are 
typical  of  normal  menstruation,  are  practically  the 
steps  which  occur  in  many  miscarriages.  There- 
fore placental  extract,  by  inhibiting  these  processes, 
furnishes  added  proof  that  it  delays  or  inhibits  the 
processes  tending  to  menstruation.  During  preg- 
nancy many  patients  are  sleepy,  drowsy  and  tired, 
without  a  suggestion  of  nausea,  and  we  presuppose 
here  that  the  placenta  has  put  the  posterior  pituitary 
to  sleep. 

The  premenstrual  rousing  action  which  the  corpus 
lutevim  exerts  upon  the  thyroid  and  the  important 
relation  between  the  corpus  luteum  and  the  thyroid 
during  pregnancy  emphasize  the  place  of  these  two 
glands  in  the  scheme  of  endocrines  as  sensitized 
allies  in  a  process  that  concerns  opposition  to  the 
posterior  pituitary.  This  sensitization,  designed 
for  aid  to  the  processes  of  procreation,  is  one  of 
the  factors  which  makes  thyroid  aberrations  so 
frequent  in  women.  It  is  this  uncertain  balance 
between  thyroid  and  corpus  luteum  and  posterior 
pituitary  which  tends  to  make  pituitary  aberrations 
so  frequent  in  women. 

The  effect  of  placental  extract  in  frequently  re- 
lieving the  psychic  symptoms  of  restlessness,  marked 
irritability  and  physical  and  mental  wanderlust, 
which  I  attribute,  in  many  cases  at  least,  to  over- 
activity of  the  posterior  pituitary,  has  led  me  to 
think  that  deviations  in  the  activity  of  the  posterior 
pituitary  may  be  responsible,  not  only  for  altera- 
tions in  the  amount  and  character  of  the  cerebro- 
spinal fluid,  but  for  changes  in  certain  cerebrospinal 
areas  which  cannot,  as  yet,  be  defined,  and  for 
changes  in  the  autonomic  nervous  system,  and  con- 
sequently for  changes  in  behavior. 

Judging  from  the  quieting  effects  of  placental 
extract  in  those  cases  where  the  symptoms  are 
seemingly  due  to  posterior  pituitary  overactivity,  I 
translated  my  observations  to  the  realm  of  that  phase 
of  human  instinct  called  the  libido  sexualis.  If  we 
take  the  libido  into  consideration,  we  must  grant 
the  relation  of  the  endocrines  to  this  element  in  the 
human  being.  In  the  female,  the  pituitary  plays 
an  extremely  important  part  not  only  so  far  as 
concerns  the  physical  but  likewise  as  regards  the 
psychic  association.  I  consider  this  condition  to  be 
an  urge  with  an  endocrine  basis,  and  for  that  reason 
its  variations  in  intensity  arc  numerous  and  the 
variations  at  different  periods  of  life  are  often  note- 
worthy- Placental  extract  is,  so  far  as  I  know, 
the  most  valuable  of  the  endocrines  administered 
for  the  purpose  of  controlling  or  modifying  this 
human  instinct.  Though  Freud  would  have  us  be- 
lieve that  the  neuroses  and  psychoses  are  related 


November  13,  1920.] 


BANDLER:  PLACENTAL  EXTRACT. 


749 


almost  entirely  to  the  instinct  of  sex,  it  requires 
little  experience  and  little  study  to  prove  that  this 
is  certainly  not  the  case.  But  many  of  the  endo- 
crines  are  related  to  growth  and  to  the  preservation 
of  function,  and  most  of  the  important  ones  are 
naturally  related  in  part  to  the  development  and 
preservation  of  the  organs  of  sex  and  of  the  in- 
stincts and  emotions  associated  therewith.  Hence 
among  the  neuroses  and  psychoses  there  must  of 
necessity  arise  symptoms  and  phenomena,  often 
overexaggerated  as  to  their  importance,  which  bear 
'  an  intimate  relation  to  the  physical  or  psychic 
processes  associated  with  the  sex  side  of  man.  In 
many  of  these  aberrations  the  balance  in  the  glands 
and  between  glands  which  stimulate  and  those  which 
inhibit  is  lost,  most  often  through  a  physical  endo- 
crine predominance  and  not  as  a  matter  of  will  or 
even  desire.  I  find  the  thymus  and  the  placental 
extracts  valuable  when  our  purpose  is  that  of 
anesthetizing  or  modifying  the  socalled  libido 
sexualis. 

Many  factors  of  an  apparently  unrelated  nature 
may  influence  cerebrospinal  pressure.  Thus  the  in- 
jection of  duodenal  mucosa  extract  exercises  an 
effect  on  the  cerebrospinal  fluid.  Hypertonic  and 
hypotonic  solutions  injected  into  the  veins  or  intro- 
duced into  the  gastrointestinal  tract  or  into  the 
rectum  lower  and  raise  the  cerebrospinal  pressure 
(Weed  and  McKibbon).  The  therapeutic  effect  of 
spinal  puncture  in  some  cases  of  eclampsia  is  re- 
markable, and  so  in  many  severe  as  well  as  in  mild 
conditions  this  factor  must  be  taken  into  considera- 
tion. For  this  reason,  but  without  the  support  of 
results  furnished  by  animal  experimentation,  I  have 
used  placental  extract  when  headaches,  stiffness  of 
the  neck,  and  other  disorders,  seem  by  their  loca- 
tion to  be  possibly  connected  with  variations  in 
pressure  or  possibly  qualitative  complications  in  the 
cerebrospinal  fluid. 

It  is  stated  that  tlie  noimal  escape  from  the  cere- 
bral chamber  is  by  way  of  the  arachnoid  villi  direct 
into  the  dural  sinuses,  and  along  perineural  spaces 
about  the  cranial  and  spinal  nerves.  The  cell  mem- 
brane of  Gley  is  believed  to  be  concerned  by  osmosis 
with  the  amount  and  character  of  the  cerebrospinal 
fluid.  Dr.  A.  Goodman  is  more  than  ever  con- 
vinced by  his  more  extensive  work  of  the  beneficial 
effect  in  chorea  of  injecting  the  serum  of  the  patient 
to  take  the  place  of  the  withdrawn  cerebrospinal 
fluid-  It  was  for  these  reasons  that  I  have  noted 
the  action  of  placental  extract  by  mouth  and  by 
hypodermic  injection  because  it  seemed  possible 
that  it  might  be  influential  in  promoting  osmosis  or 
exchange.  I  have  to  this  day  no  proofs  that  it  in 
any  way  alters  pressure  within  the  cerebrospinal 
canal,  either  raising  or  lowering  it.  But  the  very 
gratifying  relief  of  many  of  the  typical  headaches 
makes  me  lean  to  the  notion  that  it  probably 
(Jiminishes  pressure. 

The  study  of  gland  modifications  in  pregnancy 
divulges  the  thyroid  as  an  all  important  structure 
designed  for  the  protection  of  the  pregnant  woman 
and  for  the  preservation  of  a  normal  state.  The 
pituitary,  however,  by  its  interference  with  this 
normal  balance,  is  of  the  greatest  importance  in  the 
production  of  pathological  conditions.    Many  con- 


siderations have  entered  into  the  study  and  observa- 
tion of  these  phenomena  and  I  have  come  to  the 
conclusion  that  in  thyroid  minus  and  posterior  pitu- 
itary plus  we  have  a  very  frequent  combination, 
associated  in  many  cases  with  the  toxemia  of  preg- 
nancy in  its  various  well  known  manifestations. 
Not  the  least  noteworthy  is  the  increase  in  blood 
pressure,  the  headaches,  and  the  excess  of  the  cere- 
iDrospinal  fluid.  In  this  latter  condition  the  cell 
membrane  of  Gley  is  apparently  involved  and  by 
reason  of  its  very  location  and  its  relation  to  the 
cerebrospinal  fluid  this  posterior  pituitary  gland 
may  well  be  related  to  the  processes  of  osmosis  and 
exchange.  That  this  should  be  the  case  in  a  secre- 
tory structure  like  the  cell  membrane  of  Gley  is  a 
natural  deduction,  since  we  know  the  relation  of 
the  posterior  pituitary  to  renal  function  and  to  renal 
excretion. 

The  great  and  complex  metabolic  changes  of  the 
body  in  its  normal  state  yield  to  important  meta- 
bolic alterations  in  the  pregnant  individual,  and 
without  attempting  to  solve  or  even  explain  the 
intricate  processes  which  have  yet  to  be  discovered, 
we  are  therapeutically  depending  more  and  more  on 
our  conception  of  endocrine  aberrations  to  aid  in 
the  solution ;  and  as  the  thyroid  gland  is,  to  my 
mind,  one  of  the  important  protecting  organs,  espe- 
cially over  the  renal  epithelium,  it  is  only  necessary 
to  conceive  of  a  myxedematous  change  in  the  renal 
epithelium  and  in  altered  kidney  function  produced 
by  the  posterior  pituitary,  to  furnish  ourselves  with 
at  least  an  outline  of  some  of  the  changes  occurring 
in  the  socalled  pregnancy  kidney.  A  like  change  "in 
the  cell  membrane  of  Gley  would  serve  to  explain 
many  of  the  cerebrospinal  symptoms  in  the  pre- 
eclamptic and  eclamptic  states^.  It  was  a  study  of 
this  condition  that  attracted  my  attention  to  that 
form  of  headaches  so  peculiarly  typical  in  women, 
the  headaches  in  the  occipital  region  radiating  be- 
hind the  ear  and  down  the  cervical  spine,  associated 
with  soreness  and  stiffness.  I  set  out  with  the  idea 
that  these  changes — which  are  so  often  premen- 
strual, but  not  always — may  be  due  to  altered  ac- 
tivity of  the  posterior  pituitary  (though  possibly 
in  part  to  a  swelling  or  hyperemia  of  this  struc- 
ture), but  more  probably  due  to  some  interference 
with  osmosis,  the  cell  membrane  of  Gley,  and  the 
spinal  nerve  roots. 

While  some  were  helped  by  thyroid  and  some 
by  corpus  luteum,  I  have  found  that  in  a  number 
of  cases  placental  extract  gives  surprisingly  effec- 
tual results ;  and  when  with  peculiar  headaches 
of  this  type  we  find  not  infrequently  psychic  dis- 
turbance characterized  by  restlessness  and  inability 
to  be  physically  or  mentally  quiet — a  typical  mental 
zvandcrlust .  as  we  might  call  it — it  is  the  first 
thought  to  attribute  both  to  the  same  cause,  and  if 
this  be  true,  what  stretch  of  the  imagination  is  it 
to  conclude  that  mental  wanderlust,  without  these 
typical  headaches,  may  be  due  to  the  same  cause? 
Only  by  dissociating  associated  phenomena  can 
we  lay  the  finger  of  investigation  on  many  of  our 
puzzling  problems.  Furthermore,  when  by  the 
therapeutic  application  of  placental  extract  the  phy- 
sical manifestations  disappear  and  the  psychic  pe- 
culiarities  often  improve  noticeably,   the  test  of 


750  > 


OLIVER:  MEXSTRUATIOX. 


[New  York 
Medical  Journal. 


therapy  justifies  the  conclusion  that  the  primary 
conception  was  correct. 

Since  in  many  of  these  cases  the  blood  pressure 
was  above  normal,  a  test  was  made  concerning  high 
blood  pressure  in  general,  and  it  became  apparent 
that  a  number  of  the  endocrines  enter  into  the 
causation  of  high  blood  pressure  in  many  cases, 
and  metabolic  changes  occurring  in  the  body  serve 
as  an  explanation  for  the  apparently  contradictory 
basic  theories.  Hence  it  is  apparent  to  me  that 
there  are  no  one,  tWo,  or  three  endocrine  causes 
of  high  blood  pressure,  but  that  each  individual 
with  this  symptom  must  be  viewed  as  a  distinct 
entity  and  the  gland  aberrations  of  that  individual 
must  be  sought  for  and  disclosed,  of  course  first 
taking  physical  states  into  consideration. 

Pursuing  this  plan  from  the  basis  of  menstrua- 
tion alone,  and  treating  the  conditions  of  amenor- 
rhea, menorrhagia,  metrorrhagia,  and  dysmenor- 
rhea by  endocrines,  not  infrequently  I  noticed  a 
reduction  of  the  blood  pressure,  even  though  no 
attempt  at  a  solution  of  the  primary  cause  was  in 
mind  at  the  time;  and  taking  a  large  number  of 
patients  at  the  climacteric  period  and  noting  their 
symptoms  after  this  basic  experience,  the  fact  was 
likewise  disclosed  that  in  many  cases  the  blood 
pressure  was  noticeably  reduced. 

Considering  this  material,  the  fact  stands  out 
that  thyroid  minus  and  pituitary  plus  explain  a 
certain  proportion  of  cases  of  high  blood  pressure. 
When  this  is  traced  back  to  the  domain  of  physiol- 
ogy, it  suggests  the  influence  which  the  thyroid 
and  the  pituitary  probably  have  on  the  cerebro- 
spinal fluid,  and  on  the  kidneys  and  their  excretory 
function ;  but  to  state  that  a  pituitary  minus  may 
not  be  associated  with^iigh  cerebrospinal  fluid  pres- 
sure is  to  disregard  entirely  the  metabolic  changes 
associated  with  endocrine  activities  and  to  overlook 
the  relation  of  either  plus  or  minus  pituitary  to  the 
osmosis  and  interchange  in  the  cerebrospinal  fluid. 
For  while  diabetes  insipidus  is  attributed  to  pitu- 
itary minus,  I  am  inclined  to  believe  that  in  some 
cases  pituitary  plus  increases  the  urinary  output. 
So,  reviewing  the  theoretical,  the  physiological  and 
the  therapeutic  conditions,  I  have  become  satisfied 
that  we  have  in  placental  extract  a  substance  which 
should  be  ranked  among  our  therapeutic  agen- 
cies as  worthy  of  study.  If  posterior  pituitary 
does  half  the  harm  for  which,  in  my  opinion,  its 
overactivity  is  responsible ;  if  placental  extract  does 
only  half  as  much  as  I  have  gleaned  from  my  thera- 
peutic endeavors,  I  may  still  safely  suggest  that  the 
important  factor  concerning  placental  extract  is  its 
ability  to  influence  the  posterior  pituitary  and  to 
stimulate  the  anterior  pituitary  and  the  adrenal 
cortex. 

134  West  Eighty-seventh  Street. 


Rhabdomyoma  of  the  Ovary. — H.  E.  Himwich 
(Journal  of  Cancer  Research,  July,  1920)  reports 
a  case  of  rhabdomyoma  of  teratomatous  origin  of 
the  ovary  in  an  infant.  Cells  were  discovered  in 
the  tumor  which  are  found  exclusively  in  rhabdomy- 
oma of  the  heart,  and  the  fact  that  there  was  branch- 
ing in  some  of  the  fibres  led  the  author  to  conclude 
that  the  tumor  described  arose  from  the  heart  muscle. 


NEW  ASPECTS  OF  MENSTRUATION 
Based  on  an  Analysis  of  the  Menstrual  Fluid. 

By  James  Oliver,  M.  D.,  F.  R.  S.  (Edin.), 
London,  England, 
Gynecologist  to  the  Hospital  for  Women. 

The  menstrual  fluid,  amounting  to  seventy  ounces, 
of  which  an  analysis  was  kindly  made  for  me  by 
Dr.  Francis  Goodbody  of  University  College,  Lon- 
don, was  preserved  for  examination  with  thymol 
and  was  obtained  from  a  girl  of  eighteen  who  had 
never  seen  her  menses  because  the  hymen  was  im- 
perforate. This  girl  for  eighteen  months  before 
coming  under  my  care  had  complained  of  periodical 
attacks  of  pain  in  the  abdomen  and  back  which  had 
recurred  regularly  every  month  and  had  on  each 
occasion  continued  more  or  less  severe  for  five 
days.  The  pain  was  always  worse  in  the  abdomen 
but  was  never  accompanied  by  sickness  and  some- 
times she  stayed  in  bed  two  days  out  of  the  five  on 
account  of  the  pain  which  was  always  greatly  re- 
lieved by  hot  applications  to  the  abdomen.  For  six 
months  she  had  remarked  that  her  abdomen  was 
getting  larger  and  for  this  same  length  of  time  she 
had  a  more  frequent  desire  to  pass  urine.  On 
March  1st  and  during  the  four  succeeding  days 
she  had  one  of  her  usual  attacks  of  pain  and  when 
I  examined  her  seven  days  later  the  physical  signs 
then  noted  were  the  following : 

As  the  patient  lies  on  her  back  the  anterior  ab- 
dominal wall  in  the  hypogastric  and  umbilical 
regions  is  pushed  markedly  forward  by  a  large 
and  somewhat  ovoid  swelling  which  extends  out 
of  the  pelvis  and  reaches  to  two  inches  above  the 
umbilicus.  From  it  there  can  be  elicited  an  ill 
defined  feeling  of  fluctuation.  The  vagina  is  com- 
pletely closed  by  a  bulging  membrane  of  apparently 
great  thickness  and  on  the  surface  of  this  membrane 
in  the  centre  is  a  deficiency  of  material  which  looks 
like  the  spot  where  the  perforation  of  the  hymen 
should  have  been  exhibited. 

On  March  15th,  ten  days  after  what  undoubtedly 
was  the  last  menstruation,  I  made  a  crucial  incision 
through  the  thick  and  tough  imperforate  hymen  and 
collected  seventy  ounces  of  menstrual  fluid.  With- 
out further  interference — no  douching  even — the 
patient  was  returned  to  bed  and  from  six  hours 
after  the  operation  there  was  no  discharge  what- 
ever until  April  13th,  when  without  pain  the  men- 
strual discharge  made  its  appearance  and  continued 
in  evidence  for  five  days.  This  discharge,  during 
the  first  four  hours,  was  rather  watery  and  of  a 
pale  red  color,  but  thereafter  and  until  it  ceased  it 
was  of  a  dark  cherry  red  hue.  Judging  from  the 
patient's  records  of  confinements  to  bed  on  account 
of  pain  before  the  hymen  was  incised,  the  menstrual 
cycle  was  one  of  about  thirty-one  days,  but  it  will 
be  observed  that  the  first  menstruation  after  the 
evacuation  of  the  retained  menstrual  fluid  was 
twelve  days  late.  This  I  attribute  to  the  fact  that 
the  uterus  which  was  somewhat  hypertrophied, 
took,  after  the  evacuation  of  the  retained  fluid,  ten 
days  to  return  to  a  normal  size. 

DESCRIPTION  AND  ANALYSIS  OF  THE  FLUID. 

The  fluid  as  it  flowed  through  the  incised  hymen 
presented  from  first  to  last  the  same  appearance 


November  13,  1920.] 


OLIVER: 


MENSTRUATIOX. 


751 


and  was  throughout  of  a  uniform  consistence. 
These  are  noteworthy  points '  because  fresh  men- 
strual fluid  .must* have  been  poured  out  ten  days 
before  the  retained  fluid  was  evacuated  and  be- 
cause quite  as  much  of  the  fluid  had  been  pent  up 
in  the  uterus  itself  as  had  actually  accumulated  in 
the  vaginal  sac.  It  is  truly  remarkable  that  the 
fluid  as  it  escaped  showed  no  evidence  that  the  por- 
tion which  must  have  been  in  contact  with  the  imper- 
forate hymen  for  two  years  or  more  was  of  a 
different  character  or  different  age  from  that  which 
came  from  the  cavity  of  the  uterus.  It  was  thick 
like  treacle  and  tenacious  and  diffusion  could  have 
played  no  part  in  establishing  its  homogeneity.  It 
exhibited  no  free  fluid  and  there  was  not  a  trace 
of  blood  clot  to  be  seen.  It  was  of  a  dark  reddish 
brown  color  with  light  nut  brown  streaks  through 
it.  The  nut  brown  strata  were  probably  due  to 
hematin.  After  the  fluid  had  been  kept  thirty  days 
the  nut  brown  streaks  had  disappeared  and  the 
color  was  uniformly  dark  reddish  brown  of  a 
slightly  deeper  hue  than  when  fresh.  The  fluid 
showed  a  faintly  alkaline  reaction.  It  gave  mark- 
edly the  spectrum  of  hemoglobin  and  on  qualitative 
examination  it  was  found  to  contain  a  large  quan- 
tity of  albumin.  The  fluid  poured  sluggishly  but 
on  the  addition  of  water  it  became  perfectly  fluid. 

Quantitative  examination  disclosed  the  following : 
specific  gravity  1031,  water  87.13  per  cent.,  and 
solids  12.87  per  cent.,  consisting  of  organic  material 
95.02  per  cent,  and  ash  4.98  per  cent.  Further 
analysis  showed :  serum  albumin  12.49  per  cent., 
serum  globulin  16.56  per  cent.,  mucin  3.37  per  cent., 
and  fat  0.0051  per  cent. 

The  inorganic  ash  contained  sodium,  potassium, 
calcium,  magnesium,  phosphorus  and  iron  and  the 
salts  present  were  principally  sodium  chloride  and 
sodium  carbonate  with  small  amounts  of  phosphates 
and  sulphates.  It  is  extremely  doubtful  whether 
the  fluid  contained  iodine  and  after  repeated  test- 
ings it  was  determined  that  if  iodine  was  present 
the  amount  was  so  small  that  it  could  not  be  esti- 
mated.   It  contained  no  arsenic. 

Microscopically  large  numbers  of  red  blood  cor- 
puscles and  some  leucocytes  were  seen  together 
with  small  crystals  of  hemoglobin  enclosed  in  a 
colorless  matrix. 

Judged  by  its  physical  characters  we  have  no 
reason  to  believe  that  the  retained  menstrual  fluid 
had  ever  at  any  time  behaved  as  blood  poured  out 
from  broken  down  capillary  vessels  would  or  should 
have  done.  Its  consistence  like  that  even  of  men- 
strual fluid  retained  in  the  uterus  alone  was  such 
that  diffusion  could  not  possibly  have  played  any 
part  in  establishing  its  distinctive  glutinous  charac- 
ter. Moreover,  the  pressure  exerted  by  seventy 
ounces  of  fluid,  which  after  distending  the  vagina 
had  so  accumulated  in  the  uterus  as  to  form  an 
abdominal  tumor  almost  as  large  as  an  adult  head, 
must  necessarily  have  prevented  the  periodical 
degenerations  and  disintegrations  of  the  endome- 
trium and  the  concomitant  capillary  hemorrhages  to 
say  nothing  of  the  recuperation  and  healing  month 
after  month  of  such  devastated  structures.  As  a 
matter  of  fact  the  continued  recurrence  of  men- 
struation in  marked  cases  of  retained  menstrual 


fluid  is  only  conceivable  on  a  secretory  hypothesis. 

Again  on  scrutinizing  the  analytical  findings 
there  cannot  be  the  least  shadow  of  a  doubt  that 
the  retained  menstrual  fluid  was  not  and  never  had 
been  blood  poured  out  by  broken  down  capillary 
vessels.  We  can  at  the  outset  banish  from  our 
minds  the  question  of  the  probability  of  any  ad- 
mixture of  vaginal  secretion  modifying  or  affect- 
ing the  fluid,  since  there  could  have  been  to  all 
intents  and  purposes  no  secretion  from  the  vaginal 
mucous  membrane  as  otherwise,  because  the  vagina 
had  never  been  anything  but  a  closed  sac,  the 
secretion  would  have  been  accumulating  for  at  least 
thirteen  years  before  menstruation  set  in  and  that 
secretion  could  not  possibly  have  diffused  through 
the  fluid  of  the  recurring  menstrual  periods.  It 
will  be  remarked  that  the  specific  gravity  of  the 
fluid,  1031,  is  much  below  that  of  normal  blood, 
the  specific  gravity  of  which  averages  from  1055 
to  1060  and  that  the  quantity  of  serum  albumin  in 
12.49  per  cent,  is  half  as  much  again  as  that  found 
in  blood  serum.  The  mucin  content,  3.37  per  cent., 
is  remarkably  high  and  no  doubt  the  viscous  char- 
acter of  the  fluid — homogeneous  in  this  respect — 
was  largely  if  not  entirely  due  to  the  presence  of 
that  substance,  and  there  can  be  no  gainsaying  the 
fact  that  the  mucinogen  which  is  the  precursor  of 
mucin  was  secreted  simultaneously  with  the  men- 
strual fluid  and  was  not  added  afterwards,  for  as 
I  have  already  observed  diffusion  could  have  played 
no  part  in  establishing  the  homogeneity  of  the  fluid. 
By  the  hypobromite  test,  moreover,  there  was  no 
evidence  that  the  fluid  contained  urea,  neither  was 
there  any  evidence  of  the  presence  of  sugar  nor  of 
cholesterol. 

It  is  noteworthy  that  there  was  in  the  fluid  an 
abundance  of  hemoglobin  and  hemoglobin  products. 
Regarding  the  presence  of  hemoglobin  crystals  I 
would  remind  my  readers  that  in  the  laboratory 
it  is  an  extremely  difficult  matter  to  obtain  oxyhemo- 
globin or  hemoglobin  cr>-stals  from  human  blood. 
That  hemoglobin  in  some  remarkable  way  plays  an 
all  important  role  in  the  phenomena  of  menstrua- 
tion and  in  the  function  of  gestation  is  certain.  In 
cases  of  pronounced  anemia  and  chlorosis,  for  ex- 
ample, it  is  common  knowledge  that  menstruation 
is  often  suspended  for  a  greater  or  less  length  of 
time  and  only  becomes  reestablished  under  such 
circumstances  when  the  hemoglobin  content  of  the 
red  blood  corpuscles  has  been  adequately  improved 
and  increased.  That  hemoglobin  plays  a  most  im- 
portant part  in  starting  and  carrying  on  gestation 
there  can  be  no  doubt,  for  the  oxidative  processes 
and  powers  of  the  uterus  must  be  enormously  in- 
creased at  this  time  and  from  the  hemoglobin  the 
fetus  derives  the  iron  it  stands  in  need  of  for  its 
immediate  and  future  requirements. 

Confronted  with  such  facts  as  I  have  here  de- 
tailed there  clearly  is  no  justification  for  clinging 
to  the  belief  that  menstrual  fluid  is  purely  and  sim- 
ply blood  poured  out  by  vessels  which  have  been 
opened  into  in  consequence  of  a  degeneration  and 
disintegration  of  the  mucous  lining  of  the  uterus. 
On  a  secretory  hypothesis  alone  is  it  possible  to 
account  for  the  great  variation  in  the  amount  and 
in  the  physical  characters  of  the  menstrual  fluid. 


752  MONTGOMERY :  DIFFEREXTIAL  PELVIC  AND  ABDOMINAL  DIAGNOSIS  INew  Yokk 

Medical  Journal. 


not  only  in  dif¥erent  individuals  but  in  the  same 
individual  at  different  times  and  even  during  the 
same  menstrual  period. 

In  dealing  with  the  question  of  the  mechanism 
whereby  the  different  bodies  entering  into  the  com- 
position of  menstrual  fluid  are  produced  we  are 
dealing  with  a  problem  vastly  more  difficult  than 
that  concerned  in  the  production  of  milk  but  by 
careful  clinical  observation  valuable  light  may 
eventually  be  thrown  on  this  all  important  matter. 

123  Harley  Street. 


DIFFERENTIAL     DIAGNOSIS  BETWEEN 
DISORDERS  OF  THE  PELVIC  ORGANS 
IN  WOMEN  AND  OF  THE  ABDOM- 
INAL VISCERA.* 

Bv  E.  E.  MoxTGOMERY,  M.  D.,  LL.  D.,  F.  A.  C.  S., 

Philadelphia, 

Professor  of  Gynecology,  Jefferson   Medical  College;  Gynecologist  to 
Jefferson  •  and  St.  Joseph's  Hospitals, 

An  accurate  diagnosis  of  abdominopelvic  condi- 
tions is  of  the  utmost  importance  for  the  proper 
treatment  of  disease.  An  inaccurate  or  careless 
study  of  such  conditions  will  result  in  unnecessary 
or  improper  operative  procedures.  Certain  groups 
of  subjective  and  objective  symptoms  are  often 
associated  with  diseased  conditions  in  such  a  fash- 
ion as  to  present  an  almost  absolute  physiognomy 
of  the  disorder.  I  once  heard  a  prominent  surgeon 
say,  "A  woman,  fair,  fat  and  forty  belching;  gall- 
stones." This  diagnosis  may  be  found  true  in  the 
majority  of  such  cases  but  it  is  a  dangerous  assump- 
tion, and  capable  of  much  harm.  The  surgeon 
who  operates  on  such  a  conclusion  is  executing  sen- 
tence on  the  victim  on  circumstantial  evidence. 

Gastric  distention,  discomfort  after  eating,  dys- 
pnea, frequent  and  ineffectual  efforts  to  yawn,  fre- 
quent eructations,  are  all  indications  of  gastric, 
duodenal  and  hepatic  disorders,  and  with  the  ex- 
ception of  jaundice  may  arise  from  the  pressure  on 
the  sigmoid  or  rectum  of  a  large  retroverted  uterus 
or  one  with  a  fibroid  in  the  fundus.  Such  pres- 
sure by  interfering  with  the  transmission  through 
the  tract  of  its  contents  through  reversed  peristal- 
sis refers  the  discomfort  to  tlie  upper  abdominal 
portion  of  the  alimentary  canal.  Such  pressure,  by 
interfering  with  the  pelvic  circulation,  is  also  a  fre- 
quent cause  of  hemorrhoids,  fissure  and  pruritus 
ani.  It  must  become  evident,  then,  that  no  woman 
should  be  subjected  to  operation  on  either  end  of 
her  gastrointestinal  canal  or  the  adjacent  structure 
at  the  upper  end,  the  gallbladder,  until  a  careful 
bimanual  investigation  of  her  pelvic  viscera  has 
been  made.  I  recall  a  sister,  who  came  to  this 
hospital  from  Baltimore  and  was  referred  to  me 
for  treatment  of  hemorrhoids,  in  whom  an  exami- 
nation disclosed  that  the  cause  of  the  hemorrhoids 
was  the  presence  of  fibroid  growths  filling  up  the 
pelvis.  The  hemorrhoids  were  in  evidence  but 
operation  on  them  alone  would  have  been  unsatis- 
factory as  the  injured  rectal  structures  under  such 
circumstances  are  slow  in  healing. 

•Read  before  the  St.  Joseph's  Hospital  Clinical  Society,  June  8, 
1920. 


The  recognition  of  retrodisplacements  and  en- 
largement of  the  uterus  from  whatever  cause  is 
readily  determined  by  careful  bimanual  examina- 
tion. While  the  evidence  of  such  a  condition  does 
not  preclude  the  simultaneous  occurrence  of  ab- 
normal conditions  in  the  upper  abdomen,  the  pro- 
cedure necessary  for  its  relief  affords  an  oppor- 
tunity to  explore  the  entire  abdomen  and  deter- 
mine abnormal  conditions  affecting  gallbladder, 
duodenum  and  stomach,  and  possibly  save  the  op- 
erator from  the  mortification  and  discredit  of  know- 
ing that  he  had  subjected  the  patient  to  an  unneces- 
sary operation. 

Probably  a  more  frequent  cause  for  error  in 
diagnosis  is  the  presence  of  pain  or  discomfort  in 
the  right  lower  quadrant  of  the  abdomen.  In  the 
female,  the  gallbladder,  kidney,  ureter,  appendix 
and  uterine  appendages  must  all  be  kept  in  mind 
as  possible  causes  of  discomfort  in  the  right  side. 
Inflammation  of  any  of  these  structures  may  cause 
such  discomfort.  That  the  general  surgeon  often 
errs  is  shown  by  the  frequency  with  which  women 
are  subjected  to  operation  for  removal  of  the  ap- 
pendix, without  obtaining  relief  from  the  discom- 
fort for  which  the  surgeon  was  consulted,  subse- 
quent examination  disclosing  evidence  of  tubal  in- 
flammation from  which  relief  is  obtained  only  by 
another  operation  for  the  removal  of  the  offending 
structures. 

Such  experiences  demonstrate  very  clearly  the 
necessity  of  a  careful  study  of  the  individual 
patient ;  nothing  should  be  taken  for  granted. 
Disease  of  the  adnexa  is  too  easily  excluded  by 
abdominopelvic  examination  to  justify  the  operator 
in  overlooking  its  existence  and  thus  subjecting  the 
patient  to  an  unnecessary  operation  upon  the  ap- 
pendix or  an  inadequate  one  in  the  sense  that 
equall}'  serious  conditions  are  overlooked.  Lesions 
of  the  urinary  tract  should  be  suspected  when  the 
kidney  is  palpable  as  an  enlarged,  tender  and  drag- 
ging organ.  The  urine  is  likely  to  contain  pus  and 
blood  and  the  frequency  of  micturition  points  to 
irritation  of  this  tract.  Rarely,  an  appendiceal  ab- 
scess will  involve  the  peritoneum  over  the  ureter 
to  such  an  extent  as  to  simulate  ureteral  disease. 
I  had  a  case  of  carcinoma  of  the  appendix  in  which 
the  carcinoma  had  infiltrated  the  peritoneum  and 
through  it  the  wall  of  the  ureter.  The  patient  died 
from  a  recurrence  of  the  disease. 

]\Ialignant  disease  of  the  ovary,  or  of  the  intes- 
tines, may  present  conditions  rendering  difificult  a 
definite  diagnosis  previous  to  abdominal  incision. 
Malignant  disease  of  the  ovary  presents  no  dis- 
tinctive symptoms  from  an  ordinary  ovarian  cyst, 
until  it  has  infiltrated  the  wall  and  extended  to  the 
surrounding  structures,  or  has  ruptured,  producing 
a  more  disseminated  spread  of  the  disorder  at- 
tended with  ascites.  In  addition  to  the  mass  which 
can  be  palpated  in  the  pelvis,  such  patients  present 
palpable  evidence  of  secondary  nodules  through  the 
peritoneum  and  especially  marked  infiltration  of  the 
omentum.  It  seems  a  part  of  the  function  of  this 
structure  to  aid  in  covering  up  and  assist  in 
forming  a  guard  against  the  spread  of  infection. 
I  have  seen  the  omentum,  having  wrapped  up 
within  its  folds  a  suppurating  appendix,  closing 


November  13,  1920  ]     MOXTGOMERV :  DlffEREXTIAL  PELVIC  AND  ABDOMIXAL  DIAGNOSIS 


753 


every  avenue  for  the  further  spread  of  the  infec- 
tion ;  so  it  is  also  seen  enveloping  a  threatened  rup- 
ture of  a  malignant  ovary  and  itself  receiving  the 
charge  which  led  to  its  infiltration.  In  the  major- 
ity of  cases  of  malignancy  originating  in  the  intes- 
tine the  cell  infiltration  leads  to  early  constriction 
and  obstruction  of  the  intestine  before  there  is  in- 
filtration of  the  surrounding  structures.  Here  the 
signs  of  obstruction  and  reversed  peristalsis  soon 
occur.  The  natural  tendency  of  all  enlargements 
of  the  adnexa  and  intestines  is  to  drop  into  the 
retrouterine  pouch  and  as  the  disease  progresses 
they  become  adherent  and  sooner  or  later  lead  to 
infiltration  to  the  adjoining  structures  forming  a 
mass  which  adds  to  the  difficulty  of  diagnosis. 

The  progress  of  the  condition  originating  in  the 
ovary  may  be  much  slower  in  its  progress  and  be 
attended  with  greater  accumulations  of  ascitic  fluid 
and  not  infrequently  great  distention  of  the  intes- 
tines with  gas.  ]\Iany  cases  illustrating  these  con- 
ditions which  have  occurred  in  the  last  few  years 
come  to  mind,  three  of  which  I  will  present. 

Case  I. — Mrs.  S.,  aged  forty-eight,  referred  Feb- 
ruary 22,  1919,  by  Dr.  Goldberg,  had  been  pregnant 
twice,  delivered  at  full  term  with  natural  labors. 
A  curettage  followed  the  last.  Menstruation  was 
regular,  lasting  four  to  five  days :  no  leucorrhea. 
Bowels  had  always  been  regular,  but  she  was  unable 
at  the  time  to  have  ^a  movement  because  of  some 
obstruction.  Her  abdomen  was  greatly  distended 
especially  at  the  upper  part.  She  gave  a  history 
of  having  had  an  operation  last  June  when,  her 
daughter  informed  me,  it  was  necessary  to  suture 
the  bowel  in  two  places.  Examination  revealed  a 
mass  in  front  of  the  rectum  which  pressed  upon 
it  and  was  evidently  the  cause  of  the  obstruction. 
On  February  27,  1919,  she  was  operated  upon  in 
St.  Joseph's  Hospital.  A  median  incision  dis- 
charged a  large  quantity  of  ascitic  fluid  and  the 
pelvis  was  found  filled  with  a  mass  of  cancerous 
growth  involving  both  ovaries  with  secondary 
nodules  in  the  peritoneum  of  the  bladder  and  other 
points.  The  omentum  was  extensively  infiltrated. 
The  uterus  contained  fibroid  growths.  I  pulled 
the  mass  out  of  the  pelvis,  removed  both  ovaries 
and  the  fundus  uteri ;  covered  the  raw  surfaces 
with  peritoneum  and  closed  the  abdomen  after  hav- 
ing irrigated  the  belly  with  hot  saline  solution.  Her 
condition  was  so  bad  that  we  resorted  at  once  to 
intravenous  injection.  The  patient  recovered  from 
the  operation  and  was  first  seen  at  my  office  doing 
fairly  well,  on  April  18th,  and  again  on  June  23rd 
and  July  17th,  feeling  quite  uncomfortable.  There 
was  evidence  of  a  return  of  the  mass  in  the  pelvis. 
On  July  22nd  I  tapped  her  in  m.y  office  and  drew  oflf 
about  a  gallon  of  fluid.  I  tapped  her  again  on 
August  4th,  when  nearly  as  much  fluid  was  with- 
drawn. Dr.  Richards  subsequently  attended  her 
at  her  home  and  I  saw  her  with  him  October  17th. 
I  believe  she  lived  over  the  end  of  the  year  but  was 
uncomfortable  all  the  time. 

Case  II. — A  colored  woman  at  the  Jefferson 
Hospital  had  undergone  operation  nearly  a  year 
before  when  Dr.  Bland  removed  the  fundus  of  the 
uterus  for  fibroids.  Her  abdomen  was  quite  dis- 
tended and  a  mass  could  be  felt  in  the  pelvis.  The 


abdomen  was  opened  which  revealed  carcinoma  of 
the  ovaries.  The  mass  was  removed  and  the  patient 
recovered  and  left  the  ho.spital.  Two  months  later 
this  woman  returned  with  ascites.  Examination  re- 
vealed that  there  was  a  recurrence  of  the  growth 
in  the  pelvis.  After  an  evacuation  of  the  fluid  by 
trocar  this  patient  was  lost  sight  of. 

Case  III.— On  October  1,  1919,  Mrs.  G.  came 
under  observation.  She  was  forty-seven  years  old, 
pregnant  three  times,  in  all  of  which  she  went  to 
full  term.  She  had  not  menstruated  for  a  year,  and 
did  not  show  leucorrhea.  She  had  been  obsti- 
nately constipated  and  without  urinary  disturbance. 
She  had  pain  in  the  lower  abdomen.  My  notes  say 
that  the  examination  disclosed  a  fibroid  in  the  pos- 
terior wall  of  the  viterus  and  hysterectomy  was 
advised.  The  obstruction  was  ascribed  to  the  pres- 
sure of  the  mass  on  the  sigmoid. 

On  November  13.  1919,  it  was  noted  that  the 
patient  had  had  no  movement  of  the  bowels  since  I 
last  saw  her,  which  made  the  necessity  for  relief 
very  urgent.  At  St.  Joseph's  Hospital,  the  abdomen 
was  opened  in  the  median  line  which  revealed  that 
the  mass  was  a  tumor  between  the  rectum  and  the 
uterus  adherent  to  both.  The  principal  mass  was 
found  to  be  a  carcinomatous  involvement  of  the 
ileum  which  had  dropped  down  and  become  adherent 
and  infiltrating  the  tissues  with  which  it  lay  in 
contact.  Both  the  posterior  wall  of  the  bladder, 
the  fundus  and  posterior  surface  of  the  uterus  and 
the  anterior  surface  of  the  rectum  were  involved. 
I  resected  the  ileum  and  made  an  end  to  end  anasto- 
mosis, cut  away  the  peritoneal  surfaces  of  the  rec- 
tum and  fimdus  of  the  bladder  and  removed  the 
uterus.  Proctoclysis  was  instituted  at  once.  She 
had  some  distention  on  the  second  day  but  was 
given  fractional  doses  of  calomel  every  fifteen  min- 
utes and  saline  following.  She  had  five  movements 
of  the  bowels  the  next  morning  and  improved 
steadily.  A  week  after  the  operation  she  had  a 
very  offensive  discharge  from  the  vagina.  It  was 
so  foul  that  the  intern  attributed  it  to  a  fecal  fistula, 
but  it  was  evidently  due  to  colon  bacillus  infection 
and  "ioon  cleared  up.  She  soon  had  a  recurrence  of 
the  disease  and  although  she  lived  some  months  her 
condition  was  so  uncomfortable  that  one  could  not 
but  regret  that  she  had  not  been  permitted  to  die 
without  the  first  operation. 

These  cases  are  not  reported  on  account  of  the 
successful  result  of  the  operative  procedures,  but 
for  the  purpose  of  illustrating  the  difficulties  of 
diagnosis.  A  proper  diagnosis  is  of  importance  to 
determine  not  only  the  condition  but  to  be  able  to 
advise  as  to  whether  any  operative  treatment  should 
be  employed. 

Pregnancy  often  "affords  a  cause  for  error  in  diag- 
nosis of  supposed  appendicitis.  If  the  tumor  is  a 
fibroid,  a  subperitoneal  one,  as  the  uterus  increases 
in  size  such  a  tumor  may  be  squeezed  between  the 
developing  uterus  and  the  bony  pelvis  or  abdominal 
wall  and  the  pressure  thus  induced  lead  to  its  being 
pressed  into  the  uterine  wall  like  a  cork  in  a  bottle 
until  its  circulation  is  cut  off  and  it  begins  to  set 
up  inflammation  as  a  foreign  body.  The  pain,  ten- 
derness and  muscular  rigidity  frequently  lead  to 
the  diagnosis  of  appendicitis.    I  have  seen  three 


754 


POLAK:   RECENT  ADVANCES  IN  OBSTETRICS. 


[New  York 
Medical  Journal. 


such  patients,  two  of  whom  were  subjected  to  op- 
eration for  supposed  appendicitis.  In  the  third 
case,  recognizing  the  condition,  I  attempted  to  carry 
the  patient  along  by  pushing  up  the  uterus  to  release 
the  pressure  but  the  condition  caused  an  abortion 
and  the  condition  had  become  so  disturbing  as  to 
later  require  an  abdominal  hysterectomy. 

Ordinarily  in  acute  appendicitis  complicating 
pregnancy,  the  cecum  generally  being  somewhat 
fixed,  the  gravid  uterus  lies  in  front  of  it  and 
consequently  the  pain  may  be  aggravated  by  making 
pressure  over  the  uterus  or  in  pushing  behind  the 
uterus.  In  a  fibroid  causing  the  condition  the  pres- 
sure and  pain  are  more  anterior  to  the  position  of 
the  appendix. 

1426  Spruce  Street. 


RECENT  ADVANCES  IN  OBSTETRICAL 

PRACTICE.* 
By  John  Osborn  Polak,  M  Sc.,  M.D..  F.A.C.S., 

Brooklyn, 

Professor  of  Obstetrics  and  Gynecology,   Long  Island 
College  Hospital. 

Obstetrics  has  become  a  specialt}'.  The  obstetri- 
cian is  no  longer  a  medical  man,  but  an  obstetrical 
surgeon.  We  have  passed  out  of  the  period  of 
the  midwife ;  the  public  demands  a  specialist,  and 
he  must  be  fully  equipped  with  a  training  in  the 
fundamentals  of  the  science  and  art  of  obstetrics, 
general  and  special  diagnosis,  and  an  appreciation 
of  the  principles  underlying  obstetrical  surgery. 

The  existence  of  the  trained  obstetrician  is  justi- 
fied, if  he  is  able  to  produce  a  living  child  with  a 
reasonable  certainty  of  life,  with  less  mortality  and 
morbidity  to  the  mother,  and  has  the  ability  to 
restore  the  parturient  woman  to  the  proper  economic 
state  of  health,  and  as  perfect  anatomically  as  before 
she  was  delivered.  x 

Prenatal  care  is  the  right  of  every  prospective 
mother.  This  does  not  mean  an  occasional  exam- 
ination of  the  urine  when  we  happen  to  remember 
to  make  one,  and  a  record  of  the  expected  date  of 
confinement,  but  a  searching  and  painstaking  exam- 
ination of  the  individual.  This  investigation  should 
not  only  include  an  examination  of  the  heart,  lungs, 
kidney,  and  other  general  condition,  but  of  the 
thyroid  and  kidney  function,  repeated  estimations 
oi  the  phthalein  elimination  and  its  relation  to  the 
blood  pressure,  and  a  routine  blood  Wassermann 
test,  together  with  careful  observations  as  to  the 
development  of  the  pregnancy,  inquiry  into  the 
character  of  the  discharges,  and  a  bacterial  examina- 
tion of  these  discharges ;  and  finally,  the  diagnosis 
of  the  presentation,  position,  posture,  and  pelvic 
mensuration  of  both  the  pelvi'c  brim  and  outlet. 
For  not  only  has  the  child  to  enter  the  bony  pelvis, 
but  it  has  also  to  pass  through  it  and  get  out  of  it, 
and  this  can  onl3-  be  determined  by  a  proper  appre- 
ciation of  the  relative  size  of  the  child  to  the 
mother's  pelvis. 

This  prenatal  investigation  permits  u^  to  discover 
syphilis ;  prevents  the  occurrence  of  eclampsia : 
allows  the  recognition  of  maloositions  and  dispro- 

*Read  at  the  C-ntennial  Meeting  of  the  Oswego  Countv,  N.  Y., 
Medical  Society,  October  13,  1920. 


portion,  and  thus  minimizes  the  difficulties  of  labor. 
Being  thus  forewarned,  we  are  foreanned  for  any 
emergency,  and  consequently  we  know  how  to  con- 
duct the  labor  in  the  best  interests  of  both  the 
mother  and  the  child. 

Nothing  has  done  so  much  to  improve  both 
maternal  and  fetal  mortality  as  accurate  pre- 
natal work.  In  our  clinic  at  the  Long  Island  Col- 
lege Hospital,  in  over  five  thousand  consecutive 
cases  in  which  there  had  been  done  the  most  careful 
antepartum  work,  including  routine  salvarsan  treat- 
ment of  all  syphilitics,  there  were  but  two  per  cent, 
of  stillbirths.  No  case  of  eclampsia  occurred  in 
this  series,  and  the  operative  procedures  were  re- 
duced to  a  minimum ;  while  the  mortality  and  mor- 
bidity v.-ere  both  lowered. 

Next  in  importance  is  the  prevention  of  infection, 
and  no  one  procedure  has  contributed  so  much  to 
the  diminution  of  this  serious  complication,  which 
alone  causes  over  ten  thousand  deaths  annually  in 
the  United  States,  as  the  routine  employment  of 
abdominal  diagnosis  and  a  rectal  examination  in 
following  the  course  of  ordinary  labor. 

While  it  has  been  contended  by  those  who  are 
making  routine  vaginal  examinations  that  it  is  safe 
under  proper  precautions  to  enter  the  vagina  at 
will,  or  at  least  as  freely  as  is  necessary  to  follow 
the  advance  of  labor,  our  experience  has  shown  us 
that  not  only  the  morbidity  but  the  mortality  has 
actually  been  reduced  by  the  adoption  of  routine 
rectal  examinations.  The  vulva  and  vagina  are 
the  constant  habitat  of  bacterial  flora  which  are 
readily  carried  into  the  uterus  by  vaginal  examina- 
tions. This  can  be  absolutely  prevented  by  con- 
fining our  explorations  to  the  rectum.  One  can 
follow  the  course  of  labor  by  rectal  touch  after 
very  little  experience,  and  determine  the  dilatation 
of  the  cervix,  the  descent  of  the  head,  the  rotation 
of  the  vertex,  with  almost  as  much  accuracy  as  by 
vaginal  feel.  Only  when  the  progress  of  labor  has 
become  arrested,  is  it  our  custom  to  make  a  vaginal 
examination.  When  this  is  necessary  it  should  be 
made  a  surgical  procedure.  The  patient's  vulva  is 
clipped,  scrubbed,  and  sterilized.  The  examining 
hand  is  scrubbed  and  glcved,  and  with  the  patient 
under  an  anesthetic,  a  careful  examination  is  made 
and  the  cause  of  the  dystocia  determined.  Besides 
this,  an  accurate  knowledge  of  the  physiological 
processes  of  labor  is  essential,  for  labor  is  a  me- 
chanical process. 

In  the  ordinary  obstetrical  case  when  the  woman 
falls  into  labor,  if  she  is  a  primipara  and  there  is 
no  disproportion,  the  he.'id  should  be  in  the  pelvis ; 
while  in  the  multipara,  during  the  stage  of  dilata- 
tion, or  shortly  after  dilatation  is  complete,  the 
head  either  engages  in  the  pelvis  or  it  does  not. 
This  is  fundamental.  It  would  engage  if  it  could, 
and  if  it  does  not,  there  is  some  defect  in  the  power, 
the  passage  or  the  passenger.  Consequently  every 
labor  must  be  studied  and  conducted  in  such  a  way 
by  our  knowledge  of  the  presentation,  position  and 
posture,  the  preservation  of  the  membranes,  the 
maintenance  of  absolute  asepsis,  and  the  conserva- 
tion of  the  nervous  energy  of  the  patient  by  rest. 

Should  intervention  be  demanded  in  the  interest 
of  mother  or  child,  such  operation  can  be  done  with 


November  13,  1920.] 


POLAK:  RECENT  ADVANCES  IN  OBSTETRICS. 


755 


the  greatest  margin  of  safety.  Anodynes  and  anal- 
gesics are  absolutely  necessary  for  the  patient's 
comfort  in  every  prolonged  labor ;  for  certain 
mechanical  processes  must  be  effected  in  order  that 
the  child  may  pass  through  the  pelvis,  and  these  take 
time  to  accomplish  and  require  active  labor  pains ; 
and  pain  exhausts.  The  steps  of  the  mechanism 
occur  after  there  is  dilatation  of  the  cervix  and  the 
presenting  part  passes  the  brim  and  reaches  the  pel- 
vic floor ;  this  in  turn  is  followed  by  dilatation  of 
the  vulva  outlet.  When  the  head  passes  out  of  the 
cervix,  the  uterus  moulds  itself  about  the  child,  and 
this  interferes  with  the  uteroplacental  circulation, 
hence  the  importance  of  an  accurate  record  of  the 
fetal  heart,  its  action  under  the  influence  of  uterine 
contraction,  and  its  reaction  during  the  periods  of 
uterine  rest,  are  essential  in  order  to  estimate  the 
effect  of  labor  on  the  child. 

With  this  knowledge,  should  the  necessity  for 
operative  intervention  arise,  the  woman  is  reason- 
ably safe,  for  the  child  is  in  good  condition,  the 
woman's  strength  is  not  exhausted,  infection  has 
been  minimized,  and  sufficient  time  has  been  given 
to  accomplish  the  opening  up  of  the  soft  parts  by 
Nature's  processes,  consequently  it  may  be  deduced 
that  every  obstetrical  cas-i  unless  the  delivery  is  spon- 
taneous, will  fall  into  one  of  two  general  classes, 
namely,  either  the  child  will  come  into  the  pelvis 
and  providing  the  outlet  is  ample  allow  of  infra- 
vaginal  delivery,  or  it  will  fail  to  enter  the  pelvis 
when  supravaginal  delivery  will  be  necessary. 

In  the  first  class,  where  infravaginal  delivery  is 
possible,  certain  essentials  must  be  observed  in  or- 
der to  have  a  favorable  outcome.  First  of  all,  the 
cervix  must  be  fully  dilated  and  this  takes  time;  to 
give  this  time  to  the  patient,  and  yet  conserve  her 
nervous  energy  requires  the  use  of  anodynes.  Here 
morphine  and  scopolamine  used  judiciously  have 
given  the  greatest  comfort  to  the  woman,  and  have 
accomplished  much  which  could  not  have  been  done 
without  their  aid. 

Secondly,  ithe  membranes  should  be  preserved 
until  complete  cer\'ical  canalization  ha!s  been  accom- 
plished. The  patient's  comfort  may  be  further 
advanced  by  keeping  both  bladder  and  rectum 
empty.  A  tight  abdominal  binder  aids  materially 
in  crowding  the  head  into  the  pelvis  besides  main- 
taining flexion,  and  it  further  maintains  a  better 
driving  axis  for  force  of  the  pain.  Not  until  the 
head  has  reached  the  spines  or .  has  passed  them 
should  forceps  be  resorted  to,  for  in  good  practice 
today  median  and  high  forceps  are  seldom  if  ever 
used.  Both  of  these  procedures  have  a  high  fetal 
mortality.  On  the  other  hand,  low  forceps  is  a 
•life  saving  operation,  and  should  be  frequently  em- 
ployed, more  frequently,  perhaps,  than  at  present, 
when  the  head  is  at  the  spines  or  below  them  and 
the  cervix  is  fully  dilated,  and  the  outlet  is  ample ; 
for  many  children  lose  their  lives  after  they  have 
reached  the  pelvic  floor  by  too  long  delay  in  the 
perineal  stage.  Furthermore,  the  fascial  sheets 
become  overstretched  and  pelvic  relaxation  follows. 
Both  Pomeroy  and  DeLee  have  called  attention  to 
this  and  have  suggested  prophylactic  forceps  and 
perineal  section  in  the  interest  of  the  child.  This 
perineal  section  may  be  done  through  the  median 


raphe  or  laterally,  and  so  remove  the  soft  part 
dystocia  which  is  jeopardizing  the  fetal  life. 

Probably  no  advance  in  obstetrics  has  been  so 
great  as  the  recognition  of  danger  to  the  child  by 
routine  auscultation  of  the  fetal  heart  done  at 
regular  intervals  throughout  the  entire  perineal 
stage,  as  by  this  means  we  are  able  to  recognize  cord 
complications  as  coils,  short  cord  and  shoulder  cord, 
by  the  arrhythmias  and  souffles  and  so  terminate 
labor  promptly  in  the  interest  of  the  child.  Only 
in  funnel  pelves  where  the  outlet  is  contracted, 
namely,  when  the  biischial  and  posterior  sagittal 
diameters  total  less  than  fifteen,  is  infrapelvic  de- 
livery of  the  engaged  head  by  forceps  absolutely 
contraindicated.  It  is  here  with  a  contracted  outlet, 
with  the  head  well  in  the  pelvis,  at  or  below  the 
spines,  and  a  living  child,  that  pubiotomy  has  its 
principal  indication.  Hcbosteotomy  is  also  permis- 
sible in  occipitoposterior  positions  of  the  vertex 
arrested  at  the  pelvic  outlet  by  contracted  hard  parts. 

Again,  in  mentoposteriors  impacted  in  the  pelvis 
with  a  living  child,  by  increasing  the  size  of  the  pel- 
vis by  pubic  section  the  chin  may  be  successfully 
rotated.  Pubiotomy  is  not  fraught  with  the  serious 
dangers  that  we  have  been  told  about,  and,  while  the 
field  is  limited,  it  has  a  distinct  place  in  obstetrics, 
and  in  certain  outlet  contractions  we  may  frequently 
be  able  to  save  a  child  without  excessive  trauma  by 
its  adoption.  Do  not  for  a  moment  understand  that 
we  place  pubiotomy  against  CiEsarean  section.  To 
make  pubiotomy  successful,  the  head  should  be  well 
in  the  pelvis  and  arrested  at  the  outlet,  while  Caesar- 
ean  section  has  its  chief  indication  in  arrest  of  the 
head  at  the  brim.  In  the  past  few  years,  indica- 
tions for  Caesarean  section  have  been  broadened ; 
not  only  is  suprapubic  delivery  done  for  contracted 
pelves,  but  for  many  relative  conditions  in  the 
interests  of  the  unborn  child. 

Davis  has  successfully  used  it  in  the  treatment  of 
placenta  praevia.  Occasionally  it  is  of  value  in  pro- 
lapse of  the  cord.  Peterson  has  recommended  it  in 
eclampsia,  and  many  operations  have  been  done  be- 
cause of  soft  part  dystocia.  Many  of  these  dys- 
tocias have  been  brought  about  by  the  procedures 
used  for  the  correction  of  retroversion,  such  as  the 
socalled  suspension  of  the  uterus,  and  have  con- 
tributed a  very  large  percentage  of  these  dystocias 
which  have  necessitated  the  delivery  of  the  child- 
by  the  suprapubic  method. 

Csesarean  section  is  not  without  danger.  In  the 
collective  records  of  two  thousand  cases  of  various 
operators  in  America,  almost  all  of  whom  are  rec- 
ognized as  obstetrical  surgeons,  we  found  that  there 
was  a  mortality  of  over  eight  per  cent.,  with  a  mor- 
bidity of  between  thirty  and  thirty-five.  This  high 
percentage  of  mortality  and  morbidity  should  not 
he  credited  to  Caesarean  section,  but  to  the  results 
of  not  knowing  what  class  of  patients  would  need 
section  before  we  started. 

In  our  own  service,  where  the  prenatal  work  is 
exacting,  we  know  practically  from  the  very  begin- 
ning in  what  case  Caesarean  section  will  be  required. 
Consequently,  our  mortality  has  been  lowered  as 
well  as  the  maternal  morbidity.  If  the  labor  has 
been  conducted  along  aseptic  lines,  and  the  progress 
watched  by  rectal  and  abdominal  examinations,  the 


756 


DAVIS:  COMPLETE  FORCEPS  OPERATIOX. 


(Nkw  Vork 
Medical  Journal. 


suprapubic  transperitoneal  operation  may  be  done  at 
almost  any  time  during  labor  with  a  mortality  of  less 
than  one  per  cent.  Primiparous  labors  are  always 
trial  laliors,  while  in  multiparae  we  have  a  history 
of  past  performances,  consequently  these  trial  la- 
bors should  be  given  the  trial  on  aseptic  lines  and 
every  precaution  we  can  take  in  the  interest  of  the 
mother  and  child  is  justified. 

What  runner,  what  athlete,  what  horse,  what  crew 
goes  into  the  supreme  contest  without  preparation 
and  training ;  yet  many  women  go  into  labor  with- 
out training  or  even  knowledge  of  what  is  before 
them.  Potter,  of  Buffalo,  arbitrarily  shortens  labor 
by  the  election  of  version  in  every  case  with  no  dis- 
proportion. While  we  cannot  agree  that  his  teach- 
ings are  sound,  he  has  certainly  succeeded  in  what 
he  started  out  to  do.  Potter  is  an  artist,  but  who 
of  us  can  duplicate  his  i-ecord  without  increasing- 
cur  fetal  and  maternal  mortality,  and  we  ques- 
tion the  advisability  of  deliberately  disengaging  the 
engaged  and  moulded  head  and  bringing  down  the 
feet  as  a  routine,  just  to  relieve  the  woman  of  the 
pain  and  exertion  of  the  second  stage  of  labor, 
when  by  the  employment  of  morphine  and  scopola- 
mine in  the  first  stage  and  anesthesia  with  gas  and 
oxygen  or  ether  and  oxygen  in  the  second  stage — 
together  with  the  judicious  use  of  forceps  when  the 
head  is  below  the  spines  supplemented  by  perine- 
otomy— we  can  have  a  fetal  mortality  of  between 
three  and  four  per  cent,  or  about  half  of  that 
reported  by  Potter. 

287  Clinton  Avenue. 


THE  COMPLETE  FORCEPS  OPERATION. 

By  Edward  P.  D.wis,  M.  D.,  F.  A.  C.  S., 
Philadelphia. 

Professor  of   Obstetrics,   Jefferson    Medical  College. 

If  the  histories  were  taken  of  patients  who  had 
had  bad  deliveries  followed  by  worse  recovery, 
usually  in  private  practice,  and  if  these  histories 
were  analyzed,  it  would  be  found  that  in  many  cases 
the  circumstances  were  essentially  as  follows : 
There  may  have  been  slight  disproportion  between 
mother  and  child,  or  failure  in  the  development  of 
the  natural  forces  of  labor.  From  whatever  cause 
the  mother  failed  to  deliver  herself  and  assistance 
was  required ;  with  the  help  of  a  trained  nurse  only 
or  possibly  without  such  assistance,  the  attending 
physician  anesthetized  the  patient  and  delivered  her 
by  forceps.  There  was  more  or  less  laceration,  for 
which  an  attempt  was  made  at  repair.  The  circum- 
stances were  such  that  this  was  not  done  in  a  man- 
ner satisfactory  to  the  physician,  for  a  tendency  to 
postpartum  hemorrhage  developed  in  the  patient, 
and  it  was  necessary  to  check  that  as  soon  as 
possible.  The  child  was  injured  somewhat,  but 
apparently  no  permanent  results  followed  these 
injuries. 

Convalescence  in  this  case  was  prolonged,  tem- 
perature was  higher  than  normal,  and,  while  the 
mother  nursed  her  child,  her  recovery  was  not  com- 
plete. Some  time  afterward,  it  was  found  upon 
examination  that  considerable  tear  of  the  cervix  had 
occurred  which  had  not  completely  healed,  and  that 


the  repair  of  the  pelvic  floor  and  perineum  had  not 
been  completely  successful.  For  this,  secondary 
operation  was  required,  and  in  all  between  one  and 
two  years  passed  before  the  woman  recovered  some- 
thing like  her  previous  health.  In  other  cases  there 
is  the  distinct  history  of  postpartum  hemorrhage 
after  such  delivery,  or  of  well  defined  puerperal 
septic  infection. 

If  these  histories  are  analyzed,  it  is  found  that 
the  primary  cause  of  the  unsatisfactory  result  did 
not  lie  with  the  inefficiency  or  neglect  of  the  attend- 
ing physician.  He  possessed  such  average  knowl- 
edge and  operative  skill  as  the  law  demands ;  he 
took  such  precautions  as  he  could  to  make  his 
operation  aseptic.  The  nurse  had  been  properly 
trained  and  did  her  work  as  carefully  as  circum- 
stances permitted.  Two  factors  caused  the  bad 
result.  One  was  delay  in  delivery,  for  the  general 
practitioner  frequently  does  not  recognize  symp- 
toms of  threatened  exhaustion,  but  waits  until  the 
patient  is  thoroughly  tired  before  interfering.  The 
second  factor  was  insufficient  appliances  and  as- 
sistance and  an  incomplete  and  a  nonsurgical  opera- 
tion. The  circumstances  were  such  that  an  aseptic 
technic  could  not  be  thoroughly  carried  out  and 
efforts  at  checking  hemorrhage  and  repair  were  not 
carried  out  in  a  thoroughly  efficient  manner. 

How  can  better  results  be  obtained?  Must  the 
profession  be  content  with  such  procedures?  The 
most  important  factor  in  all  discussion  relative  to 
obstetrical  practice  is  the  question  as  to  whether 
obstetrical  practice  should  be  put  on  the  same  pro- 
fessional level  as  surgical  practice.  So  long  as 
obstetrics  is  considered  essentially  the  practice  of 
midwives,  and  so  long  as  complications  in  obstetrical 
cases  receive  adequate  attention  as  a  last  resort  only, 
no  improvement  can  be  expected.  When  cases  of 
abnormal  labor  are  treated  by  obstetricians  in 
properly  equipped  hospitals,  or  when  the  obstetrician 
takes  to  the  private  house  the  necessary  equipment 
for  good  work,  then,  and  then  only,  will  substantial 
improvement  occur.  In  suggesting  what  can  be 
done  in  this  matter,  I  advance  no  theory.  I  merely 
state  what  has  been  done  in  my  personal  experience 
and  observation. 

It  is  most  important  that  signs  of  approaching 
exhaustion  be  detected  by  nurse  and  physician  be- 
fore the  patient  reaches  a  point  where  haste  may  be 
necessary.  Medical  teaching  should  emphasize  this 
fact.  When  interference  is  imperative,  it 'must  be 
remembered  that  a  vagina'  operation,  whereby  hands 
or  mstruments  are  passed  from  without  into  the 
uterus,  cannot  be  a  strictly  aseptic  procedure.  In 
the  present  state  of  our  knowledge,  or  ignorance, 
it  is  practically  impossible  to  invade  the  uterus 
tlirf)ugh  the  vagina  without  introducing  bacteria. 
In  carrying  out  the  principles  of  surgery,  the 
operator  must  remember  that  in  such  cases  drain- 
age cannot  be  neglected.  Normally  the  genital 
track  drains  after  labor  by  intermittent  uterine  con- 
traction and  by  gravity.  When  interference  is 
practised,  these  factors  must  be  more  than  usually 
developed  and  additional  precautions  must  be  ta.cen. 

No  more  efficient  cause  exists  for  the  develop- 
ment of  septic  infection  than  hemorrhage  preceding 
or  accompanying  an  operation.    Hence,  to  conduct 


November  13,  1920.] 


DAVIS:   COMPLETE  FORCEPS  OPERATION. 


757 


an  obstetrical  operation  upon  surgical  principles, 
the  operator  must  see  to  it  that  precautions  are  taken 
to  avoid  hemorrhage  and  to  secure  necessary  drain- 
age. To  bring  these  observations  into  a  concrete 
form,  the  following  technic  has  been  successfully 
practised  for  a  considerable  period  of  time : 

A  thorough  examination  of  each  patient  and  as 
careful  and  complete  a  history  as  possible  will  show 
the  shape  and  size  of  the  birth  canal,  the  strength 
and  development  of  the  mother,  and  approximately 
the  size  of  the  child.  With  these  data  symptoms 
of  exhaustion  in  labor  are  carefully  watched  for 
and  recognized  as  soon  as  possible.  The  forceps 
delivery  is  never  attempted  unless  the  head  is  well 
engaged  and  the  birth  canal  dilated  or  practically 
dilatable.  It  is  unnecessan,-  to  give  details  of  hos- 
pital technic.  In  operating  in  private  houses  a 
portable  sterilizer  is  necessary.  Gowns,  dressings, 
and  other  appliances  may  be  sterilized  in  a  hospital 
and  taken  to  a  private  house,  carefully  protected 
from  contamination.  Boiled  water  and  antiseptic 
fluids  can  be  procured.  A  kitchen  table,  suitably 
prepared,  makes  a  good  operating  table.  Such 
matters  of  aseptic  technic  as  are  necessary  can 
readily  be  managed,  provided  the  operator  is  willing 
to  take  the  trouble  and  give  the  attention  to  the 
problem. 

It  is  especially  important  that  a  competent  anes- 
thetist, who  has  had  obstetrical  experience,  and  an 
additional  nurse  be  at  hand.  Ether-oxygen  is 
the  anesthetic  of  choice,  and  in  giving  anesthesia 
for  such  an  operation,  obstetrical  experience  will 
indicate  when  the  anesthetic  is  to  be  pushed  and 
when  its  administration  may  be  relaxed.  Further- 
more, the  obstetrical  anesthetist  must  b"e  competent  to 
observe  with  his  hand  the  contractions  of  the  uterus 
and  the  downward  passage  of  the  child.  He  must 
also  be  able  to  take  charge  of  the  patient  imme- 
diately after  delivery,  watch  her  general  condition, 
and  recognize  symptoms  of  threatened  shock  or 
hemorrhage. 

The  additional  nurse  should  have  had  experience 
with  the  individual  operator.  She  should  have 
charge  of  his  instruments  and  appliances,  be  re- 
sponsible for  their  condition  and  sterilization,  and 
be  able  to  assist  in  the  operation.  The  nurse  who 
has  charge  of  the  patient  will  have  enough  to  do 
in  the  general  care  of  the  mother  and  the  infant. 

Elaborate  appliances  are  unnecessary.  The  legs 
of  the  patient  can  be  held  in  position  by  the  use  of 
a  folded  sheet,  and  it  is  not  the  number  or  elaborate 
character  of  instruments  or  appliances  which  is  of 
value,  but  the  judgment  and  skill  of  the  operator, 
the  fact  that  he  places  his  patient  under  the  best 
possible  conditions  for  operation  and  that,  in  justice 
to  himself,  he  has  adequate  assistance. 

It  is  not  my  purpose  to  describe  delivery  by  for- 
ceps. Attention  is  directed,  however,  toward  what 
should  be  done  after  the  delivery  of  the  child.  The 
uterus,  having  been  invaded,  may  be  considered  as 
possibly  infected.  Sufficient  time  should^  elapse  after 
the  birth  of  the  child  before  an  attempt  is  made  to 
deliver  the  placenta.  Should  hemorrhage  begin,  this 
should  be  done  at  once  by  the  introduction  of  the 
gloved  hand.  If  conditions  are  favorable,  the  opera- 
tor may  wait  from  ten  to  twenty  minutes  with  the 


patient  partially  anesthetized  before  delivering  the 
placenta.  If  the  hand  is  introduced,  it  is  well  to 
note  the  location  of  the  placenta  as  a  guide  for 
further  procedure. 

The  uterus  having  been  emptied,  strychnine  and 
aseptic  ergot  should  be  given  b^-  hypodermic  injec- 
tion. The  uterus  should  be  irrigated  with  one  per 
cent,  lysol  solution  and  thoroughly  packed  with  ten 
per  cent,  iodoform  gauze.  After  trying  various 
ways,  I  have  discarded  specula  and  tenaculum  for- 
ceps and  introduce  the  gauze  with  the  left  hand, 
while  the  right  hand  places  the  gauze  in  the  fingers 
of  the  left  and,  by  pressure  on  the  uterus,  aids  in 
placing  the  gauze  accurately.  We  have  found  by 
observation  that  the  recently  emptied  average  uterus 
will  contain  and  retain  a  strip  of  gauze  nine  inches 
wide  and  four  yards  long.  Where  relaxation  is 
threatened,  more  may  be  required ;  in  rare  cases, 
less  is  used.  The  advantage  of  this  procedure  is 
its  tendency  to  prevent  postpartum  hemorrhage  and 
the  fact  that  the  gauze  acts  as  an  efficient  antiseptic 
drain.  _ 
Following  the  introduction  of  the  gauze,  the  cer- 
vix is  drawn  down  by  tenaculum  forceps,  inspected, 
and,  if  torn,  the  lacerations  are  closed.  No.  2  chro- 
micized  catgut  is  employed.  The  cervix  is  then 
released,  the  uterus  carried  forward  in  the  pelvic 
cavity,  the  cervix  pressed  backward  by  aspetic 
gauze  packed  in  the  upper  vagina  and  the  uterus  is 
watched  by  the  hand  of  the  anesthetizer.  The  pel- 
vic floor  and  perineum  are  then  inspected.  The 
lacerations  are  closed.  In  the  majority  of  cases  in 
primiparje  the  median  incision  will  greatly  lessen 
injury  to  the  pelvic  floor  and  perineum.  The  gauze 
is  then  removed  from  the  vagina  and  a  vaginal 
douche  of  one  per  cent,  lysol  is  given.  A  strip  of 
bichloride  gauze  is  then  tied  to  the  end  of  the  iodo- 
form gauze  within  the  uterus  and  the  cervix  is 
carried  backward  and  the  uterus  put  in  normal 
position  by  this  moderate  vaginal  packing  of  bichlo- 
ride gauze.  If  the  patient  requires  stimulation, 
this  should  be  given  by  hypodermic  injection  before 
she  leaves  the  operating  table.  In  cases  where  it 
is  desirable  to  leave  the  patient  undisturbed  so  long 
as  possible,  she  should  be  catheterized  twice,  just 
before  the  operation  and  at  its  conclusion. 

It  may  be  urged  in  criticism  that  this  is  meddle- 
some midwifery;  that  in  many  cases  all  that  is 
needed  is  to  extract  the  head  and  that  such  a  pro- 
cedure is  more  dangerous  than  beneficial.  So  long- 
as  human  beings  remain  as  they  are  now,  it  will 
always  l:ie  possible  to  say  that  if  a  physician  had 
not  interfered,  a  different  result  might  have  oc- 
curred. We  can  only  reason  from  a  considerable 
experience  and  avail  ourselves  also  of  the  recorded 
experience  of  others.  Meddlesome  midwifery  con- 
sists in  repeated  vaginal  examinations,  infrequent 
and  futile  attempts  to  dilate  the  cervix  and  in  un- 
successful application  of  the  forceps. 

A  very  practical  question  would  indicate  that 
such  a  procedure  might  be  followed  by  the  develop- 
ment of  septic  infection.  After  a  considerable  per- 
sonal experience,  both  in  private  and  hospital  prac- 
tice, and  with  the  accumulated  experience  of  those 
who  work  with  me.  it  has  been  shown  that  this  is 
not  the  case. 


758 


LAXGSTROTH:  PELVIC  IXFECTIOX. 


[New  York 
Medical  Jourmal^ 


\\  e  have  yet  to  find  a  case  in  whicli  it  could 
be  shown  that  septic  infection  has  developed  in 
the  patient  following  this  procedure.  Our  experi- 
ence indicates  that  this  is  beneficial  and  successful 
in  preventing  relaxation,  hemorrhage  and  infection 
and  in  securing  primary  union  of  lacerations  and 
in  promoting  complete  recovery  of  the  patient.  It 
is  also  of  some  importance  that  under  such  precau- 
tions an  accurate  and  proper  application  of  the 
forceps  to  the  child's  head  is  more  readily  made 
than  when  the  operator  is  at  a  disadvantage  and 
also  that  those  precautions  which  protect  the  mother 
from  infection,  give  like  protection  to  the  child. 

In  aftertreatment  the  gauze  is  removed  in  from 
thirt}--six  to  forty-eight  hours.  If  the  upper  gauze 
is  dry  and  clean  on  removal,  it  is  unnecessary  to 
irrigate  the  uterus.  If  there  are  particles  of  decidua 
or  membranes  on  the  gauze,  it  is  well  to  irrigate 
the  uterus  with  one  per  cent,  lysol  solution.  Xo 
other  douching  is  practised.  After  the  operation 
tonic  doses  of  strychnine  are  given,  to  which  some 
form  of  digitalis  is  added,  if  needed.  In  our  experi- 
ence, afterpains  are  caused  by  faulty  contraction  of 
the  uterus  and  the  presence  of  clots.  It  has  been 
interesting  to  observe  that  under  this  method  pain 
after  deliver}-  is  rare.  After  the  removal  of  the 
gauze,  strychnine  and  ergot,  in  moderate  doses,  are 
given  for  a  week  or  ten  da3's.  External  stitches 
are  removed  in  from  seven  to  ten  days ;  internal 
catgut  stitches  are  absorbed. 

An  interesting  and  natural  question  arises.  Will 
patients  pay  for  the  trouble,  attention,  skill  and 
expense  which  such  a  procdeure  involves,  in  hos- 
pital or  in  private  houses?  The  anesthetist  must 
receive  compensation,  and  the  whole  procedure  calls 
for  more  expense  than  the  public  expect  in  an 
ordinary  case.  Under  the  usual  circumstances,  physi- 
cians realize  that  they  will  receive  for  their  services 
only  such  compensation  as  the  profession  asks  and 
as  people  under  ordinary  circumstances  are  willing 
to  give.  For  years  the  profession  has  held  ob- 
stetrical practice  to  be  the  cheapest  sort  of  medical 
work,  and  the  public  have  held  that  as  the  produc- 
tion of  the  child  is  thought  to  be  a  natural  process, 
therefore  it  should  be  cheap.  !Much  of  the  injus- 
tice and  negligence  of  the  present  can  be  traced  to 
these  two  causes.  At  present  the  majority  of 
patients  on  first  confinem.ents  go  to  hospitals.  All 
of  them  should  do  so.  All  patients,  whether  in  first 
or  other  labors,  in  whom  there  is  any  reason  to 
suspect  complications,  should  be  sent  to  hospitals 
for  their  confinement. 

If  it  is  necessary  to  operate  in  private  houses,  it 
should  be  distinctly  made  clear  that  the  operation  is 
as  difficult,  responsible,  and  expensive  as  the  removal 
of  the  appendix  or  the  removal  of  a  complicated 
ovarian  cyst  would  be  in  a  private  house.  Payment 
will  be  made  for  the  removal  of  an  appendix  or 
cyst  because  it  is  not  believed  the  appendix  or  cyst 
will  return.  If  a  higher  value  can  be  placed  on 
human  life,  the  public  may  be  brought  to  believe 
that  it  might  be  well  to  pay  adequately  for  the 
safe  removal  from  the  body  of  a  mother  of  a  child, 
although  there  may  be  others  later.  The  mother's 
health  is  also  of  value. 

250  South  Twenty-first  Street. 


SEVERE  PELMC  IXFECTIOX  FOLLOWING 
HYSTERECTOMY. 

Report  of  a  Case  Where  Radium  Had  Been  Used 
Two  Weeks  Before  Operation. 

By  Francis  Ward  Langstroth,  Jr..  M.  D.. 
Xew  York, 

Consulting  Gynecologist  to  the  New  Jersey  State  Hospital,  Trenton. 

The  time  when  the  report  of  a  single  case  history 
could  have  any  interest  to  the  medical  profession  is 
long  since  passed.  We  think  in  big  figures  these 
days,  and  do  things  in  a  large  way.  However,  it 
would  seem  that  an  intensive  study  of  a  case  illus- 
trative and  suggestive  of  so  many  diverse  aspects 
might  be  a  source  of  fruitful  thought  not  only  to 
those  who  devote  their  time  so  largely  to  gyne- 
cology and  obstetrics,  but  also  to  those  in  general 
practice.  The  case  here  reported  seems  to  bring 
before  us  clearly  the  following  gynecological  needs 
and  problems : 

1.  The  extreme  importance  of  surgical  judg- 
ment at  the  time  of  the  first  operation,  so  that  gyne- 
cology is  not  subjected  to  disrepute  and  ill  fame, 
by  the  unnecessary  need  of  an  almost  immediate 
secondary  operation  for  conditions  which  existed, 
and  whose  cause  existed,  at  the  time  of  the  first  op- 
eration. 

2.  That  a  focal  infection  of  the  cervix  will  al- 
ways continue  to  be  the  cause  of  further  trouble 
until  it  is  completely  eradicated,  as  has  been  pointed 
out  by  Sturmdorf  (1  to  5),  myself,  and  others. 

3.  The  importance  of  a  more  careful  diagnosis 
of  cancer  before  much  dependence  can  be  placed 
upon  reported  cases  of  improvement  from  the  use 
of  radium  treatment. 

4.  Can  the  use  of  radium  cause  the  lighting  up 
of  a  subacute  or  chronic  pelvic  inflammation  into  an 
acute  one,  as  Graves  (6)  suggests? 

5.  How  long  should  we  wait  before  operating 
after  radium  has  been  used  in  cases  of  pelvic  in- 
fection ? 

Case. — !Miss  W.,  aged  thirty-seven ;  past  historj' 
and  family  history  were  negative,  except  for  ap- 
pendectomy twelve  years  ago.  Present  trouble 
started  about  a  year  ago,  and  consisted  of  severe 
pain  in  the  abdomen  at  times,  which  the  patient  said 
was  not  always  in  the  same  place.  About  six  months 
ago  the  patient  was  operated  upon  for  some  pehac 
condition  at  a  hospital  in  St.  Paul.  She  was  better 
for  about  two  months  and  then  the  pain  returned. 
The  history  of  the  previous  operation  was  not  very 
complete,  but  the  diagnosis  from  that  hospital  was 
"right  OA"arian  cyst  and  double  hydrosalpinx."  The 
report  of  the  operation  was  "double  salpingectomy, 
ovariotomy  and  removal  of  cyst."  After  this  first 
operation  the  patient  had  a  slight  amount  of  fever 
for  several  days  without  a  wound  infection.  This 
rise  in  temperature  was  probably  due  to  a  mild  pel- 
vic infection.  The  patient  was  referred  to  me  in 
]May,  1920,  by  her  physician.  Dr.  Thelberg.  on  ac- 
count of  the  return  of  the  pain  in  the  right  side. 
This  pain  was  worse  at  the  time  of  her  menstrual 
period.  Pelvic  examination  disclosed  an  irregular, 
firm  mass  rather  low  down  in  the  right  pelvis,  which 
was  only  moderately  sensitive  to  pressure.  The 
uterine  bodv  was  normal  in  size  and  consistency. 


November  13,  1920.] 


LANGSTROTH:  PELVIC  INFECTION. 


759 


but  was  displaced,  either  by  this  mass  or  from  ad- 
hesions, to  the  patient's  left  side.  Inspection  of  the 
cervix  showed  a  nonlacerated  but  markedly  infected 
cervix  from  which  an  almost  mucopurulent  dis- 
charge was  issuing.  A  diagnosis  was  made  of  cystic 
right  ovary  which  had  been  left  at  the  time  of  the 
previous  operation,  and  an  infected  cervix.  Oper- 
ation was  advised  and  good  prognosis  offered.  The 
patient  did  not  act  upon  this  advice  but  consulted 
several  other  surgeons  who,  I  understand,  consid- 
ered the  condition  a  recurrent  cystoma.  She  then 
had  one  application  of  radium  to  the  right  external 
abdominal  wall.  About  two  weeks  later  the  patient 
returned  and  again  sought  my  advice,  and  was 
again  advised  to  allow  me  to  operate  upon  her.  The 
patient  entered  the  hospital  on  May  4,  1920.  Physical 
examination  was  negative  except  for  the  patient's 
pelvic  condition.  The  uranalysis  showed :  Color 
yellow,  appearance  slightly  cloudy,  reaction  acid, 
specific  gravity  1,032,  no  albumin,  no  sugar,  no  in- 
dican,  no  acetone,  no  crystals,  no  casts,  many 
squamous  cell  epithelium,  few  pus  cells.  Repeated 
examinations  of  her  urine  all  showed  similar  find- 
ings, except  for  slight  trace  of  albumin  after  the 
operation. 

Operation :  Surgeon,  Dr.  Langstroth ;  anesthetist. 
Dr.  Coburn ;  anesthetic,  gas-oxygen-ether  qs.  nitrous 
oxide-oxygen.  Hysterectomy,  begun  at  9.15  a.  m. 
and  finished  at  11.15  a.  m.  The  left  tube  and  ovary 
were  missing  and  a  peculiar  thickened  inflammatory 
condition  of  all  the  pelvic  tissues  was  noted.  The 
appearance  of  the  tissues  while  hard  to  describe, 
differed  from  that  of  ordinary  subacute  inflamma- 
tion of  these  tissues.  A  multiple  cystic  right  ovary 
was  found.  This  was  bound  down,  back  of  the 
uterus,  with  inflammatory  adhesions.  The  tube  and 
uterus  were  involved  in  adhesions  so  it  was  thought 
best  to  remove  the  whole  mass,  supravaginall3\ 
The  cysts  contained  what  appeared  to  be  clotted 
blood,  but  may  possibly  have  been  corpus  luteum 
cysts.  The  endometrium  of  the  cervix  was  cored 
out  from  above  in  order  to  remove  this  infected 
tissue,  and  a  drain  was  left  through  the  cervical 
stump.  The  abdomen  was  closed  in  the  usual  man- 
ner. The  condition  of  the  patient  at  the  end  of  op- 
eration showed  respiration  20,  and  pulse  120. 

REMARKS. 

The  case  was  not  inoperable  in  the  sense  that 
there  was  any  outgrowth  of  malignant  tissues  into 
the  pelvic  tissues  and  there  was  no  reason  to  expect 
any  return  of  the  trouble.  An  examination  of  the 
specimen  showed  the  tube  to  be  thickened  and  in- 
flamed, otherwise  negative,  and  the  uterus  normal. 
In  the  rest  of  the  mass  there  was  nothing  to  sug- 
gest a  malignant  condition.  It  was  not  malignant 
in  the  sense  of  being  a  solid  sarcoma,  or  carcinoma 
of  the  ovary ;  however,  as  many  of  these  cysts  are 
of  an  adenocarcinomatous  type,  a  specimen  was 
sent  to  the  laboratory  for  microscopical  diagnosis. 
A  report  of  the  microscopical  examination  showed 
that  there  was  no  reason  to  expect  any  second  or 
malignant  growth  in  this  case. 

This  patient  started  to  show  a  septic  temperature 
almost  immediately  after  the  operation.  The  first 
day  at  4  p.  m.  it  reached  100.1°  F.,  the  following 
afternoon  at  4  p.  m.,  102.1°  F.    On  the  fourth  af- 


ternoon, however,  it  was  only  100.2°  F.,  and  on 
the  morning  of  the  fifth  day  it  was  98.2°.  The 
packing  was  removed  at  this  time,  and  the  tempera- 
ture went  up  to  nearly  102°  in  the  afternoon.  At 
this  time  the  patient  complained  of  some  pain  in 
the  lower  abdomen.  Examination  disclosed  rigidity 
of  the  abdominal  muscles.  The  following  day  the 
temperature  in  the  afternoon  was  again  101.5°.  A 
mass  was  now  discernible  above  the  pelvic  brim  and 
it  was  seen  that  we  had  to  deal  with  a  large  pelvic 
abscess.  The  patient's  condition  remained  about  the 
same,  and  it  was  thought  best  to  allow  the  abscess 
to  become  well  walled  off  before  operating.  On 
May  17th,  thirteen  days  after  the  first  operation, 
the  dulness  had  reached  above  the  umbilicus,  and  it 
was  decided  to  operate  at  this  time. 

Operation :  Surgeon,  Dr.  Langstroth ;  anesthet- 
ist. Dr.  Coburn ;  anesthetic,  gas-oxygen-ether  q.s. 
(grams  iv).  The  abdomen  was  opened  and  a 
cervical  drain  inserted,  and  a  large  amount  of 
pus  was  evacuated  from  both  the  abdomen  and 
the  cervix.  Rubber  drains  were  inserted  in  the  ab- 
domen.   Immediate  operative  recovery  was  good. 

The  patient  from  this  time  on  made  a  tedious, 
but  progressive,  recovery,  the  only  real  setback  be- 
ing a  slight  pleurisy  with  effusion  which  cleared  up 
without  drainage  being  necessary.  On  June  16th 
the  patient  was  examined  by  Dr.  Satterlee,  who  re- 
ported her  to  be  normal  except  for  a  few  rales  at 
the  right  base  posteriorly  and  some  dulness  in  the 
same  area.  On  June  18th,  according  to  the  hospital 
record,  there  was  a  very  moderate  discharge  from 
the  wound  and  the  patient  was  greatly  improved  in 
every  way.  On  June  30th,  the  patient,  who  had 
been  walking  about  the  ward  for  nearly  a  week, 
went  home.  At  the  present  time  of  writing  the 
patient  is  in  the  best  of  health. 

The  first  point  which  we  wish  to  consider  in 
studying  this  case  is  the  importance  of  correct  sur- 
gical judgment  in  connection  with  gynecological 
operations,  in  order  that  secondary  operations  may 
become  necessary  less  frequently,  and  at  the  same 
time  we  shall  consider  the  second  point  of  impor- 
tance in  this  case,  i.  e.,  that  infections  of  cervical 
endometrium  are  responsible  for  most  of  the  dis- 
eased conditions  in  the  tubes  and  ovaries. 

As  has  been  pointed  out  by  Sturmdorf  (1)  and 
others,  cystic  conditions  of  the  ovary  follow  infec- 
tive endocer^icitis  very  frequently.  In  fact,  the 
writer  is  now  convinced  that  this  condition  is  the 
usual,  if  not  the  only,  cause  of  simple  follicular 
and  corpus  luteum  cysts  of  the  ovary.  We  do  not 
yet  know  if  these  infections  act  in  causing  cystoma 
of  the  ovary,  either  the  simple  multilocular  cystoma 
or  papuliferous  cystoma,  which  are  probably  due  to 
an  epithelial  hyperplasia,  although  it  is  reasonable 
to  suppose  that  the  endocervical  infection  may  act 
as  the  chronic  irritant  which  induces  this  epithelial 
proliferation.  The  infection  from  an  endocervicitis 
spreads  up  through  the  lymphatics  of  the  cervix, 
uterus  and  broad  ligament,  thus  reaching  the  ovary. 
'There  it  may  cause  a  thickening  of  the  tunica  albu- 
ginea  delaying  or  preventing  the  rupture  of  Graafian 
follicles,  thus  producing  cystic  conditions  of  the 
ovary  and  causing  many  of  the  menstrual  disorders 
which  are  so  common  in  this  class  of  patients. 


760 


CUMSTOX:  PUERPERAL  INFECTION. 


[New  York 
Medical  Journal. 


In  the  case  under  discussion  we  had  to  deal  with 
severe  chronic  endocervical  infection,  so  that  it  was 
only  reasonable  to  expect,  if  much  ovarian  struc- 
ture was  left  after  the  first  operation,  that  it  would 
still  be  subject  to  cystic  disease  of  the  unruptured 
Graafian  follicular  t3-pe.  The  writer  believes  that 
if  the  infected  cervical  endometrium  had  been  re- 
moved at  the  first  operation  this  patient  would  have 
remained  well. 

Let  us  next  consider  briefly  the  question  of  diag- 
nosis. As  stated  in  the  history,  the  patient  had  been 
operated  upon  about  four  months  previous  for  the 
removal  of  a  cystic  ovary  and  a  resection  of  the 
other  ovary.  The  only  point  not  clear  was  which 
OA-ary  had  been  entirely  removed.  The  pelvic  ex- 
amination disclosed  a  firm  moderately  sensitive 
nodular  mass  in  the  right  pelvis,  which,  although 
adherent,  did  not  seem  to  blend  at  all  with  the  sur- 
rounding tissue,  but  could  be  freely  outlined.  It 
caused  severe  pain  only  at  the  time  of  menstruation. 
Taking  into  consideration  the  fact  that  the  patient 
also  had  a  badly  infected  cervix,  was  it  not  reason- 
able in  the  Hght  of  our  present  knowledge,  to 
suppose  that  a  cystic  condition  existed  in  the 
remaining  ovary  and  that  this  condition  should  have 
been  considered  a  nonmalignant  ovarian  cyst,  since 
the  patient's  general  condition  was  good,  she  had 
not  lost  much  weight,  and  had  no  symptoms  of  peri- 
toneal or  bowel  involvement,  neither  did  she  appear 
cachectic.  Diagnosis  of  nonmalignant  ovarian  cyst 
was  confirmed  by  microscopical  findings  of  the  re- 
moved ovary.  If  this  patient  had  not  returned  for 
operation  the  case  would  have  undoubtedly  been 
looked  upon  as  one  of  recurrent  malignant  ovarian 
cyst  cured  by  radium,  since  the  patient  probably 
would  have  lived  without  any  treatment  for  many 
vears  and  remained  in  a  fair  condition  of  health. 

^^'e  now  come  to  the  most  important  and  inter- 
esting consideration  in  this  case,  namely:  Can  the 
use  of  radium  light  up  a  subacute  or  chronic  pelvic 
inflammation  into  an  acute  one,  as  Graves  suggests  ? 
I  can  offer  very  little  information  on  this  point,  but 
call  attention  to  the  fact  that  I  have  noted,  during 
operation,  a  peculiar  swollen,  boggy  and  friable 
condition  of  the  pelvic  tissues,  different  from  any- 
thing I  have  encountered  in  chronic  pelvic  infec- 
tions. Graves's  article  had  not  then  been  published 
and  I  was  at  a  loss  to  explain  this  condition  which  I 
now  believe  to  have  been  due  to  the  action  of  radium 
on  the  old  chronic  pelvic  infection  from  which 
this  patient  had  suffered  for  a  long  time.  Graves, 
after  reporting  two  very  similar  cases,  says  (6)  : 
"The  injurious  influence  of  radium  on  chronic  in- 
flammatory pelvic  conditions  is  perhaps  the  most 
important  reason  why  in  the  extensive  clinical  use 
to  which  radium  is  destined  very  soon  to  be  put,  its 
employment,  in  gynecological  practice  at  least, 
should  be  limited  to  responsible  and  well  trained 
operators." 

In  answer  to  the  question,  how  long  should  we 
wait  before  operating  after  radium  has  been  used 
in  pelvic  cases,  it  is  difticult  at  this  time  to  express 
an  "opinion  of  any  value.  The  length  of  time  would, 
of  course,  depend  somewhat  upon  the  urgency  of 
the  case,  but  the  writer  would  suggest  that  as  long 
an  interval  as  possible  be  allowed  to  elapse.  The 


pelvic  abscess  in  one  of  the  cases  that  Graves  re- 
ports did  not  develop  for  six  mofiths  after  the  use 
of  radium  (Case  II  in  the  article  referred  to  above.) 

CONCLUSIONS. 

It  would  seem  that  we  were  justified  in  drawing 
the  following  conclusions  from  a  study  of  this  case : 

1.  The  chronic  cervical  infections  are  the  cause 
of  a  great  proportion  of  uterine,  ovarian  and  tubal 
disease,  and  often  cause  a  return  of  the  trouble,  if 
the  infected  cervical  endometrium  is  not  thoroughly 
removed. 

2.  The  cases  for  treatment  by  radiation  should 
be  selected  most  carefully  and  the  ultimate  outcome 
reported. 

3.  Operation  is  better  than  radiation  for  early 
or  doubtful  malignancies. 

4.  Operations  should  not  follow  radiation  ex- 
cept after  careful  consideration  of  the  case,  and 
then  only  when  absolutely  necessary. 

REFERENCES. 

1.  Sturmdorf,  Arnold:  Tracheoplastic  Methods  and 
Results,  Surgery,  Gynecology,  and  Obstetrics,  lanuary,  1916. 

2.  Idem:  Gxneplastic  Technology,  F.  A.  Davis,  Phila- 
delphia, 1919. 

3.  Langstroth  :  The  Treatment  of  Infections  of  the 
Uterus  and  Cervix,  Preliminary  Report  of  Seventy-five 
Cases,  Medical  Record.  June  28,  1919. 

4.  Idem:  Plastic  Conical  Enucleation  of  the  Cervix; 
Surgical  Indications  and  Clinical  Results  in  Seventy-five 
Cases,  Journal  of  the  Medical  Society  of  Nezv  Jersex,  Oc- 
tober, 1919. 

5.  Idem:  Preservation  of  the  Procreative  Function  in 
Women,  New  York  Medical  Journal,  June  5,  1920. 

6.  Graves,  W.  P. :  Radium  Treatment  of  Nonmalignant 
Uterine  Bleeding;  Some  Immediate  Aftereffects,  New 
York  Medical  Journal,  June  5,  1920. 


TREATMENT  OF  PUERPERAL  INFECTIOX. 

By  Charles  Greene  Cumston,  M.  D., 
Geneva,  Switzerland. 

I  wish  first  to  speak  of  a  treatment  for  puerperal 
sepsis  by  an  old  method  which  is  being  revived 
in  France  and  was  first  carried  out  by  Prof.  Fochier, 
of  Lyons,  some  thirty  years  ago.  I  refer  to  fixa- 
tion abscess.  The  success  of  this  procedure,  which 
is  undeniable  in  the  case  of  puerperal  infection,  de- 
pends upon  its  early  employment,  when  other  ordi- 
nary therapeutic  measures  have  failed.  An  impor- 
tant point  to  remember  is  that  when  an  abscess  does 
not  form  its  prognostic  value  is  a  hundred  per 
cent. ;  for  it  means  that  recovery  will  not  take 
place.  I  shall  not  take  up  space  with  statistics,  but 
would  say  that  out  of  a  total  of  132  cases  collected 
by  Cassedevant  an  abscess  formed  in  113,  with 
nine  deaths.  In  the  remaining  nineteen  cases  an 
abscess  did  not  result  and  only  two  patients  re- 
covered. The  total  percentage  of  recoveries  was, 
therefore,  seventy-seven. 

In  spite  of  these  figures,  and  many  other  similar 
ones  could  be  produced,  the  procedure  has  been 
neglected.  It  is  true  that  it  is  painful  but  this  is 
likewise  true  of  the  surgical  intervention  required  in 
puerperal  infection.  Energetic  treatment  can  alone 
give  results  in  serious  morbid  processes.  When  it 
is  objected  that  pain  and  suppuration,  being  de- 
pressing to  the  vitality,  should  cause  one  to  reject 
this  procedure  it  need  merely  be  remarked  that  when 


November  1.1.  1920.] 


KELLGREX-C 1  'RIA  X : 


VOMITIXG  OF  PREGXAXCY. 


761 


neither  suppuration  nor  pain  occurs  and  death  en- 
sues, recovery  will  take  place  when  the  injection 
causes  a  marked  local  reaction.  However,  on  ac- 
count of  the  violence  of  the  reaction  in  some  cases 
— severe  pain,  prolonged  suppuration  and  occasion- 
ally some  undermining — this  treatment  should  not 
be  resorted  to  without  reasonable  motive. 

The  question  of  contraindications  for  fixation  ab- 
scess requires  attention.  It  does  not  seem  that  the 
presence  of  albumin  has  any  bearing  against  its 
employment,  for  cases  of  recovery  are  recorded 
where  it  was  present  and  it  is  unlikely  that  the 
treatment  caused  it  to  appear.  On  the  other  hand, 
edema  should  be  regarded  as  a  contraindication  be- 
cause an  abscess  developing  in  these  circumstances 
will  give  rise  to  considerable  tissue  destruction  on 
account  of  its  low  vitality. 

The  indications  are  dedticed  from  the  form  and 
gravity  of  the  septic  process.  The  procedure  is 
useless  when  the  infection  is  confined  to  the  organs 
of  generation,  as  is  also  the  case  when  there  is  a 
generalized  peritonitis.  Septicemia,  and  especially 
pyemia,  are  the  two  processes  where  good  results 
may  be  looked  for.  The  time  at  which  resort  to 
fixation  abscess  should  be  had  is  somewhat  delicate 
to  decide  but  is  of  utmost  importance,  because  suc- 
cess depends  upon  the  early  application  of  the  treat- 
ment. There  are  no  definite  rules  to  go  by  and 
each  symptom  taken  by  itself  will  give  no  indica- 
tion. The  early  onset  of  the  infection,  a  temperature 
with  great  oscillations,  the  rapidity  of  the  pulse,  the 
dyspnea,  repeated  chills,  and  the  earthy  complexion 
are  all  sure  signs  of  gravity,  but  when  they  are  all 
present  the  infection  is  too  far  advanced  for  any 
treatment  to  be  effective.  When  proper  disinfection 
of  the  uterus  has  been  accomplished  by  modern 
means  and  the  infectious  phenomena  persist,  it  is 
better  practice  not  to  wait  too  long  for  a  hypo- 
thetical improvement.  There  are,  however,  certain 
types  of  subacute  pyemia  which  can  be  allowed  to 
run  and  in  these  cases  a  fixation  abscess  will  work 
wonders.  In  one  instance  the  treatment  was  given 
on  the  fifty-eighth  day  after  the  onset  of  the  infec- 
tion and  two  weeks  later  the  patient  was  discharged 
well.  In  another  instance  the  injection  was  given 
on  the  thirty-sixth  day  and  nevertheless  recovery 
was  rapid.  Therefore,  the  form  of  the  infectious 
process  must  be  taken  seriously  into  consideration; 
if  the  treatment  is  undertaken  too  early  it  may  be  a 
useless  interference,  but,  on  the  other  hand,  if  it  is 
resorted  to  too  late  it  will  not  save  the  patient.  Of 
the  two  mistakes  it  is  better  to  err  in  being  too  early 
in  ai)i)lying  the  treatment. 

It  was  Fochier's  practice  to  make  the  injection 
as  near  as  possible  to  the  focus  of  infection  in  order 
to  obtain  a  revulsive  action  as  well.  However,  the 
thigh  is  the  best  site  for  giving  it  and  this  appears 
to  be  the  consensus  of  opinion.  It  is  readily  ac- 
cessible and  the  dressings  can  be  easily  attended  to. 
The  same  cannot  be  said  of  the  flanks  because  the 
development  of  a  large  abscess  over  the  peritoneum 
is  not  without  danger  and  although  the  pus  is  ordi- 
narily sterile  it  occasionally  contains  endogenous 
bacteria.  Then,  too,  the  connective  tissue  being  very 
loose  here  extensive  undermining  may  occur.  Is  a 
single  injection  sufficient?    Yes.  if  the  abscess  de- 


velops well  and  an  amelioration  is  obtained.  In 
some  particularly  serious  cases  it  will  be  more  pru- 
dent, in  order  to  gain  time  should  reaction  be  de- 
layed, to  repeat  the  injection  at  the  same  spot  on 
the  next  day  or  a  little  later.  This  has  been  suc- 
cessful in  several  instances. 

The  quantity  of  turpentine  to  be  injected  should 
not  be  more  than  two  cubic  centimetres;  larger 
doses  do  not  appear  to  be  necessary  for  the  forma- 
tion of  the  abscess,  while  there  is  every  reason  to 
believe  that  in  predisposed  subjects,  larger  quantities 
of  turpentine  may  cause  trouble.  The  injection 
should  be  made  in  the  subcutaneous  connective  tis- 
sue with  all  aseptic  precautions.  Incision  of  the  ab- 
scess should  never  be  made  until  convalescence  is 
distinctly  established.  Once  incised  its  action  ceases 
so  that  until  the  patient  is  well  on  the  road  to  re- 
covery the  pus  must  be  allowed  to  remain.  It  is  also 
well  to  employ  coUargol  or  a  serum  at  the  same  time. 


TREATMENT  OF  PERSISTENT  VOMITING 
OF  PREGNANCY. 

By  Mrs.  Kellcrex-Cyriax,  L.R.C.P..  Edix., 
London. 

Up  to  the  present  none  of  the  methods  of  treat- 
ment of  persistent  vomiting  of  pregnancy  have  been 
so  successful  as  might  have  been  hoped.  I  therefore 
venture  to  think  that  it  may  be  of  interest  to  give 
my  experience  in  connection  with  the  mechanothera- 
peutics  for  the  condition,  as  I  have  by  their  use  at- 
tained very  good  and  rapid  results  in  several  cases. 

The  pathology  of  the  vomiting  of  pregnancy  has 
always  been  obscure.  From  time  to  time  various 
theories  as  to  its  cause  have  been  suggested,  the 
chief  ones  being,  a,  Toxemia ;  b,  stretching  of  the 
nerves  of  the  uterus ;  c,  reflex  irritation  of  the  gastric 
nerves  from  stimulation  of  the  abdominal  sympa- 
thetic induced  either  by  expansion  of  the  uterus  or 
a  tendency  for  that  organ  to  sink,  or  both.  Per- 
sonally I  have  always  inclined  toward  the  latter 
theory  and  have  been  led  to  this  conclusion  because : 
a,  The  drug  treatment  of  the  condition  is  generally 
unsuccessful ;  b,  the  vomiting  usually  ceases  when  the 
uterus  rises  above  the  pelvic  brim ;  c,  manipulations 
directed  toward  removing  the  pelvic  pressure  and  ir- 
ritation have  proved  efficacious  in  several  cases  in 
which  I  have  employed  them. 

The  actual  treatment  applied  is  based  upon  the 
late  Henrik  Kellgren's  modification  of  Ling's  sys- 
tem of  mechanotherapeutics,  and  consists  for  the 
condition  under  consideration,  of  the  following  man- 
ipulations : 

1.  Lifting  of  the  pelvic  organs.  The  patient 
should  be  placed  in  the  semirecunibent  position  with 
the  knees  straight  (technically  known  as  the  half 
lying  position).  To  have  the  patient  with  the  knees 
drawn  up,  i.  e.,  in  the  socalled  crook  half  lying  posi- 
tion, is  not  only  unnecessary  but  is  an  actual  dis- 
advantage, as  this  causes  the  pelvic  organs  to  slip 
back  somewhat  rendering  them  more  difficult  of  ac- 
cess through  the  abdominal  wall.  The  operator,  sit- 
ting to  the  right  of  the  patient  and  holding  his 
right  forearm  horizontal,  places  his  right  hand  just 


762  KELLGREK-CYRIAX:  VO 

above  the  symphysis  so  that  the  fingers  He  in  the 
left  iliac  region  just  above  Poupart's  ligament  and 
the  thumb  on  the  corresponding  spot  on  the  right 
side.  The  fingers  should  be  kept  flat,  i.  e.  nearly  fully 
extended  in  all  their  joints.  Employing  the  palmar 
surfaces  of  the  distal  phalanges  the  operator  gently 
works  down  on  either  side  of  the  uterus  until  they 
have  gently  closed  on  it,  and  then  executes  small  lift- 
ing movements  applied  with  simultaneous  vibrations 
(1  to  5)  ;  in  other  words,  vibrolif tings  in  an  upward 
direction.  These  should  not  be  applied  continuously 
but  intermittently  foir  about  ten  seconds  at  a  time 
followed  by  a  pause  of  a  few  seconds — this  is  re- 
peated during  a  period  of  about  ten  minutes.  If  the 
pregnancy  is  not  sufficienth-  advanced  to  enable  the 
operator  to  define  the  uterus  the  mere  fact  of  the 
manipulation  mentioned  above  when  applied  just 
above  the  pubis  will  make  itself  felt  upon  the  organ. 
The  immediate  effect  of  the  manipulation  is  that  the 
patient  experiences  a  feeling  of  wellbeing  and  relief 
of  the  existing  tension  in  the  pelvis.  Incidentally  it 
also  relieves  incontinence  of  urine.  As  regards  the 
possibility  of  performing  lifting  of  the  uterus  per 
vaginam,  I  have  never  had  recourse  to  it  as  I  have 
such  good  results  from  the  external  liftings  just 
described. 

2.  Stationary  manual  vibrations  applied  over  the 
stomach  itself,  paying  special  attention  to  any  par- 
ticularly tender  area ;  they  should  be  administered 
continuously  for  the  space  of  about  ten  minutes. 
They  have  the  eflfect  of  further  allaying  the  gastric 
irritation  that  is  present. 

3.  Frictions  applied  to  the  posterior  cervical,  dor- 
sal, lumbar  and  sacral  nerves  applied  for  the  space 
of  about  half  a  minute  (6  to  10.)  These  act  as  a 
general  nerve  tonic. 

4.  If  excessive  salivation  is  present  I  apply  gentle 
vibrations  to  the  parotid  and  submaxillary  glands 
which  usually  in  a  very  few  minutes  markedly  re- 
duce the  amount  of  secretion. 

The  following  cases  serve  as  illustrations : 
Case  I. — Mrs.  A.,  aged  thirty-two.  One  previ- 
ous pregnancy  with  normal  termination  ten  years 
ago.  When  I  first  saw  the  patient  she  was  in  the 
third  month  of  pregnancy ;  vomiting  had  com- 
menced four  weeks  previously  and  had  been  get- 
ting progressively  worse,  so  that  during  the  last  two 
weeks  she  had  been  vomiting  twelve  times  a  day 
or  oftener.  After  the  first  application  of  the  treat- 
ment she  only  vomited  three  times  during  the  course 
of  the  day  and  after  the  fourth  application  the 
vomiting  entirely  ceased.  The  treatment  was  ad- 
ministered on  three  subsequent  days  in  order  to 
prevent  a  relapse.    Normal  partus  six  months  later. 

Case  II.— Mrs.  B.,  aged  twenty-five;  neurotic 
subject,  in  the  sixth  week  of  her  first  pregnancy. 
Vomiting  had  commenced  about  a  fortnight  before 
and  had  rapidly  increased  in  severity  so  that  when 
I  first  saw  the  patient  she  could  not  even  look  at 
food  and  was  quite  weak  from  want  of  nourish- 
ment ;  she  was  vomiting  eight  to  ten  times  a  day. 
The  treatment  was  applied  on  twelve  successive 
days.  After  its  first  application  there  was  no  vomit- 
ing for  two  days,  then  once  a  day  on  the  third  and 
fourth  days,  after  which  there  was  complete  cessa- 
tion with  one  exception  ten  days  later,  in  spite  of 


ITING   OF  PREGNANCY.  [New  York 

Medical  Journal. 

the  fact  that  the  patient  had  to  work  very  hard 
moving  into  a  new  house.  Normal  partus  ensued 
later. 

Case  III. — Mrs.  C,  aged  thirty-seven.  The 
patient  was  a  healthy  subject;  she  had  had  two 
previous  children,  seven  and  five  years  ago,  respec- 
tively. During  both  pregnancies  she  suft'ered  from 
vomiting  (though  not  salivation)  through  their  en- 
tire duration ;  it  was  worse  during  the  first  three 
or  four  months  (vomiting  eight  times  a  day),  after 
which  it  became  better  (vomiting  only  twice  a  day). 
She  had  tried  all  the  usual  remedies,  none  of  which 
produced  even  temporary  amelioration.  During  the 
third  pregnancy,  vomiting  again  set  in  at  an  early 
stage  and  became  progressively  worse.  When  I 
first  saw  the  patient  she  was  in  the  thirteenth  week 
of  her  pregnancy.  She  had  sometimes  vomited  as 
much  as  twenty  times  a  day  with  simultaneous 
heartburn  during  the  second  and  third  month ;  this 
had  improved  somewhat,  but  she  still  vomited  about 
eight  times  a  day  and  had  continual  nausea.  Coin- 
cident, however,  with  the  improvement  in  the  vomit- 
ing, excessive  salivation  had  come  on  and  was  so 
severe  that  her  expectoration  filled  a  three  pint  jar 
five  times  during  the  course  of  the  day  and  she 
was  unable  to  speak  even  a  short  sentence  without 
having  to  expectorate.  In  conseq-uence  she  was 
compelled  to  partake  her  meals  alone  and  was  un- 
able to  see  either  friends  or  children.  Her  general 
condition  was  one  of  great  weakness ;  she  was  only 
just  able  to  walk  across  the  room.  The  fir.st  day 
I  saw  the  patient  she  had  already  vomited  three 
times ;  there  was  hypersensitiveness  in  the  epigas- 
trium and  the  submaxillary  glands  felt  hard  and 
shotty.  Treatment  was  applied  in  all  on  ten  suc- 
cessive days.  After  the  first  application  there  was 
only  one  vomit  during  the  ensuing  twenty-four 
hours  and  there  ensued  some  diminution  in  the 
amount  of  sahvation.  After  the  next  application 
vomiting  entirely  ceased  for  the  next  day  and  sali- 
vation rapidly  diminished,  ceasing  first  for  three 
and  then  for  six  hours  at  a  time ;  finally,  on  the 
eighth  day  after  coming  on  very  slightly  before 
breakfast,  it  became  normal.  At  the  close  of  the 
eighth  and  ninth  days,  both  very  fatiguing  for  the 
patient,  she  vomited  once.  By  this  time  there  was 
a  great  improvement  in  the  general  condition  and 
she  was  enabled  to  take  walks  and  traveled  home, 
this  entailing  a  railway  journey  of  several  hours' 
duration.  Her  general  condition  during  the  re- 
mainder of  the  pregnancy  was  better  than  during 
any  of  the  previous  ones.  A  slight  amount  of 
vomiting  occurred  about  once  a  week  during  the 
ensuing  month  and  the  confinement  was  normal  in 
every  respect. 

Case  IV. — IMrs.  D.,  strong,  healthy  subject  under 
ordinary  circumstances.  She  had  had  three  previ- 
ous children ;  during  her  first  pregnancy  she  vomited 
the  whole  of  the  nine  months,  during  the  last  two 
pregnancies  four  and  a  half  months.  All  the  ordinary 
remedies  had  proved  quite  unsuccessful.  When  I 
first  saw  the  patient  she  was  in  the  second  montlx. 
She  suffered  from  continual  severe  nausea  and 
had  been  vomiting  about  ten  times  a  day.  During 
the  vomiting  she  strained  so  much  t  lat  she  broke 
capillaries  in  the  face  and  neck  on  several  occa- 


November  13,  1920.] 


STEWART-COGILL:  PRENATAL  CARE. 


763 


sions.  She  was  unable  to  take  any  food  after  tea 
and  often  could  take  nothing  after  breakfast.  She 
was  very  weak,  had  not  left  her  room  for  six  weeks, 
and  had  become  very  emaciated.  After  the  first 
treatment  the  patient  felt  better  and  there  was  great 
diminution  of  the  nausea  and  she  only  vomited  once 
during  the  ensuing  twenty-four  hours.  The  next 
day  the  improvement  was  fully  maintained  and  she 
only  vomited  slightly  once.  xA.fter  the  fourth  treat- 
ment the  vomiting  was  in  abeyance  for  thirty-six 
hours  and  the  patient  felt  so  well  that  she  went  for 
a  short  walk.  On  the  fifth  day,  during  which  no 
treatment  was  applied,  she  vomited  once  in  the 
evening;  there  was  no  recurrence  on  the  following 
day.  During  the  seventh  day  she  was  able  to  eat 
some  food  in  the  evening  and  was  not  sick  though 
slight  nausea  ensued.  The  patient  received  seven 
more  applications  of  the  treatment;  the  vomiting 
did  not  return,  and  the  sensation  of  nausea  was 
practically  never  felt.  The  patient  felt  stronger 
every  day.  Four  months  later  there  had  been  no 
recurrence  of  the  vomiting  and  the  patient  felt  very 
well. 

REFEREN'CES. 

1.  CYViixx:  Arch.  gen.  d<:  ther.  phys.,  mo,  19:^9^. 

2.  Idem:  New  York  Medical  Journal,  1910.  xcii. 
171-175. 

3.  Idem:  International  Clinics,  1912,  xxii,  S,  i,  41-57. 

4.  Idem:  Edinburgh  Medical  Journal,  1913,  N.  S.,  xi, 
504-515. 

5.  Idem:  Medical  Press  and  Circular,  1914,  xcvii,  489-49, 
1915,  xcix,  291-294. 

6.  Idem:  New  York  Medical  JoL"R>iAL,  loc.  cit. 

7.  Idem:  International  Clinics,  loc.  cit. 

8.  Idem:  British  Journal  of  Children's  Diseases,  1914, 

xi,  155-167. 

9.  Idem:  Review  of  Neurology  and  Psychiatry,  1914. 

xii,  148-151. 

10.  Idem:  New  York  Medical  Tourkal,  1919,  xcii,  171- 
175;  1912,  xcvi,  897-899;  1917,  cvi,  "1021-1025. 


PRENATAL  CARE  FROM  THE  VIEWPOINT 
OF  THE  HOSPITAL. 
By  LiDA  Stewart-Cogill,  M.  D.,  F.A.C.S., 

Philadelphia. 

It  is  estimated  by  the  Children's  Bureau  at 
Washington,  D.  C,  that  in  the  United  States, 
sixteen  thousand  mothers  die  needlessly  each  j-ear 
from  childbirth,  and  two  hundred  and  fifty  thou- 
sand infants  are  lost  annuallv  in  the  first  week 
of  life. 

According  to  Snow's  statistics,  based  on  one 
hundred  million  population,  there  must  be  two  and 
a  half  million  births  annually  and  half  a  million 
abortions,  making  a  loss  to  our  population  of  three- 
fourths  of  a  million  a  year — largely  preventable  by 
better  obstetrics  and  prenatal  care. 

The  newborn  babe,  the  most  helpless  and  most 
precious  of  all  animals,  is  the  most  valuable  asset 
to  our  nation,  and  yet  the  medical  profession,  with 
all  its  knowledge  of  the  value  of  prenatal  care,  has 
been  silent  on  the  subject  or  evidenced  an  indif- 
ference which  is  quite  as  deplorable  and  discour- 
aging. But,  like  the  cause  of  prohibition  and  suf- 
frage, in  due  time  prenatal  care  is  bound  to  become 
a  popular  topic  and  a  vital  issue  of  the  day.   I  feel, 


however,  that  the  credit  should  be  given  the  pedi- 
atrists  for  bringing  this  subject  to  a  focus. 

It  is  said  that  the  index  to  a  city's  civic  pride  is 
determined  by  the  death  rate  among  its  babies.  Nat- 
urally the  pediatrists  have  been  interested  in  finding 
the  cause  of  the  high  infant  mortality,  and  after 
robbing  the  second  summer  of  its  terrors  and  solv- 
ing the  difficult  problem  of  infant  feeding,  the  rate 
still  being  too  high,  they  went  still  further  back  until 
they  found  themselves  in  the  obstetrician's  domain 
and  it  became  necessary  to  insist  that  the  high  death 
rate  among  infants  could  be  lowered  if  obstetricians 
would  do  more  prenatal  work.  They  showed  by 
statistics  that  the  majority  of  babies  dying  during 
the  first  year  of  life  did  so  before  reaching  the 
first  month  of  life,  and  that  seventy-five  per  cent, 
of  these  deaths  could  be  prevented  by  prenatal  care. 

A  supervisor  of  nurses  in  one  of  the  hospitals 
with  which  I  am  connected,  who  is  of  German 
birth  and  education,  remarked  to  me  that  she  had 
never  seen  anything  like  the  American  husband. 
It  seemed,  as  she  expressed  it,  as  if  he  could  not 
do  enough  for  the  comfort  of  his  wife ;  he  fairly 
carried  her  around  on  his  hands.  "We  have  nothing 
like  that  in  our  country,"  she  said.  We  American 
women  proudly  acknowledge  this  to  be  true,  that 
the  American  man  and  husband  cannot  be  excelled 
by  any  nation.  But  do  you  think  we  are  treating 
him  quite  fairly — he  who  is  so  anxious  to  have 
everything  done  for  the  best  interest  of  his  wife — 
in  keeping  him  in  ignorance  of  the  great  value  of 
prenatal  care  to  his  wife  and  child  ?  Or  quite  fair 
to  that  splendid  body  of  workers,  composed  of  a 
million  women,  who  in  two  years  turned  out  one 
hundred  million  dollars'  worth  of  surgical  articles 
and  garments  that  the  soldiers  fighting  for  democ- 
racy might  have  everj-thing  necessary  for  their 
welfare?  For  while  seventy  thousand  of  these 
faithful  soldiers  died  in  eighteen  months  of  war,, 
there  were  two  hundred  and  fifty  thousand  babies 
under  a  month  who  died  in  one  year,  and  seventy- 
five  per  cent,  of  these  deaths  were  due  to  prevent- 
able diseases. 

Of  all  the  Philadelphia  soldiers  who  were  engaged 
in  eighteen  months  of  war,  only  1,267  were  killed 
or  died  of  wounds,  while  according  to  the  Division 
of  Vital  Statistics  for  1918,  in  this  city,  5,366  babies 
died  who  were  under  a  year,  4,172  of  whom  were 
less  than  a  month  old,  which  means  that  over  four 
times  as  many  Philadelphia  babies  under  one  year 
of  age  died  in  a  year  (1918)  as  Philadelphia  sol- 
diers engaged  in  eighteen  months  of  war,  showing 
it  to  be  true  that  it  is  more  dangerous  to  be  a  baby 
under  one  year  of  life  than  to  be  a  soldier  in  the 
front  line  trench. 

According  to  the  Children's  Bureau,  the  United 
States  stands  fourteen*:h  on  the  list  of  sixteen 
civilized  nations,  in  its  maternal  mortality  at  child- 
birth, and  eleventh  on  the  list  in  its  infant  mortality 
for  the  first  year  of  life.  These  statistics  must  be 
kept  before  the  public  until  every  citizen  is  familiar 
with  them  and  realizes  his  duty  in  the  matter,  until 
the  banker,  the  broker,  and  the  business  man  are 
asking,  What  is  prenatal  care,  and  why  does  my 
wife  need  it?  and  until  newspapers  and  magazines 
have  properly  written  articles  on  the  subject.  When 


764 


STEIVART-COGILL: 


PRENATAL  CARE. 


[New  York 
Medical  Journal. 


x\merican  men  and  women  understand  that  a  large 
percentage  of  these  maternal  and  infant  deaths 
are  preventable,  do  you  think  they  will  allow 
such  frightful  wastage  of  life  to  go  on?  Never! 
I  feel  sure  when  they  fully  understand  the  need 
they  will  work  just  as  hard  to  see  that  the  mothers 
and  babies  receive  proper  attention  and  care  as  they 
did  for  those  soldiers. 

While  searching  for  words  with  which  to  express 
my  deep  feeling  in  regard  to  the  necessity  of  saving 
those  two  hundred  and  fifty  thousand  children,  and 
sixteen  thousand  mothers,  it  seemed  to  me  nothing 
could  be  more  beautifully  expressed  than  a  para- 
graph in  Mr.  Roosevelt's  article;  you  are  probably 
all  familiar  with  the  article,  but  permit  me  to  quote 
this  one  part;  "Alone  of  human  beings  the  good 
and  wise  mother  stands  on  a  plane  of  equal  honor 
with  the  truest  soldier ;  for  she  has  gladly  gone  down 
to  the  brink  of  the  chasm  of  darkness  to  bring  back 
the  children  in  whose  hands  rests  the  future  of  the 
years."  And  the  nation  should  by  action  mark  its 
attitude  alike  toward  the  fighter  in  war  and  the 
childbearer  in  peace  and  war. 

As  it  is  an  acknowledged  fact  that  prenatal  care 
is  the  greatest  factor  in  the  lowering  of  the  death 
rate  of  mothers  and  babies,  it  is  up  to  the  medical 
profession  to  depart  from  its  policy  of  silence  on 
this  subject,  and  present  a  constructive  platform 
for  the  furtherance  of  this  work,  which  will : 
1.  Arouse  the  community  to  the  need  for  more  pre- 
natal work.  2.  Educate  the  public  for  the  need  of 
supporting  institutions  doing  this  woriv.  3.  Arouse 
the  interest  and  enthusiasm  of  managers  of  institu- 
tions and  agencies  doing  this  work,  to  the  impor- 
tance of  having  a  budget  of  sufificient  size  for  a 
well  developed  social  service  department.  4.  And 
which  will  see  to  it  that  every  baby  enjoys  its  in- 
herent birthright  of  being  properly  born. 

There  is  no  better  place  in  which  to  demonstrate 
the  effect  of  prenatal  care  upon  maternal  and  infant 
mortality  and  morbidity  than  in  the  clinics  and 
wards  of  a  well  equipped  maternity  hospital,  where 
there  is  every  facility  for  the  proper  supervision, 
care  and  treatment  of  the  pregnant  woman,  from 
the  earliest  months  of  pregnancy  to  the  end  of  the 
puerperium.  With  a  properly  equipped  clinic, 
properly  kept  records  and  laboratory  facilities,  and 
an  enthusiastic  corps  of  workers,  composed  of  phy- 
sician, nurse,  social  worker  and  clerk,  wonderful 
results  can  be  secured,  but  there  must  be  a  co- 
operative spirit — without  this,  no  matter  what  the 
equipment  or  number  of  workers,  little  can  be 
accomplished. 

Crane  states:  "It  is  the  team  work  that  counts, 
not  the  individual  capacity  but  the  linked  capacity 
that  makes  a  group  efficient."  In  the  prenatal 
clinics  every  patient  must  be  encouraged  to  register 
as  early  in  pregnancy  as  possible,  and  attend  the 
clinic  at  stated  intervals,  the  minimum  being  every 
month  up  to  the  fifth  month,  every  two  weeks  until 
the  seventh  month,  and  then  be  seen  either  at  home 
or  in  the  clinic  every  week  until  delivery.  All  patients 
showang  toxic  symptoms  or  other  serious  complica- 
tions of  pregnancy,  which  are  not  yielding  to  treat- 
ment, must  be  admitted  to  the  maternity  hospital 
for  observation  and  treatment.    Every  patient  must 


have  a  thorough  physical  and  internal  examination. 
The  pelvic  measurements  must  be  taken  as  well 
as  auscultation  and  palpation  of  the  abdomen.  The 
blood  pressure  must  be  taken  at  each  visit,  also 
uranalysis.  The  Wassermann  test  must  be  done 
for  each  patient,  and  as  a  matter  of  routine  a 
microscopical  examination  made  of  the  cervix, 
vaginal  secretions,  and  Bartholinian  glands. 

Instructions  should  be  given  as  to  proper  food, 
clothing  of  self  and  infant,  exercise,  hygiene  of 
home,  care  of  nipples,  bowels,  and  avoidance  of 
miscarriage.  A  card  or  leaflet  should  be  given  to 
each  patient  containing  instructions  as  to  care  of 
self  and  child  and  the  significance  of  certain  dan- 
gerous symptoms,  such  as  those  of  toxemia,  bloody 
discharge,  and  others.  The  development  of  the 
child  in  proportion  to  the  pelvis  must  be  watched, 
also  cardiac  conditions ;  tuberculous  patients  must 
be  looked  after,  and  a  gradual  or  sudden  rise  in 
blood  pressure  must  put  us  on  guard  as  to  the  pos- 
sible development  of  a  toxic  condition.  The  patients 
showing  a  positive  Wassermann  test  must  be  placed 
under  proper  treatment,  also  those  suflFering  from 
gonorrhp.  The  social  worker  often  has  difficulty 
in  having  these  patients  attend  the  clinics  regularly 
for  treatment.  It  is  needless  to  state  the  earlier 
the  treatment  is  started  the  better  the  results  will 
be.  Without  a  social  worker  to  carry  out  follow- 
up  work,  little  can  be  accomplished.  Properly  kept 
records  and  the  proper  kind  of  records  are  essential. 

There  is  great  need  for  the  intensive  study  of 
the  mortality  from  childbearing.  The  mother  must 
be  under  complete  supervision  before  labor,  after 
labor,  and  between  pregnancies  in  order  to  accom- 
plish this.  A  study  of  the  last  census  shows  the 
death  rate  for  1900  among  w-omen  of  childbearing 
age  to  be  50.3  to  the  100,000,  and  this  includes  a 
rate  of  21.6  for  puerperal  sepsis  alone,  which  is  a 
preventable  condition.  The  hospital  should  carry 
on  a  detailed  study  of  the  efifect  of  venereal  diseases 
upon  mother  and  child. 

There  will  be  little  decrease  in  the  mortality  from 
childbirth  until  the  standard  of  obstetrics  is  raised 
to  its  proper  place,  wdiere  it  will  rank  with  major 
surgery.  The  public  should  recognize  the  necessity 
for  skilled  attention  for  every  pregnant  woman. 
Upon  discharge  from  the  maternity  hospital,  the 
mother  and  baby  should  be  referred  to  a  health 
clinic,  where  they  should  report  at  stated  intervals 
for  observation  and  care.  Keeping  the  mother 
well  between  pregnancies  is  a  most  essential  factor 
in  reducing  the  mortality  and  morbidity  of  mother 
and  baby.  There  should  be  a  prematernity  depart- 
ment, distinct  from  the  maternity  hospital,  for  the 
pregnant  woman  who  needs  rest  and  good  food 
before  confinement,  and  for  those  who  have  had 
complications  in  former  labors  and  for  those  whose 
condition  make  it  necessary  for  them  to  be  kept 
imder  observation  and  treatment. 

The  Babies'  Welfare  Association  seems  to  be  the 
only  organization  which  is  endeavoring  to  put  on 
record  the  amount  and  character  of  the  prenatal 
work  being  done  by  institutions  and  agencies  in 
Philadelphia.  There  are  thirty-two  of  these  or- 
ganizations, all  members  of  the  Babies'  Welfare 
Association,  and  forming  five  distinct  types,  namely : 


November  13.  1920.] 


LOB  SEN  Z:  PRENATAL  CARE. 


765 


1,  Division  of  child  hygiene;  2,  visiting  nurse  so- 
ciety ;  3,  dispensary  with  its  own  maternity ;  4,  dis- 
pensary without  maternity,  and  5,  health  centres. 
In  order  to  obtain  these  data  a  questionnaire  is  sent 
each  year  to  these  different  organizations,  the  results 
are  compiled,  and  a  copy  sent  to  the  Children's 
Bureau  at  Washington,  D.  C,  and  the  American 
Child  Hygiene  Association,  for  their  files.  The 
obtaining  of  these  data  is  attended  with  considerable 
difficulty,  and  we  are  indebted  to  the  untiring  efforts 
of  our  assistant  secretary  that  so  much  has  been 
accomplished. 

At  the  suggestion  of  one  of  the  social  workers, 
a  monthly  record  sheet  has  been  printed  by  the 
Babies'  Welfare  Association  to  be  used  by  the  dif- 
ferent organizations  in  order  to  facilitate  this  work. 
This  sheet  contains  all  the  questions  asked  on  the 
questionnaire  and  seems  to  be  giving  satisfaction. 
Twenty  of  the  organizations  are  using  them  at  the 
present  time,  so  that  statistics  are  more  readily 
obtained.  The  main  handicap  in  securing  data 
seems  to  be  due  to  the  poorly  developed  Social 
Service  Department.  The  governing  bodies,  either 
not  realizing  the  great  necessity  for  such  a  depart- 
ment or  being  unable  to  provide  funds  for  the 
proper  carrying  out  of  this  work.  Only  twenty  of 
the  thirty-two  organizations  sent  in  their  question- 
naires this  year,  but  each  year  shows  more  co- 
operation. We  are  unable  to  give  the  number  of 
babies  living  and  breast  fed,  one  month  after  birth, 
due  to  lack  of  followup  work.  Only  five  of  the 
twenty  organizations  are  taking  routine  Wasser- 
mann  tests  and  making  microscopical  examinations 
of  the  vaginal  secretions,  and  only  fifteen  are  taking 
the  blood  pressure  of  the  patients  as  a  matter  of 
routine,  and  yet  all  obstetricians  realize  the  great 
importance  of  these  tests. 

Before  these  institutions  realized  what  the  Babies' 
\\'elfare  Association  was  trying  to  accomplish,  the 
questionnaire  was  received  by  them  with  varying 
degrees  of  cordiality.  This  was  due,  I  feel,  to  the 
following  reasons :  1 .  The  organizations  which 
were  rather  indifferent  toward  prenatal  work  con- 
sidered it  a  bore.  2.  The  organization  which  was 
interested  and  anxious  to  do  good  work,  but  were 
prevented  either  by  lack  of  funds  or  the  proper  kind 
of  workers.  3.  Those  workers  who  had  properly 
kept  records  in  a  well  organized  social  service  de- 
partment were  pleased  to  show  the  kind  of  work 
they  were  doing. 

Do  we  not  owe  it  to  that  little  atom  of  humanity, 
starting  on  a  life  more  hazardous  than  that  of  a 
soldier  in  the  front  line  trench,  to  put  into  effect 
these  measures  which  are  known  to  remove  seventy- 
five  per  cent  of  its  perils  ? 

1831  Chestnut  Street.  ■  " 

Rontgen  Ray  Studies  of  the  Bronchial  Func- 
tion.— Jesse  G.  M.  BuUowa  and  Charles  Gottlieb 
{American  Journal  of  the  Medical  Sciences,  July, 
1920)  have  observed  a  bellows  like  action  in  the 
trachea  and  bronchi  which  may  be  limited  by  con- 
traction of  the  hrrnchial  murcles,  and  a  peristaltic 
•action  of  the  bronchial  muscles  which  seems  ad- 
equate to  empty  them  without  invoking  ciliary 
movement. 


THE  IMPORTANCE  OF  PRENATAL  CARE. 
By  Moses  Lobsenz,  M.  D., 

New  York, 

Attending   Obstetrician,   Berwind   Maternity  Clinic. 

In  modern  medical  progress,  particularly  in  rela- 
tion to  definite  diagnosis  and  treatment,  the  ten- 
dency has  been  toward  group  diagnosis.  Why, 
then,  should  not  a  gravid  woman  receive  the  benefit 
of  this  advance?  Prenatal  care  in  clinics  and 
among  general  practitioners  is  treated  with  the  pre- 
sumption that  pregnancy  is  a  physiological  process, 
able  to  take  care  and  dispose  of  itself.  At  some 
clinics  Wassermann  tests  are  taken.  These  clinics 
pride  themselves  justly  with  doing  a  great  deal  for 
the  woman  if  the  Wassermann  happens  to  be  posi- 
tive and  they  inaugurate  the  proper  treatment.  This 
is  truly  a  great  advance  and  of  great  assistance  to 
the  woman,  the  coming  fetus,  and  the  community. 
But  the  amount  of  syphilis  found  by  the  Wasser- 
mann reaction  depends  entirelv  upon  the  locality 
of  the  clinic,  hospital,  or  types  of  patient  the  phy- 
sician encounters.  We  know  that  in  the  colored 
race  syphilis  is  far  more  prevalent  than  in  the  white 
race  and,  therefore,  when  we  study  statistics  we 
must  weigh  them  by  their  locality.  The  blood  pres- 
sure of  the  patients  is  taken;  if  taken  carefully,  it 
is  of  assistance  in  corroborating  other  findings,  such 
as  nephritis.  Uranalyses  are  performed,  but  in 
most  clinics  and  by  most  physicians,  single  speci- 
mens are  examined.  This  is  erroneous  and  leads 
to  nothing.  A  twenty-four  hour  specimen  should 
be  required  and  a  careful  examination  made,  par- 
ticularly as  to  specific  gravity,  amount  excreted, 
albumin,  urea,  acetone  and  acetic  acid ;  and  a  micro- 
scopical report  of  casts,  blood,  and  pus. 

Measurements  of  pelvis  are  taken.  These  natur- 
ally help  us  find  gross  abnormalities.  Measure- 
ments, even  when  taken  by  the  most  expert,  are 
erroneous,  due  to  the  impossibility  of  measuring 
accurately  the  internal  strait  and  the  fetus.  We 
have  all  had  the  experience  of  making  a  diagnosis 
of  a  contracted  pelvis  and  preparing  the  patient 
for  a  Csesarean  section  only  to  have  labor  terminate 
in  a  perfectly  normal  delivery.  Similarly  a  diag- 
nosis of  an  ample  pelvis  may  be  made,  only  to  have 
to  resort  to  Csesarean  section  after  an  attempt  at 
labor.  Therefore  a  certain  number  of  mishaps  to 
mother  and  fetus  will  always  occur  from  this  cause. 
There  will  always  remain  a  certain  number  of 
fatal  results  from  placenta  praevia  and  accidental 
hemorrhage,  eclampsia  and  nephritic  convulsions. 
Aside  from  the  patients  lost  from  these  causes, 
there  are  a  marked  proportion  lost  from  infection 
of  unknown  origin.  A  great  many  miscarriages  and 
abortions,  breast  abscesses,  pyelitis,  and  perhap.s 
even  cases  of  placenta  pra?via  and  accidental  hemor- 
rhage are  due  to  unknown  causes.  What  should  be 
done  to  give  more  information  in  these  cases? 
What  are  the  different  channels  by  which  infection 
may  travel? 

It  is  readily  seen  that,  due  to  engorgement,  the 
uterus  would  be  a  favorable  seat  for  almost  any 
focal  infection  through  venous,  lymphatic,  or  ar- 
terial channels.  It  is  therefore  essential  that  all 
possible  focal  areas  of  infection  should  be  elim- 


766 


LAZARUS:  DIAGNOSIS  OF  PREGXAXCV. 


[New  York 
Medical  Jdurnal. 


inated.  First  in  importance  are  the  teeth.  The 
services  of  a  dentist  with  the  proper  x  ray  faciUties 
are  necessary  to  the  obstetrician.  He  should  correct 
all  cases  of  pyorrhea,  and  see  that  all  abscess  cav- 
ities are  properly  drained.  The  late  Dr.  Joseph 
Bryant  always  impressed  it  upon  students  that 
wherever  pockets  of  pus  were  found,  immediate 
drainage  should  be  carried  out  for  fear  that  these 
foci  would  lead  to  ultimate  infection  of  some  other 
organ.  It  is  known  that  abscessed  teeth  and  pyor- 
rhea are  the  cause  of  rheumatism  and  joint  infec- 
tions, as  well  as  disorders  of  the  organs  of  the  chest 
and  abdomen.  What  is  to  prevent  the  bacteria 
from  these  abscesses  finding  lodgment  in  the  uterus  ? 
Like  the  spirochete  in  syphilis,  cannot  these  same 
bacteria  lodge  themselves  in  the  placenta  and  be 
the  cause  of  some  of  our  cases  of  miscarriage, 
abortion,  placenta  prsevia,  and  accidental  hemor- 
rhage? Can  they  not  also  be  the  cause  of  some  of 
the  breast  abscess  and  pyelitis  cases  of  unknown 
origin?  It  would  be  foolish  to  enumerate  cases  of 
this  type,  for  everyone  doing  obstetrical  work  has 
encountered  them. 

Next  in  importance  is  the  iiose  and  throat  spe- 
cialist, who  should  carefully  examine  the  patient. 
He  should  treat  any  infection  from  the  tonsils  or 
sinuses.  The  lung  specialist  should  note  any  areas 
of  tuberculosis.  If  such  an  area  is  found,  the 
patient  should  be  kept  under  close  observation 
and  the  obstetrician  advised.  It  is  known  that 
tuberculosis  advances  with  pregnancy;  a  patient  of 
this  type  in  the  proper  environment  and  under  close 
scrutiny  could  perhaps  continue  in  her  pregnancy 
and  give  birth  to  her  child,  the  obstetrician  being 
advised  however  if  interference  is  necessary. 

The  heart  specialist  should  examine  and  treat  all 
cases  of  heart  murmur.  Cardiogram  tracings  should 
be  taken  as  well  as  the  blood  pressure.  In  this  way 
instead  of  the  casual  taking  of  blood  pressure  it 
would  be  taken  by  a  man  interested  in  that  par- 
ticular field  in  conjunction  with  his  other  exam- 
inations, and  would  prove  of  great  value  to  us. 
Examinations  of  blood,  urine,  sputum  and  feces  by 
a  man  skilled  and  interested  in  this  work,  would 
bear  great  weight  in  the  ultimate  treatment  of  a 
patient.  A  social  service  organization  with  properly 
trained  nurses,  to  look  after  and  correct  faulty 
surroundings  and  hygiene  and  to  see  that  patients 
report  back  as  requested,  would  be  excellent.  It 
would  be  the  duty  of  these  nurses  to  inform  the 
obstetrician  of  a  previous  miscarriage,  abortion,  or 
dead  fetus,  and  the  cause  of  the  accident,  if  found. 
In  case  of  syphilis  the  nurse  should  follow  up 
patient  after  discharge  (postpartum)  and  see  that 
another  Wassermann  is  taken  subsequently  and  if 
positive  treatment  be  continued.  The  husband  of 
such  a  patient  should  have  a  Wassermann  taken  and 
if  positive  should  be  properly  treated.  The  obstetri- 
cian would  then  be  called  upon  to  pay  attention  only 
to  his  particular  field  and  with  all  other  data  on 
hand  would  be  fit  ■  to  treat  the  patient  correctly, 
conscientiously  and  conservatively. 

CONCLUSION. 

In  order  to  give  the  gravid  woman  proper  care, 
therefore,  the  following  routine  ought  to  be  ar- 
ranged:   1.  History  taking  room  for  taking  careful 


and  detailed  histories ;  2,  dentist  with  proper  x  ray 
facilities ;  3,  nose  and  throat  laboratory  with  proper 
facilities ;  4,  lung  examination ;  5,  heart  examina- 
tion ;  6,  laboratory ;  7,  social  service,  and  8,  ob- 
stetrical care. 

This  routine,  although  cumbersome  at  the  start, 
I  am  sure  could  readily  be  arranged  and  would  do 
away  with  much  of  our  maternal  and  fetal  mortal- 
ity, for  the  obstetrician  who  has  access  to  accurate 
data  furnished  by  physicians  interested  in  their 
particular  fields  could  pay  proper  attention  to  his 
one  duty,  namely,  the  passenger  and  its  passage. 

233  West  122xd  Street. 


THE  EARLY  DIAGNOSIS  OF-PREGXANXY. 
By  David  Lazarus,  M.  D., 

Xew  York. 

Normally  every  girl  at  or  about  the  age  of  four- 
teen begins  to  show  signs  of  a  bloody  discharge 
from  the  vagina,  known  as  menstruation.  This 
process  occurs  with  a  regularity  of  from  twenty- 
four  to  twenty-eight  days,  except  during  pregnancy,, 
lactation,  and  often  in  tuberculosis,  severe  anemia, 
exposure  to  sudden  cold,  weather  changes  or 
changes  of  climate,  as  is  noted  in  girls  emigrating 
from  foreign  countries  to  this  land.  Should  the 
period  not  occur,  and  should  there  be  a  clear  history 
of  sexual  intercourse,  with  or  without  the  penetra- 
tion of  the  penis  into  the  vagina,  the  absence  of 
menstruation  may  be  regarded  as  the  first  sign  of 
pregnancy.  Often,  however,  the  sexual  act  or  the 
coaptation  of  the  penis  to  or  with  the  vagina  is 
denied,  and  it  is  in  these  cases  that  other  and  more 
reliable  signs  than  amenorrhea  must  be  sought. 
These  signs  can  be  classified  as  subjective  and 
objective  signs  and  symptoms. 

Subjective  symptoms. — Sensation  in  the  breasts 
in  that  they  are  feeling  heavy,  distended  and  heated ; 
it  is  also  noted  that  they  are  beginning  to  enlarge ; 
feeling  ill  or  nauseated  every  morning  on  arising, 
although  not  actually  vomiting ;  the  abdomen  is  dis- 
tending and  getting  larger  and  fuller ;  dark  rings 
are  noticed  under  the  eyes ;  there  is  a  longing  for 
foods  never  or  very  seldom  desired  before ;  the 
desire  for  sexual  intercourse  is  stimulated  almost 
to  excess. 

Objective  signs. — These  are  best  divided  into  ex- 
ternal and  internal  signs. 

The  external  signs  are  manifested  in  a  rather 
self  consciousness  of  expression  of  the  patient,  in 
that  she  imagines  all  are  looking  at  her  and  that 
her  condition  or  state  of  pregnancy  is  visible ; 
enlargement  of  the  breasts  with  an  increase  of  the 
pigmentation  area  about  the  nipple,  and  the  presence 
of  enlarged  or  radiating  veins ;  colostrum  may  be 
squeezed  from  the  nipple,  or  in  the  very  early  days 
of  pregnancy  only  a  few  drops  of  a  clear  liquid 
may  be  expressed  from  the  nipple ;  enlargement  of 
the  abdomen  consistent  with  the  period  of  gestation ; 
a  dark  line  beginning  to  form  in  the  midline  of  the 
body  extending  from  the  pubis  to  the  umbilicus ; 
enlarged  veins  about  the  vagina,  causing  the  well 
known  classical  purplish  discoloration. 

The  internal  signs  of  pregnancy  are  indeed  the 


November  13,  1920.] 


ROOT:  DIAGNOSIS  OF  PREGNANCY. 


767 


more  reliable  especially  in  those  cases  where  sexual 
relationship  has  been  denied.  These  signs  are 
ascertainable  by  a  vaginal  examination  with  or 
without  an  accompanying  abdominal  palpation : 

A  feeling  of  warmth  in  the  vagina  as  the  hand 
is  introduced  therein ;  an  enlarged  uterus,  assuming 
a  pear  shaped  outline  and  uniform  softness;  soften- 
ing of  a  small  area  in  the  junction  of  the  cerv^ix 
with  the  body  of  the  uterus,  known  as  the  Ladinski 
sign  (1),  as  early  as  the  third  week  of  pregnancy. 
This  in  reality  is  the  beginning  of  the  softening  of  the 
entire  cervix,  which  in  the  later  weeks  of  gestation 
becomes  known  as  the  Hegar  sign.  However,  it  is 
a  reliable  sign  and  shoyld  always  be  sought  for  in 
the  examination  for  pregnancy.  Ballotement  is  per- 
ceived in  later  pregnancy  and  depends  upon  the 
development  of  the  fetus ;  fetal  heart  signs  are 
audible  at  about  the  fifth  month  and  is  the  undeni- 
able symptom  of  pregnancy,  as  is  also  the  sensation 
of  quickening. 

Aside  from  the  symptoms  and  signs  mentioned, 
one  may  arrive  at  a  fair  diagnosis  of  pregnancy  by 
the  serum  test  of  Abderhalden  (2),  which  manifests 
the  presence  of  placental  tissue  as  early  as  the  fifth 
week ;  this  examination  of  the  blood  taken  in  con- 
junction with  some  of  the  signs  and  symptoms 
quoted  above  certainly  diagnose  pregnancy.  The 
microscopic  examination  of  the  urine  reveals  the 
presence  of  endogenous  new  formations  in  the  cells 
and  is  a  valuable  aid  in  making  a  diagnosis. 

Recapitulating,  the  early  signs  of  pregnancy  are : 
amenorrhea,  morning  sickness,  perversion  of  appe- 
tite, enlarged  breasts,  enlarged  abdomen,  discolora- 
tion of  the  vagina,  enlarged  uterus,  Ladinski  sign, 
.Abderhalden  test,  urine  examination. 

REFEREXCES. 

1.  Ladinski,  L.  J.:  Elastic  Area  in  the  Isthmus  of 
Uterus,  American  Journal  of  Obstetrics,  vol.  Ixviii,  p.  210, 
August,  1913. 

2.  Abderhaldex,  E.  :  Diagnose  der  Schwangerschaft, 
Handbuch  der  Biochem.  arbcit.  method. 

327  Centr.\l  Park  West. 


THE  DIAGNOSIS  OF  PREGNANCY. 

By  M.vxly  B.  Root,  M.  D., 
Syracuse,  N.  Y. 

Pregnancy,  usually  correctly  diagnosed  by  the 
woman  herself,  demands  considerable  obstetrical 
skill  for  its  positive  recognition.  The  numerous 
mistakes  that  have  been  made  justify  a  careful  con- 
sideration of  the  subject.  In  a  short  article  we 
must  presuppose  a  knowledge  of  the  various  symp- 
toms and  signs  and  attempt  merely  to  discuss  their 
relative  values.  We  are  discussing  a  positive  diag- 
nosis. Presumptive  symptoms  and  signs  have 
therefore  no  interest  for  us  except  that  their  ab- 
sence often  makes  us  hesitate  to  diagnose  preg- 
nancy. 

An  absolutely  positive  diagnosis  can  not,  it  is  true, 
be  made  before  the  eighteenth  or  twentieth  week. 
But  to  one  thoroughly  familiar  with  the  size,  shape, 
consistency  and  relations  of  normal  and  pregnant 
uteri,  bimanual  examination  reveals  the  presence 
of  signs  dependent  on  uterine  changes  which  make 


possible  in  a  normal  uncomplicated  case  a  practic- 
ally certain  diagnosis  from  the  second  to  the  fourth 
month.  The  lower  uterine  segment  fills  out  first,, 
changing  the  shape  of  the  uterus  from  pyriform  to 
jugshaped,  the  body  becoming  spherical.  This  al- 
lows the  latter  to  be  felt  by  vagina  more  easily  than 
that  of  a  nonpregnant  uterus.  Moreover  it  results 
in  an  apparently  well  marked  shortening  of  the  cer- 
vix so  that  the  examining  finger  has  less  room  in 
the  anterior  and  posterior  vaginal  fornices.  Careful 
palpation  gives  us  von  Fernwald's  sign :  the  antero- 
posterior thickening  of  the  uterus  is  more  marked  on 
the  side  containing  the  ovum,  if  it  is  located  on  one 
side. 

The  gravid  titerus  always  undergoes  a  softening 
which  commences  about  the  fifth  week  as  a  soft 
fluctuating  area  on  the  anterior  wall  just  above  the 
cervix.  The  recognition  of  this  is  known  as  Ladin- 
ski's  sign.  This  softening  soon  extends  throughout 
the  uterus  and  by  the  tenth  week  we  can  get  Hegar's 
sign:  with  fingers  of  one  hand  in  the  posterior  fornix 
and  of  the  other  on  the  abdominal  wall,  these  fingers 
can  be  nearly  approximated  due  to  the  giving  away 
of  the  softened  uterine  body.  The  steady,  rapid 
growth  of  the  uterus  at  this  period  is  very  significant, 
no  ttimor  increasing  as  rapidly  in  size. 

When  all  or  nearly  all  of  these  signs  are  present 
a  tentative  diagnosis  can  be  made.  It  is  verified, 
of  course,  by  the  early  presumptive  symptoms : 
amenorrhea,  morning  nausea  and  vomiting,  saliva- 
tion, vesical  irritability,  and  nervous  phenomena ; 
and  by  the  presumptive  signs :  pigmentation,  breast 
changes,  purple  color  of  vulvar  and  vaginal  mucosa 
(Chadwick's  sign),  and  softening  of  the  cervix. 

After  the  eighteenth  or  twentieth  week  a  diag- 
nosis can  be  made  which  cannot  be  questioned.  This 
is  dependent  on  three  signs:  1.  Hearing  the  fetal 
heart,  a  sound  resembling  that  made  by  a  watch 
ticking  beneath  a  pillow,  with  a  rate  of  120-160  a 
minute  and  not  synchronous  with  the  mother's  pulse ; 
2.  Feeling  the  fetal  movements,  active  and  passive; 
the  former  as  transmitted  to  the  hand  of  the  ex- 
aminer through  the  abdominal  wall.  The  move- 
ments felt  by  the  woman  are  of  little  value.  The 
passive  movement  may  be  obtained  as  abdominal 
ballotment  between  the  fourth  and  seventh  months. 
With  one  or  two  fingers  in  the  anterior  vaginal 
fornix  if  a  tap  is  imparted  upward  to  the  fetus 
the  latter  strikes  the  anterior  abdominal  wall  and 
returns  to  the  fingers.  3.  Ability  to  map  out  the 
parts  of  the  fetus.  Any  of  these  three  signs  make 
a  positive  diagnosis,  but  as  a  verification  the 
earlier  symptoms  and  signs  shotild  still  be  present. 

A  word  must  be  said  about  the  diflPerential  diag- 
nosis. Pregnancy  is  most  often  simulated  by  subin- 
volution, chronic  metritis,  myomata,  ovarian  cysts, 
fatty  enlargement  of  'he  abdomen,  and  ascites. 
A  careftil  physical  examination  resulting  in  deter- 
mining the  presence  or  absence  of  the  symptoms  and 
signs  described  above  usually  make  the  diagnosis 
clear  as  far  as  pregnancy  is  concerned.  Here  espe- 
cially the  absence  of  the  early  presumptive  symp- 
toms and  signs  of  pregnancy  is  of  aid  in  preventing 
a  false  diagnosis,  althotigh  the  final  decision  is  de- 
pendent on  the  results  of  bimanual  examination. 

121  Greene  Street. 


768 


iriLEiVSKV:  ILEOCECAL  TUBERCULOSIS. 


[New  York 
Medical  Journal. 


ILEOCECAL  TUBERCULOSIS* 
By  Abraham  O.  Wilensky,  M.  D.,  F.  A.  C.  S., 
New  York. 

The  cases  which  I  shall  describe  illustrate  excep- 
tionally well  some  of  the  manifestations  under 
which  tuberculous  affections  make  their  appearance 
in  the  ileocecal  region.  The  group  in  which  these 
cases  fall  is  a  very  large  one  and  is,  perhaps,  most 
noted  for  the  frequency  with  which  its  acute  phe- 
nomena mimic  other  surigcal  emergencies  in  the 
right  iliac  fossa  and  for  the  difficulties  in  differen- 
tial diagnosis. 

Case  L — A  young  man  of  eighteen  years  was 
admitted  to  the  hospital  with  the  clinical  picture  of 
an  acute  perforating  lesion  of  the  appendix.  His 
family  and  previous  history  had  no  essential  bear- 
ing on  the  present  condition  and,  in  fact,  this  was 
the  first  illness  the  patient  had  ever  had.  The  ill- 
ness jjbegan  on  the  previous  day,  was  ushered  in 
with  severe  generalized  abdominal  cramps  and  was 
associated  with  vomiting  and  with  an  inability  to 
move  the  bowels.  Within  a  few  hours  after  the 
onset  the  pain  localized  to  the  right  iliac  fossa  and 
fever  appeared.  Thereafter  the  symptoms  pro- 
gressed so  that  at  the  time  of  admission  to  the 
hospital  they  were  well  marked.  The  physical 
examination  disclosed  generalized  abdominal  rigid- 
ity, most  marked  on  the  right  side  with  tenderness 
limited  to  the  right  iliac  fossa  where  a  small  mass 
was  palpable.  The  examination  of  the  rest  of  the 
patient's  body  disclosed  nothing  abnormal. 

There  seemed  to  be  no  doubt  about  the  diagnosis 
of  an  acute  appendicitis  and  the  patient  was  imme- 
diately subjected  to  an  operation.  On  opening  the 
abdomen  a  large  inflammatory  mass  was  seen  to 
occupy  the  right  iliac  fossa,  involving  the  angle  of 
junction  of  the  ileum  and  ascending  colon.  On 
unravelling  the  mass  it  was  found  that  a  much 
thickened,  inflamed,  gangrenous  and  perforated 
appendix  passed  upward  from  its  usual  point  of 
origin  in  the  ileocecal  junction  to  the  left  and  in- 
ward toward  the  median  line ;  partly  it,  and  partly 
the  adjacent  coils  of  ileum  and  ascending  colon 
formed  the  dense  walls  of  a  small  abscess  contain- 
ing about  an  ounce  of  grayish  white  pus.  The 
abscess  had  burrowed  through  the  mesentery ;  the 
abscess  cavity  lay  partly  to  the  right  and  partly  to 
the  left  of  the  corresponding  leafs  of  the  mesentery ; 
and  the  tip  of  the  appendix  projected  through  the 
resulting  communicating  opening.  As  far  as  one 
could  see  there  were  no  other  evidences  of  further 
disease  in  the  operative  field.  As  a  matter  of  fact, 
the  condition  resembled  in  every  particular  that 
seen  with  the  ordinary  forms  of  suppurative  ap- 
pendicitis. The  appendix,  therefore,  was  removed, 
the  abscess  cavity  was  cleansed,  and,  the  appropriate 
drainage  having  been  adequately  provided,  the  ab- 
dominal incision  was  closed  with  the  exception  of 
that  part  from  which  the  drainage  emerged.  It 
was  expected  that  the  usual  postoperative  course 
would  follow  and  that  healing  would  result  in  the 
ordinary  manner. 

Much  to  our  surprise  and  chagrin  a  fecal  fistula 
developed  at  the  end  of  the  first  week.    The  dis- 

*  From  the  Mount  Sinai  Hospital. 


charge  was  never  profuse  and  the  fecal  discharge 
ceased  within  a  short  time.  Then  the  sinus  con- 
tracted to  a  narrow  deep  channel  from  which  an 
insignificant  amount  of  purulent  discharge  escaped 
each  day.  Every  opportunity  was  afforded  for  the 
closure  of  the  wound  but  at  the  end  of  the  fourth 
month  practically  no  progress  was  made  and  it 
became  apparent  that  a  secondary  operation  would 
be  necessary  to  insure  healing. 

At  the  second  operation  the  cause  for  the  per- 
sistent sinus  became  apparent  immediately.  The 
sinus  led  down  to  a  pmpoint  perforation  in  the 
beginning  of  the  ascending  colon ;  from  the  latter 
and  extending  on  both  sides  but  much  more  in  an 
upward  direction,  a  segment  of  colon  was  demar- 
cated by  an  extraordinary  rigidity  and  thickening 
of  its  walls  on  the  peritoneal  surface  of  which  a 
profuse  crop  of  small  miliary  tubercles  testified  to 
the  tuberculous  nature  of  the  process.  No  other 
lesion  being  found,  the  terminal  portion  of  the 
ileum  and  the  caput  and  ascending  colon  as  far  as 
the  hepatic  flexure  were  excised  and  the  continuity 
of  the  intestine  was  reestablished  by  a  side  to  side 
suture  anastomosis.  No  drainage  was  employed 
and  the  abdominal  wound  was  closed.  An  unevent- 
ful convalescence  followed  and  at  the  end  of  the 
second  week  the  patient  was  discharged  from  the 
hospital. 

In  this  case  an  examination  of  the  specimen 
showed  that  the  entire  lesion  was  in  the  ascending 
colon  and  was  of  the  peritoneal  variety.  The  mu- 
cous membrane  showed  no  ulcerations.  The  thick- 
ened wall  of  the  colon  encroached  somewhat  on 
the  lumen  of  the  bowel  but  no  actual  stenosis  was 
present  and  a  finger  passed  easily  upward  and 
downward  through  the  compromised  area. 

Case  II. — The  second  patient  was  a  young  girl 
aged  sixteen  years,  who,  similarly  to  the  previous 
patient,  was  admitted  to  the  hospital  with  what  was 
thought  to  be  an  acute  appendicitis.  The  history 
was  quite  the  orthodox  one  for  such  an  illness  and 
included  an  acute  onset  with  generalized  abdominal 
pain  associated  with  vomiting  and  constipation, 
followed  by  a  fairly  rapid  subsidence  of  the  gen- 
eral symptoms  concomitantly  with  the  localization 
and  intensification  of  the  symptoms — pain,  rigidity 
and  tenderness — in  the  right  iliac  fossa.  There  was 
nothing  in  the  family  or  previovis  history  to  cause 
one  to  suspect  an  unusual  etiology.  This  patient, 
too,  had  never  been  ill  before.  The  general  physical 
examination  disclosed  no  abnormal  findings  and 
locally  a  small  mass  was  palpable  which  was  inter- 
preted as  being  a  much  thickened  appendix  or  an 
abscess  derived  therefrom. 

Operation  was  done  immediately-  On  opening  the 
abdomen,  however,  it  was  found  that  the  small 
mass  xvas  a  group  of  inflamed  glands  buried  in  the 
mesentery  near  the  ileocecal  junction.  These  were 
matted  together  and  contained  a  soft  area.  The 
appendix,  although  it  lay  close  by,  was  not  involved 
in  the  process.  Nowhere  else  in  the  belly  could 
any  other  lesion  be  demonstrated  and  in  the  im- 
mediate neighborhood  there  was  no  indication  of 
a  spread  of  the  pathological  process  either  from, 
or  to,  the  intestinal  tract.  The  appendix  was  re- 
moved.   An  attempt  was  also  made  to  enucleate 


IS'ovembcr  13,  1920.] 


tVILENSKV 


ILEOCECAL  TUBERCULOSIS. 


769 


the  glands  but,  owing  to  the  very  nature  of  the 
process,  this  was  only  partially  successful.  During 
the  manipulations  the  abscess  ruptured  and  dis- 
charged a  small  quantity  of  yellowish  pus.  Finally, 
a  drain  was  inserted  and  the  abdominal  wound  was 
partially  sutured. 

A  fecal  discharge  appeared  in  the  second  week. 
This  was  rather  profuse  and  continued  for  more 
than  four  months  unchanged.  The  sutured  part  of 
the  abdominal  wound,  having  become  infected  dur- 
ing the  operation,  parted  later  and  thereafter  the 
liealing  proceeded  slowly  for  a  number  of  months 
until  nothing  was  left  but  an  extremely  narrow 
fistula  through  which  fecal  material  continued  to 
discharge.  The  sinus  showed  no  tendency  to  close. 
Again  exhausted  patience  prompted  the  secondary 
operation.  Examination  of  the  lymph  nodes,  excised 
during  the  operation,  demonstrated  that  the  process 
was  tuberculous  so  that,  when  the  sinus  developed, 
became  persistent  and  refused  to  heal,  we  were 
quite  cognizant  of  the  underlying  cause  which,  pre- 
vented the  healing.  Examination  of  the  rest  of  the 
patient's  body  failed  to  reveal  any  other  focus  of 
tuberculosis,  and,  when  the  secondary  operation 
was  determined  upon,  one  felt  confident  that  the 
success  of  the  procedure,  which  would  prove  neces- 
sary to  ensure  closure  of  the  fecal  fistula,  would 
not  be  ultimately  jeopardized,  or  rendered  futile, 
by  the  flaring  up  of  any  pulmonary,  or  other, 
focus.   To  revert  to  the  patient's  history: 

The  abdomen  was  again  opened.  Conditions 
similar  to  those  in  the  first  patient  were  found. 
The  lesion  was  partly  in  the  ascending  colon  and 
to  a  slight  extent  in  the  terminal  ileum.  The  sinus 
lead  down  to  a  pinpoint  opening  in  the  bowel.  The 
wall  of  the  latter  was  thickened  and  rigid  without, 
however,  having  any  tubercles  visible  on  its  exposed 
surface ;  but  the  general  appearances  of  the  gross 
pathology  indicated  the  tuberculous  nature  of  the 
infection,  even  if  we  had  had  no  previous  evidence  in 
the  microscopical  examination  of  the  lymph  nodes. 
No  other  lesion  being  demonstrable  in  the  adjoining 
coils  of  gut,  the  involved  ileocecal  junction  was  ex- 
cised and  the  continuity  of  the  alimentary  canal 
reestablished  by  a  side-to-side  suture  anastomosis. 
Drainage  in  this  patient,  too,  was  omitted  and  the 
abdominal  wound  was  closed.  The  convalescence 
was  again  most  uneventful  and  at  the  end  of  the 
fourteenth  day  the  patient  left  the  hospital  cured. 

The  excised  specimen  dififered  from  the  previous 
one  in  having  the  bulk  of  the  lesion  on  the  mucosa 
side.  Here  there  were  a  number  of  large  and 
small  ulcerations  with  overhanging  edges  and  show- 
ing a  tendency  to  have  their  longest  diameter  in  the 
transverse  direction.  There  was  no  stenosis  of  the 
lumen  even  at  the  ileocecal  valve.  The  walls  of 
the  bowel  showed  a  marked  thickening. 

The  dominating  fact  evidenced  by  these  notes  is 
the  striking  similarity  of  the  initial  clinical  pictures 
with  that  of  the  ordinary  forms  of  acute  nonsup- 
purative and  suppurative  appendicitis.  This  simi- 
larity is  not  peculiar  to  tuberculous  lesions  and  I 
have  seen  similar  marked  resemblances  in  the  clin- 
ical course  of  other  pathological  lesions  such  as 
carcinoma,  lymphosarcoma,  or  surgical  forms  of 
productive  colitis  of  limited  extent,  all  located  in 


the  right  lower  quadrant  of  the  abdomen.  The  co- 
incidence may  have  one  of  two  explanations :  In 
the  one  case  the  pathological  condition  involves  the 
appendix  directly  and  there  are  a  fair  number  of 
cases  on  record  in  which  the  tuberculous  (or  other) 
lesion  is  readily  demonstrable  in  the  appendix.  In 
the  other  case,  the  lesion  originally  involves'  an  ad- 
jacent portion  of  either  the  colon  or  the  small  in- 
testine ;  the  appendix  is  subsequently  afifected  either 
as  an  entirely  new  process  in  which  the  pathological 
condition  is  that  of  the  ordinary  forms  of  appen- 
dicitis, or  the  inflammation  is  directly  due  to  the 
extension  of  the  original  disease,  or  is  aided  by 
mechanical  disabilities  produced  by  the  latter  lead- 
ing to  stricture  and  obstruction  of  the  appendix 
lumen. 

The  literature  of  the  past  few  years  contains 
numerous  allusions  to  the  difficulties  in  the  dif¥er- 
ential  diagnosis  of  conditions  in  the  right  iliac  fossa. 
All  of  these  enhance  the  importance  of  constantly 
keeping  in  mind  the  various  forms  of  disease  in 
the  latter  region  which  can  be  masked  under  similar 
subjective  and  objective  symptomatologies.  Besides 
disease  of  the  appendix  itself  and  the  neighboring 
parts  of  the  small  and  large  intestine,  these  include 
affections  of  the  omentum,  of  the  mesentery  or  its 
contained  lymph  nodes,  of  the  appropriate  part  of 
the  genitourinary  tract,  and  of  the  cellular  tissue 
of  the  retroperitoneal  space,  all  of  these  comprising 
both  inflammatory  and  neoplastic  lesions.  In  a 
general  way  the  symptomatologies  of  all  of  these 
are  not  peculiar  to  any  particular  one  and  only 
indicate  the  location  of  the  body  in  which  the  lesion 
is  to  be  found.  The  differentiation  must  be  made 
upon  conclusive  local  evidence  such  as  is  produced 
by  the  aid  of  the  cystoscope,  upon  the  conclusive 
or  relative  evidence  of  the  rontgen  ray,  or  it  is  based 
upon  the  accumulated  experience  of  the  individual 
observer  and  is  then  largely  determined  by  the  rela- 
tive frequency  of  occurrence  of  the  various  forms 
of  disease  and  is  limited  by  the  frailty  of  the  human 
equation. 

In  the  more  chronic  forms  of  disease  the  diffi- 
culties are  not  nearly  so  marked  and  with  sufficient 
care  in  the  taking  of  histories  and  in  examining  the 
patients  the  diagnosis  should  be  made  and  com- 
paratively few  errors  should  occur.  In  the  acute 
cases  the  differential  diagnosis  is  sometimes  ex- 
tremely difficult  and  often  accuracy  is  not  possible 
until  the  lesion  is  exposed  during  the  operation. 
Fortunately,  in  the  majority  of  such  patients  the 
indications  are  the  same  and,  when  it  is  found  that 
the  appendix  is  involved  in  a  suppurative  process, 
a  suspicion  that  underlying  it  is  a  more  important 
lesion,  such  as  a  tuberculosis  or  carcinoma,  would 
not  detract  from  the  necessity  of  reserving  for  a 
secondary  operation  the  more  extensive  resection 
which  would  be  necessary. 

In  children  the  difficulties  in  the  atute  cases  are 
multiplied  by  certain  possible,  and  unavoidable, 
inaccuracies  in  the  histories,  and  by  the  patient's 
lack  of  cooperation  when  the  physical  examinations 
are  being  made.  I  have  in  mind  a  certain  group 
occurring,  in  my  experience,  in  young  children  in 
which  the  history  is  always  that  of  a  typical  attack 
of  acute  appendicitis.    The  physical  findings  are  of 


770 


iriLEXSKV:  ILEOCECAL  TUBERCULOSIS. 


[New  York 
Medical  Journal. 


sufficient  intensity  to  demand  an  emergency  ex- 
ploration ;  then  one  is  astonished  to  find  that  the 
appendix  shows  practically  no  abnormal  change, 
but  that  the  glands  of  the  mesentery  show  a  uniform 
discrete  enlargement.  Usually  the  appendix  is  re- 
moved and  one  of  the  glands  is  excised  for  micro- 
scopical examination.  The  postoperative  course 
thereafter  includes  an  immediate  drop  in  the  tem- 
perature and  an  improvement  in  the  local  and 
general  symptoms  that  is  progressive  and  permanent. 

Such  adenopathies  are  rather  frequent  in  the 
angle  of  junction  of  the  small  and  large  bowel. 
Xot  always  is  the  microscopical  picture  that  of 
a  tuberculous  infection  and  the  assumption  seems 
not  unreasonable  that  the  adenitis  is  the  reply  to 
some  bacterial  or  other  trauma  derived  from  the 
appropriate  part  of  the  alimentary  tract.  More 
advanced  cases  include  those  in  which  the  gland? 
become  matted  together,  or  undergo  suppuration 
and  in  many  of  these  the  infection  is  demonstrably 
of  a  tuberculous  nature.  There  seems  to  be  marked 
resemblances  between  these  forms  of  mesenteric 
adenitis  and  those  occurring  in  the  neck.  The 
second  case  described  belongs  in  this  group. 

\'ery  frequently,  whether  the  essential  lesion  is 
in  the  appendix  or  bowel,  or  whether  it  is  in  the 
mesenteric  nodes,  the  character  of  the  pathological 
condition  is  such  as  to  demand  the  institution  of 
drainage.  This  was  so  in  both  of  the  cases  de- 
scribed. The  occurrence  of  the  fecal  fistula  in 
both  of  the  patients  seems  to  be  a  very  common 
complication  of  the  postoperative  period  in  cases 
of  this  kind :  in  some  the  wound  discharges  are 
profuse,  in  the  others  they  are  not.  In  all  of  them 
the  sinus  persists  for  long  periods  of  time  and 
either  heals  after  the  lapse  of  many  months,  or 
shows  no  tendency  at  all  to  close.  The  obstinacy 
displayed  in  healing  is  due  to  the  presence  of  the 
comnumication  with  the  interior  of  the  bowel.  In 
the  cases  in  which  the  appendix  has  been  ablated 
the  line  of  closure  of  the  appendix  stump,  whether 
it  be  treated  by  simple  ligation  and  cauterization 
as  in  our  cases,  or  whether  the  stump  is  further 
buried,  is  rendered  rather  insecure  because  of  the 
tuberculous  nature  of  the  accompanying  lesion  and 
the  intestinal  fistula  is  directly  attributable  to  the 
latter.  In  extraintestinal  lesions  the  sinus  can  be 
due  to  the  extension  of  the  pathological  process; 
or  the  removal  of  the  gland,  or  glands,  is  accom- 
panied by  some  compromise  of  the  blood  supply 
large  enough  to  result  in  a  local  area  of  necrosis 
in  the  bowel  wall.  I  think  that  all  of  these  mech- 
anisms played  a  part  at  some  time  or  other  in  the 
pathological  findings  of  the  cases  described. 

In  any  given  case  it  is  not  at  all  simple  to  decide 
accurately  prior  to  the  second  operation  as  to  the 
nature  of  the  impediment  which  persists  in  keeping 
the  sinus  open.  This  is  all  the  more  so  inasmuch 
as  in  certain  of  the  ordinary  forms  of  appendicitis 
in  which  drainage  is  instituted,  sinuses  persist  and 
are  due  to  mechanical  causes,  to  a  reopening  of  the 
appendix  stump,  or  to  the  retention  ..of  foreign 
bodies.  In  the  first  of  the  cases  reported  the  actual 
nature  of  the  lesion  was  not  suspected  and  when 
the  sinus  refused  to  heal  it  was  feared  that  some 
foreign  body  had  been  accidentally  retained. 


In  neither  of  the  two  cases  did  I  make  use  of 
the  rontgen  ray  as  a  help  towards  elucidating  the 
nature  of  the  obstacle  which  was  impeding  the 
healing.  In  the  one  case  the'  microscopic  examina- 
tion of  one  of  the  excised  glands  had  demonstrated 
conclusively  the  tuberculous  nature  of  the  affection ; 
in  the  other  it  was  feared  that  some  foreign  body 
— a  piece  of  rubber  tubing  or  gauze — was  present 
in  the  wound ;  in  either  case  it  was  thought  that 
the  X  ray  would  throw  no  additional  light  which 
would  be  of  sufiicient  value.  In  uncomplicated 
cases  in  which  no  previous  operation  had  preceded, 
the  X  ray  is  undoubtedly  of  great  help  for  more 
than  one  reason.  A  rontgenographic  picture  show- 
ing hj-pennotility  and  spasm,  or  filling  defects  in 
a  patient  with  pulmonary  tuberculosis,  should  lead 
to  a  definite  diagnosis  of  colonic  tuberculosis.  In 
moderately  early  cases  ceitain  radiographic  shadows 
cast  by  the  barium  meal  at  the  end  of  six,  eighteen 
or  twenty-four  hours,  determine  definitely  to  the 
trained  radiologist  the  presence  of  colonic  ulcera- 
tions ;  their  absence  does  not,  however,  exclude 
their  presence.  In  the  presence  of  a  wound  the 
picture  would  iindoubtedly  suffer  much  distortion 
owing  to  the  abnormalities  which  could  cpnceivabh' 
result  from  the  operative  interference,  and  the 
assuredness  with  which  the  rontgenographic  picture 
would  be  interpreted  would  suffer  much  deteriora- 
tion. There  would  be  little  need  for  the.x  ray  to 
demonstrate  the  exact  point  of  entry  of  the  sinus 
into  the  bowel,  inasmuch  as  such  information  would 
be  available  with  sufficient  accuracy  for  practical 
purposes  from  the  findings  of  the  primary  operation. 

I  am  not  in  favor  of  any  of  the  temporizing 
measures  or  local  plastic  operations  for  the  closure 
of  these  sinuses.  With  cases  of  this  kind  the  fistula 
is  very  deep  and  the  mucous  surface  of  bowel  with 
which  the  latter  becomes  continuous  is  at  quite  a 
distance  from  the  skin.  Mechanically,  conditions 
are  most  favorable  for  spontaneous  closure  and, 
when  for  one  or  another  reason  there  is  a  refusal 
to  heal,  a  complete  exposure  of  the  parts  is  impera- 
tive in  order  to  accurately  disclose  the  ofi'ending 
pathological  process. 

My  usual  practice  is  to  close  the  sinus  opening 
with  a  running  suture  after  creating  by  dissection 
appropriate  skin  flaps  on  either  side.  Then  the 
surface  is  again  sterilized  with  tincture  of  iodine 
and,  with  clean  instruments,  the  abdomen  is  entered 
in  the  free  portion  of  its  peritoneal  cavity  either 
above  or  below  the  previous  operative  field  and 
directly  in  its  line.  That  poition  of  the  intestinal 
tract  to  which  the  sinus  leads,  as  well  as  the  entire 
surrounding  mass  of  adjacent  and  adherent  coils  of 
intestine  and  omentum,  together  with  the  sinus 
containing  scar  in  the  skin  and  abdominal  wall,  can 
now  easily  be  circumscribed  in  the  dissection  until 
the  whole  can  be  freely  delivered  without  the  body 
cavity.  The  pathological  condition  is  then  apparent, 
the  extent  of  the  lesion  can  be  accurately  delimited, 
and,  if  necessary,  any  further  exploration  can  be 
done  in  complete  safety.  The  risks  of  infection 
with  this  technic  are  at  a  minimum  and  are  not 
any  greater,  in  my  experience,  than  with  any  other 
laparotomy ;  so  much  is  this  so,  that  I  do  not  hesi- 
tate^ at  the  conclusion  of  the  operation  to  omit  any 


November  13,  1920.] 


WILENSKY:  ILEOCECAL  TUBERCULOSIS. 


771 


form  of  intraabdominal  drainage  and  to  close  the 
abdominal  wound  in  its  entirety. 

With  the  parts  adequately  exposed  it  is  essential 
to  make  sure  that  the  lesion  is  one  whose  extent 
is  limited  within  the  boundaries  of  operative  re- 
moval, and  that  there  are  no  other  similar  lesions 
at  some  distance  away  which  would  nullify  the 
success  of  the  operation.  This  is  absolutely  so  in 
any  uncomplicated  case  in  which  the  operative 
exploration  demonstrates  a  tuberculous  lesion ;  and 
when  the  latter  is  too  extensive,  or  is  spread  about 
in  multiple  fashion,  the  attempt  to  do  anything  of 
a  radical  nature  must  necessarily  be  abandoned.  In 
the  presence  of  a  sinus,  however,  as  in  both  of  the 
reported  cases,  an  added  indication  exists,  the 
urgency  of  which  would  impel  one  to  resort  to  some 
method  competent  to  result  in  closure  of  the  fistula 
even  when  the  operation  would  nol  remove  the 
entire  lesion.  There  should  be  no  hesitancy  in 
doing  so  with  tuberculous  lesions  inasmuch  as 
nature  frequently  helps  materially  and  succeeds  in 
completing  the  cure  when  the  tissues  are  primarily 
aided  by  the  removal  of  the  major  focus ;  this  ex- 
perience is  quite  common  with  tuberculous  lesions 
elsewhere- 

The  procedure  of  choice  in  my  experience  is  a 
clean  resection  of  the  ileocecal  junction  extending 
well  into  healthy  portions  on  either  side.  Especially 
with  tuberculous  conditions  it  seems  much  the  safest 
way  to  close  completely  the  stumps  of  the  bowel 
and  to  reestablish  the  continuity  of  the  intestine  by 
side  to  side  suture  anastomoses.  A  great  deal  of 
valuable  time  can  be  saved  by  closing  the  open  end 
of  the  large  bowel  and  by  anastomosing  the  stump 
of  the  small  bowel  into  the  side  of  the  colon  very 
near  the  line  of  section  and  closure.  With  both  of 
these  two  methods  additional  time  can  be  saved  by 
making  the  anastomosis  with  a  Murphy  button.  I 
have  operated  according  to  all  of  these  methods 
and  have  had  almost  equal  satisfaction  with  all.  In 
one  of  the  button  cases  a  leak  developed  and  the 
sinus  persisted  for  several  months ;  drainage  had 
been  employed  and  contributed  materially  towards 
this  complication.  In  subsequent  cases  the  oppor- 
tunity for  this  complication  was  so  minimized  by 
the  avoidance  of  any  drainage  that  it  did  not  occur. 
I  prefer  the  second  of  the  two  methods  outlined 
(with  or  without  the  aid  of  a  Murphy  button), 
both  because  of  the  time  saving  factor  and  because 
of  the  close  approach  of  the  resulting  anatomical 
relationship  to  the  normal  morphology. 

With  good  technic  the  operative  field  is  not  con- 
taminated and  the  abdominal  wound  can  be  closed 
entirely.  It  is  not  necessary  and  it  is  a  distinct 
disadvantage  to  drain  in  any  of  these  cases ;  drain- 
age is  frequently  a  broad  invitation  for  trouble.  The 
presence  of  a  tuberculous  lesion  furnishes  an  addi- 
tional and  powerful  factor  for  the  avoidance  of 
any  drainage. 

Intestinal  tuberculosis  is  a  very  common  condi- 
tion, more  frequently  than  not  associated  with  pul- 
monary foci.  When,  however,  limited  to  the  ileo- 
cecal region  the  tuberculous  lesion  is  quite  com- 
monly independent  of  any  other  focus  in  the  body 
and,  as  a  primary  condition,  forms  the  portal  of 
entry  of  the  infection.    Advanced  forms  of  either 


disease  can  be  recognized  with  the  clinical  means  at 
our  command  with  a  fair  degree  of  certainty.  The 
early  and  latent  cases  are  not  so  susceptible  of 
recognition;  have  few,  if  any,  symptoms;  are  not 
accompanied  by  a  perceptible  cachexia,  and  fre- 
quently make  their  initial  appearances  under  the 
acute  and  urgent  circumstances  of  an  acute  appendi- 
citis in  the  pathological  condition  of  which  the  true 
nature  of  the  lesion  is  successfully  camouflaged. 
This  local  form  of  tuberculosis  lends  itself  very 
readily  and  efficiently  to  surgical  treatment  and  gives 
promise  of  affording  a  complete  cure  when  the 
condition  is  properly  handled. 
1200  Madison  Avenue. 


Surgical  Aspect  of  Dysentery. — Z.  Cope  (Lan- 
cet, March  13,  1920)  gives  the  results  of  his  experi- 
ence in  Mesopotamia,  together  with  a  review  of  the 
literature  regarding  this  subject.  Dysentery  may 
develop  in  the  course  of  the  surgical  treatment  of 
almost  any  condition  as  a  lighting  up  of  an  old 
process  by  the  preliminary  purgation  or  as  a  ter- 
minal event  in  a  long  drawn  out  surgical  condition. 
It  may  simulate  carcinoma  of  the  gut  or  almost 
any  of  the  acute  surgical  conditions  of  the  abdomen. 
But  of  chief  interest  to  the  surgeon  are  the  com- 
plications of  dysentery  due  to  local  processes  set 
up  by  the  inflammatory  reactions  in  various  parts 
of  the  organism.    These  are: 

1.  Perforation  of  the  gut,  comparatively  rare  in 
occurrence,  most  common  in  the  cecum  and  sigmoid. 
When  the  perforation  is  into  the  peritoneal  cavity 
the  treatment  is  rendered  difficult  by  the  debilitated 
state  of  the  patient  and  by  the  fact  that  the  intes- 
tinal wall  of  dysentery  is  extremely  friable  about 
the  site  of  the  perforation.  Suture  is  rarely  suc- 
cessful and  patients  occasionally  recover  without 
interference.  Abscesses  due  to  retroperitoneal  rup- 
ture of  the  wall  respond  well  to  incision  and 
drainage.  2.  Acute  edematous  localized  colitis  pro- 
duces symptoms  so  similar  to  those  of  appendicitis 
that  this  must  be  constan^-ly  kept  in  mind.  The  con- 
dition at  this  point  in  the  intestinal  tract  does  not 
give  rise  to  the  more  urgent  symptoms  of  dysentery, 
so  careful  stool  examinations  are  necessary.  3. 
Dysenteric  appendicitis  occurs  occasionally.  4.  Ex- 
tensive sloughing  with  the  formation  of  large  sec- 
ondarily infected  ulcerating  areas  which  fail  to 
respond  to  emetine  requires  appendicostomy  or 
valvular  cecostomy  with  systematic  irrigations  of 
the  large  intestine.  If  this  fails  to  heal  the  ulcera- 
tion, open  cecostomy  or  enterostomy  with  complete 
division  of  the  small  gut  to  give  the  colon  a  com- 
plete rest  for  some  weeks  should  be  performed. 

5.  Cicatrization  is  exceedingly  rare,  probably  because 
the  cases  with  ulceration  and  inflammation  enough 
to  produce  large  cicatrices  are  so  commonly  fatal. 

6.  In  eleven  cases  of  perinephritic  abscess  not  due 
to  gross  disease  of  the  kidney,  the  writer  found  four 
with  a  history  of  previous  dysentery  or  diarrhea  and 
in  two  of  these,  amebse  were  found  in  the  stool. 

The  more  remote  complications,  amebic  hepatitis, 
abscess  of  the  liver,  brain  and  spleen,  and  cysto- 
pyelitis,  are,  aside  from  the  hepatitis  and  liver  ab- 
scess, rare  in  occurrence.  They  must  be  treated 
with  emetine  as  well  as  surgically 


Editorial  Notes  and  Comments 


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NEW  YORK,  SATURDAY.  NOVEMBER  13,  1920. 


INTRALIGAMENTOUS  UTERINE 
FIBROMYOMATA. 
Myomata  of  the  uterus  found  in  the  folds  of  the 
broad  Hgament  represent  a  special  variety  of  these 
nedsplasms.  They  merit  a  special  study  by  them- 
selves both  because  of  their  peculiar  clinical  char- 
acter and  the  somewhat  special  conduct  to  be  fol- 
lowed in  their  treatment.  These  growths  are  char- 
acterized by  their  implantation  on  the  sides  of  the 
uterus,  in  the  body  of  the  organ  and  more  especially 
the  cervix.  In  order  to  understand  the  evolution  of 
intraligamentous  myomata  the  shape,  direction  and 
exact  site  of  the  broad  ligaments,  their  relationship 
to  all  the  pelvic  viscera — bladder,  ureter,  intestine, 
rectum,  vessels  and  nerves — must  be  clearly  under- 
stood. The  two  layers  of  the  broad  Hgament  are 
separated  by  a  cellular  layer — the  socalled  umbilico- 
pelvic  aponeurosis  of  Petit — which  lines  each  broad 
ligament  and  separates  their  two  folds.  These 
neoplasms  are  variable  in  size,  sometimes  single,  at 
other  times  multiple,  of  hard  or  soft  consistency, 
and  always  develop  in  a  transversal  direction.  Like 
other  uterine  fibromyomata  the  intraligamentous 
variety  may  undergo  malignant  changes,  and  septic 
processes  may  occur.  Separating  the  two  folds  of 
the  broad  ligament  they  may  likewise  dissect  oiT 
the  mesodermic  layer  or  even  decorticate  the  parie- 
tal peritoneum  to  some  extent.  The  bladder,  ureter, 
rectum,  vessels  and  nerves  of  the  pelvis  are  often 
deformed,  flattened  or  changed  in  their  anatomical 
relationships.  , 


The  cause  of  intraligamentous  development  of 
uterine  fibromyomata  is  not  clear;  their  frequency 
as  compared  with  other  similar  uterine  neoplasms  is 
about  one  to  ten.  The  symptoms  to  which  they  give- 
rise  are  above  all  disturbances  resulting  from  com- 
pression, while  the  functional  disturbances  that  con- 
stitute the  uterine  syndrome  are  usually  mild  in 
these  cases.  The  physical  signs  are  otherwise  im- 
portant. The  tumor  is  fibrous  in  consistency,  with 
a  transversal  development,  slightly  movable,  con- 
nected with  the  uterus  and  projecting  into  one  of 
the  vaginal  culs-de-sac.  The  diagnosis  is  not  al- 
ways an  easy  matter  and  can  be  made  by  combined 
abdominal  and  vaginal  palpation.  When  the  growth 
has  a  pelvic  development  the  differential  diagnosis 
must  be  made  between  hematocele  or  perhaps  in- 
flammation of  the  adnexa  and,  when  abdomino- 
pelvic,  between  tumors  of  the  iliac  bones,  ovary, 
or  broad  ligament  and  pregnancy. 

The  prognosis  is  somewhat  serious.  When  once 
developed  the  compression  disturbances  do  not 
retrogress  and  more  than  any  other  type  of  fibro- 
myomata those  comprised  within  the  broad  ligaments 
di.sturb  pregnancy  and  interfere  with  labor.  Op- 
eration is  indicated  when  the  onset  of  disturbances 
from  compression  is  detected.  Myomectomy  should 
only  be  employed  when  the  growth  is  single  and 
connected  with  the  uterus  by  a  thin  pedicle,  other- 
wise hysterectomy  should  be  done.  If  the  growth 
is  of  medium  size  and  inserted  at  the  upper  part 
of  the  side  of  the  uterus,  supravaginal  hysterec- 
tomy will  suffice,  but  it  .should  be  total  when  the 
neoplasm  is  inserted  in  the  cervix  or  is  large. 
Should  decortication  of  the  tumor  prove  to  be  la- 
borious, with  rupture  of  numerous  adhesions,  not 
only  should  careful  abdominal  drainage  be  carried 
out  but  it  is  better  not  to  suture  the  vagina.  When 
the  case  is  complicated  by  pregnancy  and  surgical 
intervention  is  necessary,  myomectomy  should  be 
done,  if  gestation  is  in  the  early  months,  and  if  to- 
ward the  end,  hysterecfomy  or  Porro's  operation. 
The  induction  of  premature  labor  should  invariably 
be  pro,scribed. 


THE  FUTURE  OF  HOSPITALS. 
The  trend  of  the  practice  of  medicine  appears 
to  be  in  many  respects  changing,  that  is  to  say,  it 
seems  that  the  medicine  cf  the  future  will  be  more 
of  a  preventive  character  than  formerly.  If  this  be 
so  then  the  ho.spital  system  will  require  a  certain 
amount  of  revision.    .Students  must  be  trained  as 


November  13,  1920.] 


EDITORIAL  ARTICLES. 


773 


thoroughly  in  diagnosing  early  symptoms  of  dis- 
ease and  in  the  best  ways  of  preventing  them  from 
becoming  serious,  as  in  treating  diseases  when  they 
have  obtained  a  foothold.  This  is  preventive  medi- 
cine as  expounded  by  Sir  James  ^Mackenzie.  In 
this  country  as  in  every  civilized  country  the  hos- 
pital system  must  be  made  to  conform  with  modern 
views  and  not  continued  on  the  old  lines  mei'ely  be- 
cause these  are  hallowed  by  tradition.  In  Great 
Britain,  however,  the  hospital  situation  is  more 
insistent  and  acvite  than  in  America.  The  hospitals 
there  are  one  and  all  financially  embarrassed,  as 
well  as  being  subject  to  the  defects  mentioned. 

British  hospitals,  from  time  immemorial  almost, 
have  depended  for  their  support  on  voluntary  con- 
tributions, and,  up  to  the  time  of  the  war,  this  sys- 
tem acted  in  a  satisfactory  manner  on  the  whole. 
But  the  war  has  changed  the  entire  aspect  of  aflfairs 
and  at  the  present  time  most  of  the  British  hos- 
pitals are  in  a  very  parlous  condition.  In  fact,  if  a 
rational  scheme  is  not  evolved  soon  worse  results 
will  ensue.  The  question  is  how  are  these  indis- 
pensable institutions  to  be  placed  on  a  sound  and 
solvent  footing?  While  the  voluntary  system  of 
maintaining  hospitals  has  much  to  be  said  in  its 
favor,  it  is  nevertheless  obvious  that  if  this  method 
does  not  bring  in  enough  money  to  conduct  the  in- 
stitutions in  a  proper  way,  it  must  either  be  modi- 
fied or  another  plan  must  be  thought  out. 

The  statement,  that  without  ample  resources 
neither  a  hospital  nor  a  medical  school  can  discharge 
its  functions  or  even  continue  to  carry  on  at  all, 
needs  no  argument.  This  fact  is  so  thoroughly 
realized  in  most  European  countries  that  hospitals 
are  maintained  by  the  State  or  aided  by  municipal- 
ities or  wealthy  religious  communities.  It  will  be 
superfluous  to  enter  into  the  many  reasons  why  the 
voluntary  system  has  proved  inadequate.  It  is  plainly 
evident  that  hospitals  cannot  continue  to  provide 
gratis  medical  and  surgical  attendance  to  all  who 
ask  for  it.  The  most  sensible  way  out  of  the  quan- 
dary would  seem  to  be  the  introduction  of  the  pay 
ward  system  or  partial  pay  ward  system.  At  any 
rate,  the  hospitals  might  charge  for  the  board, 
lodging  and  drugs  supplied.  Some  institutions 
have  done  this. 

The  Class  for  whom  the  British  voluntarv  hos- 
pitals were  in  the  first  instance  established,  the 
really  poor,  are  no  longer  with  us.  or  rather  are 
with  us  in  another  guise,  ^^'orking  men  and  small 
tradesmen  are  nowadays  comparatively  well  to  do 
and  can  easily  aflford  to  pay  for  hospital  care  and 
treatment  and  undoubtedly  many  in  and  outpatients 
are  obtaining  for  nothing  the  treatment  and  medi- 
cines for  which  they  are  able  to  make  a  moderate 


payment.  The  poor  in  Great  Britain  at  the  present 
time  are  the  middle  classes  who  are  overburdened 
with  taxation  from  which  the  working  classes  are 
almost  entirely  exempt,  and  the  former  have  never 
resorted  to  hospitals,  but  doubtless  would  be  glad 
to  do  so  if  they  could  be  received  as  paying  guests. 
State  aid  is  abhorrent  to  British  individualism  and 
the  alternative,  the  pay  ward,  would  appear  to  be 
much  better  suited  to  the  character  of  the  people. 
In  this  country  the  pay  ward  system,  as  a  rule, 
works  well,  it  tends  to  promote  selfrespect  and 
independence  and  is  fair  to  all.  People  will  go  to 
hospitals  much  more  than  ever  before.  Home  treat- 
ment, except  for  minor  ailments,  is  becoming  less 
and  less  common. 

The  future  of  hospitals  is  full  of  promise  but 
at  the  same  time  it  should  be  understood  that  they 
must  move  with  the  times,  and  that  both  for  pre- 
ventive and  curative  and  remedial  treatment  they 
must  be  so  constituted  and  equipped  that  they  pro- 
vide absolutely  the  best  means  of  treatment.  The 
situation  as  regards  British  hospitals  has  been  dealt 
with  in  order  that  the  American  medical  profession 
may  understand  the  difficulties  which  confront  the 
medical  profession  in  the  British  Isles.  Some  of 
our  readers  may  like  to  discuss  the  point  as  to  how 
the  pay  ward  system  has  worked  generally  in 
America  and  to  suggest  ideas  as  to  the  hospital 
of  the  future. 


PHYSICIAX-AUTHORS:    DR.  ERASMUS 
DARWIN. 

All  educated  people  today  are  more  or  less 
familiar  with  the  Darwinian  theory,  evolved  b)' 
Charles  R.  Darwin,  the  greatest  English  naturalist 
of  the  nineteenth  century  and  author  of  The 
Origin  of  Species  and  Tlie  Descent  of  Man.  Com- 
paratively few,  however,  know  that  Darwin  suc- 
ceeded to  an  intellectual  inheritance  and  carried 
out  a  program  sketched  and  left  behind  by  his 
grandfather,  Dr.  Erasmus  Darwin,  an  eighteenth 
century  English  physician  who  was  possessed  of 
an  indefatigable  spirit  of  research  and  almost  the 
same  biological  tendenc)*  as  his  illustrious  grand- 
son. Both  had  theories  of  evolution.  The  fame  of 
the  grandson  is  based  almost  wholly  upon  the  theor}'' 
he  so  ably  expounded,  but  the  grandfather  and  his 
theory  have  been  lost  sight  of  almost  completely. 
And  yet  it  was  he,  and  not  Lamarck,  the  French 
zoologist,  who  originated  the  doctrine  of  organic 
evolution  and  of  invertebrate  paleontology — in 
other  words,  that  all  living  beings  arose  from  germs 
through  spontaneous  generation.  Dr.  Samuel  But- 
ler— the  Erwlwnian  Butler — openly  accused  La- 
marck "of  having  gotten  his  ideas  from  Erasmus 


774 


EDITORIAL  ARTICLES 


[New  York 
Medical  Journai.. 


Darwin's  Zoonomia,  and  in  his  Evohttion  Old  and 
New  Butler  takes  pains  to  show  the  complete  co- 
incidence of  Dr.  Darwin's  views  with  those  later 
expressed  by  Lamarck.  "The  chief  fault  \vith  Dr. 
Darwin's  treatise  on  evolution/'  says  Butler,  "is 
that  there  is  not  enough  of  it;  what  there  is,  so  far 
from  being  'erroneous'  (as  Charles  Darwin  con- 
tended), is  admirable.  But  so  great  a  subject  should 
have  had  a  book  by  itself,  not  a  mere  fraction  of  a 
book.  .  .  That  is  the  only  way  men  can  expect  to 
succeed  against  the  vested  interests.  Dr.  Darwin 
has  said  enough  to  show  that  he  had  the  whole 
thing  clearly  before  him,  and  could  have  elaborated 
it  as  finely  as  or  better  than  Lamarck  himself  has 
done,  yet  the  palm  must  be  given  to  Lamarck  on 
the  score  of  what  he  actually  did,  and  this,  I  ob- 
serve to  be  the  verdict  of  history,  for  whereas 
Lamarck's  name  is  still  daily  quoted.  Dr.  Darwin's 
is  seldom  mentioned,  and  never  with  the  applause 
it  deserves." 

The  essence  of  Dr.  Darwin's  theory  of  evolution 
is  contained  in  the  following  passage :  "Would  it 
be  too  bold  to  imagine  that,  in  the  great  length  of 
time  since  the  earth  began  to  exist,  perhaps  millions 
of  ages  before  the  commencement  of  the  history  of 
mankind — would  it  be  too  bold  to  imagine  that  all 
warm  blooded  animals  have  arisen  from  one  living 
filament,  which  the  First  Cause  endued  with  ani- 
mality,  with  the  purpose  of  acquiring  new  parts, 
attended  with  new  propensities,  directed  by  irrita- 
tions, sensations,  volitions  and  associations,  and 
thus  possessing  the  faculty  to  continue  to  improve 
by  its  own  inherent  activity,  and  of  delivering  down 
these  improvements  by  generation  to  its  posterity, 
world  without  end !" 

Zoonomia,  in  which  this  theory  appeared,  was 
Dr.  Darwin's  chief  prose  work.  It  has  been  de- 
scribed as  "an  exhaustless  repository  of  interesting 
facts,  of  curious  experiments  in  natural  produc- 
tion and  in  medical  effects."  The  second  part  of 
it  is  devoted  to  an  enumeration  of  diseases,  classi- 
fied, and  suggestions  as  to  their  medical  treatment, 
illustrated  by  brief  reports  on  cases.  His  theory 
of  evolution  was  closely  connected  with  his  scheme 
of  classifying  diseases.  The  book  was  read  ex- 
tensively by  medical  men  of  Darwin's  day,  who 
highly  esteemed  him  as  a  practitioner.  The  aver- 
age man  today  never  so  much  as  heard  of  Dr. 
Darwin,  but  a  little  more  than  a  century  ago  he 
enjoyed  a  world  wide  reputation  as  aft  author. 
This  was  due  chiefly  to  his  long  didactic  poem.  The 
Botanic  Garden,  which  was  a  literary  sensation  and 
enjoyed  a  best  seller  vogue  not  only  in  all  English 
speaking  countries  but  also  in  France,  Germany, 
Spain,  Italy  and  other  countries. 


It  was  in  verse  that  Dr.  Darwin  usually  expressed 
himself — verse  that  has  been  condemned  by  the 
critics  as  being  more  rhetorical  than  poetical,  and 
monotonously  bloodless  and  mechanical.  Schiller, 
speaking  of  The  Botanic  Garden,  called  it  "cold 
intellectuality  disguised  in  verse" ;  Coleridge  com- 
pared it  to  a  Russian  ice  palace,  "glittering,  cold 
and  transitory" ;  and  the  ruthless  Sidney  Lanier 
branded  it  as  "the  funniest  earnest  book  in  our 
language."  It  took  Dr.  Darwin  several  years  to 
write  The  Botanic  Garden."  Every  line  of  it  was 
polished  and  sharpened  elaborately,  much  of  this 
being  done  as  he  rode  from  one  patient  to  another. 
The  first  part  appeared  in  1781  and  it  was  not  until 
eight  years  later  that  the  second  part,  called  The 
Loves  of  the  Plants,"  appeared.  But  despite  the 
infinite  pains  Dr.  Darwin  took  with  it,  its  only 
merit  lies  in  its  scientific  enthusiasm  and  the  great 
knowledge  of  nature  which  it  displays.  Dr.  Darwin 
decidedly  was  no  poet.  Here  and  there  there  are 
flashes  of  genuine  beauty,  but  these  are  very  rare. 
Generally  his  style  is  so  pompous  that  it  becomes 
ridiculous  and  the  whole  effect  is  one  of  artifi- 
ciality. 

The  novelty  of  The  Botanic  Garden  had  much  to 
do  with  its  wide  popularity.  It  personified  the 
plants  (in  accordance  with  the  system  of  Lin- 
niEUS,  the  Swedish  naturalist,  who  demonstrated 
that  all  flowers  contain  families  of  males  or  fe- 
males or  both)  and  described  their  love  affairs. 
It  was  an  ingenious  attempt  to  unite  science  and 
poetry  but  was  almost  as  short  lived  as  a  flower 
itself.  In  personifying  plant  life  the  Belgian  au- 
thor, Maeterlinck,  has  done,  a  much  better  job. 

Dr.  Darwin's  other  poetical  works  were  The 
Temple  of  Nature  with  philosophical  notes,  and  The 
Shrine  of  Nature,  both  of  which  were  published 
posthumously,  and  in  both  of  which  Darwin  em- 
bodied an  amazing  amount  of  nature  research  and 
observation. 

Besides  Zoonomia,  Darwin's  prose  works  included 
Phytologia,  or  The  Philosophy  of  Agriculture  and 
Gardening,  in  which  he  announced  his  belief  that 
plants  have  sense  and  volition,  and  a  paper  on 
Female  Education  in  Boarding  Schools. 

In  addition  to  his  medical  practice  and  his  writing, 
Darwin  was  an  ardent  prohibition  worker,  one  of 
the  pioneer  drys,  and  did  much  to  diminish  drunk- 
enness among  the  poorer  classes.  Dr.  Darwin  was 
born  at  Elton,  Nottinghamshire,  England,  on 
December  12,  1731.  He  studied  at  St.  John's  Col- 
lege, Cambridge,  then  at  Edinburgh,  and  in  1756 
began  the  practice  of  medicine  in  Nottingham. 
Later  he  practised  at  Litchfield  and  at  Derby,  where 
he  died  on  April  18,  18C2. 


Novcinlxr  13,  1920.] 


OBITUARY. 


775 


SELFCERTIFIED. 

Efforts  at  prevention  of  disease  have  gone  as 
far  back  as  endeavoring  to  influence  the  shadowy 
ghost  of  infant  Hfe  which  feebly  raps  upon  the 
gate  of  life  as  it  still  lies  in  the  womb.  Giving  all 
prenatal  care  to  the  mother  of  the  unborn  child  is 
a  great  advance.  The  great  cry  now  is  "Prevent, 
prevent,"  and  one,  almost  as  loud,  is  "cooperate," 
the  last  phase  of  cooperation  occurring  in  the  Brit- 
ish Ministry  of  Health  Bill,  Part  II,  asking  the  vic- 
tims of  incipient  mental  disorder,  but  not  yet 
lunatic,  to  become  voluntary  boarders  for  six 
months  at  an  institution  approved  by  the  Minister 
of  Health,  two  doctors  certifying  that  by  such 
treatment  he  is  likely  to  benefit.  No  stigma  of 
insanity  will  be  attached,  and  free  exit  will  be 
allowed.  Periodical  inspection  by  health  officials 
will  be  made.  It  will  also  ease  families  from  that 
most  dreaded  task  of  having  a  member  put  away 
for  his  own  protection  and  that  of  others. 

The  special  committee  of  the  medicopsychological 
urge  this  as  an  amendment  and  not  a  revision  of 
the  Lunacy  Acts.  They  urge  the  need  of  imposing 
upon  local  authorities  the  duty  of  providing  the 
requisite  treatment  directly  or  through  voluntary 
organization  and  insist  there  shall  be  special  staffing 
and  special  management,  the  institution  shall  be 
apart  from  the  asylum,  as  any  association  would 
fatally  prejudice  the  place  in  the  eyes  of  the  people. 

It  is  true  that  there  are  hundreds  who  feel  they 
are  going  mad  who  dare  not  confess  to  being  con- 
scious of  it  because  of  the  stigma  on  the  family 
(hereditariness)  and  the  horrible  fear  of  being  shut 
up  behind  bolts  and  bars,  release  coming  only  by 
consent  of  relations  and  doctors.  If  such  institu- 
tions were  established,  a  man  would  have  the  same 
relief  on  giving  up  the  fight  against  insanity  as  he 
has  when  beaten  by  any  other  disease  and  finally 
lays  his  weary  head  on  the  pillow  and  lets  that 
mighty,  swift  flying,  life  battering  business  world 
go  its  way  without  his  very  important  direction. 
There  would  be  no  madness  in  taking  a  prolonged 
rest,  rather,  the  most  suspicious  would  be  inclined 
to  regard  a  man  as  sane  for  so  doing.  A  difficulty 
will  be  in  keeping  out  those  neurotics  who  keep  a 
mental  microscopic,  periscopic,  telescopic,  eye  open 
to  all  their  own  symptoms  and  would  rather  be 
treated  for  insanity  than  not  noticed  at  all. 


A  NEW  OBSTETRICAL  JOURNAL. 
The  American  Journal  of  Obstetrics  and  Gyne- 
cology, a  new  monthly  periodical  devoted  to  ob- 
stetrics and  gynecology,  made  its  first  appearance  in 
October.  Dr.  George  W.  Kosmak,  of  New  York, 
is  editor  of  the  new  journal;  Dr.  Hugo  Ehrenfest, 


of  St.  Louis,  is  associate  editor,  and  many  of 
America's  leading  obstetricians  and  gynecologists 
lend  their  names  to  the  editorial  board.  It  is  stated 
that  a  special  feature  will  be  the  department  devoted 
to  current  medical  literature,  which  will  be  under 
the  direction  of  Dr.  Ehrenfest.  The  first  issue  of 
the  new  journal  presents  an  excellent  appearance, 
and  if  it  fulfills  the  promise  of  this  first  issue  it 
should  prove  a  valuable  addition  to  the  medical 
publications  of  this  country.  It  is  published  by 
the  C.  V.  Mosby  Company,  St.  Louis,  Mo. 


A  PHYSICIAN  IN  THE  HALL  OF  FAME. 
Dr.  William  Thomas  Greene  Morton  has  been 
elected  to  a  place  among  the  men  of  achievement 
in  the  Hall  of  Fame.  Dr.  Morton  was  first  a  dental 
surgeon  and  later  a  physician.  He  received  his 
M.  D.  from  Washington  University  in  1849.  He 
discovered  anesthesia  and  in  this  way  brought  a 
boon  to  mankind.  Artificial  sleep  could  be  induced, 
enabling  surgeons  to  perform  the  needful  opera- 
tions, at  the  same  time  avoiding  pain  for  the  patient. 
His  discovery  he  called  letheon ;  today  it  is  known 
as  ether.  The  discover}'  was  made  public  b}'  an 
operation  performed  in  the  Massachusetts  General 
Hospital,  October  16,  1846,  by  Dr.  J.  C.  Warren, 
to  whom  Morton  had  communicated  his  discovery. 
To  honor  the  discoverer  of  this  blessing  to  dis- 
ordered humanity,  the  French  Academy  of  Science 
awarded  Morton  the  Moiithyon  prize  of,  twenty-five 
hundred  francs. 


Obituary. 


ISADORE  DYER,  M.  D., 

of  New  Orleans. 

One  of  the  best  known  and  most  loved  of  Amer- 
ica's physicians,  Dr.  Isadore  Dyer,  died  at  his  home 
in  New  Orleans  on  the  morning  of  October  12,  1920. 
For  thirty  years  he  had  given  the  best  of  himself  in 
his  practice,  in  his  writings  and  as  the  coeditor  of 
the  New  Orleans  Medical  and  Surgical  Journal  and 
the  American  Journal  of  Tropical  Medicine. 
He  was  born  in  Galveston,  Texas,  fifty-four  years 
ago  and  was  graduated  from  the  Sheffield  Scientific 
School  in  1887  and  from  Tulane  University  in  1889. 
He  then  began  to  specialize  in  skin  diseases,  serving 
an  internship  at  the  New  York  Skin  and  Cancer 
Hospital.  For  thirteen  years  he  lectured  on  dis- 
eases of  the  skin  at  Tulane  University.  In  1905 
he  was  made  associate  piofessor  and  finally  in  1908 
he  became  professor  and  dean  of  the  medical  school, 
a  position  he  held  until  his  death.  The  study  of 
leprosy  attracted  him  and  it  was  with  this  disease 
that  his  name  was  most  frequently  associated.  He 
was  the  founder  and  the  president  of  the  first  board 
of  directors  of  the  Louisiana  Lepers'  Home,  and 
one  of  the  most  active  physicians  connected  with 
this  institution.  Dr.  Dyer  was  also  a  member  of 
the  Medical  Corps  of  the  U. 'S.  x'Vrmy,  achieving 
the  rank  of  colonel  in  1919.  His  was  a  useful 
work  in  the  service  of  mankind  and  for  this  and 
for  his  pleasing  personality  he  will  be  remembered 
by  his  patients  and  colleagues. 


776 


NEWS  ITEMS. 


[New  York 
Medical  Journal. 


News  Items. 


Harvey  Lecture. — The  third  lecture  in  the 
course  will  be  given  Saturday  evening,  November 
20th,  by  Dr.  Nellis  B.  Foster, 'of  Cornell  University 
^Medical  College,  his  subject  being  Uremia. 

New  Building  for  National  Academy  of  Sci- 
ences.— A  site  has  been  obtained  for  the  new 
building  which  is  to  be  erected  in  ^^'ashington. 
D.  C,  to  serve  as  a  home  for  the  National  Academy 
of  Sciences  and  the  National  Research  Council.  It 
comprises  the  block  bounded  by  B  and  C  and 
Twenty-first  and  Twenty-second  Streets. 

New  York  State's  Birth  Rate.— During  the 
four  years  1914-1917  the  average  annual  birth  rate 
for  the  State  of  New  York  was  23.8  to  the  thou- 
sand population ;  in  1918  it  fell  to  22.7  and  in  1919 
it  declined  still  further  to  20.8.  During  the  first 
eight  months  of  1920  the  birth  rate  was  21.7  for 
the  entire  .state;  22.2  for  New  York  city  and  21.0 
for  the  rest  of  the  state. 

Mental  Hygiene  Course  at  Columbia. — An  ex- 
tension course  in  mental  hygiene  for  community 
workers  is  being  given  in  the  sociology  department  of 
Columbia  University.  During  the  course  lectures 
on  special  topics  will  be  delivered  bv  Dr.  Thomas 
W.  Sal  mon.  Dr.  \V.  A.  \\  hite.  Dr.  Pearce  Bailev, 
Dr.  Louis  Casamajor.  Prof.  R.  S.  \\'oodworth.  Dr. 
William  Healy,  Dr.  Charles  B.  Davenj^ort,  Dr.  F.  E. 
\Villiams,  Dr.  Walter  E.  Fernald,  Dr.  Bernard 
Glueck.  and  Miss  Maude  ^liner. 

American  Public  Health  Association. — At  the 
annual  meeting  of  this  association,  held  in  San 
Francisco,  Cal.,  on  September  15th.  the  following 
officers  were  elected:  President,  Dr.  M.  P.  Ravenel. 
of  Columbia,  Mo. ;  first  vice-president,  Dr.  Theo- 
dore B.  Beatty,  of  Salt  Lake  City,  Utah;  second 
vice-president,  Dr.  Louis  I.  Dublin,  of  New  York; 
third  vice-president.  Dr.  W.  C.  Hassler,  of  San 
Franci.sco;  secretary,  Mr.  A.  W.  Hedrich,  of  Bos- 
ton: treasurer.  Dr.  Roger  L  Lee,  of  Cambridge. 
Mass. 

American  Association  of  Military  Rontgenolo- 
gists.— At  the  recent  annual  meeting  of  the 
Aiuerican  Rontgen  Ray  Society,  the  American 
Association  of  Military  Rontgenologists  was  organ- 
ized, with  the  following  of¥icers  to  serve  for  the 
first  year:  Dr.  Arthur  C.  Christie,  of  Washington, 
D.  C,  president;  Dr.  Henry  K.  Pancoast,  of  Phila- 
delphia, vice-president ;  Dr.  Francis  F.  Borzell,  of 
Philadelphia,  secretary.  All  otTicers  of  the  medical 
and  .sanitary  corps  who  were  actively  engaged  in 
X  ray  work  during  the  war  are  eligible  to  member- 
ship in  the  association. 

Danger  in  Horse  Hair  Shaving  Brushes. — The 
United  States  Public  Health  Service  issues  a  warn- 
ing against  the  use  of  horsehair  shaving  brushes, 
as  a  nuiuber  of  cases  of  anthrax  have  been  traced 
to  their  use.  Surgeon  General  Cumming  says  that 
every  efifort  possible  under  existing  laws  has  been 
made  to  prevent  the  occurrence  of  anthrax  due 
to  infected  shaving-brushes,  but  in" spite  of  all 
efforts  cases  of  anthrax  will  occur  as  long  as  the 
public  buys  and  uses  shaving  brushes  made  of  horse 
hair.  He  says  that  Congress  will  be  asked  to  pro- 
hibit the  use  of  horsehair  for  that  purpose. 


Plague  Research  in  Florida. — The  United 
States  Public  Health  Service  has  established  at  Pen- 
sacola.  Fla.,  a  research  station  for  the  study  of  bu- 
bonic plague.  Additional  trained  experts  have  been 
detailed  to  cooperate  with  those  already  stationed 
there,  and  an  increase  in  research  equipment  to 
facilitate  investigations  \vill  be  provided. 

Johns  Hopkins  May  Have  a  Reserve  Medical 
Officers'  Training  School. — Surgeon  General 
Merritte  W.  Ireland,  United  States  Army,  has 
ofifered  to  establish  a  Reserve  Officers'  Medical 
Training  Corps  at  Johns  Hopkins  Medical  School, 
provided  at  least  fifty  students  will  agree  to  enroll 
in  it.  The  trustees  of  the  school  have  accepted  the 
offer. 

Brooklyn  Hospitals  Meet  Requirements  of 
American  College  of  Surgeons. — Standards  of 
hospital  efficiency  and  administration  set  by  the 
American  College  of  Surgeons  have  been  met  by 
the  following  Brooklyn  hospitals  :  Cumberland  Street 
Hospital,  Greenpoint  Hospital,  Coney  Island  Hos- 
pital, and  Kings  County  Hospital.  These  are  all 
general  hospitals  conducted  under  the  direction  of 
the  Department  of  Public  Welfare. 

Philadelphia  County  Medical  Society. — At  a 
business  meeting  of  this  society,  held  on  the  evening 
of  October  20th,  the  following  officers  were  nom- 
inated for  the  comipg  year :  President,  Dr.  John  W. 
West  and  Dr.  G.  Morris  Piersol ;  vice-president. 
Dr.  \\^ilmer  Krusen ;  secretary.  Dr.  J.  Morton 
Boice ;  treasurer.  Dr.  Edward  A.  Shumway ;  as- 
sistant secretary.  Dr.  Charles  Scott  Miller ;  directors. 
Dr.  F.  Hurst  Maier,  Dr.  William  E.  Parke,  and  Dr. 
George  A.  Knowles ;  censor.  Dr.  Levi  J.  Hammond : 
district  censor  to  the  State  society.  Dr.  E.  E.  Mont- 
gomery. 

Kentucky  Medical  Association. — At  the  seven- 
tieth annual  meeting  of  this  association,  held  in 
Lexington  on  September  27th  to  30th,  Dr.  William 
W.  Anderson,  of  Newport,  was  elected  president, 
succeeding  Dr.  John  G.  South,  of  Frankfort,  and 
other  officers  were  elected  as  follows:  Dr.  Joseph 
A.  Stucky,  of  Lexington,  president-elect;  Dr.  Rob- 
ert H.  Cowley,  of  Berea,  first  vice-president;  Dr. 
Alice  N.  Pickett,-  of  Louisville,  second  vice-presi- 
dent ;  Dr.  Elbert  W.  Jackson,  of  Paducah,  third 
vice-president ;  Dr.  Arthur  T.  McCormack,  of 
Bowling  Green,  secretary.  Next  year's  meeting 
will  be  held  in  Louisville. 

University  of  Buffalo  Endowment  Fund. — The 
long  felt  need  for  an  adequate  endowment  fund  for 
the  University  of  Buffalo  has  been  recently  realized, 
a  camjiaign  made  from  October  7th  to  17th  for  a 
five  million  dollar  endowment  fund  resulting  in  a 
total  of  about  $5,100,000.  The  scheme  of  the 
campus  was  chosen  from  competitive  plans  sub- 
mitted by  landscape  architects.  The  style  of  the 
architecture  is  to  be  Georgian  Colonial.  The  first 
building,  now  in  process  of  construction  at  an  esti- 
mated cost  of  $400,000,  will  be  devoted  to  the  teach- 
ing of  chemistry.  The  liberal  arts,  library  and  ad- 
ministration buildings  will  be  the  next  erected.  Other 
buildings  will  naturally  follow  in  the  development 
of  the  University  plan.  The  income  from  the  re- 
maining funds  will  be  available  for  the  use  of  the 
several  departments. 


.\uiembcr  13.  1920.] 


XEIVS  ITEMS. 


777 


Relief  Work  in  the  Crimea. — To  meet  the  in- 
creasing needs  of  the  civiHan  population  and  thou- 
sands of  refugees  in  the  Crimea,  the  American  Red 
Cross  unit  there  has  been  authorized  to  increase  its 
distribution  of  food  and  supplies  to  500  tons 
weekly.  Supplies  now  held  at  the  Constantinople 
base  have  been  made  immediately  available  for  this 
purpose  and  will  be  rushed  to  the  Crimean  unit  as 
rapidly  as  distribution  warrants.  For  the  purpose 
of  quickly  organizing  an  effective  system  of  distri- 
bution throughout  the  stricken  areas,  the  personnel 
of  the  Red  Cross  unit  has  been  increased  to  twenty- 
five  men.  Native  labor  is  assisting  in  the  work. 
The  work  of  the  American  Red  Cross  in  this  sec- 
tion is  confined  entirely  to  the  civilian  population. 

Civil  Service  Examinations.  —  The  United 
States  Civil  Service  Commission  announces  an 
examination  for  the  position  of  physician  in  the 
Panama  Canal  Service,  which  will  be  held  at  vari- 
ous points  throughout  the  United  States  on  Decem- 
ber 15,  1920,  and  January  19  and  March  9,  1921. 
The  entrance  salary  is  3250  a  month,  and  promo- 
tion may  be  made  to  as  high  as  S360  and  to  higher 
rates  for  special  positions.  The  salary  begins  on 
the  date  of  sailing.  Applicants  must  have  gradu- 
ated from  a  recognized  medical  school  and  have  had 
at  least  one  year's  postgraduate  hospital  experience. 
They  must  have  reached  their  twenty-second  l)ut 
not  their  thirty-first  birthday. 

Another  examination  will  be  held  for  the  ])Osition 
of  medical  intern  in  St.  Elizabeth's  hospital,  Wash- 
ington, D.  C,  for  which  applications  will  be  re- 
ceived until  March  1,  1921.  The  salary  is  $1200 
a  year  and  maintenance.  Applicants  must  not  liave 
graduated  in  .medicine  previous  to  the  year  1915 
unless  they  have  been  continuously  engaged  in  hos- 
pital, laboratory,  or  research  work  along  the  lines 
of  neurology  or  psychiatr\-  since  graduation. 

Personal. — Dr.  James  F.  ^NIcKernon  has  been 
elected  president  of  the  Xew  York  Post-Graduate 
Medical  School  and  Hospital,  to  succeed  Dr.  Fred- 
eric E.  Sondern. 

Dr.  Blanche  Norton,  an  American  physician,  has 
been  awarded  the  Cross  of  King  George  I  in  recog- 
nition of  her  work  among  the  trachoma  victims 
in  Greece. 

Dr.  Jose  S.  Salas,  of  the  Chilean  Army  Medical 
Cor])s,  is  visiting  the  United  States  for  the  purpose 
of  studying  methods  of  venereal  disease  control. 

Dr.  Bowman  L.  Robinson,  of  the  University  of 
Wisconsin,  has  been  appointed  professor  of  hygiene 
in  the  University  of  Mississippi. 

Dr.  David  E.  Hoag,  has  been  made  associate  in 
neurology,  in  the  department  of  nervous  and  mental 
diseases,  at  the  New  York  Post-Graduate  ^ledical 
School  and  Hospital ;  also  lecturer  on  nervous  and 
mental  diseases,  at  the  University  and  Bellevue  Hos- 
l)ital  Medical  College. 

Dr.  James  Ewing,  professor  of;  plathology  at 
Cornell  University  Medical  College,  and  former 
director  of  cancer  research  at  the  General  Memorial 
Hospital,  Xew  York,  has  been  appointed  a  member 
of  the  board  of  trustees  of  the  State  Institute  for 
the  Study  of  Malignant  Disease,  at  Buffalo,  to 
fill  a  vacancy  caused  by  the  resignation  of  Dr. 
Seymour  Oppenheimer. 


To  Register  Disabled  Veterans  for  Vocational 
Training. — A  three  months'  campaign  to  register 
disabled  soldiers  and  sailors  for  vocational  training 
and  education  has  been  inaugurated  by  the  Federal 
Board  for  \'ocational  Training.  The  board  an- 
nounces that  no  effort  will  be  spared  to  locate  de- 
serving men  who  have  been  injured  in  military  serv- 
ice and  to  see  that  every  ex-service  man  entitled  to 
training  actually  gets  it.  The  $90,000,000  appro- 
priated by  congress  for  their  rehabilitation  is  -now 
being  distributed  in  the  form  of  compensation 
ranging  from  $80  to  $170  a  month. 

Meetings  of  Local  Medical  Societies. — ^The  fol- 
lowing medical  societies  will  meet  in  New  York  dur- 
ing the  coming  week : 

^loxDAY,  Xovcniber  13th. — Xew  York  Academy  of  Medi- 
cine (Section  in  Ophthalmologj')  ;  Medical  Association  of 
the  Greater  City  of  New  York ;  Psychiatric  Society  of 
Ward's  Island. 

Tuesday,  Xovei)ibcr  i6tli. — New  York  Academy  of  Medi- 
cine (Section  in  Medicine)  ;  Federation  of  Medical  Eco- 
nomic Leagues  of  New  York. 

Wedxesdav,  November  17th. — New  York  Academy  of 
Medicine  (Section  in  Genitourinary  Diseases)  :  Medico- 
legal Society ;  Northwestern  Medical  and  Surgical  Society 
of  New  York ;  Woman's  Medical  Association  of  New  York 
City ;  Alumni  Association  of  the  City  Hospital. 

Thursday.  November  iSth. — New  York  Academy  of 
Medicine  (stated  meeting)  ;  New  York  Celtic  Medical 
Society. 

Friday,  November  iglh. — New  York  Academy  of  Medi- 
cine (Section  in  Orthopedic  Surgery)  ;  Clinical  Society  of 
the  New  York  Postgraduate  Medical  School  and  Hospital ; 
New  York  Microscopical  Society :  Alumni  Association  of 
Roosevelt  Hospital ;  Brooklyn  Medical  Society. 



Died. 

Bfrxard. — In  Boston.  Mass.,  on  Thursday,  October  28th, 
Dr.  Barnard  L.  Bernard,  aged  fifty-seven  years. 

Bell. — In  Ogdenshurg.  N.  Y..  on  Thursday,  October 
28th,  Dr.  Willard  N.  Bell,  aged  sixty-two  years. 

BouTWELL. — In  Manchester.  N.  H.,  on  Tuesday,  Novem- 
ber 4th,  Dr.  Henry        Boutwell,  aged  seventy-two  years. 

CoHOOX. — In  Los  Angeles,  Cal.,  on  Friday,  October  22nd, 
Dr.  Brock  E.  Cohoon.  of  Seattle,  Wash.,  aged  thirty-seven 
years. 

CoLEMAX. — In  Mineral,  Va..  on  Sunday,  October  31st, 
Dr.  William  J.  Coleman,  aged  sixty-four  years. 

Dexchfield. — In  New  York,  on  Thursday,  November 
4th,  Dr.  Levi  J.  Denchfield,  aged  sixty-five  years. 

Featherstoxhaugh. — In  Duanesburg.  N.  Y.,  on  Wednes- 
day, October  27th,  Dr.  Thomas  Featherstonhaugh,  aged 
seventy-two  years. 

Gerhard. — In  Philadelphia,  Pa.,  on  Tuesday,  October 
26th,  Dr.  George  Gerhard,  aged  seventj'-one  years. 

Hawi-Ey. — In  Kalamazoo,  Mich.,  on  Monday,  October 
25th,  Dr.  Alanson  W.  Hawley,  of  Seattle,  Wash.,  aged 
fifty-four  years. 

HoRXiXG. — In  Norristown,  Pa.,  on  Friday,  October  26th, 
Dr.  Samuel  W.  Horning,  aged  fifty-eight  years. 

Lothrop. — In  Stanley.  Wis.,  on  Tuesday,  October  6th, 
Dr.  C.  A.  Lothrop,  aged  thirty-eight  years. 

Meltzer. — In  New  York,  on  Sunday,  November  7th,  Dr.. 
Samuel  James  Meltzer,  aged  sixty-nine  years. 

Morris. — In  Rockville,  Ind.,  on  Thursday,  October  28th, 
Dr.  Charles  C.  Morris,  aged  seventy-two  j'ears. 

Newcomet. — In  Stouchsburg,  Pa.,  on  Monday,  November 
1st,  Dr.  I.  W.  Newcomet,  aged  seventy-seven  years. 

Noble. — In  Greencastle,  Pa.,  on  Thursday,  October  29th, 
Dr.  William  P.  Noble,  aged  seventy-five  years. 

P.\lmer. — In  Johnsonburg.  Pa.,  on  Wednesday,  Novem- 
ber 3rd.  Dr.  William  R.  Palmer,  aged  fifty-seven  years. 


Book  Reviews 


STERILITY. 

Stcrilit\  in  Ji'onicn.  Bv  Arthur  E.  Giles,  ^I.  D.,  B.  Sc. 
(London),  M.  B.,  Ch.  B.  (Vict.),  F.  R.  C.  S.  (Edin.), 
M.  R.  C.  P.  (London),  Captain,  R.  A.  M.  C.  (Temp.)  ; 
Senior  Surgeon  to  the  Chelsea  Hospital  for  Women ; 
Gynecologist  to  the  Prince  of  Wales's  General  Hospital. 
Tottenham.  Illustrated.  London:  Henry  Frowde  (Ox- 
ford University  Press)  and  Hodder  &  Stoughton,  1919. 
Pp.  xi-227. 

Giles,  in  his  preface,  considers  sterility  as  an 
important  after  the  war  problem  rather  than  a  socio- 
logical or  biological  one.  He  thinks  that  with  the 
limitation  of  marriages  those  that  are  consummated 
should  at  least  be  fruitful.  Of  course  it  is  to  be 
remembered  that  he  is  speaking  now  for  England, 
where  conditions  are  not  the  same  as  in  this  coim- 
try.  On  the  other  hand,  when  he  takes  up  the 
issue  from  his  point  of  view  he  straightway  en- 
counters opposition.  First,  he  will  find  those  who 
believe  in  birth  control  and  in  this  camp  recruits 
have  come  for  two  main  reasons :  The  expenditure 
of  energy,  men  and  materials  have  accentuated  the 
struggle  for  livelihood,  and  the_  lesson  of  the  war, 
when  the  sons  of  Europe's  greatest  countries  were 
lined  up  one  camp  against  the  other.  They  do  not 
want  their  offspring  to  furnish  cannon  fodder ;  to 
live  in  vermin  filled  dugouts ;  or  to  become  fertilizer 
for  fields  made  bloody  at  the  will  of  senile  states- 
men who  have  outlived  their  usefulness.  This  at 
least  is  the  argument  offered  by  a  faction  of  the 
great  group  who  are  more  interested  in  controlling 
the  number  of  their  of¥spring  rather  than  in  meth- 
ods which  will  ensure  their  having  offspring.  This 
argument  is  mentioned,  not  to  disprove  any  of  the 
scientific  facts  which  Giles  presents,  but  merely  to 
check  up  the  motives  for  which  the  book  was  writ- 
ten. Europe  was  steeped  in  the  turmoil  of  war  for 
so  long  a  period  that  many  of  the  inhabitants,  A'ic- 
tims  of  quickly  formed  habits,  began  to  think  that 
Avar  was  a  normal  state  of  affairs.  Many  of  these 
people  find  it  hard  to  adjust  themselves  to  the  new 
conditions ;  in  fact,  for  a  goodly  portion  of  the 
population  peace  brought  few  changes.  The  ten- 
sion has  been  removed,  somewhat,  but  conditions 
are  far  from  what  we  were  pleased  to  call  normal 
before  the  war. 

In  view  of  all  this  we  shall  disregard  v,  hat  Giles 
says  in  his  none  too  spontaneous  introduction  and 
consider  his  researches  from  a  scientific  viewpoint 
alone. 

First  of  all,  in  considering  the  etiology  of  sterility 
in  women,  which  is  the  subject  discussed,  it  must  be 
ascertained  if  the  fault  lies  with  the  man.  This  is 
for  the  process  of  elimination.  Various  authors 
differ  in  their  estimate  of  the  responsibility  of  the 
male,  the  figures  var3dng  from  ten  to  ninety  per  cent., 
a  wide  range,  certainly.  Most  of  these  references 
are  taken  from  Hiihner.  The  estimates  of  the  pro- 
portion of  unproductive  marriages  also  vary  from 
two  to  over  twenty  per  cent.  These  figures  do  not 
seem  high,  for  most  women  who  are  desirous  of 
offspring  will  sooner  or  later  seek  the  aid  of  a 
gynecologist,  and  often  more  than  one.  So,  con- 
sidering these  points,  the  figures  when  reduced  to 
the  lowest  estimate  could  be  lowered  considerably 


as  applied  to  the  population  at  large.  It  is  some- 
what confusing  in  studying  these  statistics  to  find 
spinsters  listed  among  the  case  histories  studied. 
From  any  angle  it  is  difficult  to  find  a  reason  for 
this  compulsion  for  completeness  on  the  part  of  the 
author.  The  same  note  may  be  made  about  acro- 
batic statements  such  as,  "We  can  say  that  a  woman 
is  sterile  and  will  remain  so,  whether  she  be  a  virgin 
or  a  married  woman." 

First  of  all  the  various  mechanical  defects  and 
obstacles  are  considered.  These  are  many  and 
varied,  some  capable  of  correction  and  others  ir- 
remedial.  Then  sterility — and  here  the  author 
makes  the  distinction  between  sterility  and  non- 
productiveness — is  divided  into  functional,  primary 
(acquired  and  congenital),  and  secondary.  A  glance 
at  the  list  will  convince  one  that  many  conditions 
are  to  be  considered.  Among  the  functional  causes 
are  grouped :  impotence  of  husband,  nonocctirrence 
of  coittTS,  vaginismus,  dyspareunia,  sex  incompati- 
bility. Then  primary  sterility  is  made  to  embrace 
the  congenital  variety,  of  malformations  preventing 
intercourse,  such  as  absence  of  vagina,  atresia  of 
the  vagina,  stenosis  of  the  vagina,  and  where  inter- 
course is  allowed,  absence  or  underdevelopment  of 
the  ovaries,  atresia  of  the  fallopian  tubes,  atresia 
of  the  OS  uteri,  underdevelopment  or  anteflexion 
and  stenosis  of  the  uterus.  Then  we  have  a  long 
list  under  acquired  sterility  due  to  causes  such  as 
injtiries  to  the  vagina  and  cervix  causing  stenosis 
and  atresia,  cessation  of  ovarian  activity,  pelvic 
inflammation,  uterine  displacements,  ovarian  and 
uterine  tumors  and  uterine  fibrosis. 

We  have  yet  to  dispose  of  the  secondar}^  sterility 
due  to  the  effects  of  labor  and  the  other  effects  of 
acquired  sterility.  Quite  a  list  for  so  small  a  propor- 
tion of  sterile  women.  However,  we  might  add  that 
this  list  is  not  complete,  for  there  are  other  causes  in 
addition  to  the  long  list  enumerated.  These  vari- 
ous causes  of  sterility  have  been  carefully  gone 
over  by  Giles  and  he  has  assembled  a  formidable 
array  of  literature  on  the  subject.  There  is  little 
to  denote  that  much  recent  progress  has  been 
made.  For  example,  in  considering  vaginismus,  after 
allowing  that  the  condition  is  one  of  psychic  origin, 
the  treatment  advised  is  dilatation.  It  is  stated 
that  the  results  have  been  satisfactory  for  this 
method  of  treatment.  But  it  hardly  seems  con- 
sistent to  find  one  cause  and  then  turn  about  and 
treat  the  effect.  More  recent  workers  have  been 
successful  in  their  treatment  of  sterility,  when  the 
dysfunction  is  due  to  endocrine  disorders,  by  the  use 
of  various  glands  of  internal  secretion.  This  seems 
a  field  of  considerable  importance,  yet  Giles  has 
little  to  say  about  it.  He  confines  himself  in  the 
main  to  the  grosser,  more  obvious  anatomical  and 
physiological  disorders  which  usually  require  the 
surgical  or  medical  hero  to  correct.  So  it  is 
with  the  psychic  disorders  which  he  brushes  away 
with  a  mere  mention.  The  fact  that  sterility  is 
encountered  almost  twice  as  frequently  among  the 
well  to  do  should  lead  us  to  look  into  the  finer  and 
more  important  mechanisms  which  control  the 
workings  of  the  complex  human  organism. 


November  13,  1920.] 


BOOK  REVIEirS. 


779 


MATERNITY. 

Mateniitas.  A  Book  Concerning  the  Care  of  the  Pro- 
spective Mother  and  Her  Child.  By  Charles  E.  Pad- 
dock, M.  D.,  Professor  of  Obstetrics,  Chicago  Post- 
graduate Medical  School ;  Assistant  Clinical  Professor 
of  Obstetrics,  Rush  M.edical  College;  Attending  Ob- 
stetrician, St.  Luke's  Hospital.  Illustrated.  Chicago ; 
Lloyd  J.  Head  &  Co.,  1920.    Pp.  210. 

Half  a  century  ago,  the  condition  of  pregnancy 
and  the  safe  delivery  of  babies  was  considered 
rather  an  indelicate  subject,  and  it  was  only  whis- 
pered that  a  lady  was  "in  the  family  way."  Books 
on  the  subject  were  few  and  any  possessed  were 
carefully  hidden,  and  so  was  the  young  mother  to 
within  a  month  of  her  delivery,  her  nerves  and  her 
appearance  supposedly  justifying  this,  and  for  a 
month  afterwards  she  kept  to  her  bed  or  sofa  mainly 
with  the  idea  of  preserving  her  figure. 

Perhaps  the  young  mother  of  today  goes  to  the 
other  extreme  through  ignorance  or  daring.  In 
this  book  she  finds  none  but  reasonable  precautions 
urged  and  their  necessity.  Elderly  mothers  may 
dissuade  the  younger  ones  from  reading  by  quoting 
those  who  have  had  large  and  healthy  families  in 
defiance  of  all  the  rules  now  considered  obligatory, 
but  if  a  record  of  those  who  failed  were  given  it 
would  considerably  outnumber  the  totally  healthy. 
The  book  is  not  overloaded  with  details  likely  to 
alarm  the  mother,  because  the  advice  generally  winds 
up  with  "send  for  the  physician."  There  might 
be  a  chapter  for  mothers  in  outlying  districts  and 
far  away  places  on  What  to  Do  When  the  Doctor 
Can't  Come ;  but,  seriously,  the  book  seems  suffi- 
cient without  sending  for  him. 

The  new  baby  is  to  have  no  rubber  "comforter," 
and  no  kisses  except  a  few  sterilized  ones  from  the 
parents  on  the  forehead  or  cheek.  It  is  not  to  suck 
its  thumb  or  eat  pins,  buttons  and  marbles.  Part 
of  the  daily  exercise  is  "kicking,  screaming,  and 
waving  the  arms,"  but  the  screams  of  illness, 
hunger  and  cussedness  should  be  differentiated. 
Mrs.  John  Wesley  used  to  spank  it  for  the  third, 
first  for  crying,  then  for  crying  because  it  dis- 
approved the  laying  on  of  hands.  The  infant  is  to 
be  on  good  terms  with  the  doctor,  though  the  next 
bit  of  advice  that  the  child  should  be  taught  as 
soon  as  possible  to  put  out  its  tongue,  is  rather 
suggestive  of  a  baby  cave  dweller,  and  not  to  be 
followed  by  polite  infants. 

The  volume  concludes  with  some  useful  recipes 
for  both  mother  and  child,  and  the  whole  tone  is 
so  reassuring  and  cheerful  that  prospective  mothers 
may  face  maternity  with  a  light  heart. 

MEDICAL  BIOGRAPHIES. 

American  Medical  Biographies.  By  Howard  A.  Kelly, 
M.D.,  LL.D.,  F.A.C.  S.,  Hon.  F.  R.  C.  S.  (Edin.),  and 
Walter  L.  Burrage,  A.  M.,  M.  D.  Second  Edition,  Re- 
vised and  Enlarged.  Baltimore :  The  Norman,  Remington 
Company,  1920.    Pp.  xix-1320. 

In  seeking  biographical  material  from  books  or 
friends,  you  get  the  man  from  various  points  of 
view — as  his  family,  his  patients,  his  confreres, 
and  friends  saw  him.  Often  the  titles,  not  the 
worth  of  his  writings,  is  given,  or  his  work  is  in- 
tentionally minimized  or  exaggerated.  A  man's 
work  was  not  of  much  worth,  perhaps,  but  he  was, 
as  his  biography  says  "the  beloved  physician" :  yet 


such  qualification  standing  alone,  though  not  ex- 
cluding from  an  ordinary  cemetery,  would  exclude 
from  a  hall  of  fame  such  as  this  volume  appears 
intended  to  be.  In  the  first  edition  such  assertion 
was  sometimes  weakly  conceded,  but  the  editor  says 
adverse  criticism  resulted  in  fifty-one  exhumations 
before  the  second  edition  came  out. 

There  will  always  be  men  who  mistake  fault- 
finding for  criticism,  but  these,  having  scanned  the 
lists,  will  agree  that  an  adequate  representation  has 
been  given  to  the  three  cities  of  New  York, 
Philadelphia  and  Baltimore.  Then  there  is  the 
question  of  priority  in  work.  The  records  of  any 
law  court  will  give  surprising  cases  of  similarity 
in  ideas.  Also,  a  man  may  conceive  the  idea  but 
neither  publish  it  nor  give  details  except  to  a 
friend,  so  that  when  the  other  man  proudly  claims 
it  as  original,  he  is  often  quite  justified,  though 
the  priority  as  given  in  a  biography  gives  rise  to 
some  bitterness. 

One  good  thing  about  the  book  is  that  it  does  not 
include  the  living.  The  inclusion  would  not  matter 
so  much  if  the  men  could  undertake  to  live  until  a 
second  edition  appeared,  otherwise  there  would  be 
awkward  fragments  of  mortality  round  the  now 
completed  life.  Every  day  the  tide  of  healers, 
themselves  now  wounded,  is  swirling  on  to  death 
and  a  second  edition.  Many  are  said  to  create  a 
void  which  can  never  be  filled,  or  to  have  caused 
an  irreparable  loss,  but  such  bold  assertions  as  to 
the  Creator's  power  to  duplicate  sink  silent  when 
the  place  is  once  more  filled. 

The  book  is  not  only  useful  for  reference,  but 
interesting  in  the  glimpses  it  gives  of  the  grim 
struggles  of  our  earliest  doctors  against  poverty, 
booklessness,  ignorance,  and  loneliness.  Interesting, 
too,  to  see  how  near  they  came  to  seeing  truths  now 
proved,  how  strenuously  they  fought  for  that  which 
is  now  proved  wrong ;  how  pestilence  and  epidemic, 
their  true  cause  now  known,  ruthlessly  swept  away 
both  patients  and  doctors.  This  second,  revised  edi- 
tion of  Kelly's  book  should  be  welcomed  everywhere. 

NOCTURNE. 

Nocturne.    By  Frank  Swinxerton.    New  York :  George 
H.  Doran  Company,  1917. 

A  reputation  for  perfection  is  a  cross  that  any 
writer  must  bear  as  best  he  may.  Frank  Swinncr- 
ton  seems  to  have  achieved  this  dubious  distinction 
by  the  publication  of  Nocturne  and  several  otb.er 
novels :  as  in  the  case  of  Leonard  Merrick,  the 
acclaim  comes  mostly  from  his  fellow  writers.  It 
is  only  fair  to  say  that  Mr.  Swinnerton  will  be 
most  enjoyed  where  his  reputation  has  not  preceded 
him.  But  Nocturne  is  exceedingly  interesting  from 
another  point  of  view.  It  is  not  perfect,  but  it 
is  alive.  Its  spirit  and  imperfections  are  of  the 
twentieth  century ;  it  is  sharply  modern  even  in 
the  self  consciousness  that  keeps  it  from  quite 
achieving  beauty.  Few  studies  of  women  are  more 
searching.  There  is  in  th.is  book  an  unusual  com- 
bination of  effort  and  artlessness,  of  psychology 
and  emotion,  of  classic  unity  with  modern  turbu- 
lence. It  is  a  book  which  the  reader  will  not  im- 
mediately forget. 

Emmy  and  Jenny,  the  two  sisters  of  the  story, 
are  opposites.    Emmy   is   the   passive,  incurious 


780 


BOOK  REVIEWS. 


[New  York 
Medical  Journal. 


woman,  finding  her  complete  expression  in  affection 
and  homekeeping.  Jenny  is  keen,  restless,  rebel- 
lious, impatient  of  restraints.  The  entire  action  of 
the  story  takes  place  on  one  night  when  Jenny  finds 
that  Emmy  is  in  love  with  Al,  a  victim  whom  Jenny 
herself  is  merely  dangling.  Jenny  sends  them  off 
to  the  theatre  together  and  remains  at  home  with 
Pa,  who  is  paralyzed.  But  there  comes  a  note 
from  Keith,  her  sailor,  saying  that  he  is  in  London 
for  just  one  night  and  cannot  leave  his  ship,  and 
asking  her  to  come  to  him.  Jenny  hesitates  between 
Pa  and  Keith,  between  duty  and  the  one  mad 
moment  of  adventure  that  may  ever  come  to  her, 
and  she  chooses  Keith.  When  she  returns  it  is  to 
find  Emmy  and  Al  engaged.  On  the  same  evening 
each  of  the  sisters  has  met  her  great  moment  in 
her  own  way.  Emmy,  of  course,  has  no  problem ; 
she  has  found  her  man  and  she  is  satisfied.  But 
there  is  still  Jenny,  poignant,  unsatisfied  Jenny, 
whose  lover  has  sailed  away  again  and  who  in  addi- 
tion has  to  bear  her  own  reproaches  because  during 
her  absence  Pa  fell  and  hurt  himself  ;  Jenny  who 
does  not  want  a  stew  and  bread  pudding  existence ; 
Jenny  who  is  not  commonplace  but  who  has  nothing 
ahead  of  her  but  commoni^laceness.  Jenny  is  not 
to  be  so  easily  dismissed.  Her  voice  is  added  to 
the  voices  of  revolt  that  are  crying  out  everywhere 
in  the  world  today — revolt  against  humdrum,  empty 
lives,  against  the  conditions  that  make  men  and 
women  machines.    She  is  youth  demanding  its  own. 

Mr.  Swinnerton  has  done  a  rare  thing  in  this 
book — he  has  made  his  characters  reveal  themselves 
to  a  remarkable  extent  through  their  own  conver- 
sation. But,  not  satisfied  with  this,  he  has  inter- 
polated lumps  of  psychology  that  float  around  like 
indigestible  dvunplings  in  one  of  Emmy's  own  stews. 
It  is  drama  plus  a  diagram,  and  the  diagram  is 
superfluous  and  annoying.  One  third  of  Nocturne 
could  easily  be  cut  out.  But  this,  too,  is  charac- 
teristic. If  Jenny  is  youth  of  today,  Swinnerton  is 
the  writer  of  today,  with  a  w'orthy  desire  to  analyze 
and  a  fear  of  being  merely  limpid.  But  Nocturne 
is  an  arresting  book,  and  if  its  faults  are  those  of 
modernity,  who  are  we  to  cavil  ? 

MAC  OF  PLACID. 

Mac  of  Placid.    Bj-  T.  Morris  Loxgstreth.    New  York : 
The  Century  Company,  1920.    Pp.  xi-339. 

It  will  soon  be  necessary  to  chart  the  world  for 
writers  and  note  the  places  where  there  is  enough 
room  for  adventures.  Travel  by  land,  water  and 
air,  now  so  easy,  quickly  makes  the  unknown 
familiar  and  the  poor  authors  have  to  stage  their 
stories  in  long  ago  times  when  real  estatists  and 
bacteriologists,  automobiles,  thermos  flasks,  canned 
goods  and  first  aid  had  not  arrived.  Longstreth 
chooses  the  Adirondacks  when  loggers,  hunters  and 
trappers  were  the  chief  dwellers,  and  here  he  plants 
Mac  at  Saranac  to  win  Hallie  and  circumvent  the 
evil  designs  of  a  certain  wild  Tess  and  her  helper, 
Ed  Touch.  Robert  Louis  Stevenson  also  spends  a 
winter  with  Mac  and  draws  plans  for  Mac's  suc- 
cessful wooing  of  Hallie.  But  it  is  not  the  story 
itself,  though  that  is  sufficiently  thrilling;  it  is  the 
pictures  of  the  country,  or,  more  than  pictures, 
scenes  in  which  you  feel  the  blinding  snow  and  seek 
some   shelter   from  the  pitiless   rainstorm.  You 


stand,  forgetting  it  is  only  in  a  book,  in  reverent 
silence  among  the  giant  trees  and  see  the  final 
advent  of  spring  as  a  marvelously  beautiful  coming 
never  seen  before.  Longstreth  loves  the  Adiron- 
dacks and  makes  his  readers  see  and  love  them  also. 

PEARLS  ASTRAY. 

Pearls  Astray.  A  Romantic  Episode  of  the  Last  Democ- 
racy. By  C0XST.A.XCE  M.  Warren.  Illustrated.  Boston  : 
Small,  Maynard  &  Co..  1920.    Pp.  158. 

This  is  the  dream  of  a  millionaire  whose  dinner 
has  evidently  disagreed  with  him.  It  embodies  all 
the  delusions  caused,  and  then  some.  It  is  a 
misleading  and  clever  piece  of  work,  with  apt 
characterizations  and  amusing  pictures. 

 ^  

New  Publications  Received. 


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


.\XNIVERSARV  TRIBUTE  TO  GEORGE  MARTIN  KOBER  IN  CELE- 
BRATION OF  HIS  SEVENTIETH  BIRTHDAY.  By  His  Friends  and 
Associates,  on  March  28.  1920.    Edited  by  Rev.  Francis 

A.  ToNDORF,  S.  J.,  Ph.D.  Washington,  D.  C,  1920.  Pp. 
381. 

THE  SCHOOL  OF  SALERNUM.     REGIMEN  SANITATIS  SALERNI- 

TA.xuM.  The  English  Version  by  Sir  John  Haringtox. 
History  of  the  School  of  Salernum,  by  Francis  R.  Pack- 
ard M.  D.  A  Note'on  the  Prehistory  of  the  Regimen  Sani- 
tatis.  by  Fielding  H.  Garrison,  M.  D.    New  York :  Paul 

B.  Hoeber,  1920.   Pp.  213. 

ELECTROTHERAPY.      ITS   RATIONALE    AND   INDICATIONS.  Bv 

J.  Curtis  Webb,  M.  A..  M.  B.,  B.C.  (Cantab.),  Hon.  As'- 
sociate  of  the  Order  of  St.  John  of  Jerusalem ;  Order  of 
Merit  of  the  Cruz  Vermehla;  Hon.  Associate.  King's  Col- 
lege, London,  etc.  With  Six  Diagrams.  Philadelphia :  P. 
Blakiston's  Son  &  Co.,  1920.    Pp.  90. 

A  COURSE  OF  LECTURES  ON  MEDICINE  TO  NURSES.  By  HER- 
BERT E.  Cuff,  M.  D.,  F.  R.  C.  S.,  Principal  Medical  Of- 
ficer to  the  Metropolitan  Asylum  Board;  Late  Medical 
Superintendent,  North  Eastern  Fever  Hospital,  Tottenham, 
London.  Seventh  Edition,  with  Twenty-Nine  Illustrations. 
Philadelphia:  P.  Blakiston's  Son  &  Co.,  1920.    Pp.  vii-257. 

PUBLIC    HEALTH     LABORATORY    WORK     (CHEMISTRV).  Bv 

Henry  R.  Kenwood,  C.  M.  G.,  M.  B.,  F.  R.  S.  (Edin.), 
D.  p.  H.,  F.  C.  S.,  Chadwick  Professor  of  Hygiene  and  Pub- 
lic Health,  University  of  London ;  Medical  Officer  of 
Health  and  Public  Analyst  for  the  Metropolitan  Borough 
of  Stoke  Newington.  Seventh  Edition,  with  Illustrations. 
New  York:  Paul  B.  Hoeber,  1920.    Pp.  xi-420. 

PHYSIOLOGY  AND  BIOCHEMISTRY  IN  MODERN  MEDICINE.  Bv 

J.  J.  R.  Macleod,  M.  B.,  Professor  of  Physiologj'  in  the 
University  of  Toronto,  Toronto,  Canada ;  Formerly  Pro- 
fessor of  Physiology  in  the  Western  Reserve  Universit}\ 
Cleveland,  Ohio,  Assisted  by  Roy  G.  Pearce,  A.  C.  Red- 
field,  N.  B.  Taylor,  and  Others.  Third  Edition,  with  Two 
Hundred  and  Forty-three  Illustrations,  Including  Nine 
Plates  in  Color.  St.  Louis :  C.  V.  Mosby  Company,  1920. 
Pp.  xxxii-992. 

MASSAGE.     ITS  PRINCIPLES   AND  PRACTICE.      By   JaMES  B. 

Mennell,  M.  D.,  M.  B.,  B.C.  (Cantab.),  etc.,  Medical 
Officer,  Physico-Therapeutic  Department,  St.  Thomas's 
Hospital ;  Medical  Officer  in  Charge  of  the  Massage  De- 
partment, Special  Surgical  Hospital,  Shepherd's  Bush ; 
Author  of  The  Treatment  of  Fracture  by  Mobilisation  and 
Massage.  With  an  Introduction  by  Sir  Robert  Jones,  K.B.E., 

C.  B.,  F.  R.  C.  S.,  Major  General,  A.  M.  S.,  Inspector  of 
Special  Military  Surgery.  Second  Edition.  With  One 
Hundred  and  Sixty-seven  Illustrations  and  Two  Appen- 
dices. Philadelphia:  P.  Blakiston's  Son  &  Co.,  1920.  Pp. 
xvi-535. 


Practical  Therapeutics  and  Preventive  Medicine 

A  Compendium  of  Treatment  and  Prophylaxis,  Original  and  Adapted 


Venous  Thrombosis,  Pulmonary  Infarction, 
and  Embolism  Following  Gynecological  Opera- 
tions.— H.  H.  Hampton  and  Lawrence  R.  Whar- 
ton (Bulletin  of  the  Johns  Hopkins  Hospital,  April, 
1920)  have  analyzed  the  cases  of  thrombosis  occur- 
ring in  the  Johns  Hopkins  Hospital  from  1890  to 
1918  inclusive.  During  the  period  21,000  patients 
were  operated  on  in  the  gynecological  clinic,  with 
205  cases  of  femoral  thrombophlebitis  following  all 
types  of  gynecological  operations,  or  an  incidence  of 
one  per  cent.  From  their  extensive  study  of  these 
cases  the  following  conclusions  are  drawn :  Post- 
operative venous  phlebitis  and  thrombosis  are  not 
peculiar  to  any  particular  type  of  gynecological  oper- 
ation. Of  the  conditions  favoring  thrombus  for- 
mation infection  and  trauma  are  the  most  impor- 
tant. Nearly  all  the  cases  of  thrombophlebitis  are 
associated  with  a  slight  rise  in  temperature.  Phle- 
bitis and  thrombosis  when  associated  with  jiain  and 
swelling  are  rarely  ever  followed  by  fatal  embolism. 
Puhnonary  infarction  occurs  most  often  in  the  same 
class  of  cases  and  during  the  same  period  of  con- 
valescence as  femoral  thrombophlebitis.  Pulmonary 
infarction  may  precede  pulmonary  embolism.  Post- 
operative pulmonary  infarction  in  the  majority  of 
cases  has  heretofore  been  unrecognized.  Its  diag- 
nosis must  be  based  on  the  clinical  picture  rather 
than  the  physical  findings  alone,  and  the  authors 
believe  that  with  proper  care  pulmonary  infarction 
should  be  diagnosed. 

Cicatricial  Laryngeal  Stenosis  in  Children. — 

E.  J.  Moure  (Journal  dc  mcdccinc  dc  Bordeaux, 
February  10,  1920)  notes  that  occasionally  this  con- 
dition is  due  to  ulcerations  of  the  laryngotracheal 
canal ;  from  diphtheria,  measles,  scarlet  fever,  or 
rarely,  typhoid  fever.  More  frequently,  however, 
it  results  from  tracheotomy  improperly  performed, 
viz.,  through  the  thyroid  cartilage,  the  intercrico- 
thyroid  space,  or  simply  through  the  cricoid.  The 
practitioner  called  in  an  emergency  to  a  child  threat- 
ened with  asphyxia  opens  into  the  laryngotracheal 
canal  at  the  most  convenient  point  for  insertion  of 
the  cannula.  Some  time  later  he  finds  that  upon 
tentative  removal  of  the  cannula  dysi:)nea  reappears, 
and  is  prone  at  once  to  ascribe  the  difficulty  to  a 
spasmodic  closure  of  the  glottis,  preventing  removal 
of  the  cannula.  Examination  of  the  child,  still 
wearing  the  cannula,  some  months  later,  reveals  a 
more  or  less  tight  stenosis  of  the  larynx,  with  im- 
mobility of  the  arytenoids  in  the  median  line,  and 
below  these,  bilateral  subglottic  infiltration.  Exter- 
nal inspection  shows  that  the  opening  for  the  can- 
nula had  been  made  in  a  faulty  position.  The  proper 
treatment  in  such  cases  is  to  ignore  the 'larynx  and 
simply  make  a  new  opening  for  the  cannula  into  the 
trachea  itself.  Under  these  conditions  patency  of 
the  canal  will  become  gradually  reestablished  and 
the  opportunity  given  for  removal  of  the  tube.  Dur- 
ing this  time  the  attendant's  chief  solicitude  should 
be  to  prevent  pericannular  accumulation  of  granula- 


tions by  excising  from  tmie  to  time  or  cauterizing 
with  the  electrocautery  or  one  in  ten  chloride  of  zinc 
solution  the  exuberant  granulations  which  invariably 
develop  within  a  few  months.  In  no  case,  however, 
should  the  cannula  be  removed  without  examina- 
tion as  to  the  permeability  of  the  larynx  by  laryngo- 
scopy. The  children  should  be  trained  to  breathe 
through  the  normal  channels  by  stopping  the  can- 
nula at  first  during  the  daytime  only,  and  later  at 
night.  The  special  cannulas  recommended  by  for- 
mer writers  are  unnecessary.  In  the  exceptional 
cases  in  which  stenosis  is  actually  found  to  be  due 
to  cicatricial  tissue  within  the  larynx,  the  delay  will 
not  have  been  without  advantage,  for  children  seven 
or  eight  years  old  are  much  more  favorably  situated 
for  supporting  the  necessary  operative  procedure 
than  smaller  children. 

Barium   Chloride   and   Cardiac    Inhibition. — 

Tournade  (Paris  medicalc,  March  13,  1920)  notes 
that  barium  chloride  antagonizes  the  slowing  of  the 
heart  rate  caused  by  stimulation  of  the  vagus  nerve. 
The  problem  arises,  whether  this  effect  on  the  part 
of  the  barium  salt  is  due  to  paralysis  of  the  vagus, 
or  to  a  stimulation  of  the  intracardiac  nervous  struc- 
tures, thus  rendering  the  heart  refractory  to  the 
influence  of  the  vagus.  The  author  placed  a  liga- 
ture about  the  auriculoventricular  furrow  on  the 
heart  of  a  young  dog  extracted  from  the  "uterus  at 
term.  The  frequency  of  the  auricular  contractions 
was  thus  rendered  double  that  of  the  ventricular 
beats.  When  a  few  drops  of  barium  chloride  solu- 
tion were  then  injected  into  the  left  ventricle,  the 
ventricular  beats  were  accelerated  and  became  much 
more  frequent  than  the  auricular.  This  was  taken 
to  show  that  barium  chloride  acts  by  excitation  of 
the  cardiac  nervous  mechanism. 

Intracardiac  Pressure  as  a  Standard  in  Cardio- 
therapy. — I.  Harris  (Lancet,  May  i,  1920)  bases 
his  therapy  in  cardiac  failure  on  the  intracardiac 
pressure  as  determined  by  measuring  the  length  of 
diastole  in  comparison  with  the  length  of  systole. 
The  measurement  is  done  with  the  electrocardio- 
graph. It  is  assumed  that  a  relatively  long  diastole 
compared  with  systole  signifies  a  high  intracardiac 
pressure,  since  a  long  diastole  allows  a  large  amount 
of  blood  to  collect  in  the  ventricle  which  nnist  be 
forced  out  quickly  during  the  short  systole.  The 
fact  that  this  measure  is  only  approximate  and  not 
necessarily  true  in  all  circumstances  is  recognized, 
but  it  is  considered  true  in  the  majority  of  cases. 
Two  types  of  cardiac  failure  are  recognized  in 
this  classification,  the  first  with  a  low  intracardiac 
pressure  because  of  a  short  diastole  and  rapid  heart 
rate  accompanying  a  flabby  inefficient  heart  muscle, 
and  the  second  accompanied  by  arterial  damage, 
high  blood  pressure,  slow  heart  rate,  long  relative 
diastole,  and  a  very  high  intracardiac  pressure.  The 
treatment  of  the  first  type  must  obviously  be 
directed  toward  an  improvement  of  the  tone,  and 
strength  of  the  muscle  wall.    Digitalis  is  the  drug 


782 


PRACTICAL  THERAPEUTICS   AND  PREVENTIVE  MEDICINE.  [New  York 

Medical  Journal. 


of  all  Others  to  be  chosen  here  as  its  tonic  efifects 
will  be  produced  before  its  pressure  raising  effect 
can  do  damage.  The  amount  of  drug  to  be  used 
is  regulated  by  observing  the  effects  of  the  intra- 
cardiac pressure.  In  the  second  type  of  case  it  is 
necessary  to  reduce  the  intracardiac  pressure  and 
caffeine  seems  to  be  the  most  satisfactory  drug, 
though  in  many  cases  it  cannot  be  used  over  long 
periods  because  of  its  property  of  increasing  the 
nervous  excitability  of  the  patient.  When  it  can 
be  no  longer  used  atropine  must  take  its  place.  As 
this  reduces  the  intracardiac  pressure  by  increasing 
the  heart  rate,  digitalis  in  small  doses  should  be 
used,  for,  even  in  rapid  heart  action,  digitalis  bene- 
fits the  heart  muscle.  Adrenalin  also  seems  to  be 
beneficial  in  such  cases,  particularly  in  cases  with 
edema,  since  the  author  considers  it  to  be  a  diuretic 
which  does  not  affect  the  intracardiac  pressure. 

Effect  of  High  Temperature  upon  the  Action 
and  Toxicity  of  Digitalis. — Hirschfelder,  Bicek, 
Kucera,  and  Hanson  {Journal  of  Pharmacology  and 
Experimental  Therapeutics,  July,  1920)  found  that 
the  lethal  dose  of  digitalis  for  cats  whose  temper- 
ture  was  elevated  to  43°  C.  is  much  smaller  than  the 
lethal  dose  at  normal  temperatures.  In  the  febrile 
animals  the  drug  was  found  to  cause  the  typical 
slowing  of  the  pulse  rate  and  increase  in  the  blood 
pressure,  as  well  as  ventricular  extrasystoles  and 
inversion  of  the  T  wave  in  the  electrocardiogram. 
Although  the  heart  muscle  in  these  experiments  was 
free  from  any  injury  due  to  prolonged  fever  or 
toxemia,  the  high  temperature  factor  alone  was 
enough  to  increase  greatly  its  susceptibility  to  the 
effects  of  digitalis.  Great  care  should  therefore 
be  exercised  in  using  digitalis  in  large  doses  in 
patients  with  high  fever.  For  animals  at  43°  C, 
the  dose  recommended  by  Eggleston  in  the  treat- 
ment of  clinical  cases  of  myocardial  insufficiency 
would  represent  about  the  average  lethal  dose.  The 
experimental  results  were  in  harmony  with  the 
recent  report  of  T.  Stuart  Hart  that  in  four  cases 
of  his  series  of  influenzal  bronchopneumonia  cases 
heart  block  resulted  from  the  administration  of  three 
drams  of  tincture  of  digitalis — about  half  the  dose 
at  which  similar  effects  might  be  expected  in  afebrile 
heart  cases.  In  patients  with  fever  the  larger  doses 
of  digitalis  should  be  avoided,  and  the  effects  of 
the  drug  carefully  watched  throughout  the  course 
of  the  treatment. 

Resuscitation  of  the  Heart. — K.  Henschen 
{Schwcizerische  medizinische  Wochenschrift,  April 
1,  1920)  reviews  the  attempts  which  have  been 
made  in  the  past  to  effect  a  resuscitation  of  the 
heart  after  it  has  ceased  to  beat  through  the  in- 
jection of  a  stimulant  into  the  pericardium  or  into 
one  of  the  cavities  of  the  heart,  either  with  or 
without  the  withdrawal  of  blood  or  the  infusion  of 
a  fluid.  It  appears  from  his  account  that  a  few 
experiments  have  succeeded  in  reviving  the  heart, 
at  least  for  a  short  time,  in  a  number  of  instances. 
He  reports  four  cases,  which  may  perhaps  be 
called  successful,  although  in  only  one  did  the 
patient  survive.  In  two  patients  an  injection  of 
one  c.  c.  of  adrenalin  and  0.5  c.  c.  of  pituitrin  into 
the  left  ventricle  a  few  minutes  after  the  heart  had 
stopped  beating  started  the  heart  beat  again,  but 


both  died  within  an  hour.  In  a  case  of  bullet  wound 
of  the  heart  a  similar  injection  revived  the  heart 
and  the  patient  seemed  to  be  doing  well  until  a 
pericarditis  proved  fatal  on  the  second  day.  The 
fourth  patient,  his  second,  had  suffered  a  very 
severe  contusion  of  his  chest  and  upper  abdomen. 
The  heart  stopped  beating  during  an  exploratory 
laparotomy  and  could  not  be  revived  by  massage. 
One  and  a  half  cubic  centimetres  of  a  one  in  one 
thousand  adrenalin  solution  were  injected  in  the 
pericardium  through  the  fourth  interspace,  inside 
the  mammillary  line,  to  a  depth  of  about  two  cm. 
The  heart  then  began  to  beat  again,  and  an  intra- 
venous injection  was  made  at  once  into  the  arm  of 
700  c.  c.  physiological  salt  solution  to  which  had 
been  added  ten  drops  of  adrenalin  and  0.5  c.  c.  of 
pituitrin.    This  patient  recovered. 

Fibromata,  with  Especial  Reference  to  Radium 
Treatment. — Everett  S.  Hicks  {Canadian  Medical 
Association  Journal,  July,  1920)  states  that  he  has 
treated  ninety-eight  cases  during  the  past  six  years 
with  the  following  results :  Failure,  two ;  all  symp- 
toms relieved,  tumor  largely  reduced,  twelve ;  all 
symptoms  relieved,  tumor  small,  seventeen ;  all 
symptoms  relieved,  no  appreciable  tumor,  fifty- 
three  ;  recent  cases,  too  recent  to  classify,  fourteen. 
The  disadvantages  of  radium  as  a  treatment  are; 
To  the  patient,  some  slight  nausea  in  about  five 
per  cent,  of  the  cases;  to  the  surgeon,  the  fear  of 
overlooking  a  possible  carcinoma.  The  advantages 
he  claims  are:  Its  safety;  no  loss  of  patient's  time 
in  treatment  or  convalescence ;  less  expense ;  patients 
are  in  better  general  health  than  after  operation ; 
radium  can  be  used  where  operative  mortality 
would  be  high,  as  in  chronic  nephritis,  diabetes, 
severe  anemias,  heart  lesions,  or  tuberculosis. 

Physiological  Action  of  Iodine  Fumes. — Luck- 
hardt,  KoCh,  Schroeder,  and  Weiland  {Journal  of 
Pharmacology  and  Experimental  Therapeutics, 
March,  1920)  found  that  iodine  deposited  on  the 
skin  from  iodine  fumes  is  absorbed  and  appears,  in 
the  urine.  The  iodine  content  of  the  thyroid  gland 
is  greatly  increased,  and  there  is  a  pronounced 
change  in  the  histological  features  of  the  gland 
which  clearly  indicates  absorption  of  iodine.  When 
iodine  fumes  are  inhaled  in  the  respiratory  tract, 
the  excess  of  iodine  appears  promptly  in  the 
urine  and  the  iodine  content  of  the  thyroid  gland  is 
invariably  increased.  Indiscreet  use  of  iodine 
fumes  for  inhalation  leads  to  dyspnea,  due  to  an  in- 
flammatory reaction  in  the  lungs.  When  the  fumes 
are  inhaled  in  quantities  greater  than  eighteen  mil- 
ligrams to  the  kilogram  of  body  weight  the  animal 
dies  within  twenty-four  hours  from  acute  pulmo- 
nary edema.  Intratracheal  administration  of  iodine 
fumes  leads  to  a  temporary  moderate  rise  in  blood 
pressure  and  an  acceleration  and  increased  ampli- 
tude of  the  respiration.  Later  there  occurs  a  more 
pronounced  fall  in  the  arterial  pressure,  followed 
hy  a  partial  recovery,  and  finally,  after  an  interval, 
a  quick  drop  in  arterial  pressure,  with  marked  signs 
and  symptoms  of  pulmonary  edema.  The  respira- 
tion ceases  while  the  heart  usually  shows  a  decided 
vagal  inhibition.  The  cause  of  death  is  an  acute, 
rapid  edem^  involving  chiefly  the  basal  portions  of 
the  lungs. 


Xovember  13,  1920.]        PRACTICAL  THERAPEUTICS  AND  PREVENTIVE  MEDICINE. 


783 


Treatment  of  Bronchial  Fistulas. — Carl  Eggers 
(Annals  of  Surgery,  September,  1920)  gives  the 
following  conclusions  from  the  results  obtained  in 
the  treatment  of  bronchial  fistulae : 

1.  Bronchopleural  fistulae  usually  close  spontane- 
ously. 

2.  In  the  few  cases  in  which  a  fistula  is  respon- 
sible for  the  persistence  of  a  chronic  empyema, 
treatment  favoring  the  obliteration  of  that  cavity 
will  result  in  a  closure  of  the  bronchus. 

3.  Bronchocutaneous  fistulae  must  be  carefully 
studied  and  their  etiology  and  the  present  condition 
of  the  lung  taken  into  consideration. 

4.  As  long  as  the  fistula  acts  as  a  safety  valve 
for  intrapulmonary  suppuration,  it  must  not  be 
interfered  with. 

5.  Mobilization  of  the  lung  and  fistula,  allowing 
it  to  recede  from  its  fixed  position,  is  the  most 
important  factor  in  bringing  about  closure. 

6.  Muscle  flaps  are  valuable  to  cover  the  bron- 
chial sinus  after  the  necessary  preparation  has  taken 
I)lace.  They  aid  in  the  closure  and  obviate  de- 
formity. 

7.  Cauterization  of  the  fistula  should  always  be 
done  very  slightly,  simply  to  destroy  the  epithelium, 
never  so  deep  as  to  produce  a  slough. 

8.  In  case  the  wound  is  clean,  suture  of  the  bron- 
chus should  be  done. 

9.  In  cases  due  to  lung  abscess,  in  which  it  is 
feared  that  closure  of  the  bronchus  may  result  in 
damming  back  of  secretions  with  the  danger  of 
pneumonia,  the  bronchus  should  not  be  sutured, 
but  a  muscle  flap  simply  laid  over  it,  placing  a  drain- 
age tube  at  some  distance  to  act  as  a  safety  valve. 

10.  Whenever  possible  the  operation  should  be 
done  under  local  anesthesia. 

Specific  Treatment  of  Tuberculosis  at  High 
Elevation. — Carl  Spengler  (Presse  medicale,  April 
24,  1920)  describes  the  treatment  with  the  socalled 
immune  bodies  as  applied  in  Davos,  Switzerland. 
During  one  week  before  the  specific  treatment  is 
begun  hemoglobin  is  administered  to  enhance  the 
formation  of  red  blood  cells.  Iodine  with  albumen 
by  mouth  or  inunctions  of  iothion  are  also  given. 
For  cough  and  pain  codeine  or  codeine  and  mor- 
phine are  given  by  mouth,  and  for  insomnia  due  to 
the  tuberculosis  poison,  hypnotics  such  as  dial,  bro- 
mural,  and  adalin  until  the  specific  treatment  has 
begun  to  benefit.  The  open  air  cure  must  be  adapted 
to  the  individual  case.  Rest  on  the  steamer  chair 
out  of  doors  is  not  continued  longer  than  an  hour 
or  two  morning  and  afternoon,  and  in  the  winter  is 
ordered  only  on  bright,  sunny  days.  By  this  plan 
the  patients  gain  much  more  weight  than  they  do 
upon  the  arbitrary  open  air  treatment.  Anemic  and 
anorexic  patients  are  not  put  out  of  doors  at  all  in 
the  winter  season  at  high  altitudes.  In  cold  weather 
all  patients  are  put  in  warm  beds  in  their  own  rooms 
in  the  afternoon,  with  the  windows  open".  Un- 
doubtedly many  therapeutic  failures  at  high  altitudes 
are  due  to  excessive  open  air  treatment.  The  im- 
mune bodies  or  IK  are  given  either  hypodermically, 
by  inunction,  or  by  the  mouth.  One  of  the  chief 
rules  of  administration  is  never  to  increase  the  dose 
where  the  patient's  temperature  continues  to  de- 
scend ;  in  contrast  to  tuberculin  therapy,  increased 


dosage  is  indicated  only  when  the  temperature  has 
become  stabilized  or  has  begun  to  rise  again.  Tuber- 
culin is  dangerous  except  in  the  hands  of  specialists, 
while  the  immune  bodies  may  be  used  by  any  physi- 
cian without  risk  in  all  cases  that  are  not  far 
advanced.  Increased  dosage  is,  furthermore,  em- 
ployed only  when  local  reaction  from  the  previous 
amount  has  completely  disappeared.  Inunctions, 
when  used,  are  given  at  weekly  intervals,  and  by 
mouth  the  remedy  is  given  two  or  three  times  a 
week ;  less  caution  is  here  required  than  in  the 
hypodermic  method.  Excellent  analgesic  and  cura- 
tive results  have  been  noted  upon  application  of  a 
0.1  per  cent,  solution  of  IK  over  tuberculous  ulcer- 
ations ;  pain  and  photophobia  in  ophthalmic  involve- 
ments are  also  similarly  relieved.  Iodine  with 
albumen  is  particularly  indicated  in  scrofulosis  and 
torpid  tuberculosis.  In  children  one  or  two  drops 
and  in  adults  five  or  six  drops  of  freshly  prepared 
tincture  of  iodine,  diluted  in  a  cupful  of  milk,  are 
given  at  breakfast  for  two  weeks,  to  be  followed  by 
an  equal  period  of  rest,  and  so  on.  Such  medica- 
tion should  be  applied  en  masse  in  schools  and 
among  children  showing  signs  of  tuberculous  her- 
edity or  incipient  tuberculosis.  Iothion  inunctions 
— 0.5  to  one  gram  a  day — are  administered,  like 
mercury,  on  dififerent  surfaces  of  the  body,  in  for- 
nightly  courses  followed  by  rest  for  an  equal  period. 
By  this  plan  of  treatment  permanent  recoveries  are 
obtained  in  ninety  to  150  days  in  many  cases  of 
tuberculosis  not  yet  too  far  advanced.  Artificial 
pneumothorax  and  extrapleural  thoracoplasty  are 
indicated  only  in  cases  in  which  specific  immunizing 
therapy  has  failed,  and  cannot  prove  successful  un- 
less there  is  mobilization  from  the  thorax,  i.  e.,  col- 
lapse of  the  lung,  and  also  autoimmunization  due  to 
the  lung  collapse.  Specific  therapy  and  iodine  with 
albumen  should  always  precede  such  measures  in 
order  to  improve  the  condition  of  the  lung  tissues 
and  increase  their  ability  to  undergo  atelectasis. 

Mode  of  Administration  of  Antitoxin  in  Diph- 
theria.— Weill-Halle  (Bulletins  et  memoires  de  la 
Societe  medicale  des  hopitaux  de  Paris,  January  29, 
1920)  recommends  the  intramuscular  route  as  a 
regular  method  of  antitoxin  administration  in  diph- 
theria. Injections  thus  given  are  better  borne  than 
subcutaneous  injections,  causing  none  of  the  sharp 
and  persistent  local  pain  induced  by  the  latter.  On 
the  other  hand,  they  are  much  more  easily  adminis- 
tered than  intravenous  injections.  The  action  is 
more  rapid  than  upon  subcutaneous  use.  Maximum 
concentration  in  the  blood  is  obtained  in  from  twen- 
ty-four to  forty-eight  hours,  whereas  subcutaneous 
administration  yields  the  maximum  concentration 
only  after  two  or  three  days.  In  the  majority  of 
cases  the  dosage  used  is  250  units  to  the  kilogram 
of  body  weight  in  mild  cases  and  500  to  600  units  in 
moderately  severe  and  severe  cases.  A  single,  mas- 
sive injection  of  the  entire  amount  indicated  is 
given.  Sometimes  the  dose  is  made  even  slightly 
larger  in  order  to  make  good  any  possible  deficiency 
in  the  quality  of  the  serum.  By  this  procedure  the 
total  amount  of  antitoxin  used  is  reduced  as  com- 
pared to  that  employed  in  the  repeated  injection 
method,  and  the  clinical  results  obtained  have  been 
satisfactory.  I 


Miscellany  from  Home  and  Foreign  Journals 


Acute  Mania  Associated  with  Plasmodium 
Vivax  Infection. — Haughwout,  Lantin,  and  Fer- 
nandez (Philippine  Journal  of  Science^  December, 
1919)  report  the  case  of  a  Filipino,  aged  nineteen 
years,  who  was  being  experimental!}'  treated  with 
X  rays  for  splenomegaly  of  malarial  origin,  and  in 
whom,  eight  days  after  the  first  irradiation,  severe 
mental  disturbance  occurred  and  was  followed  by 
death  after  eight  more  days.  Few  cases  had  been 
previously  recorded  in  which  Plasmodium  vivax  in- 
fection was  associated  with  cerebral  symptoms  and 
death.  In  this  patient  the  parasites  were  present  in 
the  peripheral  circulation  in  small  numbers  only 
and  the  temperature  at  no  time  rose  above  39°  C. — 
a  point  reached  a  few  hours  before  death.  The 
feces  revealed  ankylostoma  infection.  The  delirium 
was  preceded  for  a  short  time  only  by  restlessness. 
The  eyes  then  became  bloodshot  and  delirium  so 
noisy  and  violent  that  the  patient  had  to  be  tied  in 
bed.  He  bit  both  tongue  and  lips  and  spat  bloody 
saliva  upon  all  who  came  near  him.  He  refused  all 
food  and  medicine,  and  his  general  condition  de- 
clined very  rapidly.  Fairly  numerous,  characteristic 
trophozoites  of  Plasmodium  vivax  were  found  in 
the  peripheral  blood.  Intramuscular  injections  of 
quinine  and  urea  failed  to  yield  any  benefit  save 
disappearance  of  the  parasites  from  the  peripheral 
blood.  The  patient  gave  no  history  of  previous  at- 
tacks of  mania  and  the  necropsy  failed  to  disclose 
any  evidence  of  syphilis.  Pais's  belief  that  new 
generations  of  the  malarial  parasite  appear  to  show 
exalted  virulence  under  the  influence  of  the  x  rays 
is  offered  as  a  possible  explanation  of  the  symptoms 
in  this  case.  Yet,  the  parasites  never  were  in  the 
circulation  in  large  numbers  and  hyperpyrexia  never 
developed.  •» 

Acquired    Immunity    Following    Influenza. — 

Dopter  (Bulletin  dc  1' Academic  dc  medccine,  May 
4,  1920)  relates  that  the  division  to  which  he  was 
attached  in  April,  1918,  was  among  the  first  to  be 
aflfected  by  influenza,  nearly  all  the  infantry  and 
engineers  contracting  a  mild  form  of  the  disease, 
unaccompanied  by  pulmonary  or  other  complica- 
tions. By  the  close  of  the  month  of  May  the  epi- 
demic among  these  troops  had  completely  ceased. 
During  this  time  few  cases  of  the  disease  developed 
in  the  field  artillery  regiment  in  the  same  division, 
but  in  August  it  was  joined  by  a  group  of  heavy 
artillery  which  brought  influenza  along  with  it,  and 
soon  the  field  artillery  fell  a  prey  to  the  infection. 
At  this  time  the  infection  was  particularly  severe 
in  the  men  who  had  been  spared  in  the  earlier  epi- 
demic. Very  few  of  the  men  previously  ill  con- 
tracted the  disease.  In  the  battery  most  severely 
involved,  the  only  men  remaining  healthy  were  the 
few  who  had  had  the  disease  in  the  earlier  epidemic. 
During  the  severe  infection  among  the  artillery, 
moreover,  the  infantry  and  engineers,  although  nec- 
essarily in  frequent  contact  with  the  artillery  regi- 
ment, remained  unaffected.  Finally,  about  the 
middle  of  September,  fresh  troops  joined  the  divi- 
sion for  an  attack,  all  derived  from  formations 


subject  at  the  time  to  a  severe  epidemic  of  influenza. 
These  troops  continued  to  exhibit  severe  influenzal 
manifestations  in  their  new  assignment,  but  the 
original  divisional  infantry  and  engineers,  who  had 
already  gone  through  the  disease  in  May,  remained 
practically  unscathed,  only  a  very  few  mild  cases 
occurring  among  them.  Recurrences  occurred  only 
in  the  small  ratio  of  1.6  per  cent.  These  observa- 
tions constitute  important  evidence  in  favor  of  an 
acquired  immunity  following  an  initial  attack  of 
influenza. 

Lethal  Aspects  of  Artillery  Fire.— R.  Mercier 
(Bulletin  de  I' Academic  de  medccine,  April  20, 
1920)  presents  a  statistical  study  of  this  question 
based  on  five  months'  continuous  observation  on 
three  French  army  fronts  during  the  year  1917. 
One  army,  holding  a  quiet  sector,  was  subjected  to 
the  effects  of  363,000  German  shells — exclusive  of 
gas  shells — and  suffered  casualties  of  809  killed  and 
4,168  wounded,  or  0.2  killed  and  1.03  wounded  per 
100  shells.  Another  army,  holding  a  somewhat 
more  active  sector,  received  717,000  shells,  with 
2,753  killed  and  10,756  wounded,  or  0.38  killed  and 
1.50  wounded  per  100  shells.  A  third  army,  in  an 
attacking  sector,  received  2,529,000  shells,  with 
9,703  killed  and  40,488  wounded,  or  0.38  killed  and 
1.60  wounded  per  100  shells.  Even  during  the  vic- 
torious offensive  of  this  same  army,  deducting  losses 
due  to  small  arms,  the  proportion  of  casualties  per 
100  German  shells  was  only  0.45  killed  and  2.33 
wounded.  In  one  of  the  five  test  months,  account 
was  taken  of  the  different  varieties  of  enemy  artil- 
lery causing  the  casualties.  During  this  time  four- 
fifths  of  the  projectiles  fired  were  found  to  be  from 
the  German  heavy  artillery.  The  final  conclusion 
reached  was  that  during  the  summer  and  fall  of 
1917  it  took  395  German  shells  to  kill  and  seventy- 
six  shells  to  wound  one  French  soldier.  Knowing 
the  density  of  the  opposed  forces  and  the  fact  that 
the  French  fire  was  five  times  as  heavy  as  the  Ger- 
man, the  French  commanders  were  able  to  deduce 
accurately  the  rate  of  reduction  of  the  enemy's  di- 
visions. 

Blood  Pressure  and  the  Gallop  Rhythm. — A. 

Amblard  (Presse  medicate,  May  1,  1920)  discusses 
in  particular  the  mesosystolic  gallop  rhythm  occur- 
ring in  infectious  diseases,  in  which  the  adventitious 
third  sound  is  mesosystolic  in  time,  and  the  diastolic 
or  presystolic  gallop  rhythm  noted  in  patients  with 
combined  cardiac  and  high  pressure  arterial  disease. 
Concurrent  study  of  the  blood  pressure  and  pulse 
in  these  cases  shows  that,  however  different  may  be 
the  apparent  origin  and  the  classes  of  cases  in  which 
these  two  forms  of  gallop  rhythm  occur,  they  both 
set  in  at  a  special  stage  of  the  disturbance,  viz.,  the 
moment  at  which  the  heart  is  about  to  yield.  Their 
appearance  is  accompanied  by  a  rise  in  arterial  pres- 
sure and  their  disappearance  by  a  reduction  in  the 
systolic  pressure  and  the  increase  of  tachycardia 
necessitated  by  diminished  contractile  power  of  the 
ventricle.  Both  types  are  of  considerable  prognostic 
value  and  afford   definite   therapeutic  indications. 


November  13,  1920.]  MISCELLANY  FROM  HOME   AND  FOREIGN  JOURNALS. 


785 


In  the  mesosystolic  gallop  rhythm  there  is  no  true, 
continuous  arterial  hypertension,  but  instead  a  weak- 
ening of  heart  action  which  indicates  the  use  of 
phosphorus,  strychnine,  and  sparteine.  The  presys- 
tolic gallop  rhythm  occurs  in  cases  of  permanent 
high  tension,  and  the  appropriate  therapeutic  meas- 
ures are  purgation,  diuretics,  venesection,  and  die- 
tetic regulation.  In  these  cases,  however,  the  cardiac 
insufficiency  of  which  the  gallop  rhythm  is  a  fore- 
runner must  also  be  combatted  through  absolute 
rest  in  recumbency  and  digitalis.  When  intelligently 
used,  digitalis  does  not  raise  the  blood  pressure  in 
hypertension  cases.  Its  administration  should  be 
begun  as  soon  as  the  exercise  test  brings  on  an  in- 
cipient presystolic  gallop  rhythm  perceptible  upon 
auscultation  or  palpation. 

Friedlander  Pleuropneumonia  with  Fetid  Rhi- 
nitis and  Jaundice. — C.  Flandin  and  M.  Debray 
(Bulletins  et  memoires  de  la  Societe  medicale  des 
hopitaux  de  Paris,  January  29,  1920)  report  the 
case  of  a  woman,  aged  forty  years,  who  was  sud- 
denly seized  with  sharp  pain  in  the  side  and  a  chill, 
followed  by  fever  and  cough.  Pleurisy  was  sus- 
pected, but  repeated  punctures  were  negative.  On 
the  eleventh  day,  after  defervescence,  signs  of  pneu- 
monia appeared,  persisting  for  over  twenty  days 
thereafter.  A  series  of  febrile  movements  gave  the 
case  the  appearance  of  subacute  illness.  There 
was  also  ozena  from  the  start,  and  a  varying  degree 
of  jaundice.  In  view  of  the  bloody  sputum,  infec- 
tion by  the  pneumobacillus  of  Friedlander  was  sus- 
pected, and  this  was  confirmed  by  microscopic  study. 
The  condition  is  believed  to  have  been  a  Friedlander 
septicemia,  beginning  in  the  nose,  mainly  localized 
in  one  pulmonary  lobe,  with  extension  to  the  biliary 
tract,  causing  infectious  jaundice.  Recovery  took 
place  in  one  month,  in  spite  of  a  mitral  lesion. 

Leptospira  Icteroides  and  Yellow  Fever. — 
Hideyo  Noguchi  (Proceedings  of  the  National 
Academy  of  Sciences,  March,  1920)  notes  that  in 
the  course  of  studies  conducted  in  Guayaquil,  Ecua- 
dor, he  was  able  to  detect  in  certain  cases  of  yellow 
fever  a  special  spiral  organism  subsequently  termed 
Leptospira  icteroides.  Guineapigs  and  puppies, 
inoculated  with  the  blood  of  yellow  fever  patients 
or  with  cultures,  present  symptoms  and  lesions 
closely  approximating  those  of  yellow  fever  in  man. 
The  outstanding  signs  are  jaundice,  hemorrhage 
into  the  lungs  and  stomach,  and  albumin  and  casts 
in  the  urine.  At  autopsy,  as  in  man,  the  liver,  kid- 
neys, and  other  internal  organs  are  found  severely 
degenerated.  The  spiral  organisms  are  recoverable 
from  the  inoculated  guineapigs,  and  with  them  the 
disease  is  transmissible  through  an  indefinite  series 
of  animals.  Furthermore,  guineapigs  have  been 
successfully  infected  with  the  spiral  organisms  by 
means  of  Stegomyia  mosquitoes,  and  Stegomyias 
fed  on  infected  guineapigs  are  capable  of  trans- 
mitting die  active  microbe  to  still  other  guineapigs. 
Immunological  studies  indicated  the  possibility  of 
developing  a  vaccine  and  even  a  curative  serum. 
But  until  the  finding  of  Leptospira  icteroides  is 
confirmed  by  the  investigation  of  cases  of  yellow 
fever  in  still  other  places,  its  standing  as  the  inciting 
agent  of  yellow  fever  will  have  to  be  regarded  as 
not  yet  certainly  established. 


Yellow  Fever. — Hideyo  Noguchi  (Journal  of 
Experimental  Medicine,  February,  1920)  used  poly- 
valent immune  serum  of  high  potency  in  treating 
guineapigs  experimentally  infected  with  Leptospira 
icteroides.  When  the  serum  was  injected  during 
the  time  of  incubation  it  prevented  further  develop- 
ment of  the  infection.  Used  in  the  early  stages,  it 
appears  to  be  capable  of  averting  an  early  termina- 
tion of  the  disease,  but  if  it  is  employed  when  the 
guineapigs  are  inoculated  with  a  highly  virulent 
culture  when  the  jaundice  has  existed  for  some 
time  and  the  animal  is  nearing  collapse,  it  is  unable 
to  check  the  course  of  the  infection.  Noguchi  states 
that  irrespective  of  the  relation  which  Leptospira 
icteroides  may  prove  to  have  to  the  etiology  of  yel- 
low fever,  such  patients  will  probably  have  little  or 
no  chance  of  deriving  benefit  from  the  use  of  a 
specific  immune  serum,  when  the  temperature  is 
subnormal,  and  the  stage  of  hemorrhages  from  the 
gums,  nose,  stomach,  and  intestines,  with  uremia 
and  cholemia,  has  been  reached. 

Sulphur  Metabolism  in  the  Cancerous  Liver. — 

A.  Robin  and  A.  Bournigault  (Bulletin  de  I'Aca- 
demie  de  tnedecine,  February  24,  1920)  found  that 
the  least  involved  portions  of  the  cancerous  liver 
contain  about  twenty  per  cent,  more  of  total  sul- 
phur than  the  portions  m.ost  diseased.  These  and 
other  estimations  tend  to  show  that  cancer  tissue  is 
built  up  with  much  less  sulphur  than  normal  liver 
tissue,  and  also  that  the  sulphur  in  the  cancerous 
liver  tends  to  accumulate  in  the  least  involved  por- 
tions of  the  organ.  The  ratio  of  sulphur  to  dried 
proteins  is  much  less  in  cancerous  liver  tissue  than 
in  the  uninvolved  portions  and  in  normal  liver  tis- 
sue. The  accumulation  of  sulphur  in  the  least  in- 
volved portions  seems  to  be  due  to  a  special  mode 
of  disintegration  of  proteins,  this  process — prepara- 
tory to  cancerization — involving  the  liberation  of 
only  certain  ones  among  the  aminoacids  of  the  pro- 
tein molecule  in  the  as  yet  uninvolved  tissues.  These 
special  aminoacids  are  the  hexone  bases,  already 
found  in  excessive  amounts  in  cancer  tissue  by  R. 
A.  Kocher,  while  the  sulphur  containing  cystein  re- 
mains unafifected.  A  contrast  to  this  condition  is 
.seen  in  tuberculous  tissue  in  which  the  sulphur  in 
the  least  affected  portions  of  the  lungs  is  16.3  per 
cent,  less  than  in  the  most  aflfected  portions,  and 
20.8  per  cent,  less  than  in  normal  lung  tissue. 
Different  from  the  cancer  ferment,  the  tubercle 
bacillus  disintegrates  all  proteins  of  the  lung  tissue, 
including  cystein,  and  constructs  the  tuberculous 
tissue  from  the  debris — another  argument  against 
the  parasitic  theory  of  cancer.  The  marked  rela- 
tive increase  of  sulphuric  sulphur,  i.  e.,  sulphur 
oxidized  to  sulphuric  acid,  in  the  most  involved 
portions  of  the  cancerous  liver  may  be  considered 
an  indication  of  a  defensive,  oxidizing  reaction 
against  the  noxious  aromatic  products  formed 
through  disintegration  of  the  cancerous  tissue.  This 
particular  type  of  defensive  reaction  does  not  occur 
in  tuberculous  tissue.  The  study  as  a  whole  points 
to  the  existence  of  a  dissociating  ferment  that  acts 
in  a  special  manner  upon  the  proteins  of  the  tissues 
in  which  cancer  is  subsequently  to-  develop.  New 
problems  to  be  solved  in  the  chemotherapy  of  cancer 
are  thus  suggested. 


Proceedings  of  National  and  Local  Societies 


AMERICAN  ASSOCIATION  OF  OBSTETRI- 
CIANS, GYNECOLOGISTS,  AND 
ABDOMINAL  SURGEONS. 

Thirty-third  Annual  Meeting,  Held  at  Atlantic  City, 
N.  J.,  September  20,  21,  and  22,  1920. 

The  President,  Dr.  George  W.  Crile,  in  the  Chair. 

{Continued  from  page  744.) 

Pseudocholecystitis. — Dr.  Harold  D.  Meeker, 
of  New  York,  drew  the  following  conclusions : 

1.  The  occurrence  of  adventitious  bands  in  the 
upper  abdomen  had  been  established  beyond  ques- 
tion. 2.  These  bands  gave  rise  to  definite  symp- 
toms. 3.  The  gallbladder  was  the  viscus  most  fre- 
quently involved ;  the  resulting  symptoms  simulated 
a  cholecystitis.  4.  Plastic  surgery  had  given  defi- 
nite relief.  As  complete  freedom  from  symptoms 
had  been  recorded  ten  years  after  operation,  it  was 
reasonable  to  suppose  relief  might  be  permanent. 
5.  It  was  illogical  and  unfair  to  patients  to  with- 
hold a  chance  of  relief  because  the  Origin  of  these 
bands  might  not  yet  have  been  definitely  estab- 
lished. 6.  The  frequency  with  which  adventitious 
bands  in  other  parts  of  the  abdomen  coexisted  with 
those  of  the  upper  abdomen,  emphasized  the  im- 
portance of  a  thorough  search  of  the  entire  gastro- 
intestinal tract  for  abnormal  bands  and  fixed  points. 
7.  It  was  to  be  hoped  that  a  comprehensive  discus- 
sion of  these  bands  would  be  found  in  the  surgical 
textbooks  of  the  near  future.  A  knowledge  of  the 
condition  would  be  the  means  of  restoring  to  a 
life  of  comfort  many  individuals  otherwise  con- 
demned to  continued  suffering. 

Results  of  Double  Flap  Low  Caesarean  Section. 

— Dr.  Thurston  Scott  Welton,  of  Brooklyn,  N. 
Y.,  stated  that  as  a  result  of  the  findings  in  this  series 
of  a  total  of  fifty-five  cases,  he  had  reached  the  fol- 
lowing conclusions:  1.  The  double  flaps  and  low  in- 
cision offered  great  protection  against  extension  of 
infection  to  the  peritoneum  from  an  infected  uterus. 

2.  As  a  result  this  should  be  the  operation  of  choice 
in  all  potentially  infected  cases.  3.  This  fact,  also, 
should  extend  the  field  for  Caesarean  section  to  in- 
clude such  patients  as  had  been  long  in  labor  with  the 
membranes  ruptured  and  potentially  infected  from 
frequent  vaginal  manipulation  in  which  most  men 
would  elect  to  do  a  craniotomy  on  a  living  child 
rather  than  do  a  classical  section.  4.  The  double 
flaps,  likewise,  so  completely  peritonealized  the 
uterine  wound  that  adhesions  and  postoperative 
disturbances  were  greatly  minimized.  5.  From  the 
results  obtained  and  the  reasons  given,  the  two  flap 
low  Caesarean  section  should  be  the  operation  of 
choice  even  in  elective  cases. 

A  Preliminary  Report  of  Pyelitis  in  Pregnancy 
with  Report  of  Cases. — Dr.  Greer  Baughman,  of 
Richmond,  Va.,  reported  three  cases  oi  pyelitis 
complicating  pregnancy.  He  showed  lantern  slides 
and  charts  and  pyelograms  indicating  the  progress 
of  the  cases.  All  the  patients  were  treated  with 
pelvic  lavage.    Living  babies  were  liorn  to  the  two 


patients  in  whom  labor  was  induced  at  a  selected 
time,  while  in  the  patient  who  entered  labor  before 
the  time  set  for  the  induction  of  labor,  the  child 
died.  With  the  exception  of  a  few  treatments,  the 
patients  after  the  first  reaction  showed  marked  im- 
provement in  symptoms.  In  all  the  patients  the 
right  pelvis  was  primarily  involved ;  in  two  the  blad- 
der was  involved  early,  in  the  other  the  bladder 
signs  were  not  prominent.  Bacillus  coli  was  the  ex- 
citing cause  of  two ;  staphylococcus  albus  of  the 
other.  In  all  the  cases  the  curve  representing  the 
right  and  left  pelvic  sizes  were  parallel.  A  marked 
improvement  was  noted  in  all  symptoms,  pelvic  size, 
and  urinary  findings  following  delivery,  showing 
that  the  obstruction  did  take  place  from  the  uterus 
and  its  contents.  It  was  found  possible  to  irrigate 
all  of  these  patients  within  two  weeks  after  the 
time  of  their  delivery;  in  none  was  there  any  rise  in 
temperature  during  the  puerperium. 

Borderline  Carcinoma  of  the  Cervix  and  Its 
Treatment. — Dr.  Edward  A.  Weiss,  of  Pitts- 
I)urgh,  Pa.,  said  that  when  a  diagnosis  of  cancer 
of  the  cervix  had  been  made,  appropriate  treatment 
should  be  given  at  the  earliest  possible  moment, 
nevertheless  haste  in  operating  was  not  always  ad- 
visable. He  had  found  from  practical  experience 
that  preliminary  preoperative  rest  in  bed  for  several 
days  resulted  in  a  marked  diminution  in  the  size  of 
the  diseased  cervix,  but  more  important  still  there 
was  often  noticed  a  decided  decrease  in  the  thicken- 
ing and  fixation  of  the  broad  ligaments,  proving 
that  the  fixation  was  inflammatory  rather  than  a 
malignant  invasion  of  the  lymphatics  of  the  broad 
lisaments.  As  a  result  of  this  observation  he  had 
frequently  found  that  the  supposedly  moperable 
case  was  really  operable  or  borderline.  During 
the  period  of  rest  in  bed,  more  careful  study  of 
the  patient's  resistance  could  be  made,  and  should 
radical  treatment  follow,  the  condition  of  the 
patient  was  greatly  improved  and  offered  a  better 
operative  risk. 

In  the  borderline  cases,  the  improved  Byrne 
cautery  technic,  which  was  practically  the  first  stage 
of  the  Werder  radical  igniextirpation,  had  given 
him  the  best  results  in  many  years,  and  while  only  a 
few  socalled  permanent  or  five  year  cures  were  ob- 
tained, yet  he  had  had  several  instances  of  complete 
freedom  from  symptoms  for  periods  of  from  three 
to  five  years.  In  thirty-eight  borderline  cases  so 
treated,  there  was  recurrence  with  death  in  one 
case  at  six  months;  two  in  nine  months;  five  in 
twelve  months ;  five  in  eighteen  months ;  eight  in 
two  years ;  five  in  two  and  a  half  years ;  two  in 
three  years ;  three  in  three  and  a  half  years ;  two 
in  four  years;  one  in  five  years,  and  four  were  not 
to  be  traced  after  the  first  year.  In  this  series  one 
death  resulted  on  the  fourth  day  from  embolism. 

The  results  obtained  by  Dr.  Weiss  with  radium 
in  a  series  of  advanced  or  inoperable  cases  were  so 
striking,  that  a  series  of  forty-five  borderline  or 
Group  IV.  cases,  radium  instead  of  the  cautery 
was  used,  and  while  the  results  were  disappointing 


November  13,  1920.] 


PROCEEDINGS  OF  NATIONAL   AND  LOCAL  SOCIETIES. 


72,7 


in  some  instances,  he  was  forced  to  admit,  after 
taking  all  factors  into  consideration,  that  in  a  small 
series  radium  had  proved  to  be  a  most  valuable 
adjunct,  both  as  to  immediate  and  remote  results. 
To  say  that  radium  used  in  the  cervix  was  a  harm- 
less procedure  was  not  in  accordance  with  facts 
and  its  indiscriminate  use  would  bring  discredit 
to  a  very  valuable  adjunct  in  gynecological  therapy. 
In  using  the  cautery  in  the  treatment  of  borderline 
cancer,  a  clear  distinction  must  be  made  between 
the  socalled  Percy  cauterization  and  high  amputa- 
tion by  the  cautery.  In  the  former  the  cervix  was 
not  removed,  but  a  deep  charring  resulted  which 
was  often  followed  by  fistula  formation  and  severe 
constitutional  reaction.  The  subsequent  use  of 
radium  would  not  only  be  of  little  value,  but  would 
increase  the  tendency  to  fistula.  Cancer  of  the 
cervix  was  still  to  be  classed  as  an  operative  con- 
dition when  discovered  early  and  the  patient  a  good 
risk.  When  a  doubtful  borderline  condition  was 
presented  treatment  by  radium  was  advisable  and 
the  question  of  subsequent  operation  should  be  de- 
cided by  the  reaction  obtained ;  but  if  the  operation 
was  contraindicated  by  age,  general  condition, 
heart,  kidney,  or  blood  vessels,  radium  alone  should 
be  used. 

Splenic  Leucemia  Associated  with  Pregnancy. 

— Dr.  George  W.  Kosmak,  of  New  York,  stated 
that  a  survey  of  the  reported  cases  of  leucemia 
complicating  pregnancy  in  which  a  fairly  definite 
diagnosis  from  the  blood  picture  was  made,  dis- 
closed a  total  of  twelve,  including  two  of  his  cases. 
The  ages  of  the  patient  varied  from  twenty-four 
to  forty,  the  majority  being  between  thirty-two  and 
thirty-six.  With  the  exception  of  Peterson's  case 
all  were  multiparae.  A  possible  hereditary  history 
was  mentioned  in  only  one  case.  The  parity  varied 
from  three  to  nine.  In  most  of  the  cases  he  got  a 
history  of  living  children  that  showed  no  tendency 
to  the  disease  up  to  the  time  of  the  report,  but  in 
a  few  instances  he  was  told  that  the  babies  died  at 
varying  periods  after  labor,  from" a  few  days  to 
five  months.  In  four  cases  mention  was  made  of 
the  birth  of  macerated  or  stillborn  fetuses.  Among 
these  twelve  cases  the  mother  survived  in  but  two, 
but  how  long  these  mothers  lived  was  not  stated, 
nor  the  subsequent  course  of  the  disease.  In  the 
majority  of  cases  he  found  that  the  woman  sur- 
vived, but  a  short  time  after  labor.  One  of  his 
patients  died  before  delivery  took  place.  In  Peter- 
son's case,  death  came  on  an  hour  after  labor,  in 
Hubert's  case,  ten  hours,  and  in  Laubenburg's, 
forty  hours  after  labor.  There  was  a  record  of 
death  in  Stillman's  case  one  month  after  delivery, 
in  his  second  case  death  occurred  in  two  weeks, 
and  in  Jaggard's  case  in  eleven  months  after  de- 
livery. In  every  instance  but  one  (his  own  case), 
in  which  the  definite  diagnosis  was  presented  the 
splenomedullary  type  of  the  disease  was  observed. 
It  would  be  noted  that  in  many  cases  the  authors 
mentioned  a  prodromal  period  in  which  progressive 
emaciation,  anemia  and  loss  of  strength  were  noted 
soon  after  a  pregnancy,  from  which  no  recovery 
resulted,  and  during  which  period  the  woman  again 
became  pregnant.  The  leucemia  itself  did  not,  there- 
fore, appear  to  be  a  deterrent  factor  to  conception. 


Although  the  presence  of  a  true  leucemia  as  a 
complication  of  pregnancy  was  from  all  available 
records  a  very  rare  condition,  nevertheless,  one 
ought  to  be  on  his  guard  against  it.  Probably  a 
considerable  number  of  cases  of  marked  anemia  in 
which  no  satisfactory  blood  count  had  been  made 
might  have  been  true  instances  of  this  disease.  In 
any  case  where  an  anemic  patient  failed  to  recover 
under  proper  treatment,  a  more  minute  and  detailed 
examination  of  her  blood  should  be  made  with  ref- 
erence to  the  possible  diagnosis  of  leucemia.  The 
occurrence  of  pregnancy  in  this  disease  indicated 
a  most  unfavorable  outlook  for  the  mother  and  con- 
ception must  therefore  not  be  allowed  to  take  place 
where  the  condition  was  suspected.  The  prognosis 
was  undoubtedly  worse  in  the  pregnant  than  in  the 
nonpregnant  and  whether  the  association  was  acci- 
dental or  not  was  immaterial.  Where  the  disease 
was  already  present  abortion  seemed  to  be  the  rule, 
with  a  rapidly  progressing  course  and  a  fatal  issue. 
The  presence  of  an  enlarged  spleen  was  an  almost 
constant  factor  in  the  disease  and  should  lead  one 
to  look  for  this  sign  in  every  anemic  patient.  The 
value  of  the  x  rays  in  leucemia  had  been  brought 
forward,  but  in  the  event  of  a  pregnancy  its  appli- 
cation, as  a  cure  for  the  disease,  might  work 
an  undoubted  harm  on  the  fetus  and  the  induction 
of  labor  should  be  done  before  radiation  was 
begun. 

It  was  necessary  to  distinguish  between  the  acute 
and  chronic  forms  of  leucemia.  Pregnant  women 
might  contract  a  rapidly  fatal  leucemia  if  the  evi- 
dence of  the  cases  thus  far  reported,  was  to  be 
believed,  although  it  seemed  possible  that  the  dis- 
ease was  present  in  a  milder  form  in  many  of  these 
patients  before  their  last  and  usually  fatal  preg- 
nancy occurred.  It  would  be  noted  that  there  were 
apparently,  cases  of  chronic  leucemia  in  this  series 
in  which  pregnancy  and  labor  occurred,  and  for 
this  reason  conservative  treatment  had  been  advised 
under  such  circumstances.  In  view  of  the  rapidly 
fatal  ending  during  the  puerperium  it  would  appear 
that  this  advice  was  not  justifiable  and  that  in  order 
to  avoid  such  an  outcome  labor  had  better  be  in- 
duced in  all  cases. 

Benign  Mammary  Tumors  and  Interstitial 
Toxemia. — Dr.  William  Seaman  Bainbridge,  of 
New  York,  reported  a  series  of  twenty-five  cases 
of  abnormal  mammary  changes  apparently  caused 
by  autointoxication.  Each  of  the  patients  who 
suff'ered  from  abnormal  breast  conditions  had  in 
addition  to  the  breast  changes,  coexistent  chronic 
intestinal  toxemia,  the  mammary  gland  frequently 
registering  the  degree  of  toxic  poisoning.  He  divided 
the  cases  roughly  into  three  classes:  1.  Patients 
with  a  condensation  or  lobulated  induration  of  the 
upper,  outer  quandrant  of  the  breasts,  usually  along 
the  edge  of  the  large  pectoral  muscle  and  where 
the  dependent  breast  dragged  on  the  upper  axillary 
margin.    These  were  lumpy,  toxic,  or  stasis  breasts. 

2.  Patients  with  breast  changes  as  in  Class  I  but 
with  the  added  condition  of  localized  degeneration 
of  the  mammary  gland,  such  as  adenomata  or  cysts. 

3.  Patients  with  breast  changes  as  in  Classes  I  or  II 
and  in  conjunction  an  abnormal  discharge  from  the 
nipples. 


788 


PROCEEDINGS  OF  NATIONAL   AND  LOCAL  SOCIETIES. 


[New  York 
Medical  Journal. 


The  majority  of  the  cases  were  in  patients  with 
marked  intestinal  toxemia ;  a  few  had  compHcating 
pelvic  conditions.  1.  Patients  cured  with  medical 
measures,  five ;  patients  cured  by  surgical  relief  of 
the  chronic  intestinal  stasis  and  without  operation 
on  the  mammae,  fifteen ;  patients  cured  after  opera- 
tion for  adenoma  or  cystoma  and  for  the  intestinal 
stasis,  the  remaining  indurated,  lobulated  portion  of 
the  breast  returning  to  a  normal  condition,  one ; 
patients  cured  by  the  removal  of  an  adenoma  or 
cystoma  from  a  toxic  breast,  and  by  preliminary  and 
aftertreatment  for  the  intestinal  toxemia,  three,  and 
patients  from  which  stasis  breasts  were  removed, 
the  underlying  intestinal  toxemia  not  being  recog- 
nized, one.  Dr.  Bainbridge  presented  the  following 
conclusions:  1.  There  are  definite  abnormal  condi- 
tions of  the  breast  tissue  due  to  intestinal  toxemia. 
As  the  thyroid  gland  is  changed  by  toxemia,  so  the 
mammary  gland  may  be  altered  completely  by 
chronic  intestinal  stasis.  2.  Under  medical  treat- 
ment an  appreciable  number  of  these  patients  with 
fibnormal  breast  conditions  are  cured.  A  proper 
uplifting  abdominal  corset  applied  for  enteroptosis, 
a  careful  diet,  catharsis,  breast  supports  for  de- 
pendent organs,  digestants,  intestinal  antiseptics, 
and  certain  physiotherapeutic  agents  are  among  the 
corrective  measures  which  often  cause  even  well 
defined  tumors  of  the  breast  to  disappear.  Any 
element  which  tends  to  diminish  the  gastrointestinal 
fermentation  is  of  value.  A  preliminary  lessening 
•of  the  general  toxic  condition  of  the  patient  mate- 
rially aids  the  surgeon  in  determining  the  true 
benign  neoplasm  and  saves  a  considerable  amount  of 
recoverable  breast  tissue  too  often  unnecessarily 
sacrificed.  3.  Surgical  procedures  frequently  are 
required  for  the  correction  of  the  intestinal  stasis 
and  the  removal  of  the  cystoma  or  the  adenoma 
before  the  indurated,  lobulated  tissue  resumes  a 
healthy  gland .  condition  and  the  breast  is  brought 
back  to  normal.  4.  When  these  toxic  cases  are 
seen  early  the  beginning  changes  in  the  breast  are 
often  overlooked,  or,  when  the  condition  is  well 
developed,  the  incorrect  diagnosis  of  malignancy  is 
made.  One  question  naturally  forces  itself  upon 
;the  profession  in  this  connection :  Would  an  early 
recognition  of  the  toxic  breast  and  the  timely  and 
efficient  treatment  of  the  underlying  cause  tend  to 
lessen  the  danger  of  malignant  degeneration  of  the 
mammary  gland  and  thereby  render  unnecessary 
much  of  the  mutilation  of  the  human  breast? 

Cases  of  Thrombophlebitis  During  the  Puer- 
perium  Following  Influenza. — Dr.  Lewis  F. 
Smead,  of  Toledo,  Ohio,  said  that  the  present  in- 
terest in  septic,  puerperal,  pelvic  tlirombophlebitis 
dated  from  a  paper  by  Trendelenburg  in  1902.  The 
condition  was  not  infrequent  in  the  puerperium,  be- 
cause of  the  slowed  blood  current  and  the  oppor- 
tunities for  infection.  The  disease  consisted  usu- 
ally of  a  streptococcus  infection,  entering,  as  a  rule, 
through  the  placental  site,  extending  by  the  ovarian 
and  uterine  veins,  and  resulting  in  pyemia  and  death 
in  about  fifty  per  cent,  of  the  cases.  The  acute 
cases  were  rapidly  fatal,  but  in  the  subacute  cases 
the  prognosis  was  better.  The  disease  was  marked 
by  a  sudden  fluctuating  temperature,  severe  chills, 
a  relatively  low  pulse  rate,  and  a  prolonged  course 


of  the  disease.  A  sharply  defined,  painless,  slightly 
tender,  cordlike  induration  in  the  region  of  the 
pelvic  veins  could  be  made  out  sooner  or  later.  The 
results  of  the  blood  cultures  were  uncertain.  A 
striking  feature  was  the  surprisingly  good  condi- 
tion of  the  patient  between  the  rigors. 

The  diagnosis  of  pelvic  thrombophlebitis  was 
fairly  accurate.  Differentiation  must  be  made  from 
septicemia,  pelvic  lymphangitis,  uterine  infection, 
and  thrombophlebitis  in  other  vessels.  The  opera- 
tive mortality  was  undoubtedly  somewhat  lower 
than  the  nonoperative.  The  indications  for  opera- 
tion were  hard  to  define,  but  in  cases  with  sep- 
ticemia, metastatic  foci,  and  vena  cava  involvement, 
operation  was  not  impossible.  Prophylaxis  con- 
sisted of  intelligent  obstetrics,  careful  asepsis,  com- 
plete evacuation  of  the  uterus,  and  good  drainage, 
with  a  minimum  amount  of  traumatism  and  hem- 
orrhage. The  circulation  in  the  puerperium  was 
kept  active  by  good  food,  fresh  air,  early  rising, 
and  heart  stimulation  if  necessary. 

The  nonsurgical  treatment  consisted  of  general 
supportive  measures  with  the  avoidance  of  anything 
which  might  dislodge  a  thrombus,  such  as,  douches, 
enemata,  and  pelvic  examinations.  Vaccine  and 
serum  treatment  had  been  disappointing.  The  sur- 
gical treatment  consisted  in  the  ligation  or  excision 
of  the  involved  veins  by  the  transabdominal  route 
and  by  the  drainage  of  perivascular  abscesses. 
Opinion  upon  the  question  of  surgical  intervention 
in  pelvic  thrombophlebitis  was  still  divided,  but  all 
agreed  that  great  conservatism  must  govern  the 
choice  of  cases  and  the  decision  for  operation. 

Fibroma  of  the  Ovary. — Dr.  Edmund  D. 
Clark  and  William  E.  Gabe,  of  Indianapolis, 
Ind.,  presented  the  following  conclusions:  1. 
Ovarian  fibromata  are  sufficiently  rare  to  warrant 
their  report  in  all  carefully  studied  cases.  2.  The 
diagnosis  is  dependent  <5olely  on  microscopic  ex- 
amination. 3.  In  the  presence  of  a  hard,  unilateral, 
movable  tumor,  with  ascites,  where  the  more  com- 
mon causes  of  ascites  can  be  ruled  out,  ovarian 
fibroma  is  highly  probable.  4.  The  treatment  is 
operation ;  the  prognosis  good.  5.  The  gross  path- 
ology of  the  condition  is  extremely  variable;  the 
microscopic  pathology,  as  pointed  out  by  Hellman, 
must  show  regularity  of  the  individual  fibres  or 
muscular  cells  and  strands,  despite  varying  quanti- 
ties of  cells,  fibres,  vessels  and  degenerative  changes. 

Indications  for  Hysterectomy. — Dr.  James  F. 
Baldwin,  of  Columbus,  Ohio,  states  that  very 
many  women  suffered  from  chronic  uterine  hyper- 
plasia, frequently  complicated  with  laceration  of 
the  cervix,  retroversion,  a  tendency  to  procidentia, 
with  leucorrhea,  dyspareunia,  sterility,  backache, 
and  general  ill  health.  In  this  type  of  disease  no 
treatment  effected  a  cure,  and  little  could  be  ac- 
complished in  palliation.  Other  women  suffered 
from  imperfect  development  of  the  uterus,  with 
sterility,  painful  menstruation  and  other  disturb- 
ances. The  paper  was  a  plea  for  the  radical  cure 
of  these  two  classes  of  cases  by  hysterectomy,  but 
with  saving  of  appendages  so  as  to  obviate  the 
symptoms  of  the  menopause,  except  as  to  the  ab- 
sence of  menstruation. 

(To  be  concluded.) 


New  York  Medical  Journal 

INCORPORATING  THE 

Philadelphia  Medical  Journal     Medical  News 

A  Weekly  Review  of  Medicine,  Established  ISJ^S. 

Vol.  CXII,  No.  21.  NEW  YORK.  SATURDAY,  NOVEMBER  20,  1920.  Whole  No  2190. 

Original  Communications 


THE  UNCONSCIOUS. 

By  W.  H.  R.  Rivers,  M.  D.,  LL.  D.,  F.  R.  S., 
Cambridge,  England. 

The  concept  of  the  uncon.sciou.s  in  psycl\ologv  is 
one  which  has  aroused  the  livehest  differences  of 
opinion  and  lias  been  met  by  bitter  opposition. 
Even  those  who  are  ready  to  accept  the  vast  influ- 
ence of  unconscious  factors  in  psychology  may  well 
be  appalled  by  the  difficulties  of  treating  the  un- 
conscious in  a  scientific  manner  and  fitting  so  neces- 
sarily hypothetical  a  factor  into  the  explanation  of 
behavior.  One  line  of  opposition  has  come  from 
advocates  of  the  older  introspective  school  of  psy- 
chologists who  have  found  it  difficult  to  fit  an  un- 
conscious region  of  the  mind  into  their  schemes  of 
description  and  explanation.  The  aim  of  the  older 
psychology  was  to  furnish  a  rational  explanation 
of  human  behavior  and  endeavor.  As  the  material 
for  such  explanation  they  used  almost  exclusively 
die  happenings  in  their  own  minds  which  could  be 
directly,  though  really  only  retrospectively,  observed, 
and  made  this  material  the  basis  of  constructions 
whereby  they  fitted  into  coherent  schemes  the  infi- 
nitely ^varied  experience  of  the  human  mind.  When 
their  introspective  method  failed  them,  and  they 
were  driven  to  assume  the  existence  of  factors  lying 
outside  those  accessible  to  introspection,  they  were 
accustomed  to  assume  subconscious  processes  or  to 
speak  of  psychological  dispositions  and  tendencies, 
or  they  would  even  throw  psychology  wholly  aside, 
bringing  into  their  schemes  of  explanation  factors 
l)elonging  to  the  wholly  different  order  of  the 
material  world,  and  used  physiological  processes  as 
links  in  the  chain  whereby  they  connected  one  psy- 
chological happening  with  another. 

It  is  noteworthy  that  the  due  recognition  of  the 
importance  of  the  unconscious  and  the  first  compre- 
hensive attempt  to  formulate  a  scheme  of  its  organ- 
ization and  of  the  mechanisms  by  which  it  is 
brought  into  relation  with  the  conscious,  should 
have  come  from  those  whose  business  it  is  to  deal 
with  the  morbid  aspect  of  the  human  mind.  The 
necessity  for  the  use  of  unconscious  factors  con- 
tinually arises  when  dealing  with  the  experience  of 
health,  but  the  opportunities  afTorded  by  such  ex- 
perience are  usually  so  fleeting,  and  the  experience 
itself  often  so  apparently  trivial,  that  they  failed  to 
force  the  psychologists  of  the  normal  to  face  the 
situation.  It  was  only  when  unconscious  experi- 
ence had  contributed  to  wreck  a  life  or  produce  a 


state  with  which  the  physician  had  to  struggle,  and 
then  often  ineffectually,  for  months  or  years,  that 
it  became  impossible  to  push  such  experience  aside 
or  take  any  other  line  than  that  involved  in  the  full 
recognition  of  its  existence.  It  is  only  the  urgent 
and  inevitable  needs  of  the  sick  that  have  driven  the 
physician  into  the  full  recognition  of  the  uncon- 
scious, while  it  has  needed  the  vast  scale  on  which 
nervous  and  mental  disorders  have  been  produced 
in  the  war  to  force  this  recognition  upon  more  than 
the  few  specialists  to  whom  it  had  been  previously 
confined. 

In  entering  upon  an  attempt  to  make  clear  the 
sense  in  which  the  term  unconscious  should  be  used, 
1  will  begin  by  pointing  out  one  sense  in  which  it 
ft'ill  not  be  used.  At  any  given  moment  we  are 
only  clearly  conscious  of  the  experience  which  is 
in  the  focus  of  attention.  This  forms  only  an  in- 
finitesimal proportion  of  the  experience  which  is 
capable,  by  being  brought  into  the  focus  of  atten- 
tion, of  becoming  conscious  with  an  equal  degree 
of  clearness.  Again,  at  any  one  moment  a  much 
larger  amount  of  experience  is  within  the  region 
of  the  conscious  though  less  clearly,  but  even  the 
largest  amount  which  can  thus  be  brought  within 
the  outermost  fringe  of  consciousness  at  any  instant 
or  even  within  any  brief  space  of  time,  forms  but 
a  very  small  proportion  of  that  which,  with  other 
directions  of  the  attention,  could  come  into  the  field 
of  consciousness.  At  any  given  instant  there  is  a 
vast  body  of  experience  which  is  not  in  conscious- 
ness only  because  at  that  instant  it  is  neither  the 
object  of  attention  nor  so  connected  therewith  as 
to  occupy  consciousness  with  more  or  less  clearness 
at  the  same  time.  Experience  of  this  kind  will  not 
be  included  within  the  unconscious  as  I  shall  use 
the  term.  In  so  far  as  the  term  the  unconscious 
applies  to  experience  it  will  be  limited  to  such  as 
is  not  capable  of  being  brought  into  the  field  of 
consciousness  by  any  of  the  ordinary  processes  of 
memory  or  association,  but  can  only  be  recalled 
under  certain  special  conditions,  such  as  sleep, 
hypnotism,  the  method  of  free  association,  and 
certain  pathological  states. 

A  good  instance  of  the  unconscious  is  afforded 
by  the  conditions  underlying  the  claustrophobia  of 
a  sufferer  from  war  neurosis.  For  as  long  as  he 
could  remember  this  patient  had  been  subject  to  a 
dread  of  confined  spaces  so  severe  and  producing 
states  so  painful  and  unendurable  that  he  was  de- 
barred from  taking  part  in  many  of  the  ordinary 


Copyright,  1920,  by  A.  R.  Elliott  Publishing  Company. 


790 


RIVERS:   THE  UNCONSCIOUS. 


[New  York 
Medical  Journal, 


occupations  of  life,  or  could  do  so  only  at  the  risk 
of  siififering  and  discomfort.  When  I  first  saw  him 
his  earliest  memory  of  the  dread  went  back  to  the 
time  when  at  the  age  of  six  he  slept  with  his  elder 
brother  in  what  is  known  in  Scotland  as  a  box  bed. 
The  bed  stood  in  a  recess  with  doors  which  conld 
be  closed  so  as  to  give  the  appearance  of  a  sitting 
room.  The  child  slept  on  the  inner  side  of  the 
bed  next  to  the  wall,  and  he  still  vividly  remembers 
his  fear  and  the  desire  to  get  out  of  bed,  which  he 
did  not  satisfy  for  fear  of  waking  his  brother.  He 
would  lie  in  a  state  of  terror,  wondering  if  he 
would  be  able  to  get  out  if  the  need  arose. 

The  next  memory  bearing  on  his  phobia  is  of 
being  taken  to  see  some  men  descending  the  shaft 
of  a  coal  pit.  There  came  to  him  at  once  the  fear 
that  were  he  going  down  something  might  happen 
to  prevent  his  getting  out  Whenever  he  was  taken 
in  childhood  for  a  journey  by  train  he  dreaded  the 
tunnels,  and  if  by  chance  the  train  stopped  in  a 
tunnel  he  feared  that  there  might  be  an  accident 
and  that  he  would  not  be  able  to  get  out.  This  fear 
of  tunnels  became  worse  as  he  grew  older.  When 
he  began  to  go  to  the  theatre  or  other  crowded 
building  he  was  always  troubled  unless  he  was  near 
the  door,  and  he  was  never  happy  unless  he  could 
see  a  clear  and  speedy  mode  of  exit.  He  would 
not  travel  by  the  tube  railway,  and  vividly  remem- 
bers his  horror  when  on  one  occasion  he  had  to 
do  so.  As  long  as  he  can  recollect  he  has  felt  an 
intense  sympathy  whenever  he  has  read  of  prisoners 
being  confined  in  a  narrow  cell,  and  he  has  always 
been  greatly  disturbed  by  tales  of  burial  alive. 

When  during  the  war  he  went  to  France  as  a 
doctor,  he  was  greatly  disturbed  by  having  to  live 
and  work  in  dugouts  and  would  seek  excuses  to 
go  to  the  trenches  in  order  to  escape  from  experi- 
ences which  were  to  him  far  more  trying  than  the 
dangers  of  the  front  line.  As  a  result  of  the  strain 
he  broke  down  and  some  time  later  came  under  my 
care.  In  obtaining  his  history  I  found  that  he  had 
been  through  a  course  of  psychoanalysis  of  a  very 
crude  kind  and  had  for  ypars  been  seeking  some 
event  of  childhood  which  could  explain  his  dreads. 
We  then  started  on  a  new  attempt  in  this  direction. 
I  asked  him  to  remember  as  fully  as  possible  his 
dreams  and  to  record  any  memories  which  came 
into  his  mind  while  thinking  over  the  dreams.  A 
few  days  later  he  related  a  dreatn  which  I  do  not 
purpose  to  consider  here,  because  it  does  not  directly 
concern  the  claustrophobia.  Its  interest  from  the 
present  point  of  view  is  that  in  thinking  over  the 
dream  there  had  come  into  his  mind  an  incident 
going  back  to  the  age  of  six  which  had,  so  far  as 
he  knew,  gone  completely  out  of  his  mind  for  many 
years.  Taking  the  dream  and  memory  as  a  starting 
point,  he  was  led  on  to  recall  two  other  incidents 
of  this  time,  one  of  which  seemed  to  be  definitely 
related  to  the  dream.  All  three  incidents  had  been 
completely  forgotten  till  recalled  on  this  occasion, 
though  they  were  all  associated  with  a  strong 
emotional  tone  and  had  afYected  him  greatly  at  the 
time.  None  of  them  seemed  to  have  any  relation 
to  the  claustrophobia,  but  they  were  very  useful 
in  demonstrating  to  the  patient  the  value  of  analyz- 
ing dreams,  and  in  showing  him  that  the  method,  if 


persevered  in,  might  lead  to  something  more  olni- 
ously  related  to  his  symptoms. 

Three  nights  later  he  had  another  dream.  As  he 
lay  in  bed  thinking  over  the  dream,  there  came  into 
his  mind  an  incident  dating  back  to  three  or  four 
years  of  age  which  had  so  greatly  affected  him  at 
the  time  that  it  now  seemed  to  the  patient  almost 
incredible  that  it  could  ever  have  gone  out  of  his 
mind,  and  yet  it  had  so  completely  gone  from  his 
manifest  memory  that  all  his  attempts  at  analysis 
prolonged  over  years  had  failed  to  resuscitate  it. 
The  incident  was  of  a  kind  which  convinced  him 
at  once  that  the  long  sought  memory  had  been  found. 

The  incident  which  he  remembered  was  a  visit  to 
an  old  rag-  and  bone  merchant  who  lived  near  the 
house  which  his  parents  then  occupied.  This  old 
man  was  in  the  habit  of  giving  boys  a  small  reward 
when  they  took  to  him  anything  of  value.  Tlie 
child  had  found  something  and  had  taken  it  alone 
to  the  house  of  the  old  man.  He  had  been  admitted 
through  a  dark  narrow  passage,  from  which  he 
entered  the  house  by  a  turning  about  half  way  along 
the  passage.  At  the  end  of  the  passage  was  a 
brown  spaniel.  Having  received  his  reward  the 
child  came  out  alone  to  find  the  door  shut,  lie 
was  too  small  to  open  the  door,  and  the  dog  at  the 
other  end  of  the  passage  began  to'  growl.  The 
child  was  terrified.  His  .state  of  terror  came  back 
to  him  vividly  as  the  incident  returned  to  his  mind 
after  all  the  years  of  oblivion  in  which  it  had  lain. 

Ten  days  later  the  patient  dreamed  that  he  visited 
Edinburgh  for  the  purpose  of  taking  the  diploma 
in  psychological  medicine.  .As  he  lay  in  bed  think- 
ing over  his  dream  and  its  possible  antecedents,  he 
foimd  that  he  was  saying  to  himself  over  and  over 
again  the  name  "McCann."  He  could  not  at  first 
remember  that  he  knew  anyone  so  called,  but  it 
suddenly  flashed  on  his  miml  that  it  was  the  name 
of  the  old_  rag  and  bone  merchant  in  whose  house 
he  had  been  terrified. 

One  thing  was  needed  to  make  the  story  complete. 
It  seemed  possible  that  these  thoughts,  recalled  in 
consequence  of  thinking  over  dreams,  might  be 
purely  fictitious.  It  might  be  that  in  his  intense 
desire  to  find  some  experience  of  childhood  which 
would  explain  his  dread  the  patient  might  have 
dreamed,  or  thought  of,  purely  imaginary  incidents 
which  had  been  mistaken  for  real  memories.  Luckily 
the  patient's  parents  are  still  alive,  and  on  inquiry 
from  them  it  was  learned  that  an  old  rag  and  bone 
merchant  had  lived  in  the  neighborhood  in  such  a 
house  as  the  patient  remembered  and  that  his  name 
was  McCann.  Until  they  were  told  some  twenty- 
seven  years  later  they  had  no  idea  that  their  child 
knew  anything  of  the  old  man  or  had  ever  entered 
his  house. 

The  recovery  of  his  long  forgotten  fright  was 
followed  by  a  remarkable  improvement  in  his  spe- 
cific dread.  A  few  days  after  recalling  the  memory 
he  .sat  without  disturbance  in  the  middle  of  a 
crowded  moving  picture  house  under  conditions 
which  for  years  before  would  have  given  him  the 
most  serious  discomforc  and  dread.  The  patient 
was  so  confident  that  he  wished  me  to  lock  him 
in  some  subterranean  chamber  of  the  hospital,  but 
I  need  hardly  say  that  I  declined  to  put  him  to 


November  20,  1920.] 


RIVERS:   THE  UNCONSCIOUS. 


791 


any  such  heroic  test.  He  has  since  traveled  in  the 
tube  railway  with  no  discomfort  whatever,  so  that 
the  ordinary  conditions  which  had  brought  his 
jihobia  into  activity  for  niany  years  no  longer  have 
this  efYect.  He  has  even  been  down  a  coal  mine, 
wliich  was  especially  the  object  of  his  former 
dread,  and  went  more  than  a  mile  along  narrow 
passages  beneath  the  ground,  the  mere  thought  of 
which  would  once  have  made  him  shrink  in  horror. 
A  striking  sequel  of  thfi  recovery  of  his  infantile 
memory  is  that  terrifying  dreams  of  being  unable 
to  escape  from  enclosed  spaces  from  which  he  for- 
merly suffered  now  trouble  him  no  longer,  and  he 
had  a  dream  in  which  he  found  himself  in  a  narrow 
cell  in  the  company  of  a  bloodhound,  and  was 
amazed  in  the  dream  that  he  should  be  so  happy 
and  comfortable  in  this  situation.  We  have  here 
a  typical  example  of  the  kind  of  experience  I  have 
in  mind  when  I  speak  of  the  unconscious.  We 
have  no  direct  evidence  that  the  incident  has  been 
wholly  unconscious  during  childhood,  but  owing 
to  his  prolonged  search  for  such  experience  at  a 
later  period  of  life,  and  its  total  failure  to  appear 
in  consciousness,  we  have  the  most  decisive  evidence 
that  an  arresting  experience,  one  accompanied  by 
an  emotional  state  of  the  most  poignant  kind,  can 
lie  dormant  and  evade  the  most  searching  attempts 
to  bring  it  into  the  field  of  consciousness.  When 
it  was  at  last  brought  to  consciousness,  this  did 
not  happen  through  any  association  of  waking  life 
but  came  in  the  semiwaking  state  following  a  dream. 
Its  coming  to  consciousness  occurred  in  definite 
connection  with  an  experience  of  sleep  which  we 
know  to  furnish  conditions  especially  favorable  to 
emergence  from  the  unconscious 

This  patient  not  only  aflfords  conclusive  evidence 
for  the  existence  of  experience  shut  ofiF  from  con- 
sciousness under  ordinary  conditions,  but  his  case 
shows  that  this  experience,  though  inaccessible  to 
consciousness  directly,  may  yet  be  capable  of  afifect- 
ing  it  indirectly.  His  dread  of  confined  spaces  had 
so  definite  a  relation  to  the  early  experience  that 
the  two  were  undoubtedly  connected,  while  the  com- 
plete disappearance  of  his  claustrophobia  after 
bringing  the  long  dormant  experience  to  the  sur- 
face affords  further,  though  standing  alone  not 
necessarily  conclusive,  evidence  in  the  same  direc- 
tion. 

Psychological  literature  contains  many  similar 
histories.  I  take  this  case  of  claustrophobia  as  an 
example,  partly  because,  having  come  under  my 
own  notice,  I  am  able  to  estimate  its  trustworthi- 
ness. Still  more  important  is  the  fact  that  it  was 
])Ossible  to  obtain  conclusive  evidence  that  the  in- 
fantile experience  had  really  occurred,  and  was 
neither  the  fancy  of  the  patient  nor  the  result  of 
.suggestion  on  the  part  cf  the  physician,  the  latter 
possibility  being  especially  present  when  a  sup- 
posed experience  of  childhood  is  discovered  by 
means  of  hypnotism. 

The  records  of  others  can  never,  however,  carry 
the  conviction  which  comes  from  one's  own  experi- 
ence, even  though  such  experience  can  rarely  have 
the  dramatic  and  conclusive  character  of  that  I 
have  just  cited.  One  who  wishes  to  satisfy  himself 
whether  or  no  unconscious  experience  exi.sts  should 


subject  his  own  life  history  to  the  severest  scrutiny, 
either  aided  by  another  in  a  course  of  psycho- 
analysis or,  though  less  satisfactory  and  less  likely 
to  convince,  b}-  a  process  of  selfanalysis.  It  will 
perhaps  be  instructive  if  I  give  a  result  of  my  own 
selfanalysis,  which  though  at  present  incomplete, 
has  done  much  to  convince  me  of  the  reality  of  the 
unconscious. 

I  am  one  of  those  persons  whose  normal  waking 
life  is  almost  wholly  free  from  sensory  imagery, 
either  vistial,  auditor}-,  tactile  or  of  any  other  kind. 
Through  the  experience  of  dreams,  of  the  half 
waking,  half  sleeping  state,  and  of  slight  delirium 
in  fever,  I  am  quite  familiar  with  imagery,  espe- 
cially of  a  visual  kind,  which,  so  far  as  I  can  tell, 
corresponds  with  that  of  the  normal  experience  of 
others.  I  am  able  to  recognize  also  that  in  the  fully 
waking  state  I  have  imagery  of  the  same  order, 
but  in  general  it  is  so  faint  and  fragmentary  that 
the  closest  .scrutiny  is  required  for  its  detection. 
It  is  clear  to  me  that  if  it  were  not  for  my  special 
knowledge  and  interest  I  should  be  wholly  ignorant 
of  its  existence.  On  looking  back  in  my  life  1 
am  aware  that  my  mental  imagery  was  more  definite 
in  youth,  and  I  can  remember  the  presence  at  that 
period  of  fairly  vivid  visual  imagery  in  connection 
with  certain  kinds  of  experience,  especially  of  an 
emotional  kind. 

Some  years  ago,  as  part  of  an  examination  into 
my  memories  of  childhood,  I  discovered  that  I  had 
a  more  definite  knowledge  of  the  topography  of  the 
house  1  left  at  the  age  of  five  than  of  any  of  the 
many  houses  I  have  lived  in  since.  I  can  make 
a  plan  of  that  house  far  more  detailed,  based  on 
memories  clearer  to  myself,  than  I  can  make  of 
houses  in  which  I  have  lived  far  longer  and  at 
times  of  life  when  one  might  expect  more  perma- 
nent and  vivid  memories.  Moreover,  I  can  even 
now  obtain  visual  images  of  the  early  house  more 
clear  and  definite  than  any  I  usually  experience, 
while  other  memories  of  my  first  five  years  of  life 
bring  with  them  imagery  more  definite  than  accom- 
pany the  memories  of  later  years.  I  have  con- 
cluded that  before  tlT*  a^'^e  of  five  my  visual 
imagery  was  far  more  definite  than  it  became  later 
and  was  jirobablv  as  good  as  that  of  the  average 
child. 

For  some  time  I  explained  the  loss  of  imagery 
of  which  I  am  the  subject  as  part  of  a  process  by 
which  I  had  become  especially  interested  in  the  ab- 
stract. I  supposed  that  my  imagery  had  faded  for 
lack  of  the  attention  and  interest  which  would  have 
kept  it  active,  even  if  it  had  not  promoted  its 
development  into  the  instrument  which  imagery  has 
become  in  the  mental  life  of  the  majority  of  human 
beings.  It  is  only  during  the  last  year  or  two  that 
I  have  discovered  an  aspect  of  my  early  experience 
which  has  led  me  to  revise  this  earlier  opinion. 
This  discovery  is  that  my  knowledge  of  the  house 
I  left  when  five  years  old  is  strictly  limited  to  cer- 
tain parts  of  it  and  that  the  rest  is  even  more  in- 
accessible to  memory  than  any  of  the  houses  in 
which  I  have  lived  since.  So  far  as  I  remember  the 
house  had  three  floors.  I  can  remember,  and  even 
now  image  fairly  vividly,  every  room,  passage  and 
doorway  of  the  ground  floor.    I  can  in  imagination 


792 


Rll-ERS:   THE  UXCONSCIOUS. 


[New  York 
Medical  Jowrnal. 


go  down  stairs  into  a  kitchen  in  a  basement  and  I 
can  go  upstairs  toward  the  upper  floor,  but  when 
I  reach  the  top  of  the  ftairs  I  come  to  the  abso- 
lutely unknown,  an  unknown  far  more  complete 
than  is  the  case  with  any  house  occupied  more 
recently,  where  I  have  some  idea  of  the  topography 
though  this  is  inexact  and  vague.  For  more  than 
a  year  I  have  been  attempting,  by  means  which 
have  succeeded  in  evoking  other  early  experience, 
to  penetrate  into  the  mysterious  unknown  of  the 
upper  story.  Though  I  have  recalled  many  inci- 
dents of  my  early  life  which  took  place  on  the 
ground  floor,  in  the  basement,  in  the  regions  be- 
fore and  behind  the  house,  no  event  of  any  kind 
which  happened  in  the  upper  story  has  ever  come 
to  my  consciousness.  Now  and  then,  when  in  the 
half  waking,  half  sleeping  state  peculiarly  favorable 
in  my  experience  to  the  recovery  of  long  forgotten 
events,  I  have  had  the  sense  that  something  is 
there,  lying  very  near  emergence  into  consciousness. 
But  I  have  not  yet  succeeded  in  penetrating  the  veil 
which  separates  me  from  all  knowledge  of  my  life 
in  that  upper  story. 

The  evidence  for  the  existence  of  unconscious 
experience  which  is  provided  by  these  memories  of 
my  infancy  is,  of  course,  incomplete  in  that  I  have 
not  yet  discovered  the  nature  of  the  unconscious 
experience  and  have  even  no  certain  guarantee  that 
it  exists.  The  feature  of  the  experience  which  im- 
presses me — I  cannot  expect  it  to  have  an  equal 
influence  on  others — is  the  completeness  of  the 
blank  in  my  mind  in  connection  with  that  upper 
story.  I  fail  to  explain  that  blank  by  any  mechan- 
ism provided  by  differences  in  affect  or  interest  on 
memory.  A  psychologist  of  the  old  school  would 
probably  say  that  we  tend  especially  to  remember 
the  striking  and  imusual,  and  that  it  is  therefore 
natural  that  my  memories  of  the  upper  story, 
where  I  probably  passed  most  of  my  life  at  that 
time,  should  be  less  vivid  than  those  of  the  lower 
parts  of  the  house  which  I  visited  less  often.  This 
might  well  explain  a  different  degree  of  distinct- 
ness of  memory,  but  it  cannot  explain  the  complete- 
ness of  the  blank  left  by  the  memories  of  the  upper 
story.  Another  line  which  misfht  be  taken  is  that 
at  any  rate  during  the  year  before  I  left  the  house, 
I  lived  on  the  ground  floor  during  the  day  and 
only  visited  the  upper  floor  at  night  when  tired. 
But  even  if  such  a  reason  were  valid,  it  cannot 
explain  the  completeness  of  the  blank.  Moreover, 
such  explanations  seem  to  be  put  out  of  court  by 
the  fact  that  when  I  recall  memories  of  houses  lived 
in  later,  I  find  no  such  difference  between  upper 
and  lower  stories.  Though  my  memories  of  later 
houses  are  more  vague  than  the  early  memory,  they 
are  quite  as  definite  for  the  upper  as  for  the  lower 
parts  of  the  buildings. 

The  two  cases  I  have  described  as  examples  of 
the  experience  of  early  life  which  has  become  in- 
accessible to  consciousness.  This  period  of  life  is 
especially  likely  to  afford  occasions  for  experiences 
to  become  unconscious,  but  the  passing  of  ex- 
perience into  the  unconscious  may  happen  at  any 
age,  and  its  occurrence  has  been  brought  to  notice 
very  widely  by  the  experience  of  war.  One  of  the 
most  frequent  features  of  the  nervous  disturbances 


of  war  has  been  the  complete  blotting  out  of  tlie 
memories  of  certain  events,  the  obliteration  usually 
extending  considerably  beyond  the  event  which  fur- 
nished its  special  occasion.  In  some  cases,  where 
the  loss  of  memory  for  a  period  of  the  soldier's  life 
has  been  produced  by  physical  shock  accompanied 
by  complete  unconsciousness,  as  in  cerebral  con- 
cussion, the  obliteration  has  been  complete  and  the 
case  does  not  come  within  the  scope  of  the  present 
subject,  for  there  is  no  evidence  that  any  experi- 
ence exists  capable  of  being  again  brought  to  con- 
sciousness. In  many  cases,  however,  in  which  the 
obliteration  is  due  to  mental  shock  or  other  ps\- 
chical  factors,  the  experience  which  is  inaccessible 
to  the  consciousness  of  the  subject  under  the  usual 
conditions  of  memory  has  been  recovered  in  the 
hypnotic  state  or  by  the  method  of  free  association 
or  has  expressed  itself,  usually  in  a  distorted  form, 
in  dreams.  In  such  cases  soldiers  have  lost  the 
entire  memory  of  their  lives  from  some  moment 
preceding  a  shock  or  severe  strain  untiji  they  have 
found  themselves  in  hospital,  perhaps  weeks  later, 
although  during  at  least  part  of  the  intervening 
time  they  may  have  been  to  all  appearance  fully 
conscious  and  may  even  have  distinguished  them- 
selves by  actions  on  the  field  of  which  they  have 
no  recollection.  Although  these  memories  may  re- 
main for  months  or  years  quite  inaccessible  to 
memory  when  approached  by  the  ordinary  chan- 
nels, they  may  be  brought  to  the  surface  by  means 
of  hypnotism  or  by  the  method  of  free  association. 

In  a  case  of  a  somewhat  different  kind  under 
my  care  a  soldier  had  lo.st  all  memory  of  his  life 
from  a  day  in  July  when  he  was  training  in  Eng- 
land until  the  following  January  when  he  found 
himself  in  hospital  in  Egypt,  having  no  recollection 
whatever  of  his  service  in  various  parts  of  Eng- 
land, of  the  voyage  to  Egypt,  or  of  his  life  in  Egypt 
before  going  to  hospital.  The  memory  of  this 
period  was  not  recovered  until  more  than  a  year 
later  following  the  disclosure  of  a  painful  experi- 
ence in  his  life  which  had  a  definite  connection 
with  his  amnesia. 

In  cases  such  as  these  the  loss  of  memory  forms 
part  of  the  complex  group  of  changes  which  make 
up  the  state  we  call  psychoneurosis.  There  is 
reason  to  believe  that  many  of  the  manifestations 
or  symptoms  of  this  state  are  due  to  the  activity 
of  the  experience  which  has  become  unconscious 
just  as  the  dread  of  my  claustrophobic  patient  has 
been  ascribed  to  the  unconscious  experience  of 
which  he  was  the  subject  at  the  age  of  four.  The 
effects  which  can  be  thus  ascribed,  at  any  rate  in 
part,  to  the  unconscious  experience  of  war  fall 
into  two  main  groups.  There  are,  on  the  one  hand, 
general  changes  in  personality,  and  changes  in 
tastes,  in  likes  and  dislikes,  in  preferences  and 
prejudices,  while  on  the  other  hand,  there  are  spe- 
cific dreads  or  other  morbid  experiences  of  waking 
or  sleeping  life,  such  as  nightmares,  hallucinations 
or  morbid  impulses,  which  can  be  more  or  less 
directly  ascribed  to  the  activity  of  the  unconscious 
experience.  In  such  cases  we  have  definite  evi- 
dence, not  merely  for  the  existence  of  unconscious 
experience,  but  for  its  activity,  or  capacity  for 
activity,  in  this  unconscious  state. 


Xrrveraber  20,  1920.] 


RIVERS:   THE  UNCOXSCIOUS. 


793 


I  have  now  attempted  to  make  clear  the  sense  in 
which  we  should  speak  of  the  unconscious,  i  liave 
illustrated  its  nature  by  means  of  three  kinds  of 
example ;  one  taken  from  a  definitely  pathological 
state  dependent  on  an  experience  of  early  life;  the 
second  derived  from  my  own  histor}*,  also  derived 
from  the  unconscious  experience  of  early  life,  but 
one  which  may  be  regarded  as  coming  within  the 
limits  of  normal  psychology ;  while  the  others  are 
taken  from  cases  of  .psychoneurosis  in  which  the 
experience  which  has  become  unconscious  is  made 
up  of  the  events  and  memories  of  warfare.  I 
have  now  to  consider  how  such  experience  be- 
comes unconscious.  I  shall  speak  of  this  process 
as  suppression.  Writers  on  the  unconscious  often 
use  repression  for  the  process  in  question,  but  I 
propose  to  reserve  this  term  for  the  process  by 
which  we  wittingly  endeavor  to  banish  experience 
from  consciousness.  It  seems  that  this  process  of 
witting  repression  may  Le  one  means  of  producing 
suppression,  that  experience  wittingly  repressed 
may,  at  any  rate  under  certain  conditions  succeed 
in  becoming  inaccessible  to  the  general  body  of 
consciousness.  But  there  is  little  doubt  that  this 
is  only  one  of  the  ways  in  which  suppression  oc- 
curs, and  that  more  often  it  takes  place  wholly 
without  the  intervention  of  volition,  especially  when 
it  occurs  as  the  result  of  some  physical  or  mental 
shock. 

We  are  still  in  much  uncertainty  concerning 
the  exact  -mechanism  by  which  suppression  occurs, 
but  there  is  reason  to  believe  that  in  the  majority 
of  cases  it  takes  place  without  conscious  effort, 
or  according  to  the  terminology  I  propose  to  use, 
unwittingly.  There  is  even  some  reason  to  believe 
that  suppression  only  follows  witting  repression, 
when  conditions  of  some  other  kind  favorable  to 
suppression  are  present. 

I  propose  now  to  compare  suppression  with  the 
ordinary  process  of  forgetting.  Suppression  is 
only  one  form  of  forgetting — a  form  in  which  the 
forgetting  is  especially  complete — and  light  should 
be  thrown  upon  the  nature  of  suppression  by  a 
general  study  of  the  process  by  wliich  we  forget. 
Formerly  psychologists  were  especially  concerned 
with  the  process  by  which  we  remember,  but  they 
have  gradually  been  coming  to  recognize  that  the 
more  important  problem  is  to  discover  how  and 
why  we  forget.  It  is  one  of  the  many  merits  of 
Freud  that  he  has  thrown  much  light  on  this  prob- 
lem and  with  a  wealth  of  examples  has  illustrated 
the  complex  nature  of  forgetting  in  the  ordinary 
course  of  daily  life.  According  to  him  forgetting 
is  not  a  passive  process,  dependent  on  lack  of  in- 
terest and  meaning,  or  varying  with  the  intensity 
of  an  impression,  but  is  an  active  process  in  which 
some  part  of  the  mental  content  is  suppressed.  The 
content  which  is  thus  suppressed  does  not  disap- 
pear because  it  is  uninteresting  or  unimportant ; 
on  the  contrary,  it  is  usually  of  very  special  interest 
and  has  a  very  definite  meaning.  It  is  suppressed 
because  the  interest  and  meaning  are  of  a  kind 
which  arouse  pain  or  discomfort  and,  if  present  in 
consciousness,  would  set  up  activities  which  would 
be  painful  or  uncomfortable.  Active  forgetting  is 
thus  a  protective  process,  one  by  which  conscious- 


ness is  protected  from  influences  which  would  in- 
terfere with  the  harmony  essential  to  pleasure  or 
comfort. 

The  examples  of  the  unconscious  which  I 
have  given  are  only  pronounced  examples  of  a 
similar  process.  Just  as  we  tend  to  forget  an  ap- 
pointment which  seems  likely  to  be  the  occasion 
of  a  quarrel  or  may  forget  to  write  a  letter  which 
involves  the  undertaking  of  an  unpleasant  respon- 
sibility, so  we  may  suppose  that  the  painful  ex- 
perience of  my  claustrophobic  patient  was  forgot- 
ten because  the  memories  of  the  passage  and  the 
dog  were  so  painful  as  to  interfere  with  his  happi- 
ness. The  completeness  of  the  suppression  may 
have  been  due  to  the  fact  that  the  interference  with 
the  comfort  of  the  child  was  so  great  as  seriously 
to  disturb  his  health.  In  the  case  of  my  own  ex- 
perience it  is  not  possible  to  say  why  the  memory 
of  the  upper  floor  has  been  forgotten,  since  I  do 
not  yet  know  the  nature  of  the  suppressed  experi- 
ence, but  we  can  be  fairly  confident  that  it  was  of 
an  unpleasant  kind  and  was  forgotten  because  the 
memory  of  it  interfered  with  my  comfort  and  hap- 
piness. 

The  memories  which  disappear  in  warfare  are 
always  of  happenings  so  distressing  that  the 
utmost  pain  is  aroused  when  they  reappear  in  con- 
sciousness. The  conclusion  to  which  we  are  led 
both  by  the  experience  of  everyday  life  and  by  the 
analysis  of  pathological  and  semipathological  states 
is  that  there  is  no  difference  in  nature  between  the 
forgetting  of  the  unpleasant  experience  of  ordinary 
life,  often  quite  trivial  m  character,  and  such  ex- 
amples of  complete  and  fife  long  suppression  as 
those  which  I  have  chosen  to  illustrate  the  nature 
of  the  unconscious. 

If  these  two  kinds  of  forgetting  are  essentially 
alike,  if  they  furnish  the  two  ends  of  a  continuous 
series,  a  study  of  the  forgetting  of  everyday  life 
should  provide  a  means  of  studying  the  suppression 
which  occurs  in  pathological  states.  If  we  attempt 
such  a  study  the  first  pomt  which  may  be  notice'd 
is  that  the  active  forgetting  of  everyday  life  is  not 
voluntary  and  intentional,  but  is  essentially  a 
process  which  takes  place  unwittingly.  If  we  try 
to  forget  an  appointment  which  we  expect  to  lead 
to  a  quarrel  or  try  to  forget  a  letter  undertaking 
an  unpleasant  responsibility,  we  should  not  suc- 
ceed. We  should  probably  only  fix  these  duties 
the  more  firmly  in  our  memories.  It  is  character- 
istic of  the  active  forgetting  of  which  Freud  (1) 
has  provided  such  a  wealth  of  examples  that  it 
occurs  spontaneously.  In  such  instances  as  I  have 
given,  we  do  not  know  that  we  have  forgotten.  It 
is  only  when  we  are  reminded  of  the  missed  ap- 
pointment or  the  overdue  letter  that  we  become 
aware  of  the  lapse.  In  other  cases,  as  when  we 
forget  the  name  or  address  of  a  correspondent  to 
whom  we  should  write,  we  know  that  we  have  for- 
gotten, but  the  act  of  forgetting  has  still  been 
involuntary  and  unwitting. 

The  pathological  suppression  taking  place  in 
adult  life  seems  in  most  cases  to  be  clearly  involun- 
tary and  unwitting.  The  most  complete  cases  of 
suppression  do  not  occur  in  people  who  have  tried 
consciously  to  repress  painful  experience,  but  has 


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(Niivv  York 
Medical  Journal. 


come  about  without  any  conscious  activity  on  the 
part  of  the  sufferer,  especially  as  the  result  of 
shock  or  illness.  Hypnotism  furnishes  a  striking- 
example  of  the  process  by  which  experience  is  sup- 
pressed. By  means  of  suggestion  given  in  the 
hypnotic  state  any  experience,  pleasant  or  painful, 
which  occurs  during  this  state  may  be  banished 
from  the  memory.  When  this  has  been  done  the 
hypnotized  person  is  quite  unable  to  recall  the  ex- 
perience, and  it  will  remain  unconscious  until  he 
is  again  hypnotized  or  until  the  experience  is  re- 
called under  some  other  condition  in  which  uncon- 
scious suppressed  experience  comes  to  the  surface. 
In  this  case  the  suppression  takes  place  quite  inde- 
];endently  of  the  will  of  the  hypnotized  person,  but 
tliere  is  reason  to  believe  that  the  suggestion  to  for- 
get is  more  likely  to  be  successful,  the  more  the 
forgetting  is  in  consonance  with  the  conscious 
wishes  of  the  subject.  This  probably  gives  the  clue 
to  the  fact  that  conscious  repression  seems  often 
to  lead  to  suppression.  The  suppression  itself  is 
unwitting,  but  the  wish  of  the  sufferer  for  sup- 
])ression  assists  the  process,  or  at  least  helps  in  its 
maintenance  and  completeness. 

I  must  now  consider  briefly  a  characteristic  of 
active  forgetting  and  suppression  which  is  of  great 
importance  in  vmderstanding  its  nature.  The  ex- 
perience which  tends  to  be  forgotten  or  repressed 
is  the  immediately  painful.  If  we  forget  an  ap- 
pointment or  a  letter  in  connection  with  which  we 
anticipate  unpleasant  emotions,  the  ultimate  conse- 
quences may  be  even  more  unpleasant  than  the  im- 
mediate exi:)erience  from  which  we  escape  by  the 
act  of  forgetting.  If  we  were  able  to  consider 
rationally  the  consequences  of  the  la])se,  we  should 
find  that  in  most  cases  the  course  which  would 
give  us  least  trouble  and  inconvenience  in  the  long- 
run  would  be  to  keep  the  appointment  or  write  the 
letter. 

The  process  of  acdve  forgettii-ig,  however, 
takes  no  account  of  these  ultimate  consequences, 
but  is  directed  exclusively  towards  the  avoidance 
of  the  more  immediate  pains  and  discomforts.  The 
same  seems  to  be  true  of  cases  of  pathological  sup- 
pression. If,  as  I  suppose,  the  claustrophobia  of 
my  patient  -w^as  the  result  of  the  suppression  of  his 
four  year  old  experience,  there  can  be  little  doubt 
that  the  sum  total  of  unhappiness  due  to  his  dreads 
ivas  far  greater  than  that  which  would  have  re- 
.sulted  from  the  immediate  memories  of  his  terror 
when  in  the  passage  with  the  dog.  The  memory 
was  suppressed  because  of  its  immediately  painful 
character,  and  in  following  this  cour.se  Nature  took 
no  account  of  the  effects  of  the  suppression,  which 
were  to  torment  the  child  and  man  for  thirty  years. 
The  suppressions  which  form  so  large  an  element 
in  the  neuroses  of  war  are  also  directed  to  allow 
escape  from  the  immediately  unpleasant,  regardless 
of  the  future  consequences.  Suppression  is  a 
process  of  reaction  to  pleasures  and  pains  which 
are  immediately  present  and  takes  no  account  of 
the  more  extended  experience  with  which  it  is  the 
function  of  intelligence  to  deal. 

REFERENCES. 

1.    Freud:  The  PsychopathoJogy  of  Everyday  Life. 

St.  John's  College. 


A  NEW  PSYCHOANALYTICAL  THEORY. 

Kcmpf's  Dynamic  Mechanism. 

By  Andre  Tridon, 
New  York. 

Valuable  as  their  theories  are,  one  cannot  help 
feeling  that  Freud's  and  Jung's  mode  of  thinking 
is  still  closely  related  to  that  of  the  academic  psy- 
chologists. They  give  the  impression  that  the  men- 
tal and  the  physical  are  two  separate  entities.  The 
term  conversion  used  by  Freud  to  designate  the 
physical  symptoms  accompanying  certain  emotions 
seems  to  imply  a  duality  in  organic  manifestations 
which,  to  modern  scientists,  appears  unfounded. 
When  Freud  and  Jung  speak  of  libido,  cravings, 
and  censor,  they  are  almost  as  vague  and  uncon- 
vincing as  Bergson  when  he  speaks  of  the  vital 
urge.  Adler  felt  the  necessity  of  establishing  a 
more  intimate  connection  between  physical  and 
mental  manifestations  but  he  did  not  make  the ' 
mechanism  of  compensation  clearer  to  his  readers 
than  Freud  did  the  mechanism  of  conversion. 

It  will  be  only  when  we  know  what  part  of  the 
organism  produces  an  emotion  and,  reciprocally, 
what  part  of  the  organism  is  affected  by  a  given 
emotion,  that  we  shall  visualize  clearly  the  relations 
between  mind  and  body.  Then  we  shall  understand 
the  meaning  of  the  vital  urge  and  of  the  libido ; 
then,  the  socalled  nervous  disturbances  as  well  as 
consciousness  and  its  content  (thought)  shall  lose 
their  mystery. 

Edward  J.  Ken-ipf,  of  Saint_  Elizabeth's  Hospital, 
Washington,  D.  C,  attacks  the  problem  from  a  new 
and  original  point  of  view.  Kempf  states  frankly 
his  dislike  of  the  term  libido.  Although  that  term 
attempts  to  represent  graphically  the  energetic  con- 
stitution of  man  and  his  love  of  life,  it  lacks  clear- 
ness, for  the  human  mind  cannot  very  well  con- 
ceive of  a  process  as  such,  unless  there  is  some 
thing  that  proceeds.  The  concept  of  electricity 
would  be  hazy,  indeed,  were  it  not  that  we  can 
visualize  dynamos,  wires,  sparks,  bulbs  and  many 
other  visible  means  of  production  or  manifestation 
of  the  force  called  electricity. 

In  order  to  explain  the  great  physiological 
changes  which  influence  human  thought  and  be- 
havior and  the  biological  nature  of  man,  Kempf 
has  developed  a  conception  of  the  personality  based 
on  the  reflex  actions  of  the  autonomic  nervous 
system. 

To  him  the  human  organism  is  a  biological  ma- 
chine which  assimilates,  conserves,  transforms  and 
expends  energy.  .All  those  o])erations  are  regulated 
])y  the  autonomic  apparatus  which  keeps  in  touch 
with  the  environment  through  the  projicient  sen- 
sorimotor nervous  system.  As  the  autonomic  ap- 
paratus becomes  conditioned  (trained)  to  have  ac- 
quisitive and  avertive  tendencies  toward  its  environ- 
ment, according  to  which  cravings  are  active  in  a 
given  situation,  the  organism's  behavior  is  the  re- 
sultant of  a  compromise  between  the  opposed 
cravings.  The  importance  of  the  brain  is  greatly 
minimized  by  this  conception.  Experiments  have 
proved  that  the  same  form  of  behavior  is  not  al- 
ways due  to  the  activity  of  the  same  brain  cells 
and  the  theories  which  localize  in  certain  regions 


November  20,  1920.] 


TRIDON:  NEW  PSYCHOANALYTICAL  THEORY. 


795 


of  the  brain  the  controlling  forces  of  all  human 
conduct  must  be  abandoned. 

According  to  Kempf,  brain  and  personality,  so 
long  associated  in  popular  parlance,  must  no  longer 
be  considered  as  interchangeable  terms.  In  fact, 
every  part  of  the  body  contributes  something  to  the 
personality  and  to  its  consciousness  of  itself. 
Should  some  one  lose  a  limb  or  a  group  of  muscles, 
he  would  lose  at  the  same  time  an  important  part 
of  his  personality.  This  would  manifest  itself  in 
the  manner  in  which  he  would  adjust  himself  to 
the  stresses  o'f  daily  life,  what  he  would  try  to  do 
and  feel  compelled  to  avoid.  Analysis  alone  would 
reveal  that  fact ;  the  natural  readjustment  of  the 
remaining  muscles  would  prevent  any  gross  change 
from  being  observable.  For  instance,  the  loss  of 
the  eyes  and  arms  would  greatly  reduce  the  ability 
to  understand  new  machinery,  new  situations  and 
probably  reduce  to  an  enormous  extent  the  power 
of  recalling  experiences  in  which  the  eyes  and  hands 
played  a  predominant  part,  such  as  writing. 

Because  most  of  our  thoughts  are  dependent 
upon  our  muscle  sense,  it  may  be  said  that  we 
actually  think  with  our  muscles.  If  we  allow  our- 
selves to  become  aware  of  the  visual  image  of  an 
automobile,  we  are  aware  that  it  is  moving,  because 
the  muscles  of  the  eyeball  shift  the  image  by  modi- 
fying their  postural  tensions.  Sometimes  the  mus- 
cles of  the  neck  may  contribute  more  information 
by  moving  the  head.  If  we  are  pushing  the  auto- 
mobile ourselves,  the  muscles  of  the  body  come 
into  play  to  furnish  other  images,  and  if  we  are 
pushing  it  along  a  cold,  wet,  muddy  road,  the  sensa- 
tions of  cold,  wetness  and  mud  arise  from  the 
tactile  receptors  of  our  legs. 

Such  a  perfect  correlation  between  our  autonomic 
apparatus  and  the  sensorimotor  system  is  a  gradual 
acquisition  of  the  human  being  in  the  course  of  its 
development.  At  birth,  we  have  a  welldeveloped, 
wellbalanced  autonomic  apparatus  and  a  poorly  co- 
ordinated sensorimotor  system.  The  autonomic  ap- 
paratus, however,  begins  immediately  to  coordinate 
and  control  the  sensorimotor  system  in  order  to 
master  its  environment. 

A  most  important  factor  begins  to  exert  pressure 
upon  the  infant  from  the  moment  of  its  birth  and 
exerts  it  throughout  life.  It  is  the  incessant  pres- 
sure of  the  social  herd,  which  modifies  the  autono- 
mic apparatus  and  compels  it  to  adopt  less  and  less 
primitive,  more  and  more  civilized  and  indirect 
methods  of  satisfying  the  various  human  cravings. 
The  tone  or  tension  produced  by  the  autonomic 
apparatus  in  the  muscles  which  move  our  body  and 
limbs  determines  largely  the  content  of  our  con- 
sciousness or  thoughts.  This  leads  us  to  a  complete 
reversal  of  the  view  held  by  the  academic  philoso- 
phers and  psychological  laboratory  observers. 

According  to  them  the  emotions  are  one  of  the 
results  of  the  mind's  contemplation  of  phenomena 
taking  place  within  or  without  the  organism. 
Bodily  reactions  and  mental  reactions  take  place 
after  the  emotion  has  been  experienced.  James 
and  Lange  advanced  the  theory  that  our  feeling  of 
bodily  changes,  following  the  perception  of  a  stimu- 
lus, is  the  emotion.  Kempf  goes  further  and  states 
that  if  we  experience  an  emotion,  it  is  because  some 


parts  of  the  autonomic  apparatus  have,  assumed  a 
certain  tension  which  produces  the  motion.  As 
evidence,  he  cites  the  fact  that  we  are  at  times 
disturbed  at  night  by  fearful  tensions  whose  cause 
is  unknown  and  then  awaken  to  find  that  there  is 
some  one  in  our  room.  Nursing  mothers  experi- 
ence vigorous  disturbances  in  their  sleep  long  be- 
fore they  become  aware  that  their  child  is  in  dis- 
tress. We  become  conscious  of  images  of  urinat- 
ing in  our  dreams  and  find,  upon  awakening,  that 
uncomfortable  tensions  of  the  bladder  have  been 
active  for  some  time  owing  to  the  accumulation  of 
urine. 

Kempf 's  theory  of  the  dynamic  mechanism  is 
worded  as  follows :  "Whenever  any  segment  of 
the  autonomic-afifective  apparatus  is  forced  into  a 
state  of  hypertension  through  the  necessities  of 
metabolism  or  endogenous  or  exogenous  stimuli, 
the  hypertense  segment  gives  ofif  a  stream  of  emo- 
tion or  effective  craving  which  compels  the  pro- 
jicient  apparatus  to  so  adjust  the  exteroceptors  in 
the  environment  as  to  acquire  stimuli  which  have 
the  capacity  to  produce  comfortable  postural  re- 
adjustments in  those  autonomic  segments." 

In  other  words,  whenever  autonomic  nerves,  for 
instance  the  nerves  causing  the  contractions  of  the 
stomach  known  as  hunger  are  made  extremely  tense 
by  the  sight  or  smell  of  food,  they  produce  a  strong 
emotion  or  desire  which  compels  the  sensorimotor 
nerves  to  apply  the  mouth  to  food,  after  which  the 
tension  of  the  autonomic  nerves  is  relieved. 

Kempf  maintains  that  this  biological  principle 
or  law  is  the  foundation  of  all  human  and  animal 
behavior,  to  be  seen  throughout  all  its  workings, 
whether  brief  and  trivial  or  prolonged  and  elabor- 
ate. "The  seeking  and  creating  follows  the  corol- 
lary 'to  obtain  a  maximum  of  autonomic  gratifica- 
tion with  a  minimum  expenditure  of  energy,'  thus 
developing  increasing  skill  and  power,  extension  of 
influence  and  assurance  of  comfort  and  an  increas- 
ing margin  of  safety  from  liability  to  failure." 

Most  of  the  nervous  tensions  originating  in  the 
autonomic  apparatus  have  as  their  biological  aim 
the  acquisition  of  appropriate  pleasant  stimulations 
and  the  avoidance  of  destructive  unpleasant  ones ; 
for  instance,  they  direct  us  toward  food  and  away 
from  some  danger.  They  are  relieved  only  when 
their  objective  stimulus  is  attained.  In  certain 
cases  the  object  is  imattainable,  being  socially 
tabooed  or  having  passed  beyond  our  reach,  as  for 
example  when  a  loved  person  dies.  In  such  cases, 
tensions  will  remain  unrelieved  and  become  seri- 
ously distressing  as  well  as  dangerous  for  our 
mental  and  physical  health.  Among  other  things, 
they  disturb  the  blood  supply  to  certain  organs  and 
hence  weaken  them  in  their  struggle  against  the 
bacteria  of  infectious  diseases.  In  case  of  tuber- 
culosis, pneumonia,  typhoid,  excessive  fatigue,  an 
exaggerated  emotional  tension  may  be  fatal.  In 
other  words,  the  individual  who  represses  certain 
cravings  because  they  are  ungratifiable  or  for  fear 
of  the  influence  their  gratification  may  have  on  his 
social  standing,  tends  to  have  organs  which  are  more 
susceptible  to  disease. 

The  struggle  between  conflicting  cravings  was 
considered  by  psychologists  of  the  old  school  as 


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[New  York 
Medical  Journal. 


taking  place, in  our  mind.  Kempf  shows  us  that  it 
takes  place  in  our  autonomic  apparatus.  The  sacral 
division  may  be  conditioned  to  need  stimuli  that 
are  perverse  or  tabooed  and  cause  irritabihty  and 
depression  until  gratified,  whereas  their  unrestrained 
indulgence  may  greatly  jeopardize  the  love  for 
social  esteem  and  the  feeling  of  social  fitness.  The 
secret  sense  of  social  inferiority,  due  to  some  one's 
awareness  of  tabooed  pelvic  cravings,  makes  life 
in  human  society  a  fearful  ordeal,  which  in  turn 
disturbs  the  respiratory,  circulatory  and  gastronomic 
functions.  Hence  the  needs  or  cravings  of  the 
different  autonomic  segments  converge  upon  the 
projicient  apparatus  and  behavior  is  the  physical 
or  mechanical  resultant.  This  compels  tlie  differ- 
ent autonomic  segments  to  wage  fierce  conflict  for 
control  of  our  conduct  and  our  conduct  reveals 
the  conflict. 

That  struggle  grows  fiercer  as  the  civilization 
in  which  we  live  grows  more  complex.  At  birth, 
the  autonomic  apparatus  works  smoothly,  because 
the  infant  is  dependent  upon  the  mother  and  hence 
irresponsible.  But  when  the  mother  begins  to  train 
the  infant  to  nurse,  urinate  and  defecate  under 
certain  specific  conditions,  the  autonomic  apparatus 
for  the  first  time  clashes  with  society  which  insists 
on  selfrestraint,  selfcontrol  and  selfrefinement. 

Heedless  indulgence  by  an  individual  of  any 
age  causes  uncomfortable  tensions  in  his  associates 
(disgust,  fear,  anger),  and  therefore  they  are  com- 
pelled to  control  social  tendencies  in  every  indivi- 
dual from  his  earliest  childhood.  Acquisitive  crav- 
ings know  no  social  law,  however,  and  often 
threaten  to  jeopardize  the  personality  by  impelling 
it  to  do  something  which  is  illegal  or  immoral. 
For,  after  all,  man  is  simply  an  ape  that  has  learned 
to  wear  clothes,  to  use  words  and  signs  and  that 
can  foresee  in  a  general  sense  the  possible  biological 
and  social  results  of  certain  indulgences. 

Autonomic  segments  of  the  infant  are  then 
trained  (conditioned)  to  react  to  certain  stimuli, 
for  instance,  to  certain  vocal  sounds  and  touches 
indicating  the  time  for  nursing,  to  signs  and  touches 
indicating  disapproval  of  certain  acts ;  the  fear  of 
losing  certain  agreeable  stimuli  gradually  develops 
in  him  a  certain  degree  of  selfcontrol.  Many  crav- 
ings of  an  vingratifiable  or  unjustifiable  nature, 
however,  resist  all  attempts  on  the  part  of  our 
environment  to  curb  them.  Compensatory  striv- 
ings are  then  set  in  motion  to  prevent  them,  either 
from  manifesting  themselves  or  from  being  recog- 
nized in  order  that  the  organism  may  escape  the 
concomitant  fear.  A  state  of  fear  induces  mal- 
nutrition and  impotence  and  hence  would  be  de- 
structive for  the  individual  and  the  race. 

When  a  craving  is  allowed  to  make  the  organism 
aware  of  its  needs,  but  is  not  allowed  to  cause  overt 
acts,  it  is  said  to  be  suppressed.  When  it  is  not 
allowed  to  cause  the  organism  to  become  aware  of 
its  needs,  it  may  be  said  to  have  been  repressed. 
But  neither  suppression  nor  repression  is  synony- 
mous with  annihilation.  Whether  we  remain  in 
ignorance  of  the  fact  that  a  boiler  is  full  of  steam 
or  simply  disregard  that  fact,  the  steam  is  there, 
seeking  an  outlet  and  likely  to  create  an  abnormal 
one,  unless  a  normal  outlet  is  provided. 


Repressed  autonomic  segments,  like  steam  in  a 
boiler,  need  but  the  slightest  opportunity  offered 
by  the  environment,  or  the  slightest  relaxation  of 
the  repressing  forces  to  obtain  control  of  the  sen- 
sorimotor nervous  systemi.  We  may  suppress  our 
disgust  or  anger  to  save  appearances,  but  we  will 
at  the  same  time,  by  remarks,  by  our  very  tone  of 
voice  or  gestures,  betray  our  real  feelings ;  we  will 
have  dreams  which  picture  the  attempted  or  suc- 
cessful gratification  of  suppressed  cravings.  The 
essential  difference  between  most  sane  and  insane 
people  is  that  insane  people  cannot  tontrol  their 
repressed  cravings  while  sane  people  can.  That 
is  to  say,  when  people  become  fatigued,  toxic,  dazed, 
and  can  no  longer  control  their  repressed  cravings, 
those  cravings  cause  a  form  of  behavior  which  is 
termed  insane 

As  the  human  individual  grows  and  develops,  he 
gradually  becomes  able  to  control  the  activities  of 
the  various  cravings  with  the  exception,  however, 
of  the  sexual  cravings.  When  sexual  cravings  are 
normal,  they  are  naturally  justified,  and,  under  cer- 
tain conditions,  they  are  permitted  socially  to 
dominate  our  behavior. 

When  the  personality,  on  the  other  hand,  con- 
siders sexual  cravings  as  shameful  inferiorities, 
either  because  they  are  perverse  or  because  the 
personality  has  been  educated  in  a  prudish  way,  the 
individual  becomes  forced  into  a  form  of  adjust- 
ment which  is  abnormal  on  the  account  of  the 
autonomic  conflict  it  entails.  Whenever  a  violent 
conflict  rages  in  our  autonomic  apparatus  between 
acquisitive  and  avertive  cravings,  a  neurosis  ensues, 
or  rather,  the  neurosis  is  the  conflict.  No  consti- 
tutional predisposition  is  needed  to  bring  about  its 
onset.  Life's  experiences  and  the  influence  of  our 
environment  and  associates  are  sufficient  as  deter- 
mining factors. 

Kempf  does  not  accept  Freud's  theory  as  to  the 
importance  of  sex  (love)  in  the  causation  of  neu- 
rotic disturbances.  Any  of  the  primary  cravings, 
love,  hate,  hunger,  shame,  sorrow,  fear,  or  disgust, 
may  cause  a  neurosis  under  appropriate  conditions. 
The  neurotic  is  suffering  from  cravings  which  he 
cannot  allow  to  dominate  his  personality.  Those 
cravings  are  so  often  located  in  postural  tensions  of 
certain  organs  that  they  are  probably  consistent 
things,  even  if  they  are  not  always  discoverable. 
A  strong  craving,  like  the  famishing  influence  of 
protracted  hunger,  which  originates  in  the  stomach, 
or  the  severe  itching  of  an  area  of  the  skin,  may 
finally  determine  all  the  adjustments  of  the  entire 
personality  and  be  felt  over  the  entire  body.  The 
result  may  be  a  severe  struggle  to  eliminate  the 
craving  from  the  personality.  Or  the  personality 
may  resign  itself  to  the  domination  of  the  craving 
and  to  a  regression  in  which  the  individual  enjoys 
tensions  and  images,  fancies,  delusions,  hallucina- 
tions which  simulate  the  craved  reality. 

On  the  basis  of  this  conception  of  the  personality, 
Kempf  rejects  entirely  the  usual  classification  of 
mental  disturbances  into  neuroses,  psychoneuroses 
and  psychoses.  That  classification  is  very  unscien- 
tific and  unbiological  for  it  is  based  upon  symptoms 
which  may  change  under  difTerent  conditions  or 
under  the  care  of  different  physicians.    In  many 


November  20,  1920.] 


TRIDON:  NEW  PSYCHOANALYTICAL  THEORY. 


797 


institutions,  for  example,  the  diagnosis  manic  de- 
pressive tacitly  means  recoverable,  while  dementia 
prsecox  means  incurable,  so  that  if  a  dementia 
praecox  patient  shows  a  tendency  to  recovery  he 
is  reclassified  as  manic  depressive.  Kempf's  classi- 
fication takes  into  account  the  nature  of  the  patient's 
autonomic  cravings  and  his  attitude  toward  them. 
It  is.  therefore,  essentially  mechanistic  and  truly 
biological.  Every  nervous  disturbance  is  designated 
as  a  neurosis. 

The  neurosis,  then,  is  termed  acute,  chronic,  or 
periodic,  according  to  its  duration.  The  term  acute 
is  reserved  for  cases  of  less  than  a  year's  duration. 
Chronic  is  applied  to  cases  having  had  more  than 
a  year's  duration,  or  which  have  had  an  insidious 
course  for  more  than  a  year  before  the  consulta- 
tion. 

Periodic  is  applied  to  cases  which  have  periodic 
or  intermittent  episodes  or  recurrences  accompany- 
ing natural  phenomena,  such  as  menstruation,  preg- 
nancy, marriage,  death  of  a  child,  or  other  occur- 
rences. 

The  neurosis  is  further  qualified  with  regard  to 
its  mechanism,  that  is,  ihe  insight  the  patient  has 
retained.  The  neurosis  is  benign  when  the  patient 
recognizes  that  his  distress  or  disease  is  due  to 
the  suppression  of  unjustifiable  or  ungratifiable 
cravings  which  are  a  part  of  his  personality.  The 
neurosis  is  pernicious  when  the  patient  refuses  to 
attribute  his  trouble  to  a  personal  cause  or  wish, 
insists  that  it  is  due  to  an  impersonal  cause  or  a 
malicious  influence  and  tends  to  hate  anyone  who 
would  attribute  it  to  a  personal  source. 

According  to  the  mechanism  of  the  autonomic 
conflict  involved,  neuroses  are  differentiated  into 
five  types : 

The  suppression  neuroses  are  characterized  by 
the  fact  that  the  patient  is  more  or  less  conscious 
of  the  nature  and  effect  upon  himself  of  his  un- 
gratifiable cravings.  For  instance,  a  man  may  be 
affected  by  his  love  for  a  faithless,  indifferent  or 
dead  woman ;  a  soldier  may  be  caught  between  two 
fears,  that  of  death  and  that  of  a  court  martial, 
and  know  that  it  causes  him  insomnia,  headache, 
cardiac  anxiety,  diarrhea,  or  other  disturbance. 

In  repression  neuroses,  the  individual  tries  to 
prevent  the  autonomic  cravings  from  making  them- 
selves known  and  influencing  his  personality.  A 
repressed  fear  may  make  a  man  blind  or  lame  and 
he  may  feel  convinced  that  an  actual  fall,  bruise 
or  wrench  is  responsible  for  his  condition,  because 
he  has  succeeded  in  making  himself  forget  the 
cravings  that  are  relieved  by  being  blind  or  lame. 

Compensation  neuroses  are  characterized  by  a 
reflex  effort  to  develop  functions  which  will  com- 
pensate for  some  organic  or  functional  inferiority 
or  keep  an  undesirable  craving  repressed,  which  is 
unconsciously  causing  fear.  Often  the  effort  is 
adapted  or  designed  to  destroy  or  defeat  environ- 
mental factors  which  arouse  the  intolerable  craving 
or  oppose  the  compensation.  Egotism,  intolerance, 
and  exaggerated  claims  are  typical  of  compensation 
neuroses. 

Regression  neuroses  are  just  the  opposite.  The 
individual  makes  no  effort  to  win  or  retain  social 
esteem  and  regresses  to  a  lower,  childlike  or  infantile 


level,  becoming  apathetic,  slovenly,  irresponsible, 
often  showing  suicidal  tendencies,  and  allowing  the 
cravings  to  do  as  they  please.  The  regression  may 
be  a  relatively  benign  episode  of  a  few  months' 
duration.  It  may  in  other  cases  be  followed  by  a 
feeling  of  having  died  and  passed  through  a  rebirth, 
and  also  of  having  eliminated  all  the  sinful  cravings 
in  order  to  begin  life  anew.  This  form  of  adjust- 
ment may  work  as  long  as  the  subject  lives  in  a 
protected,  noncompetitive  environment.  Later,  an 
eccentric  overcompensation  often  takes  place  which 
eventually  leads  to  another  neurosis  or  a  perma- 
npit  deterioration  of  the  personality. 

In  dissociation  neuroses,  the  patient  succeeds  in 
keeping  his  undesirable  cravings  repressed  until 
they  finally  become  dissociated.  The  individual  is 
then  conscious  of  weird  distorted  images,  hallucina- 
tions of  past  sensations,  and  experiences  which  seem 
to  gratify  the  dissociated  effect  although  they  hor- 
rify the  individual.  The  individual  is  also  dom- 
inated by  unacceptable,  mysterious  obsessions,  fears, 
compulsions  and  inspirations.  There  may  be  also 
severe  visceral  distress,  motor  disturbances,  amnesia, 
or  other  manifestations. 

The  analytical  treatment,  as  mapped  out  by 
Kempf,  consists  in  establishing  a  transference,  that 
is,  giving  the  subject  an  opportunity  to  rely  upon 
the  altruistic  judgment  of  some  authoritative  prac- 
titioner and  enabling  him  to  allow  his  repressions  to 
make  themselves  conscious.  Kempf  disagrees  with 
Jung  on  the  extent  to  which  the  transference  should 
be  used  and  he  considers  it  essential  in  order  to  help 
the  neurotic  to  become  socially  constructive.  Only 
in  that  way  can  the  analyst  fulfill  the  mission  in 
which  the  neurotic's  parents  failed. 

After  the  subject  succeeds  in  giving  full  expres- 
sion to  his  repressed  affects,  those  affects  become 
assimilated  with  the  personality  and  form  an  inti- 
mate part  of  it,  instead  of  remaining  uncontrollable, 
unconscious  or  mysterious  factors.  In  that  way 
the  dissociated  cravings  which  cause  obsessions, 
phobias,  mannerisms,  compulsions,  delusions,  hal- 
lucinations, regressions,  eccentric  compensations, 
and  prejudices,  are  once  more  merged  with  the 
organism  from  which  they  had  been  abnormally 
separated  and  the  functional  distortion  disappears. 
The  subject  having  acquired  insight  and  being  free 
from  the  fear  of  something  within  himself,  becomes 
capable  of  making  a  sensible,  practical  adjustment. 

When  that  readjustment  is  effected  an  intelligent 
use  of  the  reconstructive,  suggestive  method  seems 
to  be  most  effective  in  giving  the  neurotic  new 
interests  for  which  to  live  and  work,  without  seek- 
ing abnormal  compensat'ons  for  prudish  or  fearful 
repressions  or  yielding  to  perverse  cravings. 

The  choice  of  a  method,  Kempf  thinks,  should  be 
left  to  the  patient,  but  he  should  not  be  allowed  to 
avoid  the  work  of  reconstruction.  Furthermore, 
the  analysis  should  be  accompanied  by  vigorous 
indulgence  in  social  play  requiring  exposure  of 
functional  or  organic  inferiorities  to  more  or  less 
critical  evaluation  by  competitors.  Thus  the  sub- 
ject will  become  immime  to  the  fear  of  failure  or 
inferiority  and  will  avoid  eccentric  compensation 
and  a  seclusive  mode  of  life. 

121  Madison  Avenue. 


798 


YOUNG  AND  COTTER:  TRICUSPID   STENOSIS  AND  INSUFFICIENCY. 


[New  York 
Medical  Journal. 


TRICUSPID   STENOSIS   AND  TRICUSPID 
INSUFFICIENCY* 
By  John  J.  Young,  M.  D., 

New  York, 

Instructor   in   Clinical   Medicine,   Columbia   University,   College  of 
Physicians  and  Surgeons;   Physician  to  Outpatient  Department 
and  Adjunct  Assistant  Visiting  Physician  Bellevue  Hospital, 

AND 

Lawrence  H.  Cotter,  M.  D., 
New  York, 

Resident   Physician,   Bellevue  Hospital. 

A  review  of  the  standard  works  on  diseases  of 
the  heart  shows  that  the  physical  signs  of  lesions  of 
the  tricuspid  valve  are  exceedingly  indefinite.  Char- 
acteristic, if  not  pathognomonic,  auscultatory,  palpa- 
tory and  percussion  phenomena  are  known  of  most 
lesions  of  the  heart  and  great  vessels,  but  the  con- 
ventional description  of  the  physical  signs  referable 
to  disease  of  the  tricuspid  A-alve  is  of  little  value  in 
distinguishing  this  lesion  from  that  of  mitral  sten- 
osis, which,  moreover,  is  an  almost  constant  associa- 
tion. For  example,  it  is  stated  that  in  tricuspid  sten- 
osis cyanosis  is  marked,  but  in  our  experience 
cyanosis  in  these  circumstances  is  no  greater  in  de- 
gree, perhaps  less  so,  than  that  usually  encountered 
in  mitral  stenosis.  Clubbing  of  the  fingers  is  a  non- 
commital  sign  and  is  in  no  wise  characteristic  of  tri- 
cuspid disease.  The  existence  of  a  presystolic  thrill 
over  the  tricuspid  area,  if  it  occurs  at  all,  is  ex- 
tremely rare.  A  tapping  systolic  impulse  over  the 
lower  sternal  region  and  the  adjoining  intercostal 
spaces  is  of  highly  doubtful  value,  since  a  coexist- 
ing mitral  tap  cannot  be  excluded. 

By  percussion  it  is  difficult,  if  not  impossible,  to 
distinguish  whether  enlargement  of  the  right  side 
of  the  heart  is  due  to  right  auricular  dilatation  or 
right  ventricular  hypertrophy.  The  presence  of 
a  sharp  valvular  sound  over  the  tricuspid 
region  is  not  necessarily  indicative  of  stenosis  of 
the  corresponding  orifice,  in  view  of  the  fact  that  the 
sharp  contraction  of  the  hypertrophied  right  ven- 
tricle may  be  invoked  to  explain  the  alteration  of  the 
first  sound  in  mitral  stenosis. 

The  lack  of  specificity  in  the  symptomatology  of 
tricuspid  disease,  as  usually  described,  prompts  us 
to  record  the  anatomical  and  clinical  findings  in  a 
series  of  four  cases  of  tricuspid  disease,  and  to  call 
attention  to  certain  pulsatory  phenomena  in  the 
liver,  which,  we  think,  are  characteristic  of  certain 
lesions  of  the  right  side  of  the  heart. 

True  intrahepatic  pulsation  may  be  venous  or 
arterial  in  origin.  In  rare  cases  of  aortic  insuffi- 
ciency expansile  enlargement  of  the  liver  is  clinically 
appreciable  and  is  arterial  in  nature.  Venous  pulsa- 
tion of  the  liver  is  produced  by  the  reflux  of  blood 
from  the  right  side  of  the  heart  through  the  inferior 
vena  cava,  thence  to  the  hepatic  vein  and  through  the 
liver  lobule.  It  is  known  that  regurgitation  through 
the  great  veins  from  the  auricles  of  the  heart  is 
favored  by  dilatation  of  these  chambers  and  that  the 
venous  orifices  of  communication  with  the  atria  par- 
ticipate in  the  process.  In  normal  circumstances,  the 
circular  layer  of  smooth  muscle  in  the  walls  of  the 
cavae  at  their  entrance  to  the  heart  acts  as  a  valve  and 

*From  the  service  of  the  First  Medical  Division,  Bellevue  Hos- 
pital. 


by  its  contraction  effectually  prevents  excessive  back- 
ward flow  of  blood  during  auricular  systole.  Re- 
gurgitation is  furthermore  favored  by  anatomical  al- 
terations in  the  musculature  of  the  right  side  of  the 
heart  so  that  dilatation  is  brought  about,  producing 
relative  insufficiency  of  the  tricuspid  orifice,  the  valve 
segments  themselves  being  unchanged  but  never- 
theless inadequate  to  guard  an  orifice  rendered  ab- 
normally large  by  muscular  relaxation. 

The  presence  of  the  normal  jugular  pulse  with  its 
positive  and  negative  components  may  be  determined, 
of  course,  by  graphic  methods  and,  indeed,  in  many 
individuals  several  of  the  waves  can  be  identified  by 
inspection.  True  intrahepatic  pulsation,  on  the  other 
hand,  is  never  encountered  in  normal  individuals. 

Clinically,  pulsation  of  the  liver  may  be  transitory 
or  permanent.  The  former  is  often  observed  in  as- 
sociation with  myocardial  insufficiency  attended  by 
marked  dilatation  of  the  right  side  of  the  heart. 
Physical  examination  corroborated  by  graphic  meth- 
ods, shows  that  this  type  of  pulsation  in  the  jugular 
vein  and  in  the  liver  is  synchronous  with  ventricular 
systole,  and  that  during  systole  a  certain  quantity  of 
Ijlood  is  regurgitated  through  the  incompetent  tri- 
cuspid orifice  into  the  auricles  and  thence  into  the 
cavae.  Under  the  influence  of  rest,  with  or  without 
digitalis  or  its  allies,  the  liver  ceases  to  pulsate  and 
venous  engorgement  and  pulsation  in  the  neck  be- 
come less  marked,  an  effect  due,  presumably,  to  de- 
crease in  the  size  of  the  heart  with  resumption  of 
the  function  of  the  tricuspid  valve. 

Thus,  a  patient  who,  on  early  examination,  pre- 
sents hepatic  pulsation  with  or  without  signs  of 
venous  engorgement  and  pulsation  in  the  neck  sliould 
be  investigated  from  the  point  of  view  of  possible 
organic  disease  of  the  tricuspid  valve,  if  these  signs 
do  not  abate  vinder  appropriate  treatment,  and  if  in 
other  respects  improvement  occurs,  as  manifested, 
for  example,  by  decrease  in  the  amount  of  edema, 
lessening  of  ascites,  hydrothorax  and  other  physical 
signs. 

The  almost  constant  association  of  mitral  and  tri- 
cuspid stenosis  and  the  not  infrequent  lack  of  local- 
ization of  the  mitral  direct  murmur,  often  render  it 
impossible  to  accomplish  satisfactory  examination  of 
the  tricuspid  area  as  delimited  on  the  precordium ; 
that  is  to  say,  the  xiphoid  region  and  the  adjoining 
portions  of  the  sternum  and  the  ribs.  Consequently, 
no  satisfactory  inference  can  be  drawn  from  the 
presence  of  a  rumbling  diastolic  or  presystolic  mur- 
mur over  the  tricuspid  area  that  does  not  differ  in 
quality  from  the  murmur  commonly  heard  over  the 
apex  in  mitral  stenosis,  because  the  possibility  of 
transmission  cannot  be  ignored.  If,  on  the  other 
hand,  there  is  present  over  the  lower  sternum  a 
rumbling  diastolic  or  presystolic  murmur  differing  in 
quality  and,  perhaps,  in  intensity  and  duration  from 
a  murmur  of  similar  time  heard  in  the  apical  region, 
this  finding  may  serve  to  aid  in  the  diagnosis  of  tri- 
cuspid stenosis.  Nevertheless,  corroborative  signs 
are  to  be  sought.  For  example,  if  the  auricles  are  act- 
ing properly,  an  excessively  large  wave  in  the  jugular 
pulse  and  in  the  liver  phlebogram  is  suggestive  of 
tricuspid  stenosis.  In  some  cases  double  liver  pul- 
sation is  appreciable  and  is  explainable  on  the  basis 
of  a  hypertrophied  right  auricle  together  with  hin- 


November  20,  1920.]     YOUNG  AND  COTTER:   TRICUSPID    STENOSIS  AND  INSUFFICIENCY. 


799 


drance  to  the  entrance  of  blood  into  the  right  ven- 
tricle. Combined  examination  of  the  apex  beat  and 
the  jugular  pulse  may  indicate  that  the  exaggerated 
wave  is  synchronous  with  auricular  systole,  even 
without  the  aid  of  instruments  of  precision.  Tri- 
cuspid regurgitation  is  always  a  companion  lesion  of 
tricuspid  stenosis. 

When  the  auricles  are  fibrillating,  the  diagnosis  is 
more  difficult.  In  such  cases  the  existence  of  organic 
insufficiency  of  the  tricuspid  valve  must  first  be  as- 
certained on  the  strength  of  continued  pulsation  of 
the  liver  and  impro\'ement  in  other  respects,  as  pre- 
viously noted.  In  many  instances  increased  pulsa- 
tion in  the  jugular  veins  may  likewise  be  present. 
In  some  cases  it  is  extremely  marked,  the  bulb  easily 
attaining  the  size  of  a  large  adult  thumb.  In  other 
cases,  however,  jugular  pulsation  is  a  negligible  fac- 
tor. In  our  experience,  on  the  other  hand,  hepatic 
pulsation  was  present  as  a  constant  phenomenon 
both  in  those  cases  in  which  the  condition  was  cor- 
rectly diagnosed  during  life  and  those  in  which  its 
clinical  recognition  was  overlooked.  Pulsation  is, 
of  course,  synchronous  with  ventricular  systole.  In 
our  experience,  too,  enlargement  of  the  liver  is  con- 
stantly present  and  depends  on  chronic  passive  con- 
gestion. If,  in  addition,  a  distinct  rumbling  diastolic 
murmur  is  heard  over  the  tricuspid  area,  the  diag- 
nosis becomes  still  more  probable. 

E\*en  though  such  a  murmur  cannot  be  distin- 
guished from  an  apical  murmur  similar  in  time,  if 
tricuspid  insufficiency  is  present,  it  is  reasonable 
to  assume  the  existence  of  some  degree  of  stenosis 
in  view  of  the  frequent  association  of  mitral  sten- 
osis with  mitral  insufficiency.  In  adults  with  or- 
ganic mitral  disease  it  is  unusual  to  find  pure  mitral 
insufficiency.  In  such  individuals  a  diastolic  rum- 
ble can  usually  be  heard  in  the  region  of  the  apex 
of  the  heart  after  having  the  patient  exercise  or  by 
placing  him  in  the  left  lateral  recumbent  posture, 
or  even  without  resorting  to  these  expedients.  As 
a  rule,  stenosis  of  the  tricuspid  valve  is  seldom  of 
the  tight  variety,  although  those  pathological  con- 
ditions of  the  valve  segments  which  make  for  in- 
sufficiency also  determine  the  occurrence  of  stenosis. 

Case  I. — The  patient,  a  male,  aged  twenty-seven 
years,  was  admitted  to  Bellevue  Hospital  complain- 
ing of  dyspnea  and  edema  of  the  legs.  Examina- 
tion revealed,  in  brief,  the  apex  beat  of  the  heart 
in  the  fifth  left  interspace  at  the  nipple  line.  The 
right  border  of  the  heart  was  made  out  by  percus- 
sion midway  between  the  right  mammillary  line  and 
the  sternal  line.  An  inconstant  presystolic  thrill 
was  palpable  at  the  apex  and  there  was  felt  a  dis- 
tinct epigastric  systolic  shock.  On  auscultation,  a 
rumbling  presystolic  murmur  was  heard  at  the  apex, 
and  as  the  sternum  was  approached  another  murmur, 
systolic  in  time,  was  heard,  increasing  in  intensity 
to  the  right  of  the  lower  part  of  the  sternum,  being 
heard  almost  to  the  right  nipple  line.  This  murmur 
was  quite  harsh.  Over  the  lower  part  of  the  ster- 
num a  soft  diastolic  murmur  was  heard,  which  at 
first  varied  with  respiration,  disappearing  with  a 
full  inspiration.  On  the  day  before  the  patient's 
death  it  was  quite  constant.  There  was  no  accentua- 
tion of  either  second  sound  at  the  base.  No  pulsa- 
tion was  noted  in  the  vems  of  the  neck.    The  liver 


w-as  large  and  pulsated  distinctly.  The  radial  pulses 
were  small  and  equal  on  the  two  sides.  There  were 
signs  of  congestion  at  the  bases  of  the  lungs.  The 
clinical  diagnosis  was:  Chronic  cardiac  valvular  dis- 
ease ;  mitral  stenosis  and  regurgitation ;  tricuspid 
stenosis  and  regurgitation.  The  diagnosis  of  old 
tricuspid  valvulitis  was  made  in  this  case  because  of 
the  marked  extension  of  cardiac  dullness  to  the  right 
of  the  sternum,  the  peculiar  murmurs  heard  at  the 
tricuspid  area,  entirely  different  from  those  heard 
at  the  apex  and  the  forcibly  pulsating  liver.  The 
patient  died  suddenly. 

Autopsy  revealed  the  lungs  more  or  less  adherent. 
There  was  a  hemorrhagic  area  in  one  lower  lobe. 
The  heart  was  enormously  enlarged  and  the  peri- 
cardium adherent  throughout.  There  was  marked 
hypertrophy  and  dilatation  of  the  right  auricle  and 
ventricle  and  their  cavities  were  filled  with  blood. 
The  left  auricle  and  veritricle  were  likewise  hyper- 
trophied  and  dilated.  The  pulmonic  segments  were 
normal.  The  tricuspid  leaflets  were  adherent  and 
thickened,  leaving  a  ring  that  admitted  two  fingers. 
The  mitral  orifice  was  quite  contracted,  admitting 
a  lead  pencil ;  chordae  tendinese  thickened  and  re- 
tracted ;  aortic  valves  thickened  and  edematous,  but 
not  indurated ;  liver  enlarged  and  congested ;  spleen 
and  kidneys  firm  and  congested. 

Case  II.- — The  patient,  a  male,  single,  aged 
twenty-eight  years,  a  native  of  Poland,  entered  the 
medical  service  of  Bellevue  Hospital  with  a  com- 
plaint of  shortness  of  breath  of  four  years'  dura- 
tion. His  family  history  was  negative.  Except  for 
two  attacks  of  gonorrhea  in  youth,  a  chancre  five 
years  ago,  and  an  attack  of  pains  in  the  legs,  not 
localized  to  the  joints,  in  childhood,  his  past  history 
was  negative. 

Four  years  previous  to  admission  to  the  hospital, 
the  patient  noticed  dyspnea,  palpitation  and  rapid 
heart  action  on  exertion,  and  became  easily  fatigued. 
For  the  same  length  of  time  he  suffered  from 
pain  in  the  right  upper  quadrant  that  was  not  re- 
lated to  the  ingestion  of  food.  Two  years  preced- 
ing his  entrance  into  the  hospital,  he  first  noticed 
swelling  of  the  legs  that  became  more  marked  in 
the  four  months  just  before  admission,  necessitat- 
ing confinement  to  bed  at  intervals.  The  patient 
stated  that  he  was  distresed  by  attacks  of  vertigo, 
without  syncope  or  convulsions,  and  by  sharp  non- 
radiating  precordial  pain. 

Physical  examination  showed  a  well  nourished, 
well  developed  adult  male  patiei^t,  acutely  ill.  There 
was  no  orthopnea,  and  cyanosis  was  moderate. 

Examination  of  the  heart  on  the  day  of  admission, 
September  21,  1917,  revealed  systolic  heaving  of  the 
entire  precordium.  The  apex  beat  was  felt  as  a 
diffuse  impulse  in  the  sixth  left  intercostal  space, 
well  outside  the  nipple  line.  The  percussion  out- 
lines of  the  heart  borders  were  five  cm.  to  the  right 
in  the  fourth  space,  and  16  cm.  to  the  left  in  the 
sixth  space.  There  was  increased  dullness  over  the 
second  left  interspace.  Over  the  apex  was  heard  a 
blowing  systolic  murmur  transmitted  to  the  axilla, 
and  a  rumbling  diastolic  murmur  with  presystolic 
intensification.  At  the  ensiform  cartilage  another 
blowing  systolic  murmur  was  heard.  A  blowing 
diastolic  murmur  was  heard  along  the  left  margin 


800 


YOUNG  AND  COTTER:   TRICUSPID   STENOSIS  AND  INSUFFICIENCY.  [New  York 

Medical  Journal. 


of  the  Sternum,  with  maximum  intensity  in  the 
fourth  left  intercostal  space ;  also  a  soft  systolic 
murmur  at  the  aortic  area  that  was  not  transmitted. 
The  pulmonic  second  sound  was  accentuated  and 
reduplicated  and  accompanied  by  a  diastolic  shock 
felt  in  the  second  left  interspace.  The  heart  action 
was  regular,  the  radial  pulses  equal,  regular,  small, 
and  of  low  tension.  On  September  22nd,  a  whis- 
tling diastolic  murmur  was  noted  over  the  ensiform 
that  was  different  in  quality  from  any  other  mur- 
mur heard  in  the  heart.  On  September  26th,  a 
superficial  to  and  fro  scratching  murmur  was  heard 
to  the  left  of  the  sternum  in  the  fourth  and  fifth 
spaces.  The  rub  was  intensified  by  pressure  of  the 
stethoscope.  On  October  21st,  there  was  heard  a 
systolic  murmur  over  the  lower  part  of  the  xiphoid, 
and  at  times  a  wavy  diastolic  murmur  was  audible 
in  the  same  location,  and  was  different  from  the 
murmur  heard  at  the  apex.  The  spleen  was  en- 
larged to  percussion,  but  ifs  edge  was  not  felt.  On 
admission,  the  liver  edge  was  felt  four  and  one-half 
fingers'  breadth  below  the  costal  margin  in  the 
mammillary  line.  The  organ  was  tender  and 
showed  distinct  pulsation ;  its  surface  was  smooth. 
An  electrocardiographic  tracing  taken  on  September 
26th  showed  auricular  flutter  and  relative  prepon- 
derance of  the  right  side  of  the  heart.  Phlebo- 
grams  showed  a  pronounced  a  wave  in  the  jugular 
pulse  and  a  large  v  wave  in  the  liver  pulse.  Urinary 
and  ophthalmoscopic  examinations  were  negative. 

At  autopsy  the  precordial  area  was  large,  measur- 
ing seventeen  cm.  from  apex  to  base,  sixteen  cm. 
in  the  transverse  direction.  The  parietal  pericar- 
dium was  qvtite  thin.  The  pericardial  cavity  con- 
tained about  eight  ounces  of  blood  tinged  fluid  with 
fibrin  flocculi.  The  visceral  pericardium  was  gran- 
ular in  appearance.  There  were  several  small  milk 
patches  scattered  over  the  epicardium  of  the  right 
ventricle.  The  heart  was  huge,  weighing  570  grams. 
The  apex  was  blunt  but  was  still  formed  by  the 
left  ventricle.  The  right  auricle  was  dilated  and 
the  musculi  pectinati  hypertrophied.  The  tricuspid 
orifice  was  constricted,  the  valve  margins  being 
thickened,  adherent  and  rounded.  On  the  edges  of 
the  line  of  closure  there  were  a  few  small  recent 
verrucous  vegetations.  The  right  ventricle  was 
hypertrophied,  its  wall  measuring  eight  mm.  The 
pulmonary  valve  was  normal.  The  left  ventricle 
was  contracted,  its  wall  measuring  twelve  mm.  The 
left  auricle  showed  considerable  dilatation  with 
slight  thickening  of  its  walls.  There  was  marked 
stenosis  of  the  mitral  orifice,  the  ring  being  re- 
duced to  a  narrow  slit  which  did  not  admit  the  tip  of 
the  little  finger.  The  valve  segments  were  thickened, 
adherent  and  calcified.  The  chordae  tendineae  were 
short  and  thick.  The  aortic  cusps  were  consider- 
ably fused,  thickened  and  retracted ;  coronary 
arteries  and  aorta  showed  no  noteworthy  changes. 
The  clinical  diagnosis  was :  Chronic  valvular  dis- 
ease; mitral  stenosis  and  regurgitation;  tricuspid 
stenosis  and  regurgitation ;  aortic  ■  regurgitation. 

The  anatomical  diagnosis  was :  Chronic  mitral 
valvulitis ;  chronic  and  acute  verrucous  tricuspid 
valvulitis  ;  chronic  aortic  valvulitis. 

Case  III. — A  middle  aged  male  patient  entered 
Bellevue  Hospital  in  March,  1920,  complaining  of 


dyspnea  and  sharp  pain  in  the  left  side  of  the  chest. 
His  past  history  was  negative  except  for  gonor- 
rhea followed  by  multiple  arthritis  in  early  life. 
The  patient  had  no  recollection  of  rheumatic  fever. 
He  stated  that  in  early  childhood  he  suffered  from 
dyspnea  on  exertion,  which  became  progressively 
worse,  and  recently  had  necessitated  complete  rest 
in  bed. 

Examination  showed  a  poorly  nourished  male/ 
quite  dyspneic  and  cyanotic,  propped  up  in  bed. 
His  bodily  configuration  and  the  hair  distribution 
conformed  to  that  of  status  lymphaticus.  There 
was  marked  arterial  pulsation  in  the  neck.  There 
were  signs  of  a  small  amount  of  fluid  in  both  pleural 
cavities.  The  apex  beat  of  the  heart  was  felt  in 
the  sixth  left  intercostal  space  in  the  anterior  axil- 
lary line.  There  was  dullness  to  the  right  in  the 
third  space,  extending  ahnost  to  the  nipple  line.  In 
the  region  of  the  apex  there  was  forcible  systolic 
retraction  of  the  ribs  and  the  soft  parts;  there  was 
a  similar  phenomenon  posteriorly  in  the  tenth  and 
eleventh  interspaces  on  the  left.  The  lung  did  not 
move  over  the  precordium  on  inspiration.  It  was 
impossible,  in  view  of  the  size  of  the  heart,  to 
determine  whether  its  outlines  changed  with  altera- 
tion of  the  patient's  position.  The  sternum  rose 
with  inspiration.  The  pulmonary  conus  percussed 
enlarged.  At  the  aortic  cartilage  there  was  heard 
a  harsh  systolic  murmur  transmitted  to  the  v^essels 
of  the  neck.  Along  the  left  margin  of  the  sternum 
a  blowing  diastolic  murmur  was  audible.  At  the 
apex  there  were  heard  a  blowing  systolic  murmur 
and  a  rumbling  diastolic  murmur.  Over  the  tip  of 
the  xiphoid  there  was  a  systolic  murmur  of  higher 
pitch  than  that  heard  at  the  apex  and  more  musical 
than  the  aortic  murmur.  The  diastolic  rumble  in 
this  area  was  not  as  rough  as  that  heard  at  the  apex. 
The  pulmonic  second  sound  was  accentuated;  the 
aortic  second  sound  was  not  heard.  The  rate  of 
the  heart  was  slow,  and  its  action  was  absolutely 
irregular.  The  radial  pulses  were  small.  The 
liver  edge  was  felt  three  fingers'  breadth  below  the 
costal  margin,  firm  and  sharp,  and  the  liver  pulsated 
vigorously.  There  was  moderate  edema  of  the 
lower  extremities  with  slight  decubital  edema. 
During  the  entire  stay  of  the  patient  in  the  ward, 
even  though  he  improved  markedly  for  a  time,  the 
liver  continued  to  pulsate. 

The  clinical  diagnosis  was:  Chronic  cardiac  val- 
vular disease ;  aortic  stenosis'  and  regurgitation ; 
mitral  stenosis  and  regurgitation ;  tricuspid  stenosis 
and  regurgitation;  adherent  pericardium  (indura- 
tive mediastinopericarditis) . 

At  autopsy,  the  heart  was  large,  the  pericardium 
being  everywhere  densely  adherent,  so  that  it  had 
to  be  dissected  away  from  the  heart  muscle.  The 
right  auricle  was  tremendously  dilated,  the  tricuspid 
valves  were  thickened  and  their  edges  fused.  The 
right  ventricle  was  dilated  and  somewhat  hyper- 
trophied. The  pulmonic  valves  were  normal.  The 
left  auricle  was  considerably  dilated,  the  mitral  valve 
presenting  a  buttonhole  stenosis.  The  left  ventricle 
was  much  hypertrophied  and  dilated.  The  aortic 
cusps  were  thickened,  retracted  and  fused  for  a 
short  distance.  The  spleen,  liver  and  kidneys 
showed  chronic  passive  congestion. 


November  20,  1920.]     VOUXG  AXD  COTTER:   TRICUSPID    STEXOSIS  AXD  IXSU E F IC lEXCY . 


801 


Case  IV. — The  patient,  a  man,  single,  aged 
twenty-seven  years,  a  native  of  the  Philippine 
Islands,  was  admitted  to  Bellevue  Hospital,  January 
24,  1920.  The  patient  stated  that  he  had  had  an  at- 
tack of  rheumatic  fever  two  years  previously.  Three 
weeks  before  his  entrance  to  Bellevue  Hospital,  he 
was  admitted  to  the  New  York  Hospital  with  the 
symptoms  of  acute  heart  failure.  At  that  time  the 
Wassermann  reaction  was  strongly  positive,  and 
mixed  treatment  was  given  in  conjunction  with 
injections  of  salvarsan.  At  the  time  of  admission 
to  Bellevue  Hospital  the  patient  was  dyspneic  and 
had  to  be  propped  up  in  bed.  Cyanosis  was  mod- 
erate. There  was  no  tracheal  tug,  no  tracheal  dis- 
placement, no  tracheal  fixation.  Venous  pulsation 
was  present  in  the  neck  but  was  not  well  marked. 
Examination  of  the  heart  showed  that  the  apex  beat 
was  to  be  felt  in  the  seventh  left  interspace,  about 
seven  inches  from  the  midsternal  line.  It  was 
forcible  and  locaHzed.  The  dullness  measured  two 
inches  to  the  left  and  an  inch  to  the  right  in  the 
second  intercostal  space,  and  one  and  one  half  inches 
to  the  right  in  the  third  space.  At  the  apex  were 
to  be  heard  a  blowing  systolic  and  a  rumbling  dias- 
tolic murmur.  At  the  base  o£  the  heart  a  long, 
soft,  blowing  diastolic  murmur  was  heard  with 
maximum  intensity  in  the  third  left  interspace, 
adjoining  the  sternum.  A  soft  systolic  murmur  was 
also  heard  at  ihe  base.  The  pulmonic  second  sound 
was  accentuated  and  the  heart's  action  was  rapid 
and  irregular.  Diagnosis,  on  admission  was :  Syph- 
ilitic aortitis ;  dilatation  of  arch  of  aorta ;  aortic 
insufficiency ;  cardiac  hypertrophy  and  dilatation 
with  relative  mitral  insufficiency,  relative  tricuspid 
insufficiency ;  apical  murmur,  probably  Flint. 

Two  days  after  admission,  a  rough  systolic  mur- 
mur was  heard  over  the  pulmonic  area,  sharply  cir- 
cumscribed on  the  precordium,  yet  heard  in  the 
vessels  of  the  neck.  The  aortic  second  sound  was 
not  audible  over  the  aortic  cartilage  nor  in  the  ves- 
sels of  the  neck.  The  second  sound  over  the  pul- 
monic area  was  sharply  accentuated  and  accom- 
panied by  a  diastolic  shock.  On  January  31st,  a 
ioud  rough  systolic  murmur  was  heard  with  maxi- 
mum intensity  in  the  third  left  interspace.  It  was 
transmitted  upwards  and  was  heard  distinctly  in 
the  carotid  vessels  and  there  was  also  a  marked 
systolic  thrill  to  be  felt  in  the  third  left  intercostal 
space.  The  aortic  second  sound  was  faint,  if  heard 
at  all.  On  this  day  it  was  also  noted  that  the 
radial  pulses  were  strikingly  small  for  an  uncom- 
plicated aortic  insufficiency,  and  the  diagnosis  was 
altered  to  that  of  aortic  stenosis  and  insufficiency  of 
specific  origin,  with  relative  mitral  and  tricuspid 
leakage  with  Flint  murmur.  On  Februarj-  3rd,  a 
loud  systolic  murmur  was  heard  over  the  tricuspid 
area  that  was  different  from  other  murmurs  noted 
hitherto,  and  on  the  8th,  a  questionable  diastolic 
rumble  of  different  quality  was  also  noted  at  the 
same  situation.  There  was,  however,  but  little 
venous  pulsation  in  the  neck.  The  clinical  diag- 
nosis was  again  altered  to  that  of  aortic  stenosis 
and  insufficiency;  mitral  stenosis  and  insufficiency, 
all  lesions  of  the  rheumatic  type.  An  explanatory 
digression  may  not  be  amiss.  Organic  mitral  dis- 
ease was  diagnosed  because  of  the  patient's  previous 


history  of  rheumatic  fever,  the  enlargement  of  the 
pulmonary  conus  as  indicated  by  extension  of  per- 
cussion dullness  to  the  left  in  the  second  inter- 
space, the  accentuated  pulmonic  second  sound 
coupled  with  a  diastolic  shock,  and,  perhaps,  the 
small  pulse — features  indicative  of  right  heart  hyper- 
trophy and  characteristic  of  mitral  stenosis.  As  it 
is  a  safe  clinical  working  rule  never  to  invoke  two 
pathological  causes  to  explain  a  given  abnormality 
if  such  can  be  accounted  for  on  a  single  etiological 
basis,  the  diagnosis  of  syphilitic  aortic  disease  was 
abandoned  for  that  of  old  rheumatic  endocarditis. 
The  curious  tricuspid  findings  also  pointed  against 
the  diagnosis  of  specific  aortic  valvulitis. 

The  radial  pulses  were  uniformly  small  but  ir- 
regular in  force  and  frequency  and  Corrigan  in 
type ;  all  palpable  pulses  were  small.  The  scrotum 
was  markedly  edematous  and  there  was  marked 
edema  of  the  lower  extremities.  The  abdomen  was 
distended;  there  was  slight  shifting  dullness.  The 
liver,  on  admission,  extended  two  fingers'  breadth 
below  the  costal  margin,  was  tender,  and  pulsated. 
On  January'  31st,  the  liver  was  still  pulsating;  like- 
wise on  February  2nd.  On  February  8th,  the  liver 
was  pulsating  strongly,  in  spite  of  the  fact  that 
there  was  a  decrease  in  the  amount  of  the  edema. 
On  February  9th,  there  was  no  change.  Two  mur- 
murs were  heard  over  the  tricuspid  area,  probably 
different  in  quality  from  the  others.  In  view  of 
these  findings,  coupled  with  the  fact  that  the  hepatic 
pulsation  had  become  more  marked  with  slowing  of 
the  heart,  the  diagnosis  was  changed  to  mitral 
stenosis  and  regurgitation ;  tricuspid  stenosis  and 
regurgitation ;  aortic  stenosis  and  regurgitation. 
The  patient  died  on  February  27th. 

Autopsy  showed  tremendous  enlargement  of  the 
heart,  especially  the  right  side,  the  inferior  vena 
cava  at  its  junction  with  the  auricle  being  about 
twice  the  normal  diameter  of  the  vessel.  A  small 
seropurulent  encapsulated  pericardial  effusion  lay 
posteriorly.  The  diaphragmatic  pericardial  sur- 
faces were  adherent.  The  aorta  lay  to  the  left  of 
the  median  line,  having  been  displaced  by  the  dilated 
right  heart.  The  right  ventricle  was  markedly 
dilated  and  hypertrophied.  The  tricuspid  valve  was 
thickened ;  its  segments  were  adherent  so  that  the 
valves  resembled  a  continuous  sheet  of  tissue.  The 
chordae  tendineas  were  shortened  and  thickened.  The 
orifice  admitted  about  two  fingers.  The  right  aur- 
icle was  huge.  The  mitral  valve  was  thickened,  the 
segments  fused,  the  chordae  short  and  thick,  and 
there  were  many  soft,  fresh,  warty  nodules  on  the 
line  of  closure  of  the  valve.  The  orifice  admitted 
the  tips  of  two  fingers.  The  left  auricle  was 
dilated,  its  walls  being  somewhat  thickened.  There 
was  hypertrophy  and  dilatation  of  the  left  ventricle. 
The  aortic  cusps  were  thickened  and  partly  fused. 
There  were  manv  fresh  verrucous  vegetations  alons: 
the  line  of  closure  of  the  valve.  The  pulmonary 
valve  was  normal,  as  was  also  the  aorta  in  its  entire 
extent.    There  was  no  anatomical  evidence  of  lues. 

The  most  valuable  clinical  sign  of  organic  tri- 
cuspid disease  is  the  presence  of  a  pulsating  liver 
which  continues  to  pulsate  or  even  pulsates  more 
markedly  under  influences  calculated  to  effect  dis- 
appearance of  this  phenomenon. 


802 


NICOLL  AND  RAMMOL: 


CLINICAL  NOTES. 


[New  York 
Medical  Journal. 


CLINICAL  NOTES  FROM  THE  FIRST  SUR- 
GICAL DIVISION  OF  FORDHAM 
HOSPITAL. 
(Second  Series.) 

By  Alexander  Nicoll,  M.  D.,  F.  A.  C.  S., 
New  York, 

Director  First  Surgical  Di%-ision, 

AND  Harry  M.  Rammol,  M.  D., 
New  York, 
House  Surgeon,  First  Surgical  Division. 

The  work  which  forms  the  basis  for  this  report 
embodies  the  efforts  of  many  men  associated  with 
the  first  surgical  division  of  the  hospital.  Without 
going  too  deeply  into  mutters  of  organization  we 
should  like  to  say  that  every  effort  is  made  to  bring 
our  patients  into  contacts- with  the  group  idea.  By 
close  association  of  visiting  surgeons,  associate  sur- 
geons, the  house  staff  and  the  outpatient  staffs  we 
attempt  to  afford  the  patient  the  best  available  skill 
in  diagnosis  and  treatment  while  within  the  hospital 
walls,  together  with  a  properly  supervised  subse- 
quent treatment  after  the  patient  has  sufficiently  re- 
covered to  leave  the  wards.  To  this  end  consultation 
between  the  attending  surgeon  and  his  associates  is 
frequent,  and  interchange  of  opinion  is  sought,  that 
the  best  interests  of  the  patient  may  be  served.  Co- 
operation between  the  strictly  professional  staff  and 
the  social  service  department  is  well  maintained. 

Our  first  case  in  this  series  deals  with  a  condi- 
tion which  is  not  so  frequently  met  .with  today  as  in 
the  past — at  least  not  in  the  degree  observed  in  our 
patient.  We  present  this  case  because  of  the  diffi- 
culties of  diagnosis  arising  from  the  magnitude  of 
the  pathological  condition — a  rather  unusual  reason 
for  difficulty  in  diagnosis : 

Case  I. — The  patient,  a  girl  of  twenty,  was  sent 
to  the  hospital  with  a  provisional  diagnosis  of  asci- 
tes. For  this  reason  she  was  admitted  to  the  medi- 
cal wards  and  after  a  short  period  of  observation 
surgical  consultation  was  asked  for.  She  gave  the 
following  history:  Occupation,  stenographer.  Fam- 
ily history :  Father  and  mother  both  living  and  well : 
five  brothers  and  two  sisters  living  and  well.  Pre- 
vious history :  Up  to  a  year  ago  the  patient  had  been 
perfectly  well.  Present  illness :  A  year  ago  the  pa- 
tient noticed  that  her  abdomen  was  increasing  in 
size.  She  suffered  no  pain  nor  discomfort,  being 
able  to  go  about  her  daily  work.  Because  of  the 
enlargement  she  consulted  a  physician  who  told  her 
that  she  had  fluid  in  her  abdomen  and  advised  her 
to  go  to  a  hospital  for  treatment.  She  did  not  at 
once  accept  his  advice.  Six  months  ago  she  found 
that  her  menstruation  was  becoming  irregular ;  pre- 
viously she  had  menstruated  in  a  normal  manner, 
beginning  when  she  was  twelve  years  of  age,  the 
periods  recurring  regvilarly  every  twenty-eight  days, 
lasting  three  days,  a  little  scant  if  anything,  and 
associated  with  slight  premenstrual  pain.  Six 
months  ago  she  began  to  menstruate  in  a  fourteen 
day  cycle,  the  character  of  the  epoch  remaining 
unchanged.  Her  chief  complaint,  therefore,  was 
enlargement  of  the  abdomen  with  marked  menstrual 
disturbance. 

Examination :  In  general  the  patient  appeared  to 


be  a  fairly  normal  young  woman,  slight  in  build, 
somewhat  delicate  in  appearance,  rather  markedly 
anemic,  but  fairly  well  nourished.  Examination  of 
the  heart  and  lungs  showed  normal  organs.  Ex- 
amination of  the  liver,  kidneys,  and. spleen  was  un- 
satisfactory because  of  the  enlargement  of  the 
abdomen.  The  urine  was  normal.  Leucocyte  count 
showed  a  total  of  8,400  cells,  with  a  percentage  count 
as  follows :  polymorphonuclear  cells  sixty-six  per 
cent.,  lymphocytes  twenty-eight  per  cent.,  large 
mononuclear  cells  six  per  cent.  The  contour  of  the 
abdomen  was  smooth  and  generally  rounded,  with 
a  slight  sagging  in  the  flanks — equally  noticeable  on 
right  and  left  sides.  The  skin  was  glossy,  apparently 
under  some  tension,  and  the  superficial  veins  were 
dilated  in  an  irregular  manner.  The  percussion  note 
was  flat  over  all  the  abdomen,  and  with  a  change  of 
position  of  the  patient  from  side  to  side  no  tympany 
could  be  demonstrated.  The  position  of  the  intes- 
tines could  not  be  made  cut  by  percussion.  A  fluid 
wave  was  easily  demonstrated.  There  were  no 
masses,  and  no  points  of  tenderness.  By  rectal 
examination  a  small  markedly  retroverted  uterus 
was  felt  in  the  posterior  cul-de-sac.  Diagnostic 
consultation  participated  in  by  members  of  the  staff 
gave  us  a  choice  of  three  probable  diagnoses :  a, 
ascites  associated  with  some  form  of  portal  obstruc- 
tion due  to  an  hepatic  sclerosis ;  b,  tuberculous  peri- 
tonitis ;  c,  a  very  large  ovarian  cyst. 

Operation  :  Under  ether  anesthesia  a  median  hy- 
pogastric incision  revealed  an  enormous  unilocular 
ovarian  cyst  springing  from  the  left  side.  The  left 
tube,  greatly  enlarged  and  thickened,  curved  over 
the  summit  of  the  cyst,  which  lay  partly  between  the 
folds  of  the  extremity  of  the  broad  ligament.  The 
cyst  contained  perfectly  clear  limpid  fluid.  There 
was  no  distention  of  the  cyst  with  fluid.  It  had  the 
appearance  of  a  cyst  which  had  been  partially  emp- 
tied, and  this  semifilled  condition  allowed  it  to 
accommodate  itself  to  the  irregularities  of  contour 
of  the  walls  of  the  abdominal  cavity.  It  was  re- 
moved together  with  the  incorporated  tube.  The 
patient  made  an  uneventful  recovery. 

It  is  rare  that  the  large  things  which  we  encoun- 
ter make  diagnosis  difficult,  but  in  this  case  it  was 
the  hugeness  of  the  cyst,  allowing  it  to  fill  the  ab- 
dominal cavity,  that  caused  a  doubt  to  enter  our 
minds  as  to  the  correctness  of  the  diagnosis.  After- 
thought, which  is  so  helpful,  pennits  us  to  make 
the  diagnosis  without  difficulty  by  relying  upon  the 
outstanding  features  of  the  history  and  examina- 
tion :  Enlargement  of  the  abdomen  without  symp- 
toms other  than  those  of  ovarian  dysfunction,  the 
presence  of  fluid,  and  the  markedly  retroverted 
uterus. 

The  next  case  serves  to  emphasize  the  value 
of  close  association  among  members  of  the  staff. 
In  no  other  type  of  case  is  the  need  for  consultation 
greater  than  in  the  head  cases  of  a  surgical  division. 
Here  the  neurologist,  the  ophthalmologist,  the  otolo- 
gist, and  in  suitable  cases  the  orthopedist,  bring  help 
of  a  very  vital  nature  and  it  is  only  by  the  liberal  aid 
of  our  associates  in  these  lines  that  the  best  results 
can  be  obtained  by  the  attending  surgeon.  It  is  also 
in  this  type  of  case  that  the  wideawake  house  sur- 
geon proves  his  quality  by  anticipating  the  need  and 


November  20,  1920.] 


NICOLL  AND   RAMMOL:   CLINICAL  NOTES. 


803 


arranging  for  the  necessary  collaboration.  We  be- 
lieve that  real  team  work  made  possible  the  favorable 
outcome  in  the  following  case : 

Case  II. — Mrs.  M.  McK.,  aged  fifty-six,  was 
injured  in  the  collision  of  two  automobiles.  The  car 
in  which  she  was  riding  was  thrown  against  a  pillar, 
but  it  is  not  known  that  she  struck  the  pillar.  The 
early  notes  by  the  ambulance  surgeon  show  that  the 
patient  was  found  unconscious  shortly  after  the 
accident,  and  could  not  be  aroused.  Her  left  clavi- 
cle was  broken  at  the  midpoint,  and  there  was  a 
severe  abrasion  over  the  sacrum.  There  were  no 
other  marks  of  external  injury.  There  was  a  slight 
amount  of  hemorrhage  from  the  mouth,  but  none 
from  the  ears  or  nose.  There  was  no  local  injury 
about  the  eyes.  There  was  no  laceration  of  the  scalp. 
No  paralysis  was  evident,  and  the  patient  had  had 
no  convulsions.  Immediate  examination  of  the 
eyes  showed  no  nystagmus,  and  no  strabismus ;  the 
pupils  were  equal,  small,  and  reacted  to  light.  The 
pulse  was  eighty-four  with  one  beat  skipped  in  ten, 
and  the  breathing  was  thirty  to  the  minute,  and 
stertorous. 

The  patient  was  brought  to  the  hospital  and,  after 
being  placed  in  bed,  vomited  a  large  amount  of 
brownish  material,  with  considerable  undigested 
food ;  there  was  no  blood  in  the  vomitus.  She 
roused  from  her  unconsciousness  and  was  incoher- 
ent, and  irrational,  and  inclined  to  be  noisy.  Her 
blood  pressure  was  160  systolic,  120  diastolic. 
Otologist's  note  (Dr.  W.  M.  Dunning)  :  "The  ears 
are  normal  except  for  the  presence,  on  the  left  side, 
of  the  evidence  of  an  old  inflammatory  middle  ear 
condition.  There  is  no  evidence  here  of  cranial 
injury."  Neurological  examination  :  Eyes  :  no  con- 
junctival or  subconjunctival  ecchymosis ;  no  stra- 
bismus;  no  nystagmus;  pupils  were  ec|ual,  smaller 
than  normal,  and  reacted  briskly  to  light.  Reflexes: 
both  knee  jerks  are  lively,  the  left  reflex  greater  than 
the  right.  There  was  no  Babinski  reaction  and  none 
of  the  associated  and  confirmatory  signs.  Triceps 
and  supinator  reflexes  were  normal.  The  superficial 
abdominal  reflexes  could  not  be  elicited.  There  was 
no  paralysis,  and  no  anesthesia. 

The  first  day  following  injury :  The  patient  was 
kept  in  bed,  and  an  ice  bag  was  applied  to  the  head. 
The  fractured  clavicle  was  dressed.  Her  condition 
changed  little ;  bowels  moved  and  she  was  able  to 
void  urine ;  there  was  no  incontinence.  Her  mental 
condition  approached  stupor  from  which  she  could 
be  aroused  for  nourishment,  and  in  the  periods  of 
consciousness  she  was  irrational  but  easily  con- 
trolled. Her  temperature  was  100.5°,  and  her 
breathing  changed  from  stertor  to  regular  and  quiet 
respiration.  Her  pulse  remained  about  80  and  still 
showed  the  tendency  to  skip.  Blood  pressure  was 
140  systolic,  105  diastolic. 

The  second  day  following  injury :  The  following 
ophthalmological  observation  was  made  (Dr.  Charles 
Graef )  :  "The  pupils  are  equal  and  react  to  light; 
there  is  fulness  of  the  veins  and  a  blurring  of  the 
disc  margins ;  there  is  evidence  of  a  low  grade  neu- 
ritis in  the  left  eye,  less  noticeable  in  the  right  eye. 
There  is  nothing  to  base  the  cerebral  condition  on 
at  present ;  patient  is  rather  dull  but  conscious." 
The  temperature  ranged  between  99°  and  100°,  the 


respiration  was  normal  in  rhythm  and  rate.  The 
blood  pressure  was  160  systolic,  120  diastolic. 

The  third  day  following  injury:  The  patient's 
condition  was  not  markedly  changed  except  for  les- 
sened irrationality,  although  any  attempt  at  eliciting 
information  from  her  caused  her  soon  to  relapse 
into  incoherence.  She  complained  of  headache. 
The  knee  jerks  were  still  very  active.  The  blood 
pressure  was  145  systoHc,  110  diastolic.  Tempera- 
ture, pulse,  and  respiration  were  normal.  * 

The  fourth  day  following  injury:  The  patient  had 
a  little  respiratory  irregularity  which  slightly, — but 
definitely, — upset  the  rhythm  of  her  breathing. 
This  condition  was  transitory  and  was  not  repeatecl ; 
the  observation  was  made  by  the  nurse  (Miss  Kelly). 
Observation  of  the  mastoid  processes  at  this  time 
did  not  show  any  evidence  of  ecchymosis.  Mentally 
the  patient  was  dull  and  in  her  periods  of  conscious- 
ness the  same  tendency  to  trail  of¥  into  irrationality 
was  observed.  She  still  complained  of  headache. 
Except  as  noted,  pulse,  temperature,  and  respira- 
tion were  normal.  Blood  pressure  had  fallen  to  130 
systolic,  90  diastolic. 

The  fifth  day  following  injury:  The  signs  of  in- 
creased intracranial  pressure  were  more  marked  on 
ophthalmoscopic  examination.  Dr.  Graef  confirmed 
the  findings  of  the  director  in  the  following  note: 
"Signs  of  low  grade  neuritis  most  marked  in  pa- 
tient's left  eye.  Very  tortuous  veins  and  marked 
edema  of  the  disc."  Neurological  examination  con- 
firmed the  first  findings  without  disclosing'  any  new 
lesion.  The  knee  jerks  were  still  very  lively,  and 
the  left  more  so  than  the  right.  The  cranial  nerves 
showed  no  lesion  other  than  that  indicated  by  Dr. 
Graef's  note.  The  superficial  abdominal  reflexes 
were  still  absent.  The  blood  pressure  was  130  sys- 
tolic, 85  diastolic.  The  patient  still  complained  of 
headache  but  the  mental  condition  showed  improve- 
ment in  that  the  irrationality  was  not  so  marked, 
although  the  dulness  continued. 

In  the  morning  of  this  day  the  rhythm  of  the  res- 
piration was  again  disturbed,  the  attack  this  time 
not  being  transitory  in  character  but  tending  dis- 
tinctly to  increase  in  gr,ivity.  The  periods  of  ap- 
nea increased  from  four  or  five  seconds  in  dura- 
tion, to  an  alarming  condition  in  which  the 
respiration  was  decidedly  of  the  Cheyne  Stokes 
type,  and  the  periods  of  ?.pnea  occasionally  exceeded 
twenty  seconds  in  duration.  Before  operation  the 
minute  count  of  respirations  was  frequently  less 
than  seven.  The  pulse  began  to  share  in  the  em- 
barrassment of  the  medullary  centres  and  decom- 
pression was  resorted  to. 

Operation  :  Subtemporal  craniotomy  was  done  on 
the  left  side,  the  opening  being  by  means  of  the 
Hudson  drill  and  rongeur.  The  exposed  dura  was 
seen  to  be  whitened,  and  the  vessels  not  clearly  in- 
dicated. The  feeling  transmitted  to  the  finger  as  it 
touched  the  dura  was  that  of  boardlike  resistance. 
There  was  no  transmitted  pulsation.  A  small  prick 
was  made  with  the  point  of  a  knife  in  the  dura  and 
clear  fluid,  in  a  jet  six  inches  high,  spurted  from 
the  opening.  A  test  tube  was  not  at  hand  imme- 
diately and  while  one  was  being  secured  from  the 
laboratory  adjoining  a  finger  was  held  over  the 
opening  and  the  fluid  allowed  to  escape  slowly. 


S04 


XICOLL  AND  RAMMOL:    CLINICAL  NOTES. 


[New  York 
Medical  Journal. 


When  the  test  tube  was  ready  the  finger  was  re- 
moved and  again  the  jet  of  fluid  appeared  and  con- 
tinued till  the  tube  was  filled,  as  from  a  fountain, 
when  its  escape  was  again  controlled.  Decompres- 
sion was  allowed  to  progress  slowly,  and  it  was 
impossible  to  estimate  the  amount  of  fluid  that 
escaped  from  the  dural  opening.  When  the  flow  had 
ceased  the  opening  was  enlarged  and  the  brain  was 
seen,  as  though  at  the  bottom  of  a  well ;  it  was 
white,  the  convolutions  were  flattened,  and  only  the 
feeblest  pulsation  was  visible ;  it  had  the  appearance 
of  an  organ  which  had  been  held  in  the  hand  and 
squeezed  till  it  had  become  bloodless.  In  spite  of 
the  efficient  decompression  which  had  taken  place 
the  brain  did  not  show  any  tendency  to  take  advan- 
tage of  the  large  amount  of  room  that  had  been 
created  for  it  by  the  escape  of  the  fluid.  It  was 
quite  apparent  both  from  the  appearance  within  the 
cranial  cavity,  and  from  the  changed  and  vastly 
improved  quality  of  the  respiration  and  pulse, 
that  decompression  had  been  accomplished  and  was 
efficient.  There  was  considerable  annoying  bleed- 
ing from  the  space  between  the  dura  and  the  bone, 
and  this  bleeding  was  checked  as  far  as  possible  by 
pressure  from  within  the  cranial  cavity  before  the 
closure  of  the  dura.  The  dura  was  sutured  with 
silk.  Provision  was  made  for  the  escape  of  fluid 
by  means  of  a  gauze  wick  led  down  to  the  wound  in 
the  bone  and  the  soft  tissue  flap  was  replaced  and 
sutured  without  any  other  drainage  than  this  wick, 
which  was  led  out  at  the  upper  angle  of  the  skin 
wound.  During  the  operation  the  pulse  varied 
from  70  to  100,  and  the  respiration  became  normal 
in  rate  and  rh>lhm.  Immediately  after  the  opening 
of  the  dura  the  blood  pressure  was  105  systolic,  75 
diastolic.  The  patient  was  returned  to  bed  in  good 
condition. 

The  subsequent  history  of  the  case  is  without 
special  interest  except  for  the  smoothness  of  recov- 
ery. The  temperature  never  was  elevated  above 
100°,  the  pulse  remained  between  70  and  80,  and 
the  respirations  continued  regular  in  rh}-thm  and 
normal  in  rate.  Blood  pressure  varied  between 
105-75,  and  120-75.  The  wound  was  dressed  on 
the  third  day,  the  gauze  wick  removed,  and  primary 
union  secured.  The  mental  condition  of  the  patient 
was  most  satisfactory  and  there  was  no  recurrence 
of  periods  of  irrationality ;  the  only  symptom  refer- 
able to  brain  injury  was  a  pronounced  euphoria, 
which  was  remarked  by  her  famil}',  but  which  was 
apparent  to  us  only  as  that  delightful  state  of  mind 
which  we_  sum  up  in  the  phrase,  "a  very  good 
patient."  The  clavicle  healed  in  due  course,  and 
since  discharged  from  the  hospital  the  patient  has 
remained  in  good  health  except  for  an  occasional 
slight  attack  of  vertigo. 

The  following  cases  are  presented  together  be- 
cause of  the  similarity  of  the  symptom  complex ; 
both  patients  were  admitted  to  the  ser\'ice  at  about 
the  same  time  and  the  temptation  to  place  them  in 
the  same  diagnostic  niche  was  strong: 

Case  III. — Iris  L.,  aged  nine  years,  was  brought 
to  the  hospital  acutely  ill.  Past  histoiy :  The 
patient  had  had  measles,  whooping  cough,  and 
bronchitis.  Surgical  history:  Two  year?,  ago  the 
little  girl  had  been  operated  on  for  intussusception, 


the  appendix  being  removed  at  the  operation,  after 
reduction  of  the  invagination. 

Present  illness :  Patient  had  been  well  up  to  the 
morning  of  admission  when  she  was  awakened  by 
a  sharp  pain  in  the  right  lower  quadrant  of  the  ab- 
domen. The  pain  showed  no  signs  of  disappearing 
and  she  was  given  a  dose  of  castor  oil ;  she  imme- 
diately vomited  a  large  amount  of  undigested  food. 
The  vomiting  recurred  ^very  five  minutes  until  the 
patient  was  brought  to  the  hospital  some  five  hours 
later.  Shortly  after  the  vomiting  began  the  patient 
had  several  movements  of  the  bowels,  at  first  diar- 
rheal in  character,  then  becoming  decidedly  mucous 
in  quality,  and  finally  being  bloody.  Examination 
at  the  time  of  admission:  The  patient  was  markedly 
in  shock,  temperature  99°  and  pulse  100.  She  com- 
plained of  pain  in  her  abdomen  and  examination 
showed  that  it  was  distended,  rigid,  tender,  and 
contained  an  irregular  ovoid  mass  in  the  region  of 
the  ascending  colon.  Operation  was  clearly  indi- 
cated both  by  the  findings  on  examination,  and  on 
the  history ;  she  was  removed  to  the  operating  room. 

Case  IV. — Mar>-  P.,  aged  three  years,  was  admit- 
ted to  the  hospital  and  placed  in  the  medical  ward. 
The  early  history  of  the  little  patient  was  not  ob- 
tainable, except  that  she  was  always  considered  a 
perfectly  healthy  child  up  to  the  day  before  ad- 
mission. 

Present  illness :  The  day  before  admission  the 
patient  ate  a  large  bag  of  plums — pits  and  all. 
Twenty-four  hours  later  she  began  to  vomit,  had 
a  little  elevation  of  temperature,  and  a  number  of 
stools  filled  with  mucus.  She  was  brought  to  the 
hospital  with  a  diagnosis  of  gastroenteritis.  Ex- 
amination at  the  time  of  admission  did  not  reveal 
an\-thing  unusual  except  for  the  noticeable  disten- 
tion of  the  abdomen.  The  child  was  given  castor 
oil  and  the  symptoms  abated,  but  did  not  completely 
clear  up.  The  stools  continued  to  have  a  decided 
mucus  content.  For  the  first  four  days  the  tem- 
perature ranged  between  101°  and  normal,  remain- 
ing normal  after  the  fifth  day,  and  until  the  eighth 
day.  The  urine  was  quite  normal.  Blood  count 
made  on  the  third  day  showed  a  total  cell  count  of 
6.800  with  a  percentage  count  of  polymorphonu- 
clear cells  of  sixty-five  per  cent.,  lymphocytes  nine- 
teen per  cent.,  transitional  type  four  per  cent.,  and 
mononuclear  cells  twelve  per  cent.  For  the  first 
week  of  its  illness  the  child's  diet  was  carefully 
super\-ised  and  in  spite  of  some  loss  of  weight  its 
condition  was  considered  satisfactory. 

On  the  eighth  day  of  the  disease  the  patient  was 
seized,  suddenly,  with  acute  abdominal  pain,  with 
distention,  rigidity,  and  tenderness.  All  these  symp- 
toms were  more  marked  on  the  left  side  of  the 
abdomen.  No  movement  of  the  bowels  occurred, 
and  no  return  was  obtained  from  an  enema.  No 
mass  was  felt.  The  patient  began  to  grow  worse 
very  rapidly.  On  the  day  following  the  patient  was 
transferred  to  the  surgical  division,  and  examination 
revealed  an  emaciated  child  in  marked  shock,  with 
a  distended  and  tender  abdomen,  in  which  could  be 
felt  an  irregular  ovoid  mass  in  the  region  of  the 
descending  colon.  Blood  and  mucus  had  been 
passed  during  the  night.  The  temperature  was  sub- 
normal, the  pulse  was  thready,  and  the  little  pa- 


November  20,  1920.] 


NICOLL  AND   RAMMOL:    CLINICAL  NOTES. 


805 


tient's  face  was  pinched  and  white.  During  the 
time  of  her  illness  the  little  girl  had  lost  so  much 
weight — most  of  it  in  the  twenty-four  hours  imme- 
diately after  the  onset  of  the  acute  pain — that  the 
parents  were  scarcely  able  to  recognize  her.  The 
blood  count  showed  a  total  white  cell  count  of  6,000 
with  percentage  counts  as  follows :  polymorphonu- 
clear cells  eighty-three,  Ij^phocytes  sixteen,  tran- 
sition type  cells  one.  Operation  was  determined 
upon  and  the  patient  was  removed  to  the  operating 
room. 

There  is  a  decided  similarity  in  the  two  histories 
just  given :  Both  patients  had  sudden  onset  of  pain, 
with  blood  and  mucus  in  the  stools,  both  had  all  the 
signs  of  shock,  each  had  a  distended,  tender,  rigid 
abdomen,  and  each  had  an  irregular  ovoid  mass  in 
the  abdomen — in  the  one  case  over  the  ascending 
colon,  in  the  other  over  the  descending  colon.  Di- 
agnosis was  perfectly  clear  in  the  first  case — the 
patient  was  suffering  from  a  recurrence  of  her  in- 
tussusception. Diagnosis  in  the  second  case  was 
not  so  clear  but  the  weight  of  evidence  favored  the 
diagnosis  of  intussusception ;  in  fact  it  appeared 
that  the  signs  and  symptoms,  together  with  a  care- 
ful consideration  of  the  history,  pointed  toward  the 
diagnosis  of  a  chronic  intussusception  suddenly 
grown  acute.  (We  should  like  to  say,  parenthetic- 
ally, that  we  have  not  yet  seen  a  case  in  which  the 
diagnosis  of  chronic  intussusception  was  substan- 
tiated.) Brief  extracts  from  the  findings  at  opera- 
tion are  herewith  appended,  together  with  the 
pathologist's  report  in  the  second  case : 

Case  III. — Iris  L. :  The  abdomen  was  opened  in 
the  median  line  and  we  immediately  encountered 
and  were  able  to  reduce  a  well  marked  ileocecal  in- 
tussusception, the  summit  of  the  intussusceptum 
having  reached  the  middle  of  the  transverse  colon. 
After  reduction  the  abdomen  was  closed  in  the 
usual  manner,  and  there  is  nothing  further  to  report 
other  than  a  smooth  convalescence.  We  feel  that 
this  case  is  unusual  in  that  it  is  a  recurrence  of  in- 
tussusception, the  first  operation  having  been  done 
only  two  years  previously. 

,  Case  IV. — Mary  P. :  Laparotomy  revealed  a 
mass  the  size  of  a  cantaloupe  lying  in  the  retroperi- 
toneal tissue  behind  the  descending  colon,  and  sep- 
arating the  layers  of  the  descending  mesocolon. 
This  tumefaction  was  found  to  merge  into  another 
irregular  mass  occupying  the  region  of  the  pan- 
creas, and  spreading  laterally  into  the  kidney  re- 
gions. There  was  no  exudate  of  any  kind  within 
the  abdominal  cavity ;  the  peritoneal  covering  of 
the  colon,  together  with  the  separated  leaves  of  the 
mesocolon,  showed  marked  discoloration,  and  con- 
tained petechial  hemorrhages.  Incision  was  made 
into  the  swelling,  through  the  external  leaf  of  the 
descending  mesocolon,  and  the  larger  portion  of  the 
mass  was  entered  and  found  to  consist  of  blood 
clot.  The  patient's  condition  forbade  further  inves- 
tigation; a  tube  was  placed  in  the  cavity  from 
which  the  blood  clots  had  been  evacuated  and  the 
abdomen  was  rapidly  closed.  The  little  patient  did 
not  rally.  Pathologist's  report  (Dr.  George  Hoh- 
mann)  :  "A  large  mass  is  palpable  in  the  retroperi- 
toneal space  on  the  left  side.  At  the  base  of  this 
mass  there  is  a  peritoneal  perforation  one  inch  in 


diameter  (the  site  of  the  drain).  Dissection  of  the 
mass  reveals  the  following :  It  is  posterior  to  the 
peritoneum ;  it  is  round,  the  size  of  a  small  orange, 
and  situated  in  the  region  of  the  left  adrenal  which 
it  entirely  surrounds.  The  left  renal  vessels  are 
involved  in  the  new  growth.  The  peritoneal  cov- 
ering gives  it  an  encapsulated  appearance.  The 
tumor  tissue  is  soft,  mushy,  and  mottled  in  appear- 
ance, due  to  hemorrhagic  infiltration.  It  has  the 
gross  appearance  of  hypernephroma ;  microscopical 
section  of  the  tumor  and  enlarged  retroperitoneal 
nodes  reveal  the  growth  as  a  very  vascular  myxo- 
sarcoma, originating  in  the  retroperitoneal  tissue." 

The  following  cases  of  biliary  system  disease  are 
interesting  in  view  of  the  wide  prevalence  of  such 
disease.  Otfr  tendency  is  to  get  way  from  the  con- 
ception of  biliary  disease  as  a  disease  of  middle 
life,  and  to  attempt  to  bring  these  patients  under 
treatment  as  soon  after  the  initial  attack  of  infec- 
tion as  possible.  It  is  our  belief  that  treatment 
means  operation,  and  that  early  operation  will  be 
infinitely  more  successful  and  much  less  dangerous 
than  the  same  measure  applied  once  the  disease  has 
gained  complexity.  The  following  views  and  rules 
guide  us  in  our  treatment  of  this  type  of  case, 
namely,  the  infectious  conditions  of  the  biliary  sys- 
tem, gallbladder  and  ducts,  liver,  and  pancreas : 
1.  Operation  for  the  relief  of  biliary  system  dis- 
ease is  essentially  an  exploration :  therefore  it  is 
necessary  that  the  incision  should  be  so  situated 
and  of  such  extent  that  visual  inspection  of  the  gall- 
bladder and  ducts  is  possible.  2.  The  appendix  is 
more  often  at  fault  primarily  than  not,  and  should 
be  removed  excepi:  when  acute  peritoneal  inflamma- 
tion exists  about  the  gallbladder,  when  all  intra- 
peritoneal manipulations  should  be  reduced  to  the 
minimum.  3.  Removal  of  the  gallbladder  is  indi- 
cated in  all  conditions  in  which  it  is  diseased.  4. 
In  selected  cases  the  operative  treatment  is  not  com- 
plete until  exposure  and  exploration  of  the  common 
bile  duct  has  been  done,  and  conditions  found  there- 
in properly  treated;  our  rule  for  this  additional 
procedure  of  exposure  and  exploration  of  the  com- 
mon bile  duct  is  this :  The  common  bile  duct  is  to  be 
exposed  and  explored  in  all  cases,  a,  in  which  there 
is  jaundice  or  in  which  there  is  a  history  of  jaun- 
dice ;  b,  in  which  there  is  associated  pancreatic  dis- 
ease ;  c,  in  which  the  gallbladder  is  found  to  contain 
many  little  stones ;  and,  d,  in  which  stones  can  be 
felt  in  the  common  or  hepatic  ducts.  The  following 
cases  illustrate  the  working  of  these  simple  rules : 

Case  V. — S.  L.,  an  ironworker,  thirty  years  of 
age.  He  had  been  a  perfectly  normal,  healthy  indi- 
vidual until  the  beginning  of  his  present  illness, 
without  marked  constipation,  and  never  having  suf- 
fered from  indigestion.  He  was  able  to  do  his 
work  without  undue  effort,  and  ate  and  slept  well, 
— until  a  month  ago.  Present  illness :  A  month  ago 
the  patient  awoke  with  no  more  definite  symptom 
than  distaste  for  food.  He  went  to  his  work  with- 
out eating  and  continued  without  food  for  twenty- 
four  hours,  simply  because  of  complete  loss  of 
appetite.  At  the  end  of  this  twenty-four  hours  he 
was  seized  with  a  severe  pain  in  the  pit  of  the 
stomach,  had  a  sour  taste  in  his  mouth,  heart- 
burn developed,  and  he  began  to  belch  gas.  Six 


806 


XICOLL   AND  RAMMOL: 


CLIXICAL  NOTES. 


[New  York 
Medical  Journal. 


hours  later  he  vomited.  He  began  to  notice  that  his 
skin  was  discolored.  He  was  compelled  to  take  to 
his  bed,  and  he  remained  there  for  three  days  in 
about  the  same  condition,  namely,  with  heartburn, 
pain  in  the  stomach,  belching  of  gas,  and  an  occa- 
sional attack  of  vomiting.  At  the  end  of  the  third 
day  he  was  able  to  leave  his  bed  and  call  on  his  doc- 
tor. At  this  time  he  was  markedly  jaundiced. 
Under  medication  he  improved  somewhat  but  was 
never  able  to  resume  his  work,  and  eventually — 
a  month  after  the  onset  of  the  disease — -he  came 
to  the  hospital  for  treatment. 

Examination  revealed  a  man  profoundly  jaun- 
diced, complaining  of  marked  pain  in  his  abdomen. 
He  did  not  appear  to  be  acutely  ill.  Abdominal 
examination  showed  that  there  was  slight  tender- 
ness all  over  the  right  side  of  the  abdomen,  and 
over  the  epigastrium  in  the  median  line.  The  most 
marked  tenderness  was  over  the  location  of  the  py- 
lorus. There  was  slight,  but  distinct,  rigidity  in 
the  right  upper  quadrant.  X  ray  examination  gave 
no  direct  evidence  of  gallstones.  The  \\'assermann 
was  negative.  Temperature  was  normal,  and  pulse 
varied  between  64  and  90.  At  no  time  did  his  tem- 
perature rise  above  99°,  until  after  operation. 
Clinical  diagnosis :  Infectious  disease  of  the  biliary 
system. 

Operation :  a.  Exploration ;  right  transrectus  in- 
cision over  the  gallbladder ;  the  gallbladder  itself  did 
not  appear  to  be  the  focus  of  trouble,  there  was 
no  change  in  its  color,  no  adhesions,  and  no  thick- 
ening of  its  coats ;  there  were  no  stones  in  the  gall- 
bladder. There  were  many  enlarged  lymph  nodes 
about  the  head  of  the  pancreas  and  at  the  junction 
of  the  cystic  and  common  ducts ;  the  head  of  the 
pancreas  was  large — as  big  as  the  clenched  fist — 
soft  and  bulging  forward  through  the  encircling 
grasp  of  the  duodenum.  The  neck  and  body  of  the 
pancreas  were  not  enlarged;  the  foramen  of  Win- 
slow  was  patent ;  the  common  bile  duct  was  en- 
larged but  did  not  show  any  mflammatory  change : 
there  was  no  fat  necrosis  and  no  effusion  of  fluid 
into  the  peritoneal  cavity,  b.  Operative  diagnosis : 
acute  pancreatitis  of  the  head.  c.  Treatment :  The 
gallbladder  was  removed ;  the  common  duct  was 
opened,  explored  for  stones  or  debris,  and  none 
found ;  a  No.  10  French  catheter  was  sutured  into 
the  common  duct  and  the  abdomen  was  closed. 

Postoperative  course :  The  patient  made  a  smootli 
operative  recovery ;  drainage  of  bile  reached  its 
high  point  on  the  fifth  day  after  operation  when 
600  c.  c.  were  collected.  During  the  next  six  weeks 
the  flow  of  bile  averaged  about  300  c.  c.  a  day,  in 
addition  to  which  amount  a  certain  leakage  into  the 
dressings  occurred.  At  the  end  of  the  third  week 
the  jaundice  was  imperceptible. 

The  next  case  serves  to  emphasize  the  early  oc- 
currence of  infectious  disease  of  the  biliary  system, 
and  is  reported  for  the  purpose  of  again  calling 
attention  to  the  fact  that  disease  of  this  system  is 
not  confined  to  middle  life : 

Case  VI. — Miss  S.  K.,  twenty-four  years  of  age, 
born  in  Russia.  This  patient  had  been  sick  ever 
since  she  was  six  years  of  age ;  she  had  always  had 
stomach  trouble.  She  complained  of  fullness  and 
discomfort  after  eating,  especially  after  a  meal  in 


which  there  was  a  large  amount  of  meat.  The 
sense  of  fullness  and  discomfort  would  come  on 
immediately  after  eating  and  would  last  for  about 
two  hours.  She  had  never  suffered  from  consti- 
pation. From  time  to  time  she  had  suffered  attacks 
of  pain  on  the  right  side  of  the  abdomen,  these  at- 
tacks having  increased  in  severity  and  frequency  in 
the  past  two  years.  Three  months  before  admis- 
sion she  suffered  an  especially  severe  attack  of 
abdominal  pain  and  was  advised  to  come  to  the  hos- 
pital for  treatment.  Examination :  The  patient  was 
anemic  and  rather  thin.  There  was  no  marked 
abnormality  except  in  the  abdominal  region ;  here 
there  was  marked  pain  and  tenderness  along  the 
entire  right  side  of  the  abdomen,  with  a  slight 
amount  of  muscular  defense ;  distinctly  tender  spots 
were  discovered  over  the  region  of  the  appendix 
and  the  gallbladder.  Her  urine  contained  albumin 
and  hyalin  and  granular  casts.  Temperature  and 
pulse  were  normal.  White  blood  count  showed  a 
total  of  10.800  cells,  seventy-six  per  cent,  of  which 
were  polymorphonuclear.  Diagnosis :  Chronic  ap- 
pendicitis and  chronic  cholecystitis. 

Operation :  a.  Exploration :  Through  an  incision 
placed  midway  between  gallbladder  and  appendix 
regions,  and  transrectus  in  type,  both  gallbladder 
and  appendix  were  found  buried  in  adhesions. 
These  adhesions  by  their  attachment  to  the  hepatic 
flexure  and  to  the  caput  coH,  respectively,  markedly 
limited  the  normal  motility  of  the  colon,  b.  Opera- 
tive diagnosis :  Chronic  appendicitis  and  chronic 
cholecystitis,  c.  Treatment :  Gallbladder  and  ap- 
pendix removed  after  a  clean  dissection  of  the  sur- 
rounding adhesions.  The  abdomen  was  closed 
about  a  drainage  tube,  Xo.  30  French,  leading  down 
to  the  duodenorenal  recess. 

Postoperative  course  :  The  patient's  recovery  was 
decidedly  stormy  for  a  few  days,  and  there  was 
some  drainage  of  bile  from  the  wound  for  about 
ten  days.  Following  the  removal  of  the  tube  on 
the  third  day  her  condition  improved  and  she  left 
the  hospital  well  on  the  road  to  complete  recovery. 

We  have  observed  drainage  of  bile  from  the 
wound  in  a  certain  small  percentage  of  our  chole- 
cj'Stectomy  cases  in  spite  of  the  fact  that  care  is 
always  taken  to  tie  off  the  cystic  duct  close  to  its 
junction  with  the  common  duct,  and  always  sepa- 
rately from  the  cystic  artery.  Drainage  of  bile  un- 
questionably comes  from  the  blowing  off  of  this 
ligature.  We  think  it  likely  that  this  is  the  result 
of  sphincterospasm  at  the  lower  end  of  the  com- 
mon duct,  induced  by  the  trauma  of  operation.  It  is 
of  minor  importance  and  except  for  the  necessity 
for  a  few  more  dressings  it  does  no  harm.  It  is 
possible  that  the  use  of  a  drainage  tube  favors  leak- 
age from  the  stump  of  the  cystic  duct ;  we  feel  that 
the  security  afforded  by  the  temporary  drainage 
more  than  compensates  for  the  annoyance  of  the 
occasional  case  which  exhibits  biliary  drainage  for 
a  day  or  two. 

Case  VIL- — Mrs.  I.  S.,  born  in  Russia,  thirty- 
two  years  of  age.  This  patient  was  operated  on 
nine  months  before  admission  to  the  first  division 
of  Fordham  Hospital.  Before  this  first  operation 
she  had  complained  of  stomach  trouble  which  had 
persisted  for  a  number  of  years.    She  had  suffered 


November  20,  1920.] 


XICOLL  AXD   RAMMOL:   CLIXICAL  XOTES. 


807 


from  the  usual  type  of  fullness  in  the  epigastrium 
after  meals,  belching  of  gas,  and 'constipation.  In 
addition  to  these  symptoms  she  had  suttered  pain 
over  the  region  of  the  gallbladder  for  the  year  pre- 
vious to  operation,  and  before  this  operation  she 
had  noticed  a  tender  spot  at  the  free  border  of  the 
ribs  to  the  right  of  the  median  line.  Immediately 
following  her  operation  she  complained  of  the  same 
pain  and  when  she  was  eventually  discharged  from 
the  hospital  her  condition  was  not  improved.  Ex- 
amination :  The  patient  was  thin,  anemic,  and  of 
sallow  complexion.  Her  chief  complaint  was  con- 
stant pain  in  one  spot,  over  the  region  of  the  gall- 
bladder, associated  with  persistent  indigestion. 
There  was  a  scar  in  the  abdominal  wall  at  about  the 
level  of  the  umbilicus,  two  inches  in  length.  She 
said  that  the  pain  occasionally  radiated  to  the  groin 
and  thigh.  She  had  never  been  jaundiced,  and  had 
never  had  clay  colored  stools. 

We,  therefore,  were  faced  with  this  proposition: 
A  patient  who  had  all  the  signs  of  chronic  chole- 
cystitis but  who  had  been  subjected  to  an  explora- 
tory operation  only  nine  months  previously  as  a 
result  of  which  the  operating  surgeon  had  caused  to 
be  recorded  that  "gallbladder,  duodenum,  pancreas, 
and  pelvic  organs  were  all  negative."  \Ve  were 
moved  to  stick  by  our  guns  in  spite  of  the  findings 
at  this  operation,  and  subject  this  patient  to  reop- 
eration for  chronic  cholecystitis.  The  determining 
factor  lay  in  the  scar  of  the  previous  operation ;  we 
felt  that  thorough  and  definite  exploration  of  the 
condition  of  the  gallbladder  could  not  be  done 
through  a  wound  only  two  to  two  and  a  half  inches 
long,  and  placed  at  the  level  of  the  umbilicus  or  a 
little  above.  In  fact,  we  feel  that  in  order  definitely 
to  rule  out  gallbladder  disease  the  surgeon  must  see 
the  gallbladder  as  well  as  feel  it ;  palpation  of  the 
gallbladder  and  the  ducts  with  the  tips  of  the  fin- 
gers may  detect  the  presence  of  gross  lesions  such 
as  stones,  but  will  fail  to  detect  the  finer — but  very 
definite  and  significant — signs  of  infectious  disease, 
some  of  the  most  delicate,  and  significant,  of 
which  lie  not  in  the  gallbladder  itself  but  in  the 
contiguous  peritoneum. 

Operation :  a.  Exploration ;  the  abdomen  was 
carefully  opened  beside  the  old  scar.  A  mass  of 
adhesions  firmly  bound  the  small  intestines  to  the 
parietal  peritoneum ;  at  its  upper  end  this  mass  of 
adhesions,  reinforced  with  omental  grafts,  involved 
the  hepatic  flexure  of  the  colon  and  the  edge  of  the 
liver,  the  upper  right  quadrant  of  the  abdominal 
cavity  being  completely  shut  off  from  exploration 
by  this  mass  of  new  formed  tissue.  In  order  to 
complete  exploration  of  the  gallbladder  region  it 
was  necessary  to  resect  these  adhesions,  and  this 
was  done,  making  use  of  sharp  dissection  and  liga- 
tion where  necessary.  Coming  down  upon  the  edge 
of  the  liver  in  the  gallbladder  region  it  was  seen 
that  the  hepatic  flexure  of  the  colon  was  firmly 
united  to  the  liver  at  this  point ;  in  freeing  these 
adhesions  the  edge  of  the  liver  was  exposed  and  it 
was  then  found  that  a  small  process  of  liver  tissue, 
about  two  inches  in  width,  hung  down  over  the  gall- 
bladder completely  hiding  it.  This  little  canopylike 
process  was  turned  upward  and  the  gallbladder,  the 
centre  of  a  mass  of  adhesions,  was  seen.    b.  Op- 


erative diagnosis :  Chronic  cholecystitis,  c.  Treat- 
ment: The  gallbladder  was  freed  of  all  adhesions 
down  to  the  junction  of  cystic  and  common  ducts ; 
the  cystic  artery  was  ligated  and  turned  aside,  and 
the  cystic  duct  ligated  just  above  its  junction  with 
the  common  duct,  and  cut  away.  Tube  drainage  was 
introduced  to  the  duodenorenal  recess  and  the  ab- 
domen closed. 

Postoperative  course :  Immediate  operative  re- 
cover}- was  satisfactory;  the  patient  still  suffers 
from  some  stomach  trouble,  and  a  little  tenderness 
along  the  scar,  together  with  vague  abdominal  pains. 
We  do  not"  feel  that  her  progress  is  as  rapid  as  we 
should  like  to  see  it  but  feel  that  we  should  not  ex- 
pect a  quick  and  easy  recovery  in  a  patient  who  has 
been  twice  subjected  to  laparotom)-  within  a  period 
of  a  year. 

It  seems  to  be  a  more  or  less  generally  accepted 
opinion  that  it  is  very  difficult  to  determine  posi- 
tively by  palpation  plus  visual  inspection  the  condi- 
tion of  the  gallbladder,  when  the  pathological 
condition  of  that  organ  is  in  a  quiescent  stage :  is  it 
not  likely  that  a  pathological  condition  of  the  gall- 
bladder expressed  only  in  perivesical  adhesions  of 
the  cobweb  type  may  be  overlooked  when  examina- 
tion is  made  only  by  palpation  with  the  tips  of  the 
fingers,  and  through  an  inadequate  incision? 

The  following  case  history  indicates  the  value  of 
the  history  in  biliary  system  disease,  and  the  com- 
parative lack  of  value  of  phj^sical  examination. 

Case  VIII. — Thomas  C,  thirty-eight  years  of 
age,  a  bookkeeper.  His  family  history  had  no  bear- 
ing on  his  present  condition.  His  past  history  in- 
dicates that  he  had  suffered  from  pulmonary 
tuberculosis  in  an  active  stage  some  three  years  ago. 
Present  illness :  For  the  past  nine  months  the  pa- 
tient had  suffered  from  loss  of  appetite,  constipa- 
tion, and  pains  in  the  abdomen.  Xine  months  ago 
the  first  attack  of  abdominal  pain  occurred,  and  it 
had  been  repeated  at  various  and  irregular  times. 
The  duration  of  the  intense  pain  had  frequently  been 
six  hours.  \''omiting  had  always  relieved  him.  Two 
to  three  hours  after  meals  had  been  the  favorite 
time  for  the  appearance  of  a  painful  attack.  He 
had  never  been  jaundiced,  but  had  noted  clay  col- 
ored stools  on  several  occasions.  Physical  exami- 
nation :  The  patient  was  a  rather  slender,  anemic 
male.  There  was  nothing  abotxt  his  objective  exam- 
ination to  indicate  disease.  Specifically  there  were  no 
tender  points,  masses,  or  areas  of  muscular  defense 
in  the  abdomen. 

Operation :  The  appendix  was  chronically  in- 
flamed ;  it  was  removed.  The  gallbladder  was  sur- 
rounded by  many  delicate  adhesions,  and  contained 
many  small  stones.  The  pancreas  was  normal,  and 
the  foramen  of  Winslow  patent.  The  cystic  and 
hepatic  ducts  were  much  dilated,  and  the  common 
duct  was  at  least  a  half  inch  in  diameter.  The 
common  duct  was  opened,  explored  with  a  scoop 
and  a  small  stone  removed  from  the  ampulla.  The 
common  duct  was  drained  with  a  Xo.  10  French 
catheter,  and  the  abdomen  closed  in  the  usual  man- 
ner after  the  removal  of  the  gallbladder. 

Again  the  close  association  of  the  attending  sur- 
geon, the  neurologist,  and  the  orthopedist,  proved 
of  great  value  to  the  following  patient: 


808 


NICOLL  AND   RAMMOL:'  CLINICAL  NOTES. 


[New  York 
Medical  Journal. 


Case  IX. — T.,  a  boy  of  sixteen,  injured  his  left 
elbow  a  month  before  admission  to  the  hospital. 
The  injury  was  treated  as  a  dislocation,  but  func- 
tion did  not  tend  to  return  after  reduction  had  been 
accomplished.  He  came  to  the  hospital  complain- 
ing of  inability  to  extend  the  forearm  on  the  arm, 
pain  over  the  injured  joint,  and  loss  of  sensation 
in  the  skin  of  the  little  finger  and  half  the  ring 
finger.  Examination  revealed  a  firmly  fixed  elbow. 
The  forearm  was  held  at  an  angle  of  90°  with  the 
arm,  and  motion  was  limited  to  an  arc  of  about  10°. 
The  elbow  was  swollen  and  tender,  especially  over 
the  inner  aspect,  and  over  the  internal  condyle  of 
the  humerus.  Passive  motion  beyond  the  narrow 
limits  mentioned  produced  much  pain.  The  finger 
grip  was  also  limited  because  of  pain.  Neurolog- 
ical examination  (Dr.  Joseph  Byrne)  indicated  a 
partial  division  of  the  ulnar  nerve.  X  ray  exam- 
ination (Dr.  I.  J.  Landsman)  disclosed  an  old  frac- 
ture of  the  internal  condyle  of  the  humerus,  with 
an  absence  of  the  epicondyle  at  its  proper  position, 
and  the  presence  within  the  joint  of  a  foreign  body 
• — probably  the  missing  epicondyle.  Dr.  Byrne  ad- 
vised open  operation  with  suitable  neurorrhaphy. 
The  orthopedist  (Dr.  S.  W.  Boorstein)  also  advised 
immediate  operation  for  the  correction  of  the  anky- 
losis, the  cleaning  out  of  the  joint  cavity,  and  the 
earlv  restoration  of  motion,  l^i  the  meantime  the 
Wassermann  had  proved  negative. 

Operation :  A  semicircular  incision  with  convex- 
itv  toward  the  radial  side  of  the  arm  exposed  the 
inner  aspect  of  the  joint.  The  ulnar  nerve  was 
recognized  above  the  joint  and  was  carefully  dis- 
sected from  its  bed  to  a  point  corresponding  with 
the  extreme  lower  level  of  the  joint :  here  the  nerve 
was  seen  to  be  injured,  a  well  marked  fibrocystic 
mass  occupying  the  nerve  sheath  at  this  point,  the 
lesion  not  affecting  the  entire  circumference  of  the 
nerve.  Dissection  of  the  nerve  was  carried  out  to 
a  point  about  a  half  inch  lower  than  the  point  of 
ganglion  formation,  and  the  nerve  was  gently  drawn 
aside.  The  capsule  of  the  joint  was  incised  and 
the  internal  epicondyle  found  to  be  missing  from 
its  normal  position.  Investigation  of  the  joint 
cavity  proper  disclosed  the  missing  internal  epicon- 
dyle lying  between  the  articular  surfaces  of  the 
humerus  and  ulna,  with  its  articular  surface  looking 
upward  and  the  line  of  fracture  impinged  upon  the 
articular  surface  of  the  ulna.  This  little  mass  of 
bone  was  removed  and  the  capsule  sutured.  The 
ulnar  nerve  was  freed  of  all  surrounding  scar  tis- 
sue, the  little  cysHike  mass  was  punctured,  and  the 
nerve  allowed  to  drop  back  into  its  normal  position. 
The  wound  was  closed  without  drainage.  The  el- 
bow was  fixed  in  marked  flexion.  Postoperative 
course;  the  patient  made  a  smooth  recovery,  and 
primary  union  was  secured.  Active  motion  \yas 
encouraged  on  the  eighth  day,  and  passive  motion 
and  massage  was  added  in  a  day  or  two.  Dr. 
Byrne's  examination  showed  that  there  was  im- 
provement in  sensation  on  the  tenth  day.  The 
patient  was  discharged  from  the  hospital  at  the  end 
of  three  weeks,  improving  in  a  satisfactory  manner, 
and  withdrew  himself  from  observation  at  the  end 
of  about  a  month,  well  on  the  road  to  complete 
restoration  of  function. 


The  following  case  well  illustrates  the  wisdom 
of  close  association  between  the  attending  surgeon 
and  the  members  of  the  associated  staff,  especially 
the  rontgenologist.  We  are  indebted  to  Dr.  I.  J. 
Landsman  for  the  careful  and  repeated  x  ray  exam- 
inations of  this  case  which  enabled  us  to  eventually 
clinch  the  diagnosis : 

Case  X. — S.  H.,  male,  thirty-two  years  of  age, 
married.  His  family  history  was  not  significant.  He 
denied  lues  and  there  was  no  evidence,  direct  or 
otherwise,  of  such  infection.  He  had  never  been 
operated  on.  His  history  as  it  bore  upon  the  condi- 
tion for  which  he  came  to  the  hospital  was  as  fol- 
lows :  He  had  always  been  in  fair  health  up  to  four- 
teen years  ago ;  at  that  Lime  he  was  seized  with  an 
attack  of  abdominal  cramps,  v.ith  obstinate  consti- 
pation, but  no  vomiting.  Ten  years  ago  he  had  a 
similar  ■  attack,  and  again  seven  years  ago.  In  the 
intervals  between  attacks  he  enjoyed  moderately 
good  health,  though  he  was  never  robust.  Since  the 
attack  seven  years  ago  he  had  had  occasional  attacks 
of  vomiting.  About  two  years  ago  he  showed  symp- 
toms of  pulmonary  tuberculosis  and  since  that  time 
he  had  never  been  well.  Eight  months  ago  the  pa- 
tient had  an  attack  of  abdominal  cramps  that  lasted 
for  three  weeks.  Seven  weeks  ago  he  had  a  similar 
seizure,  and  in  this  attack  the  pain  radiated  to  the 
back  on  the  right  side ;  this  pain  recurred  at  irregular 
intervals  throughout  the  day,  each  attack  lasting 
about  five  minutes.  He  always  had  the  pain  if  he 
went  any  unusual  time  without  food,  and  he  had 
moderate  comfort  for  about  one  hour  and  a  half 
after  his  meals ;  the  pain  had  a  tendency  to  localize 
in  the  right  iliac  fossa.  During  this  period  of  seven 
weeks  he  had  repeated  attacks  of  vomiting,  had 
persistent  sour  taste  in  the  mouth,  had  gaseous  eruc- 
tations, and  had  been  obstinately  constipated.  He 
says  that  he  never  had  a  'satisfactory  movement  of 
the  bowels,  cathartics  and  enema  being  used  con- 
tinually. ■  In  this  latest  attack  he  had  great  diffi- 
culty in  urinating;  he  found  that  he  was  not  able 
to  void  while  standing,  nor  while  lying  upon  his 
back  or  right  side — it  was  necessary  for  him  to  lie 
upon  his  left  side  in  order  to  void,  and  even  then 
urination  was  difficult  and  painful.  Since  the 
beginning  of  this  latest  attack  the  patient  had  lost 
sixteen  pounds.  Examination  :  His  appearance  was 
that  of  a  chronically  ill  individual  who  was  suff^- 
ing  from  a  distinct  toxemia ;  he  was  emaciated,  and 
the  conjunctivae  were  blanched;  his  skin  was  moist 
— wet,  in  fact — with  a  clammy  sweat,  and  his  eyes 
were  unnaturally  bright,  and  the  mucous  mem- 
branes of  his  nostrils  and  lips  were  a  brilliant 
carmine.  His  mental  condition  was  dull.  His 
lungs  showed  the  evidence  of  chronic  inflammatory 
disease  in  a  quiescent  stage.  There  was  nothing 
noteworthy  about  the  extremities.  The  abdomen 
was  markedly  distended  symmetrically,  and  there 
was  a  general  tenderness.  Two  masses  were  dis- 
covered, one  of  these  about  the  size  of  a  baby's 
head  and  the  other  a  little  smaller;  these  masses 
were  very  hard  to  the  touch,  slightly  tender;  the 
smaller  one  was  rather  freely  movable,  not  con- 
nected with  the  larger  one,  but  superimposed  upon 
it;  the  larger  mass  was  firmly  fixed  just  above  the 
symphysis  pubis,  a  little  to  the  right  of  the  median 


November  20,  1920.] 


WOODBURY :   CELLULAR  THERAPEUTICS. 


809 


line ;  rectal  examination  showed  that  this  larger 
mass  almost  completely  filled  the  pelvis,  and  could 
be  moved  slightly  by  pressure  from  within  the 
rectum,  through  the  rectal  wall.  Cystoscopic  exam- 
ination was  impossible  because  of  the  firm  impac- 
tion of  this  larger  mass  in  the  pelvis.  Examination 
of  the  urine  disclosed  perfectly  normal  urine — quite 
dear. 

Shortly  after  admission  the  patient's  temperature 
rose  to  104°  and  the  pulse  to  108.  After  catharsis 
and  the  use  of  the  enema  the  temperature  returned 
to  normal,  although  the  amount  of  the  bowel  move- 
ment was  slight  and  no  gas  was  passed. 

The  X  ray  examination :  The  first  examination 
was  made  at  a  time  when  the  more  movable  mass 
was  in  the  region  of  the  right  kidney,  and  the  plates 
showed  what  appeared  to  be  a  very  large  calculus 
in  the  right  kidney.  Reexamination  disclosed  a  very 
large  mass  in  the  pelvis,  the  more  movable  of  the 
two  masses  having  deserted  the  kidney  region  and 
come  to  lie  in  close  contact  with  the  larger  mass, 
in  such  a  way  as  to  cause  the  blending  of  the  two 
shadows.  In  view  of  the  urinary  difficulty  experi- 
enced by  the  patient  and  because  of  the  density  of 
the  mass  and  its  position,  it  appeared  that  we  might 
have  to  deal  with  a  very  large  vesical  calculus ; 
however,  the  bladder  was  filled  with  collargol  and 
the  patient  reexamined,  when  the  mass  was  clearly 
shown  to  lie  outside  the  urinary  tract.  By  a  pro- 
cess of  exclusion  the  diagnosis  was  arrived  at. 
Operation :  Median  hypogastric  incision ;  as  soon  as 
the  peritoneum  was  opened  a  tremendously  dilated 
and  hypertrophied  sigmoid  came  into  view,  within 
which  lay  the  tumor ;  an  attempt  was  made,  by 
working  from  within  the  abdomen  and  against  the 
fingers  of  an  assistant's  hand  within  the  rectum,  to 
break  up  the  mass,  but  this  was  found  to  be  im- 
possible both  because  of  the  hardness  of  the  lump 
and  because  the  finger  within  the  rectum  could  not 
reach  it.  The  sigmoid  was  incised  in  the  anti- 
mesenteric  line  and  a  huge  enterolith  turned  out. 
A  second,  slightly  smaller,  enterolith  was  removed 
from  the  afferent  loop  of  the  sigmoid,  and  several 
smaller  rocklike  pieces  of  fecolith  were  removed 
from  the  portion  of  the  sigmoid  immediately  below 
the  primary  mass.  Firm  lockstitch  suture  of  the  sig- 
moid wound  was  made  and  a  row  of  Lembert  stitch- 
ing covered  the  watertight  stitch.  The  empty  sig- 
moid was  seen  to  be  in  a  state  of  very  active  peris- 
talsis. The  peritoneal  toilet  was  completed  and  the 
abdomen  closed  with  a  drainage  tube  led  down  to 
the  sigmoid  wound.  Postoperative  course :  The  pa- 
tient reacted  well  from  the  operation.  There  ensued 
suppuration  in  the  abdominal  wound.  Movement  of 
the  bowels  was  very  sluggish  and  unsatisfactory, 
and  we  were  convinced  that  the  toxic  condition, 
noted  before  operation,  was  entirely  unchanged  by 
the  operative  relief  of  the  mechanical  condition  from 
which  he  had  suffered.  At  the  end  of  ten  days  the 
suppurating  wound  in  the  abdominal  wall  was  im- 
proving, but  the  patient's  general  condition  did  not 
improve ;  at  no  time  since  operation  had  there  been 
any  vomiting.  When  the  patient's  temperature 
eventually  arrived  at  normal,  and  the  pulse  dropped 
to  60,  it  was  apparent  that,  while  the  bowels  were 
moving  fairly  well,  the  patient  was  suffering  from 


the  accumulated  toxins  of  months  of  obstipation. 
This  patient  was  removed  from  the  hospital  in  the 
fifth  week  of  his  convalescence,  and  two  weeks  later 
died  in  another  institution.  The  cause  of  death  was 
apparently  this  peculiar  toxic  condition  from  which 
he  suffered,  and  which  persisted  unchanged  after 
the  condition  which  had  called  it  into  being  had 
been  disposed  of. 

17  West  Seventy-third  Street. 

217  East  116th  Street. 


CELLULAR  THERAPEUTICS, 

By  Frank  Thomas  Woodbury,  B.A.,  M.D., 
Edgewood  Arsenal,  Md. 
Lieutenant  Colonel,  Medical  Corps,  U.  S.  Army. 

The  disabled  cell. — The  cell  is  the  unit  of  altered 
structure  and  disordered  function.  No  treatment 
can  be  rational  which  does  not  consider  the  cell 
because  the  sum  total  of  physiology  and  pathology- 
is  but  the  aggregate  of  cellular  physiology  and  path- 
ology. Cellular  wellbeing  is  health;  cellular  dis- 
ability is  ill  health.  The  relative  seriousness  of  the 
symptoms,  signs,  complications,  sequelae  and  termi- 
nation of  any  disability  will  be  directly  proportion- 
ate to  the  importance  of  the  functions  which  the 
affected  cells  normally  perform. 

The  physiological  needs  of  cells. — All  cells  need, 
1,  a  constant  supply  to  the  cells  of  reparative  and 
building  material  and  kinetic  energy  (furnished  as 
dissolved  digested  food  and  oxygen),  chemical  mes- 
sengers from  the  endocrine  glands  and  internal 
secretions  and  antitoxins.  This  is  the  duty  of  the 
arterial  blood  stream.  2.  A  constant  flow  from  the 
cells,  draining  off  excess  of  blood  (thus  preventing 
stasis)  whereby  wastes  and  formed  products  (the 
result  of  their  life  activity  and  special  function)  are 
removed.  This  is  the  duty  of  the  lymph  channels 
and  the  venous  system.  3.  A  coordinating  govern- 
ment by  vibratory  messages  from  the  cerebrospinal 
sympathetic  system. 

Rational  therapeutics  regards  the  cell  and  its  activ- 
ities and  considers  the  appropriate  treatment  to  re- 
move disabling  causes  and  restore  the  relationship 
outlined  above,  viz.,  opening  the  channels  of  blood 
supply  to  the  disabled  cells ;  opening  up  the  channels 
of  drainage  from  them,  and  controlling  the  nervous 
messages.  Rational  therapeutics  goes  even  farther. 
It  assists  the  individual  cells  to  throw  off  their  in- 
cubus, spew  out  their  poison,  and  absorb  kinetic 
energy  and  reparative  and  building  material,  thus 
renewing  their  accustomed  relation  to  the  rest  of 
the  body. 

Nature  has  but  one  remedy — blood.  Blood  is  the 
vis  medicatrix  natures.  Nature's  effort  is  always 
to  afford  the  disabled  cell  an  increased  blood  supply. 
If  we  employ  this  agent  we  follow  Nature  and  the 
cell,  if  viable  and  not  crippled,  will  then  build  itself 
up  and  resume  its  function,  if  crippled  it  may  be 
helped  by  therapeutic  agents  acting  directly  on  and 
in  the  cell ;  if  dead,  the  leucocytes  will  remove  the 
corpse. 

If  Nature  were  always  successful  in  her  effort, 
no  therapeutic  assistance  would  be  required.  The 
body  would  be  its  own  physician  in  great  as  well  as 
in  small  disabilities,  but  unfortunately  in  the  desire 


I 


810 


IkOODBURY:  CELLULAR  THERAPEUTICS. 


[New  York 
Medical  Journal. 


to  protect  the  injured  cell  and  to  restore  continuity 
and  function,  deplorable  results  occur  which  may 
be  seen  in  any  clinic  and  most  frequently  among 
those  races  or  creeds  whose  therapeutic  knowledge 
and  skill  are  primitive  or  nonexistent.  Examples 
of  these  failures  of  Nature  are:  spontaneous  ampu- 
tation, necrotic  sphacelus,  abscess,  intestinal  adhe- 
sions, bony  deformities  following  fractures,  anky- 
losis following  injury  or  inflammation  of  joints, 
cardiac  hypertrophy,  hob  nail  liver,  pancreatitis, 
nerve  atrophy  with  loss  of  motor  and  sensory  func- 
tion, neuromuscular  cripples  from  neuritis,  toxic 
goitre,  uremia  from  nephritis  following  toxemia, 
or  diarrhea,  etc.  Warned  by  these  unhappy  results 
we  try  to  avoid  Nature's  mistakes  in  our  efforts  to 
aid  her. 

THE  BASIS  OF  THERAPEUTIC  PROCEDURE. 

In  making  our  choice  of  agent  or  method  we 
should  ask  ourselves  the  following  questions,  the 
answers  to  which  will  be  our  guide  in  selection  and 
application  of  our  treatment :  What  cells  are  suffer- 
ing altered  function?  What  is  the  nature  of  the 
alteration  ?  What  are  the  causes  of  the  altered  func- 
tion ?  How  would  Nature  restore  the  cells  to  normal 
function?  What  aid  does  Nature  need  to  bring 
about  the  normal  function  and  what  agents  have 
we  with  which  to  afford  that  aid?  Which  of  our 
agents  is  preferable?  What»degree  of  restoration 
to  normal  is  attainable? 

Proceeding  in  this  manner  we  may  find  ourselves 
considering  any  of  a  thousand  and  one  pathological 
conditions,  but  all  resolving  themselves  into  cellular 
disability,  altered  blood  supply,  impaired  drainage. 
It  is  true  that  surgery  relocates  the  dislocation,  re- 
places the  broken  ends  of  fractures,  transplants  tis- 
sues to  restore  function  and  continuity,  removes 
harmful  growths,  drains  toxic  abscesses,  restores 
mechanical  ability  and  relieves  pressure,  but  surgery 
is  only  a  special  branch  of  therapeutics  and  must  in 
the  last  analysis  consider  the  cell,  which  is  the  agent 
to  complete  the  restoration  of  continuity  and  func- 
tion, and  the  blood  supply,  the  sine  qua  non.  Surgery- 
is  always  a  violence  done  to  repair  a  violence  or  pre- 
vent a  violence. 

NATURAL    THERAPEUTIC  AGENCIES. 

To  supply  affected  cells  as  well  as  all  cells  with 
the  life  giving,  life  maintaining  blood.  Nature  em- 
ploys the  following  combination  of  agencies  work- 
ing in  harmonious  balance :  Cardiac  integrity  and 
rhythm ;  vascular  continuity  and  permeability ;  lym- 
phatic continuity  and  permeability;  normal  blood 
constituents,  which  in  turn  depend  upon  adequate 
qualitative  and  quantitative  diet ;  alimentary  ade- 
quacy to  convert  diet  into  soluble  kinetic  energy  and 
reparative  and  building  materials ;  pulmonary  res- 
piratory exchange  and  capacity ;  renal,  dermal  and 
pulmonary  excretion ;  endocrine  balance  between 
pituitary,  thyroid,  adrenals,  and  gonads ;  and  peri- 
odical removal  of  waste  residue  from  diet;  and, 
finally,  automatic  (or  reflex)  cerebrospinal  sympa- 
thetic control  and  coordination  including  special 
sense  organ  functions. 

When  this  combination  of  agencies  gets  out  of 
proper  balance  we  have  first  the  cells  immediately 
disabled  and  then  in  cooidinating  series  other  cells 
which  they  control  or  with  which  they  are  associated 


in  bodily  functions  which  may,  and  usually  do, 
create  a  vicious  circle  whose  point  of  creation  we 
must  discover. 

CLASSES  OF  DISEASE. 

There  are  only  two  general  classes  of  diseases: 
Class  I,  diseases  not  transferable  (noninfectious), 
and.  Class  II,  diseases  transferable  (infectious). 

The  causes  of  the  first  class  are:  Inherited  an- 
omalies ;  poisons  ingested,  inhaled  or  absorbed ; 
traumatisms,  mechanical,  thermal,  electrical;  and 
disregard  of  the  physiological  needs  of  the  body  as 
an  organism  whereby  the  harmonious  relations  of 
the  agencies  mentioned  above  are  destroyed  or  hin- 
dered. The  second  class  has  the  first  class  as  a 
predisposing  cause  and  live  parasitic  plants  and  ani- 
mals as  its  exciting  cause. 

THERAPEUTIC  AGENTS  WHICH  REMOVE  DISABLING 
CAUSES  OF  CLASS  I. 

1.  Exercise:  This  includes  developmental,  correc- 
tive and  remedial  exercise. 

2.  Dietetics  :  This  comprises  a  chemical  and  physi- 
ological consideration  of  foods;  rations  adopted  to 
work,  curative  and  restorative  diets. 

3.  Heat :  This  includes,  a,  convection  heat  ob- 
tained by  hot  water  baths,  electric  hot  pads,  hot 
packs,  hot  water  bottles,  hot  air,  hot  mud,  vapor  and 
shower  baths;  b,  penetration  heat  obtained  by  light 
baths,  diathermy,  induction,  condensation  and  mon- 
opolar high  frequency  d'Arsonval,  Tesla  and  Oudin 
currents,  brush  and  spark  static  current ;  c,  convec- 
tion cooling  or  abstraction  of  heat  by  cold  immer- 
sion, ice  baths,  cold  packs,  Scotch  douche,  needle 
shower,  sea  baths. 

4.  Vibration :  a.  Mass  vibration  obtained  by  mas- 
sage (manual  and  mechanical)  ;  b,  tissue  vibration 
obtained  by  faradic  and  sinusoidal  electricity ;  c, 
cellular  vibration  obtained  by  actinio  (spectral) 
light;  high  frequency  alternating  and  oscillating 
electricity  (d'Arsonval,  Tesla,  Oudin)  in  the  form 
of  induction,  condensation,  bipolar  and  monopolar 
application,  static  electricity  in  the  form  of  wave 
current,  induced  current,  spark,  spray,  brush  and 
breeze,  rontgen  ray  and  radium  ray. 

5.  Antitoxins  and  vaccines. 

6.  Opotherapy :  The  use  of  glandular  substances, 
glandular  extracts  and  glandular  active  principles  as 
well  as  the  use  of  drugs  directly  affecting  the  activ- 
ities of  the  endocrine  glands. 

7.  Surgery. 

8.  Galvanism  :  Dissimilar  and  characteristic  effects 
of  positive  and  negative  poles. 

9.  Drugs,  including  ionization  by  galvanic  current. 

AGENTS    AFFECTING    CELLULAR  PHYSIOLOGY. 

1 .  Static  electricity ;  the  wave,  induced,  spark, 
spray,  brush  and  breeze.  2.  Bipolar  indirect ;  Tesla 
or  d'Arsonval  high  frequency  current  using  the 
effluve,  spark  or  vacuum  tube.  3.  Direct  bipolar 
application  causing  thermal  penetration  at  any  de- 
gree up  to  incineration  according  to  electrode  used. 
4.  Monopolar  high  frequency — Oudin  current.  5. 
High  frequency  condensation  and  induction.  6. 
Light  rays :  Krohmyer  or  Hanovia  lamp  or  low 
power  Mazda  lamps.  7.  Rontgen  and  radium  rays. 
8.  Drugs  which  can  be  carried  by  ionization,  with  a 
galvanic  current,  and  9,  Opotherapy. 


November  20,  1920.]  BARACH:  CHOLESTEROL  THORAX.  811 


THERAPEUTIC   AGENTS    WHICH   REMOVE   THE  DIS- 
ABLING CAUSES  OF  THE  SECOND  CLASS  OF 
DISABILITIES  BY  BEING  BACTERICIDAL 
WITHIN  THE  LIVING  TISSUES. 

Rontgen  ray  and  radium  ray ;  light,  especially 
ultraviolet  rays;  d'Arsonval  and  Tesla  bipolar  (in- 
direct and  direct)  ;  Oudin  current;  galvanic  positive 
electrode ;  antitoxins  and  vaccines,  and  antiseptic 
drugs,  especially  when  ionized  by  the  galvanic 
current. 

USE  OF  PHYSICAL  AGENTS. 

The  physical  agents  mentioned  are  directly  in- 
dicated in  cellular  therapy,  but  to  employ  them  suc- 
cessfully requires  an  intelligent  acquaintance  with 
the  physics  of  each  form  as  well  as  their  physiolog- 
ical effect,  and  this  also  implies  a  thorough  knowl- 
edge of  the  technic,  that  is,  the  machines  and 
apparatus,  their  dose  and  mode  of  optimum  appli- 
cation, to  obtain  the  desired  therapeutic  effect. 

These  physical  agents  have  been  much  neglected 
because  of  the  failure  of  medical  schools  to  ground 
their  students  in  the  science  of  physiology  and  the 
art  of  gymnastics,  the  science  of  nutrition  and  the 
art  of  dietetics,  the  science  of  electricity  and  the 
art  of  electrotherapeutics,  the  science  of  vibration 
and  the  art  of  massage  (molar,  cellular  and  mole- 
cular), the  science  of  radiant  energy  and  the  art  of 
phototherapy,  rontgen  tlierapy,  and  radiotherapy. 

This  neglect  has  led  our  fraternity  into  the  camp 
of  the  pharmaceutical  nihilist,  and  expectant  treat- 
ment which  is  but  one  step  removed  from  absent 
treatment  and  mental  healing.  It  has  led  us  to 
look  askance  at  what  we  did  not  understand  and  be 
satisfied  to  see  the  irregular  practitioner  seize  upon 
these  agents  as  his  peculiar  field  and  call  himself 
by  a  new  name.  It  has  permitted  medicine  to  hand 
over  to  surgery  many  conditions  which  should  never 
require  the  knife.  It  has  made  gynecology  almost 
synonymous  with  surgery. 

Cellular  therapeutics  demand  the  use  of  these 
agents.  It  will  be  impossible  to  make  therapeutic 
stabs  in  the  pathological  dark  when  we  turn  our 
attention  to  cellular  physiology  and  cellular  path- 
ology' because  we  will  practice  cellular  threapeutics. 

The  cell  is  the  unit  of  altered  structure  and  dis- 
ordered function. 


CHOLESTEROL  THORAX 

Report  of  a  Case. 

By  Joseph  H.  Barach,  M.  D., 
Pittsburgh,  Pa. 

Since  cholesterin  is  at  most  only  infrequently 
found  it  will  not  be  amiss  to  review  without  too 
much  detail  what  is  generally  known  about  its 
occurrence  in  the  body.  It  is  defined  as  a  mona- 
tomic  unsaturated  secondary  alcohol  or  a  complex 
terpene ;  its  chemical  formula  is  said  to  be  Co^H^gO. 
It  occurs  in  small  amounts  in  nearly  all  fluids  and 
juices  of  the  body ;  in  the  blood  and  lymph  it  exists 
as  a  fatty  acid  ester ;  in  the  bile  it  exists  in  a  free 
state.  Cholesterinemia  occurs  when  there  is  ob- 
struction to  the  free  flow  of  bile  into  the  intestines. 
It  is  especially  abundant  in  the  brain,  nerve  tissues. 


and  semen.  It  appears  in  the  contents  of  the  in- 
testine, in  the  excreta  and  in  meconium.  Ordinarily 
it  is  not  recognized  in  the  tissues,  but  under  certain 
pathological  conditions  necrotic  and  degenerative 
crystals  are  found.  They  occur  in  atheromatous 
areas  of  the  aorta,  in  arcus  senilis,  retinitis,  ather- 
omatous cysts,  in  pus,  in  sputum,  in  tuberculous 
masses,  old  transudates,  in  tumors  undergoing  ne- 
crosis, in  xanthomia  (xanthomia  tuberosa  multi- 
plex occurring  about  the  joints),  in  gallstones,  in 
old  inflammatory  processes  of  the  tunica  vaginalis 
and  testes  with  hydrocele,  in  fluid  long  retained  in 
a  shut  off  gallbladder,  and  in  old  pericardial  eft'u- 
sions.  From  the  sites  enumerated  above,  it  may 
readily  be  seen  that  in  certain  locations  following 
the  accumulation  of  fluid,  if  that  fluid  remains 
stagnant  for  a  sufficient  length  of  time,  a  deposit, 
or  a  crystallization  of  cholesterin,  may  occur. 

The  fluid  of  cholesterol  thorax  may  be  mistaken 
for  chylous  or  pseudochylous  fluid  if  one  were  to 
rely  upon  the  macroscopic  appearance  of  the  fluid. 
True  chyle  will  show  a  fat  content  of  about  ten 
per  cent,  and  small  fat  globules,  while  pseudochy- 
lous fluid  will  have  a  fat  content  of  about  one  half 
of  one  per  cent.,  and  its  fat  globules  are  much 
larger.  Whereas  the  chylous  fluids  are  milky  in 
appearance,  the  cholesterol  fluids  are  more  of  the 
color  of  butter. 

Case. — Air.  J.  H.,  aged  sixty-seven,  a  native  of 
Ireland,  a  laborer,  was  admitted  to  my  service  in 
the  medical  ward  of  the  Presbyterian  Hospital  on 
December  8,  1919.  He  had  just  recovered  from  a 
right  apical  pneumonia.  His  history  revealed  the 
fact  that  his  last  illness  had  occurred  thirty  years 
ago,  prior  to  his  coming  to  this  country.  At  that 
time  he  suffered  from  an  attack  of  pleurisy,  with 
which  he  was  ill  for  two  months.  Since  that  time 
he  had  worked  regularly  for  thirty  years,  and  did 
not  recall  that  he  had  experienced  any  physical 
discomfort. 

Physical  examination  revealed  a  poorly  nour- 
ished man,  with  marked  arcus  senilis ;  his  radials 
and  other  superficial  vessels  contained  numerous 
atheromatous  areas  and  were  of  pipe  stem  hardness. 
His  cardiac  dullness  was  increased  to  the  right,  left 
border  extended  10.5  cm.  from  the  median  line. 
Epigastric  pulsation  was  prominent.  No  murmurs 
could  be  detected.  The  first  diagnosis  was  chronic 
myocarditis,  but  later  events  warranted  our  giving 
up  this  diagnosis.  When  the  effusion  was  removed, 
the  heart  settled  down  to  a  simple  sinus  irregularity 
and  showed  no  evidences  of  myocardial  deficiency. 

Examination  of  the  lungs  showed  that  his  right 
apical  pneumonia  had  not  completely  resolved.  On 
the  left  were  found  the  usual  physical  signs  of 
pleural  effusion.  This  diagnosis  was  verified  im- 
mediately by  aspirating.  His  temperature  for  two 
days  had  been  not  over  100°  F.,  his  pulse  rate  90- 
100,  but  his  respiratory  rate  was  32-40.  He  had 
leucocytosis  and  lymphocytosis.  The  aspirated  fluid, 
which  presented  the  physical  appearance  of  pus  and 
was  entirely  odorless,  was  sent  to  the  laboratory  for 
culture.  The  following  report  on  the  examination 
was  wholly  unexpected :  No  pus  cells,  no  bacteria, 
sediment  consists  of  rhomboid  crystals — cholesterin. 

The  following  day,  with  an  aspirator  we  removed 


812 


CRAMPTON:   GOOD  POSTURE. 


[New  York 
Medical  Journal. 


450  c.  c.  of  this  fluid,  which  gave  the  patient  con- 
siderable relief.  Two  days  later  physical  examina- 
tion revealed  a  characteristic  metallic  tinkling  and 
other  evidences  of  pneumohydrothorax.  This  was 
verified  by  fluoroscopic  examination.  His  condition 
did  not  change  much  and  twenty  days  later,  owing 
to  a  reaccumulation,  we  removed  960  c.  c.  of  fluid 
of  the  same  character.  After  this  he  steadily  im- 
proved, and  was  walking  about  two  weeks  later. 
At  no  time  did  we  find  evidences  of  a  lung  abscess 
or  a  tuberculous  infection. 

The  history  and  course  of  this  case  suggests  a 
latent  pleural  eflfusion  with  precipitation  of  choles- 
terin,  and  after  the  first  aspiration,  a  reaccumulation 
of  serum.  The  fistula  from  which  metallic  tinkling 
occurred  was  probably  produced  by  removal  of  the 
fluid  which  had  acted  as  a  support  to  the  atelectatic 
lung.  I  have  previously  explained  how  metallic 
tinkling  is  produced  (1).  That  the  lower  lobe  of 
the  left  lung,  was  collapsed  was  seen  at  the  fluoro- 
scopic and  radiographic  examination. 

To  the  naked  eye  the  fluid  in  this  case  appeared 
to  be  light  yellow  in  color,  of  the  shade  of  butter. 
Upon  standing,  it  separated  into  two  parts,  the 
lower  half  being  fatty,  and  the  upper  being  a 
slightly  opalescent  straw  colqred  fluid.  Microscopic 
examination  showed  no  fat  globules,  no  pus  cells, 
and  no  bacteria.  The  only  visible  constituents  were 
the  characteristic  rhomboid  cholesterin  crystals.  The 
reaction  to  Benedict's  solution  for  sugar  was  nega- 
tive. The  fluid  showed  no  changes  after  standing 
twelve  months. 

Two  cases  of  cholesterin  in  pleural  eft'usions  were 
recently  reported  by  Sharpe  (2).  The  first  case 
occurred  in  an  adult,  thirty- four  years  of  age,  who 
had  an  encysted  pleural  effusion  with  a  straw 
colored  fluid,  containing  some  cells.  The  cells  were 
polynuclears  eight  per  cent.,  endothelial  fifteen  per 
cent.,  and  lymphocytes  seventy-seven  per  cent.  After 
aspiration  the  patient  recovered  and  worked  for 
six  years.  In  the  seventh  year  he  had  a  recurrence 
of  symptoms  referable  to  the  chest,  and  aspiration 
showed  a  fluid  free  from  cellular  elements  contain- 
ing many  cholesterin  crystals.  The  sputum  showed 
tubercle  bacilli. 

The  second  case  occurred  in  a  male  child  who 
at  the  age  of  two  years  had  an  empyema.  Seven 
years  later  symptoms  developed  and  a  left  pleural 
effusion  was  diagnosed.  One  and  a  half  pints  of 
spangled  fluid  were  removed.  One  month  later  the 
patient  was  again  tapped  and  fifty-six  ounces  of 
fluid  containing  cholesterin  crystals  were  removed. 
At  a  third  tapping  two  pints  of  pus  were  removed. 

Alexander  has  also  reported  a  case  of  pericardial 
effusion  in  which  the  fluid  had  the  appearance  of 
gold  paint,  produced  by  cholesterin  crystals.  The 
patient  was  a  male,  aged  thirty-two,  who  had  been 
complaining  of  symptoms  for  the  past  five  years, 
which  were  diagnosed  as  hypothyroidism.  Super- 
imposed upon  these  were  cardiac  symptoms  of  a 
few  months'  duration  which  led  to  the  diagnosis  of 
a  pericardial  effusion.  He  was  discharged  from  the 
hospital  after  six  weeks  and  resumed  his  work. 
Thirteen  weeks  later  he  was  readmitted,  his  peri- 
cardium was  aspirated  and  three  pints  of  scintil- 
lating gold  paint  were  removed.    At  tlie  end  of 


two  months  the  patient  left  the  hospital  free  from 
symptoms. 

Comment. — One  thing  stands  out  clearly  in  the 
cases  here  cited,  and  that  is,  in  not  one  of  them 
did  the  cholesterol  deposit  occur  at  the  time  of  the 
primary  attack  upon  the  diseased  part.  The  de- 
posit or  precipitation  of  cholesterin  crystals  occurred 
in  inflammatory  exudates  within  serous  sacs,  fol- 
lowing the  subsidence  of  acute  inflammatory  pro- 
cesses. The  cases  cited  show  that  the  antecedent 
history  of  a  deposit  of  cholesterol  may  be  five  or 
as  long  as  thirty  years. 

REFERENCES. 

1.  Norris-Landis  :  Diseases  of  the  Chest,  Second  Edi- 
tion, p.  131,  W.  B.  Saunders  Company,  Philadelphia,  1920. 

2.  Sharpe:  British  Medical  Journal,  October  11,  1919. 

3.  Alexander  :  Ibid. 


UNDERLYING  FACTORS  IN  GOOD 
POSTURE.* 
By  C.  Ward  Cramptox,  M.  D. 

Battle  Creek,  Mich. 

Gravity  is  continually  pulling  down  the  human 
body.  The  erect  position  of  man  makes  him  pecu- 
liarly subject  to  its  influence.  He  is  balanced  upon 
a  small  base  and  must  necessarily  keep  his  balance 
lest  he  fall.  At  various  places  in  his  anatomy  there 
are  joints  which  must  be  kept  from  bending  too  far, 
for  the  more  nearly  vertical  the  body  is  held,  the 
less  force  need  be  exerted  to  hold  it  erect.  The 
ankle,  knee,  hip  and  the  whole  spinal  column  up  to 
the  cranium  must  be  kept  in  balance  with  the  super- 
incumbent weight  squarely  above.  The  contents  of 
the  trunk  are  inore  fluid  and  tend  to  flow  down- 
ward.   They  also  must  be  held  up  against  gravity. 

Bad  posture  is  essentially  a  ptosis  or  a  group  of 
ptoses.  Ptosis  is  a  downward  displacement  or  de- 
pression of  the  various  body  parts.  It  is  found  in 
the  drooping  of  the  head,  shoulders,  ribs ;  frequently 
in  the  depression  of  the  stomach,  intestines,  and 
other  abdominal  organs ;  in  forward,  backward  and 
lateral  curvatures  of  the  spine.  Any  of  these  gives 
the  body  an  appearance  of  sagging  downward.  There 
are  four  kinds  of  ptosis ;  skeletal,  visceral,  circulatory 
and  emotional.  They  are  more  often  found  asso- 
ciated than  singly.  Each  syinptom  evidences  a  con- 
dition which  is  the  result  of  low  vitality  and  which 
in  turn  tends  to  cause  low  vitality,  thereby  estab- 
lishing a  vicious  circle. 

TYPES  OF  PTOSIS 

Skeletal  ptosis  is  the  downward  displacement  of 
bones,  and  is  shown  in  the  drooping  of  the  head, 
the  exaggeration  of  the  normal  curves  of  the  spine, 
the  falling  in  and  down  of  the  chest.  These  caiise 
a  decrease  in  standing  height  as  compared  with  hori- 
zontal length,  a  comparison  which  is  a  definite  test 
of  poor  skeletal  posture.  The  less  the  decrease  in 
the  standing  height,  the  better  the  posture.  Skeletal 
ptosis  is  caused  by  weak  tone,  or  the  relaxation  or 
chronic  weariness  of  the  muscles  which  hold  the 
body  erect.  It  is  the  natural  adjustment  of  the 
body  to  fatigue. 

*Address  of  Temporary  President  of  the  Association  of  Insti- 
tutions Giving  Normal  Instruction  in  Physical  Training  delivered 
at  Waldorf-Astoria,  New  York  City,  April  10,  1920. 


November  20,  1920.] 


CRAMPTON:   GOOD  POSTURE. 


813 


Visceral  ptosis  is  the  downward  displacement  of 
the  internal  organs  and  is  usually  accompanied  by 
skeletal  ptosis.  It  may  be  local,  that  is,  one  organ 
only  may  be  displaced;  or  general,  in  which  case 
the  whole  body  contents  sag  downward.  In  the 
latter  case  the  chest  is  flattened,  its  capacity  is  de- 
creased, and  the  abdomen  becomes  protuberant,  the 
lower  ribs  often  bulging.  It  is  the  result  of  consti- 
tutional inferiority,  low  vitality  or  bad  habit.  Its 
presence  may  be  ascertained  by  percussion  of  the 
organs  to  determine  their  position,  by  the  use  of  the 
X  ray  and  by  comparing  the  girth  of  the  chest  and 
the  abdomen. 

Circulatory  ptosis  is  the  downward  displacement 
of  blood  and  its  collection  in  the  abdominal  veins 
and  arteries.  The  splanchnic  veins  in  the  abdomen 
form  the  most  capacious  system  of  blood  vessels  in 
the  body,  and  if  they  are  relaxed  and  distended,  a 
large  amount  of  the  blood  which  should  be  in  other 
parts  of  the  body  drains  into  them.  In  the  erect 
position,  these  vessels  continually  work  against  the 
force  of  gravity.  They  are  kept  from  distention  by 
the  contraction  and  tone  of  the  muscles  in  their 
walls,  which  are  under  sympathetic  nervous  control, 
and  by  the  contraction  and  tone  of  the  walls  of  the 
abdomen.  If  there  is  an  insufficiency  of  nervous 
control  or  if  the  abdominal  wall  is  weak,  permitting 
relaxation,  the  resistance  to  the  pressure  of  gravity 
is  lessened  and  ptosis  results. 

An  emotional  ptosis  is  a  depression  of  the  spirits. 
The  terms  dejected,  depressed  and  downcast  are  all 
derived  from  descriptions  of  physical  states.  By 
racially  old  practice  and  habit  these  expressions  are 
applied  to  emotional  states  and  refer  to  unpleasant 
feelings  of  the  asthenic  type.  .Other  more  or 
less  colloquial  terms  are  downhearted  and  down-in- 
the-mouth.  These  terms,  descriptive  of  emotional 
ptosis,  derived  from  physical  conditions,  indicate  the 
correlation  between  the  m.ental  and  the  physical. 

CORRELATION  OF  PTOSES 

All  four  ptoses  as  a  rule  occur  together.  Any 
one  of  them  tends  to  cause  the  others  but  the  rela- 
tion of  ptoses  to  each  other  is  not  primarily  that  of 
cause  and  effect.  They  are  related  to  each  other 
mainly  as  eflfects  of  a  common  cause,  to  \Vit,  lowered 
vitality. 

Ptoses  are  likely  to  occur  after  illness,  a  period  of 
loss  of  sleep,  chronic  digestive  disturbances  and  the 
like.  Therefore,  ptoses  are  not  to  be  removed  per- 
manently without  the  removal  of  the  common  cause, 
i.  e.  lowered  vitality — the  very  term  in  itself  ex- 
pressing a  ptosis.  There  are,  however,  various  other 
influences  which  bear  upon  the  case. 

Hereditary  maladjustment. — The  biological  causes 
of  bad  posture  are  disharmonies,  which  correspond 
to  the  same  forms  of  ptosis.  These  are  due  to  the 
fact  that  evolution  has  brought  the  body  from  a  pos- 
ture of  locomotion  on  all  fours  with  the  trunk  hori- 
zontal, up  through  gradual  stages  to  the  posture  with 
the  trunk  erect.  The  body  has  not  yet  sufficiently 
adapted  itself  to  the  'change,  and  the  various  dishar- 
monies remain. 

Skeletal  disharmony. — The  head,  instead  of  be- 
ing in  the  long  axis  of  the  body,  has  rotated  ninety 
degrees  to  this  axis.  It  is  kept  erect  by  muscular 
force  only  and  tends  to  go  forward  and  downward  if 


the  muscles  are  weak.  Of  the  changes  in  articu- 
lation, the  hip  changes  and  neck  changes  are  rela- 
tively well  adjusted.  The  arch  of  the  foot  presents 
a  skeletal  disharmony  of  the  worst  type;  the  weight 
of  the  body  comes  on  the  arch,  which  was  never 
meant  for  that  purpose.  Frequently  the  arch  breaks 
down,  causing  flat  foot. 

Visceral  disliarmony. — In  the  old  horizontal  posi- 
tion of  the  trunk,  the  internal  organs  hung  from 
their  attachments  to  the  spinal  column  with  suffi- 
cient room  and  in  proper  interrelationship.  In 
the  erect  position  they  hang  from  the  rear  rather 
than  from  the  top  of  the  abdominal  cavity.  The 
intestines  are  heaped  in  the  bottom  of  the  abdominal 
chamber  and  constipation  and  autointoxication  re- 
sult. The  contents  of  the  chest  rest  upon  the  dia- 
phragm, which  in  turn  presses  upon  the  intestines. 
The  abdominal  wall  tends  to  relax,  allowing  the 


Fig.  1. 

Good  Posture.  Poor  Posture      Good  and    Poor  Posture 


whole  body  contents  to  sag  down  upon  the  pelvis 
and  causing  the  abdomen  to  protrude.  The  best 
that  can  be  done  to  relieve  this  condition  is  to  keep 
the  chest  raised  and,  by  means  of  strong  lower  ab- 
dominal muscles,  to  keep  the  intestines  from  crowd- 
ing down. 

Circulatory  disharmony. — Our  physical  machinery 
is  relatively  weak  because  of  the  change  of  position 
from  the  horizontal  to  the  erect.  Because  it  is  re- 
cent biologically,  it  is  easily  wearied,  and  allows  the 
blood  and  lymph  to  go  down  in  response  to  the 
influence  of  gravity.  Circulatory  disharmony  is 
evidenced  in  the  difficulty  that  is  experienced  in 
getting  the  blood  returned  from  the  feet  up  to  the 
right  side  of  the  heart.  This  is  accomplished  by 
the  action  of  the  leg  muscles,  the  contraction  and 
tone  of  the  muscles  of  the  abdomen,  which  helps  to 
force  the  blood  upward  and  the  suction  of  the  chest 
(aspiration  of  the  thorax),  which  lifts  the  blood 
out  of  the  abdomen  and  delivers  it  to  the  heart. 
Circulatory  ptosis  is  relieved  by  increasing  the  tone 
and  contraction  of  the  abdominal  walls,  and  by 
raising  the  chest,  which  increases  the  thoracic  aspira- 


814 


CRAMPTON:   GOOD  POSTURE. 


[New  York 
Medical  Journal. 


tion,  but  most  of  all  by  increasing  the  tone  and 
vitality  of  the  muscles  in  the  blood  vessels  of  the 
abdomen  by  hygienic  measures. 

Lack  of  vitality  or  tone. — Anything  that  causes 
lower  vitality,  anything  that  works  against  health, 
and  anything  that  works  against  happiness,  increases 
the  tendency  toward  bad  posture.  Bad  posture  is 
not  so  much  a  cause  of  low  vitality  as  it  is  a  sign 
or  expression  of  past  or  present  physical  or  mental 
depression.  If  the  person  is  sick  or  hurt,  the  skel- 
etal muscles  lose  tone  and  the  body  droops ;  if  the 
mind  is  dejected  and  low  spirited,  the  physical  atti- 
tude corresponds  to  the  mental  state.  Body  and 
mind  are  depressed  together. 

Posture  and  efficiency. — It  has  been  established  by 
statistical  tests  that  physical  or  mental  defect  or 
weakness  is  related  to  poor  posture.  The  average 
record  of  pupils  in  the  poor  posture  group  has  been 
found  to  be  appreciably  lower  than  the  good  posture 
group  in  attendance,  in  deportment,  in  physical 
activity  and  endurance,  in  manual  training,  and  in 
commercial  success  after  leaving  school.  It  is  clear 
that  anything  that  lowers  vitality  causes  bad  posture. 
To  what  extent  bad  posture  causes  poor  vitality  is 
not  accurately  known.  It  is  certain  that  by  assum- 
ing good  posture,  raising  the  chest  and  head,  one 
feels  better.  This  is  partly  psychological  and  partly 
due  to  an  actual  improvement  in  the  circulation  of 
the  blood. 

Limitation  of  corrective  measures. — In  the  en- 
deavor to  correct  bad  posture  by  removing  causes 
which  result  in  ptosis,  nothing  can  be  done  about 
hereditary  disharmonies,  and  little  is  possible  in 
resisting  the  influence  of  gravity,  except  the  seek- 
ing of  proper  rest  and  the  habitual  assumption  of 
corrective  positions ;  but  in  overcoming  the  third 
factor,  lack  of  vitality  or  tone,  physical  training 
finds  its  great  opportunity. 

The  essentials  of  tone. — The  body  is  kept  erect 
by  bones,  muscles,  and  ligaments.  The  muscles 
keep  the  bones  and  ligaments  in  position.  Thus,  if 
the  muscles  are  strong  and  in  good  tone,  they  will 
hold  the  body  parts  up  properly,  the  posture  will  be 
good,  the  trunk  erect,  the  chest  up  and  the  head 
held  high.  These  are  the  signs  of  vitality.  On  the 
contrary,  if  the  vitality  is  low,  the  body  yields  to 
the  influence  of  gravity  and  relaxes.  Muscular  tone 
continually  works  against  this  influence.  It  is  de- 
pendent upon  muscular  training  and  upon  the  power 
of  the  nervous  system  which  presides  over  the  nutri- 
tion of  the  muscles.  This  applies  to  both  the  skel- 
etal muscles  and  the  muscles  of  the  veins  of  the 
abdomen  which  control  blood  ptosis. 

The  muscular  element  in  muscular  tone'. —  1.  The 
nutrition  of  the  muscles  which  keep  the  trunk  erect, 
chest  high  and  abdomen  flat  in  a  large  part  deter- 
mines their  tone  and  their  success  in  doing  the  work 
for  good  posture.  Hence,  good  food,  fresh  air  and 
the  like  are  fundamental  to  good  posture.  2.  The 
actual  strength  of  the  muscles  is  important,  for  they 
must  be  kept  in  a  state  of  semicontraction,  holding 
the  body  straight  and  its  parts  adjusted  and  high. 
The  stronger  they  are,  within  reasonable  limits,  the 
better.  Hence,  they  must  get  sufficient  special  exer- 
cise. 3.  The  muscles  which  hold  body  parts  in  good 
position  against  gravity  must  acquire  the  structural 


habit  of  being  short,  for  lengthening  means  giving 
way,  and  permits  their  loads  to  droop  and  fall  to 
lower  positions.  Muscles  tend  to  assume  the  state 
in  which  they  are  most  used ;  hence,  if  we  desire 
short  muscles,  we  must  exercise  them  in  a  shortened 
state.  Thus,  we  use  exercises  in  which  the  move- 
ment is  confined  to  the  proxal  (nearest  to  the  trunk), 
third  or  half  of  the  arc  or  movement,  and  in  this 
we  emphasize  complete  contractions  of  the  muscles 
we  desire  to  shorten. 

The  nerve  element  in  muscular  tone. — Muscular 
tone  is  a  continual  unnoticed  contraction  of  the 
muscle  which,  though  practically  static,  is  really  due 
to  nerve  impulses  flowing  to  the  muscle  along  the 
motor  nerve  at  the  rate  of  twelve  to  twenty  impulses 
a  second.  These  impulses  come  from  the  motor  cells 
in  the  interior  of  the  spinal  cord  and  are  vigorous 
or  weak  according  to  their  nutrition  and  the  amount 
of  fatigue.  When  they  are  well  nourished  and 
fresh,  the  muscular  tone  is  good.  When  they  are 
overcome  or  exhausted,  the  muscular  tone  is  cor- 
respondingly poor.  Hence,  nutrition  and  rest  have 
an  increased  significance  in  posture. 

When  the  motor  nerve  is  cut  or  the  motor  cells 
are  destroyed  by  disease,  as  in  infantile  paralysis, 
the  muscle  loses  its  tone,  becomes  weak  and  anemic 
and  ceases  to  grow;  it  becomes  atrophic.  This 
proves  that  the  motor  cells  preside  over  the  nutri- 
tion of  the  muscles,  sending  them  continually  what 
is  called  the  trophic  force.  This  indicates  again  the 
role  the  nervous  system  plays  in  muscle  condition. 

The  important  little  muscles  surrounding  the 
arteries  and  veins  are  supplied  with  nerves  coming 
from  centres  in  various  parts  of  the  body  called 
sympathetic  ganglia,  and  are  dependent  upon  them 
in  much  the  same  way  as  the  voluntary  muscles  are 
dependent  upon  the  cells  of  the  spinal  cord.  Since 
these  muscles  control  the  distribution  of  the  blood, 
and  particularly  prevent  blood  ptosis,  the  condition 
of  the  sympathetic  nervous  system  is  of  great 
importance. 

The  digestive  glands — the  liver  and  the  pancreas 
and  the  muscular  walls  of  the  stomach  and  intestines 
— are  all  directed  and  managed  by  the  sympathetic 
nervous  system.  Thus  the  nerve  centres  direct  pro- 
cesses upon  which  they  themselves  depend  for  nour- 
ishment. 

The  photographs  of  the  excellently  built  young 
man  should  be  studied  carefully,  for  they  illustrate 
the  important  points  in  the  discussion  of  posture. 
The  photographs  were  taken  within  a  few  minutes 
of  each  other.  The  subject  remained  standing  with 
his  feet  in  the  same  place.  The  only  difference  is 
in  his  slumping  from  good  posture  to  bad.  The 
cigarette  is  included  because  the  bad  posture  pro- 
duced is  a  perfect  representation  of  that  pose  of 
chronic  lassitude,  the  effect  of  excessive  cigarette 
smoking. 

The  decrease  in  total  height  amounts,  in  this  case, 
to  four  and  a  half  inches.  This  is  not  the  result 
of  bending  the  knee,  fc>r  the  right  leg  is  just  as 
straight  as  it  was  in  good  posture.  The  decrease 
in  height  comes  from  the  slumping  down  of  one  side 
of  the  pelvis,  the  increase  in  the  curves  of  the  lum- 
bar, dorsal  and  cervical  spine. 

The  illustration  shows  clearly  the  downward  dis- 


November  20.  1920.] 


CRAMPTOX:   GOOD  POSTURE. 


815 


placement  of  the  dilterent  parts  of  the  body,  which, 
summed  up,  make  the  difference  in  the  total  height. 
The  head  is  downward,  tilted  forward,  hanging 
heavily  upon  the  posterior  neck  muscles  instead  of 
being  evenly  poised  on  the  cervical  vertebrae.  The 
shoulders  go  downward.  It  will  be  seen,  however, 
that  they  do  not  go  forward,  but  the  chest  rolls 
downward  under  the  arm,  and  the  back  protrudes 
outward.  Notice  the  whole  downward  displacement 
of  the  chest  and  the  disappearance  of  the  line  of 
the  lower  ribs. 

In  good  posture  the  outline  of  the  body  from  the 
neck  downward  over  the  abdomen  is  convex,  par- 
ticularly over  the  thorax.  In  bad  posture  this  line 
is  concave  except  for  the  slight  projection  of  the 
pectoral  muscles.  The  chest  in  good  posture  is  deep, 
the  abdomen  slim.  In  bad  posture  the  contents  of 
the  abdomen  simply  drop  downward  and  cause  a 
bulge  at  the  lower  waistline.  The  two  photographs 
clearly  show  the  difference  in  aspect.  The  one  pos- 
ture is  high,  straight,  elevated,  inspired  and  strong : 
the  other  lax,  depressed,  downcast  and  weak. 

HOW  TO  GET  GOOD  POSTURE 

1.  Description.- — In  our  endeavor  to  get  good  pos- 
ture, children  should  be  informed  in  a  lively  in- 
teresting way  as  to  what  it  is.  Emphasis  should  be 
placed  upon  the  high  head,  lifted  chest,  straight  back, 
etc.,  choosing  words  which  will  be  of  use  afterward 
as  elevation  cues.  Little  time,  however,  need  be 
wasted  upon  description  for  the  most  important 
thing  for  the  people  to  know  is  how  it  feels  to  stand 
in  good  posture.  Before  the  class,  the  teacher 
should  demonstrate  the  various  points  contrasting  the 
good  high  erect  posture  with  the  lowered  poor  pos- 
ture. 

2.  Demonstration. — The  teacher  of  physical  train- 
ing experiences  the  greatest  difficulty  in  making  his 
pupils  understand  just  why  their  postures  are  wrong, 
and  furthermore  what  kind  of  effort  they  should 
make  to  correct  the  bad  postures.  This  was  the 
great  fundamental  difficulty  in  the  endeavor  to  get 
school  children  to  stand  up  straight.  They  had  been 
told  to  stand  up  straight,  but  did  not  know  how. 
Usually  they  threw  the  shoulders  back  and  in  an 
endeavor  to  throw  the  chest  out,  stick  oiit  the 
stomach,  drawing  the  hips  forward,  stiffening  the 
arms  straight  down  to  the  sides  like  pokers.  This 
is  wrong. 

3.  Experience  in  good  posture. — There  are  vari- 
ous devices  used  to  put  children  in  good  posture. 
The  first  one  is  the  use  of  commands  called  eleva- 
tion cues  because  they  are  calculated  to  work  against 
ptoses.  The  most  important  of  these  are  as  follows : 
Stand  tall,  head  up,  head  high,  lift  the  head,  stretch 
the  head  upward,  chest  high,  and  lift  the  chest. 

Waist  flat,  lift  the  waist  up,  stretch  the  knees,  lift 
upward  from  the  ankle,  and  stretch  the  body  up- 
ward— all  these  cues  result  in  increased  action  of 
the  muscles  which  keep  the  body  erect.  Additional 
colloquial  adjurations  may  be  used  by  the  teacher 
such  as,  "try  to  make  the  head  touch  the  ceiling," 
"stand  as  if  you  were  looking  over  a  fence,"  "pick 
up  your  ears,"  "make  believe  you  are  a  soldier," 
"grow  up  tall,"  etc.  The  commands  "chest  out," 
"shoulders  back,"  "hips  back,"  "chin  in"  and  others 
calling  for  anterolateral  adjustments  are  discarded. 


Words  alone  will  not  bring  results.  A  pupil 
who  cannot  take  correct  posture  exercises  may  be 
stood  up  with  back  against  the  wall  and  a  book 
placed  upon  his  head.  Feeling  the  wall  on  his  back 
he  will  straighten  up  and  try  to  be  as  tall  as  possible. 
Placing  the  hand  on  the  abdomen  and  pressing  in  and 
up  will  help  him  decrease  the  lumbar  curve.  Stretch- 
ing the  arms  down  at  the  side,  still  keeping  the 
shoulders  and  hips  back  against  the  wall  will  help 
him  straighten  up  taller. 

Once  good  posture  is  obtained,  a  pupil  should 
leave  and  go  about  his  ordinary  business,  sitting, 
standing,  working  or  exercising,  but  always  main- 
taining the  high  head  and  chest  position.  A  full 
'length  mirror  in  w'hich  pupils  can  see  their  defects 
and  finally  their  good  posture,  is  valuable  to  good 
posture  work.  Every  well  equipped  gymnasium 
should  have  a  double  or  triple  mirror  permitting  the 
pupil  to  see  himself  in  profile. 

STATIC  EXERCISES 

The  use  of  the  wall  and  the  mirror  confine  the 
teacher's  attention  to  the  individual.  There  are  cer- 
tain static  exercises  which  may  be  used  for  the  wdiole 
class.  These  were  the  only  good  posture  exercises 
which  I  put  into  official  use  for  all  of  the  eight  hun- 
dred thousand  children  in  the  public  schools  of  New 
York  city,  not  because  there  are  not  other  good 
exercises  but  because  these  are  the  simpler  and  most 
effective.  It  has  been  found  when  these  exercises 
are  taken  there  is,  by  the  process  of  association,  a 


Fig.  2. 

Static  Exercise  Xo.  1.  Static  Exercise  No.  2. 

straightening  up  of  the  body.  It  is  necessary,  how- 
ever, to  use  them  correctly. 

Exercise  1. — Stand  erect,  stretch  the  arms  down- 
ward at  the  side,  pointing  the  fingers  forward,  bend- 
ing the  hands  back  on  the  wrists  so  the  palms  are 
horizontal  to  the  floor.  \Mien  you  have  assumed 
this  position,  the  exercise  has  only  begun.    It  is 


816 


BARNES:  ASTIGMA TISM. 


[New  York 
Medical  Journal. 


necessary  for  you  to  press  down  as  hard  as  possible 
toward  the  floor,  still  maintaining  the  hands  in  ex- 
actly the  same  position,  in  the  meanwhile  lifting 
the  chest  and  head  and  endeavoring  to  straighten  up 
as  vigorously  as  possible.  This  will  raise  the  chest, 
lift  the  head  and  stretch  the  body  most  effectively. 


Fig.  3. 

Static  Exercise  No.  3.  Static  Exercise  No.  4. 


This  position  should  be  held  from  five  to  ten  seconds. 
The  hands  and  wrists  are  then  released,  and  the 
body  should  remain  erect  and  poised  high.  The 
body  should  never  be  allowed  to  slump. 

When  the  initial  position  is  taken,  there  is  a 
tendency  to  take  a  full  breath  and  to  hold  it  dur- 
ing the  whole  of  the  exercise.  At  the  end  of  ex- 
ercise the  tendency  is  to  let  the  breath  out  and  to 
slump  again.  The  subject  should  practice  breath- 
ing in  and  out  in  this  upwardly  held  position.  In 
giving  this  exercise  to  children  it  is  necessary  to  give 
them  helpful  upward  stretching  commands  when  the 
position  is  held.  These  are  stand  tall,  raise  the 
chest,  press  down  on  the  hands,  stretch  upward  from 
the  ankles,  stretch  the  knees,  and  the  like.  These 
elevation  cues  are  quite  as  important  to  the  success 
of  the  procedure  as  the  a:tual  exercise  itself. 

Commands. — 1,  Bending  wrists  backward,  palms 
toward  floor,  bend ;  2,  Press  hard !  Push  down !  Lift 
the  chest.  Stand  tall ;  3,  Holding  the  head  and  chest 
up  !  wrists — Relax. 

Exercise  2. — Raising  the  arms  sideways,  palms 
turned  up  at  the  level  of  the  eyes.  In  this  position 
the  hands  are  flattened  and  pressed  up,  lifting  the 
arms,  at  the  same  time  trying  to  stand  as  tall  as 
possible,  lifting  the  chest  and  stretching  upward 
from  the  ankles  and  knees. 

Commands. — 1,  Stretching  arms  sideward  height 
of  eyes,  palms  up — Stretch!  2,  (Elevation  cues.) 
Lift!  Press  up!  Stretch  up!  Stand  tall!  3,  Keeping 
head  and  chest  up ;  arms — Down. 


Exercise  3. — Bending  arms  forward  at  shoulder 
level.  Palms  should  be  perfectly  flat  and  hands  free 
from  the  chest.  The  same  endeavor  should  be  made 
to  lift  the  hands  as  high  as  possible,  and  this  will  lift 
the  chest  and  straighten  the  body. 

Commands. — 1.  Bending  arms  at  shoulder  level — 
Bend;  2.  Elevation  cues;  3.  Keeping  head  and 
chest  up,  arms — Down. 

Exercise  4. — Finger  tips  on  shoulders,  wrist  high, 
elbows  to  the  side.  In  this  position  an  effort  should 
be  made  to  lift  the  wrists  as  high  as  possible  without 
permitting  the  finger  tips  to  leave  the  shoulders. 
The  same  results  are  obtained,  lifting  the  head  and 
chest  and  straightening  the  body. 

Commands.- — 1,  Finger  tips  on  shoulder,  wrist 
high,  elbows  up, — Place;  2,  (Elevation  cues.)  Raise 
the  chest.  Lift  the  head.  Stretch  up.  Waist  flat. 
Lift  up  the  waist ;  3,  Keeping  head  and  chest  up, 
arms — Down. 

These  static  exercises  should  be  used  at  the  be- 
ginning of  every  physical  training  lesson  and  in  the 
relief  exercises  taken  between  class  periods.  Em- 
phasis should  be  f^laced  on  the  elevation  cues  while 
the  uplifted  position  is  being  held.  They  not  only 
lift  the  head  and  chest  but  they  actually  lift  the 
abdominal  viscera  and  relieve  blood  ptosis  as  well. 

The  second  class  of  good  posture  exercises  are 
those  which  strengthen  the  muscles  that  hold  up 
the  head,  chest  and  various  body  parts  against  grav- 
ity. In  order  for  one  to  have  good  posture,  these 
sustentacular  muscles  should  be  constantly  exercised 
and  strongly  developed. 

(To  be  concluded.) 


THE  CAUSE  OF  ASTIGMATISM. 

By  George  Edwaed  Barnes,  M.  D., 
Herkimer,  N.  Y. 

What  is  the  cause  of  ordinary  astigmatism? 
Examining  eyes  for  glasses  is  one  thing  that  I  do 
not  do,  so  I  have  little  opportunity  to  investigate 
this  problem.  However,  I  have  an  idea  which  I 
believe  is  correct.  Judging  from  the  history  of 
patients,  astigmatism  often  appears  at  the  same  time 
when  more  or  less  general  ill  health  appears.  When 
ophthalmologists  find  astigmatism  in  patients'  eyes 
it  seems  to  be  the  prevailing  opinion  that  the  patients 
have  always  had  it  and  that  they  have  only  recently 
been  bothered  by  it. 

Undoubtedly  some  cases  of  astigmatism  date 
from  the  earliest  days  of  life,  but  I  do  not  believe 
by  any  means  that  all  cases  do.  Intelligent  patients 
observe  a  sharp  transition  from  many  years  of  per- 
fect and  comfortable  vision  to  a  time  of  blurred 
and  uncomfortable  (astigmatic)  vision.  They  state 
on  being  questioned  that  their  general  health  became 
somewhat  impaired  at  the  same  time.  This  is  most 
significant.  Any  sickness  which  directly  or  in- 
directly affects  the  sympathetic  and  autonomic  nerv- 
ous systems  (1)  may  directly  or  indirectly  alter 
the  tension  of  the  eyeball  and  thereby  change 
its  curvature.  Chronic  emotional  disturbances  ( 1 ) 
through  the  sympathetic  and  autonomic  nervous 
systems  aflfect  the  general  blood  pressure,  which 
in  turn  affects  the  ocular  tension  and  these  emo- 
tional   disturbances    also    afifect    the    activity  of 


November  20,  1920.] 


COOPER:  ERYSIPELAS  AND  LOSS  OF  VISION. 


817 


Mueller's  muscle.  I  have  never  seen  or  heard  it 
stated  that  the  general  blood  pressure  had  any  influ- 
ence on  the  ocular  tension,  but  it  seems  to  me  that 
it  must  have.  I  believe  it  is  of  prime  importance 
as  a  factor  in  determining  this  tension.  Further- 
more, the  condition  of  the  general  circulation  influ- 
ences the  fullness  of  the  blood  vessels  ii^  the  orbit 
and  thus  influences  the  pressure  exerted  on  the  eye 
by  the  tissues  surrounding  it  and  therefore  afifects 
its  curvature.  The  general  circulation  and  general 
health  also  influence  the  amount  of  fat  in  the  orbit. 
It  is  plain  that  the  effect  of  the  action  of  the  ex- 
trinsic muscles  on  the  curvature  of  the  eye  varies 
somewhat  with  the  extension  of  the  eyeball. 

REFERENCES. 

Affective  Activity,  Emotions,  as  the  Cause  of  Various 
Neurasthenic  Bodily  Diseases,  New  York  Medical  Jour- 
nal, April  4,  1914. 

The  Rationale  of  Neurasthenia  and  of  Disturbances  of 
Arterial  Tension,  Boston  Medical  and  Surgical  Journal, 
October  18,  1917. 

The  Etiology  of  Disturbances  of  the  Heart  Beat,  Boston 
Medical  and  Surgical  Journal,  October  25.  1917. 

The  Explanation  and  Treatment  of  the  Effort  Syndrome, 
Neurocirculatory  Asthenia  (Soldiers')  Irritable  Heart, 
Medical  Record,  July  26,  1919. 

■ 

A  CASE  OF  ERYSIPELAS  WITH 
COMPLETE  LOSS  OF  VISION 
Cured  and  Vision  Restored. 
By  Navroji  A.  Cooper,  M.  D., 

Bombay,  India, 
Honorary  Physician  to  the  B.   D.   Petit  Parsee  General  Hospjfal. 

A  patient  with  erysipelas  of  a  severe  form  com- 
plicated with  loss  of  vision  was  admitted  under  the 
care  of  my  predecessor  at  the  B.  D.  Petit  Parsee 
General  Hospital  on  December  9,  1919.  The  patient 
was  a  female,  aged  twenty-eight  years,  very  poorly 
nourished,  having  had  continuous  fever  for  ten 
days  with  a  large  patch  of  erysipelas  on  the  external 
surface  of  the  right  thigh.  The  heart  sounds  were 
feebly  audible ;  pulse  weak  and  of  low  volume,  with 
slow  and  shallow  breathing,  with  normal  liver  and 
spleen  outline.  There  was  total  bhndness  of  both 
eyes,  one  eye  having  been  sightless  from  infancy 
and  the  other  aff^ected  only  a  few  days  after  her 
■present  illness.  This  patient,  who  was  delirious  at 
times,  was  treated  on  ordinary  lines  with  anti- 
streptococcic (erysipelas)  serum  injections  in  large 
doses.  In  all  about  eight  injections  were  given, 
together  with  appropriate  local  treatment. 

When  the  patient  came  under  my  care  for  treat- 
ment on  October  1,  1919.  she  was  in  an  extremely 
bad  condition,  highly  anemic,  prostrated,  with  the 
heart  sounds  feebly  audible.  She  had  a  rapid,  weak 
pulse  combined  with  low  muttering  delirium.  The 
spleen  was  normal,  but  the  liver  was  greatly  en- 
larged and  tender.  A  further  dose  of  twenty-five 
c.c.  of  antistreptococcic  serum  was  given  and  the 
patient  was  put  on  a  simple  mixture  of  iron  and 
given  brandy  in  liberal  doses  as  a  stimulant.  The 
temperature,  which  had  been  99.6°  F.,  rose  after 
three  or  four  days,  and  at  the  same  time  there  was 
a  marked  increase  in  tenderness  'in  the  hepatic 
region.  Emetine  injections  of  a  quarter  grain  were 
given  every  day  for  three  days.  After  the  third 
injection  of  emetine  the  temperature  dropped  to 


normal.  Pain  and  tenderness  in  the  liver  disap- 
peared and  the  patient  was  a  trifle  better.  Three 
more  injections  were  given  and  the  fever  remained 
below  normal.  During  this  period  the  only  drug 
that  was  administered  to  the  patient  by  mouth  was 
liquor  ferri  perchloridi  several  times  a  day.  The 
blood  picture  showed,  instead  of  a  leucocytosis, 
a  marked  leucopenia,  which  is  very  unusual  in  such 
diseases,  with  the  red  blood  cells  2,020,000  to  the 
c.c.  and  a  few  microc>i:es.  There  were  no  other 
changes  in  the  blood.  About  eight  days  after  the 
complete  fall  in  temperature,  large  abscesses  sud- 
denly developed  on  the  face  of  the  patient,  in  both 
the  arm  pits  and  on  the  buttocks.  Autogenous  vac- 
cine was  prepared  and  four  injections  were  given. 
This  prevented  the  development  of  further  abscesses 
and  inhibited  the  ripening  of  those  already  formed. 
There  were  no  other  pyemic  complications.  About 
ten  days  after  this  the  vision  of  the  patient  im- 
proved. The  leucopenia  was  less  marked.  On 
November  2,  1919,  the  patient  told  me  that  she 
could  then  see  things  as  well  as  she  used  to  before 
her  illness.  During  all  the  time  that  she  was  under 
my  care,  she  was  kept  on  a  mixture  of  iron  which 
was  given  in  increasing  doses.  It  was  due  to  the 
iron  that  her  vision  was  restored  and  her  general 
health  improved  so  quickly.  Though  the  antistrep- 
tococcic serum,  the  autogenous  vaccine  and  emetine 
each  played  their  own  part  against  the  infection  and 
its  pyemic  complications,  her  recovery  was  due  to 
the  iron. 

CONCLUSIONS. 

1.  No  case  of  loss  of  vision  in  erysipelas  has  been 
recorded  as  far  as  I  know. 

2.  The  vision  was  completely  restored  under  a 
simple  treatment  of  a  mixture  of  iron. 

3.  Hepatic  and  pyemic  complications  yielded  rap- 
idly to  emetine  and  autogenous  vaccine  treatment. 

4.  Exceptionally  quick  and  complete  recovery  was 
due  to  the  iron,  which  acted  as  a  specific  more  than 
the  other  drugs  which  were  used. 

The  patient  left  the  hospital  in  perfect  health. 
289  Hornby  Road,  Fort. 


Quinine  in  the  Treatment  of  Hemoptysis. — 

Joseph  E.  Strobel  {Medical  Record,  August  21, 
1920)  reports  favorable  results  from  the  admin- 
istration of  five  grains  of  quinine  every  four  hours 
for  a  week  in  cases  of  hemoptysis.  Assuming  that 
the  theory  of  mixed  infection  was  the  correct  ex- 
planation of  hemoptysis,  Strobel  injected  into  fifty- 
four  rabbits  subcutaneously  one  half  a  cubic  centi- 
metre of  fresh  bloody  sputum  from  as  many  dif- 
ferent patients  during  different  seasons  of  the  year. 
The  result  was  that  in  fifty-one  of  the  rabbits  lobar 
pneumonia  and  pneumococcic  septicemia  developed, 
in  two  a  localized  tuberculous  abscess,  and  in  one 
an  abdominal  abscess.  Five  of  the  fifty-one  rab- 
bits were  controlled  by  a  rabbit  of  similar  weight 
receiving  a  similar  inoculation  but  to  which  had 
been  given  fifteen  minutes  previously  one  grain  of 
quinine  bisulphate  intravenously.  These  controls 
were  killed  after  two  to  three  months,  presenting 
all  organs  and  blood  free  from  tubercles  and  diplo- 
coccic  pneumonia. 


Editorial  Notes  and  Comments 


NEW  YORK  MEDICAL  JOURNAL 

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NEW  YORK.  SATURDAY.  NOYEMBER  20,  1920. 


THE  NEW  HYGIENE. 

The  human  organism  might  be  defined  as  a  col- 
lection of  habits  (or  memories  if  we  use  Butler's 
expression).  The  production  of  germ  cells  is  a 
habit  and  a  strong  one ;  the  whole  process  of  de- 
velopment is  a  habit  influenced  to  some  extent  by 
surrounding  conditions ;  the  business  of  feeding  and 
sleeping  and  getting  about  and  of  fighting  bacteria 
are  other  habits,  more  modifiable  but  still  habits 
which  become  more  and  more  fixed  with  years.  Ill- 
ness is  brought  on  by  mistakes  in  attempts  to  estab- 
lish new  habits  beyond  the  capacity  of  the  organism, 
as  in  the  attempts  to  overfeed  or  overwork  or  under- 
sleep.  It  is  comparatively  easy  to  see  what  has 
gone  wrong  and  usually  the  sick  themselves  are 
aware,  but  there  is  a  wide  range  of  habit  within 
which  the  organism  can  persist  for  years  and  it  is 
the  course  of  bad  habits  of  mild  degree  which  slow- 
ly kill  or  slowly  injure  and  which  it  is  the  realm 
of  personal  hygiene  to  correct.  But  habits,  being 
fundamental  to  existence,  are  exceedingly  difficult  to 
change  once  they  become  established.  Function 
makes  structure  and  structure  reacts  to  fix  function 
and  make  it  tyrannous. 

The  new  method  of  teaching  hygiene,  fortunately, 
is  based  upon  an  early  establishment  of  healthy 
habits — not  by  telling  what  they  are,  but  by  seeing 
that  they  are  established.  It  is  surprising  how  few 
the  fundamental  habits  for  health  are,  and  how 
simple  to  establish  as  compared  with  those  developed 
by  other  school  work.  The  school,  therefore,  which 
fails  to  make  the  teaching  of  hygiene  by  the  new 


method  an  essential  part  of  its  course  is  deserving 
of  strongest  condemnation.  It  must  be  remembered 
that  the  public  school  child  has  already  spent  from 
four  to  SIX  years  in  the  formation  of  habits,  in 
many  instances  more  or  less  bad  from  the  begin- 
ning. The  results  of  medical  inspection  have  made 
clear  the  ef?ect  of  bad  habits  of  the  child  growing 
out  of  bad  family  habits  or  customs.  The  pediatrist, 
the  family  physician,  and  the  welfare  nurse,  are  the 
most  important  teachers  of  hygiene  because  they 
preside  at  its  source.  The  welfare  of  the  nation 
will  depend  to  a  large  extent  on  the  skill  of  these 
workers  in  properly  starting  the  human  machine. 


THE    PHYSIOPATHOLOGY   OF  THE 
TENDON  REFLEXES. 

According^  to  the  recent  researches  carried  out 
by  Lhermitte  there  are  two  theories  applicable  to 
tendon  reflexes  ;  the  old  one,  according  to  which  these 
have  a  mesocephalic  origin — the  cutaneous  reflexes 
being  cortical — or  more  correctly  have  their  centre 
in  the  nucleus  ruber.  Crocq  and  Van  Gehuchten 
maintain  that  the  preservation  of  the  tendon  reflexes 
is  dependent  upon  the  rubrospinal  tract,  whose 
origin  is  the  nucleus  ruber,  the  ending  point  of  the 
superior  cerebellar  peduncles.  Whenever  this  tract 
is  morbidly  disordered  the  tendon  reflexes  are  also 
abnormal.  This  theory  is  directly  related  to  the 
opinion  upheld  by  Jackson  and  Bastian,  according  to 
which  the  cerebellum  and  cerebrum  exercise  an 
antagonistic  action  on  the  cord,  the  cerebrum  hav- 
ing an  inhibitory  action,  the  cerebellum  a  tonic  one. 
Now,  how  is  it  possible  to  explain  by  these  hypothe- 
ses an  increase  of  the  subjacent  tendon  reflexes 
which  occurs  after  experimental  division  of  the 
cord?  In  point  of  fact,  complete  division  of  the  cord, 
so  frequently  observed  ditring  the  recent  war,  has 
shown  that  from  this  viewpoint  only  secondary  dif- 
ferences exist  between  man  and  animals,  and  that  in 
the  former,  in  cases  of  medullary  division  the  tendon 
reflexes  are  exaggerated,  sometimes  even  accompa- 
nied by  spinal  and  patellar  trepidation,  as  observed 
by  Lhermitte,  Claude  and  Roussy. 

In  reality  this  phase  of  exaggeration — immediate 
in  animals — is  tardy  in  man  and  appears  to  be  pre- 
ceded by  shock ;  therefore,  the  reflexes  are  abolished 
in  the  paralyzed  segment  of  the  body,  so  that  this 
absence  has  as  origin  the  inhibitory  action  of  the 
medullary  wound  on  the  spinal  segments  separated 
from  their  upper  connections.  Consequently,  the 
centres  of  tendon  reflexes  are  medullary  and  not 
mesocephalic.    As  to  the  cutaneous  reflexes,  it  is 


November  20,  1920.] 


EDITORIAL  ARTICLES. 


819 


known  that  they  consist  of  reflex  contraction  of  a 
given  muscle  following  a  mild  stimulation  produced 
on  the  cutaneous  surface.  According  to  the  classic 
textbooks,  they  have  cortical  origin,  while  Van  Ge- 
huchten  maintains  that  they  are  abolished  in  many 
cases  and  preserved  in  animals  with  a  complete  divi- 
sion of  the  cord.  Here  again  the  war  has  shown 
that  it  is  erroneous  to  compare  men  with  animals  in 
respect  to  their  cutaneous  reflexes.  All  observers 
who  have  studied  complete  revision  of  the  cord  in 
warfare  have  noted  that  the  cutaneous  reflexes  re- 
mained and  this  immediately  after  receipt  of  the 
trauma  and  from  the  very  onset  of  medullary  shock. 
As  to  Babinski's  reflex  it  varies,  sometimes  being 
absent,  at  others  distinctly  present.  Generally  it  is 
associated  with  other  reflex  manifestations  of  greater 
interest  as  pointed  out  by  Marie  and  Foix,  viz.,  re- 
flexes of  medullary  automatism. 

Marie  and  Foix  had  previously  demonstrated  that 
in  nontraumatic  paraplegia  the  principal  phenomena 
of  muscle  shortening  could  be  made  to  reappear. 
The  varied  movements  that  Claude,  Lhermitte  and 
Roussy  were  able  to  demonstrate  in  their  cases  of 
total  transverse  division  of  the  cord  have  a  special 
significance  because  with  one  exception  they  repre- 
sent the  reflexes  of  the  automatism  of  walking  more 
marked  in  man  than  experimentally  in  animals.  Bab- 
inski's phenomenon  is  related  to  movements  of  de- 
fense, and  this  would  appear  to  apply  as  well  to  the 
visceral  reflexes.  The  sphincters  do  not  remain  in- 
definitely paralzyed  after  total  division  of  the  cord 
because  quite  independently  of  the  will  they  acquire 
in  time  an  automatic  action.  It  may,  perhaps,  be  the 
same  with  the  genital  functions.  But  it  would  at 
present  seem  to  be  proved  that  all  the  reflexes — 
tendon,  cutaneous  and  visceral — have  a  medullary 
origin. 


INDUSTRIAL  DIRT. 
A  new  offensive  is  being  launched  against  the 
twin  enemies,  disease  and  dirt.  Xo  section  of  labor 
brings  more  dirt  home,  or  is  more  reluctant  to  avail 
itself  of  cleansing,  than  the  coal  miner;  yet  think 
what  the  providing  of  means  for  washing  the  man 
and  his  clothes  means  to  the  wife.  The  Board  of 
Health  in  Great  Britain  is  tr}-ing  to  establish  pit- 
head baths  for  use  at  the  end  of  the  day.  The 
difficulty  is  that,  given  all  facilities,  how  many 
working  men  of  any  dirty  occupation  would  care  to 
take  a  bath  save  in  a  comfortable  bathroom  at  home  ? 
To  turn  out  again  to  get  home  sounds  cheerful. 
Moreover,  the  old  miner  has  a  confirmed  belief  that 
washing  the  back  has  a  weakening  eflfect,  and  the 
elderly  wives  maintain  bathing  gives  one  a  cold.  The 
younger  miners,  fortunately,  are  becoming  interested 


in  athletics  and  physical  culture ;  the  feeling,  too, 
of  selfrespect  is  growing,  the  dislike  of  having  to 
face  clean  people  on  the  cars  with  dirty  clothes  and 
blackened  exteriors  is  inclining  them  tubwards.  It 
is  easy  to  understand  the  objections  to  taking  a  bath 
away  from  home.  Forty  per  cent,  of  the  deaths  in 
Welsh  collieries  are  due  to  phthisis,  pneumonia,  and 
bronchitis,  and  an  enormous  number  are  due  to 
rheumatism,  lumbago,  and  sciatica.  Also,  some 
statistics  made  a  few  years  ago  in  a  Scotch  colliery 
district  showed  eleven  per  cent,  of  the  families  had 
one  room;  sixty-five  per  cent,  two,  and  twenty-four 
per  cent,  three;  none  had  a  bathroom.  It  was 
even  worse  in  Yorkshire  in  1919 :  2.793  families 
lived  in  one  roomed  houses  and  31,908  in  two,  and 
the  water  supply  was  deficient. 

It  all  returns  to  the  same  issue :  bad  housing.  The 
doctors,  full  of  zeal,  full  of  righteous  anger,  realize 
how  they  are  handicapped  and  defeated  every  day 
by  lack  of  cooperation  on  the  part  of  employers. 
The  details  are  rarely  published  in  their  actual  sor- 
didness,  and,  if  pubHshed,  would  do  no  good  unless 
some  citizens,  bold  and  brave  enough,  took  up  and 
hung  on  to  the  matter  tenaciously  to  shame  those 
responsible.  Unaided,  the  doctor  is  made  to  feel 
bitterly  his  utter  impotence,  and  the  futility  of  urg- 
ing obviously  necessary  refonus. 

PHYSICIAX-AUTHORS:    DR.  ABRAHAM 
COLES. 

One'  of  the  most  famous  American  hymn  writers 
was  Dr.  Abraham  Coles,  a  staunch  old  Covenanter, 
who  was  born  at  Scotch  Plains,  X.  J-,  on  December 
26,  1813,  and  died  on  May  3,  1891.  at  Monterey, 
Cal.  (where  he  had  gone  for  his  health),  after  a 
distinguished  career  in  the  fields  of  literature  and 
medicine.  "Dr.  Coles  is  a  born  hymn  writer,"  said 
John  Greenleaf  Whittier,  the  Quaker  poet.  "He 
has  left  us  a  legacy  of  inestimable  worth,  some  of 
the  sweetest  of  Christian  hymns.  His  All  the  Days 
and  his  Ever  With  Thee  are  immortal  songs.  It  is 
better  to  have  written  them  than  the  stateliest  epics. 
No  man  living  or  dead  has  so  rendered  the  text 
and  spirit  of  the  old  and  wonderful  Latin  hymns." 
Oliver  Wendell  Holmes,  who,  like  Dr.  Coles,  was 
a  physician,  compared  his  hymns  to  the  verses 
"which  John  Bunyan  sprinkles  like  drops  of  heav- 
enly dew  along  the  pages  of  Pilgrim's  Progress." 
Ccrles's  hymns  were  praised  with  equal  enthusiasm 
by  Henry  Wadsworth  Longfellow,  William  Cullen 
Bryant,  James  Russell  Lowell,  William  E.  Glad- 
stone, England's  grand  old  man,  and  others. 

Dr.  Coles  was  a  deeply  religious  man  and  through 
the  large  number  of  hymns  which  he  wrote  and 


S20 


EDITORIAL  ARTICLES. 


[New  York 
Medical  Journal. 


translated  he  promulgated  his  gospel  of  faith.  He 
wrote  poetry  and  prose  of  other  sorts,  too,  but  his 
fame  is  based  primarily  on  his  translation  of  the 
supreme  product  of  Latin  hymn  writing,  the  Dies 
Ircc.  Coles  astonished  the  literary  world  a  few 
decades  ago  with  no  less  than  eighteen  versions  of 
this  masterpiece  of  hymnology,  and  they  are  among 
the  finest  of  the  one  hundred  and  fifty  or  more  ver- 
sions of  it  in  the  English  language.  James  Russell 
Lowell  called  them  the  very  finest  of  all  the  trans- 
lations. Dies  Ires  originally  was  written  in  Latin 
by  the  monk  Thomas  of  Celana,  in  Italy,  in  the 
thirteenth  century.  It  is  a  chant  of  eight  stanzas 
of  eight  lines  each,  giving  a  terrible  description  of 
the  Judgment  Day,  painting  in  vivid  colors  the 
anguish  of  the  selfcondemned  sinner  and  reciting 
his  piteous  appeals  for  mercy.  "It  is,"  Coles  said, 
"instinct  with  music.  It  sings  itself.  The  grandeur 
of  its  rh}l:hm  and  the  assonance  and  chime  of 
its  fit  and  powerful  words  are,  even  in  the  ears  of 
those  unacquainted  with  the  Latin  language,  sug- 
gestive of  the  richest  and  mightiest  harmonies." 
His  eighteen  versions  of  it  show  a  surprising  mas- 
tery of  language  and  illustrate  the  possibilities  of 
variation  of  language  without  alteration  of  the  sense. 

Coles  also  translated  the  Stahat  Mater  Dolorosa 
and  the  Stahat  Mater  Speciosa,  and  these,  together 
with  a  collection  of  hymns  under  the  title  of  Old 
Gems  in  Kc-d:  Settings,  ran  through  several  editions 
and  are  still  standbys  in  standard  hymnals.  One 
of  his  most  popular  original  hymns  was  In  the  Sweet 
By  and  By.  He  also  translated  from  the  Hebrew 
the  Psalms  of  David,  published  with  extensive  his- 
torical and  critical  notes.  His  other  writings  in- 
cluded The  Light  of  th'e  World,  and  The  Evangel, 
a  life  of  Christ  in  verse,  which  Oliver  Wendell 
Holmes  called  "charming  and  impressive"  and  which 
Whittier  described  as  "a  work  of  piety  and  beauty." 

The  Microcosm,  a  long  poem  which  was  written 
for  the  centenary  anniversary  of  the  Medical  So- 
ciety of  New  Jersey,  of  which  Dr.  Coles  was  presi- 
dent at  the  time,  was  published  in  1881,  together 
with  his  National  Lyrics  and  Miscellaneous  Poems. 
It  took  five  editions  to  supply  the  demand  for  this 
book.  George  Ripley,  one  of  the  pioneer  journalists 
of  New  York  city,  writing  in  the  Tribune,  described 
The  Microcosm  as  "an  ingenious  attempt  to  present 
the  principles  of  the  animal  economy  in  a  philosoph- 
ical poem,  somewhat  after  the  manner  of  Lucretius, 
and  combining  scientific  analysis  with  religious  sen- 
timent." Dr.  Coles  always  linked  medicine  and 
religion  and  regarded  his  profession  as  a  sacred  one. 
How  loyal  he  was  to  that  profession  amid  the  glow 
of  literary  fame  is  shown  in  The  Microcosm,  a 
physician's  edition  of  which  was  published. 


Dr.  Coles  wrote  a  large  number  of  medical  and 
scientific  papers  which  were  published  in  various 
periodicals,  and  he  also  translated  The  Address  to 
Christ  on  the  Cross,  by  Bernard  of  Clairvaux,  and 
Hildebert's  Address  to  the  Three  Persons  of  the 
Most  Holy  Trinity,  together  with  several  selections 
from  the  Greek  and  Latin  Classics.  These,  how- 
ever, were  not  published. 

When  he  was  fifteen  Coles  became  a  clerk  in  a 
New  York  dry  goods  store  and  two  years  later  he 
became  a  teacher  of  Latin  and  mathematics  in  the 
Bond  Academy  at  Plainfield,  N.  J.  At  eighteen  he 
studied  law  for  a  year  and  then  definitely  decided 
to  make  medicine  his  life  work.  He  entered  the 
College  of  Physicians  and  Surgeons,  New  York,  and 
after  studying  there  for  a  while,  went  to  Jefferson 
Medical  College,  Philadelphia,  where  he  received 
his  degree  in  1835.  He  practised  mostly  in  New- 
ark, N.  J.,  and  was  prominent  in  civic  and  literary 
circles  there.  He  served  sev.eral  terms  on  the  New- 
ark Board  of  Education,  was  one  of  the  founders 
of  the  famous  Newark  Public  Library  and  also  of 
the  New  Jersey  Historical  Society.  He  made  two 
trips  to  Europe,  in  1848  and  1854,  and  was  in  Paris 
during  those  stormy  revolutionary  days  of  May  and 
June,  1848,  which  gave  him  special  opportunities 
for  surgical  experience  and  study. 

This  sturdy  old  Baptist  doctor  was  one  of  the 
most  lovable  of  men  personally.  "I  have  always 
considered  it  a  privilege,"  said  Oliver  Wendell 
Holmes,  "to  enjoy  the  friendship  of  so  pure  and 
lofty  a  spirit;  a  man  who  seemed  to  breathe  holi- 
ness as  his  native  atmosphere  and  to  carry  its  influ- 
ence into  his  daily  life."  For  his  literary  work  Dr. 
Coles  received  the  degree  of  A.  ^I.  from  Rutgers 
College ;  the  Ph.D.  degree  from  Lewisburg  Uni- 
versity, and  the  LL.D.  from  Princeton  University. 


McGILL  UNIVERSITY. 
Of  the  twelve  pamphlets  published  by  McGill 
University,  Montreal,  in  connection  with  the  cam- 
paign now  in  progress  for  a  five  million  dollar  fund 
that  entitled  A  Greater  McGill  is  most  inter- 
esting. In  all  its  histor}-  that  great  university  has 
made  only  three  appeals  to  the  public  for  assist- 
ance. The  first  was  in  1881,  when  an  appeal  was 
made  for  thirty-three  thousand  dollars  to  save  the 
uniA-ersity  from  a  financial  crisis.  The  second  was 
launched  in  1911  and  brought  the  university  a 
million  dollars.  Now  the  third  is  on  for  the  amount 
stated  above  and  the  outlook  is  very  promising. 
Part  of  the  donations  to  be  received  will  be  set 
apart  for  memorial  purposes  as  the  donors  stipulate. 
The  war  depleted  the  ranks  of  the  professorial 


November  20,  1920.] 


NEPVS  ITEMS. 


821 


staffs  as  well  as  the  student  body,  and  it  is  the 
desire  of  the  governors  that  their  names  be  per- 
petuated. During  that  stressful  period  no  appeals 
for  money  were  made.  On  the  other  hand,  the 
strictest  economy  was  practised  in  every  depart- 
ment. No  buildings  were  enlarged,  but  the  whole 
policy  of  the  university  was  one  of  retrenchment, 
even  to  carrying  on  with  the  old  equipment  and 
apparatus  as  in  the  days  prior  to  the  Great  War. 

In  1919  students  began  to  return  and  more 
new  ones  were  being  admitted  than  ever  before, 
until  it  soon  began  to  appear  that  there  was  in- 
adequate accommodation  all  round.  Registration 
in  arts  sprang  from  389  in  1918  to  632  in  1919; 
in  medicine  and  dentistry,  from  526  to  724;  and 
in  applied  science,  from  242  to  643.  This  large 
increase  in  attendance  necessitated  additional  funds 
to  provide  competent  professors  and  instructors. 
Prewar  salaries,  never  great,  under  the  changed 
conditions  of  living  did  not  allow  professors  to 
live  any  better  than  many  of  the  industrial  classes. 
As  the  average  salary  of  a  professor  at  McGill  is 
about  three  thousand  dollars,  the  university  needs 
at  least  a  hundred  and  ninety-five  thousand  dol- 
lars to  give  living  wages  to  a  staff  of  about  five 
hundred. 

If  the  standard  of  the  work  of  McGill  is  to  be 
kept  up  additional  professors  must  early  be  ap- 
pointed and  provided.  Recently  a  new  depart- 
ment of  biochemistry  has  been  established  with 
Professor  A.  B.  Macallum  occupying  the  chair. 
Professor  Macallum  is  a  distinguished  scientist, 
formerly  in  charge  of  the  similar  department  in  the 
University  of  Toronto,  but  latterly  chairman  of  the 
Research  Commission  of  the  Dominion  Govern- 
ment. There  will  be  established  shortly  another 
new  department  in  industrial  chemistry. 

For  some  time  the  accommodation  for  biological 
work  has  not  been  adequate.  For  that  there  is  now 
available  the  sum  of  seventy-five  thousand  dollars. 
The  old  medical  building  will  be  used  for  this  pur- 
pose, but  the  sum  of  a  hundred  thousand  dollars 
will  be  needed  for  endowment.  Then  there  is  in 
view  a  new  building  to  house  pathology,  medical 
jurisprudence,  hygiene  and  psychiatry,  to  cost  about 
four  hundred  and  sixty  thousand  dollars  and  a 
further  hundred  and  fifty  thousand  dollars  for 
endowment.  Without  the  five  million  dollars  McGill 
would  not  be  able  to  keep  up  its  high  standard,  the 
equal  of  any  other  university  on  the  continent  of 
America,  and  to  cover  all  its  requirements  no  less 
amount  than  ten  million  dollars  would  begin  to 
meet  them.  While  it  is  true  that  McGill  has  in  the 
past  been  most  fortunate  in  many  generous  dona- 
tions from  friends,  including  Lord  Strathcona,  Sir 


William  ^IcDonald.  and  the  late  Sir  James  Doug- 
las, of  New  York,  it  was  felt  by  the  new  president, 
Sir  Arthur  Currie,  that  this  appeal  should  be  made 
to  a  wide  constituency  so  that  the  many  graduates 
in  Canada  and  the  United  States  could  have  an 
opportunity  to  come  to  the  assistance  of  their  alma 
mater.  The  campaign  is  said  to  be  progressing 
most  favorably  and  the  outlook  is,  therefore,  most 
promising.   

WOMEN  WORKERS  IN  NOVA  SCOTIA. 

Working  conditions  of  women  in  Xova  Scotia 
have  been  under  scrutiny  by  the  Nova  Scotia  Com- 
mission on  Women  in  Industry,  which  has  recently 
issued  a  report.  The  general  conclusions  reached 
by  the  commission  were  that  hours  were  frequently 
too  long,  especially  where  women  have  to  stand  or 
where  work  is  heavy  or  unhealthy ;  that  working 
conditions  could  be  improved  and  should  be  sub- 
ject to  standard  regulations;  that  the  lack  of  medical 
inspection,  especially  in  food  factories,  constitutes 
a  public  menace.  It  was  suggested  that  a  board  be 
appointed  representative  of  women  workers,  em- 
ployers and  the  public,  with  power  to  secure  im- 
provement of  conditions.  Though  the  commission 
found  that  a  large  number  of  women  were  not 
earning  enough  to  live  on,  it  did  not  recommend 
a  flat  minimum  wage  but  suggested  that  the  pro- 
posed board  be  empowered  to  fix  suitable  standards 
from  time  to  time.   


MENTAL  STARVATION. 
Those  doctors  who  have  a  pile  of  medical  journals 
arriving  every  month,  many  of  which  they  have  not 
time  to  read,  can  hardly  imagine  the  lassid  feeling 
of  the  man  far  away  from  any  library  and  too  poor 
to  afford  the  latest  textbooks.  Owing  to  the  war, 
some  of  the  physiological  journals  in  India  are 
dated  1915.  The  editor  of  the  Indian  Medical 
Journal  has  therefore  resolved  to  devote  a  section 
to  physiological  science,  and  invites  those  who  have 
new  ideas  and  journals  to  fill  it.  Dealing  food  to 
the  starving  mind  will  meet  with  a  rich  reward  in 
helping  the  all  too  few  doctors  for  India's  millions. 

 «>  

News  Items. 


Bequests  to  Hospitals. — The  will  of  Henry 
Culver,  of  Southampton,  L.  I.,  contains  a  bequest 
of  $500  to  the  building  fund  of  the  Southampton 
Hospital. 

Medical  Society  of  the  County  of  New  York.— 

The  annual  meeting:  of  the  society  will  be  held 
Monday  evening,  November  22d.  in  Hosack  Hall, 
New  York  Academv  of  Medicine. 

Whooping  Cough  in  New^  York. — From  Janu- 
ary 1  to  October  1,  1920.  6,602  cases  of  whooping 
cough  were  reported  to  the  Department  of  Health 
of  the  City  of  New  York.  During:  the  same  period 
in  1919  only  827  cases  were  reported.  Thus  far 
this  year  550  deaths  have  been  reported,  of  which 
ninety-five  to  ninety-seven  per  cent,  occurred  in 
children  under  five  years  of  age. 


822 


XEirS  ITEMS. 


[New  York 
Medical  Journal. 


Public  Health  Affected  by  High  Rents.— Ac- 
cording to  a  report  concerning  housing  conditions  in 
Brooklyn,  issued  recenth*  by  the  Brooklyn  Bureau 
of  Charities,  many  of  the  poorer  families  are  living 
in  such  crowded  quarters  that  their  health  is  en- 
dangered. 

Fifth  Avenue  Hospital  Building  Fund. — Re- 
cent contributions  have  brought  the  amount  in  hand 
up  to  Sl.G+S.SOO;  the  amount  desired  is  $2,000,000. 
The  Barrymores,  John,  Lionel,  and  Mrs.  Ethel 
Barrymore  Colt,  have  driven  830,000  to  endow  a 
room  in  their  name  for  the  benefit  of  members  of 
the  theatrical  profession. 

The  Police  Hospital. — The  first  step  in  the 
campaign  to  raise  85.000,000  to  build,  equip,  and 
endow  the  proposed  Police  Hospital  was  a  luncheon 
given  by  Police  Commissioner  Richard  E.  Enrisrht 
to  three  hundred  men  of  the  theatrical  and  moving- 
picture  professions,  at  which  875,000  was  raised. 
The  campaign  for  subscriptions  will  begin  on 
December  9th. 

Syracuse  Academy  of  Medicine  Meeting  Post- 
poned.— Owing  to  a  death  in  the  family  of  Pro- 
fessor Simon  Henry  Gage,  the  regular  monthly 
meeting  of  the  Syracuse  Academv  of  Medicine  has 
been  postponed  to  X'ovember  23d.  Prof.  Gage 
will  present  at  this  meeting  a  paper  on  Free  Gran- 
ules of  the  Blood  and  Their  Dependence  on  the 
Kinds  of  Food  Ingested. 

Low  Death  Rate  for  1919. — .\ccording  to  the 
Census  Bureau's  annual  bulletin  on  mortalitv  sta- 
tistics, 1,096,436  deaths  occurred  in  the  reeistration 
area  of  the  United  States  during  the  year  1919. 
This  represents  a  rate  of  12.9  in  a  thousand  of 
population,  the  lowest  on  record.  The  rate  for 
1918  was  18  in  a  thousand,  due  lareelv  to  the 
pandemic  of  influenza. 

Research  Information  Bureau. — The  Xational 
Research  Council,  of  Washington,  D.  C,  announces 
the  establishment  of  a  research  infonuation  service 
as  a  general  clearing  house  and  information  bureau 
for  scientific  and  industrial  research.  Wherever 
possible  information  is  furnished  free  of  charge. 
All  inquiries  should  be  addressed  to  Research 
Information  Ser\-ice.  Xational  Research  Council, 
1701  Massachusetts  Avenue.  Washington,  D.  C. 

Medical  Supervision  of  Football. — The  health 
aspect  of  football  was  discussed  at  a  recent  meeting 
of  Brooklyn  physicians.  Dr.  Robert  E.  Coughlin, 
who  has  made  a  studv  of  this  sport,  considers  it  a 
dangerous  pastirne  for  boys  of  immature  age  and 
physical  development.  Others  who  sooke  were  Dr. 
Edward  J.  Grace  and  Dr.  Earl  Wayne,  who  pointed 
out  that  most  of  the  injuries  occurred  in  informal 
games  where  the  plavers  were  not  properly  trained. 

State  Civil  Service  Examinations. — Among  the 
positions  for  which  the  New  York  State  Civil 
Service  Commission  will  hold  examinations  on 
December  4th  are  the  following:  Assistant  x  ra}- 
operator.  State  Department  of  Health,  81500  to 
$1800;  laboratory  technician,  Coimty  tuberculosis 
hospitals,  8900  to  81500;  resident  physician.  State 
institutions,  $2000.  For  full  particulars  and  the 
proper  application  forms  address  the  Commission, 
Albany,  X.  Y. 


Academy  Anniversary  Address. — Mr.  James 
'M.  Beck  delivered  the  annual  anniversary  address 
at  the  Xew  York  Academy  of  Medicine,  Thursday 
evening,  X'ovember  18th,  his  subject  being  One 
Cause  of  the  World  Xeuroses. 

Gross  Lecture. — Dr.  Raymond  Pearl,  professor 
of  biometry  and  vital  statistics  at  the  School  of 
Hygiene,  Johns  Hopkins  University,  delivered  the 
annual  Gross  lecture  of  the  Pathological  Society  of 
Philadelphia,  Thursday  evening,  Xovember  11th, 
his  subject  being  Some  Biological  Aspects  of  Human 
:Mortalit}-. 

Typhoid  Epidemic  in  Salem,  Ohio. — An  epi- 
demic of  typhoid  fever  has  been  raging  in  Salem, 
Ohio,  for  the  past  month,  and  has  got  beyond  the 
control  of  the  local  authorities.  There  are  approxi- 
mately one  thousand  cases  in  the  citv.  constituting 
one  eleventh  of  the  total  population.  Seven  deaths 
have  been  reported.  An  appeal  for  help  has  been 
sent  to  the  State  authorities. 

Drug  Addicts  Transferred  from  Sing  Sing  to 
Dannemora. — Twenty-nine  drug  addicts  recently 
received  at  Sing  Sing  Prison  were  among  seventy- 
six  prisoners  transferred  to  Clinton  Prison  at  Dan- 
nemora. Some  of  these  drug  addicts,  all  of  whom 
were  suflFering  when  received  at  Sing  Sing,  had  to 
be  treated  in  the  prison  hospital.  Unable  to  get  any 
drugs  in  Sing  Sing,  some  of  them  had  collapsed. 

Patient  Receives  Fatal  Shock  from  X  Ray  Ma- 
chine.— While  an  x  ray  photograph  was  being 
made  of  his  jaw,  Casimir  Ilg,  thirty-five  years  of 
age,  received  a  fatal  shock  in  the  office  of  Dr. 
Charles  F.  Baker,  Xewark,  X'.  J.  It  is  believed 
that  the  patient  probably  came  in  contact  with  the 
steel  ann  frotu  which  the  x  ray  bulb  was  suspended, 
sending  eighteen  milliamperes  of  electricity  through 
his  body. 

Personal. — Sir  Berkeley  Moynihan.  professor 
of  clinical  surgery.  University  of  Leeds,  England, 
has  been  recommended  for  election  to  honorary 
fellowship  in  the  Xew  York  Academv  of  ^ledicine. 

Dr.  Otto  Huffman  has  removed  his  office  to 
25  East  Sixty-fourth  Street.  Xew  York. 

Dr.  William  Delanev  Thomas,  of  Baltimore,  was 
elected  president  of  the  Homeopathic  ^ledical  and 
Surgical  Club,  at  its  recent  annual  meeting. 

Charles  Edouard  Guillaume  Breteuil,  head  of  the 
International  Bureau  of  Weights  and  Measures, 
was  awarded  the  Xobel  prize  for  1920  for  ohvsics 
by  the  Swedish  Academv  of  Science,  recentlv.  His 
discoveries  relative  to  the  alloys  of  nickel  steel  won 
him  this  honor. 

Druggists  Object  to  Dispensing  Whiskey. — 

The  Kings  County  Pharmaceutical  Societv.  at  a 
recent  meeting,  went  on  record  as  favoring  the 
establishment  of  government  dispensaries  at  which 
whiskey  could  be  sold  to  people  needing  it  for 
medicinal  purposes.  Dr.  William  Anderson,  chair- 
man of  the  legislative  committee,  reported  that 
under  the  Volstead  act  retail  druggists  alone  have 
the  legal  authority  to  deal  out  alcoholic  stimulants. 
The  societ>-  is  opposed  to  having  druggists  deal  in 
whiskey,  even  on  doctors'  prescriptions,  and  it  was 
for  this  reason  that  the  movement  to  have  the 
Government  undertake  the  work  was  started. 


November  20,  J  920.] 


NEH'S  ITEMS. 


823 


Antinoise  Campaign  in  New  York. — Health 
Commissioner  Royal  S.  Copeland  will  soon  begin  an 
active  campaign  to  suppress  all  unnecessary  noises 
in  the  city  of  Xew  York.  An  investigation  of  the 
automobile  as  a  noise  maker  will  be  a  part  of  it. 
and  a  survey  of  every  motor  vehicle  in  the  citv 
will  be  made,  to  ascertain  how  many  of  them  are 
mechanically  perfect.  From  now  on  the  police  will 
be  instructed  that  on  a  certain  day  each  week  they 
are  to  give  special  attention  to  noises  and  their 
suppression.  They  will  be  expected  to  note  the 
causes  of  noises,  to  report  flat  wheels,  barking  dogs, 
hucksters,  etc.  Xoisy  industrial  plants  will  also  be 
listed,  and  will  be  inspected  with  a  view  to  stopping 
all  unnecessar\-  noise. 

State  Hospitals  Overcrowded. — Xe\y  York 
State's  hospitals  for  the  insane  are  overcrowded  to 
eighteen  per  cent,  above  their  normal  capacity,  ac- 
cording to  the  annual  report  of  the  State  Charities' 
Aid  Association  which  has  iust  been  issued.  Insti- 
tutions built  to  accommodate  30.324  persons  now 
contain  35.845,  and  congestion  brought  about  by 
the  entrance  of  patients  who  must  l>e  admitted  is 
causing  a  serious  situation,  especially  in  hospitals 
in  and  near  Xew  York  city.  These  conditions  are 
expected  to  be  remedied  throueh  new  construction 
pro\-ided  for  in  state  appropriations  totaling  $5.- 
000,000,  Mentally  disabled  soldiers,  now  in  vari- 
ous State  hospitals,  will  be  centred  at  the  new  State 
military  hospital  at  Creedmoor.  X'.  Y..  when  it  is 
completed  about  next  Tune. 

Fatalities  on  the  Railroads. — Fewer  persons 
were  killed  on  railroads  during  1919  than  in  any 
year  since  1898.  and  fewer  were  injured  than  in 
any  year  since  1910,  acco-ding  to  a  statement  issued 
today  by  the  Interstate  Commerce  Commission. 
During  1919  a  total  of  6,978  persons  were  killed 
and  149.053  injured,  compared  with  6.859  killed  in 
1898  and  119,507  injured  in  1910.  Of  the  killed 
273  were  passengers  and  of  the  injured  7.456  were 
passengers.  Employees  killed  during  the  year  num- 
bered 2,138  and  131.018  were  injured. 

Fewer  trespassers  on  railroads  were  killed  in  1919 
than  during  any  year  of  the  commission's  records, 
which  go  back  to  1890.  Last  year  2.553  trespassers 
were  killed  and  2.658  injured.  Railroad  officials 
pointed  out  that  there  were  fewer  tramps  than 
formerly. 

Ohio  Public  Health  Association. — This  organi- 
zation has  been  formed  for  the  purpose  of  pro- 
moting proper  health  administration  in  the  State  of 
Ohio.  In  addition  to  taking  over  the  duties  of  the 
Ohio  Society  for  the  Prevention  of  Tuberculosis, 
its  objects  are  to  promote  the  organization  of  local 
public  health  leagues ;  the  dissemination  of  knowl- 
edge concerning  the  prevention  of  disease,  the 
encouragement  and  support  of  organized  official 
work  for.  the  prevention  of  disease,  the  securing  of 
proper  legislation  for  the  prevention  of  disease, 
encouraging  adequate  p'-ovision  for  the  prevention 
of  disease  by  the  establishment  of  hospitals  and 
dispensaries,  etc..  and  the  study  of  conditions  re- 
garding the  prevalence  of  preventable  disease.  The 
work  of  the  as>ociation  is  educational  in  character, 
and  does  not  in  any  way  encroach  upon  the  func- 
tions of  the  state  health  department. 


Yale  University  Department  of  Health. — The 

new  department  of  health  at  Yale  University  is  in 
complete  operation.  Drastic  rviles  have  been  adopted 
to  stamp  out  disease  and  illness  of  every  kind  which 
students,  and  especially  athletes,  may  contract. 
Hereafter  a  general  physical  examination  will  be 
required  of  every  student  before  he  will  be  per- 
mitted to  matriculate.  Frequent  examinations  dur- 
ing the  year  will  follow.  Rigorous  rules  for  ath- 
letes who  wish  to  enter  universit}"  sports  will  be 
adopted,  and  the  health  officials  will  reserve  the 
right  to  order  out  of  competition  any  athlete  found 
unsound  physically. 

The  board  of  health  will  be  headed  by  Dr. 
Charles  E.  A.  AVinslow,  Dr,  William  G.  Anderson, 
Dr.  X'elson  Winternitz,  new  dean  of  Yale  Medical 
School,  and  Dr.  James  C.  Greenway.  They  will 
be  assisted  by  George  P-  Day,  treasurer  for  the 
university ;  Clarence  Mendell,  head  of  the  Yale 
Athletic  Council,  and  Professor  L,  E.  Rettger,  pro- 
fessor of  bacteriology". 

Meetings  of  Local  Medical  Societies. — The  fol- 
lowing medical  societies  will  meet  in  Xew  York 
during  the  coming  week: 

TuESD.w,  Xcn'ember  23rd. — Xew  York  Academy  of  Med- 
icine (Section  in  Obstetrics  and  Gynecology")  ;  Xew  York 
Dermatological  Society ;  Xew  York  Medical  Union ;  Metro- 
politan Medical  Societj'  of  X'ew  York;  Xew  York  Oto- 
logical  Societ)'  (annual  meeting)  ;  Xew  York  Psycho- 
anah'tical  Society ;  Therapeutic  Club ;  \'alentine  Mott  So- 
cietj";  Washington  Heights  Medical  Society"  (annual); 
Clinical  Society"  of  the  Hospital  and  Dispensary  for  De- 
formities and  Joint  Diseases. 

Wednesday,  Xoz'ember  24th. — Xew  York  Academy  of 
Medicine  (Section  in  Laryngology  and  Rhinology)  ;  Xew 
York  Society  of  Internal  Medicine;  Xew  York  Surgical 
Society";  Brooklyn  Pediatric  Society. 

Thursd.w,  Xovember  25th. — Hospital  Graduates'  Club  of 
Xew  York :  Xew  York  Physicians'  Association ;  Ex-Intern 
Society  of  the  Methodist  Episcopal  Hospital,  Brooklyn. 

Frid.w,  November  26th. — Academy  of  Pathological 
Science ;  Audubon  Medical  Society ;  X'ew  York  Clinical 
Society;  Brookly"n  Society  of  Internal  Medicine. 

Satl"rdav,  Xozrmber  27th. — Hanard  Medical  Society ; 
Lenox  Medical  and  Surgical  Society ;  Xew  York  Medical 
and  Surgical  Society;  West  End  Medical  Society. 

 ^  

Died. 

Broxk. — In  Amsterdam,  X.  Y.,  on  Tuesday",  October  2nd, 
Dr.  E.  F.  Bronk,  aged  sixty-two  years. 

J.\MES. — In  Lexington,  Ky.,  on  Sunday,  Xovember  14th. 
Dr.  Robert  C.  Tames,  aged  fifty-five  years. 

JoERG. — In  Brooklyn,  X.  Y..  on  Thursday.  Xovember  4th. 
Dr.  Oswald  Joerg,  aged  seventy-six  years. 

Perkixs. — In  South  Otselic,  X.  Y.,  on  Tuesday,  Xovem- 
ber 2nd.  Dr.  Archibald  T.  Perkins,  aged  fifty-three  years. 

Pr.mt. — In  Binghamton.  X.  Y..  on  Wednesday,  Novem- 
ber 3rd,  Dr.  John  F.  Pratt,  aged  sixty- four  years. 

Wright. — In  Xew  York,  on  Monday,  Xovember  1st.  Dr. 
T.  S.  Wright,  aged  eighty-six  years. 

Whittex. — In  Peoria,  111.,  c«i  Sunday,  October  31st.  Dr. 
Thomas  J.  Whitten,  aged  seventy-six  years. 

William  SOX. — In  Santa  Monica,  Cal.,  on  Thursday, 
October  21st.  Dr.  Alonzo  P.  Williamson,  aged  sixty-six 
years. 

YouxG. — In  Amesbury,  Mass..  on  Saturday,  October  23rd, 
Dr.  Benjamin  Young,  aged  sixty-six  years. 


Book  Reviews 


LOOSE  LEAF  MEDICINE. 

The  Oxford  Medicine.  By  Various  Authors.  Edited  by 
Henry  A.  Christian,  A.  M.,  M.  D.,  Hersey  Professor  of 
the  Theory  and  Practice  of  Physic,  Harvard  University ; 
Physician  in  Chief  to  the  Peter  Bent  Brigham  Hospital. 
Boston,  Mass.,  and  Sir  James  ^^ACKENZIE,  M.  D. 
F.  R.  C.  P.,  LL.  D.,  F.  R.  S.,  Consulting  Physician  to  the 
London  Hospital,  and  Director  of  the  Clinical  Institute, 
St.  Andrews,  Scotland.  In  Six  Volumes.  Illustrated. 
Volume  I :  Medicine ;  Volume  II :  Diseases  of  Bronchi, 
Lungs,  Mediastinum,  Heart,  Arteries,  and  Blood.  Lon- 
don, Toronto,  Melbourne,  Bombay,  and  New  York :  Ox- 
ford University  Press,  1920.    Pp.  xv-817. 

Two  volumes  of  the  Oxford  loose  leaf  system 
of  medicine  have  been  published.  The  loose  leaf 
system  as  applied  to  a  publication  of  this  kind  is 
splendid,  as  it  will  allow  for  great  flexibility. 
Changes  that  occur  in  one  branch  of  medicine  will 
not  necessitate  a  complete  new  edition.  In  other 
fields  where  progress  does  not  take  place  with  the 
same  rapidity  the  new  pages  will  not  be  required 
so  frequently.  In  a  work  of  this  kind  two  principal 
requirements  stand  out :  first,  the  quality  of  the 
initial  material  presented,  and,  second,  keeping  the 
new  sections  abreast  of  the  times.  The  first  re- 
quirement has  been  met  fully.  In  the  first  volume 
the  subject  of  medicine  is  covered  in  a  broad  and 
understanding  way.  Two  more  progressive  and 
able  men  could  not  have  been  selected  as  editors, 
Henry  A.  Christian,  of  Boston,  and  Sir  James 
Mackenzie,  of  Scotland.  A  list  of  contributors,  as 
a  rule,  makes  dull  reading,  but  in  this  case  medical 
men  who  follow  the  work  of  achievement  in  modern 
medicine  will  recognize  among  the  following  list 
names  of  men  who  have  prevented  medicine  from 
falling  into  the  quagmire  of  mediocrity.  So  with- 
out apology  we  may  name  the  following  contribu- 
tors: Lewellys  F.  Barker,  Frank  Billings,  William 
T.'  Bovie,  Richard  Cabot,  Joseph  A.  Capps,  Henry 
A.  Christian,  Charles  B.  Davenport,  Eugene  F.  Du 
Bois,  Frederick  P.  Gay,  Lawrence  J.  Henderson, 
Walter  A.  Hewlett,  Guy  Hinsdale,  Walter  B.  James, 
William  B.  Johnston,  Lucas  P.  Williams,  Elmer  V. 
McCoUum,  Sir  James  Mackenzie,  Sir  William  Osier, 
John  J.  Mackenzie,  Francis  W.  Peabody,  Leonard 
G.  Rowntree,  Henry  Sewall,  Donald  D.  Van  Slyke, 
William  H.  Wilmer. 

The  entire  work  is  to  consist  of  six  volumes. 
The  publishers  feel  that  the  change  brought  about 
by  the  war,  in  regard  to  the  manner  in  which  patients 
were  handled  and  the  new  point  of  view  gained  by 
the  medical  men  who  were  engaged  in  active  work, 
should  be  emphasized  in  the  medical  works  of  today. 
This  influence  is  noted  'n  the  first  two  volumes  that 
have  appeared.  Sir  James  Mackenzie  has  been 
saying  many  very  essential  things  in  regard  to 
medicine  recently.  His  views  are  sane  and  have 
a  tendency  to  induce  the  too  theoretical  practitioner 
who  has  his  head  in  the  clouds,  or  the  practitioner 
who  places  too  much  reliance  on  laboratory  find- 
ings, to  come  back  to  earth,  stand  on  his  own 
feet,  and  develop  the  faculty  of  relying  upon  him- 
self. Too  much  cannot  be  said  upon  this  subject. 
We  have  been  too  prone  to  remember  the  test  tube 
and  forget  the  patient.  In  his  chapter  on  The 
Future  of  Medicine  Sir  James  brings  these  points 


home  with  great  vigor.  The  first  volume  is  replete 
with  chapters  as  essential  as  those  of  Mackenzie's. 
They  deal  with  problems  ranging  from  those  of 
focal  infection  to  others  of  a  forensic  nature.  These 
fields  are  well  covered. 

The  second  volume  takes  up  the  diseases  of  the 
bronchi,  lungs,  mediastinum,  heart,  arteries,  and 
blood.  Many  new  names  are  among  the  contribu- 
tors of  this  volume;  names  that  have  appeared  fre- 
quently in  the  current  medical  literature  associated 
with  the  disorders  of  respiration  and  circulation.  A 
great  effort  has  been  made  to  incorporate  the  latest 
findings  and  it  is  gratifying  to  see  under  the  various 
headings  the  most  modern  views  as  they  have  ap- 
peared in  the  current  literature.  The  project  of 
the  loose  leaf  system  is  not  a  fad.  It  should  super- 
sede the  older  forms  of  binding  for  works  of  this 
character.  Fortunately,  this  effort  is  being  made 
by  men  of  repute  and  should  meet  with  success. 

EXPERIMENTS  IN  VITAL  ENERGY. 

Life.  A  Study  of  the  Means  of  Restoring  Vital  Energy 
and  Prolonging  Life.  By  Dr.  Serge  Voronoff,  Director 
of  Experimental  Surgery  at  the  Laboratory  of  Physiology 
of  the  College  de  France.  Translated  by  Evelyn  Bost- 
wicK  Vernoff.  New  York:  E.  P.  Dutton  &  Co.,  1920. 
Pp.  xx-160. 

Frequently  an  attempt  is  made  to  present  scien- 
tific works  in  an  entertaining  manner.  At  times 
success  is  attained.  Fabre,  in  his  descriptions  of 
animal  life,  and  the  elder  Darwin  in  his  writings 
on  plants  and  insects,  and  others,  have  been  success- 
ful in  cotnbining  literature,  art  and  science,  and  at 
times  have  awakened  an  interest  in  topics  which 
are  usually  presented  in  a  dry  and  uninteresting 
fashion.  VoronofT  has  attempted  something  similar 
in  his  near  dramatic  book.  Life.  He  appears  to  be 
appealing  to  the  gallery,  crying  aloud  his  wares  and 
findings  over  the  heads  of  the  medical  profession. 
Can  it  be  that  this  is  necessary? 

He  presents  a  few  interesting  findings  and  if 
they  prove  to  be  corroborated  by  further  experi- 
ments in  the  hands  of  otlier  observers  no  doubt  will 
prove  a  boon  to  many  who  have  neglected  to  make 
the  most  of  life  as  they  have  found  it;  for  others 
it  will  mean  an  opportunity  of  completing  unfinished 
tasks.  Truly  the  span  of  life  of  man  seems  short. 
The  time  he  actually  lives  after  he  is  equipped  for 
life's  struggle  and  after  he  has  attained  maturity 
of  physical  and  mental  development  is  brief.  It 
seems  but  a  fleeting  moment  that  the  race  is  run 
after  the  years  of  training  and  growth  that  man 
passes  through  in  order  to  attain  his  adult .  status. 
Many  other  fields  of  application  will  also  present 
themselves  when  the  technic  of  glandular  trans- 
plantation is  perfected.  A  case  is  shown  where 
the  thyroid  of  an  ape  was  successfully  transplanted 
to  a  boy  with  beneficial  results.  The  point  made 
that  the  transplants  should  be  made  from  man  to 
man  or  from  the  animals  more  closely  related  to 
man  is  important.  Too  frequently  in  animal  ex- 
perimentation the  error  is  made  of  using  the  lower 
animals  and  attempting  to  apply  the  results  to  the 
human  family. 

A  definite  result  cannot  be  asserted  at  the  present 


November  2U,  1920.] 


BOOK  REVIEWS. 


825 


time.  More  work  must  be  done.  Steinach,  of 
Vienna,  has  many  contributions  to  offer  in  this  field 
which  seem  to  be  more  far  reaching  than  those  of 
Voronoff.  Lydston,  of  Chicago,  has  also  done 
much  work  along  similar  lines.  His  papers  have 
appeared  in  the  New  York  Medical  Journal. 
All  of  these  men  are  undoubtedly  the  heralders  of 
what  will  be  an  important  therapeutic  branch  of 
medicine  in  the  future. 

PROGRESS  OF  SCIENCE. 

The  New  World  of  Science.  Its  Development  During  the 
War.  Edited  by  Robert  M.  Yerkes,  Chairman,  Research 
Information  Service,  National  Research  Council.  Illus- 
trated. New  York:  The  Century  Company,  1920.  Pp. 
vi-443. 

Prowling  around  the  second  hand  bookshops  on 
Third  Avenue,  the  reviewer  came  across  many  old 
volumes  detailing  the  wonderful  progress  science 
had  made,  and  it  seemed  that  the  title  New  World 
was  a  trifle  arrogant,  that  the  enlarging  world 
would  be  more  correct,  for  nothing  has  been  sudden 
in  discovery.  The  origin  has  lain  far  away  back 
some  hundreds  of  years.  Glimpses  they  had,  those 
old  scientists,  of  possibilities,  faith  they  had  that 
knowledge  has  no  boundaries.  Nevertheless,  the 
great  tide  of  progress  today  astonishes  us,  awes  us, 
sweeps  us  off  our  feet,  destroys  our  conservative 
clinging  to  the  old,  lands  us  on  eminences  from 
whence  we  see  all  nations  deserving  recognition  as 
the  marvelous  facts  are  garnered  and  used  for  man's 
help  and  delight. 

Now  that  the  war  is  said  to  be  over,  those  in 
authority  are  showing  us  what  a  haggard,  over- 
worked, weary  eyed  servant  science  was.  How 
she  was  referred  to  even  in  small  matters,  such  as 
the  amount  of  wool  in  military  breeches,  and  the 
total  of  calories  in  a  soldier's  stew,  how  metallurgists 
and  explosivists,  bacteriologists,  geologists,  geog- 
raphers, psychologists,  radiotherapists,  and  physicists 
brought  her  their  problems  to  solve  and,  war  being 
ended,  they  gave  her  the  biggest  of  all,  how  to 
avert  another  carnage,  how  to  economize  in  and 
rightly  use  the  new  powers  she  had  bestowed. 

The  first  question  should  have  been  a  just  reward 
to  the  poorly  paid  scientist,  whose  incidental  ex- 
penses often  consume  nearly  all  his  income.  There 
are  scientists  today  who  cheerfully  gave  their  whole 
time  during  the  war  who  find  themselves  worse  off, 
financially,  than  the  artisan. 

Each  section  of  the  volume  is  a  book  in  itself, 
increasing  our  feeling  of  indebtedness  to  those  who 
have  studied  man  and  natural  forces.  A  long  list 
of  familiar  names  tell  us  of  deeds  done :  Ellery 
Hale,  Robert  Nillikan,  Augustus  Trowbridge,  Her- 
bert Ives,  Harrison  Howe,  deal  with  the  physical 
sciences.  The  role  of  chemistry  has  papers  from 
Arthur  Noyes,  Charles  Munro  and  Clarence  West. 
Douglas  Johnson  records  the  wonderful,  hitherto 
unknown,  work  done  in  geography,  and  equally  good 
is  the  account  of  geology,  though  few  associate  its 
vital  connection  with  wartime.  Engineering  is  told 
by  A.  E.  Kenelly;  metallurgy  by  Henry  Howe. 
Biology  and  medicine  are  safe  with  Vernon  Kel- 
logg, Frederick  Russell,  John  Hanner,  and  Robert 
Yerkes. 

To  appreciate  the  medical  and  surgical  side,  it 


would  be  well  to  read  some  of  the  books  on  those 
subjects  during  the  Civil  and  the  Criinean  wars. 
It  might  be  well  also  to  read  some  of  that  date  when 
the  foolhardiness  of  risking  one's  life  in  a  railway 
train  was  denounced  in  the  pulpit,  and  the  sugges- 
tion of  gas  illumined  streets  was  greeted  with  deri- 
sive laughter  in  the  House  of  Commons.  At  an 
annual  picnic  of  the  Philosophical  Society,  Benjamin 
Franklin  jestingly  said  the  society  might  some  day 
cross  the  Schuylkill  in  an  electric  boat  and  dine  off 
a  turkey  cooked  by  electricity.  Rather  a  mad 
president,  the  guests  deemed  him,  but  the  river 
is  crossed,  the  turkey  cooked,  and  incredulous  old 
ghosts  are  convinced. 

The  people  should  be  glad  of  this  book.  It  gives 
in  one  volume  that  which  has  only  appeared  at 
intervals  in  scientific  journals  inaccessible  to  most. 
Even  while  the  volume  was  in  printing  science  has 
gone  on  still  farther,  lighting  up  obscurities,  excit- 
ing her  followers,  and,  fifty  years  hence,  when  the 
undreamed  of  has  become  the  commonplace,  the 
account  of  the  New  World  will  provoke  even  a 
smile  for  the  scientists  who  only  guessed  at  the 
marvels  to  be  revealed  before  1970.  Even  then, 
though  disease  may  have  its  strongholds  shaken,  the 
Power  which  lets  loose  the  fury  of  a  tornado,  an 
earthquake,  a  tumultuous  flood,  may  see  us  still 
impotent  before  these  forces. 

THE  HISTORY  OF  MEDICINE 

An  Introduction  to  the  History  of  Medicine.  By  Fielding 
H.  Garrison,  A.  B.,  M.  D.,  Principal  Assistant  Librarian, 
Surgeon  General's  Office,  Washington,  D.  C.  Second  Edi- 
tion, Revised  and  Enlarged.  Illustrated.  Philadelphia : 
W.  B.  Saunders  Company,  1917.    Pp.  vii-905. 

Only  those  who  have  tried  to  write  the  history 
of  any  science  can  appreciate  the  immense  amount 
of  research  in  the  first  edition  of  this  book;  only 
those  who  know  Fielding  Garrison  and  his  intense 
desire  for  accuracy,  could  be  sure  that  in  a  second 
edition  all  which  had  provoked  criticism  as  to  cor- 
rectness or  omission  would  be  rectified.  One  great 
attraction  is  the  grouping,  so  arranged  that  any 
man  wanting  to  know  the  stars  in  any  particular 
science  will  find  them  under  that  heading,  the  diffi- 
culties of  a  man  being  eminent  in  two  sciences,  say, 
anatomy  and  biology,  being  obviated  by  his  name 
being  given  under  both.  The  fact  that  it  is  not 
a  biographical  volume  permits  the  allusion  to  the 
work  of  many  men  still  living,  though  the  rapidity 
of  time  is  somewhat  sadly  shown  by  men  who,  in 
the  first  edition  had  just  a  birth  date,  now  appear- 
ing with  two. 

The  most  exigent  should  be  satisfied  with  a 
medical  chronology  which  extends  from.  B.  C.  7000 
to  1914  A.  D.  It  has  also  references  for  those 
wanting  to  study  medical  history,  and  an  index  of 
personal  names  and  one  of  subjects.  There  are 
many  pictures  added  in  the  new  edition  which  give 
pleasure  to  those  who  have  never  seen  some  of 
the  modern  men.  One  of  its  best  tributes  is  the 
fact  that  the  reviewer  mistook  it  for  the  first  edition 
on  the  New  York  Academy  of  Medicine  shelves 
when  it  had  only  been  there  three  weeks :  it  already 
bore  the  traces  of  much  consultation.  And  the  men 
who  had  used  it  were  perfectly  safe  in  quoting  it 


826 


BOOK  REVIEWS. 


[New  York 
Medical  Journal. 


as  a  reference.  There  is  a  report  at  Johns  Hopkins 
Hospital  that  if  you  were  to  ask  WilHam  Welch 
something  on  medical  history  while  he  was  asleep, 
a  correct  answer  would  be  given.  Assuredly  Field- 
ing Garrison  would  stand  the  same  test. 

ANALOGIES 

Our  Great  War  and  the  War  of  the  Ancient  Greeks.  By 
Gilbert  Murray.  LL.  D.,  D.  Litt.,  F.  B.  A.,  Regius  Pro- 
fessor of  Greek  in  the  University  of  Oxford.  New  York: 
Thomas  Seltzer,  1920.    Pp.  v-85. 

Gilbert  Murray,  that  most  imaginative  of  scholars, 
who  has  recreated  an  interest  in  so  much  of  Greek 
thought  in  his  writings  and  his  incomparable  trans- 
lations, has  written  a  little  book  about  two  wars. 
He  is  ostensibly  writing  about  the  Peloponnesian 
War — the  book  purports  to  be  "a  study  of  the  criti- 
cisms passed  on  the  War  Party  at  Athens  by  their 
contemporaries."  But  one  feels  that  for  Professor 
Murray  this  study  has  been  used  to  symbolize,  to 
some  slight  extent,  the  hate  and  ferocity  engendered 
by  the  world  catastrophe  just  passed.  His  interpre- 
tation of  affairs  at  Athens  is  too  clear, 'too  warmed 
by  the  lacrimae .  rerum  to  which  he  refers,  for  a 
hundred  per  cent,  imperialist.  He  is  a  poet  as  well 
as  a  scholar,  and  he  knows  that  history  repeats 
itself. 

The  war  between  Atliens  and  Sparta,  as  he 
shows,  was  "in  many  respects  curiously  similar  to 
the  present  war."  It  was  a  war  primarily  due  to  com- 
mercial rivalries,  a  fight  to  the  last  ditch,  involving 
the  attrition  of  both  of  the  combatants.  In  the 
Athens  of  that  day  there  were  refugees  and  inform- 
ers, militarists  and  rational  persons ;  it  was  a  war 
in  which  glory  was  mixed  with  sordidness,  and  in 
which  the  people  who  were  responsible  for  the  whole 
business  suffered  the  least.  And  it  left  both  Athens 
and  Sparta  ruined.  Professor  Murray  sees  the 
analogy  clearly,  but  when  it  comes  to  the  future  out- 
look he  is  sympathetic,  and  disquieted,  and  hopeless. 
He  hopes  civilization  will  recover,  but  he  is  not 
entirely  sure  about  it.  He  has  a  pathetic  faith  that 
by  "some  spirit  of  cooperation  instead  of  strife,  by 
sobriety  instead  of  madness,  by  rfesolute  sincerity  in 
public  and  private  things,  and  surely  by  some  self- 
consecration  to  the  great  hope  for  which  those  who 
loved  us  gave  their  lives"  things  may  be  made  better. 
But  his  faith  is  not  the  faith  that  moves  mountains, 
and  his  last  words  are  tinged  with  disillusionment: 
"That  was  the  old  dream  that  failed.  Is  it  to  fail 
always  and  forever?" 

 <f>  

New  Publications  Received. 


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


THE  ADVENTUROUS  LADY.  By  J.  C.  Snaith.  New  York : 
D.  Appleton  &  Co.,  1920.   Pp.  321. 

THE  NERVOUS  HOUSEWIFE.    By  ABRAHAM  MvERSON.  BoS- 

ton :  Little,  Brown  &  Co.,  1920.    Pp.  273. 

CHARLES  E.  chapin's  STORY.  Written  in  Sing  Sing 
Prison.  With  an  Introduction  by  Basil  King.  New  York : 
G.  P.  Putnam's  Sons ;  London :  The  Knickerbocker  Press, 
1920.    Pp.  xv-334. 


the  age  of  INNOCENCE.  By  Edith  Wharton.  New 
York :  D.  Appleton  &  Co.,  1920.    Pp.  365. 

official  bulletin  of  the  royal  society  of  medicine. 
London :  John  Bale,  Sons  &  Danielsson,  1920.    Pp.  19. 

LIFE.  By  Johan  Bojer.  Translated  from  the  Norwegian 
by  Jessie  Muir.  New  York:  Moffat,  Yard  &  Co.,  1920. 
Pp.  339. 

the   story  of   the   AMERICAN   RED   CROSS   IN   ITALY.  By 

Charles  M.  Bakewell.  New  York :  The  Macmillan  Com- 
pany, 1920.  Pp.  viii-253. 

A   TEXTBOOK    OF    HISTOLOGY.      By    FREDERICK  R.~-BaILEY, 

A.  M.,  M.  D.  Sixth  Revised  Edition.  Profusely  Illustrated, 
New  York :  William  Wood  &  Co.,  1920.   Pp.  xviii-733. 

PROCEEDINGS  OF  THE  ROYAL  SOCIETY  OF  MEDICINE.  Edited 

by  Sir  John  Y.  W.  MacAlister,  Under  the  Direction  of 
The  Editorial  Committee.  New  York,  Bombay,  Calcutta, 
Madras,  and  London :  Longmans,  Green  &  Co.,  1920. 

the  new  world  OF  science,  its  development  DURING  THE 

W  AR.  Edited  by  Robert  M.  Yerkes,  Chairman  of  the  Re- 
search Information  Service,  National  Research  Council. 
Illustrated.  New  York:  The  Century  Company,  1920. 
Pp.  vi-443. 

morale,  the  supreme  standard  of  life  and  conduct. 
By  G.  Stanley  Hall,  Ph.D.,  LL.  D.,  President  of  Clark 
University ;  Author  of  Adolescence,  Founders  of  Modern 
Psychology,  etc.  New  York:  D.  Appleton  &  Co.,  1920. 
Pp.  ix-378. 

PHYSIOLOGICAL  CHEMISTRY.  A  Textbook  and  Manual  for 
Students.  By  Albert  P.  Mathews,  Ph.  D.,  Professor  of 
Biochemistry,  University  of  Cincinnati.  Third  Edition, 
Illustrated.  New  York:  William  Wood  &  Co.,  1920.  Pp. 
xiv-1154 

patient's  handbook  on  the  treatment  of  diabetes 
MELLiTus.  By  Thomas  W.  Edgar,  M.  D.,  Author  of 
Psychology  of  Prognosis,  Edgar  Serum  Treatment  of 
Diabetes,  Limitation  of  Starvation  in  Diabetes.  Boston: 
Richard  G.  Badger,  1920.    Pp.  100. 

A  PRACTICAL  MEDICAL  DICTIONARY.     By  ThOMAS  LaTHROP 

Stedman,  a.  M.,  M.  D.,  Editor  of  the  Tiventieth  Century 
Practice  of  Medicine,  of  the  Reference  Handbook  of  the 
Medical  Sciences,  and  of  the  Medical  Record.  Sixth  Re- 
vised Edition.  Illustrated.  New  York:  William  Wood  & 
Co.,  1920.    Pp.  viii-1144. 

lehrbuch  der  mikrophotographie.  Von  Dr.  med.  Kurt 
Laubenheimer  a.  o.  Professor  fiir  Hygiene  und  Bakteriolo- 
gie  an  der  Universitat  Heidelberg.  Mit  116  zum  Teil  farbi- 
gen  Abbildungen  im  Text  und  13  mikrophotographischer 
Aufnahmen  auf  6  Tafeln.  Berlin-Wien :  Urban  &  Schwarz- 
enberg,  1920.    Pp.  viii-220. 

RELIGION  and  HEALTH.  By  James  J.  Walsh,  M.  D.,  Ph.  D., 
Sc.  D.,  Medical  Director  of  Fordham  University 
School  of  Sociology ;  Professor  of  Physiological  Psychol- 
ogy, Cathedral  College  Lecturer  on  Psychology  and  So- 
ciology, Marywood  College,  Scranton,  Pa.,  Mt.  St.  Mary's, 
Plainfield,  N.  J.  Boston:  Little,  Brown  &  Co.,  1920. 
Pp.  341. 

DIATHERMY    IN     MEDICAL    AND    SURGICAL    PRACTICE.  By 

Claude  Saberton,  M.  D.,  Hon.  Radiologist  to  the  Harro- 
gate Infirmary  and  to  the  Royal  Bath  Hospital,  Harrogate ; 
Late  Hon.  Medical  Officer  to  the  X  Ray  and  Electrical 
Department,  Royal  Victoria  and  West  Hants  Hospital. 
With  Thirty-three  Illustrations.  New  York :  Paul  B. 
Hoeber,  1920.    Pp.  xii-138. 

THE  OXFORD  MEDICINE.  By  Various  Authors.  Edited  by 
Henry  A.  Christian,  A.  M.,  M.  D.,  Hersey  Professor  of 
the  Theory  and  Practice  of  Physic,  Harvard  University ; 
Physician  in  Chief  to  the  Peter  Bent.  Brigham  Hospital, 
Boston,  Mass.,  and  Sir  James  Mackenzie,  M.  D.,  F.  R.  S. 
P.,  LL.  D.,  F.  R.  C.  P.,  Consulting  Physician  to  the  London 
Hospital,  and  Director  of  the  Clinical  Institute,  St.  An- 
drews, Scotland.  In  Six  Volumes,  Illustrated.  Volume  II, 
Diseases  of  Bronchi,  Lungs,  Mediastinum,  Heart,  Arteries, 
and  Blood.  London,  Toronto,  Melbourne,  Bombay,  New 
York:  Oxford  University  Press,  1920.    Pp.  xv-817. 


Practical  Therapeutics  and  Preventive  Medicine 

A  Compendium  of  Treatment  and  Prophylaxis,  Origmal  and  Ada  pted 


Operation  for  Spinal  Fusion. — A.  Mackenzie 
Forbes  (Journal  of  Ortliopedic  Surgery,  Septem- 
ber, 1920)  gives  the  technic  of  his  operation  for 
spinal  fusion  as  follows :  A  flap  of  skin  sufficiently 
long  to  expose  the  area  to  be  operated  on  is  reflected 
from  the  concave  side  as  in  the  Albee  operation. 
The  muscles  on  either  side  of  the  spinous  processes 
are  separated  and  retracted,  exposing  the  laniinte. 
The  supraspinous  ligament,  the  interspinous  liga- 
ments, and  other  tissues  between  the  adjacent  spin- 
ous processes  are  removed.  In  the  case  of  the 
dorsal  vertebrae  the  following  additional  steps  are 
carried  out.  The  spinous  processes  and  lamina? 
are  so  gouged  by  means  of  a  concave  chisel  that 
their  cortical  layers  are  separated  from  the  medulla 
beneath  and  a  series  of  chips  of  bone  and  periosteum 
are  pried  up  along  the  superior  and  inferior  surfaces 
of  these  parts  of  the  vertebra?.  These  chips  of 
bone  are  made  to  interdigitate  with  each  other  thus 
.similar  cortical  chips  or  digitations  from  the  ad- 
jacent vertebrae  are  so  apposed  that  the  new  bone 
thrown  out  from  the  raw  surfaces  of  the  exposed 
medulla  will  unite  in  one  bridge  or  band  extending 
from  vertebrae  to  vertebr:e.  In  other  words,  the 
laminae  and  spines  in  this  region  are  in  such  close 
apposition  that  the  interval  between  them  is  easily 
bridged  by  pushing  the  elevated  fragments  adherent 
to  the  periosteum  alternately  upwards  and  down- 
wards from  the  laminae  and  spinous  processes,  thus 
making  a  form  of  connecting  trellis. 

Chromic  Acid  in  Suppurative  Dacryocystitis. — 

L.  Chenisse  (Prcssc  iiudicalc.  April  24,  1920)  de- 
scribes a  plan  of  treatment  recently  recommended 
by  \'acher  and  Denis  and  which,  it  is  stated,  permits 
of  maintaining  j^atency  of  infected  lachrymal  pas- 
sages and  removes  the  necessity  for  surgical  exci- 
sion of  the  lachrymal  sac.  Thorough  anesthesia  of 
the  eye  is  first  obtained  with  five  per  cent,  cocaine 
solution  and  the  sac  cleansed  with  boiled  water 
introduced  by  means  of  a  syringe  and  fine  blunt 
needle  into  the  lower  lachrymal  canal.  A  few 
drops  of  the  cocaine  solution,  with  adrenalin,  are 
then  injected  through  the  .'^ame  needle,  and  patency 
of  the  lachrymal  passages  ascertained  by  means  of 
a  No.  .3  or  4  probe,  left  situ  for  a  few  minutes. 
One  third  mil  of  a  two  per  cent,  or  even  a  3.33 
per  cent,  solution  of  chromic  acid  is  then  drawn 
u]i  int  othe  .syringe  and  injected  slowlv  through 
the  lower  lachrymal  duct,  an  assistant  meanwhile 
introducing  pure  hydrogen  peroxide  solution  drop 
by  drop  into  the  eye  in  order  to  neutralize  the 
small  amount  of  chromic  acid  solution  which  fre- 
(|uently  flows  back  through  the  lachrymal  passages. 
In  sensitive  patients  one  may  supplant  the  oph- 
thalmic anesthesia  by  spraying  cocaine  into  the  nose, 
a  little  of  the  caustic  solution  sometimes  passing 
into  the  nasal  cavities.  The  chromic  solution  is 
permitted  to  act  for  two  or  three  minutes  on  the 
mucous  membrane  of  the  lachrymal  passages  and 
the  treatment  concluded  by  injection  of  a  few  drops 


of  hydrogen  perox'ide  solution  into  the  lachrymal 
sac.  On  the  succeeding  days  the  lids  and  eyes  are 
washed  with  warm  boiled  water  and  the  sac  emp- 
tied by  pressure  at  the  inner  angle  of  the  eye. 
After  a  few  days  the  lachrymal  passages  are  ex- 
amined for  permeability  and,  if  neces.sary,  a  perma- 
nent probe  of  silver  wire  inserted  to  restore  it. 
W^here  the  first  chromic  acid  injection  fails  to  yield 
perfect  results  the  treatment  is  repeated  once  or 
twice,  sometimes  with  stronger  chromic  solutions. 

Blood  Sugar  Tolerance  as  an  Index  in  the 
Early  Diagnosis  and  Rontgen  Treatment  of 
Hyperthyroidism. — Eric  R.  Wilson  (Journal  of 
Laboratory  and  Clinical  Medicine,  August,  1920) 
studied  the  blood  sugar  tolerance  in  five  cases  of 
hyperthyroidism  in  young  women  between  the  ages 
of  twenty-three  and  thirty-three,  all  unmarried. 
The  determinations  were  made  before  rdntgen 
therapy,  after  two  series  of  rontgen  treatments,  and 
after  the  completion  of  three  series  of  these  treat- 
ments. As  a  result  of  this  study  the  following  con- 
clusions are  drawn :  The  blood  sttgar  tolerance  test  is 
of  distinct  advantage  in  the  early  diagnosis  of 
hyperthyroidism.  That  seemingly  advanced  cases 
of  hyperthyroidism  will  respond  moderately  only  to 
rontgen  treatment,  as  shown  by  the  blood  sugar 
tolerance  test.  An  abnormal  blood  sugar  tolerance 
curve  when  due  to  hyperthyroidism  will  tend  to 
approach  the  normal  under  rontgen  therapy,  indi- 
cating that  excessive  toxic  secretion  is  lessened. 
Clinical  manifestations  of  hyperthyroidism  may  be 
lessened,  but  an  abnormal  blood  sugar  tolerance 
curve  may  exist  after  series  of  rontgen  treatments. 
The  blood  sugar  tolerance  curve  is  an  index  to  thy- 
roid hypersecretion  in  those  cases  in  which  toxic 
secretion  has  manifested  it.self  bv  a  decreased  glu- 
cose tolerance. 

Influence  of  Calcium  upon  Glycosuria.— A.  G. 
Phocas  (Bulletin  dc  1' Academic  dc  nicdccine,  March 
23,  1920),  mindful  of  Fischer's  assertion  that  cal- 
cium chloride  removes  glycosuria  experimentally 
induced  by  sodium  ions  and  of  the  known  dynamic 
antagonism  between  sodium  and  calcium  ions,  was 
led  to  think  that  administration  of  calciinn  might 
be  of  service  in  some  cases  of  diabetes.  He  gives 
brief  histories  of  nine  cases,  in  all  of  which  the 
(|uantity  of  sugar  passed  was  considerably  reduced, 
or  even  glycosuria  completely  checked  by  this 
measure.  In  one  of  the  most  striking  cases  a  sugar 
output  of  sixty  grams  a  day  was  wholly  arrested 
upon  ingestion  of  calciinn  chloride  for  one  week. 
The  best  ])reparation  of  calcium  for  these  patients 
is  asserted  to  be  lime  water,  given  in  a  daily  dose 
of  100  to  200  mils.  Preference  is  given  to  this 
preparation  because  its  alkalinity  may  be  of  value 
in  combating  acidosis  and  in  improving  the  patient's 
power  to  oxidize  glucose.  In  fact,  lime  water  is 
in  one  sense  preferable  to  sodium  bicarbonate  as 
a  general  remedy  for  acidosis  because  the  latter 
supersaturates  the  organism  with  carbon,  dioxide, 


828 


PRACTICAL   THERAPEUTICS     AND  PREVENTIVE  MEDICINE.  [New  Vo«k 

Medical  Jocrnal. 


which  acts  as  an  obstacle  to  organic  combustion. 
An  excess  of  lime,  on  the  other  hand,  tends  to  fix 
a  certain  proportion  of  the  carbon  dioxide  set  free 
in  combustion,  and  may  thus  indirectly  improve 
Oxidation,  besides  controlling  any  overstimulation 
of  the  nerve  cells  due  to  the  action  of  the  sodium 
ions.  The  strict  milk  diet  in  diabetes  probably  acts, 
in  removing  glycosuria,  by  restoration  of  balance 
between  the  sodium  and  calcium  ions.  While  re- 
ducing the  sodium  chloride  in  the  system,  the  milk 
introduces  a  considerable  quantity  of  calcium  in 
the  highly  assimilable  calcium  compound  it  contains. 

Syphiloma  Vulvae.  —  Arthur  Stein  (^Surgery, 
Gynecology  and  Obstetrics,  September,  1920)  pre- 
sents the  following  conclusions  in  regard  to 
syphiloma  vuIvje  :  1.  In  conformity  with  modern 
knowledge  and  in  the  interest  of  a  better  under- 
standing of  the  disease,  all  misleading  names  such 
as  esthiomene  or  lupus  vulvae  should  be  extermin- 
ated from  the  literature.  2.  Syphiloma  vulvae  cor- 
rectly designates  the  disease  as  a  manifestation  of 
tertiary  lues.  3.  A  positive  Wassermann  test  is 
not  essential  in  view  of  the  long  standing  char- 
acter of  the  specific  infection  in  the  majority  of 
the  cases.  4.  The  treatment  under  all  circum- 
stances should  consist  of,  1,  operative  removal  of 
all  tumors,  hypertrophied  tissues  and  ulcers,  fol- 
lowed in  the  same  session  by,  2,  energetic  cauter- 
ization and  combined  with,  3,  intensive  antisyphi- 
litic  medication. 

Plastic  Surgery  of  the  Ear. — Julien  Bourguet 

(Bulletin  do  I'Academie  dc  mcdccinc,  April  13, 
1920)  describes  surgical  procedures  appropriate  in 
various  kinds  of  deformity  of  the  ear.  In  cases 
of  excessively  large  external  ear  a  wedge  shaped 
piece,  extending  through  the  entire  thickness  of  the 
ear,  is  removed.  If  the  upper  portion  of  the  ear 
then  seems  too  broad,  two  additional  wedges  are 
taken  out,  the  one  above  and  the  other  below  and 
perpendicular  to  the  first.  The  raw  margins  are 
then  sutured  together.  The  lobule  may  also  be 
reduced  by  removal  of  a  triangular  segment.  Where 
the  lobule  alone  is  too  long,  a  lozenge  shaped  sec- 
tion is  removed  and  the  lobule  reduced  to  its 
normal  size  by  appropriate  suturing.  Where  the 
external  ear  is  flat,  having  no  helix,  a  crescentic  skin 
incision  is  made  on  the  anterior  surface  of  the  ear, 
four  millimetres  from  the  flattened  margin,  the 
cartilage  exposed,  and  at  a  distance  of  three  milli- 
metres excision  of  skin  and  cartilage  is  performed 
without  injuring  the  skin  on  the  posterior  aspect. 
The  band  of  cartilage  thus  liberated  from  the  main 
cartilage  falls  forward  to  form  a  curled  margin  and 
is  sutured  in  proper  position.  In  triangular  ears 
a  T  shaped  piece  of  tissue  is  removed  and  the 
margins  sutured.  Undue  protrusion  of  the  ear  is 
corrected  by  removing  opposite  crescentic  pieces  of 
skin  on  either  side  of  the  furrow  behind  the  ear 
and  also  a  sickle  shaped  piece  of  cartilage,  carefully 
avoiding  injur}'  to  the  skin  on  the  anterior  aspect ; 
skin  sutures  are  then  inserted  Sagging  ears  are 
corrected  in  nearly  the  same  manner,  with  the 
exception  that  in  these  cases  a  sickle  shaped  piece 
of  skin  of  varying  breadth  is  alone  removed;  the 
skin  of  the  upper  and  lower  margins  is  dissected 
up  and  then  sutured,  thus  straightening  the  ear. 


Production  of  Hemolysins  by  Injection  of 
Salts  of  the  Rare  Earth  Metals. — Frouin  {Paris 
medicale,  March  13,  1920)  was  able  to  cause  the 
production  of  hemolysins  by  intraperitoneal  injec- 
tion in  rabbits  of  salts  of  the  rare  earth  metals. 
This  process  constitutes  an  example  of  the  produc- 
tion of  antibodies  in  the  animal  system  without  pre- 
vious stimulation  of  a  defensive  reaction  by  the 
corresponding  specific  antigens. 

Heteroplastic  Bone  Formation  in  the  Fallopian 
Tube. — Goichi  Asami  {American  Journal  of  the 
Medical  Sciences,  July,  1920)  reports  a  case  of 
aberrant  bone  formation  in  the  fallopian  tube. 
Cartilage  was  undergoing  ossification  and  was 
surrounded  by  an  organization  tissue,  some  of  which 
had  been  converted  into  an  osteoid  tissue.  It  is 
assumed  that  a  metaplasia  of  the  connective  tissue 
occurred  with  the  formation  of  cartilage  and  the 
production  of  bone,  but  how  it  was  done  is  left 
unexplained. 

Arthroplasty  of  Knee  Joint. — Putti  {Journal  of 
Orthopedic  Surgery,  September,  1920),  from  a  re- 
port of  ten  cases  of  arthroplasty  of  the  knee  joint, 
gives  the  following  as  the  lessons  learned:  1.  Com- 
plete removal  of  all  intraarticular  structures  is 
necessary.  2.  The  knee  operated  upon  is  usually 
larger  than  the  other  from  hypertrophy  of  tissues. 
3.  Operation  too  soon  after  acute  inflammation  in 
the  joint  has  subsided  means  failure.  4.  In  gonor- 
rheal knees  with  arthroplasty  the  postoperative  care 
should  be  gentle.  A  longer  time  is  required  for 
good  results. 

Arthrodesis  for  Nontuberculous  Hip  Joint. — 

H.  W.  Spiers  {Journal  of  Orthopedic  Surgery, 
September,  1920)  presents  the  following  conclu- 
sions from  a  study  of  thirty-four  operative  cases 
from  the  orthopedic  clinic  of  the  Massachusetts 
General  Hospital:  1.  Arthrodesis  for  painful  hips 
of  traumatic  origin  gives  a  satisfactory  end  result. 

2.  Arthrodesis  for  painful  hips  of  hypertrophic 
arthritic  origin  are  less  satisfactory  but  justified. 

3.  The  time  of  convalescence  is  a  long  one,  ap- 
proaching a  year.  4.  The  tendency  of  the  extrem- 
ity is  to  return  to  the  position  of  adduction  and 
little  should  be  promised  in  this  regard. 

Blood  Changes  Following  Rontgen  Ray  Treat- 
ment of  Leucemia. — Charles  L.  Martin  and  W. 
Denis  {American  Journal  of  the  Medical  Sciences, 
August,  1920)  report  the  results  obtained  in  four 
cases  of  myelogenous  leucemia  in  which  the  chemi- 
cal changes  occurring  in  certain  of  the  nonprotein 
constituents  of  the  blood  during  rontgen  ray  treat- 
ment have  been  followed.  In  the  more  severe  cases 
the  nonprotein  nitrogen  was  extremely  high ;  after 
treatment  a  gradual  but  steady  fall  was  noted.  In 
view  of  the  fact  that  the-creatinin  values  are  invari- 
ably normal  and  that  in  the  most  severe  case  the 
urea  accounted  for  only  twenty  per  cent,  of  the 
nonprotein  nitrogen  fraction,  instead  of  the  usual 
fifty  per  cent.,  the  suggestion  is  made  that  in  leu- 
cemia there  is  present,  possibly  as  a  constituent  of 
the  white  cells,  some  nitrogenous  constituent  not 
accounted  for  in  the  present  scheme  of  blood  an- 
alysis. The  true  acid  content  of  the  blood  was 
much  increased. 


Proceedings  of  National  and  Local  Societies 


AMERICAN  ASSOCIATION  OF  OBSTETRI- 
CIANS,  GYNECOLOGISTS,  AND 
ABDOMINAL  SURGEONS. 

Thirty-third  Annual  Meeting,  Held  at  Atlantic  City, 
'  N.  J.,  September  20,  21,  and  22,  1920. 

The  President,  Dr.  George  W.  Crile,  in  the  Chair. 

{Concluded  from  page  788.) 

Treatment  of  Abortion  Complicated  by  Sepsis. 
— Dr.  George  A.  Peck,  of  New  Rochelle,  drew  the 
following  conclusions:  1.  The  conservative  treat- 
ment of  abortion  complicated  by  sepsis  is  based 
on  pathological  entities  and  clinical  end  results. 
2.  Hemorrhage  is  the  only  symptom  that  may  de- 
mand a  prompt  and  thorough  emptying  of  the 
uterus  for  its  control.  3.  Every  intrauterine 
manipulation  or  procedure  should  be  executed  with 
the  greatest  care  to  avoid  traumatizing  and  other- 
wise injuring  the  endometrium.  4.  Late  cases, 
and  especially  those  in  which  the  patients  had  al- 
ready been  subjected  to  curettement.  are  eminently 
suitable  for  this  form  of  treatment. 

Missed  Abortion. — Dr.  Jennings  C.  Litzen- 
BERG,  of  Minneapolis,  Minn.,  stated  that  missed 
abortion  was  the  retention  of  a  dead  fetus  before 
viability  retained  in  utero  more  than  two  months 
after  birth.  It  was  a  common  condition  and  was 
dangerous,  as  temporary  ill  health  until  the  uterus 
was  emptied,  or  pennanent  ill  health  would  result. 
The  diagnosis  was  not  unusually  difficult.  The 
uterus  should  be  emptied  before  the  condition  be- 
came a  menace  to  health  and  life. 

Preparation  of  the  Skin  for  Operation  with 
Special  Reference  to  the  Use  of  Picric  Acid. — 
Dr.  H.  W.  Hewitt,  of  Detroit,  Mich.,  stated  that 
it  seemed  clear  that  a  good  preparation  for  disin- 
fection of  the  skin  should  possess  the  following 
properties,  namely:  1.  It  should  be  simple  and 
easy  of  application.  2.  It  should  be  efficient,  i.e., 
have  the  power  of  destroying  the  common  skin 
organisms  in  a  comparatively  short  time  (not  over 
three  minutes),  and  be  sufficiently  powerful  to 
keep  the  skin  sterile  during  the  operation.  3.  It 
should  not  macerate  or  injure  the  skin  in  any  way. 
4.  In  laparotomies  it  should  not  injure  the  peri- 
toneal coat  of  the  intestine,  if  the  intestine  acci- 
dentally came  in  contact  with  it.  5.  It  should  be 
of  universal  application.  6.  It  should  contain  no 
proprietary  preparations,  since  these  were  of  un- 
known strength  and  could  not  be  depended  upon. 
7.  It  should  be  standardized,  so  that  its  antiseptic 
value  might  be  known.  Solutions  might  be  stand- 
ardized by  the  Walker-Rideal  method.  Of  all  the 
methods  and  chemicals  in  use  today,  very  few  ap- 
proached this  standard.  Bichloride  of  mercury  in 
aqueous  solution  would  not  sterilize  the  skin ;  in 
Harrington's  solution  it  was  efficient,  but  this  so- 
lution contained  hydrochloric  acid  and  injured  the 
skin.  Dr.  Hewitt  said  that  he  had  used  this  solu- 
tion extensively,  but  had  discarded  it. 

About  three  years  ago  his  attention  was  attracted 
to  picric  acid  as  used  in  the  British  Army.  Chemic- 


ally, picric  acid  was  known  as  trinitrophenol,  its 
formula  was  C6H2(N02)30H,  and  it  was  soluble 
in  ninety-five  parts  of  water  and  sixteen  parts  of 
alcohol.  It  had  been  used  to  a  large  extent  in  the 
treatment  of  burns  and  was  known  as  a  parasiti- 
cide. It  was  also  astringent  and  penetrated  deeply 
the  corneous  layer  of  the  skin.  Its  only  disad- 
vantage had  been  in  staining  the  skin,  an  effect 
which  would  last  from  twelve  to  eighteen  days  but 
might  be  removed  by  the  application  of  a  five  per 
cent,  solution  of  carbonate  of  soda,  or  a  twenty- 
five  per  cent,  solution  of  ammonia  in  ethyl  alcohol, 
provided  this  was  done  immediately  after  the  opera- 
tion was  finished.  The  picric  acid  solution  used 
in  these  experiments  and  in  his  clinic  was  made  by 
saturating  a  seventy  per  cent,  ethyl  alcohol  solu- 
tion with  picric  acid,  which  made  a  six  per  cent, 
solution. 

The  merits  of  this  method  of  preparation  were 
many,  namely,  it  was  simple ;  it  was  cheap ;  it  was 
efficient ;  it  did  not  injure  the  skin  in  any  way,  and 
might  be  used  on  any  part  of  the  body ;  it  did  not 
injure  the  peritoneal  coat  of  the  intestine ;  it  con- 
tained no  proprietary  preparation,  and  its  anti- 
septic strength  might  be  standardized.  This  was 
only  a  preliminary  report.  The  staft'  of  Grace 
Hospital,  Detroit,  had  used  this  preparation,  up  to 
August  1,  1920,  in  926  cases,  and  it  was  now  the 
adopted  method  of  skin  preparation  in  that  hospi- 
tal. The  number  of  cases  reported  Was  still  too 
small  to  justify  definite  conclusions,  but  Dr.  Hewitt 
said  he  hoped  at  some  future  time  to  report  a  series 
sufficiently  large  to  be  of  clinical  value. 

Pathology  of  Common  Puerperal  Lesions. — 

Dr.  John  Osborn  Polak.  of  Brooklyn,  N.  Y., 
stated  that  in  order  thoroughly  to  grasp  the  physi- 
ological patholog}'  which  actually  took  place,  one 
must  appreciate  that  the  uterus,  during  involution, 
was  a  puerperal  wound.  Its  interior  was  under- 
going the  normal  process  of  repair  and  inoculation 
of  this  wound  would  produce  either  a  toxemia  or  a 
definite  inflammatory  reaction,  depending  largely  on 
the  character  of  the  infecting  organism.  At  first, 
this  wound  infection  was  a  local  process  which  might 
be  illustrated  in  the  infected  perineum,  or  the  in- 
fected cervix  tear,  or  the  infected  endometrium.  In 
each,  there  was  an  inflammatory  reaction  in  the 
adjacent  tissues,  which  limited  extension  of  the  in- 
fective process  and  confined  it  to  a  circumscribed 
area  about  the  wound  or  within  the  uterus.  In 
these  localized  lesions  the  pyrexia  and  other  con- 
stitutional symptoms  were  due  to  two  factors.  The 
toxemia  resulting  from  an  absorption  of  the  toxins 
liberated  by  the  bacteria  and  second,  to  the  tissue 
reaction  excited.  On  the  other  hand,  the  process 
might  be  a  spreading  infection  extending  beyond 
the  wound  area.  This  was  due  either  to  the  in- 
creased virulence  of  the  infecting  bacterium  or  to 
the  diminished  resistance  of  the  tissues.  This 
spreading  infection  might  occur  by  extension 
through  the  lymphatics  within  the  walls  of  the 
uterus,  spreading  to  the  lymphatics  in  tlie  para- 


PROCEEDINGS  Of  NATIONAL   AND  LOCAL  SOCIETIES. 


[New  York 
Medical  Journal. 


metrium  producing  a  parametritis,  or  a  peritonitis, 
or  even  a  bacteriemia,  or  the  infection  might  extend 
through  the  blood  vessels,  in  which  case  it  mani- 
fested itself  clinically  as  a  thrombophlebitis,  an 
embolic  pyemia,  or  a  bacteriemia. 

Clinical  experience  had  shown  him  that  a  well 
contracted  uterus  in  normal  anteversion  was  cap- 
able of  emptying  itself  of  its  contents  if  infection 
was  not  introduced  from  the  outside.  Experience 
had  taught  him  that  any  sort  of  trauma  to  the  del- 
icate granulation  wall  of  the  puerperal  uterus  which 
was  confining  the  infection  within  the  cavity, 
opened  avenues  of  extension,  and  that  lateral  para- 
metritis was  a  constant  sequel  of  attempts  at  dig- 
ital or  instrumental  exacuation.  It  was  important 
to  note  that  the  encajjsulated  germs  did  not  always 
lose  their  virulence,  but  might  on  the  occasion  of 
subsequent  traumatism  or  operation  break  out  with 
increased  virulence  and  cause  a  bacteriemia. 

In  blood  stream  infections  the  local  pathological 
reaction  was  consideraljle.  consequently  the  local 
symptomatology  was  insignificant ;  for  whether  the 
bacteria  entered  the  l)lood  stream  via  the  lymphatics, 
or  via  the  veins,  their  transit  was  so  rapid  and  the 
leaction  caused  so  insignificant,  that  appreciable 
local  lesions  must  necessarily  be  absent.  For  the 
entrance  of  bacteria  into  the  blood  .stream,  there 
must  be  a  puerperal  wound  which  was  inoculated 
by  bacteria.  Broadly  speaking,  the  treatment  de- 
])ended  on  the  pathological  diagnosis  and  might  be 
considered  under  the  following  heads:  1.  Local 
measures  which  secured  drainage  and  uterine  con- 
traction. 2.  General  supportive  measures  that  in- 
creased the  -patient's  resistance.  3.  Specific  rem- 
edies, especially  of  value  in  blood  stream  infections. 
4.  Finally,  surgical  measures.  These  were  only 
a]:)plicable  to  abscess  formations  and  thrombotic 
lesions  of  the  pelvic  veins. 

Factors  That  Determine  Tissue  Resistance  to 
Cancer. — Dr.  James  E.  Davis,  of  Detroit,  Alich., 
said  that  the  life  of  a  complex  organism  was  the 
result  of  cell  interactions  and  the  internal  metabolism 
of  the  individual  cells.  Factors  altering  cell  inter- 
actions were  tolerated  by  the  high  vertebrate  forms 
only  when  it  was  possible  to  accomplish  conforma- 
tion within  a  limited  period  of  time.  Convincing 
examples  of  this  fact  were  observed  after  amputa- 
tions, resections,  traumatizations,  autotransplants 
and  homotransplants  and  heteroplastic  grafts.  Loeb 
transplanted  thyroid  into  subcutaneous  tissue,  re- 
moved it  seven  days  later,  and  found  the  transplant 
surrounded  by  a  connective  tissue  capsule  rich  in 
fibroblasts.  Inside  the  capsule  a  large  vessel  was 
proliferating.  In  the  capsule  and  about  the  vessel 
a  few  thyroid  acini  in  contracted  form  were  per- 
sisting. Necrosis,  hemorrhage  and  organization 
were  going  on  elsewhere  conforming  the  transplant. 

The  transplantation  of  tumors  in  the  higher 
species  of  annuals  had  failed,  excepting  the  infec- 
tious sarcoma  of  the  dog.  In  the  normal  tissues 
resistance  was  adequate  for  control  and  destruction 
of  inherent  neoplastic  dynamic  growth  power 
which  was  uncontrollable  in  its  autogenetically  pre- 
pared tissue.  The  cell  and  its  surrounding  fluid 
possessed  interactive  and  retroactive  properties. 
The  most  convincing  proof  of  this  was  given  by 


Carrel  who  had  grown  connective  tissue  in  vitro 
for  almost  eight  years.  The  plasmatic  jelly  med- 
ium when  used  too  long  became  licjuefied,  its  fibrin 
disappeared  and  the  air  rarefied,  effecting  a  marked 
slowing  of  growth.  Fresh,  unused  plasma  from 
the  icebox  promptly  quickened  the  growth  rate. 
The  plasma  from  a  chicken  four  to  five  months  old 
caused  a  growth  fifteen  microns  more  extensive 
than  did  that  from  a  five  to  six  year  old  chicken. 

The  reactions  following  exhaustion,  irritation 
and  specific  diet,  gave  acidity,  toxicity,  and  cyto- 
plasmic sensitization.  Measurement  of  these  states 
was  a  procedure  of  real  scientific  value  to  the  clin- 
ician. The  reaction  of  coiuiective  tissue  to  epithelial 
neoplasia  before  and  after  its  invasion  was  signifi- 
cant and  important.  Epithelial  cell  disintegration 
stimulated  phagocytic  and  proliferative  connective 
tissue  reaction  and  ,the  latter  in  turn  might 
j)0ssil)]y  cause  increase  of  dynamic  growth  power, 
without  a  corresponding  increase  of  nutrition.  The 
clinical  recognition  of  long  continued  cell  irritation 
and  unbalance  of  tissue  was  too  frequently  delayed 
until  after  the  expression  of  organic  functional  dis- 
order. The  determination  of  stressed  or  irritated 
tissue  potentiality  should  have  much  attention. 
The  determination  of  sensitization  acidity  and  oxi- 
dation reactions  were  essentially  cjuantitative  tests 
which  had  relational  value  in  this  problem.  It  was 
mainly  a  quantitative  difference  in  energy  and  time 
factors  that  existed  between  regenerating  and  can- 
cerous cells  and  it  was  for  this  difference  one  shotild 
test.  Physiological  growth,  regeneration  and 
neoplasia  utilized  the  same  means  to  produce  a 
product  and  resistance  was  an  e.s.sential  cause  for 
all  three.  Normal  growth  was  production  under 
control,  regeneration  was  production  to  control,  and 
neoplasia  was  productioii  without  control. 

BRITISH  NATIONAL  ASSOCIATION 
FOR  THE  PREVENTION  OF 
TUBERCULOSIS. 
Auiiital  Conference  Held  in  Liverpool.  England. 
October  7.  5,  and  9,  1920. 
The  President,  Sir  Arthur  Stanley,  in  the  Chair. 

Prevention  and  Treatment  of  Tuberculosis. — A 

paper  on  this  subject  by  Dr.  E.  \V.  Hope,  officer 
of  health  of  Liverpool,  was  read  by  Dr.  Musson, 
deputy  medical  officer.  It  presented  a  review  of 
the  various  methods  of  prevention  and  treatment 
of  tuberculosis,  advocated  from  time  to  time,  the 
extent  to  which  they  have  been  followed,  and  the 
results  obtained.  Dr.  Hope  pointed  out  that  treat- 
ment had  hitherto  received  an  overwhelmingly 
greater  amount  of  attention  than  prevention.  In 
the  case  of  the  other  great  scourges  of  the  human 
race  in  bygone  days,  plague,  leprosy,  smallpox, 
t\'phus.  and  malaria,  the  same  phenomenon  was  ob- 
served, but  prevention  had  come  into  its  own  at  last. 
He  thought  that  there  was  no  doubt  that  the  sana- 
torium had  been  introduced  with  an  unfortunate 
flourish  of  trumpets,  which  resulted  in  inflated  ex- 
pectations among  those  who  did  not  appreciate  the 
precise  functions  of  such  institutions.  Sanatoriums 
were  necessary,  but  the  lienefits  that  they  conferred 


Novtmher  20.  1920.] 


PROCEEDINGS  OF  XATIOXAL 


.1X1)  LOCAL  SOCIETIES. 


831 


w  ould  be  more  effective  and  more  lasting  the  earlier 
the  patient  could  be  brought  under  their  good  influ- 
ences. The  value  of  educational  methods  in  the 
prevention  of  tuberculosis  could  hardly  be  exag- 
gerated. The  sanatorium,  the  tuberculosis  dispen- 
sary, and  the  medical  practitioner,  all  had  their  part. 

Tuberculosis — a  Social  Problem. — Lieutenant 
Colonel  Nathan  Raw,  M.  D.,  M.  P.,  said  that -of 
all  the  diseases  with  which  authorities  were  called 
u])on  to  deal  none  was  more  difficult,  perplexing, 
and  unsatisfactory  than  tuberculosis.  It  was  diffi- 
cult because,  unlike  any  other  disease,  tubercidosis 
was  part  and  parcel  of  the  social  problem  of  the 
country.  It  thrived  and  was  spread  in  insanitary 
housing  conditions  and  in  turn  tuberculosis  caused 
poverty  and  di.stress  with  unemployment  and  desti- 
tution. The  problem  was  perplexing,  because  we 
had  not  yet  an  accurate  knowledge  of  the  di.scase. 
It  was  known  that  tuberculosis  was  caused  by  a 
germ,  the  tubercle  bacillus,  and  was  therefore  an 
infectious  disease,  but  they  were  not  by  any  means 
certain  as  to  how  or  when  infection  took  place  in 
the  human  body.  It  was  known  that  tuberculosis 
was  never  hereditary,  and  that  it  was  therefore  a 
preventable  disease,  and,  given  proper  and  adequate 
treatment,  it  was  curable.  The  results  of  treatment 
were  at  the  present  time  unsatisfactory,  due  almost 
entirely  to  tlie  fact  that  sufficient  time  could  not  be 
devoted  by  the  patient  to  his  cure.  In  his  opinion, 
nothing  less  than  six  months'  treatment  under  open 
air  conditions  was  of  much  service,  and  manv 
patients  recjuired  one  or  two  years.  The  jirovision 
of  village  settlements  in  which  suitable  men  might 
permanently  reside,  earn  their  own  living,  and  have 
their  relatives  live  near  them,  was  the  most  satis- 
factory method  of  treatment,  but,  of  course,  it  was 
the  most  costly.  He  felt  sure  that  the  removal  of 
tuberailosis,  more  especially  in  regard  to  treatment, 
from  the  provisions  of  the  National  Insurance  Act, 
and  its  constitution  as  a  special  branch  of  the 
Ministry  of  Health,  the  responsibility  for  dealing 
with  it  being  given  to  the  local  authorities  with  a 
substantial  grant  from  Imperial  funds  toward  the 
cost  of  treatment,  would  result  in  enormous  im- 
provement. 

Sanatorium  Treatment  of  Tuberculosis. — Dr. 

Iax  Stewart  Stkothers,  of  Aberdeenshire,  said 
that  in  his  opinion  people  were  not  justified  in  being 
content  with  the  results  obtained  from  sanatorium 
treatment,  and  this  belief  was  shared  by  others  who 
had  to  deal  with  individual  patients.  He  thought 
that  there  was  a  growing  sense  of  dissatisfaction 
among  the  laity  with  the  small  number  of  cures 
turned  out  by  sanatoriums.  Nevertheless,  experi- 
ence showed  that  these  institutions  remained  the 
best  means  at  their  disposal.  What  was  most 
urgently  needed  was  a  national  scheme  of  widely 
organized  research  directed  toward  the  treatment 
of  pulmonary  tuberculosis.  He  suggested  that  every 
sanatorium  should  be  a  centre  where  students  and 
graduates  could  have  a  few  weeks  of  instruction  to 
increase  their  knowledge  of  tuberculosis.  Two 
factors  militated  against  good  results  from  sana- 
toriums, a,  the  large  number  of  patients  allocated 
to  one  medical  officer,  and,  b,  the  late  stas^e  of  the 
disease  when  patients  arrived. 


A  Specific  for  Tuberculosis. — Dr.  Paul  Lewis, 
of  the  Henry  Phipps  Institute,  gave  a  brief  account 
of  the  experimental  work  in  tuberculosis  that  was 
being  carried  on  there,  and  said  he  felt  confident 
that  systematic  trial  would  re.^^ult  in  the  finding  of 
a  specific  chemical  substance  that  would  be  as 
beneficial  in  tuberculosis  as  salvarsan  was  in  syphilis. 

Crowding  in  Tuberculosis  Clinics. — Dr.  H. 
HvsLOP  Thomsox,  county  medical  officer  of  Hert- 
fordshire, County  Council,  referred  to  the  undesir- 
able crowding  that  existed  in  certain  -tuberculosis 
clinics,  and  of  the  necessity  for  coordinating  home 
and  dispensar)'  treatment.  Such  coordination  was 
most  necessary  in  scattered  rural  districts.  He  sug- 
gested the  appointment  of  medical  practitioners  as 
part  time  tuberculosis  officers  to  work  in  coopera- 
tion with  whole  time  officers  whose  duty  would 
include  attendance  at  the  clinic  at  each  session  with 
the  tuberculosis  officer  and  the  attending  of  domi- 
ciliary cases  at  their  homes. 

The  Human  Element  in  Tuberculosis  Work. — 
Sir  Henry  Gauvain,  medical  superintendent  of 
Lord  Mayor  Ireloar  Cripples'  Hospital,  .said  that 
money  might  be  lavished  on  a  scheme  for  tuber- 
culosis control,  but  unless  the  htmian  element  was  at 
work  the  money  would  be  wasted  or  \  ield  a  poor 
return.  The  British  Government  had.  realized  that 
important  grants  of  money  must  be  made,  and  was 
not  only  doing  much,  but  was  prepared  to  do  much 
more.  The  Mini.stry  of  Health  had  recognized 
its  responsibilities,  was  makinji-  increased  provision 
for  treatment,  establishing  more  beds,  founding 
colonies  for  the  tubercuk)us.  and  straining  every 
nerve  by  exhortation  and  grants  of  money  to  meet 
the  needs  of  the  unfortunate  sufferers  from  tuber- 
culous disease.  But  was  it  doiny  enough ;  was 
it  getting  or  going  to  get  the  best  value  for  the 
money  and  effort  expended?  If  not,  how  could  it 
do  better?  Were  its  energies  being  utilized  in  the 
best  direction?  If  not,  could  they  suggest  better  or 
more  perfect  methods?  These  were  tiuestions  which 
those  seriously  engaged  in  solving  tuberculosis 
problems  must  endeavor  to  answer.  They  were 
fighting  an  enemy  more  difficult  to  subdue  than  any 
human  foe.  They  were  spending  vast  sums  of 
money ;  they  were  going  to  spend  more,  but  they 
lacked  a  clearly  defined  policy.  The  remedy  was 
reasonably  clear.  Intensive  and  well  planned  ef- 
forts to  educate  the  public  to  the  danger  confront- 
ing it  should  be  made.  These  were  preventive  and 
defensive  measures,  but  the  surest  means  of  defen.se 
was  o*fTense.  It  was  here,  perhai)s,  that  they  couhl 
do  much  more.  The  neglect  of  adecjuate  instruc- 
tion in  the  prevention,  diagnosis  and  treatment  of 
tuberculous  disease  in  the  medical  schools  was  seri- 
ous. -A  few  teachers  did  take  some  interest  in  the 
treatment  of  tuberculosis,  but  they  appeared  to  be 
the  exception  and  not  the  rule.  Much  more  time 
should  be  devoted  in  medical  schools  to  really  in- 
telligent instruction  in  tuberculous  disease.  It  was 
imperative,  if  real  and  speedy  progress  was  to  be 
made,  that  thorough  and  systematic  instruction  in 
all  forms  of  tuberculous  disease  should  be  given  in 
the  medical  schools  and  facilities  given  for  extra- 
mural knowledge  to  be  obtained.  In  all  the  British 
Empire  only  one  imiversity  had  established  a  pro- 


832 


LETTERS  TO  THE  EDITORS. 


[New  York 
Medical  Journal. 


fessorship  in  tuberculosis.  That  was  at  Edinburgh, 
where  the  chair  was  held  by  the  distinguished  vice- 
president  of  the  association  council,  Sir  Robert 
Philip.  As  far  as  he  was  aware,  in  only  one  spe- 
cial hospital  for  nonpulmonary  consumption  was 
regular  and  systematic  instruction  given,  and  that 
was  at  Alton,  where  the  wards  were  thrown  open 
to  medical  men  and  students  by  the  generosity  of 
Sir  William  Ireloar  and  his  cotrustees,  and  even 
meals  were  supplied  to  students  attending  the 
courses,  all  without  a  fee  of  any  kind.  He  held 
strongly  that  their  first  hne  of  oflfense  against  tuber- 
culosis was  held  by  the  general  medical  practitioner. 
Too  little  had  been  done  to  enlist  his  powerful  help. 

When  they  came  to  the  tuberculosis  service  an 
even  worse  state  of  affairs  obtained.  He  realized  that 
he  was  treading  now  on  dangerous  ground.  He 
had  the  greatest  admiration  for  those  devoted  men 
engaged  on  this  thankless  and  comparatively  unre- 
mvmerative  task.  Only  those  who  had  had  an 
opportunity  of  seeing  their  work  closely,  under- 
standing the  difficulties  of  their  position,  and  the 
depressing  nature  of  their  duties,  could  realize  the 
disadvantages  under  which  they  labored.  Happily, 
a  large  proportion  were  men  of  vast  experience  in 
tuberculosis,  experience  acquired  after  many  years 
of  close  study,  but  that  was  due  to  a  combination 
of  circumstances  for  which  the  public  was  to  be 
congratulated  and  was  not  the  result  of  generous 
or  even  good  management.  Only  enthtisiasm  and 
a  high  sense  of  duty  could  sustain  them  in  a  thor- 
oughly disheartening  task.  There  was  much  dis- 
content in  the  service,  and  the  members  of  it  would 
be  more  than  human  if  tliere  was  not.  That  state 
of  affairs  should  be  remedied. 

How  could  the  necessary  reform  be  effected?  It 
might  not  apparently  be  so  urgent  now.  But  what 
about  the  time  when  these  highly  skilled  and  experi- 
enced men  were  no  longer  able  to  continue?  It 
might  be  urged  that  they  would  be  replaced ;  but 
by  whom?  It  was  not  generally  known  and  it 
should  be  known  that  not  one  single  regulation  had 
been  framed  governing  the  admission  of  recruits  to 
the  tuberculosis  service.  A  man  might  have  had 
no  experience  whatever  in  such  work,  might  be 
unsuited  by  temperament  or  by  training,  but  so  long 
as  he  was  a  qualified  medical  man,  he  was  eligible 
for  appointment  as  tuberculosis  officer.  And  when 
appointed  it  must  be  remembered  that  he  was  given 
no  facilities  whatever  for  becoming  a  real  expert 
at  the  work.  He  was  thrown  straight  into  an  ap- 
pointment, and  had  to  acquire  knowledge  of  the 
work  as  best  he  could  in  a  limited  field,  tie  had 
urged  the  establishment  of  a  diploma  in  tubercu- 
losis which  would  prove  the  holder's  competence  in 
the  duties  he  had  to  undertake.  If  the  Government 
was  going  to  launch  a  great  campaign  against  tuber- 
culosis, half  measures  would  not  do ;  efficient  work 
was  essential  and  was  obtainable.  The  tuberculosis 
service  must  be  regarded  seriously ;  the  human  fac- 
tor required  to  achieve  success  must  be  fostered, 
encouraged,  and  given  power  to  achieve  substantial 
results.  The  tuberculosis  service  must  be  an  at- 
tractive service,  offering  scope  and  substantial  re- 
ward to  those  entering,  and  facilities  for  research 
and  progress. 

(To  be  concluded.) 


Letters  to  the  Editors. 

THE  MEDICAL  PROFESSION  AND 
THE  HALL  OF  FAME. 

New  York,  November  lo,  1920. 

To  the  Editor: 

A  few  months  ago  I  sent  out  a  plea  for  recogni- 
tion of  the  medical  profession  in  the  Hall  of  Fame 
and  especially  for  Morton  as  perhaps  the  most  out- 
standmg  figure  in  American  medicine.  This  was 
published  in  many  of  our  leading  medical  periodicals, 
and  as  yours  was  one  which  extended  the  hospitality 
of  its  columns  to  the  cause,  I  am  sure  you  have  in 
no  small  degree  helped  in  the  election  of  Morton's 
name.  The  outcome  of  the  recent  election  must  be 
gratifying  to  every  American  physician  who  is 
familiar  with  Morton's  life,  his  struggles  for  recog- 
nition, and  the  sad  experience  he  was  made  to 
undergo  by  those  who  attacked  him  during  life  and 
those  who  up  to  this  time  wished  to  withhold  from 
him  the  credit  for  his  work. 

Our  never  to  be  forgotten  Osier,  with  his  keen 
sense  of  justice,  gave  us  the  result  of  his  profound 
study  of  historical  medicine  concerning  Morton's 
share  in  the  discovery  and  promulgation  of  ether 
anesthesia  in  the  following  words :  "William  T.  G. 
Morton  was  a  new  Prometheus  who  gave  a  gift  to 
the  world  as  rich  as  that  of  fire,  the  greatest  single 
gift  ever  made  to  suffering  humanity."  And  Pro- 
fess(jr  Welch  confirms  the  investigation  of  his  life- 
long friend  and  in  one  of  his  recent  letters  to  me 
says :  "Surgical  anesthesia  has  been  America's 
greatest  contribution  to  medicine  and  surgery  and 
it  would  be  a  thousand  pities  not  to  have  this  recog- 
nized in  the  Hall  of  Fame.  As  only  one  name  can 
be  selected  for  this  purpose,  it  is  clear  to  me  that 
this  name  should  be  Morton."  Professor  Welch 
was  one  of  the  electors  and  his  influence  was  un- 
doubtedly an  important  factor  in  Morton's  final 
triumph. 

It  will  doubtlessly  interest  the  readers  of  the 
New  York  ]\Iedical  Journal  to  know  the  exact 
outcome  of  this  year's  election  of  America's  im- 
mortals for  the  Hall  of  Fame.  Of  the  178  names 
voted  on  the  following  ^even  were  chosen :  Samuel 
Langhorne  Clemens  (Mark  Twain),  who  received 
seventy-two  votes ;  James  Buchanan  Eads,  the  en- 
gineer, fifty-one;  Patrick  Henry,  statesman,  fifty- 
seven  ;  William  Thomas  Green  Morton,  discoverer 
of  ether,  seventy-two;  Augustus  Saint-Gaudens, 
the  sculptor,  sixty-seven,  and  Roger  Williams,  the 
minister,  a  leader  in  liberal  religion  and  founder  of 
Providence.  R.  I.,  sixty-six.  The  only  woman  who 
received  enough  votes  to  place  her  name  on  the  roll 
was  Alice  Freeman  Palmer,  the  educator,  who  re- 
ceived fifty-three  votes. 

That  Morton,  together  with  our  most  beloved 
Mark  Twain,  should  have  received  more  votes  than 
any  other  candidate,  is  a  particularly  good  omen 
for  the  medical  profession,  and  it  is  to  be  hoped 
that  in  future  elections  the  names  of  our  other 
great  pathfinders  in  medicine  and  surgery  may  not 
be  forgotten.  Such  names  as  Ephraim  McDowell. 
J.  Marion  Sims,  Benjamin  Rush,  Walter  Reed,  all 
deserve  a  place  among  the  immortals  in  America's 
Hall  of  Fame.         S.  Adolphus  Kxopf,  M.  D. 


New  York  Medical  Journal 


INCORPORATING  THE 


Philadelphia  Medical  Journal  the  Medical  News 

A  Weekly  Review  of  Medicine,  Established  184-3. 


Vol.  CXII.  No.  22. 


NEW  YORK,  SATURDAY,  NOVEMBER  27,  1920. 


Whole  No.  2191. 


Original  Communications 


THE    THEORY    OF    THE    PNEUMA  IN 
ARISTOTLE. 
By  Jonathan  Wright,  M.  D., 

Pleasantville,  N.  Y. 

The  revolt  of  Hippocrates  against  the  Nature 
philosophers  is  set  forth  in  the  opening  paragraphs 
of  the  essay  on  TIic  Ancient  Medicine.  They  had 
indeed  failed  to  solve  the  mystery  of  life  and  they 
had  also  failed  to  correct  the  erroneous  and  folly 
laden  assumption  as  to  the  pneuma  and  the  air, 
but  in  order  to  secure  the  resumption  of  that  pro- 
gress which  the  Nature  philosophy  had  initiated  and 
of  wliich  Hippocrates  was  the  heir,  this  was  a  neces- 
sity. That  was  to  begin,  however,  only  after  the 
passing  of  Hippocrates  and  Plato  and  Aristotle. 
Galen  credits  them,  apparently  only  on  evidence  ac- 
cessible to  us  still,  with  very  much  more  knowledge 
of  anatomy  than  is  apparent  to  us  in  their  writings. 
He  says  (la)  they  did  not  write  of  what,  by  virtue 
of  their  manner  of  medical  training,  they  had  ac- 
quired in  home  instruction  as  boys,  apprenticed  to 
a  preceptor  who  was  often  a  father,  but  this  is 
hardly  convincing  to  the  modern  reader  who  easily 
perceives  the  cause  of  error  into  which  before  the 
time  of  the  Alexandrians,  the  Greeks  fell  in  the 
explanation  of  morbid  phenomena  they  encountered 
in  practice. 

It  would  seem  as  though,  if  the  pneuma  entered 
the  hollow  channels  of  the  body  and  was  seen  to 
pulsate  in  the  heart  and  in  the  peripheral  blood  ves- 
sels, from  which  blood  spurted  when  cut,  that  blood 
must  accompany  the  pneuma.  Indeed  this  is  still 
further  remarkable  from  a  historical  point  of  view. 
"Blood  is  the  life"  was  a  dogma  accepted  by  primi- 
tive man  and  by  civilization  immeasurably  older 
than  Greek  culture.  It  apparently  had  been  modified 
by  some  of  the  orientals  and  had  been  thought  of 
rather  as  the  vehicle  of  life  or  of  the  pneuma,  but  it 
was  apparently  in  Egypt  that  the  vessels  were  first 
thought  of  as  carrying  it  exclusively.  One  fails  to 
be  at  all  assured  of  any  provision  made  for  a  dis- 
tinction between  those  which  did  and  those  which 
did  not  carry  blood.  Until,  therefore,  there  came  a 
time  when  the  purely  objective  differentiation  of  ar- 
tery from  vein  began  to  be  made,  it  was  quite  im- 
possible for  any  theory  to  arise  which  separated  the 
blood  from  the  air.  The  separation  of  purely  blood 
channels  from  gastrointestinal,  from  air  channels 
and  from  other  ducts  and  conduits  of  the  body  was 
probably  never  entirely  complete  in  the  anatomy  of 


the  Egyptians  (2).  The  confusion  of  the  trachea  and 
the  other  air  channels  with  blood  channels  appears 
in  the  earliest  of  the  Greek  records  and  this  lack 
of  differentiation  of  the  veins  from  the  arteries  was 
the  origin  of  that  school  of  pneumatists  who  de- 
clared the  arteries  contained  both  blood  and  air, 
when  that  differentiation  was  once  made,  but  ap- 
parently by  the  time  of  Galen  the  majority  believed 
the  arteries  carried  air  alone  and  the  veins  blood 
alone.  I  shall  have  occasion  to  discuss  the  doctrine 
as  to  this  point,  which  obtained  in  the  time  of 
Hippocrates,  but  the  state  of  belief  may  be  in- 
ferred from  the  fact  that  Aristotle,  who  lived  after 
him  by  a  generation  at  least,  knew,  apparently,  all 
that  had  been  done  by  his  predecessors,  and  yet 
made  no  mention  of  the  differentiation,  but  himself 
advanced  it  so  far  only  as  to  name  the  trachea  the 
aspera  artcria,  instead  of  calling  it  simply  arteria 
and  giving  the  modern  name  to  the  aorta  (3a),  and 
saying  some  blood  vessels  have  thicker  coats  than 
others. 

]\Ian  had  begun  to  reason  that  if,  as  was  quite 
apparent,  the  pneuma  was  the  regulator  and  direc- 
tor of  all  things  in  the  body  and  directly  continuous 
with  the  world  soul  outside  of  it,  then  all  the  emo- 
tions and  intelligence  of  man  must  dwell  in  his 
heart,  whence  it  could  regulate  all  peripheral  man- 
ifestations. I  am  not  going  to  detail  the  urgent  rea- 
sons he  found  in  facts  known  to  him  and  in  the 
beliefs  of  the  more  ancient  nature  philosophers,  but 
Aristotle  believed  this.  He  sought  support  in  the 
facts.  The  greatest  mind,  not  only  of  philosophy, 
for  Plato  also  believed  it  with  reservations  and 
explanations,  but  Aristotle,  the  greatest  observer 
perhaps  of  all  time,  believed  it,  just  as  Homer  and 
Hesiod,  the  greatest  of  poets,  believed  it.  We  may 
laugh  at  Diogenes  Apollonius,  since  we  know  little 
else  about  him  except  that  Aristotle  quotes  (3a)  his 
description  of  the  veins,  but  no  one  laughs  at  Plato 
and  Aristotle  who  has  read  a  page  of  them,  or  at 
Homer,  either,  who  has  read  a  line  of  him.  The 
intellect,  as  well  as  the  emotions,  was  located  in 
the  heart,  because  the  soul  pneuma  went  there,  and 
thither  went  the  air  when  it  was  identified  as  the 
material  part  of  the  pneuma. 

The  belief  in  this  basis  fixed  in  the  minds  of 
men,  the  beating  of  the  heart  from  fear  or  exultation, 
elated  by  love  and  distressed  by  sorrow,  we  can 
easily  understand,  was  a  suggestion  of  proof,  if 
any  were  needed,  which  was  weighty  enough  though 
it  mav  seem  to  us  trivial.    The  eructations  of  a 


Copyright,  1920,  by  A.  R.  Elliott  Publishing  Company. 


834 


WRIGHT:   THEORY  OF  THE   PNEUMA  IN  ARISTOTLE. 


[New  York 
Medical  Journal. 


disordered  stomach,  accompanied  by  cardiac  sensa- 
tions, are  a  familiar  phenomenon  easily  attributable 
to  disturbance  of  the  pneuma.  The  latter  passes,  it 
is  true,  into  the  mouth  and  down  the  windpipe  to 
the  root  of  the  lungs,  but  there  a  complexity  of 
structures  was  found  that  defied  exact  definition.  If 
the  pneuma  was  the  regulator  of  life,  if  the  brain 
was  not  yet  known  as  the  centre  of  thotight,  emo- 
tion and  of  sensation  and  the  organ  from  which 
voluntary  motion  received  its  orders,  then  the 
pneuma  which  presides-  over  all  these  must  pass  to 
the  uttermost  regions  of  the  body  and,  in  default 
of  the  nerves  also  unknown,  must  regulate  matters 
on  the  spot  or  have  its  seat  in  the  blood  which 
reaches  all  parts.  In  the  sensory  centres  is  the 
heart  which  is  the  reservoir  of  the  blood.  Thus 
all  concepts  of  anatomy  and  physiology  hung  upon 
the  central  belief  in  some  material  thing  which 
traversed  the  conduits  of  the  body  with  the  blood 
or  through  certain  of  them  which  we  now  know 
carry  arterial  blood  and  which,  at  the  root  of  the 
lungs  or  in  their  substance,  was  in  continuity  or  in 
direct  connection  with  what  we  now  know  as  the 
air  passages. 

I  have  purposely  referred  to  the  pneuma  as  a 
material  thing,  despite  the  fact  that  philosophers 
identified  it  with  the  soul  within  the  body  and  with 
the  world  soul  or  universal  pneuma  without  the 
body.  Those  of  us  who  think  of  the  soul  no  longer 
connect  it  with  material  things.  We  no  longer  thus 
think  of  fear,  joy,  hate;  they  no  longer  have  for  us 
a  local  habitation  as  well  as  a  name.  All  these 
concepts,  however,  for  the  ancients  were  realities. 
Galen,  paraphrasing  the  way  of  Plato  in  the 
Timseus  describes  (lb)  the  Creator,  or  Nature, 
making  the  substance  of  the  humors  out  of  the  dry 
and  the  wet.  Out  of  the  cold  and  the  hot  he  con- 
structed the  pneuma,  and  this  he  used  as  an  instru- 
ment to  mold  the  humors  into  the  shape  of  the  or- 
gans of  the  body.  Of  course  it  is  not  difficult  to 
find  many  passages  in  which  we  miss  this  mate- 
rialistic acceptation  of  abstract  ideas,  but  it  never- 
theless will  be  found  to  lie  at  the  bottom  of  what, 
unless  we  realize  its  existence,  would  otherwise  be 
quite  inexpHcable  in  the  thought  of  ancient  philoso- 
phers from  Plato  down. 

Plutarch  said  the  Stoics  make  the  qualities  which 
we  designate  as  descriptive  adjectives  or  attributes 
to  nominal  or  actual  objects,  "bodies  also."  They 
must  have  their  seat  somewhere  in  the  body,  chiefly 
as  parts  incorporated  with  the  pneuma  or  soul.  We 
may  call  this  mysticism,  but  it  has  a  material  con- 
notation which  we  must  not  allow  to  escape  us  in 
the  study  of  ancient  anatomical  thought.  It  is  not 
.sufficient  for  us  to  know  that  practically  all  medi- 
cine was  originally  written  in  the  temples  but  we 
must  see  clearly  the  origin  of  the  ideas  which  entered 
into  the  history  of  medicine  after  it  left  the  temples. 
For  more  than  a  thousand  years  they  bore  the  stamp 
of  their  birthmark. 

"  Aristotle  did  not  escape  their  influence.  He  had 
noted  indeed  the  difference  in  the  thickness  of  the 
tunics  of  the  blood  vessels.  Herophilus  after  him 
said  (Ic)  the  pulmonary  artery  had  walls  six 
times  as  thick  as  the  pulmonary  vein.  But  the 
pneuma  was  still  such  a  real  thing  to  Aristotle, 


though  evidently  the  concept  of  the  soul  was  a  little 
separated  in  this  thought  f  rom  the  pneuma,  that  he 
explains  the  voice  (3f),  in  contradistinction  to  the 
other  noises  of  respiration  in  the  larynx,  as  the 
force  of  the  soul  striking  on  the  respired  air.  We 
gain  the  impression  from  this  that  it  is  not  the 
command  of  the  brain  sending  a  message  through 
the  laryngeal  nerves  for  the  larynx  to  produce  a 
sound  indicating  what  is  going  on  in  the  brain 
That,  I  take  it,  is  the  modern  view  in  the  simplest 
words.  In  the  ancient  view  it  is  the  pneuma  on  the 
spot  which  orders  things  so  that  the  thought,  in 
which  it  participates  and  which  it  connects  with  the 
outside  world,  finds  expression.  I  may  attempt  to 
render  it  more  plain  by  another  illustration.  Today, 
as  of  old,  a  cut  made  at  the  surface  of  the  skin 
seems  instantaneously  apprehended  by  conscious- 
ness. We  can  now  measure  the  time,  it  is  true, 
but  it  seems  still  that  we  instantly  jerk  away  the 
injured  finger.  We  understand  it  as  a  fact  now, 
but  if  we  had  had  to  explain  it  to  an  ancient 
Greek,  that  the  sensation  must  travel  i4p  one  nerve 
to  the  brain,  or  spinal  cord,  and  then  have  its 
message  translated  and  orders  issued  and  sent  down 
another  nerve  for  the  withdrawal  of  the  finger, 
the  Greek  would  have  thought  it  one  of  Aristo- 
phanes's  jokes.  For  him  the  pneuma  was  on  the 
spot,  in  communication  through  the  blood  channels 
with  the  heart,  it  is  true,  but  ready  to  act  in  an 
emergency  on  its  own  initiative  reflex  action,  with- 
out wating  for  orders  from  headquarters  in  the 
heart.  This  is  the  conception  Galen  in  his  turn, 
having  discovered  the  laryngeal  nerve,  set  himself  to 
dispel.   It  took  a  thousand  years  and  more. 

Aristotle  was  not  ready  to  go  as  far  as  the  half 
mythical  Orpheus,  Simplicius  says,  and  "call  the 
aptitude  of  bodies  to  life  respiration,"  but  to  the 
modern  reader  his  attitude  does  not  seem  far  re- 
moved from  this  pantheism  of  primitive  man.  In  his 
History  of  Animals  (3b)  Aristotle  refers  to  the 
heart,  "or  a  part  analogous  to  the  heart,"  as  the 
principle  of  motion  and  the  principle  of  the  senses 
and,  therefore,  of  the  whole  animal ;  the  brain  only 
tempers  the  heat  of  the  heart.  Others,  Plato  and 
the  authors  of  some  of  the  spurious  Hippocratic 
books,  some  supposed  to  be  earlier,  some  certainly 
later  than  Hippocrates,  also  thought  it  was  the  pul- 
monary air  that  cooled  the  heart.  In  his  treatise  on 
the  respiration  (3g)  Aristotle  agrees  with  them 
that  the  function  of  respiration  is  the  regulation  of 
the  heat  and  the  moisture,  because  of  the  porous 
nature  of  the  lungs  and  because  the  air  is  so  attenu- 
ated. In  his  tract  on  Sleep  and  Wakefulness  (3h) 
he  says  the  intelligence  is  shut  off  from  the  head 
by  the  ligature  of  the  jugular  veins,  but  evidently, 
from  what  precedes,  this  is  due  to  the  pneuma  of 
the  blood  having  its  communication  with  the  heart 
interrupted,  and  not  due  to  the  blood  stasis  in  the 
brain. 

The  soul  of  man  includes  the  principle  of  sense 
and  motion.  As  it  has  become  clear  that  Plato  (5), 
like  the  African  and  American  philosophers  of 
primitive  man,  was  driven  to  the  expedient  of  mul- 
tiple souls  or  the  manifold  function  of  the  soul,  so 
Aristotle  carries  a  full  cargo  of  functions  for  it  and 
evidently  sails  the  seas,  as  they  did,  on  a  pneuma 


November  27,  1920.] 


WRIGHT:  THEORY  OF  THE  PNEUMA  IN  ARISTOTLE. 


635 


ship.  He  adjusts  .his  anatomy  of  the  heart  and 
blood  vessels  better  than  did  Polybus  and  Syennesis 
and  Diogenes  Apollonius,  whom  he  quotes ;  but  the 
trachea  remains  the  aspera  arteria,  with  no  indica- 
tion, but  a  note  on  the  variations  in  their  calibre 
and  wall  thickness,  that  blood  vessels  are  divisible 
into  veins  and  arteries. 

Aristotle  is  thought  to  have  attended  Plato's 
teachings  in  the  Academy  for  some  years  succeed- 
ing 367  B.  C,  founding  the  lyceum  at  Athens  per- 
haps thirty  years  later.  The  son  of  a  distinguished 
physician,  the  ^sclepiad  Nichomachus,  and  himself 
apparently  versed  in  all  the  theoretical  medical 
learning  of  the  day,  he  knew  much  more  of  the  in- 
ternal anatomical  structure  of  animals  than  of  man. 
Galen  said,  despite  his  great  knowledge,  he  knew  lit- 
tle of  dissection.  We  must  keep  this  in  mind  in 
thinking  out  a  consistent  explanation  for  the  per- 
sistence of  the  fundamental  theory  of  life  phenom- 
ena represented  by  the  pantheistic  conception  of  the 
pneuma.  I  have  emphasized  elsewhere  (5)  its  inti- 
mate association  with  the  very  fibre  of  the  thought 
of  primitive  man,  but  it  could  only  persist  as  an 
interpretation  of  human  anatomy  in  the  absence  of 
an  intimate  acquaintance  with  practical  experience 
in  the  dissection  of  the  human  body.  It  is  true  we 
must  accept  this  explanation  with  all  its  limiting 
modifications.  There  are  abundant  examples  of 
the  existence  of  a  knowledge  of  the  most  element- 
ary facts  which  are  entirely  inconsistent  with  long 
prevailing  theory.  The  facts  often  fade  from 
men's  consciousness  before  they  have  destroyed  the 
false  belief  and  have  to  be  discovered  again.  We 
may  find  one  exemplification  of  this  in  Galen's  atti- 
tude toward  the  pneuma.  He  was  blinded  by  the 
prevailing  belief,  doubtless,  to  such  an  extent  that 
he  missed  the  evidence  open  to  his  sight  in  the  dis- 
section of  animals,  but  nevertheless  he  was  by  vir- 
tue of  that  experience  only  a  faint  hearted  believer 
and  pointed  out,  not  enough  evidently  to  dispel  all 
his  prepossessions,  but  ample  to  allow  us  to  per- 
ceive that  had  he  had  sufficient  moral  support  he 
would  have  preceded  Har^vey  in  a  proper  under- 
standing of  the  circulation.  As  it  was  Galen  fal- 
tered and  his  mental  process  seems  to  have  been : 
li  there  is  such  a  thing  as  the  pneuma  then  we  must 
accept  the  following  as  the  physiological  fact; 
whereupon  he  proceeds  (Id)  with  a  scheme  that 
was  as  preposterous  then  for  him  as  it  would  be  for 
the  most  experienced  naked  eye  observer  today. 
Galen,  however,  had  a  very  mediocre,  if  very  vig- 
orous, mind.  We  may  conjecture  that  the  results 
would  have  been  dififerent  if  Galen's  facts  had  been 
food  for  the  intellect  of  a  Plato  or  an  Aristotle. 
But  despite  all  the  philosophy  and  notwithstanding 
the  profound  skepticism  of  the  minds  of  these 
Greeks,  in  their  day  they  were  slaves,  if  not  to  the 
feelings  of  horror  of  the  contact  of  the  dead  human 
body  entertained  by  the  common  people,  at  least  they 
were  subservient  to  the  laws  and  the  public  senti- 
ment arising  out  (^f  that  primitive  terror  which  to 
some  extent  is  still  with  us.  That  real  dissection  of 
the  human  body  should  apparently  have  begun  at 
Alexandria,  on  the  continent  of  Africa,  the  birth- 
place and  the  domicile  of  religious  faith  and  fanati- 
cism, is  explicable  only  on  the  reflection   that  the 


Greek  rulers  were  enlightened  men,  free  from  the 
dangers  the  superstitions  of  the  masses  create  for 
those  innovators  living  under  more  democratic 
forms  of  government.  Every  rose  has  its  thorn,  as 
we  modern  democrats  often  have  occasion  to  reflect. 

But  we  should  not  be  blinded  by  the  absence  of 
freedom  of  thought  which  finds  courage  under  the 
aegis  of  autocracy  to  fly  in  the  face  of  popular 
prejudice.  There  was  something  more  than  the 
shudder  at  the  sight  of  death,  something  more 
deeply  grounded  than  the  religious  and  legal  formu- 
la based  on  it.  Both  Aristotle  and  Hippocrates 
were  alike  ignorant  as  to  the  number  and  arrange- 
ment of  the  sutures  of  the  human  skull,  which  in 
those  days  must  often  enough  have  offered  itself 
for  observation.  It  is  plain  that  Hippocrates  must 
have  examined  skulls,  as  in  self  criticism  for  a  mis- 
take in  diagnosis  he  reveals  an  acquaintance  with 
sutures,  but  he  gives  no  coherent  account  of  them, 
while  Aristotle  seems  to  have  examined  them  in 
the  most  superficial  fashion.  There  seems  indeed 
to  have  existed  an  unconquerable  repugnance  even 
to  look  at  the  dead  human  body,  which  we  can 
easily  understand,  but  singular  to  say  this  coexisted 
with  an  indifference  to  what  a  careful  study  of  its 
anatomy  might  have  taught  them  which  amounted 
to  apathy  and  which  it  is  more  difficult  to  under- 
stand. Instead,  therefore,  of  wondering  at  the  er- 
rors of  Aristotle's  physiology  of  the  circulation  and 
the  respiration  we  should  realize  his  deep  ignor- 
ance of  anything  in  the  hidden  anatomy  of  man 
which  differed  from  that  of  animals.  This  he  man- 
ifestly was  well  acquainted  with,  yet  even  in  ani- 
mals he  missed  the  obvious  features  in  the  thoracic 
viscera  which  should  have  given  him  a  clear  insight 
into  the  erroneous  details  of  his  theory  of  the 
pneuma.  Fundamentally  it  rested  on  the  truth 
which  we  still  recognize  in  the  chemical  term,  oxy- 
genation. That  we  know  lies  at  the  basis  of  all 
animal  life  manifestations  and  the  pneuma  we  may 
look  upon  as  that  indispensable  and  chief  element 
in  the  air  which  must  go  everywhere  in  the  body  to 
maintain  life. 

Yet  for  Aristotle  the  chief  function  of  respira- 
tion was  to  supply  air  and  water  to  the  heart  for 
the  regulation  of  the  animal  heat  which  had  its  chief 
seat  there,  the  brain  sharing  the  function  of  mois- 
tening the  heart.  We  may  find  a  sufficient  explan- 
ation for  the  ignorance  of  anatomy  in  the  few  gen- 
erations which  cover  the  life  spans  of  Hippocrates, 
Plato  and  Aristotle,  if  not  for  their  apathy  in  the 
matter,  but  that  Aristotle,  with  all  his  biological 
knowledge  of  bird  and  beast,  including  an  unrivalled 
knowledge  of  their  anatomy,  with  the  advantages  of 
the  parental  training  and  those  of  Plato  himself,  that 
a  mind  such  as  his  thus  equipped  should  on  the 
whole  have  had  less  accurate  ideas  of  human  physi- 
ology than  Plato's  seems  to  me  singular.  It  would 
seem  that  so  long  as  a  scientific  man  does  not  use 
his  facts  in  a  critical  analysis  of  his  theories,  so 
long  as  he  does  not  practise  those  rules  of  deduc- 
tive reasoning  which  Aristotle  himself  formulated, 
so  long  as  he  does  not  combine  induction  and  de- 
duction in  his  every  day  thought,  he  is  sure  to  go 
wide  of  the  path  of  the  truth. 

Correct  as  the  fundamental  idea  of  the  primitive 


836 


WRIGHT:   THEORY  OF  THE   PXEUMA  IX  ARISTOTLE. 


[New  York 
Medical  Journal. 


pneumatist  was,  it  led  astray  one  of  the  greatest 
minds  of  antiquity  not  only  as  to  the  physiology  but 
as  to  the  anatomy  itself  of  man.  Unaccustomed,  as 
we  must  suppose  Plato  was,  to  study  at  first  hand 
the  facts  of  nature,  untaught  in  the  knowledge  his 
eminent  pupil  brought  into  the  world,  he  was  still 
able  to  construct  a  less  erroneous  view  of  physio- 
logical processes  than  Aristotle.  He  arrived  at  a 
basis  more  in  accord,  crude  as  it  was,  with  the  prin- 
ciples which  underlie  the  teachings  of  modern  his- 
tolog}',  than  did  the  great  naturalist.  If  I  have  read 
Plato  aright  he  appreciated  the  necessity  for  the  exist- 
ence of  the  capillary  circulation,  if  not  for  the  lymph- 
atics and  his  deductive  reasoning  supplied  what  Aris- 
totle's facts  failed  to  reveal.  In  his  History  of  Ani- 
mals (3)  Aristotle  declares:  "When  the  trachea 
is  filled  with  air,  it  distributes  breath  (pneuina) 
to  the  cavities  of  the  lungs  .  .  ' .  it  only  inhales 
and  exhales  breath  and  nothing  else  either  dry  or 
moist."  There  is  no  germ  here  or  elsewhere  of  a 
capillary  circulation,  no  hint  of  the  life  giving  oxy- 
gen, the  real  food  of  life,  indeed  he  denies  the  idea 
of  it.  In  his  essay  on  Respiration  he  says:  "It 
must  not  be  considered  that  respiration  is  produced 
for  the  sake  of  nutriment,  as  if  the  inward  fire 
were  nourished  by  spirit,  just  as  fire  is  nourished 
by  combustible  matter  and  the  vital  heat  being  nour- 
ished the  relics  of  the  nutriment  are  emitted  by  ex- 
piration." As  a  matter  of  fact  this  is  in  general 
outline  just  what  occurs.  His  denial  of  it  was  in 
opposition  to  the  views  of  others  who  had  arrived 
thus  far  on  the  right  path  without  the  encyclopedic 
knowledge  of  the  Stagyrite.  He  could  repeat  (3d) 
with  apparent  credulity  the  mythical  view  of  an 
Australian  savage,  that  impregnation  with  the 
pneuma  is  possible,  telling  of  a  hen  partridge  fecun- 
dated by  a  breath  blowing  on  her  from  the  male — 
but  the  biochemical  significance  of  the  pneuma  when 
it  is  taken  in  by  respiration  he  missed ;  not  only  that, 
he  rejected  any  suggestion  pointing  in  that  direction. 
He  criticized  the  passage  in  the  Timseus  on  which 
in  the  last  essay  I  dwelt  at  some  length,  because  it 
makes  the  inspired  air  take  part  in  the  process  of 
digestion  also  and  it  is  not  confined  to  his  idea  of 
cooling  and  moistening  the  pneuma  in  the  heart. 

As  soon  as  we  reach  Plato  and  Aristotle  we  find 
the  soul  quite  a  complicated  affair.  This  is  very 
likely  because  we  have  so  much  more  of  their  work 
than  that  of  other  philosophers  left  to  us.  From 
others  there  remain  to  us  only  isolated  sentences  or 
phrases  from  which  we  are  to  infer  their  views, 
isolated  and  quoted  by  Aristotle  himself  or  by  Theo- 
phrastus,  his  successor  or  by  others  much  later,  but 
in  all  probability  the  views  of  others,  as  completely 
developed  as  those  of  Plato  and  Aristotle,  would 
show  a  like  confusion  and,  of  course,  a  greater 
variety.  To  Aristotle,  in  his  treatise  on  The  Soul 
we  owe  what  we  have  of  the  views  of  Thales  and 
Democritus,  of  Hippo  and  Heraclitus,  of  Empedo- 
cles  and  of  many  others.  To  the  extent  with  which 
he  notices  these  is  due  our  somewhat  uncertain  idea 
as  to  just  what  he  believed  himself.  AVe  get  enough 
out  of  it  all,  however,  to  see  that  he  entertained  es- 
sentially the  ideas  of  the  Egyptians,  as  set  forth  in 
the  papyri  we  now  have.  The  soul,  if  not  identified 
fully  with  the  air  of  the  breath,  had  its  seat  with  it 


chiefly  in  the  blood.  In  referring  to  the  heart  or 
a  part  "analogous  to  the  heart"  as  the  principle  of 
motion  and  the  site  where  the  apperceptions  of  the 
senses  are  interpreted,  he  is  in  opposition  to  Alc- 
mseon  and  Plato.  That  was  the  seat  of  the  intellect, 
which  Plato,  doubtless  influenced  by  the  traditions 
of  Alcjnaeon's  teachings  in  the  Sicilian  School, 
placed  in  the  head,  in  his  tripartite  divison  of  the 
soul  of  man.  For  Aristotle  the  regulation  of  the  heat 
and  the  moisture  of  the  system  was  the  manifes- 
tation of  the  pneuma  or  the  soul  mingled  with  the 
blood  near  the  heart,  as  we  have  seen  in  his  treatise 
on  the  respiration,  but  in  his  History  of  Animals 
we  read  (3c)  :  "Passages  lead  from  the  lungs  to  the 
heart  and  they  are  divided  in  the  same  way  as  the 
trachea  throughout  the  whole  lungs  and  the  passages 
leading  from  the  heart  are  at  the  upper  part.  There 
is  no  passage  which  is  common  to  them  both,  but  by 
their  union  they  receive  the  breath  and  transmit  it 
through  the  heart,  for  one  of  the  passages  leads  to 
the  right  cavity  and  the  other  to  the  left."  The  con- 
tradiction and  the  obscurity  here  we  have  every  rea- 
son to  believe  were  due  to  the  necessity  that  pressed 
upon  him  to  get  the  pneuma  out  of  one  set  of  ves- 
sels and  into  the  other.  The  imion  of  them  he  had 
never  seen  and  his  conception  of  it  is  not  suggestive 
of  anything  but  his  embarrassment  when  confronted 
by  the  theory  and  his  inability  to  find  support  for 
it  in  fact.  His  imagination  did  not  serve  him  as 
well  as  Plato's  did  him. 

Aristotle  is  credited  with  having  named  the  aorta. 
He  seems  to  have  used  the  word  previously  applied 
by  some  of  the  Hippocratic  writers  to  the  lower  part 
of  the  air  passages.  Some  have  ascribed  to  Hippo- 
crates the  first  differentiation  of  artery  from  vein, 
but  his  allusion  to  the  fact  that  some  veins  have 
thicker  walls  than  others  is  the  only  intimation 
that  I  find  of  it.  while  Galen  ascribes  the  differen- 
tiation more  specifically  to  Praxagoras,  the  instructor 
of  Herophilus,  but  he  makes  the  assertion  without 
citation.  The  ascription  of  sensory  phenomena  to 
the  heart  does  not  seem  to  have  been  worked  out 
very  satisfactorily,  but  sensation  for  Aristotle,  as 
Beare  (6)  thinks,  seems  to  have  been  carried  in  the 
same  vessels  with  the  blood  associated  with  the 
pneuma,  just  as  we  have  seen  the  soul  or  the  pneuma 
producing  the  voice  in  the  larynx.  It  seems  to  me 
quite  clear  that  the  whole  scheme  in  Aristotle's  mind 
was  blurred  by  his  clinging  to  the  pantheistic  basis 
of  primitive  man's  conception  of  the  soul  as  re- 
sponsible for  all  the  details  of  bodily  movement  and 
sensation  after  his  own  observations  had  necessi- 
tated its  modification. 

REFERENCES. 

1.  Claudii  Galcni  Opera  Omnia.  (Ed.  Kuhn.)  (a) 
Anatomicis  Admin,  Lib.  II,  i.  (b)  De  Usu  Partium,  Lib. 
VI,  xiii.  (c)  De  Usu  Partium,  Lib.  VI,  x.  (d)  De  Usu 
Partium,  Lib.  VI,  xvii. 

2.  Papyrus  Ebers.    Ubrszt  von  H.  Jo.\chmi. 

3.  Aristotle  :  History  of  Animals,  (a)  Lib.  Ill,  cap. 
ii,  iii,  iv.  (b)  Lib.  II,  cap.  iv.  (c)  Lib.  I,  cap.  xiii.  7,  8. 
(d)  Lib.  VI,  cap.  i,  9.  (e)  Lib.  I,  cap.  iv,  3.  (f)  On  the 
Soul,   (g)  On  Respiration,   (h)  On  Sleep  and  Wakefulness. 

4.  Plutarch  :  Common  Conceptions  Against  the  Stoics, 
No.  50. 

5.  Wright:  The  Blood  and  the  Soul,  New  York  Medi- 
cal Journal,  July  20,  1918. 

6.  Beare,  John  I. :  Greek  Theories  of  Elementary  Cogni- 
tion, 1906.    Oxford:  Clarendon  Press. 


November  27,  1920.] 


FOX:  ROEXTGEX  RAY  IX  SKIX  DISEASES. 


837 


STANDARDIZED  ROENTGEN  RAY  IN  THE 
TREATMENT   OF   SKIN  DISEASES. 
With  Special  Reference  to  Eczema. 
By  Howard  Fox,  M.  D., 

Xew  York. 

One  of  the  greatest  advances  in  dermatological 
therapeutics  has  been  the  standardization  of  the 
rontgen  ray.  Previous  to  the  introduction  of  the 
Coolidge  tube  all  routine  rontgen  ray  treatment  was 
attended  with  danger  even  in  the  hands  of  an  ex- 
pert. It  was  necessary  for  each  operator  to  evolve 
his  own  technic,  which  varied  according  to  the  ap- 
paratus used.  Only  by  radiometric  measurement 
was  it  possible  to  compute  the  amount  of  ray  given 
in  any  particular  case.  At  the  present  time  it  is  as 
easy  to  give  a  precisely  measured  amount  of  rontgen 
ray  as  it  is  to  prescribe  a  measured  amount  of 
strychnine.  To  obtain  this  desirable  result  it  is  nec- 
essary to  use  a  Coolidge  tube  and  an  interrupterless 
transformer.  The  dosage  can  then  be  measured  by 
pastilles  (of  platinocyanide  of  barium)  or  by  arith- 
metical computation.  IMeasurement  by  pastilles  is 
not  ver\-  satisfactory  as  this  method  is  difficult  for 
some  to  learn  and  in  any  case  introduces  the  element 
of  personal  equation.  Through  the  splendid  pioneer 
work  of  MacKee,  Shearer,  Remer  and  Witherbee, 
it  is  now  possible  to  dispense  entirely  with  pastilles 
•  and  depend  upon  a  simple  arithmetic  formula  to 
standardize  a  rontgen  ray  apparatus. 

THE  QUAXTITV  OF  THE  RAY. 

The  quantity  of  ray  depends  on  four  factors, 
namely,  spark  gap  (representing  voltage)  milliam- 
perage,  time  and  tube  distance  (  from  anode  to  skin) . 
Within  certain  limits  these  can  be  changed  to  suit 
the  convenience  of  the  operator.  In  most  of  my 
work  the  following  figures  have  been  used :  six  inch 
spark  gap,  two  milliamperes,  three  minutes  and 
eight  inch  distance,  for  one  socalled  skin  unit.  A 
half  unit  was  obtained  in  a  minute  and  a  half,  and 
a  quarter  unit  in  forty-five  seconds,  the  other  three 
factors  remaining  unchanged.  In  cases  of  ring- 
worm where  short  exposures  were  preferred  the 
figures  were  as  follows :  six  inch  spark  gap,  five 
milliamperes,  a  minute  and  nineteen  seconds  and 
six  and  one  half  inch  distance. 

The  skin  unit  corresponds  to  one  H  (Holzknecht) 
unit  with  pastille 'lying  on  the  skin  (skin  distance) 
or  about  five  H  units  with  pastille  at  middistance 
between  anode  and  skin.  This  dose  will  epilate  the 
scalp  but  will  not  produce  an  erythema  except  as 
MacKee  says,  "if  given  at  one  sitting,  on  very  sen- 
sitive parts  such  as  the  face  of  a  young  girl."  In 
speaking  of  H  units  or  fractions  thereof  in  the 
further  course  of  this  article,  the  words,  skin  dis- 
tance, will  always  be  understood. 

Over  three  years  ago  I  published  some  observa- 
tions on  The  Coolidge  Tube  in  the  Treatment  of 
Nonmalignant  Diseases  of  the  Skin.  This  was 
based  on  an  experience  of  eighteen  months  with  a 
standardized  technic,  though  I  had  previously  used 
the  ray  for  a  dozen  years  in  the  old  inaccurate  and 
unsatisfactory  manner.  It  is  not  often  that  a  paper 
on  a  therapeutic  subject  can  be  quoted  three  years 
later  without  making  certain  reservations  if  not 
repudiating  much  that  was  previously  written. 


In  the  present  instance  my  feeling  on  the  subject 
is  best  expressed  by  saying  that  I  enthusiastically 
agree  with  my  former  statement  as  follows:  '"With 
the  new  apparatus  and  technic,  my  opinion  of  ront- 
gen ray  therapy  has  entirely  changed  and  I  may  add 
that  I  have  never  made  a  change  in  therapeutic 
measures  that  compares  in  satisfaction  with  the 
change  from  the  old  to  the  new  method  of  using 
rontgen  rays."  My  subsequent  experience  has  sub- 
stantiated this  opinion  and  enabled  me  to  enlarge 
the  usefulness  of  the  standardized  treatment.  I 
also  subscribe  thoroughly  to  another  former  state- 
ment that  "I  feel  certain  that  the  next  generation 
of  rontgen  ray  therapeutists  will  all  adopt  the  newer 
methods  of  treatment  and  think  it  likely  that  before 
long  the  question  of  having  used  the  safer  technic 
may  have  a  medicolegal  bearing  in  cases  of  rontgen 
ray  burns." 

What  has  been  said  will  sound  like  the  veriest 
platitudes  to  those  who  use  a  standardized  technic. 
Unfortunately  there  are  still  many  dermatologists 
who  either  continue  to  use  the  old  methods  in  a 
desultory  way  or  do  not  use  rontgen  ray  at  all.  The 
profession  as  a  whole  is  certainly  ignorant  of  the 
possibilities  of  modern  rontgen  ray,  while  our  pa- 
tients (except  those  who  have  been  treated  by  this 
method)  are  generally  astonished  to  learn  that  tlie 
value  of  this  agent  is  not  confined  to  fluoroscopic 
or  photographic  work.  The  technic  of  giving  meas- 
ured doses  is  not  difficult  to  learn,  even  for  those 
who  have  had  no  previous  experience  with  the  ray. 
For  the  trained  rontgenologist  it  is  child's  play. 

In  regard  to  filtration  it  should  be  said  that  prac- 
tically all  of  my  work  has  been  done  with  unfiltered 
rays.  I  can  see  no  advantage  in  using  an  aluminum 
or  other  filter  in  the  great  majority  of  skin  diseases, 
situated  as  they  are  on  the  surface  of  the  body.  In 
a  few  cases,  where  deep  subcutaneous  lesions  are 
present  as  in  a  case  of  true  Hodgkin's  disease,  I 
have  pi*eferred  to  use  a  filter  of  three  millimetres  of 
aluminum.  Filtration,  of  course,  is  necessary  in 
treating  lymphatic  glands  or  carcinoma  of  the 
breast,  etc.,  but  this  is  hardly  within  the  province 
of  dermatological  therapeutics. 

PROTECTION  OF  THE  SKIN. 

Protection  of  the  skin  which  is  not  desired  to  be 
rayed  is  amply  aflforded  by  lead  foil  of  the  thickness 
of  one  thirty-second  of  an  inch.  As  a  substitute 
for  lead  foil  I  have  used  rubber  cloth  one  eighth 
inch  in  thickness.  One  advantage  of  the  rubber 
cloth  is  that  a  single  piece  of  it  can  be  used  to  cover 
a  considerable  area  of  the  body.  It  is  also  much 
more  durable  than  the  lead  foil  though  less  flexible. 
It  supplements  the  lead  foil  as  a  protection,  each 
having  its  use  according  to  the  locality  treated.  In 
treating  large  areas,  such  as  the  back,  it  often  seems 
best  to  dispense  with  the  protecting  foil  and  give 
several  exposures  at  different  points  and  rely  upon 
overlapping  of  the  ray  as  described  by  Fred  Wise. 
I  still  find  it  most  convenient  to  treat  my  patients  in 
the  recumbent  position  on  a  wooden  table.  A  metal 
table  was  early  discarded  after  the  tube  had  been 
punctured  by  accidental  contact  with  -the  metallic 
portion  of  the  tube  stand. 

An  erythema  should  always  be  avoided  except 
when  treating  malignant  conditions  where  two  II 


838 


rOX:  ROEXTGEX  RAV  IX  SKIX  DISEASES. 


[New  York 
Medical  Journal. 


units  or  even  larger  doses  are  given.  It  is  only 
when  an  erythema  is  produced  that  there  is  any  like- 
lihood of  future  telangiectases.  In  nearly  five  years' 
experience  with  the  new  technic  I  have  only  pro- 
duced an  erythema  (unintentionally)  in  one  case 
(generalized  psoriasis)  in  which  I  foolishly  tried  to 
accommodate  the  patient  by  expediting  the  treat- 
ment. 

Pigmentation  of  the  skin  was  noted  in  a  small 
proportion  of  cases,  even  though  the  dreaded  ery- 
thema had  been  avoided.  Fortunately  the  pigmenta- 
tion was  never  permanent,  though  at  times  it 
persisted  for  months.  The  tendency  of  the  skin  to 
become  pigmented  is  most  marked  in  brunettes  and 
especially  in  negroes.  One  of  my  patients,  from 
the  Harlem  Hospital,  a  young  negro  boy,  was 
treated  for  chronic  exfoliation  of  the  lips.  A  few 
days  after  a  single  dose  of  only  one  quarter  H  unit 
there  was  a  marked  pigmentation  of  the  adjacent 
portion  of  the  lips  which  had  not  been  covered  by 
lead  foil. 

To  safeguard  the  patient  and  to  obtain  the  most 
accurate  results  the  operator  should  remain  at  his 
post  during  the  entire  seance.  Standing  behind  the 
leaded  screen  and  looking  through  the  lead  glass 
window  he  should  see  that  the  patient  does  not 
move  and  that  the  milliamperage  remains  as  con- 
stant as  possible.  He  should  also  watch  the  anode, 
when  it  becomes  white  hot  from  a  large  quantity  of 
ray  and  be  ready  instantly  to  throw  off  the  current 
in  the  very  unusual  event  of  softening  of  the  metal 
support  of  the  anode  and  possibly  burning  the  pa- 
tient. It  is  best  to  use  one  hand  for  the  milliampere 
control  and  the  other  for  the  switch  which  discon- 
tinues the  current.  The  practice  of  operating  two 
or  three  machines  simultaneously  by  one  individual 
is,  I  think,  improper.  A  clock  may  be  used  to  shut 
off  the  current  automatically  at  the  desired  time, 
but  this  should  not  relieve  the  operator  of  the  re- 
sponsibility of  closely  watching  the  patient  and  the 
apparatus. 

TREATMENT   OF  ECZEMA. 

Among  the  various  diseases  of  the  skin  that  were 
treated,  eczema  perhaps  occupied  the  most  impor- 
tant place.  I  am  now  as  enthusiastic  as  before 
over  the  treatment  of  eczema  of  all  varieties  and 
in  all  stages,  by  the  rontgen  ray.  With  the  excep- 
tion of  a  very  acute  vesicular  eczema  with  marked 
edema,  etc.,  I  think  that  all  cases  of  the  disease 
are  amenable  to  rontgen  therapy.  In  a  very  acute 
case  (resembling  rhus  poisoning)  I  would  prefer 
to  use  wet  dressings  of  boric  acid  or  a  calamine 
and  zinc  lotion  for  a  week  or  so  till  the  swelling 
had  largely  subsided,  when  I  would  not  hesitate 
to  begin  rontgen  treatment.  The  general  opinion 
seems  to  be  that  the  ray  is  only  suited  for  exceed- 
ingly chronic,  thickened  patches  of  eczema.  While 
it  does  clear  up  patches  of  this  kind  the  most  bril- 
liant results  are  seen  in  the  subacute  cases  of  papular 
and  vesicular  type.  The  cases  that  are  most  resist- 
ent  to  the  ray  as  well  as  to  other  methods  of  treat- 
ment are  those  of  the  erythematous  type.  I  have 
also  had  disappointing  results  in  a  few  cases  of 
vesiculosquamous  eruptions  of  the  hands  which  I 
had  classed  as  eczema.  I  now  feel  it  is  quite  possible 
that  some  of  these  cases  were  examples  of  epider- 


mophyton  infection,  though  the  demonstration  of 
the  fungus  in  this  region  is  always  difficult. 

It  is  of  course  realized  that  in  treating  an  eczema 
by  the  rontgen  ray  that  we  are  not  attempting  to 
remove  the  cause  of  the  disease.  As  a  matter  of 
fact  we  do  not  know  the  essential  cause  of  what  is 
called  eczema.  I  had  hoped  that  some  light  might 
be  thrown  on  the  subject  by  the  protein  sensitiza- 
tion tests.  The  results  of  some  recent  work  along 
this  line,  in  conjunction  with  Dr.  J.  Edgar  Fisher, 
were,  however,  most  disappointing  in  eczema  in 
adults.  Whether  the  rontgen  ray  removes  the 
cause  of  eczema  or  not  it  certainly  clears  up  the 
lesions  in  a  large  proportion  of  cases  in  a  much 
more  satisfactory  manner  than  by  any  other  thera- 
peutic measure  with  which  I  am  acquainted.  In  a 
few  cases  a  single  treatment  effects  a  permanent 
cure.  In  a  large  number  of  cases,  from  four  to 
eight  weekly  exposures  are  followed  by  permanent 
removal  of  the  disease,  without  the  necessity  of  any 
local  application  or  internal  medication.  The  rontgen 
ray  treatment  is  not  only  quicker  and  surer  in  its 
action  but  is  infinitely  more  agreeable  than  salves, 
such  as  tar,  ichthyol,  or  chrysarobin.  Two  hundred 
and  sixty-nine  cases  of  eczema  were  treated,  the 
patients  varying  in  age  from  fifteen  months  to 
eighty-five  years.  The  dose  was  a  one  half  H  unit 
for  the  first  and  a  one  fourth  H  unit  for  successive 
treatments  given  at  weekly  intervals.  An  improve- 
ment was  generally  noted  after  the  first  and  almost  * 
invariably  after  the  second  exposure.  The  anti- 
pruritic effect  of  the  ray  has  also  been  quickly 
shown  in  treating  eczema. 

PSORIASIS. 

In  regard  to  psoriasis  my  former  opinion  remains 
practically  unchanged  when  it  was  stated  that  "the 
lesions  themselves  were  easily  cleared  up  but  they 
returned  with  discouraging  frequency.  The  rontgen 
ray  appears  to  be  especially  useful  for  lesions  of 
the  hands  and  face  where  chrysarobin  is  objection- 
able. ...  Its  value  in  psoriasis  is  certainly  below 
that  in  eczema."  I  formerly  felt  that  the  ray  was 
"a  less  valuable  remedy  than  chrysarobin  in  the 
treatment  of  psoriasis,'*  but  now  consider  the  two 
methods  of  treatment  about  on  a  par  as  regards 
efficienc)-.  There  can,  however,  be  no  question  that 
rontgen  therapy  is  a  less  disagreeable  procedure 
than  inunctions  of  chrysarobin  ointment.  It  is 
often  difficult  with  any  method*  of  treatment  to 
clear  up  an  attack  of  psoriasis  entirely,  while  it  is 
impossible  to  prevent  future  outbreaks  of  the  dis- 
ease. Arsenic  is  undoubtedly  of  value  at  times, 
while  treatment  by  a  low  protein  diet  is  of  very 
little  value  in  my  experience,  an  opinion  that  is  now 
shared  by  many  dermatologists.  For  the  solution 
of  the  problem  of  psoriasis  we  must  for  the  present 
depend  upon  the  rontgen  ray  or  chrysarobin.  It 
might  be  mentioned  in  this  connection  that  the  ray 
should  never  be  applied  to  a  region  that  has  been 
recently  treated  with  strong  irritants  such  as  chrys- 
arobin, iodine,  phenol,  or  other  similar  drugs,  on 
account  of  the  danger  of  a  possible  erythema.  An 
interval  of  two  or  preferably  three  weeks  should 
elapse  between  the  employment  of  a  local  irritant 
and  the  rontgen  ray. 

It  is  hardly  necessary  to  say  that  the  ray  is  not 


Kovember  27,  1920.] 


FOX:  ROEXTGEN  RAV  IN  SKIX  DISEASES. 


839 


suited  for  treating  psoriasis  of  the  scalp,  though  in 
a  few  cases  I  have  cautiously  given  a  one  fourth  H 
unit  followed  by  improvement.  In  my  series  there 
were  sixty-seven  cases  of  psoriasis  treated  b}'  the 
ray.  The  dose,  as  a  rule,  was  one  H  unit  (at 
monthly  intervals),  six  areas,  as  a  rule,  being  the 
maximum  number  treated  at  one  sitting.  In  my 
experience  I  have  obtained  much  better  results  with 
large  than  with  fractional  doses,  and  in  this  respect 
differ  from  some  of  my  colleagues. 

Good  results  were  obtained  in  the  majority  of 
cases  (thirty)  of  socalled  seborrhoic  eczema.  The 
ray  was  fully  as  effective  as  ointments  in  this  dis- 
ease and  certainly  a  more  agreeable  method  of 
treatment  for  the  patient.  It  was  particularly  use- 
ful where  the  disease  was  limited  in  extent.  The 
usual  dose  was  the  same  as  that  given  for  eczema. 
In  some  of  the  more  deeply  infiltrated  cases  one 
half  H  units  at  intervals  of  two  weeks  were  given. 

THE  X  RAY  IX  ACNE. 

Acne  is  one  of  the  few  skin  diseases  that  has 
been  treated  successfully  by  the  rontgen  ray  for  a 
considerable  number  of  years,  and  I  still  feel  as 
before  that  the  ray  is  "the  most  efficient  agent  for 
the  treatment  of  acne,  and,  with  the  modem  meas- 
ured dose,  do  not  hesitate  to  treat  any  case  of  acne, 
whether  occurring  on  the  back  of  an  older  person 
or  the  face  of  a  young  girl."  In  point,  of  efficiency 
and  comfort  of  the  patient  the  rontgen  ray  should 
be  the  method  of  choice.  I  am  willing  to  admit  that 
good  results  can  be  obtained  by  mechanical  methods 
such  as  the  dull  curette  and  comedoextractor  com- 
bined with  soap  frictions.  Such  treatment,  how- 
ever, is  often  disagreeable  for  both  patient  and 
physician,  and  its  results  are  not  as  permanent  as 
when  the  ray  is  used.  The  ordinary  lotio  alba  so 
commonly  used  for  acne  has  little  more  value  than 
that  of  a  placebo,  while  vaccines  of  the  socalled 
acne  bacillus  I  feel  sure  are  utterly  worthless  from 
a  therapeutic  viewpoint.  One  hundred  and  thirty- 
eight  cases  of  acne  of  the  face,  chest  and  back  were 
treated.  The  usual  course  ot  treatment  consisted 
of  twelve  exposures  of  one  fourth  H  unit  given  at 
weekly  intervals.  At  times  it  has  seemed  advisable 
to  follow  the  suggestion  of  MacKee  and  omit 
every  fourth  treatment  and  extend  the  course  over 
a  period  of  four  instead  of  three  months.  As  a 
rule  there  was  not  any  noticeable  improvement  until 
after  a  half  dozen  or  more  treatments  had  been 
administered. 

Rosacea  did  not  respond  very  well  in  my  experi- 
ence to  rontgen  ray,  eighteen  cases  of  various  types 
having  been  treated  with  rather  unsatisfactory  re- 
sults. While  some  of  the  pustular  cases  were 
improved,  there  was  naturally  no  improvement  in 
the  telangiectases  or  large  masses  of  rhinophyma. 

LICHEN  PLANUS. 

Lichen  planus  of  the  ordinary  type  is  another  of 
the  group  of  inflammatory  skin  diseases  that  is 
favorably  affected  by  the  rontgen  ray.  When 
treated  by  this  agent  the  pruritus  is  quickly  relieved 
and  the  lesions  gradually  disappear,  though  much 
slower  than  in  eczema.  I  still  feel  sure  that  the 
rontgen  ray  is  the  only  local  remedy  that  causes 
involution  of  lesions  of  ordinary  lichen  planus. 


Other  local  remedies  simply  relieve  the  itching.  In 
the  hypertrophic  type  of  the  disease  my  experience 
has  been  limited,  one  case,  however  (previously 
quoted),  responding  favorably.  Eighteen  cases  of 
lichen  planus  were  treated,  the  dose  being  the  same 
as  that  in  eczema. 

Lichenification  (lichen  circumscriptus)  also  proved 
very  amenable  to  rontgen  therapy,  nine  cases  of  this 
chronic  obstinate  condition  having  been  treated.  In 
two  cases  the  eruption  disappeared  quickly  after  a 
single  treatment,  while  in  others  the  results  were 
not  so  rapid.  The  best  effects  were  obtained  by 
doses  of  one  H  unit  at  monthly  intervals  or  one 
half  H  unit  given  every  fortnight. 

SYCOSIS   AXD  FOLLICULITIS. 

The  results  in  twenty-four  cases  of  sycosis 
(staphylococcic)  and  folliculitis  were  fairly  satis- 
factory. In  many  cases  of  sycosis  nothing  but 
rontgen  ray  (or  radium)  seems  to  have  any  per- 
manent effect  at  all.  Some  cases  were  cured  or 
improved  without  causing  the  fall  of  hair,  while 
in  others  epilation  was  necessary.  The  obstinacy 
of  the  disease  was  shown  by  a  case  which  I  treated 
twelve  years  ago  by  the  old  method  of  giving  large 
numbers  of  unmeasured  fractional  doses.  The 
patient  who  had  suffered  from  this  affliction  for 
nine  years  had  been  previously  epilated  by  an  ex- 
perienced colleague  and  in  spite  of  this  a  second 
epilation  was  necessary  to  effect  a  cure.  Needless 
to  say,  I  could  not  be  induced  at  the  present  to 
repeat  such  a  procedure  with  any  but  the  modern 
technic. 

Three  cases  of  the  unusually  obstinate  condition 
known  as  cheilitis  exfoliativa  were  treated  with 
very  satisfactory  results.  The  scaling  which  had 
not  even  been  temporarily  helped  by  any  other 
remedies  was  entirely  removed  in  two  cases,  after 
five  and  in  another  after  nine  treatments  of  one 
fourth  to  one  half  H  unit.  The  cases  were  treated 
recently,  one  patient  remaining  well  for  five;  months. 

RINGWORM   AND  FAVUS. 

The  great  therapeutic  value  of  the  rontgen  ray 
is  shown  by  the  variety  of  conditions  in  which  it 
can  be  employed.  The  fact  that  a  certain  quantity 
of  the  ray  will  cause  a  fall  of  hair  is  utilized  in 
treating  ringworm  and  favus  of  the  scalp.  In  these 
conditions  the  result  is  certainly  brilliant.  Instead 
of  treating  ringworm  with  salves  and  mechanical 
epilation  for  months  or  even  years,  we  are  now 
able  to  cure  permanently  nearly  even,-  case  of  ring- 
wonn  and  the  majority  of  cases  of  favus  of  the 
scalp  in  three  months.  The  modified  Kienboeck- 
Adamson  technic  as  described  by  !MacKee  and 
Remer,  Hazen  and  others,  is  not  at  all  difficult, 
though  it  requires  considerable  patience  on  the 
part  of  the  operator  in  treating  young  and  restless 
children.  The  patient's  scalp  is  previously  clipped 
(not  shaved)  and  after  the  preliminary  markings 
with  a  blue  pencil,  one  H  unit  is  given  at  right 
angles  to  the  five  intersecting  points  upon  the  scalp. 
In  about  two  or  three  weeks  the  hair  falls  com- 
pletely or  is  loose  enough  to  be  removed  with  gentle 
traction.  The  scalp  then  remains  bald  for  the 
following  six  to  twelve  weeks,  after  which  the  hair 
returns  completely  and  the  disease  is  cured.  As 


840 


FOX:  ROENTGEN  RAY  IN  SKIN  DISEASES. 


[New  York 
Medical  Journal. 


pointed  out  by  Hazen  it  is  advisable  to  epilate  the 
entire  scalp  even  when  the  disease  is  not  widely 
disseminated,  as  the  new  hair  may  have  a  somewhat 
different  color  and  consistency.  Occasionally  there 
is  a  reinfection  and  a  second  epilation  six  months 
later  is  necessary.  ]\Iy  series  includes  seventeen  cases 
of  ringworm  and  four  of  favus.  A  few  of  these 
have  been  treated  recently  and  the  patients  are  still 
in  the  stage  of  temporary  baldness.  The  others 
made  an  uneventful  recovery  in  about  three  months. 
One  of  my  cases  was  in  a  child  three  and  a  half  years 
of  age.  While  the  treatment  of  ringworm  of  the 
scalp  is  not  difficult,  it  is  a  satisfactory  proof  that 
the  standardization  of  the  apparatus  is  accurate. 

Other  classes  of  cutaneous  diseases  in  which  the 
rontgen  ray  is  of  great  value  include  hyperidrosis, 
pruritus,  the  leucemic  affections,  and  carcinoma. 
Localized  sweating  of  the  palms,  soles  and  axillae 
is  a  disease  in  which  the  ordinary  remedies  are 
only  palliative.  The  rontgen  ray,  on  the  other  hand, 
is  the  only  agent  with  which  I  am  acquainted  that 
can  effect  a  permanent  cure.  My  experience  has 
been  limited  to  the  treatment  of  seven  cases.  I  am 
convinced  that  large  doses  such  as  one  H  unit  every 
month  are  necessary  to  produce  results.  At  the 
suggestion  of  a  colleague  I  recently  treated  two 
cases  by  small  doses  (one  fourth  H  unit)  weekly, 
giving  a  total  of  ten  to  twelve  treatments  respec- 
tively, and  failed  utterly  to  obtain  any  appreciable 
results.  On  the  other  hand,  a  complete  and  per- 
manent cure  was  obtained  in  a  cello  player  who  had 
suffered  for  two  years  from  -hyperidrosis  of  the 
palms.  He  was  given  eight  exposures  of  one  H 
unit  at  monthly  intervals. 

The  antipruritic  action  of  the  rontgen  ray  is  well 
known  in  inflammatory  diseases  such  as  eczema, 
psoriasis,  lichenification,  etc.  In  both  localized  and 
generalized  pruritus  without  visible  cutaneous  lesions 
its  effect  is  often  most  striking,  as  in  a  case  (previ- 
ously quoted)  of  pruritus  of  the  vulva  and  anus  of 
four  years'  duration.  After  a  single  exposure  of 
one  H  unit  the  pruritus  disappeared  completely  and 
had  not  reappeared  at  the  end  of  nine  months.  At 
times  the  ray  was  only  palliative,  while  in  one  case 
of  general  pruritus,  after  persistent  treatment,  no 
appreciable  relief  was  obtained.  Fourteen  cases  of 
pruritus  were  treated,  the  best  results  being  obtained 
by  a  dose  of  one  H  unit. 

LYMPHATIC  DISEASES  AND  CARCINOMA. 

That  the  rontgen  ray  has  an  important  place  in 
the  treatment  of  the  lymphatic  diseases  and  carci- 
noma is,  of  course,  well  known.  In  the  lymphatic 
diseases  involving  the  skin,  such  as  leucemia, 
Hodgkin's  disease,  and  the  allied  condition  of  my- 
cosis fungoides,  the  rontgen  ray  is  the  only  remedy 
that  has  a  favorable,  if  only  palliative,  effect  on  the 
lesions.  There  can  be  no  doubt  that  the  ray  alone 
will  cure  a  large  proportion  of  cases  of  epithelioma 
of  the  basal  cell  type  (rodent  ulcer),  though  it  must 
be  admitted  that  this  relatively  benign  form  of  can- 
cer can  be  easily  eradicated  by  a  number  of  other 
methods  of  treatment.  The  ray  will  also  cure  a 
small  proportion  of  cases  of  metastasizing  type 
(squamous  cell)  epithelioma.  In  my  treatment  of 
epithelioma  I  have  combined  the  rontgen  ray  treat- 
ment with  a  preliminary  vigorous  curettage  under 


local  anesthesia.  Immediately  after  curetting,  the 
ray  has  been  given  in  doses  of  two  H  units,  includ- 
ing a  border  of  a  quarter  to  a  half  inch  of  normal 
skin,  the  neighboring  parts  being  carefully  screened. 
In  some  cases  a  second  similar  exposure  has  been 
given  a  month  later. 

LESS  FAVORABLE  RESULTS. 

In  a  number  of  miscellaneous  affections,  my  re- 
sults have  been  disappointing,  including  some  in 
which  beneficial  effects  have  been  asserted  by  others. 
Although  the  rontgen  ray  is  supposed  to  have  a 
favorable  action  upon  diseases  characterized  by 
warty  lesions,  such  as  common  warts,  senile  kera- 
tosis and  Darier's  disease,  it  has  not  been  a  brilliant 
success  in  my  hands.  It  is  quite  possible  that  my 
dose  has  been  too  small.  In  all  events  I  have  seen 
better  results  in  some  cases  from  the  use  of  ra- 
dium. I  have  not  been  impressed  with  the  useful- 
ness of  the  rontgen  ray  in  lupus  erythematosus, 
having  personally,  however,  only  treated  three 
cases  with  little  benefit.  I  have  found  radium  more 
effective  in  this  extremely  obstinate  condition.  The 
result  in  five  cases  of  dermatitis  herpetiformis,  two 
cases  of  sarcoid,  and  one  case  each  of  keloid 
and  pityriasis  rubra  pilaris  were  very  disappointing. 
In  certain  nail  conditions,  notably  ringworm  and 
paronychia,  the  results  were  equally  bad,  with  the 
exception  of  a  single  case  of  ringworm  involving 
two  nails,  in  which  the  disease  completely  cleared  up 
after  five  exposures  of  one  H  unit  given  at  monthly 
intervals. 

As  the  gamma  rays  of  radium  and  the  rontgen 
ray  have  similar  physical  qualities,  it  is  natural 
that  their  effect  upon  certain  skin  diseases  should 
also  be  similar.  Owing,  however,  to  the  limited 
areas  that  can  be  treated  in  reasonable  time  by 
radium,  its  practical  utility  in  dermatology  is  de- 
cidedly less  than  that  of  the  rontgen  ray.  In  a  few 
conditions,  such  as  nsevus  (of  various  types),  lupus 
erythematosus,  leucoplasia,  and  possibly  warty  and 
keloidal  lesions,  it  is  of  much  more  value  thaii  the 
rontgen  ray. 

CONCLUSIONS. 

1.  The  rontgen  ray  is  probably  the  most  useful 
therapeutic  agent  for  the  treatment  of  skin  diseases. 

2.  Its  versatility  is  shown  by  the  great  variety  of 
conditions  in  which  it  can  be  used,  including  inflam- 
matory diseases,  those  depending  on  epilation,  pruri- 
tus and  hyperidrosis,  lymphatic  disease  and  cancer. 

3.  It  is  only  by  means  of  accurate  standardization 
that  its  full  value  can  be  realized  and  its  dangers 
eliminated. 

4.  Standardized  treatment  requires  the  use  of  a 
Coolidge  tube  and  interrupterless  transformer.  The 
quantity  of  ray  can  then  be  measured  by  pastilles  or 
by  arithmetical  computation. 

5.  The  routine  use  of  pastilles  is  unsatisfactory, 
as  considerable  experience  is  required  and  as  they 
introduce  the  element  of  personal  equation. 

6.  By  means  of  the  simple  method  of  computation 
devised  by  MacKee  and  Remer,  the  treatment  of 
skin  diseases  by  the  rontgen  ray  has  been  revolu- 
tionized and  a  great  contribution  made  to  dermato- 
logical  therapeutics. 

7.  The  most  brilliant  results  in  my  experience 
have  been  attained  in  eczema  and  in  ringworm  of 


November  27,  1920.] 


NORRIS:  DIAGNOSIS  OF   PULMONARY  DISEASE. 


841 


the  scalp,  where  the  rontgen  ray  is  certainly  the 
method  of  choice. 

8.  It  has  also  been  of  great  value  in  acne,  psori- 
asis, seborrheic  eczema,  lichen  plants  and  epithe- 
lioma. 

9.  In  chronic  sycosis,  localized  hyperidrosis  and 
some  cases  of  localized  pruritus  it.is  the  only  remedy 
(except  radium)  that  can  eflfect  a  permanent  cure. 

10.  Leucemic  conditions  and  mycosis  fungoides 
cannot  be  even  temporarily  improved  by  anything 
except  the  rontgen  ray  (or  radium). 

I  wish  to  express  my  thanks  to  my  former  asso- 
ciate. Dr.  S.  J.  Nilson,  and  my  office  assistant,  Miss 
Ruth  Kane,  for  continuing  this  work  during  my 
absence  in  the  military  service,  and  to  my  associate 
of  the  past  year.  Dr.  J.  Edgar  Fisher,  for  his  as- 
sistance. 

1.  MacKee,  G.  M.  :  Arithmetical  Computation  of  Ront- 
gen Dosage,  Journal  of  Cutaneous  Diseases,  37,  783,  Decem- 
ber, 1919. 

2.  Sheaker,  J.  S. :  Factors  Governing  Photographic  Ac- 
tion of  Rontgen  Rays.  American  Journal  of  Rontgenology, 

2,  900,  December,  1915. 

Idem:  The  Physical  Aspects  of  Rontgen  Ray  Measure- 
ments and  Dosage,  American  Journal  of  Rontgenology, 

3,  298,  June,  1916. 

3.  I^MER,  J.,  and  Witherbee,  W.  D.  :  The  Action  of 
the  Rontgen  Ray  in  Plate,  Pastille,  and  Skin,  American 
Journal  of  Rontgenology,  4,  303,  June,  1917. 

Witherbee,  W.  D.,  and  Remer,  J. :  A  Practical  Method 
of  Rontgen  Rav  Dosage  without  the  Aid  of  a  Radiometer, 
Archives  of  Dermatology,  38,  N.  S.  1,  558,  May,  1920. 

Remer,  J.,  and  Witherbee,  W.  D.  :  The  Cause  of  X  Ray 
Burns,  Medical  Record,  98,  183,  July  31,  1920. 

Witherbee,  W.  D.,  and  Remer^  J. :  Filtered  X  Ray 
Dosage,  New  York  Medical  Journal,  111,  1105,  June  26, 
1920. 

4.  Fox,  H. :  The  Coolidge  Tube  in  the  Treatment  of 
Nonmalignant  Diseases  of  the  Skin,  Journal  of  Cutaneous 
Diseases,  35,  599,  September,  1917. 

5.  Wise,  F.  :  Rontgen  Ray  Treatment  of  Widespread  and 
Generalized  Diseases  of  the  Skin,  Journal  A.  M.  A.,  73, 
1491,  November  15,  1919. 

6.  Fox,  H. :  Treatment  of  Sycosis  by  the  X  Ray,  Medi- 
cal Review  of  Rez'iews,  14,  111,  February,  1908. 

7.  MacKee,  G.  M.,  and  Remer,  J. :  The  X  Ray  Treat- 
ment of  Ring\vorm  of  the  Scalp,  Medical  Record,  88,  217, 
August  7,  1915. 

8.  Hazen,  H.  H.  :  The  Rontgen  Ray  Treatment  o_f 
Tinea  Tinsurans,  Journal  of  Cutaneous  Diseases.  37,  307, 
May,  1919. 

616  Madison  avetme. 


PHYSICAL  DIAGNOSIS  VERSUS  THE 
X  RAY  IX  DISEASE  OF 
THE  LUNGS. 
By  George  William  Xorris,  A.  B.,  M.  D., 
Philadelphia, 

Assistant  Protessor  of  Medicine  in  the  University  of  Pennsylvania; 
\isitiiig  Physician  to  the  Pennsylvania  Hospital;  Fellow  of  the 
'  College  of  Phvsicians  of  Philadelphia;  Colonel 

M.'  R.  C,  U.  S.  Army. 

Among  the  numerous  advances  in  diagnostic 
accuracy  within  recent  years,  the  x  ray  is  by  com- 
mon consent  accorded  a  high  place.  Its  successes, 
however,  have  been  much  greater  in  some  fields 
than  in  others.  In  the  following  discussion  we 
shall  limit  ourselves  to  a  consideration  of  the  x  ray 
in  relation  to  diseases  of  the  lungs. 

DISEASE  OF  THE  PLEURA. 

Pleural  adhesions  can  often  be  determined  by 
careful  inspection  of  the  chest,  by  the  observance 


of  the  diaphragmatic  shadow,  and  by  percussion 
and  auscultation  of  the  lower  pulmonary  margin. 
A  far  greater  degree  of  accuracy  is  possible,  how- 
ever, if  the  fluoroscope  or  plates  are  used.  Asso- 
ciated with  the  recent  influenza  epidemic,  cases 
were  noted  in  which  great  thickening  of  the  pleura 
occurred.  These  cases  presented  the  physical  signs 
of  a  pleural  efifusion  and  an  x  ray  picture  which 
could  hardly  be  differentiated  from  that  presented  by 
fluid  in  the  pleural  cavity.  It  is  usually  impossible 
by  means  of  physical  diagnosis  to  demonstrate  the 
presence  of  pleural  effusions  until  four  hundred 
c.  c.  have  accumulated.  The  x  ray  will  usually 
show  the  presence  of  fluid  in  smaller  amounts  and 
with  a  greater  degree  of  certainty.  In  regard  'to 
loculated  fluid  collections,  the  advantage  of  the 
X  ray  is  still  more  greatly  enhanced. 

Radiographic  studies  have  confirmed  the  clinical 
suspicion  that  localized  pneumothorax  is  much  more 
common  than  was  at  one  time  believed  and,  as  a 
rule,  enables  us  to  outline  accurately  the  region 
involved.  Interlobar  collections  of  fluid  are  also 
often  located  with  greater  precision  than  is  possible 
by  physical  diagnostic  methods.  The  x  ray  also 
has  a  useful  field  in  connection  with  artificial  pneu- 
mothorax, since  it  enables  one  to  detect  adhesions 
which  may  make  the  procedure  useless,  and  it  also 
enables  one  to  determine  accurately  the  degree  of 
lung  compression  which  has  been  attained. 

PULMONARY  ABSCESS. 

In  this  condition  great  help  is  usually  afforded 
in  determining  the  exact  site,  size,  and  proximity 
to  the  surface  of  deeph'  situated  pus  collections. 

FOREIGN   BODIES   IN   THE  BRONCHI. 

Another  signal  triumph  is  here  accorded  to  the 
X  ray.  Not  that  foreign  bodies  are  never  over- 
looked, because  they  are,  especially  when  organic 
substances,  such  as  peanuts,  have  been  inhaled. 
Nevertheless,  x  ray  results  are  infinitely  better  and 
more  accurate  in  this  field  than  physical  diagnosis 
is,  or  can  ever  hope  to  be.  Without  a  history  of 
a  foreign  body  having  been  inhaled,  the  elusive 
peanut  may  readily  be  overlooked,  but  when  such 
a  history  exists  the  foreign  body  can  nearly  always 
be  localized  by  radiographic  methods. 

Attention  has  properly  been  called  by  David  R. 
Bo  wen  (1)  to  the  necessity  of  an  x  ray  examination 
in  all  cases  of  persistent  bronchitis,  without  demon- 
strable cause.  More  frequently  than  one  would 
suspect  such  cases  are  due  to  the  presence  of  a 
foreign  body. 

PNEUMONIA. 

By  means  of  x  ray  observations  our  knowledge 
of  the  gross  pathology  of  lobar  pneumonia  has  been 
advanced.  We  have  learned  that  many,  if  not  all, 
pneumonias  begin  as  central  lesions  and  spread 
toward  the  periphery.  As  a  result  of  this  knowl- 
edge we  know  definitely  why  early  pneumonias 
often  yield  no  definite  physical  signs  and  why 
bronchial  breathing  often  appears  several  days  after 
the  onset,  if  not  actually  after  the  crisis. 

While  an  acute  process  in  the  lungs  is  under 
way,  no  clinician  will  venture  an  opinion  as  to  the 
degree  of  antecedent  pulmonary  lesions.  Nor  will 
the  radiologist.    But  later,  when  it  may  become  a 


842 


NORRIS:  DIAGNOSIS  OF    PULMONARY  DISEASE. 


[New  York 
Medical  Journal. 


question  of  unresolved  pneumonia,  interlobar  ab- 
scess, pleural  exudation — fibrinous  or  fluid — or 
of  chronic  pulmonary  tuberculosis,  the  clinician  is 
often  immeasurably  aided  by  the  radiologist. 

MEDIASTINITIS,  ADENITIS,  ETC. 

The  clinical  methods  of  determining  the  presence 
of  mediastinal  abnormalities  before  they  have 
reached  an  advanced  degree,  are  but  meagre. 
Spinal  percussion,  d'Espine's  sign,  Eustace  Smith's 
sign,  and  others,  are  of  doubtful  value  and  uncer- 
tain significance.  The  presence  of  mediastinal 
adenitis  or  neoplasm,  or  their  dififerentiation  from 
thoracic  aneurysm,  is  usually,  if  not  alwa3^s,  deter- 
mined definitely  by  the  x  ray. 

ADVANCED  TUBERCULOSIS. 

The  actual  degree  of  involvement  and  the  exact 
location  and  size  of  cavities,  although  often  of 
secondary  importance,  are  often  more  accurately 
established  by  means  ot  the  x  ray.  In  patients 
dying  of  tuberculosis,  involvement  is  often  more 
extensive  than  physical  signs  would  lead  us  to 
believe. 

BRONCHIECTASIS. 

In  the  early  stages  of  this  condition  the  uncer- 
tainty of  x  ray  diagnosis  equals  that  made  by  clinical 
means.  In  the  later  stages,  when  bronchial  thicken- 
ing, glandular  enlargement  and  cavity  formation 
occur,  a  doubtful  clinical  diagnosis  can  often  be 
substantiated. 

"Rontgenograms,  although  invaluable  in .  certain 
cases,  may  be  very  misleading  at  times  when  the 
disease  has  spread  so  as  to  affect  the  upper  as  well 
as  the  lower  lobe.  When  showing  clear  apices  the 
plate  is  of  extreme  diagnostic  value  in  ruling  out 
tuberculosis.  Slight  shadows  at  the  base,  however, 
which  are  all  one  frequently  sees  in  typical  cases 
of  bronchiectasis,  cannot  usually  be  correctly  inter- 
preted, and  very  often  definite  sacculations,  found 
on  physical  examination  and  confirmed  by  anatom- 
ical investigation,  cannot  be  seen  either  on  flat  or 
stereorontgenograms"  (2).  The  fault  most  com- 
monly committed  is  that  of  insufficient  observation. 
If  repeated  examinations  over  prolonged  periods 
are  made — before  and  after  expectoration  has  oc- 
curred— many  more  cases  will  be  demonstrable  by 
means  of  the  x  ray. 

PNEUMOCONIOSIS. 

Clinically  the  differentiation  between  dust  disease 
of  the  lungs  and  tuberculosis,  or  the  coincident 
presence  of  both  conditions,  is  usually  made  with 
difficulty  and  after  prolonged  study.  In  this  study 
the  X  ray  may  be  a  useful  adjuvant,  but  in  many 
cases,  especially  those  in  which  the  apices  are  in- 
volved, the  radiograph  may  leave  us  quite  as  much 
in  doubt  as  before  the  examination  was  made. 

Concerning  the  foregoing  statements  there  can,  it 
would  seem,  be  no  difference  of  opinion,  but  when 
we  come  to  early  pulmonary  or  lymphatic  tubercu- 
losis, the  question  of  its  activity  or  latency,  its 
differentiation  from  anthrocosis,  syphilis,  or  fungus 
disease,  opinions  differ  widely. 

Some  time  ago  a  number  of  clinicians  in  Phila- 
delphia, who  were  interested  in  pulmonary  diseases, 
examined  the  patients  in  a  series  of  cases  of  sus- 
pected early  tuberculosis  referred  to  them  by  an 


independent  observer  at  the  Phipps  Institute.  Later 
these  patients  were  examined  radioscopically  by  a 
number  of  x  ray  specialists  in  the  city,  and  finally 
all  met  together  to  discuss  their  findings.  The  pro  - 
cedure was  a  most  instructive  one.  As  a  general 
rule,  the  more  experienced  the  examiners  in  each 
branch,  the  more,  closely  did  their  findings  tally. 
The  two  facts  which  most  forcibly  impressed  us 
clinicians  were,  first,  the  different  interpretations  of 
the  same  plate  by  different  radiographers,  and, 
second,  the  greater  conservatism  of  the  more  ex- 
perienced radiographers. 

From  the  discussion  which  took  place,  it  became 
painfully  evident  that  some  of  the  x  ray  specialists 
had  not  even  the  haziest  conception  of  the  pathology 
of  tuberculosis.  It  was  doubtless  some  kindred 
experience  that  once  led  Sir  William  Osier  to  remark 
that  no  class  of  the  medical  fraternity  was  so  much 
in  need  of  the  "salutary  lessons  of  the -dead  house." 

In  a  recent  article  based  upon  a  study  of  about  six 
hundred  cases  at  Camp  Lewis  (3)  it  is  stated  that 
tubercle  bacilli  are  inhaled  deeply  into  the  distal 
bronchioles  of  the  lower  lobes.  Thence  infection 
travels  with  the  lymph  stream  to  the  hilus,  but  from 
there  it  travels  against  the  lymphatic  flow  to  the 
apices. 

In  defense  of  the  radiologist,  however,  it  should 
be  stated  that  too  often  the  clinician,  especially  the 
man  who  has  been  poorly  schooled  in  the  subject, 
insists  on  a  positive  answer  from  the  radiologist. 
Naturally,  in  many  cases,  if  a  definite  yes  or  no 
is  demanded,  mistakes  are  the  inevitable  result. 

There  are  scattered  through  the  land  a  great 
number  of  x  ray  stations  where  much  good  and 
useful  work  is  done ;  but  relatively  few  of  the  men 
who  operate  them  have  or  can  have  the  careful, 
prolonged,  intensive  training  and  the  correlation  of 
autopsy  material  to  make  their  x  ray  plates,  or  the 
deductions  they  make  from  them,  of  any  great  value. 
To  their  credit,  be  it  said,  some  of  them  admit  this. 

Nor  is  it  necessary  to  state  that  relatively  few 
internists  are  expert  diagnosticians  of  early  tuber- 
culosis. Our  war  experience,  which  showed  the 
necessity  of  reeducating  physicians  by  means  of 
special  courses  in  the  elements  of  physical  diagnosis, 
is  a  sad  and  sufficient  commentary.  Nevertheless, 
one  finds  as  a  rule  far  less  cocksureness  in  the 
average  physician  than  in  the  average  radiologist, 
when  the  diagnosis  of  early  tuberculosis  is  in 
question.  Mistakes  are  common  to  all.  In  one 
case  of  which  I  have  knowledge,  the  x  ray  diagnosis 
of  acute  miliary  tuberculosis,  which  was  scoffed  at 
by  an  eminent  physician,  was  corroborated  at 
autopsy  within  two  weeks.  And  several  times  I 
have  seen  an  x  ray  diagnosis  of  extensive  tuber- 
culosis of  both  lungs,  made  on  fat,  fever  free,  hard 
working,  and  practically  symptomless  patients. 
Quite  recently,  in  Philadelphia,  a  patient  in  whom 
a  diagnosis  of  tuberculosis  was  made  at  a  well 
known  sanatorium  and  corroborated  by  the  radiolo- 
gist of  the  institution,  was  cured  by  the  surgical 
drainage  of  an  interlobar  empyema  undertaken  on 
the  advice  of  an  internist.  Again  I  have  known 
of  cases  which  were  clinically  diagnosed  emphy- 
sema to  be  %hown  by  x  ray  and  autopsy  to  be  miliary 
tuberculosis. 


November  27,  1920.] 


STEVENS:  ROENTGENOTHERAPY. 


843 


Between  the  two  extremes  of  x  ray  being  every- 
thing and  physical  diagnosis  nothing,  and  vice  versa, 
there  must  be  a  middle  ground  of  truth.  No  one  who 
has  received  x  ray  reports  from  competent  radi- 
ologists during  the  last  five  or  six  years,  but  feels 
that  the  technic  is  better,  the  observations  more 
accurate,  and  the  pronouncements  more  conserva- 
tive. One  does  not  now  hear  so  much  about  root 
shadows,  areas  of .  congestion,  calcified  lymph  nodes, 
and  other  visionary  interpretations,  to  use  another 
expression  of  Sir  William's.  That  the  x  ray  can 
demonstrate  incipient  tuberculosis  before  it  is  clin- 
ically possible,  has,  to  say  the  least,  not  been  proved. 
Other  types  of  acute  infection  may  produce  a  re- 
action in  the  lymph  channels  and  in  the  fibrous  tis- 
sue surrounding  the  arteries,  veins,  and  bronchi. 
Further,  it  is  in  just  such  cases  that  diagnostic  aid 
is  most  desired.  Nor  has  it  been  shown  that  the 
activity  or  nonactivity  of  a  tuberculous  process  can 
be  radiographically  determined. 

Some  influenzal  infections  may  cause  a  slight 
clouding  of  the  apex,  slight  flattening  of  the  first 
rib,  a  shrunken  apex,  and  small  areas  of  apparent 
pulmonary  consolidation.  Such  findings  are  ident- 
ical with  those  often  presented  by  pulmonary  tuber- 
culosis. The  X  ray  findings  are  characteristic  of 
tuberculosis  only  in  the  later  stages.  It  may  show 
very  slight  changes  which  cannot  be  detected  by 
ordinary  clinical  methods,  as  well  as  the  exact  site 
of  the  lesion,  but  not  the  gravity  of  it  (4).  The 
stethoscope  will  remain  the  chief  instrument  of 
pulmonary  diagnosis,  because  it  gives  a  better  idea 
of  the  activity  and  nature  of  the  process,  though 
not  the  exact  extent  of  it  (5). 

In  the  vast  majority  of  early  cases  the  old  methods 
of  diagnosis  yield  satisfactory  results.  Only  rarely 
is  the  X  ray  essential.  Occasionally  the  x  ray  gives 
positive  information  not  otherwise  obtainable,  and 
at  times  it  helps  to  corroborate  evidence  in  suspected 
cases,  but,  on  the  other  hand,  one  finds  cases  clinic- 
ally definite  in  which  the  x  ray  reveals  nothing. 
A  few  conglomerate  tubercles  and  a  local  increase 
in  moisture  do  not  show  upon  the  plate. 

There  can  be  no  question  that  the  accuracy  of 
the  X  ray  diagnosis  of  pulmonary  tuberculosis  has 
advanced  greatly  within  the  last  few  years,  this 
relative  advance  being  far  greater  than  has  that  of 
physical  diagnosis  in  the  same  time.  The  use  of 
anterior  or  posterior  stereoscopic  plates,  of  plates 
made  at  dil¥erent  angles,  of  observations  made  dur- 
ing an  arrested  inspiration  or  expiration,  as  well  as 
the  use  of  serial  records  made  at  intervals  of  weeks 
or  months,  has  added  greatly  to  our  diagnostic 
ability.  The  combined  study 'of  a  case  by  means  of 
physical  methods  and  the  x  ray  has  such  manifest 
advantages  over  either  method  singly,  that  they 
should  be  jointly  employed  whenever  possible,  but 
if  only  one  method  is  to  be  chosen,  the  older  method 
is  still  the  preferable  one.  This  was  tersely  empha- 
sized in  a  remark  made  not  •  long  since  by  one  of 
the  leading  radiologists  of  the  country :  "No  x  ray 
man  shall  ever  send  me  to  a  sanatorium." 

In  closing,  it  may  not  be  out  of  place  to  say  a 
word  regarding  the  isolation  of  the  radiologist. 
Too  often,  I  fear,  he  is  called  upon  for  a  report, 
which  we  receive  and  file,  and  thereafter  he  dis- 


appears from  the  scene.  Regarding  the  antecedent 
history  of  the  patient  he  may  be  but  scantily  in- 
formed, and  regarding  the  future  progress  of  the 
case  or  the  findings  at  the  autopsy  he  is  often  left 
in  entire  ignorance.  It  may  be  his  fault,  or  it  may 
be  ours,  but  it  would  seem  that  the  point  is  worthy 
of  consideration. 

REFERENCES. 

1.  BowEN,  David  R.  :  The  Unsuspected  Foreign  Body 
as  a  Frequent  Cause  of  Chronic  Bronchitis,  American  Jour- 
nal of  Rontgenology,  vi,  1919,  111. 

2.  Stivelman,  B.  :  Bronchiectasis,  American  Journal  of 
the  Medical  Sciences,  clviii,  1919,  516. 

3.  Diemer  and  Cramer  :  Rontgenological  Determination 
of  Pulmonary  Tuberculosis,  American  Journal  of  the  Medi- 
cal Sciences,  1920. 

4.  Boetger. 

5.  Minor,  C.  L. 

1830  South  Rittenhouse  Square. 


ROENTGENOTHERAPY. 
By  J.  Thompson  Stevens,  M.  D., 

Montclair,  N.  J. 
Fellow  of  the  American  Rontgen  Ray  Society. 

The  success  that  is  being  obtained  in  various  parts 
of  the  country  at  present  with  rontgenotherapy  is 
due  to  four  factors:  1,  The  interrupterless  trans- 
former ;  2,  the  Coolidge  tube ;  3,  filtration,  and,  4, 
crossfiring  in  deep  work. 

The  first  interrupterless  transformer  was  put  out 
about  thirteen  years  ago  by  H.  Clyde  Snook,  of 
Philadelphia.  Owing  to  the  construction  of  this 
machine  it  is  possible  to  deliver  large  quantities  of 
electrical  energy  over  long  periods  of  time  without 
variation  in  voltage.  Since  the  advent  of  this 
machine  others  have  appeared  from  time  to  time, 
all  being  more  or  less  efficient  in  rontgenotherapy. 

With  the  invention  of  the  Coolidge  tube,  we  had, 
for  the  first  time  since  the  appearance  of  the  inter- 
rupterless transformer,  a  tube  which  was  able  to 
receive  the  heavy  output  of  the  transformer  over 
long  periods  of  time  without  variation.  From  this 
time  on,  rontgenologists  were  able  to  give  massive 
doses  of  the  rays  at  will.  Doses  are  now  given  at 
one  sitting  which  formerly  were  impossible.  And 
so  the  instruments  were  at  last  supplied  whereby 
we  were  placed  in  a  position  to  do  great  good,  and 
also  great  harm  by  imperfect  technic. 

Filtration  has  received  a  superabundance  of  at- 
tention from  all  and,  as  might  be  expected,  is  still 
being  improved  from,  time  to  time.  About  the 
only  point  upon  which  all  agree  is  heavy  filtration 
for  deep  work  and  lighter  for  superficial  work. 
Sole  leather  has  been  used,  aluminum,  glass,  various 
papers,  felt,  and  combinations  of  any  or  all  of  the 
materials  just  mentioned.  At  present  in  this  coun- 
try, sole  leather,  aluminum,  and  glass  are  favored, 
usuall)'  in  combination.  Personally,  I  use  for 
superficial  work  a  layer  of  sole  leather  and  either 
one  millimetre  of  aluminum  or  two  millimetres  of 
pure  glass.  In  deep  therapy,  I  use  as  a  routine 
four  millimetres  of  aluminum,  two  of  glass,  and 
a  layer  of  sole  leather. 

Crossfiring  has  for  its  purpose  the  application 
of  a  sufficient  dose  of  the  rays  to  a  pathological 
process  lying  well  under  the  superficial  structures 
without  injuring  the  skin.    We  attempt  to  deliver 


844 


STEVENS:  ROENTGENOTHERAPY. 


[New  York 
Medical  Journal. 


into  the  diseased  area  enough  of  the  rays  to  destroy 
it.  This  is  done  by  blocking  out  areas  on  the  skin, 
through  each  of  which  is  delivered  as  much  of  the 
rays  as  the  skin  will  stand.  Over  each  area  the  tube 
is  tilted  so  that  an  enormous  amount  of  the  rays 
is  delivered  to  the  diseased  area. 

In  spite  of  the  fact  that  most  writers  describe 
at  length  the  technic  used  for  each  disease  treated, 
I  find  that  with  slight  variation  of  the  technic,  at 
times,  that  all  rongenotherapy  naturally  falls  into 
three  groups,  viz:  1,  superficial;  2,  deep,  and,  3, 
superficial  and  deep  combined.    In  superficial  work 
we  want  our  maximum  dose  to  be  absorbed  by  the 
skin.    We  may  use  a  light  filter  made  up  of  a  layer 
of  sole  leather  or  one  of  either  aluminum  or  glass. 
Generally  I  make  use  of  a  layer  of  sole  leather  to- 
gether with  one  millimetre  of  aluminum  or  two 
millimetres  of  pure  gUss.    In  superficial  work  we 
do  not  make  use  of  crossfiring  but  if  the  diseased 
area  is  too  large  to  cover  with  one  exposure  we 
must  block  off  areas  on  the  skin,  and  then  administer 
a  dose  of  the  rays  to  each,  until  we  have  covered 
the  entire  area.    To  give  a  dose  of  the  rays  to  any 
one  area  we  can  make  use  of  one  of  two  methods : 
1,  The  massive  dose  method  in  which  an  erythema 
dose  is  given  at  one  sitting,  or,  2,  the  fractional  dose 
method.    As  all  skins  do  not  respond  equally  to  a 
given  dose  of  the  rays,  I  prefer  the  fractional  method 
in  superficial  therapy,  as  by  this  method  we  can 
keep  close  watch  on  our  patient  and  can  give  just 
enough.    Enough  is  generally  an  erythema  dose. 
This  is  done  by  setting  the  machine  so  that  the 
tube  will  back  up  five  inches  and  will  draw  two 
milliamperes     (at    a    focal    distance    of  eight 
inches).    The  exposure  should  last  three  minutes. 
This  is  repeated  every  other  day  until  the  erythema 
is  seen  on  the  skin.    Ten  such  treatments  will  pro- 
duce a  marked  erythema,  and  sometimes  as  few  as 
four  will  give  the  desired  result.    In  a  month's 
time  we  can  repeat  the  series  if  necessary.  The 
parts  not  under  treatment  must  of  course  be  pro- 
tected with  lead  sheeting  and  leaded  rubber  sheeting. 

In  deep  rontgenotherapy  we  deliver  into  the  dis- 
eased area  a  sufficiently  large  dose  of  the  rays  to 
destroy  the  disease.  This  must  usually  be  done 
without  harming  the  skin,  although  at  times,  when 
the  pathological  process  is  not  too  deeply  located, 
we  may,  with  advantage,  continue  our  treatment  to 
the  point  of  ulceration.  An  ulcerated  area  gen- 
erally clears  up  as  readily  after  rontgen  treatment 
as  does  the  burn  following  massive  doses  of  radium. 
To  do  this  we  make  use  of  a  heavy  filter,  a  hard 
tube,  and  crossfiring. 

According  to  Pfahler,  of  Philadelphia,  the  filter 
should  consist  of  six  millimetres  of  aluminum  or 
the  equivalent  of  glass.  I  generalh^  use  two  milli- 
metres of  glass,  four  of  aluminum,  and  a  layer  of 
sole  leather.  The  tube  should  be  made  to  draw 
five  milliamperes  and  to  have  a  parallel  spark 
gap  of  nine  inches  or  the  equivalent  of  90,000  volts. 
At  a  focal  distance  of  eight  inches  with  the  Hamp- 
son  radiometer  it  will  require  five  minutes  to  give 
.m  erythema  dose  to  a  given  area.  In  treating 
malignant  disease  I  sometimes  give  as  much  as  two 
.md  three  times  the  pastille  erythema  dose,  that  is, 
nftv  to  seventy-five  milliampere  minutes  respectively. 


Owing  to  the  fact  that  the  tissues  overlying  the 
diseased  area  will  absorb  the  rays,  we  must  cross- 
fire in  order  to  get  the  required  dose  to  the  disease. 
This  is  done  by  blocking  out  on  the  skin  areas  as 
large  as  can  be  covered  with  an  exposure  protecting 
the  other  areas  with  lead  strips  and  so  passing  from 
one  area  to  the  next,  giving  to  each  area  at  least 
an  erythema  dose  or  as  much  as  is  indicated  by  the 
disease  under  treatment.  Crossfiring  is  done  by 
so  tilting  the  tube  that  through  each  area  the  rays 
will  be  focussed  on  the  seat  of  the  disease.  Unless 
I  am  treating  malignancy,  which  I  treat  as  just 
mentioned,  I  let  the  tube  deliver  to  each  area  forty 
milliampere  minutes.  As  said  before,  the  areas  not 
under  treatment  should  be  covered  with  lead  sheet- 
ing, i.  e.,  the  parts  directly  under  the  tube,  and  the 
remainder  of  the  patient's  body  should  be  covered 
with  rubber  sheeting  heavily  impregnated  with  lead. 

In  conclusion  I  wish  to  state  that  nothing  that 
is  not  positive  fact  has  been  put  into  this  paper ; 
that  it  is  free  from  anything  that  is  in  the  experi- 
mental stage  of  development.  I  have  tried  to  make 
it  understandable  by  the  practitioner  and  the  spe- 
cialist other  than  the  rontgenologist  so  that  they 
might  have  in  one  small  paper  the  facts  of  rontgeno- 
therapy without  being  bored  by  voluminous  read- 
ing in  order  to  get  a  little  meat.  For  this  reason 
I  have  tried  to  cut  down  the  detail  as  much  as  is 
possible  with  a  basic  understanding  of  the  principles 
involved. 

ILLUSTRATIVE  CASES. 

Case  I. — Mr.  F.  K.,  came  to  me  on  June  6,  1918, 
with  a  large  eczematous  spot  upon  his  right  foot 
which  had  been  present  for  years.  Technic,  routine 
superficial ;  result,  vivid  erythema  resulted  following 
the  fourth  dose  and  treatment  was  stopped.  Erup- 
tion has  never  reappeared. 

Case  II. — Mr.  A.  M.,  referred  with  a  large  spot 
of  psoriasis  upon  the  left  elbow.  Disappeared  be- 
fore an  erythema  dose  had  been  given.  Technic, 
routine  superficial,  one  series  of  ten  treatments 
being  given. 

Case  III. — Mr.  T.  D..  came  to  me  with  a  large 
ulcer  on  the  right  temple  which  had  been  diagnosed 
as  lupus.  He  had  had  x  ray  treatment  elsewhere 
but  as  no  erythema  was  present  I  subjected  him  to 
the  usual  superficial  treatment.  The  fifth  dose  was 
the  last,  as  the  lesion  had  entirely  -healed  and  patient 
stopped  treatment  in  spite  of  the  fact  that  he  was 
earnestly  advised  to  continue.  Final  result  I  can- 
not report,  as  I  have  lost  track  of  this  patient. 

Case  IV. — Mr.  L.  H.  E.  was  referred  with  a 
small  ulcer  on  the  lower  lip,  a  section  of  which 
showed  it  to  be  epithelioma.  Technic,  removal  of 
diseased  area  with  the  actual  cautery ;  routine  super- 
ficial therapy;  deep  therapy  over  front,  back,  and 
both  sides  of  neck.  Result,  patient  was  well  eleven 
months  after  last  treatment. 

Case  V. — A.  E.  came  to  me  with  a  cervical  ade- 
nitis and  fistula  which  was  probably  tuberculous. 
Technic,  routine  deep.  Result:  Two  months  after 
last  treatment  swollen  glands  had  disappeared,  fis- 
tula was  closed,  and  there  was  very  little  induration 
at  that  time. 

Case  VI. — Mrs.  J.  Mc.  had  had  x  ray  treatments 
for  a  long  time  for  an  exopthalmic  goitre,  but  with- 


November  27,  1920.] 


LAXKFORD:  FOODS  AND  RACES. 


845 


out  result.  Symptoms  cf  hyperthyroidism  gradu- 
ally increased  in  spite  of  treatments.  There  was  no 
evidence  of  there  having  been  an  erythema.  Technic, 
routine  deep.  Several  series  of  treatments  were 
given  once  a  month  over  the  tumor  and  down  over 
the  mediastinum,  five  series  in  all  being  given. 
Result :  Two  months  after  first  series  patient  felt 
well,  ate  and  slept  well ;  pulse  was  normal ;  tumor 
a  little  smaller,  possibly.  After  three  more  treat- 
ments tumor  became  the  size  of  a  large  marble;  it 
was  the  size  of  a  grape  fruit  at  the  beginning  of 
treatment. 

Case  \TI. — Mrs.  P.  S.  C.  was  sent  to  me  for 
X  ray  treatment  of  a  fibroid  on  the  posterior  wall  of 
the  uterus.  The  tumor  was  about  the  size  of  an 
orange  and  the  patient  suft'ered  from  severe  menor- 
rhagia  and  metrorrhagia  so  much  that  she  was  seldom 
free  from  the  discharge  for  more  than  three  days  out 
of  each  month.  Technic,  routine  deep;  seven  series. 
Result :  Bleeding  stopped  entirely  two  weeks  after 
first  series  and  at  present  the  timior  is  barely  pal- 
pable. 

Case  VIII. — Mrs.  A.  A.  J.  had  been  operated 
upon  for  cancer  of  the  right  breast.  Two  months 
later  recurrence  in  mediastinum  was  diagnosed. 
Technic,  deep,  front,  back,  and  both  sides  of  chest. 
Five  series  were  given,  one  series  each  month. 
Result :  Deposits  in  mediastinum  disappeared,  but 
patient  died  of  a  recurrence  in  the  rectum  which  I 
was  not  permitted  to  treat. 

Case  IX. — Mrs.  C.  A.  C,  referred  for  palliative 
treatment  of  an  inoperable  cancer  of  the  uterus  and 
pelvis.  Technic,  deep,  fift\-  milliampere  minutes 
given  through  each  of  ten  areas  from  navel  to 
pubes,  front  and  back.  Treatment  resulted  in  a 
marked  tanning  of  the  skin.  Result :  Well  two  years 
after  last  treatment. 

FOODS  AND  K\CES.* 
By  J.  S.  Laxkford,  M.  D., 

San  Antonio,  Texas. 

Of  the  two  great  hungers  of  the  human  race  the 
desire  for  food  is  paramount.  Extreme  scarcity 
leads  to  grave  contention ;  at  the  point  of  starvation 
all  the  primitive  instincts  are  aroused,  and  the  indi- 
vidual may  steal  or  rob  to  satisfy  hunger ;  the  group 
will  lose  sight  of  justice,  and  use  every  compelling 
force  for  relief ;  in  the  last  extremity  the  individual 
will  turn  to  cannibalism. 

Anthropological  and  biological  investigation  point 
clearly  to  the  unity  of  aboriginal  man.  A  single 
species  of  a  single  genus,  influenced  by  varied  en- 
vironment, became  the  divergent  races  we  now  see, 
"and  one  of  the  strongest  factors  in  the  causation  of 
racial  variation  is  the  quality  and  quantity  of  food. 
Of  course  divergence  has  been  in  part  due  to  cli- 
mate, but  the  greater  climatic  effect  is  through  the 
influence  of  local  food  production  with  geographical 
isolation. 

In  considering  racial  distinctions  in  relation  to 
food,  it  is  not  sufficient  to  compass  the  life  and  en- 
vironment of  man  within  historical  knowledge ;  nor 
does  it  suffice  to  study  the  evidences  of  the  less 
remote    prehistoric    times    of    the  Cro-Magnon, 

*Read  before  the  San  Antonio  Scientific  Society. 


Xeanderthal,  or  Piltdown  man.  We  must  run  back 
the  line  to  earlier  prehimian  forms,  even  beyond  the 
Javanese  ape-man,  and  think  of  the  painful  and  pre- 
cariotis  evolution  before  the  mind  of  man  had 
developed  sufficiently  to  utilize  the  products  around 
him,  or  to  travel  far  in  search  of  food,  when  geo- 
graphical restrictions  and  ignorance  were  cruel 
factors  in  life.  In  this  way  we  can  understand  the 
small  stature  of  island  peoples,  limited  to  little 
space,  with  sparse  supply  of  food;  and  the  same 
conditions  among  people  of  larger  areas  of  infer- 
tile, overpopulated  territory,  suffering  hunger  for 
long  periods  of  time. 

The  subject  is  so  broad,  and  touches  so  many 
phases  of  the  development  of  man,  that  it  is  pro- 
posed to  limit  consideration  mainly  to  racial  stature 
and  some  allied  subjects;  and  to  suggest  a  probable 
cause  of  the  emotionalism  of  certain  races. 

In  order  to  understand  the  effects  of  food  supply 
on  racial  evolution,  it  is  necessary,  first,  to  note  the 
requirements  of  the  individual.  A  well  balanced 
and  safe  ration  is  composed  of  fifteen  per  "cent,  of 
proteins,  twenty-five  per  cent,  of  fats,  and  sixty 
per  cent,  of  carbohydrates,  with  a  daily  allowance  of 
forty  calories  to  the  kilogram  of  weight,  a  range  of 
two  thousand  to  three  thousand  calories,  according 
to  size  and  vocation.  In  occupations  of  hard  physi- 
cal labor,  an  addition  of  one  thousand  or  fifteen 
hundred  calories  of  carbohydrates  and  fats  are  nec- 
essary to  furnish  energy.  The  haversack  ration  of 
the  American  soldier  in  the  recent  war  had  a  fuel 
value  of  four  thousand  four  hundred  and  forty- 
eight  calories. 

The  individual  must  be  well  nourished  to  thrive, 
as  can  readily  be  seen  in  any  community;  the  prog- 
eny of  the  poor  develop  slowly  and  growth  is  in- 
hibited ;  the  children  of  the  well  to  do  grow  rapidly 
and  attain  a  larger  size.  In  the  growing  years  it  is 
highly  essential  that  the  dietary  contain  an  ample 
supply  of  lime  and  phosphorus  for  the  skeletal 
frame.  Another  item  of  great  importance  is  the 
vitamines,  only  recently  discovered,  and  found  in 
the  covering  of  grains,  fresh  vegetables,  milk,  citrus 
fruits,  probably  animal  proteins  and  other  products. 

It  is  well  to  understand  how  food  is  utilized  in 
the  process  of  growth  and  repair.  This  is  one  of 
the  many  functions  of  the  wonderful  system  of 
ductless  glands,  especially  the  pituitary,  the  thyroid, 
the  sex  glands,  the  pineal,  and  the  thymus.  This 
physicochemical  or  electrochemical  system  is  known 
to  perform  this  service  through  countless  cases  of 
arrested  development,  where  one  or  more  of  these 
glands  were  diseased,  and  by  the  direct  and  re- 
markable development  that  occurs  in  glandular 
feeding  in  such  cases.  Xo  more  interesting  fact  is 
found  in  the  whole  field  of  medicine  than  the  in- 
fluence of  the  endocrine  glands  in  physical  and 
mental  development.  The  growth  of  the  body  may 
be  retarded,  or  decidedly  altered,  by  deficient  work- 
ing of  any  one  of  these  glands,  or  even  by  unbal- 
anced function.  It  is  known  that  the  pituitary 
governs  the  development  of  the  frame ;  over  func- 
tion leads  to  giantism  and  underfunction  to  dwarf- 
ing. It  is  definitely  settled  that  the  thyroid  is 
concerned  in  stature  also,  and  that  it  determines  the 
traits  of  hair,  skin,  features,  and  mentality,  thus 


846 


LANKFORD:  FOODS  AND  RACES. 


[New  York 
Medical  Journal. 


differentiating  races.  The  pineal,  suprarenals,  and 
sex  glands,  all  play  an  important  part  in  growth 
and  the  maintenance  of  function.  This  is  all  ac- 
complished by  utilizing  the  minerals  in  the  food 
supply,  applying  them  to  the  appropriate  tissue.  So 
vital  is  this  fact  that  it  has  probably  been  the  chief 
means  of  race  divergence.  It  is  not  improbable  even 
that  it  is  at  the  root  of  the  cephalic  index  of  races ; 
that  the  brachycephalic  and  the  dolicocephalic  heads 
date  back  to  some  very  remote  period  of  anthropo- 
geographical  isolation  for  ages  when  the  endocrine 
glands  were  working  industriously  with  the  poorly 
differentiated  material  available  in  the  food  supply. 
The  dwarfing  of  races  has  evidently  been  caused  in 
considerable  part  by  lack  of  proper  stimulation  of 
the  pituitary  bod}'  and  other  glands  by  proper  food 
supply. 

In  studying  the  ,  stature  of  races,  the  Japanese 
Empire  furnishes  us  the  best  example  of  insular 
island  life.  The  area  of  tillable  soil  is  only  about 
fifteen  per  cent.,  and  a  considerable  part  of  this  by 
expert  terracing  and  by  irrigation.  The  rest  of  the 
surface  is  mountainous,  volcanic,  nonproductive, 
and  even  unfavorable  to  the  propagation  of  wild 
animal  life  for  sustenance.  The  lowlands  in  many 
places  are  untillable  on  account  of  the  rocks  washed 
down  from  the  mountains  by  torrential  rains.  Pas- 
turage vocations  have  been  impracticable  because 
the  arable  land  must  be  used  for  agriculture ;  and 
the  volcanic  wastes  and  the  bamboo  in  the  lowland 
is  a  further  barrier,  and  stock  for  food  cannot  be 
raised,  fish  being  the  main  supply  of  animal  pro- 
teins and  fats.  It  is  conceivable  that  the  Japanese 
have  lived  on  this  restricted  territory  for  countless 
ages,  and  have  suffered  from  food  shortage  for 
long  periods,  and  from  recurring  famine ;  and  the 
population  has  likely  run  beyond  possible  produc- 
tion at  different  periods.  We  may  get  some  idea  of 
what  this  race  must  have  suffered  in  food  depriva- 
tion in  earlier  time  by  our  knowledge  of  the  inci- 
dents of  the  two  hundred  and  fifty  years  of 
seclusion.  From  sheer  necessity  agriculture  in 
Japan  during  that  period  attained  a  degree  of  per- 
fection found  nowhere  else  at  any  time.  Less  than 
three  acres  were  allotted  to  the  family,  and  every 
foot  of  arable  land  was  kept  under  intensive  culti- 
vation by  skilfully  fertilizing  the  individual  plants, 
by  constant  manual  turning  of  the  soil,  by  irrigation, 
and  by  every  possible  artificial  aid  to  nature ;  and 
those  things  were  planted  that  promised  the  greatest 
returns,  as  rice,  beans,  and  other  grains,  and  nour- 
ishing vegetables  and  fruits.  And  in  spite  of  the 
greatest  production  by  these  ingenious  people,  dur- 
ing one  known  period  of  one  hundred  and  twenty- 
three  years,  from  1723  to  1846,  the  nation  made 
little  progress,  and  the  population  declined  at  times. 
Infant  mortality  was  high,  and  means  were  em- 
ployed to  limit  population  because  of  the  scarcity  of 
food.  It  is  believed  that  racial  stature  was  affected 
to  some  extent  during  the  seclusion  period,  though 
this  is  a  slow  process  and  probably  depends  upon 
long  ages.  During  the  next  fifty  years,  after  the 
policy  of  seclusion  was  abandoned,  living  in  inti- 
mate association  with  continental  peoples,  and  with 
ample  food  supply,  including  a  large  quantity  of 
Australian  cold  storage  meats,  the  population  of  the 


Empire  made  tremendous  gains,  and  it  is  asserted 
that  the  stature  has  improved,  though  this  is  doubt- 
ful, and  intelligent  progress  in  every  department  of 
life  is  one  of  the  startling  things  in  history.  An- 
other thing  of  great  importance  in  fixing  the  stature 
of  the  Japanese  is  the  lack  of  animal  proteins.  For 
the  reasons  given,  they  have  been  without  the  ani- 
mal proteins  so  essential  to  full  development  of 
stature.  It  is  a  notable  fact  that  in  moderately  cold 
countries,  where  large  quantities  of  meat  are  con- 
sumed, other  things  being  equal,  man  is  of  large 
stature,  as  the  North  Chinamen,  some  of  the  Rus- 
sians, the  Teutonic  peoples,  Anglo-Saxons,  and 
other  north  country  mixed  breeds. 

Notwithstanding  the  contention  of  vegetarians, 
science  has  proved  the  great  value  of  animal  pro- 
teins in  tissue  building  and  in  the  sustenance  of  life 
when  consumed  in  reasonable  quantity.  It  is  re- 
markable with  what  unanimity  all  people,  both 
savage  and  civiHzed,  have  unconsciously  adjusted 
themselves  to  something  like  an  even  ration  of  pro- 
tein foods,  usually  about  ten  to  twenty  per  cent., 
and  the  most  eminent  physiologists  of  the  world 
have  uniformly  contended  that  the  proteins  are 
essential  to  physical  wellbeing.  There  is  a  quality 
in  animal  proteins  that  stimulates  cell  life  and  func- 
tion, and  promotes  physical  and  intellectual  devel- 
opment that  does  not  exist  in  fats,  carbohydrates, 
or  minerals,  unassisted,  probably  operating  through 
pituitary  stimulation.  The  population  of  the  Cen- 
tral Powers  in  the  recent  war  suffered  intensely 
from  the  lack  of  fats  and  proteins  especially,  and 
now  it  is  found,  after  the  starvation  period,  that  an 
abundance  of  fats  and  carbohydrates  does  not  re- 
build without  the  addition  of  meats.  Even  when 
inbreeding,  selection  and  restrictions  of  climate  are 
considered,  we  must  admit  that  the  Japanese  stature 
has  been  limited  by  the  several  causes  mentioned. 

The  same  proposition  applies  to  other  island  peo- 
ples similarly  situated,  and  many  less  striking  ex- 
amples can  be  found.  A  fact  of  singular  interest  is 
that  where  Oriental  races  have  drifted  away  in  early 
periods  to  more  productive  lands,  where  game  and 
fruit  were  abundant,  a  larger  growth  has  been  at- 
tained. No  finer  physical  men  exist  than  some  of 
the  Pacific  Islanders,  especially  the  Polynesian  New 
Zealanders. 

The  small  stature  and  slender  build  of  most 
Asiatic  peoples,  such  as  the  Chinese,  the  Hindus, 
and  others,  as  related  to  food  supply,  is  due  to 
several  causes ;  overpopulation  and  hunger  over 
long  periods ;  a  monotonous  rjce  diet ;  the  lack  of 
animal  proteins,  the  meat  animal  in  the  Orient  being 
absent  or  held  sacred,  aesthetic  tastes  barring  ani- 
mal foods. 

The  races  that  have  attained  the  best  develop- 
ment and  made  the  greatest  intellectual  and  com- 
mercial progress  have  been  favorably  located,  with 
ports  open  to  all  the  world,  attracting  ample  supplies 
of  a  great  variety  of  foods  including  proteins,  as 
the  Greeks  and  Romans,  and  the  well  favored  mod- 
ern peoples. 

A  monotonous  food,  though  of  animal  protein,  is 
not  wholesome,  for  the  Arctic  peoples,  the  Eskimoes, 
Laps,  and  others,  whose  food  is  highly  nitrogenous, 
are  of  short  stature.    It  is  probable,  however,  that 


November  27,  1920.] 


LANKFORD:  FOODS  AND  RACES. 


847 


this  is  in  part  due  to  the  hunger  of  the  long  winters, 
recurring  famine,  and  the  age  long  conflict  with  the 
cold.  Dr.  Helen  Churchill  Semple,  a  profound  stu- 
dent of  races  and  a  distinguished  authority,  says  that 
the  dwarf  races  of  Africa  live  almost  exclusively  on 
meat,  a  monotonous  diet,  and  that  the  supply  is 
often  precarious.  She  is  referring  to  the  Bushmen 
who  are  desert  hunters,  the  Watmas  who  are  hunt- 
ers of  big  game,  and  to  the  Hottentots  who  are 
herders  on  uncertain  grass  lands.  These  races  have 
all  suf¥ered  much  from  scant  supply  and  monotony 
of  food,  and  while  they  have  not  had  to  contend 
with  intense  cold,  they  may  have  had  to  endure  a 
good  deal  from  climatic  disease. 

Alpine  people  are  of  short  stature,  and  the  higher 
the  altitude  the  shorter  the  measurements.  In  the 
more  moderately  high  altitudes  they  have  a  little 
meat  and  some  vegetables,  but  in  the  higher  alti- 
tudes the  lack  of  pasturage  makes  it  too  expensive  to 
raise  food  stock,  and  they  subsist  largely  on  dairy 
products. 

Many  examples  might  be  cited  showing  the  influ- 
ence of  the  food  supply  on  racial  growth  of  island, 
continental,  mountain,  desert,  and  coastal  peoples. 
The  Jewish  people  have  suff^ered  a  decided  short- 
ening of  stature  from  two  causes,  prolonged  perse- 
cution and  hardships  in  various  countries,  and  from 
the  inhibiting  influences  of  city  life ;  and  yet  they 
are  singularly  long  lived  on  account  of  their  cus- 
tom of  carefully  selecting  food,  and  the  sanitary 
precautions  taken  in  their  food,  especially  meat. 

It  is  probable  that  the  influence  of  heredity  and 
environment  operating  through  biological  law,  using 
the  materials  at  hand  in  various  parts  of  the  earth, 
has  permanently  fixed  the  stature  of  the  various 
races.  Transportation  facilities  will  furnish  ample 
and  varied  food  supply,  except  when  interrupted 
by  war,  and  there  will  be  no  further  radical  change. 
Nevertheless,  there  will  be  some  modifications,  and 
the  advantage  will  be  with  those  people  who  for  rea- 
sons of  location,  soil,  water,  climate,  etc.,  have  a 
large  and  varied  supply  of  food  with  a  good  lime, 
phosphorus,  and  chlorophyl  content,  and  whose 
marvelous  workshop,  the  endocrine  gland  system, 
is  not  handicapped  by  disease.  It  would  be  inter- 
esting here  to  speculate  on  the  probable  degree  of 
the  leveling  up  of  the  human  races  in  the  future. 
We  started  as  one,  we  separated  into  many,  and  the 
trend  will  be  to  unite  again,  in  spite  of  strong  ethni- 
cal tendency.  Anthropogeographical  limitations 
will  no  longer  bar  any  branch  of  the  human  family 
from  a  good  varied  food  supply  long  at  a  time. 
Napoleon  started  something  greater  than  his  wars 
when,  urged  on  by  his  great  necessity,  he  originated 
the  canning  and  preserving  industry  and  beet  sugar, 
for  this  made  possible  the  universal  feeding  of  all 
races  at  all  times.  Trade  and  the  intercommunica- 
tion of  peoples  will  favor  the  equal  feeding  of  all, 
and  the  interbreeding  of  the  past  indicates  that  races 
will  tend  to  vanish  under  the  stimulus  of  a  broader 
democracy  and  greater  facilities  of  transportation 
of  foodstuffs.  We  shall  move  back  a  considerable 
point  toward  our  original  place  in  the  ages  to  come, 
in  blood  and  in  stature,  but  the  mark  of  progress 
will  never  be  lost,  and  the  present  racial  traits  will 
persist. 


The  agonizing  hunger  and  suffering  of  millions 
on  account  of  the  recent  war,  illustrates  what  might 
happen  if  the  Malthusian  idea  is  correct;  but  the 
possible  supply  of  food  in  the  world  is  now  enor- 
mous, rendering  that  theory  untenable.  New  items 
are  constantly  being  added  to  man's  dietary.  It 
was  long  after  the  conquest  of  Peru  that  the  white 
potato  spread  out  from  the  land  of  the  Incas  to  the 
uttermost  parts  of  the  earth  nourishing  all  races, 
and  now  it  is  threatening  the  horse  with  its  alcohol 
power ;  the  universally  popular  tomato  was  growing 
wild  in  South  America  and  little  known  scarcely 
more  than  a  century  ago ;  grain  culture  is  constantly 
improving  and  extending,  and  everything  is  Bur- 
banked  ;  the  growth  of  banana  cultivation  and  the 
possibilities  of  banana  flour  are  immense;  the  cat- 
tail is  coming  into  its  own,  and  plants  of  thousands 
of  kinds  are  under  investigation,  and  we  have  but 
touched  the  vast  supply  of  food  in  the  sea  and  the 
mighty  rivers.  And  the  synthetic  process  in  the 
chemical  laboratory  promises  marvelous  things. 
There  can  be  no  danger  of  a  starving  world  till  that 
very  remote  time  when  the  earth  itself  shall  perish 
for  lack  of  moisture,  as  foreshadowed  by  the  immor- 
tal Byron. 

One  point  we  want  to  emphasize  especially  in  this 
discussion  of  food  in  relation  to  races  is  that  the 
emotionalism  of  the  Latins  and  other  people  of  the 
temperate  zone,  and  of  tropical  peoples,  is  due  to  the 
large  intake  of  sugar,  which  has  always  been  avail- 
able in  abundance.  Not  only  is  sugar  always  at 
hand,  but  the  natives  consume  large  quantities  of 
raw  ribbon  cane  in  sugar  growing  countries.  We 
will  lay  it  down  as  a  definite  proposition  that  this 
large  consumption  of  sugar,  a  quickly  acting  fuel, 
stimulates  and  overdevelops  the  pituitary  body  and 
its  functions.  This  little  organ  at  the  base  of  the 
brain  is  a  partly  glandular  and  partly  nervous  struc- 
ture, and  it  is  known  to  be  the  centre  of  all  sensa- 
tion and  emotion,  and  at  the  same  time  it  rules  and 
directs  all  the  activities  of  the  whole  system  of  duct- 
less glands,  and  the  vegetative  nervous  system,  gov- 
erning all  the  functions  of  organic  life.  It  also 
serves  as  a  communicating  centre  between  the  brain 
and  the  other  organs.  The  constant  stimulation  of 
sugary  products  over  centuries  of  time  has  over- 
wrought this  important  organ  and  overdeveloped  it 
in  some  of  its  functions,  and  thus  races  have  been 
permanently  affected. 

As  a  proof  .of  this  contention,  the  difference  be- 
tween the  Romans  of  two  thousand  years  ago  and 
their  Italian  successors  might  be  cited.  The  Ro- 
mans were  a  peculiarly  stoical,  strong,  and  unshak- 
able people,  and  we  know  the  Italians  of  the  present 
day  are  very  emotional.  The  Romans  had  no  sugar, 
for  it  was  not  introduced  into  the  Mediterranean 
Basin  by  the  Saracens  till  about  the  eighth  century, 
and  was  not  abundant  till  it  came  from  the  West 
Indies  later.  The  Romans  of  course  had  honey  and 
raisins,  but  the  quantity  was  limited,  and  not  in  such 
universal  use  as  to  afifect  the  race.  Sugar  has  been 
pouring  in  a  stream  down  tlie  throats  of  the  Medi- 
terranean peoples  for  hundreds  of  years,  not  only 
from  the  table,  but  in  candy  and  drinks.  History 
will  show  that  the  French  have  undergone  a  similar 
change,  and  perhaps  the  Spanish.    The  emotional 


848 


EDGAR:  STERILITY,  SEX, 


AND   THE  ENDOCRINES. 


[New  York 
Medical  Journal. 


mentality  of  tropical  peoples  is  well  known.  It  is 
not  only  a  reasonable  bilief,  but  a  fact  easily  dem- 
onstrated by  scientific  observation  and  will  be 
proved,  that  the  excessive  use  of  sugar  coiild  pro- 
duce such  results.  Only  recently  a  Bengalese  sci- 
entist has  found  that  the  blood  of  tropical  peoples 
contains  a  higher  per  cent,  of  sugar  than  others. 
The  rapid  increase  in  the  consumption  of  sugar 
may  portend  evil  for  our  own  country.  The 
American  people  are  now  consuming  annually 
eighty-five  pounds  per  capita,  an  increase  of  sixty- 
seven  pounds  in  forty  years^  and  still  there  seems 
to  be  no  limit.  In  fact,  it  is  increasing  more  rapidly 
since  we  have  prohibition,  and  many  are  using  it 
unconsciously  as  a  stimulant.  Its  almost  universal 
excessive  use  threatens  serious  detriment  to  the 
various  organs  with  impairment  of  function  and 
degenerative  disease.  And  ultimately  it  will  afifect 
the  emotional  side  of  life  and  tend  to  make  us  un- 
stable as  a  people.  It  would  be  well  for  those  who 
think  to  give  some  thought  to  this  proposition,  and 
warn  others  of  the  dangers  ahead. 

Perhaps  increased  emotionalism  has  enriched  the 
world  in  romance,  poetry,  art,  and  music.  It  were 
better  that  the  human  race  suffer  some  deterioration 
than  to  have  been  without  the  rich  romance  of 
French  literature,  the  entrancing  stories  of  Ibanez, 
the  passionate  truth  in  the  art  of  Italy,  France,  and 
Spain,  and  the  matchless  melody  of  Mexican  music. 
But  it  is  wise  to  moderate  oiir  excesses  in  the  use  of 
this  valuable  food  and  safeguard  the  health  and  sta- 
bility of  our  people. 


STERILITY,  SEX  STIMULATION  AND 
THE  ENDOCRINES. 

By  Thomas  W.  Edgar,  M.  D., 
New  York. 

In  presenting  this  paper  to  the  profession  I  feel 
that  it  is  my  duty  to  preface  what  follows  by  a  few 
words  in  reference  to  the  subject,  in  order  that 
conditions  regarding  the  contained  facts  be  realized. 
Almost  thirty  years  ago,  Brown-Sequard  published 
in  the  Archives  de  Physiologic  a  treatise  dealing 
with  his  research  on  testicular  organotherapy.  He 
went  so  far  as  to  offer  himself  as  a  medium,  and 
had  injected  into  his  body  a  preparation  prepared 
from  the  testes  of  a  dog.  He  reported  that  almost 
instantaneously  he  was  endowed  with  renewed  vigor 
and  virility :  in  his  own  words,  "Considerable  lab- 
oratory work  produced  hardly  any  fatigue,  and  to 
the  astonishment  of  my  two  assistants  I  was  able 
to  work  for  several  hours  in  a  standing  position." 

Unfortunately,  the  charlatans  of  Paris  commer- 
cialized this  fact  by  promptly  seizing  Brown- 
Sequard's  announcement ;  as  a  result  the  real  sig- 
nificance of  the  facts  established  by  this  master 
was  drowned  by  the  acts  of  these  unethical  prac- 
titioners to  mulct  their  susceptible  patients  of  more 
money.  Thus  his  work  and  its  result  fell  into  dis- 
repute, and  up  to  the  present  this  bad  repute  has 
stayed  with  organotherapy,  whether  it  be  testicular, 
or  what  not.  Nevertheless,  to  those  of  us  who  have 
become  interested  in  endocrinology,  the  facts  pre- 
sented   in   rough   form  in   1888  have  formed  a 


basis  on  which  to  work  miracles  in  spite  of  the 
ever  unfortunate  and  cold  reception  given  the  per- 
petrator of  any  new  method  of  procedure  of  rob- 
bing life  of  its  degenerations  or  bringing  back  the 
sex  instinct  with  its  consequent  happiness  of  mind 
and  healthiness  of  body. 

Volumes  have  been  written  on  the  subject,  and 
there  have  been  many  criticisms  offered.  Testicular 
and  ovarian  organotherapy  have  suflfered  most.  In 
my  estimation  three  fourths  of  the  unkind  things 
said  about  this  branch  of  endocrinology  have  been 
the  result  of  expecting  the  miraculous  to  happen, 
and  the  setting  of  one's  hopes  too  high.  Again, 
many  failures  have  been  due  to  slipshod  methods 
and  treatment.  Results  have  not  been  obtained  in 
short  intervals,  and  as  a  consequence  the  treatment 
has  been  abandoned. 

AX  INDIVIDUAL  IS  AS  OLD  AS  HIS  OR  HER  INTERNAL 
SECRETIONS. 

Senility  and  presenility,  in  my  estimation,  are 
nothing  more  nor  less  than  a  waning  of  the  endo- 
crine function,  accompanied  by  functional  cellular 
inactivity,  with  the  resultant  increase  in  toxeiuia, 
which  poisons  and  degenerates ;  repair,  if  it  does 
take  place,  is  slow,  and  the  organs  gradually  fall 
into  disuse,  followed  by  atrophy.  Ideals,  ambitions 
and  desires  are  but  memories,  while  procreation  is 
impossible. 

When  the  ability  to  procreate  wanes,  the  indi- 
vidual is  then  to  be  considered  senile,  unless  the 
causative  factor  is  a  specific  disease.  This  hypo- 
gonadism may  exist  at  any  period.  It  is  seen  dur- 
ing early  adult  life  and  is  then  due  to  indiscretion, 
or  is  the  result  of  presenile  changes  in  the  internal 
glandular  system,  as  portrayed  by  malnutrition, 
wrinkling  and  shrinking  of  the  skin.  The  eyes 
become  dull  and  the  movements  slow,  while  the 
spennatogenic  function,  as  well  as  the  ovarian 
sequence,  disappears.  This  presenile  stage  may  be 
also  initiated  by  indiscretion,  as  shown  by  the  sex 
glands  becoming  functionally  inactive,  and  the  case 
may  present  the  same  hypogonadism  that  is  found 
in  pathological  conditions. 

I  quote  the  following  from  an  author  who  is  evi- 
dently of  the  same  opinion  as  myself : 

"The  diagnosis  need  not  be  discussed  further, 
and  its  successful  control  through  a  mythical  elixir 
■zitcc  has  been  the  goal  of  many  from  time  imme- 
morial, and  from  Ponce  de  Leon  to  the  present 
day.  Hypogonadism  may  be  amenable  to  organo- 
therapy even  in  elderly  men,  and  the  fundamental 
principles  of  homostimulation  holds  good  in  pro- 
portion to  the  responsiveness  of  the  glands  thus 
stimulated.  It  is  a  broader  matter  than  the  gonads 
alone,  as  the  thyroid,  pituitary  and  other  endocrine 
glands  all  play  their  part.  Senility  then  is  hypo- 
crinism  rather  than  hypogonadism  alone,  and  if  we 
must  treat  it,  it  should  be  treated  in  the  larger 
sense,  and  when  organotherapy  is  in  mind,  it  should 
be  pluriglandular  therapy. 

Thus  the  failures  of  the  past  have  acted  as  step- 
ping stones  to  a  more  thorough  investigation  and 
firmer  understanding  of  the  subject.  The  solution 
of  the  vital  functioning  of  the  body  depends  on 
endocrine  secretion,  as  do  the  senile  and  presenile 
phenomena. 


November  27,  1920.]  EDGAR:  STERILITY,  SEX,   AND   THE  ENDOCRINES. 


849 


• 

Senility  or  old  age  is  inevitable.  It  is  the  logical 
termination  of  the  human  organism.  The  allotted 
time  of  threescore  years  and  ten,  however,  is  only 
traditional,  and  there  is  no  scientific  reason  why 
the  human  being  must  wither  and  cease  to  become  a 
functioning  factor  after  this  time.  We  have  ac- 
cepted the  age  of  seventy  as  the  time  for  dysfunc- 
tion, because  we  have  had  no  specific  therapy  to 
combat  its  ravages.  In  other  words,  we  have 
accepted  the  ultimatum  because  we  have  had  no 
argument  in  the  form  of  resistance  to  combat  its 
ravages. 

Senility  is  not  dependent  on  the  age  of  tissue, 
but  on  the  condition  or  nutrition  of  that  tissue  by 
internal  glandular  functioning.  Lack  of  function- 
ing is  inevitably  followed  by  atrophy,  while  atrophy 
is  followed  by  death.  Dysfunctioning  of  the  endo- 
crine system  regardless  of -age  is  followed  by  senile 
or  presenile  changes.  In  the  young  we  find  these 
conditions  simulating  changes  that  take  place  in 
late  life,  all  due  to  singular  or  pluriglandular  dys- 
function of  the  internal  glandular  system. 

The  internal  glandular  system  throughout  life  is 
capable  of  rendering  its  specific  stimuli  against  a 
certain  amount  of  resistance.  If  called  upon,  or 
taxed  at  any  period  of  time,  beyond  its  maximum 
output,  fatigue  results,  with  a  retardation  of  func- 
tion. Following  this  senile  changes  occur:  a  con- 
crete example  being  in  the  roue  whose  spermatogenic 
function  is  at  a  minimum,  also  as  shown  in  the 
neurotic  individual  who  suddenly  flares  into  tem- 
pers, only  to  call  forth  the  adrenal  secretion  which 
in  the  end  fatigues  the  gland,  and  due  to  a  decrease 
in  pressure  caused  by  said  fatigue  the  patient  be- 
comes asthenic.  Again  the  unconscious  dysfunc- 
tion, such  as  decrease  in  the  secretion  from  the 
anterior  or  posterior  lobes  of  the  pituitary,  the 
thyroid  persistence  of  the  thymus,  all  have  their 
effect  on  tissue  nutrition.  Activity  of  mind  and 
body  are  registered  on  the  dial  of  life  in  proportion 
to  the  nourishment  of  said  tissue  (not  the  age  of 
tissue)  which  is  dependent  in  great  part  by  activa- 
tion by  the  endocrines. 

Death  in  the  broad  meaning  of  the  word  as  ap- 
plied to  the  animal  organism  is  always  specific ; 
it  is  due  to  lack  of  internal  secretions  to  prevent 
their  atrophy  and  death.  Death  is  always  due  to 
cessation  of  vital  function,  caused  in  each  and  every 
case  by  the  absence  of  that  factor  which  under 
normal  conditions  activates  or  keeps  active  vital 
function,  the  endocrines.  Disease,  aside  from 
severe  traumatisms,  causes  in  the  organism  a  toxic 
condition  which  retards  by  action  of  the  degenera- 
tive changes  produced  the  delicate  metabolic  equi- 
librium, and  as  a  result  death  ensues  either  from 
paralysis  of  the  res|ftratory  centre  or  a  failure  of 
the  myocardium.  In  other  words,  the  endocrines 
are  reduced  to  a  minimum,  activation  ceases  and 
death  ensues. 

In  nineteen  hundred  and  fourteen  it  was  my 
privilege  to  be  in  Bahia,  Brazil,  at  the  time  Dr. 
Fernandez,  a  Spaniard,  was  using  with  some  success 
a  serum  (pluriglandular)  in  treating  sex  conditions, 
such  as  sterility  in  the  young  female.  His  method 
was  to  give  an  injection  of  his  product  intramuscu- 
larly twelve  hours  previous   to   the   act  of  inter- 


course. He  was  able  in  a  series  of  twenty  cases  to 
induce  pregnancy  in  two  women  so  treated.  All 
applicants  were  examined  previous  to  injection,  and 
any  visible  gynecological  condition,  such  as  atresia, 
or  malpositions  of  the  uterus  were  ehminated. 

Dr.  Fernandez's  work  on  the  internal  secretions 
interested  me,  and  as  I  was  personally  interested  in 
metabolism,  I  devoted  my  time  to  its  study :  not, 
however,  from  the  viewpoint  of  sterility,  but  meta- 
bolism in  general,  especially  diabetes  mellitus.  In 
March,  1919,  I  published  a  paper  dealing  with  the 
treatment  of  diabetes  by  the  Edgar  serum.  At  a 
later  date  a  second  paper  was  presented  dealing 
with  cases  treated.  At  this  time  I  was  impressed 
with  the  number  of  patients  who  showed  improve- 
ment in  their  sex  relationship.  Other  patients 
manifested  improvement  in  their  mental  condition. 
I  became  interested  and  found  that  many  patients 
had  regained  the  power  of  erection  and  ejacula- 
tion. I  became  interested  in  the  surprising  results 
and  immediately  studied  a  series  of  cases  that  were 
not  diabetic,  in  order  to  check  up  my  results. 
.  My  idea  in  presenting  this  short  paper  is  simply 
to  place  myself  on  record  as  being  interested  in  sex 
stimulation  and  at  present  using  a  pluriglandular  en- 
docrine serum  with  success  in  the  treatment  of  this 
condition.  It  was  not  my  intention  originally  to 
depart  from  the  specific  therapy  of  diabetes,  but 
my  unusual  observations  in  the  cases  treated  have 
been  so  promising  in  producing  a  state  of  wellbeing 
in  my  elderly  adult  patients,  that  I  feel  entitled  to 
state  that  I  have  a  distinctly  beneficial  serum  for 
Wit  alleviation  of  presenile  and  senile  deficiency : 
and  that  my  product  is  capable  of  producing  a  new 
lease  of  life  in  those  whose  functions  have  been 
reduced  to  a  minimum. 

Previous  to  reviewing  several  cases,  I  may  state 
that  as  I  did  not  decrease  the  diets  of  these  indi- 
viduals, or  try  to  build  up  their  tolerance  by  starva- 
tion, I  do  not  feel  that  their  improvement  was  due 
to  this  form  of  therapy.  Secondly,  the  last  three 
patients  were  not  diabetic,  and  presented  no  evi- 
dence of  any  objective  or  subjective  disease,  aside 
from  their  presenile  conditions. 

Case  I. — Male,  aged  eighty-four.  Consulted  me 
because  he  was  losing  weight  and  becoming  weak. 
Complained  of  frequent  urination,  loss  of  memory. 
The  patient  had  been  employed  by  one  of  the  large 
periodicals  as  a  political  writer  on  account  of  his 
intimate  knowledge  of  politics.  For  the  past  six 
months  he  was  unable  to  deliver  any  speeches,  and 
because  of  his  inability  to  concentrate  was  unable 
to  write.  Physical  examination  revealed  a  remark- 
ably well  preserved  individual,  skin  ruddy  and 
moist.  The  radial  and  temporal  arteries  only 
slightly  sclerotic;  eyes  clear  and  moist;  knee  jerks 
absent ;  venereal  history  negative ;  fine  tremor  of 
hands  present;  musculature  flabby;  weight  210 
pounds.  The  patient  consulted  me  on  account  of 
his  mental  condition,  thinking  it  might  be  due  to 
diabetes,  which  was  sapping  hi^  strength,  and  caus- 
ing him  loss  of  sleep.  I  informed  my  patient 
that  I  did  not  think  it  wise  to  treat  the  diabetes 
heroically,  as  we  might  upset  his  metabolic  equilib- 
rium, as  is  often  done  in  elderly  diabetic  patients 
w.hen  the  diet  is  radically  changed.    He  persisted, 


850  EDGAR:  STERILITY,  SEX,   AND  THE  ENDOCRINES.  [New  York 

Medical  Journal. 


however,  in  his  desire  for  treatment,  and  it  was  ad- 
ministered with  reluctance.  The  injections  took  place 
as  follows:  September  10th,  September  25th,  Octo- 
ber 4th,  October  18th,  October  27th,  November  7th. 
At  this  time  my  patient  voiced  the  opinion  that  he 
was  feeling  ever  so  much  better,  and  that  his  memory- 
had  greatly  improved,  so  much  so  that  he  had  writ- 
ten an  article  for  a  Washington  paper  which  had 
been  accepted.  He  then  received  injections  on : 
November  18th,  November  28th,  and  December  15th. 
The  patient  was  so  much  improved  mentally  that  he 
was  busy  writing  every  day ;  his  mentality  was  that 
of  a  man  of  forty.  He  was  able  to  express  himself  in 
definite  terms,  and  recall  past  events  that  had  hap- 
pened in  the  political  world  years  ago ;  sleep  was  un- 
disturbed. He  informed  me  that  he  did  not  become 
fatigued  on  exertion,  either  physically  or  mentally. 

During  the  course  of  treatment  his  sugar  output 
remained  unchanged,  although  the  polyuria  and 
weakness  disappeared.  This  is  a  remarkable  case 
in  that  definite  results  were  produced  in  a  man  of 
this  age,  as  evidenced  by  a  dismissal  of  all  symp- 
toms that  might  be  referable  to  a  final  waning  of 
all  endocrine  functioning. 

Case  II. — Young  man,  aged  thirty-four,  instru- 
ment maker  by  trade ;  venereal  history  negative.  A 
history  of  diabetes  extending  back  three  years.  Com- 
plained on  visiting  me  of  general  weakness,  loss  of 
weight  and  ability  to  concentrate.  Sexual  instinct 
at  a  minimum  ;  erection  impossible.  Physical  exami- 
nation revealed  a  prematurely  old  man.  Skin  dry 
with  beginning  wrinkles ;  heart  and  lungs  negative. 

First  injection  October  17,  1919,  continued  for  a 
period  of  four  months  at  intervals  of  seven  days. 
There  was  no  dietetic  treatment  advised,  and  none 
indulged  in.  On  discharge,  the  patient  was  sugar 
free,  had  gained  thirty  pounds  and,  as  he  expressed 
it,  was  feeling  like  a  new  man.  He  also  gained 
back  the  power  of  erection.  His  spermatogenic 
function,  which  had  been  absent  for  two  years,  re- 
turned gradually.  His  wife  became  pregnant  in 
May,  1920,  seven  months  after  the  patient  received 
his  first  injection,  but  unfortunately  miscarried  at 
the  third  month.  He  now  enjoys  better  health  than 
at  any  time  during  the  past  five  years,  and  is  doing 
hard  manual  work  without  any  appreciable  fatigue. 

Case  III. — Female,  married ;  no  children.  Men- 
struated at  the  age  of  fifteen.  Periods  remained 
regular  until  the  age  of  twenty-seven,  usually  last- 
ing four  or  five  days ;  no  pain.  At  this  time  the 
patient  came  home  one  evening  to  find  her  cousin 
dead  in  bed.  Following  this  shock  she  swooned,, 
was  revived  and  continued  in  her  usual  good  health, 
but  did  not  menstruate.  She  had  suffered  from 
amenorrhea  for  the  past  two  years,  previous  to  con- 
sulting me.  Physical  examination  revealed  no  ob- 
struction or  malposition  of  the  uterus.  There  was 
no  tenderness  over  the  ovarian  area,  nor  was  there 
any  leucorrhea.  Skin  was  lightly  icteric,  and  drawn 
in  appearance.  Frontal  headache  was  complained 
of.    The  patient  presented  an  apathetic  appearance. 

A  specimen  of  the  husband's  semen  examined  on 
a  warm  stage  microscope  showed  very  active 
spermatozoa.  His  Wassermann  was  negative,  as 
was  that  of  his  wife.  I  advised  routine  injection 
of  my  serum.    The  patient  received  one  injection 


weekly  for  a  period  of  four  months.  During  the 
middle  of  the  fourth  month  she  menstruated.  I 
visited  her  the  following  day,  and  found  that  she 
was  losing  a  normal  amount  of  menstrual  blood. 
The  flow  continued  for  two  days  and  subsided.  The 
next  period  was  regular,  and  they  have  continued 
so  to  the  present.  This  patient  had  been  curetted 
previous  to  the  administration  of  the  serum,  with- 
out result.  Undoubtedly  her  ovarian  dysfunction 
was  due  to  the  sudden  shock  she  received  over  two 
years  ago,  and  as  a  result  her  endocrine  equilibrium 
was  disturbed  and  normal  stimulus  did  not  take 
place. 

Case  IV. — Male,  aged  fifty-seven;  hatter  by 
trade.  History  elicited  the  fact  that  the  patient's 
skin  was  becoming  dry  and  rough.  The  sexual 
function  had  been  impaired  for  the  past  four 
months,  with  inability  either  to  ejaculate  or  main- 
tain erection.  The  patient  was  unable,  at  times,  to 
sleep  more  than  two  hours  a  night.  He  became  un- 
interested in  his  work,  lost  weight  and  strength, 
and  presented  an  apathetic  appearance.  The  physi- 
cal findings  were  negative  throughout,  except  for 
a  slight  hypertrophy  of  the  prostate.  There  was  a 
definite  mental  obsession  due  to  anxiety  over  his 
condition.  After  receiving  ten  injections  of  the  serum 
the  patient  had  improved  greatly  and  had  resumed 
business.  His  nights  were  comfortable,  and  he  felt 
much  improved.  Three  months  after  beginning 
treatment  he  gained  back  the  power  of  erection  and 
ejaculation.  Microscopical  examination  of  the  semen, 
however,  revealed  the  fact  that  the  spermatozoa 
were  not  motile.  The  psychological  stimulus  coin- 
cident to  the  return  of  the  function  was  indeed 
wonderful  in  that  it  changed  the  mental  aspect 
entirely,  allowing  him  to  dispel  the  pseudoobsession 
under  which  he  was  laboring.  This  patient  is  well 
and  working  eight  hours  every  day.  His  mental 
attitude  is  cheery,  and  he  looks  and  acts  twenty 
years  younger. 

Case  V. — Capitalist,  aged  fifty-four,  past  history 
negative  as  to  medical  and  surgical  illness.  Has  al- 
ways indulged  in  alcohol  to  excess.  History  of 
sexual  indiscretion  dates  back  for  the  past  twenty 
years.  Consulted  me  June,  1919,  because  of  in- 
ability to  maintain  erection,  with  partial  loss  of 
ejaculative  powers.  This  condition  had  been  present 
for  a  year.  Physical  findings  negative  aside  from 
hypertrophied  prostate.  Administration  of  serum 
commenced  June  15,  1919.  Received  ten  injections 
in  all.  On  discharge  function  had  returned.  I 
may  state  that  there  was  no  medication  aside  from 
the  serum  used  in  this  case.  This  patient  was  of 
the  roue  type  and  the  condition  was  the  result  of 
fatigue  of  the  endocrine  secretion  which  responded 
to  specific  stimulation  in  the*  form  of  activating 
substances. 

In  none  of  these  cases  was  there  any  evidence  of 
disease  of  the  interstitial  cells  of  Leydig.  In  each 
case  electric  stimulation  caused  a  slight  erection  of 
the  penile  musculature,  with  a  short  contraction  of 
the  sphincter  muscle.  The  patient  in  Case  II  did 
not  react  in  any  way  to  large  doses  of  strychnine, 
which  lead  me  to  believe  that  neurological  condi- 
tions existed.  In  spite  of  this  fact  endocrine  stimu- 
lation produced  results.     Last  but  not  least,  the 


November  27,  1920.] 


SCHROEDER:  CHRISTIAN  SCIENCE  AND  SEX. 


851 


psychological  effect  produced  by  the  renewing  or 
revitalizing  of  a  dormant  function  was  capable  in 
these  five  cases  of  so  changing  the  outlook  on  life 
that  bodily  vigor  and  mental  acuity  were  substituted 
for  morbid  forebodings. 

The  question  of  grafting  or  implanting  testes 
is  a  satisfactory  procedure  in  the  majority  of 
cases,  but  as  sex  dysfunction  is  pluriglandular  in 
its  entirety,  it  is  necessary  to  ascertain  the  meta- 
bolic rate  and  function  quotient  of  the  other  secre- 
tory glands  before  operative  procedure  is  advised. 
In  a  testicular  implant  case  in  which  operation 
was  performed  some  time  ago,  it  was  necessarj'  to 
resort  to  thyroid  feeding  after  the  implantation  in 
order  to  coordinate  the  vis  a  tergo  of  the  secretory 
equilibrium,  the  patieni  being  myxedematous  as 
well  as  suffering  from  hypogonadism. 

I  am  now  working  with  a  solution  composed  of 
the  salts  of  the  blood,  the  concentration  being 
isotonic  with  the  blood  serum,  into  which  the  gland 
of  the  donor  is  placed  to  facilitate  its  state  of 
resistance,  during  the  interim  between  removal  and 
implantation.  By  this  method  the  functioning 
power  of  the  gland  may  be  kept  in  a  highly  nour- 
ished state.  The  spermatogenic  function  of  the 
testes  is  not  endogenous,  but  pluriglandular  in  its 
sequence.  In  other  words,  sex  dysfunction,  or 
testicular  dysfunction,  is  hypoendocrinism,  rather 
than  hypogonadism. 

766  West  Exd  Avenue. 


CHRISTIAN  SCIENCE  AND  SEX. 

By  Theodore  Schroeder,  M.  D., 
Cos  Cob,  Conn. 

It  might  be  interesting  to  see  if  some  of  the  more 
fundamental  doctrines  of  Christian  Science  can 
be  explained  as  the  intellectualization  of  psycho- 
erotic  states  and  attitudes.  My  own  past  observa- 
tion impels  me  to  seek  the  interpretation  of  all 
mystical  philosophies  of  like  tendencies  in  terms  of 
the  emotional  conflict  over  sex.  Intensified  sexual 
impulses  are  often  accompanied  by  an  equally  in- 
tense and  often  inefficient  urge  to  exclude  the 
physiological  aspects  of  sex  from  consciousness. 
Thus  it  often  happens  that  nymphomania  or  eroto- 
mania manifests  itself  to  the  rest  of  the  world  as 
erotophobia.  When  this  becomes  formulated  ac- 
cording to  various  degrees  of  intensity  and  with 
var\'ing  cultural  development,  we  find  a  great  variety 
of  resulting  metaphysical  theory  and  theological 
morality.  Let  us  restate  a  little  of  Christian  Science 
doctrine  just  to  see  if  it  lends  itself  to  explanation 
from  this  viewpoint ;  that  is,  in  terms  of  the  internal 
erotic  conflict. 

First  let  us  remember  that  !Mrs.  .Mary  ^loss- 
Baker-Glover-Patterson-Eddy  had  more  husbands 
than  she  had  children.  This  is  some  evidence  of 
her  having  been  afflicted  by  sexuoemotional  con- 
flicts. Without  the  satisfaction  of  the  biological 
impulse  for  progeny,  she  became  afflicted  with  the 
compensatory  psj'chological  urge  to  become  the 
"mother"  of  all  who  are  "born  of  truth  and  love" 
(1).  God  "is  the  universal  father  and  mother  of 
man"  (2),  perhaps  because  bisexual  impulses  in 


herself  required  the  projection  of  these  dual  qual- 
ities into  her  God.  She  discoursed  glibly  about  "the 
womanhood  as  well  as  the  manhood  of  God"  (3). 
Probably  because  with  this  concept  she  could  achieve 
a  needed  compensation  for  her  feeling  of  inferi- 
ority, due  to  her  femininity  (4).  This  compensa- 
tion consisted  in  identifying  herself  wnth  God,  in 
the  role  of  being  his  feminine  part. 

Though  differently  expressed  and  perhaps  dif- 
ferently theorized  about,  she  yet  laid  claim  to  the 
same  perfectionism  asserted  by  Mormons  and  the 
free  lovers  among  the  Bible  Communists  of  Oneida. 
Sin  is  but  "an  error  of  mortal  mind,"  and  Mrs. 
Eddy  having  come  to  a  realizing  sense  thereof,  to 
her  all  "evil  is  unreal"  (5).  That  is  to  say,  all  her 
own  "shameful"  past  had  to  be  pushed  out  of 
consciousness ;  had  to  be  treated  as  unreal,  in  order 
to  neutralize  her  feelings  of  shame,  of  inferiority. 
Of  course,  one  who  needed  such  a  psychological 
remedy  for  a  feeling  of  depression  had  to  abolish 
"the  erring  testimony  of  mortal  sense"  so  that  she 
could  receive  into  consciousness  no  evidence  of  her 
own  sin.  She  could  not  commit  an  unreality  which 
alone  is  sin.  Those  who  are  excessively  burdened 
by  the  feeling  of  their  own  sinful  flesh  tend  to  find 
compensations  in  rising  above  the  flesh,  in  identify- 
ing themselves  with  the  supernatural  generally,  or 
with  God.  So  they  argue  that  God,  being  the  "all 
in  all,"  one  like  Mrs.  Eddy  is  herself  a  part  of 
God,  and  how  could  she,  a  part  of  God,  commit  any 
sin  so  long  as  she  rejects  the  "erroneous  belief" 
^  that  "evil  is  real"  (6)  ?  No.  She  is  "no  longer 
obliged  to  sin"  (7).  To  such  persons  all  is  pure, 
even  though  to  unspiritual  vision  it  may  still  seem 
both  real  and  evil.  Having  herself  experienced  that 
"spiritual  birth"  which  "opens  to  the  enraptured 
understanding"  (8)  many  things,  she  readily  dis- 
covered (perhaps  with  the  help  of  her  many  hus- 
bands) that  lust  is  "always  wrong"  (9)  unless  the^ 
physiological  factors  can  be  excluded  from  con- 
sciousness. Then  we  can  oppose  to  the  "material 
sense  of  love"  a  purely  psychological  erotism,  that 
is  a  "spiritual  law  of  love"  (10)  and  "spiritual 
love"  (11)  with  "spiritual  oneness"  (12),  with  God 
or  anyone  else  in  the  universe,  either  dead  or 
alive  (13). 

Thus,  through  Christian  Science  ideals  will  "the 
attraction  between  the  sexes  be  perpetual,  bringing 
sweet  changes  and  renewal."  So  it  can  be  described 
if  we  succeed  in  excluding  from  consciousness  all 
the  physical  sexuality,  and  enjoy  approximately  the 
continuous  ebb  and  flow  of  ecstasy  due  to  eroto- 
mania. Since  the  "material  sense  of  love"  is  but 
an  "error  of  mortal  mind"  it  follows  that  all  erotic 
love  is  wholly  psychological,  that  is,  spiritual.  If  it 
is  unceasing,  as  in  extreme  erotomania,  then  we  can 
say  that  God  is  love  and  love  is  all  there  is  of  God. 
It  follows  that  celibacy  is  nearer  right  than  mar- 
riage (14),  because  normal  marital  relations  tend 
to  dilute  the  psychosexual  ecstasy.  Now  genera- 
tion "rests  on  no  sexual  basis"  (15).  In  all  climes 
and  times,  neurotics  have  found  their  way  to  cel- 
estial exaltation,  through  spiritual  connubiality, 
heavenly  bridegrooms,  and  offspring  begotten  by 
ghosts.  Mrs.  Eddy  had  experienced  the  pains  of 
parturition  at  least  once,  but  under  the  inhibiting 


852 


CRAMPTON:  GOOD  POSTURE. 


[New  York 
Medical  Journal, 


compulsion  of  her  neurosis  she  could  exclude  even 
that  from  memory  and  consciousness,  and  she 
may  have  believed  herself  to  have  begotten  her 
child  on  no  sexual  basis.  The  psychiatrist  can 
give  her  a  sympathetic  understanding  if  he  cannot 
agree  with  her.  When  the  "spiritual  creation  is 
discerned  and  the  union  of  male  and  female  appre- 
hended as  in  the  Apocalypse,"  (16)  then  will  mar- 
riage be  abolished.  In  the  meantime  those  of  us 
who  continue  to  suffer  frem  the  error  of  mortal 
mind  that  sex  is  real  and  some  of  its  lusts  are  whole- 
some will  continue  to  mate  on  a  physical  instead  of 
a  purely  p'sychoerotic  basis.  "But  to  force  the  con- 
sciousness of  scientific  being  before  it  is  understood 
is  impossible."  (17)  So  Mary  Moss-Baker-Glover- 
Patterson-Eddy  leaves  us  to  our  physical  illusions 
and  refuses  to  disclose  any  more  of  her  vagaries  on 
the  spiritual  process  of  begetting  offspring,  which 
"rests  on  no  sexual  basis,"  perhaps  because  such 
exposure  might  reveal  too  much  of  the  psychoerotic 
mystery  of  bisexual  attributes  of  God  in  herself. 

Eddyism  proves  the  correctness  of  Father  Noyes 
of  the  Oneida  Community  when  he  concluded  that 
a  celibate  church  is  a  woman's  church.  Christian 
Science  with  its  feminine  predisposition  to  celibacy 
has  .seventy-two  per  cent,  of  women  in  its  following 
(18).  Eor  many  more  wholesome  women  in  other 
churches,  a  virile  pastor  and  the  glorification  and 
-sanctification  of  heterosexuality  as  expressed  in 
conventional,  parsonized  marriage  constitute  the 
lure.  Not  so  in  a  church  that  discredits  marriage. 
Here  we  should  expect  to  find  a  haven  for  the  vic- 
tims of  inhibitions  against  normal  heterosexual 
relations,  who  wish  to  make  a  virtue  of  their  mis- 
fortune. Those  whose  impulses  tend  toward  per- 
version and  inhibition  need  a  compensation  and  thus 
find  it  in  the  "spiritualization"  and  glorification  of 
the  resultant  psychoerotic  states,  that  are  alleged  to 
rest  on  no  physical  basis. 

Here,  as  always,  the  development  is  the  same. 
From  some  abnormal  sex  tendencies  through  sexual 
allegories  to  a  firm  belief  that  all  lust  is  evil.  Hence 
celibacy,  spiritual  love,  eternity  of  sex  attraction 
through  piety,  and  finally  the  overthrow  of  the  rea- 
son upon  the  subject  of  the  mania  as  shown  in  the 
illusions  about  the  spiritual  generation  of  flesh 
and  blood  offspring  which  "rests  on  no  sexual 
basis."  This  belief  that  some  day  either  men  or 
women  will  beget  human  offspring  without  the  help 
of  the  other  sex,  is  an  oft  recurring  symptom  of 
psychoneurosis.  Its  most  distinguished  victim  was 
probably  Auguste  Compte.  (19)  Recently  I  saw 
a  letter  from  a  male  physician — not  yet  confined  in 
an  asylum,  but  asserting  that  soon  men  without  the 
aid  of  women  would  propagate  the  human  species. 
So  the  male  homosexual  may  formulate  the  logical 
outcome  of  his  conflict.  The  late  William  T.  Stead 
assured  me  that  he  had  seen  (but  only  with  his 
spiritual  eyes  of  course)  children  begotten  without 
a  fleshly  father.  Every  asylum  has  its  inmates  who 
have  sufficiently  imperative  emotional  needs  to  en- 
able or  compel  them  to  create  in  the  objective  world 
what  others  cannot  see  there,  or  to  enable  or  compel 
them  to  ignore  and  deny  objective  realities  that 
most  of  the  rest  of  us  have  to  admit  the  reality  of, 
both  in  our  theories  of  life  as  well  as  by  our  conduct. 


For  a  few  the  denial  for  a  part  or  all  of  the  time, 
of  some  or  all  of  the  objective  realities  is  made  pos- 
sible by  such  a  relatively  complete  obsession  by  the 
erotic  ecstasy  that  it  excludes  from  consciousness, 
at  least  for  a  time,  both  its  sexual  origin  and  the 
related  objective  realities.  Under  this  obsessing 
erotic  ecstasy,  the  sensations  derived  from  objec- 
tives do  not  register  in  consciousness,  or  only  so 
faintly  that  all  seems  unreal.  "The  testimony  of 
mortal  sense"  is  weakened  or  abolished.  As  the 
state  of  erotic  ecstasy  approaches  continuity  with 
relatively  small  variations  of  intensity  it  is  readly 
formulated  in :  "the  attraction  between  the  sexes  is 
perpetual."  But  since  the  physical  causes  of  this 
attraction  are  (because  of  shameful  experiences) 
excluded  from  consciousness,  the  material  sense  of 
love  is  also  abolished.  Yet  we  are  here.  If  now 
you  unite  with  our  consciousness  of  existence  the 
theories  necessitated  by  the  erotic  inhibitions  we 
come  logically  to  the  conclusion  that  human  beings 
can  be  begotten  on  some  other  basis  than  that  of 
sexual  methods  of  reproduction.  For  all  those  who 
need  that  sort  of  theory,  I  should  think  it  is  just 
the  sort  of  theory  they  need.  Obviously  there  are 
many  such  persons.  Hence  Christian  Science  and 
its  popularity.  There  is  one  "error  of  mortal  mind" 
that  Mrs.  M.  M.  B.  G.  P.  Eddy  did  not  abolish 
either  in  herself  or  her  followers,  and  that  is  an 
adipose  belief  in  dollars  as  real  substance. 

REFERENCES. 

1.  Eddy,  Mary  Baker:  Miscellaneous  Writings,  p.  317. 

2.  Idem:  Ibid,  p.  186. 

3.  Idem:  Ibid,  p.  33. 

4.  Adler,  Alfred  :  The  Neurotic  Constitution. 

5.  Eddy,  Mary  Baker:  Miscellaneous  Writings,  p.  10. 

6.  Idem:  Ibid,  p.  10. 

7.  Idem  :  Ibid,  p.  234. 

8.  Idem:  Ibid,  p.  17. 

9.  Idem:  Ibid,  p.  19. 

10.  Idem:  Ibid,  p.  17. 

11.  Idem:  Ibid,  p.  15. 

12.  Idem:  Science  and  Health,  p.  153. 

13.  ScHROEDER,  T. :  Heavenly  Bridegrooms,  Alienist  and 
Neurologist,  1915,  18. 

14.  Eddy,  Mary  Baker:  Miscellaneous  Writings,  p.  288. 

15.  Idem:  Science  and  Health,  p.  162. 

16.  Idem:  Ibid,  p.  152. 

17.  Idem:  Miscellaneous  Writings,  p.  288. 

18.  Neit'  York  Herald,  October  11,  1903. 

19.  Lombroso,  Cesare  :  The  Men  of  Genius,  p.  73,  Revue 
Philosophiquc,  1886. 


UNDERLYING  FACTORS   IN  GOOD 
POSTURE.* 

By  C.  Ward  Crampton,  M.  D., 
Battle  Creek,  Mich. 

(Concluded  from  page  816.) 

The  neck  is  one  of  the  most  important  and  most 
neglected  regions  of  the  body.  The  cervical  spine 
holds  up  the  head.  It  surrounds  and  protects  the 
spinal  cord,  which  in  this  locality  controls  the  body 
processes  of  circulation,  respiration,  heat  production, 
and  to  a  great  degree  digestion  and  nutrition.  Yet 
these  bones  are  frequently  badly  adjusted  to  each 
other,  and  frequently  the  spinal  column  of  the  neck 
sags    forward   and   downward.    The  debutante's 

*Address  of  Temporary  President  of  the  Association  of  Insti- 
tutions Giving  Normal  Instruction  in  Physical  Training  delivered 
at  Waldorf-Astoria,  New  York  City,  April  10,  1920. 


November  27,  1920.] 


CRAMP  TON: 


GOOD  POSTURE. 


853 


slouch  is  characteristically  weak  necked,  quite  typical 
of  the  young  girl  graduate  who  has  had  no  physical 
exercise,  no  vigorous  games,  and  has  received  all 
of  her  instruction  in  health  from  books  on  anatomy 
and  physiology  instead  of  from  daily  life. 

In  the  neck  are  the  four  great  arteries  which  bring 
blood  to  the  brain  and  the  big  jugular  veins  through 
which  it  is  returned  from  the  head.  The  thyroid 
gland  is  saddled  across  the  front  of  the  neck,  and 
this  has  an  exceedingly  important  function  in  main- 
taining the  nutrition  of  the  body.  Tucked  away  on 
either  side  of  the  throat,  in  a  fold  between  the  larynx 
and  the  lateral  neck  muscles,  are  three  sympathetic 
ganglia  which  have  much  to  do  with  the  circulation 
and  respiration.  It  will  be  seen  that  the  neck  is  an 
important  segment  of  the  human  body.  !\ecks 
are  as  characteristic  as  faces,  and  they  tell  the  story 
of  weakness,  power,  vitality,  illness  past  and  present, 
and  even  prophesy  illness  to  come. 

That  neck  which  has  fine,  strong  muscular  pillars 
on  either  side  running  from  the  ears  down  to  the 
junction  of  clavicle  and  sternum,  and  heavy  pos- 
terior masses  of  powerful  muscle  running  from  the 
occiput  back  to  the  spine  and  scapula — that  neck  is, 
indeed,  likely  to  be  surmounted  with  a  head  worth 
while  in  this  generation  of  high  deeds  and  great 
events.  Few  people  realize  what  tremendous  valtte 
there  is  in  a  well  muscled  neck.  It  holds  the  head 
high.  The  circulation  in  the  neck  itself  is  improved 
in  all  its  various  important  parts,  the  spine,  the 
cervical  central  nervous  system,  the  sympathetic 
ganglia  and  even  the  larynx  and  the  esophagus.  The 
high  held  head  puts  these  various  parts  in  their 
proper  position.  The  low  drooped  head  falls  in 
upon  itself  and  allows  each  part  to  discommode 
itself  and  its  neighbor.  The  exercisd  of  the  muscles 
of  the  neck  not  only  improves  the  power  and  tone 
of  the  circulation  but  it  also  mechanically  massages 
the  throat  and  related  parts.  Exercise  of  the  cerv- 
ical muscles  will  do  more  to  correct  a  bad  condition 
of  the  tonsils  than  anything  else  except  the  surgeon's 
knife.  Therefore,  for  the  sake  of  the  high  head 
and  of  all  of  the  body  processes  that  are  affected 
for  good  or  for  ill  by  the  condition  of  the  neck, 
the  muscles  of  the  neck  should  be  strengthened. 

Exercise  No.  1. — 1,  Press  the  chin  down  on  the 
chest  as  low  and  as  hard  as  possible,  raising  the 
chest  to  meet  it ;  2,  Scrape  the  chin  along  the  neck 
as  closely  as  possible,  making  as  many  double  cliins 
as  you  can ;  3,  Raise  the  head,  look  upward,  and 
press  far  back ;  4,  Hold  this  position,  emphasizing  it 
as  vigorously  as  you  can.  Try  to  look  at  the  back 
of  your  head.  In  doing  this  exercise  it  is  impor- 
tant at  first  not  to  press  too  hard  with  the  chin  nor 
to  strain  too  hard  in  going  backward,  lest  the  un- 
trained and  anemic  muscles  become  overworked  and 
made  sore.  This  dampens  ardor  and  diminishes 
determination.  Begin  by  doing  the  exercise  five 
times,  quietly  and  easily.  Increase  one  or  two  a 
day  to  ten  times.  The  four  counts  should  take  four 
full  seconds.  This  means  that  it  should  be  done 
at  the  rate  of  fifteen  times  a  minute.  Under  no  cir- 
cumstances should  they  be  done  more  quickly,  _but 
when  one  becomes  accustomed  to  the  exercises,  they 
should  take  at  least  six  seconds.  There  should  be 
three  to  six  seconds  between  each  repetition. 


The  name  of  this  exercise,  neck  massage,  is  very 
well  justified;  for  there  is  an  alternation  of  strongest 
possible  compression  and  stretching  of  the  whole 
of  the  neck  within  physiological  limits,  and  if 
this  exercise  did  not  have  the  additional  effect  of 
strengthening  the  posterior  muscle  masses,  it  would 
be  sufficiently  useful  for  the  massage  eft'ects  alone. 
When  the  muscles  relax,  the  head  will  fall  forward, 
because  the  greater  part  of  the  weight  of  the  head 
is  in  front  of  the  spine  upon  which  it  rests.  These 
muscles  are  in  constant  contraction  when  the  head 
is  held  up.  They  relax  when  one  gets  sleepy  and 
besrins  to  nod.    The  nodding  is  merelv  due  to  the 


Fig.  4. — Cervical  exercise  No.   1.     Xeck  massage. 

temporary  relaxation  of  these  muscles,  which  are 
brought  back  to  contraction  again  when  we  awake 
with  a  start.  The  extent  of  the  contraction  of 
these  muscles  is  great. 

This  exercise  is  unusual  in  more  than  one  respect. 
One  of  its  peculiarities  is  that  the  fourth  count  does 
not  change  the  position  but  merely  emphasizes  the 
position  taken  on  the  third  count.  This  is  for  the 
specific  purpose  of  shortening  the  neck  muscles  and 
illustrates  the  application  of  an  important  physi- 
ological principle  frequently  used  in  physical  training, 
as  follows :  A  muscle  tends  to  assume  the  position 
it  occupies  during  its  work.    The  operation  of  the 


854 


CRAMPTON:  GOOD  POSTURE. 


[New  York 
Medical  Journal. 


principle  may  be  seen  in  the  resting  position  of  the 
fingers  of  the  farm  hand  or  coal  heaver  who  habitu- 
ally uses  a  shovel,  a  pick  or  some  implement  which 
must  be  grasped  and  held  tightly.  This  work  re- 
quires the  muscles  of  the  forearm  to  be  kept  con- 
tinually shortened,  with  the  result  that  during  rest 


Fig.  8. — Test  exercise,  "Th?  Bridge" 


when  the  hand  is  no  longer  at  work,  the  hand  still 
maintains  the  position  in  which  it  worked,  and 
remains  half  closed.  This  is  why  we  emphasize  the 
hard  overcontraction  of  the  posterior  muscles  of 
the  neck,  being  confidently  assured  that  if  we  prac- 
tise it  often  enough,  they  will  surely  tend  to  remain 
shortened  and  the  result  we  desire  will  be  obtained ; 
just  as  the  fingers  of  the  farm  laborer  are  kept  bent 
after  their  hard  work,  so  the  head  will  be  held  up. 
This  principle  is  just  becoming  recognized  as  an 
integral  part  of  physical"  training  and  is  essential 
in  procedures  involving  the  change  of  posture  rela- 
tion or  position  of  parts  of  the  body.  Other  exer- 
cises which  strengthen  the  muscles  of  the  neck  and 
should  be  used  diligently,  are  as  follows : 

Exercise  No.  2. — Position :  Raise  the  arms  in  a 
half  forward  bent  position  with  the  wrists  rigidly 
straight,  the  hands  flattened,  palms  toward  the  face, 
thumb  at  side  of  index  finger,  the  pads  of  the  index 
and  middle  fingers  resting  lightly  upon  the  chin. 
The  shoulders,  arms,  forearms  and  hands  are 
straightened  upward  and  backward.  This  position 
in  itself  straightens  the  spine  and  lifts  the  chest  and 
constitutes  an  excellent  static  exercise.  1.  Head 
turning  to  the  right.  The  head  is  turned  squarely 
to  the  right  as  far  as  possible,  tilted  slightly  but  very 
slightly  backward.  2,  Return  to  position.  This 
exercise  should  be  done  both  right  and  left,  six  to 
twenty  times.  It  should  be  noted  that  the  head 
turns  away  from  the  hand  and  is  held  well  back 
of  it.  This  is  important,  for  the  head  should  be 
held  back  both  in  position  No.  1  and  in  position 
No.  2.  This  is  again  putting  into  operation  the 
principle  given  above  in  discussion  of  the  first  exer- 
cise, and  one  can  see  why  it  is  necessary  to  keep 
the  posterior  muscles  contracted  and  the  head  held 
well  back.  Keeping  the  head  well  back  is  necessary 
to  keep  the  muscles  of  the  neck  shortened  while  they 
are  working,  and  thus  to  put  into  operation  the 
principle  indicated  above. 

Exercise  No.  3. — Position :  Chin  resting  on  right 
shoulder.    Do  not  lift  the  right  shoulder  to  the 


chin,  but  use  every  effort  to  place  the  chin  down 
and  far  back.  Do  not  permit  the  shoulder  to  come 
forward.  1.  The  head  is  thrown  back  and  toward 
the  other  shoulder  in  an  endeavor  to  place  the  back 
of  the  head  upon  it;  2.  Return  to  position.  The 
exercise  continues  in  an  alternate  endeavor  to- press 
.the  chin  on  one  shoulder  and  the  back  of  the  head 
upon  the  other  shoulder.  It  should  be  done  slowly 
from  ten  to  twelve  times  on  each  side.  This  exer- 
cise keeps  the  posterior  muscles  of  the  neck  in  a 
contracted  or  semicontracted  state. 

The  posterior  triangle  of  the  neck  extends  from 
the  ear  along  the  line  of  the  sternocleidomastoid 
muscle  to  the  top  of  the  sternum  and  is  prominently 
shown.  The  base  of  the  triangle  extends  from  the 
insertion  of  the  muscle  of  the  sternum  along  the 
clavicle  to  the  point  of  the  shoulder.  The  other 
side  of  the  triangle  extends  in  a  line  not  quite 
straight  from  the  point  of  the  shoulder  upward  to 
the  rear.  Iricidentally  the  anterior  triangle  is  mas- 
saged in  a  way  similar  to  Exercise  1.  These  three 
exercises  should  be  practised  daily  by  every  man, 
woman  and  child  in  the  United  States.  The  most 
favorable  time  is  in  the  early  morning  on  arising, 
for  they  form  a  part  of  the  regular  daily  morning 
lifeprolonging  exercises. 

The  results  of  these  exercises  are  as  follows : 
Good  posture  of  the  head,  good  posture  of  the  chest 
and  back,  stronger  muscles  of  the  neck,  improved 
circulation  in  the  important  structures  of  the  cerv- 
ical regions  and  a  general  improvement  in  the  whole 
body  metabolism.,  The  muscles  of  the  neck  of  every 
man,  woman  and  child  should  be  strong  enough  to 
do  the  test  exercise,  the  "bridge."  The  man  who 
can  do  this  has  a  set  of  muscles  sufficiently  strong 
to  hold  his  head  up,  and  it  is  perfectly  clear  that  the 
exercise  taken  to  make  the  neck  muscles  strong 
must  have  done  his  whole  system  a  marvelous  amount 
of  good.  This  test  should  not  be  attempted  within 
a  month  from  the  time  of  beginning  the  exercises 
indicated  above,  or  strained  neck  will  result. 

Good  posture  is  a  three  storied  afiFair.  It  concerns 
the  head,  the  chest,  and,  perhaps  most  important  of 
all,  the  abdomen.  We  have  noted  the  methods  of 
raising  the  chest  by  simple  static  exercises  and  the 
great  importance  of  the  tone  and  development  of 
the  muscles  of  the  neck  in  holding  the  head  high 
and  raising  the  chest.  The  abdominal  features  of 
both  good  and  bad  posture  are  perhaps  the  most 
important  of  all. 

ABDOMINAL  EXERCISES. 

Biologists  tell  us  that  the  normal  attitude  of  pre- 
Adamitic  man  was  on  all  fours.  This  placed  the 
spine  and  ribs  above  the  abdominal  contents,  which 
were  suspended  from  them  by  strong  ligaments,  the 
kidneys  snugly  attached  behind  the  peritoneum,  the 
intestines  hanging  like  a  bunch  of  grapes  from  the 
mesentery,  and  the  liver,  stomach,  spleen,  all  with 
appropriate  sustentacular  ligaments.  Man,  on  ris- 
ing from  this  horizontal  position,  found  his  abdom- 
inal contents  attached  to  the  rear  wall  of  the  ab- 
dominal cavity,  instead  of  hanging  from  above. 

The  liver  soon  obtained  an  attachment  to  the 
diaphragm,  from  which  it  now  hangs  suspended  as 
it  did  previously  from  the  posterior  abdominal  wall. 
The  other  organs  still  retain  their  posterior  attach- 


Xovember  27,  1920.] 


CRAMPTOX:  GOOD  POSTURE. 


855 


ments.  This  constitutes  a  hereditary  disharmony, 
which  is  constantly  causing  trouble.  The  kidneys 
are  prone  to  leave  their  moorings  and  slide  down 
the  back,  sometimes  behind  their  peritoneal  cover- 
ings and  sometimes  pushing  the  peritoneum  in  a 
pouch  before  them.  The  small  intestines  hang 
down  from  their  attachments  and  occupy  as  low  a 
space  as  possible  in  the  abdomen,  flowing  down  into 
the  pelvis,  their  weight  pressing  upon  the  pelvic 
contents,  i.  e.,  rectum,  bladder,  and  generative  or- 
gans, the  lower  layers  of  this  mass  of  intestines 
being  pressed  "  upon  by  the  weight  of  the  upper 
layers. 

This  is  bad  for  the  pelvic  organs,  for  they  are 
crowded,  congested,  and  generally  discommoded  in 
action,  and  it  is  bad  also  for  the  intestines  them- 
selves. This  condition  results  in  constant  pressure 
being  exerted  upon  the  abdominal  wall  from  within 
outward.  In  the  erect  position,  this  outward  pres- 
sure is  greatest  at  the  lower  levels  of  the  abdominal 
walls  and  decreases  gradually  as  we  go  upward  un- 
til the  ribs  are  reached,  where  the  dragging  effect 
of  the  abdominal  contents  begins  to  pull  it  in,  in- 
stead of  pushing  it  out.  Hence,  when  the  abdomen 
is  weak,  the  trunk  assumes  the  shape  of  the  ancient 
leather  water  bottles  which  when  filled  were  bulging 
and  round  at  the  bottom,  but  sloped  to  a  thin  neck 
above.  Not  only  is  the  upper  part  of  the  abdomen 
drawn  in,  but  the  chest  itself  is  dragged  down  and 
sinks  inward.  The  weighty  liver  pulls  down  the 
diaphragm,  which  in  turn  pulls  downward  and  in- 
ward the  lower  ribs  which  in  turn  pull  down  the 
upper  part  of  the  chest,  and  the  bottle  shaped  ap- 
pearance extends  from  pubis  to  neck. 

This  is  the  picture  so  frequently  presented  by 
the  chronic  invalid,  the  man  in  bad  posture,  the 
man  who  has  never  taken  exercise.  This  is  the 
effect  of  gravity,  that  constant  force  which  con- 
stantly drags  us  down  toward  the  earth.  It  is  a 
picture  of  gravity  victorious  over  the  strength  and 
vitality  of  a  man,  the  picture  of  a  man  defeated  by 
the  forces  of  Nature.  He  is  still  erect,  still  pos- 
sessed of  a  certain  amount  of  vigor  and  muscular 
strength,  but  Nature  is  dragging  him  down  piece- 
meal and  has  proceeded  a  long  way  toward  the 
winning  of  the  ever  waging  tug  of  war,  which 
finally  and  inevitably  she  must  win,  for  gravity 
brings  us  all  at  last  to  rest. 

GOOD  TONE. 

The  strong  abdomen  is  a  flat  abdomen ;  therefore, 
make  it  flat  and  keep  it  flat.  All  that  is  necessary 
in  the  normal  individual  is  merely  an  effort  of  the 
will,  calling  upon  the  abdominal  muscles  to  contract. 
As  a  rule,  however,  men  are  not  normal,  and  the 
abdominal  muscles  are  incompletely  under  the  con- 
trol of  the  will,  and  in  many  cases  are  half  par- 
alyzed. For  ninety-nine  per  cent,  of  the  people  it 
is  necessary  to  reeducate  as  well  as  to  strengthen 
these  muscles. 

ABDOMINAL  COXTRACTIOX   AND  RELAXATION. 

Exercise  1. — Position:  Leaning  forward  with  the 
hands  on  the  knees,  which  are  slightly  bent.  1. 
Contract  the  abdomen,  pulling  it  in  and  up  as  far 
as  possible.  2.  Relax  the  abdomen,  allowing  it  to 
fall  down  under  the  pressure  of  the  abdominal  con- 


tents ;  one  count  to  the  second ;  two  seconds  to  the 
exercise.    Repeat  ten  to  thirty  times. 

ABDOMINAL  CONTRACTION  WITH  BREATHING. 

Exercise  2. — Position :  Hands  on  the  knees  the 
same  as  in  No.  1.  Count  1.  Abdominal  contrac- 
tion, the  same  as  in  Exercise  1 ;  Count  2.  Breathe 
in  (abdomen  contracted)  ;  Count  3.  Breathe  out 
(abdomen  remains  contracted)  ;  Count  4.  Breathe 
in  (abdomen  remains  contracted)  ;  Count  5.  Breathe 
out  (abdomen  remains  contracted)  ;  Count  6.  Breathe 
in  (abdomen  remains  contracted)  ;  Count  7.  Breathe 
out  (abdomen  remains  contracted)  ;  Count  8. 
Breathe  in.  (Abdomen  remains  contracted.  Keep 
it  contracted).  Two  seconds  to  each  count;  sixteen 
seconds  to  the  exercise.    Repeat  six  to  twelve  times. 

These  are  probably  the  best  of  all  the  abdominal 
exercises  and  are  the  results  of  many  years  of 
patient  research  and  experience.  The  first  exercise 
gives  a  training  in  the  voluntary  control  of  the  ab- 
dominal muscles,  improving  their  circulation  and 
strengthening  them.  It  forces  the  abdominal  con- 
tents up  into  the  upper  part  of  the  abdomen,  de- 
creases the  cricumference  of  the  lower  segment  and 
increases  the  circumference  of  the  upper  segment. 
In  a  well  trained  athlete,  this  is  readily  seen.  Chest 
expansion  is  important,  but  abdominal  contraction 
is  a  far  more  significant  measure  of  vital  power. 

The  relaxation  of  the  abdominal  walls  permits 
the  viscera  to  fall  again,  the  alternating  contraction 


COOD  POSTURE 


TEST 
A  B  C  D  E 

HABIT 
12  3  4  5 


Fig.   6.— Posture  chart  for  schoolroom. 

and  relaxation  causes  a  churning  kind  of  massage 
which  stimulates  the  living  tissues  which  form  the 
abdominal  contents,  heightening  their  activity.  The 
muscular  structure  of  the  bowels  becomes  less  lax 
and  more  active,  the  glandular  lining  of  the  intes- 
tines, the  actuating  nervous  ganglia,  the  arteries, 
veins,   and   lymphatics    receive   their  appropriate 


856 


CRAMPTON:  GOOD  POSTURE. 


[New- 
Medical 


York 
Journal. 


mechanical  stimulation,  all  of  which  is  conducive 
to  health. 

If  the  diet  is  even  approximately  near  the  bio- 
logical normal,  and  the  condition  has  not  lasted  long- 
enough  for  the  intestinal  muscles  to  become  semi- 
paralyzed  or  spastic,  this  exercise  will  completely 
relieve  intestinal  stasis.  The  improvement  which 
this  makes  in  the  taut  and  strengthened  abdominal 
wall  gives  it  sufficient  power  to  support  the  abdom- 
inal contents.  Such  power  is  tested,  practised,  and 
improved  by  Exercise  2.  This  exercise,  breathing 
with  a  contracted  abdomen,  simulates  the  normal 
tonic  condition  of  good  posture.  The  abdomen  is 
first  contracted  and  held  taut  while  the  breath  is 
taken  in  and  allowed  to  go  out  of  the  lungs.  This 
is  the  state  of  affairs  which  should  obtain  at  all 
times  during  the  day  when  a  man  sits  or  stands 
erect,  particularly  when  he  is  standing  still. 

In  the  first  exercise,  the  lower  and  inner  wall  of 
the  abdomen  was  acted  upon.  In  the  second  exer- 
cise, it  is  held  normally  contracted  while  it  is  put 
under  a  rhythmical  strain  by  the  movements  of  the 
upper  part  of  the  chest.  It  remains  in  static  con- 
traction, which  is  exactly  the  position  in  which  it 
must  remain  during  daily  life.  These  two  exercises 
are  given  in  a  position  in  which  the  trunk  is  nearly 
horizontal,  a  return  to  Nature,  with  a  simulation 
of  the  natural  mechanical  strains  on  the  trunk  and 
abdomen. 

THE  MEASUREMENT  OF  POSTURE. 

The  measurement  of  the  posture  of  children  in 
school  should  be  made  as  simple  as  possible.  It 
should  be  based  upon  sound  scientific  principles  but 
it  should  be  relieved  from  the  necessity  of  painful 
accuracy  of  scientific  method.  All  measurements 
of  posture  whether  scientific  or  merely  practical 
should  be  based  upon  the  recognition  of  the  fact 
that  good  posture  is  an  evidence  of  good  gravity 
resistance,  for  bad  posture  is  on  the  other  hand  a 
submission  to  gravity.  If  the  child  is  standing  as 
tall  as  it  is  possible  for  his  physical  frame  to  stand, 
he  is  in  good  posture.  If  gravity  pulls  hinr  down 
an  inch  or  two  or  three,  he  is  in  correspondingly 
bad  posture. 

Bad  posture  may  be,  therefore,  measured  by  de- 
crease in  height.  This  may  be  shown  by  actual 
measurement  of  height  or  by  observation  of  the 
contour  of  the  body  in  profile  for  a  poor  posture 
will  show  various  displacements  forward  and  back- 
ward. If,  for  example,  we  take  a  piece  of  wire 
thirty-six  inches  long  and  lay  it  upon  a  yard  stick 
in  a  vertical  position,  it  will,  if  the  wire  is  perfectly 
straight,  measure  just  thirty-six  inches.  Now  let 
us  take  this  wire  and  bend  it  slightly  at  the  middle 
and  call  this  the  position  of  hips  forward.  Bend 
it  also  at  twenty-four  inches  from  the  ground  mak- 
ing an  increased  dorsal  curve.  Bend  it  again  far- 
ther up,  corresponding  to  the  "head  forward"  posi- 
tion, and  then  lay  it  alongside  the  yard  stick  and  we 
will  see  that  the  wire,  although  it  is  thirty-six  inches 
long,  only  measures  thirty-two  or  thirty-three  or 
possibly  thirty-one  inches,  depending  upon  how 
much  we  have  bent  it  at  the  various  points  cor- 
responding to  the  hip,  back  and  neck.  This  then  is 
the  way  to  measure  how  bad  posture  is. 

Other  measures  of  posture  may  be  obtained  by 


noting  actual  visceral  ptosis,  i.  e.,  the  depression  of 
internal  organs  below  their  normal  positions.  If 
the  abdomen  bulges  and  the  chest  is  flat,  there  is  bad 
posture  and  visceral  ptosis. 

We  should  be  able  to  arrive  at  an  index  of  com- 
parative girths  of  chests  and  abdomens.  In  a 
healthy  young  man  the  average  chest  girth  should 
be  from  twenty-five  to  forty  per  cent,  greater  than 
the  smallest  abdominal  girth ;  in  woman  it  might  be 
less.  The  proportions  of  five  to  four  are  approxi- 
mately normal.  This  measurement  is  complicated 
by  the  amount  of  abdominal  fat  and  other  factors. 
Circulatory  ptosis  can  be  determined  by  the  author's 
test,  which  is  based  upon  an  observation  of  the 
systolic  pressure  and  heart  rate  in  the  horizontal 
and  vertical  positions. 

For  the  school  room,  however,  we  wish  to  meas- 
ure posture  merely  to  stimulate  improvement.  For 
this  purpose  there  is  ofifered  a  chart  showing  succes- 
sive photographs  of  the  same  individual  ranging 
from  perfect  posture  to  very  poor  posture.  This 
indicates  that  a  child  may  have  excellent,  very  good, 
fair,  poor  or  bad  posture,  that  it  is  possible  for  any 
child  to  be  either  good  or  bad  in  this  regard.  It  is 
evidence  on  the  one  hand  that  good  posture  is  not 
impossible  for  any  one  if  effort  and  application  are 
brought  to  bear  and,  on  the  other  hand,  it  is  evi- 
dence that  those  who  have  good  posture  may  if  thev 
are  not  careful  tend  to  lose  it. 

In  this  respect,  an  important  distinction  must  be 
made.  Many  children  can  assume  good  posture 
during  a  posture  test,  but  make  no  effort  to  keep 
good  posture  at  arty  other  time.  Hitherto  they 
have  been  placed  in  the  good  posture  division,  but 
they  deserve  this  distinction  far  less  than  the  B 
posture  children  who  try  very  hard  all  the  time. 
I  strongly  recommend  that  good  posture  tests  should 
be  continued  in  a  standard  fashion,  i.  e.,  while 
standing,  marching  and  exercising,  but  that  in  addi- 
tion a  rating  should  be  given  for  habitual  posture, 
and  I  suggest  the  following  set  of  instructions  for 
the  teacher : 

THE  POSTURE  RATING. 

1.  The  teacher  should  be  provided  with  posture 
charts  showing  a  child  appropriate  in  size  to  her 
grade  showing  the  five  posture  positions. 

2.  She  will  conduct  a  test  in  posture,  including 
standing,  marching,  and  exercising  with  half  of  the 
class  acting  as  assistant  judges  while  the  other  half 
is  being  tested. 

3.  The  pupils  will  be  graded  on  this  test  with  the 
letters  A,  B,  C,  and  D  corresponding  to  the  pictures 
on  the  chart. 

4.  The  teacher  will  observe  the  posture  habit  of 
pupils  in  their  daily  work,  particularly  upon  stand- 
ing for  recitation  of  lessons,  writing  at  the  black- 
board, marching  to  assembly,  and,  in  short,  rate  the 
pupils  on  their  habitual  posture. 

It  is  preferable  to  have  one  or  more  posture  mon- 
itors selected  because  of  their  superiority  in  physi- 
cal training  and  in  good  posture,  and  it  should  be  his 
or  her  duty  to  record  the  ratings  and  relieve  the 
teacher  of  the  time  and  trouble  rather  than  to  nag 
and  browbeat  their  fellow  pupils,  as  monitors  are 
sometimes  prone  to  do. 

The  rating  for  habit  in  posture  should  be  in  nu- 


Jsovember  27,  1920.] 


CUMSTON:   THE  HEART  IX  IXFLUENZA. 


857 


■nierals,  1,  2,  3,  4,  and  5,  referring  to  the  values 
exhibited  on  the  chart.  Thus  we  will  have  each 
pupil  rated  by  letter  and  by  number  very  much  as 
business  organizations  are  rated  in  financial  reports. 
A  will  stand  for  the  best  posture  on  test,  but  the 
pupil  in  order  to  get  in  A  1  must  stand  in  good  pos- 
ture all  of  the  time,  otherwise  if  he  slumps  he  may 
get  a  rating  of  A  2  or  even  A  4,  or  A  5.  A  pupil  in 
C  posture  may  be  C  4,  or  C  5,  depending  upon  his 
posture  habit.  It  is  theoretically  possible  for  a 
pupil  in  C  posture  to  be  2,  or  even  1,  on  habit, 
because  some  pupils  during  the  test  have  an  incon- 
querable  tendency  to  assume  rigid  overstraightened 
posture,  which  cannot  be  rated  perfect;  but  when 
they  are  unconscious  of  observation  sit  and  stand 
perfectly.  Pupils  and  teachers  alike  take  quickly 
and  easily  to  these  ratings,  for  A  1  has  a  well  under- 
stood significance  the  world  over  and  all  departures 
from  it  have  a  common  meaning. 


CARDIAC  MANIFESTATIONS  IN 
INFLUENZA. 

By  Charles  Greexe  Cumstox,  M.  D., 
Geneva,  Switzerland. 

Although  some  attention  has  been  given  in  the 
past  in  France,  England,  and  the  United  States,  to 
the  cardiac  manifestations  of  influenza,  it  is  prob- 
able that  the  most  important  work  on  the  question 
has  been  done  by  that  veteran  cHnician,  Professor 
Eichhorst,  of  Zurich,  and  his  school.  \\'e  know 
at  present  that  during*  the  evolution  of  influenza 
some  one  or  all  of  the  structures  of  the  heart  or 
its  elements  of  innervation  may  become  involved, 
the  endocardium,  the  pericardium,  or  the  myocar- 
<iium,  and  this  means  that  there  exists  a  vast  variety 
of  symptoms,  according  to  the  cardiac  structures 
involved.  Cardiac  influenza,  therefore,  may  mani- 
fest itself  as  an  endocarditis,  pericarditis,  or  myo- 
carditis, likewise  b}^  disturbances  of  nervous  origin, 
such  as  syncope,  bradycardia,  tachycardia,  or  ar- 
rhythmia. It  is  also  probable  that  these  influenzal 
lesions  are  far  more  frequent  than  is  generally 
supposed  or  as  given  in  the  classic  textbooks  on 
medicine,  and  if  the  disturbances  in  cardiac  con- 
traction are  compared  with  organic  lesions  it  be- 
■comes  evident  that  their  frequency  is  about  equal, 
although  Eichhorst  maintains  that  the  innervation 
system  is  more  frequently  involved  than  the  histo- 
logical structures  of  the  heart  itself.  Sex  or  age 
appear  to  play  no  part  as  the  bulbocardiac  accidents 
have  been  met  with  in  infants  as  well  as  in  the  aged, 
but  I  would  point  out  that  the  majority  of  recorded 
cases  have  been  encountered  in  subjects  varying  in 
age  from  twenty  to  forty-five  years. 

It  also  appears  probable  that  hearts  already  the 
seat  of  lesions,  the  result  of  previous  infections, 
"become  more  readily  the  prey  of  the  virus  of  influ- 
enza than  normal  hearts,  and  the  grippe  may  like- 
wise either  awaken  old  lesions  into  activity  or 
create  new  ones  in  a  neighboring  valve ;  it  also 
attacks  the  system  of  cardiac  innervation,  destroys 
the  cardiac  equilibrium,  and  forces  the  condition  of 
affairs  toward  a  systolia.  It  must  be  frankly  ad- 
mitted that  the  causative  factor  of  the  cardiac  pro- 


cesses is  unknown,  although  bacteriological  research 
work  has  occasionally  revealed  the  agents  of  sec- 
ondary infection,  such  as  Pfeififer's  bacillus,  the 
pneumococcus,  or  the  streptococcus.  But  just  as 
frequently  no  bacterium  has  been  found,  in  which 
case  the  lesions  can  only  be  explained  by  the  action 
of  a  filtrating  virus,  which  Prof.  Bard,  of  Geneva, 
and  others  regard  as  the  probable  agent  of  influenza, 
or  by  the  action  of  a  toxin  acting  indirectly  as  in 
the  case  of  diphtheria. 

The  symptomatology  of  the  cardiac  manifesta- 
tions of  influenza  will  depend  upon  the  variety  or 
type  of  the  cardiac  involvement,  but  often  in  the 
same  subject  a  combination  of  several  types  of 
symptomatology  may  exist.  One  of  the  tissues 
composing  the  heart's  walls  can  never  be  morbidly 
involved  without  reacting  upon  other  component 
structures  so  that  a  series  of  general  symptoms  must 
inevitably  result  which  are  found  in  all  cases. 

The  onset  of  the  symptoms  may  be  very  sudden, 
a  syncope,  a  paroxysm  of  angina  pectoris,  or  dysp- 
nea revealing  the  influenzal  attack.  But  frequently 
these  startling  accidents  only  arise  some  days  after 
the  onset  of  the  disease,  or  occasionally  during  con- 
valescence when  all  danger  is  supposed  to  have  been 
passed.  Huchard  insisted  upon  this  latent  period 
— which  may  be  long — between  the  influenzal  in- 
fection and  the  onset  of  the  first  cardiac  manifes- 
tations. 

But  all  forms  of  influenzal  heart  do  not  ofter 
this  sudden  onset ;  the  lesions  develop  quietly  and 
it  is  only  by  mere  chance  that  an  examination  or 
the  development  of  serious  complications,  such  as 
embolus  or  asystolia,  reveals  them.  Among  the 
more  constant  subjective  symptoms  should  be  men- 
tioned a  severe  acute  pain  in  the  cardiac  area  or  a 
sensation  of  cold  or  crushing  in  the  rectrosternal 
region,  extending  to  the  neck  and  arm.  The  as- 
thenia and  prostration  are  very  evident  in  this 
clinical  form  of  influenza,  while  the  suddenness 
of  their  onset  is  rather  characteristic.  The  dyspnea 
is  intense  and  cannot  be  explained  by  the  slight 
pulmonary  lesions  found  on  auscultation.  It  is 
accompanied  by  cyanosis,  algidity  and  peripheral 
coldness.  Hypotension  is  constant  and  very  marked. 
The  weak,  small  pulse  is  very  unstable ;  arrh}'thmia 
is  frequent.  The  evolution  of  the  process  varies 
and  occasionally  all  morbid  manifestations  subside 
without  leaving  any  trace,  or  the  subject  recovers 
with  a  well  compensated  valvular  lesion  and  this 
is  perhaps  the  most  common  occurrence  in  practice. 
On  the  contrar}',  in  other  instances  the  process  be- 
comes aggravated  and  the  patient  dies  either  from 
asystolia  or  collapse. 

In  referring  to  the  syndromes  that  are  commonlv 
met  with  in  practice  it  may  be  well  to  follow  Eich- 
horst's- division  as  follows:  The  pericarditic  s>ti- 
drome,  the  endocarditic  syndrome,  and  the  myo- 
carditic  syndrome,  as  well  as  some  special  forms 
which  have  been  recently  described  by  Minet  and 
Legrand,  of  Lille,  under  the  name  of  grippal  brady- 
cardiac  heart,  grippal  tachycardiac  heart,  grippal 
arrh}i:hmic  heart,  and  grippal  cyncopal  and  neuralgic 
heart.  The  pericarditic  syndrome  offers  two  prin- 
cipal forms,  namely,  dry  pericarditis  and  pericar- 
ditis with  effusion.    There  is  nothing  which  can 


858 


CUMSTON:   THE  HEART  IN  INFLUENZA. 


[New  York 
Medical  Journal. 


help  the  physician  to  distinguish  these  influenzal 
pericarditides  from  the  same  morbid  process  en- 
countered in  other  infectious  diseases.  A  fibrinous 
deposit  arises  on  the  serous  membrane,  giving  rise 
to  the  friction  sound,  or  the  pericardial  sac  may  be 
distended  by  a  serous  or  purulent  collection.  The 
latter  may  reach  a  considerable  amount,  and  the 
late  Prof essor*  Grasset,  of  Moutpellier,  had  a  case 
under  his  care  in  which  the  amount  of  fluid  was 
seven  hundred  cubic  centimetres.  A  fact  to  be 
noted  is  that  in  this  syndrome  the  myocardium  is 
very  frequently  simultaneously  involved. 

The  principal  symptoms  that  may  be  encountered 
are  the  intensity  of  the  general  phenomena,  the 
oppression,  distress,  increase  of  the  area  of  cardiac 
dullness,  the  smallness  of  the  pulse,  the  weakness 
of  the  heart  sounds,  and  the  presence  of  friction 
sounds,  symptoms  common  to  all  types  of  peri- 
carditis. The  outcome  of  the  process  is  often  fatal, 
particularly  when  a  fluid  collection  develops. 

Among  the  cardiac  manifestations  accompanied 
by  an  organic  lesion,  the  endocarditic  syndrome  is 
by  far  the  most  commonly  met  with  in  practice,  and 
generally  makes  itself  evident  during  the  progress 
of  the  influenza  or  at  the  time  of  convalescence,  and 
in  the  latter  case  it  would  seem  to  assume  a  much 
more  serious  aspect  since  all  the  valves  may  become 
involved.  Nevertheless,  influenza  is  more  prone  to 
attack  the  left  heart,  attacking  both  valves 
with  about  the  same  frequency  and  occasionally 
becoming  located  on  both  at  the  same  time.  How- 
ever, cases  have  been  recorded  in  which  lesions 
developed  on  the  tricuspid  and  even  on  the  valves 
of  the  pulmonary  artery.  The  morbid  process  may 
also  involve  the  parietal  endocardium  or  invade  the 
intima  of  the  large  vessels. 

From  the  viewpoint  of  pathology,  the  ulcerating 
and  vegetating  types  of  endocarditis  have  been 
found  to  be  about  equally  frequent.  The  onset  of 
the  process  is  ordinarily  silent,  but  frequently  there 
is  a  recrudescence  of  the  general  phenomena,  the 
dyspnea  and  tachycardia  attracting  the  clinician's 
attention  to  the  heart.  The  temperature  chart  as- 
sumes the  pyemic  character,  the  percussion  dullness 
of  the  cardiac  area  increases,  infarcts  may  occur 
and  the  pulse  is  poor  in  equality.-  The  diagnosis 
will,  however,  be  made  by  the  detection  of  a  souffle, 
and  in  influenzal  cardiac  phenomena  the  souffles 
possess  two  distinctive  characters,  namely,  rough- 
ness and  an  early  onset.  They  are  fully  developed 
in  a  few  days  and  it  is  not  at  all  uncommon  to  find 
them  within  four  or  five  days  after  the  recrudescence 
of  the  general  phenomena.  Such  cases  of  endo- 
carditis are  serious  when  not  fatal  and  when  death 
does  not  ensue  a  serious  lesion  of  the  valves  re- 
mains. The  lesions  are  never  limited  to  the  endo- 
cardium alone,  and  are  invariably  accompanied  by 
a  process  in  the  pericardium  and  myocardium. 

Perhaps  more  than  in  the  two  preceding  forms, 
the  word  syndrome  should  be  employed  for  the 
clinical  disturbances  originating  from  the  myo- 
cardium. In  point  of  fact  this  syndrome  includes 
a  great  number  of  most  varied  phenomena  which 
point  to  an  undoubted  disturbance  of  the  cardiac 
contractions.  Nevertheless,  this  disturbance  is  not 
of  necessity  dependent  upon  an  anatomical  lesion  of 


the  muscle,  so  that  the  term  myocarditic  syndrome 
is  to  be  preferred  to  that  of  influenzal  myocarditis. 
Eichhorst  maintains  that  he  has  never  observed  myo- 
cardic  lesions,  even  microscopic.  But  for  all  that 
myocarditis  exists  and  lesions  of  the  muscle  have 
been  frequently  found  at  necropsy,  but  they  are 
often  hidden  by  a  coexisting  endopericarditis.  It 
would  seem  that  this  pathological  involvement  of 
the  cardiac  muscle  has  a  predilection  for  hearts 
which  have  been  attacked  by  an  antecedent  infection. 
The  lesions  found  are  those  of  acute  myocarditis. 

The  clinical  signs  are  classical :  precardiac  pain  and 
a  weak,  small  and  irregular  pulse.  The  arrhythmia 
is  important  to  detect,  as  well  as  a  special  "trotting 
sound"  described  by  Huchard,  found  by  ausculta- 
tion. This  consists  of  a  three  time  rhythm,  the 
result  of  a  systolic  effort  which  takes  place  between 
the  two  principal  times.  It  should  be  mentioned 
that  the  myocarditis .  may  undergo  its  evolution 
silently,  and  it  is  only  upon  the  occurrence  of  an 
effort  that  syncope  arises,  which  may  be  fatal,  and 
gives  an  indication  of  the  true  state  of  affairs.  The 
accidents  which  will  now  be  referred  to  as  special 
syndromes,  combined  with  those  given  above,  will 
allow  the  clinician  to  come  to  a  correct  diagnosis. 

The  influenzal  bradycardiac  heart  has  been  known 
for  some  time  and  is  looked  upon  as  frequent, 
although  some  maintain  the  contrary  to  be  true. 
It  may  appear  at  various  periods  of  the  influenza, 
sometimes  at  the  onset  and  in  other  cases  it  may  de- 
velop during  the  progress  or  at  the  end  of  the  disease, 
or  even  during  convalescence.  Should  it  be  con- 
tinued it  usually  presents  a  paroxysmal  charac- 
ter, in  which  case  it  may  bring  about  serious  dis- 
turbances. The  lowest  pulse  rate  averages  from 
forty  to  fifty  beats,  but  it  has  been  known  to  be  as 
slow  as  nineteen  or  even  fifteen  beats  to  the  minute. 
These  disturbances  of  the  heart  contraction  are 
accompanied  by  asthenia  and  intense  prostration 
which  may  persist  for  a  long  time  after  the  patient 
has  recovered.  Although  some  of  these  disturb- 
ances rapidly  subside,  there  are  others  that  persist 
for  some  time,  as  much  as  a  year  or  fifteen  months 
after  recovery  from  the  influenza.  However,  the 
bradycardia  is  not  often  fatal  per  se. 

Influenzal  tachycardia  is  considered  frequent  by 
some,  while  Eichhorst  maintains  that  it  is  uncom- 
mon, and  others  uphold  this  view.  The  time  of 
its  onset  varies ;  it  may  be  very  early  in  the  disease 
or  not  arise  until  defervescence  or  convalescence 
have  taken  place,  and  this  a  very  long  time  after 
the  acute  accidents  have  disappeared.  Usually  in- 
termittent, it  may  be  continued,  the  beats  averaging 
from  one  hundred  and  twenty  to  one  hundred  and 
forty  a  minute.  These  attacks  are  accompanied  by 
thoracic  pains,  distress,  and  stasis  in  the  pulmonary 
circulation.  Instances  have  been  recorded  in  which 
paroxysms  occurred  which  brought  the  pulse  rate  as 
high  as  three  hundred  beats  a  minute. 

The  evolution  of  this  clinical  form  is  essentially 
variable.  The  tachycardia  may  suddenly  subside 
after  a  more  severe  paroxysm  than  the  previous 
ones,  or  it  may  persist  for  a  long  time  after  re- 
covery from  influenza,  as  much  as  eight  months  in 
a  case  recorded  by  Sansom.  The  prognosis  is  seri- 
ous in  all  cases  and  a  fatal  outcome  is  not  uncom- 


November  27,  1920.] 


CUMSTON:   THE  HEART  LV  IXFLUENZA. 


859 


mon.  The  coexistence  of  phenomena  similar  to 
those  encountered  in  Basedow's  disease  is  not  in- 
frequently observed  with  postinfluenzal  tachycardia, 
to  which  the  name  of  vagus  storms  has  been  given. 

The  arrhythmic  influenzal  heart  is  another 
form,  designated  by  Eichhorst  as  influenzal  extra- 
systolic  heart.  Some  English  observers  maintain 
that  there  is  no  relationship  between  the  cardiac 
disturbance  and  the  subjective  sensations  experienced 
by  the  patient.  A  severe  arrhythmia  may  not  be 
accompanied  by  any  subjective  symptom,  while  a 
very  mild  form  can  very  well  be  accompanied  by 
serious  accidents  of  precardiac  distress.  The  ar- 
rhythmia may  be  bigeminate,  trigeminate,  alternat- 
ing, or  complete.  The  characteristic  unstableness 
of  the  influenzal  pulse  is  here  to  be  found  in  its 
highest  degree.  The  numerous  extrasystoles  which 
characterize  this  form  appear  during  the  same 
phases  of  the  disease  as  the  bradycardia.  The  pro- 
cess undergoes  an  evolution  toward  recovery  or  to 
chronic  myocarditis  and  asystolia. 

The  syncopal  heart  of  influenza  is  rather  more 
of  an  important  symptom  than  a  clinical  entity  and 
in  reality  indicates  a  profound  disturbance  of  the 
heart's  contraction.  It  appears  at  times  as  an 
initial  symptom  announcing  the  onset  not  only  of 
the  cardiac  complications,  but  of  the  causal  infection 
as  well.  At  others  it  is  a  complication  of  con- 
valescence, or  as  a  frequently  fatal  accident  arising 
during  the  evolution  of  some  other  form  of  influ- 
enzal heart.  It  occasionally  completely  occupies  the 
clinical  picture  on  account  of  its  repetition  and  with 
the  instability  of  the  pulse,  presents  the  only  sign 
of  the  cardiopathy  present.  The  prognosis  is  in- 
variably extremely  serious. 

Influenzal  cardiac  neuralgia  has  been  known  for 
years  and  many  instances  have  been  recorded  in  the 
Anglo-Saxon  medical  press,  but  Eichhorst,  on  the 
contrary,  regards  it  as  of  extreme  rarity  and  only 
to  be  encountered  in  young  people.  It  would  seem 
that  this  opinion  of  the  eminent  professor  of  Zurich 
is  exaggerated  because  if  one  regards  it  as  a  mere 
symptom,  it  will  be  found  noted  in  nearly  all  cases 
recorded.  Often  early  in  its  onset,  the  pain  appears 
with  the  beginning  of  the  cardiac  accidents.  It  is 
a  violent,  sharp  pain,  a  crushing  sensation  or 
one  of  torsion  at  the  anterior  portion  of  the  ster-' 
num,  shooting  to  the  back,  neck,  shoulder  and  arm. 
It  is  prone  to  occur  in  paroxysms,  its  evolution  in 
some  cases  being  in  the  form  of  a  series  of  neuralgic 
crises.  It  also  may  arise  very  late  in  convalescence. 
Usually  benign,  it  has  been  known  to  cause  death  in 
a  few  instances.  Huchard  was  of  the  opinion  that 
these  cases  are  often  instances  of  old  angina  pec- 
toris, aggravated  by  influenza. 

As  to  the  pathogenesis,  so  far  as  the  endomyoperi- 
carditic  lesions  are  concerned,  the  lesions  met  with 
at  necropsy  show  unquestionably  that  it  is  in  the 
heart  itself  that  the  cause  of  the  clinical  signs  met 
with  are  to  be  found.  In  those  instances  where  no 
lesions  can  be  discovered  at  necropsy,  Huchard  ex- 
plained them  by  a  cardioplegia  resulting  from  in- 
volvement of  the  pneumogastric  nerve  as  well  as  by 
an  involvement  of  the  motor  centres  of  the  heart  in 
the  bulb.  Cardiac  influenza  is  a  bulbar  process ; 
alone,  the  arrhythmia  is  the  result  of  a  morbid 


change  in  the  muscle  fibre.  Huchard  also  attributed 
an  important  part  to  an  influenzal  coronary  endo- 
carditis which  remains  latent  for  a  long  time  until 
one  fine  day  it  sets  up  a  degeneration  of  the  myo- 
cardium. Other  observers  believe  that  there  is  an 
irritative  lesion  of  the  accelerator  nerve  of  the  heart 
in  cases  of  tachycardia  and  a  neuritis  of  the  vagus 
in  cases  of  bradycardia.  It  has  also  been  maintained 
that  there  is  a  possible  action  from  thyroid  hyper- 
secretion on  account  of  the  phenomena  of  basedow- 
ism  sometimes  met  with.  xA.s  to  the  pain,  it  has  been 
attributed  to  an  involvement  of  the  ganglions  of  the 
cardiac  plexus  or  to  a  phenomenon  similar  to  vis- 
ceral neuralgia. 

Althaus  is  of  the  opinion  that  there  is  a  neuritis 
of  the  vagus  and  also  a  lesion  of  the  bulbar  centres, 
but  given  our  present  knowledge  of  cardiac  anatomy 
and  physiology,  other  explanations  may  be  put  for- 
ward. The  bundle  of  His  and  the  various  cardiac 
ganglions,  the  relation  existing  between  the  gang- 
lions and  their  motor  and  regulating  action  over  the 
movements  of  the  heart,  might  very  properly  lead 
one  to  suppose  that  there  may  be  a  single  patho- 
genesis for  all  cardiac  influenzal  processes. 

If  the  infection  involves  the  heart  en  masse,  then 
we  will  have  the  classical  forms  of  acute  myocarditis, 
endocarditis  or  pericarditis.  But  let  us  suppose  that 
there  is  a  milder  action  of  the  infective  matter, 
which  attacks  only  the  more  noble  elements  of  the 
heart,  either  the  ganglions  and  conducting  fasciculi, 
giutomotors  of  cardiac  contraction,  or  the  neuromus- 
cular cells  scattered  throughout  the  cardiac  muscle 
and  which,  when  irritated,  may  be  the  starting 
point  of  cardiac  contractions  which  are  extrasystolic 
in  nature.  If  the  toxin  acts  on  the  former  of  these 
elements  an  arrest  will  take  place  in  the  conduction 
of  the  excitations,  the  ventricles  will  have  a  tendency 
to  take  on  their  own  rhythm  and  the  result  is  a 
bradycardia. 

Xow,  let  us  suppose  that  the  infection  produces 
very  small  isolated  areas  of  myocarditis  in  the  midst 
of  the  muscle ;  these  can  be  the  starting  point  of 
extrasystoles  which,  according  to  their  frequency, 
will  give  rise  to  either  arrh\1:hmia  or  tachycardia. 
All  of  these  accidents  of  influenzal  cardiac  processes 
can  be  explained,  either  by  a  massive  action  of  the 
influenzal  toxin  on  the  heart  or  by  a  milder  action 
acting  upon  more  differentiated  elements.  This  is 
merely  an  hypothesis.  On  the  other  hand,  the  symp- 
toms common  to  all  forms  of  influenza  with  cardiac 
manifestations,  viz :  hypotension,  unstable  pulse, 
asthenia,  collapse,  prostration  and  sudden  death, 
represent  the  clinical  picture  of  suprarenal  in- 
sufficiency. In  certain  infectious  diseases — diph- 
theria for  example — myocardic  syndromes  are 
occasionally  observed  which  may  be  due  to  an  acute 
suprarenal  insufficiency,  and  it  seems  rational  to 
suppose  that  the  toxin  of  influenza  may  act  in  the 
■same  way  in  this  respect  as  that  of  diphtheria.  The 
cases  of  basedowism  observed  in  influenza  would 
seem  to  support  this  view. 

I  believe  that  in  this  brief  summary  I  have  cov- 
ered the  subject  of  influenzal  cardiac  complications 
sufficiently  to  give  the  present  views  held  on  the 
subject  in  France  and  Switzerland  and  need  merely 
add  that  the  prognosis  in  all  cases  is  serious. 


Editorial  Notes  and  Comments 


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NKW  YORK.  SATURDAY.  NOVKMBER  27,  1920. 

ESTIMATING  EMOTIONS. 
The  doorways  of  Man's  existence  have  been 
thrown  wide  open.  He  is  as  neatly  exposed  as  a 
child's  doll's  house  with  the  front  off.  Doctors,  sur- 
geons, alienists,  theologians,  i>sychoanalysts,  lawyers, 
philosophers,  have  crowded  in  and  left  no  room  un- 
examined, and  no  theory  concerning  it  unwritten. 
They  pursue  the  owner  to  his  bedroom  to  steal 
and  analyze  his  dream'^,  they  describe  his  wilful 
waste  in  kinetics  as  he  gets  into  his  clothes,  and  his 
repressed  emotion,  finding  an  oathly  outlet  as  he 
struggles  with  hyperstarched  buttonholes.  In  vain 
he  protests,  they  solemnly  produce  cards  and  file  a 
list  of  his  every  possession  with  brain  racking  charts 
showing  horrible  probabilities  because  he  has  for- 
gotten how  to  solve  simple  tests  which  his  kinder- 
garten progeny  regard  as  a  very  small  matter.  In 
fact  there  is  a  report  that  British  working  men  are 
attending  evening  schools  so  as  to  keep  up  to  their 
children  and  not  be  shamed  by  them.  An  industrial 
commission  set  out  recently  to  ascertain  whether 
employees'  thoughts  were  on  their  work  while  they 
were  employed.  About  only  two  per  cent.  were. 
One  woman  said  she  was  "thinking  of  nothing,"  a 
deceptive  statement,  because  the  commission  de- 
clared this  an  impossibility  and  commissioners  are 
always  right  I  Now  comes  along  Dr.  Waller,  direc- 
tor of  the  laboratory  in  the  London  University,  who 
puts  you  in  a  chair,  fixes  up  an  electric  apparatus 
which  includes  a  pair  of  electrodes,  a  Wheatstone 
bridge  and  a  galvanometer.  Opposite  the  patient 
is  a  strip  of  linen  bearing  measurements.    The  in- 


ventor asserts  that  it  will  ilirow  a  new  light  upon 
many  important  physiological  and  psychological 
problems,  for  a  doctor  can  understand  his  patient's 
temperament  with  its  help  as  the  betraying  beam 
of  light  traces  its  way  accusingly  across  the  record. 
The  spoken  word  may  be  controlled  and  looks  dis- 
guised, but  few  can  control  the  sudden  ceding  of 
the  mind  to  an  emotion,  not  even  a  Scotsman  or  a 
Red  Indian.  Dr.  Waller  hopes  in  time  to  make  the 
instrument  record  will  power.  At  present  he  admits 
its  limitations.  Hatred  or  love  may  produce  an 
equal  wave  of  emotion,  also  the  hearing  of  a  crime 
or  being  accused  of  it;  dread  of  pdn  or  efforts  to 
endure  it. 

What's  done  we  partly  may  compute. 

We  know  not  what's  resisted. 

A  doctor  does  not  generally  require  a:i>  cicctric 
device  to  ascertain  emotionalism,  for  those  who  come 
are  usually  somewhat  unbalanced  by  disease  and  the 
flushed  face,  nervous  fumbling  with  articles  of  attire, 
-hifting  of  position  and  uncertain  replies  give  him 
as  much  information  as  he  requires.  For  ordinary 
use  we  do  not  need — indeed,  had  better  not  learn 
what  our  acquaintances  are  thinking.  The  profane 
sailor,  who  resolved  to  give  up  swearing  at  his 
mates,  used  to  say :  "Gwl  bless  you :  you  know  what 
I  mean."  It  may  be  that  the  recording  light  l>eam 
would  have  been  slightly  modified  even  by  the 
more  temperate  form  of  e.xpression  as  it  indicated 
a  slightly  disciplined  emotion. 


THE    PROGRESS    OF  INDUSTRIAL 
MEDICINE. 

Indu.>5trial  medicine  is  making  great  headway  and 
more  so  in  America  than  in  any  other  country.  Most 
of  the  large  industrial  concerns  here  have  their 
medical  staffs,  their  hospitals,  convalescent  homes  and 
so  on.  It  has  been  found  to  be  true  economy  and 
quite  as  much  in  the  interest  of  employer  as  of  em- 
ployee, to  keep  the  latter  in  good  health  and  to  afford 
him  or  her  competent  medical  or  surgical  attendance 
when  sick  or  injured. 

While  the  practice  of  industrial  medicine  of  the 
future  will  be  more  and  more  in  the  nature  of  pre- 
vention,-there  will  still  be  plenty  of  scope  for  the 
practice  of  curative  and  healing  medicine.  In  in- 
dustrial businesses  there  will  always  be  ample  oppor- 
tunities for  the  practice  of  the  surgeon's  art.  The 
injuries  and  sickness  brought  about  by  industrial 
work  more  than  rival  similar  disabilities  produced  by 
war.  There  is  a  machine  shock  resulting  in  neuras- 
thenia and  ner\'Ous  breakdown  as  well  as  shell  shock 
of  war  occasioning  like  affections.    In  fact,  most  of 


November  27,  1920  ] 


EDITORIAL  ARTICLES. 


861 


the  injuries  and  illnesses  produced  by  war  can  be 
duplicated  in  industrial  civil  life.  Recently,  in 
Great  Britain,  a  good  deal  of  work  was  done  in  this 
direction.  A  medical  research  council  and  depart- 
ment of  scientific  and  industrial  research  have 
been  formed,  the  annual  report  of  which  has  been 
issued  recently.  The  investigations  of  this  body 
are  of  great  interest  and  have  borne  good  fruit. 
The  latest  development  of  this  kind,  however,  is  con- 
tained in  an  appeal  which  St.  Clary's  Hospital 
Medical  School,  London,  has  issued  asking  the  heads 
of  industry  to  endow  a  Chair  of  Industrial  Medi- 
cine. The  holder's  duty  would  be  to  visit  heads 
of  great  industries  throughout  Great  Britain  and  to 
find  out  from  them  what  special  diseases  are  leading 
to  the  loss  of  working  hours.  He  would  investigate 
the  effect  of  fatigue  on  workers  and  their  efficiency 
and  also  all  trade  diseases.  Further,  he  would  be 
responsible  for  the  instruction  of  students  in  this 
branch  of  medicine.  It  is  hoped  in  this  way  to  pro- 
vide a  service  of  doctors  thoroughly  conversant 
with  industrial  health  problems.  It  has  been  shown 
already  what  can  be  done  in  this  field  by  the  work 
of  Dr.  Lister  Llewellyn  on  miners'  nystagmus.  The 
causation  of  a  disorder  which  is  costing  Cireat  Britain 
five  million  dollars  a  year,  according  to  a  recent  esti- 
mate, has  been  discovered  by  this  physician. 

In  the  last  years  of  the  war  a  quarter  of  all  cas- 
ualties were  gassed  men  ;  that  is  the  number  of  men 
gassed  in  the  British  Army  ran  into  six  figures.  For 
several  months  nearly  ninety  per  cent,  of  these 
patients  that  came  to  the  base  were  evacuated  to 
England.  It  became  obvious  that  if  the  war  were  to 
be  won  by  the  Allies  that  this  loss  must  stop.  The 
matter  was  grappled  with  in  earnest,  and  a  hospital  at 
Boulogne  was  set  aside  to  discover  a  means  of  clieck- 
ing  the  wastage.  In  a  short  time  eighty-seven  per 
cent,  of  all  gassed  men  coming  to  the  base  marched 
half  a  mile  in  their  equipment  to  convalescent  depots 
within  a  moftth  of  their  gassing,  and  the  percentage 
evacuated  to  England  from  one  hospital  dwindled 
from  nearly  ninety  per  cent,  to  two  per  cent.  Wast- 
age of  a  similar  nature  occurs  in  the  labor  world. 
Every  year  sick  workers  lose  wages  amounting  to 
millions  of  pounds,  and  they  become  a  cliarge  on 
the  State  for  treatment  and  insurance  amounting  to 
millions  more. 

The  object  of  the  appeal  of  St.  Mary's  Hospital 
is  to  deal  with  this-  problem  as  the  war  hospital  at 
Boulogne  dealt  with  gas  casualties.  It  is  only  neces- 
sary that  first  class  men  be  afforded  the  facilities 
that  exist  in  medical  schools  for  investigating  these 
problems.  The  trend  of  the  practice  of  medicine 
is  changing,  and  medical  students  of  the  pre<^ent 
day  must  be  so  trained  that  they  will  be  able  to 
adapt  themselves  to  the  altered  conditions. 


PH YSICI AX-AUTHORS  :  DR.   SILAS  WEIR 
MITCHELL. 

There  are  two  ways  of  classifying  Dr.  Silas  Weir 
Mitchell — the  most  celebrated  Philadelphian  since 
Benjamin  Franklin — for  he  attained  international 
distinction  in  two  widely  separated  lines.  It  is 
purely  a  matter  of  choice  whether  you  call  him  an 
eminent  physician  who  was  also  a  prominent  author" 
or  a  prominent  author  who  was  also  an  eminent 
physician.  Mitchell  was,  in  fact,  a  master  mind  in 
several  distinct  circles  of  intellectual  activity.  In 
literature  he  was  not  only  a  novelist  of  the  first  rank 
but  also  a  poet  of  high  distinction,  and  in  medicine, 
although  his  specialty  was  neurology,  he  also  was  a 
recognized  authority  on  toxicology  (particularly 
snake  poisons )  and  his  researches  on  the  reflexes  of 
the  lower  limbs  were  the  most  comprehensive  made 
in  this  country.  On  these  and  other  medical  sub- 
jects in  which  he  conducted  elaborate  experiments 
and  made  exhaustive  research,  he  wrote  more  than 
one  hundred  and  fifty  monographs,  many  of  which 
are  still  the  last  word  of  authority  in  the  medical  pro- 
fession. Medical  work  was  distinctly  Dr.  Mitchell's 
chief  life  work,  though  one  might  be  inclined  to 
doubt  it  after  a  glance  at  the  long  list  of  volumes  of 
poetry  and  fiction  which  bear  his  name.  There  are 
thirty-five  of  these  and  practically  all  were  written 
in  the  last  thirty-five  years  of  his  life,  after  he  had 
turned  the  age  of  fifty.  Few  writers  who  begin 
at  twenty  are  more  fruitful. 

Dr.  Mitchell  always  gave  first  importance  to  his 
medical  duties  and  never  let  literary  work  interfere 
with  his  practice  and  research.  At  a  reception  in 
his  honor  at  the  L'niversity  Club  in  Philadelphia  he 
once  sai<l  that  if  he  had  to  choose  between  literature 
and  medicine  he  would  abandon  literature.  "If  I 
could  be  remembered  for  but  one  thing,"  he  said, 
"I  would  rather  it  would  be  for  the  work  I've  been 
able  to  do  for  my  fellowmen  in  the  practice  of  medi- 
cine." Practically  all  of  his  writing  was  done  during 
his  summer  vacation  period.  It  was  his  custom  in 
June  to  go  to  Canada  for  a  month  of  salmon  fishing 
and  camping,  after  which  he  went  to  his  summer 
home  at  Bar  Harbor.  Me.,  to  devote  himself  to  writ- 
ing during  the  remainder  of  the  summer.  His  con- 
tention was  that  the  best  rest  is  acquired  by  a  change 
of  work. 

It  was  as  the  author  of  Hugh  Wynne,  Free 
Quaker — called  by  many  critics  the  "best  historical 
novel  of  the  American  Revolution  ever  written" — 
that  Dr.  ^Mitchell  is  best  known.  Hugh  Wynne  is  a 
faithful  picture  of  Philadelphia  life  during  the  War 
of  Independence  and  many  of  the  characters  in  it  are 
historic  j^ersonages.  One  of  these  is  George  Wash- 
ington.   The  rise  and  fall  of  Benedict  Arnold  is  a 


862 


EDITORIAL  ARTICLES. 


[New  York 
Medical  Journal. 


tragic  element  in  the  story  and  the  chapter  on  the 
death  of  Major  Andre  is  a  classic  bit  of  writing. 
Hugh  Wynne  was  the  first  of  a  series  of  novels  from 
the  pen  of  Mitchell  dealing  with  various  periods  in 
American  history.  In  War  Time  also  dealt  with  the 
Revolutionary  period  and  The  Red  City  portrays 
life  during  the  second  administration  of  WashingtQn 
as  President,  with  Philadelphia  as  the  background. 
The  Youth  of  W ashington  was,  of  course,  pre-Revo- 
lutionary,  and  is  told  in  the  form  of  an  autobi- 
ography. Roland  Blake  and  Westways  are  Civil 
War  novels.  Many  of  Dr.  Mitchell's  short  stories 
had  Revolutionary  and  Civil  War  settings.  Through- 
out the  latter  conflict  he  served  as  an  army  surgeon 
and  was  in  charge  of  the  military  hospital  at  Phila- 
delphia. 

Ivlitchell's  other  novels  dealt  mainly  with  contem- 
porary American  life,  with  the  notable  exception  of 
The  Adventures  of  Francois,  a  lively  story  of  the 
French  Revolution  which  paralleled  HiigJi  Wynne  in 
popularity.  Frangois  is  the  only  one  of  Dr.  Mit- 
chell's novels  in  a  foreign  setting,  but  several  of  his 
dramatic  poems  have  backgrounds  in  other  countries, 
or  at  sea.  The  Cup  of  Youth  deals  with  Galileo,  the 
astronomer  and  philosopher ;  Philip  Vernon  is  a 
metrical  tale  of  the  Elizabethan  period  and  Francis 
Drake  recounts  in  verse  an  episode  in  the  life  of 
that  well  known  seafaring  man.  All  of  Dr.  Mit- 
chell's novels,  whether  historical  or  not,  were  strong-, 
ly  psychological,  aod  this  applies  to  his  poetry  as 
well.  He  was  particularly  successful  in  the  por- 
traiture of  women  characters  and  through  his  writ- 
ings can  be  noticed  the  strong  influence  which  the 
medical  profession  exerted.  To  a  greater  or  less 
extent  nearly  all  his  stories  are  pathological  por- 
traitures with  plots  based  on  episodes  from  his  life 
as  a  practitioner.  There  are  physicians  as  charac- 
ters in  practically  all  his  novels  and  in  Dr.  North 
and  His  Friends,  The  Autobiography  of  a  Quack, 
and  others,  physicians  and  their  experiences  and 
problems  are  the  chief  motifs.  His  first  story — 
aside  from  a  few  juveniles  written  in  the  sixties — 
was  The  Case  of  George  Dedlow,  which  appeared  in 
the  Atlantic  Monthly,  when  that  publication  was  un- 
der the  editorship  of  Edward  Everett  Hale.  It  de- 
scribed a  case  in  what  he  called  the  Stump  Hos- 
pital of  a  man  who  had  lost  his  legs  and  arms,  and  it 
undertook  to  diagnose  the  effect  of  this  on  the  man's 
individuality.  So  realistically  written  was  this  frag- 
ment that  the  public  supposed  George  Dedlow  to 
be  a  genuine  case,  the  newspapers  took  it  up  and 
subscriptions  began  to  pour  in. 

But  it  was  not  the  entertaining  pathological  infor- 
mation which  made  Dr.  Mitchell's  writings  popular. 
TTis  popularity  was  due  to  his  imaginative  virility. 


his  deep  comprehension  of  human  nature  and  hu- 
man thought,  his  fascinating  analyses  of  character 
and  the  fact  that  he  always  had  a  good  story  to  tell 
and  knew  how  to  tell  it.  Although  he  never  was  a 
best  seller  (except  in  the  cases  of  Hugh  Wynne 
and  Frangois)  his  books  still  have  a  steady  sale  and 
more  than  a  million  copies  have  been  sold. 

Dr.  Mitchell  was  born  in  Philadelphia  on  February 
15,  1829,  and  died  there  on  January  4,  1914,  of  in- 
fluenza, after  six  days'  illness,  at  the  age  of  eighty- 
four.  He  derived  his  medical  and  literary  gifts 
from  his  father.  Dr.  John  Kearsley  Mitchell,  who 
was  for  several  years  a  professor  in  Jefferson  Medi- 
cal College  and  was  a  poet  of  note.  It  was  in  Jef- 
ferson Medical  College  that  the  son  obtained  his 
medical  degree  in  1850.  He  also  studied  at  the 
University  of  Pennsylvania.  In  1887  he  was  presi- 
dent of  the  Association  of  American  Physicians  and 
in  1908-9  was  president  of  the  American  Neurologi- 
cal Association.  His  eminence  in  science  and  let- 
ters was  recognized  by  universities  and  societies  all 
over  the  world  which  conferred  degrees  and  honors 
upon  him. 


FREE  ASSOCIATION  AND  ITS  RIGHT  TO 
USE. 

The  use  of  free  association  in  psychoanalytical 
therapy  meets  with  familiar  forms  of  criticism. 
There  are  some  who  boast  an  intellectual  modesty, 
which  has,  however,  a  stale  odor  of  intellectual  and 
moral  laziness.  To  them  any  feature  of  the  psy- 
chology of  the  unconscious  seems  too  deep,  too  ob- 
scure. Others,  with  a  more  openly  acknowledged 
superciliousness,  consider  the  seemingly  random 
memories  brought  into  view  by  free  association  too 
trivial  for  serious  technical  attention.  Would  it  aid 
in  obtaining  a  truer  valuation  of  the  patient's  free 
associations  and  of  the  method  which  deliberately 
makes  use  of  them,  if  a  psychological  appraisal  could 
be  found  for  both  classes  outside  of  psychoanalysis? 
Perhaps  such  an  estimate  would  also  throw  light 
where  the  employment  of  such  apparent  vagaries 
of  memory  seems  too  obscure  a  procedure.  Berg- 
son  never  laid  claim  to  being  a  psychoanalyst.  The 
matter  of  his  Mind-Energy  was  written  or  spoken 
independently  of  the  teachings  of  Freud.  He  has  a 
fondness,  nevertheless,  for  delving  into  psychic  facts 
and  a  keen  sense  of  the  practical  implication  of 
psychic  actualities  in  each  moment  of  life. 

Bergson  has  already  made  classic  the  statement 
that  the  function  of  the  past,  stored  in  memory,  is 
to  illumine  the  present  moment,  to  direct  and  fur- 
ther the  action  in  hand.  The  task  of  mental  therapy 
is  surely  the  freeing  of  memory  to  such  service, 
memory  that  has  been  too  long  held  back — repressed. 


November  2/,  1920.] 


EDITORIAL  ARTICLES 


863 


In  order  to  release  energy  at  such  a  point,  energy 
painfully  caught  and  held  in  the  repressed  matter, 
is  it  effective  to  turn  upon  the  situation  the  logic 
of  intellect  ?  Is  any  patient  ever  reasoned  out  of  an 
incessantly  haunting  obsession,  compulsion,  phobia? 

Bergson  suggests  a  different  sort  of  light.  He  says 
that  memories  are  recalled  "in  order  that  the  circum- 
stances which  have  preceded,  accompanied,  and  fol- 
lowed the  past  situation,  should  throw  some  light 
on  the  present  situation  and  indicate  the  way  out  of 
it."  Bergson  is  talking  of  memories  which  flood 
upon  a  new  perception  but  it  is  not  amiss  to  apply 
his  appreciation  of  the  service  of  memories  to 
such  a  particular  point,  the  blocked  up  issue  which 
has  appeared  like  a  new  perception  in  a  dream 
phenomenon  or  a  stubbornly  unchangeable  one  in  a 
symptom. 

This  philosopher-psychologist  at  any  rate  finds 
room  in  theory  and  practice  for  a  thinking  process 
which  reaches  in  two  opposite  directions,  and  counts 
each  of  equal  dignity.  Thought  forms  and  follows 
a  directed  scheme  but  this  is  meaningless,  yes  impos- 
sible, unless  there  is  "a  descent  of  the  scheme  toward 
the  image,  and  a  moving  of  the  mind  among  the 
images  themselves." 

A  careful  reading  of  Bergson's  chapter  on  Intel- 
lectual Effort  convinces  the  reader  that  to  this 
thinker  at  least  all  intellection  makes  use  continually 
of  the  method  of  free  association.  There  is  no  word 
either  of  exclusion  on  the  ground  of  triviality  or 
any  other  quality.  The  only  criterion  of  selection  is 
serviceableness  to  the  matter  in  hand. 


LET  THERE  BE  LIGHT. 
We  are  ceasing  to  regard  fresh  air  with  suspicion. 
It  is  no  longer  regarded  as  poisonous  after  sunset 
or  dangerous  if  encountered  as  a  draught.  We  have 
even  a  Fresh  Air  Fund,  out  of  door  sleeping  places, 
and  now  a  big  campaign  is  going  on  to  get  light. 
Xot  bursts  of  light  as  on  the  Fourth  of  July,  not  like 
illumined  Broadways,  not  glaring  ballrooms,  but 
steady  light  for  workers,  without  glare,  without 
flickering. 

Eyestrain  means  headache,  and  headache  has  a 
hundred  little  devils  called  minor  ailments  dancing  in 
attendance.  Strained  eyesight  means  that  the  pretty 
eyes  of  our  girls  are  hideously  bespectacled ;  strained 
eyesight  in  youth  means  almost  sightless  old  age  and 
no  occupation  which  accentuates  the  dreariness  of 
the  long  days.  So  now  there  is  cropping  up  in 
every  city  long  titled  municipal  bodies  which  demand 
light,  but  graded  light  for  employees.  Light  not  only 
in  the  rooms  but  on  staircases,  in  basement  passages, 
on  fire-escapes.  Some  of  us  can  recall  the  revolting 
odor  of  a  work  room,  gas  illumined,  and  used  all 


day,  the  single  gas  jets  on  dark  staircases,  and  now 
we  see  the  harsh  glare  of  unshaded  electric  light. 
These  things  cannot  be  trusted  for  rectification  to 
the  uncertain  humanity  of  employers.  Wise  munici- 
pal law  spells  industrial  efficiency,  industrial  effi- 
ciency would  mean  a  good  strikebreaker,  because  it 
would  mean  efficient  brains.  Xew  York,  New  Jer- 
sey, Pennsylvania,  California,  Oregon  and  Ohio  have 
excellent  codes  based  on  a  tentative  code  drawn  up 
by  the  Committee  of  the  Illuminating  Engineering 
Society,  afterward  adopted  by  the  Committee  of 
National  Defence.  There  will  be  a  sensible  diminu- 
tion of  young  patients  at  otir  eye  clinics  if  all  the 
good  these  codes  hold  out  is  brought  to  bear  on  the 
tired-eyed,  painted,  powdered,  high  shouldered,  nar- 
row chested  girls  who  trip  mincingly  along  in  tight 
skirts  after  work  to  halls  and  movies  to  further 
strain  their  pretty  eyes. 


A  MEDICAL  LUXCH. 
The  English  are  becoming  as  clever  in  their  ways 
of  getting  money  as  their  American  cousins.  Who 
could  refuse  an  invitation  to  a  lunch  given  by  one 
hundred  clever  women  to  one  hundred  clever  men? 
The  object  was  to  get  money  for  the  Royal  Free 
Hospital  School  of  IMedicine,  where,  sixty  years 
ago,  Elizabeth  Garrett  achieved  distinction  as  the 
first  Englishwoman  to  take  a  medical  degree.  There 
are  now  five  hundred  women  students  in  the  school. 
The  air  must  have  been  rather  too  exhilarating, 
with  the  powers  of  two  hundred  clever  men  and 
women  let  loose.  Fortunately,  there  were  no  dis- 
cussions or  the  roof  might  have  been  blown  off. 
Sir  Alan  Garrett  Anderson,  M.  D.,  said  that  the 
best  places  of  the  profession  were  reserved  for  the 
consulting  staffs  of  the  great  teaching  hospitals, 
and  the  Royal  Free  was  the  only  general  hospital 
in  the  kingdom  to  admit  women  to  the  desired  top 
platfonii.  Princess  Louise  was  the  guest  of  honor, 
and  had  at  her  table  women  doctors  of  Harley 
Street  fame.  The  home  secretary  was  one  clever 
man.  Some  others  were  Sir  Eric  Geddes,  M.  D., 
Sir  George  Xewnian,  M.  D.,  and  Sir  Owen  Seaman, 
of  Punch. 


THE  EYEBROW. 
There  is  hardly  a  feature  today  which  si  not  sub- 
jected to  strict  examination  by  the  ubiquitous  psy- 
chologist. An  Italian  doctor  has  been  making  a 
study  of  the  eyebrow,  and  he  has  found  that  in 
dementia  prsecox  there  are  nearly  always  short, 
bushy  hairs  nearly  meeting  in  the  space  between  the 
eyebrows  and  a  noticeable  thinning  toward  the 
external  side.  In  epileptic  women  the  eyebrow  is 
made  up  of  two  portions,  the  inside  is  in  the  form 
of  a  comma,  of  which  the  tail  enters  in  the  two 
branches  of  the  external  portion  in  the  form  of  a  Y. 
In  epileptic  men  one  often  sees  large  tufted,  heavily 
haired  eyebrows,  united  at  the  median  line.  In 
maniac  depressive  cases  the  absence  of  the  outer 
third  of  the  eyebrow  is  common. 


864 


NEIVS  ITEMS. 


[New  York 
Medical  Journal. 


News  Items. 


A  Police  Hospital  in  Tokio. — A  hospital  is  to 
be  erected  in  Tokio,  at  a  cost  of  $300,000,  for  the 
benefit  of  the  city's  8,000  policemen  and  their 
families. 

State  Consultation  Clinics  for  Tuberculosis. — 

The  State  Department  of  Health  of  Massachusetts 
has  established  a  series  of  consultation  clinics  for 
early  pulmonary  tuberculosis. 

Jewish  Hospital  Clinical  Society  of  Philadel- 
phia.— Dr.  Myer  Solis-Cohen  has  been  elected 
president  of  this  society  to  serve  for  the  ensuing 
year.  Dr.  Irwin  S.  Meyerholf  was  elected  vice- 
president,  and  Dr.  Joseph  P.  Besser,  secretary  and 
treasurer. 

Woman's  Hospital  Society  Gives  Dinner  to  Dr, 
McGinnis. — The  Woman's  Hospital  Society,  of 
New  York,  gave  a  dinner  to  Dr.  E.  L'H.  McGinnis 
on  Tuesday  evening,  November  16th,  in  recognition 
of  the  work  done  by  him  during  his  many  years' 
service  at  the  Woman's  Hospital. 

Antituberculosis  Crusade  in  Japan. — Accord- 
ing to  press  dispatches  from  Tokio,  Japan  has 
inaugurated  a  widespread  crusade  against  tubercu- 
losis and  a  general  campaign  for  public  sanitation. 
Important  social  legislation  has  recently  been  enacted 
and  national  and  municipal  authorities  are  cooperat- 
ing to  enforce  the  new  laws. 

Dr.  Baruch  Honored. — A  dinner  was  given  in 
New  York  on  Sunday 'evening,  November  21st,  in 
honor  of  Dr.  Emanuel  de  Marnay  Baruch,  organizer 
of  relief  work  for  Germany  and  Austria.  Two 
thousand  persons  attended  the  dinner,  among  them 
being  Dr.  Royal  S.  Copeland,  commissioner  of 
health  of  the  city  of  New  York,  and  other  -city 
officials. 

Chicago  Physicians  Receive  Honorary  De- 
grees.— Dr.  Ludvig  Hektoen,  of  Chicago,  had 
conferred  upon  him  the  honorary  degree  of  Doctor 
of  Laws  at  the  centennial  celebration  of  the  Medical 
College  of  the  University  of  Cincinnati.  The  hon- 
orary degree  of  Doctor  of  Science  was  conferred 
upon  Dr.  Dean  Lewis  and  Dr.  Edward  O.  Jordan 
at  the  same  time. 

Hookworm  Infection  in  Australia. — Reports  to 
the  United  States  Public  Health  Service,  dated 
August  24,  1920,  state  that  a  vigorous  campaign 
against  hookworm  disease  is  in  progress  in  Aus- 
tralia. In  one  district  in  the  northeastern  section 
of  Queensland,  out  of  L433  natives  examined  216 
were  found  infected,  and  in  another  district  in  the 
same  .section  out  of  1.592  natives  examined  182 
were  found  infected. 

International  Public  Health  Journal. — The 
first  number  of  the  new  International  Public  Health 
Journal  has  just  been  issued  by  the  Department  of 
Medical  Information,  General  Medical  Department 
of  the  League  of  Red  Cross  Societies  at  Geneva, 
Switzerland.  The  journal  will  be  devoted  to  all 
phases  of  public  health  work  and  preventive  medi- 
cine and  will  be  published  every  two  months  in  four 
languages,  French,  English,  Italian,  and  Spanish. 
Dr.  Thomas  R.  Brown,  of  Baltimore,  is  editor,  and 
Dr.  William  F.  Francis,  of  Montreal,  is  associate 
editor. 


Married. — Dr.  Arthur  Lewis  Root,  of  New 
York,  to  Miss  Edith  Dow  Merrill,  in  New  York, 
on  Wednesday,  November  17th. 

Dr.  Harold  F.  Cleveland,  of  Holyoke,  Mass.,  to 
Miss  Regina  B.  Madden,  at  Brockton,  Mass.,  on 
Sunday,  November  14th. 

Medal  of  Honor  Awards. — Among  the  thirteen 
men  in  the  Navy  and  Marine  Corps  who  were 
awarded  the  Medal  of  Honor  are  the  following: 
Lieutenant  J.  Boone,  Medical  Corps,  United  States 
Navy;  A.  G.  Lyle,  dental  surgeon.  Medical  Depart- 
ment of  the  Navy;  Lieutenant  Orlando  H.  Petty, 
Medical  Corps,  R.  F. 

Lectures  by  Dr.  Kenyon. — The  Federation  for 
Child  Study  announces  three  lectures  by  Dr.  Jose- 
phine Hemenway  Kenyon  on  The  New  Ideal  of 
Health,  Wednesday  afternoons,  at  2  West  Sixty- 
fourth  Street,  as  follows:  December  1st,  Influence 
Before  Birth ;  December  8th,  The  Vital  First  Three 
Years;  December  15th,  The  Neglected  Preschool 
Period. 

A  Merger  of  Psychological  Journals. — An- 
nouncement is  made  that,  commencing  with  the 
January,  1921,  issue,  the  two  journals,  Psychobi- 
ology,  and  Journal  of  Animal  Behavior,  will  be 
merged  under  the  new  name  of  the  Journal  of 
Comparative  Psychology.  The  new  journal  will  be 
edited  by  Knight  Dunlap  and  Robert  M.  Yerkes 
and  will  be  published  by  the  Williams  &  Wilkins 
Company,  Baltimore. 

Spanish  Physicians  Appeal  to  Government  to 
Bar  Foreign  Competitors. — Press  dispatches  from 
Madrid  state  that  the  physicians  and  surgeons  of 
Spain,  are  greatly  perturbed  over  the  recent  inva- 
sion of  their  country  by  foreign  practitioners,  more 
especially  Austrians,  who  have  been  unable  to  find 
sufficient  means  for  subsistence  in  their  own  country. 
In  consequence,  it  was  decided  to  appeal  to  the 
Government  to  make  regulations  under  wliich 
foreign  practitioners  would  have  to  acauire  a  med- 
ical degree  in  Spain  before  being  allowed  to  practice. 

St.  Louis  University  Centennial  Endowment 
Fund. — St.  Louis  University  has  asked  its 
alumni  and  friends  to  raise  the  sum  of  $3,000,000 
as  a  Centennial  Endowment  Fund,  in  commemora- 
tion of  the  one  hundredth  anniversary  of  the  found- 
ing of  the  institution.  The  anniversary  occurred 
in  1918,  but  because  of  war  conditions  existing  at 
that  time,  with  over  three  thousand  of  the  under- 
graduates and  alumni  of  the  University  having 
answered  the  call  to  arms,  the  celebration  was  post- 
poned until  conditions  were  more  nearly  normal. 

St.  Louis  University  holds  the  distinction  of 
having  established  in  the  great  Louisiana  Purchase 
tract  the  first  colleges  of  medicine,  dentistry,  law, 
and  commerce.  Of  the  $3,000,000  asked,  the  in- 
come on  $1,500,000  is  for  salaries  of  the  teaching 
stafYs  of  tjie  colleges  of  medicine  and  dentistry ;  the 
cost  of  a  new  laboratory  for  the  school  of  medicine 
is  estimated  at  $250,000;  new  buildings  and  clinics 
for  the  schools  of  medicine  and  dentistry  will  cost 
an  additional  $550,000.  The  remainder  of  the 
$3,000,000  will  be  applied  to  the  needs  of  the  Insti- 
tute of  Law,  School  of  Commerce  and  Finance,  and 
the  College  of  Arts  and  Sciences. 


November  27,  1920.] 


NEWS  ITEMS. 


865 


New  York  Neurological  Society. — At  the  next 
meeting  of  the  New  York  Neurological  Society,  to 
be  held  Tuesday  evening,  December  7th,  under  the 
presidency  of  Dr.  Walter  Timme,  the  work  of  the 
Memorial  Hospital  on  the  radium  treatment  of 
tumors  of  nerve  tissue  will  be  presented,  with  lan- 
tern slide  demonstration,  as  follows :  Dr.  Halsey  J. 
Bagg,  Experimental  Study  of  the  Effects  of  Radium 
on  the  Brains  of  Animals ;  Dr.  James  Ewing,  the 
Structure  of  Nerve  Tissue  Tumors  with  Reference 
to  Radium  Therapy ;  Dr.  Douglas  Quick,  Clinical 
Results  of  Treatment  of  Nerve  Tissue  Tumors  by 
Radium.  Dr.  Walter  AI.  Kraus  will  present  two 
cases  of  Friedreich's  Ataxia,  and  Dr.  Charles  Rosen- 
heck  will  read  a  paper  on  Juvenile  Tabes. 

Associate  in  Clinical  Psychiatry  and  Psycho- 
therapy.— The  United  States  Civil  Service  Com- 
mission announces  an  examination  for  associate  in 
clinical  psychiatry  and  psychotherapy,  to  fill  a 
vacancy  at  St.  Elizabeth's  Hospital,  Washington, 
D.  C,  at  $2,500  a  year  and  maintenance.  The  duties 
of  the  appointee  will  be  to  act  as  consultant  to  the 
different  medical  services  of  the  hospital,  with  the 
particular  end  in  view  of  assisting  in  analyzing  and 
understanding  their  patients.  He  will  specifically 
undertake  analytical  and  therapeutic  measures  in 
special  functional  cases  that  it  would  appear 
possible  to  benefit  in  this  way.  In  addition  to  this 
work  the  appointee  will  be  expected  to  avail  himself 
of  the  clinical  material  and  laboratory  opportunities 
for  special  observation  and  research.  It  is  desired 
to  secure  the  services  of  a  person  familiar  with  the 
modern  therapeutic  movements  in  the  practice  of 
mental  medicine.  The  appointee  must  not  only  be 
familiar  with  these  movements,  but  he  must  be 
capable  of  an  analytical  and  interpretative  application 
of  psychological  principles  to  the  individual  case. 

Personal. — Dr.  W.  A.  Bridges,  for  the  past  year 
acting  medical  director  of  the  Maryland  Tubercu- 
losis Association,  has  resigned  to  become  superin- 
tendent of  the  Eudowood  Sanatorium,  Baltimore. 

Dr.  Walter  Dill  Scott,  professor  of  psychology 
in*  Northwestern  University,  has  been  elected  presi- 
dent of  the  tmiversity. 

Dr.  Alfred  L.  Gray,  of  Richmond,  has  been  elected 
president  of  the  Medical  Society  of  Virginia,  suc- 
ceeding Dr.  Fletcher  J.  Wright,  of  Petersburg. 

Dr.  Rudolph  Matas,  of  New  Orleans,  has  been 
elected  vice-president  of  the  American  Medical 
Association  to  fill  the  vacancy  caused  by  the  death 
of  Dr.  Isadore  Dyer. 

Dr.  Frederick  W.  Johnson,  of  Boston,  has  been 
appointed  professor  of  clinical  gynecology  at  Tufts 
Medical  College,  and  Dr.  Louis  E.  Phaneuf,  of 
Boston,  associate  professor  of  gynecology. 

Dr.  William  C.  Braisted,  surgeon  general  of  the 
United  States  Navy,  and  Dr.  Robert  E.  Le  Conte, 
of  Philadelphia,  have  been  awarded  the  Navy  Dis- 
tinguislied  Service  Medal  for  meritorious  service 
during  the  war. 

Dr.  Lewis  W.  Fetzer  has  resigned  as  professor  of 
physiology  and  phamiacology  at  the  Baylor  Univer- 
sity College  of  Medicine  and  will  take  charge  of 
the  laboratories  of  the  St.  Paul  Sanatorium  at 
Dallas,  Texas. 


Women    Physicians    in    the    Orient.  —  The 

Woman's  Foreign  ^Missionary  Society  of  the  Meth- 
odist Church  has  just  commissioned  four  women 
physicians  and  eleven  women  nurses  for  work  in 
their  hospitals  in  the  Orient.  The  twenty  hospitals 
under  their  care  were  depleted  by  the  call  for 
medical  workers  during  the  war  and  seven  of  them 
had  to  be  closed,  but  these  are  now  to  be  reopened. 
Among  the  physicians  whom  the  society  is  sending 
is  a  young  Chinese  woman  who  has  been  studying 
medicine  in  this  country  for  the  past  eleven  years. 
She  is  to  be  at  the  head  of  one  of  the  mission 
hospitals  in  her  own  country. 

Meetings  of  Local  Medical  Societies. — The  fol- 
lowing medical  societies  will  meet  in  New  York 
during  the  coming  week : 

Wedxesday,  December  isf. — New  York  Academy  of 
Medicine  (Section  in  Historical  Medicine)  ;  Bronx  Medical 
Association :  Harlem  Medical  Association ;  Psychiatrical 
Society  of  New  York ;  New  York  Urological  Society ;  So- 
ciety of  Alumni  of  Bellevue  Hospital ;  Brooklyn  Society  for 
Neurology  (annual). 

Thursd.w,  December  2nd. — New  York  Academy  of 
Medicine  (stated  meeting)  ;  Brooklyn  Surgical  Society. 

Frid.w,  December  srd. — New  York  Academy  of  Medi- 
cine (Section  in  Surger)-)  ;  New  York  Microscopical  So- 
ciety: Practitioners'  Society  of  New  York;  Society  for 
Serology  and  Hematology;  Alumni  Association  of  Roose- 
velt Hospital ;  Gj'necological  Society  of  Brooklyn. 

Saturday,  December  4th. — Benjamin  Rush  Medical 
Society. 

A  Medical  Unit  for  Overseas. — Announcement 
is  made  by  the  Joint  Distribution  Committee  of  the 
American  Funds  for  Jewisli  War  Sufferers  that  a 
medical  unit  will  be  sent  overseas  next  month  to 
fight  disease  in  Eastern  Europe. 

Dr.  Harry  Plotz,  of  Mount  Sinai  Hospital,  medical 
adviser  of  the  committee,  has  asked  for  $2,000,000 
to  cover  the  first  year's  work  and  to  provide  for 
payment  of  the  medical  personnel,  the  purchase  of 
medical  suppHes,  the  construction  of  bath  houses, 
etc.  ]\Iedical  and  hospital  supplies  will  be  dis- 
tributed in  connection  v/ith  an  educational  health 
campaign.  Dr.  Plotz  will  be  in  charge  of  the  work 
and  will  head  the  unit,  which  is  to  be  made  up  of 
physicians  with  military  experience.  Applications 
for  volunteers  for  the  unit  will  be  received  bv 
Dr.  Plotz. 

 «^  

Died. 

Chase. — In  Brooklyn,  N.  Y.,  on  Monday,  November  16th, 
Dr.  Walter  B.  Chase,  aged  sevent}--eight  years. 

Devor. — In  Chambersburg,  Pa.,  on  Monday,  November 
15th,  Dr.  John  H.  Devor,  aged  sixty-three  years. 

De  Liguori. — In  Waterbur>-,  Conn.,  on  Tuesday,  Novem- 
ber 2nd,  Dr.  John  de  Liguori,  aged  seventy-four  years. 

Gere. — In  New  York  City,  on  Friday,  November  19th, 
Dr.  James  Belden  Gere,  aged  fort>--eight  j^ears. 

Hayes. — In  New  Bedford,  Mass.,  on  Tuesday,  Novem- 
ber 2nd,  Dr.  Stephen  W.  Hayes,  aged  seventy-two  years. 

James. — In  Lexington,  Ky.,  on  Monday,  November  15th, 
Dr.  Robert  C.  James,  aged  fift>--five  years. 

AIuRRAY. — In  New  York  City,  on  Fridaj%  November  12th, 
Dr.  Elizabeth  C.  Murray,  formerly  of  Cleveland,  Ohio, 
aged  sixty-five  years. 

Salter. — In  Buffalo,  N.  Y.,  on  Friday,  November  12th, 
Dr.  Albert  E.  Salter,  aged  seventy-three  years. 

White. — In  Florence,  Miss.,  on  Saturday,  November 
13th,  Dr.  E.  K.  White,  aged  sixt>'-three  years. 


Book  Reviews 


NEW  X  RAY  MANUALS. 

Rontgen  Interpretation.  A  Manual  for  Students  and  Prac- 
titioners. By  George  W.  Holmes,  M.  D.,  Rontgenologist 
to  the  Massachusetts  General  Hospital  and  Instructor  in 
Rontgenology,  Harvard  Medical  School,  and  Howard  E. 
RuGGLES,  M.  D.,  Rontgenologist  to  the  University  of 
California  Hospital,  and  Clinical  Professor  of  Ront- 
genolog}'.  University  of  California  Medical  School.  Il- 
lustrated. Philadelphia  and  New  York :  Lea  &  Febiger, 
1919.    Pp.  xviii-211. 

X  Ray  Observations  for  Foreign  Bodies  and  Their  Local- 
ization. By  Captain  Harold  C.  Gage,  A.  R.  C,  O.  I.  P., 
Consulting  Radiographer  to  the  American  Red  Cross 
Hospital  of  Paris ;  Radiographer  in  Charge,  Military 
Hospital  V.  R.  76;  Ris  Orangis,  and  Complementary 
Hospitals.  Illustrated.  St.  Louis :  C.  V.  Mosby  Com- 
pany, 1920.    Pp.  i-83. 

Radiography  in  the  Examination  of  the  Liver,  Gallbladder, 
and  Bile  Ducts.  By  Robert  Knox,  M.  D.,  Hon.  Ra- 
diographer, icing's  College  Hospital,  London,  England. 
A  Series  of  Articles  Reprinted  from  Archives  of  Radi- 
ology and  Electrotherapy,  July,  August,  September,  and 
October,  1919.  Illustrated.  St.  Louis :  C.  V.  Mosby  Com- 
pany, 1920.    Pp.  i-64. 

The  X  ray  has  invaded  so  many  fields  and  engaged 
so  many  speciaUsts  in  the  task  of  perfecting  technic 
and  of  working  out  new  interpretations,  that  no 
general  textbook  covering  the  entire  subject  is  avail- 
able. For  this  reason  the  various  manuals  and 
monographs,  of  which  the  following  are  excellent 
examples,  are  of  particular  service: 

An  extensive  territory  is  covered  in  Dr.  Holmes's 
small  volume  Rontgen  Interpretation.  First  the 
reader  is  cautioned  against  the  errors  he  is  likely 
to  encounter,  such  as  confusing  shadows  and  arte- 
facts. These  have  frequently  led  to  faulty  diagno- 
sis in  the  past  and  will  no  doubt  continue  to  do  so 
in  the  future,  but-  if  the  operator  is  on  guard  the 
possibility  of  error  may  be  reduced  to  a  minimum. 
Then  some  of  the  anatomical  variations  are  pre- 
sented. These,  too,  have  led  to  error.  Diagnoses 
of  fracture  have  been  made  when  the  condition  was 
merely  one  of  delayed  union  of  symphj^sis  and  dia- 
physis.  We  are  then  presented  with  a  resume  of 
the  most  common  usages  of  the  x  ray,  fractures 
and  dislocations  in  various  parts  of  the  body,  the 
pathology  of  bone  lesions  and  disorders,  then  the 
more  common  uses  of  the  x  ray  on  the  skull.  The 
chapter  dealing  with  the  joints  is  especially  good,  the 
illustrations  being  extremely  clear.  This  is  fol- 
lowed by  chapters  on  the  chest,  the  gastrointestinal 
tract,  and  the  genitourinary  tract. 

The  work  is  not  complete  and  some  of  the  illus- 
trations, such  as  those  illustrating  pathological 
changes  at  the  roots  of  teeth,  are  not  satisfactory, 
but  on  the  whole  it  is  a  most  useful  little  guide  book 
for  the  practitioner,  showing  him  the  many  uses  to 
which  the  x  ray  may  be  put  as  an  aid  in  diagnosis. 
*    *  * 

Mr.  Gage  was  associated,  for  the  greater  part  of 
the  war,  with  Dr.  Joseph  Blake.  He  devised  many 
useful  methods  for  the  localization  of  foreign  bod- 
ies and  these  are  described  rather  concisely  in  his 
small  manual.  No  more  painstaking  worker  could 
be  found  and  his  constant  aim  was  to  devise  meth- 
ods that  were  as  simple  and  practicable  as  possible. 
He  did  away  with  many  of  the  cumbersome  meth- 


ods that  on  account  of  their  complexity  gave  the 
impression  of  great  precision  and  substituted  de- 
vices which  were  far  simpler  and  at  the  same  time 
no  less  exact.  He  was  aided  in  his  work  by  follow- 
ing the  patients  into  the  operating  room  after  the 
foreign  bodies  had  been  localized  and  seeing  his 
methods  put  to  practical  application.  He  presents 
a  minimum  of  theory  with  a  maximum  amount  of 
utility. 

^    ^  ^ 

This  compend  by  Knox  consists  of  a  series  of 
articles  reprinted  from  the  Archives  of  Radiology 
and  Elcctrotlierapy,  and  are  worthy  of  being 
brought  out  in  book  form.  The  illustrations  are 
the  most  valuable  part  of  the  book.  They  help 
clarify  many  of  the  hazy  points  in  the  none  too  sim- 
ple problem  of  x  ray  examination  of  the  gallbladder 
region.  Among  the  photographs  are  several  stere- 
opticon  views,  which  may  be  removed  from  the 
book  and  examined  through  a  stereoscope,  giving 
the  exact  relationships  of  the  technic  described. 
Surgeons  are  prone  to  place  little  reliability  on  radio- 
graphic findings  in  the  gallbladder  region.  Perhaps 
this  presentation  will  establish  confidence  in  the 
method. 

PHYSIOLOGY  AND  BIOCHEMISTRY. 

Physiology  and  Biochemistry  in  Modern  Medicine.  By  J.  J. 
R.  Macleod,  M.  B.,  Professor  of  Physiology  in  the  Uni- 
versity of  Toronto;  Formerly  Professor  of  Physiology 
in  the  Western  Reserve  University,  Cleveland,  Assisted 
by  Roy  G.  Pearce,  A.  C.  Redfield,  N.  B.  Taylor,  and 
Others.  Third  Edition,  with  Two  Hundred  and  Forty- 
three  Illustrations,  Including  Nine  Plates  in  Color.  St. 
Louis :  C.  V.  Mosby  Company,  1920.   Pp.  xxxii-992. 

jVIost  important  changes  have  been  made  in  the 
section  on  the  nervous  system  in  this,  the  third, 
edition  of  Macleod's  book.  This  work  was  done 
by  A.  C.  Redfield  and  he  has  succeeded  in  present- 
ing the  subject  in  a  manner  best  calculated  for 
practical  application  in  a  therapeutic  sense.  Fortu- 
nately, the  striving  shown  here  is  constantly  toward 
the  clinical  usages  to  which  the  researches  of  both 
laboratory  workers  and  clinicians  may  be  ptit. 

Other  subjects  which  have  called  for  changes  in 
the  text  due  to  the  progress  made  in  their  respec- 
tive fields  are  the  chapters  on  vitamines,  surgical 
shock,  and  capillary  circulation.  While  the  endo- 
crines  have  come  in  for  their  share  in  the  revision 
it  seems  as  though,  in  a  book  of  this  character, 
more  could  have  been  said  without  going  beyond 
the  borders  of  safety.  For  example,  Httle  is  said 
about  the  pineal  or  thymus.  Perhaps  the  authors 
have  not  dared  to  venture  in  this  little  explored 
field  in  a  work  of  this  kind,  yet  a  beginning  should 
be  made,  and  it  might  be  well  to  present  what  i? 
known  of  the  more  obscure  subjects  rather  than 
rehash  and,  elaborate  some  of  the  physiological  phe- 
nomena merely  because  there  is  less  divergence  of 
opinion  regarding  a  special  subject.  The  parts  deal- 
ing with  the  chemistry  of  respiration  are  entirely 
revised,  yet  it  seems  as  though  some  of  the  work 
done  on  the  endocrine  glands,  especially  on  the 
adrenals,  could  have  been  incorporated  into  this 
phase  of  physiology. 


November  27,  1920.] 


BOOK  REVIEWS. 


867 


RELIGION  AND  HEALTH. 

Religion  and  Health.  By  James  J.  Walsh,  M.  D.,  Ph.  D., 
Sc.  D.,  etc.,  Medical  Director  of  Fordham  University 
School  of  Sociology;  Professor  of  Physiological  Psy- 
chology, Cathedral  College  Lecturer  on  Psychology  and 
Sociology,  Marywood  College,  Scranton,  Pa.,  Mt.  St. 
Mary's,  Plainfield,  N.  J.  Boston:  Little,  Brown  &  Co., 
1920.    Pp.  341. 

A  cheery  young  lieutenant  who  spent  his  leave 
during  the  war  with  a  sad  relative,  said,  "I  suppose 
it's  being  religious  makes  aunt  so  beastly  miserable." 
He  was  only  voicing  a  thought  which  comes  to 
many  who  are  chilled  and  puzzled  by  the  behavior 
of  the  religious.  A  young  man  who  was  accident- 
ally locked  up  in  a  refrigerating  room,  when  asked 
how  he  felt,  said,  "Just  as  I  did  when  I  went  to  a 
social  tea  at  a  church."  Such  discourteous  young- 
sters would  do  well  to  listen  to  Dr.  Walsh,  as  he 
gives  an  absolutely  fair  hearing  to  the  assertions 
of  religion  and  health.  What  one  man  has  done, 
man  can  do.  Disease,  plus  religion,  can  see  a  man 
mentally  and  morally  triumphant.  Disease,  lacking 
religion,  sees  the  pitiable  sight  of  a  slow  deteriora- 
tion in  body  and  also  in  soul. 

That  which  should  have  been  Chapter  One  has 
wandered  away  to  the  end  of  the  book.  This  treats 
of  a  morbid  condition  in  which  ill  health  is  mistaken 
for  spiritual  declension  and  gloom  settles  down  be- 
cause a  person  is  too  lazy  to  take  a  walk  or  a  blue 
pill.  To  the  question  at  the  beginning  of  the  book, 
Can  we  still  believe?  Dr.  Walsh  brings  a  long  array 
of  eminent  scientists  to  prove  that  the  divorce  be- 
tween science  and  religion  is  three  quarters  imag- 
ination. The  calming  effects  of  prayer  in  disease 
and  health  are  more  powerful  than  is  realized.  An 
old  French  invocation  to  prayer  begins :  "Come,  let 
us  gather  ourselves  together,"  which  exactly  ex- 
presses that  calm  concentration  of  thought  likely  to 
make  the  practice  beneficial.  Fasting  and  abstinence, 
holidays  and  holydays  are  shown  to  have  sound 
medical  backing  for  their  reasonable  usage,  though 
the  author  believes  in  a  more  extensive  abstinence 
from  excessive  rest,  regarding  it  as  a  mischievous 
source  of  selfishness  and  laziness.  The  old  eight 
hour  plan  is  his. 

We  sin  always  when  we  think  too  much 

Of  what  we  think  and  are.    Albeit  our  thoughts 

Be  verily  a:s  bitter  as  selfsacrifice. 

If  we  sleep  on  rocks  or  roses,  sleeping  past  the  hour 

of  noon 
We're  lazy. 

A  sharp  distinction  is  drawn  between  recreation 
and  dissipation,  and  he  deplores  those  who  have  no 
mental  recreation,  but  must  seek  it  all  outside  in 
shows  and  vaudeville  and  dances.  The  pleasures 
of  sense,  unbridled  by  religion,  are  never  held  fully 
in  check  by  mere  commonsense  motives.  He  de- 
precates the  modern  idea  of  sex  teaching  in  schools 
and  public  places.  Young  folk  have  not  been  ter- 
rified by  the  knowledge  of  the  hideous  possible  con- 
sequences of  impurity.  The  temptation  comes  with 
hurtling  force  against  those  who  have  not  been 
grounded  in  faith.  You  cannot  neutralize  sex 
temptations  by  the  provision  of  knowledge  alone. 

The  increase  in  suicide  is  traced  to  the  decrease 
of  attention  to  religion  and  the  absence  of  religious 
training  in  youth.    The  suicides  have  no  courage  to 


face  the  small  trials  which  lead  to  it.  Lessening  of 
the  reverence  for  hutnan  life  and  a  lessening  of  the 
awfulness  of  murder  have  also  increased  homicide. 

The  author  quotes  from  his  own  experience  with 
patients  to  show  how  true  religion  may  dominate 
pain  and  continuous  suffering.  Of  cancer  alone 
scarcely  less  than  a  hundred  thousand  persons  will 
die  of  it  during  the  next  twelve  months  in  this 
country  alone;  over  a  million  and  a  half  throughout 
the  world.  Where  no  religion  is  this  must  only 
mean  just  so  much  pain  to  be  borne  without  any 
good  reason  as  far  as  they  can  see.  He  gives  so 
many  instances  of  work  heroically  done  in  spite  of 
suffering  that  it  almost  seems  as  if  those  enduring 
it  were  called  to  "active  service"  instead  of  in- 
gloriously  abiding  in  barracks. 

The  book  will  deter  irrany  from  suffering  the  will 
of  God,  when,  in  reality,  they  are  yielding  to  their 
own  inclination  in  not  resisting  disease.  Fewer 
persons  will  put  "Thy  Will  Be  Done"  on  tomb- 
stones, because  they  will  realize,  after  listening  to 
Dr.  Walsh,  that  the  Lord  prefers  living,  healthy 
persons  to  diers,  and,  having  realized,  will  brace 
themselves  to  eradicate  all  that  is  unseemly  in  their 
religion  and  health. 

THE  LIGHT  HEART. 

The  Light  Heart.    By  Maurice  Hewlett.    New  York: 
Henry  Holt  &  Co.,  1920.    Pp.  xii-188. 

Maurice  Hewlett  knows  how  to  write  of  men 
and  things  as  they  are.  He  gives  flashing  pictures 
from  human  life  and  its  settings,  or  better  still  he 
has  the  grace  that  lets  such  pictures  speak  for  them- 
selves. There  were  men  of  old  times  whose  lives 
as  they  moved  and  spoke  were  much  like  the  abrupt 
setting  in  which  they  lived.  Hewlett  has  searched 
their  records,  the  tales  of  Iceland  and  the  forbidding 
country  about  it.  He  reads,  as  no  one  who  comes 
close  to  their  literature  can  fail  to  do,  the  direct 
honesty,  clearcut  action,  and  the  play  of  heart 
gripping  love  or  the  impairing  subtlety  of  treachery 
which  passed  over  their  lives.  Though  "the  stark- 
ness  of  their  Sagas  shocks"  this  writer  of  modern 
times  he  is  skillful  in  his  sympathy  in  portraying 
the  high  relief  and  the  softer  shadows  of  these 
people.  They  are  far  .away  in  time  as  they  are 
remote  through  their  difference  in  climate  and  the 
forbidding  circumstances  which  this  brings  with  it. 
No  time  or  space  separates  them  from  us  in  ele- 
ments of  character,  in  the  varying  interplay  of 
the  elements  which  distinguishes  each  individual  so 
clearly  in  these  northern  tales.  There  is  here  in 
The  Light  Heart  a  man  who  is  a  friend  of  man, 
devoted  to  an  ideal  attachment  even  unto  death. 
Thormod  carries  a  light  heart  toward  the  neces- 
sities of  everyday  toil  or  everyday  re.sponsibilities. 
"He  had  the  poet's  way  of  thinking  rather  than 
of  doing,  that  knack  of  working  out  the  ways  of 
a  deed  so  fully  in  the  mind  that  when  the  time 
comes  to  do  it,  it  seems  already  done,  and  done 
with :  wherefore  you  simply  leave  it  undone."  He 
was  equally  indecisive  in  his  affairs  with  women, 
and,  therefore,  took  such  affairs  lightly  and  left 
them  off  without  further  concern,  or  only  that  of 
the  feeblest.  He  could  turn  and  look  back  upon 
him.self  in  a  similar  impersonal  fashion. 


868 


BOOK  REVIEWS. 


[New  York 
Medical  Journal. 


His  devoticn  to  his  'riend,  Thorgar,  had  some- 
thing of  the  same  objectivity.  He  felt  that  he 
loved  him  for  what  he  saw  him  to  be  and  dared 
not  risk  surprising  him  lest  he  should  find  him 
sometime  something  dif¥erent.  But  there  was  a 
steadfastness,  a  seriousness,  in  his  love  for  this 
friend,  and  then  for  the  hero  that  follows  that  means 
his  life  for  them.  There  are  these  two  tales  of 
the  power  of  one  man's  love  which  Hewlett  has 
woven  into  one  continued  story.  Thorgar  is  slain 
and  Thormod,  half  heathen  as  he  was  in  the  dawn 
of  a  Christian  Iceland,  consecrates  himself  to  a 
sweeping  vengeance  in  the  spirit  of  the  sworn 
friendship  they  had  compacted.  This  done,  carried 
out  with  cold  deliberateness  and  unstaying  violence 
in  the  narrow  settlements  of  Greenland,  Thormod 
returns  to  a  newly  found  friend.  King  Olaf.  At 
their  first  meeting  at  King  Olaf's  court,  in  the 
slaughter  of  the  king's  losing  battle,  Thormod's  love 
is  swift,  intuitivel}'  sensitive,  straight  to  its  mark. 
It  renders  simple  uncringing  homage,  and  in  the 
end  can  be  satisfied  only  to  be  with  the  king  also 
in  death. 

The  book  has  not  such  inspiriting  force  as  some 
of  Hewlett's  earlier  reproductions  of  Icelandic 
literature.  But  neither  has  Thormod  the  vigor  of 
character  which  marks  the  Icelander's  restraint  and 
ferocious  unrestraint.  There  is  a  roundabout 
elaborateness  in  the  execution  of  Thormod's  deeds, 
and  in  the  general  light  aloofness  of  his  character. 
A  light  heart,  yet  a  widely  human  one,  and  it  centres 
itself  on  the  type  of  love  which  is  his.  Hewlett 
found  Thormod  the  man,  not  Thormod's  deeds, 
the  theme  of  the  two  tales  woven  here.  Through 
him  modern  literature  is  enriched  •  by  one  more 
representative  human  soul. 

THE  AMERICAN  RED  CROSS  IN  ITALY. 

The  Story  of  the  American  Red  Cross  in  Italy.  By 
Charles  M.  Bakewell.  New  York :  The  Macmillan  Com- 
pany, 1920.   Pp.  viii-2S3. 

The  Armistice  had  been  signed.  The  tricolor  had 
been  planted  on  the  Brenner  in  the  north  and  the 
Julian  Alps  in  the  east.  All  Italian  lands  had  been 
redeemed,  but  new  burdens  had  to  be  carried,  for 
the  prosperous  little  towns  along  the  Piave  were 
heaps  of  ruins.  Along  the  Brenta,  up  through  the 
Val  Sugana  and  the  Val  Lagurina,  desolation,  deso- 
lation. Army  banners  were  furled,  the  fight  was  not 
now  against  alien  foes,  but  against  starvation,  de- 
spair, disease,  and  thousands  of  ill  clad,  hungry 
released  prisoners. 

The  one  unfurled  banner  bore  an  emblem  of 
defeat.  "The  Kingliest  Kings  are  crowned  with 
thorns,"  the  royal  arms  had  been  stretched  on  a 
cross,  yet,  for  four  long  years  they  had  valiantly 
headed  a  fight  unarmed,  but  victoriously,  against 
slaughter  and  hellish  pain,  rapine  and  desolation. 

The  story  of  the  American  Red  Cross,  read  when 
the  Armistice  is  two  years  old.  read  in  the  relative 
quiet  of  a  restless  peace  thrills  with,  its  brimming 
cup  of  misery  its  triumph  when  tears  of  blood 
marred  strong  men's  faces,  when  hatred  and  despair 
were  just  able  to  nerve  shaking  hands  for  one  more 
effort. 

When  the  first  call  came  for  help,  the  American 
Relief  Clearing  House  had  emptied  its  warehouse 


and  treasury.  It  turned  its  offices  over  to  the 
Emergency  Commission,  and  the  Clearing  House 
became  the  agent  of  the  Red  Cross  in  the  Roman 
district,  being  given  at  once  100,000  lire  for  pur- 
chase of  supplies  for  refugees.  One  afternoon 
news  was  received  that  12,000  refugees  would  pass 
through  the  Portonaccio  Station,  the  first  train  ar- 
riving at  six.  Within  an  hour  the  Red  Cross  had 
the  baggage  car  on  the  northbound  Florence  express 
loaded  with  supplies,  and  it  arrived  before  the  first 
refugee  train.  The  Permanent  Commission  of  the 
Red  Cross,  under  Colonel  Perkins,  arrived  in  Rome 
in  December,  1917. 

There  were  only  thirty-two  workers  at  first;  at 
the  end  of  the  war  it  numbered  949  not  including 
the  enrollment  of  Italians,  approximately  one  thou- 
sand more. 

The  book  is  not  written  in  praise  of  America.  It 
is  a  modest  record  penned  for  those  interested,  but 
it  is  wonderfully  lucid,  keeping  a  clear  track  right 
through  the  war,  never  wearying  with  statistics  and 
accounts,  but  giving  stern  facts  and  glances  humor- 
ous and  tender,  of  helpers  and  helped.  One  little 
piece  of  postwar  work  was  the  returning  to  Amer- 
ica (according  to  promise)  of  Italian  American 
citizens  who  went  over  to  serve.  In  November, 
1919,  nearly  four  thousand,  mostly  with  families, 
were  gathered  in  Naples,  waiting  to  embark.  The 
Red  Cross  came  forward  with  funds  to  provide 
extra  clerkage  for  checking  the  passports  and  re- 
lieving the  wants  of  those  necessarily  detained  in 
Naples. 

The  Red  Cross  Army  of  every  nation  sets  out 
this  year  on  a  peace  time  campaign  against  the 
Devil  and  all  his  works,  and  the  Devil  is  a  fine  mili- 
tary tactician.  Perhaps  the  words  of  a  young  Ital- 
ian learning  English  may  aptly  close  this  brief 
review:  "Hurry  for  Uncle  Sam:  Hurry  for  Wil- 
son :  Hurry-  for  Italy  and  our  King." 

 ^  

New  Publications  Received. 


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


THE  DARK  MOTHER.  Bv  W.\LDO  Frank.  New  York : 
Boni  &  Liveright,  1920.   Pp.  376. 

man's  uxcoxscious  passiox.  Bv  Wilfred  Lay,  Ph.  D. 
New  York :  Dodd,  IMead  &  Co.,  1920.    Pp.  246. 

THE  CRESCENT  MOON.  By  F.  Brett  Young.  New  York : 
E.  P.  Button  &  Co.,  Third  Edition,  1920.    Pp.  284. 

THE  HOUSE  OF  LYNCH.  By  LEONARD  Merrick.  With  an 
Introduction  by  G.  K.  Chesterton.  New  York:  E.  P. 
Button  &  Co.    Pp.  324. 

resurrection.  By  Leo  Tolstoy.  Translated  by  Archi- 
bald J.  Wolff.  In  Two  Volumes.  New  York:  Interna- 
tional Book  Publishing  Company,  1920.  Pp.  vol.  i.  Lx-337; 
vol.  ii.  398. ' 

taschenbuch  der  knochen-und  celenktuberkulose 
(Chirurgische  Tuberkulose)  mit  einem  Anhang:  Bie  Tuber- 
kulosc  dcs  Ohres,  des  Auges  und  der  Haut.  Ein  Leitfaden 
fiir  den  praktischen  Arzt.  Von  Br.  H.  Scn\\-ERMANN, 
Facharzt  fiir  Tuberkulose,  Oberarzt  am  Sanatorium 
Schwarzwaldheim  Schomberg-Neuenbiirg.  Mit  10  Abbil- 
dungen  im  Text.  Leipzig:  Verlag  von  Curt  Kabitzsch, 
1920.   Seiten  ISO. 


Practical  Therapeutics  and  Preventive  Med  icine 

A  Compendium  of  Treatment  and  Prophylaxis,  Original  and  Ada  pted 


Intravenous  Hydrogen  Peroxide  in  Influenzal 
Pneumonia. — T.  H.  Oliver  and  D.  V.  Murphy 
(Lancct,  February  21,  1920)  report  an  exceedingly 
severe  epidemic  of  influenza  among  the  Indian 
troops  in  Busrah  where  the  mortality  in  the  toxic 
bronchopneumonia  cases  was  eighty  per  cent.  So 
hopeless  were  all  of  the  accepted  methods  of  treat- 
ment that  they  felt  justified  in  trying  intravenous 
hydrogen  peroxide  to  combat  in  a  measure  the  anox- 
emia and  theoretically  to  attack  the  toxemia  by 
means  of  the  nascent  oxygen  liberated.  Two 
ounces  of  ozone  in  eight  ounces  of  water 
were  injected  into  the  veins  during  the  course  of 
fifteen  minutes,  with  stops  of  half  a  minute  in  every 
four.  The  danger  of  gas  embolism  was  appreciated, 
hence  the  long  duration  of  the  infusion.  Also  the 
infusion  was  watched  very  closely  at  the  cannula 
and  when  a  large  bubble  was  seen  the  rate  of  infu- 
sion was  greatly  reduced.  The  method  was  used  on 
twenty-five  patients,  all  of  whom  were  in  extremis. 
Thirteen  recovered  and  twelve  died.  Of  these 
twelve,  nine  showed  no  visible  change  either  for  the 
better  or  the  worse,  while  three  improved  tempo- 
rarily. One  patient  only  died  within  five  hours  of 
the  infusion,  in  a  rigor.  Of  the  thirteen  recoveries, 
ten  patients  were  delirious  at  the  time  of  the  infu- 
sion and  three  were  comatose.  In  these  patients  the 
average  respiration  before  was  46,  and  twenty-four 
hours  after  infusion  it  was  31.5.  The  average  pulse 
was  118  before  and  98  twenty-four  hours  later. 
The  average-  temperature  was  from  101-103  and  in 
all  save  one  instance  the  injection  was  followed  by 
a  rigor,  after  which — except  in  two  cases — the  tem- 
perature fell  to  normal.  The  afebrile  period  lasted 
eighteen  to  thirty-six  hours  when  the  temperature 
rose  to  99-101  and  fell  by  lysis  in  four  to  seven 
days. 

Certain  Points  in  the  Diagnosis  and  Treatment 
of  Pulmonary  Tuberculosis. — Lawrason  Brown 
(American  Journal  of  the  Medical  Sciences,  Sep- 
tember, 1920)  asserts  that  not  every  patient  in 
whom  a  diagnosis  of  pulmonary  tuberculosis  can  be 
made  needs  vigorous  treatment.  It  was  an  attempt 
to  discover  a  simple  method  that  any  practitioner 
could  use  in  his  office  that  led  to  the  study  of  active 
and  inactive  cases,  but  no  simple  method  was  found. 
He  believes  that  in  considering  the  need  for  treat- 
ment, symptoms  vastly  outweigh  physical  findings 
in  the  majority  of  cases.  Tubercle  bacilli  can  oc- 
cur in  a  perfectly  quiescent  case,  where  it  is  only 
necessary  for  the  patient  to  lead  a  quiet  life,  but 
when  the  bacilli  are  found  in  a  patient  who  has 
recently  begun  to  show  symptoms,  vigorous  treat- 
ment is  demanded.  Rales  can  persist  for  years  in 
arrested  cases.  The  x  ray  helps  greatly  in  revealing 
changes  that  occur  from  time  to  time,  but  an  in- 
crease of  X  ray  shadows  may  occur  months  before 
the  last  plate  has  been  taken,  and  at  that  time  the 
disease  may  have  been  arrested.  Any  patient  with 
unexplained  pleurisy  with  effusion  needs  treatment 
for  pulmonary  tuberculosis,  unless  a  parenchymat- 


ous lesion  in  the  lungs  can  be  definitely  excluded, 
and  even  then  he  inclines  to  the  side  of  caution,  for 
a  slight  deposit  may  be  lost  in  the  cloudiness  that 
obscures  that  part  of  the  plate.  An  inexplicable 
hemoptysis  should  be  similarly  treated.  Suspected 
pulmonary  tuberculosis  he  treats  by  rapidly  increas- 
ing the  patient's  exercise  to  the  unlimited  stage,  and 
after  about  three  months,  if  all  has  gone  well,  re- 
turn him  to  his  work.  Dr.  Brown  believes  that  after 
a  careful  study  the  patient  can  be  taken  into  confi- 
dence and  told  the  possibilities  frankly. 

Glucose  as  an  Adjunct  Measure  in  the  Treat- 
ment of  Pneumonia. — Henry  J.  John  (American 
Journal  of  the  Medical  Sciences,  October,  1920) 
comes  to  the  following  conclusions:  1.  The  ad- 
ministration of  glucose  is  without  danger  pro- 
vided any  reasonable  care  is  used.  In  the  twelve 
hundred  administrations  not  a  single  accident 
occurred.  The  patient  is  made  comfortable 
and'  sleep  is  provided  for  him.  Through  this 
the  whole  organism  is  strengthened  for  the  pro- 
longed fight  against  the  infection.  3.  The  tempera- 
ture is  lowered.  4.  Nutrition  is  provided  for  the 
overtaxed  heart  muscle  without  having  to  go 
through  the  ordinary  digestive  processes,  storage  in 
the  liver  as  glycogen  and  reconversion  into  glucose 
again  before  it  can  be  burned  by  the  tissues.  One 
hundred  to  three  hundred  calories  are  thus  supplied 
to  the  body  in  each  dose.  5.  A  considerable  amount 
of  fluid  is  provided  for  the  circulation.  This,  to- 
gether with  the  preceding,  slows  the  heart,  thus 
producing  artificial  rest.  6.  The  elimination  through 
kidneys  and  skin  is  increased.  7.  Practically  all  the 
medication  can  be  supplied  in  the  glucose,  thus  a 
much  more  accurate  dosage  can  be  depended  on. 

8.  The  antipneumococcic  serum  type  I  or  the  anti- 
streptococcic serum,  the  antitetanic  serum,  can  be 
administered  in  this  glucose  medium.  This  is  far 
superior  to  saline,  for  glucose  will  do  much  more 
than  saline,  thus  being  a  much  more  rational  medium 
to  use  as  a  diluent  for  any  intravenous  medication. 

9.  The  use  of  glucose  is  strictly  a  physiological 
measure  and  is  to  be  used  as  such. 

Therapeutic  Tracheal  Fistula  in  Laryngeal 
Tuberculosis.— G.  Rosenthal  (Paris  medical,  April 
17,  1920),  in  cases  in  which  the  initial  examination 
of  the  larynx  already  reveals  large  ulcerations,  loss 
of  epiglottic  tissue,  and  grape  seed  points  of  edema 
on  the  arytenoids,  already  threatening  closure  of 
the  larynx,  performs  tracheotomy  in  order  to  resr 
the  larynx.  Injection  of  oil  containing  gomenol 
and  guaiacol  or  iodoform  three  times  daily  through 
the  cannula  is  at  once  instituted.  Large  amounts 
are  given,  either  with  the  syringe — twenty  mils — 
or  by  the  author's  "drop"  procedure — twenty  to 
fifty  mils.  Two  or  three  syringefuls  of  a  one  in 
200  solution  of  French  novocaine  are  introduced 
beforehand  to  anesthetize  the  parts.  As  soon  as 
rest  has  led  to  some  regression  of  the  laryngeal 
lesions,  the  necessary  surgical  measures  are  carried 


870 


PRACTICAL  THERAPEUTICS  AND  PREVENTIVE  MEDICINE. 


[New  York 
Medical  Journal. 


out  by  direct  laryngoscopy  to  destroy  completely  the 
local  tuberculous  process.  The  ordinary  cannula  is 
then  replaced  by  the  author's  cannula  for  therapeu- 
tic tracheal  fistula,  which  is  shaped  like  the  adult's 
cannula  but  has  the  calibre  of  that  used  for 
tracheotomy  in  a  child.  The  oily  injections  are 
continued  through  this  small  cannula,  and  also 
through  the  third  one,  subsequently  used,  which 
measures  only  three  millimetres  in  external  diame- 
ter. Later,  if  improvement  continues,  a  two  milli- 
metre cannula  is  substituted,  and  the  injections  are 
given  by  the  natural  route,  i.  e.,  by  way  of  the 
mouth.  In  cases  not  so  advanced  as  to  demand 
ordinary  tracheotomy,  though  too  far  advanced  for 
the  ultraviolet  rays  and  chemical  or  galvanic  cau- 
terization, a  small  tracheal  fistula  cannula  is  first 
inserted,  and  larger  cannulas  later  inserted  if  neces- 
sary, before  resorting  to  the  actual,  mutilating 
tracheotomy.  The  needle  used  to  prepare  the  way 
for  the  small  cannula  is  curved  and  measures  six 
to  seven  tenths  of  a  millimetre  in  diameter..  It  is 
introduced  through  the  cricothyroid  space,  but  fails 
to  injure  the  posterior  tracheal  wall,  as  do  the 
straight  needles  rather  recently  recommended.  The 
two  or  three  millimetre  cannula,  coupled  with  the 
pulmonary  "drop"  instillations,  may  suffice  to  arrest 
the  expectoration.  Later,  if  required,  the  larger 
tube  may  be  used,  though  without  causing  closure 
of  the  upper  respiratory  route.  By  this  general 
method  the  need  for  ordinary  tracheotomy  is  re- 
stricted to  the  most  severe  cases. 

Action  of  Rare  Earth  Salts  of  the  Cerium 
Group  in  Experimental  Tuberculosis. — Albert 
Frouin  (Bulletin  dc  rAcademie  de  medecine,  June 
15,  1920)  injected  sulphates  of  lanthanum,  neodym- 
ium,  praseodymium,  and  samarium  intraperitoneally 
in  fifty  animals,  beginning  seven  days  after  inocu- 
lation with  tubercle  bacilli  and  repeated  twice 
weekly  and  later  once  weekly.  In  guineapigs  0.2 
mil  of  a  one  per  cent,  solution  of  the  salts  was  the 
amount  injected.  These  animals  lived  an  average 
of  sixty-three  days  longer  than  the  ten  controls  not 
receiving  salt  injections.  In  a  second  series  of  thirty 
guineapigs  those  receiving  the  salts  lived  an  aver- 
age of  forty-five  days  longer  than  the  ten  controls. 
Rabbits  were  inoculated  in  the  marginal  ear  vein 
with  a  suspension  of  bovine  bacilli,  and  six  hours 
later  ten  of  them  were  given  0.5  mil  of  the  one  per 
cent,  solution  of  salts  intravenously ;  0.25  mil  was 
administered  twice  weekly  thereafter.  Three  rab- 
bits died  before  the  two  controls,  but  the  other  seven 
lived  three  to  five  months  longer  than  the  controls. 
In  many  of  the  guineanigs  there  was  found  in  ad- 
dition to  extensive  tuberculous  lesions,  an  adhesive 
peritonitis  uniting  all  the  abdominal  viscera  and  the 
abdominal  wall  with  sheets  of  connective  tissue. 
The  omentum  appeared  as  a  fibrous  cord.  In  other 
animals,  with  less  extensive  adhesions,  a  more  or 
less  ])ronounced  fibrosis  of  the  lymphnodes,  omen- 
tum, and  the  liver  was  observed.  This  connective 
tissue  reaction  is  looked  upon  as  a  defensive  process 
similar  to  that  met  with  in  old,  latent  tuberculous 
foci  which  are  being  recovered  from.  A  connective 
tissue  in  the  lungs  was  similarly  met  with  in  rabbits 
that  had  lived  four  or  more  months  after  tubercle 
inoculation  in  the  blood  stream. 


Heat  Hyperpyrexia.— W.  H.  Willcox  {Lancet, 
March  20,  1920)  discusses  his  observations  on  this 
condition  as  it  existed  among  the  troops  in  Mesopo- 
tamia. Regarding  etiology,  the  chief  factors  were 
a  temperature  of  over  110°  F.  in  the  shade,  lasting 
over  several  days  with  a  stagnation  of  the  air.  No 
age  is  peculiarly  susceptible  to  the  condition  but 
the  mortality  is  higher  in  men  over  forty.  Predis- 
posing causes  are  exertion  during  the  heat  of  the 
day  and  any  infectious  disease  which  normally 
raises  the  temperature  of  the  patient.  The  types  of 
illness  into  which  the  cases  were  classified  are:  1, 
]\lild  heat  exhaustion;  2,  gastric  type  where  the 
patient  had  a  flushed  face,  was  restless  and  irritable 
with  nausea  and  occasionally  vomiting  and  where 
the  temperature  was  only  slightly  elevated;  3,  gas- 
trointestinal type  with  sudden  onset  and  collapse, 
nausea,  vomiting  and  diarrhea,  and  often  with 
cramps  in  the  legs  and  abdomen ;  and  4,  heat  hyper- 
pyrexia with  sudden  rise  in  temperature  and  loss 
of  consciousness  and  finally  death  after  convulsions. 
The  onset  and  course  varied  greatly  and  all  sorts 
of  peculiar  symptoms  were  noted.  Among  the 
more  constant  findings  were  a  marked  cardiac  dila- 
tation with  a  systolic  murmur  lasting  several  weeks, 
an  excess  of  indican  in  the  urine,  and  a  very  fre- 
quent loss  of  the  knee  jerks  in  the  more  severe  cases. 
Acetone  and  diacetic  were  found  in  the  urine  in 
only  a  few  cases.  The  treatment  of  the  gastric  types 
consisted  in  removal  of  the  patient  to  a  cool  atmo- 
sphere, bicarbonate  of  soda  in  full  doses  by  mouth, 
and  free  purgation.  Heat  hyperpyrexia  demands 
treatment  with  sprays  of  ice  cold  water,  fans,  and 
quinine  hydrochloride  intravenously  or  intramuscu- 
larly if  there  is  the  slightest  suspicion  of  malaria. 
Convulsions  are  treated  by  venesection  morphine  or 
chloroform  inhalations. 

Influenza  as  an  Etiological  Factor  in  Nephritis. 

— W.  W.  D.  Thomson  and  H.  F.  Macauley  {Lancet, 
February  28,  1920)  report  four  cases  of  nephritis 
in  the  children  of  one  family,  manifesting  itself 
about  three  weeks  after  an  attack  of  influenza  in 
each  instance.  The  condition  was  characterized  by 
an  edema  and  albuminuria  of  varying  severity,  the 
presence  of  epithelial  and  blood  casts  with  erythro- 
C}tes  and  leucocytes  in  the  urine,  and  by  a  favorable 
course  with  recovery.  The  literature  on  the  sub- 
ject is  extensively  siimmarized  and  the  following 
conclusions  are  drawn :  1 .  Nephritis  is  a  more  com- 
mon complication  of  influenza  than  is  generally 
supposed.  2.  The  virus  may  affect  the  kidneys  in 
various  ways :  a,  producing  a  transient  albuminuria ; 
b,  causing  an  acute  nephritis  during  the  course  of 
the  disease ;  c,  resulting  in  an  acute  nephritis  during 
the  coui-se  of  convalescence ;  d,  lighting  up  a  latent 
nephritis.  3.  Nephritis  may  follow  even  a  mild  at- 
tack of  influenza.  4.  The  nephritis  may  be  such  a 
slight  and  transient  affair  and  the  symptoms  of  the 
influenza  §o  pronoimced  that  the  diagnosis  will  not 
be  made  unless  a  careful  routine  examination  of  the 
urine  is  done.  5.  Probably  the  frequency  and  se- 
verity of  the  complication  varies  in  different  epi- 
demics and  in  different  localities.  6.  The  examiners 
of  applicants  for  -life  insurance  may  expect  to  find 
a  higher  proportion  of  albuminuria  than  in  normal 
times. 


November  27,  1920.]  PRACTICAL  THERAPEUTICS 


AND  PREVENTIVE  MEDICINE. 


871 


Radium  Treatment  of  X  Ray  Epithelioma. — 

P.  Degrais  and  A.  Bellot  (Presse  medicale,  June  5, 
1920)  report  three  cases  in  which  epithelioma  or 
obstinate  ulcerations  due  to  orofessional  x  ray  ex- 
posures were  successfully  cured  with  radium.  Such 
results  will  enable  those  called  upon  to  treat  cases 
of  this  type  to  dispense  with  amputation  of  the 
affected  extremity  in  the  future.  In  one  of  the 
cases  reported  by  the  authors  three  excision  opera- 
tions had  already  been  performed  and  been  followed 
by  recurrence.  The  ulcers  soon  healed  under  radi- 
um, and  the  accompanying  severe  pain  was  wholly 
relieved.  Hyperkeratosis  due  to  the  x  rays  likewise 
yielded  to  radium,  used  in  the  same  manner  as  for 
the  treatment  of  warts. 

A  Study  of  the  Relative  Toxic  Effects  Pro- 
duced by  Regional  Radiation.— W.  Denis  and 
Charles  L.  Martin  {American  Journal  of  the  Medi- 
cal Sciences,  October,  1920  )  thus  summarize  their 
paper :  1 .  A  definite  massive  dose  of  x  rays  admin- 
istered to  the  body  of  a  rabbit  produces  a  severe 
systemic  reaction  and  death  only  when  some  portion 
of  the  intestinal  tract  lies  within  the  irradiated  area. 
2.  It  is  possible  to  produce  a  definite  acidosis  (lower- 
ing of  the  alkaline  reserve)  in  rabbits  by  adminis- 
tering a  heavy  dose  of  x  rays  over  the  abdomen. 
Such  animals  give  no  evidence  of  suffering  from  a 
rontgen  ray  nephritis.  3.  The  results  suggest  the 
hypothesis  that  acidosis  may  be  a  factor  in  treat- 
ment sickness  following  abdominal  irradiation. 

Treatment  of  Penetrating  Injuries  of  the  Eye- 
ball.— H.  H.  Roth  {International  Journal  of  Sur- 
gery, September,  1920)  gives  the  following  conclu- 
sions for  the  conservative  treatment  of  penetrating 
injuries  of  the  eyeball:  1.  Radiographic  examina- 
tions should  be  made  in  every  case  of  ocular  injury 
from  any  penetrating  substance,  especially  where 
lowered  visual  acuity  is  the  result  of  the  accident. 
2.  The  use  of  the  conjunctival  flap  in  penetrating 
injuries  of  the  cornea  and  sclera  is  our  greatest  aid 
in  preventing  infection  and  prolapse  of  the  internal 
structures  of  the  eye.  3.  Hexamethylenetetramine 
is  a  remedy  to  be  used  in  all  injuries  involving  the 
.  opening  of  the  eyeball  in  order  to  prevent  and  com- 
bat infection,  and  it  can  be  given  freely  and  over 
an  extended  period  of  tim.e,  and  in  only  a  few  cases 
does  it  produce  renal  symptoms. 

The  Bone  Flap  in  Cranial  Surgery. — Harvey 
C.  Masland  {Annals  of  Surgery,  October,  1920) 
gives  the  following  summary  of  the  operation  he 
uses  for  cutting  the  bone  flap  in  cranial  surgery : 
The  preliminary  openings,  usually  but  two,  are 
small.  The  relations  of  the  power  and  of  the  con- 
struction of  the  trephine  to  the  skull  opening  are 
so  adjusted  that  the  trephine  must  jam  before  pene- 
trating the  dura.  If  the  preliminary  saw  cut 
through  the  outer  table  is  used  the  guard  is  imme- 
diately adjustable  to  the  depth  desired.  The  inside 
guard  is  of  a  shape  ro  secure  easy  separation  of  the 
dura,  and  there  is  fine  tactile  sense  of  its  efficiency 
in  this  respect.  .  There  is  no  burning  of  the  bone 
and  so  the  vitality  of  the  exposed  osteoblasts  is 
preserved.  There  is  bone  support  for  the  replaced 
bone  flap.  If  a  greater  provision  for  internal  pres- 
sure is  desired  the  bone  flap  can  be  variously  sec- 
tioned in  vital  fragments  to  gain  the  desired  end. 


X  Ray  Treatment  of  Universal  Psoriasis. — ■ 

John  Remer  and  W.  D.  Witherbee  {Medical  Rec- 
ord, August  28,  1920)  report  approximately  one 
hundred  cases  successfully  treated  in  the  past  year 
by  this  method.  They  are  convinced  that  it  is  the 
simplest  and  most  satisfactory  method  of  treating 
this  disease.  The  x  ray  exposures  are  preferably 
given  three  times  a  week,  allowing  a  day  between 
each  two  exposures.  For  the  first  treatment,  the 
head  and  arms  are  exposed,  in  the  second  treatment 
the  trunk  and  buttocks ;  in  the  third,  the  legs  and 
thighs.  The  treatment  is  concluded  in  from  four 
to  eight  weeks,  depending  on  the  severity  of  the  case. 

Preoperative  Treatment  of  Diabetic  Patients. 
— Max  Kahn  {Surgery,  Gynecology  and  Obstetrics. 
October,  1920)  gives  the  following  rules  for  pre- 
operative treatment  of  diabetes:  1.  Keep  the  bowels 
open,  preferably  by  enemata,  in  order  to  avoid  diar- 
rhoea and  the  consequent  drainage  of  alkaline  salts 
from  the  body.  2.  Administer  fluids  .in  liberal 
amounts — a  glass  of  liquid  every  hour  or  hour  and 
a  half.  3.  Increase  the  tolerance  for  carbohydrates. 
4.  Avoid  substances  that  induce  the  formation  of 
the  acids — such  as  fats,  and  sometimes  proteins.  5. 
Administer  substances  which  favor  the  combustion 
of  the  ketones,  as  for  example,  oatmeal,  levulose, 
alcohol,  etc.    6.  Do  not  prescribe  alkalies. 

Advantages  of  Extension  in  Diseased  Joints. — 
W.  A.  Lane  {Lancet,  March  22,  1920)  records  his 
conversion  to  the  use  of  traction  instead  of  fixation 
in  the  treatment  of  diseased  articular  surfaces.  The 
reason  why  the  method  is  so  useful  is  that  trac- 
tion permits  of  so  little  friction  between  the  sur- 
faces that  only  a  mild  transient  inflammation  is  set 
up  when  the  joint  is  moved  instead  of  the  severe 
inflammation  which  results  from  the  bruising  of 
surfaces  which  are  not  held  apart  by  traction.  Then 
too  such  a  procedure  tends  to  furnish  the  joint  with 
a  more  free  blood  supply  than  is  otherwise  the  case 
and  the  muscles  are  allowed  to  function  normally. 

Combined  Intramuscular  and  Subcutaneous 
Antitoxin  Administration  in  Diphtheria. — P.  F. 
Armand-Delille  {Bulletins  et  memoir es  de  la  So- 
ciete  medicale  des  hopitaux  de  Paris,  March  18, 
1920)  comments  on  the  rapidity  of  absorption  of 
antitoxin  when  it  is  administered  intramuscularly, 
the  use  of  this  route  constituting  a  definite  step  for- 
ward in  diphtheria  treatment.  Since,  however,  se- 
rum thus  given  is  rapidly  eliminated,  late  symptoms 
such  as  paralyses  developing  where  this  method  is 
used  alone,  it  should  be  supplemented  next  day  by 
another  dose  given  subcutaneously  in  order  to  keep 
up  the  efifect.  The  author's  present  routine  procedure 
in  cases  of  average  severity  in  children  three  to  ten 
years  of  age  is  to  give  thirty  to  forty  mils  of  serum 
intramuscularly  at  once,  and  on  the  next  day  forty 
mils  subcutaneously.  This  dose  may  be  increased 
in  the  event  of  toxic  or  malignant  angina  with  ex- 
tensive and  extending  membranes.  If,  on  the  third 
day,  there  is  still  a  membrane,  leading  to  the  suspi- 
cion that  toxin  is  still  being  formed  owing  to  insuf- 
ficient neutralization  by  the  earlier  injection,  a  third 
subcutaneous  injection  of  thirty  to  sixty  mils  is 
given.  In  croup  the  speed  of  action  of  the  intra- 
muscular dose  is  plainly  manifest,  but  the  added 
subcutaneous  dose  should  nevertheless  be  given. 


Miscellany  from  Home  and  Foreign  Journals 


Clinical  Diagnosis  of  Diphtheria. — H.  Drink- 
water  (Lancet,  May  29,  1920)  reaffirms  the  neces- 
sity of  early  diagnosis  in  diphtheria  and  gives  sev- 
eral clear  directions  for  the  accurate  clinical  diag- 
nosis of  the  condition  with  points  of  differentiation 
from  follicular  tonsillitis  and  Vincent's  angina. 
He  divides  the  fauces  into  six  areas,  three  on  either 
side,  the  tonsillar,  the  uvular  and  the  palatal  areas. 
Every  area  may  show  some  deposit  and  in  any  area 
there  may  be  one  or  more  patches.  In  diphtheria 
the  deposit  in  any  one  area  is  always  single  though 
there  may  be  several  patches  on  the  fauces.  The 
same  is  true  in  Vincent's  angina.  In  follicular  ton- 
sillitis there  are  several  patches  on  the  tonsils  and 
the  same  is  found  in  influenza.  The  characteristics 
of  the  diphtheritic  patch  are  three.  1.  It  is  raised 
above  the  level  of  the  mucous  membrane.  2.  The 
edges  are  sharply  defined  all  around.  3.  The  color 
varies  greatly  from  glistening  white  to  bluish  or 
yellowish  with  patches  of  black  or  red.  Vincent's 
angina  is  the  most  difficult  to  differentiate  from 
diphtheria  and  in  some  cases  it  is  impossible  to 
make  the  differentiation  without  microscopic  and 
cultural  methods.  But  there,  are  several  character- 
istics which  when  present  serve  to  make  the  diag- 
nosis. When  the  fauces  show  a  sharply  defined 
vertically  directed  ulcer  in  which  the  membrane 
extends  scarcely  beyond  the  edges  of  the  ulcer  the 
diagnosis  is  clinically  Vincent's.  Also  when  the 
lower  edge  of  the  membrane  is  thinned  out  and  the 
border  is  ill  defined,  a  diagnosis  of  Vincent's  should 
be  made.  In  follicular  tonsillitis  and  influenza  the 
multiple  patches  in  the  various  areas  rule  out  the" 
diagnosis  of  diphtheria. 

Abscess  of  the  Liver.— A.  L.  Candler  (Lancet, 
February  21,  1920)  discusses  his  experience  with 
liver  abscess  in  the  British  general  hospitals  of 
Mesopotamia.  Entamceba  histolytica  was  the  cause 
of  the  condition  but  in  the  series  of  three  cases  of 
hepatitis  and -thirteen  of  abscess,  a  history  of  diar- 
rhea was  obtainable  in  only  three  instances.  Of  the 
two  fatal  cases  the  bowel  at  postmortem  showed 
only  one  small  healing  ulcer  in  the  ascending  colon 
in  one  instance  and  no  abnormality  at  all  in  the 
other.  Also  in  the  stools  of  twelve  of  the  series 
amebae  were  found  in  only  three.  Hence  the  con- 
clusion is  made  that  probably  in  the  amebic  dysen- 
tery cases  so  slight  in  bowel  involvement  that  the 
diagnosis  is  impossible,  hepatic  abscess  is  much 
more  likely  to  develop  than  in  the  clear  cut  cases 
which  are  diagnosed  early  and  the  patients  given 
a  thorough  course  of  treatment.  Liver  abscess  does 
not  give  a  clear  cut  clinical  picture  as  there  are  wide 
variations  in  temperature,  pulse,  respiration  and 
leucocytosis,  though  all  are  often  moderately  raised. 
Tenderness  or  tumor  can  usually  be  made  out  when 
the  process  is  on  the  anterior  surface  below  the 
costal  margin.  In  the  usual  .subdiaphragmatic  loca- 
tion, however,  the  signs  are  less  characteristic. 
Enlarged  liver,  raised  upper  border  of  dullness, 
bulging  of  diaphragm  as  shown  by  x  ray,  and  raised 
arch  of  dullness  under  the  axilla  must  suggest  the 


condition  strongly.  The  diagnosis,  however,  is 
made  by  obtaining  pus  through  a  needle,  if  possible, 
or  by  laparotomy,  if  necessary.  Treatment  consists 
in  opening  and  draining  the  wound,  irrigating  it 
with  a  solution  of  ten  grains  of  quinine  to  the  ounce 
and  keeping  both  the  wound  and  the  cavity  sterile 
by  careful  dressing.  Withdrawal  of  the  drainage 
tubes  at  the  earliest  possible  moment  lessens  the 
likelihood  of  infecting  the  wound  and  so  hastens 
the  healing  process.  Hypodermic  injections  of  one 
grain  of  emetine  hydrochloride  daily  for  ten  days 
must  be  given  as  general  treatment  and,  after  a  rest, 
repeated  if  necessary. 

The  Thymus  as  an  Endocrine  Organ. — A.  P. 
Dustin  (Presse  medicale,  June  5,  1920)  asserts  that 
the  hitherto  accredited  theory  that  the  small  thymic 
cells  are  true  lymphocytes  and  the  Hassall  bodies 
epithelial  derivates  with  an  endocrine  function  can 
no  longer  be  considered  valid.  The  only  really 
functionating  cell  is  the  small  thymic  cell,  which  re- 
sembles a  lymphocyte  but  is  actually  derived  by  a 
strictly  special  process  from  the  primordial  epi- 
thelium of  the  thymus.  The  main  function  of  the 
organ  is  division  of  these  small  cells  by  karyokinesis 
and  disappearance  of  the  cells  by  pyknosis.  nuclein 
derivatives  being  set  free  in  the  system.  This  lib- 
eration of  nuclein  material  by  the  thymus  is  strongly 
influenced,  if  not  initiated,  by  the  thyroid  gland. 
The  thymus  thus  acts  as  a  regulator  and  dissem- 
inator of  nucleins  and  their  derivatives  in  the 
organism.  Important  applications  of  these  facts 
may  be  made  in  morbid  conditions  of  the  thymus, 
lymphoid  formations,  tumors,  and  in  the  biochem- 
ical disturbances  of  nucleinic  metabolism.  The 
organ  does  not  operate,  as  would  a  gland,  through 
a  secretion,  but  by  fixation  of  substances  of  the 
nucleoproteid  group  in  the  condition  of  actual 
formed  elements  or  cells. 

Clinical  Diagnosis  of  Typhus  Fever. — J.  Rieux 
(Paris  medical,  June  5,  1920)  summarizes  the  • 
earlier  clinical  manifestations  of  typhus  fever  as 
follows:  Any  patient  who,  after  being  taken  ill 
rather  suddenly — i.  e.,  who  can  tell  on  what  day 
he  became  ill — without  any  definite  localization  of 
the  disease,  shows  a  progressively  rising  and  later 
constant  febrile  temperature,  marked  headache  with 
unpleasant  dreams,  severe  pro.stration,  a  pulse  rate 
of  100  to  120  a  minute,  always  proportionate  to 
the  temperature,  and  injection  of  the  conjunctivae, 
without  any  abdominal  or  pulmonary  symptoms, 
should  be  looked  upon  as  a  typhus  suspect.  The 
suspicion  is  confirmed  when  the  typhus  eruption  ap- 
pears, about  the  fourth  or  fifth  day.  The  differen- 
tiation from  typhoid  fever  rests  mainly  upon  the 
mode  of  onset,  the  lack  of  agreement  between  the 
pulse  and  temperature  in  typhoid  fever,  the  pres- 
ence of  intestinal  and  pulmonary  symptoms  in  the 
latter  affection,  and  the  presence  of  conjunctival 
injection  in  typhus.  Extraneous  factors  of  diag- 
nostic import  include  the  epidemicity  of  the  disease, 
which  is  a  cold  weather  affection  and  occurs  in 
massive  but  dragging  epidemics,  similar  to  epi- 


November  27,  1920.]  MISCELLANY  FROM  HOME    AND  FOREIGN  JOURNALS. 


875 


demies  of  measles  or  mumps.  Transmission  of 
the  disease  by  lice  is  also  an  established  fact  of 
possible  diagnostic  significance,  though  some  phy- 
sicians, orderlies,  and  especially  nurses  contracting 
the  disease  have  asserted  that  they  did  not  harbor 
any  of  these  parasites.  The  Weil-Felix  reaction 
is  an  accepted  laboratory-  test,  but  is  not  available 
until  the  end  of  the  first  week.  Negative  results 
of  blood  cultures  and  examinations  for  malarial 
organisms  and  the  spirillum  of  Obermeier  are 
thus  of  greater  significance  early  in  the  disease. 

A  Study  of  the  Blood  after  Splenectomy,  with 
Special  Reference  to  the  Leucocytes. — ]\Iilton  W. 
Hall  (American  Journal  of  the  Medical  Sciences, 
July,  1920)  thus  summarizes  the  results  of  his  ob- 
servations: The  removal  of  the  spleen  resulted  in 
a  considerable  increase  in  the  total  leucocyte  count 
which  persisted  with  much  irregularity  for  over 
three  months.  In  the  early  period  all  types  of 
white  cells  were  increased  in  nearly  the  same  pro- 
portion, although  a  slight  increase  of  endothelial 
cells  was  noted  at  the  expense  of  the  lymphocytes. 
In  the  intermediate  period  both  total  and  dififeren- 
tial  count  showed  such  marked  variation  as  to  ren- 
der averages  valueless,  but  the  total  count  usually 
was  high.  In  the  final  period  a  comparative  equili- 
brium was  reached,  with  a  moderate  increase  in  the 
total  count,  due  entirely  to  lymphocytes  and  endo- 
thelial cells,  while  the  granular  leucocytes  showed 
strictly  normal  figures.  The  endothelial  cells  were 
constantly  increased  both  relatively  and  absolutely. 
The  observations  in  the  Arneth  index  suggest  that 
the  increase  in  the  count  is  at  least  in  part  due  to 
the  removal  of  some  factor  restricting  the  produc- 
tion of  white  cells.  No  eosinophilia  appeared  dur- 
ing the  course  of  the  work. 

Effects  of  Occupation  and  Race  on  the  Health 
of  Recruits. — G.  R.  Hall  {Lancet,  June  5,  1920) 
compiles  statistics  made  rvailable  by  the  wholesale 
examinations  of  British  recruits.  An  examination  of 
2,500  men  suffering  from  heart  dise^.se  revealed  the 
fact  that  only  forty  per  cent,  suff'ered  from  valvu- 
lar disease  of  the  heart,  while  in  the  rest  illness  was 
due  to  want  of  tone  or  to  other  minor,  and  nearly 
all  curable,  conditions.  Apparently  there  were  two 
cardiac  cases  among  the  dark  recruits  to  one  among 
the  light.  In  8,000  men,  the  feet  were  defective 
in  23.8  per  cent,  of  cases,  flatfoot  being  the  usual 
fault.  The  teeth  were  bad,  in  a  state  to  affect 
health,  in  42.5  per  cent,  of  the  8,000 ;  14.6  per  cent, 
also  showed  defects  of  the  genitalia  but  varicocele 
was  the  chief  defect,  comprising  eighty  per  cent,  of 
the  cases.  Of  20,141  recruits,  6.2  per  cent,  were 
referred  to  the  ophthalmic  surgeon,  and  2.5  per 
cent,  of  these  men  were  rejected.  As  to  racial 
effects  on  the  health  of  the  individuals,  it  was  found 
that  among  the  Russian  Jews  there  was  a  definitely 
higher  incidence  of  various  diseases  and  defects 
than  among  the  British  men  in  all  cases  except  in 
valvular  disease  of  the  heart  where  the  incidence  was 
distinctly  higher  among  the  British.  It  was  also 
found  that  the  young  Jews  who  had  been  brought  up 
in  England  were  approxirnately  as  healthy  as  the 
British  youths,  indicating  that  the  Russian  Jew  is 
not  racially  defective  but  that  he  has  suffered  from 
his  environment. 


Delayed  Symptoms  in  Fracture  of  Vertebral 
Bodies.^ — Robert  H.  Baker  (Surgery,  Gynecology 
and  Obstetrics,  October,  1920)  in  a  discussion  of 
Kiimmel's  disease  presents  the  following  conclu- 
sions: 1.  Compression  fracture  of  the  spinal  bodies 
without  cord  symptoms  is  frequehtly  undiagnosed, 
or  incorrectly  diagnosed  at  the  time  of  injury.  2. 
A  negative  finding"  by  the  x  ray  at  the  period  of 
initial  injury  is  not  proof  positive  against  fracture. 
3.  Symptoms  referable  to  the  fracture  may  not  oc- 
cur for  some  time  after  injury.  4.  At  this  later 
period  the  signs  and  x  ray  findings  are  all  in  keep- 
ing with  a  diagnosis  of  compression  fracture  oi  the 
spinal  bodies.  5.  The  exact  sequence  in  the  pathol- 
ogy leading  to  such  a  diagnosis  is  not  understood. 
6.  The  prognosis  will  depend  on  the  time  of  diag- 
nosis and  the  institution  of  proper  treatment.  7. 
The  treatment  is  that  of  compression  fracture  of 
the  spine. 

Involvement  of  the  Auricle  and  Conduction 
Pathways  of  the  Heart  Following  Influenza. — 

Walter  W.  Hamburger  (American  Journal  of  the 
Medical  Sciences,  October,  1920)  reports  six  cases 
of  postinfluenzal  myocardial  involvement,  in  which 
the  auricle  and  conduction  pathways  of  the  heart 
were  particularly  affected.  From  a  study  of  the 
literature,  together  with  clinical  and  electrocardio- 
graphic studies,  he  offers  the  following  grouping  of 
postinfluenzal  cardiac  complications.  1.  Fatal  cases 
showing  actite  parenchymatous  degeneration  and 
vacuolization  of  the  myocardium.  2.  Nonfatal 
acute  cases  showing  involvement  of  auricle  and 
conduction  system  during  height  of  infection,  with 
complete  restoration  to  normal  cardiac  mechanism 
with  stibsidence  of  infection.  Duration  two  to  six 
weeks.  3.  Nonfatal  chronic  cases  with  arrhythmia 
and  involvement  of  the  auricle  persisting  and  caus- 
ing partial  invalidism  long  after  subsidence  of  acute 
infection.  Duration  twelve  to  seventeen  months — 
plus.  He  suggests  that  acute  respiratory  infections 
single  out  early  the  auricle  and  conduction  pathways 
of  the  heart. 

Vital  Capacity  Constants  in  the  Study  of  Pul- 
monary Tuberculosis. — G.  Dreyer  and  L.  S.  T. 
Burrell  (Lancet,  June  5.  1920)  report  the  results 
of  their  studies  on  the  vital  capacity  in  normal  in- 
dividuals and  in  persons  suffering  from  active  or 
quiescent  pulmonary  tuberculosis.  The  formulae 
with  the  methods  of  measurement  are  given  in 
detail  together  with  brief  abstracts  of  the  reports 
on  two  hundred  cases.  The  authors  feel  justified 
in  drawing  the  following  conclusions:  1.  There  is 
a  definite  decrease  in  the  vital  capacity  of  the  tuber- 
culous ])atient,  taking  into  accotint  the  nature  of 
his  emploj'ment  and  his  general  physical  condition. 
2.  The  vital  capacity  of  the  individual  increases 
with  the  clinical  improvement  and  decreases  with 
advance  of  the  disease,  thus  giving  a  numerical  in- 
dex as  to  the  progress  of  the  case.  3.  The  deter- 
mination of  the  vital  capacity  of  the  case  furnishes 
a  useful  means  of  classification  of  the  extent  and 
severity  of  the  condition.  4.  The  measurement 
furnishes  an  aid  to  diagnosis  in  doubtful  cases  for 
if  it  is  normal  there  is  no  tuberculosis  present.  5. 
The  measurement  also  furnishes  an  index  to  the 
efficacy  of  any  method  of  treatment. 


Proceedings  of  National  and  Local  Societies 


BRITISH  NATIONAL  ASSOCIATION 
FOR  THE  PREVENTION  OF 
TUBERCULOSIS. 

Annual  Conference  Held  in  Liverpool,  England, 
October  7,  8,  and  9, 1920. 
The  President,  Sir  Arthur  Stanley,  in  the  Chair. 

{Concluded  from  page  832.) 

Importance  of  Early  Treatment. — Dr.  Halli- 
DAY  Sutherland,  of  London,  dwelt  upon  the  great 
need  for  timely  treatment.  The  reason  why  results 
were  so  bad  was  that  patients  arrived  in  a  too  far 
advanced  stage  of  the  disease.  On  one  occasion 
he  was  asked  by  a  doctor  to  take  in  a  favorable  case. 
Not  knowing  the  doctor,  he  consented.  When  the 
cab  arrived  at  the  institution  the  man  in  it  was  dead. 
They  could  not  expect  a  miracle  in  anything  sub- 
ject to  natural  forces.  If  the  machinery  they  now 
had  was  used  properly  the  problem  would  be  solved 
in  a  generation.  He  strongly  deprecated  the  lump- 
ing together  of  all  cases,  slight  and  advanced. 

Tuberculosis  and  Poverty. — Baillie  James 
Stewart,  of  Glasgow,  said  that  poverty,  with  its 
attendant  disabilities,  bad  housing  and  food,  was 
the  chief  cause  of  tuberculosis,  and  asserted  that 
until  poverty  was  abolished  these  conferences  would 
go  on. 

Practical  Difficulties  in  Connection  with  Car- 
rying Out  Tuberculosis   Schemes. — Dr.  J.  G. 

Adami,  F.  R.  S.,  formerly  professor  of  pathology  in 
McGill  University,  Montreal,  now  vice-chancellor 
of  the  University  of  Liverpool,  delivered  a  forceful 
address  in  which  he  pointed  out  that  the  tuberculosis 
problem  was  not  altogether  or  even  primarily  a 
medical  one  unless  it  was  considered  as  possible 
that  some  specific  medicinal  cure,  that  would  be 
promptly  effective,  could  be  discovered.  If  such  a 
drug  could  be  obtained,  one  that  would  destroy  the 
bacillus,  he  doubted  whether  it  could  be  introduced 
into  the  body  in  sufficient  concentration.  Could  all 
cases  of  tuberculosis  be  isolated  and  kept  isolated, 
in  ten  years'  time  tuberculosis  would  be  rendered 
as  rare  in  Great  Britain  as  was  leprosy.  This  idea 
was  not  feasible,  however ;  no  Chancellor  of  the 
Exchequer  would  advance  the  funds  requisite,  nor, 
unless  a  periodical  physical  examination  of  the 
entire  population  was  inaugurated,  could  a  consider- 
able proportion  of  these  cases  be  detected.  What 
was  possible,  however,  in  positive  cases,  was  to 
segregate  the  patients  in  large  numbers.  The 
greater  the  proportion  of  those  isolated,  the  more 
rapid  the  reduction  in  the  incidence  of  the  disease. 
The  four  essentials  were  recognition,  notification, 
isolation,  and  treatment.  A  combination  of  volun- 
tary and  official  support  was  essential  and  would  be 
most  economically  brought  about  by  the  establish- 
ment of  local  tuberculosis  dispensaries.  Professor 
Adami  went  on  to  describe  the  working  at  the  Royal 
Institution,  Montreal,  of  the  class  treatment  intro- 
duced by  Dr.  Joseph  Pratt,  of  Boston,  Mass.,  and 
declared  that  this  method  of  treatment  gave  far 
better  results  than  the  sanatorium  treatment  at  a 


lower  cost  for  each  patient.  He  urged  a  modifica- 
tion of  the  system,  together  with  the  establishment 
of  camps  and  night  camps  for  open  air  treatment 
in  the  parks  and  gardens  of  cities  and  towns,  as 
being  the  course  along  which  the  best  and  most 
economical  results  could  be  obtained. 

Dr.  W.  H.  Dickinson,  of  Newcastle-on-Tyne, 
said  recovery  among  the  poor  was  nearly  always 
retarded  by  financial  embarrassment.  This  should, 
as  far  as  possible,  be  remedied  by  local  and  State 
assistance. 

Reforms  Needed  in  Sanatorium  Management. 

— Dr.  Charles  Minor,  of  Asheville,  N.  C,  said 
that  what  was  needed  was  reform  in  the  manage- 
ment of  public  sanatoriums  for  the  working  classes. 
The  whole  staff  from  the  medical  superintendent 
down  should  be  of  the  right  kind,  who  would  treat 
the  patients  as  human  beings  having  souls  as  well 
as  bodies.  No  good  results  could  be  obtained  by 
mixing  cases.  When  managed  aright,  tuberculosis 
was  not  the  hopeless  disease  it  was  supposed  to  be. 
However,  Dr.  Minor  advocated  the  mixing  of  the 
sexes.  If  the  assembly  were  all  women  it  became 
catty,  and  if  all  men  it  became  rude,  and  they  had 
to  be  brought  together  in  order  to  get  a  civilized 
family.  The  cantankerous  people  should  be  put 
together  in  one  ward.    He  advocated  cheerfulness. 

Importance  of  an  Accurate  Diagnosis. — Dr.  B. 

J.  I.  Glover,  of  Liverpool,  referred  to  the  impor- 
tance of  making  an  accurate  diagnosis  on  the  part 
of  the  tuberculosis  officer,  and  to  the  fact  that  cer- 
tain cases  of  chronic  bronchitis  were  sometimes 
wrongly  labeled  as  tuberculous  and  sent  into  sana- 
toriums, thus  wasting  valuable  beds. 

Milk  and  Tuberculosis. — The  last  session  of  the 
conference  was  devoted  to  a  discussion  of  the  milk 
question.  Sir  Robert  Philip,  of  Edinburgh,  was  in 
the  chair. 

"  Dr.  A.  W.  Macfadden,  of  the  Ministry  of  Health, 
opened  the  discussion  and  said,  in  part,  that  the 
figures  indicated  the  present  exceedingly  low  con- 
sumption of  milk  in  industrial  districts  and  the 
wastage  in  milking  herds  from  tuberculosis.  He 
laid  stress  on  the  importance  of  milk  to  the  com- 
munity, especially  as  a  means  for  supplying  acces- 
sory food  factors.  Tuberculosis  in  cattle  made 
the  business  of  milk  production  an  unprofitable  one 
to  the  farmer.  When  the  new  legislation  had  come 
into  full  operation  two  per  cent,  of  their  stock  might 
be  expected  "to  come  annually  for  slaughter  under 
the  provisions  of  the  tuberculosis  order.  From 
the  consumers'  point  of  view  he  noted  that  in  Dr. 
Stanley  Griffith's  recent  report  to  the  Medical  Re- 
search Council  twenty  per  cent,  of  the  cases'  of 
human  tuberculosis  examined  by  him  were  found 
to  be  of  IwDvine  origin.  He  referred  also  to  the 
research  b^ing  carried  out  at  the  present  time  at 
the  Reading  Agricultural  College  to  determine  the 
most  economical  means  of  producing  and  distribut- 
ing wholesome  milk.  Under  the  new  legislation, 
part  of  which  is  "still  before  Parliament,  county 
councils  will,  for  the  first  time,  be  brought  into 


Xovcmber  27,  1920.]  PROCEEDIXGS  OF  XATIOXAL    AXD  LOCAL  SOCIETIES. 


875 


touch  with  the  machinery  of  production.  Local 
authorities  will  be  empowered  to  appoint  a  suffi- 
cient number  of  veterinary  surgeons  to  carry  out 
the  inspection  of  dairy  cattle  in  their  districts.  It 
is  anticipated  and  hoped  that  this  scheme  of  inspec- 
tion will  result  in  bringing  to  light  the  cases  of 
tuberculosis  in  cattle,  which  will  then  be  slaughtered 
and  compensation  paid  according  to  the  provisions 
of  the  tuberculosis  order.  The  system  of  granting 
certificates  to  farmers  who  produced  milk  of  a 
certain  quality  had  resulted  in  the  production  of 
some  tubercle  free  dairy  stock  and  was  a  valuable 
experiment. 

Professor  J.  M.  Beattie,  of  Liverpool,  stated 
that  proprietar}-  milk  preparations  for  the  feeding 
of  children  were  not  practical  substitutes  for  fresh 
milk,  and  that  the  sterilization  and  pasteurization 
of  milk  were  not  a  guarantee  against  tubercle  in- 
fection. Professor  Beattie  dealt  with  three  main 
methods  of  preventing  infection  by  means  of  milk. 
Samples  of  dried  milk  had  not  shown  tubercle 
bacilli,  but  experience  had  demonstrated  the  fact 
that  the  process  of  suspension  was  often  imperfectly 
carried  out  in  the  home,  so  that  the  child  got  some- 
times little  besides  water,  and  often  a  fluid  that 
was  contaminated  in  manufacture.  Professor  Dele- 
pine  had  found  living  bacilli  in  milk  dried  over 
cylinders  heated  to  138°  C.-140°  C.  Pasteurization 
also  killed  tubercle  bacilli  in  the  great  bulk  of 
cases  when  properly  carried  out,  but  the  commer- 
cial methods  used  in  Great  Britain  were  very  in- 
elTective.  His  experience,  however,  in  examining 
samples  from  the  Liverpool  Infant  Welfare  Centre, 
showed  that  if  properly  carried  out  the  method  of 
sterilizing  milk  by  heating  it  was  effective.  The 
milk,  however,  must  be  heated  above  70°  C,  at 
which  temperature  the  milk  proteins  underwent 
some  change.  The  results  of  sterilization  at  lower 
temperatures  by  electricity  had  been  unsatisfactory. 
The  rational  method  of  procedure  was  to  control 
milk  at  its  source  of  supply  and  he  suggested  syste- 
matic inspection  of  dairy  herds,  and  examination 
of  composite  samples  of. milk  from  these  herds,  with 
special  samples  from  animals  suspected  of  tuber- 
culosis, together  with  the  isolation,  on  special  isola- 
tion farms,  of  any  suspicious  animal. 

Sir  Robert  Joxes,  of  Liverpool,  said  that  in  any 
children's  hospital  the  cases  of  surgical  tuberculosis 
might  be  divided  into  three  groups:  1,  tuberculosis, 
2,  poliomyelitis,  3,  rickets.  Half  of  the  cripples, 
among  whom  he  practically  spent  his  life,  were 
tuberculous.  Furthermore,  two  thirds  of  the  in- 
fection in  these  tuberculous  children  was  bovine  in 
character.  In  nearly  every  instance  the  infection 
could  be  traced  back  directly  to  the  cow.  If  such 
cows  were  not  slaughtered  they  should  be  branded 
so  that  they  could  not  pass  from  a  controlled  to 
an  uncontrolled  area  to  infect  a  new  series  of 
children. 

Dr.  Paul  A.  Lewis,  of  the  Henry  Phipps  Insti- 
tute, Philadelphia,  expl^.ined  how  the  American 
system  of  grading  had  arisen  through  the  supply 
of  milk  to  large  concerns  who  often  had  to  trans- 
port it  500  miles  to  the  cities.  He  said  that  this 
system  had  been  the  largest  single  factor  in  the 
education  of  the  farmer,  who  was  naturally  anxious 
to  secure  the  higher  prices  paid  for  higher  grades 


of  milk.  In  the  large  towns  where  only  grade  A 
milk  could  be  sold  there  had  been  a  marked  diminu- 
tion of  gland  tuberculosis.  This  diminution  had 
.not  occurred  in  country  districts  where  the  less 
satisfactory  milk  was  st:ll  obtainable. 

Dr.  Dingwall  Fordvce,  of  Edinburgh,  said  that 
although  it  might  seem  ridiculous  to  say  so,  the 
medical  profession  was  not  as  well  educated  as  it 
should  be  in  the  elements  of  child  nurture.  It 
would  be  better  for  the  nation  if  there  were  small 
healthy  families  rather  than  large  ones  in  which 
many  of  the  children  died.  Dr.  Fordyce  recom- 
mended that  all  milk  sold  in  Great  Britain  today 
should  be  boiled.  Babies  could  be  fed  successfully 
on  boiled  milk  if  vitamines  were  supplied  addition- 
ally through  fruit  or  vegetable  juices. 

Professor  Stexhouse  Williams,  of  Reading, 
made  the  most  striking  speech  of  the  discussion 
and  recounted  the  difficulties  which  had  confronted 
the  dairy  trade,  the  members  of  which  had  always 
been  most  anxious  to  adopt  the  best  measures  for 
the  purification  of  the  m.ilk  supply.  It  had  been 
very  difficult  to  procure  money  or  facts  to  support 
research.  In  order  to  insure  a  decent  milk  supply 
there  must  be  the  right  man  in  the  cow  house.  Xo 
inspector  would  rise  early  enough  to  control  the 
milking  conditions.  The  milker  must,  therefore,  be 
educated  and  given  a  good  wage.  At  least  two 
per  cent,  of  cows,  which  to  outward  appearance 
were  in  good  health,  were  giving  tuberculous  milk. 
Such  milk  was  sent  out  from  four  farms  out  of 
fourteen.  Not  only  did  these  cows  affect  milk 
directly,  but  their  dung  remained  infected  for  twelve 
months  if  kept  in  a  dark  place  and  so  might  con- 
taminate other  milk.  Nothing  less  than  the  tuber- 
culin test  would  eliminate  these  cows  from  the 
herds.  The  farmer  asked  how  he  was  to  replenish 
his  stock  if  the  tuberculous  cattle  were  destro3-ed. 
They  had  presented  a  scheme  four  years  ago  for 
raising  nontuberculous  cows  at  Reading  to  replace 
cows  so  eliminated,  but  money  had  not  been  forth- 
coming. Another  practical  difficulty  was  the  absence 
of  any  standard  tuberculin  or  any  standard  method, 
of  using  it.  He  condemned  vigoroush'  the  propa- 
ganda which  would  excuse  the  consumption  of 
tuberculous  milk  on  the  ground  that  it  immunized 
children.  The  dose  of  tubercle  bacilli  was  un- 
known, and  it  was  not  possible  to  say  that  the 
bacilli  which  entered  the  child's  body  did  not  remain 
latent  and  reappeared  after  a  lapse  of  years  as 
human  bacilli. 

Dr.  J.  Rldd  Leesox,  of  Middlesex  County  Coun- 
cil, made  the  most  iconoclastic  speech  of  the  meet- 
ing, endeavoring  to  upset  all  traditional  views  as  to 
the  nutritive  properties  of  milk.  He  followed  in 
the  footsteps  of  Dr.  Harry  Campbell,  but  out- 
heroded  Herod,  denying  any  virtues  in  milk  as  a 
food.  Rather  he  regarded  it  as  a  menace  to  the 
health  of  a  country,  saying  that  he  would  prefer 
to  see  a  barrel  of  gimpowder  in  a  house  than  a 
glass  of  milk.  He  declared  that  people  had  no 
business  to  drink  milk.  It  was  quite  unnatural,  as 
was  shown  by  the  fact  that  when  a  child's  teeth 
came  the  mother's  milk  ceased  and  that  applied  to 
all  mammalia.  He  looked  upon  the  drinking  of 
milk  as  one  of  the  curses  of  civilization. 


876 


PROCEEDINGS  OF  NATIONAL  AND  LOCAL  SOCIETIES. 


[New  York 
Medical  Jourxai.. 


Dr.  William  Allex  Daley  pointed  out  that  the 
determination  of  the  presence  of  bacilli  in  milk  by 
inoculation  tests  took  too  long,  and  advocated  re- 
search to  discover  a  more  rapid  method. 

Resolutions  on  Tuberculosis  Prevention. — The 
following  resolutions  were  moved  by  Sir  Robert 
JoxES  and  seconded  by  Dr.  Hvslop  Thomsox  : 

That  this  conference  viewed  with  satisfaction 
the  growing  interest  that  was  being  shown  through- 
out the  country  in  relation  to  the  prevention  of 
tuberculosis.  It  reafifirmed  its  belief  that  the  meth- 
ods which  were  being  adopted  were  justified  by  the 
results  obtained,  and  would  urge  their  still  more 
vigorous  prosecution.  In  particular  it  would  urge 
the  Government  to  consider  the  immediate  institu- 
tion of  a  more  definite  system  of  medical  inspection 
in  the  case  of  certain  industries  where  tuberculosis 
was  especially  rife.  It  would  also  urge  that  the 
Tuberculosis  Order,  1914,  be  brought  into  opera- 
tion with  as  little  delay  as  possible.  The  conference 
further  resolved  that  these  resolutions  be  sent  to 
the  council  of  the  National  Association  for  the 
Prevention  of  Tuberculosis  with  a  view  to  their 
transmission  to  the  Prime  Minister,  the  Minister 
of  Health,  and  the  Minister  of  Agriculture. 

A  discussion  then  took  place  in  the  course  of 
which  Dr.  E.  I.  jNIcDoxald,  tuberculosis  ofticer, 
County  Carlow,  Ireland,  made  an  insistent  plea  for 
more  adequate  remuneration  for  the  general  prac- 
titioner, who  at  present  was  given  the  vital  and 
difiicult  task  of  discovering  early  cases  without 
reward.  The  resolutions  were  then  put  to  the 
meeting  and  carried  unanimously. 

The  Liverpool  branch  of  the  Church  of  England 
Temperance  Society  gave  a  breakfast  on  October  8th 
to  the  members  attending  the  conference.  Dr.  Haig, 
who  presided,  said  that  alcoholism  was  a  national 
question,  and  though  we  might  not  feel  it  wrong 
to  drink  alcoholic  beverages  ourselves,  we  must  look 
upon  the  whole  problem  w'ith  a  social  conscience. 

Alcoholism  and  Tuberculosis. — Dr.  I.  N. 
Kelvx.-vck  read  a  paper  on  this  subject,  in  which 
he  dealt  first  with  the  direct  action  of  alcohol,  quot- 
ing the  late  Sir  William  Osier  in  support  of  the 
contention  that  the  resistance  of  the  body  to  in- 
fection was  lowered  by  its  use.  But  the  chief  way 
by  which  the  alcoholic  exposed  himself  "to  infection 
from  tubercle  bacilli  was  through  the  indirect  effects 
of  addiction  upon  personal  hygiene  and  upon 
social  and  domestic  conduct.  Those  who  were  im- 
properly fed  and  clothed  as  a  result  of  poverty 
through  drink  fell  an  easy  prey.  Much  contagion 
was  contracted  at  the  public  bar.  Dr.  Kelynack 
read  a  symposium  of  opinions  in  agreement  with 
his  own,  contributed  by  Sir  Robert  Philip,  Sir 
George  Sims  Woodhead,  Sir  Thomas  Oliver,  Sir 
Henry  Gauvain,  Professor  Hope,  Professor  E.  L. 
Collis,  Dr.  Nathan  Raw,  and  Dr.  C.  T.  McAlister. 
He  concluded  by  urging  additional  research  on 
alcohol  and  tuberculosis  by  the  profession  and  for 
a  school  campaign  of  temperance  education  along 
the  lines  recommended  in  the  new  syllabus  of  the 
board  of  education.  Agents  of  insurance  bodies, 
in  his  opinion,  should  give  health  instruction  in 
England  as  they  did  in  America. 

The  keynote  of  the  meeting  with  regard  to  the 


tuberculosis  problem,  as  with  the  problem  of  all 
disease  at  the  present  time,  was  that  prevention 
is  better,  than  cure,  and  in  order  effectually  to 
prevent  there  must  be  earnest  and  intelligent 
cooperation  between  the  medical  profession  and  the 
community. 

Too  great  reliance  had  been  placed  upon  sana- 
torium treatment,  and  grave  defects  in  the  system 
had  made  themselves  evident  w^hich  to  a  considerable 
extent  minimized  its  value.  It  was  now  obvious 
that  in  order  to  stamp  out  tuberculosis  in  the  first 
instance,  early  diagnosis  was  essential.  The  dis- 
ease could  be  successfully  treated  in  the  early  stages 
but  was  not  amenable  to  successful  treatment  when 
infection  had  gained  a  firm  foothold.  Consequently 
the  rational  mode  of  dealing  with  tuberculosis  was 
by  the  exercise  of  preventive  methods.  Of  course, 
such  methods  were  notoriously  difficult  to  bring  into 
play.  Early  diagnosis  was  immensely  difficult — it 
seemed  almost  impossible — and  the  milk  question 
was  another  hard  nut  to  crack.  But  these  problems 
must  be  faced  and  solved  if  success  was  to  be  com- 
plete. Furthermore,  it  was  necessary,  if  the  spread 
of  the  disease  was  to  be  controlled,  that  those  who 
were  in  the  stage  of  the  disease  which  made  them 
a  menace  to  their  neighbors  and  the  community  must 
be  segregated.  These  were  the  two  important  prob- 
lems to  be  solved  in  the  campaign  against  tubercu- 
losis :  early  diagnosis  and  appropriate  treatment, 
and  the  segregation  of  the  sufferer  when  he  had 
become  a  danger  to  the  public. 

At  the  outbreak  of  war  progress  had  been  made 
in  the  treatment,  preventive  and  otherwise,  of  tuber- 
culosis, but  war  conditions  naturally  rendered  all 
efforts  of  no  avail,  and  during  the  war  the  disease 
had  made  great  headway.  In  Great  Britain,  at  the 
present  time,  the  whole  matter  was  being  recon- 
sidered and  the  treatment  established  on  a  somewhat 
diff'erent  basis.  It  was  recognized  that  the  main 
hope  of  eradicating  the  disease,  or  even  of  greatly 
diminishing  its  incidence  and  prevalence,  lay  in 
prevention  reinforced  by  the  segregation  of  those 
in  an  advanced  stage  of  tli.e  malady  To  this  end, 
therefore,  there  was  needed  education  of  the  public, 
for  without  education  cooperation  would  not  come, 
and  without  cooperation  an  early  diagnosis  could 
not  be  made  and  proper  treatment  instituted  before 
it  was  too  late.  With  respect  to  many  details  in- 
volved in  the  tuberculosis  question,  -Ajnerica  was 
considerably  ahead  of  Great  Britain. 


Nutrition  Clinics  and  Tuberculosis. — William 
R.  P.  Emerson  (Boston  Medical  and  Surgical  Jour- 
nal, September  16,  1920)  says  that  the  problem  of 
tuberculosis  is  for  the  most  part  the  problem  of  nu- 
trition. If  children  can  be  made  well  in  a  sanatori- 
um, they  get  health ;  but  if  they  can  be  cured  in  their 
own  homes,  they  get  health,  with  health  education 
and  character.  Nutrition  work,  which  covers  a  new 
and  hitherto  neglected  field  in  medical  work,  must 
be  carried  on  with  proper  authority.  It  cannot  fit 
in  as  an  adjunct  to  other  programs,  but  other  pro- 
grams must  be  adjusted  to  fit  the  problem  of  nutri- 
tion, which  is  the  fundamental  problem  of  tuber- 
culosis. 


New  York  Medical  Journal 

INCORPORATING  THE 

Philadelphia  Medical  Journal  the  Medical  News 

A  Weekly  Review  of  Medicine,  Established  18I^3. 

Vol.  CXII,  No.  23.  NEW  YORK,  SATURDAY,  DECEMBER  4,  1920.  Whole  No.  2192. 

Original  Communications 


THE  PARATHYROID  AND  CONVULSIVE 
STATES* 
General  Considerations. 
By  Smith  Ely  Jelliffe,  M.  D., 
New  York. 

I  shall  attempt  to  present  certain  general  concep- 
tions which  have  helped  me  in  my  efiforts  to  analyze 
some  of  the  problems  which  in  general  we  speak  of 
as  the  epilepsies.  In  this  attempt  to  bring  some  for- 
mulations before  you  I  may  be  considered  somewha't 
tedious  in  so  far  as  I  shall  deal  with  some  elementary 
considerations  which  I  deem  essential  to  pave  the 
way  to  certain  aspects  of  the  situation. 

Such  elementary  considerations  involve  the  gen- 
eral hypotheses  of  the  science  of  energetics.  For  the 
purposes  of  our  discussion  I  shall  ask  you  to  assvime 
that  the  human  being  is  liot  an  isolated  bit  of  living- 
matter,  a  shut  in  system  acting  by  itself  and 
independent  of  its  environment.  It  is  no  such  thing. 
It,  like  all  other  living  organisms,  is  a  highly  compli- 
cated, greatly  involved  and  ingeniously  intricate  sys- 
tem or  systems  of  mechanisms,  whose  chief  and 
only  functions  are  the  capture,  the  transformation, 
and  the  release  of  energy.  This  energy,  as  you  well 
know,  comes  from  cosmic  sources,  and  although  the 
human  being  has  not  yet  evolved  to  such  a  point  that 
it  can  utilize  all  of  the  surrounding  energy  it  does 
manipulate  enormous  quantities  of  the  energy  that 
impinges  upon  it  and  for  the  most  part  manipulates 
it  for  the  well  being  of  that  individual  and  for  the 
continuance  of  living  beings,  the  race. 

Further  elementary  considerations  force  me  to 
remind  you  of  some  of  the  remarkable  anatomical 
structures  by  which  the  capture,  the  transformation, 
and  the  release  of  this  energy  are  made  possible. 
Anatomically  and  neurologically  speaking,  the  term 
receptors  is  used  to  describe  those  mechanisms 
which  gather  the  energy  in  from  innumerable  cosmic 
sources.  This  capture  of  energy  by  the  receptors 
has  been  in  progress  many  million  years  and  is  per- 
formed automatically,  unconsciously,  unceasingly 
for  the  most  part,  and  the  functions  have  become 
structuralized  into  organs,  which  are  still  undergoing 
slow  evolution,  unrecognizable  as  changing  even  by 
the  best  means  at  hand  for  morphological  observa- 
tion. Solely  for  the  purpose  of  illustration  I  shall 
remind  you  of  only  a  few  of  the  receptor .  mechan- 
isms which  have  built  up  complex  structures  in  this 

'Revised  notes  of  paper  given  at  the  National  Association  for  the 
Study  of  Epilepsy,  June  14,  1920. 


effort  to  obtain  energy  from  the  universe.  The 
weight  of  the  earth,  its  relation  to  other  masses  in 
the  universe  and  the  effects  upon  all  bodies  in  the 
environment  we  speak  of  as  gravity.  The  muscular 
system,  particularly  that  part  of  it  known  as  the 
anisotropic  disc  system  in  socalled  voluntary  muscle, 
is  one  of  the  bits  of  structure  which  has  been 
evolved  in  response  to  this  constantly  acting  gravity 
energy  system.  The  chief  receptors,  so  far  as  morph- 
ology has  penetrated  these  structures,  lie  within 
the  muscles  and  tendons  and  constitute  parts  of  an 
extremely  complicated  apparatus,  which  correlates 
the  controls  from  many  sources  of  our  command 
over  spatial  relations  through  muscular  action.  We 
are  not  now  interested  in  this  control  part  of  the 
machine,  the  transformers,  but  are  speaking  of  the 
energy  source  side.  Thus  the  globe  is  constantly 
working  on  our  body  and  supplying  it  with  energy 
stimuli. 

Again  let  us  turn  to  light  stimuli.  Light  not 
only  acts  upon  the  optic  receptors  of  the  eye,  but  it 
is  acting  on  the  layer  of  pigment  which  in  the 
Malphigian  layer  is  found  throughout  the  entire 
body.  Here  is  a  constant  energy  supply  that  must 
be  handled  by  the  body  machinery.  Whereas  we 
must  confess  to  an  almost  abysmal  ignorance  con- 
cerning these  mechanisms,  Cajal's  recent  work  on 
the  nervous  structures  of  the  skin,  McCord's  obser- 
vations on  the  action  of  pineal  substance  upon  melan- 
ophores  permit  us  to  conjecture  some  tentative 
working  hypotheses  concerning  the  pineal  as  a  part 
of  this  particular  functional  group. 

Food  is,  from  my  point  of  view,  a  comparatively 
insignificant  source  of  the  energy  that  the  human 
being  captures  and  transforms.  It  is  all  important, 
however,  in  supplying  the  chemical  elements  which 
are  essential  in  the  transforming  machinery. 

As  some  of  you  know,  from  a  special  point  of 
view,  I  have  maintained  that  the  most  important 
of  the  energy  sources  that  the  human  being  handles 
is  the  energy  that  is  transformed  or  brought  over 
into  the  human  mechanism  through  the  dynamics  of 
the  symbol.  It  would  take  us  too  far  afield  to  dis- 
cuss the  hypotheses  which  science  is  working  with 
concerning  these  mechanisms. 

So,  then,  conceive  of  these  receptors,  connecftors 
and  effectors  capturing,  transforming,  and  releas- 
ing enormous  amounts  of  energy.  In  the  evolution 
of  this  process,  as  you  know  from  your  anatomical 
considerations,  a  highly  complicated  and  closely  in- 
tegrated series  of  nerve  structure  arcs  has  been 


Copyright,  1920,  by  A.  R.  Elliott  Publishing  Company. 


878 


JELLIFFE:  C"0.\7TZ.5/J '£  STATES    AND  THE  PARATHYROID.  [New  York 

Medical  Jourkal. 


devised.  These  arcs  are  broken  here  and  there,  by 
anatomical  structures  which  have  received  the  name 
of  the  synapses,  in  order  to  permit  a  greater  facility 
of  distribution  of  the  energy  being  transformed  for 
various  vital  processes.  Here  again  I  must  depre- 
ciate the  definiteness  of  our  knowledge  concerning 
the  great  complexity  of  the  synapse.  Morphologic- 
ally we  know  almost  nothing  about  them ;  physio- 
logically we  know  a  little  more.  \\'e  know  just  a 
little  concerning  the  electrophysical  resistance  to  the 
passage  of  energy  at  the  synapse.  Some  of  this  I 
have  summarized  from  my  own  observations  and 
the  literature  of  the  laboratory,  particularly  as  it 
has  been  partially  revealed  in  working  on  the  prob- 
lem of  tetany  (1).  Now  it  is  particularly  to  some 
of  the  work  that  is  carried  on  at  the  synapse  that 
I  wish  to  call  attention ;  so  far  as  convulsive  phe- 
nomena combined  with  a  series  of  other  phenomena 
are  concerned,  which  gathered  together  constitute 
the  nucleus  of  the  epilepsy  problem,  I  feel  that 
any  light  thrown  upon  the  machinery  at  the  synap- 
tic junction  level  is  of  value  in  the  solution  of 
parts  of  the  epilepsy  problem,  even  though  such 
value  may  be  restricted,  because  no  interpretation 
of  so  complicated  a  group  of  phenomena  as  the 
epileptic  phenomena  can  ever  be  completely  ex- 
plained at  a  physicochemical  level.  If  I  may  out- 
line a  very  concrete  analogy,  I  may  speak  of  this 
synaptic  junction  somewhat  in  the  light  of  a  hair 
trigger  in  a  gun.  Whereas  oiling  the  hair  trigger 
may  induce  a  more  rapid  explosion  of  the  contents 
of  the  gun,  the  directing  of  the  gun,  here,  there, 
or  somewhere  else,  namely  at  the  target,  has  little 
or  nothing  to  do  with  the  hair  trigger.  That  is, 
the  epileptic  phenomena  en  gross  can  only  be  ex- 
plained as  the  gim  in  toto  with  the  man  behind  the 
gun.  The  ultimate  comprehension  of  the  epileptic 
phenomena  will  only  receive  its  adequate  setting 
when  the  investigation  of  the  unconscious  of  the 
individual  who  is  behind  the  gun  is  integrated  with 
the  other  parts  of  the  machinery.  But  so  far  as 
the  present  analogy  is  concerned  an  analysis  of  the 
mechanisms  of  the  hair  trigger  may  be  of  certain 
limited  service.  For  it  is  certain  that  the  electrical 
resistance  at  the  synaptic  junctions,  peripheral, 
spinal,  medullary,  cerebellar,  midbrain  to  cortex, 
and  back  again  to  the  muscle  and  plate  effectors, 
control  the  energy  discharges  and  distributions,  and 
aid  in  the  integration  of  the  machine,  in  its  work 
of  proper  and  adequate  supply  of  energy  for  meta- 
bolic and  projicient  purposes.  This  electrical  re- 
sistance serves  at  least  a  double  service.  It  func- 
tions for  time,  and  thus  attempts  to  control  the  flow 
of  energy  from  one  neuron  to  another  within  orderly 
time  relations.  Concerning  this  timing  function  we 
have  some  definite  information,  loc.  cit.  It  also 
functions  for  quantitative  capacities,  and  through 
the  elaborate  network  of  synaptic  contacts  permits 
a  balancing  in  dynamic  distribution  along  physio- 
logifal  limits. 

Both  of  these  functions  are  perturbed  in  the 
groups  of  convulsive  disorders,  spasmophilia,  tics, 
choreas,  and  other  disturbances,  as  well  as  many 
of  the  convulsive  phenomena  of  the  epilepsies.  The 
problem  of  localization  of  the  perturbed  .synaptic 
junctions  cannot  be  entered  into  just  at  this  moment. 


Xow  the  functional  integrity  of  the  synapse, 
among  a  host  of  other  relations,  is  intimately  bound 
up  in  the  problem  of  the  integrity  of  the  bivalent 
kations  of  the  body,  of  which  calcium  and  mag- 
nesium are  the  most  frequently  found  in  the  chem- 
ical fundamentals  of  the  human  machine.  Calcium 
plays  an  important  role,  we  know  perfectly  well,  as 
we  more  or  less  intensely  study  the  phenomena  of 
tetany,  and  it  is  by  reason  of  this  aspect  of  the 
subject  that  I  have  hazarded  these  general  remarks. 
As  you  know,  tetany  is  almost  always  associated 
with  deficient  parathyroid  function.  Such  para- 
thyroid modifications  may  originate  from  innumer- 
able etiological  factors.  Whether  we  can  have  spe- 
cific parathyroid  malfunctioning  independent  of 
other  endocrine  activities  I  shall  not  attempt  to 
state.  In  defective  parathyroid  states  the  neces- 
sary calcium  integration  factors  seem  to  be  most 
seriously  interfered  with.  The  hypothesis  would 
state  that  these  glands  regulate  the  proper  distribu- 
tion of  the  calcium  for  its  numerous  functions,  one 
of  which  is  the  specific  activity  of  regulating  the 
synaptic  junction  function ;  there  seems  to  be  little 
doubt  that  it  is  so  involved.  So,  then,  coming 
around  to  the  physicochemical  point  of  view,  all 
convulsive  phenomena  may  be  scrutinized  to  ad- 
vantage from  the  viewpoint  of  possible  "hair  trig- 
gerness,"  that  is,  a  diminution  of  resistance  to  the 
passage  of  electrical  stimuli  with  perverted  synaptic 
junction  function,  primarily  brought  about  through 
parathyroid  dysfunction. 

This  only  takes  us  to  a  very  general  statement. 
Which  synapses  in  the  chains  are  chiefly  involved? 
Are  they  those  of  the  incoming  arcs,  or  those  of 
the  outgoing  ones?  Is  it  a  problem  of  faulty  cap- 
ture and  short  cut  distributions  in  a  faulty  manner, 
or  are  the  difficulties  to  be  sought  on  the  effector 
sides  of  the  mechanism?  These  questions  cannot 
yet  be  answered.  Paton  and  his  coworkers  have 
attempted  an  analysis  of  the  tetany  situation  along 
these  lines,  in  which,  however,  they  have  omitted 
several  synapses  in  their  discussion,  having  made 
the  functioning  neural  arcs  too  simple.  But  it  was 
not  my  mission  to  solve  the  epilepsy  problem.  I 
wished  only  to  discuss  one  defect  of  a  general 
nature,  which,  if  found  in  any  human  machine, 
made  it  more  difficult  for  that  machine  to  distribute 
its  energy  properly  under  stress  or  strain.  Clearing 
up  a  general  underlying  mechanical  defect  of  the 
distributing  apparatus,  might  permit  the  machine 
to  function  better  even  with  a  faulty  biological  tele- 
ology, which  a  study  of  the  unconscious  might 
reveal  as  present.  Certainly  a  very  poor  gunner, 
who  might  not  be  certain  concerning  his  quarry — 
a  forester  or  a  deer — would  have  a  serious  handi- 
cap if  the  trigger  of  his  gun  were  so  touchy  as  to 
go  off  with  the  slightest  pressure,  maybe  of  his 
finger,  maybe  of  a  swishing  branch  of  a  shrub,  or 
a  sudden  jolt  from  uncertain  footing.  With  secur- 
ity in  that  part  of  the  machine  his  chances  might 
be  better  for  his  goals.  Thus  the  work  at  the 
synapse  may  throw  some  important  light  on  the 
problem  to  which  this  society  has  devoted  itself. 

Just  one  word  more  then  from  a  possible  thera- 
peutic point  of  view,  which  has  been  partially  ex- 
perimented with  by  myself  and  more  or  less  ex- 


December  4,  1920.] 


SHJXAHAX:  PRO  IIS  J  OX  I- OR  EPILEPTICS. 


879 


tensively  reported  on  by  Bolten.  and  a  number  of 
investigators  who  have  found  that  by  parathyroid 
therapy  in  certain  types  of  individuals  where  there 
was  a  certain  definite  causal  relationship  between 
parathyroid  disease  and  the  possibility  of  controlling 
certain  factors  in  the  convulsive  phenomena,  very 
excellent  results  have  been  obtained. 

My  opinions  are  still  in  a  formative  state,  but 
tlie  results  which  I  have  obtained  from  investigation 
and  the  reports  obtained  by  reading  the  literature 
indicate  that  some  help  in  controlling  certain  of  the 
factors  which  I  have  outlined  may  come  from  a 
carefully  considered  parathyroid  therapy.  Just  to 
feed  parathyroid  to  every  epileptic  and  expect 
him  to  get  well  is  as  silly  as  to  give  every  man  in 
Xew  York  a  brick  and  expect  to  get  a  Woolworth 
building.  Behind  the  type  of  cases  of  possible 
action  there  should  be  present  the  specific  features 
of  the  "hair  trigger"  synaptic  activity.  Careful 
study  of  the  patient  for  all  of  the  tetany  reactions 
is  needed,  then  one  may  have  some  foundation. 
Therapeutics  is  so  empirical  at  best,  however,  that 
even  a  shotgun  use  of  the  parathyroid  may  bag  a 
bird  when  one  least  expects  it.  Interestingly  enough, 
it  has  seemed  that  parathyroid  given  by  rectum  in 
its  crude  state  is  its  most  effective  form.  Given  in 
other  ways,  by  the  gastrointestinal  canal,  it  under- 
goes destructive  digestive  changes ;  even  hypoder- 
mic use  seems  to  alter  its  composition,  but  taken  by 
way  of  the  rectum  it  would  appear  that  no  such 
deterioration  takes  place,  and  some  very  surprising 
and  striking  results  have  been  obtained,  not  in  the 
cure  of  an  epileptic  specially,  but  in  the  help  of 
this  one  particular  factor  which  I  have  tried  to 
emphasize  in  this  rather  condensed  communication. 

REFEREXCES. 

1.  Bayliss  :  General  Physiologj-. 

2.  Paton,  Noel:  Studies  in  Tetany. 

3.  Jelliffe  :  Tetany. 

4.  Jelliffe  and  White  :  Diseases  of  the  Nervous  Sys- 
tem, Third  Edition. 

5.  Jelliffe:  Proceedings  American  Neurological  Asso- 
ciation,  1919. 

64  West  Fifty-sixth  Street. 


MORE  ADEQUATE  PROVISION  FOR  EPI- 
LEPTICS.* 

By  William  T.  Shaxah.vx.  'M.  D.. 
Sonyea,  N.  Y., 

Medical   Superintendent,    Craig  Colony. 

One  may  ask  what  is  now  being  done  in  America 
to  meet  the  needs  of  the  many  thousand  epileptics 
not  under  any  particular  care  or  supervision  ?  Are 
the  established  institutions  serving  their  respective 
communities  to  the  greatest  degree  possible  ?  While 
many  of  the  epileptics  referred  to  would  probably 
never  be  required  to  come  under  direct  institutional 
care,  nevertheless  the  question  arises,  Should  ex- 
tension work  be  arranged  either  as  clinic  days  at 
Craig  Colony  or  at  a  distance  where  epileptics  un- 
able to  consult  a  physician  might  come  for  exami- 
nation and  advice?  In  a  recent  communication 
from  one  of  long  experience  in  the  care  and  treat- 

•Read  at  the  annual  meeting  f  National  Association  for  Study 
■of  Epilepsy,  New  York,  June  3,  :920. 


ment  of  epileptics,  the  present  situation  in  Xew 
York  State  regarding  the  care  of  these  people  was 
well  summed  up  in  saying  the  provision  was 
lamentably  inadequate. 

The  general  subject  of  care  and  treatment  of  epi- 
leptics in  special  colonies  or  villages,  as  well  as  in 
the  outside  world,  has  been  so  well  covered  in  the 
literature  of  the  past  thirty  years  or  more  that  there 
can  be  nothing  better  expected  at  this  time  than  to 
call  attention  to  certain  phases  of  the  problem  al- 
ready minutely  described  stress  their  importance 
and  strive  to  make  them  effective  to  a  broader  ex- 
tent than  has  been  thus  far  accomplished.  W^e  can 
but  aim  to  bring  about  a  more  general  application 
of  the  principles  advocated  by  Letchworth,  Peter- 
son, Spratling,  Clark  and  others. 

From  the  twenty-sixth  annual  report  of  the  State 
Board  of  Charities  of  the  State  of  Xew  York,  1892, 
page  373,  I  would  quote:  "The  colony  idea  is  essen- 
tial, as  is  shown  by  the  express  language  of  the  law 
as  well  as  its  spirit,  and  b\-  the  needs  and  nature 
of  the  proper  care  and  treatment  of  epileptics  in 
community  life.  This  colony  design  includes  not 
only  the  separation  of  the  patients  into  detached 
buildings,  but  the  arrangement  of  the  cottages  upon 
irregular  lines  and  at  different  distances,  in  accord- 
ance with  the  situations  of  the  various  building 
sites,  adapted  to  the  .self support  of  the  inmates 
through  natural  advantages  for  economy  of  admin- 
istration, and  for  the  successful  prosecution  of 
trades,  industries  and  agricultural  labors." 

The  writer  ot  the  foregoing  apparently  expected 
the  epileptics  to  l)e  received  would  be  of  good  men- 
tality, whereas  upward  of  sixty  per  cent,  of  those 
received  at  Craig  Colony,  since  its  first  patient  was 
admitted  in  January,  1896,  have  been  markedly  im- 
paired mentally. 

Established  in  1894,  the  Craig  Colony  with  a 
moderate  amount  of  funds  for  new  construction, 
made  available  annually,  should  have  had  before  this 
capacity  for  at  least  two  thousand  patients,  with 
every  ordinary  facility  for  affording  them  humane, 
scientific  and  eponomical  care  and  treatment.  The 
slowing  up  in  development  of  Craig  Colony  long- 
antedated  the  World  War.  As  a  fact,  during  the 
past  decade,  practically  no  appropriations  were  made 
for  additional  dormitory  cottages  or  for  other  co- 
ordinated structures  required  to  permit  of  develop- 
ing the  Colony  along  the  general  lines  so  well  laid 
down  nearly  twenty-five  years  ago.  The  few  cot- 
tages built  have  been  provided  to  replace  old  Shaker 
structures  no  longer  suitable  for  patients. 

A  portion  of  Section  1.  of  Chapter  331,  of  Laws 
of  1907,  being  an  act  authorizing  the  selection  of  a 
site  for  what  is  now  Letchworth  Village,  reads  as 
follows:  "Section  1.  Selection  of  lands. — For  the 
purpose  of  acquiring  a  site  for  the  Eastern  New 
York  State  Custodial  Asylum  which  it  is  proposed  to 
establish  for  the  care  of  epileptics  and  other  feeble- 
minded persons  needing  custodial  care." 

The  commission  appointed  to  select  the  site  men- 
tioned in  its  report  that  figures  obtained  showed 
conclusively  that  there  was  a  large  number  of  de- 
pendent epileptic  and  feebleminded  persons  for  whose 
proper  care,  treatment  and  education  the  state  had 
made  no  provision.   In  comment  upon  this,  I  desire 


880 


SHANAHAN:  PROVISION  FOR  EPILEPTICS. 


[New  York 
Medical  Journal. 


to  call  your  attention  to  the  fact  that  up  to  the  pres- 
ent, thirteen  years  later,  the  state  has  made  no 
further  provision  for  the  epileptics  referred  to  in 
this  report,  as  subsequently  the  law  governing  Letch- 
worth  Village  was  modified  or  at  least  its  interpre- 
tation changed  so  that  only  the  feebleminded  are  re- 
ceived. The  intention  of  establishing  a  separate 
institution  to  which  only  the  most  defective  class 
could  be  sent  was  not  a  good  policy. 

The  population  of  New  York  State  is  such  that 
to  care  for  its  epileptics  as  they  should  be  cared  for, 
the  state  must  needs  establish  districts  as  it  did  long 
since  for  the  insane,  and  is  now  preparing  to  do  for 
the  feebleminded.  If  this  were  accomplished  and 
the  sites  fixed  on,  there  should  be  a  sufficient  area 
in  which  to  locate  groups  for  the  housing  of  all 
types  of  epileptics  within  that  radius.  The  annual 
census  of  the  dependent  epileptics  in  the  state  as  re- 
quired by  the  State  Board  of  Charities  does  not 
bring  forth  satisfactory  information  to  approximate 
the  total  number  who  might  demand  or  desire  care 
in  a  colony.  Many  counties  either  report  no  epilep- 
tics or  very,  very  few  in  comparison  with  their  pop- 
ulation. 

The  rounding  out  of  the  Craig  Colony  by  the 
erection  of  various  buildings  Hsted  in  the  original 
plan,  is  plainly  indicated  so  that  the  scientific  and 
therapeutic  ends  for  which  the  institution  was 
established  may  be  progressively  furthered.  A 
minimum  of  markedly  defective,  primarily  custodial 
cases  should  be  ultimately  provided  for  at  the  col- 
ony. If  the  project,  already  referred  to,  of  dis- 
tricting the  state  is  eventually  accomplished,  those 
patients  offering  some  possibility  of  improvement  or 
an  arrest  of  symptoms  should  be  given  preference  in 
the  list  of  applicants  seeking  admission.  This,  how- 
ever, cannot  be  done  until  the  colony  is  provided 
with  the  necessary  places  in  which  to  accommodate 
more  applicants  of  this  type  and  the  means  of  treat- 
ing them  in  an  up  to  date,  scientific  manner. 

In  the  fifty-third  annual  report  of  the  New  York 
State  Board  of  Charities  for  the  year  1919,  the  fol- 
lowing is  submitted,  referring  to  "Craig  Colony : 
"But  as  it  is  estimated  that  the  ratio  of  epileptics  in 
the  general  population  is  one  to  five  hundred,  one 
institution  having  a  capacity  of  one  thousand  four 
hundred  inmates,  situated  in  the  extreme  western 
part  of  the  state,  is  not  sufficient  provision  for  a 
population  of  ten  million  or  more  persons.  It  is 
impossible  to  care  adequately  and  properly  for  the 
needs  of  the  state  at  Sonyea,  where  there  is  con- 
stant overcrowding  and  where  a  long  waiting  list 
is  constantly  maintained.  The  great  distance  from 
New  York  City  is  an  additional  hardship  to  the 
patients  who  are  separated  from  friends  and  rela- 
tives for  long  periods  of  time.  There  should  be  in 
the  vicinity  of  the  metropolis  an  institution  for  this 
type  of  sufferers,  and  in  addition  there  should  be 
provided  throughout  the  state  clinical  and  dispen- 
sary facilities  whereby  discharged  patients  and  po- 
tential epileptics  may  receive  aftercare  and  expert 
advice  in  the  treatment  of  their  disorder." 

The  Hospital  Development  Conimission  in  New 
York  State  in  its  report  submitted  to  the  Legisla- 
ture nnder  date  of  February  18,  1918,  stated : 
"We  are  not  prepared  to  say  that  another  institu- 


tion for  feebleminded  should  be  authorized.  The 
institution  at  Letchworth  Village  was  originally  in- 
tended for  epileptics.  Today  this  original  purpose 
has  been  lost  sight  of,  and  perhaps  properly  so.  The 
Craig  Colony  for  Epileptics  is  another  phase  of  the 
same  problem.  This  institution  has  patients  who 
are  both  insane  and  feebleminded.  A  great  many 
epileptics  ultimately  become  insane.  It  is  a  ques- 
tion whether  hospitals  for  the  insane  should  care 
for  insane  epileptics  or  whether  institutions  for  epi- 
leptics should  care  for  that  class,  or  whether  the 
Craig  Colony  should  be  regarded  as  a  charitable 
institution,  or  should  come  under  the  control  of  an 
existing  commission  or  some  commission  should  be 
formed  in  the  future.  The  question  arises  in  con- 
nection with  this  entire  situation  as  to  what  is  men- 
tal normality  and  what  is  defectiveness.  .  Can  any 
sharp  line  be  drawn  between  the  two?  The  ability 
to  make  a  proper  social  adaptation  in  one  station  of 
life  may  be  much  greater  than  that  required  in  an- 
other circle,  and  so  on." 

In  practically  every  other  state,  except  New 
York,  the  institutions  for  the  care  of  the  insane, 
feebleminded  and  epileptic  are  all  placed  under  the 
same  commission  or  board. 

On  February  1,  1920,  there  were  a  little  over  a 
thousand  epileptics  residing  in  the  various  state 
hospitals  for  the  insane  in  New  York  State :  Bing- 
hamton  73 ;  Brooklyn  34 ;  Buffalo  77 ;  Central  Islip 
128;  Gowanda  29;  Hudson  River  117;  Kings  Park 
128;  Manhattan  162;  Middletown  65;  Ogdensburg 
61 ;  Rochester  42 ;  Utica  49,  and  Willard  90 ;  giving 
a  total  of  1,055.  Of  this  number,  a  considerable  pro- 
portion might  be  cared  for  in  an  institution  such  as 
the  Craig  Colony  if  proper  buildings  were  avail- 
able. With  the  removal  of  the  majority  of  the  epi- 
leptics from  the  hospitals  for  the  insane,  there  would 
then  be  made  available  many  beds  for  the  ordinary 
insane. 

At  the  present  time,  the  only  states  providing 
separate  institutions  solely  for  the  care  of  epileptics 
are  the  following:  Ohio,  New  York,  Massachusetts, 
Kansas,  New  Jersey,  Indiana,  Texas,  Michigan, 
Iowa  and  Ontario,  Canada.  Pennsylvania  and  Mis- 
souri have  private  institutions  for  epileptics.  Of 
the  remaining  states,  the  majority  either  care  for 
epileptics  in  separate  cottages  or  wards  in  institu- 
tions for  the  insane  or  the  ordinary  mentally  defec- 
tive. Three  states,  Illinois,  Connecticut  and  Vir- 
ginia, originally  established  separate  institutions  to 
be  devoted  solely  to  the  care  of  epileptics,  but  have 
since  changed  the  type  of  institutions  so  as  to  care 
for  both  epileptics  and  feebleminded  in  the  same 
institution.  In  most  of  those  states  having  separate 
institutions,  because  of  the  present  unsettled  state  of 
affairs,  it  is  not  expected  to  increase  their  capacity 
materially  in  the  near  future.  In  Ohio  there  has 
been  some  agitation  for  the  starting  of  another  hos- 
pital for  epileptics,  as  well  as  in  New  York.  In 
Ohio,  during  the  past  year,  there  has  been  an  in- 
creased capacity  by  250,  and  by  next  year  it  is  ex- 
pected that  there  will  be  a  similar  additional  increase 
in  capacity.  In  Michigan  the  capacity  was  increased 
by  215  during  last  year.  Indiana  has  buildings  rear- 
ing completion  to"  permit  of  adding  to  its  capacity 
for  a  considerable  number,  but  owing  to  such  a 


December  4,  1920.] 


SH  AX  AH  AN:  PROVISION  FOR  EPILEPTICS. 


881 


great  increase  in  the  cost  of  construction,  appropri- 
ations will  not  nearly  permit  of  erecting  buildings 
of  the  size  originally  planned  for.  Indiana  desires 
to  erect  a  structure  where  any  physician  in  the  state 
can  send  an  epileptic  for  observation,  diagnosis  and 
suggestions  as  to  treatment,  similar  arrangement 
for  which  should  be  available  in  all  states,  so  that 
such  individual  could  be  received  for  a  short  period 
without  any  steps  for  commitment  being  made  nec- 
essary. New  Jersey  is  seeking  to  secure  a  consider- 
able appropriation  so  as  to  enlarge  its  village  for 
epileptics.  At  the  Craig  Colony  additional  struc- 
tures have  been  built  to  increase  the  capacity  by  two 
hundred,  but  cannot  be  made  available  until  provi- 
sion is  made  for  housing  nurses  and  attendants, 
when  they  can  be  secured. 

I  may  be  pardoned  perhaps  if  I  review  some  of 
the  ideals  to  be  sought  after  when  establishing  a 
colony.  The  site  should  be  reasonably  near  a  city 
or  large  town,  and  contafn  tracts  available  for  the 
erection  of  buildings  without  necessitating  a  great 
amount  of  landscape  effort. 

The  first  patients  to  be  admitted  should  be  those 
epileptics  mentally  and  physically  capable,  barring 
an  occasional  seizure,  of  working  regularly  and  re- 
quiring the  least  supervision.  If  at  the  onset 
patients  are  admitted  irrespective  of  their  physical 
or  mental  disability,  or  of  both,  it  will  be  difficult 
with  such  a  handicap  to  develop  the  institution  prop- 
erly during  the  early  days  of  its  existence  when 
every  bit  of  energy  that  can  be  secured  should  be 
utilized  for  constructive  purposes.  The  colony  will 
grow  toward  completion  more  satisfactorily  if  this 
one  idea  is  borne  in  mind.  Many  of  those  sent  to 
a  colony  should  be  kept  there  indefinitely,  both  for 
their  own  good  and  for  that  of  the  public. 

One  of  the  greatest  problems  institutions  have  to 
contend  with  is  the  providing  of.  proper  care  and 
supervision  for  those  of  its  inmates  who  are  mark- 
edly defective  mentally.  These  will  not  ordinarily 
improve  materially  as  a  result  of  colony  treatment. 
The  average  epileptic  does,  however,  after  a  resi- 
dence of  several  months  show  more  or  less  improve- 
ment, in  regard  both  to  his  epilepsy  and  to  his*  gen- 
eral health,  some  having  a  complete  cessation  of 
seizures. 

The  educational  work  of  an  institution  for  epi- 
leptics is  exceedingly  important.  It  should  be  de- 
veloped along  such  lines  as  not  onl}-  to  care  for  all 
of  the  younger  patients  whose  mental  state  permits 
of  educational  effort  being  applied  but  should  be 
extended  so  as  to  care  for  some  of  the  patients  of  a 
more  advanced  chronological  age,  who  because  of 
restricted  environment  during  their  earlier  years 
were  deprived  of  educational  advantages.  Education 
with  the  epileptic  is  of  peculiar  value  as  it  must  be 
considered  not  only  from  the  ordinary  viewpoint  of 
assisting  in  the  mental  development  of  the  individ- 
ual but  also  for  its  therapeutic  value.  The  pathetic 
side,  especially,  of  the  epileptic  school  child  should 
appeal  to  all.  He  is  capable  of  study,  yet  deprived 
of  school  opportunities  because  of  his  disorder. 
This  is  often  sufficient  to  prevent  any  relief  being 
afforded  him,  as  it  brings  discouragement  and  per- 
haps results  in  an  exaggeration  of  his  symptoms. 
Craig  Colony  is  arranging  to  have  its  educational 


department  affiliated  with  a  neighboring  State  Nor- 
mal School.  Under  such  an  extension  plan  the  pu- 
pils will  receive  desired  standards  of  instruction  and 
the  Normal  School  can  train  many  of  its  student 
teachers  in  methods  practical  in  nature  to  be  made 
use  of  in  special  classes  in  schools  throughout  the 
state  and  really  give  better  understanding  of  normal 
children. 

William  Pryor  Letchworth  mentions  the  impor- 
tance of  extended  classification  in  institutions  for 
epileptics,  e.  g.,  sex,  adults  from  children,  different 
grades  of  mentality,  etc.  All  of  those  having  ex- 
perience in  state  institutions  will  agree  that  the 
thoroughness  with  which  this  classification  can  be 
carried  out  has  a  great  bearing  on  the  degree  of  suc- 
cess attainable  in  care  and  treatment,  especially  o^ 
those  of  better  mentality.  As  classification  is  of 
fundamental  importance  in  approaching  the  ideal 
of  individual  treatment,  too  much  stress  cannot  be 
laid  on  the  desirability  of  having  small  buildings, 
the  details  of  the  interior  construction  of  which 
make  for  not  only  easier  and  safer  but  more  bene- 
ficial care  for  epileptics.  Large  buildings  in  a  col- 
ony are  entirely  contrary  to  the  first  principle  of 
colony  organization.  The  smaller  the  cottages  and 
the  nearer  they  approach  a  home,  the  greater  the 
success  in  classifying  and  the  more  nearly  the  struc- 
ture affords  contentment  for  its  residents. 

There  should  be  available  in  a  colony,  cottages 
for  patients  who  become  temporarily  confused. 
From  time  to  time  patients  who  under  ordinary  cir- 
cumstances are  of  such  a  status  mentally  as  to  per- 
mit of  their  residing  with  the  more  intelligent 
patients,  become  temporarily  mentally  unbalanced 
and  require  at  such  times  close  supervision  and  spe- 
cial treatment.  Special  facilities  should  be  provided 
for  their  humane  care  during  the  existence  of  such 
periods  in  the  way  of  simply  arranged  one  story 
structures  with  proper  outfit  .  for  hydrotherapy, 
special  diet  kitchen  and  other  essentials. 

As  to  the  ultimate  size  of  a  colony  there  has  been 
much  discussion  along  both  theoretical  and  practical 
lines.  "One  fundamental  error  in  founding  many 
institutions  is  in  making  them  too  small."  This 
statement  made  by  Dr.  William  P.  Spratling  many 
years  ago  still  holds  true.  A  moderate  sized  colony 
or  village  can  have  available  many  important  fea- 
tures that  cost  prohibits  to  the  institution  which  is 
too  small.  The  epileptic  population  in  the  district 
will  naturally  regulate  to  a  great  extent  the  ultimate 
size  of  the  institution.  Ordinarily,  the  institution 
having  capacity  for  from  five  hundred  to  a  thou- 
sand patients  can  have  a  reasonable  variety  of  occu- 
pational and  recreational  activities  for  therapeusis, 
can  maintain  various  industries  of  a  value  toward 
lessening  the  net  cost  of  maintenance,  and  can  pro- 
vide facilities  for  satisfactory  classification  and 
scientific  care  and  treatment,  under  the  guidance  of 
an  executive  who  can  have  a  close  personal  and  in- 
timate familiarity  with  the  operation  of  the  colony 
and  an  acquaintance  with  its  inmates.  In  an  insti- 
tution with  two  or  three  times  this  population,  the 
superintendent  must  perforce  have  a  less  direct 
relation  to  the  various  phases  of  institutional  activ- 
ities. As  to  the  economical  administration,  there 
is   probably   nothing  gained   after   an  institution 


882 


SHAA-AHAX 


PROVISION  FOR  EPILEPTICS. 


[New  York 
Medical  Journal. 


passes  a  capacity  of  perhaps  a  thousand  inmates. 
Another  point  made  by  IMr.  Letchworth  many  years 
ago  and  which  I  believe  should  be  borne  in  mind 
'.vhen  new  institutions  are  established  is  to  give  the 
institution  a  title  without  inserting  in  the  same  the 
word  epileptic.  The  Craig  Colony  has  this  year 
secured  the  enactment  of  legislation  restoring  its 
original  title,  Craig  Colony. 

The  occupations  ottered  the  colonists  should  be 
most  varied.  There  is  no  good  reason  why  the  epi- 
leptic whose  mentality  is  not  too  low  should  not, 
under  proper  direction,  pursue  any  ordinary  avoca- 
tion barring  one  which  would  place  him  in  situations 
dangerous  to  him  because  of  his  seizures.  Work  is 
e^pecially  valuable  as  a  means  of  treatment,  as  care- 
fully regulated  occupations  often  seem  to  lessen  the 
number  of  seizures  and  prevent  mental  deteriora- 
tion. The  type  of  employment  should,  if  possible, 
prove  interesting  and  in  many  cases  must  be  of  a 
character  different  from  that  pursued  previous  to 
admission  to  the  colony. 

The  most  valuable  form  of  labor,  both  from  the 
viewpoint  of  treatment  and  from  that  of  monetary 
return  to  the  colony,  is  perhaps  out  of  door  work  in 
the  garden  and  on  the  farm,  with  their  diversified 
interests,  including  forestry,  breeding  and  raising  of 
live  stock,  and  other  occupations.  After  that  in  im- 
portance comes  the  work  in  shops,  household, 
laundry,  and  sewing  rooms.  If  sufficient  suitable 
land  and  equipment  are  available,  there  is  no  good 
reason  why  all  vegetables  and  milk  required  and  a 
considerable  portion  of  meat,  eggs,  fruit,  and  other 
articles  of  diet  cannot  be  raised  on  the  colony  prem- 
ises. A  considerable  proportion  of  repairs  and 
minor  improvements  can  be  done,  largely  by  patient 
labor,  and  many  articles,  such  as  mats,  rugs, 
brushes,  brooms,  willow  baskets  and  furniturer 
mattresses,  clothing,  stockings,  caps,  hats,  and  other 
utensils  can  be  made  by  the  colonists.  The  making 
of  soap,  printing  and  binding,  caning  chairs  and 
other  activities  can  easily  be  carried  on.  As  the  in- 
stitution grows,  the  industrial  work  can  be  progres- 
sively developed.  Local  conditions  may  permit 
special  industries,  for  instance,  brick  and  tile  mak- 
ing, forestry,  butter  and  cheese  making. 

The  earning  capacity  of  the  epileptic,  as  a  class, 
has  been  overestimated  by  many  of  the  general  pub- 
lic, and  even  by  some  more  familiar  with  their 
special  care.  The  very  word  defective  should  im- 
ply that  one  must  not  expect  a  community  of 
defectives  to  be  selfsupporting.  Of  the  total  num- 
ber of  epileptics  in  the  average  state  colony,  about 
fifty  per  cent,  are  capable  of  doing  labor  of  some 
kind  and  from  ten  to  fifteen  per  cent,  can  perform 
considerable  work  when  not  incapacitated  in  conse- 
quence of  seizures.  Various  games  and  sports,  both 
indoor  and  out,  should  be  provided. 

Conscientious  heads  of  departments,  sympathetic 
in  nature,  should  be  appointed  so  that  it  will  always 
be  evident  that  the  diversions  are  therapeutic  meas- 
ures primarily,  and  for  entertainment  secondarily, 
and  that  industrial  depai-tments  are  ior  monetary 
return  less  than  for  therapeutic  value. 

A  state  institution  must  perforce  expect  to  pro- 
vide the  common  necessities  of  life  without  the 
luxuries  which  a  private,  well  endowed  institution 


would  be  in  a  position  to  furnish  its  inmates.  In 
judging  a  state  institution's  standards,  this  fact 
must  always  be  foremost  in  the  mind  of  the  exami- 
ner. Proper  housing,  food,  clothing,  medical  and 
nursing  care,  sensible  hygienic  methods  as  to  bath- 
ing, recreation,  and  other  activities,  with  all  reason- 
able opportunities  for  relatives  and  friends  to  visit 
patients  and  assignment  so  far  as  means  permit  of 
compatible  patients  in  each  cottage,  are  demands 
which  should  be  met.  The  proper  care  of  inmates 
should  not,  however,  be  based  solely  on  economy. 
The  best  care  in  the  proper  sense  is  most  economical. 

\Miile  the  per  capita  cost  of  maintenance  must 
receive  careful  consideration,  nevertheless  we  must 
bear  in  mind  that  there  is  a  certain  irreducible  mini- 
mal plane  which  we  must  keep  above  if  the  epilep- 
tic is  to  receive  the  consistently  regulated  care  and 
treatment  required  by  one  of  his  makeup.  Some 
nonessentials  may  be  ignored,  efforts  toward  re- 
search and  investigation  rpay  be  deferred  and  hy- 
gienic and  dietary  standards  may  be  modified  but 
cannot  be  abolished,  unless  we  seek  to  disregard 
entirely  the  purposes  for  which  the  special  institu- 
tions have  been  established. 

The  social  aspects  of"  epilepsy  have  in  recent  years 
been  recognized  to  a  greater  extent  by  the  general 
public  than  formerly.  The  difficulty  experienced  in 
ordinary  homes  in  giving  care  to  an  epileptic  rela- 
tive is  such  that  urgent  relief  is  often  demanded. 
Not  only  may  the  epileptic  in  the  family  cause 
much  worry  to  the  other  members,  but  such  special 
attention  is  required  by  him  that  another  member 
i^iust  remain  in  the  home,  who  could  otherwise  add 
to  the  family  income.  Except  in  families  with 
means,  an  epileptic  having  frequent  seizures  or 
showing  mental  change  cannot  be  kept  at  home 
indefinitely,  but  must  be  placed  in  an  institution 
when  such  is  available.  In  the  specially  arranged 
institution  he  is  allowed  all  the  liberty  which  broad 
consideration  of  his  condition  would  warrant.  He 
is  afforded  a  more  comfortable  existence  than  can 
ordinarily  be  obtained  outside,  removed  from  an 
environment  where  many  irritating  and  annoying 
stresses  are  active  and  placed  where,  so  far  as 
facilities  permit,  all  the  upsetting  factors  are 
obviated. 

The  true  epileptic,  as  has  been  mentioned,  has 
an  abnormal  makeup,  and  while  he  may  be  fortu- 
nate enough  to  have  his  convulsions  and  other 
seizure  phenomena  in  abeyance,  his  mannerisms,  his 
reactions  to  various  influences  in  ordinary  environ- 
ment, can  only  be  changed  in  part  and  not  entirely 
removed.  His  is  a  receptive  state  which  differs 
from  the  nonepileptic,  so  that  disturbing  influences 
acting  upon  him  may  bring  to  light  or  cause  a 
recurrence  of  attacks  which  had  been  thought  to 
be  permanently  removed. 

Individualization  is  mandatory  for  success  in 
treatment.  Relief,  so  far  as  possible  from  disturb- 
ance from  environment,  must  be  secured  to  make 
socialization  possible,  with  little  or  no  lowering  of 
the  intellectual  level.  Music,  artistic  pursuits,  re- 
education, must  be  made  use  of  for  epileptics  with 
sufficient  mentality.  Mental  and  physical  recrea- 
tion and  rest  in  proper  proportion  for  the  abnormal 
physical  and  mental  endowment  which  exists  are 


December  4,  1920.] 


SHANAHAN:  PROVISION  FOR  EPILEPTICS. 


883 


required.  Entertainments  and  amusements  are 
primarily  part  of  treatment.  All  work  and  no  play 
makes  for  mental  dullness.  Recreation,  properly 
arranged,  promotes  a  cheerful  atmosphere  every- 
where, but  especially  so  in  an  isolated  community 
like  a  colony.  Employees  to  be  retained  in  the 
service  must  also  have  means  of  recreation  afiforded 
them.  If  those  having  to  do  with  the  making  of 
appropriations  had  to  live,  day  in  and  day  out,  in 
an  institution  for  the  care  of  defectives,  an  always 
depressing  situation,  they  might  be  more  considerate 
of  requests  for  funds  for  establishing  means  of 
diversion  and  recreation  as  well  as  for  expedience 
in  advancing  the  general  purposes  for  which  the 
institution  was  established.  One  potent  reason  why 
we  meet  with  such  apathy  from  those  who  could 
help  the  situation  is  that  they  forget  the  individual 
in  considering  the  mass. 

The  average  epileptic  in  a  colony  can  be  allowed 
entire  liberty  about  the  premises  and  various  privi- 
leges consistent  with  the  mental  status  of  the  indi- 
vidual. Serious  quarrels  or  infractions  of  rules  are 
not  more  frequent  than  in  an  ordinary  village  of 
the  same  population. 

The  village  idea,  with  varied  but  harmonious 
types  of  architecture,  should  always  be  foremost  in 
the  development  of  a  colony  so  that  the  stamp  of 
the  institution  may  be  as  much  in  the  background 
as  possible.  Preceding  the  inauguration  of  the 
colony  development,  complete  plans  as  to  its  ulti- 
mate size,  arrangements  of  groups,  and  other  details 
should  be  carefully  formulated,  but  these  plans 
should  not  be  so  fixed  that  the  benefits  of  experience 
cannot  be  applied  as  the  colony  passes  through  its 
dift'erent  stages  of  growth. 

Difficulties  encountered  by  hospitals  in  obtaining 
funds  for  development  are  common,  but  often  there 
are  special  troubles  besetting,  state  institutions, 
owing  to  lack  of  sufficient  first  hand  information 
by  the  appropriating  bodies  of  actual  requirements 
and  the  purposes  of  the  particular  institution.  Plans 
for  progressive  development  may  be  delayed  for 
many,  many  years  because  of  lack  of  adequate  funds. 

It  has  been  demonstrated  upon  investigation  made 
in  various  parts  of  the  country  that  a  considerable 
proportion  of  adult  epileptics  of  better  mentality 
would  be  able  to  live  fairly  well  as  wage  earners, 
and  could  accomplish  var>tly  more  than  the  majority 
of  people  think  possible,  if  the  general  public  would 
appreciate  the  fact  that  many  of  them  are  incapaci- 
tated but  for  brief  periods  and  would  make  allow- 
ance for  these  interruptions  in  their  conscious  life. 
It  has  been  well  said  that  many  of  them  are  obliged 
to  accept  work  which  is  not  congenial  and  often 
far  below  their  capacity  and  that  the  length  of  their 
service  depends  more  upon  infrequency  of  seizures 
than  it  does  upon  their  efficiency  or  the  character  of 
their  occupation.  Too  often  the  unfortunate  epi- 
leptic of  better  mentality  is  relegated  to  unskilled 
labor,  even  in  which  capacity  he  is  buffeted  about 
from  place  to  place  when  his  seizures  occur.  If 
employers  and  fellow  employees  could  be  made  to 
look  upon  him  in  a  different  manner,  be  a  little 
patient  and  sympathetic,  one  might  say  human,  the 
problem  of  adequate  provision  for  many  epileptics 
would  be  reasonably  well  solved.    There  is  no  doubt 


whatever  that  the  epileptic  of  better  mentality  who 
has  to  maintain  himself  and  often  others,  has  his 
condition  made  worse  by  constantly  worrying  over 
the  difficulty  of  obtaining  and  retaining  a  position. 

For  this  class,  a  more  numerous  one  than  is 
ordinarily  thought,  there  is  an  almost  unlimited 
opportunity  of  service  by  those  interested  in  their 
afflicted  fellowmen.  Outpatient  clinics  maintained 
by  special  institutions  for  consultation  can  accom- 
plish much  for  them.  Every  human  individual 
should  have  the  privilege  of  living  under  the  best 
possible  conditions.  It  is  not  only  a  duty  but  an 
obligation  of  the  normal,  healthy  group  to  afford 
reasonable  opportunities  and  assistance  to  the  handi- 
capped to  bring  this  to  pass  in  our  great  nation. 

A  salary  commensurate  with  qualifications  de- 
manded and  suitable  living  accommodations  for 
members  of  the  resident  medical  staff  should  be 
provided  with  separate  cottages,  permitting  married 
officers  to  live  an  ordinary  family  -  life,  tending 
to  attract  men  of  a  professional  type,  interested  and 
inclined  to  pursue  institutional  activities  as  a  life 
specialty.  Adequate  compensation  and  proper  liv- 
ing accommodations  must  also  be  had  to  insure  a 
nursing  and  teaching  force,  equipped  to  carry  out 
the  therapeusis  of  remedial  cases  as  outlined  and 
directed  by  the  medical  staff. 

A  public  institution  cannot,  with  justice,  be  criti- 
cized adversely  when  it  is  beyond  its  power  because 
of  inadequate  salaries,  as  well  as  insufficient  living 
accommodations  to  attract  nurses  and  attendants 
who  are  sympathetic,  intelligent  and  altruistic  and 
with  sufficient  inherent  ability  and  selfcontrol  to 
meet  the  stress  of  institutional  employment.  Under 
these  circumstances  we  cannot  expect  to  obtain  even 
an  ordinary  class  of  employees.  The  care  of 
patients,  let  alone  the  treatment,  cannot  be  carried 
out  in  the  manner  sought  for  unless  there  are 
available  in  sufficient  numbers  nurses  and  attend- 
ants possessing  these  C|ualities. 

Every  institution  for  epileptics,  after  it  is  well 
established,  should  have  as  part  of  its  organization 
a  training  school  for  nurses  and  attendants.  Such 
a  school  has  many  advantages  and  can  do  much  to 
elevate  the  general  standard  of  care  of  the  patients 
in  the  institution.  In  the  last  analysis  the  end 
results  and  work  of  an  institution  for  epileptics,  the 
same  as  for  other  mentally  or  physically  ill,  rests 
upon  a  foundation  more  or  less  firm,  depending 
upon  the  quality,  of  its  nursing  force  as  it  is  the 
members  of  this  particular  organization  who  come 
in  intimate  contact  with  the  patients  at  the  colony. 
Every  legitimate  means  should  be  exerted  to  attract 
to  the  service  of  the  institution  the  most  efficient 
individuals  to  compose  its  nursing  force.  While 
the  majority  of  the  graduates  of  the  training  school 
for  nurses  leave  the  institution  in  which  they  are 
trained,  nevertheless,  during  the  course  of  training 
the  institution  has  the  benefit  of  their  work. 

An  institution  has  to  contend  with  the  proposition 
of  preventing,  so  far  as  possible,  patients  leaving 
without  permission.  In  the  open  colony  system, 
there  is  a  maximum  of  liberty  for  the  majority  of 
the  patients  and  occasionally  one  takes  advantage 
of  the  privilege  extended  and  departs.  Minimal 
custodial  care  is  the  ideal  to  be  sought  for  in  aiming 


884 


SliANAHAN:  PROVISION  FOR  EPILEPTICS. 


[New  York 
Medical  Journal. 


to  effect  a  satisfactory  improvement  in  the  health 
of  the  colonist.  Not  infrequently  relatives  and 
friends  of  the  patients  arc  at  fault,  as  they,  by  their 
manner  or  attitude,  incite  the  particular  patient  to 
run  away.  Newly  admitted  patients  at  times  fail 
to  adapt  themselves  to  their  unaccustomed  environ- 
ment. Suffering  from  nostalgia,  they  become  dis- 
contented or  dissatisfied  because  of  not  finding  con- 
ditions as  represented  by  relatives  or  friends  who 
make  false  or  misleading  statements  to  them  so  as 
to  induce  them  to  come  to  the  institution.  With 
epileptics  subject  as  they  are  to  loss  of  consciousness 
and  occasionally  a  wandering  impulse,  a  few  leave 
because  of  such  irresponsible  condition,  which  is 
temporary  in  nature. 

It  is  my  opinion  that  all  institutions  fqr  epileptics 
should  operate  under  a  law  which  would  provide 
that  all  of  those  applicants  who  are  mentally  in- 
competent should  be  duly  committed  by  law  through 
a  proper  court,  and  that  those  applicants  who  are 
of  normal  mentality  should  be  received  as  volun- 
tary patients,  it  being  provided  that  upon  short 
written  notice  they  may  leave  the  institution.  It 
is  not  an  uncommon  experience  to  find  many  phy- 
sicians, social  workers  and  poor  law  officers  who 
cannot  recognize  the  fact  that  some  epileptics  are 
quite  normal  mentally ;  they  seem  to  feel  that  all 
are  in  every  respect  different  from  ordinary  indi- 
viduals. Every  effort  should  be  made  to  obtain 
applicants  who  are  normal  mentally,  or  who  ap- 
proach that  status.  Not  only  is  the  outlook  for  the 
epileptic  of  normal  mentality  quite  good  if  put 
under  proper  care  at  an  early  period  of  his  disorder, 
but  the  care  of  such  a  patient  is  much  easier  and 
more  pleasant,  and  adds  materially  to  the  en- 
couragement of  those  working  in  institutions.  This- 
is  a  feature  which  should  be  given  consideration  as 
time  goes  on.  Since  Craig  Colony  was  first  opened 
for  patients,  over  five  thousand  have  been  received, 
of  which  number  ten  per  cent,  have  graded  mentally 
as  approximately  normal ;  fifteen  per  cent,  have 
been  found  to  have  undergone  a  more  or  less  marked 
mental  deterioration  from  what  was  apparently 
originally  an  average  normal  mental  condition ; 
seventy-five  per  cent,  of  the  entire  number  have 
been  primarily  mentally  defective,  exhibiting  dif- 
ferent grades  of  feeblemindedness. 

Broad  viewpoints  of  the  treatment  of  the  epi- 
leptics must  embrace  not  only  the  question  of  intra- 
institutional  but  also  extrainstitutional  care,  depend- 
ing on  the  various  circumstances  of  the  individual 
epileptic.  Every  legitimate  means  of  publicity  should 
be  employed  in  communities  towards  encouraging 
epileptics  and  those  interested  in  them  to  place  this 
class  under  early  proper  guidance  in  an  effort  to 
effect  such  change  in  their  mode  of  life  as  may  be 
indicated.  Common  sense  principles  should  prevail 
in  giving  advice  as  to  the  general  treatment  of 
epilepsy  and  related  conditions.  Success  can  only 
be  obtained  from  individual  treatment  founded 
upon  the  critical  analysis  of  the  epileptic  himself. 
A  prescription  of  sedatives  and  a  few  words  per- 
taining to  diet  and  hygiene  will  accomplish  little. 

The  possibility  of  social  advantages  in  the  way 
of  extension  work  by  institutions  for  epileptics  and 
following  up  discharged  patients  is  not  given  suffi- 


cient recognition.  All  institutions  for  epileptics 
should  have  a  sufficiently  expansive  organization  to 
permit  of  care  being  extended  along  these  lines, 
such  work  ultimately  proving  of  material  value  to 
the  various  communities  thus  served.  Craig  Colony 
was  a  pioneer  in  requesting  funds  for  field  workers, 
but  unfortunately,  its  requests  have  not  thus  far 
borne  fruit.  In  an  eft"ort  to  diffuse  information 
not  only  by  word  of  mouth  but  by  action,  in  regard 
to  prophylaxis,  social  adaptation,  support  of  insti- 
tution and  other  important  matters  so  far  as  epi- 
leptics are  concerned,  too  much  stress  cannot  be 
laid  on  the  necessity  for  applicants  of  better  men- 
tality being  truthfully  told  the  purpose  for  which 
they  are  sent  to  the  state  colony.  They  should  not 
be  deceived  by  pretending  they  are  to  be  placed  in 
a  summer  hotel,  taken  on  a  pleasure  trip,  assigned 
to  new  employment,  or  some  other  falsehood.  The 
failure  to  properly  acquaint  the  applicant  with  the 
reason  why  he  or  she  should  enter  the  institution 
naturally  causes  loss  of  confidence  in  relatives  and 
friends  and  gives  rise  to  suspicion,  not  only  of  those 
persons  but  also  the  institution  itself,  and  is  a 
potential  source  of  difficulty  in  bringing  about  a 
readjustment  to  the  new  living  conditions  and  the 
cooperation  so  essential  on  the  part  of  the  patient 
is  either  halfheartedly  given  or  lacking  to  such  a 
degree  as  to  amount  to  an  antagonistic  attitude.  I 
remember  reading  sometime  since  a  comment  by 
Dr.  Copp  that,  "No  institution  can  accept  the  fact 
that  it  is  only  a  place  to  live  in.  It  is  more  than 
a  custodial  function.  You  cannot  say  'There  is 
nothing  to  be  done'  because  the  patient  is  not  going 
to  get  well." 

It  has  been  stated  by  investigators  that  about  ten 
per  cent,  of  epileptics  seek  institutional  care  because 
of  present  conditions.  Our  efforts  should  be  exerted 
toward  affording  care  and  relief  when  such  is 
possible  to  many  now  uncared  for.  It  should,  how- 
ever, be  borne  in  mind  that  the  majority  of  epileptics 
socalled  do  not  require  institutional  care,  nor  is  it 
demanded  by  the  community  as  for  the  insane  whom 
people  fear. 

When  a  benevolent  public  and  well  disposed  legis- 
lators can  once  forget  the  existing  erroneous  idea 
of  epilepsy  and  look  on  it  as  an  illness  which  is 
likely  to  attack  their  nearest  and  dearest  of  any 
age,  and  at  any  time,  we  hope  in  our  own  state  at 
least,  when  the  financial  crisis  passes  and  things 
assume  a  more  normal  aspect,  they  will  awake  and 
wonder  and  reproach  themselves  for  their  neglect 
toward  this  class  of  patients,  making  amends  by 
supplying  the  places  so  sadly  needed. 

When  the  condition  of  the  respective  states  war- 
rants, I  would  urge  an  energetic  campaign  to  pro- 
vide colony  care  or  proper  supervision  for  a  much 
larger  number  of  the  great  group  of  epileptics  with 
little  mental  defect  in  whom  there  is  promise  of 
improvement  and  who  are  now  unable  for  one 
reason  or  another  to  obtain  the  continued  advice 
they  so  much  need.  All  agencies  interested  must 
cooperate  if  success  is  to  be  had.  New  York  should 
further  develop  Craig  Colony  and  ultimately  estab- 
lish another  colony  near  Greater  New  York. 

REFERENCES. 

1.    Letch  WORTH,  William  Pryor:  Care  and  Treatment 
of  Epileptics. 


December  4.  1920.] 


MARSH:  PHENOMENA   OF  EPILEPSY. 


885 


A  COMPAR-\TIVE  STUDY  OF  THE  - 
PHEXOMEXA  OF  EPILEPSY* 
IV Uh  the  Actions  of  Normal  Man. 
By  Chester  A.  Marsh,  M.  D., 
New  Castle,  Ind., 
Assistant  Physician,  Indiana  Village  for  Epileptics. 

The  spirit  of  the  day'  is  one  of  intense  eagerness 
to  build  anew.  The  medical  profession  has  taken 
part  in  the  world's  militant  conflict  which  brought 
about  the  destruction  of  institutions  that  had  ceased 
to  insure  progress  and  growth.  But  as  order  and 
purpose  must  always  govern  mankind,  we  now  look 
for  the  signs  of  new  laws  and  principles,  growing 
out  of  the  ruins  of  war,  which  shall  make  for  a 
higher  state  of  civilization.  This  is  what  is  taking 
place  throughout  the  world  today  and  what  is  true 
of  the  social  organism  as  a  whole  we  must  expect 
of  its  parts.  The  stimulus  for  this  new  growth  in 
medicine  is  felt  when  we  review  the  progress  made 
in  this  field  during  the  war.  We  point  with  pride 
to  important  advances  made,  under  army  influences, 
in  surgical  measures,  and  to  new  discoveries  in 
immunology ;  to  increased  efficiency  in  methods  of 
diagnosis  and  to  standardization  in  rontgenological 
technic.  Truly  a  new  foundation  has  been  laid 
out  of  the  materials  of  destruction  for  a  greater 
development  in  the  science  of  medicine. 

But  this  vast  medical  force,  having  been  released 
from  the  paternalistic  control  of  the  army  by 
demobilization,  now  faces,  upon  its  own  resources, 
the  problems  of  readjustment.  Although  there  is 
a  general  hope  and  confidence  for  better  things,  not 
a  few  men  view  with  alarm  our  present  status. 
Such  a  position  can  be  held  only  by  men  who  lack 
proper  perspective.  In  our  own  particular  field — 
the  study  of  the  phenomena  of  epilepsy — we  find 
example  of  this  narrowness  of  vision  in  those  who 
cry  that  nothing  but  conflicting  views  are  presented 
concerning  the  cause  and  treatment  of  epilepsy; 
that  nothing  but  a  confusion  of  ideas  exists  in  what 
is  said  or  done  to  help  the  epileptic.  Such  men  are 
wont  to  say  that  alcohol  as  a  causative  factor  in 
epilepsy  is  overrated  and  that  all  who  suffer  from 
epilepsy  do  not  show  a  taint  in  their  family  history. 
They  believe  that  the  psychogenic  theory  of  the 
cause  of  epilepsy  is  a  bursting  bubble  and  that 
feeble  facts  marshalled  against  the  pituitary  gland 
have  greatly  increased  the  consumption  of  pituitary 
extract.  They  feel  that  surgical  measures  of  what- 
ever kind  perfonned  on  the  epileptic  are  ill  advised 
and  indiscriminate,  whether  it  be  on  the  colon  to 
alleviate  intestinal  stasis  or  on  the  skull  to  relieve 
intracranial  pressure ;  and  that  eye  strain  as  a  cause 
of  epilepsy  cannot  be  held  as  important  until  some 
institution  can  prove  conclusively  that  there  is  such 
a  thing  as  an  epileptic  eye.  They  are  able  to  offer 
only  unfavorable  criticism  as  a  reward  to  the 
workers  of  the  past. 

Knowing  then  that  in  past  experience  is  found 
the  elements  of  truth  upon  which  progress  is  made, 
we  cannot  wholly  disregard  any  particular  line  of 
investigation  that  has  been  made  in  the  study  of 
epilepsy.    Though  we  realize,  perhaps,  that  we  can 

•Read  before  the  National  Association  for  the  Study  of  Epilepsy  at 
the  New  York  Academy  of  Medicine,  Tune  3,  1920. 


Utilize  but  little  of  the  information  thus  obtained, 
we  are  compelled  to  examine  in  detail  material  that 
often  seems  irrelevant.  Our  reason  for  wanting  to 
know  something  of  the  family  history,  something 
of  the  health  or  sickness  of  brothers  and  sisters,  of 
father  and  mother  and  other  close  relatives,  then 
becomes  apparent.  We  see  why  it  is  important 
to  know  something  of  their  mental  calibre,  of  their 
temperament  as  to  industriousness,  of  family  traits, 
of  tendencies  to  nervousness — in  sickness  or  in 
health — of  insanity,  feeblemindedness  or  epilepsy, 
peculiarities  as  to  eccentricities,  mannerisms,  geni- 
uses or  cranks,  of  immorality,  sexual  or  criminalistic 
tendencies,  of  chronic  disease,  including  syphilis, 
tuberculosis,  cancer,  alcoholism  or  drug  addiction. 
All  of  these  are  important  as  well  as  any  other 
condition  of  disorder  the  family  may  manifest. 

In  the  personal  history  of  the  patient,  also,  we 
spare  no  effort  in  our  examination  of  details. 
Factors  bearing  on  the  prenatal  history  of  the 
patient  are  not  without  importance  in  the  disorder 
of  epilepsy.  We  want  to  know  in  particular  some- 
thing of  the  general  condition  of  the  father  and 
mother  at  the  time  of  conception  of  the  patient — 
were  they  healthy — were  they  intoxicated — what 
was  their  mental  state  at '  the  time — was  the  child 
desired  or  was  it  an  accidental  conception — was 
there  an  attempt  at  the  time  or  afterward  to  inter- 
rupt the  pregnancy?  It  is  important  to  know  how 
many  induced  abortions  and  how  many  which  were 
without  intervention ;  the  condition  of  the  mother's 
health,  both  mental  and  physical,  during  the  preg- 
nane}';  whether  or  not  at  this  time  she  was  sick  or 
received  an  injury. 

In  the  postnatal  history  we  should  know  some- 
thing of  the  health  of  the  patient  at  birth  and  dur- 
ing the  nursing  period ;  something  of  his  mental  and 
physical  characteristics  up  to  the  school  age,  and  in 
particular  his  temperament ;  as  to  whether  or  not 
he  had  crying  spells,  fits  of  anger,  or  a  tendency 
toward  whims,  and  whether  or  not  he  had  broad 
interests  in  play.  In  his  school  history  we  should 
know  whether  or  not  he  was  normal,  slow  or  pre- 
cocious in  his  studies.  Whether  or  not  he  took  well 
with  playmates  and  possessed  lots  of  friends ;  were 
broad  interests  developed,  and  the  nature  of  them. 

When  we  take  up  the  immediate  complaint  of  the 
patient,  it  is  interesting  to  know  the  patient's  and 
family's  assigned  cause  of  the  disorder;  the  char- 
acter of  seizures  and  the  duration  of  the  affliction ; 
the  disposition  of  the  patient  previous  to  the  onset 
of  the  affliction  and  before  and  after  seizures. 

The  physical  examination  should  be  thorough  and 
complete ;  any  physical  defect  on  inspection,  palpa- 
tion, percussion  and  auscultation,  should  be  noted. 
This  should  include  complete  laboratory  tests  of 
the  urine  and  blood,  with  x  ray  findings  of  the 
head,  chest  and  alimentary  tract.  This  of  course 
includes  a  complete  neurological  examination,  local- 
izing as  far  as  possible  the  seat  and  type  of  lesion 
discovered.  In  doing  this,  all  reflexes  should  be 
tested,  including  the  pupillary,  abdominal,  knee, 
and  others ;  sensation,  tactile  and  deep  muscle  sense ; 
station,  cerebellar  by  the  Romberg;  tremors  of  the 
eyes,  mouth,  face  and  fingers  ;  speech  by  test  phrases. 

The  mental  examination  should  be  as  complete 


886 


MARSH:  PHENOMENA  OF  EPILEPSY. 


[New  York 
Medical  Journal. 


as  we  can  make  it.  In  this,  the  mental  age  of  the 
patient  should  be  determined,  as  by  the  Simon-Binet 
test,  for  example.  His  emotional  life-  should  be 
viewed  as  manifested  at  different  periods  in  his  life, 
showing  particular  and  general  interests  in  sur- 
rounding affairs,  noting  especially  his  temperament 
under  conditions  of  stress  and  under  favorable  cir- 
cumstances, with  special  emphasis  of  any  manifes- 
tations of  a  lack  or  poverty  of  emotional  interests. 
It  is  particularly  important  to  note  how  the  patient 
sleeps,  if  well  and  how  long,  whether  or  not  it  is 
shallow,  restless,  or  with  a  tendency  to  dream  and 
the  nature  of  the  dreams.  The  mental  examination 
should  include  an  observation  of  the  patient's  powers 
of  perception,  noting  illusions,  hallucinations  and 
delusions,  either  admitted,  elicited  or  indicated ;  his 
powers  of  consciousness,  whether  clear  or  befogged  ; 
of  attention,  whether  normal  or  distractable ;  of 
memory,  whether  it  is  good  for  recent  as  well  as 
remote  events ;  of  orientation  as  to  time,  place  and 
person;  his  train  of  thought,  whether  it  shows 
retardation  or  a  flight  of  ideas ;  his  power  of  judg- 
ment, rational  or  delusional;  if  the  latter,  whether 
of  persecution,  fears,  selfaccusation  or  of  grandiose 
ideas;  his  judgment  as  to  the  value  of  things;  and 
his  general  conduct  at  play  or  at  work,  at  home  or 
in  an  institution,  without  restraint  or  under  close 
guard. 

In  a  general  way  this  is  the  nature  of  a  proper 
examination  of  our  patient.  The  rehashing  of  these 
points  no  doubt  has  been  tiresome.  It  has  not  been 
my  purpose,  however,  to  put  myself  in  a  position 
to  say  what  method  should  constitute  a  proper 
examination.  My  purpose  is  rather  to  emphasize 
the  importance  of  a  careful  examination  of  the 
patient.  Through  such  an  examination,  we  are  abls 
to  discover  not  only  any  process  of  disease  or  men- 
tal disorder  which  our  patient  may  have,  but  we 
come  into  possession  of  knowledge  which  helps  us 
to  understand  more  fully  the  factors  at  work  \yhich 
produce  a  convulsion  and  tend  to  its  repetition. 
We  are  able  to  pick  up  those  elements  of  truths 
from  these  various  sources  of  investigation  once 
supposed  to  explain  the  phenomena  of  epilepsy  and 
putting  them  together  we  are  able  not  only  to  see 
their  particular  application,  but  we  are  able  to  draw 
conclusions  from  them  -vhich  throw  a  better  light 
on  our  problem. 

In  the  past  we  were  wont  to  look  upon  epilepsy 
as  an  entity  in  itself,  just  as  we  now  view  syphilis, 
typhoid  or  cancer.  From  such  a  viewpoint,  the 
bacteriologist  hoped  to  find  a  germ  as  the  causative 
agent.  But  no  infectious  organism  is  found  which 
produces  the  disorder.  From  a  similar  position  the 
pathologist  with  untiring  toil  labored  to  discover 
some  gross  lesion  which  would  account  for  the  con- 
dition. But  no  pathological  condition  is  known  that 
is  common  to  all  so  afflicted.  In  a  similar  manner 
the  clinician  has  failed  to  establish  such  theories  as 
endocrinological  disturbance, .  acidosis  or  increased 
intracranial  pressure.  The  psychiatrist,  by  a  classi- 
fication of  abnormal  mental  symptoms  as  seen 
in  the  epileptic,  points  to  a  generalized  instability 
of  the  cortical  centres  and  to  an  inherited  nervous 
tendency.  A  more  recent  classification  presents  a 
very  careful  study  of  the  mental  symptoms  of  the 


epileptic,  from  which  a  conclusion  is  drawn  that 
there  is  an  epileptic  type,  a  person  with  a  peculiar 
but  definite  mental  -makeup,  which,  when  present, 
constitutes  a  potential  epileptic  character  that  goes 
the  epileptic  way  when  a  certain  type  of  stress  is 
encountered.  Unfavorable  criticism  is  not  to  be 
passed  upon  any  of  these  theories  for  it  is  work  of 
a  constructive  nature  which  guides  us  in  the  care 
and  treatment  of  our  patient. 

\\'e  cannot,  however,  in  our  study  of  the  phenom- 
ena of  epilepsy,  view  it  from  any  particular  angle 
alone.  We  must  strike  a  deeper  level  than  that 
where  mental  symptoms  are  classified  or  where 
epilepsy,  spoken  of  in  the  plural  as  the  epilepsies, 
is  classified  according  to  known  or  unknown  symp- 
toms. We  must  do  more  than  classify.  Our  prob- 
lem leads  us  to  a  point  ot  broader  perspective  where 
processes  of  physical  and  mental  disease  may  be 
observed  in  their  proper  relation  in  the  disorder. 
We  must  see  that  both  physical  disease  and  abnormal 
mental  processes  produce  activity  of  a  particular 
character  and  that  the  whole  phenomena  of  a  partial 
or  entire  loss  of  consciousness,  with  or  without  con- 
vulsions, can  be  explained  only  in  terms  of  action 
of  a  definite  type. 

Bodily  activity  of  all  kinds  is  dependent  upon 
mental  states  of  which  we  may  or  may  not  at  the 
time  be  aware.  These  mental  states  are  purposeful 
in  their  operation  for  they  act  as  the  motive  force 
behind  our  actions.  When  they  find  expression  in 
a  normal  manner,  they  tend  to  secure  for  us  our 
general  good  fortune.  Should  they  find  expression 
in  an  abnormal  manner,  however,  and  be  habitually 
exercised  in  this  way  they  may  lead  to  the  possessor's 
destruction. 

The  phenomena  of  epilepsy  is  an  example  of  an 
habitual  abnormal  expression  of  mental  activity. 
The  epileptic,  when  he  meets  unsurmountable 
difificulties,  is  beset  with  mental  states  over  which 
he  has  no  control.  Everything  which  emphasizes 
the  futility  of  his  efforts  serves  all  the  more  to 
increase  his  emotional  drive  until  the  higher  brain 
centres,  which  have  to  do  with  the  directing  and 
the  consciousness  of  efforts,  are  exhausted  from 
overwork  because  of  this  extreme  nervous  tension. 
This  exhaustion  means  a  cessation  of  function  until 
a  period  of  rest  intervenes.  So  the  patient  suffers, 
according  to  the  degree  of  fatigue  or  exhaustion 
which  exists,  a  partial  or  complete  loss  of  conscious- 
ness. This  is  not  deep  enough  to  involve  the 
motor  centres,  so  the  emotion  goes  on  to  expression 
in  muscular  activity  partially  or  wholly  unguided 
and  undirected,  which  we  know  as  a  convulsive 
seizure.  When  this  becomes  the  patient's  habitual 
channel  of  outlet  for  strong  emotional  states,  we 
denote  the  condition  as  epilepsy. 

The  factors  which  tend  to  produce  these  strong 
mental  states,  while  numerous  and  varied,  are 
cryptogenic  in  their  nature.  By  a  classification  of 
the  mental  'symptoms  as  seen  in  the  epileptic,  some 
workers  have  thought  that  they  could  account  for 
the  disorder  on  the  basis  of  an  instability  of  the 
cortical  centres  of  the  brain.  From  a  similar  reason- 
ing we  have  heard  of  the  term  psychogenic  epilepsy. 
Such  a  conception  is  confusing  and  misleading,  for 
mental  states,  as  such,  which  cause  us  to  act,  come 


December  4,  1920.] 


MARSH:  FHENOMEXA   OF  EFILEFSY. 


887 


only  as  things  attract  or  excite  us  and  they  come 
from  without  and  not  from  within  the  brain  itself. 

The  manner  in  which  we  react  to  these  things 
which  draw  our  attention  is  dependent  largely  upon 
our  general  attitude  toward  things  about  us.  A 
normal  man  has  always  cultivated  broad  interests  in 
the  things  of  life  so  that  when  he  is  confronted 
with  an  experience  of  an  unpleasant  nature,  he  is 
able  to  escape  it  by  entertaining  more  pleasant 
thoughts,  that  are  ever  striving  for  recognition  in 
his  mind.  Such  conflicting  thoughts  tend  to  weaken 
strong  emotional  states.  The  epileptic,  however,  is 
not  of  this  temperament.  He  gradually  drifts  into 
a  life  of  restriction  through  an  intensive  applica- 
tion of  his  energy  to  particular  instead  of  broad 
interests. 

The  tendency  of  the  epileptic  toward  a  poverty 
of  interests  in  life  is  one  largely  of  circumstances 
over  which  he  has  but  little  control.  Such  persons, 
it  is  true,  are  often  endowed  with  family  traits  of 
nervousness,  manifested  usually  in  overindustrious- 
ness ;  )-et  misfortunes  of  some  kind  in  which  there 
are  blighted  hopes  can  usually  be  found  which  lead 
them  irtto  a  life  of  restricted  pursuits.  Sickness, 
sin  and  poverty  have  been  said  to  be  three  of  the 
greatest  scourges  of  society,  which  lead  to  untold 
misery  and  suflfering.  They  w^ork  hand  in  hand, 
often  as  a  vicious  circle,  reducing  the  possibilities 
of  pleasurable  activities  of  every  individual  touched 
by  them.  These  conditions,  as  manifested  in  the 
epileptic,  do  not  point  so  much,  then,  to  an  individual 
endowed  primarily  with  inherited  mental  stigmata 
as  they  do  to  the  handicap  society  places  before  him 
as  he  seeks  good  fortune. 

The  following  case  histories  are  presented  to  show 
the  processes  at  work  which  produce  thwarted  am- 
bitions, narrowing  of  life  interests  and  an  epileptic 
reaction  as  a  result  of  strong  emotional  states  of 
mind : 

Case  L— 751— Patient  O.  A.  S.— Male,  aged 
forty-one,  divorced,  admitted  December  19,  1919. 
First  epileptic  attack  at  age  of  thirty-two.  Infre- 
quent at  first,  but  later  occurring  about  once  a  month, 
at  which  time  he  had  three  or  four  severe  spells. 
Patient  gave  a  history  of  several  convulsions  at  the 
age  of  two  years,  when  h.e  sufifered  much  from  colic 
and  indigestion.  The  patient's  family  history  was 
negative  for  chronic  or  mental  disease  of  any  kind. 
Physical  examination  of  the  patient  was  negative 
except  for  partial  atrophy  of  both  testicles  which 
followed  as  a  complication  of  mumps  at  the  age  of 
fourteen.  ]\Ientally  the  patient  seemed  normal, 
except  that  he  was  of  a  nervous  and  restless  dis- 
position. He  was  very  industrious  and  headstrong 
at  times.  While  he  was  ever  ready  to  carry  on  a 
general  conversation,  it  was  impossible  to  get  him  to 
talk  of  his  own  life. 

The  following  information  was  obtained  from  his 
sister,  who  visited  him  at  the  institution :  She  related 
that  as  a  boy  he  was  exemplary  in  his  habits  and  not 
different  from  his  associates.  At  the  age  of  twenty 
he  was  married  to  a  beautiful  girl,  a  woman  ideal 
in  character  and  disposition.  They  lived  prosper- 
ously and  happily  on  a  farm  in  Indiana  for  eight 
years,  but  no  children  were  born  to  them.  At  the 
end  of  this  time,  upon  the  solicitation  of  his  wife, 


who  wished  to  live  near  her  brother,  they  moved 
to  Oregon.  Shortly  after  a  year  had  passed  the 
patient  suddenly  appeared  at  his  mother's  home  in 
Indiana.  He  was  found  walking  back  and  forth 
in  the  back  yard  of  her  home.  Upon  being  asked 
what  he  was  doing  back  home,  he  remarked  that 
he  had  stayed  away  from  his  mother  as  long  as  pos- 
sible. His  mother  and  sister,  noting  that  his  visit 
was  rather  an  extended  one,  persuaded  him  to  have 
his  wife  return.  After  six  months  she  came  back. 
Five  months  later  she  gave  birth  to  a  baby  boy. 
Nothing  was  said  to  either  the  wife  or  patient  and 
no  trouble  arose  between  them.  Shortly  afterward, 
they  returned  to  Oregon.  A  year  later  the  patient 
suffered  his  first  epileptic  attack. 

Having  given  me  this  information,  the  sister 
warned  me  not  to  mention  this  to  her  brother,  say- 
ing that  he  became  raving  mad  when  the  subject  was 
mentioned.  Thinking  that  the  patient  would  be 
benefited  by  an  explanation  of  the  factors  at  work 
in  his  disorder,  her  admonition  was  disregarded.  Al- 
most at  the  first  word,  the  patient  was  aware  of  the 
nature  of  my  interview.  He  became  violent  in  his 
manner  of  speech,  censuring  me  in  vigorous  terms 
for  bringing  up  unpleasant  memories  which  he  so 
earnestly  attempted  to  keep  frorrt  his  mind.  After 
his  anger  was  spent,  an  attempt  was  made  to  have 
him  understand  that  he  could  not  ^expect  to  bear  his 
troubles  alone  in  silence  and  that  W'ith  a  better  in- 
sight into  the  workings  of  his  mind,  he  probably 
could  be  helped  to  avoid  his  silent  brooding  which 
had  much  to  do  with  his  seizures.  He  sat  in  silence, 
but  before  many  words  were  said,  he  fell  uncon- 
scious in  a  convulsion.  The  syndrome  of  physical 
disease  and  permanent  disability,  marriage  and 
thwarted  ambition  because  of  this  disability,  the 
invasion  of  his  home,  the  sin  of  his  wife  and  all 
that  went  with  it,  and  finally  the  bearing  of  his 
unpleasant  experience  without  visible  complaint  un- 
til the  break  came,  is  interesting  material  for  specu- 
lation. 

Case  II. — 525 — E.  S.,  male,  aged  forty-eight, 
married ;  admitted  October  16,  1916.  Seizures, 
grand  mal  in  type ;  patient  often  irritable  before  a 
period  of  seizures,  which  come  at  about  three  weeks' 
intervals  or  oftener,  and  disturbed  a  few  days  fol- 
lowing. During  disturbed  spells  he  had  illusions  of 
things  crawling  about  him ;  "wants  to  settle  the 
thing ;  put  over  the  deal  in  first  class  order."  At 
such  times  he  had  a  tendenc}'  toward  violence  and 
destructiveness. 

The  family  history  was  negative.  Patient  had 
three  healthy,  grown  children.  The  personal  history 
showed  that  the  patient  had  always  been  healthy 
except  for  scrofula  at  six  years  of  age,  which  w-as 
said  to  have  been  very  severe.  Patient  showed  no 
present  signs  or  symptoms  of  this  condition.  Physi- 
cal examination  on  entrance  to  the  institution  nega- 
tive. The  patient  was  a  robust  man  with  no  ap- 
parent physical  defects.  Blood  and  spinal  fluid  re- 
peatedly negative.  IMental  examination  during  the 
intervals  between  seizures  showed  that  the  patient 
had  no  marked  mental  deterioration.  He  was  very 
industrious  and  capable.  He  was  able  to  direct 
other  patients  in  their  work,  but  was  prone  to  use 
force  when  his  leadership  was  questioned. 


888 


MARSH:  PHENOMENA   OF  EPILEPSY. 


[New  York 
Medical  Journal. 


Careful  inquiry  regarding  the  patient's  past  his- 
tory brought  out  these  interesting  facts.  As  a  boy, 
his  school  days  were  limited.  Most  of  his  time  was 
spent  in  his  father's  mill,  where  he  did  more  than 
a  man's  work.  He  never  had  a  vacation,  never  had 
time  of¥,  but,  as  he  himself  said,  "always  had  his 
head  to  the  grindstone."  His  married  life,  although 
happy,  stimulated  him  to  increased  efforts,  more 
especially  when  it  became  necessary  to  provide  for 
his  children.  He  became  a  man  of  means,  yet  he 
never  gained  the  wealth  he  desired  for  his  family. 
In  late  years  he  became  farmer,  merchant  and 
automobile  salesman,  so  eager  was  he  to  accumulate 
money.  He  has  often  said  that  he  never  could 
stand  to  fail  in  selling  an  automobile.  In  fact,  he 
stated  that  he  never  gave  up  until  a  deal  was  made. 

While  at  the  institution  his  main  desire  was  to 
get  back  home  to  his  family.  When  it  was  ex- 
plained that  he  must  get  his  mind  off  this  subject 
if  he  ever  expected  to  get  home,  he  agreed  to  try 
to  do  so.  He  succeeded  for  a  time  in  keeping  un- 
pleasant thoughts  away  by  employing  his  mind  in 
work  at  hand.  He  went  over  two  months  without 
a  seizure,  when  one  Sunday  evening  he  suffered  an 
attack.  The  next  morning  he  admitted  that  he 
had  been  thinking*  about  his  family,  but  stoutly 
maintained  that  he  had  not  let  his  thoughts  get  to 
the  point  of  unpleaTsantness  or  worry.  He  explained 
that  he  had  been  sitting  on  a  bench  in  the  yard 
watching  the  road.  As  each  automobile  approached 
he  would  say  to  himself :  "That's  my  wife  and 
children  coming  for  me."  When  they  passed  by, 
however,  he  urgently  maintained  that  he  did  not 
worry  about  it,  but  watched  for  the  next  machine 
in  order  to  repeat  the  same  process.  He  was  quite 
surprised  when  he  was  told  that  the  whole  experi- 
ence was  an  unpleasant  one ;  that,  to  be  a  pleasant 
one,  the  machine  would  have  to  turn  in,  bringing 
his  wife  and  children;  that  to  watch  each  car  with 
a  desire  in  his  mind  was  building  up  hope  after 
hope,  with  the  greatest  suspense  which  is  always 
unpleasant  until  the  desire  is  satisfied.  The  patient 
was  never  able  to  stop  worrying  about  his  family. 
With  a  broad  smile  on  his  face  he  was  ever  ready 
to  say,  "Doctor,  I  believe  that  we  ought  to  be  able 
to  get  together  in  an  agreement  whereby  I  can  get 
home  for  a  while  at  least."  He  died  recently  in 
an  epileptic  seizure. 

We  might  go  on  indefinitely  reciting,  from  case 
histories,  the  influences  at  work  in  the  disorder  of 
epilepsy  which  limit  the  patient's  field  of  pleasur- 
able activity,  for  they  are  infinite  in  number.  Each 
case  manifests  them  in  its  own  peculiar  manner. 
But,  aside  from  mental  complexes,  the  stigmata  of 
disease  plays  a  .strong  part  in  this  way.  Syphilis 
probably  is  one  of  the  greatest.  Between  twenty- 
five  and  thirty  per  cent,  of  our  patients  show  a 
positive  blood  Wassermann,  all  of  which,  except  a 
very  small  proportion,  is  congenital  in  type.  The 
body  as  a  living  organism  resents  such  infringement 
upon  its  welfare  and  when  consciousness  is  im- 
paired, a  convulsion  is  one  of  the  forms  of  resent- 
ment. 

It  is  difficult  to  say  just  to  what  extent  the  toxins 
of  syphilis  and  other  diseases,  or  exogenous  and 
endogenous  toxins  of  whatever  source,  affect  the 


conscious  centres  of  the  brain.  The  greatest  ap- 
parent damage  results,  however,  from  permanent 
disablement,  which  is  an  end  result  of  pro- 
cesses of  disease.  The  hemiplegic  patient,  for 
example,  is  prevented  from  entering  into  normal 
pleasurable  activity  because  of  his  affliction.  If  he 
is  energetic,  he  becomes  the  victim  of  thwarted 
ambitions.  He  comes  not  only  to  a  full  realization 
of  his  physical  and  mental  handicap  resulting  from 
the  inroads  of  disease,  but  he  is  made  to  feel  that 
he  is  different  from  normal  people  and  conse- 
quently is  no  longer  able  to  associate  with  them 
on  an  equal  footing.  His  life  from  this  time  be- 
comes one  of  isolation  in  spite  of  his  efforts  to 
prevent  it.  If  he  persists  in  his  attempts  to  take 
part  in  the  activities  of  those  about  him,  he  becomes 
an  object  of  ridicule  and  abuse.  Denied  desired 
pleasurable  pursuits  and  being  handicapped  because 
of  a  restriction  of  outside  interests,  the  patient 
tends,  when  obstacles  on  every  hand  confront  him, 
to  become  explosive  in  character.  In  the  face  of 
unsurmountable  difficulties,  which  serve  only  to 
increase  strong  emotional  states  of  mind,  the  epi- 
leptic reaction  comes  as  a  complete  breakdown  to 
physical  and  mental  effort. 

Examining  the  disorder  of  epilepsy  from  this 
point  of  view,  we  come  into  possession  of  definite 
principles  applicable  in  the  care  and  treatment  of 
our  patient.  These  principles  have  long  been  under- 
stood by  those  experienced  in  handling  the  epileptic, 
but  the  general  practitioner  and  surgeon  have  often 
been  the  victims  of  advice  of  doubtful  value.  When 
in  this  light  we  come  into  a  full  realization  of  the 
meaning  of  the  phenomena  of  epilepsy,  we  see  in 
our  patient  a  person  who  m,ay  be  afflicted,  not  dif- 
ferent from  any  other  person,  with  a  surgical  or 
diseased  condition.  Disease  processes  are  then 
combatted,  not  with  the  hope  of  curing  epilepsy, 
but  because  the  patient  is  sick.  Surgical  procedure 
is  instituted  when  the  patient  has  a  surgical  condi- 
tion and  not  to  stop  epileptic  attacks. 

We  treat  the  patient,  and  not  a  disorder.  Our 
patients,  for  example,  may  have  syphilis,  which  has 
much  to  do,  as  we  have  seen,  as  a  causative  agent 
in  the  production  of  seziures,  yet  we  do  not  hope 
to  cure  epilepsy  by  arresting  syphilitic  processes. 
We  may,  by  treatment,  produce  a  negative  blood 
and  spinal  fluid.  We  may  also  place  a  patient  in 
such  an  environment  that  he  may  be  helped  to  avoid 
strong  emotional  states  of  mind  and  therefore  have 
his  seizures  temporarily  or  permanently  controlled. 
Perhaps  even  then  our  prognosis  can  be  no  greater 
than  is  offered  in  other  processes  of  disease.  The 
army  ruling  held  that  malaria  is  never  cured,  but 
only  arrested.  Syphilis,  once  thought  to  be  com- 
pletely driven  from  the  human  body  by  salvarsan 
and  mercury,  is  now  thought  to  be  arrested  only 
and  not  cured.  Epilepsy  no  doubt  will  be  con- 
sidered in  this  way.  Our  hopes  then  in  controlling 
the  disorder  will  he  similar  to  those  in  diseases 
of  all  kinds.  Understanding  the  phenomena,  we 
shall  expect  only  to  arrest  and  not  cure  the  dis- 
order. The  future  problem  will  engage  our  efforts 
in  the  prevention  of  epilepsy  just  as  the  supreme 
purpose  of  the  medical  profession  is  to  prevent 
disease. 


December  4,  1920.] 


KWDEK:   MENTALITV  IN  El'lLEFSY. 


889 


In  conclusion,  then,  it  may  be  said  that  construc- 
tive thought  is  fostered  today  in  every  human  in- 
terest. The  ideas  set  forth  in  this  brief  space  are 
intended  only  in  this  spirit  and  the  views  presented 
make  no  assertion  to  any  sort  of  completeness. 
They  aim  at  stimulating  thought  and  challenging 
discussion,  for  it  is  only  by  exposing  our  own  and 
correcting  each  other's  errors  that  thought  is  ad- 
vanced. Likewise,  originality  is  not  claimed  in  all 
•that  is  said  here,  for  we  build  only  upon  the 
materials  of  past  experience.  Perhaps  when  all  is 
known  about  the  phenomena  here  considered,  some 
one  will  come  forth  with  a  review  of  the  literature, 
giving  everyone  due  credit  for  the  part  which  they 
have  played  in  the  work.  At  the  present,  as  we 
gather  from  all  the  sources  possible,  the  beginnings 
of  knowledge  on  the  subject,  we  can  but  strive  to 
see  it  in  its  proper  relation.  In  this  light,  epilepsy 
is  considered  here  as  an  abnormal  muscular  expres- 
sion of  strong  mental  states.  It  is  a  particular  type 
of  reaction  which  occurs  when  purposeful  ef¥orts 
of  mind  and  body  come  to  defeat.  It  is  seen  in  an 
individual  who,  possessing  a  poverty  of  interests  in 
his  environment,  cannot,  as  the  normal  man  does, 
escape  strong  emotional  feeling  by  entertaining  con- 
flicting thoughts  which  weaken  strong  mental  states. 


MENTALITY  IN  EPILEPSY.* 

By  Walter  H.  Kidder,  M.  D., 
Oswego,  N.  Y. 

However  clear,  however  familiar  to  even  the 
casual  observer,  are  the  grosser  symptoms  of  those 
manifestations  which  we  call  epilepsy,  the  causes, 
the  pathology,  and  even  the  more  detailed  symp- 
tomatology, are  so  vague  and  so  shrouded  in  mystery 
that  he  whoever  writes  upon  the  subject  must  needs 
be  either  very  brave  or,  perhaps,  sometimes  only 
foolish.  However,  even  in  this  day  of  specializa- 
tion, epileptics  are,  in  the  main,  observed  and  cared 
for  by  general  practitioners,  and  it  may  not  be  inapt 
for  one  who  represents  in  some  degree  the  unspe- 
cialized  mind  to  bring  before  you  briefly  observa- 
tions of  a  few  simple  things  which  help  the  less 
skilled  in  the  study  and  care  of  the  epileptic. 

Looking  back  over  the  writings  of  the  past  three 
or  four  generations  we  find  a  fairly  clear,  if  wholly 
arbitrary,  distinction  made  between  nervous  disease 
and  mental  disease.  Even  though  the  present  day 
neurologist  has  allowed  the  psychiatrist  to  pvirloin 
some  of  his  neurasthenics,  and  the  psychiatrist  has 
been  forced  to  accept  epileptics,  provided,  of  course, 
their  epilepsy  was  with  psychoses,  the  nervous  and 
the  mental  classifications  remain  apart,  as  separate 
and  distinct. 

To  the  casual  observer  the  nervous  symptoms  of 
epilepsy  have  been  so  manifest  that  it  is  not  strange 
that  writers  have  uniformly  classed  this  disorder 
with  the  nervous  diseases.  Without  regard  to  its 
technical  accuracy,  this  classification  has  given  to 
the  student  and  to  the  general  observer  the  tendency 
to  pay  more  particular  attention  to  the  somatic  and 

*Read  before  the  National  Association  for  the  Study  of  Epilepsy. 
New  York,  June  3,  1920. 


nervous  manifestations  than  to  the  less  apparent, 
if  none  the  less  definite,  mental  picture.  From  the 
earliest  days  there  has  been  recognition  of  the 
grosser  effects  of  this  disease  on  the  mind.  In 
ancient  times  it  was  called  the  sacred  disease, 
"Because  it  affects  the  Mind,  the  moft  noble  and 
f acred  Part  of  a  rational  Creature"  (1).  To  this 
terminology  Hippocrates  took  exception,  and  of 
those  who  called  it  the  sacred  disease  he  said,  "Such 
persons,  then,  using  the  divinity  as  a  pretext  and 
screen  of  their  own  inability  to  afford  any  assistance, 
have  given  out  that  the  disease  is  sacred,  adding 
suitable  reasons  for  this  opinion,  they  have  insti- 
tuted a  mode  of  treatment  which  is  safe  for  them- 
selves, namely,  by  applying  purifications  and  incan- 
tations, and  enforcing  abstinence  from  baths  and 
many  articles  of  food  which  are  unwholesome  to 
men  in  diseases.  .  .  .  All  these  they  enjoin  with 
references  to  its  divinity,  as  if  possessed  of  more 
knowledge,  and  announcing  before  other  pretents, 
so  that  if  the  person  should  recover,  theirs  would 
be  the  honor  and  credit;  and  if  he  should  die,  they 
would  have  a  certain  defense,  as  if  the  gods,  and 
not  they,  were  to  blame."  (2).  In  the  fifth  century 
Cfelius  Aurelianus  wrote  a  masterful  description 
of  the  physical  characteristics  of  epilepsy,  and 
added,  "The  Mind  is  anxious  and  uneasy,  prone 
to  anger  on  the  slightest  occasions,  .  .  .  forgetful  of 
circumstances  almost  immediately  before  transacted, 
and  ready  to  be  clouded  and  overcast  with  the  im- 
pressions of  gloom  and  melancholy"  (3).  Nearly 
two  centuries  ago  an  English  writer  opened  a  dis- 
sertation on  epilepsy  with  this  sentence :  "Among 
the  feveral  Calamities  to  which  human  Nature  is 
fubjected,  none  is  more  juftly  formidable,  than  that 
univerfal  and  involuntary  concuffion,  and  violent 
Agitation,  of  the  external  Parts,  which  is  accom- 
panied with  a  Sufpenfioii  both  of  the  external  and 
internal  Senfes,  and  which  we  commonly  call  an 
Epilepfy;  for,  during  the  Shocks  of  this  terrible 
Misfortune,  the  body  is  not  only  varioufly  diftorted 
and  deform'd,  but  alfo  the  Mind,  as  it  were,  un- 
hing'd,  and  deprived  of  its  genuine  Powers"  (4). 
So,  wherever  we  turn  in  literature,  descriptions  of 
the  epileptic  contain  references  to  the  effect  of  the 
disease  upon  the  mind. 

As  an  important  factor  in  the  causation  of  the 
epileptic  attack  mental  influence  received  early 
attention.  After  advising  that  patients  suffering 
from  epileptic  convulsions  "abstain  from  food  one 
day  in  four,"  Celsus,  writing  in  the  first  century, 
says :  "Intense  thoughtf ulness,  or  fatigue  of  mind, 
is  also  to  be  guarded  against  .  .  .  for  application  of 
mind  is  not  safe  for  those  who  are  subject  to  this 
disorder."  In  the  second  century  Galen  made  sim- 
ilar comment,  citing  the  case  of  a  schoolmaster; 
and  an  old  but  more  recent  writer  said :  "But,  above 
all  things,  every  occasion  of  terror,  dread,  or  anger, 
is  to  be  carefully  avoided ;  because  these  have  a 
strong  tendency  to  bring  on  the  paroxysms"  (5). 
In  all  of  these  early  comments  the  question  of  men- 
tal influence  receives  little  attention  except  in  rela- 
tion to  the  individual  convulsion,  though  many 
writers,  from  Caelius  Aurelianus  down,  including 
Esquirol,  Jules  Falret  and  Trousseau,  came  hope- 
fully near  to  drawing  a  picture  of  the  basic  epileptic 


890 


KIDDER:  MENTALITY  IN  EPILEPSY. 


[New  York 
Medical  Journal. 


mentality.  In  1861  Jules  Falret  wrote:  "The  intel- 
lectual disorders  observed  in  epileptics  may  be 
divided  into  three  principal  categories :  First,  those 
which,  manifesting  themselves  in  the  intervals  be- 
tween the  attacks,  are  independent  of  these,  and 
constitute  the  habitual  mental  state  of  epileptics ; 
second,  those  which  occur  temporarily  before,  dur- 
ing or  after  the  attack,  and  may  be  considered  as 
epiphenomena  of  the  attack  itself ;  third,  and  last, 
intellectual  disorders,  more  or  less  prolonged,  which 
coming  on  in  paroxysms,  either  directly  connected 
with  the  convulsive  or  vertiginous  phenomena,  or 
occurring  independently  of  these,  specially  deserve 
the  name  of  epileptic  insanity."  Again,  when  we 
compare  the  basic  epileptic  mentality  with  that  of 
simple  developmental  inferiority,  this  writer  helps 
us  in  the  establishment  of  a  difterentiation,  mention- 
ing particularly  the  high  degree  of  capability  to 
which  the  epileptic  mind  will  at  times  rise,  as  shown 
by  well  known  historical  characters. 

Perhaps  it  was  only  suggestions  of  history  which 
led  Dr.  Ireland  in  his  series  of  charming  psycho- 
logical biographies  to  dwell  upon  the  epileptic  men- 
tality as  attributed  to  Csesar,  Mahomet,  Napoleon, 
and  others.  Some  of  us,  however,  prefer  to  believe 
that  his  long  association  with  the  developmentally 
subnormal  and  the  epileptic  had  bred  in  him  con- 
sciousness of  the  existence  of  a  distinct  t3'pe  of 
mentality  in  the  epileptic,  and  that  his  recognition 
in  these  historical  characters  of  an  often  diminished 
repressive  function  and  a  moral  obliquity  to  conse- 
quences furnished  a  basis  to  his  diagnoses. 

Two  years  ago,  Dr.  L.  Pierce  Clark  said : 
".  .  .  Given  a  certain  potential  constitution  plus  a 
special  type  of  stress  applied  to  it,  we  gain  a  cer- 
tain psychological  effect  which  we  have  called  the 
epileptic  reaction.  .  .  .  The  epileptic  constitution 
has  long  been  recognized  as  the  enduring  mental 
stigma  of  essential  epilepsy  itself.  Only  recently 
have  studies  disclosed  that  the  main  tenets  of  such 
a  character  are  present  years  before  the  nervous 
disorder  of  epilepsy  is  shown  in  fits.  ...  A  dis- 
integration of  habits  and  character,  known  as 
deterioration,  occurs  more  easily  in  one  thus  handi- 
capped by  a  defective  endowment.  Therefore, 
mental  or  behavior  deterioration  often  precedes 
actual  epileptic  seizures  for  a  considerable  time. 
.  .  .  Any  efifective  plan  of  treatment  must  essen- 
tially take  strict  and  early  account  of  the  makeup 
of  epileptics,  before  all  else"  (7). 

That  epilepsy,  or  for  that  matter  any  other  dis- 
order which  profoundly  afifects  the  neurological, 
the  psychological  and  the  sociological  life  of  the 
individual,  usually  induces  pronounced  mental  in- 
volution, is  recognized.  It  has  been  remarked  that 
"Epilepsy  and  feeblemindedness  show  a  great  sim- 
ilarity in  their  hereditary  reactions  and  both  appear 
to  be  due  to  a  defect  of  the  germ  plasm,  that  is, 
they  are  both  recessives"  (8).  In  the  true  case  of 
feeblemindedness  we  expect  change  to  be  limited 
to  a  single  direction,  regression.  On  the  other  hand, 
we  meet  epileptics  whose  mentality  shows  what  we 
may  regard  as  the  psychic  epileptic  characteristic, 
and  we  find,  under  wise  direction  and  treatment, 
these  patients  showing  improvement  in  mental  con- 
dition and  adaptability.    In  other  words,  in  the 


epileptic  mind  we  find  two  more  or  less  distinct 
types  of  subnormality.  The  one  is  relatively  obvi- 
ous, occurring  particularly  in  the  epileptic  of  long 
standing, .  a  resultant  condition  fraught  with  hope- 
lessness. The  other  is  more  vague,  representing  a 
basic  state  which  may  long  antedate  the  appearance 
of  the  grosser  symptoms,  or  may  even  exist  through- 
out life  without  the  accompaniment  of  convulsions 
or  other  somatic  disturbances,  and  which  is  not 
necessarily  progressive. 

Of  epilepsy  we  are  told  that  it  is  "worth  while 
to  consider  the  attack  as  due  to  a  faulty  distribu- 
tion of  energy  which  may  be  brought  about  in  many 
ways  and  through  divers  mechanisms"  (9).  How- 
ever we  regard  the  ailment,  wh.ether  as  a  disease,  a 
symptom,  complex,  or  what  not,,  we  must  recognize 
one  fact:  Its  symptoms  are  strikingly  definite. 
Physically,  few  diseases  exhibit  a  clearer  or  more 
constant  line  of  symptoms.  To  some  of  us  the 
mental  picture  seems  no  less  determinate.  The 
deductions  of  logic  do  not  lead  us  to  expect  definite 
results  from  various  and  indefinite  causes.  How- 
ever much  we  may  be  impressed  by  the  variousness 
of  influences  which  may  promote  the  development 
of  epilepsy,  he  who  asserts  that  the  disease  is  not 
an  entity  will  do  well  to  gu.ard  his  declaration  with 
qualifications.  If  we  ha\e  a  basic  mental  condition 
essential  to  the  development  of  epilepsy,  whatever 
influence  tends  to  better  that  condition  must  in 
great  measure  help  in  combatting  the  general  epi- 
leptic state. 

Some  of  us  have  come  to  the  idea  of  basing  our 
prognoses  on  the  mental  state,  and  to  gauge  pro- 
gress by  mental  change.  In  children  we  even  go 
so  far  as  to  base  our  estimate  in  part  on  the  psy- 
chology of  the  child's  adult  associates  and  mentors. 
"We  impress  upon  the  child  and  upon  the  parents 
the  necessity  of  developing  the  cheerful  viewpoint, 
of  avoiding  displays  of  temper,  the  suIks  and  the 
general  spirit  of  contrariness.  To  the  parents  of 
the  child  and  to  the  adult  or  near  adult  epileptic  we 
give  a  matter  of  fact  explanation  of  the  seriousness 
of  the  disease,  and  we  tell  them  that  a  patient  enter- 
ing upon  a  course  of  treatment  is  like  the  acolyte 
who  seeks  entrance  to  a  monkish  order.  Trials  and 
tribulations  and  selfdenials  will  be  his,  and  they 
must  be  met  with  fortitude  and  with  cheerfulness. 
To  each  epileptic  we  give  a  life  purpose,  the  pur- 
pose of  overcoming  his  disease.  Without  effort  to 
eliminate  individual  mental  conflicts,  the  effort  is 
made  to  develop  a  poise  which  makes  conflicts 
unlikely. 

It  is  interesting  to  note  that  in  an  epileptic  whose 
acute  attacks  are  fairly  well  controlled  by  a  given 
dose  of  bromide  or  other  sedative  drug,  consistent 
mental  therap\-  permits  equally  good  results  with  a 
much  reduced  dose  of  medicine.  Moreover,  when 
so  administered  the  use  of  bromides  is  not  accom- 
panied by  increased  mental  dulling,  but  oftentimes 
l)y  a  distinct  gain  in  mental  acuity.  In  prognosis 
it  is  much  safer  to  base  predictions  upon  this  mental 
cliange  than  upon  the  exact  numbers  or  character 
of  the  fits.  Though  the  administration  of  the  bro- 
mides to  these  patients  has  been  strongly  criticized, 
few  now  deny  their  usefulness.  Let  me  predict 
that  the  time  .will  be  when  the  place  of  mental 


December  4,  1920.] 


W ATKINS:  LUMINAL    TREATMENT  FOR  EPILEPSY. 


891 


therapy  in  the  treatment  of  such  patients  will  be 
as  firmly  established. 

REFEREXCES. 

1.  James,  R.  :  London,  1745. 

2.  Adams:  The  Genuine  Works  of  Hippocrates. 

3.  James,  R.  :  London,  1745. 

4.  Idem:  London,  1745. 

5.  Hoffmaxx,  Frederic:  Halle. 

6.  Ireland  :  The  Blot  on  the  Brain. 

7.  Clark,  L.  Pierce  :  Some  Suggestions  for  More  Acute 
Mental  Therapy,  Journal  A.  M.  A. 

8.  Jelliffe  and  White  :  Diseases  of  the  Nervous 
System. 

9.  Idem. 

123  West  Fifth  Street. 


EPILEPSY  TREATED  WITH  LUIMINAL.* 
Preliminary  Report  of  Twenty-tivo  Cases. 
By  Harvey  M.  Watkins,  M.  D., 
Palmer,  Mass., 

Assistant  Physician,   ilonson   State  Hospital. 

The  treatment  of  epilepsy  has  always  been  most 
unsatisfactory.  Each  year  we  see  new  drugs  and 
new  combinations  being  introduced  as  curealls  for 
the  relief  of  convulsions  and  as  each  of  them  is  gradu- 
ally discarded  we  again  turn  to  the  bromides,  mean- 
while continuing  to  look  for  something  better,  more 
satisfactory  and  with  less  bad  effects.  Before  the 
war  a  new  product,  luminal,  appeared  on  the  market. 
This  was  used  at  the  IMonson  State  Hospital  during 
part  of  1913  and  1914  after  which  it  could  not  be 
obtained.  Since  then  it  has  again  appeared  and 
various  assertions  have  been  made  for  its  use,  par- 
ticularly in  epilepsy. 

CLASS  OF  DRUG  AND  DOSE. 

Luminal,  known  chemically  as  phenylethylma- 
lonylurea,  belongs  to  the  same  class  of  drugs  as 
veronal,  trional  and  barbital — the  socalled  ethylated 
compounds.  It  was  first  made  in  Germany  but  re- 
cently has  been  made  in  this  country.  It  is  made 
in  two  forms,  tablet  and  powder.  In  epilepsy  the 
dose  varies  from  three  quarters  to  one  and  a  half 
grains  twice  daily  in  tablet  form  although  the  pow- 
der form,  luminal  sodium,  may  be  used  subcutane- 
ously,  five  to  ten  grains  in  freshly  prepared  solution. 
The  assertions  made  for  luminal  vary.  According 
to  the  manufacturers  it  possesses  a  pronounced  seda- 
tive and  antispasmodic  action  in  epilepsy  even  in 
small  doses  and  according  to  a  prominent  authority, 
acts  virtually  as  a  specific  in  some  cases.  Bad  ef- 
fects are  practically  absent  when  given  in  customary 
doses. 

Dercum  (1)  reports  that  in  epilepsy  even  when 
most  confirmed,  the  drug  exercises  a  remarkable 
control  over  the  seizures.  "The  latter  were  usually 
promptly  inhibited  altogether."  Also  that  the  drug 
seemed  to  exercise  more  control  over  the  group  of 
socalled  essential  epilepsies.  "Indeed  in  some  in- 
stances the  drug  acted  virtually  as  a  specific." 

My  own  rather  brief  observation  with  luminal 
covers  a  period  of  three  months,  February,  ^larch 
and  April  of  1920.  During  this  time  I  have  ad- 
ministered the  drug  to  twenty-two  patients,  no  other 
medicine  being  used  except  an  occasional  laxative. 

*Read  before  the  National  Association  for  the  Study  of  Epilepsy. 
New  York  Academy  of  Medicine,  June  3,  1920. 


Seven  of  my  patients  were  of  the  idiopathic  type, 
five  were  patients  in  whom  the  petit  mal  seizures  pre- 
dominated, two  were  status  patients  and  the  remain- 
ing eight  patients  were  those  in  whom  there  was 
an  equal  distribution  of  grand  mal  and  petit  mal 
seizures.  The  method  of  administration  has  been 
one  and  a  half  grains  in  tablet  form  twice  daily, 
night  and  morning. 

Among  the  first  symptoms  noted  following  its  use 
was  the  constant  and  almost  universal  complaint  of 
sleepiness  and  drowsiness.  These  later  developed 
into  various  symptoms  resembling  those  of  bromism 
— dizziness,  depression,  mental  apathy,  confusion, 
memory  defects,  hallucinations  and  delusions — 
practically  all  of  the  bad  effects  of  bromides  were 
observed  with  the  exception  of  the  rash.  At  the 
end  of  two  weeks  the  drug  was  reduced  one  half 
in  seven  patients  who  showed  the  more  marked 
symptoms  of  bromism,  but  the  symptoms  persisted, 
although  with  less  severity.  In  two  cases  it  was 
necessary  to  withdraw  the  drug  entirely  at  the  end 
of  one  month  on  account  of  the  development  of 
severe  mental  symptoms. 

The  most  marked  effect  of  the  drug  was  noted  in 
the  decrease  in  the  number  of  convulsions.  This 
effect  was  noticeable  the  second  and  third  days  fol- 
lowing its  administration.  There  was  a  decrease  in 
the  number  of  convulsions  in  every  case  with  the 
exception  of  two  in  which  there  was  an  increase. 
The  seizures  were  greatly  reduced  even  in  the  two 
cases  in  tv^hich  the  drug  was  entirely  withdrawn 
after  a  month. 

The  number  of  convulsions  during  the  three 
months  while  taking  luminal  was — first  month  199, 
second  month  143,  third  month  141,  a  total  of  483 
and  an  average  per  month  of  161  or  7.31  per  pa- 
tient per  month.  For  three  months  previous  to 
luminal  administration  there  was  a  monthly  average 
of  532  convulsions  or  24.18  per  patient  per  month. 
These  figures  are  based  on  three  month  periods  and 
indicate  a  reduction  of  seventy  per  cent,  in  the  num- 
ber of  convulsions  while  taking  the  drug.  The 
monthly  average  for  one  year  previous  to  luminal 
administration  was  476  as  compared  to  161  convul- 
sions while  taking  luminal,  showing  a  reduction  in 
number  of  sixty-six  per  cent,  in  all  classes,  which 
seems  to  be  the  more  accurate  percentage  of  reduc- 
tion. 

The  lessening  in  the  number  of  convulsions  was 
most  marked  in  the  idiopathic  cases,  the  percentage 
varying  from  twenty-two  to  one  hundred  per  cent. 
There  was  also  marked  reduction  in  the  petit  mal 
cases  except  in  one  instance  in  which  there  was  a 
very  high  increase  of  330  per  cent.  In  one  other 
case  there  was  an  increase  of  108  per  cent,  in  about 
an  equal  distribution  of  grand  mal  and  petit  mal 
seizures.  In  the  two  status  cases  there  were  no 
attacks  of  status  during  the  three  months,  but  the 
patients  did  have  an  occasional  grand  mal  convulsion. 

The  smaller  doses  seemed  to  have  practically  the 
same  eft'ect  on  the  control  of  seizures  as  the  larger. 
There  was  no  appreciable  change  observed  by  me  in 
the  weights  of  the  patients,  little  or  no  change  in 
blood  pressure,  temperature  or  respiration.  The 
mentality  did  not  seem  to  improve  under  its  use  as 
in  only  one  case  was  there  improvement  mentally. 


892 


UNIKER:   TRAINING  EPILEPTICS. 


[New  York 
Medical  Journal. 


UNTOWARD  EFFECTS. 

The  manufacturers  assert  that  under  the  use  of 
customary  doses  bad  ef¥ects  are  practically  absent. 
Dercum  states  that  he  observed  at  no  time  the 
slightest  deleterious  or  untoward  effects  on  the  men- 
tal life  of  the  patient — "nothing  indeed  save  the 
cessation  of  the  attacks."  Farnell  (2)  reported  two 
cases  in  which  there  were  toxic  effects,  both  patients 
showing  speech  disturbances,  slurring,  scanning  and 
parasphrasic.  Ataxia  was  marked  in  both  cases.  In 
one  there  was  tendency  to  drop  foot  and  the  knee 
reflexes  were  absent.  The  dose  employed  was  from 
five  to  ten  grains. 

Symptoms  of  bromism  were  present  in  the  ma- 
jority of  my  patients,  but  in  only  two  would  I  con- 
sider the  effect  toxic.  One  patient  began  to  show 
untoward  symptoms  from  the  first,  had  periods  of 
crying  and  confusion  which  later  developed  into  de- 
lusions of  persecution.  Finally  she  threatened  bod- 
ily harm  to  anyone  who  came  near  her  and  it  was 
necessary  to  watch  her  closely.  The  luminal  was 
reduced  one  half  without  any  change  in  her  mental 
condition  and  at  the  end  of  a  month  was  discon- 
tinued entirely. 

In  the  other  patient  there  were  hallucinations, 
both  auditory  and  visual,  later  crawling  on  the  floor, 
climbing  the  doors  and  windows,  appeared  unsteady 
in  gait,  would  disrobe  frequently  and  remain  in  a 
nude  condition  unless  constantly  watched.  The 
drug  was  discontinued  after  a  month  as  she  became 
more  confused.  She  was  in  this  mental  sta'te  eighteen 
days  out  of  the  thirty  during  its  administration. 
After  having  five  seizures  she  became  more  rational. 

The  first  patient  had  no  convulsions  during  lu- 
minal administration  and  the  second  patient  showed 
a  decided  decrease  in  the  number  of  convulsions. 
I  believe  I  would  have  had  a  higher  percentage  of 
toxic  effects  had  the  drug  not  been  reduced  in  seven 
cases.  Its  effect  should  be  watched  carefully  as  its 
administration  is  not  unattended  with  untoward 
symptoms. 

WITHDRAWAL  SYMPTOMS. 

Immediately  following  the  withdrawal  of  luminal 
there  was  a  large  increase  in  the  number  of  convul- 
sions in  practically  every  case.  As  is  true  in  all 
drugs  that  have  a  tendency  to  control  convulsions, 
once  the  drug  is  discontinued  the  number  of  seizures 
rapidly  increases.  Seventeen  of  the  twenty-two  pa- 
tients had  convulsions  within  the  first  ten  days, 
three  of  them  being  in  bed  for  one  week.  The  two 
status  patients  had  severe  attacks  of  status  within 
fifteen  days.  There  was  an  average  of  32.64  con- 
vulsions per  patient  per  month  following  its  with- 
drawal as  compared  to  24.18  previous  to  taking  the 
drug  and  7.31  convulsions  per  patient  while  taking 
luminal,  showing  that  the  epileptic  habit  returns 
seemingly  with  increased  vigor  following  its  with- 
drawal. No  other  withdrawal  symptoms  were  noted 
as  the  use  of  the  drug  appeared  to  be  unattended  by 
pleasant  or  euphoric  sensations. 

CONCLUSIONS. 

Cures  are  not  to  be  expected.  It  is  at  best  a  palli- 
ative remedy.    It  is  not  virtually  a  specific. 

It  reduces  the  total  numl)er  of  convulsions  in  all 
classes  sixty-six  per  cent,  although  a  small  proportion 


of  patients  have  an  increased  number  of  convulsions 
during  its  use.  It  has  practically  no  effect  upon 
some  patients,  and  about  ten  per  cent,  show  unto- 
ward symptoms  from  its  use. 

It  has  all  the  bad  effects  of  bromides  with  the  ex- 
ception of  the  rash. 

The  drug  must  be  used  over  a  long  period  of  time 
and  continually,  as  once  its  administration  is  dis- 
continued the  epileptic  habit  returns  with  increased 
severity. 

Undoubtedly  luminal  serves  a  field  in  the  thera- 
peutics of  epilepsy.  It  is  worth  a  trial  in  every  case 
bvtt  to  determine  its  relative  value  it  will  be  neces- 
sary to  use  it  in  a  great  number  of  cases  and  over 
a  long  period  of  time. 

REFERENCES. 

1.  Dercum,  F.  X. :  On  the  Complete  Control  of  Epileptic 
Seizures  by  Luminal,  Therapeutic  Gazette,  September  15, 
1919. 

2.  Farnell,  Fred  J. :  Luminal,  Its  Toxic  Effect.  Journal 
A.  M.  A.,  July  19.  1913. 


PRACTICAL  EXPERIENCE  IN  THE 
TRAINING  TREATMENT  OF 
EPILEPTICS.* 

By  T.  E.  Uniker, 
Stamford,  Conn. 

This  paper  contains  data  taken  from  notes  ob- 
tained in  a  careful  study  of  a  series  of  cases  of 
essential  epilepsy,  ranging  in  age  from  ten  to  fifty 
years  and  covering  a  period  of  ten  years'  duration. 
During  this  period  of  observation,  the  general  plan 
as  regards  physical  treatment,  changed  but  little. 
At  first  the  attention  was  centred  upon  the  possi- 
-  bility  of  some  physical  defect  being  responsible  for 
the  attack.  Extensive  x  ray  examinations  were 
made  of  the  head,  the  stomach  and  intestinal  tract. 
The  blood  and  spinal  fluid  in  each  case  were  care- 
fully examined  and  a  daily  analysis  of  urine  made 
until  all  signs  of  intestinal  putrefaction  had  dis- 
appeared. Special  attention  was  given  to  the  cor- 
rection of  poor  digestion,  constipation  and  faulty 
circulation  and  a  proper  diet  administered  at  all 
times,  but  as  the  physical  defects  were  relieved  and 
the  attacks  continued,  more  attention  was  paid  to 
assisting  the  patients  to  adjust  and  adapt  them- 
selves to  the  simple  environment  the  club  life 
offered,  for  the  patients  were  housed  in  a  simple 
homelike  residence  in  the  country  which  we  called 
The  Club.  It  had  been  evident  from  the  begin- 
ning that  all  the  patients,  without  exception,  showed 
periodic  states  of  annoyance,  irritation  and  lethar- 
gies in  various  degrees  of  severity  according  to 
their  character  makeup,  and  it  was  further  noted 
that  such  states  always  terminated  in  a  climax  of 
one  or  more  attacks. 

All  patients  gave  a  history  of  sedative  treatment 
before  coming  under  observation  and  all  showed 
a  general  tendency  to  sluggish  circulation  and  low 
blood  pressure.  They  were  constipated  and  had 
mucocolitis  in  various  stages.  All  the  sedatives 
were  stopped  soon  after  the  beginning  of  treatment. 

"Read  before  the  N.itional  Association  for  the  study  of  Epilepsy, 
New  York  Academy  of  Medicine,  .Tunc  3,  1920.  The  case  inaterial 
used  in  this  paper  was  obtained  while  assisting  Dr.  L.  Pierce  Clark 
in  his  private  service. 


December  4,  1920.] 


UXJKER:   TRAINING  EPILEPTICS. 


893 


Colon  irrigations  were  given  at  frequent  intervals 
until  the  colitis  disappeared.  A  daily  routine  was 
prescribed  for  each  patient  that  involved  more  or 
less  physical  activity,  such  as  walking,  gardening, 
tennis,  baseball  and  shop  work.  Under  this  careful 
training  all  the  patients  soon  began  to  take  on  a 
healthy  appearance.  Their  skin  became  clear,  the 
expression  bright,  they  were  more  alert  and  the 
muscles  were  firm.  The  constipation  and  colitis 
were  corrected ;  the  poor  digestion  returned  to  nor- 
mal ;  the  sluggish  circulation  improved  and  to  all 
appearances  these  patients  were  as  perfect  physically 
as  medical  science  could  make  them,  but  neverthe- 
less their  attacks  continued  with  the  same  degree  of . 
force  and  frequency.  It  was  noted,  however,  that 
as  they  gained  in  physical  strength,  their  attacks  did 
not  seem  to  produce  as  much  fatigue,  and  they 
recovered  more  quickly. 

The  one  dominating  factor  that  remained  un- 
changed was  the  attitude  of  the  patients  toward  their 
environment.  This  was  characterized  by  a  rather 
passive,  indifferent  state  as  regards  routine  work. 
If  they  did  display  a  normal  reaction  to  their  en- 
vironment, it  was  short  lived  and  what  they  accom- 
plished was  but  little  compared  to  the  time  and 
energy  expended.  They  performed  their  daily  tasks 
in  a  mechanical  sort  of  way  and  had  to  be  con- 
stantly directed,  or  it  was  necessary  to  make  sug- 
gestions that  would  remind  them  of  their  respon- 
sibility. Little  or  no  spontaneous  action  on  their 
part  was  observed  unless  the  task  promised  some 
personal  reward.  They  were  not  consistent  in  their 
work  but  had  fits  and  starts  of  action  and  it  was 
noticeable  that  they  found  it  difficult  to  concentrate 
well  for  any  length  of  time  without  becoming  men- 
tally fatigued  and  showing  distraction.  Above  all, 
they  were  extremely  sensitive.  Some  personal  dis- 
comfort, however  trivial,  caused  great  anxiety, 
while  a  greater  disaster  to  a  fellow  club  member 
caused  no  eflFect  and  was  promptly  forgotten.  The 
patients  seemed  always  to  be  wishing  they  could 
do  something  that  was  beyond  their  mental  and 
physical  fitness  and  were  extremely  selfcentred. 
They  had  few  interests  outside  that  which  imme- 
diately concerned  themselves  or  their  family.  Re- 
gardless of  age,  they  showed  an  abnormal  infantile 
attachment  to  parents.  They  were  slow  both  men- 
tally and  physically ;  stood  stress  of  any  sort  poorly 
and  rarely  if  ever  appeared  genuinely  happy.  They 
appeared  to  be  constantly  at  war  with  their  environ- 
ment and  were  forever  finding  it  difficult  to  adjust 
and  adapt  themselves  to  any  change,  no  matter  how 
simple.  What  seemed  quite  pleasing  one  day  might 
be  annoying  and  irritating  the  next.  Their  rapid 
change  of  mood  went  hand  in  hand  with  their  ability 
to  adjust  to  the  social  demands  their  very  existence 
imposed  upon  them.  They  got  along  poorly  with 
each  other  and  were  constantly  pointing  out  defects 
the  others  had,  but  failed  to  note  or  recognize  that 
they  possessed  the  same  fraits  themselves.  They 
would  have  quiet  spells  where  they  displayed  a 
strong  desire  to  retreat  from  the  club  group  and 
would  go  to  their  rooms,  busy  themselves  with  look- 
ing over  their  personal  belongings  and  lapse  into 
day  dream  states.  The  content  of  the  dreamy 
states  always  revealed  a  personal  wish  that  the 


patient  seemed  unable  to  gratify  or  to  find  anything 
that  would  compensate. 

All  of  the  characteristic  traits  mentioned  above 
continued  as  the  patient  retreated  from  his  environ- 
ment. This  retreat  varied  in  length  according  to 
the  individual's  ability  to  stand  the  mental  stress 
that  such  a  condition  involved  and  then  the  cycle 
terminated  in  a  climax  of  convulsive  attacks. 

Following  the  attacks  there  was  a  short  period 
of  mild  lethargy  and  then  the  patient  began  life 
anew,  with  a  clean  slate.  The  environment,  that 
previous  to  the  attacks  seemed  so  annoying  and 
irritating,  now  was  no  longer  troublesome.  It  ex- 
isted just  as  it  did  before  the  attacks.  The  patient 
came  in  contact  with  it,  but  the  attack  had  evidently 
compensated  in  some  way  for  the  time  being  and  left 
him  apparently  contented  under  conditions  that 
were  previously  unbearable  to  him. 

In  nearly  every  case  the  attack  acted  as  a  sort  of 
protective  mechanism  by  creating  an  amnesia  for  all 
the  annoying  and  irritating  factors  present  previous 
to  its  occurrence.  Conditions  and  events  that  the 
patient  could  not  make  adjustments  to  were  erased 
from  his  memory,  sometimes  forever,  never  to  be 
recalled,  while  in  other  cases  a  recalling  of  painful 
events  immediately  brought  on  another  seizure.  This 
protective  mechanism  enabled  the  patient  to  exist 
with  a  fair  degree  of  comfort  for  a  time,  until  the 
effort  to  adjust  and  adapt  himself  to  his  environ- 
ment once  more  automatically  caused  the  retreat. 
The  symptoms  continued  until  the  attack  came  to  his 
rescue. 

Further  details  concerning  the  constitutional  make- 
up of  the  epileptic  as  I  had  opportunity  to  observe 
it  during  this  study,  while  I  lived  constantly  in  daily 
contact  with  the  patients,  are  unnecessary.  Dr.  L. 
Pierce  Clark  has  frequently  given  the  facts  to  the 
medical  profession.  They  prove  the  existence  of 
this  characteristic  makeup  so  conclusively  that  there 
is  no  room  for  doubt  that  it  exists  and  is  present 
long  before  the  first  seizure.  It  is  needless  for  me 
to  say  that  I  found  all  the  patients  under  my  care 
battling  with  reality  from  day  to  day  just  as  they 
were  able  to  adjust  and  adapt ;  being  governed  en- 
tirely b}'  the  degree  of  constitutional  makeup  they 
possessed. 

The  periodical  seizure  reactions  always  relieved 
the  stress  of  meeting  responsibilities  the  club  life 
presented  and  shut  out  the  painful  conflicts.  It 
then  became  obvious  that  the  problem  was  one  of 
reeducation.  Once  it  had  been  proved  that  every- 
thing possible  had  been  done  to  correct  physical  fac- 
tors, and  no  relief  from  the  attacks  occurred,  it  was 
assumed  that  the  patient  being  unable  to  meet  reality, 
retreated  away  from  it  and  that  the  attack  was  the 
climax  that  brought  relief  from  a  state  that  was 
unbearable.  It  was  at  this  point  of  the  study  that  a 
plan  of  reeducation  and  tactful  training  was  inaug- 
urated with  the  hope,  that  by  frequent  explanatory 
interviews,  at  a  level  of  the  patient's  ability  to  grasp, 
he  would  gradually  gain  an  insight  into  his  defects 
and  learn  to  adjust  and  adapt  accordingly,  thereby 
preventing  the  necessity  of  the  retreat  which  always 
resulted  in  attacks.  With  this  view  in  mind,  a  care- 
ful study  was  made  of  each  patient's  reactions  to 
his  environment.    His  character  behavior,  charted 


894 


UNIKER:   TRAINING  EPILEPTICS. 


[New  York 
Medical  Journal. 


daily,  showed  that  when  his  interests  were  spon- 
taneous and  he  was  actively  engaged  with  his  tasks, 
he  had  httle  difficulty,  hut  as  soon  as  he  began  to  day 
dream  and  display  states  of  irritation  and  annoy- 
ance, it  was  always  a  sign  that  sooner  or  later  an 
attack  would  follow,  unless  something  could  be  done 
to  assist  him  to  meet  the  issues  that  were  evidently 
the  cause  of  the  retreat. 

The  following  plan  was  then  put  into  operation. 
Just  as  soon  as  the  patient  began  to  display  day 
dream  states,  or  became  unduly  annoyed  or  irritated, 
he  was  taken  to  a  cjuict  room  and  told  that  we 
would  try  to  find  out  what  the  difficulty  was  and 
correct  it.  He  was  given  to  understand  that  this 
was  just  a  friendly  chat  and  great  care  was  always 
taken  to  show  a  kind  and  sympathetic  attitude  in 
getting  him  to  consent  to  this  plan.  He  was  never 
given  the  impression  that  he  was  expected  to  do  as 
was  requested  but  shown  that  there  was  some  one 
who  was  genuinely  interested  in  him  and  who  wished 
to  assist  him. 

It  was  soon  learned  that  while  each  case  under 
observation  presented  a  supersensitive  makeup,  this 
sensitiveness  had  to  be  measured  in  order  to  permit 
the  worker  to  know  just  how  to  approach  the  patient 
and  get  him  to  reveal  willingly  the  nature  of  the 
conflict  that  was  gradually  causing  him  to  drift  away 
from  reality.  An  actual  indictment  is  too  painfuL 
Most  of  the  patients  even  resented  being  told  that 
they  were  day  dreaming,  and  would  frown  and  set 
up  such  a  defense  that  nothing  could  be  gained. 
Therefore,  in  beginning  the  treatment  the  talks  were 
always  referred  to  a  group  setting  rather  than  to  the 
individual  himself.  The  very  realization  of  his  de- 
fects is  too  painful  to  the  epileptic,  so  care  must  be 
taken  to  gain  the  patient's  full  and  willing  coopera-- 
tion  during  the  training  treatment.  Once  the  pa- 
tient relaxes  sufficiently  to  realize  his  shortcomings, 
the  teaching  is  then  more  acceptable  to  him,  but  it 
will  be  found  that  the  lesson  must  be  gone  over  many 
times  before  he  will  actually  begin  to  put  it  into 
operation  of  his  own  accord.  The  epileptic  is  quick 
to  note  character  defects  in  others  but  fails  to  apply 
this  ability  where  he  is  personally  concerned,  hence 
the  necessity  of  tactfully  bringing  to  his  notice,  char- 
acter traits  that  require  correction. 

The  following  episodes  are  good  examples  of  the 
types  of  conflicts  displayed  by  the  epileptic  and 
the  method  used  in  obtaining  the  mental  content  of 
the  dream  states  is  equally  applicable  to  the  states 
of  lethargy,  annoyance  and  irritation.  It  is  not  as- 
serted that  in  every  case,  where  the  cause  of  the  re- 
treat is  learned,  and  means  are  produced  for  its 
correction,  that  the  attack  is  prevented,  but  it  was 
ol)served  that  this  approach  never  failed  to  relieve 
the  acuteness  of  the  conditions  noted  and  put  the 
patient  in  a  mental  attitude  that  enabled  him  to  be- 
come productive  once  more.  As  the  training  con- 
tinued, it  was  further  noted  that  the  patients  be- 
came changed  individuals.  Their  interests  in  the  club 
affairs  awakened,  their  memory  improved  and  their 
attacks  began  to  decrease  in  force  and  frequency. 
They  took  on  new  responsibilities  just  as  they 
showed  ability  to  do  so  and  best  of  all  became  aware 
that  it  was  this  insight  mto  their  defects  that  was 
enabling  them  to  exist  in  a  happier  .state  thaii  ever 


before.  Patients  who  displayed  a  marked  and 
active  automatism  following  their  attacks  soon 
showed  that  this  symptom  was  getting  milder  and 
milder  until  little  or  no  activity  was  noted  after 
the  seizure.  Encouraged  by  the  good  results,  the 
training  treatment  was  continued  and  enlarged  upon 
and  in  every  instance  the  patients  showed  their 
pleasure  at  finding  some  means  that  would  enable 
them  to  meet  the  conflicting  trials  that  reality  pre- 
sented to  their  peculiar  makeup. 

Case  I. — This  patient  was  fifty  years  old  and  had 
had  epilepsy  for  the  greater  part  of  his  life.  His 
attacks  were  petit  mal  in  type  but  varied  in  degrees 
of  severity  according  to  his  conflicts.    He  had  been 
expecting  a  visit  from  his  wife  for  several  days. 
She  had  written  him  the  exact  date  and  train  she 
would  arrive  on.    He  made  elaborate  preparations 
for  this  event  and  appeared  childishjy  happy.  They 
had  lunch  together  in  a  little  hotel  in  the  village 
after  which  they  returned  to  the  club.    The  patient's 
wife  reported  that  when  she  met  him  he  was  all 
smiles  and  apparently  happy  and  in  the  best  of 
spirits  and  that  this  good  feeling  continued  through- 
out most  of  the  meal  but  as  they  prepared  to  return 
to  the  club  she  noticed   that  he  was  beginning 
to  have  one  of  his  quiet  spells.    He  appeared  de- 
pressed and  when  his  wife  asked  him  what  was 
wrong  he  would  not  tell,  saying  everything  was  all 
right.    He  became  pouty  and  disagreed  with  his 
wife  in  everything  she  suggested.    If  she  wanted  to 
go  for  a  walk,  he  found  fault  and  wanted  to  re- 
main at  home.    This  attitude  kept  up  all  afternoon 
until  his  wife  left.    For  a  time  the  symptoms  noted 
continued  but  not  with  the  same  force.    He  was 
taken  aside  in  the  evening  for  a  therapeutic  talk 
which  occurred  as  follows:  Nurse: — "I'm  sure  you 
must  have  had  a  very  pleasant  time  today,  was 
everything  quite  all  right?"    The  patient  was  silent 
for  a  time,  assuming  a  thoughtful  attitude  and  then 
said :  "Well  it  was  and  it  wasn't — I  seemed  to  be 
happy  to  meet  my  wife  and  for  a  time  while  we  were 
having  lunch  together  everything  seemed  quite  all 
right,  but  then  I  began  to  feel  depressed — things 
didn't  go  right."    Nurse : — "Was  there  anything 
wrong  with  the  dinner  or  the  service,  did  you  feel 
you  wanted  anything,  wished  for  anything?"  The 
patient  was  again  silent  for  a  long  period,  then  be- 
gan to  smile  boyishly. and  after  several  unsuccess- 
ful attempts   finally  resumed  : — "Yes — there  was 
something  wrong — now  that  I  think  of  it — but  that 
could  not  have  caused  me  to  feel  so  mean — could  it? 
You  see  I  have  had  a  cold  for  several  days — I  had 
written  my  wife  about  it — and  she  delayed  her  visit 
to  me  on  this  account — did  not  want  me  to  give 
her  the  cold  I  guess — but  it  was  almost  gone  today, 
T  thought,  and  I  wanted  to  kiss  her — but  I  said  to 
myself  that  I  could  not  kiss  her  because  I  might 
give  her  my  cold — I  just  couldn't  help  feeling  put 
out  to  think  she  was  right  there  and  I  couldn't  kiss 
her — and  it  made  me  mhd,  I  guess — " 

Here  at  last  was  revealed  the  underlying  cause  of 
the  dissatisfied  state.  A  wish  for  personal  gratifi- 
cation that  the  patient  could  not  gain,  plus  his  in- 
ability to  even  express  his  thoughts  so  that  there 
was  nothing  to  do  hut  repress  his  emotions.  If 
the  epileptic  could  give  vent  to  his  feelings  in  the 


December  4,  1920.] 


UNJKER:   TRAINING  EPILEPTICS. 


895 


form  of  verbal  expression,  he  would  not  be  com- 
pelled to  suffer  in  silence.  This  training  treatment 
enables  the  epileptic  to  acquire  gradually  the  ability 
to  express  himself  and  in  consequence  there  is  a 
marked  change  in  his  behavior  reactions. 

As  soon  as  the  conflict  was  revealed  in  this  case, 
the  patient  was  given  the  following  advice:  "Now 
John,  when  this  desire  to  kiss  your  wife  came  to 
you  and  you  realized  that  having  a  cold  there  was 
a  possibility  of  transferring  it  to  her,  you  should 
have  spoken  up  and  told  her  about  it  and  at  the 
same  time  kissed  her  hand.  In  this  w^ay  you  would 
not  have  had  to  repress  the  desire  so  sharply,  there 
would  have  been  an  understanding  between  you  and 
there  would  have  been  no  necessity  of  finding  fault 
with  your  wife  all  on  account  of  not  being  able  to 
kiss  her."  This  was  imparted  to  the  patient  in  the 
most  kindly  tone,  not  really  as  a  corrective  measure, 
but  rather  as  brotherly  or  fatherly  advice.  Then 
after  the  talk  was  over  he  was  asked  to  give  his 
view  of  the  matter,  and  it  was  surprising  to  note  the 
changed  attitude.  He  was  no  longer  pouty,  annoyed 
or  irritated,  but  gave  a  ffee  account  of  his  feelings 
during  the  day  and  said  that  now  he  realized  that 
if  he  could  have  had  everything  as  he  wished  it, 
there  would  not  have  been  any  necessity  of  acting 
as  he  did.  He  retired  to  his  room  and  wrote  a  let- 
ter to  his  wife  explaining  the  situation  to  her  and 
asked  her  to  excuse  him  for  his  actions  and  told  her 
he  was  going  to  be  more  thoughtful  in  the  future. 

This  patient  was  extremely  sensitive  and  the  ap- 
proach necessary  to  get  his  confidence,  had  to  be 
done  in  this  kindly  manner.  First,  no  mention  that 
he  had  appeared  annoyed  or  irritated  during  this 
visit,  had  to  be  kept  in  mind.  The  talk  was  brought 
about  in  such  a  way  that  it  was  made  easy  for  him 
to  reveal  the  conflict.  To  have  asked  him  why  he 
had  appeared  annoyed  and  irritated  with  his  wife 
would  have  caused  him  to  set  up  a  defense  that 
M'ould  have  prevented  any  cooperation.  This  is  a 
most  important  point  and  one  that  has  to  be  kept 
constantly  in  mind  when  training  such  patients. 
When  this  patient  came  under  observation  he  was  so 
sensitive  that  he  took  exception  to  almost  every  sug- 
gestion. He  had  to  receive  prompt  attention  to  all 
his  demands  or  he  became  violently  annoyed.  This 
annoyance  lasted  for  hours  and  nearly  always  ter- 
minated in  an  attack  but  after  training  treatment 
had  been  in  force  for  a  year,  it  was  noticeable  that 
he  was  beginning  to  put  into  operation  the  methods 
that  the  teaching  offered  and  in  consequence  of  this 
insight,  the  annoyance  slowly  disappeared  and  the 
attacks  dropped  from  six  and  eight  a  week  to  three 
and  four  a  month.  It  was  further  noted  that  in 
the  beginning  of  treatment  the  automatism  follow- 
ing seizures  was  prolonged  and  of  a  destructive 
type,  but  as  he  gained  in  insight  and  actually  kept 
within  his  limits,  this  activity  following  the  at- 
tacks soon  passed  away  and  the  attack  itself  lasted 
but  half  a  minute  or  so.  This  patient  for  a  long 
time  insisted  that  his  bowels  and  stomach  played  a 
great  part  in  these  attacks.  He  didn't  know  just 
how,  but  said  he  had  always  been  told  that  consti- 
pation caused  attacks.  As  he  gained  in  insight  he 
slowly  gave  up  the  idea,  and  he  said :  'Tt  looks  as  if 
I  would  have  to  change  my  whole  character." 


Case  II. — Young  man,  aged  twenty-five  years, 
who  had  had  epilepsy  since  he  was  eighteen.  He 
displayed  all  the  characteristic  signs  of  the  consti- 
tutional makeup.  From  earliest  infancy  he  was  a 
stubborn,  difficult  child  and  had  frequent  tantrums 
all  through  childhood.  While  he  learned  easily  he 
never  did  things  that  were  original  or  clever  and 
never  went  into  anything  deeply.  If  he  had  an  idea 
and  was  balked  in  it  he  never  argued  or  teased,  but 
at  once  threw  himself  on  the  floor  and  went  into  a 
tantrum.  As  he  grew  older  the  tantrums  were  no 
longer  present  but  were  replaced  by  attacks.  For 
days  previous  to  an  attack  he  slowly  began  to  re- 
treat from  activity  with  the  group  and  could  be 
seen  sitting  alone  apparently  in  deep  thought.  He 
would  find  fault  with  the  different  members  of  the 
group.  Finally  things  would  get  so  unbearable  he 
would  say:  "If  I  am  going  to  have  an  attack  I 
wish  I  would  have  it  and  get  this  feeling  over 
with." 

This  patient  had  been  taking  bromide  at  the  rate 
of  120  grains  a  day  over  a  long  period  when  he 
first  came  under  observation.  Even  then  he  was 
having  three  attacks  of  grand  mal  a  month  together 
with  three  or  four  of  petit  mal  weekly.  The  brom- 
ide was  slowly  withdrawn  and  his  attacks  increased 
to  two  attacks  of  grand  mal  a  week  with  one  of 
petit  inal  daily.  The  training  treatment  began  just 
as  soon  as  he  was  in  perfect  physical  condition.  He 
was  gradually  shown  how  his  attitude  toward  his 
environment  was  not  just  normal ;  that  it  appeared 
to  be  rather  childish  at  times  and  not  at  all  what 
one  would  expect  for  a  young  man  of  his  age.  Of 
course  the  whole  approach  had  to  be  very  tactfully 
applied  so  as  not  to  make  it  too  painful  for  him. 

At  first  he  was  inclined  to  think  he  was  doing  quite 
right  but  soon  began  to  see  the  logic  of  it  all  and 
then  carefully  tried  to  follow  out  the  training  treat- 
ment. He  learned  exactly  how  to  control  his 
physical  activities,  his  diet,  and  to  apply  the  daily 
teaching  in  stich  a  way  that  brotight  abotit  the  best 
results.  His  grand  mal  attacks  decreased  from  the 
number  mentioned  to  one  every  six  or  eight  weeks 
and  the  attacks  of  petit  mal  occurred  at  intervals  of 
four  or  five  days.  His  interests  increased.  He  took 
tip  a  cotirse  in  agriculture  and  became  more  spon- 
taneous in  all  his  activities.  At  first  his  onlv  topic 
of  conversation  was  his  parents  and  other  relatives. 
He  carried  their  letters  about  in  his  pocket  and  used 
them  to  produce  talk  with  the  club  members  and 
strangers  whom  he  met.  He  was  not  happy  unless 
he  received  a  letter  a  day  from  his  parents  and 
wrote  one  to  them  but  as  his  interests  increased  and 
he  became  more  active  in  the  club  life,  he  soon  be- 
gan to  regtilate  the  letter  writing  to  once  a  week 
and  take  up  other  topics  of  conversation  besides  his 
relatives.  This  character  change  all  came  hand  in 
hand  with  his  insight  into  his  defects  and  a  realiza- 
tion of  the  conflicts  that  resulted  from  them.  This 
patient  gave  the  following  view  of  his  difficulty: 
"If  my  parents  would  understand  me — they  treat 
me  like  a  child — will  never  let  me  do  anything  so, 
how  can  I  learn? — I  never  was  let  do  anything  and 
was  always  kept  down  and  grew  up  in  a  sort  of  a 
fear  that  no  matter  what  I  did  it  was  sure  to  be 
wrong — and  then  I  got  into  the  habit  of  always  let- 


896 


COOPER:  CEREBROSPIXAL  FEl'ER. 


[New  York 
Medical  Journal. 


ting  Others  decide  for  me — it  was  easier  I  guess — 
but  I  can  see  now  that  it  was  wrong — and  I  want 
to  learn  how  to  get  over  this  trouble." 

He  lost  his  intensive  childish  attachment  for  his 
parents  and  became  more  active  in  the  group  set- 
tings. Just  as  he  gained  insight  into  his  defects  and 
acted  accordingly,  he  became  more  proficient  and 
had  less  difficulty  with  his  environment,  in  conse- 
quence of  which  he  had  fewer  attacks. 

Case  III. — Another  patient,  a  youthful  epileptic, 
showed  a  marked  antagonism  toward  his  mother 
and  other  members  of  th'=:  family.  He  insisted  that 
they  did  not  understand  him,  and  by  their  very  at- 
titude, created  stressful  states  that  caused  him  to 
break.  In  other  words,  they  held  him  to  too  high 
a  standard  and  expected  too  much  of  him.  This 
patient  presented  a  classical  constitutional  makeup. 
He  was  taught  in  the  same  careful  manner  and 
assisted  from  day  to  day  to  put  into  operation  the 
lessons  given,  for  he  was  possessed  of  a  poor 
machine  and  simply  couldn't  do  wliat  he  realized 
was  right.  As  he  learned  and  saw  the  great  ad- 
vantage to  be  gained  by  this  proper  approach,  he 
wrote  frequent  letters  imploring  his  mother  and 
other  members  of  the  family  to  learn  this  method 
of  approach  and  assist  him.  It  is  just  as  essential 
that  the  parents  have  this  insight  as  it  is  for  the 
patients.  With  this  in  mind,  the  parents  and  people 
with  whom  the  patients  expected  to  live  after  they 
concluded  treatment,  were  given  frequent  talks  in 
which  they  were  taught  just  how  the  work  was 
carried  on.  One  patient  remarked:  "If  I  could  get 
the  folks  at  home  to  create  the  same  kind  of  en- 
vironment as  I  have  here,  I  know  I  could  go  home 
and  do  my  work  there  and  get  well,  but  things 
seem  different  at  home ;  the  folks  don't  understand 
and  I'm  always  getting  into  trouble.  I  can't  do 
things  the  way  they  want  me  to.  I  have  my  own 
way  and  if  I'm  let  work  along  the  lines  that  are 
easiest  for  me  I  can  accomplish  more  and  am 
happier." 

From  the  notes  cited  in  this  paper  it  will  be  seen 
that  the  patients  studied  showed  an  inability  to 
adjust  and  adapt  themselves  to  their  environment, 
which  in  turn  seemed  to  cause  them  to  retreat  from 
reality.  They  stood  mental  and  physical  stress 
poorly  and  lacked  the  ability  to  give  expression  in 
any  way,  appearing  to  suffer  in  silence  until  the  fit 
relieved  them.  The  stress  of  life  was  too  great, 
yet  they  were  constantly  irritated  and  annoyed  be- 
cause they  could  not  accomplish  their  desires, 
regardless  of  the  fact  that  they  were  aware  of  the 
poor  machine  that  nature  had  given  them.  The 
training  treatment  that  brought  such  good  results  in 
the  cases  cited  was  characterized  by  a  gentleness  of 
approach  that  inspired  the  patient  to  reveal  the 
conflict  in  time  so  that  something  could  be  done 
to  prevent  the  great  damage  caused  by  repression. 
In  this  way  the  patient  realized  that  the  difficulty 
was  within  and  not  with  reality.  He  released  an 
affect  and  had  an  opportunity  to  get  square  with 
things.  He  was  rendered  more  receptive,  realized 
that  at  least  some  one  was  interested  who  under- 
stood him,  and,  in  consequence  of  this  good  feeling, 
he  was  more  willing  to  accept  the  corrective  advice 
offered.    In  every  case  so  treated,  I  have  had  the 


patients  tell  me  that  they  derived  instant  relief  from 
the  acute  annoyance  and  irritation,  and  the  depres- 
sion that  seemed  to  cloud  their  minds  passed  away 
and  irrade  the  outlook  brighter,  which  in  turn  en- 
abled them  to  resume  their  routine  work.  They 
became  changed  persons  as  they  gradually  learned 
to  know  themselves ;  they  became  more  proficient 
and  assumed  charge  of  their  affairs  and  directed 
their  actions  with  good  judgment. 

The  epileptic  requires  more  rest  than  most  people. 
He  can  never  be  hurried.  If  this  training  treat- 
ment enables  such  patients  to  recognize  the  neces- 
sity of  this  and  by  carefully  following  out  such 
teachings.  Their  attacks  are  reduced,  they  become 
happier  and  more  contented,  and  it  would  seem  that 
this  form  of  approach  was  well  worth  serious 
consideration. 

I  might  conclude  by  saying  that  at  no  time  is  it 
ever  advisable  to  keep  from  the  patient  the  true 
nature  of  his  disease.  From  the  very  beginning, 
just  as  soon  as  a  positive  diagnosis  has  been  made, 
efforts  should  be  centred  on  imparting  to  the  patient 
in  the  most  acceptable  form,  a  thorough  knowledge 
of  his  disease  and  the  methods  by  which  he  is  to 
secure  an  arrest  or  cure.  By  showing  him  the  per- 
sonal gain  to  be  had  from  carefully  adhering  to  the 
rules  governing  his  particular  case,  he  will  have  this 
as  an  incentive,  giving  hope  when  reality  tends  to 
block  his  progress. 

The  cessation  of  attacks  is  by  no  means  an  indi- 
cation that  the  patient  is  cured.  It  is  also  necessary 
that  the  patient  be  able  to  assume  charge  of  his  or 
her  own  affairs  and,  above  all,  to  have  a  true  in- 
sight into  the  nature  and  conditions  that  brought 
about  his  disease.  He  must  be  able  of  his  own 
accord  to  direct  his  actions  so  as  to  avoid  the 
stresses  that  cause  him  trouble.  A  changed  mental 
attitude  toward  himself  and  his  environment  must 
take  place  before  any  real  successful  results  can  be 
expected.  The  training  treatment  seems  the  best 
method  of  reeducating  the  epileptic,  but  it  requires 
great  patience  and  much  time  to  accomplish  even 
a  little,  but  if  the  fight  is  carried  on  tactfully  the 
results  are  always  gratifying  and  never  fail,  once 
the  patient  begins  to  act  of  his  own  accord. 

The  Club. 

INTECTIOXS  OF  CEREBROSPINAL  FLUID 
IX  CEREBROSPINAL  FEVER. 
By  Navrgji  A.  Cooper,  M.  D., 

Bombay,  India. 
Honorary  Physician,  B.  D.  P.  P.  G.  Hospital. 

An  interesting  case  of  a  young  boy  of  fourteen 
years  of  age  suffering  from  a  severe  form  of  cere- 
brospinal fever  was  admitted  into  the  B.  D.  Petit 
Parsee  General  Hospital  on  April  7.  1920.  As  the 
case  was  unique  of  its  kind  in  the  matter  of  bringing 
about  the  patient's  complete  recovery  from  the  mal- 
ady as  well  as  all  its  concomitant  adverse  symptoms, 
nervous,  sensory,  and  muscular,  under  the  injections 
of  the  patient's  own  cerebrospinal  fluid,  my  col- 
league, Dr.  R.  Rao,  who  saw  the  patient,  desired 
me  to  report  it  fttlly  for  the  information  of  the 
profession  at  large. 


December  4,  1920.] 


COOPER:  CEREBROSPIXAL  I-El'ER. 


897 


The  affection  started  with  swelHngs  and  pains  in 
the  joints,  of  a  shifting  character  (even  the  smaller 
joints  of  the  fingers  being  involved),  accompanied 
by  fever  and  occasional  vomiting.  He  was  treated 
by  a  local  practitioner  for  about  a  month  by  anti- 
rheumatic drugs.  These  had  no  effect  and  the  condi- 
tion went  from  bad  to  worse.  Bronchopneumonia 
supervened  and  the  patient  was  delirious  at  times. 
In  this  condition  the  patient  was  brought  to  the  hos- 
pital and  placed  under  the  care  of  one  of  my  col- 
leagues. The  temperature  went  up  from  102°  F. 
to  105°,  with  an  increase  in  respiration.  The  pulse 
was  feeble  and  rapid.  He  continued  to  be  very  ex- 
cited and  was  delirious  at  times.  All  the  larger 
joints  showed  a  condition  of  arthritis.  There  was 
a  bronchopneumonia  in  the  right  lung  and  the  gen- 
eral Qpndition  was  very  low. 

The  following  findings  were  shown  from  day  to 
day.  April  8,  1920,  slight  leucocytosis,  nothing  ab- 
normal in  the  urine.  April  10th,  the  Widal  test  was 
negative.  On  April  Uth,  a  throat  swab  showed 
nothing  important  bacteriologically.  On  April  13th, 
the  condition  seemed  serious.  The  patient  improved 
somewhat  under  stimulants  and  oxygen  inhalation 
towards  evening  but  the  mental  symptoms  were  more 
marked.  On  April  15th,  signs  of  meningeal  irritation 
were  noticed.  There  was  a  marked  retraction  of  the 
neck,  and  rigidity  of  the  limbs.  Kernig's  sign  and 
ankle  clonus  were  present  as  well  as  a  bronchopneu- 
monia in  both  lungs.  The  general  condition  was 
extremely  unfavorable.  There  was  a  loss  of  control 
of  the  bladder  and  rectum.  A  lumbar  puncture  was 
made  on  the  16th,  and  about  one  and  one  half  ounces 
of  fluid  removed,  which  was  turbid  with  an  abun- 
dance of  albumin  and  a  negative  Fehling  reaction. 
No  tubercle  bacilli  or  other  microorganisms  found. 
There  was  a  relative  increase  of  polymorphonuclear 
cells.  The  culture  was  sterile.  Lumbar  puncture 
was  again  made  on  the  18th.  The  fluid  was  slightly 
turbid.  There  were  a  few  diplococci  present  resem- 
bling pneumococci  but  they  showed  no  capsule.  The 
culture  was  negative.  On  the  19th,  a  lumbar  punc- 
ture was  again  made  and  fifteen  c.  c.  of  fluid  re- 
moved. On  the  20th  the  patient  seemed  to  be  a  bit 
brighter  but  the  general  condition  was  very  low,  with 
a  rapid,  feeble  pulse.  Smear  from  a  throat  swab 
showed  a  fair  number  of  squamous  epithelial  cells, 
a  fair  number  of  pus  cells,  a  few  staphylococci, 
streptococci  and  diplococci  and  bacilli.  There  were 
no  tubercle  bacilli.  A  lumbar  puncture  was  again 
made  on  the  21st.  The  fluid  was  turbid,  the  culture 
was  negative.  On  the  24th  the  patient  seemed  to  be 
a  little  better  after  the  last  lumbar  pinicture.  As  my 
colleague  had  to  leave  Bombay  on  the  27th  for  some 
time,  the  patient  was  transferred  to  me  for  further 
treatment.  From  the  7th  to  the  27th  the  patient  had 
had  nineteen  injections  of  camphor  in  oil,  three  of 
pituitrin,  four  of  digitalin,  and  five  of  strychnine 
(before  meningeal  symptoms  were  discovered)  and 
four  lumbar  punctures  together  with  stimulants  by 
mouth  such  as  musk,  ammonia,  digitalis,  brandy, 
and  oxygen  inhalations.  On  the  27th  I  noted  the 
condition  of  the  patient  to  be  as  follows : 

The  patient  was  unconscious,  lying  with  his  head 
rigidly  retracted  with  staring  eyes  and  dilated  pupils, 
which  did  not  react  to  light  or  accommodation. 


There  was  no  nystagmus  or  strabismus,  a  marked 
rigidity  of  the  muscles  of  the  neck,  abdomen,  and 
back  was  manifest  and  all  the  limbs  were  strongly 
flexed.  There  was  absolutely  no  control  of  bladder 
or  rectum.  Kernig's,  Babinski's,  and  ankle  clonus 
were  present.  There  were  tremors  of  the  limbs  and 
body  (more  of  the  upper  half)  with  bronchopneu- 
monia of  both  lungs  and  a  rapid  feeble  pulse.  The 
patient  would  shriek  at  times  and  utter  low  moans 
frequently. 

The  patient  was  put  on  a  simple  diaphoretic  mix- 
ture with  aromatic  spirits  of  ammonia  as  the  only 
stimulant.  Urotropin  and  guaiacol  carbonate,  five 
grains  of  each,  were  given  twice  a  day  and  an  injec- 
tion of  mixed  influenza  vaccine  consisting  of  pneu- 
monia, streptococci,  influenza  bacilli  and  staphylo- 
cocci was  given  every  day. 

On  May  8th  the  signs  of  bronchopneumonia 
were  not  so  extensive,  and  though  the  temperature 
was  slightly  affected  under  vaccine  therapy,  the  men- 
ingeal symptoms  remained  the  same.  On  the  9th 
all  medication  was  stopped.  On  the  1 1th  the  patient 
was  restless  all  the  night,  shrieking  loudly  all  the 
time.  Hyoscine  injections  and  bromides  were  given 
but  had  no  effect.  At  3  a.  m.  cold  sponging  was  re- 
sorted to  as  the  entire  body  of  the  patient  was  trem- 
bling. On  the  12th  a  lumbar  puncture  was  made 
and  ten  c.  c.  of  fluid  was  withdrawn.  It  was  sterile. 
Chemicals  reactions  could  not  be  taken  as  the  amount 
of  fluid  was  too  small.  Of  this  fluid  three  quarters 
c.  c.  was  injected  subcutaneously  and  it  was  repeated 
every  day  till  the  17th.  Gradually  the  temperature 
fell  and  meningeal  symptoms  abated  with  every  in- 
jection until  the  18th,  when  the  temperature  dropped 
to  97°  F.  The  patient  appeared  brighter  with  a 
marked  improvement  in  his  general  condition.  The 
pupils  were  still  dilated  but  reacted  to  light.  On  the 
22nd  the  condition  was  better.  He  kept  his  eyes 
closed.  The  pupils  were  not  so  widely  dilated. 
Stiffness  of  the  neck  was  less  marked.  On  the  24th 
the  patient  put  out  his  tongue  on  being  asked  to  do 
so  for  the  first  time.  Intelligence  was  improving 
every  day  and  at  times  he  answered  questions  in 
monosyllables.  On  the  26th  the  patient  spoke  a 
short  sentence  for  the  first  time,  ^lemory  seemed  to 
have  failed.  He  knew  nothing  about  his  illness. 
The  stiffness  of  the  neck  was  not  so  marked.  He  lay 
with  his  upper  extremities  and  left  leg  extended.  On 
June  6th  the  tremor  was  still  present,  though  not  con- 
tinuous. On  the  8th  the  tremors  disappeared.  There 
was  very  little  rigidity  of  the  limbs.  The  pupils  were 
gradually  contracting  but  the  patient  could  not  read 
clearly  and  lucidly.  It  took  time  for  the  patient  to 
recognize  letters  and  he  made  mistakes  in  deciphering 
what  he  had  learned  before.  His  memory  had  failed 
to  a  great  extent  though  he  could  give  his  own  name 
and  the  names  of  his  father  and  one  sister,  he  had 
forgotten  the  names  of  his  six  brothers,  one  sister, 
and  his  mother.  He  was  given  daily  lessons  and  was 
made  to  read  papers  and  school  books.  On  the  10th 
he  was  able  to  speak  and  read  without  difficulty  and 
imder stand  what  he  read.  The  rigidity  of  all  the 
muscles  excepting  those  of  the  right  leg  disappeared. 
He  still  passed  urine  in  bed.  On  the  16th  he  was 
better  in  all  respects,  and  asked  for  the  urine  bottle 
when  he  wished  to  pass  urine.  On  the  20th  he  spoke 


898 


KRAMER: 


VENESECTION. 


[New  York 
Medical  Journal. 


intelligently  and  was  able  to  read  without  difficulty 
and  sat  up  in  bed  without  any  help.  On  the  26th  of 
July  he  left  the  hospital  in  perfect  health  without 
the  slightest  defect. 

Conclusions. 

1.  The  case  was  very  serious  and  of  a  severe  form 
of  cerebrospinal  meningitis  from  the  very  be- 
ginning. 2.  The  disease  simulated  rheumatism  in  the 
beginning.  Neither  the  salicylates  nor  other  medica- 
tion had  any  effect  on  the  course  of  the  disease.  If 
anything,  the  condition  went  from  bad  to  worse. 
3.  There  was  a  distinctly  good  effect  from  the  mixed 
influenza  vaccine  in  the  bronchopneumonic  condi- 
tion, but  not  on  meningeal  symptoms.  4.  After  the 
administration  of  the  vaccine  and  urotropin  the  cere- 
brospinal fluid  was  found  sterile  and  clear.  5.  It  is 
certain  that  both  the  vaccine  and  urotropin  had  no 
ef¥ect  on  his  meningeal  symptoms  and  fever.  6.  The 
fever  and  meningeal  symptoms  abated  gradually 
every  day  under  injection  of  the  cerebrospinal  fluid. 
7.  His  complete  recovery  was  due  to  the  injections 
of  his  own  toxins  contained  in  the  cerebrospinal 
fluid  without  which  the  patient  could  not  have  made 
an  advance  toward  such  an  uninterrupted  and  per- 
fect recovery. 

CuMBALLA  Hall. 


VENESECTION  :  A  LOST  ART.* 
By  David  W.  Kr.\mer,  M.  D., 
Philadelphia, 

Demonstrator  of  Clinical   Medicine,  Jefferson   Medical   College;  As- 
sistant Visiting  Physician,  Jewish  Hospital  and  Phila- 
delphia   General  Hospital. 

HISTORY  OF  VENESECTION. 

Venesection  or  blood  letting  is  a  measure  that  has 
been  employed  almost  universally  and  has  been 
traced  back  to  about  2500  B.  C.  (1),  its  unwritten 
history  probably  being  of  far  greater  antiquity. 
Hippocrates  (460-370  B.  C.)  bled  extensively  and 
wrote  a  treatise  upon  the  subject.  Galen  also  let 
blood  in  many  cases ;  he  is  quoted  as  the  first  to 
specify  the  proper  quantities  to  be  withdrawn  under 
various  conditions,  recommending  from  a  half  pint 
to  a  pint  and  a  half  in  the  average  case. 

Through  centuries  of  ancient  and  medieval  his- 
tory frequent  references  are  made  to  venesection, 
and  there  is  no  doubt  that  the  practice  was  often 
abused.  In  the  fifteenth  and  sixteenth  centuries  (2), 
Pierre  Brissot  stands  out  as  a  reformer.  There  was 
much  controversy  over  the  site  of  bleeding,  the  Ara- 
bic teaching  being  that  blood  .should  be  drawn  at  a 
distance  from  the  lesion,  whereas  the  more  strict 
followers  of  Hippocrates  preferred  to  open  a  vein 
near  the  lesion  and  on  the  same  side  of  the  body. 

Sydenham  (1624-1689)  revised  the  application  of 
blood  letting,  and  used  it  extensively  but  with  dis- 
cretion ;  usually  he  began  treatment  by  opening  a 
vein,  but  seldom  took  more  than  eight  or  ten  ounces 
at  a  time.  Hahnemann  and  the  homeopathic  school 
(1779-1843)  founded  their  indictment  rtf  orthodox 
medical  practice  largely  upon  the  indiscriminate 
bleeding  in  favor  with  the  German  physicians  of 
their  day.    In  the  early  part  of  the  nineteenth  cen- 

'Cases  studied  in  0r.  S.  Solie-Cohen's  service  at  the  Jewish 
Hospital. 


tury,  venesection  was  still  in  vogue,  with  a  tendency 
toward  its  abuse.  Louis,  in  1835,  advised  against 
its  promiscuous  employment  and  especially  insisted 
that  it  was  of  little  worth  in  pneumonia.  In  the 
latter  part  of  the  nineteenth  century,  blood  letting 
had  become  restricted  to  conditions  clearly  indicat- 
ing its  employment.  Of  late  it  seems  to  be  used 
only  on  rare  occasions.  If  we  were  to  question  in- 
terns in  nearly  all  hospitals  as  to  the  number  of 
venesections  performed  during  a  six  months'  period 
of  their  service  in  medical  wards,  their  replies  would 
indicate  that  it  is  almost  a  forgotten  measure.  Yet, 
when  we  come  to  consider  the  number  of  conditions 
in  which  it  gives  relief  without  danger,  especially 
in  certain  phases  of  common  diseases,  we  find  that 
definite  indications  for  its  application  are  by  no 
means  so  rare. 

INDICATIONS  FOR  BLOOD  LETTING. 

Blood  may  be  taken  by  opening  a  vein,  by  insert- 
ing a  cannula  into  a  vein,  or  by  means  of  wet  cups 
or  leeches.  Each  method  has  conditions  of  election, 
but,  generally  speaking,  venesection  is  the  most 
prompt  and  certain.  It  is  a  relatively  simple  meas- 
ure, and  is  easily  carried  out,  both  at  home  and  in 
the  hospital.  No  doubt  it  may  be  a  somewhat  grue- 
some affair  when  performed  at  the  house  with  little 
or  no  assistance,  but  it  is  feasible  even  then.  Its 
indications  are,  in  general,  of  two  classes — a,  pallia- 
tive, where  its  employment  materially  adds  to  the 
patient's  comfort  for  the  time  being ;  and  b,  restora- 
tive, when  it  may,  in  addition,  prolong  life  or  even 
determine  recovery. 

Textbooks  (3)  furnish  us  with  lists  of  condi- 
tions in  which  venesection  may  be  of  use.  I  need 
not  emphasize  apoplexy.  Osier's  or  Vaquez's  dis- 
ease, pulmonary  edema,  eclampsia,  or  other  condi- 
tions in  which  blood  letting  is  more  or  less  recog- 
nized as  part  of  the  routine  treatment.  Nor  shall  I 
dwell  on  all  the  others;  but  for  present  purposes 
shall  limit  myself  to  some  five,  in  wdiich  it  may  be 
safely  done  with  marked  benefit  but  is  too  often 
omitted.  These  are — pneumonia,  influenza,  and 
other  acute  intoxications,  cardiac  affections,  uremia, 
and  vascular  hypertension. 

It  is  understood,  of  course,  that  I  refer  only  to 
certain  phases  of  certain  cases.  Venesection  is  not 
to  be  ordered  promiscuously  in  any  class  or  set  of 
cases.  Only  when  cleai-ly  indicated  will  it  reward 
us  with  definite  and  helpful  results. 

BExXEFITS  TO  BE  DERIVED  FROM  VENESECTION. 

The  amount  of  blood  in  an  animal  is  said  by  most 
authorities  to  be  about  one  thirteenth  of  the  body 
weight.  Haldane  and  Smith  (4)  give  one  twentieth 
of  the  body  weight  as  the  figure  in  man. 

In  venesection,  as  in  hemorrhage,  there  is  loss  in 
vascular  content  both  in  fluid  and  in  cells  (5).  The 
diminution  in  volume  manifests  itself  at  once;  that 
in  the  corpuscular  elements  may  not  reach  its  great- 
est point  for  several  days,  evidently  depending  upon 
the  manner  in  which  blood  replacement  takes  place. 
The  volume  is  probably  restored  in  a  few  hours  by 
rapid  absorption  of  fluid  from  the  tissues;  thus  the 
blood  becomes  greatly  diluted,  as  manifested  by  the 
reduction  in  hemoglobin.  This  is  a  natural  sequence 
of  events.  Lee  (6)  makes  use  of  the  hemoglobin 
estimation  as  a  guide  to  blood  volume,  and  this  has 


December  4.  1920.] 


KRAMER:  VENESECTION. 


899 


its  prognostic  value.  A  patient  presenting  a  rela- 
tively low  hemoglobin — say  sixty  to  eighty  per  cent. 
— at  the  end  of  twenty-four  hours  or  more  after 
hemorrhage  is  in  much  better  condition  than  one 
who  presents  a  hemoglobin  ratio  of  a  hundred  per 
cent.  In  the  former  case  the  vessels  have  been 
refilled.  In  the  latter  case  there  has  been  no  influx 
of  fluid. 

Bearing  these  facts  in  mind,  we  may  discuss  the 
benefits  of  venesection.  These  may  be  enumerated 
as  follows : 

1.  Relief  of  an  overdist ended  right  auricle,  a  fact 
noted  in  animal  experimentation,  and  which  plays 
an  important  role  in  therapeutics. 

2.  Diminution  in  blood  volume;  this  is  only  tem- 
porary. 

3.  Diminution  in  blood  viscosity,  as  a  result  of 
replacing  the  diminished  volume  by  the  fluids  of 
the  tissues. 

4.  Reduction,  or  sometimes  elevation,  of  blood 
pressure.  This  demands  fuller  discussion  else- 
where. 

5.  Diminution  of  toxemias.  This  is  to  be  ob- 
served not  only  in  uremia  but  markedly  in  certain 
acute  infections,  particularly  that  baffling  group 
which  we  have  been  in  the  habit  of  calling  grippe  or 
influenza.  I  shall  speak  first  of  these  toxic  infec- 
tions in  the  discussion  of  conditions  in  which  vene- 
section is  useful. 

INDICATIONS   FOR   BLOOD  LETTING. 

Infectious  toxemia. — This  type  of  infection  comes 
on  with  an  apparent  suddenness,  perhaps  after  a 
precedent  coryza  or  sore  throat,  and  manifests  itself 
as  an  overwhelming  intoxication,  with  prostration, 
intense  headache,  and  cyanosis.  It  seems  to  have 
a  predilection  for  attacking  the  heart  muscle  almost 
from  its  very  onset,  as  evidenced  by  the  feeble  heart 
sounds  and  the  weak,  rapid  pulse,  commonly  of  a 
low  pressure.  S.  Solis-Cohen,  in  his  clinical  con- 
ferences with  classes  at  Jefferson  Medical  College, 
has  pointed  out  that  cases  in  which  hemoptysis  or 
profuse  epistaxis  occurs  early,  have,  as  a  rule,  a 
favorable  prognosis;  terming  this  "Nature's  hint 
to  the  physician." 

Venesection  is  accordingly  indicated  when  the 
pulse  rate  increases,  the  systolic  pressure  diminishes, 
cyanosis  becomes  more  intense,  and  evidences  of 
pulmonary  congestion  appear,  together  with  an  in- 
crease in  cardiac  dullness  to  the  right — in  short, 
when,  with  progress  of  the  toxemia,  the  heart  is 
about  to  give  way.  Blood  letting,  with  the  removal 
of  eight  to  ten  ounces,  exerts  an  obvious  beneficial 
influence  upon  the  course  of  the  infection,  and  this 
may  prove  to  be  the  turning  point  toward  recovery. 
If  for  any  reason  venesection  is  impracticable,  wet 
cups  or  leeches  may  be  applied  instead. 

The  benefits  observed  may  be  attributed,  in  part, 
no  doubt,  to  the  relief  of  the  overburdened  right 
heart;  but  I  do  not  believe  that  this  factor  alone 
is  to  be  credited  with  the  resulting  rise  of  blood 
pressure,  disappearance  of  cyanosis  and  improve- 
ment in  heart  sounds.  The  removal  of  so  much 
blood,  overladen  with  toxic  products  or  bacteria, 
possibly  both,  plus  the  resulting  factor,  viz :  the 
draining  oflf  of  tissue  fluids,  evidently  has  something 


to  do  in  bringing  about  the  happy  change  of  con- 
dition. 

Is  it  not  possible  that  when  the  fluid  is  drained 
off  from  the  tissues,  more  or  less  of  the  toxins 
which  have  been  harassing  the  tissue  cells  are 
removed  and  normal  function  is  encouraged  to 
reestablish  itself?  In  the  few  cases  that  I  have 
observed,  this  influence  seems  to  be  quite  evident 
and  asserts  itself  quickly,  say  within  twenty- four 
hours.  Patients  who  had  the  appearance  of  being 
washed  out,  who  were  rapidly  going  down  hill,  and 
in  whom  the  prognosis  seemed  grave,  appeared  to 
pass  through  a  peculiar  period,  analogous  to  the 
crisis,  after  which  period  they  not  only  looked 
stronger  and  more  comfortable,  but  voluntarily  told 
us  that  they  felt  so. 

This  may  be  illustrated  in  the  following  case, 
which  ordinarily  would  be  diagnosed  influenza,  but 
which  I  think  belongs  to  the  group  of  streptococcus 
infections.  It  may  be  noted,  in  passing,  that  the 
danger  in  influenza  is  virtually  always  from  some 
concurrent  infection ;  in  the  recent  epidemics,  ap- 
parently streptococcic. 

STREPTOCOCCIC  TOXEMIA. 

Case  I. — Mrs.  B.  G..  aged  sixty  years  Admitted 
June  13,  1920,  with  the  history  of  a  socalled  cold 
in  the  head,  soreness  of  throat,  intense  headache, 
palpitation.  Had  been  suffering  with  heart  trouble 
during  the  past  twenty  years.  Examination  revealed 
an  angry  looking  and  injected  throat;  cyanosis  of 
lips  and  finger  tips.  Heart  showed  auricular  fibril- 
lation and  partial  heart  block ;  congestion  of  lungs. 
White  blood  cells,  8500 ;  blood  pressure,  systolic  90, 
diastolic  50.  The  patient's  condition  became  pro- 
gressively worse  despite  the  usual  medicinal  treat- 
ment. 

June  16th,  6  p.  m.  Patient  was  very  restless, 
stuporous,  did  not  recognize  her  children.  Tem- 
perature 102.3°  F. ;  pulse  120;  respiration  30. 
White  blood  cells,  10,000;  blood  pressure,  systolic 
108,  diastolic  58.  8  p.  m.,  venesection ;  ten  ounces 
of  blood  taken.  10  p.  m.,  the  patient  seemed 
brighter,  with  the  .stupor  subsiding.  June  17th, 
the  appearance  was  brighter,  respirations  less 
labored,  blood  pressure  105-62.  June  19th,  tem- 
perature normal,  pulse  70,  respiration  28,  blood 
pressure  110-65.  In  this  case  venesection  was  per- 
formed despite  a  relatively  low  blood  pressure.  The 
patient  made  an  uneventful  recovery,  except  for  a 
pleuritic  pain,  whidi  disappeared  within  two  days. 

PNEUMONIA. 

I  shall  not  discuss  the  advisability  of  bleeding  early 
in  pneumonia.  Personally,  I  have  not  resorted  to  it. 
Years  ago  it  was  a  routine  measure,  but  despite  the 
fact  that  some  still  teach  it  to  be  indicated  when 
dealing  with  full  blooded,  plethoric  individuals  with 
high  tension,  I  doubt  whether  it  is  now  applied  in 
even  a  small  proportion  of  cases. 

It  is  my  intention,  on  the  other  hand,  to  empha- 
size as  strongly  as  possible  the  good  results  of  vene- 
section in  certain  stages  presented  during  the  course 
of  a  pneumonia,  especially  when  there  are  signs  of 
impending  danger  from  a  dilating  right  heart.  This,- 
as  is  commonly  recognized,  may  be  manifested  by 
feeble  pulse,  with  increase  in  rate,  more  or  less- 


900 


KRAMER:  VENESECTION. 


[New  York 
Medical  Journal. 


marked  cyanosis,  signs  of  increasing  pulmonary 
congestion,  and  extension  of  cardiac  dullness  to  the 
right.  A  gradual  or,  less  commonly,  a  sudden  drop 
of  the  diastolic  pressure  may  be  added  to  the  list  of 
ominous  happenings.  When  this  clinical  picture  is 
present,  we  must  realize  that  we  are  dealing  with  a 
profound  toxemia  and  an  overworked,  tired  and 
softened  myocardium,  which  is  trying  to  continue 
functioning  but  is  slipping  and  failing.  We  may 
likewise  realize  that  pneumonia  kills  not  through 
consolidation  of  the  lungs,  but  by  depressing  the 
heart  and  vessels  both  directly  and  through  the  auto- 
nomic nervous  system. 

Prevalent  treatment  in  the  form  of  medication  is 
directed  chiefly  to  stimulating  and  encouraging  the 
heart  to  keep  up  its  good  work,  with  the  hope  that 
the  infection  will  run  its  limited  course  before  the 
heart  collapses  and  the  patient  dies.  With  this  in 
mind,  why  not  materially  aid  the  heart  instead  of 
merely  encouraging  it?  Words  of  ^heer  in  the  form 
of  stimulation  will  give  us  results — that  is  true 
enough — but  venesection  will  enable  the  heart  to 
respond  more  promptly  and  probably  save  a  certain 
percentage  of  patients  who  would  otherwise  perish. 
Pneumonia,  truly,  is  a  battle  for  life  from  its  very 
beginning,  and  every  patient  has  a  chance  so  long  as 
the  heart  beats  and  so  long  as  the  lungs  functionate. 
Therefore,  we  should  stand  by  and  fight  for  and 
with  the  patient  regardless  of  how  dark  the  outlook. 
It  may  require  a  little  courage  to  decide  upon  vene- 
section when  conditions  are  so  poor,  but  we  may 
give  the  sick  man  the  benefit  of  the  doubt.  Nor 
have  I  permitted  a  low  blood  pressure  to  deter  me 
from  this  course  of  treatment.  Nothing  is  more 
startling  to  the  inexperienced  than  the  manner  in 
which  the  pulse  steadies  and  the  pressure  rises  after 
bleeding,  in  cases  of  the  kind  described.  In  the  in- 
stance which  I  am  about  to  cite,  the  systolic  pressure 
never  reached  higher  than  120,  and  the  diastolic 
pressure  dropped  steadily  from  fifty  to  ten.  At  this 
point  venesection  was  performed,  removing  ten  to 
twelve  ounces  of  blood.  In  my  judgment,  this 
enabled  the  man  to  make  his  successful  fight  for  life. 

MASSIVE  BRONCHOPNEUMONIA. 

Case  II. — H.  D. ;  twenty-two  years;  mechanic. 
Admitted  May  21,  1920,  with  a  history  of  shortness 
of  breath  and  pain  in  the  left  side  following  a  chill, 
the  preceding  day,  May  20th.  There  had  been  be- 
fore this  a  cold  in  the  head  and  chest  lasting  three 
or  four  days.  Examination  revealed  an  extensive 
bronchopneumonia  approaching  the  lobar  type  on 
account  of  the  large  area  involved.  Temperature, 
102;  pulse,  120;  respiration,  34.  Lips  and  finger 
tips  were  cyanosed  and  there  was  some  tenderness 
over  the  liver — a  symptom  that  I  have  noticed  in 
others  suffering  from  this  type  of  infection.  Leu- 
cocj-te  count,  7,000;  blood  pressure  on  admission, 
systolic  105,  diastolic  30. 

May  27th,  patient's  condition  very  low.  Tem- 
perature, 102.4°  F;  pulse,  116;  respiration,  50. 

The  man  complained  of  tearing  like  pains  in  the 
right  side  of  chest,  when  coughing.  He  presented  a 
picture  of  prostration  and  exhaustion.  The  systolic 
pressure  remained  at  120.  due  to  stimulation,  as  the 
patient  was  being  treated  according  to  the  definite 
plan  (7).   The  diastolic  pressure,  however,  dropped 


to  ten ;  this  was  the  time  selected  for  venesection. 
Ten  to  twelve  ounces  of  blood  were  removed  from 
a  superficial  vein.  The  patient's  condition  remained, 
at  first,  unchanged  except  for  an  improvement  in 
diastolic  pressure,  whicli  rose  to  forty.  The  follow- 
ing day.  May  28th,  the  patient  was  more  comfort- 
able ;  blood  pressure,  120-20 ;  pulse  subsiding,  drop 
in  temperature.  ]\Iay  29th,  a  definite  change  in 
patient's  condition.  Although  examination  revealed 
persistent  consolidation  in  the  right  base,  there  was 
marked  general  improvement ;  the  temperature  was 
normal ;  the  pulse  ranged  between  eighty  and  ninety, 
and  blood  pressure  was  more  stable,  systolic,  118; 
diastolic,  45.  June  11th,  patient  showed  delayed 
resolution.  Gradual  recovery  ensued,  and  the  man 
was  discharged  well,  June  20th.  a  month  after  ad- 
mission. 

Permit  me  now  to  cite  another  case  of  pneumonia 
where  venesection  was  successful  in  giving  needed 
relief.  The  patient  was  seen  in  consultation  with 
Dr.  Joseph  Aspel,  to  whom  I  am  indebted  for  the 
report. 

Case  III. — Lobar  pneumonia,  with  dilating  right 
heart  and  tendency  to  pulmonary  edema.  B.  R., 
aged  forty-seven  years ;  illness  began  June  8th,  with 
chill  and  fever.  Examination  revealed  poor  heart 
sounds,  some  rales  at  bases  especially  on  left ;  mild 
delirium.  Temperature  102.2°  F.,  pulse  124,  res- 
piration 40 ;  blood  pressure,  systolic  98,  diastoHc  58 ; 
respirations  moist  and  labored ;  treated  by  definite 
plan.  June  11th.  The  condition  was  worse ;  patient 
delirious;  distinct  cyanosis  about  lips  and  finger 
tips ;  heart  sounds  more  feeble.  June  14th.  Condi- 
tion grave ;  patient  very  toxic ;  abdomen  dis- 
tended ;  cyanosis ;  moist  breathing ;  pulmonary  con- 
gestion marked ;  pulse  more  rapid ;  9  p.  m.,  tem- 
perature 103,  pulse  140,  respiration  40;  10  p.  m., 
venesection  was  performed ;  sixteen  ounces  of  blood 
removed  from  superficial  vein ;  midnight,  tempera- 
ture 102,  pulse  118,  respiration  36;  pulse  good. 
June  15th.  Rested  more  comfortably,  seemed 
brighter ;  respirations  not  so  moist.  From  this  day 
patient  made  a  gradual  but  uneventful  recovery. 

CARDIAC  CONDITIONS. 

Cardiac  dyspnea. — When  dyspnea  in  cardiac  af- 
fections becomes  so  acute  as  to  make  the  patient 
decidedly  uncomfortable,  even  while  resting  in  bed, 
the  advisability  of  venesection  should  be  seriously 
considered. 

Case  I\'. — The  clinical  picture  indicating  its  em- 
ployment may  be  illustrated  by  this  case  which  pre- 
sented a  mitral  regurgitant  lesion  and  an  enlarged 
heart,  with  all  the  evidences  of  decompensation. 
While  making  rounds,  my  attention  was  called  to 
this  man,  who,  with  a  blue  face,  was  having  extreme 
difficulty  in  breathing,  moaning  and  groaning  with 
his  respirations.  The  eyes  were  staring ;  the  dysp- 
nea was  so  intense  that  speech  was  impossible ;  the 
hands  werp  cold  and  the  pulse  almost  gone.  This 
])atient  seemed  moribund  and  I  had  little  hope  that 
anything  could  be  done.  He  responded  somewhat 
to  camphorated  oil,  but  did  not  improve  sufficiently 
to  change  the  prognosis.  Venesection  was  done  as 
a  last  resort.  The  loss  of  sixteen  ounces  of  blood 
produced  an  immediate  change  for  the  better.  The 
cyanosis  lessened,  the  dyspnea  soon  became  less 


December  4,  1920.] 


KRAMER: 


VEXESECTIOX. 


901 


urgent  and  the  man  was  able  to  speak.  His  heart 
now  responded  more  readily  to  medicinal  stimula- 
tion and  in  a  few  days  showed  decided  improvement. 

Another  cardiac  case  in  which  dyspnea  was  the 
main  symptom  but  did  not  have  in  the  background 
the  picture  of  an  impending  acute  dilatation,  may 
be  cited. 

AORTIC    REGURGITATIOX    WITH  FAILING 
COMPENSATION. 

Case  V. — M.  C,  aged  forty-eight  years;  in  Dr. 
S.  Solis-Cohen's  service  at  the  Jefferson  Medical 
College  Hospital.  This  man  suffered  from  aortic 
regurgitation  of  long  standing.  I  was  going  through 
the  wards  with  Dr.  Solis-Cohen,  when  he  found  the 
patient  markedly  distressed  with  dyspnea  and  pro- 
found cyanosis.  He  at  once  ordered  bleeding.  The 
withdrawal  of  sixteen  ounces  of  blood  from  a  super- 
ficial vein  brought  about  relief,  which  lasted  not  for 
a  few  days  only  but  for  the  rest  of  the  patient's  stay 
in  the  hospital ;  and,  when  discharged,  he  Avas,  and 
had  been  for  two  or  three  weeks,  able  to  move  freely 
about  the  ward.  This  result  was  impressive  and  is 
indeed  largely  responsible  for  this  paper. 

Acute  dilatation. — Venesection  is  so  clearly  indi- 
cated that  it  scarcely  needs  comment.  I  would  only 
say  that  it  is  often  delayed  too  long. 

UREMIA. 

Uremia  is  an  interesting  field  for  venesection 
since  it  is  an  intoxication,  whatever  the  toxic  sub- 
stances may  be.  There  is  usually  an  associated  vas- 
cular hypertension,  particularly  when  we  are  deal- 
ing with  uremic  dyspnea ;  and  occasionally  we  are 
called  upon  to  treat  cerebral  accidents  simulating 
embolism  and  apoplexy,  presenting  a  clinical  picture 
of  unconsciousness  and  paralysis  or  spasm ;  and,  at 
times,  convulsions ;  pulmonary  edema  may  likewise 
occur  in  uremics. 

In  uremic  dyspnea  (8),  when  associated  with  high 
blood  pressure,  an  effort  should  be  made  to  relieve 
the  left  heart,  either  by  vasodilators  or  bleeding. 
Bleeding  gives  better  results  than  the  vasodilators. 
The  benefits  derived  from  venesection  are  attributa- 
ble to : 

1.  Relieving  the  burden  of  an  overworked  heart, 
by  diminution  both  in  the  volume  and  the  viscosity 
of  blood. 

2.  Removal  of  toxins  and  toxic  products. 

3.  The  resultant  drainage  of  the  fluid  from  the 
tissues,  thereby  giving  more  or  less  aid  to  the  tissue 
cells  in  their  attempt  to  get  rid  of  waste  products. 

UREMIC   INTOXICATION   WITH  DYSPNEA. 

Case  VI. — I.  W.,  aged  sixty  years;  admitted 
June  12,  1920,  complaining  of  dyspnea  and  drowsi- 
ness. The  eyes  were  bagg\',  temporals  tortuous ; 
peculiar  foul  odor  in  breath ;  tongue  coated ;  skin 
dry ;  abdomen  and  extremities,  no  bearing  on  case : 
blood  pressure,  systolic  160,  diastolic  68 ;  oliguria ; 
blood  urea  90. 

The  patient  did  not  respond  to  medication,  nor 
to  the  usual  procedures  to  stimulate  elimination 
through  the  skin,  e.  g.,  hot  packs,  electric  (hot  air) 
cabinet,  and  pilocarpine.  June  16th.  Drowsiness 
more  intense,  approaching  stupor ;  very  restless ; 
stertorous  breathing.  Venesection  performed ;  six- 
teen ounces  removed,  with  resulting  improvement 


of  patient's  condition,  especially  lessening  of  rest- 
lessness. However,  all  attempts  to  get  the  skin 
active  were  futile  and  the  patient  died  June  30th. 

This  case  is  cited  merely  to  show  that  bleeding 
may  be  indicated  palliatively  even  if  it  does  not 
give  us  a  curative  result.  It  cannot,  of  course, 
make  a  new  heart  or  new  kidneys. 

I  shall  not  take  time  to  discuss  in  detail,  but  may 
mention  that  blood  letting  is  indicated  in  uremic 
coma,  in  pulmonary  edema  occurring  in  uremics,  in 
hypertension  and  early  stages  of  uremic  spasm  and 
paralysis,  particularly  when  they  do  not  respond  to 
the  ordinary  measures.  Incidentally,  I  may  call 
attention  to  muscular  twitchings  as  an  early  and 
neglected  symptom  of  uremic  intoxication. 

VASCULAR  HYPERTENSION. 

This  measure  need  not  be  considered  routinely 
when  dealing  with  cases  of  h}-pertension,  a  condi- 
tion about  which  so  little  is  known  from  the  etio- 
logical viewpoint.  However,  after  we  have  treated 
our  patients  with  the  usual  array  of  medication, 
electrotherapy,  and  cabinet  baths,  with  little  or  no 
success,  and  they  are  beginning  to  show  signs  of  dis- 
comfort from  the  general  disturbance  of  circulation, 
then  I  do  think  venesection  is  indicated,  being  in 
reality  a  measure  of  last  resort,  which  should  result 
in  more  or  less  relief,  particularly  in  cases  in  which 
pulmonary  edema  has  developed.  The  following 
case  may  be  cited  : 

HYPERTENSION  AND  CHRONIC  DIFFUSE  NEPHRITIS. 

Case  VII. — H.  S.,  aged  thirty-five  years;  ad- 
mitted June  11,  1920,  with  dyspnea.  The  patient 
had  recently  been  discharged  from  the  wards  as 
improved.  The  hypertension  had  previously  been 
treated  with  everything  at  our  command,  both  medi- 
cation and  eliminative  measures.  The  man  re- 
sponded at  first,  but  later  the  blood  pressure  again 
reached  its  height.  On  readmission  the  blood  pres- 
sure was  205-130;  the  urine  showed  a  light  cloud 
of  albumin  with  a  few  hyalogranular  casts.  Blood 
urea  was  39.  During  the  night  of  Jime  12th,  there 
developed  an  acute  dyspnea  followed  by  pulmonary 
edema ;  frothy,  bloody  fluid  exuding  from  nose  and 
mouth.  Fortunately,  a  resident  physician  was  at 
hand.  Venesection  was  done  promptly,  sixteen  to 
eighteen  ounces  of  blood  being  taken.  A  hypo- 
dermic injection  of  morphine  and  atropine  was 
given.  The  patient  went  to  sleep  and,  in  the  morn- 
ing, was  none  the  worse  for  his  experience.  In 
this  instance,  the  venesection  was  instrumental 
in  tiding  the  patient  over  a  critical  period :  but 
would  it  not  have  been  more  advisable  to  bleed 
earlier  and  thus  avoid  such  accidents  as  the  pul- 
monary edema,  which  if  not  managed  promptly  and 
judiciously,  may  end  disastrously? 

SUMMARY  AND  CONCLUSIONS. 

To  recapitulate.  It  is  not  my  intention  to  urge 
blood  letting  in  a  haphazard  manner.  We  should 
always  have  in  mind  some  definite  benefit  reasonably 
to  be  expected  from  its  immediate  effect.  In  the 
course  of  the  paper,  I  have  endeavored  to  point  out 
these  effects  and  conditions  wherein  they  are  indi- 
cated. Bearing  such  qualifications  in  mind,  venesec- 
tion or  other  forms  of  blood  letting  may  be  useful 
in  the  conditions  to  be  enumerated. 


902 


RHODES:   TONSILS  AXD  TUBERCULOSIS. 


[New  York 
Medical  Journal. 


1.  In  the  toxemias  associated  with  influenza  and 
in  the  grave  stages  of  pneumonia,  when  the  intoxica- 
tion is  overcoming  the  ei?orts  of  the  heart  and  the 
circulatory  system  to  maintain  life ;  the  clinical  pic- 
ture being  that  of  a  dilating  right  heart  with  rapid 
and  feeble  pulse  of  low  tension,  cyanosis,  dyspnea 
and  more  or  less  stupor.  Venesection,  under  these 
conditions,  may  be  the  deciding  factor  of  recovery. 

2.  In  cardiac  affections.  Blood  letting  for  acute 
cardiac  accident — acute  dilatation — needs  no  com- 
ment. Here  we  may  observe  that  when  a  patient, 
with  chronic  valvular  or  myocardial  lesion,  is  de- 
cidedly uncomfortable,  when  the  dyspnea  is  so  per- 
sistently constant  and  severe  as  to  make  his  existence 
one  of  torture,  this  manifestation  usually  having  a 
clinical  picture  of  failing  compensation  in  the  back- 
ground, well  timed  blood  letting  will  not  only  pro- 
long life,  but  will  give  the  patient  a  degree  of 
comfort  surpassing  that  obtainable  through  mor- 
phine. 

3.  In  vascular  hypertension.  Blood  letting  will 
not  remove  the  cause  of  trouble ;  but  after  all 
other  methods,  medicinal,  electrotherapeutic  and 
hydrotherapeutic.  have  failed  to  give  relief,  vene- 
section does  palliate,  at  least  temporarily ;  and  it  may 
be  instrumental  in  warding  off  complications,  such 
as  acute  pulmonary  edema  and  apoplexy.  The  ques- 
tion of  the  possible  benefit  of  earlier  and  repeated 
minor  blood  lettings  is  raised  but  will  not  be  dis- 
cussed here. 

4.  In  uremia.  \'enesection — sometimes  leeching 
— is  of  benefit  in  the  uremic  cerebral  accidents,  such 
as  coma,  convttlsions  and  paralysis  or  spastic  con- 
traction. It  should  be  done  earlier  in  uremic  dysp- 
nea, which  is  usually  associated  with  hypertension ; 
and  the  measure  is  especially  indicated,  as  shown  in . 
Case  VI,  when  we  are  dealing  with  an  intense  ure- 
mic poisoning,  with  no  diaphoretic  reaction  to  heat 
or  pilocarpine.  Blood  letting  is  then  the  only  means 
whereby  toxic  substances  can  be  eliminated. 

5.  Other  conditions.  It  is  obvious  that  states, 
such  as  apoplexy,  eclampsia,  polycythemic  cyanosis, 
certain  phases  of  aneurysm,  carbon  monoxide 
poisoning  and  pulmonary  edema,  regardless  of  the 
underlying  cause,  afford  suitable  indications  for 
blood  letting. 

TECHNIC. 

Beyond  asepsis,  the  technic  of  venesection  is  not 
highly  important.  Whether  a  large  calibre  needle 
is  inserted  into  a  superficial  vein,  or  whether  the 
vein  is  opened,  with  or  without  cutting  down  upon 
it,  matters  little.  Personally,  when  there  is  time,  I 
prefer  to  use  a  local  anesthetic,  and  to  cut  down 
upon,  dissect  and  open  a  vein  of  the  elbow.  It  is  a 
clean  and  not  difficult  way  of  going  about  it.  The 
other  details  do  not  call  for  discussion.  The  amount 
to  be  withdrawn  should  be  not  less  than  eight  to  ten 
ounces  and  not  more  than  sixteen  to  twenty-four 
ounces  at  a  time,  depending  upon  the  pathological 
indications  and  the  condition  of  the  patient. 

In  concluding,  I  may  say  that  this  paper  is  simply 
a  plea  for  a  more  frequent  use  of  venesection  when 
indicated.  I  do  not  profess  to  bring  out  anything 
original,  but  merely  to  emphasize  the  fact  that 
blood  letting  is  a  useful  measure,  especially  in  con- 
ditions of  poisoning  and  of  embarrassment  of  the 


circa' ation  that  other  means  have  failed  to,  or  obvi- 
ously cannot,  relieve;  and  that  when  applied  judi- 
ciously it  should  give  us  the  pleasing  results  that  we 
strive  for  in  medical  practice. 

REFERENCES. 

1.  DuTTOx,  W.  S. :  Venesection,  1916. 

2.  Garrison,  F.  H.  :  History  of  Medicine,  1917. 

3.  Sous-Cohen,  S.  :  System  of  Physiologic  Therapeu- 
tics, vol.  X,  1905. 

4.  Burton-Opitz  :  Physiology,  1920,  p.  227. 

5.  Williamson,  C.  S.  :  Forclihcimer's  Therapeusis,  vol. 
iii,  667,  1914. 

6.  Lee,  Robert  I. :  Blood  Volume  in  Wound  Hemorrhage 
and  Shock,  American  Journal  of  the  Medical  Sciences,  vol. 
clviii.  No.  4,  1919,  p.  571. 

7.  SoLis-CoHEN,  S. :  Journal  A.  M.  A.,  December  6, 
1919,  p.  1741. 

8.  FoRCHHEiMER,  F. :  Forchhcimer's  Therapeusis,  1914, 
vol.  iv,  55. 

2035  Chestnut  Street. 


THE  RELATIONSHIP  BETWEEN  DISEASED 
TONSILS  AND  PULMONARY 
TUBERCULOSIS. 

By  William  L  Rhodes,  M.  D., 
Wichita  Falls,  Tex. 

That  diseased  tonsils  have  a  direct  relationship  to 
pulmonary  tuberculosis  in  its  initial  stage  is  becom- 
ing more  and  more  evident  as  time  goes  on  and 
opportunities  for  the  study  of  the  great  white 
plague  present  themselves.  In  a  series  of  cases  of 
pulmonary  tuberculosis  referred  for  nose  and 
throat  examination  during  the  past  six  years,  it  has 
been  my  observation  that  practically  every  case 
gives  a  history  of  recurrent  inflammation  of  the 
tonsils  at  some  time  or  other,  and  upon  examination, 
the  crvpts  are  found  to  be  filled  with  a  deposit  of 
thickened  pus.  This  history  of  a  recurrent  inflam- 
mation of  the  tonsils,  in  connection  with  a  tubercu- 
lous infection  of  the  lungs,  does  not  always  hold 
good.  Some  cases  give  no  history  of  a  tonsillar 
inflammation  but  upon  examination  of  the  tonsils 
we  find  the  crypts  filled  with  deposits  of  thickened 
pus. 

While  in  the  Army,  I  had  the  opportunity  of 
doing  practically  all  the  eye,  ear,  nose,  and  throat 
work  for  the  thirty-fifth  division,  approximately 
28,000  men,  and  the  opportunities  for  the  study  of 
the  relationship  between  diseased  tonsils  and  pul- 
monary tuberculosis,  in  its  incipient  stage,  were 
manifold.  In  looking  over  the  records  of  the  vari- 
ous cases,  I  cannot  find  a  single  case  of  tuberculous 
infection  which  did  not  give  a  history  of  tonsillar 
involvement  associated  with  it. 

It  is  common  knowledge  that  diseased  tonsils 
may  cause  rheumatic  conditions,  and  that  upon  re- 
moval of  the  tonsils,  the  rheumatic  condition  sub- 
sides a  short  time  after  operation.  It  is  also 
common  knowledge  that  the  worst  types  of  carrier 
case  during  a  diphtheria  epidemic  are  the  types 
having  hypertrophied  and  diseased  tonsils  preceding 
the  diphtheritic  attack.  This  was  brought  to  our 
attention  in  a  striking  manner  during  an  epidemic 
of  diphtheria  among  the  men  of  the  thirty-fifth 
division  in  Alsace  during  the  months  of  July  and 


December  4,  1920.] 


RHODES:   TONSILS  AND  TUBERCULOSIS. 


903 


August,  1918.  The  entire  personnel  of  one  field 
liospital  during  the  epidemic  devoted  their  whole 
time  to  the  treatment  and  care  of  the  infected  men. 
A  field  laboratory,  in  charge  of  two  able  and  ex- 
perienced laboratory  men,  was  added  to  the  per- 
sonnel of  the  company,  aijd  did  good  work  in 
helping  to  eradicate  the  epidemic. 

The  division  surgeon  instituted  a  novel  feature 
in  the  form  of  a  gas  chamber,  in  an  attempt  to 
eliminate  the  disease  from  the  carrier  cases.  The 
men  were  subjected  to  the  treatment  of  chlorine 
gas  for  several  minutes  each  day  for  several  days, 
but  with  no  appreciable  result.  Following  the  gas 
treatment,  cultures  were  made  by  the  laboratory 
men,  who  reported  the  organisms  as  virulent  as  ever. 
These  patients  were  then  referred  for  tonsillectomy, 
after  which  they  were  again  placed  under  the  ob- 
servation of  the  field  laboratory  men,  and  in  the 
■course  of  another  week  were  sent  back  to  duty  as 
noncarriers. 

It  may  be  of  interest  to  note,  as  a  refutation  of 
the  theory  that  chlorine  gas  is  of  benefit  in  the 
treatment  of  carrier  cases,  that  eventually  a  number 
of  cultures,  in  open  tubes,  were  placed  in  the  gas 
chamber  and  exposed  to  the  action  of  the  gas  for 
several  hours  each  day,  for  a  period  of  three  or 
four  days.  The  laboratory  men  reported  absolutely 
no  detrimental  effect  upon  the  organism. 

Getting  back  to  the  subject  of  the  relationship 
between  diseased  tonsils  and  pulmonary  tubercu- 
losis, I  will  state  that  men  sent  into  the  hospital 
with  symptoms  of  an  incipient  pulmonary  phthisis 
were  referred  for  a  nose  and  throat  examination. 
These  examinations  consistently  revealed  diseased 
tonsils.  In  a  nvmiber  of  cases,  in  fact  as  a  routine 
-measure,  tonsillectomy  was  advised  and  performed 
as  an  adjunct  to  the  treatment  of  the  pulmonary 
condition.  In  the  larger  proportion  of  cases  thus 
treated,  beneficial  results  were  obtained  in  the  gen- 
eral physical  wellbeing  of  the  patient.  Men  were 
frequently  returned  to  active  duty,  who  otherwise 
-would  have  been  sent  to  the  rear,  and  eventually 
lost  to  the  service. 

The  opportunities  for  further  study  of  these  cases 
were  limited,  due  to  the  rapid  movement  from  sec- 
tor to  sector,  together  with  the  losses  sustained  in 
action,  both  from  wounds  and  from  sickness,  so 
that  it  is  impossible  to  state  whether  or  not  bene- 
ficial results  of  a  permanent  nature  were  obtained. 
However,  since  returning  to  private  practice  it  is 
-possible  to  study  further  the  cases  of  incipient 
pulmonary  tuberculosis  in  which  tonsillectomies 
liave  been  performed,  with  the  result  that  up  to 
date,  in  the  majority  of  such  cases,  a  decided 
improvement  has  been  observed. 

It  is  somewhat  premature  to  assert  that  an  actual 
■cure  took  place  in  these  cases,  but  it  is  safe  to  say 
that  there  is  a  notable  improvement  in  the  general 
physical  wellbeing  of  the  patients  thus  treated, 
where  the  pulmonary  infection  was  not  too  far  ad- 
vanced at  the  time  of  operation. 

It  is  not  my  intention  to  create  the  impression 
that  I  advocate  the  removal  of  the  tonsils  as  a  cure 
for  pulmonary  tuberculosis.  It  is  advanced  as  a 
theory  only,  unsustained  as  yet  by  laboratory  and 
■clinical  findings.      I   do  mair^ain,  however,  that 


there  is  a  distinct  relationship  between  diseased  ton- 
sils and  pulmonary  tuberculosis,  and  that  marked 
beneficial  results  upon  the  general  wellbeing  of  the 
patient  are  obtained  by  tonsillectomy  when  per- 
formed during  the  initial  stage  of  the  disease.  It 
is  my  personal  opinion  that  in  at  least  fifty  per  cent, 
of  all  cases  of  pulmonary  tuberculosis  the  infection 
is  derived  primarily  from  a  focus  of  infection  in  the 
crypts  of  the  tonsils,  and  that  a  tonsillectomy  is  a 
highly  important  and  necessary  procedure  as  an 
adjunct  to  the  general  treatment  of  this  condition. 
518-22  American  National  B.vxk  Building. 


Postoperative  Analgesia.  —  B.  van  Hoosen 
(American  Journal  of  Obstetrics,  December,  1919) 
states  that  the  technic  of  postoperative  analgesia 
should  be  directed  toward  the  prevention  rather 
than  the  relief  of  pain.  It  should  include  the  avoid- 
ance of  psychic  trauma  before  and  tissue  trauma 
during  the  operation.  Gas  pains,  thirst,  emesis, 
and  catheterization  must  become  avoidable  and  in- 
frequent occurrences.  The  procedure  recommended 
comprises  scopolamine  morphine  anesthesia — begun 
very  early  on  the  morning  of  the  operation — no 
catharsis  before  or  during  the  week  following 
operation,  and  all  preparation  of  the  operative  field, 
including  catheterization,  in  the  operating  suite  one 
half  hour  after  the  second  hypodermic  injection  of 
scopolamine  and  morphine.  The  latter  combina- 
tion yields  a  period  of  analgesia  of  from  eight  to 
twelve  hours  after  return  of  consciousness.  If  it 
is  desirable  to  continue  the  analgesia  for  a  longer 
time,  one  two  hundredth  grain  of  scopolamine  and 
one  thirty  second  grain  of  morphine,  or  one  four 
hundredth  grain  of  scopolamine  and  one  sixty 
fourth  grain  of  morphine,  may  be  prescribed  every 
four  hours,  beginning  about  four  hours  after  the 
operation  and  oontinuing  for  twenty-four  to  forty- 
eight  hours,  according  to  the  probable  length  of  the 
period  of  postoperative  pain.  Relief  of  gas  pains 
and  of  thirst,  and  avoidance  of  catheterization,  are 
all  obtained  by  a  simple  procedure : 

While  the  patient  is  on  the  operating  table  and  the 
abdomen  is  being  closed,  an  enema  of  two  quarts 
of  water  containing  three  hundred  and  sixty  grains 
of  sodium  bicarbonate  is  rapidly  administered — 
average  time,  two  minutes — through  a  colon  tube 
inserted  into  the  rectum  not  farther  than  three 
inches.  This  enema  is  retained  by  all  patients 
except  in  hemorrhoidectomies  and  in  some  thy- 
roidectomies. After  the  patient  has  been  taken  to 
her  room  and  is  comfortable  in  bed — about  twenty 
minutes  after  the  first  enema — another  enema  of 
two  or  three  quarts  with  or  without  the  bicarbonate, 
is  given,  but  more  slowly,  viz.,  in  ten  to  fifteen 
minutes.  This  enema  is  likewise  retained.  Pain 
in  the  wound  should  not  be  appreciable  and  is  ob- 
viated by  the  use  of  sharp  instruments  during  the 
operation,  blunt  dissection  being  avoided,  and  by 
gentle  and  infrequent  sponging.  The  position  in 
which  the  patient  is  placed  after  operation  also 
plays  a  part  in  the  relief  of  pain ;  it  should  be  com- 
fortable and  such  as  to  afford  relaxation  or  support 
to  the  parts,  according  to  the  reauirements  in  the 
individual  case. 


Editorial  Notes  and  Comments 


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NEW  YORK,  SATURDAY,  DECEMBER  4,  1920. 


HYPNOTISM  AND  PSYCHOTHERAPY  IN 
THE  SIXTEENTH  CENTURY 
Dr.  Camille  Rouzeaud,  in  an  interesting  student's 
dissertation  (L'Hypnotismc  ct  la  PsycJiotherapic  an 
XVI  Sicclc,  Camille  Rouzeaud,  Jouve  &  Co.,  Paris, 
1918),  throws  new  light  on  this  subject  as  con- 
sidered from  a  historical  viewpoint.  While  the 
recognition  of  hypnosis  as  a  true  state  dates  well  back 
into  history,  it  has  been  commonly  assumed  that  it 
did  not  excite  serious  scientific  attention  until  the 
nineteenth  century,  when  Charcot  in  his  article  on 
Faith  Healing  set  the  medical  world  by  the  ears  in 
discussion  for  and  against  his  theories.  The  accepted 
belief  has  been  that  although  the  influence  of  mind 
over  matter  was  acknowledged  at  a  much  earlier 
date  than  this,  the  source  of  the  power  was  ac- 
counted altogether  supernatural :  if  beneficent,  to  be 
assimied  as  a  miracle  and  if  otherwise,  to  be  laid  at 
the  door  of  sorcery.  The  principal  interest  in  what 
Rouzeaud  has  written  lies  in  the  fact  that  he  quotes 
as  authorities  for  the  affirmative  side  of  his  discus- 
sion the  names  of  authors  little  known  to  the  ma- 
jority of  the  medical  world.  Paracelsus  and  Kirch- 
er  are  names  which  are  familiar  in  connection  with 
the  subject,  but  those  of  Cornelius  Agrippa,  Pietro 
Pomix)nazzi,  Cardan  and  Van  Helmont  do  not  ap- 
pear in  the  lists  of  those  who  dealt  with  tliis  subject. 
Braid,  Esdaile  and  Elliotson,  who  saw  service  with 
the  British  Army  in  the  East,  learned  of  hypnotism 
from  the  Hindus  and  their  contributions  to  the  lit- 
erature of  the  subject  made  hypnotism  a  going  con- 


cern in  the  nineteenth  century  but  back  of  them 
there  is  little  evidence  to  prove  that  in  earlier  times 
either  hypnotism  or  psychotherapy  was  considered  as 
a  natural  process  rather  than  a  supernatural  mani- 
festation. 

While  Rouzeaud  readily  admits  that  the  deduc- 
tions of  Agrippa,  Pomponazzi  and  the  other  ob- 
servers quoted  were  in  part  crude  and  faulty,  he 
makes  the  claim  that  they  did  recognize  the  fact 
that  there  was  a  distinct  and  natural  relation  between 
the  mind  and  certain  pathological  states  of  the  body 
and  furthermore,  that  these  mental  processes  could 
be  utilized  as  therapeutic  agents.  Faulty  reasoning 
was  to  be  expected  in  times  when  scientific  methods 
were  vague  and  when,  in  addition,  investigations 
along  this  line  were  difficult  because  they  carried  the 
stigma  of  witchcraft  to  those  who  pursued  them. 
Rouzeaud  quotes  extensively  froin  Agrippa  and 
also  from  Pomponazzi  in  proof  of  the  fact  that 
these  men  recognized  as  fundamental  truths  what 
we  know  to  exist  from  the  more  enlightened  re- 
search of  later  years,  and  while  transcription  of  all 
that  he  has  cited  would  occupy  undue  space,  it  is 
allowable  to  extract  from  it  in  order  to  show  that 
there  was  in  the  sixteenth  century  a  recognition  of 
the  loffic  of  cause  and  efifect  in  the  relation  of  certain 
states  of  the  mind  and  the  body. 

Pietro  Pomponazzi,  professor  at  the  University  of 
Padua,  wrote  a  treatise  on-  enchantments  which  was 
published  after  his  death  in  1525  and  was  his  answer 
to  a  question  as  to  the  possible  explanation  of  mir- 
aculous cures.    In  this  he  says : 

"The  people  are  in  the  habit  of  attributing  to  Di- 
vine or  demoniac  origin  those  things  which  they  are 
unable  to  understand.  Every  science  grows  by  the 
aid  of  research  and  by  recorded  experience.  Spirits 
can  influence  matter  only  by  the  exercise  of 
material  laws.  It  is  possible  for  men  to  discover 
these  natural  laws  and  make  use  of  them  to  obtain 
the  same  natural  effects.  Many  learned  men  who 
have  been  regarded  as  magicians  or  necromancers 
have  never  had  any  intercourse  with  the  spirit  world, 
and  it  is  further  probable  that  they  hold  with  Aris- 
totle that  spirits  (demons)  do  not  exist.  It  is  en- 
tirely right  and  proper  to  look  for  the  natural  cause 
of  these  socalled  supernatural  cures  and  this  cause 
is  the  imagination  which  gives  rise  to  four  im- 
portant states — desire,  pleasure,  fear  and  pain." 
Pomponazzi  goes  on  with  the  theory  that  the  imagin- 
nation  can  produce  material  changes  in  the  material 
body  and,  perhaps  heretically,  suggests  that  it  was 
through  this  means,  rather  than  by  any  miraculous 


December  4,  1920.] 


EDITORIAL  ARTICLES. 


905 


agency  that  St.  Francis  acquired  the  marks  of  cruci- 
fixion borne  by  Christ.  (Charcot,  The  New  Rcviezv, 
December,  1893).  He  says,  "We  have  already  seen 
what  influence  faith  and  the  imagination  play  in 
these  cures  and  in  their  failures.  The  cures  obtained 
by  touching  sacred  relics  are  producd  only  by  means 
of  the  imagination  of  one  of  great  faith." 

He  cites  the  effect  of  prenatal  influence  on  the 
child  and  asks  if  this  be  so  why  the  production  of 
the  same  effect  should  not  take  place  in  the  body 
of  one  who  refers  the  same  mental  effort  to  his  own 
person.  All  in  all,  a  very  frank  expose  of  what  is 
a  recognized  part  of  the  psychotherapy  of  today — 
autosuggestion. 

Cornelius  Agrippa  was  the  physician  of  Maria 
Theresa,  mother  of  Francis  I  of  France,  and  Rouze- 
aud  in  comparing  his  opinions  with  those  of  Pom- 
ponazzi  says:  'Tn  La  Phi'cosophic  occultc  Cornelius 
Agrippa  describes  and  explains  the  same  extraor- 
dinary phenomena  due  to  the  action  of  the  mind  on 
organic  life.  His  explanation  in  this  work  reminds 
us  much  of  that  of  Pomponazzi :  but  it  is  much 
more  complete  and  precise  and  furthermore  he  mar- 
shals a  great  niunber  of  facts  as  evidence.  There 
were  already  enough,  but  he  cites  many  more,  and  in 
this,  according  to  our  view,  his  originality  lies.  He 
essays  to  connect  pathological  and  normal  pheno- 
mena, convinced  that  the  same  laws  govern  each, 
something  which  modern  science  has  conclusively 
demonstrated.  He  points  out  the  effect  on  the  body 
of  joy,  fear,  grief  and  the  other  emotions ;  the  an- 
esthetic effect  of  extreme  ecstasy  and  in  regard  to 
autosuggestion  carries  on  the  line  of  reasoning  fol- 
lowed by  Pomponazzi.  As  a  means  of  inducing 
the  hypnotic  state  he  cites:  1,  Narcotics  and  anes- 
thetics ;  2,  amulets,  talismans  and  similar  objects ;  3, 
strong  imagination  and  'animal  magnetism' ;  4,  action 
on  the  sense  of  sight ;  5,  action  on  the  sense  of  hear- 
ing; 6,  effect  on  the  emotions  (fear,  etc.),"  and  as 
Rouzeaud  says,  "This  list  is  very  complete  and  we  of 
later  years  have  added  little  if  an>'thing  to  it." 

The  later  investigations  of  Bernard,  Dusart,  Janet 
and  others  confirmed  the  theories  of  these  pioneers 
of  the  sixteenth  century  in  the  field  of  psycho- 
therapy. 

In  addition  to  the  quotations  from  medical  men 
of  the  times,  Rouzeaud  cites  as  significant  of  the 
truth  that  other  than  a  supernatural  origin  was 
ascribed  to  the  relation  between  the  mind  and  the 
body  at  this  early  date,  the  fact  that  in  the  writings 
of  laymen  of  the  period  there  is  not  infrequent  ref- 
erence to  the  very  probable  natural  origin  of  these 
phenomena.  In  support  of  this  he  cites  from  Chap- 
ter XX  of  the  first  book  of  Montaigne's  Essays, 
that  on  the  imagination,  and  in  parallel  column,  ex- 


tracts from  Agrippa  which  suggest  that  the  great 
essayist  borrowed  freely  from  his  scientific  contem- 
porary. He  quotes  further,  from  Rabelais  {Le  cin- 
quieme  et  dernier  livrc  de  faicts  et  diets  heroiques 
du  bon  Pantagruel,  Chapters  XLIII  et  XLVIII),  in 
the  same  tenor. 

In  his  conclusion,  Rouzeaud  says,  "Finally,  we 
may  make  one  statement  with  conviction.  Hypno- 
tism was  known  in  the  sixteenth  century.  The  writ- 
ings of  Pomponazzi,  Cornelius  Agrippa,  Paracelsus, 
Cardan,  Van  Helmont  and  Kircher  prove  this.  In- 
terest in  scientific  matters  was  so  keen  that  these  new 
ideas,  stripped  of  their  clumsy  Latinity,  were  popu- 
larized by  lay  writers  and  dressed  in  plain  language 
for  the  French  public.  Montaigne,  Charron  and 
Rabelais  all  speak  of  the  mysterious  power  of  the 
imagination,  which,  as  they  say,  explains  miraculous 
cures,  puzzling  nerA^ous  states  and  the  art  of  sorcery. 
The  power  of  the  imagination  can  be  exercised  over 
the  body  in  two  ways :  on  the  body  of  him  who 
imagines,  in  which  event  it  is  autosuggestion;  and 
on  the  body  of  another,  which  is  real  hypnotism. 
The  learned  doctors  whom  we  have  quoted  were 
familiar  with  both  states.  Even  at  that  early  period 
the  influence  which  a  word  or  a  sensation  might  have 
on  the  human  body  was  clearly  known  and  demon- 
strated. It  must  be  admitted  that  Pomponazzi,  as 
well  as  Agrippa,  knew  all  the  power  of  autosugges- 
tion. They  explained  by  its  action  the  occurrence 
of  certain  skin  lesions  (stigmata),  and  the  many 
cures  which  up  to  that  time  had  been  accredited  to 
supernatural  power.  We  have  seen  that  Agrippa 
was  the  first  to  employ  the  word  suggestion,  and 
furthermore  he  has  left  in  his  work  on  occult  phil- 
sophy  a  most  interesting  study  of  the  curative  power 
of  the  imagination,  of  ecstasy,  anesthesia,  hallucina- 
tions and  somnambulism.  He  confirmed,  in  a  pass- 
ing way.  the  existence  of  mental  suggestion  at  a 
distance. 

"One  finds  in  these  writings  the  absurd  alongside 
what  is  rational.  These  medical  men  who  repre- 
sented the  elite  of  their  time  tell  us  seriously,  for 
example,  that  a  little  fish  called  the  remora  was 
able  to  stop  the  progress  of  a  great  ship  and  that 
the  eating  of  garlic  would  weaken  the  power  of  a 
lover.  Be  that  as  it  may,  is  it  just  to  condemn  their 
work,  en  bloc,  when  we  can  find  in  the  writings  of 
profound  men  such  as  Aristotle  and  Pliny  state- 
ments equally  fantastic?"  As  stated  in  the  begin- 
ning of  this  note,  the  interest  which  attaches  to 
the  writings  of  Dr.  Rouzeaud  is  due  to  the  little 
known  authors  whom  he  quotes  and  because  he 
seems  to  demonstrate  with  unquestionable  clarity 
that  Charcot,  Freud  and  others  were  not  digging 
in  virgin  fields. 


906 


EDITORIAL  ARTICLES. 


[New  York 
Medical  Journal. 


PHYSIGIAN-AUTHORS :  HENRY 
VAUGHAN. 
It  sometimes  happens  that  a  man  writes  some- 
thing or  other  exceptionally  well  which  is  not  ap- 
preciated by  his  contemporaries,  and  that  as  a  result 
he  falls  into  obscurity  after  his  death  and  has  to  Ije 
discovered  in  a  later  generation.  This  is  what  hap- 
pened in  the  case  of  Henry  Vaughan,  the  Silurist. 
Although  Vaughan  at  his  best  was  the  greatest  of 
seventeenth  century  religious  poets  of  England,  for 
more  than  two  hundred  years  his  writings  remained 
almost  unnoticed.  Not  even  the  numerous  antholo- 
gies of  British  poetry  made  mention  of  him.  But 
now  it  is  different.  He  is  in  all  the  anthologies  and 
a  whole  flock  of  critics  never  seem  to  tire  of  singing 
his  praises. 

Henry  Vaughan  was  rescued  from  obscurity 
chiefly  through  the  instrumentality  of  the  poet 
Wordsworth  and  the  Reverend  Henry  L>-te,  best 
known  as  the  author  of  the  hymn  Abide  With 
Me.  Wordsworth  came  into  possession  of  a  rare 
old  volume  of  Vaughan's  poems  and  was  fulsome 
in  his  appreciation  of  the  beauty  of  its  contents. 
That  brought  the  long  neglected  Vaughan  to  the 
front  and  created  a  demand  for  his  work,  with  the 
result  that  a  volume  of  selections,  edited  by  the 
Reverend  Mr.  Lyte,  was  published  in  1847.  Since 
then  there  have  been  several  publications  of 
\"aughan's  work,  singly  and  in  sets,  and  no  library 
is  complete  without  them.  As  recently  as  1892 
his  complete  work'?  were  published  in  this  country. 

Wordsworth  admitted  that  Vaughan  had  a  great 
influence  on  his  work,  and  confessed  that  Vaughan's 
most  famous  poem,  Tlie  Retreat,  was  the  germ  of 
the  Ode  on  the  Intimations  of  hnmortality.  Both 
men  loved  to  brood  on  immortality  and  muse  about 
death  and  both  were  passionately  fond  of  Nature 
and  all  her  works.  This  mutual  love  of  Nature 
and  deep  interest  in  immortality  figures  conspicu- 
ously in  the  work  of  both  writers  and  gives  them 
more  than  a  common  kinship  in  the  field  of  letters. 
Vaughan's  poems  abound  in  delicate  descriptions  of 
.  natural  beauty  and  in  the  historic  valley  of  the 
river  Wye,  where  he  was  born  and  spent  most  of 
his  life,  there  was  an  abundance  of  natural  beauty 
to  inspire  a  pen  so  gifted. 

But  why  was  Vaughan  in  obscurity  so  long? 
Perhaps  the  best  ejcplanation  is  given  by  Edith 
Sichel  in  the  Monthly  Review.  Miss  Sichel  points 
out  that  intermingled  with  his  gold  is  much  base 
metal  and  that  a  great  deal  of  what  he  wrote  was 
dull,  tedious  and  obscure.  He  did  not  keep  a  steady 
level,  and  it  was  by  his  faulty  work,  which  bulked 
large  against  his  perfect  work,  that  his  contem- 
])orarics  judged  against  him.    Miss  Sichel,  in  line 


with  other  critics,  classes  Vaughan  with  George 
Herbert,  author  of  The  Temple.  "But  Vaughan  is 
more  intellectual,  more  highly  strung  than  Herbert," 
she  says.  "Where  Herbert  is  pious  Vaughan  is 
mystical.  .  .  .  Vaughan's  mind  is  subtler,  loftier, 
more  imaginative  than  Herbert's,  and  therefore  often 
more  farfetched.  At  his  best,  when  emotion  has 
worked  him  up  to  a  white  heat,  none  can  be  simpler 
than  he,  and  he  moves  out  into  depths  in  a  way 
George  Herbert  can  never  do.  But  when  he  is  not 
fully  inspired  he  is  likely  to  grow  elaborate ;  and 
where  Herbert's  homely  simplicity  goes  straight  to 
the  heart  and  gives  a  loving  welcome  to  the  soul, 
Vaughan  may  have  nothing  to  offer  but  an  abstruse 
thought  magnificently  embroidered."  Thus  Vaughan 
holds  his  place  today  not  for  the  mass  of  his  work 
but  for  a  few  unforgettable  poems  that  outshine  all 
others  of  their  kind. 

The  failure  of  his  contemporaries  to  appreciate 
him  discouraged  \^aughan  to  such  an  extent  that  he 
quit  writing  early  in  life  and  confined  his  activities 
to  the  practice  of  medicine.  All  told  he  wrote  five 
voiumes  of  poetry  and  prose.  The  first  was  a 
volume  of  amatory  and  nature  poems  together  with 
a  translation  of  the  Tenth  Satire  of  Juvenal'.  His 
next  volume  was  Silex  Scintillans  (Sparks  from  the 
Flint),  a  book  of  religious  verse  which  contains  the 
bulk  of  his  masterpieces.  This  was  followed  by 
Olor  Iscanns  (The  Swan  of  the  Usk),  his  second 
book  of  sacred  verse;  The  Mount  of  Olives,  a  book 
of  private  devotions ;  and  Flores  Solitudinas,  which 
contained  religious  prose  translations  and  The  Life 
of  Paulinas,  Bishop  of  Nola.  All  these  were  writ- 
ten when  he  was  between  twenty-nine  and  thirty- 
four  years  old,  and  all,  except  the  first,  were  of  a 
devotional  nature.  Although  he  still  had  some  forty 
years  to  live,  henceforth  he  wrote  nothing  and  pub- 
lished nothing.  However,  in  1678  his  twin  brother, 
Thomas,  the  noted  alchemist,  issued,  without  Henry's 
knowledge  or  consent,  a  volume  entitled  Thalia 
Rediviva,  the  Pastimes  and  Diversions  of  a  Country 
Muse.  The  book  consisted  chiefly  of  amatory  and 
pastoral  poems  which  Henry  had  written  early  in 
life  and  had  condemned  to  oblivion  because  of  the 
lack  of  the  religious  element  in  them.  Vaughan's 
religious  fervor  had  deepened  during  a  severe  illness 
following  the  publication  of  his  first  book,  and  he 
turned  absolutely  away  from  worldly  writings. 
Herbert's  poetry,  read  during  his  convalescence,  also 
deepened  bis  religious  convictions  and  molded  the 
form  of  his  future  work. 

Vaughan  was  a  direct  descendant  of  those  royal 
Celtic  princes  of  southern  Wales  whom  Tacitus 
mentioned  and  wiiose  abode  in  the  days  of  the 
Roman  domination  of  Britain  was  in  the  district 


December  4,  1920  ]  EDITORIAL 

I 

called  Siluria.  Vaughan  always  called  himself  "the 
Silurist."  He  and  his  twin  brother  were  born  on 
April  17,  1622,  at  Newton  St.  Briget,  within  the 
shadow  of  the  ruined  castle  of  Tretower,  where  their 
royal  ancestors  had  held  forth.  Both  brothers  were 
active  on  the  Royalist  side  during  the  civil  war 
which  ended  in  the  triumph  of  Cromwell  and  both 
attended  Jesus  College,  Oxford.  Henry  received  his 
medical  education  in  London,  and  began  practising 
about  1645  at  Brecknock,  a  country  town  near  his 
birthplace,  where  he  died  at  the  age  of  seventy-three 
on  April  23,  1695. 


LARGE  PLACENTAS  AND  SYPHILIS. 

The  problem  to  solve  in  regard  to  large  placentas 
and  syphilis  is  to  ascertain  if  every  child  born  with 
a  large  placenta  should  be  regarded  as  a  syphilitic 
and  treated  as  such  in  future  life.  Recent  re- 
searches, particularly  those  of  Labourdette,  seem  to 
show  that  when  syphilis  is  a  certainty  the  placenta, 
far  from  being  unusually  heavy,  only  presents  this 
condition  in  a  relatively  small  number  of  cases,  at 
least  when  the  child  is  born  at  term  and,  secondly, 
if  careful  research  is  made  for  syphilis  in  women 
who  have  large  placentas,  the  affection  can  rarely 
be  detected.  If  all  the  children  born  at  term  were 
taken  indiscriminately  in  the  statistics  published  by 
either  Blanchet  or  Labourdette,  it  will  be  found 
that  out  of  a  hundred  and  thirty-nine  deliveries  of 
females  with  unquestionable  syphilis  there  was  a 
large  placenta  in  fourteen.  If,  on  the  other  hand, 
we  take  all  the  Blanchet  cases,  it  will  be  found  that 
the  average  weight  of  the  placenta  to  that  of  the 
child  is  1 :7,  which  is  below  normal  and,  according 
to  Labourdette's  statistics,  the  average  ratio  of  the 
placental  weight  to  that  of  the  child  is  1 :5.8,  cor- 
responding to  an  increase  in  the  weight  of  the 
placenta  of  thirteen  grams  above  the  average. 

In  these  circumstances  it  would  seem  only  log- 
ical to  regard  an  increase  in  the  placental  weight 
to  have  no  bearing  whatever  as  to  possible  syphilis 
in  parent  and  offspring.  The  exceptions  are  far 
too  numerous  to  make  large  placentas  a  diagnostic 
sign  of  lues.  In  all  of  Labourdette's  cases  a  Wasser- 
mann  test  was  performed  with  the  same  antigen, 
namely,  an  alcoholic  extract  of  the  liver  of  an 
hereditary  syphilitic  fetus.  The  result  of  the  Was- 
sermann  reaction  in  the  offspring  need  not  be  con- 
sidered, since  in  the  newly  born  it  has  no  value 
whatever.  It  is  manifest  that  the  results  of  the 
reaction  in  mother  and  child  do  not  always 
agree,  as  Bar  and  Daunay  have  shown,  and  a 
negative  reaction  in  a  newly  born  infant  does  not 
mean  that  he  is  asyphilitic,  even  if  he  appears  per- 


ARTICLES.  907 

fectly  healthy.  Likewise,  the  Wassermann  may  be 
frankly  positive  in  an  asyphilitic  infant,  especially 
when  icterus  is  present. 

In  the  mother,  the  Wassermann  has  only  an 
absolute  value  when  the  spirocheta  and  its  culture 
furnish  the  antigen  and  every  element  not  of  human 
origin  has  been  removed  from  the  reaction.  These 
reservations  made,  it  is  probable  that  considerable 
value  may  be  placed  on  the  indications  furnished 
by  the  Wassermann.  It  is  evident  that  the  number 
of  positive  Wassermanns  attain  their  maximum  in 
the  secondary  phase  of  syphilis — 87  per  cent.  Briick, 
92  per  cent.  Levaditi,  96  per  cent.  Blumenthal,  98 
per  cent.  Blaschkeo,  100  per  cent.  Schmenfeld — and 
these  figures  are  all  the  more  important  because 
the  statistics  relating  to  the  question  under  con- 
sideration relate  to  a  large  number  of  cases.  The 
age  of  the  syphilis  has  a  great  influence  over  the 
Wassermann  reaction,  so  much  so  that  Kirschbaum 
maintains  that  it 'is  positive  in  only  sixty-eight  per 
cent,  of  old  syphilkics,  but  in  Labourdette's  statis- 
tics the  negative  results  obtained  in  the  mothers 
could  not  have  been  due  to  an  old  syphilis  in  a 
latent  stage,  because  the  average  age  of  the  women 
was  twenty-three  years. 

A  thorough,  energetic  treatment  will  render  the 

Wassermann  reaction  negative  and  in  the  pregnant 

female  with  active  luetic  accidents,  treatment  will 

lower  the  number  of  positive  reactions  to  less  than 

fifty  per  cent.    This  does  not,  however,  apply  to 

Labourdette's  statistics,  because  he  onlv  took  those 

• 

women  into  consideration  who  never  had  under- 
gone antisyphilitic  treatment  in  any  form.  In  six 
cases  this  observer  was  able  to  corroborate  the  data 
obtained  by  the  Wassermann  with  a  very  prolonged 
control  of  the  infant.  The  six  infants  whose  pla- 
cental weight  ratio  was  respectively  1 :4.4,  1 :4.5, 
1 :4.7,  1 :4.6,  1 :5.2,  and  1  :5.2,  never  presented  the 
slightest  evidence  of  syphilis.  This  may  be  a  sim- 
ple coincidence  and  it  is  certain  that  the  results 
obtained  would  be  much  more  conclusive  had  the 
number  of  infants  been  larger,  but  Labourdette 
only  took  into  consideration  those  infants  which  he 
was  able  to  follow  beyond  an  age  where  syphilitic 
accidents  would  not  be  likely  to  appear.  It  might 
be  said  that  the  large  placentas  were  due  to  syphilis 
in  the  father,  and  that,  therefore,  the  mother  would 
not  offer  any  evidence  of  the  infection,  but  Bauer's 
researches  unquestionably  show  that  Wassermann 
was  positive  in'socalled  immunized  women,  accord- 
ing to  Colles's  law.  For  all  these  reasons  it  is  safe 
to  rely  on  Wassermann's  reaction.  According  to 
Labourdette's  statistics  it  would  appear  that  syphilis 
was  rarely  the  cause  of  large  placentas  in  eight 
women,  as  it  occurred  in  only  twenty-two  and  five 


908  NEWS 

tenths  per  cent,  of  the  cases  and  usually  these  were 
not  unusually  heavy  placentas,  so  that  as  a  sign  of 
syphilis  relatively  little  importance  should  be  at- 
tributed to  it,  especially  when  the  offspring  is  strong 
and  vigorous.  On  the  other  hand,  if  the  infant  is 
puny  and  weakly,  Wassermann  reactions  should  be 
done  to  affirm  the  diagnosis  in  order  to  ascertain 
the  true  condition  of  affairs. 


MIDDLE  CLASS  FERTILITY. 

Our  journals  dealing  with  mentality,  sane  or 
insane,  present  today  a  delirious,  bewildering  set 
of  charts  of  no  use  to  anyone  but  the  Qwner;  that 
is,  they  need  the  author  to  explicate  the  waves 
traced  apparently  by  an  intoxicated  thermometer. 
We  advise  those  interested  in  The  Fertility  of  the 
English  Middle  Classes  (Eugenics  Review,  October, 
1920)  to  leave  the 'charts  and  take  the  conclusions, 
which  are,  that  there  is  no  essential  difference  be- 
tween the  fertility  of  university  and  nonuniversity 
women.  Also,  it  is  found  that  the  mean  size  of  the 
family  is  small  and  a  considerable  proportion  of 
the  parents  restrict  fertility,  and  the  whole  study 
of  sampling  middle  class  families  has  led  to  no 
result  incompatible  with  the  conclusions  drawn  by 
Karl  Pearson  and  his  collaborators  from  wider  data 
of  a  different  kind. 

It  is  left  to  the  reader  to  determine  whether  these 
results,  or  any  results  of  wider  analysis,  suggest 
that  neglect  of  eugenic  principia  is  leading  to  a 
steady  deterioration  of  the  race  or  likely  to  influ- 
ence the  reproductive  habits  of  the  educated  classes. 
There  is  much  subject  for  reflection.  We  were 
sure  that,  having  set  out  on  exploring  that  horrible 
jungle  revealed  by  "the  mental  and  moral  condition 
of  childbearing  women  in  the  criminal,  mentally 
deficient,  and  poverty  haunted  classes,  that  the 
severely  respectable,  detached  from  the  world's 
strife  in  a  semidetached  villa,  would  not  long  escape 
an  analysis. 

 ^  

News  Items. 


Asthma  and  Hay  Fever  Clinic. — A  public 
clinic  for  asthma  and  hay  fever  has  been  established 
at  the  New  York  Hospital.  Dr.  Robert  A.  Cooke 
is  in  charge  of  the  clinic  and  will  give  treatments 
Monday  and  Friday  afternoons. 

The  Mutter  Lectures. — The  Miitter  Lecture 
on  Surgical  Pathology  of  the  College  of  Physi- 
cians of  Philadelphia,  for  1920,  will  be  delivered  on 
Friday,  December  10th,  by  Dr.  J.  C.  Chalmers  Da 
Costa,  Samuel  D.  Gross  Professor  of  Surgery,  Jef- 
ferson Medical  College  of  Philadelphia.  His  subject 
will  be  Paget's  Diseases  of  the  Bones. 

Harvey  Society  Lectures. — Dr.  *  Carl  J.  Wig- 
gers,  of  the  Western  Reserve  University,  Cleveland, 
will  deliver  the  fourth  Harvey  Society  Lecture  at 
the  New  York  Academy  of  Medicine,  Saturday 
evening,  December  11th.  His  subject  will  be  the 
Present  Status  of  Cardiodynamic  Studies  on  Normal 
and  Pathological  Hearts. 


ITEMS.  [New  York 

Medical  Journal. 

( 

Personal. — Dr.  and  Mrs.  Abraham  Jablons,  of 
New  York,  announce  the  birth  of  a  son,  Friday, 
November  26th. 

Japanese  Leper  Colony  in  Need  of  a  Micro- 
scope.— The  Leper  Colony  at  Kusatsu  Mission, 
Japan,  is  urgently  in  need  of  a  microscope  powerful 
enough  to  detect  leprosy  bacillus.  Should  any  of 
our  readers  know  of  anyone  who  would  be  willing 
to  donate  such  a  microscope,  or  where  one  could  be 
purchased  for  a  small  price,  we  should  be  glad  to 
hear  from  him. 

High  Death  Rate  in  Austria.-^According  to 
press  dispatches  from  Vienna,  dated  November  26th, 
deaths  are  exceeding  births  in  Austria  by  100  per 
cent,  and  the  mortality  rate  is  without  parallel  in 
history.  This  condition  has  resulted  from  the  food 
shortage  and  the  attendant  undernourishment  of 
the  population,  only  a  small  percentage  of  the  deaths 
being  due  to  diseases  not  directly  attributed  to  mal- 
nutrition. 

University  Course  in  Public  Health  Nursing. — 

A  Department  of  Instruction  in  Public  Health 
Nursing  has  been  established  in  the  University  of 
Toronto  in  connection  with  the  Faculty  of  INIedicine. 
This  course  requires  the  attendance  of  graduate 
nurses  at  the  university  for  one  year.  The  Ontario 
Red  Cross  is  providing  ten  scholarships  of  $350 
each,  five  of  which  are  to  be  assigned  to  nurses 
who  served  overseas. 

Medical  Society  of  the  County  of  New  York. — 
At  the  annual  meeting  of  the  society,  held  Monday 
evening,  November  22nd,  the  following  officers  were 
elected  to  serve  for  the  ensuing  year :  President, 
Dr.  George  Gray  Ward,  Jr. ;  first  vice-president. 
Dr.  Orrin  S.  Wightman;  second  vice-president,  Dr. 
Arthur  F.  Chace;  secretary.  Dr.  Daniel  S.  Dough- 
erty; assistant  secretary,  Dr.  J.  Millon  Mabbott ; 
treasurer.  Dr.  James  Pedersen ;  censors  for  three 
years.  Dr.  Edward  M.  Colie,  Dr.  Gustav  G.  Fisch, 
and  Dr.  De  Witt  Stetten.  . 

Medical  Society  of  the  County  of  Kings. — The 
following  officers  of  the  Medical  Society  of  the 
County  of  Kings  have  been  nominated  for  election 
at  the  next  meeting  of  the  society.  Dr.  Arthur  H. 
Bogart,  president ;  Dr.  Frank  D.  Jennings  and  Dr. 
William  V.  Brinsmade,  vice-presidents ;  Dr.  Lewis 
P.  Addoms,  secretary ;  Dr.  John  Shields,  associate 
secretary;  Dr.  Robert  L.  IMoorehead,  treasurer;  Dr. 
Alfred  Bell,  associate  treasurer ;  Dr.  William 
Browning,  directing  librarian ;  Dr.  William  Webster 
and  Dr.  William  Lindner,  trustees. 

French  Surgeon  Dies  of  X  Ray  Burns. — An- 
nouncement was  made  in  Paris  on  November  29th 
that  Dr.  Charles  Infroit  had  died  from  the  effects 
of  x  ray  burns.  One  of  Dr.  Infroit's  hands  became 
infected  in  1898  as  a  result  of  his  constant  use  of 
the  x  ray,  and  an  operation  was  performed.  Since 
that  time  he  had  undergone  twenty-four  operations. 
twenty-twQ  of  which  were  performed  in  the  last 
ten  years.  The  last  was  on  August  1st,  when  his 
right  arm  and  left  wrist  were  amputated.  Dr. 
Infroit  was  a  celebrated  surgeon,  and  his  announce- 
ment in  1915  in  the  Academy  of  Medicine  of  Paris 
that  he  had  extracted  a  bullet  from  the  heart  of  a 
soldier  was  read  with  interest  throughout  the  world. 


December  4,  1920.] 


NEM'S  ITEMS. 


909 


American  Child  Hygiene  Association. — At  the 
annual  meeting  of  this  organization,  which  was 
formerly  called  the  American  Association  for  the 
Study  and  Prevention  of  Infant  Mortality,  the  fol- 
lowing officers  were  elected :  Dr.  Henry  L.  K.  Shaw, 
of  Albany,  president ;  Mr.  Herbert  Hoover,  of  Xew 
York,  president-elect ;  ]Miss  Minnie  H.  Ahrens,  of 
Chicago,  and  Mr.  Sherman  C.  Kingsley,  of  Cleve- 
land, vice-presidents ;  Dr.  Harr}^  F.  Helmholz,  of 
the  Mayo  Clinic,  Rochester,  IMinn.,  secretary'.  Dr. 
Richard  A.  Bolt  ;s  general  director  of  the  executive 
staff  and  Dr.  Philip  Van  P'gcr  is  chairman  of  the 
executive  committee. 

Janssen  Medal  Awarded  to  American  Physi- 
cist.— The  French  Academy  of  Sciences,  Paris, 
has  awarded  the  Janssen  medal  to  \\'illiam 
Coblentz,  physicist  in  the  Bureau  of  Standards,  in 
Washington,  for  his  discoveries  in  connection  with 
rays  emanating  from  the  earth  and  stars.  !Mr.  Co- 
blentz has  ben  attached  <;o  the  Bureau  of  Standards 
for  twelve  years,  and  has  developed  a  method  of 
measuring  radiant  heat  by  infrared  and  ultraviolet 
rays.  He  has  devised  an  instrument  for  astronomers 
with  which  to  measure  heat  from  the  stars,  and  also 
developed  yin  the  course  of  the  war  signal  instru- 
ments for  ships  at  sea  and  an  instrument  for  detect- 
ing moving  bodies,  such  as  ships,  by  their  heat 
emanations  in  the  dark. 

Dr.  Brush  Commended  for  Relief  Work  in 
Near  East. — Dr.  Barton  W.  Brush,  of  Elmhurst. 
L.  I.,  who  for  more  than  a  year  past  has  been 
engaged  in  relief  work  in  Transcaucasia,  has  been 
commended  by  the  Xear  East  Relief,  for  his  cour- 
age and  devotion  in  refusing  to  abandon  his  post 
when  the  city  of  Kars,  Armenia,  fell  to  the  Turkish 
Nationalists.  Captain  Ernest  A.  Yarrow,  director 
general  of  the  relief  activities  in  the  Caucasus  area, 
said,  in  a  letter  to  Dr.  Brush,  that  he  could  not  too 
highly  commend  him  for  remaining  at  his  post  in 
the  very  serious  and  dangerous  crisis,  and  that  on 
behalf  of  the  Xear  East  Relief  he  wished  to  express 
their  profoundest  gratitude  and  appreciation. 

Red  Cross  League  Appointments. — The  fol- 
lowing appointments  are  announced  in  the  October 
BuUetin  of  the  League  of  Red  Cross  Societies : 

Dr.  Hermann  ^L  Biggs,  health  commissioner  of 
Xew"-  York  State,  has  temporarily  assumed  the  duties 
of  General  Medical  Director,  to  succeed  Dr.  Richard 
P.  Strong,  who  has  resigned  this  position  to  resume 
his  duties  as  professor  of  tropical  medicine  at 
Harvard  University. 

Dr.  William  H.  Park,  dire.':tor  of  the  Bureau  of 
Laboratories,  Department  of  Health.  X"ew  York 
City,  has  been  for  several  weeks  in  Geneva,  where 
he  has  been  giving  assistance  and  advice  regarding 
the  work  of  the  medical  department. 

Dr.  William  W.  Francis,  assistant  chief  of  the 
Department  of  ^Medical  Information,  has  been 
appointed  editor  of  the  International  Journal  of 
Public  Health. 

Professor  George  C.  Whipple,  who  has  been  chief 
of  the  Department  of  Sanitation,  is  returning  to  the 
L'nited  States  to  take  up  his  work  again  at  Harvard 
University.  He  retains  his  connection  with  the 
League  of  Red  Cross  Societies  in  the  capacity  of 
consulting  sanitar\-  engitu^er. 


Health  Commissioners  Attend  Housing  Con- 
ference.— Dr.  Royal  S.  Copeland,  Health  Com- 
missioner of  Xew  York,  presided  at  a  housing  con- 
ference held  in  Detroit,  Mich.,  last  Tuesday  and 
Wednesday.  The  health  commissioners  of  thirty- 
three  cities  were  in  attendance.  The  conference 
was  held  for  the  purpose  of  determining  so  far  as 
possible  the  exact  effect  on  public  health  of  the 
present  hoiising  situation  in  the  United  States.  Dr. 
Copeland  said  that  the  survey  of  Xew  York  City 
had  been  completed  by  the  Health  Department,  and 
that  about  75,000  homes  were  visited. 

Chief,  Section  of  Medical  Referees. — The 
United  States  Civil  Service  Commission  announces 
an  examination  for  Chief,  Section  of  Medical 
Referees,  to  fill  a  vacancy  in  the  Bureau  of  War 
Risk  Insurance,  Washington,  D.  C,  at  $4,000  to 
$6,000  a  year.  The  duties  of  the  appointee  will 
consist  of  supervision  of  the  Section  of  Medical 
Referees  engaged  in  examining  case  files  and  making 
disability  ratings  based  upon  medical  evidence  con- 
tained in  reports  of  physical  examinations  obtained 
from  medical  officers  in  the  field,  answering  cor- 
respondence relative  to  claimants,  and  performing 
routine  work  connected  with  the  medical  aspect  of 
claimants.  Apphcations  will  be  received  up  to 
Januan-  11,  1921. 

Meetings  of  Local  Medical  Societies. — The  fol- 
lowing medical  societies  will  meet  in  Xew  York 
during  the  coming  week: 

Monday,  December  6th. — Clinical  Society  of  the  Xew 
York  Polyclinic  Medical  School  and  Hospital;  New  York 
German  Medical  Society  (annual). 

TvESD.w.  December  yth. — Xew  York  Academy  of  Medi- 
cine (Section  in  Dermatology-  and  Syphilis)  ;  Clinical  So- 
ciety of  Harlem  Hospital :  Xew  York  Xeurological  Society ; 
Society  of  Alumni  of  Lebanon  Hospital  (annual). 

^VED^-ESDAY,  December  8th. — Medical  Society  of  the 
Borough  of  the  Bronx;  New  York  Pathological  Society; 
X'ew  York  Surgical  Society :  Alumni  Association  of  Xor- 
wegian  Hospital  (annual)  ;  Brooklyn  Medical  Association. 

Thursday.  December  Qth. — Xew  York  Academy  of 
^ledicine  (Section  in  Pediatrics)  ;  ^Vest  End  Clinical  So- 
ciety (annual)  ;  Brooklyn  Pathological  Society. 

Friday,  December  loth. — Xew  York  Academy  of  Medi- 
cine (Section  in  Otologv")  ;  Eastern  Medical  Society  of  the 
City  of  Xew  York  (annuals  :  Flatbush  Medical  Society; 
Society  of  Externs  of  the  German  Hospital  in  Brooklyn-. 

 €>  

Died. 

Day. — In  Waterloo,  X'.  Y..  on  Monday.  X'ovember  15th, 
Dr.  John  ^V.  Day,  aged  seventy-four  years. 

Ferraco. — In  Southampton,  L.  I.,  on  Thursday,  Novem- 
ber 25th,  Dr.  Almedes  F.  Ferraco,  of  Brooklyn,  N.  Y., 
aged  twent\'-seven  years. 

HoPKE. — In  Brooklyn,  X.  Y.,  on  Tuesday,  November 
23rd,  Dr.  F.  E.  Hopke,  aged  forty-six  years. 

KiRKPATRicK. — In  Philadelphia,  Pa.,  on  Sunday,  Novem- 
ber 21st,  Dr.  Andrew  B.  Kirkpatrick.  aged  sixty-six  j-ears. 

KxAPP. — In  Brooklyn,  N.  Y.,  on  Friday,  November  26th, 
Dr.  Mark  Israel  Knapp,  aged  fift\-two  years. 

Luce. — In  Oneonta.  X'.  Y.,  on  Tuesday,  Xovember  16th, 
Dr.  Daniel  Luce,  aged  fift>--seven  years. 

McBeax. — In  Los  Angeles,  Cal.,  on  Friday,  November 
12th.  Dr.  Anna  G.  McBean,  aged  thirtj  -seven  years. 

Myers. — In  Twin  Falls,  Idaho,  on  Fridav,  November 
12th,  Dr.  J.  P.  :Myers. 

Spragg. — In  \Vheeling,  W.  Va.,  on  Sunday.  X'ovember 
21st,  Dr.  Sylvanus  L.  S.  Spragg.  aged  sixty-eight  years. 

Thorn. — In  Deerfield,  Mass..  on  Friday,  Xovember  12th. 
Dr.  Edwin  C.  Thorn,  Jr..  aged  fort>--six  years. 

Walp. — In  Philadelphia.  Pa.,  on  Thursday,  November 
18th.  Dr.  George  L.  Walp,  aged  fort>-four  years. 


Book  Reviews 


VACCINE  TREATMENT. 

Practical  Vaccine  Treatment.  For  the  General  Practitioner 
By  R.  W.  Allen,  M.  A.,  M.  D.,  B.  S.,  Late  Captain, 
N.  Z.  M.  C.  New  York:  Paul  B.  Hoeber,  1920.  Pn 
xii-308. 

Dr.  Allen  pleads  for  a  fair  hearing.  For  many 
years  he  "preached  the  doctrine  of  doses  capable  of 
exciting  a  reaction,  of  doses  and  intervals  con- 
trolled by  close  clinical  observation."  He  hopes  a 
strict  observation  of  his  methods  will  help  recon- 
struct vaccine  treatment  and  enable  it  to  take  its 
rightful  position  as  the  most  truly  scientific  thera- 
peutic agency  in  the  doctor's  armamentarium.  He 
very  politely  but  definitely  shows  Sir  Almoth 
Wright's  definition  of  a  vaccine  to  be  the  classic 
one,  but  cumbrous,  now  inaccurate,  and  in  the 
future  likely  to  be  more  so.  Sir  Almoth,  quoted, 
says :  "Bacterial  vaccines  are  sterilized  and  enum- 
erated suspensions  of  bacteria  which  furnish,  when 
dissolved,  substances  which  stimulate  the  healthy 
tissues  to  a  production  of  specific  bacteriotropins, 
substances  which  fasten  upon  and  directly  or  in- 
directly contribute  to  the  destruction  of  the  corre- 
sponding bacteria."  They  are  not,  says  Allen, 
always  sterilized,  nor  always  enumerated.  Sera, 
again,  are  often  conftised  by.  many  with  vaccines, 
whereas  the  immunity  a  serum  brings  about  is 
passive — that  by  vaccines  active. 

As  to  the  aim  of  vaccine  treatment,  he  says : 
"The  injection  of  a  vaccine  into  healthy  tissues 
results  in  the  elaboration  in  the  tissues  of  certain 
protective  substances  inimical  to  the  wellbeing  of 
these  particular  microbes  which  is  being  injected. 
This  process  we  imitate  when  vaccinating  the  human 
subject — we  exploit  the  healthy  tissues  in  the  interest 
of  those  which  are -infected  and  unhealthy." 

He  particularly  emphasizes  that  the  protective 
substances  elaborated  by  the  healthy  tissues  in  re- 
sponse to  the  stimulus  of  the  introduction  of  a 
certain  microbe,  are  highly  specific,  i.  e.,  of  pro- 
tective use  only  against  that  particular  one.  Thus, 
the  Bacillus  typhosus  only  avails  with  the  Bacillus 
typhosus  and  holds  no  protection  against  the  para- 
typhoid fevers.  Many  doctors,  not  realizing  this, 
are  often  greatly  disappointed  with  results. 

Immunity  against  several  microbes  must  be  treated 
with  a  combined  or  compound  vaccine.-  The  first 
used — then  much  derided — was  the  author's  own, 
though  several  imitations  got  on  the  market  and 
the  most  worthless  was  adopted  by  the  military 
authorities  for  Army  use.  It  has  been  proved  that 
the  combination  has  the  same  effect  as  using  separate 
bacilli  for  each  microbe. 

Prophylactic  inoculation,  too,  has  made  great 
strides,  evidenced  by  the  successful  fight  against 
some  dozen  diseases  by  the  author  himself,  tliough 
he  had  a  wearying  fight  for  the  use  of  the  combined 
vaccines  during  the  Boer  War,  thousands  of  men 
being  rendered  unfit  for  service.  Castellani  was 
with  him  finally,  and  other  bacteriologists.  He 
alludes  to  the  successful  treatment  of  that  strong 
enemy,  rheumatoid  arthritis,  of  which  no  one  has 
yet  succeeded  in  finding  a  specific  bacterial  origin, 
though  it  has  for  causative  factors  toxins  derived 
from  bacteria  resident  somewhere  in  the  tissues,  its 


vaccine  treatment  must  be  that  dealing  with  the 
associated  primary  focus  of  toxic  absorption.  This 
is  given.  There  are  useful  chapters  on  Therapeutic 
Immunization  and  one  of  actual  questions  asked  and 
the  answers  given.  Diseases  of  the  circulatory 
system,  the  genitourinary  system,  the  intestinal 
tract,  and  ductless  glands,  are  some  of  the 
interesting  studies  presented.  Because  written  by 
an  eager  fighter  and  not  by  a  mere  looker  on,  the 
book  is  vital  and  merits  both  praise  and  a  good 
welcome. 

THE   NEW  PHYSIOLOGY. 

The  New  Physiology  in  Surgical  and  General  Practice. 
By  A.  Rendle  Short,  M".  D.,  B.  S.,  B.  Sc.  (Lond.), 
F.  R.  C.  S.  (Eng.),  Examiner  in  Physiology  for  the 
F.  R.  C.  S.,  etc.  Fourth  Edition,  Revised  and  Enlarged. 
Illustrated.  New  York:  William  Wood  &  Co.,  1920 
Pp.  xi-291. 

Many  new  editions  do  not  justify  their  existence, 
the  new  pages  being  culled  by  subordinates  and 
insufficiently  edited,  and  the  fresh  original  matter  is 
not  important  enough  to  tax  the  purse  of  an  impe- 
cunious doctor  who  conscientiously  tries  to  have 
the  very  latest  in  his  library.  But  men  must  have 
found  what  they  sought  in  the  three  previous  edi- 
tions of  this  physiology,  the  revisions  must  have 
been  honestly  done,  or  a  fourth  would  not  have 
been  sure  of  a  welcome. 

The  first  chapter  is  on  food  deficiency  diseases, 
emphasis  being  laid  on  the  fact  that  a  capability  for 
living  even  a  long  time  on  little  does  not  prove  the 
wisdom  of  so  doing,  nor  that  of  keeping  to  a  certain 
quantity,  if  the  quality  is  not  nourishing. 

The  old  questions  of  rice  polished  and  unpolished 
are  ventilated,  also  that  of  leinon  and  lime  juice  as 
an  antiscorbutic.  Babies  and  lion  cubs,  where 
causes  of  rickets  were  mvestigated,  were  found  to 
have  had  too  much  starch  and  sugar  and  too  little 
fat  and  protein.  The  cubs,  by  the  way,  had  been 
fed  on  London  cab  horse — doubtless  the  babies  had 
had  some,  too — and  anyone  who  is  familiar  with 
the  appearance  of  that  curious  animal  will  doubt 
its  efficiency  as  diet,  the  tires  of  a  motor  car  being 
quite  as  satisfactory.  In  Greenland's  icy  moun- 
tains, where  babies  are  given  and  vocally  emit,  plenty 
of  blubber,  rickets  do  not  exist. 

The  author  alludes,  in  his  chapter  on  Researches 
on  Blood,  to  the  greater  researches  in  America  as 
compared  with  those  in  Britain,  particularly  when 
writing  of  an  enemy  during  the  war  which  had  only 
been  scotched,  not  killed,  in  civil  practice,  and  now 
wrought  havoc,  that  is,  secondary  hemorrhage.  He 
speaks  of  the  still  active  efficacy  of  red  corpuscles 
kept  for  two  or  three  weeks  in  an  ice  chest,  con- 
firming Rotis  and  Turner's  experiments.  On  one 
occasion,  forty  pints  of  blood,  iiicluding  one  from 
a  wellknown  surgeon,  were  sent  to  him  at  a  casualty 
station  just  before  the  battle  of  Cambrai.  It  was 
stored  in  ic^,  in  a  citrate-dextrose  solution.  In  a 
week,  the  supernatant  plasma  was  drawn  off,  as  it 
might  have  proved  dangerous  after  keeping,  and  the 
blood  used  was  just  as  efficacious  as  that  which  was 
fresh. 

Surgical  shock,  though  illuminated  by  the  flaring 
torches  of  war  and  studied  by  the  best  young  brains 


December  4,  1920.] 


BOOK  REVIEWS. 


911 


in  Europe  and  America,  leaves  the  surgical  world 
not  much  nearer  solving  some  of  its  problems,  and 
this  Short  frankly  admits,  though  he  rewrites  the 
chapter,  giving  the  best  of  the  newer  knowledge. 
It  is  this  comfortable  stating  in  each  chapter  what 
to  exi>ect  that  is  new  and  where  only  a  clearer 
stating  of  the  old  can  be  given  which  renders  the 
book  valuable  as  a  reference.  From  the  great 
junction  of  physiological  problems  there  are  start- 
ing new  trains  of  thought  every  year.  How  far 
they  will  safely  run,  wherewith  they  will  connect, 
depends  partly  on  the  capable  study  by  young  men 
of  the  work  already  done,  and  in  Short  and  the 
men  whose  names  he  gives,  much  help  will  be  found, 
much  weariness  in  research  avoided. 

TUBERCULOSIS. 

Zcitschrift  fiir  Tuhcrkulosc.  Unter  Mitworkung  der 
Herrn  Prof.  Babes  (Bukarest),  Prof.  Baxg  (Kopen- 
hagen),  Geh.  Med.  Rat.  Dr.  Behla  (Charlottenburg). 
Dr.  Leo  Berthexsox  (St.  Petersburg),  und  so  weiter. 
Herausgegeben  von  ^I.  Kirchxer,  F..  Kraus,  W.  \'. 
Leube,  J.  Orth,  F.  Pexzoldt.  Leipzig :  Verlag  von 
Johann  Ambrosius  Barth,  1920.    Seiten  64. 

The  editorial  office  of  the  New  York  Medical 
Journal  has  recently  received  a  copy  of  the  Zeit- 
schrift  fiir  Tuberkiilose,  published  by  Johann  Am- 
brosius Barth,  Leipzig,  Germany.  To  the  best  of 
the  reviewer's  knowledge,  this  is  the  first  copy  which 
has  reached  this  country  since  we  entered  the  world 
war.  We  welcome  it  again  because  of  the  quality 
of  its  contribvitions.  In  the  number  before  tis, 
being  issue  No.  1  of  Vol.  33,  October,  1920,  there 
are  two  excellent  articles  on  Chest  Wounds  and 
Pulmonary  Tuberculosis.  Dr.  O.  Seitler,  who 
wrote  the  first  article  comes  to  the  conclusion  that 
a  tuberculous  lesion  is  much  more  likely  to  become 
activated  as  the  result  of  the  trauma  than  has  been 
heretofore  noted.  In  the  second  article  by  Dr.  Ger- 
hard Frischbier,  these  conclusions  are  confirmed. 
He  makes  the  statement  that  even  an  absolutely 
latent  case  of  pulmonary  tuberculosis  frequently 
becomes  active  as  the  restilt  of  a  bullet  woiuid. 

Another  article  in  this  ntmiber  treats  of  tuber- 
culosis of  the  kidney,  and  others  are  devoted  to 
antigen  therapy  and  the  symptomatic  forms  of 
chronic  tuberculosis.  Interesting  is  a  contribution 
by  Gruber,  of  Mainz,  concerning  a  number  of  post- 
mortem examinations  on  tuberculous  French  negro 
soldiers  of  the  Army  of  Occupation.  The  author 
comes  to  the  conclusion  that  in  these  African  tttber- 
culous  patients  the  tuberculous  infection  almost  in- 
variably follows  in  the  direction  of  the  lymphatic 
vessels  and  that  pneumoconiosis  has  not  then  ap- 
peared in  their  lungs.  The  remainder  of  the  maga- 
zine is  devoted  to  reviews  of  contributions  on  the 
^  subject  of  tuberculosis  from  all  over  the  world. 
In  prewar  times  original  contributions  in  English 
and  French  appeared  side  by  side  with  German 
articles  in  this  magazine. 

Authorities  from  nearly  all  the  allied  countries 
and  former  Central  Powers  are  still  mentioned  as 
coeditors,  only  France  is  not  again  represented 
since  the  death  of  the  great  Landouzy.  The  manag- 
ing editors  of  the  Zeitschrift  are  Prof.  Dr.  A.  Kutt- 
ner  and  Prof.  Dr.  Lydia  Rabinowitsch ;  the  latter 
is  particularly  well  known  to  Atnerican  ttiberculosis 


workers  from  her  former  residence  in  Philadelphia. 
The  Zcitschrift  fiir  Tuberkitlose  is  up  to  date  in 
all  its  contributions  and  it  is  to  be  hoped  that  when 
peace  will  at  last  again  unite  the  science  of  medicine 
throughout  the  civilized  world,  the  magazine  will 
again  be  the  avenue  for  the  interchange  of  ideas 
for  the  welfare  of  tuberculous  sufferers. 

THE  DUODENAL  TUBE. 

The  Duodenal  Tube  and  Its  Possibilities.  By  Max  Ein- 
HORN,  M.  D.,  Professor  of  Medicine  at  the  New  York 
Post-Graduate  Aledical  School ;  Visiting  Physician  to  the 
Lenox  Hill  Hospital,  New  York.  Illustrated.  Philadel- 
phia and  London  :  W.  B.  Saunders  Company,  1920.  Pp. 
xiii-122. 

Originally  Dr.  Einhorn  perfected  the  duodenal 
tube  for  the  purpose  of  having  a  convenient  method 
of  diagnosis.  Recently  the  field  of  usefulness  for 
the  tube  has  been  extenc'ed  so  that  it  may  be  used 
therapeutically.  Much  light  has  been  shed  upon  the 
nature  of  the  secretions  m  the  vicinity  of  the  duo- 
denum by  the  use  of  this  method.  Some  of  these 
findings  have  been  presented  by  Dr.  Einhorn  from 
time  to  time  in  the  New  York  Medical  Journal. 
In  the  hands  of  a  careful  worker  like  Dr.  Einhorn 
it  has  proved  to  be  a  most  useful  appliance.  It  has 
proved  to  be  a  useful  adjunct  in  diagnosis  to  the 
X  ray,  stomach  pump  and  duodenal  bucket.  An- 
other useful  purpose  the  tube  serves  is  as  a  con- 
ductor of  alimentation  to  the  patient.  Stretching 
of  the  pylorus  by  means  of  the  pyloric  dilator  has 
also  proved  of  value,  as  well  as  stretching  of  the 
cardia  in  impermeable  cardiospasm. 

The  book  is  replete  with  illustrations  showing 
the  various  methods  of  application  for  the  tube,  as 
well  as  X  ray  photographs  showing  the  tube  in  vari- 
ous parts  of  the  intestinal  canal.  The  illustrations 
in  color  show  specimens  of  normal  and  abnormal 
duodenal  contents  after  they  have  been  removed  by 
means  of  the  tube. 

LIFE. 

Life.  By  Johax  Bojer.  Translated  from  the  Norwegian 
by  Jessie  Muir.  New  York:  AIofTat,  Yard  &  Co.,  1920. 
Pp.  339. 

Life.  Our  first  impressions,  our  first  fears,  have 
more  to  do  with  death  than  with  that  more  mysteri- 
ous state,  life.  Death  and  far  off  things  were  stu- 
died more  by  the  ancients  than  life  and  self.  More 
recently  man  has  begun  seriously  to  be  introspective. 
So  Bojer,  who  comes  to  us  with  worthy  studies 
translated  from  the  Norwegian,  attempts  the  pres- 
entation of  a  few  of  the  actions  and  reactions  of  a 
certain  group  of  people  and  calls  ij  life.  Let  the 
title  stand ;  we  shall  endeavor  to  follow  him  and  see 
what  he  has  to  do. 

He  gathers  up  an  armful  of  characters  and  shows 
us  how  they  behave  under  certain  stressful  condi- 
tions. Here,  one  has  an  old  grudge,  a  captain  in 
the  army ;  his  fellows  go  on  to  advancement  while 
he  remains  a  captain.  The  world  is  against  him, 
all  are  plotting  to  prevent  his  promotion.  He  seeks 
a  retreat  and  plans  revenge.  He  draws  plans  for 
the  reorganization  of  the  army,  he  compensates  for 
his  inferiority,  he  is  greater  than  all  the  generals, 
he  who  has  been  overlooked  and  downtrodden.  In 
this  half  fantasy  world  he  finds  his  haven  of  refuge. 
In  his  defeat  during  the  struggle  with  reality  and  in 


912 


BOOK  REVIEWS. 


[New  York 
Medical  Journal. 


his  retreat  he  drags  others  down  with  him;  his  son 
and  daughter.  But  they  too  have  their  difificulties 
aside  from  their  environment  and  the  heritage  from 
their  paternal  ancestor.  The  difificulties  of  his 
daughter's  mother  while  not  depicted  are  alluded  to 
frequentlj^.  She  too  finds  the  struggle  for  existence 
and  expression  a  difficult  one  and  at  a  critical  period 
yields  to  one  man  while  she  transforms  him  through 
a  process  of  mental  imagery,  reinforced  by  circum- 
stance, into  the  man  she  really  cares  for.  This 
momentary  weakness  hangs  like  a  heavy  cloud  over 
her  and  when  finally  she  achieves  her  dreams  of 
marriage  to  the  man  she  really  loves,  and  emanci- 
pation, she  finds  herself  too  weak  to  face  the  situa- 
tion and,  through  an  unconscious  process,  solves  her 
problems  through  a  foolhardy  adventure  in  a  small 
boat.  Her  minor  difficulties  were  met  by  white  lies 
and  evasions,  each  one  leaving  her  weaker  and  less 
able  to  meet  the  real  problems  when  they  came  up 
to  her  for  solution. 

With  great  skill  Bojer   shows  how  the  weak- 
nesses of  one  character  involve  the  lives  and  happi- 
ness of  all  who  with  them  may  happen  to  come  \\\ 
contact.    Those  who  refuse  to  stand  on  their  own 
feet  push  down  others  upon   whom  they  lean. 
Bojer's  sketches  are  like  dr>^  point  etchings,  clear 
cut  and  not  flamboyant.    His  hope  for  a  newer  and 
finer  social  structure,  which  he  bases  on  the  devel- 
opment of  men  and  women  by  their  interest  in 
healthful  outdoor  living  and  an  interest  in  things 
beautiful,  is  all  very  well  but  he  completely  ignores 
changes  in  social  structures  and  environmental  fac- 
tors which  go  so  far  in  determining  the  conditioning 
of  all  human  beings.   He  contends  that  the  individ- 
ual is  always  stronger  than  his  environment  and  can 
model  his  life  as  he  wills.     This  may  be  true  in- 
certain,  or  if  he  will,  in  many  individual  cases,  but 
no  matter  how  finely  he  may  divide  iron  the  specific 
gravity  will  always  be  greater  than  water.   It  is  true 
that  ice  will  sustain  iron  and  a  ship  made  of  iron 
will  float,  but  the  ice  one  day  will  melt  and  the  ship, 
one  day,  may  leak.   While  we  may  not  agree  on  all 
points  with  the  philosophy  of  our  Norwegian  au- 
thor, we  must  admit  the  power  of  his  writings  and 
grant  him  a  place  among  the  foremost  novelists  of 
today.    He  has  not  exactly  presented  life  to  us ; 
just  a  few  of  the  problems  of  man  ;  just  a  few,  but 
important  ones  nevertheless. 

 <S>  

New  Publications  Received. 


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


DIABETES.  A  Handbook  for  Physicians  and  Their  Pa- 
tients. By  Philip  Horowitz,  M.  D.  With  Twenty- Seven 
Text  Illustrations  and  Two  Colored  Plates.  New  York : 
Paul  B.  Hoeljer,  1920.    Pp.  xii-196. 

SHORT  TALKS  ON  PERSONAL  AND  COMMUNITY  HEALTH.  By 

Louis  Lehrfeld,  A.  M.,  M.  D.,  Agent  for  the  Prevention 
of  Diseases,  Department  of  Public  Health,  Philadelphia, 
with  an  Introduction  by  Wilmer  Krusen,  M.  D.,  LL.  D., 
Director  0916-1919),  Department  of  Public  Health  and 
Charities,  Philadelphia.  Philadelphia :  F.  A.  Davis  Com- 
pany, Publishers,  1920.    Pp.  xii-271. 


THE  HYPHEN.  By  LiDA  C.  ScHEM.  In  Two  Volumes. 
New  York:  E.  P.  Dutton  &  Co.,  1920.   Pp.  1052. 

HUNGRY  HEARTS.  By  Anzia  Yezierska.  Boston  and 
New  York:  Houghton  Mifflin  Company,  1920.    Pp.  297. 

CAius  GRACCHUS.  A  Tragedy.  By  Odin  Gregory.  With 
an  Introduction  by  Theodore  Dreiser.  New  York:  Boni  & 
Liver  ight,  1920.    Pp.  172. 

THE  JEWISH  FAIRY  BOOK.  Translated  and  Adapted  by 
Gerald  Friedlander.  With  Eight  Illustrations  in  Color 
by  George  W.  Hood.  New  York:  Frederick  A.  Stokes 
Company,  1920.    Pp.  188. 

Satan's  diary.  By  Leonid  Andreyev.  Authorized 
Translation  Never  Before  Published  in  Any  Language, 
with  a  Preface  by  Herman  Bernstein.  New  York:  Bcni 
&  Liveright.    Pp.  xvii-263. 

THE  bride  of  CORINTH  AND  OTHER  POEMS  AND  PLAYS.  By 

Anatole  France.  A  Translation  by  Wilfred  Jackson  and 
Emilie  Jackson.  London  and  New  York :  John  Lane 
Company,  1920.    Pp.  xv-285. 

einfuhrung  von  fmil  abderhalden.  Halle  a.  d.  Saale, 
nebst  einer  vollstandigen  und  ausfuhrlichen  Inhaltsiibersicht 
der  13  Abteilungen  des  Gesamtwerkes.  Berlin-Wien : 
Urban  &  Schwarzenberg,  1920.    Seiten  44. 

THE  story  of  DOCTOR  DOLiTTLE.  Being  the  History  of  His 
Peculiar  Life  at  Home  and  Astonishing  Adventures  in 
Foreign  Parts.  Never  Before  Printed.  Told  by  Hugh 
Lofting.  Illustrated  by  the  Author.  New  York :  Frederick 
A  Stokes  Company,  1920.    Pp.  180. 

HOOKWORM    AND    MALARIA    RESEARCH    IN    MALAYA,  JAVA, 

AND  THE  FIJI  ISLANDS.  Report  of  Uncinariasis  Commission 
to  the  Orient,  1915-1917.  By  S.  T.  Darling,  M.  D.  ;  M.  A. 
Barber,  Ph.  D.,  and  H.  P.  Hacker,  M.  D..  Publication 
No.  9.  New  York :  The  Rockefeller  Foundation  Interna- 
tional Health  Board,  1920   Pp.  x-191. 

a  HISTORY  OF  THE  CONCEPTIONS  OF  LIMITS  AND  FLUXIONS 
IN  GREAT  BRITAIN  FROM  NEWTON  TO  WOODHOUSE.    By  FlORIAN 

Cajori,  Ph.  D.,  Professor  of  History  of  Mathematics  in  the 
University  of  California.  With  Portraits  of  Berkeley  and 
Maclaurin.  Chicago  and  London :  The  Open  Court  Pub- 
lishing Company,  1919.    Pp.  viii-299. 

AN     introduction    TO    BACTERIOLOGY    FOR    NURSES.  By 

Harry  W.  Carey,  A.  B.,  M.  D.,  Assistant  Bacteriologist, 
Bender  Hygienic  Laboratory,  Albany,  N.  Y.  (1901-3)  ; 
Pathologist  to  the  Samaritan  (Troy)  and  Cohoes  Hospitals, 
and  City  Bacteriologist,  Troy,  N.  Y.  Second  Revised  Edi- 
tion. Philadelphia :  F.  A.  Davis  Company,  Publisher. 
English  Depot :  Stanley  Phillips,  London,  1920.  Pp.  vii- 
149. 

REFRACTION  AND  MOTILITY  OF  THE  EYE.  With  Chapters  on 
Color  Blindness  and  the  Field  of  Vision.  Designed  for 
Students  and  Practitioners.  By  Ellice  M.  Alger,  M.  D., 
F.  A.  C.  S.,  Professor  of  Ophthalmology  at  the  New  York 
Postgraduate  Medical  School,  etc.  With  One  Hundred  and 
Twenty-five  Illustrations.  Second  Revised  Edition.  Phila- 
delphia :  F.  A.  Davis  Company,  Publishers.  English  Depot : 
Stanley  Philips,  London,  1920.    Pp.  xiv-394. 

practical  massage  and  corrective  exercises  WITH  AP- 
PLIED ANATOMY.  By  Hartvig  Nissen,  President  of  Posse 
Normal  School  of  Gymnastics ;  Superintendent  of  Hospital 
Clinics  in  Massage  and  Medical  Gymnastics ;  For  Twenty- 
four  Years  Lecturer  and  Instructor  of  Massage  and  Swed- 
ish Gymnastics  at  Harvard  University  Summer  School,  etc., 
etc.  Fourth  Revised  Edition,  with  Sixty-eight  Original 
Illustrations,  Including  Several  Full  Page  Half  Tone 
Plates.  Philadelphia :  F.  A.  Davis  Company,  Publishers. 
English  Depot :  Stanley  Phillips,  London,  1920.  Pp.  xii-225. 

occupational  affections  of  THE  SKIN.  Their  Preven- 
tion and  Treatment.  With  an  Account  of  the  Trade  Pro- 
cesses and  Agents  which  Give  Rise  to  Them.  By  R. 
Prosser  White,  M.  D.  (Ed.),  M.  R.  C.  S.  (Lond.),  Life 
Vice-President,  Dermatologist,  Senior  Physician,  and 
Enthetic  Officer,  Royal  Edward  Infirmary,  Wigan :  Vice- 
President,  Association  Factory  Surgeons,  etc.  Second 
Edition.  With  Twenty- four  Plates  (Comprising  Twenty- 
eight  Figures).  New  York:  Paul  B.  Hoeber,  1920.  Pp. 
xiv-360. 


Practical  Therapeutics  and  Preventive  Medicine 

A  Compendium  of  Treatment  and  Prophylaxis,  Original  and  Adapted 


Dilatation  of  the  Lateral  Ventricles  as  a  Com- 
mon Brain  Lesion  in  Epilepsy.—  Dr.  A.  Thorns 
{Journal  of  Nervous  and  Mental  Disease,  January, 
1920)  finds  from  observation  that  dilatation  of  the 
lateral  ventricles  is  a  common  abnormality  of  the 
brain  in  epileptic  subjects,  but  fails  to  find  in  liter- 
ature mention  of  this  phenomenon.  A  study  of 
the  brains  of  seventy-five  epileptic  subjects  made 
during  the  past  seven  years  showed  that  seventy-six 
per  cent  or  fifty-seven  cases  had  gross  brain  lesions. 
Thirty-one  of  these  fifty-seven  cases  presented  cor- 
tical lesions  as  well  as  dilated  ventricles,  sixteen 
showed  lesions  of  the  cortex  alone,  and  fourteen 
had  dilated  lateral  ventricles,  though  the  cortex 
looked  normal.  In  the  cases  with  cortical  lesions 
the  hind  part  of  the  brain,  especially  the  occipital 
lobe,  was  most  frequently  affected.  General  cerebral 
gliosis  involving  the  entire  cerebrum  was  the  next 
most  frequent  manifestation.  Softenings,  usually 
localized,  were  noted  in  surprisingly  few  instances. 

The  dilated  ventricle  group  comprising  forty-one 
cases,  or  54.6  per  cent,  showed  abnormalities  of 
the  cortex  in  twenty-seven  brains,  which  cortical 
lesions  were  the  probable  cause  of  the  convulsions. 
The  ventricular  dilatation  in  the  remaining  fourteen 
cases  in  which  there  was  no  cortical  involvement, 
raises  the  question  as  to  whether  lesions  affecting 
primarily  the  white  matter  may  not  be  a  factor  in 
producing  epilepsy.  A  summary  of  the  ages  at 
which  convulsions  began  in  the  group  with  both 
dilated  ventricles  and  cortical  lesions  showed  that 
the  onset  occurred  before  twenty  years  of  age  in 
sixty-three  per  cent  of  the  cases,  whereas  it  occttr- 
red  at  this  period  in  only  forty-three  per  cent  of 
the  cases  in  which  there  were  no  cortical  lesions. 
In  cases  presenting  dilated  A'entricles  without  cor- 
tical lesions  the  greatest  number  of  onsets  after 
thirty  years  of  age  occurred. 

The  Therapeutics  of  Essential  Epilepsy. — ^L. 

Pierce  Clark  {Boston  Medical  and  Surgical  Journal, 
September  30,  1920)  says  that  in  handling  the  indi- 
vidual epileptic  it  is  first  necessary  to  analyze  the 
specific  conflicts  which  he  has  to  meet  in  life  and 
note  his  type  of  mismanagement  of  them.  Then 
consciously  to  increase  the  patient's  insight  into  the 
situation  is  absolutely  necessary.  It  has  been  the 
custom  so  long  merely  to  note  the  epileptic  defect 
and  not  make  him  aware  of  his  own  inherent  fault 
that  this  method  alone  is  almost  revolutionary. 
Heretofore  this  kind  of  autognosis,  or  selfknowl- 
edge,  has  been  left  to  wellmeaning  friends,  nurses, 
religious  instructors  or  tutors,  and  has  not  been 
brought  into  the  physician's  own  armamentarium. 
Perhaps  it  has  been  held  to  be  of  so  little  medical 
importance,  or  that  the  process  of  wise  teaching  en- 
tailed has  been  thought  to  be  so  time  consuming  that 
the  physician  has  neglected  his  plain  duty.  But 
since  the  newer  principles  of  reeducation  and 
psychoanalysis  in  the  neuroses  have  been  established, 
similar  methods  are  really  found  to  be  of  service  in 


essential  epilepsy.  Proceeding  with,  this  method 
sooner  or  later  one  finds  that  the  epileptic  individual 
possesses  a  crude  type  of  personality.  No  explana- 
tory talk  about  his  character  defect  will  remove  it. 

Essential  epilepsy  in  its  inability  to  be  analyzed 
away  demonstrates  that  it  is  not  a  neurosis  but  a 
profound  disorder  of  the  instinctive  life.  Analysis 
but  points  out  the  glaring  defect  and  it  is  then  pos- 
sible to  lay  down  a  daily  schedule  of  character  train- 
ing and  practice  in  concrete  instances  wherein  the 
epileptic  may  learn  day  by  day,  little  by  little,  the 
means  of  overcoming  his  faults  of  character.  An- 
alysis only  points  out  the  specific  reeducation  possi- 
ble. In  many  instances  notes  of  the  analyzed  de- 
fects should  be  taken  by  the  patient  himself  or  sum- 
marized by  the  teaching  physician  so  that  the  epi- 
leptic individual  may  go  over  it  again  and  again. 
He  is  likely  to  forget  the  explanatory  talks  as  a  pro- 
tective mechanism  common  to  all  humanity.  The 
fit  itself  obliterates  the  imprint  of  the  corrective  ad- 
vices. Thus  it  would  seem  that  the  epileptic  seizure 
is  a  magic  talisman  in  more  than  one  direction.  It 
reduces  the  sting  of  the  affective  stress  which 
springs  the  epileptic  reaction.  Be  it  fit  or  explosive 
temper,  it  carries  of?  the  keenness  of  the  epileptic 
initiation  of  helping  himself  and  obliterates  the 
teachings  formerly  given  him. 

Potassium  Borotartrate  in  Epilepsy. — Pierre 

Marie,  Crouzon  and  Bouttier  {Bulletin  d  1' Academic 
de  mcdccinc.  June  1,  1920)  report  clinical  tests 
demonstrating  that  boron  compounds,  and  in  par- 
ticular potassium  borotartrate — sometimes  termed 
soluble  cream  of  tartar — exert  an  effect  in  epilepsy 
much  like  the  bromides,  but  without  the  drawbacks 
attending  the  use  of  the  latter.  A  marked  reduction 
in  the  intensity  and  frequency  of  the  seizures  was 
obtained.  Potassium  borotartrate  occurs  in  trans- 
parent scaly  crystals,  colorless,  with  an  acid  taste, 
and  very  soluble  in  water.  Where,  owing  to  a 
change  in  the  molecular  condition,  the  solubility 
diminishes,  it  can  be  promptly  restored  by  treating 
the  compound  with  hot  water.  The  dose  of  the 
drug  administered  was  generally  three  grains  a  day, 
given  in  three  tablespoonfuls  of  the  following  solu- 
tion :  Potassium  borotartrate,  twenty  grams ;  chemi- 
cally pure  glycerin,  ten  grams,  and  distilled  water, 
enough  to  make  three  hundred  mils.  This  dose 
could,  if  necessary,  be  largely  increased,  as  formu- 
laries generally  give  the  dose  of  potassium  borotar- 
trate as  a  purgative  as  twenty  to  thirty  grams  a  day. 
In  the  clinical  tests,  ten  chronic  epileptics,  previously 
under  prolonged  observation  and  many  of  them  no 
longer  amenable  to  bromides,  were  given  three 
grams  a  day  of  either  the  salt  mentioned,  sodium 
tetraborate,  or  ordinary  borax.  As  with  bromides, 
the  benefit  appeared  first  as  a  transformation  of  the 
seizures  to  mere  dizziness,  and  later  by  progressive 
diminution  of  the  intensity  of  the  latter.  The  aver- 
age number  of  seizures  a  month  in  these  ten  pa- 
tients was  30.5  before  the  boric  treatment,  eighteen 


914 


PRACTICAL   THERAPEUTICS   AND  PREJ'ENTIVE  MEDICINE. 


[New  York 
Medical  Journal. 


during  the  first  month  of  treatment,  11.5  during  the 
second  month,  and  nine  in  the  third  month.  Only 
once  or  twice  was  there  any  vomiting,  and  when  it 
occurred  it  yielded  promptly  to  cessation  of  the  drug, 
as  did  also  looseness  of  the  bowels.  An  important 
advantage  over  the  bromides  was  the  entire  absence 
of  any  evidences  of  mental  depression  by  the  drug, 
which  seems  to  act  directly  upon  the  primary  patho- 
logical cause  of  epilepsy  rather  than  by  depressing 
the  nerve  centres.  The  fact  that  three  grams  of 
potassium  bromide  contain  two  grams  of  bromine, 
whereas  three  grams  of  potassium  borotartrate  con- 
tain only  0.155  gram  of  boron,  also  points  to  a  dif- 
ferent mode  of  action  on  the  part  of  the  two  agents. 
Possibly  the  boron  acts  after  the  manner  of  a  cata- 
lyzer. Potassium  borotartrate  was  well  borne,  alike 
in  children  and  aged  individuals,  but  borax  some- 
times brought  on  eczema.  The  former  agent  is  al- 
most invariably  to  be  preferred  to  borax  or  sodium 
tetraborate.  The  latter,  however,  gives  better  results 
than  borax.  Favorable  clinical  effects  were  likewise 
obtained  in  traumatic  epilepsy  and  in  epilepsy  due 
to  brain  tumor. 

A  Consideration  of  the  Aftercare  in  Arrested 
Cases  of  Essential  Epilepsy. — L.  Pierce  Clark 
(American  Journal  of  the  Medical  Sciences,  Octo- 
ber, 1920)  concludes  as  follows:  1.  Socalled 
cures  or  arrests  in  essential  epilepsies  are  brought 
about  only  by  the  most  thoroughgoing  and  prolonged 
plan  of  neurological  and  hygienic  training  treatment 
in  which  reeducation  is  the  basic  factor.  2.  Re- 
lapses in  arrested  cases  occur  through  negligence  or 
disregard  of  the  essential  factors.  There  is  renewed 
and  intensive  physical  and  mental  stress  and 
proper  and  appropriate  medical  supervision  should 
be  continued  throughout  the  lives  of  such  individ- 
uals. Such  a  plan. of  aftercare  in  private  and  insti- 
tutional practice  would  greatly  diminish  the  pos- 
sibilities of  relapse.  3.  A  more  or  less  enduring 
arrest  and  cure  in  essential  epilepsy  may  be  con- 
sidered permanent  when  the  environment  and  life 
reactions  as  regards  the  secondary  epileptic  reactions 
are  approximately  normal.  No  mere  cessation  of 
epileptic  fits  under  sedatives  should  be  held  out  as 
an  enduring  arrest  unless  the  individual  shows  a 
corresponding  absence  of  epileptic  reactions. 

Sympathetic  Disturbances  in  the  Upper  Extrem- 
ities in  Middle  or  Lower  Dorsal  Involvements 
of  the  Spinal  Cord. — J.  A.  Barre  and  R.  Schrapf 
(Presse  medicate,  April  28,  1920)  call  attention  to 
certain  disturbances,  in  all  likelihood  of  sympathetic 
origin,  which  occur  in  the  upper  extremities  and  are 
caused  by  a  lesion  of  the  spinal  nerve  roots  not  in 
the  cervical  but  in  the  middle  or  lower  dorsal  region. 
These  disturbances  affect  the  ulnar  area  of  the  ex- 
tremities and  especially  the  last  fingers.  They  may 
constitute  a  forerunner  of  a  spinal  symptom  com- 
plex and  precede  the  oncoming  of  paralysis  of  the 
lower  extremities.  Failure  to  recognize  the  site  of 
the  disturbance  in  the  middorsal  region  may  lead  to 
mistaken  localization  in  the  cervicodorsal  region  of 
a  pathological  cause  actually  located  between  the 
sixth  and  eleventh  dorsal  segments.  In  the  presence 
of  these  apparently  sympathetic  disturbances,  the 
possibility  of  a  lesion  of  the  spinal  nervp  roots  in 
the  dorsal  region  should  be  borne  in  mind. 


The  Significance  of  Meningeal  Symptoms. — 

A.  C.  Eastman  (Boston  Medical  and  Surgical  Jour- 
nal, October  28,  1920)  says  that  meningeal  symp- 
toms are  frequently  present  in  many  of  the  infec- 
tions of  childhood  and  may  represent  either  a 
meningism  or  a  meningitis.  Unless  definitely  posi- 
tive of  some  diagnosis  besides  meningitis,  the  only 
means  of  determining  their  significance  is  by  lum- 
bar puncture,  which,  in  many  cases,  requires  several 
repetitions  before  a  definite  diagnosis  can  be  made. 
Like  other  laboratory  examinations,  the  findings  in 
the  cerebrospinal  fluid  must  be  considered  in  con- 
junction with  the  clinical  progress  of  the  disease. 
In  the  final  analysis  we  must  depend  upon  the  bac- 
teriological examination  to  furnish  a  positive  diag- 
nosis. 

Cause  and  Prevention  of  Overstimulation  of 
the  Modern  American  Child. — Erik  St.  J.  John- 
son (Boston  Medical  and  Surgical  Journal,  Octo- 
ber 28,  1920)  asserts  that  the  automobile,  the  motor 
boat,  graphophones,  pianolas,  and  cinematographs, 
together  with  wrongly  proportioned  extravagance  in 
ambition  and  money,  in  schools  and  in  homes,  are 
all,  in  certain  ways,  seriously  harmful  to  the  exist- 
ence and  development  of  normal  children.  Chiefly 
so  in  that  unless  used  with  more  than  average  care 
and  forethought,  they  render  children  dissatisfied 
with  normal  home  life.  There,  and  there  only,  are 
laid  the  true  foundations  for  natural  strength  and 
lasting  qualities  in  mind  and  body.  Though  eco- 
nomic checks,  such  as  the  high  cost  of  living,  and 
future  shortage  of  gasolene,  are  bound  to  operate 
before  long  in  the  line  of  general  stabilization,  medi- 
cal men  should  use  every  opportunity  to  warn 
parents  of  the  causes  and  evil  results  of  over- 
stimulation of  children  outside  the  home.  Children 
need  a  less  hurried,  more  simple  existence  in  order 
to  build  up  lasting  qualities. 

Acute  Myoclonic  Encephalitis. — Sicard  and  Ku- 
delski  (Bulletins  et  memoir es  de  la  Societe  medicale 
des  hopitaux  dc  Paris,  January  29,  1920)  describe 
a  recently  observed  clinical  condition  characterized 
by  lassitude  and  malaise,  severe  lancinating  pains 
in  all  parts  of  the  body,  a  rise  of  temperature  to 
about  38°  C,  and  occasionally  slight  headache. 
After  about  a  week  there  appear  brief,  quick,  ex- 
plosive muscular  contractions  of  the  limbs,  face,  and 
diaphragm,  sometimes  localized  in  one  portion  of 
the  body.  The  myoclonic  seizures  affect  a  single 
entire  muscle  or  group  of  muscles,  and  are  not  ac- 
companied by  fibrillary  contractions.  The  pains  in 
various  parts  and  the  slight  fever  persist.  There  is 
no  eye  symptom  or  somnolence ;  as  a  rule,  insomnia 
is  present.  About  the  third  week  slight  delirium 
appears.  The  reflexes,  objective  sensibility,  and  pu- 
pils remain  normal.  In  the  terminal  stage,'  lasting 
three  or  four  days,  speech  becomes  difficult  and 
jerky.  There  are  automatic  gestures,  nearly  con- 
tinuous delirium,  lessened  intensity  of  the  myoclonic 
seizures,  artd  finally  coma  and  death.  The  cerebro- 
spinal fluid  is  nearly  normal ;  at  times,  particularly 
toward  the  close  of  the  case,  it  shows  slis^ht  albumi- 
nosis  and  lymphocytosis.  The  Bordet-Wassermann 
test  of  the  spinal  .fluid  and  blood  is  negative.  In 
one  case  the  myoclonic  seizures  were  followed  by 
paresis  of  the  extensors  in  the  upper  extremities. 


December  4,  1920.] 


FRACTICAL  THERAPEUTICS  AND  PREVENTIVE  MEDICINE. 


915 


Intravenous  Injection  of  Ammoniacal  Copper 
Sulphate  Solution  in  Puerperal  Sepsis. — H.  Noire 
(Prfssc  medicalc,  June  5,  1920),  at  Mante's  behest, 
treated  an  apparently  hopeless  case  of  puerperal 
sepsis  by  this  measure  and  was  amazed  to  see  the 
]:)atient  recover.  He  later  employed  the  treatment 
in  three  other  cases,  with  like  success.  The  ammo- 
niacal copper  sulphate  yields  absolutely  clear  solu- 
tions if  not  made  more  dilute  than  four  per  cent., 
whereas  solutions  of  ordinary  copper  sulphate, 
whether  concentrated  or  dilute,  are  always  turbid 
and  sometimes  cause  reactions  similar  to  those  fol- 
lowing injections  of  the  colloidal  metals.  The  am- 
moniacal copper  sulphate  solution  mixes  in  all  ratios 
with  blood  serum  without  causing  the  least  turbidity, 
and  its  intravenous  administration  awakens  no  re- 
action. The  preparation  of  the  solution  consists  in 
placing  anhydrous  copper  sulphate  and  ammonia 
■water  in  a  bottle  so  as  to  form  a  saturated  solution, 
the  bottle  being  meanwhile  corked.  An  equal  vol- 
ume of  ninety  per  cent,  alcohol  is  then  added,  the 
two  liquids  being  separated  by  dialyzing  paper. 
After  twenty-four  hours,  crystals  of  ammoniacal 
copper  sulphate  are  formed.  These  are  rapidly  dried 
in  blotting  paper,  after  having  been  washed  with 
alcohol,  and  are  kept  in  well  stoppered  bottles.  In 
injecting  the  solution,  care  should  be  taken  that  all 
of  it  passes  into  the  vein,  as  the  least  amount  passing 
Leneath  the  skin  will  cause  sloughing.  In  puerperal 
fever  the  author  injects  two  mils  of  the  solution, 
i.  e.,  eight  centigrams  of  the  salt,  morning  and  eve- 
ning, until  the  temperature    descends   to  normal. 

Injury  of  Intraabdominal  Viscera. — Frank  T, 
Fort  {International  Journal  of  Surgery,  September, 
1920)  in  a  plea  for  early  surgical  intervention  in 
imrecognized  wounds  of  the  intraabdominal  viscera 
])resents  the  following  arguments :  The  increasing 
frequency  with  which  preventable  fatalities  are  ob- 
served from  injury  to  intraabdominal"  viscera  ac- 
companying external  trauma  without  production  of 
positively  indicative  local  or  general  symptoms, 
should  cause  every  conscientious  practitioner  of 
medicine  to  indulge  in  serious  introspective  stud}' 
and  reflection :  the  medical  man,  because  he  often- 
times first  sees  the  injured  individual  and  much 
depends  upon  the  promptness  and  thoroughness  of 
his  investigation  and  his  diagnostic  and  prognostic 
acumen ;  the  surgeon,  because  upon  his  diagnostic 
confirmation,  his  technical  ability  and  keen  surgical 
sense  will  usually  depend  the  life  (or  death)  of  the 
individual. 

It  is  important  that  an  accurate  history  of  the 
accident  be  obtained  in  every  instance  where  exter- 
nal abdominal  trauma  has  been  inflicted :  the  nature 
of  the  traumatizing  agent,  the  attitude  of  the  indi- 
\idual  when  injured,  the  exact  anatomical  region 
implicated,  the  probable  force  and  direction  of  the 
violence,  and  the  time  with  relation  to  food  inges- 
tion. The  data  thus  collected  should  be  carefully 
considered  in  connection  with  existing  local  and 
general  symptoms  in  estintating  the  possibilities  of 
coincident  internal  injury.  The  pertinent  fact  must 
not  be  forgotten,  however,  that  extensive  visceral 
damage  may  be  produced  by  apparently  slight  ex- 
ternal trauma ;  also,  that  there  may  be  no  coincident 
internal  damage  despite  violent  external  injury. 


There  being  no  pathognomonic  early  signs  by 
which  visceral  injury  may  be  recognized,  early  ac- 
curate diagnosis  is  often  delayed  or  rendered  im- 
possible. This  fact,  however,  is  unimportant  since 
it  is  the  imperative  duty  of  the  surgeon  to  intervene 
provided  there  exists  even  presumptive  evidence  of 
internal  damage.  Procrastination  more  often  than 
otherwise  means  a  fatal  issue,  and  properly  ex- 
ecuted celiotomy  is  practically  devoid  of  clinical  risk. 
Where  visceral  damage  has  occurred  the  mortality 
under  expectant  treatment  is  nearly  100  per  cent, 
as  illustrated  by  statistics  cited. 

Promptly  instituted  surgical  intervention,  based 
upon  suspicion  or  presumption  of  internal  injury 
after  exhausting  reasonable  efiforts  to  complete  an 
accurate  diagnosis,  with  adequate  repair  of  visceral 
damage  when  such  has  occurred,  should  markedlv 
reduce  the  unreasonably  high  mortality  prevailing 
in  the  class  of  cases  under  discussion.  The  dictum 
"the  earlier  operative  treatment  is  instituted  where 
visceral  injury  has  occurred,  the  greater  the  proba- 
bihty  of  saving  the  life  of  the  individual,"  should 
be  accorded  more  consideration  than  has  hitherto 
obtained. 

Diagnosis  and  Treatment  of  Hydrocephalus.— 

\\'alter  E.  Dandy  (Surgery,  Gynecology  and  Ob- 
stetrics, October,  1920)  discusses  the  diagnosis  and 
treatment  of  hydrocephalus  resulting  from  stric- 
tures of  the  aqueduct  of  Sylvius  and  presents  the 
following  conclusions:  1.  Cicatricial  stenosis  of 
the  aqueduct  of  Sylvius  is  the  most  frequent  lesion 
in  congenital  hydrocephalus  (about  fifty  per  ceht.), 
and  is  found  in  a  large  percentage  of  cases  of  hy- 
drocephalus occurring  in  infancy  and  early  child- 
hood.   It  may  occur  (though  rarely)  in  adult  life. 

2.  Hydrocephalus  always  follows  occlusion  of 
the  aqueduct.  The  third  and  both  lateral  ventricles 
progressively  dilate.  The  fourth  ventricle,  being 
posterior  to  the  obstruction,  does  not  enlarge. 

3.  In  the  gross,  the  occluded  aqueduct  appears  to 
be  replaced  by  a  fibrous  tissue  which  microscopic- 
ally is  neuroglia.  Microscopic  remnants  of  the 
aqueduct  are  usually  but  not  invariably  found. 

4.  The  stenosis  may  occupy  the  entire  length  of 
the  aqueduct,  or  varying  parts ;  it  may  be  only  a 
thin  even  transparent  membrane.  Again,  the  stric- 
ture may  be  only  partial. 

5.  Strictures  of  the  aaueduct  of  Sylvius  can  be 
diagnosed  and  accurately  localized.  The  indigo- 
carmine  test  will  indicate  that  an  obstruction  is 
present ;  ventriculography  will  be  the  means  of  pre- 
cisely locating  the  obstruction. 

6.  Spontaneous  relief  is  not  possible.  Surgical 
attempts  to  drain  the  fluid  from  the  third  ventricle 
to  the  exterior  of  the  brain  have  all  proved  futile. 
The  openings  invariably  close  and  the  fluid  cannot 
absorb  in  the  subdural  space. 

7.  A  surgical  procedure  is  suggested  which  is  di- 
rected toward  the  cause.  A  new  aqueduct  of  Syl- 
vius is  constructed ;  a  tube  is  left  in  place  for  two  to 
three  weeks.  It  is  hoped  the  epithelium  will  regen- 
erate and  establish  a  new  canal. 

8.  This  operation  has  been  performed  in  two 
cases,  both  patients  recovering  from  the  operation. 
One  patient  died  of  pneumonia  several  weeks  later, 
the  second  seemed  well  one  year  after  the  operation. 


916 


PRACTICAL   THERAPEUTICS   AND  PREVENTIVE  MEDICINE. 


[New  York 
Medical  Jourxal. 


Role  of  Cancellous  Tissue  in  Healing  Bone. — 

T.  Wingate  Toed  (Annals  of  Surgery,  October, 
1920)  gives  the  following  resume  of  his  studies  of 
the  role  of  cancellous  tissue  in  bone  healing:  1. 
Cancellous  tissue  is  one  of  the  chief  agents  in  re- 
generation of  bone,  and  like  the  cambium  layer  of 
periosteum,  should  be  treated  at  operation  in  the 
most  conservative  manner,  consistent  with  thor- 
ough exploration  and  drainage.  2.  In  regeneration 
the  cancellous  tissue  nearest  the  midlength  of  the 
bone  grows  most  rapidly,  whereas  that  in  or  near 
the  articular  extremities  shows  less  readiness  to 
proliferate  and  fill  the  cavity.  3.  Septic  bone  cav- 
ities should  be  permitted  to  heal  from  the  bottom, 
the  wound  in  the  soft  tissues  being  kept  widely 
open  until  this  has  occurred.  The  least  possible 
mechanical  disturbance  of  the  cancellous  tissue 
should  be  employed  and  no  disinfection  of  the  cavity 
attempted,  for  this  simply  kills  the  remaining  tissue 
from  which  regeneration  is  expected.  4.  Regener- 
ating bone  is  very  sensitive  to  and  easily  affected 
by  pressure,  even  of  soft  tissues,  and  by  inefficient 
drainage.  It  is  not  adversely  affected  by  the  ambu- 
latory method  of  treatment.  5.  Compact  bone  plays 
a  very  minor  part  in  regeneration. 

Gonococcemic  Pseudomalarial  Fever.  —  M. 
Bloch  and  P.  Hebert  (Bulletins  et  memoires  de  la 
Sociite  medicale  des  hopitaux  de  Paris,  March  4, 
1920)  report  the  case  of  a  man  aged  twenty- five 
in  whom  various  clinical  features,  such  as  pseudo- 
malarial  fever,  arthralgia,  and  maculonodose  and 
even  purpuric  eruptions,  reproduced  precisely  the 
picture  of  meningococcemia  as  described  by  Netter, 
Marie,  and  others.  Attention  not  having  been 
drawn  at  the  beginning  to  an  existing  chronic  gon- 
orrhea, and  the  blood  culture  having  revealed  a- 
gram  negative  coffee  grain  diplococcus.  intensive 
antimeningococcic  serum  therapy  was  at  once  in- 
stituted, but  yielded  no  results.  On  the  other  hand, 
injection  of  a  vaccine  made  from  the  germ  found 
in  the  patient's  blood  brought  about  rapid  recovery 
from  the  septicemia,  though  the  genitourinary  foci 
apparently  failed  to  benefit  from  it.  In  such  a  case 
the  diagnosis  could  be  made  only  by ,  agglutination 
tests,  the  diplococcus  from  the  blood  being  found 
inagglutinable  by  antimeningococcic  serums  though 
agglutinable  by  antigonococcic  serum.  The  com- 
plete failure  of  antimeningococcic  serum  in  this  case 
would  seem  to  negative  the  good  results  claimed 
for  it  in  gonococcal  arthritis  by  certain  observers. 

Treatment  of  Fracture  of  Femur. — Moorhead 
(Surgery,  Gynecology  and  Obstetrics,  September, 
1920)  gives  the  following  treatment  for  fracture 
of  the  femur:  1.  Treatment  of  fracture  of  the 
femur  starts  with  first  aid  designed  to  place  the 
limb  at  rest  in  traction  in  a  Thomas  splint,  or  in 
traction  straps  with  weights  attached.  '  Ambulance 
surgeons  and  first  aid  men  should  be  supplied  with 
Thomas  splints.  2.  The  patient  and  not  the  frac- 
ture will  demand  most  attention  in  the  feeble  or 
diseased.  3.  Any  method  that  does  tiot  combine 
reduction  with  early  massage  and  motion  fails  to 
give  the  maximum  service.  4.  The  former  idea 
that  deformity  and  disability  are  inevitable  in  femur 
fractttres  should  be  abandoned.  5.  Two  attempts 
at  reduction  should  be  made  before  skeletal  traction 


or  open  operation  is  performed.  6.  For  the  non- 
displaced  and  reducible  group,  plaster  of  Paris 
(spica  or  molded)  is  an  efficient  form  of  splintage. 
7.  In  the  irreducible  group  described,  skeletal  trac- 
tion by  transfixion  offers  a  safe,  efficient  method.  8. 
This  fracture  entitles  the  patient  to  a  high  grade  of 
surgical  care  and  exacts  from  the  surgeon  a  degree 
of  diligence  and  skill  at  least  equal  to  that  necessary 
in  the  management  of  many  other  major  surgical 
problems.  9.  Fractures  have  been  too  much  slight- 
ed by  surgeons  and  for  that  reason  the  fracture 
field  is  being  encroached  upon  by  orthopedists  who 
b}^  their  training  are  better  fitted  for  the  aftercare 
than  for  the  initial  care  of  this  acute  variety  of 
traumatic  surgery.  10.  There  is  great  need  for 
standardization  and  uniformity  in  fracture  work 
and  in  no  group  is  this  more  necessary  than  in  frac- 
tures of  the  femur. 

Intoxication  from  the  Rectum. — L.  Dreyfus 
(Presse  medicale,  February  18,  1920)  states  that 
the  possibility  of  intestinal  intoxication  by  bacterial 
toxins  or  toxic  products  resulting  from  the  decom- 
position or  putrefaction  of  proteins  has  not  yet 
been  experimentally  demonstrated.  He  has  per- 
sonally succeeded,  however,  in  demonstrating  ex- 
perimentally the  possibility  of  intestinal  intoxication 
by  acids.  This  occurs  almost  exclusively  in  the 
large  intestine,  and  chiefly  in  the  rectum.  Clinical 
occurrence  of  such  a  condition  may  be  considered 
very  probable,  as  there  exist  in  the  feces  many 
acids  which  might  give  rise  to  it.  Under  normal 
conditions  the  stools  should  be  neutral  in  reaction. 
The  principal  factors  that  may  render  them  acid 
are  a  too  copious  or  exclusive  carbohydrate  diet 
and  insufficient  secretion  of  bile.  These  conclu- 
sions open  up  a  new  field  in  the  treatment  of  acute 
or  chronic  intestinal  intoxication  and  the  disturb- 
ances of  health  dependent  upon  such  intoxication. 

Treatment  of  Carbon  Monoxide  Intoxication. 
— Leon  Binet  (Presse  medicale.  May  15,  1920) 
emphasizes  the  fact  that  the  simplest  and  best 
plan  of  treatment  in  this  condition  is  to  break 
down  the  carbon  monoxide  hemoglobin  in  vitro. 
The  combination  of  the  gas  with  hemoglobin  is  an 
unstable  one.  which  can  be  broken  up  by  oxygen 
provided  the  latter  is  administered  in  pure  form,  as 
shown  by  Nicloux.  Achard  has  pointed  out  that 
inhalation  of  pure  oxygen  is  capable  of  yielding  a 
maximum  therapeutic  effect  from  the  start  in  this 
condition.  The  respiratory  capacity  of  the  blood 
comes  back  to  normal  under'  these  conditions  and 
cannot  be  further  raised  by  a  second  inhalation  of 
oxygen  gas.  It  is  never  too  late  in  a  case  of  carbon 
monoxide  poisoning  to  use  pure  oxygen,  for  even 
several  days  after  the  intoxication  the  poison  is  dis- 
placed from  the  hemoglobin  combination  just  as 
readily  as  it  is  immediately  after  the  intoxication. 
The  richer  the  air  respired  in  oxygen,  the  more  rap- 
idly the  displacement  of  carbon  monoxide  from  the 
combined  hemoglobin  will  proceed.  Giving  oxygen 
through  the  usual  cannula  held  in  front  of  the  pa- 
tient's mouth  and  nose  is  definitely  insufficient  in 
these  cases.  A  chloroform  mask  or  emergency 
pasteboard  mask  must  be  used,  and  if  the  gas  is 
inhaled  in  large  amounts,  recovery  may  be  procured 
within  a  few  minutes. 


Proceedings  of  National  and  Local  Societies 


NEW  YORK  NEUROLOGICAL  SOCIETY. 

Three  Hundred  and  Seventy-ninth  Regular  Meeting, 
Held  March  2,  1920. 

The  President,  Dr.  Walter  Tim  me,  in  the  Chair. 

Chronic  Nondegenerative  Hereditary  Chorea. 

— Dr.  I.  S.  Wechsler  presented  a  case  showing  a 
clinical  picture  closely  resembling  Huntington's  dis- 
ease, but  certain  distinctive  features  removed  it 
.  from  that  category  and  suggested  that  it  might  be 
a  distinct  clinical  entity.  An  American,  female, 
married,  aged  thirty-six,  had  had  peculiar  move- 
ments of  arms,  hands,  body  and  legs,  twitchings  of 
the  face,  for  some  sixteen  years,  gradually  increas- 
ing in  intensity  for  a  time,  then  remaining 
comparatively  improgressive.  A  slight  weakness  of 
the  heart,  with  faintness,  was  complained  of  about 
the  time  of  the  onset,  which  was  said  to  have  fol- 
lowed a  miscarriage.  There  were  no  convulsions, 
biting  of  tongue,  nor  amnesia.  The  attacks  were 
closely  linked  with  the  patient's  emotional  state, 
suggesting  a  possible  hysterical  condition.  The 
patient's  father,  who  was  the  tincle  of  her  mother, 
also  suffered  from  chorea  for  twenty  years.  One 
brother  had  shakings.  Of  her  children  one  daugh- 
ter was  not  nervous,  but  had  poor  eyesight  and 
nystagmus ;  the  second  daughter  had  twitching  and 
attacks  of  weakness.  The  shaking  was  not  choreic. 
Two  small  boys  had  chorea  and  nystagmus. 

The  patient  showed  a  number  of  abnormal  Invol- 
imtar}-  movements ;  irregular,  jerky,  purposeless 
movements  of  whole  parts,  arms,  legs,  body,  hands ; 
twisting  of  the  whole  body.  The  eyeballs  wandered 
in  irregular  fashion  in  their  sockets.  All  these  move- 
ments were  intensified  by  emotion,  while  control 
inhibited  them  for  a  short  time.  The  movements 
were  in  general  more  rapid  than  in  chorea.  Xo 
pathological  reflexes  were  found.  Vision  and  hear- 
ing were  normal,  except  for  the  choreic  nonrhyth- 
mic  movement  of  the  eyes.  Mental  status  was 
perfectly  normal,  with  a  slight  tendency  to  forget- 
ting, probably  due  to  lack  of  attention. 

In  the  oldest  boy,  aged  nine  and  a  half,  a  con- 
dition diagnosed  at  the  hospital  as  acute  chorea 
developed  at  the  age  of  seven.  The  condition  im- 
proved somewhat  after  six  months,  but  two  years 
ago  there  was  a  second  acute  attack.  The  younger 
boy,  aged  six.  had  had  slight  twitchings  since  he 
was  three.  Slight  unsteadiness  in  equilibrator\'  and 
nonequilibratory  tests,  of  a  choreic  nature,  was  ob- 
tained on  examination.  Some  nystagmus  on  look- 
ing forward  and  trying  to  fix  the  gaze  was  also 
noted. 

Unlike  the  condition  usually  met  with  in  Hunt- 
ington's chorea  the  onset  of  the  attack  was  at  the 
early  age  of  twenty.  The  movements  were  quicker, 
the  face  showed  more  grimaces,  speech  was  dif- 
ferently affected,  somewhat  forced  and  slow  but 
not  scanning.  The  gait  was  clownish.  Mental 
degeneration  was  absolutely  absent.  Hysteria  might 
be  adduced  as  a  cause,  especially  hysteria  associated 
with  chorea,  while  other  forms  of  chronic  chorea, 
such   as   chorea   gravidarum   and  paramyoclonus 


multiplex,  had  features  suggestive  of  this  case,  but 
did  not  correspond  sufficiently  to  warrant  the  diag- 
nosis. The  point  of  particular  interest  in  this  case 
was  that  it  was  a  nondegenerative,  nonprogressive 
type  of  hereditary  chorea 

Hyperthyroidism  in  a  Girl  Nine  Years  of  Age. 
— Dr.  Morris  H.  Fraxtz  presented  a  case  which 
he  considered  was  of  interest  because  of  the  infre- 
quency  of  the  condition  in  children.  The  patient 
had  come  to  the  Neurological  Institute  clinic  a  year 
before.  She  was  fidgety,  would  get  into  rages,  and 
had  palpitation  on  violent  exercise.  Muscular  sthe- 
nia,  ocular  manifestations  and  a  distinct  exoph- 
thalmus  were  present.  Tachycardia  and  slight 
tremor  of  the  hand  were  also  noted.  Laboratory 
findings  were  negative ;  mental  age  was  twelve  and 
a  half. 

The  patient's  father  had  had  rheumatic  arthritis, 
the  mother  suffered  from  hyperthyroidism.  Goitre 
had  been  present  in  a  maternal  aunt.  The  child  was 
born  in  a  little  town  in  Germany  where  goitre  was 
prevalent.  At  the  time  of  the  child's  birth  a  goitre 
developed  in  her  mother,  and  the  same  condition 
was  diagnosed  in  the  child  at  the  age  of  one  and  a 
half.  The  condition  became  aggravated  at  the  time 
of  the  emigration  of  the  family  to  America  during 
the  submarine  blockade. 

Acute  Infectious  Myoclonus  Multiplex  and 
Epidemic  Myoclonus  Multiplex. — Dr.  J.  Rams.w 
Hunt  called  attention  to  the  problem  of  localiza- 
tion of  acute  infections  in  some  part  of  the  nervous 
system.  The  varieties  of  clinical  types  in  Heine- 
^ledin's  disease,  for  instance,  emphasized  the  fact 
that  certain  strains  of  the  same  infective  organism 
might  have  special  affinities  for  certain  tissues  of 
the  nervous  system,  and  thus  bring  about  the  spe- 
cial clinical  type  of  reaction.  Such  special  forms 
of  localization  of  an  actue  infection,  he  said,  were 
to  be  found  in  acute  infectious  myoclonus  multi- 
plex and  epidemic  myoclonus  multiplex.  The  form 
was  characterized  by  lancinating  pains,  muscular 
contractions  and  twitchings,  and  a  delirium  of  toxic 
origin.  This  group  of  symptoms.  Doctor  Hunt 
found,  constituted  a  well  defined  clinical  type  of 
neural  infection  which  differed  from  those  previ- 
ously recognized  and  was  encountered  both  in 
sporadic  and  epidemic  form. 

The  onset  of  the  disease  was  acute  and  was  char- 
acterized by  shooting  pains  of  great  intensity  in  the 
trunk  and  extremities.  Spinal  pains  were  some- 
times present.  The  pains  were  followed  by 
characteristic  muscle  jerks,  waves  and  twitchings 
f  myoclonus  multiplex,  myokymia,  and  fibrillary 
contractions.)  The  contractions  made  their  appear- 
ance first  in  the  parts  where  the  pains  were  first 
felt.  A  week  might  elapse  in  some  cases  between 
the  appearance  of  the  pains  and  the  myoclonus  and 
myokymia.  The  twitchings  were  bilateral,  mul- 
tiple, and  might  become  generalized.  There  was 
sometimes  a  tendency  to  localization  in  certain  re- 
gions of  the  body,  especially  in  the  abdominal 
musculature.    The  contractions  were  quick  and  of 


918 


PROCEEDINGS  OF  NATIONAL  AND  LOCAL  SOCIETIES. 


[New  York 
Medical  Journal. 


short  duration,  individual  muscles  or  portions  of 
muscles  were  involved,  but  not  synergic  groups. 
Slight  movements  of  the  toes,  fingers,  and  extremi- 
ties might  occur  in  severe  myoclonic  twitchings,  but 
never  to  the  extent  found  in  chorea  or  cortical  myo- 
clonia. 

There  was  usually  moderate  fever.  In  some 
cases  that  proved  fatal  the  temperature  rose  in  the 
later  stage  of  the  disease.  An  acceleration  of  the 
pulse  rate  was  noted  and,  in  most  cases,  a  delirium 
which  varied  in  duration  and  intensity  with  the  de- 
gree of  infection.  There  was  often  marked  hyper- 
idrosis,  and  the  degree  of  sweating  seemed  to  bear 
some  relation  to  the  activity  of  the  myoclonus  phe- 
nomena. There  was  no  paralysis  or  paresis  of  any 
muscle  or  group  of  muscles ;  no  anesthesia  was  en- 
countered with  the  exception  of  occasional  transient 
areas  of  hypalgesia.  There  was  no  ataxia  nor  loss 
of  deep  sensibility ;  tendon  reflexes  were  present 
and  active.  Rarely  the  knee  jerks  might  be  dimin- 
ished and  the  Achilles  jerks  absent  during  the 
height  of  the  disease.  The  cranial  nerves  showed 
no  evidences  of  involvement  except  for  the  myoky- 
mic  twitchings.  The  optic  nerves  were  normal. 
Skin  reflexes  were  present  and  equal  (no  Babinski). 
When  abdominal  myokymia  was  present,  the  ab- 
dominal reflexes  w-ere  exaggerated. 

Doctor  Hunt  had  observed  twelve  cases  of  this 
aflfection  in  the  past  sixteen  years ;  two  cases  were 
seen  more  than  ten  years  ago,  and  the  remaining 
ten  within  the  last  three  months.  The  first  cases 
were  evidently  sporadic,  the  latter  epidemic.  The 
distinguishing  features,  acute  pain  of  lancinating 
variety,  with  muscular  waves  and  twitchings,  were 
always  present.  Delirium  was  present  in  eight  of 
the  cases.  The  myoclonus  deliriuin  was  a  charac- 
teristic toxic  delirium  with  hallucinations,  illusions, 
and  transitory  delusions.  Restlessness,  insomnia, 
apprehension,  disconnected  thought  and  mental  con- 
fusion were  present.  Apathy  and  a  tendency  to 
stupor  were  sometimes  met  with  in  the  late  stage. 
In  the  four  cases  without  distinct  delirium  there 
were  insomnia,  restlessness,  irritability  and  excite- 
ment in  this  early  stage  and  later  a  tendency  to 
apathy  and  dulness. 

That  an  infectious  disease  was  under  discussion 
was  clear  from  the  character  of  the  onset,  the  fever 
and  delirium.  Multiple  neuritis  and  acute  polio- 
myelitis might  be  excluded  as  diagnoses  since  the 
paralysis  or  weakness  of  the  muscles  associated  with 
these  diseases  was  absent.  There  was  no  appre- 
ciable tenderness  along  nerve  trunks.  Dubini's 
disease  might  also  be  excluded  since  it  involved 
paralysis.  Epidemic  encephalitis  or  lethargic  en- 
cephalitis were  especially  interesting  possibilities. 
The  epidemic  myoclonus  multiplex  probably  be- 
longed to  this  g^oup  and  represented  a  special 
myoclonus  type  of  the  aflfection.  The  infectious 
agent  of  epidemic  encephalitis  and  epidemic  myo- 
clonus multiplex  was  apparently  the  same. 

The  motor  and  sensory  symptoms  of  the  disease 
studied  by  Doctor  Hunt  were  only  irritative  in 
character,  in  .spite  of  the  very  severe  and  sometimes 
lethal  infection  of  the  nervous  system.  There  was 
no  paralysis  or  anesthe.^ia,  and  this  fact  gave  the 
tlistase  an  added  interest,  since    the  myoclonus 


symptom  complex  was  iiot  found  in  other  forms  of 
spinal  and  neural  infections. 

Tw^o    Cases    of    Brain    Tumor. — Dr.    C.  C. 

Belixg,  Dr.  H.  W.  Martland,  and  Dr.  W.  B.  Eagle- 
ton  reported  on  the  neurological  findings,  the  path- 
ology   and    autopsy    results,    and    the  surgical 
procedure  respectively,  in  two  cases,  the  first,  tumor 
of  the  pineal  gland,  which  was  presented  as  a  clini- 
cal entity,  the  second,  cerebellar  tumor,  presented 
as  a  pathological  and  clinical  entity.    The  first  pa- 
tient, a  man   aged   twenty-five,   an  experimental 
engineer  with  negative  personal  historj-,  sufifered 
superficial  burns  of  both  corneas  in  an  explosion 
of  barium  chlorate  in  1913.   Recovery  was  complete. 
In  October,  1913,  he  began  to  see  double,  and 
lenses  and  general  treatment  failed  to  produce  any 
improvement.    In  March,  1919,  an  examination  by 
Dr.  Eagleton  showed  R.  V.  20/100.  L.  V.  20/50. 
There  existed  marked  papillitis  of  the  right  optic 
nerve,  diplopia  as  a  result  of  paralysis  of  the  supe- 
rior rectus  of  the  right  eye,   and  a  spontaneous 
nystagmus.    There  was  an  increasing  difficulty  in 
looking  upward.    When  Doctor  Beling  examined 
this  patient  the  papillitis  of  the  right  optic  nerve 
was  very  marked.    There  was  no  deviation  of  the 
tongue  or  tremor.    Knee  jerks  and  plantar  reflexes 
were  normal  except  for  a  slight  tendency  to  slow 
reaction  on  the  right  side  in  the  latter.    On  May 
15th  the  patient  contracted  grippe  and  was  sick 
from  that  time  on.    From  July  1st  a  dull  pain  in 
the  top  of  his  head  with  slight  frontal  headaches 
persisted.    His  mental  condition  seemed  to  deteri- 
orate.   He  w^as  often  nauseated  and  vomited.  He 
could  walk  for  a  short  time,  then  his  body  would 
stiffen  and  his  head  jerk  back. 

A  left  subtemporal  decompression  was  performed 
by  Dr.  Eagleton.  The  brain  was  under  great  tension, 
the  dura  widely  exposed.  The  operation  was  fol- 
lowed by  an  uninterrupted  recovery,  and  the  man's 
condition  improved,  although  the  papilledema  per- 
sisted. Several  weeks  .  later,  however,  greatly 
increased  intracranial  pressure  was  apparent,  and 
for  the  first  time  he  showed  a  tendency  to  fall  back- 
ward. The  examination  at  this  time  showed  an  in- 
tense double  papilledema.  There  was  generalized 
tremor,  with  profuse  hyperidrosis  and  tonic  con- 
traction of  the  muscles.  Knee  reflexes  were 
exaggerated.  There  was  clonus  of  the  toes.  Men- 
tal state  was  somewhat  confused,  he  had  lost  track 
of  dates,  but  knew  the  year  and  that  he  was  in  a 
hospital.  Cerebration  was  difificult  and  tremor  was 
jiroduced  by  attempts  to  answer  questions.  Priap- 
ism was  noted ;  no  abnormal  psychosexual  phe- 
nomena. His  condition  became  steadily  worse,  the 
tremor  increased,  eyes  bulged,  jaws  were  set.  On 
November  8th  he  began  to  have  convulsions  in 
rapid  succession,  with  profuse  perspiration,  and  he 
began  to  grow  cyanotic.   He  died  a  few  hours  later. 

Slides  of  the  hospital  history  and  the  autopsy 
findings  were  shown  by  Doctor  Martland.  The 
diagnosis  had  been  tumor  of  the  midbrain.  It  was 
found,  however,  that  there  was  a  small  psammoma 
of  the  pineal  gland.  An  enormous  dilatation  of  the 
third  ventricle  had  resulted.  The  pineal  gland  was 
visible  in  the  x  ray.  •  Doctor  Eagleton  in  discussing 
the  surgical  features  of  this  case  pointed  out  how 


December  4,  1920.] 


PROCEEDIXGS  OF  XATIONAL  .iXD  LOCAL  SOCIETIES. 


919 


useless  further  decompression  would  have  been. 
The  possibility  of  a  pineal  gland  tumor  had  never 
been  suggested,  since  the  usual  symptom  of  head- 
ache was  lacking.  Relief  for  the  increased  intra- 
cranial pressure  was  sought  by  the  left  sided  de- 
compression earlier  in  the  case,  since  Doctor 
Eagleton  had  come  to  the  conclusion  that  the  pa- 
tient was  left  handed.  But  this  had  had  no  effect 
on  the  papilledema. 

The  second  case,  one  of  cerebellar  tumor,  was 
in  a  man  of  forty  who  began  to  lose  weight,  vomited 
every  morning,  had  increasing  dizziness,  and  began 
to  see  double.  There  were  severe  headaches. 
Examination  by  Doctor  Befmg  showed  slight  swell- 
ing of  r.  papilla,  vertigo,  ataxia,  and  asynergia  of 
the  right  side;  deviation  to  the  right  on  walking; 
nystagmus  with  rapid  movements  to  the  left  and 
slow  to  the  right.  Hearing  was  about  equal.  Symp- 
toms pointed  to  a  lesion  in  the  posterior  chamber, 
subtentorial  pressure.  There  was  probably  a  cere- 
bellar tumor  with  slight  involvement  of  the  pons 
since  the  left  face  and  hearing  showed  slight  affec- 
tion. 

Doctor  Eagleton  noted  the  following  phenomena : 
The  patient  showed  a  Romberg;  spontaneous 
pointing  deviation  of  the  right  hand  to  the  right; 
more  marked  spontaneous  nystagmus  on  looking  to 
the  right.  Rotation  to  the  right  produced  nystagmus 
and  possibly  to  the  left,  though  whether  spontane- 
ous or  induced  could  not  be  determined,  duration 
apparently  about  eighteen  seconds.  Rotation  to 
the  left  produced  nystagmus  of  fifteen  seconds' 
duration.  There  was  deviation  of  both  hands  to 
the  left ;  no  dizziness  in  either  rotation.  Cold 
caloric  in  the  right  produced  no  nystagmus,  no  past 
pointing,  or  dizziness.  Cold  caloric  in  the  left  had 
no  effect  either.  XA'stagmus  could  be  induced  by 
turning  the  head  backward,  showing  that  tracts  of 
the  vertical  canals  were  not  functioning  while  the 
horizontal  were  functioning. 

The  tumor  was  thought  to  be  pressing  somewhat 
on  both  sides.  Cases  of  this  sort.  Doctor  Eagleton 
felt,  where  the  exact  nature  of  the  tumor  was  not 
recognized  were  better  left  unoperated. 

Trauma  and  Other  Nonluetic  Influences  in 
Paresis. — Literature,  Dr.  Michael  Os'xato  said, 
could  yield  practically  nothing  on  the  question  of 
the  influence  of  trauma  in  the  production  or  pre- 
cipitation of  neurosyphilis,  in  view  of  the  brief 
time  that  it  had  been  possible  to  diagnose  the  con- 
dition. From  a  study  of  the  very  few  cases  that 
could  be  included  under  this  category  at  the  Van- 
derbilt  Qinic  in  the  past  three  or  four  years  since 
careful  histories  had  been  kept,  and  from  Doctor 
Osnato's  own  files,  only  thirteen  cases  could  be 
assembled  for  study.  These  were  all  proved  cases, 
proved  either  by  laboratory  examinations  or  by 
autopsy.  This  deficiency  of  cases  in  which  trauma 
was  an  associated  factor  whether  recognized  or  not, 
was  to  be  noted  in  Southard  and  Solomon's  Case 
History  Series,  where  a  few  cases  only  were  men- 
tioned. The  posttraumatic  paresis  usually  occurred, 
these  authors  stated,  citing  ilott's  study  of  the  same 
subject,  after  at  least  a  week's  interval,  since  the 
time  required  for  the  destruction  in  the  brain  pro- 
ductive of  the  necessary  symptoms  would  seem  to 


be  at  least  that.  Three  months  was  the  limit  of 
time  that  Southard  felt  should  be  set  to  determine 
the  influence  of  trauma  as  a  causative  factor.  An 
increase  in  the  number  of  cases  of  neurosyphilis 
during  the  war  noted  by  the  Canadian  medical  offi- 
cers was  thought  to  have  been  due  to  the  great 
strain  at  the  front,  and  the  frequent  physical  inju- 
ries resultant  upon  being  buried,  etc. 

A  possible  influence  in  the  production  or  stimula- 
tion of  paresis  was  accordingly  granted  by  other 
observers.  .Doctor  Osnato  described  the  following 
cases  in  support  of  the  traumatic  theory:  In  a  pa- 
tient who  had  been  struck  on  the  back  of  the  head 
eighteen  months  before  by  a  heavy  object,  mental 
inefficiency  soon  became  apparent.  The  only  mental 
signs  presented  were  perseveration  of  thought  and 
speech  and  memor}-  defect.  The  physical  signs  of 
paresis  were  present.  A  second  patient,  in  whom 
the  trauma  was  emotional,  had  been  entirely  efficient 
and  dependable  in  his  work  until  he  was  drafted 
into  the  army.  His  mental  reaction  was  like  a  war 
neurosis  in  every  respect.  After  his  diagnosis  as 
a  psychoneurotic  and  after  his  discharge  he  con- 
tinued to  fail  and  finally  came  to  the  clinic 
complaining  of  gross  memory  defects,  fifteen  min- 
ute attacks  of  amnesia,  dullness  and  retardation 
amounting  almost  to  negativism,  loss  of  interest. 
The  mental  picture  was  that  of  a  psychoneurosis  of 
the  phobic  type ;  a  diagnosis  of  general  paresis  was 
made  from  investigation  of  the  blood  and  spinal 
fluid.  The  problem  of  the  emotional  factors  in  the 
production  of  this  condition  was  forcibly  intro- 
duced here.  The  study  must  be  speculative  since 
the  exact  physiological  changes  that  might  take 
place  as  a  result  of  fear  or  other  emotions  were 
not  known. 

In  a  third  patient,  a  woman,  the  paretic  picture 
developed  after  a  prolonged  etherization.  Follow- 
ing an  operation  she  complained  of  pains  in  the 
chest,  legs,  and  abdomen,  and  right  upper  extrem- 
ity. Grave  memory  defects  also  appeared.  The 
physical  signs  of  tabes  were  present,  but  mentally 
the  patient  was  a  general  paretic.  She  was  under 
treatment  and  showed  progressive  mental  deteri- 
oration, without  delusions  or  hallucinations.  The 
fourth  patient  had  a  severe  attack  of  influenza  and 
complained  of  lancinating  pains  in  the  right  arm 
and  both  legs  shortly  after.  She  became  depressed, 
slept  badly,  had  tremor  of  face,  hands  and  tongue, 
was  ataxic,  and  had  a  moderate  memory  defect. 
The  blood  Wassermann  and  spinal  fluid  findings  in 
this  case  were  those  of  a  cerebrospinal  syphilis 
rather  than  general  paresis.  Before  the  attack  of 
influenza  she  had  been  perfectly  well.  In  the  last 
patient  cited  the  trauma  had  been  caused  by  a  fall- 
in?  plank  which  struck  the  right  parietal  skull  and 
glanced  off  striking  the  dorsal  region  of  the  spine. 
He  was  in  Bellevue  Hospital  three  days.  There 
was  evidence  of  a  depressed  fracture  of  the  right 
vault  of  the  skull  in  the  frontoparietal  region,  over 
the  Rolandic  area.  Left  hemiplegia  had  developed 
when  he  left  the  hospital.  A  few  days  later  there 
was  unsteadiness  of  gait,  ataxia,  Romberg,  typical 
paretic  speech,  stuttering  memon,-  defect,  tremor. 
The  initial  hemiplegia  was  undoubtedly  due  to  the 
trauma.   L'p  to  the  date  of  his  injury  he  had  worked 


920 


PROCEEDINGS  OF  NATIONAL  .sXD  LOCAL  SOCIETIES. 


[New  York 
Medical  Jowrnal. 


Steadily,  and  had  shown  no  apparent  signs  of 
paresis. 

In  conclusion  Doctor  Osnato  emphasized  the  fact 
that  there  were  undoubted  acute  and  chronic  path- 
ological lesions  of  the  brain  ascribable  to  trauma  of 
the  head.  Something  seemed  to  alter  the  perme- 
ability of  the  blood  A^essels  of  the  brain,  thus  en- 
abling the  attack  of  the  spirochetes  upon  the  brain 
tissue.  In  the  cases  described  craniocerebral  injury 
seemed  to  have  precipitated  cases  of  paresis  or  ad- 
versely influenced  them.  The  toxin  of  influenza, 
infections,  or  ether,  might  have  an  effect  similar  to 
trauma,  while  the  effect  of  emotional  stress  offers 
food  for  interesting  investigation. 

Meeting  Held  on  April  6,  1920. 

Familial  Dystonia  Musculorum  of  Oppenheim. 

—Dr.  I  SADORE  Abrahamsox  presented  three  pa- 
tients from  one  family  with  dystonia  musculorum 
of  Oppenheim.  The  progressive  stages  of  the  dis- 
ease were  singularly  well  demonstrated.  They  were 
of  the  pure  idiopathic  variety,  noteworthy,  first,  for 
their  definite  familial  character ;  second,  for  their 
resemblance  in  the  deviations  from  type  that  are  to 
be  met  with  in  all  famiHal  diseases;  third,  for  a 
distinct  involvement  of  speech,  which  Oppenheim 
denied  in  his  cases;  fourth,  for  the  involvement  of 
the  musculature  of  the  neck  not  common  in  these 
cases;  fifth,  for  the  varying  mental  attitude  in  the 
three  patients,  and  sixth,  for  the  unusual  propulsive 
phenomenon  which  had  not  previously  been  noted 
in  cases  of  this  sort. 

The  first  patient,  a  Russian  woman  aged  twenty, 
with  unimportant  family  and  personal  tjistory,  at 
the  age  of  twelve  experienced  difficulty  in  writing 
and  became  clumsy  in  her  gait.  The  muscles  of  her 
legs  would  stiflFen,  this  stiffening  gradually  spread- 
ing to  other  muscles  and  increased  by  effort  or 
emotion.  On  attempting  to  grasp  an  object  a  coarse 
tremor  appeared.  Her  symptoms  had  become  ag- 
gravated during  the  last  three  months  so  that  she 
could  neither  sit  nor  walk.  During  sleep  all  symp- 
toms disappeared.  The  muscles  were  hypotonic. 
There  was  no  paralysis.  An  abnormal  wrinkling 
of  the  forehead  existed  and  general  anxiety,  w-hich 
was  a  deviation  from  the  usual  Oppenheim  mani- 
festations. Speech  was  dysarthric,  bulbar  type. 
The  legs  were  paraplegic,  were  usually  kept  crossed, 
the  typical  inward  rotation  of  the  thigh  was  clearly 
apparent,  and  the  feet  were  turned  down.  A 
marked  involvement  of  the  neck  was  of  interest,  the 
Adam's  apple  was  prominent,  and  she  showed  tor- 
ticollis. Dystonia,  tortipelvis,  lordosis,  clonic 
movements  of  the  left  hand  with  tonic  movements 
in  legs,  and  a  rhythmical  tremor  characterized  the 
disease  in  this  patient. 

In  the  second  sister,  aged  eighteen,  the  disease 
had  an  insidious  onset.  She  first  noticed  difficulty 
in  writing,  her  muscles  began  to  stiffen  involun- 
tarily, the  left  arm  was  drawn  up  in  a  flexor  spasm, 
and  the  hand  turned  outward.  She  complained 
that  the  hip  joint  on  the  right  would  not  stay  in 
place,  and  a  drawing  feeling  above  the  knee  was 
experienced  which  produced  in  her  a  type  of  pro- 
pulsion that  was  very  interesting.  Her  body  was 
thus  bent  forward  and  laterally  twisted  around  the 


vertical  axis  of  the  spine.  There  was  inward  rota- 
tion of  the  thigh.  The  gait  was  bounding.  Her 
condition  was  much  improved  when  she  felt  well 
and  rested. 

The  third  member  of  the  family,  a  boy  of  fifteen, 
showed  the  disease  in  its  early  stages.  He  had  the 
inward  rotation  of  the  thigh,  the  toes  pointed  down, 
the  heel  was  carried  high.  This  condition  had  been 
getting  slowly  worse  for  the  last  two  years.  His 
first  difficulty  was  also  with  writing.  In  walking  he 
swished  his  foot,  and  there  was  a  very  slight  for- 
ward bend.  He  could  run  well  but  had  difficultv 
in  stopping.  Some  hand  movements  could  be  ac- 
complished, such  as  threading  a  needle  and  playing 
marbles.  A  fine  tremor  was  noted.  Scoliosis  and 
tortipelvis  were  present. 

The  three  patients  showed  interesting  differences 
in  emotional  states.  The  first  was  extremely  anx- 
ious, emotional,  and  worried  about  her  condition. 
The  second  was  optimistic  and  wanted  to  get  well. 
The  boy  was  apathetic,  had  no  interest  in  his  con- 
dition, and  in  general  showed  the  mental  state  usu- 
ally found  in  such  cases,  which  caused  them 
sometimes  to  be  classed  as  hysterias. 

Dr.  Smith  Ely  Jelliffe  expressed  the  opinion 
that  it  had  been  a  rare  opportunity  for  himself,  and 
also,  he  thought,  for  other  members  of  the  society, 
to  have  presented  in  so  thorough  a  manner  the  de- 
velopmental history  of  this  interesting  syndrome. 
It  was  unique  to  have  three  members  of  a  family 
showing  the  beginning,  middle,  and  developed 
phases  as  had  been  demonstrated.  Doctor  Abra- 
hamson  had  mentioned  Ziehen's  famiHal  group, 
which  Doctor  Jelliffe  had  had  the  good  fortune  to 
study  in  Berlin.  There  were  three  in  that  group 
"also,  and  Schwalbe's  monograph  had  presented  the 
features,  but  in  Ziehen's  group  the  disorder  had 
progressed  to  a  more  or  less  uniform  pattern  and 
no  developmental  study  was  possible  such  as  the 
present  presentation  offered. 

Doctor  Jelliffe  was  disposed  to  emphasize  the 
varying  clinical  trends  of  a  larger  group  of  stri- 
atum syndromes  of  which  these  cases  were  but  one 
of  the  striking  types.  It  had  become  increasingly 
evident  that  dystonia  musculorum,  Vogt's  double 
athetosis,  Westphal's  pseudosclerosis,  Wilson's  len- 
ticular degeneration.  Huntington's  chorea,  tuberous 
sclerotic  idiocy,  and  even  paralysis  agitans  were  to 
be  regarded  as  but  variants  in  this  larger  picture  of 
striatum  syndromes. 

It  was  recalled  that  one  of  Ziehen's  patients  had 
come  to  autopsy  and  negative  findings  had  been 
reported,  but  more  recently  one  of  Flatau  and 
Sterling's  cases  had  been  autopsied  and  Thomalla, 
Schneider,  and  v.  Economo  had  respectively  stu- 
died the  striatum  pathology  and  the  liver,  for  the 
case  of  Flatau  and  Sterling  had  afforded  a  combi- 
nation of  the  Ziehen-Oppenheim  group  of  dystonia 
musculorum  types  and  Wilson's  lenticular  degen- 
eration types,  'since  the  clinical  picture  was  charac- 
teristic of  the  former  trend,  while  the  hypertrophic 
sclerosis  of  the  liver  was  of  the  Wilson  lenticular 
degeneration  type.  The  pathological  picture  of  the 
striatum  was  one  of  an  abiotrophic  atrophy  of  the 
cells  of  the  putamen. 

(Tc^  he  roneluded.) 


New  York  Medical  Journal 

INCORPORATING  THE 

Philadelphia  Medical  Journals  Medical  News 

A  Weekly  Review  of  Medicine,  Established  184S. 

Vol.  CXII.  Xo.  24.  XEW  YORK.  SATURDAY,  DECEMBER  11.  1920.  Whole  Xo.  2193. 

Original  Communications 


THE  FACULTY  AND  THE  STUDENT.* 

By  Johx  a.  Fordyce,  M.  D., 
New  York. 

Many-  classes  at  this  time  are  striving  to  find  their 
proper  place  in  the  partially  reorganized  and  tran- 
sitional state  of  society.  Under  the  pressing  de- 
mands of  war  a  comparatively  short  time  was 
required  to  enlist  the  man  power,  the  technical 
knowledge  and  skill  of  the  country  to  meet  the 
national  emergency.  The  mental  and  physical  forces 
necessary  to  organize  and  achieve  were  direct  and 
etYective.  The  problems  which  were  so  promptly 
and  efficiently  met  and  solved  by  our  profession  in 
war  times  were  no  more  serious  than  those  arising 
in  the  reconstructive  era  through  which  we  are  now 
passing. 

The  after  war  reorganization  of  existing  social 
conditions  requires  no  less  the  directing  force  of  a 
dominant  idea.  It  must  first  of  all  take  cognizance 
of  the  individual  as  influenced  by  his  education, 
work,  environment,  and  recreations.  The  large 
percentage  of  young  men  rejected  by  our  draft 
boards  as  unfit  for  military  service  points  to  some- 
thing radically  at  fault  in  the  education  and  physical 
training  of  the  youth  of  our  country. 

The  prosperity  and  contentment  of  each  class  in 
a  community  means  the  prosperity  of  all.  When 
this  fundamental  fact  is  generally  recognized  the 
search  for  a  universal  cureall  for  real  or  imaginary 
ills  will  be  unnecessary.  Although  the  mutual 
obligations  and  responsibilities  of  nations,  classes 
and  individuals  have  largely  been  lost  sight  of  in 
their  immediate  requirements  and  ambitions,  a  con- 
dition of  stable  equilibrium  must  sooner  or  later 
take  place,  for  the  biological  law  of  the  trend  to  the 
normal  applies  to  groups  no  less  than  to  individuals. 

Inventive  genius  developed  by  the  demands  of 
war  is  further  stimulated  in  many  of  the  former 
beUigerent  countries  by  dire  necessity  and  will  help 
to  counteract  the  discontent  and  disorganization 
which  are  now  not  conducive  to  loc^cal  thinking  or 
orderly  behavior.  Optimism  should  be  the  prevail- 
ing note.  It  can  be  made  real  by  individual  and 
class  cooperation.  The  medical  profession  must 
follow  the  lead  of  modem  psychologists  and  en- 
deavor to  comprehend  the  fundamental  reasons  for 
the  present  social  unrest  and  help  to  direct  the 
public  mind  into  normal  instead  of  pathological 

*Address  delivered  September  22,  1920,  at  the  opening  of  the 
session  1920-21  of  the  College  of  Ph.vsicians  and  Surgeons  of  Colum- 
bia University. 


channels.  If  medical  opinion  is  influenced  by  great 
political  events,  our  era  should  be  marked  by  a 
study  of  the  individual  reaction  to  present  day 
problems. 

From  the  student  bodies  in  our  institutions  of 
today  are  trained  and  developed  the  teachers  and 
leaders  of  public  thought  of  tomorrow.  Bodily  ills 
are  often  less  dangerous  than  the  fancies  and  bizarre 
theories  of  minds  distressed  or  diseased.  The  one 
affects  the  individual ;  the  other  may  imperil  the 
integrity  of  the  nation. 

Knowledge  of  the  fundamental  facts  of  science, 
correct  economic  ideas  and  logical  methods  of  think- 
ing, can  do  more  to  correct  false  theories  of  life 
than  the  delusions  and  quack  remedies  of  socalled 
reformers.  By  reason  of  his  intimate  and  confi- 
dential relations  with  all  classes  in  a  communitj^  the 
physician  may  administer  not  only  to  disease  of  the 
body,  but  often  can  direct  his  patients  in  matters 
of  public  policy  and  antidote  mistaken  social  theories. 
Concerted  efforts  of  medical  men  to  achieve  reform 
for  the  public  good  are  often  successful  because 
they  are  unselfishly  advocated  and  because  profes- 
sional politicians  regard  not  only  the  individual  but 
the  group  influence  they  can  bring  to  bear  both  in 
and  out  of  the  profession. 

The  practitioner  is  not  a  mere  dispenser  of  drugs 
nor  a  technician  skilled  in  removing  offending 
organs.  He  is  an  educated  scientist  whose  advice 
is  often  invoked  in  questions  of  individual  and  pub- 
lic welfare.  In  addition  to  healing  the  sick,  he 
should  anticipate  and  endeavor  to  prevent  disease. 
He  should  know  the  psychology  of  childhood  as 
related  to  heredity,  environment  and  proper  feeding, 
and  advise  as  to  the  best  educational  methods  to  be 
employed  in  the  impressionable  age  of  the  young. 
He  should  be  able  to  anticipate  educational  misfits, 
and  limit  the  failures  too  often  resulting  therefrom. 
He  can  "minister  to  minds  diseased"  and  learn 
from  faith  curists  valuable  lessons  in  psychotherapy. 
These  are  some  of  the  qualifications  necessary  for 
the  educated  physician  of  today,  in  addition  to  the 
technical  subjects  which  confront  the  entering 
student  and  the  practical  branches  which  complete 
his  four  years  of  work. 

The  education  acquired  by  the  medical  student 
aside  from  its  practical  application  is  a  useful  and 
liberal  one.  Knowledge  of  the  fundamental  sciences 
preparatory  to  practical  medicine  is  as  well  worth 
while  as  that  acquired  bv  the  engineer,  the  lawyer, 
or  the  theologian.    The  structure  and  functions  of 


Copyright,  1920,  by  A.  R.  Elliott  Publishing  Company. 


922 


FORDVCE:  FACULTY  AND  STUDENT. 


[New  York 
Medical  Journal. 


the  human  machine  and  its  living  variabilities  offer 
more  intricate  and  interesting  problems  in  chemistry 
and  physics  than  those  confronting  the  engineer  in 
metallurgy,  mining,  or  in  the  building  of  bridges. 

Is  it  not  worth  while  to  know  something  of  the 
organ  which  directs  all  intellectual  and  physical 
endeavor;  which  retains  and  coordinates  the  im- 
pressions of  centuries ;  originates  infinite  combina- 
tions, and  expresses  them  in  works  of  art,  immortal 
prose  and  poetry,  and  changes  the  crude  materials 
of  nature  into  magical  shapes?  The  study  of  men- 
tal phenomena  in  health  and  disease  opens  the  door 
to  many  obscure  problems  in  the  social  relations  of 
mankind  and  concerns  not  only  the  psychiatrist  but 
the  statesman  and  all  who  have  to  do  with  their 
fellowmen.  A  conception  of  the  individual  reaction 
to  his  surroundings  means  much  to  the  teacher  and 
his  pupil.  It  develops  in  the  one  a  more  intimate 
and  sympathetic  attitude  and  a  corresponding  desire 
in  the  other  to  profit  by  the  teacher's  advice  and 
instruction. 

The  study  of  medicine  in  its  varied  relations  ap- 
peals to  minds  inclined  to  abstract  and  speculative 
reasoning,  to  the  research  worker,  who  is  chiefly 
concerned  in  looking  for  causes  and  is  constantly 
demanding  the  reason  for  things,  as  well  as  to  men 
who  are  only  interested  in  the  concrete  and  obvious. 
In  addition  to  the  development  of  the  power _  to 
observe  and  interpret  it  broadens  one's  viewpoint, 
awakens  the  logical  sense,  and  stimulates  the  desire 
to  penetrate  further  into  the  great  mystery  of  life. 

It  is  as  much  the  duty  of  the  instructor  to  teach 
the  student  to  think  clearly  and  reason  logically  as 
to  convey  facts  or  discuss  theories.  Inability  to 
examine  evidence  in  a  critical  manner,  and  to  form 
independent  judgments,  leads  too  often  to  blind 
acceptance  of  the  dictum  of  one  who  occupies  a 
position  which  gives  him  the  reputation  of  an 
authority.  The  written  and  unwritten  history  of 
medicine  is  replete  with  theories  of  disease,  systems 
of  cures,  and  operative  procedures,  based  on  imma- 
ture knowledge,  wrong  interpretation  of  facts,  and 
hasty  generalizations.  More  accurate  knowledge  of 
the  fundamental  sciences  and  a  wider  grasp  of 
pathological  processes  have  revealed  the  limitations 
of  our  art,  and  should  make  us  more  conservative 
in  accepting  new  methods  of  treatment. 

The  delightful  paper  by  our  colleague,  Dr.  Karl 
Vogel,  on  Oliver  Wendell  Holmes  and  the  Medical 
Student,  recalls  to  all  of  us  one  who  was  not  only 
a  great  physician,  a  philosopher  and  a  poet,  but  a 
logical  thinker,  and  one  honest  enough  to  expose 
the  humbugs,  inconsistencies,  and  crudities  of  drug 
giving  as  practised  in  his  day.  The  collateral  read- 
ing of  every  student  of  medicine  at  some  time  during 
his  early  years  should  include  his  medical  essays 
and  especially  his  paper  on  the  Contagiousness  of 
Puerperal  Fever,  published  in  1843,  long  before  our 
knowledge  of  the  bacterial  cause  of  disease.  It  is 
a  model  of  such  careful  collection  and  interpretation 
of  facts,  and  clear  and  logical  reasoning,  that  it  now 
seems  impossible  to  comprehend  the  bitterness, 
scepticism  and  opposition  which  it  evoked  among 
the  obstetricians  of  that  day.  Refusal  to  accept 
(lemojistrated  truths  when  opposed  to  preconceived 
ideas  was  not  confined  to  days  gone  by.    We  see 


it  too  often  ifi  minds  guided  only  by  precedent  and 
tradition. 

The  motives  which  have  led  you  to  begin  the 
study  of  medicine  would  perhaps  be  difficult  for  you 
to  analyze.  Inherited  bent,  love  of  science,  the 
desire  to  be  a  member  ot  a  learned  profession,  dis- 
like of  the  routine  of  a  business  life,  may  be  some 
of  the  reasons  why  you  are  here  today.  The  pre- 
liminary work  required,  and  the  crowded  curri- 
culum which  awaits  you,  mean  serious  work,  and 
it  is  reasonable  to  assume  you  desire  the  best  in- 
struction it  is  possible  to  obtain  and  are  willing 
and  desirous  to  cooperate  with  your  teachers  to 
secure  it.  Your  work  has  a  definite  aim.  You  are 
striving  to  become  practitioners.  Some  will  doubt- 
less acquire  a  love  for  research  work,  and  will 
devote  their  lives  to  that.  Others  may  find  they 
have  made  a  mistake  in  selecting  an  uncongenial 
profession,  or  for  other  reasons  may  not  be  able 
to  complete  the  outlined  course.  No  tnatter  what 
the  future  may  hold  for  you,  an  impression  on 
your  minds  and  characters  will  result  from  your 
work  and  associations. 

Modern  teaching  methods  correct  some  of  the 
defects  of  medical  instruction  in  the  past,  but  we 
are  yet  in  a  state  of  evolution.  Each  year  the 
public  demands  a  higher  type  and  better  educated 
practitioners.  They  can  only  be  supplied  by  public 
cooperation  and  support.  The  growth  of  the  pure 
sciences  with  resulting  multiplication  of  methods  in 
diagnosis  and  treatment  demands  more  laboratories, 
additional  apparatus,  and,  above  all,  accurately 
trained  instructors. 

Individual  gifts,  endowments  and  liberal  facilities 
in  our  public  hospitals  for  clinical  instruction  and 
the  study  of  autopsy  material  are  needed  to  further 
the  work  of  the  student  and  to  train  the  future 
instructor. 

The  student  should  be  as  familiar  with  the  ter- 
minal stage  of  disease  processes  in  death  as  with 
the  more  subtle  chemical  reactions  which  take  place 
in  life.  The  cycle  of  knowledge  which  should  form 
our  complete  picture  of  disease  is  as  imperfect 
without  the  one  as  the  other. 

Our  present  daj'  means  of  imparting  information 
is  chiefly  by  experiments  and  concrete  demonstra- 
tions and  less  by  didactic  lectures.  The  textbook 
sources  from  which  lectures  are  usually  compiled 
are  at  all  times  accessible  to  the  student.  Labora- 
tory work,  individual  study  and  interpretation  of 
problems  of  disease,  and  demonstration  of  autopsy 
material  are  more  tangible  than  the  finesse  of 
rhetoric  or  the  skilled  oratory  of  the  professor. 

In  speaking  of  the  medical  teaching  today,  it  is 
difficult  to  avoid  a  certain  amount  of  retrospection 
(a  sure  indicat^^n  of  old  age).  It  may  be  worth 
while,  however,  to  contrast  briefly  medical  teaching 
as  now  conducted  with  conditions  as  they  existed 
more  tharr  forty  years  ago. 

Many  subjects  which  have  to  do  with  medicine 
as  a  whole  are  in  a  state  of  flux.  What  is  con- 
sidered knowledge  today  is  discarded  tomorrow. 
Some  theories  have  become  established  facts,  others 
have  been  scrapped.  All,  however,  have  served  a 
useful  purpose,  and  have  proved  to  be  stepping 
stones  on  the  road  of  progress. 


\ 


December  11,  1920.] 


FORDYCE:  FACULTY  AND  STUDENT. 


923 


Since  the  earliest  days  of  medical  instruction,  I 
imagine,  the  prospective  student  has  always  been 
regarded  as  fortunate  in  beginning  his  work  in  a 
progressive  age.  He  has  been  told  by  his  teachers 
that  had  they  been  accorded  the  same  facihties  he 
now  enjoys,  their  own  careers  would  have  been  more 
successful  and  brilliant.  These  encouraging  words 
will  probably  be  made  to  the  future  pupils  of  our 
present  undergraduates,  and  will  be  heard  with  the 
same  polite  scepticism.  Many  who  practise  medi- 
cine today  are  handicapped  by  lack  of  knowledge 
of  the  fundamental  sciences,  which  have  made  such 
astonishing  progress  in  the  last  fifty  years.  Medicine 
can  now  be  placed  among  the  exact  sciences,  but 
it  is  always  progressive  and  will  always  present  new- 
problems  to  be  solved.  No  matter  how  many  cases 
of  one  type  of  disease  are  seen,  variations  in  the 
picture  are  always  present.  Medicine  will,  there- 
fore, never  lose  its  interest  to  the  mind  which 
observes  'and  asks  the  reason  why. 

Changes  have  taken  place  in  the  methods  of  teach- 
ing as  well  as  in  the  subjects  taught.  Formerly 
the  medical  student  was  talked  to  by  his  teachers 
and  told  about  all  things  in  the  curriculum.  Now 
he  is  not  only  instructed  bv  word  of  mouth,  but 
does  things  with  his  hands.  He  conducts  experi- 
ments and  sees  the  relation  of  cause  and  effect. 
\Mien  only  one  sense  is  appealed  to,  the  mental 
impression  is  not  deep  enough  to  be  permanent. 
Modern  methods  develop  the  student,  but  afford  less 
opportunity  to  develop  the  oratory  of  the  teacher. 
]\Iany  of  the  spectacular  and  picturesque  features 
of  teaching  have  given  way  to  more  intimate,  direct 
and  effective  ways. 

During  the  forty  odd  years  which  have  elapsed 
^ince  my  student  days  in  medicine,  the  new  sciences 
of  bacteriology,  serology  and  immunology  have 
developed  with  their  profound  influences  in  all 
l)ranches  of  our  art.  Organic  chemistry,  then  only 
taught  in  the  most  elementary  way,  has  been  enor- 
mously elaborated  and  now  supplies  the  key  to 
many  obscure  problems  in  physiology  and  path- 
ology. The  manipulation  of  chemical  substances 
made  possible  by  a  knowledge  of  their  graphic 
formulae  has  resulted  in  sitbstitution  products  and 
many  valuable  therapeutic  agents.  It  has  made 
possible  the  new  science  of  chemotherapy,  li  one 
seeks  magic  in  medicine  it  can  be  found  in  the  final 
achievement  of  the  life  work  of  Paul  Ehrlich. 

What  is  more  remarkable  in  its  benefit  to  the 
human  race  than  the  specific  selective  action  of  a 
chemical  agent  on  a  given  type  of  disease  prodttcing 
organisms?  The  culmination  of  Ehrlich's  work, 
the  products  of  a  scientific  mind  stimulated  by 
scientific  imagination,  has  given  to  the  world  a  cure 
for  .syphilis,  yaws,  and  relapsing  fever.  It  is  not 
alone  the  achievement  in  question,  but  the  funda- 
mental principle  established,  which  opens  the  way 
for  results  equally  as  important  and  brilliant. 

Scientific  research  has  developed  laboratory  aids 
in  diagnosis  and  treatment  which  have  made  the 
guesswork  of  former  years  the  certainty  of  today. 
One  procedure  alone — the  Wassermann  reaction — 
has  revealed  the  enormous  importance  of  syphilis 
as  an  etiological  factor  in  hitherto  unsuspected  con- 
ditions.   It  is  an  invaluable  aid  in  the  diagnosis  of 


all  stages  of  this  protean  infection  and  .is  equally 
important  as  a  criterion  of  cure. 

In  our  zeal  and  enthusiasm  for  exact  technical 
procedures  we  should  never  forget  the  prolonged 
clinical  study,  keen  observation  and  ability  to  inter- 
pret symptoms  of  disease  which  formed  so  large  a 
part  of  the  attainments  of  the  older  practitioners. 
The  clinical  acquirements  of  centuries  are  an  indis- 
pensable part  of  our  present  day  knowledge. 

If  we  were  to  eliminate  from  medicine  the  con- 
tributions of  the  clinician,  our  profession  would  be 
poor,  indeed.  The  discoveries  of  the  pure  scientist 
were  often  anticipated  by  the  clinician  and  fur- 
nished the  former  the  incentive  for  his  work. 
Tuberculosis  was  considered  an  infectious  process 
and  its  clinical  picture  was  almost  complete  before 
Koch's  discovery.  Foumier's  clinical  acumen  en- 
abled him  to  recognize  the  syphilitic  factor  in  tabes 
and  paresis.  His  observations  have  been  fully  con- 
firmed by  the  laboratory  worker.  Examples  along 
these  lines  might  be  multiplied  indefinitely  if  we 
had  the  time  or  inclination  to  defend  a  useless  thesis 
as  to  the  relative  superiority  of  the  one  or  the  other 
method.  Both  are  needed.  They  supplement  each 
other.  The  experienced  teacher  neglects  neither 
clinical  study  nor  laboratory  aids.  He  emphasizes 
the  relative  value  of  each  and  reveals  the  pitfalls 
which  await  him  who  relies  on  one  method  at  the 
expense  of  the  other. 

In  practical  medicine  the  transition  from  the 
older  to  the  newer  therapeutic  procedures  has  been 
gradual  and  progressive.  Serum,  vaccine  and 
cheinotherapy  have  superseded  many  empirical  drugs 
now  discarded  btit  formerly  a  part  of  the  doctor's 
armamentarium.  Empiricism  has  given  us  many 
valuable  remedies  from  the  animal,  vegetable  and 
inineral  kingdoms  and  even  Chinese  medicine  in 
employing  dried  snakes  and  lizards  finds  an  ex- 
planation in  the  revelations  of  endocrinology. 

With  more  exact  knowledge  of  disease,  we  guide 
nature  in  her  efforts  to  citre  and  rely  less  on  poly- 
pharmacy. We  have  little  sympathy  for  the  prac- 
titioner who  has  a  specific  for  every  symptom  and 
who  always  accepts  personal  credit  for  nature's 
work.  It  may  be  taken  as  an  axiom  that  many 
remedies  for  one  ailment  mean  that  none  is  effec- 
tive. At  the  beginning  of  practice  young  doctors 
have  twenty  remedies  for  one  disease ;  the  old  doc- 
tor twenty  diseases  for  one  remedy.  A  single  rem- 
edy spells  specific  therapy.  An  intimate  friendship 
with  one  drug  is  better  than  a  speaking  acquaint- 
ance with  many. 

Our  textbooks  discuss  in  a  learned  way  the  pos- 
sible causative  factors  in  diseases  of  unknown 
origin,  and  in  so  doing  cause  the  student  as  much 
confusion  as  in  enumerating  a  long  list  of  drugs 
which  may  be  employed  in  affections  for  which  we 
have  no  specific.  As  soon  as  the  real  agent  is  dis- 
covered the  long  list  of  possible  immediate  and  re- 
mote factors  becomes  obsolete  and  meaningless. 

The  chief  and  perhaps  the  only  reason  for  the 
existence  and  development  of  medicine  as  a  pro- 
fession is  the  prevention,  control  and  cure  of  dis- 
ease. In  endeavoring  to  solve  the  many  compli- 
cated probleins  which  are  concerned  in  abnormal 
bodily  states,  many  collateral  sciences  are  invoked 


924 


FORDVCE:  FACULTY  AND  STUDEXT. 


[New  York 
Medical  Journal. 


as  aids.  The  preliminary  work  required  of  the 
prospective  medical  student  is  such  that  he  is  no 
longer  confronted  with  subjects  entirely  new.  He 
has  learned  something  of  the  basic  sciences  that 
comprise  his  first  and  second  years'  work. 

The  teachers  of  anatomy,  physiology,  chemistry, 
bacteriology  and  other  highly  technical  subjects, 
have  devoted  a  lifetime  to  their  mastery.  The  stu- 
dent is  expected  to  acquire  the  essentials  of  these 
branches  in  a  comparatively  short  time.  The  knowl- 
edge which  is  commonplace  to  the  professor  is  al- 
most a  terra  incognita  to  the  entering  student.  He 
is  confronted  with  a  new  nomenclature  and  a  maze 
of  details  which  he  must  master  in  a  given  time. 
When  it  is  realized  that  a  lifetime  must  be  spent  to 
become  an  expert  in  one  science  or  in  one  special 
branch  of  our  profession,  the  little  that  can  be 
taught  in  the  medical  course  and  the  yet  smaller 
quantity  that  can  be  retained  and  assimilated  is  not 
surprising.  The  graduate  is  not  a  master  of  the 
science  and  the  art  of  medicine.  He  has  only  be- 
gim  to  learn. 

Each  teacher  is  nnpressecl  with  the  relative  im- 
portance of  his  own  subject  and  perhaps  exaggerates 
at  times  the  value  of  minor  technicalities  that  are 
only  learned  to  be  forgotten.  If  the  main  theme 
or  purpose  of  medical  education  is  kept  in  mind  by 
the  teacher  and  the  student,  the  facts  which  have 
directly  to  do  with  the  diagnosis  and  cure  of  dis- 
ease will  be  emphasized  by  the  one  and  acquired  by 
the  other. 

A  direct  correlation  of  the  work  in  the  prelimi- 
nar\-  subjects  with  its  relationship  to  the  practical 
branches  renders  the  subjects  less  abstract,  prepares 
the  student  for  advanced  work,  and  avoids  needless, 
repetition.  The  eflforts  now  being  made  to  corre- 
late and  avoid  overlapping  of  the  work  in  the 
practical  departments  should  include  the  preliminary 
and  scientific  subjects.  H  the  teachers  of  the  latter 
subjects  were  more  fully  informed  of  the  require- 
ments of  the  third  and  fourth  year  faculties,  a 
closer  cooperation  would  no  doubt  be  secured. 

.\  teacher  who  is  the  master  of  his  subject  can 
emphasize  the  essential  facts  which  are  of  real  im- 
portance and  which  can  be  applied  in  a  practical 
manner.  He  can  sift  and  select.  The  student  is 
not  yet  sufficiently  advanced  to  do  it,  and  is  often 
bewildered  with  details  of  little  value.  The  more 
thoroughly  a  subject  is  grasped  by  the  teacher,  the 
more  simply  it  can  be  conveyed  to  the  pupil.  Com- 
plicated and  lengthy  explanations  usually  mean 
superficial  or  poorly  digested  information.  Lack 
of  real  knowledge  of  many  subjects  is  too  frequently 
concealed  by  a  complicated  and  foolish  nomenclature. 

In  his  zeal  to  acquire  names  their  real  significance 
and  the  conditions  they  stand  for  are  often  lost  sight 
of  by  the  student.  A  book  on  almost  any  specialty 
in  medicine  expressing  in  a  clear  and  concise  manner 
our  ])ositive  knowledge  would  be  a  small  one.  The 
majority  of  our  textbooks  contain  too  much  irrel- 
event  matter,  and  too  much  pedantic  discussion 
regarding  phases  of  subjects  of  which  we  are  in 
complete  ignorance.  Our  future  developments  will 
deiH-nd  largely  on  recognizing  our  present  limita- 
tions and  on  continuing  to  build  our  superstructure 
on  the  solid  foundations  of  accurate  knowledge. 


Ideals  in  science  and  the  pursuit  of  knowledge 
for  its  own  sake  are  inspiring  phrases,  but  in  a 
school  of  medicine  for  undergraduates  more  will 
be  accomplished  by  having  in  view  a  definite  pur- 
pose. The  arguments  advanced  to  further  coopera- 
tion between  scientific  and  the  socalled  practical 
subjects  apply  with  equal  force  to  the  various 
divisions  of  the  latter. 

It  is  not  the  purpose  of  an  undergraduate  medical 
school  to  make  specialists.  The  student  is,  however, 
entitled  to  the  special  knowledge  acquired  by 
specialists.  The  viewpoint  of  the  specialist,  which  is 
often  limited,  needs  the  perspective  of  inedicine  as 
a  whole,  .as  well  as  a  fundamental  grasp  of  the 
general  principles  of  experimental  pathology,  bac- 
teriology and  other  scientific  branches,  so  that  he 
may  direct  research  work  in  his  own  department 
and  add  each  year  something  of  permanent  value. 

The  routine  work  in  most  of  our  practical  depart- 
ments is  carried  on  by  voluntary  assistaiits,  hence 
frequent  changes  are  inevitable  unless  something 
is  done  to  stimulate  their  interest  in  research 
problems.  A  trained  and  perinanent  personnel  in 
any  department  simplifies  the  teaching  of  students, 
the  care  of  patients  and  eventually  supplies  men 
capable  of  occupying  responsible  positions  in  his 
own  or  other  institutions. 

A  well  equipped  laboratory  in  each  department 
which  could  make  use  of  it  would  further  research 
work  by  the  staf¥,  improve  the  teaching  facilities 
and  keep  alive  the  scientific  methods  acquired  early 
in  the  medical  course  by  the  student.  Problems 
arise  in  every  department  which  can  only  be  solved 
by  help  from  our  colleagues. 

The  medical  horizon  of  each  of  us  would  be 
widened  by  a  more  liberal  give  and  take  policy,  and 
by  more  frequent  conferences  about  conditions 
which  touch  at  the  borderlines  of  the  variou- 
specialties.  In  speaking  of  the  mutual  obligations 
of  the  teaching  and  student  bodies,  it  must  not  be 
taken  for  granted  that  all  things  are  given  by  the 
former  and  received  without  return  by  the  alert 
and  intelligent  young  women  and  men  who  com- 
prise the  latter.  The  mental  reactions  benefit 
the  one  as  much  as  the  other.  Contact  with  serious 
students  having  the  desire  tq  acquire  knowledge 
does  much  to  keep  alive  the  scientific  spirit  in  the 
teacher.  As  one  grows  older  this  necessity  becomes 
more  imperative. 

The  busy  specialist  may  sacrifice  something  in 
teaching,  but  he  is  more  than  repaid  by  the  oppor- 
tunities to  continue  in  touch  with  the  younger  men 
in  his  department  as  well  as  with  the  inquiring 
student  he  is  instructing.  These  in  turn  he  directs 
in  lines  of  research  and  imparts  to  them  his  rijier 
acquirements. 

In  the  strain  and  stress  of  modern  life,  the  events 
of  the  past  are  pushed  aside  and  eventually  for- 
gotten. We  seldom  stop  to  consider  the  work  done 
by  the  masters  who  have  preceded  us  and  made  our 
present  secure  position  possible.  We  accept  their 
gifts  but  forget  even  their  names.  It  would  be  a 
graceful  and  well  deserved  tribute  to  the  epoch 
making  men  in  his  own  special  work  were  each 
instructor  to  outline  at  the  beginning  of  his  course 
the  important  discoveries  in  his  own  field  and  their 


December  11,  1920.] 


FORDVCE:  FACULTY  AXD  STLDEXT. 


925 


influence  on  our  present  day  knowledge.  Were  it 
not  for  the  combined  work  of  the  many  wliich 
leads  to  our  gradual  growth  the  great  epochs  which 
mark  our  progress  would  not  stand  out. 

Years  of  work  and  careful  observation  are  re- 
quired to  gather  the  necessary  facts  and  prepare 
the  way  for  some  great  generalization.  The 
achievements  of  modern  surgery  would  have  been 
impossible  had  it  not  been  for  the  bacteriological 
discoveries  of  Pasteur  and  their  practical  applica- 
tion by  Lister.  Every  obstetrician  and  all  women 
owe  a  debt  of  gratitude  to  Ohver  \\'endell  Holmes 
and  Semmelweiss.  Our  pathological  superstructure 
is  built  on  the  solid  foundation  of  Virchow's 
cellular  pathology.  ^Modern  scientific  medicine  has 
been  developed  from  so  many  sources  that  it  is 
difficult  to  apprize  them  properly.  Many  fallacious 
doctrines  were  swept  aside  by  Louis  and  new 
methods  of  investigation  begun,  which  influenced 
in  a  marked  degree  the  advancement  of  knowl- 
edge abroad  as  well  as  in  our  own  country. 
The  great  clinician  Laennec  should  always  be  re- 
called to  the  student  of  exact  methods  of  chest 
examination. 

At  this  time  the  currents  of  medical  knowledge 
and  inspiration  had  their  sources  in  France.  At 
the  same  time  Great  Britain  was  developing  her 
school  of  great  clinicians  which  included  the  names 
of  Cheyne,  Graves,  Stokes,  Bright,  Addison,  Hodg- 
kin,  Watson  and  many  others.  Austria  and  Ger- 
many in  turn  because  of  their  scientific  achievements 
and  the  personality  of  their  great  teachers  turned 
the  student  tide.  The  depression  of  defeat,  the 
overthrow  of  stable  governments,  and  changed 
economic  conditions  have  for  the  time  retarded 
scientific  development  in  the  countries  of  Central 
Europe.  W'e  have  no  desire  to  profit  by  the  mis- 
fortune of  our  professional  colleagues.  We  do 
not  forget  their  constructive  scientific  work  and 
their  stimulating  teaching.  Xothing  good  can  re- 
sult from  keeping  alive  the  war  bitterness,  but  much 
mutual  benefit  will  follow  the  restoration  of  inter- 
national relations  and  help  extended  to  the  innocent 
sufferers  of  the  great  calamity.  America's  oppor- 
tunity is  not  due  to  the  misfortune  of  others,  but 
to  the  impelling  force  of  past  and  present  achieve- 
ments. 

Have  we  not  much  to  stimulate  tis  in  the  work 
of  Marion  Sims,  of  !McDow-ell,  and  in  the  deeds 
of  our  other  dead  and  living  pioneers  and  leaders? 
Compare  the  Medical  cud  Surgical  History  of  the 
War  of  the  Rebellion  with  that  of  the'  World 
War.  Read  in  the  former  accounts  of  wound 
infection,  hospital  gangrene,  tetanus,  typhoid  fever, 
and  you  will  see  the  graphic  contrast  of  medical 
and  surgical  conditions  then  and  now. 

Can  one  estimate  the  millions  of  lives  saved  bv 
vaccination  against  smallpox?  Do  you  grasp  the 
significance  of  preventive  vaccines  in  typhoid  fever 
and  the  millions  of  lives  saved  in  war  by  this  pro- 
cedure? Is  not  the  conquest  of  diphtheria  by  anti- 
toxin a  victory  no  less  renowned  than  one  of  war? 
Do  not  forget  that  the  elimination  of  yellow  fever 
was  made  possible  by  the  scientific  work  of  Walter 
Reed  and  the  personal  sacrifices  of  Lazear  and 
Carroll.    Could  the  Panama  Canal  have  been  con- 


structed had  not  Gorgas  foreseen  and  applied  the 
necessary  measures  of  disease  prevention? 

We  shall  not  dwell  upon  the  slight  recognition 
accorded  by  our  government  to  the  medical  heroes 
who  have  sacrificed  their  lives  in  eft'orts  to  find  the 
cause  and  control  of  epidemic  and  contagious  dis- 
eases, but  we  may  keep  their  memories  fresh  in  our 
own  hall  of  fame  and  convey  to  our  students  and 
the  public  something  of  which  we  and  they  may 
well  be  proud. 

What  has  the  present  day  student  of  medicine 
to  anticipate?  Xot  all  drudgery,  let  us  hope,  but 
four  years  of  interesting  and  delightful  work  in 
which  new  vistas  of  science  are  to  reveal  their 
mysteries  and  charm.  Mewed  in  the  right  manner 
and  approached  in  the  proper  spirit,  one  can  well 
say,  ''The  work  that  one  delights  in  physics  pain." 
Each  month,  each  year  offers  new  facts  to  learn 
and  new  problems  to  solve.  Knowledge  of  the 
physiology  of  the  wonderful  and  complicated  human 
machine  prepares  one  to  grasp  the  abnormal  func- 
tioning. A  study  of  normal  psychology  affords  us 
an  insight  into  the  mechanism  of  abnormal  mental 
processes.  The  tissue  changes  caused  by  injuries, 
infections  and  new  growths  are  made  clearer  by 
the  study  of  gross  and  microscopic  anatomy.  Each 
science  is  a  liberal  education  and  a  foundation  stone 
in  your  future  building. 

A  stimulating  teacher  directs  your  vision  beyond- 
his  immediate  demonstrations  and  embellishes  his 
dry  facts  with  concrete  illustrations  of  their  rela- 
tion to  your  future  work.  As  time  goes  on  a 
mosaic  will  finally  be  completed  in  which  a  picture 
of  the  body  in  health  and  disease  stands  revealed. 
Work  well  done  now  makes  the  work  to  follow 
simpler  and  easier.  The  will  to  do,  the  desire  to 
excel,  already  means  the  battle  is  half  won.  The 
psj'chology  of  achievement  reveals  latent  possibilities 
of  W'hich  perhaps  you  have  never  dreamed,  and 
urges  you  to  high  ambitions. 

Leave  thy  low-vaulted  past, 

Let  each  new  temple  nobler  than  the  last 

Shut  thee  from  Heaven  with  a  dome  more  vast. 

8  West  Sevexty-sevexth  Street. 


Coccygeal  Neuralgia. — Chartier  (Presse  medi- 
cale,  April  10,  1920)  describes  tmder  the  appella- 
tion "painful  syndrome  of  the  filum  terminale"  a 
definite  form  of  coccygeal  neuralgia  characterized 
by  continuous  pain  at  the  level  of  the  second  and 
third  coccygeal  vertebrae.  The  pain  is  of  the  draw- 
ing type  and  extends  from  the  coccyx  to  the  lumbar 
spine  upon  forAvard  bending  of  the  trunk,  which 
causes  elongation  of  the  filum  temiinale.  Neither 
pressure  nor  forcible  motion  of  the  coccyx  cause 
pain — a  feature  differentiating  the  condition  from 
the  true  coccygeal  disorders.  The  condition  is  an 
expression  of  pathological  change  of  or  pressure 
upon  the  filum  and  the  coccygeal  nerves  it  embod- 
ies, either  in  its  intradural  portion — as  in  meningitis 
— or  in  the  sacral  canal — as  in  gouty  accumulations, 
etc.  In  the  treatment,  x  ray  therapy  or  the  high 
frequency  effluve  may  be  used  with  success  accord- 
ing to  the  type  of  case. 


926 


GORDON:  ENCEPHALITIS  LETHARGlCri. 


[New  York 
Mkdical  Journal. 


POLVMORrHlSM  OF  EPIDEMIC  ENCEPH- 
ALITIS LETHARGICA* 

Clinical  and  PafJwlogiccl   Types  and  Differential 
Diagnosis. 

By  Alfred  Gordon,  M.  D., 

Philadelphia. 

In  the  early  month.s  of  1919  the  attention  of  the 
medical  men  in  the  United  State.s  was  called  to  a 
relatively  new  disease  whose  chief  anatomical  local- 
ization was  the  midbrain.  This  afifection,  which  is 
popularly  known  as  sleeping  sickness,  but  which 
must  be  distinctly  separated  from  the  African  disease 
of  the  same  name,  which  is  due  to  a  trypanosome, 
is,  accurately  speaking,  not  new.  As  far  back  as 
1712  an  outbreak  of  socalled  sleeping  sickness" 
occurred  in  Germany  and  again  in  1890  in  Austria, 
Switzerland  and  Italy.  Von  Economo  observed  it 
in  an  epidemic  form  in  1917  in  Vienna.  Whether 
the  disease  under  discussion  was  recognized  for- 
merly or  not  it  is  difficult  to  say.  At  present,  since 
Netter's  observation  in  France  in  1917,  the  disease 
is  known  to  exist  in  epidemic  or  sporadic  form. 
The  epidemicity  or  sporadicity  suggested  a  microbic 
origin  of  the  disease.  Experiments  have  been 
conducted  in  various  countries  by  inoculating  with 
the  nervous  tissue  from  fatal  cases  (1  and  2),  or 
with  filtered  extracts  of  the  nasopharynx  (3),  ap- 
parently with  positive  results.  Loewe,  Hirshfeld 
and  Strauss  believe  that  they  have  succeeded  in 
isolating  a  microorganism  which  is  analogous  to 
that  of  poliomyelitis  but  from  which  it  nevertheless 
differs.  All  these  investigations  suggest  that  the 
disease  probably  belongs  in  the  category  of  com- 
municable diseases,  hence  the  necessity  of  isolation 
in  suspicious  cases  and  therefore  of  prophylaxis." 
In  view  of  this  role  of  the  nasopharyngeal  secretions 
appropriate  measures  are  indicated. 

The  clinical  picture  of  lethargic  encephalitis 
presents  many  varieties.  The  literature  abounds  with 
examples  of  its  polymorphous  character.  In  view 
of  the  latter,  errors  of  diagnosis  are  likely  to  be 
made.  A  presentation  of  all  possible  occurrences, 
with  emphasis  on  the  differential  diagnosis,  may  be 
warranted  and  this  is  the  chief  object  of  the  present 
contribution.  Three  principal  symptoms,  rise  in 
temperature,  ocular  palsies  and  somnolence,  consti- 
tute the  general  characteristics  of  the  malady.  The 
onset  is  characteristic  of  an  infectious  process ; 
the  fever  is  accompanied  by  headache,  backache, 
and  sometimes  vomiting.  After  the  disease  has 
reached  the  phase  of  full  development  it  presents 
the  above  mentioned  triad  of  symptoms.  During 
this  period  the  polymorphism  of  the  principal 
manifestations  and  of  additional  phenomena  some- 
times presents  diagnostic  difficulties. 

The  ambulatory  form. — There  are  various  de- 
grees of  .somnolence.  In  mild  ca.scs  the  patient  has 
merely  a  fre(|uent  desire  to  sleep,  although  he  may 
attend  to  his  daily  occupation.  As  soon  as  he  sits 
down  he  goes  to  sleep.  This  is  called  the  ambu- 
latory form.  The  following  brief  history  illustrates 
the  fact  that  cases  of  this  character  may  be  over- 
If  oked  and  treated  for  different  affections : 

'To  he  rcarl  before  the  Philadelphia  County  Medical  Society,  De 
crmher  22,  1920. 


A  young  married  man,  who  was  a  cashier  in  a 
bank,  would  frequently,  while  at  work,  close  his  eyes 
and  go  to  sleep ;  at  the  same  time  he  complained  of 
exhaustion.  Upon  examination  I  could  observe  a 
paretic  condition  of  the  external  rectus  of  the  left 
eye.  When,  during  the  examination,  his  brother 
would  engage  me  in  a  brief  conversation,  the  patient 
would  fall  asleep.  This  condition  lasted  four  weeks, 
after  which  complete  recovery  took  place.  This 
affection  was  formerly  diagnosed  as  a  very  probable 
case  of  brain  tumor  for  which  the  physician  in 
charge  was  contemplating  engaging  a  surgeon  for 
operative  procedures.  The  patient  did  not,  how- 
ever, present  other  s\-m])toms  of  a  neoplasm. 

In  another  series  of  cases  the  somnolence  may 
be  somewhat  more  pronounced.  The  patient  invari- 
ably falls  asleep  after  meals  or  after  the  least  amount 
of  exercise.  His  eyelids  have  always  a  tendency  to 
droop  and  he  has  to  struggle  against  sleep.  Al- 
though he  can  be  aroused  for  food,  and  will  answer 
questions  correctly,  he  nevertheless  rapidly  resumes 
his  sleep  as  soon  as  he  has  answered. 

In  some  cases  the  sleep  may  be  still  more  pro- 
nounced. The  patient  is  in  a  state  of  absolute 
inertia,  the  features  are  immobile,  the  cutaneous 
folds  are  effaced,  feeding  by  mouth  is  impossible 
and  one  has  to  have  recourse  to  nutritive  enemas. 
In  one  case,  a  girl  of  eighteen,  during  the  deep 
sleep,  Clieyne-Stokes's  respiration  was  observed, 
which  led  her  physicians  to  think  of  cerebral  hemor- 
rhage. The  patient  nevertheless  made  a  complete 
recovery.  The  diagnostic  error  consisted  in  over- 
looking the  absence  of  localizing  symptoms,  such 
as  abnormal  reflexes,  etc.  In  another  similar  case 
in  addition  to  the  deep  sleep,  there  was  marked 
rigidity  of  the  neck  and  the  attending  physician 
concluded  that  this  was  a  case  of  tuberculous 
meningitis.    Here  also  the  patient  recovered. 

Palsy  of  ocular  muscles  is  a  common  symptom 
in  lethargic  encephalitis.  It  is  usually  an  early 
manifestation.  The  most  frequent  symptom  is 
ptosis  which  is  in  the  majority  of  cases  bilateral. 
Here  we  observe  various  degrees,  either  complete 
drooping  of  the  eyelids  or  merely  a  heavy  feeling. 
Ptosis,  strabismus  and  diplopia  will  also  be  observed. 
Here  again  various  degrees  of  these  disorders  may 
be  present  and  they  may  be  unequally  distributed 
in  both  eyes.  For  example,  in  three  patients  under 
the  writer's  observation,  there  was  ptosis  on  one 
side  and  external  strabismus  on  the  other.  The 
third  cranial  nerve  is  more  frequently  involved 
than  the  fourth  and  sixth.  The  various  muscles 
supplied  by  the  third  nerve  are  usually  unequally 
involved  in  the  same  eye  or  in  both  eyes. 

The  internal  muscles  of  the  eyes  are  less  fre- 
(juently  involved.  Inequality  of  the  pupils, 
mydriasis  and  myosis,  paralysis  of  accommodation, 
mild  nystagmus,  are  the  conditions  observed.  The 
intrinsic  and  extrinsic  ocular  palsies  nm  an  irregular 
course  and  (heir  degree  is  variable. 

In  addition  to  the  ocular  nerves,  other  cranial 
nerves  may  be  affected  in  the  following  order : 
facial,  hypoglossus,  motor  branch  of  the  trigeminal, 
glossopharyngeal  and  spinal.  Facial  paralysis, 
difficulty  in  swallowing,  in  masticating,  in  breath- 
ing, in  speaking  (dysarthria),  are  then  observed. 


December  11.  1920.] 


GORDOS 


EX  CEP  MALI  TfS  LE  THA  RGlC  A . 


927 


In  the  latter  case  it  may  give  the  impression  of 
pseudobulbar  paralysis.  Facial  palsy  may  be 
bilateral.  Xot  only  paralysis  of  the  cranial  nerves 
but  other  paralyses  have  been  observed.  In  a  case 
under  my  care,  that  of  a  colored  man,  there  was  a 
mild  but  distinct  right  hemiplegia  with  increased 
patellar  tendon  reflex  and  toe  phenomenon.  A 
similar  case  was  reported  by  Halbron  and  Coudrain 
(4).  Page  (5)  also  reports  a  case  with  monoplegia 
in  the  upper  extremity. 

Sensor}-  disttirbances  are  usually  rare.  In  one 
case  in  my  series  (6)  there  was  a  very  marked 
tenderness  of  the  left  infraorbital  nerve  at  its  exit 
from  the  foramen  and  anesthesia  of  the  left  cheek. 
In  Sainton's  cases  (7)  there  was  a  generalized 
cutaneous  hyperesthesia  so  that  the  least  touch  pro- 
duced pain.  In  a  number  of  cases  other  disorders 
have  been  observed,  such  as  excessive  salivation, 
involvement  of  sphincters  in  grave  cases,  vasomotor 
display,  gustatory  disturbances,  but  these  are  all 
infrequent.  Great  variability  has  been  observed  in 
the  course  of  the  disease ;  its  duration  may  be  from 
several  weeks  to  many  months.  The  fever,  the 
ocular  palsies  and  the  somnolence  may  present  great 
oscillations  in  intensity  and  duration.  One  may 
say.  however,  that  when  the  temperature  remains 
high,  the  outlook  is  serious,  and  when  myoclonic 
phenomena  occur,  that  the  prognosis  is  equally 
«;rave.  A  number  of  other  manifestations  of  a 
motor  or  psychic  character  are  met  with  at  times 
either  in  the  early  course  of  or  during  phases  of 
exacerbation  of  lethargic  encephalitis. 

The  myoclonic  type.  This  is  one  of  the  most 
striking  clinical  types.  The  following  case  is  an 
example :  A  young  man  aged  twenty-seven,  a  shoe- 
maker, had  a  mild  attack  of  lethargic  encephalitis. 
There  was  somnolence,  bilateral  ptosis  and  a  slight 
rise  in  temperature.  The  reflexes  were  increased. 
The  disease  ran  a  mild  course  and  the  patient  began 
to  improve.  During  convalescence  his  family  physi- 
cian observed  slight  twitchings  in  the  muscles  of 
his  shoulder.  Soon  muscular  contractions  were 
seen  in  the  face  and  in  all  four  extremities.  A  few 
days  later  I  found  the  patient  affected  with  violent 
twitchings,  brief  and  rapid,  at  irregular  intervals 
but  close  to  each  other  and  involving  ever\-  segment 
of  the  body.  He  was  unable  to  eat,  to  rest,  or  to 
sleep.  His  respiration  was  rapid  and  his  pulse  could 
not  be  taken.  He  expired  on  the  following  day.  In 
two  cases  the  myoclonia  was  accompanied  by  severe 
hiccough,  evidently  due  to  violent  contractions  of  the 
diaphragm. 

Brouardel,  Levaditi  and  Forestier  (8)  report  a 
case  (verified  by  autopsy)  without  ocular  disturb- 
ances, but  with  abdominodiaphragmatic  myoclonic 
contractions,  which  rapidly  invaded  all  the  four 
extremities.  Sicard  (9)  obsei^ed  five  cases  in 
which  the  initial  symptoms  were  lancinating  pain 
especially  in  the  neck  and  arms,  muscular  twitchings 
in  the  arms,  abdomen  and  diaphragm.  The  same 
author  with  Kudelski  observed  also  hemimyoclonia 
confined  to  one  side  while  on  the  other  the  seventh 
and  sixth  nerves  were  involved.  It  is  evidently  a 
mesocephalic  condition  of  the  Millard-Gubler  variety. 

Choreic  type.  In  a  girl  thirteen  years  of  age, 
the  attack  of  encephalitis  began  with  choreic  move- 


ments in  the  right  arm  and  face.  A  few  days  later 
somnolence  made  its  appearance  and  soon  the 
involvement  of  the  superior  rectus  and  the  external 
rectus  on  the  left  side  became  evident.  Her  tem- 
perature was  100.2''.  The  choreic  movements  lasted 
through  the  entire  course  of  the  encephalitis. 
Recovery  took  place  at  the  end  of  three  months. 
The  letharg}-  and  the  muscular  movements  disap- 
peared totally,  the  superior  rectus  recovered  but  the 
external  rectus  is  still  paretic.  The  concurrence  of 
acute  chorea  with  a  febrile  encephalitis  supports 
the  view  of  the  infectious  nature  of  the  former 
(10).  It  is  interesting  to  note  a  marked  hypotonia 
of  the  limbs  alTected  with  choreic  movement.  Cases 
of  electric  chorea  (Dubini;  have  been  reported  in 
conjunction  with  lethargic  encephalitis. 

Hemiplegic  form.  Cases  with  one  sided  paralysis 
are  not  frequently  encountered.  In  addition  to  my 
case  and  Halbron  and  Coudrain's  case,  no  record 
could  be  found  in  the  literature.  In  my  case  the 
paralysis  was  mild.  At  the  time  of  writing  these 
notes  the  patient  shows  evidence  of  considerable 
improvement  of  all  symptoms.  The  paralysis  may 
be  confined  to  one  limb  (monoplegia).  Such  a  case 
was  observed  by  Page  (5). 

Convulsive  type.  One  such  case  came  under  my 
observation.  It  occurred  in  a  middle  aged  man 
whose  W'assermann  test  was  positive,  but  who  for- 
merly was  free  from  epilepsy.  On  the  third  day 
convulsions  of  a  generalized  character  occurred. 
During  the  entire  illness  which  lasted  three  months 
the  patient  had  three  attacks.  Recovery  was  com- 
plete. He  was  treated  with  antiluetic  remedies. 
In  some  cases  the  epileptiform  convulsions  were  of 
Jacksonian  type.  In  such  cases  a  paretic  condition 
or  contractures  on  the  same  side  have  been  observed. 
The  prognosis  in  such  instances  is  very  grave  (11). 
Aubry  and  Froment  report  two  cases  of  trismus. 
One  occurred  in  a  pregnant  woman  who  presented 
in  addition  to  the  characteristic  symptoms,  dysar- 
thria, difficulty  of  swallowing,  and  trismus.  The 
patient  died.  In  the  other  case  there  were  myoclonus 
and  trismus.  Trismus  was  probably  due  to  an  irri- 
tation of  the  motor  nucleus  of  the  fifth  nerv-e. 

Meningeal  type.  The  triad  of  encephalitis  leth- 
argica  symptoms  developed  in  a  girl,  sixteen  years 
of  age.  Her  temperature  rose  to  102.4°.  At  that 
time  her  neck  was  rigid  and  Kemig's  sign  was 
present,  facts  which  led  the  attending  physician  to 
reject  the  diagnosis  of  encephalitis.  Within  a  week 
the  two  meningeal  signs  subsided  and  rapidly  dis- 
appeared. The  oculomotor  palsies  and  somnolence 
remained.  The  patient  died  at  the  end  of  nine 
weeks  after  a  period  of  Cheyne-Stokes  respiration 
and  difficulty  in  swallowing. 

In  this  case  the  meningeal  phenomena  somewhat 
obscured  the  encephalitic  manifestations.  Never-- 
theless  the  disease  began  with  the  characteristic 
symptoms.  It  is  to  be  borne  in  mind,  therefore, 
that  the  same  infectious  agent  which  affects  the 
nervous  tissue  of  the  mesencephalon  or  other  por- 
tions of  the  brain  tissue,  may  simultaneously  involve 
the  meninges  and  thus  present  a  complex  clinical 
picture.  Rather}-  and  Bonnard  (12)  report  the  case 
of  a  young  girl  in  whom,  in  addition  to  ocular  palsy, 
fever  and  somnolence,  there  were  also  Kernig's 


928 


GORDON:  ENCEPHALITIS  LETHARGICA. 


[New  York 
Medical  Journal. 


sign  and  rigidity  of  the  neck.  The  spinal  fluid  was 
under  great  pressure  and  distinctly  hemorrhagic, 
containing  5.40  gr.  glucose,  with  marked  leucocy- 
tosis  (50.000).  Bassoe  (13)  also  reports  cases  of 
meningeal  type. 

Sometimes  encephalitis  lethargica  may  present  a 
condition  suggesting  strongly  a  basilar  meningitis. 
In  a  yovmg  lady  aged  twenty-four  years  the  disease 
began  with  vertigo  and  headache.  The  temperature 
rose  to  101°.  On  the  following  day  the  patient 
noticed  that  she  had  great  difficulty  in  keeping  her 
eyes  open.  She  was  drowsy,  could  not  keep  up  a 
conversation.  Her  neck  was  somewhat  rigid. 
Kemig's  sign  was  absent.  There  was  a  mild  crossed 
paralysis.  The  facial  nerve  on  the  left  was  involved 
and  right  leg  presented  an  increased  knee  jerk  with 
ankle  clonus  and  toe  phenomenon.  There  was 
paresis  of  the  left  external  rectus  and  also  bilateral 
ptosis.  The  patient  came  of  a  tuberculous  family 
and  she  was  treated  for  suspected  pulmonary  tuber- 
culosis. For  three  months  her  condition  remained 
stationary  with  the  exception  of  the  temperature 
which  fluctuated  from  99.2°  to  100°.  Her  lethargy 
became  more  and  more  pronounced.  Finally  she 
began  to  improve,  the  crossed  paresis  disappeared, 
the  left  external  rectus  became  normal,  the  ptosis 
improved  greatly.  ■  There  was  no  more  rigidity  of 
the  neck.  For  weeks  thereafter,  however,  she  felt 
drowsy.  Eventually  she  recovered  completely.  A 
basilar  tuberculous  meningitis  suggested  itself  very 
strongly,  but  the  entire  course  of  the  illness,  to- 
gether with  the  spinal  fluid  findings,  proved  the  case 
to  be  one  of  encephalitis. 

Parkinsonian  f\pe.  In  two  male  patients,  both 
of  middle  age,  there  was  a  typical  picture  of 
encephalitis.  On  the  third  week  after  the  onset, 
passive  tremor  in  the  right  hand  with  facies  char- 
acteristic of  paralysis  agitans  developed.  On 
recovery  from  the  encephalitis  the  tremor  disap- 
peared but  for  a  long  time  the  general  attitude,  the 
rigid  and  fixed  position  of  the  trunk  and  the  mask 
like  expression  of  the  face  remained  typical.  In  a 
third  case  the  tremor  was  absent  but  the  facial 
expression  was  that  observed  in  Parkinson's  dis- 
ease. After  recovery  from  the  original  disease,  the 
evidences  of  shaking  palsy  disappeared.  Marie  and 
Levy  (14)  in  describing  their  autopsied  cases  call 
attention  to  the  lesions  of  the  locus  niger  observed 
in  paralysis  agitans  by  some  writers  and  to  the 
predominance  of  encephalitis  lesions  in  the  mesen- 
cephalon. In  a  recent  case  of  Tretiakoflf  and  Bremer 
(15)  paralysis  agitans  developed  in  the  course  of 
encephalitis  lethargica.  At  autopsy  a  pronounced 
degeneration  of  locus  niger  was  found  in  addition 
to  other  nuclear  lesions. 

Bulbar  type.  Four  cases  came  under  observa- 
tion. In  two  of  them  (6)  there  was  difficulty  in 
swallowing  and  dysarthria  because  of  a  paretic 
condition  of  the  lips  and  tongue.  In  the  second 
case  there  was  also  unilateral  facial  paralysis  and 
in  the  third  involvement  of  the  fifth  nerve  on  one 
side.  Both  of  these  patients  recovered.  In  two 
unpublished  cases  the  initial  symptoms  were  bulbar. 
One  patient  had  difficulty  in  swallowing  for  several 
days,  with  temperature  rise  to  100°.  On  the  fourth 
day  the  patient  became  somnolent,  complained  of 


vertigo  while  in  bed  and,  at  the  sam.e  time,  bilateral 
ptosis  and  external  strabismus  on  the .  right  made 
their  appearance.  It  is  interesting  to  note  that 
when  improvement  eventually  set  in,  it  was  evident 
first  in  the  symptom  which  developed  first,  viz.,  in 
the  act  of  swallowing.  The  aflection  of  the  eye 
muscle  persisted  the  longest.  In  the  second  case 
a  difficulty  in  speaking  was  noticed  in  the  course 
of  the  encephalitis,  when  the  patient  was  aroused 
for  food.  He  was  unable  to  move  his  tongue  and 
lips  properly  in  speaking  as  well  as  in  masticating, 
but  there  was  no  difficulty  in  swallowing.  It  was 
observed  that  this  disorder  appeared  on  the  day 
when  there  was  a  rise  of  temperature  (102°)  as  if 
an  infectious  element  had  penetrated  the  nucleus 
of  the  hypoglossal  nerva.  This  particular  disorder 
lasted  a  long  time  after  the  lethargy  had  disappeared. 
The  patient  made  a  complete  recovery. 

Neuralgic  and  ncuritic  types.  Cases  have  been 
reported  in  which  pain  appeared  in  the  face  and  m 
the  extremities  or  was  of  a  generalized  character. 
In  case  number  one  of  the  first  contribution  (6) 
the  encephalitis  began  with  generalized  pain  which 
persisted  as  long  as  the  temperature  remained  at 
100°  but  subsided  when  the  latter  remained  below 
that  figure.  In  this  case  the  pain  was  unusually 
severe  and  continuous  in  the  neck  more  on  one  side 
than  on  the  other.  In  Salmont's  case  (16)  the 
patient,  during  four  consecutive  days,  had  violeut 
pain  in  one  arm.  The  radial  reflex  on  the  same 
side  was  altered,  revealing  the  presence  of  a 
cervicobrachial  radiculitis.  On  the  fifth  day  lethar- 
gic encephalitis  developed  from  which  the  patient 
subsequently  died.  Sicard  (17)  reports  a  case  in 
which  at  the  onset  there  was  pronounced  intercostal 
pain  persisting  during  ten  days  and  followed  on  the 
eleventh  day  by  contractions  of  the  diaphragm  and 
somnolence  and  terminating  in  death.  Similar  cases 
were  reported  by  Bassoe  (13). 

Mental  type.  In  the  apparently  uncomplicated 
forms  of  encephalitis  lethargica  while  there  are  no 
mental  phenomena  of  a  special  character,  neverthe- 
less the  sleep  is  not  that  of  normal  men.  It  is  true 
that  when  the  patient  is  aroused,  he  opens  his  eyes, 
answers  questions  more  or  less  correctly  and  returns 
to  his  sleep,  but  back  of  the  lethargy  the  psychic 
state  is  always  more  or  less  benumbed  and  func- 
tionates defectively,  i.  e.,  the  patient's  orientation 
or  appreciation  of  the  condition  is  defective,  he 
frequently  makes  mistakes,  there  is  a  certain  slug- 
gishness in  associating  ideas.  Sometimes  we  observe 
what  the  French  call  etat  crepusculaire.  This  is 
analogous  to  the  mental  state  observed  in  exhausted 
or  inebriate  individuals,  the  patient  shows  a  very 
mild  confusional  appearance;  his  facial  expression 
and  his  entire  attitude  exhibits  surprise  and  aston- 
ishment when  he  is  being  observed  or  addressed. 

In  some  cases,  hcnvever,  there  is  a  genuine 
confusional  state  with  delirium.  With  eyes  closed 
the  patient  mutters  unintelligible  words  and  when 
he  is  awakened  will  look  around  as  if  bewildered 
and  may  not  recognize  surroundings.  In  another 
group  of  cases  a  genuine  psychosis  may  make  its 
appearance  in  the  course  of  encephalitis  lethargica 
and  continue  as  such  after  the  latter  has  recovered. 

An  interesting  case  of  this  type  came  under  my 


December  11,  1920.] 


GORDON 


ENCEPHALITIS  LETHARGICA. 


929 


observation.  A  young  man,  aged  twenty-three,  had 
a  mild  attack  of  the  disease  from  which  he  recovered 
completely.  During  the  illness,  when  aroused  for 
food  he  was  disorientated  in  time  and  space,  and 
had  a  tendency  to  get  out  of  bed  .  This  latter  effort 
would  last  about  five  minutes,  after  which  he  would 
become  somnolent  again.  Upon  recovery  from  the 
somnolence  and  when  eye  conditions  and  fever  had 
subsided,  his  mental  state  remained  unimproved, 
even  became  more  and  more  accentuated.  When 
he  was  able  to  be  about,  he  showed  a  hypomaniacal 
state,  restlessness,  talkativeness,  voracious  appetite, 
excessive  desire  for  smoking,  also  puerilism.  He 
talked  like  a  child,  laughed  at  the  most  insignificant 
remarks,  acted  in  a  silly  manner,  preferred  to  play 
with  children.  All  the  physical  symptoms  of  the 
encephalitis  had  disappeared,  but  the  mental  condi- 
tion was  persisting  five  months  after  onset  of  the 
illness.  The  patient's  personal  previous  history  was 
negative,  but  the  family  history  recorded  mental  dis- 
orders in  several  of  its  members. 

In  another  case,  that  of  a  man  thirty-nine  years 
of  age,  there  was  marked  depression  at  first.  The 
hopelessness  and  despair  expressed  by  the  patient 
gradually  led  his  physician  to  view  possible  melan- 
cholia, especially  when  the  patient  began  to  speak 
of  suicide.  Upon  examination  made  ten  days  later, 
the  writer  noticed  left  sided  ptosis,  right  sided 
internal  strabismus  and  actual  somnolence.  The 
latter  developed  after  the  phase  of  depression.  The 
patient  was  ill  for  nine  weeks.  As  soon  as  the 
lethargy  began  to  disappear,  the  former  depressive 
state  reasserted  itself.  Fifteen  months  after  the 
recovery  from  encephalitis  the  patient  was  still  in  a 
state  of  depression  with  suicidal  tendencies. 
Froment  and  Comte  (18)  report  a  case  which 
started  with  epileptic  seizures  of  Jacksonian  type 
and  delirium  with  visual  hallucinations.  Cortical 
involvement  is  here  evident. 

Cerebellar  type.  A  man,  aged  thirty,  after  having 
recovered  from  somnolence  in  encephalitis  showed 
the  following  symptoms  in  addition  to  oculomotor 
disturbances :  ataxic  gait  with  tendency  to  fall  to 
the  right,  right  hemiasynergia,  adiadochokinesia  on 
the  right,  pastpointing  on  the  right,  and  diminished 
patellar  tendon  reflex  on  the  right.  Eventually  the 
man  made  a  complete  recovery.  The  examination 
of  the  patient's  labyrinth  was  negative.  A  similar 
observation  is  reported  by  Achard  and  Leblanc  (19). 

Poliomyelitic  type. — Tilney  (20)  reports  the  case 
of  a  child  of  four  in  whom  prolonged  somnolence 
was  associated  with  acute  anterior  poliomyelitis. 
Such  combinations  are  rare,  nevertheless  they  show 
the  possibility  of  simultaneous  involvement  of  the 
spinal  cord  and  brain. 

Sensorial  type. — Amaurosis  and  deafness  have 
been  observed  in  some  cases  as  conspicuous  symp- 
toms. In  Vincent's  two  cases  and  in  Carnot's  case 
day  could  not  be  distinguished  from  night.  In  the 
former's  cases  there  were  achromatopsia  and  deaf- 
ness :  in  the  latter  case  the  amaurosis  subsided  a  long 
time  after  the  somnolence  and  at  the  same  time  the 
syndrome  of  bulbar  palsy  made  its  appearance  (21). 

Paraplegic  type. — Sicard  (22)  gives  the  history 
of  a  woman  who  at  first  had  an  attack  of  flaccid 
paraplegia  accompanied  by  retention  of  urine  and 


lethargy.  During  convalescence  muscular  twitch- 
ing and  rhjihmic  tremor  in  the  upper  extremities 
developed.  I  believe  that  there  was  simultaneous 
involvement  of  the  mesencephalon  and  of  the  spinal 
cord  with  its  roots  in  the  lumbar  region-.  . 

Incomplete  forms. — In  a  certain  number  of  cases 
the  triad  of  symptoms  has  not  been  complete.  Thus 
cases  have  been  reported  without  ophthalmoplegia 
or  without  lethargy-,  or  else  with  very  slight  somno- 
lence, and  finally  in  some  cases  there  was  little  or 
no  rise  in  temperature.  Abortive  forms  have  also 
been  reported.  In  a  case  under  the  writer's  observa- 
tion the  patient  had  a  slight  rise  in  temperature, 
general  malaise,  diplopia  in  looking  toward  the  right ; 
he  felt  drowsy  and  frequently  would  close  his  eyes. 
The  entire  condition  lasted  six  days.  Recavery 
was  complete. 

DIFFERENTIAL  DIAGNOSIS. 

In  making  a  diagnosis  of  encephalitis  lethargica 
one  should  bear  in  mind  the  three  fundamental 
symptoms,  ocular  palsies,  somnolence,  and  rise  in 
temperature.  It  may  be  of  interest  to  add  a  few- 
data  concerning  the  humors.  The  cerebrospinal 
fluid  is  usually  clear,  without  undue  pressure  and 
without  lymphocytosis,  and  these  negative  findings 
are  uniform  in  all  stages  of  the  disease.  Some 
observers,  however,  speak  of  a  lymphocytosis  in  the 
early  stages  which  gradually  diminishes  and  dis- 
appears. This  fact  is  important,  for  in  meningitis 
the  reverse  is  true  (23).  In  a  certain  number  of 
cases  the  spinal  fluid  contained  an  increased  amount 
of  sugar  (24).  In  Netter's  last  six  cases  there 
were  seventy,  eighty-five,  eighty-five,  ninety-five, 
eighty-three  and  ninety-seven  centigrams  to  the 
litre.  According  to  Benard  (25),  a  glucose  content 
of  0.67  to  1.06  gram  is  a  material  aid  in  the  diag- 
nosis. It  is  possible  that  the  richness  in  sugar  is 
due  to  the  irritative  process  in  the  medulla  in  which 
the  centre  discovered  by  Claude  Bernard  is  situated. 
In  meningitis,  on  the  contrary,  glucose  is  diminished. 
The  blood,  as  a  rule,  presents  no  appreciable  change 
in  numerical  count.  How-ever,  in  some  cases  a 
moderate  leucocvtosis  was  observed  (26). 

In  view  of  the  large  number  of  associated  symp- 
toms and  the  multiplicity  of  varieties,  the  diagnosis 
of  lethargic  encephalitis  is  sometimes  surrounded 
with  difficulties.  The  protean  character  of  the  dis- 
ease must  be  borne  in  mind,  as  grave  errors  of 
diagnosis  have  been  reported  and  very  serious 
maladies  have  been  overlooked. 

One  of  the  diseases  with  which  the  affection  under 
discussion  may  be  confounded  is  meningitis.  The 
above  mentioned  progressive  increase  of  lympho- 
cytes as  the  disease  advances  and  the  decreased 
amount  of  glucose  in  the  spinal  fluid  are  evidences 
of  meningitis.  In  the  tuberculous  form  of  the 
latter  somnolence  is  usually  present  but  the  abundant 
lymphocytosis  and  tubercle  bacillus  in  the  spinal 
fluid,  the  dissociation  of  temperature  and  pulse,  also 
the  irregularity  of  the  latter,  are  all  absent  in  leth- 
argic encephalitis.  In  cases  of  doubt  as  to  the  pos- 
sibility of  syphilitic  meningitis,  Wassermann  re- 
action, and  treatment  with  antiluetic  remedies  will 
ascertain  the  nature  of  the  condition.  Meningitis 
of  other  forms  w-ill  be  recognized  by  rigidity  of 
the  neck,  by  the  presence  of   Brudzinski's  and 


930 


GORDON 


ENCEPHALl  TIS  LETHARGIC  A. 


[New  York 
Medical  Jovrxal. 


Kernig's  signs,  retraction  of  the  abdomen,  dissocia- 
tion of  pulse  and  tempt rature,  and  finally  by  the 
state  of  the  spinal  fluid  (see  above),  Of  course 
the  observations  recorded  above  demonstrate  the 
fact  that  the  meningeal  manifestations  should  not 
be  taken  as  absolutely  final.  Epidemic  cerebro- 
spinal meningitis  is  characterized  by  a  cloudy  spinal 
fluid,  marked  leucocytosis  and  meningococci. 

The  English  writers  considered  the  first  cases 
observed  in  England  as  instances  of  botulism  in 
view  of  the  pronounced  asthenia  and  paralysis  of 
accommodation,  but  in  this  disease  there  is  usually 
a  dryness  of  the  throat  and  mouth,  with  thirst, 
obstinate  constipation,  and  extreme  dilatation  of  the 
pupil,  all  symptoms  which  are  wanting  in  encepha- 
litis. Besides,  fever  is  absent  in  botulism  and  there 
is  not  a  true  somnolence  but  a  rapid  coma. 

Lethargic  encephalitis  may  be  confounded  with 
hemorrhagic  superior  polioencephalitis,  but  the  latter 
runs  its  course  without  rise  in  temperature  and  is 
accompanied  by  marked  nervous  manifestations  in 
the  motor  and  sensory  spheres,  such  as  ataxia,  uni- 
lateral paralysis  of  the  extremities,  exaggeration  or 
abolition  of  tendon  reflexes,  disturbances  of  speech, 
deglutition,  and  mastication.  Finally,  there  are  grave 
ocular  lesions  (optic  neuritis,  nystagmus,  associated 
paralysis).  Tumor  of  the  brain  may  simulate  an 
encephalitis,  in  view  of  the  motor  disturbances  and 
the  drowsiness,  but  severe  headache,  vomiting,  optic 
neuritis,  or  atrophy,  or  papilledema,  are  encountered 
only  in  cerebral  neoplasms. 

Cerebral  abscess  may  also  simulate  lethargic 
encephalitis  because  of  the  somnolence,  but  the  eye 
ground  changes,  the  condition  of  the  blood,  slow- 
ness of  the  pulse  will  enable  one  to  recognize  the 
former.  Anterior  poliomyelitis  in  its  bulbar  and  - 
pontine  varieties  may  sometimes  give  the  impression 
of  encephalitis,  but  the  predilection  for  early  child- 
hood, its  occurrence  chiefly  in  warm  seasons,  absence 
of  meningeal  reactions,  paralysis,  and  atrophy  of  the 
afifected  extremities  due  to  serious  alterations  of 
the  cellular  elements,  are  all  characteristic  of  the 
former.  Encephalitis  attacks  adults  preferably, 
produces  but  slight  cellular  lesions,  and  is  usually 
of  a  more  favorable  prognosis. 

Intoxications  may  be  accompanied  by  a  state  of 
stupor  simulating  ietharg}\  The  mental  state  fol- 
lowing the  administration  of  opium  and  chloral  is 
analogous  to,  if  not  identical  with  that  in  encepha- 
litis. Uremia  and  diabetes  may  present  the  same 
picture. 

Narcolepsy  is  a  functional  nervous  disorder  which 
may  be  confounded  with  the  somnolence  of  en- 
cephalitis. It  is  to  be  borne  in  mind  that  narcolepsy 
is  a  manifestation  of  hysteria  and  may  be  removed 
by  suggestion,  psychotherapy,  or  psychoanalysis. 
Besides,  it  is  totally  free  from  organic  smptoms 
characteristic  of  encephalitis. 

Comatose  states  are  diflferentiated  frotri  encepha- 
litic  lethargy  by  total  loss  of  reaction  to  sensory 
stimulation,  while  the  essential  characteristic  of 
somnolence  in  encephalitis  consists  of  responsive 
reactions  to  stimulation ;  the  patient  can  be  aroused 
for  partaking  of  food,  and  to  answer  questions  asked. 
Besides,  profound  coma  is  associated  frequently 
with  conspicuous  motor  disorders  due  to  profound 


cerebral  lesions.  Neither  do  we  find  the  ocular 
disorders  characteristic  of  encephalitis. 

Stupor  due  to  cerebral  syphilis  may  present  great 
obstacles  in  formulating  a  diagnosis.  In  both  con- 
ditions we  find  somnolence  and  palsies  of  ocular 
muscles.  In  such  cases  we  must  recall  the  character 
of  the  somnolence  of  encephalitis.  In  syphilis  the 
stupor  is  continuous  and  if  the  patient  is  aroused 
the  mental  hebetude  is  pronounced,  the  patient  is 
unable  to  understand  fully  what  is  spoken  to  him. 
In  encephalitis  the  patient  answers  questions  cor- 
rectly and  takes  his  food  properly ;  in  other  words, 
there  is  comparative  mental  lucidity.  Finally,  the 
state  of  the  cerebrospinal  fluid  with  its  lymphocy- 
tosis and  positive  Wassermann  reaction  will  decide 
in  favor  of  cerebral  syphilis. 

The  modifications  in  the  clinical  picture  of  the 
disease,  thus  presenting  special  forms,  correspond  to 
the  many  variations  in  the  pathological  findings. 
The  clinical  polymorphism  finds  its  explanation  in 
the  anatomical  polymorphism.  Let  us  now  con- 
sider the  varieties  of  lesions. 

Grossly  speaking,  the  pathology  of  lethargic  en- 
cephalitis consists  of  inflammatory  degenerative 
processes  chiefly  in  the  midbrain.  Despite  the 
variability  and  irregularity  of  localization,  the  lesion 
predominates  in  the  cerebral  peduncles.  According 
to  Marie  and  Tretiakofif  the  locus  niger  is  most 
frequently  involved  (27).  As  to  the  lesions,  there 
is  essentially  a  perivascular  inflammation  with  all 
its  characteristics :  dilatation  of  the  blood  vessels 
with  cellular  infiltration,  occasional  rupture  of  the 
vascular  wall,  and  hemorrhagic  inundation  of  the 
adventitia  and  the  neighboring'  tissue.  Transuda- 
tion with  localized  edema,  especially  in  the  cortex, 
is  sometimes  seen.  The  cellular  infiltration  is  not 
confined  to  the  vascular  wall  and  very  frequently 
invades  the  gray  matter.  In  addition  to  the  inflam- 
matory process  there  is  also  a  secondary  destruction 
of  nerve  cells  and  fibres.  The  cells  present  all 
degrees  of  chromatolysis.  Neuroglia  cells  partici- 
pate in  the  pathological  process.  The  localization 
of  all  these  lesions  presents  all  degrees  of  chroma- 
tolysis. Neuroglia  cells  participate  in  the  patho- 
logical process. 

The  maximum  of  involvement  is  found  in  the 
gray  matter  of  the  aqueduct  of  Sylvius  and  the 
fourth  ventricle.  The  lesion  radiates  toward  the 
gray  substance  of  the  pons  and  medulla.  On  the 
other  hand,  it  may  reach  upward  to  the  basal 
ganglia,  viz.,  the  optic  thalamus  and  striate  bodies. 
The  nuclei  of  the  fifth,  sixth,  and  seventh  nerves 
are  sometimes  involved,  and  Marinesco  observed 
atrophy  of  the  dorsal  nucleus  in  the  pneuniogastric 
nerve.  In  the  cases  cited  above  the  ninth,  tenth  and 
twelfth  nerves  were  also  involved.  In  Marie's  and 
Tretiakoff's  cases  (27)  not  only  the  above  men- 
tioned structures  were  involved,  but  also  the  red 
nucleus,  interpeduncular  space,  the  tegmentum,  the 
locus  niger,  tile  floor  of  the  fourth  ventricle,  nuclei 
of  the  pons,  the  first  two  cervical  segments,  cerebral 
and  cerebellar  cortex,  finally  the  meninges  and 
ependyma  of  the  ventricles. 

We,  therefore,  see  that  the  pathological  condition 
is  vast  and  concerns'  particularly  the  entire  central 
nervous  system.    Of  course,  as  such  it  is  not  met 


December  11,  1920.] 


GRAHAM:   CUTAXEOUS  AXTHRAX. 


931 


with  in  all  the  cases,  but  the  distribution  of  the 
lesions  presents  great  irregularities.  In  pronounced 
or  generalized  cases,  the  entire  cerebrospinal  axis 
may  become  involved.  In  less  pronounced  cases  the 
lesions  are  distributed  in  the  pons  and  medulla,  in 
mild  cases  only  in  the  locus  niger  and  its  vicinity. 
There  is  also  a  large  number  of  intermediary  cases. 
The  polymorphous  character  of  the  anatomical  find- 
ings is,  therefore,  in  keeping  with  the  polymorphism 
in  the  clinical  picture.  The  distribution  of  the 
lesions  has  a  considerable  bearing  not  only  on  the 
diagnosis  but  also  on  the  prognosis.  The  knowl- 
edge of  the  state  of  reflexes  is  important  from  this 
viewpoint.  It  seems  that  abolition  of  the  tendon 
reflexes  (which  is  observed  in  some  cases)  with 
preservation  of  the  cutaneous  reflexes  shows  that 
the  disease  is  not  always  confined  to  the  bulbo- 
pontinepeduncular  region,  but  it  has  a  tendency  to 
become  diffuse  eventually.  Guillain  makes  an  in- 
teresting prognostic  observation  in  four  cases : 
precocious  abolition  of  tendon  reflexes  has  a  bad 
outlook,  as  all  the  patients  died.  In  two  cases  in 
which  the  reflexes  remained  normal,  the  patients 
recovered. 

Lethargic  encephalitis  is  a  protean  disease  with 
its  histological  characteristics  of  a  definite  type  but 
with  a  great  variety  of  localizations  throughout  the 
entire  central  nervous  system.  The  infectious  char- 
acter which  has  been  determined  presents  a  promis- 
ing field  in  the  domain  of  treatment  and  therefore 
of  prophylaxis.  In  view  of  continuously  accumu- 
lating data  the  final  word  is  approaching. 

REFERENCES. 

1.  Vox  Wiesxer:  Wieii.  Klin.  JVoch..  xxx,  933.  1917. 

2.  McIxTOSH  :  Report  of  Government  Board  of  London. 

1919.  p.  76. 

3.  Loewe,  Hirshfeld,  and  STR.\rss :  Journal  of  Infec- 
tious Diseases,  1919,  xx%',  p.  377. 

4.  Halbrox  and  Coudraix  :  Bull,  de  la  Soc.  Med.  dcs 
Hop.,  28.  June.  1918,  p.  692. 

5.  Page:  Gaz.  des  Hdpitau.r,  11,  p.  171.  1920. 

6.  GoRDOX :  New  York  Medical  Jourxal,  Mav  17.  1919. 

7.  Saixtox  :  Soc.  Med.  dcs  Hop.  de  Paris.  19'l8.  p.  424. 

8.  Brouardel,  Levaditi,  and  Forestier  :  Presse  Med., 
17.  1920,  p.  166. 

9.  Sicard:  Presse  Med.,  22.  1920,  p.  213. 

10.  GoRDOx:  Journal  A.  M.  A.,  October  1.  1910. 

11.  DuMOL.\RD  et  Aubry:  Presse  Med.,  17,  1920,  p.  166. 

12.  R.\therv  et  Bonxard:  Presse  Med.,  17.  1920,  p.  165. 

13.  Bassoe:  Journal  A.  M.  A.,  April  10.  1920,  p.  1009. 

14.  Marie  et  Levy  :  Soc.  Med.  des  Hop.  de  Paris,  26. 
March,  1920. 

15.  Tretiakoff  and  Bremer:  Soc.  de  Xeur.  de  Paris. 
July,  1929. 

16.  Salmoxt:  Presse  medicale,  17,  1920,  p.  165. 

17.  Sicard:  Presse  medicale,  17,  1920,  p.  166. 

18.  Fromext  et  Comte  :  Bull.  Soc.  Med.  d.  Hop.,  20 
April,  1920. 

19.  AcHARD  et  Leblaxc:  Soc.  Med.  d.  Hop.,  Mav  14. 
1920. 

20.  TiLXEY  :  Xeur.  Bull.,  vol.  i,  January,  1918. 

21.  VixcEXT  and  C.\rxot:  Presse  Med.  17.  1920.  p.  166. 

22.  Sicard:  Bull,  de  la  Soc.  Med.  des  Hop.,  February- 
27,  1920. 

23.  Achard  and  Widal:  Acad,  de  Med.  Leance  du  27, 
Januarj-,  1920. 

24.  Mestrezat   and   Dopter  :   Paris  Med.,   March  20 

1920,  p.  242. 

25.  Bexard:  Journal  A.  M.  A.,  vol.  xx,  1920,  p.  474. 

26.  Vaidya:  Lancet,  September,  1918,  p.  322. 

27.  M.\rie  and  Tretiakoff:  Ann.  de  Med.,  vol.  vii.  No 
1,  1920,  p.  1. 

1812  Spruce  Street. 


CUTAXEOUS  ANTHIL\X.* 
By  John  R.\n'dolph  Graham,  M.  D., 
New  York, 

Borough   Diagnostician,   Deoarrment   of  Health  of  the  City  of 
Xew  York. 

This  paper  will  deal  particularly  with  the  mani- 
festations of  anthrax  as  I  have  observed  them  in 
the  course  of  my  work  dtiring  the  last  few  years, 
and  let  me  say  at  the  outset  that  my  remarks  will 
be  confined  to  a  discussion  of  that  type  of  the  dis- 
ease known  as  ctitaneous  anthrax,  or  malignant 
pustule,  for  I  have  never  seen  a  case  of  the  internal 
variety,  variously  known  as  intestinal  mycosis, 
woolsorters'  disease,  and  splenic  fever.  Anthrax  is 
of  rare  occurrence  in  this  vicinity  and  heretofore 
the  mortality  has  been  very  high,  especially  in  cases 
involving  the  face  or  neck ;  but  in  spite  of  a  decided 
increase  in  the  number  of  reported  cases  during 
the  last  three  or  four  years,  methods  of  treatment 
adopted  and  perfected  within  this  period  have 
apparently  resulted  in  a  notable  reduction  in  the 
percentage  of  deaths.  It  has  been  my  unusual  good 
fortune  to  inspect  at  some  time  during  the  duration 
of  the  attack,  almost  all  the  cases  reported  to  the 
Health  Department  from  the  Borough  of  Man- 
hattan since  January,  1915;  also  occasional  cases 
prior  to  that  date.  It  seems  probable  that  neglect 
to  report  cases,  whether  deliberate  or  as  the  result 
of  failure  to  recognize  the  condition,  is  rare.  And 
even  thotigh,  now  and  then,  one  victim  may  die  with 
the  disease  incorrectly  diagnosed,  and  another  may 
recover  withotit  his  physician  going  through  the 
formalit}-  of  notifying  the  atithorities,  I  believe  that 
the  total  of  cases  on  file  at  the  department  approxi- 
mates very  closely  the  actual  number  of  infections 
that  have  been  incurred  here  in  the  period  mentioned. 

I  do  not  desire  to  burden  you  with  figures,  and  my 
only  offense  of  this  character  will  be  to  quote  statis- 
tics showing,  1.  the  incidence  of  known  cases  in 
the  whole  city  and  in  Manhattan  since  January  1, 
1915.  and,  2,  the  recoveries  and  deaths  from  the 
disease  during  the  same  period. 


Ji'hole  City  Manhattan  Rectn'eries  Deaths 


1915 

9 

4 

0 

9 

1916 

4 

2 

1 

3 

1917 

17 

8 

8 

9 

1918 

15 

10 

11 

4 

1919 

17 

10 

8 

9 

1920.... 

.  20 

13 

18 

o 

(To  Nov.  I.) 


My  acquaintance  with  anthrax  began  in  the 
autumn  of  1911.  A  patient,  who  was  a  delivery 
wagon  driver  by  occupation,  and  who,  incidentally, 
took  partial  care  of  his  horse,  came  to  see  me,  look- 
ing ill  and  thoroughly  exhausted.  In  reply  to  a 
question  as  to  what  ailed  him,  he  said  he  had  a 
"pimple"  on  his  arm,  which,  by  the  way,  is  the  usual 
description  of  the  aft'ection  offered  by  the  patient. 
The  mental  picture  afforded  by  the  subsequent 
examination  is  still  most  vivid.  On  the  ulnar  side 
of  the  left  forearm,  just  above  the  wrist,  was  a 
black  scab,  the  size  of  a  dime,  depressed,  craterlike, 
in  a  brawny  looking  inflamed  mass  about  four  inches 

*Read  before  the  Riverside  Practitioners'  Society  of  Xew  York, 
November   23,  1920. 


932 


GRAHAM:   CUTANEOUS  ANTHRAX. 


[New  York 
Medical  Journal. 


Fig,  1. — Striking    drawing    made  at 

bedside  of  patient  in  Bellevue  Hospital 

by  Dr.  Windom  Blanton,  of  Richmond, 
Va. 


in  diameter.    This  eschar  was  bordered  by  a  pus- 
tular rim  and  just  outside  its  edge  were  numerous 
little  vesicles  dotting  the  red  surface.    From  the 
finger  tips  to  the  shoulder  there  extended  a  huge 
edema,  the  limb  appearing  twice  its  normal  size,  and 
had  it  not  been 
for  the  angry  look 
of  the  centre  of 
infection  the 
whole  affair  would 
have  resembled  a 
dropsical  edema. 
The  man  said  that 
the  first  indication 
that  there  was 
anything  wrong 
had  appeared 
about  three  days 
before   in  the 
shape  of  a  trou- 
blesome burning 
sensation   on  his 
wrist ;    that,  al- 
though he  noticed 
a   pimple  had 
formed  and  was 
steadily  enlarging, 
it  had  not  bothered  him  specially ;  in  fact,  in  de- 
cided contrast  to  its  very  ominous  look,  it  was  not 
hurting  him  then.    A  head  had  developed,  how- 
ever, and  he  had  pricked  it,  thinking  it  a  small  boil. 
Following  this  operation,  the  process  had  spread 
with  such  rapidity  that  he  thought  it  ought  to  be 
treated.    Suffice  it  to  say  that  after  a  long  and 
serious  illness,  this  man  got  back  to  work,  though 
with  his  health  permanently  impaired  by  a  bad ' 
heart,  a  condition  which  developed  during  his  attack. 

I  confess  with  some  hesitation  that  I  failed  for 
some  time  to  recognize  the  true  nature  of  this  infec- 
tion, and  you  may  rest  assured  that  these  details 
have  not  been  recounted  for  the  purpose  of  glorying 
in  my  ignorance.  But  in  thinking  over  my  experi- 
ence in  this  particular  case  and  in  stu^iying  other 
attacks  of  a  similar  character,  two  things  have 
impressed  me  and  have  influenced  me  very  much  in 
preparing  this  paper.  First,  that  the  lack  of 
familiarity  with  the  appearance  of  this  lesion,  due 
to  its  rarity,  has  probably  resulted  in  others 
also  having  diagnostic  difficulties,  such  as  I  have 
confessed,  and  second,  that  inasmuch  as  the  infec- 
tion is  almost  invariably  far  advanced  when  the 
patient  first  . appears  for  treatment,  it  is,  generally 
speaking,  essential  to  a  successful  result  that  we 
identify  the  lesion  promptly  when  we  see  it,  and 
that  with  equal  promptness  we  institute  proper  treat- 
ment. This  last  point  is  put  forward  with  the  pro- 
viso, of  course,  that  we  accept  the  fact  that  treatment 
is  efficacious. 

It  will  not  be  amiss  to  say  tliat  very  few  doctors 
ever  see  a  case  of  this  disea.se.  An  incident  which 
in  a  way  bears  out  the  correctness  of  this  assertion 
occurred  in  an  Army  camp  in  1918.  Two  .soldiers, 
of  whom  I  shall  have  more  to  say  later,  were  sent 
to  the  Base  Hospital  infected  with  anthrax,  and  of 
the  threescore  or  more  medical  officers  stationed 
there  at  the  time,  it  appeared  that  but  two  had  had 


any  previous  experience  with  the  malady;  and  this 
is  probably  a  considerably  higher  proportion  than 
would  be  found  to  exist  among  the  profession  as  a 
whole.  On  the  other  hand,  this  lesion  is  so  unique 
in  appearance  that,  once  it  is  identified,  I  believe  it 
will  remain  fixed  in  the  mind's  eye  for  all  time. 

ETIOLOGY  AND  MODE  OF  TRANSMISSION. 

The  Bacillus  anthracis  is  the  causative  organism. 
It  uses  as  its  portal  of  entry  to  the  body  any  con- 
veniently placed  abrasion  of  the  skin.  Upon  its 
entry,  there  promptly  ensues  the  formidable  inflam- 
matory disturbance  originating  at  and  spreading 
from  the  point  of  inoculation,  and,  what  is  more 
serious,  if  the  infection  is  not  energetically  attacked, 
there  will  develop  later  an  overwhelming  bacteremia. 
I  am  told  that  it  is  comparatively  easy  to  find  the 
bacillus  in  smears  and  to  grow  it  in  cultures  taken 
from  the  pustule;  positive  blood  cultures  are, 
however,  obtained  only  in  cases  approaching  a  fatal 
termination.  The  bacillus  is  not  a  pus  producer  and 
is  itself  easily  killed,  but  its  spores  are  very  resistant 
to  heat  and  germicidal  agents.  I  should  say  possibly 
in  this  connection  that  the  fatal  attacks  are  generally 
those  in  which  the  face  or  neck  is  the  site  of  the 
lesion,  for  there  the  tissue  is  loose  and  elastic  and 
the  blood  supply  plentiful.  In  each  of  the  attacks 
which  I  have  personally  seen,  where  an  extremity 
was  the  part  involved,  the  patient  has  recovered. 

The  disease  is  most  often  found  in  those  engaged 
in  the  handling  of  horses,  sheep,  and  cattle,  in  fact, 
of  all  herbivorous  animals ;  also,  in  those  employed 
in  the  handling  of  the  hair  and  hides  of  such 
animals.  In  late  years,  it  has  become  a  well  recog- 
nized and  established  fact  that  shaving  brushes, 
especially  of  the  cheaper  sort,  may  and  frequently 
do  carry  the  infection.  The  resistance  of  the  spores 
to  measures  of  sterilization  already  mentioned  makes 
it  very  difficult  to  free  hides  and  bristles  from 
infection  without  at  the  same  time  ruining  their 
texture ;  and  this  fact  readily  accounts  for  the 
brushes  acting  as  carriers  of  the  disease.  An  inter- 
esting etiological  point  is  that  while  anthrax  is 
quickly  and  easily  transmitted  under  certain  condi- 
tions from  an  infected  animal  or  its  hair  or  hide  to 
a  human  being,  there  is  very  trifling  danger,  judging 
from  our  experience  here,  of  this  type  of  the  disease 
passing  from  man  to  man.  At  best,  human 
susceptibility  to  this  infection  appears  very  slight. 

SY  M  PTOM  ATOLOG  Y. 

The  incubation  period  is  short,  probably  less  than 
three  days.  The  primary  lesion  is  practically  always 
single  and  appears  on  an  exposed  portion  of  the 
body — the  face,  neck,  wrists  and  hands — with  the 
neighborhood  of  the  angle  of  the  jaw  the  most 
favored  point  of  attack.  Perhaps  to  be  quite  accurate, 
it  should  be  said  that  on  rare  occasions  there  may 
be  double  lesions,  though  always  in  the  same  locality, 
and  just  as  rarely  the  socalled  pustule  is  located 
elsewhere  than  on  the  parts  named.  The  patient 
will  state  that  the  first  evidence  of  infection  was  a 
slight  but  persistent  itching  or  burning  sensation  at 
the  point  of  inoculation,  which  is  probably  an  abra- 
sion resulting  from  a  scratch,  a  razor  cut,  or  other 
minor  injury.  Very  quickly  there  forms  on  this 
spot  a  tiny  papule,  no  larger  often  than  a  mosquito 


December  11,  1920.] 


GRAHAM:   CUTANEOUS  ANTHRAX. 


933 


bite  or  an  acne  lesion  and  causing  just  about  as 
much  discomfort  as  one  would  experience  from 
such  an  affection.  Little  attention  is  paid  to  it, 
though  in  a  few  hours  a  chill  or  at  least  a  chilly 
sensation  may  occur.  Some  time  after  this  chill, 
the  papule  develops  a  head,  the  contents  of  which 
may  be  either  hemorrhagic  or  vesicular  in  character. 
This  head  will  shortly  break  down  of  itself,  be 
opened  by  the  patient,  or  be  cut  in  the  process  of 
shaving.  On  its  destruction,  there  regularly  forms 
in  its  place  a  black  necrotic  eschar.  From  the  time 
of  its  appearance,  this  eschar  is  a  very  intimate, 
prominent,  and  ever  present  part  of  the  lesion  and 
it  adds  to  the  clinical  picture  a  diagnostic  point  of 
such  importance  that  we  may  well  pause  long 
enough  to  set  forth  the  following  facts  regarding  it : 
1.  It  is  purplish  black  in  color.  2.  It  appears  to 
be  set  into  or  framed  in  the  papule.  3.  Its  size 
may  vary  from  a  coffee  bean  to  a  silver  dollar.  4.  Its 
border  may  be  smooth  and  clean  cut,  or  serrated. 

5.  Its  contour  may  be  round,  oval  or  irregular. 

6.  It  may  have  a  pustular  rim,  which  is  not  infre- 
quently a  delicate  gray  line,  apparently  inlaid  be- 
tween the  scab  and  the  deep  red  tissue  outside  its 
border. 

I  return  to  the  consideration  of  the  papule  with 
the  remark  that,  while  in  its  early  state  it  is  cer- 
tainly insignificant  and  harmless  enough  in  its 
general  appearance,  this  is  no  longer  true  after  the 
formation  of  the  pustule  and  its  successor,  the 
eschar.  From  that  time  it  enlarges  very  rapidly 
until  it  becomes  an  irregular,  though  fairly  circum- 
scribed mass.  This  is  sometimes  tumor  like  and 
may  attain  the  size  of  a  hen's  egg,  but  more  often  it 
is  flat,  much  resembling  a  carbuncle  in  this  respect, 
with  its  elevation  above,  the  surface  scarcely  appre- 
ciable owing  to  the  adjacent  edema.  This  mass  is 
dark  red  'in  color,  firm  to  touch,  indurated  and 
brawny ;  altogether  a  thoroughly  vicious  looking 
affair.  When  incised  it  offers  almost  as  much 
resistance  to  the  knife  as  would  fibrous  tissue  and 
it  may  turn  the  point  of  a  large  hypodermic  needle 
with  ease.  When  the  disease  has  existed  three  or 
four  days,  at  which  belated  time  the  patient  usually 
seeks  the  advice  of  a  physician,  the  lesion  will 
have  lost  most  or  all  of  its  individuality,  by  having 
merged  itself  into  the  edematous  tissue  around  it, 
and  it  then  presents  to  the  eye  the  appearance  of  a 
more  or  less  diffuse  cellulitis.  The  eschar  sticks 
through  thick  and  thin,  and  will  be  found  embedded 
in  this  mass.  With  the  continued  advance  of  the 
disease,  the  induration  becomes  more  widespread 
and  the  redness  creeps  further  out  until  it  finally 
covers  the  whole  of  the  edematous  area. 

I  believe  that  the  most  striking  thing  about  anthrax 
is  the  edema.  It  starts  early,  very  soon  after  the 
papule  begins  to  assume  form :  it  spreads  rapidly 
and  its  extent  is  apparently  unlimited,  although  it 
must  depend  to  some  degree  on  the  laxity  of  the 
tissue  in  the  region  involved.  The  initial  lesion  is 
not  always,  in  fact,  I  think  not  often,  in  the  centre 
of  the  edematous  area,  and  the  edema  may  be  noted 
spreading  out  from  it  somewhat  in  the  same  manner 
that  erysipelas  spreads  from  the  point  of  inoculation. 
Perhaps  I  can  emphasize  how  impressive  this  edema 
often  is.  by  describing  a  case  seen  this  year. 


A  truckman  for  a  firm  dealing  in  hides  presented 
himself  at  one  of  the  hospitals  for  treatment.  He 
was  a  sorry  looking  spectacle.  (Fig.  1.)  The  left 
side  of  his  face  was  so  swollen  and  distorted  that 
he  hardly  looked  human ;  the  left  eye  was  closed  by 
great  edematous  eyelids ;  the  right  cheek  and  eyelids 
were  also  tremendously  puffed  up ;  the  lines  of  his 
neck  on  the  left  side  were  almost  obliterated  and 
an  enormous  edematous  collar  ran  most  of  the  way 
around  his  neck,  and  made  evident  pressure  on  the 
trachea.  The  edema  involved  besides  to  some  extent 
the  soft  tissue  in  the  pharj-nx  and  larynx,  though 
strangely  enough  in  this  case  it  hardly  lapped  over 
at  all  on  the  chest  wall,  as  so  often  happens  where 
there  is  a  cervical  lesion.  Though  he  had  been  ill 
but  three  days,  all  semblance  of  the  papule  had 
disappeared.  In  its  place,  there  was  a  good  sized, 
angry  looking  area  of  inflammation  below  and 
behind  the  left  ear,  with  the  smallest  eschar  I  have 
ever  seen  embedded  at  the  point  of  inoculation. 
There  were  no  difficulties  of  diagnosis  offered  by 
this  patient,  but  in  addition  to  illustrating  the  wide- 
spread area  which  can  be  covered  by  the  edema,  it 
showed  too  the  rather  startling  rapidity  with  which 
the  affection  can  develop.    You  may  be  interested 


Fig.  2. — Case  I.  (Published  by  courtesy  of  Dr.  Douglas  Symraers, 
Director  of  Laboratories  of  Bellevue  and  Allied  Hospitals.) 


to  hear  that  in  spite  of  the  critical  condition  and 
horrible  appearance  of  this  patient,  he  recovered  in 
due  time. 

To  complete  the  description  of  the  cutaneous 
lesion,  it  remains  only  to  mention  the  fact  that  an 


934 


GRAHAM: 


CUTANEOUS  ANTHRAX. 


[New  York 
Medical  Journal. 


indefinite  number  of  vesicles,  arranged  singly  or  in 
groups,  are  generally,  but  not  necessarily,  scattered 
over  the  inflamed  surface  of  the  mass  just  outside 
the  edge  of  the  scab.  They  have  no  connection  with 
the  actual  border  of  the  eschar,  which  you  will 
remember  can  be  pustular  in  its  makeup. 

The  lymphatic  glands  near  the  lesion  are  enlarged. 
There  is  a  leucocytosis,  sometimes  marked.  I  have 
read  of  cases  in  which  the  count  was  30,000  white 
cells.  Anders  and  Boston  in  M cdical  Diagnosis  give 
the  average  leucocytes  in  thirteen  cases  as  13,900. 
There  is  no  special  combination  of  constitutional 
symptoms  which  can  be  considered  as  regularly 
associated  with  anthrax,  nor  do  such  general  symp- 
toms as  are  found  bear  any  direct  relation  to  the 
virulence  of  the  attack.  The  temperature  may  be 
moderate  even  in  severe  cases ;  or  it  may  reach  106° 
or  higher.  The  pulse  is  usually  rapid,  but  I  have 
seen  wicked  attacks  in  which  the  rate  was  slow. 
The  patients  may  have  a  pasty  pallor,  but  they  rarely 
betray  by  their  appearance  the  severe  character  of 
the  infection  which  has  gripped  them.  There  is  one 
characteristic  feature  which  will  generally  be  found, 
namely,  marked  physical  weakness  on  exertion  in 
surprising  contrast  to  the  appearance  when  at  rest. 
The  patients  also  exhibit  mental  apathy  as  a  rule, 
are  easily  wearied  by.  questioning  and  often  act  as 
if  dazed,  though  even  in  fatal  cases  they  retain 
consciousness  to  the  end.  A  point  which  I  think 
is  significant  and  about  which  I  invariably  inquire, 
is  the  unanimity  with  which  these  patients  declare 
they  have  little  or  no  pain  and  I  have  no  doubt  that 
this  feature  of  the  disease  accounts  to  a  large  extent 
for  the  long  time  which  usually  elapses  before  they 
come  for  treatment. 

DIAGNOSIS. 

With  laboratory  facilities  available,  the  diagnosis 
can  generally  be  confirmed  in  a  short  time,  though 
once  in  a  while  the  bacillus  is  not  found.  I  believe 
that  in  view  of  the  rather  easily  recognized  earmarks 
shown  by  anthrax,  one  is  justified  in  most  cases  in 
basing  his  opinion  purely  on  clinical  evidence.  To 
wait  for  bacteriological  proof  is  a  doubtful  expedi- 
ent and  may  have  serious  consequences  for  the 
patient.  By  way  of  illustrating  the  futility  of 
depending  too  much  on  the  microscope,  I  am  led  to 
refer  again  and  more  in  detail  to  the  case  of  the  two 
soldiers  mentioned  in  passing  a  while  ago.  These 
boys  were  admitted  to  the  hospital  a  few  days  apart 
and  although  from  the  same  organization,  indeed 
from  the  same  tent,  they  were  unacquainted  with 
each  other,  the  second  man  having  been  mustered 
into  the  service  after  the  removal  of  the  first  man 
to  the  base.  Both  exhibited  a  typical  papule  at  the 
angle  of  the  jaw,  and  though  in  dilTerent  stages  of 
development,  the  lesion  in  each  case  was  surrounded 
by  considerable  edema.  They  complained  of  practic- 
ally the  entire  list  of  symptoms  enumerated  as  char- 
acterizing anthrax.  Furthermore,  the  first  patient 
stated  that  he  had  purchased  a  cheap  shaving  brush 
in  a  railroad  station  on  his  way  down  to  camp  and 
that  he  had  used  it  but  twice  when  he  began  noticing 
symptoms.  We  could"  never  actually  verify  it,  but 
there  was  ground  for  rather  more  than  a  strong 
suspicion  that  the  second  patient  had  found  this 
brush  and  had  ap])roprialed  it  for  his  own  use. 


The  point  v/hich  I  wish  to  emphasize  in  this  in- 
cident is  that,  notwithstanding  the  history  and  in 
spite  of  the  thoroughly  typical  picture  presented  by 
these  patients,  the  organism  was  not  found  in  the 
smear  or  culture  taken  from  the  lesion  in  either  case, 
and  so  they  are  not  mentioned  in  the  War  Depart- 
ment records.  But  in  the  minds  of  the  two 
physicians  at  hand  who  were  familiar  with  the  dis- 
ease, the  diagnosis  was  clear  beyond  the  shadow  of 
a  doubt,  and  the  fact  that  energetic  measures  of 
treatment  were  applied  at  once,  despite  negative 
findings,  was  I  believe  in  a  large  way  responsible 
for  complete  recovery  in  both  cases. 

Bearing  in  mind  then  that,  if  I  am  right  in  the 
opinion  just  expressed,  the  diagnosis  of  anthrax 
based  on  clinical  evidence  alone  is  not  only  feasible, 
but  as  a  rule  comparatively  simple,  let  us  review  the 
salient  points  in  the  rapidly  developed  picture, 
which  may  have  to  be  considered  in  arriving  at  our 
conclusion.  It  is  essential  as  a  preliminary  step  to 
ascertain  if  the  patient  was  employed  in  caring  for 
cattle  or  in  the  handling  of  their  hides  or  hair ;  or 
if  perchance  he  had  recently  used  for  the  first  time 
a  new  shaving  brush.  By  a  combination  of  ques- 
tions and  personal  observation,  we  will  learn  that 
the  first  evidence  of  disease  was  a  burning  or  itching 
sensation  at  the  point  of  inoculation ;  that  on  and 
around  this  point  there  developed  in  rapid  succes- 
sion a  small,  insignificant  papule,  then  a  much  larger 
papule,  then  a  mass  of  intensely  inflamed  tissue, 
fairly  circumscribed,  sometimes  tumor  like  in  form 
but  more  often  flat,  resembling  in  a  general  way  a 
carbuncle,  and  finally  a  dififuse,  indurated  cellulitis 
like  area  of  inflammation,  which  merged  itself  into 
the  encircling  edema  without  showing  any  distinct 
line  of  demarcation.  It  is  significant  too  that  with 
all  this  objective  display,  we  will  probably  be  told 
that  pain  is  negligible.  We  will  learn  further  that 
quite  early  the  papule  developed  a  hemorrhagic  or 
vesicular  head ;  that  this  quickly  ruptured  and  that 
its  place  was  taken  by  the  telltale  black  eschar.  Just 
outside  the  border  of  the  black  crust,  we  will  ob- 
serve in  most  cases  a  number  of  vesicles  scattered 
over  the  inflamed  surface,  singly  or  in  groups. 
Finally  we  will  note  the  edema,  which  in  all  likeli- 
hood will  literally  fill  the  eye,  and  we  will  be  told 
that  it  began  early  and  that  it  attained  its  present 
extensive  proportions  by  Steady  and  quick  progress. 

Having  touched  on  these  important  diagnostic 
points,  let  me  say  that  the  early  stage  of  the  disease 
is  likely  to  interest  us  only  from  the  viewpoint  of 
building  up  our  history,  for  it  is  seldom  that  we  see 
the  patient  until  the  disease  has  existed  at  least  three 
or  four  days.  At  this  period  of  the  attack,  I  think 
we  can  regularly  expect  to  find,  1,  a  large  area  of 
inflammation,  perhaps  circumscribed,  perhaps  dif- 
fuse, surrounding  the  point  of  inoculation  :  2,  a  black 
eschar  superimposed  on  that  point ;  and  3,  an  edema 
which  will  probably  be  farreaching  and  entirely  out 
of  proportion  to  the  cutaneous  disturbance  around 
the  focus  of  infection.  When  we  find  this  trio  of 
signs  associated,  we  can  be  certain  that  we  are  deal- 
ing with  anthrax.  Constitutional  symptoms  have 
not  been  dwelt  upon  here  for  they  aid  us  not  at  all 
in  making  a  decision. 

The  disease  can  be  differentiated  clinically  from 


December  31.  1920.]    REMER  AXD  WITHERBEE:  X  RAY    TREATMENT  OF  EPITHELIOMA. 


935 


carbuncle  by  the  lack  of  an  eschar,  the  absence  of 
extensive  edema,  the  less  marked  constitutional 
symptoms,  and  the  presence  of  cribriform  openings 
in  the  latter  affection.  To  mistake  it  for  a  syphilitic 
chancre  appears  far  fetched. 

TREATMENT. 

I  shall  mention  briefly  the  various  methods  of 
treatment  which  have  been  used  in  the  years  cover- 
ing my  familiarity  with  the  disease.  I  wish  it  to  be 
remembered  that  practically  all  that  is  said  in  this 
paper  is  based  on  personal  observation  of  this  affec- 
tion as  it  has  occurred  in  New  York  city,  and  while 
an  earnest  effort  has  been  put  forth  to  portray  accu- 
rately the  results  of  this  study,  no  claim  is  made 
that  every  case  of  anthrax  must  needs  accord  with 
the  picture  drawn  here  in  all  its  details.  In  fact,  in 
reading  papers  and  reports  by  men  who  know  the 
subject  in  other  localities,  one  is  impressed  with  the 
very  material  dift'erence  which  often  exists  between 
figures  given  by  them  as  to  the  incidence,  results 
of  treatment,  and  mortality  of  the  disease,  and 
similar  data  on  record  here.  It  is  fair  to  say,  too, 
that  not  a  few  good  men  scoff  at  the  idea  that  the 
treatment  of  anthrax  is  of  any  avail,  and,  be  it  said, 
we  now  and  then  see  a  patient  act  in  such  a  way  as 
to  make  us  think  their  opinion  may  be  correct. 
However,  after  following  up  a  considerable  number 
of  cases  and  after  talking  the  matter  over  with 
physicians  skilled  in  the  handling  of  the  disease, 
I  for  my  part  feel  that  it  is  hard  to  deny  that  treat- 
ment is  efficacious  in  the  face  of  the  increasingly 
satisfactory  results  which  follow  the  method  now 
in  vogue  here. 

Up  until  very  recent  years,  there  appeared  to  be 
no  uniform  opinion  as  to  the  proper  method  of 
attacking  the  lesion.  It  was  cauterized,  excised, 
incised,  poulticed  with  various  supposedly  curative 
applications,  or  left  alone,  and  truth  to  tell,  one  mode 
of  procedure  seemed  about  as  potent  as  another 
and  the  mortality  was  rather  appalling.  Some  time 
in  1916,  I  first  heard  of  the  use  in  the  treatment  of 
human  anthrax  of  the  serum  prepared  by  the  U.  S. 
Agricultural  Department  and  known  as  Eichhorn's 
serum.  The  method  then  followed  was  to  combine 
as  wide  an  excision  of  the  lesion  as  was  practicable, 
with  the  intramuscular  or  intravenous  injection  of 
the  serum  at  certain  intervals.  This  was  undoubtedly 
a  step  forward  and  was  signalized  by  an  improve- 
ment in  the  mortality  records.  However,  there 
was  certainly  a  question  about  the  propriety  of 
making  an  extensive  fresh  incision  in  this  danger- 
ously infected  area,  and  the  method  was  inadequate, 
too,  in  that  it  offered  no  relief  in  those  cases, 
frequently  seen,  where  the  inflammatory  infiltration 
of  the  tissues  was  so  widespread  as  to  make  an 
operation  out  of  the  question. 

About  two  years  ago,  Dr.  Joseph  C.  Regan  of  the 
Kingston  Avenue  Hospital,  Brooklyn,  evolved  a 
scheme  of  treatment  which  meets  effectively  the 
difficulty  in  such  cases,  but  which  is  applicable  also 
.to  any  surface  anthrax  lesion.  He  discards  entirely 
the  cutting  and  destructive  operations,  and  intro- 
duces the  antianthrax  serum  directly  into  the  body 
of  the  lesion  itself  by  means  of  several  small 
injections  around  the  periphery  of  the  eschar.  He 
uses  seven  to  ten  c.  c.  locally  once  daily  and  at  the 


same  time  administers  twenty  to  forty  c.  c.  intra- 
muscularly, or  intravenously,  if  the  bacillus  is  found 
in  the  blood.  At  Bellevue  Hospital,  where  this  idea 
has  been  put  into  erfect  in  a  routine  way,  they  have 
not  been  so  conservative,  for  there  they  have  used 
the  serum  intravenously  in  all  cases,  and  have 
repeated  the  doses  locally  and  in  the  vein  every  four 
hours  for  several  days  at  a  stretch,  without,  so  far 
as  my  knowledge  goes,  any  serious  or  even  espe- 
cially unpleasant  consequences.  The  results,  though, 
have  been  no  better  than  at  Kingston  Avenue. 

Let  me  say,  in  conclusion,  that  practically  all  the 
cases  this  year  have  been  treated  by  this  method ; 
furthermore,  they  have  been  as  serious  as  any  I 
have  ever  seen.  Then  let  me  ask  you  to  call  to  mind 
the  figures  on  recoveries  and  deaths  for  the  year, 
quoted  at  the  beginning  of  this  paper,  and  to  com- 
pare them  with  the  figures  for  the  preceding  years. 
When  you  have  done  this,  I  believe  you  will  agree 
that  if  we  have  not  attained  actual  perfection  in 
treatment,  we  are  at  least  making  progress  toward 
a  happy  solution  of  this  serious  problem. 

202  West  Eighty-sixth  Street. 


X  RAY  TREATMENT  OF  EPITHELIOMA 
WITH  THIN  FILTER. 

By  John  Remer,  M.  D., 
New  York, 
AND  W.  D.  W^itherbee,  M.  D., 
New  York. 

Filtered  x  ray,  from  the  viewpoint  of  dosage, 
requires  only  twice  the  time  for  a  given  number  of 
skin  units  at  full  distance  as  at  half  distance,  whereas 
in  unfiltered  dosage  four  times  the  time  would  be 
required  to  produce  the  s?me  effect.  This  was  exem- 
plified both  biologically  and  by  pastille  in  a  recent 
article  in  the  New  York  Medical  Journal  (1). 

The  results  in  the  treatment  of  basal  cell  epithe- 
lioma are  the  most  striking  and  encouraging  of  any 
of  the  cancerous  lesions,  the  reason  being  that  basal 
celled  epitheliomata  are  localized  lesions  and  not 
metastasizing  until  very  late  in  the  disease,  if  at  all. 
However,  cases  that  have  been  allowed  to  go  without 
treatment  until  the  disease  is  rather  extensive,  in- 
vading mucous  membrane  and  showing  marked 
induration,  do  not  always  do  well  with  routine  un- 
filtered treatment.  This  appHes  more  particularly 
to  the  ulcerated  type  of  epithelioma.  It  is  in  this 
class  of  cases,  as  well  as  in  recurrent  nodules,  that 
we  have  used  the  thin  filter.  The  lesion  and  from 
a  half  to  three  quarters  of  an  inch  of  surrounding 
skin  should  be  subjected  to  radiation.  The  rest  of 
the  surface  must  be  protected  by  lead  foil,  a  window 
being  cut  in  the  lead  foil  to  conform  to  the  condi- 
tions and  shape  of  the  growth. 

A  filter  of  one  quarter  of  a  millimetre  of  aluminum 
is  used,  the  factors  for  treatment  being  a  six  inch 
spark  gap,  five  milliamperes,  ten  inch  distance,  with 
a  time  varying  from  three  to  seven  minutes  (one 
and  one  half  to  two  and  one  half  skin  units), 
depending  on  the  severity  of  the  case. 

While  our  work  has  been  done  with  one  quarter 
of  a  millimetre  of   aluminum,   we  consider  this 


936 


MEYER:  ROENTGEX  DOSAGE  ESTIMATION. 


[New  York 
Medical  Journal. 


purel}-  arbitrary,  as  from  one  quarter  to  three  quar- 
ters of  a  millimetre  of  aluminum  may  be  used,  pro- 
vided one  and  one  half  to  two  and  one  half  skin 
units  of  filtered  ray  are  obtained.  Although  the 
number  of  cases  thus  far  treated  with  a  thin  filter 
have  been  somewhat  limited,  and  the  results 
obtained  are  not  of  long  standing,  we  are  using  this 
method  in  those  cases  that  do  not  do  well  with  the 
routine  unfiltered  method. 

The  advantages  of  filtered  x  ray  over  the  inten- 
sive dosage  of  unfiitered  x  ray  are:  1.  The  filtered 
dose  enables  one  to  repeat  the  treatment  in  from 
three  to  four  weeks,  preferably  three  weeks,  with- 
out causing  any  degree  of  local  reaction.  2.  These 
treatments  at  short  intervals  should  produce  more 
favorable  results  owing  to  the  direct  action  of  the 
ray  on  those  cells  which  are  undergoing  mitosis. 
In  other  words,  the  action  of  the  x  ray  on  embryonic 
cells  is  dependent  on  the  principle  that  the  cells 
during  certain  phases  of  mitoses  are  easily  destroyed 
by  moderate  amounts  of  x  ray.  Also,  as  the  cells 
are  constantly  undergoing  mitosis,  it  seems  reason- 
able that  more  cells  will  be  found  in  the  sensitive 
phase  and  destroyed  by  the  ray  when  applied  at 
more  frequent  intervals.  3.  The  size  of  the  dose 
in  filtered  x  ray  is  correspondingly  less  than  the 
unfiltered  and  would  tend  to  produce  less  severe 
reactions,  and  consequently  less  danger  to  the  eye  or 
any  other  sensitive  mucosa.  4.  This  method  is 
applicable  for  use  with  the  smaller  (2  kw.)  machine, 
which  is  commonly  used  in  superficial  or  unfiltered 
treatment. 

REFERENCES. 

1.  WiTHERBEE  and  Remer:  Filtered  X  Ray  Dosage,  New- 
York  Medical  Jourxal,  June  26,  1920. 

170  West  Fifty-xixth  Street. 
116  East  Fifty-third  Street. 


SUPERFICIAL  AND  DEEP  ROENTGEN 
DOSE  ESTIMATION. 
Abstract  of  Several  Lectures. 

By  Willi.\m  H.  Meyer,  M.  D., 
New  York, 

Director,    X    Ray    Department,    New    York    Post-Graduate  Medical 
School  and  Hospital. 

INIany  methods  of  superficial  rontgen  dose  esti- 
mation have  been  devised,  lengthy  descriptions  of 
which  exist  in  medical  literature  and  will  therefore 
be  omitted  here.  However,  three  important  facts, 
if  not  faults,  common  to  the  several  radiometers  are: 
First,  that  they  indicate  the  local  skin  erythema 
reaction  only,  and  give  no  clue  to  either  the  sub- 
cutaneous or  true  biological  effect ;  second,  that  the 
erythema  reaction  is  measurable  with  a  reasonable 
degree  of  accuracy  only  when  that  particular  ray 
quality  (penetration)  is  employed  for  which  the 
particular  instrument  was  graded  ;  third,  that  none 
of  the  meters  indicate  the  erythema  reaction  when 
variable  filter  thicknesses  are  employed. 

A  table  (Fig.  1)  is  here  appended  giving  the 
approximate  values  of  several  of  the  most  popular 
radiometers.  However,  at  the  risk  of  repetition,  it 
is  to  be  remembered  that  the  higher  the  penetration, 
or  the  stronger  the  filtration,  the  greater  is  the  neces- 
-sary  radiometer  reading  in  order  to  produce  an 


erythema ;  and  conversely,  the  lower  the  penetration 
(below  that  for  which  the  particular  instrument  was 
devised),  the  lower  the  numerical  reading. 

For  average  radiographic  purposes  with  unfiltered 


rays,  the  formula 


A  X  \'  X  T 
D- 


=  I  is  quite  satis- 


factory. To  be  sure,  some  variation  will  occur 
at  the  extremes  of  penetration,  due  to  change  in 
reaction  of  the  silver  salts  with  rays  of  varying  wave 
length.  On  the  other  hand,  this  formula  cannot  be 
strictly  applied  when  dealing  with  pastilles  in  rela- 
tion to  the  erythema  reaction.  Experience  has 
shown  that  employing  the  Sabouraud  scale  and 
varying  the  penetration,  for  example,  with  parallel 
spark  backups  of  four,  six,  and  nine  inches,  then 
an  erythema  would  obtain  at  readings  of  .8, — 1.,  and 
1.2, — tint  B  Sabouraud  respectively. 


Siiounu  d  Tint 
ini  Noire   A 

4 

HtltxknecM  ' 

0 

-r 

+ 

A 

Berdiet 

1 

- 

Hi mpsen  ' 

— 1 

1 

r. 

- 

1 

—r- 

1 

i 

K/en bocH 

_ 

— 1 — 

i 

t 

i 

r 

~ 

'  1 

Fig.  1. — Four  comparative  radiometer  values.  In  employing  the 
various  radiometers  it  is  important  to  use  that  tube  quality  for 
which  the  instrument  was  graded.  Only  und;r  these  conditions  are 
these  relative  values  correct.  An  e.vample  of  the  variations  that 
will  otherwise  occur  is  shown  in  the  last  column,  where  the 
various  readings  with  a  tube  of  high  penetration  are  given. 

A  graphic  illustration  of  these  variations  is  shown 
in  Fig.  2.  The  dose  time  for  an  erythema  reaction 
has  been  calculated  for  the  several  backups  ranging 
between  two  and  ten  inches,  with  a  fixed  skin  focus 
distance  of  seven  and  one  half  inches  and  with  the 
indicated  M.  A. 

For  an  explanation  of  the  aforementioned  ap- 
parent empiricism,  one  would  naturally  turn  to  the 
various  penetrometer  measures.  ' 

A  table  of  the  better  known  penetrometers  (Fig. 
3)  is  herewith  appended,  arranged  as  closely  as 
possible  to  their  relative  numerical  values.  In  look- 
ing over  these  scales,  one  notes  that  the  only  one 
of  the  older  methods  that  associates  penetration  and 
intensity  is  the  half  absorption  rate  of  Christen. 
Here  the  factors  are,  a,  incident  intensity ;  b,  one 
half  of  incident  intensity  or  the  transmitted  inten- 
sity through  ;  c,  various  thicknesses  of  a  substance, 
water  in  various  cm.  depths  (1),  in  order  to  show 
the  thickness  necessary  to  cut  the  intensity  in  half. 
In  other  words,  the  cm.  depth  of  water  necessary 
to  absorb  fifty  per  cent,  of  the  incident  beam. 

I  prefer  and  employ  a  fixed  thickness  of  sub- 
stance, usually  one  mm.  aluminum,  and  determine 
the  absorption  percentage  under  varying  conditions 
of  penetration  and  filtration.  This  is  accompli.shed 
with  two  rotating  (or  sliding)  rontgen  opaque  discs 
revolving  concentrically,  one  about  one  inch  larger 
than  the  other.  The  larger  is  about  three  inches 
in  diameter  and  has  a  half  open  section  cut  in  the 
periphery ;  the  smaller  has  only  a  quarter  section 
removed.  These  are  made  to  rotate  (or  slide)  in 
such  a  way  (the  smaller  at  one  half  the  time  of  the 


December  11,  1920.] 


MEYER:   ROEXTGEX  DOSAGE  ESTIMATION. 


937 


kv 

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t 

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-  1 

s.  Tin%&- 

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trith 

lor 

a. 

93 

T ' 

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f 

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— 1 — 

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H 

Fig.  2. — Photographic  and  pastille  intensity  vis  ervthema  reaction.  In  the  first  vertical  column  will  be  found  the  half  absorption  rate 
of  Christen  as  compared  with  the  kilo  volts  in  the  second  column,  and  the  parallel  gap  in  the  third  column;  the  square  of  the  gap 
is  shown  next  to  the  diagram.    Along  the  bottom  of  the  diagram  the  relative  intensity   values  are  given.     The  oblique  line  represents 

A  X  \-  X  T 

the   variations   in    photographic   intensity,    according   to   the    rule  =  I,    in    which    A    equals    quantity    expressed    in  milliam- 

peres,  V  equals  quality  expressed  in  the  square  of  the  spark  gap,  T  equals  time,  and  D  equals  distance.  The  curved  shaded  area 
represents  the  zone  of  erythema  reaction  in  relation  to  the  penetration  and  intensity,  but  with  the  latter  graded  according  to  the 
Sabouraud  scale.  In  the  last  columns,  the  milliamperes  and  minutes  time  for  an  erythema  reaction  with  unfiltered  ravs  and  various 
backups  are  given  calculated  from  the  chart.     These  figures  the  author    believes    the   maximum    with    which    present    day    tubes  should 

be  taxed,  and  then  only  when  good  cooling  conditijns  obtain. 


larger)  that  during  a  full  continuous  exposure  under 
the  outer  disc,  a  graded  exposure  from  0  to  full 
time  occurs  under  the  inner  disc.  The  percentage 
of  absorption  for  any  substance  of  a  given  thickness 
can  thus  be  determined.  Fig.  4  shows  the  author's 
penetrometer  or  absorption  meter  with  a  sketch  of 
the  result  obtained  with  a  tube  of  medium  penetra- 
tion.   We  can  also  gain  a  rough  idea  of  the  absorp- 

Jmt  fu.rK  eni 
Sp&rk  Gap  u>Air 


I lo -Volts 
B&uer 


den  0  is  t 

»^m.Al,  Am. 


denoist-lVAlier 


Walter 
Pt. 


Christen 
Abiorp  ti'en  % 


4n  r 


Fig.  3. — Comparative  penetrometer  values. 

tion  rate  with  the  preseni  day  radiometers.  If,  for 
example,  we  place  one  Kienbock  strip  or  Sabouraud 
pastille  over  a  mm.  thickness  of  aluminum,  and 
another  strip  or  pastille  under  the  aluminum ;  after 
exposure  at  standard  distance  we  would  have  the 
incident  dose  on  the  upper  and  the  transmitted  dose 
on  the  under  strip  or  pastille.  Thus  we  can  say 
that  the  incident  dose  minus  the  transmitted  dose 


equals  the  absorption  for  the  given  thickness  of 
substance. 

Notwithstanding  that  secondary  ray  effects  play 
a  part  in  the  transmitted  intensit\%  and  though  the 
character  of  the  rav  be  altered  bv  filtration,  it  still 


Fig.  4. — A. — Author's  absorption  penetrometer.  A  schematic  illus- 
tration of  absorption  penetrometer:  S,  Graded  sector,  to  read  in 
absorption  percent;  F,  fixed  segment  of  one  mm.  aluminum;  H, 
rotating  disc  with  half  section  removed  from  periphery;  Q,  disc 
rotating  at  half  time  of  H  with  quarter  section  removed  from 
edge;   M,  operating  mechanism;   L,  starting  lever;  cc,  clamps. 

remains  a  fact  that  the  absorption  as  indicated  by 
a  mm.  thickness  of  aluminum,  w-hen  taken  in  con- 
junction with  the  several  radiometer  readings,  gives 
a  close  index  of  skin  tolerance  or  the  er\-thema  dose. 
Due  to  the  difficulty  of  obtaining  standardized 


938 


MEYER:   ROENTGEN  DOSAGE  ESTIMATION. 


[\e\v  York 
Medical  Journal. 


materials  of  continental  origin  during  the  war,  the 
author  constructed  his  own  radiometer,  using  car- 
bon velox  paper.  The  standard  tint  was  graded 
in  one  tenth  erythema  dose,  using  unfiltered  rays 
with  a  tube  backup  of  six  inches,  the  maximum  tint 
equivalent  to  three  times   an   erythema  reaction. 

B 


Fig.  4.  B. — Author's  absorption  penetrometer,  presenting  a 
sketch  of  result  of  test  with  a  tube  showing  50  per  cent,  ab- 
sori)tion  in  one  mm.  aluminum.  The  outer  segment  of  even  shade 
is  the  uniform  exposure  obtained  under  one  mm.  aluminum.  The 
graded  shaded  inner  segment  has  been  produced  by  the  revolving 
double  discs  allowing  a  graded  exposure.  Exposing  from  full  time 
at  0 — to  nothing  at  100.  Where  the  shades  of  the  two  segments 
match  3  direct  reading  of  the  absorption  percent  can  be  obtained 
N.  B.  Any  thickness  of  any  desired  substance  can  be  substituted 
for  the  one  mm.  aluminum  above  used. 

The  double  strip  readings  were  used  to  determine 
the  absorption  percentage.  The  instrument  was  so 
constructed  that  a  direct  reading  of  the  total  cumu- 
lative absorption  was  possible. 

The  principle  involved  can  be  illustrated  as  fol- 
lows :  If  we  ray  through  a  filter  of  three  and  one  half 
mm.  of  aluminum  with  a  tube  backing  up  a  nine  and 
one  half  inch  parallel  gap,  until  a  photographic  strip 
shows  the  equivalent  of  10^'  Kienbock ;  then  a 
.second  strip  under  a  mm.  of  aluminum  (both  im- 
mediately under  the  first  strip)  would  register  8^. 
(Fig.  5.)  Further,-  if  we  accept  the  10^  as 
standard  for  surface  dose  measure  and  call  it  an 
incident  dose  of  one  hundred  per  cent.,  then  the 


rate  is  still  twenty  per  cent.  However,  if,  as  men- 
tioned above,  we  accept  the  10^  as  standard  repre- 
senting one  hundred  per  cent,  surface  intensity,  then 
the  difference  between  16^  and  20^  in  the  second 
example  will  represent  a  total  cumulative  time 
absorption  of  40. 

It  will  be  shown  that  an  erythema  reaction  re- 
quires a  total  cumulative  dose  time  absorption  of 
over  fifty  per  cent. ;  thus,  in  this  particular  example, 
the  uppermost  strip  musL  record  over  25  ^  and  the 
lower  strip  over  20^,  so  that  the  total  cumulative 
absorption  in  one  mm.  aluminum  exceeds  50. 

If  we  study  the  varying  absorption  with  tubes  of 
varying  penetration,  as  illustrated  in  Fig.  5,  and 
again  the  altered  absorption,  when  using  different 
filter  thickness  as  illustrated  in  Fig.  11,  then  one 
will  realize  the  futility  of  surface  dose  measure- 
ment and  the  advantage  of  the  far  more  accurate 
dose  estimation  by  total  cumulative  absorption. 

It  has  been  stated  that  the  erythema  reaction  is 
indicated  by  one  tint  B  Sabouraud  only  when  un- 
filtered rays  with  about  a  six  inch  backup  are  used.. 
Under  these  conditions,  the  absorption  in  one  mm. 
aluminum  approaches  fifty  per  cent,  of  the  incident 
beam.  It  will  also  be  seen  that  with  a  softer  tube, 
the  absorption  rate  rises,  and  that  less  than  a  pastille 
dose  is  required  to  produce  an  er>lhema.  Again 
with  hard  and,  above  all,  with  filtered  rays,  the 
absorption  rate  decreases,  whereas  the  number  of 
pastille  doses  necessary  to  produce  a  skin  reaction 
increases  markedly.  The  fact  to  which  I  wish  to 
call  attention  here  is  that  if  one  multiply  the 
absorption  in  one  mm.  of  aluminum  by  the  number 
of  unit  pastille  doses  necessary  to  produce  an 
erythema,  the  total  cumulative  absorption  in  the 
first  mm.  thickness  of  aluminum  invariably  approxi- 
mates 50.^ 

To  be  sure,  this  percentage  should  be  somewhat 
higher  when  strongly  filtered  rays  are  employed, 
since  with  such  rays  the  transmission  through  a 


cmDephIk 


5oit  Tube 


Pasti))e 


Sheufd  tead  shorl 


oyer 


60%  tn  the  l**c^ 


Medium.  Tube. 


/id-rd  Tube       I    H^rdjube  ! 

ir~*77      An  •9/7  ' 


reading  corr»ci  -^he^ild  r^ad  full 
erythema  reaction.  \under-iic3» 


Inc  ident% 


•tJJi  TiaiB 

Vilh  tujl  I Tm1B]£rythen<^  react, 
^ho   et-ythen*.      Tfe(} Hires  frf/ni 

J      ic3  T,-*  °  ' 


Fig.   5. — Schematic  illustration  of  llic  absorption  in  the  first  cm.  d.pth  of  tissue  in  relation  to  pastille  dose  and  the  actual  erythema. 


transmitted  dose  through  one  mm.  aluminum  equals 
eighty  per  cent,  and  the  absorption  equals  the 
difference,  or  twenty  per  cent. 

If  we  ray  further  until  the  strip  over  the  one 
mm.  aluminum  shows  20^,  then  the  strij)  under  the 
m-.,i.  will  register  16^.    To  be  sure,  the  absorption 


given  thickness  of  substance  is  more  uniform, 
whereas  the  maximum  absorption  in  the  superficial 
layers  is  most  pronounced  with  soft  unfiltered  rays. 

^An  indifferent  skin  surface  is  here  .suggested,  that  is,  the  skin 
of  the  back  or  an  extensor  surface.  The  skin  of  the  face,  neck, 
axilla,  uroin.  and  flexor  surfaces  generally  being  ni.ire  Stiisitive. 


December  11,  1920.] 


MEYER:   ROEXTGEN  DOSAGE  ESTIMATION 


939 


A  graphic  illustration  of  the  absorption  rate  with 
tubes  of  varying  penetration,  along  with  the  pastille 
dose  necessary  to  produce  an  erythema,  will  be  seen 
in  Fig.  5. 

Experimentally  and  in  practice,  it  is  a  fact  that 
if  to  human  skin  we  give  the  pastille  doses  with  the 
backup  and  filtration  indicated  in  Fig.  5,  an  ery- 
thema and  epilation  will  invariably  result. 

The  successive  steps  in  the  line  of  reasoning  thus 
far  are : 

1.  The  assumption  that  the  absorption  of  one  mm. 
aluminum  is  practically  equal  to  the  absorption  in 
one  cm.  of  water,  and  this  in  turn  is  approximately 
equal  to  the  absorption  in  one  cm.  of  human  flesh. 
Thus  the  absorption  in  one  mm.  aluminum  is  roughly 
equivalent  to  the  absorption  in  one  cm.  of  human 
flesh^  (2). 

2.  With  unfiltered  rays  and  a  medium  tube,  a 
pastille  dose  delivered  to  the  skin  will  result  in  an 
erythema  and  temporary  epilation  (Fig.  1),  as 
well  as  checking  the  function  of  the  sebaceous  and 
sweat  glands. 

3.  The  pastille  dose  achieved  with  a  medium  tube 
and  unfiltered  rays  shows  a  half  absorption  of  fifty 
per  cent,  in  one  cm.  of  Avater  (3).  This  in  turn  is 
roughly  equal  to  the  same  absorption  in  one  mm. 
aluminum^  (Fig-  3). 

4.  An  erythema  will  result,  irrespective  of  pene- 
tration or  filtration,  providing  the  total  cumulative 
absorption  exceeds  50  in  the  first  cm.  of  flesh  as 
measured  in  one  mm.  of  aluminum  (Fig.  5). 

5.  Since,  irrespective  of  penetration  or  filtration, 
a  cumulative  time  absorption  of  over  50  in  one  cm. 
of  human  flesh  produces  an  inhibitory  action  on  cells 
of-  special  function,  then  it  is  reasonable  to  assume 
that,  irrespective  of  depth,  the  metabolic  process  of 
radiosensitive  structures  should  be  subject  to  inhi- 
bition when  the  total  cumulative  time  absorption 
per  cent,  per  cm.  exceeds  50.* 

'  I  do  not  wish  to  affirm  that  .the  absorption  rate  in  the  first  cm. 
depth  of  tissue,  as  measured  in  one  mm.  aluminum,  is  an  absolute 
measure  of  skin  or  biological  reaction.  As  a  matter  of  fact,  the 
al)orption  iii  the  half  cm.  is  a  better  guide,  and  the  absorption  per 
mm.  depth  of  tissue  still  more  accurate.  However,  for  average  pur- 
poses, the  method  employed  has  proven  sufficient. 

»  If  one  will  study  the  ever  changing  absorption  in  the  first  cm. 
depth,  as  measured  in  one  mm.  aluminum,  even  with  fixed  backup, 
but  employing  various  filter  thicknesses  (Fig.  12),  one  will  realize 
that  no  such  single  rule  as  originally  devised  by  Wetherbee  and 
A  X  \'  X  T 

Remer,  i.e.,   =  I  can  apply,  excepting  in  a  single  specific 

D 

instance.  In  their  more  recent  communications,  this  has  perhaps 
inadvertently  been  admitted  by  the  injection  of  multiple  exceptions 
with  varying  filter  thicknesses. 

That  the  dose  time  for  an  erythema  reaction  is  shortened  by  sup- 
posed increased  penetration  with  unfiltered  rays,  is  due  to  the  fact 
that  the  whole  heterogeneous  ray  complex  is  increased  with  the  sur- 
face intensity,  varying  roughly  as  the  square  of  the  parallel  spark 
backup.  However,  as  shown  in  Fig.  2,  this  cannot  be  unconditionally 
accepted  as  the  measure  of  skin  reaction,  since  the  absorption  rate 
varies  with  change  of  backup.  Therefore,  surface  dosage  is  no 
more  an  index  to  erythema  reaction  than  either  of  these  is  to  the 
biological  reaction,  unless  considered  in  relation  to  absorption. 

*  From  some  fifteen  years'  experience,  I  have  arrived  at  the  fol- 
lowing conclusions:  a.  That  with  unfiltered  rays,  an  erythema  will 
result  with  a  dose  time  absorption  of  fifty  per  cent,  in  the  first  cm. 
of  flesh  as  measured  in  one  ram.  aluminum,  b.  That  with  filtered 
rays,  the  dose  time  will  have  to  be  continued  until  the  cumulative 
absorption  in  the  first  cm.  approximates  sixty  per  cent.  c.  If  a 
similar  reaction  is  desired  in  the  deeper  seated  structures,  the  ctimu- 
lative  absorption  will  have  to  be  somewhat  increased  because  of  the 
increased  filtration   produced  by  the  overlying  tissue  thickness. 

With  due  respect  for  the  opinion  of  such  investigators  as  Belot  (7), 
Speder  (8),  and  Regaud  (9),  there  are  others,  myself  included,  who 
believe  that  with  sufficient  dosage,  very  similar  skin  reactions  can 
be  brought  about,  be  the  radiations  soft  or  hard,  filtered  or  unfiltered, 
rontgen  ray,  or  radium. 

In  drawing  conclusions  from  measured  absorption,  it  must  be 
remembered  that  the  higher  the  penetration  and  the  stronger  the 
filtration,  the  less  the  superficial  absorption.  Therefore,  when  com- 
paring reactions  with  soft  and  hard  rays,  the  unit  of  measure  will 
have  to  be  exceedingly  small,  before  offering  too  definite  an  opinion. 


6.  a.  Experience  has  shown  that  less  than  a  pas- 
tille dose  with  unfiltered  rays  to  the  skin  is  stimu- 
lative in  action.  (For  mild  stimulation,  I  employ 
one  fourth  to  one  third  pastille  dose,  and  for  very 
strong  stimulation  from  one  half  to  two  thirds  pas- 
tille dose.  These  represent  respectively  a  total 
cumulative  absorption  of  fifteen  to  twenty,  and 
twenty-five  to  thirty-five  per  cent,  per  cm.  depth  of 
tissue.) 

b.  The  pastille  dose  with  unfiltered  rays  (repre- 
senting approximately  fifty  per  cent,  total  cumu- 
lative absorption  in  the  first  cm.)  is  the  erythema 
dose  and  generally  recognized  as  of  passing  inhibi- 
tive  action  to  cells  of  special  function. 

c.  A  double  pastille  dose  with  imfiltered  rays  has 
been  found  necessary  to  produce  a  more  profound 
inhibitive  action  with  retrogression  (McKee  and 
others)  ;  this  in  turn  equals  a  total  cumulative  ab- 
sorption of  about  100. 

d.  Complete  destruction  with  necrosis  will  occur 
with  from  two  hundred  to  two  hundred  and  fifty 
per  cent,  total  cumulative  absorption. 

The  lethal  dose  in  mahgnancy  has  been  variously 
estimated  at  from  one  and  one  half  to  fovir  skin 
doses.  I  believe  that  the  total  destruction  of  malig- 
nant tissue  should  be  the  aim ;  not  allowing  some 
cell  elements  to  remain  to  light  up  at  a  future  date. 
The  latter  has  all  too  frequently  been  the  case  where 
momentary  brilliant  results  have  been  obtained. 

To  summarize  rontgen  dosage  in  relation  to  the 
total  cumulative  absorption  per  cm.  depth : 


Action . 


Total  cum. 
absorption 
per  cent,  per 
cm.  depth. 

Biological 

effect 
Period  


Stimulative 
Mild  Strong 


Inhibitive 
Mod.  Prolonged 


10 
to 

20 


25 
to 
3S 


50 
to 
60 


100 
to 
120 


Destructive 
Total 

200 

to 

250 


Increased  metabolism 
Passing 

Repetition  of  dosage 
necessary  for  con- 
tinuation of  effect. 
Full  recovery  to 
normal  activity  in 
from  one  to  three 
months. 


Anabolic 

Prolonged  Catabolic 

Possible  recov-  Ulceration  and 

ery    in    from  necrosis, 

one   to   three  Slow  to  heal 

years.  with  scar  tis- 
sue formation. 


Since  under  varying  degrees  of  penetration  and 
filtration  and  for  deep  therapy,  the  present  day 
radiometers  do  not  indicate  the  various  reactions; 
and  since  the  total  cumulative  absorption  per  cm. 
depth  does,  then  this  is  the  logical  method  of 
dosimetry. 

Thus,  whether  the  lesion  be  superficial  or  deep, 
the  factors  to  be  determined  are :  First,  whether 
stimulation,  inhibition,  or  destruction  is  indicated ; 
second,  what  quantity  and  penetration,  filtration, 
distance  and  time,  and  in  deep  cases  what  number 
of  areas  for  crossfire  are  necessary  to  bring 
about  the  desired  total  cumulative  absorption  at  the 
site  of  the  lesion ;  third,  protection  of  normal  tissues 
as  far  as  possible  with  special  attention  in  deep 
cases  to  normal  skin  tolerance.  Every  means  at  our 
disposal  should  be  employed  to  arrive  at  a  correct 
diagnosis  with  a  definite  notion  as  to  the  location 
and  extent  of  the  lesion.  It  must  also  be  remem- 
bered that  along  the  path  of  a  single  beam  of  x  rays, 
various  reactions  may  occur.  Thus  we  may  have 
destruction  with  necrosis  at  the  skin  surface ;  imme- 
diately beneath  this  a  strong  inhibitive  reaction  may 


940 


MEYER:  ROENTGEN  DOSAGE  ESTIMATION. 


[New  York 
Medical  Journal. 


occur,  while  but  a  little  deeper  we  will  have  a 
stimulative  action  diminishing  as  the  depth  increases. 

Again,  at  the  same  plane,  all  three  reactions  may 
occur,  depending  upon  the  radiosensibility  of  the 
structures  involved.  From  observations  too  numer- 
ous to  mention  here  it  can  be  said  that  organs  of 
highly  specialized  function,  tissues  of  embryonal 
type,  young  or  rapidly  growing  structures,  multiple 
small  cells  with  large  nuclei  and  rich  in  chromatine, 
are  all  highly  radiosensitive. 

These  facts  are  so  closely  associated  with  high 
atomic  weight  and  specific  gravity,  that  a  chart  is 
herewith  appended  (Fig.  6),  and  it  appears  to  indi- 
cate that  the  higher  the  atomic  weight  and  specific 
gravity  of  a  living  structure,  the  greater  is  the  radio- 
sensibility. 

specific  Gravity 


2  High 

1.75  Bone — young 

Bone — old 

1.50 

1.25  Cartilage — young 

Cartilage — old 

1.1  Ovaries 

Skin 

Epithelium 

1.09  Glandular 

Red  blood  corpuscles  1  ;88 

Connective  tissue 
1 .08   Mucous  membrane 

Spleen 

Liver 

Kidney 

1.06  White   blood  cells 

Muscle 
Blood  1.062 
1.055 

1.05  Brain 

1.04 

1.03  Blood  serum  1.03 

1.025 

1.02 

1.00  Water 

Low  Fat 


Fig.  6. — Chart  showing  the  relation  of  radiosensibility  and  specific 
weight.  Tissues  and  organs  in  order  of  approximate  radiosensibility 
are:  Testicle,  ovary,  choroid,  thyroid,  intima  of  blood  vessels,  lymph 
glands,  epithelium  of  mucous  membrane,  hair  follicle,  glands,  and 
epithelium  of  skin. 

It  remains  then  to  determine  with  what  penetra- 
tion and  filtration  and  with  how  many  areas  the 
desired  total  cumulative  absorption  can  be  brought 
to  bear.  As  far  as  superficial  conditions  are  con- 
cerned, the  chart  in  Fig.  5  speaks  for  itself,  in  so  far 
that  in  lesions  so  located,  the  unfiltered  or  weakly 
filtered  ray  is  indicated.  The  more  superficial  the 
disease,  the  softer  the  ray  quality.  I  always  employ, 
however,  one  sixteenth  inch  of  pressed  fibre  as  a 
protection  from  heat,  light,  corpuscular  and  the  ex- 
tremely soft  rays. 

Our  greatest  difficulty  has  been  with  the  estima- 
tion of  deep  dosage,  and  rather  than  accept  mathe- 
matical conclusions  relative  to  absorption  at  various 
depths,  and  with  due  respect  for  the  elaborate  studies 
of  Guilleminot  (4)  along  the  same  line,  I  have 
preferred  my  own  data  drawn  from  experiments 
conducted  on  principles  similar  to  those  described 
by  Gaus  and  Tvembcke  (6). 

In  measuring  the  half  absorption  rate  by  the 
photographic  method,  as  illustrated  in  Fig.  4,  the 
penetration  appears  almost  double  that  shown  when 
using  either  the  pastilles  or  photographic  test  strips 
by  means  of  the  phantom,  as  illustrated  in  Figs. 
7  and  8.  There  is  a  very  close  association  between 
the  half  absorption  rates  of  Christen  (1  and  3)  and 
those  shown  in  the  table  of  Guilleminot  (4).  It 
is  quite  likely  that  secondary  ray  effects  may  be 


responsible  for  the  increased  absorption  shown  in 
the  upper  strata  in  the  method  employed  by  me. 
The  question  is,  Are  not  such  secondary  rays  ef¥ec- 
tive  in  the  body  as  well?  (5).  Be  that  as  it  may, 
the  area  selection  as  practised  here  shows  results, 
whereas  a  lesser  number  of  areas  of  crossfire,  as 
might  be  indicated  by  the  half  absorption  rate,  has 
in  our  hands  failed. 

The  method  of  carrying  out  these  experiments  is 
illustrated  in  Figs.  7,  8,  and  9.  In  Fig.  7  water- 
proofed photographic  strips  (or  pastilles)  are  ar- 
ranged vertically  at  cm.  spacings,  and  the  whole 
submerged  in  water.  After  exposure  the  intensity 
of  each  is  determined,  from  which  a  transmission 
curve  is  constructed,  such  as  those  illustrated  in 
Fig.  8.  The  result  of  such  an  experiment  is  illus- 
trated in  Fig.  9.  Here  the  Kienbock  strips  used 
lend  themselves  well  to  photographic  reproduction. 
The  distance,  depth,  and  transmission  rate  will  be 
noted  in  the  various  columns.  In  this  manner  the 
best  ray  quality  and  filtration  is  determined,  which 
gives  the  maximum  absorption  at  the  various  cm. 


Fio.  7.- — Measuring  transmission  (.schematic).  E  represents  a 
wooden  frame  so  notched  as  to  receive  the  Kienbock  test  strips,  in- 
dicated by  the  letter  A.  Each  strip  is  one  centimetre  lower  than  its 
immediate  predecessor.  This  frame  is  submerged  in  water  contained 
in  the  jar  D;  the  water  at  a  level  with  the  uppermost  strip  and  in 
close  apposition  with  the  filter  B. 


December  11,  1920.] 


MEYER:   ROENTGEN  DOSAGE  ESTIMATION. 


941 


depths.  From  many  such  experiments,  the  com- 
posite results  of  which  are  shown  in  the  charts  in 
Figs.  10  and  11,  the  final  chart  in  Fig.  12  has  been 
compiled.  On  the  surface  the  pastille  may  be  used, 
though  the  absorption  in  the  first  cm.  is  the  surest 
guide.  Below  the  surface,  be  the  depth  the  first  or 
the  tenth  cm.,  the  absorption  is  the  dose  measure. 

I  have  taken  as  standard  the  strong  inhibitive  dose 
as  represented  by  a  total  cumulative  absorption  of 
one  hundred  per  cent.  In  the  first  two  vertical 
columns  of  the  chart  in  Fig.  12  will  be  found  the 
skin  focus  distance  and  the  depth  below  the  skin 
surface  in  cm.  and  inches.  In  the  third  vertical 
column  the  most  desirable  filter  thickness  is  given, 
with  a  tube  of  the  indicated  hardness ;  the  absorp- 
tion rate  will  be  found  in  the  fourth  column,  and 
in  the  last  four  columns,  the  number  of  areas  for 
multiple  crossfire  will  be  found.  (The  oblique  line 
roughly  indicates  the  dividing  line  between,  under 
and  over  skin  reaction.  Thus  in  the  third  column 
we  expect  an  erythema.)  Using  a  hypothetical 
example,  if  we  had  a  lesion  situated  at  about  the 


Deph 


th  em. 


lenbock 


Fig.    8. — Measuring    transmission    (actual    testing  conditions). 

fourth  and  fifth  cm.  depth  in  which  a  strong  in- 
hibitive action  was  desired,  yet  a  skin  reaction  was 
not  justifiable,  then  the  most  desirable  filter  thick- 
ness would  be  three  to  four  mm.  aluminum  and  the 
number  of  areas  with  maximum  safe  dosage  would 
be  five  to  six,  found  in  the  double  pastille  dose 
column. 

It  is  evident  that  each  area  must  be  large  enough 
to  include  the  whole  of  the  lesion,  and  the  direc- 
tion and  depth  reasonably  correct.  The  most  fre- 
quent causes  of  error  with  a  technic  as  accurate 
as  the  foregoing,  are  incorrect  diagnosis,  and  faulty 
posture  ;  thus  failure  to  obtain  the  proper  total  cumu- 
lative absorption.  Fortunately,  I  have  had  the 
opportunity  to  put  the  foregoing  to  practical  test 
and  am  ready  to  report  numerous  cases : 

1.  As  illustration  of  superficial  dose  estimation 
by  absorption,  one  hundred  consecutive  cases  of 


Hard  tuie 
Filter  3^J^ 

Fig.  9. — Transmission  curves,  witli  varying  [jcnetration  and  with 
filtration. 

epithelioma  and  rodent  ulcer  and  chronic  ulcerating 
warts  and  moles  (malignant)  successfully  removed 
within  a  period  of  one  to  two  months  following 
a  single  application,  with  but  a  single  recurrence 
within  a  period  of  three  years.  2.  As  illustration 
of  deeper  dosage  estimation,  one  hundred  consecu- 
tive cases  of  hyperthyroidism  and  thymic  enlarge- 
ment, with  clinical  cessation  of  symptoms  in  every 
case.  3.  As  illustration  of  deep  seated  conditions, 
twenty-five  consecutive  cases  in  which  complete 
amenorrhea  was  produced  in  a  single  sitting.  Also 
a  similar  number  of  cases  of  splenomegaly,  lym- 
phoma (Hodgkin's  disease),  etc.,  with  disappearance 
of  the  mass  in  from  one  to  three  months. 

Other  conditions  treated  and  the  classification 
employed  are  as  follows : 

1.  Mild  stimulation:   Superficial   skin  lesions — - 

Ti-inS  missicn.  R&te  tvithaut  and  tfith  filtrst  ion 

Cool  id  ge  Tu  he-  Broad  focus 
Fi'liment  3.9-Antp's.       Pant,  dp  9^'*  (Paints 
Rhcoitii    7  Bulhn       /d'h-ynlti  9r 
JnducUn<.e/9:/>y.3JX       B»uer  SMBent'iSt) 


Foe  A  I 


k  i  e  n.}b  o  c  k  Xilmts 


\Dcpnth, 


Fig.  10. — Transmission  rate  without  and  with  filtration  (Kienbock 
test  strips).  The  result  of  two  experiments  carried  out  as  de- 
scribed and  shown  in  Figs.  7  and  8.  Experiment  A,  with  no  filter. 
Experiment  B,  with  filter.  The  two  central  columns  are  the  Kien- 
bock strips;  the  columns  on  either  side  of  the  strips  represent  the 
approximate  Kienbock  readings;  the  column  to  the  extreme  left, 
the  strip  focus  distance;  the  column  to  the  extreme  right,  the  centi- 
metre depth  of  the  strips  in  water.  The  comparative  tints  of  the 
transmitted  intensity  of  both  tests  is  clearly  shown;  the  marked  im- 
provement with  the  filter  is  quite  evident. 


942 


MEYER:  ROENTGEN  DOSAGE  ESTIMATION. 


[New  York 
Medical  Journal. 


Time. 


Filter 


iiiii*>,i>i 
mi9t  A  I. 


Tube     i¥igh     Penetration  "^M/.r 
Fo  c  a)      Pis  fane,  e  J9 


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I.I 


ll-" 


5.5^ 


4.S~ 


J.  7 


1.3 


I  - 

-.9 


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JJL 


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30" 


Suria.ce.  Dose.  /O^  K-ien  hoc  k 


6.6 


3. 


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I. 


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a.  I 


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a.  I 


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i.c 


Fig.  11. — Table  of  transmission  rate. 

chronic  ulcer,  eczema,  seborrhea,  psoriasis,  lichen, 
prurigo,  syphilides,  and  acne  vulgaris. 

2.  Strong  stimulation:  a.  Superficial — tubercu- 
lides, lupus  vulgaris,  sycosis  (nonparasitic),  fissure," 
leucoplasia,  neurodermatitis,    b.  Deep — tuberculous 


•  0 

I'X 

Jl^3 

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Surf,: 

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n  boc  k 

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XS% 

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1  itrge,  /igures  «/•(  tj.'i«tf«<  aiscrptttn 

i 

J"- 

T,„t         J  I.I-  1^1  i 

Fig.  12. — Table  of  absorption  rate  in  various  cm. 
various  filters  and  high  penetrating  rays. 


3i 

depth  with 


(adenitis  and  lung),  anemia  (pernicious),  lymph- 
adenitis, leucemia,  neuritis,  arthritis  deformans. 

3.  Moderate  inhibition:  Superficial — trichophy- 
tosis, sycosis  (parasitic)  hyperidrosis  and  bromi- 
drosis,  pruritis,  superficial  nsevi. 

4.  Strong  inhibition  (with  filtration)  :  a.  Super- 
ficial— keloid,  njevi,  hypertrichosis,  b.  Deep — men- 
orrhagia,  metrorrhagia,  myoma  uteri,  prostatic  hy- 
pertrophy, goitre  (hyperthyroidism),  lymphoma, 
Hodgkin's  disease,  splenomegalj',  thymic  hyper- 
trophy. 

5.  Destruction:  a.  Superficial — verrucse,  moles, 
epithelioma,  rodent  ulcer,  b.  Deep — carcinoma,  sar- 
coma. 

COXCLUSIOXS. 

Well  cognizant  of  the  fact  that  certain  structures, 
both  normal  and  pathological,  show  a  pronounced 
radiosensibility,  yet  in  connection  with  the  absorp- 


=<T  J 

Fc^AlDiihiKt  dtp  9'* 


fihrnhtr  otAretS  *■  Surf  an* 
m  rATim  am  t/*ph1k^ 


1  — Table  of  deep  dosage 


estimation  and  area  computation. 


tion  in  one  cm.  of  flesh  as  measured  in  one  mm. 
aluminum  with  present  day  apparatus,  the  following 
conclusions  are  justifiable: 

That  a  total  cumulative  absorption  percentage  of 
thirty-five  or  less  is  stimulative  in  action  (increased 
metabolism) . 

That  a  total  cumulative  absorption  of  plus  fifty 
is  mildly  inhibitive  in  action  to  radiosensitive  struc- 
tures. 

That  a  total  cumulative  absorption  of  one  hundred 
produces  strong  inhibition  with  retrogression. 

That  a  total  cumulative  absorption  of  plus  two 
hundred  is  catabolic  in  action  with  retrogression 
and  necrosis. 

That  any  of  these  effects  may  be  produced  at 
will  within  the  first  half  cm.  depth  of  tissue. 

That  as  a  rule  only  the  first  three  reactions  can 
be  brought  to  bear  below  the  first  cm.  depth,  with- 
out producing,  at  the  same  time,  total  skin  destruc- 
tion. Therefore,  with  wide  spread,  deep  seated 
lesions,  besides  stimulation,  an  inhibitive  dose  is 
frequently  all  that  can  be  hoped  for. 

From  these  conclusions  I  wish  to  go  on  record 
as  stating,  without  reservation,  that  any  superficial 
malignancy  can  be  destroyed ;  and  that  with  the  early 


December  11,  1920.] 


MEYER: 


ROEXTGEX   DOSAGE  ESTIMATIOX. 


943 


cases  a  far  better  cosmetic  result  can  be  obtained 
with  radiant  energy  than  with  any  other  procedure, 
and  this  without  pain  or  inconvenience  and  fre- 
quently within  one  month  following  a  single  treat- 
ment :  and  that,  when  properly  applied,  recurrence 
within  three  years  is  rare.    Therefore,  any  case  of 


Fig.  14. — Three  large  and  satisfactory  areas  for  crossfire  of  the 
pelvic  viscera.  It  will  be  noticed  that  each  area  is  sufficiently  large 
to  include  practically  the  whole  of  the  true  pelvis. 

threatened  superficial  malignancy  should  receive  the 
benefit  of  such  procedure,  and  this  in  preference  to 
the  knife,  caustics,  freezing,  or  any  other  method, 
since  our  most  difficult  cases  have  been  those  sub- 
ject to  such  previous  interference. 

On  the  other  hand,  as  far  as  I  am  aware,  in  few 
bona  fide  cases  of  deep  seated  malignancy  have  the 
patients  been  reported  as  having  been  cured  and 
remaining  alive  and  well  for  a  minimum  period  of 
three  years.  This  may  partly  be  explained  by  the 
fact  that  as  a  rule  the  radiologist  does  not  see  cases 
of  malignancy  until  every  possible  surgical  procedure 
has  been  attempted,  and  the  patient  is  practically 
moribund  when  presented  for  treatment.  There  is 
not  the  least  doubt  that  in  many  cases  of  malig- 


Fig.  15. — Correct  and  faulty  technic.  The  usual  errors  that  oc- 
cur by  using  too  small  areas,  or  by  incorrect  focusing.  In  the 
mesial  abdominal  section  the  heavy-  lines  from  target  to  patient 
show  the  advantage  of  the  large  area  as  compared  with  the  small 
cone  of  dotted  lines  representing  a  smaller  diaphragm  or  area.  The 
failure  to  include  all  the  viscera  one  desires  to  affect  is  illustrated 
by  the  dotted  lines  in  the  transverse  section.  It  will  be  seen  that 
by  incorrect  focusing  or  too  great  a  focal  distance  even  with  the 
same  sized  diaphragm,  certain  pelvic  organs  will  not  be  included 
in  the  given  exposure. 


nancy  the  patients  have  been  improved  (12  ).  Hem- 
orrhage can  be  controlled,  foul  discharge  reduced, 
pain  relieved,  ulcers  made  to  film  over,  and  occa- 
sionally by  shrinking  and  retrogression  (13),  an 
otherwise  hopeless  case  may  be  brought  within  the 
pale  of  operative  intervention.  Again,  experience 
has  shown  that  both  preoperative  and  postoperative 
radiation  are  indicated. 

Though  the  present  outlook  in  these  cases  of  deep 
seated  malignancy  is  not  over  promising,  yet  I  am 
far  from  giving  up  hope  in  regard  to  rontgen  treat- 
ment. The  road  to  complete  success  appears  to 
lead  along  the  lines  above  described — not  in  the 
excessively  filtered,  over  penetrative  and  scanty 
gamma  rays  (10),  for  these  lack  both  intensity  in 
quantity  (11)  and  absorption,  and,  as  a  matter  of 
fact,  excepting  perhaps  in  the  hollow  organs,  noth- 
ing has  as  yet  been  accomplished  with  radium  that 
has  not  been  done  before  with  the  x  rays.  There- 
fore, in  apparatus  of  greater  capacity  and  tubes  to 
stand  the  output  that  we  may  have  quantit}-  ( 14) 
and  penetration  plus  absorption,  lie  the  future  and 
hope  of  rontgen  therapy. 

REFEREXCES. 

1.  Christen:  Fortschritte  auf  dem  Gebiete  der  Ront- 
gentlierapie.  Band  15. 

2.  Perthes  :  Fortschritte  auf  dem  Gebiete  der  Rontgen 
Strahlen,  Band  8,  1905. 

3.  Christen  :  Miinchner  medisinische  Wochenschrift, 
1911,  Nr.  37. 

4.  Guillemixot  :  Rayons  X  de  haute  penetration  ob- 
tcnus  par  filtrage.  Leur  advantage  en  radiotherapie  pour 
le  traitement  des  tumeurs  profondes.  Complete  rendues, 
1909,  vol.  i,  p.  186.    Rayons  X,  p.  153.  ■ 

5.  Barkla  :  Philadelphia  Magazine,  16,  1908,  pp.  550- 
580. 

6.  Gaus  and  Lembcke  :  Rontgen  ticfcn  therapic. 

7.  Belot:  Archives  d'electrique  medicale,  1910.  p.  161. 

8.  Speder:  Ibid,  1911. 

9.  Regaud  and  Nocier:  Ibid.,  vol.  xxii,  1913,  pp.  49  and 
97. 

10.  Russ:  Journal  Rontgen  Society,  1912,  p.  38, 

11.  E\-e:  Philadelphia  Magazine,  1912,  p.  683. 

12.  CoxTAMix :  Compt.  rend.  Academie  des  Sciences. 
June  6.  1910. 

13.  Cluxet,  Ral'lot,  and  Lapoixte  :  Clunet's  Tumeurs, 
Malignes,  1910, 

14.  NoGiER  and  Regaud  :  Compt.  rend.  Academic  des 
Sciences,  June  8,  1914. 

15.  Meyer,  William  H.  :  New  York  Medical  Tourxal, 
November  3,  1917,  and  January  24,  1920. 


Duality    of    the    Syphilitic    Virus.  —  Milian 

(Presse  medicale,  June  19,  1920)  believes  in  the 
duality  of  the  germ  of  syphilis.  In  fact,  he  thinks 
distinction  of  tissues  as  regards  the  germ  may  be 
pushed  still  further,  i.  e.,  that  some  of  the  germs 
have  an  affinity  for  bones,  others  for  the  arterial 
system,  etc.  To  induce  tabes  or  general  paralysis 
it  is  not  sufficient,  however,  that  the  germ  be  neuro- 
tropic. In  tabetics  gummata  are  not  ordinarily 
seen ;  leucoplasia,  on  the  other  hand,  is  frequent. 
Tabes  and  leucoplasia  are  affections  of  the  same 
order,  due  to  a  germ  of  the  same  nature.  Thus, 
it  is  not  merely  the  factor  of  tissue  tropism,  but 
also  that  of  special  virulence,  which  make  for  re- 
sistance of  the  disease  to  treatment.  Inoculation  of 
leucoplasia  tissue  into  the  testicle  of  the  rabbit 
produces  lesions  similar  to  those  which  Levaditi  ob- 
tained with  the  blood  of  cases  of  general  paralysis. 


944 


LLOYD:  CAMPIMETER  SLATE. 


[New  York 
Medical  Journal. 


THE  STEREOSCOPIC  CAMPIMETER 
SLATE. 

Demonstration  at  the  New  York  Ophthalmic 
Hospital  During  the  Clinical  Congress. 

By  R.ALPH  I.  Llo\t),  M.  D.,  F.  A.  C.  S., 

Brooklyn,  X.  Y. 

If  one  gazes,  without  deviation,  at  a  certain  point, 
there  is  for  each  eye  a  surrounding  area  within 
which  one  is  able  to  recognize  colors  and  objects. 
Each  color  has  a  field  of  different  size ;  white  is  the 
largest,  extending  55°  above  the  fixing  point,  60° 
internal,  70°  below  and  90°  external  to  this  same 
point.  Blue  has  a  field  somewhat  smaller  than 
white,  red  is  smaller  than  the  blue,  and  green  is  the 
smallest  field  of  all.  Visual  acuity  is  not  the  same 
throughout  the  field,  neither  are  the  functions  of 
the  field  the  same  in  all  parts.  A  diagram  may  be 
made  to  show  how  the  visual  acuity  at  the  periphery 
is  almost  zero  and  increases  as  we  approach  the 
fixing  area ;  so  the  diagram  appears  like  a  high 
mountain  with  steep  slopes  on  either  side.  A  fonn- 
ula  has  been  oft'ered  to  represent  the  rapid  shading 
ofT  of  visual  acuity  as  we  pass  from  the  centre 
toward  the  periphery.  Representing  perfect  cen- 
tral visual  acuitv  as  one,  the  vision  at  anv  deejee 
may  be  roughly  estimated  by  dividing  one  by  the 
distance  from  the  centre  multiplied  by  three,  one 
divided  by  three  n:  (n  equals  distance  from  centre). 
The  functions  of  the  re'tina  in  different  parts  are 
also  of  interest  and  have  a  direct  bearing  upon  the 
topic. 

The  central  area  is  especially  fitted  for  reading  and 
noting  fine  detail  and  is  practically  vision,  as  it  is 
usually  understood.  Vision  of  detail  and  a  good 
part  of  color  vision  are.  located  in  the  small  central 
area.  Without  these,  one  is  practically  blind  as  we 
can  easily  understand  if  detail  is  eliminated  from 
ever\-thing  we  look  at  and  mass  vision  substituted. 
To  be  sure,  the  individual  if  afflicted  in  this  way, 
would  not  bump  into  objects  or  persons  as  he 
walked  along,  even  in  strange  places,  but  over  the 
centre  of  the  precise  place  where  his  •  vision  was 
directed  for  obtaining  an  exact  visual  impression, 
would  be  a  vacancy.  He  would  know  that  large 
objects  were  round  about  him,  would  know  just 
where  to  put  his  feet  and  where  not  to,  would 
know  whether  the  sun  shone  or  not  but  could  not 
read  or  obtain  visual  impressions  except  in  mass 
form.  His  color  vision  would  be  defective  also. 
But  if  there  was  a  movement  at  the  side,  he  would 
be  instantly  aware  that  something  was  going  on 
there  and  would  involuntarily  turn  his  eyes  as  had 
been  his  habit  and  must  be  the  habit  of  all  man- 
kind, to  have  the  image  of  the  area  whence  came  the 
movement  fall  upon  the  central  area,  which  would, 
if  normal,  give  him  all  the  detail  of  the  small  field 
upon  which  the  fixing  area  was  centred.  Rapidly 
then,  his  busy  eyes,  for  even  the  proverbial  bee  is 
no  busier,  would  move  around  to  allow  the  image 
of  various  parts  of  the  part  of  the  room  or  the  floor 
which  was  now  occupying  his  conscious  effort,  to 
fall  in  astoundingly  rapid  succession  upon  a  small 
but  central  part  of  the  retina  (macular  area  or  area 
of  fixation).  After  these  images  have  like  a  mov- 
ing picture  film  been  passing  before  the  part  of  the 


brain  devoted  to  vision,  he  will  add,  as  it  were, 
these  various  pictures  together  like  a  mosaic  to 
make  a  finished  single  picture  or  mental  image. 

The  moving  picture  film  is  a  succession  of  small 
but  complete  pictures;  the  successive  visual  impres- 
sions are  small  detailed  bits  of  a  large  picture  which 
must  be  added  together  to  get  a  result,  the  adding 
is  mental.  In  this  important  manner,  the  moving 
picture  film  and  the  visual  impressions  differ.  Our 
patient  without  normal  central  vision  comes  now  to 
the  end  of  his  day  and  as  the  sun  goes  down,  there 
comes  a  change.  In  the  dusk  of  the  evening,  he  sees 
quite  well  because  vision  in  dull  lights  or  darkness 
is  mass  vision  and  no  impressions  of  detail  are  pos- 
sible. He  is  under  these  conditions  as  good  as  the 
next  fellow.  From  the  foregoing  it  is  plainly  seen 
that  each  of  the  eyes  given  us  is  a  double  organ ; 
divided  into  a  central  eye  upon  which  we  depend 
for  detail  vision  and  color  vision.  This  part  of  the 
eye  works  best  in  good  light,  dayhght  for  instance, 
and  it  does  not  work  well  in  the  dark.  We  can 
prove  that  the  central  e^-e  is  normally  night  blind  by 
a  simple  experiment.  If  one  will  step  into  a  dark 
room  or  wait  until  nightfall  for  experimenting,  and 
gaze  upon  a  self  illuminating  watch  dial,  he  will  see 
it  dimly.  If  he  turns  his  eyes  slightly  to  the  side  and 
permits  this  same  image  to  fall  upon  a  part  of  the 
retina  just  a  little  external  to  the  macular  area,  the 
glowing  image  is  clear  and  distinct.  Astronomers 
know  this  and  tell  us  that  a  star  is  best  observed 
through  the  telescope  by  directing  the  gaze  a  little 
to  one  side  of  the  star  they  wish  to  observe,  moving 
the  image  of  the  star  against  the  dark  background 
from  the  night  blind  macular  area  over  to  the  night 
seeing  peripherj'. 

The  peripheral  eye  is  particularly  fitted  for  not- 
ing motion  at  the  side  and  giving  warning  of  loca- 
tion of  things,  a  most  valuable  function  which  we 
use  continually  while  walking  through  busy  streets, 
keeping  our  eye  upon  the  line  we  are  reading,  etc. 
This  is  called  vision  of  discovery.  It  works  well 
in  daylight  but  in  the  dark  this  part  of  the  eye  func- 
tions also  and  does  not  become  night  blind.  This 
function  in  the  dark  is  called  achromatic  vision. 
Our  patient  who  lost  his  central  vision,  was  defec- 
tive in  his  color  perception  and  had  lost  his  vision 
of  detail.  He  got  along  quite  well  in  the  darkness 
or  dull  light.  The  patient  who  loses  his  peripheral 
eye  is  night  blind,  cannot  protect  himself  against 
objects  coming  at  him  from  the  side,  bumps  into 
people,  but  can  read,  etc. 

The  retina  is  made  up  of  rods  and  cones,  the 
first- predominate  in  the  periphery  and  increase  as 
we  proceed  from  the  centre  to  the  outer  limit,  but 
the  cones  exist  at  the  centre,  or  macular  area,  to  the 
exclusion  of  the  rods  and  decrease  in  number  as 
we  go  externally.  It  is  conceded  that  the  cones  are 
the  organs  which  give  the  central  eye  its  character- 
istics, just  as  the  rods  give  the  peripheral  eye  the 
power  of  vision  in  dull  light  and  ability  to  detect 
motion  in  either  kind  of  illumination. 

Huey  and  others  have  studied  the  action  of  the 
human  eye  and  mind  in  the  act  of  reading  and  the 
preceding  facts  are  plain  in  his  conclusions  as  well 
as  some  others.  He  says  the  eye  appreciates  about 
four  letters  of  average  type  if  held  absolutely  still. 


December  11,  1920.] 


LLOYD:  CAMPIMETER  SLATE. 


945 


Another  iriteresting  fact  is  the  demonstration  that 
the  eye  jumps  from  letter  group  to  letter  group  in 
the  most  amazing  fashion  and  does  not  naturally 
remain  long  in  one  spot.  Steady  fixation  is  not 
habitual.  Reading  is  done  then  by  letter  groups, 
the  main  groups  being  picked  out  by  characteristic 
form  and  aid  is  given  by  the  sense  of  the  sentence 
already  interpreted.  Thus  in  the  group  of  words 
"The  act  of  reading,"  no  time  would  be  wasted 
upon  the  "ing"  as  the  sense  of  the  sentence  would 
indicate  that  no  other  termination  was  reasonable. 
While  the  central  eye  fixes  upon  about  four  letters, 
the  contiguous  area  of  the  field  of  vision  would 
give  some  hint  of  the  form  of  the  letters  standing 
next  in  line  and  the  areai  still  further  out  would  act 
as  a  guide  in  keeping  the  jumping  eye  on  the  line 
as  it  goes  rapidly  along. 

There  is  one  other  bit  of  eye  physiology  which 
is  of  importance  to  us  in  discussing  or  planning 
instruments  for  testing  various  functions  of  the 
eye  and  that  is  what  is  known  as  "phenomena  of 
Troxler."  If  bright  images  are  held  steadily  in 
fixation,  some  parts  will  fade  and  others  become 
bright,  and  so  on.  In  fact,  prolonged  fixation  with- 
out change  of  field  is  sure  to  produce  eventually  .this 
alternation  of  supremacy  of  one  part  of  the  image 
over  another,  even  if  the  images  are  subdued. 

Graefe  was  the  first  one  to  measure  and  study 
the  size  and  shape  of  the  field  of  vision.  In  1855 
he  mapped  out,  upon  a  wall  painted  black,  a  series 
of  concentric  circles  giving  the  five  or  ten  degree 
zones  from  the  centre  out  to  90°,  although  he  used 
the  rectangular  method  of  obtaining  these  circles 
instead  of  the  tangential.  In  spite  of  the  fact  that 
90°  was  parallel  to  the  wall  and  could  not  be 
measured  thereon,  some  important  facts  were  soon 
discovered.  Atrophy  of  the  optic  nerve  produced 
a  narrowing  of  the  field  of  vision  by  affecting  first 
green,  then  red,  and  finally  white,  so  that  the  early 
stages  might  have  a  normal  sized  field  for  white 
but  a  very  small  one  for  green. 

Various  other  diseases  and  conditions  aflfected  the 
field  in  peculiar  ways  and  were  valuable  in  diag- 
nosis and  prognosis.  Forster,  in  1867,  made  an 
instrument  with  a  semicircular  arm  along  which  the 
test  object  ran,  equidistant  at  all  times  from  the  eye. 
This  corrected  the  error  of  the  Graefe  plan.  When 
the  flat  surface  was  used,  the  test  object  soon  got 
farther  and  farther  from  the  eye,  as  it  passed  later- 
ally and  subtending  an  ever  diminishing  visual  angle, 
seriously  affected  the  value  of  the  test  beyond 
twenty-five  or  thirty  degrees,  according  to  the  dis- 
tance of  the  eye  under  examination  from  the  fixing 
point.  Forster's  invention  was  improved  upon 
from  time  to  time  until  with  the  added  devices  for 
recording  the  various  points,  changing  size  and 
color  of  test  object,  perfection  seemed  at  hand. 
The  recording  surface  of  the  modern  perimeter  is 
compressed,  as  much  as  twelve  times  in  some,  so 
it  happens  that  the  test  ofeject  will  travel  on  the 
arc  about  two  inches  for  ten  degrees  and  one  sixth 
inch  is  allotted  for  this  space  on  the  recording 
surface.  A  ten  degree  scotoma  is  indeed  a  large 
defect  especially  near  the  central  portion  of  the 
field  and  it  is  evident  that  outlining  scotomas  is  not 
the  function  of  a  perimeter.    The  perimeter  is  also 


inelastic  and  permits  the  approach  of  the  test  object 
from  external  or  internal  limit  only.  The  flat  sur- 
face with  test  object  in  the  hand  of  the  examiner 
permits  outlining  scotomas,  especially  those  near  the 
central  area,  because  of  the  fact  that  the  test  object 
can  approach  the  defect  from  any  angle  and  the 
record  made  is  not  compressed  but  is  recorded  as 
large  as  it  appears.  Although  this  distinction  in  the 
function  of  the  perimeter  and  the  campimeter  is 
evident,  for  years  the  perimeter  was  used  for  cen- 
tral field  work,  but  it  is  now  certain  that  many 
defects  were  overlooked. 

We  might  say  here,  then,  that  the  perimeter  is  an 
indispensable  instrument  for  outlining  fields  of 
vision  for  color  or  white,  but  the  campimeter  in 
some  form  is  indispensable  for  mapping  out  defects 
of  the  central  portion  of  the  field  of  vision.  Bjer- 
rum  introduced  his  screen  which  is  a  modification, 
one  might  say,  of  the  Graefe  flat  surface.  Bjerrum 
was  aware  of  the  limit  of  usefulness  of  the  flat 
surface  to  the  central  twenty-five  or  thirty  or  forty- 
degrees,  according  to  the  distance  of  the  patient 
from  the  screen.  This  screen  was  a  black  curtain 
with  concentric  five  or  ten  degree  circles  upon  it 
and  was  limited  as  suggested  above.  Dr.  Duane, 
of  New  York,  modified  the  screen  so  the  distance 
from  the  patient  was  lessened,  but  the  screen  could 
be  raised  or  lowered  to  bring  the  centre  opposite  the 
eye  of  the  patient,  and  the  degree  markings  are 
placed  on  one  side  and  squares  on  the  other,  so  the 
screen  may  be  also  used  as  a  muscle  screen.  The 
pins  marking  the  outline  of  the  defect  may  be 
inserted  from  the  side  opposite  to  the  patient,  thus 
preventing  any  influence  of  recording  where  the 
patient  might  observe  it. 

Haitz  in  1907  introduced  his  charts  which  were 
to  be  observed  in  an  ordinary  stereoscope.  Other 
binocular  methods  had  been  tried  but  none  so  suc- 
cessful or  simple  as  this.  The  stereoscope  was 
familiar  to  all  but  was  relegated  by  most  to  the 
position  of  an  entertaining  toy.  Haitz  saw  the  use- 
fulness and  possibilities  which  others  overlooked. 
He  utilized  only  a  ten  degree  field  but  each  eye 
could  be  examined  independent  of  the  other, 
binocular  fixation  was  employed  unless  one  eye  was 
defective,  in  which  case  the  good  eye  fixed  and  held 
the  poor  one  in  position.  The  perimeter  and  screen 
are  monocular  instruments  and  if  the  fixing  power 
of  an  eye  is  bad,  the  eye  is  unsteady  with  the  ex- 
pected result  upon  the  record.  Haitz  charts  are 
made  of  paper  and  the  recording  of  the  defect 
necessitated  the  counting  of  squares  in  order  to 
transfer  the  record  to  paper  for  permanency.  This 
slowed  up  the  process  and  with  the  unsteadiness  in- 
separable from  the  hand  stereoscope  together  with 
<he  limited  field  made  three  unpleasant  features. 

Dr.  Peter,  of  Philadelphia,  soon  after  this  intro- 
duced his  campimeter  which  is  really  a  Bjerrum 
screen  brought  close  to  the  ej-e.  The  available  field 
is  about  forty  degrees,  the  instrument  is  easily 
carried  about  and  may  be  used  with  the  patient  in 
bed.  The  defect  is  recorded  upon  the  campimeter 
as  large  as  it  appears  to  the  patient,  and  there  is  no 
loss  of  time.  It  is  of  necessity  somewhat  unsteady, 
as  it  is  held  in  the  hand  and  is  a  monocular  device. 

The  blind  spot  has  been  known  since  Mariotte 


946 


LLOYD:   CAMPIMETER  SLATE. 


[New  York 
Medical  Journal. 


discovered  it  in  the  year  1668,  but  only  in  recent 
years  has  it  entered  into  field  study  as  an  important 
factor.  Coccius  showed  in  1859  that  glaucoma 
enlarged  the  blind  spot  and  Leber,  1869,  proved  its 
enlargement  in  tobacco  poisoning.  But  in  recent 
years,  it  has  been  thoroughly  studied,  and  blind  spot 


Fig.  1. — Case  of  old  tobacco  alcohol  scotoma.  Vision  of  O.  S. 
much  better  than  O.  D.  because  fixing  area  of  left  eye  retains  its 
usefulness.     Defect  outlined  is  for  red  five  mm.  test  object. 

studies  are  now  very  important  in  many  conditions, 
especially  glaucoma. 

It  seemed  to  me  that  there  was  room  for  another 
instrument.  The  stereoscopic  or  binocular  method 
appealed  strongly  because  of  steady  fixation,  indeed, 
it  seemed  the  only  way  in  the  many  important  cases 
with  impaired  fixation  in  one  eye.  All  kinds  of 
central  scotoma,  amblyopia,  exanopsia,  cases  of 
traumatic  macular  changes,  and  others,  made  a  group 
of  cases  which  any  monocular  method  seemed  not 
to  fit.  Mindful  of  evils  of  retinal  fatigue  (Trox- 
ler's  phenomena),  it  seemed  necessary  to  record  the 
outline  of  the  defect  upon  the  surface  of  the  instru- 
ment and  save  time  and  avoid  weariness.  The 
stereoscope  should  have  a  field  large  enough  to  per- 
mit blind  spot  studies  as  well  as  studies  of  the 
central  area  and  it  should  stand  upon  a  table  and 
permit  the  patient  to  seat  himself  comfortably  and. 
eliminate  all  motion  possible.  Another  idea  was 
included  to  avoid  retinal  fatigue ;  the  avoidance  of 
strong  contrasts  and  bright  colors  in  laying  out  the 
diagram  of  the  campimeter. 

The  negatiA'e  fixation  point  of  Haitz  was  incor- 
porated because  there  is  no  doubt  that  this  plan 
tends  to  encourage  relaxation  of  accommodation 
and  give  true  impressions  of  distance.  Further- 
more, the  central  circles  were  decentred  outward  so 
the  image  when  fused  is  that  of  a  large  circle  placed 
somewhat  farther  from  the  eye^  than  the  surface 
of  the  chart  and  a  smaller  circle  yet  farther  off, 
but  within  the  first  circle.  Thus  a  sort  of  psychic 
invitation  to  gaze  into  infinity  is  created.  The 
degree  marks  are  corrected  for  each  degree  as  we 
pdss  from  the  fixation  point  to  the  periphery.  It 
is  true  that  the  deviation  from  a  fixed  value  is  not 
great  until  we  reach  the  vicinity  of  the  blind  spot, 
but  there  is  no  reason  why  we  should  not  have 
accuracy  when  it  is  within  reach.  The  location  of 
the  average  blind  spot  is  indicated  upon  the  surface 
of  the  apparatus  and  the  figures  of  Dr.  H.  S.  Gradle 
of  Chicago  are  used  in  locating  the  position  and 
size  of  this  standard  normal  field  defect.  His 
figures  seem  altogether  the  best  at  hand  because  of 
the  excellent  method  used  in  obtaining  them  and  the 
fact  that  his  examinations  were  made  in  a  larger 
number  of  cases  than  any  other  student  of  the  blind 
spot. 

The  first  efforts  were  made  with  an  ordinary  wide 
angle  stereoscope  and,  while  they  were  successful, 


there  were  certain  annoying  features  which  were 
most  appreciated  when  absent.  To  avoid  color  dif- 
fraction, unsteadiness,  and  to  gain  a  larger  field, 
I  appealed  to  Mr.  ]\Iax  Poser  for  a  wide  angle 
stereoscope  which  would  cover  eleven  degrees 
above,  below,  and  internally,  and  twenty  degrees 
externally.  He  responded  with  an  instrument  which 
was  optically  perfect,  included  correction  for  ver- 
tical and  lateral  muscular  errors  of  the  patient,  and 
had  a  generous  field  of  twenty-five  degrees  above 
and  below  the  fixation ;  the  usual  eleven  degrees  in- 
ternally, and  thirty-five  degrees  externally.  The 
instrument  stood  upon  the  table,  allowing  the 
patient  and  examiner  to  seat  themselves,  doing 
away  with  all  motion  possible.  The  name  given  to 
the  instrument  is  selfexplanatory,  the  stereoscopic 
campimeter  slate.  I  am  fully  aware  of  the  fact 
that  so  many  instruments  have  been  hurled  at  the 
physician  that,  in  order  to  survive,  it  must  over- 
come prejudice  and  pessimism.  To  speak  of  an 
instrument  as  "just  another  instrument"  is  usually 
sufficient  to  consign  it  to  the  limbo.  For  many 
years,  oculists  have  endeavored  to  do  what  cannot 
reasonably  be  expected  of  the  perimeter.  This 
instrument  has  sharp  and  narrow  limitations,  and 
we  are  indebted  chiefly  to  Dr.  Luther  Peter  for 
calling  attention  to  the  fact  that  for  years  medical 
men  have  tried  to  do  the  impossible  and  map  out 
central  and  paracentral  defects  on  the  perimeter. 

There  is  no  one  instrument  which  will  meet  the 
demand  of  every  case,  but  we  ought  to  eliminate 
this  ancient  error.  The  stereoscopic  campimeter 
slate  is  not  adapted  to  work  on  peripheral  fields.  It 
is  especially  fitted  for  work  in  the  central  and  para- 
central areas,  blind  spots  and  fixation  areas.  As  each 
field  may  be  examined  independently  of  the  other 


lo  r      I       .-,     \o     i.j     .M      J.:,  .io 


( I 


!•■]..  -IVima!  -Coll  in. I  laus  .i  !■>  wv.  a  alch.  i.  D.ii  k  c.i.lr..! 
area  is  defect  for  three  mm.  white  test  object  and  lighter  area  sur- 
rounding is  defect  for  three  ram.  red  test  object.  Vision  of  this 
eye,  right,  4/200.  Apparently,  the  macular  area  has  escaped  but 
the  fixation  has  been  eccentric,  thus  accounting  for  the  impression. 

but  with  binocular  fixation,  steadiness  and  accuracy 
are  evident.  If  one  fixation  area  is  affected,  the 
good  eye  will  fix  and  hold  the  one  not  able  to  fix  by 
itself,  and  each  field  may  be  investigated.  (Fig.  1.) 
The  octagonal  figure  helps  the  poor  eye  to  no  small 
degree  to  cooperate  with  its  fellow.    This  class  of 


December  11.  192U.] 


LLOYD:  CAM  PI  METER  SLATh. 


947 


case  is  probably  the  most  common  of  the  various 
kinds  of  field  defects.  A  small  lesion  of  the  macu- 
lar area  of  one  eye  is  immediately  noticed  and  the 
patient  is  examined  by  the  usual  methods  and  it 
is  found  that  he  cannot  read  20/20  and  a  glass  does 
not  improve.    The  ophthalmoscope  will  not  reveal 


Fig.  3. — The  difference  between  location  of  blind  spot  of  I  ft 
eye  when  the  right  eje  fixes  (marked  1),  and  the  location  of  the 
same  blind  spot  when  the  left  e;  e  fixes  (marked  2)  is  the  accurate 
measurement  of  the  deviation,  15°  which  is  about  one  half  of  the 
amount  recorded  by  the  perimetric  method. 

anything  in  cases  in  which  the  deeper  layers  of  the 
retina,  the  ner\-e  fibres  or  tracts  or  brain  are  in- 
volved. Are  we  to  stop  here  with  a  diagnosis  by 
exclusion?  Too  often  we  have  done  so.  The  lover 
of  the  concrete  and  absolute  vrill  deride  any  evidence 
which  he  cannot  see  himself  or  place  his  finger  upon. 
(Fig.  2.) 

We  can  outline  these  defects  day  after  day  and, 
if  the  outlines  agree,  we  have  evidence  of  great 
value.  If  the  lesion  is  in  the  choroid  or  superficial 
layers  of  the  retina,  some  will  say  there  is  no  need 
of  indirect  evidence.  But  there  are  quite  a  number 
of  cases  of  eye  injuries  in  which  the  macular  changes 
are  slight,  indeed — apparently  negligible.  But  by 
the  stereoscopic  method,  it  is  easy  to  show  that  a 
small  central  defect,  even  a  degree,  will  have  a 
serious  eltect  upon  the  vision.  Again,  there  are 
cases  in  which  the  diagnosis  between  glaucoma  and 
optic  nerve  atrophy  or  arteriosclerosis  is  so  close 
that  every  bit  of  evidence  is  of  value.  But  of  far 
greater  value  in  glaucoma  is  the  prognostic  influ- 
ence and  suggestion  for  operative  treatment  in 
glaucoma  cases,  of  the  hngerlike  scotomas  which 
reach  out  from  the  blind  spot,  reaching  with  sinister 
effect  upon  the  all  important  few  central  degrees. 
It  would  seem  that  too  often  we  have  felt  that  the 
vision  will  remain  good  as  long  as  the  field  is  of 
fair  size.  This  is  a  delusion,  for,  independent  of 
the  peripheral  field,  to  a  great  extent,  a  scotoma  may 
develop  from  the  blind  spot  and  affect  the  macular 
area  and,  in  some  cases,  the  process  may  even  be 
reversed  and  proceed  from  the  macular  area  to  the 
blind  spot.  In  the  early  stages,  these  defects  are 
relative  and  detectable  only  by  small  test  objects 
and  when  the  examination  is  most  carefully  done. 

If  we  find  our  patient's  poor  vision  is  due  to 
kidney  disease  or  diabetes,  we  are  likely  to  be  satis- 
fied without  going  further.  It  is  not  unusual  to 
find  a  nephritic  patient  with  white  spots  in  both 
macular  areas,  but  the  vision  of  one  eye  much  worse 
than  the  other.  Examination  will  show  a  central 
scotoma  in  the  one  and  not  the  other.  Diabetic 
cases  are  similar.  Acute  changes  in  either  type  of 
case  attended  by  edema  of  the  retina  is  destructive 
of  vision.  EWerly  patients  often  appeal  to  us, 
stating  that  a  black  spot  is  before  one  eye.  If 
these  patients  are  watched  the  usual  history  is  that 


the  process  goes  on  to  marked  change  in  the  retina 
in  the  macular  area  with  very  poor  vision.  The 
blood  vessels  show  the  changes  of  arteriosclerosis 
and  the  finer  arteries  are  particularly  angular  and 
tortuous.  Usually  the  second  eye  becomes  in- 
volved, but  not  infrequently  the  processes  resulting 
from  general  vascular  change  abruptly  end  the 
patient's  life.  In  the  early  stages,  when  ophthal- 
moscopic evidence  is  scant,  we  can  obtain  evidence 
of  a  relative  scotoma  near  the  fixing  point.  Later, 
ophthalmoscopic  evidence,  may  be  more  pronounced 
but  the  pigment  migration  to  the  superficial  visible 
layers  of  the  retina  is  not  necessarily  the  place 
where  the  perceiving  organs  are  affected.  In  other 
words,  the  lesion  which  produces  loss  of  vision  is 
not  always  the  one  which  we  can  see.  There  is  not 
always  a  correspondence  between  the  objective 
symptom  and  the  subjective  symptom. 

\\^t  are  taught  that  scotoma  is  ari,  islandlike  defect 
in  the  field  of  vision,  but  if  we  could  realize  that 
defective  vision  means  central  scotoma  and  that  our 
work  was  incomplete  until  we  had  investigated  that 
scotoma,  better  diagnosis  would  result.  The  pre- 
ceding remarks  have  been  included  to  give  some 
idea  of  the  usefulness  of  the  slate  in  field  defects, 
but  there  are  also  other  fields.  Amblyopia  ex- 
anopsia  can  be  studied  to  advantage.  Here  there 
is  one  poor  eye  and  in  about  ten  per  cent,  of  the 
cases  will  be  found  a  central  scotoma,  small  but 
absolute.  In  a  larger  number  will  be  found  a  rela- 
tive scotoma.  Color  vision  is  not  to  be  confounded 
with  visual  acuity,  though  both  are  mainly  to  be 
found  in  the  macular  area.  The  patient  cannot 
have  good  visual  acuity  and  have  a  color  scotoma, 
but  he  can  have  very  low  visual  acuity  and  not 


3.i       30  2.-. 

5       <»       •>  !<► 

20 

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5 

g^l-  

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.J  J 

t 

(> 

-t- 

_  A 



-1  I 

f  IG.  4. — Set  over  obtained  by  Lancaster  method  in  a  case  of 
divergent  strabismus.  Dotted  outline  is  that  obtained  by  three  mm. 
red  test  object  after  operation  and  the  continuous  outline  is  the 
field  obtained  by  the  same  test  ojjject  before  the  operation.  The 
perimeter  registered  30°  left  exotropia  but  the  campimeter  slate 
shows  about  12°  and  a  single  operation  gave  perfect  result. 

have  a  color  scotoma.  We  should  not  forget  that 
we  are  frequently  using  these  terms  one  for  the 
other.  Another  use  of  the  stereoscopic  campimeter 
slate  is  that  of  measuring  deviations  of  squinting 
eyes.  Sequential  to  this  use  is  the  proving  up  of 
the  effects  of  muscle  operations.    (  Fig.  3.) 


948 


RIVIERE:  PHYSICOTHERAPY. 


[New  York 
Medical  Joirxal. 


For  a  long  time  the  perimeter  has  been  used  to 
measure  the  degree  of  deviation  in  a  case  of  squint. 
Does  not  the  variation  of  the  angle  gamma  influ- 
ence our  readings  as  much  as  twenty  degrees  ?  Why 
do  some  cases  with  thirty  degrees  of  divergent 
squint  seem  so  much  harder  to  cure  than  other 
cases?  If  one  will  outline  the  blind  spot  of  each 
eye  in  a  case  of  squint,  and  also  for  greater  ac- 
curacy, outline  the  field  of  vision  of  each  eye  for 
a  red  one  millimetre  test  object,  the  patient  will 
fix  with  the  good  eye.  Then  cover  the  good  eye 
and  have  the  patient  fix  with  the  poor  eye  and 
repeat  the  process  for  that  eye  only ;  the  difference 
between  the  centre  of  the  blind  spot  in  trial  one  and 
trial  two  is  the  amount  of  deviation.  The  field  for 
red  one  millimetre  test  object  may  be  used  as  a 
check.  Comparison  with  the  result  on  the  peri- 
meter is  enlightening.  If  one  has  operated  in  a  case 
which  has  been  .measured  as  described  above,  the 
position  of  the  deviating  eye  can  be  accurately 
located  after  the  operation  and  the  set  over  accu- 
rately measured  (Fig.  4). 

450  Ninth  Street. 


A  PLEA  FOR  PHYSICOTHERAPY.* 

By  Joseph  Riviere,  M.  D., 
Paris,  France. 

The  word  physiotherapy,  which  in  my  opinion 
seems  to  be  too  extensive,  too  vague  and  ill  defined, 
is  far  less  suitable  than  physicotherapy,  which  is  far 
more  precise  and  the  limits  of  which  are  much  more 
definite.  It  may  be  that  my  fancy  for  the  second 
word  arises  from  its  having  been  coined  by  me ;  but 
I  indulge  the  hope  that  you  will  also  appreciate,  as 
I  have  done  long  ago,  the  scientific  reasons  which 
favor  its  adoption. 

Physiotherapy     (from  nature)  simply 

means  the  natural  cure,  naturism,  that  is,  the  util- 
ization, by  the  physician,  of  all  the  elements  sup- 
plied to  him  by  nature  for  the  treatment  of  dis- 
eases. 

Physicotherapy  (from  '^■'"Tr^r ,  physics)  prop-  • 
erly  signifies  the  application  to  daily  therapeutics  of 
all  apparatus,  instnnnents  and  machines  which 
physical  science  furnishes  us.  In  other  words, 
physiotherapy  is  accessible  to  all  practitioners, 
whereas  physicotherapy,  to  be  practised  appropri- 
ately, needs  the  combination  of  a  good  clinician,  a 
learned  physician  and  even  a  skilled  mechanician. 
For  the  practice  of  physicotherapy  utilizes  physical 
science,  clinicophysiological  observation,  and  the 
experience  gained  in  the  handling  of  the  countless 
instruments  which  it  is  likely  to  make  use  of.  With- 
out this  threefold  combination,  nothing  truly  good 
can  be  obtained.  The  physiologist  skilled  in  theory 
but  lacking  any  clinical  experience  cannot  be  a  good 
physicotherapeutist. 

This  failure  in  satisfying  the  proverbial  condition 
of  the  right  man  in  the  right  place  has  given  insig- 
nificant curative  results,  and  produced  definite  con- 
sequences disastrous  to  victims  of  the  war. 

The  sphere  of  action  of  physical  agents,  how- 

•Rcad  at  the  twentv-ninth  annual  meeting:  of  the  American  Elec- 
trotherapeutics Association  at  Philadelphia,  September  19,'  1919. 


ever,  has  become  so  important  and  varied,  that 
medical  science,  formerly  so  disdainful  toward 
these  methods,  is  no  longer  allowed  to  neglect  the 
present  resources  of  physicotherapy  or  to  look  down 
upon  this  important  branch  of  the  medical  art  as 
being  menial  or  of  an  inferior  quality. 

When,  some  thirty  years  ago,  I  ventured  to  group 
under  this  heading  of  physicotherapy,  in  a  single 
sanitary  formation,  the  combined  action  of  the  vari- 
ous physical  agents,  I  declared  my  desire  of  utilizing 
all  instruments  constructed  according  to  the  physical 
laws  of  gravity,  heat,  light,  electricity  and  kinetics 
(together  with  vibrotherapy,  atmiatry,  hydriatry, 
etc.)  adapted  to  the  improvement  or  the  correction 
of  the  most  varied  vital  acts  and  of  all  our  organic 
molecular  exchanges;  all  in  view  of  the  perfect  and 
normal  regularization  of  physiological  health. 

I  also  added,  that  the  more  complete  the  scale  of 
instruments  made  use  of  the  more  intense  and  deci- 
sive favorable  antipathological  reactions  should 
prove  to  be.  It  is  especially  in  the  struggle  against 
chronic  diseases,  which  so  deeply  shatter  the  organ- 
ism, that  the  abundance  and  the  perfect  condition 
of  the  curative  instruments  become  attendant  on 
our  duty.  If  it  becomes  necessary  to  replace  or  at 
least  to  complete  an  inadequate  chemicotherapy  by 
our  methods,  while  carefully  sparing  the  refractory 
"or  already  imperilled  digestive  organs,  we  shall  ob- 
tain mild  and  truly  beneficial  reactions  to  correct 
the  deviated  nervous  function,  to  hasten  the  periph- 
eral circulation,  to  secure  the  required  eliminations, 
to  pick  up  the  trophism  of  the  tissues  and  to  restore 
the  humors  to  their  normal  condition. 

All  these  methods,  whether  they  remain  isolated 
and  specialized  (as  is  most  often  the  case)  or 
whether  they  are  collected  together  and  combined, 
as  I  recommended  in  France  in  a  debate  dating 
thirty  years  back — all  these  curative  methods  belong 
to  the  province  of  physicotherapeutic  science,  an  im- 
portant branch  of  the  legitimate  practice  of  medi- 
cine, which  require  the  diligent  control  of  a 
practitioner  conversant  with  clinical  science  quite 
as  much  as  the  pharmacological  branch,  and,  in  ad- 
dition, a  person  well  versed  in  physics  and  mechan- 
ics, straightforward,  honest  and  disinterested 
according  to  the  noble  Hippocratic  tradition. 

In  creating  and  vulgarizing  the  word  physico- 
therapy, I  was  therefore  working  out  a  reasonable 
acceptation  thereof,  well  defined  in  its  determina- 
tion. It  by  no  means  had  to  do  with  the  utilizing  of 
physical  agents  in  their  natural  state ;  but  it  dealt 
with  their  precise  domestication,  in  separate  instru- 
ments and  within  a  synergical  group.  Physio- 
therapy appeared  to  be,  thirty  years  ago,  and  seems 
to  be  at  present,  an  expression  much  too  vague ; 
without  any  paradox,  the  contention  may  be  raised 
that  the  whole  medical  art  is  essentially  physio- 
therapeutic. Do  not  medicines  themselves  form  part 
of  the  domain  and  the  province  of  nature?  On  the 
other  hand,  the  physicotherapeutist,  without  de- 
spising chemistry  and  its  vast  pharmacologicJil  vis- 
tas, takes  his  stand  upon  physical  science,  wherewith 
he  controls  and  limits  the  scope  of  his  operations 
rationally  adapted  to- a  method. 

The  progress  attained  by  physicomechanical  pro- 
cesses within  the  last  quarter  of  a  century  has  caused 


December  11,  1920.] 


RI VI ERE :  PH VSICO THERAPY. 


949 


excellent  results  to  be  obtained  by  our  instruments, 
for  altering  the  complex  modalities  of  vital  energy 
~and  the  potential  function  of  biodynamical  phe- 
nomena. This  is  readily  understood  if  one  consid- 
ers that  the  human  body  is  the  greatest  transmuter 
of  force  and  of  matter.  Reactional  expedients  are 
infinite,  when  one  knows  how  to  incorporate  in  a 
methodical  manner  the  electrical,  the  thermody- 
namic, the  hydriatic,  the  mechanokinetic  energies 
duly  adapted  in  our  usual  treatments.  Electricity, 
heat,  light,  motion,  these  are  the  unerring  causes  of 
our  physiological  existence,  these  are  the  agents  of 
our  biodynamism  and  the  equipoising  principles  of 
our  nutritive  economy.  Chemical  medication,  on 
the  other  hand,  has  mainly  disturbing  effects. 

A  medicine  acts  only  on  the  condition  of  its  be- 
ing a  body  foreign  to  the  organism,  of  a  taste  gen- 
erally unpleasant ;  it  has  never  been  in  request, 
otherwise  it  would  become  a  food  without  any 
healing  effect.  The  fashion  which  prevails  in  phar- 
macological therapeutics  is  explained  by  custom. 
The  property  of  transforming  and  utilizing  ambiant 
physical  energies  is  increased  by  exercise,  and  such 
a  training  is  highly  profitable  to  us.  When  it  is 
desired  to  obtain  an  equitable  and  judicious  appli- 
cation of  our  treatments,  it  is  indispensable  to  pos- 
sess physical  science  and  to  be  a  practical  mech- 
anician able  to  supply  the  workmanship  if  required ; 
also  to  appreciate  the  possible  resources  of  human 
physiology  allowing  a  cure  to  be  hoped  for,  or,  at 
any  rate,  an  improvement  and  a  change  for  the  bet- 
ter in  a  countless  number  of  chronic  diseases  which 
cause  the  despair  and  opprobrium  of  drug  medi- 
cation. 

To  repair  the  human  motor,  to  unstiffen  or 
.strengthen  its  machinery,  to  stop  lesions  and  re- 
store the  normal  utilization  of  imperilled  or  disor- 
dered functions,  it  must  be  known  how  to 
administer,  in  a  timely  and  adequate  manner,  the 
variable  modalities  of  the  physical  cure,  which  is 
universally  admitted  to  be  .the  least  fallacious  for 
all  functional  restorations  and  recoveries.  Physico- 
therapy  gives  the  best  results  in  diseases  of  the 
nervous  system  (neurosis,  neuralgia,  neuritis,  par- 
alysis, atony,  ataxy,  atrophy,  tics,  tremors,  cramps, 
etc.)  ;  in  nutritive  slackenings  and  the  pathological 
condition  of  sedentariness  (obesity,  migraine,  gout, 
rheumatism,  lithiasis,  congestive  state  of  the  viscera, 
overworked  brain,  diabetes,  albuminuria)  ;  in  the 
diseases  of  women  (pelvic  congestions,  metritis, 
fibroma,  dysmenorrhea,  ovarian  neuralgia)  ;  in  the 
diseases  of  the  senses,  debility,  ptosis,  stricture, 
prostatic  hypertrophy,  impotency,  incontinence  of 
urine  ;  dyspepsia  and  gastric  dilatation  ;  enteropathy, 
constitutional  constipation,  intestinal  occlusion, 
cardiorespiratory  disorders  (asthma  and  emphy- 
sema, tuberculosis,  arteriosclerosis,  fatty  heart)  ; 
diseases  of  the  blood  (anemia,  leucemia,  various 
infectious  toxemias)  ;  the  various  kinds  of  dermo- 
pathy  and  the  most  malignant  neoplasms.  In  sur- 
gery, all  traumatic  and  trophic  lesions,  stiffness, 
impotence,  atrophy,  ankylosis,  congenital  and  ac- 
quired malformations;  all  cases  requiring  the  re- 
education of  attitudes  (scoliosis,  deviation  of  the 
waist,  growth  disorders),  or  the  mobilization  of  the 
articulations ;  the  correction  of  old  traumatic  le- 


sions and  the  timely  resumption  of  a  maximum 
useful  amount  of  work,  also  fall  in  the  sphere  of 
physicotherapy,  in  its  successive  modalities  and 
stages.  We  may  add :  the  cicatrization  of  wounds 
and  ulcers,  the  retrocession  of  certain  tumors,  the 
cure  of  varices  and  hemorrhoids.  In  a  word,  the 
restoration  of  physiological  equilibrium  and  the 
niaintenance  for  a  long  time  of  the  good  results 
achieved,  are  the  usual  rule  in  physicotherapy. 
Thanks  to  the  perpetual  improvements  and  to  the 
easy  doses  of  treatments,  to  the  variety  of  the  in- 
struments and  the  machines  employed,  the  practi- 
tioner may  combine  gentleness  with  energy  and  add 
to  the  curative  precision  and  extent. 

By  regenerating  the  energies,  by  reinforcing  the 
resistance  and  the  means  of  defence  of  the  organ- 
ism, by  improving  cellular  gymnastics,  physicother- 
apy has  revolutionized  the  art  of  healing.  Thanks  to 
the  penetrating  activity  of  the  potential  function 
infused  by  our  various  instruments,  economical 
forces  are  restored,  nutrition  is  spurred  on,  sleep 
is  regained,  nervous  pains  are  allayed  and  circula- 
tory disorders  are  regularized.  Power  for  effort 
energy  for  work  is  kindled,  with  the  joy  of  life 
and  cerebrospinal  equilibrium.  These  are  all  the 
happy  results  (obvious  to  the  least  attentive  of  ob- 
servers), which  have  conquered  for  sure  methods 
a  most  lasting  and  cheering  popularity. 

25,  RUE  DES  MaTHURINS. 


Skin  Lesions  in  Measles. — F.  B.  Mallory  and 
E.  M.  Medlar  (Journal  of  Medical  Research, 
March,  1920)  base  this  study  on  examinations  made 
on  130  patients  covering  a  period  of  over  two 
years.  Blood  culture,  smears,  and  the  dark  field 
illumination  of  fresh  blood  were  negative  for  any 
organisms  which  might  have  an  etiological  relation 
to  the  disease.  A  study,  of  the  nasal,  pharyngeal, 
laryngeal  and  conjunctival  secretions  also  failed  to 
reveal  any  significant  facts  about  the  cause  of 
measles.  The  skin  lesions  are  considered  to  be 
infectious  in  origin  without  much  question,  and  due 
to  the  causal  agent  of  the  disease.  The  reasons  for 
this  belief  are  that  the  lesions  are  focal  in  character 
and  discrete,  not  uniformly  distributed  like  the  rash 
in  scarlet  fever,  but  scattered  irregularly,  sometimes 
singly,  often  in  smaller  and  larger  groups,  becom- 
ing confluent  when  sufficiently  numerous.  Tissue 
from  thirty-five  patients  was  studied,  using  small 
pieces  of  skin  removed  during  life.  The  reaction 
is  almost  entirely  on  the  part  of  the  endothelial  cells 
and  leucocytes,  as  in  certain  other  infectious  proc- 
esses. The  endothelial  cells  lining  the  capillaries 
in  the  lesions  have  swollen,  finely  granular  cyto- 
plasm, which  in  the  earliest  lesions  often  contain 
one  to  four  minute  intensely  staining  spherical 
bodies,  varying  in  size  a  little.  These  bodies  are 
fewer  in  older  lesions,  and  usually  more  evident 
at  the  periphery  of  the  lesion,  disappearing  entirely 
later  in  the  disease.  It  was  impossible  to  determine 
the  nature  of  these  bodies,  and  no  similar  bodies 
have  been  found  in  the  endothelial  cells  lining  the 
blood  vessels  in  other  acute  lesions  examined  as  a 
control.  The  suggestion  is  offered  that  they  may 
be  the  causal  agent. 


Editorial  Notes  and  Comments 


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XEW  YORK,  SATURDAY.  DECEMBER  11,  1920. 


THE  MENACE  OF  TYPHUS  IN  EUROPE. 

One  of  the  most  serious  aftermaths  of  the  war 
is  the  prevalence  of  the  disease  known  as  typhus 
fever,  which  is  incubated  and  fostered  by  filthy 
conditions,  for  the  cause,  the  louse,  can  only  exist  in 
such  conditions.  During  the  war  it  raged  in  Serbia, 
and  is  of  peculiar  interest  to  the  American  medical 
profession,  because  the  discovery  of  its  main  means 
of  development  and  dissemination  was  due  to 
American  investigation.  At  the  present  time  the 
presence  on  a  large  scale  of  typhus  in  Russia  and 
other  parts  of  Central  Europe  is  a  distinct  and  grow- 
ing menace  to  the  health  of  the  rest  of  Europe. 

According  to  the  report  of  the  chief  medical  ad- 
viser to  the  British  Ministry  of  Health,  issued 
recently,  during  the  past  two  winters  almost  the 
whole  of  what  used  to  be  the  Russian  Empire  has 
experienced  the  ravages  of  typhus  and  relapsing 
fever  in  a  very  grave  .epidemic  form.  For  Soviet 
Russia  alone  it  has  been  stated  officially  that  at  least 
1,600.000  cases  of  typhus  were  reported  in  1919, 
while  extensive  and  severe  epidemics  have  occurred 
in  tlie  border  countries  of  Rumania,  Poland,  Lithu- 
ania and  Esthonia.  The  country  of  the  Ukraine 
has  also  sufifered  most  severely  and  conspicuously. 
In  this  connection  it  may  be  said  that  now  refugees 
from  Soviet  Russia  are  crossing  the  Ukraiiian  fron- 
tier, as  well  as  persons  being  repatriated,  in  a  fear- 
fully filthy  condition,  infested  with  lice  and  some  of 
them  stricken  with  typhus.  Their  disinfestation  and 
disinfection  at  the  frontier  towns  are  being  done 
under  American  auspices,  so  that  although  the  ques- 


tion does  not  directly  concern  America,  yet,  at  the 
same  time,  it  is  one  of  intimate  interest.  The  report 
just  referred  to  points  out  that  the  condition  of 
Poland  in  this  respect  has  called  for  special  considera- 
tion on  account  of  the  geographical  position  of  that 
country  in  relation,  on  the  one  side  to  Russia,  and 
on  the  other  to  the  exhausted  and  presumably  sus- 
ceptible Germanic  countries,  which  up  to  now  have, 
for  the  most  part,  escaped.  Attention  is  drawn  to 
the  fact  that  in  the  first  instance  this  distribution, 
which  occurred  both  in  1918-19  and  1919-20,  has 
been  due  to  the  importation  of  typhus  infection 
from  its  permanent  focus  in  Russia,  under  condi- 
tion which  would  have  put  a  most  severe  strain 
upon  the  sanitary  service  even  of  the  best  organized 
government  of  a  settled  and  peaceful  country. 

Infection  has  again  and  again,  during  the  past  two 
years,  been  introduced  in  mass  by  the  large  number 
of  prisoners  of  war  and  refugees  reaching  Polish 
territory;  many  actually  sufifering  from  typhus  or 
carrying  its  infection.  It  seems  practically  certain 
that  in  Soviet  Russia  typhus  will  continue  and  in- 
crease again  this  winter,  while  in  Poland  further 
opportunities  for  constant  introduction  of  infection 
will  arise  in  consequence  of  the  return  to  Poland, 
or  through  Poland,  to  other  countries  of  large  num- 
bers of  persons  waiting  to  be  repatriated,  and  of  the 
influx  of  refugees  and  returning  prisoners  of  war. 
Indeed,  the  menace  of  typhus  to  western  Europe 
is  so  evident  as  to  need  little  emphasis. 

The  outstanding  question  is  how  to  prevent 
its  gaining  a  foothold  and  devastating  the  popula- 
tion. It  is  fortunate  that  there  are  few  diseases  in 
which  the  necessary  preventive  measures  are  so 
well  known  or  the  principles  of  prevention  so  well 
established  as  typhus  and  relapsing  fever.  Further- 
more, the  experience  of  the  war  has  taught  that  the 
work  of  disinfection  can  be  ef¥ectively  carried  out 
by  the  observance  of  a  few  simple  rules  and  with 
improved  apparatus  for  the  destruction  of  the  in- 
sects and  their  eggs  dependent  on  currents  of  steam, 
hot  air,  petrol  and  various  other  methods. 

But  in  order  to  carry  out  measures  for  previention 
on  a  large  scale,  as  well  as  treatment  and  the  obser- 
vation of  typhus  contacts,  a  large  quantity  of  raw 
material,  a  considerable  and  trained  personnel,  and 
a  satisfactory  organization  of  the  whole  of  the  anti- 
typhus  work  are  required.  In  this  campaign, 
American  medical  men  and  lay  helpers  have  greatly 
assisted.  There  is  yet  much  to  be  done,  and  it  is 
to  be  hoped  that  .American  efforts  will  not  be 
relaxed,  and  that  Europe  may  be  saved  from  the 
impending  menace  of  typhus. 


December  11.  1920.] 


EDITORIAL  ARTICLES. 


951 


BLOOD  TRANSFUSION  IN  OBSTETRICAL 
PIL\CTICE. 

Direct  transfusion  of  blood  is  certainly  worthy  of 
taking  a  foremost  place  among  modern  therapeutic 
measures.  It  is  an  operation  that  no  longer  presents 
any  serious  danger,  and  in  obstetrical  j)ractice  may 
render  real  service  in  certain  circumstances.  Animal 
experiments  and  the  practical  results  in  man  leave  no 
doubt  of  its  superiority  over  injections  of  physio- 
logical salt  solution  in  the  treatment  of  simple 
hemorrhage  with  or  without  shock.  Performed 
with  Elsberg's  or  Bernheim's  instruments  the  anas- 
tomosis of  the  vessels  is  rapidly  and  easily  made, 
and  the  dangers  of  coagulation  are  avoided.  Care 
should  be  taken,  as  far  as  possible,  to  ascertain  the 
hemolysis  of  both  the  donor  and  the  recipient,  as 
well  as  the  agglutination  of  the  blood  of  each.  If 
time  is  lacking  to  make  these  tests,  the  donor  should 
be  selected  from,  the  patient's  near  relatives. 

In  very  serious  puerperal  hemorrhage,  when  the 
usual  means  of  treatment  by  subcutaneous  injections 
of  ether,  camphorated  oil  or  caffein,  or  the  subcuta- 
neous or  intravenous  injection  of  artificial  serum, 
are  insufficient  to  control  the  situation,  blood  trans- 
fusion should  be  resorted  to  without  delay.  Even  if 
the  source  of  the  hemorrhage  is  not  completely 
arrested  the  oozing  will  subside  after  a  time  on  ac- 
count of  the  increased  coagulability  of  the  blood 
resulting  from  the  transfusion.  This  operation  is 
also  useful  when  the  hemorrhage  is  combined  with 
shock,  as  occurs  in  rupture  or  inversion  of  the 
uterus,  as  well  as  in  premature  detachment  of  the 
placenta.  In  ruptured  tubal  pregnancy  transfusion 
will  hardly  ever  be  required,  as  in  most  cases  rapid 
recover}-  will  ensue  by  dealing  directly  with  the 
source  of  the  loss  of  blood.  In  puerperal  eclampsia 
transfusion  has  given  some  good  results,  and  al- 
though this  question  requires  further  study,  trans- 
fusion of  blood  should  be  employed  when  other 
classical  means  of  treatment  have  failed. 

In  serious  hemorrhage  in  the  newly  born,  trans- 
fusion has  given  unquestionably  good  results. 
Nevertheless,  before  resorting  to  it,  injections  of 
human  or  animal  serum  should  be  essayed.  In  case 
of  failure  or  at  the  onset  of  the  hemorrhage  when 
unusually  severe,  in  spite  of  the  technical  difficulties 
of  the  operation,  direct  transfusion  of  blood  offers 
the  only  chance  of  saving  the  baby. 

The  only  real  accident  to  be  feared  is  acute  dila- 
tation of  the  heart,  which  is  due  to  a  too  large 
quantity  or  too  great  rapidity  of  the  flow  of  blood 
from  the  donor.  This  accident  is  particularly  to  be 
feared  when  an  organic  disease  of  the  heart  exists 
in  the  recipient.  Acute  dilatation  does  not  take 
place  suddenly,  and  the  onset  is  usually  ushered  in 


by  dyspnea,  cough,  cyanosis  and  precardiac  dis- 
tress, and  if  the  transfusion  is  not  stopped  at  once, 
the  condition  of  affairs  will  go  from  bad  to  worse. 
When  hemolysis  or  agglutination  of  the  blood  occurs, 
it  is  usually  when  the  recipient  is  afflicted  by  some 
serious  affection  of  the  blood. 

The  transmission  of  an  infectious  process  must 
never  be  lost  sight  of,  and  not  long  since  de  Martel 
reported  a  case  of  transmission  of  syphilis.  It  was 
a  case  of  transfusion  from  a  mother  to  her  offspring, 
and  very  shortly  after  the  operation  the  baby  pre- 
sented a  specific  roseola  without  any  primary  sore. 

The  results  obtained  in  hemorrhages  in  the  newly 
born  are  so  favorable  that  this  would  seem  to  dis- 
prove the  infectious  nature  of  these  hemorrhages. 
It  is  likewise  difficult  to  admit  the  vascular  theory 
of  hemorrhage  in  the  newly  born  which  supposes 
an  anomaly  in  the  structure  of  the  capillary  vessels, 
because  the  sudden  change  for  the  better  following 
transfusion  cannot  be  accounted  for  b}-  a  structural 
regeneration  of  these  vessels  nor  to  a  cure  of  an 
infection.  The  only  explanation  for  so  rapid  a  re- 
covery in  these  cases  is  some  abnormal  chemical 
condition  of  the  blood  of  a  congenital  nature,  more 
particularly  of  the  serum,  whose  chemical  makeuo  is 
not  yet  clearly  understood. 


PHYSICIAN-AUTHORS :  ANTON 
PAVLOVITCH  CHEKOV. 
"The  picturesque  and  pathetic  pageant  of  Russian 
letters,"  writes  Christian  Brinton,  "shows  no  figure 
comparable  to  Anton  Pavlovitch  Chekov" ;  and  it 
might  be  added  that,  in  recent  times  at  least,  there 
have  been  comparatively  few  literary  figures  of  any 
other  nationality  that  are  comparable  to  him,  espe- 
cially in  the  field  of  the  short  story,  on  which  his 
fame  is  primarily  based.  Chekov  was  one  of  the 
supreme  masters  of  the  short  story,  and  even  in 
this  golden  age  of  short  story  writing,  his  work  is 
like  manna  to  the  reader  of  cultivated  taste.  We  of 
America  are  not  yet  wholly  familiar  with  the  great 
procession  of  characters  who  march  through 
Chekov's  pages.  With  us,  although  he  has  been 
dead  since  1904,  he  can  still  be  regarded  as  a  con- 
temporary author,  since  new  translations  of  him 
are  still  appearing.  Thus  far  ten  A'olumes  of 
Chekov's  stories  have  been  published  in  English,  and 
each  succeeding  volume  has  enhanced  the  author's 
reputation.  A  large  section  of  the  reading  public 
has  yet  to  learn  that  Chekov  is  not  merely  another 
of  those  gloomy  Russian  authors.  He  is  much 
more  of  a  genial  philosopher  than  those  compatriots 
of  his  who  established  in  this  country  the  grim  tra- 
dition of  perpetual  Russian  literary  gloom.   Like  the 


952 


EDITORIAL  ARTICLES. 


[New  York 
Medical  Journal. 


Others,  it  is  true,  he  paints  the  banal  life  of  Russia, 
the  prerevolutionary  Russia  that  is  gone,  but  un- 
like the  others  he  has  the  saving  grace  of  a  sense  of 
humor.  "If  his  palette  was  gray,  if  the  monotony 
of  the  steppe,  the  disillusion  and  disenchantment  of 
the  Russian  soul  covered  his  canvas,"  says  one 
critic,  "it  is  because  they  were  factors  in  contem- 
porary life  and  because  Chekov  always  remained 
resolutely  true  to  conditions  around  him."  But 
Chekov's  palette  is  not  gray — that  is,  not  solid  gray. 
Satire  and  sadness,  gaiety  and  grief,  go  hand  in 
hand  through  his  pages.  His  stories  are  fnW  of 
well  flavored  humor.  He  is  the  true  realist  who 
sees  all  sides  of  life,  and  who  does  not  forget  that 
laughter  and  tears  never  are  far  apart. 

Humor  was  a  natural  characteristic,  an  ingrained 
habit,  with  Chekov,  and  even  life's  bitterness  could 
not  turn  him  wholly  from  it.  He  began  his  writing 
career  by  contributing  farcical  contcs  (in  1879,  un- 
der the  pen  name  of  Chekonte)  to  a  Russian  humor- 
ous paper  called  the  Dragon  Fly.  It  is  true  that  in 
later  years  he  became  tinged  with  pessimism,  but  his 
humor  simply  took  on  a  more  significant  form.  Rol- 
licking drollery  became  keen  satire  and  subtle  irony. 
In  the  English  translations  of  his  stories,  the  pub- 
lishers have  made  each  volume  a  judicious  mixture 
of  his  earlier  and  his  later  work,  and  this  disregard 
of  chronological  sequence  is  a  happy  idea,  despite 
the  inevitable  violent  contrasts,  since  it  gives  the- 
reader  of  a  single  yolume  a  more  complete  idea  of 
Chekov's  range  and  his  supreme  artistry  within  that 
range. 

Although  it  is  as  a  short  story  writer  that  we 
know  Chekov  best,  he  also  "transgressed,"  as  he 
himself  puts  it,  in  other  directions.  He  wrote 
several  longer  stories,  but  they  are  hardly  of  novel 
length — at  best  they  are  but  novelettes.  These  have 
not  the  charm  of  his  shorter  work,  because  of  their 
lack  of  action  and  plot;  but  they  reveal  the  same 
close  observation  of  and  insight  into  the  human 
animal  that  marks  the  briefer  tales.  He  also  wrote 
eleven  plays,  five  of  which  are  serious  dramas  and 
six  farces.  These  dramatic  efforts  achieved  great 
success  on  the  Russian  stage,  but  they  have  hardly 
been  successful  elsewhere,  probably  because,  as  has 
been  said,  they  are  too  indigenous  to  Russia  and,  like 
the  novelettes,  are  too  deficient  in  action  and  climax. 
They  are  .said,  however,  to  be  admirable  pictures  of 
ordinary,  everyday  life,  and  are  excellent  reading. 
Five  of  them  have  been  published  in  English. 

Chekov's  medical  training  undoubtedly  was  of 
great  value  to  him  in  his  literary  work.  Hospital 
scenes  abound  in  his  .stories,  and  in  nearly  all  there 
are  physicians  as  characters.  It  was  in  the  capacity 
of  doctor  that  Chekov  was  able  to  familiarize  him- 


self with  the  moral  frailties  of  the  average  man  and 
woman,  their  banality  and  stupidity,  their  grossness 
of  habit  and  lack  of  heart.  "Chekov  looks  upon 
human  nature  with  the  charitable  eye  of  the  wise 
doctor  who  has  learned  from  experience  that  people 
cannot  be  other  than  what  they  are,"  says  Edward 
Garnett,  the  English  critic.  .  .  .  "Of  all  modern 
masters  of  fiction,  he  is  the  most  delicately  respon- 
sive to  the  spectacle  of  life's  ceaseless  intricacy.  .  .  . 
He  strips  the  last  rags  of  dignity  from  the  human 
soul  with  pitiless  assiduity  and  wanton  ferocity." 

Chekov  was  born  on  January  17,  1860,  at  Tagan- 
rog, in  southern  Russia.  He  was  the  son  of 
liberated  serfs  and  got  his  early  education  in  a 
school  at  Taganrog,  after  which  he  entered  the 
University  of  Moscow,  where  he  was  graduated  as 
a  physician  in  1884.  At  the  outset  of  his  career  he 
was  pitifully  poor  and,  to  make  his  handicap  all  the 
greater,  was  afflicted  with  the  white  plague.  He 
continued  in  the  dual  role  of  physician  and  writer 
for  nearly  a  score  of  years,  until  at  last  his  writings 
began  to  bring  him  such  prosperity  that  he  was  able 
to  retire  to  a  villa  on  the  Black  Sea  where  the  mild 
climate  was  favorable  to  his  health.  Even  then, 
however,  he  continued  to  practise  a  little,  and  on  the 
occasion  of  the  twenty-fifth  anniversary  of  his  debut 
as  a  writer,  in  1904,  he  said  in  a  little  autobiography 
which  he  wrote  for  the  journal  which  had  published 
many  of  his  writings:  "Medicine  is  my  occupation, 
and  to  such  a  degree,  in  fact,  that  some  time  during 
the  year  I  perform  more  forensic  medical  dissec- 
tions than  I  once  completed  in  two  or  three  years." 
Chekov  lived  only  a  few  months  after  this  anniver- 
sary. He  died  of  tuberculosis  in  the  fall  of  that 
year,  at  Badenweiler,  Germany. 


LIVING  BEYOND  OUR  MEANS. 
Living  beyond  our  means,  psychologically.  In 
lesser  ways,  too,  accusations  have  been  made  in 
many  directions.  They  will  always  be  made  until 
the  day  of  wisdom  comes,  when  psychological 
knowledge  of  ourselves  is  complete  enough,  serene 
enough  to  take  ourselves  for  what  we  are.  Wherever 
we  strain  on  tiptoe  to  maintain  a  level  not  really 
ours,  the  larger  background  of  psychological  ignor- 
ance is  at  fault.  The  picture  which  decorates  the 
walls  is  not  there  because  it  gives  expression  to 
something  truly  within  or  to  some  aspiration  which 
would  release  that  something  into  healthy  freedom. 
Our  clothes  form  the  same  oppressive  mold,  be- 
cause we  are  trying  to  maintain  something  which  is 
not  ourselves.  But"  much  more  serious  is  this  state 
of  things  in  moral  attitudes  and  in  the  graver  ques- 
tions of  life.     Certain  standards,  ideas  accepted 


December  11,  1920.] 


EDITORIAL  ARTICLES. 


953 


ready  made,  seem  good  in  themselves,  but  there  is 
no  question  if  they  represent  inner  truth — the  truth 
of  human  life  and  individual  human  lives. 

It  was  Freud  chiefly  who  taught  us  how  different 
this  latter  is  from  the  external  standards  toward 
which  we  strain.  He  saw  why  we  come  away 
broken  when  the  strain  cannot  endure.  A  rereading 
of  his  Reflections  on  War  and  Death  revives  for  us 
his  plea  to  nations  as  well  as  to  individuals.  We  go 
on  fooling  ourselves  as  to  our  high  standards,  which 
then  inexplicably  collapse ;  our  denial  of  death,  which 
comes  after  all.  He  begs  us  to  ask  if  we  have  not 
"again  lived  psychologically  beyond  our  means." 

Freud  is  being  more  and  more  widely  accepted  as 
the  world's  greatest  physician,  who  heals  because  he 
turns  his  patients  away  from  such  placebos  to  the 
actual  man  and  woman  which  these  have  sprung  up 
to  conceal.  His  searching  reveals  the  weaknesses  in 
individuals,  in  social  institutions,  in  national  and 
international  character.  But  at  least  it  strips  away 
the  lies  that  cover  them.  And  beneath,  if  there  is 
weakness,  there  is  also  the  bedrock  of  actual  ma- 
terial for  more  genuine  and  lasting  construction. 

Prostitution  continues  to  prey  upon  infantile 
natures,  while  the  veil  of  separate  moral  pride  for- 
bids the  frank  discovery  of  the  undisciplined  crav- 
ings which  prostitution  serves.  Alcoholism  is  only 
covered  over  by  a  zealous  repression  which  knows 
little  of  the  forces  it  seeks  to  restrain.  Religion, 
patriotism,  fear  to  take  the  real  measure  of  man,  or 
to  gage  both  preaching  and  science  by  man  himself. 
Therefore,  nations  befuddle  themselves  and  one  an- 
other, until  their  need  breaks  out  in  greedy  violence. 
Society  wonders  at  the  cankers  which  continue  to 
gnaw.  The  individual  flings  himself  into  lawless- 
ness or  more  often  falls  into  helpless  neurosis.  Can 
medicine,  politics,  statesmanship,  religion  do  better 
than  to  find  out  just  what  human  means  are,  and 
educate  themselves  and  their  dependents  down  to 
them  ? 


THE  SORROWS  OF  TK-WEL. 
The  joys  of  travel  have  been  much  mentioned  but 
its  discomforts  and  dangers  have  been  too  much 
ignored.  Even  the  fatigue  of  riding  without  a  seat 
is  accepted  on  some  local  lines  of  railway  as  a  matter 
of  almost  daily  necessity  provided  by  Providence. 
There  are  certain  features  of  travel  that  cannot 
be  done  away  with  until  there  are  further  develop- 
ments in  methods  of  conveyance.  We  refer  to  the 
noise  and  dirt,  which  in  themselves  are  sufiicient 
to  take  the  joy  out  of  railroad  travel.  Just  why 
ugly  sights  should  be  added  to  the  dirt  and  noise 
we  must  wonder.  It  would"  seem  as  if  all  the 
dwarfs  and  hunchback  creatures  in  the  land  had 
been  culled  over  for  representative  specimens  to 
be  exhibited  in  the  aisles  of  railway  coaches,  and 
not  merely  presented  to  the  eye  of  the  traveler  once. 


but  shown  again  and  again,  every  day  in  the  year. 
Xow  if  these  unfortunates  could  find  no  other 
employment  so  suitable  to  their  capacity,  or  if  they 
could  be  made  to  serve  as  an  object  lesson  in  public 
health — as  a  walking  placard  of  the  results  of  pre- 
ventable disease — there  might  be  less  objection,  but 
why  a  railroad  coach  should  be  turned  into  an 
objectless  sideshow  we  are  in  doubt. 

Railway  toilets,  in  stations  and  on  trains,  are, 
as  a  rule,  unspeakable  examples  of  what  they  should 
not  be,  and  are  often  sources  of  disease  transmis- 
sion. We  have  already,  in  these  pages,  gone  more 
into  detail  with  this  unpleasant  subject.  But  the 
mental  wear  and  tear  of  travel  is  e\'en  worse  than 
its  physical  discomforts,  especially  for  the  many 
who  are  not  constant  travelers.  For  most  people 
traveling  is,  from  the  outset,  a  source  of  anxiety, 
and  this  anxiety  is  not  always  lessened  by  the  kindli- 
ness of  agent,  baggageman,  or  conductor.  We 
know  of  no  business  in  which  kindliness  is  more 
needed  for  the  welfare  of  those  in  their  charge. 
We  see  no  reason  why  the  hygiene  of  travel  should 
be  overlooked,  in  a  day  when  health  conditions  are 
being  developed  elsewhere.  If  traveling  can  be  made 
less  wearisoiTie,  uncomfortable,  and  dangerous,  the 
public  deserves  the  benefit. 


THE  TOO   POPULAR  TREATMENT 
CLINIC. 

In  many  of  the  clinics  the  child,  where  possible, 
is  treated  at  home  under  supervision  by  the  visiting 
nurse,  or,  if  an  ambulatory  case,  has  to  appear  at 
the  clinic  during  school  hours.  Two  difficulties 
have  arisen:  many  children  are  excluded  from  school 
dozens  of  times  during  the  term  for  that  which 
the  mother,  had  she  cared  to  note  the  nurse's  treat- 
ment or  to  use  it,  could  easily  have  prevented.  The 
children  also,  in  slight  cases,  enjoy  being  excused 
from  school  and  the  importance  of  being  a  patient. 

\Miat  a  terrible  time  these  clinicians  have  I  First 
the  people  will  not  come,  then  they  abuse  the  oppor- 
tunit}-.  It  has  been  resolved  to  teach  the  mothers 
and  elder  girls  when  domicila^y  visits  are  made, 
and  to  let  children  attend  the  clinic  after  school 
hours.  This  latter  has  already  had  a  good  effect. 
xA.s  to  payment,  a  small  charge  would  cause  the 
treatment  to  be  valued  accordingly.  The  over- 
worked nurse  is  not  supposed  to  replace  the  mother, 
but  to  teach  hygiene,  and  the  tired  doctor  should 
not  have  children  returning  again  and  again  because 
the  mother  has  been  too  indifferent  to  acquire  a 
little  knowledge. 

A  CORRECTION. 

In  Dr.  Howard  Fox's  article  on  Standardized 
Rontgen  Ray  in  the  Treatment  of  Skin  Diseases, 
which  appeared  in  our  November  27th  issue,  p.  837, 
an  error  occurred  in  the  last  sentence  in  the  second 
paragraph  of  the  first  column.  The  word  five  should 
be  changed  to  three,  the  sentence  reading  as  follows : 

"In  cases  of  ringworm  where  short  exposures  were 
preferred  the  figures  were  as  follows :  six  inch  spark 
gap,  three  milliamperes,  a  minute  and  nineteen  sec- 
onds and  six  and  one  half  inch  distance." 


954 


XEirS  ITEMS. 


[New  York 
Medical  Journal- 


News  Items. 


Federal  Permits  to  Prescribe  Alcoholic 
Liquors. — It  is  reported  that  out  of  the  6,131 
physicians  in.  New  York  State  who  in  1920  had 
federal  permits  to  prescril)e  alcoholic  Hquors  for 
medicinal  purposes,  only  985,  or  less  than  one  sixth, 
have  applied  for  similar  privileges  in  1921. 

The  New  Surgeon  General  of  the  Navy. — It  is 
announced  that  Rear  Admiral  E.  R.  Stitt,  Medical 
Corps,  U.  S.  Xavy,  has  heen  selected  to  succeed 
Surgeon  General  W.  C.  Braisted,  who  is  to  retire, 
in  confomiity  with  his  own  request,  after  more 
than  thirty  years'  service  m  the  Medical  Department 
of  the  Xavy. 

Wellcome  Prize  Essay  Medals. — Medals  in  the 
annual  competition  for  prizes  given  by  Henry 
Wellcome,  of  London,  for  the  best  essay  on  medico- 
military  subjects,  have  been  awarded  to  Assistant 
Surgeon  W.  C.  Rucker,  United  States  Public  Health 
Service :  Lieutenant  Colonel  E.  B.  \'edder.  Colonel 
James  L.  Bevans,  Captain  Mahlon  Ash  ford,  and 
Captain  Carl  INI.  Bowman,  Medical  Corps,  U.  S. 
Army. 

Associated  Out  Patient  Clinics. — The  annual 
meeting  of  this  organization  will  be  held  at  the  New 
York  Academj-  of  Medicine,  Wednesday  evening, 
December  15th,  in  Du  Bois  Hall.  The  address  of 
the  evening  will  be  delivered  l)y  Dr.  W.  Oilman 
Thompson  on  the  Present  Inadequate  Dispensary 
Service  for  the  Treatment  of  Industrial  Accident 
Cases.  All  who  are  interested  in  the  subject  are 
invited  to  attend  the  meeting. 

Prevalence  of  Venereal  Diseases. — During  the 
months  of  July,  August,  and  September,  1920, 
there  were  reported  to  State  Boards  of  Health 
91,195  cases  of  venereal  diseases,  an  increase  over 
the  preceding  three  months  of  21,781  cases,  or  about 
thirty-one  per  cent.  It  is  not  considered  that  this 
indicates  an  increase  in  the  prevalence  of  these  dis- 
eases, but  is  a  result  of  more  complete  reporting  on 
the  part  of  physicians. 

Rontgenologists  Wanted  in  the  Public  Health 
Service. — Tlie  United  States  Civil  Service  Com- 
mission announces  examinations  for  the  following 
positions  in  the  United  States  Public  Health  Serv- 
ice: Rontgenologist,  $200  to  $250  a  month;  asso- 
ciate rontgenologist,  $130  to  $180  a  month;  assistant 
rontgenologist,  $90  to  $130  a  month;  junior  ront- 
genologist, $70  to  $90  a  month.  For  full  particulars 
regarding  the  requirements  for  eligibility,  duties, 
etc.,  write  to  the  Civil  Service  Commission,  Wash- 
ington, D.  C. 

James  C.  Farrell  Memorial  Hospital. — Mrs. 
James  C.  Farrell,  daughter  of  the  late  Anthony 
N.  Brady,  is  planning  to  build  a  million  dollar 
hospital  in  Albany,  as  a  memorial  to  her  husband, 
who  died  about  a  year  ago.  It  will  be  called  the 
James  C.  Farrell  Memorial  Hospital  and  will  take 
tlie  place  of  St.  Peter's  Hospital,  which  is  badly 
located  and  is  in  need  of  renovation.  The  new 
liospital  will  be  erected  on  a  large  plot  of  ground 
in  the  Pine  Hill  residential  section,  and*  will  be 
thf)roughly  equipped  with  all  the  most  modern 
a])pliances. 


Football  Victims. — During  the  1920  season 
there  were  eleven  deaths  due  to  football  games, 
five  more  than  in  1919  and  one  more  than  in  1918. 
Twelve  lives  were  lost  during  the  1917  season, 
eighteen  in  1916,  and  fifteen  in  1915.  The  majority 
of  deaths  this  }ear  occurred  among  high  school 
players,  none  among  the  big  universities. 

Annual  Meeting  of  the  New  York  Academy  of 
Medicine. — Dr.  George  David  Stewart  was  re- 
elected president  of  the  New  York  Academy  of 
Medicine,  at  the  annual  meeting  held  on  November 
18th.  Dr.  Edward  L.  Keyes,  Jr.,  was  elected  vice- 
president,  and  Dr.  D.  Bryson  Delavan  and  Dr.  Seth 
Milliken  were  reelected  corresponding  secretary 
and  treasurer,  respectively. 

An  Outbreak  of  Botulism  in  California. — Dur- 
ing the  month  of  October.  1920,  there  occurred 
in  the  St.  Anthony's  Hospital,  Oakland,  Cal.,  an 
outljreak  of  l:)0tulism.  There  was  a  total  of  six 
cases,  two  of  which  could  be  considered  mild  and 
four  severe;  of  these  latter,  three  were  fatal.  Un- 
fortunately none  of  the  cases  was  recognized  as 
botulism  until  the  third  day  of '  illness,  and  there- 
fore they  were  not  immediately  reported. 

Personal. — Dr.  Edward  J.  Kempf.  formerly 
clinical  psychiatrist  to  the  Government  Hospital  for 
the  Insane,  Washington,  D.  C.  announces  the  open- 
ing of  an  office  at  100  Central  Park  South.  New 
York.  His  practice  will  be  limited  to  psycho- 
pathology. 

Dr.  Haven  Emerson,  formerly  health  commis- 
sioner of  New  York  city,  has  been  appointed  medical 
adviser  and  assistant  director  of  the  Bureau-  of 
War  Risk  Lisurance. 

Medical  Association  of  the  Southwest. — At  the 
fifteenth  annual  meeting  of  this  society,  held  in 
Wichita,  Kan.,  November  22nd  to  24th,  Dr. 
Edward  H.  Skinner,  of  Kansas  City,  Mo.,  was 
elected  president,  to  succeed  Dr.  Ernest  F.  Day, 
of  Arkansas  Cit}-,  Kan.  Other  officers  were  elected 
as  follows :  Dr.  William  W.  Rucks,  of  Oklahoma 
City,  Dr.  John  T.  Axtell,  of  Newton,  Kan.,  and 
Dr.  Herbert  Moulton,  of  Fort  Smith,  Ark.,  vice- 
presidents  :  Dr.  Fred  H.  Clark,  of  Oklahoma  City, 
secretary-treasurer.  The  next  meeting  will  be  held 
in  Kansas  City.  Mo.,  in  October.  1921. 
'  Brooklyn  Cardiological  Society. — This  society, 
the  only  one  of  its  kind  in  New  York  State,  held  its 
first  meeting  on  Monday  evening,  November  29th, 
at  the  office  of  the  president.  Dr.  William  J.  Cruik- 
shank,  102  Fort  Greene  Place,  Brooklyn.  Other 
officers  of  the  new  society  are :  Dr.  Glentworth  R. 
Butler,  vice-president;  Dr.  William  W.  Laing,  sec- 
retary; Dr.  Frank  Bethel  Cross,  treasurer.  The 
society  has  twelve  members,  all  of  whom  are  active 
in  cardiological  work,  and  the  following  honorary 
members :  Dr.  Thomas  Lewis,  of  London  ;  Sir  James 
Mackenzie,  of  London ;  Dr.  John  Cowan,  of  Glas- 
gow;  Dr.  Robert  H.  Halsey,  of  New  York;  Dr. 
\Villiam  Thomas  Ritchie,  of  Edinburgh,  and  Dr. 
W.  S.  Thayer,  of  Baltimore.  Dr.  Cruikshank  made 
the  opening  address  at  the  first  meeting  and  other 
addresses  were  delivered  by  Emil  Krading,  Ph.D., 
Phil.D.,  the  Hon.  Andrew  MacLean.  and  Mr. 
Henry  Allan  Price.  The  society  will  meet  for 
scientific  di.scussion  every  two  months. 


Deceralier  11.  1920.] 


XEirS  ITEMS. 


955 


A  Medical  Regiment. — The  new  Army  reor- 
ganization laws  provide,  it  is  said,  for  a  complete 
medical  regiment,  consisting  of  ambulance,  sanitary 
and  hospital  battalions,  veterinary  and  administra- 
tive companies,  medical  supply  division,  and  medical 
laboratory.  All  its  members  will  be  trained  for  the 
special  technical  ser\ices  involved.  Such  a  regi- 
ment is  now  being  organized  and  will  be  attached 
to  the  Second  Division  at  Camp  Travis,  Texas. 

Infant  Mortality  Affected  by  Housing  Situ- 
ation.— The  crowding  caused  bv  a  shortage  of 
houses  has  caused  an  increase  of  fifty  per  cent,  in 
the  infant  death  rate  in  some  localities,  according 
to  the  findings  of  the  conference  of  health  author- 
ities held  recently  in  Detroit  for  the  purpose  of 
considering  housing  conditions  in  relation  to  public 
health.  It  was  also  found  that  tuberculosis  and  other 
diseases  were  being  spread  by  overcrowding. 

Needs  of  the  Charity  Organizations  Society. — 
At  the  thirty-eighth  annual  meeting  of  the  Charity 
Organization  Society,  held  recently,  reports  were 
made  that  during  the  last  year  it  received  S590,- 
450.97  and  spent  5590,490.21  in  its  welfare  work. 
The  general  work  of  the  society  caused  a  disbtirse- 
ment  of  $230,218.40,  while  the  income  from  special 
endowments  amounted  to  897.183.  Actual  family 
relief  was  $187,420.25  this  year,  against  $151,346.71 
the  year  before.  The  relief  budget  for  the  coming 
year  was  set  at  $190,000,  while  to  cover  all  expenses 
the  organization  must  raise  $511,500. 

Quarantine  for  .Venereal  Diseases. — The  First 
District  Court  of  Appeals  of  California  has  upheld 
the  right  of  a  local  health  officer  to  detain  and 
quarantine  persons  who  are  venereally  infected.  A 
woman  was  arrested  on  a  charge  of  vagrancy.  She 
voluntarily  submitted  to  a  physical  examination,  and 
tests  were  made  which  showed  that  she  was  infected 
with  venereal  disease.  The  health  officer  of  the 
city  and  county  of  San  Francisco  ordered  her  de- 
tained and  quarantined.  Habeas  corpus  proceed- 
ings were  instituted  to  secure  the  woman's  release 
from  quarantine,  but  the  district  court  of  appeals 
held  that  the  health  authorities  had  the  power  to 
isolate  venereally  infected  persons. 

Johns  Hopkins  Hospital  to  Be  Remodeled. — 
It  is  reported  that  Johns  Hopkins  Hospital,  Balti- 
more, is  to  be  reconstrticted  on  the  most  approved 
plan.  The  estimated  cost  of  the  proposed  recon- 
struction of  the  hospital  group,  with  provision  for 
endowment,  will  amount  to  between  $11,000,000 
and  $12,000,000.  A  new  pathological  building  will 
be  erected  at  a  cost  of  $600,000,  to  replace  the  old 
one  which  was  burned  last  winter.  The  construc- 
tion of  a  woman's  clinic,  to  provide  for  obstetrical 
and  gynecological  patients,  will  be  begun  next  year. 
The  estimated  cost  is  $400,000.    Other  plans  are : 

Outpatient  or  dispensary  building,  $1,714,000; 
endowment  for  dispensarv,  $1,000,000;  heating  and 
power  plant,  $100,000  to  $500,000;  addition  to 
nurse's  home,  $500,000 ;  teaching  building  for  school 
of  ntirses,  $250,000 ;  endowment  for  school  of 
nurses,  $750.000 ;  convalescent  branch,  $250,000, 
endowment  $500,000 :  medical  clinics  for  men  and 
women  suffering  from  general  medical,  nervous 
and  skin  diseases,  $500,000.  endowment  $1,500,000; 
additions  to  service  building,  $200,000. 


League  of  Nations  Discusses  Typhus  and 
Cholera  in  Poland. — According  to  cable  dis- 
patches from  Geneva,  the  League  of  Nations  devoted 
Tuesday,  December  7th,  to  a  discussion  of  typhus 
and  cholera.  The  net  results  of  this  meeting  were, 
first,  the  announcement  that  £200,000  onlv  of  the 
i2,000,000  asked  for  had  been  subscribed  by  the 
world  in  reply  to  the  Council's  appeal ;  second,  it  was 
decided  that  the  Assembly  should  make  a  new  appeal 
to  nations  and  welfare  societies,  and,  third,  that 
the  Assembly  should  appoint  a  committee  of  three 
to  conduct  the  fight  against  typhus.  Sir  George  E. 
Foster  said  that  Canada  withdrew  the  conditions 
attached  to  her  oflEer  of  $200,000.  IM.  Hanotaux, 
of  France,  said  that  there  were  no  strings  to  the 
French  offer  of  1,000,000  francs.  A.  J.  Balfour 
said  the  same  of  England's  £50,000.  Wellington 
Koo  pledged  China's  support.  Palaccio,  of  Greece, 
said  that  his  country  would  give  £40.000. 

Meetings  of  Local  Medical  Societies. — The  fol- 
lowing medical  societies  will  meet  in  New  York 
during  the  coming  week : 

Monday,  December  isth. — Societj-  of  Medical  Juris- 
prudence (annual);  Xew  York  Ophthalmological  Society; 
Yorkville  Medical  Societj';  Williamsburg  Medical  Society. 
Brooklyn. 

Tuesday,  December  14th. — New  York  Academy  of 
Medicine  (Section  in  Xeurologj-  and  Psychiatry)  ;  Man- 
hattan Dermatological  Societv- ;  Xew  York  Obstetrical 
Society:  Clinical  Society  of  the  Hospital  and  Dispensarj- 
for  Deformities  and  Joint  Diseases. 

Wednesday,  December  ijth. — New  York  .Academy  of 
Medicine  (Section  in  Genitourinary  Diseases)  ;  •  Geriatric 
Society-:  Medicolegal  Society  (annual);  Xorthwestern 
Medical  and   Surgical   Society  of  New  York  (annual): 

Oman  s  Medical  Association  of  New  York  City;  Alumni 
Association  of  the  Citj-  Hospital. 

Thl-rsday,  December  i6tlt. — New  York  Academy  of 
Medicine  (stated  meeting)  ;  New  York  Celtic  Medical 
Society. 

Friday,  December  17th. — New  York  Academy  of  Medicine 
(Section  in  Orthopedic  Surgery);  Clinical  Society  of  the 
New  York  Post-Graduate  ^^ledical  School  and  Hospital 
(annual)  ;  Xew  York  Microscopical  Societj- ;  Brooklyn 
Medical  Societj". 

 <^  

Died. 

.Abr.^ham.— In  Appleton.  Wis.,  on  Monday,  Xovember 
22nd,  Dr.  Henrj-  W.  Abraham,  aged  fiftj-four  years. 

BoLEX.— In  Brooklyn,  X.  Y.,  on'  Monday,  September 
20th,  Dr.  Xicholas  Thomas  Bolen,  aged  fifty-nine  j^ears. 

BovcE. — In  Memphis.  Tenn.,  on  Friday,  X'ovember  12th, 
Dr.  James  D.  Boyce.  aged  sixty-five  years. 

Brecht. — In  Lebanon,  Pa.,  on  Saturday,  November  27th, 
Dr.  Samuel  A.  Brecht,  aged  sLxtj-one  j'ears. 

CoxROY.— In  Everett,  Mass.,  on  Saturday,  Xovember 
27th,  Dr.  Peter  J.  Conroy,  aged  sixtj-five  years. 

HoGE. — In  Richmond,  Va..  on  Fridaj-,  Xovember  19th, 
Dr.  Moses  D.  Hoge,  Jr.,  aged  fifty-nine  years. 

H.\_MiLTox.— In  Holdenville,  Okla.,  on  Mondaj-,  Xovem- 
ber 15th.  Dr.  Charles  M.  Hamilton,  aged  sixty-four  jears. 

Leightox. — In  Xew  Haven,  Conn.,  on  Sunday,  Xovem- 
ber 21st,  Dr.  Alton  Winslow  Leighton,  aged  fiftv-two 
jears. 

Moore.— In  Birmingham,  Ala.,  on  Friday,  Xovember  19th, 
Dr.  John  A.  Moore,  aged  fifty-nine  j-ears. 

Sharples.— In  Ck)shen,  Ore.,  on  Saturday,  November 
20th.  Dr.  Abraham  Sharpies,  aged  seventj--nine  jears. 

ScHLiTZ.— In  Brooklyn,  N.  Y.,  on  Friday,  November 
19th,  Dr.  Francis  A.  Schlitz,  aged  seventj-four  years. 

ScHCYLER.— In  Utica,  N.  Y.,  on  Saturday,  November 
20th.  Dr.      illiam  J.  Schuyler,  aged  fift>--nine  years. 


Book  Reviews 


ELECTRICITY  IN  MEDICINE. 

Electric  Ionization.  A  Practical  Introduction  to  Its  Use 
in  Medicine  and  Surgery.  By  A.  R.  Friel,  M.  A.,  M.  D. 
(Dub.),  F.  R.  C.  S.  I.,  Aural  Specialist,  Ministry  of  Pen- 
sions, London  District,  etc.  Illustrated.  New  York : 
William  Wood  &  Co.,  1920.    Pp.  i.x-78. 

Electrotherapy.  Its  Rationale  and  Indications.  By  J.  Cur- 
tis Webb,  M.  A.,  M.  B.,  B.C.  (Cantab.),  Hon.  Associate 
of  the  Order  of  St.  John  of  Jerusalem ;  Order  of  Merit 
of  the  Cruz  Vermehla ;  Hon.  Associate,  King's  College, 
London,  etc.,  etc.  With  Six  Diagrams.  Philadelphia : 
P.  Blakiston's  Son  &  Co.,  1920.    Pp.  90. 

Electrical  Treatment.  By  Wilfred  Harris,  M.  D.,  F.  R.  C. 
P.,  Senior  Physician  and  Lecturer  on  Neurology,  St. 
Mary's  Hospital ;  Physician  to  the  Hospital  for  Epilepsy 
and  Paralysis,  Maida  Vale.  Illustrated.  Third  Edition. 
New  York :  William  Wood  &  Co.,  1520.    Pp.  x-354, 

Diathermy  in  Medical  and  Surgical  Practice.  By  Claude 
Saberton,  M.  D.,  Hon.  Radiologist  to  the  Harrogate 
Infirmary  and  to  the  Royal  Bath  Hospital,  Harrogate ; 
Late  Hon.  Medical  Officer  to  the  X  Ray  and  Electrical 
Departmeut,  Royal  Victoria  and  West  Hants  Hospitals. 
With  Thirty-three  Illustrations.  New  York :  Paul  B. 
Hoeber,  1920.    Pp.  xii-138. 

The  war  did  much  to  bring  the  use  of  electricity 
as  a  therapeutic  agent  to  the  fore.  In  many  in- 
stances the  use  of  this  important  physical  agent  has 
been  the  most  valuable  at  our  command  in  the 
treatment  of  lesions  caused  mechanically.  Healing 
has  been  hastened  and  function  restored.  A 
great  deal  that  has  been  done  during  the  war  can 
be  duplicated  in  civil  practice.  Fqr  this  reason  we 
feel  the  importance  of  presenting  the  findings  of 
the  men  engaged  in  this  field. 

*    *  * 

Vague  theories  and  untried  methods  do  not  attract, 
the  too  busy  practitioner  who  wants  sixty  minutes 
in  his  hour.  He  will  flutter  the  leaves  of  the  book, 
and,  if  something  novel  does  not  catch  his  eye,  he 
will  put  it  aside  until  coaxed  back  to  a  reperusal 
by  hearing  it  praised. 

But  Dr.  Friel  carries  his  credentials  on  the  front 
page,  and  the  B.  E.  F.  certainly  does  mean  real 
work,  dwarfing  even  the  M.  D.  He  reiers  to  Pro- 
fessor Leduc,  of  Nantes,  who  discovered  the  laws 
which  regulate  ionization,  and  defines  that  term  as 
a  form  of  treatineht  which  means  electrically  intro- 
ducing into  the  tissues  one  or  other  of  the  com- 
pounds known  as  salts.  It  also  expresses  the  ex- 
change of  ions  which  takes  place  in  the  tissues 
following  the  continuous  electric  current. 

What  can  it  do?  It  promises  speedy  relief  to  a 
number  of  those  complaints  which  are  due  to  the 
inoculation  of  microorganisms  into  tissues  or  organs, 
where,  owing  to  lowered  vitality  and  mechanical 
conditions,  they  find  a  lodgment  and  set  up  irrita- 
tion. It  need  not  supersede  other  agencies ;  rather, 
it  favors  their  successful  use. 

A  clear  description  of  what  ionization  really 
means,  and  the  ecfuipiVient  necessary,  leads  the 
reader  on  to  effects  of  dififerent  ions.  One  instance, 
when  used  in  ankylosis,  is  worth  quoting: 

"An  officer,  early  in  the  war,  had  a  gunshot 
wound  in  the  thigh  and  a  compound  fracture  of 
the  lower  third  of  the  femur.  The  fracture  was 
excised ;  recovery  followed,  but  with  shortening  and 
an  ankylosed  knee.    He  was  discharged  as  unfit, 


but  he  came  to  Professor  Leduc  and  asked  if  he 
could  be  helped.  The  knee  was  treated  by  salicylate 
ionization  twice  a  week  for  five  weeks,  each  treat- 
ment lasting  an  hour,  a  current  of  60,  80  or  100 
ma.  used.  At  the  end  of  that  tiine  movement  had 
been  so  restored  that  the  minister  of  war  had  him 
reinstated  and  advanced  to  a  captaincy,  and  he  led 
his  men  to  the  attack  on  Chemin  des  Dames." 

Even  better  are  the  results  on  cerebral  afifections. 
The  bones  of  the  skull  conduct  well  enough  to 
allow  of  action  on  the  brain,  and  the  brain  tissue 
is  an  excellent  conductor.  The  ionic  changes, 
which  take  place  between  the  brain  cells  and  the 
fluids  surrounding  them,  promote  nutrition.  That 
old  enemy,  suppuration,  is  dealt  a  deadly  blow  by 
ionization  with  zinc,  also  boils  and  abscesses,  ulcer, 
ringworm,  acne,  pyorrhea.  One's  satisfaction  grows 
with  the  list  of  diseases  subdued ;  even  eye  aflfections 
are  conquered. 

Full  details  are  given  of  the  treatment  for  each 
case,  but  it  is  specially  urged  that  the  doctor  should 
not  send  his  patient  for  ionization  to  another  doctor, 
losing  sight  of  the  invalid  for  some  weeks,  because, 
receiving  him  back  and  not  knowing  exactly  what 
has  been  done,  he  is  unable  to  go  a  step  further 
and  perhaps  free  the  patient  from  an  unhealed 
woinid.  Cooperation  is  becoming  imperative  in  the 
medical  as  well  as  the  labor  world.  The  book  is 
clearly  written  in  good  English  and  is  not  a  heavy 
volume  in  any  sense. 

In  reading  Webb's  book  one  is  reminded  that 
there  are  many  doctors  who  send  their  patients  to 
the  electrotherapist  because  they  know  by  results  the 
advantages  of  his  treatment,  but  cannot  carry  it  out 
themselves.  In  the  scanty  leisure  of  a  crowded 
life  they  have  often  picked  up  books  giving  technical 
details,  because  they  honestly  wanted  to  understand, 
but  the  inquiry  was  given  up  as  one  requiring  too 
much  time.  Moreover,  the  cures  wrought  by  an 
inappreciable  dose  or  by  a  pretended  one  which 
were,  in  reality,  due  to  psychotherapy,  not  electro- 
therapy, were  puzzling  and  disconcerting.  A  case  is 
recalled  of  a  lady  suffering  from  hysterical  aphonia 
who  frequently  made  a  long  journey  to  recover 
powers  of  speech  b)'  an  electric  cure,  which  was 
always  successful,  though  the  doctor  declared  he 
did  not  use  enough  to  "worry  a  kitten." 

Bearing  all  this  in  mind,  Webb  has  confined  him- 
self  to  a  little  practical  volume,  nontechnical,  giving 
the  modern  view  as  to  the  action  on  the  human 
body  of  each  form  of  electric  current  and  how  these 
currents  may  cure  disease,  with  a  list  of  the  diseases 
most  amenable  to  treatment,  all  of  which  he  has 
treated  himself.  He  gives  a  list  of  the  larger  works 
he  has  consulted  in  order  that  the  readers  may  do 
the  same  when  time  is  not  limited. 

Very  carefully,  never  presutning  anything  to  be 
known,  the  mysteries  of  currents,  static  electricity, 
radium,  x  rays,  are  simplified,  and  their  action  on 
the  body  described.  Part  II  is  devoted  to  general 
diseases,  then  to  diseases  in  particular.  His  success 
in  treating  diseases  of  the  nervous  system  and  in 
gj'irecology  has  been  encouraging,  and  equally  so 


December  11,  1920.] 


BOOK  REVIEWS. 


957 


in  those  commonplace  bugbears,  dyspepsia  and  con- 
stipation. Most  doctors  will  be  grateful  to  the 
author  for  giving  them  the  cream  of  his  own  and 
other  men's  work  and  successes  in  one  small  volume. 

Dr.  Wilfred  Harris  gives  us  a  third  edition, 
necessitated  by  all  that  the  war  has  taught.  It  might 
almost  be  imagined  that  the  war  epoch  had  been 
intended  by  Nature  as  a  postgraduate  school  in 
which  should  be  put  to  the  test  all  that  was  new  in 
the  medical  and  surgical  world,  so  many  men  have 
furbished  up  their  old  editions,  assuring  us  there 
is  no  doubt  about  their  assertions  because  they  have 
been  converted  into  stern  facts  during  the  war. 
Harris  has  borne  in  mind  that  many  men  have  only 
a  faradic  or  a  galvanic  battery,  that  very  few  can 
get  the  use  of  radium,  that  the  thorough  knowledge 
of  X  ray  treatment  is  rare,  the  theor}^  of  the  various 
forms  of  current  somewhat  hazy,  and  has  written 
for  such,  so  that  the  wayfaring  man  need  not  err 
and  the  experienced  traveler  be  gladdened  to  find 
old  stumbling  blocks  cleared  away. 

Methods  and  apparatus  fill  the  first  chapter,  the 
faradic  current  the  second  and  third.  Galvanism, 
with  all  its  possibilities,  is  thoroughly  worked  out 
before  the  question  of  electric  baths  is  dealt  with  or 
the  electric  light  baths  and  x  rays.  Finally,  a  study 
of  medical  applications  of  sinusoidal  currents,  static 
electricity,  and  high  frequency  currents  end  this 
accumulation  of  garnered  facts. 

It  will  be  a  revelation  to  many  to  find  how  sure 
an  aid  electricity  has  been  and  still  is  in  troubles 
small  and  great,  from  the  neurasthenic  with  logor- 
rhea  and  the  woman  who  is  "so  ill  as  to  think  she  is 
ill  when  she  is  not"  to  the  despondent,  mutilated, 
war  spent  soldier  with  increasing  paralyses.  It  can 
soothe  and  banish  all  those  everyday  attacks  of 
headache,  tics,  neuritis,  and  make  all  nerves 
approach  the  happy  condition  of  the  ninth  one. 
Only  those  who  have  tested  the  restfulness  of  what 
is  sometimes  termed  the  fatigue  couch  can  appre- 
ciate its  consoling  power. 

The  various  diseases  are  not  given  a  place  in  the 
index  and  only  a  few  lines  devoted  to  them  in  the 
text,  as  is  the  case  in  so  many  manuals.  Harris 
has  remembered  that  that  which  may  seem  insig- 
nificant is,  to  the  seeking  doctor,  the  one  important 
thing  demanding  treatment  by  the  worried  radio- 
therapist. 

*    *  * 

Let  not  the  amateur  who  doesn't  think  he  can 
diathermatize  but  would  rather  like  to  know,  think 
he  can  seriously  practise  without  danger  to  patients 
until  he  has  given  some  time  and  much  study  to  it. 
Not  everyone  who  possesses  a  dry  battery  may  give 
electric  treatment.  First  of  all,  high  frequency  cur- 
rents are  dealt  with,  then  a  description  of  the  ap- 
paratus is  given,  and  an  account  of  physical  prop- 
erties and  physiological  efTects,  followed  by  methods 
of  appHcation. 

Where  it  helps  in  diseases  of  the  circulatory  and 
nervous  systems,  in  joint  disease,  in  thoracic  affec- 
tions, forms  Part  II,  and  surgical  diathermy  the 
third.  In  these  days,  when  old  age  finds  people 
rebellious,  not  resigned,  the  hope  given  in  their 


iniscre  physiologique  is  cheerful.  Appetite,  diges- 
tion, general  health,  are  improved.  The  artificial, 
general  pyrexia  resulting  from  diathermy  treatment 
differs  from  ordinary  pyrexia  in  that  it  is  not  pro- 
duced by  toxins  circulating  in  the  blood.  One  of 
the  evils  which  inexperience  may  bring  about  is 
an  attempt  to  produce  a  raised  blood  pressure  by 
means  of  high  frequency  currents  in  chronic  auto- 
intoxication during  constipation.  An  excessive  ab- 
sorption of  enterotoxins  from  the  intestines  may 
be  set  up  which  will  raise  the  blood  pressure  and 
produce  an  acute  toxemia.- 

In  brachial  neuritis,  so  difficult  to  combat,  par- 
ticularly when  there  are  trophic  changes  and  atrophy, 
the  author  finds  that  diathermic  application  to  the 
joints,  followed  by  x  ray  treatment,  often  causes 
absorption  of  the  periarticular  adhesions.  Insomnia, 
too,  a  dreaded  foe,  is  defeated  by  faradization  of  the 
brain.  All  those  diseases  vaguely  grouped  under 
socalled  rheumatism,  especially  osteoarthritis,  have 
been  much  eased. 

The  author  is  quite  frank  about  its  disadvantages 
in  surgery ;  the  healthy  structures  may  also  be 
destroyed ;  the  surgeon  cannot  see  important  vessels 
and  nerves ;  secondary  hemorrhage  may  result  if 
operating  near  large  blood  vessels ;  cheloid  may 
form  when  skin  surfaces  are  involved.  As  exact 
references  are  given  when  other  men  are  quoted,  this 
handbook  is  the  key  to  much  valuable  literature 
which  will  help  the  serious  student  and  deter  those 
inclined  to  practise  with  only  a  superficial  knowl- 
edge. 

HYDROTHER.\PY. 

An  Epitome  of  Hydrotherapy.  For  Physicians,  Architects, 
and  Nurses.  By  Simox  Baruch,  M.  ID.,  LL.  D.,  Consult- 
ing Physician  to  Knickerbocker  and  Montefiore  Hos- 
pitals :  Hydrotherapeutist  to  Sea  View  Hospital  for 
Tuberculosis,  etc.  Illustrated.  Philadelphia  and  London  : 
W.  B.  Saunders  Company,  1920.    Pp.  xi-205. 

Curious,  how  obstinately  we  have  fought  our 
three  benefactors,  sun,  air,  and  water.  "I  can't 
imagine  how  you  can  worship  the  sun,"  said  a  Lon- 
don lady  to  the  Persian  ambassador.  "Oh,  but 
Madam,  if  you  could  only  see  it,"  he  answered. 
That  was  some  years  ago.  Now  stuffy  curtains 
and  ill  lighted  rooms  are  vanishing,  bath  rooms  are 
in  every  house,  the  poisonous  night  air  is  admitted 
and  everywhere  extolled.  There  are  still  a  few 
old  people  who  never  take  a  bath  in  case  they  should 
take  cold,  and  some  invalids,  who  would,  specially 
benefit,  who  content  themselves  with  a  foot  bath  for 
the  same  reason.  In  the  largest  lycee  in  Rheims 
it  used  to  be  put  on  the  prospectus  that  the  pupils 
had  a  footbath  once  a  fortnight.  In  middle  class 
houses  the  water  for  the  children's  Saturday  tub- 
bing had  all  to  be  carried  from  the  kitchen  to  the 
nursery.  At  the  end  of  each  tubbing  one  pailful 
was  emptied  out,  one  of  clean  put  in.  An  upstairs 
water  supply  was  a  luxury. 

But  hydro  has  now  to  carry  the  word  therapy, 
and  such  is  the  charm  of  the  unknown,  many  will 
go  in  for  hj^drotherapy  who  would  despise  the  cold 
water  cure.  That  it  is  not  more  appreciated  and 
effectual  Dr.  Baruch  ascribes  to  faulty  instalment, 
conscientious  but  untrained  directors  in  hospitals 
and  sanatoria,  and  the  ignorance  of  doctors  con- 
cerning its  theory  and  technic. 


958 


BOOK  REVIEWS. 


[New  York 
Medical  Journal. 


When  in  the  chair  of  hydrotherapy  at  the  College 
of  Physicians  and  Surgeons,  Cohnnbia  University, 
the  author  was  able  to  train  five  hundred  students 
without  difficulty.  Xow  he  has  sent  out  the  printed 
word  that  it  may  be  used  in  large  institutions  and 
in  class  teaching.  There  are  special  chapters  on 
typhoid,  influenza,  sunstroke,  tuberculosis,  neuras- 
thenia, and  one  on  whirlpool  baths,  also  a  special 
one  on  correct  instalment.  Through  this  book 
hydrotherapy  regains  its  lost  status,  for  it  is  not  a 
mere  statement  of  what  might  be  but  a  record  of 
results  gained  by  the  author  when  on  the  staf¥  of 
New  York  hospitals.  Any  mistrust  of  the  cure  now 
is  akin  to  Naaman's  contempt  for  Jordan  and  ours 
for  simple  fresh  water  as  a  curative  agent.  There 
is  one  rather  odd  sentence : 

"In  the  management  of  chronic  diseases,  the 
espousal  of  the  water  cure  by  socalled  empirics 
created  bitter  opposition,  especially  when  eminent 
men  like  Sir  Bulwer  Lytton  aided  their  cause  by 
excessively  lauding  water  in  literary  contributions." 
Here,  at  least,  it  was  somewhat  out  of  place. 

A  CORNER  IN  AMERICA. 

Poor  White.    By  Sherwood  Anderson.    New  York :  B. 
W.  Huebsch,  Inc.,  1920.    Pp.  371. 

Too  often  the  psychology  of  present  day  writers 
of  fiction  struggles  with  an  oppressive  selfconscious- 
ness.  The  unaffected  telling  of  this  tale  is,  there- 
fore, strangely  refreshing.  It  is  like  coming  upon 
a  fragrant,  straight  limbed  growth  of  pine  in  a  dry 
northern  sand,  after  wading  the  dank  growth  of  a 
tropical  jungle.  It  has  this  simple  fragrance  of  the 
earlier  days  in  our  northern  central  states — most 
of  the  story  happens  there.  But  into  such  an 
atmosphere  creeps  and  hardens  the  merciless  greed 
of  capitalistic  industrialism  with  its  rasping  worship 
of  mone}'  power  and  steel  made  success. 

The  story  is  well  told.  The  strokes  are  almost 
homely  in  their  directness  as  this  development  is 
traced  and  those  characters  are  drawn  which  so  well 
typify  the  sons  of  this  American  age  of  "success." 
It  is  the  true  homeliness  which  lies  close  to  the 
inner  lives  of  the  men  and  the  few  women  of  the 
book.  It  is  not  wanting  even  when  they  become 
encased  in  the  mail  which  their  greed  for  success 
has  forged  upon  them.  There  is  a  sincerity  to 
nature  in  the  writing  which  maintains  about  and 
beneath  the  harshness  the  softness  of  the  Ohio 
country,  and  finds  its  influence  unmarred  in  certain 
truer  souls. 

Jim  Priest,  the  farmhand,  and  Joe  Wainsworth, 
the  harnessmaker,  preserve  their  integrity  in  spite 
of  the  weakness  of  the  former  and  the  crazed 
tragedy  of  the  latter.  Chiefly  does  Hugh  McVey, 
the  "poor  white"  hero,  keep  his  life  clear  from 
contamination.  He,  moreover,  shows  what  dreams 
are  for.  He  fought  bravely  against  their  slothful 
grip  upon  him,  and  then  at  last  his  long  struggle 
brought  him  the  knov/ledge  that  dreams  are  the 
background  for  creative  achievement.  So  faithful 
was  he  further  to  the  reality  of  dreaming  that  when 
the  steel  age  had  burnefl  out  the  creative  force  from 
his  inventions,  he  could  drop  a  barren  success  and 
go  back  to  the  fountain  of  dreams  for  new  creation. 
There  the  story  leaves  him. 


Very  often  the  author  goes  back  to  tell  of  some 
previous  events,  often  rather  far  from  the  move- 
ment of  his  story.  This  is  a  somewhat  disturbing 
device  for  providing  the  necessary  settings  for 
men  and  events.  Yet  even  this  is  so  straightfor- 
ward, the  sentences  always  so  clearcut,  that  it  can 
scarcely  be  complained  of.  The  writer  makes  no 
lumbered  pretense  of  an  astute  psychology.  But 
whether  only  intuitively  or  with  a  specialist's  knowl- 
edge he  reveals  many  a  clear  gem  of  deep  psychic 
fact.  Is  the  cabbage  patch  chapter,  for  instance, 
one  of  those  spontaneous  revelations  which  writers 
make?  The  association  of  the  crooked  body,  the 
crooked  mind  soured  against  progress,  and  the 
hunched  position  over  the  brown  earth  among  the 
cabbage  plants  give  a  by  no  means  unfamiliar  psy- 
chic constellation. 

Sex  is  handled  with  healthy  freedom.  The  writer's 
mind  is  uncluttered  and  able  to  take  the  existence 
of  sex  in  its  psychic  and  bodily  naturalness.  Behind 
his  hero's  struggle  into  its  reality,  behind  the  various 
phases  in  which  he  treats  the  subject,  the  author 
maintains  a  clear  understanding.  One  would  look 
far  to  find  a  subtler  or  more  genuine  appreciation 
of  its  homopsychic  phase  than  in  the  character  of 
Kate  Chanceller,  a  familiar  type  of  woman. 

 <^  

New  Publications  Received. 


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


HELPING  THE  RICH.  A  Play  in  Four  Acts.  By  J.\mes 
Bay.    New  York:  Brentano's,  1920.    Pp.  107. 

CAPTAIN    MACEDOINE's   DAUGHTER.      By   WiLLIAM  McFeE. 

Garden  City,  N.  Y. :  Doubleday,  Page  &  Co.,  1920.  Pp. 
xxii-326. 

SEX  AND  LIFE.  By.  W.  F.  RoBiE,  M.  D..  Superintendent 
of  Pine  Terrace,  Baldwinville,  Mass.  Boston :.  Richard 
G.  Badger,  1920. 

domnei.  a  Comedy  of  Woman  Worship.  By  James 
Branch  Cabell.  New  York :  Robert  M.  McBride  & 
Co.,  1920.    Pp,  viii-218. 

WARFARE  IN  THE  HUM.\N  BODY.  Essays  on  Method. 
Malignity,  Repair  and  Allied  Subjects.  By  Morley 
Roberts.  With  an  Introduction  by  Professor  Arthur 
Keith,  M.  D.,  F.  R.  C.  S.,' F.  R.  S.,  etc.  London:  Eveleigh 
Nash  Company,  Limited,  1920.   Pp.  xii-286. 

vorlesungen  uber  bakteriologie,  immunitat,  spe- 
ZIFISCHE  diagnostik  und  therapie  der  tuberkulose.  Fiir 
.'Xerzte  und  Tierarzte.  Von  Dr.  Ernest  LowENSTEiN.a.o.  Pro- 
fessor an  der  Universitat  Wien.  Mit  1  Abbildung  im 
Text  und  2  Kurventafcln.  Jena :  Verlag  von  Gustav 
Fischer,  1920.    Seiten  viii-476. 

BACKWATERS  OF  LETHE  ( Some  Ancsthetic  Notions).  By 
G.  A.  H.  Barton,  M.  D.,  Anesthetist  to  the  Hampstead 
General  and  Royal  National  Orthopedic  Hospitals ;  For- 
merly Anesthetist  to  the  Throat  Hospital  (Golden  Square), 
etc.  With  Illustrations.  New  York:  Paul  B.  Hoeber,  1920. 
Pp.  vii-151.  , 

A    MANUAL    OF    PllACTICAL    ANATOMY.      .\    Guide    tO  the 

Dissection  of  the  Human  Body.  By  Thomas  Walmley, 
Professor  of  Anatomy  in  the  Queen's  University  of  Bel- 
fast. With  a  Preface  by  Thomas  H.  Brvce,  M.  A., 
M.  D.,  Professor  of  Anatomy  in  the  University  of  Glas- 
gow. In  Three  Parts.  Part  1 :  The  Upper  and  Lower 
Limbs.  New  York  and  London:  Longmans,  Green  &  Co., 
1920.    Pp.  viii-176. 


Practical  Therapeutics  and  Preventive  Medicine 

A  Compendium  of  Treatment  cind  Prophylaxis,  Original  and  Adapted 


A  Therapeutic  Study  of  Whooping  Cough. — - 

David  I.  Macht  {Bulletin  of  the  Johns  Hopkins 
Hospital,  July,  1920)  studied  115  cases  of  whoop- 
ing cough,  a  few  of  which  were  in  adults,  but  the 
majority  were  in  children  from  a  few  weeks  to 
fourteen  years  old.  All  the  cases  were  characterized 
by  whooping  and  in  many  vomiting  and  small 
hemorrhages  accompanied  the  paroxysm.  'Most  of 
the  patients  before  coming  to  Macht  had  been  un- 
successfully treated  by  paregoric  and  other  popular 
drugs ;  some  had  had  no  treatment,  while  others 
received  vaccines,  with  no  noteworthy  results.  The 
author  discontinued  all  medication  but  a  twenty 
per  cent,  solution  of  benzyl  benzoate  by  mouth,  the 
doses  varving  from  live  to  forty  drops  in  water, 
three  or  four  times  a  day  or  oftener,  according  to 
the  age  of  the  patient  and  the  severity  of  the  dis- 
ease. A  little  benzaldehyde  added  to  a  solution  of 
benzyl  benzoate  in  amounts  var\ung  from  one  per 
cent,  to  five  per  cent,  seemed  to  act  more  efTectively 
than  the  benzyl  benzoate  ajone.  The  medicine  can 
be  given  in  sugar  water  or  milk  where  the  simple 
alcoholic  solution  of  benzyl  benzoate  is  distasteful. 
It  was  not  found  satisfactory  to  give  benzyl  benzo- 
ate in  the  form  of  a  suspension  in  simple  elixir,  in 
syrup  of  yerba  santa  and  other  syrups  or  elixirs. 
Clinically,  about  ninety  per  cent,  of  the  patients 
showed  more  or  less  beneficial  results,  and  there 
was  marked  improvement  in  the  symptoms  in  about 
fifty  per  cent.  The  drug  exerts  only  a  palliative 
effect  on  the  violence  and  number  of  whooping 
cough  paroxysms;  it  is  not  curative. 

Radium  in  the  Treatment  of  Diseases  of  the 
Eye  and  Adnexa. — G.  B.  Xew  and  W.  L.  Bene- 
dict {  American  Journal  of  Ophthalmology.  April, 
1920)  state  that  their  experience  with  radium  in 
<:liseases  of  the  eye  has  been  in  two  groups  of  cases, 
first,  those  in  which,  in  their  judgment,  treatment 
should  be  with  radium  alone,  and  second,  those  in 
which  the  radium  treatment  is  emplo3-ed  in  addition 
to  surgery.  The  malignant  cases  were  selected  on 
a  basis  of  the  character  of  growth,  chronicity,  and 
extent  of  involvement  of  the  tissues.  \'arious  tj-pes 
of  epithelioma  may  be  found  about  the  lids  and 
globe  as  well  as  within  the  eye.  They  may  be  situ- 
ated on  the  margins  of  the  lid,  at  the  canthus,  or  at 
the  limbus.  The  degree  of  malignancy  will  be 
determined  by  the  type  of  cell  most  abundant,  and 
by  the  location  and  direction  in  which  the  tumor 
extends.  A  basal  cell  epithelioma  may  extend  over 
considerable  area  on  the  surface  of  the  lids  and  do 
less  permanent  damage  than  a  much  smaller,  similar 
epithelioma  at  the  inner  canthus,  which  is  rapidly 
extending  toward  the  apex  of  the  orbit.  Epithelio- 
matous  nests  that  lie  deep  in  the  tissues  are  difficult 
to  reach,  and  for  several  months,  or  even  years, 
after  treatment  with  radium,  it  is  impossible  to 
determine  whether  or  not  the  growth  has  become 
inactive.  A  section  of  tissues  which  had  been  sub- 
jected to  treatment  with  radium  years  before  for 
e])it]ielioma,  was  found  to  be  imdergoing  epithelial 


cell  proliferation  and  infiltration  without  evidence 
on  the  surface.  In  some  cases,  therefore,  it  is  better 
to  remove  the  involved  tissue  with  the  knife  or 
cautery  and  apply  radium  later.  In  other  cases 
radium  alone  may  be  sufficient  to  effect  a  cure.  The 
action  of  radium  in  infectious  diseases  of  the  eye 
is  comparatively  slow.  Rapidly  extending  ulcers 
of  the  cornea  should  be  treated  locally  by  the  rem- 
edies commonly  employed  in  addition  to  the  use 
of  radium,  if  it  is  used.  Vernal  catarrh  is  probably 
benefited  by  radium  treatment,  but  a  report  on  this 
disease  is  withheld  pending  further  study. 

The  Cure  of  Hookworm  Infection. — John  L 
Kantor  (American  Journal  of  the  Medical  Sciences, 
April,  1920)  says  that  an  individual  from  a  hook- 
worm district  should  not  be  pronounced  hookworm 
free  until  a  series  of  at  least  five  negative  stools  has 
been  obtained,  and  then  only  if  the  last  treatment 
took  place  six  or  more  weeks  previously.  The  latent 
period  after  treatment,  that  is.  the  period  in  which 
the  egg  laying  tunction  of  the  hookworm  is  de- 
pressed by  the  vermifuge  so  that  the  persistence  of 
worms  cannot  be  revealed  by  stool  examination, 
may  extend  up  to  six  weeks.  However,  the  great 
majority,  ninety-eight  per  cent.,  of  cases  become 
positive  again  within  four  weeks  after  treatment. 
The  usttal  form  of  treating  ankylostomiasis  with 
drugs  given  by  mouth  has  been  shown  to  be  unsat- 
isfactory, even  relatively  mild  infections  resisting 
as  many  as  seven  or  eight  treabnents.  IVIuch  more 
efficient  results  can  be  obtained  by  the  method  of 
intraintestinal  tube  treatment,  owing  to  the  fact  that 
the  full,  concentrated  dose  of  vermifuge  is  delivered 
precisely  at  the  point  of  infection.  Instead  of 
thirty-four  per  cent,  of  cures,  as  in  the  case  of  a 
first  mouth  treatment,  fully  eighty  per  cent,  are 
cured  by  a  first  tube  treatment.  Only  one  repetition 
is  necessary  for  relief  in  the  majority  of  cases. 

Cardiovascular  Reaction  to  Epinephrin. — Paul 
W.  Clough  (BuUelin  of  the  Johns  Hopkins  Hospi- 
tal, August,  1920)  records  his  observations  of  a 
group  of  patients  in  which  the  cardiovascular 
response  to  epinephrin  was  studied  in  detail,  because 
of  the  increasing  use  as  a  diagnostic  procedure  of 
the  response  of  a  patient  to  a  subcutaneous  injec- 
tion of  epinephrin.  Tests  were  carried  out  on 
ninety-five  subjects,  of  which  thirty-two  were  either 
normal  controls  or  patients  who  were  regarded  as 
physically  normal.  Marked  dififerences  in  the 
cardiovascular  reaction  to  a  subcutaneous  injection 
of  one  mg.  of  epinephrin  were  noted.  The  reactions 
Clough  classifies  as  negative,  moderate,  marked, 
and  very  marked.  A  moderate  reaction  consisted 
of  a  rise  in  systolic  and  a  fall  in  diastolic  blood 
pressure,  an  increased,  often  doubled,  pulse  rate, 
and  slight  tachycardia.  \\'ith  marked  reactions 
there  was  also  sometimes  glycosuria,  and  often 
tachycardia,  palpitation,  pallor,  mydriasis,  tremor, 
nervousness,  and  anxiety.  Two  factors  seem  to  be 
concerned  in  these  reactions :  a  direct  stimulation 


960 


PRACTICAL  THERAPEUTICS  AND  PREVEXTIl'E  MEDICI XE. 


[New  York 
Medical  Journal. 


of  the  heart  with  increase  in  the  force  of  the  beat, 
and  in  the  volume  output,  as  well  as  in  the  rate, 
and  constriction  of  the  peripheral  vessels.  Atro- 
pine often  exaggerated  the  response  to  a  subse- 
quent injection  of  epinephrin.  Eighty-two  per 
cent,  of  the  thirty-two  normal  individuals  gave  a 
slight  or  moderate  response.  Patients  with  hyper- 
tension often  showed  severe  reactions,  which 
occurred  irrespective  of  the  cause,  the  degree,  or 
the  duration  of  the  hypertension.  None  of  the 
patients  gave  evidence  of  significant  endocrine  dis- 
turbance. This  epinephrin  sensitiveness  in  hyper- 
tension may  be  only  one  manifestation  of  a  general 
abnormal  reactivity  of  the  cardiovascular  system 
to  stimuli,  and  need  not  be  attributed  to  a  hyper- 
activity of  the  chromaffin  system  or  the  thyroid. 

Jejunocolic  Fistula  After  Gastrojejunostomy. 
— C.  Bolton  and  W.  Trotter  (British  Medical 
Journal,  June  5,  1920)  report  in  detail  four  cases 
of  this  complication  and  summarize  the  literature 
on  the  subject.  Twenty-seven  cases,  beside  their 
own  series,  are  quoted.  The  symptoms  develop 
after  the  symptoms  of  jejunal  ulcer  have  existed 
for  some  time.  The  onset  is  usually  with  diar- 
rhea, intestinal  colic,  and  finally  fecal  vomiting. 
Ph}-sical  examination  is  not  of  much  assistance  in 
establishing  a  positive  diagnosis,  but  the  x  ray  may 
lielp.  There  are  various  tests  of  feeding  or  of 
rectal  injections  with  the  examiratioh  of  rectal  or 
gastric  contents  shortly  afterward  which  may  help 
considerably  in  the  diagnosis.  Prognosis  in  the 
condition  is  fair  if  an  operation  is  performed,  as 
in  the  thirty-one  cases  investigated,  in  twenty-seven 
operations  were  performed,  with  twenty-one  re- 
coveries. The  four  cases  in  which  no  operation, 
was  performed  wer?  fatal.  Realizing  the  possibility 
of  this  complication  of  gastrojejunostomy,  it  is 
highly  important  that  we  use  such  prophylactic 
methods  as  are  at  hand.  The  aim  must  be  to 
reduce  the  acidity  of  the  gastric  contents  by  a 
correct  diet  and  by  the  use  of  alkalies. 

The  Effect  of  Arteriovenous  Fistula  upon  the 
Heart  and  Bloodvessels. — Mont  R.  Reid  (Bulletin 
of  the  Johns  Hopkins  Hospital,  February,  1920) 
gives  abstracts  of  experiments  on  twelve  dogs  in 
which  fistulse  were  produced,  in  the  femoral  vessels 
in  five  instances,  and  in  the  remaining  seven  between 
the  internal  carotid  artery  and  the  jugular  vein. 
Ab.stracts  are  also  given  of  fourteen  cases  of  arterio- 
venous fistula  treated  in  the  wards  of  Johns  Hop- 
kins Hospital.  From  thifi  clinical  observation  and 
experimental  study  Reid  concludes  that  an  arterio- 
venous fistula  of  long  standing  usually  causes  dila- 
tation of  the  artery  proximal  to  the  fistula,  which 
dilatation  may  extend  as  far  as  the  heart.  An 
acquired  arteriovenous  fistula  of  long  duration  may 
])roduce  cardiac  hypertrophy  and  dilatation  with 
eventual  decompensation.  The  wall  of  the  vein 
involved  in  an  arteriovenous  fistula  becomes  hyper- 
Irophied,  and  though  the  vein  on  the  proximal  side 
of  the  fistula  does  not  increase  greatly  in  size,  its 
wall  does  show  a  greater  increase  of  elastic  tissue 
than  the  wall  of  the  vein  distal  to  the  fistula.  There 
is  an  increase  in  the  venous  blood  pressure  in  the 
part  of  the  body  distal  to  an  arteriovenous  fistula, 
which  returns  to  nonnal  when  the  fistula  is  cured. 


Treatment  of  Industrial  and  Traumatic  De- 
formities.— Walter  G.  Stern  (Ohio  State  Medical 
Journal,  May,  1920),  in  discussing  the  treatment 
of  these  conditions,  concludes  that  infection  must  be 
avoided  at  all  costs  by  thorough  asepsis,  the  avoid- 
ance of  needless  operations,  and  perfect  fixation 
during  the  stage  of  first  aid.  Fractures  must  be 
thoroughly  reduced  and  accurately  fixed  in  appro- 
priate positions.  All  fractures  should  be  radio- 
graphed for  study  and  record.  After  the  danger 
of  infection  has  passed  corrective  operations  can 
be  safely  performed.  Closed  fractures  are  not  to 
be  unnecessarily  opened  up.  End  to  end  apposition 
is  not  always  the  best  method  to  obtain  a  good 
functional  result.  Hydrotherapy,  electrotherapy, 
mechanotherapy,  massage,  and  active  and  passive 
exercises  should  be  employed. 

Treatment  of  Diphtheria.— Aurelio  Ramos 
(La  Mcdicina  Ihcra,  June  5,  1920)  divides  the 
treatment  into  specific,  local  and  general.  As  to 
specific  treatment  he  emphasizes  the  importance  of 
the  administration  of  a  sufficient  dose  of  serum  at 
the  outset,  preferably  by  the  intravenous  route,  and 
he  does  not  repeat  the  dose  until  the  second  or 
third  day.  He  disregards  the  dangers  of  ana- 
phylaxis as  being  very  .rare.  Locally  he  has  had 
the  greatest  success  with  Dakin's  solution  and 
pyocyanase  which  is  an  enzyme  obtained  from  cul- 
tures of  the  pyocyaneus  bacillus.  This  enzyme  was 
found  by  Emmerich  and  Loew  to  inhibit  the  growth 
of  the  diphtheria  bacillus  and  to  fix  its  toxins,  at 
the  same  time  dissolving  the  membrane.  General 
treatment  consists  of  rest  in  bed  with  attention  to 
tachycardia,  high  temperature,  and  albuminuria. 

Intermittent  Hydrops  of  the  Parotid  Due  to 
Artificial  Dentures. — Jardet  (Bulletin  de  I'Acadc- 
mic  de  medccine,  April  13,  1920)  observed  in  four 
healthy  persons  a  sudden  painful  but  temporary 
swelling  of  the  parotid  gland,  which  he  ascribes 
to  the  wearing  of  new  artificial  dentures.  The  con- 
dition generally  appeared  within  a  few  days  after 
initial  use  of  the  dentures,  and  set  in  suddenly,  as 
a  rule  at  breakfast  time.  The  gland  enlarged 
rapidly  during  mastication,  and  soon  reached  the 
size  of  a  mandarin  or  even  an  orange.  The  initial 
sharp  pain  passed  into  a  dull  pain,  suggesting 
mumps.  The  gland  gradually  subsided  in  the  after- 
noon, but  the  swelling  recurred  on  the  next  day. 
Suppression  or  modification  of  the  denture  was 
always  followed  by  recovery  in  two  or  three  days. 
Where  the  denture  was  not  removed,  the  acute 
manifestations  subsided  after  four  or  five  days, 
but  recurrence  took  place  frequently  within  three 
or  four  weeks,  continuing  in  one  case  as  long  as 
eighteen  months.  In  such  instances  the  gland 
showed  slight  induration  and  sometimes  slight  en- 
largement in  the  intervals  between  attacks.  In  each 
of  the  author's  cases  the  prosthetic  apparatus  used 
was  a  plate  -of  hard  rubber  bearing  upper  molars 
on  the  affected  side  and  with  a  markedly  prominent 
outer  border,  impinging  on  the  tissues  between  the 
gums  and  cheek  with  each  movement  of  mastication. 
Abrasions  of  the  mucous  membrane  in  this  situation 
were  noted.  In  no  case  was  a  gold  plate  in  use; 
such  plates  are  considered  to  have  antiseptic  prop- 
erties and  are  lighter  than  the  hard  rubber  i)lates. 


Proceedings  of  National  and  Local  Societies 


NEW  YORK  NEUROLOGICAL  SOCIETY. 
Regular  Meeting,  Held  April  20,  1920. 
The  President,  Dr.  Walter  Tim  me,  in  the  Chair. 
( Concluded  from  page  920.) 

Acute  Descending  Radiculitis — A  Spinal  Type 
of  Epidemic  Encephalitis. — Dr.  Irving  H.  Pardee 
in  this  paper  offered  a  survey  of  the  Hterature  on 
the  subject,  notably  in  its  connection  with  herpes 
zoster  and  syphilis.  During  the  influenza  epidemic 
he  had  had  occasion  to  study  a  number  of  cases  of 
radiculitis  all  of  vv^hich  invaded  the  cord  in  a  de- 
scending fashion,  and  presented  characteristic 
symptoms  of  sharp  lancinating  root  pains,  pares- 
thesia, muscular  spasms,  hyperesthesia,  delirium, 
and  fever.  Several  days  after  the  onset  of  the 
pains,  involuntary  muscular  spasms  appeared,  caus- 
ing coarse  tvi^itching  movements  of  head,  shoulder 
and  neck,  like  the  spasmodic  contractions  sometimes 
observed  in  spinal  cord  tumors.  About  a  v^^eek 
later  vi^hen  the  symptoms  had  become  much  less  se- 
vere a  mild  delirium  usually  appeared.  A  confu- 
sional  state  persisting  for  three  or  four  days  was 
noted,  followed  by  a  two  week  period  of  dulness 
and  general  apathy. 

The  clinical  course  of  the  disease  was  peculiar. 
The  symptoms  were  at  first  confined  to  the  arm  and 
neck,  then  progressed  downward  in  orderly  fashion. 
Radiating  pain  was  first  felt  in  the  upper  chest, 
then  girdle  sensations  around  the  waist.  While  the 
symptoms  were  at  their  height  in  the  intercostal 
and  abdominal  region  there  was  delirium,  but  the 
pain  was  usually  less  severe.  The  symptoms  then 
descended  to  the  legs,  the  pain  increasing  greatly 
in  intensity.  A  slight  increase  in  fever  preceded 
the  invasion  in  the  lumbosacral  region,  which 
diminished  again  in  about  four  or  five  days.  There- 
after a  slow  convalescence  of  many  weeks'  duration 
began.  During  this  convalescence  there  was  a 
coarse  tremor  of  the  arms  and  legs.  No  other 
vasomotor,  trophic,  or  sensory  changes  were  to  be 
noted.  There  was  no  anesthesia  to  touch,  pain  or 
temperature,  no  disturbance  of  deep  sensibility,  and 
no  herpes.  The  reflexes  were  not  profoundly 
altered,  though  at  the  onset  slight  exaggeration 
of  the  deep  reflexes  was  noted  with  a  diminution  in 
their  activity  several  days  after  the  invasion  in 
eacli  region.  There  was  no  alteration  in  pupillary 
reaction,  no  blurring  of  vision,  nor  oculomotor 
weakness.  Control  of  the  bladder  and  rectum  was 
retained.  One  symptom  of  interest  observed  in  all 
the  cases  was  an  involuntary  flexion  of  the  head. 
It  was  not  necessary  for  comfort,  and  resembled 
the  attitude  seen  in  cervical  spinal  cord  tumor, 
syringomyelia,  and  sometimes  in  amyotrophic  lateral 
sclerosis.  The  results  of  laboratory  analysis  showed 
a  leucocytosis  in  the  blood — and  in  the  spinal  fluid 
an  increase  in  globulin  and  a  pleocytosis. 

Dr.  Pardee  gave  the  history  of  one  case  that 
presented  all  the  characteristics  outlined.  Clinical 
evidence  from  this  and  numerous  other  cases 
studied  showed  that  there  was  frequently  an  involve- 
ment of  the  posterior  spinal  roots,  appearing  either 


alone  or  in  conjunction  with  signs  of  an  encepha- 
litis. All  Dr.  Pardee's  patients  recovered,  so  other 
reports  had  to  be  resorted  to  for  autopsy  findings. 
Round  cell  infiltration  in  the  posterior  root  ganglia 
was  noted  by  Strauss  and  Loewe,  and  a  like  involve- 
ment with  some  small  hemorrhages  and  perivascular 
infiltration  by  Flexner  and  Amoss. 

In  summarizing  the  points  brought  out  by  his 
study,  Dr.  Pardee  stressed  the  frequency  with  which 
epidemic  encephalitis  might  invade  almost  any  por- 
tion of  the  nervous  system.  It  seemed  to  show  a 
predilection  for  the  basal  ganglia,  nuclei  of  cranial 
nerves,  and  posterior  roots,  as  evidenced  in  the  cases 
that  he  studied.  Acute  descending  radiculitis  was 
an  infection  of  the  posterior  spinal  roots  which  might 
appear  as  a  separate  clinical  entity  and  pursued  a 
stereotyped  course,  ending  in  recovery.  It  might 
also  antecede  in  a  more  or  less  typical  but  usually 
attenuated  course,  the  cerebral  form  of  epidemic 
encephalitis.  If  a  posterior  root  syndrome  might 
be  considered  a  prominent  complication  of  epidemic 
encephalitis.  Dr.  Pardee  believed  that  myoclonic 
twitchings,  hyperesthesia,  and  radicular  pains  might 
be  considered  as  much  a  part  of  the  picture  of  the 
disease  as  diplopia,  somnolence,  and  cranial  nerve 
palsies.  The  concomitance  of  radicular  pains  and 
influenza  offered  another  suggestion  on  the  obscure 
etiology  of  this  disease  manifestation. 

An  Analysis  of  the  Cases  Admitted  to  the 
Neurcpsychiatric  Services  of  the  U.  S.  A.  Gen- 
eral Hospital  Number  i. — Dr.  Sylvester  R. 
Leahy,  of  Brooklyn,  described  the  opening  of  the 
ward  for  neuropsychiatric  patients  from  overseas 
and  such  cases  as  developed  in  hospitals  under  the 
jurisdiction  of  the  Port  of  New  York.  The  hospital 
was  opened  on  November  22,  1918,  in  the  former 
Messiah  Home.  It  contained  five  wards,  two  of 
which  were  devoted  to  the  psychoses,  one  for  dis- 
turbed patients,  and  one  for  quiet  depressed  ones. 
The  remaining  space  was  allotted  to  mild  mental 
states,  epilepsies,  psychoneurotics,  constitutional 
psychopaths.  The  bed  capacity  was  220.  During 
the  fime  that  the  hospital  was  in  operation,  nine 
months  and  twenty-two  days,  2,750  patients  were 
admitted,  2,126  patients  came  from  overseas,  and 
624  were  local  cases.  Since  the  hospital  was  an 
evacuation  unit,  urgent  conditions  only  were  treated, 
but  its  facilities  were  very  complete,  and  detailed 
reports  and  recommendations  for  treatment  were 
forwarded  to  each  patient's  final  destination. 

Of  the  total  number  of  cases,  twenty-four  per 
cent,  were  psychoneurotics,  twenty  per  cent,  were 
of  the  dementia  prjecox  type,  twelve  per  cent,  were 
of  the  manic  depressive  group,  ten  per  cent,  were 
mental  defectives,  five  per  cent  were  organic  nerv- 
ous disease,  principally  of  the  syphilitic  type,  four 
per  cent,  were  definitely  epileptic,  and  four  per 
cent,  were  constitutional  psychopaths.  Doctor 
Leahy  made  a  comparison  between  the  group  per- 
centages of  the  hospital  with  the  group  percentages 
of  the  New  York  State  Hospital  service  male  ad- 
missions ;  twenty  per  cent,  army  and  twenty-seven 
per  cent,  civilian  was  the  result  for  dementia  prae- 


9()2 


PROCEEDINGS  OF  NATIONAL  AND  LOCAL  SOCIETIES. 


[New  York 
Medical  Journal. 


COX,  and  twelve  per  cent,  army  and  nine  per  cent, 
civilian  for  manic  depressive  psychoses.  The  de- 
mentia praecox  was  predominant  in  both  groups.  A 
certain  number  of  psychoses  were  left  ungrouped 
because  of  lack  of  data  sufficient  to  make  a  differen- 
tiation possible.  Some  of  the  patients  refused  to 
answer  questions.  They  appeared  confused  and  in 
a  dreamlike  perplexed  state.  At  times  they  were 
very  depressed. 

Dr.  Sanger  Brown,  II,  in  discussing  this  paper 
offered  some  statistics  regarding  the  Hospital  Cen- 
tre at  Savenay,  France.  From  this  centre  nearly  all 
the  disabled  of  the  A.  E.  F.  were  returned  to  Amer- 
ica and  it  was  at  this  point  that  neuropsychiatric 
cases  were  evacuated.  The  census  of  the  centre 
was  about  ten  thousand  patients,  and  of  this  num- 
ber about  one  thousand  were  in  the  neuropsychiatric 
service ;  in  other  words,  one  tenth  of  the  cases. 
From  a  survey  of  all  cases  in  the  centre  made  later, 
it  was  found  that  about  twelve  per  cent,  of  all  the 
injuries  involved  the  central  or  peripheral  nervous 
system ;  and  it  was  thought  that  in  the  general  wards 
were  other  patients  suffering  from  neurotic  symp- 
toms of  sufficient  number  to  bring  the  total  percent- 
age of  cases  coming  under  the  care  of  the 
neuropsychiatrists  to  about  thirty  in  that  centre. 

Of  the  patients  returned  to  the  United  States  from 
!he  neuropsychiatric  service  about  thirty  per  cent, 
v.-ere  suffering  from  psychoses,  thirty-three  per  cent, 
suffered  from  psychoneuroses,  ten  per  cent,  were 
mental  defectives,  eight  per  cent,  were  epileptics, 
ten  per  cent,  were  psychopaths,  and  five  per  cent, 
suffered  from  organic  diseases  with  mental  mani- 
festations ;  the  remaining  four  per  cent,  were  un- 
determined types. 

The  staff  was  conservative  in  rendering  a  posi-" 
tivc  diagnosis  of  dementia  prjecox  since  the  symp- 
tom^  were  acute  and  the  imusual  circumstances 
were  taken  into  consideration.  A  number  of  mental 
conditions  were  encountered,  with  which  the  staff 
was  not  familiar  in  civil  life — the  socalled  war 
psychoses,  physical  exhaustion,  delirium,  and  fear, 
with  disorientation,  were  especially  common.  A 
second  imusual  condition  was  the  combination  of 
hysterical  states,  such  as  palsies,  contractures  or 
tremors  with  a  psychosis,  or  with  epilepsy  or  mental 
defect.  Lethargic  encephalitis,  new  at  that  time, 
was  encountered  to  a  considerable  extent,  and  as  no 
literature  was  available,  these  cases  were  very  puz- 
zling when  they  first  began  to  appear. 

A  Study  of  Pubertas  Praecox. — Dr.  J.  H. 
Li:i.m:r  reviewed  the  historical  references  to  cases 
of  pubertas  jjnecox.  In  this  syndrome  it  would 
seem  that  the  child  passed  through  several  stages  of 
life  /))  utcro.  The  endocrines  seemed  to  be  a  pri- 
mary factor  in  the  causation  of  this  condition. 
Secondary  factors  were  climate,  race,  and  heredity. 
As  was  well  known,  menstruation  appeared  nor- 
mally at  a  somewhat  earlier  age  among  women  in 
southern  countries,  while  the  inhabitants  of  the 
north  normally  did  not  begin  to  menstruate  until 
from  fourteen  to  sixteen.  Marriage  in  Oriental 
races  took  place  very  early,  and  the  precocity  of  the 
southern  races  might  be  due  to  this  inbreeding. 

Doctor  Leiner  described  two  cases  in  which  there 
had  apparently  l)een  direct  hereditary  transmission. 


One  subject,  a  girl,  at  birth  gave  the  impression  of 
a  twelve  year  old  child ;  menstruation  began  at  six 
weeks,  and  was  regular  thereafter.  A  second  case, 
that  of  a  boy,  at  four  years  of  age  looked  as  though 
he  were  at  least  ten,  and  had  the  physical  develop- 
ment of  a  young  man  of  twenty-one.  The  parents 
in  both  cases  reported  marked  virility,  or  there  was 
actual  pubertas  prsecox  in  the  parent. 

Precocious  puberty  is  caused  by  a  hypersecretion 
of  either  the  gonads,  pineal,  or  corticoadrenal  glands. 
A  secondary  involvement  of  the  pituitary  and  thy- 
roid is  also  unquestionable.  Clinicopathological 
evidence  showed  that  the  first  three  glands  were 
involved  in  this  syndrome,  either  in  the  form  of 
hyperplasia  affecting  them,  or  neoplasms. 

Rogers  collected  101  cases  of  pubertas  praecox, 
eighty-one  in  the  female  and  twenty  in  the  male; 
out  of  the  eighty-one  cases  in  the  female,  seventy- , 
three  pointed  to  the  hyperovarian  type.  Other  writers 
had  recorded  cases  of  this  type,  among  them  Lenz, 
who  described  the  case  of  a  girl  in  whom  menstrua- 
tion began  at  sixteen  weeks.  The  secondary  sex 
characteristics  were  those  of  a  mature  woman.  As 
she  grew  up  she  became  a  good  scholar,  but  pre- 
ferred the  society  of  children  of  her  own  age.  At 
twelve  she  was  very  shy  and  childish  in  behavior. 

Lucas  reported  neoplasm  of  the  ovary  as  a  cause 
of  pubertas  prscox.  At  seven  his  patient  showed 
all  the  signs  of  genitosomatic  maturity,  with  early 
menses.  After  removal  of  a  tumor  of  the;  ovary, 
all  signs  of  adolescence,  and  menstruation,  disap- 
peared. Eleven  cases  of  sexual  precocity  associated 
with  ovarian  neoplasms  were  collected  by  Roger 
Williams.  This  did  not  necessarily  indicate  that 
tumors  of  the  ovary  lead  to  sexual  precocity,  since 
other  factors  entered  into  the  causation.  The  men- 
tality in  the  ovarian  cases  never  seemed  to  be  very 
great ;  in  fact,  the  patients  spoke  and  acted  their 
true  age.  Early  menstruation  in  hyperovarianism 
produced  excess  calcium  elimination,  which  resulted 
in  short  stature. 

In  the  corticoadrenal  types  of  cases  the  clinical 
picture  differed  according  to  whether  the  involve- 
ment was  in  the  male  or  the  female.  Hyperplasia 
of  the  adrenals  in  the  male  tended  to  accentuate 
male  precocity ;  in  the  female,  the  tendency  was  to 
change  the  female  into  the  male  type  with  all  the 
secondary  sexual  characteristics  of  the  male.  The 
mentality  in  these  cases  was  low. 

In  cases  of  hypergonadal  condition  in  the  male, 
mentality  was  usually  retarded.  In  one  case  of 
precocious  sexuality  the  removal  of  a  malignant 
tumor  of  the  testicle  caused  the  disappearance  of 
the  adult  characteristics.  Tumors  of  the  pineal  and 
their  effect  upon  se.xual  precocity  had  been  exten- 
sively studied,  but  as  yet  no  direct  connection 
seemed  to  have  been  demonstrated,  aside  from  the 
statistical  fact  that  pineal  tumors  occurred  pre- 
dominately ix>  the  male  while  those  of  the  adrenals 
were  most  frequent  in  the  female.  There  was  little 
or  no  real  mental  precocity  in  all  these  types,  the 
patients  were  usually  shy  and  reserved  on  account 
of  their  appreciation  of  their  differences  from  the 
normal  type.  Early  diagnosis  in  the  hyperplastic 
types  might  result  in  improvement  by  ])roper  endo- 
crine therapy. 


December  11.  1920.]  FROCEEDIXGS  OF  NATIONAL  AND  LOCAL  SOCIETIES. 


963 


Meeting  Held  on  May  4,  1920. 

Presentation  of  a  Case  of  Epileptic  Seizures, 
Transient  Hemiplegias,  and  Temporary  Papille- 
dema of  Doubtful  Etiology. — Dr.  Thomas  K. 
Davis  showed  a  patien!:  who  had  had  typical  epi- 
leptic seizures  since  her  eleventh  year.  There  was 
usually  temporary  weakness  of  the  right  side  after 
an  attack.  She  was  brought  to  Bellevue  after  an 
especially  severe  attack,  where  her  condition  was 
diagnosed  as  a  straight  case  of  epilepsy.  On  the 
tenth  day,  however,  she  awoke  with  a  severe  hemi- 
plegic  condition  on  the  right  side  with  a  partial 
motor  aphasia.  The  fundi  were  considered  normal 
on  the  day  that  the  hemiplegic  symptoms  developed, 
but  forty-eight  hours  afterward  a  papilledema  was 
found  on  the  right  and  a  blurring  of  the  disc  on  the 
left.  The  papilledema  did  not  continue,  so  the 
theory  of  a  neoplasm  with  a  hemorrhage  into  it 
had  to  be  abandoned.  A  month  after  the  onset  of  the 
hemiplegia  the  patient  had  recovered  the  motor 
function  of  the  right  side,  and  was  able  to  walk 
without  support. 

In  reviewing  the  possible  causes  for  this  papill- 
edema, ethmoid  sinus  infection  was  ruled  out  by 
absence  of  fever  and  by  negative  findings  of  the 
nose  and  throat.  No  edema  or  other  signs  of  acute 
nephritis  had  been  observed  in  the  patient  and  the 
high  tension  cardiac  changes  were  also  lacking. 
Epidemic  encephalitis  did  not  seem  probable,  since 
there  was  no  somnolence,  no  ocular  palsies  occurred, 
and  the  patient  had  no  fever.  Finally,  Dr.  Davis 
called  attention  to  the  glandular  makeup  of  the 
patient,  pigmentation  and  evidence  of  suprarenal 
deficiency,  with  gonadal  deficiencies  also,  and  sug- 
gested a  possible  etiolog}-  in  focal  compensatory 
changes  in  the  pituitary  gland  causing  temporary- 
pressure  on  the  third  ventricle  with  resultant  swell- 
ing of  the  optic  nerve  heads. 

An  Unusual  Case  of  Epidemic  Encephalo- 
myelitis.— Dr.  Walter  M.  Karus  presented  the 
case  of  a  riveter,  aged  thirty-two,  who  was  admitted 
to  Bellevue  Hospital  on  February  23,  1920,  com- 
plaining of  pains  and  weakness  in  the  shoulders  and 
arms.  These  pains  he  had  had  in  the  shoulders 
and  arms  for  three  to  four  weeks  prior  to  admission. 
They  were  increased  by  movement.  Soon  after 
the  onset,  weakness  of  the  upper  extremities  became 
noticeable  and  finally  compelled  the  patient  to  stop 
work  on  February  10th.  He  noticed  diplopia  one 
week  before  admission. 

On  admission  there  was  weakness  and  tenderness 
of  the  muscles  of  both  arms  from  the  deltoids  down. 
There  were  fibrillary  twitchings  (paralysis  of  the 
long  respiratory  nerve  of  Bell  to  the  serratus  mag- 
nus).  Some  winging  of  the  left  scapula  was  also 
present.  The  weakness  was  generally  greater  on 
the  right  than  on  the  left.  This  may  have  been  due 
to  the  fact  that  for  twenty  years  the  patient  had 
been  accustomed  to  carry  heavy  pieces  of  iron  on 
the  right  shoulder.  The  pectoral  muscles  were 
strong.  There  was  a  slight  weakness  of  the  muscles 
supplied  by  the  left  seventh  cranial  nerve,  and  a 
-  masklike  expression.  There  were  nystagmoid  move- 
ments of  both  eyes  to  right  and  left.  Tremor  of 
the  eyelids,  tongue  and  hands  was  present.  The 
triceps  jerks  were  absent;  supinator  jerks  present; 


other  reflexes  normal ;  no  sensory  changes  beyond 
the  pain  noted,  and  no  incoordination.  On  April  26th 
the  diplopia  was  still  present;  March  1st,  sleepiness 
very  marked  and  hard  to  control;  March  4th,  atro- 
phy and  tenderness  of  both  infraspinati  noted; 
W.B.C.  10,400,  polymorphonuclears  sixty  per  cent. ; 
March  13th,  tenderness  in  the  shoulders  had  gradu- 
ally disappeared  and  there  was  tenderness  in  the 
hands;  ]\Iarch  17th,  pill  rolling  type  of  tremor 
noticed  in  both  hands ;  March  18th,  gait  was  shuf- 
fling, conjugate  movement  of  both  eyes  downward 
poorly  done.  Laboratory  findings  showed  the  spinal 
fluid,  on  admission,  forty  cells;  globulin,  colloidal 
gold  0000121000,  Wassermann  negative.  There 
existed  slight  left  facial  weakness ;  complete  paraly- 
sis of  the  right  serratus  magnus  and  partial  paralysis 
of  the  left  serratus  magnus  (winging)  ;  electrical 
reaction,  complete  R.D.  in  the  right  serratus  magnus. 
All  the  other  muscles  of  both  arms,  forearms  and 
hands  showed  a  partial  R.D.  There  were  fibrillary 
tremors,  atrophy  and  weakness  of  all  the  muscles 
of  both  upper  and  lower  extremities.  In  brief,  a 
case  of  acute  epidemic  encephalomyelitis  showing 
among  other  signs  the  results  of  involvement  of  the 
anterior  horn  cells  of  the  lower  cervical  (5,  6,  7,  8) 
and  first  thoracic  spinal  segments. 

Myotonia  Accusata. — Dr.  I.  Abrahamsois'  pre.- 
sented  a  patient  who  had  been  shown  two  years 
before  by  him  as  an  interesting  example  of  myotonia 
accusata.  The  condition  was  of  six  years'  dura- 
tion, no  illness  preceded  the  onset,  the  patient  was 
simply  unable  to  move  as  quickly  as  before,  and 
found  that  he  could  not  swallow.  The  initial  move- 
ment was  always  difficult,  ^and  at  the  present  time 
this  was  one  of  the  few  symptoms  retained.  The 
patient  could  clench  his  fist,  but  an  additional  effort 
was  required  to  unclench  it.  The  Erb  sign  still 
continued.  When  the  tongue  was  pressed  a  distinct 
ridge  lasting  for  several  seconds  could  be  evinced. 
The  treatment  had  been  three  fourths  grain  of 
thyroid  daily,  and  forty-five  grains  of  calcium  lac- 
tate. Under  this  treatment  the  patient  had  re- 
covered from  his  clumsiness  and  was  able  to  work. 

Doctor  Abrahamson  called  attention  lo  the  fact 
that  the  left  sternomastoid  was  beginning  to  waste, 
and  remarked  that  certain  myotonias  of  Thomsen 
merge  into  myotonia  atiophica. 

The  Motofacient  and  Nonmotofacient  Cycles 
in  Elevation  of  the  Humerus. — Dr.  Byrox 
Stookey  read  a  paper  in  which  the  results  of  his 
investigations  on  the  muscles  which  act  in  the  eleva- 
tion of  the  humerus  were  set  forth.  Heretofore  it 
had  been  generally  accepted  that  the  deltoid  raised 
the  arm  approximately  to  a  right  angle  and  the 
elevation  was  completed  by  scapular  rotation.  His 
study  made  by  means  of  radiographic  plates  proved 
that  the  deltoid  without  rotation  of  the  scapula  was 
unable  to  raise  the  humerus  beyond  60°.  From 
this  height  to  about  115°  scapular  rotation  was 
called  into  play,  and  finally  the  elevation  from  115° 
to  an  approximate  straight  angle  was  completed  by 
the  deltoid.  The  deltoid  accordingly  acted  first  as 
abductor,  then  after  the  scapular  rotation  had  raised 
the  arm  over  the  intervening  55°  from  60°  to 
115",  the  deltoid  acted  as  abductor  for  the  rest  of 
the  distance. 


964 


PROCEEDINGS  OF  NATIONAL  AND  LOCAL  SOCIETIES. 


[New  York 
Medical  Journal. 


The  elevation  of  the  humerus  was  accordingly- 
effected  by  alternating  cycles.  In  the  first  cycle 
the  deltoid  and  supraspinatus  were  motofacient 
while  the  scapular  muscles  were  nonmotofacient. 
In  the  second  cycle  it  was  the  scapular  muscles  that 
were  motofacient,  while  the  deltoid,  supraspinatus 
teres  major,  pectoralis  major  and  latissimus  dorsi 
were  nonmotofacient.  The  completing  cycle  again 
called  into  play  the  deltoid  and  supraspinatus.  Sup- 
plementary factors,  hitherto  ignored,  that  played 
an  important  part  in  this  last  stage  of  elevation, 
were  two  muscles,  the  clavicular  head  of  the  pector- 
alis ajor,  and  the  coracobrachialis.  These  muscles 
participated  in  elevation  especially  when  great  force 
was  required,  or  when  there  was  impairment  of 
the  normal  function  of  the  deltoid. 

Medical  and  Social  Problems  of  Childhood  De- 
linquency.— Dr.  Sanger  Brown,  II,  in  reviewing 
the  question  of  the  medical  and  social  aspects  of 
childhood  delinquency,  spoke  of  a  survey  which  was 
being  made  in  one  of  the  probationary  schools  in 
New  York  city,  under  the  auspices  of  the  National 
Committee  for  Mental  Hygiene,  and  upon  the  in- 
vitation of  the  public  school  authorities.  This 
survey  consisted  of  a  thorough  physical  examination 
of  the  child,  a  mental  examination,  psychological 
test,  and  a  social  survey  of  his  home  and  environ- 
ment. To  carry  on  this  work  a  physician,  a 
psychologist  and  a  social  service  worker  had  been 
appointed.  In  their  inquiry  as  to  the  causes  of 
delinquency,  an  attempt  had  been  made  to  determine 
to  what  extent  this  condition  arose  from  physical 
causes,  mental  defect,  inherent  personality,  disorder, 
and  environmental  influences.  In  describing  the  cases 
so  far  examined,  certain  groups  of  children  were 
found.  There  were  the  nervous  children,  not  desig- 
nated as  neurotic  in-  the  way  adults  are  generally 
described,  but  children  who  showed  increased 
motor  activity,  decreased  motor  activity,  lack  of 
emotional  control,  such  as  explosive,  irritable  or 
sensitive  states,  and  disorders  of  sleep.  These 
nervous  symptoms  were  considered  benign  in 
character  and  amenable  to  treatment.  The  causes 
were  considered  both  physical  and  mental.  In  the 
physical,  they  might  be  malnutrition,  overstimula- 
tion from  unsuitable  food  and  physical  exhaustion. 
In  the  mental  sphere  a  child  might  become  neurotic 
and  emotional  for  many  reasons.  A  child  was 
particularly  sensitive  to  faulty  home  influences — a 
nervous  mother,  friction  between  parents,  all  of 
which  caused  social  misunderstanding.  The  child 
might  be  unfavorably  compared  with  another  in 
the  family  and  might  feel  a  sense  of  failure  or 
inferiority.  Such  maladjustments  might,  of  course, 
arise  in  school  and  they  might  arise  from  sources 
within  the  child  itself — from  his  instinctive  life. 
Nervous  children  became  delinquent  because  they 
could  not  conform  to  the  ordinary  school  discipline. 
Reasons  for  their  irritability  and  emotional  state 
were  not  understood,  and  when  they  were  disciplined 
they  did  not  improve  and  were  likely  to  become 
truant.  They  associated  with  bad  companions,  and 
delin(|uency  was  engrafted  upon  a  nervous  state. 

Doctor  Brown  did  not  consider  mental  deficiency 
as  important  a  factor  in  childhood  delincjuency  as 
had  been  often  stated.    The  real  problem  of  delin- 


quency was  not  one  primarily  of  mental  defect, 
but  was  one  of  maladjustment.  About  twenty  per 
cent,  of  this  particular  group  were  mentally  defec- 
tive, and  with  them  the  delinquency  was  a  secondary 
feature. 

The  question  of  personality  and  delinquency 
was  considered  by  Doctor  Brown.  Although  in 
the  adult  delinquent  one  felt  that  the  personality 
was  primarily  at  default,  one  did  not  seem  warranted 
in  assuming  that  delinquent  children  had  any  special 
personality  disorders  or  tendencies  toward  delin- 
quency because  of  inherent  mental  traits.  So  many 
causative  factors  were  found  in  their  environment 
or  in  their  physical  condition  that  one  did  not  seem 
justified  in  considering  the  symptoms  which  they 
showed  as  inherent.  One  did  find  in  delinquent 
children  many  with  special  aptitudes  and  interests 
who  did  not  get  along  well  in  the  regular  classes, 
and  also  children  of  rather  dull  intellect  who  did 
not  like  school ;  but  they  were  delinquent  secondar- 
ily, and  not  because  of  their  mental  traits.  If, 
however,  ill  conduct  continued  over  a  period  of 
some  years  there  was  reason  to  believe  that  these 
traits  of  character  became  established  and  were 
very  difficult  to  eradicate  in  the  adult. 

In  the  management  of  childhood  delinquency,  the 
need  of  individual  study  as  to  the  needs  of  each 
case  was  urged  from  a  physical,  mental  and  social 
viewpoint.  The  social  attitude  of  the  community 
toward  delinquency  was,  as  a  rule,  an  unfavorable 
setting  for  the  child  because  he  received  unfavor- 
able judgment  before  his  case  was  thoroughly 
understood.  Doubtless  the  main  way  of  dealing 
with  delinquency  was  by  preventive  treatment,  and 
much  could  be  accomplished  by  separate  classes  for 
children  with  special  aptitudes,  neurotic  symptoms, 
and  for  those  who  could  not  do  the  regular  class 
work  for  any  reason.  This  would  tend  to  improve 
the  delinquency  which  eventually  developed  in  these 
cases,  and  there  was  reason  to  believe  that  it  would 
also  prevent  considerable  adult  delinquency,  since 
maladjusted  children  tended  to  drift  to  permanent 
conduct  disorders  unless  corrected. 

An  Emotional  Crisis. — Dr.  Edith  R.  Spaul- 
DiNG  told  of  the  opening  of  the  Psychopathic 
Hospital  of  the  Laboratory  of  Social  Hygiene  at 
Bedford  Hills.  The  attempt  had  been  made  to  treat 
the  patients  as  though  they  were  in  a  psychopathic 
hospital  that  had  no  connection  with  a  reformatory 
institution.  Sources  of  irritation  were  removed  and 
the  patients  were  helped  to  make  the  necessary 
adjustments  to  make  it  possible  for  them  td  live 
in  a  social  group.  The  various  known  methods  of 
treatment  and  training  were  installed.  None  of  the 
punitive  measures  usually  practised  in  reformatories 
were  used  unless  it  was  necessary  to  segregate  an 
individual  patient  who  would  disturb  the  equilibrium 
of  the  group.  The  final  solution,  Doctor  Spaulding 
stated,  of  this,. very  intricate  problem,  would  never 
be  found  in  therapy  alone,  in  educational  or  in  self- 
government  alone,  or  in  discipline  alone,  but  in  the 
utilization  of  all  these  resources  by  those  who  had 
made  a  close  study  of  t!ie  problem.  It  was  urged 
that  all  neurologists  •  and  psychiatrists  contribute 
their  findings  in  an  efYort  to  solve  this,  one  of  the 
most  difficult  of  all  social  problems. 


New  York  Medical  Journal 


INCORPORATING  THE 


Philadelphia  Medical  Journal thiMedical  News 

A  Weekly  Review  of  Medicine,  Established  ISJfS. 


Vol.  CXII.  No.  25. 


NEW  YORK.  SATURDAY.  DECEMBER  18,  1920. 


Whole  No.  2194. 


Original  Communications 


AN  UNUSUAL  CASE  OF  ALKALOSIS  AND 

IMPAIRMENT  OF  THE  EXCRETORY 

POWER  OF  THE  KIDNEYS. 

By  John  Lovett  Morse,  A.  M.,  M.  D., 
Boston,  Mass. 

Professor  of  Pediatrics,  Harvard  Medical  School. 

Clara  G.  was  admitted  to  the  Children's  Hospital 
May  3,  1920,  when  ten  and  a  half  years  old.  Her 
parents  and  two  other  children  were  alive  and  well. 
There  had  been  no  deaths  or  miscarriages.  There 
was  no  tuberculosis  in  the  family  and  there  had  been 
no  known  exposure  to  it. 

She  was  born  at  full  term  after  a  normal  delivery, 
was  normal  at  birth,  and  weighed  eight  and  three 
quarter  pounds.  She  v/as  nursed  for  eighteen 
months,  but  took  cereals  also  at  nine  months.  She 
had  had  what  was  called  meningitis  at  two  years, 
whooping  cough  at  four  years,  diphtheria  at  five' 
years,  measles  at  six  years  and  chickenpox  at  nine 
years.  She  had  never  been  very  strong.  She  had 
wet  the  bed  since  she  was  two  years  old,  having 
stopped  previously.  Her  urine  had  been  examined 
in  1916  and  the  slightest  possible  trace  of  albumin 
and  "quite  a  large  amount  of  pus"  found.  It  is 
presumable  that  the  pyelitis  had  persisted  since  that 
time.  She  was  said  to  drink  much  water  and  to 
pass  large  amounts  of  urine.  She  had  had  pain  in 
her  feet  for  three  months  and  in  her  knees  for  a 
week. 

Physical  examination. ~Sh&  was  poorly  devel- 
oped and  nourished.  Her  complexion  was  pale  and 
sallow.  Her  teeth  were  poorly  cared  for  and  there 
were  several  cavities  and  old  roots.  There  was  very 
little  tonsillar  tissue.  Her  tongue  was  coated  and 
her  breath  was  foul.  D'Espine's  sign  was  absent. 
There  was  a  slight  systolic  murmur  at  the  base  of 
the  heart  and  a  venous  hum  in  the  neck.  The  heart 
was  otherwise  normal.  The  lungs  were  normal. 
The  abdomen  was  somewhat  sunken.  The  liver, 
spleen  and  kidneys  were  not  palpable.  There  was 
no  tenderness  in  the  region  of  the  kidneys.  The 
external  genitals  showed  nothing  abnomial.  The 
extremities  were  normal.  There  was  no  spasm  or 
paralysis.  The  knee  jerks  were  equal  and  rather 
active.  There  was  no  clonus.  Babinski's  and 
Kernig's  signs  were  absent.  There  was  no  edema 
or  enlargement  of  the  peripheral  lymph  nodes. 

The  examination  of  the  blood  showed:  Hemo- 
globin (Tallqvist),  sixty  to  sixty-five  per  cent.,  red 
cells,  2,932,000,  white  cells,  5,300,  small  mononu- 


clears, thirty-two  per  cent.,  large  mononuclears  and 
transitionals,  three  per  cent.,  polynuclear  neutro- 
philes,  sixty-four  per  cent.,  and  mast  cells,  one  per. 
cent.  The  red  cells  showed  slight  variation  in  size, 
but  none  in  shape.  There  was  very  little  achromia. 
No  nucleated  cells  were  seen.  The  blood  platelets 
were  apparently  somewhat  decreased. 

The  urine  was  pale,  very  cloudy,  slightly  acid  in 
reaction  and  of  a  specific  gravity  of  1005.  It 
showed  a  slight  trace  of  albumin,  but  no  sugar, 
acetone  or  diacetic  acid.  There  were  five  mm.  of 
sediment  after  centrifugalization.  This  contained 
a  great  many  pus  cells,  singly  and  in  clumps,  and  a 
few  small,  rovmd  cells,  but  no  red  cells  or  casts. 
It  also  contained  many  motile  bacilli.  The  tuber- 
culin test  was  negative. 

She  was  started  at  once  on  thirty  grains  of 
bicarbonate  of  soda  every  four  hours.  On  the 
morning  of  May  5th  the  dose  was  increased  to  sixty 
grains  every  four  hours.  That  afternoon  her  hands 
and  fingers  began  to  be  stiff'  and  in  the  evening- 
were  in  the  typical  position  of  tetany.  The  next 
morning  her  legs  and  feet  also  assumed  the  position 
of  tetany.  There  was  a  marked  facial  phenomenon 
on  both  sides.  At  that  time  she  had  had  two  hun- 
dred and  seventy  grains  of  bicarbonate  of  soda  and 
the  urine  was  alkaline  in  reaction  for  the  first  time. 
The  diagnosis  -of  spasmophilia  was  made,  but  the 
importance  and  the  possible  gravity  of  the  condition 
were  not  appreciated  and  the  bicarbonate  of  soda 
was  continued.  She  was  drows}-  that  da  v.  was 
very  thirsty  and  passed  much  urine. 

Edema  of  the  face  appeared  the  morning  of  Mav 
7th.  The  signs  of  tetany  continued.  There  were 
also  attacks  of  slight  spasm  of  the  larynx.  The 
urine  contained  the  slightest  possible  trace  of 
acetone  but  no  diacetic  acid.  The  carbon  dioxide 
tension  of  the  alveolar  air  was  forty-five.  During 
the  morning  she  began  to  vomit  continuously. 

She  began  to  have  convulsions  the  morning  of 
May  8th  and  soon  became  unconscious.  The  cere- 
brospinal fluid  obtained  by  lumbar  puncture  was 
clear  and  under  normal  pressure.  It  contained  two 
cells  to  the  cubic  millimetre.  There  was  no  globulin 
present  and  Fehling's  solution  was  reduced.  The 
fundi  showed  no  signs  of  increased  cerebral  pres- 
sure. The  bicarbonate  of  soda  was  then  stopped, 
after  she  had  had  a  total  of  750  grains  in  five  days. 

The  diagnosis  of  spasmophilia  was  made  and  it 
seemed  reasonable  to  suppose  that  it  was  due  to  the 
bicarbonate  of  soda  which  had  been  given  for  the 


Copyright,  1920,  by  A.  R.  Elliott  Publishing  Company. 


MORSE:  ALKALOSIS. 


[New  York 
Medical  Journal. 


l)yelitis.  It  was  difficult,  however,  to  understand 
why  the  bicarhonate  of  soda  had  brought  on  the 
spasmophiHa,  because  doses  of  this  size  are  given 
A'ery  frequently  in  the  treatment  of  pyelitis  with  no 
untoward  results.  A  plausible  explanation  seemed 
to  be  that  oflfered  by  Dr.  Aub,  that  the  sodium  had 
driven  out  the  calcium  and  that  on  account  of  the 
disturbance  of  the  normal  balance  between  sodium 
and  potassium  on  the  one  side  and  calcium  and 
magnesium  on  the  other  side,  the  spasmophilia  had 
developed.  Dr.  Aub  tested  the  alkali  reserve  of  the 
blood  and  found  it  to  be  thirty-one  volumes  per 
cent,  carbon  dioxide  for  one  c.  c.  of  plasma,  that  is, 
diminished.  It  is  very  difficult  to  understand  this 
finding,  because  it  would  seem  as  if  the  alkali 
reserve  could  not  be  reduced  under  the  circum- 
stances. It  is  possible,  but  not  probable,  that  there 
was  an  error  in  the  observation.  "  It  is  more  reason- 
able to  suppose  that  the  observation  was  correct 
and  that  we  are  unable  to  interpret  it  because  of 
lack  of  knowledge. 

Under  active  treatment  with  glucose  and  water 
by  mouth  and  by  rectum  and  with  water  subcutane- 
ously,  she  gradually  improved  and  by  the  end  of  a 
week  all  signs  of  spasmophilia  were  gone  and  she 
was  in  good  condition.  The  urine  still  showed 
evidences  of  pyelitis. 

As  the  urine  continued  to  show  all  the  signs  of 
pvelitis,  on  June  3rd  she  was  started  on  fifteen 
grains  of  urotropin  and  twenty  grains  of  acid 
sodium  phosphate  three  times  a  day.  As  the  urine 
was  not  very  acid  and  Burnham's  test  was  negative, 
the  acid  sodium  phosphate  was  increased  June  9th 
to  twenty  grains  every  four  hours.  The  next  morn- 
ing she  complained  of  being  tired,  went  to  bed  and 
was  more  or  less  drowsy  all  day.  In  the  afternoon 
she  complained  of  headache  and  began  to  vomit: 
The  facial  phenomenon  and  peroneal  reflexes  were 
present.  She  was  very  thirsty  and  edema  of  the 
face  developed. 

The  carbon  dioxide  tension  of  the  alveolar  air 
was  between  ten  and  fifteen  on  June  10th  and  again 
on  Tune  12th.  The  urine,  however,  did  not  contain 
either  acetone  or  diacetic  acid.  Here  again  it  is 
difficuh  to  explain  the  low  carbon  dioxide  tension, 
when  the  spasmophilia  was  presumably  due  to  the 
intake  of  sodium.  It  is  probable  that  there  may 
have  been  some  error  in  the  observations,  as  when 
there  is  an  error  in  estimating  the  carbon  dioxide 
tension  in  the  alveolar  air,  the  mistake  is  always  in 
getting  it  too  low.  It  is  possible,  however,  that  the 
estimations  may  have  been  correct  and  that  the  low 
tension  was  due  to  some  action  of  the  acid  portion 
of  the  acid  sodium  phosphate  on  the  blood.  The 
acid  sodium  phosphate  and  urotropin  were  stopped 
the  next  morning.  She  had  had  during  the  week 
660  grains  of  acid  sodium  phosphate,  which  is 
equivalent  to  110  grains  of  sodium  by  weight.  The 
evidences  of  spasmophilia  began  to  diminish  as  soon 
as  the  drugs  were  stopped  and  on  June  14th  she 
was  well  again.  The  carbon  dioxide  tension  had 
then  risen  to  between  fifteen  and  twenty. 

Dr.  Lewis  W.  Hill  then  called  attention  to  the 
fact  that  the  ^specific  gravity  of  the  urine  had  been 
extremely  low  from  the  beginning,  running  1005,  9. 
8,  8.  10,  7,  8.  5.  6.  S,  4.  6.  4.  4,  2.  1.  4.  1.  4. 


4,  4,  5,  2,  5,  3,  0,  3,  2,  3.  He  suggested  that  the 
trouble  might  be  that  the  kidneys  were  unable  to 
eliminate  salts  and  that  that  was  the  explanation  of 
the  retention  of  the  sodium  and  the  development 
of  the  spasmophilia.  The  patient  was  then  studied 
with  this  idea  in  mind.  The  in\-estigations  which 
were  made  from  June  15th  to  21st  gave  the  follow- 
ing results :  Phthalein  test,  first  hour,  seventy-five 
c.  c,  no  color,  second  hour,  seventy  c.  c,  less  than 
five  per  cent.  The  gravity  fixation  test  which  was 
done  by  giving  the  child  three  meals  of  practically 
the  usual  house  diet  to  which  two  grains  of  caffeine 
sodium  benzoate  and  fifteen  grains  of  sodium 
chloride  were  added  at  each  meal,  the  fluid  being 
limited  to  ten  ounces  at  each  meal,  with  nothing  be- 
tween meals,  showed : 

6  :00  a.  m.    220  c.  c.  1004 
8:00  a.  m.    125  c.  c.  1005 
10:00  a.  m.    120  c.  c.  1005 
12:00  m.        180  c.  c.  1004 
2:00  p.  m.    160  c.  c.  1005 
4:00  p.  m.    155  c.  c.  1009 
4:00  p.  m.  to    6:00  a.  m.    625  c.  c.  1007 

1585  c.  c. 

The  blood  showed  sixty-seven  milligrams  of  urea 
nitrogen  to  the  100  c.  c.  of  blood.  A  few  days  later 
the  urea  nitrogen  rose  to  eighty-five  and  seven 
tenths  milligrams.  These  figures  show,  of  course, 
that  the  excretory  powers  of  the  kidney  were  very 
much  diminished  and  there  was  nitrogen  retention. 
The  facts  that  she  was  very  thirsty  and  that  the 
output  of  the  urine  was  about  the  same  as  the  in- 
take of  fluid  corroborates  the  conclusions  drawn 
from  the  examinations  detailed  above.  It  would 
be  expected  that  under  these  conditions  the  urine 
would  show  the  evidences  of  an  interstitial  process 
in  the  kidneys  and  that  the  blood  pressure  would 
be  raised.  Such,  however,  was  not  the  case.  The 
urine,  although  examined  daily,  had  never  shown 
casts  or  red  cells. 

The  systolic  blood  pressure  was  110  and  the 
diastolic.  90. 

The  electrical  reactions  done  at  this  time  were  as 
follows:  C.  C.  C.  4.50.  A.  C.  C.  2.00,  A.  O.  C. 
5.00,  C.  O.  C.  3.50.  That  is  to  say,  the  low  C.  O. 
C.  shows  that  she  was  still  electrically  oversensitive, 
although  there  were  no  clinical  evidences  of  spasmo- 
philia. 

She  was  put  on  a  low  protein  diet  without  salt 
and  directed  to  drink  large  amounts  of  water.  She 
was  kept  under  observation  in  the  outpatient  de- 
partment. On  August  9th  one  of  the  outpatient 
physicians,  who  was  not  well  acquainted  with  her 
-Story,  ordered  small  amounts  of  bicarbonate  of  soda 
three  times  a  day.  The  amount  was  not  specified. 
Five  days  later  she  had  tetanic  manifestations  last- 
ing a  few  minutes.  She  was  brought  to  the  hospital 
the  next  day.  August  15th.  and  admitted.  The 
facial  phenomenon  and  peroneal  reflexes  were  pres- 
ent. The  urine  still  showed  the  evidences  of 
pvelitis  and  was  of  a  low  specific  gravity,  running 
along  the  next  few  days  1003,  4,  2.  4.  4,  5.  7.  6. 
The  bicarbonate  of  soda  was  stopped  at  once.  The 
peroneal  reflex  was  gone  .^ugust  19th  and  the  facial 
l)henomenon  was  barely  obtainable.  As  it  was 
thought  that  there  might  have  been  something  spe- 


Dec.mber  18,  1920.] 


SOLIS-COHEN 


INTERESTING   PEDIATRIC  CASES. 


967 


cific  in  the  action  of  soda,  she  was  then  given  fifteen 
grains  of  citrate  of  potash  every  four  hours,  this 
l:)eing  increased  to  thirty  grains  every  four  hotirs  on 
August  23rd.  Three  days  later  the  facial  phenome- 
non was  increased  and  the  peroneal  reflexes  reap- 
peared. The  urine,  however,  was  still  acid.  The 
citrate  of  potash  was  then  stopped  because  of  vom- 
iting and  a  large  number  of  loose,  watery  stools. 
It  is  presumable  that  the  reason  the  citrate  of 
potash  did  not  cause  more  marked  nervous  symp- 
toms is  that  much  of  the  salt  was  carried  away  in 
the  intestinal  discharges.  She  was  discharged  from 
the  hospital  soon  after,  on  her  former  diet  with  the 
low  protein  and  forced  fluids. 

She  was  readmitted  to  the  hospital  for  further 
study  October  26.  1920,  having  been  well  since  her 
discharge  two  months  before.  She  had  gained  in 
weight  and  strength  and  symptomatically  was  well. 
The  physical  examination  showed  no  evidences  of 
spasmophilia.  The  examination  of  the  blood  re- 
sulted as  follows :  hemoglobin,  eighty  per  cent. 
(Tallqvist),  red  corpuscles,  4,380,000,  white  cor- 
puscles, 6,400,  mononuclears,  forty-four  per  cent., 
polynuclear  neutrophiles,  fifty-four  per  cent.,  and 
basophiles,  two  per  cent.  The  red  cells  showed  no 
abnormalities  and  the  platelets  were  apparently 
normal  in  number. 

The  urine  was  pale,  cloudy,  acid  in  reaction,  and 
of  a  specific  gravity  of  1006.  It  contained  no  albu- 
min and  only  one  millimetre  of  sediment  after  cen- 
trifugalization.  This  sediment  showed  leucocytes, 
but  no  bacteria.  The  phthalein  test  showed :  First 
hour,  110  c.  c.  1006,  less  than  five  per  cent. ;  second 
hour,  84  c.  c.  1007,  less  than  five  per  cent. 

The  gravity  fixation  test  showed : 

8:00  a.  m.  115  c.  c.  1006 

10:00  a.  m.  145  c.  c.  1004 

12:00  m.  105  c.  c.  1006 

2:00  p.  m.  45  c.  c.  1004 

4:00  p.  m.  70  c.  c.  1006 

6:00  p.  m.  60  c.  c.  1005 

6:00  p.  m.  to    6:00  a.  m.  880  c.  c.  1006 

1420 

The  urea  nitrogen  unfortimately  could  not  be  done, 
as  the  chemist  was  ill  at  the  time.  The  carbon 
dioxide  tension  in  the  alveolar  air  was  thirty-five. 
The  electrical  reactions  were :  A.  C.  C.  6.00,  A. 
O.  C.  5.00,  C.  C.'  C.  2.50,  and  C.  O.  C.  6.00.  The 
systolic  blood  pressure  was  140  and  the  diastolic  110. 

It  is  very  hard  to  understand  or  explain  the 
marked  impairment  of  the  excretory  powers  of  the 
kidneys,  there  never  having  been  at  any  time  any 
evidence  in  the  urine  of  disease  of  the  kidneys  them- 
selves. It  is  hard  to  tmderstand  how  a  low  grade 
inflammatory  process  in  the  pelves  of  the  kidneys, 
which  is  the  condition  in  pyelitis,  could  interfere 
with  the  excretory  powers  of  the  kidneys.  Fur- 
thermore, there  were  no  evidences  of  disease  of 
the  circulatory  system,  except  the  slight  rise  in 
l)lood  pressure  at  the  last  examination.  It  is  hard 
to  believe  that  the  pyelitis  could  by  reflex  action 
through  the  nervous  system  have  had  any  such 
action.  The  tuberculin  test  was  negative  and  there 
were  no  evidences  of  syphilis.  Neither  of  these 
conditions  would,  moreover,  be  likely  to  cause  the 
mariifestations  present  in  this  instance.  Neither 


does  it  seem  reasonable  to  suppose  that  such  condi- 
tions as  stone  in  the  kidney,  twisting  or  kinking  of 
the  tireters  or  displacement  of  the  kidneys,  even  if 
it  was  possible  for  them  to  exist  for  so  long  a  time 
without  symptoms  pointing  definitely  to  them, 
w^ould  cause  such  a  peculiar  impairment  of  the  func- 
tions of  the  kidneys. 

The  development  of  the  spasmophilia  is  easier  to 
explain.  On  account  of  the  impairment  of  their 
functions  the  kidneys  were  tmable  to  excrete  the 
salts  given  for  the  treatment  of  the  pyelitis.  If 
spasmophilia  is  due,  as  it  seems  reasonable  to  sup- 
pose, to  a  disturbance  of  the  balance  between  soditim 
and  potassium  on  the  one  side  and  calcitim  and 
magnesium  on  the  other,  all  the  conditions  neces- 
sary for  the  development  of  the  disease  were 
present.  Practically,  it  makes  no  difference  whether 
the  balance  was'  disturbed  by  a  simple  retention  of 
sodium  or  potassium  without  any  driving  otxt  of 
calcium  and  magnesium  or  by  a  combination  of  the 
two. 

The  prognosis  seems  absolutely  bad.  Even  if  it 
was  possible  to  cure  the  pyeHtis,  that  would  pre- 
sumably not  improve  the  excretory  powers  of  the 
kidneys,  in  fact,  there  is  nothing  which  can  be  done 
to  accomplish  this.  The  only  treatment  seems  to  be 
to  spare  the  kidneys  as  much  as  possible  by  limiting 
the  proteins  in  the  diet  to  minimum  needs  and 
to  favor  the  elimination  of  excretory  products 
through  the  kidneys  by  the  administration  of  large 
amounts  of  water.  Furthermore,  the  alkaline  salts 
should  be  eliminated  from  the  diet  as  far  as  possible 
and  certainly  none  of  them  should  be  given  for  the 
treatment  of  the  pyelitis. 

70  B.w  State  Road. 


SOME  INTERESTING  PEDIATRIC  CASES 

IVitli  a  New  Method  of  Bacteriological  Study 
and  Treatment.* 
By  Myer  Solis-Cohex,  A.  B.,  AI.  D., 
Philadelphia, 

Pediatrist  to  the  Jewish   Hospital,  Philadelphia,   and  to  the  Eagle- 
ville  Sanatorium  for  Consumptives:  Director  of  the  Jules  E. 
Mastbaum    Research     Laboratory    of    the  Jewish 
Hospital,  Philadelphia. 

The  bacteriological  studies  made  in  the  four 
cases  reported  are  based  on  a  test  for  immunity 
and  susceptibility  described  by  the  writer  in  conjunc- 
tion with  George  D.  Heist  and  Solomon  Solis- 
Cohen  (1).  We  found  that  the  whole,  fresh,  tin- 
coagulated  blood  of  animals  immune  to  pneumo- 
coccic  infection,  such  as  the  pigeon  and  the  chicken, 
killed  the  pneumococcus ;  while  the  whole  blood  of 
animals  highly  susceptible  to  pneumoocccic  infec- 
tion, such  as  the  mouse  and  the  rabbit,  served  as 
an  excellent  culture  medium  for  the  pneumococcus. 
Similarly  we  found  (1)  that  the  globoid  bodies 
grew  vigorously  in  the  whole  blood  of  human 
beings,  who  are  stisceptible  to  acute  anterior  polio- 
myelitis, but  were  killed  by  the  whole  blood  of 
rabbits,  which  are  immune ;  and  that  diphtheria 
bacilli  (2)  multiplied  rapidly  in  the  whole  blood 
of  the  susceptible  guineapig  and  are  destroyed  by 

*Read  before  the  Philadelphia  Pediatric  Society,  November  9, 
1920.  The  bacteriological  studies  recorded  in  this  paper  were  made 
in  the  Jules  E.  Mastbaum  Research  Laboratory  of  the  Jewish 
Hospital. 


968 


SOUS-COHEN:  INTERESTING    PEDIATRIC  CASES. 


[New  York 
Medical  Journal. 


the  whole  blood  of  the  immune  rat.  Matsunami 
and  Kolmer  (3),  using  our  method,  demonstrated 
similarly  that  little  or  no  growth  of  meningococci 
takes  place  in  the  fresh,  whole  blood  of  the  immune 
rabbit,  while  in  the  susceptible  mouse  growth  is 
vigorous.  Incidental  to  our  work  we  found  that 
contaminating  organisms  usually  failed  to  grow  in 
whole  uncoagulated  blood. 

These  facts  make  us  think  that  animals  possess 
in  their  blood  a  bactericidal  power  against  all  organ- 
isms that  are  not  pathogenic  for  them  or  for  their 
species  and  lack  bactericidal  power  against  those 
organisms  that  are  pathogenic  for  them  or  their 
species. 

The  question  then  arose  in  my  mind  whether 
infection  in  man  might  not  be  due  to  or  associated 
with  absent  bactericidal  power  in  the  infected  in- 
dividual against  the  infecting  orgatiism.  In  such 
an  event  it  might  be  possible  from  a  number  of 
organisms  present  in  a  discharge  to  separate  those 
that  are  etiological  or  infecting  from  those  that  are 
merely  saprophytic  or  accidental  contaminations. 
At  least,  if  the  patient's  blood  were  bactericidal  to 
an  organism  present,  it  would  be  reasonable  to 
infer  that  the  patient  was  immune  at  the  time  to 
that  organism,  which  consequently  could  hardlv 
have  any  part  in  the  infection.  On  the  other  hand, 
if  the  patient's  blood  had  little  or  no  bactericidal 
power  against  an  organism  present,  it  would  indi- 
cate susceptibility  on  the  part  of  the  patient  to  that 
organism,  which  therefore  might  be  regarded  as 
possibly  being  an  infecting  organism.  The  late 
George  D.  Heist  studied  a  number  of  cases  with 
me  at  the  Jules  E.  Mastbaum  Research  Laboratory 
of  the  Jewish  Hospital  and  Louis  S.  Borow  has 
studied  others  with  me  in  the  same  laboratory.  Our 
studies  (4 )  demonstrate  that  the  blood  of  human 
beings  possesses  bactericidal  power  against  large 
numbers  of  organisms ;  that  the  blood  of  an  indivi- 
dual differs  in  its  bactericidal  power  against  dif- 
ferent organisms ;  that  bactericidal  power  against 
a  particular  organism  varies  in  different  individuals ; 
that  in  the  discharge  of  an  infected  area  organisms 
can  usually  be  found  against  which  the  blood  of 
the  infected  person  has  little  or  no  bactericidal 
power;  that  frequently  in  such  discharge  or  on  such 
area  other  organisms  are  found  against  which  the 
patient's  blood  has  good  bactericidal  power ;  that 
organisms  that  are  supposed  to  grow  well  in  human 
blood  fail  to  grow,  at  all  in  the  blood  of  some 
individuals ;  and  that  organisms  that  are  supposed 
to  grow  poorly  or  not  at  all  in  human  blood  may 
grow  with  the  greatest  vigor  in  the  blood  of  some 
individuals. 

The  practical  object  of  these  studies  was  to  make 
vaccine  treatment  more  specific.  It  was  thought 
that  failure  of  autogenous  vaccine  treatment  might 
be  due  sometimes  to  failure  to  include  the  etiolog- 
ical organisms  in  the  autogenous  vaccine  and  that 
certain  harmful  effects  might  be  due  to  the  injec- 
tion of  unneces.sary  foreign  protein  in  the  form  of 
organisms  that  have  no  part  in  the  infection.  We 
regard  the  object  of  vaccine  treatment  to  increase 
the  bactericidal  ])owcr  of  the  blood  against  the 
infecting  organism. 

This  view  was  l)ased  on  observation  made  in 


association  with  George  D.  Heist,  and  Solomon 
Solis-Cohen  (1),  that  recovery  from  an  attack  of 
lobar  pneumonia  is  paralleled  by  an  increase  in  the 
power  of  the  patient's  blood  to  kill  the  type  of 
pneumococcus  causing  the  infection,  and  that  the 
intravenous  injection  of  dead  pneumococci  into 
rabbits  produces  bactericidal  activity  in  the  rab- 
bit's blood  which  is  specific  to  type.  A  similar 
rise  in  the  bactericidal  power  of  the  blood  was 
observed  by  Black,  Fowler  and  Pierce  (5)  in  rab- 
bits following  their  intravenous,  subcutaneous  or 
intraperitoneal  inoculation  with  dead  typhoid  bac- 
illi and  Bacillus  dy-senterise  of  Shiga.  We  conse- 
quently regard  it  as  at  least  unnecessary,  if  not 
harmful,  to  introduce  into  the  system  dead  organ- 
isms against  which  the  patient  already  has  high 
bactericidal  power. 

In  each  of  the  four  cases  here  reported  an  at-' 
tempt  had  been  made  to  discover  the  infecting 
organism ;  three  received  vaccines  containing  only 
those  of  the  organisms  present  against  which  the 
patient's  blood  lacked  bactericidal  power ;  to  the 
fourth  serum  was  given.  The  cases  are  reported 
because  of  a  number  of  interesting  features  they 
present.  No  assertion  is  made  that  the  organisms 
obtained  were  actually  etiological  or  that  the  im- 
provement was  due  to  the  treatment.  It  is  felt, 
however,  that  the  results  warrant  further  investiga- 
tion and  study  of  the  method  employed. 

Case  I. — A.  M.  J.,  a  baby  girl,  fourteen  months 
old,  was  brought  to  my  office  on  October  10,  1919. 
She  had  been  a  full  term  child,  delivered  normally. 
When  four  weeks  old  she  had  had  diarrhea,  which 
was  cured  after  three  months.  When  the  child 
was  nine  months  of  age  fever  developed,  the  cause 
of  which  was  obscure.  The  condition  was  regard- 
ed as  acute  double  otitis  media.  Incision  of  both 
tympanic  membranes  had  no  effect  on  the  high 
temperature,  which  persisted  for  two  weeks.  There 
was  never  any  discharge  from  the  ears,  although 
a  few  particles  were  washed  out.  During  the  sum- 
iner  preceding  her  visit  the  baby  had  several  attacks 
of  fever  accompanied  by  a  whining  cry  of  discom- 
fort and  evidences  of  pain.  Apparently  there  had 
been  no  pain  on  urination,  but  there  had  occasion- 
ally been  pain  on  defecation.  During  the  last 
week  in  August  the  temperature  had  been  104°  to 
105°.  Pus  had  been  found  in  the  urine  in  Septem- 
ber and  a  diagnosis  of  pyelitis  was  made.  Since 
then  the  pus  had  appeared  and  disappeared  and 
the  attacks  had  returned  at  intervals.  Between  the 
attacks  the  child  was  peevish  and  awakened  at 
night.  She  had  been  in  the  best  hands  medically 
and  had  received  the  ordinary  treatment. 

Examination  of  the  child  was  negative,  except 
for  a  furunculosis,  present  chiefl\'  on  the  buttocks. 
A  culture  on  blood  agar  was  made  from  the  child's 
urine  and  from  a  papule  on  the  buttocks.  Staphylo- 
coccus albus  and  Staphylococcus  citreus  were  iso- 
lated from  both.  A  broth  culture  of  each  organism 
was  diluted  1:10,  1:100,  1:1000  and  1:10,000  and 
each  dilution  was  allowed  to  run  in  and  out  of  a 
separate  capillary  tube,  which  was  then  filled  with 
the  baby's  blood  and  sealed.  After  twenty-four 
hours'  incubation  the  tubes  were  broken  and  a  drop 
of  each  stained  and  examined  under  the  microscope 


December  18,  1920.] 


SOLIS-COHEN:  INTERESTING    PEDIATRIC  CASES. 


969 


to  see  if  any  organisms  were  present.  Staphylo- 
coccus citreus  had  grown  well  in  most  of  the  tubes, 
but  Staphylococcus  albus  had  practically  disap- 
peared. A  vaccine  was  prepared  from  Staphylo- 
coccus citreus. 

TABLE  I. 

Dilutions  of  a  tzventy-four  hours  broth  culture 
Undil.       1:10      1:100    1:1,000  1:10,000 

Staphylococcus  citreus 

+    Case   1   ±  —  +        ++        +  + 

Staphylococcus  citreus 

-f-  Human  Control   +  ±  —  - —  — 

Staphylococcus  albus  + 

Case    1    —  —  +  —  — 

Staphylococcus  a  1  b  u  s   +  • 

Human  Control    • —  —  —  —  — 

—  Indicates  no  growth. 

±  Indicates  doubtful  growth. 

4-  Indicates  growth. 

+  +  Indicates  vigorous  growth. 

Thirteen  doses  of  a  vaccine  prepared  from  Sta- 
phylococcus citreus  were  administered  at  five  day 
intervals,  the  dose  being  one  hundred  million,  two 
hundred  million,  four  hundred  million,  eight  hun- 
dred million,  and  thereafter  a  thousand  million. 
The  baby  improved  in  general  health  and  appear- 
ance after  the  first  dose.  The  crying  spells  with 
fever,  etc.,  gradually  diminished.  The  furunculo- 
sis  cleared  up.  The  urine  showed  some  pus  cells, 
on  December  10,  1919,  but  none  on  February  26, 
1920,  or  on  October  25,  1920. 

Case  II. — R.  H.,  a  little  girl  six  years  of  age, 
came  to  my  office  on  August  10,  1917,  with  a  story 
that  she  had  been  subject  since  three  years  of  age 
to  attacks  of  high  fever  lasting  two  weeks,  occur- 
ring chiefly  in  the  spring  and  fall  and  preceded, 
accompanied  and  followed  by  weakness.  These 
attacks  had  been  diagnosed  as  malaria.  For  a 
year  previous  she  had  complained  of  frequent  and 
urgent  urination  but  had  not  wet  her  clothes.  For 
the  previous  six  months  she  had  been  irritable  and 
easily  upset,  screaming  and  crying.  She  had  lost 
weight.  Physical  examination  was  negative.  The 
case  at  the  time  was  regarded  as  one  of  enuresis 
and  treated  with  tonic  and  belladonna,  with  some 
improvement.  At  this  time  the  child  was  under 
observation  for  only  three  weeks. 

Three  years  later,  on  Augnast  16,  1920,  the  child 
returned  with  a  history  that  the  attacks  with  fever 
had  continued,  the  last  having  been  five  days  prior 
to  the  visit  and  the  previous  one  two  weeks  before. 
Pain  in  the  right  lower  abdomen  had  accompanied 
the  last  attack.  The  heart  frequently  became  ir- 
regular during  the  attack.  Between  the  attacks  the 
child  seemed  well  but  had  never  been  strong.  She 
had  lost  weight,  was  always  nervous  and  cried 
easily  and  frequently.  Her  appetite  was  poon  She 
had  complained  of  palpitation  and  dyspnea  on  ex- 
ertion for  the  past  year  and  a  half.  For  several 
years  past  she  had  suft'ered  great  distress  when  the 
bladder  was  full,  which  distress  was  somewhat 
relieved  by  doubling  up.  The  urgency  when  the 
impulse  to  urinate  came  was  so  acute  that  she 
would  wet  herself  if  unable  to  relieve  her  bladder 
naturally. 

The  child  was  pale  and  poorly  nourished.  The 
heart  was  enlarged  in  all  dimensions,  its  muscle 
was  poor,  and  its  action  slightly  irregular.  There 
Avere  some  signs  of  infiltration  of  the  upper  lobe 


of  the  right  lung,  without  activity.  The  hemo- 
globin was  sixty  per  cent.  The  urine  showed  pus 
cells  in  large  numbers.  A  diagnosis  was  made  of 
pyelocystitis.  A  blood  agar  culture  of  a  catheter- 
ized  specimen  of  urine  contained  Bacillus  coli  and 
Bacillus  lactis  aerogenes,  both  of  which  grew  in 
the  child's  blood,  the  former  very  vigorously.  This 
is  the  more  remarkable  as  colon  bacilli  do  not  as 
a  rule  grow  in  human  blood.  Of  fifteen  men  tested 
by  George  D.  Heist  and  Solomon  Solis-Cohen  (6), 
Bacillus  coli  failed  to  grow  in  the  blood  of  all. 


TABLE  II. 

Dilutions  of  a  twenty-four  hours  broth  culture 
1:10       1:100  1:1,000  1:10,000  1:100,000 


Bacillus  coli  +  Case  2... 

+ 

++ 

Bacillus    coli    -f-  Human 

control   

+  + 

+  + 

-lr  + 

+  + 

Bacillus   coli    +  Defibrin- 

ated  blood   

+-h 

++ 

++ 

+  + 

+  + 

Bacillus    lactic    aerog.  -|- 

Case  2   

++ 

++ 

+  + 

+  + 

Bacillus    lactic    aerog.  -|- 

Human  control   

+  + 

+ 

Bacillus    lactic    aerog.  + 

Defibrinated   blood  .... 

++ 

+  + 

+  + 

+  + 

+  + 

As  a  control,  one 

set 

of  tubes  was 

loaded 

with 

defibrinated  blood.  When  growth  takes  place  in 
the  defibrinated  blood  and  not  in  the  whole  blood, 
it  indicates  the  presence  in  the  whole  blood  of  an 
antibacterial  factor  which  is  lacking  in  the  defibri- 
nated blood. 

A  vaccine  was  made  of  both  organisms.  A  first 
injection  of  twenty-five  million  on  September  20, 
1920,  was  not  followed  by  any  general  reaction, 
but  the  arm  was  sore  for  two  days.  The  arm  was 
slightly  sore  for  one  day  following  the  injection  of 
fifty  million  on  September  27th.  Injection  of  sev- 
enty-five million  a  week  later  was  followed  by  the 
development  of  a  large  areola  with  swelling  and 
induration,  lasting  two  days,  and  by  the  child  be- 
coming irritable  and  nervous.  Two  subsequent 
doses  of  fifty  million  each  and  two  of  sixty  million 
and  seventy-five  million  respectively,  produced  no 
reaction.  Hexamethylenamine  and  liquor  potasii 
citratis  have  also  been  administered.  There  has 
been  distinct  general  improvement  with  a  gain  of 
five  pounds  and  three  quarters  in  seven  weeks  until 
the  severe  reaction.  For  the  past  six  weeks  the 
child  has  not  experienced  pain  or  urgency  when 
the  bladder  is  full  and  has  not  wet  herself.  Ex- 
amination of  the  urine  on  November  9,  1920, 
showed  only  a  few  leucocytes. 

Case  III.— L.  W.,  a  httle  girl,  four  years  of  age, 
was  admitted  to  my  service  at  the  Jewish  Hospital 
on  July  20th,  1920.  No  history  was  obtainable. 
The  child  was  well  develop^ed  but  rather  poorly 
nourished  and  lay  somewhat  listless,  suffering  from 
orthopnea.  The  pupils  were  equal  and  reacted  nor- 
mally to  light  and  accommodation.  The  tongue  had 
a  curious  geographical  appearance,  the  epithelium 
being  apparently  denuded  in  places,  where  the  pa- 
pilla were  prominent,  the  normal  epithelium  about 
their  margins  forming  linear  ridges  which  de- 
scribed circinate  designs.  The  pulse  was  regular, 
weak,  and  of  ■  low  tension.  The  left  chest  was 
slightly  fuller  than  the  right.  A  double  thrill  was 
present  over  the  precordia.  The  apex  beat  was  in 
the  fifth  interspace,  a  quarter  of  an  inch  outside  of 
the  nipple.    There  was  a  diffuse,  undulating  pulsa- 


970 


SOLIS-COHEN :  INTERESTING    PEDIATRIC  CASES. 


[New  York 
Medical  Journal. 


tion  from  one  inch  to  the  right  of  the  sternum  to 
the  left  axilla  and  episternal  notch.  The  heart  ex- 
tended upward  to  the  upper  border  of  the  third 
rib,  on  the.  left  to  one  inch  to  the  left  of  the  nipple, 
and  on  the  right  to  half  an  inch  to  the  right  of  the 
sternum.  The  heart  sounds  were  obscured  by  niur- 
murs  which  at  first  could  not  be  well  made  out. 
Later  a  double  murmur,  crescendo  in  character, 
was  heard  definitely  over  the  entire  chest,  and  trans- 
mitted toward  the  axilla  (2)  and  scapula.  The 
lungs  and  abdomen  were  negative.  The  systolic 
blood  pressure  was  75  and  the  diastolic  50.  The 
temperature  curve  was  septic  in  type,  reaching  100° 
every  afternoon,  being  unaffected  by  sodium  salicyl- 
ate in  doses  of  seven  grains  and  a  half  every  three 
hours,  or  by  quinine  and  urea  hydrochloride  in 
three  grain  doses  three  times  daily. 

The  rhinopharynx  was  cultured  on  August  12th 
and  from  the  blood  agar  plate  three  organisms  were 
isolated,  gram  diplococcus,  diphtheroid  and  Mi- 
crococcus catarrhalis.  When  incubated  in  the 
child's  blood,  the  first  grew  up  well,  the  last  irregu- 
larly and  the  other  only  in  undiluted  culture. 

TABLE  III. 

Dilutions  of  t-wentv-four  hours  broth  culture 
Undil.       1:10      1:100    1:1,000  1:10,000 
Gram  diplococ.  -|-  Case  34-+        ++  +  +  + 
Gram     diplococ.     +  Hu- 
man control                                         -|-           —           —  — 

Gram    diplococ.  Defi-  i 

brinated  pig's  blood...  +-|-  -|-+  +-|-  -|--|-  +-|- 
Diphtheroid  -|-   Case  3 .  .  .       -j-  —  —  —  — 

Diphtheroid      +  Human 

control    +  —  —  — 

Diphtheroid    -|-  Defibrin- 

ated  pig's  blood    ++        ++        ++       ++        +  + 

ilicrococ.    catarrhalis  -j- 

Case  3    —  O  +  —  -f 

Micrococ.     catarrhalis  -|- 

Human  control    +-|-  —  ±  —  — 

Micrococ.     catarrhalis  -\- 

Defibrinated   pig's   blood  ++        -|--|-  +  + 

A  vaccine  was  made  of  the  gram  diplococcus. 
Twenty-five  million  were  administered  on  Septem- 
ber 6th.  and  again  six  days  later.  A  week  later  fifty 
million  were  given  and  ten  days  later  a  hundred 
million.  There  was  never  any  reaction.  The  tem- 
perature had  been  practically  below  99°  since  the 
second  dose,  most  of  the  time  being  practically 
normal,  until  October  14th  when  it  went  up  to 
98.8°,  going  to  99°  on  October  18  and  99.4°  on 
October  22d.  I  went  ofif  the  service  on  October 
1st  and  my  successor  failed  to  administer  any  more 
of  the  vaccine,  which  probably  accounts  for  the 
subsequent  rise  in  temperature.  In  my  opinion  the 
vaccine  treatment  should  have  been  continued  for 
several  months. 

C.VSE  IV. — R.  D.  Upon  coming  on  duty  in  the 
pediatric  ward  of  the  Jewish  Hospital  on  July  1st 
of  this  year,  I  found  a  girl  of  ten  years  who  had 
been  admitted  a  week  before  with  violent  nose- 
bleed. The  only  points  of  interest  in-  the  family 
history  were  that  a  maternal  uncle  had  been  sub- 
ject to  severe  hemorrhages,  her  mother  was  subject 
to  urticaria,  and  her  father  used  to  per.spire  freely. 
The  jjatient  was  said  to  have  been  a  full  term  baby, 
with  normal  delivery,  but  to  have  weighed  only 
three  pounds  at  birth.  She  had  never  been  ill  until 
her  third  year, .  when  she  contracted  pneumonia, 
followed  by  empyema,  for  which  rib  resection  was 
performed.    Convalescence  was  protracted  for  nine 


months  and  the  child  had  never  been  robust  since, 
but  had  always  been  pale  and  had  experienced  diz- 
ziness. She  never  had  had  tonsilitis.  A  year  pre- 
viously she  had  had  a  vulvar  abscess.  She  had 
had  no  cardiac  symptoms  prior  to  a  year  before, 
when  the  first  epistaxis  occurred  upon  stooping 
after  running.  (3ther  nasal  hemorrhages  had  oc- 
curred since,  a  very  serious  one  four  months  be- 
fore admission  and  another,  also  severe,  one  week 
before  admission.  She  complained  of  excessive 
perspiration  at  night,  on  exertion  and  on  excite- 
ment, but  not  of  weakness,  dyspnea  or  palpitation. 

The  chil'd  was  poorly  developed,  poorly  nour- 
ished, and  very  pale,  her  lips,  gums  and  conjunc- 
tiva being  extremely  jjale.  The  pupils  were  equal 
and  reacted  well  to  light  and  accommodation.  The 
tongue  was  slightly  coated.  The  pulse  was  160,  reg- 
ular, weak,  and  of  low  tension.  The  apex  beat 
was  in  the  fifth  interspace,  anterior  axillar}-  line. 
There  was  a  pulsation  over  the  lower  precordia. 
The  cardiac  boundaries  were  the  upper  liorder  of 
the  second  rib,  the  left  anterior  axillary  line  and 
an  inch  and  a  half  to  the  right  of  the  sternum,  the 
transverse  diameter  measuring  six  inches  and  a 
quarter  and  the  vertical  diameter  four  inches.  At 
the  mitral  area  a  blowing  systolic  murmur,  with 
probably  a  presystolic  element,  was  heard,  which 
was  also  heard  all  over  the  precordia  and  in  the 
axilla.  A  soft  systolic  murmur  was  also  heard 
at  the  base  of  the  heart,  more  pronouncedly  to  the 
left  of  the  sternum.  In  the  sixth  interspace  in  the 
left  axilla  was  a  scar  two  inches  in  length.  There 
were  no  depressions  above  or  below  the  clavicle. 

The  veins  were  slightly  prominent  over  the  chest. 
Expansion  was  slightly  diminished.  There  was 
moderate  dullness  on  the  right  anteriorly  on.  above 
and  below  on  the  clavicle  and  slight  dullness  below 
this  down  to  the  lower  border  of  the  second  rib. 
There  was  dullness  over  the  whole  left  chest  an- 
teriorly. The  percussion  note,  though  resonant, 
was  somewhat  impaired.  Posteriorly  there  was 
dullness  on  the  left  above  the  third  rib  and  on  the 
right  above  the  first  rib  and  below  the  fourth  rib, 
becoming  flatness  below  the  eighth  rib.  Fremitus 
was  increased  anteriorly  on  the  right  and  dimin- 
ished on  the  left.  It  was  increased  posteriorly  on 
the  right  above  the  fifth  rib  and  absent  below  the 
seventh  rib,  and  on  the  left  it  was  increased  above 
the  eighth  rib.  \'ocal  resonance  anteriorly  was 
increased  on  the  right  above  the  second  rib  with 
slight  whispering  pectoriloquy  on  the  left  above 
the  second  rib.  Posteriorly  it  was  increased  on 
the  right  above  the  fourth  rib  and  absent  below  the 
seventh  rib,  and  increased  slightly  on  the  left  be- 
tween the  fourth  and  eighth  ribs,  more  markedly 
above.  There  was  .slight  whispering  pectoriloquy 
po.steriorly  above  the  third  rib  on  the  left.  The 
breath  sounds  were  faint  anteriorly  and  negative 
posteriorly.  The  x  ray  demonstrated  •  both  lungs 
somewhat  infiltrated,  the  right  hilus  showing  many 
enlarged  glands.  The  heart  was  seen  to  be  greatly 
enlarged,  mb.stly  upwards  and  to  the  left.  Stereo- 
scopic examination  with  the  tube  thirty  inches  from 
the  plate  showed  the  greatest  width  of  the  heart  to 
be  six  inches  and  the  greatest  height  of  the  heart 
shadow  four  inches  and  a  half.    The  urine  con- 


Deccmbr  18,  1920.] 


KAISER:   THE  HYPERTONIC  IXFAXT. 


971 


tained  a  faint  trace  of  albumin,  a  few  light  granu- 
lar cast>  and  many  leucocytes.  The  blood  had  a 
hemoglobin  content  of  fijty  per  cent. ;  the  leucocytic 
count  was  7000  and  the  differential  count,  poly- 
morphonuclear neutrophiles  sixty-nine  per  cent., 
large  lymphocytes  nine  per  cent.,  small  lymphocytes 
twenty  per  cent.,  eosinophiles  one  per  cent.,  baso- 
philes  one  per  cent.  The  clotting  time  of  the  blood 
taken  with  my  modification  of  Gillian's  method  (7) 
was  ten  minutes.  The  systolic  blood  pressure  was 
124  and  the  diastolic  55.  The  sputum  contained 
pneumococci,  streptococci,  ^Micrococcus  catarrhalis, 
pus  cells  and  blood,  but  no  tubercle  bacilli.  The 
vaginal  smear  was  negatiAC.  Xo  reaction  followed 
the  intracutaneous  injection  of  old  tuberculin 
CO.  T.)  in  doses  of  0.000,0001  mg.,  0.000,01  mg.. 
and  0.000.1  mg.  The  temperature  was  of  the  septic 
type. 

My  feeling  was  that  an  organism  that  had  par- 
ticipated in  the  pneumonic  process  seven  years  be- 
fore had  caused  the  empyema  and  was  probably 
responsible  for  the  cardiac  complication  and  possibly 
also  for  the  vulvar  abscess  of  a  year  previously. 
There  was  also  a  possibility  that  the  pulmonary  in- 
filtration was  a  chronic  process  dating  from  and 
consequent  to  the  pneumonia.  It  was  thought  that 
the  etiological  organism  might  be  found  on  blood 
culture,  but  a  culture  of  the  blood  on  broth  proved 
sterile.  It  was  then  thought  that  if  the  same  organ- 
ism was  the  infecting  agent  of  both  the  heart  and 
the  lungs  it  would  be  found  in  the  rhinopharynx  and 
might  be  recognized  by  the  absence  of  bactericidal 
power  against  it  in  the  patients  blood.  We  employed 
a  different  method  of  culture  and  test  than  we  used 
in  the  other  cases,  one  that  permits  a  rapid  isola- 
tion and  identification  of  the  organisms  against 
which  the  blood  is  lacking  in  bactericidal  action, 
but  which  does  not  measure  the  degree  of  bacteri- 
cidal power  present.  It  is  best  applicable  in  adults 
and  older  children.  A  swab  from  the  rhinopharynx 
was  lightly  rubbed  on  the  bottom  of  a  sterile  test 
tube,  into  which  five  cubic  centimetres  of  blood 
from  the  child's  vein  was  then  introduced.  A  cul- 
ture was  also  made  on  'a  blood  agar  plate,  upon 
which  grew  Staphylococcus  albus,  streptococctis 
and  a  diphtheroid  bacillus.  The  culture  in  the 
child's  blood  was  incubated  for  twenty-four  hours 
and  then  a  blood  agar  plate  was  inoculated  with  a 
drop  of  the  blood. 

A  pure  culture  of  many  hemolytic  streptococci 
grew  up.  We  deemed  it  unwise  to  administer  a 
vaccine  and  instead  injected  .antistreptococcic 
serum.  One  dose  of  ten  c.  c,  two  doses  of  twenty 
c.  c.  and  four  doses  of  forty  c.  c.  were  given  at 
intervals  of  from  one  to  four  days.  After  the 
third  dose  the  temperature  carx&  began  to  drop, 
reaching  normal  two  days  after  the  fourth  dose 
and  remaining  normal  two  days  later.  It  rose 
again  and  did  not  begin  to  fall  again  until  two  days 
after  the  last  dose.  A  gradual  decline  then  oc- 
curred, no  rise  over  99^  occurring  after  the  eight- 
eenth day  following  the  last  dose,  and  there  being 
little  rise  at  all  a  month  later  and  thereafter.  The 
child  improved  clinically,  being  allowed  to  sit  up 
in  bed  on  Augtist  14th,  to  sit  on  a  chair  a  week 
later  and  to  begin  walking  ten  days  subsequently. 


She  gained  two  pounds  and  three  quarters  in 
twelve  days.  Quinine  and  urea  hydrochloride  in 
five  grain  doses  was  given  three  tijnes  a  day  from 
August  5th  to  10th  and  four  times  a  da\-  from 
August  10th  to  September  9th.  without  producing 
tinnitus.  She  was  discharged  from  the  hospital  on 
October  8th,  at  which  time  she  was  walking  about 
all  day.  " 

REFERENCES. 

1.  Heist,  George  D.,  Sous-Cohex,  Solomox.  and 
SoLis-CoHEX,  Myer  :  The  Bactericidal  Action  of  Whole 
Blood,  with  a  New  Technic  for  Its  Determination.  Jour- 
nal of  Imimmology,  1913,  vol.  iii,  p.  261. 

2.  Idem:  Observations  on  the  Behavior  of  Diphtheria 
Bacilli  in  WTiole  Coagulable  Blood,  with  a  Comparison  of 
the  Results  of  the  Tests  for  Bactericidal  and  Antitoxic 
Immunity  in  the  Same  Persons.  (As  yet  unpublished.) 

3.  Matsux.ami,  Toitsu,  and  Kolmer,  Johx  A. :  The 
Relation  of  the  Meningococcidal  Power  of  the  Blood  to 
Resistance  to  Virulent  Meningococci.  Journal  of  Immun- 
ology, 1918,  vol.  iii,  p.  201. 

4.  Sous-Cohex,  Mver,  and  Heist,  George  D.  :  A 
Method  of  Distinguishing  from  Among  A'arious  Micro- 
organisms Present  in  a  Patient,  Those  That  Are  and  Those 
That  Are  Not  Acted  Upon  by  That  Patient's  Whole  Blood. 
(As  yet  unpublished.) 

5.  Bl.\ck,  J.  H.,  Fowler,  Kenneth,  and  Pierce,  Paul: 
Development  of  the  Bactericidal  Power  of  Whole  Blood 
and  Antibodies  in  Serum.  Jourhal  A.  M.  A.,  1920,  vol.  Ixxv, 
p.  915. 

6.  Heist.  George  D.,  and  Solis-Cohex.  Solomox  :  The 
Virulence  of  Meningococci  for  Man  and  Human  Suscepti- 
bility to  Meningococcic  Infection.    (As  yet  unpublished.) 

7.  Solis-Cohex,  Myer:  A  Simple  and  Accurate  Method 
for  Measuring  the  Clotting  Time  of  the  Blood,  University 
of  -Pennsylzwiia  Medical  Bulletin.  1908.  vol.  xxi,  p.  203. 

2113  Chestxut  Street. 


~  THE  USE  OF  ATROPINE  IX  THE 
TREATMEXT  OF  THE  HYPER- 
TOXIC  IXFAXT.* 

By  Albert  D.  Kaiser.  ^I.  D., 
Rochester,  N.  Y. 

Tliere  exists  in  the  hypertonic  infant  a  definite 
physical  and  psychic  s}Tidrome  which  is  characterized 
by  hypertonicity  of  all  the  skeletal  muscles.  The 
sjTuptoms  presented  by  this  class  of  infants  are 
those  of  vagotonia.  The  occurrence  of  hyper- 
tonicity among  infants  is  not  rare.  It  is  found  in 
breast  as  well  as  bottle  fed  babies.  The  most  com- 
mon picture  is  that  of  the  unhappy  and  restless  baby, 
crying  a  great  deal,  sleeping  for  short  periods  only, 
and  subject  to  frequent  attacks  of  colic,  accom- 
panied by  vomiting.  Constipation  is  common.  In 
spite  of  these  symptoms  the  infant  may  be  taking 
food  regularly  and  show  a  satisfactory  growth  and 
increase  in  weight.  Attempts  to  alter  the  food 
seem  to  have  little  or  no  effect  in  eradicating  these 
symptoms.  These  mild  manifestations  generally 
go  uncorrected  until  the  infant  takes  solid  food. 
In  other  cases  malnutrition  results  from  the  vomit- 
ing and  lack  of  sleep,  presenting  a  serious  picture. 

The  symptoms  of  hypertonia  can  be  grouped 
under  physical  and  psychic  as  outlined  by  Haas  in 
his  description  of  this  condition.  The  physical 
sv-mptoms  are  chiefly  expressed  by  muscular  irrita- 

*Read  before  the  Seventh  District  Branch  of  the  New  York  State 
Medical  Society,  October  7,  1920,  at  Rochester,  X.  Y. 


972 


KAISER: 


THE  HVPERTOXIC  INFA.XT. 


[New  York 
Medical  Journal. 


bilit)^  visible  peristalsis,  vomiting  which  begins  in 
early  infancy,  mild  at  first  but  later  becoming  pro- 
jectile in  type,  leading  to  a  diagnosis  of  pyloro- 
spasm,  constipation,  and  malnutrition.  The  psychic 
symptoms  are  general  restlessness,  crying,  and  in- 
somnia. In  studying  these  infants  it  becomes  ap- 
parent that  the  fault  is  not  with  the  food  or  environ- 
ment, but  w^ith  the  infant  itself.  There  is  some 
mechanism  in  the  hypertonic  infant  which  is  un- 
stable and  causes  these  manifestations. 

In  order  to  make  clear  the  reason  for  using 
atropine  in  the  treatment  of  this  condition,  it  is 
important  to  review  w^hat  is  meant  by  the  symptoms 
of  vagotonia.  The  nervous  system  is  made  up  of 
the  sensorimotor  and  the  vegetative  systems.  The 
vegetative  is  composed  of  the  sympathetic  and  auto- 
nomic. Under  normal  conditions  a  sort  of  balance 
exists  between  the  innervations  in  the  two  antag- 
onistic systems,  this  balance  being  kept  up  probably 
by  chemical  action  of  hormones  upon  the  nerve  cells. 
Any  disturbance  in  equilibrium  may  cause  a  tem- 
porary upset  in  the  exercise  of  physiological  func- 
tion. In  vagotonia  there  are  various  clinical  symp- 
toms indicating  heightened  tonus  throughout  the 
craniosacral  autonomic  system.  This  heightened 
tonus  may  cause  stimulation  of  the  vagus,  which 
would  lead  to  turbulent  gastric  peristalsis  which 
readily  changes  into  retrograde  peristalsis  and  may 
manifest  itself  in  vomiting.  As  atropine  paralyzes 
the  vagus  and  causes  a  relaxation  of  the  intestines, 
its  use  can  readily  be  seen  in  this  condition.  Inas- 
much as  there  is  a  close  relationship  between  th.e 
autonomic  nervous  system  and  the  glands  of  in- 
ternal secretion  it  must  have  an  influence  upon  the 
mechanism  of  digestion. 

If  the  assumption  that  the  disorder  is  due  to 
impaired  action  of  the  vegetative  nervous  system  is 
correct,  the  use  of  atropine  as  a  therapeutic  agent 
is  sound.    Atropine  is  the  drug  of  choice  of  those 
paralyzing  the  vagus  endings,  inasmuch  as  it  is  well 
tolerated  by  infants  and  particularly  by  the  hyper- 
tonic baby.    To  procure  desired  results  it  must'  be 
administered  accurately,  bearing  in  mind  that  an 
active  preparation  is  essential  and  that  the  drug 
deteriorates.    The  method  of  treatment  as  outlined 
by  Haas  has  given  the  best  results  and  has  been 
followed  in  these  cases.    A  one  in  a  thousand  solu- 
tion is  used.    The  usual  dose  to  begin  with  is  one 
drop  or  one  thousandth  of  a  grain  in  each  feed- 
ing, or  in  a  small  amount  of  water  before  breast 
feedings.    The  mother  or  nurse  is  informed  of  the 
toxic  symptoms.    The  dose  is  increased  to  two 
drops  for  the  next  twenty- four  hours  if  no  un- 
toward symptoms  develop.    In  order  to  procure 
the  desired  relief  of  symptoms  three  or  four  drops 
six  or  seven  times  a  day  may  be  necessary.  The 
average  hypertonic  infant  will  tolerate  from  one 
fiftieth  to  one  twenty-fifth  of  a  grain  of  atropine  a 
day.     It  is  rare  to  find  an  infant  in  whom  a 
thousandth  of  a  grain  will  cause  flushing  of  the  face. 
The  toxic  symptoms  that  develop,  in  the  order  of 
their  frequency,  are:  Flushing  or  reddening  of  the 
face  and  body  (this  may  simulate  a  scarlet  fever 
rash)  ;  dilated  pupils  and  absence  of  reaction  to 
light;  dryness  of  the  lips  and  mouth  and  inability 
to  secrete  tears;  irritability  with  evidences  of  jerky 


movements.  The  symptoms  are  not  serious  as  in 
most  instances  the  flushing  is  first  observed,  which 
disappears  in  a  short  time  ^fter  discontinuing  the 
use  of  the  drug. 

The  hypertonic  infants  treated  presented  different 
pictures,  but  the  treatment  was  the  same  as  far  as 
the  use  of  atropine  was  concerned.  In  most  cases 
there  was  no  change  in  diet,  although  it  was  neces- 
sary to  make  additions  to  the  dietary  as  soon  as  the 
irritability  was  lessened.  A  description  of  a  few 
type  cases  representing  the  dififerent  groups  of 
symptoms  manifested  in  the  hypertonic  infant  will 
give  a  better  picture  of  the  results  of  the  treatment. 

REPORT    OF  C.VSES. 

Case  I. — Raymond  B..  normal,  full  term  baby;, 
birth  weight  seven  and  one  half  pounds.  He  was 
breast  fed  for  two  months :  did  poorly  on  breast, 
vomited  frequentl}',  had  colic,  and  was  restless. 
The  baby  was  put  on  a  whole  milk  mixture,  but  no 
improvement  was  noted.  When  first  seen  the  baby 
was  three  months  of  age  and  presented  the  following 
symptoms :  Vomiting  with  no  relation  to  feedings, 
marked  irritability,  restlessness,  crying,  and  in- 
somnia. The  weight  was  eight  pounds.  The  stools 
were  well  digested  and  the  formula  seemed  to  be  a 
rational  one,  so  was  not  changed.  Two  drops  of  a 
one  thousandth  solution  of  atropine  were  given 
in  each  feeding.  A  definite  improvement  was  noted 
in  fort3'-eight  hours.  The  vomiting  ceased,  there 
was  less  crying,  and  the  infant  slept  better.  There 
was  a  gain  in  weight  the  first  week,  which  con- 
tinued. In  the  next  six  weeks  the  baby  gained  two- 
and  a  half  pounds  and  seemed  to  be  normal  in 
every  respect. 

Case  II. — Lena  G.  was  sixteen  months  old  when 
she  was  sent  into  the  hospital.  She  had  always  been 
"an  irritable  baby  and  no  food  seemed  to  agree  with 
her.  For  some  months  she  had  been  taking  cow's 
milk,  but  made  no  apprecial)le  gain.  On  entrance 
her  weiglit  was  fourteen  and  a  half  pounds.  Crying 
was  the  outstanding  symptom ;  this  was  so  severe 
tliat  it  was  feared  the  child  would  go  into  convu'- 
sions.  The  crying  spells  occurred  frequently  at 
night.  There  was  a  mild  diarrhea,  but  no  vomiting. 
It  was  estimated  that  the  baby  was  getting  sufticient 
food,  though  apparently  -not  assimilating  enough. 
-Assured  there  was  nothing  else  at  fault  but  the 
hypertonicity.  atropine  was  administered. 

There  was  a  rapid  movement  in  the  general  condi- 
tion of  the  child.  The  child  became  happy  and  con- 
tented, crying  little  and  sleeping  all  night.  With 
increased  food  the  weight  went  from  fourteen  and  a 
half  to  nineteen  pounds  and  three  quarters  in  seven 
weeks.  The  atropine  was  discontinued  after  six 
weeks. 

Case  III. — John  S.  was  a  full  term  baby.  He  had 
breast  milk  for  only  two  weeks.  Cow's  milk  and 
a  prepared  food  were  given.  The  birth  weight  was 
seven  and  a  quarter  pounds.  At  the  end  of  the  third 
week  vomiting  began,  which  became  more  and  more 
.severe  and  eventually  projectile  in  type.  Little 
food  was  retained  and  it  became  difficult  to  secure 
a  bowel  movement.  At  the  end  of  the  fifth  week, 
v.hcn  the  baby  was  first  seen,  it  presented  the  picture 
of  a  starved  baby.  The  least  little  sound  would 
startle  it.    There'  was  visible  peristalsis  and  pro- 


Decaub-r  18,  1920.] 


DOSXELLY:   MALSUTRITIOX  IX  CHILDREX. 


973 


jectile  vomiting,  but  no  tumor  mass  felt.  The 
weight  was  seven  pounds.  A  diagnosis  of  hyper- 
tonia and  pylorospasm  was  made.  The  color  was 
poor  and  on  the"  whole  the  prognosis  did  not  seem 
good.  The  baby  was  first  given  a  thick  gruel  feed- 
ing but  even  this  could  not  be  retained  until  atropine 
had  been  given.  No  results  were  obtained  until 
three  drops  were  given  before  each  feeding.  The 
intestinal  activity  became  less  marked  and  the  food 
was  retained.  When  the  vomiting  ceased  the  old 
formula  of  milk  and  the  prepared  food  was  again 
given.  The  irritability  subsided  and  the  baby  began 
to  gain.  From  June  5th  to  September  2nd  the  baby 
gained  five  and  a  quarter  pounds  and  seemed  normal 
in  every  way.  Twice  the  atropine  was  discontinued 
and  promptly  the  vomiting  returned.  Now  the 
mother  does  not  dare  leave  out  the  atropine. 

In  the  last  six  months  ten  babies  classified  as 
hypertonic  infants  have  been  treated  in  this  way. 
A  marked  improvement  followed  in  all  with  the 
use  of  atropine,  without  any  change  in  diet.  It 
must  be  remembered  that  not  all  cases  of  vomiting, 
constipation  and  malnutrition  are  due  to  hyper- 
tonia, so  imless  the  use  of  atropine  is  restricted  to 
undoubted  cases  of  hypertonicity,  failure  will  result. 
Corrections  in  diet  and  habits  should  be  made,  but 
if  in  spite  of  this  the  infant  presents  symptoms  of 
irritability  atropine  should  be  tried.  The  use  of 
atropine  will  soon  demonstrate  the  correctness  of 
the  diagnosis,  for  the  relief  of  symptoms  is  evident 
in  a  few  days  and  improvement  continues  as  long 
as  the  drug  is  maintained.  Atropine  must  be  con- 
tinued for  a  variable  time. 

SUMMARY. 

The  hypertonic  infant  presents  a  definite  clinical 
picture,  due  to  a  disturbance  of  the  autonomic  nerv- 
ous system  whicli  gives  rise  to  physical  and  psychic 
disturbances. 

The  usual  manifestations  are  irregular  vomiting 
often  with  visible  peristalsis,  constipation,  malnu- 
trition, muscular  irritability,  representing  the  physi- 
cial  defects,  and  with  insomnia  and  crying  as  psychic 
disturbances. 

The  diet  usually  needs  no  change  in  the  hypertonic 
infant  and  the  food  is  well  digested. 

A  solution  of  atropine  gives  early  relief  of  symp- 
toms in  these  cases  and  thereby  metabolism  is  in- 
creased, bringing  about  the  desired  gain  in  weight. 

The  use  of  the  atropine  is  not  dangerous  if  given 
in  guarded  doses  and  the  early  toxic  symptoms  are 
noted. 

29  BucKixGH.vM  Street. 

Case  of  Lethargic  Encephalitis  with  Post- 
mortem Examination. — Ducamp,  Blouquier  de 
Claret,  and  Tzelepoglou  {Bulletin  dc  I' Academic  de 
medecine,  May  11,  1920)  report  a  typical  fatal 
case  of  lethargic  encephalitis  with  pathological 
study  of  the  brain.  The  lesions  at  present  con- 
sidered characteristic  of  the  disorder  were  found, 
namely,  acute  perivasculitis  with  diapedesis  and 
cellular  degeneration,  the  process  as  a  whole  being 
situated  particularly  in  the  gray  matter  of  the  mid- 
brain. The  cause  of '  certain  ocular  disturbances 
witnessed  during  life  was  accounted  for  by  degen- 
erative changes  in  the  corresponding  centres. 


THE   CLASS   METHOD   OF  TREATING 
MALNUTRITION   IN  CHILDREN.* 

By  William  Henry  Donnelly,  M.  D.. 
Brooklyn,  N.  Y., 

Instructor   in   Pediatrics   in  the   New   York   Post-Graduate  Medical 
School  and  Hospital;   Chief  of  Nutrition   Clinic   in  the 
Brooklyn  Hospital. 

At  the  outset  in  a  paper  on  malnutrition  in  chil- 
dren it  might  be  well  to  make  clear  what  shall  be 
understood  by  malnutrition,  subnutrition,  or  under- 
nourishment. Emerson,  of  Boston,  at  first  classed 
as  undernourished  any  child  ten  per  cent,  under 
weight  for  his  height,  but  later  he  made  seven  per 
cent,  the  standard.  This  is  one  criterion  by  which 
to  judge  the  state  of  nutrition  of  any  child,  but 
there  are  other  factors  involved,  and  it  has  seemed 
to  some  of  us  interested  in  this  work  that  a  child 
can  be  up  to  the  standard  of  weight  for  its  height 
and  still  be  sufficiently  undernourished  to  attract 
attention  and  require  active  treatment.  Dr.  George 
Newman,  chief  medical  officer  of  the  Board  of 
Education  for  England  and  Wales,  clearly  has  this 
in  mind  when,  in  his  annual  report  for  1915-16  he 
defines  malnutrition  as  "a  low  condition  of  health 
and  body  substance.  It  is  measurable  not  only  by 
height  and  weighty  and  robustness,  but  by  many 
other  signs  and  symptoms."  These  signs  are  the 
color,  the  brightness  of  the  eyes,  the  carriage,  the 
disposition,  sleep,  digestion,  regularity  of  the  bowels, 
and  the  condition  of  the  muscles. 

Malnutrition  in  childhood  is  the  underlying 
reason  for  the  alarming  proportion  of  defects  and 
rejections  found  in  the  physical  examination  of 
recruits  in  the  late  war.  It  has  been  estimated  by 
Emerson  and  other  observers  that  about  a  third  of 
all  school  children  are  undernourished,  and  yet  this 
school  age  is  the  one  most  neglected  by  the  average 
practitioner  and  medical  school  teacher. 

The  student,  whether  undergraduate  or  graduate, 
has  the  importance  constantly  impressed  upon  him 
of  the  feeding  and  general  care  of  the  infant  up 
to  the  end  of  the  first  year  of  life ;  there  is  much 
less  attention  paid  to  the  welfare  of  the  child 
during  the  next  period  of  early  childhood,  whereas 
once  he  reaches  the  school  age  he  gets  scarcely  any 
attention  at  all. 

If  the  school  child  has  glaring  defects  they  are 
noted  by  the  school  ph3'sician  in  his  routine  examina- 
tion, but  he  cannot  compel  their  correction.  As  a 
result  there  is  in  every  community  a.  veritable  army 
of  children  whose  appearance  is  such  that  with  a 
casual  looking  over  they  will  pass  as  normal  in 
health  and  nutrition,  whereas  they  may  be  in  such 
a  state  of  subnutrition  as  not  only  to  render  them 
more  susceptible  to  disease  but  also  to  ])rejudice  their 
chance  and  right  ta  grow  up  to  normal  adult  hei^^ht. 
weight,  and  health. 

Causes  of  malnutrition  may  be  divided  into  real 
disease  or  abnormal  condition,  and  faulty  hygiene 
and  diet.  In  the  first  class  three  conditions  occupy 
the  foreground,  namely,  diseased  tonsils,  tubercu- 
losis, and  concealed  or  latent  congenital  lues. 
Tuberculosis  is  usually  glandular  in  its  origin  in 
childhood  and  the  mediastinal  gland  groups  should 

*Read  b?fore  the  Medical  Society  of  the  County  of  Kings,  Brodk- 
1;  n.  New  York  City,  October  19,  1920. 


974 


DONNELLY:  MALNUTRITION  IN  CHILDREN. 


[New  Vork 
^[ed^cal  joirxal. 


especially  be  suspected.  Here  the  x  ray  and 
D'Espine's  sign  will  help  in  the  diagnosis.  Our 
conception  of  this  sign  is  based  upon  the  original 
interpretation  of  D'Espine  (1)  himself,  who  wrote: 
"The  first  signs  of  bronchial  adenopathy  are  fur- 
nished by  the  auscultation  of  the  voice,  and  are 
observed  almost  always  in  the  immediate  neighbor- 
hood of  the  vertebral  column,  between  the  seventh 
cervical  and  upper  dorsal  vertebrte,  either  in  the 
supraspinous  fossa  or  lower  down  in  the  inter- 
scapular space.  They  consist  in  a  timbre  added  to 
the  voice  which  one  may  call  whispering  (chuchote- 
mcnt)  in  the  first  stage,  and  bronchophony  in  a 
later  stage."  \\'e  have  always  considered  any 
whispering  bronchophony  below  the  level  of  the 
seventh  cervical  vertebra  as  presumptive  evidence 
of  the  existence  of  enlarged  bronchial  glands, 
whether  tuberculous  or  not. 

Persistent  failure  of  a  child  to  gain  after  the 
performance  of  corrective  measures,  such  as  ton- 
sillectomy and  dental  repair,  is  always  suggestive 
of  either  tuberculosis  or  congenital  lues.  In  the 
absence  of  a  positive  Wassermann  test  certain  den- 
tal stigmata  may  help  in  the  diagnosis  of  lues. 
These  are  the  separation  of  the  upper  central  in- 
cisors first  described  by  Roberts  and  the  presence 
of  accessory  cusps  on  the  upper  permanent  molars 
first  reported  by  Sabouraud. 

Diseased  tonsils  are  now  looked  upon,  with  other 
factors  in  nasopharyngeal  obstruction,  as  more  com- 
mon in  the  cause  of  malnutrition  than  carious  teeth. 
One  reason  for  this  is  that  at  the  age  when  under- 
nourishment is  most  marked,  namely,  the  preschool 
and  early  school  years,  caries  exists  mainly  in  the 
persisting  deciduous  teeth,  whose  apices  and  roots 
liave  been  partially  or  wholly  absorbed,  and  hence, 
focal  infection  from  apical  abscesses  is  physicallv 
improbable. 

Cyclic  vomiting  or  food  idiosyncrasies  may  be 
found  to  be  causative  factors  in  many  cases  repre- 
senting real  food  sensitization,  which  may  be  veri- 
fied and  the  treatment  indicated  by  doing  the  skin 
tests  with  the  various  proteins.  Organic  disease  of 
the  kidneys,  blood,  intestines,  especially  the  presence 
of  intestinal  parasites,  must  be  ruled  out  or  cor- 
rected before  the  case  will  respond  to  the  general 
treatment  laid  down  for  the  imdernourished  child. 

The  second  class  of  cases  are  not  due  to  real 
disease,  but  to  errors  of  hygiene  or  diet,  or  to  the 
abuse  or  improper  use  of  exercise  and  muscular 
activity.  Food  may  be  insufficient  in  many  ways. 
It  may  be  insufficient  in  quantity  and,  therefore, 
cause  constipation  from  lack  of  bulk  in  the  bowel, 
or  it  may  be  deficient  in  calories  or  vitamines,  or 
both.  Especially  to  be  mentioned  and  condemned 
are  tea,  cofiFee,  candy  and  ice  cream  between  meals, 
cake,  thin  broths,  too  much  fluid  at  meals,  and 
similar  errors  in  diet. 

Factors  other  than  food  in  the  causation  of  mal- 
nutrition were  well  brought  out  in  a  paper  read 
before  the  Child  Welfare  Convention  in  New  York 
in  IVIay,  1920,  by  Dr.  Hugh  L.  Chaplin.  We  can 
heartily  endorse  his  statements  regarding  the  impor- 
tance of  insufficient  sleep,  improper  ventilation  of 
rooms  during  .sleep,  too  short  lunch  periods,  insuffi- 
ci'ent  or  too  much  exercise,  uncleanliness  of  the 


body,  and  many  other  faulty  habits  of  life.  The 
undernourished  child  should  be  looked  upon  as  a 
sick  child  and  his  habits  and  activities  should  be 
regulated  and  not  left  to  him  to  decide.  These 
children  are  possessed  of  a-  restless  spirit  out  of 
proportion  to  their  physical  strength,  and  if  left  to 
their  own  inclinations  will  exhaust  themselves  and 
prevent  the  desired  gain  in  weight  and  strength. 
It  has  been  found  that  these  children  become 
physically  tired  in  the  early  afternoon  and,  there- 
fore, it  has  been  made  a  universal  rule  in  this  work 
to  insist  on  a  rest  period  of  preferably  a  whole  hour 
after  school,  with  the  taking  of  a  light  lunch  of 
bread  and  butter  and  a  glass  of  milk  to  restore 
the  flagging  energy  of  the  imdernourished  body. 

Within  recent  years  there  has  been  a  startling 
awakening  to  the  vital  importance  of  the  malnu- 
trition problem  in  school  children,  and,  as  the  most 
efficient  and  practicable  method  of  combatting  the 
evil  has  been  found  to  be  the  nutrition  class,  it 
would  seem  that  a  brief  history  of  class  methods 
deserves  a  place  here.  Investigation  of  the  litera- 
ture reveals  the  fact  that  as  far  back  as  1890,  Dr. 
]\Iinor,  of  Asheville,  N.  C,  used  the  class  method 
of  treating  tuberculosis  in  his  private  patients. 
However,  it  was  not  until  July,  1905,  that  this 
method  was  applied  to  poor  patients  by  Dr.  J.  H. 
Pratt,  of  Boston,  who  in  that  month  organized  the 
Emanuel  Church  Tuberculosis  Class,  which  met  at 
the  Massachusetts  General  Hospital,  and  for  which 
funds  were  provided  by  the  church  from  which  it 
derived  its  name.  This  was  the  first  attempt  to 
treat  poor  patients  in  their  homes  in  a  large  city. 
The  patients  were  given  directions  as  to  hygiene, 
rest,  outdoor  air,  and  other  essentials,  and  were 
instructed  to  keep  a  record  of  their  temperature, 
hours  of  rest,  food  taken,  action  of  the  bowels,  and 
other  data.  This  record  was  brought  to  the  weekly 
meeting  of  the  class,  where  it  was  gone  over  by 
the  medical  director,  who  gave  such  individual 
advice  as  seemed  necessari-  and  then  gave  a  talk 
to  the  whole  class.  It  was  happily  seen  at  the  out- 
set of  this  class  work  that  a  social  service  worker 
or  visiting  nurse  was  indispensable,  and  this  agrees 
perfectly  with  the  experience  of  everyone  who  has 
since  attempted  to  conduct  a  class  of  any  kind, 
whether  in  tuberculosis,  cardiac  disorders,  or  nutri- 
tion. In  1906,  Dr.  John  B.  Hawes,  2nd,  also  of 
Boston,  organized  the  Suburban  Tuberculosis  Class, 
with  equally  good  results,  and  from  that  time  on 
the  class  treatment  has  been  allied  to  various  condi- 
tions with  gratifying  results. 

Having  taken  up  the  development  of  the  class 
method  of  treatment,  we  naturally  go  on  to  the 
application  of  this  method  to  the  treatment  of 
nutritional  disturbances  in  children  especially  of 
the  school  age.  It  seems  that  the  first  serious 
attention  to  the  problem  was  given  in  England 
during  the  Boer  war,  when  the  war  department 
was  chagrirted  at  the  enormous  number  of  rejections 
of  applicants  for  enlistment  in  the  Army  and  Navy. 
This  gave  rise  to  an  investigation,  after  the  war. 
of  the  health  conditions  in  the  schools,  resulting  in 
the  providing  of  .school  lunches  in  the  endeavor  to 
correct  malnutrition.  These  lunches  were  finally 
given  up  as  inefficacious. 


Dec.ml)  r  18,  192u.] 


DONNELLY 


MALNUTRITION  IN  CHILDREN. 


975 


On  this  continent  Dr.  W.  R.  P.  Emerson  (2),  of 
Boston,  was  tlie  pioneer  not  only  in  calling  attention 
to  the  widespread  existence  of  malnutrition  in  school 
children,  but  also  in  organizing  classes  for  its  treat- 
ment. In  the  fall  of  1908  he  collected  fifteen  chil- 
dren at  the  Boston  Dispensary,  who  were  the 
weakest  and  poorest  nourished  of  four  or  five  thou- 
sand children  seen  during  that  year.  He  laid  down 
rules  of  rest,  hygiene,  diet,  and  of  conduct  of  the 
class,  which  have  required  remarkably  few  changes 
up  to  the  present  time,  and  he  has  regarded  from 
the  beginning  as  indispensable  the  services  of  a 
good  social  worker  to  visit  the  homes  of  the  children. 
By  the  aid  of  such  a  worker  it  is  possible  to  find 
out  on  what  floor  the  child  lives  and,  therefore, 
whether  excessive  stair  climbing  has  a  bearing  on 
the  case,  whether  there  is  overcrowding  in  the 
household,  whether  the  mother  is  preparing  or 
knows  how  to  properly  prepare  the  food  prescribed. 

Having  secured  the  assistance  of  such  a  social 
worker,  the  next  important  point  in  the  organiza- 
tion of  a  nutrition  class  is  the  preparation  of  a 
proper  physical  examination  blank.  Emerson  again 
was  the  first  to  draw  attention  to  the  necessity  of  a 
complete  standardized  blank  form.  Whatever  form 
is  adopted  there  are  a  few  essentials  to  its  rapid 
and  practical  use,  namely,  the  placing  in  such  a 
prominent  position  as  to  be  seen  at  a  glance,  the 
child's  age,  height,  weight  for  height  and  age,  aver- 
age normal  weight  for  height  and  age,  number  of 
pounds  below  weight,  and  percentage  below  weight. 
In  most  blanks  available  these  figures  are  placed 
in  such  a  position  and  in  such  a  part  of  the  form 
as  not  to  be  easily  found.  Other  requisites  are 
suitable  rooms  for  weighing,  accurate  scales  and 
measuring  rods,  a  large  table  of  weight  standards 
so  placed  as  to  be  seen  at  a  glance ;  if  possible,  a 
food  exhibit  in  wax  or  other  plastic  materia?  which 
may  be  studied  by  the  children  and  their  mothers 
while  awaiting  their  examination,  and  which  may  be 
used  by  the  class  director  or  nurse  for  demonstrating 
relative  food  values. 

A  special  point  which  has  been  taken  up  in  the 
Brooklyn  Hospital  Nutrition  Class,  and  which  pre- 
sents great  possibilities,  is  the  utilization  of  what 
is  otherwise  wasted  time  in  the  presentation  of 
suitable  moving  picture  films,  or  the  instructive  and 
amusing  antics  of  Cho-Cho  the  Health  Clown,  or 
the  dazzling  appearance  of  the  Health  Fairy.  The 
Health  Department  of  the  State  of  New  York  has 
educational  motion  picture  films  available  for  this 
purpose.  In  order  that  the  nutrition  class  or  clinic 
may  be  able  to  do  its  best  work  without  handicap, 
there  should  be  the  closest  interlocking  and  coopera- 
tion of  the  other  clinics  in  the  hospital,  such  as  the 
eye,  ear,  nose  and  throat,  the  orthopedic  and  the 
surgical.  Furthermore,  there  should  be  active  and 
real  cooperation  of  the  indoor  department  of  the 
hospital  so  that  cases  sent  into  the  hospital  for 
treatment  or  operation  should  have  the  corrective 
measures  advised  by  the  nutrition  clinic  carried  out, 
and  of  the  greatest  importance,  so  that  a  complete 
and  accurate  record  of  such  treatment  should  be 
sent  back  to  the  clinic  for  the  intelligent  further 
nutritional  management  of  the  case.  Of  great  value 
in  the  actual  conduct  of  the  class  have  been  found 


two  forms,  for  which  we  are  indebted  to  Dr.  Charles 
Hendee  Smith,  of  Bellevue,  namely,  the  home  record 
sheet  and  the  complete  diet  list  for  the  guidance  of 
the  mother  in  the  preparation  of  the  food.  The 
home  record  sheet  is  given  to  each  child  at  its  first 
visit  to  have  recorded  thereon  a  full  report  of 
activities  and  food  taken  for  forty-eight  hours,  and 
this  is  repeated  when  at  any  time  the  child  ceases 
to  gain  and  a  cause  for  such  failure  is  sought.  A 
suitable  weight  chart  is  necessary,  competition  is 
encouraged  by  the  offering  of  rewards  for  gain  in 
weight,  or  carrying  out  of  corrective  measures,  and, 
finally,  in  order  to  know  definitely  the  efficacy  of 
hygienic,  dietetic  and  corrective  measures,  no  medi- 
cine is  given  where  it  is  possible  to  avoid  it. 

By  the  carrying  out  of  these  simple  measures, 
without  the  administration  of  any  medicine,  whether 
tonics  or  otherwise,  a  large  group  of  under- 
nourished children  have  been  made  to  gain  m  a 
nutrition  class  at  Brooklyn  Hospital  at  almost  one 
and  a  half  times  the  normal  rate.  The  actual  figures 
of  the  class  record  for  six  months  will  be  considered 
elsewhere. 

From  a  review  of  the  literature,  from  personal 
interviews  with  other  workers  in  this  field,  and  from 
personal  experience  in  the  conduct  of  a  nutrition 
class,  the  following  conclusions  seem  justified: 

1.  Malnutrition  is  widespread  in  children,  espe- 
cially those  of  the  school  and  preschool  age. 

2.  The  class  method  is  the  one  of  choice  in  the 
treatment  of  malnutrition  cases. 

3.  Essentials  in  the  efficient  conduct  of  a  nutrition 
class  are  a  trained  social  service  worker,  a  thorough 
physical  examination  recorded  on  a  standardized 
blank,  correction  of  organic  defects  and  of  faulty 
diet,  insistence  on  rest  periods  during  the  day,  the 
arousing  and  sustaining  of  the  child's  interest. 

REFERENCES.. 

1.  D'EspiNE :  Bulletin  de  I'Academic  de  Medicine.  1907. 

2.  Emerson,  W.  R.  P.:  Class  Methods  in  Dietetic  and 
Hygienic  Treatment  of  Delicate  Children,  Pcdialrics.  vol. 
xxii,  1910,  p.  626. 

BIBLIOGRAPHY. 

Emerson,  W.  R.  P. :  Food  Habits  of  Delicate  Children, 
New  York  Medical  Journal,  vol.  cv,  1917,  p.  361. 

Standardized  Physical  Examinations,  Archives  of  Pedi- 
atrics, vol.  XXXV,  1918,  p.  411. 

A  Nutrition  Clinic  in  a  Public  School,  American  Journal 
of  Diseases  of  Children,  vol.  xvii,  1919,  p.  251. 

Nutrition  Clinics  and  Classes,  Their  Organization  and 
Conduct,  Boston  Medical  and  Surgical  Journal,  July  31, 
1919,  vol.  clxxxi,  No.  5. 

Smith,  Charles  Hendee:  Methods  Used  in  a  Class  for 
Undernourished  Children,  American  Journal  of  Diseases 
of  Children,  vol.  xv,  1918,  p.  373. 

How  to  Conduct  a  Nutrition  Class :  Brochure  for  Child 
Health  Organization. 

Manny,  Frank  A. :  Nutrition  Clinics  and  Classes, 
Modern  Hospital,  vol.  x,  1918,  p.  129. 

Wilson,  May  G.  :  Report  of  the  Cornell  Nutrition  Class,. 
Archives  of  Pediatrics,  vol.  xxxvi,  1919,  p.  37. 

Kantor,  John  L.  :  Experiences  with  a  Class  in  Nutri-- 
tion,  New  York  Medical  Journal,  vol.  cviii,  1918,  p.  241.. 

Holt,  L.  Emmet:  Standards  for  Growth  and  Nutrition 
of  School  Children,  Archives  of  Pediatrics,  vol.  xxxv 
1918,  p.  359. 

Standards  for  Growth  and  Nutrition,  American  Journal 
of  Children's  Diseases,  vol.  xvi,  1918,  p.  359. 

Mitchell,  David:  Malnutrition  and  Health  Education, 
Pedagogic  Seminary,  March,  1919,  vol.  xxvi,  pp.  i-26,  PS' 
64,  4  mos.  from  February,  1918. 


976 


RUDERMAN:  NUTRITION  CLASS. 


[New  York 
.vIedical  Journal. 


SIX  MONTHS-  EXPERIENCE  WITH  A 
NUTRITION  CLASS.* 
By  Louis  M.  Ruderman,  M.  D., 
Brooklyn,  N.  Y., 

Clinical    .Assistant    in    Pediatrics    in    the    New    Y'ork  Post-Graduate 
Medical  School  and  Hospital,  and  in  the  Brooklyn  Hospital. 

The  nutrition  class  of  the  Brooklyn  Hospital 
commenced  its  work  at  about  the  beginning  of  the 
current  year  with  a  small  initial  attendance.  Mem- 
bership in  the  class  was  limited  to  children  of  school 
and  kindergarten  age  five  per  cent,  or  more  under 
weight.  The  class  increased  in  size  so  rapidly  that 
after  two  months  no  more  new  material  was  added, 
and  intensive  work  continued  with  the  fifty  children 
in  attendance.  This  number  has  formed  a  basis 
for  our  present  report  and  conclusions. 

Before  proceeding  with  our  figures  it  should  be 
bome  in  mind  that  the  average  child  we  had  to 
deal  with  was  rather  satisfied  with  the  old  factors 
of  its  environment,  and  that  the  work  which  we 
attempted  to  do  imposed  a  sort  of  burden  which 
some  were  unwilling  to  assume.  Thus,  it  had  been 
the  custom  of  our  average  child  to  rise  late,  eat  a 
hurried  breakfast  without  washing  its  hands  and 
face  or  brushing  the  teeth.  The  midday  meal  would 
be  rushed  through  in  the  same  manner.  After 
school  the  child  would  remain  playing  in  the  street 
till  sunset  or  later,  or  would  be  put  to  some  quasi- 
profitable  task  at  home.  After  the  evening  meal 
the  child  would  resume  its  recreation  outdoors,  often 
until  midnight.  Toothbrushes  as  personal  property 
were  almost  unheard  of,  and  a  bath  was  either  a 
monthly  feature  or  a  pleasure  indulged  in  only 
during  the  warm  season,  when  the  family  enjoyed 
its  weekly  immersion  in  the  surf 

The  nutrition  class  cam.e  and  superseded  this  un- 
hygienic routine  by  a  more  rational  regimen,  more 
healthful  and  natural.  There  was  a  good  measure 
of  inertia  to  overcome,  and  the  work  often  taxed 
all  the  ingenuity  of  physician,  nurse,  and  social 
worker.  The  mother,  whose  cooperation  was  es- 
sential to  our  success,  was  often  hard  to  win  over, 
due  chiefly  to  her  ignorance  of  our  purpose  and  to 
the  novelty  of  the  idea.  She  probably  considered 
our  efforts  an  interference  with  her  domestic 
regime,  hence  the  indifference  which  occasionally 
militated  against  our  endeavors.  To  these  factors 
must  be  added  the  poor  intellectual  material  gener- 
ally prevailing  in  our  field  of  operations.  Our  nurse 
has  had  to  contend  with  these  obstacles,  and  even 
after  much  patient  coachings  we  have  often  received 
but  a  weak  response.  For  example,  a  child  advised 
to  take  an  afternoon  nap  would  be  put  by  the  mother 
to  the  task  of  pulling  bastings  or  sewing  on  buttons, 
and  as  a  result  she  lost  her  opportunity  either  for 
sleep  or  for  outdoor  exercise.  Again,  a  mother  of 
seven  children,  one  of  whom  is  the  object  of  our 
study  and  help,  would  not  prepare  any  cereal  for 
the  morning  meal  when  they  were  accustomed  to 
bread  and  butter  and  coffee.  It  was  therefore  much 
easier  for  us  to  give  advice  than  for  them  to  follow  it. 
The  following  figures  are  based  on  our  records: 

Total  number  of  children,  fifty. 
Period  of  observation,  six  months. 

*Read  before  the  Medical  Society  of  the  Countv  of  Kings,  Brook- 
lyn, New  York  City,  October  19,  1920. 


Average  age,  eight  years  eight  and  one  half  months. 
Average  height,  forty-nine  inches. 

Average  weight  on  admission,  fifty-two  and  one  half 
pounds. 

Normal  weight  for  age  and  heights  fifty-seven  pounds. 

Average  per  cent,  under  weight  on  admission,  eight. 

Average  weight  at  the  end  of  six  months,  fifty- four 
pounds  thirteen  ounces. 

Normal  weight  for  age  and  height  at  the  end  of  six 
months,  fifty-eight  pounds. 

Average  per  cent,  under  weight  at  the  end  of  six  months, 
five  and  one  half. 

ANALYSIS   OF   OUR  FIGURES. 

Attendance. — The  average  number  of  visits  of 
each  child  was  nine  and  five  tenths,  or  about  thirty- 
five  per  cent,  of  the  total.  The  older  children  were 
more  faithful  in  this  regard,  since  distance  and  the 
weather  did  not  interfere"  so  much  with  their 
attendance.  The  younger  members,  however,  had 
to  come  accompanied  by  a  parent  or  an  older  child, 
hence  the  larger  number  of  absences.  Influenza 
and  the  usual  seasonal  respiratory  diseases  kept 
some  children  away  for  a  month  or  longer.  How- 
ever, once  the  interest  was  acquired,  many  children 
presented  themselves  every  Saturday  morning  for 
a  number  of  weeks  in  succession. 

Age. — The  youngest  member  of  the  class  was  five 
and  the  oldest  fourteen.  The  older  children  could 
be  reasoned  with  more  successfully  and  their  co- 
operation gained  more  easily  than  the  younger  ones, 
who  could  not  fix  their  attention  very  long,  and  in 
whom  the  interest  in  the  class  was  likely  to  lag 
quickly. 

Weight. — Our  standard  was  the  table  of  weights 
for  both  sexes  at  different  ages  and  heights  issued 
by  the  Child  Health  Organisation.  We  assume  that 
a  normal  steady  gain  in  weight  indicates  general 
good  health,  except  in  cases  of  myxedema,  nephritis 
and  other  infrequent  conditions.  Our  aim  has  been 
to  regulate  the  life  of  the  child  so  that  it  would 
show  a  gradually  mounting  weight  curve,  although 
such  a  curve  often  showed  many  capricious  varia- 
tions which  at  times  were  difiicult  to  explain.  One 
child  would  gain  but  little  under  most  careful  super- 
vision and  strict  obedience  of  orders  as  to  diet  and 
hygiene.  Another  would  gain  considerably  in  spite 
of  poor  all  around  management.  While  a  child 
of  eight  or  nine  years  should  gain  two  pounds  in 
six  months,  our  children  showed  an  average  gain 
of  two  and  one  half  pounds,  reducing  the  per- 
centage under  weight  from  eight  to  five  and  five 
tenths.  There  was  no  great  accuracy  in  weighing, 
since  the  children  were  weighed  in  their  stockings, 
with  all  their  clothes  on,  and  their  clothes  would 
vary  inevitably  with  the  season  and  the  weather. 
Again,  the  scales  themselves  were  a  considerable 
source  of  error,  since  they  varied  under  changing 
conditions  of  weather,  roughness  of  handling,  and 
length  of  time  in  use.  However,  all  these  errors 
are  minimized  when  the  figures  covered  fifty  chil- 
dren for  a  period  of  six  months. 

Defects. — The  detection  and  elimination  of  defects 
formed  a  large  and  important  part  of  our  work. 
After  a  thorough  physical  examination,  various  de- 
fects were  discovered  and  noted.  Twenty  had  one 
or  more  carious  teeth ;  these  children  were  referred 
for  dental  treatment.  Four  were  found  to  have 
stigmata,  of  congenital  lues,  and  our  diagnosis  was 


Deccmlx-r  18,  1920.] 


RICHARDSON :  INFANT  FEEDING. 


977 


confirmed  in  each  instance  by  the  Wassermann 
test ;  these  too  were  referred  for  treatment.  Nine- 
teen had  diseased  tonsils  and  adenoids ;  ten  had  them 
removed  and  the  others  are  awaiting  their  turn. 
Twenty-four  showed  a  positive  D'Espine's  sign,  the 
meaning  of  which  has  been  ably  discussed  by  Dr. 
Donnelly.  One  had  kyphosis  and  one  scoliosis ; 
one  had  phimosis ;  one  had  spastic  paraplegia. 

Procedure. — The  general  procedure  with  the  class 
was  as  follows :  Each  new  member  at  his  first  visit 
underwent  a  complete  physical  examination,  and  all 
findings,  both  positive  and  negative,  were  entered  on 
a  well  planned  and  comprehensive  chart.  Here  a 
prominent  place  was  reserved  for  the  summary  of 
defects,  which  determined  our  treatment  of  the  case. 
Height,  and  weight  for  height  and  age,  were  re- 
corded, as  well  as  the  normal  weight  according  to 
our  standard  table  of  weights.  Laboratory  work, 
such  as  a  Wassermann  test,  blood  count  and  urine 
examination,  was  done  if  necessary.  Whenever  any 
special  examination  or  treatment  was  indicated,  the 
child  was  referred  to  the  several  special  departments 
of  the  hospital.  Upon  revisits  the  child  was  weighed 
and  the  weekly  gain  or  loss  in  weight  recorded. 
Then  followed  an  individual  conference  with  the 
child  and  the  parent.  The  daily  routine  of  the  child 
was  closely  reviewed,  and  the  questions  of  diet, 
sleep,  play,  and  personal  hygiene  were  thoroughly 
gone  into  and  advice  given  accordingly,  li  there 
was  a  loss  in  weight  this  conference  was  particularly 
earnest  and  searching.  The  work  of  the  morning 
was  wound  up  with  a  short,  simple  arid  direct  talk 
by  one  of  the  stafif,  addressed  to  the  children  and 
parents,  epitomizing  the  experience  of  the  mornin 
and  drawing  conclusions  therefrom.  Sometimes  it 
took  the  form  of  a  quiz,  utilizing  the  apperceptive 
mass  of  the  children  in  teaching  them  the  elementary 
principles  of  diet,  hygiene  and  health. 

CONCLUSIONS. 

While  these  fifty  children  are  still  below  par 
in  state  of  nutrition,  considerable  improvement 
has  been  shown  during  the  period  of  our  work, 
being  now  only  five  and  five  tenths  per  cent, 
under  weight.  It  must  be  remembered  that  these 
children  came  to  us  on  account  of  their  poor  nutri- 
tional status.  We  have  apparently  succeeded  in 
raising  them  to  a  nutritional  level,  where  they  are 
accomplishing  what  is  expected  of  a  normal  child 
in  this  regard.  They  are  all  quite  familiar  with 
what  we  are  trying  to  do,  and  are  desirous  of  going 
ahead  with  the  work.  They  are  enthusiastic  about 
it,  and  a  friendly  rivalry  has  sprung  up  among  them 
as  to  the  greatest  gain  in  weight.  By  gaining  the 
child's  confidence  and  by  showing  it  the  way  we 
hope  to  prosecute  the  work  with  even  greater  suc- 
cess than  heretofore.  We  believe  that  if  similar 
work  is  undertaken  in  every  congested  district  of 
our  larger  cities  it  will  greatly  contribute  toward 
making  stronger  men  and  women  and  better  citizens. 

958  Eastern  Parkway. 


Edema  in  Children  Due  to  Fat  Starvation. — 
A.  B.  Grubb  {Western  Medical  Times,  June  1920) 
says  that  edema  in  children  is  very  often  due  to 
fat  stclrvation  and  will  respond  within  a  few  days 
to  butter  and  cream. 


SIMPLIFIED   INFANT  FEEDING.* 

A  Rational  Feeding  Program  for  the  First 
Year  of  Life. 

By  Frank  Howard  Richardson,  M.  D., 

Brooklyn, 

Assistant    EediatBist,    and    Chief    of    Children's  Clinic, 
Brooklyn  Hospital. 

Infant  feeding,  whether  simplified  or  complicated, 
is  something  to  be  approached  with  caution.  The 
changes  have  been  rung  upon  it  so  often  and  in  so 
many  dififerent  keys  that  one  feels  like  treading 
lightly  and  asking  for  a  special  dispensation  for 
discussing  it.  And  yet  I  think  that  no  one  will 
deny  that  infant  feeding  needs  simplifying,  if  there 
is  any  subject  within  the  broad  scope  of  modern 
medicine  that  does.  There  are,  perhaps,  a  number 
of  reasons  for  this.  Pediatrics,  along  with  a  num- 
ber of  other  subjects  in  the  medical  curriculum 
that  are  of  greater  age  as  recognized  specialties,  is 
considered  a  minor  subject  in  our  medical  schools, 
and  is  crowded  out  of  the  students'  time  and  interest 
by  other  supposedly  more  important  subjects.  And 
yet  pediatrics  is  the  only  branch  of  the  whole  array 
that  deals  with  the  well  organism,  and  the  only 
specialty  that  must  be  practised  by  the  general 
practitioner. 

As  a  result  of  this  compression  of  a  large  and 
important  subject  into  such  a  very  small  compass, 
the  professor  and  instructors  are  inclined  to  empha- 
size the  striking  cases,  the  types  less  commonly 
encountered,  rather  than  to  dwell  upon  those  far 
commoner  and  hence  (to  them)  less  interesting 
problems  of  everyday  occurrence,  and  especially 
those  concerned  with  infant  feeding.  The  subject 
of  infant  feeding  itself  is  one  that  has  given  rise 
to  most  acrimonious  debate,  due  to  honest  divergence 
of  opinion  on  the  part  of  widely  differing  schools 
of  thought.  This  difference  of  opinion  as  to  what 
constitutes  a  satisfactory  system  for  the  feeding  of 
infants  has  been  able  to  persist  as  it  has,  because 
of  the  relatively  wide  limits  of  tolerance  possessed 
by  different  infants,  and  by  the  same  infant  at 
different  times  for  the  most  widely  differing  articles 
of  diet.  We  have  each  of  us  but  to  consult  our 
very  recent  memory  in  order  to  recall  some  perfect 
specimen  of  babyhood  that  has  arrived  at  this  con- 
dition on  some  feeding  that  we  would  have  said 
must  surely  lead  to  speedy  marasmus — explicable  on 
no  other  grounds  than  the  tremendously'  wide  limits 
of  food  tolerance  possessed  by  some  babies. 

The  fact  that  such  widely  differing  schools  of 
thought  could  each  of  them  point  to  a  highly  satis- 
fying and  successful  series  of  cases,  has  led  each 
group  to  believe  that  it  had  fairly  solved  the  prob- 
lem of  infant  feeding.  It  has  also  caused  each 
group  to  doubt  the  possibility  of  attaining  the  equally 
successful  series  of  cases  claimed  by  the  proponents 
of  some  entirely  different  set  of  principles.  All 
have  perhaps  failed  to  put  proper  emphasis  upon 
the  fact  that  a  great  body  of  babies,  fed  according 
to  any  old  methods  or  no  methods  at  all,  were 
worrying  along  perhaps  almost  as  well  as  some  of 
their  special  series  had  been  doing.    They  had  been 

*Read  before  the  Pediatric  Section  of  the  Medical  Society  of  the 
State  of  North  Carolina,  at  the  Sixtv-seventh  annual  meeting, 
held  at  Charlotte,  N.  C,  April  21,  1920. 


978 


RICHARDSON:  INFANT  FEEDING. 


[New  York 
Medical  Tovrxal. 


Studying  especially  the  sick  baby,  with  his  greatly 
narrowed  limits  of  food  tolerance  due  to  the  food 
injury  that  he  had  sustained;  and  had  failed  to 
attempt  to  formulate,  from  the  experiences  of  this 
large  mass  of  carelessly  fed  but  fairly  healthy  babies. 
This  is  a  simple  method  that  could  be  readily 
taught  the  average  student,  graduate  or  under- 
graduate, and  by  him  passed  on  to  the  average 
mother  or  nurse.  In  other  words,  the  student  has 
been  taught  a  complicated  method  of  feeding, 
desirable  enough  perhaps  in  special  cases  of  food 
injury,  but  by  no  means  essential  for  the  great  mass 
of  well  babies.  Accordingly,  he  has  been  well  nigh 
helpless  in  the  face  of  the  demand  of  the  mothers 
for  instructions  for  the  feeding  of  their  well  chil- 
dren. This  occurred  because  he  had  never  been 
taught  a  simple  system  which  simple  folk,  with  a 
well  baby,  would  take  the  time  and  trouble  to  follow. 

The  result  of  this  lack  of  a  definite  routine  pro- 
cedure for  use  in  the  case  of  the  average  well  child, 
such  as  can  readily  be  taught  to,  and  learned  by. 
the  average  medical  student,  and  by  him  translated 
into  simple  instructions  for  the  average  mother  or 
nurse  to  carry  out  from  day  to  day,  can  frequently 
be  seen.  We  know  that  many  otherwise  able  and 
conscientious  physicians  never  attempt  to  interfere 
in  the  management  of  the  well  babies  of  their 
families.  They  regularly  allow  some  elderly  female 
to  use  her  experiences  of  a  generation  ago  to  decide 
proportions,  dilutions,  quantities,  and  feeding  inter- 
A-als,  for  instructing  the  young  mother  when  to  take 
her  baby  away  from  the  breast!  Others,  when 
appealed  to,  turn  with  a  sigh  of  relief  to  the  pro- 
prietary foods,  which  never  fail  to  promise  most 
flattering  results — and  at  times,  let  us  be  frank 
enough  to  admit,  achieve  them.  Many  babies,  we 
know,  with  the  broad  limits  of  tolerance  that  we 
have  spoken  of,  survive  this  catch-as-catch-can  pro- 
cess.   Many  more  succumb. 

While  granting  that  we  must  individualize,  even 
with  our  well  babies,  just  as  we  individualize  in 
cases  of  typhoid  fever  and  in  appendectomies, 
we  can  standardize  and  teach  infant  feeding  just  as 
we  standardize  and  teach  typhoid  therapy  and  sur- 
gical technic.  It  does  not  seem  too  much  to  ask 
that  the  outHning  of  general  principles  should  pre- 
cede rules  for  specialization  to  meet  individual 
conditions. 

I  have  been  brought  to  believe,  from  a  survey 
of  my  own  experience,  that  a  large  proportion  of 
the  cases  that  are  referred,  or  drift,  to  the  man 
practising  pediatrics  exclusively,  whether  in  private 
practice  or  in  hospital  work,  are  feeding  babies 
that  could  have  been  handled  perfectly  well  by  the 
family  physician.  He  has  failed,  from  the  lack  of 
a  definite  technic,  to  apply  in  his  infant  feeding  cases 
the  routine  procedures  which  he  is  wont  to  apply 
in  other  cases.  In  other  words,  the  pediatrist  is 
achieving  much  of  his  reputation  as  the  result  of 
his  successes  with  easy  feeding  cases,  instead  of 
being  compelled  to  tax  his  skill  and  ingenuity  over 
the  difficult  ones  alone.  If  this  is  true,  then  there 
is  a  serious  flaw  somewhere  in  the  program  of 
medical  edutation  today.  For  the  future  .welfare 
of  the  race  is  in  the  hands,  not  of  the  pediatrist,  who 
sees  comparatively  few  of  the  entire  infant  popu- 


lation, but  of  the  family  doctor,  who,  sooner  or 
later,  sees  the  vast  majority  of  them  at  least  once 
in  their  lives.  But  it  is  to  the  pediatrist  that  the 
family  practitioner,  when  in  the  embryo  stage  rep- 
resented by  the  medical  student,  looks  for  his  in- 
struction in  this  most  important  matter.  If  we  fail 
him  (and  my  memory  of  the  instruction  given  me 
during  my  undergraduate  years  leads  me  to  think 
that  we  are  failing  him),  can  we  blame  him  when 
he  allows  that  more  plausible  teacher,  the  detail  man 
from  the  proprietary  food  concern,  to  usurp  the  seat 
in  the  teaching  chair  that  has  been  so  inadequately 
filled? 

And  yet,  hand  in  hand  with  this  admitted  un- 
familiarity  with  the  intricacies  of  infant  feeding 
on  the  part  of  the  great  majority  of  the  medical  pro- 
fession, goes  a  most  amazing  readiness  to  wean 
babies  for  the  most  trivial  and  inadequate  of 
reasons.  When  one  has  struggled  as  desperately 
as  every  man  in  this  section  has  done,  over  the 
artificial  ahmentation  of  a  puzzling  case,  one  is 
simply  awestruck  at  the  sang  froid  with  which 
babies  are  taken  away  from  the  breast,  every  day, 
for  causes  so  trifling  as  to  be  laughable,  were  not 
the  results  likely  to  be  so  serious  and  even  tragic. 
"The  baby  doesn't  get  enough  milk" ;  "I  never  have 
been  able  to  nurse  my  babies" ;  "My  milk  is  blue 
and  watery — I  know  it  doesn't  nourish  the  baby" ; 
"My  baby  didn't  gain  this  week" ;  "My  milk  poisons 
the  baby,"  or  any  one  of  a  dozen  other  such  state- 
ments that  should  mean  nothing  more  radical  than 
an  inquiry  by  the  physician  into  the  state  of  nursing 
afifairs,  and  some  simple  adjustment  or  explanation, 
ushers  in  the  change  from  nature's  feeding,  which 
works  so  well  that  no  one  needs  to  understand  it, 
to  bottle  feeding,  which  is  admittedly  the  poorest  of 
substitutes,  and  is  wretchedly  understood  by  the 
most  learned.  As  often  as  not  it  is  the  grand- 
mother, the  aunt,  or  the  nurse,  who  blithely  crosses 
this  Rubicon,  with  never  a  qualm  over  future 
hazards  and  never  a  regret  over  bridges  burned 
behind.  One  can  hardly  imagine  a  shipwrecked 
sailor's  pushing  away  his  life  preserver,  or  a  moun- 
tain climber  tossing  away  his  hobnailed  boots ;  and 
yet  either  of  these  would  be  taking  a  far  less  serious 
risk  than  is  thus  imposed  upon  the  infant  whose 
breast  alimentation  is  thus  discontinued  for  these 
absolutely  inadequate  causes. 

I,  personally,  am  firmly  convinced  of  what  is  by 
no  means  imiversally  conceded  or  recognized, 
namely,  that  practically  every  mother  can  succeed 
in  nursing  her  own  child.  I  say  practically,  ad- 
visedly, in  the  face  of  the  testimony  of  the  text- 
books, which  are  fond  of  citing  cases  of  congenital 
or  acquired  intolerance  on  the  part  of  certain 
infants  toward  their  mother's  milk.  I  am  willing 
to  go  a  step  farther  and  concede  that  probably  each 
man  here  can  call  to  mind  one  or  more  cases  in  his 
own  experience  in  which  every  elTort  to  keep  a  baby 
on  its  mother's  milk  failed  ignominiously.  And 
yet,  to  strike  a  quick  percentage,  what  tiny  fraction 
of  a  per  cent,  is  represented  in  the  practice  of  any- 
one who  recalls  such  a  case  of  socalled  toxicity  or 
idiosyncrasy,  as  compared  with  the  total  number 
of  babies  he  has  seen?  We  have  all  of  u4  heard 
or  read  of  the  existence  of  two  headed  calves,  and 


December  18.  1920.] 


RICHARDSON:  INFANT  FEEDING. 


979 


yet  we  do  not  ordinarily  construct  our  stanchions 
so  as  to  accommodate  these  rare  freaks  of  nature. 

I  do  not  assert  that  every  mother  can  carry  her 
baby  through  the  nine  months  that  we  set  aside  for 
lactation,  without  help,  but  I  do  say  that,  given  a 
realization  on  the  part  of  the  mother  and  of  her 
medical  attendant,  of  the  truth  in  her  particular 
case  of  what  both  recognize  to  be  true  in  the  vast 
majority  of  cases;  and  every  man  who  wishes  it  can 
reduce  his  panel  of  exclusively  bottle  fed  babies 
almost  to  the  irreducible  minimum  supplied  by 
motherless  babies,  and  those  that  have  been  weaned 
three  or  four  weeks  before  he  sees  them.  And,  if 
we  are  to  credit  the  results  of  Moore,  of  Portland, 
Oregon,  as  set  forth  in  his  fascinating  paper  (1), 
even  this  minimum  may  prove  not  to  be  an  irre- 
ducible one,  for  he  records  a  case  of  reestablishment 
of  breast  feeding  after  eight  weeks  of  weaning, 
and  another  after  eleven. 

Granted,  then,  that  mother  and  physician  are  in 
accord,  and  resolved  to  do  their  best  to  keep  the 
baby  on  the  breast,  what  can  we  do  to  help  them? 
In  view  of  the  universally  admitted  superiority  of 
breast  feeding,  it  is  rather  surprising  that  we  can 
find  so  little,  relatively  speaking,  of  real  practical 
help  in  the  textbooks  or  in  the  literature,  to  aid  us 
in  this  task.  The  task  is  a  twofold  one :  first,  the 
maintenance  of  lactation,  and,  secondly,  the  adjust- 
ment of  the  milk  to  the  baby,  or  of  the  baby  to  the 
milk.  In  comparison  with  the  volumes  and  reams 
devoted  to  the  intricacies  of  artificial  feeding,  the 
space  given  to  the  problems  connected  with  the  far 
more  common  form  of  breast  feeding,  seems  almost 
negligible.  I  want  to  outline  the  regimen  that  has 
been  found  most  successful  here,  emphasizing  the 
details,  which  are  perhaps  the  most  important 
feature  in  the  management.  In  a  word,  this  con- 
sists in  the  inauguration  of  what  is  variously  known 
as  auxiliary,  complementary,  or  supplementary 
feeding. 

By  whatever  name  we  call  it,  let  it  be  distinctly 
understood  that  what  is  meant  is  oflFering  the  baby 
a  bottle,  with  a  formula  appropriate  to  its  age, 
weight,  and  general  condition,  after  every  breast 
feeding,  and  letting  him  take  as  much  or  as  little 
of  it  as  he  will.  What  is  not  meant  is  alternate 
breast  and  bottle  feeding,  for  reasons  that  will  be 
dealt  with  directly.  The  baby  may  be  kept  any- 
where from  five  to  thirty  minutes  at  the  breast, 
until  he  shows,  in  short,  by  his  restlessness  and  the 
tossing  about  of  his  head,  that  he  has  about 
exhausted  the  possibilities  of  the  one  breast.  He 
is  then  allowed  to  swing  over  to  the  bottle,  previ- 
ously heated  and  in  readiness,  and  permitted  to  take 
as  much  as  he  will  of  the  complementary  feeding. 
It  is  probably  well  within  the  bounds  of  truth  to 
say  (grandmothers  to  the  contrary  notwithstanding) 
that  a  reasonably  well  baby  never  overeats,  if  given 
a  food  of  the  proper  strength.  Colic,  socalled,  from 
this  cause  can.  far  more  often  than  is  realized,  be 
proved  to  be  nothing  but  hunger,  by  allowing  the 
child  to  take  even  more  of  the  food  than  he  has 
already  taken.  Even  that  infallible  argument, 
"Why,  doctor,  I  know  it's  colic :  he  just  draws  his 
little  legs  up  on  his  stomach  when  he  cries,"  will 
fail  of  effect  when  the  mother  sees  the  colicky  baby 


fall  asleep  just  as  soon  as  he  is  allowed  to  be  the 
judge  of  his  own  capacity.  In  other  words,  we 
are  quite  safe  in  allowing  the  baby  in  this  way  to 
tell  us  how  much  too  little  breast  milk  he  is  getting. 

The  following  ideas  should  gradually  be  incul- 
cated in  the  mind  of  the  mother.  It  is  especially 
useful,  in  this  connection,  to  give  a  small  slip  or 
folder,  preferably  typed  or  printed  in  simple  lan- 
guage, embodying  these  points : 

1.  That  she  should  get  away  from  the  baby  at  least 
once  in  the  twenty-four  hours— for  the  sake  of  both 
of  them. 

2.  That  she  should  get  enough  sleep,  eight  hours 
representing  a  minimum  rather  than  a  maximum. 

3.  That  worry  is  a  great  milk  reducer.  If  the 
doctor  can  keep  up  the  baby's  weight  and  satisfy 
his  appetite  with  complementary  feeding,  and  give 
the  mother  confident  assurance  of  ultimate  success, 
he  can  generally  obviate  the  untoward  influence  of 
worry. 

4.  That  she  may  eat  whatever  she  pleases,  within 
ordinary  bounds  of  reason,  provided  it  does  not 
cause  indigestion  on  her  part.  The  baby  will  not 
be  affected  by  what  she  eats. 

5.  That  excessive  amounts  of  milk,  cocoa,  beer, 
or  even  water,  do  not  necessarily,  or  even  usually, 
aid  in  improving  either  the  quality  or  the  quantity 
of  milk  produced.  That  such  excesses,  on  the  con- 
trary, usually  end  in  harm,  by  spoiling  the  good 
appetite  so  necessary  to  lactation,  if  not  actually 
upsetting  the  digestion. 

6.  That,  in  general  terms,  the  same  regimen  that 
produces  health  and  strength  and  bodily  well  being 
produces  milk. 

7.  That  no  special  diet  can  greatly  modify  the 
chemical  constituents  of  the  milk.  The  best  opinion 
today  is  emphatically  agreed  on  this.  Further,  some 
authorities  believe  that  quantity  'alone  can  be  altered 
— that  the  quality  is,  in  an  overwhelming  majority 
of  cases,  always  good. 

8.  That  a  laboratory  test  of  the  character  of  the 
milk  is  never  of  any  practical  use.  The  only  test 
that  is  worth  while  is  the  practical  test  as  to  its 
effect  on  the  baby.  If  he  is  hungry,  or  is  failing 
to  gain,  he  should  have  complementary  feedings 
until  the  breast  supply  becomes  adequate,  as  shown 
by  these  two  criteria. 

9.  That  the  milk  never  disappears  beyond  recall 
suddenly,  say,  within  twenty-four  or  forty-eight 
hours.  Such  an  apparent  vanishing  of  lactation  is 
always  evanescent,  if  complementary  feeding  is 
instituted  promptly.  The  temporary  diminution  of 
the  milk  secretion  can  in  this  way  always  be  made 
up  for,  the  baby  be  tided  over,  and  an  enforced 
weaning  be  done  away  with. 

10.  That  the  care  of  the  nipples  is  a  most  impor- 
tant phase  of  the  periods  of  later  gestation  and 
lactation.  Where  a  mother  has  depressed  nipples, 
it  should  begin  a  month  or  two  before  the  birth 
of  the  baby ;  gentle  manipulation  for  a  few  minutes 
daily  will  make  these  easy  for  the  baby  to  manage. 
Cleanliness,  hardening  by  the  application  of  half 
strength  alcohol,  and  protection  by  the  employment 
of  inch  square  bits  of  sterile  waxed  paper,  are 
important  aids  in  keeping  the  nipples  fit.  Bismuth 
and  castor  oil,  equal  parts,  may  be  used  for  incipient 


980 


RICHARDSON 


I. \ FA  X  T  FEEDING. 


I  New  York 
Medical  Journal. 


cracking.  Many  women  find  that  their  nipples  will 
not  stand  the  wear  and  tear  incident  to  nursing  a 
child  on  both  breasts  at  each  feeding.  Nursing  on 
alternate  breasts  is  usually  advisable.  However,  as 
early  milk  is  thin  and  watery,  compared  with 
later  milk,  which  is  richer,  or  strippings,  which  are 
very  high  in  fat,  we  may  if  we  wish  diminish  the 
fat  content  of  what  we  are  offering  the  baby  by 
allowing  him  a  shorter  period  at  each  of  the  two 
breasts  at  one  feeding.  As  he  fails  thus  to  empty 
the  breasts  completely,  we  must  be  on  the  lookout, 
in  such  cases,  for  a  reduction  in  the  milk  supply. 

11.  That  we  know  of  but  two  galactagogues.  One 
is  the  stimulation  of  the  infant  suckling  at  the  nipple. 
The  other  is  the  complete  emptying  of  the  breast  at 
each  nursing.  These  can  be  temporarily  simulated ; 
the  first,  by  the  breast  pump  and  nipple  massage, 
the  second,  by  the  breast  pump  and  manual  stripping 
of  the  breast,  preferably  after  the  manner  described 
by  Moore,  of  Portland  (1).  But  the  best  agency 
of  all  is  the  one  that  combines  the  two,  namely,  the 
nursing  baby. 

12.  That  milk  is  like  the  manna  that  the  Lord 
provided  for  the  children  of  Israel :  it  cannot  be 
stored  up  in  the  breast  nor  saved  there  for  future 
use.  A  thorough  understanding  of  this  will  do 
away  with  that  bane  of  the  doctor  who  is  trying 
to  improve  a  breast  supply,  namely,  the  alternate 
feeding  of  breast  and  bottle  (supplementary  feeding 
proper).  This  is  frequently  indulged  in  on  the 
mistaken  supposition  on  the  part  of  the  mother  or 
her  friends  that  there  is  not  enough  milk  for  all 
the  feedings,  and  that  in  this  way  it  can  be  eked 
out.  Lacteal  glands,  like  muscle  tissue,  work  better 
the  more  they  are  called  upon  to  perform,  within 
physiological  limits.  The  surest  way  in  which  to 
dry  up  a  breast  supply  is  to  skip  several  feedings 
a  day. 

There  seems  to  be  no  reasonable  doubt  that  a 
moderate  amount  of  breast  milk  does  remove  the 
disadvantage  of  the  bottle  feeding.  Whether  it  is 
a  question  of  carrying  over  antibodies  from  the 
mother  to  the  baby,  or  whether  it  is  a  question  of 
vitamines,  or  whatever  ;he  cause,  we  know  that 
the  child  on  complementary  feedings  shares  much 
of  the  good  fortune  of  the  entirely  breast  fed  infant. 
Then,  too,  after  weeks  or  perhaps  even  months,  the 
breast  may  begin  to  function  to  such  an  extent  as 
to  render  further  artificial  feeding  unnecessary, 
either  temporarily  or  until  weaning  time.  Such  a 
simple  solution  as  this,  of  a  feeding  problem,  never 
offers  itself  unasked,  in  the  case  of  the  entirely 
bottle  fed  baby. 

A  fair  degree  of  familiarity  on  the  part  of  the 
attending  physician  with  some  comparatively  simple 
form  of  infant  feeding  procedure  to  employ  for  the 
complementary  feeding  is,  of  course,  necessary. 
Surely,  however,  this  is  not  too  much  to  ask  of  any 
man  who  is  dealing  as  extensively  with  women  and 
children  as  is  the  general  practitioner. 

And  so,  back  we  come  to  the  favorite  topic  of 
pediatrists,  infant  feeding.  The  practitioners  (and 
they  are  not  few)  who  refuse  to  admit  that  there 
is  such  a  specialty  as  pediatrics,  taunt  us  with  the 
gibe  that  every  pediatric  meeting,  whatever  its  an- 
nounced topic,  either  starts  out  or  ends  up  with  a 


fuss  over  infant  feeding.  If  a  personal  experience 
is  allowable,  I  confess  that  after  years  in  hospital 
and  clinic  work  with  children,  it  is  still  with  fear 
and  trembling  that  I  approach  an  ordinary  feeding 
case ;  and  it  is  largely  a  matter  of  chance  what 
feeding  mixture  such  a  new  case  would  receive  at 
my  hands.  I  felt  convinced  that  the  old,  compli- 
cated methods  on  which,  pediatrically  speaking,  I 
had  been  brought  up,  were  somehow  wrong ;  and 
yet  I  did  not  know  what  was  right.  My  feeling 
of  dissatisfaction  with  the  old  methods  may  per- 
haps best  be  expressed  by  an  illustration  from  life. 
If  the  operation  of  a  trolley  car  were  such  a  deli- 
cate, complicated  matter  that  no  one  but  an  Edison 
could  compass  it,  and  you  needed  fifty  trolley  cars 
to  handle  the  traffic  of  your  city,  then  you  will 
agree  with  me  that  the  trolley  car,  as  a  means  of 
handling  your  traction  needs,  would  fail  as  a  work- 
ing, practical  proposition.  For  there  are  not  enough 
Edisons  available  to  go  around.  Similarly,  if  it 
takes  a  Holt,  a  Morse,  or  a  Kerley  to  feed  your 
baby  and  mine.  Mrs.  Jones's  and  Mrs.  Brown's, 
then  infant  feeding  as  taught  today,  in  the  East 
at  least,  is  a  failure.  But  we  know  that  it  is  by 
no  means  as  rare  an  occurrence  as  we  could  wish, 
to  have  a  mother  bring  back  to  us,  after  two  or 
three  months'  absence,  a  big  fat  baby  that  we  have 
failed  to  make  gain  on  the  most  scientific  formulae, 
with  the  triumphant  remark,  "Oh,  Doctor,  see  what 
Blank's  Food  did  for  my  baby !"  Not  pleasant, 
is  it?  Nor  yet.  as  sometimes  has  happened  to  the 
best  of  us,  to  have  Grandma's  mixtures  preferred 
by  an  ungrateful  child  to  our  elaborate  formulae ! 
Such  occurrences  compel  serious  consideration. 

The  first  step  that  I  would  urge  in  the  simplifying 
of  infant  feeding,  then,  would  be  to  keep  every 
*baby  on  the  breast.  I  grant  you  at  once  that  such 
a  dictum  as  this,  solemnly  enunciated  without  fur- 
ther amplification,  would  constitute  at  once  an  insult 
to  your  intelligence,  and  an  admission  of  my  igno- 
rance of  the  state  of  medical  knowledge  today.  I 
should  not  have  the  effrontery  to  urge  upon  anj' 
body  of  phj'sicians— much  less  upon  a  group  of  men 
engaged  wholly  with  the  problems  of  infancy  and 
childhood — the  already  universally  acknowledged 
superiority  of  breast  feeding  over  the  best  of  arti- 
ficial feeding.  This  has  been  so  generally  conceded, 
and  the  literature  has  been  piled  so  high  with 
reports,  experiences,  statistics,  and  conclusions,  to 
this  effect,  that  it  would  be  a  waste  of  time  to  try 
to  find  anyone  who  would  oppose  what  has  come 
to  be  considered  almost  an  axiom  of  pediatric 
practice.  What  I  do  want  to  stress,  however,  is 
the  disparity  existing  between  our  theory  and  our 
practice  in  this  regard.  What  I  do  want  to  plead 
for  is  the  realization,  first  upon  the  part  of  the 
individual  practitioner  and  through  him  upon  the 
individual  mother,  that  what  both  know  and  concede 
to  be  true  in  the  great  mass  of  cases,  is  in  all  proba- 
bility tnie  in  the  individual  case  that  they  are  con- 
sidering, and  whose  weaning  they  are  proposing. 
No  one  ever  states  that  bottle  feeding  in  the  abstract 
is  better  than  breast  feeding.  It  is  only  when  we 
urge  a  mother  to  keep  her  own  baby  on  the  breast, 
even  at  the  expense  of  some  pains  and  effort  on 
her  part  and  ours,  that  we  meet  with  any  opposition 


December  18,  1920.] 


RICHARDSON:  INFANT  FEEDING. 


981 


to  the  continuance  of  breast  feeding.  And  we  cer- 
tainly do  meet  with  it,  as  every  one  of  you  will 
testify  with  me. 

Some  time  ago  my  attention  was  called  to  what 
was  to  me  an  interesting  attempt  to  join  the  two 
systems,  namely,  the  percentage  and  the  caloric  ideas 
of  infant  feeding.  I  believe  that  Dennett  (2)  has 
done  more  than  anyone  else  to  popularize  this  union 
in  a  workable  technic.  In  order  to  fulfill  the 
requirements  that  we  set  for  ourselves  in  naming 
this  investigation,  we  must  produce  something  that 
is  really  simplified.  It  must  be,  not  a  head  splitting, 
arithmetical  jumble  of  proteins,  carbohydrates,  fats, 
and  calories,  but  a  simple,  straightforward  rule  of 
thumb  working  system. 

The  part  in  our  scheme  that  the  percentage  method 
is  to  play,  was  to  determine  how  best  to  make  our 
mixture  digestible — a  matter  that  the  socalled 
caloric  method  never  attempted  to  help  us  with. 
This  simple  point  Chapin  absolutely  disregards  in 
his  diatribes  against  calories,  in  which  he  attempts 
to  reduce  the  whole  idea  to  the  ridiculous  by  sug- 
gesting that  we  furnish  the  necessary  calories  to 
the  youngster  in  the  form  of  coal  oil. 

Without  getting  ourselves  into  the  usual  arith- 
metical tangle  by  comparing  the  percentages  of  the 
three  food  elements  in  human  milk  and  in  cow's 
milk,  let  us  recognize  that  there  are  three  elements 
that  may  under  certain  conditions  give  us  trouble 
in  adapting  the  milk  of  ihe  cow  to  the  stomach  of 
the  human — namely,  fat,  sugar,  and  protein.  We 
will  disregard  the  salts,  about  which  we  know  as 
yet  so  painfully  little.  Let  us  dispose  of  the  danger 
due  to  the  fat  by  reducing 'it  to  a  very  low  amount, 
by  diluting  ordinary  cow's  milk  with  twice  as  much 
water,  i.  e.,  one  third  milk  and  two  thirds  water. 
This  same  process  will  reduce  the  harmful  poten- 
tialities of  the  sugar  by  reducing  it  so  far  that  we 
shall  later  add  sugar  to  our  mixture  in  order  to 
have  enough  to  ppproximate  it  to  the  human  norm. 
The  protein  can  be  disposed  of  even  more  simply 
by  subjecting  the  diluted  milk  to  a  boiling  process 
for  three  minutes,  which  completely  breaks  up  the 
curd  when  acted  upon  by  the  stomach  juices,  as 
has  been  conclusively  demonstrated  by  Brenneman, 
of  Chicago,  in  his  classic  work  on  boiling  milk. 
That  the  protein  of  the  milk  is  "the  cause  of  many 
of  the  nutritional  disorders  encountered  in  infancy" 
is  categorically  denied  by  Grulee  (6).  He  is  sure 
that  the  socalled  casein  curds  are  only  mechanically 
irritant,  and  that  this  source  of  trouble  is  eliminated 
by  boiling.  The  only  possible  objection  to  this, 
that  it  may  cause  scurvy  in  time,  is  done  away  with 
by  the  feeding  of  orange  juice. 

If  we  agree  to  start  any  child  that  comes  to  us 
on  a  mixture  of  one  part  cow's  milk  and  two  parts 
water,  boiled  together  for  three  minutes,  with  no 
sugar  added,  we  shall  at  least  be  giving  a  mixture 
that  can  do  no  harm.  For  the  fat  is  diluted  far 
below  the  amount  found  in  human  milk,  the  sugar 
is  almost  absent,  and  the  casein,  the  protein  con- 
stituent, has  been  rendered  harmless  by  boiling,  so 
that  it  will  form  a  finely  divided  curd  when  it  meets 
with  the  digestive  juices  of  the  infant's  stomach. 
Any  possible  ill  efifect  of  the  boiled  milk  we  shall 
eliminate  by  feeding  a  little  orange  juice  once  or 


twice  a  day.  If  we  start  with  ten  ounces  of  milk 
and  twenty  ounces  of  water,  this  will  probably  be 
insufficient.  We  can  prove  this  by  multiplying  ten, 
the  number  of  ounces  of  milk,  by  twenty,  the  num- 
ber of  calories  in  an  ounce  of  milk,  the  water  having 
no  caloric  value.  This,  our  initial  formula  which 
we  agree  is  digestible,  is  worth  two  hundred  digest- 
ible calories.  While  it  is  much  better  to  give  too 
little  of  a  digestible  food  than  to  give  any  amount 
of  an  indigestible  one,  if  we  are  to  look  for  a  gain 
we  must  eventually  come  up  to  the  digestive  require- 
ments which  is  best  measured  in  calories.  How  are 
we  to  ascertain  what  the  caloric  need  is  ?  By  mul- 
tiplying the  number  of  pounds  the  baby  weighs  by 
fifty,  which  is  an  average  calculation  of  the  require- 
ments of  the  average  child  for  each  pound  each  day, 
we  shall  arrive  at  the  number  of  calories  that  we 
must  eventually  give  the  baby  in  assimilable  form. 
Starting  with  our  trial  or  initial  formula  of  ten 
ounces  of  milk  and  twenty  ounces  of  water,  worth 
two  hundred  calories,  we  may  gradually  strengthen 
this  until  we  have  brought  it  up  to  the  number  of 
calories  that  we  have  determined  upon  as  a  normal 
daily  feeding  for  the  baby.  Our  strengthening 
must  be  in  terms  of  two  factors  only,  namely,  milk 
with  twenty  calories  to  the  ounce,  and  sugar,  with 
thirty  calories  to  the  level  tablespoon  ful,  five  level 
tablespoon fuls,  or  150  calories,  may  be  taken  more 
or  less  arbitrarily  as  the  total  sugar  content  at 
which  to  aim.  This  mixture  is  probably  better  borne 
in  the  form  of  dextrimaltose  than  in  that  of  either 
cane  sugar  or  milk  sugar.  In  order  to  decide  how 
many  ounces  of  milk  we  shall  eventually  give  our 
baby,  we  may  subtract  150,  the  number  of  calories 
to  be  contributed  by  our  five  level  tablespoon  fuls 
of  sugar  from  the  total  number  of  calories  previously 
determined  upon  (by  multiplying  the  number  of 
pounds  the  baby  weighs  by  fifty,  his  daily  require- 
ment to  the  pound).  This  total,  divided  by  twenty 
(the  number  of  calories  to  the  ounce  of  milk),  gives 
the  ounces  of  milk  needed. 

This  leaves  us  nothing  more  to  determine  but 
the  amount  of  water  to  be  used  in  the  final  total 
feeding.  In  order  to  do  this,  we  shall  simply  have 
to  determine  the  total  bulk  to  be  given  the  baby 
in  the  course  of  the  day,  which  will  be  the  number 
of  bottles  to  be  given,  times  the  number  of  ounces 
in  each  bottle,  determined  by  any  rule  that  you 
have  been  using  in  the  past.  A  general  average 
might  be  represented  by  seven  (which  gives  bottles 
enough  for  a  feeding  every  three  hours  during  the 
day,  and  one  night  feeding),  times  three,  four,  five, 
six,  or  seven,  the  number  of  ounces  to  the  bottle, 
according  to  the  age  of  the  child.  This  bulk  must 
be  furnished  by  the  water  plus  the  milk,  as  the 
sugar,  goes  into  solution.  As  the  number  of  ounces 
of  milk  required  has  previously  been  determined, 
we  need  only  add  water  to  bring  up  the  total  to 
the  total  bulk  desired. 

Now  we  need  not  aspire  to  reach  this  desired 
haven  of  the  optimum  number  of  calories  at  a 
bound.  Grant  that  our  baby  may,  and  probably 
will,  be  hungry  long  before  we  have  advanced  him 
from  the  ten  ounces  of  milk  and  twenty  ounces  of 
water,  on  which  we  started  him,  to  the  optimum 
formula  that  we  have  decided  he  must  ultimately 


982 


RICHARDSON :  INFANT  FEEDING. 


I  New  Vork 
Medkai.  Journal. 


reach.  But  all  of  us  are  committed  to  the  prin- 
ciple of  making  haste  slowly,  in  feeding  babies,  and 
at  least  we  do  away  with  the  formerly  commonly 
accepted  twenty-four  hour  starvation  period.  The 
hungry  baby  worries  the  mother  with  his  crying, 
but  the  child  that  worries  the  doctor  is  the  baby 
that  has  no  appetite. 

Leaving  all  theory  aside,  the  practice  is  this: 
Start  virtually  every  baby  on  a  mixture  of  ten 
ounces  of  milk  and  twenty  ounces  of  water,  boiled 
together  for  three  minutes,  with  no  sugar  added. 
The  caloric  value  of  this  is  10  X  20,  or  200. 
Experience  will  tell  you  when  it  is  safe  and  advis- 
able either  to  give  a  stronger  mixture  or  a  greater 
bulk  at  the  start  for  this  trial  formula,  as  we  may 
call  it.  With  this  weak  strength  and  small  amount, 
the  preliminary  star\^ation  period,  that  we  all  used 
to  insist  upon,  has  been  found  quite  unnecessary 
and  a  loss  of  valuable  time,  in  most  straight  feeding 
cases.  Add  an  ounce  of  milk  a  day.  In  this  way 
the  caloric  value  increases  twenty  a  day.  Add  a 
level  tablespoonful  of  sugar  (preferably  in  the  form 
of  a  malt  sugar)  gradually,  every  few  days,  in  place 
of  the  increase  in  the  milk,  computing  the  value  of 
the  food  on  those  days  by  adding  thirty  calories 
for  each  level  tablespoonful  of  sugar  added,  instead 
of  the  twenty  that  would  have  been  added  by  the 
addition  of  an  ounce  of  milk.  Five  level  table- 
spoonfuls  of  sugar  is  a  good  average  quantity  to  aim 
at.  In  order  to  determine  whether  water  should  be 
increased,  left  as  it  is,  or  decreased,  we  must  know 
how  much  bulk  we  want  our  baby  to  have  in  the 
twenty-four  hours.  This  is  easily  arrived  at  by 
multiplying  the  number  of  feedings  (say  six  or 
seven)  by  the  number  of  ounces  the  baby  is  to 
receive  at  each  feeding  (which  averages  an  ounce 
a  month — more  in  the  early  months,  of  course,  and 
less  in  the  later).  The  difference  between  this  total 
and  the  number  of  ounces  of  milk  will  represent  the 
amount  of  water  needed — as  the  sugar  dissolves 
and  so  occupies  no  bulk.  Before  long,  the  juice  of 
half  an  orange  a  day  may  be  added. 

The  question  of  the  best  interval  at  which  to  feed 
is  a  point  which  is  variously  settled  by  diflterent 
schools.  My  own  custom  has  been  largely  the 
result  of  the  method  described  by  the  homely  phrase 
"cut  and  try."  The  two  hour  interval  I  use  only 
in  the  case  of  premature  babies ;  and  the  two  and 
a  half  hour  interval  only  as  a  step  or  half  way  stop 
in  the  course  of  changing  from  the  two  hour  inter- 
val on  which  a  baby  may  be  when  first  seen,  to  the 
three  hour  interval  at  which  I  always  prefer  to 
start.  As  soon  as  the  baby  is  doing  perfectly  well 
on  this — by  which  we  understand  that  he  is  being 
fed  at  6  a.  m.,  9  a.  m.,  12  m..  and  3,  6,  and  10 
p.  m.,  and  once  during  the  night — and  seems  per- 
fectly satisfied  to  wait  from  one  feeding  to  another, 
and  occasionally  sleep  till  well  along  toward  morn- 
ing, I  advise  the  mother  to  dispense  with  the  night 
feeding,  by  giving  first  water  when  the  baby  wakes 
and  cries,  and  finally  omitting  both  nursing  and 
water.  This  is  the  routine  for  babies  who  are  not 
seen  at  birth ;  such  babies  do  not  receive  any  night 
feeding  at  all,  being  given  warm  water  at  two 
o'clock  or  later  if  they  wake,  which  they  soon  cease 
to  do.     As  early  as  the  end  of  the  first  month,  I 


suggest  to  the  mother  that  she  will  probably  find  it 
easier  for  both  the  baby  and  herself  if  she  can 
change  over  to  the  four  hour  interval.  If  the  idea 
appeals  to  her,  I  have  her  allow  the  baby  to  remain 
as  long  as  he  will  from  feeding  to  feeding — three 
and  a  half  hours  if  he  will  not  remain  four  hours — 
for  about  a  week.  Before  the  end  of  that  time,  a 
well  fed  baby  is  usually  established  on  the  four  hour 
schedule.  The  same  free  and  easy  method  is  used 
at  the  age  of  three  or  four  months,  if  the  baby  is 
satisfied  and  the  mother  cares  to  try  omitting  the 
10  p.  m.  feeding.  These  changes  are  so  much 
easier  for  the  mother,  and  involve  so  much  less 
handling  of  the  baby,  that  it  is  usually  easy  to  per- 
suade the  mother.  It  is  hardly  worth  insisting 
upon,  however;  and  is  especially  contraindicated  if 
the  baby  is  hungry,  and  ready  for  the  bottle  at  the 
end  of  the  three  hour  interval. 

A  most  valuable  adjunct  to  employ  at  times  in 
the  management  of  difficult  cases  is  that  much  talked 
of  agent,  dry  milk.  Like  most  other  proprietary 
preparations,  it  has  its  very  definite  dangers,  in  its 
likelihood  to  become  a  very  intolerant  master,  as 
soon  as  it  gains  a  place  in  the  minds  of  the  laity. 
In  the  child  who  has  suffered  a  food  injury,  it  is 
often  a  valuable  aid,  with  the  lowered  fat  content 
that  at  least  one  brand  offers,  and  the  apparently 
increased  adaptability  conferred  by  the  heating 
process.  If  one  has  reason  to  doubt  either  the 
intelligence  of  the  zeal  of  the  one  who  is  to  prepare 
the  complementary  food,  this  is  an  efficient  and 
valuable  ally.  Its  caloric  value  is  given  as  sixteen 
calories  to  the  level  tablespoonful. 

A  word  as  to  the  management  of  premature 
infants,  in  order  to  cover  the  various  phases  of  the 
feeding  of  the  first  year  of  life.  It  is  coming  to 
be  realized  more  and  more  that  it  is  a  waste  of 
time — nay,  of  human  life — to  attempt  the  feeding 
of  the  premature  infant  with  an^iihing  other  than 
human  breast  milk,  either  whole  or  diluted. 
Strengths  and  intervals  may  well  be  left  to  the 
individual  feeding  the  individual  case.  I  am  per- 
suaded that  the  obtaining  of  the  tiny  amount  of 
breast  milk  needed  for  the  first  days  and  weeks  of 
the  life  of  the  premature  infant,  is  by  no  means  the 
difficult  or  impossible  matter  that  we  are  likely  to 
believe.  That  community  must  be  a  tiny  one,  in- 
deed, in  which  there  is  at  any  one  time  but  one 
nursing  baby.  And  it  should  be  most  rare  to  fail 
to  find  a  mother  who,  if  the  need  were  fully  and 
carefully  explained  to  her,  would  be  glad  to  spare 
the  few  drops  necessary  to  save  the  life  of  the 
starving  baby.  In  the  larger  community  it  is 
easier :  in  the  hospital,  comparatively  simple.  Co- 
operation between  the  obstetricians  and  the  pedia- 
trists  has  in  more  than  one  instance  resulted  in 
the  establishment  of  some  central  agency,  at  which 
the  parents  of  the  infant  whose  need  for  human 
milk  is  urgent,  can  be  put  in  touch  with  the  mother 
who  is  willing  to  supply,  on  a  financial  basis,  a 
stated  amont  of  breast  milk  a  day.  A  more  inter- 
esting method  has  been  the  feeding  of  the 
premature  infant  hy  means  of  a  pipette  or  Brcc' 
feeder,  with  a  diluted  breast  milk  expressed  from 
a  mother  in  the  maternity  ward,  while  the  supply 
of  its  own  mother  was  started  by  placing  to  her 


Decanber  18,  1920.] 


RICHARDSON :   INFANT  I-EEDIN(,. 

I 


983 


breast  a  needy  baby  from  the  pediatric  ward,  who 
greatly  benefits  by  the  operation,  until  the  prema- 
ture baby  can  get  its  supply  direct,  by  nursing  at 
its  own  mother's  breast. 

Weaning  is  a  procedure  which  entails  no  suffer- 
ing on  the  part  of  the  mother  or  child,  since  the 
brutal  old  custom  of  abrupt  weaning  was  done  aw-ay 
with.  At  about  the  sixth  month,  the  mother  is 
told  to  precede  each  breast  feeding  with  a  table- 
spoonful  or  two  of  a  cereal.  As  soon  thereafter 
as  one  wishes,  the  vegetables  may  be  added,  one  by 
one,  as  baked  potato  with  milk,  spinach,  carrots, 
mashed  peas  and  beans.  As  these  additional  articles 
are  judiciously  used  to  expand  the  baby's  dietary,  it 
will  naturally  become  less  and  less  dependent  upon 
the  breast  milk,  which,  toward  the  end  of  the  nurs- 
ing period,  it  will  be  using  more  as  a  beverage  than 
as  a  sole  dependence  for  nourishment.  Milk,  either 
diluted,  and  without  sugar,  or  straight,  may  be 
added  as  desired.  In  this  wa}*  the  change  from 
breast  feeding  to  general  diet  is  made  so  gradual 
as  to  be  almost  imperceptible.  It  is  only  fair,  in 
this  connection,  to  mention  the  paper  in  which 
Morse,  of  Boston,  sums  up  very  fairly  his  objec- 
tions to  this  procedure,  and  his  reasons  for 
adhering  more  strictly  to  the  older  custom  of 
introducing  these  articles  of  diet  considerably  later. 
The  change  can  be  made  as  gradually  from  the  four 
hour  feeding  intervals  to  the  more  conventional 
hours  of  meal  times.  The  six  o'clock  feeding 
becomes  a  seven  o'clock  breakfast  with  cereal,  milk, 
orange  juice,  and  bread.  The  ten  o'clock  feeding 
becomes  the  prenap  lunch  of  crackers  and  milk. 
The  two  o'clock  feeding  is  easily  recognized  in  the 
afternap  dinner,  with  baked  potato  and  milk,  one 
other  vegetable,  bread  or  toast  or  zwieback,  and  a 
simple  pudding.  The  six  o'clock  feeding  is  less 
deeply  camouflaged,  appearing  as  supper,  with 
crackers  and  milk,  and  stewed  fruit.  The  omission 
of  eggs  in  any  form,  and  of  the  elaborately  pre- 
pared beef  broth  or  scraped  beef,  is  intentional. 
The  value  of  the  former  is  more  than  problematical ; 
the  labor  spent  on  the  latter  is  out  of  all  proportion 
to  its  value,  which  has  undoubtedly  been  greatly 
exaggerated. 

I  have  tried  to  give  you  my  articles  of  faith  with 
regard  to  the  management  of  the  feeding  of  the 
ordinary  baby — or  one  that  approximates  the  ordi- 
nary. (For  no  mother  will  ever  admit  that  her 
baby  could  be  classed  as  ordinary",  by  the  dullest 
imagination.)  Endless  variations  from  the  aver- 
age may  be  made,  to  suit  the  individual  baby,  and 
to  increase  its  flexibility  in  the  hands  of  the  indi- 
vidual infant  feeder.  A  necessary  part  of  the 
technic,  in  actual  practice,  that  I  have  not  attempted 
to  bring  out,  consists  in  the  rendering  of  frequent 
reports  and  maintaining  constant  touch  between 
mother  and  doctor.  This  is  absolutely  essential, 
for  checking  up  results,  to  see  if  directions  are 
being  carried  out,  and  to  detect  and  correct  errors 
arising  from  a  misunderstanding  of  directions. 
(In  my  own  case,  this  is  covered  by  the  morning 
telephone  consultation  hour,  at  which  time  mothers 
are  encouraged  to  telephone  in  reports  and  ques- 
tions, with  absolute  freedom.) 

Some  such  technic,  flexibly  and  humanly  applied, 


that  may  easily  be  taught  to  any  man  who  has  to 
deal  with  babies,  will  carry  perhaps  ninety-five  per 
cent,  of  our  babies  safely  through  the  first,  or 
critical,  year  of  life.  If  this  is  true,  and  I  believe 
that  a  large  number  of  men  might  easily  be  found 
whose  experience  will  confirm  it,  we  may  reason- 
ably leave  the  remaining  five  per  cent,  or  less  to  be 
discussed  in  some  more  highly  technical  treatise 
than  I  have  attempted  here. 

SUMMARY. 

1.  Infant  feeding,  as  taught  until  recently  in  the 
schools,  urgently  needs  simplification. 

2.  The  first  step  in  simplification,  and  the  most 
important  for  the  welfare  of  the  race  in  the  future, 
is  the  maintenance  of  breast  feeding,  partial  or 
complete,  in  the  majority  of  our  babies. 

3.  Such  a  statement  alone  is  inadequate.  Proof 
of  the  assertion,  as  well  as  help  to  the  mother  in 
accomplishing  it,  are  needed.  This  consists  in  the 
adjustment,  as  I  like  to  call  it,  of  the  breast  to  the 
baby,  or  the  baby  to  the  breast. 

4.  I  have  attempted  to  show  how  any  man  may 
keep  that  wonderful  ally,  Nature,  on  his  side,  and 
in  many  cases,  take  all  the  credit  while  he  allows 
her  to  do  most  or  all  of  the  work. 

5.  To  do  this,  requires  a  reasonable  familiarity 
with  some  reasonably  simple  form  of  infant  feed- 
ing procedure,  for  use  in  connection  with  the  breast 
feeding,  at  some  time  during  the  period  of  lactation. 
I  have  tried  to  formulate  the  simplest  that  I  have 
yet  found. 

6.  A  useful  servant,  but  one  that  must  be  watched 
lest  it  assume  the  mastership,  is  some  form  of  dry 
milk. 

7.  The  successful  care  of  any  goodly  proportion 
of  premature  babies  presupposes  the  employment 
of  breast  milk  in  all  cases. 

8.  Breast  milk  is  not  the  rare  thing  we  like  to 
consider  it — we  can  get  it  for  the  premature  infant, 
if  we  go  after  it. 

9.  Weaning  is  a  gradual  affair — as  such  it  may 
be  accomplished  without  disagreeable  effect  upon 
either  mother  or  child,  if  it  is  begun  early  enough. 

REFERENCES. 

1.  ArooRE,  C.  Ulysses:  Reestablishment  and  Develop- 
ment of  Breast  Feeding,  Archives  of  Pediatrics,  January, 
1920. 

2.  Dennett,  Roger  H.  :  Simplified  Infant  Feeding. 

3.  Chapin,  H.  D.  :  Do  Calories  Measure  the  Value  of 
Food?  Journal  A.  M.  A.,  December  27,  1919,  vol.  Ixxiii. 

4.  Brenneman  :  American  Journal  of  Diseases  of  Chil- 
dren, 1911,  vol.  i,  341. 

5.  Ibrahim:  Monatschrift  f.  Kinderheii,  1911,  x,  55. 

6.  Grulee  :  Infant  Feeding. 

7.  Holt  and  Rowland:  Diseases  of  Childhood,  1918. 

8.  Hill  and  Gerstley  :  Clinical  Lectures  on  Infant 
Feeding. 

9.  Rubner,  M.,  and  Heubner,  O.  :  Die  Natiirliche 
Ernahrung  eines  Sauglinges,  Zeitschrift  f.  Biologie,  1898, 
neue  Folge  xviii,  pp.  1-55. 

10.  Hill,  Lewis  Webb:  Review  of  Methods  of  Infant 
Feeding,  Boston  Medical  Jourtial,  April,  1920. 

11.  Talbot,  Fritz:  Archives  of  Pediatrics,  1910,  xxvii, 
440. 

12.  Morse,  Robert  Lovett:  Weaning,  Journal  A.  M.  A. 
102  Hanson  Place. 


984 


GERSHEMFELD:  EXAMINATION   OF  HUMAN  MILK. 


[New  York 
Medical  Journal. 


THE  IMPORTANCE  OF  THE  MICRO- 
SCOPICAL EXAMINATION  OF 
HUMAN  MILK. 

By  Louis  Gershenfeld,  Ph.  M.,  B.  Sc., 
Philadelphia, 

Professor   of    Bacteriology    and    Hygiene,    Philadelphia    College  of 
Pharmacy  and  Science. 

Considerable  work  has  been  done  on  the  chemical, 
microscopical  and  bacteriological  examination  of 
cow's  milk.  Experimentation  on  human  milk  has, 
unfortunately,  been  mainly  confined  to  its  chemical 
examination,  inasmuch  as  the  latter  determination 
has  been  found  of  great  value  in  solving  many 
problems  of  infant  feeding.  But  in  attempting  to 
see  whether  a  product  is  being  furnished  that  may 
be  regarded  as  fit,  from  a  chemical  viewpoint,  many 
pediatrists  and  physicians  overlook  the  fact  that 
preparations  are  being  administered  to  children  that, 
in  many  instances,  are  detrimental  to  their  health. 
It  is  with  this  fact  in  mind  that  I  always  advise  a 
careful  microscopical  examination  in  addition  to  the 
general  routine  chemical  examination. 

It  is  difficult  to  formulate  standards  for  cow's 
milk,  due  to  the  fact  that  many  questions  are  to  be 
considered.  The  farmer  is  interested  in  milk  pro- 
duction so  as  to  secure  a  reasonable  financial  return. 
The  same  is  probably  true  in  regard  to  all  others 
who  handle  and  sell  this  product.  The  sanitarist 
and  the  consumer,  however,  consider  the  milk  prob- 
lem only  from  the  point  of  view  of  its  effect  on  the 
health  of  those  who  use  it.  It  is,  therefore,  apparent 
that  the  question  of  formulating  standards  on  cow's 
milk  with  as  little  discrepancies  as  possible,  is  one 
which  will  be  open,  to  a  greater  or  less  extent,  to 
misunderstandings,  due  to  the  fact  that  many  phases 
of  the  whole  problem  must  be  taken  into  considera- 
tion. Such  is,  however,  not  the  case  with  human 
milk.  For  here,  after  all,  no  problems  are  en- 
countered as  are  observed  in  cow's  milk,  and  its 
effect  on  the  health  of  the  child  is  the  only  question 
to  be  considered. 

SOURCES  OF  BACTERIA  IN   HUMAN  MILK. 

There  is  no  doubt  in  my  mind  that  human  milk 
is  rarely,  if  ever,  bacteria  free.  Specimens  that 
were  collected  under  the  most  favorable  conditions 
showed  the  presence  of  bacteria.  This  is  not  due 
to  the  fact  that  the  healthy  milk  gland  does  not 
secrete  a  sterile  product,  but  mainly  for  the  reason 
that  bacteria  probably  find  their  way  through  the 
nipples  and  other  sources.  Furthermore,  there  is 
little  cause  for  arguing  this  question,  for,  after  all, 
whether  milk  secreted  by  the  milk  glands  is  or  is 
not  germ  free,  it  is  a  known  fact  that  the  milk  at 
the  time  it  is  taken  by  the  child,  contains  bacteria. 

The  bacteria  of  the  healthy  mammary  glands  form 
but  a  small  porportion  of  the  total  bacterial  content 
in  milk  consumed  during  nursing.  The  skin  of  the 
mother,  directly  or  indirectly,  through  clothing, 
handling,  etc.,  contributes  the  abundant  quantity  of 
bacteria  found  in  human  milk  and  fed  to  the  child. 
Within  the  last  four  months  two  hemolytic  strep- 
tococci infections  in  nursing  infants  were  traced  by 
mc  to  human  milk.  In  both  cases,  the  physical 
examination  of  the  mammary  glands  of  the  mother 
by  the  attending  physician  showed  no  inflammation, 


and  the  microscopical  examination  of  the  milk  did 
not  show  any  abnormal  quantity  of  pus  cells  or 
cellular  matter.  It  is,  therefore,  more  than  probable 
that  these  microorganisms  found  their  way  into  the 
milk  from  the  skin  of  the  mother.  How  many 
pediatrists  and  physicians  advise  the  cleansing, 
washing,  or  merely  wiping  with  a  wet  cloth,  of  the 
nipple  and  surrounding  area,  before  nursing?  And 
how  many  mothers  actually  take  such  precaution? 

In  six  different  samples  of  human  milk,  collected 
under  conditions  almost  identical  with  actual  con- 
ditions at  the  time  an  infant  is  about  to  begin 
nursing,  after  a  careful  bacteriological  examination 
I  found  only  two  of  the  samples  of  such  a  bacterial 
count  as  to  regard  it  fit  for  consumption.  The  other 
four  had  a  bacterial  count  ranging  between  1,110,000 
to  4,260,000  to  the  c.  c.  In  the  case  of  cow's  milk, 
we  hear  of  the  cleansing  of  the  skin  of  the  cows, 
the  hands  of  the  milker,  the  vessels  used  for  collec- 
tion, and  other  implements.  Why  not  observe  pre- 
cautions of  cleanliness  in  the  case  of  human  milk? 

It  cannot  be  pointed  out  too  frequently,  that  the 
excessive  bacterial  contamination  in  human  milk  is 
not  only  avoidable,  but  unnecessary.  It  can  be 
prevented  to  a  large  degree  by  closely  guarding  the 
simple  rules  of  cleanliness.  This  involves  no  in- 
crease in  expense.  It  usually  means  less  suffering, 
little  or  no  worry,  and,  if  anything,  a  decrease  in 
expense  in  the  long  run.  The  time  may  come  that 
the  science  of  bacteriology  will  develop  to  an  even 
greater  exactness  than  it  is  today,  and  the  direct 
relationship  between  many  of  the  diseases  of  chil- 
dren may  be  traced  to  mother's  milk,  contaminated 
carelessly  from  the  skin. 

In  addition  to  the  previously  outlined  sources  of 
"contamination,  there  may  be  another :  that  is,  from 
a  diseased  mammary  gland.  The  latter,  when  dis- 
eased to  such  an  extent  that  a  physical  diagnosis 
reveals  the  fact,  quickly  places  the  attending  phy- 
sician on  his  guard.  But  it  is  those  diseased  condi- 
tions, wherein  the  mother  apparently  feels  no 
discomfort,  and  where,  nevertheless,  an  inflamma- 
tion (or  mastitis)  exists,  which  produce  a  serious 
source  of  danger. 

It  has  been  my  privilege  to  examine  numerous 
specimens  of  human  milk,  which,  though  the  chem- 
ical analyses  showed  perfect  samples,  the  micro- 
scopical observations,  however,  revealed  the  fact 
that  they  were  highly  contaminated  with  bacteria, 
lymphocytes,  polymorphonuclear  leucocytes,  epi- 
thelial cells,  and  other  cellular  matter.  In  most  of 
these  instances,  the  mother  felt  no  discomfort,  while 
the  nursing  infant  showed  little  or  no  progress.  In 
many  of  them  various  diseased  conditions  prevailed. 
This  was  afterward  found  to  be  caused  by  the 
use  of  contaminated  milk.  It  is  almost  impossible 
to  attempt  to  tabulate  my  findings  in  the  many 
samples  mentioned.  In  the  first  place,  a  total  bac- 
terial count  was  made  only  when  asked  for  by  the 
physician  and' experimentally  in  the  few  instances 
reported.  A  microscopical  examination  was.  how- 
ever, made  on  every  sample.  The  Stokes  method 
was  used,  a  smear  being  made  from  the  fat  layer 
as  well  as  from  the  centrifugalized  sediment.  In 
many  of  the  instances  a  quantitative  estimation  of 
the  leucocytes  was  made,  the  Doane  Buckley  method 


December  18,  1920.] 


RAVDIN:   XERODERMA  PIGMENTOSUM. 


985 


(as  reported  by  them  in  1910  before  the  laboratory 
section  of  the  American  Pnbhc  Health  Association) 
being  used.  The  epidemiological  connection  between 
various  attacks  of  illness  in  children  and  the  use  of 
the  milk  of  mothers  sufifering  from  diseased  mam- 
mary glands  (not  observable  by  a  physical  diagnosis) 
is  not  altogether  clear,  and  the  causative  agents  (i.  e., 
types  of  microorganisms  or  toxins)  concerned 
therein  are  still  obscure. 

Little  work  has  been  done  in  regard  to  the 
occurrence  of  pathogenic  and  nonpathogenic  bac- 
teria in  human  milk,  whether  found  naturally  or 
through  contamination.  The  occurrence  of  disease 
producing  bacteria  have  been  reported  by  some 
workers  every  now  and  then.  To  attempt  and 
formulate  standards  is  not  an  easy  task,  for  anyone 
familiar  with  analyses  of  breast  milk  is  aware  of 
the  existence  of  wide  variations  in  chemical  and 
bacterial  compositions  not  only  in  samples  from 
different  individuals  but  also  in  portions  obtained 
from  the  same  sample  at  different  intervals.  The 
structure  of  the  mammary  glands  and  their  mech- 
^inism  of  secretion,  together  with  the  histological 
changes  taking  place  during  the  periods  of  lactation, 
are  familiar  to  all.  The  chemical  examination  of 
milk  and  the  methods  of  correcting  a  faulty  chemical 
composition  have  been  studied  thoroughly  and  con- 
siderable data  are  available,  from  which  valuable 
information  can  be  obtained.  But  the  literature 
pertaining  to  the  microscopical  and  bacteriological 
examination  of  human  milk  is  far  from  complete, 
and  the  little  that  is  available  is  uncertain.  A  more 
direct  recognition  of  infectious  diseases  traceable  to 
breast  milk,  obtained  from  a  diseased  mammary 
gland  or  introduced  through  other  infectious  human 
material,  is  still  to  be  produced  by  a  close  and 
thorough  scientific  study.  Most  of  the  information 
available  is  merely  assumed  and  an  exact  degree 
of  danger  from  this  source  is  needed. 

This  short  exposition  is  the  outgrowth  of  my 
personal  observation.  The  subject  is  of  the  greatest 
importance  and  it  is  my  belief  that  one  of  the  most 
pressing  needs jof  the  present  time  is  a  more  thorough 
investigation  into  the  relationship  of  human  milk 
and  the  nursing  infant,  from  microscopical  and 
bacteriological  viewpoints. 

1831  Chestnut  Street. 


XERODERMA  PIGMENTOSUM.* 

By  I.  S.  Ratoin,  B.  S.,  M.  D., 
Philadelphia. 

This  disease  was  unknown  until  1870,  when 
Kaposi  (1)  described  it  with  a  report  of  four 
patients.  Three  years  later  he  reported  briefly  and 
tabulated  thirty-eight  cases.  Since  that  time  over 
eighty-five  cases  have  been  reported.  Many  ob- 
servers regard  this  condition  as  an  aggravated  form 
and  sequel  of  common  lentigenes ;  others  regard  it 
as  potentially  a  malignant  disease.  It  usually  de- 
velops in  early  life  (in  the  present  case  the  mother 
asserts  that  the  pigmentation  was  present  at  birth), 
and  is  characterized  by  overgrowth  of  pigmented 

*Frora  the  Hospital  of  the  University  of  Pennsylvania. 


epithelium,  especially  on  the  exposed  surfaces,  as 
the  face,  scalp,  neck,  upper  shoulders,  hands,  and 
forearms.  In  our  case  the  scalp  was  not  nearly  as 
much  afifected  as  were  the  other  exposed  surfaces. 

The  pigmentation  is  always  more  marked  in  the 
summer,  and  may  disappear  for  one  or  two  winters, 
when  it  finally  remains.  Shortly  afterward  telan- 
giectasis and  atrophic  white  spots  appear,  giving  the 
skin  a  scarred  character  similar  to  that  seen  after 
long  X  ray  exposure.  According  to  Dalous  and 
Constantin  (2),  they  are  the  most  marked  features 
of  xeroderma.  The  cicatricial  like  areas  are  smooth, 
shiny,  and  wrinkle  very  much  as  does  the  senile  skin. 
There  is  a  tendency  toward  the  coalescence  of  these 
areas.  The  sensibility  of  the  atrophic  areas  becomes 
lessened,  and  glandular  secretion  is  not  so  active. 


Fig.  1. — Patient,  H.  M.,  in  author's  case  of  .xeroderma  pigmen- 
tosum. 


The  skin  becomes  darker,  which,  on  close  examina- 
tion, is  seen  to  be  due  to  the  excessive  freckling. 

The  disease  may  continue  for  months  or  even 
years,  in  this  apparently  benign  character,  but  sooner 
or  later  more  pathological  characteristics  become 
apparent.  Wartlike  growths  appear,  which  are 
overgrowths  of  the  lentiginous  spots.  As  in  our 
case,  ectropion,  blepharitis,  conjunctivitis,  and  even 
ulcerative  keratitis  are  likely  to  occur.  There  need 
be  no  dependence  of  one  lesion  upon  the  other, 
however,  according  to  Kaposi,  the  lentiginous  areas 
become  telangiectatic,  later  scaly,  and  finally  there  is 
atrophy  of  the  afifected  skin.  Crocker  (3)  has 
reported  a  case  in  which  the  disease  remained 
quiescent  for  about  six  years,  but  as  a  rule  there  is 


986 


RADVIN:   XERODERMA  PIGMENTOSUM. 


[New  York 
Medical  Journal. 


a  gradual  progression,  so  that  sooner  or  later  to 
the  symptom  complex  is  added  the  appearance  o{ 
ulcerating  tumorlike  processes,  malignant  in  charac- 
ter, belonging  to  the  epitheliomatous  or  sarcomatous 
group.  This  is  the  time  at  which  the  malady  be- 
comes a  grave  one.  Kreibich,  Fernet,  and  Halle 
(4  and  5)  say  the  epitheliomata  may  be  of  the  type 
of  acanthoma  or  of  rodent  ulcer  type,  while  Unna 
finds  that  they  are  often  pigmented  as  in  sailor's 
carcinoma.  The  case  which  we  are  reporting  is 
similar  to  those  described  by  Hutchinson  (6)  as 
lentigo  maligna  juvenalis,  v.  senilis,  in  that  his  cases 
of  progressive  freckles  of  the  cheek  and  eyelid 
became  the  seat  of  epithelioma. 

The  disease  is  usually  confined  to  the  skin  or 
mucocutaneous  junctions,  the  internal  organs  rarely 
becoming  involved.  Death  does  not  usually  occur 
until  many  years  after  the  lesions  appear^  and  is 


Fic.  2. — Same  patient  as  in  Fig.  1,  after  treatment. 

due  to  the  exhaustion  from  pain  and  the  effect  of 
the  malignant  ulcerative  lesions.  In  exceptional 
cases  the  disease  becomes  stationary  after  a  number 
of  years. 

The  etiology  is  not  established.  Councilman  (7), 
IMagrath  (8),  and  Corbett  (9),  think  the  exciting 
cause  is  exposure  to  sunlight  acting  on  the  skin  of 
congenitally  and  constitutionally  predisposed  sub- 
jects. On  account  of  the  behavior  of  the  disease 
and  its  occurrences  in  two  or  three  members  of  a 
family,  Rouviere  (10),  White  (11),  Brayton  (12), 
and  Riider  have  suggested  a  parasitic  etiology,  but 
this  has  not  been  substantiated.  Kaposi  believed 
it  due  to  a  congenital  formative  and  nutritive 
anomaly  of  the  vascular  and  pigmented  portions 
of  the  papillary  layer  of  the  skin.  Recently  a  num- 
ber of  these  cases  with  epitheliomatous  change  have 
been  reported  by  G.  W.  Grier  (13)  as  being  treated 
\\  ith  X  ray  with  very  good  results. 


Case. — H.  M.,  aged  nine,  was  admitted  to  the 
service  of  Dr.  G.  P.  Miiller  and  Dr.  J.  P.  Crozer 
Griffith,  University  Hospital,  January  30,  1920,  the 
chief  complaint  being  a  sore  on  the  nose.  The 
mother  said  that  the  child  was  slightly  pigmented 
at  birth,  but  this  became  very  much  exaggerated 
about  six  weeks  later.  It  was  associated,  according 
to  the  mother,  with  an  eczema,  which  was  charac- 
terized by  oozing  and  scaling.  The  pigmentation 
increased  with  each  succeeding  year.  It  was  espe- 
cially marked  during  the  summer  months,  when  the 
skin  became  very  red,  and  this  was  also  the  case 
when  the  child  was  exposed  to  an  excessive  wind. 
In  August,  1919,  the  patient  noticed  a  small  papule, 
wartlike  in  character,  about  the  size  of  a  pea,  on 
the  bridge  of  the  nose.  It  was  very  hard  and, 
according  to  the  mother,  the  top  was  black.  It 
enlarged  very  rapidly,  but  never  ulcerated  or  bled. 
At  first  there  was  very  little  pain,  but  this  increased 
as  the  tumor  enlarged.  On  December  27th  she 
entered  one  of  the  state  hospitals,  where  the  tumor 
was  cauterized.  There  was  a  rapid  recurrence 
which  gradually  extended  along  the  lower  margin 
of  the  left  eyelid.    The  mass  bled  now  very  freely. 

The  physical  examination  showed  a  fairly  well 
nourished  child  about  nine  years  old.  The  scalp 
appeared  scaly  and  was  pigmented.  There  was  a 
marked  injection  of  both  conjunctiva  with  a  mar- 
ginal blepharitis.  The  left  lower  lid  was  ulcerated, 
the  ulceration  being  continuous  with  the  fungating 
mass  over  the  bridge  of  the  nose.  This  mass  was 
about  the  size  of  half  a  dollar,  and  was  craterlike 
in  character.  The  skin,  especially  that  of  the  face, 
neck,  hands,  forearms,  and  upper  part  of  the  chest 
and  back,  resembled  that  of  a  very  old  individual, 
there  being  numerous  leucodermic  areas  interspersed 
between  the  areas  of  deep  pigmentation.  The  skin 
over  these  areas  was  smooth,  shiny,  and  wrinkled 
very  easily.  It  resembled  the  skin  of  those  who 
have  been  subjected  to  prolonged  x  ray  exposure. 
The  pigmentation  was  most  marked  on  the  back  of 
the  neck,  the  dorsum  of  the  hands,  and  the  face. 
There  was  a  pigmentation,  with  ulceration  of  the 
mucous  membrane  of  the  lips  aiid  inside  the  mouth. 
The  mass  on  the  nose  was  fulgurated,  as  was  the 
growth  on  the  lower  eyelid.  One  week  later  the 
patient  was  treated  with  fifty  mgms.  of  radium  for 
four  hours.  When  last  heard  from,  in  March,  1920. 
the  patient  had  not  improved. 

The  pathological  report,  from  the  Laboratory  of 
Dermatological  Research,  presented  by  Dr.  Weid- 
man,  was  as  follows : 

Slide  No.  1 :  Showed  none  of  the  histology  of 
skin,  but  consisted  of  closely  placed  large  squamous 
cells  with  broad  markedly  coalescent  cytoplasms  and 
large  but  pale  nuclei.  There  was  no  good  pearl 
formation,  although  from  time  to  time  there  were 
sufficient  small  concentric  arrangements  of  keratin 
to  distinctly  .indicate  an  attempt  thereat.  Small  foci 
of  lymphocytes  occurring  around  small  blood  vessels 
were  the  only  things  left  to  indicate  the  original 
fibrous  stroma  of  the  parts  invaded.  The  extreme 
disorderly  arrangement  of  the  squamous  cells  and 
their  highly  atypical  and  hyperchromatic  nuclei 
could  leave  no  doubt  of  the  squamous  carcinomatous 
nature  of  this  disease. 


December  18,  1920.] 


GLENN:  EMPYEMA  IN  CHILDREN. 


987 


Slide  No.  2:  This  time  the  surface  epiderm  was 
shown  over  one  side  of  section.  All  of  the  layers 
were  represented.  Interpapillary  pegs  were  mark- 
edly elongated,  broadened,  irregular  in  form,  and 
extended  deeply  into  the  underlying  corium.  At 
opposite  end  of  section  the  epiderm  dipped  down- 
ward, and  became  continuous  with  a  large  mass  of 
squamous  epithelial  cells  which  were  arranged  in 
the  classical  and  characteristic  fashion  of  squamous 
cell  carcinoma  of  the  prickle  cell  type.  The  under- 
lying corium  was  practically  entirely  occupied  by 
the  tumor  elements  in  this  section.  They  were 
arranged  in  the  usual  interlacing  intercommunicating 
trabecular  fashion  with  extensive  permeation  of 
lymphatics,  and  showed  exquisite  examples  of 
pearly  body  formation.  At  the  more  peripheral 
borders  the  stroma  was  heavily  infiltrated  with 
lymphocytes. 

Summary  of  microscopical  description  of  skin 
from  back  of  neck:  A  marked  hyperpigmentation 
of  rete  cells,  occurring  irregularly  as  to  intensity 
along  different  stretches  of  the  freckle.  There  was 
a  little  irregularity  of  interpapillary  pegs  and  in  one 
place  a  slight  exfoliation  of  epiderm  in  the  floor 
of  a  surface  pocket.  The  chromatophores  of  the 
corium  were  also  a  little  more  conspicuous  than 
normal.    Intradermal  fat  was  noted. 

REFERENCES. 

1.  Kaposi:  Wiener  medicinischer  Jahrbiicher,  1882,  619; 
Wiener  viedicinische  Wochenschrift,  1885,  1334. 

2.  Dalous  and  Constantin  :  Annales  de  dermatologie, 
1904,  961. 

3.  Crocker:  British  Journal  of  Dermatology,  1896,  442; 
Diseases  of  the  Skin,  1893. 

4.  Kreibich  :  Archives  fiir  Dermatologie,  57. 

5.  Halle:  Wiener  klinische  Wochenschrift,  1901,  765. 

6.  Hutchinson:  Deutsche  incdicinische  Wochenschrift, 
1904,  1378. 

7.  Councilman:  Journal  of  Medical  Research,  October. 
1900. 

8.  McGrath  :  Ibid. 

9.  Corlett:  Journal  of  Cutaneous  Diseases,  1915,  164. 

10.  Rouviere:  Annales,  January,  1910,  34. 

11.  White:  Boston  Medical  and  Surgical  Journal,  Mav 
4,  1911. 

12.  Brayton  :  Journal  of  Cutaneous  Diseases,  1893,  402. 

13.  Grier,  G.  W.  :  American  Journal  Of  Rontgenology, 
1919,  556. 


EMPYEMA  IN  CHILDREN. 

Report  of  Sixty-four  Consecutive  Cases.* 

By  Elizabeth  Glenn,  A.  B.,  M.  D., 
Philadelphia. 

Empyema  in  children  is  a  very  interesting  subject. 
The  statistics  given  below  are  those  of  the  Children's 
Service  of  the  University  Hospital  since  1907: 

Discharged,  cured,  twenty-f our ;  discharged,  im- 
proved, twenty-eight ;  died,  twelve  ;  total,  sixty-four. 
Length  of  stay  in  hospital,  under  one  month, 
twenty-two ;  under  two  months,  twenty-four ;  over 
two  months,  six. 

It  is  interesting  to  note  that  the  mortality  in  these 
children,  all  of  whom  were  under  twelve  years  of 
age,  was  only  18.7  per  cent.,  while  the  average  adult 
mortality  ranges  from  twenty  per  cent.  up. 

*From  the  Children's  Service  of  the  University  Hospital.  Re- 
ported through  the  courtesy  of  Dr.  J.  P.  Crozer  Griffith  and  the 
Surgical  Service. 


Chart  showing  mortality  from  empyema  in  si.vty-four  cases. 

AGE  INCIDENCE  AND  MORTALITY  BY  AGE. 
Age                                       No.  of  cases       No.  of  deaths 
Under  1  year   6  4 

1  year    5  2 

2  years    11  2 

3  years    12  1 

4  years   4 

5  years   5 

6  years    6  2 

7  years   (   4 

8  years    2 

9  years    3 

10  years    1 

11  years    3  1 

12  years    2 


This  may  be  partly  due  to  the  fact  that  many  of 
these  cases  were  admitted  to  Dr.  Griffith's  service 
with  a  primary  pneumonia,  the  empyema  developing 
in  the  hospital.  Surgical  intervention  was,  there- 
fore, prompt.  Thirty-seven  rib  resections  were 
done,  with  six  deaths ;  twenty-seven  thoracotomies, 
with  six  deaths. 

Another  fact  worthy  of  note  is  the  preponderance 
of  leftsided  empyemas  in  children.  In  thirty-four  of 
our  cases  there  was  leftsided  involvement,  in  twenty- 
three  rightsided  involvements,  and  in  seven  the 
histories  are  deficient  in  stating  the  location.  Two 
of  the  empyemas  originated  on  the  left  side  and 
involved  the  right  side  secondarily.  Both  of  these 
patients  died.  There  is  also  a  marked  preponder- 
ance of  males,  there  being  over  twice  as  many  males 
as  females.  These  admissions  were  to  a  ward 
where  no  distinction  is  made  as  to  sex  in  admissions. 
There  were  forty-four  males  and  twenty  females. 

The  great  majority  of  these  cases  were  post- 
pneumonic, fift3'-four  being  due  to  this  cause.  Of 
the  two  tuberculous  empyemas,  one  did  not  recur 
after  drainage.  The  primary  infections  were  as 
follows:  Pneumonia,  one  with  typhoid,  fifty-four; 
influenza,  three ;  pulmonary  tuberculosis,  two ;  scar- 
let fever,  one;  unspecified,  four. 

Although  the  mortality  usually  given  for  empyema 
in  children  under  one  year  is  100  per  cent.,  in 
our  series  of  six  cases  the  mortality  is  only  66.6 
per  cent.    If  we  subtract  these  six  cases  from  our 


988 


SCHEIMBERG:   WEAK.  FOOT  IN  THE  CHILD. 


[New  York 
Medical  Jourxal. 


total  number  of  cases,  the  general  mortality  would 
be  only  13.6  per  cent.  Of  the  twenty-three  patients 
cured  before  discharge,  eleven  had  been  operated 
on  in  one  week  or  less  after  the  presence  of  pus  was 
suspected,  five  more  within  two  weeks  of  this  time. 
The  average  length  of  stay  in  the  hospital  after 
operation  of  those  operated  on*  in  less  than  a  week 
from  the  onset  was  thirty-five  days,  while  for  those 
operated  on  one  week  later,  it  was  forty-three  days. 

Conclusions  must  be  drawn  cautiously  from  a 
series  of  this  number,  but  it  is  safe  to  conclude 
the  following: 

1.  The  incidence  in  males  is  greater  than  in  fe- 
males. 

2.  The  left  side  is  more  often  involved  than  the 
right. 

3.  If  the  mortality  rate  for  empyema  in  children 
under  one  year  is  excluded,  the  death  rate  is  lower 
in  children  than  in  adults. 

4.  In  children  under  one  year  the  mortality  in  our 
six  cases  was  66.6  per  cent.,  instead  of  the  90  to 
100  per  cent,  usually  given. 

5.  In  the  postpneumonic  empyemas,  where  the 
patient  is  operated  on  within  the  first  week  after 
onset,  the  average  stay  in  the  hospital  was  shorter 
and  the  proportion  of  cures  higher  than  in  those 
operated  on  at  a  later  time. 


THE   WEAK   FOOT   IX    THE  CHILD. 
Flexible  Flat  Foot. 
By  H.  Scheimberg. 

Brooklyn, 

Lecturer  on  Mechanical  Orthopedics,  The  First  Institute  of 
Podiatrj-,   New  York. 

In  an  article  of  scientific  interest,  it  is  natural  to 
expect  a  direct  statement  of  fact,  devoid  of  sensa- 
tion or  sentiment.  I  shall  attempt  to  comply  with 
this  essential  in  presenting  a  few  preliminary  con- 
siderations that  prove  the  common  weak  foot  (or, 
as  it  is  sometimes  called,  the  flexible  flat  foot)  in 
the  child  to  be  not  only  a  medical  paradox  but  also 
a  national  calamity.  That  it  is  a  national  calamity 
becomes  evident  from  ^he  fact  that  from  sixty  to 
seventy  per  cent,  of  the  children,  particularly  in  the 
metropolitan  centres,  are  through  numerous  exam- 
inations found  to  be  afflicted ;  in  that  the  condition 
most  often  remains  ingrown  instead  of  outgrown ; 
and  because  the  weak  foot  too  often  becomes  the 
forerunner  to  permanent  postural  defects,  creating 
or  enhancing  other  organ  disorders  and  bringing 
with  it  economic  inefficiency  and  often  failure  in 
later  life.  It  is  manifestly  a  medical  paradox  in 
that  with  the  exception  of  the  few  orthopedists, 
who  giv^  the  feet  only  incidental  study  and  treat- 
ment, or  of  the  few  podiatrists,  who  treat  the  feet 
alone,  there  is  no  specific  attention  being  paid  by 
the  medical  profession  to  the  development  of  a 
rational  policy  on  this  important  phase  of  child 
welfare. 

We  need  not  travel  far  to  obtain  direct  evidence. 
We  observe  the  curious  spectacle  of  thousands  of 
children  who  actually  required  trained  medical  guid- 
ance being  brought  to  the  shoe  store  for  diagnosis 
and  treatment  of  foot  trouble.  The  treatment  gener- 


ally takes  the  form  of  a  brand  shoe  that  is  sold 
without  understanding  the  actual  need  of  the  patho- 
logical instance  at  hand.  Additional  treatment 
often  obtains  in  the  further  sale  of  commercial  arch 
supports  or  archsupport  shoes.  It  is  amazing  to 
note  how  lacking  the  agencies  are  to  furnish  reliable 
advice  or  treatment  and  to  see  how  this  deficiency 


Fio.  1. — ^The  foot  viewed  as  an  arch  consisting  -of  two  pillars, 
line  A-B  and  line  B-C,  with  the  astragalus  as  the  keystone. 

serves  generally  to  confuse  a  frantic,  foot  sore  and 
nervous  populace  in  its  search  for  advice. 

A  little  thought  shows  this  neglect  to  be  such  a 
serious  detriment  to  child  welfare  as  to  make  some 
action  imperative.  Parents  should  be  instructed  not 
to  depend  on  shoe  stores  or  stock  arch  supports  for 
the  cure  of  foot  conditions.  The  results  from  such 
•sources  are  too  often  such  as  almost  to  warrant 
legislative  interference  of  some  kind.  I  have  in 
mind  at  the  present  writing  several  instances  of 
tuberculous  ankle  joints  and  arthritides  in  the  feet 
which,  under  the  incenti\  e  of  selling  arch  supports 
at  a  commission,  were  diagnosed  in  shoe  stores  as 
flat  foot,  and  where  accordingly  valuable  time  was 
lost  before  the  true  state  of  affairs  was  made  known 
at  a  hospital  or  in  the  practitioner's  office.  When 
occasion  arises,  parents  should  be  cautioned  to  have 
the  child's  foot  examined  by  the  physician  or  spe- 
cialist first  as  is  done  with  the  other  organs. 
Periodical  inspections  of  the  feet  of  children  in 
public  institutions  should  be  made  a  routine  as  for 
other  body  deficiencies.  In  treating  a  foot  condi- 
tion in  the  child,  the  general  practitioner  should  be 
prepared,  if  he  advises  shoes  or  supports,  to  check 
these  items  in  connection  with  his  other  treatment. 
The  physician  certainly  does  not  leave  the  prescrib- 
ing of  medication  to  the  druggist.  Yet  with  feet, 
it  is  common  to- shift  the  responsibility  to  the  shoe 
clerk,  and  the  public  has  thus  in  time  become  accus- 
tomed to  regard  the  shoe  clerk's  knowledge  of  feet 
as  superior  to  that  of  the  doctor  and  diagnosis  as 
within  the  province  of  the  shoe  store.  As  a  matter 
of  fact,  the  shoe  clerk  cannot  be  prepared  under 
the  strain'  of  making  sales  or  by  virtue  of  previous 
training  to  be  the  logical  guardian  of  the  child's  foot. 
He  is  incapable  of  differentiating  between  cases  of 
font  ailments  of  a  localized  nature  and  those  ail- 
ments that  reflect  constitutional,  nervous  or  mechan- 
ical disorders  elsewhere  in  the  body.  This  differen- 
tiation constitutes  a  prime  requisite  for  the  success- 
ful diagnosis  and  treatment  of  any  foot  condition. 
Further  evidence  of  these  facts  is  furnished  by  the 
histories  of  the  thousands  of  patients  who  eventu- 


December  18,  1920.1 


SCHEIMBERG:  WEAK  FOOT  IX  THE  CHILD. 


989 


ally  arrive  at  the  office  of  the  practitioner  or  at  some 
hospital  for  advice  after  having  experimented  many 
years  with  shoes  and  arches  and  where  the  dis- 
ability again  often  finds  its  source  elsewhere  than 
in  the  feet. 

Military  authorities  require  those  who  care  for 
the  horse  to  have  a 
preliminary  knowledge  ^ 
of  the  anatomy  and  ; 
physiolog}'  of  the  loco- 
motive apparatus  of 
this  animal.  The  shoe- 
ing of  the  horse  is  gen- 
erally considered  an  art 
of  the  highest  utility 
toward  the  preserv  ation 
of  the  animal's  effici- 
ency, and  this  expert 
care  is  but  natural  and 
proper.  The  growing 
child,  however,  whose 
foot  is  not  an  inco- 
ordinate mass  like  the 
horse's  hoof,  and  which 
is  called  upon  for  a 
greater  delicacy  of 
function  as  indicated 
in  the  grace  and  elas- 
ticity of  the  human 
gait,  is  recklessly  rele- 
gated to  such  empirical 
factors  as  stores  and 
arch  support  specialists. 
Thus  the  weaknesses 
are  permitted  to  develop 

and  create  later  disability.  This  situation  might  be 
ludicrous  were  not  its  outcome  so  serious.  It  is 
obvious  that  the  attention  and  action  of  all  agencies 
in  caring  for  the  child  are  thus  challenged. 

Incidentally,  we  see  the  general  public  depending 
upon  com  cures  for  relief  from  excrescences  that 
generally  reflect  a  malposition  of  the  delicate  struc- 
tures of  the  foot,  which  malposition  occasions  un- 
due friction  or  pressure  at  the  point  where  the 
excrescence  occurs.  Here  it  is  again  evident  that 
minor  orthopedic  measures  and  scientific  guidance 
are  needed  in  preference  to  the  much  lauded  pro- 
prietaries heralded  as  a  cureall  for  foot  ills. 

So  extensive  is  the  effect  of  this  neglect  uf>on 
children  that  if  legislation  were  enacted  and  rigidly 
enforced  to  prevent  the  diagnosis  of  foot  ailments 
in  shoe  stores,  or  this  legislation  to  permit  such 
diagnosis  only  through  the  employment  of  a  spe- 
cialist, the  community  would  thereby  eliminate  a 
potent  factor  in  undermining  the  vital  efficiency  of 
present  and  future  generations.  This  suggestion 
of  medical  specialists  in  stores  may  sound  unusual ; 
but  a  little  thought  proves  it  logical  and  essential. 
Experience  has  demonstrated  the  logic  of  this 
routine  so  far  as  the  eye  is  concerned,  as  the  leading 
optical  concerns  now  employ  oculists.  The  penal- 
ties for  the  neglect  of  foot  ailments  are  certainly 
as  exacting  as  for  the  neglect  of  the  eye. 

As  to  the  increase  and  extensive  prevalence  of 
weak  feet  in  children  and  the  fact  that  the  condi- 
tion as  hereafter  explained  more  often  remains  in- 


FiG.  2. — ^Dorsal  view  of  right 
foot  in  outline.  Line  A-A  repre- 
sents the  weight-bearing  axis  of 
the  foot  and  corresponds  to  line 
A-A  of  Fig.  7.  Greater  area  of 
the  OS  calcis  as  the  posterior  pillar 
of  the  arch  is  outside  this  axis. 
Observe  that  greater  area  of 
weight  bearing  surface  of  the  foot 
is  also  outside  this  axis.  Thus 
body  weight  through  each  leg  is 
carried  by  a  structure  that  is  not 
centralized  beneath  it. 


grown,  we  again  have  ready  evidence.  Institutional 
statistics  are  constantly  making  this  fact  plain.  It 
was  panicularly  brought  to  hght  with  the  great 
number  of  rejections  from  militarv'  service  in  the 
early  recruiting  for  the  late  war  and  before  an 
order  was  eventually  issued  to  reject  no  more  foot 
cases.  On  several  occasions  when  I  have  examined 
groups  of  children  for  this  ailment,  the  percentage 
of  those  who  showed  little  or  more  advanced  symp- 
toms of  this  condition  was  about  sixty.  This  per- 
centage I  find  confirmed  by  those  who  have  had 
occasion  to  make  special  examinations  for  the  same 
ailment. 

That  the  present  attitude  of  the  general  public  is 
in  nowise  likely  to  reduce  this  proportion  of  weak 
feet  is  ver>-  likely.  There  is  a  too  frequent  ten- 
dencv  to  regard  most  pains  where  present  as  rheu- 
matic or  neurotic;  or  to  depend,  as  mentioned,  on 
shoes  or  supports  as  cures,  or  to  be  misled  by  a 
popular  fallacy  that  pain  in  the  lower  extremities 
is  of  Httle  consequence,  will  right  itself  and  war- 
rants no  special  attention.  It  is,  however,  to  the 
credit  of  some  of  the  more  progressive  shoe  manu- 
facturers and  stores  that  the  nature  of  shoe  adver- 
tisements is  assuming  a  different  tone  that  would 
indicate-  a  healthy  awakening.  Where  formerly 
st>'le  and  wear  were  featured  in  the  advertisement, 

these  concerns  are 
now  directing  atten- 
tion to  proper  fitting 
and  to  general  foot 
care  in  the  child,  and 
thus  parents  are  being 
benefited.  The  neglect 
of  the  child's  foot  can 
hardly  be  blamed  en- 
tirely on  the  parent, 
as  it  seems  unlikely, 
assuming  the  latter  to 
have  been  properly 
advised,  that  there 
should  result  a  will- 
ful neglect 
child's  feet 
detriment  of 
economic  efficiency 
and  earning  power, 
and  which  neglect 
might  later  bar  the 
child  from 
positions  in 
military  life. 

There  is,  perhaps, 
a  too  general  reliance 
on  natural  therapeu- 
tics by  assuming  that 
the  soft  and  pliable 
structures  of  the  child 
assure 

Such  an  attitude 
however,  puzzling  to 
me,  as  it  seems  plain  that  pliability  of  bone  lends 
itself  as  much  to  natural  distortion  as  to  natural 
therapeutics,  particularly  where  bones  are  meeting 
the  pressure  of  body  weight  as  in  the  case  of  the 
lower  extremities.    The  extensive  prevalence  of  flat 


Fig.  3. — The  incorrect  altitude 
in  standing  or  walking.  Line  of 
body  weight  A-B.  Pressure 
through  this  line  being  concen- 
trated at  keystone  region  of  arch 
as  indicated  by  arrow.  This  atti- 
tude contradicts  the  leverage  func- 
tion of  entire  foot  by  diverting  the 
muscular  action  from  leg  to  foot. 
The  consequent  overstretching  of 
the  inner  muscles  and  ligaments 
predisposes  to  an  inward  displace- 
ment of  the  pillars  of  the  arch, 
partictilarly  with  prolonged  stand- 
ing characteristic  of  many  com- 
mon occupations. 

Fig.  4. — The  correct  attitude  in 
standing  or  walking.  Leverage 
action  of  the  foot  facilitated  by 
undiverted  muscular  action  and 
the  fact  that  body  weight  now  falls 
over  entire  length  of  foot.  The 
segments  of  the  longitudinal  arch 
are  kept  from  falling  inward  by 
the  direct  action  of  muscles  from 
leg  to  foot.  (This  attitude  in 
marching  would  mean  a  gain  of 
about  one  inch  to  the  step  as 
compared  to  attitude  of  Fig.  5 
where  about  an  inch  is  lost.  In  a 
march  of  about  thirty  miles  with 
its  average  of  2000  steps  to  the 
mile,  there  would  be  a  clear  gain 
of  about  one  mile,  while  the  same 
thirty  miles  performed  with  the 
feet  as  in  Fig.  3  would  incur  loss 
of  a  mile  in  distance). 


of  the 
to  the 
a  later 


desirable 
civil  or 


outgrowth. 


990 


SCHEIMBERG:  WEAK  FOOT  IN  THE  CHILD. 


[New  York 
Medical  Journal. 


feet  in  the  adult  consequent  so  often  to  weak  feet 
in  the  child  proves  that  the  condition  of  weak  foot 
is  not  so  readily  outgrown  as  is  generally  thought. 

The  subject  of  weak  foot  (flexible  flat  foot)  will 
be  principally  discussed  from  the  viewpoint  of  a 
visible  mechanical  deformity,  commonly  seen  in 
children,  and  irrespective  of  its 
prime  etiology,  existing  as  an 
end  result  of  any  one  or  more 
of  a  variety  of  causes  herein- 
after enumerated. 

The  weak  foot  may  be  de- 
fined as  a  foot  which  in  contour 
and  action  resembles  a  perfect 
foot  until  weight  is  borne  on 
it  as  in  standing  when  it  as- 
sumes an  attitude  of  deformity 
corresponding  to  flat  foot,  and 
as  later  detailed.  The  change 
under  weight  bearing  is  due  to 
the  inability  of  muscles  and 
ligaments  to  maintain  sufficient 
tension  to  hold  the  superim- 
posed weight.  The  term  weak 
foot  or  flexible  flat  foot  is 
preferable  to  flat  foot,  the  latter 
being  restricted  to  the  later 
fixed  stage  where  the  deformity 
is  visible  even  with  the  foot  off 
the  ground.  As  with  flat  foot, 
the  condition  is  generally  found 
in  both  feet  instead  of  one  foot 
alone,  though  the  term  seems  to 
imply  an  affection  of  one  foot 
alone.  The  weak  foot  may  be 
congenital;  more  often  it  ap- 
pears to  have  been  acquired 
through  a  variety  of  factors  to 
be  outHned. 

As  to  congenital  cases,  I  do 
not  refer  to  the  relatively  in- 
frequent congenital  talipes  valgus  where  there  is 
some  contraction  of  tissue  and,  therefore,  resistance 
to  manual  correction,  or  to  paralytic  conditions. 
I  have  in  mind  the  common  form  with  unrestricted 
active  or  passive  -motion  of  the  feet  and  which 
becomes  apparent  as  soon  as  the  child  starts  to 
stand  and  walk.  If  present  before  locomotion 
commences,  it  would  seem  difficult  to  identify 
the  condition  so  as  actually  to  class  it  as  congenital. 
This  must  be  so,  because  a  weak  foot  is  generally 
identified  by  a  change  of  contour  from  the  attitude 
of  rest  to  that  of  standing.  We  cannot,  however, 
get  the  infant  in  arms  to  stand  for  us.  Even  if 
the  infant  could  stand  unassisted,  the  additional 
adipose  tissue  under  the  child's  arch,  together  with 
the  lack  of  complete  development  of  this  arch 
(which  can  only  occur  consequent  to  muscular 
activity)  would  still  make  the  diagnosis  of  a  purely 
congenital  case  difiicult  if  not  impossible.  Of 
course,  in  the  relatively  more  rare  cases  of  con- 
genital talipes  valgus,  the  deformity  is  visible  even 
with  the  foot  at  rest. 

Assuming,  however,  a  case  to  be  purely  con- 
genital, its  prime  etiology  as  with  other  congenital 
deformities  remains  speculative.    It  is  impossible  to 


Fig.     5.  —  Posterior 

view  of  skeleton  of 
right  leg,  showing  the 
slight  but  normal  knock- 
knee  existing  in  the 
standing  position  due 
to  inclination  of  femora 
from  hips  to  knees. 
Line  B-B  shows  ap- 
proximate inclination  of 
femur.  Weak  feet  re- 
flect themselves  in  an 
inward  shift  of  the 
tibia,  thus  an  approxi- 
mation of  the  knee 
joints  thereby  with  an 
increased  tilting  of  the 
femora  creating  more 
or  less  secondary  knock- 
knee.  Thei  reciprocal 
relationship  between 
weak  feet  and  knock- 
knees    is    thus  evident. 


state  definitely  to  what  extent  prenatal  influences 
have  contributed  to  the  condition,  or  whether  post- 
natal influences  in  the  period  before  walking  begins 
might  not  have  been  chiefly  causative  particularly 
with  a  history  of  defective  assimilation. 

When  viewed,  however,  as  an  acquired  condition, 
or  when  we  observe  the  cases  that  are  distinctly 
acquired,  the  etiology  is  more  definitely  assignable 
to  a  single  or  combined  operation  of  any  of  the 
following:  A  too  rapid  growth  or  increase  in 
weight ;  confinement  by  illness ;  sudden  strain  after 
such  confinement;  local  tissue  effects  of  certain  ill- 
nesses themselves ;  improper  support  of  the  foot 
during  prolonged  confinement  to  bed ;  city  pave- 
ments ;  commercial  arch  supports ;  improper  atti- 
tudes in  standing  or  walking ;  the  distortion  at  the 
ankle  induced  by  favoring  a  part,  as  with  excres- 
cences such  as  corns,  callosities,  or  ingrowing 
nails  ;  or  as  with  sprains  of  the  ankle  joint ;  improper 
footgear.  Among  the  relatively  rarer  causes  which, 
though  not  bearing  on  the  common  weak  foot  under 
discussion,  may  be  mentioned  for  completeness, 
are  found:  spasm  of  the  peroneal  muscles  (spastic 
weak  foot  and  really  an  inflexible  form)  ;  genu 
valgum  (knock  knee),  where  the  foot  is  forced  into 
valgus  by  the  outward  swing  of  the  legs  which  con- 
centrates the  weight  of  the  body  on  the  inner  arch ; 
paralytic  taHpes  valgus;  or  accompanying  the  early 

or  rachitic  type  of  genu 

varum  (bow  leg).  The 

prime  etiology,  however, 

may  nevertheless  be  ob- 
scure in  those  cases 

where,  for  example,  we 

find  weak  feet  that  have 
.  developed   in  children 

who  give  no  history  of 

illness,  pain  or  trauma, 

and  who  besides  are 

light  in  weight  and  fairly 

muscular.    An  inquiry 

into  the  causes  men- 
tioned seems  to  indicate 

that,   excluding  disease, 

faulty  nutrition  and  the 

like,  two  factors  stand 

out  prominently  as  being 

directly  predisposing  and 

which  will  be  referred 

to  seriatim.    At  least, 

no  intelligent  treatment 

of    this    condition  can 

occur    without  primary 

attention  to  the  elements 

of   attitude  and  foot- 
gear. 

ATTITUDE. 

So  far  as  the  stability 
of  the  huma^i  foot  or 
efficient  gait  is  concerned,  we  have  erred  by  teach- 
ing the  child  to  toe  out  in  standing  or  walking. 
To  appreciate  why  turning  the  toes  outward  is 
decidedly  antagonistic  to  good  foot  function,  let  us 
observe  some  anatomical  peculiarities  of  interest 
and  the  arch  itself.    In  Fig.  1,  we  see  that  this  arch 


Fig.  6. — Normal  feet  at  rest. 
This  may  also  illustrate  the  weak 
feet  at  rest  in  which  attitude 
no  abnormality  is  ordinarily  visi- 
ble. Lines  A-A  pass  about  cen- 
trally through  ankle  joints  as 
with  the  .same  normal  feet  stand- 
ing in  Kigs.  7  and  8.  Short 
dotted  lines  A-B  in  their  angula- 
tion at  the  metatarso-phalangcal 
joints  show  how  in  the  rest  at- 
titude, the  large  toes  abduct 
from  median  line  of  body  and 
lean  over  against  the  second  toi  s. 


December  18,  1920.] 


SCHEIMBERG:   WEAK  FOOT  IN  THE  CHILD. 


991 


may  be  conveniently  referred  to  as  consisting  of 
two  limbs,  the  os  calcis,  line  B-C,  forming  the 
posterior  and  shorter  limb,  while  the  anterior  seg- 
ment, line  A-B,  is  formed  by  the  bones  in  front  of 
the  astragalus  and  which  extends  to  the  heads  of 
the  metatarsal  bones,  the  astragalus  itself  forming 


Fig.  7.  Fic.  8. 

Fig.  7. — Anterior  view  of  normal  feet  in  standing  position.  Long 
dotted  lines  centralize  through  ankle  and  foot  in  contrast  with  the 
weak  foot  standing  in  Fig.  9.  Short  dotted  lines  B-B  show  in  each 
case  how  large  toe  has  now  swung  away  from  the  second  toe  so  as 
to  point  toward  line  of  progress  and  bear  body  weight.  A  space  is 
now  evident  between  the  first  and  second  toes. 

Fig.  8. — Posterior  view  of  normal  feet  in  standing  position.  Con- 
trast (with  respect  to  the  ankle  joint)  the  locus  of  this  line  in 
the  weak  foot  standing,  Fig.  10. 

a  sort  of  keystone  and  being  the  first  structure  to 
receive  the  direct  body  weight  which  is  transmitted 
vertically  through  the  tibia.  The  first  anatomical 
peculiarity  that  is  immediately  apparent  is  concerned 
with  the  relationship  of  the  bones  of  the  foot,  as 
shown  in  Fig.  2.  Here  we  note  that  the  os  calcis 
as  the  posterior  segment  of  the  arch  is  not  cen- 
tralized under  the  weight  bearing  axis  of  the  foot, 
Hne  A-A,  but  that  the  greater  part  of  its  body  is 
outside  of  such  axis.  We  observe  in  addition  that 
the  greater  area  generally  of  the  weight  bearing 
foot  is  outside  of  this  same  axis.  Now  we  should 
also  bear  in  mind  that  in  the  normal  standing  atti- 
tude, the  astragalus  or  keystone  rolls  slightly  down- 
ward and  inward  on  the  os  calcis  until  it,  the  tibia, 
the  knee  joint  and  the  hip  joint,  are  checked  from 
inward  dislocation  by  powerful  muscular  tension, 
and  which  muscles  are  principally  located  or  act  at 
the  inner  side  of  the  entire  leg.  The  muscles  be- 
tween the  knee  joint  and  the  foot  which  directly 
keep  the  arch  with  the  keystone  intact  by  a  com- 
bined tightening  are  the  flexors  of  all  the  toes,  and 
the  peroneus  longus  which  tend  to  flex  the  longi- 
tudinal segments  of  the  arch ;  the  tibialis  anticus 
which  by  tension  from  its  upper  origin  in  leg  has 
an  adducting  and  inwardly  rotating  effect  on  the 
internal  cuneiform  and  first  metatarsal  bones,  thereby 
tending  to  invert  the  sole  and  to  throw  the  weight 
of  body  on  outer  side  of  foot  and  thus  less  weight 


on  the  inner  or  springy  and  more  elastic  side  of 
foot ;  the  tendon  of  the  tibialis  posticus  which  passes 
directly  beneath  the  inferior  calcaneoscaphoid  liga- 
ment, on  which  ligament  the  head  of  the  astragalus 
reclines ;  and  in  a  lesser  measure,  this  inferior  cal- 
caneoscaphoid or  spring  ligament  extending  from 
the  inner  surf  ace,  of  the  os  calcis  to  the  scaphoid. 

Thus  the  body  is  actually  resting  on  an  arched 
foundation  that  is  not  centralized  beneati?  it,  and 
with  this  there  exists  a  normal  tendency  for  the 
weight  of  the  body  to  force  inward  the  posterior 
segment  or  heel  bone  as  a  result  of  which  the  key- 
stone or  astragalus  and  its  superimposed  structures 
tend  to  slide  in  and  off  the  foot  in  normal  standing 
and  more  so,  of  course,  in  walking,  which  tendency 
receives  a  powerful  muscular  check.  This  check, 
however,  can  operate  most  efficiently  if  direct  mus- 
cular action  is  not  diverted  as  shown  by  the  correct 
attitude  in  Fig.  4,  instead  of  the  incorrect  one  in 
Fig.  3.  We  see  in  the  correct  attitude  how  the 
muscles  act  directly  in  maintaining  the  arch  and 
effecting  graceful  locomotion  because  the  line  of 
action  through  these  muscles  is  a  straight  one  and 
is  not  diverted  by  the  break  at  point  C  of  Fig.  3. 
We  observe  also  that  in  the  correct  attitude,  the 
direction  of  body  weight,  line  A-B,  continues  as  it 
should  through  the  length  of  the  weight  bearing  foot. 
In  the  incorrect  attitude  of  Fig.  3,  the  weight  of 
the  body  is,  as  shown  by  the  arrow,  concentrated 
against  the  keystone  region  of  the  arch  instead  of 
through  the  length  of  the  foot  and  thus  together 
with  a  diverted  muscular  play,  the  tendency  of  the 
ankle  joint  to  roll  inward  is  enhanced.  In  other 
words,  in  the  incorrect  attitude  the  greater  area  of 
the  outer  and  normal  weight  bearing  foot  has  been 


Fig.  9.  Fig.  10. 

Fig.  9. — Anterior  view  of  weak  foot  (flexible  flat  foot)  standing. 
Note  displacement  laterally  of  longitudinal  arch  with  its  secondary 
pronation  at  ankle  joints.  Thus  this  condition  is  often  mistaken 
for  socalled  weak  ankles. 

Fig.  10. — Posterior  view  of  weak  foot  (flexible  flat  foot)  standing. 

relieved  of  its  share  of  work  which  is  being  added 
in  weight  at  the  very  point  in  the  arch  that  was 
intended  mainly  for  elasticity,  thus  lessening  the 
spring  by  this  pressure  of  added  weight.  The 
incorrect  attitude  thus  contradicts  the  normal  action 


992  SCHEIMBERG:   WEAK  FOOT  IN  THE  CHILD.  [New  York 

Medical  Journal. 


of  the  various  muscles  referred  to  in  preserving  the 
integrity  of  the  arch  and  general  hody  balance  and 
occasions  mechanical  strain.  Such  an  attitude  if 
maintained  habitually  helps  to  produce  a  weakening 
of  the  arch  by  an  overstretching  and  relaxation  of 
muscles  and  ligaments,  and  when  accompanied  by 
other  factors  that  may  weaken  the  general  or  local 
musculature,  as  overweight,  overstrain,  disease,  and 
the  like,  can  only  result  in  a  natural  lateral  and  in- 
ward displacement  of  the  component  segments  of 
the  arch,  lines  A-B  and  B-C,  Fig.  1,  and  which  is 
the  prime  objective  symptom  of  the  weak  foot  here- 
inafter detailed. 

It  should  not  be  assumed,  however,  that  this 
muscular  play  against  an  arch  that  tends  to  fall 
inward  means  defective  construction  on  the  part  of 
Nature.  As  a  matter  of  fact,  a  midplay  at  the 
tarsal  region  is  thus  effected  that  makes  for  the 
grace  and  elasticity  characteristic  in  man  who,  of  all 
bipeds,  carries  his  weight  constantly  on  two  feet 
with  most  remarkable  ease.  Besides  this  lateral 
midtarsal  play  is  safer  than  a  vertical  up  and  down 
flexibility  of  the  arch  because  of  the  danger  entailed 
to  the  delicate  plantar  vessels  and  nerves  by  com- 
pression between  the  body  and  the  ground  if  the 
arch  could  rock  up  and  down.  The  needed  vertical 
elasticity  is  sufficiently  compensated  by  the  ready 
flexibility  of  the  knee  joint ,  itself.  Thus  where 
correct  attitude  is  maintained,  the  muscular  play  is 
such  as  to  amply  offset  what  might  otherwise  be 
a  mechanical  difficulty. 

An  observation  of  the  alignment  at  the  knee  and 
hip  joints  reveals  another  anatomical  peculiarity  that 
indicates  a  reciprocal  relationship  between  weak 
feet  and  knock  knees,  explaining  why  both  condi- 
tions invariably  coexist,  and  which  confirms  the 
necessity  for  the  attitude  of  Fig.  4.  By  reference 
to  Fig.  5,  showing  the  posterior  skeletal  view  of  the 
right  leg  standing,  we  see  that  the  thigh  bones  in- 
cline inward  toward  the  knees,  which,  in  view  of  the 
proximity  of  the  knees,  must  occur  because  the 
upper  ends  of  the  thighs  at  the  hip  joint  are  sep- 
arated in  standing  by  the  normal  breadth  of  the 
pelvis  and  the  extended  necks  of  the  femora.  The 
normal  inclination  of  the  femora  is  then  inward  to 
the  knees,  which  really  means  that  there  already 
exists  a  normal  amount  of  knock  knee  in  the  stand- 
ing attitude,  the  knees  tending  to  collide  with  any 
tendency  acting  from  below  that  would  throw  the 
tibia  and  thus  the  knee  joint  inward.  But  here 
again,  as  \v\th  the  tendency  of  the  leg  to  roll  in  on 
the  foot  counteracted  by  muscular  resistance,  we 
have  the  muscles  and  ligaments  in  the  upper  leg 
and  thigh  counteracting  (by  tension  and  outward 
force)  the  knock  knee  tendency.  This  again  is  a 
natural  provision  for  a  useful  lateral  mobility  of 
the  limb,  the  necessary  vertical  flexibility  being 
facilitated  as  stated  by  simple  knee  flexion.  But 
the  improper  attitude  shown  in  Fig.  3,  which  makes 
for  the  inward  displacement  of  the  arch  by  inter- 
fering with  normal  muscular  tension,  similarly 
diverts  the  direct  action  of  the  muscles  concerned 
in  checking  the  tendency  to  knock  knee,  though  in  a 
much  slighter  degree,  by  rotating  the  entire  leg 
outward. 

A  resume  of  the  foregoing  furnishes  these  facts: 


That  there  exists  a  normal  tendency  to  weak  foot 
and  knock  knee;  that  this  tendency  if  unrestrained 
would  interfere  with  the  stability  of  .equilibrium  and 
efficient  locomotion;  that  such  tendency  is  checked 
through  muscular  tension  from  hip  to  heel ;  that  this 
play  between  muscle  ten.sion  and  joints  is  a  physio- 
logical necessity  to  elasticity  and  to  protection  of 
the  delicate  plantar  structures  in  the  arch  con- 
cavity; that  the  muscles  concerned  can  best  act  if 
their  action  is  direct,  not  diverted,  and  that  direct 
action  or  pull  of  the  musculature  can  only  occur 
when  the  feet  are  kept  parallel  in  standing  and 
particularly  in  walking. 

The  foregoing,  discussion  is,  of  course,  not  in- 
tended to  be  exhaustive  as  to  the  relationship 
between  incorrect  attitudes  and  weak  feet.  What 
is  made  plain,  however,  is  that  as  a  prime  element 
of  physical  education  with  children,  no  time  should 
be  lost  in  making  the  correct  attitude  of  Fig.  4 
a  fixed  routine. 

FOOTGEAR. 

The  numerous  objections  justly  advanced  against 
the  vicious  types  of  shoes  worn  by  adults  does  not 
warrant  discussion  here  as  such  do  not  entirely 
apply  to  children's  shoes.  This  is  so,  fortunately, 
because  the  community  has  become  sufficiently 
civilized  as  to  not  put  fashion  above  health  with  the 
child's  foot  by  encasing  it  in  tight,  narrow  and  short 
shoes.  Even  the  girl  is  allowed  a  few  years  lease 
of  foot  life  before  being  started  on  the  painful,  dis- 
abling errand  of  competing  with  the  Chinese  lady 
in  transforming  an  exceedingly  useful  organ  into 
a  monstrosity.  One  element  of  interest  concerns 
us  with  respect  to  the  shoes  of  the  adult  female  that 
may  bear  on  the  child's  foot.  I  have  in  mind  pre- 
natal influences  that  operate  to  induce  a  predis- 
position to  foot  ailments  generally  and  the  weak 
foot  in  particular.  Here  we  should  view  with  no 
little  suspicion  as  a  possible  contributing  agent,  the 
high  heel  and  narrow  pointed  shoes  that  are'  worn 
by  the  women  especially  while  pregnant.  Such 
shoes,  by  compressing  the  toes  and  restricting  the 
elasticity  of  the  gait,  weaken  the  muscles  which  are 
concerned  in  maintaining  the  integrity  of  the  arch, 
and  thus  through  the  generations  may  result  in 
conferring  a  predisposition  to  weakness  of  the  arch 
by  an  evolutionary  degeneration  of  muscles  and 
ligaments. 

What  is  of  direct  concern,  however,  with  the 
footgear  of  the  child,  is  the  faith  of  the  public  in 
a  commercial  market  flooded  with  anatomic,  ortho- 
pedic, and  Dr.  Blank  shoes,  to  which  we  have  pre- 
viously alluded.  Curiously  enough,  the  importance 
of  other  elements  of  foot  pathology  are  overlooked 
when  it  is  assumed  that  a  certain  manufacturer's 
label  in  a  shoe  is  curative.  In  the  fitting  element 
alone,  it  should  be  borne  in  mind  that  the  feet  of 
children  vary  in  contour  and  action,  and  as  to  con- 
tour do  not  follow  the  very  few  patterns  of  the 
shoe  manufacturer.  Some  feet  are  long  and  thin, 
some  short  and  thick,  some  highly  arched ;  some 
have  low  arches,  some  possess  delicate  heel  cushions ; 
one  child  may  throw  more  weight  on  the  ball,  another 
on  the  heel ;  most  children  throw  more  weight  on 
the  inner  margin,  but  some  throw  weight  on  the 
outer  margin  ;  ligaments  of  the  knee  or  ankle  may 


December  18,  1920.] 


SCHEIMBERG:   W  EAK  FOOT  IX  THE  CHILD. 


993 


be  weak  or  disease  may  have  weakened  certain 
structures,  and  so  on. 

These  and  many  other  considerations  do  not  neces- 
sarily call  for  a  special  shoe  in  every  case,  but 
should  be  met  by  trained  medical  guidance  in  fitting 
with  the  required  modifications  provided.  Even  in 
the  normal  child's  foot,  m  view  of  the  rapid  and 
varied  growth,  it  is  plain  that  merely  depending 
on  a  branded  shoe  out  of  stock  is  insufficient  care. 
The  urgent  necessity  in  the  case  of  the  pathological 
foot  is  thus  undeniable.  The  specific  essentials  of 
correct  fitting  are  later  mentioned  in  connection 
with  treatment. 

WEAK  FEET. 

The  weak  foot  occurs  commonly  in  both  sexes 
and  generally  afiFects  both  feet.  Its  mechanical 
pathological  condition  is  decidedly  peculiar.  When 
ofT  the  ground  its  appearance  as  mentioned  is  nor- 
mal ;  under  weight  as  in  standing  or  walking  it 
becomes  deformed.  At  rest,  there  is  practically 
nothing  wrong  to  be  seen.  A  normal  range  of 
motion,  active  and  passive,  is  apparent;  there  is  no 
muscular  restriction  or  spasm,  and  only  the  experi- 
enced hand  and  eye  of  one  who  had  made  a  study 
of  the  foot  might  recognize  the  defect  by  plantar 
flexion  while  viewing  the  foot  plantarwise.  Fig.  6 
shows  a  normal  foot  at  rest  and  will  serve  as  well 
to  illustrate  the  weak  foot  at  rest.  In  standing,  as 
shown  in  Figs.  7  and  8,  the  line  of  body  weight 
in  the  normal  foot  seems  to  run  straight  through 
the  ankle  joint  on  to  the  arch.  When  weak  feet 
bear  body  weight,  as  in  Figs.  9  and  10,  we  see 
indications  of  the  inability  of  the  muscles  and  liga- 
ments to  maintain  a  normal  relationship  between 
the  segments  of  the  arch  and  manifest  in  the  abduc- 
tion of  the  forefoot,  reflecting  the  angulation  through 
the  longitudinal  axis  of  the  foot  at  the  astragalo- 
scaphoid  articulation  with  the  convexity  inward. 
The  head  of  the  astragalus  now  becomes  prominent 
in  front  of  and  lower  than  the  internal  malleolus. 
The  posterior  view  of  normal  standing  feet.  Fig.  8, 
shows  the  tendon  Achilles  to  be  a  straight  line  all 
the  way  to  its  insertion  into  the  heel  bone,  while  in 
the  standing  weak  foot.  Fig.  10,  the  line  of  the 
tendon  Achilles  curves  in  and  tinder  the  ankle  joint 
and  in  an  outward  direction  at  its  termination. 
This  curvature  of  the  heel  cord  in  the  weak  foot 
reflects  the  inward  collapse  of  the  rear  segment  of 
the  longitudinal  arch,  the  heel  bone  itself,  whose 
upper  articulating  surface  has  swung  inward  and 
its  lower  weight  bearing  area  otitward. 

THE  FEET  AND  THE  SKELETON. 

The  feet  being  obviously  the  foundation  of  a 
relatively  heavy  and  flexible  skeleton,  we  can  under- 
stand that  the  weak  feet  must  induce  a  secondary 
misalignment  of  other  structures  above.  There  is, 
therefore,  almost  invariably  a  secondary  knock  knee 
accompanying,  although,  of  course,  an  independent 
form  of  knock  knee  may  exist  without  the  weak 
foot  influence.  But  the  weak  foot  creates  its  o%vn 
degree  of  knock  knee  due  to  the  adduction  of  the 
OS  calcis  toward  the  median  line  of  the  body.  On 
top  of  the  heel  bone  rests  the  astragalus  and,  on  top 
of  the  astragalus,  the  tibia.  The  astragalus  in  the 
weak  foot  condition  cannot  follow  the  same  inward 
and  lateral  tilt  of  the  heel,  because  of  its  being 


firmly  wedged  between  the  tibia  and  fibula,  but,  as 
previously  mentioned,  follows  a  natural  tendency 
to  slide  in  and  forward  on  the  os  calcis.  With  the 
astragalus  the  tibia  also  moves  inward  through  its 
length  and  thus  the  knee  joints  tend  to  approximate. 
That  even  slight  weak  foot  induces  adduction  of 
the  knee  joints  toward  the  median  body  line  may 
be  demonstrated  by  placing  the  finger  tips  on  the 
patelL'e  while  standing  and  then  voluntarily  rolling 
the  two  ankles  inward.  This  inward  ankle  rolling 
simulates  in  great  measure  the  mechanical  patho- 
logical condition  of  the  weak  feet  and  the  secondary 
inward  shifting  of  the  knee  joints  will  be  easily 
perceptible. 

SECONDARY  CHANGES. 

Above  the  knee  joint,  secondary  mechanical 
deviations  are  similarly  reflected.  In  advanced 
cases,  particularly  with  a  heavy  child,  manual  pal- 
pation at  the  hip  region  while  having  the  child 
voluntarily  adopt  the  normal  position  and  then 
comparing  this  with  the  elYect  of  allowing  the  child 
to  fall  into  the  weak  foot  attitude,  will  demonstrate 
the  referred  misalignment  at  the  pelvic  region  during 
the  weak  foot  attitude.  With  this  we  get  an  accom- 
panying increase  of  curvature  at  the  lumbar  spine 
(lordosis)  and,  of  course,  the  corresponding  pro- 
jection of  the  abdomen.  The  increased  lumbar 
curve  again  often  reflects  itself  in  a  mild  stoop 
of  the  shoulders  and  thus  a  flattening  of  the  chest 
results. 

The  symptoms  in  individual  cases  vary  as  to 
number  and  degree.  The  following  is  a  resume  of 
typical  eft'ects :  the  child  tires  easily,  is  disinclined 
to  play  much,  rests  often,  wants  to  be  carried  after 
walking  a  little,  complains  of  general  undefined 
strain,  may  show  little  appetite,  and  is  irritable. 
It  may  awaken  at  night,  complaining  of  unlocalized 
foot  and  leg  pains.  There  may  be  a  general  nerv- 
ousness without  apparent  specific  cause,  and  a 
complaint  of  pain  in  the  head  or  back.  As  a  result 
of  these  effects,  its  school  work  may  be  below  the 
average.  The  shoes  wear  at  the  inner  heel  and 
sole,  and  at  times  holes  may  be  worn  at  the  region 
of  the  internal  malleolei  due  to  excessive  friction 
and  even  occasionally  to  the  knocking  of  the  ankle 
bones  in  walking.  The  child  is  often  brought  for 
examination  because  it  frequently  stumbles  and  falls. 
This  stumbHng  and  falling  is,  of  course,  occasioned 
by  incorrect  posture,  the  abduction  of  the  forefeet 
and  the  referred  misalignment  at  knee,  hip  and 
lumbar  joints,  which  materially  interferes  with  a 
normal  gait. 

In  other  cases,  the  child  is  brought  for  examina- 
tion because  excessive  intoeing  has  first  attracted 
the  attention  of  the  parents.  In  walking,  the  child 
either  toes  in  or  out,  but  rarely  maintains  the  feet 
parallel.  When  the  child  toes  in,  it  indicates 
nature's  efforts  to  conserve  the  integrity  of  the  arch 
through  an  instinctive  impulse  in  the  child  to  throw 
the  body  weight  on  the  outer  and  stronger  side  of 
the  foot.  When  the  child  toes  out,  it  may  be  a 
symptom  of  this  impulse  being  too  weak  or  having 
lost  its  resistance  in  combatting  the  weakness  of 
the  affected  structures. 

(To  be  concluded.) 


Editorial  Notes  and  Comments 


NEW  YORK  MEDICAL  JOURNAL 

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NEW  YORK.  SATURDAY,  DECEMBER  IS,  1920. 

DIPHTHERIA  TOXINS. 

It  would  appear  from  the  recent  experimental 
work  carried  out  by  Menard  that  the  bacillus  of 
diphtheria  contains  two  toxic  substances,  namely, 
lipoids  and  proteins.  Both  orders  are  toxic,  but 
differ  in  their  effects.  The  lipoids,  above  all,  pro- 
duce local  lesions.  Injected  subcutaneously,  intra- 
venously, into  the  trachea  or  peritoneal  cavity,  they- 
invariably  provoke  local  lesions  characterized  essen- 
tially by  a  rapidly  occurring  necrosis  and  fibrinous 
exudate.  This  combined  necrosing  and  fibrino- 
plastic  action  should  lead  us  to  regard  the  lipoids 
as  possessing  an  important  part  in  the  production 
of  local  compHcations  in  diphtheria,  false  mem- 
branes, and  bronchopneumonia.  On  the  other  hand, 
the  local  action  of  the  proteins  is  very  trifling  or  nil. 
But  when  introduced  into  the  circulation  they  are 
extremely  toxic  and  possess  a  peculiar  affinity  for 
the  nervous  centres.  The  lipoids  also  possess  the 
property  of  fixing  to  a  certain  extent  the  soluble 
toxin,  and  this  toxin,  when  secondarily  freed,  may 
be  the  cause  of  serious  tardy  accidents. 

These  experimental  results  have  led  Menard  to 
suppose  that  although  difTusible  toxin  of  the  diph- 
theria bacillus  plays  the  mo.st  important  part  in 
diphtheritic  intoxication,  the  constitutive  poisons  of 
this  bacterium  must  have  a  no  less  important  action, 
the  lipoids  in  producing  local  lesions,  the  proteins 
in  causing  general  accidents,  although  it  is  as  yet 
impossible  to  specify  their  exact  nature.  Finally, 
it  is  perhaps  possible  that  the  late  occurring  acci- 
dents of  diphtheria  are  the  result  of  the  freeing  of 
the  soluble  toxin  fixed  to  the  microbic  lipoids  them- 


selves and  to  those  of  the  tissues  in  which  the 
organism  pullulates  or  that  it  impregnates  in  remote 
parts.  Antidiphtheritic  or  antitoxic  sera  have  no 
prophylactic  or  curative  action  on  the  lesions  deter- 
mined by  the  constitutive  poisons  of  the  bacillus  of 
diphtheria.  It  would  certainl)-  appear  that  this  like- 
wise applies  to  bactericidal  sera  in  general.  The 
practical  conclusions  of  Menard's  experiments,  given 
the  present  state  of  our  knowledge,  is  that  to  the 
use  of  antidiphtheritic  serum,  whose  exhibition 
should  invariably  constitute  the  basis  of  the  treat- 
ment of  diphtheria,  the  prudent  application  of 
selected  antiseptics  should  be  added,  by  means  of 
spraying  and  irrigations,  care  being  taken  not  to 
injure  the  mucosae.  This  is  also  the  best  means 
of  sterilizing  the  nasopharynx  in  germ  carriers. 

THE  CAUSATION   OF  RICKETS. 

The  causation  of  rickets  is  still  an  undecided 
question,  but,  of  ' course,  it  is  a  complex  one.  A 
finger  cannot  be  pointed  at  a  single  factor  as  the 
definite  cause.  The  condition  has  been  for  many 
years  ascribed  to  errors  of  diet,  to  lack  of  fat  and 
excess  of  carbohydrates  in  particular,  to  unhealthy 
living  conditions,  to  a  deficiency  of  calcium  salts, 
to  aberrant  or  lacking  function  of  one  or  other 
of  the  internal  secretions,  or  even  to  an  infection 
or  intoxication.  However,  the  exact  causes  are  not 
yet  known.    Its  origin  remains  obscure. 

Dr.  Findlay,  in  the  report  of  the  British  Medical 
Research  Committee  for  1918,  draws  attention  to 
the  fact  that  in  rickets  there  exist  hyperplasia  of 
cartilage,  deficient  absorption  of  that  tissue  with 
imperfect  calcification,  and  defective  formation  of 
bone.  He  holds  that  a  disturbance  of  calcium  meta- 
bolism is  not  infrequent,  but  that  loss  of  calcium 
is  not  invariable  even  in  acute  rickets.  In  his 
opinion  the  entire  matter  of  calcium  metabolism  both 
in  health  and  disease  re(|uires  revision.  He  believes 
that  the  condition  is  due  rather  to  unhygienic  living 
than  to  diet  deficiency.  Dr.  Eric  Pritchard,  in  a 
paper  contributed  to  the  British  Medical  Journal, 
November  15,  1919.  expresses  the  view  that  the 
essential  and  central  feature  of  rickets  is  the  want 
of  calcification  or  mineralization  of  developing  bone 
due  to  the  existence  of  requirements  for  calcium 
which  for  the  time  being  are  more  urgent  than  those 
of  developing  bone,  namely,  the  necessity  for 
neutralizing  or  compensating  an  existing  acidosis. 
Chronic  conditions  of  malnutrition  of  whatever  kind 
or  from  whatever  cau.se  arising,  finally  terminate 
in  acidosis,  and  all  varieties  of  malnutrition  during 


Decemb.r  18,  1920.] 


EDITORIAL  ARTICLES. 


:)9S 


infancy  and  early  childhood  tend  to  terminate  in 
rickets.  Other  factors,  such  as  want  of  muscular 
exercise,  impure  air,  lack  of  sunshine,  bad  housing, 
and  overfeeding,  play  important  parts.  Miss  Mar- 
garet Ferguson  states  frankly  as  a  result  of  an 
investigation  undertaken  by  her  into  the  social  and 
economic  factors  in  tlie  causation  of  rickets  that 
the  evidence  is  against  dietetic  cause  of  the  disease, 
but  she  does  think  that  unsatisfactory  conditions  in 
the  home  and  particularly  inadequate  air  and  exer- 
cise are  potent  factors  in  determining  its  onset. 

In  \'ienna  at  the  present  time  there  seems  to 
be  an  almost  universal  incidence  of  rickets  among 
children  of  the  poorer  classes  when  older  than 
one'  year,  and  both  rickets  and  scurvy  have  fre- 
quently developed  in  breastfed  infants,  often  when 
less  than  six  months  old.  But  these  facts  do  not 
go  far  toward  solving  the  problem,  because  condi- 
tions, both  dietetic  and  unhygienic,  are  as  bad  as 
possible  in  Vienna,  although  perhaps  the  dietetic 
factor  seems  to  intrude  itself  more  obviously  than 
that  of  environment.  Undoubtedly  the  causation 
of  rickets  is  complex  and  the  views  of  Dr.  Pritchard 
appear  to  be  the  most  rational,  that  diet  plays  the 
most  important  part,  overfeeding  for  example,  but 
that  several  other  factors  must  be  taken  into  account. 
Rickets  may  be  a  deficiency  disease  in  that  it  is 
due  to  diets  which  are  unbalanced  because  they 
contain  too  little  of  those  substances  which  include 
antirachitic  factors  and  too  much  of  those  sub- 
stances deficient  in  this  respect. 

PARADOX. 
Syphilis  is  good.  This  is  the  position  held  by 
some  of  the  delegates  at  the  convention  in  Washing- 
ton on  venereal  diseases  the  week  of  December  6th. 
How  could  they  in  any  possible  way  twist  them- 
selves into  this  paradoxical  attitude.  First  let  it 
be  understood  that  these  delegates  were  typical 
reactionaries.  This  will  explain  much.  But  let  us, 
in  all  justice  to  them,  go  on  and  develop  their  point 
of  view.  These  men  and  women  opposed  educa- 
tion in  regard  to  venereal  prophylaxis.  They  held 
that  it  would  lower  our  morals  if  we  knew  how  to 
use  certain  methods  for  the  prevention  of  syphilitic 
and  gonorrheal  infection.  They  stated  that  a  cer- 
tain number  of  men  abstained  from  illicit  inter- 
course from  fear  of  infection.  If  this  fear  was 
removed  it  would  increase  the  number  of  contacts 
and  prostitution.  Therefore,  the  knowledge  of  the 
possibility  of  infection  by  syphilis  kept  men  chaste. 
If  this  last  barrier  was  broken  down  it  would 
influence  the  morals  of  thirty  per  cent,  of  the  men 
who  were  chaste,  according  to  their  figures.  These 


men  would  no  longer  restrain  themselves,  and  would 
join  the  larger  group  who  were  not  influenced  l)y 
fear.  P'or  this  reason  the  knowledge  of  prophy- 
laxis must  be  kept  from  men.  Syphilis  in  the  guise 
of  a  punishment  for  transgression  would  serve  a 
definite  purpose.  Syphilis  was  good,  for  it  was 
the  only  thing  that  kept  chaste  the  good  men  whom 
they  wanted  to  protect. 

If  all  this  is  true,  afifairs  are  in  a  lamentable  state. 
The  remedy  cannot  come  by  suppressing  knowledge. 
If  the  fear  of  syphilis  is  the  only  thing  that  keeps 
men  chaste,  then  there  fs  something  fundamentally 
wrong  with  our  moral  code.  These  matters  should 
receive  attention  from  the  men  and  women  who  are 
engaged  in  trying  to  improve  moral  ethics.  If  the 
group  engaged  in  this  work  at  present  cannot  solve 
the  problem  without  the  aid  of  syphilis  and  gonor- 
rhea as  their  henchmen  they  should  abandon  their 
tactics  and  seek  an  occupation  for  which  they  are 
better  fitted.  As  medical  men  we  cannot  allow  these 
people,  who  confess  their  inadequacy,  to  invade  our 
field  and  try  to  prevent  us  from  impai^ting  the 
knowledge  of  medical  science  to  all  men  and  women 
who  care  to  learn.  We  cannot  permit  these  incom- 
petent puritans  to  fill  our  hospitals  and  allow  twelve 
per  cent,  of  our  population  to  suffer  from  syphilis 
and  a  large  number  from  gonorrhea  when  we  have 
nieans  at  our  disposal  to  prevent  infection  of  the 
majority.  We  use  the  Crede  method  to  protect  the 
eyes  of  the  newborn  infant.  W^hy  not  a  similar 
method  for  the  prevention  of  venereal  disease? 

All  this  talk  of  venereal  prophylaxis  lowering 
morals  and  increasing  contact  is  childish.  With  the 
general  introduction  of  prophylaxis  education  will 
follow  and  the  real  danger  of  infection  will  be 
shown.  At  present  it  is  a  vague,  half  formed  idea. 
The  necessity  for  venereal  prophylaxis  will  be  a 
constant  warning  and  serve  to  decrease  contact 
among  all  groups  rather  than  to  increase  it  among 
the  chaste  wdio  are  chaste  through  fear  of  syphilis. 
If  men  are  chaste  through  fear  of  syphilis  alone  and 
have  no  other  moral  factor  in  their  makeup,  there 
can  be  little  real  worth  in  them.  If  there  are  other 
factors,  then  the  protection  from  venereal  infection 
will  not  change  their  attitude. 

Venereal  prophylaxis  will  not  solve  the  venereal 
problem.  Many  other  factors  are  to  be  considered. 
Prophylactic  stations  will  not  solve  the  problem,  nor 
will  education  alone.  But  all  of  these  weapons 
.should  be  used  just  as  is  being  done  at  present  in 
the  State  of  Pennsylvania.  If  the  uplifters  lose 
ground  through  the  education  of  men  and  women, 
let  them  redouble  their  efiforts  in  other  directions 
and  perhaps  they,  too,  will  come  nearer  the  truth 
in  their  quest  for  morals. 


996 


EDITORIAL  ARTICLES. 


[New  Vork 
Medical  Journal. 


PHYSICIAN  AUTHORS:    JOHANN  C.  F. 
VON  SCHILLER. 

German  militarism,  now  happily  a  thing  of  the 
past,  had  no  more  bitter  opponent  than  Johann 
Christoph  Friedrich  von  Schiller,  an  obscure  army 
surgeon  who  became  the  Fatherland's  beloved  "Poet 
of  Liberty."  Schiller  knew  military  bondage  at  its 
worst,  and  hated  it  with  all  his  heart.  This  hatred 
generated  a  love  of  liberty  which  dominated  his 
whole  life.  The  passion  for  freedom,  the  instinct 
of  revolt,  was  ever  present  in  his  writings.  From 
the  very  beginning,  when  as  a  school  boy  he  began 
writing  lyrics,  his  work  breathed  defiance  against 
the  feudalism  of  the  period,  and  this  defiance  never 
subsided.  Instead,  his  zeal  for  correcting  abuses 
grew  with  the  years  so  that  by  the  time  he  wrote 
William  Tell,  his  last  completed  work,  liberty  had 
become  to  him  a  mania,  a  religion.  Schiller  was 
perhaps  the  earliest  spiritual  predecessor  of  the 
Revolution  of  1918.  The  seeds  of  discontent  which 
he  planted  against  military  despotism  were  a  long 
time  in  bearing  fruit,  and  the  revolution  came  about 
with  such  a  tragic  mixture  of  circumstances  that 
sometimes  one  is  likely  to  overlook  the  fact  that 
any  pioneering  whatever  was  done.  Schiller's  in- 
fluence was  indirect,  but  those  who  have  read  him 
and  his  successors  know  that  the  end  of  Hohen- 
zollernism  was  not  wholly  a  thunderbolt  out  of 
the  blue  sky,  much  as  it  seemed  to  be  at  the  time. 

-Schiller  was  born  on  November  10,  1759,  the- 
son  of  an  army  surgeon,  and  early  evinced  a  liking 
for  the  study  of  medicine.  But  whatever  liking  he 
had  for  the  profession  was  driven  out  of  him  by 
the  distasteful  conditions  under  which  he  had  to 
study  and  practise,  and  he  quit  at  the  earliest  oppor- 
tunity. To  put  it  bluntly,  he  deserted,  That  was 
his  only  way  out.  At  fifteen  he  had  been  con- 
scripted into  a  school  established  by  Duke  Karl 
Eugen  of  Wurtemburg.  This  school  was  operated 
along  the  severest  military  lines,  and  that  it  should 
grate  on  young  Schiller's  sensibilities  was  inevitable. 
In  1780  he  qualified  as  a  surgeon,  but  instead  of 
being  allowed  to  choose  his  own  field  of  practice, 
he  was  forced  to  become  physician  to  a  regiment 
stationed  at  Stuttgart,  at  eighteen  florins  a  month — 
about  seven  dollars.  Even  under  these  unsatisfac- 
tory conditions  .Schiller  might  have  continued  his 
medical  work  in  the  army  had  it  not  been  for  the 
fact  that  the  iron  handed  duke  attempted  to  repress 
the  literary  activities  with  which  the  young  surgeon 
sought  to  beguile  the  hours  of  his  leisure.  Schiller 
had  slipped  away  from  the  army  post  on  two  occa- 
sions to  attend  performances  of  his  first  drama. 
The  Robbers,  at  the  court  theatre  in  Mannheim. 
On  the  first  occasion  his  unauthorized  leave  was 


not  discovered,  but  on  the  second  he  was  out  of  luck. 
The  duke  not  only  imprisoned  him  for  two  weeks 
but  also  forbade  him  to  write  any  more  dramas. 
After  serving  his  sentence  Schiller  fled  to  Bauer- 
bach,  in  Thuringia,  and  not  only  his  military  career 
but  also  his  medical  career  came  to  an  abrupt  end. 
Tlic  Robbers  was  written  while  Schiller  was  still 
at  the  military  academy.  Finished  when  he  was 
nineteen,  it  has  been  called  "probably  the  greatest 
triumph  ever  achieved  in  the  entire  field  of  litera- 
ture by  one  so  young."  It  has  its  faults,  to  be 
sure,  but  for  a  school  boy  of  nineteen  it  is  truly 
remarkable.  The  drama  has  been  described  as  a 
declaration  of  war  against  the  feudalistic  society 
of  the  period,  denouncing  with  burning  zeal  the 
social  and  political  crimes  of  the  day. 

Schiller  is  best  known  as  a  poet.  His  lyrics  have 
had  an  immense  popularity  in  Germany.  He  also 
turned  out  much  ballad  poetry  of  bold  and  simple 
outline.  There  was  a  more  or  less  steady  flow 
of  this  poetry  from  his  pen  throughout  his  career, 
despite  his  ambitious  activities  in  the  fields  of  the 
drama,  history,  and  philosophy.  Germany  has  pro- 
duced no  poet  more  beloved  by  his  c-ountrymen. 
Although  Goethe  excelled  him  in  nearly  every  field 
and  Heine  outstripped  him  in  lyric  perfection,  it 
was  Schiller  whom  the  German  people  took  to 
their  hearts.  He  is  a  giant  figure  in  Gennan  litera- 
ture, but  in  world  literature  his  rank  is  somewhat 
subordinate.  Somehow  his  genius  fails  to  enthuse 
those  not  of  Germanic  temperament  and  back- 
ground. Even  in  Germany,  where  his  star  blazed 
supreme  for  more  than  a  century,  there  is  said  to 
be  less  enthusiasm  for  him.  He  is  slowly  going  out 
of  fashion.  But  his  decHne  is  likely  to  be  very 
slow.  He  is  still  a  textbook  for  German  youth  and 
his  words  are  still  in  the  mouths  of  men. 

Of  Schiller's  dramas,  William  Tell  has  produced 
the  deepest  and  most  enduring  impression.  His 
dramas  are  full  of  grave  eloquence,  and  considerable 
coarseness,  but  critics  have  pointed  out  that  no  verv 
exalted  moments  mark  his  work.  His  best  mood 
was  one  of  dignified  melancholy.  In  the  first  period 
of  his  literary  career  he  wrote  three  prose  tragedies, 
followed  by  a  blank  verse  tragedy,  Don  Carlos. 
During  the  following  years  he  studied  and  wrote 
history  and  philosophy.  His  histories  include  The 
History  of  the  Revolt  in  The  Netherlands  and 
History  of  the  Thirty  Years'  War,  both  written 
with  splendid  dignity  and  both  immensely  popular. 
He  also  wrote  a  volume  of  Historical  Memoirs. 
His  philosophical  writings  were  largely  an  elucida- 
tion and  widening  of  Kant's  theories.  Kant's 
Critique  and  Schiller's  The  Robbers  appeared  in 
the  .same  year,  1781. 


December  18,  1920.] 


EDITORIAL  ARTICLES. 


997 


Goethe  and  Kant  both  had  an  immense  influence 
on  Schiller's  work.  Goethe's  influence  was  direct. 
The  two  were  inseparable  friends  during  Schiller's 
later  years.  It  was  under  Goethe's  stimulus  that 
Schiller  won  fresh  laurels  in  poetry  at  the  time  the 
two  were  coeditors  of  Die  Horen  and  Thalia.  In 
the  last  six  years  of  his  brief  span  of  life  Schiller 
produced  five  verse  tragedies  and  part  of  a  sixth. 
All  are  dominated  by  the  idea  of  Nemesis.  Schil- 
ler's admiration  for  Greek  tragedy  in  his  last  few 
years  left  him  always  in  search  of  subjects  in  which 
the  Greek  idea  of  destiny  prevailed:  Wallcnstein 
was  the  most  ambitious  of  the  list,  William  Tell  the 
most  popular.  The  other  three  also  are  on  his- 
torical subjects — Marie  Stuart,  based  on  the  life  of 
Mary,  Queen  of  Scots ;  TJie  Maid  of  Orleans,  and 
The  Bride  of  Messina.  He  also  translated  and 
adapted  Macbeth  and  Gozzi's  Turnadot,  Racine's 
Phcdre,  and  two  comedies  by  Picard.  In  the  last 
two  months  of  his  life  he  began  a  new  tragedy, 
Demetrius,  based  on  Russian  history,  which  remains 
a  fragment  in  two  acts.  Schiller  died  in  1805  at 
the  age  of  forty-five.  Personally  he  was  one  of 
the  most  lovable  of  men.  As  his  great  admirer, 
Thomas  Carlyle,  pointed  out,  he  "had  all  the  good 
qualities  of  the  German  character  in  a  high  degree 
and  few  of  its  defects." 


POET  AND  PHILOSOPHER. 
Poet  philosopher,  Henri  Bergson  has  been  called, 
sometimes  with  profound  appreciation,  sometimes 
with  disparagement.  Is  he  a  poet,  is  he  a  phil- 
osopher, and  in  either  capacity  does  he  eflfect  any 
benefit  to  humanity?  All  men  are  full  charged  with 
poetry,  according  to  his  doctrines,  for  all  are  in- 
separably one  with  the  stream  of  living,  compact 
with  all  that  has  been,  and  charged  with  the  possi- 
bilities of  what  may  be.  But  even  in  the  form  of 
life  at  the  head  of  the  stream,  the  human,  this  full- 
ness is  dumb.  It  manifests  itself  only  imperfectly, 
restrained,  yet  always  bursting  the  bonds  of  static 
definition  or  of  the  materialism  which  it  has  set 
itself. 

Amid  this  multitude  of  restrained  and  unwitting 
poets  there  arises  occasionally  the  rarer  poet  of 
expression.  He  sets  forth  in  winged  words  the 
truth  of  these  created  limitations  which  are  ordi- 
narily recognized  as  the  sum  of  life.  Much  more 
he  proclaims  the  compressed  power  which  creates 
these,  only  again  to  outflow  them.  This  is  pregnant 
poetry.  It  is  a  philosophy  of  life  which  men  crave, 
even  if  they  know  it  not.  Many  philosophers  have 
so  befuddled  their  task  of  discovering  the  meanings 
in  life  that  for  such  an  one  as  Bergson  it  is  fitting 


to  seek  a  new  term.  Philosopher,  lover  of  wisdom, 
should  become  lover  of  life.  His  love  of  life  is 
simple  enough,  genuine  enough,  to  search  for  its 
meanings  exactly  where  they  are  displayed,  just 
within  our  vital  activities.  The  term  humanist 
ought  to  cover  the  depth  of  his  insight  and  the 
elasticity  of  his  vision  backward  into  the  depths  of 
Mind  Energy,  or  onward  into  its  unceasing  creative 
activity.  Therefore  we  may  borrow  this  term  from 
the  "humanist"  thinkers.  Biergson  reveals  kinship 
with  those  philosophers  who  come  down  to  examine 
the  every  day  matters  of  the  human  mind,  a  com- 
mon kinship  with  each  separate  human  existence. 
This  appears  both  in  the  translator's  introduction  to 
a  recently  appearing  handbook  of  some  of  Bergson's 
investigations  into  mental  facts,  as  well  as  in  the 
actual  text  throughout  the  book.  [^Mind  Energy. 
By  Henri  Bergson.  New  York :  Henry  Holt  and 
Company,  1920.] 

Bergson  sets  forth  there  in  such  forceful  manner 
so  many  much  disputed  or  even  ordinarily  undis- 
covered mental  facts  that  it  may  be  profitable  to 
analyze  into  the  duller  but  more  familiar  language 
of  every  day  some  of  his  more  compact  expressions. 
A  few  of  them  brought  before  the  reader  now  and 
then  may  recall  him  to  the  dynamic  intensity 
whereby  alone  man  "inserts  his  free  action  into  this 
material  world."  Often  for  physician,  commonly 
for  patient,  life  has  lost  its  savoriness  or  the  flames 
of  enthusiasm  have  died  down  under  the  ashes  of 
depression.  Image  it  as  we  will,  the  poet  phil- 
osopher restores  the  flavor,  revives  desire.  He 
directs  telling  words  into  the  heart  of  facts.  Knowl- 
edge of  them  is  power,  his  spirit  of  comprehension 
of  them  enkindles  determination.  It  is  a  privilege 
of  the  present  day  to  examine  the  words  and  enter 
into  the  inspiration  of  this  writer. 


PROPER  MEDICAL  ATTENTION. 
It  is  gratifying  in  these  days  of  sullen  reproach 
by  labor  against  employers,  to  learn  that  one 
injured  seaman,  an  illiterate  Porto  Rican,  was  able 
to  obtain  compensation  which  satisfied  even  his 
union.  The  law  is  that  a  ship  carrying  above  fifty 
passengers  beyond  cabin  passengers  must  provide 
a  doctor.  In  this  case  there  were  not  fifty.  The 
man  scratched  his  hand  on  a  rusty  nail  and  the 
steward  gave  him  a  bichloride  tablet  to  dissolve  for 
bathing,  and  some  iodine  to  paint  the  wound.  How- 
ever, it  grew  worse,  and  he  had  to  have  the  hand 
amputated  on  arrival  in  New  York.  The  conten- 
tion was  that  there  was  time  before  the  ship  left 
the  Antilles  to  see  a  doctor,  and  the  steward  ought 
to  have  recognized  the  necessity.  The  man  was 
awarded  ten  thousand  dollars,  though  the  doctor 
called  said  the  steward  had  erred  through  ignorance 
of  the  danger. 


998 


XEIVS  ITEMS. 


[New  York 
Medical  Journal. 


News  Items. 


Deaths  from  Automobile  Accidents.- — During 
the  year  1919  there  were  7,969  deaths  from  auto- 
mobile accidents  in  the  Census  Bureau's  registration 
area,  which  comprises  about  eighty  per  cent,  of 
the  countr}-'s  population.  This  is  an  increase  of 
444  over  the  total  for  1918. 

A  Union  Health  Centre. — A  health  centre  has 
l)eeu  established  at  131  East  Seventeenth  Street, 
Xew  York,  by  the  International  Ladies'  Garment 
\\'orkers'  Union,  to  guard  and  promote  the  health 
of  the  workers  in  the  garment  industry.  This  insti- 
tution, the  first  health  centre  to  be  established  on 
an  industrial  basis,  will  serve  the  100,000  workers 
of  the  union.  The  formal  opening  will  take  place 
Saturday  evening,  December  18th,  at  7 :30  o'clock, 
and  among  the  speakers  will  be  Dr.  Royal  S.  Cope- 
land.  Dr.  George  M.  Price  is  director  of  the 
institute. 

Walter  Reed  Hospital  Damaged  by  Fire. — Two 

of  the  psychopathic  wards  of  the  Walter  Reed 
^Military  Hospital  were  destroyed  by  fire  on  Sunday, 
December  12th.  The  two  wards,  in  one  of  which 
the  violently  insane  were  confined  and  in  the  other 
psychopathic  patients  received  treatment,  contained 
about  seventy-five  patients.  The  fire  threatened  to 
spread  to  other  wards,  including  several  in  which 
disabled  war  veterans  were  patients,  but  it  was 
checked.  One  patient,  a  soldier,  is  missing,  and  it 
is  believed  that  he  was  burned  to  death.  Several 
were  injured,  but  none  seriously.  The  loss  is 
estimated  at  825,000. 

Medical  Association  of  the  Greater  City  of 
New  York. — A  stated  meeting  of  the  association  - 
will  be  held  in  Dubois  Hall,  Xew  York  Academy 
of  Medicine.  Monday,  December  20th,  vmder  the 
presidency  of  Dr.  George  L.  Brodhead.  The  pro- 
gram will  include  the  following  papers :  Use  of 
Radium  in  Gynecology,  by  Dr.  Howard  C.  Taylor : 
Use  of  Radium  in  Surgery,  by  Dr.  W.  S.  Schley ; 
Use  of  Radium  in  Genitourinary  Diseases,  by  Dr. 
B.  S.  Barringer.  Among  those  who  will  take  part 
in  the  discussion  are  Dr.  Robert  Abbe,  Dr.  James 
Ewing,  Dr.  William  S.  Stone,  Dr.  D.  C.  IMoriarta, 
Dr.  C.  E.  Field,  Dr.  James  A.  Corscaden.  Dr.  George 
Willis,  Dr.  Oswald  S.  Lowsley,  Dr.  E.  L.  Keyes, 
Jr.,  and  Dr.  Winfield  Ayres. 

Dietitians  Wanted  by  the  Public  Health  Serv- 
ice.— The  United  .States  Public  Health  Service 
announces  that  dietitians  are  needed  in  the  hospitals 
of  the  service.  Women  graduates  of  schools  of 
household  economics,  who  have  had  student  train- 
ing or  hospital  experience  in  civilian  or  Army  hos- 
pitals, are  eligible  for  appointment.  The  work, 
which  has  to  do  with  the  victualing  of  the  hospitals, 
was  transferred  a  year  ago  from  the  phannacists 
to  a  newly  established  dietitian  service.  The  sec- 
tion has  steadily  expanded,  but  owing  to  the  open- 
ing of  many  new  hospitals  and  the  enlargement  of 
those  already  in  operation  the  dietetic  per.sonnel  is 
as  yet  not  nearly  up  to  the  requirements.  Applica- 
tions for  appointment  should  be  made  to  the  Sur- 
geon General,  United  States  Public  Health  Service, 
Washington,  D.  C. 


Bequests  to  Hospitals. —  By  the  will  of  the  late 
Commodore  Elias  C.  Benedict,  the  Flower  Hospital 
and  the  Ophthalmic  Hospital,  of  Xew  York,  will 
each  receive  $150,000. 

By  the  will  of  the  late  Francis  Lynde  Stetson, 
St.  Luke's  Hospital  and  the  Lying-in  Hospital, 
X"ew  York,  will  each  receive  S25,000. 

Psychopathic  Hospitals  for  Soldiers. — Senator 
Wadsworth,  of  Xew  York,  has  introduced  a  reso- 
lution authorizing  the  Secretary  of  the  Treasury  to 
lease  from  Xew  York  State  a  83,000,000  hospital 
for  the  care  of  nervous  and  mental  disease  cases 
among  disabled  soldiers,  which  would  be  built  in 
Xew  York  city.  The  resolution  also  would  give 
the  Treasury  Department  authority  to  lease  any 
other  hospitals  built  for  like  purposes  by  other 
States. 

.Life  History  of  Mosquito  Shown  in  Moving 
Pictures. — A  new  motion  picture  film,  prepared 
at  the  request  of  the  United  States  Public  Health 
Service,  presents  the  life  history  of  the  mosquito, 
especially  of  the  kind  that  transmits  malaria  germs 
and  costs  the  United  States  people  about  8200,000 
a  year  by  so  doing.  The  film  was  exhibited  for 
the  first  time  at  the  meeting  of  the  Southern 
Medical  Association  held  recently  in  Louisville, 
Kentucky. 

Women  Ask  for  $4,000,000  Appropriation  to 
Reduce  Infant  Mortality.— The  women  of  the 
United  States  have  asked  Congress  to  appropriate 
$4,000,000  to  carry  on  a  campaign  of  education 
among  young  mothers.  They  call  attention  to  the 
fact  that  last  year  there  were  250,000  deaths  of 
infants  in  America,  or  about  20.000  a  month,  and 
most  of  these  deaths  could  have  been  averted  by 
proper  attention.  In  1918,  23,000  mothers  died 
from  preventable  causes.  Fully  eighty  per  cent, 
of  the  cases  investigated  showed  that  lack  of  care 
was  the  principal  cause  of  death.  The  Sheppard- 
Towner  Bill  which  will  be  presented  to  Congress 
soon  provides  for  an  appropriation  of  $2,000,000  at 
first,  with  an  annual  increase  until  the  sum  equals 
$4,000,000.  The  various  states  will  be  asked  to 
cooperate  by  appropriating  dollar  for  dollar  with 
the  federal  government. 

Inadequate  Hospital  Accommodation  for  Ex- 
Service  Men. — Surgeon  General  Hugh  S.  Cum- 
ming,  of  the  United  States  Public  Health  -Service, 
calls  attention  to  the  fact  that  additional  hospital 
facilities  are  needed  for  the  treatment  of  former 
service  men  and  women,  and  recommends  the  ap- 
pointment of  an  administrative  head  for  the  three 
major  agencies  involved  in  rehabilitation  work. 
Emphasizing  the  need  for  additional  hospital  facili- 
ties, Dr.  Gumming  pointed  out  that  twenty  thousand 
patients  were  receiving  hospital  care  from  the  Pub- 
lic Health  Service  on  July  1,  1920.  compared  with 
two  thousand  in  October,  1919,  and  urged  that  Con- 
gress make  available  funds  for  new  construction. 
]\Iany  of  the  hospitals  now  owned  and  operated  by 
the  Public  Health  Service  are  dilapidated.  These 
patients  will  require  treatment  for  long  periods  of 
time,  and  their  demand  is  for  care  and  treatment  in 
govenimental  institutions. 


December  18,  1920.] 


XEWS  ITEMS. 


999 


Police  Association  Oppose  Hospital  Project. — 

The  Patrolmen's  Benevolent  Association,  which  has 
a  membership  of  nearly  10.000  of  the  rank  and  hie 
of  the  uniformed  force,  has  gone  on  record  as  being 
opposed  to  the  proposed  .55,000.000  Police  Hospital. 
Opposition  to  the  hospital  is  based  on  six  points, 
among  which  were  that  the  patrolmen  did  not  wish 
to  be  regarded  as  objects  of  charity,  and  that  there 
was  no  need  for  such  a  hospital. 

Child  Labor  Increasing. — The  National  Child 
Labor  Committee  calls  attention  to  the  fact  that  in 
spite  of  increasing  adult  unemployment  more  chil- 
dren left  school  to  go  to  work  in  1920  in  many  in- 
dustrial centres  than  in  1919.  Fourteen  states  re- 
port an  increase  in  child  labor  during  the  first  six 
or  eight  months  of  1920.  In  Xew  York  city  5,283 
more  children  applied  for  work  permits  in  the  first 
six  months  of  1920  than  in  the  same  period  last 
year,  but  in  the  last  three  months  there  has  been  a 
decrease  in  applications  so  that  the  total  increase  is 
only  2.353.  In  Baltimore  County.  Md.,  there  were 
4,064  more  appUcations  for  work  permits  up  to 
October  31,  1920,  than  in  1919,  while  during  the 
summer  the  Chicago  authorities  reported  an  in- 
crease of  13,000.  and  in  Minnesota  there  was  an 
increase  of  193  per  cent,  since  1915. 

Yellow  Fever  Control. — A  new  factor  has  been 
introduced  in  yellow  fever  control  by  the  possibility 
of  rendering  persons  immune  to  the  disease  by 
vaccination.  People  going  to  tropical  countries  are 
now  being  vaccinated  at  the  Broad  Street  Hospital, 
the  vaccine  being  furnished  by  the  Rockefeller 
Institute.  This  vaccine  for  yellow  fever  was  dis- 
covered by  Dr.  Hideyo  Xoguchi,  of  the  Rockefeller 
Institute.  The  first  shipment  of  vaccine  from 
the  Rockefeller  Institute  to  tropical  countries  was 
made  a  year  ago,  when  three  hundred  bottles  were 
sent  to  Mexico.  Other  shipments  have  been  made 
since  then,  the  latest  on  November  10th.  AU  vac- 
cine supplied  to  Mexico  is  sent  to  the  ^Mexican 
Department  of  Health,  which  arranges  for  its  dis- 
tribution. The  Central  American  countries  are  so 
well  con\-inced  of  the  efficacy  of  Dr.  Xoguchi's 
vaccine  that  they  are  permitting  travel  without 
quarantine  detention  of  those  who  have  been  success- 
fully vaccinated. 

Boston  Meeting  of  the  A.  M.  A. — The  local 
Committee  on  Arrangements  for  the  annual  meet- 
ing of  the  American  Medical  Association,  to  be 
held  in  Boston,  June  6  to  10,  1921,  has  been 
organized  as  follows :  Chairman,  Dr.  F.  B.  Lund ; 
secretary,  Dr.  Richard  H.  ^Miller.  Subcommittee  on 
finance:  chairman.  Dr.  Hugh  Williams;  secretary, 
Dr.  Channing  Frothingham ;  treasurer.  Dr.  A.  Wil- 
liam Reggio.  Subcommittee  on  sections :  chairman. 
Dr.  William  H.  Robey.  Jr. ;  secretary,  Dr.  H. 
Archibald  Xissen.  Subcommittee  on  exhibits  and 
printing:  chairman.  Dr.  D.  F.  Jones;  secretary, 
Dr.  George  Gilbert  Smith.  Stibcommittee  on  hotels : 
chairman.  Dr.  John  T.  Bottomley;  secretary.  Dr. 
Stephen  Rushmore.  Subcommittee  on  entertain- 
ments :  chairman.  Dr.  C.  A.  Porter ;  secretary.  Dr. 
A.  W.  Allen.  Subcommittee  on  registration :  chair- 
man. Dr.  A.  S.  Begg:  secretary.  Dr.  Samuel  R. 
Meaker.  Subcommittee  on  clinics :  chainnan,  Dr. 
J.  C.  Hubbard;  secretary.  Dr.  R.  S.  Eustis. 


Meetings  of  Local  Medical  Societies. — The  fol- 
lowing medical  societies  will  meet  in  Xew  York 
during  the  coming  week : 

Monday,  December  20th. — Xew  York  Academy  of  Medi- 
cine (Section  in  Ophthalmology' )  :  Medical  Association  of 
the  Greater  City  of  Xew  York :  Psj  chiatric  Society  of 
Ward's  Island ;  Yorla  ille  Medical  Society-. 

Tuesday,  December  21st. — Xew  York  Academy  of  Medi- 
cine (Section  in  Medicine)  :  Federation  of  Medical  Eco- 
nomic Leagues. 

^VED^"ESD.\Y,  December  22nd. — X'ew  York  Academy  of 
Medicine  (Section  in  Lar>-ngolog>-  and  Rhinology )  ;  Xew 
York  Society'  of  Internal  Medicine ;  Brooklyn  Pediatric 
Society. 

Thursday,  December  2^rd. — X'ew  York  Physicians'  As- 
sociation ;  Ex-Intern  Society  of  Methodist  Episcopal  Hos- 
pital, Brooklyn;  Hospital  Graduates'  Club.  Xew  York. 

Friday,  December  24th.-. — Academy  of  Pathological 
Sciences :  Audubon  Medical  Society ;  Xew  York  Clinical 
Society:  Brooklyn  Society  of  Internal  Medicine  (annual). 

Personal. — Professor  C.  E.  A.  Winslow,  of 
Yale  University,  will  direct  the  public  health  work 
of  the  League  of  Red  Cross  Societies  in  Europe, 
and  has  been  granted  leave  of  absence  for  five 
months,  beginning  February  1,  1921. 

Dr.  A.  Strachstein  has  been  appointed  chief  of 
clinic  and  cystoscopist  to  the  Bronx  Hospital. 

Dr.  George  L.  Laporte  has  resigned  as  assistant 
professor  of  clinical  medicine  at  the  College  of 
Physicians  and  Surgeons,  Columbia  University. 
His  resignation  took  effect  on  December  1st. 

Surgeon  J.  W.  Kerr,  of  the  United  States  Public 
Health  Service,  sailed  for  Europe  on  Xovember  20th, 
with  Commissioner  (j^eral  of  Immigration  Cami- 
netti,  to  assist  in  the  investigation  of  emigrant 
conditions  in  Europe. 

Dr.  Arthur  S.  Tenner  announces  his  return  from 
the  Xear  East  and  will  resume  practice  at  70  East 
Fifty-sixth  Street,  Xew  York.  Dr.  Tenner,  for- 
merly a  captain  in  the  ^Medical  Corps,  L'.  S.  Army, 
served  in  Turkey  and  Syria  as  chief  eye  surgeon 
of  the  Xear  East  ReUef  Expedition,  residing  in 
Aleppo,  Syria,  for  the  past  year  and  a  half. 

French  Physician  Acquitted. — A  noncommittal 
verdict  has  been  rendered  by  the  judges  at  Ximes, 
France,  in  the  case  in  v.iiich  the  parents  of  two 
girls  brought  stiit  against  Dr.  ]Mazel  for  damages 
for  the  death  of  the  girls  while  under  his  medical 
care.  The  case  against  the  doctor  was  that  he 
employed  an  unskilled  nttrse,  who,  by  not  paying 
proper  attention  to  the  cleanliness  of  surgical  instru- 
ments, aggravated  the  illness  of  the  girls,  and  that 
the  doctor  did  not  follow  the  prescribed  treatment. 
The  father  of  the  girls,  Commandant  Arnattd,  sued 
for  200,0(X)  francs,  and  at  the  same  time  the  charge 
of  criminal  homicide  was  brought  against  the  doctor 
by  the  public  atithorities. 

The  court,  after  long  deliberation,  brought  in 
a  verdict  acquitting  the  doctor,  refusing  damages 
to  Commandant  Arnaud,  and  at  the  same  time 
refusing  the  counterclaim  for  one  franc  damages 
brought  by  the  doctor.  Commandant  Arnaud  mil 
have  to  pay  the  costs.  In  the  verdict  the  judges 
state  that  they  found  that  the  nurse  employed  did 
not  take  proper  precautions,  and  that  the  doctor 
ought  to  have  supervised  her  work  more  closely. 
The  death  of  the  patients,  they  found,  did  not, 
however,  result  from  neglect,  and  it  was  on  that 
that  they  based  their  judgment. 


Book  Reviews 


NEW  BOOKS  ON  PEDIATRICS. 

Diseases  of  Cliildren.  Prtsented  in  Two  Hundred  Case 
Histories  of  Actual  Patients  Selected  to  Illustrate  the 
Diagnosis,  Prognosis,  and  Treatment  of  the  Diseases  of 
Infancy  and  Childhood.  With  an  Introductory  Section 
on  the  Normal  Development  and  Physical  Examination 
of  Infants  and  Children.  By  John  Lovett  Morse,  A.  M., 
M.  D.,  Professor  of  Pediatrics,  Harvard  Jvledical  School; 
\'isiting  Physician  to  the  Children's  Hospital,  and  Con- 
sulting Physician  to  the  Infants'  Hospital  and  at  the 
Floating  Hospital,  Boston.  Third  Edition.  Illustrated. 
Boston:  W.  M.. Leonard,  1920.    Pp.  v-639. 

Diseases  of  Nutrition  and  Infant  Feeding.  By  John 
LovETT  Morse,  A.  M.,  M.  D.,  Professor  of  Pediatrics, 
Harvard  Medical  School ;  Visiting  Physician  to  the  Chil- 
dren's Hospital;  Consulting  Physician  to  the  Infants' 
Hospital  and  the  Floating  Hospital,  Boston ;  and  Fritz 
B.  Talbot,  A.  B.,  M.  D.,  Chief  of  Children's  Medical  De- 
partment, Massachusetts  General  Hospital ;  Physician  to 
Children,  Charitable  Eye  and  Ear  Infirmary;  Consult- 
ing Physician  at  the  Lying  In  Hospital,  and  at  the 
Floating  Hospital,  Boston.  Second  Edition,  Revised. 
New  York:  The  Macmillan  Company,  1920.    Pp.  ix-384. 

Manual  of  Diseases  of  Children.  By  J.ames  Burnet, 
M.  A.,  M.  D.,  M.  R.  C.  P.,  Physician  for  Diseases  of  In- 
fancy and  Childhood  at  the  Marshall  Street  Dispensary, 
Edinburgh.  Second  Edition.  Illustrated.  New  York : 
William  Wood  &  Co.,  1919.    Pp.  i-416. 

Principles  and  Practice  of  Infant  Feeding.  By  Julius  H. 
Hess,  M.  D.,  Professor  and  Head  of  the  Department  of 
Pediatrics,  University  of  Illinois  College  of  Medicine. 
Illustrated.  Second  Revised  Edition.  Philadelphia :  F. 
A.  Davis  Company,  1919.    Pp.  i-343. 

Leitfaden  der  Kinderheilkunde  fiir  Studierende  iind 
Arete.  Von  Dr.  Walter  Birk,  Professor  d.  Kinder- 
heilkunde a.  d.  Universitat  Tiibingen.  Erster  Teil ;  Saug- 
lingskrankheiten  Vierte,  verbesserte  Auflage.  Alit  25 
Abbildungen  im  Text.  Bonn :  A.  Marcus  &  E.  Webers 
Verlag  (Dr.  zur.  Albert  Ahn),  1920. 

Leitfaden  der  Kinderheilkunde  fiir  Studierende  und 
Arete.  Von  Dr.  Walter  Birk,  Professor  d.  Kinder- 
heilkunde a.  d.  Universitat  Tubingen.  Zweiter  Teil ;  Kin- 
derkrankheiten  mit  10  Abbildungen  im  Text  und  auf 
einer  Tafel.  Bonn:  A.  Marcus  &  E.  Weber's  Verlag 
(Dr.  zur.  Albert  Ahn),  1920.    Seiten  138. 

Diagnostik  und  Therapie  der  Kinderkrankheiten.  Mit 
speziellen  Arzneiverordnungen  fiir  das  Kindesalter.  Ein 
Taschenbuch  fiir  den  praktischen  Arzt.  Yon  Prof.  Dr. 
F.  Lust,  Oberarzt  der  Universitats-Kinderklinik  in 
Heidelberg.  Zweite  neubearbeitete  Auflage.  Berlin  N- 
Wien  I:  Urban  &  Schwarzenberg,  1920.    Seiten  vi-471. 

Morse,  in  his  textbook  on  Diseases  of  Cliildren, 
has  followed  the  excellent  example  set  by  Southard 
and  (^reen  in  publishing  his  works  in  the  form  of 
ca.'ie  histories.  While  we  have  been  accustomed  to 
seeing  case  histories  quoted  in  papers  and  even  in 
textbooks,  we  have  not  had  them  presented  to  us 
in  the  same  way  before.  In  this  instance  the 
emphasis  is  placed  on  the  case  history.  It  is  an 
individual  example.  It  acquires  individuality  by 
virtue  of  the  variations  it  possesses  and  these  varia- 
tions are  the  puzzling  things  encoimtered  in  medical 
practice  which  make  a  differential  diagnosis  difificult. 
Autopsy  reports  fre(|uently  tell  the  final  story  of 
a  wrong  diagnosis.  We  are  too  prone  to  seize  on" 
a  symptom  or  syndrome  in  a  certain  case  and  con- 
clude our  diagnosis,  forgetting  for  the  moment  that 
other  diseases  may  present  a  similar  train  of  symp- 
toms.   From  the  study  of  case  histories,  or,  we 


may  say,  the  study  of  additional  patients,  for  that 
is  all  it  amoimts  to,  we  learn  to  look  upon  each 
patient  as  an  individual  suffering  from  some  mal- 
adjustment to  surrounding  conditions ;  we  realize 
that  a  certain  individual,  even  an  infant,  will  react 
much  the  same  to  many  different  infections  or 
afflictions.  In  this  way  the  patient  becomes  the 
more  important,  the  disease  the  less  important 
problem. 

Morse  takes  us  to  his  clinic  and  presents  two 
hundred  case  histories  of  actual  patients.  His 
object  is  to  illustrate  the  diagnosis,  prognosis,  and 
the  treatment  of  the  diseases  of  infancy  and  child- 
hood. He  also  gives  an  introduction  which  deals 
with  the  normal  development  and  physical  examina- 
tion of  infants  and  children  We  are  told  all  this 
on  the  frontispiece,  but  it  covers  the  ground.  A 
book  of  this  kind  acts  as  a  stimulus  to  the  prac- 
titioner, for  it  brings  to  him  the  familiar  phases  and 
conditions  as  he  encounters  them  at  the  bedside  and 
at  the  clinic.  It  is  far  more  stimulating  than  the 
cut  and  dried  statements  generally  found  in  the 
ordinary  textbook. 

This  is  the  third  edition  of  the  work.  In  it  the 
table  of  growth  for  the  first  four  years  has  ampli- 
fied, a  blood  pressure  table  has  been  added,  there 
is  additional  comment  on  congenital  obliteration  of 
the  bile  ducts,  obstetrical  paralysis  is  discussed  and 
directions  given  for  serum  treatment.  The  entire 
section  on  the  gastroenteric  tract  has  been  rewritten, 
and  case  reports  given  of  indigestion  from  an  excess 
of  breast  milk,  of  artificial  food,  of  fat  in  artificial 
food,  of  sugar,  of  maltose,  and  of  starch.  A  valua- 
-ble  chapter  has  been  added  on  the  home  modification 
of  infant  foods  and  the  determination  of  their 
composition  and  value.  The  directions  for  the 
administration  of  salvarsan  and  mercury  have  been 
extended.  Many  other  parts  have  been  added  to 
and  changed.  There  has  been  no  fear  shown  in 
discarding  methods  proved  to  be  superseded  by 
others  more  advantageous, ,  nor  in  adopting  others 
more  efficacious,  no  matter  from  what  source  they 
came.  More  light  is  shed  on  tetany,  the  treatment 
of  whooping  cough,  nephritis,  food  values,  and 
enuresis.  There  is  a  freedom  in  the  handling  of 
these  subjects  that  is  gratifying.  The  book  falls 
naturally  into  three  divisions,  the  normal  child, 
infant  feeding,  and  the  diseases  of  children.  More 
could  be  said  in  praise  of  the  book,  but  the  prac- 
titioner can  readily  see  the  advantage  of  a  textbook 
which  handles  the  problem  from  the  viewpoint  of 
the  case  history,  and  Professor  Morse  has  the 
faculty  of  giving  a  most  human  touch  to  the  subjects 
he  brings  before  his  readers. 

*    *  * 

Morse  and  Talbot  have  revised  their  textbook  on 
Diseases  of  Nutrition  and  Infant  Feeding.  The 
methods  described  are  those  taught  in  the  Harvard 
Medical  School.  The  various  aspects  of  infant 
feeding  are  described.  The  advantages  and  disad- 
vantages of  changes  from  normal  feeding  are  taken 
up  in  detail  from  the  chemical  and  biological  view- 
points.   The  proteins,   fats,  sugars,  starches  and 


Decsmber  18,  1920.] 


BOOK  REVIEWS. 


1001 


salts  are  taken  up  and  discussed  in  turn.  Breast 
feeding  also  occasions  disorders.  The  subject  of 
the  wet  nurse  is  also  presented.  Then  the  diseases 
of  the  gastrointestinal  tract  are  discussed  in 
detail,  and  the  book  closes  with  a  section  on  the 
diseases  of  nutrition.  A  very  broad  attitude  is  taken 
throughout  the  book  and  extensive  references  are 
given. 

^    *  * 

Burnet's  small  book  on  the  diseases  of  children 
covers  an  extensive  field.  When  pediatrics  first 
became  a  specialty  a  book  of  this  scope  would  have 
been  considered  an  undertaking  of  some  magnitude, 
but  today,  with  the  subdivisions  of  feeding,  ntitri- 
tion,  infections,  and  various  other  disorders,  and 
the  groupings  of  the  newborn,  the  nursing  child, 
it  is  convenient  to  have  a  small  textbook  for  refer- 
ence which  will  cover  the  entire  field  which  has  been 
so  finely  subdivided.  The  divisions  are  necessary 
for  the  scientific  worker,  but  they  serve  little  pur- 
pose for  the  practitioner.  The  first  two  chapters 
on  the  examination  of  sick  children,  which  might 
have  been  made  to  include  all  children,  and  the 
points  of  difference  between  adults  and  children, 
are  of  especial  value.  Usually  the  physician  thinks 
he  knows  how  to  approach  a  child  and  how  to  handle 
it,  but  careful  observation  will  show  that  if  he 
would  give  the  matter  more  thought  and  heed  the 
admonitions  of  men  of  experience,  like  Burnet,  they 
would  make  better  progress.  Burnet  is  sometimes 
very  vague  in  his  treatment,  and  is  especially  prone 
to  make  general  sweeping  statements.  He  assumes 
frequently,  under  this  heading,  that  the  physician 
knows  what  to  do,  even  to  the  point  of  com- 
pletely ignoring  his  generalized  instructions  when 
they  are  not  found  satisfactory.  In  the  chapter 
on  mental  and  nervous  disease,  many  statements 
are  made  in  regard  to  diagnosis,  and  more  espe- 
cially in  regard  to  treatment  and  prognosis,  to  which 
the  modern  neurologist  will  take  exception.  There 
is  too  much  generalization  and  apparently  in  this 
field  the  author  is  not  as  much  at  home  as  in  some 
of  the  other  sections  of  the  book.  Burnet  makes 
a  needless  apology  for  the  inclusion  of  the  diseases 
of  the  ear,  nose  and  throat.  This  section  is  a  most 
necessary  one,  for  frequently  diseases  which  would 
eventually  become  systemic  can  be  detected  by  a 
careful  observation  of  these  special  organs.  Again, 
much  information  of  value  will  come  from  a  care- 
ful examination  of  these  anatomical  parts  in  every 
case. 

^  ^ 

Hess  presents  no  new  or  startling  ideas  in  his 
book  on  the  Practice  of  Infant  Feeding.  In  fact, 
most  of  the  ideas  set  forth  are  a  resume  of  the  work 
of  other  writers.  However,  he  has  endeavored  to 
pick  out  the  best  methods,  the  most  simple  and  the 
most  satisfactory,  and  give  them  to  the  reader  in 
a  simple  fashion  so  as  not  to  complicate  matters 
too  much.  The  computation  of  feedings  and  feed- 
ing time  for  the  general  practitioner  has  always  been 
somewhat  of  a  puzzle  and  frequently  a  bore.  It  is 
hard  for  a  busy  physician  to  realize  the  difference 
in  the  dietary  between  his  own  and  a  very  young 
infant.    It  is  hard   for  him  to  realize  that  the 


amount  of  care  and  mathematical  calculation  re- 
quired to  make  a  correct  feeding  scale  for  each 
infant  was  at  one  time  necessar\-  for  him.  This 
book  will  serve  as  an  eflScient  reminder  and  will 
also  enable  him  to  establish  a  correct  diet  for  the 
most  difficult  feeding  case  in  a  minimum  amount 
of  time. 

*    *  * 

New  editions  of  Birk  on  the  diseases  of  the  nurs- 
ing child  have  been  rather  prolific.  Less  than  a  year 
elapsed  between  the  third  and  fourth  editions.  Due 
to  the  adverse  living  conditions  in  the  central 
European  countries,  on  account  of  the  war,  many 
new  problems  have  confronted  the  pediatrists.  Birk 
is  very  thorough  in  the  field  he  covers.  In  his 
analysis  of  feeding  conditions  he  presents  some 
graphic  formulas  which  are  extremely  simple.  When 
he  speaks  of  the  chemistry  of  food  he  is  somewhat 
didactic.  He  goes  intoi  a  careful  examination  of 
the  comparative  values  of  cow's  milk  and  breast 
milk. 

First  we  have  the  pathology  and  physiology 
of  the  stillborn,  the  premature  child  and  the  socalled 
normal  child.  Then  come  the  nursing  problems 
and  hygiene,  the  disorders  of  alimentation,  and 
finally  the  various  diseases  and  disorders.  The 
book  is  of  especial  value  to  the  pediatrists  in  this 
country,  for  it  contains  a  vast  amount  of  wcirk 
which  was  done  in  the  Germanic  countries  during 
the  war  and  which  has  been  inaccessible  to  the 
physicians  in  this  country. 

^       :jc  ^ 

Birk's  second  book  on  the  diseases  of  children 
older  than  the  nursing  age  is  a  first  edition  and 
should  not  be  confused  with  his  book  for  nursing 
children.  Here  he  handles  in  a  very  satisfactory 
fashion  the  common  infections.  He  places  more 
emphasis  on  the  treatment  and  diagnosis.  He  does 
not  pretend  to  cover  the  entire  field,  but  the  subjects 
he  covers  are  well  done  His  writing  is  not  in- 
volved and  has  a  certain  amount  of  wholesome 
vigor  that  takes  away  from  the  ordinary  textbook 
monotony.  On  the  whole,  his  presentations  are 
good.  The  second  book  of  the  series  is  not  as 
finished  as  the  book  on  suckling  infants,  but  con- 
tains many  illuminating  deductions. 

V  ^ 

Lust  is  rather  ambitious  in  attempting  to  cover 
a  rather  extensive  territory  in  his  book  on  children's 
diseases,  or,  more  accurately,  the  therapy  of  pedi- 
atrics. This  is  the  second  edition  of  his  book,  yet 
we  may  look  upon  it  as  his  first,  for  while  the  first 
edition  was  published  in  1918,  on  account  of  the 
war  it  was  not  available  in  this  country. 

A  goodly  portion  of  the  book  is  devoted  to  the 
formulas  of  various  therapeutic  measures,  prescrip- 
tions, regimes,  etc.  These  are  not  as  valuable  in  this 
country  as  they  may  be  in  Germany,  for  in  regard 
to  drugs  and  methods  our  line  of  procedure  is  at 
variance  with  theirs  in  many  respects.  The  merits 
or  demerits  of  the  various  schools  need  not  be  gone 
into.  However,  many  physicians  in  this  country 
will  avail  themselves  of  the  opportunity  of  finding 
out  what  progress  has  been  made  in  the  Central 
European  countries  during  the  years  of  the  war. 


1002 


BOOK  REVIEWS. 


[New  York 
Medical  Journal. 


TYPHUS   AND   RELAPSING  FEVERS 
IN  SERBIA. 

The  Serbian  Epidemics  of  Typlnis  and  Relapsing  Fevers  in 
J915.  Their  Origin,  Course,  and  Preventive  Measures 
Employed  for  their  Arrest.  An  Etiological  and  Pre- 
ventive Study  Based  on  Records  of  British  Sanitary- 
Mission  to  Serbia  in  1915.  With  Maps  and  Charts.  By 
WiLLi.\M  Hunter,  C.  B.,  Colonel,  A.  M.  S.  Reprinted 
from  the  Proceedings  of  the  Royal  Society  of  Medicine, 
1919.  Vol.  iii,  Section  of  Epidemiology  and  State  Medi- 
cine, pp.  xxix-158.  London:  John  Ball.  Son  &  Daniels- 
son,  Ltd.,  1920.    Pp  158. 

This  little  monograph  has  been  prepared  with 
great  care  and  is  an  excellent  piece  of  work.  Ty- 
phus, once  the  nature  of  the  disease  and  the  manner 
of  its  transmission  were  known,  was  thought  to  be 
wiped  out,  but  the  wars  of  man  and  life  in  the 
trenches  brought  the  disease  back  in  epidemic  fonn. 
It  swept  through  Serbia  like  a  prairie  fire  and 
scarcely  a  family  remained  untouched.  It  was  here 
that  Hunter  made  his  studjes.  He  presents  them 
now  that  the  benefits  of  his  findings  may  be  applied 
in  the  countries  which  are  yet  in  a  state  of  war. 
Typhus  is  still  rampant  in  Poland  and  parts  of  Rus- 
sia. In  certain  districts  it  occurs  in  endemic  form ; 
in  parts  of  Mexico  and  on  the  lower  east  side  of 
New  York  City.  It  seems  strange  that  this  dread- 
ful disease,  which  is  so  easily  eradicated,  should  still 
be  prevalent.  Perhaps  with  a  reappearance  of  a 
semblance  of  sanity  among  the  peoples  of  earth  ty- 
phus will  become  extinct.  In  the  meanwhile  there 
is  still  need  for  a  study  of  the  malady  and  no  more 
complete  work  has  been  offered  recently  than  that 
of  William  Hunter. 

LIMITS  AND  FLUXIONS. 

A  History  of  the  Conceptions  of  Limits  and  Fluxions  in 
Great  Britain  from  Newton  to  IVoodhonse.  By  Florian 
Cajori,  Ph.  D.,  Professor  of  History  of  Mathematics ' 
in  the  University  of  California.  With  Portraits  of 
Berkeley  and  Maclaurin.  Chicago  and  London :  The 
Open  Court  Publishing  Company,  1919.    Pp.  viii-299. 

He  who  professes  to  give  an  account  of  men  who 
have  cleared  a  path,  to  tell  of  their  work  and  its 
value,  should  remember  that  insufficient  references 
annoy  rather  than  help.  To  pretend  that  a  man  or  a 
book  is  so  well  known  that  full  titles  are  not  neces- 
sary is  really  a  lazy  way  of  escaping  trouble  and 
makes  the  real  student  distrustful  of  the  whole 
work.  To  seek  an  initialless  author  and  his  book 
(wrongly  titled)  makes  the  most  patient  reader 
sadly  sigh  or  strongly  swear.  But  no  such  emotion 
will  tarnish  the  welcome  given  to  Florian  Cajori, 
for  he  marshals  his  exponents  of  limits  and  fluxions 
in  admirable  order,  and,  not  only  that,  but  the  full 
title  and  date  of  the  work  of  each  is  supplied.  The 
audience  room  is  crowded — Newton,  Berkeley,  the 
celebrated  Bishop  of  Cloyne,  Maclaurin,  a  keen  dis- 
putant, Carnot,  D'Alembert,  Legrange,  Cauchy,  all 
with  their  own  ideas  and  unwilling  to  admit  those 
of  Newton.  There  is  a  doctor,  too,  George  Cheyne, 
of  Edinburgh,  who,  besides  the  differential  calculus, 
also  treats  the  pathological  calculus,  and,  besides 
that,  atheism  and  other  more  light  subjects.  A  few 
of  the  men  are  denying  that  the  circumference  of  a 
circle,  or  any  other  curve,  can  be  identical  with  the 
periphery  of  any  polyon  whatever.  Berkeley  also 
wrote  to  lurin,  "For  a  fluxionist  writing  about 
•inomentums  to  argue  that  quantities  must  be  equal 


because  they  have  no  assignable  difference,  seems 
the  most  injudicious  step  that  could  be  taken;  it  is 
directly  demolishing  the  very  doctrine  you  would 
defend.  For,  it  will  thence  follow  that  all  homo- 
geneous momentums  are  equal,  and,  consequently, 
the  velocities,  mutations  or  fluxions  proportional  to 
these  are  likewise  equal.  There  is,  therefore,  only 
one  proportion  of  equality  throughout  which  at  once 
overthrows  the  whole  system  you  undertake  to 
defend." 

The  dispute  waxes  hot,  but,  with  the  main  state- 
ments of  each  man  in  Cajori's  book,  we  can  follow 
the  argument  easily,  or,  being  amply,  richly  leisured, 
the  arguer's  own  books.  Among  the  disturbing  pile 
of  volumes  in  the  educational  booksellers  this  should 
be  the  one  the  tired  man  will  get  most  help  from 
on  the  subject.  Certainly  it  shows  the  amount  of 
thoughtful  work  put  into  it. 

THE  DARK  MOTHER. 

The  Dark  Mother.    By  Waldo  Frank.    New  York:  Boni 
and  Liveright,  1920.    Pp.  376. 

The  book  is  too  long,  the  sentences  too  short. 
The  book  with  all  its  length  arrives  at  no  particular 
place.  The  sentences,  often  only  choppy  groupings 
of  words,  finish  nothing,  explain  comparatively  little, 
splash  color  about  with  too  much  of  the  disjointed- 
ness  of  ineffectual  pain. 

And  that  is  it.  The  reader  feels  that  there  must 
be  behind  the  book  an  author  who  is  vainly  catching 
at  life  in  many  directions,  ignorant  of  a  "canaliza- 
tion" that  brings  its  fragments  into  relation  to  pur- 
pose. His  pages  give  one  the  sense  of  acquaintance 
in  part  with  many  partial  urges,  but  not  yet  de- 
veloped out  of  their  childish  separateness.  There 
are  evidences  of  deeper  psychic  penetration  into 
some  of  these  phases.  There  are  episodes  of  reveal- 
ing discussion  of  the  relation  of  parents  and  chil- 
dren, of  brother  and  sister,  both  running  with  the 
lives  of  the  main  characters  of  the  book.  These 
fatnily  relationships  with  their  dominations,  their 
fierce  reactions,  their  estrangements,  their  drawing 
power  toward  unsafe  dependence,  all  these  are 
handled  with  insight  into  their  real  significance. 
They  follow  with  the  sharply  individual  character 
drawings  that  fill  the  many  pages  of  the  volume. 

Unfortunately,  Frank  has  been  imable  to  gather 
all  this  into  that  undefined  unity  which  makes  a 
work  of  art.  Such  a  work  must  represent  the 
scattered  elements  of  the  real  world.  It  must, 
however,  at  least  point  a  synthesis,  which  is  only 
that  same  canalization  which  finds  in  the  elements 
the  material  by  which  it  travels  onward.  It  is  the 
same  with  some  of  the  more  external  promises  of 
the  book.  They  lead  us  to  expect  something  of  the 
light  of  thoughtful  fiction  upon  political  and  eco- 
nomic (juestions  of  two  decades  ago.  The  promises 
soon  fade.  Like  the  stories  of  the  chief  characters 
themselves,  their  mentions  seem  to  be  unrelated  to 
a  goal. 

The  lives  of  Tom  and  Cornelia  have  been  beaten 
upon  early  by  the  blows  of  a  father,  which  have 
prevented  wholesome  unity  in  its  most  essential 
sphere,  their  own  true  inward  selves.  They  cannot 
unite  their  scattered  impulses.  Both  achieve  mate- 
rial success,  but  both  are  divided  as  to  their  deepest 
needs.    So  was  their  attitude  toward  their  father 


December  18,  192U.] 


BOOK  REVIEIVS. 


1003 


split  into  the  ambivalence  of  love  and  hate.  Strange 
wonder  that  Tom  lives  a  conscious  double  life  with 
himself,  and  Cornelia's  creativeness  puffs  itself  out 
in  a  final  renouncement  of  the  boy  David.  She 
realizes  the  maternal  in  her  love,  but  its  hopeless 
incongruity  also,  as  only  a  gathered  reaction  against 
father  and  brother  entanglement. 

David's  life  carries  the  dreams  of  the  ideal.  Yet 
it,  too,  is  an  unsatisfactory  picture  of  one  knows 
not  what.  The  same  cool,  meaningless  separateness 
lies  between  his  attempts  to  hold  his  ideal  and  to 
find  the  world  of  harder  things.  A  curioush-  crass 
carnalism  seems  as  little  to  disturb  the  tenor  of  his 
aims  as  in  any  way  to  perform  any  service  really 
linked  with  those  aims.  He,  too,  struggles  purpose- 
less in  the  more  embracive  sense.  True,  his  fleshly 
affairs  give'  him  some  glow  of  awakening,  but  one 
asks  whether  such  mere  casualness  marks  the  life 
of  men  and  women  so  generally  as  the  author  would 
lead  us  to  believe.  These  incidents,  just  like  all  the 
sketchy  pictures  of  the  great  city  where  the  story 
nioves.  show  distraughtness  in  the  mind  of  the  writer. 
The  book  is  too  indicative  of  partial  trends,  of  an 
imsynthesized  grouping  of  interest,  to  be  real 
literature. 

DOM  NET 

Domnei.  A  Comedy  of  Woman  Worship.  By  James 
Branch  Cabell.  Xew  York :  Robert  M.  McBn'de  &  Co., 
1920.    Pp.  viii-218. 

^Minstrelsy  knew  this  story  long  ago  as  each  one 
of  us  dreams  it  to  himself  today.  A  life  devoted 
to  the  fairest  lady,  a  heart  swoni  to  her  service, 
with  torture  and  waiting,  hardship  and  bitter  fight- 
ing endured  on  her  behalf. 

The  troubadours  vied  with  each  other  to  sing  of 
such  devotion :  we  have  the  privilege  of  living  it 
breathlessly,  painfully,  and  blissfully  with  Perion. 
This  is  not  lovemaking  according  to  note.  The 
medieval  songsters  had  their  formulae,  but  some- 
where outside  the  rules  laid  down  living  beings 
loved ;  and  here  they  are. 

It  is  for  you  to  discover  the  tender  melody  in 
Cabell's  romance  of  Perion  and  Melicent.  We  can 
only  tell  you  how  they  met  and  parted,  how  Perion, 
warring  against  the  unbelievers,  was  captured  by 
Demetrius  of  Anatolia,  and  how  ^Melicent  went  in 
search  of  Perion.  The  story  is  A'ivid  enough  for 
any  lover  of  adventure  and  brave  deeds. 

The  men  and  women  in  it  you  must  learn  to 
know  for  yourselves,  to  recognize  in  your  secret 
hearts  all  that  there  is  of  poetry,  beauf\-,  and  un- 
wavering truth  in  this  simple  tale. 

TRUE  LOVE. 

True  Loir.  By  Allan  Moxkhouse.  Xew  York :  Henr\- 
Holt  and  Co.,  1920.    Pp.  vi-373. 

The  author  had  a  collection  of  fine  ideas  on  play 
writing,  also  on  unity  of  nations,  conscientious 
objectors,  and  war  generally.  They  were  all  piled 
up  on  his  study  floor  and  he  wanted  to  talk  to  the 
people  about  them.  An  essay?  Xo;  the  subjects 
did  not  run  smoothly  together.  There  was  that 
question  whether  an  English  soldier  should  marry 
a  German  girl.  Why  not  write  a  novel?  So  he 
gathered  characters  vvho  by  their  deeds  would  show 
forth  his  views. 


The  hero,  playing  his  part,  suddenly  remembers 
he  is  a  mouthpiece  for  Mr.  Monkhouse,  and  talks 
accordingly,  but  too  lengthily.  Sister  Mary  and 
the  German  girl,  Sibyl,  whom  Arden,  the  hero, 
marries,  are  fine  characters,  but  they  too  are  wor- 
ried by  the  amount  of  information  they  have  to 
give  the  reader  and  so  become  dull.  There  is  so 
much  which  is  good  in  the  book  that  one  may  con- 
fidently say  the  author  will  be  more  at  home  with 
the  characters  he  creates  and  the  readers  he  hopes 
to  gain  in  his  second  inky  venture.  The  death  of 
both  hero  and  heroine  rather  indicate  the  author  to 
have  been  a  trifle  tired  of  his  own  creations. 

 ^  

New  Publications  Received. 


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


CHILDREN  BY  CHANGE  OR  BY  CHOICE.  And  Some  Cor- 
related Considerations.  By  William  H.\wley  Smith. 
Boston:  Richard  G.  Badger  (The  Gorham  Press),  1920. 
Pp.  361. 

ELECTRICAL    TREATMENT.       By    WiLFRED    HaRRIS,    M.  D.. 

F.  R.  C.  P.,  Senior  Physician  and  Lecturer  on  Xeurolog>-. 
St.  Mar}''s  Hospital ;  Physician  to  the  Hospital  for  Epi- 
lepsy and  Paralysis,  Maida  Vale.  Illustrated.  Third  Edi- 
tion.  New  York:  William  Wood  &  Co.,  1920.    Pp.  x-354. 

THE   SYSTEMIC  TREATMENT  OF   GONORRHE.\   IN   THE  MALE. 

By  XoRMAN  LuMB,  O.  E.  B.,  Late  R.  A.  M.  C.  Specialist 
in  Venereal  Diseases,  and  Officer  in  Charge  of  Division. 
39  and  51  General  Hospitals,  B.  E.  F. :  Clinical  Assistant. 
St.  Peter's  Hospital  for  Stone.  Second  Edition.  Philadel- 
phia and  New  York :  Lea  &  Febiger,  1920.    Pp.  viii-123. 

ZEITSCHRIFT   fCr    TUBERKULOSE    VNTER    MITWIRKLNt,  DER 

HERRN  PROF.  B.-vBES  (Bukarest),  Prof.  Bang  (Kopen- 
hagen),  Geh.  Med. -Rat.  Doktor  Behla  ( CharlcttJii- 
burg),  Dr.  Leo  Berthenson  (St.  Petersburg)  und  so 
weiter.  Herausgegeben  von  M.  Kirchner,  F.  Krals. 
W.  v.  Leube,  J.  Orth,  F.  Penzoldt.  Leipzig :  Verlag 
von  Johann  Ambrosius  Barth,  1920.    Seiten  64. 

PUBLIC  HE.\LTH  AND  HYGIENE.  In  Contributions  by  Emi- 
nent Authorities.  Edited  by  William  Hallock  P.\rk, 
M.  D.,  Professor  of  Bacteriologj"  and  Hygiene.  L'niversity 
and  Bellevue  Hospital  Medical  College,  and  Director  of  the 
Bureau  of  Laboratories  of  the  Department  of  Health.  Xew 
York  Cit>-.  Illustrated  with  One  Hundred  and  Twenty- 
three  Engravings.  Philadelphia  and  Xew  York :  Lea  & 
Febiger,  1920.   Pp.  xvi-884. 

SURGERY.  ITS  PRiNCiPLFS  AND  PRACTICE.  For  Students 
and  Practitioners.  By  Astley  Paston  Cooper  Ashhurst. 
A.  B.,  M.  D.,  F.  A.  C.  S.,  Associate  in  Surgery  in  the  Uni- 
versity of  Pennsylvania ;  Surgeon  to  the  Episcopal  Hospital 
and  to  the  Philadelphia  Orthopedic  Hospital  and  Infirmary 
for  Xervous  Diseases ;  Colonel,  Medical  Reserve  Corps. 
U  S.  Army.  Second  Edition,  Thoroughly  Revised.  With 
Fourteen  Colored  Plates  and  1,129  Illustrations  in  the 
Text,  Mostly  Original.  Philadelphia  and  Xew  York :  Lea 
&  Febiger,  1920.    Pp.  xi-1202. 

PRACTICAL     B.^CTERIOLOGY,     BLOOD     WORK,     AND  ANIMAL 

parasitology.  Including  Bacteriological  Keys.  Zoologi- 
cal Tables,  and  Explanator\-  Clinical  Xotes.  Bv  E.  R. 
Stitt,  .\.  B.,  Ph.  G.,  M.  D.,  Sc.  D..  LL.  D..  Rear  Admiral. 
Medical  Corps,  U.  S.  Xa\T;  Commanding  Officer  and 
Head  of  Department  of  Tropical  Medicine.  U.  S.  Xaval 
Medical  School ;  Graduate,  London  School  of  Tropical 
Medicine,  etc.  Sixth  Edition,  Revised  and  Enlarged,  with 
One  Plate  and  One  Hundred  and  Seventy-seven  Other 
Illustrations  Containing  Six  Hundred  and  Thirtv-seven 
Figures.  Philadelphia:  P.  Blakiston's  Son  &  Co.,  1920. 
Pp.  xi-633. 


Practical  Therapeutics  and  Preventive  Medicine 

A  Compendium  of  Treatment  and  Prophylaxis,  Original  and  Ad  apted 


Experimental  Pneumectomy.— George  J.  Heuer 
and  George  R.  Dunn  (Bulletin  of  the  Johns  Hop- 
kins Hospital,  February,  1920)  performed  total 
pneumectomy  on  twenty-three  dogs,  with  thirteen 
recoveries  and  ten  deaths  occurring  from  four  days 
to  two  months  after  the  operation.  Six  of  the 
fatalities  were  caused  by  an  epidemic  of  distemper 
among  the  dogs  in  the  earlier  part  of  the  work. 
At  autopsy  none  of  these  dogs  showed  infection  of 
the  parietal  wound  or  pleura  or  leakage  from  the 
bronchial  stump.  The  following  causes  •  were  re- 
sponsible for  the  deaths  of  the  rest:  Simple  pneu- 
monia unassociated  with  other  evidences  of  dis- 
temper, one ;  starvation,  two  months  after  opera- 
tion, one,  with  remarkable  emaciation  at  autopsy, 
but  no  other  cause  for  death ;  acute  pneumothorax, 
two  animals,  as  a  result  of  leakage  from  the  bron- 
chial stump.  In  one  of  these  failure  to  secure  an 
adequate  closure  of '  the  bronchial  stump  was  in- 
tentional ;  in  the  other  necrosis  of  the  bronchial 
wall  followed  the  application  of  an  intentionally 
flattened,  not  rolled,  metal  band.  The  animals  were 
kept  under  observation  in  some  instances  for  a  year, 
and  were  returned  to  the  yards  with  the  other  dogs 
as  soon  as  they  recovered  from  the  operation.  They 
were  apparently  active,  healthy,  free  from  dyspnea, 
and  held  their  own  with  the  other  animals.  The 
technic  for  the  lung  excision  is  given  in  detail, 
together  with  various  methods  for  treating  the 
bronchial  stump. 

Treatment  of  Pneumonia. — J.  W.  Preston- 
(Virginia  Medical  Monthly,  November,  1920)  notes 
that  while  type  I  serum  is  curative  in  type  I  cases, 
it  has  not  come  into  general  use  because  of  the 
existing  impracticability,  outside  of  large  centres, 
of  securing  prompt  typing  of  pneumonia  cases,  as 
well  as  because  of  the  minute  detail  necessary  in 
the  administration  of  the  serum.  Further,  type  I 
represents  less  tlian  one  third  of  all  lobar  pneu- 
monias, and  the  great  majority  of  cases  in  the  past 
two  years  have  been,  not  lobar,  but  bronchopneu- 
monia. In  most  cases  in  which  a  severe  type  of 
pneumonia  develops,  the  author  has  noticed  some 
basis  for  it  either  in  loss  of  sleep,  physical  exhaus- 
tion, mental  upset,  or  an  inability  or  unwillingness 
to  remain  quiet  in  bed  in  a  room  maintained  at  a 
comfortable  temperature.  The  picture  in  severe 
bronchopneumonia  is  one  of  exliauslion  of  the 
vegetative  nervous  system,  resembling  that  of  shock, 
and  the  author's  best  results  have  been  obtained 
from  treatment  such  as  would  forestall  or  benefit 
shock.  Such  treatment  excludes  severe  purges,  any 
except  the  smallest  doses  of  coal  tar  products,  sponge 
baths,  cold  air,  and  all  e.xertion,  whether  mental  or 
physical.  Of  the  drugs,  opium,  preferably  in  tlie 
form  of  codeine  by  the  mouth,  or  one  twelfth  grain 
doses  of  morphine  given  hypodermically  at  intervals 
sufficiently  short  to  control  cough  and  restlessness, 
])roved  of  greatest  value.  As  adjuvant,  atropine  is  a 
close  second,  but  only  in  doses  of  one  six  hundredtli 
grain,  given  wiib  the  opiate,  e.  g.,  hourly,  until 


some  ef¥ect  is  noted,  then  at  longer  intervals.  To 
sensitize  the  heart  to  digitalis  action  it  seems  advis- 
able to  begin  with  a  small  dose  of  the  tincture,  e.  g., 
ten  drops  three  times  daily.  This  dose  does  not 
upset  the  digestion,  yet  is  sufficient,  should  the  cir- 
culation weaken,  to  enable  one  quickly  to  digitalize 
the  patient  by  giving  one  half  to  one  dram  at  a 
dose,  repeated  as  indicated.  A  frequent  cause  of 
cardiac  and  respiratory  embarrassment  is  gaseous 
distention.  The  diagnosis  of  pneumonia  having 
once  been  established,  frequent  examination  of  the 
abdomen  is  strongly  indicated.  In  addition  to 
enemas  and  turpentine  stupes,  pituitrin  is  of  the 
greatest  service.  It  should  be  given  early  and  at 
regular  intervals  in  cases  showing  a  marked  ten- 
dency to  distention.  A  small  rectal  tube  introduced 
and  allowed  to  remain  in  severe  cases  also  affords, 
pronounced  relief.  As  a  quick  pickup  for  the  heart 
and  for  relief  where  there  is  an  asthmatic  tendency, 
adrenalin  has  seemed  to  aid,  but  its  action  is  more 
transient.  Hot  mustard  pastes  applied  early  over 
file  entire  chest  are  a  great  help.  Intravenous 
administration  of  glucose  is  destined  to  be  of  great 
assistance  in  patients  not  annoyed  or  upset  by  it, 
especially  those  with  a  tendency  to  acidosis. 

Purpura  and  Meningococcic  Septicemia. — P. 
Lereboullet  and  J.  Cathala  (Paris  medical,  October 
30,  1920)  point  out  that  meningococcic  septicemia 
is  by  no  means  a  rare  condition.  In  recent  years 
cerebrospinal  meningitis  seems  to  have  assumed 
purpuric  and  septicemic  characteristics  more  fre- 
quently than  before.  The  disorder  may  appear  as 
a  simple  infectious  purpura  which  continues  clinic- 
ally mild  until  the  terminal  meningeal  symptoms 
supervene.  Any  case  of  rheumatoid  purpura  of 
obscure  origin  should  lead  at  once  to  the  suspicion 
of  meningococcic  septicemia.  For  the  early  detec- 
tion of  this  type  of  purpura  consideration  should  be 
given  to  the  question  whether  the  purpura  appeared 
in  a  locality  in  which  cerebrospinal  meningitis  had 
previously  occurred.  In  one  of  Netter's  cases  the 
coexistence  of  cerebrospinal  meningitis  in  the  sister 
of  a  little  girl  of  six  years  exhibiting  purpura  led 
to  the  discovery  of  the  meningococcic  origin  of  the 
latter.  On  lumbar  puncture,  cloudy  fluid  points 
definitely  to  meningococcic  infection.  A  clear  fluid 
docs  not,  however,  exclude  such  infection.  A  blood 
culture  .should  be  made  on  bouillon  and  ascitic  fluid, 
but  is  often  negative.  Under  exceptional  conditions 
meningococci  may  be  found  by  staining  tissue  sec- 
tions of  a  purpuric  spot,  or  the  organism  found  in 
smears  of  bloody  fluid  from  such  a  spot;  or,  again, 
it  may  be  demonstrated  in  the  fluid  contained  in  the 
seropurulent  vesicles  sometimes  formed  on  the  sur- 
face of  a  petechia.  The  meningococcus  may  like- 
wise be  sought  in  the  pus  from  definite  foci  of 
infection  accompanying  the  septicemia,  as  in  sup- 
purative arthritis  or  iridochoroiditis.  In  severe 
cases,  even  where  the  meningococcus  cannot  be 
identified,  antimeningococcic  serum  should  be  given 
In-  intramuscular  injection.    If  a  polyvalent  .serum 


Dec.nb.r  IS.  1920.]         FRACTICAL  THERAPEUTICS   A\D  PREVEXTIVE  MEDICLXE. 


1005 


is  unavailable,  B  meningococcus  serum  should  be 
chiefly  used,  as  the  B  organism  has  been  found  in 
nearly  all  the  cases  of  this  type  so  far  reported. 
The  serum  should  be  administered  as  soon  as  the 
suspicion  of  meningococcic  infection  arises.  These 
cases  are  more  frequently  fatal  than  the  ordinary 
forms  of  cerebrospinal  meningitis. 

Presence  of  the  Tubercle  Bacillus  in  the  Blood 
Stream. — Sabathe  and  Buquet  {Presse  medicale. 
October  27,  1920),  to  demonstrate  the  tubercle 
bacillus  in  the  circulating  blood,  collect  six  mils 
of  blood  in  a  test  tube  and  allow  it  to  coagulate. 
After  the  clot  has  contracted,  some  of  the  fluid  is 
withdrawn  by  megns  of  a  pipette  placed  in  contact 
with  the  clot  and  smears  made  arid  stained  b)-  the 
Ziehl  method.  Tubercle  bacilli  will  be  found  in  the 
blood  of  tuberculous  patients  by  this  procedure. 

Sodium  Citrate  in  the  Treatment  of  Pneumonia. 

— L.  Cheinisse  {.Presse  medicale,  February  14, 
1920),  commenting  on  Weaver's  pneumonia  treat- 
ment with  large  doses  of  sodium  citrate,  notes  that 
observations  with  the  viscosimetre  on  pneumonia 
cases  would  appear  to  justify  the  citrate  treatment. 
The  viscosity  of  the  blood  has  almost  invariably 
been  found  high  in  pneumonia,  especially  in  com- 
parison with  the  hemoglobin  values.  Hence  the 
seeming  advantage  of  acting  remedially  upon  the 
viscosity  and  restoring  it  to  normal.  Sodium  citrate 
may  also  be  held  to  act  by  reducing  the  coagulability 
of  the  blood  and  by  increasing  its  alkalinity,  which 
is  lowered  in  pneumonia. 

The  Bacteriology  of  Colitis. — H.  L.  Lyon- 
Smith  (Lancet,  June  12,  1920)  considers  that  the 
usual  methods  of  investigating  the  stool  in  colitis 
for  the  purpose  of  identifying  the  chief  organism 
producing  the  inflammation  are  unsatisfactory.  He 
points  out  that  we  are  anxious  to  learn  what  bac- 
teria is  present  in  the  mucosa  rather  than  in  the 
feces.  In  order  to  get  as  accurately  as  possible 
this  information,  he  first  gives  a  Plombiere  douche 
of  a  pint  of  warm  water.  Then  a  second  injection 
of  two  or  three  pints  is  given  and  retained  for  six 
minutes  while  the  patient  is  moved  from  side  to 
side.  The  washing  is  received  in  a  clean  receptacle 
and  is  searched  for  particles  of  mucus  which  are 
placed  in  a  sterile  container  to  be  kept  for  such 
examinations  as  seem  necessary. 

Control  of  Epileptic  Seizures. — Irving  J.  Sands 
(State  Hospital  Quarterly.  February.  1920  ),  in  dis- 
cussing the  control  of  epileptic  seizures,  gives  the 
following  summary  of  his  findings:  1.  Epilepsy  in 
the  present  state  of  information  might  be  best 
regarded  as  a  disease  entity,  as  nothing  might  be 
gained  from  including  under  the  same  caption  those 
forms  of  convulsions  which  are  occasioned  by  defi- 
nite etiological  agents  and  in  which  constant  and 
definite  pathological  changes  are  seen  at  necropsy. 
2.  To  combat  convulsions  the  drug  giving  the  most 
satisfactory  results  is  luminal.  A  review  of  the 
literature  and  citation  of  cases  are  given  to  prove 
its  usefulness  and  efficacy  in  the  management  of 
this  disease.  3.  Ordinary  hygienic  measures,  proper 
exercise,  hydrotherapy,  rigid  attention  to  the  diet 
and  to  the  bowels,  are  indispensable  agents  in  con- 
trolling epileptic  seizures. 


The  Dose  of  Iron. — Albert  Adler  (Schweizer- 
isclic  mcdizinischc  U'ochensclirift,  July  29,  1920), 
who  is  apparently  Xaegeli's  assistant,  discusses  the 
dose  of  iron  to  be  employed  in  chlorosis.  In  bad 
cases  he  gives  from  three  to  ten  doses  a  day  of  0.1 
gram  of  reduced  iron.  The  improvement  in  the 
blood  reaches  its  acme  in  about  three  weeks.  He 
is  more  enthusiastic  than  Xaegeli  concerning  the 
benefit  to  be  expected  in  the  very  bad  cases. 

Action  of  Iron  in  Chlorosis.  —  Naegeli 
{Schweizerische  medizinische  Wochenschrift,  July 
29,  1920)  considers  that  chlorosis  is  in  fact  a  torpor 
of  the  blood  formation  which  differs  in  degree  in 
different  cases,  and  can  scarcely  be  overcome  in  the 
worst.  Iron,  when  given  in  sufficient  doses,  acts 
as  a  stimulant,  particularly  of  the  bone  marrow.  In 
this  it  excites  a  stormy  reaction,  which  causes  quan- 
tities of  young  elements  to  be  thrown  into  the 
blood.  Xot  only  the  hemoglobin  elements,  but  the 
whole  of  the  bone  marrow  appears  to  be  stimulated. 

The  Milk  Situation. — Howard  Swift  (Boston 
Medical  and  Surgical  Journal,  April  29,  1920)  says 
that  milk  in  a  raw  form  often  endangers  the  health 
of  infants.  The  amount  of  immunity  that  is  trans- 
mitted through  infected  milk  for  tuberculosis  is  an 
unknown  quantity.  Pasteurization,  as  called  for 
by  the  present  law,  may  not  be  so  safe  as  is  gener- 
ally believed.  There  is  a  considerable  loss  of  life 
and  impaired  health  directly  attributable  to  the  use 
of  infected  dairy  products.  Under  the  present 
demand  by  the  public,  the  producer  cannot  afford 
to  manufacture  a  cleaner  and  better  product.  He 
urges  a  campaign  to  secure  tuberculosis  free  milk. 

Epidemic  Hemeralopia  Due  to  Lack  of  Vita- 
mines. — R.  Tricoire  (Paris  medical,  February  21, 
1920)  states  that  epidemic  hemeralopia  may  occur 
ill  the  human  subject  when  certain  vitamines  of 
group  A  are  lacking  from  the  diet.  The  condition 
may  be  classified  as  an  avitaminosis,  in  conjunction 
with  scurvy,  which  is  due  to  lack  of  substances  of 
the  same  type — liposoluble  vitamines.  Like  other 
avitaminoses,  epidemic  hemeralopia  develops  only 
after  the  deficient  diet  has  been  emplo3'ed  for  a 
certain  period  of  time.  Apparently  the  avitaminoses 
set  in  only  after  an  actual  incubation  period,  which, 
in  the  case  of  epidemic  hemeralopia,  is  probably 
from  three  to  four  months  The  hemeralopia  dis- 
appears rapidly  after  the  vitamines  are  supplied. 

Diabetes  in  Wartime. — D.  Gerhardt  (ScJnvei- 
ceriscl'.e  medizinische  JVochenscIirift.  February  19, 
1920)  says  that  during  the  war  the  food  conditions 
were  more  unfavorable  for  diabetics  than  for  any 
other  class  of  patients,  so  physicians  looked  for  a 
marked  change  for  the  worse  in  them.  But  these 
fears  were  not  realized.  On  the  contrar\-,  the  die- 
tetic restrictioiis  had  a  favorable  influence,  which 
he  ascribes  to  the  low  calorie  content  of  the  food, 
the  small  proportion  of  albumin,  and  the  large 
amount  of  vegetables  eaten.  Meat  and  cheese  were 
not  absolutely  forbidden,  and  the  diabetics  did  better 
than  they  could  have  been  expected  to  do  on  a  strict 
antidiabetic  diet  without  careful  medical  supervision. 
He  is  inclined  to  think  that  too  little  carbohydrate 
may  do  harm,  as  well  as  too  much,  and  that  the 
entire  quantity  of  food  should  be  limited. 


Proceedings  of  National  and  Local  Societies 


AMERICAN   PEDIATRIC  SOCIETY. 

Thirtx-sccond  Annual  Meeting,  Held  in  Highland 
'Park,  III,  May  31,  June  1  and  2,  1920. 

The  President,  Dr.  Thomas  S.  Southworth,  of  New  York, 
in  the  Chair. 

Segregation  of  Pneumonia. — Dr.  Thomas  S. 
Southworth,  in  his  presidential  address,  declared 
that  pneumonia  was  today  one  of  the  greatest 
endemic  plagues  of  the  world,  and  one  for  which 
less  had  been  accomplished  in  the  way  of  limiting 
its  ravages  than  for  any  other  malady  of  like  import 
save  pandemic  influenza.  This,  he  said,  was  not 
due  to  lack  of  interest  in  the  problem  but  rather  to 
its  complications,  since  the  processes  we  called 
pneumonia  were  several  pathological  entities  of 
diverse  etiolog}',  and  with  somewhat  loosely  corre- 
lated clinical  manifestations.  Untiring  zeal  had 
been  expended  to  find  a  remedy  for  the  pneumonias, 
but  the  possibility  of  guarding  against  their  incep- 
tion had  not  been  considered  as  clearly.  Here  the 
field  was  a  wide  one  worthy  of  further  patient 
study.  One  avenvie  not  properly  guarded  was  the 
exposure  of  susceptible  individuals  in  dangerous 
propinquity  to  active  cases  of  the  disease. 

It  had  long  been  recognized  that  pneumonias  were 
caused  by  microorganisms  of  recognized  pathogenic 
virulence,  yet  it  had  been  the  custom  to  treat 
pneumonias  in  the  general  wards  of  hospitals  and 
to  place  about  them  in  the  home  the  ordinary  pre- 
cautions of  the  sick  room.  Segregation  of  such 
cases  might  have  been  practised  by  thoughtful 
individuals,  but  the  idea  had  not  found  its  way  into 
the  general  medical  ■  conscience  nor  been  advocated 
widely  in  our  literature.  Dr.  Southworth  said  that 
for  years  he  had  insisted,  when  possible,  upon  the 
prompt  isolation  of  the  first  cases  of  pneumonia 
among  children  having  measles  with  a  resulting 
limitation  of  the  number  of  cases  and  had  extended 
segregation  to  all  the  pneumonias.  The  real  ques- 
tion was  not  whether  the  case  for  the  individual 
infectiousness  of  the  pneumonias  was  fully  proved 
to  the  satisfaction  of  the  most  skeptical  but  whether, 
as  physicians,  they  were  individually  to  assume 
responsibility  for  permitting  exposure  in  cases  of 
pneumonia  which  they  would  not  permit  in  many 
types  of  much  less  serious  illness,  the  latter  having 
been  declared  quarantinable  while  pneumonias  thus 
far  had  not  been.  The  obligation  was  imperative  to 
anticipate  the  day.  not  far  distant,  when  the  move- 
ment to  control  the  scourge  of  pneumonia  might 
make  the  retention  of  such  cases  in  a  general  ward 
as  re])ugnant  to  our  medical  sense  of  propriety  as 
the  retention  of  a  case  of  open  tuberculosis. 

Studies  on  Blood  Sugar :  The  Effect  of  Blood 
on  Picrate  Solutions.  —  Dr.  David  Murray 
CowiE  and  Dr.  John  Purl  Parsons,  of  Ann 
Arbor,  described  experiments  which  they  had  made 
tending  to  show  that  blood  contained  substances 
other  than  sugar  which  induced  a  color  change  in 
the  picrate  solution  employed  in  the  modified  Lewis- 
Benedict  blood  sugar  method.    Under  normal  con- 


ditions these  substances  did  not  interfere  with  the 
established  normal  range  tor  this  method.  Under 
pathological  conditions  several  of  these  substances 
which  showed  the  most  marked  influence  were 
epinephrine,  acetone,  and  diacetic  acid.  Creatinine 
might  interfere  but  did  so  in  a  less  marked  degree 
if  we  considered  the  comparative  sensitiveness  of 
the  picrate  solution  to  these  substances. 

As  picrate  solution  reacted  to  smaller  quantities 
of  acetone  than  were  normally  found  in  the  blood, 
the  question  might  well  be  raised,  "Do  not  the 
acetone  bodies  of  the  blood  contribute  to  the 
established  normal  blood  sugar  range  for  the  Lewis- 
Benedict  test?"  Still  another  question  might  be 
asked :  "As  epinephrine  in  infinitesimally  small 
quantities  induces  a  color  change  in  picrate  solu- 
tion, is  it  not  possible  that  this  substance  when 
thrown  into  the  general  circulation,  as  is  supposed 
to  happen  in  emotional  states,  may  induce  a 
socalled  hyperglycemia  without  moliilizihg  the 
glycogen  stores  of  the  liver?" 

Epidemic  Encephalitis  Lethargica. — Dr.  Lix- 
XAEUS  E.  La  Fetra,  of  New  York,  stated  that  cases 
of  a  disease  accompanied  by  profoimd  somnolence 
and  lethargy  had  occurred  at  various  times  in 
sufficient  number  to  have  been  regarded  as  epidemics. 
It  was  evident  both  from  the  difference  in  the 
lesions  and  also  from  the  results  of  animal  experi- 
mentation that  poliomyelitis  and  epidemic  encepli- 
alitis  were  distinct  disea.ses.  In  his  experience 
epidemic  encephalitis  had  not  followed  influenza 
with  sufficient  regularity  to  warrant  one  in  stating 
that  it  was  caused  by  influenza,  though  influenza 
might  possibly  predispose  the  patient  to  infection 
or  increase  the  virulence  of   the   prevalent  virus. 

After  reviewing  the  recent  work  of  Loewe  and 
.Strauss  Dr.  La  Fetra  presented  an  analysis  of  eleven 
cases  of  encephalitis  seen  at  Bellevue  Hospital  since 
January  1.  1920.  Of  these  eleven  cases  four  were 
fatal.  There  was  no  relationship  between  any  two 
of  the  patients  and  they  did  not  live  in  close 
proximity  to  each  other.  In  only  two  was  there  any 
history  of  influenza.  The  symptoms  were  variable, 
but  in  most  instances  there  was  marked  headache 
accompanied  by  occasional  dizziness :  vomiting 
occurred  in  about  one  half  the  cases :  pain  in  the 
eyes  and  cheeks  compelling  drowsiness  was  present 
in  most  of  the  cases.  When  the  disease  was  well 
under,  way  the  outstanding  features  were  lethargy, 
general  weakness,  and  ptosis  or  paralysis  of  the 
ocular  or  facial  muscles,  with  double  vision  in 
several  instances.  Fever  was  usually  very  slight, 
and  lasted  for  only  a  few  days.  The  spinal  fluid 
was  under  little  or  no  increased  pres.sure,  and  in 
some  instances  was  perfectly  normal.  It  was  noted 
that  in  the  fatal  cases  there  was  a  higher  white  cell 
count  than  in  those  where  recovery  took  place.  In 
most  cases  globulin  was  present,  and  there  was  an 
increase  in  the  number  of  cells.  The  highest  numl)er 
of  cells  was  275  in  a  fatal  case;  the  average  num- 
ber, however,  ranged  from  fifty  to  one  hundred, 
all  of  which  were  mononuclears.     The   fluid  was 


Dec  mb  r  18.  1920.]  PROCEEDINGS  OF  NATIONAL   AND  LOCAL  SOCIETIES. 


1007 


sterile  on  culture.  Recovery  took  place  gradually, 
there  being  first  a  return  to  consciousness,  then  a 
diminution  of  catatonia  and  paralysis,  and  last  of 
all  the  asthenia  and  ptosis  disappeared.  Undoubt- 
edly, as  in  poliomyelitis,  abortive,  mild,  atypical 
cases  of  the  disease  occurred,  many  of  them  prob- 
ably being  unrecognized.  The  disease  had  to  be 
differentiated  from  tuberculous  meningitis,  polio- 
myelitis, cerebrospinal  syphilis,  brain  tumor  and 
meningism.  The  mortahty  of  the  disease  was  about 
the  same  as  that  of  poliomyelitis.  How  great  a 
proportion  of  the  patients  might  later  show  damage 
to  the  brain  it  was  too  early  to  state.  The  treatment, 
until  a  specific  serum  was  produced,  was  sympto- 
matic. 

Acute   Cerebrocerebellar   Ataxia. — Dr.   J.  P. 

■Crozer  Griffith,  of  Philadelphia,  presented  three 
new  cases  of  encephalitis  and  a  resume  of  a  case 
previously  reported,  all  of  them  pointing  to  an 
involvement  of  the  cerebellum  as  well  as  the  other 
parts  of  the  brain.  The  first  case  exhibited  incoordi- 
nation, nystagmus,  aflfection  of  speech,  confusion 
of  mind,  increased  knee  jerks,  but  no  paralysis. 
This  patient  made  a  rapid  and  complete  recovery. 
The  second  case  exhibited  a  staggering  gait,  dizzi- 
ness, incoordiation,  no  nystaginus  or  affection  of 
speech.  This  child  showed  some  incoordination 
three  and  three  quarters  years  later.  The  third 
patient  had  a  staggering  gait,  strabismus,  nystag-' 
mus,  vertigo,  mental  backwardness,  afifection  of 
speech ;  normal  eyegroimds.  A  year  later  the 
symptoms  were  still  present  but  improved.  The 
fourth  case  exhibited  early  symptoms  suggesting 
encephalitis  lethargica.  During  improvement  marked 
incoordination  and  afifection  of  the  speech  became 
manifest.  Recovery  was  very  slow.  At  last  report 
the  slow  speech  still  persisted. 

The  conclusion  reached  from  a  study  of  these 
cases  and  of  seventeen  cases  previously  collected 
from  the  literature,  was  that  this  was  not  a  common 
condition  but  that  it  occurred  more  frequently  than 
was  ordinarily  supposed,  in  which  acute  hemorrhagic 
encephalitis  involved  the  cerebellum  and  which 
might  be  designated  acute  cerebellar  encephalitis. 
With  this  disease  there  were  always  combined 
symptoms  indicating  an  involvement  of  the  large 
brain  as  well,  and  for  these  the  title  cerebrocere- 
bellar encephalitis  or  cerebrocerebellobulbar  enceph- 
alitis was  to  be  preferred.  The  degree  to  which  the 
process  involved  one  or  another  part  of  the  brain 
varied,  but  in  all  cases  there  was  a  combination  of 
the  symptoms  aflFecting  both  regions.  The  cause  of 
cerebrocerebellar  encephalitis  varied  decidedly.  In 
the  majority  of  cases  previously  reported  some 
infectious  disease  had  preceded  the  attack.  This 
was  true  in  two  of  the  cases  reported  in  the  paper ; 
in  the  other  two  no  such  connection  could  be  discov- 
ered. The  symptoms  were  those  mentioned  in  the 
cases  cited.  The  prognosis  so  far  as  life  was 
concerned  seemed  good.  That  clinical  evidence  of 
the  disease  would  not  persist  was  uncertain,  but  so 
far  as  statistics  went  it  would  appear  that  the 
disease  would  leave  no  traces  in  the  majority  of 
instances.  Lumbar  puncture  was  done  in  all  the 
cases  reported  by  the  writer  and  was  always 
negative. 


The  Significance  of  Xanthochromia  of  the 
Cerebrospinal  Fluid,  with  Report  of  a  Case  in  a 
Premature  Infant. — Dr.  Isaac  Abt,  of  Chicago, 
said  this  case  was  reported  because  of  the  yellow 
coloration  of  the  spinal  and  ventricular  fluid.  The 
infant  was  thirty-seven  days  old  at  the  time  of  death 
and  was  of  eight  months'  gestation.  Interest  also 
attached  to  the  case  because  of  the  occurrence  of 
bronchopneumonia  and  pyelitis.  Xanthochromia 
was  found  in  the  complete  syndrome  of  Froin  and 
in  the  incomplete  syndrome  of  Xonne.  Froin's 
syndrome  included  massive  coagulation,  while 
Nonne's  syndrome  included  increased  globulins, 
but  not  massive  coagulation.  The  importance  of 
cell  increase  was  mentioned  by  some  and  ignored 
by  others.  Considering  xanthochromia  by  itself 
was  the  simplest  way  of  elucidating  the  subject. 
It  was  most  frequently  found  in  cases  of  tumor, 
inflammation,  or  trauma,  cutting  of¥  part  of  the 
spinal  canal.  The  cul-de-sac  so  formed  usually  con- 
tained a  yellow  fluid  which  coagulated  cu  uiassc. 
The  pigment  comes  from  the  blood  ultimately.  In 
addition  to  the  process  of  transudation  which 
occurred  in  a  cord  compression,  it  was  readily  seen 
that  any  condition  which  permitted  red  blood  cells 
to  escape  into  the  spinal  fluid  might  produce  a  yel- 
low color  when  the  red  cells  had  been  dissolved  and 
the  hemoglobin  freed.  The  globulins  were  always 
increased  in  a  yellow  fluid,  whether  massive  coagu- 
lation occurred  or  not.  It  might  be  due  to 
transudate  in  the  case  of  a  tumor  pressing  on  the 
cord :  exudate  in  the  case  of  a  meningeal  inflamma- 
tion, and  hemorrhage  in  cases  due  to  trauma, 
inflammations,  and  tumors. 

Increased  cell  count  occurred  in  cases  of  menin- 
gitis, and  was  also  found  in  cases  of  tumor  and 
hemorrhage.  In  the  last  case  the  presence  of  red 
cells  usually  excluded  other  conditions,  although 
blood  might  be  present  as  a  concomitant  finding  in 
tumors  and  meningitis.  Pellicle  formation  was  of 
little  importance,  was  usually  found  in  meningitis, 
and  had  been  reported  in  a  case  of  tumoE  without 
meningitis.  Where  the  process  had  been  of  short 
duration  and  where  the  compressions  had  not  been 
sufficient,  massive  coagulation  might  not  occur.  In 
fact,  many  writers  stated  that  Xonne's  complete 
S3-ndrome  was  merely  a  precursor  of  Froin's  com- 
plete syndrome.  Some  cases  of  Nonne's  syndrome 
probably  never  reached  Froin's  stage.  Similarly 
conditions  causing  hemorrhage  might  never  give 
sufficient  plasma  and  fibrin  to  cause  coagulation. 
Another  class  of  cases  causing  a  yellow  spinal 
fluid  was  that  type  associated  with  red  cells  in  the 
fluid.  ^lany  considered  this  a  separate  syndrome 
and  applied  the  name  erythrochromia  to  it. 

The  case  reported  was  that  of  a  child  brought  to 
the  hospital  for  special  feeding.  About  the  four- 
teenth day  the  temperature  rose  to  about  106°  F. 
and  the  child  was  seized  with  severe  convulsions. 
The  urine  showed  pyelitis,  and  upon  examining  the 
lungs  patches  of  bronchopneumonia  were  found. 
The  convulsions  and  the  urinar}-  and  pulmonary 
findings  persisted  until  the  end.  The  anterior 
fontanel  was  tense  and  bulging.  On  the  thirtieth 
day  spinal  puncture  yielded  four  c.  c.  of  distinctly 
yellow  fluid.    The  fluid  was  clear  but  the  first  two 


t 


1008 


PROCEEDINGS  OF  NATIONAL   AND  LOCAL  SOCIETIES. 


[New  York 
Medical  Journal. 


cubic  centimetres  yielded  a  filmy  pellicle.  The  sec- 
ond tube  containing  two  c.  c.  did  not  change.  Three 
days  later  the  right  ventricle  was  punctured  and 
twenty  c.  c.  of  yellow  fluid  was  removed.  In  both 
specimens  of  fluid  there  were  red  cells,  increased 
globulin,  and  increased  cell  count,  most  of  which 
were  polymorphonuclears.  The  child  died  on  the 
thirty-seventh  day  and  autopsy  showed  a  fibrinous, 
hemorrhagic  meningitis  and  encephalitis.  There 
were  subpial  hemorrhages,  marked  internal  hydro- 
cephalus, subacute  pyelitis,  and  broncliopneumonia. 

Nature  of  the  Reducing  Substance  in  the  Urine 
of  Children  Suffering  from  Nutritional  Disorders. 

— Dr.  Oscar  M.  Schloss,  of  New  York,  said  that 
the  work  of  Langstein  and  Steinitz  had  led  them  to 
believe  that  this  reducing  substance  was  lactose  or 
galactose.  Experiments  which  he  had  carried  out 
did  not  confirm  this  finding.  The  only  reducing 
substance  which  he  had  found  constantly  present 
in  perceptible  amounts  was  glucose.  There  was 
usually  a  nonfermentable  reducing  substance  simi- 
lar to  that  found  in  normal  urine.  This  might  be 
lactose,  but  its  amount  was  too  small  to  identify  it 
with  certainty. 

Bodily  Mechanics  in  Relation  to  Cyclic  Vomit- 
ing and  Other  Obscure  Intestinal  Conditions. — 

Dr.  Fritz  B.  Talbot  and  Dr.  Llo\'d  T.  Browx. 
of  Boston,  stated  that  faulty  bodily  mechanics  had 
been  responsible  for  a  great  loss  of  efficiency  among 
adults  during  the  war.  Many  men  broke  down  in 
France  under  the  strain  of  training  and  war.  Such 
large  numbers  of  men  could  not  be  sent  home  and 
they  were  therefore  given  special  physical  training. 
This  brought  back  eighty  per  cent,  to  full  physical 
efficiency.  Of  seven  hundred  men  entering  Harvard- 
University,  twenty .  per  cent,  had  good  bodily  me- 
chanics and  eighty  per  cent,  had  bad"  mechanics. 
The  human  machine  might  be  far  from  the  standard 
type  and  might  yet  be  very  efficient  in  spite  of  phys- 
ical disability.  Poor  bodily  mechanics  were  more 
easily  prevented  and  corrected  in  childhood  than  in 
adult  life,  and  time  spent  on  training  at  this  age  pro- 
duced more  far  reaching  results  than  the  same  time 
spent  on  adults.  Three  abnormal  conditions  which 
came  in  children  with  poor  bodily  mechanics  were 
so  frequently  relieved  by  correcting  the  posture  that 
posture  must  be  considered  the  principal  cause  or 
the  principal  contributing  cause  of  these  conditions, 
granting  that  all  other  Causes  were  ruled  out.  Cor- 
recting improper  posture  often  corrected  chronic 
constipation,  hastened  the  cure  of  recurrent  vomit- 
ing, and  the  cure  of  certain  types  of  acute  abdominal 
pain  in  children. 

An  Epidemic  of  Hemorrhagic  Diarrhea  Due  to 
the  Streptococcus  Mucosus. — Dr.  A.  D.  Black- 
ader,  of  Montreal,  said  he  was  summoned  to 
Waterloo,  sixty  miles  southeast  of  Montreal,  because  . 
of  an  epidemic  of  diarrhea.  The  first  case  occurred 
on  March  22d,  five  on  the  following  day,  and  since 
then  the  number  had  increased  to  sixty-five  in  the 
town  itself  and  there  were  other  cases  withjn  a 
short  radius.  Adults  composed  about  one  fourth 
the  entire  number.  The  larger  proportion  of  cases, 
however,  occurred  in  children  under  the  age  of  six 


years.  The  attack  began  abruptly  with  high  fever, 
nervous  symptoms,  and  vomiting,  and  diarrhea  set 
in  early.  Mucus  and  blood  appeared  in  the  stools 
and  the  amount  increased  rapidly  as  the  stools 
became  more  frequent,  and  in  the  severe  cases 
seemed  to  form  almost  all  of  the  stool.  Blood  was 
a  prominent  feature  in  the  stools  in  sixty  per  cent, 
of  the  cases.  The  attack  lasted  from  a  few  days  to 
twelve,  fourteen  or  even  twenty-one  days.  The 
temperature  in  the  severe  cases  went  as  high  as  106", 
while  in  the  milder  cases  it  was  comparatively  low, 
100°  or  102°  F.  In  a  few  cases  there  was  no  rise 
above  normal.  Notwithstanding  the  severity  of  tlie 
cases  no  deaths  occurred.  Examination  of  the 
stools  in  one  case  showed  large  numbers  of  chains 
of  Streptococcus  encapsulatus,  and  about  an  ecjual 
number  of  colon  bacilli.  There  were  very  few  other 
bacteria.  There  were  no  organisms  of  any  of  the 
types  of  Bacillus  dysenteriae.  In  a  second  case 
examined  there  were  large  numbers  of  the  Strepto- 
coccus mucosus.  In  searching  for  the  origin  of 
this  epidemic  an  inspection  had  been  made  of  the 
milk  supply,  but  a  careful  study  of  the  situation 
seemed  to  eliminate  milk  as  the  source  of  infection. 
The  water  supply  came  from  springs  and  several 
of  these  were  .thought  to  be  insufficiently  protected 
against  contamination.  The  epidemic  occurred 
after  a  few  days  of  pronounced  warm  weather  when 
the  snows  melted  rapidly  on  a  frozen  soil.  The 
presence  of  such  large  numbers  of  the  Streptococcus 
mucosus,  associated  with  other  streptococci  and 
equal  numbers  of  colon  bacilli,  and  the  absence  of 
any  Bacillus  dysenteriae,  indicated  that  the  strepto- 
coccus must  be  regarded  as  the  chief  organism  in 
the  production  of  the  epidemic. 

Phlyctenular  Ophthalmia  and  Its  Relation  to 
Tuberculosis. — Dr.  Border  S.  Veeder  and  Dr. 
T.  C.  Hempelmann,  of  St.  Louis,  presented  this 
study  which  was  read  by  Dr.  Hempelmann.  He 
stated  that  there  was  a  widespread  impression  among 
l^ediatrists  that  phlyctenular  ophthalmia  was  closely 
associated  in  some  way  with  tuberculosis,  but  many 
ophthalmologists  were  as  yet  unwilling  to  concede 
this  relationship.  In  an  effort  to  gather  additional 
clinical  evidence  on  this  point,  196  children  with 
phlyctenular  disease  were  subjected  to  a  careful 
study  to  determine  the  possible  presence  or  absence 
of  tuberculous  infection.  The  study  revealed  an 
intimate  association  between  the  two  diseases. 
Skin  tuberculin  tests  were  positive  in  over  ninety- 
two  per  cent,  of  the  cases.  The  results  of  the  com- 
plement fixation  test  for  tuberculosis  were  strik- 
ingly similar  to  those  obtained  in  cases  of  proved 
tuberculosis.  Tuberculous  lesions  involving  other 
organs  than  the  eye  were  definitely  demonstrable  in 
over  half,  and  seemed  probable  in  almost  two  thirds 
of  the  cases.  Children  observed  over  periods  of 
one  year  or  more  showed  an  even  greater  proportion 
of  tuberculous  lesions,  more  than  four  fifths  of 
this  series  giving  such  evidence.  Cough,  malnutri- 
tion, and  history  of  exposure  to  other  cases  of 
tuberculosis  were  frequent.  No  other  points  were 
brought  up  in  the  study  which  would  seem  to  have 
a  bearing  on  the  etiology. 

(To  he  continued.) 


New  York  Medical  Journal 


INCORPORATING  THE 


Philadelphia  Medical  Journal     Medical  News 

A  Weekly  Review  of  Medicine,  Established  18Jf3. 


Vor..  CXII.  No.  26. 


NEW  YORK.  SATURDAY.  DECEMBER  2-5.  1920. 


Whole  No.  2195. 


Original  Communications 


VARIATION   IX   THE  R.\TE  OF  INFANT 

:\IORTALITY  IN  THE  UNITED  STATES 

BIRTH  REGISTRATION  AREA.* 

By  Raymond  Pearl.  Ph.D.. 
Baltimore,  Md. 

Until  recently  it  has  been  impossible  to  discuss 
on  any  accurate  or  satisfactor}"  basis  the  infant 
mortality  of  any  considerable  portion  of  the  United 
States.  This  difficulty  has  arisen  from  the  fact 
that  except  in  a  few  localities,  notably  some  of  the 
New  England  States,  there  has  been  in  the  past  no 
adequate  system  of  birth  registration.  The  most 
accurate  practical  method  of  presenting  the  subject 
of  infant  mortality  is  to  relate  the  number  of  deaths 
of  infants  under  one  year  of  age  in  a  given  time 
unit  to  the  number  born  in  the  same  time  unit. 
Consequently  one  needs  accurate  birth  statistics 
before  infant  mortality  can  be  adequately  discussed. 

It  is  a  matter  of  great  satisfaction  to  everyone 
interested  in  the  subject  of  infant  mortality  that  at 
last  there  is  well  established  a  birth  registration  area 
for  the  United  States,  and  four  annual  reports  on 
birth  statistics  of  this  area  have  been  issued  to  date 
by  the  census  bureau.  We  are  well  embarked  now 
on  the  policy  of  adequate  birth  statistics  for  the 
country  and  unquestionably  within  a  comparatively 
few  years  the  birth  registration  area  will  cover  the 
major  portion  of  the  country  as  the  death  registra- 
tion area  now  does.  In  the  short  period  since  the 
birth  registration  area  has  been  established  its 
growth  in  extent  has  been  gratifyingly  rapid.  The 
first  report  on  birth  statistics  for  the  year  1915 
comprised  data  from  an  area  including  approxi- 
mately thirty-one  per  cent,  of  the  population  of  the 
country.  The  1918  birth  statistics  report  gives  data 
from  an  area  including  fifty-three  per  cent,  of  the 
population.  This  furnishes  a  sufficient  volume  of 
material  so  that  one  may  begin  the  matlitmatical 
analysis  of  some  of  the  problems  of  infant  mor- 
tality with  some  assurance  of  reaching  valid  con- 
clusions. 

The  purpose  of  the  present  paper  is  a  modest 
one.  It  aims  simply  to  present  briefly  some  of  the 
facts  of  variation  in  rate  of  infant  mortality  in  dif- 
ferent geographic  or  demographic  units  of  the 
population.    The  first  step  in  the  solution  of  any 

*Papers  from  the  Department  of  Biometry  and  Vital  Statistic.^;, 
School  of  Hygiene  and  Public  Health,  Johns  Hopkins  University, 
No.  18.  Read  before  the  Eleventh  Annual  Meeting  of  the  Ameri- 
can Child  Hygiene  Association,  St.  Louis,  October  .11-13,  1920.  A 
preliminary  and  condensed  abstract  of  a  more  detailed  investiga- 
tion of  the  subject  to  be  published  shortly. 


problem  is  obviously  a  clear  definition  of  the  prob- 
lem itself.  We  shall  see,  as  we  pass  from  city  to 
city,  town  to  town,  or  rural  county  to  rural  county, 
that  the  rate  of  infant  mortality  varies  greatly.  In 
a  hypothetical,  visionary  community  where  the  most 
perfect  administrative  control  over  infant  mortality 
possible  or  conceivable  had  been  attained  this 
variation  would  largely  disappear,  the  only  residue 
of  diversity  between  communities  in  respect  of  in- 
fant mortality  being  such  as  arose  purely  by  the 
operation  of  chance,  that  is,  from  random  sampling. 
Now,  with  the  actually  existing  condition  of 
variation  between  different  communities  in  respect 
of  infant  mortality,  it  is  obvious  that  there  must  be 
particular  and  presumably  determinable  reasons  for 
each  particulate  difference  which  exists.  Operating 
on  a  basis  largely  of  empiricism  and  a  priori  rea- 
soning, efforts  to  reduce  infant  mortality  have  in 
the  past  been  attended  with  considerable  success. 
Also,  with  the  advance  of  general  sanitation  the 
death  rate  under  one  year  of  age  has  fallen  enor- 
mously. Greenwood  (1)  quotes  some  interesting 
figures  on  the  point  from  Farr,  which  we  may  well 
reproduce  here  to  show  how  great  has  been  the 
improvement. 


Period 


PERCEXT.\GE  DE.'MHS  UNDER  FIVE  YEARS. 
1730-49      .17-50-69      .  1770-89       1790-1809  1810-29 


74.5  63.0  51.5  41.3  31.8 
But  after  such  a  decline  as  these  figures  indicate 
the  continuation  of  the  business  offers  a  difficult 
problem  to  the  administrative  official,  whose  pro- 
cedures are  grounded  essentially  only  on  the  two 
pedestals  of  what  he  thinks  has  worked  in  the  past 
and  what  he  believes  logically  ought  to  work.  The 
easy  part  of  the  conflict  has  happened  and  is  in  the 
past.  To  continue  the  good  fight  with  the  same 
relative  measure  of  success,  one  presently  must 
needs  know  more  precisely  than  is  now  known  the 
pattern  of  the  causal  nexus  which  controls  and  de- 
termines the  rate  of  infant  mortality.  And  it  is  real 
knowledge,  not  a  priori  logic,  that  is  wanted.  Let 
a  single  example  illustrate.  It  has  been  maintained 
that  excessive  infant  mortality  is  primarily  the 
resultant  of  the  socalled  "degrading  influences"  of 
poverty,  and  such  a  contention  stirs  a  warmly 
sentimental  feeling  of  agreement  in  the  minds  of 
the  well-meaning  public  zealous  to  do  good.  This 
relationship  obviously  ought  to  be  true,  therefore 
to  a  too  common  type  of  mind  it  must  be  and  is 
true.  But  Greenwood  and  Brown  (2)  in  what  may 
fairly  be   regarded   the   most   thoroughly  sound. 


Copyright,  1920,  by  A.  R.  Elliott  Publishing  Company. 


1010 


PEARL: 


INFANT  MORTALITY. 


[New  Vokk 
Medical  Jovrxal. 


critical,  and  penetrating  contribution  which  has  yet 
been  made  to  the  problem  of  infant  mortality  are 
unable  "to  demonstrate  any  unambiguous  associa- 
tion between  poverty  .  .  .  and  the  death  rate  of 
infants." 

The  plain  fact  is  that  before  control  or  ameliora- 
tive measures  can  be  applied  with  the  maximum  of 
efficient  economy  to  the  general  public  health  prob- 
lem of  infant  ^mortality  we  must  know  a  great  deal 
more  than  we  now  do  about  the  '  factors  which 
induce  spatial  and  temporal  dif¥erences  in  the  rate 
of  that  mortaHty.  But  first  we  must  get  an  ade- 
quate conception  of  the  magnitude  and  character 
of  the  dififerences  themselves.  Let  us,  therefore, 
turn  to  the  examination  of  the  facts  regarding 
variation  in  infant  mortalitj-  in  the  United  States 
birth  registration  area. 

VARIATIOX  DATA. 

In  this  work  we  have  studied  the  variation  in  the 
rate  of  infant  mortality  (deaths  to  the  thousand 
births)  for  the  following  groups: 

1.  Total  population  in  cities  of  population  of  25,000  or 
over  in  1910. 

2.  Total  population  in  cities  of  under  25,000  population 
in  1910. 

3.  Total  population  in  rural  counties  of  registration 
states. 

4.  White  population  in  cities  of  population  of  25,000  or 
over  in  1910. 

5.  White  population  in  cities  of  under  25,000  population. 

6.  White  population  in  rural  counties  of  registration 
states. 

7.  Colored  population  in  cities  of  population  of  25.000  or 
over  in  1910. 

8.  Colored  population  in  cities  of  under  25,000  popula- 
tion. 

9.  Colored  population  in  rural  counties  of  registration 
states. 

In  order  to  make  possible  a  better  appreciation 
of  the  nature  of  the  frequency  distributions  a  chart 
(Fig.  1)  has  been  prepared.  This  shows  for  the 
year  1918  the  frequency  polygons  for  the  total 
population  of,  a,  cities  of  25,000  and  over,  b,  cities 
of  under  25,000,  and,  c,  rural  counties. 


25,000  and  over;'  b,  cities  of  under  25,000;  and,  c,  rural  counties. 

This  diagram  iS  fairly  representative  of  all  the 
distributions. 


The  most  striking  immediately  observable  feature 
of  these  distributions  is  the  great  range  of  variation 
which  they  exhibit.  For  example  in  1918  the  236 
cities  of  under  25,000  inhabitants  showed  infant 
mortality  rates  ranging  all  the  way  from  the  class 
40-59  deaths  to  the  thousand  births  to  the 
class  300-319  deaths  to  the  thousand  births.  The 
range  of  variation  is  even  greater  than  this  in  the 
case  of  the  distributions  for  the  colored  population. 
These  extraordinarily  large  ranges  of  variation 
demonstrate  perhaps  more  clearly  than  could  be 
done  in  any  other  way  the  opportunity  which  exists 
for  effective  administrative  contfol  and  reduction 
of  infant  mortality.  If  there  are  communities,  as 
there  are  in  plenty,  showing  infant  mortality  rates 
under  a  hundred  deaths  to  the  thousand  births  it 
suggests  at  once  that  it  is  possible  if  the  right  meas- 
ures are  systematically  and  efTectively  applied  to 
reduce  the  infant  mortality  in  those  other  communi- 
ties showing  very  high  rates  to  something  like  the 
level  of  these  at  present  more  fortunate  communities. 

In  Table  1,  are  presented  the  chief  physical  con- 
stants* of  the  distributions  of  variation  in  infant 
mortality.  These  constants  have  been  determined 
by  the  method  of  moments  from  the  original  raw 
data.  (I  am  greatly  indebted  to  my  assistant.  Mrs. 
Charmian  Howell,  for  aid  in  the  arithmetical  work 
of  this  paper.) 

The  constants  tabled  are : 

1.  The  arithmetic  mean. 

2.  The  median.  This  measures  the  value  above 
and  below  which  exactly  half  of  the  variates  occur. 

3.  The  standard  deviation.  This  constant  meas-  i 
ures  in  absolute  units  the  degree  of  "scatter"  or  i 
variation  exhibited  by  the  distribution.  ' 

4.  The  skewness.  This  constant  measures  the 
degree  of  asymmetry  of  a  frequency  distribution. 
If  a  distribution  is  perfectly  symmetrical  on  both 
sides  of  the  mean  so  that  if  folded  over  upon  the 
mean  as  an  axis  the  two  limbs  would  exactly  coin- 
cide, the  value  of  the  skewness  is  zero. 

From  the  data  presented  in  Table  I  the  following 
points  are  to  be  noted : 

1.  There  is  no  certainly  significant  decline  in  the 
mean  value  of  the  rate  of  infant  mortality  during  , 
the  four  years. covered  by  these  statistics  in  any  of 

the  demographic  units  considered. 

2.  In  1918  there  was  a  general  tendency  towards 
an  increase  in  the  mean  rate  of  mortality  over  that 
which  obtained  in  1917.  This  increase  is  unques- 
tionably to  be  attributed  to  the  influenza  epidemic 
of  the  autumn  and  winter  of  1918.  A  careful 
examination  of  the  rates  by  months  will  convince 
one  that  the  mortality  of  infants  increased  materially 
during  the  period  of  the  epidemic.  Whether  this 
increased  number  of  deaths  was  truly  to  be  charged 
to  influenza  does  not  concern  us  here.  The  impor- 
tant fact  .is  that  the  rate  of  infant  mortality 
markedly  Increased  coincidentally  with  the  existence 
of  the  epidemic.  It  is  noteworthy  that  this  increase 
in  the  infant  mortality  rate  in  1918  is  practically 
confined  to  the  cities.    The  rural  counties,  whether 

'  For  .1  very  brief  and  summarized  introduction  to  the  modern 
mathematical  treatment  of  frequency  curves  see  Pearson,  K. 
Tables  for  Statisticians  and  Bionictricians.  1914,  pp.  Ix  to  Ixx. 
References  to  the  basic  literature  on  the  subject  wdl  be  found  there. 


December  25.  1920.] 


PEARL:   I X PANT  MORTALITY. 


1011 


for  white  or  colored  or  total  population,  show  little 
or  no  change  in  1918  as  compared  with  1917.' 

3.  There  is  no  unequivocal  difference  in  the  mean 
rates  of  infant  mortality  in  the  larger  as  compared 
with  the  smaller  cities.  Considering  the  largest  dif- 
ferences in  mean  rates  for  total  populations  in  cities 
of  25,000  and  over  as  compared  with  cities  of  under 
25.000  there  is  no  difference  which  is  as  much  as 
even  three  times  its  probable  error. 

4.  The  mean  rates  of  infant  mortality  are  notably 
smaller  in  the  rural  than  in  the  urban  areas.  This 
fact  has,  of  course,  long  been  well  known.  The 
first  writer  on  vital  statistics,  in  the  sense  in  which 
we  now  understand  that  subject.  Captain  John 
Graunt,  more  than  250  years  ago  pointed  out  that 
rural  communities  exhibited  generally  a  lower  rate 
of  mortality  than  urban  communities.  The  differ- 
ence between  urban  and  rural  rates  of  infant  mor- 
tality is  reflected  just  as  clearly  in  the  high  absolute 


that  the  greater  the  variation  exhibited  by  a  given 
class  of  the  community  in  respect  of  infant  mor- 
tality, the  greater  the  chance  of  effective  control 
and  reduction  of  the  average  infant  mortality  by 
administrative  measures.  There  can  be  no  question 
that  there  is  no  field  which  offers  so  great  oppor- 
tunities in  this  direction  as  the  colored  population. 

7.  The  skewness  is  seen  to  be  positive  in  sign 
in  every  case  but  one.  In  that  case  (1916,  cities 
over  25,000,  total)  the  skewness  is  not  significant 
in  comparison  with  its  probable  error.  With  this 
exception  the  curves  tend  to  tail  off  more  gradually 
and  farther  towards  the  right  end  than  towards  the 
left  end  of  the  range.  In  other  words,  the  rate  of 
infant  mortality  in  these  different  American  demo- 
graphic units  tends  generally  to  distribute  itself  in 
a  substantially  asymmetrical  fashion  about  the 
mean,  extremely  high  rates  occurring  more  fre- 
quently than  correspondingly  low  rates.    This  fact 


TABLE  I. 

Constants  of  variation  in  rate  of  infant  mortality  {deaths  under  the  age  of  one  to  the  1000  births) 


Group 

Cities  over  25,000",  Total, 


Cities  unacr  25.000', 


1917. 


  "  1917. 

1918. 

Rural   counties,   Total,  1915  

1916  

"    "  ."'  '•  1917  

1918  

Cities  over  25,000',  White,  1917. 

1918. 

Cities  under  25,000',  White,  1917. 

Rural  counties.  White, 

Cities  over  25,000',  Co 

Cities  under  25,000',  Colored,  191 
19] 

Rural  counties,  Colored,  1917.... 

1918  

»  In  1910. 


1917. 
1918. 


Mean  (2) 

Median  (2) 

Standard  deviation  (2) 

Skeuness 

104.49  -t- 

1.78 

102.76 

26.14  -H  1.26 

-r 

.3148  -i- 

.0937 

102.53  ■+■ 

1.67 

103.24 

24.69  -i-  1.18 

.0786  ± 

.0848 

99.58  -i- 

1.32 

98.00 

23.45  -!-  .93 

-1- 

.2455  ±  .0858 

107.78  -t- 

1.41 

105.50 

25.07  ■+-  1.00 

.3237  -h 

.0800 

100.98  -t- 

1.68 

97.95 

30.81  -H  1.18 

.1934  -!- 

.0657 

104.23  -t- 

1.75 

101.03 

32.38  -1-  1.24 

-1- 

.2217  -t- 

.0678 

99.24  -1- 

1.32 

94.74 

29.94  .93 

.4840  -1- 

.1197 

111.61  ■+- 

1.66 

104.17 

37.78  -1-  1.17 

-r 

.5625 

83.07  -t- 

.85 

79.54 

23.95  -+-  .60 

.3204  -!- 

.1454 

85.28  -1- 

.90 

82.15 

25.94  -1-  .63 

.3536  -r- 

.0509 

82.01  -1- 

.52 

78.96 

25.71  -h  .37 

.2833 

.1157 

84.43  -H 

.57 

80.97 

28.40  ■+■  .40 

-r 

.4328  ± 

.0409 

92.22 

2.02 

92.14 

15.60  ^  1.43 

102!59  ■+■ 

2.00 

99.23 

15.42  -i-  1.42 

98.46  -f- 

2.75 

97.50 

20.82  -i-  1.95 

114.62  -1- 

4.17 

113.33 

31.49  H-  2.95 

86.21  -h 

1.07 

84.24 

24.15  -+■  .76 

.1799 

85.90  -1- 

J.27 

83.75 

28.90  -1-  .90 

-j- 

.2802  ± 

.0650 

202.59 

8.88 

194.00 

68.45  -+-  6.28 

216.67  -H 

11.15 

214.0C 

85.87  -i-  7.88 

213.08  -1- 

9.92 

228.00 

74.96  -)-  7.01 

217.69  -!- 

11.46 

225.00 

86.65  8.10 

134.76  -f- 

2.55 

127.25 

57.37  -i-  1.80 

.4984 

147.26  -H 

2.92 

134.59 

66.15  ■+-  2.06 

.5819 

'In  concrete  units,  i.e.  rate  of  deaths  under  1  per  1000  births. 


rates  of  t,he  colored  population  as  it  is  in  the  lower 
rates  of  the  white  population. 

5.  The  mean  rates  of  infant  mortality  are. 
roughly  speaking,  something  like  twice  as  high  for 
the  colored  population  as  for  the  white  population 
in  each  of  the  demographic  units  considered,  and 
at  all  times.  This  again  is  a  fact  in  general  well 
known,  but  here  we  have  precise  figures  on  the 
point,  with  probable  errors,  which  show  definitely 
how  tremendously  poorer  the  negro  baby's  chances 
of  surviving  the  first  vear  of  life  are  than  the  white 
baby's. 

6.  The  cities  of  over  25,000  exhibit  distinctly 
less  variation  in  respect  of  infant  mortality  than  do 
either  the  smaller  cities  (under  25,000)  or  the  rural 
counties.  The  smaller  cities  and  the  rural  counties 
exhibit  about  the  same  degree  of  variation  relative 
to  their  means,  but  absolutely,  in  terms  of  standard 
deviation,  the  rural  counties  show  less  variabilitv 
than  the  cities  under  25,000.  The  colored  distri- 
butions exhibit  a  much  higher  degree  of  variation 
in  respect  of  infant  mortality  however  measured, 
whether  absolute  or  relative,  than  do  the  white 
populations.    In  general,  it  may  fairly  be  assumed 


might  perhaps  be  taken  to  indicate  that  the  task 
confronting  the  administrative  control  of  infant 
mortality  in  the  United  States  and  yet  to  be  accom- 
plished is  even  greater  than  what  has  already  been 
accomplished  in  the  past,  great  and  worthy  of  com- 
mendation as  that  is. 

D.\TA    ox     THE    LIMITATIONS    TO    ADM  I X  ISTR.\TI\'E 
COXTROL  OF  IXFAXT  MORTALITY. 

^^'e  have  seen  that  there  is  a  high  degree  of  vari- 
ation in  the  rate  of  infant  mortality  as  we  pass  from 
community  to  community.  Some  communities  have 
infant  mortality  rates  several  times  higher  than 
those  prevailing  in  other  communities  of  the  same 
size.  This  creates  the  presumption  at  once  that 
proper  administrative  activity  might  reduce  the 
rates  of  these  abnormally  high  communities  to  a 
level  commensurate  with  those  found  in  the  lower 
group.  It  is  the  purpose  of  this  section  of  the  paper 
to  examine  this  presumption  critically. 

At  the  start  it  is  evident  that  there  are  some 
causes  of  infant  mortalitj'  which  are,  in  their  ver\- 
nature,  beyond  hope  of  effective  practical  human 
control.  Thus,  children  born  with  marked  congeni- 
tal hydrocephalus  will   presently  die,  in   spite  of 


1012 


PEARL:  INFANT  MORTALITY. 


[New  York 
Medical  Journal. 


Other  forms  of  tuberculosis 
Syphilis 


anything  the  health  officer  can  do,  no  matter  how 
active  and  intelligent  he  may  be.  There  are  many 
other  causes  of  death  falling  in  essentially  the  same 
category  in  this  respect. 

Not  as  any  final  or  dogmatic  settlement  of  the 
matter,  but  rather  as  a  tentative  first  approximation 
made  for  the  purpose  of  seeing  whether  any  sug- 
gestive lead  may  appear,  I  have  ventured  to  attempt 
to  classify  the  principal  causes  of  mortality  in  the 
first  year  of  life  into  two  groups.  The  first  of 
these  groups  aims  to  include  those  important  causes 
of  infant  mortality  which  are  either,  a,  actually  now 
effectively  controlled  by  the  efforts  of  health  offi- 
cials, either  directly  or  indirectly  through  general 
sanitary  and  hygienic  improvements,  or,  b,  are 
obviously  capable  theoretically  of  control  and 
amelioration  if  sufficient  pains  be  taken.  The 
second  group  aims  to  include  those  causes  of  infant 
deaths  which  are,  in  the  nature  of  the  case,  out  of 
the  present  range  of  effective  practical,  direct  con- 
trol or  amelioration.  Let  us  see  what  such  a  classi- 
fication, to  a  first  approximation,  looks  like. 

TEXTATIVE  CLASSIFICATIOX  OF  PRINCIPAL  CAUSES  OF  IXFAXT 
MORTALITY. 

A. — Causes  of  death  actually  no-w      B. — Causes    of    death    not  now 
well    controlled,    or    capable  capable  practically  of  direct 

theoretically    of   direct    con-  control, 
trol  in  greater  or  less  degree. 

Measles  Tuberculosis  of  the  lungs 

Scarlet  fever 

Whooping  cough  Tuberculous  meningitis 

Diphtheria  and  croup 
Dysentery 
Erysipelas 
Tetanus 

Meningitis  Organic  diseases  of  the  heart 

Convulsions 

Acute  bronchitis  Malformations 
Pneumonia  r>        ^       i,-  ^i. 

Bronchopneumonia       -  Premature  birth 

Diseases  of  the  stomach  Congenital  debility 

Diarrhea  and  enteritis 

External  causes  Injuries  at  birth 

One  realizes  that  it  is  a  bold  thing  even  to  set 
down  such  a  classification  as  the  above.  It  is  cer- 
tain to  stir  up  the  rancor  of  extremists  in  both 
directions.  But  extremists  are  nearly  always  wrong. 
Calm  and  unprejudiced  persons  will  admit  that  some 
such  classification  as  that  here  attempted  is  possible. 
Perhaps  some  further  discussion  of  this  classifica- 
tion may  make  clearer  its  point  of  view,  and  may 
win  at  least  that  measure  of  agreement  with  it  which 
will  at  least  permit  the  consideration  of  the  discus- 
sion of  its  consequences  which  follows. 

Taking  column  A  first,  j^resimiably  no  competent 
health  official  would  deny  that  the  first  five  diseases 
in  the  list  (measles,  scarlet  fever,  whooping  cough, 
diphtheria  and  croup,  and  dysentery)  have  been,  can 
be,  and  are  in  greater  or  less  degree  effectively  con- 
trolled in  respect  both  of  their  incidence  and  their 
mortality.  With  this  same  group  clearly  belongs 
also  diarrhea  and  enteritis,  and  convulsions,  on  the 
justifiable  assumption  that  in  the  vast  majority  of 
cases  convulsions  in  infants  are  con.scquent  upon 
violent  enteric  infections,  which  clearly  belong  in 
the  controllable  class.  Diseases  of  the  stomach,  as 
causes  of  death  under  one  year  of  age,  again  in 
the  vast  majority  of  cases  undoubtedly  tnean  infec- 
tion— filth  diseases,  in  short — which  come  in  the 
same  category,  so  far  as  concerns  control,  as  diar- 


rhea and  enteritis.  Regarding  the  rest  of  the 
diseases  in  the  A  group  (erysipelas,  tetanus,  menin- 
gitis, acute  bronchitis,  pneumonia,  bronchopneu- 
monia, and  external  causes),  the  point  of  view  which 
led  to  their  inclusion  here  is  as  follows:  Tf  the 
environmental  conditions  surrounding  the  infant  in 
the  community  and  in  the  home,  and  the  care  given 
it,  were  made  as  favorable  as  they  might  be  made, 
and  actually  are  in  the  homes  of  the  hygienically 
intelligent  well  to  do,,  the  death  rate  from  each  of 
these  causes  would  be  enormously  reduced  relatively 
in  comparison  with  what  it  actually  is.  As  a  matter 
of  fact,  visiting  child  welfare  nurses  are  doing  a 
mighty  work  in  just  this  direction  in  many  com- 
munities. They  teach  parents  how  to  care  for  their 
infants,  protect  them  from  these  infections,  and 
nurse  them  to  a  non- fatal  issue  in  many  cases  if  they 
do  get  infected.  No  one  who  knows  at  first  hand 
what  child  welfare  public  health  nursing  is  actually 
accomplishing  in  these  directions  will  question  the 
putting  of  these  diseases  in  the  controllable  column. 
Their  mortality  rate  can  be  materially  reduced  if 
communities  will  take  the  trouble  to  go  intelligently 
about  it. 

Now  for  the  B  column.  The  first  three  items 
are  the  various  forms  of  tuberculosis.  The  fanatic 
will  no '  doubt  promptly  and  violently  assert  that 
nothing  is  so  easily  and  readily  controllable  as  these. 
But  let  us  make  haste  slowly  and  remember  certain 
things:  First,  that  we  are  here  talking  about  deaths 
under  one  year  of  age,  that  is  fatal  tubercitlosis  in 
the  first  niontks  of  life;  and  second,  that  our  classi- 
fication premises,  in  specific  and  stated  terms,  direct 
control,  that  is,  control  through  agencies  now  capa- 
ble of  being  brought  to  act  directly  upon  the  infant 
or  his  environment.  Is  any  competent  and  experi- 
enced health  officer  prepared  seriously  to  assert 
that  he  can,  by  measures  applied  to  the  infant  or 
his  environment,  significantly  reduce  the  mortality 
from  tuberculosis  in  infants  under  one  year  of  age? 
If  anyone  has  the  temerity  to  make  such  an  asser- 
tion the  instant  demand  will  be  for  his  evidence. 
It  is,  of  course,  recognized  that  the  infant  mortality 
rate  from  tuberculosis  may  theoretically  be  reduced, 
and  presumably  some  time  will  be,  by  reduction  of 
the  prevalence  of  adult  tuberculosis.  But  this  is 
beside  the  point  for  present  consideration,  for 
reasons  stated  above,  and  from  the  further  fact  that 
administrative  measures  are  not,  in  reality,  con- 
trolling or  ameliorating  the  infant  mortality  from 
tuberculosis. 

About  fatal  congenital  syphilis,  fatal  congenital 
organic  diseases  of  the  heart,  congenital  nialfonna- 
tions  grave  enough  to  be  fatal  in  the  first  year  of 
life,  and  fatal  congenital  debility,  there  will  probably 
be  no  dispute.  Regarding  premature  birth,  and 
injuries  at  birtli,  much  the  .same  reasoning  applies, 
but  with  the  additional  consideration  that  presum- 
ably intelligent  prenatal  education  of  the  mothers 
and  improvement  of  prenatal  environmental  condi- 
tions would  reduce  these  mortality  rates  in  some 
unknown,  but  .probably  not  very  large  degree. 
There  is  no  tangible  evidence  that  these  causes  of 
death  are  in  effect  administratively  controlled  in  any 
appreciable  degree  in  this  country  at  this  time. 

Finally,  it  should  be  .said  that  one  occasionally 


Dec  mbei-  .^5.  19JU.] 


PEARL:   JM'A.XT  MURTALIT) 


1U13 


important  cause  of  infant  mortality  is  omitted 
entirely  from  the  classification.  This  is  influenza. 
The  reason  for  the  omission  is  simply  that  the 
statistical  discussion  which  follows  is  based  upon 
1918  mortality  figures  and  inasmuch  as.  that  was  a 
year  in  which  the  influenza  mortality  was  abnormally 


TABLE  II. 

SHOWI.NG    THE   DEATHS   UNDER  ONE 

YEAR  OF 

ACE   TO   THE  1000 

LIVIX 

BIRTHS  FOR, 

CONTROI 

I  ED,  .\ND 

.  E,   .NONC  ONTROI  LED  CAUSES 

OF 

DE.ATH 

I.N'  CERT.\ 

N      .AMERICAN      CITIES  OF 

100, OUO 

POPUL.^TIOX'  OR 

OVER  I.N 

IQIO. 

—  Deaths  under  one  year  — 

'  A. 

A. 

B. 

B. 

From 

Rate 

Rate 

causes 

Rate 

From 

of     per  100 

controlled  of 

causes 

noncon- 

births 

Births 

ill  some 

controlled  not 

t  rolled  from  ai 

City 

1)1  1918 

degree 

deaths 

controlled 

deaths 

causes 

Bridgeport  .... 

4,910 

226 

46 

224 

46 

100 

Xew  Haven  .  . . 

4,869 

190 

39 

200 

41 

90 

Washington    .  . . 

8,1-62 

399 

49 

450 

55 

112 

Indianapolis  .  . . 

6,196 

270 

44 

269 

44 

93 

4,368 

239 

55 

210 

48 

112 

Baltimore   

15,143 

1,225 

81 

847 

56 

149 

Boston   

20,062 

1,092 

54 

984 

49 

115 

Cambridge    ;  . .  . 

2,672 

144 

54 

111 

42 

107 

Fall  River  

3,646 

403 

111 

183 

50 

180 

3,286 

302 

92 

180 

55 

159 

Worcester  .... 

5,238 

212 

40 

248 

47 

97 

27,036 

1,296 

48 

1,199 

44 

100 

Grand  Rapids  .  . 

2,836 

110 

39 

119 

42 

86 

Minneapolis   .  .  . 

8,704 

198 

23 

358 

41 

73 

St.  Paul   

5,155 

160 

31 

135 

26 

87 

2,153 

96 

45 

122 

57 

115 

Buffalo   

13.989 

866 

52 

653 

47 

121 

Bronx  Borough 

16,763 

496 

30 

669 

40 

75 

Brooklyn  Bor.  . 

49,515 

2  232 

45 

1,889 

38 

90 

Manhattan  Bor. 

59,227 

2,855 

48 

2,456 

41 

97 

Queens  Borough 

9,467 

389 

41 

417 

44 

93 

Richmond  Bor. 

2,677 

113 

42 

139 

52 

106 

6,855 

283 

41 

276 

40 

92 

Syracuse   

4.352 

265 

61 

206 

47 

119 

Cincinnati  .... 

7,913 

326 

41 

404 

51 

104 

Cleveland   

20,699 

963 

47 

790 

38 

98 

Columbus   

4,464 

163 

37 

255 

57 

101 

Davton   

3,282 

109 

33 

143 

44 

87 

Toledo   

5,524 

186 

34 

270 

49 

94 

Philadelphia 

43,408 

2,876 

66 

1,993 

46 

124 

Pittsburgh  .... 

15,875 

1,179 

74 

805 

51 

139 

Scranton   

3,139 

263 

84 

141 

45 

141 

Providence 

6,384 

342 

54 

352 

55 

123 

Richmond,   Va. . 

3,840 

199 

52 

285 

74 

147 

Seattle   

5,910 

93 

16 

218 

37 

61 

Spokane   

2,194 

55 

25 

90 

41 

77 

Milwaukee  .... 

11.090 

574 

52 

4SS 

44 

106 

heavy,  owing  to  the  epidemic,  it  was  thought  that 
it  would  be  unfair  to  the  general  relationships 
exhibited  to  include  this  epidemic  mortality.  Pre- 
sumably normal  endemic  influenza  should  be  in  the 
A  group,  on  the  same  reasoning  as  the  pneumonias. 

With  so  much  of  explanation  as  to  the  point  of 
view  of  this  classification,  let  us  examine  some  of 
its  statistical  consequences.  These  consequences  I 
have  tested  in  a  preliminary  way  upon  the  Ijirth  and 
death  data  for  certain  large  cities  and  the  registra- 
tion states  in  1918.  There  were  found  to  be  thirty- 
seven  large  cities  included  in  both  birth  and  death 
registration  areas  in  that  year,  and  twenty  states. 
For  each  of  these  cities  and  states  the  births  were 
taken  from  the  1918  birth  statistics  and  the  deaths 
under  one  3'ear  of  age  according  to  causes  from 
Table  II  of  the  19.18  mortality  statistics.  From 
these  data  the  rates  per  thousand  living  births  for 
all  class  A  and  all  class  B  diseases  were  separatelv 
calculated.  The  results  are  set  forth  in  Tables  II 
and  III. 

In  the  last  column  of  these  tables  the  gross  infant 
mortality  rates  from  all  causes  of  death  have  been 
inserted  for  comparison  and  to  furnish  the  basis  of 
certain  discussions  which  will  follow.  It  will  be 
noted  that  the  five  boroughs  of  New  York  City  have 
been  treated  as  separate  cities.  This  appears  to  be 
entirely  justifiable,  both  on  grounds  of  size  and  of 
diflferentiation,  any  two  of  these  boroughs  being  as 


much  differentiated  biologically  and  demograj)hically 
as.  for  example,  Minneapolis  and  St.  Paul. 

The  fir.st  point  which  strikes  one  in  examining 
Tables  II  and  III  i.s- that  in  the  group  of  causes  of 
death  subjected  to  our  classification  (which  includes 
in  most  cases,  as  will  be  seen,  something  over  ninety 
per  cent,  of  all  the  mortality  imder  one  year  of 
age )  the  controllable  and  uncontrollable  causes  are 
responsible  "for  approximately  an  equal  degree  of 
mortalit}".  In  other  words,  it  appears  that  if  any 
degree  of  justification  attaches  to  the  classification 
here  suggested,  the  infant  mortajity  beyond  present 
control  by  administrative  measures  is  by -no  means 
a  negligible  fraction  of  the  total  infant  mortality. 
On  the  contrary,  it  represents  a  substantial  lower 
limit  below  which  the  health  officer,  no  matter  how 
zealous  and  intelligent  his  activities,  may  not  hope 
to  go  at  the  present  time,  or  in  the  indefinite  future. 

If  there  is  a  substantial  moiety  of  the  existing 
infant  mortality  which  is  beyond  control  by  admin- 
istrative measures  at  present,  and  is  essentially  un- 
affected by  the  present  or  past  application  of  such 
measures,  we  should  expect  that  the  rate  of  mor- 
tality represented  by  this  moiety  would  va'ry  but 
little  from  city  to  city  or  state  to  state.  As  we  have 
seen,  the  reason  why  the  major  portion  of  this  part 
of  the  total  infant  mortality  is  beyond  control  is 
because  it  depends  tipon  fundamental  biological 
factors  inherent  in  the  parents  and  the  infants. 
Clearly  if  this  is  so.  whatever  variation  appears 
in  this  portion  of  the  total  infant  mortality  rate 
as  we  pass  from  community  to  community  must 
arise  from  some  combination  of  two  factors,  of 
which  the  first  and  less  important  is  pure  chance, 
that  is,  variation  arising  from  random  sampling 
purely :  and  of  which  the  second  is  diflfering  racial 
and  other  biological  characteristics  of  the  popula- 
tions of  the  several  communities.    We  should  expect 

TABLE  III. 


SHOWING   THE    DE.\THS   UNDER   ONE    YEAR   OF    .\GE   TO   THE    lOOO  LIVING 
BIRTHS  FOR.  A,  CONTROLLED,  AND.  B.  NON CONTROLLED  CAUSES  OF 
DE.\TH    IN    TWENTY    REGISTRATION  STATES. 


/■ 

Deaths  under  one  \ear  — 

A. 

A. 

B. 

B. 

From 

Rate 

Rate 

causes 

Rate 

From 

of 

per  1000 

controlled 

of 

causes 

noncoi 

-  births 

Births 

in  some  controlled  not 

trolled  from  all 

State 

in  1918 

degree 

deaths 

controlled  deaths 

causes 

Connecticut    .  . . 

36,971 

1.755 

47 

1,723 

47 

107 

Indiana   

64,385 

2,482 

39 

2,526 

39 

87 

Kansas   

39,117 

1.163 

30 

1,522 

39 

80 

62,338 

2,325 

37 

2,328 

37 

93 

Maine  r  

16,798 

670 

40 

743 

44 

101 

Marvland   

34,113 

2,531 

74 

1.730 

51 

140 

Massachusetts  . 

95,640 

5.284 

55 

4,324 

45 

113 

Michigan   

91,011 

3,496 

38 

3,760 

41 

89 

Minn<  sota  .... 

55,941 

1.317 

24 

2,060 

37 

71 

Xew  Hampshird 

9,642 

451 

47 

499 

52 

113 

Xew  York   

242,155 

10,897 

45 

10,333 

43 

97 

Xorth  Carolina. 

75.525 

2,850 

38 

2,319 

31 

102 

Ohio   

124.586 

5,029 

40 

5,206 

42 

94 

Pennsylvania  .. 

220,170 

14,506 

66 

10,295 

47 

129 

Rhode  Island  .  . 

15,499 

947 

61 

783 

51 

126 

Utali   

14,478 

308 

21 

474 

33 

64 

Vermont   

7,507 

258 

34 

343 

46 

93 

Virginia   

63,062 

2,529 

40 

2,448 

39 

103 

Washington    .  .  . 

25,682 

544 

21 

980 

38 

69 

Wisconsin  .... 

60,867 

1,854 

30 

2,334 

38 

79 

the  variation  in  the 

death 

rate 

from 

the  class  B 

group  of  causes  to  show  very  little  variation  as 
compared  either  with  the  variation  in  the  rate  from 
class  A  causes  or  in  the  gross  infant  mortality  rate 
from  all  causes.  This  a  priori  expectation  is 
realized  in  the  actual  statistics. 

It  is  seen  that  the  class  B  causes  of  death,  which 
are  not  practically  capable  of  administrative  control 


1014 


BREWER:  INFANT  MORTALITY. 


[New  York 
Medical  Journal. 


or  amelioration  at  the  present  time,  exhibit  less 
than  half  as  much  variation  in  the  rate  of  infant 
mortality  for  which  they  are  responsible,  as  we 
pass  from  city  to  city  or  from  state  to  state,  as  do 

TABLE  IV. 

FREQUENCY   DISTRIBUTIONS    OF   VARIATION    IN    RATES   OF  MORTALITY 
UNDER   ONE   PER   THOUSAND   BIRTHS   FOR,    A,    CONTROLLED,  AND, 
B,     NONCONTROLLED  CAUSES. 


Rate 

15-24  . 

25-34  . 

35-44  . 

45-54  . 

55-64  . 

65-74  . 

75-84  . 

85-94  . 

95-104. 
105-114. 
115-124. 
125-134. 
135-144. 
145-154. 
155-164. 
165-174. 
175-184. 


A. 
Causes 
2 
5 
9 

13  . 


-  Cities  ^ 

B.  All 
Causes  Causes 

i 
16 

13 

5  1 
2  1 
2 
9 
7 
5 
6 


1 


A. 
Causes 
3 
3 
7 
3 
2 


■  States  - 

•  B. 
Causes 


All 
Causes 


Totals. 


37 


20 


20 


20 


37  37 
TABLE  V. 

VARIATION    CONSTANTS   FROM   THE   DISTRIBUTIONS   OF   T.\BLE  IV. 

Standard 

Group  Mean  Median  deviation 

Cities,  A,  controlled  causes.  49.46  ±  2.04       47.08  18.37  ±  1.44 
Cities,  B,  noncontrolled 

causes    47.30  ±    .90        46.15         8.09  ±  .63 

Cities,  all  causes    107.84  ±  2.75  102.86  24.78  ±  1.94 

States,  A,  controlled  causes.  42.00  ±  2.17       40.71  14.41  ±  1.54 
States,  B,  noncontrolled 

causes    42.50  ±    .83       42.27         5.52  ±  .59 

States,  all  causes    97.00  ±  3.03       95.00  20.07  ±  2.14 

the  class  A  causes  of  death,  which  are  capable  of 
administrative  control.  This  relation  is  true,  how- 
ever the  variation  is  measured.  This  is  a  novel 
result,  of  interest  from  several  points  of  view. 

In  the  first  place,  the  suggestion  lies  near  at  hand 
that  if  the  class  A  causes  of  death,  which  are" 
controllable,  show  such  great  variation  relatively  as 
they  do,  it  must  mark  an  approximately  equal  varia- 
bility in  the  zeal,  intelligence,  and  efficiency  of  the 
administrative  health  officials  of  these  communities. 
Anyone  at  all  familiar  with  the  organizations  of 
municipal  and  state  health  departments  in  this  coun- 
try will  find  it  extremely  interesting  to  study  in 
detail  the  entries  of  Tables  II  and  III,  noting  how 
the  class  A  (controlled)  and  the  all  causes  rates 
fluctuate  up  and  down,  while  the  class  B  (non- 
controlled)  rates  stay,  with  a  very  few  exceptions, 
so  extremely  constant.  One  will  observe,  with  great 
satisfaction,  what  splendid  work  is  being  done  in 
some  communities  in  holding  down  to  a  low  level 
the  infant  death  rate  from  controllable  causes. 
Table  II  forms  a  real  justification  of  the  faith  that 
is  in  the  public  health  official  of  vi.sion.  It  shows 
that  the  infant  mortality  from  controllable  causes 
"can  be  kept  down  to  a  low  level,  and  is  in  some 
communities.  In  the  following  cities  (seventeen  out 
of  thirty-seven)  the  rate  of  infant  mortality  from  the 
controlled  causes  of  class  A  is  actually  lower  than 
the  rate  from  the  noncontrolled  causes  (class  B)  : 

New  Haven  Cincinnati 

Washington  Columbus 

Worcester  Dayton 

Grand  Rapids  Toledo 

Minneapolis  Providence 

Alban}'  Richmond 

Borough  of  the  Bronx  Seattle 

P>orough  of  Queens  Spokane 
Borough  of  Richmond 


These  cities  stand  as  examples  of  the  fact  that 
a  considerable  portion  of  the  infant  mortality  rate 
can  be  eflfectively  controlled  on  the  basis  of  knowl- 
edge we  now  passed. 

SUMMARY. 

This  paper  is  a  first  biometric  survey  of  the 
infant  mortality  statistics  of  the  recently  established 
birth  registration  area.  It  is  to  be  regarded  as  pre- 
liminary to  certain  analytical  studies  of  the  problem 
of  infant  mortality  now  in  progress  in  this  labora- 
tory. The  chief  results  of  the  paper  are  first  to  set 
forth  and  discuss  the  chief  analytical  constants  of 
variation  in  infant  mortality  in  the  different  demo- 
graphic units.  This  variation,  which  is  large  in 
amount,  markedly  and  consistently  skew  in  the 
positive  direction,  and  markedly  leptokurtic,  defines 
and  throws  into  high  relief  the  fundamental  public 
health  or  administrative  problem  of  infant  mortality. 
Why  do  the  communities  having  rates  of  infant 
mortality  higher  than  the  mode  occupy  that  position  ? 
Is  it  from  causes  capable  of  human  control,  or  from 
causes  beyond  the  present  possibility  of  such  con- 
trol? A  special  preliminary  analysis  of  the  data 
for  cities  of  over  100,000,  and  the  registration  states, 
indicates  that  causes  of  death  capable  of  adminis- 
trative control  are  chiefly  responsible  for  the  varia- 
tion observed  in  the  total  infant  mortality  rate, 
while  those  causes  of  infant  deaths  which,  for 
fundamental  biological  reasons,  are  incapable  of 
being  sensibly  influenced  or  controlled  at  the  present 
time  by  administrative  measures,  are  a  highly  stable 
and  constant  factor,  from  community  to  community 
contributing  little  to  the  observed  variability  of  the 
total  infant  mortality  rate.  In  absolute  terms,  how- 
ever, these  causes  of  death  not  administratively 
controlled  are  responsible  for  roughly  forty  per 
cent,  of  the  total  infant  mortality  in  the  communi- 
ties discussed. 

REFEREXCES. 

1.  Greenwood,  M.  :  Infant  Mortality  and  Its  Adminis- 
trative Control,  Eugenics  Review,  October,  1912,  pp.  (of 
reprint)  1-23. 

2.  Greenwood,  M.,  and  Browx,  J.  W. :  An  Examination 
of  Some  Factors  Influencing  the  Rate  of  Infant  Mortality, 
J  our.  Hyg.,  vol.  xii,  pp.  5-45,  1912. 

JoHxs  Hopkins  University. 


THE  INFANT  MORTALITY  IN  THE  CITY 
OF  WATERTOWN,  N.  Y. 
During  the  Period  of  1916  to  1919,  Inclusive. 

By  Isaac  W.  Brewer,  M.  D., 
Watertown,  N.  Y. 

Prior  to  taking  office  as  health  officer  of  the  City 
of  Watertown  a  preliminary  survey  of  the  vital 
statistics  of  the  city  was  made.  This  disclosed 
among  other  things  that  the  infant  mortality  was 
somewhat  higher  than  obtained  in  other  cities  in  the 
state  of  the  same  class.  After  taking  office  the 
study  was  extended  to  include  the  period  from 
1916  to  1919  and  this  paper  is  based  upon  that  study. 
It  showed  that  there  were  2,996  births  exclusive  of 
stillbirths  of  which  there  were  115  or  three  and 
seven  tenths  per  cent,  of  all  the  pregnancies  re- 
corded during  the  period.    The  records  show  that 


December  25,  19J0.] 


BREWER:  IXFAXT  MORrALITY. 


1015 


tliere  were  also  ninety- four  premature  births  or 
two  and  seven  tenths  per  cent,  of  all  the  recorded 
pregnancies.  It  therefore  appears  that  six  and  four 
tenths  per  cent,  of  all  the  pregnancies  resulted  in 
disaster.  Of  the  3,111  pregnancies  recorded  110 
or  three  and  five  tenths  per  cent,  were  attended  by 
niidwives  or  inembers  of  the  family.  The  greatest 
number  of  such  deliveries  was  thirty-three  in  1917 
and  there  has  been  a  decrease  since  that  time. 

In  the  following  table  are  shown  the  births,  still- 
births and  infant  mortality  for  each  year  and  also 
the  average  for  the  period  from  1911  to  1915: 

TABLE  I. 

Year  Infant  mortality 

Average  from  Births  Stillbirths         '  per  1000 

1911   to  1915   ..  137 

1916    685  29  130 

1917    718  28  120 

1918    765  30  125 

1919    728  28  88 

The  increase  in  the  rate  for  1918  is  due  to  the 
epidemic  of  socalled  influenza  in  the  fall  of  that 
year  and  it  is  to  be  noted  that  the  rate  was  low  all 
over  the  state  in  1919.  The  average  for  the  last 
four  years  is  115.75  or  a  reduction  of  fifteen  and 
five  tenths  per  cent.  The  rate  for  1919  is  thirty-five 
per  cent,  below  that  for  the  period  from  1911  to 
1915.  We  feel  that  these  results  are  largely  due  to 
the  child  welfare  work  carried  on  by  the  \'isiting 
Xurse  Association  with  a  small  appropriation  from 
the  city,  since  July,  1915. 

Watertown  is  essentially  an  American  city,  in 
which  a  considerable  proportion  of  the  population 
own  their  homes.  There  are,  however,  several 
large  groups  of  foreign  born,  principally  Italians. 
As  it  is  frequently  stated  that  the  infant  mortality 
in  a  community  is  largely  due  to  deaths  among  the 
foreign  population  I  studied  the  problem  with  this 
in  view,  using  the  birthplace  of  the  mother  as  an 
index  of  nationality.  The  result  is  shown  in  the 
following  table  which  is  based  upon  2,907  births 
and  362  deaths  of  infants,  a  mortality  of  124  to  the 
thousand : 

TABLE  II. 

Infant  mortality,  Watertown,  N.  Y.,  from  Januarj^  1,  1916, 
to  December  31,  1919,  by  nationalitj-  of  the  mother. 

Infant 

Birthplace  of  mother  Births  Deaths  of  Infants  mortality 

United  States  ....  2,083  224  111 

Canada    381  38  99 

Italy    242  22  91 

Austria  -  Hungary.  78  8  102 
England,  Wales, 

Scotland    46  6  130 

Russia   24  0  0 

Other  countries....  54  94 

This  surely  does  not  show  that  the  foreign  ele- 
ment is  in  an}^  way  responsible  for  the  conditions 
which  are  found  in  this  city.  We  recognize  that 
in  some  instances  the  number  of  births  are  so  few 
that  the  statistics  may  be  influenced  thereby.  It  is 
not  assuring  to  find  that  the  highest  rates  are 
among  the  English  speaking  people  and  that  the 
lowest  is  among  the  Italians. 

A  further  study  of  this  question  is  shown  in  the 
following  table  where  are  collected  the  percentages 
of  the  deaths  by  causes  for  each  group  of  inhabi- 
tants of  the  citv:  . 


The  Americans  and  Canadians  show  practically 
identical  conditions.  While  it  appears  that  premature 
birth  is  a  more  frequent  cause  of  death  amongst 
the  Italians,  they  also  seem  to  suffer  more  from 
communicable  diseases.  The  comparatively  low 
figures  for  diseases  of  the  digestive  system  among 
the  Italians  is.  in  all  probability,  due  to  the  fact  that 
most  of  these  children  are  breast  fed. 

TABLE  III. 

f  Percentage  of  deaths  by  nations  s 


•2  5 


Nationality  of  mother 


^        S  ?        5  2        =  ^"S  S>  2 

United  States..  26  22  16  IS  10  4  7 

Canada    26  26  26  5  5  5  3 

Italy    32  14  23  5  16  5  5 

All  other  coun- 
tries   19  28  14  23  10  0  5 

Average   for  all 

countries    ....  26  23  16  15  10  4  6 

For  all  of  the  infant  deaths  during  the  period  we 
find  that  twenty-six  per  cent,  were  due  to  premature 
birth,  twenty-three  per  cent,  to  diseases  of  the 
digestive  system,  sixteen  per  cent,  to  diseases  of  the 
respiratory  system,  fifteen  per  cent,  to  congenital 
malformations  and  debility,  ten  per  cent,  to  com- 
municable disease,  and  four  per  cent,  to  accidents 
of  birth.  Following  the  first  tabulation  of  these  data 
the  Msiting  Xurse  Association  opened  a  prenatal 
clinic. 

A  further  study  of  the  problem  is  sho\\m  in  Table 
IV,  w^hich  presents  the  causes  of  death  among  chil- 
dren who  lived  less  than  a  month,  the  neonatal 
infant  mortality. 

TABLE  IV. 

Percentage 

Cause  of  death  ■  of  deaths 

Premature  birth    47 

Congenital  malformations  and  debilitj-   20 

Accidents  of  birth,  including  difficult  labor. .  9 

Diseases  of  the  digestive  system   8 

Diseases  of  the  respiratory  system   7 

Communicable  diseases    1 

All  other  diseases   8 

100 

This  table  is  based  upon  180  deaths  and  shows 
the  seriousness  of  the  problem.  It  shows  that 
seventy-six  per  cent,  of  the  deaths  in  this  group  are 
due  to  causes  over  which  the  health  officials  can 
exercise  but  little  direct  control.  It  is  probable  that 
a  few  of  the  premature  children  might  be  saved  by 
an  incubator  room  and  it  is  hoped  to  have  such  a 
room  in  the  near  future.  It  is  also  probable  that  in 
a  few  cases  prenatal  care  may  reduce  the  number 
of  premature  births,  especially  among  those  who  are 
syphilitic.  However,  prenatal  clinics  are  new  and 
in  small  communities  are  not  very  popular. 

To  aid  the  nurses  who  are  engaged  in  infant  wel- 
fare work  the  percentage  of  infant  mortality  for 
each  month  from  1916  to  1919  was  studied,  and  is 
shown  in  the  following  table : 

Month  Percentage  of  mortality 

January    8.4 

February    6.6 

Alarch    9.2 


1016 


KERLEY:  DEFECTIVE  DEVELOPMENT 


[New  York 
Medical  Journal. 


Month  Percentage  of  mortality 

April    92 

May    8.7 

June    8.9 

July    8.9 

August    10.5 

September    9  8 

October    'yi 

November    64 

December    76 


This  shows  two  peaks,  the  highest  in  the  summer 
and  early  fall,  due  to  diseases  of  the  digestive  sys- 
tem. Of  seventy-eight  deaths  from  such  diseases, 
forty-eight  occurred  during  July,  August,  Septem- 
ber, and  October.  The  second  peak  occurs  in  the 
spring,  and  is  due  to  diseases  of  the  respiratory 
system,  the  highest  number  of  deaths  from  this 
cause  occurring  in  May.  As  a  solution  of  the  prob- 
lem we  have  adopted  the  following  measures : 

1.  Extending  the  infant  welfare  work. 

2.  Having  a  nurse  visit  all  new  babies  in  sections 
where  it  is  believed  her  services  will  be  of  value. 

3.  A  prenatal  clinic. 

4.  A  campaign  against  the  fly. 

5.  Abolishing  as  many  outside  toilets  as  possible, 
and  rendering  others  flyproof. 

6.  Campaign  of  education,  consisting  of  frequent 
articles  in  the  local  papers  regarding  infant  mor- 
tality, and  tlie  publishing  of  the  monthly  statistics 
regarding  infant  mortality. 


UNAPPRECIATED  AGENCIES   IN  THE 
DEFECTIVE  DEVELOPMENT 
OF  CHILDREN.* 

By  Charles  Gilmore  Kerley,  M.  D., 
New  York. 

All  those  individuals  who  had  taken  no  interest 
in  children  or  young  people,  other  than  in  their 
immediate  family  or  in  those  of  their  friends,  sus- 
tained a  decided  shock  when  the  reports  of  the 
various  examining  boards  for  recruits  in  the  late 
international  war  were  made  public.  From  forty- 
five  to  sixty-five  per  cent,  were  rejected,  with 
poverty  having  little  to  do  with  the  case  in  many 
instances.  It  was  for  the  first  time  realized  how 
sadly  remiss  we  had  been  in  our  care  of  children. 
That  the  greatest  national  asset  is  a  strong,  vigorous 
race  no  one  can  deny.  At  the  age  of  seven  years 
the  boy  is  seven  tenths  the  man  and  the  girl  seven 
tenths  the  woman.  If  errors  in  development  from 
whatever  cause  exist  at  this  age  they  will  never  be 
entirely  eradicated.  Evidences  of  this  is  apparent 
in  the  physical  condition  of  those  who  have  grown 
up  on  the  continent  during  the  war.  ' 

Miss  Julie  I^throp  reports  of  her  recent  investi- 
gation in  Europe  as  follows :  "In  Prague,  the 
capital  of  Bohemia,  I  went  one  day  to  a  paper  box 
factory  whose  workers  there,  as  in  the  United 
States,  are  chiefly  young  girls.  All  of  the  party 
noted  the  small  stature  but  mature  faces  of  the  girls. 
Most  of  them  were  in  the  middle  teens,  but  they 
looked  younger  until  you  saw  their  faces.  The 
manager  said :  'Yes,  it  is  so ;  we  always  had  some 
girls  who  were  small,  but  now  they  all  appear  to 
be  small.'  "   Had  these  individuals  been  investigated 

•Rfad  before  the  Southern  Medical  Society,  November,  1920. 


further,  it  would  have  been  found  that  not  only 
were  they  physically  smaller  but  that  they  were 
generally  inferior  individuals.  It  would  have  been 
found  that  they  lack  resistance  and  have  a  dimin- 
ished capacity  for  sustained  effort,  both  mental  and 
physical,  all  of  which  means  that  their  labor  output 
would  be  below  that  of  a  normal  individual  of 
corresponding  age. 

I  shall  make  no  attempt  to  cover  all  that  relates 
to  proper  development.  It  is  my  hope  to  call  your 
attention  to  certain  factors  that  have  an  important 
bearing  on  this  subject,  generally  unappreciated. 

DEFECTIX'E  BREAST  FEEDING. 

It  is  a  usual  error  to  believe  that  breast  feeding 
is  always  efficient  and  the  best  means  of  nourish- 
ment. Breast  feeding  may  supply  a  substance  en- 
tirely inadequate  to  the  demands  of  the  infant. 
Because  good  breast  milk  is  superior  to  all  other 
forms  of  food  for  the  infant,  it  does  not  mean 
that  inferior  breast  milk  may  be  much  less  desirable 
than  suitable  substitute  foods.  Breast  milk  is  a 
commodity,  and  there  are  varieties  of  breast  milk 
as  well  as  all  other  commodities.  Every  year  I  see 
a  goodly  number  of  cases  of  malnutrition  in  infants 
aged  from  six  months  to  a  year  of  age  fed  exclu- 
sively on  the  breast.  We  find  these  infants  under 
weight  in  some  instances,  but  the  most  usual  evi- 
dence of  defective  nutrition  will  show  itself  in 
flabby  muscles,  secondar}-  anemia,  and  beginning 
rachitis. 

In  spite  of  the  best  intention  on  the  part  of 
mother  and  physician,  the  child  has  been  given  a 
poor  start.  A  considerable  number  of  nursing 
women  can  supply  the  child  adequately  until  the 
eompletion  of  the  fifth  month.  Fewer  can  supply 
the  baby  adequately  until  the  completion  of  the 
seventh  month.  After  this  period  practically  all 
babies  in  this  country  should  have  the  advantage  of 
additional  feeding.  Breast  milk  should  be  repeatedly 
examined  as  to  quantity  and  quality  during  the 
nursing  period,  and  the  child  kept  under  at  least 
monthly  supervision.  A  frequent  error  in  breast 
feeding  is  to  assume  that  the  nourishment  must  be 
adequate.  Kindly  understand  I  am  criticising  de- 
fective breast  feeding  only.  I  have  helped  thou- 
sands of  infants  to  better  breast  milk  and  for  a 
longer  period  than  they  otherwise  would  have  had. 
I  appreciate  also  that  there  are  exceptions  to  what 
I  have  already  stated  relating  to  the  limitations  of 
the  nursing  period.  A  mother,  a  former  patient 
at  the  outpatient  department  of  the  Babies'  Hos- 
pital, nursed  five  children  almost  continuously  over 
a  period  of  eight  years,  the  nursing  being  inter- 
rupted but  about  six  months  during  this  time.  The 
longest  period  of  continuous  nursing  to  come  under 
my  observation  was  in  an  Italian  woman  who 
nursed  a  boy  three  and  a  half  years.  She  informed 
me  that  her  milk  had  nearly  failed  after  eighteen 
months,  when  she  had  a  miscarriage,  and  the  flow 
returned,  when  the  nursing  was  continued  much 
more  satisfactorily  than  before. 

cow's  MILK  FOR  OLDER  CHILDREN. 

After  the  eighteenth  month  in  the  average  well 
child  better  growth  will  result  with  a  reduction  of 
the  daily  milk  allowance  to  approximately  twenty 


Dec  mber  25.  1920.] 


KERLEV:   DEE  EC  Til  E  DEIEEOIMEST 


1017 


ounces  daily,  providing  adequate  nourishment  can 
otherwise  be  furnished.  Under  conditions  when 
other  foods  cannot  be  given  and  in  suitable  amounts 
a  larger  daily  milk  content  in  the  diet  may  be  of 
advantage  to  balance  up  a  defective  dietery.  In 
such  instances  cod  liver  oil  and  iron  should  be  given. 
I  have  seen  a  vast  number  of  children  with  varying 
degrees  of  malnutrition  who  were  taking  from  one 
to  two  quarts  or  more  of  milk  daily.  Almost  in- 
variably such  children  have  a  capricious  appetite, 
they  dislike  other  articles  of  diet  largely  because 
they  are  never  given  an  opportitnity  to  become  real 
hungry  and  get  acquainted  with  a  wider  range  of 
foods. 

Physically  these  children  show  poor  muscle 
development,  are  pot  bellied,  constipated,  under- 
weight, and  flabby.  They  are  subject  to  frequent 
socalled  bilious  attacks.  Blood  examination  seldom 
fails  to  show  a  secondary  anemia  because  of  the 
poor  iron  content  in  their  milk  food.  ^Mentally 
they  are  irritable  and  difficult  of  management. 
Nattire  has  fashioned  a  child  for  other  foods  than 
milk  after  and  even  before  the  cessation  of  the 
normal  nursing  period.  Cow's  milk  never  entered 
into  the  calculation.  Advocating  a  quart  of  milk  is 
bad  teaching. 

PERSISTENT   ANEMIA    IX    INFANTS  AND 
YOUNG  CHILDREN. 

I  refer  to  those  who  show  a  hemoglobin  content 
under  thirtv  per  cent,  with  red  cells  varying  from 
1.500,000  to  2,500,000,  a  condition  which  is  not 
unusual.  The  child  is  pale,  weakly,  with  very 
faulty  development.  Treated  along  the  ttsual  lines 
of  feeding  changes  and  drugs,  the  child  makes  little 
or  no  progress.  These  cases  are  not  simple  mal- 
nutrition, with  anemia ;  they  are  cases  of  anemia 
with  secondary  malnutrition,  and  are  most  fre- 
quently seen  in  quite  young  infants.  The  treatment 
that  has  been  most  successful  in  my  cases  has  been 
intravenous  blood  transfusion.  The  cause  of  the 
anemia  is  obscure.  There  is  some  radical  defect 
in  the  blood  making  processes.  The  introduction 
of  120  to  150  c.  c.  of  human  blood  into  the  circu- 
lation supplies  the  required  stimulating  agency. 
Food  which  before  had  only  a  sustaining  value  is 
now  well  assimilated  and  a  satisfactory  growth 
follows.  In  some  young  infants  an  astonishingly 
rapid  increase  in  weight  resulted.  The  following 
is  my  most  recent  case  of  this  nature : 

Case  I. — A  boy  four  months  old,  weighing  ten 
pounds,  was  brought  to  me  because  of  anemia  and 
marked  malnutrition.  Blood  examination  showed  a 
hemoglobin  content  of  thirty  per  cent,  and  red 
cells  2,005,000.  Before  any  attempts  at  feeding 
were  made,  he  was  given  120  c.  c.  of  the  mother's 
blood  intravenously  by  Dr.  P.  W.  Bevans  at  the 
Babies'  Hospital.  The  following  day  the  hemo- 
globin content  was  fifty-five  per  cent,  and  the  red 
cells  4,100,000.  Sixteen  days  later  a  blood  exam- 
ination showed  hemoglobin  fifty-five  per  cent,  and 
red  cells  4,000,000.  He  was  then  put  on  a  formula 
of  fat,  two  per  cent.;  protein,  one  and  a  half  per 
cent.,  and  sugar,  six  per  cent.  He  immediately 
began  to  gain,  and  six  weeks  after  the  transfusion 
he  weighed  thirteen  pounds,  with  the  blood  condi- 
tions unchanged. 


WASTED  ENERGY. 

Excessive  activity,  which  means  overwork,  con- 
tributes its  quota  to  the  hordes  of  poorly  developed 
children.  The  young  child  who  awakens  early  and 
is  busy  all  day  in  childish  activities  until  seven  or 
eight  o'clock  at  night  will  not  thrive  as  well  as  if 
there  were  reasonable  restraint  and  a  rest  period, 
after  the  midday  meal  of  an  hour  or  two  and  who 
retires  at  an  early  hour.  I  attempt  to  cultivate 
indolence  in  such  natures. 

Until  the  completion  of  the  sixth  year  in  all 
such  children,  and  in  many  until  the  completion 
of  the  seventh  year,  there  must  be  the  daily  mid- 
day rest  if  we  are  to  secure  proper  growth.  This 
is  a  rule  that  is  invariably  carried  out  among  my 
patients.  We  often  see  the  harmful  effects  of 
wasted  energy  in  the  second  or  third  child  whose 
strength  is  overtaxed  in  his  efforts  to  keep  the  pace 
set  by  older  brothers  or  sisters.  This  feature  of 
wasted  energy  must  always  be  investigated  in 
children  who  come  to  us  because  of  defective  de- 
velopment. It  is  also  to  be  remembered  that  stress 
is  an  important  deterrent  factor  in  the  child's 
capacity  for  food  assimilation.  The  overworked, 
tired  child  does  not  assimilate  his  food  to  the  best 
advantage. 

LOSS  OF  TIME. 

A  considerable  number  of  children  come  to  me 
because  of  inadequate  growth  who  have  been  sub- 
ject to  frequent  illness.  When  a  child  is  ill,  develop- 
ment is  suspended.  Such  children  are  often  the 
members  of  indulgent  families  who  are  not  at  all 
careful  as  regards  meal  time  and  the  food  given. 
Several  illnesses  will  leave  an  appreciable  mark 
upon  the  chilci.  Recurrent  attacks  Of  indigestion 
every  few  weeks,  which  occur  in  not  a  few  chil- 
dren, have  a  pronounced,  deterrent  effect  on  growth. 

THE  GASTROINTESTINAL  TRACT. 

I  have  found  it  necessary  in  eighty-three  cases 
of  tardy  malnutrition  to  make  x  ray  studies  of  the 
gastrointestinal  tract.  In  children  with  a  persist- 
ently poor  appetite,  those  who  have  to  be  coaxed  or 
forced  to  eat,  we  have  found  the  explanation  in 
a  pylorospasm,  in  dilated  stomachs,  and  in  ptosed 
stomachs.  We  frequently  find  food  residue  in  the 
abnormal  stomach  from  six  to  ten  hours  after  a 
bismuth  meal.  A  child  will  not  be  hungry  with 
food  residue  in  the  stomach.  In  addition  to  defec- 
tive food,  they  are  time  losers  in  that  they  are  those 
who  have  frequent  attacks  of  recurrent  illness  in 
the  nature  of  vomiting  and  fever. 

An  explanation  of  persistent  malnutrition  in 
children  is  sometimes  found  in  the  digestive  tract. 
Thus  we  find  the  dilated  cecum ;  the  ptosed  or 
dilated  colon ;  angulations,  and,  frequently,  enlarged 
sigmoids.  The  elongated  sigmoid  is  one  of  the 
most  frequent  cattses  of  obstinate  constipation,  low 
degrees  of  toxemia,  and,  not  infrequently,  recurrent 
vomiting.  For  the  reason  that  when  there  is  a 
delay  in  the  intestine  there  is  often  a  corresponding 
delay  in  the  emptying  time  of  the  stomach.  I  will 
not  undertake  the  care  of  a  case  of  habitual  mal- 
nutrition in  a  runabout  child  without  an  x  ray  of 
the  gastrointestinal  tract.  Children  with  grave 
mechanical  defects  in  the  gastrointestinal  tract  are 


1018 


CARTER:  MENTAL  HEALTH  OF  CHILD. 


[New  York 
Medical  Journal. 


never  fully  nourished,  even  though  they  may  not  be 
made  acutely  ill;  neither  will  they  be  as  bright  and 
alert  mentally  as  those  with  a  normal  digestive 
equipment. 

The  twenty  lantern  slides  that  •  were  shown 
represented  in  each  instance  a  case  of  mahiutrition. 
.The  youngest  patient  was  two  years  of  age.  They 
were  all  under  weight  from  five  to  fifteen  pounds; 
the  majority  under  height  as  well.  Each  case 
had  been  referred  to  me  because  of  defective 
growth  and  development.  The  personal  history  of 
all  showed  persistent  gastrointestinal  derangement. 
In  some  there  was  simply  loss  of  appetite :  in  others 
recurrent  vomiting:  in  others  recurrent  vomiting 
with  fever,  usually  very  high.  In  others  there  was 
obstinate  constipation.  Each  case '  showed  gastro- 
intestinal symptoms  of  sufficient  severity  to  call  for 
an  X  lay  study.  In  each  case  it  was  apparent  that 
there  was  sufficient  abnormalities  to  account  for  the 
persistent  digestive  derangement. 

The  lantern  slides  shown  demonstrated  dilated 
stomach,  ptosed  stomach,  pylorospasm,  gastroptosis, 
dilated  cecum,  ptosed  colon,  massive  dilatation  of 
the  colon,  angulated  sigmoid,  dilated  sigmoid,  and 
elongated  sigmoid.  > 

132  West  Eighty-first  Street. 


THE  MENTAL  HEALTH  OF  THE  CHILD. 

Some  Physical  Determinants  and  a 
J  Method  of  Observation. 

By  C.  Edgerton  Carter,  M.  D., 

Los  Angeles,  Cal., 

Formerly  Instructer  in  the  Pediatric  Department,  Xew  York  Post-  ^ 
Graduate  Medical  School  and  Hospital. 

In  connection  with  my  pediatric  work  at  the 
Orthopedic  Hospital  School  of  Los  Angeles,  the 
interdependence  of  the  mental  and  physical  has 
loomed  so  large  that  it  has  seemed  worth  while  to 
emphasize  this  relation  as  a  factor  in  the  mental 
health  of  the  child.  Obviously  the  general  con- 
sideration of  mens  sana  in  sano  corpore  needs  no 
stressing.  In  a  vague  way  we  are  all  conscious  of 
that  relation.  It  is  to  impress  the  direct  causative 
factor  abnormal  physical  conditions  may  have  spe- 
cifically upon  the  child's  mental  hygiene  that  the 
subject  is  discussed  from  the  physical  angle. 

The  great  difference  in  the  treatment  of  crippled 
children,  who  exhibit  biased  mentality,  and  the  child 
of  normal  mentality,  with  inclinations  toward 
physical  defect,  is  that  of  conservation.  In  the 
chronic  cripples  marvelous  reconstructive  work  is 
done,  but  at  best  it  is  reparative.  In  the  mentally 
normal,  the  future  possibilities  are  so  much  greater 
that  eventually  we  shall  have  preventive  and  cor- 
rective clinics  for  the  child  of  preschool  age,  as  we 
now  have  medical  and  surgical  clinics  for  the 
afflicted.  One  such  clinic  under  the  management 
of  the  Federation  of  the  Parent  Teachers'  Associa- 
tion in  Los  Angeles  has  made  a  modest  beginning. 
Its  purpose  has  been  to  give  the  supposedly  well 
child  of  preschool  age,  from  two  to  six  years,  an 
opportunity  to  become  a  superior  child.  Instead 
of  attempting  to  restore  to  possibly  normal  the  ill 
or  defective  child,  we  start  with  the  apparently 


normal  and  endeavor  to  give  him  endurance  and 
robustness  which  are  requisite  for  superior  attain- 
ment. Incidentally,  we  find  that  over  three  quarters 
of  the  children  examined  reveal  varying  abnor- 
malities of  more  or  less  consequence.  Naturally 
these  defects  are  corrected  where  possible ;  so  the 
clinic  proves  corrective  as  well  as  educative. 

The  importance  of  our  endeavor,  however,  lies 
in  the  attempt  that  is  being  made  to  better  the 
average — to  surpass  the  "fairly  well"  standard  of 
the  present,  and  to  inspire  parents  and  children 
toward  being  (and  doing)  better.  The  returns 
noted  in  this  clinic  already  have  vindicated  its 
existence,  and  furthermore  the  conviction  that  cor- 
rection of  chronic  physical  defects  liberates  new 
mental  force,  has  caused  to  materialize  the  Ortho- 
pedic Hospital  School  in  Los  Angeles  for  the  ex- 
plicit purpose  of  training  these  resultant  mental 
abilities  with  treatment,  often  tedious,  which  the 
child's  crippled  condition  demands. 

A  health  status  chart  (1)  in  use  at  the  clinic 
has  been  adopted  as  the  method  of  presenting  the 
physical  findings  to  the  parents,  thus  proving  its 
practical  adaptation.  Children  who,  upon  super- 
ficial examination,  impress  one  as  being  sound 
physically,  are  not  uncommonly  found  to  reveal  a 
health  status  from  sixty  to  seventy-five  per  cent, 
normal  when  charted  upon  the  basis  of  values. 
These  estimated  values  are  arbitrary  and  may  be 
modified  to  meet  the  requirements  of  individual 
examiners  or  special  conditions.  The  one  requisite 
is  that  of  visualizing  health  or  body  defects,  that 
progress  in  condition  may  be  estimated. 

So  largely  is  preventive  work  in  children  a  ques- 
tion of  parental  education,  and  so  impossible  of 
enforcement  are  personal  health  measures,  that 
mental  hygiene,  to  be  applied,  must  have  a  practical 
elemental  basis  easily  comprehended  by  the  parents. 
For  this  reason,  approaching  the  subject  through 
the  medium  of  the  physical  defects  and  disorders, 
concerning  which  the  parent  has  an  intimate  knowl- 
edge, one  finds  a  welcome  avenue  to  a  fertile  field. 
It  matters  little  whether  the  parent  completely 
comprehends  the  reflex  processes  by  which  results 
are  obtained  upon  mind  and  character  through  these 
physical  determinants.  The  vital  fact  is  that  this 
intimate  association  exists,  and  that  the  intangible 
can  be  reached  through  the  tangible.  Thus  the 
parent  comes  to  realize  that  improvement  upon 
temperament  and  ability  may  be  accomplished, 
specifically  through  these  physical  health  measures. 
For  instance,  tonsils  have  long  been  enucleated  for 
the  relief  of  septic  absorption,  and  because  of  their 
deleterious  effect  upon  the  blood  stream  and  general 
metabolism— little  argument  is  needed  on  that  score 
— but  that  tonsils  should  be  removed  to  prevent 
cardiac  involvement  is  a  step  farther  and  is  usually 
accomplished  because  of  the  parents'  confidence  in 
the  physician  rather  than  from  being  convinced  of 
any  real  danger.  The  third  step  in  the  argument 
for  the  removal  of  pathological  conditions,  or  for 
the  correction  of  defects,  viz..  that  the  child's  mental 
development  shall  show  definite  response  to  such 
treatment,  requires  for  a  convincing  presentation 
not  only  the  enthusiasm  of  the  believer  but  knowl- 
edge of  actual  experience. 


December  25,  1920.] 


CARTER:  MENTAL  HEALTH  OF  CHILD. 


1019 


A  practical  method  of  physical  examination 
whereby  comparisons  of  conditions  may  be  appre- 
ciated at  a  glance,  is  thus  a  necessary  corollary,  for 
parents  readily  bridge  the  gap  between  the  physical 
status  and  its  possible  effects  upon  mind  and  dis- 
position, provided  they  can  be  convinced  that  the 
child's  condition  is  subnormal.  Here  graphic  charts 
serve  an  essential  purpose  since  the  physician  is  thus 
enabled  to  translate  his  findings  to  the  visible  scale 
which  represents  the  condition  with  reasonable 
accuracy. 

Heredity. — Perhaps  upon  no  other  claim  has  there 
been  laid  greater  burden  of  proof  than  that  of 
heredity.  Parents  too  often  are  satisfied  to  let 
Jimmie  be  thin  because  his  father  is ;  to  permit 
Mary  to  refuse  vegetables  because  mother  does ; 
to  tolerate  an  irritable  nervous  child  because  he  is 
"high  strung,"  etc.,  while  the  possible  inheritance 
of  value  from  the  parent,  the  character  impress 
made  by  daily  example,  are  given  little  thought. 
It  is  so  much  easier  to  fall  back  upon  the  hackneyed 
excuse,  "He  inherits  that  from  his  father." 

If,  as  a  parent  one  delves  into  the  study  of  in- 
herited traits,  one  finds  that  acquired  characteristics 
are  buffeted  about,  confused  in  experimental  proof 
with  mutilations,  the  influence  of  throwbacks  (or 
primitive  reversions),  often  ignored  in  the  reckon- 
ing, the  power  of  environment  underestimated  until 
one  is  in  a  quandary  at  each  last  analysis  and  un- 
certain as  to  what  constitutes  a  w'orking  basis. 
Undoubtedly  we  reflect  our  own  uncertain  attitude 
when  we  fail  to  urge  upon  the  child  the  acquire- 
ment of  a  taste  for  all  wholesome  foods  and  health- 
ful games.  In  nourishment  for  the  growing  body 
as  well  as  knowledge  for  the  growing  mind,  "such 
stuff  as  dreams  are  made  of"  will  not  furnish  a 
healthy  basis  for  future  expansion.  Homely,  simple 
food  for  body  and  mind  must  form  the  foundation 
of  any  stability  in  health  or  character.  Yet  so 
much  in  our  likes  and  dislikes  is  explained  upon 
the  basis  of  heredity  that  unconsciously  we  allow 
our  children  to  form  pernicious  tastes  in  the  choice 
of  food  and  in  the  formation  of  habits.  Instead  of 
the  child  inheriting  a  dislike,  he  acquires  a  fixed 
antipathy  through  the  daily  imitation  of  a  parent 
lacking  control,  and  wholly  unaware  of  thus  in- 
fluencing the  tastes  and,  through  them,  the  growth 
of  the  child.  Often  these  food  impressions  are 
left  to  the  haphazard  choice  of  a  nursemaid  abetted 
by  the  whims  of  a  difficult  to  please  child.  It  is 
bad  enough  to  have  our  children  acquire  their  accent 
from  nursemaids,  whose  nasal  or  strident  tones 
leave  an  indelible  stamp  upon  the  speech  of  their 
charges,  that  is  vmfortunate  and  a  handicap. 

The  maturing  mind  in  after  years  seeks  to 
cast  off  these  acquired  peculiarities  (alas,  often 
unsuccessfully!),  but  food  dislikes  and  idiosyn- 
crasies in  eating  are  even  more  vital  and  may  be 
the  direct  and  only  cause  of  nutritional  disturbances 
resulting  in  rickets,  flat  foot,  bony  deformities,  and 
other  developmental  defects.  Here  the  psychology 
of  the  mother,  assuming  that  she  has  the  intimate 
charge  of  the  child,  affects  its  physiology  and 
growth ;  this  in  turn  gives  an  undeniable  twist  to 
the  outlook  on  life  of  the  child  and  may  figure 
in  the  distorted  philosophy  which  the  resulting  adult 


so  easily  acquires.  The  kingdom  that  was  lost  "all 
for  the  want  of  a  horseshoe  nail"  does  not  compare 
with  the  myriads  who  never  glimpse  their  kingdom 
because  of  reasons  seemingly  as  insignificant.  An 
old  established  and  influential  rehgious  order  is 
credited  with  the  dogma  that,  given  a  religious 
training  until  seven  years  old,  the  child  will  never 
depart  therefrom.  In  no  other  instance  apparently 
do  we  find  a  well  recognized  and  accepted  working 
hypothesis  that  takes  into  account  this  preschool 
period  as  a  possible  determiner  of  the  child's  future. 
It  is  a  period,  nevertheless,  in  which  imitation  of 
conduct,  temperament,  and  habits  hold  supreme 
sway.  Reason  and  decision  not  yet  formed,  imita- 
tion and  imagination  are  dominant.  The  influence 
that  health  has  upon  mentality  and  habit  upon  health 
is  not  appreciated.  If  it  were,  the  preschool  child 
in  the  family  of  ideals  would  not  be  permitted  to 
drift  into  a  haphazard  physical  condition  as  he  is 
today.  He  would  receive  at  least  as  much  routine 
attention  as  does  the  family  automobile,  toward 
keeping  his  combustion  perfect  and  his  "machinery" 
in  order. 

In  other  ways  than  by  diet,  however,  can  the 
child's  mental  growth  be  encouraged.  Right  physi- 
cal hygiene  fosters  healthy  mental  hygiene.  The 
influence  of  carriage  upon  conduct,  of  posture  upon 
principle,  is  too  well  known  to  need  more  than 
passing  rhention.  "Poor  bodily  mechanics,"  quoted 
by  Fritz  Talbot  and  Lloyd  T.  Brown,  of  Boston, 
are  responsible  in  great  measure  for  at  least  three 
abnormal  physical  conditions.  These  in  turn  act 
as  nerve  irritants  and  affect  the  mental  horizon. 
Concrete  illustrations  of  physical  determinants  upon 
mental  health  are  found  in  the  commoner  health 
problems.  Among  those  producing  direct  eft'ect 
upon  the  adolescent  outlook,  consider  first  a  simple 
surgical  procedure  that  is  best  performed  during 
infancy  or  childhood,  e.  g.,  circumcision  in  the  male. 
This  should  be  universal,  not  alone  as  a  protection 
against  irritation  and  possible  later  infection,  but  in 
the  nervous  child  a  scientific  operation  is  an  eft'ec- 
tive  means  of  aiding  his  mental  equilibrium. 
Habitual  apprehension  of  the  future,  as  well  as 
timidity  and  senseless  fears  exhibited  in  the  child's 
daily  life,  is  not  infrequently  the  result  of  physical 
reflexes.  Eyestrain,  phimosis,  anemia,  and  intes- 
tinal toxemia  are  common  contributors.  Freeing 
the  clitoris  in  the  female  often  allays  irritation  and 
should  also  be  a  routine  procedure  in  infancy. 
Bernard  Shaw's  satire  on  specific  surgery  makes  one 
hesitant  to  assert  that  tonsillectomy  in  the  child 
from  three  to  six  years  as  a  practically  routine 
procedure  would  save  countless  lives  from  sporadic 
and  epidemic  infections.  However,  when  one  con- 
scientiously observes  the  multitude  of  adults  who, 
after  dragging  through  half  their  lives,  are  finally 
rejuvenated  by  parting  with  a  cryptic  tonsil,  or 
hidden  source  of  sepsis,  he  finds  it  hard  to  defend 
any  tonsil  under  the  least  suspicion.  Furthermore, 
the  death  rate  from  heart  disease  receives  its  greatest 
impetus  from  infected  tonsils  of  preadolescent  years. 
Kerley  has  data  revealing  the  ages  from  five  to 
twelve  to  be  the  period  of  greatest  susceptibility. 
This  is  a  consideration  against  the  doubtful  tonsil 
upon  which  not  enough  emphasis  is  given.  As 


1020 


CARTER:  MENTAL  HEALTH  OF  CHILD. 


[New  Ymk 
Medic.u.  Journal. 


physicians  assuming  the  care  of  children,  we  have 
been  caught  napping  because  we  have  no  habitual 
method  of  checking  up  the  supposedly  well  child. 
Our  observations  are  usually  made  after  the  heart 
damage  is  done.  Adenoid  and  tonsillar  hyper- 
troph)^  or  infection  are  so  commonly  noted  among 
school  children  as  a  cause  of  retarded  mentality 
that  they  need  to  be  merely  mentioned  as  obvious 
physical  determinants  in  the  child's  mental  health. 

Physical  defects. — Perhaps  the  commonest  and 
least  considered  physical  cause  for  defect  in  charac- 
ter development  is  found  in  the  ubiquitous  flat  foot 
or  broken  down  arches  of  the  foot.  Analyze 
for  a  moment  the  component  elements  of  character 
and  we  find  application,  or  stick-to-itiveness  a  sine 
qua  710)1  in  all  well  balanced  minds.  This  is  a 
quality  implying  the  ability  for  persistent  effort. 
Let  the  child  find  that  standing  tires  him,  that  long 
tramps  over  the  hills  leave  him  exhausted  and 
without  appetite,  that  tennis  makes  his  back  ache, 
that  skating  causes  his  feet  to  pain,  and  .we  soon 
find  that  child  losing  interest  in  these  physical 
efforts,  yet  by  such  physical  efforts  demanding 
skill,  strength  and  endurance,  are  bodies  made  sym- 
metrical and  minds  trained  to  coordinate.  In  a 
word,  it  is  true  that  the  boy  who  doesn't  enjoy 
outdoor  contests  loses  the  greatest  possible  stimulant 
to  clean  character  building.  He  is  handicapped  by 
this  loss  of  mental  training  in  the  perception,  com- 
prehension, courage,  and  coordination  which  con- 
tests give.  Weak  arches  are  directly  responsible 
for  many  mollycoddles  in  boys  and  girls. 

The  condition  of  constitutional  asthenia  to  which 
Lewis  has  applied  the  term  effort  syndrome, '  and 
which  Kerley  pertinently  says  permits  of  "poor  - 
student  material,  fifty  per  cent,  of  which  should  be 
scrapped  and  put  to  productive  occupation,"  is  not 
always  found  in  mental  weaklings.  Physical  handi- 
caps may  be  their  mental  retardants,  and  in  many 
cases  these  are  conditions  which  are  prevented  or 
effectively  counteracted  only  during  the  early 
formative  years.  Again,  while  Nature  starts  us 
forth  physically  equipped  with  heads  asymmetrical, 
legs  unequal,  ears  imperfect,  and  eyes  astigmatic, 
not  all  such  stigmata  have  an  appreciable  effect  upon 
character.  In  fact,  every  normal  man,  like  every 
healthy  dog,  has  several  "fleas"  of  degeneration  to 
keep  him  humble  and  to  make  him  hustle.  But  too 
many  fleas,  like  too  much  degeneration  in  the  child, 
makes  training  difficult.  However,  one  common 
anatomical  fault  leaves  its  mental  mark  because  of 
the  intimate  association  that  necessarily  lies  between 
breathing  and  effort.  Without  argument  we  all 
agree  that  courage  and  control  are  desirable  quali- 
ties to  ailtivate  in  the  budding  mind,  yet  the  boy 
with  ineffectively  approximating  jaws,  with  teeth 
failing  to  function  because  of  malocclusion,  is  barred 
by  reason  of  this  defect  from  a  fair  chance  in  the 
game  of  life.  His  utmost  physical  efforts  are  made 
unnecessarily  difficult.  Observe  him  whose  teeth 
do  not  effectively  approximate  and  you  will  find 
that  he  does  not  excel  in  feats  which  demand  the 
clenched  jaw  of  determination  "to  do  or  die." 
However,  malocclusion  receives  attention  only 
because  of  its  influence  upon  mastication  or  for 
cosmetic  effect.    It  deserves  a  more  serious  con- 


sideration, for  an  "Andy  Gump"  type  of  facial 
contour'  is  not  to  be  chosen  as  winner  in  any 
endurance  contest,  physical  or  mental,  while  a  man 
with  the  viselike  jaws  of  Roosevelt  carries  no 
handicap  durifig  the  formative  years  of  childhood 
as  he  clicks  them  together  in  friendly  rivalry  or 
determined  eft'ort  to  overcome.  Children  with  the 
undeveloped  lower  jaw  have  been  needlessly  handi- 
capped by  adenoids  or  dental  malocclusion,  and  their 
mental  training  is  made  easier  if  these  physical 
deformities  are  corrected. 

Opportunity  for  giving  a  national  uplift  to  the 
health  of  the  future  is  apparently  at  hand.  Statistics 
of  the  draft  examinations  in  the  United  States, 
revealing  the  now  well  known  rejection  for  physical 
defect  of  every  third  young  man  under  thirty-one 
years  of  age,  have  proved  most  unexpected  food  for 
thought.  Permit  the  briefest  possible  reference. 
Our  athletes  have  beaten  the  world,  mortality  and 
morbidity  rates  have  shown  amazing  decreases  in 
diphtheria  and  typhoid,  resources  have  seemed 
exhaustless,  until  we  have  taken  it  for  granted  that 
to  be  "a  young  American"  was  equivalent  to  win- 
ning the  threescore  and  ten  lease  on  life.  Cold 
statistics  convince  us  there  is  on  the  contrary  a  lien 
on  the  lease,  which  will  either  seriously  embarrass 
the  life  activities,  or  stop  them  altogether,  in  a 
million  men  supposedly  of  the  nation's  strength. 
How  does  this  directly  relate  to  the  child's  mental 
hygiene?  Physical  handicaps  are  to  be  prevented 
only  by  educational  influences  wisely  and  construc- 
tively utilized  among  our  children.  The  five  groups 
of  defects  or  diseases,  constituting  over  three  fourths 
of  the  million  rejected,  fall  within  the  limits  of 
diseases  preventable,  or  possibly  correctable,  if  seen 
early.  These  same  conditions  are  incurable  if 
advanced.  It  is  to  the  effect  upon  the  reconstructed 
lives  which  children  so  afflicted  must  form,  to  the 
influence  these  abnormalities  have  upon  mentality, 
that  present  emphasis  is  laid. 

Heart  disease  heads  the  list.  It  is  often  incurable, 
and  so  ranks  first  as  a  physical  determinant  on 
future  efficiency.  To  treat  this  as  a  physical  prob- 
lem merely,  without  a  consideration  of  the  mental 
warp  and  fear  psychoses  the  confirmed  cardiac 
exhibits,  is  to  beg  the  question.  The  prevention 
of  heart  disease  is  emphatically  a  physical  problem 
of  childhood,  but  the  burden  of  its  weight  is  dis- 
tributed throughout  the  years  that  remain,  be  they 
few  or  many ;  and  the  physical  limitations  of  chronic 
cardiac  patients  are  the  least  of  their  burdens,  as 
everyone  familiar  with  the  fear  psychoses  of  these 
unfortunates  will  attest. 

Tuberculosis,  with  its  roster  claiming  distinguished 
and  brilliant  minds  the  world  over,  shows  its  preva- 
lence in  the  war  data,  where  every  tenth  man,  or 
over  100,000  of  the  flower  of  our  youth,  was  afflicted 
with  the  disease  in  active  process.  The  point  in 
preventive  wvrk  is  that  infection  begins  in  child- 
hood, that  it  has  already  decimated  the  health  ranks 
of  our  young  men,  and  even  though  the  mental 
impress  may  be  exhilarating  and  stimulating  instead 
of  depressing  and  fear  inspiring,  as  in  chronic  heart 
disease,  both  diseases  are  factors  in  the  mental  out- 
look and  the  preschool  age  should  he  the  time  for 
their  consideration  and  prevention. 


December  25.  1920.} 


APFEL:  LUMBAR  PUNCTURE. 


1021 


Nutritional  disorders  per  se,  with  their  sequelae 
of  bony  distortions  and  developmental  defects, 
claimed  another  third  of  our  rejected  young  men. 
A  third  of  a  million  youths,  whose  fundamental 
nutrition  was  defective,  proves  we  have  much  to 
teach  (perhaps  to  learn)  about  elemental  body 
requirements  and  food  balance.  These  deficiencies 
in  nutrition  are  from  ignorance,  not  poverty,  and 
Hindehede's  observations  upon  the  blockade  in 
Denmark,  during  which  the  mortality  decreased 
thirty-four  per  cent.,  are  revolutionary.  He  says : 
"It  would  seem,  then,  that  the  principal  cause  of 
death  lies  in  food  and  drink.  The  people  must  first 
have  bread,  potatoes,  and  cabbage,  in  sufficient 
quahtity,  and  then  some  milk."  He  further  says : 
"If  central  Europe  had  adopted  this  plan  there  would 
have  been  no  starvation  or  malnutrition."  Chapin 
(2)  points  the  way  to  the  pediatrist's  possible 
influence  upon  the  national  welfare.  Children  with 
chronic  indigestion  or  constipation  or  with  faulty 
bodily  hygiene  are  not  the  ones  who  radiate  happi- 
ness. It  is,  furthennore,  impossible  for  a  child  to 
have  a  happy  outlook  upon  life,  who  doesn't 
habitually  feel  well,  and  the  habit  of  being  well 
carries  with  it  the  possible  habit  effects  upon  mental 
and  moral  quaHties.  It  is  not  at  all  uncommon  for 
the  pediatrist  to  encounter  children  of  six  or  seven 
years  who  complain  of  "the  hardness  of  life,"  whose 
brows  are  already  w-rinkled  in  habitual  brooding, 
and  whose  mental  attitude  is  habitually  apprehensive. 
These  children  are  not  defectives  nor  are  they 
normal  children  suffering  from  the  occasional 
upset  which  is  part  of  childhood,  but  are  already 
"chronics"  and  as  surely  growing  up  into  social 
agitators  and  fault  finders,  disgruntled  with  them- 
selves and  their  associates,  as  are  the  borderline 
cases  and  degenerates,  productive  of  morons  and 
criminals.  The  latter  classes  are  congenital  and  a 
problem  set  apart,  but  the  embryo  pessimist  is  not 
one  decreed  by  fate,  nor  does  he  become  that  from 
choice  but  rather  because  of  a  wrong  habit  hygiene, 
moulding  his  psychologv',  his  habitual  attitude  to- 
ward the  world. 

It  is  imnecessary  to  note  further  correlations. 
Progress  in  glandular  therapy  is  daily  making  thera- 
peutic history.  It  is  not  inconceivable  that  blood 
analysis  eventually  will  enable  us  to  estimate  what 
hormone  is  out  of  balance.  Undoubtedly  in  certain 
groups  great  strides  have  been  made,  and  in  glandu- 
lar dyscrasia  a  physiological  basis  is  commonly 
found  for  the  mental  aberrations.  Indeed,  so  great 
is  this  factor  in  the  correlation  of  the  child  mind 
and  body  function  that  I  hope  to  present  some  of 
these  practical  applications  at  a  later  date.  If  in 
this  present  discussion  there  is  suggested  a  means 
whereby  the  supposedly  well  child  may  be  "dry 
docked"  every  three  or  six  months  during  the  pre- 
school period  from  two  to  seven  years  and  freed 
from  the  barnacles  that  retard  his  mental  progress, 
ultimate  good  will  come  in  far  greater  measure  than 
mere  physical  findings  at  first  glance  would  indicate. 

REFEREN'CES. 

1.  Health  Status  Chart,  California  State  Health  Bulle- 
tin, June,  1919. 

2.  Chapix.  Hexry  Dwight  :  Nutrition,  Journal  A.  M. 
A..  August  7,  1920. 

1109  Brockm.\x  Buildixg. 


LUMBAR   PUNCTURE   IN  DISEASES 
OF  CHILDREN.* 
Its  Indications  and  Technic. 
By  H.  Apfel,  M.  D.. 

Brooklyn,  X.  Y. 

Instructor  in  Pediatrics,  New  York  Post-Graduate  Medical  School 
and   Hospital;   Assistant  Attendant   in    Kingston   Avenue  Hos- 
pital,   Brooklyn,    Attending    Pediatrist,    Brownsville  and 
East  New  York  Hospitals. 

Lumbar  puncture  was  first  employed  by  Quincke, 
in  1890,  for  the  relief  of  intracranial  pressure 
symptoms  in  cases  of  tuberculous  meningitis.  Fur- 
bringer  followed  in  1895  and  employed  this  means 
for  diagnostic  purposes  (1). 

As  an  aid  in  makmg  a  diagnosis,  lumbar  punc- 
ture is  recognized  by  clinicians  the  world  over. 
Every  obscure  case  deserves  it ;  some  cases  cannot 
be  correctly  diagnosed  otherwise,  while  others  can- 
not be  successfully  treated  without  it.  Its  diag- 
nostic value  is  the  more  important  one ;  as  one 
author  states,  "The  diagnostic  value  of  lumbar 
puncture  far  exceeds  any  therapeutic  value  yet 
described."  While  most  conditions  having  their 
pathological  basis  in  the  cerebrospinal  nervous  sys- 
tem can  fairly  well  be  diagnosed  by  clinical  observa- 
tions alone,  it  remains  ^or  the  lumbar  puncture  to 
corroborate  or  disprove  such  a  diagnosis.  It  is  not 
at  all  rare  that  the  symptom  complex  of  a  given 
case  closely  fit  the  diagnosis,  we  will  say,  of  puru- 
lent meningitis,  but  after  a  lumbar  puncture  has 
been  done  and  the  spinal  fluid  examined  the  verdict 
is  changed  to  that  of  poliomyelitis,  or  vice  versa. 
While  no  one  today  questions  the  value  or  practica- 
bility of  a  blood  count  or  urine  examination,  there 
still  remain  a  goodly  number  of  practising  physicians 
who  deny  their  little  patients  the  benefit  which  may 
be  derived  from  an  early  lumbar  puncture,  carefully 
performed. 

Dr.  Neal  (2),  of  the  laboratory  of  the  Depart- 
ment of  Health,  of  the  City  of  New  York,  says: 
"Spinal  puncture  and  the  examination  of  the  con- 
tents are  our  most  reliable  aid  in  the  recognition 
of  poliomyelitis."  La  Fetra  (3)  wrote  as  follows: 
"Lumbar  puncture  may  show  bloody  fluid  where 
intracranial  hemorrhage  is  diagnosed."  Holt  (4) 
in  his  book  states  that  lumbar  puncture  "is  the 
most  important  means  of  diagnosis  we  possess," 
and  further  says  "I  believe  it  to  be.  absolutely  free 
from  danger  if  properly  performed."  Koplik  (5) 
may  be  quoted  as  follows:  "Lumbar  puncture  is 
devoid  of  danger  and  should  be  performed  without 
delay  in  all  cases  in  which  we  have  reason  to  suspect 
meningitis.  The  aim  should  be  to  puncture  early, 
for  delay  means  spread  of  the  inflammation  and  the 
rapid  advance  of  the  disease."  Heiman  (6)  says: 
"The  procedure  itself  is  harmless  and  is  of  the 
greatest  diagnostic  value." 

I  believe  that  quoting  the  conclusions  gained  from 
experience  by  these  clinicians  will  help  convince 
those  who  are  still  skeptical,  as  to  both  the  value 
and  the  safety  of  this  procedure.  There  is  another 
group  of  men  who  are  fairly  well  convinced  of  the 
value  of  lumbar  puncture,  but  who  constantly  har- 
bor fears  of  infecting  the  spinal  canal  and  its 
meninges  in  making  a  lumbar  puncture. 

*P.ead  before  the  East  New  York  Medical  Society,  May  20.  1920. 


1022 


APFEL:  LUMBAR  PUNCTURE. 


[New  York 
Medical  Journal. 


It  is  not  at  all  rare  for  one  to  hear  that  a  lumbar 
puncture  might  have  been  resorted  to,  but  the  fear 
of  a  fatality  as  a  result  was  held  out.  In  fact,  the 
case  which  suggested  to  me  the  topic  of  this  paper 
as  being  timely  for  discussion  was  that  of  a  new- 
born baby  seen  by  me  with  Dr.  A.  Koplowitz, 
where  we  made  the  diagnosis  of  intracranial  hemor- 
rhage and  a  lumbar  puncture  was  quite  naturally 
suggested.  The  parents  readily  consented,  but  a 
relative  of  the  family  from  New  England,  who 
unfortunately  happened  to  be  a  physician,  strenu- 
ously objected  to  the  procedure  as  being  a  dangerous 
operation,  and  no  reasoning  could  convert  him  to 
the  contrary.  That  patient  died,  in  accordance  with 
the  prognosis,  within  twenty-four  hours,  having 
been  denied  the  probable  benefit  of  a  lumbar  punc- 
ture with  the  consequent  relief  of  pressure. 
Having  established  the  exactn^s  of  the  diagnosis 
by  the  presence  of  bloody  fluid,  an  immediate 
operation  might  have  saved  that  child's  life.  Even 
though  the  number  of  patients  who  recover  are 
few,  the  fear  of  infection  should  not  deter  anyone 
from  doing  a  lumbar  puncture,  for  the  same 
reason  that  no  surgeon  would  hesitate  to  do  a 
laparotomy  for  fear  that  he  may  infect  the  peri- 
toneum. Michael,  of  Chicago  (7),  states:  "The 
meninges  are  very  difficult  to  infect  by  lumbar 
puncture."  It  is  understood  that  the  most  stringent 
rules  of  asepsis  should  be  observed  in  the  prepara- 
tion as  well  as  throughout  the  course  of  the  opera- 
tion. Of  all  the  numerous  lumbar  punctures  which 
I  have  done,  both  in  the  wards,  in  the  outpatient 
clinic,  as  well  as  in  my  private  practice,  not  one  case 
resulted  in  infection. 

Pfaundler  (8)  reported  two  hundred  cases  of 
lumbar  puncture  without  a  single  bad  result,  except 
in  one  case,  where  there  was  collapse  due  to  the 
removal  of  too  much  fluid.  Northrup  (8)  reported 
no  ill  effects  in  fifty  cases.  Gumprecht  (8),  in 
1900,  collected  fifteen  cases  of  sudden  death  and 
added  two  cases  of  his  own,  following  lumbar 
puncture,  but  in  not  one  of  these  cases  could  it  be 
proved  with  satisfaction  that  death  was  due  to  the 
lumbar  puncture  itself.  McDonald  (9)  reports  no 
bad  results  except  in  one  case  where  the  patient 
suffered  from  headache  and  syncope,  following  the 
removal  of  fluid.  Here  also  it  is  possible  an  exces- 
sive amount  of  fluid  was  removed.  Weinlander 
(10)  reports  a  fatal  outcome  in  a  boy  of  twelve, 
but  his  patient  suffered  from  acute  nephritis  and 
uremia  at  the  time  of  puncture,  a  sufficient  cause 
for  the  end  result  even  without  his  having  done  a 
lumbar  puncture. 

During  the  last  epidemic  of  poliomyelitis,  a 
thousand  punctures  (4)  were  performed  at  the 
Kingston  Avenue  Hospital  with  no  ill  effects  in 
any  case.  It  is  perhaps  timely  to  repeat  the  ad- 
monition made  by  many  observers  never  to  perform 
a  lumbar  puncture  when  the  patient  is  moribund, 
if  one  fears  the  possible  blame  to  be  laid  to  the 
lumbar  puncture,  instead  of  to  the  disease  which 
indicated  the  puncture.  What  are  some  of  the 
indications  of  a  lumbar  puncture  in  a  child?  The 
indications  might  for  practical  purposes  be  divided 
into  three  general  groups: 

1.  For  the  relief  of  pressure  symptoms. 


2.  For  the  purpose  of  differential  diagnosis. 

3.  For  the  purpose  of  administering  therapeutic 
aid  intraspinally. 

Under  the  first  group  come  a  large  number  of 
conditions,  both  in  infancy  and  childhood. 

A.  It  is  a  well  recognized  fact  that  some  cases 
ok  hydrocephalus  are  greatly  improved  by  repeated 
lumbar  punctures,  according  to  Quincke  (12). 
This  is  true  both  of  the  congenital  type  as  well  as 
of  the  one  secondary  to  meningitis.  This  statement 
will  bear  modification,  namely,  that  experience  has 
taught  us  that  a  goodly  number  of  cases  of  hydro- 
cephalus only  refill  much  more  rapidly  after  they 
have  been  tapped  once  or  twice.  I  recall  one  case 
which  refilled  within  a  week  after  the  first  puncture 
when  the  head  assumed  such  large  proportions  that 
the  patient  could  not  be  recognized  on  the  next 
visit  to  the  clinic.  On  the  other  hand,  I  recall  two 
other  cases  where  the  head  circumference  measured 
about  twenty-three  inches  on  the  first  visit  and  by 
the  help  of  weekly  punctures,  both  spinal  and  also 
of  the  lateral  ventricles  according  to  Kausch  (13), 
I  succeeded  in  arresting  the  abnormal  growth  of  their 
heads  and  they  are  now  able  to  walk  around  and 
are  happy. 

B.  In  types  of  meningitis  due  to  some  type  of 
organism  against  which  we  have  no  specific  antidote, 
the  simple  drawing  off  of  the  fluid  accomplishes 
drainage  as  well  as  relieves  pressure  symptoms, 
temporarily  perhaps,  as  in  tuberculous  meningitis. 
Convulsions  may  subside  and  the  patient  may  get 
a  temporary  rest.  In  fact,  there  are  on  record  some 
fourteen  cases  of  tuberculous  meningitis  reported 
cured  by  repeated  lumbar  puncture,  and  while  we 
question  the  authenticity  of  the  diagnosis,  we  must 
still  bear  in  mind  that  it  happened  in  the  realm 
of  medicine,  hence  why  doubt  it? 

C.  In  acute  infectious  diseases,  pneumonia  for 
example,  complicated  with  serous  meningitis  or  so- 
called  meningismus,  the  headache,  convulsions  and 
opisthotonous  are  relieved  almost  immediately  after 
puncture  is  done. 

Considering  the  second  group,  every  time  one  is 
called  upon  to  make  a  differential  diagnosis  between 
an  acute  disease  complicated  with  meningismus  and 
purulent  meningitis,  or  when  one  is  confronted  with 
the  problem,  is  it  a  case  of  tuberculous  meningitis 
or  of  poliomyelitis  ;  or  a  given  case  may  present  some 
symptoms  of  cerebral  lues  and  colloidal  gold  and 
Wassermann  tests  on  the  spinal  fluid  have  to  be  done, 
then  our  mind  immediately  reverts  to  the  name 
Quincke.  We  send  the  patient's  spinal  fluid  to  the 
laboratory  for  a  cell  count  and  for  the  determina- 
tion of  the  predominating  type  of  cells  and  type  of 
organism.  A  lumbar  puncture  not  only  helps  us 
in  suggesting  the  proper  management  of  the  case, 
but  it  also  directs  us  with  regard  to  the  prognosis, 
from  the  viewpoint  of  the  family,  which  must  be 
taken  into  consideration. 

What  may  be  learned  from  a  careful  examination 
of  the  spinal  fluid  may  be  answered  by  briefly  quot- 
ing Dunn,  as  quoted  by  Rachford,  who  sums  up 
the  diagnostic  importance  of  a  carefully  examined 
cerebrospinal  fluid  specimen  in  the  following  man- 
ner: "If  the  fluid  is  cloudy,  some  form  of. menin- 
gitis is  present.    If  the  fluid  is  clear,  no  form  of 


December  25,  1920.] 


APFEL:  LUMBAR  PUXCTURE. 


1023 


meningitis  can  be  present  except  tuberculous."  If 
the  cell  count  is  normal  (under  ten  to  the  c.mm.), 
no  meningitis  is  present.  If  the  cell  count  is  over, 
ten  to  the  c.mm.,  some  form  of  meningitis  is 
present.  In  tuberculous  meningitis,  the  mononu- 
clear leucocytes  predominate  and  the  fluid  is  clear. 
If  the  predominating  cell  is  of  the  polynuclear  type, 
that  points  to  a  suppurative  form  of  meningitis. 
In  poliomyelitis  or  encephalitis  the  fluid  is  clear, 
no  bacteria  are  found,  and  there  is  a  preponderance 
of  large  mononuclear  cells.  In  meningismus,  while 
the  fluid  is  increased  in  quantity  it  is  normal  in 
character."  (2). 

As  for  the  third  group  of  indications,  one  need 
only  refer  to  the  difference  in  the  mortality  rate 
of  cerebrospinal  meningitis  previous  to  1890,  and 
the  present  time  to  convince  the  most  sceptical  as 
to  its  benefits  as  a  therapeutic  measure. 

\\'ith  the  advance  in  therapeutics  the  administra- 
tion of  the  Flexner's  antimeningococcic  serum  is 
onh-  one  type  of  intraspinal  treatment,  and  already 
there  are  other  remedies  for  different  diseases  being 
utilized,  for  example,  in  severe  cases  of  cerebro- 
spinal lues,  neosalvarsan  is  used  intraspinally  with 
marked  success.  In  1916,  Goodman  (15),  of  the 
Jacobi  clinic,  introduced  the  autoserum  treatment 
for  cases  of  chorea,  and  while  the  results  are  not 
tmiform  at  the  hands  of  all  observers,  it  neverthe- 
less merits  a  trial,  especially  in  the  cerebral  type 
of  chorea.  Gemma  (12),  in  1914,  two  years  be- 
fore Goodman,  advised  lumbar  puncture  for  severe 
cases  of  chorea,  also  for  whooping  cough,  etc. 

Perhaps  the  most  important  part  of  this  paper 
should  be  the  paragraph  dealing  with  the  technic  of 
the  subject  in  question.  The  procedure  need  never 
be  limited  to  the  environs  of  an  operating  room  of 
a  modern  hospital.  In  fact,  any  fairly  clean  home 
is  well  fitted  for  the  carrying  out  of  lumbar  punc- 
ture. The  kitchen  table  forms  a  desirable  operating 
table  and  the  fear  of  infection  is  a  good  prophylactic 
measure  for  one  to  carry  in  his  mind  and,  therefore, 
take  every  aseptic  precaution  to  avoid  such  an 
accident. 

Necessary  articles. — A  clean  sheet  for  the  table 
and  another  to  cover  the  child's  body,  a  few  sterile 
towels,  a  sterile  gown,  rubber,  several  sterile  test 
tubes,  and  a  pus  basin,  all  of  which  are  indispensable. 

Instruments  employed.- — One  twenty  c.  c.  Luer 
syringe,  and  two  needles.  (The  usual  Quincke 
needle  is  found  to  be  too  large  and  is  not  recom- 
mended for  children.  Strauss  has  devised  a  needle 
for  lumbar  puncture  (20),  but  is  rarely  used  for 
children.)  The  operator  should  always  examine 
these  instruments  himself.  A  glass  funnel  and 
proper  tubing  attachment  to  fit  the  needles  should 
be  provided,  all  sterile  and  in  working  order.  This 
preparation  can  be  carried  out  in  any  private  resi- 
dence within  short  notice.  Occasionally  members 
of  the  family  must  take  the  place  of  nurse  and 
assistant. 

TJie  position  of  the  patient. — Much  has  been 
written  by  various'  authors  on  this  question. 
Campbell  and  Kerr  (16)  advise  against  the  sitting 
posture,  because  of  the  danger  of  breaking  the 
needle.  Fischer  (17)  in  his  textbook  recommends 
the  right  or  left  side.    Norman  Williamson  (18) 


describes  a  special  chair  for  lumbar  puncture,  but 
this  chair  calls  for  cooperation  on  the  part  of  the 
patient,  hence  its  impracticability  in  children.  This 
question  may  be  settled  by  compromising  and  recom- 
mending both  the  sitting  and  the  recumbent  posture. 
At  times  it  serves  the  interests  of  the  patient  to 
combine  the  tw^o  postures  at  a  single  puncture.  As 
a  result  of  eight  years  of  experience  the  sitting 
posture  can  be  recommended  for  the  inexperienced 
and  the  recumbent  posture  for  the  man  who  is  well 
trained.  Any  discussion  as  to  which  side  is  prefer- 
able, right  or  left,  when  employing  the  recumbent 
posture,  only  occupies  unnecessary  time  and  is  of 
no  importance  from  the  practical  point  of  view. 
One  has  to  be  a  well  trained  acrobat  to  do  a  lumbar 
puncture  with  the  patient  on  his  left  side,  unless 
the  operator  is  left  handed.  The  body  should  be 
well  flexed,  regardless  of  the  posture  employed. 
The  parts  having  been  made  aseptic  with  tincture  of 
iodine  and  alcohol,  one  chooses  the  third  or  fourth* 
lumbar  interspace ;  a  line  drawn  between  the  crests 
of  the  ilia  across  the  back,  where  the  line  intersects 
the  spine  at  the  level  of  the  fourth  lumbar  vertebra ; 
you  can  therefore  choose  the  interspace  above  or 
below.  The  forefinger  of  the  left  hand  is  used  as 
a  guide.  Holding  the  needle  in  the  right  hand,  it 
is  inserted  perpendicularly  to  the  spine,  and  the 
needle  is  firmly  forced  in  the  median  line  into  the 
spinal  canal. 

The  next  question  that  usually  arises  is  how  deep 
the  needle  should  be  inserted.  This  question  is 
answered  differently  by  different  authors.  Kerley 
(19)  recommends  an  inch.  Other  authors  recom- 
mend an  inch  and  a  quarter.  I  feel  that  such  advice 
only  tends  to  confusion.  The  answer  we  usually 
give  is,  go  ahead  until  you  get  fluid,  for  the  depth 
varies  greatly  with  the  age  as  well  as  with  the  degree 
of  development  and  the  weight  of  the  patient.  In 
some  cases  you  may  feel,  by  the  diminished  resist- 
ance, that  you  entered  the  spinal  canal.  But  not  in 
older  and  well  developed  children. 

Dry  tap. — A  good  deal  of  criticism  has  been 
aroused  against  the  technic  which  results  in  a  dr\- 
tap.  One  prominent  New  York  pediatrist,  when 
asked  what  he  would  do  if  he  got  a  dry  tap,  replied 
sharply :  "Get  somebody  that  knows  how  to  do  a 
lumbar  puncture."  And  still  it  must  be  conceded 
that  occasionally  one  will  get  a  dry  tap.  Dunn 
makes  the  following  statement :  "Peculiar  anatomical 
conditions  or  certain  pathological  conditions  at  the 
base  of  the  brain  may  prevent  one  from  reaching 
the  lumbar  portion  of  the  spinal  canal,  hence  a  dry 
tap."  Again,  one  may  also  get  a  dry  tap  as  a 
result  of  adhesions  around  a  point  of  a  previous 
puncture  (17).  It  is,  therefore,  advisable,  in  the 
treatment  of  a  case  of  meningitis,  where  you  expect 
to  give  serum  injections,  to  begin  at  the  lowest  point 
possible  in  order  to  avoid  such  occurrence.  When- 
ever such  adhesions  have  taken  place  we  must  utilize 
the  lateral  ventricles.  Holt  (4)  reports  a  dry  tap 
in  four  out  of  thirty-nine  cases.  In  a  case  of  cere- 
bral hemorrhage  in  a  newborn  baby  admitted  to  the 
Post-Graduate  Hospital,  in  May,  1918,  on  which 
several  attempts  to  obtain  some  spinal  fluid  made 
by  myself  as  well  as  by  two  men  of  the  house  staff, 
were  unsuccessful.    The  necropsy  findings  by  Dr. 


1024         PR!  EDM  AX  AND  GREENFIELD:  MIDDLE    EAR  DISEASE  IN  CHILDREN.  [New  York 

Medical  Journal. 


McNeal  justified  the  dry  tap  by  disclosing  a  large 
blood  clot  extending  from  the  brain  into  the  spinal 
canal.  These  facts  are  sufficient  to  prove  that  a 
dry  tap  is  not  always  explained  by  an  inefficient 
technic. 

A  word  concerning  possible  accidents  in  the  course 
of  or  following  lumbar  puncture.  Breaking  of  the 
needle  happens  occasionally,  and  should  not  frighten 
one.  If  you  are  careful  and  avoid  using  a  long 
pointed  needle,  and  if  you  do  not  bend  the  needle 
while  introducing  it,  you  may  save  yourself  that 
accident.  If  the  needle  should  break,  unless  the 
broken  end  can  be  easily  extracted,  it  is  best  to 
defer  its  removal  to  a  future  time  when  the  patient 
has  recovered  from  the  acute  stage  of  his  illness, 
and  even  then  you  may  decide  to  leave  it  alone. 

Koplik  (21)  reports  two  cases  of  apnea  from 
shock  more  alarming  than  a  broken  needle,  but  he 
does  not  tell  us  the  state  of  health  of  the  patients 
et  the  time  of  the  puncture.  In  such  an  occurrence 
one  should  stop  the  operation  immediately,  lower 
the  patient's  head,  resort  to  artificial  respiration, 
administer  adrenaline,  and  apply  external  heat  to 
the  body. 

In  cases  of  chronic  hydrocephalus,  where  one 
expects  to  remove  large  quantities  of  fluid,  the 
patient  should  always  be  kept  on  his  side  during 
puncture,  in  order  to  avoid  undue  shock.  The 
wound  should  always  be  properly  dressed,  with 
cotton  and  collodion,  or  with  adhesive  plaster.  It 
is  not  advisable  to  use  collodion  when  repeated 
punctures  are  planned.  Occasionally  a  bloody  fluid 
complicates  the  procedure.  By  using  a  short  pointed 
needle  this  may  be  avoided.  This  is  not  a  dangerous 
accident,  but  a  bloody  specimen  is  useless  for  the 
purpose  of  examination.  Occasionally  only  the  first 
few  drops  are  bloody,  .when  a  fresh  test  tube  will 
collect  a  desirable  specimen. 

CONCLUSIONS. 

The  operation  is  simple,  with  practically  no  danger 
to  the  patient.  Its  usefulness  for  diagnostic  pur- 
poses is  indispensable,  and  should  be  done  early  in 
the  course  of  the  illness.  The  technic  should  be 
learned  by  all  physicians. 

REFERENCES. 

1.  Cook.  E.  P. :  New  York  Medical  Jourx.'^l,  Feb- 
ruary 25,  1905. 

2.  Neal:  Archives  of  Pediatrics.  1916,  p.  596. 

3.  Idem:  Archives,  1916,  p.  403. 

4.  Holt:  Infancy  and  Childhood,  Appleton  &  Co. 

5.  Koplik,  Osler  and  AIcRae  :  Modern  Medicine,  1913. 

6.  Hfiman  :  Archives  of  Pediatrics,  1916,  p.  581. 

7.  Michael:  Archives  of  Pediatrics,  1916,  p.  281. 

8.  Cook  :  New  York  Medical  Journal,  1905. 

9.  McDonald  :  New  York  Medical  Journal,  1905. 

10.  Weinlander  :  Wiener  klin.  Wochenschrift,  vol. 
xxvi. 

11.  Regan:  Archives  of  Pediatrics,  March,  1919. 

12.  Quincke:  Thcrapeut.  Monatsch'dfte,  July,  1914. 

13.  Kausch  :  Therapeut.  Monatscluifte,  July,  1914. 

14.  Rachford:  Diseases  of  Children,  Appleton. 

15.  Goodman:  Archives  of  Pediatrics,  September,  1915. 

16.  Campbell  and  Kerr:  Surgical  Diseches  of  Children, 
Appleton. 

17.  Fischer:  Infancy  and  Childhood,  Davis  &  Co. 

18.  Williamson  :  Journal  A.  M.  A.,  February,  1920. 

19.  Kerley:  Practice  of  Pediatrics,  Saunders. 

20.  Strauss:  Journal  A.  M.  A.,  1914,  p.  1327. 

21.  Koplik:  Archives  of  Pediatrics,  1916,  p.  486. 

327  Pennsylvania  Avenue. 


MIDDLE  EAR  DISEASE  IN  CHILDREN. 
By  Joseph  Friedman,  M.  D., 

Brooklyn,  N.  Y., 

Instructor,  Department  of  Nose  and  Throat,  Post-Graduate  Medical 
School   and   Hospital;    Associate   to   the    Beth    Moses  and 
Bikur  Cholira  Hospitals;  Assistant  to  the  Williams- 
burgh  and  Coney  Island  Hospitals. 

AND  Samuel  D.  Greenfield,  M.  D., 

Brooklyn,  N.  Y., 

Assistant  Attending  Ophthalmologist,  Beth  Moses  Hospital;  Assistant 
Otolaryngologist    Williamsburgh    Hospital;    Clinical  Assistant, 
Nose   and  Throat   Department,    Manhattan   Eye,  Ear, 
Nose  and  Throat  Hospital,  New  York. 

Of  all  conditions  that  prove  an  enigma  to  the 
average  general  practitioner,  none  can  quite  equal 
the  case  of  a  young  child  with  an  unexplained 
hyperpyrexia.  Being  fairly  well  satisfied  that  the 
respiratory  tract  is  clear,  and  if,  after  the  routine 
laboratory  aids,  the  physician  comes  to  the  conclu- 
sion that  a  pyelitis  does  not  serve  to  explain  the 
temperature,  his  case  becomes  infinitely  more  com- 
plicated. After  a  day  or  two  of  observation,  with- 
out the  appearance  of  those  manifestations  which 
point  to  a  possible  exanthem,  he  often  finds  himself 
confronted  with  that  familiar  interrogation:  "Well, 
doctor,  what  do  you  think  is  the  trouble  with  my 
child?"  We  do  not  think  we  are  taking  too  much 
for  granted  when  we  say  that  at  this  stage  of  the 
game  the  attending  physician  is  at  a  loss  to  explain 
the  child's  condition,  and  if  he  is  possessed  of  a 
conscience,  would  almost  wish  that,  through  some 
good  fortune,  Providence  might  rid  him  of  the  case. 
Unfortunately,  many  men  find  themselves  in  a 
predicament  similar  to  the  one  we  have  just  depicted, 
and  we  are  certain,  if  one  will  take  the  trouble  to 
recall  those  cases  which  have  baffled  him  most  in 
his  practice,  a  large  percentage  of  therri  will  find 
a  place  in  this  category. 

It  is  unquestionably  true  that,  from  the  viewpoint 
of  holding  his  patient,  the  practitioner  finds  it  a 
most  difficult  task  to  perform.  Although  knowing 
that  he  has  failed  to  account  for  the  child's  condi- 
tion, he  will  persist  in  procrastination  and  defer 
that  assistance  which,  in  addition  to  solving  the 
problem  for  him,  would  afford  him  an  unusual 
opportunity  to  crown  himself  with  glory  and  estab- 
lish himself  most  firmly  with  many  a  family,  and 
also  bring  to  his  weary  and  much  concerned  mind 
a  feeling  of  peace  and  satisfaction. 

It  is  only  upon  the  appearance  of  an  aural  dis- 
charge— and  this  most  often  discovered  by  the 
mother— supplemented  b}'  the  usual  history  that  the 
child  slept  soundly  last  night  for  the  first  time  in 
seventy-two  hours  or  more,  that  the  unsuspecting 
physician's  attention  is  first  directed  to  the  existing 
and  undoubtedly  causative  aural  condition.  There 
is  no  question  in  our  minds — and  many  men  will 
bear  out  our  statement,  that  of  all  conditions  met 
with  in  children,  middle  ear  affections  rank  first 
among  those  most  frequently  overlooked.  Very 
often  the  early  detection  of  an  otitis,  although  not 
yet  fully  established,  will  frequently  lead  to  a  satis- 
factory explanation  of  these  temperatures  and  will, 
in  addition,  insure  early  operative  intervention, 
should  such  measures  become  necessary.  Further- 
more, it  will  assure  the  patient  that  the  attending 
physician  is  alert  and  on  the  job  and  the  physician 


December  25.  192U.]     FRIEDMAN  AND  GREENFIELD:  MIDDLE    EAR  DISEASE  IN  CHILDREN.  1025 


himself  will  not  overlook  a  condition  for  which,  in 
the  majority  of  cases,  one  can  hardly  find  a  just 
.  vindication. 

We  are  indeed  well  aware  of  the  many  difficulties 
with  which  the  general  physician  is  confronted,  and 
especially  those  obstacles  with  which  he  must  con- 
tend when  attempting  to  induce  his  patient  to  con- 
sent to  a  consultation  with  the  aurist,  and  we  are 
certain  no  orfe  can  appreciate  this  more  than  we  do. 
It  is  with  this  understanding  that  we  feel  most 
keenly  for  the  general  practitioner,  and  although  we 
may  appear  somewhat  censorious  in  our  statements, 
we  assure  you  there  is  not  the  slightest  intention 
on  our  part  to  reproach  him.  He  has  far  too  many 
cares  and  worries,  and  with  this  in  mind,  the  spe- 
cialist must  not  be  unreasonably  severe  in  his  criti- 
cism. But  we  do  feel  we  are  not  overstepping 
bounds,  no  matter  how  emphatic  and  exacting  we 
may  seem,  when  our  efforts  and  endeavors  are 
directed  toward  awakening  in  the  mind  of  the 
general  practitioner  a  sense  of  the  colossal  impor- 
tance of  ear  examinations  in  children.  Too  much 
stress  cannot  be  laid  upon  this  subject,  and  the 
general  practitioner  must  constantly  bear  in  mind 
that  a  physical  examination  in  a  child  is  never 
complete  without  paying  adequate  time  and  attention 
to  the  ears. 

The  external  auditory  canals  in  infants  are  nar- 
row and,  in  younger  children,  it  is  often  no  easy 
matter  to  obtain  a  good  view  of  the  drumhead,  but 
we  believe  that  in  many  of  the  cases  we  have  seen 
there  was  no  reason  whatsoever  for  error,  or 
apparent  neglect  to  examine  the  ears.  We  will 
grant  you  that  the  general  practitioner  is  not  to 
determine  whether  the  child  is  suffering  from  a 
catarrhal  or  a  suppurative  form  of  otitis  media,  or 
whether  there  is  bulging  here  or  retraction  there; 
but  we  do  feel  that  he  should  at  least  suspect  the 
ear  condition  when  his  patient  presents  an  unex- 
plained temperature,  and  when  in  doubt  he  should 
seek  advice  so  that  his  suspicions  ma}'  be  either 
confirmed  or  dispelled. 

We  have  here  in  mind  a  case  we  saw  only  recently 
in  which  both  the  attending  physician  and  the  con- 
sulting pediatrist  failed  to  recognize  the  aural  con- 
dition. For  twelve  days  the  child  had  a  tempera- 
ture ranging  from  101°  to  104°  F.  Although  not 
established  by  the  laboratory,  the  consulting  pedi- 
atrist made  a  diagnosis  of  pyelitis,  "as  a  result  of 
exclusion,"  he  termed  it,  having  taken  into  con- 
sideration the  child's  age  and  the  fact  that  he  failed 
to  find  any  other  cause  to  which  to  attribute  the 
temperature.  When  we  saw  the  child,  we  found  a 
subperiosteal  abscess  had  already  formed.  It  should 
be  remembered  that  the  pediatrist  had  seen  the  child 
only  forty-eight  hours  previously,  and  apparently 
neglected  to  examine  the  ears,  or  failed  to  recognize 
the  existing  ear  condition. 

We  sometimes  fail  to  understand  why  general 
practitioners  will  permit  cases  similar  to  the  one  we 
have  cited,  to  go  on  for  days  without  seeking  advice, 
and  even  when  the  diagnosis  of  purulent  otitis  has 
been  established  by  the  presence  of  a  discharge,  will 
permit  these  cases  to  go  unseen  for  weeks,  with 
more  or  less  indifference,  giving  little  thought  to 
the  dangerous  sequete  that  might  follow.    The  at- 


tending physician  is  then  suddenly  overwhelmed 
when  his  attention  is  called  to  swelling  and  edema 
over  the  mastoid,  obliteration  of  the  postauricular 
fold,  and  an  auricle  standing  away  from  the  child's 
head.  It  is  only  upon  the  recognition  of  these 
dangerous  complications  that  the  practitioner  is 
aroused  from  his  lethargy  to  seek  aid.  The  presence 
of  a  subperiosteal  abscess  is  very  often  the  only 
pathognomonic  sign  of  mastoid  disease  known  to 
some  practitioners,  and  we  have  had  occasion  to 
come  in  contact  with  men  who  believed  this  was 
the  only  indication  for  operative  intervention  in 
children.  Whether,  in  view  of  our  modern  knowl- 
edge of  handling  these  conditions,  this  belief  should 
still  be  prevalent,  we  leave  it  to  your  own  judgment. 
True,  many  cases  of  middle  ear  disease  clear  up 
without  operation  and,  as  a  matter  of  fact,  most  of 
them  have  such  a  happy  termination ;  but  if,  after 
a  reasonable  length  of  time,  one  fails  to  clear  up, 
investigation  should  not  be  delayed  too  long  in 
ascertaining  the  cause. 

If  discharging  ears  are  associated  with  even- 
ing rises  in  temperature,  namely,  101°  to  103°  F., 
whether  this  temperature  is  the  result  of  the  otitis 
must  be  decided.  In  other  words,  if  an  ear  has 
been  discharging"  for  one  or  two  weeks,  associated 
with  evening  elevations  of  temperature,  our  exam- 
ination must  determine  whether  there  is  evidence 
of  insufficient  drainage  facilities,  as  indicated  by 
the  size  and  location  of  the  perforation  or  incision. 
If  there  is  a  good  sized  opefting,  without  a  bulging 
drum,  with  little  or  no  sagging  of  the  posterior 
superior  canal  wall,  in  the  absence  of  a  profuse 
discharge,  we  can  rest  assured  that  the  cause  for 
the  temperature  should  be  sought  for  elsewhere. 
If,  on  the  other  hand,  we  note  a  nipple  shaped  pro- 
jection, at  the  apex  of  which  we  find  a  pinpoint 
perforation,  through  which  a  drop  of  pus  can  be 
seen  exuding — which  picture  is  good  evidence  of 
insufficient  drainage — we  may  justly  attribute  all 
or  at  least  part  of  the  temperature  to  pus  retention. 
There  is  essentially  no  difference  in  pus  retention 
here  from  that  in  any  other  part  of  the  body. 

Sagging  of  the  posterior  superior  canal  wall  is 
of  great  importance  when  taken  together  with  all 
the  other  signs  and  symptoms.  In  itself,  in  early 
cases  and  in  very  young  children,  as  far  as  being 
an  operative  indication,  its  value,  we  believe,  has 
been  overestimated.  We  have  seen  cases  in  which 
there  was  sagging  with  a  vengeance,  so  to  speak, 
which  cleared  up  most  rapidly  and  completely,  and 
on  the  other  hand,  we  have  seen  cases  which  ex- 
hibited very  little  sagging  and  upon  operation  dis- 
closed extensive  erosion  of  the  sinus  and  dural 
plates  and  even  destruction  of  these  structures,  with 
exposure  and  disease  of  sinus  and  dura. 

The  amount  of  discharge  itself  is  often  a  most 
important  operative  indication.  A  socalled  water- 
fall discharge,  one  which  reappears  abundantly  im- 
mediately upon  wiping  away,  even  if  unattended 
by  marked  rises  in  temperature,  and,  if  of  any 
duration,  is  strong  evidence  that  the  infection  is 
not  limited  to  the  middle  ear  spaces,  but  the  attic 
and  antrum  and  possibly  more  important  structures 
are  also  involved.  The  diseased  mucous  membrane 
in  the  middle  ear  when  alone  involved  cann  jt  pro- 


1026 


SCHEIMBERG:  WEAK  FOOT  IN  THE  CHILD. 


INew 
Medicat, 


York 
Journal. 


duce  so  profuse  a  discharge.  Hence  it  is  gross 
neglect  to  permit  these  children  to  go  on  for  weeks 
and  months  with  profusely  discharging  ears.  It  is 
only  later  in  life  that  the  bad  efifects  of  this  neglect 
are  made  apparent.  At  this  time  is  laid  the  founda- 
tion for  cholesteatoma  cases,  for  semicircular  canal 
fistulae,  and  for  labyrinthine  and  intracranial  com- 
plications, not  mentioning  the  concomitant  impair- 
ment of  hearing  which  follows,  even  if  these  patients 
escape  the  more  serious  complications. 

In  passing,  it  is  well  to  mention  that  the  middle 
ear  conditions  occurring  with  little  or  no  elevation 
of  temperature  and  few  constitutional  symptoms, 
such  as  are  seen  in  undernourished,  debilitated 
and  marantic  children,  and  those  seen  in  the  tuber- 
culous, are  not  included  in  this  category.  These 
children  very  often  present  serious  effusions  and 
even  purulent  secretions  in  the  middle  ear,  with 
practically  no  constitutional  reaction  that  might  serve 
to  call  our  attention  to  the  existing  otitis.  During 
the  routine  examination  of  these  children  the  ear 
condition  is  accidentally  discovered.  We  make 
mention  here  only  of  aural  affections  occurring  in 
the  young  and  healthy  infant. 

It  is,  therefore,  the  duty  of  every  general  prac- 
titioner to  whom  is  entrusted  the  care  of  children, 
especially  those  in  the  early  years  of  life,  never 
to  fail  to  examine  the  ears.  This  is  particularly 
true  in  children  suffering  from  measles,  diphtheria 
or  scarlatina.  Ear  complications  are  most  prone 
to  develop  in  these  children,  and  the  usual  symptoms 
which  direct  our  attention  to  the  ears  are  often 
absent  or  masked  by  the  symptoms  of  the  initial 
disease.  We  cannot  impress  upon  you  too  strongly 
the  rapid  and  extensive  destruction  that  takes  place, 
especially  in  the  last  mentioned  disease.  It  is  of 
the  greatest  importance  to  bear  this  fact  in  mind. 
One  examination  of  the  ears  in  such  cases  is  entirely 
inadequate,  but  an  examination  conducted  at  regu- 
lar intervals  during  the  course  of  the  disease  is  of 
paramount  importance. 

If  the  attending  physician  has  not  had  sufficient 
experience  in  examining  ears,  so  that  he  may  arrive 
at  a  satisfactory  conclusion,  he  should  not  hesitate, 
in  justice  to  the  patient  and  to  himself,  to  seek 
advice,  especially  in  those  cases  in  which  he  cannot 
satisfy  himself  as  to  the  cause  of  an  abnormal 
temperature.  If  the  patient  comes  to  him  with  a 
running  ear,  he  should  not  be  content  with  merely 
prescribing  an  irrigation,  but  should  be  sufficiently 
interested  to  ascertain  the  exact  state  of  affairs 
behind  the  discharge.  Above  all,  he  should  not  be 
guilty  of  sitting  aside,  idly  waiting  for  the  more 
serious  complications  to  stir  him. 

We  feel  assured  that  if  the  proper  precautions 
are  taken  in  determining  these  cases  at  the  outset ; 
if  the  general  practitioner  will  exhibit  the  interest 
becoming  such  conditions ;  if  he  will  always  bear 
in  mind  the  great  frequency  of  aural  affections  in 
infants  and  will  endeavor  to  bring  them  under  the 
care  of  the  otologist,  who  can  do  most  for  these 
cases  in  the  early  stages  of  the  disease,  he  will  be 
,"^nng  a  long  way  toward  averting  and  offsetting 
t''Ose  serious  complications  which  the  aurist  is  so 
often  called  to  treat. 

691  L.\FAYETTE  AvENUE. 


THE  WEAK  FOOT  IN  THE  CHILD. 
Flexible  Flat  Foot. 
By  H.  Scheimberg, 

Brooklyn, 

Lecturer  on  Mechanical  Orthopedics,  The  First  Institute  of 
Podiatry,  New  Y'ork. 

(Concluded  fi'om  page  993.) 

It  is  peculiarly  unfortunate  that  persistent  pain 
in  the  young  children  is  often  lacking.  I  say  unfor- 
tunate, because  if  direct  pain  were,  more  marked, 
parents  would,  of  course,  give  the  condition  early 
attention.  Where  pain  is  present,  the  tendency  is 
to  regard  it  as  growing  pains.  The  absence  of 
persistent  pain  is  easily  explained.  Pain  itself  can 
only  occur  with  or  be  consequent  to  such  factors  as 
overstrain,  actual  injury,  or  in  disease  as,  for  ex- 
ample, a  tuberculous  arthritis  of  the  ankle  or  neigh- 
boring joints,  in  the  foot,  or,  for  that  matter,  in 
any  joint.  In  the  common  weak  foot,  however,  we 
have  no  history  of  direct  injury  or  disease,  while  the 
element  of  overstrain  cannot  operate  to  produce 
persistent  pain  because  of  the  relatively  lighter 
weight  of  the  child's  body  and  the  frequent  rest 
periods  to  which  the  child  resorts.  It  is  only  when 
the  child  gets  older  and  heavier,  or  where  we  have 
an  unusual  rapid  growth  or  increase  of  weight,  or 
where  employment  necessitates  foot  work  without 
a  choice  of  rest  periods,  that  the  element  of  over- 
strain enters  and  painful  disability  and  often  nerv- 
ous exhaustion  become  the  dominating  symptoms. 

We  can  thus  realize  the  intimate  relationship 
between  the  weak  foot  and  the  body  mechanism. 
It  becomes  clear  that  in  attempting  to  correct  faulty 
.  posture  in  any  part  of  the  body,  the  feet  should 
not  be  overlooked  as  a  possible  direct  or  contributing 
factor  in  creating  lack  of  body  balance.  Where  the 
abdomen  projects  excessively  or  round  shoulders 
exist,  where  there  is  clumsiness  in  action  and  fre- 
quent falling,  we  may  also  find  that  the  child  is 
suffering  consciously  or  unconsciously  from  a  weak 
foot  which  may  require  prime  consideration.  The 
general  practitioner  might  do  well,  therefore,  to 
include  the  feet  in  a  routine  examination  of  the 
child,  particularly  after  acute  illnesses  that  may 
have  weakened  the  general  musculature. 

In  the  treatment  of'  the  ordinary  weak  feet  in 
children  the  use  of  operative  surgery  is'  not  a  logical 
expedient  because  as  we  have  seen  the  problem  is 
not  one  of  a  fixed  and  localized  deformity  as  much 
as  a  functional  weakness  on  the  part  of  several 
structures  and  restoration  of  functional  ability  on 
the  part  of  the  weakened  structures  is  of  prime 
importance,  not  the  correction  of  the  deformity. 
When  functional  tonicity  on  the  part  of  the  weak- 
ened fleshy  structures  has  occurred,  the  deformity 
automatically  disappears.  Operative  methods  are 
contraindicated  also,  because  of  the  danger  to  ulti- 
mate bone  guowth  from  interference  with  rapidly 
developing  bone ;  but  primarily  because  the  prog- 
nosis by  the  use  of  simple  measures  and  the  co- 
operation of  the  patient,  is  both  excellent  and  fairly 
immediate. 

The  use  of  plaster  of  paris  or  adhesive  plaster 
dressings  for  the  purpose  of  maintaining  the  foot 
in  an  overcorrected  (inverted  and  adducted)  posi- 


December  25,  1920.] 


SCHEIMBERG:  WEAK  FOOT  IN  THE  CHILD. 


1027 


tion  is  contraindicated  here.  Such  measures  are 
appropriate  to  overcome  spasm,  or  fixed  shortening 
of  the  peronei  muscles,  or  where  immobilization  is 
sought,  as  in  an  acute  inflammatory  condition. 
Here,  however,  none  of  these  conditions  obtain  while 
the  element  of  continued  immobilization,  more  so 
with  the  plaster  of  paris,  incident  to  these  methods 
contradicts  the  prime  essential  for  the  cure  of  the 
condition,  namel}-,  the  restoration  of  functional 
ability  which  can  only  be  secured  by  function.  With 
adhesive  plaster,  we  have  less  immobilization,  but 
the  continuance  of  adhesive  on  the  skin  over  a  period 
of  time  as  required  in  the  majority  of  these  cases 
cannot  long  be  tolerated.  In  some  cases,  however, 
I  have  found  that  several  adhesive  plaster  strap- 
pings so  adjusted  as  to  throw  back  the  heel  bone, 
when  used  in  conjunction  with  due  attention  to 
other  elements  of  treatment,  has  resulted  in  an 
unusually  rapid  correction  in  a  few  weeks  and  in 
some  rare  cases  in  about  a  week.  This  is  not 
typical,  but  where  it  has  occurred  the  child  seemed 
to  be  unusually  intelligent,  and  this  intelligence  may 
have  operated  reflexly  to,  effect  an  instinctively  en- 
forced assumption  of  the  correct  position  during 
the  time  that  the  adhesive  plaster  dressings  pre- 
vented the  assumption  of  the  incorrect  posture. 
The  objection  of  immobilization  holds  also  with 
leg  braces  that  are  intended  to  hold  the  foot  in  an 
overcorrected  position. 

The  successful  treatment  of  the  majority  of  these 
cases  demands  specific  attention  to  the  following 
essentials:  1,  Attitude;  2,  footgear;  3,  exercise  to 
restore  functional  tonicity  to  the  relaxed  muscles 
and  ligaments  ;  4,  preventing  the  feet  from  assuming 
the  attitude  of  deformity,  but  without  functional 
interference. 

Attitude.— This  needs  no  further  comment  ex- 
cept that  care  should  be  taken  that  improper  stand- 
ing or  walking  is  not  secondary  to  other  postural 
or  structural  causes.  _ 

Footgear. — As  already  stated,  correct  fitting 
should  be  understood  and  checked  by  the  practitioner 
treating  the  patient.  In  the  shoe  itself,  the  fore 
part  should  adduct  slightly  toward  the  median  line 
of  the  body  so  as  to  help  preserve  a  normal  relation- 
ship of  the  longitudinal  segments  of  the  arch. 
Excessive  adduction,  however,  of  the  front  of  the 
shoe,  may  by  pressure  induce  an  irritation  at  the 
region  of  the  fifth  metatarsophalangeal  joint,  and 
thus  aff^ect  gait.  It  is  absolutely  necessary  to  avoid 
impingement  against  the  large  toe — a  caution  which 
cannot  be  too  strongly  emphasized.  Pressure 
against  the  large  toe  is  the  forerunner  of  the  hallux 
valgus  and  the  unsightly  bunion  or  the  two  condi- 
tions combined.  Primarily  such  pressure  by  abduct- 
ing the  large  toe  from  the  median  line  of  the  body 
diverts  direct  action  of  the  exterior  longus  hallucis 
and  the  flexor  longvis  hallucis.  v.hich  muscles  attach 
to  the  large  toe  from  the  leg  and  are  important 
adjuncts  to  the  maintenance  of  the  arch.  Counter 
and  waist  should  be  snug.  From  the  viewpoint  of 
prevention  in  a  normal  foot,  such  factors  as  the 
softness  of  growing  bone  combined  with  the  un- 
yielding .street  pavements  and  the  normal  tendency 
of  the  OS  calcis  to  rotate  inward,  seem  sufficient 
argument  against  sandals,  sneakers,  and  flexible 


shank  shoes  generally,  and  these,  therefore,  are  cer- 
tainly barred  as  therapeutic  considerations.  Though, 
perhaps,  the  subject  in  hand  does  not  warrant  an 
unduly  prolonged  discussion  on  the  shoe  question, 
two  interesting  items  warrant  reference.  One  re- 
lates to  the  socalled  problem  of  making  a  proper  shoe 
for  the  child.  My  observation  of  the  children's  shoes 
on  the  market  show  me  that  no  problem  would  exist 
if  an  attempt  were  actually  made  to  simply  follow 
the  contour  of  activity  of  a  normal  child's  foot — 
something  that  has  not  yet  been  done  from  the  view- 
point of  manufacturing  a  standard  shoe.  Of  course, 
the  fitting  problem  for  a  particular  case  still  exists. 
The  other  item  of  interest  on  the  shoe  question  is 
the  favorite  argument  resorted  to  by  the  exponents 
of  the  flexible  shank  shoes  that  nature  intended  per- 
fect freedom  of  function  for  the  delicate  plantar 
structures  of  the  foot  in  order  to  attain  perfect 
development.  But  was  it  Nature  or  man  who 
evolved  city  walks — hard,  unyielding  surfaces,  and 
which  are  themselves  so  artificial  that  even  the  horse 
must  be  shod  for  protection  against  the  jar? 
Besides,  proof  is  lacking  that,  given  a  rigid  shank 
shoe  in  a  particular  case,  the  shoe  to  be  well  fitted, 
interference  with  foot  function  actually  exists. 

Nor  should  we  overlook  the  directly  contributing 
influence  of  stockings  in  producing  mechanical  foot 
disorders,  particularly  the  weak  foot.  It  has  always 
been  a  matter  of  surprise  to  me  to  find  that  in 
written  or  oral  discussions  on  foot  ailments,  too  little 
consideration  has  been  given  to  the  stocking.  It 
should  pass  as  too  plain  for  discussion  that  even 
with  proper  shoes,  much  damage  can  be  effected 
through  stockings  that  are  too  short,  of  unyielding 
texture,  and  which,  therefore,  by  cramping  the  toes, 
interfere  with  circulation  and  function. 

But  with  the  weak  foot  in  particular,  the  stocking 
has  an  intimate  relationship.  This  can  only  be 
appreciated  by  observing  the  peculiar  changes  that 
take  place  in  and  about  the  large  toe  when  off  the 
ground  at  rest  and  when  bearing  weight  in  activity. 
When  weight  bearing  its  function  distinct  from  that 
of  the  smaller  toes  is  that  of  a  weight  bearing  base 
from  which  the  body  is  thrust  forward  while  at  the 
same  time  the  smaller  toes  grip  the  ground  by  a 
flexion  or  bending  at  their  first  interphalangeal 
joints.  To  bear  the  body  weight,  the  great  toe 
remains  straight  through  its  length  while  the  grip- 
ping action  of  the  other  four  toes  is  manifest  in 
the  flexion  mentioned.  But  this  is  not  all.  With 
the  foot  off  the  ground  in  the  rest  attitude,  the 
tendons  attaching  to  the  great  toe  are  relaxed,  per- 
mitting that  toe  to  lean  up  against  and  come  in  con- 
tact with  the  second  toe  (Fig.  6),  and  a  straight 
line  if  extended  on  the  inner  margin  of  the  foot 
from  heel  to  toe  would  not  come  in  contact  with 
the  entire  inner  margin  of  the  great  toe.  Under 
weight  bearing,  however,  the  large  toe  swings  in 
toward  the  median  line  of  the  body  (Fig.  7)  so 
that  a  straight  line  extended  on  the  inner  side  of 
the  foot  from  heel  to  toe  would  touch  the  large 
toe  along  its  length  and  a  spaCe  now  exists  between 
the  large  toe  and  its  neighbor.  As  the  large  toe 
swings  toward  the  other  foot  in  the  upright  position 
to  take  the  weight  of  the  body,  it  does  so  by  the 
tightening  of  the  tendons  of  the  muscles  attaching 


1028 


SCHEIMBERG:   WEAK  FOOT  IN  THE  CHILD. 


tXsW  VORK 

Medical  Journal. 


to  it,  the  extensor  longus  hallucis  and  particularly 
the  flexor  longus  hallucis.  The  tautness  of  the 
flexor  longus  hallucis  tendon,  which  runs  across 
the  entire  sole  forward  to  the  extremity  of  the  large 
toe,  results  also  in  a  bracing  of  the  segments  of  the 
longitudinal  arch  so  that  the  concavity  under  'the 
arch  becomes  visibly  increased,  particularly  in  the 
tip  toe  position  at  the  end  of  the  step,  when,  through 
the  tightening  of  this  tendon,  the  concavity  of  the 
longitudinal  arch  is' at  its  greatest.  The  ordinary 
stocking  is,  however,  median  pointed  as  if  both 
sides  of  the  foot  were  symmetrical  and  terminated 
in  a  tip  with  its  farthest  extremity  at  the  third  toe 
instead  of  at  the  first.  Thus  ordinary  stockings  by 
compression  maintain  the  large  toe  against  the 
second  even  when  the  foot  is  bearing  weight  and 
when  the  large  toe  should  adduct  inward.  Besides 
the  stocking  is  put  on  with  the  foot  off  the  ground, 
which  is  the  position  in  which  the  large  toe  leans 
against  the  second.  Thus  there  exists  a  combination  - 
of  factors  that  tend  to  make  inevitable  the  inefficient 
operation  of  the  large  toe  as  a  weight  bearing  and 
locomotive  factor,  and  with  this,  therefore,  a  con- 
sequent weakening  of  the  long  muscles  attaching  to 
it  and  to  all  the  toes  which  brace  up  the  arch. 
Almost  invariably,  therefore,  in  cases  of  hallux 
valgus  do  we  find  an  associated  weak  foot  or  flat 
foot,  or  symptoms  of  arch  strain.  A  fuller  realiza- 
tion of  the  special  function  of  the  large  toe  and  its 
essential  shifting  toward  the  other  foot  in  weight 
bearing,  may  some  day  result  in  stockings  with 
separate  stalls  for  the  large  toes  and  shoes  with 
straight  inner  lines  becoming  more  universal  items 
of  dress.  When  that  day  arrives,  a  great  propor- 
tion of  weak  and  flat  foot  cases  will  simultaneously 
begin  to  disappear. 

Exercises. — The  anatomical  pathological  condi- 
tion is  a  varying  degree  of  relaxation  of  the  ad  duct- 
ing muscles  and  of  the  ligaments  of  the  legs  and 
feet,  thus  resulting  in  abduction  and  eversion.  The 
exercises  should  be  suited  to  the  particular  case  and 
are  such  as  invert  the  entire  foot,  adduct  the  fore- 
foot, throw  the  ankle  outward,  besides  training  in 
normal  posture  and  locomotion  with  the  child  bare- 
footed. As  structural  shortening  of  muscles  is  rare, 
manipulation  seems  hardly  necessary. 

In  general,  exercise  in  the  child's  case  can  be 
easily  effected  by  converting  an  otherwise  dull  pro- 
ceeding into  a  session  of  play.  This  can  be  done 
by  having  the  seated  child  rotate  its  feet  around  the 
fingers  held  at  certain  heights  and  angles,  or  catch- 
ing and  tagging  a  finger  that  is  actually  guiding  the 
foot  in  active  overcorrection. 

It  is  perhaps  unnecessary  to  state  that  in  the 
treatment  of  the  weak  foot  or  any  other  condition, 
if  an  accompanying  active  destructive  process  is 
present,  such  as  tuberculosis  of  bone  or  joint, 
rachitis,  or  an  infectious  arthritis,  rest  and  the 
maintenance  of  the  foot  in  an  attitude  that  will 
prevent  jicrmanent  subsequent  deformity  are  indi- 
cated instead  of  exercises. 

As  prevention  is  always  of  prime  interest,  it_  is 
proper  to  here  allude  to  an  element  of  care  which 
may  prevent  weak  feet  consequent  to  prolonged 
confinement  to  bed.  .\side  from  the  direct  weaken- 
ing effects  on  the  tissues  of  the  foot  due  to  the 


disease  itself  which  has  occasioned  confinement,  a 
change  often  occurs  in  the  legs  and  feet  which  ma}- 
affect  the  weak  feet.  This  occurs  because,  in  the 
attitude  of  rest  as  in  bed,  the  foot  tends  to  lie  in 
extension,  that  is,  at  an  angle  of  over  ninety  degrees 
between  it  and  the  leg.  This  angulation  is  illustrated 
in  the  rest  attitude  that  has  been  assumed  by  the 
child  in  Fig.  6.  When  this  attitude  is  maintained 
over  a  period  of  time  as  with  continued  confine- 
ment, structural  shortening  of  the  calf  muscles 
takes  place  with  a  corresponding  relaxation  and 
weakening  of  the  anterior  muscles — a  sort  of  mild, 
nonparalytic  talipes  equinus.  With  walking  re- 
sumed after  confinement,  such  structural  shortening 
of  posterior  and  relaxation  of  anterior  muscles  of 
the  leg  interferes  with  normal  flexion  and  extension 
of  the  foot  on  the  leg  which  is  required  in  loco- 
motion and  may  occasion  a  secondary  flexion  or 
lateral  displacement  of  the  midtarsal  joints  just  as 
occurs  in  the  weak  foot  and  as  more  fully  detailed 
in  a  previous  article  on  the  high  heeled  shoe  (1). 
To  prevent  these  structural  changes  in  the  leg 
muscles,  it  is  advisable  .during  confinement  and 
where  a  local  condition  does  not  contraindicate  to 
daily  manipulate  both  feet  in  flexion,  extension  and 
circumflexion,  or  to  have  the  patient  engage  actively 
in  these  movements  if  possible. 

Preventing  the  foot  from  assuming  the  attitude 
of  deformity  without  interference  -with  function. — 
We  have  seen  that,  in  weak  foot,  the  heel  bone  en- 
hanced by  normal  anatomic  peculiarities  and  a 
weakened  musculature  falls  inward,  and  that  with 
this  the  forefoot  abducts  and  the  arch  thus  angulates 
with  an  inward  lateral  convexity.  Where  in  the 
normal  foot,  the  entire  force  of  the  body  weight 
was  directed  vertically  through  the  tibia  and  astra- 
galus on  to  the  heel  bone  and  eventually  over  the 
longitudinal  axis  of  the  foot,  it  is  now  to  a  great 
extent  diverted  toward  the  inner  m.argins  cf  both 
feet.  By  bringing  a  sufficient  pressure  to  bear  in 
a  reverse  direction  to  the  inclination  of  the  heel 
bone,  that  is,  both  at  the  upper  inner  and  lower  outer 
surfaces  of  this  bone,  we  automatically  restore  the 
normal  alignment  of  the  longitudinal  arch  and  cor- 
rect whatever  secondary  misalignment  exists  in  the 
knee,  hip  and  spinal  articulations.  Our  problem 
then  concerns  itself  with  forcing  and  holding  this 
bone  in  place.  In  the  very  mild  cases  this  bone  may 
be  ultimately  thrown  back  and  the  condition  cured 
by  attention  to  attitude,  footgear,  exercises,  and 
the  elevation  of  the  inner  margin  of  the  shoe  heel, 
a  requisite  height  depending  on  the  particular  case. 
In  the  more  advanced  cases,  however,  this  is  insuffi- 
cient, and  experience  has  demonstrated  the  final 
expediency  in  even  a  majority  of  these  cases  for 
the  unyielding  and  corrective  pressure  that  only 
metal  can  give. 

The  necessary  lateral  pressure  to  counteract  the 
force  of  the  bqdy  weight  concentrated  at  and  below 
the  ankle  joint  cannot  be  .secured  by  stiff  counter 
shoes,  commercial  supports  and  the  like,  as  these 
cannot  prevent  the  ankle  bulging  and  their  rigidity 
is  lost  through  softening  by  body  heat.  The  sug- 
gestion of  metal,  however,  raises  the  natural  ques- 
tion of  how  to  utilize  it  to  the  best  advantage  with- 
out immobilization  of  the  foot.    This,  in  turn,  calls 


December  25.  1920.] 


SCHEIMBERG:  IVEAK  FOOT  IX  THE  CHILD. 


1029 


for  a  little  inquiry  into  the  commercial  appliances 
now  on  the  market,  with  particular  relation  to  their 
value  in  treatment. 

In  referring  to  the  arch  support,  it  should  be 
borne  in  mind  that  promiscuous  application  of  foot 
plates  has  been  justly  condemned  by  many  eminent 
orthopedists,  imless  made  over  a  specially  corrected 
plaster  positive  of  the  foot  to  secure  the  proper 
indications  in  a  particular  case,  and  then  used  as  an 
adjunct  in  treatment  which  aims  to  discard  them 
when  their  use  is  no  longer  necessary.  This  is  all 
in  perfect  accord  with  the  experience  of  those  who 
have  successfully  treated  many  cases  of  weak  foot 
in  the  child.  But  in  the  general  sale  of  commercial 
appliances,  the  noncompliance  with  the  essentials  of 
scientific  treatment  has  led  to  an  unmerited  con- 
demnation ot  supports  as  a  whole. 

The  specific  objections  against  market  appliances 
are  easily  evident  so  far  as  the  treatment  of  the 
common  weak  foot  is  concerned.  In  the  first  place, 
their  construction  is  based  upon  a  few  fixed  pat- 
terns that  cannot  meet  the  indications  as  to  fit  and 
correction  in  the  varieties  of  weak  feet.  With  teeth 
by  way  of  illustration,  the  community  would  deride 
the  idea  of  patronizing  an  establishment  that  pro- 
fessed to  sell  well  fitting  stock  teeth,  realizing  that 
each  case  requires  specific  preparation.  The  public 
is  not  yet  aware  that  the  variations  in  the  case  of 
the  feet  are  just  as  numerous.  Again,  it  is  assumed 
in  these  stock  supports  that  the  arch  has  broken 
down,  and  that  it  needs  to  be  lifted  up.  Xo  pro- 
vision is  made  for  the  exact  and  powerful  lateral 
pressure  essential  for  correction.  Merely  pressing 
upward  cannot  correct  a  laterally  displaced  arch, 
and  only  furnishes  relief  to  the  ligaments  while  the 
arch  remains  tilted.  Between  the  ligamentous 
strain  which  where  present  is  temporarily  relieved, 
and  the  assurances  of  the  salesman  of  perfect  cure, 
further  neglect  ensues  with  a  loss  of  time  and  money. 

One  excellent  adjunct  in  compl}-ing  with  the 
requirements  of  correction  without  immobilization 
is  the  Whitman  plate  with  a  higher  inner  flange  and 
a  smaller  and  lower  outer  flange,  the  flanges  being 
devised  to  exert  the  necessary  lateral  pressure  to 
counteract  the  tilting  of  the  os  calcis.  This  brace, 
of  course,  is  to  be  made  over  a  plaster  positive  of 
the  foot.  The  cast  should  be  taken  with  the  foot 
at  right  angles  to  the  leg  and  slightly  inverted.  The 
element  of  overcorrection,  often  essential  for  cure, 
is  secured  by  careful  deepening  of  certain  points 
on  the  positive  to  obtain  extra  pressure  where 
desired  and  before  the  final  construction  of  the  plate 
over  this  positive.  When  viewed  plantanvise,  the 
plate  should  terminate  behind  the  head  of  the  first 
metatarsal,  run  thence  diagonally  across  foot  to  the 
outer  flange  situate  at  the  posterior  lateral  surface 
of  the  foot,  and  the  rear  margin  running  trans- 
versely across  the  bottom  of  the  foot  a  little  in  front 
of  the  back  curve  of  the  heel.  When  thus  con- 
structed and  properly  adjusted,  it  may  be  safely 
worn  without  any  interference  to  function.  At  the 
same  time  it  acts  as  an  effective  reminder  to  the 
child  to  maintain  the  correct  attitude  by  making  the 
assumption  of  the  weak  foot  pose  painful.  Proper 
accompanying  treatment  now  facilitates  cure  because 
the  relaxed  structures  are  prevented  from  lengthen- 


ing in  standing  and  walking  and  thus  given  an 
opportunit}'  to  shorten  structurally.  The  assump- 
tion of  the  normal  foot  attitude  is  also  materially 
enhanced  and  made  habitual  because  the  improper 
pose  cannot  be  assumed.  The  support  should  be 
discarded  when  the  correct  attitude  is  assured,  but 
care  to  be  continued  for  a  while  to  attitude,  exer- 
cises and  footgear. 

Though  appreciating  the  seeming  logic  of  those 
who  argue  for  physiological  treatment  solely  in 
preference  to  any  arch  supports,  there  are  considera- 
tions with  respect  to  weak  feet  often  overlooked  that 
often  justify  support  by  braces  as  a  measure  of 
prime  value.  Weak  feet  by  referred  misalignment 
often  occasion  stumbling  and  falling,  together  with 
general  mechanical  strain.  This  stumbling  and 
strain  exist  as  omnipresent  mediums  for  a  possible 
tuberculosis  of  bone  or  joint  which  in  childhood  is 
commonly  consequent  to  trauma.  But  stumbling, 
falling  or  strain  are  immediately  checked  and  nor- 
mal balance  and  locomotion  promptly  effected  by 
proper  bracing.  On  the  other  hand,  physiological 
treatment  cannot  always  check  this  faulty  balance 
and  strain,  but  must  await  actual  correction. 
Besides,  by  a  scientific  preparation  of  the  positive 
before  making  the  support,  overcorrection  of  the. 
condition  through  extra  pressure  against  the  heel 
bone  can  be  obtained  and  the  value  of  overcorrection 
in  treating  any  deformity  so  as  to  secure  perfect 
correction  is  axiomatic  in  orthopedic  practice.  As 
with  the  pro  and  con  of  many  other  questions,  the 
actual  truth  exists  between  both  sides  of  the  argu- 
ment, and  to  my  mind  there  has  been  as  much  of 
too  little  use  when  warranted  of  supports  as  well 
as  an  excessive  dependence  upon  such  appliances. 

The  cure  of  the  weak  foot  is  almost  invariably 
assured  by  the  proper  application  of  the  foregoing 
principles  of  treatment.  Where  it  is  apparent  that  • 
the  weak  feet  are  associated  with  a  general  lack  of 
tone,  treatment  of  the  general  weakness  is  naturally 
indicated,  but  never  without  attention  to  the  local 
condition  which  too  often  survives.  The  length  of 
time  required  for  a  cure  varies  from  a  few  weeks 
to  several  years.  Such  factors  as  excessive  weight, 
general  weakness  due  to  disease  or  otherwise,  lack  of 
cooperation  on  the  part  of  patient  or  even  child, 
are  examples  of  causes  that  may  delay  ultimate  cure. 

COXCLUSIOXS. 

1.  The  feet  of  children  should  be  examined  when 
walking  begins,  to  determine  whether  abnormalities 
exist  that  require  attention. 

2.  Routine  examinations  of  children  by  physi- 
cians or  pediatrists  should  include  observation  of 
the  feet  as  a  possible  source  of  contributing  factor 
to  disability-  or  ailment. 

3.  The  feet  of  children  in  public  schools  should 
be  examined  periodically  by  duly  qualified  specialists 
as  is  now  done  with  the  other  organs. 

4.  A  greater  number  of  cHnics  for  the  particular 
observation  of  children's  feet  should  be  established. 

5.  The  diagnosis  of  foot  ailments  in  the  shoe  store 
should  be  prohibited  by  legislation. 

REFEREXCES. 

1.    ScHEiMBERG :  New  York  Medic.\l' Jourxal,  February 
28,  1920. 


1030 


POPPER:  HIRSCHSPRUNG'S  DISEASE. 


[New  York 
Medical  Jovrnal. 


CONGENITAL  MEGACOLON    (HIRSCH-  ' 
SPRUNG'S  DISEASE). 

With  a  Report  of  a  Case  in  Twins* 

By  Joseph  Popper,  M.  D., 
New  York, 

Attending  Physician,   Infant  Welfare   Department,    Lebanon  Hospi- 
tal;  Attending  Physician,  Israel   Orphan  Asylum. 

The  cases  I  am  about  to  report  are  true  cases  of 
congenital  megacolon  of  the  type  often  referred  to 
as  Hirschsprung's  disease.  In  1880  Hirschsprung 
first  called  attention  to  this  condition  and  published 
his  complete  exposition  of  the  subject  in  1896. 
Cases  were  reported  in  this  country  before  188Q, 
but  the  first  authoritative  study  of  the  subject 
in  this  country  was  made  by  Finney  in  1908.  The 
literature  abounds  in  reports  of  socalled  Hirsch- 
sprvmg's  disease  and  the  condition  is  now  so  well 
recognized  as  to  be  treated  in  most  textbooks  on 
pediatrics. 

However,  lest  it  be  imagined  that  the  disease  is 
fairly  common,  I  should  like  to  state  that  of  the 
abundance  of  reports  and  studies  on  the  subject  many 
of  them  concern  another  condition  which  is  prob- 
ably acquired  and  not  congenital  in  the  same  sense  . 
as  the  cases  described  by  Hirschsprung,  and  which 
fonn  the  basis  of  this  report.  Thus  in  speaking  of 
the  condition  congenital  megacolon  one  should  dis- 
tinguish between  the  two  types. 

The  first  or  Hirschsprung's  type  of  congenital 
megacolon  is  characterized  by  the  following  symp- 
toms and  signs  beginning  at  birth  or  shortly  after 
birth :  Obstinate  constipation,  marked  distention, 
active  and  visible  peristalsis,  and  finally  accom- 
panied by  symptoms  of  intestinal  toxemia.  This 
type,  according  to  recent  investigators,  begins  as  a 
definite  pathological  entity  from  birth,  the  large 
•  intestine  being  both  dilated  and  hypertrophied  from 
the  beginning.  This  type  is  extremely  rare  and  is 
usually  fatal  in  a  short  time  in  most  cases.  As 
evidence  of  the  infrequency  of  this  condition  I  may 
state  that  in  a  personal  communication  Dr.  Rongy 
and  Dr.  Aranow,  attending  obstetricians  to  the 
Lebanon  Hospital  of  this  city,  assured  me  that  they 
had  never  seen  a  case  in- their  many  years  of  service 
in  the  hospital,  and  that  there  was  no  record  of  any 
case  having  occurred  in  the  hospital  during  its 
entire  existence,  a  matter  of  over  a  quarter  of  a 
century  and  covering  many  thousands  of  births. 
That  it  is  more  common  than  the  published  reports 
of  authentic  cases  would  indicate  is  very  likely,  for 
undoubtedly  many  deaths  from  this  disease  are 
reported  as  due  to  intestinal  obstruction,  as  was 
the  case  with  one  of  the  twins  reported  below. 

The  other  type,  and  one  which  is  by  far  much 
more  commonly  met  with,  is  that  which  begins  late 
in  infancy  or  in  early  childhood,  characterized  by 
abdominal  enlargement  and  severe  constipation  with 
its  associated  symptoms.  It  probably  has  a  dif- 
ferent pathology  in  that  it  is  probably  acquired  and 
not  congenital  and  is  secondary  to  some  spastic 
condition  of  some  part  of  the  colon  with  resulting 
dilatation  and  hypertrophy  of  the  gut  immediately 
above  it.    It  is  analogous  to  the  hypertrophy  and 

•Read  before  The  Bronx  County  Medical  Society,  December  16, 


dilatation  of  the  stomach  secondary  to  pylorospasni. 
For  the  same  reason  it  dift'ers  from  Hirschsprung's 
disease  in  its  amenability  to  treatment.  Thus 
^leyers  (1)  succeeded  in  relieving  the  patients  in 
a  series  of  cases  by  proper  diet  and  the  administra- 
tion of  atropine  just  as  Haas  (2)  has  successfully 
treated  pylorospasm.  Other  measures  have  likewise 
succeeded,  such  as  exercise  and  posture  and  local 
treatment.  Thus  far  only  operative  interference 
has  offered  any  hope  in  the  treatment  of  Hirsch- 
sprung's disease,  but  as  yet  the  mortality  from  such 
treatment  is  extremely  high. 

HISTORY. 

This  history  practically  concerns  only  one  of  the 
twins,  for  the  other  had  died  shortly  before  I 
arrived  at  the  patient's  home.  However,  from  the 
previous  history  and  from  a  superficial  inspection 
of  the  dead  twin,  I  am  convinced  that  death  was 
due  to  the  same  malady  from  which  the  live  twin 
is  now  suffering. 

The  twins  were  females  who  came  under  my 
observation  on  the  fourth  day  of  life.  This  was 
the  mother's  fourth  pregnancy,  and  birth  took  place 
at  full  term,  delivery  being  normal.  Birth  weight 
of  the  patient,  five  pounds  eight  ounces ;  that  of 
the  dead  twin,  three  pounds  eight  ounces.  The 
family  history  was  negative.  From  birth  on  the 
history  was  one  of  progressive  intestinal  obstruc- 
tion, the  symptoms  and  signs  being  identical  in 
both  up  to  the  fourth  day.  Neither  infant  had 
passed  meconium  nor  expelled  flatus  since  birth, 
in  spite  of  cathartics,  enemata,  and  various  other 
measures.  After  the  first  day  attempts  at  nursing 
were  unsuccessful,  and  even  water  was  not  retained. 
Vomiting  steadily  increased  and  on  the  third  day 
the  vomitus  consisted  of  black  stained  fluid.  Weak- 
ness, loss  of  weight  and  distention  soon  became 
quite  marked.  On  the  fourth  day  the  distention 
had  assumed  such  proportions  as  to  interfere  with 
the  cardiac  action,  with  resulting  cyanosis  and,  in 
the  case  of  one  of  the  twins,  death. 

I  arrived  on  the  scene  shortly  after  the  death  of 
one  twin,  and  inspection  of  the  live  one  revealed  an 
infant  practically  in  a  moribund  state.  This  child 
wSs  markedly  cyanosed,  the  abdomen  was  tremend- 
ously enlarged,  the  breathing  was  shallow,  the 
extremities  cold,  the  radial  pulse  imperceptible,  the 
heart  rapid  and  feeble.    The  diagnosis  occurred  to 


KiG.  1. — Case  of  Hirschsprung's  disease  in  one  of  twins,  at  five 
months. 


me  after  taking  the  patient's  temperature,  which 
was  96°  F.  I  experienced  a  slight  difficulty  in 
passing  the  anal  sphincter,  and  after  the  ther- 
mometer was  within  the  bowel  it  seemed  to  me  that 
the  gut  was  unusually  roomy.  I  then  withdrew  the 
thermometer  and  in  its  place  inserted  a  glass  test 


December  25.  1920.] 


POPPER:  HIRSCHSPRUXG'S  DISEASE. 


1031 


tube  about  four  and  a  half  inches  long  and  three 
eighths  of  an  inch  in  diameter.  This  tube  also 
had  to  be  forced  through  the  anal  sphincter,  and 
when  in  the  bowel  I  was  able  to  make  wide  excur- 
sions with  the  free  end  of  the  tube  within  the  gut. 
Holding  the  tube  in  place  with  my  right  hand,  I 


Fig.   2. — X   ray  photograph   showing  markedly  dilated  colon. 

proceeded  to  exert  considerable  pressure  with  my 
left  palm  on  the  distended  abdomen.  Presently  a 
large  amount  of  fluid  mixed  with  meconium  and 
gas  was  expelled  past  the  tube.  I  continued  this 
treatment  until  the  abdominal  distention  was  almost 
completely  reduced.  The  relief  experienced  by  the 
infant  was  immediately  apparent,  the  heart  action 
improved,  the  cyanosis  cleared  up,  the  breathing 
became  deeper,  and  within  less  than  an  hour  water 
was  retained  by  mouth  and  the  baby  even  made 
an  attempt  to  take  the  breast. 

Inspection  of  the  abdomen  after  the  distention 
was  reduced  revealed  the  presence  of  active  peri- 
stalsis throughout,  a  large  wave  extending  from  the 
right  iliac  region  up  and  across  and  down  the  left 
side,  seeming  to  follow  the  course  of  the  colon  and 
several  smaller  waves  going  across  the  centre  of  the 
abdomen  from  left  to  right.  At  the  same  time  on 
palpation  through  the  thin  abdominal  wall  and 
especially  in  the  centre  of  the  abdomen,  which  was 
the  seat  of  diastasis  recti,  one  could  grasp  the 
thickened  and  enlarged  coils  of  intestine.  There 
was  no  doubt  of  the  fact  that  the  gut  was  hypgr- 
trophied  to  the  touch.  The  diagnosis  was  verified 
by  fluoroscopic  examination  as  well  as  radiograph 
made  when  the  baby  was  sixteen  days  old.  (Fig.  2.) 
A  complete  physical  examination  made  on  the  fifth 
day  of  life  revealed  only  one  other  abnormality, 
viz.,  a  distinct  but  not  very  loud  systolic  murmur 
at  left  pulmonic  area  transmitted  to  the  back. 


SUBSEQUENT  HISTORY. 

At  the  time  of  writing  my  little  patient  is  twenty- 
eight  weeks  old.  During  that  short  period  she  has 
led  a  very  eventful  and  precarious  existence.  On 
several  occasions  she  was  at  the  point  of  death. 
Her  bowels  have  never  moved  completely  without 
assistance.  Occasionally  she  would  have  a  spon- 
taneous movement.  At  three  different  times  as  a 
result  of  intestinar toxemia  she  has  had  severe  con- 
vulsions, vomiting,  fever,  distention,  and  generalized 
edema.  Her  stools  at  this  time  would  contain  a 
considerable  amount  of  mucus  and  blood.  On  the 
other  hand,  on  two  occasions  such  severe  diarrhea 
developed  that  in  about  twenty- four  hours  her  body 
became  practically  dehydrated.  When  four  weeks 
old  she  contracted  a  pneumonia  involving  the  right 
upper  lobe  and  lasting  about  two  weeks.  At  eight 
weeks  an  abscess  developed  in  the  lower  central 
abdominal  wall  which  discharged  through  the  um- 
bilicus, probably  an  infection  of  the  patent  urachus. 

Most  of  her  severe  ailments  occurred  during  the 
first  three  months.  Following  that  she  seemed  to 
be  getting  along  fairly  well  until  when  five  months 
old  a  severe  eczema  developed,  involving  the  scalp, 
face,  and  elbows,  and  resulting  from  the  addition 
of  fruit  jtiices  to  the  diet.  This  has  improved  con- 
siderably since  correcting  the  diet. 

Her  weight  curve  with  many  interruptions  has 
continued  to  ascend,  so  that  today  she  weighs  eleven 
pounds  three  ounces.  With  gain  in  weight  her 
abdominal  muscles  have  lost  their  thinness,  so  that 
one  can  no  longer  grasp  the  hypertrophied  coils  of 
intestine,  but  peristalsis  is  still  visible  and  distinct. 
The  cardiac  murmur  also  has  persisted. 

The  treatment  of  this  case  has  been  and  still  is 
beset  with  great  difficulty.  In  the  feeding  of  this 
baby  I  have  tried  breast  feeding,  mixed  feeding, 
dry  milk  and  whole  milk  dilutions.  For  the  past 
five  months  she  has  been  doing  best  on  whole  milk 
diluted  with  very  thin  barley  water  and  with  the 
addition  of  very  little  sugar  in  the  form  of  lactose. 
Other  sugars  have  been  tried,  but  they  always  pro- 
duced a  great  deal  of  fermentation  with  resulting 
increase  of  distention.  She  has  also  been  getting 
lately  zwiebach  or  toast  with  milk  and  water  and 
stewed  fruits.  In  attempting  to  treat  the  local 
condition  I  have  used  without  success  atropine, 
pituitary  and  suprarenal  extracts.  The  only  meas- 
ures that  have  succeeded  in  keeping  this  baby  com- 
fortable thus  far  are  a  proper  diet,  an  abdominal 
binder,  and  the  daily  use  of  saline  or  sodium  bicar- 
bonate irrigations  assisted  by  abdominal  massage. 

REFERENCES. 

1.  Meyers,  A.  E. :  American  Journal  Diseases  of  Chil- 
dren, 19:167,  1920. 

2.  H.\.AS.  S.  V. :  American  Journal  Diseases  of  Chil- 
dren, 15  :323,  1918. 

628  East  163rd  Street. 


The  Malnourished  Child  in  the  Public  School. 

— ^^'illiam  R.  P.  Emerson  (Boston  Medical  and 
Surgical  Journal,  June  24,  1920)  names  in  order 
as  the  five  principal  causes  of  malnutrition,  physical 
defects,  lack  of  home  control,  overfatigue,  improper 
food  habits,  and  improper  health  habits. 


1032 


HLAUKER:  PNEUMONIA  IN  CHILDREN. 


[New  York 
Medical  JouRXAf, 


THE  PHYSICAL  SIGXS  OF  PNEUMONIA 
IN  CHILDREN. 
By  Samuel  A.  Blauner,  M.  D., 
New  York, 

Ailjunct  Pediatrist,  Lebanon  Hospital;  Medical  Director,  Israel 
Orphan  Asylum. 

Tlie  diagnosis  of  pneumonia  in  infancy  and  in 
early  cliildhood  is  distinctly  by  physical  signs.  We 
cannot  conceive  of  a  pneumonia  without  some  form 
of  consolidation,  and  consolidation  means  a  change 
in  the  physical  notes  from  those  of  the  normal 
chest.  Of  course,  pneumonia  being  a  severe  acute 
iUness  involving  the  lungs,  we  may  feel  that  from 
the  subsidiary  symptoms,  especially  the  external 
respiratory  changes  and  the  severe  toxemia  that 
usually  accompany  this  illness,  a  diagnosis  can  be 
suspected  without  awaiting  the  physical  signs.  That 
may  be  true  to  a  considerable  degree  in  adults,  but 
in  children  these  symptoms  are  too  variable  to  be 
dependable,  and  frequently  an  error  in  diagnosis 
creeps  in  if  relied  upon,  for  rise  of  temperature, 
rapid  pulse,  rapid  respiration,  are  not  unusual  in 
other  febrile  conditions  of  childhood,  and  even  dila- 
tation of  the  alse  nasas  is  frequently  encountered, 
especially  in  affections  of  the  upper  respiratory 
tract.  Toxemia,  an  accompaniment  of  pneumonia 
in  adults,  giving  an  early  clue  to  the  probable  affec- 
tion of  the  patient,  is  also  a  most  varying  symptom 
of  pneumonia  in  children,  and  in  fact  is  just  as 
frequently  absent  as  present,  and  even  in  the  apical 
types  of  pneumonia  where  it  is  usually  expected  it 
is  not  infrequently  absent. 

In  the  diagnosis  of  the  various  febrile  conditions 
temperature  plays  its  important  role.  In  adults 
especially  the  temperature  curve  is  often  of  great 
assistance  in  particular  diseases,  and  long  before 
other  symptoms  are  elicited  this  curve  will  suggest 
the  most  likely  diagnosis.  This  is  particularly  true 
in  the  pneumonias  and  even  in  differentiation  of  the 
lobar  and  bronchopneumonic  types — the  temperature 
will  often  be  sufficiently  characteristic  to  be  of  as- 
sistance in  the  separate  diagnosis.  However  true 
this  may  be  in  adults,  the  same  cannot  be  said  of 
the  pneumonias  in  children.  It  is  true  that  the 
temperature  curve  frequently  follows  the  typical 
course  of  the  pneumonias  in  adults,  but  as  a  general 
rule  other  febrile  conditions  in  childhood  may  act 
similarly,  and  we  therefore  cannot  definitely  deter- 
mine the  diagnosis  in  the  absence  of  physical  signs. 
Who  has  not  seen  in  a  case  of  ordinary  grippe  the 
temperature  run  high  for  several  days  and  then 
suddenly  drop  to  normal?  For  example,  a  child 
eight  months  old  has  a  sore  throat,  with  fever. 
The  temperature  rises  quickly  to  103°  and  104°, 
remains  that  way  for  five  days,  and  then  falls  to 
normal  within  twelve  hours,  the  closest  examination 
not  revealing  the  slightest  sign  of  pneumonia.  Who 
has  not  seen  in  similar  conditions  in  childhood,  the 
temperature  run  high  and  then  come  down  to  nor- 
mal, either  slowly  or  .suddenly?  It  may  be  argued, 
of  course,  that  such  temperature  may  be  indicative 
of  consolidation,  although  we  are  unable  to  elicit 
the  signs,  but  whatever  the  reasons  a  diagnosis  of 
jineumonia  under  such  conditions  is  made  on  hypo- 
thesis only  and  not  on  positive  data ;  for  in  insti- 
tutions with  radiographic  facilities  it  can  be  shown 


that  many  of  these  socalled  pneumonias  are  not 
pneumonias  at  all. 

My  observation  has  been,  however,  that  the 
characteristic  feature  of  temperature  in  febrile  con- 
ditions in  childhood  is  its  extreme  irregularity  and 
our  thorough  inability  to  read  symptoms  into  the 
curve  the  same  as  we  do  in  adults,  this  holding  true 
even  in  the  pneumonias  in  children;  for  instance,  a 
lobar  pneumonia,  contrary  to  our  expectations,  may 
run  wide  variations,  and  either  suddenly  or  gradu- 
ally reach  normal,  while  often  in  a  case  of  broncho- 
pneumonia, with  all  the  typical  signs  of  this  disease, 
the  temperature  may  remain  high  with  slight  remis- 
sions for  several  days,  and  then  suddenly  or  slowly 
reach  normal. 

In  Case  No.  7764,  a  child,  aged  eight  years,  typical 
signs  of  bronchopneumonia  developed ;  -for  eight 
days  the  temperature  curve  remained  typically  lobar 
in  type,  for  five  days  variations  became  wider,  and 
then  the  temperature  suddenly  reached  normal. 
There  was  an  uneventful  convalescence.  If  there 
is  any  similarity  between  the  temperatures  of  lobar 
and  bronchopneumonia  it  is  the  fact  that,  although 
variations  in  temperature  may  be  wide  in  both 
instances,  in  bronchopneumonia  they  may  touch 
normal  or  even  subnormal,  while  in  lobar  pneu- 
monia they  usually  do  not  reach  normal,  although 
at  times  they  do.  In  fact,  it  is  not  always  an  easy 
matter  to  differentiate  between  lobar  and  broncho- 
pneumonia, for  only  too  frequently  bronchopneu- 
monia is  limited  to  one  lobe  and  is  massive  in 
character.  From  the  physical  signs  and  the  varia- 
tions in  temperatures  that  may  be  present  in  either 
form,  it  is  utterly  impossible  to  differentiate  the  two 
conditions,  although  when  the  temperature  is 
normal  we  may  suspect  a  bronchopneumonia.  In 
other  words,  from  the  subsidiary  and  subjective 
symptoms  alone  it  is  unwarranted  to  make  a  posi- 
tive diagnosis  of  any  form  of  pneumonia.  This  is 
as  it  should  be,  for,  in  justice  both  to  ourselves 
and  to  our  patients,  we  should  not  make  a  positive 
diagnosis  on  impressions  alone.  Changes  in  the 
lung  produce  sufficient  acoustic  changes  for  us  to 
recognize  them,  and  our  failure  to  do  so  lies  rather 
in  our  inability  to  recognize  these  changes  than  in 
their  absence,  and  also  because  of  the  false  acoustic 
principles  which  we  have  been  taught  and  which 
have  been  retained  by  many  of  us. 

It  will  be  appropriate  here,  before  I  consider 
the  physical  signs  of  pneumonia  in  its  different 
stages  and  varying  fomis,  to  say  that  central  lobar 
pneumonia  does  not  exist  and  we  are  only  besetting 
ourselves  with  difficulties  when  we  reach  such  a 
conclusion.  If  a  pneumonia  is  present  we  can  find 
it,  and  it  is  only  the  varying  and  finer  acoustic 
changes  that  occur  that  make  it  difficult  for  the 
busy  practitioner  to  recognize  them.  We  must 
recognize,  too,  the  great  acoustic  principle  that  pitch 
remains  unchanged  only  if  it  travels  through  a 
urfiform  me'dium  and  that  it  will  promptly  change 
if  the  medium  changes.  In  other  words,  a  note 
traveling  through  an  air  containing  lung  will  not 
change  its  pitch  by  striking  a  consolidated  area, 
for  the  consolidated  area  cannot  act  the  part  of  a 
condenser  and  rechange  the  vesicular  note  to  a 
bronchial  note. 


December  25,  1920.] 


BLAUNER:  PNEUMONIA  IX  CHILDREN. 


1033 


We  must  remember  that  the  bronchial  breathing 
we  hear  in  pneumonia  is  really  the  tracheal  tubular 
breathing  produced  in  the  larynx  and  trachea 
transmitted  unchanged,  as  far  as  pitch  is  concerned, 
through  a  consolidated  area  of  uniform  medium, 
but  to  produce  this  physical  possibility  the  consoli- 
dation must  extend  down  to  the  hilum  of  the  lung 
or  be  at  least  in  connection  \vith  a  fair  sized  bron- 
chus so  that  the  tubular  breathing  can  go  through 
unchanged.  If  the  note  first  enters  the  lung  and 
becomes  vesicular,  it  remains  vesicular  even  though 
it  may  later  impinge  upon  a  consolidated  area,  for 
the  consolidated  area  has  no  physical  means  of  re- 
changing  the  pitch.  This  law  of  sound  explains 
the  many  varying  physical  signs  of  pneumonia,  and 
also  explains  why  the  bronchial  breathing  is  delayed 
or  even  absent  in  some  cases_.  Another  point  it  is 
well  to  euTphasize  is  that  pneumonia  begins  with  a 
wedgeshaped  triangular  patch  with  base  at  surface 
of  lung  and  apex  pointing  inward,  and  whether 
bronchial  breathing  will  or  will  not  be  heard  depends 
upon  whether  the  consolidated  area  is  in  communi- 
cation with  a  bronchus  or  has  reached  the  hilum 
of  the  lung.  These  assertions  are  not  merely 
theoretical ;  they  are  ver\^  practical,  and  our  success 
in  finding  a  pneumonia  patch  will  depend  on  our 
knowledge  of  these  two  facts,  for  otherwise,  expect- 
ing some  change  in  the  auscultatory  note,  we  will 
overlook  a  slight  grade  of  dullness  indicating  a 
pneumonic  area. 

As  an  instance  of  the  difificulty  of  diagnosis  we 
may  cite  the  case  of  a  child  treated  by  Dr.  H., 
who  for  three  weeks  had  had  a  cough  and  a 
temperature  with  wide  variations.  Several  con- 
sultants expressed  various  opinions,  and  it  was 
finally  thought  that  the  case  was  one  of  malaria,  as 
the  child  came  from  a  malarial  district  and  the 
l)lood  examination  revealed  suspicious  bodies.  I 
was  asked  to  see  the  child.  I  discovered  a  dull 
patch  in  the  left  subclavicular  region,  but  normal 
vesicular  breathing  was  present.  Diagnosis  of 
pneumonia  was  confirmed  by  radiographic  findings. 
Similarly  in  Dr.  A's  case  a  right  apical  dullness 
developed,  lasting  ten  weeks,  but  at  no  time  was 
Ijronchial  breathing  to  be  heard.  This  was  also 
confirmed  by  radiographic  findings. 

With  these  facts  in  mind  I  may  say  that  in  the 
diagnosis  of  early  pneumonia  the  percussion  note 
is  the  most  important  sign  to  be  depended  on.  We 
must  remember,  too,  that  a  child's  chest  is  very 
resilient  and  its  lungs  highly  elastic,  and  a  slight 
change  in  percussion  note  will  often  be  overlooked 
unless  we  use  the  lightest  stroke  so  as  to  throw 
as  little  of  the  surrounding  chest  into  vibration  as 
l)ossible.  The  child  must  be  placed  in  a  position, 
preferably  supine,  so  as  to  relax  the  entire  muscu- 
lature of  the  chest  thoroughly,  otherwise  tension 
of  the  muscles  on  one  side  will  give  a  higher  note, 
with  the  possibility  of  a  mistake  in  diagnosis.  In 
the  early  diagnosis  w^e  must  not  depend  on  any 
auscultatory  assistance  for  even  rales  in  the  pneu- 
monias of  childhood  are  as  often  absent  as  present. 
A  child  may  go  through  a  pneumonia  without  a 
rale  and  even  in  the  stage  of  resolution  none  or 
very  few  rales  may  be  heard.  Because  of  this 
marked  variation  of  the  presence  of  rales  I  teach 


my  interns  not  to  place  too  much  interpretative  value 
on  rales  in  a  chest.  They  indicate  a  pathological 
process,  but  the  exact  nature  of  this  process  it 
would  be  difficult  to  state  because  of  this  variation. 
As  the  process  continues  the  auscultatory  changes 
begin  to  come  to  the  fore.  The  breathing  becomes 
high  pitched,  bronchovesicular,  and  then  bronchial, 
with  or  without  rales. 

All  that  has  been  said  above  holds  true  for  the 
lobar  type  of  pneumonia  and  not  for  the  broncho- 
pneumonia type.  Because  of  its  dififerent  pathology 
and  the  usually  accompanying  bronchitis  the  patches 
are  frequently  too  small  to  be  detected  by  percussion 
note,  and,  for  that  matter,  even  for  the  radiograph. 
Frequently,  with  otherwise  positive  signs  of  bron- 
chopneumonia, a  radiograph  will  often  be  negative, 
and  we,  therefore,  have  learned  to  expect  little 
confirmation  from  the  x  ray  findings,  and  unless  the 
patches  become  confluent  and  more  or  less  massive 
we  can  find  few  signs  except  those  of  a  fine  bron- 
chitis. Because  of  this  bronchitis  with  tenacious 
mucus  in  the  finer  bronchioles,  unaffected  lung  vesi- 
cles about  the  bronchopneumonic  patches  may  be 
put  in  a  state  of  atalectasis  or  high  tension  and, 
therefore,  either  apparently  extending  the  consoli- 
dated area,  enabling  us  to  obtain  a  dull  note,  or 
overshading  the  bronchopneumonic  patch,  giving  a 
hyperresonant  note.  Aside  from  these  slight  per- 
cussion changes  in  nonconfluent  bronchopneumonia 
we  have  little  to  expect  in  the  way  of  physical  signs 
except  those  of  a  bronchitis.  As  far  as  bronchial 
breathing  is  concerned  it  is  most  frequently  absent 
for  the  very  reasons  I  have  explained  that  the 
patches  are  usually  noncommunicating  with  a  suf- 
ficiently sized  bronchus,  or  have  reached  the  hilum 
of  the  lung. 

The  physical  signs  of  resolution  in  lobar  pneu- 
monia in  children  are  somewhat  dif?erent  from  those 
in  adults.  As  a  rule,  resolution  in  adults  takes 
place  cn  masse,  a  quick  liquefaction  of  the  consoli- 
dated area  and  the  presence  of  the  characteristic 
rales  redux.  In  children  the  same  thing  may  occur, 
but  just  as  often  the  resolution  is  a  slow  process 
extending  from  three  to  seven  days,  the  percussion 
note  and  bronchial  breathing  if  present  slowly 
diminishing  in  pitch  until  normal  vesicular  sounds 
are  heard.  Here,  too,  rales  play  an  unimportant 
role,  for  frequently  a  child  will  go  through  the 
resolution  stage  with  very  few  rales  or  none  at  all. 

Z.  F.,  six  years  old,  entered  the,  hospital  with  a 
right  lower  lobar  pneumonia.  Temperature  receded 
by  lysis,  but  during  the  entire  course  of  the  disease 
scarcely  a  rale  was  to  be  heard.  In  other  words, 
aside  from  the  critical  descent  of  the  temperature, 
the  physical  signs  may  remain  unchanged,  but  if 
the  descent  of  temperature  is  gradual  we  have  no 
means  of  telling  from  the  physiclal  signs  alone 
whether  the  patient  has  entered  the  crisis  or  not. 
Another  variation  from  the  adult  I  have  noticed 
is  that  after  complete  resolution  has  taken  place  in 
lobar  pneumonia  without  any  demonstrable  con- 
comitant pleurisy,  there  often  persists  a  certain 
degree  of  dullness  which  lasts  for  a  varying  time 
and  which  may  be  wrongly  interpreted  as  of  some 
pathological  significance,  as  I  shall  point  out  later. 

The  great  bugbear  of  pneumonia  in  children  is 


1034 


BLAUNER:  PNEUMONIA  IN  CHILDREN. 


[New  Vork 
Medical  Journal. 


the  complication  of  fluid,  either  serous  or  purulent, 
usually  the  latter.  According  to  our  textbooks  with 
the  description  of  the  socalled  classical  signs  nothing 
should  be  simpler  than  a  diagnosis  of  empyema. 
Aside  from  the  falsity  of  some  of  these  socalled 
cardinal  symptoms,  I  know  of  no  more  perplexing 
,  situation  than  a  diagnosis  of  empyema,  and  often 
even  in  spite  of  radiographic  examination,  an  ex- 
ploratory puncture  must  be  made  to  settle  the 
question,  and  that  even  is  often  not  conclusive. 

Patient,  M.  B.,  a  boy,  nine  years  old,  went  through 
a  typical  lobar  pneumonia  of  the  right  lower  lobe ; 
crisis  occurred  at  the  end  of  seven  days,  but  physical 
signs  persisted.  Despite  .fourteen  negative  punc- 
tures, negative  radiographic  findings,  and  consulta- 
tions aplenty,  it  was  finally  decided  that  the  boy 
is  suffering  from  tuberculous  pneumonia  and 
should  be  sent  away.  Having  followed  the  case 
very  closely,  I  maintained  that  the  child  had  the 
physical  signs  of  fluid  despite  our  negative  findings. 
The  fifteenth  puncture  finally  revealed  pus,  and  an 
operation  by  Dr.  R.  showed  an  ordinary  empyema, 
and  that  not  even  of  the  encapsulated  type. 

PHYSICAL  DIAGNOSIS. 

The  physical  diagnosis  of  empyema  should  be  con- 
sidered from  two  angles,  first,  ordinary  empyema 
with  the  ordinary  amount  of  fluid,  and  secondly, 
the  type  with  considerable  fluid  of  long  standing, 
for  both  have  distinctive  symptoms.  In  the  first 
place  it  should  be  remembered  that  the  child's  lung 
is  very  resilient  and  that  it  takes  considerable  and 
continuous  pressure  to  compress  it.  This  is  of 
prime  importance  for,  because  of  this  physiological 
fact,  the  signs  at  least  of  moderate  empyema  have 
not  the  auscultatory  note  (bronchial  breathing)  we 
are  taught  to  believe.  Secondly,  for  the  same  rea- 
son empyema  fluid  spi-eads  out  over  the  affected  side 
like  a  sheet  on  the  posterior  surface  and  does  not 
collect  underneath  the  lung  to  form  the  socalled 
spiral  line.  With  this  in  view  we  can  see  why  there 
is  little  compression  of  the  lung  and  slight  displace- 
ment of  the  abutting  organs,  especially  the  heart. 
Again  the  upper  edge  of  the  empyema  fluid  has  a 
tendency  to  form  adhesions,  making  the  condition 
an  enclosed  sac  and  abolishing,  therefore,  the  ten- 
dency to  a  change  of  percussion  note  with  change  of 
position.  However,  I  have  noticed  that  this  ten- 
dency to  fibrin  formation  shutting  off  the  fluid  is 
absent  along  the  spine,  thus  g'ving  the  fluid  a  chance, 
with  change  of  position,  to  flow  into  the  reflected 
portion  of  the  pleura  along  the  spine  (medias- 
tinum), with  a  corresponding  change  of  the  percus- 
sion note.  This  I  have  called  the  "ribbon  sign" 
because  its  width  is  about  that  of  ordinary  baby 
ribbon.  I  have  been  able  to  demonstrate  this  in 
about  ten  cases,  but  the  number  is  far  too  few  to 
be  of  positive  value.  I  believe,  however,  from  the 
experience  already  obtained,  that  the  sign  will  be 
of  value  in  recent  cases  of  empyema,  but  in  old 
standing  cases  with  fibrin  formation  even  along  the 
inner  edge  of  the  fluid  it  will  not  aid  us. 

In  the  ordinary  type  of  empyema  the  percussion 
note  is  of  prime  importance.  The  note  is  dull  but 
more  often  flat,  and  the  flat  note  in  itself  is  sus- 
picious of  fluid.  Unless  we  are  dealing  with  a 
localized  encapsulated  or  intralobar  empyema  a  dull 


note  becoming  progressively  deeper  as  we  reach  the 
base  is  always  suspicious  in  postpneumonic  condi- 
tions. If  the  pneumonia  has  been  thoroughly  re- 
solved, the  auscultatory  note,  though  somewhat 
diminished  in  intensity,  will  be  vesicular  in  type  or 
only  a  slight  variation  from  the  normal  in  pitch. 
We  should  not  expect  bronchial  breathing,  as  the 
textbooks  tell  us,  for  the  fluid  overlies  the  lung 
and  the  lung  is  too  resilient  to  be  compressed  in 
order  to  obtain  the  bronchial  breathing.  For  the 
pneumonic  process  having  resolved  we  will  need  a 
compressed  or  nearly  compressed  lung  to  obtain  the 
imiform  medium  for  the  transmission  of  the  bron- 
chial breathing,  as  I  have  explained  above.  For 
the  same  reason  we  do  not  get  a  displaced  heart  or 
one  so  slightly  displaced  that  for  ordinary  percus- 
sion it  would  be  difficult  to  appreciate.  Therefore  a 
dull  or  flat  note  follo^Ving  an  otherwise  frank  lobar 
pneumonia  with  no  or  but  slight  vesicular  changes, 
with  little  or  no  displacement  of  the  heart,  and  with 
a  possible  ribbon  sign,  is  justifiably  a  procedure  for 
chest  puncture. 

EMPYEMA  WITH  FLUID 

In  types  of  empyema  with  considerable  fluid,  or 
in  those  of  long  standing  with  distinct  fibrin  for- 
mation, along  the  edges  of  the  fluid  and  where  the 
lung  is  finally  compressed,  the  signs  are  all  those 
of  a  frank  lobar  pneumonia  with  the  exception  that 
in  this  type  the  heart  is  usually  displaced.  Here 
we  have  the  dull  or  flat  note,  bronchial  breathing, 
bronchial  voice,  etc.,  but  here  too  we  are  assisted 
by  a  little  pathological  anomaly  which  is  frequently 
forgotten.  This  was  pointed  out  to  us  by  the  late 
Dr.  Hodenpyl,  and  consists  of  the  fact  that  the  very 
apex  of  the  lung  is  as  a  rule  uninvolved  in  lobar 
pneumonia,  and  when  a  dull  or  flat  note  is  present 
there  we  are  dealing  with  some  other  condition, 
such  as  bronchopneumonia,  tuberculosis,  or  with  a 
compressed  lung,  so  that  with  a  previous  history 
of  a  lobar  pneumonia,  with  signs  still  simulating  a 
lobar  pneumonia,  a  dull  or  flat  apex  displaced  heart, 
we  can  only  diagnose  empyema  but  an  empyema 
of  long  standing  or  of  considerable  fluid. 

In  differential  diagnosis  between  empyema  and 
other  conditions  we  have  to  consider  the  possibility 
of  bronchopneumonia  of  lower  lobe  of  more  or 
less  massive  involvement  where  bronchial  breathing 
was  absent,  or  even  the  possibility  of  a  lobar  pneu- 
monia where  the  consolidated  area  about  the  hilum 
has  resolved  more  quickly  than  the  rest  of  the 
affected  lung  and  eliminating  the  pure  bronchial 
breathing.  Under  such  conditions  the  previous 
history  with  the  physical  signs  will  be  of  great 
assistance. 

In  conclusion,  let  me  say  that  the  diagnosis  of 
either  pneumonia  or  empyema  is  as  a  rule  not 
difficult.  It  is  only  necessary  to  unlearn  some  of 
the  false  teachings  of  our  textbooks  and  to  remem- 
ber that  to  obtain  bronchial  breathing  we  must  have 
a  uniform  consolidated  area  extending  to  the  hilum 
of  the  lung  or  in  communication  with  a  bronchus, 
and  that  the  apparent  variation  in  the  physical  signs 
results  from  the  failure  of  the  original  tracheal 
breathing  to  reach  a  uniform  consolidated  area  and 
be  transmitted  unchanged. 

1323  Madison  Avenue. 


December  25,  1920.] 


GOLDBERGER:  NEW  SITE  FOR  VACCIXATION. 


1035 


A   NEW   SITE  FOR  SMALLPOX 
VACCINATIOX. 

By  I.  H.  GoLDBERGER,  M.  D., 
New  York. 

The  ugly  looking,  hideous  and  disfiguring  scars 
that  result  from  vaccinations  against  smallpox 
prompted  me,  many  years  ago,  to  discontinue  the 
use  of  the  outer  side  of  the  arm  as  a  site  for  the 
inoculation  against  this  disease.  Others,  too,  realiz- 
ing that  visible  scars  on  the  outer  side  of  the  arm 
were  objectionable  esthetically,  especially  in  girls 
and  women,  found  that  by  vaccinating  on  the  lower 
extremity  (thigh,  calf,  etc.)  the  objection  was  par- 
tially overcome.  The  selection  of  this  latter  site 
overcomes,  partially,  the  objection  to  the  visible 
scar,  but,  on  the  other  hand,  in  infants  the  danger 
of  local  infections  resulting  from  wet  and  soiled 
diapers  is  frequent  and  serious  enough  to  make  the 
lower  extremity  objectionable,  also  as  a  routine  site 
for  vaccinations.  Then,  too,  infants  and  young 
children  are  in  the  habit  of  being  bathed  daily,  and 
if  they  are  vaccinated  on  the  lower  extremity,  this 
hygienic  measure  has  to  be  interrupted  for  at  least 
a  period  of  fourteen  to  twenty-one  days.  This 
feature  alone,  aside  from  the  possibility  of  local 
infections,  contraindicates  the  selection  of  the  lower 
extremity  as  a  routine  site  for  vaccinations. 

For  the  past  seven  years  I  have  used  the  inner 
and  back  side  of  the  arm  as  the  ideal  site  for  vac- 
cination against  smallpox.  In  this  manner  I  have 
overcome  the  objection  against  a  visible  scar.  I 
have  vaccinated  over  five  hundred  children,  and  in 
spite  of  the  fact  that  the  vaccination  was  made  near 
the  lymphatics  of  the  arm,  in  not  a  single  case  did 
enlarged  glands  develop  in  the  axillae.  Possibly  this 
has  been  because  the  vaccinations  have  been  free 
from  secondary  infections  and  because  the  vaccina- 
tion is  not  performed  over  muscle  fibres,  the  fre- 
quent contractions  of  which  are  apt  to  cause  irrita- 
tion and  deep  induration  involving  skin,  fascia  and 
groups  of  muscles.  Vaccinating  over  the  loose, 
fleshy  portion  of  the  arm,  not  directly  over  bone  or 
muscle,  has  resulted  in  less  inflammation,  indura- 
tion and  infection  than  that  which  follows  vaccina- 
tions over  muscle  and  bone  areas. 

The  vaccination  scars  in  my  cases  are  so  small 
and  so  superficial  that  in  a  hurried  examination  of 
the  arm  the  scar  is  apt  to  be  overlooked  entirely. 
This  fact  was  emphasized  recently  when,  during  a 
survey  of  the  public  schools  of  the  City  of  New 
York  by  medical  inspectors  of  the  Department  of 
Health,  many  of  my  little  patients  were  informed 
that  they  would  have  to  be  vaccinated  because,  on 
baring  the  arm,  the  scar  was  overlooked. 

The  method  I  employ  is  as  follows:  After  the 
arm  has  been  properly  cleansed,  the  forearm  is 
flexed  at  right  angles  to  the  arm  and  the  vaccine 
is  applied  below  a  line  midway  between  the  internal 
condyle  of  the  humerus  and  the  anterior  axillary 
line.  A  Von  Pirquet  platinum  borer  is  turned  once 
or  twice  through  the  vaccine  virus.  The  virus  is 
permitted  to  dry  thoroughly  before  placing  over 
the  abrasion  a  sterile  pad  of  gauze,  held  in  place  by 
two  wide  strips  of  adhesive  plaster. 

In  my  opinion,  the  inner  and  back  side  of  the 


arm  is  the  ideal  location  for  the  inoculation  of 
smallpox  virus,  for  the  following  reasons : 

1.  It  leaves  no  visible  scar. 

2.  It  does  not  keep  children  from  having  their 
daily  tub  bath  while  the  vaccination  is  passing 
through  its  various  stages. 

3.  There  is  little  or  no  exposure  to  infection  from 
outside  sources  of  infection. 

4.  It  minimizes  possibilities  of  trauma. 

5.  There  are  no  infiltrations,  extensive  indurations, 
sloughings,  or  extensive  scars. 

2562  Grand  Concourse. 


Public  School  Clinics  in  Connection  with  State 
School  for  the  Feebleminded. — Edith  E.  Wood- 
hill  (Mental  Hygiene.  October,  1920)  presents 
a  report  of  the  public  school  clinics  established 
in  Massachusetts,  in  connection  with  the  weekly 
outpatient  clinics  at  the  Massachusetts  School  for 
the  Feebleminded,  at  Waverly.  The  cases  seen  at 
the  clinics  are  mostly  children  of  school  age,  with- 
out special  character  defect,  selected  for  examina- 
tion because  of  backwardness  in  the  grades  or 
truancy,  while  a  large  number  of  those  presented 
at  the  institution  clinics  are  borderline  cases  that 
have  become  problems  on  account  of  social  or  moral 
delinquencies.  The  organization  and  method  of 
conducting  these  school  clinics  are  similar  to  those 
vised  at  the  clinic  at  Waverly,  and  the  methods  of 
diagnosis  are  the  same.  The  staff  of  examiners, 
consisting  of  a  psychiatrist,  a  psychologist,  a 
teacher,  and  a  school  nurse,  visits  the  various  schools 
monthly.  These  school  clinics  benefit  the  child  by 
helping  the  teacher  to  understand  the  mentality  of 
the  feebleminded  pupil  and  the  kind  of  training 
needed.  They  serve  the  school  b)^  selecting  chil- 
dren for  special "  classes  and  taking  out  feeble- 
minded children  who  are  incapable  of  making  more 
progress.  They  serve  the  community  by  advising 
and  instructing  parents  as  to  home  care  and  super- 
vision, and  by  helping  to  take  out  of  the  community 
the  feebleminded  who  need  institution  protection 
and  training  and  who  may  become  a  menace  to  the 
community.  With  the  exception  of  a  few  idiots,  all 
feebleminded  children  pass  the  public  schools  at 
some  time.  If  systematic  examination  of  all  the 
retarded  children  in  the  public  schools  could  be 
made,  in  time  there  would  be  a  complete  registration 
and  census  of  all  the  feebleminded. 

Massachusetts  has  passed  a  law  requiring  a  mental 
examination  of  all  children  three  years  retarded. 
Partly  on  this  account,  the  need  for  more  school 
clinics  has  become  so  pressing  that  the  work  has 
been  broadened  and  a  traveling  clinic  is  now  being 
organized  by  the  Department  of  Mental  Diseases. 
A  staff  of  experienced  examiners  will  spend  their 
entire  time  in  this  work.  They  will  visit  various 
sections  of  the  state,  in  turn,  making  surveys  of  the 
schools  in  these  sections.  This  is  part  of  a  con- 
structive program  for  better  care  of  the  feeble- 
minded of  the  entire  state.  The  benefit  of  a  school 
clinic  is  not  all  on  the  side  of  the  schools  and  the 
community.  It  is  a  distinct  advantage  to  an  insti- 
tution staff  to  come  in  contact  with  these  school 
problems  and  this  number,  of  undiagnosed  cases. 


Editorial  Notes  and  Comments 


NEW  YORK  MEDICAL  JOURNAL 

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NEW  YORK,  SATURDAY,  DECEMBER  25,  1920. 


LATENT  SINUSITIS  IN  CHILDREN. 
While  infective  sinusitis  in  adults,  associated,  as 
is  usually  the  case,  with  symptoms  suggestive  of  a 
sinus  infection,  is  commonly  suspected  and  diag- 
nosed, similar  conditions  arise  in  children  of  all 
ages,  but  are  more  prone  to  remain  undiagnosed 
imless  attended  with  acute  or  manifest  symptoms. 
Acute  sinusitis  in  infants  is  rarely  localized,  but 
involves  the  nasal  mucosa  and  the  relatively  unde- 
veloped sinuses  as  a  whole,  usually  with  symptoms 
of  purulent  rhinitis,  which  may  become  chronic  or 
subside  into  a  recurring  nonpurulent  nasal  catarrh, 
or  eventuate  in  recovery;  or,  on  the  other  hand, 
the  process  may  finally  produce  a  large  area  of 
external  suppuration,  as  described  by  Skillern.  In 
children  between  the  ages  of  five  or  six  and  fifteen 
years,  a  nasal  sinus  infection  is  more  likely  to  be 
localized  and  occasionally  present  symptoms  such  as 
lead  one  to  suspect  nasal  sinusitis  in  adults.  A 
chronic  or  recurring  nasal  catarrh  in  a  child  is 
usually  attributed  correctly  to  adenoids  or  to  in- 
fected tonsils,  and,  if  the  symptoms  persist  after 
an  operation  for  the  removal  of  the  ofYending 
organs,  the  child  is  sometimes  supposed  to  have  a 
recurrence  of  enlarged  tonsils  and  adenoids,  so  that 
a  second,  not  to  say  a  third,  operation  is  sometimes 
performed. 

The  symptoms  of  chronic  latent  sinusitis  are 
essentially  similar  to  those  of  infected  tonsils  and 
adenoids,  namely,  a  recurrent  nasal  catarrh, 
buccal  respiration,  catarrhal  deafness,  aprosexia, 
mental  backwardness  and  chronic  sepsis.  In  the 
sphenoidal  simi-  ct^p';  (--pecially,  other  manifesta- 


tions may  arise,  such  as  restriction  of  visual  and 
color  fields,  as  has  recently  been  pointed  out  by 
Watson-Williams,  but  if  they  are  not  suspected  and 
sought  for,  these  symptoms  will  be  overlooked. 
More  serious  results  of  chronic  sinus  infection  are 
those  of  infecting  bacteria  passing  continually,  oiv 
the  one  hand,  into  the  gastrointestinal  tract,  and 
sometimes  infecting  the  appendix;  on  the  other 
hand,  the  bronchi  and  lungs  may  become  involved. 

A  persistent  anterior  unilateral  nasal  discharge 
is  highly  suggestive  of  sinus  infection,  provided 
the  presence  of  a  foreign  body  can  be  eliminated. 
A  posterior  rhinoscopic  view  showing  pus  or  muco- 
pus  in  one  choana  is  similarly  strong  evidence  of  a 
nasal  sinusitis.  It  is  necessary  to  make  examina- 
tions on  more  than  one  occasion  to  eliminate  the 
possibihty  of  an  adventitious  collection  being 
mistaken  for  a  persistent  secretion.  According  to 
Watson- Williams,  the  most  useful  methods  of 
examination  are  endorrhinoscopy  and  exploration  of 
the  sinuses  by  the  suction  syringe.  Endorrhinoscopy 
in  children  over  seven  years  of  age  is  often  possible 
with  local  anesthesia,  but,  on  the  other  hand,  it  is 
often  impossible  without  general  narcosis.  When 
a  definite  streak  of  pus  is  seen  coming  from  the 
sphenoethmoidal  region  or  from  the  middle  meatus 
of  one  or  both  sides,  the  evidence  of  the  correspond- 
ing sphenoidal  or  antral  cavities  being  the  source 
of  the  purulent  discharge  is  almost  conclusive. 

Exploration  of  the  maxillary  antra  or  sphenoidal 
sinuses  by  means  of  the  suction  syringe  is  most 
valuable,  but  necessitates  a  general  narcosis  in 
children.  Unfortunately,  the  exploration  of  the 
sphenoidal  sinuses  in  young  children  is  far  less  easy 
than  the  exploration  of  the  maxillary  antra,  and  is 
not  so  free  from  risk.  Nevertheless,  the  exploration 
of  the  sphenoidal  sinuses  in  children  is  usually  a 
fairly  easy  and  safe  procedure,  provided  one  is 
accustomed  to  such  investigations  in  adults. 


DRIED  MILK  AS  A  FOOD. 
When  the  great  number  of  women  in  America 
who  do  not  nurse  their  babies  and  who  rely  on  sub- 
stitutes for  mother's  milk  to  feed  them  is  taken  into 
consideration,  it  is  obvious  that  the  greatest  care 
should  be  taken  in  the  selection  of  a  substitute. 
Upon  the  proper  rearing  of  a  child  during  the  first 
few  years  of  life  depends  largely  its  future  health. 
Also  upon  the  proper  rearing  of  children  in  the 
mass  depends  the  health  and  therefore  the  prosperity 
of  a  nation.  Of  course,  the  most  common  substitute 
for  an  infant's  natural  food  is  cow's  milk  modified 


December  25,  1920.] 


EDITORIAL  ARTICLES. 


10.37 


in  the  manner  which  the  medical  attendant,  as  a  rule, 
prescribes.  But  even  when  the  most  careful  atten- 
tion is  paid  to  obtaining  a  milk  as  uncontaminated 
as  possible,  there  is  no  certain  guarantee  that  this 
end  is  always  achieved.  Sterilization  and  pasteur- 
ization both  have  their  drawbacks,  and  therefore 
any  substitute  for  mother's  which  possesses  the 
nutritive  properties  of  cow's  milk  and  which,  in 
addition,  can  be  guaranteed  as  absolutely  clean  and 
free  from  hurtful  germs,  would  be  hailed  with  ac- 
clamation by  all  those  who  have  the  health  of  the 
people  at  heart.  By  some  it  is  asserted  that  dried 
milk  possesses  these  attributes,  which  are  absent  in 
many  instances  from  milk  transported  considerable 
distances  and  probably  subject  to  contamination  or 
perhaps  infection  before  it  is  used  as  a  food. 

Among  those  who  have  recently  spoken  in  favor 
of  dried  milk  as  a  food  is  Col.  R.  J-  Blackham, 
M.  D.,  who  gave  an  address  on  the  matter  before 
the  British  Sanitary  Congress,  held  in  Birmingham 
in  August  last.  Blackham  has  had  much  experience 
in  the  use  of  dried  milk  in  the  British  arm)-  and  in 
civil  life,  and  his  conclusions  are  valuable.  His  ad- 
dress was  somewhat  lengthy,  as  he  dealt  with  the 
question  from  all  aspects  and  minutely,  so  only 
the  outstanding  points  will  be  discussed  briefly. 
Fats  are  no  longer  in  emulsion,  but  in  a  condition 
resembling  butter  and  quite  granular.  When  mixed 
with  water  the  fat  globules  are  considerably  fewer 
and  much  larger  than  in  fresh  milk.  Albumin  and 
globulin  are  coagulated,  but  caseinogen  is  not  coagu- 
lated. All  observers  are  agreed  that  the  protein 
content  is  more  digestible  than  in  fresh  milk.  The 
milk  sugar  is  unchanged.  The  ferments  are  all 
destroyed,  but  Lane-Claypon  has  shown  that  this 
loss  is  of  no  importance  as  regards  the  value  of 
dried  milk  for  haad  feeding  of  infants. 

As  for  the  vitamines,  according  to  existing  views 
an  essential  part  of  the  infant's  diet,  Blackham 
points  out  that  until  Professor  Halliburton  found 
that  some  vitamines  will  stand  high  temperatures,  it 
was  generally  thought  that  the  milk  vitamines  were 
destroyed  by  the  heat  used  in  the  process  of  manu- 
facture. Funk,  however,  demonstrated  the  presence 
of  vitamines  in  dried  milk,  and  showed  that  there 
was  sufficient  of  the  antiscorbutic  substance  in  boiled 
milk  to  supply  the  needs  of  infants,  although  some 
was  destroyed  by  heating.  Leonard  Hill  goes  fur- 
ther, and  states  that  the  antiscorbutic  food  accessory 
is  not  destroyed  in  boiled  milk.  Blackham  draws 
attention  to  the  fact  that  confusion  seems  to  have 
arisen  over  failure  to  differentiate  the  three  acces- 
sory growth  substances  all  grouped  together  as  vita- 
mines, and  goes  on  to  show  that  fat  soluble  A  is 
the  antirachitic  factor  and  it  is  present  in  all  animal 


fats,  but  absent  from  most  vegetable  oils.  It  is  not 
affected  by  heat,  and  is  therefore  present  in  dried 
milk.  Water  soluble  B  is  the  antineuritic  factor. 
It  stands  desiccation  and  is  therefore  present  in 
dried  milk.  Water  soluble  C  is  the  antiscorbutic 
factor,  and  here  the  ver>'  crux  of  the  question  is 
reached.  Experiments  at  the  Lister  Institute  sb.ow 
that  the  antiscorbutic  property,  which  is  poor  even 
in  fresh  cow's  milk,  is  largely  diminished  in  the 
preparation  of  dried  milk,  whereas  the  results  of 
American  investigators — Hess,  Fisk,  Unger,  and 
others — demonstrate  that  there  is  no  diminution 
of  this  factor,  and  that  they  have  actually  cured 
cases  of  scurvy  by  the  use  of  dried  milk.  It  may  be 
added  that  Dr.  Eric  Pritchard,  the  well  known 
English  authority  on  children's  disease,  has  reported 
favorably  on  the  use  of  dried  milk  as  an  infant's 
food,  and  that  Blackham  himself  states  that  he  has 
never  seen  infantile  scurvy -in  a  child  fed  on  dried 
milk.  Compared  with  fresh  milk,  numerous  French 
and  Belgian  doctors  consider  it  superior  to  sterilized 
cow's  milk  or  even  humanized  cow's  milk.  Others 
regard  it  as  a  temporar\-  diet  to  be  given  for  a  short 
time  when  other  foods  disagree. 

The  following  is  Blackham's  opinion  of  this 
product:  1.  In  dried  milk  we  have  a  valuable  food 
which  has  a  wide  sphere  of  usefulness,  not  only  in  the 
feeding  of  infants  and  invalids,  but  in  domestic  and 
commercial  cookery.  2.  For  use  with  tea  or  coffee  it 
cannot  be  claimed  that  reconstituted  dried  milk  is 
likely  to  be  popular,  and  up  to  the  present  it  has  not 
been  placed  on  the  market  at  a  price  sufficiently  at- 
tractive to  induce  the  public  to  put  up  with  the 
difference  between  the  fresh  and  reconstituted  article. 
3.  For  use  in  the  tropics  and  in  places  such  as  ^lalta, 
where  cow's  milk  is  unobtainable,  and  goat's  milk 
dangerous,  it  has  a  large  range  of  applicatioli,  and 
on  long  voyages  it  presents  many  advantages  over 
condensed  milk.  4.  For  military  purposes  it  will 
probably  entirely  displace  condensed  miUc  in  future 
campaigns.  It  must  be  understood  that  milk  should 
be  scrupulously  clean  at  the  time  of  drying,  for  no 
process  will  make  dirty  milk  into  clean  milk,  and 
also  the  process  should  be  carried  on  under  the  best 
sanitary  conditions. 

It  seems  that  dried  milk  may  be  used  to  advantage 
as  an  infant's  food  mainly,  perhaps,  on  account  of 
its  greater  digestibility.  It  is  difficult,  often  im- 
possible, to  so  modify  fresh  cow's  milk  as  to  render  it 
digestible  to  some  infants.  This  is  certainly  a  point 
in  favor  of  dried  milk.  As  for  the  other  advantages 
claimed  for  this  product  as  an  infant's  food,  it  may 
be  said  that  while  a  good  case  has  been  made  out  for 
it,  no  decided  verdict  can  be  given.  It  must  be 
tested  further  and  on  a  wider  scale. 


1038 


EDITORIAL  ARTICLES. 


[New  York 
Medical  Journal. 


MEN  OF  SCIENCE  IN  RUSSIA. 

From  time  to  time  news  filters  through  from 
Russia.  Hysterical  observers  have  given  us  their 
impressions  and  created  a  sentiment  among  the 
reading  public.  Countless  reports,  unauthentic  and 
biased,  have  contributed  to  this  feeling.  We  have 
come  to  believe  that  Russia  is  a  savage  country, 
inhabited  by  a  barbarous  horde  bent  on  the  exter- 
mination of  themselves  and  all  others  with  whom 
they  may  come  in  contact.  Nothing  is  further  from 
truth.  The  Russians  are  a  peaceful,  kindly  people, 
and  their  men  of  culture  have  done  much  to  enrich 
the  world  of  science.  At  present  the  Russian  peo- 
ple are  suffering  from  privation  and  hunger.  Their 
transport  system  has  broken  down.  At  best  the 
country  was  not  in  a  state  of  high  development 
from  the  industrial  point  of  view,  and  it  is  easy 
to  see  how  seven  years  of  warfare  and  an  internal 
upheaval  would  cause  the  breakdown.  But  it  is 
not  our  purpose  to  discuss  the  reasons.  We  shall 
only  consider  some  of  the  actual  conditions  as 
reported  by  Wells,  Brailsford,  Lansbury,  and  other 
unbiased  observers,  and  shall  consider  these  con- 
ditions only  as  they  pertain  to  the  medical  and 
scientific  field,  with  perhaps  a  word  of  inquiry  in 
regard  to  Red  Cross  activities. 

First  of  all,  let  us  consider  an  editorial  in  Thg 
Freeman  of  November  24,  1920,  which  emphasizes 
the  horrible  situation  among  men  of  science,  includ- 
ing the  medical  profession  in  Russia.  The  follow- 
ing statement  and -appeal  is  made: 

"Science  is  universal,  like  art,  music,  literature, 
or  any  other  purely  spiritual  activity  of  mankind. 
There  is  no  such  thing,  except  for  pure  convenience 
of  designation,  as  Russian  science  or  American 
science;  there  is  only  science.  The  obstacles  put 
by  political  government  against  the  progress  of 
science  in  Russia  is  primarily  not  a  crime  against 
Russia  but  against  science ;  and  it  seems  to  us  that 
men  of  science  in  the  United  States  should  not  be 
backward  about  so  declaring  it.  By  all  means  sup- 
ply the  Russians  with  the  literature  they  need;  but 
let  our  men  of  science  get  out  a  manifesto,  saying 
what  they  think  about  the  unconscionable  effronterj' 
of  the  United  States  Government  in  the  premises, 
and  why  they  think  it.  That  is  what  would  help 
more  than  anything  to  set  people  thinking  about  the 
rightful  place  of  science  in  the  world.'" 

This  statement  is  made  in  response  to  the  report 
presented  by  H.  G.  Wells,  of  which  the  following 
is  an  extract : 

"If  St.  Petersburg  starves  this  winter,  the  House 
of  Science,  unless  meantime  some  special  effort  is 
made  on  its  behalf,  will  starve  too.  But  these 
scientific  men  said  very  little  to  me  about  the  possi- 
bility of  sending  them  supplies.  The  House  of 
Literature  and  Art  talked  a  little  of  want  and 
miseries,  but  not  the  scientific  men.    What  they 


were  keen  about  was  the  possibility  of  getting  scien- 
tific publications.  They  value  knowledge  more  than 
bread.  Upon  that  matter  I  hope  I  may  be  of  some 
help  to  them.  I  got  them  to  form  a  committee  to 
make  me  out  a  list  of  all  books  and  publications  of 
which  they  stood  in  need,  and  I  have  brought  this 
list  back  to  the  Secretary  of  the  Royal  Society  of 
London,  which  had  already  been  stirring  in  this 
matter.  Funds  will  be  needed,  three  or  four  thou- 
sand pounds  perhaps — the  address  of  the  Secretary 
of  the  Royal  Society  is  Burlington  House,  W. — but 
assent  of  the  Bolshevist  Government  and  our  own 
to  this  mental  provisioning  of  Russia  has  been 
secured,  and  in  a  little  time  I  hope  the  first  parcels 
of  books  will  be  going  through  to  these  men  who 
have  been  cut  off  for  so  long  from  the  general  men- 
tal life  of  the  world." 

As  seen  from  the  foregoing,  steps  have  been  taken 
by  the  British  Government  to  feed,  mentally,  these 
men  of  science  who  are  laboring  for  the  good  of 
all  mankind.  By  the  progress  they  make  their 
results  will  one  day  be  of  service  to  us  ;  it  will  save 
lives — our  own,  perhaps.  So  it  behooves  us,  from 
a  purely  selfish  point  of  view,  to  do  all  we  can  to 
enable  them  to  continue  their  labors.  We  surely 
should  not  allow  them  to  be  segregated  from  the 
rest  of  the  world.  We  should  make  an  effort  to 
get  in  touch  with  them ;  find  out  what  they  are 
doing,  and  supply  their  immediate  needs — books, 
periodicals,  and  supplies  to  carry  on  their  work. 
Perhaps  our  readers  will  have  some  suggestions  to 
offer  in  this  matter.  We  will  welcome  any  that 
you  may  send. 

Now  a  word  in  regard  to  the  activities  of  the 
Red  Cross.  Here  again  we  cannot  do  better  than 
to  quote  George  Lansbury  {What  I  Saw  in  Russia, 
Boni  and  Liveright)  :  "...  for  instance.  Allied 
soldiers,  in  common  with  Russian,  who  have  fallen 
into  the  hands  of  the  Soviet  Government,  have  had 
to  suffer  for  months  from  neglected  wounds,  and 
undergo  major  operations  without  anesthetics  he- 
cause  there  were  none  in  the  country.  Further- 
more, without  medical  and  sanitary  supplies,  dis- 
eases have  become  endemic  in  Russia,  the  public 
health  of  the  entire  nation  being  in  jeopardy,  and 
tens  of  thousands  of  preventable  deaths  occurring." 

The  following  is  taken  from  the  introduction  to 
Lansbury's  book : 

"Mr.  Lansbury  raises  a  question  concerning  the 
Red  Cross.  As  an  international  organization, 
founded  to  administer  relief  and  afford  medical 
aid  impartially  wherever  its  services  can  be  utilized, 
it  has  been  supported  by  voluntary  contributions 
from  the  people  of  the  whole  world.  It  is  non- 
national,  nonpolitical,  and  purely  humanitarian  in 
its  origin,  its  organization  and  profession.  But 
according  to  Lansbury  it  has  given  all  aid  to  the 
Army  Medical  Corps  in  Poland;  it  has  refused  to 
give  any  aid  to  Russia." 


December  25,  1920.] 


EDITORIAL  ARTICLES. 


1039 


As  medical  men  we  are  not  interested  in  politics. 
Our  business  is  to  prevent  suffering  and  not  to 
inquire  into  what  form  of  government  suffering 
men  and  women  are  obliged  to  live  under.  Here 
again  we  ask  our  readers  to  express  themselves 
freely  by  writing  to  the  editor  of  the  New  York 
Medical  Journal,  stating  what  they  think  should 
be  done  in  the  matter. 


PHYSICIAN  AUTHORS:    DR.  BERNARD 
DE  MANDEVILLE 

History  was  repeating  itself  when,  a  few  years 
ago,  a  flurry  of  interest  was  created  by  discovery 
of  the  fact  that  Joseph  Conrad's  incomparable  sea 
stories  were  the  work  of  a  man  who  had  had  to  learn 
the  English  language  after  he  had  grown  up.  That 
a  man  should  attain  such  rare  mastery  of  style  and 
expression  in  English  under  such  conditions  was  in- 
deed unusual,  but  not  unprecedented.  Something 
over  two  hundred  years  ago  Dr.  Bernard  de  Mande- 
ville,  a  Dutch  physician,  went  to  London  when  he 
was  twenty-one  years  old  to  learn  English.  In  a 
few  years  he  was  talking  it  so  well  that  Londoners 
who  did  not  know  him  refused  to  believe  he  was  a 
foreigner.  Moreover,  in  a  few  years  he  was  writine 
English  with  the  brilliancy  of  a  genius.  Dr.  dc 
Mandeville  was  born  about  1670  at  Dordrecht 
(Dort),  Holland,  where  his  father  practised  as  a 
physician.  He  went  to  London  shortly  after  his 
graduation  from  the  University  of  Leyden  on  March 
30,  1691,  intending  to  remain  there  only  a  year  or 
two.  Instead,  he  spent  the  rest  of  his  days  there  and 
became  the  most  talked  of  writer  in  England.  He 
amazed  all  men  of  learning  by  the  boldness  of  his 
thought  and  the  richness  of  his  literary  style.  His 
Fable  of  The  Bees  was  the  literary  sensation  of  the 
hour  and  became  the  storm  centre  of  a  controversy 
that  was  about  as  furious  as  any  rumpus  of  its  kind 
that  ever  raged -in  merrie  England. 

This  controversy  arose  over  the  audacious  doc- 
trines that  de  Mandeville  propounded  with  such 
vigor  and  lucidity.  The  moot  point  in  The  Fable 
of  The  Bees  was  that  individual  virtues  are  det- 
rimental to  the  welfare  of  the  state  in  its  commer- 
cial and  intellectual  progress  and  that  private  vices 
are  public  benefits.  This  hypothesis  at  once  set  in 
motion  a  flood  of  attack  and  defense.  Some  said 
it  was  truth  and  others  said  it  was  twaddle.  In 
the  main,  however,  British  intellectuals  stigmatized 
this  bizarre  philosophy  as  false,  cynical  and  de- 
grading. The  matter  even  reached  the  stage  of  a 
grand  jury  investigation,  but  nothing  much  ever 
cariie  of  that  except  that  it  stimulated  de  INIande- 
ville,  his  supporters  and  his  opponents,  to  fresh 


onslaughts  of  debate.  The  jury  investigation  hinged 
largely  on  the  charge  that  de  Mandeville's  book  was 
oversalacious,  and  it  must  be  admitted  that  even  for 
that  free-spoken  day  and  age  it  was,  to  say-  the 
least,  a  trifle  immodest  and  gross,  particularly  in 
those  erotic  stanzas  wherein  the  genial  Dutch 
doctor  sotight  to  fortify  his  paradoxical  arguments 
by  examples. 

The  Fable  of  The  Bees  was  a  satire  in  the 
Hudibrastic  vein  showing  a  society  possessed  of  all 
the  virtues  and  devoid  of  all  vices  falling  into  apathy 
and  utterly  paralyzed.  It  was  a  humdrum,  sluggish 
world,  this  supervirtuous  world  that  de  Mandeville 
depicted — stagnant  from  lack  of  luxuries,  miserable 
from  absence  of  selflove  and  indulgence.  In  such 
a  world,  he  contended,  civilization  marks  time, 
comes  to  a  standstill  because  there  is  nothing  to 
stimulate  society  into  action  and  progress,  to  arouse 
inventive  ambition  and  keep  up  the  proper  circu- 
lation of  capital.  In  teaching  that  men  who  restrain 
their  selfish  appetites  and  sacrifice  their  own  inter-, 
ests  for  the  public  good  are  fools  and  dupes,  de 
Mandeville  anticipated  a  good  part  of  the  teachings 
of  Nietzsche,  the  selfstyled  immoralist,  who  con- 
tended that  all  the  conventional  morality  and  tradi- 
tional ethics  of  the  human  race  are  absurd. 

As  Chamber's  Encyclopedia  of  English  Litera- 
ture points  out,  de  Mandeville  was  at  his  best  and 
nearer  to  modern  views  in  his  account  of  the  origin 
of  modern  society.  There  is,  in  fact,  a  lot  of  sound 
reasoning  in  de  Mandeville's  fable  outside  his  main 
thesis  concerning  virtue  and  vice.  Contempora- 
ries who  attacked  him  condemned  him  tliroughout, 
but  as  has  been  pointed  out  by  several  critics  in  more 
recent  times,  it  is  mere  prejudice  to  deny  that  he 
had  considerable  philosophic  insight.  Not  all  of  his 
ideas  were  buncombe.  Samuel  Johnson  says  "de 
Mandeville  opened  my  views  into  real  life  very 
much"  and  Macaulay  was  exceptionally  loud  in 
his  praise  of  the  ability  of  de  Mandeville  to  trace 
the  motives  of  human  actions.  Other  defenders  of 
de  Mandeville  point  out  that  his  antimoral  specula- 
tions were  not  written  with  an  immoral  object  but 
were  rather  the  outcome  of  a  playful  desire  to  shock 
and  divert  his  contemporaries.  In  one  respect  it 
may  be  said  that  de  Mandeville  was  somewhat  like 
George  Bernard  Shaw.  It  was  well  nigh  impossible 
to  tell  at  times  when  he  was  in  jest  and  when  in 
earnest.  It  is  reasonable  to  suppose,  however,  that 
he  more  than  half  believed  most  of  the  things  he 
advocated.  There  was,  for  instance,  never  any 
doubt  as  to  his  attitude  toward  free  schools  for  the 
poor.  He  was  absolutely  against  them.  They  were 
his  pet  aversion  and  he  never  tired  of  railing  at 
them.   When  the  first  was  founded  in  1699  he  con- 


1040 


NEIVS  ITEMS. 


[New  York 
Medical  Journal. 


tended  that  if  parents  were  too  poor  to  afford  their 
children  the  elements  of  learning  the  children  should 
remain  ignorant  and  the  money  could  better  be  spent 
on  the  higher  and  professional  education. 

De  Mandeville's  first  work  was  Typhoon:  A  Bur- 
lesque Poem,  followed,  in  1704,  by  Aesop  Dressed, 
or  Fables  in  Familiar  Verse.  Then  came  The 
Grumbling  Hive,  or  Knaves  Turned  Honest.  This 
was  enlarged  into  The  Fable  of  The  Bees  in  1714, 
and  still  further  enlarged  in  1723,  at  which  time  the 
Middlesex  jury  investigated  it  as  a  nuisance.  There 
were  two  other  editions  of  it  during  his  lifetime. 
His  other  works  include  A  Treatise  on  the  Hypo- 
chondriac and  Hysteric  Passions,  highly  commended 
by  Johnson ;  The  Planter's  Charity  and  The  Virgin 
Unmasked,  a  work  in  which  the  coarser  side  of  his 
nature  is  prominent ;  Free  Thoughts  on  Religion, 
equally  unpleasant  in  tone ;  The  Origin  of  Honor 
and  Usefulness  of  Christianity  in  War,  and  some 
disquisitions  on  the  social  evil. 

De  Mandeville  practised  medicine  in  London  until 
his  death,  but  his  practice  was,  much  of  the  time, 
secondary  to  his  writing,  from  which  he  gained  a 
large  income.  He  was,  incidentally,  one  of  the  first 
of  the  tribe  of  press  agents.  Even  in  those  days 
the  drys  were  active  and  King  Gambrinus  felt  the 
need  of  an  able  pleader  before  the  bar  of  public 
opinion.  Dr.  de  Mandeville  was  that  pleader  and 
was  well  remunerated  for  his  work  by  the  brewery 
interests  of  London.  The  genial  old  doctor  sperit 
much  of  his  time -in  their  tap  rooms.  It  was  in  one 
of  these  that  Benjamin  Franklin  met  him  and  found 
him  to  be  "a  most  entertaining,  facetious  companion." 

 ^  

News  Items. 

Anthrax. — During  October,  1920,  one  case  of 
anthrax  was  reported  in  Washington,  one  in  Maine, 
and  two  in  Pennsylvania.  During  November  two 
cases  were  reported  in  ]\Iassachusetts.  During  the 
week  ending  November  20,  1920,  one  case  was 
reported  in  Lowell,  Mass.,  and  one  in  Bloomfield, 
N.  J. 

Hospital  for  Women  to  Be  Opened  in  Pitts- 
burgh.— The  Elizabeth  Steel  Magee  Hospital  will 
be  opened  in  Pittsburgh  early  next  year  as  a  gen- 
eral hospital  for  women.  The  construction  and 
endowment  of  this  hospital  were  made  possible  by 
a  bequest  of  $3,000,000  by  the  late  Christopher 
Magee. 

Borough  Park  Residents  Object  to  Hospital. — 

An  injunction  has  been  asked  by  a  number  of  resi- 
dents of  the  Borough  Park  section  of  Brooklyn  to 
restrain  Dr.  Philip  Mininberg  from  building  and 
maintaining  a  matemi^  hospital  on  his  property 
at  Forty-fifth  street  and  Fifteenth  avenue.  They 
assert  that  the  hospital  is  undesirable  and  would 
lower  property  values. 


A  Nutrition  Clinic  in  the  Far  West. — The  Anti- 
tuberculosis League  of  King  County,  Wash.,  has 
established  a  nutrition  clinic  in  Seattle,  which  is 
said  to  be  the  first  of  its  kind  established  in  the 
Far  West  by  an  antituberculosis  organization. 

National  Tuberculosis  Association. — The  sev- 
enteenth annual  meeting  of  this  association  will  be 
held  in  New  York,  June  13th  to  17th,  with  head- 
quarters at  the  Waldorf-Astoria.  Mr.  Homer 
Folks  is  chairman  of  the  committee  of  arrangements. 

New^  York  Neurological  Society. — A  stated 
meeting  of  the  society  will  be  held  on  Tuesday, 
January  4th.  Dr.  E.  David  Friedman  will  present 
a  case  of  Dyspituitarism  with  Hypertension,  and 
papers  will  be  read  by  Dr.  Charles  Rosenheck,  Dr. 
George  H.  Kirby,  Dr.  L.  Pierce  Clark,  and  Dr. 
Philip  R.  Lehrman. 

Diphtheria  in  New  York. — During  the  four 
weeks  beginning  October  23rd  and  ending  Novem- 
ber 20th,  1,354  cases  of  diphtheria  were  reported 
to  the  Department  of  Health  of  the  City  of  New 
York,  with  sixty-seven  deaths.  The  average  num- 
ber of  cases  and  deaths  during  the  corresponding 
period  of  the  five  preceding  years  was  855  cases 
and  sixty  deaths. 

Brooklyn  M.  E.  Hospital  Plans  Maternity  Hos- 
pital.— On  December  15th,  the  thirty-third  anni- 
versary of  the  Methodist  Episcopal  Hospital,  of 
Brooklyn,  announcement  was  made  that  the  estab- 
lishment of  a  Maternity  Hospital  was  being  seri- 
ously considered  by  the  board  of  managers,  and 
that  an  anonymous  gift  of  $30,000  had  been  received 
to  launch  the  enterprise,  which  it  is  estimated  will 
cost  $200,000.  No  immediate  action  will  be  taken, 
but  a  committee  of  five  has  been  appointed  to  study 
modern  methods  of  construction  and  equipment  of 
maternity  hospitals. 

St.  Louis  University  Establishes  a  Department 
of  Pharmacology. — Announcement  has  been 
made  by  the  president  of  St.  Louis  University  that 
Dr.  John  Auer,  pharmacologist  of  the  Rockefeller 
Institute  of  New  York,  has  been  secured  to  insti- 
tute and  conduct  a  department  of  pharmacology  in 
the  College  of  Medicine  of  the  University.  It  is 
the  hope  of  the  faculty  of  the  university  to  be  able, 
through  the  Centennial  Endowment  Fund  of  $3,- 
000,000  now  being  raised  by  the  friends  and 
alumni  of  the  institution,  to  establish  complete 
departments  in  every  line  of  medical  instruction 
and  research. 

Vital  Statistics  in  New  York. — During  the 
week  ending  December  11th  there  were  1,144  deaths 
from  all  causes  reported  to  the  Department  of 
Health  of  the  City  of  New  York,  corresponding  to 
an  annual  death  rate  of  9.72  in  a  thousand  of 
population,  compared  with  a  rate  of  11.18  for  the 
corresponding  period  in  1919.  Of  these  deaths, 
44  were  due  to  acute  infectious  diseases,  86  to  pul- 
monary tuberculosis,  9  to  influenza,  64  to  lobar 
pneumonia,  56  to  bronchopneumonia,  and  66  were 
violent  deaths.  The  violent  deaths  do  not  include 
suicides,  of  which  there  were  18.  The  deaths  under 
one  year  numbered  160 :  under  five  years,  221 ;  be- 
tween five  and  sixty-five.  659:  sixty-five  years  and 
over;  264.  The  births  during  the  week  numbered 
2,302:  stillbirths,  123,  and  marriages,  1,368. 


December  25.  1920.] 


NEWS  ITEMS. 


1041 


American  Association  for  the  Advancement  of 
Science. — The  seventy-third  meeting  of  the 
American  Association  for  the  Advancement  of 
Science  will  be  held  in  Chicago,  December  27th  to 
January  1st,  under  the  presidency  of  Dr.  L.  O. 
Howard,  of  Washington,  D.  C.  The  retiring 
president,  Dr.  Simon  Flexner,  of  New  York,  will 
deliver  an  address  on  Twenty-five  Years  of  Bac- 
teriological Research. 

Personal. — Dr.  Edward  A.  Park,  associate  pro- 
fessor of  pediatrics  at  Johns  Hopkins  University, 
has  accepted  the  chair  of  pediatrics  in  the  Yale 
Medical  School. 

Surgeon  General  Ireland,  of  the  United  States 
Army,  has  been  awarded  the  silver  medal  of  the 
Serbian  Red  Cross. 

Dr.  E.  Ellis  Owen  has  been  appointed  health 
officer  of  Louisville,  Ky.,  to  succeed  Dr.  Thomas 
H.  Baker,  deceased. 

Rockefeller  Foundation  to  Aid  Medical  Schools 
of  Central  Europe. — To  assist  medical  schools  in 
Central  Europe,  the  Rockefeller  Foundation  an- 
nounces a  cooperative  program  covering  the  follow- 
ing points:  1.  Aid  in  the  rehabilitation  of  scientific 
equipment  for  medical  teaching  and  research.  2. 
Aid  in  furnishing  medical  journals  to  universities 
throughout  Europe.  3.  An  invitation  to  the  author- 
ities of  Belgrade  University  Medical  School  to  study 
medical  education  in  America  and  England,  as  guests 
of  the  Foundation.  Colonel  F.  F.  Russell,  who  has 
been  in  Prague  since  August,  serving  as  technical 
adviser  in  public  health  laboratory  organization  to 
the  Czech  Ministry  of  Hygiene,  will  arrange  the 
details  of  the  plan. 

Brooklyn  Cardiological  Society. — The  next 
meeting  of  the  Brooklyn  Cardiological  Society  will 
be  held  Monday  evening,  January  31st,  at  8:30 
o'clock,  at  the  office  of  the  president.  Dr.  William 
J.  Cruikshank,  102  Fort  Greene  Place,  Brooklyn. 
The  paper  of  the  evening  will  be  read  by  Dr.  Harold 
E.  B.  Pardee,  of  Manhattan,  on  the  Field  of  Use- 
fulness of  Polygraph  and  Electrocardiograph  Diag- 
nosis of  Cardiac  Disease. 

In  a  previous  item  concerning  this  society,  pub- 
lished in  our  December  11th  issue,  page  954,  the 
name  of  Dr.  Richard  C.  Cabot,  of  Boston,  was 
inadvertently  omitted  from  the  list  of  honorary 
members  of  this  society,  and  through  a  typographical 
error  the  name  of  one  of  the  speakers,  the  Rev. 
Dr.  Kraeling,  was  spelled  incorrectly. 

Resolutions  on  the  Death  of  Dr.  Hyman  Cli- 
menko. — Resolutions  on  the  death  of  Dr.  Hyman 
Climenko,  which  occurred  in  New  York  on 
December  16th,  were  adopted  by  the  Neurological 
Staff  of  Mount  Sinai  Hospital,  as  follows : 

Wherfas,  The  untimely  death  of  Dr.  Hyman  Climenko 
has  deprived  the  Neurological  Staff  of  Mount  Sinai  Hos- 
pital of  a  beloved  colleague ;  and 

Where.\s,  We,  his  associates,  wish  to  recognize  his 
great  attainments  as  a  true  physician,  his  nobility  of  char- 
acter, the  simplicity  of  his  life,  his  devotion  to  ethical 
conduct  and  his  love  of  social  justice;  and 

Where.\s,  We,  his  intimate  friends,  feel  keenly  the  ir- 
reparable loss  which  his  death  has  caused,  therefore  be  it 

Resolved.  That  we  express  our  sympathy  with  his  widow 
in  her  sorrow  over  the  loss  of  so  devoted  a  husband,  and 
with  the  children  who  have  been  prematurely  deprived  of 
the  tender  guidance  of  their  father. 


Meetings  of  Local  Medical  Societies. — The  fol- 
lowing medical  societies  will  meet  in  New  York 
during  the  coming  week : 

Tuesday,  December  28th. — New  York  Academy  of  Medi- 
cine (Section  in  Obstetrics  and  Gynecology)  ;  New  York 
Dermatological  Society ;  New  York  Medical  Union ;  Metro- 
politan Society  of  New  York  City  (annual)  ;  New  York 
Psychoanalytic  Society;  Riverside  Practitioners'  Society; 
Therapeutic  Club ;  Valentine  Mott  Society ;  Washington 
Heights  Medical  Society;  Woman's  Hospital  Society; 
Clinical  Society  of  the  Hospital  and  Dispensary  for  De- 
formities and  Joint  Diseases. 

Friday,  December  31st.- — Hospital  Graduates'  Club  of 
Brooklyn. 

Legal  Status  of  the  Public  Health  Service. — ■ 

Surgeon  General  Hugh  S.  Gumming,  of  the  United 
States  Public  Health  Service,  in  his  annual  report, 
said  that  in  his  opinion  it  was  of  the  utmost  impor- 
tance that  the  legal  status  of  the  Public  Health 
Service  in  its  war  risk  work  should  be  firmly  estab- 
lished by  placing  an  administrative  head  over  the 
three  major  agencies  involved,  namely,  the  War 
Risk  Insurance  Bureau,  the  Federal  Board  for 
Vocational  Education,  and  the  Public  Health  Serv- 
ice, and  that  these  three  bureaus  should  operate 
thereunder  as  coordinate  and  independent  bureaus 
in  close  cooperation.  • 

 «^  

Died. 

Backman. — In  Philadelphia,  Pa.,  on  Monday,  December 
6th,  Dr.  Edward  F.  Backman,  aged  sixty  years. 

Bishop.— In  Edensburg,  Pa.,  on  Saturday,  November 
27th,  Dr.  William  T.  Bishop,  aged  eighty  years. 

Brown. — In  Boston,  Mass.,  on  Thursday,  December  9th, 
Dr.  Louis  Sumner  Brown. 

BuECHNER.— In  Youngstown,  Ohio,  on  Wednesday,  De- 
cember 15th,  Dr.  William  H.  Buechner,  aged  fifty-six  years. 

Climenko. — In  New  York  City,  on  Thursday,  December 
16th,  Dr.  Hyman  Climenko,  aged  forty-five  years. 

Cornwell. — In  Buffalo,  N.  Y.,  on  Saturday,  November 
27th,  Dr.  Benjamin  W.  Cornwell,  aged  fifty-eight  years. 

Davis. — In  Ellicott  City,  Md.,  on  Tuesday,  December 
14th,  Dr.  John  W.  Davis. 

Douglass. — In  Philadelphia,  Pa.,  on  Tuesday,  December 
7th,  Dr.  John  S.  Douglass,  of  Cape  May  Court  House, 
N.  J.,  aged  forty-five  years. 

Kinsman.- — In  Saginaw,  Mich.,  on  Sunday,  December 
5th,  Dr.  Enos  C.  Kinsman,  aged  fifty-six  years. 

Martin. — In  Baltimore,  Md.,  on  Wednesday,  December 
8th,  Dr.  Frank  Martin,  aged  fifty-eight  years. 

Merrill. — In  Dozier,  Ala.,  on  Sunday,  November  28th, 
Dr.  J.  P.  Merrill,  aged  forty-six  years. 

Miller.^ — In  Somers,  Mont.,  on  Tuesday,  November  30th, 
Dr.  Charles  E.  Miller,  aged  seventy-seven  years. 

Millett. — In  Belfast,  Me.,  on  Wednesday,  November 
16th,  Dr.  Adelbert  Millett,  aged  sixty-two  years. 

Padiera.— In  Rochester,  N.  Y.,  on  Thursday,  December 
2nd,  Dr.  G.  W.  Padiera,  aged  eighty-three  years. 

Philips. — In  Linesville,  Pa.,  on  Friday,  December  3rd, 
Dr.  David  A.  Philips,  aged  eighty  years. 

Plummer. — In  Boston,  Mass.,  on  Thursday,  December 
2nd,  Dr.  Frank  J.  Plummer,  of  Maiden,  Mass.,  aged  sixty- 
six  years. 

Pyles. — In  Washington,  D.  C,  on  Sunday,  December 
Sth,  Dr.  Richard  Pyles,  aged  fifty-eight  years. 

Smith. — In  New  York  City,  on  Thursday,  December 
16th,  Dr.  Edwin  Fayette  Smith. 

Stewart. — In  Memphis,  Tenn.,  on  Monday,  December 
6th,  Dr.  C.  M.  Stewart,  aged  eighty-nine  years. 

Weed. — In  Cleveland,  Ohio,  on  Saturday,  November  30th,> 
Dr.  Theodore  A.  Weed,  aged  sixty-four  years. 

Woehnert. — In  Buffalo,  N.  Y.,  on  Friday,  December 
10th,  Dr.  Albert  E.  Woehnert,  aged  fifty -two  years. 


Book  Reviews 


OCCUPATIONAL  SKIX  DISEASES. 

Occupational  Affections  of  the  Skin.  Their  Prevention  and 
Treatment.  With  an  Account  of  the  Trade  Processes 
and  Agents  Which  Give  Rise  to  Them.  By  R.  Prosser 
White,  M.D.,  Ed.,  M.R.C.S..  Lond.  Life  Vice-President, 
Dermatologist,  Senior  Physician  and  Enthetic  Officer, 
Royal  Edward  Infirmarj',  Wigan ;  Vice-President  Asso- 
ciation Factory  Surgeons,  etc.  Second  Edition.  With 
Twenty-four  Plates  (Comprising  Twenty-eight  Figures). 
New  York:  Paul  B.  Hoeber,  1920.    Pp.  xiv-360. 

There  was  a  tremendous  outcry  during  the  war 
whenever  it  was  found  that  the  men  were  running 
some  unnecessary  risk  or  Hving  tinder  bad,  prevent- 
able circumstances,  the  outcry  promptly  bringing 
about  a  change,  particularly  when  human  lives  be- 
came costly  and  scarce. 

And  that  many  millioned  army  which  each  morn- 
ing sets  forth  in  the  dawning !  It  must  gain  a  liveli- 
hood for  itself,  also  comfort  and  luxury  for  non- 
combatants.  It  has  to  face,  and  is  facing,  hundreds 
of  foes,  silent,  hidden,  unsuspected,  lurking  even 
in  flowers  and  trees,  attendant  on  every  new  inven- 
tion, every  discovery,  from  a  new  dye  for  a  lady's 
scarf  to  the  patent,  little  known  radium. 

So  great  the  risks,  so  woeful  their  wreckage,  that 
scientists  for  philanthropy's  sake,  and  trade  econo- 
mists for  very  shame,  have  set  to  work  and  found 
many  evils  preventable  and  all  amenable  to  early 
treatment.  Everyone  should  read  the  results,  for, 
in  reading,  they  would  shoulder  the  responsibility 
of  knowledge  and,  if  honest,  would  not  enjoy  their 
food,  clothes,  books,  carriages,  and  luxuries  until 
the  preventable  had  become  prevented. 

Mere  reading  of  the  index  of  this  book  will  rouse  . 
one  to  activity.  Foes  there  are  to  electric  workers, 
to  the  washer  woman,  the  fish  packer,  the  photog- 
rapher, the  spinner,  the  dyer,  the  woodworker,  the 
tanner,  the  chemist,  the  farmer,  and  danger  is  not 
over  when  the  various  things  pass  from  gross  manu- 
facture to  individual  workers  using  additional  things 
in  finishing.  Dermititis  venenata — what  is  that? 
The  chapters  so  headed  describe  the  skin  diseases 
which  may  arise  from  some  plant,  dye  or  drug  with 
which  the  worker  comes  in  contact.  The  lacquer 
tree  of  Japan  (Rhus  vcrnicifera)  is  a  bad  enemy, 
so  is  the  tomato  and  the  beautiful  primula  ohconica, 
which  af¥ects  the  skin  of  those  who  gather  it  for 
florists.  Gardeners  also  sufifer  from  handling  the 
\'irginia  creeper,  which  causes  great  skin  irritation, 
and  the  Vanilla  plantifoUa,  so  mttch  used  in  flavor- 
ing, is  a  source  of  skin  disease  to  the  cleansers  and 
packers  of  the  pods,  and  to  those  who  put  up  the 
packets  of  powder.  Even  the  aircraft  factory  has 
revealed  two  enemies.  The  splinters  of  the  silver 
spruce  are  one,  producing  small,  gradually  enlarging 
blebs,  and  the  Indian  satinwood,  even  in  the  trans- 
porting, gives  rise  to  a  kind  of  erysipelas  among 
the  dockers. 

Most  people  have  heard  of  the  dangers  which 
skin  dressers  and  those  who  work  on  wool  and 
hair  are  liable;  butchers  also  contract  an  acute 
febrile  pemphigus  through  handling  diseased  animal 
tissues,  which  often  ends  fatally.  Then,  too,  the 
streptococcus  is  lurking  in  the  sausage  skins  which 
employment   of   cleansing   is   generally   done  by 


women.  From  tree  top  to  ocean  depths  dangers 
lurk.  A  parasite  of  the  sponge,  much  dreaded  by 
divers,  is  the  Sargasia  rosea.  Blisters  form  all  over 
the  part  stung;  multiple  abscesses  and  skin  slough- 
ing follows. 

Not  only  workers,  as  generally  understood,  are 
in  danger.  Theie  is  the  Verruca  necrogenica,  or 
anatoinical  tubercle,  found  most  frequently  in  the 
human  cadaver,  which  attacks  doctors,  veterinarians, 
bacteriologists,  postmortem  attendants,  nurses,  and 
imdertakers. 

The  list  of  enemies  is  enough  to  scare  any  fighter, 
yet,  curiously,  vmtil  recently  the  workers  regarded 
them  as  a  necessary  accompaniment  and,  disabled, 
received  no  compensation.  The  great  difficulty  now 
is  to  make  employers  fully  alive  to  the  crime  of 
nonprevention  and  the  employees  to  the  necessity 
of  it.  Rich  women  who  wept  as  the  troops  marched 
warwards  cannot  yet  pocket  their  handkerchiefs  if 
their  sorrow  was  sincere,  for  every  morning  the 
great  army  of  toil  stained,  toil  stunted,  patient  people 
go  marching  out  to  meet  invisible  foes,  and  women's 
tears  and  women's  protests  would  speedily  stay  the 
hardships  and  force  Dr.  Prosser  White  to  bring  out 
a  third  edition  to  report  jubilant  victories. 

PHYSICAL  CULTURE. 

Massage  and  Exercises  Combined.  A  Permanent  Physical 
Culture  Course  for  Men,  Women,  and  Children.  Health 
Giving,  Vitalizing,  Prophylactic,  Beautifying.  A  New 
System  of  the  Qiaracteristic  Essentials  of  Gymnastic 
and  Indian  Yogis  Concentration  Exercises  Combined  with 
Scientific  Massage  Movements.  With  Eighty-six  Illus- 
trations and  Deep  Breathing  Exercises.  By  Albrecht 
Jensen,  Formerly  in  Charge  of  Medical  Massage  Clinics 
at  Polyclinic  Hospital  and  Other  Hospitals,  New  York. 
New  York :  Published  by  the  Author,  1920.   Pp.  xiii-93. 

Many  writers  on  nervous  diseases  are  averse  to 
massage  for  some  patients  because  they  are  already 
self  concentrated  and  lazy,  and  massage,  being  an 
exterior  aid,  makes  no  demands  on  the  patient 
in  the  way  of  exertion.  INIany  hysterics  will  have 
a  thorough  course  of  treatment  and,  though  ac- 
knowledging an  improvement  to  themselves,  will 
tell  others  it  hasn't  helped  them  much  as  it  was  not 
suited  to  their  particular  malady.  Such  are  really 
not  worth  the  trouble  of  massaging,  but  if  they 
can  be  coaxed  or  compelled  to  do  the  exercises  them- 
selves the  feeling  of  dependence  is  removed  and 
introduces  other  good  habits,  useful  to  the  patient, 
and  a  blessing  to  the  tired  family.  The  great  thing 
with  all  patients  is  to  induce  them  to  persevere  when 
the  novelty  is  over.  Who  does  not  know  the  dusty 
chart  of  exercises  nailed  up  in  the  bathroom,  now 
hardly  looked  at,  or  the  book  with  curled  corners 
and  full  of  passages  scored  approbatively  with 
whose  contents  we  bored  our  friends  until  we  our- 
selves were  .bored  and  the  book  became  hidden 
under  piles  of  others.  The  exercises  detailed  in 
this  book  are  easy  to  follow  because  shown  in  good 
illustrations.  The  chapter  on  special  and  general 
deep  breathing  exercises  gives  easily  followed  direc- 
tions. How  faulty  our  breathing  we  disrealize 
until  we  try  to  do  it  properly.  When  the  Maori 
football  team  came  over  to  play  against  England, 


December  25,  1920.] 


BOOK  REVIEWS. 


1043 


the  English  were  easily  beaten.  Asking  a  ^laori 
how  this  came  about,  he  said :  "You  English,  no  air 
inside ;  we  breathe  all  over  from  mouth  to  toes." 
That  was  at  a  time  when  soldiers  were  thought 
beautiful  when  the  chest  protruded  and  was  rigid, 
the  shoulders  well  set  back.  Whereas  the  natural, 
healthy  man  has  his  chest  walls  relaxed,  his  shoul- 
ders fall  comfortably,  yet  he  does  not  stoop.  The 
humped  up  shoulder  is  indicative  of  fault}-  breath- 
ins,  of  tension,  of  selfconsciousness. 

Eastern  cities  abound  with  masseurs,  but  they 
live  in  bathing  places,  not  *in  parlors ;  they  are 
stalwart  negroes  who,  after  the  steam  bath,  seize 
you  and  pound  you  and  knuckelize  you  with  strong 
oils  "until  you  expect  to  be  carried  away  defunct; 
instead,  you  are  lithe  and  happy  and  long  for  the 
next  time.  This  book  of  selfmassage  will  keep 
many  from  the  foolish  ladies  and  inept  men  who 
open  massage  establishments  without  any  knowledge 
of  anatomy  and  less  of  disease.  It  will  give  a  pleas- 
ant feeling  of  cooperation  even  when  the  massage 
is  not  selfdone;  diseased  conditions  are  improved, 
even  chronic  ones. 

EVOLUTION  OF  THE  DrL\GOX. 

The  Evolution  of  the  Dragon.  By  G.  Elliot  Smith.  M.A., 
M.D.,  F.R.  S.  Illustrated.  London,  New  York,  Chicago, 
Bombay,  Calcutta,  iladras :  Longmans,  Green  and  Com- 
pany, 1919.    Pp.  xx-234. 

The  writer  of  this  book  is  hardly  just  to  its  value. 
He  designates  it  as  "little  more  than  a  collection  of 
data  and  tags  of  comment."  One  feels  this  in  cer- 
tain places  and  accepts  the  author's  apology  for  it. 
In  much  of  the  book  any  such  criticism  is  forgotten 
in  interest  in  its  vivid  facts.  The  data  it  presents 
have  this  vividness,  for  they  are  the  strange  facts 
not  of  material  reality  but  the  products  of  man's 
fertile  ability  for  pl^antasy  creation.  They  are  vivid 
also  with  Smith's  owti  interest  in  searching  them 
out  and  presenting  them.  Even  more  are  they  alive 
with  the  keen  interpretation  with  which  he  views 
them  as  expressions  of  man's  basic  strivings. 

He  has  been  fearless  in  carrying  them  back  to  an 
expression  of '  the  ever  active  reproductive  need. 
This  has  always  sought  varying  expression.  So 
there  are  ample  discussions  of  some  of  these  large 
features  which  form  great  psychic  way  stations 
where  desires  stop,  start  out  again,  and  again  return. 
The  study  of  the  Great  jNIother,  typified  in  Aphro- 
dite but  symbolized  over  and  over  again,  in  part 
and  in  whole,  is  one  of  these.  The  Dragon  is  a 
picture  of  the  same  and  of  more  besides.  One  could 
ask  for  an  even  deeper  penetration  of  the  sym- 
bolism, a  profounder  comprehension  of  the  striving 
dreams  of  man. 

Then  we  are  confronted  with  the  again  raised 
question  of  spontaneous  arising  of  all  this  symbolic 
matter  in  different  parts  of  the  world,  or  its  diffu- 
sion from  one  cradled  origin  would  fade  into  insig- 
nificance. ^Migrations  preser\-e  and  carry  fonvard 
the  past,  but  ever}-Avhere  this  past  meets  fertile 
growths  like  itself  and  is  reimpregnated  by  them. 
Together  they  form  new^  products,  the  origins  of 
which  can  as  little  exclude  one  another  as  either 
parent  can  with  egotism  exclusively  assume  the 
production  of  a  child. 


MEDICAL  LECTURES  TO  NURSES. 

A  Course  of  Lectures  on  Medicine  to  Nurses.  By  Herbert 
E.  Cuff,  M.  D.,  F.  R.  C.  S.,  Principal  Medical  Officer 
to  the  Metropolitan  Asylums  Board ;  Late  Medical  Super- 
intendent, Xorth  Eastern  Fever  Hospital,  Tottenham, 
London.  Seventh  Edition.  With  Twent>'-nine  Illustra- 
tions. Philadelphia:  P.  Blakiston's  Son  &  Co.,  1920. 
Pp.  vii-257. 

The  tired  nurse  with  ragged  nerves  and  aching 
feet  does  not  always  respond  cheerfully  to  the 
invitation  to  improve  her  mind,  but  there  are  some, 
wearied  with  routine  and  hard  work,  who  will 
resolve  to  make  themselves  fit  for  something  better, 
out  of  pure  desperation.  When  the  lectures  are 
given  by  a  man  interested  in  the  nursing  world  and 
is  a  clear  expositor,  he  rarely  lacks  an  audience. 
To  fortify  the  little  knowledge  posessed  by  the 
nurse  of  anatomy  and  pathology,  and  to  prevent 
discouragement,  the  author  .  has  fully  explained 
enough  to  launch  her  safely  on  the  sea  of  medical 
knowledge.  The  fact  that  a  seventh  edition  has 
been  called  for  is  sufficient  recommendation  of  the 
teacher.  In  it  a  lecture  on  pulmonary  tuberculosis 
and  sanatoria  treatment  has  been  added.  He  deals 
with  many  forms  of  disease  not  usually  given  in 
nursing  manuals,  having  noted  the  anxiety  of  the 
nurse  to  understand  what  he  is  saying  to  students 
in  his  clinical  rounds,  and  knows  she  often  falls  into 
despair  when  trying  to  find  out  for  herself  in 
textbooks.  The  chapter  on  Children's  Diseases  is 
good,  as  these  inarticulate  patients  who  cannot 
explain  their  pain  often  sorely  puzzle  the  nurse. 
Hemorrhage,  too,  especially  when  internal,  often 
makes  for  alarm.  The  book  is  small  and  pocketable. 
We  are  safe  in  predicting  an  eighth  edition. 

A   MEDIEVAL  ROMANCE. 

Tlie  Revels  of  Orsera.  A  Mediaeval  Romance.  Bv  Ronald 
Ross.   New  York:  E.  P.  Dutton  &  Co..  1920.    Pp.  vi-393. 

With  one  or  two  exceptions,  doctors  as  story 
writers  are  as  big  a  failure  as  a  la3-man  attempting 
a  surgical  treatise.  They  are  so  accustomed  to  con- 
densation in  case  writing  that  they  cannot  put  in 
enough  frills  and  thrills  and  scenery  to  expand  and 
beautify  stem  facts.  Their  characters  are  often 
only  animated  megaphones.  It  was  therefore  with 
a  melancholy  sniffleness  that  the  reviewer  took  up 
this  book,  only  consoled  by  the  fact  that  a  Scotsman 
might  be  dry  but  would  never  be  foolish.  Hope 
is  realized.  Curiosity  is  awakened  as  the  reader 
travels  back  to  the  Swiss  mountains  in  1495  and 
encounters  Morova  Neroni  and  her  deformed  son, 
Zozimo.  with  his  twin  sister,  the  man-elously  beau- 
tiful Astrella.  She,  with  Count  Reichenfel's  daugh- 
ter, Lelita,  move  the  hearts  of  and  influence  the 
Prince  of  Astra,  Trullo,  the  Count's  nephew.  Bran, 
his  captain  of  arms,  a  crowd  of  knights,  guards, 
priests,  a  deformed  jester,  and  a  witch.  There  is 
an  uneasy  mystery  hanging  heavily  on  the  story, 
for  there  is  a  Voice,  the  supernatural  Astrella,  the 
rapidly  appearing  and  disappearing  Count  Azrimar, 
who  becomes  the  chosen  suitor  for  Lelita,  he  win- 
ning her  by  adventure  in  joust  and  tourney,  and 
recovering  after  blows  so  hard  that  the  author  must 
be  supposed  to  have  been  attacked  by  the  dime  novel 
germ  at  an  early  age,  for  his  career  as  a  doctor 
could  hardly  have  included  such  cases. 


1044 


BOOK  REVIEWS. 


[New  York 
Medical  Journal. 


Irrespective  of  the  fine  storm  drenched  pictures 
of  the  mountains,  there  are  good  descriptions  of 
the  emotions.  One  is  on  the  weapon  of  silence, 
where  the  witch,  Brunde,  is  being  tried : 

"  'What  is  your  name  ?'  thundered  the  Cardinal 
again. 

"Brunde's  eyes  remained  fixed  on  vacancy. 
Only  retort  of  the  wretched  against  the  world 
arrayed  in  judgment  before  them — silence!  'What 
is  your  condition?' — rags.  'What  is  your  crime?' — 
misery.    'What  is  your  name?' — no  answer. 

"The  world  rises,  puts  both  his  fists  on  the  table, 
and  shouts  at  her.  Or  he  flings  himself  backward, 
smiles  deprecatingly,  and  loosens  his  waistcoat  but- 
tons, or  his  doublet  or  his  tunic,  as  the  case  may  be. 
The  law,  in  the  shape  of  policeman,  halberdier,  or 
beadle,  looks  ferociously  at  her,  squints  down  his 
red  nose  or  shakes  her  arm.  No  answer.  The 
whole  court  is  insulted.  The  judges  turn  round 
their  heads  like  parroquets  and  look  at  each  other, 
while  their  tongues  click  in  their  mouths  with 
amazement.  Are  we,  God's  vicegerents  of  justice, 
to  be  insulted  by  you,  God  forgotten?  They  leap 
up  and  roar  at  her,  they  smile  at  the  ceiling,  scratch- 
ing their  chins  with  theii  pens ;  they  grow  apoplec- 
tically  crimson ;  they  nod  their  heads  gravely  seven 
times ;  they  lift  their  hands  and  call  Heaven  to 
witness.    'Wlfat  is  your  name?' — no  answer." 

The  Revels  were  begun  thirty  years  ago.  In  them 
the  author  has  "tried  to  analyze  character  into  its 
constituent  elements  and  to  set  forth  each  element 
by  itself  in  apposition." 

But,  with  the  author's  permission,  we  will  not  try 
to  find  his  second  meaning.  Let  it  be  strong  enough 
to  strike  us  or  it  shall  go  unheeded.  The  book  is 
one  of  great  interest  right  away  to  the  end.  Why 
does  he  require  wearied  men,  armed  only  with 
papercutters,  to  halt  during  the  reading  and  dig  for 
his  hidden  meanings?  The  story  shall  be  enjoyed 
for  its  own  sake  first,  and  readers  can  wait  for  the 
solution  until  some  learned  psychologist  finds  out 
exactly  what  the  author  meant  and  tells  us. 

SATAN'S  DIARY. 

Satan's  Diary.  By  Leonid  Andreyev.  Authorized  Trans- 
lation Never  Before  Published  in  Any  Language.  With 
a  Preface  by  Herman  Bernstein.  New  York :  Boni  and 
Liveright,  1920.    Pp.  xvii-263. 

In  reading  Satan's  Diary  one  is  strongly  tempted 
to  contrast  it  with  some  of  Andreyev's  earlier  works 
— his  realistic  Red  Laugh,  for  instance,  one  of  the 
most  powerful  stories  that  has  ever  been  written 
on  war,  or  The  Black  Maskers,  a  play  rich  in  its 
wealth  of  symbolisms.  But  here  we  have  the  man 
in  another  mood,  no  longer  the  weaver  of  mystic 
drama,  no  longer  the  bokl  propagandist,  flinging 
aside  the  curtain  on  abominable  scenes  he  wished 
to  have  abolished  from  the  history  of  man.  He 
has  attempted  to  combine  realism  and  fantasy,  the 
conflict  of  Wondergood,  American  millionaire,  and 
Satan.  The  workmanship  is  crude,  the  fusion  has 
been  incomplete,  and  the  result  is  far  from  con- 
vincing, as  a  work  of  art.  He  has  attempted  what, 
under  ordinary  circumstances,  would  have  turned 
out  a  masterly  thing  from  the  pen  of  Andreyev — 
something  akin  to  his  Judas — which  was  a  finished 


piece  of  work.  Can  it  be  that  he  was  fatigued  or 
that  he  was  unable  to  polish  the  product  as  he 
would  have  liked  to?  Can  it  be  that  the  bleak 
Finnish  wastes  only  reflected  the  barren  phases  of 
the  Russian  upheaval?  These  questions  are  diffi- 
cult to  answer.  At  any  rate,  admirers  of  Andreyev 
will  read  this,  his  last  book,  and  wonder  where  the 
skill  and  warmth  of  the  old  Andreyev  have  van- 
ished ;  they  will  read  and  compare  the  old  Andreyev 
with  the  new,  and  they  will  feel  that  the  new 
Andreyev  had  grown  old  too  soon. 

MOONS  AND  MISSIONARIES. 

The  Crescent  Moon.   By  F.  Brett  Young.   Third  Edition. 
New  York:  E.  P.  Button  &  Co.,  1920.   Pp.  284. 

Africa  has  meant  many  things  to  many  men. 
To  Francis  Brett  Young,  author  of  The  Young 
Physician,  it  is  "the  land  above  all  others  which 
men  of  European  race  have  never  conquered,"  a 
land  of  lush  beauty,  of  mystery  and  of  a  sinister 
horror,  a  land  where  the  clerical  virtues  of  the 
Anglo-Saxon  go.  down  to  defeat  before  the  untamed 
things  in  the  swamps.  The  Crescent  Moon  has  all 
these  qualities.  It  recreates  with  unfailing  fidelity 
the  terror  and  unwilling  fascination  with  which  an 
unsophisticated  English  girl  finds  herself  for  the 
first  time  thrown  face  to  face  with  the  primitive 
things  of  the  forest.  More  than  that,  it  is  a  pitying 
and  ironic  study  of  that  temperament  which,  essen- 
tially artistic,  expresses  itself  in  religion  through 
the  pressure  of  generations  of  puritanism  and 
ignorance. 

As  an  adventure  story  The  Crescent  Moon  can 
give  points  to  many  of  the  current  mystery  tales. 
It  details  the  life  of  Eva  Burwarton,  a  girl  from 
a  tiny,  shut  in  English  town,  who,  on  the  death  of 
her  father,  goes  to  Africa  with  her  brother,  a  young 
missionar}-.  Their  mission  is  situated  on  a  hillside 
above  the  "dark  forest"  wherein  seethes  the  life, 
human  and  subhuman,  which  is  so  far  outside  of 
their  limited  experience.  James,  the  evangelical 
brother,  is  thus  epitomized: 

"I  suppose  in  the  class  from  which  he  came  there 
are  any  number  of  young  men  of  this  kind,  born 
mystics  with  a  thirst  for  beauty  which  might  be 
slaked  in  any  glorious  way,  yet  finds  its  satisfaction 
in  the  only  revelation  that  comes  their  way  in  a 
religion  from  which  even  the  Reformation  has  not 
banished  all  beauty  whatsoever.  They  find  what 
they  seek  in  religion,  in  music  (such  musicH  .  .  . 
but  I  suppose  it's  better  than  nothing),  in  the 
ardours  of  lovemaking ;  and  they  go  out,  the  poor, 
uncultured  children  that  they  are,  into  the  'foreign 
mission  field,'  and  for  sheer  want  of  education  and 
breadth  of  outlook  die  there  .  .  .  the  most  glorious, 
the  most  pitiful  of  failures.  That,  I  suppose,  is 
where  Christianity  comes  in.  They  don't  mind  being 
the  failures  that  they  are.  Oh,  yes,  James  was 
sufficiently  consistent.  .  .  ." 

By  contrast  with  their  only  neighbor,  Godovius, 
a  German  Jew  with  a  smattering  of  culture  and  a 
whip  hand  over  the  ladies,  James  is  sufficiently  in- 
adequate, and  all  through, Eva's  struggle  against  the 
power  of  Godovius  he  grows  more  so.  He  is  con- 
sistently drawn.  "To  him  religion  was  such  a  simple 
thing."  And  in  the  uprising,  fomented  by  Godovius 


December  25,  1920.] 


BOOK  REVIEWS. 


1045 


and  suddenly  grown  beyond  his  control,  he  dies, 
pitifully  and  consistently. 

It  is  James's  inadequacy  that  nourishes  the  friend- 
ship between  Eva  and  Hare,  the  keen  and  self- 
reliant  refugee  whom  she  finds  in  the  forest  one 
night  with  a  broken  arm.  Hare  is  everything  that 
James  is  not,  and  the  two  of  them,  he  and  Eva, 
are  drawn  together  as  the  web  of  hostile  circum- 
stance tightens  about  James.  The  ending  to  this 
story,  too,  is  inevitable. 

This  book  should  appeal  to  a  divergent  public — 
probably  has  so  appealed  since  this  is  the  third 
edition.  It  contains  thrills,  color,  and  an  unexpected 
irony.  Above  all,  it  is  Africa  as  seen  through 
several  differing  temperaments. 

ANATOLE  FRANCE. 

The  Bride  of  Corinth  and  Other  Poems  and  Plays.  By 
Anatole  France.  A  Translation  by  Wilfred  Jackson 
and  Emilie  Jackson.  London  and  New  York:  John 
Lane  Company,  1920.    Pp.  xv-285. 

The  Seven  Wives  of  Bluebeard  and  Other  Marvelous  Tales. 
By  Anatole  France.  A  Translation  by  D.  B.  Stewart. 
London  and  New  York :  John  Lane  Company,  1920. 
Pp.  vi-216. 

In  The  Bride  of  Corinth  we  find  Fraiice  at  work 
on  the  conflicts  which  touched  him  the  most  deeply. 
Here  we  find  him  contending  with  restraint  in  the 
portrayal  of  an  old  struggle,  the  soul  and  the  heart 
of  woman,  and  the  bivalent  pull  that  is  exerted,  the 
old  fixations  on  home  and  mother,  and  again 
expressed  by  church  and  a  complete  heterosexual 
creative  call ;  neither  of  these  is  answered  and  it  is 
only  by  the  skill  of  France  that  the  dominant  note 
is  not  one  of  black  despair.  In  the  end,  neither 
object  is  attained  and  we  witness  the  emotional 
distress  which  is  not  allowed  to  become  too  pro- 
found. The  story  is  worth  reading,  if  only  for 
the  skill  with  which  it  has  been  handled. 

In  the  same  volume  we  find  Crainquehille  and 
The  Man  Who  Married  a  Dumb  Wife  in  addition 
to  a  third  play.  The  first  two  plays  have  been 
presented  and  well  appreciated  in  America,  the  first 
in  French  and  the  second  a  satirical  farce  in  English. 
Crainquehille  portrays  failure  through  weakness ; 
weakness  on  the  part  of  a  sympathetic  old  character 
and  the  weakness  of  a  social  order  which  reflects 
an  all  too  frequent  condition  in  many  countries  and 
during  many  crises.  The  reactions  he  shows  of 
the  small  social  group  could  well  be  applied  to  the 
majority  of  the  hysterical  French  press  of  today. 
Anatole  France  has  made  Crainquehille  a  national 
character  in  France.  Fie  was  aided  in  this  by 
the  masterly  interpretation  of  the  character  by 
Lucien  Guitry,  to  whom  he  has  inscribed  the  play. 
*    *  * 

In  The  Seven  Wives  of  Bluebeard  we  find  France 
in  his  most  clever  mood.  In  this  group  of  charming 
stories  he  shows  the  errors  of  history  and  how 
famous  characters,  Macbeth,  Bluebeard,  Jean  d'Arc, 
and  many  others  have  been  grossly  maligned.  He 
attributes  these  misconceptions  to  the  inaccuracy  of 
various  writers  and  historians.  He  thinks  it  just 
as  well  that  we  have  his  interpretation  of  these 
various  characters,  and  it  must  be  acknowledged 
that  his  is  the  more  human  concept  of  the  lives  and 
doings  of  these  people.    If  France  had  the  time  he 


would  rewrite  all  history,  mythology,  and  folk- 
lore, and  give  us  a  new  history,  mythology,  and  folk- 
lore, not  more  nearly  accurate  but  more  as  he  would 
like  to  have  it,  and  it  seeins  fairly  certain  we  would 
appreciate  his  concepts  more  than  the  older  ones. 
His  myths  are  more  plausible  and  less  monotonous, 
for  it  must  be  admitted  that  he  has  great  versatility. 
These  stories  should  furnish  deep  pleasure  to  his 
readers.  ^ 


New  Publications  Received. 


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


POTTERISM.  By  Rose  Macaulay.  New  York :  Boni  and 
Liveright,  1920.    Pp.  x-227. 

REPRESSED  EMOTIONS.  By  ISADOR  H.  CoRi.\T,  M.D.,  New 
York:  Brentano's,  1920.    Pp.  213. 

WHAT  I  SAW  IN  RUSSIA.  By  George  Laksbury.  New 
York :  Boni  and  Liveright,  1920.    Pp.  172. 

THE    "wELLCOMe"    PHOTOGRAPHIC    EXPOSURE    RECORD  AND 

DIARY.   London  :  Burroughs  Wellcome  &  Co.,  192L   Pp.  260. 

THE  NEW  DECAMERON.  Volume  the  Sccond,  Containing 
the  Second  Day.  New  York:  Robert  M.  McBride  &  Co., 
1920.    Pp.  vi-183. 

THE  SECRET  CORPS.  A  Tale  of  Intelligence  on  All  Fronts. 
By  Captain  Ferdinand  Tuohy.  New  York :  Thomas 
Seltzer,  1920.    Pp.  289. 

elftes  heft.  Krankheiten  des  Riickenmarks  und  der 
peripherischen  Nerven.  Von  Professor  Dr.  R.  Cassirer 
in  Berlin.  Mit  1  Abbildung.  Leipzig :  Verlag  von  Georg 
Thieme,  1920.  Sehntes  Helf,  Seiten  72.  Elftes  Heft, 
Seiten  157. 

diagnostische  und  therapeutische  irrtumer  und 
deren  verhutung.  Innere  Medizin.  Herausgegeben  von 
Prof.  Dr.  J.  ScHWALBE,  Geh.  San. -Rat  in  Berlin.  Zehntes 
Heft.  Krankheiten  des  Blutes  und  der  Driisen  mit  innerer 
Sekretion.  Von  Prof.  Dr.  O.  Naegeli,  Direktor  der  Me- 
dizinischen  Poliklinik  in  Ziirich.    Mit  4  Abbildungen. 

diagnostische  und  therapeutische  irrtumer  und 
deren  verhutung.  Chirurgie.  Herausgegeben  von  Prof. 
Dr.  J.  ScHWALBE,  Geh.  San. -Rat  in  Berlin.  Erstes  Heft. 
Chirurgie  des  Thorax  und  der  Brustdriise.  Von  Geh.  Med.- 
Rat  Prof.  Dr.  G.  Ledderhose  in  Miinchen.  Mit  8  Abbil- 
dungen. Leipzig :  Verlag  von  Georg  Thieme,  1920. 
Seiten  iv-123. 

'  LABORATORY  MANUAL  OF  THE  TECHNIC  OF  BASAL  METABOLIC 
RATE  DETERMINATIONS.      By   WALTER   M.   BOOTHBY,   A.  M., 

M.  D.  and  Irene  Sandiford,  Ph.D.,  Section  on  Clinical 
Metabolism,  the  Mayo  Clinic,  Rochester,  Minnesota,  and 
the  Mayo  Foundation,  University  of  Minnesota.  Illustrated. 
Philadelphia  and  London  :  W.  B.  Saunders  Company,  1920. 
Pp.  117. 

CHEMICAL  PATHOLOGY.  Being  a  Discussion  of  General 
Pathology  from  the  Standpoint  of  the  Chemical  Processes 
Involved.  By  H.  Gideon  Wells,  Ph.D.,  M.D.  Professor 
of  Pathology  in  the  University  of  Chicago  and  in  Rush 
Medical  College,  Chicago;  Director  of  the  Otho  S.  A. 
Sprague  Memorial  Institute.  Fourth  Edition,  Revised  and 
Reset.  Philadelphia  and  London :  W.  B.  Saunders  Com- 
pany, 1920.  Pp.  695. 

PRACTICAL    PREVENTIVE    MEDICINE.      By    MaRK    F.  BoYD, 

M.  D.,  M.  S.,  C.  p.  H.,  Professor  of  Bacteriology  and 
Preventive  Medicine  in  the  Medical  Department  of  the 
University  of  Texas;  Passed  Assistant  Surgeon  (Reserve), 
U.  S.  Public  Health  Service ;  Formerly  Epidemiologist  of 
the  Iowa  State  Board  of  Health  and  Associate  Professor 
of  Preventive  Medicine  in  the  College  of  Medicine  of  the 
University  of  Iowa,  etc.  With  135  Illustrations.  Philadel- 
phia and  London :  W.  B.  Saunders  Company,  1920.   Pp.  352. 


Practical  Therapeutics  and  Preventive  Medicine 

A  Compendium  of  Treatment  and  Prophylaxis,  Original  and  Adapted 


Childhood  the  Period  for  Mental  Hygiene. — 
William  A.  White  (Mental  Hygiene,  April  1920  ) 
says  that  one  of  the  most  important  issues  in  mental 
hygiene  is  to  correlate  the  sick  adult  with  the 
knowledge  we  have  that  his  illness  is  traceable  in  its 
beginnings  to  his  early  life.  This  must  be  done  by 
a  more  developed  knowledge  of  the  psychology  of 
childhood,  which  is  reflected  in  the  home,  in  the 
school,  and  in  the  principles  and  methods  of 
education.  Efforts  to  improve  the  environment, 
even  with  reference  to  such  obvious  features  as 
food,  clothes,  and  ordinary  sanitation,  are  not 
lacking  in  their  general  effect  upon  the  mind  of  the 
developing  child.  Recent  observations  in  the  devas- 
tated countries  of  Europe  have  shown  how  quickly 
destitution,  which  takes  all  the  joy  out  of  life,  is 
reflected  in  the  mental  makeup  of  the  children. 
Such  problems  as  the  care  of  the  pregnant  woman, 
child  labor,  sex  education,  school  sanitation,  and 
more  specifically  the  problems  of  the  atypical  child 
and  juvenile  delinquency,  all  can  be  better  dealt 
with  in  proportion  to  our  increased  knowledge  of 
child  psychology.  Social  problems  have  a  direct 
bearing.  Inasmuch  as  many  of  the  breaks,  perhaps 
most  of  them,  occur  in  the  adolescent  or  early  adult 
period,  it  would  be  of  inestimable  value  if  help 
could  be  systematically  extended  to  the  youth  when 
the  symptoms  of  final  disaster  are  likely  to  be 
discoverable. 

Malignant  Tumors  in  Childhood. — IMalvern  B. 
Clopton  (Journal  of  the  Missouri  State  MedicUl 
Association,  September,  1920)  writes  that  malig- 
nant tumors  in  children  are  far  from  rare,  and 
sarcoma  is  the  type  of  growth  almost  always 
encountered  in  childhood,  just  as  epithelial  cancer 
is  the  common  type  in  old  age.  Sarcoma  in  chil- 
dren often  follows  a  more  rapid  course  than  in 
adult  life,  and  the  most  malignant  growths  are 
those  which  appear  earliest  in  life,  some  of  these 
possibly  being  congenital.  Often  there  is  no  change 
from  normal  good  nourishment  of  the  child  until 
metastasis  occurs,  when  the  downward  course  is 
most  rapid.  Febrile  reaction  may  mislead  the  ob- 
server into  thinking  that  the  mass  is  due  to  an 
infection.  Xo  organ  is  exempt  from  these  new 
growths,  but  it  is  generally  considered  that  the  kid- 
ney is  the  seat  of  sarcoma  more  often  than  any  other 
organ.  Two  types  of  eye  tumors  occur  in  child- 
hood :  sarcoma  of  the  iris  or  choroid,  and  glioma 
of  the  retina.  Brain  and  spinal  tumors  are  not 
uncommon,  the  greatest  mortality  being  in  glio- 
mata.  Sarcoma  or  mixed  celled  growths  of  the 
testicle  are  not  common,  and  a  few  cases  are  found 
ih  the  literature  of  carcinoma  and  sarcoma  of  the 
ovaries.  Carcinoma  of  the  small  intestine  is 
practically  never  found  in  children ;  when  sarcoma 
occurs  it  is  in  the  small  intestine.  Sarcoma  of  the 
long  bones  occurs  rather  infrequently  in  childhood. 
As  to  treatment,  early  operation  offers  the  best 
chance  for  recovery,  but  Clopton  is  convinced  that 
Colev's  toxin  should  be  used  in  these  cases  with 


great  thoroughness.  He  does  not  agree  that  all 
giant  celled  growths  should  have  the  toxin,  because 
they  are  benign  and  should  be  eradicated  if  pos- 
sible ;  but  all  other  growths,  whether  operated  upon 
or  not,  should  get  the  injections  and  have  the  bene- 
fit of  the  rontgen  ray  in  massive  doses,  or  be  treated 
with  radium. 

Differential  Diagnosis  of  Diseases  of  the  Hip 
Joint  in  Children. — Arthur  T.  Legg  (Boston 
Medical  and  Surgical  Journal,  June  10,  1920)  says 
that  at  times  it  is  a  matter  of  great  difficulty  to 
differentiate  between  the  tuberculous  and  the  non- 
tuberculous  infection  of  this  joint,  and  impossible 
until  the  case  has  been  thoroughly  studied.  A  most 
careful  history  should  be  obtained.  A  most  com- 
plete physical  examination  should  be  made.  A 
rontgenogram  should  be  taken  in  every  case  of 
suspected  bone  or  joint  disease ;  and  every  labora- 
tory method  at  our  disposal  should  be  used  before 
making  a  positive  diagnosis. 

Complications  of  Bacillary  Dysentery. — P. 
Manson-Bahr  (British  Medical  Journal,  June  12, 
1920)  describes  an  arthritis  which  occurs  in  the 
course  of  bacillary  dysentery.  It  was  noted  twice  in 
cases  not  treated  with  serum,  but  in  the  majority  of 
cases  it  appeared  subsequent  to  the  injection  of 
serum.  There  were  two  types  of  arthritis  observed. 
The  first  was  a  transient  polyarthritis  appearing  on 
the  seventh  to  the  twelfth  day  after  serum  injection 
and  ushered  in  by  symptoms  of  serum  sickness. 
The  second  type  was  a  prolonged,  intractable  form 
accompanied  by  a  sudden  effusion  into  the  joint 
cavity  but  without  signs  of  local  inflammation,  such 
as  redness  and  heat.  Of  twent\'-nine  cases  treated 
with  serum,  the  transient  type  developed  in  eleven, 
and  in  eight  the  intractable  type  developed,  while 
in  three  hundred  and  thirty-five  cases,  convalescent 
or  light,  not  treated  with  serum,  arthritis  developed 
in  only  one. 

Bacillary  Dysentery  in  Children. — Wilburt  C. 
Davison  (Bulletin  of  the  Johns  Hopkins  Hospital, 
July,  1920)  used  as  the  basis  for  this  study  134 
cases  of  diarrhea,  seventy-one  of  which  were 
diagnosed  clinically  as  dysentery.  More  than 
eighty  per  cent,  of  the  acute  cases  if  ileocolitis  were 
due  to  infection  with  Bacillus  dysenterije.  In  a 
control  series  of  sixty-three  cases  of  simple  diar- 
rhea and  one  hundred  normal  children  Bacillus 
dysenteriaj  was  not  recovered  from  the  stools  in  any 
instance.  Dysentery  was  less  prevalent  among 
children  receiving  breast  milk  or  boiled  milk  and 
boiled  milk  mixtures  in  boiled  containers.  Assi.st- 
ance  in  the  diagnosis  of  dysentery  can  be  gained  by 
the  agglutination  reations  of  the  patient's  serum  by 
standardize'd  technic.  Bacillus  morgan  No.  1, 
Bacillus  welchii.  Bacillus  pyocyaneus.  Bacillus  pro- 
teus,  and  the  Streptococcus  fccalis  are  not  the  cause 
of  dysentery  (ileocolitis)  or  diarrhea.  Davison 
suggests  that  the  name  ileocolitis  should  be  changed 
to  dysentery  in  children  and  the  disease  made  re- 
portable to  the  health  authorities. 


Dec.-mVr  25,  1920.]        PRACTICAL   THERAPEUTICS   AND  I  REVENTIVE  MEDICINE. 


1047 


Modification  of  the  Action  of  Adrenalin  by 
Chloroform. — W.  J.  R.  Heinekamp  {Journal  of 
Pharmacology  and  Experiment  al  Therapeutics, 
November,  1920)  describes  experiments  proving  the 
fact  that  chloroform  is  toxic  for  heart  muscle,  pro- 
ducing or  tending  to  .  produce  weakening  of  the 
organ.  Inhibition  under  chloroform  anesthesia 
after  administration  of  adrenalin  is  due  primarily 
to  the  toxic  or  paralytic  dilatation  of  the  heart,  ven- 
tricular fibrillation  supervening.  Because  of  the 
action  of  chloroform  on  the  heart,  adrenalin  is 
contraindicated  wherever  chloroform  is  employed 
and  chloroform  wherever  adrenalin  is  used.  The 
blood  pressure  lias  no  definite  reflex  relation  to  the 
production  of  the  condition  of  paralytic  dilatation, 
but  has  a  most  important  direct  action  by  preventing 
the  ventricle  from  emptying  itself.  The  adrenalin 
action  is  peripheral,  since  it  occurs  after  section  of 
the  vagi. 

Diagnostic  Signs  in  Tracheobronchial  Adenop- 
athy.— Garcia  Trivino  (La  MedicinQ  Ibera,  March 
20,  1920)  notes  that  the  tracheobronchial  glands 
are  divided  into  two  groups.  The  first  or  pre- 
tracheobronchial  group  lies  in  two  parts  alongside 
the  trachea  and  in  the  superior  angle  formed  by  the 
trachea  and  the  large  bronchi.  The  second  or 
intertracheobronchial  group  lies  in  the  inferior  angle 
formed  by  the  bifurcation  of  the  trachea.  Clinical 
physical  signs  of  enlargement  of  these  glands 'are 
Smith's  sign  or  venous  hum  over  the  manubrium 
of  the  sternum  with  the  head  in  forced  extension  ; 
D'Espine's  sign  of  bronchophony  or  pectoriloquy 
below  the  level  of  the  seventh  cervical  vertebra ; 
Hochsinger's  sign  of  glandular  enlargement  in  the 
fourth  and  fifth  intercostal  spaces  in  the  median 
axillary  line.  This  condition  of  enlargement  of 
the  bronchial  glands  is  much  more  common  in  chil- 
dren than  in  adults,  and  it  predisposes  to  the  inva- 
sion of  the  tubercle  bacillus  although  the  primary 
infection  may  be  due  to  grippe,  whooping  cough, 
measles,  or  syphiHs.  In  a  final  analysis  a  radio- 
graph will  either  prove  or  disprove  the  existence 
of  the  glandular  enlargement. 

Tuberculous  Myocarditis. — E.  Lenoble  (Bulle- 
tin de  I' Academic  de  medccine,  October  19,  1920) 
states  that  various  arrhythmias  may  be  met  with  in 
chronic  or  acute  pulmonary  tuberculosis.  He  has 
personally  witnessed  one  case  of  sinus  arrhythmia 
with  alternating  pulse ;  six  cases  of  auricular  fibril- 
lation ;  two  of  nodal  rhythm ;  three  of  premature 
beats ;  one  of  paroxysmal  tachycardia  with  alternat- 
ing pulse;  one  of  prolongation  of  the  a-v  interval 
with  alternation  of  the  jugular  pulse,  and  one 
showing  secondary  waves  during  the  a-v  interval. 
Fluoroscopic  studies  showed  the  heart  to  be  soqie- 
times  small,  as  in  the  average  case  of  tuberculosis; 
generally,  however,  it  was  enlarged  as  a  whole  or 
in  one  of  its  parts.  The  blood  pressure  ranged 
from  seventy  to  190  millimetres  of  mercury.  The 
prognosis  is  unfavorable  in  these  cases  because  the 
heart  disturbances  are  an  expression  of  a  deep  seated 
pathological  change  in  the  myocardium,  superadded 
upon  the  tuberculous  disease  involving  other  organs. 
The  existence  of  paroxysmal  tachycardia  or  of 
nodal  rhythm  is  particularly  ominous.  The  diag- 
nosis is  based  partly  on  the  absence  of  a  history 


of  rheumatism  or  other  major  infections.  Out  of 
fourteen  cases  in  which  a  Wassermann  test  was 
made,  the  author  obtained  only  one  positive  result. 
The  gross  pathology  of  the  heart  was  rather  variable, 
but  microscopic  study  sometimes  yielded  rather 
striking  changes.  Actual  angiomas  were  found  at 
the  junction  of  the  superior  vena  cava  with  the 
auricular  muscle  tissue.  Other  conditions  noted 
included  fibrosis  and  lime  infiltration  about  the 
bundle  of  His;  peri  fascicular  fibrous  deposition, 
and  changes  in  the  vessel  walls.  In  one  of  the  eases 
of  nodal  rhythm  the  node  of  Keith  and  Flack  was 
infiltrated  with  small  primitive  connective  tissue 
cells  compressing  the  muscle  fibres.  In  the  other 
case  there  was  in  addition  thrombosis  of  the  pecti- 
neal tissues.  Out  of  nine  guineapig  inoculations, 
two  were  positive.  The  author  recognizes  not  only 
an  active  type  of  heart  muscle  disease  in  tuber- 
culosis, viz.,  bacillary  myocarditis,  but  also  a  type 
attended  with  cicatricial  deposits  due  to  healed  tuber- 
culosis, such  deposits  being  responsible  for  the  ar- 
rhythmias observed.  The  connective  tissue  deposits, 
as  in  the  case  of  the  kidneys,  need  not  necessarily 
contain  tubercle  bacilli.  These  deposits  are  due  to 
the  sclerosing  toxins  uf  the  tubercle  bacillus. 

Determination  of  the  Need  of  Surgery  in  Pep- 
tic Ulcer. — W.  A.  Bastedo  (American  Journal  of 
the  Medical  Sciences,  October,  1920)  maintains 
that  surgery  in  a  case  of  peptic  ulcer  must  not  be 
resorted  to  too  lightly.  He  considers  surgery  im- 
perative and  medical  treatment  futile  in  the 
following  conditions:  1.  Chronic  penetration  as 
shown  by  radiographs ;  2,  palpable  induration ;  3, 
adhesions  which  cause  distortion  of  the  stomach, 
interference  with  peristalsis,  or  much  pain  during 
the  digestive  period ;  4,  permanent  hourglass ;  5, 
pyloric  stenosis  not  syphilitic ;  6,  repeated  copious 
hemorrhages ;  7,  conditions  which  suggest  that  an 
ulcer  is  becoming  carcinomatous.  The  majority  of 
peptic  ulcers  can,  in  his  opinion,  be  definitely  said 
to  require  surgery  only  after  the  failure  of  thorough 
and  prolonged  medical  treatment.  When  the  case 
is  medical,  the  relief  of  symptoms  (not  the  cure) 
by  treatment  is,  as  a  rule,  quite  prompt.  There- 
fore, on  the  one  hand,  the  failure  of  the  treatment 
to  relieve  the  symptoms  suggests  that  the  case  is 
probably  surgical ;  whereas,  on  the  other  hand, 
when  a  case  seems  in  all  likelihood  surgical,  but  not 
certainly  so,  a  course  of  medical  treatment  is  ad- 
visable to  prove  the  point.  Furthermore,  if  the 
patient  shows., a  positive  Wassermann  reaction  or 
gives  a  history  or  any  physical  evidence  of  syphilis, 
antiluetic  treatment  should  be  tried.  Given  a  thor- 
ough medical  trial  by  someone  competent  to 
supervise  the  treatment,  we  should  consider  those 
cases  surgical  which  continue  to  show :  1 ,  persistent 
or  recurrent  hemorrhage  even  small  in  amount ;  2, 
pain ;  3,  nausea ;  4,  pylorospasm  of  such  persistence 
as  to  simulate  pyloric  stenosis ;  5,  inability  to  ingest 
comfortably  the  ordinary  wholesome  foods  permit- 
ted by  the  circumstances  of  the  patient,  this  making 
the  poor  patient  a  surgical  case  earlier  than  one  who 
is  well  to  do;  6,  inability  to  ingest  comfortably 
enough  food  to  maintain  inUrition  while  living 
a  normally  occupied  life;  7,  recurrence  after  ap- 
parently a  cure. 


1048 


PRACTICAL  THERAPEUTICS 


AND  PREVENTIVE  MEDICINE. 


[New  Vork 
Medical  JrivKNAi  . 


Dry,  Wet,  and  Ointment  Dressings  for 
Wounds. — Charles  T.  Souther  {Ohio  State  Medi- 
cal Journal,  May,  1920)  advises  the  use  of  dry 
sjauze  dressings  in  clean  surgical  cases.  They  may 
he  used  in  cases  in  whicli  suppuration  is  already 
estahlished,  especially  when  the  wound  is  united  or 
connected  with  a  serous  lined  cavity.  When  mucous 
lined  cavities  are  involved  some  form  of  ointment 
dressing  is  to  be  preferred.  Wet  dressings  are 
indicated  in  the  presence 'of  cellulitis  or  wlien  there 
is  much  edema  in  and  about  the  wound.  The  use 
of  Dakin's  solution  should  be  limited  to  the  wound 
area  and  not  come  in  contact  with  the  skin.  Wet 
dressings  are  contraindicatcd  in  outpatient  clinical 
work  in  cold  weather  because-  of  the  danger  .of 
freezing.  Bichloride  does  harm  in  solutions 
stronger  llian  one  in  10,000.  Carbolic  acid  is 
extremely  dangerous,  even  in  weak  solutions. 
Ointment  dressings  are  of  great  value  l)ecause  they 
facilitate  drainage,  protect  the  surrounding  skin 
from  eczema,  prevent  albuminous  exudate  from 
getting  dry  and  sealing  a  wound,  and  prevent  infec- 
tious material  from  being  absorbed.  There  is  no 
pain  on  changing  ointment  dressings,  nor  any  ])u!l 
on  the  stitches.  Epithelium  grows  faster  under  an 
ointment  dressing.  Ointment  dressings  need  not 
be  changed  as  frequently.  Ointments  witli  a 
mineral  fat  base  are  preferalile. 

Experimental  Studies  on  Effects  of  Carbo- 
hydrate Diets  in  Diabetes. — Frederick  M.  Allen 
{Jounial  of  Experimental  Medicine,  April,  1920) 
reports  that  the  injurious  effects  of  excessive  carbo- 
hydrate feeding  are  demonstrable  in  partially  dejian- 
creatized  dogs  in  the  same  manner  as  in  human 
patients,  and  that  when  a  severe  diabetes  is  pro- 
duced there  is  a  consequent  rapid  progress  of 
emaciation,  weakness,  and  early  death  of  the  animal. 
\Mien  a  milder  degree  of  diabetes  is  produced,  the 
result  after  the  operation  frequently  depends  on  the 
diet,  so  that  if  the  tolerance  is  spared  for  a  time 
recovery  may  occur  to  such  a  degree  that  it  is  im- 
possible to  produce  diabetes  l)y  any  kind  or  quantity 
of  feeding,  but  a  second  operation,  removing  a 
small  additional  fragment  of  the  pancreatic  tissue 
is  necessary.  In  this  early  period  it  is  very  impor- 
tant to  give  the  proper  degree  of  carl)ohydrate  over- 
feeding in  order  to  produce  the  most  useful  type  of 
diabetic  animals,  that  is,  those  with  good  digestion 
and  general  health,  and  with  a  permanent  lowering 
of  assimilative  power  comparable  to  the  condition 
of  the  human  diabetic.  In  the  early  part  of  the 
disease  glucose  was  more  powerful  in  producing 
glycosuria  than  starch.  Admixtures  of  glucose 
given  to  an  animal  progressing,  toward  complete 
recovery  on  a  starch  diet  were  capable  of  producing 
a  helpless  diabetes.  This  is  accounted  for  by  a 
difference  in  the  rate  of  absorption,  showing  that 
a  rapid  flood  of  carbohydrate  is  more  injurious  to 
the  pancreatic  functon  than  a  slow  absorption.  But 
when  a  permanent  diabetes  is  establi.shed,  with  no 
hope  of  recovery,  starch  ])rings  on  a  glycosuria  just 
as  surely  as  sugar,  if  more  .slowly.  From  such 
experimental  evidence  the  clinical  deduction  is 
drawn  that  even  if  a  patient  becomes  free  from 
glycosuria  on  withdrawal  of  sugar  only,  other  foods 
should  also  be  restricted.    Experiments  on  com- 


parisons' of  starches  showed  no  significant  difference 
in  their  assimilation,  nor  was  there  any  extreme 
lowering  of  the  carbohydrate  tolerance  by  proteins, 
sucli  as  has  been  claimed  l^y  some  authors  in  con- 
nection with  the  "oatmeal  cure."  As  the  basis  for 
the  early  tendency  to  recovery,  Allen  mentions 
repair  of  traumatic  inflammation  and  hypertrophy 
of  the  pancreas  remnant,  and  as  an  accompaniment 
of  the  lowering  of  tolerance  by  excessive  diet, 
hydropic  degeneration  of  the  islands  of  Langerhans. 

A  Simple  Means  of  Obviating  Anaphylactic 
Shock. — .\.  Lumiere  and  J.  ChevrtJtier  {Presse 
incdiealc.  Xovember  6,  1920)  report  experimental 
work  indicating  that  anaphylactic  manifestations  are 
due  to  the  formation  in  the  blood  plasma,  at  the 
time  of  the  second  injection,  of  a  colloidal  floccu- 
lent  precipitate  which  causes  asphyxia  by  obstruct- 
ing the  capillaries.  Seeking  to  find  substances 
which  might  prevent  such  precipitation,  they  ascer- 
tained that  among  the  few  compounds  eft'ectual  in 
this  direction  vodium  hyposulphite  was  by  far  the 
least  toxic.  Addition  of  a  considerable  proportion 
of  this  salt  to  the  animal  serum  constituting  th.e 
second  injection  of  protein  was  observed  in  experi- 
ments to  prevent  anaphylactic  shock,  to  which,  on 
the  other  liand,  the  control  animals,  unprotected  by 
the  .salt,  invariably  succumbed.  .Similar  experi- 
ments with  antidiphtheritic  serum  gave  the  same 
results.  The  authors  dqem  addition  of  sodium 
hyposulphite  in  suitable  amount  to  therapeutic 
serums  a  simple,  practical,  and  harmless  means  of 
obviating  anaphylactic  manifestations  in  clfnical 
work. 

Aftertreatment  in  Surgical  Cases. — D'Arcy 
Power  {Practitioner,  July,  1920)  gives  the  follow- 
ing suggestions  concerning  postanesthetic  vomiting : 
The  smell  and  the  vomiting  both  have  to  be  com- 
batted  after  ether  and  chloroform  anesthesia.  The 
smell  of  ether  can  be  lessened  by  equal  parts  of 
eau-de-Cologne  and  water,  used  on  a  handkerchief, 
or  sprinkled  on  the  beard  or  mustache.  The  taste 
can  be  reduced  by  ordering  a  mouth  wash  of  carbo- 
late  of  soda  (phenol,  eight;  caustic  soda,  three  and 
one  half;  distilled  water,  one  hundred),  diluted  ten 
or  twenty  times;  or  by  phenol,  six  grains;  citric 
acid,  five  grains  to  an  ounce  of  Cologne  water 
diluted  to  two  ounces  with  warm  water.  The  de- 
gree of  vomiting  varies  with  the  length  of  the 
operation,  the  previous  preparation  of  the  patient, 
and  with  his  individuality.  It  is  most  severe  after 
the  removal  of  enlarged  cervical  glands.  When 
vomiting  is  not  very  severe,  sips  of  hot  water  niay 
be  given.  In  more  persistent  cases  fifteen  grains 
of  bicarbonate  of  soda  may  be  dissolved  in  a 
tumblerful  of  hot  water;  the  patient  vomits  it 
directly,  but  the  sickness  afterwards  subsides.  In 
very  severe  cases  give  nothing  by  mouth,  but  ad- 
mini.ster  a  sejdative  enema,  consisting  of  bromide 
of  potassium  and  chloral  hydrate,  each  twenty 
grains,  and  mucilage  of  starch,  two  ounces.  The 
author  has  never  had  to  wash  the  stomach  out  to 
stop  the  vomiting.  When  vomiting  has  been  un- 
duly prolonged  it  is  sometimes  a  good  plan  to  feed 
the  patient  so'id  food  rather  than  to  restrict  him 
to  slops. 


Proceedings  of  National  and  Local  Societies 


AMERICAN   PEDIATRIC  SOCIETY. 

Tliirfx-sccond  Annual  Mcctinq,  Held  in  Highland 
'Park,  III.,  May  31.  June  1  and  2.  1920-. 

The  President,  Dr.  Thom.^s  S.  Solthwortii,  of  Xew  York, 
in  the  Chair. 

(Continued  from  page  1008.) 

The  Ulcerated  Meatus  in  the  Circumcised 
Child. — Dr.  Joseph  Brexxeman,  of  Chicago, 
stated  that  ulceration  of  the  meatus  was  very  com- 
mon in  circumcised  children.  There  was  usually 
ulceration,  scab  formation,  narrowing  of  the  meatus, 
painful  urination,  often  partial  obstruction,  and 
occasionally  hemorrhage  at  the  end  of  urination. 
The  condition  seemed  always  associated  with  what 
was  known  as  the  ammoniacal  diaper,  and  appa- 
rently resulted  from  direct  contact  of  the  meatus 
with  the  wet  diaper.  The  treatment  consisted  in 
applying  vaseline  or  wet  boric  acid  dressings  to 
the  meatus  if  inflamed  and  in  the  prophylaxis  of 
the  ammoniacal  diaper.  The  latter  was  probably 
due  to  a  metabolic  disturbance  that  was  not  yet  fully 
understood,  but  probably  commonly  due  to  over- 
feeding with  cows'  milk  fat,  as  a  result  of  which 
there  was  an  excessive  excretion  of  ammonium  salts 
in  the  urine.  Inasmuch  as  the  ammonium  salts 
must  be  broken  down  to  liberate  ammonia,  and  this 
was  commonly  effected  by  an  alkali,  it  was  well  in 
addition  to  reducing  the  ammonium  content  of  the 
urine  to  rinse  the  diapers  to  remove  all  excess  of 
soap  and  also  to  boil  them  for  a  long  time  to 
eliminate  the  possible  influence  of  bacterial  action. 

Treatment  of  Congenital  Syphilis  in  Infants 
and  Children. — Dr.  Walter  R.  Ramsey  and  Dr. 
O.  A.  Groebner,  of  Minneapolis,  presented  a  com- 
munication on  further  progress  in  the  study  of  the 
relative  efficiency  of  the  different  mercurial  prepa- 
rations in  the  treatment  of  congenital  syphilis  in 
infants  and  children  as  determined  by  a  quantitative 
analysis  of  the  mercury  elimination  in  the  urine. 
The  paper  was  read  by  Dr.  Ramsey  who  said  that 
the  treatment  of  syphilis  with  the  diflferent  mercu- 
rial preparations  was  still  a  haphazard  afifair,  the 
rule  being  to  give  as  much  mercury  as  the  patient 
would  tolerate  without  salivation  or  diarrhea. 
Assuming  that  the  amount  of  mercury  eliminated 
in  the  urine  during  a  given  time  would  give  'a  fair 
index  of  the  amount  in  the  circulation,  Dr.  Ramsey 
and  Dr.  Ziegler  had  made  some  experiments,  the 
report  of  which  was  read  before  this  society  in 
1918  and  had  been  published.  In  these  experiments 
it  was  demonstrated  that  mercury,  whether  given 
by  inunction,  by  mouth  or  by  hypodermic  injection, 
was  eliminated  in  the  urine  in  appreciable  amounts. 
Where  only  one  dose  was  given  by  any  of  these 
methods  mercury  continued  to  be  eliminated  in  the 
urine  for  a  variable  time  and  in  one  case  as  long 
as  ten  days. 

In  this  new  series  of  experiments,  they  had  sought 
to  determine  with  some  degree  of  accuracy  the 
amount  and  rapidity  of  absorption  and  elimination 
of  the  common  mercurial  preparations  in  common 
use  as  determined  by  quantitative  estimate  of  the 


amounts  eliminated  in  the  urine.  The  method  was 
the  same  as  that  employed  in  the  previous  experi- 
ments. 

The  practical  deductions  which  might  be  drawn 
from  this  series  of  experiments  were  as  follows: 
1.  Mercurial  ointment  fifty  per  cent,  was  to  be 
preferred  to  the  less  concentrated  preparations  and 
should  be  'repeated  not  more  often  than  twice 
weekly  instead  of  daily.  2.  Calomel  ointment  was 
absorbed  but  less  rapidly  and  to  a  less  extent  than 
mercurial  ointment  and  should  therefore  be  given 
in  greater  concentration  twice  weekly.  3.  The 
salicylate  of  mercury  in  oil  should  be  given  liypo- 
dermically  twice  weekly  instead  of  once.  4.  The 
mercury  chloride  administered  by  hypodermic 
injection,  although  the  dose  was  very  small,  con- 
tinued to  be  eliminated  for  several  days,  but  owing 
to  the  fact  that  its  use  was  frequently  followed  by 
the  appearance  of  protein  in  the  urine  should 
exclude  it  from  the  treatment  of  syphilis.  5.  Calo- 
mel by  the  mouth  was  absorbed  in  small  amounts 
and  continued  to  be  eliminated  for  a  considerable 
time,  therefore  it  was  probable  that  it  would  be 
sufficient  to  give  it  at  intervals  of  several  days 
without  producing  diarrheas.  6.  Gray  powder  was 
absorbed  to  a  small  degree  and  eliminated  rapidly 
so  that  fairly  large  doses  repeated  daily  would 
probably  be  necessary  to  maintain  mercury  in  the 
circulation.  Experiments  were  being  continued  to 
determine,  if  possible,  whether  the  clinical  results 
would  bear  out  the  observations  made  in  this  paper. 
In  one  case  of  congenital  syphilis  treated  by  inunc- 
tions, and  not  repeated  oftener  tlian  once  weekly, 
the  clinical  progress  was  apparently  not  less  satis- 
factory than  in  cases  in  which  dail}-  inunctions  were 
given. 

A  Study  of  the  Incidence  of  Hereditary  Syphi- 
lis.— Dr.  P.  G.  Jeaxs  and  Dr.  J.  V.  Cooke,  of  St. 
Louis,  made  this  study  which  was  aided  through  a 
grant  from  the  U.  S.  Interdepartmental  Social 
Hygiene  Board.  The  material  was  collected  from 
several  sources,  being  almost  equally  divided 
between  charity  and  private  patients.  The  results 
presented  were  based  on  data  collected  from  the 
first  one  thousand  cases  and  as  many  of  these  as 
possible  were  examined  at  the  end  of  two  months. 
In  these,  histological  examination  of  the  placenta 
as  to  the  presence  or  absence  of  syphilitic  changes 
corresponded  to  the  established  diagnosis  in  95.5 
per  cent,  of  the  cases.  The  lack  of  correspondence 
consisted  entirely  in  finding  no  syphilitic  changes  in 
the  placenta  in  cases  in  which  the  infants  had 
s3-philis.  In  every  instance  in  which  the  placenta 
was  noted  as  having  syphilitic  changes  the  infant 
was  found  later  to  have  syphilis.  In  this  group  of 
cases  in  which  the  diagnosis  was  established,  the 
Wassermann  reaction  on  the  placental  cord  blood 
corresponded  to  the  diagnosis  in  the  infant  in  96.5 
per  cent.  Here  also  the  discrepancies  were  entirely 
due  to  finding  a  negative  Wassermann  reaction  in 
the  fetal  blood  in  instances  in  which  the  infant  was 
syphilitic.  In  every  instance  in  which  the  fetal 
blood   gave   a   positive  Wassermann  reaction  the 


1050 


PROCEEDINGS  OF  NATIONAL   AND  LOCAL  SOCIETIES. 


[New  York 
Medical  Journal. 


infant  was  later  found  to  have  syphilis.  Of  the 
1,000  cases,  574  were  of  the  dispensary  or  poorer 
class,  and  in  this  group  there  was  an  estimated 
incidence  of  syphilis  in  9.6  per  cent.  Classified 
according  to  race,  the  incidence  among  negroes  was 
14.4  per  cent.,  and  among  the  whites  5.8  per  cent. 
The  ohservations  tended  to  confirm  the  reliability 
of  these  methods  and  established  the  justification 
of  applying  either  or  both  methods  in  making  esti- 
mations. Among  private  patients  able  to  pay  a 
physician's  fee  and  private  room  rates  in  a  hospital, 
the  estimated  incidence  based  on  an  examination  of 
placentas  was  1.4  per  cent.  Including  the  doubtful 
cases  the  incidence  was  1.9  per  cent.  Estimating 
the  incidence  from  the  Wassermann  reaction  on  the 
cord  blood,  it  was  found  to  be  1.6  per  cent.,  again 
showing  the  close  agreement  between  the  two 
methods.  In  some  instances  in  which  the  infant 
had  syphilis  the  maternal  Wassermann  alone  was 
positive,  in  others  the  placenta  alone.  Therefore, 
in  order  to  give  a  clean  bill  of  health  to  an  infant 
at  birth  it  was  necessary  that  all  three  examinations, 
maternal  Wassermann,  placenta  and  cord  blood, 
should  be  negative.  The  fact  that  the  treatment 
of  the  mother  during  pregnancy  would  result  in  a 
nonsyphilitic  child  had  been  confirmed  by  these 
observations.  The  total  incidence  of  syphilis  in  the 
whole  group  was  six  per  cent.  It  was  their  belief 
that  the  whole  group  fairly  represented  a  cross 
section  of  the  population  of  St.  Louis,  and  if  such 
was  the  case  the  incidence  of  hereditary  syphilis  at 
birth  was  six  per  cent. 

A  Study  of  Pneumonia  in  Infants  and  Children 
during  the  Recent  Epidemics. — Dr.  Henry 
Heiman,  of  New  York,  presented  an  analysis  of 
336  cases  of  pneumonia  admitted  to  the  pediatric 
service  of  Mt.  Sinai"  Hospital  during  the  pandemic 
of  influenza.  Not  all  of  these  cases  were  influenza 
pneumonias ;  there  were  288  bronchial  pneumonias 
and  forty-eight  lobar  pneumonias.  The  mortality 
was  16.6  per  cent.  With  the  exception  of  the  two 
to  five  year  period  the  mortality  varied  inversely  as 
the  age.  A  variety  of  organisms  had  been  found 
in  the  sputum,  including  the  influenza  bacilli,  pneu- 
mococci,  streptococci,  staphylococci,  but  none  in 
sufficient  predominance  to  justify  conclusions.  The 
x  ray  had  been  found  to  be  of  valuable  assistance  in 
the  diagnosis  of  both  types  of  pneumonia.  The  most 
frequent  complication  was  otitis  media  which 
occurred  in  seventy-five  of  the  336  cases.  Empyema 
developed  in  seventeen  cases.  When  this  compli- 
cation occurred  Dr.  Heiman  had  advised  against 
early  operation  before  the  acute  stage  of  the  pneu- 
monic process  had  subsided. 

Of  prime  importance  in  the  treatment  of 
pneumonia  in  children  were  hygienic  care  and 
efficient  nursing,  a  bright  sunny  room  and  an  abun- 
dance of  fresh  air,  quiet  .surroundings  and  close 
supervision.  Vigilance  should  be  exercised  to  pro- 
tect against  infection  of  the  eyes,  skin  and  mouth. 
A  cleansing  bath  should  be  given  each  morning  as  a 
routine  measure.  While  fresh  air  was  very  neces- 
sary, the  author  did  not  favor  the  cold  air  treatment. 
It  was  important  that  the  digestive  tract  should 
receive  the  closet  attention.  Milk  of  magnesium 
as  an  enema  might  be  given  at  night.    As  a  stimu- 


lant aromatic  spirits  of  ammonia  might  be  given. 
In  the  moderately  severe  cases  with  high  tempera- 
ture hydrotherapy  might  be  employed  in  the  form 
of  warm  packs.  In  toxic  cases  atropine  and 
adrenalin  might  be  given.  The  promiscuous  use  of 
dry  cupping  was  to  be  condemned.  Dr.  Heiman 
did  not  recommend  the  general  use  of  digitalis  in 
children,  since  as  a  rule  the  pulse  was  not  lowered 
or  the  blood  pressure  raised  by  this  agent.  It  was 
to  be  hoped  that  there  would  be  a  further  differen- 
tiation of  types  of  pneumonia  in  infants  and  children 
with  the  hope  of  securing  specific  therapy. 

Lesions  in  the  Midbrain. — Dr.  J.  H.  M.  Knox, 
Jr.,  of  Baltimore,  reviewed  the  anatomy  of  the  mid- 
lirain  and  referred  to  the  difficulty  of  distinguishing 
between  symptoms  that  might  be  due  to  the  destruc- 
tion of  nerve  tissue  by  disease  and  those  which  were 
produced  by  alteration  in  function  in  the  same  area 
because  of  the  involvement  of  neighboring  struc- 
tures. The  syndromes  of  Weber,  Benedict,  and 
Nothnagel  were  described.  In  view  of  the  confusing 
symptomatology  often  noted  in  patients  suffering 
from  midbrain  lesions  the  case  reported,  in  which  * 
the  symptoms  were  comparatively  definite  and  the 
pathological  findings  fairly  circumscribed,  was  of 
interest.  The  patient  was  a  colored  boy,  three 
years  of  age,  brought  to  the  Harriet  Lane  Home, 
Johns  Hopkins  Hospital,  on  February  3,  1915, 
because  of  general  weakness,  trembling,  and  droop- 
ing of  the  eyelids.  The  family  and  personal  history 
of  the  patient  were  negative,  the  boy  appeared  per- 
fectly normal  until  six  months  before  admission, 
when  he  stopped  crying  almost  completely.  About 
four  months  later  the  tremor  was  noted  and  a  little 
later  the  drooping  of  the  eyelids.  The  outstanding 
abnormalities  revealed  by  ph)^sical  examination 
were  some  enlargement  of  the  epitrochlear  glands 
and  the  eye  symptoms.  The  pupils  reacted  to  light, 
the  left  better  than  the  right.  There  was  occasional 
lateral  nystagmus  of  the  right  eye,  marked  bilateral 
ptosis  of  the  eyelids,  apparently  equal  on  both  sides, 
and  a  definite  deviation  of  the  eyeball  to  the  right. 
Two  weeks  later  the  patient  returned  with  the 
history  of  having  had  two  attacks  of  paraplegia, 
having  become  very  weak  and  limp  after  the  second 
one.  The  symptoms  before  noted  were  increased. 
There  was  great  uncertainty  of  movement  and  an 
examination  of  the  fundi  showed  a  very  slight 
degree  of  secondary  atrophy. 

The  spinal  fluid  was  under  marked  pressure,  gave 
a  reaction  for  globulin,  and  contained  an  increased 
number  of  cells,  mostly  mononuclears.  The  x  ray 
examination  of  the  head  showed  a  moderate  hydro- 
cephalus and  a  probable  tumor  above  the  sella  tur- 
cica. About  ten  days  after  his  admission  a  slight 
rigidity  of  the  neck  was  noted,  and  from  that  time 
on  the  child  grew  constantly  weaker,  and  there  were 
slight  daily  fluctuations  of  temperature  of  about  two 
and  a  half  degrees.  He  died  after  being  under 
observation  for  forty-two  days.  The  acquired 
ptosis,  the  curious  tremor  of  long  standing  noted 
in  the  extremities,  and  the  gradually  developing 
paralysis  of  the  movements  of  the  eyeballs,  except 
those  produced  by  the  external  recti  with  resulting 
external  strabismus,  in  a  child  previously  well,  led 
one  to  venture  the  diagnosis  of  a  tumor  of  the  mid- 


December  25,  1920.  PROCEEDINGS  01-   XATIOXAL   JXl)  LOCAL  SOCIETIES. 


1051 


brain,  interfering  with  the  nuclei  of  the  third  and 
fourth  cranial  nerves.  The  ataxia  might  also  be 
accounted  for  by  lesions  in  this  region,  involving 
the  red  nucleus  or  cerebellar  tracts.  Toward  the 
end  there  was  certainly  meningitis,  probably  of 
tuberculous  origin,  associated  with  hydrocephalus, 
although  the  tubercle  bacillus  was  not  demonstrated. 
The  positive  von  Pirquet  reaction  and  the  subse- 
quent development  of  meningitis  suggested  that  the 
tumor  was  probably  tuberculous  in  origin. 

The  postmortem  findings  were  given  leading  to 
the  anatomical  diagnosis  of  solitan.-  tubercle  of  the 
midbrain  and  right  parietal  lobe,  together  with 
tuberculous  meningitis.  The  anatomical  findings 
confirmed  in  the  main  the  clinical  symptoms 
described.  The  writer  further  discussed  the  afTec- 
tions  produced  by  midbrain  injury,  and  also  the 
symptomatolog}'  of  pineal  tumor,  which  was  iden- 
tical with  that  of  priman,-  lesions  of  the  midbrain. 
The  order  in  which  the  symptoms  developed  was 
of  the  utmost  importance  in  reaching  an  accurate 
diagnosis.  When  the  early  symptoms  were  general 
and  attributable  to  increased  cerebral  pressure,  such 
as  headache,  vomiting,  optic  atrophy,  and  hydro- 
cephalus followed,  it  might  be  with  ptosis  and 
oculomotor  palsies,  one  wotild  be  inclined  to  place 
the  initial  lesion  outside  of  the  midbrain,  such  sj-mp- 
toms  might  result  from  meningitis  or  tumor  else- 
where, possibly  originating  in  the  pineal  gland. 
Whereas,  as  in  the  case  of  the  boy  here  reported, 
the  limitation  of,  the  symptoms  for  months  to  ptosis 
and  paralysis  of  the  oculomotor  nerves  and  tremor 
without  evidence  of  intracranial  pressure  supported 
the  diagnosis  of  an  injury  beginning  in  the  mid- 
brain and  as  far  as  it  went  the  absence  in  this  case 
of  an  increase  of  growth  or  of  sexual  development 
suggested  that  neither  the  pineal  nor  pituitary 
glands  were  involved. 

Dyspituitarism,  Socalled :  Absorption  of  Mem- 
branous Bones,  Exophthalmus,  and  Polyuria. — 
Dr.  Alfred  Hand,  of  Philadelphia,  recalled  a  case 
which  he  had  reported  in  the  Transactions  of  the 
Pathological  Society  of  Philadelphia.  \'ol.  X\T. 
1891-93.  under  the  heading  General  Tuberculosis, 
and  also  in  the  Archives  of  Pediatrics,  Vol.  X,  1893. 
under  the  title  of  Polyuria  and  Tuberculosis.  The 
patient  was  a  boy  three  years  old,  seen  December  1, 
1892,  with  a  history  of  great  thirst  and  polyuria  of 
sudden  onset  eight  weeks  earlier.  He  had  had  entero- 
colitis at  the  age  of  eight  months,  and  croup  and. 
measles  at  the  age  of  two  years.  The  family  his- 
tor\-  was  negative.  The  boy  was  undersized,  with 
a  dry  bronzed  skin,  exophthalmos,  corneal  opacities 
in  each  eye.  and  anterior  synechias  in  the  right.  The 
thyroid  was  not  enlarged.  There  had  been  rachitis. 
The  urine  had  a  specific  gravity  of  1,000  and  the 
maximum  quantity  in  twent\--four  hours  was  150 
ounces,  containing  neither  sugar  nor  albumin. 
After  two  months  the  boy  died  of  bronchopneu- 
monia, the  main  feature  of  autopsy  being  a  yellow 
area  of  softening  in  the  right  parietal  bone  involv- 
ing both  tables  of  the  skull,  with  other  areas  affect- 
ing only  the  outer  table.  The  kidneys  were  en- 
larged, the  left  had  three  small  cysts,  and  in  the 
pelvis  of  each  was  a  hard,  tuberculous  mass;  the 
lungs  showed  bronchopneumonia,  and  there  was 


small  round  celled  infiltration  of  the  liver,  .spleen 
and  kidneys,  with  degeneration  of  the  epithelium 
of  the  tiriniferous  tubules. 

Dr.  Hand  quoted  the  notes  of  a  case  shown  before 
the  ^ledical  Society  of  the  State  of  Pennsylvania, 
in  1906,  by  Dr.  T.  \\'.  Kay,  and  reported  by  him 
as  a  case  of  acquired  hydrocephalus,  with  atrophic 
bone  changes,  exophthalmos  and  polyuria.  In  the 
Osier  ^Memorial  \'olume  there  was  an  article  en- 
titled Defects  of  Membranous  Bones,  Exophthalmos 
and  Polyuria,  an  Unusual  Syndrome  of  Dyspitu- 
itarism, by  Dr.  Henry  A.  Christian,  who  reported 
such  a  case  and  had  found  two  similar  ones  described 
by  a  German  writer,  Schiiller.  The  latter  said : 
"We  can,  therefore,  make  a  presumptive  diagnosis 
of  anomaly  of  the  skeleton  as  a  result  of  disease 
of  the  hypophysis."  Dr.  Christian  treated  his 
patient  with  pituitrin,  which,  when  given  under  the 
skin  and  into  a  vein,  caused  great  diminution  in 
the  amount  of  fluid  ingested  and  excreted,  but,  given 
b\"  mouth  or  rectum,  had  no  effect.  Dr.  Christian 
also  concluded  that  the  condition  was  due  to  dis- 
turbed pituitary  function. 

Dr.  Hand  added  to  the  group  a  sixth  case  which 
he  had  seen  recently.  This  patient  was  a  boy,  four 
years  of  age.  from  whom  there  was  removed  at 
the  age  of  two  years  a  tumorlike  swelling  from  the 
left  parietal  region ;  there  was  absence  of  bone 
beneath  the  tumor  down  to  the  dura.  Section 
showed  a  .slight  degree  of  inflammation,  but  mainly 
a  myxomatous  change.  Since  then  other  swellings 
had  appeared,  and  exophthalmos  which  was  greater 
on  the  right,  btit  as  yet  there  had  been  no  pohoiria. 

Analysis  of  these  six  cases  seemed  to  render  the 
theory  of  dyspituitarism  insufficient  to  explain  the 
syndrome,  although  the  polyuria  undoubtedly  de- 
pended on  a  disturbance  of  the  hypophysis ;  the  bone 
changes  seemed  to  be  the  primar\-  condition,  causing 
the  exophthalmos  mechanically  by  changes  in  the 
orbital  plates,  and  the  polyuria  by  changes  in  the 
sella  turcica.  The  cause  of  the  bone  changes  was 
not  clear,  and  further  observations  were  needed 
before  this  interesting  and  curious  group  of  symp- 
toms could  be  satisfactorily  explained. 

Use  of  Fresh  Vaccines  in  Whooping  Cough. — 
Dr.  Rowland  G.  Freemax,  of  Xew  York,  stated 
that  vaccines  for  the  prevention  and  cure  of  whoop- 
ing cough  had  been  used  for  the  past  eight  years, 
and.  while  some  enthusiasm  had  been  shown,  the 
general  opinion  had  been  that  they  were  of  but 
little  service  in  the  treatment  of  whooping  cough, 
although  possibly  of  some  value  in  its  prevention. 
His  own  attitude  was  that  they  did  not  modify  the 
course  of  whooping  cough,  and  he  had  never-  seen 
a  case  of  whooping  cough  apparently  prevented  by 
their  use. 

Two  years  ago  he  saw  Dr.  Hueneken's  paper  on 
the  application  of  the  complement  fixation  test  for 
the  detection  of  antibodies  after  the  injection  of 
whooping  cough  vaccines,  in  which  he  showed  that 
the  antibodies  were  not  present  tinless  the  vaccines 
were  freshly  prepared,  and  that  after  a  week  of 
storage  but  little  antibody  protection  resulted  from 
their  injection  even  in  large  doses.  It  seemed  to 
him  that  this  fact  might  explain  the  contradictory 
reports  from  the  use  of  whooping  cough  vaccines 


1052 


PROCEEDIXGS  OF  XATIOXAL   AND  LOCAL  SOCIETIES. 


[New  York 
Medical  Journal. 


in  the  course  of  their  work.  He  felt  that  it  should 
be  tried  out.  He  was,  however,  unable  to  report 
any  institution  work,  but  had  brought  together  all 
the  cases  in  which  he  had  used  it  in  private  practice, 
hoping  to  stimulate  interest  in  these  fresh  vaccines 
and  thus  render  it  easier  to  obtain  them.  If  we 
were  to  have  an  opportunity  to  give  the  vaccines  a 
fair  trial  we  must  have  a  laboratory  producing  fresh 
vaccines  every  week. 

The  present  series  of  cases,  which  Dr.  Freeman 
reported,  included  sixteen  children  with  whooping 
cough,  in  whom  the  vaccines  had  been  used  at 
various  periods  of  the  disease.  In  five  cases  no 
results  were  obtained.  In  three  of  these  cases  the 
vaccines  were  used  early  in  the  disease,  and  in 
the  other  two,  very  late.  Of  the  eleven  remaining 
cases,  in  nine  a  material  improvement  took  place 
and  in  four  a  practical  cure  was  obtained.  His 
confidence  in  the  vaccines  had  been  somewhat  shaken 
by  the  results  in  one  family  of  six  children,  reported 
in  this  paper,  who  failed  to  react,  but  the  good 
results  obtained  in  other  cases  and  the  quite  remark- 
able results  obtained  in  certain  beginning  cases  con- 
vinced him  that  these  vaccines  should  have  an 
extended  use,  particularly  in  institutions,  where 
control  might  be  used  to  demonstrate  whether  we 
might  not  have  in  these  vaccines  a  valuable  method 
of  reducing  the  large  mortality  from  whooping 
cough. 

Some  Observations  on  Rickets. — Dr.  Johx 
HowLAXD  and  Dr.  Edwards  A.  Park,  of  Balti- 
more, presented  a  contribution  on  this  subject, 
which  consisted  of  a  lantern  slide  demonstration 
showing  the  alterations  at  the  junction  of  the  shaft 
and  cartilage  in  rickets,  as  determined  by  the  x  ray^ 
A  definite  correlation  was  shown  between  the  x  ray 
signs  and  the  actual  pathological  conditions.  Proof 
was  adduced  that  the  calcium  deposits  in  the  carti- 
lage cast  well  defined  shadows.  The  effectiveness 
of  cod  liver  oil  as  a  therapeutic  agent  in  rickets  was 
demonstrated  by  serial  x  ray  pictures.  In  animal 
experiments  a  beginning  calcium  deposit  was 
demonstrated  two  days  after  beginning  the  admin- 
istration of  cod  liver  oil.  In  human  beings  the 
calcium  deposit  in  the  cartilage  was  definitely 
demonstrable  at  the  end  of  three  weeks  after 
beginning  the  administration  of  cod  liver  oil.  The 
probable  relation  of  cod  liver  oil  to  the  process  of 
repair  was  discussed. 

Hypertrophic  Stenosis. — Dr.  H.  M.  McClaxa- 
HAX,  of  Omaha,  stated  that  since  June,  1919,  he 
had  had  under  his  care  six  cases  of  congenital 
hypertrophic  stenosis  complying  with  the  following 
syndrome :  Loss  of  weight :  vomiting  several  times 
a  day.  frequently  expulsive  in  character  ;  stools  small, 
dark,  and  without  any  evidence  of  milk  digestion ; 
visible  peristalsic  wave,  and  scanty  urine.  In  three 
or  four  patients  recovering  without  operation  a 
movable  tumor  could  be  palpated.  In  one  of  the 
patients  not  operated  upon  the  diagnosis  was  fur- 
ther confirmed  by  an  x  ray  plate.  Four  of  the  six 
patients  recovered  under  gruel  feeding,  their  ages 
being  five,  five,  seven,  and  eleven  weeks.  These 
infants  were  placed  on  thick  gruel  in  the  manner 
described  by  Dr.  Saiier  and  later  by  Dr.  Langley 
P'-irt'^r.    Tlic  rate  of  gain  \aricd.  biU  all  made  slow 


but  steady  improvement.  The  fifth  baby  made  fair 
progress  for  two  weeks,  but  the  parents,  seeing  the 
results  in  the  next  case  reported,  demanded  opera- 
tion. This  baby  was  operated  on  and  made  a  good 
recovery,  but  it  was  Dr.  McCIanahan's  belief  that 
this  baby  would  have  recovered  without  operation. 
The  sixth  patient  was  in  desperate  condition  at  the 
time  of  operation,  the  walls  of  the  stomach  being 
dark  in  color,  in  striking  contrast  to  that  of  the 
intestines.  This  infant  had  congenital  hypertrophic 
stenosis,  general  staphylococcus  infection,  and  acute 
gastritis.  The  case  would  undoubtedly  have  ter- 
minated fatally  without  operation. 

Focal  Infections  in  Children. — Dr.  Oscar  'SI. 
ScHLOss  Stated  that  this  report  concerned  cases  of 
focal  infection  of  the  tonsils  which  were  responsible 
for  two  types  of  disturbances.  In  one  group  of 
.  cases,  the  disturbances  were  cjxlic  in  character, 
were  accompanied  by  fever  and  persistent  vomiting, 
with  a  large  elimination  of  acetone  bodies  in  the 
urine  and  an  accumulation  of  acetone  bodies  in  the 
blood.  There  were  eight  cases  in  this  group.  The 
other  type  of  disturbance  was  evidenced  by  mild 
nephritis.  The  urine  contained  albumin  in  mod- 
erate amoimts,  red  blood  cells,  hyaline  and  granular 
casts,  and  some  leucocytes.  These  children  were 
not  especially  ill.  The  symptoms  were  traced  to 
a  tonsillar  infection  and  subsided  promptly  when 
the  infected  tonsils  were  removed.  Two  such  cases 
were  observed.  In  most  of  the  cases  in  both  groups 
the  tonsils  were  not  large.  In  several  instances  the 
tonsils  had  been  previously  removed  and  there 
remained  only  a  small  amount  of  tonsillar  tissue 
between  the  faucal  pillars. 

Sarcoma  of  the  Kidney. — Dr.  Rowland  G. 
Freeman,  of  Xew  York,  stated  that  this  case  was 
of  interest  because  of  the  rapid  production  of  meta- 
stases after  operation,  and  also  because  of  the  t3-pe 
of  tumor.  The  child  was  two  and  a  half  years  of 
age  and  weighed  twenty-six  and  a  half  pounds. 
When  she  came  under  observation  she  had  been 
failing  in  health  for  two  months.  X  ray  examina- 
tion confirmed  the  diagnosis  of  tumor  of  the  kidney 
on  the  left  side.  Six  weeks  after  operation  she 
was  brought  back  to  the  hospital  in  a  desperate  con- 
dition, with  a  temperature  of  102°  F.,  dyspnea,  and 
rales  over  the  entire  chest.  The  x  ray  showed 
numerous  metastases  in  the  lungs. 

A  Case  of  Portal  Thrombosis. — Dr  Richard 
M.  Smith,  of  Boston,  stated  that  portal  thrombosis 
was  a  rare  condition  in  children.  This  patient,  a 
child  three  years  old,  gave  a  history  of  acute  rise 
in  temperature  with  a  cough  of  seven  days'  dura- 
tion at  the  time  of  admission.  The  striking  points 
in  this  case  were  the  persistent  fever,  the  enlarged 
liver  and  spleen,  engorgement  of  the  superficial 
abdominal  veins,  severe  anemia,  and  intestinal  hemor- 
rhage. No  diagnosis  was  reached  during  life.  At 
autopsy  throhibosis  of  the  portal  vein  and  its  great 
radicles  was  found,  with  passive  congestion  of  the 
spleen,  ascites,  hypertrophy  and  dilatation  of  the 
heart,  edema  of  the  lungs,  and  anemia.  Undoubt- 
edly the  thrombosis  was  of  infectious  origin  arising 
it)  connection  with  the  initial  infection  of  the 
respiratory  tract. 

(To  br  coiifiiiucd . ) 


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